GYNECOLOGY

GENERAL CONCEPTS
*different types of estrogen:
-estradiol ovary
-estriol placenta
-estrone peripheral conversion from fat
*hCG
-secreted by syncytiotrophoblast
-preserves corpus luteum during early pregnancy to maintain
progesterone secretion until placenta takes over
-begins 8 days after ferilization doubles every 48 hours until peak at
6-8 weeks
-alpha subunit is common to hCG, TSH, LH and FSH
-beta subunit specific to hCG (basis of pregnancy tests)
MENSTRUAL CYCLE
Ovulatory phase:
-cervical mucus is profuse, CLEAR AND THIN (post and pre ovulatory
mucus is scant, opaque and thick)
-pH is 6.5 or greater (more basic than other phases)
-mucus will demonstrate ferning when smeared on microscope slide
PUBERTY
-age = 13 for Caucasian, 12 for blacks/Hispanics
-pulsatile GnRH secretion causes FSH/LH secretion from pituitary
estradiol production
-stages = TAGM
-THELARCHE - breast bud development
-ADRENARCHE zona reticularis of adrenals secrete sex steroids
(DHEA-S, DHEA, androstenedione)
-GONADARCHE FSH/LH secretion
-MENARCHE
**PRECOCIOUS PUBERTY concerned about short stature due to early
epiphyseal closure b/c estrogen
-before age 6 for blacks, age 7 for Caucasian
-heterosexual changes: 1. Virilizing tumor/2. CAH
-CENTRAL isosexual changes RESPONDS TO GNRH STIMULATION/GET
HEAD MRI give GnRH agonist to treat
-PERIPHERAL isosexual changes DONT RESPOND TO GNRH
STIMULATION TEST caused by adrenal neoplasm (abdominal CT),
ovarian neoplasm, MCCUNE ALBRIGHT SYNDROME (caf au lait spots,
bone fibrous dysplasia, adrenal hypercoricolism)
MENOPAUSE

*premature = before age 40 years (must have 1 year of amenorrhea)

-causes:
1. karyotype (turner, fragile X syndrome)
2. autoimmune (hypothyroid, adrenal insufficiency,
hypoparathyroidism, type 1 DM, SLE, RA)
3. environmental pelvic radiation, chemo, hysterectomy, uterine
artery embolization
*hormone changes:
-increase FSH (>40)/LH
-low estradiol lower sex hormone binding globulin testosterone
increased
-low estrone but higher than estradiol
*diseases:
1. Cardiovascular lipid profile worsens
2. Cancer breast (mammograms every year after age 50),
colorectal (colonoscopy after 50 yrs every 10 yrs)
3. Osteoporosis
-risk factors = smoking, alcohol, rheumatoid arthritis
-DEXA scan test all women >65, T score <-2.5
-tx = BISPHOSPHONATES (alendronate), estrogen agonists
(RALOXIFENE), calcitonin, synthetic PTH (teriparatide)
*hormone therapy:
-use estrogen if NO UTERUS
-use estrogen progestin therapy with uterus
-increased risk of coronary heart dx, stroke, breast cancer, dvt
-CI = abnormal genital bleeding, hx of DVT/PE, recent
stroke/MI, liver disease
CONTRACEPTION
COMBINATION CONTRACEPTIVES:
*mechanism:
-estrogen decreases FSH, prevents follicle maturation
-progestin decreases LH, inhibits ovulation, thickens cervical mucus
*absolute CI to oral contraception:
-hx of thrombophlebitis (DVT/PE)
-smokers >35yo
-hepatic neoplasm, cirrhosis
-hx of stroke or MI
-migraines with aura(might have increased stroke risk switch
to progestin only)
-breast cancer
-major surgery with prolonged immobilization

