1. March, 2016 Back to Basics: Gynecology Dr. John Lamensa Assistant Professor Department of Obstetrics and Gynecology University of Ottawa

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

4. A mother is concerned that her 12 year old daughter has not had her period yet (the other girls in her daughter’s class have already started theirs). She also thinks her daughter does not show other signs of puberty yet. Knowing the first sign at 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 clinically recognized sequence of events in normal pubertal development are: a) Accelerated growth, pubic hair, breast budding, menarche b) Breast budding, peak growth, pubic hair, menarche c) Breast budding, menarche, pubic hair, accelerated growth d) Pubic hair, breast budding, menarche, accelerated growth

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

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

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

9. Normal Menstrual Cycle

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

11. 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

12. 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 ( autoimmune, infection, irradiation, surgery, chemo ) Anovulation (PCOS, tumors) Congenital Absence, Imperforate hymen, Vaginal septum, Asherman’s syndrome Drugs (Metoclopramide, neuroleptics) ALWAYS NEED TO RULE OUT!

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

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

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

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

17. Approach to Abnormal Bleeding

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

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

20. DUB Longterm Treatment Hormonal Manipulation of Cycle Combined ContraceptivesCombined Contraceptives Progesterone onlyProgesterone only Progesterone IUD (Mirena)Progesterone IUD (Mirena) GnRH analogueGnRH analogue Control of Menorrhagia NSAIDs for menorrhagiaNSAIDs for menorrhagia Anti-fibrinolytic agents (oral Cyklokapron)Anti-fibrinolytic agents (oral Cyklokapron)Surgical endometrial ablationendometrial ablation hysterectomyhysterectomy

21. A 26 year old G0 complains of being too hairy. Her menses have always been irregular occurring every 2 to 6 months. She also complains of acne and is seeing a dermatologist for this. She denies any other medical problems. She is 5’ 5’’ tall, weighs 200 lbs, and her BP is 100/60. On exam, there is sparse hair around the nipples, chin and upper lip. There is no galactorrhea, thyromegaly, or temporal balding. Pelvic examination is normal. Which is the most likely condition in this patient? a)Idiopathic hirsutism b)Polycystic ovarian syndrome c)Late onset congenital adrenal hyperplasia d)Sertoli-leydig cell tumor of the ovary e)Adrenal tumor

22. PCOS Features: Features: Menstrual irregularity (typically oligomenorrhea/anovulation) Menstrual irregularity (typically oligomenorrhea/anovulation) Possible androgen excess (clinical: acne, hirsutism, male-pattern hair loss)± biochemical. Possible androgen excess (clinical: acne, hirsutism, male-pattern hair loss)± biochemical. ± polycystic ovaries ± polycystic ovaries Metabolic issues/cardiovascular risks ( BMI; insulin resistance; DM2; dyslipidemia) Metabolic issues/cardiovascular risks ( BMI; insulin resistance; DM2; dyslipidemia) Rotterdam Criteria Rotterdam Criteria

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

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

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

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

27. 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

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

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

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

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

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

33. 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

34. Method-related Pregnancy

35. Methods of Birth Control Currently Used By Women Who Have Had Intercourse Method% Oral contraceptives32 Condom21 Sterilization, male15 Sterilization, female8 Withdrawal6 Injection (DMPA)2 Intrauterine device1 Rhythm2 (DMPA) depot-medroxyprogesterone acetate

36. Canadian Contraceptive Survey (2006) Rank of most common methods: Oral contraceptive? Oral contraceptive? Withdrawal? Withdrawal? LARC (long-acting reversible)? LARC (long-acting reversible)? Condoms? Condoms? Condoms (54%) Oral contraceptive (44%) Withdrawal (12%) LARC (4.6%)

37. Pill-Related Problems Bloating, nausea, and breast tenderness Breakthrough bleeding Amenorrhea goal of continuous or extended cycle bothersome for cyclic regimens Post-pill amenorrhea median time for menses was 32 days and < 90 days for 99% consider amenorrhea w/u

38. 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

39. In combined hormonal contraceptives, which of the following is the primary contraceptive effect of the estrogenic component? a) Conversion of ethinyl estradiol to mestranol b) Atrophy of the endometrium c) Suppression of cervical mucus secretion d) Suppression of LH secretion e) Suppression of FSH secretion

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

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

42. 27 yo nulligravid student was “celebrating” with her male partner after passing her exams. Immediately after intercourse she noticed that the condom was broken. Her LMP was 12 days ago. She has regular 28 day cycles with molimina. She normally takes Alesse but had stopped 6 months ago. She pages you at 2 am. She does not want to get pregnant. What would be the appropriate management(s) to offer this couple? (You may chose up to three answers)

43. Emergency 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.

44. Emergency Contraception Plan B, Norvelo, Next Choice, Option 2  within 72 hours of intercourse. Available OTC.  0.75 mg (LNG) every 12h x 2 doses (less nausea) or 1 double dose of the LNG EC regimen (1.5 mg) may be used, as they have similar efficacy with no difference in side effects.  increase in efficacy compared to Yuzpe with 1.1% pregnancy rate.  Decreased efficacy BMI 25-29. Yuzpe Method  within 72 hours of intercourse. Requires Rx.  2 Ovral tablets q12h x 2 doses (with Gravol!)  100 µg estradiol + 500 µg levonorgestrol (LNG) EACH dose.  6% chance of pregnancy decreases to 2% with Yuzpe  recent estimate of pregnancy 3.2%

45. Emergency Contraception Copper IUD Insertion (Liberte, Mona Lisa, Flexi-T approved for EC use)  most effective. Need Rx.  within 5 days of intercourse (extended up to 7 days in Canada)  1% failure rate Ulipristal acetate (Fibristal)  Selective Progesterone Receptor Modulator (sPRM). Need Rx.  30 mg po once up to 5 days of UPI.  More effective than LNG over 5 days (can suppress pregnancy after LH surge) and BMI>25  Decreased efficacy with BMI>35 Follow-up Follow-up

46. OVRAL AND SUBSTITUTIONS BrandPills/Dose EE (μg)/Dose LNG (μg)/Dose Ovral2100500 Alesse5100500 Triphasil 4 yellow 120500 Triquilar 120500 Minovral4120600 Follow Yuzpe, therefore, repeat dose in 12h.

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

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

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

50. Continuous & Extended Hormonal Contraception commonly used to various degrees worldwide commonly used to various degrees worldwide consider offering it to women for contraception, medical reasons, and personal preferences consider offering it to women for contraception, medical reasons, and personal preferences as effective as cyclic regimens as effective as cyclic regimens fewer total days bleeding and similar BTB pattern compared to cyclic. Both improving over time. fewer total days bleeding and similar BTB pattern compared to cyclic. Both improving over time. short-term safety data similar to cyclic short-term safety data similar to cyclic

51. Continuous & Extended Hormonal Contraception Non-contraceptive benefits: Pain suppression (endometriosis) Bleeding suppression (fibroids, bleeding diathesis) Suppression of withdrawal symptoms (PMS) Suppression of menstrual migraine Management of perimenopausal symptoms

52. Pelvic Pain: Differential Diagnosis ACUTE: Adnexal:Adnexal: MittelschmerzMittelschmerz Ovarian cysts, rupture, torsionOvarian cysts, rupture, torsion Hemorrhage into ovarian cyst or neoplasmHemorrhage into ovarian cyst or neoplasm Uterine:Uterine: Degenerating fibroidsDegenerating fibroids Torsion of pedunculated fibroidTorsion of pedunculated fibroid Pyometra/hematometraPyometra/hematometra InfectiousInfectious Acute PIDAcute PID EndometritisEndometritis CHRONIC: Endometriosis/adenomyosisEndometriosis/adenomyosis Dysmenorrhea (cyclic pain)Dysmenorrhea (cyclic pain) Ovarian cystsOvarian cysts Chronic PIDChronic PID AdhesionsAdhesions Uterine prolapseUterine prolapse Cancer invasive (late)Cancer invasive (late) FibroidsFibroids Pelvic congestion syndromePelvic congestion syndrome * RULE OUT PREGNANCY *

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

54. Endometriosis Abnormal growth of endometrial glands and stroma outside the uterine cavityAbnormal growth of endometrial glands and stroma outside the uterine cavity Pathogenesis is unknownPathogenesis is unknown InfertilityInfertility Dysmenorrhea, dyspareunia, dyscheziaDysmenorrhea, dyspareunia, dyschezia On pelvic exam:On pelvic exam: Tender nodules especially over uterosacralsTender nodules especially over uterosacrals Uterine retroversion with decreased mobilityUterine retroversion with decreased mobility Adnexal enlargement with tendernessAdnexal enlargement with tenderness May also be normalMay also be normal

55. “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 non/cyclic pelvic pain c)Biopsy and treat endometriotic lesions d)Lyse all adhesions

56. 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.

