GY

Gynecology
Hannah Chiu, Roopan Gill. and Rebecca Menzies, chapter editors Christopher Kitamura and Michelle Lam, associate editors Jauine Hutaon, EBM editor Dr. Jason Dodge and Dr. Sari Kives, staff editors
Basic Anatomy Review ................... 2 Menstruation ........................... 3 Stages of Puberty Menstrual Cycle Premenstrual Syndrome (PMS) Premenstrual Dysphoric Disorder (PMDD) Differential Diagnoses of Common Presentations . 6 Abnormal Uterine Bleeding (AUB) Dysmenorrhea Vaginal Discharge/Pruritus Pelvic Pain Pelvic Mass Dyspareunia Common Investigations .................. 8 Bloodwork Imaging Common Procedures ..................... 8 Genital Tract Biopsy Colposcopy Dilatation and Curettage (D&C) Laparoscopy Hysteroscopy Endometrial Ablation Hysterectomy Disorders of Menstruation ............... 12 Amenorrhea Abnormal Uterine Bleeding (AUB) Dysmenorrhea Endometriosis ......................... 15 Adenomyosis .......................... 16 leiomyomata (Fibroids) ................. 16 Contraception ......................... 18 Hormonal Methods Intrauterine Device (IUD) Emergency Postcoital Contraception (EPC) Infertility .............................. 21 Female Factors Male Factors Polycystic Ovarian Syndrome (PCOS) ..... 23 Gynecological Infections ................. 24 Physiologic Discharge Vulvovaginitis Sexually Transmitted Infections (STis) Bartholinitis/Bartholin Gland Abscess Pelvic Inflammatory Disease (PID) Toxic Shock Syndrome Surgical Infections Sexuality and Sexual Dysfunction ......... 31 Menopause ............................ 32 Hormone Replacement Therapy (HRT) Urogynecology......................... 34 Pelvic Relaxation/Prolapse Urinary Incontinence Gynecological Oncology . 36 Uterus Ovary Cervix Vulva Vagina Fallopian Tube Gestational Trophoblastic Disease/Neoplasia (GTD/GTN) Common Medications ................... 50 References ............................ 52

Toronto Notes 2011

Gynecology GYI

GY2 Gynecology

Basic Anatomy Review

Toronto Notes 2011

Basic Anatomy Review

A. EXTERNAL GENITALIA (Figure I) referred to collectively as the vulva blood supply: internal pudendal artery sensory innervation: pudendal nerve lymphatic drainage: inguinal nodes

Ischiocavernosus muscle - - Labium majus External urinary meatus Paraurethral duct orifice Vestibule Labium minus - - Vaginal orifice Greater vestibular glands of Bartholin - Posterior fourchette (Frenulum of labia) - - - -- -Anus
... +>

- -- - Bulbocavernosus muscle __ - - Superficial transverse perineal muscle External anal sphincter levator ani muscle Anus

Figure 1. Vulva and Perineum B. VAGINA muscular canal extending from cervix to vulva, anterior to rectum and posterior to bladder lined by rugated, stratified-squamous epithelium upper vagina separated by cervix into anterior, posterior and lateral fornices blood supply: vaginal branch of internal pudendal artery with anastamoses from uterine, inferior vesical and middle rectal arteries C. UTERUS thick walled, muscular organ between bladder and rectum, consisting of two major parts: uterine corpus blood supply: uterine artery (branch of the internal iliac artery) cervix blood supply: cervical branch of uterine artery position (Figure 2) anteverted (majority) retroverted supported by the pelvic diaphragm, the pelvic organs and 4 paired sets of ligaments round ligaments: travel from anterior surface of uterus, through broad ligaments, through inguinal canals then terminate in the labia majora function: anteversion blood supply: Sampson's artery (branch of uterine artery running through round ligament) uterosacral ligaments: arise from sacral fascia and insert into posterior inferior uterus function: mechanical support for uterus and contain autonomic nerve fibres cardinal ligaments: extend from lateral pelvic walls and insert into lateral cervix and vagina function: mechanical support, prevents prolapse broad ligaments: pass from lateral pelvic wall to sides of uterus; contains fallopian tube, round ligament, ovarian ligament, nerves, vessels and lymphatics infundibulopelvic ligament: continuous tissue that connects ovary to pelvic wall contains the ovarian artery, ovarian vein, ovarian plexus, lymphatic vessels

...._,

..

Anteversion: forward tilted uterus Anteflexion: bending of uterus so the fundus is thrust forward Retroversion: backward tilted uterus Retroflexion: bending of uterus so the fundus is thrust backward

.------""""l,,_/
Coccyx + ---"1:-.:'.J.\. Rectum

Uterus in retroverted position

. -- '-"-----71 Uterus in anteverted position 'Bladder

Figure 2. Positioning of Uterus

'IbroDlo Nota 2011

Bask Anatomy Rniew/Menstruation

Gynecology GY3

m
Ill

Anaiorviaw

Figure 3. lntBmal Ganibll Organs

D. FAU.OPIAN TUBES

8-14 em muscular tubes extending laterally from the uterus to ovary interstitial, isthmic, ampullary and infundibular segments; terminates at fimbriae mesosalpinx: peritoneal fuld that attaches fullopian tube to broad ligament o blood supply: uterine and ovarian arteries

E. OVARIES
cons1st of cortex with ova and medulla with blood supply

supported by iDfundibulopeMc Ugament (suspensory ligament ofovary) mesovarium: peritoneal fuld that attaches ovary to broad ligament blood supply: ovarian arteries {branches offaorta), left ovarian vein (drains into left renal vein), right ovarian vein (drains into inferior vena cava)
The ul'lla's All posllrior1o the ut.me arterie5 W..r wrdtrtM ddge

. Abdomil'lll aartl.

unmr
ltagnrANaty lkrlk.I'IIHI. .._, RDW -n.larche, Pub_,., Growth IIPUrt. Manlitha-

..._. I

..
jij

TIIIIII'Stql

! "'
Figure 4. VBKIIIIr S..ply

J 0

Tbellrchl I. No1111 II. Bnlat bud Ill. Further enlqement Dl-illlld breQt:l with no nparation of lh*
conlDurs

IV. 2 mound Di awla and papilla V. Anoia n1t:WHd tu g-1111 cuntour of bi'HII: =llllull
l'lmrcH

Menstruation
Stages of Puberty
o
o

I. No1111 II. DDwny hli' llongllbil only Ill. Dart./C11ara ._ir txt.ndnvar
pl6il

IV.

------------------------------------

thigh involllement
IIXlllnd& over thiuhl

1111. no

V. Albl hlir in quentit.y end typa ...

o thelarche: breast development pubarche; pubic and axillary hair development menarche: onset of menses, usually fullowing peak height velocity and/or 2 years fullowing breast budding

see Pediat:rlc&. Pl7 adrenarche: lnaease In seaetlon ofadrenal androgens; usually precedes gonadarche by 2 years gonadarche: lnaeased secretion ofgonadal sex steroids; -age 8

i!
CD -;

Day1

Day5 :
I 1

Day28 ;oay 1
Estrogen ""/
,'

>

J
::!!i

I
1

-1- - . .

'

', -LH '

Progesterone " "

7""-FSH

-_:.;-..:-.:..:.--= ,.__
Prima_, ry
'
_;,

-::_-_
Mature secondary follicle seconday : follicle
t

... ::-.--: ::.... ..

.. ..

!!
'' '

'

Developing corpus luteum

"' !
i

'
+------Menstrual-------+ + - - - - - -

.i!
------------ '+------LUTEAl/SECRETORY PHASE (Fixed Duration -14 daysl OVUlATION Sudden from negative to feedback (E and Pnow 1' FSH & LH) Early-Mid Switch back to negative feedback Lata No fertilized oocyte

!!!

-Early Initiating events HPO axis previous cycle)

---

............. -

'

n < I

.. ..
CD :I

s:l
en

c;'l

s 0

n
CD

FOLLICULARJPROLIFERATAIVE PHASE (Variable Duration! Mid Lata Growing follicles continue to secrete E

.J.. Eand .J.. P(from end of

1' GnRH pulse frequency NSH 1' LH pulse frequency

1' FSH acts on ovarian

granulosa cells

1' Efrom follicles (ovary)

1'1' LH pulse amplitude (LH surge)

.J.. LH
1' Pfrom corpus luteum
Negative feedback P-> .J.. FSH, .J.. LH Cessation of Pfrom corpus luteum

Hormones Faadback on HPO axis Ovaries

1' Efrom follicles, esp. from dominant follicle

Negative feedback E-> .J.. FSH, .J.. LH Dominant follicle persists, remainder 1' FSH -> stimulates follicular 1' follicular growth (by reducing growth in 3-30 follicles atresia) -> 1' E undergo atresia Menses from Pwithdrawal (from end of previous cycle) Ebuilds up endometrium

Epeaks -> LH surge -> ovulation Positive feedback Eand P-> 1' FSH, 1' LH

.J.. Psecondary to degeneration of corpus luteum

-36 hrs after LH surge, dominant follicle releases oocyte; corpus luteum (remnant Granulosa cells luteinize -> produce P of dominant follicle) produces P Pstabilizes endometrium

Endometrium

of P-> menses
Opaque, scant amount, Spinnbarlreit 1-2 em

Cervical mucus: Clear, 1' amount, Spinnbarkeit 8-10 em, more stringy Cervical Mucus E= estrogen, P= progesterone, FSH = follicle-stimulating hormone, LH = hormone, GnRH = gonadotropin-releasing hormone, HPO

Figure 5. Events of the Normal Menstrual Cycle

Characteristics Menarche 10-15 years Average 12.2 years Entire cycle 28 7 days with bleeding for 1-6 days 25-80 ml blood loss per cycle Estrogen ESTROGEN is the main hormone in the follicular/proliferative phase. Stimulated by LH. Estrogen mainly decreases FSH. The majority of estrogen is secreted by the dominant follicle. Estrogen effects: On the follicles in the ovaries: Reduces atresia On the endometrium: Proliferation of glandular and stromal tissue On all target tissues: Decreases E receptors Progesterone PROGESTERONE is the main honnone in the luteaVsecretory phase stimulated by LH. Progesterone mainly decreases LH and is secreted by the corpus luteum (remnant of dominant follicle). Progesterone effects: On the endometrium: cessation of mitoses (stops building endometrium up) "organization" of glands (initiates secretions from glands) inhibits macrophages, interleukin-8 and enzymes from degrading endometrium On all target tissues: decreased E receptors (the "anti-estrogen" effect) decreased P receptors

f ...
!;

...

Toronto Notes 2011

MeDBtruation

Gynecology GY5

Premenstrual Syndrome (PMS)

synonyms: "ovarian cycle syndrome,N "menstrual molimina" (moodiness)

.....

,...-----------------, "

Etiology not completely understood, multifactorial, genetics likely play a role CNS-mediated neurotransmitter interactions with sex steroids (progesterone, estrogen and testosterone) serotonergic dysregulation - currently most plausible theory Diagnostic Criteria for Premenstrual Syndrome at least one ofthe following affective and somatic symptoms during the 5 days before menses in each of the three prior menstrual cycles affective: depression, angry outbursts, irritability, anxiety, confusion, social withdrawal somatic: breast tenderness, abdominal bloating, headache, swelling of extremities symptoms relieved within 4 days of onset of menses symptoms present in the absence of any pharmacologic therapy, drug or alcohol use symptoms occur reproducibly during 2 cycles of prospective recording patient mffers from identifiable dysfunction in social or economic performance Treatment goal: symptom relief psychological support diet/supplements avoid sodium, simple sugars, caffeine and alcohol calcium (1200-1600 mgld), magnesium (400-800 mgld), vitamin E (400 IU/d), vitaminB6 medications NSAIDs for discomfort, pain spironolactone for fluid retention: used during luteal phase SSRI antidepressants: used during luteal phase x 14 days or continuously progesterone suppositories OCP: primarily beneficial for physical/somatic symptoms danazol: an androgen that inhibits pituitary-ovarian axis GnRH agonists if severe PMS unresponsive to other treatment mind/body approaches regular aerobic exercise cognitive behavioural therapy relaxation, light therapy biofeedback and guided imagery herbal remedies (variable evidence) evening primrose oil, black cohosh, St. John's wort, kava, ginkgo

Pr-llllr1111l Syndrama Phy5iological and amutianll disturbances which gene111lly oc:cur

1-2 week$ preceding men... until a few days afDr onut of 11111n-. Cornman IYfllptom& include dupmsion.

irritability, 118/fulnass and mood swings.

Premenstrual Dysphoric Disorder (PMDD)

Definition official diagnosis in the DSM-IV-TR described as a more severe form ofPMS with specific diagnostic criteria treatment with SSRis (first line), and yaz- OCP (highly effective) see Psychiatry. PSll

GY6 Gynecology

Differential Diagnose5 of Common Presentations

Toronto Notes 2011

Differential Diagnoses of Common Presentations

Abnormal Uterine Bleeding (AUB)
--------------------

see Disorders ofMenstruation, GY13 definition: change in frequency, duration or amount ofmenstrual flow classified as amenorrhea, oligomenorrhea, menorrhagialhypermenorrhea, hypomenorrhea, metrorrhagia, menometrorrhagia, polymenorrhea, postmenopausal bleeding hypomenorrhea: bleeding that is decreased in amount polymenorrhea: bleeding occurring at intervals <21 days menorrhagialhypermenorrhea: bleeding at regular intervals that is prolonged in duration (>7 days) or excessive in amount (>80 cc per menstrual cycle) metrorrhagia: bleeding at irregular intervals, particularly between expected menstrual periods menometrorrhagia: excessive bleeding at usual time of menstrual periods and at other irregular intervals postmenopausal bleeding: any bleeding that presents >1 year after menopause; endometrial cancer until proven otherwise

Dysmenorrhea
see Disorders ofMenstruation, GY12 primary/idiopathic secondary (acquired) endometriosis adenomyosis uterine polyps uterine anomalies (e.g. non-communicating uterine horn) leiomyoma intrauterine synechiae ovarian cysts cervical stenosis imperforate hymen, transverse vaginal septum peMc inflammatory disease (PID) IUD - copper foreign body

Vaginal Discharge/Pruritus
see Gynecological Infections, GY24 physiologic discharge and cervical mucus production non-physiologic genital tract infection vulvovaginitis: candidiasis, trichomoniasis, bacterial vaginosis (BV), polymicrobial superficial infection chlamydia, gonorrhea pyosalpinx, salpingitis genital tmct inflammation (non-infectious) local: chemical irritants, douches, spmys, foreign body, trauma, atrophic vaginitis, desquamative inflammatory vaginitis, focal vulvitis neoplasia: vulvar, vaginal, cervical, endometrial systemic: toxic shock syndrome, Crohn's disease, collagen disease, dermatologic (e.g. lichen sclerosis) IUD, OCP (secondary to progesterone)

Toronto Notes 2011

Differential Diagnosea of Common Presentations

Gynecology GY7

Pelvic Pain I
Pelvic Pam

I Gynecolagical

+ Al:ut8
No111YJ11C0Iagical

..

I I

Png111ncyrelllllld Labour Ectopic pnagllllncy Spontaneaus abortion PlaCII'l!al abruption

..

+ Gl
Appendicitis M81ianlllricedlllitis IBD

+ GU
lJTI (e.g. pyulonephritis) Renal colic

...
Adneul Mittalschmarz Ruptured OVIIrian C\'lf: Ruptunad actopic pregnancy Hemorrhage into cyst/neoplasm Ovarianftubal torsion

...
Utllrina Fibroid degeneration Torsion of pedunculatad fibroid Pyometrt;' hematometre

...
lnfiM:tio AcutePID

GyniCOiogicill Chronic PID Endomstriosis Ad111omyosis Adhesions Dysmenorrhea Ovarian cyst l'lllvic congestion syndrome Ovarian remnant syndrome Fibroid (11111) Utaina prolapse (1818)

..

Chronic

Chronic: P.lvic Plin (CPP)

No111J11ICOIDgical Referred pain Uri1111ryrelllnlion Urethral syndroma lnlllrstitial cystitis Glneaplasm IBS IBD ConstipBiion Pll1ial bowel obstruction Divllrliculitis Hernia formation Narve anlrllpmant SexuaVphysicaV psydlological abuse Deprussion

.I

lnbJrmittent or con5tant p11in of >6 months dumion.

'20'lla of CPP patients have a history of

previous SBXUII abus!l/assault (remember to ask about

l'yolllltre

Pus

lhe uterine ciiVity.

HelllltDmetna Blood within the uterine cavity.

Anxiety
SolllllliZlllion

Figure &. Approach to Pelvic Pain

Pelvic Mass

Corpus luteum cyat Follicular c\'lf: Thaca lutain cyst Hemonhagic cyst

Benign: Dermoid c\'lf: (most common) Malignant Epithalial call (most common in >40 yrs) Germ call (most common in <20 vrsl

PCOS Endometrioma Tuba-ovarian abscess lut!oma ol pregnancy

Pregnancy Adenomyosis Hematometrafpyometra Endometrial cancer lmparfollllll hymen

G..-logical: Ectopic pragnancy Pelvic adhesions [resulting in fluid entrapment) f'aratubal cysts Py06111piror/Hydrosalpinx Primary fallopian tube neoplasms
Gllllnlllllllldnal: Appendiceal abscess Divarticular abscass Diverticulosis, divertic... Carcinoma of r&ctunv'colon Ganilourinary: Distandad bladder Pelvic kidney Carciloma of bladder Lymphoma

Figure 7. Differential Diagnosis of Pelvic Mass

GYB Gynecology

Dift"erential Diagnoses of Common Presentations/Common Investigations

Toronto Notes 2011

Dyspareunia

I Dyspareunia I
1 lrm.illll

lnaduqUBIB lubrication Vaginismus Rigill/inllct hymen Bartholin's or Skene's gland infection Lichen sclerosis \\llvovaginitis: atrophic chemical, ilfectious (chlamydia, trichomoniasis)

I Midngmllll
Short vagina Trigonitis Cong111ibd abnonmality of lha vagina (e.g. vaginal seplllm)

+ + Urvlhritis

EndometriO&is Adenomyosis Leiomyomlbi/Fibroids PID (acUb vs. chronic) HydroSIIpinx Tuba-ovarian absCIIS Uterine retroversion

Ovari.,cyst

Figura 8. Approach to Dyspareunia

Common Investigations
Bloodwork
CBC evaluation of severity of abnormal uterine bleeding, pre-op investigation ferritin if anemic beta-hCG investigation of possible pregnancy, ectopic pregnancy, ovarian germ cell tumour work-up for gestational trophoblastic disease/neoplasia (GTD/GTN) monitored after medical management of ectopic pregnancy and GTN to assess for cure or recurrence Ill, FSH, TSH, free T4o PRL, DHEA, testosterone, estradiol, androstenedione investigation of amenorrhea. menstrual irregularities, menopause, infertility

Imaging
Ultrasound (U/S) transabdominal or transvaginal U/S is imaging modality of choice for pelvic structures transvaginal U/S provides better resolution of uterus and adnexal structures detects early pregnancy ifbeta-hCG (beta-hCG must be for transabdominal U/S) may be used to identify pelvic pathology identify ectopic pregnancy, intrauterine pregnancy assess uterine, adnexal, cul-de-sac, ovarian masses (e.g. solid or cyme) determine endometrial thickness, locate/characterize fibroids monitor follicles during assisted reproduction

,, ,
Check for S11s bsfor8 perfunning SHG and HSG to pravent PID in high-risk individuals.

Sonohysterography (SHG) saline infusion into endometrial cavity expands endometrial cavity, improving visualization of uterus and fallopian tubes useful for investigation of abnormal uterine bleeding (AUB) uncertain endometrial findings on transvaginal U/S infertility (tubal patency) congenital/acquired uterine abnormalities (e.g. fibroids, endometrial polyps) easily done, minimal cost, well-tolerated, sensitive and specific frequently avoids need for diagnostic hysteroscopy Hysterosalpingography (HSG) x-ray contrast introduced through the cervix into the uterus used for evaluation of size, shape, configuration of uterus, congenital uterine abnormalities, tubal patency, or obstruction useful for investigation of infertility

Toronto Notes 2011

Common Procedures

Gynecology GY9

Common Procedures
Genital Tract Biopsy
Vulvar Biopsy
performed under local anesthetic Keyes/punch biopsy hemostasis achieved with local pressure and Mansel's solution (ferric sulfate), silver nitrate or suture (rarely)

Yaginal Biopsy and Cervical Biopsy

anesthetic not necessary punch biopsy or biopsy forceps hemostasis with Mansel's solution and pressure

Endometrial Biopsy
performed in the office using an endometrial suction curette (pipelle) guided through the cervix to aspirate fragments of endometrium pre-treatment with misoprostol (Cytotec) ifnulliparous or postmenopausal more invasive procedure (D&C) may be done in the office or operating room hysteroscopy

Colposcopy
diapostic use
magnifies surface structures of the vulva, vagina, cervix and perianal region 1% acetic acid wash applied to cervix dehydrates cells and reveals "acetowhiteu areas that correspond to increased nucleus-to-cytoplasm ratio (abnormal) allows biopsy of acetowhite lesions for early identification of dysplasia and cancer therapeutic use cryotherapy: nitrous oxide or carbon dioxide freezes dysplastic lesions, genital warts laser vaporization: used to treat dysplastic lesions of the exocervix and benign ectropion loop electrosurgical excision procedure (LEEP): excision of transformation zone with the cervical lesion; provides a specimen for pathological examination

Dilatation and Curettage (D&C)

prior to procedure, determine depth with uterine sound dilatation of cervix with dilators of increasing diameter scrape entire uterine cavity with sharp curette anesthesia: general or local

Indications
diagnostic (rarely done without hysteroscopy) abnormal uterine bleeding (AUB) dysfunctional uterine bleeding (DUB) therapeutic removal of retained products of conception following abortion termination of pregnancy in 1st trimester removal of small uterine polyps or pedunculated submucosal :fibroids

Complications
bleeding infection perforation of uterus, laceration of cervix reduce risk with preoperative misoprostol (Cytotec) inserted per vagina to soften cervix and stimulate uterine contraction incompetent cervix- extremely rare

GYIO Gynecology

Common Procedura

Toronto Notes 2011

Laparoscopy
laparoscope (fiber optic camera) used to view pelvic/abdominal contents through small incisions
Indications

diagnostic evaluation of infertility, pelvic pain, pelvic masses, congenital anomalies, hemoperitoneum and endometriosis therapeutic tubal ligation lysis of adhesions excision of ectopic pregnancy excision/ablation of endometriosis retrieval oflost nJDs cystectomy, salpingo-oophorectomy and hysterectomy myomectomy treatment of stress urinary incontinence
Contralndlcatlons

bowel obstruction large hemoperitoneum clinically unstable patient inability to maintain pneumoperitoneum multiple previous abdominal surgeries (ie. adhesions) general anesthetic insufilati.on of the preperitoneal abdominal wall injury to vascular structures (e.g. aorta, inferior epigastric vessels) injury to viscous (bowel, bladder, ureters) may need to convert to laparotomy infection

Complications

Hysteroscopy
1l.exible or rigid scope inserted through cervix into uterus to visualize uterine cavity distension medium is used to allow inspection of this potential space
Indications

diagnostic detection of uterine anomalies or pathology (e.g. infertility work-up) AUB DUB therapeutic removal of uterine polyps, fibroids, adhesions, septums endometrial ablation
Complications

perforation of uterus, laceration of cervix bleeding infection absorption of excess distension medium (when sugar solutions utilized) fluid overload, hyponatremia procedure should be abandoned if the fluid deficit rises toIL; consider stopping at 500 cc air emboli anaphylactic shock

Toronto Notes 2011

Common Procedures

Gynecology GY11

Endometrial Ablation
alternative invasive procedure to hy5terectomy for treatment of AUB; performed as outpatient rationale is to coagulate or resect the endometrium basalis layer to prevent monthly build-up and reduce menstrual losses

Methods
rollerball electrode coagulation or resection microwave endometrial ablation thermoablation (hot water), balloon ablation laser photocoagulation

Complications
infection injury to pelvic viscera ifperforated uterus hematometra absorption of excess distention medium -+ fluid overload, hyponatremia failure (ie. bleeding/menorrhagia persists) may eventually require hysterectomy for recurrence of symptoms (-20% at 5 years)

Hysterectomy
Indications

------------------------------------------------

uterine fibroids endometriosis, adenomyosis uterine prolapse pelvic pain AUB cancer (endometrium, ovaries, fallopian tubes, cervical)

Complications
general anesthetic bleeding infection injury to other organs (ureter, bladder, rectum) loss of ovarian function (if ovaries removed, iatrogenic menopause)

....

