CASE

DISCUSSIONS
EMINE ZEYNEP YILMAZ, MD, ASSISTANT PROFESSOR

MEDIPOL UNIVERSITY HEALTH CARE

PRACTICE & RESEARCH CENTER ESENLER HOSPITAL
 A 23-year-old woman underwent a dilation and curettage
(D&C) for an incomplete abortion 3 days previously.
She complains of continued vaginal bleeding and lower
abdominal cramping.
Over the last 24 hours, she notes significant fever and chills.
On examination, her temperature is 102.5°F (39.2°C), blood

CASE 1 pressure (BP) is 90/40 mm Hg, and heart rate (HR) is 120
beats per minute (bpm). The cardiac examination reveals
tachycardia, and the lungs are clear.
There is moderately severe lower abdominal tenderness.
The pelvic examination shows the cervical os to be open to
1.5 cm, and there is uterine tenderness.
The leukocyte count is 20000. Hb:12 Urinalysis 2 wbc/hpf.
 What is the most likely diagnosis?

Septic abortion (with retained placental tissue)

What is your next step?

Broad spectrum antiobiotics and fluid resuscitation

following the D/C of the uterus
 A 23-year-old woman underwent a dilation and curettage
(D&C) for an incomplete abortion 3 days previously.
She complains of continued vaginal bleeding and lower
abdominal cramping.
Over the last 24 hours, she notes significant fever and chills.
On examination, her temperature is 102.5°F (39.2°C), blood
pressure (BP) is 90/40 mm Hg, and heart rate (HR) is 120
Key points? beats per minute (bpm). The cardiac examination reveals
tachycardia, and the lungs are clear.

There is moderately severe lower abdominal tenderness. The

pelvic examination shows the cervical os to be open to 1.5 cm,
and there is uterine tenderness.
The leukocyte count is 20000. Hb:12 Urinalysis 2 wbc/hpf.
  Signs and symptoms of septic abortion are uterine
bleeding and/ or spotting in the first trimester with clinical
signs of infection. The infection ascends from the vagina
or cervix to the endometrium to myometrium to
parametrium, and, eventually, the peritoneum.
 Affected women generally will have fever and leukocyte
counts of > 10 500 cells/ μL. There is usually lower
Septic Abortion abdominal tenderness, cervical motion tenderness, and a
foul-smelling vaginal discharge.
 The infection is almost always polymicrobial, involving
anaerobic streptococci, bacteroides species, Escherichia
coli and other gram-negative rods, and group B β-
hemolytic streptococci.
  The treatment has four general parts: (1) maintain the
blood pressure; (2) monitor the blood pressure,
oxygenation, and urine output; (3) start antibiotic therapy;
and (4) perform a uterine curettage.
 Immediate therapeutic steps include intravenous isotonic
fluid replacement, especially in the face of hypotension.
Concurrently, intravenous broad-spectrum antibiotics with

Septic Abortion particular attention to anaerobic coverage should be

infused.
 Because retained POC are common in these situations,
becoming a nidus for infection to develop, evacuation of
the uterine contents is important.
 Uterine curettage is usually performed approximately 4
hours after antibiotics
 A 34-year-old woman undergoes an elective termination of
pregnancy at 12 weeks’ gestation. She develops fever,
uterine tenderness, and is diagnosed with a septic abortion.
Which of the following is the most likely mechanism of her
infection?
 A. Instrumental contamination
Q&A  B. Ascending infection
 C. Skin organisms
 D. Urinary tract penetration
 E. Hematogenous infection
  A 22-year-old woman is diagnosed with a septic abortion
after an incomplete abortion, fever, and uterine
tenderness. She is treated with triple IV antibiotics and
D&C of the uterus. After 48 hours of antibiotic therapy,
she still has a fever of 102°F (38.8°C), BP of 80/ 40 mm
Hg, and HR of 105 bpm. A computed tomography (CT)
scan of the abdomen and pelvis is performed revealing
pockets of air within the muscle of the uterus. Which of
Q&A the following is the best treatment for this patient?
 A. Add extended anaerobic coverage to the antibiotic
regimen
 B. Add intravenous heparin to the regimen
 C. Continue the present antibiotic therapy
 D. Counsel the patient regarding need for hysterectomy
  A 23-year-old G2P1 woman at 16 weeks’ gestation complains of a
12-hour history of colicky, right lower abdominal pain, and nausea
with vomiting.
 She denies vaginal bleeding or leakage of fluid per vagina. She
denies diarrhea or eating stale foods.
 She has a history of an 8-cm ovarian cyst, and otherwise has been
in good health.
 She denies dysuria or fever, and has had no surgeries.
CASE 2  Her vital signs include a blood pressure (BP) of 100/70 mm Hg,
heart rate (HR) of 105 beats per minute (bpm), respiratory rate (RR)
of 12 breaths per minute, and temperature of 99°F (37.2°C).
 On abdominal examination, her bowel sounds are hypoactive. The
abdomen is tender in the right lower quadrant region with significant
involuntary guarding.
 The cervix is closed. The fetal heart tones are in the range of 140
bpm.
What is the most likely diagnosis?

