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KRITERIA MEDIS OBGYN

Syndromes or Disease Entities That Have Been Associated with Polycystic Ovaries
Hyperandrogenism o Steroidogenic enzyme deficiencies Congenital adrenal hyperplasia Aromatase deficiency o Androgen-secreting tumors Ovarian Adrenal o Exogenous androgens Anabolic steroids Transsexual hormone replacement o Other Acne Idiopathic hirsutism Hyperandrogenism and Insulin Resistance o Congenital Type A syndrome Type B syndrome Leprechaunism Lipoatrophic diabetes Rabson-Mendenhall syndrome Polycystic ovary syndrome o Acquired Cushing's syndrome Insulin Resistance o Glycogen storage diseases o Type 2 diabetes Other o Central nervous system Trauma/lesions Hyperprolactinemia o Nonhormonal medications Valproate o Heriditary angioedema o Bulimia

dr. Justisiani Fatira

Syndromes or Disease Entities That Have Been Associated with Polycystic Ovaries............................................................1 Diagnostic Criteria in Polycystic Ovary Syndrome (PCOS)....................................................................................... 3 Amsel's Diagnostic Criteria for Bacterial Vaginosis.............5 CDC Diagnostic Criteria for the Diagnosis of Pelvic Inflammatory Disease (PID)................................................................... ....................... 5 2001 Bethesda System Terminology.......................................7 ACR/BI-RADS Breast Imaging Reporting and Data System...................................... .............................................. ..10

Idiopathic (includes normoandrogenic women with cyclic menses)

Diagnostic Criteria in Polycystic Ovary Syndrome (PCOS)


Revised diagnostic criteria of PCOS 1999 criteria (both 1 and 2) 1. Chronic anovulation 2. Clinical and/or biochemical signs of hyperandrogenism, and exclusion of other aetiologies

References: 1. The Rotterdam ESHRE/ASRM-Sponsored PCOS consensus workshop group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome (PCOS). Hum Reprod. 2004 Jan;19(1):41-7. [Medline] Legro R. Diagnostic Criteria in Polycystic Ovary Syndrome. Semin Reprod Med. 2003 Aug;21(3):267-75 [Medline] Reaven G. The metabolic syndrome or the insulin resistance syndrome? Different names, different concepts, and different goals. Endocrinol Metab Clin North Am. 2004 Jun;33(2):283-303. [Medline]

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Revised 2003 criteria (2 out of 3) 1. Oligo- and/or anovulation 2. Clinical and/or biochemical signs of hyperandrogenism 3. Polycystic ovaries and exclusion of other aetiologies (congenital adrenal hyperplasias, androgen-secreting tumours, Cushings syndrome)

Other Proposed Diagnostic Criteria in Polycystic Ovary Syndrome 1. Inappropriate gonadotropin secretion a) Elevated LH-to-FSH ratio b) Abnormal response to GnRH agonist testing 2. Hyperandrogenism a) Hirsutism, androgenic alopecia, acne b) Hyperandrogenemia I. Total testosterone II. Free testosterone (free androgen index, etc.) 3. Ovarian appearance a) Polycystic-appearing ovaries b) Increased (stromal) size 4. Insulin resistance a) Acanthosis nigricans b) Fasting measures of insulin/glucose c) Oral glucose tolerance test d) Dynamic tests of insulin sensitivity I. Euglycemic II. Frequently sampled intravenous glucose tolerance test 5. Chronic anovulation a) Self-reported history b) Tests of ovulatory function I. Basal body temperature charting II. Urinary LH testin

III. IV.

Serum progesterone measurement Endometrial biopsy

Amsel's Diagnostic Criteria for Bacterial Vaginosis


Three of four criteria must be met; establishes accurate diagnosis of bacterial vaginosis in 90 percent of affected women. y y y y Homogeneous vaginal discharge (color and amount may vary) Amine (fishy) odor when potassium hydroxide solution is added to vaginal secretions (commonly called the "whiff test") Presence of clue cells (greater than 20%) on microscopy* Vaginal pH greater than 4.5

FSH, follicle-stimulating hormone; GnRH, gonadotropin-releasing hormone; LH, luteinizing hormone. References: 1. The Rotterdam ESHRE/ASRM-Sponsored PCOS consensus workshop group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome (PCOS). Hum Reprod. 2004 Jan;19(1):41-7. [Medline] Legro R. Diagnostic Criteria in Polycystic Ovary Syndrome. Semin Reprod Med. 2003 Aug;21(3):267-75 [Medline] Reaven G. The metabolic syndrome or the insulin resistance syndrome? Different names, different concepts, and different goals. Endocrinol Metab Clin North Am. 2004 Jun;33(2):283-303. [Medline]

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* Highly significant criterion. References: 1. 2. Egan ME, Lipsky MS. Diagnosis of vaginitis. Am Fam Physician. 2000 Sep 1;62(5):1095-104. [Medline] Amsel R, Totten PA, Spiegel CA, Chen KC, Eschenbach D, Holmes KK. Nonspecific vaginitis. Diagnostic criteria and microbial and epidemiologic associations. Am J Med. 1983 Jan;74(1):14-22. [Medline]

CDC Diagnostic Criteria for the Diagnosis of Pelvic Inflammatory Disease (PID) Minimal criteria* y y y Lower abdominal tenderness Uterine/adnexal tenderness Cervical motion tenderness

