Gynecology

Menstrual Hx

Pelvic pain

Cyclic

Non-cyclic
Sudden, sharp pain:

appendicitis, pyelonephritis, nephrolithiasis, musculoskeletal pain, irritable bowel syndrome, growth or degeneration of fibroids

Pelvic pain in early pregnancy

	Ectopic Preg	Spont Abortion	Corpus Luteal Cyst
Hemorrhagic shock out of proportion to external bleeding	Y (if ruptured)	N	N
Peritonitis	Y (if ruptured)	N	Y (if ruptured)
Vaginal bleeding	Y	Y	N
Adnexal mass	Y	N	Y
Open cervical os or tissue passed through vagina	N	Y	N
Colicky pain	N (usually)	Y	N

Tests:

If the internal cervical os is open or if tissue has passed, further testing may be unnecessary unless septic abortion is suspected; then, blood cultures are obtained.
If the os is closed and there is no evidence of tissue passage, ectopic pregnancy must be excluded. Testing begins with quantitative β-hCG and pelvic ultrasonography.

Vaginal bleeding

Early preg:

Ectopic pregnancy

β-HCG doubling time calculator

Gestational trophoblastic disease

Dx: β-hCG (very high levels) & pelvic U/S. Bx is required for definitive Dx.

Hormonal contraception
SOGC CANADIAN CONTRACEPTION CONSENSUS

Combined OC's

Contraindications

Absolute

Relative

2. on the first Sunday after menses begin (backup method of contraception is necessary).

Never exceed the 7 day pill-free interval between packs.

Dual protection with condoms should be emphasized.

A follow-up visit should be scheduled to review the pt's experience, satisfaction, and compliance, as well as check BP. If indicated, a pelvic examination can be performed.

Trouble-shooting

Breakthrough bleeding

If the bleeding persists after 3 mos, or has a new onset (e.g. chlamydia), other causes of bleeding must be ruled out. Possible reasons for irregular bleeding while taking the combined OC include irregular pill taking, smoking, uterine or cervical pathology, malabsorption, pregnancy, use of concomitant medications (e.g. anticonvulsants, rifampin, herbal medicines), and infection.

In the case of persistent or new onset bleeding, a short course of oral estrogen may be helpful, such as 1.25 mg of conjugated estrogen or 2 mg of estradiol-17β daily for 7 days. If no improvement is seen, a therapeutic trial of another combined OC may be indicated. It may be useful to offer a combined OC containing a different type of progestin, such as switching from a preparation that contains a gonane progestin to one that contains an estrane progestin (or vice versa).

Amenorrhea

Is not dangerous & occurs in 2-3% of combined OC users. Pregnancy should first be ruled out.

Chloasma

Changing to another pill will not help & the hyperpigmentation may never completely disappear. The use of sunscreen may help to prevent further pigmentation.

Mastalgia

Often resolves after several cycles of combined OC use. Decreasing caffeine intake may be helpful in reducing mastalgia. Decreasing the estrogen content of the combined OC may also be helpful.

Edema

↓ estrogen or switch to Yasmin.

Acne or hursuitism

↓ progestin or switch to Diane.

Non-contraceptive benefits

The use of monophasic combined OC preparations continuously for several cycles, without periodic withdrawal, is a reasonable approach to the management of severe dysmenorrhea, menorrhagia, menstrual migraine, or where there is a desire or need to postpone withdrawal bleeding.

Combined OC use reduces the risk of developing cancer of the ovary and cancer of the endometrium, and does not increase the overall risk of developing breast cancer.

Use of low-dose combined OCs increases the risk of venous thromboembolism 3- to 4-fold. Because VTE is rare in women of childbearing age, this increase in risk has minimal clinical significance in women without additional risk factors for VTE.

Use of progestin-only preparations has not been shown to decrease breast milk production. The small amounts of steroid hormones secreted into breast milk do not have an adverse effect on the baby.

The use of progestins given at contraceptive doses does not appear to increase the risk of VTE, myocardial infarction, or stroke. Thus, progestin-only preparations may be appropriate for women who have a past history of VTE, or have a higher risk of myocardial infarction or stroke.

Whether the use of progestin-only preparations in women with a proven thrombophilia alters the risk of VTE is not known. In such women, these preparations should be used with caution.

The use of DMPA in healthy young women is associated with a decrease in bone mineral density that appears to be reversible.

