Gynecology

Gynecolog Kim Bremer, Meg Gemmill and Heather Millar, chapter editors Ascem Bishnoi and Grace Yeung, associate editors Amy Shafey, EBM editor Dr. Jason Dodge and Dr. Sari Kives, staff editors Basic Anatomy Review ......-.+-.+.s++++.2 Gynecological Infections «......2..+0+06+.28 Physiologic Discharge Menstruation ..... ceveeeeeeseesee:3 — Vulvovaginitis Stages of Puberty Sexually Transmitted Infections (STIs) Menstrual Cycle Bartholinitis/Bartholin Gland Abscess Premenstrual Syndrome (PMS) Pelvic Inflammatory Disease (PID) Premenstrual Dysphorie Disorder (PMDD) Toxic Shock Syndrome Surgical Infections iagnoses of Common 6 Sexuality and Sexual Dysfunction, a1 Abnormal Uterine Bleeding (AUB) Dysmenorthea Menopause oo... c..seeeeceveeeeeesee 82 Vaginal Discharge/Pruritus Hormone Repiacement Therapy (HT) Pelvic Pain Pelvic Mass Urogynecology 34 Dyspareunia Pelvic Relaxation/Prolapse Urinary Incontinence Common Investiga 10 Bloodwork Gynecological Oncology «... 36 Imaging Uterus Ovary Common Procedures .....2..eeseeseeee10 Cervix Genital Tract Biopsy Vulva Colposcopy Vagina Dilatation and Curettage (OGC) Fallopian Tube Laparoscopy Gestational Trophoblastic Disease/Neoplasia Hysteroscopy (GTDIGTN) Endometrial Ablation Hysterectomy Common Medications 8 jorders of Menstruation .........c000.18 References .....0cccccceeeseeeeeeee ee 88 Amenorthea ‘Abnormal Uterine Bleeding (AUB) Dysfunctional Uterine Bleeding (DUB) Dysmenorthea Endometriosis ........0..cceeeereeee IB Adonomyosis ....2..2.6.c0eceeeeeeeee dT Contraception 18 Hormonal Methads Intrauterine Device (IUD) Emergency Postcoital Contraception (EPC) Infertility... eee sees eeeeeeeteeeeeeee BT Female Factors Male Factors Polycystic Ovarian Syndrome (PCOS) 23 Toronto Notes 2000 Gynecology GTGY? Gynecology Basic Anatomy Review Toronto Notes 2010, i bein wpe Ao * blood supply —uterine artery (branch of the interna iliac artery) ee * blood supply ~ cervical branch of uterine artery ‘tesa: ending cf ues athe | * Position (see Figure 2) dei tistfed etroveso: acon ied tre + retroverted Mutstonon tenigufucessene | * Supported by the pelvic diaphragm, the pelvic organs, and 4 paired sets of ligaments dori tht tock * anteverted (majority) * round ligaments: travel from anterior surface of uterus, through broad ligaments, through inguinal canals, and terminate in the labia majora * function: anteversion * uterosacral ligaments: arise from sacral fascia ancl insest into posterior inferior uterus * function: mechanical support for uterus and contain autonomic nerve Fibres + cardinal ligaments: extend from lateral pelvie walls and insert into lateral cervix and vagina * function: mechanical support, prevents prolapse * broad ligaments: pass from lateral pelvic wall to sides of uterus; contains fallopian tube, round ligament, ovarian ligament, nerves, vessels, and lymphatics / adie 2. Positioning of Uterus“Toronto Notes 2000, Basic Anatomy Review/Menstuaton Gynecology G3 Figure 3 Internal Gonital Organs D. FALLOPIAN TUBES ‘14cm muscular tubes extending laterally from the uterus erstitial,isthmic, ampullary and infunciibular segments; end with fimbriae a the ovary xesonalpinxs peritoneal fold that attaches fallopian tube to broad ligament lood supply "uterine and ovarian arteries ovaries onsist of cortex with ova and medulla with blood supply ced By infundibulopevic ligament (suspensory ligament of ovary) sovaruin peritoneal fod that attaches ovary to Broad ligament * blood supply © ovarian arteries (branch of aorta) left ovarian ven drains int the et renal vey ght ovarian vein drain into inferior vena cava we g ne oe = . __ Overian end tubal branches Segue] — Sempse's stride “Thc, se, Gh re igure Menu ~ vray oe Vin atery cot “en TAGE Figuce 4 Vascular Supply 1 brates i. Frere of tens pen Menstruation oy Sando nop 1 heed oa coo tint aa taco Stages of Puberty None 1 Boy ang in ves Pallatsicn PIS ieee oo drenacche 7 increase in secretion of adrenal androgens usually precedes gonadarche by 2 years | © ABM on caesar on + gonadarche ar uty ap * creased secretion of gonadal sex steroids age 8 “Sneoeg + thelarche + "preast development + pubarche wv pubic and axillary hair development =ox—________ + menatche nef abet ech ‘onset of menses usualy follows peak height velocity and/or 2 years following breast | Gesain sel budding.“Toronto Notes 2010 Menstruation GY Gynecology Menstrual Cycle [anuauopaGapebop wy saute pw gpaya sifoyoDs SIN 5 pu oan « (ang scp san) ne, « Cee ta (Grunnonp tp ss ee pores una aH sone Ee ee 4 8 9} 989 + (op tans og ss 6 sebo3 «| err e+ ‘Srove abet « oo some wba53 of nd spon Ww 2 + suumebar 9a sanoes wows pana snd ‘op 9 pang an la + 91a am loo monoamine sy ye meso AQ ‘es aon aang wh a ones > HR a Steal 77 ay + ns se naracieary aw nu YEG 8 ROKaLSANOKd | | pRATURS ne tmeyNaRES 4 uA UE a 8 NEDO ‘aks ace ‘ooratad tan a) ‘210k jens euLON oi jo swweNa “sembly {eR ar ‘ane aS ae IN ene Feoseatps san sP ep womans enna gsm | eam saptonyenu | gpl me Ng ous inn we en (eats sewioct an yg psy ounce ARMRUR NARS - | RMR — MIRE UMAR ISIS 0 IVA SH aro, ALIBI dRRS SRO a emp rena (wae ‘oun aa guoyeepeaia amos, mene syne sms | uy IS way Ingenta ‘si ine Ryne YY uns Forte | ry ogy nso apea yea sonnet tpioemut aso ‘epawataaonews — snuiuondauiers | sume sopitang csnonansiy peel nesy | emote“Toronto Notes 2010 Menstruation Gynecology GS Premenstrual Syndrome (PMS) + synonyms: “ovarian eycle syndrome”, “menstrual molimina” (moodiness) * occurs during most menstrual cycles ee ‘ener pone + incompletely understood, multifactorial, genetics likely play a role eee *& CNSenediated neurotransmitter interactions with sex terouds (progesterone, estrogen, escapee os and testosterone) Seeirneetsams ares) « erotonergi dysregulation currently most plausible theory ‘sup eee person Pen ones oa Diagnostic Criteria for Premenstrual Syndrome suo « atleast one of the following affective and somatic symptoms during the 5 days before ‘menses in each ofthe three prior menstrual cycles "affective ~ depression, angry outbursts irritability, anxiety, confusion, social withdrawal + Somatic ~ breast tendemess, abdominal bloating, headache, swelling of extremities + symptoms relieved within 4 days of onset of menses + symptoms present inthe absence of any pharmacologic therapy, drug or alcohol use + symptoms occur reproducibly during 2 cycles of prospective recording «+ patient suffers from identifiable dysfunction in social or economic performance Treatment + goal: symptom relief + no proven beneficial treatment, suggestions indude: * psychological support * Gict/supplements ‘+ avoid sodium, simple sugars, caffeine and alcohol + calcium ~ 1200-1600 mg/d ‘+ magnesium ~ 400-800 mg/d + vitamin E400 1U/d * vitamin By + medications ‘+ NSAIDs for discomfort, pain + spironolactone for fluid fetention — used during luteal phase + SSRI antidepressants ~ used during luteal phase x Lf days or continuously + progesterone suppositories + OCP~ primarily beneficial for physical/somatic symptoms ‘+ danazol ~ an androgen that inhibits pituitary-ovarian axis + GnRH agonists f severe PMS unresponsive to other treatment + mind /body approaches * regular aerobic exercise + cognitive behavioural therapy + relaxation and light therapy” * biofeedback and guided imagery * herbal remedies (variable evidence) ‘evening primrose oil, black cohosh, St. John’s wort, kava, ginkgo Premenstrual Dysphoric Disorder (PMDD) Definition * official diagnosis in the DSM-IV-TR + described as.a more severe form of PMS with specific diagnostic criteria * treatment with SSRIs (ist line) highly effective + see Psychiatry, PSIGY6 Gynecology Differential Diagnoses of Common Presentations Toronto Notes 2010, Pye mes item me eli] PCC) ©: Abnormal Uterine Bleeding (AUB) + see Disorders of Menstruation, GY! + classified as amenorrhea, oligomenorthea, menorthagia/hypermenorthea, hypomenorchea, metrorthagia, menometrorshagia, polymenorthea, post-menopausal a ine en ‘aon UTERINE BLDG Crag n ene St — ram einsena ew — Veto a inde riage Common came seg me pr ‘that is decreased in amount a eee Dei 0873 fom = Peete: vi eg Noramepec) —Rmnlpesey > aya se Ses biteardy Bpparin - Gai Ena + Mea pemenri: {Spree eatfre —ersee
6 ‘newts ten 20% of CP pattshave astro ‘evi spl sts ea Aronenberin kant) Pram Pisin erin avy, Homan Baden Beare cy ' Aincol sini ‘Mrsshree Find Acad" Aperdts Sagar pein “nme - Meas tweanomt Tonal Meera pened pte fd Orn Pyne Figure 7. Approach to Pelvic Pain“Toronto Notes 2000, Differential Diagnoses of Common Presentations Pelvic Mass functional eysts (always benign) * corpus luteum cyst + follicular cyst * theca lutein eyst + hemorthagic cyst polycystic ovary tubo-ovarian abscess Tateoma of pregnancy benign neoplasms * dermoid cyst most common rmalignant neoplasms ‘epithelial cell most common in >40 yrs + germ cell most common in <20 yrs + metastases (e.g, Krukenberg tumour from gastric cancer) * uterine ‘symmetrical "pregnancy «+ adenomyosis + endometrial cancer + imperforate hymen * hematometra/ pyometra asymmetrical * Ieiomyomata + Ieiomyosarcoma + other gynecological ectopic pregnancy 5 pele adhesions eling in id entaprent) 5 paratbal eyte 5 pyosalpinshyrosalpin + blimaiy fallopian tube neoplasms gosteintetnal appendices abscess 1 skeicar abscess 5 diveteulos, diverts + Garinomaof rectum eon genitourinary distended bladder 5 pelvic adney + Sarina of bladder Iymphoma Dyspareunia + introital inadequate bration Si intat hymen sshovagie 1 sirophi (hypoestrogen) + hemi * infectious (chlamydia, trichomoniasis) Bartoli’ or Skene’s gland infection Helen adele + midvaginal + deep Urethrits short vagina frigonitis congenital abnormality ofthe vagina (eg. vaginal septum) ‘endometriosis adenomyosis Teiomyomata PID (acute vs. chronic) ‘+ hydrosalpinx + tubo-ovarian abscess uterine retroversion ovarian cyst Gynecology G9 Posed aces,GMI0 Gynecology heck Sistas partrig SH sos peeve nigh sk insite Common investigations\Common Procedures, Toronto Notes 2010, Corto de rhe Clit Bloodwork cae * evaluation of severity of abnormal uterine bleeding, pre-op investigation + ferritin if + betahCG investigation of possible pregnancy, ectopic pregnancy, ovarian germ cell tumour + work-up for GID/GTN * monitored after medical management of ectopic pregnancy and GTN to assess for cure or recurrence + LH, FSH, TSH, PRL, DHEA, testosterone, estradiol, androstenedione investigation of amenorthea, mensteual irregularities, menopause, infertility Imaging Ultrasound (U/S) + transabdominal or transvaginal U/S is imaging modality of choice for pelvie structures + transvaginal U/S provides better resolution of uterus and adnexal structures * detects early pregnancy if betachCG 21500 (beta-hCG must be 26500 for transabdominal U/S) ‘+ may be used to identify pelvic pathology rule in or out ectopic pregnancy, intrauterine pregnancy * assess uterine, adnexal, cul-de-sac, ovarian masses (ie. solid or cystic) * determine endometrial thickness, locate/ characterize fibroids + monitor follicies during assisted reproduction ‘Sonohysterography (SHG) * saline infusion into endometrial cavity under ultrasound visualization expands endometrial cavity allowing visualization of uterus and fallopian tubes + Useful For investigation of * abnormal uterine bleeding (AUB) * ancertain endometrial Findings on vaginal U/S infertility (tubal patency) * congenital/acquired uterine abnormalities ~ rule out fibroids or endometrial polyps asily done, minimal cost, extremely well-tolerated, sensitive and specific «+ frequently avoids need for diagnostic hysteroscopy. Hysterosalpingography (HSG) ‘Koray contrast introduced through the cervix into the uterus * used for evaluation of size, shape, configuration of uterus, congenital ute abnormalities, tubal patency, or obstruction + Useful for investigation of infertility Genital Tract Biopsy Vulvar Biopsy + performed under local anesthetic + Keyes/ punch biopsy + hemostasis achieved with loc nitrate, or suture (rarely) pressure and Monse’s solution (frre sulfate) or silver Vaginal Biopsy and Cervical Biopsy ‘generally no anesthetic used + punch biopsy oF biopsy forceps «+ hemostasis with Monsel’s solution and pressure Endometrial Biopsy «performed in the office using an endometrial suction curete(pipel Cervix to aspirate fragments of endometrium * pretreatment with misoprostol (Cytotec*) if nulliparous or postmenopausal ‘+ more invasive procedure (D&C) may be done inthe office or operating room + hysteroscopy ) guided through the“Toronto Notes 2010 ‘Common Procedures Gynecology GYEL Colposcopy eS + diagnostic use Pings surface structures ofthe vulva, vagina, cervix and perianal eon + Tet aid wach appa to cervix dhyates cls and reveals aceite” arco that corespond fo incense nae o-ytoplas ato abnormal) + lowes Bop’ of actowhite lesions for cari idenfcaton of dysplasia and cancer + therapeutic wee + Cryotherapy nitrous oxide or carbon dioxide feces dysplastic sions, genital warts + Ir vaporaation usd to teat Gyspatcestons ofthe exoervs and nig copion + lop electrosurgical excision procedure (LEEP} excision of transformation zone with the cervical esos provides specimen for pathological examination latation and Curettage (D&C) * prior to procedure, determine depth of uterus with sound * ilatation of cervix with dilators of increasing diameter * Scrape entire uterine cavity with sharp curette + anesthesia ~ general o local Indications + diagnostic (today rarely done without hysteroscopy) * abnormal uterine bleeding (AUB) * dysfunctional uterine bleeding (DUB) + therapeutic ‘emoval