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Endometriosis: Etiology, Pathology, Diagnosis, Management

Key points Endometriosis is a benign, usually progressive, and sometimes recurrent disease that invades locally and disseminates widely. Causes include retrograde menstruation, coelomic metaplasia, vascular metastasis, immunologic changes, iatrogenic dissemination, and a genetic predisposition. Endometriosis lesions produce estrogen locally and have increased secretion of prostaglandins and inflammatory cytokines, which can cause pain and contribute to infertility. There is also a relative resistance to progesterone in endometriosis…

Benign gynecologic lesions: Vulva, Vagina, Cervix, Uterus, Oviduct, Ovary, Ultrasound Imaging of Pelvic Structures

Key points The most common large cyst of the vulva is a cystic dilation of an obstructed Bartholin duct, with a lifetime risk estimated to be 2%. These cysts occur most often during the third decade. Inflamed cysts may be treated with oral antibiotics or incision and drainage. The vulva contains 1% of the skin surface of the body, but 5% to 10% of all malignant…

Ectopic pregnancy : Etiology, Pathology, Diagnosis, Management, Fertility Prognosis

Key points The rate of ectopic pregnancy in the United States has remained fairly constant since the early 2000s and is approximately 6.6 in 1000 pregnancies in women aged 15 to 24. Risks of ectopic pregnancy include age, smoking, pelvic inflammatory disease, infertility, and prior tubal surgery. After tubal sterilization, the risk of ectopic pregnancy if a pregnancy occurs is about 30%, reaching 50% if the…

Early and recurrent pregnancy loss: Etiology, Diagnosis, Treatment

Key points Pregnancy loss affects approximately 10% to 30% of all clinically recognized pregnancies, with nearly 80% occurring in the first trimester. The majority of pregnancy losses are sporadic and result from genetic causes that are greatly influenced by maternal age. Fewer than 5% of women will experience two consecutive pregnancy losses and only 1% experience three or more. Women with two prior losses and no…

Breast diseases: Detection, Management, and Surveillance of Breast Disease

Key points The breast consists of approximately 20% glandular tissue and 80% fat and connective tissue; increasing proportions of fibroglandular to fatty tissues are the mark of denser breasts. Breast density is associated with increased risks of malignancy. Lymph drainage of the breast usually flows toward the most adjacent group of nodes. This concept represents the basis for sentinel node mapping in breast cancer. In most…

Menopause and care of the mature woman: Endocrinology, Consequences of Estrogen Deficiency, Effects of Hormone Therapy, and Other Treatment Options

Key points The average age of menopause in the United States is 51.3 years; it is younger in certain ethnic groups, and is genetically predetermined and is not related to the number of ovulations, race, socioeconomic conditions, education, height, weight, age at menarche, or age at last pregnancy. Because most diseases in women occur after menopause, the onset of menopause heralds an important opportunity to institute…

Contraception and abortion

Key points Approximately 45% of all pregnancies in the United States are unintended, and among women who experience unintended pregnancy, more than half are not using contraception. By age 45, at least half of U.S. women will experience an unintended pregnancy, and one in four will have had an abortion. Failure rates in the first year of contraceptive use are highest for coitus-related methods (e.g., withdrawal,…

Pediatric and adolescent gynecology: Gynecologic Examination, Infections, Trauma, Pelvic Mass, Precocious Puberty

Key points It is important to give the child a sense that she will be in control of the examination process. Emphasize that the most important part of the examination is just “looking” and that there will be conversation during the entire process. Many gynecologic conditions in children can be diagnosed by inspection alone. The vaginal epithelium of the prepubertal child appears redder and thinner than…

Congenital abnormalities of the female reproductive tract: Anomalies of the Vagina, Cervix, Uterus, and Adnexa

Key points Gender identification in a newborn infant has emotional and psychological implications and should be performed as accurately as possible. However, in the setting of ambiguous genitalia, gender assignment should not be considered without definitive testing and multidisciplinary participation. Congenital adrenal hyperplasia is an autosomal recessive condition, most commonly the result of an inborn error of metabolism involving the enzyme 21-hydroxylase. Homozygous individuals account for…

Endoscopy in minimally invasive gynecologic surgery

Key points Technological developments in hysteroscopy and laparoscopy favor a smaller footprint to facilitate ambulatory procedures, with a trend toward smaller-caliber endoscopes and instruments and creative specimen removal with attention to safety. Indications for hysteroscopy include removal of endometrial polyps or submucous myomas, retained intrauterine devices or Essure coils, the diagnosis and treatment of intrauterine adhesions, and resection of a uterine septum or cesarean niche. Hysteroscopy…

