6.3 Common Gynecological Conditions

Common Gynecological Conditions

Mastering the diagnostic evaluation and management of common gynecological conditions is key for primary care clinicians. This section covers the clinical workup for abnormal uterine bleeding (AUB), Pelvic Inflammatory Disease (PID) diagnostic and treatment guidelines, and the clinical signs, diagnosis, and management of ectopic pregnancy.

1. Abnormal Uterine Bleeding (AUB) & Menorrhagia Workup

Abnormal Uterine Bleeding (AUB) is defined as any variation in the regularity, frequency, heaviness, or duration of menstrual flow in non-pregnant women. The International Federation of Gynecology and Obstetrics (FIGO) uses the PALM-COEIN classification system to distinguish between structural and non-structural etiologies.

Etiology (PALM-COEIN Mnemonic)

• Structural Causes (PALM) - Visualized on imaging or histology:
  • P - Polyp: Endometrial or cervical polyps.
  • A - Adenomyosis: Ectopic endometrial glands and stroma within the myometrium, causing a symmetrically enlarged, boggy, and tender uterus.
  • L - Leiomyoma (Fibroids): Benign smooth muscle tumors of the myometrium. Submucosal fibroids are the most likely to cause heavy bleeding.
  • M - Malignancy and Hyperplasia: Endometrial hyperplasia or endometrial carcinoma.
• Non-Structural Causes (COEIN):
  • C - Coagulopathy: Disorders of hemostasis, most commonly von Willebrand disease (vWD), which should be suspected if heavy menstrual bleeding began at menarche.
  • O - Ovulatory Dysfunction: Manifests as irregular, unpredictable bleeding due to lack of progesterone withdrawal. Common causes include Polycystic Ovary Syndrome (PCOS), hypothyroidism, hyperprolactinemia, and extreme stress or weight loss.
  • E - Endometrial Primary Dysfunction: Primary disturbances in local endometrial hemostasis (often normal cycles but heavy bleeding).
  • I - Iatrogenic: Anticoagulants, copper IUDs, or tricyclic antidepressants.
  • N - Not yet classified.

Diagnostic Workup Algorithm

1. Rule Out Pregnancy: A urine or serum Beta-hCG is the mandatory first step in any woman of reproductive age presenting with AUB.
2. Laboratory Evaluation:
   • Complete Blood Count (CBC) to evaluate for iron deficiency anemia.
   • Thyroid-Stimulating Hormone (TSH) to rule out thyroid dysfunction.
   • Coagulation screening (PT, aPTT, von Willebrand factor antigen) if the patient has a positive screening history (e.g., bleeding since menarche, postpartum hemorrhage, or epistaxis).
   • Prolactin, Free Testosterone, and DHEAS if PCOS or ovulatory dysfunction is suspected.
3. First-Line Imaging: Transvaginal Ultrasound (TVUS). TVUS is highly sensitive for evaluating the endometrium (thickness, regularity) and detecting structural lesions like fibroids, polyps, or adenomyosis.
4. Endometrial Biopsy (EMB): Indicated to rule out endometrial hyperplasia or malignancy in:
   • All women aged ≥ 45 years presenting with AUB.
   • Women aged < 45 years with risk factors for endometrial cancer (e.g., obesity, chronic anovulation in PCOS, type 2 diabetes, nulliparity, family history of Lynch syndrome, or failure of medical management for AUB).

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2. Pelvic Inflammatory Disease (PID)

Pelvic Inflammatory Disease (PID) is an acute infection of the upper female genital tract, including the endometrium, fallopian tubes (salpingitis), ovaries (oophoritis), and pelvic peritoneum. It is typically polymicrobial, ascending from the vagina or cervix, with Chlamydia trachomatis and Neisseria gonorrhoeae being the primary pathogens, along with vaginal anaerobes.

Clinical Diagnosis

Because delay in treatment increases the risk of long-term sequelae (infertility, ectopic pregnancy, and chronic pelvic pain), a low threshold for clinical diagnosis is recommended. Empiric treatment should be initiated in sexually active young women if they present with lower abdominal/pelvic pain and one or more of the following minimum criteria on pelvic examination:

• Cervical motion tenderness (the chandelier sign)
• Uterine tenderness
• Adnexal tenderness
• Supporting signs: Oral temperature > 38.3°C (101°F), abnormal mucopurulent cervical discharge, abundant white blood cells on wet mount microscopy of vaginal fluid, or elevated ESR/CRP.

