Handbook of Gynecology

Preface to the Second Edition
Preface to the First Edition
Acknowledgements
Contents
About the Editor
Section Editors of the First Edition
Contributors
Part I: General Office Gynecology
1 Anatomy of the Female Genital System
Introduction
Genital Structures
Vagina
Uterus
The Uterine Corpus
The Uterine Cervix
Adenexal Structures
The Fallopian Tubes
The Ovaries
Support Structures
Blood Supply
Innervation
Lymphatics
The Ureter
The Vulva and Erectile Structures
The Pelvic Bones
Pelvic Bones and Ligaments
Avascular Planes
Cross-References
References
2 Gynecologic History and Examination of the Patient
Introduction
History
Gynecologic History
Obstetrical History
Medical and Surgical History
Family History
Social History
Focused History/Common GYN Complaints
Abnormal Uterine Bleeding
Vaginal Discharge/Itching
Pelvic Pain
Contraceptive Counseling
Infertility
Pelvic Organ Prolapse
Physical Examination
When to Start?
Components of the Physical Exam
Breast Exam
Abdominal Exam
Pelvic Exam: Bimanual and Speculum Examination
Tests Performed on Exam
Pap Smear
STD Testing
Conclusion
Cross-References
References
3 Contraception
Introduction
Principles of Contraceptive Counseling
Starting Contraception
Assessments Required Before Starting Contraception
Contraception in Clients with Complex Medical Conditions
Contraceptive Efficacy
Tier 1: Long-Acting Reversible Contraception
Copper IUD
Hormone-Releasing IUDs
Hormone-Releasing Subdermal Implants
Tier 1: Permanent Contraception
Male Vasectomy
Female Permanent Contraception
Tier 2: Short-Acting Reversible Contraception
Combined Hormonal Contraceptives (CHCs)
Progestin-Only Oral Contraception
Progestin-Only Injectable Contraception: Depot Medroxyprogesterone Acetate (DMPA)
Tier 3: Fertility Awareness-Based and Barrier Methods
Fertility Awareness-Based Methods
Lactational Amenorrhea Method (LAM)
Withdrawal, Spermicides, and Vaginal pH Modulators
Barrier Methods
External Condoms
Internal Condoms and Barriers
Postpartum Contraception
Emergency Contraception
Oral Formulations
Intrauterine Devices
Conclusion
References
4 Preconception Care: In the Continuum of Women´s Healthcare
Introduction
Definition and Rationale of Preconception Care
Reproductive Life Plan
Components of Preconception Counseling
Family History
Maternal Genetic Conditions
Infections and Immunizations
Chronic Medical Conditions
Neurologic
Cardiovascular
Pulmonary
Gastrointestinal
Renal
Hematological and Immune
Endocrine
Mental Health
Oral
Medications
Environmental Exposures
Weight
Bariatric Surgery
Weight Gain
Nutrition
Folic Acid
Exercise
Age
Assisted Reproductive Technologies
Social and Lifestyle History
Cancer Survivors
Reproductive and Sexual Health Equity
Prenatal Care
Summary
References
5 Management of Intraepithelial Lesions of the Cervix
Cervical Cancer Screening
Cytology
HPV Testing
Screening Risk Evaluation and Triage to Surveillance or Assessment and Therapy
Abnormal Cytology
ASC-US
LSIL
ASC-H
HSIL
AGC
Other
Management of Histopathology
Therapeutic Modalities
LEEP
CKC
Cryosurgery
Laser Ablation
Colposcopic Results and Histopathology
No Lesion
Discordant Cytology and Histology
CIN 1
CIN2-3
AIS
Special Populations
Patients Younger Than 25 Years
Patients with Immunosuppression
Pregnant
Patients After Hysterectomy
Patients Over 65 with Abnormal History
Conclusion
References
6 Impact of Obesity on Gynecological Diseases
Introduction
Obesity and the Menstrual Cycle
Puberty
PCOS and Insulin Resistance
Infertility and ART
Fertility
Miscarriage
Assisted Reproductive Technology (ART)
Contraception
Combination Oral, Transdermal, and Vaginal Contraceptives
Progestin-Only Contraceptives
Intrauterine Devices (IUD)
Surgical Risk
Surgery in the Obese Patient
Anesthesia in the Obese Patient
Urinary Incontinence
Endometrial Cancer and Other Malignancies
Pelvic Imaging in the Obese Patient
Ultrasound
Computed Tomography (CT)
Magnetic Resonance Imaging (MRI)
Weight Loss
Diet
Exercise
Pharmacotherapy
Bariatric Surgery
Conclusion
Cross-References
References
7 Urinary Tract Infections and Asymptomatic Bacteriuria
Introduction
Epidemiology
Microbiology and Pathogenesis
Diagnosis
Presentation
Testing
Voided Specimen Collection Technique
Treatment
Uncomplicated Cystitis
Pyelonephritis
Recurrent UTI
Catheter-Associated UTIs
Asymptomatic Bacteriuria
Prevention: Nonantimicrobial
Conclusion
References
8 Reproductive Effects of COVID-19: A Journey Through COVID-19 Pathogenesis
General Pathogenesis of COVID-19
COVID-19 Pathogenesis: The Lung Is a Common Primary Target
Spike Protein Binding to AC2 Receptors and TMPRSS2 Activation
Synthesis of Viral Proteins
Host Cytokine Response
COVID-19 and CNS: Nervous System
COVID-19 and the Cardiovascular System
COVID-19 in Other Tissues: Gastrointestinal Tract, Liver, Kidneys, and Skin
COVID-19 and the Hematologic System
COVID-19: Multiple Attacks on the Cortisol Stress Response
COVID-19 Conclusion
References
9 Reproductive Effects of COVID-19: COVID Manifestations on the Endocrine and Reproductive Systems
COVID-19 and the Hypothalamic-Pituitary Axis
COVID-19 and Gonadal Function in Women
Risks Associated with Polycystic Ovary Syndrome
COVID-19 and Gonadal Function in Men
Decreases in Testosterone, Sperm Count, and Testicular Damage
Biphasic Effect of Testosterone Levels on Severity of Disease
Sexual Transmission
Orchitis
Poorer Response in Men to COVID-19
COVID and the Endometrium
Expression of SARS-CoV-2 Entry Genes Across the Menstrual Cycle
COVID-19 and Infertility
COVID-19 and Pregnancy
Fetal and Newborn Risks
Beneficial Pregnancy Responses
Adverse Pregnancy Responses
Pregnancy Recommendations: Not Necessary to Deliver Unless Other Factors Present
COVID-19 Conclusion
Cross-References
References
10 Pregnancy Termination
Introduction
Counseling and Consultation
Pre-abortion Evaluation
Procedural Abortion
Dilation and Curettage (D&C)
Dilation and Evacuation (D&E)
Pain Management (for Both D + C and D + E)
Antibiotics for Procedural Abortion
Complications of Procedural Abortion
Medication Abortion
The First-Trimester Medication Abortion
Candidate Selection
Pharmacology
Anticipatory Guidance
Antibiotics in Medication Abortion