of retained produlcts of conception following abortion * therapeutic termination of pregnancy in Ist trimester * removal of small uterine polyps, pedunculated submucosal fibroids Complications * bleeding. * infection + perforation of uterus, laceration of cervix ‘reduce risk with preoperative misoprostol (Cytotec*) inserted per vagina to soften cervix and stimulate uterine contraction + incompetent cerv extremely rare Laparoscopy * laparoscope (fer optic camera) sed to view pelvie/ abdominal contents through small Indications * diagnostic * evaluation of infertility, pelvic pain, pelvic masses, congenital anomalies, hemoperiioneum, and endometriosis + therapentie + Tubal ligation “si fheton + excision of ectopic pregnan + cxcsion/ ablation of endometriosis + retrieval of lost IUDs ‘eystectomy,salpingo-oophorectomy and hysterectomy myomectomy. treatment of stress urinary incontinence Contraindications = bowel obstruction ge hemoperitoneum * clinically unstable patient * inability to maintain preumoperitoneum + multiple previous abdominal surgeries Complications + general anesthetic * insufflation ofthe preperitoneal abelominal wall * injury to vascular structures (e.g. aorta, inferior epigastric) sty to viscous (bowel, bladder, ureters) * may need to convert to laparotomyYIP Gynecology (Common Procedures “Toronto Notes 2010, Hysteroscopy + flexible or rigid scope inserted through cervix int uterus to visualize uterine cavity, distension medium is used to allow inspection ofthis potential space Indications diagnostic * detection of uterine anomalies or pathology (i.e infer + AUB * DUB + therapeutic ‘removal of uterine polyps, fibroids, adhesions, septums * ablation Complications + perforation of uterus, laceration of cervix | bleeding + infection ‘+ absorption of excess distension medium (when sugar solutions utilized) ~ fluid overfoad, Ihyponatremia; procedure should be abandoned ifthe fluid deficit rises to 2L + airemboli «anaphylactic shock Endometrial Abla' + an alternative to hysterectomy for treatment of AUB + performed as outpatient surgery 1 Fotionae sto coagulate or reset the endometrium basalis layer to prevent monthly buildasp and dice menstrial losses + anesthesia usually general may be local Methods * rolleball electrode coagulation or resection 1 Inicrowave endometrial ablation * thermoablation (hot water) * balloon ablation + laser photocoagulation Complications * infection injury to pelvic viscera if perforated uterus * hematometra + absorption of excess distention medium ~ fluid overload, hyponatremia * failure (ie. bloeding/menorrhagia persists) {+ may eventually require hysterectomy for recurrence (-20% at 5 years) Hysterectomy Indications ‘uterine fibroids + endometriosis + adenomyosis * uterine prolapse pelvic pain ‘AUB «+ cancer (endometrium, ovaries, fallopian tubes, cervical) Complications ‘general anesthetic + Bleeding + infection + injury to other organs (ureter, bladder, rectum) 4 Tons of ovarian function (if ovaries removed, iatrogenic menopause) ‘Approaches [vaginal vs, abdominal * advantages of vaginal approach —less pai, faster recovery time, allows for Simultaneous repair of retocele cystocele enterocele, improved esthetics indications for vaginal approach ~ mobile uterus, uterine size <12 weeks 2. open vs, laparoscopic ™ advantages of laparoscopy — les pain, faster recovery, improved esthetics, shorter Hospital stay"‘Toronto Notes 2010, (Comon ProceduresDisorders of Menstruation Gynecology GYIS se. Classification of Hysterectomy Tniatione Sito ysteectomy ‘usseaion Tess Ronored Vans Total ystrctony ns cen Total ysterctmy ons cen, lpn bes, oes + lateral sbing-coptarectomy crweso} aia hysterctoay ons, cei, lpn bes vas, ‘wea iganens rane peta Taxable (cg ates) Pat chiaetoence in frie Enis oryoss Neortaga ow Exdoneidaner eign erat thea rsses > yeas aé Cs fr ene Cail caer up tage sl 15) tage ena rg es Disorders of Menstruation or Amenorrhea Etiology + see Differential Diagnoses of Common Presentations, GY6 Clinical Features * depends on etiology * signs of pregnancy (see Obstetrics, OB2) + hypothalamic/ pituitary dysfunction ~ galactorshea, headache, visual changes * ovarian dysfunction ~ menopinse (ae Menopnuse. GYR * endocrine ~ recent changes in Weight signs of vieliza * external genitalia and vagina ~ atrophy, citoromegaly, septum, absence of vagina + family history of delayed puberty + prolonged intense exercise, excessive dieting « absent puberty (eg. Turner's syndrome) Pimary Anenortea omens by ge ia abso of? oun resis ery ope 1h? seul nace Secondary Anenehon omens or bens 3 eyes lennon pun vgos bonérg oni st ‘tana > 07 2) PCOS Gane PCOS CPA) ton imperforate hymen, vaginal wv mol 8. Diagnostic Approach to Amenorrhea Toy 2d Pea Ean 2 armciepeome 7 force Papert (ee Tiana oow Sah (100 sympa thee ‘Hypothyroidsmtypertyrviise Y (CT to nde out pituitary wmour onan Cal + waa bg etic Anovultion <—_———_{ ‘Varin or Vaginal Defect aun ty ever ra Danna vitor Osan (arsenite)VIE Gynecology Disorders of Menstruation Toronto Notes 2010, Investigations (see Figure 8) * beta-ACG, hormonal workup (TSH, Prolactin, FSH, LH, androgens, and estradiol) «+ progesterone challenge to assess estrogen status * medroxyprogesterone acetate (Provera®) 10 mg PO OD for 10 days. + any uterine bleed within 2-7 days after completion of Provera® is considered to be a positive test/ withdrawal bleed * if withdrawal bleeding occurs, that means there was adequate estrogen that thickened the endometrium; thus withdrawal of progrestorone results in bleeding + Hn bleeding ocur ther inadequate estrogen fhypoesrogeism) or excessive androgens + karyotype if indicated (if premature ovarian failure or absent puberty) ‘+ UjS to confirm normal anatomy, PCOS Treatment «hypothalamic dysfunction (low or normal FSH, LH) Tow FSH/LH, consider head imaging (CT of MRI) if no obvious etiology top any medications, reduce stress adequate nutrition, decrease excessive exercise pregnancy desired, correct underying problem fst but may require gonadotropin to stimulate ovulation + Shherwise OCP to induoe menstruation (withdrawal bleed) - may not prevent manifestation of hypoestrogenic state, ie. bone loss + hyperprolactinemia consider CT of head to document presence of pituitary micro/ macroadenoma surgery for macroadenoma (rately) + bromocriptine it fertity desired; OCP if fertility not desired + premature ovarian failure (high FSH, LH) karyotype + removal of gonadal tissue if¥ chromosome present (at 18 years or earlier if dysgenie gonads) + Hig or OCP to prevent manifestations of hypoestogenic state * treat associated autoimmune disorders (hyd, adrenal) + Pcos se Poetic Ovarian Syndrome, GY23 Abnormal Uterine Bleeding (AUB) + anovulatory (90%) ~ unpredictable endometrial bleeding of variable flow and duration: Sex steroids are produced but not cyclically so bleeding isiregular * estrogen dependent breakthrough bleeding: chronic estrogen production unopposed by adequate progesterone production (du to failure of ovulation) = continued proliferation of the endometrium thickened endometrium outgrovs its blood Supply ~ focal necrosis with partial shedding, * since shedding is not uniform and progesterone and prostaglandin related changes have not occurred, bleeding is usualy irregular, prolonged, and heavy + casually due to PCOS, thyroid dysfunction, elevated prolactin levels, rare estrogen producing tumours, stress, weightloss, exercise, liver and kidney disease + ovulatory (10%) ~ typically cyclic but heavy’or prolonged * usually due to an anatomic or physical lesion (e. polyp, fibroid, adenomyosis, neoplasm, foreign body), hemostatic defect, infection, trauma, or local disturbances in prostaglandins (elevated endomyometral vasodilatory prostaglandins and decreased vasoconstrictive prostaglandins) Etiology *# see Differential Diagnoses of Common Presentations, GY6 Investigations *# CBC, serum ferstin beta hCG TSH * consider according to presentation * coagulation profile (esp. adolescent) ~ rule out von Willebrand's disease * prolactin if amenortheie + FSH, LH. serum androgens (esp. fee testosterone) * day 21 (luteal phase) progesterone to confirm ovulation = Pap test + pelvic U/S — detect polyps, fibroids; measure endometrial thickness (useful in post ‘menopausal women) SHG ~ very sensitive for intrauterine pathology (polyps, submucous fibroids) + HSC * endometrial sampling — in women >40 years or at higher risk of enclometeial cancer“Toronto Notes 2000, Disorders of Menstruation Troatment underlying disorders + ifanatomic lesions and systemic disease have been ruled out, consider dysfunctional "uterine bleeding, Dysfunctional Uterine Bleeding (DUB) + rule out anatomic lesions and systemic disease (see Abnormal Uterine Bieding, GYI4) + 90% of DUB is due to anovulation; thus “anovulatory bleed” is often used synonymously with DUB + 10% of DUB is due to dysfunction of corpus lteum a ineguate progesterone production, or an atrophic enclometrium (ie, 2° to OCP) Investigations + exclude organic (systemic/ anatomic) causes first + ensue beta hCG is negative + CBC rule out anemia Treatment + medical * mild DUB, * NSAIDS + anticibrinolytic (eg, Cyklokapron’) at time of menses + combined OCP + progestins (Provera®) on first 10-14 days of each month if oligomenortheic + Mirena IUD + danazol * acute, severe DUB + replace fui losses consider admission + medical teatment a) estrogen (Premarin®) 25 mg IV qth x 24h with Gravot” 50 mg TV/PO gah or 'b) Ovral” 1 tab PO gdh x 24h with Gravol® 50 mg 1V/PO gih. Taper Ovral™ 1 tab tid x24 > bid x24.” OD + after (a) oF (b), maintain patient on monophasic OCP for next several months ‘or consider alternative medical treatment * clomiphene citrate * patients who are anovulatory and who wish to get pregnant + surgical * D&C ~ not for treatment; diagnosis only (usually with hysteroscopy) + enclometral ablation; consider pretreatment with danazol or GnRH agonists ‘if finished childbearing + repeat procedure sometimes required * hysterectomy ~ definitive treatment Dysmenorrhea Definition + see Differential Diagnoses of Conon Presentations, GYS. Primary Dysmenorrhes jegins 6 months-2 years after menarche (once ovulatory cycles established) + colicky pain in abdomen, radiating tothe lower back, labia, and inner thighs beginning hours before onset of bleeding and persisting for hours or days (48-72) + associated symptoms include nausea, vomiting, altered bowel habits, headaches, fatigue [prostaglandin (PG)-associated] + likely due to frequent and prolonged PG-induced uterine contractions - decreased myometrial blood flow ~ ischemia + diagnosis: rule out underlying pelvic pathology and confirm cyelie nature of pain + treatment: "PG synthetase inhibitors (eg, Anaprox*) + must be started before/at onset of pain + OCP to suppress ovulation and reduce menstrual flow ‘Secondary Dysmenorrhea * menstrual pain due to organic disease + usually begins in women who are in theit 20s, worsens with age + may improve temporarily after childbirth + assoclated dyspareunia, abnormal bleeding, infertility Gynecology YS Dysentona rine Blea ‘rama wg nt arate ‘rane atest rose, DUBS e dooms of excl 3 Major Causes of D8 Dorr ‘nisl acy pln or ase) Primary Dysmenartboa Mersusipon nabseeeal apne ise Second Oyamenoen Mrs pan naan deGYI6 Gynecology ox Te esate of endured sue (gos ont sare] esse he lene cay. Ta Dice Dagan "Chene earet se soi 2 Hering coms tenn 5 Beta rson eps 4 tetoc pray Exonait est tin ay = ‘ey te carton at ‘hres ot ens and =eematloge wy MO} nse aot Enon Dror Drona a esac va tore Dc osama ches eens each) ‘sap Sand gist er ‘atone urea iunert 8 Chas ets ndorae Disorders of Menstruation/Endometross Toronto Notes 2010, + investigations and treatments: * bimanual exam — uterine or adnexal tenderness, fied uterine retroflexion, ‘uterosacral nodularity, pelvic mass, or enlarged irregular uterus + UJS, laparoscopy and hysterascopy may be necessary to establish the diagnosis * treat underlying cause Etiology * not fully understood ‘+ proposed mechanisms (combination likely involved) ‘retrograde menstruation theory of Sampson ‘seeding of endometrial cells by transtubal regurgitation during menstruation + endometrial cells most often found in dependent sites ofthe pelvis ‘+ immunologic theory ~ altered immunity may limit clearance of transplanted endometrial cells from pelvic cavity (decreased NK cell activity?) * metaplasia of coelomic epithelium * undefined endogenous biochemical factor may induce undifferentiated peritoneal cells to develop into endometrial tissue + lymphatic flow from uterus to ovary may account for ovarian endometriosis + extrapelvic disease may be due to vascular or lymphatic dissemination of cells Epidemiology ‘incidence: 15-30% of premenopausal women ‘+ mean age at presentation: 25:30 years «represses after menopause Risk Factors ‘family history (7-10 fold increased risk if affected Ist degree relative) «+ obstructive anomalies of the genital tract (earlier onset) + nulliparity age 225 years Sites of Occurrence * ovaries ~ 6 patients have ovarian involvement * broad ligament ~ vesicaperitoneal fold * peritoneal surface ofthe cul-de-sac (uterosacral ligaments) ‘rectosigmoid colon + appendix Clinical Features * may be asymptomatic * history ‘menstrual symptoms * cyclic symptoms due to swelling and bleeding of ectopic endometrium, often, precede menses and continue throughout and after flow + Secondary dysmenorrhea «+ sacral backache with menses + pain may eventually become constant (cheonie pelvic pain) but remains worse