Torsion of the ovary

What is your next step?

Surgery
  A 23-year-old G2P1 woman at 16 weeks’ gestation complains of a
12-hour history of colicky, right lower abdominal pain, and nausea
with vomiting.
 She denies vaginal bleeding or leakage of fluid per vagina. She
denies diarrhea or eating stale foods.
 She has a history of an 8-cm ovarian cyst, and otherwise has been
in good health.
 She denies dysuria or fever, and has had no surgeries.
CASE 2  Her vital signs include a blood pressure (BP) of 100/70 mm Hg,
heart rate (HR) of 105 beats per minute (bpm), respiratory rate (RR)
of 12 breaths per minute, and temperature of 99°F (37.2°C).
 On abdominal examination, her bowel sounds are hypoactive. The
abdomen is tender in the right lower quadrant region with significant
involuntary guarding.
 The cervix is closed. The fetal heart tones are in the range of 140
bpm.
 A 28-year-old G1P0 woman at 28 weeks’ gestation presents to the
hospital with fever, nausea and vomiting, and anorexia of 2 days’
duration. On examination, her temperature is 100.7°F (38.16°C),
HR is 104 bpm, and BP is 100/ 60 mm Hg. Her abdomen reveals
tenderness on the right lateral aspect at the level of the umbilicus.
There is mild right flank tenderness. A urinalysis is normal. In
consideration of the diagnostic possibilities, which of the following
is most accurate regarding this patient?

Q&A  A. Appendicitis should be considered since the appendix

location changes during pregnancy.
 B. Cholecystitis is best diagnosed by CT scan of the abdomen.
 C. Pyelonephritis commonly presents with normal urinalysis
findings.
 D. Inflammatory bowel disease should strongly be considered in
this patient.
  An 18-year-old G1P0 woman complains of a 2-month
history of colicky, right abdominal pain when she eats. It is
associated with nausea and emesis. She states that the
pain radiates to her right shoulder. The patient has a
family history of diabetes. Which of the following is the
most likely diagnosis?

Q&A  A. Peptic ulcer disease

 B. Cholelithiasis
 C. Appendicitis
 D. Ovarian torsion
 A 19-year-old G1P0 woman at 28 weeks’ gestation arrives to
the obstetric (OB) triage area complaining of a 12-hour history
of abdominal pain. She denies trauma, vaginal bleeding, or
fever. On examination, her temperature is 99°F (37.2°C), HR is
100 bpm, and BP is 100/ 70 mm Hg. Her abdominal
examination reveals hypoactive bowel sounds, diffuse
abdominal pain with guarding. Which of the following statements
regarding the abdominal pain is most accurate?

Q&A  A. The absence of vaginal bleeding rules out abruption as an

etiology.
 B. Ovarian torsion is typically characterized by constant pain.
 C. The gallbladder typically moves superior and laterally with
pregnancy.
 D. Degenerating leiomyoma typically presents with localized
tenderness over the fibroid.
 A 20-year-old G1P0 woman at 12 weeks’ gestation is noted
to have a suspected ruptured ectopic pregnancy. On
sonography, there is a moderate amount of free fluid in the
abdominal cavity. The medical student assigned to evaluate
the patient is amazed by the apparent stability of the patient.
Which of the following is the earliest indicator of
hypovolemia?

Q&A  A. Tachycardia
 B. Hypotension
 C. Positive tilt
 D. Lethargy and confusion
 E. Decreased urine output
  A 48 year-old woman presents with intermenstrual bleeding for
2 months. Episodes can ocur any time of period and it is red
and lighter than normal period.
 There is no associated pain.

CASE 3  No flushes or night sweats

She is sexually active and has used minipill for 5 years.
Her last smear was 2 years ago and all smears have been normal.
No medication and no other relevant history.
 CASE 1

Speculum examination: slightly atrophic-looking vagina and cx. No

lesions or current bleeding.
Bimanual examination: Uterus in non-tender and normal size,
mobile. No adnexal masses
Ultrasound: hyperechogenic endometrial mass
  ? What is the most likely diagnosis?
Endometrial polyp
 ? What is the differential diagnosis?
 Cervical malignancy, endocervical polyp, atrophic vaginitis,
pregnancy, irregular bleeding related to contraceptive pill
 ?What is your next step?
Eliminate the cause of bleeding and
ensure that is not malignant
  A 48 year-old woman presents with intermenstrual bleeding for
2 months. Episodes can ocur any time of period and it is red
and lighter than normal period.

ABNORMAL  There is no associated pain.