Contraindications
Complications in Medication Abortion
Telehealth Considerations
Follow-up
The Second-Trimester (and Third-Trimester) Induction
Postabortion Counseling
Conclusion
Cross-References
References
Part II: Gynecologic Care of the Adolescent
11 Congenital Adrenal Hyperplasia in the Adolescent
Introduction
Background
Classical Congenital Adrenal Hyperplasia
Nonclassical Congenital Adrenal Hyperplasia
Puberty/Adolescence
Medical Management
Daily Medication Management
Sick-Day Management
Other Medications
Interdisciplinary Team Approach and Transition to Adult Care
Fertility and CAH
Comorbidities in CAH
Bone Mineral Density
Adrenal Rest Tumors
Cardiovascular Disease Risk Factors
Other Potential Morbidities
Surgical Considerations
Conclusion
Cross-References
References
12 Common Problems in Adolescent Medicine
Introduction
Consent
Confidentiality
Access to Care for Adolescents
Getting to Know the Adolescent Through the HEEADSSS Exam
Stages of Adolescent Sexual Development
Pubertal Development
Normal Menstruation
Specific Patterns of Abnormal Menstruation
Amenorrhea
Eating Disorders and Disordered Eating in Adolescents
Female Athlete Triad
PCOS in the Adolescent
Gender and Sexuality
Helping Adolescents Choose Effective Contraception
Emergency Contraception
Sexually Transmitted Infections: Special Considerations in Adolescents
Expedited Partner Therapy in Adolescents
Cervical Cancer Screening in Adolescents
HPV Infection and Vaccination
Special Consideration: Intimate Partner Violence and Sexual Assault
Conclusion
Cross-References
References
13 Management of Abnormal Bleeding in the Adolescent
Introduction
Overview of Hemostasis
Inherited Bleeding Disorders
Von Willebrand Disease
Hemophilia Carriers
Rare Factor Deficiencies
Disorders of Fibrinolysis
Inherited Platelet Disorders
Connective Tissue Disorders
Acquired Bleeding Disorders
Immune Thrombocytopenia Purpura
Thrombotic Thrombocytopenia Purpura
Liver and Renal Failure
Laboratory Evaluation
Treatment/Management
Medications to Avoid
Conclusion
Cross-References
References
14 Management of Pelvic Pain
Introduction
Neuroanatomy and Physiology
Acute Pelvic Pain
Acute Pelvic Pain Evaluation and Management
Chronic Pelvic Pain
Chronic Pelvic Pain Evaluation and Management
Important Elements of the History When Evaluating Chronic Pelvic Pain
Important Elements of the Physical Exam When Evaluating Chronic Pelvic Pain
Evaluation and Management of Chronic Pelvic Pain
Cyclic Menstrual-Related Pelvic Pain
Chronic Non-menstrual-Related Pelvic Pain
Conclusion
References
15 Treatment of Amenorrhea
Introduction
Primary Amenorrhea
Secondary Amenorrhea
History
Physical Exam
Genitourinary Exam
Normal Pelvic Anatomy
Abnormal Pelvic Anatomy
Ovarian Function
Laboratory Workup
Estrogen Measurement
Gonadotropin Measurement
Endometrial Stripe on Ultrasound
Progesterone Challenge
Positive Test
Negative Test
Normal Gonadotropin Levels
Ovarian Disorders Related to Chronic Anovulation
Polycystic Ovary Syndrome (PCOS)
Endometrial Sampling
Thyroid Dysfunction
Treatment
Hyperprolactinemia
Treatment
Elevated Gonadotropin Levels
Primary Ovarian Insufficiency
Initial Workup
Genetic Abnormalities
Low Gonadotropins
Hypothalamic Amenorrhea
Specific Causes of Amenorrhea
Disorders of Amenorrhea by Compartment
Anatomic Causes of Amenorrhea (Table 5)
Disorders of the Outflow Tract and Uterus
Asherman Syndrome
Cervical Stenosis
Androgen Insensitivity Syndrome
Imperforate Hymen
Transverse Vaginal Septum and/or Cervical Atresia
Müllerian Agenesis (Mayer-Rokitansky-Küster-Hauser Syndrome: MRKH)
Endocrine: Ovarian Disorders
Abnormal Chromosomes
Gonadal Dysgenesis
Turner Syndrome
Hormone Replacement Therapy
Swyer (46 XY Gonadal Dysgenesis)
46,XX Gonadal Dysgenesis
Fragile X Premutations (FMR1)
Normal Chromosomes
Autoimmune POI
Other Etiologies for POI
Radiation
Chemotherapy
Galactosemia
Resistant Ovary Syndrome
17-Hydroxylase Deficiency
Follicular Development Failure
Counseling and Management of POI
Pituitary Disorders
Pituitary Adenomas
Lab Testing
Gonadotroph Adenomas
Thyrotroph Adenomas
Somatotroph Adenomas
Corticotroph Adenomas
Lactotroph Adenomas (Prolactinoma)
Treatment
Medical Therapy
Surgical Therapy
Radiation Therapy
Fertility and Pregnancy
Empty Sella Syndrome
Sheehan Syndrome
Infiltrative Lesions
Hemochromatosis
Lymphocytic Hypophysitis
Hypogonadotropic Hypogonadism
Hypothalamus
Hypothalamic Amenorrhea
Eating Disorders
Exercise
Congenital GnRH Deficiency
Kallmann´s Syndrome
GnRH Receptor Mutations
Dosing
Conclusion
Cross-References
References
16 Treatment of Gynecological Congenital Anomalies
Introduction
Embryology
Molecular Origin
Classification for Müllerian Anomalies
Imaging Modalities
Reproductive Outcomes and Management Options
Non-ASRM Classifications
Conclusion
Cross-References
References
Part III: Gynecologic Care During the Early Reproductive Years
17 Diagnosis and Treatment of Premenstrual Syndrome
Introduction
Epidemiology
Clinical Presentation
Diagnosis
Pathophysiology
Treatment
Non-pharmacologic Treatment
Oral Contraceptives
Selective Serotonin Reuptake Inhibitors
Other Management
Conclusions
References
18 Abnormal Vaginal Bleeding During the Early Reproductive Years
Introduction
Definitions and Current Terminology
Disorders of Menstrual Timing
Primary Amenorrhea
Precocious Puberty
Secondary Amenorrhea
Infrequent Menses
Intermenstrual Bleeding
Postcoital/Post-traumatic Bleeding
Excessive Volume Disorders: Heavy/Prolonged Menstrual Bleeding
Definitions and Prevalence
PALM-COEIN Classification System of Abnormal Uterine Bleeding
Acute Excessive/Prolonged Menstrual Bleeding
Causes of Acute, Excessive Menstrual Bleeding
Assessment of Acute, Excessive Menstrual Bleeding
Treatment of Acute Excessive Menstrual Bleeding
Inpatient Therapies
Estrogen-Based Therapies in Inpatient Setting
Nonhormonal Adjuctive Therapies in Inpatient Setting
Outpatient Therapy
Chronic Heavy/Prolonged Menstrual Bleeding
Causes of Chronic, Heavy/Prolonged Menstrual Bleeding
Treatment of Chronic Heavy Menstrual Bleeding
Nonhormonal Therapies
Therapies to Suppress Endometrium Including COCs, Ring, Patches and Hormonal IUDs, Injections, Implants, GnRH Agonists and Ant...
Associated Menstrual Problems
Issues of Special Groups
Underserved, Resource-Poor AYA Women
AYA Women with Developmental Delays and Physical Disabilities
Transgender AYA
Conclusion
Cross-References
References
19 Sexually Transmitted Diseases: Diagnosis and Work-Up (GC, Chlamydia, Herpes, HPV)
Introduction
Chlamydia trachomatis
Epidemiology
Screening and Testing
Sites for Testing
Treatment
Expedited Partner Therapy in Management of Chlamydia and Gonorrhea Infection
Neisseria gonorrhoeae
Epidemiology
Screening and Diagnostic Testing
Sites for Testing
Treatment
Herpes Simplex Virus Types 1 and 2
Background
Testing for HSV-1 and HSV-2
Treatment
Human Papillomavirus (HPV)
Background
Screening and Diagnosis
Treatment
Conclusion
Cross-References
References
20 Diagnosis and Treatment of Vulvovaginitis
Introduction
Pathogenesis
Etiologies
Candidal vulvovaginitis
Bacterial Vaginosis
Vaginal Trichomoniasis
Other Etiologies of Vulvovaginal Symptoms
Atrophic Vaginitis
Desquamative Inflammatory Vaginitis
Vulvovaginal Dermatitis
Evaluation
History
Physical Exam
Diagnostic Studies
Treatment
Bacterial Vaginosis
Trichomoniasis
Other Causes of Vulvovaginal Symptoms
Women Without a Diagnosis After the Initial Evaluation
Post Diagnostic Management
Conclusion
Cross-References
References
21 Management of Chronic Recurrent Vulvovaginitis
Introduction
Pathophysiology
Presenting Symptoms
Physical Examination
Vulvovaginal Candidiasis
Bacterial Vaginosis
Trichomonas vaginalis
Threadworms
Atrophic Vaginitis
Lichen Sclerosus
Lichen Planus
Contact Dermatitis
Lichen Simplex Chronicus
Vulvar Care
Emotional Care
Summary
Conclusion
References
22 Pelvic Inflammatory Disease and Other Upper Genital Infections
Introduction and Epidemiology
Anatomic Considerations
Pathogenesis and Microbiology
Risk Factors
Clinical Manifestations
History and Physical Exam
Diagnosing PID
Complications of PID
Perihepatitis or Fitz-Hugh-Curtis Syndrome
Tubo-ovarian Abscess
Long-Term Sequelae
Diagnostic Testing
Pregnancy Test
Other Laboratory Tests
Microbiology
Histopathology
Pelvic Imaging
Pelvic Ultrasound
Additional Imaging
Treatment
Outpatient Management
Criteria for Outpatient Management
Inpatient Management
Criteria for Inpatient Management
Inpatient Course of Treatment
Drainage of Tubo-ovarian Abscess
Surgical Intervention
Intraoperative Findings
Other Management Considerations
Patient Counseling and STI Testing/Reporting
Intrauterine Device (IUD) in Place
Follow-Up
Long-Term Complications
Conclusion
Cross-References
References
23 Diagnosis and Treatment of Urinary Tract Infections
Introduction
Definitions (Table 1)
Epidemiology
Pathogenesis
Risk Factors (Table 2)
Microbiology
Resistance Trends
Complications of UTI
Prevention
Diagnosis and Management
Conclusion
Cross-References
References
24 Diagnosis and Management of Endometriosis
Introduction
Pathogenesis
Proposed Theories
Immune Alterations in Endometriosis
The Role of Estrogen
Pathophysiology of Pelvic Pain
Pathophysiology of Infertility
Risk Factors
Clinical Diagnosis
Patient Evaluation
Diagnostic Surgery
Screening for Endometriosis
Classification/Staging of Endometriosis
Treatment of Endometriosis
Interventions for Endometriosis-Associated Infertility
Natural History of Endometriosis
Conclusion
Cross-References
References
25 Diagnosis and Management of Ectopic Pregnancy
Introduction
Epidemiology
Pathogenesis
Risk Factors
Diagnosis
Ultrasound
Serial Beta HCG
Uterine Curettage
Treatment
Expectant Management
Medical Management with Methotrexate
Mechanism of Action
Adverse Effects
Candidates for Medical Therapy
Laboratory Evaluation
Multidose Regimen
Single-Dose Regimen
Two-Dose Regimen
Posttreatment Monitoring
Surgical Management
Salpingectomy
Salpingostomy
Adjunctive Use of Methotrexate
Conclusions
Cross-References
References
26 Diagnosis and Management of Pregnancy Loss
Introduction
Etiology
Genetic Factors
Thrombophilic Factors
Immunological Factors
Anatomic Factors
Endocrinologic Factors
Infectious Factors
Male Factors
Lifestyle, Environmental, and Chemical Factors
Evaluation
Genetic Assessment
Thrombophilia Assessment
Anatomic Assessment
Endocrine Assessment
Management
Karyotype Abnormalities
Thrombophilia
Anatomic Abnormalities
Endocrine Abnormalities
Conclusion
Cross-References
References
27 Management of Acute Pelvic Pain: Torsion, Infection, and Rupture of Tubal or Ovarian Mass
Introduction
Ovarian Torsion: Etiology and Risk Factors
Ovarian Torsion: Presenting Symptoms
Ovarian Torsion: Workup and Treatment
Ectopic Pregnancy
Tubo-Ovarian Abscess
Ruptured Ovarian Cysts
Conclusion
References
Part IV: Gynecologic Care During the Early and Late Reproductive Years
28 Management of Adnexal Masses
Introduction
Presenting Symptoms
History
Physical Exam
Laboratory and Imaging Studies
Imaging Studies Interpretation
Management
Conclusions
Follow-Up
References
29 Breast Cancer Screening
Introduction
Who Is at Increased Risk for Breast Cancer?
Impact of Race and Ethnicity on Breast Cancer Risk
Breast Screening Techniques and Technologies
Breast Exam
Clinical Breast Exam
Mammography
Tomosynthesis
Breast Ultrasound
Breast MRI
Characterization of Image-Detected Breast Lesions
When to Conclude Breast Cancer Screening
Conclusion
References
30 Benign Diseases of the Vulva
Introduction
Vulvar Dermatoses
Contact Dermatitis
Lichen Simplex Chronicus
Lichen Planus
Lichen Sclerosus
Psoriasis
Neoplasms
Vulvar Intraepithelial Neoplasia
Conclusion
Cross-References
References
31 Management of Vulvodynia
Introduction
Nomenclature of Vulvodynia
Anatomy
Taking a Patient History
Differential Diagnosis
Physical Examination of Vulvodynia
Histology and Physiology of Vulvodynia
Population Findings in Vulvodynia
Theories of Causation of Localized Provoked Vulvodynia
Low Estrogen as a Cause of Vestibulodynia
Other Potential Causes of Vestibulodynia
Vulvodynia´s Place in the History of Medicine
Comorbidities with Vulvodynia
Therapeutic Efforts: General Points
Specific Therapies for Vulvodynia
Conclusion
Cross-References
References
32 Management of Pelvic Pain, Dyspareunia, and Endometriosis
Introduction
Terminology
Pain Physiology: Basic Concepts
Sensitization
Convergence
Modulation
Neuropathic Pain and Nociceptors
Understanding Pain Physiology: Summary
Pelvic Pain Management
Pelvic Pain Story: The Initial Visit and Continued Care
Laboratory and Radiologic Studies
Chronic Pelvic Pain: Notes on Specific Assessment, Management, and Treatment of Various Causes
Dyspareunia
Dyspareunia and Sexual Physiology
Management of Dyspareunia
Endometriosis
Pathophysiology
Management of Endometriosis: Pelvic Pain
Management of Endometriosis: Infertility
Endometriosis Laboratory and Diagnostic Studies
Endometriosis Treatment
Reassessment
Conclusion
References
33 Management of Benign Breast Disease
Introduction
Clinical Breast Exam
Palpable Mass
Breast Pain
Nipple Discharge
Mastitis
Conclusion
References
34 Management of Fibroids
Introduction
Pathology and Epidemiology
Risk Factors
Oncogenic Potential
Effects on Fertility and Pregnancy
Management of Uterine Fibroids
Clinical Evaluation
Patient History
Physical Examination
Imaging
Expectant Management
Medical Management
NSAIDS
Tranexamic Acid
GnRH Agonist
GnRH Antagonists
Levonorgestrel Intrauterine Device
Ulipristal Acetate
Surgical Management
Myomectomy
Abdominal Myomectomy
Laparoscopic and Robotic Myomectomy
Hysteroscopic Myomectomy
Endometrial Ablation
Laparoscopic Radiofrequency Volumetric Thermal Ablation (LRVTA)
Uterine Artery Occlusion
Transcervical Radiofrequency Ablation
Hysterectomy
Radiologic Management
Uterine Artery Embolization (UAE)
MRI-Guided Focused Ultrasound (MRgFUS)
Conclusion
