Gynecologic Disordersfor Board Review

Jennifer H. Horan, DO PGY-4

Emergency Medicine

Arrowhead Regional Medical Center

Gynecology Cervix

◦ Cervicitis◦ Tumors

Vagina◦ Bartholin’s Abscess◦ Foreign Body◦ Vaginitis◦ Vulvovaginitis

Ovary◦ Torsion◦ Tumors

Uterus◦ Dysfunctional Bleeding◦ Endometriosis◦ Prolapse◦ Tumors

GTD Leiomyoma

Infections◦ PID◦ Fitz-Hugh-Curtis◦ Tubo-ovarian Abscess

Lesions◦ HSV◦ HPV

OvaryOvarian Cysts

◦Most frequently seen in reproductive years

◦Follicular Cyst - MC 1st 2 weeks of cycle Thin-walled, fluid filled

◦Corpus Luteal Cyst Last 2 weeks of cycle More likely to hemorrhage

◦Clinical Presentation: Pelvic Pain (generalized, dull)

Ovarian Cysts Exclude pregnancyCheck Hemoglobin (in case hemorrhagic cyst) Dx: ultrasoundTx: symptomatic treatment &

out-patient follow-upD/C: torsion precautions

Cyst is considered large if >3 cm (increased risk for torsion)

OvaryOvarian Torsion

◦Ovary twists in its vascular pedicle◦50-80% cases associated with ovarian

tumor or large cysts; previous pelvic surgery/adhesions

◦The twist causes venous/lymph obstruction leading to congestion and edema, then ischemia & necrosis

◦Ovary has DUAL blood supply so arterial obstruction is rare, thus Doppler US may show flow

Ovarian TorsionSxs: unilateral severe pain,

nausea, NO feverRisk factors

◦Hx cyst, assisted reproductive therapyPresentation atypicalExam: unilateral tendernessLabs NOT helpfulDx: Doppler ultrasound;

laparoscopy (gold standard)

OvaryOvarian Cancer

◦Peak age 55-65◦Affects 1 in 70 women◦Disease is often advanced at time of diagnosis

50% mortality

◦Risk Factors: FMH ovarian, breast or colon ca Infertility, low parity, high-fat diet, lactose

intolerance

◦Sxs: subacute abdominal pain, bloating, weight loss/gain, ascites, pleural effusion

◦Dx: US and CT Scan, CA-125 ◦Tx: surgery, chemotherapy, and/or radiation

CervixCervical Cancer

◦Risk Factor: HPV HPV Vaccine – Girls 9-26

◦In patients with HIV AIDS ◦Mostly squamous cell cancers◦Post-coital bleeding◦Dx: Pelvic exam, biopsy

CervixCervicitis

◦Inflammation of the cervix◦Also from trauma, irritants◦Can have mucopurulent cervicitis

Tx for STDs (GC, Chlamydia)

Vaginal Bleeding in NON-PregnantDifferential diagnosis:

Vaginal Bleeding in NON-PregnantDUB mcc abnormal vaginal bleeding in

reproductive women◦MC adolescence or perimenopausal

Anovulatory bleeding – failure of corpus luteal cyst formation◦Tx: OCPs, D&C, NSAIDs for pain

Ovulatory Bleeding – 10%, less understood◦Bleeding disorder, medications

Sever bleeding – CBC, transfusion/resuscitation, and consider (IV) Premarin

UterusEndometriosis

◦Endometrial tissue outside of the uterus◦6-8% of women◦Ovaries (MC) (aka chocolate cyst), fallopian tubes, abdomen, bladder, lung (catamenial pneumothorax)◦Menses-related abdominal pain◦Infertility, chronic pelvic pain◦Tx: pain management, hormonal

therapy, surgical management

UterusUterine Prolapse and Cystocele

◦Vaginal wall weakness caused by age, multiparity, decreasing estrogen levels, pelvic trauma

◦Dx: Can see bladder, uterine prolapse on pelvic exam Valsalva maneuver helpful

◦Tx: digital reduction, Pessary, surgery

UterusUterine Fibroids

(Leiomyoma)◦ Benign tumors of

uterine muscle◦ Higher incidence in AA women◦ Heavy bleeding, pelvic

pain◦ Can be submuscosal,

suberosal, intramural◦ Dx: Ultrasound◦ Tx: hormone

regulation, surgery, NSAIDs

UterusUterine Cancer

◦MC GYN malignancy, specifically endometrial ◦Risk Factors:

Early menses, late menopause, nulliparity Unopposed estrogen use DM, HTN, obesity

◦Sxs: post-menopausal bleeding◦Dx: biopsy, D&C, Hysteroscopy◦Tx: surgery, chemotherapy, and/or radiation

