Gynecology_Novak

Gynecology_Novak. Emergency Management The decision to hospitalize a patient depends on the rate of current bleeding and the severity of any existing anemia. The actual acute blood loss may not be reﬂected adequately in the initial blood count but will be revealed with serial hemoglobin assessments. The cause of acute menorrhagia may be a primary coagulation disorder; thus, measurements of coagulation and hemostasis, including screening for coagulopathy, should be performed for any adolescent patients with acute menorrhagia, as noted above in the recommendations of an international panel (81). Von Willebrand disease, platelet disorders, or hematologic malignancies can cause menorrhagia. Depending on the patient’s level of hemodynamic stability or compromise, a blood sample can be analyzed for type and screen. The decision to transfuse must be considered carefully, and the benefits and risks should be discussed with the adolescent and her parents. Generally, there is no need for transfusion unless the


Gynecology_Novak

Gynecology_Novak. The decision to transfuse must be considered carefully, and the benefits and risks should be discussed with the adolescent and her parents. Generally, there is no need for transfusion unless the patient is hemodynamically unstable.


Gynecology_Novak

Gynecology_Novak. In patients who, by exclusion, are diagnosed as having anovulatory bleeding, hormone therapy usually makes it possible to avoid surgical intervention (dilation and curettage [D&C], operative hysteroscopy, or laparoscopy). A patient who is hospitalized for severe bleeding requires aggressive management as follows: 1. After stabilization, when appropriate laboratory assessment and an examination established a working diagnosis of anovulation, hormonal management will usually control bleeding. 2. Estrogen-progestin therapy in the form of combined oral contraceptives given as one or two pills twice a day for 5 to 7 days is typically effective within 12 to 24 hours. Alternatively, conjugated estrogens, either 25 to 40 mg given intravenously every 6 hours or 2.5 mg given orally every 6 hours, will usually be effective (98). 3.


Gynecology_Novak

Gynecology_Novak. 3. If this hormonal therapy is not effective, the patient should be reevaluated and the diagnosis should be reassessed. The failure of hormonal management suggests that a local cause of bleeding is more likely. In this event, consideration should be given to a pelvic ultrasonographic examination to determine any anatomic causes of bleeding (such as uterine leiomyomas, endometrial polyps, or endometrial hyperplasia) and to assess the presence of intrauterine clots that may impair uterine contractility and prolong the bleeding episode. Although anatomic causes of heavy menstrual bleeding are rare in adolescents, they become increasingly common in women of reproductive age. 4. If intrauterine clots are detected, evacuation of the clots (suction curettage or D&C) is indicated. Although a D&C will provide effective immediate control of the bleeding, it is unusual to reach this step in adolescents.


Gynecology_Novak

Gynecology_Novak. More drastic forms of treatment other than a D&C (such as ablation of the endometrium by laser or cryotherapy) are considered inappropriate for adolescents because of concerns about future fertility.


Gynecology_Novak

Gynecology_Novak. If intravenous or oral administration of hormonal therapy controls the bleeding, oral progestin therapy should be instituted and continued for several days to stabilize the endometrium. This therapy can be accomplished by using a combination oral contraceptive, usually one with 30 to 35 mg of estrogen, or by using the tapering regimen previously described. The medication can be tapered and ultimately must be stopped to allow withdrawal bleeding, which may be heavy, given an excessively built-up endometrium. Low-dose combination oral contraception once daily should be continued for three to six cycles, or longer if desired, to provide normal menstrual cycles. Manipulation of the regimen by increasing or decreasing the dose of oral contraceptives to twice a day or three times a day after the initial high dose therapy should be discouraged.


Gynecology_Novak

Gynecology_Novak. In general, the prognosis for regular ovulatory cycles and subsequent normal fertility in young women who experience an episode of abnormal bleeding is good, particularly for patients who develop abnormal bleeding as a result of anovulation within the first years after menarche and in whom there are no signs of other specific conditions. Some girls, including those in whom there is an underlying medical cause, such as PCOS, will continue to have abnormal bleeding into middle and late adolescence and adulthood and will benefit from the ongoing use of oral contraceptives to manage hirsutism, acne, and irregular periods. Ovulation induction may ultimately be necessary to achieve fertility in these individuals, although teens should be advised that they should not assume that they are infertile. Individuals with coagulopathies may benefit from ongoing oral contraceptive use, use of tranexamic acid, or intranasal desmopressin (99).


Gynecology_Novak

Gynecology_Novak. A progestin-releasing intrauterine device (IUD) can be effective in managing heavy bleeding, and may be appropriate for adolescent use (100,101). The levonorgestrel IUD is approved by the FDA for treatment of heavy menstrual bleeding in women requiring contraception and is recommended as first-line medical therapy for this group of women (102). For patients with underlying medical conditions, such as coagulopathies, a malignancy requiring chemotherapy, or developmental disabilities, long-term therapeutic amenorrhea with menstrual suppression using the following regimens may be necessary or helpful (103): 1. Progestins such as oral norethindrone, norethindrone acetate, or medroxyprogesterone acetate on a continuous daily basis (104). 2. Continuous (noncyclic) combination regimens of oral estrogen and progestins (birth control pills) or other forms of combination estrogen/progestins (transdermal patch, vaginal ring) that do not include a withdrawal bleeding–placebo week (105,106).


Gynecology_Novak

Gynecology_Novak. 3. Depot formulations of progestins (DMPA), with or without concurrent estrogens (104). 4. Gonadotropin-releasing hormone (GnRH) analogues with or without estrogen add-back therapy (105). 5. Levonorgestrel intrauterine system (IUS) (107).


Gynecology_Novak

Gynecology_Novak. The choice of regimen depends on the presence of any contraindications (such as active liver disease precluding the use of estrogens) and the clinician’s experience. Although the goal of these long-term suppressive therapies is amenorrhea, all of these regimens may be accompanied by breakthrough bleeding. At 1 year, rates of amenorrhea approach 90% with extended cycle combination oral contraceptives, 50% with DMPA, and 50% with the levonorgestrel IUS (73,108,109). Because both DMPA and GnRH analogues are associated with disadvantageous effects on bone mineral density, the potential risks must be weighed against their medical benefits. Regular follow-up visits and continued patient encouragement are required with all of these options. Episodes of spotting and breakthrough bleeding that do not result in a lowered hemoglobin level may be managed expectantly. When breakthrough bleeding affects the hemoglobin level, it should be evaluated with respect to the underlying disease. For


Gynecology_Novak

Gynecology_Novak. do not result in a lowered hemoglobin level may be managed expectantly. When breakthrough bleeding affects the hemoglobin level, it should be evaluated with respect to the underlying disease. For example, in a patient with underlying platelet dysfunction, breakthrough bleeding may reﬂect a lowered platelet count. Bleeding in a patient with hepatic disease may reﬂect worsening hepatic function. NSAIDs and supplemental low-dose hormonal therapy can be helpful in the management of excessive breakthrough bleeding that has no specific cause other than the hormone therapy (110).


Gynecology_Novak

Gynecology_Novak. Diagnosis The history and pelvic examination are critical in the diagnosis of a pelvic mass. Considerations in adolescents include the anxiety associated with a first pelvic examination, as well as issues of confidentiality related to questions about sexual activity. Techniques for history taking and the performance of the first examination are discussed in Chapter 1. Laboratory studies should always include a pregnancy test (regardless of stated sexual activity), and a complete blood count may be helpful in diagnosing inﬂammatory masses. Tumor markers, including α-fetoprotein and human chorionic gonadotropin (hCG), may be elaborated by germ cell tumors and can be useful in preoperative diagnosis and follow-up (see Chapter 37).


Gynecology_Novak

Gynecology_Novak. As in all other age groups, the primary diagnostic technique for evaluating pelvic masses in adolescents is ultrasonography. Although transvaginal ultrasonographic examinations may provide more detail than transabdominal ultrasonography, particularly with inﬂammatory masses, a transvaginal examination may not be well tolerated by adolescents (111). Ultrasonography usually is the most helpful imaging technique for assessing ovarian masses. For cases in which the suspected diagnosis is appendicitis or another nongynecologic condition, or if the results of the ultrasonographic examination are inconclusive, CT or MRI may be helpful. An accurate preoperative assessment of anatomy is critical, particularly in cases of uterovaginal Figure 14.14 Adnexal mass with torsion.


Gynecology_Novak

Gynecology_Novak. An accurate preoperative assessment of anatomy is critical, particularly in cases of uterovaginal Figure 14.14 Adnexal mass with torsion. Differential Diagnosis of Adolescent Pelvic Masses malformations. MRI can be useful for evaluating this group of rare anomalies (88). Adolescents who present with abdominal pain should be evaluated with some type of imaging procedure because an unexpected finding of a complex uterine or vaginal anomaly requires careful surgical planning and management.


Gynecology_Novak

Gynecology_Novak. Ovarian Masses in Adolescents Many studies of ovarian tumors in the pediatric and adolescent age group do not distinguish between prepubertal or premenarchal girls and menarchal adolescents. The findings of some reports are based on age group, although this is less helpful than a distinction by pubertal development. In evaluating a pelvic or abdominal mass, the clinician must take into consideration the patient’s pubertal status because the likelihood of functional masses increases after menarche (Table 14.4). The risk of malignant neoplasms is lower among adolescents than among younger children. Germ cell tumors are the most common tumors of the first decade of life but occur less frequently during adolescence (see Chapter 37). Mature cystic teratoma is the most frequent neoplastic tumor of children and adolescents, accounting for more than one-half of ovarian neoplasms in women younger than 20 years of age (112). Epithelial neoplasms occur with increasing frequency beyond


Gynecology_Novak

Gynecology_Novak. tumor of children and adolescents, accounting for more than one-half of ovarian neoplasms in women younger than 20 years of age (112). Epithelial neoplasms occur with increasing frequency beyond adolescence.


Gynecology_Novak

Gynecology_Novak. It is well established that neoplasia can arise in dysgenetic gonads. The risk of malignant tumors in dysgenetic gonads of patients with a Y chromosome depends on the nature of the disorder of sex development, the presence of the gonadoblastoma region of the Y chromosome, and other factors—both established and as yet unknown (113). A number of genes involved in gonadal differentiation were described. In the past, it was stated that the risk of malignant tumors is approximately 25%, and thus gonadectomy was recommended (114). Other perspectives suggest that a gonadal biopsy may allow the estimation of individual risk and permit a more conservative approach to gonadectomy. A multidisciplinary approach to diagnosis of disorders of sex development with attention to biological, genetic, and psychological factors is advocated (115). Functional ovarian cysts occur frequently in adolescence. They may be an incidental finding on examination or may be associated with pain caused by torsion,


Gynecology_Novak

Gynecology_Novak. psychological factors is advocated (115). Functional ovarian cysts occur frequently in adolescence. They may be an incidental finding on examination or may be associated with pain caused by torsion, leakage, or rupture. Paratubal cysts represent embryologic remnants that may be confused with an ovarian mass; they are typically asymptomatic, but can be associated with adnexal torsion (Fig. 14.14). Adnexal or ovarian torsion is a challenging diagnosis to make in prepubertal girls or adolescents; torsion of a mass is more likely to occur than is torsion of normal adnexa, although this can occur. Doppler ultrasound examination may not predict the presence of torsion, although discrepancy in ovarian volume and large volume of the torsed adnexa may be helpful in making the diagnosis (116,117). Management should consist of detorsion rather than oophorectomy, even if the mass appears to have no blood ﬂow, as recovery of ovarian function is likely (118).


