Cervical Cancer Screening
Ages 21–29: cytology every 3 years. Ages 30–65: cytology q3y, hrHPV cotesting q5y, or hrHPV alone q5y. HPV 16 and 18 cause 70% of invasive carcinomas.
Postmenopausal Bleeding
Postmenopausal bleeding is Endometrial Carcinoma until proven otherwise; mandatory transvaginal ultrasound (endometrial stripe > 4 mm) + endometrial biopsy.
Ovarian Tumor Markers
CA-125: Epithelial serous carcinoma; AFP: Yolk sac tumor; beta-hCG: Choriocarcinoma; Inhibin: Granulosa cell tumor; LDH: Dysgerminoma.
PCOS Rotterdam Criteria
Requires 2 of 3: 1. Oligo/anovulation, 2. Hyperandrogenism (hirsutism/elevated testosterone), 3. Polycystic ovaries on ultrasound; LH/FSH ratio > 2:1.
Gynecologic Malignancies Master Comparison
| Malignancy | Key Risk Factors & Molecular Drivers | Pathognomonic Presentation & Workup | Surgical & Adjuvant Therapy |
|---|---|---|---|
| Cervical Carcinoma | High-risk HPV (HPV 16: E6 degrades p53; HPV 18: E7 degrades Rb), tobacco smoking, immunosuppression | Postcoital bleeding, foul malodorous discharge, visible exophytic cervical mass; Colposcopy with acetic acid / Schiller iodine | FIGO clinical staging; Early (IA–IIA): Radical hysterectomy + pelvic lymphadenectomy; Advanced (≥ IIB): Chemoradiation with Cisplatin (curative radiation) |
| Endometrial Adenocarcinoma | Unopposed estrogen exposure: Obesity (aromatase in adipose converts androstenedione to estrone), nulliparity, late menopause, Tamoxifen, Lynch syndrome | Abnormal uterine bleeding in postmenopausal female; TVUS endometrial thickness > 4 mm mandates office endometrial biopsy (pipelle) | Total abdominal hysterectomy + bilateral salpingo-oophorectomy (TAH-BSO) + surgical staging lymphadenectomy |
| Epithelial Ovarian Carcinoma | Repeated ovulation (incessant ovulation hypothesis), BRCA1 / BRCA2, Lynch syndrome; Protective: Multiparity, oral contraceptives, lactation | Vague abdominal bloating, early satiety, pelvic fullness, bowel habit changes; Palpable adnexal mass; Elevated serum CA-125 | Exploratory laparotomy with complete cytoreductive debulking surgery + Platinum/Taxane-based chemotherapy (Carboplatin + Paclitaxel) |
Endometriosis vs. Adenomyosis vs. Leiomyomas (Fibroids)
| Condition | Pathophysiology | Physical Exam Hallmarks & Pelvic Findings | First-Line Management |
|---|---|---|---|
| Endometriosis | Ectopic functional endometrial glands and stroma outside uterus (ovaries, uterosacral ligaments, pouch of Douglas) | The 3 Ds: Dysmenorrhea, Dyspareunia, Dyschezia (pain with defecation) + subfertility; fixed, retroverted uterus with uterosacral nodularity; 'chocolate cysts' (endometriomas) | First-line: Combined oral contraceptives (COCs) or Progestins; Definitive diagnosis: Laparoscopy with surgical excision/ablation |
| Adenomyosis | Invasion of endometrial glands and stroma into the myometrium (uterine musculature) | Multipara > 40; heavy menstrual bleeding (menorrhagia) and severe secondary dysmenorrhea; symmetrically enlarged, soft, tender, 'globular' / 'boggy' uterus | Levonorgestrel-releasing IUD (Mirena) or COCs; Definitive cure: Hysterectomy |
| Leiomyoma (Uterine Fibroids) | Benign clonal monoclonal proliferation of smooth muscle cells within myometrium; estrogen/progesterone sensitive | Heavy, prolonged menstrual bleeding ± bulk symptoms (pelvic pressure, urinary frequency, constipation); irregularly enlarged, firm, non-tender, asymmetric 'knobby' uterus | COCs, Tranexamic acid, GnRH agonists (Leuprolide - pre-op shrinkage); Myomectomy (preserves fertility) or Hysterectomy |
OMM Board Correlate: Pelvic Splanchnics & Broad Ligament Tension
- Pelvic Parasympathetics (S2–S4): Ovaries, fallopian tubes, and uterus receive parasympathetic innervation via the pelvic splanchnic nerves. Somatic dysfunction of the sacrum (bilateral sacral flexion or sacral torsion) causes pelvic venous congestion and exacerbates dysmenorrhea.
- Chapman Reflexes for Pelvic Organs: Broad ligament Chapman point is located along the posterior IT band; ovary/fallopian tube points are located on the superior pubic ramus lateral to symphysis; uterus Chapman point is at the inferior pubic ramus.
- Lumbosacral Springing: Springing the sacral base during expiration stimulates parasympathetic flow and drains the pelvic venous plexus.
Board Traps & Common Distractors
- Any postmenopausal female presenting with vaginal spotting or bleeding must undergo prompt transvaginal ultrasound and endometrial biopsy; never attribute postmenopausal bleeding to atrophy without histologic exclusion of cancer.
- Granulosa cell tumors of the ovary produce estrogen and secrete Inhibin; in postmenopausal women, excessive estrogen causes endometrial hyperplasia or carcinoma; in children, it produces precocious puberty with Call-Exner bodies (follicles filled with eosinophilic secretions) on biopsy.
- Ovarian torsion is an emergency characterized by sudden-onset severe unilateral lower abdominal/pelvic pain, nausea, and vomiting; Doppler ultrasound revealing absence of ovarian venous and arterial flow warrants emergent diagnostic laparoscopy to untwist and salvage the ovary.