Cross-References
References
35 Management of Abnormal Uterine Bleeding: Later Reproductive Years
Introduction
Structural (PALM)
Polyp
Clinical Manifestations
Diagnostics
Treatment
Adenomyosis
Clinical Manifestations
Diagnostics
Treatment
Leiomyoma
Clinical Manifestations
Diagnostics
Treatment
Malignancy
Clinical Manifestations
Diagnostics
Treatment
Nonstructural (COEIN)
Coagulopathy
Clinical Manifestations
Diagnostics
Treatment
Ovulatory Dysfunction
Clinical Manifestations
Diagnostics
Treatment
Endometrial
Iatrogenic
Not Yet Specified
Conclusion
Cross-References
References
Part V: Work-Up and Management: Reproductive Endocrinology and Infertility
36 Workup and Management of Polycystic Ovary Syndrome
Introduction
Epidemiology
Etiology
Diagnostic Criteria
Evaluation
History
Examination
Laboratory Tests
Pelvic Ultrasound
Screening for Comorbidities
Clinical Manifestations and Management
Menstrual Regulation
Subfertility
Hyperandrogenism
Obesity
Metabolic Syndrome
Cancer Risk
Conclusion
References
37 Management of Recurrent Pregnancy Loss
Introduction
Causes and Management of Recurrent Pregnancy Loss
Karyotypic Abnormalities
Other Genetic Causes
Uterine Abnormalities
Immunologic Factors
Antiphospholipid Syndrome
Celiac Disease
Endocrine Dysfunction
Thyroid Dysfunction
Hyperprolactinemia
Luteal Phase Defect
Polycystic Ovarian Syndrome
Infectious/Microbial
Unexplained
Miscellaneous
Conclusion
References
38 Hyperandrogenism: Acne and Hirsutism
Introduction
Pathogenesis
Gonadotropins
Hyperinsulinemia
Androgen Excess
Hirsutism
Alopecia
Acne
Sex Hormone-Binding Globulin (SHBG)
Etiologies of Hirsutisms and Acne
Etiologies
PCOS
Idiopathic Hirsutism
Congenital Adrenal Hyperplasia (CAH)
Ovarian Tumors
Adrenal Tumors
Cushing´s Syndrome
Drugs
Evaluation
History
Physical Examination
Diagnostic Studies
Treatment
Weight Reduction
Hair Removal Treatments
Oral Contraceptives (OCPs)
Antiandrogens
Insulin-Sensitizing Agents
Other Treatment Modalities
Postmenopausal Women
Treatment of Acne
Conclusion
Cross-References
References
39 Hyperprolactinemia, Galactorrhea, and Pituitary Adenomas
Introduction to the Pituitary and Pituitary Adenomas
Prolactin
Galactorrhea
Signs and Symptoms of Prolactinomas
Diagnosis of Hyperprolactinemia
Imaging
Diagnosing the Cause of Hyperprolactinemia
Management of Hyperprolactinemia Due to Medications
Medical Management
Surgical Management
Pregnancy
Conclusion
References
40 Basic Management of Infertility
Introduction
Epidemiology
Age and Infertility
Fecundity
Definition of Infertility
Causes of Infertility
Male Infertility
Female Infertility
Ovulatory Causes of Infertility
Structural Causes of Infertility
Tubal
Uterine
Cervical
Endometriosis
Unexplained Infertility
Diagnosis
History and Physical Exam
Physical Exam
Diagnostic Tests
Diagnostic Test for Ovulation Confirmation
Ovulation Prediction Kits
Basal Body Temperature Charts
Serum Progesterone
Diagnostic Tests for Tubal Patency
Hysterosalpingogram
Chromotubation
Diagnostic Tests to Evaluate the Uterine Cavity
Transvaginal Ultrasound
Hysterosalpingogram
Sonohystogram
Hysteroscopy
Tests for Ovarian Reserve
Serum Follicle Stimulating Hormone
Antral Follicle Count
Antimullerian Hormone
Other Laboratory Tests
Diagnostic Tests for Evaluation of Male Infertility
Semen Analysis
Treatments
Optimizing the Window of Fertility
Treatment for Ovulation Dysfunction: Ovulation Induction
Treatment for Decreased Ovarian Reserve
Egg Donation
Gestational Surrogate
Treatment for Male Infertility
Treatment for Unexplained Infertility
Intrauterine Insemination
Assisted Reproductive Technology
In Vitro Fertilization
Intracytoplasmic Sperm Injection
Gamete Intrafallopian Transfer and Zygote Intrafallopian Transfer
Surgical Treatments
Laparoscopic Treatment of Endometriosis
Tubal Reversal
Conclusion
References
Part VI: Gynecologic Care During the Perimenopausal and Menopausal Years
41 Management of the Symptoms of Perimenopause
Introduction
Menstrual Irregularity
Combination Hormonal Contraception
Progestin-Only Methods
Vasomotor Symptoms
Lifestyle Modifications
Combination Hormonal Contraception
Hormone Replacement Therapy
Compounded Bioidentical Hormones
Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
Gabapentin
Complementary Alternative Medicine
Vaginal Atrophy
Water-Based Lubricants and Vaginal Moisturizers
Vaginal Estrogen
Urinary Incontinence
Lifestyle Modifications and Behavioral Therapy
Estrogen
Mood Changes
Lifestyle Modifications
Pharmacotherapy
Conclusion
References
42 Management of Menopausal Symptoms
Introduction
Vasomotor Symptoms
Hormonal Therapies
Nonhormonal Therapies
Nonmedication Therapies
Genitourinary Syndrome of Menopause
Bone Strength
Libido
Neuropsychological Changes
Hormonal Therapies
Nonhormonal Therapies
Conclusion
References
43 Diagnosis and Management of Postmenopausal Bleeding
Introduction
Presentation
Epidemiology
Risk Factors for Endometrial Cancer
Etiology
Diagnostic Evaluation
History and Physical Examination
Endometrial Evaluation
Diagnostic Pap Test
Management
Conclusion
Cross-References
References
44 Management of Risks Factors for Older Women: Osteoporosis and Cardiovascular Disease (CVD)
Introduction
Osteoporosis
Epidemiology
Diagnosis
Pharmacological Management
Prevention of Osteoporosis and Bone Loss
Treatment for Established Osteoporosis
Risk Factors and Nonpharmacological Prevention
Cardiovascular Disease (CVD)
Background
Risk Factors: Prevention and Interventions
Hypertension
Cholesterol
Groups Benefiting from Statin Therapy (``Statin Benefit Groups´´)
Grade definitions
Risk Factors Unique to Women
Polycystic Ovary Syndrome (PCOS)
Menopause
Pregnancy Complications
Conclusion
Cross-References
References
45 Menopausal Hormone Therapy
Introduction
Physiology of Perimenopausal Transition
Climacteric Symptoms
Types of Hormone Replacement Therapy
Estrogen Therapy and Estrogen-Progestin Therapy
Oral Therapy
Transdermal
Vaginal Preparations and Rings
Conjugated Estrogen + Bazedoxifene
Selective Estrogen Receptor Modulators
Bioidentical Hormones
Other Potential Benefits
Lower Urinary Tract Symptoms
Urinary Tract Infection
Sexual Function
Dermatologic Aging
Special Populations
Endometrial Cancer
Breast Cancer
Uterine Leiomyomas
Liver Disease
Conclusion
References
46 Management of Vaginal and Vulvar Lesions in the Postmenopausal Women
Introduction
Presentation
Initial Assessment: History and Physical Examination
Biopsy
The Vulvar Dermatoses
Vulvovaginal Atrophy
Lichen Simplex Chronicus
Lichen Sclerosus
Lichen Planus
Psoriasis
Premalignant and Malignant Lesions
Vulvar Intraepithelial Neoplasia (VIN)
Vulvar Squamous Cell Carcinoma
Vulvovaginal Melanoma
Vaginal Carcinoma
Paget Disease
Conclusion
Cross-References
References
47 Management of Ovarian Masses in Older Patients
Introduction
Epidemiology
Clinical Presentation
Differential Diagnosis
Cystic Masses
Solid Masses
Evaluation
History
Physical Examination
Serum Tumor Markers
Cancer Antigen 125 (CA 125)
Human Epididymis Protein 4 (HE4)
Other Markers
Multiple Biomarker Tests
Radiological Studies
Pelvic Ultrasound
Computed Tomography
Magnetic Resonance Imaging
Management
Conservative Management
Operative Management
Conclusions
References
48 Management of Pelvic Pain in Older Women
Introduction
Clinical Assessment
Management Strategies
Pelvic Inflammatory Disease (PID)
Adenomyosis
Gastrointestinal Causes
Urological Causes
Musculoskeletal Causes
Pelvic Congestion Syndrome (PCS)
Pain After Surgery
Adhesions
Endometriosis
Physical Therapy Intervention
Conclusion
References
49 Management of Sexual Dysfunctions
Introduction
Definition and Classifications
Prevalence
Etiology
Screening
History