UTERINE  No flushes or night sweats

BLEEDING She is sexually active and has used minipill for 5 years.
Her last smear was 2 years ago and all smears have been normal.
No medication and no other relevant history.
ABNORMAL
UTERINE
BLEEDING
  Patient history
 Comprehensive physical examination

ABNORMAL  Laboratory test results

UTERINE FIRSTT OBTAIN PREGNANCY TEST ALWAYS!!!

CBC, tests for coagulation disorders, TSH, STD
BLEEDING pap-smear
 Imaging tests
 Transvaginal ultrasonography and endometrial sampling
  THE HEAVY MENSTRUAL BLEEDING?

OLIGOMENORRHEA

 IRREGULAR MENSTRUAL BLEEDING?

ABNORMAL POLYMENORRHEA

UTERINE  INFREQUENT MENSTRUAL BLEEDING? ANOVULATORY

BLEEDING
 FREQUENT MENSTRUAL BLEEDING? MENORRHAGIA

 SPOTTING DURING CYCLES? HIPOMENORRHEA

 SHORTENED MENSTRUAL BLEEDING? METRORRHAGIA

ABNORMA
L UTERINE
BLEEDING
  A 32 year old woman complains of hypomenorrhea. Her cycles
are regular but only lasts for 2 days. In the ultrasound,
endometrial thickness is normal and she has a 3 cm ovarian
cyst. She also desires pregnancy.
 What should be your diagnostic step?

Q &A  A. Endometrial sampling

 B. CBC and Coagulation profile
 C. Ovarian cystectomy
 D.Laboratory tests
 FSH, TSH, PRL
  A 40-year old woman complains with heavy menstrual
bleeding. Her cycles are regular with heavy bleeding, duration
of 7 days. Her blood count is Hb:9.8 Hct:27 Plt:138000. In the
ultrasound uterus is bigger than usual, no adnexal masses.
 Which can not be the diagnose?

Q &A
 A. Myoma uteri
 B. Anovulatory cycle
 C. Adenomyosis
 D. Malignancy
  An 18-year-old single woman showed out with a intermenstrual
bleeding. Her BMI is 30. She complains of her acneic skin. Her
LMP was 25 day ago and she said this bleeding is unusual.
Bleeding is red, not so heavy but little painful.
 What should be your first test?

Q &A  A.CBC
 B.FSH
 C.B-HCG
 D.TSH
 E.INR
 An 25-year-old nulliparous woman complains of a vaginal discharge with a fishy odor over the past 2
weeks.
 She states that the odor is especially prominent after intercourse.
CASE 2
 Her last menstrual period was 3 weeks ago.
 She denies being treated for vaginitis or sexually transmitted diseases.
 She is in good health and takes no medications other than an oral contraceptive agent.
  On examination, her blood pressure (BP) is 110/70 mm Hg,
heart rate (HR) is 80 beats per minute, and temperature is
afebrile. The thyroid is normal to palpation. The heart and lung
examinations are normal.

CASE 2
 The external genitalia are normal; the speculum examination
reveals a homogeneous, white vaginal discharge and a fishy
odor. No erythema or lesions of the vagina are noted.
 ? What is the most likely diagnosis?
Bacterial vaginosis
? What is the best treatment for this condition?
Metronidazole orally or vaginally, alternatively
clindamisin
?What are the three common infections of vaginitis?
BV, Trichomoniasis and Candidal vulvovaginitis
  An 25-year-old nulliparous woman complains of a vaginal discharge
with a fishy odor over the past 2 weeks

 She states that the odor is especially prominent after intercourse.

 Her last menstrual period was 3 weeks ago.
 She denies being treated for vaginitis or sexually transmitted diseases.
 She is in good health and takes no medications other than an oral

Key words?
contraceptive agent.
 On examination, her blood pressure (BP) is 110/70 mm Hg, heart rate
(HR) is 80 beats per minute, and temperature is afebrile. The thyroid is
normal to palpation. The heart and lung examinations are normal.
 The external genitalia are normal; the speculum examination reveals a
homogeneous, white vaginal discharge and a fishy odor. No erythema
or lesions of the vagina are noted.
  -Is not a true infection –rather an overgrowth of anaerobic
bacteria, which replaces the normal lactobacilli of the vagina
 -Most common symptom : FISHY ODOR

Bacterial  -Adding 10% KOH (potasyum hidroxide) release of amines –

whiff test
Vaginosis  -No inflammatory – no swelling or irritation –
 -Microscopy with saline– CLUE CELLS –cocoid bacteria
adherent to external surfaces of epithelial cells
  -Amsel Criteria (3 out of 4 criteria)
 Homogenous, gray-White discharge
 Vaginal pH > 4,5
 Positive whiff test
 Clue cells on wet mount
Bacterial
Vaginosis -Endometrıtıs, PID, pregnancy complications (preterm delivery, pprom)

