Presentation is loading. Please wait.

Presentation is loading. Please wait.

March 29, 2010 Back to Basics: Gynecology Dr. Jessica Dy Assistant Professor Department of Obstetrics and Gynecology University of Ottawa.

Similar presentations

Presentation on theme: "March 29, 2010 Back to Basics: Gynecology Dr. Jessica Dy Assistant Professor Department of Obstetrics and Gynecology University of Ottawa."— Presentation transcript:

1 March 29, 2010 Back to Basics: Gynecology Dr. Jessica Dy Assistant Professor Department of Obstetrics and Gynecology University of Ottawa

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

3 Female Sexual Development

4 A mother is concerned that her 12 yo daughter has not had her period yet (the other girls in her daughter’s class have already started their period). She thinks her daughter hasn’t shown signs of puberty yet. Knowing the usual first sign of the onset of puberty, you should ask which of the following questions? a) Has her daughter had any acne? b) Has her daughter started to develop breasts? c) Does her daughter have any axillary or pubic hair? d) Has her daughter started her growth spurt? e) Has her daughter had any vaginal spotting?

5 The usual events in normal pubertal development from first to last are: a) Peak growth, pubic hair, breast budding, menarche b) Breast budding, pubic hair, peak growth, menarche c) Breast budding, menarche, pubic hair, peak growth d) Pubic hair, breast budding, menarche, peak growth

6 Secondary Sexual Characteristics “Baby Has Gone Mad!” Breast Development (Thelarche) 10.5 yo Hair Development (Pubarche) 11.0 yo Growth (peak height velocity) 11.4 yo Menstruation (Menarche) 12.8 yo

7 Puberty ► Occurs between 8-13 years old in girls ► Decreased sensitivity to inhibitory effects of low levels of sex steroids ► Maturation of HPG axis: Hypothalamus(GnRH) Pituitary(FSH/LH) Gonads(Estradiol) Adrenals(Testosterone)

8 Hypothalamic-Pituitary-Ovarian Axis Hypothalamus Pituitary Ovary Breast/Uterus/Vagina GnRH FSH, LH Estradiol

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

10 Female Sexual Development In General: Low levels of FSH and LH found in infants and prepuberty Prior to onset of puberty: FSH and LH levels  Estradiol levels  and breast development occurs Eventually sufficient estrogen available to initiate endometrial growth and menses Menarche usually 2 years following breast budding Adrenarche (pubarche) biologically unrelated event Temporally related to other pubertal changes Precedes gonadarche by 2-4 years

11 Tanner Staging

12 Abnormal Sexual Maturation ► Accelerated Maturation  Precocious puberty  Dev’t of 2 o sexual characteristics < 8 years ► Delayed Maturation  Absence of thelarche by 13 years  Absence of menarche by 15 years

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

14 Precocious Puberty Isosexual: –puberty occurs in direction of expected body phenotype –Estrogen mediated Heterosexual: –Puberty occurs in direction opposite of expected body phenotype –Mediated by androgens –virilization

15 Precocious Puberty True (or Central) (GnRH dependent) Idiopathic (74%)Idiopathic (74%) CNS lesions (e.g., infections, tumors)CNS lesions (e.g., infections, tumors) Pseudo (or Peripheral) (GnRH Independent) Ovarian (e.g., granulosa cell tumor)Ovarian (e.g., granulosa cell tumor) McCune-Albright syndromeMcCune-Albright syndrome AdrenalAdrenal HypothyroidismHypothyroidism

16 Initial: Height and weight Estradiol levels Androgens: DHEAS, testosterone FSH, LH, TSH levels Bone age Secondary: Imaging of pituitary/sella Ultrasound ovaries, uterus, adrenals Bone scan (McCune-Albright) Precocious Puberty: Investigations

17 Aimed at underlying process: Tumor: resection, radiation, chemo Idiopathic: − GnRH agonist therapy suppresses GnRH − when therapy stopped, appropriate chronologic changes resume McCune-Albright syndrome: − Medroxyprogesterone acetate − Aromatase inhibitors Precocious Puberty: Treatment

18 Abnormal Sexual Maturation ► Accelerated Maturation  Precocious puberty  Dev’t of 2 o sexual characteristics < 8 years ► Delayed Maturation  Absence of thelarche by 13 years  Absence of menarche by 15 years

19 The most common cause of delayed puberty is: a) Turner’s syndrome b) Craniopharyngioma c) Constitutional delay d) Anorexia nervosa e) Primary hypothyroidism

20 Delayed Puberty Delayed Menarche + 2 o Sexual Dev’t ► Anatomic genital abnormalities ► Androgen insensitivity syndromes (complete forms) Delayed Puberty + Inadequate/Absent 2 o Sexual Dev’t ► Hypothalamic-pituitary dysfunction (low FSH)  Reversible: Constitutional delay, weight loss due to extreme dieting, protein deficiency, fat loss without muscle loss, drug abuse  Irreversible: Kallmann's syndrome, pituitary destruction ► Gonadal failure (high FSH)  Abnormal chromosomal complement (eg, Turner's syndrome)  Normal chromosomal complement: chemotherapy, irradiation, infection, infiltrative or autoimmune disease, resistant ovary syndrome