-<3 weeks postpartum

-stage 2 hypertension (>160/100mmHg)
*advantages:
-decreases risk of OVARIAN AND ENDOMETRIAL CANCER!
-less menstrual pain
-less acne
-lower risk of benign breast dx
*interactions (decrease efficacy)
-rifampin/phenytoin/carbamazepine/sulfonamides
*side effects
-estrogen increased TG, bloating, weight gain, decrease libido
-progestin sebum formation, cholestatic jaundice
-worsen HTN
PROGESTIN ONLY CONTRACEPTIVES:
*indication CI to estrogen containing contraceptives, give to
breastfeeding ladies! (no disruption of lactation)
*CI BREAST CANCER, liver dysfunction
*delivery routes:
-MINIPILL good for women >40 years
-DEPOT INJECTION every 3 months, INCREASES BMI, DECREASES
BONE MINERAL DENSITY (no increased risk of fractures though)
-IMPLANTABLE ROD (EXPLANON)
IUD
*indications: diabetes, thromboembolism, BREASTFEEDING, breast
cancer/liver disease (copper only), menorrhagia
*CI: PID, current STDs, purulent cervicitis, abnormal uterine bleeding
*copper:
-no hormone!
-lasts 10 years!
-can be used as emergency contraception 5 days after intercourse!
-rapid return of fertility after removal
*levonorgestrel releasing
-mirena (5 years)/skyla (3 years)
-rapid return to fertility
AMENORRHEA: no menstruation by 13 without breast budding, by 15
with breast budding
*primary: never had menses
1. gonadal dysgenesis:

-turner syndrome (streak ovaries, short stature, webbed neck,

shield chest with widely spaced nipples)
-pure gonadal dysgenesis
-vanishing testes syndrome
2. receptor abnormalities
-androgen insensitivity syndrome phenotypic female but
genetically male (no uterus or vagina, normal breasts, no sexual hair)
3. enzyme deficiencies
-5 alpha reductase deficiency genetically male but cant
produce DHT leading to lack of masculinization at puberty (increased
risk of cryptorchidism/testicular cancer!)
-CAH
4. hypothalamic
5. congenital
-imperforate hymen
-mullerian agenesis (absence of uterus and upper 2/3 of vagina)
-vaginal agenesis
-transverse vaginal septum
6. pituitary adenoma, hypothyroid (decreased TSH causes increased
prolactin)
7. ovarian
*secondary: used to have period, but not for 3-6 months, always do
pregnancy test first!
1. estrogen deficiency PCOS, adrenal hyperplasia, thyroid
dysfunction, obesity
2. ovarian dysfunction (FSH is still high) chemo, radiation, turner
3. asherman syndrome scarring of uterine cavity from D&C
4. Sheehan syndrome pituitary necrosis due to postpartum
hemorrhage
5. female athlete triad amenorrhea, disordered eating, osteopenia
-low GnRH low FSH/LH low estrogen
-no menstrual bleeding after progesterone challenge
*diagnosis of secondary amenorrhea
- LABS hCG, TSH, prolactin
-PROGESTERONE CHALLENGE TEST: no withdrawal bleeding get FSH,
if low, administer estrogen +progestin (withdrawal = hypogonadotropic
hypogonadism, no withdrawal asherman)
ENDOMETRIOSIS
*hormonally responsive endometrial glands in extrauterine sites
(adenomyosis: endometriosis in myometrium)
*risk factors: reproductive age, nulliparity, family history
*presentation: symptoms are cyclic
1. dysmenorrhea