perimenstrually + premenstrual and postmenstrual spotting * deep dyspareunia * infectility * 30-40% of patients with endometriosis will be infertile + 15-30% of those who are infertile will have endometriosis * bowel and bladder symptoms * frequency, dysuria, hematuria * diarthea, constipation, hematocheria, dyschezia «+ physical * tender nodularty of uterine ligaments and cul-de-sac felt on rectovaginal exam * fixed retroversion of uterus * firm, fixed adnexal mass (endometsioma) * physical findings not prosent in adolescent population Investigations * definitive diagnosis requires * direct visualization of lesions typical of endometriosis a laparoscop) * biopsy and histologic exam of specimens (2 or more of endometrial epithelium, slands, stroma, hemosiderin-laden macrophages)“Toronto Notes 2010 Endometriosis denomyosis Gynecology GY + laparoscopy Pe mulberry spots: dark bie or brownish-black implants on the uterosacral ligaments Culd-sac or anywhere inthe pelvis, tendomerioma: chocolate cysts in the ovaries “powder bum lesions onthe peritoneal surface cebnly white lesions and clear bicbs peritoneal “pockets + cad may be elevated in patents with endometriosis Treatment + depends on certainty of the diagnosis, severity of symptoms, extent of disease, desire for future ferlity, and threat to GI/GU systems + medical + NSAIDs ~ eg. naproxen sodium (Anaprox®) * pseudopregnancy oi + cyclic/ continuous estrogen-progestin (OCP) .o———_] + medroxyprogesterone (Depo-Provera) Enero essex 0 + pseudomenopause Qnd line: only short-term (<6 months) due to osteoporotic ening syst Sarda by te Potential with prolonged use, unless use ald-back therapy) ‘ance Scene Rapoaitne * danazol (Danocrine®) = weak androgen etn Sa ae ened ™ side effects: weight gain, fluid retention, aene, hirsutism, voice change | ¥en + leuprolide (Lupron®) = GaRH agonist (suppresses pituitary) side effects: hot flashes, vaginal dryness reduced libido a = can use s12 months with add-back progestin or estrogen xy + surgical i reearrative epersscopy sing lune Sibcocen = bparsiouy beng re, * bation resection of implants, ysis of adhesions, ovarian cystectomy of Creervabe say, AN fendometsiomas + definitive bilateral salpingo-cophorectomy + hysterectomy + follow-up with medical treatment for pain control NOT shown to impact on preservation of fertility + beat time to become pregnant is immediately after conservative surgery a + synonym: “endometriosis interna” (uterine wall may be diffusely involved) ‘senmyess| Epidemiology Exner *#°15% of females >35 years old (aneand sora a * mean age at presentation: 40-50 years old (older age group than seen in endometriosis) | Aymara. + adenomyosis isa common histologic finding. in asymptomatic patients * found in 20-10% of hysterectomy specimens Clinical Features * often asymptomatic * menorshagia, secondary dysmenorthea, pelvic discomfort + dyspareunia, dyschezia + ulerus symmetrically bulky, usually <14 cm, mobility not restricted, no associated adnexal pathology ‘+ Halbon sign: tender, softened uterus on premenstrual bimanal Investigations ' * clinical diagnosis © UIS or MRI can be helpful * endometrial sampling to rule out other pathology and to make definitive diagnosis oO Fra dopnss cf aanoryes it based on pte nares Treatment + iron supplements as necessary * analgesics, NSAIDs * OCP, Depo-Provera® (medroxyprogesterone) * low dose danazol 100-200 mg PO OD (trial x4 months) * GnRH agonists (ie. leuprolide) * dofinitive— hysterectomy (no conservative surgical treatment)VIB Gynecology ‘Contraception Toronto Notes 2010, Onn BET ita rear toskoogh eng ts ‘ais nt ae mane oh ring OCP Usisy Sse ar ieee Stores of aA wt ning Cy 2h Cag 8168 Shae teas Prins ora yes couin ‘asl aa > ie 2 eh Vion 28 rts ga ween seo on 117 Fup Stent yup ilvonwen aye ne ja ‘unt Fdracenty waned tt war beg ‘80 US vsion hepa ch ents 75g eee ‘none moe erage 8 ‘thy ele an weer i ‘pel 359 eal conacopve Tis Peter eras ston epare "es nam ranean att Fase, mst on wes ‘hembeenooir atau te dee ih is unde Te pharmackintes ‘the 601mg patch whch aw Palen Corde, as ee Farina a 0? rparses ot temas res rt of OV (il aya + see Family Medicine, FMIS ‘Table 2. Classification of Contraceptive Methods Te eivenes pec oe yi ws Pio ‘Wentowalns mons nos Fin eternal SEO, TEN Lataoral ameter {5 (et mers pospartun) (heres romeo it ‘a0 [Absit 0% Barr Methods Cand oe 60%, 850% Sperice doe a0 70k Sponge - Paes os, 580% Nps 310%, 980% Degg aperiede 40%, a0 Foraleconom 508 TOK Cereal ca Fas 140% 680% Nips 510, aA0k Hormona oF sare, 920% wang sar 920% Shin sare a0 Depo Paven® sas, 10% Foes anit 099% Mea? UD ced Compr ax Suri ‘align ses ‘scm am Enmorgne Postel Cntacopin (20) ‘peed ein 24 as) “Pan vrs ey See tin 24 fous) Pestotal U0 am Hormonal Methods Combined Oral Contraceptive Pills (OCP) ‘+ most contain low dose ethinyl estradiol (20-35 ug) plus progestin (norethinedrone, norgestral, levonorgestrel, desogestrel, norgestimate, drospirenone) ‘failure rate (0.3% to 8%) depending on compliance ‘+ monophasic or triphasic formulations (varying amount of progestin throughout cycle) ‘Skin Patch (Ortho Evra™) ® continuous release of 6 mg norelgestromin and 0,60 mg ethinyl estradiol into bloodstream «+ patch applied to lower abdomen, back, upper arm, buttocks, NOT breast «+ patch worn weekly for 3 consecutive weeks (changed every week) with I week off to Sllow menstruation «as effective as OCP in preventing pregnancy (99% with perfect use) * may be less effective in women #50 kg body weight ‘3% failure rate with typical use ‘+ may not be covered by drug plans Contraceptive Ring (Nuvaring™) + thin flexible plastic ring: releases etonogestrel 120 ug/d and estradiol 15 ug /d * works for 3 weeks, then removed for T week to allow menstruation «+ as effective as OCP in preventing pregnancy (957) 1 avoids first pass effect + Side effects: Vaginal infection /trtation, vaginal discharge + may have better cycle contol, ie. decreased breakthrough bleeding, ‘Starting Hormonal Contraceptives * thorough history and physical examination including blood pressue and breast exam + follow-up visit 6 weeks after hormonal contraceptives prescribed + pelvic exam can be delayed until a subsequent visit“Toronto Notes 2000 CContaception Table 3. Combined Estrogen and Progestin Contraceptive Methods Gynecology GIS ‘Mechanism of Acton ‘vata ‘Se os Carini Daley sipesin egh > Fiero, echle ——Esogonraaed ‘ose iitonal andes + Cysewopton ean 1 Hoong pogrnsy ‘Datla of endoravian + Qasr dyer ard ‘Tkanngol sical macs menor es arora) resign dened spam + Decesad enn bes Saas peeteton tn tan cpt devon + Dros rekof ot a trtareial ene + reed cecal mace wich rowers Is + Decent PS stars + irpmed soe + Ostezross protection ss) + as canes oom, slargenet) + Feta / sting / ea * Weg gan ao) + Mirae heaictes + Thanboanbai es, bar ‘ica (ae), + ems eee nitalens) Progestin ated eres ime estoy Horace + Bons cece + insect + Osan + Mood charges + Pypetenson + Aon si + roan Anois efits may be nme by psc rman canting dese, neste, spre, cproiraeansat * saree trea vara Basing + Pre Croripenele exes Hrontoeolc dso (fecerV Leen nuttin pce Sree {efcony| acon Crortephetits + Corbet or conn any ease 1 fSuogen pena aus a sts) * Inyo vt eon ssosatd wih ante er dase + Congenital hyperighcteni + Sookeroge>5yers * Mae ere oven oe + Urecorediypatasion este Wigs rafal witha <1 hu * Diss compli by vast diese +38 * Cornea ypenensin + Herndon Set al aaria * Galle cease Drug natn + Rapin pects penn, a pian can crass fea iro od tack robot + Canepnespte OCP everclear + Neves ta dese OP har mas left butt may coreno mk profs, ttre do tots wt 6 ks tr Selected Examples of OCP Alesse” y #17 ug ting! estradiol and 05 mg lovonorgestet oO + low-dose therefore often a good starting OCP ‘Mize Comnad OCP ¢ also used to help acne and lo regulate menstrual cycles Mast + low-dose pills can often result in breaktinough bleeding; if this persists for longer than ‘pias son pate 3 months, patient should be switched to an OCP with higher estrogen content Tircyclen" oS #35 yg ethinyl estradiol and 0.180 / 0.215 0.250 mg norgestimate ez ee ear ce es + triphasic oral contiaceptive (21 days of active hormone, 7 days placebo; each 7 days the | "fue apy paten progesterone dose increases) Taree, 2s rt oy. « low androgenic activity can help with acne Th icy se 4 phasic OCs should not be used continuously re + Eckopmetedsl bh otal Yasmin” and Yaz" mune dag? doa + Yasmin® ~ 30 yg ethinyl estradiol + 3 mg drospirenone (a new progestin) ‘iss 2a rowing tied + Yar""~ 20 ug ethinyl estradiol +3 mg dospirenone ~24/ 4-day pill (day pill ree interval) | weekof he eye OR mis3 Brow + drospirenone has antimineralocorticoid activity and antiandrogenicelfects '* benefits ~ decreased perception of cyclic weight gain, bloating; decreased PMS symptoms; | * RC ek ee rear naan re ‘ea ‘check K if patient also on ACE inhibitor, ARB, Ksparing diuretic, heparin pgs TNC seri tnt Pope uy oct ede rn oo ae ara re \ Rese ee ee = fencers ieanercegne eer 7x meatecremnne, amen eae eee ooetecmeeeet cee; cee cena) sean a es Irae esgic clots pois nt il oat, choontined OCs conse Ses ‘ord to crbired OO ‘Rio eran ts Fevers cd espe he ‘ea oe OF ah re ‘any tine rear pss presetGY20 Gynecology Canadian Consens Gide a0 ‘Cntr nd Eteded Harman ‘ontaopton 207) Detar "banded Thee coins amoral canrocepbes we pes amare fee eae *ornnaus Ue Unease ot cartnesremoral comcast ‘teas homeo mae Wat nb vat? read only Snr earned noma cerca ng ose gray deed cue ea anni ars Gama anc exons CE) none. teary an Adbarance Cananne orbs formar eran rire or lt eye eins n rv egwrey Use UP erred Farmar canrocesbe maybe mae "Fag ated cote! amon caneacapes acu ‘he steece of homan os Fen Sots “Th oe elec polo CE canbe mona conracapie oir ot waren we fle eps and ayes beta Mata Nar cnr acptive Usage Ferworen nih prmorepus ‘retin who ne be onan CE ‘etter concep Deterostsnomanaienaconert fray clr otorate eigen wont sry heparan unmet) (osre 98 Types ot us ioe cong Now Fact Pages cotanny Mera (an bose fr 8 yas re oriy ‘sreied wth ranml ena alone roe ec Heep ee (gj ltt Dy as aie Ta Eenecon ign ro bgt ston ‘Sense coer BN Ee hn peseony sO str ‘New SOGERacuneendnon for Depo Provera Users Sf Me Aerie coca sie eoe ress a Insimsne marae ‘oar co +E pts of otal isk and ‘meet mae taupe ‘ause orate. + Reaend way prove bane aoe cum ven, git tery eres sag Chto detned wes roves sere «Tho isre erence tose xin hi eg Contraception “oranto Noes 2010 Selected Examples of Progestin-Only Methods Progestin-Only Pill (“minipill") + Micronor"™ 0.35 mg norethindrone ‘taken daily af same time of day (within 3 hours) to ensure reliable effect: no pil ree interval + higher failure rte (1.113% with typical use 051% with perfec use than other hormonal methods ‘ovulation inhibited in 60% of women, most have regular eycles Depo-Provera” + injectable depot medroxyprogesterone acetate + dose 150 mgIM qI2-Liwhs (convenient dosing) + initiate within 5 days of beginning of normal menses, immediately postpartum in breastfeeding and non-breastceding women + regula sping that regress complete menos in 70% of women ater 2 «highly ettectve 99%; faire rate 0.3% + side fect decreased bone density (may be reversible) + disadvantage restoration of feetlty may ake up to 1-2 years Intrauterine Device (IUD) ‘Table 5. 1UD Contraceptive Methods Means of Aeon ‘Sie Eos Cosine Capercortstng UO foweT™) > demersal ed ‘Absoae i gn ody acon + ating, acto (repetunre + Kron sip pga edoresiomioictospemand Mies") + Undapesed geil rating tes som wetty + hoa bed es angen + Acer crane PD + Fogstroeasng UO Mina") mrss oper UD oh) + Lyi Ss nts by cesasten of + Dysmerones copper WD ory) Know lrg xp exper LD a Grdarcronendisenrget + Bydean Shinde te yox uses + V's dsc ape UD er) arialmucas raysiass ——_listmanhandnnulpacus ware) vse + Use wal paste (/1000)- Relat + Heine 5.9 prague acs with an U0, Vath dase ‘ale me 2 ‘armada eco Pets of Pe 2eap pean Gonrsepie eset yeas + homssdik of PD wifi 10. + Peseta Feri pia, covet days alnsin ey Atri sr city tacainy May besa in were wh fas caarscatars O0Ps ot + See dames renege ‘ani ror crtaceptan (cope U0 cy + Cai sees + Frames india fo HD“Toronto Notes 2010, ContraceptionInentitity Emergency Postcoital Contraception (EPC) Table 6, Emergency Contraceptive Methods Gynecology GDL caro of Aon Conanone Fomor, * Dripoor:sopesions we: “Resisting ‘Yupe Matiod s Supressecwtanc regan athogh + Ue win 72 us cf unpaid nsonas:iedierc of ‘cast ud se roti) bitte dys ‘+ NMoyaluradrcoumie + endo petig + Caton wenn Ou 2 ashen pesto 2s (ates pret place th catrseeatns pleas 50,0) + Maya spore wanepat To O0P tho NO + Can sisi wth any OC slong as Sane ose cess usd eave * Poovey fontardeatrs) + Bz coonasa whee gest fc at 72s thn 24 fas] ran + Casio inept gDh or 2 doses (os ake 7dses ‘apr oan wih Ts ef mee + Grn cary 25 $56 wed wih 24) ar bar ste et pte han Yep mad bt ay daa wire + Neste bs Yay ov cana ets (as asa ‘Now-oRbOWAL Pesca 1 (Capper Soles + SooTies + S07 ‘ea upt07 das pcos + Proves rata 2 1¥bluerate * Uva comida precatns UD * Gane shor tin inher kin vis 1 Nien rot tesa PC Follow-up we '=344 weoks post treatment to confirm efficacy (confirmed by spontaneous menses oF pregnancy test) ‘Contraception counseling Te jity Epidemiology = 10-15% of couples + on average 751% of couples achieve pregnancy within 6 months, 85% within 1 year, 90% within 2 years ‘+ must investigate both members of couple Female Factors Etiolosy + ovulttory dysfunction 15-20%) * hypothalamic (hypothalamic amenonthe) + piety + prolatinoma ocag kaon Pos 5 premature