-Treatment – oral or vaginal metronidazole

metronidazole and alcohol??
-Clindamisin is another effective treatment
 Single cell anaerobic flagellated protozoan – intense
inflammatory reaction
Common STD
Can survive up to 6 hours on a wet surface
Also inhabit urethra or Skene’s glands --vaginal metronidazol
is not enough
Trichomonas «Frothy» yellow-green vaginal discharge / vaginal irritation
Vaginalis Strawberry cx
Fishy odor
Microscopical flagellated organisms
High dose metronidazole (2g orally) -- partner treatment?
 o Candida albicans – common cause
o Lactobacilli inhibit fungal growth; antibiotic therapy may
decrease the lactobacilli concentration, leading to Candida
overgrowth
o DM predipose – immun supression
Candidal o Intense vulvar vaginal burning irritation and swelling
Vaginitis o Dyspareunia
o With KOH –lysing leukocytes and erythrocytes- hyphae or
pseudohyphae
o Treatment – oral fluconazole or topical imidazoles
 Bacterial Vaginosis Trichomonal Vaginitis Candidal Vulvovaginitis

Appearance Homogeneous, white Frothy, yellow to green Curdy, lumpy

Characterics of discharge

Various Vaginal
Vaginal pH >4,5 >4,5 <4,5

Infections
Whiff test + + None

Microscopy Clue cells (>20% of the Trichomonads Pseudohyphae

cells seen)
Treatment Metronidazole Metronidazole Oral fluconazole or
imidazole cream
  An 18-year-old G0P0 adolescent female is being seen at the
physician’s Office for vaginal discharge. A presumptive
diagnosis of bacterial vaginosis is made. Which of the
following is a finding consistent with BV?

Q &A  A. pH less than 4.5

 B. Frothy vaginal discharge
 C. Predominance of anaerobes
 D. Flagellated organisms
  A 26-year-old woman completed a course of oral antibiotics for
cystitis 1 week ago. She complains of a 1-day history of
itching, burning, and a yellowish vaginal discharge. Which of
the following is the best therapy?
 A. Metronidazole

Q &A  B. Erythromycin
 C. Fluconazole
 D. Hydrocortisone
 E. Clindamycin
  A 27-year-old woman complains of a fishy odor and a vaginal
discharge. The speculum examination reveals an erythematous
vagina and punctuations of the cervix. Which of the following
is the most likely treatment for this patient?

Q &A  A. Oral fluconazole

 B. Metronidazole gel applied vaginally
 C. Metronidazole taken orally in a single dose
 D. Intramuscular ceftriaxone and oral doxycycline
  A 42-year-old G2P2 woman complains of severe lower
abdominal pain over the past 3 years, which is worsening.
 She states that the pain is worse with menses.
 She denied pain with intercourse.
 She had no medical problems.

CASE 3  On examination, her blood pressure (BP) is 100/60 mm Hg,

heart rate (HR) is 78 beats per minute (bpm), and temperature
is 99°F (37.2°C). The heart and lung examinations are normal.
Her abdomen is nontender and without masses.
 Her pelvic examination shows no tenderness or trigger points.
 Her pregnancy test is negative.
 ? What is the most likely diagnosis?
Chronic pelvic pain
 ? What is the differential diagnosis?
 BROAD AND COMPLEX
 Gyn? UTI? GI? Neuro? Psych?
 ?So what’s the next step?
Careful history and physical examination
 This is a 42-year-old G2P2 woman with worsening lower
abdominal/ pelvic pain of 3 years’ duration. The physical
examination appears to be normal. We are not given further
information about the nature of the pain, but this is critically
important to try to reach a presumptive diagnosis.
• associated with bloating, diarrhea/ constipation may be ?
• urinary urgency or frequency suggests ?
Pelvic Pain • a patient with a history of depression or sexual abuse may
suggest?
• pain that is burning or radiating may be ?
• excessive vaginal bleeding associated with CPP may be ?
• dyspareunia or dyschezia may be ?
• A history of PID may be ?
  FIRST PREGNANCY SHOULD BE RULED OUT!! In every
reproductive aged women first test is BHCG!!!

 Chlamydia and gonorrhea assays, urinalysis and urine culture

and sensitivity, complete blood count, and then pelvic
ultrasound.

Pelvic pain
Nonsteroidal anti-inflammatory drugs such as ibuprofen and/ or
an oral contraceptive agent are initiated with 3 month trial.
If there is no response, additional careful history and physical
examination can be repeated. If there is non nongynecologic
etiology noted, L/S is reasonable to assess for endometriosis
  Acute pelvic pain – lower abdomen / pelvic region less than 2
weeks’
 Subacute pelvic pain – 2 weeks – 6 months
 Chronic pelvic pain-at least 6 months effects Daily function
and quality of lifw

Definitons  Chronic Pelvic Pain Syndrome- without any obvious etiology

or infection after diligent search, associated with sexual or
emotional consequences

 ?? Dyspareunia ??
 ?? Dysmenorrhea ??
 Up to 20% of women between the age of 18 and 49
years have CPP that lasts more than 1 year.