Progestin-only methods should be considered as contraceptive options for postpartum women, regardless of breastfeeding status, and may be introduced immediately after delivery.

levonorgestrel-releasing IUS may provide an acceptable alternative to hysterectomy by decreasing menorrhagia and increasing hemoglobin concentrations.

Yasmin is a monophasic combined OC that contains ethinylestradiol 30µg & drospirenone 3 mg, an analogue of spironolactone possessing anti-mineralocorticoid activity that may help to suppress estrogen-related fluid retention & breast tenderness. It is also anti-androgenic → &darr acne & hursuitism.

Medications that may cause contraceptive failure

Instructions Regarding Missed Pills

If you miss 2 pills in a row during the first 2 weeks of the pack, take 2 pills on the day you remember and 2 on the following day. Use a backup method of contraception if you have sex in the 7 days after you miss the pills.

If you have had unprotected intercourse after missing a pill, use emergency contraception.

If you miss 2 pills in a row in the third week of the pack, throw out the remainder of the pack and start a new pack on the day you remember. You may not have a period this month. If you had unprotected intercourse after missing a pill, use emergency contraception.

If you miss 3 pills in a row, throw out the remainder of the pack and start a new pack on the day you remember. If you had unprotected intercourse after missing a pill, use emergency contraception. Use a backup method of contraception if you have intercourse in the first 7 days of the new pack. You may not have a period this month.

Emergency contraception

Incontinence

Stress incontinence

Proper performance should be confirmed by digital vaginal examination or biofeedback.

Vaginal cone

A form of pelvic floor retraining. Cones are placed in the vagina above the level of the pelvic floor musculature. Contraction of these muscles is required to prevent the cone from slipping out of the vagina.

Continence pessary

Urge incontinence (overactive bladder syndrome)

V8 OAB questionnaire

How bothered have you been by:	Not at all	A little bit	Somewhat	Quite a bit	A great deal	A very great deal
1. Frequent urination during the day?	0	1	2	3	4	5
2. An uncomfortable urge to urinate?	0	1	2	3	4	5
3. A sudden urge to urinate with little or no warning?	0	1	2	3	4	5
4. Accidental loss of small amounts of urine?	0	1	2	3	4	5
5. Nighttime urination?	0	1	2	3	4	5
6. Being woken up at night because you had to urinate?	0	1	2	3	4	5
7. An uncontrollable urge to urinate?	0	1	2	3	4	5
8. Urine loss associated with a strong urge to urinate?	0	1	2	3	4	5
9. Are you a male?	Yes (2 points)

Score ≥ 8 indicates OAB.

Involves fluid management, urge suppression, scheduled voiding, bladder diaries.

Functional electrical stimulation (FES).

Electrical stimulation to the pudendal nerve → passive contraction of the pelvic floor muscles or reflex inhibition of bladder contractions.

Ditropan XL (oxybutinin) 5-10 mg PO qd (max 30 mg/d)

Infertility

Incidences: 25% for each

Polycystic ovary syndrome

Also, other endocrine disorders excluded.

Other common S&S's:

Labs:

Exclusion of other disorders that may cause similar symptoms:

Premenstrual Sx

Calendar of premenstrual experiences (COPE)

Menstrual diary

UCSD criteria for premenstrual Sx

Affective

Somatic

3. Symptoms are present in the absence of any pharmacologic therapy, hormone ingestion, drug or alcohol use.

4. Dysfunction in social or economic performance by one of the following criteria:

DSM-IV criteria for premenstrual dysphoric disorder (PMDD)

Decreased interest in usual activities, which may be associated with withdrawal from social relationships
Difficulty concentrating
Feeling fatigued, lethargic, or lacking in energy
Marked changes in appetite, which may be associated with binge eating or craving certain foods
Hypersomnia or insomnia
Subjective feeling of being overwhelmed or out of control
Other physical symptoms, such as breast tenderness or swelling, headaches, joint or muscle pain, a sensation of bloating, weight gain

Mgt

Symptom	Mgt
general	calcium 1200 mg qd chaste berry fruit
mood	as above SSRI (e.g. fluoxetine 20 mg qd or sertraline 50-150 mg qd on days 14-28 or all days) buspirone 5-10 mg on days 14-28
breast tenderness	supportive bra ↓ caffiene, smoking danazol 100-200 mg qd on days 14-28 OCs
bloating	spironolactone 50-200 mg qd
H/A, aches	NSAIDS in luteal phase (e.g. naproxen 600 mg TID)

	mm/dd/yyyy	time	β-HCG
1st β-HCG
2nd β-HCG