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Polycystic ovary syndrome

Key points Polycystic ovary syndrome (PCOS) is now diagnosed by the Rotterdam criteria, which are clinical end points, and is not a laboratory diagnosis . The diagnosis requires finding any two of the following: menstrual irregularity, hyperandrogenism (clinical or biochemical), or polycystic ovaries on ultrasound. The disorder is heterogeneous and is not a single-gene disorder, although several susceptibility genes have been identified; environmental influences are most…

Androgen excess in women

Key points The major androgen produced by the ovaries is testosterone and that of the adrenal glands is dehydroepiandrosterone sulfate; many potent 11-oxo androgens produced by the adrenal glands determine androgen action but are not currently measured. Androgen action is determined by the “free” or non–SHBG-bound component of testosterone and other androgens, but is poorly measured; and by dihydrotestosterone produced peripherally, in skin, by increased 5α-reductase…

Hyperprolactinemia: Evaluation and management

Key points The main symptoms of hyperprolactinemia are galactorrhea and amenorrhea, the latter caused by alterations in normal gonadotropin-releasing hormone release. Pathologic causes of hyperprolactinemia include pharmacologic agents, hypothyroidism, chronic renal disease, chronic neurostimulation of the breast, hypothalamic disease, and pituitary tumors. Most macroadenomas enlarge with time; almost all microadenomas do not. The dopamine agonist of choice is cabergoline because of increased efficacy and fewer side…

Primary and secondary amenorrhea and precocious puberty

Key points Primary amenorrhea is diagnosed if no menstrual function has occurred by age 15, or 5 years after initial breast development. Menarche is delayed approximately 0.4 year for each year of premenarchal athletic training. Gonadal failure is the most common cause of primary amenorrhea, accounting for almost 50% of patients with this disorder. Individuals with gonadal failure should have a peripheral karyotype obtained to determine…

Primary and secondary dysmenorrhea, premenstrual syndrome, and premenstrual dysphoric disorder : Etiology, Diagnosis, Management

Key points Approximately 75% of all women complain of primary dysmenorrhea. Approximately 15% have severe symptoms. Education, supportive therapy, and nonsteroidal antiinflammatory drugs are the treatments of choice for primary dysmenorrhea. Combined oral contraceptives (COCs) reduce the prevalence and severity of dysmenorrhea. They can be used in extended cycles for better relief. This is also a reasonable first-line treatment, especially if contraception is desired. Secondary dysmenorrhea…

Gestational trophoblastic disease: Hydatidiform Mole, Nonmetastatic and Metastatic Gestational Trophoblastic Tumor: Diagnosis and Management

Key points Persistent abnormal bleeding after normal pregnancy, abortion, or ectopic pregnancy should lead to a consideration of the diagnosis of gestational trophoblastic disease (GTD). Pulmonary nodules present on chest radiographs after a normal pregnancy suggest GTD. Beta human chorionic gonadotropin ( β -HCG) levels is elevated in these situations. Investigation of a young woman with metastatic disease of unknown primary should include a β -HCG…

Malignant diseases of the ovary, fallopian tube, and peritoneum

Key points Ovarian cancer is the leading cause of death from gynecologic cancer, but it occurs less often than endometrial cancers. Ovarian cancers in women older than 50 years are diagnosed at a more advanced stage, leading to a worse prognosis than for younger women. The risk of ovarian cancer is decreased by oral contraceptive use. Tubal ligation and hysterectomy also appear to decrease the risk.…

Malignant diseases of the uterus: Endometrial Hyperplasia, Endometrial Carcinoma, Sarcoma: Diagnosis and Management

Key points Endometrial carcinoma is the most common malignancy of the female genital tract. In the United States the lifetime risk of endometrial cancer is 3%. Most women who develop endometrial cancer are aged 50 to 65 years. Women with Lynch syndrome (hereditary nonpolyposis colorectal cancer syndrome) have a 40% to 60% lifetime risk of endometrial cancer, which is similar to their lifetime risk of colon…

Malignant diseases of the cervix: Microinvasive and Invasive Carcinoma: Diagnosis and Management

Key points Carcinomas of the cervix are predominantly squamous cell carcinomas (85% to 90%), and approximately 10% to 15% are adenocarcinomas. Squamous cell carcinomas are strongly associated with human papillomavirus (HPV) infection. Cervical carcinoma is the third most common malignancy of the lower female genital tract, after endometrial and ovarian cancer, and the second most common cause of death, after ovarian cancer. Definitive diagnosis of microinvasive…

Neoplastic diseases of the vulva and vagina

Key points VULVAR PREMALIGNANT AND MALIGNANT DISEASE Squamous cell carcinomas constitute 90% of primary vulvar malignancies. More than 80% of patients are older than 50 years at the time of diagnosis. Cancer of the vulva accounts for approximately 4% of malignancies of the lower female genital tract and occurs less often than uterine, ovarian, and cervical cancers. Paget disease generally occurs in postmenopausal women and is…