Chronic
and accounts forPelvic
 CPP comprises 20% to 30% of gynecologic visits
15% of hysterectomies in the
Pain
United States.
 Up to one-third of laparoscopies are performed for
this complaint.
 Even after diligent investigation, up to one-third of
women with CPP will have no underlying etiology. Endometriosis Pelvic adhesions or Chronic PID
Other
 • Careful history and physical examination (physician should be
patient, respectful, sensitive and meticulous)
• Dismissed as histrionic or exaggerating, or «hormonal»
Chronic Pelvic (physican should be encouraging)

Pain • The character of pain, duration, frequency, severity,

exaggerating and relieving factors, onset, associated factors are
important (ask someone to patient)
 GYNECOLOGICAL CAUSES
 Endometriosis
 Adhesions
 Chronic PID
 Ovarian remnant syndrome
 Leiomyomata (degenerating)
 Adenomyosis
 Pelvic floor and hip muscle pain

Chronic Pelvic
Pain NON-GYNECOLOGICAL CAUSES
 Genitourinary : Urethral syndrome, Interstitial cystitis
 Gastrointestinal :Irritable bowel syndrome, Partial bowel
obstruction, Inflammatory bowel disease, Diverticulitis, Hernia
 Neuromuscular: Nerve entrapment syndrome, Myofascial pain
syndrome, Fibromyalgia
 Psychological: Depression, Post-traumatic stress disorder,
  A 17-year-old G0P0 female complains of severe pain with
menses for 3 years,
 which seems to be worsening. She has tried oral contraceptives
and NSAIDs
 for 2 years without relief. Her pregnancy test is negative.
Which of the following

Q &A  is the best next step?

 A. GnRH agonist therapy
 B. Opiate medical therapy
 C. Psychiatric evaluation
 D. Laparoscopy
 E. Trigger point injection
  A-16-year-old G0P0 female complains of severe pain with
menses which began within her first year of menses. The
physical examination is normal. The pregnancy test is negative.
Which of the following is the most likely mechanism?

Q &A  A. Pelvic adhesions

 B. High prostaglandin levels
 C. Tubal inflammation
 D. Endometriosis
 A 23-year-old G0P0 woman presents to the office with complaints of irregular cycles since menarche.
 She has also noticed an increase in facial hair and acne for many years.
 She denies any history of medical problems and has a strong family medical history of diabetes.

CASE 4
 On examination, she is noted to have a normal blood pressure (BP), pulse, respiratory rate, and
temperature.
 She is obese with a body mass index (BMI) of 34 kg/m2.
 She is noted to have some hirsutism and acanthosis nigricans (of neck and inner thighs).
 Her pelvic examination is limited by her obesity but normal.
 She does not desire pregnancy at this time. Her pregnancy test is negative.
  ? What is the most likely diagnosis?
Polycystic ovarian syndrome
 ? What complications is the patient at risk for?
 DM, endometrial cancer, hyperlipidemia, metabolic syndrome,
cardiovascular disease
 ?What is your next diagnostic step?
TSH, PRL, testosterone, DHEAS, 17 OH-P, pelvic ultrasound
?What is therapeutic plan for this patient?
 Regulate mens cycles, screen for metabolic abnormalities. Encourage
diet and exercise.
  A 23-year-old G0P0 woman presents to the office with complaints of
irregular cycles since menarche.
 She has also noticed an increase in facial hair and acne for many
years.
 She denies any history of medical problems and has a strong family
medical history of diabetes.
 On examination, she is noted to have a normal blood pressure (BP),
CASE 4 pulse, respiratory rate, and temperature.
 She is obese with a body mass index (BMI) of 34 kg/m2.
 She is noted to have some hirsutism and acanthosis nigricans (of
neck and inner thighs).
 Her pelvic examination is limited by her obesity but normal.
 She does not desire pregnancy at this time. Her pregnancy test is
negative.
  Criteria for diagnosis (2 out of 3)
 Hyperandrogenism
 Oligomenorrhea
 Polycystic ovaries by ultrasound

Polycystics ovaries can occur with any state of anovulation (so its a sign
not a disease)

PCOS
Persistant anovulation  Infertility, mens irregularities, androgen
excess (hirsutism, acne, alopecia), increased risk of endometrial cancer,
CVS disease and DM

4-6% of women reported as hyperandrogenic anovulation

  -Laboratory
 TSH, PRL, lipid profile, glucose-intolerance screening,
endometrial biopsy (long standing and unopposed estrogen
exposure), 17-OH-progesterone (congenital adrenal hyperplasia)
 Testesterone and DHEAS for excess androgen stimulation or
PCOS androgen-secreting tm?
 The majority of testosterone is producted by ???
 Ovary
 DHEAS is secreted by???
 Adrenal gland
  Ultrasound presence of 12 or more follicles, each ovary
measurin 2-9 mm, increased ovarian volume >10 ml. …string
PCOS of pearls
 PCOS

 WHAT DO WE DO FOR TREATMENT ??

