Ebook Ambulatory gynecology: Part 2

Part 2 book “Ambulatory gynecology” has contents: Osteopenia and osteoporosis, basic infertility evaluation, hormone replacement therapy in menopause, elective pregnancy termination, clinical genetics for the gynecologist, female sexual dysfunction, sexual minority health,… and other contents.

Chapter 13 Office Management of Female Pelvic Floor Dysfunction Sara Kostant and Michael D. Moen Introduction Pelvic floor dysfunction, including urinary incontinence and pelvic organ prolapse, affects millions of American women These problems are more common than most healthcare providers realize About 24% of all women have at least one symptom of pelvic floor dysfunction [1] The lifetime risk of undergoing surgery for pelvic organ prolapse or incontinence is 20% [2], which does not take into account women who undergo medical management of their symptoms or not seek treatment at all The prevalence of pelvic floor disorders is set to increase significantly over the next few decades One study estimates that by 2050, the number of women with urinary incontinence will increase 55% to 28.4 million, and the number of women with pelvic organ prolapse will increase 46% to 4.9 million [3] S Kostant Hackensack University Medical Center, Department of Obstetrics and Gynecology, Hackensack, NJ, USA M D Moen (*) Rosalind Franklin University Chicago Medical School, Advocate Lutheran General Hospital, Department of Obstetrics and Gynecology, Park Ridge, IL, USA e-mail: Michael.moen@advocatehealth.com © Springer Science+Business Media, LLC, part of Springer Nature 2018 J V Knaus et al (eds.), Ambulatory Gynecology, https://doi.org/10.1007/978-1-4939-7641-6_13 195 196 S Kostant and M D Moen Increasing age is a risk factor for pelvic floor dysfunction, and the number of women over age 65 will have doubled between 2008 and 2050 [4] A general gynecologist is often the first provider to see patients with pelvic floor dysfunction, as most women not seek out a specialist when these symptoms initially occur General gynecologists can expect to see an increase in women presenting with urinary incontinence, pelvic organ prolapse, and voiding dysfunction to his or her office over the next decades Management of these issues might seem daunting to many gynecologists Graduating OB/GYN residents have less experience managing issues related to pelvic floor dysfunction than obstetric and benign gynecological issues common to the premenopausal patient The general gynecologist will have a growing responsibility to manage urinary incontinence, pelvic organ prolapse, and voiding dysfunction The purpose of this chapter is to provide a framework for the evaluation and management of these issues Voiding dysfunction, for the purposes of this chapter, refers to patient complaints of changes in her urine flow and ability to empty her bladder Pelvic Floor Dysfunction Terminology Standardized terminology for female pelvic floor dysfunction eases communication between providers and patients The following definitions are taken from the most recent International Urogynecological Association (IUGA)/ International Continence Society (ICS) guidelines [5] Stress incontinence The complaint of the involuntary loss of urine on effort or physical exertion Urgency The complaint of a sudden, compelling desire to pass urine which is difficult to defer 13.  Office Management of Female Pelvic Floor… 197 Urgency incontinence The complaint of the involuntary loss of urine associated with urgency Mixed incontinence The complaint of involuntary loss of urine associated with urgency and also with effort or physical exertion or on sneezing or coughing Frequency The complaint that urination occurs more frequently during waking hours than previously deemed normal by the woman Nocturia The complaint of the interruption of sleep one or more times because of the need to urinate Overactive bladder (OAB, urgency) syndrome Urinary urgency, usually accompanied by frequency and nocturia, with or without urgency urinary incontinence, in the absence of urinary tract infection or obvious pathology Feeling of incomplete (bladder) emptying The complaint that the bladder does not feel empty after urination This symptom may or may not actually correlate with an elevated post-void residual on exam Patients presenting with this complaint may mention a need to strain or change position in order to feel like she is emptying her bladder Pelvic Organ Prolapse The descent of one or more of the anterior vaginal wall, posterior vaginal wall, the uterus (cervix), or the apex of the vagina (vaginal vault or cuff scar after hysterectomy) 198 S Kostant and M D Moen A patient with this finding would likely be presenting with a complaint of a “bulge” sensation in the vagina Evaluation A complete medical, surgical, and gynecological history should be obtained from the patient The patient’s non-gynecological medical history may explain a patient’s symptoms Patients with neurologic disorders may experience both overactive bladder and