other

A 24-year-old woman presents to the emergency department with sudden onset of right-sided pelvic pain associated with nausea. Vital signs are T of 97.8°F, HR of 85 bpm, BP of 132/84 mm Hg, and RR of 20/min and have been stable during the patient's 4 hours in the emergency department. Physical exam reveals no vaginal bleeding but there is right-sided adnexal tenderness during bimanual exam. Pregnancy test is negative. Hemoglobin is 12.5 g/dL. Pelvic ultrasound reveals a right-sided 4 cm ovarian cyst with mild to moderate surrounding blood in the pelvis. The patient's pain is improved following intravenous ketorolac. Which of the following is the best management?

discharge with pain control

Endometriosis

is a nonmalignant condition characterized by the presence of endometrial glands and stroma outside of the uterine cavity that implant, grow, and elicit an inflammatory response. It is an estrogen-dependent disease that most commonly affects women between 25 and 35 years of age. While the ovaries are the most common site of endometriosis, other sites such as the anterior and posterior cul-de-sac, posterior broad ligaments, uterosacral ligaments, uterus, fallopian tubes, bladder, sigmoid colon, appendix, and round ligaments are commonly affected. The vagina, cervix, cecum, ileum, inguinal canal bladder, ureters, and umbilicus are less commonly affected

A diaphragm

is a shallow silicone cup that should be inserted less than 1 hours prior to intercourse up to 6 hours before intercourse and must be kept in place for at least 6 hours after intercourse. If it is placed more than 1 hour before intercourse, another applicator full of spermicide or vaginal pH regulator gel needs to be inserted into the vagina for maximum effect.

Rape

is a specific type of sexual assault that encompasses nonconsensual vaginal, oral, or anal penetration by a penis, finger, or object. Sexual assault is most common in young women between 16 and 24 years of age, with 80% of victims experiencing their first assault before 24 years of age. The majority of cases of sexual assault are committed by a perpetrator who is known to the victim

Ethinyl estradiol and norelgestromin patch

is a transdermal hormonal contraceptive containing estrogen and progesterone (combined hormonal contraceptive). The benefits to the combined hormonal patch are that it is highly effective and reversible and does not require taking a pill every day. The serum concentration of the patch is also not affected by other medications, such as antibiotics and anticonvulsants, because it does not undergo first-pass metabolism. The contraindications are similar to other methods of combined hormonal contraceptives and include history of thromboembolism, history of an estrogen-dependent tumor, abnormal liver function testing, and individuals with a body mass index ≥ 30 kg/m2. There is likely a higher risk of thromboembolism in women on a combined hormonal contraceptive patch compared to the risk seen in women taking combined hormonal contraceptive pills. This increased risk is because the average serum estrogen concentration is higher in women on a combined hormonal contraceptive patch compared to the serum estrogen concentration in women taking a combined hormonal contraceptive pill. The U.S. Food and Drug Administration issued a black box warning against the ethinyl estradiol and norelgestromin patch because of the increased risk of thromboembolism. The most common adverse effects associated with the transdermal patch are unscheduled bleeding during the first few cycles, breast tenderness, and application site reactions. The adverse effect profile is generally well tolerated and often improves within 3-6 months of use. The ethinyl estradiol and norelgestromin patch is applied weekly for 3 consecutive weeks prior to a patch-free week. The patch can be applied to the buttock, abdomen, or upper torso, and a different site should be used each time a new patch is applied. The patch can be reapplied if it is accidentally detached for < 24 hours. If it is detached for more than 24 hours, a new patch should be applied.

Intimate partner violence

is common and may manifest as psychological, physical, or sexual violence. Sexual and physical violence are particularly underreported. Risk factors for intimate partner violence include female sex, alcohol or drug use, lower education level, and a family history of violence.

Screening for intimate partner violence

is generally recommended for women presenting to a primary care clinician or obstetrics and gynecology office for the first time. Furthermore, women are routinely screened when presenting to the emergency department or being admitted to the hospital. Acknowledgment, the expression of empathy, and close follow-up are some of the most important interventions when a patient discloses intimate partner violence. There are often hospital or community domestic violence advocates, hospital social workers, or local domestic violence hotlines that can offer help to patients. Documentation is important, in case the patient seeks to file legal charges. The documentation should include quotes from the patient regarding the nature and timing of abuse, quotes that identify the perpetrator, physical exam findings, and photographs of physical injuries after obtaining the patient's signed consent. However, patients have the right to request that information regarding intimate partner violence not be included in their chart. It is important for clinicians to be aware of state and country laws regarding situations where reporting is mandated. Common examples of situations that must be reported include abuse of disabled or older persons, weapon use, and abuse involving children.

A 30-year-old nulliparous woman presents with dysmenorrhea, dyschezia, and dyspareunia. On exam, you note a retroverted uterus and a palpable adnexal mass. Which of the following is needed for the definitive diagnosis of the suspected disorder?

laporoscopy and bx

What are common adverse effects of clomiphene citrate?

Hot flashes, abdominal distention and pain, nausea and vomiting, and breast discomfort.

PCOS

. PCOS is an endocrine disorder due to insulin resistance, which leads to an increase in LH and therefore an increase in ovarian androgen production. Obesity is the most common risk factor. Patients with PCOS typically present with three clinical findings: 1) irregular menstrual periods, 2) insulin resistance, and 3) signs of increased androgen production, such as hirsutism and acne. Labs would be significant for elevated testosterone and increased LH:FSH ratio greater than or equal to 3:1. A pelvic ultrasound would note bilateral enlarged ovaries with peripheral cysts, commonly referred to as "string of pearls" sign. There is no single treatment that will resolve PCOS, rather, treatment focuses on managing the patients presenting symptoms. Metformin can be used to help improve insulin resistance. Combination oral contraceptive pills can help normalize menstruation cycles. Spironolactone can be used to decrease testosterone and therefore be used as an anti-androgenic agent for hirsutism. Lastly, lifestyle changes, such as diet, exercise, and weight loss, can also improve the patient's symptoms.

