Gynecology and Obstetrics - Merck Manuals Professional Edition

Approach to the Gynecologic Patient

Most women, particularly those seeking general preventive care, require a complete history and physical examination as well as a gynecologic evaluation.
- General Gynecologic Evaluation
Symptoms of Gynecologic Disorders

The female pelvic cavity contains the upper female reproductive tract (cervix, uterus, ovaries, fallopian tubes); the adnexa refers to the ovaries, fallopian tubes, and surrounding connective tissues. The pelvic cavity also contains the intestines, bladder, and lower ureters. A pelvic mass may originate from any of these structures.
Breast Cancer

Breast cancers are most often epithelial tumors involving the ducts or lobules. Most patients present with an asymptomatic mass discovered during examination or screening mammography. Diagnosis is made by biopsy. Treatment usually includes surgical excision, often with radiation therapy, and with or without adjuvant chemotherapy, endocrine therapy, or both.
Breast Disorders

Breast symptoms (eg, masses, nipple discharge, pain) are common, accounting for > 15 million physician visits/year. Although > 90% of symptoms have benign causes, breast cancer is always a concern. Because breast cancer is common and may mimic benign disorders, the approach to all breast symptoms and findings is to conclusively exclude or confirm cancer.
Domestic Violence and Sexual Assault

Domestic violence includes physical, sexual, and psychologic abuse between people who live together including sex partners, parents or guardians and children, children and grandparents, and siblings. Domestic violence includes intimate partner violence (IPV), which refers to physical, sexual, or psychologic abuse by a current or former sex partner or spouse.
- Domestic Violence
- Medical Examination of the Rape Victim
Endometriosis

In endometriosis, functioning endometrial cells are implanted in the pelvis outside the uterine cavity. Symptoms depend on location of the implants. The classic triad of symptoms is dysmenorrhea, dyspareunia, and infertility, but symptoms may also include dysuria and pain during defecation. Severity of symptoms is not related to disease stage. Diagnosis is by direct visualization and sometimes biopsy, usually via laparoscopy. Treatments include anti-inflammatory drugs, drugs to suppress ovarian function and endometrial tissue growth, surgical ablation and excision of endometriotic implants, and, if disease is severe and no childbearing is planned, hysterectomy alone or hysterectomy plus bilateral salpingo-oophorectomy.
- Endometriosis
Family Planning

The decision to begin, prevent, or interrupt a pregnancy may be influenced by many factors, including personal, medical, family, and socioeconomic factors.
Female Reproductive Endocrinology

Hormonal interaction between the hypothalamus, anterior pituitary gland, and ovaries regulates the female reproductive system.
- Female Reproductive Endocrinology
Gynecologic Tumors

Gynecologic cancers involve the uterus, ovaries, cervix, vulva, vagina, fallopian tubes, or peritoneum. Gestational trophoblastic disease is a group of proliferative disorders originating from trophoblastic tissue in the uterus.
Infertility

Infertility is usually defined as the inability to conceive after 1 year of regular, unprotected sexual intercourse.
Menopause

Menopause is the permanent cessation of menses (amenorrhea) due to loss of ovarian follicular function. Clinical manifestations may include hot flushes, night sweats, sleep disruption, and genitourinary syndrome of menopause (symptoms and signs due to estrogen deficiency, such as vulvovaginal atrophy). Diagnosis is clinical, based retroactively on the absence of menses for 12 months. Manifestations may be treated (eg, with lifestyle modification, complementary and alternative medicine, nonhormonal therapy, and/or hormone therapy).
- Menopause
Menstrual Abnormalities

Some common menstrual abnormalities include
Miscellaneous Gynecologic Disorders

Bartholin gland cysts are the most common large vulvar cysts. They are mucus-filled and are located on either side of the vaginal opening. Symptoms of large cysts include vulvar pressure or pain, dyspareunia, and vulvar asymmetry. Bartholin gland cysts may form abscesses, which are painful. Diagnosis is by pelvic examination. Large cysts and abscesses require drainage and sometimes excision; abscesses require antibiotics.
Pelvic Organ Prolapse (POP)

Pelvic organ prolapse results from laxities (similar to hernias) in the ligaments, fascia, and muscles supporting the pelvic organs (pelvic floor—see figure Pelvic organ prolapse). The prevalence of pelvic organ prolapse is difficult to ascertain, and treatment is based on symptoms.
Prenatal Genetic Counseling and Evaluation