incomplete emptying Frequently used medications for hypertension, such as diuretics and acetylcholinesterase inhibitors, can increase urinary frequency Sleep apnea can often be responsible for nocturia, and the introduction of CPAP therapy may resolve the patient’s symptoms The patient’s medical history may also guide treatment If a patient reports a history of closed-angle glaucoma or bowel obstructions due to constipation, anticholinergic medications will be contraindicated Increased gravidity and parity can predispose patients to pelvic floor disorders A history of a third- or fourth-degree episiotomy should be noted as fecal incontinence is more common in these patients, but women are often embarrassed to reveal this symptom Prior pelvic surgery can contribute to denervation injury, which may contribute to overactive bladder or incomplete emptying Pelvic radiation for gynecological cancer can lead to a loss of compliance of the bladder wall and urethra This can lead to stress incontinence due to the scarring of the bladder neck and urethral sphincter muscles and urinary urgency and frequency due to reduced bladder capacity The healthcare provider should thoroughly review the patient’s current symptoms The onset and duration of the patient’s symptoms is important If incontinence is the main complaint, it is critical to differentiate between stress and urge incontinence, recognizing that more than a third of women will have components of both (mixed incontinence) [6] The abdominal and pelvic examination is key to the assessment of women with pelvic floor dysfunction The vulva and 13.  Office Management of Female Pelvic Floor… 199 vagina should be examined for signs of urogenital atrophy Loss of rugations and thin, pale vaginal mucosa may be noted in this circumstance The patient is asked to cough, and the mobility of the urethra and leakage of urine is noted A change in the angle of the urethra of more than 30 degrees indicates a hypermobile urethra The neuromuscular exam includes an assessment of perineal and vulvar sensation, pelvic floor resting tone, and pelvic floor muscle strength Perineal sensation can be assessed with a q-tip or by direct light palpation The patient can then be instructed to contract her pelvic floor muscles as if she is trying to stop the flow of urine or trying to hold gas in the rectum Pelvic floor contraction strength can be graded according to a modified Oxford scale as shown in Table 13.1 Prolapse of the anterior and posterior vaginal walls, uterus, and vaginal apex are measured in the supine position with the patient performing a Valsalva maneuver A half speculum is useful for examination of the anterior and posterior walls separately Many providers are confused by the appropriate documentation of the stage of prolapse The Pelvic Organ Prolapse Quantification System (POP-Q), describes the measurement of nine points of vaginal support A newer, abbreviated system focuses on the evaluation of four points – the anterior and posterior vaginal walls, the vaginal apex, and the cervix In women who have had a hysterectomy, the cervix is left out and only three points are documented This system has been noted to have good inter-observer and inter-system reliability [7] Table 13.2 describes the points in the vagina that are used for measurement of each compartment, and Table 13.3 shows how each point corresponds to staging Multichannel urodynamic testing is not necessary in the initial evaluation of most patients with incontinence Simple cystometry, or a “bladder fill”, is a quick, inexpensive tool for bladder function assessment After the urethral meatus is swabbed with iodine, a red rubber catheter is placed in the bladder using sterile technique The end of the catheter is connected to a 50–60 ml funnel syringe The bladder is then 200 S Kostant and M D Moen Table 13.1 Modified Oxford scale for pelvic muscle contraction strength Grade Definition No contraction Flicker Weak Moderate Good (with lift) Strong (with lift) Laycock [26] Table 13.2  Simplified pelvic organ prolapse quantification (POPQ) system Vaginal Area of measurement compartment Anterior wall A point 3 cm proximal to the urethral meatus Cervix Most distal aspect of the cervix Apex/cuff Posterior fornix; if post-hysterectomy, then most distal aspect of the cuff Posterior wall A point 3 cm proximal to the hymenal remnants Swift et al [7] filled with sterile water or saline The patient is asked to report when she feels the following sensations: first sensation of fluid in the bladder, first urge to urinate, strong urge to urinate, and her maximum bladder capacity Sensations of urgency during bladder filling may be indicative of an overactive bladder After the maximum capacity is reached, the catheter is removed, and a cough stress test can be performed The physician can also re-­catheterize the patient after she voids to check a post-void residual if there is a concern for incomplete emptying 13.  