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Gynecology

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• Local: Incontincence (Urology), Osteoporosis, Osteomalacia and Paget's

Bartholin Gland Cyst

ref: Office Management of Bartholin Gland Cysts and Abscesses - April 1 1998 - AFP

• distinguish from sebaceous cyst (similar, common)
• located in the labia minora - 4 and 8 o'clock - posterolateral. Normally the size of a pea - drain into a duct 2.5 cm, exits external to the hymenal ring into a fold between the hymen and the labium
• asymptomatic < 40, leave alone. > 40 ? remove due to CA risk later
• if infected can lance to drain, but tends to recur. Use Word catheter to reduce recurrence risk
• culture for GC/chlamydia (often negative, polymicrobial)?. Rx. Augmentin/amoxil + heat

Word Catheter

• Small balloon, holds up to 5 cc sterile saline. Test balloon before using, 25 guage needle.
• 1% xylocaine with epi for local anesthesia. Use #11 blade to make 5 mm incision. Incision must be on mucosa, typically just inside mucosa. If no pus, make a second incision more proximal. Beware of making incision too large, catheter will fall out.
• Usually inject 2-5 ml of saline. Judge amount by pressure.
• recheck q2D, remove saline to decrease pressure and cavity closes. Typically 1-2 weeks to heal.

CA - Cervix

Screening

• HIV positive women: q6mo screen in first year after dx then q12mo
• if see AGUS (atypical glandular cells of undertermined significance): colposcopy, ECC, endometrial biopsy if risk factors
• if see AGUO (atypical glandular cells of unknown origin): endometrial biopsy (but can pathologists really distinguish AGUS and AGUO?)

Dysfunctional Uterine Bleeding (Menorrhagia)

See also: Abnormal Uterine Bleeding - AFP - October 1, 1999 and Polycystic Ovary Syndrome (PCOS)

Labs (as indicated)

• teen: CBC, TSH, BT, PT/PTT, LFTs, Cr/BUN, pregnancy test
• peri-menopausal: some of above, FSH +/- LH, prolactin (N FSH, Elev LH -> polycsystic ovary), endometrial biopsy (may defer until settled)

Therapy

• severe bleeding (inpatient): premarin 25 mg IV q3-4 h x 3-4 doses then OCP
• Ovral (50 mcg estrogen) 1 QID x 7 d (decrease per s/e) then regular OCP
• premarin 1.25-2.5 mg days 1-21 then provera 10 mg days 17-21. Bleed day 21-26
• if bleeding tolerable: provera 5-10 mg days 26-31. If no bleeding after 5-7 days doubt diagnosis

Fibroids (uterine leiomyomata)

symptoms

• menorrhagia
• pelvic discomfort = pregnancy of same size

management

no symptoms

• slow growth: size = 12w GA, growth < 6 week size/year: reassure, follow q6-12 mo
• >=12 w size
  • want pregnancy: reassure, myomectomy possible if no pregancy within 12 months or repeated loss and other w/u negative
  • no pregnancy wanted: hysterectomy only if other indications or extenuating circumstances

symptoms

• desire pregancy: attempt conception, consider myomectomy
• no pregnancy desired:
  • postmenopausal bleeding: hysterectomy
  • premenopausal
    • if wish to preserve uterus: conservative therapy: NSAIDS (two, not prn), low dose OCs or myomectomy
    • no wish to keep uterus: hysterectomy

Hormone Replacement Therapy and Menopause (ERT, HRT)

See also Osteoporosis, Osteomalacia and Paget's

• OCP may be useful for peri-menopausal symptoms, due to androgen loss near menopause consider higher androgen activity OCP. (No smokers, no coag hx, risks still unclear). However do not start Rx if undiagnosed bleeding, may mask a malignancy.
• Calcium 800mg-1000mg daily with Vit D or a multivitamin
• ERT optimal for higher fracture risk (thin, white, blue eye, surgical menopause) and low-average to low breast CA risk. Combination estrogen/progesterone preparations. May be able to drop estrogen below classic .625 dose to .3 mg, esp if exercise/active and not thin
• Estrogen analogues may prove safe, but data limited. Raloxifene (Evista) has same s/e as estrogen without breast action, but may worsen vasomotor symptoms of menopause. See Raloxifene 1999 - AFP.

Infertility

Evaluation sequence

Accelerate if older or other risk factors, typically start if non-pregnant after 1 year.

1. male assessment: semen analysis, prostatism screen
2. ovulation assessment: basal body temp (a bit flaky in practice) +/- ovulation prediction kit. Most screen for TSH,  prolactin and FSH/LH immediately rather than waiting.
3. luteal phase test: endometrial bx 11-12 days post ovulation (preg test first of course!). In theory do prolactin if there's a luteal phase defect. Clomid is classic Rx for luteal phase defect.
4. HSG for anatomic defects (some do post-coital test, but that's going out of favor)
5. Generally thereafter go the usual route of clomid then direct insemination then pergonal then in vitro.

Menorrhea delay (primary)

• Primary Amenorrhea if age > 16.
• low FSH/LH -> hypogonadotropic hypogonadism - usually constitutional delay.
• incr FSH/LH -> hypergonadotropic hypogonadism. Check karyotype. May be 46 XX with primary overian failure or 45 XO with Turner's syndrome.
• if no seconary sex characteristics by age 14 evaluate FSH/LH as above.
• if primary amenorrhea and secondary sex characteristics do U/S for absent uterus, outflow obstruction, etc.

Misc

• OCP does not affect regression of physiologic ovarian cysts - wait and observe with U/S

PID and STD

• PID is very hard to diagnoses but bad to miss, so tend to overtreat (but then miss other causes of symptoms, cause social stress)
• treat as PID if lower abd tenderness with adnexal tenderness and cervical motion tenderness esp. if fever, discharge or evidence of cervical infection
• if pt quite sick with PID, or risk of non-compliance, or non-responsive to initial therapy or pregnant, etc then hospitalize
• outpatient treatment
  • recheck < 72 hours
  • see Ab booklet for Rx, as of 2001 was rocephin/doxy or ofloxacin/flagyl

Polycystic Ovary Syndrome (PCOS)

• 6% of women of childbearing age: obesity, acne, hirsutism and menstrual disorders of varying severity, 74% infertile, common hyperandrogenism (not clitoromegaly, temporal balding, voice change --> look for tumor), unopposed estrogen, insulin resistance with hyperinsulinemia, 20% have DM or intolerance. Insulin levels may cause many related problems, including hypercoagulability.
• amenhorrhea and DUB.
• u/s: more than 8 follicles in ovary each < 10 mm in diameter ("pearl necklace")
• LH/FSH > 3 is typical.
• rx:
  • weight loss (even 5% loss valuable)
  • no pregnancy desired: northethindrone or medroxyprogesterone acetate
  • contraception: OCP, esp. newer pills with non-androgenic progesterone
  • preg desired: clomiphene (high miscarriage rate, ? Lupron or metformin?) or ovarian laser drilling
  • metformin may work well to reduce elevated insulin s/e.

Post-Coital Contraception (Morning-After Pill)

• missed 2 of first 7 combined OCPs, or missed 4 during 2nd week, or 1 progestin-only
• < 72 h since intercourse
• avoid if major coag hx or current migraine
• baseline prob of conception is 10% when 5 day prior to ovulation, if > 6 days prior is almost zero.
• r/o: pregnancy, vascular/hematologic disorders, active migraine
• conception occurs when intercourse takes place during a six day period ending on the day of ovulation.

Ovral (FDA approved)

• Ovral: 2 tabs and repeat in 12 hours (if < 72 hours since intercourse). $11, on HP formulary. Each Ovral tab contains ethinyl estradiol 0.1 mg (100mcg) and levonorgestrel 0.5mg. Most will have substantial nausea. "Preven" is a kit containing this preparation with directions. Contraindicated in pt with active migraine.
• antiemetics!

Levonorgetrel (!!confusing dosage!!)

• Levonorgestrel 0.75 mg, repeated 12 h later. Ovrette contains 0.075 mg of norgestrel, of which only 50% is the levonorgestrel enantiomer. So 0.75 mg of levonorgestrel is 20 Ovrette tabs. The Ovrette pack contains 28 tabs (no placebo), so this regimen requires two packs - 20 tabs initially, then 20 tabs 12 hours later. Each pack is about $35, so this comes to $70!
• Since this routine is less levonorgestrel than 2 Ovrals, is the better effectiveness due to decreased vomiting? Unclear if same mechanism of action (?more uterine, less ovarian?)
• Better, less nausea, but still suggest dramamine: antiemetics.
• 95% effective within 24 hours, 58% 49-72 h.

Vaginitis and Wet Prep

ref: Bacterial Vaginosis   - March 15 1998 - AFP. Simple version -- if it smells, then Flagyl.

• pH > 4.5 -> Bacterial (garnerella) vaginosis. Usually strong fishy odor esp. with KOH, clue cells. Rx Flagyl 500 mg 4 tabs or 500 BID for 7 days or metrogel vaginal
• leukocytes -> Trichomonas. Often copious discharge, may see in U/A, lots of WBC, pH < 4.5.
• white discharge with itchy vulva, KOH shows mycelia: candida, pH < 4.5

Other infections on wet prep

• chlamydia: yellow discharge, > 10 poly/hpf
• GC: greenish yellow cervical discharge

Vulvar disorders

See also Vulva Pathology - Non-neoplastic Epithelial Disorders

• Lichen Sclerosus - Oct 1999 - AFP
  • vulva and anogenital area
  • itchy, thin crinkled white area, telangiectasia
  • 5%  progress to vulval squamous cell carcinoma
• squamous cell hyperplasia
• atrophic vulvitis
• vulvar intraepithelial neoplasia (Bowen's disease, carcinoma in situ simplex of the vulva)
  • VIN 1, II, and III then CIS
  • 4% with VIN develop invasive cancer (HPV association?)
• Invasive Squamous Cell Carcinoma of the Vulva