Workup for Common Gynecologic Problems

TPMG CME Conference 2015Jeff Morrison, DO

Workup for Common Gynecologic Problems

• Searched for New Patient visits and Consults to TPMG Ob/Gyn in 2013 and 2014.

• 2070 Patient visits• Menorrhagia• Irregular Menses• Vaginitis• Postmenopausal bleeding• Contraceptive Counseling• Cystocele

Menorrhagia (Abnormal uterine bleeding)

• Reproductive Age Females

• 80 ml• A volume of bleeding that interferes with

daily activities• Changing a pad or tampon more that

every two hours

Menorrhagia (Abnormal uterine bleeding)

• Pregnancy, Pregnancy, Pregnancy

• Uterine abnormalities• Ovulatory dysfunction• Cancer• Bleeding disorder• Infection• Endocrine abnormalities• Medication

Menorrhagia (Abnormal uterine bleeding)

• Perimenopause• Anovulation• Uterine abnormalities• Cancer

Menorrhagia (Abnormal uterine bleeding)

• 53/1000 US women experience difficulties• 5,300/100,000• Cervical Cancer – 6/100,000• Breast Cancer – 122/100,000• Colon Cancer – 39/100,000• Influenza Deaths – 1.2/100,000

Menorrhagia (Abnormal uterine bleeding)

• What’s the source?• History• Is she pregnant?• Contraception, sexual activity?• Has this happened before?• Previous evaluation?• Last Pap smear?• Hx of abnormal pap smears?• Context of bleeding?• New medications?

Menorrhagia (Abnormal uterine bleeding)

• Physical Exam

• Ultrasound

• BHCG, CBC, TSH, Chlamydia/Gonorrhea testing

Vaginitis• History is unreliable

• Physical Exam• Ph testing, Wet prep, Culture

• 60% vulvovaginitis• 70% trichomoniasis• 90% bacterial vaginosis

Vaginitis

• Vaginal pH• BV (>4.5)• Trichomoniasis (5-6)• Candida (4-4.5)

Vaginitis

• No Microscope• Culture for yeast• NAA (nucleic acid amplification) tests for

trichmoniasis, bacterial vaginosis, candida• Culture for candida• Bacterial cultures are unreliable

Vaginitis

• DNA tests for Gonorrhea and Chlamydia• Cytology – unreliable• Confirmation with wet prep• BV – sensitivity 49% vs wet prep• Trichomoniasis – False-positive rate of 4%

Vaginitis

• Non-infectious causes• Atrophy• Lichen sclerosis• Contract dermatitis• Stress Incontinence

Vaginitis

• BV – frequently recurrent (30% within 3 months)

• Partner treatment ineffective• Prolonged antibiotic therapy

Postmenopausal Bleeding• Rule out malignancy• History• Symptoms• Timing• Aggravating Factors• Medications• OTC treatments• Family Hx of breast, colon, and gynecologic cancers• BMI

Postmenopausal Bleeding

• Pelvic US• Endometrial lining is > 4mm• Endometrial changes – diffuse or focal

increased echogenicity (heterogeneity)• Endometrium not adequately visualized

• Endometrial biopsy/sampling

Postmenopausal Bleeding

• Persistent bleeding• Endometrial biopsy/sampling

Postmenopausal Bleeding

• Cervical cancer• Mean age 52.2 years• Peaks at 35 – 39, and 60-64• Endometrial cancer• Mean Age 61 years• >40% women older than 65

Contraception• Many changes

• Permanent vs. Reversible

• Permanent Methods• Vasectomy• Hysteroscopic tubal occlusion (In-office procedure)• Laparoscopic bilateral tubal cauterization

ContraceptionReverisible methods

• Paragard IUD• Mirena IUD• Skyla IUD• Nexplanon implant• Depot Provera• Nuva ring• Ortho Evra patch• OCPs• Natural family planning• Condoms, Diaphragm• Withdrawal

Contraception

• 46% of women discontinue contraception – side effects, partner complaint

• Nexplanon implant and Progesterone IUD 84,80% continuation rate

• Copper IUD – 78 % continuation rate• Pill, patch, ring – 67 %

Cystocele/Prolapse• Asymptomatic – no treatment needed• Symptomatic

– Pessary– Surgical intervention

• Apical support – traditional vs. mesh repair• Anterior repair – High rate of recurrence

without apical support• Mesh repair – lower rate of recurrence

Cystocele/Prolapse

• Poor surgical candidate• Le Forte colpoclesis