Additional considerations in gynecologic care

Key points Depression, anxiety disorders, obsessive-compulsive disorder, and posttraumatic stress disorder are treatable with medications or psychotherapy. A history of manic or hypomanic symptoms increases the risk for a “switch” into mania with antidepressant treatment. Close follow-up, in 1 to 2 weeks, is recommended to monitor for increases in suicidal thoughts with antidepressants, especially in adolescents and young adults. Active suicidal thoughts and plans are a…

Interaction of medical diseases and female physiology

Key points Long-acting reversible contraception (LARC) methods are safe, effective, and have minimal risk of user error; thus they have become the recommended option for most women with complicated chronic illnesses. The severity of asthma symptoms increases around the time of menses. Many women with irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD) have exacerbations of symptoms with menses. Women with chronic renal disease often…

History, physical examination, and preventive health care

Key points Strive to become a culturally sensitive and aware physician with a nonjudgmental approach to women regardless of race or ethnicity, age, faith, disabilities, profession, sexual orientation/identity, or activities. Goals of preventive medicine include maintaining good health and function and promoting high-quality longevity. A complete gynecologic evaluation should always include a review of menstruation, sexuality, contraception, pregnancies, gynecologic infections, gynecologic procedures, and any history of…

Medical-legal risk management

Key points Malpractice is patient injury secondary to failure to exercise that degree of care used by reasonably careful physician of like qualifications Negligence is failure to extend the degree of diligence and care that a reasonably and ordinarily prudent person would exercise Informed consent is the physician’s fiduciary duty to give the patient all the information needed for the patient to make an intelligent decision…

Evidence-based medicine and clinical epidemiology

Key points Evidence-based medicine (EBM) seeks to improve the care of patients and the delivery of care to patients. Descriptive-observational studies, including cross-sectional studies and case series, help generate hypotheses and characterize the context of disease. Case-control studies allow us to study rare diseases and evaluate for a wide range of exposures. Cohort studies allow us to study many outcomes over time. Randomized controlled trials (RCTs)…

Reproductive endocrinology: Neuroendocrinology, Gonadotropins, Sex Steroids, Prostaglandins, Ovulation, Menstruation, and Hormone Assay

Key points Gonadotropin-releasing hormone (GnRH) analogs are synthesized by substitution of amino acids in the parent molecule at the 6 and 10 positions for GnRH agonists and at the 2 or 3 position for GnRH antagonists. The various analogs have greater potencies and longer half-lives than the parent GnRH and are used clinically for suppression. LH and FSH have the same α subunit as thyroid-stimulating hormone…

Reproductive anatomy: Gross and Microscopic Clinical Correlations

Key points The labia majora are homologous to the scrotum in the man. The labia minora are homologous to the penile urethra and a portion of the skin of the penis in men. The clitoris complex is composed of both erectile and nonerectile tissue and includes the glans, prepuce, body, crura, bulbs, suspensory ligament, and the root. The clitoral complex is the female homologue of the…

Reproductive genetics

Key points Virtually all human diseases have an underlying genetic component. All health care professionals need a basic level of familiarity with genetics and genomics because it is an integral part of mainstream medicine. Genetic variation between healthy individuals exists in the form of single nucleotide polymorphisms (SNPs) and copy number variants (CNVs) providing different “doses” of a large repeated DNA sequence at a given genetic…

Fertilization and embryogenesis

Key points Oocyte meiosis is arrested in prophase I from the fetal period until a luteinizing surge (LH) preceding ovulation. With the LH surge, the oocyte completes meiosis I associated with a decrease to 23 chromosomes with diploid (2 N ) DNA quantity and extrusion of the first polar body. With fertilization, meiosis II is completed with separation of sister chromatids resulting in 23 chromosomes with…

Hysterectomy for the Transgender Man

Introduction The World Professional Association for Transgender Health (WPATH) considers hysterectomy with or without salpingectomy and/or oophorectomy a medically necessary gender-affirming surgery for trans men interested in the procedure. The reasons for surgery are diverse: a sense of organs feeling incongruent with one’s gender identify, to promote further masculinization, to assist with changing legal documents, avoiding gynecology visits and prevention of gynecologic problems, or for specific…