Partner Assessment
Physical Examination
Laboratory Evaluation
Advanced Testing
Treatment
Educating Patients on Sexual Health
Assess the Patient´s Goals
Optimizing General Health
Use a Team Approach
Make a Treatment Plan
Treatment of Female Sexual Interest/Arousal Disorder
Nonpharmacological
Pharmacological
Treatment of Female Orgasmic Disorder
Genito-Pelvic Pain/Penetration Disorder
Conclusion
References
Part VII: Gynecologic Office and Minimally Invasive Procedures
50 Office Procedures: Endometrial, Cervical, and Vulvar Biopsy
Common Causes of Abnormal Bleeding
Evaluation: Endometrial Biopsy
Contraindications
Sampling Technique
Treatment Options
Complications and Side Effects
Evaluation: Cervical Biopsy
Differential Diagnosis
Contraindications and Complications
Follow-Up Care
Evaluation and Procedure: Vulvar Biopsy
Biopsy Techniques
Indications
Contraindications
Approach Considerations
Dressing
Aftercare
Conclusions
References
51 Operative Hysteroscopy
Introduction
Equipment
Patient Preparation
Technique
Prevention of Cervical Trauma and Perforation
Distension Media
Hysteroscopic Treatment of Fibroids
Submucous Fibroids
Endometrial Preparation
Hysteroscopic Equipment for Removal of Fibroids
Technique
Electrosurgical Resection
Tissue Removal Systems
Hysteroscopic Polypectomy
Endometrial Polyps
Hysteroscopic Equipment for Removal of Polyps
Technique
Electrosurgery
Mechanical
Endometrial Destruction for Abnormal Uterine Bleeding
Endometrial Destruction
Technique of Transcervical Resection of the Endometrium and Endometrial Electrocoagulation
Technique for Second-Generation Endometrial Ablation
Hysteroscopic Treatment of Acquired Uterine Abnormalities
Intrauterine Adhesions
Technique
Retained Products of Conception
Technique
Hysteroscopic Treatment of Congenital Uterine Anomalies
Uterine Septum
Technique
Hysteroscopic Sterilization
Hysteroscopic Tubal Cannulation
Equipment
Technique for Tubal Cannulation
Outpatient Procedures
Equipment and Technique
Safety of Operative Hysteroscopy
Complications
Case Selection
Teaching
Clinical Governance and Audit
Future Developments
Conclusion
Cross-References
References
52 Laparoscopic Ovarian Cystectomy
Introduction
Ovarian Cysts
Functional Cysts
Benign Cystic Ovarian Neoplasms
Workup
Imaging
Serum Markers
Management
Observation
Surgical Intervention
Laparoscopy
Aspiration of Cyst
Laparoscopic Ovarian Cystectomy
Standard Closed Entry
Contraindications to Laparoscopic Ovarian Cystectomy
Oophorectomy
Conclusion
References
53 Laparoscopic Myomectomy
Introduction
Indications for Myomectomy
Benefits of Laparoscopy
Patient Selection
Preoperative Evaluation and Preparation
History and Physical Exam
Laboratory Tests
Imaging Studies
Managing Preoperative Anemia
Informed Consent
Discussing Morcellation
Operative Technique
Anesthesia and Patient Positioning
Prophylaxis
Laparoscopic Port Placement
Strategies to Decrease Intraoperative Blood Loss
Uterine Incision and Leiomyoma Removal
Repair of Uterine Defects
Morcellation of Leiomyomas
Closure
Complications
Postoperative Care
Outcomes
Improvement of Symptoms
New Leiomyoma Formation
Pregnancy After Myomectomy
Interval to Conception
Risk of Uterine Rupture
Conclusion
Cross-References
References
54 Robotic Surgery in Gynecology: Indications, Advantages, Avoiding Complications, Training, and Future Platforms-Update 2022
Introduction
Early Days
Single Site
Robotic Advantages
Gynecology Adoption
Hysterectomy
Myomectomy
Sacrocolpopexy and Pelvic Support Procedures
Endometriosis and Chronic Pelvic Pain
Reproductive Surgery
Ovarian Cysts
Special Populations
Complications
Direct and Indirect Injuries
Preventing Complications
Credentialing and Privileging
Training
Future Robotic Surgery Platforms
Summary and Conclusions
Cross-References
References
55 Minimally Invasive Procedures for Incontinence and Lower Urinary Tract Disorders: Indications and Avoiding Complications
Introduction
Indications for Surgery
Mid-Urethral Sling
Retropubic Mid-Urethral Sling
Technique
Anesthesia and the Cough Stress Test for the Retropubic Mid-Urethral Sling
Retropubic Mid-Urethral Sling Compared to Open Burch Colposuspension
Bottom-Up Versus Top-Down Retropubic Sling
Complications of Retropubic Mid-Urethral Sling
Transobturator Sling
Technique
Retropubic Versus Transobturator Sling
Voiding Dysfunction After Mid-Urethral Sling
Laparoscopic Retropubic Colposuspension (Burch)
Technique
Laparoscopic Burch Compared to Open Burch
Laparoscopic Burch Compared to Mid-Urethral Sling
Conclusion
Cross-References
References
56 Laparoscopic Hysterectomy
Introduction
Types of Hysterectomy
Benefits and Risks
Benefits
Risks
Alternatives
Patient Selection
BMI
Pelvic Adhesive Disease
Uterine Size and Shape
Concurrent Procedures
Preoperative Workup
Imaging
Surgery
Intraoperative Preparation
Laparoscopic Entry and Port Placement
Types of Entry
Surgical Procedure
Intraoperative Considerations
Instruments
Bowel Injury
Bladder Injury
Ureteral Injury
Morcellation
Cross-References
References
Part VIII: Gynecologic Operative Procedures
57 Vaginal Hysterectomy: Indications, Avoiding Complications
Background
Indications and Patient Selection
Contraindications
Technique
Vaginal Prep
Antimicrobial Prophylaxis
Patient Positioning
Vasopressin
Preemptive Techniques to Minimize Postoperative Pain
Surgical Steps
Energy-Based Sealing Devices
Vaginal Salpingo-Oophorectomy
Culdoplasty
Cuff Closure
Post-op Care
Outcomes Compared to Other Types of Hysterectomy
Complications
Conclusion
Cross-References
References
58 Pelvic Organ Prolapse: Diagnosis, Treatment, and Avoiding Complications
Introduction
Anatomy/Pathophysiology
Level 1: The Cardinal and Uterosacral Ligament Complex
Level 2: The Endopelvic Fascia
Level 3: The Perineal Body
Risk Factors
Diagnosis
Patient History
Physical Exam
Sensory Exam
Pelvic Exam
Complications of Prolapse
Nonsurgical Management of Prolapse
Pessary
Pessary Fitting
Types of Pessaries
Complications
Pelvic Floor Muscle Training
Surgical Management
Anterior Prolapse
Anterior Colporrhaphy
Vaginal Paravaginal Repair
Site-Specific Repair
Graft and Mesh Augmentation
Types of Grafts
Biologic Grafts
Transvaginal Mesh for Anterior/Apical Prolapse
Concomitant Hysterectomy
Apical Prolapse
Vaginal Approach for Apical Prolapse
Mayo/McCall Culdoplasty
Uterosacral Ligament Suspension
Technique
Outcomes and Complications
Sacrospinous Ligament Fixation
Technique
Outcomes and Complications
Alternative Vaginal Approaches
Abdominal Approach to Apical Prolapse
Sacral Colpopexy
Outcomes and Complications
Abdominal Uterosacral Ligament Suspension
Obliterative Procedures
Technique/Considerations
Total Colpectomy/Colpocleisis
Partial/LeFort Colpocleisis
Posterior Prolapse
Technique
Midline Plication
Site-Specific Repair
Graft or Mesh Augmentation
Outcomes and Complications
Conclusion
Cross-References
References
59 Urinary Incontinence: Diagnosis, Treatment, and Avoiding Complications
Introduction
Diagnosis and Evaluation
History
Physical
Additional Testing
Urodynamics
Stress Incontinence
Pathophysiology/Anatomy
Treatment
Conservative
Behavioral Modifications
Pelvic Floor Muscle Training (PFMT)
Incontinence Pessary
Urethral Inserts
Surgery
Mid-urethral Sling (MUS)
Transobturator
Pubovaginal (Autologous Sling)
Retropubic Urethropexy
Urethral Bulking Agents
Urgency Incontinence
Conservative
Pharmacologic Management
Percutaneous Tibial Nerve Stimulation
Intradetrusor Onabotulinum Toxin A
Sacral Neuromodulation
Mixed Urinary Incontinence
Conclusion
Cross-References
References
60 Diagnosis and Management of Delayed Postoperative Complications in Gynecology: Neuropathy, Wound Complications, Fistulae, T...
