Gynecological Health: Diagnosis and Treatment Insights

Secondary Infertility: Diagnosis and Management

Understanding Secondary Infertility

Secondary infertility is the inability to conceive or carry a pregnancy to term after having had a successful pregnancy in the past.

Patient History (Hx)

• Obstetric History: Parity, Deliveries, Live births, Deaths (P/D/L/D)
• Sexual Activity: Regularity of intercourse
• Gynecological Diseases: History of relevant conditions
• Medications: Current and past drug use
• Lifestyle Factors: Smoking status

Key Contributing Factors

• Pelvic Inflammatory Disease (PID): Can lead to tubal damage.
• Appendicitis: May result in peritonitis and subsequent adhesions.
• Previous Surgeries: Can cause adhesions affecting fertility.
• Smoking: Associated with reduced fertility and increased risk of Sexually Transmitted Infections (STIs).

Diagnosis Timing and Gold Standard

• Diagnosis Timing: Infertility is typically diagnosed after 1 year of unprotected intercourse. If conception has not occurred after 3 years of regular sexual activity, further investigation is warranted.
• Gold Standard: Laparoscopic evaluation and management for certain cases.

Diagnostic Tests

• Gynecological Exam: Comprehensive physical assessment.
• Transvaginal Ultrasound (TV US): Evaluation of uterus and fallopian tubes.
• Semen Analysis (Spermogram): Performed after 3-7 days of abstinence.
• Ovarian Function Test: Progesterone level on Day 21 of the menstrual cycle.
• Imaging:
  • Hysterosalpingography (HSG)
  • Salpingosonography

Abnormal Uterine Bleeding (AUB)

Assessment and Management of AUB

Patient History (Hx)

• Menstrual History: Age at menarche, Last Menstrual Period (LMP)
• Surgical History: Previous operations
• Allergies: Known sensitivities
• Extragenital Diseases: Systemic medical conditions
• Medications: Current drug use
• Family History: Relevant family medical conditions

Preliminary Findings and Classification

• Dysfunctional Uterine Bleeding (DUB): Common in juvenile and perimenopausal periods.
• Menometrorrhagia: Prolonged or excessive bleeding at irregular intervals.
• Secondary Anemia: Due to significant blood loss.
• Classification: PALM-COEIN system (Polyp, Adenomyosis, Leiomyoma, Malignancy and hyperplasia; Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not yet classified).

Risk Factors (RF)

• Age: Young (adolescents) and older (perimenopausal/postmenopausal) women.
• Smoking: Can affect hormonal balance.
• Blood Pressure (BP): Hypertension.
• Family History: Genetic predispositions.
• Body Mass Index (BMI): Obesity can impact menstrual regularity.

Treatment (Tx)

For Young Patients:

• Hospitalization: For severe bleeding.
• Infusion Therapy: To stabilize patient.
• Hormonal Therapy:
  • Gestagens (Progestins)
  • Combined Oral Contraceptives (COCs)
• Blood Transfusion: If severe anemia is present.
• Anti-Anemic Treatment: Iron supplementation.

For Older Patients:

• Hysteroscopy with Uterine Abrasion: Diagnostic and therapeutic procedure (Dilation and Curettage - D&C).
• Conservative Treatment: Post-surgical management.

Acne and Hirsutism: Hormonal Considerations

Managing Skin and Hair Conditions Linked to Hormones

Patient History (Hx)

• Obstetric History: Parity, Deliveries, Live births, Deaths (P/D/L/D)
• Duration: Onset and progression of acne and hirsutism.
• Symptoms: Specific details of acne and hirsutism.

Menstrual Cycle Assessment

• Normal Cycle: Typically 21-35 days.
• Irregular Cycle: Often indicates anovulation (lack of ovulation).

Diagnostic Tests

• Hormone Levels:
  • Testosterone
  • Follicle-Stimulating Hormone (FSH)
  • Luteinizing Hormone (LH)
  • Sex Hormone-Binding Globulin (SHBG)
  • Prolactin
  • Thyroid Hormones
• Adrenal Hormones: To exclude adrenal disorders.

Treatment (Tx)

• Weight Reduction: If applicable, can improve hormonal balance.
• Hormonal Therapy:
  • Combined Oral Contraceptives (COCs)
  • Gestagens (Progestins), often in the second half of the cycle.
• Ovulation Induction: If fertility is desired and anovulation is present.

Menopause Management: Symptoms and Therapies

Navigating the Menopausal Transition

Patient History (Hx)

• Symptom Onset: When menopausal symptoms began.
• Lifestyle History: Diet, exercise, smoking, alcohol.
• Medications Used: Current and past treatments.
• Surgical History: Relevant procedures.

Treatment (Tx)

• Hormone Replacement Therapy (HRT) Indications: Discuss benefits and risks.
• Adverse Drug Reactions (ADR): Potential side effects like weight gain or edema.
• Risk vs. Benefit Assessment: Individualized evaluation for HRT.

Key Considerations and Patient Questions

• HRT and Cancer Risk: Clarify that HRT does not inherently cause cancer, but may influence risk depending on type and duration.
• Duration of HRT: Typically recommended for 5-10 years, or as clinically indicated.
• Expected Results: Improvements often seen within 1 month of starting therapy.
• Screening:
  • Mammography: Recommended every 2 years.
  • Pap Smear: Recommended every 3 years.

Oral Contraceptive Pills (OCPs) and Contraception

Understanding Birth Control Options and Effectiveness

Discussion Points

• Pearl Index: A measure of contraceptive effectiveness.

Factors to Consider and Contraindications

• Smoking: Increased cardiovascular risk.
• Sexually Transmitted Infections (STIs): OCPs do not protect against STIs.
• Migraine: Especially with aura, can be a contraindication.
• High Blood Pressure (HBP): Hypertension.
• Diabetes Mellitus (DM): Can affect glucose metabolism.
• Liver Problems: Impaired metabolism of hormones.
• Cancer: Certain hormone-sensitive cancers.

Reliable Contraception Methods

• Oral Contraceptive Pills (OCPs)
• Contraceptive Patch
• Vaginal Ring
• Intrauterine Device (IUD)
• Contraceptive Implants

Starting Oral Contraceptive Pills

• Begin on Day 1-5 of a new menstrual cycle.
• If starting on Day 3 or later, use backup contraception for the first 7 days.

Ovarian Conditions: Diagnosis and Treatment

Addressing Ovarian Cysts and Tumors

Patient History (Hx)

• Symptom Onset: When the disorder was first noticed.
• Pregnancy Test: Rule out pregnancy if applicable.
• Pain Characteristics: When pain occurs, cycle regularity.
• Last Menstrual Period (LMP): Date of last period.

Gynecological History

• Obstetric History: Parity, Deliveries, Live births, Deaths (P/D/L/D)
• Surgical History: Previous gynecological surgeries.
• Diseases: Relevant medical conditions.
• Medications Used: Current and past drug use.

Further Examination

• Abdominal Exam: Palpation and percussion.
• Ultrasound (US): Imaging of ovaries.
• CA-125: Tumor marker, elevated in some ovarian conditions.
• Potential Findings:
  • Cystoma of the right ovary.
  • Suspicion of ovarian cancer or ascites.

Treatment (Tx)

• Surgical Cystectomy: Removal of ovarian cysts, often by laparoscopy.
• Cytoreductive Surgery: For ovarian cancer, aiming to remove as much tumor as possible.

Cervical Screening and Abnormal Cytology

Understanding ASC-H and Cervical Cancer Prevention

Atypical Squamous Cells, Cannot Exclude HSIL (ASC-H)

• ASC-H indicates atypical squamous cells where a high-grade squamous intraepithelial lesion (HSIL) cannot be excluded.

Diagnostic Tests for ASC-H

• Colposcopy: Visual examination of the cervix.
• Biopsy: Tissue sample for histological analysis.

Additional Tests and Risk Factors

• Cytology: Further microscopic examination of cells.
• HPV DNA Test: To detect high-risk Human Papillomavirus types.
• Immunochemistry: Staining for markers like p16/Ki-67.

Risk Factors for Cervical Abnormalities

• Human Papillomavirus (HPV) Infection: Primary cause.
• Multiple Sexual Partners: Increases HPV exposure.
• Early Sexual Activity: Increases HPV exposure.

Prevention

• HPV Vaccine: Highly effective in preventing HPV-related cervical changes.

Cervical Cytology Screening

Importance of Pap Tests for Early Detection

Screening Guidelines

• Screening Age: Typically recommended from 21 years old.
• Pap Test Frequency: Generally needed every 3 years for average-risk individuals.
• Purpose: To find precancerous cells before they develop into cancer.

Causes of Cervical Abnormalities

• Human Papillomavirus (HPV): Main causative agent.
• Smoking: Increases risk of cervical cancer.
• Early Sexual Activity: Associated with higher HPV exposure.

HPV Vaccination

• HPV Vaccine: Protects against high-risk HPV types (e.g., 16, 18, and others).

Cervical Cancer: Diagnosis and Treatment

Managing Malignancy of the Cervix

Diagnosis and Biopsy

• Suspected Cancer: Requires a biopsy for definitive diagnosis.

Staging and Imaging

• Staging: Essential for treatment planning (e.g., FIGO staging).
• Imaging:
  • Pelvic Ultrasound (US)
  • MRI (Magnetic Resonance Imaging)
  • Chest X-ray
  • CT (Computed Tomography) Scan

Treatment Based on Stage

• Stage III Treatment Example: For advanced stages, surgery may not be the primary treatment.
• Therapies: Often involves chemotherapy and biotherapy.

Risk Factors (RF)

• Human Papillomavirus (HPV): Major risk factor.
• Smoking: Significantly increases risk.