57. Your 43 yo patient would like to get pregnant but is concerned that she may be too old. You recommend that she have her gonadotropin levels tested. Which day of the menstrual cycle is best to test this? Which day would be best to check her progesterone level to confirm ovulation? (cycle interval 28 days) FSH, AFC, AMH all designed to test ovarian reserve. a)Day 3 b)Day 8 c)Day 14 d)Day 21 e)Day 26

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

59. Infertility Investigations 1.Ovaries Day 3 FSH Day 3 FSH Day 21 progesterone Day 21 progesterone TSH, Prolactin TSH, Prolactin Basal Body Temperature Basal Body Temperature 2.Testes Semen analysis x 2 Semen analysis x 2 3.Tubes HSG/SIS (saline infusion sonohysterography)/ Tubal Patency testing (ie. Echovist – starch solution with saline shaken to form millions bubbles) HSG/SIS (saline infusion sonohysterography)/ Tubal Patency testing (ie. Echovist – starch solution with saline shaken to form millions bubbles) Laparoscopy (with chromopertubation) Laparoscopy (with chromopertubation) 4.Sex Timing Timing Frequency Frequency

60. Hysterosalpingogram (HSG)

61. HSG

62. Saline Sonohysterography

63. Laparoscopy

64. 31 y.o. woman complains of sudden onset of RLQ pain. pain is constant and worse with movements. pain is constant and worse with movements. no nausea/vomiting.no nausea/vomiting. bowel movements are normal.bowel movements are normal. Her LMP was 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 (<1 pad) that started today. The abdomen is tender with guarding.

65. What is the most likely diagnosis? a) (Ruptured) Ectopic pregnancy b) Appendicitis c) Incomplete abortion d) Ovarian torsion e) Hydatidiform mole

66. Location of Ectopic Pregnancy

67. a) CBC b) pelvic ultrasound (endovaginal and transabdominal) c) flat plate (x-ray) of abdomen d) quantitative h CG e) sigmoidoscopy with possible colonoscopy f) IVP with delayed films What 3 initial investigations would be most appropriate?

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

69. Investigations Hx & P/E hCG quantitative, CBC, blood T&S hCG quantitative, CBC, blood T&S Pelvic Ultrasound and the Discriminatory Level Pelvic Ultrasound and the Discriminatory Level - an intrauterine pregnancy should be seen if - hCG > 1 500 – 2 000 IU/L (transvaginal) - hCG > 6 500 IU/L (transabdominal) Serial hCG Serial hCG - normal doubling time is about 2 days - inadequate doubling suggests abnormal pregnancy Laparoscopy: diagnostic and therapeutic. Laparoscopy: diagnostic and therapeutic.

70. Ectopic Pregnancy

71. Treatment 1.Medical (Methotrexate): 50 mg/m 2 (1/10 th chemo dose)50 mg/m 2 (1/10 th chemo dose) serial hCG; weekly F/Userial hCG; weekly F/U 10-15% failure rate, 25% require 2 nd dose10-15% failure rate, 25% require 2 nd dose Criteria:Criteria: patient clinically stablepatient clinically stable no FHRno FHR hCG <5000hCG <5000 <3.5cm unruptured ectopic pregnancy<3.5cm unruptured ectopic pregnancy no hepatic/renal/hematologic diseaseno hepatic/renal/hematologic disease compliance and F/U essentialcompliance and F/U essential 2.Surgical Laparoscopy vs laparotomyLaparoscopy vs laparotomy Salpingectomy vs salpingostomySalpingectomy vs salpingostomy

72. A 60 year old woman presents with a pelvic mass. What percentage of ovarian neoplasms in post-menopausal women are malignant: a)5% b)10% c)30% d)50%

73. Differential diagnosis of adnexal masses in women Extra-ovarian mass Ectopic pregnancy Hydrosalpinx or tuboovarian abscess Paraovarian cyst Peritoneal inclusion cyst Pedunculated fibroid Diverticular abscess Appendiceal abscess or tumor Fallopian tube cancer Inflammatory or malignant bowel disease Pelvic kidney Ovarian mass Simple or hemorrhagic physiologic cysts (eg, follicular, corpus luteum) Endometrioma Theca lutein cysts Benign, malignant, or borderline neoplasms (eg, epithelial, germ cell, sex-cord) Metastatic carcinoma (eg, breast, colon, endometrium)