Gynecology_Novak

Gynecology_Novak. Endometriosis is less common during adolescence than in adulthood, although it can occur during adolescence. In one study of adolescents referred with chronic pain, 50% to 65% had endometriosis (119). Although endometriosis can occur in young women with obstructive genital anomalies (presumably as a result of retrograde menstruation), most adolescents with endometriosis do not have associated obstructive anomalies. In young women, endometriosis may have an atypical appearance characterized by nonpigmented or vesicular lesions, peritoneal windows, and puckering (120). Other causes of pelvic masses, such as uterine abnormalities, are rare in adolescence.


Gynecology_Novak

Gynecology_Novak. Other causes of pelvic masses, such as uterine abnormalities, are rare in adolescence. Uterine leiomyomas are not often seen in this age group. Obstructive uterovaginal anomalies occur during adolescence, at the time of menarche, or shortly thereafter. Frequently, the correct diagnosis either is not suspected or is delayed (121). A wide range of anomalies can occur, from imperforate hymen to transverse vaginal septa; from vaginal agenesis with a normal uterus and functional endometrium to vaginal duplications with obstructing longitudinal septa, and obstructed uterine horns (Fig. 14.13). Patients may seek treatment for cyclic pain, amenorrhea, vaginal discharge, or an abdominal, pelvic, or vaginal mass. A hematocolpos, hematometra, or both frequently will be present, and the resulting mass can be quite large (34).


Gynecology_Novak

Gynecology_Novak. Of all age groups of sexually active women, adolescents have the highest rates of PID (83). Thus, an adolescent who has pelvic pain may have an inﬂammatory mass. Such masses may consist of a tubo-ovarian complex (a mass of matted bowel, tube, and ovary), tubo-ovarian abscess (a mass consisting primarily of an abscess cavity within an anatomically defined structure such as the ovary), pyosalpinx, or, chronically, hydrosalpinx. The diagnosis of PID is primarily a clinical one based on the presence of lower abdominal, pelvic, and adnexal tenderness; cervical motion tenderness; a mucopurulent discharge; and elevated temperature, white blood cell count, or sedimentation rate (see Chapter 18). The risk of PID is clearly associated with that of acquiring STDs, and methods of contraception may either decrease the risk (male latex condoms) or increase it (the intrauterine device in the interval immediately after insertion) (122,123).


Gynecology_Novak

Gynecology_Novak. In adolescents, pregnancy should always be considered as a cause of a pelvic mass. In the United States, nearly half of adolescent women have experienced sexual intercourse (124). Most pregnancies in adolescents are unintended; 100% of pregnancies in adolescents younger than age 15, 87% in women aged 15 to 17, and 79% in women aged 18 to 19 are unintended (94). Adolescents may be more likely than adults to deny the possibility of pregnancy because of wishful thinking, anxiety about discovery by parents or peers, or unfamiliarity with menstrual cycles and information about fertility. Ectopic pregnancies may cause pelvic pain and an adnexal mass. The increasing incidence of ectopic pregnancies in the United States is strongly associated with rising rates of PID. With the availability of quantitative measurements of β-hCG, more ectopic pregnancies are being discovered before rupture, allowing conservative management with laparoscopic surgery or medical therapy (see Chapter 20). The risk


Gynecology_Novak

Gynecology_Novak. measurements of β-hCG, more ectopic pregnancies are being discovered before rupture, allowing conservative management with laparoscopic surgery or medical therapy (see Chapter 20). The risk of ectopic pregnancy varies by method of contraception; users of no contraception have the highest risk, whereas oral contraceptive users have the lowest risk (125). As with older patients, paraovarian cysts and nongynecologic masses can appear as a pelvic or abdominal mass in adolescents (Fig. 14.15).


Gynecology_Novak

Gynecology_Novak. Management of Pelvic The management of masses in adolescents depends on the suspected diagnosis and the initial Masses in Adolescents symptom. Figure 14.8 outlines a plan of management for pelvic masses in adolescents. Asymptomatic unilocular cystic masses are best managed conservatively because the likelihood of malignancy is low. If surgical management is required based on symptoms or uncertainty of diagnosis, attention should be directed to minimizing the risks of subsequent Figure 14.15 A: Paratubal cyst. B: Paratubal cyst, incised.


Gynecology_Novak

Gynecology_Novak. Figure 14.15 A: Paratubal cyst. B: Paratubal cyst, incised. infertility resulting from pelvic adhesions. In addition, every effort should be made to conserve ovarian tissue. In the presence of a malignant unilateral ovarian mass, management may include unilateral oophorectomy rather than more radical surgery, even if the ovarian tumor metastasized (see Chapter 37). Analysis of frozen sections may not be reliable. In general, conservative surgery is appropriate; further surgery can be performed, if necessary, after an adequate histologic evaluation of the ovarian tumor.


Gynecology_Novak

Gynecology_Novak. When symptoms persist in a patient with the clinical diagnosis of PID or tubo-ovarian abscess, laparoscopy should be considered to confirm the diagnosis. A clinical diagnosis may be incorrect in as many as one-third of patients (118). The surgical management of inﬂammatory masses is rarely necessary in adolescents, except to treat rupture of tuboovarian abscess or failure of medical management with broad-spectrum antibiotics (see Chapter 18). Some surgeons advocated laparoscopy to perform irrigation, lysis of adhesions, drainage of unilateral or bilateral pyosalpinx or tubo-ovarian abscess, or extirpation of significant disease (126). If surgical management is required because of failed medical therapy, conservative, unilateral adnexectomy usually can be performed in these situations, rather than a pelvic clean-out, thereby maintaining reproductive potential. Percutaneous drainage, transvaginal ultrasonographic drainage, and laparoscopic management of tubo-ovarian abscesses are being


Gynecology_Novak

Gynecology_Novak. than a pelvic clean-out, thereby maintaining reproductive potential. Percutaneous drainage, transvaginal ultrasonographic drainage, and laparoscopic management of tubo-ovarian abscesses are being done more often, although evidence supporting this approach is sparse. As with the laparoscopic management of ovarian masses, the surgeon’s skill and experience with this procedure are critical, and prospective studies on its effectiveness are lacking (127). Laparoscopic management is associated with a risk of major complications, including bowel obstruction and bowel or vessel injury (128).


Gynecology_Novak

Gynecology_Novak. Disorders of sex development may cause genital ambiguity, typically noted at birth, although virilization may occur at puberty (29). Adolescents with gonadal dysgenesis or androgen insensitivity may have abnormal pubertal development and primary amenorrhea (see Chapters 29 and 30). Various developmental anomalies—vaginal agenesis, imperforate hymen, transverse and longitudinal vaginal septa, vaginal and uterine duplications, hymenal bands, and septa—most frequently are diagnosed in early adolescents with amenorrhea (for the obstructing abnormalities) or with concerns such as inability to use tampons (for hymenal and vaginal bands and septa). These developmental abnormalities must be evaluated carefully to determine both external and internal anatomy. Figure 14.16 Hymenal band.


Gynecology_Novak

Gynecology_Novak. A tight hymenal ring may be discovered when the patient seeks care because of concerns about the inability to use tampons or have intercourse. Both manual dilation and small relaxing incisions at 6 o’clock and 8 o’clock in the hymenal ring can be effective. This procedure can sometimes be done in the office using local anesthesia but may require conduction or general anesthesia in the operating room. Hymenal bands are not rare and lead to difficulty in using tampons; they usually can be incised in the office using local anesthetic (Fig. 14.16). Hypertrophy of the labia minora may be considered a variant of normal, and reassurance rather than a cosmetic surgical reduction is appropriate as the primary therapy. Surgical management is described, although the procedure could be considered to be esthetic rather than medically mandated. Genital ulcerations may occur in girls with leukemia or other cancers requiring chemotherapy (129,130). Vulvar ulcerations in the absence of sexual activity


Gynecology_Novak

Gynecology_Novak. esthetic rather than medically mandated. Genital ulcerations may occur in girls with leukemia or other cancers requiring chemotherapy (129,130). Vulvar ulcerations in the absence of sexual activity or infectious etiology are described as vulvar aphthosis (46) (Fig. 14.10). The possibility of sexual abuse, incest, or involuntary intercourse should be considered for young adolescents with vulvovaginal symptoms, STDs, or pregnancy.


Gynecology_Novak

Gynecology_Novak. The presence of vulvar symptoms such as itching or burning may prompt a patient to seek care; however, this anatomic site is not one that is easily inspected by the patient. Thus, vulvar lesions may be found on examination that were not noticed by the patient. Vulvar self-examination should be encouraged and could potentially result in the earlier diagnosis of vulvar lesions such as melanoma. Adolescents presenting with vulvar itching may have lichen sclerosus; this condition can be relatively asymptomatic, even when an examination reveals loss of anatomic structures and scarring (11) (Fig. 14.4).


Gynecology_Novak

Gynecology_Novak. Adolescents and adults often incorrectly self-diagnose vulvovaginal candidiasis; in one study, only one-third of women with self-diagnosed yeast vaginitis were found to have this infection (131) (see Chapter 18). A clinical examination and appropriate testing can be performed even on young adolescents using a clinician or self-obtained cotton swab to obtain vaginal secretions for pH testing and microscopic examination (Fig. 14.17).


Gynecology_Novak

Gynecology_Novak. Vulvar condyloma is an extremely common cause of vulvar lesions in adolescents (see Chapter 18). Genital warts can affect the vulva, perineum, and perianal skin, and the vagina, urethra, and anus (Fig. 14.18). Condyloma in adolescents typically is sexually transmitted. It may be asymptomatic or cause symptoms of itching, irritation, or bleeding. Symptomatic, enlarging, or extensive vulvar condyloma can be managed with topical medication applied by the patient or clinician. The choice of treatment should be guided by patient preference, available resources, and the clinician’s experience; no one treatment is superior to the others (132). The availability of a quadrivalent human papillomavirus (HPV) vaccine that includes HPV types 6 and 11 potentially will have a beneficial impact on the incidence of vulvar condyloma and HPV-related vulvar intraepithelial neoplasia (VIN) (133). Figure 14.17 Candidal vulvitis. Figure 14.18 Extensive vulvar condyloma.