,,

Approaches
1. vaginal vs. abdominal indications for vaginal approach: mobile uterus, uterine size <12 weeks advantages of vaginal approach: less pain, faster recovery time, allows for simultaneous repair of rectocele/cystocele/enterocele, improved esthetics 2. open vs.laparoscopic-assisted advantages oflaparoscopy: less pain, faster recovery, improved esthetics, shorter hospital stay

Approaches tllllylteraatDmy

Abdomml lrystanlctamy. ulllrus r.movad viii lnlniVIIH or wrtical

laparotomy.

Vat;nal ...,.._rRtllmy: uturu5 removed via vagina. No visullilltion or BRtry into abdomen unless laparoscopic-usisted.

Tabla 1. Classificlll:ion of Hysterectomy

Cllssifil:alian
Subtutal hptlnlc:tumr Tolllllllystnctomr

Tissu Ramorad
Uterus Uterus. cervix

lndil:alians
Inaccessible cavix (e.g. acllesions) Patient choice/preference Uterine fibmids

Endometriosis
Ad1111ornyosis Menorrhagia

DUB

Tolllll hysterectDmr + billtlrll lpilgiMICipharac:tDIIIJ {T1t.IIISO} Radical hystlrectomr

Uterus. cervix, fallopian tubes, DV!Iries

Endometrial cancer Benign or malignant adnexal masses > 45 yearuld Consider for endometriosis CIIVical cancar (up to stageiBI, see Table 17)

Uterus, cervix, fallopian tubes, DVIIries. broad ligaments, parametria. upper hal of vagina, regional lymph nodes

GYI2 Gynecology

Disorders of Menstruation

Toronto Notes 2011

Disorders of Menstruation
Amenorrhea
PrimryA-mblla No menss5 by age 14 in llb111nn ol2" texual ct11111Cteriltict or no menses by age 16 with 2" s8XUIII chllrac18n.til:$.

Etiology see Differential Diagnoses ofCommon Presentations, GY6

Secondary An!Monhla No menss5 for >6 months or 3 c;yclN

afbr documented menarche.
Episodic Vll!lillill bleeding occUlTing at intervm >35

o..,.._,.....

Primary

F11111ily history of delayed puberty, absent puberty

History and Physical Exam

Pregnancy blst

TSH and prtJIIIC!in (PL)

Secondary Prolonged intense exercise, excessive dieting, pregnancy, and endocrine abnonnalities [weight change, signs of virilization)
ll\'lllp!Drnl of proillctinoma

TSH.

high 1>100)or

ao11ideber)

,, ,
ProiiCiinoma Symptams
Galactorrhea. visual changes, headache.

Hypo/hyperthyroidism

Progllltarona challanga

CT to rule out pituitary tumour

+ withlhwll bleed

Anovulation

FSH, LH

1
11 or normal +aw
Hypothalamic dysfulction (stress or anovulation)

No withdrawal bleed

Utama or Vllginal dafact (alrophy, imperforalu hymen, Mullerian agenesis)

Ovarian dysfunction {menopause, PCOS, gonadal dysgenesis, prematurn ovarian failure)

Figure 9. Diagnostic Approach to Amenorrflea

Investigations (see Figure 9)

beta-hCG, hormonal workup (TSH, prolactin, FSH, LH, androgens, estradiol) progesterone challenge to assess estrogen status medroxyprogesterone acetate (Provera) 10 mg PO OD for 10 days any uterine bleed within 2-7 days after completion of Provera is considered to be a positive test/withdrawal bleed withdrawal bleed suggests presence of adequate estrogen to thicken the endometrium; thus withdrawal of progresterone results in bleeding if no bleeding occurs, there may be inadequate estrogen (hypoestrogenism) or c:xccssivc androgens karyotype if indicated (if premature ovarian failure or absent puberty) UIS to confirm normal anatomy, identify PCOS

Treatment hypothalamic dyefundion Oow or normal FSH, LH) if low FSH/LH, consider head imaging (CT or MRI) if no other obvious etiology
stop any medications, reduce stress, adequate nutrition, decrease excessive exercise

if pregnancy desired, correct underlying problem; but may require gonadotropins to

stimulate ovulation otherwise OCP to induce menstruation (withdrawal bleed) - may not prevent other manifestations ofhypoestrogenic state, e.g. bone loss

hyperproladinemia
consider CT of head to document presence of pituitary micro/macroadenoma surgery for macroadenoma (rarely) bromocriptine if fertility desired; OCP if fertility not desired premature ovarian failUl'e (high FSH, LH) karyotype removal of gonadal tissue ifY chromosome present (at 18 years or earlier if dysgenic gonads) HRT or OCP to prevent manifestations ofhypoestrogenic state treat associated autoimmune disorders (thyroid, adrenal) PCOS see Polycystic Ovarian Syndrome, GY23

Toronto Notes 2011

Disorders of Menstruation

Gynecology GY13

Abnormal Uterine Bleeding (AUB)

-----------------

Mtlnarrhqia Harmone imbalance Fibroidr,ll.eiomyomata Uterine palyps Adenomyosis Copper lUll

..
ST1

I Abnonnal Uterine Bleellng I I

Mtltnlrrhagi-'MIDDI'IIIIIrorrhqill Trauma. s100111l abuse, foreign bady Infection: endometritis, cervicitis, Benign growths: uterine, vaginal Pregnancy-rei Bled Weight lass, axcess exen:isa, stress PCOS DUB (diagnosis of axclusionl

..

I Nan-gynacolagil:ll I
Endaaine Hyper}hypathyroidism Adrenal insulliciancy Insulin resistance (PCOSI Prolactinoma Drugs Anticoagulants llanazol OCP. HAT (braaklhmugh blaadl Spimnolllelllne Bload Dyscrasia Steroids Coagulapathy (vWill Chemotherapy Platelet abnormalities (ITPI Neuroleptics Leukemia Harnlllolagic malignancy Hepatic Disaasa .J.- coagulidian fllctars Ranll Failura lmpairad llllrogen Impaired 1151mgun matebolism axcretion

..

DUB =dylfuncti.,.l ubrrino bleodin!j OCP = onol COIIb.:aptivo jill HRT = hormone rwplacament tlnnpy PCOS = polycyatic omian synrhme ITP = immune thronmocytilponic purpura vWD = von Wlll.brwnd's di...se

Figure 10. Approach to Abnormal Uterine Bleeding

Table 2. Comparison of Anovulatory and Owlatory Abnormal Uterine Bleeding
Anowii!Dry
Incidence 90% Unpredictable endomebial bleedilg ol variable flow and duration; sax steroids are procklced bul not cyclically, 111sulting in irrvgular bleeding

IMHIDry
1II% Typically cyclic, but heavy or prolonged

Dafinitio1

Etiology

PCOS
Thyroid dysfunction BIMited prolactin levals Rare estrogen-producing tumo111 S1ress, weight loss, exercise Livar 1r1d kidney disease

Anatomic or physical lesion (e.g. polyp, fibroid, adenomyosis, neoplasm. foreign body) Hemosllltic def8ct lrlection; 1nluma Local disturbances in prostaglandins (elevated andomyomstrial vasadilatory prostaglandins, decreased vasoconstrictiva prostaglandin)

hthaphysiology

Estrogen dependent breaklhrnugh bleeding: clronic Depends on underlying stiology estrogen production unopposed by adequate progesterone production -+ continued proliferation ol 1he endometrium -+ 1hickened endometrium outgrows il5 blood supply -+ focal niiCIO&i& partial shedding not uniformly -+ bleeding is usually irregular, prolonged, and heavy

Investigations CBC, serum ferritin beta-hCG TSH, free T4 coagulation profile (esp. adolescent): rule out von Willebrand's disease prolactin if amenorrheic FSH,LH serum androgens (especially free testosterone) day 21 (luteal phase} progesterone to confirm ovulation Pap test pelvic U/S: detect polyps, fibroids; measure endometrial thickness (postmenopausal) SHG: very sensitive for intrauterine pathology (polyps, submucous fi.broids} HSG endometrial biopsy: women >40 years are at higher risk of endometrial cancer must do endometrial biopsy in all women presenting with postmenopausal bleeding to exclude endometrial cancer D&C: not for treatment; diagnosis only (usually with hysteroscopy)

GYI4 Gynecology
o.,.functiouJ Ulerme ........_ Abnonnal binding not llltributllble to organic (lllatomic/svstemic) disease. DUB is a diagnosis of MCiusion. Anowliltory AUB often used synonymou.ly with DUB.

Disorders of Menstruation

Toronto Notes 2011

Treatment treat underlying disorders: if anatomic lesions and systemic disease have been ruled out, consider dysfunctional uterine bleeding (DUB) medical mild DUB (see sidebar) NSAIDs anti-fibrinolytic (e.g. Cykl.okapron) at time of menses combined OCP progestins (Provera) on first 10-14 days of each month if oligomenorrheic Mirena IUD danazol acute, severe DUB replace fluid losses, consider admission medical treatment a) estrogen (Premarin) 25 mg IV q4h x 24h with Gravel 50 mg IV/PO q4h or b) ovral 1 tab PO q4h X 24h with Gravel 50 mg IV/PO q4h - taper ovral: 1 tab tid X 2d-+ bid X 2d -+ OD after (a) or (b), maintain patient on monophasic OCP for next several months or consider alternative medical treatment clomiphene citrate consider in patients who are anovulatory and who wish to get pregnant surgical endometrial ablation; consider pretreatment with danazol or GnRH agonists if finished childbearing repeat procedure may be required if symptom recurrence hysterectomy: definitive treatment

Dysmenorrhea
Prlmuy O,.menonbu Manllrulll Jllllin in ablanca of disease.

Etiology see Differential Diagnoses ofCommon Presentations, GY6 Table 3. Comparison of Primary and Secondary Dysmenorrhea
Menstrual pain in abs111ce of arg111ic disease Begins 6 months-2 years lifter merwche (once cyde& sstablishsd) Sig and Symptaml M111strual pain due ID organic disease Usually begins in women who are in their 20&, WOiians with i1QB May improve ter11XJrarily lifter childbirth

Secondlry O,.mnlbal Menllrulll Jllllin due to organic disease.

Colicky pan in abdomen. mdiatilg to the low111 back. labia, Associated dysparvunia, abnonnal bleeding. 111d inner thijls beginning hours before onset of bleeding irlertility 111d persisting for hours or days (4B-72 h) Associated symptoms: nausea, vomiting. altered bowel habits, headaches, fatigue [pnlslllgl111din (PG)-a11ociatad] Associated dysp5alllia, abnormal bleeding. infertility Rule oul undellying pelvic pathology and confirm cydic nature of pain Bimanualaxam: uterine or adnexal l!ndemess, fixed ulerine l!!lraflexion, uterosacral nodularity, pelvic mass, or enla111ed irregular uterus U/S,Iaparascopy and hystarascopy may be necessary to establish the diagnosis

Di111n01is

PG synthetase inhibitors (e.g.

Should be started before onset of pain OCP: suppress awlationlreduce m111strual flow

Treat underlying cause

Toronto Notes 2011

Endometriosis

Gynecology GY15

Endometriosis
Etiology
not fully understood proposed mechanisms (combination likely involved) retrograde menstruation (Sampson's theory) seeding of endometrial cells by transtubal regurgitation during menstruation endometrial cells most often found in dependent sites of the pelvis immunologic theory: altered immunity may limit clearance of transplanted endometrial cells from pelvic cavity (may be due to decreased NK cell activity) metaplasia of coelomic epithelium undefined endogenous biochemical factor may induce undifferentiated peritoneal cells to develop into endometrial tissue extrapelvic disease may be due to abherrant vascular or lymphatic dissemination of cells e.g. ovarian endometriosis may be due to direct lymphatic flow from uterus to ovaries
Endomltrialia Tha presance of endometrial tissue
(glands and stroma) outside of the uterine cllllity.

.....

'9.-----------------, '

Diflilrtntial Diag-il 1. Chronic PIO, racurrant acute salpingitis 2. Hemormagic corpus luteum J. B111igrv"malignant ovarian neoplasm 4. Eelllpic pragnancy

Epidemiology
incidence: 15-3096 of pre-menopausal women mean age at presentation: 25-30 years regresses after menopause

....

''

Risk Factors
family history (7-10 fold increased risk if affected 1st degree relative) obstructive anomalies of the genital tract (earlier onset) nulliparity age >25 years ovaries: 6096 patients have ovarian involvement broad ligament, vesicoperitoneal fold peritoneal surface of the cul-de-sac, uterosacral ligaments rectosigmoid colon, appendix rarely may occur in sites outside abdomen/pelvis, including lungs

EndometriDma endomebiotic cyst on sLriace of ovary.

Sites of Occurrence

Clinical Features
may be asymptomatic history menstrual symptoms cyclic symptoms due to growth and bleeding of ectopic endometrium, usually precede menses (24-48 hrs) and continue throughout and after flow secondary dysmenorrhea sacral backache with menses pain may eventually become chronic, worsening perimenstrually premenstrual and postmenstrual spotting deep dyspareunia infertility 30-40% of patients with endometriosis will be infertile 15-30% of those who are infertile will have endometriosis bowel and bladder symptoms frequency, dysuria, hematuria diarrhea, constipation, hematochezia, dyschezia physical tender nodularity of uterine ligaments and cul-de-sac felt on rectovaginal exam fixed retroversion of uterus firm, fixed adnexal mass (endometrioma) physical findings not present in adolescent population

.... 9.-----------------, '

There may balillfa correllllion betwa111 the IXIInt of 111dometriosis and symplllmatology.

'
'

.... 9.-----------------, '

CIUllo Trlld of Endametrloals
Oysmenormea Dyspareunia (cui de sac, uterosacnll ligament) Oysclllllia (uterosacnllligament, culdsac, rectosigmoid attacllmant)

.....

'9.-----------------, '

A sharp, firm, and IIX!fJisitaly tender "111111" on the uterosacral ligament is a classic feature of endometriosis.

Investigations
definitive diagnosis requires: direct visualization oflesions typical of endometriosis at laparoscopy biopsy and histologic exam of specimens (2 or more of: endometrial epithelium, glands, stroma, hemosiderin-laden macrophages) laparoscopy mulberry spots: dark blue or brownish-black implants on the uterosacral ligaments, cul-desac or anywhere in the pelvis endometrioma: "chocolate" cysts on the ovaries "powder-bum" lesions on the peritoneal surface early white lesions and clear blebs peritoneal "pockets" CA-125 may be elevated in patients with endometriosis

GYI6 Gynecology

Endometriosis/Adenomyosis/Leiomyomata (Fibroicls)

Toronto Notes 2011

Treatment depends on certainty of the diagnosis, severity of symptoms, extent of disease, desire for future fertility and impact to GI/GU systems (e.g. intestinal obstruction) Endometriosis is clnsifiad according medical tD a scoring system standardized by tha American Sociaty for Rapraductiva NSAIDs - e.g. naproxen sodium (Anaprox) Medicine. Score is based on location pseudopregnancy and axbmt of di111111111. cyclic/continuous estrogen-progestin (OCP) medrm.yprogesterone (Depo-Provera) pseudomenopause 2nd line: only short-term ( <6 months) due to osteoporotic potential with prolonged use, ..... unless add-back therapy (e.g. estrogen/progesterone or SERM) }-----------------, danazol (Danocrine) =weak androgen lllcll'rance R1t111 - side effects: weight gain, fluid retention, acne, hirsutism, voice change Medicallhenpy: 30-50'll. leuprolide (Lupron) = GnRH agonist (suppresses pituitary) Conservativa surgery: 14-411% - side effects: hot flashes, vaginal dryness, reduad libido - can use months with add-back progestin or estrogen surgical conservative laparoscopy using laser, electrocautery laparotomy ablation/resection of implants, lysis of adhesions, ovarian cystectomy of endometriomas definitive: bilateral salpingo-oophorectomy hysterectomy follow-up with medical treatment for pain control NOT shown to impact on preservation of fertility best time to become pregnant is immediately after conservative surgery

.....

..

}-----------------,

..

Adenomyosis
Adenomyosis Extension of areas of endometrial glands and stroma into the myometrium.

synonym: "endometriosis

(uterine wall may be diffusely involved)

Epidemiology 15% of females >35 years old; found in 20-40% of hysterectomy specimens mean age at presentation: 40-50 years old (older age group than seen in endometriosis) adenomyosis is a common histologic finding in asymptomatic patients Clinical Features often asymptomatic menorrhagia, secondary dysmenorrhea, pelvic discomfort dyspareunia, dyschezia uterus symmetrically bulky, usually <14 em, mobility not restricted. no associated adnexal pathology Halban sign: tender, softened uterus on premenstrual bimanual exam

.....

}-----------------,

Final diagnosis of adenomyosis is based

on pathologic findings.

Investigations clinical diagnosis U/S or MRI can be helpful endometrial sampling to rule out other pathology Treatment iron supplements as necessary analgesics, NSAIDs OCP, Depo-Provera (medroxyprogesterone) low dose danazoll00-200 mgPO OD (trialx4months) GnRH agonists (e.g.leuprolide) definitive: hysterectomy (no conservative surgical treatment)

Leiomyomata (Fibroids)
l.eiomyomat-.lfibroid
Benign smooth muscletllmour of the uterus (most common gynecological tllmourl.

Epidemiology diagnosed in approximately 40-50% of reproductive age women >35 years more common, larger and occur at earlier age in black women common indication for major surgery in females minimal malignant potential (1:1000) typically regress after menopause; enlarging fibroids in a postmenopausal woman should prompt consideration of malignancy

'IbroDlo Nota 2011

Leiomyomata {Fibroid&)

Gynecology GY17

Plrthogenesis
estrogen stimulates monoclonal smooth muscle proliferation; progesterone stimulates production ofproteins that inhibit apoptosis degenerative changes (occur when tumour outgroWB blood supply) hyaline degeneration (most common degenerative change) cystic degeneration (from breakdown of hyaline) redlcarneous degeneration (hemorrhage into tumour, may occur in pregnancy) fatty degeneration c::alcifiartion sarcomatous degeneration (rare) parasitic myoma: tumour becomes attached to another organ (typically omentum or small bowel mesentery), develops new blood supply and loses connection to uterus

Clinical Features
majority asymptomatic (6096), often discovered as incidental finding on pelvic eu.rn or UIS abnormal uterine bleeding (3096): dysmenorrhea, menorrhagia pressurelbulk symptoms (20-5096)
pelvic pressurelheaviness increased abdominal girth urinary frequency and urgency acute urlnary retention (enremel.y rare but surgical em.ezgency!) constipation. bloating (rare) acute pelvic pain fibroid degeneration

LllcatiDnS of UterinD LaiiiiiiJUIIIIIfB

Figu111 11. Possible Anataic

....

',

SdlmUCOSIIIriomyonudll n mast

1'(11111111ic (bleeding. inflrtilityJ.

fibroid torsion (pedunculated subserosal) infertility (submuc::o&al), recurrent pregnancy 1.0511 pregnancy complications (potential enlargement and increased pam. obstructed labour, diflicult C-section)

lnvutlgatlons
bimanual exam: uterus asymmetrically enlarged, usually mobJle CBC: anemia ultrasound: 1D confirm diagnosis and assess location of:fibroid.s sonohysterogram: useful for differentiating endometrial polyps from submucosal fibroids endometrial biopsy to rule aut uterine cancer fur abnormal uterine bleeding (especially if age >40 years) occasionally MRI is used for pre-op planning (e.g. before myomectomy)
Treatment only Ifsymptomatic, rapidly enlarging or menorrhagia treat anemia ifpresent conservative approach (watch and wait)
symptoms absent or minimal fibroids <6-8 em or stable in size not submucosal (submucosal fibroids are more ll.kel.yto be symptomatic) curre.ntly pregnant due to increased risk ofbleeding (follow-up U/S ifsymptoms progress)

....

',

Evlm will! known fibroida, lllbnal'lllll

do 1111domelrial biopll'f to rule aut cancer.

utama bleeding + IIIQ8 >40 yrs-

medlcal approach antiprostaglandins (ibuprofen, other NSAIDs) tranemmic acid (Cyklokapron)

OCP/Depo-Provera

GnRH agoDist: leuprolide (Lupron), danazol (Danocrme) short-term use only (6 months) often used pre-myomectomy or pre-hysterectomy to reduce fibroid size
interventional radiology approach uterine artery embolization occludes both uterine arteries -+ shrinb fibroids by 5096 at 6 months; improves menorrhagia in 9096 ofpatients wtthln 1-2 months; not an option in

women considering childbearing surgical approach myomect:omy (hysteroscopic, transabdominal or laparoscopic): preserva fertility endometrial resection of fibroid and endometrial ablation fur menorrhagia hysterectomy (see GYll) note: avoid operating on fibroids during pregnancy (due to ++ vascularity and potential pregnancy loss); apectant management usually best

GYIB Gynecology

Contraception

Toronto Notes 2011

Contraception
see Family Medicine. FM19

....