Prenatal genetic counseling is provided for all prospective parents, ideally before conception, to assess risk factors for congenital disorders. Precautions to help prevent birth defects (eg, avoiding teratogens, taking supplemental folic acid.) are recommended for all women who are planning to become pregnant.
Female Sexual Function and Dysfunction

Women commonly have concerns about sexual function ( 1). Concerns that cause personal or interpersonal distress are considered a sexual dysfunction disorder. Approximately 12% of women in the United States have a sexual function issue associated with distress ( 2).
Uterine Fibroids

Uterine fibroids (leiomyomas) are benign smooth muscle tumors of the uterus. Fibroids frequently cause abnormal uterine bleeding and pelvic pressure and sometimes urinary or intestinal symptoms, infertility, or pregnancy complications. Diagnosis is by pelvic examination, ultrasonography, or other imaging studies. Treatment of patients depends on symptoms and desire for fertility and preferences regarding surgical treatments. Treatment may include estrogen-progestin contraceptives, progestin therapy, tranexamic acid, and surgical procedures (eg, hysterectomy, myomectomy).
- Uterine Fibroids
- Cervical Leiomyomas
Vaginitis, Cervicitis, and Pelvic Inflammatory Disease

Vaginitis is infectious or noninfectious inflammation of the vaginal mucosa, sometimes with inflammation of the vulva. Symptoms include vaginal discharge, irritation, pruritus, and erythema. Diagnosis is by evaluation of vaginal secretions. Treatment is directed at the cause and at any severe symptoms.
Approach to the Pregnant Woman and Prenatal Care

For conception (fertilization), a live sperm must unite with an ovum in a fallopian tube with normally functioning epithelium. Conception occurs just after ovulation, about 14 days after a menstrual period. At ovulation, cervical mucus becomes less viscid, facilitating rapid movement of sperm to the ovum, usually near the fimbriated end of the tube. Sperm may remain alive in the vagina for about 3 days after intercourse.
Symptoms During Pregnancy

Pelvic pain is common during early pregnancy and may accompany serious or minor disorders. Some conditions causing pelvic pain also cause vaginal bleeding. In some of these disorders (eg, ruptured ectopic pregnancy, ruptured hemorrhagic corpus luteum cyst), bleeding may be severe, sometimes leading to hemorrhagic shock.
Abnormalities and Complications of Labor and Delivery

Abnormalities and complications of labor and delivery should be diagnosed and managed as early as possible.
Abnormalities of Pregnancy

Ectopic pregnancy is the implantation of a pregnancy in a site other than the endometrial lining of the uterine cavity—ie, in the fallopian tube, uterine cornua, cervix, ovary, or abdominal or pelvic cavity. Ectopic pregnancies cannot be carried to term and eventually rupture or involute. Early symptoms and signs include pelvic pain and vaginal bleeding. Hemorrhagic shock can occur with rupture. Diagnosis is by measurement of the beta subunit of human chorionic gonadotropin and ultrasonography. Treatment is with laparoscopic or open surgical resection or with methotrexate.
Drugs in Pregnancy

Drugs are used in over half of all pregnancies, and prevalence of use is increasing. The most commonly used drugs include antiemetics, antacids, antihistamines, analgesics, antimicrobials, diuretics, hypnotics, tranquilizers, and social and illicit drugs. Despite this trend, firm evidence-based guidelines for drug use during pregnancy are still lacking.
- Drugs in Pregnancy
High-Risk Pregnancy

In a high-risk pregnancy, the mother, fetus, or neonate is at increased risk of morbidity or mortality before, during, or after delivery.
Normal Labor and Delivery

Labor consists of a series of rhythmic, involuntary or medically induced contractions of the uterus that result in effacement (thinning and shortening) and dilation of the uterine cervix. The World Health Organization (WHO) defines normal birth as follows:
- Management of Normal Labor
- Management of Normal Delivery
Postpartum Care and Associated Disorders

Clinical manifestations during the puerperium (6-week period after delivery) generally reflect reversal of the physiologic changes that occurred during pregnancy (see table Normal Postpartum Changes). These changes are temporary and should not be confused with pathologic conditions.
Pregnancy Complicated by Disease

Normally during pregnancy, erythroid hyperplasia of the marrow occurs, and red blood cell (RBC) mass increases. However, a disproportionate increase in plasma volume results in hemodilution (hydremia of pregnancy): hematocrit (Hct) decreases from between 38% and 45% in healthy women who are not pregnant to about 34% during late single pregnancy and to 30% during late multifetal pregnancy. The following hemoglobin (Hb) and Hct levels are classified as anemic: