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Vulvar and Vaginal Cancer

Clinical Keys for This Chapter ▪ Most vulvar cancers are squamous cell carcinomas, and, etiologically, there are two different types. The more common type occurs in older women and is frequently related to long-standing lichen sclerosus. The less common type occurs in younger women and is related to infection with the human papillomavirus and smoking. ▪ Invasive vulvar cancer spreads initially to adjacent organs, such as…

Ovarian, Fallopian Tube, and Peritoneal Cancer

Clinical Keys for This Chapter ▪ Ovarian cancer is the fifth most common cancer among women in the United States, accounting for one-fourth of all gynecologic cancers. It is the leading cause of death resulting from gynecologic cancer because it is difficult to detect before it disseminates. ▪ Most ovarian neoplasms (80-85%) are derived from coelomic epithelium and are called epithelial carcinomas. The most common type…

Cervical Dysplasia and Cancer

Clinical Keys for This Chapter ▪ Cervical cancer is the major cause of death from cancer in women worldwide, but most new cases and deaths occur in developing countries where screening for cervical cancer is poorly developed. ▪ Cervical cancer is caused by persistent infection with a high-risk human papillomavirus (HPV), and vaccines have been developed against some of these viruses. Vaccination of girls (and boys)…

Principles of Cancer Therapy

Clinical Keys for This Chapter ▪ Chemotherapy and radiation therapy both work primarily by disrupting nuclear deoxyribonucleic acid and inhibiting cellular division. They potentially kill all rapidly dividing cells. Targeted therapies are directed towards specific signaling pathways within cancer cells, to spare normal cells such as bone marrow. ▪ Chronic radiation complications occur in 5-10% of patients who receive 50 centigray (cGy) or more of radiation…

Menstrual Cycle–Influenced Disorders

Clinical Keys for this Chapter ▪ Premenstrual syndrome (PMS) and its more severe form, premenstrual dysphoric disorder (PMDD) are the quintessential menstrual cycle–influenced disorders. A common feature of these disorders is the inability to distinguish between affected women and normal controls by routine measurement of the traditional hypothalamic-pituitary-ovarian (HPO) hormones. Interestingly, in many cases, dramatic relief from the symptoms can be obtained by intentionally disrupting or…

Menopause and Perimenopause

Clinical Keys for this Chapter ▪ The “climacteric” refers to the phase in a woman's reproductive life when a gradual decline in ovarian function results in decreased sex steroid production with its sequelae. Because this phase is a normal consequence of the aging process, it should not be considered an endocrinopathy. Menopause refers to the last menstrual period, and this occurs on average at age 51.5…

Infertility and Assisted Reproductive Technologies

Clinical Keys for This Chapter ▪ Eighty to eighty-five percent of fertile couples will conceive after 1 year of frequent attempts. Infertility is defined as an undesired absence of fertility for 1 year despite frequent intercourse. About 10-15% of couples in the United States are infertile. Most infertility is subfertility, and relatively few couples are sterile. ▪ A steady decrease in fertility begins at about age…

Amenorrhea, Oligomenorrhea, and Hyperandrogenic Disorders

Clinical Keys for this Chapter ▪ Amenorrhea literally means the absence of menses. As a menstrual disorder, amenorrhea is primary when menstruation has never occurred by the age of 16 years (or 14 years with the absence of breast development) and is secondary when menses has occurred at least once and then has been absent for at least 6 months. ▪ A more clinically useful classification…

Puberty and Disorders of Pubertal Development

Clinical Keys for This Chapter ▪ Both genetic and environmental factors determine the onset of pubertal change in young girls. Puberty may be delayed or may occur earlier, depending on nutrition-related factors and physical activity. Obesity causes earlier onset of puberty, and excessive exercise causes delay. Psychological disorders and chronic isolation may also affect the normal onset of puberty. ▪ The Frisch hypothesis states that an…

Gynecologic Procedures: Imaging Studies and Surgery

Clinical Keys for This Chapter ▪ Imaging studies are used in gynecology to evaluate pelvic masses and also to assist in oocyte retrieval. Common modalities used include ultrasonography, sonohysterography, computed axial tomography, magnetic resonance imaging, mammography, and hysterosalpingography. ▪ Before any gynecologic procedure is performed, a process of informed consent should occur during which the patient collaborates and makes a choice with her surgeon. Most procedures…

Breast Disease: A Gynecologic Perspective

Clinical Keys for This Chapter ▪ Mammographic screening of asymptomatic women after the age of 40 years decreases the mortality of breast cancer. About 40% of cancers detected by mammographic screening are not clinically apparent. ▪ Hyperplasia is the most common benign breast disorder. When associated with cellular atypia, there is an increased risk of subsequent malignant transformation. ▪ About 5-10% of breast cancers are hereditary…

Intimate Partner and Family Violence, Sexual Assault, and Rape

Clinical Keys for This Chapter ▪ Intimate partner violence, formerly called domestic violence, is defined as intentionally abusive or controlling behavior by a person who is (or was) in an intimate or close relationship with the victim. The relationship may be heterosexual or between two people of the same sex. Most of the time a woman is the victim, but on occasion the abused person is…

Sexuality and Female Sexual Dysfunction

Clinical Keys for This Chapter ▪ Sexuality and sexual expression are important aspects of human behavior. Recent liberalization of attitudes about sexuality and sexual expression has allowed the diversity of sexual behavior to be acknowledged. Although sexual expression is unlikely to begin before puberty, gender identity is expressed as early as 3 to 4 years of age. Gender identity disorder exists when children are unable to…

Family Planning: Reversible Contraception, Sterilization, and Abortion

Clinical Keys for This Chapter ▪ There are three types of interventions available in family planning to prevent unwanted pregnancies. The first is contraception, which prevents fertilization by blocking the union of the gametes. The second is interception, which works after fertilization but before implantation. The third is abortion, which is defined as the interruption of an established pregnancy. The patient's perspective and preferences for family…

Abnormal Uterine Bleeding

Clinical Keys for This Chapter ▪ During the reproductive years (puberty to menopause), menstrual bleeding normally occurs every 24 to 38 days, except during the first few years of menstruation, during and for a short time after pregnancy and lactation, and in the perimenopausal period. The normal duration of bleeding is 4.5 to 8 days, and the amount of normal flow is less than 80 mL of…

Endometriosis and Adenomyosis

Clinical Keys for This Chapter ▪ Endometriosis is defined as the presence of endometrial glands and stroma in extrauterine locations. An accurate prevalence for endometriosis is not known, but it is estimated that about 10% of women of reproductive age have the disease. Most women are without symptoms, but some have severe pain often manifested by dysmenorrhea, dyspareunia, and, less often, dyschezia. Infertility is often the…

Ectopic Pregnancy

Clinical Keys for this Chapter ▪ Ectopic pregnancy refers to those pregnancies that implant outside the uterine cavity. Although more than 95% of ectopic pregnancies implant in the fallopian tube, occasionally they may implant in other sites, such as the ovary, the uterine cervix, or, very rarely, in the abdominal cavity or a cesarean uterine scar. Following the use of assisted reproductive technologies (ARTs), the incidence…

Pelvic Floor Disorders: Pelvic Organ Prolapse, Urinary Incontinence, and Pelvic Floor Pain Syndromes

Clinical Keys for This Chapter ▪ Effective clinical evaluation of patients with disorders of the female pelvic floor, such as pelvic organ prolapse (POP) and stress urinary incontinence (SUI), requires a clear understanding of female pelvic anatomy. Defects of vaginal support include anterior vaginal prolapse (cystocele), posterior vaginal prolapse (rectocele and enterocele), and apical uterine prolapse. Symptoms of POP generally affect quality of life, but when…

Infectious Diseases of the Female Reproductive and Urinary Tract

Clinical Keys for this Chapter ▪ Bacterial vaginosis (BV) is caused by an alteration of normal vaginal bacterial flora that results in the loss of hydrogen peroxide-producing lactobacilli, thereby allowing an overgrowth of predominantly anaerobic bacteria. Women with BV are at increased risk for pelvic inflammatory disease (PID) and postabortal and postoperative infection. Trichomonas vaginitis, caused by a flagellated parasite, is another sexually transmitted infection (STI)…

Pelvic Pain: Acute, Cyclic (Dysmenorrhea), and Chronic

Clinical Keys for This Chapter ▪ Acute pelvic pain of sudden onset can be caused by both gynecologic and nongynecologic disorders. Adnexal accidents such as rupture or torsion of ovarian cysts, pelvic infections, tubal rupture of ectopic pregnancies, and aborting intrauterine pregnancies are the more common gynecologic causes. Gastrointestinal conditions, such as appendicitis and bowel obstruction, and genitourinary problems, such as cystitis and ureteral stones are…