74. Ovarian Neoplasms Origins of ovarian tumours UptoDate 2016

75. 1. 21 yo G2P2 with increasing hair growth, more acne, with a 7cm left adnexal mass. Sertoli-Leydig (sex chord/stromal) Sertoli-Leydig (sex chord/stromal) 2. A 23 yo woman undergoing laparoscopy for a 5 cm solid right ovarian mass. Pathology shows hair, sebum and thyroid tissue. Mature teratoma (germ cell) Mature teratoma (germ cell) 3. A 56 yo postmenopausal woman with enlarged uterus, vaginal bleeding, and a 6 cm right adnexal mass. Granulosa cell (sex chord/stromal) can produce estrogen. Granulosa cell (sex chord/stromal) can produce estrogen. 4. A 10 yo healthy young girl with LLQ pain and left ovarian mass. Germ cell Germ cell 5. A 17 yo woman with primary amenorrhea with a pelvic mass. Karyotyping revealed a mosaicism of sex chromosomes (45, X/46, XY) Gonadoblastoma (mix of sex chord and germ cell) Gonadoblastoma (mix of sex chord and germ cell)  Granulosa tumour  Germ cell tumour  Gonadoblastoma  Sertoli-Leydig cell tumour  Mature teratoma (dermoid cyst)

76. Ovarian Cysts/Tumours Benign vs. malignant Benign vs. malignant Benign Benign Physiological (follicular cysts, corpus luteal cysts, hemorrhagic cysts Physiological (follicular cysts, corpus luteal cysts, hemorrhagic cysts Endometrioma Endometrioma Cystadenomas Cystadenomas Dermoid cysts Dermoid cysts

77. Ultrasound: Ovarian Tumours

78. A 30 yo woman came to your office because her 70 yo grandmother recently died from ovarian cancer. You discuss with her the risk factors and prevention of ovarian cancer. Which of the following can decrease a woman’s risk of ovarian cancer? a) Use of combination OC therapy b) Menopause after age 55 c) NSAIDS d) Nulliparity e) Ovulation induction medications

79. Cervical Cancer Screening Guidelines (2012) Question2005 GuidelinesUpdated Cytology Guidelines (2011) Primary HPV guidelines (2011) InitiationWithin 3 years of 1 st vaginal sexual activity (with cytology) Age 21 years with cytology in sexually active women Age 30 years with primary HPV screening Interval (after a negative test)Annual until 3 consecutive negative cytology tests, then every 2-3 years Every 3 yearsAge ≥ 30: every 5 years CessationAge 70 (if adequate negative screening history in previous 10 years (≥ 3 negative tests) No changeAge 65 years if adequate negative screening history and final negative HPV test at age 65 years Follow-up (after a positive test) ASCUS (age ≥ 30): triage with HPV ASCUS (age < 30): repeat cytology at 6 mos. intervals over 12 mos. ASC-H, HSIL, sq. ca., adenoca. Refer to colposcopy AGC, atypical endocervical cells, atypical endometrial cells. Refer to colposcopy ± endometrial sampling LSIL: repeat cytology at 6 mos. Intervals over 12 mos. Or refer to colposcopy. No changeAge ≥ 30: HPV +ve: triage with cytology HPV +ve/cytology +ve (≥ASCUS): refer to colposcopy HPV +ve/cytology –ve: repeat HPV test at 12 mos. Refer HPV +ve results to colposcopy.