 REDUCE CIRCULATING ANDROGEN LEVELS

 PROTECT ENDOMETRIUM FROM UNOPPOSED ESTROGEN
 ENCOURAGE WEIGHT LOSS AND HEALTHY LIFESTYLE CHANGES
 INDUCE OVULATION WHEN PREGNANCY IS DESIRED
 MONITOR FOR DM CVS MODIFY RISK FACTORS (SMOKING CESSATION, LIPID LOWERING
AGENTS)
  A 28-year-old G0P0 woman has a chronic history of
oligomenorrhea and amenorrhea. She undergoes an endometrial
biopsy in light of her long history of anovulation, which returns as
Grade 1 adenocarcinoma of the endometrium. Magnetic
resonance imaging seems to indicate that the endometrial cancer
is isolated to the uterus. The patient desires to have children if
pos- sible. Which of the following is the best therapy for this
patient?
Q &A
 Endometrial ablation
 Radical hysterectomy
 Cervical conization
 High-dose progestin therapy
 Oral contraceptive agent
  A 32-year-old G0P0 woman is noted to
have irregular menses and hirsutism.
Which of the following is consistent with
polycystic ovarian syndrome?

Q &A  Elevated 17-hydroxyprogesterone level

 Finding of a 9-cm right ovarian mass
 DEXA scan showing osteopenia
 Serum FSH:LH levels of 1:2
  A 60-year-old nulliparous woman who
underwent menopause at age 55 years
complains of a 4-week history of vaginal
bleeding.

CASE 5  Prior to menopause, she had irregular menses

for about 20 years.
 She denies the use of estrogen-replacement
therapy.
  Her medical history is significant for diabetes mellitus
controlled with an oral hypoglycemic agent.
 On examination, she weighs 100 kg, her height is 155 cm,
blood pressure is 150/90 mm Hg, and temperature is 37.2°C.
 The heart and lung examinations are normal.
CASE 5  The abdomen is obese, and no masses are palpated.
 The external genitalia appear normal, and the uterus seems to
be of normal size without adnexal masses.
 ? What is your next step?
Endometrial biopsy
 ? What is your concern?
 Endometrial cancer
  Postmenopausal bleeding always needs to be investigated!
because it can indicate malignant disorders or premalignant
conditions, such as endometrial hyperplasia.
 The most common etiology of postmenopausal bleeding is
atrophic endometritis or vaginitis.
 Vaginal spotting can occur in a patient taking hormonal
Endometrial therapy.

Cancer
 ***However, since endometrial malignancy can coexist with
atrophic changes or in women taking hormone-replacement
therapy, endometrial carcinoma must be ruled out in any
patient with postmenopausal bleeding. Possible methods for
assessment of the endometrium include endometrial sampling,
hysteroscopy, or transvaginal sonography***
RISK FACTORS FOR ENDOMETRIAL CANCER
Early menarche
Late menopause
Obesity

Endometrial
Chronic anovulation Estrogen-secreting ovarian tumors Ingestion of unopposed estrogen Hypertension
Diabetes mellitus
Personal or family history of breast or ovarian cancer or genetic cancer syndrome (Lynch syndrome) Olderage
Cancer
History of infertility
 Endometrial Cancer

 ENDOMETRIAL SAMPLING (BIOPSY): A thin catheter is

introduced through the cervix into the uterine cavity to aspirate
endometrial cells
  Endometrial carcinoma is the most common female genital
tract malignancy.
 Although endometrial cancer is not the most common cause of
postmenopausal bleeding, it is the one that is most concerning.
 Fortunately, because endometrial cancer is associated with an
Endometrial early symptom, abnormal uterine bleeding, it is usually
Cancer detected at an early stage.
 Once diagnosed, endometrial cancer is staged surgically
 The subset of women who have grade 1 (well differentiated),
endometriod carcinoma that is minimally invasive may not
necessarily need lymph node sampling.
  Sometimes endometrial cancer may occur in the atypical patient
such as a thin patient; these cancers tend to be of the Type II
variety (clear cell and papillary serous type) and more
aggressive and associated with extrauterine metastases.
 In fact, clear cell carcinoma only accounts for 10% of uterine
cancer but is associated with 40% of deaths. Also, those patients
with uterine cancer with a thin endometrial stripe (<4 mm) post-
Endometrial menopausal bleeding are likely to have Type II cancer.