Table 4. Claasificlllion uf Contracaptiva Malhods

Type

Eflectivenea (perfect 111e, typical

Counlling the Adole-nl bout ControO!!ption More 111111 90'lfo of pn19nancias are unintended end approximately 5'"' of 1111 preg11111cies occur within 1hll first 6 months rrf initillting soual activity. In addition, 85% of &eXually ac:tiva women become pregnant 1 year Wno conbacoption i1 used and avan some rrf 1ha llff1lclive conlnlcaplivll ma1had& mlllbdly decniiiiB 1ha rilk of

Witlmw&l/coitus interruptus Rhythm me1holl'calend!mucous/symptathermal Lactational amenonhea

Chance - no method usad Abstinence Df allaaxual activity Banier Methecls Candom alona

77.0% 98.0%. 76.0% 98% (first 6 months postpartum I 10.0% 100.11% 98.0%. 85.0% 82.0%. 71.0% 80.0%. 68.0% 91.0%. 84.0% 94.0%. 84.0% 95.0%. 79.0% 74.0%. 68.0% 91.0%. 84.0%
99.7%, 92.0% 99.7%, 92.0% 99.7%, 92.0% 99.7%, 97.0% 91HI9% 99.9%

pnl9nancy.

Spermicide alene Sponge - Part111s

Female condom
Cervical cap - Parous
- Nuliparous

Rimm, t.E. the AllliiiiiDR lllout CGalniception. MilT Rev 21m; 24;162.

- Nuliparous Diaphragm with spermicide

lllkrl..._...lleiiWmTU..
llbm6)ftecu/2007; I10131:587-93.
l"'rpooe: To axnp1111 the IIIOCiltiDn lllromboe!NJolism and 1he use al etlrjiny\!sllldioV dral!iJnllllill. Yuniil Dr other ather IIIII CDII!nK:iptim. S1ody: Collort study Ulld 1 hlellll il.,. dlllblsa 11111 MlaMd Pllim lor Mlllll al7.& moatlts. l'llil* 22,429 WOII'en wllo hid inililted MIIBhld ID 44,858 wllo hid inilillal ather rl!ll canlllctptiv8i batwlan lbnga of ID 59,...._ and lllin Dldi:Gu Thrurnboariolic 88IQ. 11111111: The incidanclllll alliiDrNxllmboilm

OCP

Hannllllll Nuvaring

Transdennal (Ortho Evnl]

Progestin-any pill

Mirvna IUD

CappariUD
Surgic:ll Tubal ligation Vasectomy

99.3%
99.65% 99.9%

Emergcne, l'o.Uitill Cantriceptio1 (EPCI Yuzpemethod "Plan B"lewmrgestrel

Wlll'ln-11111 COITIIII!d 1o iriliniJ other OCPs 11.4 per 110JW011W1-y811SI (IIR 0.11; 15\ Cl D.5- 1.61. Specili: -a. ilcUfiv deep veil lbrombolis 1111 ]linanuy enDolism IIIII ac:cural Mil silrillrftlquancias.
in ltliyirrjllllrldioVd1111pillaanl camp1111d 1D att.

(1.3 pa1 1101

98% (within 24 hoursI 98% (within 24 hours) 99.9%

Hormonal Methods
Combined Oral Contraceptive Pills (OCP)
most contain low dose ethinyl estradiol (20-35 !Jg) plus progestin (norethinedrone, norgestrel, levonorgestrel, desogestrel, norgestimate, drospirenone) failure rate (0.3% to 8%) depending on compliance monophasic or triphasic formulations (varying amount of progestin throughout cycle)

.......... llllwrilnAdMtr
W4 ......

Pllilnll: Women laed 18-35 J)llltIMIIItion orhldlolulilrr18W>15mmbctlll.drf23 diNing I cydll.

SlUr:

2008; 78:1&-25 rmlanizad.

Transdarmal (Ortho Evra} continuous release of 6 mg norelgestromin and 0.60 mg ethinyl estradiol into bloodstream
applied to lower abdomen, back, upper arm, buttocks, NOT breast worn for 3 consecutive weeks (changed every week) with 1 week off to allow menstruation as effective as OCP in preventing pregnancy (>9996 with perfect use) may be less effective in women >90 kg body weight may not be covered by drug plans

a-. Slflnaian aiiMriln ICIMiy

atlliny8tllldioi2D meg lldnililllrad in 2-\14 llgirnen vs. 21fl leginen.

(Hoagllnd IICOrel. lllda: Wamtm em 24/4111Qilw1llld !Ill*

Contraceptive Ring (Nuvaring) thin flexible plastic ring; releases etonogestrel120 !lg/d and estradiollS!!g/d
works for 3 weeks then removed for 1 week to allow menstruation as effective as OCP in preventing pregnancy (9896) avoids first pass effect side effects: vaginal infection/irritation, vaginal discharge may have better cycle control, i.e. decreased breakthrough bleeding

and 11111e DDnlislertCMIU 21fl group. 87.8'J, in lhl2414 ""' hid 110 IMriln IICtMty vs. 5R in lhl21fl Pf.

....

,,

Starting Hormonal Contraceptives

thorough history and physical examination including blood pressure and breast exam follow-up visit 6 weeks after hormonal contraceptives prescribed pelvic exam can be delayed until a subsequent visit

lrTBgular bnllktllrough bllllding often occurs in 1he first f1lw mon1hs after Slllrting OCP. Usllllly rasolvasllflllr 1hnla cycles.

Toronto Notes 2011

Contraception

Gynecology GYHI

Table 5. Combined Estrogen and Progestin Contraceptive MBIIIods

Mllclllnism of Aclilln Ovulatory suppression through inhibition of LH and FSH Decidualillllian of endomlllrium Thickl!ning of cervical mucus resulting in decreased spenn penetration
Advlntaga

Side Eflects Eslrog...relltad Nausea h&t changes {tenderness, ari..gamantl Ruid retentionlbloatinQI'edema Wei!tJ! gain {rarel Migraine. headache& Thromboembolic events Liver adenoma {rarel Breakthrough bleeding {low a&lrlldiallavalsl
AbsalutB KnowrVsu.spected pregnancy UndiagnO&ed abnormal vaginal bleeding Prior thromboembolic 11V81115, thromboembolic disorder {Factcr V Leiden mullltion; proteil C, Sor Ill deficiency!, active thrombopNebitis Cerabrovascular or coronary artery disease Estrcgan-dapandant tumours (braast, ulllrusl ll!"4llired liverftn:tion associated with acute liver disease Congenital hyper1riglyceridemia Smoker age >35 years Migraines with focal neurological symptoms {excluding aural Uncontrolled hypertension

Highly effective, reversible Cyda ragulation DacraBSed dysmenorrhea and menorrhagia gess anemial Decreased benign breast disease and ovnn cyst development Dacraa&ed ri&k of !Mirian and endometrial cancer ncreased cervical mucus which may lower risk of Slls Dacraa&ed PMS S'f'lllploms Osteoporosis protection {possiblyl

PragntiHIIIIIBd Amenorrhe&Alreaklhrough bleeding Headaches Breast tendemess Increased ll!lPI!1ite Decreased libido Mood changes HypertEnsion Acno'oily skil* Hirsutism*

Relillive Migraines- non-focal with aura <1 hour Diabetes mellitus complicated by vascular disease Sl.E Controlled hypartansion Sickle cell anemia Gallbladder disease

* Androgenic side ellects may be

minimized by pnescribing formulation containing dasogastrel, no111estimate, drospirenane or cyproterane acetate

Drug lntaractillllf/llilkJ
phenobarbital, phenytoin and primidone can decrease ellicacy, requirilg use of back-(lJI method No evidence of fetal abnormalities if conceived on OCP No evidence that OCP is harmful to nursing infant but may decrease milk production, not necommended until6 weeks postpartum

Rahnnca: Wortd Health Organization Guideline& for Oral Contraceptive Pill (OCPI Use

Selected Examples of OCPs

....

Aleaee

,}-----------------, ,

17 j.lg ethinyl estradiol and 0.5 mg lovonorgestrel

Miss..t eon.ined OCPs

low-dose therefore often a good starting OCP also used to help acne and to regulate menstrual cycles low-dose pills can often result in breakthrough bleeding; if this persists for longer than 3 months, patient should be switched to an OCP with higher estrogen content
Tri-cyclen 35 j.lg ethinyl estradiol and 0.180 I 0.215 I 0.250 mg norgestimate triphasic oral contraceptive (graduated levels of progesterone) low androgenic activity can help with acne triphasic OCPs can not be used continuously (unlike monophasic formulations)

MiA1piU
Take 1 pill u soon as patifllll remembtn.llld the next pill It the 11111111 lima; OR ZpiUa at tha nut dose.
Miss zpills in row dumg tnt z -kJCif ... cycll Take 2 pills 1he day patient l'lmll!lblrs, and 2 pills the naxt day. Than I pill par day until peck is finished. Back-up method of birth control l'lquil'ld during naxt 7 Miss z pills in a row dumg third - k ClfU. cycle DR mia 3 in row atanyti... Throw out pack and s11rt a new pack immediately. Back-up malllod of birth control required during next 7

Yaamin and Yaz Yasmin: 30 f.lg ethinyl estradiol+ 3 mg drospirenone (a new progestin) Yaz-: 20 j.lg ethinyl estradiol+ 3 mg drospirenone- W4-day pill {4 day pill free interval) drospirenone has antimineralocorticoid activity and antiandrogenic effects benefits: decreased perception of cyclic weight gain, bloating; fewer PMS symptoms; improved acne adverse effects: hyperkalemia (rare, contraindicated in renal and adrenal insufficiency) check potassium if patient also on ACE inhibitor, ARB, K-sparing diuretic, heparin
PROGESTIN-ONLY METHOD
Table &. Progestin Only Contraceptive Methods
Suitable lor postparlum woman (does not alfact braast milk supplyl Women with corrtraindications to combined OCP (e.g. thromboenilolic or myocardial diseaseI Woman iiiDierant of estrogenic side effects of combiled OCPs Progestin prevents LH SUllie Thickllning of cervical mucua Decrease tubal motility Endometrial decidulllization Ovulation suppression - oral progestins {not IMI do not consisll!lrlly suppress compared tD combined OCPs

....

,}-----------------, ,

Milled ProgeltinDnlr Pilfl

lJu back-up canlnlcaptiva mathod

Sid Elfln:tJ Irregular menstrual bleeding Weight gain

Headache Breast tenderness Mood chillgas Functional ovarian cysts Acnr/oily skin Hirsutism

for It least 48 hDUrS. Continue Ill take remainder of pills 11 prncribed.

AbiDiute Nona

GY20 Gynecology

Contraception

Toronto Notes 2011

......

t-----------------,

C.nedian ConHnaua GWdlli on ConlinuoUI and Exloncled Honn01111l Contracoption 12001)

Dlfinilians

Selected Examples of Progestin-Only Methods Progestin-Only Pill ("minipffi") Micronor 0.35 mg norethindrone taken daily at same time of day to ensure reliable effect; no pill free interval higher failure rate (1.1-13% with typical use, 0.51% with perfect use) than other hormonal
methods ovulation inhibited in 60% of women; most have regular cycles (but may cause oligo/ amenorrhea) highly effective if also post-partum breasfeeding

*Extended usa: The use of combined hormonal conlnc:aptiv811 with plllnnad hormone-tree intervals. *Continuous USB: Unintenupted usa of combinad hormollll contnc:apiM without hormona-frae intarv.
Whllt Cllllbe . .d7 Oral, ban&darmal111d VBQinllly ministered combined hormonal Conii'IICeptivas, including 1ho.e originally d11ignld for cyclic u11, can b ministered in a variety at Continuous and Extended jcyEJ regimens.

Efficacy and AdlllfWIICI Continuous combinld hormonol contraceptive regimens are as elfective as cyclic r.gimans in pf'ftlllling pregnancy. Use of CIE combined hormonal conlnc:aptiw may ba more "forgiving" about missed combined hormonal contnc:aptiv811 baciiU.e of the absanco of a hormona-frn intaMII.

Depo-Provera" injectable depot medroxyprogesterone acetate dose 150 mg IM ql2-14wks (convenient dosing) initiate within 5 days of beginning of normal menses, immediately postpartum in breastfeeding and non-breastfeeding women irregular spotting progresses to complete amenorrhea in 70% of women (after 1-2 years of use) highly effective 99%; failure rate 0.3% side effect: decreased bone density (may be reversible) disadvantage: restoration of fertility may take up to 1-2 years

Intrauterine Device (IUD)

Tabla 7. IUD Contracaptiva Mathoda Machanilm Ill Action
CappaH:IIIIIIIining IUD (N-yel: mild ftnign body reaction in endamebium twcic to sperm and allen sperm motility

---------------------------------Absolute Known or

Siclo Effeets
The side effect profile of CIE combined hormonal contnc:aptiw regimens is not WOI'II then with cydic ragimans, and may be imprnvad.
MldieQ'Non.contracoptj.,_ u ....

Side EffBcll
Capper IUD: increased blood loss and of menses, dysmenanhea Progesterone IUD: bloating, headache pr&IJlancy Undiagnosed genital tract bleeding Acute or chronic PID Lifestyle risk for S'ns* Known allergy to capper (copper IUD ort(l Wilson's disease (copper IUD only)

Fll' women in the parimenopausal

transition who may M ovullltinv, CIE

combinad hormonal contraceptive is pnfarrad to hormonal replacamant therapy for controlling prnblemlltic blloding and VUOIIIDIDr symptoms.
Jcunll af Dbstllriclllnd (20071 Val29. Canlldl

......

Breakthrough bleeding ExpLJsian (5% in tha first year, 1J1111t8st i1 first month and in nulliparous women) Utaine wall perforation (1/1 DDDI an ilsearlion If pregnancy DCCW1 wilh an IUD, ilcreased risk of ectopic Highly effective (95-9!1%1; failure Increased risk of PID (within first1 0 days rateiH.Z% of insertion onlyl Contraceptive alfacts last 5years Reversible, private, convenient May be used in women wilh contraindications to OCPs or

Prageltenlne-releelilg IUD (Mirena4111: dac:Kllalimtian of endomebiwn and thickening of cervicall!llcous; minimal effect on ovulation

Relltiwe Valvul heart disease Past history of PID or ectopic pregn111cy

Presence of prosthesis Abnonnalitias of uterine cavity, intracavillry fibroids Severe dysmenonhea or menonhagia (copper IUD only) Cervical stanosis lrnnumosuppressed indivickials (e-g. HIV)

TYJIIII of IUDI Copper containing: Ffexi.J4D Progasbnnll containing: Mirana

wanting long-term contraception

*Cervical swabs for gananhea and c!Wnydia shoold be dane prior til IUD insertion

Can be inserted for 5years and fertility

is restol'lld with removal.

c.eqaiiAIIf4lnn U11al D..,.._.

Kt*tH!E 172(6):746 &lmfld Ulllup tofiw yws) af madfTayprvgllllarane IIC:8IItllu belli found to decnut spn llld lip bona IIWiml IBMDI 1rt 41 to 6.91. Two yem lifter dilcontinuab. only partial rK1M1Y aiBMD 1111'- nalld.

New SOGC Rnom-dlltiona for DQo-l'rovera1 Usan Soot NMs 1111-. Naw from lllliol1ll alrgyn soc:ie!y llllillm llet-l'nmmlll, bOlla losa. MIIY ZOO&. e.pdl Inform plltiants of potintilll risks anclbnlfits It intarvlls throughout course of tralltmant Recommend ways to improva bDfiB tlelllltl such as calcium, vitamin D, waight-baring smoking cessation, decreased alcohol and reduced cafleine There is no evidence to suggest routine BMO testing

Toronto Notes 2011

Contrauptionllnfertility

Gynecology GY21

Emergency Postcoital Contraception (EPC)

Tabla 8. Emargancy Contraceptive Methods
Mecll1nilm af Action
Side Ellec1l Nausea (due ID estnJgen; treat with Gravel) spotting PrJ-existing pregnancy (although not taraiDganic) Caution in women with contraindic:ations to OCP (although NO absolute contraindic:ations)

HORMONAL Yuz1111 Method

U&ed within 72 hour& of unlfUlected intercoun;e; limited evidence of benefitupiD 5 days OvraP 2tablets then repeat in 12 hours (ethinyt estradiol 100 jigf levonorgastrai5DD 11111 Can substitute with any OCP as long as same dose of estrogen used 2% DVII'llll risk of pregnancy Blicacy decreased with time (e.g. less effective at 72 hours than 24 hours)

Unknown; suggestions include: Suppresses owlation or causes deficient luteal phase Alters endomatrium ID prevent implantation Affucts sparmf1M11nrlsport

"PIUir
Cansists of levcnorgesln!l750 1111 q1 2h lor 2doses (can also take 2 doses 1llken within 12 hours of mrcourse Graatar allicacy (75-95% within 24 hi and batter side sffact profile than Yuzpe method but efficacy decreases with time No estrogen tills very few contraindicalion!Vside effects (less nausea)

Posll:oiiiiiUD {Capper)
Insert up to 7days postcoitus PI8Vants implantation 1% failure rate Can use for short ooration in highlf risk indiviooals Mirana41 lUll cannot ba used as EPC

NON-HORMONAL

SeeTable7

Sea Table 7

SeaTable7

Follow-up
3-4 weeks post treatment to confirm efficacy (confirmed by spontaneous menses or pregnancy test) contraception coWlSc:ling

Infertility
Epidemiology
10-15% of couples must investigate both members of couple

......

Female Factors
Etiology
ovulatory dysfunction (15-20%) hypothalamic (hypothalamic amenorrhea) pituitary (prolactinoma, hypopituitarism) ovarian

lnmtlllly: inability to conceive or CIIT'f to 1Brm a prvgnancy afiBr one year of regular, unprotected intercourse. Primlry lnr.rti&ty: infertility in the
contelcl of no prior pregnancies.

s-ndary infertility: infertility in 111a

contelcl of 1 prior conception.
pnJgnancy 6 months, 85% within 1 ye111, 90'llo within 2yam

G-rally, 75'!1. of couples achieve

PCOS
premature ovarian failure luteal phase defect (poor follicle production, premature corpus luteum failure, failed uterine lining response to progesterone), poorly understood systemic diseases (thyroid, Cushing's syndrome, renal/hepatic failure) congenital (Thrner's syndrome, gonadal dysgenesis or gonadotropin deficiency) stress, poor nutrition, excessive exercise (even with presence of menstruation) outtl.ow tract abnormality tubal factors (20-30%) PID adhesions (previous surgery, peritonitis, endometriosis) ligation/occlusion (e.g. previous ectopic pregnancy) uterine factors (<5%) congenital anomalies (e.g. prenatal DES exposure:), bicornuate: uterus, uterine septum intrauterine adhesions (e.g. Asherman's syndrome) infection (endometritis, pelvic TB) fibroids/polyps (particularly intrauterine) endometrial ablation cervical factors (5%) hostile or acidic cervical mucus anti-sperm antibodies structural defects (cone biopsies, laser or cryotherapy)

......

RlqW'emlllb for Conception 1. Ovary 2. Tuba 3. Cervix

4. Endometrium 5.Sperm

GY22 Gynecology

Infertility

Toronto Notes 2011

..,., ,

Wbn ahD..d invutipti-llegln? <35 y&lllll: after 1 of raguillr

unprotected interc01ne

.-----------------,

endometriosis (15-30%) multiple factors (30%) unknown factors (10-15%) Investigations ovnlatory day 3: FSH, LH, TSH, PRL DHEA, free testosterone (ifhirsute) day 21-23: serum progesterone to confirm ovulation initiate basal body temperature monitoring (biphasic pattern) postcoital test: evaluate mucus for clarity, pH, spinnbarkeit (rarely done) tubal factors HSG (can be therapeutic- opens fallopian tube) SHG laparoscopy with dye insufflation peritoneaUuterine factors HSG/SHG, hysteroscopy

35-40 yell'l: after >6 months >40 years: imrnedietaly Earlier if: History of PID History of infertH in previous ity l'lllllionship Prior pelvil: SUillfl!Y Chemalh8l'ljl'f/radilllion in either
partner

Recurrant P1811"1111CY loA

Modnta-s.-. andomllriosis

... , ,

Call'lniYIINial and Evahin1 Ethic..

