General Gynecology

·         Meiosis I is arrested in prOphase for years until Ovulation.

Meiosis II is arrested in METaphase until fertilization. An egg MET a sperm.

·         Relaxin is the only hormone produced both by the ovary and uterus.

Renin is the only hormone produced by both the theca and kidney.

Inhibin is produced in the granulosa, theca, and corpus luteum.

Inhibin-A under the influence of LH suppresses FSH during the luteal phase of the cycle.

Inhibin-B directly suppresses pituitary FSH secretion in the follicular phase of the cycle.

Activin is produced in the granulosa.

Follistatin is produced in follicles.

Enkephalin is produced by the ovary.

 Epidermal growth factor-like is produced in granulosa and theca.

Transforming growth factor-beta is produced in theca, ovarian interstitial tissue, and granulose.

Müllerian-inhibiting substance is produced in the granulosa.

Angiotensin II is produced in the follicular fluid.

from the granulosa: Müllerian-inhibiting substance, activin, inhibin, follicle regulatory protein, insulin-like growth factor-1, epidermal growth factor-like, platelet-derived growth factor, proopiomelanocortin, and gonadotropin surge-inhibiting factor,plasminogen activator

from the theca: transforming growth factor, renin, inhibin, and relaxin; and

from the corpus luteum: basic fibroblast growth factor,inhibin,relaxin

from follicular fluid: angiotensin II, luteinizing inhibitor and luteinizing stimulator, oocyte meiosis inhibitor, follicle regulatory protein, and renin.

·         Bacterial vaginosis is a condition is which there is an overgrowth of anaerobic bacteria in the vagina that replaces the normal lactobacillus. Women with this type of vaginitis complain of an unpleasant vaginal odor that is described as musty or fishy and a thin, gray-white vaginal discharge that is adherent to the vaginal walls. Vulvar irritation and pruritus are rarely present. To confirm the diagnosis of bacterial vaginosis, a wet smear is done. To perform a wet smear, saline is mixed with the vaginal discharge and clumps of bacteria and clue cells are identified. Clue cells are vaginal epithelial cells with clusters of bacteria adherent to their surfaces. In addition, a whiff test can be performed by mixing potassium hydroxide with the vaginal discharge. In cases of bacterial vaginosis, an amine-like odor will be detected. The treatment of choice for bacterial vaginosis is metronidazole (Flagyl) 500 mg given twice daily for 7 days.

·         In cases of candidiasis, patients commonly complain of vulvar burning, pain, pruritus, and erythema. The vaginal discharge tends to be white, highly viscous, granular, and adherent to the vaginal walls. A wet smear with potassium hydroxide can confirm the diagnosis by the identification of hyphae. Treatment of candidiasis can achieved with the administration of topical imidazoles or triazoles or the oral medication Diflucan.

·         Trichomonas vaginitis is the most common nonviral, nonchlamydial sexually transmitted disease of women. It is caused by the anaerobic, flagellated protozoan T. vaginalis. Women with Trichomonas vaginitis commonly complain of a copious vaginal discharge that may be white, yellow, green, or gray and that has an unpleasant odor. Some women complain of vulvar pruritus, which is primarily confined to the vestibule and labia minora. On physical exam, the vulva and vagina frequently appear red and swollen. Only a small percentage of women possess the classically described strawberry cervix. Diagnosis of trichomoniasis is confirmed with a wet saline smear. Under the microscope, the Trichomonas organisms can be visualized under high power; these organisms are unicellular protozoans that are spherical in shape with three to five flagella extending from one end. The recommended treatment for trichomoniasis is a one-time dose of 2 g metronidazole.

·         Chlamydia trachomatis is an intracellular parasite that can cause an infection that may be manifested as cervicitis, urethritis, or salpingitis. Patients with mild cases may be asymptomatic. On physical exam, women with chlamydial infections may demonstrate a mucopurulent cervicitis. The diagnosis of chlamydia is suspected on clinical exam and confirmed with cervical cultures. Treatment for a chlamydial cervicitis is with oral azithromycin, 1 g, or doxycycline 100 mg twice daily for 7 days.

·         Treatment of Bartholin's cysts with marsupialization has the best success rate.

Although rare, adenocarcinoma of the Bartholin’s gland must be excluded in women over 40 years of age who present with a cystic or solid mass in this area. The appropriate treatment in these cases is surgical excision of the Bartholin’s gland to allow for a careful pathologic examination. In cases of abscess formation, both marsupialization of the sac and incision with drainage as well as appropriate antibiotics are accepted modes of therapy. In the case of the asymptomatic Bartholin’s cyst, no treatment is necessary.

·         The classic physical exam finding of PID is the "chandelier sign," which describes the patient's response to severe pain caused by movement of the cervix.

·         In the female, the order of puberty is thelarche (breast bud), pubarche (pubic hair), maximum growth velocity, and menarche.

·         The two syndromes that are characterized by breast development and absence of a uterus, androgen insensitivity and müllerian agenesis, can be distinguished by a karyotype.

·         Ferriman and Gallwey Scoring system for scoring hirsutism depending on body site. Less than 8 is normal; greater than 15 is severe.

·         The two main types of specula commonly used to perform Pap smears are the Pederson and Graves specula. The Pederson speculum works best for nulliparous women and menopausal women with atrophic vaginas; the blades are flat and narrow and barely curve on the sides. The blades of the Graves speculum are wider, higher, and curved on the sides; they work better for parous women with looser vaginal walls. A child’s vagina can best be examined using an instrument called a vaginoscope or some type of endoscope such as a hysteroscope. The Graves and Pederson speculums come in pediatric sizes to be used in virginal adults or young children.

·         Vulvar vestibulitis is syndrome of unknown etiology. To make the diagnosis of this disorder, the following three findings must be present: (1) severe pain on vestibular touch or attempted vaginal entry, (2) tenderness to pressure localized within the vulvar vestibule, and (3) visible findings confined to vulvar erythema of various degrees. To treat vulvar vestibulitis, the first step is to avoid tight clothing, tampons, hot tubs, and soaps, which can all act as vulvar irritants. Topical treatments include lidocaine, estrogen, and steroids. Tricyclic antidepressants and intralesional interferon injections have also been used. For women refractory to medical therapy, surgical excision of the vestibular mucosa may be helpful.

·         The Centers for Disease Control’s recommendation for inpatient management of PID includes the following:

1. Cefoxitin 2 g IV every 6 h or cefotetan 2 g IV every 12 h plus doxycycline 100 mg PO or IV twice daily or
2. Clindamycin 900 mg IV every 8 h plus gentamicin loading dose IV or IM (2 mg/kg) followed by maintenance dose (1.5 mg/kg) every 8 h

The Centers for Disease Control’s recommendation for the outpatient management of PID includes the following:

1. Cefoxitin 2 g IM plus probenecid 1 g PO in a single dose concurrently or ceftriaxone 250 mg IM plus doxycycline 100 mg PO twice daily for 14 days or
2. Ofloxacin 400 mg PO two times a day for 14 days plus either clindamycin 450 mg PO four times a day or metronidazole 500 mg PO two times a day for 14 days.