2. dyspareunia
3. chronic pelvic pain
4. dyschezia: pain with defecation
5. infertility (formation of fibrotic pelvic adhesions)
6. menorrhagia (especially with adenomyosis!)
*MC location is ovary chocolate cyst
*diagnosis: TRIAL OF NSAIDS+OCPS, THEN LAPAROSCOPY!
-exam uterosacral nodularity, ADENOMYOSIS ENLARGED BOGGY
UTERUS
-visualization during surgery brown/gray POWDER BURN LESIONS,
dark red mulberry lesions
-BIOPSY LESIONS! endometrial glands/stroma/hemosiderin
macrophages
*treatment:
-NSAIDS for pain
-combination contraceptives
-continuous progestins
-DANAZOL weak androgen hirsutism, acne, oily skin, deep voice
-GnRH agosnist chemical menopause hot flashes, vaginal atrophy
-surgery ablation/excision of lesions, bilateral salpingooophorectomy,
hysterectomy
INFECTIONS
*vaginal infections
Bacterial vaginosis
o Sxs: fishy odor, thin gray discharge
o Vaginal pH: >4.5
o KOH whiff test fishy
o CLUE CELLS!
o Tx = ORAL OR TOPICAL metronidazole or clindamycin
Candidiasis
o Sxs: burning, itching, dysuria, dyspareunia, erythema, thick
white discharge
o Vaginal pH: normal!
o Hyphae and buds on microscopy
o Tx: topical imidazole or oral fluconazole
Trichimonas
o Sxs: FROTHY green discharge, dysuria, dyspareunia,
itching/burning, STRAWBERRY patches in upper vagina and
cervix
o Vaginal pH: >4.5
o Wet mount shows motile trichomonas organisms
o CHECK FOR OTHER STDs!
o Associated with PID, endometritis, infertility, ectopic
pregnancy, preterm birth

o Tx: ORAL metronidazole, TREAT SEXUAL PARTNERS, TREAT

DURING PREGNANCY (PROM, preterm delivery, low birth
weight)
ATROPHIC vaginitis
o pH>4.7 (lack of estrogen = less lactobacilli = less lactic
acid and alkalosis)
o sxs = dryness, itchiness, burning, dyspareunia
o tx = estrogen therapy (systemic or local)
*STDs
Chlamydia
o Gram negative INTRACELLULAR
o SCREEN ALL SEXUALLY ACTIVE WOMEN <25YO ANNUALLY
o Sxs: asymptomatic, mucopurulent cervicitis, PID
o Tx: azithromycin or doxycycline
Untreated can lead to PID, ECTOPIC PREGNANCY,
CHRONIC PELVIC PAIN, INFERTILITY
Gonorrhea
o Gram negative diplococci
o Sxs: asymptomatic, urethritis, cervicitis
o Tx: ceftriaxone
o Complications
Septic arthritis disseminated gonorrhea!
PID
o Cervical motion tenderness, abdominal/adnexal/pelvic
pain, fever, increased WBCs
FITZ HUGH CURTIS inflammation leading to
localized fibrosis and scarring of anterior liver to
peritoneum
TUBO OVARIAN ABSCESS fevers, tachycardia,
vomiting, severe pelvic/abdominal pain
IV ABX, rupture is surgical emergency
o Oral ceftriaxone+doxy+METRONIDAZOLE
o IV clindamycin + gentamicin, cefotetan
o Complications: ectopic pregnancy, TOA, infertility
Herpes
o HSV1 cold sores, HSV2 genital lesions
o 1st episode is most severe
flu like syndrome, neurologic involvement, resolution
in 1 week
syphilis
o primary
painless chancre with lymphadenopathy
o secondary

skin rash on palms and soles

lymphadenopathy, fever, muscle aches, headache,
weight loss, fatigue
condyloma lata flat topped papules in moist areas
latent asymptomatic
tertiary
CNS (TABES DORSALIS dorsal column loss of
proprioception/vibratory sense, Argyll Robertson
pupils), cardiovascular, ophthalmic, auditory
abnormalities
Gummas
Dx:
Dark field microscopy motile spirochetes
Direct fluorescent antibody
Nontreponemal tests VDRL, RPR (falsely positive in
SLE or antiphospholipid)
Treponemal confirmatory test FTA ABS (POSITIVE
FOR LIFE REGARDLESS OF TX)
Tx: IM benzathine penicillin G
VDRL titers at 3,6, and 12 months
TERTIARY REQUIRES IV THERAPY

o
o

HPV
o Warts (6,11), cancer (16,18)
o Condyloma accuminata (warts)
Tx cautery, chemical tx
o Cervical dysplasia/cancer
Chancroid
o Hemophilus ducreyi
o Single or multiple DEEP PAINFUL ulcers with
irregular/ragged border
o Lymph nodes can suppurate/rupture
Lymphogranuloma venereum
o Chlamydia trachomatis
o Painless ulcers and inguinal/femoral LAD painful BUBOES
o FISTULAS/ABSCESS if not treated
Granuloma inguinale
o Beefy appearing ulcers with bleeding
o Donovan bodies