..-----------------,

other karyotype
Treatment ed.ucatiom timing of intercourse in relation to ovulation (from 2 days prior to 2 days following presumed ovulation), every other day medical ovulation induction clomiphene citrate (Clomid): estrogen antagonist that causes a perceived decreased estrogen state, resulting in increased pituitary gonadotropins; causes increased FSH and LH, leading to ovulation induction (better if anovulatory) human menopausal gonadotropin [HMG (Pergonal)], urofollitropin [FSH (Metrodin)] - FSH and LH extracted from urine of postmenopausal women followed by beta-hCG for stimulation of ovum release m.ayadd bromocriptinc: (dopamine agonist) if elevated prolactin dexamethasone for hyperandrogenism (adult onset congenital adrenal hyperplasia), metformin (PCOS) luteal phase progesterone supplementation for luteal phase defect ASA (81 mg PO OD) daily for women with a history of recurrent spontaneous abortions surgical/procedural tuboplasty lysis of adhesions artificial insemination sperm washing IVF (in vitro fertilization) intrafallopian transfers GIFT (gamete intrafallopian transfer): immediate transfer with sperm after oocyte retrieval ZIFT (zygote intrafallopian transfer): transfer after 24 hour culture of oocyte and sperm TET (tubal embryo transfer): transfer after >24 hour culture ICSI (intracytoplasmic sperm injection) lUI (intrauterine insemination) oocyte or sperm donon IVM (in vitro maturation)

1- demands non-judgmen!lll lnfertHity

Ethical issues surrounding lhii'IPautic
donor insemin.tion in 6Sme sex coupln, swrogacy, donor 1!1Q and other advanced reproductive technologiMII'I stiU evolving nd

remain con1roversill
If certein options lie outside physician's moral boundaries, infertile couple shoQd be rufarrad ID another

physician

... , ,

Summuy Ill Current Lqilldan in

.-----------------,

C.nedll Bill C-13 Assisted H Reprodi!Ciion Act 2004:

WHAT IS NOT AlLOWED
Cloning people Cloning 111m ellis

Growing embryos for rw.rch Sax. selection Making changes ID human DNA that would pus from one gmntion 1D
the rest Craati1g people who haw llllimal DNA
Buyilg or selling embryos, spenn, eggs

or ather human raproductivu mlllerill WHAT IS ALLDWED SU11'oQIII8 mothlm Don.ting sperm, eggs and other reproductive m.tarial Using ambryos, sparrn, eggs, etc., to assist conception Using human ambryos and stem calls in research

..,., ,

Male Factors
see Urology. U34

1-----------------,
s.-

Normal Analysis (WHOcnt.rilll MUll: be obtained .tier 48-72 hours

of abstinence 1. Volume 2-5 cc 2. Count > 20 millior1/cc 3. Motiity >50% forward progra66ion 4. Morphology >31l'J. normal 5. Absence of pyospermia,
hyparviscosity, agglutination

Etiology varicocele (>40%) idiopathic (>20%) obstruction (-15%) cryptorchidism (-8%) immunologic (-3%) Investigations semen analysis and culture post-coital (Hubner) test: rarely done

NB: dOllS not 11Hea5 sperm function

Toronto Notes 2011

Polycystic Ovarian Syndrome (PCOS)

Gynecology GY23

..._,

Polycystic Ovarian Syndrome (PCOS)

also called chronic ovarian androgenism

Clini:lll Sian of Endocrine lmlll' Menstrual disorder/amenorrhea [80%1 Infertility [74'1ol

Oba&ity [49'l(,l
Hirsutism [69%1 Impaired glucose tola111nce {35%1 DiaiNrtn Mallilus [111%1

Etiology
Insulin

1' estrogen 1' peripheral cotrsion to lltrogen

Obesity 'ill

r
-

FSH sacntion

1' ovarien sec1on of androgens

Hirlllllism

t+ 1'

IJi sacntion - - - Anovuldon

Oligo1110rrhel

l'lllvqdc OV.rilln SyndnmeHAIWN Hirsutism, ltyperAndrogenism, Infertility,

lnfartility

Insulin llelistmlce, Acenlhosis NigriCIUII

Figure 12. Pathophysiology of Polycystic Ovarian Syndrome

..._,

Diagnosis 2 of 3 to make diagnosis

1. oligomenorrhea/irregular menses for 6 months 2. clinical or lab evidence ofhyperandrogenism 3. polycystic ovaries on U/S

PCOIIIIIIY be Conflleed with: Late Dll5et congenitll adrenal hyplrpluil [21-hydroxylue dlficiencyl Cushing's synrlrorn. Ovari111 and achnlll naoplalms Hyperprolllctinemia Hypothyroidism

Clinical Features average age 15-35 years at presentation abnormal/irregular uterine bleeding, hirsutism, infertility, obesity; virilization insulin resistance occurs in both lean and obese patients acanthosis nigricans: browning of skin folds in intertriginous zones (indicative of insulin resistance} family history of diabetes

Investigations
goal of investigations is to identify hyperandrogenism or chronic anovulation and rule out specific pituitary or adrenal disease as the cause labs prolactin, 17-hydroxyprogesterone, free testosterone, DHEA-S, TSH, free Toto androstenedione, sex hormone binding globulin (SHBG} LH:FSH >2:1; LH is chronically high with FSH midrange or low (low sensitivity and specificity} increased DHEAS, androstenedione and free testosterone (most sensitive}, decreased SHBG transvaginal ultrasound: polycystic-appearing ovaries ("string of pearls"} tests for insulin resistance or glucose tolerance fasting glucose:insulin ratio <4.5 is consistent with insulin resistance (U.S. units) 75g OGTT (particularly if obese) laparoscopy not required for diagnosis most common to see white, smooth, sclerotic ovary with a thick capsule; multiple follicular cysts in various stages of atresia; hyperplastic theca and stroma rule out other causes of abnormal bleeding

..._, ,.J-----------------,
Long T11r111 HNIIh Hyplltipidemill Adult-onsst dillbllbls mellitus

Endometrial Infertility
Obesity

Slaep apnea ""., Mlll'umin in l'liiJqltic: IMry .,...__ Alllll' .... 0/lllltGyrtet:a 2008; 111[41:1511-68. lllllr. Thi& IIIIU-IIIIIysiuf 17 RCT& II18H8d lila etlicley ri mefarmin ar 11111farmin in c:orminlliarl with ciblte in wamen wilh po:ystic IMrysynctome
PllllfWICy.

Treatment cycle control

lifestyle modification (decrease BMI, increase exerdse) to decrease peripheral estrone formation OCP monthly or cyclic Provera to prevent endometrial hyperplasia due to unopposed estrogen oral hypoglycemic (e.g. metformin} tranexamic add (Cyklokapron) for menorrhagia only

l'llliiO...: Owlllioa,

infertility
medical induction of ovulation: clomiphene dtrate, human menopausal gonadotropins [hMG (Pergonal)], LHRH, recombinant FSH, and metformin metformin may be used alone or in conjuction with clomiphene citrate for ovulation induction ovarian drilling (perforate the stroma}, wedge resection of the ovary bromocriptine (ifhyperprolactinemia) any OCP can be used Diane 35 (cyproterone acetate): antiandrogenic Yasmin (drospirenone and ethinyl estradiol}: spironolactone analogue (inhibits steroid receptors) mechanical removal ofhair finasteride (5-alpha reductase inhibitor) flutamide (androgen reuptake inhibitor}

hirsutism

of cUiion [Oft 4.39, M Cl1.94- U61111d The etlect ri conHstian 'dle!aw- most lll'li!ent in cloni!Nne-flli111nt llld ollase- Mil I'CDS. Nlh!rmoll.lba combinllian lbarapy hid I highll' ikllllood of IIIVing I iva bir111 carnpll8d to clomiphana Ilana. but1his did 1101 -b [CII1.74, MCI 0.79 Candllilnl; Metfannil illCRIIeS the 11111111111 aiiMiltian. wt.l Ulld tDgllbar wilh clamip.... lllllfannil n-U.illihaad of bath IMJII!ian 11111 pregniiiCV, "118Ciltt in clamipMrle-resilllrt llldob--

nat signiicntlt ilc-lhe adds ri schievi'G pregnMCy [Oft 1.56, M Cl 0.74-3.331. When CGII'Ipllld 111 allllll,lhl cantinllian ri lllllfannild damipMrla incrmld lhllblihllad

bii1IL l'ltilda:1,638 PalSW8111116Jwaci up for up to 12 rnonlls. IIIUII: Corrl!ed ID pllcebo, metlonnil inc:nued the adds of DWiation [lll2J4.M a 1.436,021. H - . Mien Ullld Ulne.lllllllwmil did

GY24 Gynecology

Gynecolopcal Infections

Toronto Notes 2011

Gynecological Infections
Physiologic Discharge
clear, white, flocculent odourless discharge; pH 3.8-4.2 smear contains epithelial cells, Lactobacilli increases with increased estrogen states: pregnancy, OCP, mid-cycle, PCOS or premenarchal if increased in perimenopausal/postmenopausal woman, consider investigation for other effects of excess estrogen (e.g. endometrial cancer)

Vulvovaginitis

I Vulvovaginills Vulvll' and vagmal1nllarnmatton.

.....

PREPUBERTAL VULVOVAGINITIS
clinical features
irritation, pruritus discharge vulvar erythema vaginal bleeding (specifically due to Group A Streptococci and Shigella) non-specific vulvovaginitis (25-75%) infections (respiratory, enteric, systemic, sexually acquired) foreign body (toilet paper most common) candida (if using diapers) pinworms polyps, tumour (ovarian malignancy) vulvar skin disease (lichen sclerosis, condyloma acuminata) trauma (accidental straddle injury, sexual abuse) psychosomatic vaginal complaints (specific to vaginal discharge) endocrine abnormalities (specific to vaginal bleeding) blood dyscrasia (specific to vaginal bleeding)

,,

Most common gynecaloviclll problem in prepubertal gills is non-specific wiVOYIIginilis.

differential diagnosis

etiology
.....

,,._________________ ,

There is no high quality evidence showing a link blrtw8en vulvovllgml candidiasis and hygienic habits or wuarinu tight ar aynthetic clothing.

.._,,
PNpaiNirtal...t Adoltlscant G,Mcologicllllnfllclionl: Llgll Alpt1cb .t Conlillentt.llly

Clinicians who treat adolescents must ba ewera of federal, stat11 and provincial laws related to adolescent consent and confidentiality. They must be aware of guidelines giMiming funding liDun:e& for plrticular SSIVices and be familiar wilh the consent and confidentiality policils of the focility in which they practice.

infectious: poor hygiene, proximity of vagina to anus recent infection (respiratory, enteric, systemic) STI: investigate sexual abuse nonspecific: lack of protective hair and labial fat pads lack of estrogenization susceptible to chemicals, soaps (bubble baths), medications and clothing enuresis investigations vaginal swab for culture (specifically state that it is a pre-pubertal specimen) treatment enhanced hygiene and local measures (handwashing, white cotton underwear, no nylon tights, no tight fitting clothes, no sleeper pajamas, sitz baths, avoid bubble baths, use mild detergent, eliminate fabric softener, avoid prolonged exposure to wet bathing suits, urination with legs spread apart) A&o dermatological ointment to protect vulvar skin infectious: treat with antibiotics for organism identified
Tabla 9. Other Common Ceusas of Vulvovaginitis in Prepubertal Girls

Pinworm Di111nD1i1
Tralltmlllt

Lichan Sdal'lllil Area of white patches and

thinning Ill skin Topical steroid creams

Foreign Body

Celophane Tape test Empirical treatment with mebendazole

Irrigation of vagina with saline, may requi'e local or an exam under anesthesia

Toronto Notes 2011

Gynecological Infections

Gynecology GY25

POSTMENOPAUSAL VAGINITIS/ATROPHIC VAGINITIS clinical features

dyspareunia
post-coital spotting

mild pruritus
investigations

atrophy is usually a visual diagnosis: thinning of tissues, erythema, petechiae, bleeding

points, dryness on speculum exam rule out malignancy: especially endometrial cancer treatment local estrogen replacement (ideal): Premarin cream, VagiFem tablets, or Estring oral or transdermal hormone replacement therapy (if treatment for systemic symptoms is

desired)
good hygiene

INFECTIOUS VULVOVAGINITIS

Table 1D. Infectious Vulvovaginitis

Drpnisms

Cllldidiuis (Moniliuis) Clndida albiC8il$ {90%) Candida glabnlta (<5%) C8ndide tropicalis (<5%)
Predisposing 1actors include: lmmunDSUppressed host (diabetes, AIDS, etc.) Recent !nlibiotic use lncludB& 85bogen level& (e.g. pregnancy, OCP) "cottage cheese," minimal 20% asymptomatic Intense Swollen, inllarned genitals Vulvar buming, dysuria, dysl)lnUllia

Bactarill Vqinosis (BV)

Trichomoniasis

GlrrJnerella Vllgina/is
AnaerobB&: PtwrJts11a, MobiJuncus. Bacteroides Replacement of Vllginall.ectoblci/lus org111isms above

Triclromonls 'lllgina/is (ftagelllllld protozoan]

Pathophyliology or

Sexually transmitted

Discharge

l:tey, thin, diffuse

50-75% asymptomatic Fishy odour, esp. after coitus Absence of vulvWvaginal inillltion

Yellow-green, malodorous, diffuse 25% asymptomatic Petechiee on vagina and cervix Occasionally initated tender wlva Dysuria, frequency

Other
Signt/Symplllml

pH
Saline Wetmaunt

s4.5
KOH wlllmount 18V8111s lryphae111d spores

>4.5

s4.5

1] Motile flagellated orgllisms 1) > 20% due cells = &qUEIIIDUI epithelial cells dotted with coccobacili {Ganfnenl//a] Z] ManyWBC 2] Paucity of WBC 3] lniiiiTITIIItory cells {PMNs) 3] Paucity of LaCIDbacilli 4] Positiw whiff test = fishy odour with addition of KOH to slide {due to formation of amines]
No 1reatment non-pregnant and asyrqltomatic, unless scheduled for pelvic surgery or procecilre Treat even if Metronidazole Zg PO single dose or 500 mg

Traatmant

Clotrimazole. butoconamle, miconamle, terconazole suppositories and/or creams for 1, 3 or 7-daytreatments Truatment in pragnancy is uully topical

treatment
fluconazole 15D II'Cl PO in single dose

bid x 7days Oral Syrromatic pregnant women should be Metronidazole 500 mg PO bid x 7 days or treated with Zg metronidazole once metronidazole gel 0.75% x 5 day OD Clindemycin 2% 5g intrevegi'lllly at bedtime for 7

days Topical
May use metronidazole in pregnancy

Other

Far repeat infections prophylaxis, treatment Associated with recurrent llld preiEnn labour, Warnings accompanying metronidazole use includes boric acid, vaginal suppositories, luteal preterrn birth and postpartum endomebitis in Treat partner{s] phase fuconamle pragnancy Routine 1reatment of partru!l1s] not recommended Need to warn patients on metronidazole not to (not sexually transmitted) consume alcohol {disulfiram-like action] Routine treatment of partner{s) not recommended (not &exually transmitted]

GY26 Gynecology

Gynecologial.Infectl.oDJ

1'oroDio

2011

o-,
..... ,

mTIItit 1. VlgllaiiWIII Tasb far bact&rillllllgillllllil..

lrichomoniasis, candida 2. CIMCII swab Tllltfor !lllflcnh8R and ehlamydil

Sexually Transmitted Infections (STis)

see Family Me<lidne. FM43
FAllDPIAN TlJBE

-----

....

Rill hciDn far 1111 Hinry ot prwiou sn wilh inler;tal person

SBICUIIIy ICiivll indi'lica.l 111111 <25'(81111 Multiple p111n811 Naw plllnlr in lilt 3 mmths

snet inwi'IWilllll (homeiiiiiiiiiS,

drug Ull)

Notllling barrier prvtection

.....

l'lllllc Hellllll Aatcr ot Callllda:

rut1ona1 Nllllllllll sns HIV Gononhea

Syphilis Hepatitis B. C. D

11 Spac...um Exam

TRICHOMONIASIS sc:c: lnfeclious Vulvovaginitis, GY25

CHLAMYDIA
Etiology Chlamydia tmchomw Epidemiology
most common bacterlal STI in Canada

often associated with N. gonorrhae

Clinical Features
asymptomatic (80% muco-purulc:nt endocervical discharge

urethral syndrome: dysuria. frequency, pyuria. no bacteria pelvic pain post-coital bleeding or intermenstrual bleeding (particularly Ifon OCP and prior history of good cycle control) symptomatic semal partner
Investigations cervical culture or nucleic acid amplification test obligate intracellular paiUl1e - tissue culture is the definitive standard urine and vaginal test now avaflable. whl.ch are equally or more effective than cervical culture
Trelltment doxycycline 100 mg PO bid fur 7d or azithromycin 1 gPO in a single dose (may use in pregnancy) also treat gonorrhea bc:c:ause of high rate of co-infection treat partners
reportable disease test ofcure for cb1amydia required in pregnancy (cure rates lower In pregnant patients) ..,. re-test 3-4 weeks after Initiation of therapy

Screening high risk groups during pregnancy

Toronto Notes 2011

Gynecological Infections

Gynecology GY27

Complications acute salpingitis, PID Fitz-Hugh-Curtis syndrome (liver capsule infection) arthritis, conjunctivitis, urethritis (reactive arthritis- male predominance, HLA-B27) infertility- tubal obstruction from low grade salpingitis ectopic pregnancy chronic pelvic pain perinatal infection - conjunctivitis, pneumonia
GONORRHEA

Etiology Neisseria gonorrheae symptoms and risk factors same as with chlamydia Investigations Gram stain shows Gram-negative intracellular diplococci cervical, rectal and throat culture Treatment single dose of ceftriaxone 125 mg IM, or cefixime 400 mg PO, or ciproflaxacin 500 mg PO if pregnant -cephalosporin regimen or 2 g spectinomycin IM (avoid quinolones) also treat chlamydia, because of high rate of co-infection treat partners reportable disease screening as with chlamydia
HUMAN PAPILLOMAVIRUS (HPV)

....

Te&t Df cure for C. tm:homlttis 111d N. 90fiO/riletle is not routinely indicated. Repeat testing if symptommic, if compliance with trea1mant is uncertain, or if pregnant

Etiology most common viral STI in Canada >200 subtypes, of which >30 are genital subtypes HPV types 6 and 11 are classically associated with anogenital warts/condylomata acuminata HPV types 16 and 18 are the most oncogenic (classically associated with cervical HSIL) types 16, 18, 31, 33, 35, 36, 45 (and others) associated with increased incidence of cervical and vulvar intraepithelial hyperplasia and carcinoma Clinical Features latent infection no visible lesions, asymptomatic only detected by DNA hybridization tests subclinical infection visible lesion found during colposcopy or on Pap test clinical infection visible wart-like lesion without magnification hyperkeratotic, verrucous or flat, macular lesions vulvar edema Investigations cytology (see Cervical Screening (Pap Test), GY43) koilocytosis - nuclear enlargement and atypia with perinuclear halo biopsy oflesions at colposcopy detection of HPV DNA subtype using nucleic acid probes not routinely done but can be done in presence of abnormal Pap test to guide treatment Treatment patient administered: podofilox 0.5% solution or gel bid x 3 days in a row (4 days off) then repeat x 4 weeks imiquimod (Aldara) 5% cream 3x/wk qhs x 16wks provider administered: cryotherapy with liquid nitrogen: repeat q1-2wks podophyllin resin in tincture of benzoin: weekly trichloroacetic acid (TCA) or bichloroacetic acid weekly (80-90%); safe in pregnancy surgical removal!laser intralesional interferon Prevention HPV types 6, 11, 16, 18- preventable with Gardasil (quadrivalent HPV recombinant vaccine) cannot be prevented by using condoms

.....

Ganital Wllrt. D1ring PntgniiiCY Condyloma tend tn get larger in pregnancy and should be treated early (consider axcisionl. C-saction only if obstruction of birth canal or risk of extensive bleeding. Do not usa imiquimod, podophyllin or podofilox.

....

Hu11111n Rights In Health Equity: CaiViclll Cane IIIII HPV VacciMI &min. JN.Ainllii:M .kmJti of t.w It MD:ill. 2009 While cervical cancer rates have drastically fallen in developed countries due to aiJactive pravention 1111d tl'lll1mant. socially disadvanlllgad women these countries remain disproportionately moruliklly to develop and die of cervical cancer. In most developing countries, in contrut, cervical c111cur retes h8V8 risen or ramained unchanged. Must recogniZI that cervical cancer disparities between race groups. urban and ruralrasidanca, and high and low wualth lllltus 118 attributed to disperate screening and vaccination coverage. Progrums ara implemantad without sufficient attention to conditions that rundar scraaning less affective or inaccessible to disadvantaged social including: lack of infonnation, undervaluing of preventive care, opportunistic delivury in limited care settings, sexual health slig1111 and ralated privacy concerns.

GY28 Gynecology

Gynecolopcal Infections

Toronto Notes 2011

HERPES SIMPLEX VIRUS OF VULVA (HSV)

Etiology
90% are HSV-2, 10% are HSV-1

Clinical Features may be asymptomatic

C..
HSV I - diuls1 abova thl batt (oral I HSV II- di...su below the belt {ganitall

initial symptoms: present 2-21 days following contact prodromal symptoms: tingling, burning, pruritus multiple, painful, shallow ulcerations with small vesicles appear 7-10 days after initial infection (absent in many infected persons); lesions are infectious inguinal lymphadenopathy, malaise, and fever often with first infection dysuria and urinary retention if urethral mucosa affected recurrent infections: less severe, less frequent and shorter in duration (especially with HSV-1)

Investigations viral culture preferred in patients with ulcer present - decreased sensitivity as lesions heal
cytologic smear multinucleated giant cells, acidophilic intranuclear inclusion bodies type specific serologic tests for antibodies to HSV-1 and HSV-2 (not available routinely in Canada) HSVDNAPCR

..... ,
HSV lnflll:tions O.rint PNgnancy Antiviralsupprwssian of woman with first episode or history of HSV infections from 36 weeks GA an. C-sectian $hauld be performed an wam1n who haVIactiw ganital lelians at time of dulivary. Traatrnant: acyclovir 400 mt PO tid.

Treatment
first episode acyclovir 400 mg PO tidx 7-10d, or famciclovir 250 mg PO tidx 7-10d, orvalacyclovir 1 g PO bidx 7-10d recurrent episode acyclovir 400 mg PO tid x 3-5d, or famciclovir 125 mg PO bid x 3-5d, or valacyclovir 500 mg P0bidx3d daily suppressive therapy consider if 6-8 recurrences per year acyclovir 400 mg PO bid, or famciclovir 250 mg bid, or valacyclovir 0.5-1 gPO OD severe disease consider IV therapy acyclovir 5-10 mg/kg IV q8h x 5-7d education regarding transmission avoid contact from onset of prodrome until lesions have cleared use barrier contraception

SYPHILIS
Etiology 1Teponema pallidum

....

,
5"' < 1%

Classifications
progresses in stages primary syphilU 3-4 weeks after exposure painless chancre on vulva. vagina or cervix painless inguinal lymphadenopathy serological tests usually negative, local infection only aecondary syphilis (can resolve spontaneously) 2-6 months after initial infection nonspecific symptoms: malaise, anorexia, headache, diffuse lymphadenopathy generalized maculopapular rash: palms, soles, trunk, limbs condylomata lata: anogenital, broad-based fleshy grey lesions serological tests usually positive

Epldutlolagy of Genllld UlcBI'I HSV 7G-80%

,. syphilis Chancroid

latent syphilis
no clinical manifestations; detected by serology only tertiary syphilU may involve any organ system neurological: tabes dorsalis, general paresis cardiovascular - aortic aneurysm, dilated aortic root vulvar gumma: nodules that enlarge, ulcerate and become necrotic (rare)

congenital syphilis
may cause fetal anomalies, stillbirths or neonatal death

Toronto Notes 2011

Gynecological Infections

Gynecology GY29

Investigations aspirate of ulcer serum or node darldield microscopy (most sensitive and specific diagnostic test for syphilis) spirochetes non-treponemal screening tests (VDRL, RPR); nonreactive after treatment, can be positive with other conditions specific anti-treponemal antibody tests (FfA-ABS, MHA-TP, TP-PA) confirmatory tests; remain reactive for life (even after adequate treatment) Treatment treatment of primary, secondary, latent syphilis of <1 year duration benzathine penicillin G 2.4 million units IM single dose treat partners, reportable disease treatment of latent syphilis >1 year duration benzathine penicillin G 2.4 million units IM q 1wk x 3 weeks treatment of neurosyphilis IV aqueous penicillin G 3-4 million units IM q4h for 10-14 days screening high risk groups in pregnancy (see Obstetrics, Table 10, OB19) Complications if untreated, 1/3 will experience late complications

HIV
see Infectious Diseases, ID29

Bartholinitis/Bartholin Gland Abscess

Etiology often anaerobic and polymicrobial U. urealyticum, N. gonorrheae, C. trachomatis, E. blockage of duct

P. mirabilis, Streptococcus

S. aureus (rare)

Clinical Features
unilateral swelling and pain in inferior lateral opening ofvagina sitting and walking may become difficult and/or painful Treatment sitz baths, warm compresses antibiotics incision and drainage using local anesthesia with placement of Word catheter (10 Fr. latex catheter) for 2-3 weeks marsupialization under general anesthetic - more definitive treatment rarely treated by removing gland

Pelvic Inflammatory Disease (PID)

up to 20% of all gynecology-related hospital admissions Etiology causative organisms (in order of frequency) C. trachomatis N. gonorrheae gonorrhea and chlamydia often co-exist endogenous flora: anaerobic, aerobic, or both
PID

Inflammation of 1ha upplll' genilllllrlct (aboVII*Vix) including andomllrium. fallopian 1uba&, ovari&l, pelvic paritoneum, contiguous stJUclu11s.