21 Delayed Puberty 1. Anatomic genital abnormalities 2. Androgen Insensitivity Syndrome 3. Central Cause (low FSH) 4. Gonadal Disorders (high FSH)

22 The Menstrual Cycle …and other menstrual abnormalities

23 Normal Menstrual Cycle

24 ► Follicular Phase ► Proliferative Phase ► Granulosa Cells (dominant follicle) ► Estrogen ► Luteal Phase ► Secretory Phase ► Corpus Luteum ► Progesterone

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

26 Hypothalamic-Pituitary-Ovarian Axis Hypothalamus Pituitary Ovary Uterus/vagina

27 Amenorrhea: Etiology ► Pregnancy – always rule out! ► Hypothalamic-pituitary-gonadal axis  anorexia nervosa, stress, tumor ► End organ (failure, abnormality, absence)  genetic, idiopathic, menopause, radiation, chemotherapy ► Outflow tract defects  Septum, Asherman’s syndrome ► Endocrine disorders  Prolactin, PCOS, Thyroid ► Other  Drugs: metoclopramide, neuroleptics, danazol

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

29 Amenorrhea - Hypothalamic ► Extreme stress/systemic illness/nutritional deprivation ► Anorexia Nervosa  Calorie restriction +/- exercise induced  Loss of pulsatile GnRH secretion  Critical body fat threshold ► Hypothalamic tumor, infiltrative disorder ► Congenital GnRH deficiency  Kallmann’s syndrome

30 Amenorrhea - Pituitary Pituitary Adenomas: ► Non-functioning – most common (30-40% of all pituitary lesions) ► Prolactinoma ► Growth Hormone secreting - Acromegaly ► ACTH secreting - Cushing’s Disease Primary Hypopituitarism Sheehan syndrome ► Postpartum hemorrhage & ischemic necrosis of anterior pituitary (portal system) ► Failure of lactation

31 Amenorrhea – Pituitary Lesions Any mass lesion may cause stalk compression ↓ dopamine suppression ↑ prolactin levels ↓ GnRH secretion ↓ FSH/LH levels amenorrhea

32 Amenorrhea – Pituitary Lesions ►  levels of prolactin cause  secretion of GnRH from hypothalamus ►  FSH/LH = amenorrhea ► Any mass lesion may cause stalk compression ►  dopamine suppression with  prolactin ► Infiltrative: sarcoidosis, tuberculosis, lymphocytic hypophysitis lymphocytic hypophysitis ► Tumour: teratomas, craniopharyngioma

33 Amenorrhea - Ovary ► Anovulatory: PCOS ► Ovarian failure  Premature exhaustion of follicles  “menopause” occurs < 40 years  Genetic, idiopathic, surgical, radiation, chemotherapy, immunological

34 Premature ovarian failure may be due to any of the following except: a) Turner’s syndrome b) Autoimmune dysfunction c) Hyperandrogenism d) Radiation exposure

35 Ovarian Abnormal Development ► Gonadal Dysgenesis  Pure gonadal dysgenesis : 46 XX  Turner’s Syndrome: 45 XO, +/- mosiacisms  Swyer’s syndrome: 46 XY ► Androgen insensitivity I (testicular feminization)  Absent receptor for testosterone  46 XY, development of female habitus, breast development, diminished pubic/axillary hair, absent uterus, blind vagina, gonads are testes ► Androgen insensitivity II  5  reductase enzyme deficiency (T → DHT)  46 XY, born with female external genitalia, but male pubertal development

36 Amenorrhea – Uterus/Vagina ► Blockage (Mullerian abnormalities)  transverse vaginal septum  imperforate hymen  non-communicating cavities  Cervical stenosis  Congenital mullerian agenesis (MRKH syndrome) ► Endometrial Failure ( Asherman’s syndrome)  2 o vigorous D&C, usually postpartum  ++ adhesions in uterine cavity

37 Amenorrhea - Endocrine ► Hyperprolactinoma ► Hyper/hypothyroidism ► Hyperandrogenism:  e.g. PCOS, ovarian/adrenal tumor, testosterone injection ► Cushing’s disease

38 The initial work-up for a patient with 2 o sexual characteristics and amenorrhea include all of the following except: a) Pregnancy test b) Pelvic ultrasound c) Prolactin level d) Thyrotropin level e) Assessment of estrogen status

39 Approach to Amenorrhea yes Stop investigating E+P challenge no bleed *Need to do Karyotype no

40 Polycystic Ovarian Syndrome (PCOS)

41 PCOS ► Syndrome resulting from chronic anovulation and/or chronic ovarian androgenism ► Can be associated with  insulin levels ► Diagnosis is made clinically +/- biochemical support ► Wide spectrum seen in clinical practice

42 PCOS - pathophysiology insulin anovulation↓FSH + ↑LH↑estrogen ↑androgens from ovary ↑peripheral estrogen oligomenorrhea INFERTILITYHIRSUTISM obesity

43 PCOS ► Clinical features:  Average age years  Hirsutism, anovulation/amenorrhea, infertility, insulin resistance, obesity, acanthosis nigricans (HAIR-AN) ► Biochemistry:   testosterone and DHEAS, LH:FSH ratio > 2:1  Fasting glucose:insulin ratio insulin resistance ► Ultrasound:  multiple follicles peripherally arranged (“string of pearls”) ► Diagnosis (need 2 out of 3 to make Dx):  Oligomenorrhea/irregular menses  Clinical or lab evidence of hyperandrogenism  Polycystic ovaries on US