ovarian falure + Tica phase detet (poor follicle production, premature corpus teu faire fle tein ining response to progesterone), poor understood + systemic diseases (thy Coshing’s syndrome, renal hepa faitre) + Cngenltal Cues syndrome, gonadal dysgenesis or gonadoinopin deficiency) + Stress, poor nutrition excessive exerise (even with presence of menstruation + outilow tact sbnormality tubs factor (20012) * bib + adhesions (previous anger, peritonitis endometriosis) + Tgstion/ctlusion (ex Previous etopi) + uterine actors 58), + congenital anomalies (eg prenatal DES exposure) bicomuate wer, uterine + inlnsterine adhesion (eg. Asherman's syndrome) + infection (endometrit, pelvic TB) 5 bros) polyps (particfaryinreuterine) 5 endomettal ston ‘yO can da FC; 100) hes PO gh Zane Ine iy concie or cay tate eran ne ef ego, poeted macouse mary fri: ney te coma of we per e Secon nteri ety nthe oat fa pcr ceecepionGYR Gynecology Inet “Toronto Notes 2010 + cervical factors (5%) hase or ace cervical mucus 5 apr anti heap) + Structural defects cone biopsies, laser, or exyotherapy) + endometrios = pone 1 multiple factors (20%) 1 tinknown factors (015%) ay a Investigations Wen shoutinvestgaons wean? | * ovulatory S738 yu: yor oe To Day 3 FSH, LH, TSH, PRL + DHEA, frve testosterone (if hirsute} ‘once + Day 21-23 serum progesterone to confiem ovulation Se yeae ater >6 manne * initiate basal body temperature monitoring (biphasic pattern) Zire emetoy * posteoital test ~ evaluate mucus for clarity, pl, spinnbarkeit (rarely done) + tubal factors Aer wean 1S ane pean atone) on 1 Esrscopy with de nalation SSESSEEEOWENE| « perincialnactds fast ot FBS hysenopy ee wear + Moderne save eametils * karyotype Tresimet Sea * non nun + Smutty gndorpin MG (pea ution FS Meee ee “+ bromocriptine (dopamine agonist) if increased hyperprolactinemia seer goa Srouiippicay mean ROS RS IIE Ee tan ya pe dt + sip = iain eect isle Male Factors ~y » + sce Usology, U35 ‘rm a ase (Wi rts) iol Mitetieaiaeedste ezztons | ENO'SY os) ata J opauie 6205) tert Zines ¢ obstruction (15%) Atay 80. mardpegesin | * cryptorchidism (-8%) ‘ Mepoy =208 era + immunologic (3%) 5 Ronee al yon omvsonsy ortin Investigations No:desretasessspemionioe | * semen analysis and culture «+ post-coital (Hubner) test“Toronto Notes 2010 Polycystic Ovarian Syndrome Gynecology GY n Syndrome (PCOS) or «+ also called chronic ovarian andragenism Etiology ral y + esrogan > Fsezetn + seatte0 —> Anondton ‘aisha conesona eager oafan seen fogs gamenoes oP a ‘tans ney Figure 9. Pathophysiology of Polycystic Ovarian Syndramo Diagnosis OF 3 to make diagnosis 1. oligomenorrhea/ irregular menses for 6 months 2 clinical or lab evidence of hyperandrogenism 3. polycystic ovaries on U/5 Clinical Feature * average age 15-35 years + anovulation, hirsutism, infertility obesity virilization + acanthosis nigricans: browning of skin folds in intrtriginous zones: + family history of diabetes + insulin resistance in both lean and obese patients Investigations 1 puupoot isto deny hyperandrogonism or chronic anovulaion and ule out specie Pitan or adrenal dicen a the cause + bis Q * prolactin, 17-hydroxyprogesterone, fee testosterone, DHEAS, TSH, androstenedione [<———————} CHEFSH 22:1; LH is chronically high with FSH midrange or low (low sensitivity and | Pulveystic Ovarian Syndrome — Speciicty) wna increased DHEAS, androstenedione and ce testosterone (most sensitiv test, ee ee docrened SHBG eae a ae + transvaginal ultrasound plyeystic appearing varies (string of pears”) + tests for insulin eotance or glucose tolerenoe fasting glucose: insulin aio 1. is consistent with inulin resistance (US. units) 3g OCT (particularly if obese) + laparoscopy not required for diagnosis ype 2 meron + most common to set white, smooth, sclerotic ovary with a thick capsule ‘acre! + mulliple follicular eysts in various stages of atresia + eg eee + hyperplastic theca and stroma + Den seers + rule out ether causes of abnormal bleeding pres + tro Treatment +'Sycle conteol * lifestyle modification (decrease BMI, increase exercise) lo decrease peripheral estrone formation + OCP monthly or cyclic Provera" to prevent endometrial hyperplasia du to unopposed estrogen + oral hypoglyeemic (metformin 500 mg PO td, rosiglitazone, pioglitazone) we ttanexannie acid (Cykfokapron™) for menorthagia only a + infenitity (ong Tom te Googe Frcs fac? esd sca cree Nana ae aoe sgonadotropins {YMG (Pengonal")] LHRH, recombinant F5H1 and metformin 1 ANT dete aan “metformin may be used alone oF in conjuction with clomiphene citrate for + remeris nersto jwulaton induction ‘lett * ovarian drilling (perforate the stroma), wedge resection of the ovary 1 sty + bromocriptine ithyperprolactinemia) ee + hirsutism ‘any OCP can be used Diane 35” (cyproterone acetate) -antiandrogenic ‘Yasmin (drospirenone and ethinyl estradiol) ~ spironolactone analogue (inhibits steroid receptors} + mechanical removal of hair * finasteride (-alpha reductase inhibitor) * flutamide (androgen reuptake inhibitor)GYM Gynecology ‘Gynecological Infections Toronto Notes 2010, faea Gynecological Infections Vsvvepais ive ara ination yy cot Tes pee ee Fete teers ongea wv a ‘Thais mihi ones ston nt tna erg Cardi and pancho teres iit orate cet Physiologic Discharge + oar, white, locculent edourless discharge smear contains epithelial cells, Lactobcil pH3s-42 + Increases with increased estrogen states: pregnancy, OCP, mid-cycle, PCOS or premenarchat + ifinereaced in perimenopausal / postmenopausal woman, consider investigation for other ‘effects of excess estrogen (eg, endometrial cancer) Vulvovaginitis PREPUBERTAL VULVOVAGINITIS + dlinical features ulvar erythema + vaginal bleeding (specifically due to Group A Streptococ’ and Shigella) + differential diagnosis * nonspecific vulvovaginitis (25-75%) * Infections (respiratory, enteric, systemic, sexual * forcign body (toilet paper most common) * candida (only if in diapers) + pimworms| + polyps, timour (ovarian malignancy) acquired) ‘vulvar skin diseaze (lichen sclerosis, condyloma acuminata) trauma (accidental straddle injury, sexual abuse) psychosomatic vaginal complaints (specific for vaginal discharge) Endocrine abnormalities (specific for vaginal bleeding) * blood dyscrasia (specifi for vaginal bleeding) + etiology ‘infectious: * poor hy + proximity of vagina to anus 4 Fecent infection (respiratory, enteric, systemic) + ST] investigate sexual abuse * nonspecific * ack of protective hair an labial fat pads # lack af estrogenization + susceptible to chemicals, soaps (bubble baths), medications and clothing gations ginal swab for culture (specifically state that it isa pre-pubertal specimen) «+ treatment ‘enhanced hygiene and local measures (handwashing, white cotton underwear, no nylon tights, no tight fitting clothes, no sleeper pajamas; sitz baths, avoid bubble baths; use mild detergent, eliminate fabric softener; avoid prolonged exposure to ‘wet bathing suits urination with legs spread apart) + AD" dermatological ointment to protect vulvar skin * infectious! treat with antibiotics for organism identified Table 7. Other Common Causes of Vlvovaginits in Prepubertal Girls Fawoms Uke Sloss Fig Body Dagpods —CalephareTopatest Awa cf whe pacts an ing sin Tepid strc ears igaten aga ith sa, may onto Ia anastca ada rare aaa POSTMENOPAUSAL VAGINITIS/ATROPHIC VAGINITIS + elinical features * dyspareunia + postcoital spotting + mild pruritus + investigations * diagnosis of atrophy is usually a visual one ~ thinning of tissues, erythema, petechiae, bleeding points, dryness + rule out malignancy ~ especially endometrial cancer“Toronto Notes 2000 + treatment ‘Gynecological lfetions Gynecology GNIS * Iocal estrogen replacement (ideal) ~ Premarin® cream, VagiFem® tablets, or Estring® * oral or transdermal hormone replacement therapy (if treatment for systemic symptoms Is desired) * good hygiene INFECTIOUS VULVOVAGINITIS Table 8. Infectious Vulvovaninitis Cosi Mona) ‘ar ais (Ganda tr | <9 Canfas 1 year duration * benzathine penicillin G 24 million units IM qlwk x 3 weeks «+ treatment of neurosyphilis ‘= IV aqucous penicillin G 3-4 million units IM qfh for 10-14 days * high risk groups + in pregnancy Complications + ifuntreated, 1/3 will experience late complications“Toronto Notes 2010, ‘Gynecological Infections Gynecology GNIS Bartholinitis/Bartholin Gland Abscess Etiology * offen anaerobic and polymicrobial © U urealyticun, N. gomorreae, C. trachomatis, Ecol, P. miei, Streptococcus, S. aureus eaze) * blockage of duct Clinical Features * unilateral swelling and pain in lower lateral opening of vagina « sithing and walking may become difficult Treatment. site baths * antibiotics + incision and drainage using local anesthesia with placement of Word catheter (10 Fe latex catheter) for 23 weeks ‘+ marsupialization under general anesthetic - more definitive twatment « rarely treated by removing gland Pelvic Inflammatory Disease (PID) + up to 20% ofall gynccology-rclated hospital admissions Etiology rere i er el int + courte organisms (in order of equency) ern Yar gt ct TC tnclonas eGo CN goer peace eee 1 fosbutice an chlamydia often coexist 1 Eilpgenous fore “anscrebie sce o both D #°E- coli, Stapylacass, Steptocucus, Enterococcus, Bacteroides, eplosteepcoscus, HE flu, G. ginal [Qraneumaase] + cause of recurrent PID apt ation + associated with instrumentation, Actinonyees inact (Gram-positive, non acic-fast anaerobe) ‘Fin 1-4 of PID associated with [UDs + others (TB, Gram-negatives, CMV, UL wreugticum, ete) Risk Factors age <3 years + fe factors as for chlamydia and gonorshea # Saginal douching, TUB (within frst 10 days post insertion) + invasive gynecologie procedures (D&C, endometrial biopsy) Clinical Present + up to 2/3 asymptomatic ~ many subtle or mild symptoms * fever =38.9°C * Tower abclominal pain and tenderness * abnormal discharge cervical or vaginal ‘nausea and vomiting = dysuria = AUB + chronic disease (often due to chlamydia) * constant pelvie pain = dyspareunia = palpable mass + very dificult to treat, may require surgery ule se i, pi aber ‘ahr as on Investigations ‘ciramval mm = bloodwore tS beta-ACG (must rae out eetopie), CBC, blood eure if suspect septicemia TEE oo po + urine REM ‘one * speculum exam * vaginal swab * Gramstain + cervical cultures for N. sonore, C. trachomatis += endometrial biopsy will give definitive diagnosis (rarely done)GY50 Gynecology Trex PD wih Foxy oe" (esloatn + dayovene) Qo == Dsomraed ac pas, cen ri meg Tone Sac Synirome Nati ope syste atue dt ‘Seis eeu fe eon. ‘Gynecological Infections “Toronto Notes 2010 + ultrasound * may be normal * Mluid in cul-de-sac + pelvic or tubo-ovarian abscess + hydrosalpinx «+ laparoscopy (gold standard) * for definitive diagnosis ~ may miss subtle inflammation of tubes or endometrtis Trestment Must ea th polymicrobial coverage ‘Inpatient ie + style infsction + tdteval aay uborovaian, or pelvic bcos moderate fo sever ess Unable to aerate ral antibiotic or fl ral therapy inmunocompromisd repent Eaalscent first pide + Sagi emergency cannot bo excluded + MBisscconday to isrumentaton + rsomended etent «colon 2g Vol (no longer availble in US.A) or cnottan 2g 1V ql2h + dlonyeyclne 100mg Iv /PO gah or « Sinden 990 mp. qth | gentamicin 2 mg 1V Tong dove then pentomicin L5 mg gdh maintenance dose « Eontinue IV anit or 2 hour afer symptoms have improved then dknyaptine 100 mg 0 bid to omplete adage « porcanens dratinge of absurd Us guidance + Glen no weapons oot lparecopic rsinage 5 itil, tetoent is surge (alpngecomy, TAHT BSO) + outpatient i pial ndings + Pld to modeate nes + Ort anontstolerted compliance ensure + follow-up within 1-72 hours (lo ensue symptoms not worsening) + recouagnded eatent *ollonain 400 my PO bid x 14d or fvollonacin 500 mg PO bid x Had & Snatoniaecle A mg PO tid 1a spect acess) « Sinmone 250 mgt xs doxyeysine It mg PO Bx Hor cfoiin 2g Ins 1s probenield I PO pls donyeline 10mg PO ba 2 mcronidale SoomgrO wid id « consider removing [UD alter a minimum of 24 hours of treatment + reportable ascase + tat partners + Conair racoening for C. racomats and. gorse 4-6 weeks after treatment document inetion Complications of Untreated PID ‘donc pelvic pain «abscess, peritonitis * lhesion formation + ectopic pregnancy + infertility * Lepisode of PID + 13% infertility + 2 episodes of PID ~ 36% infertility + bacteremia + septic artitis, endocarditis Toxic Shock Syndrome + se Inestious Diseases, 1D26 Risk Factors = mpon use «diaphragm, corvcal cap or sponge use (prolonged use, + swound infections * post-partum infections ‘+ Carly zecognition and treatment of syndrome is imperative as incorrect diagnosis can be fatal 224 hours)‘Toronto Notes 2010, Gynecological Infections Sexuality and Sexual Dysfunction Gynecology GIST Clinical Presentation * sudden high fever + sore throat, headache, diarshea * exythroderma * signs of multisystem failure * refractory hypotension * exfoliation of palmar and plantar surfaces of the hands and feet 1-2 weeks after onset of ines Treatment + remove potential sources of infection (foreign objects and wound debris) * debride necrotic iste + adequate hydration + penikillinase-resistant antibiotics eg. cloxacillin + Steroid use controversial but if started within 72 hours, may reduce severity of symptoms and duration of fever Surgical Infections Post Operative Infections in Gynecological Surgery + pelvic ellis ‘common post hysterectomy, affects vaginal vault * erythema, induration, tenderness, discharge involving vaginal cuff * treat if fever and leukocytosis with broad spectrum