Office Management of Female Pelvic Floor… 201 Table 13.3  POP-Q staging system Stage Location of area of measurement at Valsalva I More than 1 cm proximal to the hymenal remnants II Between 1 cm proximal and 1 cm distal to the hymenal remnants III More than 1 cm distal to the hymenal remnants but without complete vaginal eversion IV Vaginal mucosa is completely everted Swift et al [7] Treatment Therapies Useful for All Pelvic Floor Disorders Fluid and Diet Management Unless otherwise medically indicated, fluid restriction is not recommended as a means to decrease urinary frequency Likewise, excessive hydration is not helpful or necessary Concentrated urine can further irritate the bladder, actually increasing urgency and frequency Women should be encouraged to drink enough to satisfy their thirst and counseled that this may result in a transient exacerbation of their overactive bladder symptoms Timed Voiding/Bladder Training Timed voiding can help women manage both overactive bladder symptoms and incomplete emptying Women with frequency are encouraged to slowly increase the intervals between their voids For example, if a woman normally feels the urge to void every hour, she is encouraged to increase this interval by an additional 15 min for 1 week If she is able to wait 1 h and 15 min between voids without leakage, she should increase the interval the next week to an hour and a half, and so forth Each woman should be encouraged to pro- 202 S Kostant and M D Moen ceed at her own pace; some women may need to wait or 3 weeks before increasing their voiding intervals Timed voiding can be used in conjunction with anticholinergic therapy in women with frequent leakage Patients with incomplete bladder emptying are advised to void every 3 h, whether or not they feel the urge to void at that time “Double voiding” – having the patient stand up from the commode and then sit down again – may allow the patient to begin or continue emptying her bladder Running water from a tap can also be useful cue to help a patient start voiding Emptying the bladder more frequently may increase bladder sensitivity in women who have become accustomed to waiting several hours between voids For patients who continue to have elevated post-void residual volumes despite timed voiding, intermittent self-catheterization may be necessary Topical Estrogen Postmenopausal women with urogenital atrophy may have increased irritation of the urethra, leading to dysuria and urgency, even in the absence of a urinary tract infection Topical estrogen may be a useful adjunct to timed voiding and anticholinergic medication in these women, especially if vaginal dryness, dyspareunia, and recurrent urinary tract infections are also present Topical estrogen may be delivered by a vaginal cream (Estrace or Premarin cream), ring (Estring 2 mg/3 months), or tablet (Vagifem 10 mcg) All forms of topical estrogen are equally effective in treating vaginal atrophy A patient should use the form of delivery that most appeals to her and will increase her compliance Use of the tablet, ring, or low dose (1–2 g twice weekly) cream preparations not raise systemic serum estradiol levels to premenopausal levels [8] Traditionally, hormone replacement therapy, including topical estrogen, has been avoided in patients with a history of breast cancer There is evidence that breast cancer recurrence 13.  Office Management of Female Pelvic Floor… 203 may not be associated with either oral or vaginal hormone therapy use [9] Supplemental progesterone is not routinely recommended in women using topical estrogen who still have a uterus The endometrial safety of the estrogen ring and tablet have been shown for use up to 12 months and for low doses of estrogen cream for use up to 6 months [10] As there is a lack of data regarding topical estrogen use in these patients after 12 months of use, consideration may be given to providing supplemental progesterone in women who have been using topical estrogen for over a year; however, this is not routine in our practice Pessary users with atrophy may have less vaginal abrasions and therefore a greater likelihood of continuing pessary use, if they use topical estrogen [11] Pelvic Floor Exercises Since Dr Arnold Kegel first discussed the benefits of pelvic floor exercises, [12] multiple studies have shown they can improve symptoms of pelvic floor disorders Pelvic floor exercises, even when done correctly and regularly, will likely provide more of an improvement of incontinence and prolapse symptoms, rather than a cure Most women presenting to a gynecologist’s office with pelvic floor dysfunction have heard of “Kegel exercises” through the popular media However, less than half of patients have been taught how to properly perform pelvic floor muscle contractions, and most patients who have been taught received verbal training only [13] Verbal training and reading instructions on pelvic floor exercises not seem to be sufficient, as less than 25% of patients are able to perform a pelvic floor contraction with a strength rating of 3, 4, or on the Oxford scale [14] The ideal teaching of