44 Clinical Significance of PCOS ► Infertility ► Menstrual bleeding problems  Oligo/amenorrhea & DUB ► Androgen effects:  hirsutism, acne and alopecia ►  risk of endometrial cancer ►  risk of CAD ►  risk of type 2 diabetes if insulin resistant

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

46 Treatment of PCOS Hirsutism ► OCP or specifically Diane 35: antiandrogenic ► Mechanical removal of hair ► + spironolactone (inhibits steroid receptor) ► Finasteride (5alpha reductase inhibitor) ► Flutamide (androgen reuptake inhibitor)

47 Abnormal Uterine Bleeding

48 ► Abnormal bleeding at unexpected time (pre- menarche or post-menopausal) ► Change in pattern of menstrual flow  Frequency (interval < 24 days)  Duration (> 7 days)  Amount (> 80 cc per cycle/clots) ► Need to rule out organic causes

49 Abnormal Uterine Bleeding Menorrhagia: Cyclic menstrual bleeding occurring at regular intervals but excessive in amount (>80 cc/cycle) and/or duration (>7 days) Metrorrhagia (intermenstrual bleeding): Uterine bleeding occurring at irregular intervals Polymenorrhea Cycles occurring too frequently, < 24 days Menometrorrhagia: Excessive amount of bleeding at irregular intervals

50 Causes of Abnormal Uterine Bleeding ► Ovarian  anovulatory cycles  Ovarian cancer ► Uterine  polyps, fibroids  PID, endometritis  IUD  exogenous hormones  endometrial hyperplasia  endometrial cancer ► Cervical  Polyps  Infection  cervical cancer ► External Genitalia  Vulvovaginitis  trauma  Vaginal or vulvar cancer ► Others  Coagulation disorders  Thyroid disease

51 A 15 yo female is brought to the ED because of very heavy vaginal bleeding. Her Hb level is 90 g/L. Each of the following diagnoses should be considered except: a) Anovulatory, dysfunctional bleeding b) Coagulopathy c) Pregnancy d) Endometrial polyps e) Thyroid dysfunction

52 A 45 yo female is brought to the ED because of very heavy vaginal bleeding. Her Hb level is 90 g/L. What is the least likely diagnosis? a) Anovulatory, dysfunctional bleeding b) Coagulopathy c) Pregnancy d) Endometrial polyps e) Thyroid dysfunction

53 Approach to AUB

54 Abnormal Bleeding Investigations:

55 Dysfunctional Uterine Bleeding (DUB) Uterine bleeding without any evidence of organic disease ► i.e., no polyps, malignancy, pregnancy, etc. ► Diagnosis of exclusion Anovulatory DUB (90%) ► no ovulation = no progesterone secretion ► Prolonged, high, unopposed estrogen exposure ► Fragile endometrium, areas of shedding and re-growth Ovulatory DUB (10%) ► Luteal phase progesterone unable to maintain endometrium

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

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

58 Coffee Break !!!

59 PMS

60 Premenstrual Syndrome ► Regular monthly experience of at least one of  affective (depression, anger, irritability, anxiety)  somatic (breast tenderness, bloating, headaches)  Occurs 5 days before onset of menses  Relieved within 4 days of menses  Interferes with social/economic function ► Multifactorial: genetics, neurotransmitters, hormones ► Serotonergic dysregulation ► Premenstrual Dysphoric Disorder (PMDD)  More severe form of PMS  Specific diagnostic criteria DSM-IV

61 PMS - Treatment ► Diet/supplements  Avoid Na, sugars, caffeine, alcohol  Ca, Mg, Vit E, Vit B6 ► Psychological support, cognitive behavioral therapy ► Regular aerobic exercise ► Medications  NSAIDS  SSRI (luteal phase)  Spironolactone (luteal phase)  OCP, progesterone, Danazol, GnRH agonists


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

64 Menopause ► Physiologic  average age in North America  1-2M oocytes at birth, 500,000 in puberty, only ovulate, the rest vanish by atresia  Few remaining oocytes not responsive to gonadotropins ► Artificial  Surgery  radiation

65 Menopause ► Perimenopause  2-8 years preceding and 1 year after last menses  Elevated FSH in follicular phase  Irregular menses ► Menopause  Final menstruation ► Postmenopause  6-12 months of amenorrhea

66 Menopause

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

68 HRT ► Good  relief of vasomotor and GU symptoms  Increases BMD, decreases fracture risk ► Bad  Increases VTE, CAD, stroke ► ? Increased risk of breast cancer, dementia ► No increased risk of endometrial cancer


70 Contraception ► Permanent  Vasectomy, tubal ligation ► Reversible  Barrier methods  Hormonal Contraceptives (pill, patch, ring), progesterone only (pill, patch, ring), progesterone only  Intrauterine devices  Post-coital  Abstinence, rhythm, withdrawal, lactation

71 Barrier Contraception ► Male condom  Protects against STIs  Failure rate 10-30% in typical use ► Female barriers  Female condom, diaphragm, cervical cap  Need to fit properly, more inconvenient  Failure rate higher than male condom ► Spermicidal preparations  30% failure rate when used alone (typical use)