MALIGNANCY
*uterine fibroids
Sxs = abnormal bleeding, dysmenorrhea, pressure (urinary
incontinence, retention, hydronephrosis, constipation), infertility,
IRREGULARLY enlarged uterus

Growth promoted by estrogen grow in pregnancy, stop growing

in menopause
Risk factors AFRICAN AMERICANS, family hx, obesity
DX = TRANSVAGINAL/ABDOMINAL US, CT, MRI
Tx = OCP, GnRH agonists (limited duration), hysterectomy,
myomectomy (IMPROVE FERTILITY), endometrial ablation, uterine
artery embolization

*endometrial cancer
Unopposed estrogen: chronic anovulation, PCOS, obesity,
tamoxifen, granulosa theca cell tumors, nulliparity
Sxs = intermenstrual/heavy prolonged bleeding in women AGE
OVER 35
o Premenopausal should get ENDOMETRIAL BIOPSY
(postmenopausal women can start with transvaginal US
then get biopsy endometrial stripe <5mm is normal)
Dx = endometrial sampling/pelvic ultrasound only in
postmenopausal (thickness > 5mm = needs sampling)
GRADE is most important prognostic factor!
Tx:
o Endometrial hyperplasia WITHOUT ATYPIA PROGESTINS
o Endometrial hyperplasia WITH ATYPIA HYSTERECTOMY,
progestins (if want to get pregnant)
*cervical cancer
Screening women 21-65
o Every 3 years with cytology
o Every 5 years with cytology and HPV cotest from 30-65
years of age
Abnormal pap test
o ASCUS
Women age 21-24: ASCUS or LSIL (low grade
squamous intraepithelial lesion) REPEAT PAP SMEAR
IN 1 YEAR
Colpsocopy not done until ASC on 3
consecutive pap smears
Women >25 yrs = HPV testing
HPV positive colposcopy and biopsy of
abnormal findings
HPV negative repeat pap AND HPV in 1 year
o LSIL, HSIL colposcopy and biopsy
If HSIL with negative biopsy LEEP/cold knife cone
for diagnosis and treatment
LSIL in women >25

HPV negative repeat pap test in 12 months

HPV positive - colposcopy
CIN 1 close observation and repeat cytology
CIN 2
Women <30 managed with observation
Women > 30 excision
CIN 3 excision
PREGNANT WOMEN!
o More conservative most HGSIL will regress spontaneously
o HGSIL get colposcopy
Negative repeat pap smear and colpscopy at least
6 weeks after delivery
CIN 2 or 3 repeat cytology and biopsy (not more
frequent than every 12 weeks)
After ablative/excisional method, pap tests EVERY 6 MONTHS
FOR 2 YEARS
Risk factors:
o More than 1 sexual partner
o First intercourse at early age (<18)
o Smoking
o HIV
o Organ (kidney) transplant

*ovarian masses evaluate with US

CYST
o Follicular cyst
Unilateral tenderness with mobile adnexal mass
US shows unilocular mass without thick septations
o Theca lutein cyst
Seen in pregnancy or conditions with elevated hCG
Bilateral
Resolve spontaneously
BENIGN NEOPLASMS
o EPITHELIAL CELL TUMOR
Serous cystadenoma
Treat surgically
Mucinous cystadenoma
Can get really big, multilocular septations on
US
Treat surgically
Endometrioid
Brenner
Postmenopausal