80. A 45 yo G4P4 presents for her well-woman examination. She has had 4 vaginal deliveries. Her LMP was 1 year ago and she still has occasional vasomotor symptoms. Past health is notable for conization of the cervix for adenocarcinoma in situ (AIS) performed 5 years ago. All of her PAP smears have been normal since. How often should she undergo PAP smear testing? a) Every 3 months b) Every 6 months c) Every year d) Every 2 years e) Every 3 years

81. Colposcopy

82. 1° HPV Management Algorithm HPV testing in women age 30-65 years NegativePositive Colposcopy Repeat HPV testing at 12 months Repeat HPV testing at 5 year intervals until age 65 Positive (≥ ASCUS) Negative Cytology test Positive Negative

83. 1° HPV Screening Disconnect between the Science and Reality: Clear evidence for primary HPV screening but conventional PAP/cytology is sole modality so far Clear evidence for primary HPV screening but conventional PAP/cytology is sole modality so far HPV test not currently publicly-funded in Ontario HPV test not currently publicly-funded in Ontario Currently more of a co-test Currently more of a co-test Should implement primary HPV screening within organized program Should implement primary HPV screening within organized program OCSP not fully organized – underway with patient correspondence starting summer 2012 OCSP not fully organized – underway with patient correspondence starting summer 2012 ? implementation in 2015-2016. ? implementation in 2015-2016.

84. A 21 yo woman is seen for a Pap smear showing HSIL, colposcopy confirms a cervical lesion. Which of the following HPV types is often associated with this type of lesion? A 20 yo woman complains of bumps around her vaginal opening which have been getting bigger. On physical exam, there are multiple 2-10 mm lesions around her introitus. Her cervix has no gross lesions. A Pap test showed ASCUS. Reflex HPV testing showed no high risk HPV. Which of the following HPV types is often associated with this? a) HPV type 6 b) HPV type 11 c) HPV type 16 d) HPV type 42 e) HPV type 44

85. HPV infection is easily transmitted and does not require sexual intercourse. True or False? HPV infection is easily transmitted and does not require sexual intercourse. True or False? HPV infections can become dormant or latent. True or False? HPV infections can become dormant or latent. True or False? The quadrivalent and nonavelent vaccines are not indicated for the prevention of anal cancer and AIN. True or False? The quadrivalent and nonavelent vaccines are not indicated for the prevention of anal cancer and AIN. True or False? List 2 principle factors in HPV(-) oropharyngeal cancers: List 2 principle factors in HPV(-) oropharyngeal cancers: Smoking and EtOH. Tend to be older as well. Smoking and EtOH. Tend to be older as well. Infection and clearance of an HPV sub-type protects from re- infection of the same type. True or False? Infection and clearance of an HPV sub-type protects from re- infection of the same type. True or False? A PAP test is a screening method for HPV. True or False? A PAP test is a screening method for HPV. True or False?

86. HPV Immunization Gardasil® a quadrivalent HPV vaccine, targets HPV types 6, 11, 16, and 18 Gardasil® a quadrivalent HPV vaccine, targets HPV types 6, 11, 16, and 18  16 and 18 are 2 high-risk (HR) types associated in 70% of cervical cancer Gardasil-9®, a 9-valent vaccine, targets the same HPV types as the quadrivalent vaccine as well as types 31, 33, 45, 52, and 58. Gardasil-9®, a 9-valent vaccine, targets the same HPV types as the quadrivalent vaccine as well as types 31, 33, 45, 52, and 58. What percentage of cervical cancers are related to the HPV genotypes in this vaccine? What percentage of cervical cancers are related to the HPV genotypes in this vaccine? 90% 90% Cervarix®, a bivalent vaccine, targets HPV types 16 and 18. Cervarix®, a bivalent vaccine, targets HPV types 16 and 18. Immunized women continue to need screening. Immunized women continue to need screening.

87. A 29 yo G0 complains of a vaginal discharge that is thin, grayish white color. She noticed a slight fishy vaginal odor. She denies vaginal or vulvar pruritis or burning. She is sexually active, but denies STIs in the past. She is on OCP. Last month, she took a course of amoxicillin for a sinus infection. What is the most likely diagnosis? a) Physiologic discharge b) Candidiasis c) Bacterial vaginosis d) Trichomoniasis e) Chlamydia

