Master the board step 3

Gynecology
Endometriosis
This involves endometrial glands outside the uterus. It classically presents in
women over 30 with dysmenorrhea, dyspareunia, dyschezia (painful bowel
movements), and infertility.
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The most common site is the ovary, causing adnexal enlargements (endometriomas),
also known as a chocolate cyst.
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The second most common site is the cul-de-sac, causing uterosacral ligament
nodularity and tenderness on rectovaginal examination. This location
is associated with bowel adhesions and a fixed, retroverted uterus.
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Investigations: CA-125 may be elevated. Sonogram may show endometriomas.
Definitive diagnosis is made with laparoscopic visualization.
Treatment
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First-line therapy: Continuous oral progesterone or oral contraceptive pill
(OCP). Progesterone inhibits endometrial growth.
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Second-line therapy: Testosterone derivatives (Danocrine or danazol) or
GnRH analogs (Lupron or leuprolide)
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Laparoscopic lysis adhesions: Laser vaporization of lesions can improve
fertility.
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TAH and BSO can be done for severe symptoms when fertility is not
desired.
Don’t be fooled! Not all
elevations of CA-125 are
due to ovarian cancer. It is
also elevated in:
• Cirrhosis
• Endometriosis
• Peritonitis
• Pancreatitis
Vaginal Bleeding and Its Absence
Premenarchal Vaginal Bleeding
This is bleeding that occurs before menarche. The average age at menarche is 12.
Causes are as follows:
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The most common cause is the presence of a foreign body.
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You must rule out sarcoma botryoides (cancer of vagina or cervix suggested
by a grapelike mass arising from the vaginal lining or cervix), tumor of the
pituitary adrenal gland or ovary, and sexual abuse.
Diagnostic Testing
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Perform pelvic exam under sedation.
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Order CT or MRI of pituitary, abdomen, and pelvis to look for estrogenproducing
tumor.
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If workup is negative, the diagnosis is idiopathic precocious puberty.
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