Cancer  Women with Lynch syndrome are at increased risk of developing

colon cancer, ovarian cancer, and Type I endometrial cancer. This
is an autosomal dominant disorder and associated with mutations
of one of the mismatch repair genes. The lifetime risk of
developing endometrial cancer varies from 16% to 61% depending
on the exact mutation.
  A 60-year-old woman presents to her physician’s office with
postmenopausal bleeding. She undergoes endometrial
sampling, and is diagnosed with endometrial cancer. Which of
the following is a risk factor for endometrial cancer?
 A.Multiparity
 B.Herpes simplex infection
Q &A  C.Diabetes mellitus
 D.Oral contraceptive use
 E.Smoking
  A 48-year-old healthy postmenopausal woman has a Pap smear
performed, which reveals atypical glandular cells. She does not
have a history of abnormal Pap smears. Which of the following
is the best next step?

Q &A  A.Repeat Pap smear in 3 months

 B.Colposcopy, endocervical curettage, endometrial sampling
 C.Hormone-replacement therapy
 D.Vaginal sampling
  A 50-year-old G5P5 woman complains of postcoital spotting over the
past 6 months.
 Most recently, she complains of a malodorous vaginal discharge.
 She states that she has had syphilis in the past.
 Her deliveries were all vaginal and uncomplicated.
 She has smoked 1 pack per day for 20 years.
 On examination, her blood pressure is 100/80 mm Hg, temperature is
CASE 6 99°F (37.2°C), and heart rate is 80 beats per minute. Her heart and lung
examinations are within normal limits. The abdomen reveals no masses,
ascites, or tenderness. Her back examination shows right costovertebral
angle tenderness (CVAT).
 The pelvic examination reveals normal external female genitalia. The
speculum examination reveals a 3-cm exophytic lesion on the anterior
lip of the cervix.
 Her right leg is more swollen than her left leg.
  ? What is your next step?
Biopsy of the cervical lesion
 ? What is the most likely diagnosis?
 Cervical cancer
 with metastases to the right pelvic sidewall
 ?What is the best treatment for this condition?
 RT with a chemosensitizer
  A 50-year-old G5P5 woman complains of postcoital spotting over the past
6 months.
 Most recently, she complains of a malodorous vaginal discharge.
 She states that she has had syphilis in the past.
 Her deliveries were all vaginal and uncomplicated.
 She has smoked 1 pack per day for 20 years.
 On examination, her blood pressure is 100/80 mm Hg, temperature is
CASE 6 99°F (37.2°C), and heart rate is 80 beats per minute. Her heart and lung
examinations are within normal limits. The abdomen reveals no masses,
ascites, or tenderness. Her back examination shows right costovertebral
angle tenderness (CVAT). –ureter metastasis leading to hydronephrosis
 The pelvic examination reveals normal external female genitalia. The
speculum examination reveals a 3-cm exophytic lesion on the anterior lip
of the cervix.
 Her right leg is more swollen than her left leg.
 CERVICAL CANCER

 Early age of coitus

Sexually transmitted diseases
 Early childbearing
 Low socioeconomic status
 Human papillomavirus
HIV infection
Cigarette smoking
Multiple sexual partners
CERVICAL CANCER
 When a woman presents with postcoital spotting or has an abnormal
Pap smear, cervical dysplasia or cancer should be suspected.

 An abnormal Pap smear is usually evaluated by colposcopy with

biopsies, in which the cervix is soaked with 3% or 5% acetic acid
solution.

 The colposcope is a binocular magnifying device that allows visual

examination of the cervix. The majority of cervical dysplasia and
cancers arise near the squamocolumnar junction of the cervix.

 When a woman presents with a cervical mass, biopsy of the mass,

not a Pap smear, is appropriate. Because the Pap smear is a screening
test, used for asymptomatic women, it is not the best test for a visible
lesion.

 When cervical cancer is diagnosed, the next step is staging the severity.
 CERVICAL CANCER

 Since HPV is the etiologic agent in the vast majority of cervical cancer,
 FDA has approved three HPV vaccines. HPV subtypes 6 and 11 cause the majority of condyloma acuminata
(venereal warts), and more importantly subtypes 16 and 18, which cause 50% to 70% of cervical cancer.

 because other subtypes can still cause cervical dysplasia or cancer, regular Pap smears are still required even after
vaccination.
 Pap smear

 • < 21 years : No screening recommended

• 21 -29 years : Pap-smear every 3 years
• 30-65 years: Two options;
1.Cytology with HPV co-testing every 5 years (preferred)
2. Cytology alone every 3 years (acceptable)

• 65+ years: No screening recommended if adequate screening has been

negative and high risk is not present.
  A 48-year-old woman who presents with postcoital vaginal
bleeding is noted to have a cervical exophytic mass. A biopsy
of the mass confirms squamous cell carcinoma. If molecular
analysis of the cancer is performed, which of the following H
PV subtypes is most likely to be found in the specimen?

Q &A A. 6 and 11
B. 16 and 18
C. 55 and 57
D. 89 and 92
   A 40-year-old woman is referred for a Pap smear showing
high-grade squamous intraepithelial lesions. Which of the
following statements is most accurate?

A. If HPV subtyping reveals no high-risk virus present, then routine

cytology is recommended.