◦*Vaginal bleeding in a postmenopausal woman is (endometrial) cancer until proven otherwise*

While we are in the pelvis…Pelvic Inflammatory Disease (PID)

◦Polymicrobial◦Complications: infertility, ectopic pregnancy◦Clinical Dx – CMT (Chandelier Sign)◦Admit: pregnant, oral intolerance, TOA

Fitz-Hugh-Curtis Syndrome◦ Infection from fallopian tubes contaminates

abdomen Bacterial infection of perihepatic space

◦RUQ and shoulder pain◦“Violin-string” adhesions

VaginaVulvovagintis

◦Vaginal discharge, itching◦Causes:

Infection, allergic reaction, foreign body, irritant/chemical

Atrophic Vaginitis Post-menopausal secondary to estrogen deficiency Tx: topical or oral estrogen replacement therapy

◦MC problem in children◦Normal vaginal pH 4.0-4.5 ◦Any condition changing the vaginal pH

VaginaBacterial Vaginosis

◦ MCC of abnormal vaginal discharge◦ Gardnerella/anerobes take over normal flora◦ Dx: Amsel Criteria (3 of 4)

Copious think white discharge pH >4.5 Clue cells on wet mount; cx not helpful May have fishy odor with KOH whiff test

◦ Tx: Metronidazole (PO or gel) 500 mg PO bid for 7 days (2 g PO x1not recommended)

VaginaCandidal Vaginitis

◦Candida Albicans is part of normal flora Overgrows

◦Associated with DM, abx, pregnancy◦Sxs: vulvar pruritis (MC)◦Exam: vulvar erythema◦Dx: wet mount (psuedohyphae, budding

yeast); culture is gold standard◦Cottage cheese discharge◦Tx: Fluconazole (one dose 150mg PO), or OTC

vaginal creams Avoid PO in pregnancy

VaginaVaginitis

◦Trichimoniasis Protozoa Sxs: yellow-green, frothy, malodorous

discharge Exam: strawberry cervix Dx: wet mount Tx: Metronidazole PO

VaginaBartholin’s Cyst

◦Bartholin’s glands are normal Located inferiorly at vaginal introitus

◦Cyst (painless), abscess (painful)◦Abscess: polymicrobial

Staph, Strep, E.Coli, or STD

◦Tx: I&D, Word Catheter, Abx◦Definitive Tx: Marsupialization

Uterus Gestational Trophoblastic Disease

◦ Tumors formed form abnormal placental cells that implant and proliferate within the uterus

◦ Choriocarcinoma◦ Hydatidaform Mole – molar pregnancies

Complete MC Develops from 1 (duplicates) or 2 sperm fertilizing an empty egg

46XX or 46XY karyotype Lacks a fetus

Uterus LARGER than dates ‘grapelike vesicles’ ‘snowstorm’ on US with empty egg 20% malignant

Partial 2 sperm fertilize a normal egg

69XXX or 69XXY Fetus present

Uterus SMALLER than dates Non-viable fetus AND normal &vesicular chorionic villi 5% to malignancy

GTDs Hydatidaform Mole

◦ Sxs: Painless, abnormal vaginal bleeding Uterine size greater than normal Hyperemesis gravidarum (hCG levels >100k) Symptoms of hyperthyroid Early preeclampsia

◦ Tx: depends on type/pathology More benign (80%)or slow growing – D&C,

chemotherapy Malignant (2% choriocarcinoma), metastatic tumors –

chemo/XRT/surgery

◦ Often fertility can be maintained Monitor hCG levels after evacuation

A Few Questions… A 17 year old seually active girl present

complaining of dysuria for 3 days. She denies fever, abdominal pain, vomiting, and diarrhea. Abdominal examis normal. Pelvic examination reveals a homogenous white discharge that coats the vaginal walls. Pregnancy tests is negative, and wet mount shows clue cells. The best treatment is:

◦ A. Azithromycin◦ B. Ceftriaxone◦ C. Fluconazole◦ D. Levofloxacin◦ E. Metronidazole

A Few Questions… A 17 year old seually active girl present complaining

of dysuria for 3 days. She denies fever, abdominal pain, vomiting, and diarrhea. Abdominal examis normal. Pelvic examination reveals a homogenous white discharge that coats the vaginal walls. Pregnancy tests is negative, and wet mount shows clue cells. The best treatment is:

◦ A. Azithromycin◦ B. Ceftriaxone◦ C. Fluconazole◦ D. Levofloxacin◦ E. Metronidazole

A 23 year old woman presents complaining of lower abdominal pain. Pelvic examination reveals yellow vaginal discharge, as well as moderate cervical motion tenderness. Adnexa are tender, but no masses are present. Outpatient management may be considered if the patient has:

◦ A. A physician who can provide follow-up◦ B. Pelvic Abscess◦ C. Positive pregnancy test result◦ D. Taken antibiotics already for similar complaints◦ E. Temperature >38.8C (>102F)

A 23 year old woman presents complaining of lower abdominal pain. Pelvic examination reveals yellow vaginal discharge, as well as moderate cervical motion tenderness. Adnexa are tender, but no masses are present. Outpatient management may be considered if the patient has:

◦ A. A physician who can provide follow-up◦ B. Pelvic Abscess◦ C. Positive pregnancy test result◦ D. Taken antibiotics already for similar complaints◦ E. Temperature >38.8C (>102F)

A 25 year old female presents to the ER with left lower quadrant pain, nausea and vomiting for 6 hours. Her last menstrual period ended 10 days ago, She is afebrile, and CBC and chemistry are grossly normal. Her pregnancy test is negative. Ultrasound reveals multiple small cysts throughout both ovaries consistent with PCOS, the largest of which is on the left ovary and measures 2.5 cm. What is the most likely diagnosis?

◦ A. Arterial blood supply obstruction◦ B. Ectopic pregnancy◦ C. Follicular rupture◦ D. Venous blood supply obstruction

A 25 year old female presents to the ER with left lower quadrant pain, nausea and vomiting for 6 hours. Her last menstrual period ended 10 days ago, She is afebrile, and CBC and chemistry are grossly normal. Her pregnancy test is negative. Ultrasound reveals multiple small cysts throughout both ovaries consistent with PCOS, the largest of which is on the left ovary and measures 2.5 cm. What is the most likely diagnosis?

◦ A. Arterial blood supply obstruction◦ B. Ectopic pregnancy◦ C. Follicular rupture◦ D. Venous blood supply obstruction

A 65 year old female presents to the ER with a chief complaint of vaginal bleeding for 5 days. She is using about 2 pads per day. Prior to this episode, she has not had a menstrual period for 9 years. She has no PMH, and her only medications include hormone replacement therapy. Vital signs are normal and Hgb is 12.5. Pelvic exam reveals a small amount of blood in the vaginal vault, but no lesions, CMT, or adnexal tenderness. What is the most likely cause of this patient’s vaginal bleeding?

◦ A. Atrophic vaginitis◦ B. Estrogen deficiency◦ C. Endometrial neoplasm◦ D. Hormonal supplementation

A 65 year old female presents to the ER with a chief complaint of vaginal bleeding for 5 days. She is using about 2 pads per day. Prior to this episode, she has not had a menstrual period for 9 years. She has no PMH, and her only medications include hormone replacement therapy. Vital signs are normal and Hgb is 12.5. Pelvic exam reveals a small amount of blood in the vaginal vault, but no lesions, CMT, or adnexal tenderness. What is the most likely cause of this patient’s vaginal bleeding?

◦ A. Atrophic vaginitis◦ B. Estrogen deficiency◦ C. Endometrial neoplasm◦ D. Hormonal supplementation

A 23 year old G1P0 woman 7 weeks pregnant by dates, was discharged form another ED 3 weeks ago with a diagnosis of ‘threatened abortion’ and was given instructions for pelvic rest. She presents today for persistent vaginal bleeding and sever nausea and vomiting. She has not passed any tissue. Urine pregnancy test is positive. The top of the uterus is felt halfway between the umbilicus and pubic bone. You repeated the transvaginal ultrasound today, with the finding below. What is the clinical suspicion at this time?

◦ A. Choriocarcinoma◦ B. Hydatdiform mole, complete◦ C. Hydatidiform mole, incomplete◦ D. Incomplete abortion

A 23 year old G1P0 woman 7 weeks pregnant by dates, was discharged form another ED 3 weeks ago with a diagnosis of ‘threatened abortion’ and was given instructions for pelvic rest. She presents today for persistent vaginal bleeding and sever nausea and vomiting. She has not passed any tissue. Urine pregnancy test is positive. The top of the uterus is felt halfway between the umbilicus and pubic bone. You repeated the transvaginal ultrasound today, with the finding below. What is the clinical suspicion at this time?

◦ A. Choriocarcinoma◦ B. Hydatdiform mole, complete◦ C. Hydatidiform mole, incomplete◦ D. Incomplete abortion

References HippoEM.com Naderi, Sassan. Intensive Review for Emergency Medicine

Qualifying Examination. McGraw-Hill Companies. New York. 2010 Tintinalli MD, Judith E. Tintinalli’s Emergency Medicine: A

Comprehensive Study Guide. 7th Edition. McGraw-Hill Companies. New York. 2011.

Wagner MD, Mary Jo. Peer VII. ACEP. Dallas, Texas. 2006.