Gynecology_Novak

Gynecology_Novak. Figure 14.17 Candidal vulvitis. Figure 14.18 Extensive vulvar condyloma. Vulvovaginal symptoms in adolescents may be caused by a variety of conditions, ranging from vulvar lichen sclerosus to urinary tract infection to C. trachomatis to non-STD-related vaginitis. Urinary or vaginal symptoms do not differentiate well between urinary tract infections (UTIs) and vaginitis. Adolescent girls who are screened for both C. trachomatis and UTI have high rates of concurrent disease (134). Because clinical diagnosis based on symptoms is imprecise, female adolescents with vaginal or urinary symptoms should be tested for both


Gynecology_Novak

Gynecology_Novak. C. trachomatis and UTI. Testing with DNA-based procedures may be performed on samples obtained from the cervix, from swabs of vaginal secretions (either clinician or patient obtained), and from urine specimens. Testing that does not involve a speculum examination may be particularly helpful for adolescents; a rigorous review concluded that noninvasive chlamydia testing was comparable to cervical or urethral screening, although this was not the case with testing for gonorrhea (126,135).


Gynecology_Novak

Gynecology_Novak. Discharge is one of the most common vaginal symptoms. Conditions ranging from vaginal candidiasis to chlamydia cervicitis to bacterial vaginosis may cause vaginal discharge in adolescents. Infectious vaginal conditions are described in more detail in Chapter 18. The risks of self-diagnosis of vaginal discharge in adolescents may be greater than in adult women, as infection with STDs—including Neisseria gonorrhoea, Trichomonas vaginalis, C. trachomatis, herpes simplex, and Condyloma acuminata—are common in adolescents and may be less likely recognized. Use of tampons is associated with both microscopic and macroscopic ulcerations. Healing of the macroscopic ulcerations occurs within several weeks without specific therapy if tampon use is suspended. A follow-up examination to demonstrate healing is appropriate, with biopsy of any persistent ulcerations to rule out other lesions.


Gynecology_Novak

Gynecology_Novak. Toxic shock syndrome (TSS) is associated with tampon use and vaginal exotoxins produced by Staphylococcus aureus. This syndrome consists of fever, hypotension, a diffuse erythroderma with desquamation of the palms and soles, plus involvement of at least three major organ systems (136). Vaginal involvement includes mucous membrane inﬂammation. The frequency of TSS appears to be declining, and an increasing percentage of cases are not associated with menses. Approximately one-half of all cases of TSS are menstrual related (137). Epidemiologic studies suggest that adolescents are at greater risk of menstrual TSS than older women; however, this finding does not appear to be explained by differences in the detection of antibodies to the TSST-1 toxin-producing strain of S. aureus or in S. aureus vaginal colonization rates (138).


Gynecology_Novak

Gynecology_Novak. Abscesses of Bartholin and Skene’s glands are related to both aerobic and anaerobic organisms, with mixed infections accounting for approximately 60% of these and other vulvar and labial abscesses, although the possibility of methicillin-resistant S. aureus (MRSA) infections must be kept in mind (139,140). Therapy consists of surgical drainage, with use of antibiotics as a secondary measure. In younger adolescents, incision and drainage with insertion of a Word indwelling catheter may require general anesthesia (140).


Gynecology_Novak

Gynecology_Novak. Normal Menses After adolescence, menstrual cycles generally conform to a cycle length of 21 to 38 days, with menstrual ﬂow duration of fewer than 7 days (Table 14.9). As a woman approaches menopause, cycle length becomes more irregular as fewer cycles are ovulatory (51,141). The most frequent cause of irregular bleeding in the reproductive age group is hormonal, although other causes such as pregnancy-related bleeding (spontaneous abortion, ectopic pregnancy) should always be considered (Table 14.4). A variety of terms are used to describe abnormal menses; it is strongly recommended by an international panel of experts that the confusing terms noted in Table 14.10 be abandoned in favor of a much simpler system with description of cycle Table 14.9 Parameters for Normal Menstrual Cycles in Women of Reproductive Age Data from Fraser IS, Critchley HO, Munro MG. Abnormal uterine bleeding: getting our terminology straight. Curr Opin Obstet Gynecol 2007;19:591–595.


Gynecology_Novak

Gynecology_Novak. Data from Fraser IS, Critchley HO, Munro MG. Abnormal uterine bleeding: getting our terminology straight. Curr Opin Obstet Gynecol 2007;19:591–595. regularity (irregular, regular, or absent), frequency (frequent, normal, or infrequent), duration (prolonged, normal, or shortened), and heaviness of bleeding episodes (heavy, normal, or light) (Table 14.11) (141). Prospective charting of bleeding can be helpful in characterizing abnormal bleeding. The mean duration of menses is 4.7 days; 89% of cycles last 7 days or longer. The average blood loss per cycle is 35 mL (56). Menses is a suspension of blood-and tissue-derived solids within a mixture of serum and cervicovaginal ﬂuid; the blood content of menses varies over the days of bleeding, but on average is close to 50% (142). Recurrent bleeding in excess of 80 mL/cycle results in anemia. Differential Diagnosis of Abnormal Bleeding in Reproductive-Age Women


Gynecology_Novak

Gynecology_Novak. Differential Diagnosis of Abnormal Bleeding in Reproductive-Age Women Dysfunctional Uterine Bleeding The term dysfunctional uterine bleeding (DUB) is used to describe abnormal bleeding for which no specific cause was found. It is used as a diagnosis rather than a symptom; although there is no agreement about a simpler term to replace the phrase, idiopathic heavy, regular bleeding, idiopathic heavy, irregular bleeding, and idiopathic prolonged, irregular bleeding were suggested (141). DUB is often used as a diagnosis of exclusion, which is probably more confusing than enlightening. Other terms that are commonly used to describe bleeding abnormalities include anovulatory uterine bleeding and abnormal uterine bleeding (143).


Gynecology_Novak

Gynecology_Novak. Most anovulatory bleeding results from what is termed estrogen breakthrough. In the absence of ovulation and the production of progesterone, the endometrium responds to estrogen stimulation with proliferation. This endometrial growth without periodic shedding results in eventual breakdown of the fragile endometrial tissue. Healing within the endometrium is irregular and dyssynchronous. Relatively low levels of estrogen stimulation will result in irregular and prolonged bleeding, whereas higher sustained levels result in episodes of amenorrhea followed by acute, heavy bleeding.


Gynecology_Novak

Gynecology_Novak. Pregnancy-Related Bleeding Spontaneous abortion can be associated with excessive or prolonged bleeding. A woman may be unaware that she conceived and may seek care because of abnormal bleeding. In the United States, more than 50% of pregnancies are unintended, and about 7% of women are at risk for unintended pregnancy but use no method of contraception (94,144). These women may be at particular risk for bleeding related to an unsuspected pregnancy. About one-half of unintended pregnancies result from nonuse of contraception; the other Table 14.10 Abnormal Menses—Terminology


Gynecology_Novak

Gynecology_Novak. Table 14.10 Abnormal Menses—Terminology Table 14.11 Menstrual Terminology one-half result from contraceptive failures (145). Unintended pregnancies are most likely to occur among adolescents and women older than 40 years of age (see Chapter 10). If an ectopic pregnancy is ruled out, the management of spontaneous abortion may include either observation, if the bleeding is not excessive; medical or pharmacologic uterine evacuation (with misoprostol); or surgical management with suction curettage or D&C, depending on the clinician’s judgment and the patient’s preference (146–148). Surgical management appears to be the most likely technique to result in complete evacuation; lower rates of success are seen with both medical and expectant management, although the type of miscarriage and gestational age affect these rates (149) (see Chapter 20).


Gynecology_Novak

Gynecology_Novak. Exogenous Hormones Irregular bleeding that occurs while a woman is using contraceptive hormones should be considered in a different context than bleeding that occurs in the absence of exogenous hormone use. Breakthrough bleeding during the first 1 to 3 months of oral contraceptive use occurs in as many as 30% to 40% of users; it should almost always be managed expectantly with reassurance because the frequency of breakthrough bleeding decreases with each subsequent month of use (66). Irregular bleeding can result from inconsistent use (150–152). Other estrogen-progestin delivery systems, including the contraceptive patch, vaginal ring, and intramuscular regimens, are associated with irregular breakthrough bleeding. These nondaily contraceptive regimens may promote successful use, making irregular bleeding a less important factor for some women in assessing the balance of risks versus benefits (see Chapter 10).


Gynecology_Novak

Gynecology_Novak. Use of progestin-only methods—including DMPA, progestin-only pills, the contraceptive implant, and the levonorgestrel IUS—is associated with relatively high rates of initial irregular and unpredictable bleeding; rates of amenorrhea vary over time and by method (142,153). Because irregular bleeding is so often present with these methods of contraception, counseling before their use is imperative. Women who do not believe that they can cope with irregular, unpredictable bleeding may not be good candidates for these methods. Hormonal implants and IUDs releasing progestins do offer significant benefits of high efficacy and ease of use (154).


Gynecology_Novak

Gynecology_Novak. The management of irregular bleeding with hormonal contraceptive use can range from reassurance and initial expectant management to recommendations for a change in the hormonal delivery system or regimen. The use of additional oral estrogen improves bleeding with both DMPA and the subdermal levonorgestrel. The use of NSAIDs results in decreased breakthrough bleeding. The development of a better understanding of the mechanisms causing irregular bleeding will likely result in more effective and acceptable management strategies (153). Not all bleeding that occurs while an individual is using hormonal contraception is a consequence of hormonal factors. In one study, women who experienced irregular bleeding while taking oral contraceptives had a higher frequency of C. trachomatis infection (76). Thus, screening should be considered in women presenting with irregular bleeding while using hormonal contraception.


Gynecology_Novak

Gynecology_Novak. Endocrine Causes Both hypothyroidism and hyperthyroidism can be associated with abnormal bleeding. With hypothyroidism, menstrual abnormalities, including menorrhagia, are common (see Chapter 31). The most common cause of thyroid hyperfunctioning in premenopausal women is Graves disease, which occurs four to five times more often in women than men. Hyperthyroidism can result in oligomenorrhea or amenorrhea, and it can lead to elevated levels of plasma estrogen (155). Other causes of anovulation include hypothalamic dysfunction, hyperprolactinemia, premature ovarian failure, and primary pituitary disease (Table 14.6) (143). These conditions often are considered causes of amenorrhea, and they may cause irregular bleeding (see Chapter 30). The rare and unusual causes of abnormal bleeding should not be overlooked. Women with primary ovarian insufficiency (POI; previously termed premature ovarian failure [POF]) frequently see several clinicians with symptoms of oligomenorrhea or amenorrhea


Gynecology_Novak

Gynecology_Novak. not be overlooked. Women with primary ovarian insufficiency (POI; previously termed premature ovarian failure [POF]) frequently see several clinicians with symptoms of oligomenorrhea or amenorrhea prior to receiving a diagnosis; the diagnosis of POI is often delayed during waning ovarian function and insufficiency (156,157). POI is thought to occur in approximately 1 of 100 women by age 40, 1 of 1,000 women by age 30, and 1 of 10,000 women by age 20. Women should be encouraged to track their menstrual cyclicity and to consider that the menstrual cycle can be a “vital sign” that reﬂects overall health (61).