Outpatient Management (CDC Regimen)

For patients with mild-to-moderate PID who can tolerate oral medications:

• Ceftriaxone 500 mg IM in a single dose (to treat N. gonorrhoeae)
• PLUS Doxycycline 100 mg orally twice daily for 14 days (to treat C. trachomatis)
• PLUS Metronidazole 500 mg orally twice daily for 14 days (to cover anaerobes and treat concurrent bacterial vaginosis).

Inpatient Admission Criteria

Hospitalization for parenteral therapy is indicated if:

• Surgical emergencies (e.g., appendicitis, ectopic pregnancy, ovarian torsion) cannot be excluded.
• The patient is pregnant (high risk of maternal and fetal morbidity).
• Severe illness, high fever, or intractable nausea and vomiting prevent oral intake.
• Tubo-Ovarian Abscess (TOA) is present.
• Clinical failure of outpatient oral therapy after 72 hours.
• The patient is unable to follow or tolerate the outpatient oral regimen.
• Inpatient Regimen: Cefoxitin 2g IV every 6 hours (or Cefotetan 2g IV every 12 hours) PLUS Doxycycline 100mg IV or orally every 12 hours.

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3. Ectopic Pregnancy

An ectopic pregnancy occurs when a fertilized ovum implants outside the normal endometrial cavity, most commonly in the ampulla of the fallopian tube (95% of cases).

Clinical Signs and Symptoms

• Unruptured: The classic triad of amenorrhea, unilateral lower abdominal/pelvic pain, and vaginal bleeding or spotting.
• Ruptured: A life-threatening emergency presenting with sudden, severe pelvic pain, hemodynamic instability (tachycardia, hypotension, syncope), peritoneal signs (rebound tenderness, guarding), and shoulder pain (Kehr's sign) due to subdiaphragmatic irritation from hemoperitoneum.

Diagnostic Evaluation

1. Quantitative Serum Beta-hCG:
   • Discriminatory Zone: The Beta-hCG concentration above which a normal intrauterine gestational sac should be visible on TVUS (usually 1500 to 2000 mIU/mL).
   • If Beta-hCG is above the discriminatory zone and TVUS shows an empty uterus, an ectopic pregnancy is highly probable.
   • If Beta-hCG is below the discriminatory zone and TVUS is non-diagnostic, serial Beta-hCG levels must be measured 48 hours apart. In a normal viable pregnancy, Beta-hCG should rise by at least 35-50% in 48 hours. A slow rise, plateau, or drop indicates an abnormal pregnancy (ectopic or failing intrauterine pregnancy).
2. Transvaginal Ultrasound (TVUS): Look for:
   • An intrauterine gestational sac with a yolk sac or embryo (rules out ectopic, except in rare heterotopic pregnancies).
   • An extrauterine gestational sac or an adnexal mass (the donut sign or complex mass).
   • Free fluid (blood) in the rectouterine pouch (Pouch of Douglas).

Management Options

1. Medical Management (Methotrexate - MTX):
   • A folic acid antagonist that inhibits dihydrofolate reductase, disrupting rapidly dividing fetal cells.
   • Absolute Candidates:
     • Hemodynamically stable patient.
     • No clinical signs of rupture (no severe pain, no hemoperitoneum).
     • Gestational sac diameter < 3.5 cm (or < 4 cm).
     • Absence of fetal cardiac activity on ultrasound.
     • Baseline serum Beta-hCG < 5000 mIU/mL (success rate is > 90% below this level).
     • Normal renal and hepatic function, and normal CBC.
     • Patient is willing and able to comply with close post-treatment follow-up.
   • Follow-up Protocol: Measure Beta-hCG on Day 1, 4, and 7. There is often a transient rise between Day 1 and 4. A successful response is a ≥ 15% decrease in Beta-hCG between Day 4 and Day 7. If this is not achieved, a second dose of MTX is given or surgical intervention is planned.
2. Surgical Management (Laparoscopy):
   • Salpingectomy: Removal of the affected fallopian tube. Indicated for ruptured ectopics, hemodynamically unstable patients, or when future fertility is not a priority (or the contralateral tube is healthy).
   • Salpingostomy: Longitudinal incision to remove the pregnancy while preserving the tube. Preferred in stable patients desiring future fertility who have a compromised contralateral fallopian tube.
   • Mandatory Indications for Surgery: Hemodynamic instability, signs of rupture, contraindications to methotrexate, failed medical therapy, or heterotopic pregnancy.