E. coli, Staphylococcus, Streptococcus, Enterococcus, Bacteroides, Peptostreptococcus, H. influenzae, G. vaginalis

cause of recurrent PID associated with instrumentation Actinomyces israelii (Gram-positive, non acid-fast anaerobe) in 1-4% of PID associated with IUDs others (TB, Gram-negatives, CMY, U. urealyticum, etc.)

Risk Factors
age <30 years risk factors as for chlamydia and gonorrhea vaginal douching nm (within first 10 days after insertion) invasive gynecologic procedures (D&C, endometrial biopsy)

GY30 Gynecology

Gynecolopcal Infections
Clinical Presentation up to 2/3 asymptomatic: many subtle or mild symptoms common fever >38.30C lower abdominal pain and tenderness abnormal discharge: cervical or vaginal uncommon nausea and vomiting dysuria AUB chronic disease (often due to chlamydia) constant pelvic pain dyspareunia palpable mass very difficult to treat, may require surgery

Toronto Notes 2011

......

J-----------------,

PIDD'-tlnnia

Mtrst have: Lower abdominal pain Cervical motion tendemeN Adnexal tendiiii18SS 1'1111 on& or mors of: High risk pertn1r Temperatura >38'C Mucopurulent carvical culture for N. C. tnldlomllis. E. coli, or othw vaginal flora fluid, pelvic absceN or inllarnmi!tory mass on U/S or
Leukocytosis
ElewbJd ESR or CRP (not commonly u111d) binllooal

Investigations bloodwork P-hCG (must rule out ectopic pregnancy), CBC, blood cultures if suspect septicemia urineR&M speculum exam, bimanual exam vaginal swab for Gram stain, C&S cervical cultures for N. gonorrheae, C. trachomatis endometrial biopsy will give definitive diagnosis (rarely done) ultrasound may be normal free fluid in cul-de-sac pelvic or tuba-ovarian abscess hydrosalpinx (dilated fallopian tube) laparoscopy (gold standard) for definitive diagnosis: may miss subtle inflammation oftubes or endometritis Treatment must treat with polymicrobial coverage inpatient if: moderate to severe illness atypical infection adnexal mass, tuba-ovarian or pelvic abscess unable to tolerate oral antibiotics or failed oral therapy immunocompromised pregnant adolescent - first episode surgical emergency cannot be excluded (e.g. ovarian torsion) PID is secondary to instrumentation reconunended treatment cefoxitin 2 g IV q6h (no longer available in U.S.A.) or cefotetan 2 g IV q12h + doxycycline 100 mg IV/PO q12h or clindamycin 900 mg IV q8h + gentamicin 2 mg/kg IV loading dose then gentamicin 1.5 mglkg q8h maintenance dose continue IV antibiotics for 24 hours after symptoms have improved then doxycycline 100 mg PO bid to complete 14 days percutaneous drainage of abscess under U/S guidance when no response to treatment, laparoscopic drainage if failure, treatment is surgical (salpingectomy; TAH/BSO) outpatient if: typical findings mild to moderate illness oral antibiotics tolerated compliance ensured follow-up within 48-72 hours (to ensure symptoms not worsening) recommended treatment oflo.xacin 400 mg PO bid x 14d or levofl.oxacin 500 mg PO bid x 14d metronidazole 500 mg PO bid x 14d (if suspect abscess) ceftriaxone 250 mg IM x 1 + doxycycline 100 mg PO bid x 14d or cefoxitin 2 g IM x 1 + probenecid 1 gPO+ doxycyline 100 mg PO bid metronidazole 500 mg PO bid x 14d consider removing IUD after a minimum of 24 hours of treatment reportable disease treat partners consider re-testing for C. trachomatis and N. gono"heae 4-6 weeks after treatment if documented infection

Tlllllt PID with FOXY DOXY

+ doxycycline)

......

J-----------------,

For patienb with contraindications 1D 1rlllmant with caphalospomt or quinoloriBI, recant avidanca suggssta that athon course of IIZilhromycin at a dose of either 250 mv PO daily lor ona Wille or 1 g PO Wllklv for two week5 combined with metronidalole is aftactiva in achieving a clinical cura lor acute PID. SIIUI'CI: Lt*J tD ftl8 Cadln 6uidlillr M Sallii\t Tllllllllillld llctDblr 2008.

Toronto Notes 2011

Gynecological l.ofections/Sexuality and Sexual Dysfunction

Gynecology GY31

Complications of Untreated PID chronic pelvic pain abscess, peritonitis adhesion formation ectopic pregnancy infertility 1 episode of PID -+ 13% infertility 2 episodes ofPID -+ 36% infertility bacteremia septic arthritis, endocarditis

It'

PID Cpllcationl

IFACEPm Infertility Filz.Hugh-Cunis syndrome Abscesses

Chronic pelvic pain Ectopic pregnancy

Peritonitis Intestinal obstruction Disseminated infaction (18J11is, mdoclll'llilis, arlhrilis, llllllinvilill

Toxic Shock Syndrome

see Infectious Diseases. ID27

---------------------------------------laic SbDck Syndnlme Multiple organ system failure due 111 S. aureus exotoxin (rare condition).

Risk Factors tampon use diaphragm, cervical cap or sponge use (prolonged use, i.e. >24 hours) wound infections post-partum infections early recognition and treatment of syndrome is imperative as incorrect diagnosis can be fatal Clinical Presentation sudden high fever sore throat, headache, diarrhea erythroderma signs of multisystem organ failure refractory hypotension exfoliation of palmar and plantar surfaces of the hands and feet 1-2 weeks after onset ofillneas Treatment remove potential sources of infection (foreign objects and wound debris) debride necrotic tissues adequate hydration penicillinase-resistant antibiotics, e.g. cloxacillin steroid use controversial but if started within 72 hours, may reduce severity of symptoms and duration of fever

Surgical Infections
Post-Operative Infections in Gynecological Surgery pelvic cellulitis common post hysterectomy, affects vaginal vault erythema, induration, tenderness, discharge involving vaginal cuff treat iffever and leukocytosis with broad spectrum antibiotics, ie. clindamycin and gentamicin drain if excessive purulence or large mass can result in intra-abdominal and pelvic abscess see Post-Operative Fever, GS7

Sexuality and Sexual Dysfunction

SEXUAL RESPONSE 1. deaire: energy that allows an individual to initiate or respond to sexual stimulation 2. arousal: physical and emotional stimulation leading to breast and genital vasodilation and clitoral engorgement 3. orgasm: physical and emotional stimulation is maximized, allowing the individual to relinquish their sense of control 4. resolution: most of the congestion and tension resolves within seconds, complete resolution may take up to 60 minutes SEXUAL DYSFUNCTION Etiology intrapsychic: patient's life experiences, value system relationship/interpersonal issues physical/organic

GY32 Gynecology
Dyspareunia Cycle

Sexuality and Sexual Dysfunction/Menopause

Toronto Notes 2011

orvanic lllioloqy)
2' vagmlsmus

..

Faar of pain with

Anxiety with or

without sexual response

Classification lack of desire (60-70% of women) lack of arousal anorgasmia (5-10%) primary anorgasmia: never before achieved orgasm under any circumstances secondary anorgasmia: was able to achieve orgasms before but now unable dyspareunia (3-6%) -painful intercourse, superficial or deep vaginismus (15%) vulvodynia vaginal atrophy vulvar vestibulitis: associated with history of frequent yeast infections PID Treatment lack of desire- assess factors, rule out organic causes, relationship therapy, sensate focus exercises anorgasmia - self-exploration/pleasuring, relationship therapy if needed, bridging techniques (different sexual positions, clitoral stimulation during intercourse) dyspareunia Kegel and reverse Kegel exercises dilator treatment comfort with self-exam psychotherapy, other behavioural techniques female on top position - allows for control of speed and duration vestibulitis - remove local irritants, change in contraceptive methods, and dietary changes (increased citrate, decreased oxalate), vestibulectomy (rare) vulvodynia -local moisturization, cold compresses, systemic nerve blocking therapy (amitriptyline, neurontin), topical anesthetic, estrogen cream

,,}-----------------. ,
KagiiExen:n
Regular contraction 1111d f111axB!ion 10 strengthen pelvic floor muscles.

llenn1 llgll Exarclus

1 second contraction then 5 seconds of relaxation.

... , ,
u.n..-use: occurrenn of last spontaneous menstrual period, from loss of ovarian
function (loss of oocyt1 r.sponse to gonldotropi'ls).

Menopause
see Family Medicine, FM41

"Being In ..-op-: lack of ffi811$811 fur 1 yr.

PwlmenopiiUH: period of tine surrounding menopaU18 (2-8 yrs preceding + 1 yr after last menses)

Definitions types of menopause physiological; average age 51 years (follicular atresia) premature ovarian failure; before age 40 (autoimmune disorder, infection, Turner's syndrome) iatrogenic (surgical/radiation/chemotherapy) Clinical Features associated with estrogen deficiency vasomotor instability (tends to dissipate with time) hot flushes/flashes, night sweats, sleep disturbances, formication, nausea, palpitations urogenital atrophy involving vagina, urethra, bladder dyspareunia, vaginal itching, vaginal dryness, bleeding, urinary frequency, urgency, incontinence skeletal osteoporosis, joint and muscle pain, back pain skin and soft tissue decreased breast size, skin thinning/loss of elasticity psychological mood disturbance, irritability, fatigue, decreased libido, memory loss Investigations increased levels ofFSH (>35 IU/L) on day 3 of cycle (if still cycling) and LH (FSH>LH) decreased levels of estradiol (later) Treatment goal is for individual symptom management vasomotor instability HRT (first line), clonidine, SSRI, Effexor, gabapentin, propranolol vaginal atrophy local estrogen- cream (Premarin), vaginal suppository (VagiFem), ring (Estring') lubricants (Replens) urogenital health lifestyle changes (weight loss, bladder re-training), local estrogen replacement. surgery

chamcterizad by fluctuating honnone IIVIls, inegular mlllllrual cydls, 1111d

symptom ollllll.

,, ,

}-----------------

85'L of women experience hot ftuhlls 20-30'll. seek medicalllltBntion 1O'L are unllbla to work

,, ,
Osteoporosis is the single most important health hazard anociabld with menopause. C.rdiOVBiicular is 1ha leading caUII of death post-menopalll8.

,,}-----------------, ,
Increased risk ol breast c1111cer (RR 1.3) is1110cilltad with HAT 11111. All women taking HRT should hive pariodic: survaiUanca and counnlling regilding its benefits and risks.

Toronto Notes 2011

MenopaUBe

Gynecology GY33

osteoporosis 1000-1500 mg calciwn daily, 800-1000 IU vitamin D, weight-bearing exercise, quit smoking bisphosphonates (e.g. alendronate) selective estrogen receptor modifiers (SERMs): raloxifene (Evista) - mimics estrogen effects on bone, avoids estrogen-like action on breast and uterine cancer; does not help hot flashes HRT: second-line treatment (unless for vasomotor instability as well) decreased libido vaginal lubrication, counselling. androgen replacement (testosterone cream) cardiovascular disease management of cardiovascular risk factors mood and memory antidepressants (first line), HRT (augments effect) alternative choices (not evidence-based, safety not established) black cohosh, phytoestrogens, St John's wort, gingko biloba, valerian, evening primrose oil, ginseng, Don Quai

....

,'
Less estrogen is produced
D.cr-d negativ t..tback Dl1

Daqnrw&!g thEa ceU fail to react to s

lllldogenaus gonadotropils (FSH, LH)

hypo1halamic-piluilllry-ldrenalaxis
lncnastd FSH and IJi

Sb'omal ellis conlillliiiD produce

111drogens u 1 result of increased IJi lilinnntion

Hormone Replacement Therapy (HRT)

see Family Medicine. FM41 primary indication is treatment of menopausal symptoms (vasomotor instability) keep doses low (e.g. 0.3 mgPremarin) and duration of treatment short (<5 years)

Ablallltll Cantraindiclltio1D HRT

HRT Components estrogen oral or transdermal (e.g. patch, gel) transdermal preferred for women with hypertriglyceridemia or impaired hepatic function low-dose (e.g. 0.3 mg Estradot patch) progestin given in combination with estrogen for women with an intact uterus to prevent development of endometrial hyperplasia/cancer
Tabla 11. Eumplas of HRT Regimens HRTRaginan

ABCD
Acute liver disease

vaginal Bleeding Cancer (breasVuterine)

DVT (thromboembolic dis8Q8)

Nabll CEE 0.625 mg PO OD CEE 0.625 mg PO OD

None

Hno intact uterus

Wilhchw&l bleeding lllll'f DCCII" in a spotty, LqJredictable menner Usualy abates after s.a months due to endomebial atrophy Once patient has become amenon11eic on HRT, sigrilicant subsequent bleeding episodes require evaluation (endcmetrial biopsy) Bleeding occu111 monthly after day 14of progestin (can conti111e for years) symptoms (breast tenderness, fluid retention, headache. nausea) are more prominent

fnlm th1 SOGC 2110& Mn1111Report The primary indication lor HRT is fur the manaqement of moderate tD I8V8I1I m-pausll i'fiTIII!OIIII. HRT should be prascribed Ill thelowllst elfaeliva don fur the appropriate dullltion to achieve

c-

MPA 2.5 mg PO OD

tnlldment galls.

SW.danl-d11111 Cydie CEE 0.625 mg PO OD

days 1-14 only

with cydicHRT

Pulutile

CEE 0.625 mg PO OD

r...-rm..

EstrodermEslradiol 0.05 m!Vd or 0.1 mg/d Estalisiiii-Estradiolilll 140 IIQfd or 250 !!Wd

MPA IDYMlose EstrodermMPA

2.5 mg POOD Estalisiiii-NEA 5011Qfd

3 days on. 3 days off

Use patch twice weekly Can usa oralprllljestins {Eitmderm1111 ) Combined patches available

CI:E conjuglllld lqUillllllragln ji.Q. Pram.me); MI'A ndflllWIOIIISIIRIIIB ICiblbl ja.g.l'nMn8); NEA lllllllhilllrona11C811111 Ccmsidellower dale regimens, PRIJ.4PRCP !Pranllrin

Side Effec:ts of HRT

abnormal uterine bleeding mastodynia - breasttendemess edema, bloating, heartburn. nausea mood changes (progesterone) can be worse in progesterone phase of combined therapy

Contralndlcadona to HRT absolute acute liver disease undiagnosed vaginal bleeding known or suspected uterine cancer/breast cancer acute vascular thrombosis or history of severe thrombophlebitis or thromboembolic disease

GY34 Gynecology

Menopause/Urogynecology

Toronto Notes 2011

relative pre-existing uncontrolled hypertension uterine fi.broids and endometriosis familial hyperlipidemias migraine headaches family history of estrogen-dependent cancer chronic thrombophlebitis diabetes mellitus (with vascular disease) gallbladder disease, hypertriglyceridemia, impaired liver function (consider transdermal estrogen) fibrocystic disease of the breasts
WOMEN'S HEALTH INITIATIVE (WHI) (launched in 1991) two non-randomized studies investigating health risks and benefits of hormone therapy in healthy postmenopausal women 50-79 years old; the WHI Extension Study, involving follow-up health tracking without intervention, is due to last through 2010 continuous combined HRT (CEE 0.625 mg + MPA 2.5 mg OD) in 16,608 women with an intact uterus originally designed to run 8.5 years- stopped early after 5.2 years (July 2002) because the evidence for harm (breast cancer, CHD, stroke, PE) outweighed benefit (fracture reduction, colon cancer reduction) estrogen-alone (CEE 0.625 mg) in 10,739 women with a previous hysterectomy also stopped early (February 2004 instead of March 2005) because of increased stroke risk and no heart disease benefit benefits and risks reported as number of cases per 10,000 women each year HRT Benefrts protective against osteoporotic fractures (recommended as 2nd line treatment only) hip fractures- 5 fewer cases with combined HRT (6 fewer cases with estrogen-alone) all fractures - 47 fewer cases with combined HRT colon cancer- 6 fewer cases with combined HRT (1 additional case with estrogen-alone) HRTRisks invasive breast cancer - 8 additional cases with combined HRT risk comparable to being 20% overweight, lacking regular exercise, fewer pregnancies after 30 years of age, reduced breastfeeding, excessive alcohol or cigarette use NO increased risk with estrogen-alone (7 fewer cases) coronary heart disease - 7 additional Mis with combined HRT no significant difference in cardiac deaths between treatment and control groups NO elevated heart risks if used immediately after menopause (-45-55 years of age), or with estrogen-alone (5 fewer cases) DVTs or PEs - 18 additional cases with combined HRT 9 additional cases for women taking estrogen-alone stroke - 8 additional cases with combined HRT (not statistically significant) 12 additional cases with estrogen-alone dementia and mild cognitive impairment (WHI Memory Score) women taking estrogen-alone before 65 years of age were less likely to develop dementia, however there was a 50% increued risk of developing dementia when taken after 65 years of age (those taking combined HRT were at even greater risk) "window of opportunity" hypothesis: early use of estrogen (before pre-dementia changes) protects the healthy brain; in older women, where changes have already begun, use of estrogen accelerates the dementia process there were no significant differences in overall mortality or cause of death between treatment and placebo groups

Urogynecology
Pelvic Relaxation/Prolapse
ProbUsion of pelvic Dlllllfll into or aut of the vagina.

Etiology relaxation, weakness, or defect in the cardinal and uterosacral ligaments which normally maintain the uterus in an anteflexed position and prevent it from descending through the urogenital diaphragm (i.e. levator ani muscles) related to: vaginal childbirth aging decreased estrogen (post-menopause) following pelvic surgery increased intra-abdominal pressure (obesity, chronic cough, constipation, ascites, heavy lifting) congenital (rarely) ethnicity (Caucasian women> Asian or African women) collagen disorders

Toronto Notes 2011

GENERAL CONSERVATIVE TREATMENT (for pelvic relaxation/prolapse and urinary incontinence) Kegel exercises local vaginal estrogen therapy vaginal pessary
Table 12. Pelvic Prolapse Type Uterine Prolapse (Protrusion of cervix and uterus into vagina) Clinical Features
Groin/back pain (stretching of uterosacral ligaments) Feeling of heaviness/pressure in the pelvis Worse with standing, lifting Worse at the end of the day Relieved by lying down Ulceration/bleeding (particularly if hypo estrogenic) urinary incontinence

Urogynecology

Gynecology GY35

Treatment
See General Conservative Treatment, above Vaginal hysterectomy surgical prevention of vault prolapse Consider additional surgical procedures if urinary incontinence, cystocele, rectocele, and/or enterocele are present

',,}----------, ,
Grading of Pelvic Organ Prolapse 0 = no descent during straining 1 = distal portion of prolapse > 1em above level of hymen 2 = distal portion of prolapse s1 em above or below level of hymen 3 = distal portion of prolapse > 1em below level of hymen but without complete vaginal eversion 4 = complete eversion of total length of lower genital tract Procidentia: failure of genital supports and complete protrusion of uterus through the vagina

Vault Prolapse (Protrusion of apex of vaginal vauk into vagina, post-hysterectomy) Cystocele (Protrusion of bladder into the anterior vaginal wall) Rectocele (Protrusion of rectum into posterior vaginal wall) Enterocele (Prolapse of small bowel in upper posterior vaginal wall)

See General Conservative Treatment, above Sacral colpopexy (vaginal vauk suspension), sacrospinous fixation, or uterosacral ligament suspension

Frequency, urgency, nocturia See General Conservative Treatment, above Stress incontinence Anterior colporrhaphy ("anterior repair") Incomplete bladder emptying associated Consider additionaValtemative surgical procedure if increased incidence of urinary tract documented urinary stress incontinence infections- may lead to renal impairment Straining/digitation to evacuate stool Constipation See General Conservative Treatment, above Also laxatives and stool softeners Posterior colporrhaphy {"posterior repair"), plication of endopelvic fascia and perineal muscles approximated in midline to support rectum and perineum (can resuk in dyspareunia) Similar to hernia repair Contents reduced, neck of peritoneal sac ligated, uterosacral ligaments, and levator ani muscles approximated

', ,
The only true hernia of the pelvis is an ENTEROCELE because peritoneum herniates with the small bowel.

Sacrum Utero-sacral ligaments Uterus Rectum Bladder Vaginal Canal Urethra

Rectocele Figure 14. Pelvic Prolapse

Cystocele

Uterine Prolapse

Enterocele

GY36 Gynecology

Urogynecology/Gynecological Oncology

Toronto Notes 2011

Urinary Incontinence
see !IIQlQgy, US
S..ulnclllllilllllnvaluntary lass of urine with increased inlnl..bdaminal praSSLn (coughing. laughing, sneezing, walking, runningl.

STRESS INCONTINENCE Risk Factors for Stress Incontinence in Women pelvic prolapse pelvic surgery vaginal delivery hypoestrogenic state (post-menopause) age smoking neurologicallpulmonary disease Treatment see General Conservative Treatment, GY3S surgical tension-free vaginal tape (TVT), tension-free obturator tape (TOT), prosthetic/fascial slings or retropubic bladder suspension (Burch or Marshall-Marchetti-Krantz procedures) URGE INCONTINENCE

The gold standanl diagnostic test for urinary incontinence is multic:ilnnnel urodynamics. A proportion of cases 11111 correctly diagnosed from clinical histmy lllone and this can be supplam81118d witll patient urinary nnd

intlbdieries.
Hw/111 Tedrri/Airm 2006; 10(61:1132.

Urine loss associated with nn abrupt. IUdrlln IIIli tD void.

.......

,.._----------------,

Definition urine loss associated with an abrupt, sudden urge to void "overactive bladder" diagnosed based on symptoms Etiology idiopathic (90%) detrusor muscle overactivity ("detrusor instability") Associated Symptoms frequency, urgency, nocturia. leakage Treatment behaviour modification (reduce caffeine/liquid, smoking cessation, regular voiding schedule)

..... Out Neuralogical c - of Urge lncontln-

Multiple sclerosis Slipped disc

Dilb.Wmallillls

Kegel exercises
medications anticholinergics- oxybutinin (Ditropan), tolterodine (Detrol) tricyclic antidepressants - imipramine

Gynecological Oncology
Uterus

......