Introduction
Delayed Complications Presenting in the Immediate Postoperative Period (Within 2 Weeks)
Neurologic Injury
Femoral Nerve
Lateral Femoral Cutaneous Nerve
Ilioinguinal and Iliohypogastric
Genitofemoral
Common Peroneal
Sciatic Nerve
Obturator Nerve
Wound Complications
Cuff Infection
Cuff Evisceration
Delayed Complications Presenting in the Early Postoperative Period (Within 3 Months)
Urinary Tract Fistulae
Postoperative Recognition
Rectovaginal and Enterovaginal Fistulae
Thromboembolism
Delayed Complications Presenting in the Late Postoperative Period (Months to Years)
Pelvic Organ Prolapse
Cuff Complications
Granulation Tissue
Fallopian Tube Prolapse
Conclusion
References
Part IX: Management of Gynecologic Neoplasms and Cancers
61 Diagnosis and Management of Gestational Trophoblastic Disease
Introduction
Epidemiology
Presentation
Treatment Overview
Management of Primary GTN
Low-Risk GTN: Chemotherapy
Low-Risk GTN: Adjuvant Surgery
Second Curettage
Adjuvant Hysterectomy
High-Risk GTN: Chemotherapy
Management of PSTT/ETT
Management of Refractory/Persistent Disease
Low-Risk Refractory GTN
High-Risk Refractory/Recurrent GTN
Non-gestational Trophoblastic Tumors (Non-GTT)
Experimental Therapies for Chemoresistant GTN: Immunotherapy, High-Dose Chemotherapy, and Molecularly Targeted Agents
Special Considerations
Vaginal Metastases
Brain Metastases
Reproductive Outcomes After Treatment for GTN
Post-molar Prophylactic Chemotherapy
Phantom Beta-hCG, Quiescent GTD, and Physiologic Beta-hCG
Surveillance/Follow-Up
References
62 Diagnosis and Management of Vulvar Cancer
Introduction
Diagnosis and Staging
Tumor Imaging
Prognostic Factors
Prevention
Vaccination
Screening
Treatment of Early Stage Disease
Surgical Therapy
Surgical Management of the Primary Tumor
Management of Lymph Nodes
Adjuvant Radiotherapy
Management of Advanced Stage Tumors
Surgery Advanced Disease
Management of Groin Lymph Nodal Metastasis
Role of Chemo-Radiation Therapy
Role of Chemotherapy
Recurrence and Prognosis
Follow-Up
Melanoma of the Vulva
Vulvar Cancer in Pregnancy
Conclusion
Cross-References
References
63 Diagnosis and Management of Vaginal Cancer
Introduction
Vaginal Anatomy
Natural History
Epidemiology
Signs and Symptoms
Diagnosis
Evaluation and Staging
Screening and Prevention
Histologic Subtypes and Management
Vaginal Intraepithelial Neoplasia (VAIN)
Invasive Squamous Cell Carcinoma
Adenocarcinomas
Melanoma
Mesenchymal Tumors
Other Histologies
Conclusion
Cross-References
References
64 Cervical Cancer: General Overview
Introduction
Epidemiology
Prevalence
The Role of Human Papillomavirus and Vaccines Against It
Risk Factors
Diagnosis
Clinical Manifestations
Diagnosis
Taging
Clinical Staging
Diagnostic Studies
Tumor Size and Local Spread
Lymph Node and Distant Metastases
Histology
Spread and Metastasis
Direct Invasion
Lymphatic Spread
Hematogenous Metastasis
Surgical Staging of the PALN
Treatment
Surgical Treatment
Classification of Radical Hysterectomy
Morbidities Associated with Radical Surgery for Cervical Cancer
Nerve-Sparing Radical Hysterectomy
Radiotherapy
Prognosis
Conclusion
References
65 Fertility-Sparing Treatment for Early-Stage Cervical Cancer
Introduction
Candidate Selection
Conization
Conization Alone
Conization Plus Pelvic Lymphadenectomy
Neoadjuvant Chemotherapy Before Conization Plus Pelvic Lymphadenectomy
Radical Tracherectomy Plus Pelvic Lymphadenectomy
Outcomes
Surgical Outcomes
Surgical Complications
Intraoperative Complications
Postoperative Complications
Oncological Outcomes
Prognostic Factors
Surgical Procedures
Adjuvant Treatments
Neoadjuvant Chemotherapy Followed by Radical Trachelectomy for Tumors 2-4 Cm in Diameter
Hysterectomy in the Post-Childbearing Period
Reproductive Issues
Fertility Issues
Obstetric Outcomes
Cesarean Section for Women Who Undergo Radical Trachelectomy
Oocyte Cryopreservation for Women with Advanced Disease
Conclusion
Cross-References
References
66 Management of Early-Stage and Locally Advanced Cervical Cancer
Introduction
Early-Stage Cervical Cancer
Stage IA
Stage IA1
Stage IA2
Stage IB1-IIA
Surgery and Radiotherapy
Neoadjuvant Chemotherapy Before Radical Surgery
Risk Factors for Recurrence
Tailored Postoperative Adjuvant Radiotherapy Based on Pathological Risk Assessments
Minimally Invasive Approaches
Laparoscopic and Robotic Surgery
Less Radical Surgery
Sentinel Lymph Node Biopsy
Locally Advanced Disease (IIB-IVA)
Primary Surgical Approach for FIGO Stage IIB Disease
Radiotherapy
Definitive Radiotherapy
Adjuvant Chemotherapy After Definitive Radiotherapy
Neoadjuvant Chemotherapy
Neoadjuvant Chemotherapy Followed by Surgery Versus Chemoradiotherapy
Neoadjuvant Chemotherapy Followed by Radiotherapy
Neoadjuvant Chemotherapy Followed by Chemoradiotherapy
Prognostic Factors for Survival
Follow-Up After Primary Treatment
Conclusion
Cross-References
References
67 Management of Metastatic, Recurrent, and Unusual Cervical Cancer
Introduction
Stage IVB Cervical Cancer
Recurrent Cervical Cancer
Diagnosis
Treatment
Chemotherapy
Immunotherapy
Surgical Treatments
Pelvic Exenteration
Radical Hysterectomy
Radiotherapy
Invasive Cancer that Is Detected After Simple Hysterectomy
Cancer of the Cervical Stump
Cervical Bleeding
Invasive Cervical Cancer with Bulky Lymph Nodes
Ureteral Obstruction
Cervical Cancer in Pregnancy
Incidence
Symptoms
Diagnosis
Distribution by Stage
Staging
Management
Cases in Which Pregnancy Preservation Is Not Desired
Cases in Which Pregnancy Preservation Is Desired
Before 20 Weeks´ Gestation
After 20 Weeks´ Gestation
Prognosis
Unusual Histological Types
Glassy Cell Carcinoma
Clear Cell Carcinoma
Minimal Deviation Adenocarcinoma and Gastric-Type Mucinous Carcinoma
Minimal Deviation Adenocarcinoma (MDA)
Gastric-Type Mucinous Carcinoma (GAS)
Small Cell Carcinoma
Sarcoma
Lymphoma
Melanoma
Conclusion
Cross-References
References
68 Management of Cervical Dysplasia
Introduction
Cervical Cytology
Human Papillomavirus
Risk Factors
Management of Abnormal Screening Tests
Colposcopy
Types of Cervical Dysplasia
Cervical Intraepithelial Neoplasia
Adenocarcinoma In Situ
Management of Dysplasia
Observation
Ablation
Excision
Pharmacological Agents
Hysterectomy
Special Considerations
Dysplasia in Pregnancy
Fertility-Sparing and AIS
Human Papillomavirus Prevention
Conclusion
References
69 Endometrial Hyperplasia
Introduction
Histology and Classification
WHO Classification
EIN System
Epidemiology and Risk Factors
Obesity
Polycystic Ovarian Syndrome
Hormone Replacement Therapy (HRT)
Tamoxifen Use
Lynch Syndrome
Reproductive Factors
Clinical Presentation
Diagnostic Evaluation
Management
Surveillance
Medical Management
Surgical Management
Screening and Prevention
Conclusion
Cross-References
References
70 Conservative Management of Endometrial Cancer
Introduction to Conservative Management
Epidemiologic Considerations
Age: Young Women with Endometrial Cancer
Age: Older Age and Comorbidities
Obesity and Endometrial Cancer
Special Populations: Hereditary Syndromes
Ideal Candidates for Conservative Management
Endometrial Cancer Classification
Selection of Appropriate Cases
Pretreatment Evaluation: Diagnosis and Testing
Determining Extent of Disease
Treatment Options
Hormonal Therapy
Nonhormonal and Combination Modalities
Definition of Response
Oncologic Outcomes
Risk of Recurrence
Fertility Outcomes
Surveillance
Definitive Management
Medically Inoperable Patients
Conclusion
Cross-References
References
71 Diagnosis and Management of Epithelial Ovarian Cancer
Introduction
Presentation
Diagnosis
History and Assessment
Bloods
Imaging
Pathology
Staging
Management
Definition of Surgery in EOC
Tumor Dissemination Patterns at Relapse
Value of Secondary Cytoreduction
Value of Tertiary Cytoreduction
Salvage Surgery in Acute Situations: Bowel Obstruction and Intestinal Perforation in the Era of Targeted Antiangiogenetic Agen...