antibiotics, Le. clindamycin and gentamicin + diain if excessive purulence or large mass + can result in intra-abdominal and pelvic abscess + see General Surgery, Post-Operatie Fever, GS7 Cram Pel SEXUAL RESPONSE I.dsite~energy that allows an individual to inate or respond to sexual stimulation 2Lousal~ physical and emotional stimulation leading to breast and genial vasollation And tor gorge ‘ ; 5.ongasm™ physical and emotional stimulation i maximized allowing the individual to relinquish their sense of contra 4. resolution = most of te congestion and tension resolves within seconds complete rolution may take up co 60 minutes ‘SEXUAL DYSFUNCTION, ology * intrapsychic patients life experiences, vale system + relationship interpersonal issues * physeal/organie Cee dont wen nis to doso vaeny . ” P vegnismus Fear af pain + dysparcunia (3-64) ~ painful intercourse; superficial (pain with entry) or deep (pain with th itorcourse sopranos) cane ai witout seal + PID respons Treatment # lack of desire ~ asses factor, «Jo onganic causes relationship therapy, sensate focus exercises + anorgasmia ~ seltexploration/ plessuring, couple therapy if needed, bridging techniques (Gilferent sexual positions clitoral stimulation during intercourse)GYS2 Gynecology Po. 7 Nagel Erin apis cechirg rd cling ‘Stuer msl averse Kae "east enetin he soso ot raion or oy Menopaute: sure oat ‘porenens ners ped, Fesleg om a of ori reso Tessofcenresmseto berscoroah meres + Perinenpause: erode ee orang mere (28 ys Procetng 1 yates rene) lel reper manana eae and sree rt wy + 89. wonen xpress + roa wanescal acon {arora ay eager th sng ott pen Peat se sects + Cnidaria the lng cause of eth pst maopase Pattopsllogy Degraraig esa ofa a ett enigeais aaeeprs er oaap era Dacesed rea fedtck on pete poy tend se reread FSH nd Li angers a est of esc Sevuality and Seal Dysfunction Menopause “Toronto Notes 2010 + dyspareunia * Kegel and reverse Kegel exercises * dilator treatment * comfort with seléexam * psychotherapy, other behavioural techniques + female on top position ~ allows for control of speed and duration * vestibulitis remove local irritants, change in contracuptive methods, and dietary changes (increased citrate, decreased oxalate), vestibulectomy (rare) + vulvodynia — local moisturization, cold compresses, systemic nerve blocking therapy (amitriptyline, neurontin), topical anosthetic, estrogen cream Menopause + see Eamily Medicine FMS9 Definitions, types of menopause * physiological average age St years (ollicular atresia) + premature ovarian failure; before age 40 (autoimmune disorder, infection, Turner's Syndimme) + istingenic (surgical radiation chemotherapy) Clinical Features «associated with estrogen deficiency ‘vasomotor instability (tends to dissipate with time) ‘hot fushes/Aashes, night sweats, sleep disturbances, formication, nausea, palpitations + urogenital atrophy involving vagina, urethra, bladder * dyspareunia, vaginal itching, vaginal deyness, bleeding, urinary frequency, lurgency, incontinence + skeletal * osteoporosis, joint and muscle pain, back pain + skin and soft tissue ‘decreased breast size, skin thinning loss of elasticity + psychological ‘+ mood disturbance, iritabilty, fatigue, decreased libido, memory loss Investigations + increased levels of FSH (235 IU/L) on day 3 of cycle (i still eyeing) and LH (FSH>LH) + dcreased levels of estradiol (later) Treatment + goal is for individual symptom management * vasomotor instal ‘+ HRT (first line), clonidine, SSRI, Etfexor*, gabapentin, propanolol * vaginal atrophy * local estrogen ~ cream (Premarin*)/ vaginal suppository (VagiFem®)/ring, form (Estring®) + lubricants (Replens®) + osteoporosi ‘1000-1500 mg calcium daily, 800-1000 TU vitamin D, weight-bearing exercise, quit smoking +s bisphosphonates (eg, alendronate) + selective estrogen receptor modifiers GERMS): raloifene (Evista) — mimics estrogen effects on bone, avoids estrogen-like action on breast and uterine tancers does not help hot flashes ‘+ HRT second-line treatment (unless for vasomotor instability as well) * decreased libida * vaginal lubrication, counseling, androgen replacement (testosterone cream) * cardiovascular disease ‘+ management of cardiovascular risk factons + alternative choices (not evidence-based) ‘black cohosh, phytoestrogens, St. John’s wort, gingko biloba, valerian, evening primrose ei, ginseng, Don Quai + wellbeing * physical exercise, relaxation, yoga“Toronto Notes 2010, Menopause Hormone Replacement Therapy (HRT) + sce Family Medicine, FM39 + for HRT regimens, see Table 9 + primary indication is treatment of menopausal symptoms (vasomotor instability) + Keep doses low fexg.0.3 mg Premarin®) and duration of treatment short (<5 years) HRT Components + estrogen * oral or transdermal (eg. patch gel) * transdermal preferred for women with hypertriglyceridemia or impaired hepatic function + Low-dose (eg. 0.3 mg Premari + progestin * given in combination with estrogen for women with an intact uterus to prevent development of endometrial hyperplasia cancer 25 ug Estradot® patch) Table 9. Examples of HRT FR Regimen Esogen Dove Prgesin Dose Nate ‘noppsedEstogen CEEGEZSgPOO0 WA Trois Standard oe EEQEISmgPOOD —NPAZSmqPOOD —Witavalbeirg osasina sary, rpc rarer ay abs 68 murs det ead ty (hes pes has besae anororee on HR, siifart ssn Hood pies eto ‘aie ona igs) Standards ete CEEQEZS mg FOOD —NPAS-OmaPO Bldg ccs moni ater ay 14 of poesin ys -14ony——_omcrtue tr yas) PS he semis ost fares Rid onto, ce, mero rier wey HT Pate CEEas2SmqPOOD —WEAewaese days Saye Transom Fordam*Stadol © Emedam® MPA Uo pach ice way Oey orG mgt 25myPDOD Cans ov opens (std) EsaleBsiado™ Esa MEA Cantre paches mali ea) Oppo zO ut Sum {iE omatteeeemogreg ere) NPR rao ong ae 1ER = weaken ane ior ue ds hs EURO“ 08 Pana gin Pes Srey sen a Sa) Side Effects of HRT * abnormal wlerine bleeding astodynia + edema, bloating, heartburn, nausea + mood changes (progesterone) + can be worse in progesterone phase of combined therapy Contr abeclute * acute liver disease 2 Undiagnosed vaginal Moding + known or suspected uterine cancer /breast cancer + acute vascular thrombosis or history of severe ombophlcbits or thromboembolic disease + rolative > preexisting uncontrolled hypertension 2 Glerine fibroids and endometriosis + famlithypelipidemias + migraine headaches + family history of ettogen-dependent cancer ‘ations to HRT chronic thrombophlebitis Aiabotcs mellitus (with vascular disease) gallbladder disease, hypertsiglycoridemia, impaired liver function (consider transdermal estrogen) + fibrocystic disease ofthe breasts Gynecology GY @ ‘Asse Comrinontons to HT co fevers ‘sopra egret ning {nc ovasares) ‘UT rareoorbcte dase ‘xcept rom the SGC 2006 Manapae Carensis Report Theater reeanfor AT ere sranapanen of moteteta svee meepaal rer HT chs sce a he owes eve dose {ere operate dion waciove ‘este oaGAH Gynecology Oy be Raaxaton Pls Fromean tp eee ret {tte edo “MenopauselUrogynecology “Toronto Notes 010 WOMEN'S HEALTH INITIATIVE (WHI) (launched in 1991) + to nonrandomized studies investigating health risks and benefits of hormone therapy’ Incalthypostrnopousa women 379 year ofthe WHT Exelon Study volving follow-up health tracking without intervention, fs due to last through 2010, * comiauous combined HRT (CEE 0.625 mg + MPA 2.5 mg OD) in 16,608 women with an intact uterus * originally designed to run 85 years - stopped early after 5.2,years july 2002) because the evidence for harm (breast cancer, CHD, stroke, PE) outweighed benefit fracture reduction, colon cancer reduction} + eatgn alone (CEE 025m) In 14739 women witha previous hysterttamy ‘also stopped carly (February 204 instead of March 2005) because of increased Stroke rsk and no heat disease benefit * benefits and risks reported as # cases per 10,000 women each year HRT Benefits + protective against osteoporotie fractures (recommended as 2nd line treatment only) * hip fractures ~ 53 fewer cases with combined HIRT (6 fewer cases with estrogen-alone) + all fractures 47 fewer cases with combined HRT + colon cancer ~6 fewer eases with combined HRT (I additional case with estrogen atone) HRT Risks + Invasive breast cancer ~ 8 adltional cases with combined HRT * risk comparable to belng 20% overweight acking regular exercise, fever pregnancies after 30 years of ae, reduced breasticeding excessive alcohol oF Sigarete use + NO increased risk with estrogen alone (7 fewer cases) + coronary heart disease ~7 addtional Mis with combined HRT * no significant diference in cardiac deaths between treatment and conto! soups + NO elevated heart risks if sed right afer menopause (18.55 years of age) oF with esttogemalone (fever cass) + DVIS or PEs” 18 additional cases with combined HRT + 9 additional cases for women taking estrogen alone + stroke-~B additional eases with combined HRT (not statistically sigaifcant) * 12adaltional cases with estrogen alone + dementia and mld cognitive impalement (WHI Memory Score) * women taking estrogen-alone before 65 years af ae were less likely to develo dementia, hawever there was 250% neteased risk of developing dementia when taken after 5 years of age those taking combined HIRT were at even grcater risk) + "window of opportunity” hypothesis eaey use of estrogen fefore pre-dementia changes) protects the healthy bran in older women, where changes have already Joegun, use of estrogen aeceerates the dementia pracess + there were na significant differences in overall morta oF cause of death between treatment and placebo groups LOT eye tered tele he Pelvic Relaxation/Prolapse Etiology + relaxation, weak, or defect in th carnal and utorosacral ligaments which normal thaintan the werusin an antelleved! position and prevent i from descending through the Urogenital diaphragm (ce. levator ant muscles) + related to + vaginal chiabieh aing {decreased estrogen (post menops following pele surgery increased intra-abdominal pressure (obesity chronic cough, constipation, asctes, heavy Titting) + congenital (aely) + etinclty (white women > Asian or black women) + collagen disorders GENERAL CONSERVATIVE TREATMENT {foe Pelvic Relaxation /Prolapse and Urinary Incontinence) Kegel exercises * focal vaginal estrogen therapy” * vaginal pesary“Toronto Notes 2010, Urogynecology Table 10. Pelvic Prolapse ka Fires oo ‘ine Prapse Gonteak pan Shetding dT uscsaael + So Gol Crsonatre Tosa GH (Prion of gress Serge Ceniand done» Fel oeavineceprsarein the pais = ap ecm) eget st pis imo sre) * We wi sang ing * Const aon sui ocedes fray ‘Mort atts el day incnrace, esl ecto andro ae ae by own ese * Ueber pars pons + urna neon ak Prolapse + Se Gener Caseive Testa, G3 (Proton ape, Serge fear a * sosakelpny hag vas pasion) sexespaus mower, fone test sensor pesetystuceom) Cytocde ——* Frame gan mca + S00 ovr Case Tostan, O13 (Prnson f+ Sess renrneren Sarge Uterine + earl Beer epg esses» Atri cpntpy an eps) rt peal reread vine f wary tations + Cont adn nomatve Supe pcx wa) led od irparre seared nay sess icotrrce Receesle = Sranegignbonia aie soo! So Gas Crsnntve Fenen GoK (Prin et + Garstgaton {hc sabes nf el ere ‘osu xo ‘Surgical besieged + Post cobain bos pi" eon of wal) sdspli asa td ped muses apps in ribo spp cir ard prin ear lt spare) manele ‘Sil (Prag smal 1 Shiro onan Counts wad, eck of pres at, vaca sor etl al) gene dat a mls spot Sacrum: Utero-sacal Small ligaments intestine Uteus Rectum Bladder Vaginal Canal Urethra Rectocele Figur 10. Pelvic Prolapse Gynecology GY 11 teoenebetwean ara Fostenatichal pes +2 tesa baton stops seaymer 182 eset yen 15 bocce ee * Petits aie of ‘pats nd complete pros ot ens rash ape They ve nl ofthe pl an ENTEROCAE texas itrGY36 Gynecology or ‘rere st fur wth iene ‘neva penn esa Taupin secre wang nee ‘he ul stance cago est shar neanrercesraoans Weems. lage pepe as a corey ares om nals aoe obo inate des. a at 6 1102 ge icone Ure aa essed wth an bg, sion ‘ste Ot Anything Herlical {er Uge ncontrmnes IMstie sss Datets mats Liomanatarineis eg sath msc ar the ers mest common ayes ‘ur Urtogynecology/Gyneclogcal Oncology Toronto Notes 2010 Urinary Incontinence + sou Urology, ‘STRESS INCONTINENCE Risk Factors for Stress Incor + pelvic prolapse * pelvic suegery + Vaginal delivery \ypodstrogenic slate (post-menopause) age + Smoking. + neurological/pulmonary disease Treatment mera C wervutive Treatment, C * tension-free vaginal tape (TVT), tension-free obturator tape (TOT), prosthetie/fascal slings or retropubic bladder suspension (Burch or Marshall-Marchett-Krante procedures) URGE INCONTINENCE Defini * urine lass associated with an abrupt, sudden urge to void * Yoveractve bladder * dingnosed based on symptoms Etiology lopathic (076) + detrusor muscle overactivity ("detrusor instability") Associated Symptoms + froquency, urgency, nocturia, leakage Treatment + behaviour modification (reduce cafoine liquid, smoking cessation, regular voiding schedule) * Kegel exercises + medications * anticholinergics -oxybutinin (Ditropan”),tolterodine (Detrol") * trcyelic antidepressants ~ imipramine Gynecological Oncology Uterus LEIOMYOMATA (FIBROIDS) Epidemiology diagnosed in approximately 40-50% of reproductive age women + more common, larger, and occur at ealier age in black women + common indication for major surgery in females snant potential (1:1000) * typically regress after menopause; enlarging fibroids in 9 post-menopassal woman should prompt consideration of malignancy. Pathogenesis ‘estrogen stimulates monoclonal smooth muscle proliferation; progesterone stimulates production of proteins that inhibit apoptosis + degenerative