Intraepithelial neoplasia of the lower genital tract (cervix, vagina, vulva): Etiology, Screening, Diagnosis, Management

Key points Human papillomavirus (HPV) infection is the cause of virtually all cases of cervical dysplasia/cancer and many cases of vaginal and vulvar dysplasia The majority of HPV infections regress spontaneously, but if the infection persists, dysplasia and cancer may develop. Smoking increases the likelihood that an HPV infection will persist or progress. Preventive vaccines are available that prevent HPV infection and the development of dysplasia…

Principles of radiation therapy and chemotherapy in gynecologic cancer: Basic Principles, Uses, and Complications

Key points Electromagnetic radiation is a form of energy that has no mass or charge and travels at the speed of light. The inverse square law states that the energy measured from a radiation source is inversely proportional to the square of the distance from the radiation source. Each delivered radiation dose kills a constant fraction of tumor cells irradiated. Oxygen can render radiation-induced DNA damage…

Molecular oncology in gynecologic cancer: Immunologic Response, Cytokines, Oncogenes, and Tumor Suppressor Genes

Key points The immune system consists of the innate and adaptive immune systems. The innate system is present at birth and consists of natural barriers, natural killer (NK) cells, macrophages, and the complement system. The adaptive immune system adapts to infection and consists of T and B cells. The cellular immune response occurs as a result of T lymphocytes reacting via a surface T-cell receptor (TCR)…

Abnormal uterine bleeding: Etiology and Management of Acute and Chronic Excessive Bleeding

Key points The mean amount of menstrual blood loss in one cycle is approximately 35 mL but may be as much as 60 mL, with an average loss of 13 mg of iron. Heavy menstrual bleeding occurs in 9% to 14% of healthy women. Diagnostic tests in women with menorrhagia include measurement of hemoglobin, serum iron, serum ferritin, beta human chorionic gonadotropin, thyroid-stimulating hormone, and prolactin…

Perioperative management of complications: Fever, Respiratory, Cardiovascular, Thromboembolic, Urinary Tract, Gastrointestinal, Wound, and Operative Site Complications; Neurologic Injury; Psychological Sequelae

Key points Postoperative febrile morbidity is related to infection in approximately 20% of cases and noninfectious causes in 80% of cases. Infection in older adults will not always present with classic findings. The amount of temperature elevation may not reflect the severity of the infection. Not uncommonly, the first signs of infection in older adults will be mental status changes. Also, the degree of leukocytosis may…

Preoperative counseling and management: Preoperative Evaluation, Informed Consent, Perioperative Planning, Surgical Site Infection Prevention, and Avoidance of Complications

Key points Optimal preparation for an operation facilitates a successful result and protects the patient and physician. The most significant risk factors for postoperative morbidity are preoperative conditions. They may affect the operation, anesthesia, and postoperative course and may preclude the procedure altogether. Approximately 0.5% of the general population and 1.5% of women older than 55 years are receiving continuous glucocorticoids. Latex allergy is directly responsible…

Genital tract infections: Vulva, Vagina, Cervix, Toxic Shock Syndrome, Endometritis, and Salpingitis

Key points The Centers for Disease Control and Prevention regularly revises its treatment protocols for sexually transmitted infections (STIs). This information may be accessed online at www .cdc.gov/publications . Pediculosis pubis, an infestation by the crab louse Phthirus pubis, is characterized by constant itching, predominantly vulvar involvement, and the finding of eggs and lice by visual inspection. It may be treated by topical application of 1%…

Anal incontinence: Diagnosis and Management

Key points Estimates of fecal incontinence range from 11% to 20% of community-dwelling women older than 64 years. More than 30% of women reporting urinary incontinence also report fecal incontinence, known as dual incontinence. The internal anal sphincter, under autonomic control, maintains the high-pressure zone or continence zone, whereas the external anal sphincter (EAS) provides the voluntary squeeze pressure that prevents incontinence with increasing rectal or…

Lower urinary tract function and disorders: Physiology of Micturition, Voiding Dysfunction, Urinary Incontinence, Urinary Tract Infections, and Painful Bladder Syndrome

Key points Continence is determined by the balance between forces that maintain urethral closure and those that affect detrusor function. Parasympathetic nervous system activity via the neurotransmitter acetylcholine stimulates receptors in the bladder wall to activate detrusor contraction. Sympathetic nervous system activation leads to bladder relaxation. Nearly 50% of all women may suffer from some degree of urinary incontinence during their lifetime. Being obese or overweight…

Pelvic organ prolapse, abdominal hernias, and inguinal hernias: Diagnosis and Management

Key points Pelvic organ prolapse is defined as the descent of one or more compartments of the vagina: the anterior vaginal wall, posterior vaginal wall, uterus (cervix), or apex (vaginal vault or cuff scar after hysterectomy). Pelvic organ prolapse often includes a mixture of anterior, posterior, and apical prolapse, and each compartment should be evaluated under strain before determining the appropriate operative treatment. Pelvic organ prolapse…