Systemic Treatment of Epithelial Ovarian Cancer
Early-Stage Disease (FIGO I-IIb)
Advanced Stage Disease (FIGO IIc-IV)
Intermediate Platinum Response (PFS 6-12 Months)
Platinum-Resistant/Platinum-Refractory EOC Relapse (PFI <6 Months)
Follow-Up
Conclusion
References
72 Fertility-Sparing Treatment for Ovarian Cancer
Introduction
Surgical Management
Chemotherapy
Reproductive Outcomes
Conclusion
References
73 Diagnosis and Management of Nonepithelial Ovarian Cancer
Introduction
Sex Cord-Stromal Tumors
Pathogenesis
Granulosa Cell Tumors
Adult-Type GCT
Juvenile-Type GCT
Diagnosis of GCT
Genetic Alteration of GCT
Sertoli-Stromal Cell Tumors
Sertoli-Leydig Cell Tumors
Genetic Alteration of Sertoli-Leydig Cell Tumors
Sertoli Cell Tumors
Diagnosis of Sertoli-Stromal Cell Tumors
Sex Cord Tumor with Annular Tubules
Fibroma-Thecomas
Diagnosis of Fibroma-Thecoma
Steroid Cell Tumor
Gynandroblastoma
Unclassified Sex Cord-Stromal Tumors
Management of Sex Cord-Stromal Tumor
Preoperative Management
Surgical Management
Postoperative Management
Low-Risk Disease
Intermediate-Risk Disease
High-Risk Disease
Surveillance
Recurrent Disease
SCST in Pregnancy
Ovarian Malignant Germ Cell Tumors
Pathogenesis
Dysgerminoma
Diagnosis of Dysgerminoma
Yolk Sac Tumors
Diagnosis of Yolk Sac Tumor
Embryonal Carcinoma, Polyembryona, and Mixed Germ Cell Tumor
Nongestational Choriocarcinoma
Teratoma
Immature Teratoma
Mature Teratoma with Malignant Transformation
Malignant Struma Ovarii
Paraneoplastic Encephalitis
Diagnosis of Teratoma
Management of Ovarian Malignant Germ Cell Tumors
Preoperative Evaluation
Surgical Management
Postoperative Management
Adjuvant Chemotherapy
Surveillance
Recurrence
Ovarian Malignant Germ Cell Tumor in Pregnancy
Conclusion
References
74 Diagnosis and Management of the Cancer of the Uterus
Introduction
Epidemiology
Genetics
Histology
Diagnosis/Screening
Staging
Management of Endometrial Cancer
Lymphadenectomy
BSO
Cytologic Assessment
Risk Assessment
Low Risk
Intermediate Risk
High Risk
Recurrent or Metastatic Disease
Non-endometrioid Histologies
Uterine Papillary Serous Carcinoma (UPSC)
Uterine Carcinosarcoma
Sarcomas
Leiomyosarcoma
Adenosarcoma
Endometrial Stromal Sarcoma
Conclusion
References
75 Preinvasive Epithelial Disease of the Vulvar
Vulvar Intraepithelial Disease
Squamous Vulvar Intraepithelial Neoplasia
Introduction
Classification
Clinical Features
Risk Factors for VIN
Evaluation
Management
Surgery
Prognosis
Ablative Therapy
Medical Treatment
Follow-Up
Special Considerations
Prevention
Conclusion
Vulvar Paget´s Disease
Introduction
Classification
Clinical Features
Evaluation
Management
Surgery
Prognosis of Surgical Resection
Medical Treatment
Alternative Therapy
Follow-Up for Vulvar Paget´s Disease
Conclusion
Melanoma In Situ of the Vulva
Introduction
Clinical Features
Evaluation
Management
Conclusion
References
76 Sentinel Node Mapping in Vulva Cancer
Introduction
Patient Selection for SLNB Versus IFLD
Drainage Tracer
Ultrastaging
Recurrence Rate
Survival Rate
Complications
Quality of Life
Cost-Effectiveness of SLNB
Learning Curve for Conducting SLNB
Conclusion
References
77 Survivorship of Gynecologic Malignancy
Introduction
Effects of Gynecological Cancer and Treatment
Psychosocial Issues
Sexual Health
Fertility Implications
Loss of Ovarian Function and Bone Health
Lymphedema
Cognitive Dysfunction
Long-Term Chemotherapy and Radiation Therapy Effects
Survivorship Issues by Gynecologic Cancer Type
Endometrial/Uterine Cancer
Cervical Cancer
Ovarian Cancer
Vulvar/Vaginal Cancer
Gestational Trophoblastic Neoplasia
Conclusion
References
Part X: Pathology of the Female Gynecologic System
78 Benign Vulvar and Vaginal Pathology
Introduction
History and Basic Examination
Lichen Sclerosus
Lichen Sclerosus Symptoms
Lichen Sclerosus Clinical Findings
Lichen Sclerosus Histology
Lichen Sclerosus Diagnosis and Treatment
Lichen Simplex Chronicus
Lichen Simplex Chronicus Histology
Lichen Simplex Chronicus Diagnosis and Treatment
Lichen Planus
Lichen Planus Histology
Lichen Planus Diagnosis and Treatment
Fibroepithelial Polyp
Fibroepithelial Polyp Histology
Vulvar Melanosis
Melanocytic Nevi
Melanocytic Nevi Histology
Seborrhoeic Keratosis
Papillary Hidradenoma
Papillary Hidradenoma Histology
Vaginal Cysts (Embryonic)
Bartholin Gland Cysts
Vaginal Cysts (Nonembryonic)
Epithelial Inclusion Cysts (EICs)
Endometriosis
Conclusion
References
79 Malignant Vulvar and Vaginal Pathology
Introduction
Vulva
HPV-Driven Squamous Cell Carcinoma
Non-HPV-Driven Squamous Cell Carcinoma
Malignant Melanoma
Basal Cell Carcinoma
Adenocarcinoma
Neuroendocrine Carcinoma
Aggressive Angiomyxoma
Vagina
Vaginal Squamous Intraepithelial Lesions
Squamous Cell Carcinoma
Adenocarcinomas
Sarcoma
Malignant Melanoma
Diagnosis, Workup, and Management of Vulvar and Vaginal Malignancies
Cross-References
References
80 Lesions of the Uterine Cervix
Introduction
Epithelial Lesions/Tumors
Benign Lesions
Premalignant Squamous Cell Neoplasia/Squamous Intraepithelial Neoplasia (High Grade and Low Grade)
Cytology
Histology
Invasive Squamous Cell Carcinoma
Histology: Invasive Squamous Cell Carcinoma
Glandular Malignancies of the Cervix
Adenocarcinoma In Situ (AIS)
Invasive Adenocarcinoma
Adenosquamous Carcinoma
Neuroendocrine Tumors
Mesenchymal Tumors
Mixed Epithelial and Mesenchymal Tumors
References
81 Pathology of the Uterine Corpus
Introduction
Histology of Normal Uterine Corpus
Normal Histology
Endometrial Metaplasia
Effects of Exogenous Hormones
Non-neoplastic Endometrial Lesions
Endometrioid Adenocarcinoma Precursors
Endometrial Hyperplasia Without Atypia
Atypical Endometrial Hyperplasia/Endometrioid Intraepithelial Neoplasia
Differential Diagnosis
Uterine Tumors
Endometrial Carcinoma
Endometrioid Carcinoma
Endometrioid Carcinoma Variants
Commonly Encountered Problems in Pathologic Diagnosis and Staging of Endometrioid Adenocarcinoma
Serous Carcinoma
Clear Cell Carcinoma
Undifferentiated/Dedifferentiated Endometrial Carcinoma
Mixed-Type Carcinoma
Lynch Syndrome
Mesenchymal Lesions
Endometrial Stromal Tumors
Smooth Muscle Tumors
Mixed Epithelial-Mesenchymal Tumors
Adenosarcoma