changes (occur when tumour ou grows blood supply) erative change) * efstic degeneration (from breakdown of hyaline) red /carneous degeneration (hemorrhage into tumour, may occur with fibro pregnancy + fatty degenc * calcification + sarcomatous degeneration (rare) * parasitic myoma — tumour becomes attached to another ongan (ypically omentum ‘small bowel mesentery), develops new blood supply, and lases connection to uteras ion‘Toronto Notes 2010, ‘Gynecological Oncology Gynecology G57 Clinical Features ‘+ majority asymptomatic (60), often discovered a5 incidental finding on pelvic exam or US. + Sbnormal uterine bleeding (30%) * dysmenorrhea * menorthagia + prossure/ bulk symptoms (20-50%) * pelvic pressure/heaviness Increased abdominal girth urinary frequeney and urgency: * acute urinary retention (rare but surgical emergency!) + constipation, bloating (rare) + acute pelvie pain if * fibroid degeneration * fibroid torsion (pedunculated subserosal) + infertility (submucosal) + pregnancy complications (potential enlargement and increased pain, Obstructed labour, difficult C-section) + recurrent pregnancy loss Investigations + bimanual exam — uterus asymmetrically enlarged, usually mobile + CBC —anemis * ultrasound ~ assess location of fibroids to facilitate treatment if symptomatic Figure 11. Possible Anatomic Locations of Uterine « sonohysterogram — useful for differentiating endometrial polyps from {elarnyernata pubmitcosal fibroids ay «+ Sndometral biopsy to rule out ulerine cancer if abnormal uterine bleeding especially (9) age 40 years Submocosalicryorstaae ost + occasionally MRIs used for pre-op planning ‘roomed ein Treatment nly i symptomatic, rapily enlarging, or menorthagia wy eal anomie present so $ conservative approach (watch and wait) if ieee * symptom absent or minimal ‘crotootra ap > to 2 flbrods <8 cm or sable in size ‘oneal rue once 5 not submucosal (re. submucosa fibroids ae more likely tobe symptomatic) + medical approach + antiprostaglandins Gbuprofen) + tranesamie aid (Cyklokapron®) 2 OCP Depo-Provera® * Gh agonist leuprolide (Lupron), or androgen derivative danazol {Danocrine”); short-term use only (6 moni); often ased premyomectonyy ot Dre-hyslerecomy to lalate sungery (reduces fibroid size) + elective progesterone receptor modulators current in clinica trials prototype is IRUt6 whic reduces fibrond volume by 50% after 3 months without side effet of GinRH agonists + interventional taiology approach 7 terine artery embollzstion ocludes both uterine arteries shrinks fibroids by 5% at # months, improves menorthagia in 97% of patients within 12 months (not an option in women considering childbearing) oer emecmy Oye transabdominal or ) ildbeating capabilites Famer spp + endometrial section of froid and endometial ablation for menorthagia 1 hysterectomy (abdominal, vaginal, or laparoscopic depending on flbrosd size) = note ~avold operating on flroide during pregnancy uc to + vasculaity and Potential pregrancy lve), expectant management usally est ENDOMETRIAL CARCINOMA Epidemiology ‘'most common gynecological malignancy in North America (40%); 4th most common + 2.38) of wemen develop endometsial carcinoma in ifetime + mean age is 60 years { majority are diagnosed in early stage due to detection of symptoms + 85.90% Suyenr survival for stage | disease * overall 5:jear survival for all stages is 70-80% Classification * Type I~ endometricid adenocarcinoma (-80% of eases) *# Type I~ serous, clear cell carcinomas (~13% of cases)Thos Pie ‘rt es etnen pi te ‘ae tos tel th ‘Seni cores np une ‘Bove tha ple ot Gynecological Oncology “oranto Noes 2010 Risk Factors + Type I excess estrogen (estrogen unopposed by progesterone) obesity PCOS! ‘unbalanced HRT (balanced HRT is actually protective!) nulliparity late menopause estrogen- producing ovarian tumours (eg. granulosa cell tumours) HNPCC (hereditary non-polyposis colorectal cancer)/Lynch Il syndrome * tamoxifen + Type Il — not estrogen related * possibly tamoniten Clinical Features ‘Type [- postmenopausal bleeding in majority, abnormal uterine bleeding in majority of| alfected pre-menopausal women (menorthagia, intermenstrual bleeding) ‘+ Type Ilmay not present with Bloeding in eariy stage, more likely to present with advanced stage disease with symptoms like ovarian cancer (ke. bloating, bowel ddysfunction, pelvic pressure) ‘Table 1. FIGO Staging of Endometial Cancer ape Deon Tape Don 2 Grote Oss anand od vrs te Sutter odes a 1 igutneasoese des ear 8 ‘mvades throagh < one hat af myometriam Pietteets Cina > elt etmyrenan eens 1 Seton chert ¥ halen ask NB Distant metastases, incuding metastasis to intra abdoenind Accel garde meena 8 Cova sone sen ls ete th pat aearrguel satiny eras vaghepei ses or aie) Ta oni mend Grey OS Investigations ‘office endometrial biopsy + D&C = hysteroscopy Spread ‘most common is direct extension + Iymphatic spread to pelvic and para-aortic nodes 4 transtubal dissemination to peritoneal cavity + hematogenous spread (usally to hangs, liver) Treatment «Sarge: hysterectomy /B50 and pelvic washings + pelvic and para-aortic node dissection * gl: ditgnoss staging treatment, defining optimal adjuvant rstment {aparoscopie approach associated with improved quality of life Coptimal for most patient) + adjuvant radoherapy (for improved local contol inpatients at rsk or lea recurrence) 4nd adjuvant chemotherapy’ in patent at sick for distant recurrence or with metastatic dtbene) eon presence of poor prognostic i kine pathol (Ge: aggresive histology, depth Gf myometrial invasion, tamour grade, lymphatic involvement other metastases) + chemotherapy often used for recurrent ciscas (especially if high grade o aggressive histology) + hormonal therapy progestins canbe use or recurent disease (especialy if lowe grade) UTERINE SARCOMA «rare —2-6% of all uterine malignancies ‘arise from stromal components (endometrial stroma, mesenchymal or myometrial tissues) ‘ behave more aggressively and are associated with poorer prognosis than endometrial carcinoma; 5-year survival - 35% + vaginal bleeding is most common presenting symptom 1. Mixed Millerian Mesodermal Tumour (Carcinosarcoma) «most common type ofaterine sarcoma (43%) Poth pial aaron migra clement are rset + both components may arse from a common progenior cell thats capable of multiineage diferntiton pers ° s + tend to form bulky polypold mastes that often il the uterine cavity and extend into or through the endocervical canal ~ offen have extrauterine dleave at presentation“Toronto Notes 2010, ‘Gynecological Oncology Gynecology GY Treatment + usually treated as “very high grade endometrial carcinoma” since behaviour same Ge. surgical staging, adjuvant chemotherapy and radiation) 2. Leiomyosarcoma * account for one third of uterine sarcomas + when occurs, often coexists with benign leiomyomata (fibroids) we + 50% of time lefomyosarcomata arise within a fibroid ("sarcomatous degeneration”) werage age of presentation is 5 years but may present premenopause + histologic distinction from leiomyoma * ineteased mitotic count (10 mitoses/ 10 high power fields) + cellular atypia + often diagnosed postoperatively after uterus removed for presumed fibroids ei ean utans, pci 8 pastmenepasal wren seu broretcensdeatin ot rarosacona Clinical Features * enlarging fibroids in a postmenopausal woman + “rapidiy” enlarging flbroids in a pre-menopausal woman (unfortunately, no good standard definition exists for “rapidly”) Treatment + hysterectomy/ B50 usually without node dissection due to high propensity for vascular spread (ie liver/ung metastases) + Sujuvant chemotherapy may be used if tumour spread beyond uteras for palliation + radiation therapy does not improve local control br survival + poor outcome overall, even for early stage disease 3. Endometrial Stromal Sarcoma * usually presents in perimenopausal or post-menopausal women with abnormal uterine bleeding + diagnosed by histology of endometrial biopsy or D&C Treatment + hysterectomy /BSO (ALWAYS remove ovaries as ovarian hormones may stimulate growth) * adjuvant therapy based on stage and histologic features (hormones and Jor radiation) + hormonal therapy (progestins) may be used for metastatic disease in low grade ESS Ovary oy BENIGN OVARIAN TUMOURS * see Table 12 + most are asymptomatic usually enlarge slowly, iFat all + may rupture or undergo torsion, causing pain * the pain associated with torsion ofan adnexal mass usually originates in the iliac fossa and radiates to the flank. + peritoneal irtation may result from an infarcted tumour ~ rare MALIGNANT OVARIAN TUMOURS. soe Table 12 Epidemiology # lifetime risk 1.4% (1/70) + in women =50 years, more than 50" of ovarian tumours are malignant * causes more deaths in North America than all other gynecologic malignancies combined Sth leading cause of cancer death in women 5% epithelial, 25% non-epithelial + 5:10" of epithelial ovarian cancers are related to hereditary predisposition Risk Factors (for epithelial ovarian cancers) = nuliparity * carly’ menarche late menopause + family history of breast, colon, endometrial, ovarian cancer * race ~ Caucasian Protective Factors (for epithelial ovarian cancers) ‘OCP likely due to ovulation suppression (significant reduction in risk even after 1 year of use) rognancy /brvastieeding + tubal ligation (recently questioned)140 Gynecogy gg Se 4 ae maw ans nen eee a ae ae Soe ‘oy area as postop ‘tomers ane relent (Gul ove aber os 708 pel vin cncrs peor sage doses, agro aque gs pty, Table 12. Ovarian Tumours Gynecological Oncology “oranto Noes 2010 + hysterectomy (without removal of ovaries) « bilateral salpingoophorectomy (prophylactic surgery pesformed for this reason in women with known high tsk ~Le, BRCA mutation) Clinical Features + most women with epithelial ovarian cancer present with advanced stage disease since ttle “asymptomatic” until disseminated disease * scaly associated with vague non-speciic symptoms before diagnosis recognized + when present, symptoms may inlade = post-menopausal biceding regular menses if pre-menopausa (rar) + Nague abdominal symptoms (nausea, bloating, dyspepsia. anorexi, carly satiety) + Symptoms of mass effet ‘increased abdominal gith ~ from ascites or tumour ist + urinary frequency + constipation + fluid wave Low Malignant Potential (also called *Borderline") Tumours ‘about 15'% ofall epithelial ovarian tumours fhumour cells display malignant characteristics histologically, but no invaston is identified alle to metastasize, but not common to do so treated primarily with sungery (BSO /omental biog NO proven benefit of chemotherapy generally slow growing, excellent prognosis Sryear survival =99%, recurrences tend to occur late, may be associated with low grade serous carcinoma pregnancy, OCP, and breasticeding are found to be protective hysterectomy) ie Des oo Tandy Tae FANCTONAL TUDORS aie ole Fdiseogeedey——Unavenprie cea lea, Syn apc rm rat con loyesibar ene feats sapevensan eS tiaras oped Oran oon et es en pone! teenies eth rence Och ain ages il teetpaatw ot Ieeset tise luinont Capa tambiswnras —— Muesayocampinten Ua iISemaah__ Sewers Gertamtcnyenew hina fru ne fonenae Het tote Tiestningst Oesanectlckesinitty —sansaaitne pare rere rom jie ‘sion eseto ache So ot ama ott pesos apy Seas tein room Dennen 103 fpectpan faewnons Sx rei 8 Pao rer eh GENEL TUMORS Serinawie _ Sigerec mmo owing Unga it act Srv ml, Tee ir see TY tonometer mew ‘nse rere Semotrtea cee cxtans Thnmroastectpasene mney dow eS dara appendoges (sweat ard yeas caloicaion which is ‘ct gs wh poner ac SEL TUMOIRS Con Rey ei 20a Ue ey Sagal be ere sed ad ero Semon le are Dysyerminoma Produces lactate detydrogenase ‘OF biter Usualy very responsive to chemotherapy, ta tata cinerea coe Inns stems tn ie Yehsactumer —Pesesela mao MP) hd Nowa ip see are = es feted Pac Pc cme Chaocarivona Pods“Toronto Notes 2010, ‘Table 12. Ovarian Tumours continued) ‘Gynecological Oncology Gynecology GAT Te Descitin Prsetion Utsoodifaogy Treatment ‘EPTHELAL OVARIAD TUMOURS (ray be eign, maligno Borderie) Gonral formation Derm mest ca eg Vere: cipenirgcn Bain ‘roel ot sie secon. onto sairgoonphrectany (Gest son haw pe 2265 ef a eran recht ‘any sage ape 1: 880 = ste files mana) ‘onetectny = petal vshogs = sg (eran Bop + ade sete) ued chanthoaey 2 aaned sage pet forte big sage ‘Sennen ‘Adu chanthaoyP charac Wextafon! Swous Mos cormonorranture 2030 blared king stalin ‘SPyafalowsn canoes lube epthdm 158 fp ures (ten mutecsar tenn Hstogealy rein Peanorma as eed eos emotes) Macinows S54 btgn aly complica by estes wescenea! —Tprrapaseta dnote eh epteal wre Prwonans pene: mplets eathela aan ptt with oes soe seal aboomindeay rd Sten moter co) oda laze cuntiesaleucn Mayrach rears sis ruchous remove apni as ol Endomabiaid ——70sf pitino Hsxiog esabls igh are paid sore Charcot 1% ol witli Ca Hstvg ests igh aren pei rmesmepinc cls Brome Tumour 21% of pill oi Ca Feo tarou with Tags berign ‘ersteral ee phit ‘5X CORD STROMAL OVARIAN TUMOURS evra tortion ‘supe eset af ura Cena ey be sa kx mtsatc ionamin Frome feng) Rom mare fists in Nonna Fa, soat oes rain same (ccna) asc wih yew wth ncn Mags sion Garlosstaca Carbo asec wth sen gang + Hstiog haa of cance telmeus evar net femnangefocsecacins srl gapsct als, (enigner” Ebisu raar (aber, mentee Irom as Calne Dotes shot) pest recy testo) Swtdblonig —Canmeanee deed andogans —Andage roduc wing feltumear os ucirreces fects ruta] exp ce (evi or ‘eosin fat hate) maka) ‘METASTATIC OAR TUMOURS From Glvact, 4% orn anaes Xedenteyurcu = mastic ast, aren rom oe ste ‘oman, {ual react