, ..._----------------,

ENDOMETRIAL CARCINOMA Epidemiology most common gynecological malignancy in North America (40%); 4th most common cancer in women 2-3% ofwomen develop endometrial carcinoma during lifetime mean age is 60 years majority are diagnosed in early stage due to detection of symptoms 85-90% S-year survival for stage I disease overallS-year survival for all stages is 70-80% Classification Type I - endometrioid adenocarcinoma (-80% of cases) Type II- serous, clear cell carcinomas (-lS% of cases)

Incidence of M igllilnt Oynecalaglcill ..

Lelians in North America

endomelrium > ovary > cervix > wlva > vagina > flllopinn lube

Toronto Notes 2011

Gynecological Oncology

Gynecology GY37

Risk Factors
Type 1: excess estrogen (estrogen unopposed by progesterone) obesity PCOS unbalanced HRT (balanced HRT is actually protective) nulliparity late menopause estrogen-producing ovarian tumours (e.g. granulosa cell tumours) HNPCC (hereditary non-polyposis colorectal cancer)/Lynch II syndrome tamoxifen 'I}>pe II: not estrogen related possibly tamoxifen
Rillk Factors fur Ennm.mal C.nc

COLD NUT Cancer (ovarian, breast, colon I

Obesity
Lllbl menoJIIlllse Diabetes mellitus Nullipriy

Unopposed eslro!len: PCOS,

anovuletion, HRT Tamaxhn: chronic uu

Clinical Features
'I}>pe 1: postmenopausal bleeding in majority, abnormal uterine bleeding in majority of affected pre-menopausal women (menorrhagia, intermenstrual bleeding) 'I}>pe II: may not present with bleeding in early stage, more likely to present with advanced stage disease with symptoms like ovarian cancer (i.e. bloating, bowel dysfunction, pelvic pressure)

....

,,}-----------------,

cancw until provan otherwise.

Postmanop811SII blaading = endometrial

95% present wi1t1 vaginal bleeding.

Tabla 13. FIGO Staging of Endomatrial Cancar

O.Cription

....
IV IVA IVB Invasion of bladder :t bowel mucosa :t distant metastases Invasion of bladder :!:: bowel mucosa Distant mets, including intnHibdominal mets :!:: inguinal LNs

I lA IB II Ill lilA IIIB IIIC IIIC1 IIIC2

Confined to corpus No or len than myomlllrial inwsion Invades through one haW !i myometrium Tumour invades cervical stnma, but does not extend beyond uterus local and/or regional spn111d of the tumour Invasion of serosa. corpus Llleri :!:: adnexae Vaginal :!:: parametrial invnlvment Metastasis to pelvic :t LJoJs Positive pelvic LN Positive pera-aortic LN :t pelvic LNs

An endomutriallhickness of 5 mm

or mora is considarad abnormal in 1

p061menopauSII woman with vaginal bleeding.

Tru1 Pwlvi Area of pelvis between pelvic inlet ll1d outlet, i.e. it doel not include the

abdominlll cD11111nts in lha palvis found above the pelvic imlt.

RGO: tdlmllillllli Federation rl &jnaq and lllstatrics Nalll: endocervical gan6Jw iiNolv!menl is IICMI considered as S1IQe llp!elliously smge II)

....

,,}-----------------, ,

Investigations
endometrial sampling: office endometrial biopsy D&C hysteroscopy pelvic ultrasound (in women where adequate endometrial sampling not feasible without invasive methods) not acceptable as alternative to pelvic exam or endometrial sampling to rule out cancer

Prognuldic
1. Grade (hillllllogiclll diflerantillionl

2. Vllscular, lymphltic involvement 3. Progastarone-racaptor Iaveii 4. Myometrial invasion

Spread
most common is direct extension lymphatic spread to pelvic and para-aortic nodes transtubal dissemination to peritoneal cavity hematogenous spread (usually to lungs, liver)

Treatment
surgical: hysterectomy/bilateral salpingo-oophorectomy (BSO) and pelvic washings pelvic and para-aortic node dissection omentectomy goals: diagnosis, staging, treatment, defining optimal adjuvant treatment laparoscopic approach associated with improved quality of life (optimal for most patients) adjuvant radiotherapy (for improved local control in patients at risk for local recurrence) and adjuvant chemotherapy (in patients at risk for distant recurrence or with metastatic disease) based on presence of poor prognostic factors in definitive pathology chemotherapy often used for recurrent disease (especially ifhigh grade or aggressive histology) hormonal therapy: progestins can be used for recurrent disease (especially if low grade)

UTERINE SARCOMA
rare: 2-6% of all uterine malignancies arise from stromal components (endometrial stroma, mesenchymal or myometrial tissues) behave more aggressively and are associated with poorer prognosis than endometrial carcinoma; 5-year survival- 35% vaginal bleeding is most common presenting symptom
Ut.ine San:ama- Symp1Dm1
BAD-I'

Abdominal distention
Foul smelling vaginal Discharge Pelvic Pressure

Blallling

GY38 Gynecology

Gynecological Oncology

Toronto Notes 2011

1. Mixed Mullerian Mesodermal Tumour (Carcinosarcoma) most common type of uterine sarcoma (43%) both epithelial and sarcomatous malignant elements are present tend to form bulky polypoid masses that often fill the uterine cavity and extend into or through the endocervical canal- often have extrauterine disease at presentation Treatment usually treated as "very high grade endometrial carcinoma since behaviour and treatment similar (ie. surgical staging, adjuvant chemotherapy and radiation) 2. Leiomyosarcoma account for one third of uterine sarcomas when occurs, often coexists with benign leiomyomata (fibroids) 50% of time, leiomyosarcomata arise within a fibroid ("sarcomatous degeneration) average age of presentation is 55 years but may present in pre-menopause histologic distinction from leiomyoma increased mitotic count(> 10 mitoses/10 high power fic:lds) tumour necrosis cellular atypia often diagnosed postoperatively after uterus removed for presumed fibroids Clinical Features "rapidly" enlarging fibroids in a pre-menopausal woman enlarging fibroids in a postmenopausal woman Treatment hysterectomy/BSO usually without node dissection due to high propensity for vascular spread (ie.liver/lung metastases) adjuvant chemotherapy may be used if tumour has spread beyond uterus, for palliation radiation therapy does not improve local control or survival poor outcome overall, even for early stage disease 3. Endometrial Stromal Sarcoma usually presents in perimenopausal or postmenopausal women with abnormal uterine bleeding diagnosed by histology of endometrial biopsy or D&C Treatment hysterectomy/BSO (ALWAYS remove ovaries as ovarian hormones may stimulate growth) adjuvant therapy based on stage and histologic features (hormones and/or radiation) hormonal therapy (progestins) may be used for metastatic disease in low grade ESS

...,.,_._______________
A rapidly enlarg'ing uterus, especially in a postmenopausal woman,
should prompt consideration of

leiom'(IISIIrcORII.

.....

,,
GIIIIUIDII call- inhibin
Sertuli-Leydig - androgens

Ovary
BENIGN OVARIAN TUMOURS
see Table 14 most are asymptomatic usually enlarge slowly, if at all may rupture or undergo torsion, causing pain pain assodated with torsion of an adnexal mass usually originates in the iliac fossa and radiates to the flank peritoneal irritation may result from an infarcted tumour - rare

Onrianlaur Martc.n Epithelial cell - CA125

Stromal

Germ call DysgerminDRII -LDH

Yolk sac - AFP Choriocercinoma - bllll-hCG Immature Teratoma - nona Embryonal cell- AFP + bsta-hCG

MALIGNANT OVARIAN TUMOURS

see Table 14

Epidemiology lifetime risk 1.4% ( 1/70) in women >50 years, more than 50% of ovarian tumours are malignant causes more deaths in North America than all other gynecologic malignances combined 4th leading cause of cancer death in women 65% epithc:lial; 35% non-epithc:lial 5-10% of epithelial ovarian cancers are related to hereditary predisposition

Toronto Notes 2011

Gynecological Oncology

Gynecology GY39

Risk Factors (for epithelial ovarian cancers)

nulliparity early menarche/late menopause age family history of breast, colon, endometrial, ovarian cancer race: Caucasian

It'

Riiiii/Prot.etW. hct.rs fur

Epilhlllilllll'lllrilln C11111111r

Protective Factors (for epithelial ovarian cancers) OCP: likely due to ovulation suppression (significant reduction in risk even after 1 year of use)
pregnancy/breastfeeding tubal ligation (recently questioned) hysterectomy (without removal of ovaries) bilateral salpingo-oophorectomy (prophylactic surgery performed for this reason in women with known high risk- i.e. BRCA mutation carriers)

NO CHilD
OCP, breast-fueding. tuballigBiion,

hysterectomy (protective) Caucasian Family Hirtory

Increasing age ( > 40)

Lata menopause Delayed mild-bearing

Clinical Features
most women with epithelial ovarian cancer present with advanced stage disease since often "asymptomatic" until disseminated disease vague non-specific symptoms associated with early stage disease when present, non-specific symptoms may include: vague abdominal symptoms (nausea, bloating, dyspepsia, anorexia. early satiety) symptoms of mass effect increased abdominal girth - from ascites or tumour itself urinary frequency constipation fluid wave - signs of ascites postmenopausal bleeding; irregular menses if pre-menopausal (rare)

.....

',

Any adnexal mass in portmanopausal women should be considered malignant until provan otherwisa-

Low Malignant Potential (also called aorderllne) Tumours pregnancy, OCP and breastfeeding are found to be protective factors -15% of all epithelial ovarian tumours
tumour cells display malignant characteristics histologically, but no invasion is identified able to metastasize, but not commonly treated primarily with surgery (BSO/omental biopsy hysterectomy) NO proven benefit of chemotherapy generally slow growing, excellent prognosis 5-year survival >99% recurrences tend to occur late. may be associated with low grade serous carcinoma
Tabla 14. Ovarian Tumours

Tp
Folicular cyst

Dacription
Follicle fails to rupture lllring owlation

l'nlsellllltion
Usually asymptomatic May ruptura. bleed. tort. infarct Clllsing pain signs at peritoneal inillltion

Uttr.ound/Cytologv 4-8 an mass, unilocular, liled with calls

Tnndmllllt Symptomatic or suspicious masses warrant surgical exploration Otherwise <6 em, wait 6waeks than re-examine as cyst usually re(J'!SSes with next cycle OCP [ovarian suppression)- wil prevent development of IIBW cysbi Treatment usually laparoscopic

FUNCT10NAI. TUMOURS [alllleniga)

ttm
Lutein cyst

Corpls luteum fails to regress alter 14 days, becoming cystic or hemonhagic

More likEly to cause pain than follicular cyst May delay onset of naxt period Associated with molar owlation induction with domijtoene Associated with pregnancy

Same as lor folliculll" cysts Larger [1 ll-15 ani and timer than folliculll" cysls ConseMitive Cyst will regress as Same as lor Regr&SSIS postpartum

cyst
Lutaomarl

Due to atretic follicles stimulated by abnormal fl-hCG levels Usually bilateral Due to prolonged elevation at fl-hCG See PCOS, GY23

levels fall

pregnancy
Endomlltriama

Palyl:yltic av.ies

BENIGN GERM-CEll TUMOURS Single m061: common IMiian germ Benign cystic teratama(dennaid) cell neoplasm 8ements of all3 cell lines, contains dermal appendages [sweat and sebacaaus glands, hair follicles, telllh) May ruptura. twi&t. inhm 20% bilateral 20% occur olllside at reprockictive years Smooth-walled, mobile, unilocular Ultrasound may show calcification llllhich is pat(IDIJiomonic Treatrnant usually laparoscopic cystectomy; may recur

(ffij

GY40 Gynecology
Table 14. Ovarian Tumours (continued)
Type Description

Gynecological Oncology

Toronto Notes 2011

TI'DIIIIent

IIALJGNANT GERII-CB11UIIOURS
Guaerlllnfonmdion Rapidly growing. 2-3% cl d DVBrian Usuaty chihhn and young cancers women ( <30 years) l)ylgannin111111 Produces lactate dehydrogenase (LDH) Surgical resection (ofl!n conservative unilateral salpingo.oophorectomy :t nodes) :t chemo Usually vary rasponsiva to chllllllllharapy, therefore complete resection is not necessary for cure

1II% bilateral

1111111tun111r11D111 No blmour marker identified

Yolk sac 111mour Embryunal Choriocarcinoma Produces alpha fetuprotein (AFP) Rare Produces AFP and jl-nCG Rare Produces Varies depending on subtype Unilateral

More aggressive subtype, often need chemo

(BEP)

EPmiELIAI. OVARIAN TUMOURS fay Ill ballign, ........ II' banlrilal

Ganenillnfonmdian Derived fnm mesolhetial cells liing peritoneal cavity Classified based on histologic type 80-35% of an ovarian naoplmns (includes mali!Jlant)
Cysteclllmy vs. unilateral selpingo-oophorectomy

1. Eartystage(stage 1): BSO hystalliCIDmy ornerrtectomy :!:: peritoneal washings :!: sllging biopsies + node disssction) :t adjuvant chemotherapy 2. Advanced stage: Upfront cytoreductive (debulkilg) surgery vs. neoadjuvant chemotherapy Adjuvant chemothenpy: IP chemotherapy vs. IVCarbWI'axol
20-311% bilabnl Lining similar to fallopian tube epithelium Often multilocular Histologicaly contain Psamomma bodies (calcified concentric concretions) Resembles endocervical epithelium Often multilocular May reach enormous size Histology resembles endometrium Histology resembles mesonephric cells Fibrotic tumour with call-lika epithelial cora Surgical resection Dl tumour Chemotherapy RillY be used for malutlrtic disease not resectable
Query poor response to chemotherapy Undear role for radiation i1 patients with no residual disease (rare) If mucinous- remove appendix as well

Most common ovarian tumour 511% of all OVllian cancen 75% of epithelial rumours 711%benign

Mucinous

85%benign 20% of epithelial tumours

Rarely colllJiicated by

Pseudomy;coma periloneii:
implants seed abdonninal cavity and produce large quantities of mucin

Endomlbioil
Clair call

211% of epithelial DVBrian Ca Hill! mali!roant potential

of epithelial DVBrian Ca Hill! mali!roant potential of epithelial DV&rian Ca Majority benign

Brann tumour

SEX CORD STROMAL OVARIAN TUMOURS

Ganenillnfonmdian

Fibroma (llanign)

From mature fibroblasts in DVilrian &troma

Non-functioning OcCil$ionally associated Meig's syndrome Estrogen'P'oducilg feminizing effects (precocious puberty, menonhagia, postmenopausal bleeding) Androgen-producing virilizing ellects !hirsutism) deep voice, 18Cession of front

Firm, smooth rounded tumour with fibrocytes Histologic hallmark Dl cancer is small groups Dl cells known as Cali-Exner bodies

GranuiDIHhec:a call111mows or malignant) Sertalj.l.eydig cell111mour or malignant)

Can be associated with

endometrial cancer lmibin is blmour marker

Can measure elevated androgens as tumour markers

IIETASTAnC OVARIAN lUMOUIIS 4-8% Dl ovarian malignancias From Gl tract.

breut,

Krukanberg tumour = metastatic

ovarian tumour from other situ (usually Gltnlct. cDITII'IDIIIy stomach or colon. breast) with "sipt-ring" cals

dollatrium.

lvmPIIIII

'IbroDlo Nota 2011

Gynecological OncolOBf

GyDecology GY41

Investigation af Suspicious Ovrin Mss goals of address symptoms and optimal surgical staging of malignancy women with suspected ovarian cancer based on history, physic:al. or lnvestlgatioDS should be n::furred to a gynecologic oncologist prior to surgery to filcilitate optimalsw-gery bimanual examination solid, irregular, or fixed pelvic mass is wggest:l.ve of ovarian cancer RMI (Risk of Malignancy lndeJ:) is best tooliMJl.able to assess llkellhood ofovarian malignancy and need for pre-operative gynaecologi.c oncology referral (see sidebar) bloodwork CA-125 for baseline, CBC.liver function tests, electrolytes, creatinine radiology: transvaginal U/S best to visualize ovaries; CT scan abdomen and pelvis best to look
fur metastatic disease

MDDill at. al. Am J Ol.f Gyn<IL Mll\'2010.

lllk rl Mllaancy 1 1111111 ..

RMI =UxM xCA12S WIIAIOUND FINDINGS (1 pt fur -.:hi

Evidanca of solid II'NS Biii1Bnlllllio111

0 EvidiiiiCB of msluluu l'r8aenc;e of IIICilll

bone scan or PET scan not indicated try to rule out other primary source ifsuspected based on: occult blood per rectum; ifpositive, endoscopy barium enema ifgastric symptoms. gastroscopy upper GI aeries if abnonnal vaginal bleeding. endometrial biopsy to rule out concurrent endometrial cancer, colposcopy ECC to rule out cenical cancer ifabnormal cervix mammogram ifbreast lesion l.dentlfied or risk factors present
Screening no effi:ctive method of IIlll8ll screening routine CA-llS level measurements or U/S not recommended more wonwt suffer from false positive results than helped controversial in high risk groups- starting age 30. transvaginal U/S and CA-125 (no consensus on interval) familial ovarian cancer (>1 first degree relative afFected, BRCA-1 mutation) other cancers (Le. endometrial, breast, colon) BRCA-1 or BRCA-2 mutation: may recommend prophylactic bilateral oophorectomy after age 35 or when child-bearing is completed

U = 4 (for UJS at 2-!i) MENOPAUSAL nATUS

U = 1 (far UJS 1caras of 0 ar I)

cor.

l'oltmenapaual: M =4 Pra-manopausal: M - 1 ABSOWTE YAWE DF CA-IZ5 SERUM

IIVEL For RMI>200: Gynecologic Oncology

l'lfaml is nconrnencled

... ' ,
c._. r1 B-'811 CA-125
11rnOII matUr 50% l8ll8itivity in eartv stage averilll (pogrJ - ther8fn not gl*l fDr screllli'lg IW.IINANI" Gyne: owrv. uterw

Aga inft.JIIIICIIII nlliablily at lll$t 11 a

Non-Gyne:
I1ICbn

IIDmiiCh. colon.

Tillie 15. FIGO Stlgi1g far Primary Carcinama af the Ovary (S1rgical Sblgi1g)
I lA GRMih limil2d ID 1he 1 awry, na ascites. Ill bmoor on exlemal surfll:e, capsule iml:t 2 averin. na 18Cit81, 111 blllour an axf8mllaurface, caps!M iml:t 1 or 2 averias with lilY af11111 foilwing: capsule rupllnd. 111mour on ovarilrl uface ar malipnt calls in ascillls Growth involvilg one ar bo1h ovaries with pelvic axllnsion Extension :!:: metatases 1o uli!rur,ltubes Edanaian ID olllar pelvic s11ur:11n1 II AlB with mlli!JM cella ilacit88 or paliliva pariiDneel Tumour irrvolvir,j one ar bD111 avarias with peritoneal outside 11111 palvis ..Var positiv8181n1p8ritonaa1 ar ivJinBII'IOdiiL Supllficial ivw om is Stllge ll lolcrascapic peritaleal melasllsis beyond pelvis, LNs negative MlcroacqJic peritonllllllllltaaia beyflld palvil <2 em. LNs naglliva lmj8nt >2 em anc1or ratrapllii:Dneel or iQlinal nadas
Distllnt matastasis biJir.nd peritoneal cavily

NON MAUGNANT

Gyne; banifl OV!Irill'l naapasn,

Non-Gyna: renal failure

endometriolil.

fllroidl. PID panCillllitil..

IB
IC

II
IIA

liB

IIC
Ill

... ' ,
lld(llllll Onr... llmuur "'IIIGik S.,Ur Sininl Stage 1: 75-85% Stage II: 6G-7K Stage Ill: 2J.41'1o Stage lit. ll'llo

lilA IliB

IIIC

IV

Cervix
BENIGN CERVICAL LESIONS Nabothian cyst/inclusion cyst no treatment required endocenical polyps treatment is polypectomy (office procedure) MALIGNANT CERVICAL LESIONS majority are squamous cell. carcinomas (95%), adenocarcinomas inc.reasing (596), rare subtypes include small cell. adenosquamous 8,000 deaths annually in North America annual Pap test reduces a woman's chance ofdying from cervical cancer from 0.4% to 0.0596 average age: old
Original $qUBITliM epillllllium

Squamous metaplasia Calurnnar

r I epithlllium

Glllld

opening

Extemllo&

Nuw aquamDcolumnar junction

Original lqUBIIliiCOUnl'llll' jJnation

J J
0

I!

Figura 15. Th1 C.rwix

GY42 Gynecology

Gynecological Oncology

Toronto Notes 2011

......

, ..._----------------,
.. IICr'-HPVVIcd.....

Cervical can car is caused by HPV

infec1ion.

...

Praphwludc lllccDdDn ..... ..._ Pl!lilllllllilaW..:.InW..: A .......... tanlralld lllmbaut L. HaPtill L. Fung Ku Flllg M. 1111. CAfAJ Z007; 171

SlUr. Sysllmllic l'l'o'iiW af !lidin II p!!llllrjllcli:

Hl'VVICCinlliln.

vaccindon IPI irQction 11'111 pr&CIIICIIIIUI ciMcallasianl.