Gynecology_Novak

Gynecology_Novak. Diabetes mellitus can be associated with anovulation, obesity, insulin resistance, and androgen excess. Androgen disorders are very common among women of reproductive age and should be evaluated and managed accordingly. PCOS is present in 5% to 8% of adult women and undiagnosed in many of them (158). Because androgen disorders are associated with significant cardiovascular disease, the condition should be diagnosed promptly and treated. This condition becomes of more immediate concern in older women of reproductive age. Management of bleeding disorders associated with androgen excess consists of an appropriate diagnostic evaluation followed by the use of oral contraceptives (in the absence of significant contraindications or the desire for conception) or the use of insulin-sensitizing agents, coupled with dietary and exercise modification (159–161).


Gynecology_Novak

Gynecology_Novak. Anatomic Causes Anatomic causes of abnormal bleeding occur more frequently in women of reproductive age than in women in other age groups. Uterine leiomyomas and endometrial polyps are common conditions that most often are asymptomatic; however, they remain important causes of abnormal bleeding (162). Uterine leiomyomas occur in as many as one-half of all women older than age 35 years and are the most common tumors of the genital tract (151,152,162). The incidence varies from 30% to 70%, depending on criteria for study, whether clinical symptoms, ultrasound, or histologic assessment (163). One study of a randomly selected population estimated a cumulative prevalence of greater than 80% in black women and nearly 70% in white women (164). Abnormal bleeding is the most common symptom for women with leiomyomas. Although the number and size of uterine leiomyomas do not appear to inﬂuence the occurrence of abnormal bleeding, submucosal myomas are the most likely to cause bleeding. The


Gynecology_Novak

Gynecology_Novak. women with leiomyomas. Although the number and size of uterine leiomyomas do not appear to inﬂuence the occurrence of abnormal bleeding, submucosal myomas are the most likely to cause bleeding. The mechanism of abnormal bleeding related to leiomyomas is not well established (see Chapter 15 for further discussion of uterine fibroids).


Gynecology_Novak

Gynecology_Novak. Endometrial polyps are a cause of intermenstrual bleeding, heavy menstrual bleeding, irregular bleeding, and postmenopausal bleeding and are associated with the use of tamoxifen and with dysmenorrhea and infertility. As with leiomyomas, most endometrial polyps are asymptomatic. The incidence of endometrial polyps increases with age throughout the reproductive years (162). The diagnosis may be suspected on the basis of endometrial thickening on transvaginal pelvic ultrasound, and patterns of feeder blood vessels may aid in distinguishing endometrial polyps from intracavity fibroids and from endometrial malignancy (162,165,166). Visualization with hysteroscopy or sonohysterography or the microscopic assessment of tissue obtained by a biopsy done in the office or a curettage specimen is required for confirmation. Whether and when to recommend removal is not well established, particularly if a polyp is asymptomatic and is found incidentally. One study of randomly selected Danish women


Gynecology_Novak

Gynecology_Novak. for confirmation. Whether and when to recommend removal is not well established, particularly if a polyp is asymptomatic and is found incidentally. One study of randomly selected Danish women using transvaginal ultrasound and sonohysterography found polyps in 5.8% of asymptomatic premenopausal women and 11.8% of asymptomatic postmenopausal women, In this study abnormal bleeding was present in 38% of those without polyps versus 13% with polyps (167). Endometrial polyps can regress spontaneously, although it is not clear how frequently this occurs. In one study of asymptomatic women, the 1-year regression rate was 27% (168). Smaller polyps are more likely to resolve, and larger polyps may be more likely to result in abnormal bleeding (169). Whereas polyps may resolve spontaneously over time, a clinically important question is whether they are likely to undergo malignant transformation. Because even asymptomatic polyps usually are removed at the time of identification, this question is


Gynecology_Novak

Gynecology_Novak. a clinically important question is whether they are likely to undergo malignant transformation. Because even asymptomatic polyps usually are removed at the time of identification, this question is difficult to answer. The chance of malignancy or premalignant changes in endometrial polyps appears to be quite low in premenopausal women and higher among postmenopausal women, with bleeding reports range from premalignant change in 0.2% to 24% and malignancy in 0% to 13% (170).


Gynecology_Novak

Gynecology_Novak. Abnormal bleeding, either intermenstrual or postcoital, can be caused by cervical lesions. Bleeding can result from endocervical polyps and infectious cervical lesions, such as condylomata, herpes simplex virus ulcerations, chlamydial cervicitis, or cervicitis caused by other organisms. Other benign cervical lesions, such as wide eversion of endocervical columnar epithelium or nabothian cysts, may be detected on examination but rarely cause bleeding. Diagnosis of Abnormal Bleeding in Reproductive-Age Women


Gynecology_Novak

Gynecology_Novak. Diagnosis of Abnormal Bleeding in Reproductive-Age Women Coagulopathies and Other Hematologic Causes of Abnormal in Reproductive-Age Women As with adolescents, hematologic causes of abnormal bleeding should be considered in women with heavy menstrual bleeding, particularly in those who had abnormal bleeding since menarche. Of all women with menorrhagia, 5% to 20% have a previously undiagnosed bleeding disorder, primarily von Willebrand’s disease (171). Table 14.8 presents guidelines for a gynecologist’s suspicion of a bleeding disorder and pursuit of a diagnosis (81). Abnormal liver function, which can be seen with alcoholism or other chronic liver diseases, results in inadequate production of clotting factors and can lead to excessive menstrual bleeding.


Gynecology_Novak

Gynecology_Novak. Infections Causes As in adolescents, menorrhagia can be the first sign of endometritis in women infected with sexually transmissible organisms. Women with cervicitis, particularly chlamydial cervicitis, can experience irregular bleeding and postcoital spotting (see Chapter 18). Therefore, cervical testing for C. trachomatis should be considered, especially for adolescents, women in their 20s, and women who are not in a monogamous relationship. Endometritis can cause excessive menstrual ﬂow. Thus, a woman who seeks treatment for menorrhagia and increased menstrual pain and has a history of light-to-moderate previous menstrual ﬂow may have an upper genital tract infection or PID (endometritis, salpingitis, oophoritis). Occasionally, chronic endometritis will be diagnosed when an endometrial biopsy is obtained for evaluation of abnormal bleeding in a patient without specific risk factors for PID.


Gynecology_Novak

Gynecology_Novak. Neoplasia Abnormal bleeding is the most frequent symptom of women with invasive cervical cancer. A visible cervical lesion should be evaluated by biopsy rather than awaiting the results of cervical cytology testing, because the results of cervical cytology testing may be falsely negative with invasive lesions as a result of tumor necrosis. Unopposed estrogen is associated with a variety of abnormalities of the endometrium, from cystic hyperplasia to adenomatous hyperplasia, hyperplasia with cytologic atypia, and invasive carcinoma. Although vaginal neoplasia is uncommon, the vagina should be evaluated carefully when abnormal bleeding is present. Attention should be directed to all surfaces of the vagina, including anterior and posterior areas that may be obscured by the vaginal speculum on examination.


Gynecology_Novak

Gynecology_Novak. For all women, the evaluation of excessive and abnormal menses includes a thorough medical and gynecologic history, the exclusion of pregnancy, the consideration of possible malignancy, and a careful gynecologic examination. For women of normal weight between the ages of approximately 20 and 35 years who do not have clear risk factors for STDs, who have no signs of androgen excess, who are not using exogenous hormones, and who have no other findings on examination, management may be based on a clinical diagnosis. Additional laboratory or imaging studies may be indicated if the diagnosis is not apparent on the basis of examination and history.


Gynecology_Novak

Gynecology_Novak. Laboratory Studies In any patient with heavy menstrual bleeding, an objective measurement of hematologic status should be performed with a complete blood count to detect anemia or thrombocytopenia. A pregnancy test should be performed to rule out pregnancy-related problems. In addition, because of the possibility of a primary coagulation problem, screening coagulation studies should be considered (Table 14.8). The consensus report of an international expert panel recommends measurement of CBC, platelet count and function, PT, activated PTT, VWF (measured with ristocetin cofactor activity and antigen, factor VIII) and fibrinogen to be assessed in collaboration with a hematologist (81).


Gynecology_Novak

Gynecology_Novak. Imaging Studies Women with abnormal bleeding who have a history consistent with chronic anovulation, who are obese, or who are older than 35 to 40 years of age require further evaluation. A pelvic ultrasonographic examination may be helpful in delineating anatomic abnormalities if the examination results are suboptimal or if an ovarian mass is suspected. A pelvic ultrasonographic examination is the best initial technique for evaluating the uterine contour, endometrial thickness, and ovarian structure (172,173). The use of a vaginal probe transducer allows assessment of endometrial and ovarian disorders, particularly in women who are obese. Because of variation in endometrial thickness with the menstrual cycle, measurements of endometrial stripe thickness are significantly less useful in premenopausal than postmenopausal women (174). Sonohysterography is especially helpful in visualizing intrauterine problems such as polyps or submucous leiomyoma. Although these sonographic techniques


Gynecology_Novak

Gynecology_Novak. than postmenopausal women (174). Sonohysterography is especially helpful in visualizing intrauterine problems such as polyps or submucous leiomyoma. Although these sonographic techniques are helpful in visualizing intrauterine pathology, histologic evaluation is required to rule out malignancy. Other techniques, such as CT scanning and MRI, are not as helpful in the initial evaluation of causes of abnormal bleeding and should be reserved for specific indications, such as exploring the possibility of other intra-abdominal pathology or adenopathy. MRI can be a secondary step in evaluating location of uterine fibroids with relationship to the endometrial cavity, staging and preoperative evaluation of endometrial cancer, detecting adenomyosis, and delineating adnexal and ovarian pathology (175).


Gynecology_Novak

Gynecology_Novak. Figure 14.19 Devices used for sampling endometrium. Top: Kevorkian Curette. Bottom: Pipelle.


Gynecology_Novak

Gynecology_Novak. Endometrial Sampling Endometrial sampling should be performed to evaluate abnormal bleeding in women who are at risk for endometrial pathology, including polyps, hyperplasia, or carcinoma. Such sampling is mandatory in the evaluation of anovulatory bleeding in women older than 35 to 40 years of age, in younger women who are obese, and in those who do not respond to medical therapy or those with a history of prolonged anovulation (143). The technique of D&C, which was used extensively for the evaluation of abnormal bleeding, was largely replaced by endometrial biopsy in the office. The classic study in which a D&C was performed before hysterectomy with the conclusion that less than one-half of the endometrium was sampled in more than one-half of the patients led to questioning the use of D&C for endometrial diagnosis (176,177). Hysteroscopy, either diagnostic or operative, with endometrial sampling, can be performed either in the office or operating room (178).


