Gynecology and Obstetrics

Most women, particularly those seeking general preventive care, require a complete history and physical examination as well as a gynecologic evaluation.

A pelvic mass may be detected during routine gynecologic examination. A pelvic mass may be noncancerous or cancerous.

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.

Although legal and medical definitions vary, rape is typically defined as oral, anal, or vaginal penetration that involves threats or force against a person who is unwilling (ie, nonconsenting) or incapacitated (because of cognitive or physical disability or intoxication). Such penetration, whether wanted or not, is considered statutory rape if victims are younger than the age of consent.

In endometriosis, functioning endometrial tissue is implanted in the pelvis outside the uterine cavity. Symptoms depend on location of the implants and may include dysmenorrhea, dyspareunia, infertility, 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.

A couple’s decision to begin, prevent, or interrupt a pregnancy may be influenced by many factors including maternal medical disorders, risks involved in the pregnancy, and socioeconomic factors.

Hormonal interaction between the hypothalamus, anterior pituitary gland, and ovaries regulates the female reproductive system.

Gynecologic cancers often involve the uterus, ovaries, cervix, vulva, vagina, fallopian tubes, or the peritoneum. The most common gynecologic cancer in the US is endometrial cancer, followed by ovarian cancer. Cervical cancer is not very common in developed countries because screening with the Papanicolaou (Pap) test and with human papillomavirus (HPV) testing are widely available and effective.

Infertility is usually defined as inability of a couple to conceive after 1 year of unprotected intercourse.

Menopause is physiologic or iatrogenic cessation of menses (amenorrhea) due to decreased ovarian function. 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: absence of menses for 1 year. Manifestations may be treated (eg, with lifestyle modification, complementary and alternative medicine, and/or hormone therapy).

Menstrual abnormalities include

Adnexal torsion is twisting of the ovary and sometimes the fallopian tube, interrupting the arterial supply and causing ischemia.

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 is provided for all prospective parents, ideally before conception, to assess risk factors for congenital disorders. Certain precautions to help prevent birth defects (eg, avoiding teratogens, taking supplemental folic acid.) are recommended for all women who are planning to become pregnant. Parents with risk factors are advised about possible outcomes and options for genetic evaluation. If testing identifies a disorder, reproductive options are discussed.

Men and women initiate or agree to sexual activity for many reasons, including sharing sexual excitement and physical pleasure and experiencing affection, love, romance, or intimacy. However, women are more likely to report emotional motivations such as

Uterine fibroids are benign uterine tumors of smooth muscle origin. Fibroids frequently cause abnormal uterine bleeding, pelvic pain and pressure, urinary and intestinal symptoms, and pregnancy complications. Diagnosis is by pelvic examination, ultrasonography, or other imaging. Treatment of symptomatic patients depends on the patient’s desire for fertility and her desire to keep her uterus. Treatment may include oral contraceptives, brief presurgical gonadotropin-releasing hormone therapy to shrink fibroids, progestin therapy, and more definitive surgical procedures (eg, hysterectomy, myomectomy).

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 testing of vaginal secretions. Treatment is directed at the cause and at any severe symptoms.

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.

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

Abruptio placentae is premature separation of a normally implanted placenta from the uterus, usually after 20 weeks gestation. It can be an obstetric emergency. Manifestations may include vaginal bleeding, uterine pain and tenderness, hemorrhagic shock, and disseminated intravascular coagulation. Diagnosis is clinical and sometimes by ultrasonography. Treatment is modified activity (eg, a woman's staying off her feet for most of the day) for mild symptoms and prompt delivery for maternal or fetal instability or a near-term 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.

In a high-risk (at-risk) pregnancy, the mother, fetus, or neonate is at increased risk of morbidity or mortality before, during, or after delivery.

Labor consists of a series of rhythmic, involuntary, progressive contractions of the uterus that cause effacement (thinning and shortening) and dilation of the uterine cervix. The World Health Organization (WHO) defines normal birth as follows:

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 mild and temporary and should not be confused with pathologic conditions.

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. Thus during pregnancy, anemia is defined as hemoglobin (Hb) < 10 g/dL (Hct < 30%). If Hb is < 11.5 g/dL at the onset of pregnancy, women may be treated prophylactically because subsequent hemodilution usually reduces Hb to < 10 g/dL. Despite hemodilution, oxygen-carrying capacity remains normal throughout pregnancy. Hct normally increases immediately after birth.