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

73 Hormonal Contraception ► Combined Contraceptives  Pill, patch, ring  Most contain low dose (20-35  g) ethinyl estradiol + progestin  Mechanism of action (mainly from progestin): Ovulatory suppression by FSH/LH inhibition Ovulatory suppression by FSH/LH inhibition Decidualization of endometrium Decidualization of endometrium Thickening of cervical mucous Thickening of cervical mucous  Non-contraceptive benefits  Multiple, but mild side effects  Does not protect against STI’s

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

75 Hormonal Contraception ► Progestin Only Methods  Suitable for lactating women or women with contraindications to combined OCP  “Minipill” (Micronor) Higher failure rate Higher failure rate Taken daily, no pill free interval Taken daily, no pill free interval  Depot-medroxyprogesterone acetate Injectable, q 3 mos Injectable, q 3 mos Common irregular bleeding to complete amenorrhea Common irregular bleeding to complete amenorrhea Highly effective Highly effective Return to fertility may take up to 1-2 yrs Return to fertility may take up to 1-2 yrs Risk of osteoporosis Risk of osteoporosis

76 Intrauterine Device (IUD) ► Device that sits in the uterine cavity ► Nova-T (copper containing)  foreign body reaction in endometrium ► Mirena (levonorgestrel releasing)  decidualization of endometrium + thickening of cervical mucous ► One time insertion, lasts up to 5 years ► Very effective, failure rate 1% ► Reversible


78 IUD Absolute contraindications ► Pregnancy ► Undiagnosed vaginal bleeding ► Acute or chronic PID ► Lifestyle risk for PID ► Allergy to copper ► Wilson’s disease (for copper) ► Immunosuppressed individuals Relative contraindication ► Valvular heart disease ► Past Hx of PID ► Past Hx of ectopic pregnancy ► Abnormalities of the uterine cavity, fibroids ► Severe dysmenorrhea or menorrhagia (for copper) ► Cervical stenosis

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

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

81 Emergency Contraception Yuzpe Method  within 72 hours of intercourse  2 Ovral tablets q12h x 2 doses (often with Gravol)  6% chance of pregnancy decreases to 2% with Yuzpe ‘Plan B’  within 72 hours of intercourse  0.75 mg levonorgestrel every 12h x 2 doses (less nausea)  similar efficacy to Yuzpe Copper IUD Insertion  within 5 days of intercourse  1% failure rate

82 Contraceptive Efficacy Typical usePerfect use Pearl Index(%preg/y)(%preg/y) Chance8585 Withdrawal194 Condom123 Condom + spermicide5 Female condom215 Diaphragm186 IUD

83 Contraceptive Efficacy MethodTypical usePerfect use(%preg/y) OCP~30.1 Nuva-ring~30.1 Ortho Evra~30.1 Depo Provera Norplant Female Sterilization Male Sterilization


85 Infertility Definition: one year of ‘frequent’ unprotected intercourse without conception Primary: no prior pregnancies Secondary: previous conception 10-15% of couples in the reproductive age group must investigate both partners

86 Infertility - Epidemiology Time Required for Conception in Couples Who Will Attain Pregnancy Duration of Exposure% Pregnant 3 months57% 6 months72% 12 months85% 24 months93% Guttmacher 1956

87 Preliminary Diagnosis 1) Oocyte: regular ovulation, good quality oocytes 2) Normal Female Genital Tract: patent tubes, ‘relatively’ normal uterus, cervix and vagina 3) Sperm: sufficient quantity and quality 4) Implantation: appropriate endometrial/embryo interaction e.g. ‘luteal phase deficiency’, “septa”, ‘polyps’ 5) Immunological Factors: appropriate immunological environment e.g. ‘endometriosis’, ‘antisperm antibodies’, Antiphospholipid Syndrome, ‘Blocking antibodies’ Fertility Requirements

88 Infertility - Etiology ► Ovarian Problems (15%) ► Tubal/Pelvic Pathology (35%) ► Sperm Problems (35%) ► Unexplained (10-15%)

89 Etiology 1. Ovulatory dysfunction (15-20%) Hypothalamic (functional amenorrhea)Hypothalamic (functional amenorrhea) Pituitary: prolactinoma, hypopituitarismPituitary: prolactinoma, hypopituitarism OvarianOvarian PCOS PCOS POF POF Luteal phase defect (poor follicle production, premature corpus luteum failure, failed uterine lining response to progesterone) Luteal phase defect (poor follicle production, premature corpus luteum failure, failed uterine lining response to progesterone) Systemic diseases (thyroid, Cushing, renal/hepatic failure)Systemic diseases (thyroid, Cushing, renal/hepatic failure) Congenital (Turner, gonadal dysgenesis, gonadotropin deficiency)Congenital (Turner, gonadal dysgenesis, gonadotropin deficiency)

90 Infertility: Ovulatory Dysfunction Overall Primary Investigations: Day 3 FSH Day ‘21’ progesterone TSH Prolactin Basal Body Temperature