pelvic floor contractions occurs during the pelvic exam The healthcare provider should demonstrate the pelvic floor muscles by palpation and instruct the patient to contract these muscles around the provider’s examining finger The patient should 204 S Kostant and M D Moen be counseled to avoid performing a Valsalva maneuver or using her abdominal and gluteal muscles during the pelvic floor contraction  reatment Options Specific to Different Types T of Pelvic Floor Dysfunction Pelvic Organ Prolapse Pessaries in general have been underutilized in recent years due to misconceptions about the difficulties of pessary fitting and management Younger patients, in particular, may have a misconception that pessaries are only an option for “elderly” women or believe that they will not be able to be sexually active if they wear a pessary In fact, pessary use is an excellent option for women of all ages, especially premenopausal women who desire future pregnancies Most women can be taught to remove, clean, and replace their pessaries so that sexual activity is not precluded All women presenting with symptomatic pelvic organ prolapse should be offered a trial of a pessary A properly fitted pessary is comfortable and is not felt at all by the patient Advanced stages of prolapse should not discourage a physician from offering a pessary Successful continuation of pessary use has not been found to be related to the severity of prolapse or location of the pelvic defect (i.e., cystocele vs rectocele) [15] Pessaries come in a number of different shapes and sizes, which may seem intimidating to gynecologists unfamiliar with their use However, most patients can be fitted successfully with a ring with support pessary Ring pessaries have the longest continuation rate due to their ease of use and are the least likely to cause bothersome vaginal abrasions and ­vaginal discharge [16] In addition to standard ring pessaries, there are also ring pessaries with knobs, which can be used in patients with stress incontinence 24.  Psychiatric Disorders in Women’s Health 411 23 Kung S, Espinel Z, Lapid MI. Treatment of nightmares with prazosin: a 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risk of in utero exposure to lithium JAMA 1994;271(2):146–50 41 Epstein RA, Moore KM, Bobo WV. Treatment of bipolar disorders during pregnancy: maternal and fetal safety and challenges Drug Healthc Patient Saf 2015;7:7–29 42 Yonkers KA, Wisner KL, Stowe Z, Leibenluft E, Cohen L, Miller L, Altshuler L. Management of bipolar disorder during pregnancy and the postpartum period Am J Psychiatry 2004;161(4):608–20 43 Mines D, Tennis P, Curkendall SM, Li DK, Peterson C, Andrews EB, Chan KA. Topiramate use in pregnancy and the birth prevalence of oral clefts Pharmacoepidemiol Drug Saf 2014;23(10):1017–25 44 US Food & Drug Administration Suicidal behavior and ideation and antiepileptic drugs Retrieved from h t t p : / / w w w f d a g o v / D r u g s / D r u g S a f e t y / PostmarketDrugSafetyInformationforPatientsandProviders/ ucm100190.htm 2009 45 Dolovich LR, Addis A, Vaillancourt JM, Power JD, Koren G, Einarson TR. Benzodiazepine use in pregnancy and major malformations or oral cleft: meta-analysis of cohort and case-control studies BMJ 1998;317(7162):839–43 46 Huybrechts KF, Hernandez-Diaz S, Patorno E, Desai RJ, Mogun H, Dejene SZ, Bateman BT. Antipsychotic use in pregnancy and the risk for congenital malformations JAMA Psychiat 2016;73(9):938–46 24.  Psychiatric Disorders in Women’s Health 413 47 Galbally M, Snellen M, Power J. Antipsychotic drugs in pregnancy: a review of their maternal and fetal effects Ther Adv Drug Saf 2014;5(2):100–9 48 Sadowski A, Todorow M, Yazdani Brojeni P, Koren G, Nulman I. Pregnancy outcomes following maternal exposure to second-­ generation antipsychotics given with other psychotropic drugs: a cohort study BMJ Open 2013;3(7) pii: e003062 https://doi org/10.1136/bmjopen-2013-003062 49 US Food & Drug Administration FDA drug safety communication: antipsychotic drug labels updated on use during pregnancy and risk of abnormal muscle movements and withdrawal symptoms in newborns [press release] Retrieved from http://www fda.gov/Drugs/DrugSafety/ucm243903.htm 2011 50 Heron J, O’Connor TG, Evans J, Golding J, Glover V. The course of anxiety and depression through pregnancy and the postpartum in a community sample J Affect Disord 2004;80(1):65–73 51 Ross LE, McLean LM. Anxiety disorders during pregnancy and the postpartum period: a systematic review J Clin Psychiatry 2006;67(8):1285–98 52 Sui G, Pan B, Liu G, Liu G, Wang L. The long-term effects of maternal postnatal depression on a child’s intelligence quotient: a meta-­analysis of prospective cohort studies based on 974 cases J Clin Psychiatry 2016;77:e1474–82 53 Halbreich U, Karkun S. Cross-cultural and social diversity of prevalence of postpartum depression and depressive symptoms J Affect Disord 2006;91(2):97–111 54 Berle JØ, Spigset O. Antidepressant use during breastfeeding Curr Womens Health Rev 2011;7(1):28–34 55 O’Hara MW, Stuart