10.3 Gynecology & Breast Disorders

Gynecology & Breast Disorders: Diagnostic Workups and Guidelines

Quick Answer: Gynecology and breast mass evaluations rely on age-stratified algorithms. AUB requires pregnancy testing first, followed by ultrasound and age- or risk-indicated endometrial biopsy. Cervical cancer screening utilizes Pap cytology every 3 years (ages 21–29) and HPV co-testing or primary testing every 5 years (ages 30–65). For breast masses, choose ultrasound under age 30 and mammography plus ultrasound at age 30 or older.

Evaluation of Abnormal Uterine Bleeding

Abnormal uterine bleeding (AUB) in reproductive-age women is classified by the PALM-COEIN system, distinguishing structural (Polyp, Adenomyosis, Leiomyoma, Malignancy/hyperplasia) from non-structural (Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not otherwise classified) causes. Initial workup includes a qualitative pregnancy test, complete blood count (CBC) for anemia, and thyroid-stimulating hormone (TSH) to screen for thyroid disorders. Adolescents with heavy menstrual bleeding at menarche should undergo coagulation profile screening to rule out Von Willebrand disease. Pelvic ultrasound is the first-line imaging modality to identify structural lesions. Endometrial biopsy (EMB) is indicated to rule out malignancy or hyperplasia in women aged ≥45 with AUB, or those <45 with risk factors such as obesity, chronic anovulation (PCOS), diabetes, tamoxifen, or unopposed estrogen. In postmenopausal women, any vaginal bleeding is abnormal; a transvaginal ultrasound endometrial thickness >4 mm or persistent bleeding requires biopsy.

PALM-COEIN Classification for Abnormal Uterine Bleeding

Abnormal uterine bleeding (AUB) in non-pregnant, reproductive-age women is classified by the PALM-COEIN system to guide diagnosis and treatment:

Structural Causes (PALM - Diagnostic by Imaging or Histology):

• P - Polyp: Endometrial or cervical benign overgrowths.
• A - Adenomyosis: Endometrial glands and stroma invading the uterine myometrium.
• L - Leiomyoma: Uterine fibroids, classified by location (submucosal, intramural, subserosal).
• M - Malignancy & Hyperplasia: Endometrial cancer or atypical hyperplasia, requiring biopsy.

Non-Structural Causes (COEIN - Not Materially Seen on Standard Imaging):

• C - Coagulopathy: Systemic bleeding disorders (e.g., Von Willebrand disease).
• O - Ovulatory Dysfunction: Anovulatory cycles leading to progesterone deficiency (e.g., PCOS, hypothyroidism).
• E - Endometrial: Primary dysfunction of local endometrial hemostasis.
• I - Iatrogenic: Medication-induced bleeding (e.g., anticoagulants, copper IUD, exogeneous hormones).
• N - Not Otherwise Classified: Rare or poorly defined conditions.

Medical management includes combined oral contraceptives, oral progesterone, tranexamic acid, or the levonorgestrel-releasing intrauterine device (IUD), which is first-line for non-structural heavy bleeding. Surgical options include hysteroscopic polypectomy, myomectomy, endometrial ablation, or hysterectomy.

Cervical Cancer Screening Guidelines

Cervical screening begins at age 21. For patients aged 21 to 29, cervical cytology (Pap smear) alone is recommended every 3 years. HPV testing is not recommended in this cohort due to highly prevalent transient infections. For women aged 30 to 65, screening options include cytology alone every 3 years, primary high-risk HPV testing alone every 5 years, or Pap and HPV co-testing every 5 years. Discontinue screening at age 65 if the patient has had adequate negative screening (three consecutive negative cytology results or two negative co-tests within 10 years, with the most recent within 5 years) and no CIN 2 or higher history within 25 years. Discontinue screening after total hysterectomy for benign disease if the cervix was removed and no history of high-grade dysplasia exists. Immunocompromised patients (e.g., HIV, immunosuppressive therapy) start cytology at sexual onset, screening annually for 3 years, then every 3 years. Atypical squamous cells of undetermined significance (ASC-US) requires reflex HPV testing; colposcopy is indicated if positive, whereas negative results return patients to routine screening. In patients aged 21–24 with ASC-US or LSIL, repeat cytology in 1 year is preferred. High-grade squamous intraepithelial lesion (HSIL) or atypical squamous cells, cannot exclude HSIL (ASC-H) warrants colposcopy or immediate loop electrosurgical excision procedure (LEEP). CIN 1 is managed conservatively with observation, whereas CIN 2 and CIN 3 require LEEP or cold knife conization.

Pelvic Inflammatory Disease

Pelvic inflammatory disease (PID) is an ascending upper genital tract infection caused by Neisseria gonorrhoeae, Chlamydia trachomatis, and vaginal anaerobes. Diagnosis is clinical, based on lower abdominal or pelvic pain in a sexually active woman plus one or more minimum criteria on pelvic exam: cervical motion tenderness, uterine tenderness, or adnexal tenderness. Supportive findings include temperature >38°C (100.4°F), mucopurulent cervical discharge, abundant white blood cells on saline microscopy of vaginal fluid, and elevated inflammatory markers. Outpatient treatment includes intramuscular ceftriaxone (500 mg), oral doxycycline (100 mg twice daily for 14 days), and oral metronidazole (500 mg twice daily for 14 days) to ensure anaerobic coverage. Inpatient treatment is indicated for pregnant patients, those failing oral therapy, patients with severe clinical illness (high fever, vomiting), or those with a tubo-ovarian abscess (TOA). Inpatient regimens include intravenous cefotetan or cefoxitin plus oral or IV doxycycline, or IV clindamycin plus gentamicin. Long-term complications of PID include chronic pelvic pain, ectopic pregnancy, tubal factor infertility, and Fitz-Hugh-Curtis syndrome. Fitz-Hugh-Curtis syndrome is a perihepatitis causing liver capsule inflammation, presenting with right upper quadrant pain and 'violin-string' adhesions on the liver capsule, with characteristically normal transaminases.

Management of Breast Masses

Evaluation of a breast mass depends on the patient's age. For women under 30, ultrasound is the first-line imaging modality because dense breast tissue limits mammography's utility. A simple cyst on ultrasound can be observed or aspirated if symptomatic. If cyst fluid is bloody or the mass does not fully resolve after aspiration, an excision biopsy is indicated. A solid, well-demarcated mass is most commonly a benign fibroadenoma, which can be monitored if small and asymptomatic; however, core needle biopsy is required if the mass is growing or suspicious. For women aged 30 and older, both mammography and ultrasound are performed. Any suspicious lesion (e.g., spicular margins, microcalcifications on mammography, or a solid mass on ultrasound) must undergo core needle biopsy. Fibrocystic breast changes present with bilateral, diffuse, painful breast nodularity that fluctuates in size and tenderness with the menstrual cycle, managed with reassurance and supportive bras. An intraductal papilloma is a benign lesion that classically presents with unilateral, bloody nipple discharge. Although benign, it requires excision to rule out ductal carcinoma in situ (DCIS). Breast cancer presents as a hard, painless, fixed mass with possible skin retraction (peau d'orange), nipple inversion, or pathologic discharge, requiring tissue diagnosis via core needle biopsy and staging.