Gynecology_Novak

Gynecology_Novak. A number of devices are designed for endometrial sampling, including a commonly used, inexpensive, disposable ﬂexible plastic sheath with an internal plunger that allows tissue aspiration; disposable plastic cannulae of varying diameters that attach to a manually locking syringe that allows the establishment of a vacuum; and cannulae (both rigid metal and plastic) with tissue traps that attach to an electric vacuum pump (Fig. 14.19). Several studies comparing the adequacy of sampling using these devices with D&C showed a comparable ability to detect abnormalities. It should be noted that these devices are designed to obtain a tissue sample rather than a cytologic washing. The diagnostic accuracy of endometrial biopsy for endometrial malignancy and hyperplasia is good, although persistent bleeding should prompt further testing (179,180).


Gynecology_Novak

Gynecology_Novak. Management Attention should be directed to establishing a cause of abnormal bleeding. In most cases, medical therapy is effective in managing abnormal bleeding and should be attempted before surgical management. Medical management with either oral contraceptives or progestogens is the preferred therapy of anovulatory bleeding in women of reproductive age (143). Progestinreleasing IUDs are effective in treating heavy menstrual bleeding and demonstrate comparable benefits for quality of life (181). It is argued that the IUD should be offered prior to consideration of hysterectomy, as there are comparable benefits on heavy menstrual bleeding and clear cost benefits (182). When medical therapy fails in women with anovulatory uterine bleeding and without the desire for future childbearing, the surgical options of endometrial ablation or hysterectomy can be considered. Endometrial ablation is an efficient and cost-effective alternative to hysterectomy, although this therapy may not be


Gynecology_Novak

Gynecology_Novak. the surgical options of endometrial ablation or hysterectomy can be considered. Endometrial ablation is an efficient and cost-effective alternative to hysterectomy, although this therapy may not be definitive, with increasing rates of repeat ablation and hysterectomy over time (143). In women with leiomyomas, hysterectomy provides a definitive cure. A variety of surgical alternatives to hysterectomy are available to women with symptomatic uterine leiomyomas.


Gynecology_Novak

Gynecology_Novak. Nonsurgical Management Most bleeding problems, including anovulatory bleeding, can be managed nonsurgically. Treatment with NSAIDs, such as ibuprofen and mefenamic acid, decreases menstrual ﬂow by 30% to 50%, but is less effective than tranexamic acid, danazol, or levonorgestrel IUD (93). Antifibrinolytics such as tranexamic acid were effective in reducing menstrual blood loss, and this indication was approved by the FDA in late 2008 (183).


Gynecology_Novak

Gynecology_Novak. Hormonal management of abnormal bleeding frequently can control excessive or irregular bleeding. The treatment of choice for anovulatory bleeding is medical therapy with oral contraceptives (143). Oral contraceptives are used clinically to decrease menstrual ﬂow, although supporting data from prospective clinical trials are sparse (184). Low-dose oral contraceptives may be used by reproductive-age women without medical contraindications and during the perimenopausal years in healthy nonsmoking women who have no major cardiovascular risk factors. The benefits of menstrual regulation in such women often override the potential risks. The medical treatment of acute abnormal bleeding in reproductive-age women is the same as that described for adolescents.


Gynecology_Novak

Gynecology_Novak. For patients in whom estrogen use is contraindicated, progestins, both oral and parenteral, can be used to control excessive bleeding. Cyclic oral medroxyprogesterone acetate, administered from day 15 or 19 to day 26 of the cycle, reduces menstrual ﬂow and offers no advantages over other medical therapies such as NSAIDs, tranexamic acid, danazol, or the levonorgestrel IUD; progestogen therapy for 21 days of the cycle reduces menstrual ﬂow, although women found the treatment less acceptable than the levonorgestrel IUD (97). The benefits of progestins to the patient with oligomenorrhea and anovulation include a regular ﬂow and the prevention of long intervals of amenorrhea, which may end in unpredictable, profuse bleeding. This therapy reduces the risk of hyperplasia resulting from persistent, unopposed estrogen stimulation of the endometrium. Depot formulations of medroxyprogesterone acetate are used to establish amenorrhea in women at risk of excessive bleeding. Oral, parenteral, or


Gynecology_Novak

Gynecology_Novak. unopposed estrogen stimulation of the endometrium. Depot formulations of medroxyprogesterone acetate are used to establish amenorrhea in women at risk of excessive bleeding. Oral, parenteral, or intrauterine delivery of progestins are used in selected women with endometrial hyperplasia or early endometrial cancer who wish to maintain their fertility (185). Continued monitoring is indicated. Danazol is effective in decreasing bleeding and inducing amenorrhea; it is used rarely for ongoing management of abnormal bleeding because of its androgenic side effects, including weight gain, hirsutism, alopecia, and irreversible voice changes. GnRH analogues are used for short-term treatment of abnormal bleeding, either alone or with add-back therapy consisting of combined estrogen/progestogen or progestogen alone (186).


Gynecology_Novak

Gynecology_Novak. Surgical Therapy The surgical management of abnormal bleeding should be reserved for situations in which medical therapy is unsuccessful or is contraindicated. Although sometimes appropriate as a diagnostic technique, D&C is questionable as a therapeutic modality. One study reported a measured reduction in menstrual blood loss for the first menstrual period only (187). Other studies suggest a longer-lasting benefit (188).


Gynecology_Novak

Gynecology_Novak. The surgical options range from a variety of techniques for endometrial ablation or resection to hysterectomy to a variety of conservative surgical techniques for management of uterine leiomyoma, including hysteroscopy with resection of submucous leiomyomas, laparoscopic techniques of myomectomy, uterine artery embolization, and magnetic resonance–guided focused ultrasonography ablation (see Chapters 23 and 24) (143,189). The choice of procedure depends on the cause of the bleeding, the patient’s preferences, the physician’s experience and skills, the availability of newer technologies, and a careful assessment of risks versus benefits based on the patient’s medical condition, concomitant gynecologic symptoms or conditions, and desire for future fertility. The assessment of the relative advantages, risks, benefits, complications, and indications of these procedures is a subject of ongoing clinical research. Various techniques of endometrial ablation were compared with the gold


Gynecology_Novak

Gynecology_Novak. advantages, risks, benefits, complications, and indications of these procedures is a subject of ongoing clinical research. Various techniques of endometrial ablation were compared with the gold standard of endometrial resection, and the evidence suggests comparable success rates and complication profiles (190). The advantages of techniques other than hysterectomy include a shorter recovery time and less early morbidity. However, symptoms can recur or persist; repeat procedures or subsequent hysterectomy may be required if conservative options are chosen. Additional studies that include quality-of-life outcomes will be helpful. Collaborative decision making, taking into account individual patient preferences, should follow a thorough discussion of options, risks, and benefits (191). Much is written about the psychologic sequelae of hysterectomy, and some of the aforementioned surgical techniques were developed in an effort to provide less drastic management options. Most


Gynecology_Novak

Gynecology_Novak. (191). Much is written about the psychologic sequelae of hysterectomy, and some of the aforementioned surgical techniques were developed in an effort to provide less drastic management options. Most well-controlled studies suggest that, in the absence of preexisting psychopathology, indicated but elective surgical procedures for hysterectomy have few, if any, significant psychologic sequelae (including depression) (see Chapter 12 and 24) (192,193).


Gynecology_Novak

Gynecology_Novak. Table 14.12 Conditions Diagnosed as a Pelvic Mass in Women of Reproductive Age Less common conditions that must be excluded: Carcinoma of the colon, rectum, appendix Carcinoma of the fallopian tube Reproductive-Age Conditions diagnosed as a pelvic mass in women of reproductive age are presented in Pelvic Masses Table 14.12.


Gynecology_Novak

Gynecology_Novak. Carcinoma of the fallopian tube Reproductive-Age Conditions diagnosed as a pelvic mass in women of reproductive age are presented in Pelvic Masses Table 14.12. Differential Diagnosis It is difficult to determine the frequency of diagnoses of pelvic mass in women of reproductive age because many pelvic masses are not treated with surgery. Nonovarian or nongynecologic conditions may be confused with an ovarian or uterine mass (Table 14.12). The frequency of masses found at laparotomy was studied, although the percentages are affected by varying indications for surgery, indications for referral, type of practice (gynecologic oncology vs. general gynecology), and patient populations (a higher percentage of African Americans with uterine leiomyomas, for example). Benign masses, such as functional ovarian cysts or asymptomatic uterine leiomyoma, typically do not require or warrant surgery (Table 14.4).


Gynecology_Novak

Gynecology_Novak. Age is an important determinant of the likelihood of malignancy. In one study of women who underwent laparotomy for pelvic mass, malignancy was seen in only 10% of those younger than 30 years of age, and most of these tumors had low malignancy potential (194). The most common tumors found during laparotomy for pelvic mass are mature cystic teratomas or dermoids (seen in one-third of women younger than 30 years of age) and endometriomas (approximately one-fourth of women 31 to 49 years of age) (194,195). Uterine leiomyomas, commonly termed uterine fibroids, are by far the most common benign uterine tumors and are usually asymptomatic (195). Other benign uterine growths, such as uterine vascular tumors, are rare. See Chapter 15 for discussion of diagnosis, types and locations of fibroids, incidence, symptoms, causes, natural history, pathology, and management.


Gynecology_Novak

Gynecology_Novak. During the reproductive years, the most common ovarian masses are benign. Ovarian masses can be functional or neoplastic, and neoplastic tumors can be benign or malignant. Functional ovarian masses include follicular and corpus luteal cysts. About two-thirds of ovarian tumors are encountered during the reproductive years. Most ovarian tumors (80% to 85%) are benign, and two-thirds of these occur in women between 20 and 44 years of age. The chance that a primary ovarian tumor is malignant in a patient younger than 45 years of age is less than 1 in 15. Most tumors produce few or only mild, nonspecific symptoms. The most common symptoms include abdominal distension, abdominal pain or discomfort, lower abdominal pressure sensation, and urinary or gastrointestinal symptoms. If the tumor is hormonally active, symptoms of hormonal imbalance, such as vaginal bleeding related to estrogen production, may be present. Acute pain may occur with adnexal torsion, cyst rupture, or bleeding into a


Gynecology_Novak

Gynecology_Novak. hormonally active, symptoms of hormonal imbalance, such as vaginal bleeding related to estrogen production, may be present. Acute pain may occur with adnexal torsion, cyst rupture, or bleeding into a cyst. Pelvic findings in patients with benign and malignant tumors may differ. Masses that are unilateral, cystic, mobile, and smooth are most likely to be benign, whereas those that are bilateral, solid, fixed, irregular, and associated with ascites, cul-de-sac nodules, and a rapid rate of growth are more likely to be malignant (196).


Gynecology_Novak

Gynecology_Novak. In assessing ovarian masses, the distribution of primary ovarian neoplasms by decade of life can be helpful (197). Ovarian masses in women of reproductive age are most likely benign, but the possibility of malignancy must be considered (Fig. 14.20) (196).