Additional criteria y y Oral temperature > 38.3C (101F) Abnormal cervical or vaginal mucopurulent discharge

y y y y

Presence of white blood cells (WBCs) on saline microscopy of vaginal secretions Elevated erythrocyte sedimentation rate Elevated C-reactive protein level Laboratory documentation of cervical infection with Neisseria gonorrhoeae or Chlamydia trachomatis

2001 Bethesda System Terminology


Specimen Type: Indicate conventional smear (Pap smear) vs. liquid based vs. other Specimen Adequacy o Satisfactory for evaluation (describe presence or absence of endocervical/transformation zone component and any other quality indicators, e.g., partially obscuring blood, inflammation, etc.) o Unsatisfactory for evaluation ... (specify reason) o Specimen rejected/not processed (specify reason) o Specimen processed and examined, but unsatisfactory for evaluation of epithelial abnormality because of (specify reason) General Categorization (optional) o Negative for intraepithelial lesion or malignancy o Epithelial cell abnormality: See interpretation/result (specify squamous or glandular as appropriate) o Other: See interpretation/result (e.g. endometrial cells in a woman > 40 years of age) Automated Review If case examined by automated device, specify device and result. Ancillary Testing Provide a brief description of the test methods and report the result so that it is easily understood by the clinician. Interpretation/Result Negative for Intraepithelial Lesion or Malignancy (when there is no cellular evidence of neoplasia, state this in the General Categorization above and/or in the Interpretation/Result section of the report, whether or not there are organisms or other non-neoplastic findings) Organisms: y Trichomonas vaginalis y Fungal organisms morphologically consistent with Candida species y Shift in flora suggestive of bacterial vaginosis y Bacteria morphologically consistent with Actinomyces species. y Cellular changes consistent with Herpes simplex virus Other non neoplastic findings (Optional to report; list not inclusive): y Reactive cellular changes associated with

Definitive criteria y y Histopathologic evidence of endometritis on endometrial biopsy Transvaginal sonography or magnetic resonance imaging techniques showing thickened, fluid-filled tubes with or without free pelvic fluid or tubo-ovarian complex Laparoscopic abnormalities consistent with PID

PID, pelvic inflammatory disease * Empiric treatment is indicated in sexually active women considered at risk for PID if all three findings are present. References: 1. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2002.MMWR 2002;51(No. RR6):48-52

y y Other y

y inflammation (includes typical repair) y radiation y intrauterine contraceptive device (IUD) Glandular cells status post hysterectomy Atrophy

Educational Notes and Suggestions (optional) Suggestions should be concise and consistent with clinical follow-up guidelines published by professional organizations (references to relevant publications may be included).

Endometrial cells (in a woman > 40 years of age) (Specify if negative for squamous intraepithelial lesion)

References: 1. Solomon D, Davey D, Kurman R, Moriarty A, O'Connor D, Prey M, Raab S, Sherman M, Wilbur D, Wright T Jr, Young N; Forum Group Members; Bethesda 2001 Workshop. The 2001 Bethesda System: terminology for reporting results of cervical cytology. JAMA. 2002 Apr 24;287(16):2114-9. [Medline]

Epithelial Cell Abnormalities SQUAMOUS CELL y Atypical squamous cells (ASC) y of undetermined significance (ASC-US) y cannot exclude HSIL (ASC-H) y Low grade squamous intraepithelial lesion (LSIL) encompassing: HPV/mild dysplasia/cervical intraepithelial neoplasia (CIN) 1 y High grade squamous intraepithelial lesion (HSIL) encompassing: moderate and severe dysplasia, carcinoma in situ (CIS)/CIN 2 and CIN 3 y with features suspicious for invasion (if invasion is suspected) y Squamous cell carcinoma GLANDULAR CELL y Atypical y endocervical cells (NOS or specify in comments) y endometrial cells (NOS or specify in comments) y glandular cells (NOS or specify in comments) y Atypical y endocervical cells, favor neoplastic y glandular cells, favor neoplastic y Endocervical adenocarcinoma in situ (AIS) y Adenocarcinoma y endocervical y endometrial y extrauterine y not otherwise specified (NOS) Other Malignant Neoplasms: (specify)

ACR/BI-RADS Breast Imaging Reporting and Data System


BI-RADS Category Assessment 0 1 2 3 Assessment incomplete Negative Benign finding Clinical Management Recommendation(s) Need to review prior studies and/or complete additional imaging Continue routine screening Continue routine screening

Probably benign finding Short-term follow-up mammogram at 6 months, then every 6 to 12 months for 1 to 2 years Suspicious abnormality Perform biopsy, preferably needle biopsy

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Highly suspicious of Biopsy and treatment, as necessary. malignancy; appropriate action should be taken. Known biopsy-proven malignancy, treatment pending Assure that treatment is completed

References: 1. Liberman L, Menell JH. Breast imaging reporting and data system (BI-RADS). Radiol Clin North Am May 2002; 40: 409-30. [Medline] Eberl MM, Fox CH, Edge SB, Carter CA, Mahoney MC.BI -RADS classification for management of abnormal mammograms. J Am Board Fam Med. 2006 Mar-Apr;19(2):161-4. [Medline]

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