S, Gorman LL, Wenzel A. Efficacy of interpersonal psychotherapy for postpartum depression Arch Gen Psychiatry 2000;57(11):1039–45 56 Jones I, Chandra PS, Dazzan P, Howard LM. Bipolar disorder, affective psychosis, and schizophrenia in pregnancy and the post-­ partum period Lancet 2014;384(9956):1789–99 57 Viguera AC, Nonacs R, Cohen LS, Tondo L, Murray A, Baldessarini RJ. Risk of recurrence of bipolar disorder in pregnant and nonpregnant women after discontinuing lithium maintenance Am J Psychiatry 2000;157(2):179–84 58 Bergink V, Rasgon N, Wisner KL. Postpartum psychosis: madness, mania, and melancholia in motherhood Am J Psychiatry 2016;173(12):1179–88 414 S Chandraiah 59 Sit D, Rothschild AJ, Wisner KL. A review of postpartum psychosis J Womens Health (Larchmt) 2006;15(4):352–68 60 American Academy of Pediatrics Committee on Drugs Transfer of drugs and other chemicals into human milk Pediatrics 2001;108(3):776–89 61 Fortinguerra F, Clavenna A, Bonati M. Psychotropic drug use during breastfeeding: a review of the evidence Pediatrics 2009;124(4):e547–56 62 Seritan AL, Iosif AM, Park JH, DeatherageHand D, Sweet RL, Gold EB. Self-reported anxiety, depressive, and vasomotor symptoms: a study of perimenopausal women presenting to a specialized midlife assessment center Menopause 2010;17(2):410–5 63 Parry BL. Perimenopausal depression Am J Psychiatry 2008;165(1):23–7 64 Parry BL. Optimal management of perimenopausal depression Int J Womens Health 2010;2:143–51 65 Chandraiah S, Richter H, Holley R. Relationship of reproductive cycle-­ associated and non-reproductive cycle-associated psychological problems in women Int J Fertil Womens Med 2005;51(1):33–7 Index A Abnormal uterine bleeding (AUB) in adolescents, 63 conservative management, 64, 65 medical treatment, 67–68 PALM-COEIN classification, 60 pathophysiology, 61 peri- and postmenopausal women, 59 physical examination, 61 surgical management, 66–69 in women, 63–64, 66 Abortion first trimester dosage, 275 medications, 274–275 patient selection, 274 post-procedure follow-up, 275–276 prevalence, 274 safety, 276 second trimester analgesia, 281 anesthesia, 281 post-procedure follow-up, 281 prevalence, 278–279 safety, 281–282 safety advantage, 279 technical issues, 279–282 Activated partial thromboplastin time (APTT), 266 Adenomyosis, 95, 97, 101, 103, 104, 315 Adjunctive measures, 188–189 Adnexal mass age distribution, 132 ambulatory setting, 131 family history, 132 incidence, 132 risk of malignancy, 133–134 surveillance, 131 Adolescents, 63, 66 Amenorrhea AIS, 75 definitions, 72 delayed puberty, 83 etiologies, 71 head, 81, 82 intrauterine adhesions, 73 Mullerian anomalies, 73, 74 outflow tract, 72 ovaries, 76, 78–80 The American Academy of Pediatrics (AAP), 407 The American Cancer Society (ACS), © Springer Science+Business Media, LLC, part of Springer Nature 2018 J V Knaus et al (eds.), Ambulatory Gynecology, https://doi.org/10.1007/978-1-4939-7641-6 415 416 Index The American College of Obstetrics and Gynecology (ACOG), 59, 150, 154, 235 The American College of Radiology (ACR), The American Congress of Obstetricians and Gynecologists (ACOG), The American Society for Colposcopy and Cervical Pathology (ASCCP), 154, 157, 159 Analgesia, 275, 277–278 Anatomic factors, 262 Androgen insensitivity syndrome (AIS), 75 Anesthesia, 275, 277–278 Anorexia nervosa, 83, 85, 86 Anorgasmia, 315–316 Anovulatory bleeding, 63 Anticonvulsant mood stabilizers, 388 Antidepressants, 384, 387 Antipsychotics, 387, 402 Anxiety disorder GAD, 390–392 PTSD, 392 Arousal, 309, 311, 314, 317 Aspiration, 25, 26, 29 Atypical squamous cells of undetermined significance (ASCUS), 149 Augmentation cystoplasty, 190 B Bacterial vaginosis (BV), 166, 167 Basal Body Temperature (BBT) recording, 254 Behavioral methods, 34 coitus interruptus, 35–36 family planning, 36 Benzodiazepines, 388, 402, 407 Bioidentical hormones, 237, 238 Biopsychosocial model, 317 Bipolar disorder (BD), 385, 400, 402, 403 Birth control methods abstinence, 35 barrier methods, 37–40 coitus interruptus, 35–36 female sterilization, 49, 54 Bisphosphonates, 221–223 Bladder pain, 175, 182 Bladder pain syndrome/interstitial cystitis (IC/BPS), 175 Body mass index (BMI), 324 Bone mineral densitometry (BMD), 214 Breast cancer, 236–237, 298, 300 Breast cancer screening asymptomatic women average risk, 6, 8, high risk, 10, 11 moderate risk, 9, 10 BSE, density, 12, 13 diagnostic examination, 14 imaging, mammography, morbidity, mortality, non-imaging screening recommendations, risk assessment, 5–6 signs, 14 symptoms, 14 Breast disorder diagnostic triad, 25 mass, 29 medical malpractice, 25 needle aspiration, 26 nipple discharge, 28 risk factors, 21, 22 screening, 23, 24 screening protocols, 21 tissue diagnosis, 28 Breast Imaging Reporting and Data System (BI-RADS), 12, 15, 16 Breast self-examination (BSE), Index Bulimia, 83, 85, 86 Bump dyspareunia, 314 C Cardiovascular disease, 232 Cerebrovascular accidents (CVA), 236 Cerebrovascular diseases, 332 Cervical cancer screens cost-effectiveness and