There is a 52 mg levonorgestrel-releasing intrauterine 32 x 32 mm T-shaped device that is effective for up to

5 years. It is the only device approved by the Food and Drug Administration to treat menorrhagia (heavy menstrual bleeding). It may also reduce dysmenorrhea

A 32-year-old G3P2 woman presents to the office complaining of heavy menstrual bleeding. Menarche occurred at 12 years of age, and she reports a history of regular menses every 28 days since. After the birth of her second child, her menses were regular, but she now reports heavy menstrual bleeding. She is able to fill a super maxi pad every 2 hours. Her last Pap smear was performed 6 months ago and was normal. Transvaginal ultrasound reveals an 8 cm uterus with a 6 mm endometrial stripe. There are no uterine fibroids. Ovaries are normal and there are no adnexal masses. She is interested in a low-maintenance treatment that will prevent heavy bleeding or one that would cause menses to cease altogether. She is not interested in endometrial ablation or hysterectomy at this time since she is unsure whether she desires to preserve childbearing potential for the future. Which of the following clinical therapeutics is the most appropriate option?

52 mg levongesterol releasing intrauterine device

Patients with suspected ovarian cyst rupture must have other important diagnoses ruled out. other dx

A pregnancy test should be obtained in all women of reproductive age with lower abdominal pain to rule out an ectopic pregnancy or other pregnancy-related complication. The best imaging modality to assess for an ovarian cyst is a pelvic ultrasound. The ultrasound can identify and characterize ovarian cysts and can show serous fluid or blood in the pelvis if a cyst has ruptured. The classic ultrasound finding suggestive of cyst rupture is an ovarian cyst with surrounding fluid in the pelvis. The hemoglobin level should be assessed in patients with a suspected ruptured cyst but may be falsely normal initially since patients hemorrhaging lose whole blood. The hemoglobin does not drop until the volume loss of the blood is replenished.

A 28-year-old woman who is morbidly obese presents to her primary care office with reports of irregular menstrual periods. On physical exam, there is increased hair growth to her upper lip, jawline, and abdomen. Her most recent labs are consistent with an elevated hemoglobin A1C, elevated LH, and elevated testosterone. Which of the following would most likely be found on this patient's pelvic ultrasound?

string of pearls sign

What is a theca lutein cyst?

An ovarian cyst that results from overstimulation by beta-human chorionic gonadotropin, such as occurs during molar pregnancy, multiple gestation, or clomiphene therapy.

A 40-year-old woman presents to the clinic for her annual Pap test. On bimanual exam, right adnexal fullness is noted. Transvaginal ultrasound reveals a pedunculated mass near the right ovary that is attached to the uterus by a stalk of tissue. On surgical removal, this mass is determined to be a uterine leiomyoma. Which of the following classifications of leiomyoma is it?

subserosal myoma

A 30-year-old woman presents to the clinic complaining of infertility. She says she has had painful menses and pain with intercourse for years. Transvaginal ultrasound shows a left-sided ovarian cystic mass with homogeneous low-medium-level echoes. Which of the following exam findings supports the most likely diagnosis?

tenderness in the posterior vaginal fornix

Which two organs is the anterior cul-de-sac between?

the bladder and uterus

What is a serious complication of venous compression due to large uterine leiomyomatous disease?

venous thromboembolism

Categories 1-4

Category 1 indicates a condition where there is no restriction. Category 2 indicates a condition where contraceptive advantages typically outweigh theoretical or established risks. Category 3 indicates a condition where theoretical or established risks typically outweigh the contraceptive advantages. Category 4 indicates a condition where the health risks of contraceptive use are unacceptable.

Uterine Fibroids (Leiomyoma)

Common during reproductive-ages Menorrhagia and dysmenorrhea PE will show a enlarged, asymmetric, and nontender uterus Diagnosis is made by pelvic ultrasound Majority do not require surgical or medical treatment Severe cases: myomectomy (fertility can be preserved) or hysterectomy

Uterine Fibroids (Leiomyoma) rapid review

Common during reproductive-ages Menorrhagia and dysmenorrhea PE will show a enlarged, asymmetric, and nontender uterus Diagnosis is made by pelvic ultrasound Majority do not require surgical or medical treatment Severe cases: myomectomy (fertility can be preserved) or hysterectomy

Which class of nonsteroidal anti-inflammatory drugs should be avoided in patients with endometriosis who desire conception?

Cyclooxygenase-2 inhibitors (e.g., celecoxib, rofexocix, valdecoxib).

infertility is defined as

a couple not being able to conceive after 12 months of frequent intercourse without contraception. In women over 35 years of age, the required time for an infertility diagnosis is reduced to 6 months. Overall, 80-90% of couples conceive within 12 months of attempting pregnancy.

Peritoneal factor, or endometriosis, is associated with

anovulation, adhesions, and interference of fertilization. It should be suspected in patients with dysmenorrhea, dyspareunia, and dyschezia. Laparoscopy is diagnostic and therapeutic for peritoneal factor and tubal dysfunction

True or false: the absence of an ovarian cyst on ultrasound rules out ovarian cyst rupture.

False, ovarian cysts may collapse following cyst rupture. However, the absence of an ovarian cyst makes the diagnosis less likely.

What is the medical term for the probability of achieving a pregnancy within one menstrual cycle?

Fecundability.

Treatment options for leiomyomas depend on whether the patient desires fertility or not.

For patients who desire fertility, the first-line treatment for heavy menstrual bleeding associated with resectable leiomyomas is hysteroscopic resection of the fibroid. Pharmacologic therapy is targeted toward reducing bleeding and does not decrease fibroid size. Combined estrogen-progestin contraceptives, a progestin-releasing intrauterine device, and tranexamic acid are considered first-line pharmacologic agents. Intrauterine devices can be used in patients whose uterus size is between 6 and 10 cm and without a large submucosal component. Second-line treatments include gonadotropin-releasing hormone agonists and antagonists and uterine artery embolization, both of which decrease fibroid size and reduce bleeding. For patients desiring fertility, myomectomy is the first-line treatment. Depending on the location, a hysteroscopic, laparoscopic, or open abdominal myomectomy may be performed. Patients who do not desire fertility may be treated with a hysterectomy.

Intrauterine devices prevent pregnancy by a number of methods.

For the devices that release levonorgestrel, this medication thickens cervical mucus, preventing sperm from reaching the egg. There are many benefits of intrauterine devices. They provide immediate contraception, allow for immediate conception once removed, and may be considered in populations where estrogen use is contraindicated, including women with a history of seizures, blood clotting disorders, breast cancer, or tobacco use. Condoms should be recommended since intrauterine devices do not prevent sexually transmitted infections. There are a few contraindications for intrauterine devices. Any structural abnormality of the uterus should be evaluated prior to insertion. Intrauterine devices are contraindicated in patients with a bicornuate uterus, septate uterus, uterine fibroids, and cervical stenosis. Patients with current fibroids or a history of fibroids should be counseled prior to intrauterine device insertion. Additional contraindications include active pregnancy and current or frequent pelvic inflammatory disease. Complications associated with intrauterine devices include device expulsion from the uterine cervix, device perforation through the uterus, and implantation of the device within the uterine wall. While these complications are rare, they should be addressed with the patient at each visit. Encouraging the patient to perform routine string checks will ensure proper placement of the intrauterine device. The risk of pelvic inflammatory disease is increased with intrauterine devices. Possible side effects of intrauterine devices include metrorrhagia or amenorrhea. Amenorrhea is often a desirable side effect for patients and viewed as a benefit of intrauterine device use. Intrauterine placement should occur at the end of menses or within 7 days after the last menstrual period. If this is not achieved, backup contraception should be used 7 days following placement. At this point in the menstrual cycle, the endometrial lining is thinner, the cervix may be more accomodating, and the uterus will not contract for another 3 weeks. Prior to intrauterine device insertion, a pregnancy test should be performed.

Which class of medications do leuprolide acetate and goserelin acetate belong to?

Gonadotropin-releasing hormone agonists.

leiomyoma dx

Laboratory testing should include a hematocrit level to check for anemia, a thyroid-stimulating hormone level to check for hypothyroidism, and a pregnancy test. A pelvic ultrasound is the first-line diagnostic study and can determine the size and location of leiomyomas. A saline infusion sonography may be ordered to determine the extent of protrusion, and a hysteroscopy is useful in the planning of surgical resection. Magnetic resonance imaging is the most expensive diagnostic modality but is useful in procedural planning for complicated leiomyomas.

Ovarian Cysts Follicular: Corpus luteum: Dermoid: Theca lutein: Endometrioid:

Ovarian Cysts Follicular: most common ovarian mass, non-neoplastic, regress spontaneously Corpus luteum: most common ovarian mass in pregnancy, non-neoplastic, regress spontaneously Dermoid: teratoma Theca lutein: bilateral, ovarian enlargement Endometrioid: endometriosis within ovary, chocolate cyst Ultrasound

ovarian cysts - what are they - MC in - MC benign ovarian cysts - important considerations when. evaluating the significance of an ovarian cyst - symptoms

Ovarian cysts are fluid-filled sacs within an ovary or on the surface of an ovary. Ovarian cysts are most common in women of reproductive age, and most ovarian cysts resolve with minimal or no symptoms. The most common benign ovarian cysts are follicular cysts or corpus luteal cysts. Important considerations when evaluating the significance of an ovarian cyst are the presence of symptoms, the size of the cyst, whether the cyst is hemorrhagic, and the overall suspicion for malignancy. Ovarian cysts are usually asymptomatic. However, cysts may rupture and cause a sudden onset of severe unilateral lower abdominal pain. Cyst rupture often occurs during sexual intercourse or strenuous activity. It is important to monitor the hemodynamic status (heart rate and blood pressure) in patients with a ruptured ovarian cyst.

Polycystic Ovary Syndrome (PCOS)

Ovulatory dysfunction, hyperandrogenism, and polycystic ovaries Common PE findings: bilateral ovarian enlargement, acanthosis nigricans, high BMI Laboratory evaluation:Oligomenorrhea: hCG, FSH, TSH, prolactinHyperandrogenism: total testosterone and sex hormone-binding globulin or bioavailable and free testosterone, morning 17-hydroxyprogesteroneMetabolic disease screening: 2-hour oral glucose tolerance test, fasting lipid panel Commonly associated with insulin resistance, which may be the central etiology Treatment is combination low-dose oral contraceptive pills, lifestyle changes, metformin Most common cause of infertilityLetrozole is first-line therapy for ovulation induction

Endometriosis

Patient presents with pre- or mid-cycle dysmenorrhea, dyspareunia, dyschezia (painful bowel movement) PE may show uterosacral nodularity or a fixed or retroverted uterus or adnexal mass Definitive diagnosis is made by laparoscopy Most common site is ovaries Tx: NSAIDs, COCs, depot medroxyprogesterone acetate, GnRH agonists, surgery

leiomyoma presentation

Patients may present with a single or multiple leiomyomas of varying sizes. Larger leiomyomas tend to cause more symptoms than smaller ones. Symptoms include heavy or prolonged menstrual bleeding, abdominal pressure or pain, reproductive dysfunction, dysmenorrhea, and dyspareunia. Larger fibroids can also cause urinary obstruction, constipation, and compression of the vena cava. Physical examination may reveal the presence of a palpable abdominal or pelvic mass or an irregular, enlarged, or mobile uterus.

PCOS

Polycystic ovary syndrome involves inappropriate release of gonadotropin-releasing hormone and testosterone by the ovaries, leading to systemic hormonal and metabolic imbalance. Risk factors for the development of polycystic ovary syndrome include obesity, type 1 or type 2 gestational diabetes mellitus, use of antiepileptic drugs, family history of polycystic ovary syndrome, a history of premature adrenarche, and oligo ovulatory infertility. Signs and symptoms of polycystic ovary syndrome include hirsutism, infertility, insulin resistance, obesity, acne, and menstrual irregularity. Laboratory analysis of serum testosterone and glycosylated hemoglobin may be elevated in these patients. Diagnosis of polycystic ovary syndrome can be made when two of the following criteria are met: physical or biochemical evidence of hyperandrogenism, oligomenorrhea or amenorrhea, and ultrasonic demonstration of multiple, bilateral simple ovarian cysts. Treatment of polycystic ovary syndrome includes oral contraceptives for estrogen and progesterone replacement or spironolactone for androgen antagonism. Patients with polycystic ovary syndrome are at increased risk for the development of endometrial cancer because anovulatory cycles cause unopposed exposure of the endometrium to estrogen. Treatment with oral contraceptives is protective of the endometrium and helps to decrease the incidence of endometrial cancer in these patients.

Which diagnostic tests are recommended immediately prior to inserting an intrauterine device?

Pregnancy testing and gonorrhea and chlamydia testing.

What is the most common cause of post-traumatic stress disorder in women?

Sexual assault.

Infertility Workup

Suitable for couples with no conception after 12 months of unprotected intercourse and female patients > 35 years with no conception after 6 months Hormonal, metabolic causes: TSH, FSH, free testosterone, DHEAS Semen analysis Ovulation causes: midcycle progesterone, LH, basal body temperature Decreased ovarian reserve: day-3 FSH Anatomic causes: hysterosalpingography, hysteroscopy, laparoscopy, ultrasound

urinary incontinence treatment

The initial treatment for women with all types of urinary incontinence includes lifestyle modifications, such as weight loss, fluid restriction to < 64 ounces daily, reduced alcohol and caffeine intake, and treatment of constipation. Pelvic floor muscle (Kegel) exercises are also recommended for women with any type of urinary incontinence. Initial treatment is recommended for 6 weeks prior to pursuing further interventions. Further treatment varies based on the underlying type of urinary incontinence. Topical vaginal estrogen is recommended in peri- or postmenopausal women with either stress or urgency incontinence and signs of vaginal atrophy. However, systemic (oral) estrogen is not recommended for the treatment of urinary incontinence. Vaginal pessaries are helpful for women with stress urinary incontinence. Patients with stress urinary incontinence who have not improved with initial interventions and vaginal pessaries should be referred for consideration of surgical intervention. Bladder training can be helpful in women with urge urinary incontinence. Bladder training is based on timed voiding and attempting to gradually prolong the intervals between voids. Pharmacologic therapy can also be helpful for women with urge urinary incontinence who have not improved sufficiently with nonpharmacologic interventions. The recommended pharmacologic agents are antimuscarinic agents, such as oxybutynin, solifenacin, darifenacin, trospium, and tolterodine, or beta-agonists, such as mirabegron. Antimuscarinic agents are generally used first. In some cases, an antimuscarinic agent is used in combination with mirabegron. Women with urge urinary incontinence who do not improve with conservative measures and pharmacologic therapy should be referred for surgical consideration.

management of ruptured ovarian cyst

The management of a ruptured ovarian cyst varies based on the patient's hemodynamic status, the amount of blood loss, and the concern for malignancy. Suspicion for malignancy is higher in postmenopausal women. Blood loss is assessed similarly to hemodynamic stability and can also be seen on the ultrasound. Hemodynamic status is assessed by symptoms of hypovolemia (lightheadedness, syncope, orthostasis), signs of hemodynamic instability (tachycardia and hypotension), and a drop in hemoglobin. Patients with low concern for malignancy and hemodynamic stability are considered to have uncomplicated ovarian cyst rupture. These patients are managed outpatient with observation. The patients should be provided with pain medication, such as nonsteroidal anti-inflammatory drugs. Symptoms related to uncomplicated ovarian cyst rupture usually resolve within a few days. Patients who are hemodynamically stable but have a large hemorrhage on ultrasound may need to be admitted for observation. This allows for close monitoring of vital signs, hemoglobin and hematocrit levels, and repeat pelvic ultrasound to monitor the bleeding. Patients who become hemodynamically unstable at any point may need surgery to stop the bleeding. Furthermore, patients admitted for observation with ongoing bleeding also require surgery.

Contraception is an important topic during the postpartum period.

This is because studies show adverse maternal, perinatal, and infant outcomes in women who become pregnant within 6 months of giving birth. It is important to consider the patient's reproductive goals, desired contraception, medical comorbidities, and breastfeeding plans. The options include sterilization (for the man or woman), hormonal contraceptives (combined or progestin-only), barrier methods, and withdrawal or abstinence. Combined hormonal contraceptives (pills, patch, or ring) are contraindicated for the first 6 weeks postpartum due to the increased risk of venous thromboembolism. Progestin-only contraceptives can be used immediately following birth and do not interfere with breastfeeding. Barrier methods, abstinence, and withdrawal do not impact breast milk supply.

A 37-year-old woman presents to the office to ask about female contraceptive barrier methods and wants to be fitted for a cervical cap or diaphragm. Which of the following is a side effect of using these devices?

UTI

Patients commonly present with

abdominopelvic pain, dysmenorrhea, and heavy menstrual bleeding. Other symptoms include dyschezia, dyspareunia, dysuria, constipation or diarrhea, nausea or vomiting, and fatigue. Physical examination findings suggestive of endometriosis include tenderness during pelvic examination, nodules in the posterior fornix, adnexal masses, and a fixed, retroverted uterus.

Sexual assault

also known as sexual violence, is a comprehensive term that includes any nonconsensual sexual contact in the form of touching, kissing, or vaginal, oral, or anal penetration. Nonconsensual can apply to refusal, coercion, intoxication or drug use, inability to understand because of age, or other mental incapacities.

Leiomyomas locations

also known as uterine fibroids, are the most common pelvic tumor in women. They are benign growths in the uterus that may occur at various locations. An intramural myoma is located within the uterine wall, a submucosal myoma is located below the endometrium and protrudes into the uterine cavity, and a subserosal myoma originates from the myometrium at the serosal surface of the uterus.

A 26-year-old nulliparous woman presents with her husband to her gynecologist with concerns about family planning. She states they have been unsuccessfully attempting to conceive for 2 years. Which of the following is the most common cause of the patient's condition?

anovulation

Endometriomas

are adnexal masses that consist of ectopic endometrial tissue in patients with endometriosis. A patient with an endometrioma may report symptoms of endometriosis, including severe dysmenorrhea, dyspareunia, and abdominal pain that is not localized to the uterus during menses. On physical exam, a patient with an endometrioma may have a palpable adnexal mass and discomfort on palpation. The best modality to distinguish adnexal masses is transvaginal ultrasound. On ultrasound, an endometrioma appears smooth-walled with homogeneous internal echoes that have the appearance of ground-glass. The fluid inside endometriomas is old blood and appears chocolate-colored on biopsy, so these cysts are often referred to as chocolate cysts. Treatment of endometrioma includes observation with serial ultrasounds or surgical removal. Surgical removal provides definitive diagnosis, relief of symptoms, and protection against possible ovarian torsion or cyst rupture. However, surgery carries the risk of intraoperative complications, such as hemorrhage or infection, and slightly decreases fertility.

Diaphragms and cervical caps

are contraceptive methods that are inserted into the vagina and provide a mechanical barrier between the cervical canal and semen. Both require professional fitting since improper sizing can cause erosions to the vagina or cervix. The advantages are that they are discreet, controlled by the woman, and are not typically felt by either partner during intercourse, they do not have any systemic side effects, and they protect against pelvic infections and cervical dysplasia when used correctly

Uterine leiomyomas

are nonmalignant, arise from smooth muscle cells, and are the most common type of pelvic tumor in women.

Presumptive diagnosis may be made on history and physical examination. Definitive diagnosis is made on

biopsy during surgical evaluation (e.g., laparoscopy). Endometriomas are ovarian cysts that may be seen during surgical exploration and are formed from ectopic endometrial tissue. They are filled with a chocolate-like substance, giving them the name chocolate cysts.

Common side effects of combined oral contraceptives include

breakthrough bleeding, breast tenderness, headaches, and nausea. The most prevalent serious adverse effect is an increase in the risk of venous thromboembolism.

A 21-year-old woman presents to her gynecologist extremely upset and scared. She states she was at a fraternity party last night and blacked out. When she woke up this morning, she was completely unclothed. She reports vaginal pain and bleeding. The patient is up-to-date on her hepatitis B and human papillomavirus (HPV) vaccinations. In addition to offering prophylactic treatment for HIV, which of the following antibiotics would be most appropriate for empiric coverage of sexually transmitted infections?

ceftriaxone, doxycycline, metronidazole

A basal body temperature

chart is an easy and inexpensive way to evaluate for ovulation. Basal body temperature rises about 0.5°F after ovulation due to ovarian release of progesterone. A midluteal (day 21) serum progesterone level or testing for the luteinizing hormone (LH) surge can also be used to detect ovulation. A midluteal serum progesterone level < 10 ng/mL or the absence of the LH surge indicates ovulatory dysfunction. Other tests for ovulatory function include endometrial biopsy, ultrasound, day 3 follicle-stimulating hormone, estradiol level, antral follicle count, and antimüllerian hormone level testing.

A 28-year-old woman presents to the clinic due to infertility. She has infrequent menstrual cycles and has been unable to become pregnant despite 12 months of frequent unprotected intercourse. Physical examination is unremarkable other than hirsutism and inflammatory acne. Her husband has been evaluated and had a normal semen analysis. Which of the following is the recommended treatment for infertility in this patient?

clomiphene citrate

A 28-year-old woman with a past medical history of diabetes mellitus presents to the clinic with irregular menstrual cycles. She says her cycles occur every 2 months. Physical examination reveals male-pattern facial hair and inflammatory acne. Which of the following is the recommended treatment for her hyperandrogenic symptoms?

combined oral contraceptive pill Weight loss is considered the first-line treatment because it may improve metabolic risk, restore ovulatory cycles, and improve infertility. Combined estrogen-progestin oral contraceptives are the main pharmacologic treatment used for symptoms related to menstrual dysfunction and hyperandrogenism. They also reduce the risk of endometrial hyperplasia and cancer. The recommended starting regimen for combined oral contraceptives is 20 μg of ethinyl estradiol and norethindrone as the progestin because it has lower androgenicity than some progestins, such as levonorgestrel. Spironolactone is used as an adjunct in women who do not improve after 6 months of using combined oral contraceptives. Women with PCOS with infertility may be treated with pharmacologic agents used to induce ovulation. Clomiphene citrate and letrozole are each frequently used to induce ovulation.

A 34-year-old woman is admitted in the hospital for routine care following a vaginal delivery. She plans on breastfeeding. You are counseling her on contraceptive options during the postpartum period. Which of the following contraceptive options is contraindicated during the postpartum period?

combined oral contraceptives

Treatment involves

correcting any underlying reversible causes and overcoming irreversible factors. Lifestyle modifications include smoking cessation, reducing excessive caffeine or alcohol consumption, maintaining a healthy body weight, and appropriate timing and frequency of intercourse. Couples should have intercourse every 1-2 days around the expected time of ovulation. Ovulation induction agents are often one of the first treatments used for infertility, particularly in women suspected to have oligoovulation, and they are usually successful for women with irregular ovulation not related to ovarian failure. Clomiphene citrate is a common choice and belongs to the drug class selective electrogene receptor modulators. Assisted reproductive technology may also be used to treat infertility. In vitro fertilization is a type of assisted reproductive technology that involves fertilization occurring in a laboratory. It requires retrieval of eggs from a woman and sperm from a man. The resulting embryo is then implanted in the uterus. In some cases, a gestational carrier is used. Gestational carriers are women who carry the embryo and sperm that were each donated. Women with bilateral tubal obstruction and limited access to in vitro fertilization can be treated with reproductive surgery to open the fallopian tubes. However, these women are at high risk for ectopic pregnancy, and in vitro fertilization is preferred in women with severe bilateral tubal disease. Women with endometriosis are often treated with surgical resection of the endometriosis, ovulation induction, intrauterine insemination, and assisted reproductive technologies. Intrauterine insemination is a medical procedure in which the male partner's sperm are placed into the uterus close to the time of ovulation, shortening the distance sperm have to travel.

The following conditions are considered category 4, or absolute contraindications, to combined estrogen-progestin hormonal contraception:

current breast cancer, severe decompensated cirrhosis, acute deep vein thrombosis or pulmonary embolism, high risk for recurrence of deep vein thrombosis or pulmonary embolism, major surgery with prolonged immobilization, migraine with aura, systolic blood pressure ≥ 160 mm Hg, diastolic blood pressure ≥ 100 mm Hg, history of ischemic heart disease, known thrombogenic mutations, hepatocellular adenoma, malignant hepatoma, moderately or severely impaired cardiac function, diagnosis of normal or mildly impaired cardiac function within the previous 6 months, patients < 21 days postpartum regardless of breastfeeding status, patients ≥ 35 years of age and smoking ≥ 15 cigarettes/day, history of cerebrovascular accident, and complicated valvular heart disease.

A 35-year-old woman presents to a women's health clinic requesting oral contraceptive therapy. The physician assistant decides to prescribe a combined estrogen-progestin hormonal contraceptive. Which of the following is a relative contraindication to combined estrogen-progestin oral contraception for this patient?

current tobacco use of 10 cigarettes/day

Management for infertility

depends on the etiology. Weight loss, clomiphene, aromatase inhibitors, gonadotropin therapy, metformin, or dopamine agonists may be used for ovulatory disorders. Surgical resection of fibroids, polyps, and uterine synechiae or septa may be used for uterine abnormalities. In vitro fertilization may be used for tubal factor infertility or adhesions. Surgical resection, ovulation induction with intrauterine insemination, or other assisted reproductive technologies may be used for endometriosis. Intrauterine implantation of donor eggs, donor sperm, preimplantation genetic diagnosis, or a surrogate gestational carrier are other options. Genetic counselors should be provided to assist the patient and clinician in navigating the ethical dilemmas associated with assisted reproductive technology.

A 25-year-old woman presents to the clinic for a routine wellness exam. She is considering contraceptive options. Which of the following contraceptive options has a black box warning due to the risk of blood clots?

ethinyl estradiol and norelgestromin patch

The risk factors for urinary incontinence include meds associated with urinary incontinence

increased parity, advanced age, and obesity. It is important to address medical conditions and medications that may be contributing to urinary incontinence. Medications associated with urinary incontinence include first-generation H1 antihistamines, decongestants, opioids, benzodiazepines, and skeletal muscle relaxants.

Risk factors for the development of a uterine leiomyoma include

early menarche, paucity of parity, consumption of alcohol, and a diet rich in red meat.

Risk factors associated with leiomyomas include

early menarche, prenatal exposure to diethylstilbestrol, increasing body mass index, significant consumption of red meat, and consumption of beer.

A 24-year-old woman presents to the clinic reporting infertility. Physical exam reveals hirsutism, obesity, and a fasting glucose of 210 mg/dL. Pelvic ultrasound reveals multiple simple cysts in each ovary. Which of the following is this patient at increased risk of developing?

endometrial cancer

A 28-year-old nulliparous woman presents to the clinic reporting left lower quadrant pain and severe dysmenorrhea. A pelvic ultrasound reveals a left adnexal complex mass that has smooth walls with homogeneous internal echoes that have a ground-glass appearance. Which of the following ovarian masses is the most likely diagnosis?

endometrioma

Management of sexual assault victims includes

establishing a safe environment conducive to disclosure, disclosing reporting requirements and confidentiality, discussing the prevalence of sexual assault, and providing anticipatory guidance and education materials. Victims should be offered psychosocial support to address feelings of guilt, shame, betrayal, and anger with follow-up in 1 to 2 weeks to ensure support has been arranged. The victim must understand the rape is not their fault, regardless of the involvement of alcohol or drugs. Further evaluation regarding the safety of the victim includes assessing for suicidal ideation, self-harming behaviors, current living situation, and current relationship with the perpetrator or perpetrators. Because victims of rape or attempted rape are three to four times more likely to reexperience sexual assault during their college years compared with those who have not experienced it, prevention of revictimization by identifying sexually aggressive partners, avoiding dangerous situations, and developing sexual negotiation skills is an important part of management.

Which nerve plexus provides sympathetic innervation that relaxes the detrusor muscle, allowing urine to fill the bladder?

inferior hypogastric plexus

Examples of benign ovarian masses that are common in premenopausal, nonpregnant patients include

follicular cysts, corpus luteal cysts, theca lutein cysts, polycystic ovaries, endometrioma, leiomyoma, tubo-ovarian abscess, hydrosalpinx, cystadenoma, and mature teratoma.

Factors associated with a decreased risk of leiomyomas include

having one or more pregnancies extending beyond 20 weeks gestation and vitamin A consumption from animal sources.