91 Etiology 2. Outflow tract abnormality Tubal obstruction (~35%)Tubal obstruction (~35%) PID PID Adhesions (previous surgery, peritonitis, endometriosis) Adhesions (previous surgery, peritonitis, endometriosis) Ligation/occlusion (e.g., previous ectopic) Ligation/occlusion (e.g., previous ectopic) Uterine factors (<5%)Uterine factors (<5%) Congenital anomalies (DES exposure), bicornuate uterus, uterine septum Congenital anomalies (DES exposure), bicornuate uterus, uterine septum Intrauterine adhesions (e.g. Asherman’s) Intrauterine adhesions (e.g. Asherman’s) Infection (endometritis, pelvic TB) Infection (endometritis, pelvic TB) Fibroids/polyps Fibroids/polyps Endometrial ablation Endometrial ablation Cervical factors (5%)Cervical factors (5%) Hostile, or acidic cervical mucous Hostile, or acidic cervical mucous Anti-sperm antibodies Anti-sperm antibodies

92 Infertility: Tubal Factor Overall Primary Investigations: Hysterosalpingogram or Sonohysterogram/saline infusion scan or Laparoscopy In early proliferative phase of cycle after cessation of menses for evaluation of structural defects diagnostic and therapeutic (may open tubes)

93 Hysterosalpingogram (HSG)


95 Sonohysterogram with Echovist®

96 Laparoscopy

97 Laparoscopy

98 Etiology 3.Male factor (~40%) Pre testicularPre testicular Hypothalamic, pituitary (low LH, FSH, T) Hypothalamic, pituitary (low LH, FSH, T) TesticularTesticular Testicular failure (sometimes high FSH, low T) Testicular failure (sometimes high FSH, low T) Genetic Genetic Acquired Insult (infectious, varicocele) Acquired Insult (infectious, varicocele) Post testicular (normal FSH,LH,T)Post testicular (normal FSH,LH,T) Obstruction Obstruction

99 Infertility: Sperm/Male Factor Semen analysis WHO Criteria: volume > 2.0 ml concentration> 20 million sperm/ml motility> 50% morphology> 30% normal forms

100 Semen Variability

101 Infertility: Sperm/Male Factor Overall Primary Investigations: semen analysis x 2 Other investigations: karyotype TSH, Testosterone, PRL, FSH postcoital (sperm/cervical mucus interaction)

102 Infertility Investigations 1.Ovarian Function Day 3 FSH Day 3 FSH Day 21 progesterone Day 21 progesterone TSH, Prolactin TSH, Prolactin Basal Body Temperature Basal Body Temperature 2.Female Genital Tract HSG/SHG/SIS HSG/SHG/SIS Laparoscopy Laparoscopy 3.Male Factor Semen analysis x 2 Semen analysis x 2

103 Infertility - Treatments Approach based on fertility requirements: 1) Oocytes 2) Abnormal Female Genital Tract 3) Sperm use these categories to organize treatment options for each particular couple

104 Treatment Options 1.Ovarian problems: -Treat any hypothyroidism/hyperprolactinemia -If PCOS, weight loss, metformin, ovarian drilling -Induce ovulation (clomiphene, letrozole, etc) + IUI/IVF -donor oocytes/embryos, adoption 2.Tubal factors: -Tuboplasty -In-Vitro Fertilization (IVF) 3.Male factors: -Artificial Insemination (washed or donor sperm) -IVF + ICSI -Varicocele repair, surgical repair of obstruction

105 ICSI Intracytoplasmic Sperm Injection: Intracytoplasmic Sperm Injection: requires very few moving spermrequires very few moving sperm can combine with testicular sperm retrievalcan combine with testicular sperm retrieval requires IVF (female risks & discomfort)requires IVF (female risks & discomfort)

106 Pelvic Pain

107 26 yo G0P0 woman presents to the office with 8 years of constant pelvic pain. She has had 3 previous diagnostic laparoscopies (2 months, 2 years, and 6 years ago). All demonstrated a normal pelvis. She has recently been seen by specialists in General Surgery, GI, Urology, Orthopedics, and Gynecology. All investigations have been normal and no cause for the pain has been found.

108 Differential Diagnosis Gynecologic - ACUTE: 1. Adnexal: MittelschmerzMittelschmerz ovarian cysts, rupture, torsionovarian cysts, rupture, torsion Hemorrhage into ovarian cyst or neoplasmHemorrhage into ovarian cyst or neoplasm 2. Uterine: Degenerating fibroidsDegenerating fibroids Torsion of pedunculated fibroidTorsion of pedunculated fibroid Pyometra/hematometraPyometra/hematometra 3. Infectious Acute PIDAcute PID EndometritisEndometritis Gynecologic - CHRONIC: Endometriosis/adenomyosis dysmenorrhea (cyclic pain) Ovarian cysts Chronic PID adhesions Uterine prolapse Cancer invasive (late) Fibroids Pelvic congestion syndrome ** RULE OUT PREGNANCY!!!