Etiology at birth, vagina is lined with squamous epithelium; columnar epithelium lines only the endocervix and the central area ofthe ectocervix (original squamocolumnar junction) during puberty, estrogen stimulates eversion of a single columnar layer (ectopy), thus exposing it to the acidic pH of the vagina, leading to metaplasia (change of exposed epithelium from squamous to columnar) a new squamocolumnar junction forms as a result the transformation zone (TZ ) is the area located between the original and the current squamocolumnar junction (Figure 15) the majority of dysplasias and cancers arise in the TZ ofthe cervix must have active metaplasia in presence of inducing agent (HPV) to get dysplasia dysplasia -+ carcinoma in situ (CIS) -+ invasion slow process (-10 years on average) growth is by local extension metastasis occurs late Risk Factors HPV infection see Sexually Transmitted Injections, GY26 high risk of neoplasia associated with types 16, 18 low risk of neoplasia associated with types 6, 11 >99% of cervical cancers contain one ofthe high risk HPV types smoking high risk behaviours (risk factors fur HPV infection) multiple partners other STis (HSV, trichomonas) early age first intercourse high risk male partner poor screening uptake is the most important risk factor for cervical cancer in Canada at-risk groups include: immigrant Canadians First Nations Canadians geographically isolated Canadians sex-trade workers low socioeconomic status Prevention: Quadrivalent HPV Recombinant Vaccine (Gardasi1 8 ) currently indicated for females 9 to 26 years of age for prevention of diseases caused by HPV types 6, 11, 16 and 18 (genital warts, cervical, vulvar and vaginal dysplasias and cancers) for optimal benefit ofvaccination, should be administered before onset of sexual activity (i.e. before exposure to virus) administered IM at time 0, 2 and 6 months, may be given at the same time as Hep B or other vaccines using a different injection site not fur treatment of active infections most women will not be infected with all four types of the virus at the same time, therefore vaccine is still indicated for sexually active females or those with a history of previous HPV infection or HPV-related disease conception should be avoided until30 days after last dose of vaccination side effects: pain, swelling, erythema, low grade fever contraindications: pregnant women and women who are nursing (limited data) Clinical Features squamous cell carcinoma (SCC) exophytic, fungating tumour adenocarcinoma endophytic, with barrel-shaped cervix early asymptomatic discharge: initially watery, becoming brown or red post-coital bleeding late 80-90% present with bleeding: either p06t-coital, postmenopausal or irregular bleeding pelvic or back pain (extension of tumour to pelvic walls) bladder/bowel symptoms signs friable, raised, reddened or ulcerated area visible on cervix

CenlrllllegistJy of Controlled Trills, and 1be Coclnnl l.ilnry. 1'11111111: II siLI9s, nine- included in lila IWill'l{llillrillllalaMII RCTs).Alatll of 40,3231em*s well! errolled. AI plflicipants hid IDMid IPI WJCiillllianslllat inclJdld C1M11Q11 of lila HPV 16stnlil. lllllin IIIIII:GIMc af higll-grldl C8fl'iCII lasionl, pnisllnt HPV mctioo. krN-QIIdl cmal lasioni,IIXIemiiiJ8!'iiiiiB........ _... llld datil. 11116: HPVwc;gnrian was 111Cia1ad with 1 llductioll in lila fraqLM:y af higll-glldl C8fl'iCII lasionl c:alllld br111CCinl1!)e IPI sbainl compnd witb canlral The Hl'V..:instian ._lito flxnllll be elllclcillll in reducing persisbmt HPV inllctian, lrw-QIIde lesions, llld

IIIII s - MEDUtl,

Coclnna

genilllwn.

C..:..: Prophyllclic VICiilllion rilwumen

betYMn 1S.25 Decfld with HPV ltrlinl, hu ba found 1D be llliclciaus il HPV inflctian 11'111 praCIIIC8IIIU5 cer.ftcallasians.

Smn. c--.111
AmJIIlsllt&,necdZ001; 185{2):308-17 ...,...: To ISSeiS tile cytulogic diagnosis and llft1lleldlquq ril iquid-basld C8fl'iCII cymklgic enw[TID'Np)- COIMIIIilllll'lplnicallllll

.......
-

criteri ilcUd8d {SS) and dir8ctto-lill {IIV) {CIII-ca/atjlt!Jdias. 1'11111111: 25 &ludiu& mat111a actioa r:rUria {n=533,03hal*l; 221,864 in 11'irflwp grwp; 378,659 in COIMII1ioallllrn group; 67,484 in

Sysllmllic l'l'o'iiW af IJIO!IIICtiw 1rU llilfllp 111d CO!Mirmonllll'lp 11111-: MEiliNE.I'IIbMid, Silllllr Plltflr WUIIIIUdlad faf iflnlool publilhld in fngilh betYMn JlruJy 1990 and Alri m. Selecliln

lllin IIIIII:GIMc {i) ril ASCUS, l.Sl, HSL. { i) af AmPle colectioo {conllill squ1m0111cells, endocri:lll
Clii5,1Rd ....
IIIRIIfl (Thirl'rlp) hid

cella!.

rill.Sl {DR =1271D Z.15) and diapsiul HSL{[It - 2.26), IMlt ID dillnu in rile of of ASCUS {[It= P'P llded in ir!lnMd =
il bel.- dilgnolis ril c:eMclll pnnnlignsnllri{HSil.llld 1111 impiMd compared 111 CIIIIVIIdiallalr. srneus.

c..:..: uquid-Oasedtv1Dbait stniUI!Idld

1.64182.11).

Toronto Notes 2011

Gynecological Oncology

Gynecology GY43

Cervical Screening Guidelines {Pap Test) endocervical and exocervical cell sampling {aim is to sample the TZ) best identifies squamous cell abnormalities, less reliable for glandular abnormalities false positives 5-l 0%, false negatives 10-40% (for single test) false negative rate 50% for existing cervical cancer all women: start annual screening at age 21, or 3 years after onset of vaginal intercourse women years: if 3 normal Paps in a row, and no previous abnormal Paps, can get screened every 2-3 years (if adequate recall mechanism in place) women 2!:70 years: if3 normal Paps in a row and no abnormal Paps in last 10 years, can discontinue screening (if remain at low risk) pregnant women and women who have sex with women should follow the routine cervical screening regimen women who have had a hysterectomy: total: discontinue screening if hysterectomy was for benign disease and no history of cervical dysplasia or HPV infection subtotal: continue screening according to guidelines exceptions to guidelines: immunocompromised (transplant, steroids, DES exposure) mv and high risk previously unscreened patients

Tabla 16. Cytological Classification

llathda Grading Systam
Wrthil nonnallimils lnfectian Reactive and reparative changes S1J111mous cal abnormalities calls of undetermined significance {ASCUS) Squamoua atypia of uncertain signifiCIIlCe Atypical squamous calls, c1111ot axdude HSIL (ASC-H) Low grade squamous intraepitheliallesion (LSIL) High grade squamous intraepitheliallesian (HSL) HPV atypia or mild dysplasia (CIN I) Moderate dysplasia (CIN II)

....
a.llic Systa.V CarviCIIIIIrupithalial N...luia {CIN) Grading Syslam
Normal Inflammatory atypia (organism)

,,

The llet"-llla Cllillcdan System is based Dl1 cyiDiogical results of a Pep tllltthat penn its the examination of but not tissue structure. The diagnosis of carvicel inlmpilhelill n.oplllsia (CIN) or carvicll can:inDRII

requiras a tissue sample, obtainad by biopsy of suspicious lesions (dona colposcopy), to mllke a hiltologic

diagnosis.

Severe dysplasia (CIN Ill)

Carcinoma i1 situ {CIS) Squamous eel carciloma (SCC) Glandular call abnormalities Atypical glanW!a' cells of undetermined significance {AGUS) Endocervical adenoca"Cinoma Endomebial adenocarcinoma Extrauterine adenOCIICinoma Adenocarcinoma, not otherwise specified (NOS) NDmllll
Inadequate

Squamoua call carcinoma (SCC)

Glandula' atypia of uncertain significn:e

Adenocarcinoma

umple

Rupaat cytoloqy in 1-J yrs

Rupaat cytoloqy in 3 mos

ASCUS
I

ASC.H
Woman:!:30

Women <30or HPVbsting not IMiilable

Repalt cytulogy in 6 mos I

cellt,iatypical
endomebial

AGUS/ atypical andoc:ervical

LSIL

HSIL

Squamous

Negativa
Routine

+
Negatiw Negative
Positive

,1
testing I

calls

Colposcopy

... :!:ASCUS

...

endometrill sampling

Repeat cytulogy Colposcopy in 6 mos I

Rep IIIII: cytology

Colposcopy

Negative
Rout ina

... :!:ASCUS

in 12 mos

screening

:!:ASCUS

T + +
in 6 mos

OR

Rapuat cytoloqy

Colposcopy

can:inomw othar malignant

... Negllivl

:!:ASCUS

Colposcopy

RupeRt cytoloqy Colposcopy

in 6 mos I

Colposcopy

Figura 16. Decision Making Chart for Pap Tilt (not applicable for adolascan1s)
Adllp!Bd from rkllltioCerial
l'llt:lics Giideile.s.JL111121Xli. Cri:al sclllllinqPialinls uniiJII1D 11Ch pruvinca.

GY44 Gynecology

Gynecological Oncology

Toronto Notes 2011

Diagnosis see Colposcopy, GY9 apply acetic acid and identify acetowhite lesions, punctation, mosaicism, and abnormal blood vessels to guide cervical biopsy endocervical curettage (ECC) if entire lesion is not visible or no lesion visible diagnostic excision (loop electrosurgical excision procedure, LEEP) if: lesion extends into endocervical canal positive ECC discrepancy between Pap test results and colposcopy microinvasive carcinoma consider cold knife conization (in OR) if glandular abnormality suspected based on cytology or colposcopic findings due to concern for margin interpretation tests permitted for FIGO clinical staging include: physical exam (including EUA), cervical biopsy (including cone biopsy), proctoscopy/cystoscopy, IVP, ultrasound liver/kidneys, CXR, LFTs MRI and/or CT and/or PET scan often done to facilitate planning of radiation therapy, results do not influence clinical stage

..._,,
Cervical cam:er is most prevllent in d&Valoping countries and 1hsrefn111 is the only gynecologic Clllcer 1lilt uses clinical staging. This flcilitltlls consistent international staging with countries that do not hlva tachnologia& such u CT 111d MRI.

Table 17. FIGO Staging Classification of Cervical Cancer (clinical staging)

I lA IA1 IB 181 182 II IIA IIA1 IIAz liB Ill lilA IIIB IV IVA IVB Corlined to cervix Microinvasive (diagnosed only by microscopy) Stromal invasion not >3 mm deep, not > 7 mm wide 35 mm deep; not > 7 mm wide Clinically visible lesion confined to cervix. or microscopic lesion >lA Clinically visible lesion !:4 nrn in greatest dimension Clinically visible lesion >4 mm in greatest dimension Beyond ull!rus but not to the pelvic wall or lower 1/3 of vagine No obvious I)IU!lelrial involvement Clinically visible lesion !::4 mm in greatest dimension Clinically visible lesion >4 mm in g1811lest dimension Obvious involvement Extetlds 1D pelvic wall, ancVor involves lower 1/3 of vagina ancVor causes hydroneptr-osis or non-functioning kidney lnwlves lower 1/3 vagna but no extension into pelvic side wall lnwlves lower 1/3 vagna and extends into pelvic side wall ancVor hydronephrosis or no...functionilg kicroey Carcinoma has extended beyond bue pelvis or has ilvolved (biopsy proven) the mucosa of the bladder or rectum Spraad of the growth 1D adjacent organs Distant rnat11St8Ses

....

,,
Stlg1 D: 99'11> Stage 1: 75% Stigall: 55% Stage Ill: 30% Stage IV: 7%

CIIVical Cane PraiPIOiil I Year Survinl

Ovlnll: 50-60%

Table 18. Treatment of Patients with Cervical Dysplasia and Cervical Cancer

Tl'llllmllnt
CIN I (LSIL) Observe with regular cytology (every 6 monthsl Many lesions will regress or disappear (60%) Colposcopy f on 2 consecutive smears lesions which progress should have area excised by either LEEP, laser, ayolherapy or cone biopsy (with LEEP, tissues obtained for hist!llogicalavallllltion) Colposcopy rafeiTIII Ablation or excision therapy: LEEP.Ieser, cryotherapy, cone excision. cautery Hysterectomy- only Wno desire for future childbearing Cervical conillllion futura fertility desired Simple hysterectomy if future fertility is not desied

CIN II and CIN Ill (HSILI

l =microinvasive sec if:

<3 mm invasion and noCLSI Stage IAz, IB1

Stage lA,

Typically treated with hysterectomy and pelvic lymphadenectomy (sentinel nodes under studyI Advanlage is thai ovaries can be spared WprlHllenopausal For fertility preservation. may have radical trachelectomy and nodes insteud of 111dical hysterectomy for early-slllge disease Concurrent chemoradiatian thelliPY if adverse prognostic factors on111dical surgical specinen, poor SLI'!Iical candidate, or significantly adverse prognostic factors present at time of diagnosis Concurrent chemOilldiatian therapy

Stages 182 (> 4 emI, IL Ill, IV

Abnormal Pap Tests in Pregnancy incidence - 1/2,200 Pap test at all initial prenatal visits if abnonnal Pap or suspicious lesion, refer to colposcopy if diagnostic conization required, should be deferred until second trimester (T2) to minimize risk of pregnancy loss if invasive cancer ruled out, management of dysplasia deferred until after completion of pregnancy (may deliver vaginally)

Toronto Notes 2011

Gynecological Oncology

Gynecology GY45

if invasive cancer present, management depends on prognostic factors, degree of fetal maturity, and patient wishes general recommendations in Tl: consider pregnancy termination, management with either radical surgery {hysterectomy vs. trachelectomy if desires future fertility) or concurrent chemoradiation therapy recommendations in T2/T3: delay of therapy until viable fetus and C/S for delivery with concurrent radical surgery or subsequent concurrent chemoradiation therapy

Vulva
BENIGN VULVAR LESIONS Non-Neoplastic Disorden of Vulvar Epithelium biopsy is necessary to make diagnosis and/or rule out malignancy hyperplastic dystrophy (squamous cell hyperplasia) surface thickened and hyperkeratotic pruritus most common symptom typically postmenopausal women treatment: 1% fluorinated corticosteroid ointment bid for 6 weeks lichen aderosis subepithelial fat becomes diminished, labia become thin and atrophic, membrane-like epithelium, labial fusion pruritus, dyspareunia, burning 'figure of 8' distribution most common in postmenopausal women but can occur at any age treatment: ultrapotent topical steroid 0.05% clobetasol x 2-4wks then taper down mixed dystrophy (lichen sclerosis with epithelial hyperplasia) hyperkeratotic areas with areas ofthin, shiny epithelium treatment: fluorinated corticosteroid ointment Tumoun papillary hidradenoma, nevus, fibroma, hemangioma MALIGNANT VULVAR LESIONS Epidemiology 5% of genital tract malignancies 90% squamous cell carcinoma; remainder melanomas, basal cell carcinoma, Paget's disease, Bartholin's gland carcinoma Type I disease: HPV-related disease (50-70%) more likely in younger women 90% ofvulval intraepithelial neoplasia (VIN) contain HPV DNA (usually types 16, 18) Type II disease: not HPV-related, associated with current or previous vulvar dystrophy usually postmenopausal women Risk Factors HPV infection (see above) VIN (vulvar intraepithelial neoplasia): precancerous change which presents as multicentric white or pigmented plaques on vulva (may only be visible at colposcopy) progression to cancer rarely occurs with appropriate management treatment: local excision (i.e. superficial vulvectomy split thickness skin grafting to cover defects [if required]) vs. ablative therapy {i.e. laser, cauterization) vs.local immunotherapy (imiquimod) Clinical Features many patients asymptomatic at diagnosis (many also deny or minimize symptoms) most lesions occur on the labia majora, followed by the labia minora {less commonly on the clitoris or perineum) localized pruritus or lesion most common less common: raised red, white or pigmented plaque, ulcer, bleeding, discharge, pain, dysuria patterns of spread local groin lymph nodes (usually inguinal-+ pelvic nodes) hematogenous Investigations physical examination colposcopy ALWAYS biopsy any suspicious lesion
..... , !

,,J-----------------,

Any suspicious lesion of the wlva

should ba biopsied.

GY46 Gynecology

Gynecological Oncology

Toronto Notes 2011

Table 19. FIGO Staging Clusificltion and Treatment of Vulvar Cencar

Stage DescriptiDn 0 lntraepilhelial neoplasia (VIN), carcilama in

Treatmant
Local excision/superficial wlvectamy Laser ablation Local if1111unathsrapy {imiquimod)

I lA IB

Tumour confined to vulva Radical local excision + IJllin node dissection >1 mm invasion s2 em lesion, canlinad to wlva. perineum stromal Sentinel node dissection acceptable if lesion <4 em and no invasion s1 mm. no 1.111 involment suspicious nodes on I!XIIIIination >2 mm lesioo or stromal invasion >1 mm, no l.llls, confined to wlva t1t perineum Tumour any size with adjacent extension ID 1/3 lower Individualized uruthra, 1131ower vagina or anus Radical su111ical excision Negative inguino-femaml LNs

Ill lilA 1118 IIIC IV IVA IVB

II plu1 positive inguino-f&momll.llls 1LN met mml t1t 1-2 1.111 mets { mml <5 2 LNs mml or >3 LNs mets {<5 rT111) Positive l.1lls with extracapsular spread Regional {2/3 upper uretln, 2/3 upper vagila) spread t1t distant spread {i) Spread ID upper u1111hm vaginal mucosa, bladder, recllll mucosa or fixed to pelvic bone {ii) Fixed t1t ulcerated inguina-femoral LN Distant mets induding pelvic LN

Individualized Chernomdilllion mdical su111ical excision

Palliative therapy Individualized Charnomdilllion llldicalaurgical excision

Prognosis depends on stage and particularly nodal involvement (single most important predictor followed by tumour size) lesions >4 em associated with poorer prognosis toxicities of therapy common surgical site infection lymphedema radiation fibrosis, cystitis, proctitis overallS-year survival rate: 79%

Vagina
BENIGN VAGINAL LESIONS inclusion cysts cysts form at site of abnormal healing oflaceration (e_g_ episiotomy) no treatment required endometriosis dark lesions that tend to bleed at time of menses treatment is excision Gartner's duct cysts remnants ofWolffian duct, seen along side of cervix treatment conservative unless symptomatic urethral diverticulum can lead to recurrent urethral infection, dyspareunia surgical correction if symptomatic MALIGNANT VAGINAL LESIONS Risk Factors associated with HPV infection (analogous to cervical cancer) increased incidence in patients with prior history of cervical and vulvar cancer Investigations cytology significant false negative rate for existing malignancy (Le. if gross lesion present, biopsy!) colposcopy Schiller test (normal squamous epithelium takes up Lugol's iodine) biopsy, partial vaginectomy (wide local excision for diagnosis) rule out disease on cervix, vulva. or anus (most vaginal cancers are actually metastatic from one of these sites) staging (see Table 20)

Toronto Notes 2011

Gynecological Oncology

Gynecology GY47

VAIN (Vaginal Intra-Epithelial Neoplasia)

grades: analogous to cervical dysplasia treatment must rule out invasive cancer via biopsies and colposcopy prior to conservative treatment laser ablation vs. surgical excision vs.local immunotherapy (e.g. imiquimod)

Squamous Cell Carcinoma (SCC)

80-90% ofvaginal cancer 2% of gynecological malignancies most common site is upper 1/3 of posterior wall of vagina 5-year survival- 42% clinical features asymptomatic painless discharge and bleeding vaginal discharge (often foul-smelling) vaginal bleeding especially during/post-coitus urinary and/or rectal symptoms 2 to compression treatment usually concurrent chemoradiation therapy for 1 vaginal cancer consider radical hysterectomy/upper vaginectomy if early stage lesion and young patient

Adenocarcinoma
most are metastatic, usually from the cervix, endometrium, ovary, or colon most primaries are clear cell adenocarcinomas 2 types: non-DES and DES syndrome management as for sec

Diethylstilbestrol (DES) Syndrome fetal exposure to DES (due to maternal use) predisposes to cervical or vaginal clear cell
carcinoma, occurs in 30-95% of exposed females if exposed, <1 in 1,000 risk of developing clear cell adenocarcinoma clinical features adenosis is persistant Miillerian type glandular epithelium in vagina DES exposure associated with malformations of upper vagina, cervix, and interior of uterus (T-shaped); cockscomb or hooded cervix, cervical collar, and pseudopolyps of cervix patients with DES exposure should have annual Pap tests (cervix and vagina) and digital vaginal exam for subepithelial masses if any abnormality, refer for colposcopy

Table ZD. FIGO Staging Classification of Vaginal Cancer (Clinical Staging)

Stage Description

..._,,

,,f-----------------,
70'L 40'L 30'L 1520'11.

neoplasia (VAIN), Cli'Cinoma in situ Linned to the vaginal wall lnwlves subvaginal tissue, NO pelvic wall extEnsion
Pelvic wall extension

s Year Survival 111111

Stqal Stqall SUgelll StqaiV

Prognosil

Ill
IV IVA IVB

Extensian beyond true pelvis OR bladder/rectum involvement Bladder recllll mucosal spread extension beyond true pelvis Spread to distant organs

Fallopian Tube
least common site for carcinoma of female reproductive system (0.3%) usually adenocarcinoma analogous to ovarian cancer (may be implicated in pathogenesis of ovarian cancer) more common in fifth and sixth decade

..._,,
Clllc Trild ( <15"lft rrf pltientsl 1. vaginal disc:hatge 2. Pelvic pain 3. Veginlll bl8lding

werv

Clinical Features
classic triad present in minority of cases, but very specific watery discharge (most specific) = "hydrops tubac: profluens vaginal bleeding or discharge in 50% of patients crampy lower abdominal/pelvic pain most patients present with a pelvic mass (see Ovarian Cancer, GY38 for guidelines regarding diagnosis/investigation)

.....

,,

,,f-----------------,

Current hypotheses suggest epithelial urous overiln originms from

malignllllt fallopian tube cells.