A cervical cap

is a latex cup that fits over the base of the cervix. An advantage of the cervical cap over the diaphragm is that it can be inserted for up to 6 hours prior to intercourse and does not require reapplication of spermicide if time has elapsed between placement and intercourse. Cervical caps have a higher failure rate than diaphragms. Additionally, parous women have higher failure rates than nulliparous due to the change in size of the cervix after childbirth, causing a poor fit. Applying spermicide will help improve outcomes for both devices. Effectiveness of both devices depends on the experience and motivation of the user, care of the device, and use of spermicide.

The following conditions are considered category 3, or relative contraindications, to combined estrogen-progestin hormonal contraception:

history of breast cancer with no evidence of current disease within the previous 5 years, breastfeeding patients between 21-30 days postpartum with or without risk factors for venous thromboembolism, breastfeeding patients between 30-42 days postpartum with risk factors for venous thromboembolism, history of deep vein thrombosis or pulmonary embolism not on anticoagulant therapy at low risk for recurrence, history of deep vein thrombosis or pulmonary embolism on anticoagulant therapy for at least 3 months at low risk for recurrence, diabetic nephropathy, diabetic retinopathy, diabetic neuropathy, other vascular disease or diabetes > 20 years' duration, current or medically treated gallbladder disease, bariatric surgery for malabsorptive procedures, history of cholestasis secondary to combined oral contraceptive use, systolic blood pressure 140-159 mm Hg or diastolic blood pressure 90-99 mm Hg with or without medication, history of ulcerative colitis or Crohn disease, multiple risk factors for atherosclerotic cardiovascular disease, prolonged immobility secondary to multiple sclerosis, normal or mildly impaired cardiac function ≥ 6 months, nonbreastfeeding women 21-42 days postpartum with other risk factors for venous thromboembolism, ≥ 35 years of age and smoking < 15 cigarettes/day, current or history of superficial venous thrombosis, current fosamprenavir antiretroviral therapy, current anticonvulsant therapy (e.g., phenytoin, carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine, lamotrigine), and current rifampin or rifabutin antimicrobial therapy

A 38-year-old woman presents along with her 42-year-old husband to discuss difficulties conceiving. They have had consistent, unprotected intercourse for 8 months without a positive pregnancy test. She has never been pregnant, and he has never fathered a child. She has a history of regular menses occurring every 30 days. They both report no history of sexually transmitted infections. Neither individual has a family history of infertility or genetic diseases. Neither of them smoke or use illicit drugs, although they have an occasional drink with dinner. Which diagnostic study is most appropriate, according to this history?

hysteroscopy and scrotal ultrasound

Initial assessment and treatment

includes evaluation and treatment of physical injuries, pregnancy assessment and prevention, evaluation and treatment of sexually transmitted infections, psychological assessment and support, and an offer of forensic evaluation. Sites of physical trauma should be addressed first. A full-body examination is necessary to evaluate for the presence of bruising, abrasions, and erythema. A careful pelvic examination, including colposcopy, should be performed to identify genital trauma. Emergency contraception is offered regardless of last menstrual period because of the uncertainty in the timing of ovulation and is most effective if administered within 72 hours of the assault. Antiemetics should be given along with emergency contraception. Evaluation for sexually transmitted infections includes testing for gonorrhea, chlamydia, trichomoniasis, hepatitis B virus (HBV), and human immunodeficiency virus (HIV). Empiric antibiotic therapy to cover for sexually transmitted infections should be administered for all victims of sexual assault. Treatment is focused on immediate treatment as many victims will not return for follow-up treatment. Empiric antibiotic treatment includes ceftriaxone to cover for gonorrhea and doxycycline or azithromycin to cover for chlamydia and metronidazole or tinidazole to cover for trichomoniasis. While the December 2020 CDC recommendations for treating gonorrhea with presumptive additional chlamydial infection removed azithromycin as a preferred treatment due to increasing rates of resistance, the CDC advises that either doxycycline or azithromycin may be prescribed in the setting of sexual assault per the discretion of the treating clinician. Having the option of either treatment is helpful in the setting of sexual assault for patients who prefer same day treatment and for those in whom follow-up is uncertain. Hepatitis B immune globulin may be given if the patient has an unknown or no history of HBV vaccination or infection. Current immune status should be assessed and a booster given if antibody titers are low. The human papillomavirus vaccination series should be initiated if not already started or completed. Postexposure prophylaxis for HIV should be given within 4 hours of assault and should not be prescribed after 72 hours have passed.

Clinical findings that may suggest intimate partner violence include

inconsistent explanation of injuries, delay in seeking treatment, frequent emergency department visits, late prenatal care, overly attentive partners, and reluctance to be examined.

A hysterosalpingogram

may be used to evaluate for uterine problems and should be performed between days 6 and 10 of the menstrual cycle. If an abnormality is detected, a hysteroscopy may be used to provide direct visualization of the uterine cavity. In addition, the endometrial cavity can be evaluated with saline infusion sonohysterography. Uterine myomata may interfere with implantation and cause infertility. Tubal dysfunction should be suspected in patients with a history of sexually transmitted infections resulting in cervicitis or salpingitis, though patients without a history of sexually transmitted infections may also have tubal dysfunction. A hysterosalpingogram uses dye to evaluate the patency of the fallopian tubes. If abnormal, a definitive diagnosis with laparoscopy is indicated.

The four classifications of uterine leiomyomas depend on their location. Subserosal myomas originate from the

myometrium at the serosal surface. They often have a broad or pedunculated base, and they can extend outward along the folds of the broad ligament. Subserosal myomas may be asymptomatic or may cause mild pelvic pain or fullness depending on their size. Subserosal myomas do not commonly cause heavy menstrual bleeding because they do not involve the endometrium.

Theories for premenarchal endometriosis propose

müllerian embryonic lesions predisposed to endometriosis develop from neonatal uterine bleeding or maternal hormone exposure.