 Bladder transitional epithelium

o GERM CELL TUMOR
Most common = cystic teratoma
BILATERAL
Predisposes to torsion surgical removal
o STROMAL CELL TUMOR
Granulosa theca precocious puberty,
postmenopausal bleeding
Sertoli leydig virilization/hirsutism
Ovarian fibroma
MEIGS SYNDROME ovarian fibroma, ascites,
right pleural effusion
MALIGNANT NEOPLASMS
o Risk factors = age, BRCA1/BRCA2, Lynch syndrome,
endometriosis
o Protection = OCP
o CA 125 used to monitor therapy
o Mucinous/serous cystadenocarcinoma
Serous cystadenocarcinoma psamomma bodies
(concentric calcification)
o Endometrioid
endometriosis
o Dysgerminoma
hCG/alpha fetoprotein production
UNILATERAL
o Immature teratoma (dermoid cyst)
hCG/alpha fetoprotein production
unilateral
o Endodermal sinus/yolk sac tumor
hCG/AFP production
*vulvar disease
lichen simplex chronicus
o chornic irritant or contact dermatitis
o chronic scratching/irritations excoriations and epidermal
thickening, hyperplasia, inflammation
labia/perineum erythematous areas with
hyperpigmented plaques (dark and leathery)
o tx = oral antihistamines, topical steroids
biopsy of any lesion that persists >3 months!
LICHEN SCLEROSUS
o Associated with SQUAMOUS CELL CARCINOMA
o White onion skin/parchment epithelium

o Intense vulva pruritus, dyspareunia, bleeding with minimal

trauma
o Dx PUNCH BIOPSY
o Tx topical steroids
LICHEN PLANUS
o Associated with meds (beta blockers, ACEi, NSAIDs)
o Intense pruritus, burning, pain, dyspareunia, vaginal
discharge
o Shiny violaceous papules and desquamative ulcers on
vulva
o Scarring/shrinking of involved areas
o Dx = biopsy hyperkeratosis with basal layer destruction
o Tx = topical steroids
*breast
Palpable breast mass
o <30 years = US
simple cyst needle aspiration
complex cyst/mass image guided core biopsy
o >30 years = mammogram + US
suspicious for malignancy - core biopsy
screening
o yearly mammography age 50-75
o INHERITED GENETIC MUTATIONS: MRI recommended as
supplement to mammography
Screening starts at age 25 or 5-10 years before
diagnosis in youngest 1st degree relative
STERILIZATION
*male: vasectomy
Not immediately effective multiple ejaculations required to
empty proximal collecting system
*female
Laparoscopy
o Electrocautery
o Hysteroscopy ESSURE rod in device causes
inflammation and tubal occlusion over time AT LEAST 3
MONTHS
REPRODUCTIVE TRACT ANOMALIES
*embryology
Mullerian ducts upper vagina, cervix, uterus and fallopian tubes
Genital ridge OVARIES (not from mullerian ducts!!)
Urogenital diagphragm lower 1/3 of vagina

*mullerian anomaly
Mullerian agenesis
o Normal ovaries
Unicornate uterus
Uterine didelphys
o Failure of fusion of paramesonephric ducts 2 separate
uterine bodies
Bicornate uterus
Septate uterus
Arcuate uterus
*androgen insensitivity syndrome
Male karyotype female phenotype (breast development but NO
PUBIC HAIR)
Lack of wolffian system development b/c no androgen effect
Lack of mullerian development b/c mullerian inhibiting factor
Undescended testes surgical removal

OBSTETRICS
*general
Naegeles rule:

o EDD: add one year, subtract 3 months and add 7 days to

last menstrual period
CI vaccines in pregnancy: any live virus vaccines (MMR, nasal
influenza)

*maternal
CV
o
o
o
o
o

fetal physiology

Blood volume increases by 50% - systolic ejection murmur

CO increases
Decrease in SVR
Pulse increases
IVC SYNDROME preggo woman gets dizzy after standing
due to decreased venous return (compression of IVC by
uterus)
Respiratory
o Greater oxygen consumption
o Reduction in residual volume and functional residual
capacity (compression by uterus)
o Increase in minute ventilation and tidal volume
RESPIRATORY ALKALOSIS
Hematologic
o PHYSIOLOGIC ANEMIA plasma volume increased more
than red cell mass
o RISK FOR THROMBOEMBOLISM lasts for 6 weeks
postpartum
GI
o Decreased gallbladder contractility
GALLSTONES/CHOLESTASIS
o Intrahepatic cholestasis of pregnancy itching elevated
bile acid concentrations
Increased risk of stillbirth