efficiency, 155 evidence-based medicine, 154 Pap smears, 155 SEER cancer data, 151 Cervical cancer screens, in populations, 153 Cervical dysplasia, 331 Cervical intraepithelial neoplasia (CIN), 150 Cervical neoplasia, 159 Cervicitis, 163–165 Chancroid, 168 Chlamydia trachomatis (CT), 163 Chronic pelvic pain (CPP) anatomic sites, 96–97 components, 92 cyclic pattern, 93–95 gynecologic origin adnexal surgery, 104–105 foreign body removal, 105 hysterectomy, 103–104 laparoscopic approach, 103 medical therapy, 102 nonmedical therapies, 105–106 psychological treatments, 105 imaging, 101 noncyclic pattern, 95–99 office testing, 101 patient’s description, 92 physical examination, 99–101 sexual abuse, 93 surgical evaluation, 102 symptoms, 93 Clinical algorithm, 136 417 Clinical breast exam (CBE), Clinical issues, 351–357 Clozapine, 407 Cognitive behavioral therapy (CBT), 383 Colposcopy, 149, 150, 154, 156, 159 Constitutional delayed (CD) puberty, 84 Contraception adolescents, 55–56 health benefits, 33 medical issues, 56–57 obesity, 56 Corpus luteum, 116 Counseling, 273 Cowden syndrome, 300 Craniopharyngiomas, 82 Cryoablation, 159 Cultural competence, 321 Cystectomy, 190 Cystoscopy, 187 Cysts blood flow, 126–130 hemorrhagic, 117–118 irregular septations, 124–126 peritoneal inclusion cyst, 120 postmenopausal, 115 premenopausal, 113–115 Cytology-based cervical cancer, 148 D Densitometry, 214 Department of Health and Human Services (DHHS), 322 Depression, 398, 399 Dermatitis, 172–173 Dermoid, 118, 119, 121 DEXA testing, 215–219 Diagnosis for Bulimia nervosa (DSM-IV), 86 Diagnostic and Statistical Manual (DSM 5), 380 Dietary measures, 189 Dilipan-S™: Dilapan™, 283 418 Index Dimethylsulfoxide (DMSO), 187 Domestic violence definitions, 366, 367 documentation, 375–376 intervention, 373–375 physician’s role, 373–375 prevalence, 366, 367 risk factors, 369, 370 screening, 370–372 socioeconomic impact, 368–369 Dysmenorrhea, 327 Dyspareunia, 176–178, 185, 188, 314 E Ectopic pregnancy expectant management, 143 medical management, 143–145 physical examination, 140 progesterone level, 142 risk factors, 140 symptoms, 140 treatment options, 142 Electric vacuum aspiration (EVA), 277 Electroconvulsive therapy (ECT), 384 Embryotoxicity assay (ETA), 266 Emergency contraception adverse effects, 55 barriers, 55 copper IUD, 54 mechanism of action, 54 postcoital contraception, 54 Endocervix, 163 Endometrial cancer, 237, 299, 301, 303 Endometrial polyps, 63 Endometrioma, 118, 119, 121 Endometriosis, 92, 94, 95, 97, 101–104 Estrogen, 202–203 Estrogen plus progestin (EPT), 233 Estrogen plus progestin therapy, 239, 240 Estrogen therapy dosing, 241–244 systemic, 240 vaginal, 240 Estrogen-replacement therapy, 224 Exercise triad, 83 Expectant management, 143 Experience-based guidelines, 155, 156 F Female athlete triad, 87 Female sterilization, 49, 54 Flibanserin, 310 Follicle-stimulating hormone (FSH), 43, 61, 254, 256 Forms of abuse, 366 G Gay, 322, 325 Gender dysphoria, 334 Gender identity, 323, 333 Generalized anxiety disorder (GAD), 390–392 Genetic testing, 303–304 Glycosaminoglycan (GAG), 183, 185 Gonadotropin-releasing hormone (GnRH), 65 Gynecologic cancer susceptibility genes, 302 Gynecology, 111 H H2 blockers, 188 Health-seeking behavior, 326 Heavy menstrual bleeding, 60, 63, 65 HEENT, 251 Hematuria, 182 Hemochromatosis, 217 Index Hemorrhagic cyst, 121 early postmenopausal, 117 late postmenopausal, 118 premenopausal, 117 Hereditary Breast and Ovarian Cancer Syndrome (HBOC), 298–299 Hereditary cancer syndromes, 303 Herpes Simplex Virus (HSV), 168 High-grade squamous intraepithelial lesion (HSIL), 157, 159 High-risk HPV (HR HPV) cervical neoplasia, 149 infection, 149 screening tool, 150 sensitivity, 149 strains, 151 tests, 158 “HITS”, domestic violence screening tool, 372 Hormonal disorders, 263 Hormonal methods absolute contraindications, 43–44 clinical judgment, 44 mechanism of action, 42–43 oral contraceptives, 42, 43 pill taking, 44–46 side effects, 44 Hormone replacement therapy (HRT), 22 Human epididymis protein (HE4), 135 Human papillomavirus (HPV), 148, 168, 169 Hydrodistention, 187 Hydrosalpinx, 120 Hypnotics, 389 Hypoactive sexual desire disorder (HSDD), 310 Hypothalamic hypogonadism (HH), 83, 85, 86 419 Hypothalamic-pituitary axis disorders, 255 Hypothyroidism, 254 Hysterectomy, 103–104 Hysterosalpingo-Contrast Sonography (HyCoSy), 257, 258 Hysterosalpingogram (HSG) endometriosis, 257 prophylactic regimen, 256 Hysterosalpingography, 73 I Immunoglobulin, 266 Immunologic mechanisms, 263 Implantable devices, 48–49, 51, 52 In vitro fertilization (IVF), 253 Incontinence, 195, 198, 206–207, 210 Infectious vaginitis, 165–169 Infertility cervical factors, 258 female family, 250 gynecologic history, 248 medical history, 249 menstrual history, 248 obstetrical history, 249 sexual history, 249 social history, 249 surgical history, 249 symptoms, 250 male medical history, 250 medication exposure, 250 sexual history, 250 social history, 251 physical examination, 247–248 uterine factors, 258 women, 247 