Treatment
as for malignant ovarian tumours

GY48 Gynecology

Gynecological Oncology

Toronto Notes 2011

....
Wrth davalopmant of hypartanlion 1111rly in pngmmcy (i.1. < 20 Mllc.l), think gastatiorllltrophoblastic di1181S81

Gestational Trophoblastic Disease/Neoplasia (GTD/GTN)

refers to a spectrum of proliferative abnonnalities of the trophoblast
Epidemiology

1/1000 pregnancies marked geographic variation - as high as 1/125 in Taiwan 80% benign, 15% locally invasive, 5% metastatic cure rate >95%

HYDATIDIFORM MOLE (Benign GTD) complete mole

most common type ofhydati<liform mole diffuse trophoblastic hyperplasia, hydropic swelling of chorionic villi, no fetal tissues or membranes present 46XX or 46XY, chromosomes completely of paternal origin (90%) 2 sperm fertilize empty egg or 1 sperm with reduplication 15-20% risk of progression to malignant sequelae

risk factors
geographic (South East Asia most common) others (maternal age >40 years, ll-carotene deficiency, vitamin A deficiency) - not proven clinical features often present during apparent pregnancy with abnonnal symptoms/findings: -vaginal bleeding (97%) - excessive uterine size for LMP (51%) - theca-lutein cysts >6 em (50%) -pre-eclampsia (27%) - hyperemesis gravidarum (26%) -hyperthyroidism (7%) - beta-hCG >100,000 miU/mL - no fetal heart detected partial (or incomplete) mole hydropic villi and focal trophoblastic hyperplasia are associated with fetus or fetal parts often triploid (XXY, XYY, XXX) with chromosome complement from both parents usually related to single ovum fertilized by two sperm low risk of progression to malignant sequelae (<4%) associated with fetus, which may be growth-restricted and/or have multiple congenital malformations clinical features typically present similar to threatened/spontaneous/missed abortion pathological diagnosis often made after D&C
Investigations

quantitative beta-hCG levels (tumour marker) abnormally high for gestational age U/S findings: if complete: no fetus (classic "snow storm" due to swelling of villi) if partial: molar degeneration of placenta fetal anomalies, multiple echogenic regions corresponding to hydropic villi, and focal intrauterine hemorrhage CXR (may show metastatic lesions) features of molar pregnancies at high risk of developing persistent GTN post-evacuation local uterine invasion as high as 31% beta-hCG >100,000 excessive uterine size prominent theca-lutein cysts
Treatment

suction D&C with sharp curettage and oxytocin Rhogam ifRh negative consider hysterectomy (if patient no longer desires fertility) prophylactic chemotherapy of no proven benefit chemotherapy for GTN if develops after evacuation

Follow-up

contraception required to avoid pregnancy during entire follow-up period serial beta-hCGs (as tumour marker) every week until negative x 3 (usually takes several weeks), then monthly for 6-12 months - prior to trying to conceive again increase or plateau ofbeta-hCG indicates GTN -+ patient needs chemotherapy

Toronto Notes 2011

Gynecological Oncology

Gynecology GY49

GTN (MALIGNANT GTD) invasive mole or persistent GTN diagnosis made by rising or plateau in beta-hCG, development of metastases following treatment of documented molar pregnancy (see sidebar) histology: molar tissue from D&C metastases are rare (4%) choriocarcinoma often present with symptoms from metastases highly anaplastic, highly vascular no chorionic villi, elements of syncytiotrophoblast and cytotrophoblast may follow molar pregnancy, abortion, ectopic, or normal pregnancy placental-site trophoblastic hllnour rare aggressive form of GTN abnormal growth of intermediate trophoblastic cells low beta-hCG, production of human placental lactogen (hPL), relatively insensitive to chemotherapy CLASSIFICATION of GTN non-metastatic -15% of patients after molar evacuation may present with abnormal bleeding all have rising or plateau ofbeta-hCG negative metastases on staging investigations metastatic 4% patients after treatment of complete molar pregnancy metastasis more common with choriocarcinoma which tends toward early vascular invasion and widespread dissemination if signs or symptoms suggest hematogenous spread, don't biopsy (they bleed) lungs (80%): cough, hemoptysis, CXR lesion(s) vagina (30%): vaginal bleeding, "blue lesions" on speculum exam pelvis (20%): rectal bleeding (ifinvades bowel}, U/S lesion(s) liver (10%): elevated LFrs, UIS or CT findings brain (10%): headaches, dizziness, seizure (symptoms of space-occupying lesion), CT/MRI findings highly vascular tumour -+ bleeding -+ anemia all have rising or plateau ofbeta-hCG classification of metastatic GTN divided into good prognosis and bad prognosis features of bad prognosis - long duration (>4 months from antecedent pregnancy) - high pre-treatment beta-hCG titre: >100,000 IU/24h urine or >40,000 miU/mL ofblood - brain or liver metastases - prior chemotherapy - metastatic disease following term pregnancy good prognosis characterized by the absence of each of these features

.....

''

GTN Dillgna.il 1. 4 VIIIUH of per5illantly alavat8d beta-hCG plateau )days 1, 1, 14 and 21) or sequanlial rise of bela-hCG for
2-ks(days 1, 7, 14)orlonger 2. Lung me1astllses on CXR )rare)

.....

',

ara #1 5Q for malignlllll GTN mlllarlll... Wh., pelvic exam IIJid cheat are nagativa, rnalutualare uncommon.

Investigations- For Staging history and physical bloodwork: CBC, electrolytes, creatinine, beta-hCG, TSH, LFTs imaging: CXR, U/S pelvis, CT abdo/pelvis, CT brain if suspect brain metastasis but CT brain negative, consider lumbar puncture for CSF beta-hCG ratio of plasma beta-hCG:CSF beta-hCG <60 indicates metastases

Table 21. FIGO Staging end Management of Malignant GTN

I

Disease confined to uterine corpus

Single agent chemotlunpyfur low risk disease (WHO score 1st line: pulsed - actinDIJliiCil D(Act-DIIV qZ wks MlX-basad ragim111 211% of patients n88d to switch to albrnBte silgla-agant ragimen Combination chernrtherapy (EMA-CO: etoposide. MTX. ACTIl. cyclophos!Nmide, vilcristinel Hhigh risk (WHO score :<!71 Dr Hresistant to single agent chemotherapy Can consider hysterectomy Hfriity not dssired Dr traphoblastic tumDUJ"

Metastatic disBBSe tD genillll structures Ill IV Metastatic disBBSe tD lungs with Dr withDUt genilal1nlct inwlvernent Distant metastatic aitss including brain. liver, kidney, Gltract

A1J above

Usually hiltJ risk (EMA-CO) surgicalr&&ectiDn of ait&s of dis811sa PlnistenCI!/resistance tD chemotherapy Consider radiation for brain mets

GYSO Gynecology

Gynecological Oncology/Common Medications

Toronto Notes 2011

Follow-up (for GTN) contraception for all stages to avoid pregnancy during entire follow-up period stage I, II, III weekly beta-hCG until3 consecutive normal results

stage IV weekly beta-hCG until3 consecutive normal results

then monthly x 24 months

then monthly x 12 months

Treatment chemotherapy for all stages (see Table 21)

Common Medications
Tabla 22. Common Medications

Drug Nna!Brand Name) Ac:tian acydavir (Zavimxe) bromocriptina(Parloclal') Antivial; illibits DNA S'rfllhesis and viii repbtion Dopaminomimetic Agonist at Dzfl Antagooist at DR 1 Acts cirectly on 1l1lerilr pituitary cells Ill 5y11!hesis and release of prulllctin cutput of pii!Dy gonadotropins wlich induoos owllilian

Dning Schedule Fillt EpiiGde: 400 mg PO tid x 71lkl lleciiTince: 400 11111 PO tid xSd Initial: 1.25-2.5 11111 ells with food Than: 2.5 mg bid with meals

lndicrian1 Genital he!pes Galactnnhea +amenonhea 2" to hyperprdaclinemia Prolactit-dapendlllll11181151Ju11 diSII'ders and infertility adellomas (microlldenomas, prior Ill surgery of l'atiellts with persistent awlatuy dysfunction (e.g. amenonhea, PCOS) who dasint pr&gnancy

Sida Ellec:IIISIEI. ContraindiadionICJ1l. Drug lntlracliaRI (D,/1)

H: headache, Gl upsat
D,/1: zidowdine, probenecid
5,/E: niiUSel, vomiting. headache, post111l

hypotoosion, somnoleflce IIICOnlrolled hypertension, pregnancyinduced hypartension, CAD D/1: domperilone, macrolidas, oclrlotida

clomiphene citrate (CiomiiPI

50 11111 daily X 5days Try 100 mg ineffective 3collliiS = trial

5,/E: Common - hot flashes, abdominal

discomfort, exaggerated cycic ovarian enlargement, accentuation of Mittelschmerz Rant- oYIIi111 hypemimulation ayndrome, pregnancy, visual liming. birth defects disease, hormone-dependent hrnOIJS, ovarian cyst. unciagnosed vaginlll bleeding

clotJillazole (Canesten'l

Antifungal; disn fungal cellmanaana

Tablll: 100 mwd intravagilallyx 7d or Vulvawlgnl candilillsis 500 11111 X I dO&e Crelm [I or 2%): 1applicator intravagiRIIIV qhs X3-7d Topicel: apply bit X7d Endometriosis 1" menorrhagie,IIIUB

H: Wv!r/vaginlll

darNiltll (Cyclamen- CANI (Dncrine'- US)

Syntheti: sleroil11iat inhilits

2011-800 11111 in Z-3 civided doses gonadotropin Used fur 3-6 months output and ovarian steroid Biannulll hepslic U/S reqlired ff >6monthuse svntiJesis Has mild 111drogenic properties

H:

gllin.acne, mild hirsutism.

hepslic dysfunction

undiagnosed vaginal bleeding. ln115!188ding. 51Mnly certiiiC function. porphyria, gerital neo,-sil1 D/1: warfarin, cydospome, tacrolimus, anti-hypertensiws Chi11J1il1, gonococcal infection, syplilis candiciasis urresponsiveto clotriniiZOie Endomatriosis l.eiomyomabl DUB Precocious plDelty

doxvcvdine

Tetracycline deriva1ive; inhibit protein synthesis disrupt fungal cellmemtnne

Synthetic

10011111 PO bidx2:7d

H: Gl- hepatotoxicity 0'1: pregnancy, seven! hepatic dysfunction

D,/1: warfarin, digoxin

llJCiliiiiZIIIe(Dilllcan)

ISD11111P0xl dose

H: headiiChe. rash, nausea, vomiting. abdo pllin, diarrllea D/1: terfenadine. cisapride,astemizde,
phenyloil. warfarin. rifampin
5,/E: hat flashes, sweats, headiiChe, reduction i1 bone dansity

1-.rolile (Lupron

analog I1MIIIible hypoestrogeric slat!

3.75 mg IM ql month or 11.25 mg IM q3morths Usually months, check bone doosity ff>6months
then I0,000 UhCG one day after last

undillg11081d vagin1l breestleeding

menotropin (Pargonallt)

Human Gonadotlopin with FSH and Ul effects; induce ovulation and stimulate ovarian follicle development BactBricidal; forms toxic metabolites which damage bacterial DNA

75150 UofFSHand LH IM qdx7-1Zd, hlertility dose

H:

metnmid11111le

2gPOx 1dosear50011111PDbidx7d llact8rial vagina&i5, bichomon vaginitis

iritatian ir1actian sit&,abdw'pelvic pain, headache, nausea and vomiting lfimaryovarianfllilure, intracranial lesion (e.g. pitlitary IIJmour), uncontrolled 11iynid/adrenal dysfunction. ovarian cyst (not PCDSI, PniiJIIncy Sit: headache, dizziness, nausea, vomiting. cianl1ea, dimram-like reectian tachycardia, nausea and
(1 11

D/1: cisaprida, warfarin, cimelidine, lilhUn, alcohol

Toronto Notes 2011

Common Medications

Gynecology GYSI

Table 22. Common Medications (continued)

Drug Nama (Brud Nlme)
oxybulinin

Actian

Dosilg Schedule

lndiCIIians Overactive bladder (urge incontinence) Overactive bladder (urge incontinence)

Side Effac:ls (SIE), Conlrliedicltians (til).

DIUIIInlelllclians (011) SIE: dry mouthleyes. constipation, palpita1ions. urinary retention til: glaucoma, Gl ileus, severe colitis, obstructive uropathy, use with caution if impairBd hepaticirenal function SIE: anaphylaxis, psychosis, tachycirdia, dry mouth/eyes, hlladachs, constipation. urinary l'lltantion. chest pain C/1: glaucoma, gastrir/urinary l'lltantion, usa caution if impaired hepaticirenal function SIE: naU&8il, vomiting. diillhllil, dilzinass, rara cases of throntosis Cll: thnorrboembolic disease, acquired disturbances at colour vision, subarachnoid hemonhage, age < 15 vrs SIE: ovarian enlargement or cysts, edema and pain at injaction site, arterial thromboembolism, fever, abdo pain til: primary ovarian failure, intracranial lesion (e.g. pituitmy tumour). uncontrolled thyroiciladrenal dysfunction, ovarian cyst (not PCOS), I-Rijnancy SIE: EstnogenilllatBd - nausaa, braart chllngas (tandamass, eriargement), fluid weight gain. migraines, thromboembolic ewnts,liver adenoma. intermenstrual bleeding ProgastiiH81atBd - amenorrhaalintermenstrual blaading. headaches, breast tenderness. increased decreased libido, mood changes, hypertension. acne/oily skin, hirsutism D/1: rifampin. phenobarbital, phenytoil. primidone C/1: Absolute- knowrv'suspactBd 1)1'81Jlancy, undiagnosed abnormal vaginel bleeding, prior thromboembolic events, thromboembolic disorder, active cerebrovascular or cononary artery disease, estrogen. dapandent tumours, inpairad liwr function associated with acute liver disease, congenital hyperlriglyceridemia, smokEr age >35 years, migraines with focal neurological symptoms (exducing aura), uncontroled hypertension Ralativa- non focal migraines with aura < 1hour, diabatas mellitus by VBicular diiiiiiSII, SLE, controlled hypertension. hyperlipidemia, sickle cell anenia. gallbladder disease SIE: intermenstrual bleedinll bloating, headache (Mirenail), increased blood loss, duration at menses and dysmenonhea (copper IUD only),IIICpUision (5% in the first ysar, greatest in first month), uterine wall perfol'lltion (1/5000), greater risk al ectopic pregnancy if pregnancy occurs. increased risk at PID withil fir&t 10days at insertion only C/1: Absolute- known or suspactBd pragnancy, undiagnosed genital tract bleeding. acute or chnonic PID, lifestyle risk for STis, known to copper or Wilson's Disease {copper IUD only) Relative -valvular heart diseass, past history of PID or ectopic pregnancy, abnonnalitias of utBrila cavity, intracavitary fibroid&, severe dysmenorrhea or menonhagia (copper IUD only), cervicel stenosis, innmosuppressed individuals

Anticholinergic 5 mg PO bid-tid bladder smooth muscle, inhibits involuntary detrusor conlrlletion Anticholinergic 1-2 mg PO bid

raaxes

totlllrodine (Detrol<)

traniiXIlmic acid

AIJii.fibrilolytic, IIIV8rsibly inhibits plasminogen activation

1-1.5 gtid-qid for fir&t Manorrililgill 4 days of cycle Ophthalmic check if used for several weeks 75 U/d sex 7-12 d Ovulation induction in PCOS

urofdlilropin

FSH

combinBd oral conlrllceptiw Ovulatory supp18SSion by piii(OCP) LH and FSH Decidualillltion at endometrium Thickening of cervical mucus to p18V8nt sperm pamllllllion

Conlrllcaption Disorders of menstruation

intraull!rine device (IUD) copper IUD (NOV&-T") prog851Brune-r&l8ilsing IUD

Cappar IUD: mid foreign body reaction in endometrium which is toxic to sperm and atars sperm motility Proglllll1'11ft&onllallingiUD: decidualillltion of endometrium and thickening of cervical mucus. may supp!8SS ovulation

Conlrllceptive effects Same as above last five years

GY52 Gynecology

References

Toronto Notes 2011

References
AnuriCill Psychiltric Alsacilllion. Dilgnaltic and Slltilticlll MBIIlll rl Manlll Disordlll.fourth Editian, Till! Rll'lilian. Washington. DC. Amarican Psycliltric 2000. llicU;" R. Canlrtceptivl Pilll'llliants 9th editian. EMIS K. Medical Publishers., USA 1198. Cunninghllll FG, Mcllvnald PC, 11111 Gmt NF Wililrrls Obil&lrK:s, 14111 lid. Applltun 1983. Hacker NF and Moen JG leds], Essentials rl Obstltrics 11111 Gynecalllgy. 2nd ed. N.F. Hackennd J.G. Moore llldsl. W.B. Slllllden Co.. 1912.
Glid.._

a.. ......

ACOG Practice - Cmical Managlllleffl Guidetles for Obslelrici111-Gynecalagisl$. Premenstrual Syndrome. M.rier 15, April2000. Divis Vand Dunn S. Eme!11antY l'oslcailal SOGC Clinicall'nlctice Glidll111s. Na. B2 .lllv 2000. NlliaiiiiiJoidalina for 1ba 1r8ltnart at lllctBrial vaginlllis. Clinical Ellactiwnass Group IAisucillian of Gali1Duri1111Y Medicine 11111 1ba Macbl Society for lha S1udy at Van1111l Diseuls]. Sax Trann 1999; 75 S1 Onllria Carvical SCillllling l'nlctica Guidar1111. June 2005. hllp;l[www.caiiCifCira.lll.cr{mda- carvicai!JC118ning.hlm l'lly PJ Screeliig for the major malgnanciel decting women: curren1 AmJ Obsi2!Gynecal2001;184{51: 1021-30. NJi: Haalth Agency of Canada, m. Updells on C.aan !Pdllinas an Sbudy Tllllllmittad lnliclions 2006 Editian.httpJ,.WWW.phac-tspc.gc.ct/lldmtr/sti-itJI guida-lplllirung.php. SOGC News Relelse. New recGIIIIIIilldlllians from lllliallll oht1yn suc:ie!y Illdress Depa.f'nlve11. bone bss. May 2006. http;l[www.soge.arw'fnedilt/pdl/ldYisaries/ dmpa-may2006_s.pdf. .lalrniiArticiiS And8fltlll, GL. Limacliat, M,ll II.IWHI Stearing Conmt!Ba]. Ellaell rl ConjlgDd Ellnlgan in l'ostmanapausal Woman wi1h HyltaractDmy- Tba Woman's H11111h lnitiltiva Rllldamized Trial. JAMA2004; 291(141: 11011712. IW!i* S, BIIU J, Ba11111 R, Des in des S, Graves G. Gri!JIIildil S. et al. Canadian Consenu Conlerence an Menapue. 2006 upda11. J Obstet Gynaecal c 21106;2812 .. Suppi1]:S1S94. Canedisn Cansanlus Canlulvnca on MIJIIOPIIUit, 2006 Updlllll. JOGC 2006;171. Craange A.A. Bradley HM, McCarmck C, Witkop CT. Use fi met!Gnnin il polycystic rmtv syndJOIIIII: 1 matHnaiytis. Obsllt Gynacal 2006;1 11141:159-68. IIIYiy E, Blrrltt A, mig l alii. Hfact rlllildy design and cplity of ullAiilkdDry riiBL cytgiDIIY cllllificlllia111, 111d acwracy in iqliiHiuaiV8fliJI canvantional cervical cytglagy: a systematic lllliew. Lancet 2006; 367: 12H2. Erdman JN.Ilrrllln in Haallll Equity: Clnrical ClliCir and Hpv wccinls. AnwiCIJi journal at law &111111ciia2009; 36>387. Espaland. MA. Rrpp SR. Sln11111kar SA. at Ill Conjlgabld Ellmgans 111d Global CGgniliva Function in l'ostmlnapllllll Warrai's HHIIh lnitilliwl MemoryS1udy. JAMA 2004; 291124]: H!Jay S. Gradv D. Bush T.ll el. Randcriad bielfi Bllnlg8n pkls pogllllin for secandary pravanlian of caroiWf haut 4ilaaa in pDIImllnapiUIII Mman. JAMA 1918;280:60H13. GH, McCard MI. Slllvlln TG et al Predictms at IUCCell rl metllatrelilte trelltement in women Ylitlllubal ectopic Jl1lglllll:iel. Nf..N 2001; 341: 1974-1978. luci111a AA. Salin RG. Ec!Dpic l'niglllncy. Flllm Surgi:al Emargancyto Medical t.lanaglll'lllll. Ann NY ACid Sci 2001; 943:235-254. Manson JE, MllliiKA.1Wtmanaplusal harmo1la rupilcemeuttharlpy. NEJM 2001;345111:34-40. Moore RG. Jllbre.fliUIII"Iey M, Brawn AK,IIobisan KM, Miller MC, Allard WJ, IC&nman RJ, But AC. Skates SJ. Comparison at IIICI'Iel mu._.11111ia 11A1Y vs. the Risk af r.tllignantY lndaxfor the pradK:tion af apithaliiiiOYII"iln CIIICII' in plllian!l wi1h a palvic mm.. Am J Obltlt Gynacol. MIIY 2010. In prass. Corractsd pnJOI ME. Chizen DR. Pienun RA. crierill for Jlllycystic avuy syndrume: Pitfds and CGIItnMnies. J Obstet Gynaecal Can. 2008. PA. Alllgar JF. CcUIIIn CB, at Ill Risk IICIIJn for IIC1IIpic pr1g111ncy: 1 papulltian basad lhldy. JAMA 1198; 259: 18231827. Mmin JL. Wiliams KS. Alnms KR, at 11. Syriantic ravisw 11111 fi mathods rl.-ing uriiiJY incontinenc&. Ha111h Taclmal Alma 2006;1016]:1 132. ii.W. Rambaut L. HQI)kins L. Fung Kle Fung M.ll al. Prophylactic vaccinlllion hum111 papillomai1111 infactian ilwamm:a sysD1i: ravisw al randonil8d cantrallad trills. CMAJ 2007;177. illba"Smd twri D. ManapiUII and hannana R!pilc11111181111bartpy. WaitJ Mad 2001;175:32-34. See;et JD.I.ougllln J, Eng PM, Cliflwd CR. eutm. J, Walker AM. Risk af1hnlmbambaism in IY8IIWI takilg ethifl1estnidiaVdraspirenane IIIII alher cnl cantnlcaptivls. Obsii!Gynacal2007;1 10131:587!13. Shaptar AI! Gestational diSIIISL Obs Gynacfi Clin North Am 2001; 28(41: 80517. Shumal:ar SA.LagUt C, Kular l,llal. CatMa18d Estrogm Md lncidellca of Problbla D11111111ia and Mild Cogritivt Impairment in l'ostmanopauSII WomanWomen's HalltlllnitiiiMJ MamaryS1udy. JAMA 2004; 291124]: 29412158. lingulstad S, Hagen B. SijeldesiJd FE, et al Tbe risk of TNiignmcy index Ia IMIUte palentilll mri CIIII*S il bc:al hosptals. BR J Obsllt Gynecal. 1IB9;9313t.448-52. WaaiiDrlon. E. The Evni latliarrjllllllldi!Vncnlgalllnlmin] CGntraclpliva pildl: lltrogan lllqJOIUrt COIEamL CMAJ 21106; 174!2t. 164165. WaaliDJIDn E. Madroxypnlgaetaa 1ca1111 (Dipo-l'rNml] and bona minaral dansity IIIIa. JAMA 2005; 17216]: 746. Women's Halltll Cucil. Clinici111 Norrnalilrl Shall: HPY Vaccinl for Carvical CaiiCIII'nlmltian. MIIIIChUIIIts Gllllfll HOSJital. Au!IJst 21, 2006.
Wlblitll MIITIIQ1iiiEnl afllllrine Fibroidi. 511111111111'. EWde11ce Aepart'Teclrdlgy Assessment: Nurrmer 34.AHRQ Publicltian Na. OH051. JIIIUIJY2001. Agency for Hadhclra R111arch and Quality, Rack ill, MD. http/{ww.alrq.giJWcK/Illlnumm.hlm SIIIUIIiity and U. Sacilty rl Ob118tricianell'ld Gynaecalogim of Cllllda. http//ww.$8Uilyii!Qj.ca