armaty srach pom cok ten th sito cals + goals of management are to help patient by adelressing symptoms or optimal surgical ‘management of malignaney (if these exist) + any women with suspected ovarian cancer based on history, physical, or investigations. should be referred to a gynaecologic oncologist prior to surgery to facilitate optimal surgery * bimanual examination * soli, irregular, or fixed pelvic mass is suggestive of ovarian cancer + RMI (Risk of Malignancy Index) is best tool availabe to assess likelihood of ovarian malignancy and need for pre-operative gynavcologic oncology referral (sce sidebar) ++ bloodwork ~ CA-125 for baseline, CBC, liver function tests, electrolytes, creatinine ‘+ radiology ~ transvaginal U/S best to visualize ovaries; CT scan abdomen and pelvis best to look for metastatic disease ‘= bone sean or PET scan not indicated + try to rule out other primary source if suspected based on: * occult blood per rectum ~ if positive, endoscopy = barium enema + if gastric symptoms, gastrostopy = upper Cl series is of Metganey Ido) Rt UeMixcArs UULTRASOUD FROME 1 pore) “Matos ot eno thd arent ence of maaan: esersel wer Bites = Tr Us sores 0°) U=AtbrSsewrer 25), Menopausal sats Posmeapaa M = 3 “Peneoput = ABSOLUTE VALE OF cAt25 Senne tee Fert 200: Greco Oso teas seated ‘hose esG42 Gynecology Ww oe Coates of ovate 125 Tears aay toto ‘omer Henan ey age rr anc pw) thot eo Sceenrg tet mauouast 1 Byer er * Name panes, tana, cao ‘Mon AUGNANT 1 Oyen van reer, ‘snare oro as, ro + Nan Ge cos parce pe ay Gh 25s ne fe mnt Gynecological Oncology “oranto Noes 2010 + ifabnormal vaginal bleeding, endometrial biopsy to rule out concurrent endometrial cancer colposcopy = ECC to rule out cervical cancer if abnormal cervix ‘+ mammogram if breast lesion identified or risk factors present Screening ‘no effective method of mass screening ‘+ routine CA-125 level measurements of U/S not recommended + mote women suffer from false positive resulls than helped + controversial in high tsk groups stating age 30, transvaginal L/S and CA-125, {0 consensus on interval) + familial ovarian cancer 1 first degree relative affected, BRCA-1 mutation) + other cancers ti. endometrial breast colon) + may recommend prophylactic bilateral oophorectomy after age 35 oF when child-bearing is completed (BREA-1 or BRCA-2 mutation) ‘Table 13, F1GO Staging for Primary Carcinome ofthe Ovary (Surgical Staging) Sage Deca 7 Gonthimied ote oes WY many nasies otis, masses (61 aris wi ayo he olowiry caps pared, aru on ean sro omega asin ates 11 Geowtinsing on orb ais wih poe eteson A Esensono tous 1B Eaansensnonerpve rccus KNB wth mera cls inastes or poste pawl wastins 1 Tumcwinaing oe orbs vais wih ioe inl ust te ps ar postive rapier ‘egialndss IW Merosapc pines msasass beans pis IRB Maes pte mest bees pis <2em IRE ng >2 cr ander nonprancl r ing rods IN Disurt rasa bees pura cay ‘rgalsquareus aptheium ‘Squamous metaplasia Cotunnsr epitium ‘land opening | coumerpaon igi arts fe i Figo 12. The Cervix BENIGN CERVICAL LESIONS Nabathion et incusion no reatment que + endoervicalpy * reatment i polypectomy (office procedure) MALIGNANT CERVICAL LESIONS ‘+ majority are squamous cell carcinomas (95) adenocarcinomas increasing (5% subtypes include small cell, adenosquarous “+ 8.001 deaths annually in North America ‘annual Pap test reduces a woman's chances of dying from cervical cancer from 4/1000 to 5/10,000 + average age 52 years old Etiology ‘+ at birth, vagina is lined with squamous epithelium; columnar epithelium lines only the ‘endocervix and the central area ofthe eetocervix (original squamocolumnar junction) ‘+ during puberty estrogen stimulates evursion of 2 single columnar layer (eetopy), thus ‘exposing it to the acidic pH of the vagina, leading to metaplasia (change of exposed ‘epithelium frim squamous to columnar). Anew squamocolumnar junction forms as 2 result «+ the transformation zone (FZ) is the area located between the original and the current squamocoluranar junction (Figure 13) + the majority of dysplasias and cancers arise in the TZ. of the cervix ‘+ must have active metaplasia in presence of inducing agent (HPV) to get dysplasia + dysplasia > carcinoma in situ (CIS) ~ invasion «+ slow process (-10 years on average) + growth is by local extension 4 metastasis occurs late Risk Factors. ‘HPV infection see Sexually Transmitted Infctions, GY27 * high risk of neoplasia associated with types 16,18 + lowe risk of neoplasia associated with types 6,11 2085 of cervical cancers contain one ofthe high risk HPV types“Toronto Notes 2010, Gynecological Oncology * smoking, «high risk behaviours (risk factors for HPV infection) * multiple partners * other STIs (HSV, trichomonas) * carly age first intercourse * high risk male partner + poor screening uptake is the most important risk factor for cervical eancer in Canada; groups include * immigrant Canadians first nations Canadians geographically isolated Canadians Sextrade workers low socioeconomic status Prevention: Quadtivalent HPV Recombinant Vaccine * currently indicated for females 9 to 26 years of age for prevention of diseases caused by HPV types 6,11, 16 and 18 (genital watts, corvical, vulvar and vaginal dysplasias and cancers} + for optimal benefit of vaccination, should be administered before onset of sexual activity, before exposure to virus) + administered IM at time 0,2, and 6 months, may be given atthe same time as Hep B or other vaceines using a different injection site + nol for treatment of active infections + most women will not be infected with all four types ofthe virus atthe same time, therefore vaccine is still indicated for sexually active females or those with a history of previous HPV infection of HPV-related disease + Conception should be avoided until 30 days after last dose of vaccination, + Side effects ~ pain, swelling, erythema, low grade fever + contraindications ~ pregnant women and women who are nursing (limited data) Clinical Features + squamous cel earcinoma (SCC) * cxophytc fungating tumour + adenocainoma * endophytic, with barel-shaped cervix + eaaly * asymptomatic 2 discharge ~ intially watery becoming brown or ed + postcil bleeding state * 80.90% present with bleeding ~ cither posta, postmenopausal or ieregular bleeding + spontancousiregula Bleeding + pelvic ot back pain extension of tumour to peli walls) + Blader bowel symptoms friable, raised, reddened or ulcerated area visible on cervix Cervical Screening Guidelines (Pap Test) + enudocervical and exocervical cell sampling (aim isto sample the TZ) + false positives 510% false negatives 10-40% (fr single test) * false negative rate 50% for existing cervical eancer + best identifies squamous cell abnormalities less reliable for glandular abnormalities «all women ~ start screening at age 21, or3 years after onset of vaginal intercourse + women 230 years ~if3 normal Paps in a row, and no previous abnormal Paps, can get screened every 23 years (if adequate recall mechanism in place) + women =70 yeaes ~if 3 normal Paps in 3 row and no abnormal Paps in ast 10 years, can discontinue screening (if remain al low risk) «pregnant women and women who have sex with women should follow the routine ‘cervical serening regimen + hysterectomy *= tolal~ discontinue sereening ithysterectomy was for benign disease and ne history of cervical dysplasia or HPV infection + subtotal ~ continue sereening according to guidelines + exceptions to guidelines * immunocompromised (transplant, steroids, DES exposure) = HIV and high risk *= previously unscreened patients Gynecology GY Syma to BE P| Pega cn ht en Ferns enero: 8 St ven feed th me ra lil fy hog ee ‘wart Pra sete vocation Pies omeros ned us. Sei Senet spas Praca Das Soe IRE SE Cee eae Te er ta. Pe Thi roti ‘enon west, Rt fesse Apps ul ect Bren Peas en ma pi oes bre ps se ge cso sedges an ‘rom os tenses rere ery tga ons Deacon ate Compe tig Te ‘omar Rogobestosase ‘tompneetPvrsen ng lnctuyoui. oc Poi tin dors eye vey ome assis be toni npeety Pinas Pretrial bn ied lg Se oneal Patou Ani 0 aN) Pero eto tags are alin avalpa: ‘rar uP) crohns Suir Smet eve acon arn ei went ss. Danis MERE la Shu hae ‘ere ime tne ev ons tau a Stn ‘ond ite Sena (Diesen sas Poe eset cee (pe eer ato pga econ seg tehga ti tam cy apes 5 (SUS Oboe hts aes pr ea i a yr st tars Pa inert esa aps k (Oh 2hszisa sae tL OF = 2a stradtnrs raed de {SOS(H= 1G) Ugaonetpy me do unin reeea = Codie bc on anit apes eee be Lae apne ee soy ene neo aGynecological Oncology “oranto Noes 2010 em ted sus ase a St Sn sale oon sao | | aes ter Ses! res sorean30 coy “Seu Coban OR Remarc cacy "Sra bs cs ' covery sesann Say Neg asais ‘esing * Sou ' I Yergscney espscoy wy ASUS thee I 1 1 i — 7 Renny Copy — Raper Caesy Neg sass wn 6mos evga I I cy onan fowtne Colposcopy we aaa ee I I fie Canecey sone Figure 13. Decision Making Chart for Pap Test (nt applicable fr adolescents) Aton a oe Sn es: he Ck mie a eh Table 14 Cytological Casiieation ‘Bothesda Grading System Classic Systeav/ Cervical lntraeptholial Neoplasia (CIN) Senin Son ‘Wei ‘ors some artery en anche née hones oe = ‘pea atl unsure ster (ATS) Sqmmas ay fear spec TheBatenk Caster en | Ayal mer omc acto AH) ssbealeneiseds +P | oy gas opamp nS apn ees) fate trot ise sere The. Gapess of evel meal epi (Ae cave caches roqursa tesa enol obs by ‘eps of ssi sts (one fag cabesey| comet eae oes gh ye squamous rept WSL) ‘Sgumas ex crsroma SCE) ener cal aromas pal geet calf urdseeed ieme AGS) Enon acer Ena tence eratone sce Nedoae dspace C0) Seow eps Creema ts} Sumas cl cca (8) Gna aypa of uncran sgnomcn asmcremars Mncaeanma rt ous pc INS) Diagnosis + sce Colposcopy, GYI + apply acetic acid and identify acetowhite blood vessels to guide cervical biopsy lesions, punctation, mosaicism, and abnormat + endocervical eurcttage (ECC) ifentite lesion is not visible oF no lesion visible + diagnostic excision (LEP) If * lesion extends into endocervical canal esitive ECC iscepancy’ between Pap test results and colposcopy + mieroinvasive carcinoma ‘+ consider cold knife conization (in OR) if glandular abnormality suspected based on sxtology oF eolposcopic findings due to concern for margin interpretation + tests permitted for FIGO clinical staging include: physical exam {Including EUA), cervical biopsy (including cone biopsy), protoscopy /eystoscopy, IVP, ultrasound liver/kidneys, XR LETS ‘+ MRV and /or CT and /or PET scan often done to facilitate planning of radiation therapy, results do not influence clinical stage“Toronto Notes 2010, ‘Gynecological Oncology Gynecology GY Tobi 18. F160 Stang Classification of Corie Cancor wy Sone Descen FOS treet eee ee — Sr ecege con ts A Merve ess oy rica cee ei 1A, Stand are =i ap rot? ris eee eis 35mm wt ame rar at ti es 8 Ginically visti lesion carted to cere, or microscope lesion >A, 1d a tine ths %— heeaear ata eesaree 1B vapour inten 11st pe al ross cin atc do eng {ih other ogi am eines 1c ni ot pe Sn a yep ri WA Boon pis rt eo i anid any Tobie 16. Tantmont of Pains with Corvieal Dysplsia nd Carvel Canes Test aris Chane a apy a Sra) any esr wl esr dares OR) Capes pst on 2 conse smears ens we poges shale en sey eter LE ne, nthe area psy Wwe LE? tesa bares orhteegea eka) GN AaMCNN SL) cigs rtard Ain rin day: LEP ae. eveyone con cuy Fyswctony ~ ony ie for ae hilary siege, Cervieaeataon ue oy ese (merase SCC: Srhystenctny tin ety st sind ‘Samia 3 reais) Siege Wy 18 ‘pia oes ata hysteetay rd pvc mpaderetony ern mates un sy voriag ht cas en be prc re mers Forty pssst, rey hae ae eacomy a odes std ol oe stro fo ary stage dese Conan charity ads poate sil sce, poo scant, orf spear afvese oscars presen eo Sapass Seg 18,(>4cm), Comurechareraiiain tapy zat ‘Abnormal Pap Tests in Pregnancy * incidence ~1/2,200 {+ Pap test at all initial prenatal visits = if abnormal Pap or suspicious lesion, refer to colposcopy + if diagnostic conization required, should be deferred until second trimester (12) to minimize risk of pregnaney loss + ava cancel ldo, management of yp ered ntl er compton of ignaney (may deliver vaginally) « TFinvasive cancer present, management depends on prognostic factors, degroe of feta maturity, and patient wishes ‘general recommendations in TI ~ consider pregnancy terminatio With either radical surgery (hysterectomy vs. tracheloctomy if des br concurrent chemoradiation therapy. + recommendations in T2/T3 ~ delay of therapy wil viable fetus and C/S for delivery with concurrent radical surgery or subsequent concurrent chemoradiation therapy. management ss futie frilly) Vulva BENIGN VULVAR LESIONS 'Non-Neoplastic Disorders of Vulvar Epithelium drynapecus ale wale + biopsy is necessary to make diagnosis and or nile out malignancy uel + hyperplastic dystrophy (squamous cell hyperplasia) Surface thickened and hyperkeratotic pruritus most common symplom + typically postmenopausal women. * treatment ~ 1% fluorinated corticosteroid ointment bid for 6 weeksGY46 Gynecology lec) ‘Gynecological Oncology “oranto Noes 2010 + ichen sclerosis * subepithelial fat becomes diminished, labia become thin and atrophic, ‘membrane-like epithelium, labial fusion pruritus, dyspareunia, burning Tiguee of 8 distribution _most common in post-menopausal women but can occur at any age {treatment ~ ultrapotent topical steroid (15% clobetacol x 2-twks then taper down + mined dystrophy chen slo with epithelial hyperpla) * hyperkeratotic areas with areas of thin, shiny epithelium + trentment~ Fluorinated corticosteroid ointment Tumours + papillary hidradenoma 4 fibroma, hemangioma MALIGNANT VULVAR LESIONS