*antepartum care
Diagnosing pregnancy
o Goodell sign cervix softens, Chadwick sign vagina blue
discoloration
o Serum beta hCG
o Ultrasound: abdominal see gestational sac @ hCG 5000,
tranvaginal see gestational sac @ hCG 1500
Folic acid
o 0.4mg daily
o 4mg if prior open neural tube defect
Screening tests

o 1st trimester screen: nuchal translucency, pregnancy

associated plasma protein A, beta hCG
o 2nd trimester screen: triple (AFP, estriol, hCG)/quad screen
(+inhibin)
trisomy 21: increased inhibin A + beta hCG,
decreased estriol + AFP
trisomy 18: decreased everything
increased AFT incorrect dates, NTD, abdominal wall
defect, multiple gestations
o 10-13 weeks chorionic villus sampling
o >15 weeks amniocentesis
o >18 weeks percutaneous umbilical blood
sampling/cordocentesis
o GESTATIONAL DIABETES (24-28 weeks):
First glucose challenge test with 50g oral load
Glucose tolerance test + fasting glucose
3hr GTT with 100g
2hr GTT with 75g
o GBS @ 35-37 weeks
o RHOGAM for Rh women @ 28-30 weeks
*chromosomal disorders
Trisomy 21 (down)
o Congenital heart disease, duodenal atresia, renal
abnormalities, short long bones
o Most due to nondisjunction
Trisomy 18 (Edwards)
o Diaphragmatic hernia, renal malformations, IUGR, severe
MR
Trisomy 13 (patau)
o Holoprosencephaly, cleft lip/palate, omphalocele, heart
defects
Turner syndrome
o Cystic hygroma and lymphedema, coarctation of aorta,
bicuspide aortic valve, streak ovaries, short stature
*teratogens
Warfarin
Phenytoin microcephaly, cleft lip/palate, abnormal facies
Valproic acid spina bifida, neural tube defects
Lithium cardiovascular malformations - EBSTEIN ANOMALY
Quinolones cartilage erosion
Tetracyclines teeth discoloration
SSRI paroxetine VSD/ASD
ACEi growth restrtiction

Thiazide bleeding
Vitamin A/retinoids fetal loss
Alcohol growth restriction, microcephaly, low set ears,
shortened palpebral fissures, smooth philtrum, thin upper lip

*gestational diabetes
Get screening at 24-28 weeks 1hr 50g glucose tolerance test
o Abnormal results = glucose >140
Get 3hr 100g glucose tolerance test
Fasting <95, 1hr <140, 2hr <120
Tx: INSULIN, metformin/glyburide can also be used
Fetal hyperglycemia:
o POLYCYTHEMIA (increased metabolic demand increased
erythropoeisis)
o Organomegaly
o Macrosomia should dystocia brachial plexaopathy,
clavicle fracture, perinatal asphyxia
o Neonatal hypoglycemia
o RESPIRATORY DISTRESS SYNDROME
o Polyhydramnios
Pregestational diabetes: sacral agenesis/caudal
regression, transposition of the great vessels, small left
colon syndrome (transient inability to pass meconium
resolves spontaneously)
Maternal complications: pre eclampsia, hypertension
DELIVER BY 39 WEEKS
o C section if fetal weight >4,500g
*HTN in pregnancy
CHRONIC HTN
o Onset before 20 weeks gestation
GESTATIONAL HTN
o HTN onset after 20 weeks gestation WITHOUT proteinuria
PRE-ECLAMPSIA
o HTN (>140/90) after 20 weeks gestation WITH
PROTEINURIA (>300g on 24hr specimen)
o Risk factors: pregestational diabetes, obesity, AMA
o Findings:
Pulmonary edema, cyanosis, hypoxia
RUQ pain (subcapsular hematoma or stretching of
liver capsule)
Oliguria
Hepatic dysfunction