Gynecology_Novak

Gynecology_Novak. Nonneoplastic Ovarian Masses Functional ovarian cysts include follicular cysts, corpus luteum cysts, and theca lutein cysts. All are benign and usually do not cause symptoms or require surgical management. Cigarette and marijuana smoking are associated with an increased risk of functional cysts, although the increased risk may be attenuated in overweight or obese women (198). Oral contraceptive use is associated with a decreased risk of developing ovarian cysts, although low-dose pills may have a smaller benefit, and oral contraceptives do not hasten the resolution of ovarian cysts (199,200). The annual rate of hospitalization for functional ovarian cysts is estimated to be as high as 500 per 100,000 woman-years in the United States, although little is known about the epidemiology of the condition. The most common functional cyst is the follicular cyst, which rarely is larger than 8 cm. A cystic follicle can be defined as a follicular cyst when its diameter is greater than 3 cm. These


Gynecology_Novak

Gynecology_Novak. The most common functional cyst is the follicular cyst, which rarely is larger than 8 cm. A cystic follicle can be defined as a follicular cyst when its diameter is greater than 3 cm. These cysts usually are found incidental to pelvic examination, although they may rupture or torse, causing pain and peritoneal signs. They can resolve in 4 to 8 weeks with expectant management (201).


Gynecology_Novak

Gynecology_Novak. Corpus luteum cysts are less common than follicular cysts. Corpus luteum cysts may rupture, leading to a hemoperitoneum and requiring surgical management. Patients taking anticoagulant therapy or with bleeding diatheses are at particular risk for hemorrhage and rupture. Rupture of these cysts occurs more often on the right side and may occur during intercourse. Most ruptures occur on cycle days 20 to 26 (202). Unruptured corpus luteum cysts can cause pain, presumably because of bleeding into the enclosed ovarian cyst cavity. They can produce symptoms that can be difficult to discern from adnexal torsion.


Gynecology_Novak

Gynecology_Novak. Theca lutein cysts are the least common of functional ovarian cysts. They are usually bilateral and occur with pregnancy, including molar pregnancies. They may be associated with multiple gestations, molar pregnancies, choriocarcinoma, diabetes, Rh sensitization, clomiphene citrate use, human menopausal gonadotropin–human chorionic gonadotropin ovulation induction, and the use of GnRH analogues. Theca lutein cysts may be quite large (up to 30 cm), are multicystic, and regress spontaneously (203). Combination monophasic oral contraceptive therapy is reported to reduce the risk of functional ovarian cysts (204). It appears that, in comparison with previously available higher-dose pills, the effect of cyst suppression with low-dose oral contraceptives is attenuated (205,206).


Gynecology_Novak

Gynecology_Novak. Ultrasound Exclude nongynecologic problem, e.g., with barium enema ≤8 cm >8–10 cm Ultrasound Complex, solid, and suspicious Progression Cystic PostmenopausalPremenopausal SurgeryObservation ± suppression for 2 months Figure 14.20 Preoperative evaluation of the patient with an adnexal mass. The use of triphasic oral contraceptives is not associated with an appreciable increased risk of functional ovarian cysts (207). Other Benign Masses Women with endometriosis may develop ovarian endometriomas (“chocolate” cysts), which can enlarge to 6 to 8 cm in size. A mass that does not resolve with observation may be an endometrioma (see Chapter 17). Excision is preferable to ablative techniques with regard to resolution of pain, achievement of spontaneous pregnancy, and risk of recurrence (208).


Gynecology_Novak

Gynecology_Novak. Although enlarged, polycystic ovaries were originally considered the sine qua non of PCOS, and are included among the Rotterdam diagnostic criteria, they are not always present with other features of the syndrome (209). An enlarged ovarian volume is suggested as an alternative diagnostic criterion, although whether the threshold should be 10 cm3 or 7 cm3 is debated (210). The prevalence of PCOS among the general population depends on the diagnostic criteria used. In one study, 257 volunteers were examined with ultrasonography; 22% were found to have polycystic ovaries (211). The finding of generously sized ovaries on examination or polycystic ovaries on ultrasonographic examination should prompt evaluation for the full-blown syndrome, which includes hyperandrogenism, chronic anovulation, and polycystic ovaries (159). Therapy for PCOS is medical and generally not surgical, with lifestyle modification and weight loss playing a potentially important role (212).


Gynecology_Novak

Gynecology_Novak. Figure 14.21 Mature cystic teratoma (dermoid cyst) of the ovary.


Gynecology_Novak

Gynecology_Novak. Neoplastic Masses Most benign cystic teratomas (dermoid cysts) occur during the reproductive years, although dermoid cysts have a wider age distribution than other ovarian germ cell tumors; in some case series, up to 25% of dermoids occur in postmenopausal women, and they can occur in newborns (213). Histologically, benign cystic teratomas have an admixture of elements (Fig. 14.21). In one study of ovarian masses that were surgically excised, dermoid cysts represented 62% of all ovarian neoplasms in women younger than 40 years of age (197). Malignant transformation occurs in less than 2% of dermoid cysts in women of all ages; most cases occur in women older than 40 years of age. The risk of torsion with dermoid cysts is approximately 15%, and it occurs more frequently than with ovarian tumors, perhaps because of the high fat content of most dermoid cysts, allowing them to ﬂoat within the abdominal and pelvic cavity. As a result of this fat content, on pelvic examination a dermoid cyst


Gynecology_Novak

Gynecology_Novak. perhaps because of the high fat content of most dermoid cysts, allowing them to ﬂoat within the abdominal and pelvic cavity. As a result of this fat content, on pelvic examination a dermoid cyst frequently is described as anterior in location. They are bilateral in approximately 10% of cases, although many have advanced the argument against bivalving a normal-appearing contralateral ovary because of the risk of adhesions, which may result in infertility. An ovarian cystectomy is almost always possible, even if it appears that only a small amount of ovarian tissue remains. Preserving a small amount of ovarian cortex in a young patient with a benign lesion is preferable to the loss of the entire ovary (214). Laparoscopic cystectomy often is possible, and intraoperative spill of tumor contents is rarely a cause of complications, although granulomatous peritonitis was reported (215–217). Laparoscopic removal may be associated with a higher risk of recurrence (216).


Gynecology_Novak

Gynecology_Novak. The risk of epithelial tumors increases with age. Although serous cystadenomas are often considered the more common benign neoplasm, in one study, benign cystic teratomas represented 66% of benign tumors in women younger than 50 years of age; serous tumors accounted for only 20% (197). Serous tumors are generally benign; 5% to 10% have borderline malignant potential, and 20% to 25% are malignant. Serous cystadenomas are often multilocular, sometimes with papillary components (Fig. 14.22). The surface epithelial cells secrete serous ﬂuid, resulting in a watery cyst content. Psammoma bodies, which are areas of fine calcific granulation, may be scattered within the tumor and are visible on radiograph. A frozen section is necessary to distinguish between benign, borderline, and malignant serous tumors because this distinction cannot be made on gross examination alone. Mucinous ovarian tumors may grow to large dimensions. Benign mucinous tumors typically have a lobulated, smooth surface,


Gynecology_Novak

Gynecology_Novak. tumors because this distinction cannot be made on gross examination alone. Mucinous ovarian tumors may grow to large dimensions. Benign mucinous tumors typically have a lobulated, smooth surface, are multilocular, and may be bilateral in up to 10% of cases. Mucoid material is present within the cystic loculations. Five to 10% of mucinous ovarian tumors are malignant. They may be difficult to distinguish histologically from metastatic gastrointestinal malignancies. Other benign ovarian tumors include fibromas (a focus of stromal cells), Brenner tumors (which appear grossly similar to fibromas and are frequently found incidentally), and mixed forms of tumors, such as the cystadenofibroma.


Gynecology_Novak

Gynecology_Novak. Figure 14.22 Serous cystadenoma. Uterine, gastric, breast, and colorectal malignancies can metastasize to the ovaries and should be considered, although as with many malignancies, these tumors are more common in postmenopausal-aged women.


Gynecology_Novak

Gynecology_Novak. Masses that include the fallopian tube are related primarily to inﬂammatory causes in the reproductive age group. A tubo-ovarian abscess can be present in association with PID (see Chapter 18). In addition, a complex inﬂammatory mass consisting of bowel, tube, and ovary may be present without a large abscess cavity. Ectopic pregnancies can occur in the reproductive age group and must be excluded when a patient presents with pain, a positive pregnancy test, and an adnexal mass (see Chapter 20). Paraovarian cysts may be noted either on examination or on imaging studies. In many instances, a normal ipsilateral ovary can be visualized using ultrasonography. The frequency of malignancy in paraovarian tumors is quite low and may be more common in paraovarian masses larger than 5 cm (218).


Gynecology_Novak

Gynecology_Novak. Diagnosis A complete pelvic examination, including rectovaginal examination and Papanicolaou (Pap) test, should be performed. Estimations of the size of a mass should be presented in centimeters rather than in comparison to common objects or fruit (e.g., orange, grapefruit, tennis ball, golf ball). After pregnancy is excluded, one simple office technique that can help determine whether a mass is uterine or adnexal includes sounding and measuring the depth of the uterine cavity. Pelvic imaging can confirm the characteristics of the adnexal mass—whether solid or cystic or mixed echogenicity. Diagnosis of uterine leiomyomas usually is based on the characteristic finding of an irregularly enlarged uterus. The size and location of the usually multiple leiomyomas can be confirmed and documented with pelvic ultrasonography (Fig. 14.23). If the examination is adequate to confirm uterine leiomyoma and symptoms are absent, ultrasonography is not always necessary unless an ovarian mass cannot be


Gynecology_Novak

Gynecology_Novak. with pelvic ultrasonography (Fig. 14.23). If the examination is adequate to confirm uterine leiomyoma and symptoms are absent, ultrasonography is not always necessary unless an ovarian mass cannot be excluded.


Gynecology_Novak

Gynecology_Novak. Other Studies Endometrial sampling with an endometrial biopsy or hysteroscopy is mandatory when both pelvic mass and abnormal bleeding are present. An endometrial lesion—carcinoma or hyperplasia—may coexist with a benign mass such as a leiomyoma. In Figure 14.23 Transvaginal pelvic ultrasound demonstrating multiple uterine leiomyomas. a woman with leiomyomas, abnormal bleeding cannot be assumed to be caused solely by the fibroids. Clinicians differ in recommendations about the need for endometrial biopsy when the diagnosis is leiomyomas with regular menses. If urinary symptoms are prominent, studies of the urinary tract may be necessary, including urodynamic testing, if incontinence or symptoms of pelvic pressure are present. Cystoscopy may be necessary or appropriate to rule out intrinsic bladder lesions.


Gynecology_Novak

Gynecology_Novak. Laboratory Studies Laboratory studies that are indicated for women of reproductive age with a pelvic mass include pregnancy test, cervical cytology, and complete blood count. The value of tumor markers, such as CA125 in distinguishing malignant from benign adnexal masses in premenopausal women with a pelvic mass, is questioned. A number of benign conditions, including uterine leiomyomas, PID, pregnancy, and endometriosis can cause elevated CA125 levels in premenopausal women; thus, measurement of CA125 levels is not useful in premenopausal women with adnexal masses, because it may lead to unnecessary surgical intervention. Ultrasonographic characteristics are more helpful than CA125 in suggesting risks of malignancy in premenopausal women (219).