Q &A B. If colposcopy demonstrates the entire transformation zone, then no

further analysis is needed.
C. If an endocervical curetting shows cervical dysplasia, then an
excisional procedure of the cervix is appropriate.
D. Cervical cancer is highly unlikely due to the Pap smear revealing
only HSIL.
  An 18-year-old nulliparous adolescent woman complains that
she has not yet started menstruating.
 She denies weight loss or excessive exercise.
 Each of her sisters achieved menarche by 13 years of age.
 The patient’s mother recalls a doctor mentioning that her
daughter had a missing right kidney on an abdominal x-ray
CASE 7 film.
 On examination, she is 167 cm and weighs 63 kgs. Her blood
pressure is 110/60 mm Hg. Her thyroid gland is normal on
palpation. She has Tanner stage IV breast development and
female external genitalia. She has Tanner stage IV axillary and
pubic hair. There are no skin lesions.
  ? What is the most likely diagnosis?
Müllerian agenesis
 ? What is the next step in diagnosis?
 Serum testosterone or karyotype
?What is the most likely finding on pelvic examination?
 Blind vaginal poch or vaginal dimple
  An 18-year-old nulliparous adolescent woman complains that
she has not yet started menstruating. --PRİMER AMENORE
 She denies weight loss or excessive exercise.
 Each of her sisters achieved menarche by 13 years of age.—
OVARIES INTACT
 The patient’s mother recalls a doctor mentioning that her
Müllerian daughter had a missing right kidney on an abdominal x-ray

agenesis film. -
 On examination, she is 167 cm and weighs 63 kgs. Her blood
pressure is 110/60 mm Hg. Her thyroid gland is normal on
palpation. She has Tanner stage IV breast development and
female external genitalia. She has Tanner stage IV axillary and
pubic hair. There are no skin lesions.
Is this
müllerian ANDROGEN
Müllerian
agenesis? INSENSITIVITY
SYNDROME
agenesis
  -Difference between androgen insensitivity?
***there is typically scant axillary and pubic hair since there is a
defective androgen receptor. The diagnosis can be confirmed with
a serum testosterone, which would be normal in müllerian
agenesis,and elevated (in the normal male range) in androgen
insensitivity.
Müllerian In both conditions, there is no uterus, tubes, or cervix, and a
agenesis blind vaginal pouch or vaginal dimple.
 A karyotype would also help to distinguish the two conditions.
 Absence of breast development would point to a
hypoestrogenic state such as gonadal dysgenesis
 (Turner syndrome).
  When a young woman presents with primary amenorrhea, the differential diagnosis can
be narrowed on the basis of whether or not normal breast tissue is present, and whether a
uterus is present or absent.
 After pregnancy is excluded, the two most common etiologies that cause primary
amenorrhea associated with normal breast development and an absent uterus are
androgen insensitivity syndrome and müllerian agenesis (Table 55– 1).
 An individual with androgen insensitivity syndrome, also known as testicular
feminization, has a 46,XY karyotype with normally functioning male gonads that

Müllerian  produce normal male levels of testosterone. However, due to a defect in the androgen
receptor synthesis or action, there is no formation of male internal or external

agenesis  genitalia. The external genitalia remain female, as it occurs in the absence of sex steroids.
There are no internal female reproductive organs, and the vagina is short or absent.
Without androgenic opposition to the small circulating levels of estrogen ecreted by the
gonads and adrenals, and produced by peripheral conversion of androstenedione, breast
development is normal or enhanced. Pubic and axillary hair is absent or scant due to
defective androgen receptors. Therefore, these individuals are genotypically male
(46,XY karyotype) but phenotypically female (look like a woman). The abnormal intra-
abdominal gonads are at increased risk for malignancy, but this rarely occurs before
puberty. Thus, gonadectomy is not performeduntil after puberty is completed to allow full
breast development and linear growth
 Müllerian Agenesis Androgen Insensitivity

Breast tissue Normal breast development Normal breast development

Axillary and pubic hair Normal Scant or absent

Uterus and vagina Absent uterus and blind vagina Absent uterus and blind vagina

Testosterone level Normal testosterone High testosterone (male range)

Karyotype 46,XX 46,XY

Complications Renal anomalies Need gonadectomy

  An 18-year-old nulliparous adolescent woman complains of not
having
 started her menses. Her breast development is Tanner stage V.
She has a
 blind vaginal pouch and no cervix. Which of the following
describes the most
Q &A  likely diagnosis?
 A. Müllerian agenesis
 B. Kallmann syndrome
 C. Gonadal dysgenesis
 D. Polycystic ovarian syndrome
  Which of the following is the best explanation for breast
development in a
 patient with androgen insensitivity?

 A. Gonadal production of estrogens

Q &A  B. Adrenal production of estrogen
 C. Breast tissue sensitivity to progesterone
 D. Peripheral conversion of androgens
 E. Autonomous production of breast-specific estrogen