Malignant Mixed Müllerian Tumor
Miscellaneous Uterine Tumors
Perivascular Epithelioid Cell Tumor
Lymphoma
Others
Gestational Trophoblastic Disease
Hydatidiform Mole
Malignant Gestational Disease
Conclusion
Cross-References
References
82 Germ Cell Tumors of the Ovaries
Introduction
OGCT Epidemiology and Clinical Presentation
Mature Teratoma
Mature Teratoma Gross Pathology
Mature Teratoma Histopathology
Immature Teratoma
Immature Teratoma Serum Markers and Immunophenotype
Monodermal Teratomas
Struma Ovarii
Ovarian Carcinoid
Teratoma Malignant Transformation
Dysgerminoma
Dysgerminoma Epidemiology and Clinical Features
Dysgerminoma Gross and Histopathology
Dysgerminoma Serum Markers and Immunophenotype
Dysgerminoma Genetic Abnormalities
Yolk Sac Tumor (YST)
Yolk Sac Tumor Gross and Histopathology
Yolk Sac Tumor Serum Markers and Immunophenotype
Embryonal Carcinoma (EC)
Embryonal Carcinoma Clinical Features
Embryonal Carcinoma Gross and Histopathology
Embryonic Carcinoma Serum Markers and Immunophenotype
Non-gestational Choriocarcinoma (CC)
Conclusion
References
83 Immunohistochemistry of Gynecologic Malignancies
Introduction
Basic Principle of Immunohistochemistry
Interpretation of Immunohistochemistry
Common IHC Markers Used in Gynecologic Malignancies
Epithelial Markers
Cytokeratin
Epithelial Membrane Antigen (EMA)
Pair Box Gene 8 (PAX8)
Wilms´ Tumor 1 (WT1)
GATA3
Mesenchymal Markers
Vimentin
Actin
Desmin
Myoglobulin, MyoD1, and Myogenin
Transgelin
Sex Cord Markers
Alpha-Inhibin
CD30
Trophoblastic Markers
Human Chorionic Gonadotropin (hCG)
Human Placental Lactogen (hPL)
Other Immunomarkers
Ki67/MIB 1
P53
P16
ER and PR
Insulin-Like Growth Factor II mRNA Binding Protein 3 (IMP3)
CD10
Application of IHC to Female Genital Tract
Vulvar Lesions
High-Risk HPV-Related Cervical Neoplasms Versus Benign Reactive Cervical Lesions
Endometrial Endometrioid Adenocarcinoma Versus Endocervical Adenocarcinoma
Serous Carcinoma, Endometrial Versus Ovarian Origin
Ovarian Carcinomas Histologic Subtypes
Clear Cell Carcinoma of Ovary
Mucinous Carcinoma of Ovary Versus Lower Gastrointestinal (GI) Tract
Endometrioid Adenocarcinoma Versus Metastastic Adenocarcinoma from the GI Tract
Endometrial Stromal Sarcoma (ESS) Versus Leiomyosarcoma
Germ Cell Tumors
Conclusion
References
84 Surface Epithelial Neoplasms of the Ovary
Introduction
Benign Ovarian Cysts
Corpus Luteal Cyst
Solitary Follicular Cyst
WHO Classification of Epithelial Tumors
Serous Tumors
Serous Cystadenoma and Adenofibroma
Serous Borderline Tumor/Low Malignant Potential/Atypical Proliferative Serous Tumor
Serous Borderline Tumor (SBT) Micropapillary Variant (MSBT)
Low-Grade and High-Grade Serous Carcinoma
Mucinous Tumors
Mucinous Cystadenoma
Mucinous Borderline Tumor/Mucinous Tumor of Low Malignant Potential
Mucinous Adenocarcinoma
Pseudomyxoma Peritonei
Mucinous Tumors with Mural Nodule
Clear Cell Tumor
Borderline Clear Cell Tumor
Clear Cell Carcinoma
Endometrioid Tumors
Endometriotic Cyst
Borderline Endometriotic Tumor
Endometrioid Adenocarcinoma
Brenner Tumors
Benign Brenner Tumor
Malignant Brenner Tumor
Seromucinous Tumors
Undifferentiated Carcinoma
Ovarian Carcinoma After Neoadjuvant Therapy
Ovarian Grading Systems
Ovarian Staging FIGO 2014
Conclusion
References
85 Sex-Cord Stromal Tumors of the Ovary
Introduction
Sex-Cord Stromal Tumor Epidemiology and Clinical Presentation
Ovarian Fibroma
Fibroma Epidemiology and Clinical Features
Fibroma Gross Pathology
Fibroma Histopathology
Fibroma Differential Diagnosis
Fibrosarcoma
Fibrosarcoma Epidemiology
Fibrosarcoma Gross Pathology
Fibrosarcoma Histopathology
Fibrosarcoma Differential Diagnosis
Thecoma and Luteinized Thecoma Associated with Sclerosing Peritonitis
Thecomas Epidemiology and Clinical Features
Thecomas Gross Pathology
Thecomas Histopathology
Thecomas Differential Diagnosis
Steroid Cell Tumor
Steroid Cell Tumor Clinical Manifestations
Steroid Cell Tumor Types
Leydig Cell Tumor
Steroid Cell Tumors, Not Otherwise Specified
Sclerosing Stromal Tumor (SST)
Sclerosing Stromal Tumor Clinical Presentations
Sclerosing Stromal Tumor Gross Findings
Sclerosing Stromal Tumor Microscopic Findings
Sclerosing Stromal Tumor Differential Diagnosis
Microcystic Stromal Tumor (MST)
Microcystic Stromal Tumor Clinical Presentations
Microcystic Stromal Tumor Gross Findings
Microscopic Stromal Tumor Microscopic Findings
Differential Diagnosis
Signet Ring Stromal Tumor
Signet Ring Stromal Tumor Clinical Presentations
Signet Ring Stromal Tumor Gross Findings
Signet Ring Stromal Tumor Microscopic Findings
Signet Ring Stromal Tumor Differential Diagnosis
Adult Granulosa Cell Tumors (AGCT)
Adult Granulosa Cell Tumor Clinical Features
Adult Granulosa Cell Tumor Gross Pathology
Adult Granulosa Cell Tumor Histopathology
Adult Granulosa Cell Tumor FOXL2 Gene Mutation
Adult Granulosa Cell Tumor Differential Diagnosis
Juvenile Granulosa Cell Tumors (JGCT)
Juvenile Granulosa Cell Tumors Clinical Features
Juvenile Granulosa Cell Tumors Gross Pathology
Juvenile Granulosa Cell Tumors Histopathology
Juvenile Granulosa Cell Tumors Differential Diagnosis
Sertoli Cell Tumor (SCT)
Clinical Features
Sertoli Cell Tumor Gross Pathology
Sertoli Cell Tumor Histopathology
Sertoli Cell Tumor Differential Diagnosis
Sex Cord Tumors with Annular Tubules (SCTAT)
Sex Cord Tumors with Annular Tubules Clinical Presentations
Sex Cord Tumors with Annular Tubules Gross Findings
Sex Cord Tumors with Annular Tubules Microscopic Findings
Sex Cord Tumors with Annular Tubules Differential Diagnosis
Sertoli-Leydig Cell Tumor (SLCT)
Sertoli-Leydig Cell Tumor Epidemiology and Clinical Features
Sertoli-Leydig Cell Tumor Gross Pathology
Sertoli-Leydig Cell Tumor Histopathology
Sertoli-Leydig Cell Tumor Well-Differentiated
Sertoli-Leydig Cell Tumor Moderately Differentiated
Sertoli-Leydig Cell Tumor Poorly Differentiated
Sertoli-Leydig Cell Tumor with Retiform Pattern
Sertoli-Leydig Cell Tumor with Heterologous Elements
Sertoli-Leydig Cell Tumor DICER1 Mutation
Differential Diagnosis
Sex Cord-Stromal Tumors, Unclassified
Sex Cord-Stromal Tumors, Unclassified Immunohistochemistry
Conclusion
References
Index