109 Non-Gynecologic: 1. Urinary tract: infection, stones, retention interstitial cystitis 2. GI: appendicitis, diverticulitis, obstruction, infarct constipation, hernia, IBD, IBS 3. MSK: nerve entrapment, referred pain, abdominal wall, MS 4. Psychological trauma: Depression, anxiety, somatization ~20% of chronic pelvic pain patients have a history of sexual abuse/assault Differential Diagnosis

110 Diagnostic laparoscopy for pelvic pain should be performed to: a)Evaluate women with cyclic pain who respond to NSAIDs or OCP b)Initially evaluate women with chronic noncyclic pelvic pain c)Biopsy and treat endometriotic lesions d)Lyse all adhesions

111 Pelvic Pain - Investigations ► Gynecology related:  CBC,  hCG  vaginal/cervical cultures  pelvic U/S or MRI  Laparoscopy ► GI related:  stool cultures  abdominal U/S, CT/MRI  endoscopy ► Urologic:  urine cultures, urinalysis  IVP, U/S, CT ► Musculoskeletal:  xray, CT, MRI

112 Endometriosis ► Abnormal growth of endometrial tissue outside the uterine cavity ► Pathogenesis is unknown ► Infertility ► dysmenorrhea, dyspareunia, dyschezia ► On pelvic exam:  Tender nodules, fixed uterus  May also be normal

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

114 Case 31 y.o. woman complains of sudden onset of RLQ pain. The pain is constant and worse with movements. There is no nausea/vomitting. Bowel movements are normal. Her LMP is 7 weeks ago, and she has been actively trying to get pregnant. Past medical history is positive for PID requiring hospitalization for IV antibiotics for 4 days. Her vitals are stable, and she is afebrile. She is having mild vaginal bleeding (<1pad) that started today. What is your differential diagnosis???

115 Case What 3 initial investigations would be most appropriate? A) CBC B) pelvic ultrasound (endovaginal and transabdominal) C) flat plate (x-ray) of abdomen D) Quantitative  hCG E) sigmoidoscopy with possible colonoscopy F) IVP with delayed films

116 Ectopic Pregnancy

117 Definition embryo implants outside of the endometrial cavity Epidemiology 1-2% of all pregnancies ~14% if previous ectopic pregnancy ~1/30,000 pregnancies is heterotopic (1 IUP + 1 ectopic) 4 th leading cause of maternal mortality

118 Location of Ectopic Pregnancy

119 Ectopic Pregnancy


121 Risk FactorsRelative Risk Tubal surgery20 Previous ectopic10 Previous salpingitis4 Assisted Reproduction4 Age < 253 Previous pelvic infection3 Infertility2.5 Cigarettes2.5 * ~50% of patients have no risk factors * IUD use does not increase the risk of ectopic pregnancy

122 Ectopic Pregnancy Clinical Presentation amenorrhea abdominal pain (90%) + rebound (45%) vaginal bleeding bimanual exam: - CMT and adnexal tenderness (usually unilateral) - palpable adnexal mass (50%) ruptured ectopic pregnancy: - acute abdomen with  pain - hypovolemic shock

123 Investigations Hx & Px  HCG quantitative, CBC, blood T&S Pelvic ultrasound - an intrauterine pregnancy should be seen if  hCG > , definitely by 2,000 Serial  hCG: - normal doubling time is about 2 days - inadequate doubling suggests abnormal pregnancy Laparoscopy: definitive diagnosis

124 In order to distinguish an IUP from an ectopic pregnancy, the change in  HCG levels over 48 hours is observed. What percentage rise in  HCG represents the lower limit of normal values for viable IUP? a)33% b)50% c)66% d)100%

125 Treatment 1.Medical (Methotrexate): 50 mg/m 2 (1/5 chemo dose) serial  hCG weekly f/u 10-15% failure rate, 25% require 2 nd dose criteria: - patient clinically stable - <3.5cm unruptured ectopic pregnancy - no FHR -  hCG < no hepatic/renal/heme disease - compliance and f/u essential 2.Surgical Laparoscopy vs laparotomy Salphingectomy vs salphingotomy

126 Tea Break!!!

127 Pelvic Mass

128 Differential Diagnosis Adnexal ► Ovarian cysts/tumors ► Ectopic pregnancy ► Tubo-ovarian abscess ► hydrosalpinx Uterine ► Pregnancy ► Fibroids ► Adenomyosis ► Endometrial cancer ► hematometra *And non-gynecologic causes: Pelvic kidney, GI masses, abscess, lymph nodes

129 A 60 year old woman presents with a pelvic mass. What percentage of ovarian neoplasms in post- menopausal women is malignant a)5% b)10% c)30% d)80%

130 Ovarian Cysts/Tumors ► Benign vs. malignant ► Benign  Physiological (follicular cysts, corpus luteal cysts, hemorrhagic cysts)  Endometrioma  Benign adenomas  Germ cell tumors (dermoid cysts)

131 Ovarian Tumors


133 Pelvic Mass 1) History: - weight loss/gain - increase in abdominal girth - fatigue - fevers/chills - abnormal vaginal discharge or bleeding - menstrual history - pregnancy symptoms (amenorrhea, molimina) - pain - bowel/bladder dysfunction - family history of gynecological/bowel cancers

134 Pelvic Mass 2) Physical Exam: - complete general survey (including nodes) - abdominal exam - pelvic: speculum, bimanual, pelvi-rectal 3) Investigations: - U/S: abdominal and endovaginal - + CT or MRI - pre-op investigations - + pregnancy test

135 Pelvic relaxation/prolapse

136 Definitions Cystocele: downward displacement of bladder Uterine Prolapse: descent of the uterus and cervix into vaginal canal towards the vaginal introitus Rectocele: protrusion of rectum into posterior vagina Enterocele: herniation of small bowel into vagina Vaginal Vault Prolapse: descent of vaginal apex into vaginal canal towards introitus after a hysterectomy

137 Pelvic relaxation

138 Predisposing Factors age pregnancy and vaginal childbirth menopause (↓ estrogen) changes in pelvic anatomy (surgery) obesity chronic cough chronic constipation connective tissue disorders

139 Symptoms Pelvic pressure, bulge, heaviness Low back ache Possibly relief with lying down worse symptoms at the end of the day Voiding difficulty, incomplete emptying, UTIs, stress incontinence Constipation (need to reduce the rectocele to have BM) dyspareunia

140 Treatment 1.Conservative Pessary (not useful for rectocele) Kegels weight loss stool softeners HRT smoking cessation 2.Surgical Vaginal Hysterectomy (for uterine prolapse) Vaginal Repair (anterior, enterocele, and/or posterior repair) Vault suspension Anti-incontinence procedure


142 Pap Smear Management

143 Screening Test Sampling of transformation zone (endo/exocervix) Detection of early pre-malignant lesions Multiple classification systems Bethesda vs CIN System

144 Bethesda vs CIN

145 2005 Ontario Cervical Screening Guidelines Note:These recommendations do not apply to those women who have had previous abnormal Pap tests. ► Screening initiated within 3 years of first vaginal sexual activity ► Done annually until 3 consecutive negative Pap tests  Then every 2-3 years ► Cessation at age 70 if adequate negative screening (3-4 negatives in last 10 years)

146 PAP Smear Management Possible Results (Squamous) Within Normal Limits Atypical Squamous Cells of Undetermined Significance (ASCUS): may favour reactive or premalignant/malignant process Low Grade Squamous Intraepithelial Lesion (LSIL) High Grade Squamous Intraepithelial Lesion (HSIL) Squamous Cell Carcinoma

147 PAP Smear Management Possible Results (Glandular cells) Within Normal Limits Atypical Glandular Cells of Undetermined Significance (AGUS): may favour reactive or premalignant/malignant process Adenocarcinoma endocervical, endometrial, extra-uterine, NOS

148 Decision Making Chart

149 With endocervical assessment (If > 35yrs or abnormal bleeding) + ECC AIS Cone biopsy


151 Gynecologic Infections

152 Case 19 year old G0 woman presents to the ER with lower abdo/pelvic pain for 2 days. She had developed a fever today and a vaginal discharge. She has recently become sexually active, and is not using contraception. A pregnancy test is negative.

153 Case What is the most likely diagnosis? A) early appendicitis B) chlamydial cervicitis C) disseminated herpes D) PID E) trichomonas vaginitis

154 Acute Pelvic Inflammatory Disease (PID) Clinical diagnosis implying patient has upper genital tract infection and inflammation Ascending infection to endometrium, tubes, peritoneum Most often an STD: chlamydia, gonorrhea Rarely endogenous vaginal bacteria, TB

155 PID – Risk factors ► Age < 30, sexually active ► Vaginal douching ► IUD (esp. 1 st 10 days post insertion) ► Invasive gyne procedures: D&C, endometrial biopsy ► History of previous STI ► Multiple sexual partners ► No barrier contraception ► Contact with infected person

156 Presentation Spectrum of severity Up to 2/3 asymptomatic, many subtle or mild symptoms Common: Fever > 38.3 lower adbo pain and tenderness (adnexal) - Cervical motion tenderness on bimanual exam abnormal discharge: vaginal, cervical Uncommon: Nausea, vomiting Dysuria irregular vaginal bleeding RUQ pain (Fitz-Hugh-Curtis)

157 Investigations ► Bloodwork  BhCG (r/o ectopic), CBC, blood cultures if septic ► Speculum exam  Vaginal swab  Cervical cultures for GC and chlamydia ► Ultrasound  May be normal  Fluid in cul-de-sac  Hydrosalpinx, tubo-ovarian abscess, pelvic abscess ► Laparoscopy  For definitive diagnosis

158 What are the criteria that would require inpatient treatment of PID?

159 Treatment - Outpatient ORAL Regimen A: ► Ofloxacin 400 mg twice daily for 14 days OR ► Levofloxacin 500 mg once daily for 14 days WITH OR WITHOUT ► Metronidazole 500 mg twice daily for 14 days

160 ORAL Regimen B: ► Ceftriaxone 250 mg IM in a single dose OR ► Cefoxitin 2 g IM x 1 and Probenecid 1g PO PLUS ► Doxycycline 100 mg twice daily for 14 days WITH or WITHOUT ► Metronidazole 500 mg twice daily for 14 days Treatment - Outpatient

161 Treatment - Inpatient PARENTERAL Regimen A: Cefoxitin 2g OR Cefotetan 2g IV q6h (at least 48 h) PLUS Doxycycline 100mg IV/PO BID x 14 days PARENTERAL Regimen B: Clindamycin 900mg IV q8h (at least 48 h) PLUS Gentamicin 2mg/kg loading dose then 1.5mg/kg maintenance dose q8h (at least 48 h)

162 Treatment - Inpatient Alternative PARENTERAL Regimens: ► Ofloxacin 400 mg IV q 12 hours OR ► Levofloxacin 500 mg IV once daily WITH OR WITHOUT ► Metronidazole 500 mg IV q 8 hours OR ► Ampicillin/Sulbactam 3 g IV q 6 hrs PLUS ► Doxycycline 100 mg orally/IV q 12 hrs

163 Chlamydial Cervicitis Etiology: Chlamydia trachomatis Intracelluar parasite Most common bacterial STI in Canada Often associated with N. Gonorrhea Reportable disease Risk Factors: sexually active < 25 y.o. history of previous STI new partner in last 3 months multiple partners no barrier contraception contact with infected person

164 Presentation ► Asymptomatic (70%) ► mucopurulent endocervical discharge ► pelvic pain/discomfort to PID ► Urethral syndrome: dysuria, frequency, pyuria with no bacteria ► post coital spotting or intermenstrual bleed Investigations: ► Cervical cultures ► Rescreen women 3-4 months after treatment due to high prevalence of repeat infection

165 Treatment - Chlamydia Doxycycline 100mg PO BID x 7 days OR Azithromycin 1g PO x 1 Alternative treatments: Erythromycin base 500 mg qid for 7 days OR Erythromycin ethylsuccinate 800 mg qid for 7 days OR Ofloxacin 300 mg twice daily for 7 days OR Levofloxacin 500 mg for 7 days * if pregnant Erythromycin, Amoxicillin, Azithromycin **Screen and treat partners

166 Neisseria Gonorrhea Cervix, urethra, rectum: gram negative intracellular diplococci reportable disease Presentation and Risk Factors: same as chlamydia Investigations: cervical, rectal and throat culture

167 Gonorrhea - intracellular Gram negative diplococci

168 Treatment ► Ceftriaxone 125mg IM x 1 OR ► Cefixime 400mg PO x 1 OR ► Ciprofloxacin 500mg PO x 1 OR ► Ofloxacin 400 mg/Levofloxacin 250 mg AND ► Treatment for Chlamydia * If pregnant: cephalosporin regimen or 2g spectinomycin IM

169 Vulvovaginitis OrganismDischargeSymptomsWet MountPh Candida(Yeast)White thick -itching KOH <5 -satellite lesions -hyphae -edematous -red Bacterial Vaginosis Grey, thin, - fishy odour - clue cells5-5.5 (anaerobes, diffuse - worse after KOH (+whiff test) Gardnerella, etc.) intercourse - no irritation/ inflammation TrichomonasisYellow/green-strawberry -fagellated5-6.5 (Trichomonasspots protozoa Vaginalis) Physiologic (high E 2 states)Clear/white- no irritation/ -normal<4.5 inflammation epithelial cells

170 Vulvovaginitis Candida Vulvitis

171 Vulvovaginitis Candida - KOH prep Hyphea

172 Vulvovaginitis Clue cell - epithelial cell with bacteria clustered peripherally

173 Vulvovaginitis Trichomonas- strawberry spots

174 Vulvovaginitis Treatment Candida(Yeast)-clotrimazole, miconazole, terconazole -Diflucan 150 mg PO x 1(resistant cases) -lactobacillus acidophilus Bacterial VaginosisMetronidazole 500mg PO BID x 7 days (or 2g PO x1) OR Clindamycin 300mg PO BID x 7 days OR topical above creams QHS x 7 days TrichomonasMetronidazole 500mg PO bid x 7days or 2g PO x 1

175 Vulvar Lesions 1.Condylomata Acuminata (genital warts) human papilloma virus (HPV) strongly associated with cervical/vulvar intraepithelial neoplasia and cancer acetowhite lesions, wart-like projections Not preventable even if using condoms Treatment: podofilox solution or gel x 3 days than repeat x 4 wks Imiquimod (Aldara®) 3x/wk qhs x 16 wks liquid N repeat q1-2 wks TCA weekly laser, electro, excision intralesional interferon

176 Condylomata Acuminata


178 2.Molluscum Contagiosum Molluscipox virus mildy contagious nodule with umbilicated centre Treatment Curette TCA, silver nitrate, carbonic acid Vulvar Lesions

179 Molluscum Contagiosum


181 Genital Ulcers Organism DescriptionDiagnosis Herpes-prodromalviral culture (HSVII, I(10%))-small vesicle progresses to shallow, painful, inflamed Syphilis-smooth, raised borderdark field micro (Treponema -painless, smooth base-spirochetes pallidum) -VDRL etc. Chancroid-irregular border, deepculture Gram stain (Hemophilusundermined edges, painful-GNB in rows ducreyi)+/- buboe (tender lymphadenopathy)

182 Genital Herpes


184 Syphilis - Treponema pallidum

185 Darkfield Microscopy - Treponema pallidum

186 Organism Treatment Herpes1 0 acyclovir 400mg PO TID x 7-10d (HSVII, I(10%))2 0 acyclovir 400mg PO TID x 5d daily suppressive: if 6-8 attacks/yr: acyclovir 400mg PO BID Syphilisbenzathine penicillin G 2.4 million units IM (all stages) (Treponema -treat partners pallidum) -reportable illness Chancroid-erythromycin 500mg QID x 7 days (HemophilusOR ceftriaxone 250mg IM x 1 ducreyi)OR azithromycin 1g PO x1 -treat partners Genital Ulcers

187 Questions?

Download ppt "March 29, 2010 Back to Basics: Gynecology Dr. Jessica Dy Assistant Professor Department of Obstetrics and Gynecology University of Ottawa."

Similar presentations

Ads by Google