Gynecology_Novak

Gynecology_Novak. Imaging Studies Other studies may be necessary or appropriate. The most commonly indicated study is pelvic ultrasonography, which will help document the origin of the mass to determine whether it is uterine, adnexal, bowel, or gastrointestinal. The ultrasonographic examination provides information about the size of the mass and its consistency—unilocular cyst, mixed echogenicity, multiloculated cyst, or solid mass—which can help determine management (Figs. 14.24 and 14.25). Solid components, mural nodules, papillary excrescences, and ascites increase the suspicion of malignancy (220). A number of different ultrasound scoring systems were developed in an effort to quantify risks of malignancy.


Gynecology_Novak

Gynecology_Novak. Transvaginal and transabdominal ultrasonography are complementary in the diagnosis of pelvic masses, particularly those that have an abdominal component. Transvaginal ultrasonography has the advantage of providing additional information about the internal architecture or anatomy of the mass. Heterogeneous pelvic masses, described as tubo-ovarian abscesses on transabdominal ultrasonography, can be differentiated as pyosalpinx, hydrosalpinx, tubo-ovarian complex, and tubo-ovarian abscess with transvaginal ultrasonography (Fig. 14.26).


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Gynecology_Novak. The diagnostic accuracy of transvaginal ultrasonography in diagnosing endometrioma can be quite high (Fig. 14.27). Endometriomas can have a variety of ultrasonographic appearances, from purely cystic to varying degrees of complexity with septation or debris to a solid appearance. A variety of scoring systems were developed with the intent of predicting benign versus malignant adnexal masses using ultrasound; the ultrasonographic morphologic characteristics used in many types of scoring systems are listed in Table 14.13 (220). Color ﬂow Doppler was added to other sonographic characteristics to predict risk of malignancy; ultrasound techniques are comparable to CT and MRI in differentiating benign from malignant masses (221,222). Although an analysis of such features may be helpful, histologic confirmation of surgically removed persistent masses remains the standard of care. Figure 14.24 Transvaginal ultrasound of a unilocular ovarian cyst.


Gynecology_Novak

Gynecology_Novak. Figure 14.24 Transvaginal ultrasound of a unilocular ovarian cyst. CT seldom is indicated as a primary diagnostic procedure, although it may be helpful in planning treatment when a malignancy is strongly suspected or when a nongynecologic disorder may be present. Abdominal ﬂat-plate radiography is not a primary diagnostic procedure, although if used for other indications, it may reveal calcifications that can assist in the discovery or diagnosis of a mass. Pelvic calcifications (teeth) consistent with a benign cystic teratoma, a calcified uterine fibroid, or scattered calcifications consistent with psammoma bodies of a papillary serous cystadenoma can be seen with abdominal radiography (Fig. 14.28). Figure 14.25 Transvaginal ultrasonogram of a complex, predominantly solid mass. Figure 14.26 Transvaginal ultrasonogram of bilateral tubo-ovarian abscesses.


Gynecology_Novak

Gynecology_Novak. Figure 14.25 Transvaginal ultrasonogram of a complex, predominantly solid mass. Figure 14.26 Transvaginal ultrasonogram of bilateral tubo-ovarian abscesses. Ultrasonography or CT imaging may be appropriate to demonstrate ureteral deviation, compression, or dilation in the presence of moderately large and laterally located fibroids or other Figure 14.27 Transvaginal ultrasonogram of an endometrioma of the ovary. Table 14.13 Ultrasonographic Characteristics of Adnexal Masses That May Be Useful in Predicting Malignancy Unilocular cyst vs. multilocular vs. solid components Regular contour vs. irregular border Smooth walls vs. nodular vs. irregular Presence or absence of ascites Unilateral vs. bilateral Presence of other intra-abdominal pathology (liver, etc.) pelvic mass. Such findings rarely provide an indication for surgical intervention for otherwise asymptomatic leiomyomas.


Gynecology_Novak

Gynecology_Novak. Presence of other intra-abdominal pathology (liver, etc.) pelvic mass. Such findings rarely provide an indication for surgical intervention for otherwise asymptomatic leiomyomas. Hysteroscopy provides direct evidence of intrauterine pathology or submucous leiomyomas that distort the uterine cavity (see Chapter 23). Hysterosalpingography will demonstrate indirectly the contour of the endometrial cavity and any distortion or obstruction of the uterotubal junction secondary to leiomyomas, an extrinsic mass, or peritubal adhesions. The techniques combining hysterosalpingography, in which ﬂuid is instilled into the uterine cavity, with transvaginal ultrasonography are helpful in the diagnosis of intrauterine pathology. Hysterosalpingography or sonohysterography may be indicated in women with infertility and uterine leiomyoma (193).


Gynecology_Novak

Gynecology_Novak. MRI may be most useful in the diagnosis of uterine anomalies, although its value rarely justifies the increased cost of the procedure over ultrasonography for the diagnosis of other pelvic masses (88). Figure 14.28 Benign cystic teratoma (dermoid cyst) of the ovary with teeth seen on abdominal radiograph. Management of Pelvic Mass in Reproductive-Age Women


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Gynecology_Novak. Figure 14.28 Benign cystic teratoma (dermoid cyst) of the ovary with teeth seen on abdominal radiograph. Management of Pelvic Mass in Reproductive-Age Women The management of a pelvic mass is based on an accurate diagnosis. An explanation of this diagnosis should be conveyed to the patient, along with a discussion of the likely course of the disease (e.g., growth of uterine leiomyomas, regression of fibroids at menopause, regression of a follicular cyst, the uncertain malignant potential of an ovarian mass). All options for management should be presented and discussed, although it is appropriate for the physician to state a recommended approach with an explanation of the reasons for the recommendation. Management should be based on the primary symptoms and may include observation with close follow-up, temporizing surgical therapies, medical management, or definitive surgical procedures.


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Gynecology_Novak. The management of uterine leiomyomas is dependent on the patient’s age and proximity to anticipated menopause, symptoms, patient preference, and the experience and skills of the clinician. Variability in reporting data regarding severity of symptoms, uterine anatomy, and response to therapy makes it difficult to compare different types of therapies, which include observation, medical, surgical, and radiologic-based techniques (see Chapter 15 for discussion of uterine fibroids).


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Gynecology_Novak. Ovarian Masses The now-routine application of ultrasound technology to gynecologic examinations led to the more frequent detection of ovarian cysts, sometimes as an incidental finding. Ultrasonography is a relatively easy diagnostic study to perform, but this ease led to the labeling of physiologic ovarian morphology and cystic follicles, as pathologic and the subsequent referral of patients for therapies, including surgery, without indications. Treatment of ovarian masses that are suspected to be functional tumors is expectant (Fig. 14.24). A number of randomized prospective studies showed no acceleration of the resolution of functional ovarian cysts (some of which were associated with the use of clomiphene citrate or human menopausal gonadotropins) with oral contraceptives compared with observation alone (200). Oral contraceptives are effective in reducing the risk of subsequent ovarian cysts and may be appropriate for women who desire both contraception and their noncontraceptive


Gynecology_Novak

Gynecology_Novak. observation alone (200). Oral contraceptives are effective in reducing the risk of subsequent ovarian cysts and may be appropriate for women who desire both contraception and their noncontraceptive benefits.


Gynecology_Novak

Gynecology_Novak. Symptomatic cysts should be evaluated promptly, although mildly symptomatic masses suspected to be functional should be managed with analgesics rather than surgery to avoid the risk of surgical complications, including the development of adhesions that may impair subsequent fertility. Surgical intervention is warranted in the presence of severe pain or the suspicion of malignancy or torsion. On ultrasonography, large cysts and those that have multiloculations, solid components, septa, papillae, and increased blood ﬂow should be suspected of neoplasia (219) (Fig. 24.25). If a malignant mass is suspected at any age, surgical evaluation should be performed promptly.


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Gynecology_Novak. Ovarian or adnexal torsion is suspected on the basis of peritoneal signs and the acuity of onset. Doppler ﬂow studies suggesting abnormal ﬂow are predictive of torsion, although torsion can be seen with normal ﬂow (223). The absence of internal ovarian ﬂow is not specific to torsion and may be seen with cystic lesions, although in these situations peripheral ﬂow usually can be visualized. The management of suspected ovarian torsion, which can occur at any age from prepubertal to postmenopausal, is surgical. When torsion is confirmed by laparoscopy, untwisting of the mass and ovarian preservation rather than extirpation are generally indicated (224,225). The value of oophoropexy in preventing recurrent torsion is not well established.


Gynecology_Novak

Gynecology_Novak. Ultrasonographic or CT-directed aspiration procedures of ovarian masses should not be used in women in whom there is a suspicion of malignancy. In the past, laparoscopic surgery for ovarian masses was reserved for diagnostic or therapeutic purposes in patients at very low risk for malignancy. Although it is feasible to perform laparoscopic surgical staging and treatment of ovarian low-malignant-potential tumors and early-stage ovarian cancer safely, the role of laparoscopy versus laparotomy in a woman with ovarian cancer is debated (226). Concerns related to laparoscopy in managing gynecologic malignancy include the accuracy of intraoperative diagnosis, inadequate resection, significance of tumor spillage, inaccurate or delayed surgical staging, delay in therapy, and the possibility of port-site metastasis. In laparoscopic oophorectomy for presumed benign disease, there is a possibility of a missed diagnosis of malignancy, even with frozen section, which would necessitate


Gynecology_Novak

Gynecology_Novak. of port-site metastasis. In laparoscopic oophorectomy for presumed benign disease, there is a possibility of a missed diagnosis of malignancy, even with frozen section, which would necessitate reexploration. Whether laparoscopic management results in long-term compromise of outcome or significant benefits remains unclear and, consequently, so does the role of laparoscopic management of complex masses that may be malignant (227,228).


Gynecology_Novak

Gynecology_Novak. Figure 14.29 Laparoscopic appearance of benign ovarian mass (dermoid cyst). The management of presumed benign ovarian masses with operative laparoscopy is now routine, although complication rates may be higher with complicated operative laparoscopic procedures such as those required for extensive endometriosis (Fig. 14.29) (229). The choice of surgical approach (laparotomy or laparoscopy) should be based on the surgical indications, the patient’s condition, the surgeon’s expertise and training, informed patient preference, and the most recent data supporting the chosen approach. The advantage of this technique is the shorter hospital stay, shorter recovery time, and lessened postoperative pain. A Cochrane review concluded that these findings should be interpreted with caution, given the small numbers of high-quality studies that provide comparisons (230).


