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Complications of pregnancy
Intrauterine pregnancy
Ectopic pregnancy
Spontaneous abortion
Gestational trophoblastic disease
Placenta previa
Infection
Cervicitis
Endometritis
Trauma
Laceration, abrasion
Foreign body
Malignant neoplasm
Cervical
Endometrial
Ovarian
Benign pelvic lesions
Cervical polyp
Endometrial polyp
Leiomyoma
Adenomyosis
Systemic disease
Hepatic disease
Renal disease
Coagulopathy
Thrombocytopenia
von Willebrand's disease
Leukemia
Medications/iatrogenic
Intrauterine device
Hormones (oral contraceptives,
estrogen, progesterone)
Hormonal imbalance
Anovulatory cycles
Hypothyroidism
Hyperprolactinemia
Cushings disease
Polycystic ovarian syndrome
Adrenal dysfunction/tumor
Stress
Excessive exercise
disorder
History
Characterize menses
Age, parity, past pregnancies, sexual
history, contraception, past gyn
problems, medications
Personal or family history of bleeding
disorder
Symptoms of thyroid disease
History of liver disease
Physical Exam
Orthostatic VS if indicated by Hx
Pelvic exam vagina, cervix,
uterus, adnexa, PAP
Skin ecchymoses, hirsutism
Thyroid gland
Liver and assoc. stigmata
Signs of virulization
Labs
CBC with Plts
Urine -HCG if reproductive age
TSH anovulatory
LFTs, coagulation studies liver dz or FHx
Complete coagulation profile consider for
non-pregnant teens
GC, Chlamydia if risk or exam suggests
Androgen excess free testosterone,
DHEA-S (PCOS evaluation)
FSH suspect premature ovarian failure
Progesterone confirm ovulation, draw in
luteal phase
Life Phase
Ovulatory Status
Etiology
R/O Pregnancy
Adolescent
Likely anovulation
Pregnancy
Ovulatory
(Secretory)
Hormonal
DUB
Anovulatory
(Proliferative)
Anatomic
Reproductive age
(Usually DUB)
Coagulopathy
R/O Pregnancy
Perimenopause
Early EMB/TV Sono
Postmenopause
R/O Endometrial CA
Adolescents
Usually anovulation due to
immature Hypothal-Pit axis
Rule out pregnancy
Consider bleeding disorder
Observe or Rx with cyclic MPA or
OCs
Reproductive Age
H&P
Check urine -HCG
Genital tract lesionBx or refer
Enlarged uterus
r/o pregnancy
sono for anatomic cause
(e.g., fibroids)
Reproductive Age
If not pregnant and normal exam:
Usually DUB (i.e., hormonal)
Determine ovulatory status key!
Treatment: Usually hormonal
Ovulatory Cycles
Regular cycle length
Presence of premenstrual symptoms
Breast tenderness, dysmenorrhea
Mittleschmertz
Biphasic temperature curve
Anovulatory Cycles
Unpredictable cycle length
Unpredictable bleeding pattern
Frequent spotting
Infrequent heavy bleeding
Monophasic temperature curve
Anovulatory Bleeding
90-95% of reproductive age
Cause: systemic hormonal
imbalance
Always a relative progestindeficient state
Anovulatory Bleeding
Check TSH
Test for PCOS if indicated
Ovulatory Bleeding
Ovulatory Bleeding
Much less common5-10%
Consider empiric treatment
without further w/u (normal exam)
(water sono)
Perimenopause
H&P
Check urine -HCG
Genital tract lesionBx or refer
Enlarged uterus
r/o pregnancy
TV Sono for anatomic evaluation
(e.g., fibroids)
Perimenopause
If not pregnant and normal exam:
Consider early EMB or TV Sono
Postmenopause
5-10% endometrial carcinoma
Proceed directly to EMB or TV Sono
DDx: endometrial hyperplasia, cervical
Rx specific to cause
Surgical Treatment
Therapeutic D+C
Endometrial Ablation/Resection
laser or electrocautery
good option if fertility not desired
Surgical Treatment
Hysterectomy
Life Phase
Ovulatory Status
Etiology
R/O Pregnancy
Adolescent
Likely anovulation
Pregnancy
Ovulatory
(Secretory)
Hormonal
DUB
Anovulatory
(Proliferative)
Anatomic
Reproductive age
(Usually DUB)
Coagulopathy
R/O Pregnancy
Perimenopause
Early EMB/TV Sono
Postmenopause
R/O Endometrial CA
Adolescents
Most likely anovulatory due to
immature Hypothal-Pit axis
Rule out pregnancy
Consider bleeding disorder
Observe or Rx with cyclic MPA or
OCs
Anovulatory Adults
Identify secondary causes of
Hypothal-Pit dysfunction, thyroid
disease, PCOS
Address underlying cause
Manage bleeding with cyclic MPA,
DMPA, or OCs
Ovulatory Adults
Perimenopause
Progressive anovulation due to
declining ovarian function
Rule out pregnancy
Consider early EMB or TVSono
Postmenopause
Summary
Abnormal uterine bleeding is very
common
Life phase and detailed menstrual
history are key
Employ rational evaluation and
treatment strategy
You can manage it!
Cervical Cancer
12,800
cases/yr
50% never screened
Death rate 70% since 1940s
Pap introduced
Natural History
HPV
sexual partners
HPV
Smoking
HIV
Start:
Interval:
Stop:
Cytologic Interpretation
Adequacy
of specimen
Satisfactory or unsatisfactory
Descriptive
diagnosis
Bethesda 2001
Presence/absence
endocervical cells
of
Trichomonas
Fungus c/w candida sppNo action
Floral shift/BVNo action
Suspect Chlamydiacall back to test
HSVnotify patient
HPV/koilcytosismanage as LSIL
Actinomyces (IUD)Rx with Amox
InflammationNo action
Atrophy w/ inflam. (atrophic vaginitis)
Rx w/ topical estrogen, repeat if no
ECC
RadiationNo action
Reactive/reparative AtypiaNo action
Squamous metaplasiaNo action
Glandular Cells
Endometrial cellsconsider EMB if
age>40 or abnormal bleeding
Atypical Endocervical cellscolpo,
Bx, ECC
Atypical Endometrial cellsEMB,
D&C, or hysteroscopy
Endocervical, Endometrial, or
Extrauterine Cadefinitive Rx
ASC US
HIV
> ASC US
Colposcopy
Routine Screening
Repeat PAP
12 months
ASCH / LSIL
Colposcopy
Neg or CIN 1
PAP q6 mos x 2
CIN 2 or 3, CIS
RX
HSIL
Colposcopy + ECC
Satisfactory
No CIN or
CINI
Diagnostic
Excision
CIN 2, 3
Rx
Unsatisfactory
Diagnostic
Excision
Bottom Line
When to refer for colposcopy:
ASC-US x 2 (x1 if HIV+)
ASC-H
LSIL
HSIL