Pharmacologic treatment for endometriosis includes

nonsteroidal anti-inflammatory drugs, hormonal contraceptives, gonadotropin-releasing hormone analogs, and aromatase inhibitors. Surgical resection may be considered for patients refractory to pharmacologic treatment.

Risk factors for endometriosis include

nulliparity, early menarche, late menopause, shorter menstrual cycles, menorrhagia, obstruction of menstrual outflow, exposure to diethylstilbestrol in utero, height > 68 inches, lower body mass index, exposure to physical or sexual abuse in childhood, and excessive consumption of trans fats.

A 28-year-old woman presents to her gynecologist with concerns about pain during sexual intercourse. She reports no fever, vaginal discharge, or vaginal odor but has dull, crampy pain with menstruation and bowel movements. Pelvic examination reveals a fixed and retroverted uterus, no cervical motion tenderness, and no adnexal masses. Which of the following is the most commonly affected site of the patient's condition?

ovaries

PCOS commonly causes infertility due to anovulation, and the first-line treatment is

ovulation-inducing agents, such as clomiphene or letrozole.

In the evaluation of infertility, there are five main factors to consider:

ovulatory, uterine, tubal, male factor, and peritoneal factor. Anovulation is the most common cause of infertility. A regular menstrual cycle is typically correlated with regular ovulation.

A 58-year-old woman presents to her primary care provider with complaints of urinary incontinence. She states that, sometimes, she cannot make it to the bathroom in time and wets herself. On speculum examination, the patient is asked to cough, which results in the leakage of a small amount of urine. Her urinalysis is unremarkable. She is diagnosed with mixed urinary incontinence. Which of the following treats urge incontinence rather than stress incontinence?

oxybutynin

Diagnosis of leiomyoma is via

pelvic ultrasound. When leiomyomas cause significant symptoms, infertility, or are subserosal and cannot be differentiated from ovarian masses, they warrant surgical removal.

A 30-year-old nulliparous woman presents to her gynecologist with prolonged and heavy menstrual bleeding for the past 6 weeks. Upon further questioning, she states she has also had abdominal discomfort. She is not currently taking any medications. She is sexually active with three male partners and does not use contraception. Pelvic examination is significant for a mildly enlarged uterus (7 cm) without cervical motion tenderness or adnexal masses. Transvaginal ultrasound confirms the suspected diagnosis. Which of the following treatments is most appropriate for the patient at this time?

progestin releasing intrauterine device

A 25-year-old woman presents to the clinic for a routine wellness examination. She reports her husband is routinely controlling and humiliating her. Her husband has isolated her from her friends and family and manipulates her by withholding access to money. Which of the following is the most likely diagnosis?

psychological intimate partner violence

The Sampson theory of retrograde menstruation proposes the pathophysiology of endometriosis is

retrograde flow of menstrual blood through the fallopian tubes into the peritoneal cavity.

The recommended evaluation should include

semen analysis, hormonal evaluation and thyroid-stimulating hormone level in women, and a test for tubal patency. It is important to check for a rise in luteinizing hormone in the urine prior to ovulation and for a rise in progesterone during the luteal phase. Hysterosalpingo-contrast sonography can be used to assess for tubal patency. In some couples, laparoscopy may be performed to assess for endometriosis.

Male factor, or abnormalities in the semen, can be detected through

semen analysis. Normal results include volume > 2 mL, sperm concentration > 20 million/mL, motility > 50%, and normal morphology > 30%. Abstinence for 3 days prior to semen collection is recommended. Abnormal results should be followed up with a second analysis after 2-3 months because it takes an average of 74 days for spermatogonia to transform into mature sperm

Symptoms and sequelae of sexual assault include

sleep disturbance, change in appetite, depression, anxiety, suicidal ideation, post-tramatuic stress disorder, difficulty in school, social impairment, sexual dysfunction, and confusion of sexual orientation. Victims of sexual assault are at increased risk of alcohol or substance use disorders, revictimization, and decreased sexual negotiation skills that may result in decreased contraception use, pregnancy, or sexually transmitted infections

Primary infertility is defined as

the inability of a nulliparous woman to conceive after 12 months of unprotected intercourse in women < 35 years of age or after 6 months in women ≥ 35 years of age.

The cause of infertility can be due to

the man, woman, or both. Many couples have multiple factors contributing to their infertility. The most common causes of infertility are male factors, ovulatory dysfunction, tubal damage, endometriosis, coital problems, cervical factors, and idiopathic causes. The best approach to couples with infertility is to evaluate the man and woman during the same time period.

Psychological intimate partner violence uses

threats of action or other coercive tactics to humiliate, control what a partner can or cannot do, isolate the victim from friends or family, and deny access to money or other resources. The threats are often made verbally, with gestures, or with weapons. It is important for health care clinicians to be nonjudgmental and compassionate in their assessment of patients with suspected intimate partner violence.

A 60-year-old woman presents to the clinic complaining of urinary incontinence. She says the symptoms primarily occur when she is laughing or sneezing. She has tried losing weight, reducing caffeine and alcohol intake, restricting water intake, and performing Kegel exercises without improvement. During pelvic examination, you notice vulvovaginal pallor, loss of vaginal rugae, and decreased elasticity. Which of the following is the best next step in management?

topical estrogen

Side effects of both include increased risk of

urinary tract infections (especially with diaphragm use during multiple acts of intercourse) and a small risk of toxic shock syndrome. Therefore, a diaphragm or cervical cap should not be put in for more than 12-18 hours. They also should not be used during menstruation.

A 24-year-old woman presents to the office for evaluation of infertility after trying to conceive for several years. A transabdominal ultrasound reveals a "string of pearls" appearance to the bilateral ovaries. Which of the following clinical findings will she most likely have on a history and physical examination?

weight gain, hirsutism, acne, and insulin resistance