 Thrombocytopenia
IUGR
o managementL
FUTURE PLACEMENT:
*asymptomatic bacteriuria in pregnancy
increased risk of UTIs due to progesterone causing smooth
muscle relaxation and ureteral dilation
TREAT! With abx
o Reduces risk of preterm birth, low birth weight, and
perinatal mortality
o Recommended abx = amoxicillin, amoxicillin-clavulanate,
nitrofurantoin, cephalexin
o CI = tetracyclines, fluoroquinolones, tmp-smx
*PCOS
Symptoms: oligomenorrhea/amenorrhea, acne, hirsutism,
infertility
Criteria: oligo/anovulation, biochemical/clinical evidence of
hyperandrogenism, polycystic ovaries on US
Pathophys: INCREASED LH
Impaired glucose tolerance hyperinsulinemia, diabetes
Tx:
o Exercise and weight loss!
o OCPs prevents endometrial hyperplasia
o Metformin
o Clomiphene citrate for ovulation
*mammary paget disease:
-persistent, eczematous, ulcerating rash localized to nipple and
spreads to areola
-vesicles, scales, bloody discharge, nipple retraction
-pain, itching, burning of affected nipple no resolution with topical
steroids
-UNDERLYING BREAST CANCER ADENOCARCINOMA
*intraductal papilloma
-unilateral bloody nipple discharge
-no palpable mass or lymphadenopathy
*benign breast disease
Breast cyst
o Solitary well circumscribed mobile mass
o May be tender
Fibrocystic changes

o Multiple diffuse nodulocystic masses

o Cyclic premenstrual tenderness
Fibroadenoma
o Solitary mobile well circumscribed mass
o Cyclic premenstrual tenderness
Fat necrosis
o Breast surgery or trauma
o Fixed mass with possible skin/nipple retraction
o Calcifications on mammography/hyperechoic mass on US
o Biopsy = FAT GLOBULES AND FOAMY HISTIOCYTES
o Entire mass often excised even though its benign

*management of endometrial hyperplasia

Endometrial biopsy
o Hyperplasia without atypia PROGESTIN THERAPY
Repeat endometrial biopsy in 3 months to assess
response
o Hyperplasia with atypia
Considering future pregnancy PROGESTIN THERAPY
No plans for pregnancy/fails medical management
HYSTERECTOMY
Dont do endometrial ablation! Prevents future evaluation of
endometrium by biopsy
*vaginal cancer
Clinical features:
o Malodorous vaginal discharge
o Postmenopausal/postcoital vaginal bleeding
o Irregular mass, plaque or ulcer on vagina
Diagnosis = BIOPSY
Squamous cell
o Age >60
o Risk factors: HPV 16/18, hx of cervical dysplasia or cancer,
cigarettes
o Location: upper 1/3 of posterior vaginal wall
Clear cell adenocarcinoma
o Age <20
o Risk factor = in utero exposure to DES (diethylstilbestrol)
o Location = upper 1/3 of anterior vaginal wall
*gynecomastia
Puberty
increased estrogen production/peripheral conversion

*hiv

o testicular, adrenal or hCG secreting tumors

o cirrhosis/malnutrition
o thyrotoxicosis
o congenital excessive aromatase activity
o androgen use - steroids
o drugs - spironolactone, cimetidine
o herbal products tea tree oil, lavendar oil
androgen deficiency
o klinefeleter syndrome (INCREASED RISK OF BREAST
CANCER!)
o hyperprolactinemia
o renal failure
during pregnancy
start ART as soon as possible
Zidovudine postpartum to infant for 6 weeks after delivery
Intrapartum: if HIV RNA >1000 copies or unknown, give IV
ZIDOVUDINE 3 hours before C section