88. Parameter Normal Findings Vulvovaginal candidiasis Bacterial vaginosis Trichomoniasis Symptoms None or mild, transient Pruritus, soreness, change in discharge, dyspareunia Malodorous discharge, no dyspareunia Malodorous, purulent discharge, dyspareunia Signs Normal vaginal discharge: white/ transparent, thick, mostly odorless Vulvar erythema, edema, fissure. Thick, white, adherent, “cottage- cheese” Thin, homogeneous, gray, malodourous discharge Purulent, greenish- yellow discharge, vulvovaginal erythema Vaginal pH 4.0 - 4.5 > 4.5 5.0 - 6.0 Amine Test NegativeNegative Positive (about 70- 80%) Often positive Saline microscopy PMN:EC ratio <1; rods dominate; squames +++ PMN:EC ratio <1; rods dominate; squames +++;pseudohyphae (about 40 percent); budding yeast for nonalbicans Candida PMN:EC 90 percent) PMN ++++; mixed flora; motile trichomonads (60 percent) 10% KOH Negative Pseudohyphae (about 70 percent) NegativeNegative Other Culture if microscopy negative Culture of no value If microscopy negative perform culture or rapid antigen/nucleic acid amplification tests Differential Diagnosis Physiologic leukorrhea Contact irritant or allergic vulvar dermatitis, chemical irritation, focal vulvitis (vulvodynia) Purulent vaginitis, DIV, atrophic vaginitis, erosive lichen planus

89. GENERAL DIAGNOSTIC APPROACH ► Office-based tests are under-utilized:  Microscopy not performed in 37%  pH not measured in >90%  Whiff testing not performed in >90%  Medication prescribed in 54% without clinical evaluation.

90. Vulvovaginitis Treatment  Candida  Intravaginal OTC azole ovules and creams (clotrimazole, miconazole)  Fluconazole 150 mg po single dose  Bacterial Vaginosis Metronidazole 500 mg po BID for 7days Metronidazole 500 mg po BID for 7days Metronidazole gel 0.75%, 5g pv OD for 5 days Metronidazole gel 0.75%, 5g pv OD for 5 days Clindamycin cream 2%, 5g pv OD for 7 days (oil-based) Clindamycin cream 2%, 5g pv OD for 7 days (oil-based)  Alternatives Metronidazole 2 g PO single dose (85% cure but higher relapse) Metronidazole 2 g PO single dose (85% cure but higher relapse) Clindamycin 300 mg PO for 7 days Clindamycin 300 mg PO for 7 days  Trichomonas  Metronidazole 2 g po single dose  Metronidazole 500 mg BID for 7 days

91. 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. What is the most likely diagnosis? a) early appendicitis b) chlamydial cervicitis c) disseminated herpes d) PID e) trichomonas vaginitis

92. PID Clinical diagnosis ascending infection to endometrium, tubes, peritoneum ascending infection to endometrium, tubes, peritoneum spectrum of severity spectrum of severity 2/3 asymptomatic, many subtle or mild symptoms. 2/3 asymptomatic, many subtle or mild symptoms.Common: fever > 38.3 C fever > 38.3 C lower abdominal/pelvic pain and tenderness (adnexal) lower abdominal/pelvic pain and tenderness (adnexal) cervical motion tenderness on bimanual exam cervical motion tenderness on bimanual exam abnormal discharge: vaginal or cervical. abnormal discharge: vaginal or cervical.Uncommon: nausea, vomiting nausea, vomiting dysuria dysuria irregular vaginal bleeding irregular vaginal bleeding RUQ pain (Fitz-Hugh-Curtis) RUQ pain (Fitz-Hugh-Curtis)

93. Reasons for Hospitalization pregnancypregnancy failed outpatient management of oral antimicrobialsfailed outpatient management of oral antimicrobials unable to tolerate oral medsunable to tolerate oral meds tubo-ovarian abscesstubo-ovarian abscess severe illness, nausea/vomiting, high feversevere illness, nausea/vomiting, high fever immunocompromisedimmunocompromised previous instrumentationprevious instrumentation unreliable for follow up or complianceunreliable for follow up or compliance

94. A 50 yo woman complains of leakage of urine. In addition to genuine stress urinary incontinence (GSI), which of the following is the most common cause of urinary leakage? a) Detrusor dyssynergia b) Urethral diverticulum c) Overflow incontinence d) Mixed incontinence e) Fistula

95. A 65 yo woman presents for evaluation of pelvic prolapse. She has a history of well controlled chronic hypertension. She has had 3 SVD, the last baby weighed 9 lbs and required forceps for delivery. She has a Hx of chronic constipation and uses a laxative regularly. She has smoked for 30 years and has a smoker’s cough. She is post- menopausal and has never been on HT. Which of the following is the LEAST important in the subsequent development of genital prolapse in this patient? a) chronic cough b) chronic constipation c) chronic hypertension d) childbirth trauma e) menopause

96. Pelvic relaxation

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

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

99. Good Luck!! Any questions?