Insemination, 332 Instillation therapy, 187 420 Index Institute of Medicine (IOM), 323 International Federation of Gynecology and Obstetrics (FIGO), 59 International Ovarian Tumor Analysis (IOTA), 134 Interstitial cystitis, 183–184 Interventional radiology (IR), 105 Intimate partner violence, 365, 366, 368, 375 Intravenous immunoglobulin (IVIg), 267 J Joint Program on the Study of Abortion (JPSA), 287 K Kallmann syndrome, 84 L Lactation, 398, 400, 407 Laparoscopic uterosacral nerve ablation (LUNA), 103 Last menstrual period (LMP), 112 LAST Project, 157, 159 Leiomyomas, 60, 62, 63, 65, 69, 95, 97, 103, 104 Lesbian financial and cultural barriers, 320 health screening exams, 320 menstruation, 328 nursing and medical education, 320 pelvic pain, 327 physical and mental health, 321 sexually transmitted diseases, 328, 329 trepidation, 320 Levonorgestrel-releasing intrauterine system (LNG-IUS), 65 LGBT, 323 Libido, 309, 312 Li-Fraumeni syndrome, 300 Liquid-based cytology, 148, 149, 151 Lithium, 400 Lobular breast cancer syndrome, 301–302 Loop electrosurgical excision procedure (LEEP), 156, 159, 165 Low-grade squamous intraepithelial lesion (LSIL), 157 Luteinizing hormone (LH), 61 Lynch syndrome, 299 M Magnetic resonance imaging (MRI), Major depressive disorder (MDD), 380, 382, 383 Male factor, 250, 252 Mammogram, 26 Mammography, Mandatory reporting, 376–377 Mandatory reporting requirements, 344, 346, 348, 354 Manual vacuum aspiration (MVA), 277 Mastalgia, 29, 30 Mastitis, 29 Maternal carbamazepine, 401 Mayer-Rokitansky-Kuster-­ Hauser (MRKH) syndrome, 74 Medical errors, 346–349 Medical malpractice, 358, 359, 361, 362 Medical management, 143–145 Medical therapy, 187, 188 Index Medroxyprogesterone (PremPro), 22 Memorialization, 356 Menopausal hormone therapy (HT) benefits, 234 estrogen, 232 post-intervention reanalysis, 233 special populations, 235–236 testosterone, 238 WHI trials, 233 Menstruation, 328 Methylenetetrahydrofolate reductase (MTHFR), 264 Microsatellite instability (MSI), 300 Midluteal progesterone, 254 Miscarriages, 262–264, 267 Mismatch repair (MMR), 300 Monilia, 165 Mood disorder BD, 385, 389, 390 MDD, 380, 382, 383 PDD, 385 Mullerian anomalies, 73, 74 Multi-gene testing, 304 Multiple septations, 123 Multivariate index assay, 135 Myofascial disorder (MFD), 104 Myofascial pain disorder, 96 N National Comorbidity Survey Replication (NCS-R), 380 National Comprehensive Cancer Network (NCCN), Natural family planning, 36 Natural killer cell activity/ activation assay (NKa), 266 Needle biopsy, 24, 28, 30 Neoplasia, 170 421 Neoplastic diseases breast, 331 cervical dysplasia, 331 colon, 331 endometrium, 330 ovary, 330 Nipple discharge, 28 Nocturia, 197 Nodule, 124, 125 Nongonococcal nonchlamydial cervicitis (NGNCC), 164 Nongonococcal urethritis (NGU), 165 Non-pharmacologic therapy, 219 Non-pregnant, 112 Non-puerperal breast infection, 29 Non-puerperal mastitis, 30 Nonsteroidal anti-inflammatory drugs (NSAIDs), 65, 275 Norepinephrine dopamine reuptake inhibitor (NDRI), 382 The North American Menopause Society (NAMS), 234–235, 238 Nucleic Acid Amplification Tests (NAAT), 163 Nurses’ Health Study (NHS), 322, 323 Nutrition, 219 O Obesity, 329–332 Obstetric care FTM males, 333 MTFs, 334–335 transsexual individuals, 333 Obstetrician-gynecologists (OBGYN), 272 Office practice risk management, 345–347, 350 422 Index Oral contraceptives (OCP), 46–47, 397 Osteopenia, 214 Osteoporosis exercise, 220 fractures, 217–218 healthcare crisis, 213 nutrition, 219 pharmacologic therapy, 221 porous bones, 213 risk factors, 214 Outflow tract, 72 Outpatient abortion counseling, 273 primary care providers, 272, 273 Ovarian, 112, 113, 115 Ovarian cancer, 133–135, 298, 299, 302 Ovarian remnant syndrome, 97, 104 Ovaries, 76, 78–80 Overactive bladder (OAB), 189, 197, 207–209 Ovulation LH monitoring, 253 menstrual history, 253 Oxford scale, 200 P Pain disorders, 312–314 Painful bladder syndrome (BPS) abdomen/genital tract, 176 abdominal pain, 177 diagnosis and management, 176 diagnostic steps, 182–183 diagnostic testing, 184–186 evaluation, 177 fifth line, 192 First-line therapy, 191 fourth line, 191 IC/BPS, 184 interstitial cystitis, 183–184 PBS/IC, 176 pelvic pain etiologies, 177 pelvic pain XE “Pelvic pain” etiologies, 177 physical examination, 178, 181, 182 second line, 191 sixth line, 192 third line, 191 vagina/vulvar burning, 177 PALB2-associated breast cancer, 301 PALM-COEIN classification system, 59, 60 Panic disorder, 393 Panic disorder, social anxiety disorder, and post-­ traumatic stress disorder (PTSD), 390 Pediculosis, 169–170 Pelvic congestion syndrome, 98, 105 Pelvic examination, 251, 252 Pelvic floor disorders, 98, 100 Pelvic floor dysfunction evaluation, 198–200 mixed incontinence, 197 pelvic organ, 197 prevalence, 195 treatment estrogen, 202–203 exercises, 203–204 fluid and diet management, 201 pelvic organ prolapse, 204–206 SUI, 206–207 timed voiding, 201 urgency, 196 urgency incontinence, 197 urinary incontinence, 195 Pelvic inflammatory disease (PID), 163, 256 Pelvic