Gynecology_Novak

Gynecology_Novak. The role of laparoscopy is even more controversial in the removal of dermoid cysts than with other benign masses. Concern focuses on preventing the spill of the cyst contents. Randomized clinical trials reported variable findings regarding spill; some studies suggest that cyst contents are more likely to spill with laparoscopy, whereas others do not find a difference or note no increase in morbidity when spillage occurred. Culdotomy and the use of an endoscopic specimen bag are associated with lower rates of tumor spillage (217).


Gynecology_Novak

Gynecology_Novak. In postmenarchal individuals, vulvar symptoms are most often related to a primary vaginitis and a secondary vulvitis. The mere presence of vaginal discharge can lead to vulvar irritative symptoms, or candidal vulvitis may be present (Fig. 14.17). The causes of vaginitis and cervicitis are covered in Chapter 18. Adult women describe vulvar symptoms using a variety of terms (itching, pain, discharge, discomfort, burning, external dysuria, soreness, pain with intercourse or sexual activity). Burning with urination from noninfectious causes may be difficult to distinguish from a urinary tract infection, although some women can distinguish pain when the urine hits the vulvar area (an external dysuria) from burning pain (often suprapubic in location) during urination. Itching is a very common vulvar symptom. A variety of vulvar conditions and lesions can present with pruritus. As in adolescents, vulvovaginal symptoms may be caused by STDs, nonsexually transmitted vaginitis, or UTIs. The


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Gynecology_Novak. vulvar symptom. A variety of vulvar conditions and lesions can present with pruritus. As in adolescents, vulvovaginal symptoms may be caused by STDs, nonsexually transmitted vaginitis, or UTIs. The distinction between symptoms related to a UTI and those of vaginitis is difficult, and consideration should be given to testing for both C. trachomatis and obtaining a urine culture, particularly in young reproductive-age women (134).


Gynecology_Novak

Gynecology_Novak. Table 14.14 Subacute and Chronic Skin Recurrent Conditions of the Vulva a Etiology unknown, often secondarily infected. A number of skin conditions that occur on other areas of the body may occur on the vulvar area. Table 14.14 contains a list of these conditions classified by either infectious or noninfectious causes. Whereas the diagnosis of some of these conditions is apparent from inspection alone (e.g., a skin tag), any lesions that appear atypical or in which the diagnosis is not clear should be analyzed by biopsy, because the risks of malignant lesions increases with age (Fig. 14.30). Figure 14.30 Large benign skin tag from left labium majus. Figure 14.31 Pigmented vulvar lesion.


Gynecology_Novak

Gynecology_Novak. Pigmented vulvar lesions include benign nevi, lentigines, melanosis, seborrheic keratosis, condyloma, and some VINs, especially multifocal VIN-3 (Fig. 14.31). Suspicious pigmented vulvar lesions in particular should warrant biopsy to rule out VIN or malignant melanoma (231). Approximately 10% of white women have a pigmented vulvar lesion; some of these lesions may be malignant (see Chapter 38) or have the potential for progression (VIN) (see Chapter 19). There is an increase in rates of VIN in women younger than age 50, along with increasing rates of vulvar squamous cell carcinoma in situ, possibly related to increasing rates of HPV infection. Heightened awareness among clinicians may play a role in the increasing frequency of diagnosis; suspicious lesions warrant vulvar biopsy. Pigmented lesions include common nevi, lentigines, melanomas, dysplastic nevi, blue nevi, and a lesion termed atypical melanocytic nevi of the genital type (AMNGT) (232). AMNGTs have some histologic features


Gynecology_Novak

Gynecology_Novak. lesions include common nevi, lentigines, melanomas, dysplastic nevi, blue nevi, and a lesion termed atypical melanocytic nevi of the genital type (AMNGT) (232). AMNGTs have some histologic features that may overlap with those of melanoma, but with a benign prognosis.


Gynecology_Novak

Gynecology_Novak. Vulvar Biopsy A vulvar biopsy is essential in distinguishing benign from premalignant or malignant vulvar lesions, especially because many types of lesions may have a somewhat similar appearance. Vulvar biopsies should be performed liberally in women of reproductive age to ensure that these lesions are diagnosed and treated appropriately. A prospective study of vulvar lesions evaluated by biopsy in a gynecologic clinic found lesions occurring in the following order of frequency: epidermal inclusion cyst, lentigo, Bartholin duct obstruction, carcinoma in situ, melanocytic nevi, acrochordon, mucous cyst, hemangiomas, postinﬂammatory hyperpigmentation, seborrheic keratoses, varicosities, hidradenomas, verruca, basal cell carcinoma, and unusual tumors such as neurofibromas, ectopic tissue, syringomas, and abscesses (233). Clearly, the frequency with which a lesion would be reported after a tissue biopsy is related to the frequency with which all lesions of a given pathology are evaluated


Gynecology_Novak

Gynecology_Novak. and abscesses (233). Clearly, the frequency with which a lesion would be reported after a tissue biopsy is related to the frequency with which all lesions of a given pathology are evaluated in this manner. Thus, this listing probably underrepresents such common lesions as condylomata (Fig. 14.18).


Gynecology_Novak

Gynecology_Novak. Biopsy is easily performed in the office using a local anesthetic. Typically, 1% lidocaine is infiltrated beneath the lesion using a small (25-to 27-gauge) needle. Disposable punch biopsy instruments come in a variety of sizes from 2 to 6 mm in diameter. These skin biopsy instruments, along with fine forceps, scissors, and a scalpel, should be available in all outpatient gynecologic settings. For smaller biopsies, it is usually not necessary to place a suture. Topical silver nitrate can be used for hemostasis. Multiple tissue samples may be appropriate to obtain representative areas of a lesion if the lesion has a variable appearance or is multifocal. Although the vulvar biopsy procedure involves minimal discomfort, the biopsy sites will be painful for several days after the procedure. The prescription of a topical anesthetic such as 2% lidocaine jelly, to be applied periodically and before urinating, is appreciated by patients who require this procedure. Infection of the site can


Gynecology_Novak

Gynecology_Novak. The prescription of a topical anesthetic such as 2% lidocaine jelly, to be applied periodically and before urinating, is appreciated by patients who require this procedure. Infection of the site can occur, and patients should be cautioned to report excessive erythema or purulent drainage.


Gynecology_Novak

Gynecology_Novak. Other Vulvar Conditions Classification and description of intraepithelial lesions of the vulva are presented in Chapter 19. Pseudofolliculitis or Mechanical Folliculitis This is similar to what is described as pseudofolliculitis barbae (razor bumps) and may occur in women who follow the popular practice of shaving pubic hair (234). Pseudofolliculitis consists of an inﬂammatory reaction surrounding an ingrown hair and occurs most commonly among individuals with curly hair, particularly African Americans. Infectious Folliculitis Shaving may be associated with an infectious folliculitis, commonly caused by Staphylococcus aureus and Streptococcus pyogenes. Shaving and other methods of pubic hair removal are associated with razor burn, contact dermatitis, and the transmission of other infectious agents such as Molluscum contagiosum, HPV, and herpes simplex along with other bacteria including Pseudomonas aeruginosa (234).


Gynecology_Novak

Gynecology_Novak. Fox-Fordyce Disease This condition is characterized by a chronic, pruritic eruption of small papules or cysts formed by keratin-plugged apocrine glands. It is commonly present over the lower abdomen, mons pubis, labia majora, and inner portions of the thighs. Hidradenitis suppurativa is a chronic condition involving the apocrine glands with the formation of multiple deep nodules, scars, pits, and sinuses that occur in the axilla, vulva, and perineum. Hyper-pigmentation and secondary infection are often seen. Hidradenitis suppurativa can be extremely painful and debilitating. In the past, it was treated with antibiotics, isotretinoin, or steroids; surgical therapy with wide local excision may be necessary. Tumor necrosis factor-α inhibitors show promise in treatment (235).


Gynecology_Novak

Gynecology_Novak. Acanthosis Nigricans This disease involves widespread velvety pigmentation in skin folds, particularly the axillae, neck, thighs, submammary area, and vulva and surrounding skin (Fig. 14.32). It is of particular interest to gynecologists because of its association with hyperandrogenism and PCOS; as such, it is associated with obesity, chronic anovulation, acne, glucose Figure 14.32 Acathosis nigricans of the neck. Vulvar Tumors, Cysts, and Masses intolerance, insulin resistance, and cardiovascular disease (159,236). Topical and oral retinoids are used to treat the acanthosis nigricans, along with management of the underlying conditions including obesity and insulin resistance or diabetes (237).


Gynecology_Novak

Gynecology_Novak. Extramammary Paget’s Disease This is an intraepithelial neoplasia containing vacuolated Paget’s cells (see Chapter 19). Clinically, the appearance of Paget’s disease is variable, and it may have an appearance varying from moist, oozing ulcerations to an eczematoid lesion with scaling and crusting to a grayish lesion (238). It may be confused with candidiasis, psoriasis, seborrheic dermatitis, contact dermatitis, and VIN. A biopsy to confirm the diagnosis is mandatory. Vulvar Intraepithelial Neoplasia VIN is associated with HPV infection and is increasing in frequency, particularly among young women (see Chapter 19). Diagnosis requires biopsy of any suspicious vulvar lesions, particularly those that are pigmented or discolored. The increasing frequency of this entity dictates a careful vulvar inspection during annual gynecologic examinations.


Gynecology_Novak

Gynecology_Novak. Condylomata Acuminata These are very common vulvar lesions and are usually easily recognized and treated with topical therapies such as trichloroacetic and bichloracetic acid. Other sexually transmitted organisms, such as the virus responsible for molluscum contagiosum and the lesions of syphilis and condylomata lata, may occasionally be mistaken for vulvar condylomata acuminata caused by HPV (see Chapter 18). A summary of benign vulvar tumors is listed in Table 14.15. There is argument regarding whether sebaceous cysts exist on the vulva or whether these lesions are histopathologically epidermal or epidermal inclusion cysts (238). So-called sebaceous cysts are clinically indistinguishable from epidermal inclusion cysts that may result from the burial of fragments of skin after the trauma of childbirth or episiotomy or that arise from occluded pilosebaceous ducts. These cysts are seldom symptomatic, although if infection develops, incision and drainage may be required acutely, and


Gynecology_Novak

Gynecology_Novak. of childbirth or episiotomy or that arise from occluded pilosebaceous ducts. These cysts are seldom symptomatic, although if infection develops, incision and drainage may be required acutely, and ultimately complete excision is indicated.


Gynecology_Novak

Gynecology_Novak. Bartholin Duct Cysts These are common vulvar lesions in reproductive-age women. They result from occlusion of the duct with accumulation of mucus and may be asymptomatic. Infection of the gland can result in the accumulation of purulent material, with the formation of a Table 14.15 Types of Vulvar Tumors 1. Cystic lesions 3. Anatomic Cyst in the canal of Nuck (hydrocele) Urethral diverticulum Skene duct cyst 4. Infections 2. Solid tumors Abscess—Bartholin, Skene, periclitoral, other Cherry angioma 5. Ectopic Figure 14.33 Skene’s gland cyst.