Epidemiology “5% of genital tract malignancies ‘+ 907% squamous cel carcinoma remainder melanomas, basal cll carcinoma, Paget's disease, bartholin’s gland carcinoma * Type [disease ~ HPV-related disease (50-70%) ‘> more likely to be younger women ‘+ 90% of VIN contain HPV DNA (usually types 16, 18) + Type disease non HPV-rolated, associated with current or provious vulvar dystrophy ‘usually post-menopausal women Risk Factors. ‘= HY infection (s00 above) + VIN (vulvar intraepithelial neoplasia): precancerous change which presents as multicentsic white or pigmented plaques on vulva (may only be visible at colposcopy) * progression to Cancer rarely occurs with appropriate management * treatment ~ simple local excision (ie. superficial vulvectomy + split thickness skin grafting to cover defects [if required) vs. ablative therapy’. laser cauterization) ¥: local immanotherapy (imiguimod) Clinical Features ‘+ many patients asymptomatic at diagnosis (many also deny or minimize symptoms) ‘+ most lesions occur on the labia majora, followed by the labia minora (less commonly on. the clitoris or perineum) Jocalized pruritus or mass most common «Joss common ~ raised red, white or pigmented plague, ulcer, bleeding, dischange, pin, dysuria + patterns of spread local + gloin nodes (usualy inguinal ~ plc nes) + hematogenous Investigations «physical examination + Ecoiposcopy + ALWAYS biopsy any suspicious lesion ‘Table 17. F1GO Staging Clessiiction and Treatment of Vulvar Cancer Sage Descrion Trestmart 2 esi weopss VA cachows ns Lael eisoy patel hecory Laer Leal immoretap (rigid) | <2emeorfaato wa srwsiaersprinam feed econ + go nal scien # >I rm mason No inc gon notes Senta rede dssecion cept leson <4 dno wy Win ceworen hypanensan ach nrrney fe 20 wel ‘gotta vapor ease Gynecological Oncology “Toronto Notes 010 Diethylstilbestrol (DES) Syndrome «fetal exposure to DES (due to maternal use) predisposes to cervical or vagina clear cell carcinoma 1 Hf expoted 1 in .00 ask of developing Hear ell adenocarcinoma * clinical features ‘adenosis is persistant Mllerian type glandular epithelium in vagina — only 1/1000 ‘develop cler cell cancer ‘occurs in 30.95% of exposed females DES exposure ascociated with malformations of upper vagina, cervix, and interior of uterus (T-shaped); eockscomb or hooded cervix, eeevieal collar, and pscudopolyps of + patients with DES exposure should have annual Pap tests (cervix and vagina) and ‘Sigital vaginal exam for subepithelial masses * ifany abnormality, refer for colposcopy ‘Toble 18 F1GO Staging Clssitication of Vaginal Cancer (Ch ‘Sage _Descipon (eet esa VAN) cca sts 1 Linas aia at 1) nes snags NO pic wa eesion Rabie wallnensen| Ears beyond tuo pois OR Haderecurn inher a Staging) Fallopian Tube + east common site for carcinoma of female reproductive system (0.3%) * usually adenocarcinoma + analogous to ovarian cancer (may be implicated in pathogenesis of ovarian cancer) * more common in fifth and sixth decade Clinical Features + classic triad present in minority of cases, but very specific ‘watery dischange (most specific) = “hydrops tubae profluens" * vaginal bleeding or discharge in 50" of patients + campy lower abclominal/ pelvic pain + most patients present with a pelvic mass (see Ooarian Cancer, GY39 for guidance regarding diagnosis/ investigation) ‘Treatment +38 or malignant ovarian tumours Gestational Trophoblastic Disease/Neoplasia (GTD/GTN) + refers to a spectrum of proliferative abnormalities ofthe trophoblast Epidemiology *#°1/100 pregnancies * marked geographic variation, as high as 1/125 in Taiwan + 808; benign, 15% locally invasive, 3% metastatic + cure rate 85% HYDATIDIFORM MOLE (Benign GTD) * complete mole = difuse pb hypeplaa, hy rope sweling of chorion vil no ft sues ‘or membranes present most common fype of hydatdiform mole 46x oF 4OXY, chromosomes completely of paternal origin (50%) 2 sperm fertilize empty egg or sperm with reduplication 15.20% rsk of progression to malignant sequelae Fisk factors + geographic (South East Asia most common) + thers maternal age >40 years, beta-carotene deficiency, vitamin A deficiency) not proven * clinical features * often present during apparent pregnancy with abnormal eymptoms findings: *apina bedi 67) = theca-lutein eysts>6 cm = peesclampsi i) = fiyperemesis gravidarum (26%) = hyperthyroidism (2%) = betashCG 100,000 mIU/mL no fetal heat detected IP (51%) ve)‘Toronto Notes 2010, ‘Gynecological Oncology Gynecology GY + partial (or incomplete) mole ‘= hydropic villi and focal trophoblastic hyperplasia are associated with fetus or fetal pars + biten triploid Q0Cy, XY, 2000 with chromosome complement from both parents * usually related to single ovum fertilized by two sperm * low risk of progression to malignant sequelae (<4) * associated with fetus, which may be growth-restricted and/or have multiple Congenital malformations * clinical features "typically prosent similar to threatened /spontancous/missed abortion + pathological diagnosis often made after D&C. Investigations + quantitative beta hCG levels abnormally high for GA (tumour marker} + US findings: * if complete ~ no fotus (classic “snow storm’ due to swelling of villi) * if partial - molar degeneration of placenta t fetal anomalies, multiple echogenic regions corresponding to hydropic vill, and focal intra-uterine hemorrhage + CXR (may show metastatic lesions). * features of molar pregnancies which are high risk of developing persistent GIN after evacuation of pregnancy * Toca uterine invasion as high a5 31% * beta-hCG 100,000, = excessive uterine size * prominent theca-lutein cysts Treatment «suction D&C with sharp curettage and oxytocin + Rhogam if Rh negative + consider hysterectomy (if patient no longer desires fertility) * prophylactic chemotherapy of no proven benefit + chemotherapy for GTN if develops after evacuation. Follow-up ‘contraception required to avoid pregnaney during entire follow-up period + Serial beta-hCGs (as tumour marker) every week until negative x 3 (usually takes several ‘weeks, then monthly for 6-12 months) ~ prior to tying to conceive again + Increase or plateau of beta-hCG indicates GIN» patient needs chemotherapy GTN (MALIGNANT GTD) + Invanive moe or persistent GTN diagnosis msde by rising ova plateau in bela-hCG, development of metastases felerng test of docuncaed mola pregeancy + histology = moar 1 inctastly are rare 0 + chorioareinoma * Citen present with symptoms from metastases * Righiy anaplastic highly vascular {ng chgronc ll, clement of synctiotrophoblast and cyotophoblast 2 fry flow molar pregnancy, abortion, clap or normal pregnancy + placenta-st rophablastc tamu rare aggresive frm of GTN + abnor grow of inlermedtate trophoblast calls 2 Iow beta NCC, production of human plana lactogen (APL) relavely insensitive Dewmotheapy cuasainearion etm Sanyal + mene cee ee Ras one ety en peor cee ee , «Pepe ani esha end dot py heya * lungs (80%) ~ cough, hemoptysis, CXR lesion(s) {aha cee aed insets Us Betis thauetrent sarehiaine Pana ang Uongsae #1 ste formainant GT mets en pc nam an ester robe, tae ‘rdveret income,GYS0 Gynecology ‘Gynecological Oncology “Toronto Noes 20 + highly vascular tumour > bleeding anemia etter pulciooineet + caistin tnae GTN * divided into good prognosis and bod prognosis {eatin of ba prognosis pee “Tang duration (od months from antecedent pregnancy) = high preretment beta-HC te 10100 12th arin 40,000 ml Fmt of blood Brain rtrs metxs ~ fretastatic dss following term pregnancy + good prognostc features are the absence ofeach these features Investigations ~ for staging * history and physical + bloodwork ~ CBC, electrolytes, creatinine, beta-hCG, TSH, LFTs + imaging ~ CXR, U/S pelvis, CT abdo pelvis, CT brain + if suspect brain metastasis but CT brain negative, consider lumbar puncture for CSF betarhCG * ratio of plasma:CSF <60 indicates metastases ‘Table 19, FIGO Staging and Management of Malignant GTN ‘Stage Fnngs Manage [Diss cariedio isi coms — Sng ert charade wk disease (HD so) "steps etroryen et OW 2 wks stores tose geen 2a pts neo sho aan ssp een Cabiraton chara [EVD -pese HT, ACT cytes, pers) igh sk WMD soe 2] ress sie ape cart ay ‘Ga costerhysotony fount dested or pasate ‘phase ure 1 Maasai dase oaprar As atow ree Nets casa gs wither As above ido git tet vert NV Dhsartretesis stes redig Us igh ak |EWACO) with sag eseconc tes some tran hr bey Glee Feristrcelesisance i chonntemy (Grr asnen tea rte Follow-up (for GTN) ‘contraception forall stages to avoid prognancy during entire follow-up. «stage I It weekly beta-hCG until 3 consecutive normal results * then monthly x 12 months stage IV * weekly beta-hCG until 3 consecutive normal results * then monthly x 24 months Treatment + chemotherapy for all stages (see above chart)“Toronto Notes 2010, Common Medications Gynecology GYSt bore Creer) ny Table 20, Common Medications ‘ag ane ade) Aeon Dis Sle Indeins ‘Siac (Corinda A, ‘aya ‘oarsiat)—— ria witisDWA rtd hg AO 70H Coli ‘Sti Gist stssanvdnccin Rec Erg PO Se Di Bond, Pb bonnets") Opa: lia 12525 ust Ceotoes + reores ne The 25 gi tina 2 herder pnt Ptr pee rer ascent ‘sorely pray ods hit Fela sceig tena; mpc rol ets Site (moon pr soe poe ‘Faces curifewecrae ness oupccttiny SO mga Ses Pais inpott ony ECan bes torn tort, (Cori) watonpis chs Wy WO mg atin phen ag areursa ogra ot ori sap ansaid uae Sones abated RES)utocere pepe Miner Fae ypesin peor, utile repay velar eh {tency he de mee cep unas on ot rgd aed oy chanson ings Tee Omagh x16 hand ceiss SE wheeling amma ‘womgx me Gem «281 ater toe) gexsid Ti sods? ne Spee seth iis Oa gin? cls dares SE woh iar in, (Gym can) pay comttnn Ut 36 ron rege hepa (Dreciu-U5) Bupa sid Romulo IS et gin dag gong ress >émate ‘safe seme ins tiesto: ering epee fete tia tal ect Dk vet catarange, chs, oxi onthe: Saye Teacyediaiec tm POB ES amy pero incon SE Gt pty ec tise sh horney seein Di vate, omin Acoma an”) engtingd SMP Wage cbs ht a, tin bn drt camara ropa drnace Df nai cs came, Iota pj tarp lapeliouper) ——Speisrtacg SUS mg Meth 15eG Me Stresses etic, ecto rs ‘Gras lower intowesty Iypomognesas Usa <8rts kta cesty OE Gren, dope gig bras Freon testing recta Fagos") Hora GomaminwTS1S)UFSRBLAD 7125 en ey SE bing tana pest pvp Fe Hs WORD URE ene yarns se head muse ring ae uatone (gor ar acelin sini on (6a nutay ure wom est extant snc rian tt PDS pony moe Fag) Bact ase TPO ide ng PDE’ Earp ners SE ech, ees man dre, ‘reste accra sags isin on ung aye ra one vei gnc rst ‘cde aoc, a, eho fue Otepx®)—Age—nice—SrgPDBt wane SE cyraahis cot pains, oan rsh ma lupacrenens rasta hts onan Ch decor, in sn cai cbse ii ty wi caine hoe felon ‘eminent | che vergPO Oeosne te St amphi pcs eh ey mshi, lupe) head orstparn way ne ea (hor, gti in we hain ipa ai en serena esiicoee mestly —11Souicdinf¢sasctore Merge ‘Stenase orig date, iess (Galop) ‘bpp Opies ue esau ws Faeceisd one achion (roma do acid dubs ch colar en, sah en 1513GYS2 Gynecology Common Medications “oranto Noes 2010 Table 20. Common Medications (continued) Dn Wane ad Na Actin ‘sig See Tao ‘Sit, Conan, Dra heaton irfolnaneroie) TsUuSEATTea Oassonrdcin PE SE oor arent ops wae pnt inns toed arbor aba Ch py ne eel eg petra weal eye strc, fan ft POS, ran canted commas Duby sxe ‘Sf Ernst maa best tans (tres, oe siting Ue 4 ‘ayo aeesnbeisi wecen Decne ‘ign trboenolcoas hu aaa, cabretie ‘emai cis ‘hte fetes Fopstiies aenteattemnsna ty, ‘eget per ten nes ba ess, en at cea I roca sisi scaly ti ion ‘Df agin pent hyo, sie ih hanged pay, sie stroma eel esn pr rab: es, ‘oreo cen ave Debspibae crc ty Se sg geet aro, hci esc th ‘aleberdstee ego hpi nr > yo mgs wed manpages (Geld ae arto gen asic mnemgansinhara Ibo, bes als ore esse ns, SL ct Iypetesin pepo, cle cei Bb cone ‘aes (L0) Caper monn Create tos at hes ‘SE cms eng tnt nd i") cope D Cine) tein danse nvr draol ets sro eon dog wh step (xp Ua ond nurs ax, gots Mise) aia gem mnty ‘esr tenet 0, peyerey Progesterone wing WO: cons ese get che be epeny le ‘sae letonaan pms ak oD wt 0 eae aetna onicd iy os ay spe culticn oe lon pee racy nope gic eng ai Pst ro Stn egy perro se ap Wai Fei ah diss past ity of PD tie ay reli of cot aig ‘ods see dsremriener rege pe civ. cove ness emus ves“Toronto Notes 2010, References Gynecology GSS Tel t dear en con osm Das ski Nuff ar tom yaa ote Pau tu US ed RS Cutan Goes ree, ee pet la eb fc se ee Cok Ope 2 et eo Sn 18 fo sing Aen aa 05 Pate Bie - Orel erst Dr Gsins Port Sree, Chen rr ore Tet ns arms Mngt roe AC ‘ea Dobe ay ata men Se Paces ies 28 ad gudeeant es ol cs s Gaay Waa Sey! tau TS (escent Seri its en Sincere seit gen Pe Samir apps i re re i JO rn SS ‘SCE at en nemo ste te a Pea ees My 0 Meow he ar Ae aso Ure Mal Sc sl ysl gin gi Pees re wh ty Te as eh ‘eas Cos AO OEM Ch Cas oe ise Opt 2 i Baa hit gp iy tis nay end atin ed ay soem ns 2 sk gt Sua a Cg ere Gg Ga Oe ee repo eth at ey Sa J 0 | ley Sch renee psy yr fay he comps ek Teoh ee MMS el Peat ol nec eet tli ge MM 1, Lise Sa i eas gainer it eal S08 is. wc Poses srt ay IL 3. oe rr et el rts pen Ie tet fe Sma sue sea renege He Ae 01158 Far. epee ofa Paps tt aprehre e eceMWe ST W ES ‘oun aS dO) © Maep chee erg td 0 234 ‘Sgr Uso peta tO pe nr 2 1 ‘Surrogate al Gta eo la Pe Dera WM Cpe pre Rmempaon— net nae ara Sy he ou 208 at tet ean tater ttn peg pe ns COME ES. ota iene ae edt BIAS 261 i ae ofa Ca ines ran Hest oe tin Mss Gg ge ie apron ore Feo Sra Et pice sss abe Aor a, A 0 eyo esr oe ay oe Hcy Sly Set Oso Opin brseancn ‘ne! ies, Se a ace Bh a ey onan xeonGYS4 Gynecology “Toronto Notes 2010, Notes

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