organ prolapse, 204–206 Pelvic organ prolapse quantification (POP-Q) system, 200, 201 Index Pelvic pain, 139, 140, 175, 176, 181, 182 Pelvic ultrasounds (US) exclusion, 112 inclusion, 112 MAXIMUM size, 113 postmenopausal women, 113 SRU guidelines, 111 Pentosan polysulfate, 187 Perimenopause, 407, 408 Peritoneal inclusion cyst, 121 Persistent depressive disorder (PDD), 385 Pessary, 203–205, 207 Peutz-Jeghers syndrome, 302 Phenylethylamine (PEA), 310 Physical therapy, 105–106 Polycystic ovarian syndrome (PCOS), 76, 255 Positive predictive value (PPV), 150 Postmenopausal ovary, 116 Postpartum anxiety disorders, 406–407 BD, 405 PPD, 404 Postpartum bipolar disorder, 405 Postpartum depression (PPD), 394, 404 Postpartum disorders, 404–407 Postpartum psychosis (PPP), 405 Post-traumatic Stress Disorder (PTSD), 392 Potassium sensitivity test (PST), 185 Practice quality improvement (PQI), 126 Pregnancy anxiety disorders, 403 BD, 400, 402, 403 controlled studies, 398 depression, 398, 399 postpartum, 404–407 psychotic disorders, 403 risk assessment, 397 Preimplantation genetic diagnosis (PGD), 267 423 Premature ovarian failure (POF), 80, 81, 256 Premenstrual dysphoric disorder (PMDD), 394–397 Premenstrual syndrome (PMS), 394 Progesterone, 254 Prolactinomas, 82 Prolapse, 204–206 Prostate-specific antigen (PSA) assay, 335 Psychotherapy, 403 PUF questionnaire, 184, 186 R Radiology, 111, 126, 127 Receptor activator of nuclear factor kappa-B ligand (RANKL), 225 Recurrent pregnancy loss abnormal chromosome, 262 diagnosis, 264–267 miscarriages, 264 treatment, 267, 268 uterine environment, 262–264 Reproductive immunophenotype, 266 Risk factors, 369, 370 Risk management, 345–347 Risk of malignancy algorithm (ROMA), 135 Risk reduction high-risk specialty, 344 litigation prevention, 344 medical malpractice, 343 Roche Cobas test, 149 The Royal College of Obstetricians and Gynecologists (RCOG), 280 S Sacral nerve stimulation (SNS) therapy, 189 Salpingostomy, 142 424 Index Screening, 370–372 Selective estrogen receptor modulators (SERMs), 224 Selective serotonin reuptake inhibitors (SSRI), 382 Self-identification, 326 Semen analysis, 252–253 Sequenced Treatment Alternatives to Relieve Depression (STAR*D), 382 Serial Serum HCG, 140–142 Serotonin norepinephrine reuptake inhibitors (SNRI), 382 Serum biomarkers, 135 Sexual aversion disorder (SAD), 310 Sexual dysfunction, 170, 171 arousal disorder, women, 311 interest, 310 menopausal women, 316, 317 pain, 312–314 pain with orgasm, 315 perimenopausal women, 316, 317 sensation, 312 Sexual minority clinicians, 327 cultural competence, 321–323 health disparities, 323–325 research limitation, 326 Skin patch, 47 Smoking cessation, 220 Social anxiety disorder, 394 Stress incontinence, 196 Stress urinary incontinence (SUI), 206–207 Study of Women’s Health Across the Nation (SWAN), 231–232 Surgical abortion first trimester patient selection, 276 post-procedure follow-up, 278 prevalence, 276 procedure, 277 safety, 278 second trimester analgesia, 287 anesthesia, 287 chemical ripening, 284–286 D&E, 282–284 dilation, 282 injections, 286 peripartum, 282 post-procedure follow-up, 287–288 safety, 288 Surveillance Epidemiology and End Results (SEER), 154 Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) trial, 387 Systemic disease, 173 T Teriparatide, 223–224 Testosterone, 238 Thin-walled cyst postmenopausal, 122–123 premenopausal, 122 Thrombin, 263 Thrombophilias, 264 Thrombophilic, 262, 267 Thyrotropin, 82 Transsphenoidal surgery, 83 Trichomonas vaginalis, 166 Trichomoniasis, 166 Tubal patency, 256–258 Tumor necrosis factor (TNF), 267 Turner syndrome, 76 U Ultrasound mammography, 13 MRI, 17 Index screening, 13 Uterine environment anatomic factors, 262 antinuclear antibodies, 265 antithyroid antibodies, 265 hormonal disorders, 263 immunologic mechanisms, 263 reproductive immunophenotype, 266 V Vaginal ring, 47 Vaginitis, 328, 329 Valproate, 401 Variants of uncertain significance (VUS), 304 Vasomotor symptoms (VMS), 232, 235, 244 Venous thromboembolism (VTE), 236 Vestibulitis, 180 425 Visual analogue scale (VAS), 92 Voiding dysfunction, 209 Vulvar dermatitis, 173 Vulvar disease, 167 Vulvar dystrophy, 170 Vulvar intraepithelial neoplasia (VIN), 167, 170 Vulvar vestibulitis, 171 Vulvodynia, 172, 176 Vulvovaginal symptoms, 232 Vulvovaginitis, 165, 167 W WHO FRAX algorithm, 218 Women’s Health Initiative (WHI), 22, 232, 322, 323 Y Yeast infection, 165 ... disorders in U.S women: 20 10 to 20 50 Obstet Gynecol 20 09;114: 127 8–83 United States Census Bureau [homepage on the Internet] 20 12 National population projections: summary tables Table 2 Projections of... and sex for the United States: 20 15 to 20 60 Available from : http://www census.gov/population/projections/data/national /20 12/ summarytables.html Accessed 27 Mar 20 13 Haylen BT, de Ridder D, Freeman... Urodyn 20 10 ;29 (1):4 20 Stewart WF, Van Rooyen JB, Cundiff GW, Abrams P, Herzog AR, Corey R, et al Prevalence and burden of overactive bladder in the United States World J Urol 20 03 ;20 : 327 –36 13.