A PRIMER IN PRIMARY OB-GYN
Educational Objectives
| The goal of this program is to improve the management of common gynecologic and obstetric conditions. After hearing and
assimilating this program, the clinician will be better able to:
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 | 1. Identify causes of abnormal uterine bleeding.
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| 2. List the differential diagnosis of chronic pelvic pain.
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| 3. Select effective treatment for fibroids.
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| 4. Counsel patients about contraception, vaginal birth after cesarean delivery, and depression.
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| 5. Screen for gestational diabetes and risks for preterm labor.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the
planning committee to disclose relevant financial relationships within the past 12 months that might create any personal
conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes
quality in health care and not a proprietary business or commercial interest. For this program, the faculty and planning
committee reported nothing to disclose.
Acknowledgements
Dr. Paik was recorded in Monterey, CA, at the Women’s Health Conference, presented June 15-19, 2008, by the University
of California, Davis, Health System. Dr. Diaz spoke in Kiawah Island, SC, at An Intensive Review of Family
Medicine, presented June 9-14, 2008, by the Medical University of South Carolina. The Audio-Digest Foundation
thanks the speakers and the sponsors for their cooperation in the production of this program.
| OFFICE GYNECOLOGY FOR PRIMARY CARE PHYSICIANS —Clara K. Paik, MD, Assistant Professor, Department
of Obstetrics and Gynecology, University of California, Davis, School of Medicine, Sacramento
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| Abnormal uterine bleeding: dysfunctional uterine bleeding (DUB)—diagnosis of exclusion; hormonal imbalance;
anovulation results in high levels of estrogen and breakthrough bleeding (BTB; sloughing of uterine lining occurring irregularly
and unpredictably, often causing acute profuse bleeding episodes); long term, increased risk for endometrial hyperplasia
and cancer; progesterone withdrawal bleeding—part of normal menstrual cycle, but abnormal bleeding can
be caused by starting and stopping progesterone-containing medications (eg, oral contraceptives [OCs]); estrogen withdrawal
bleeding—eg, midcycle bleeding with decrease in estrogen near time of ovulation; progesterone BTB—
progesterone-dominant state in patients taking, eg, long-term OCs; thin friable uterine lining prone to more bleeding
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| Etiologies by age: adolescence—anovulatory uterine bleeding; life-threatening bleeding with first menstrual cycle, or
need for blood transfusion may be due to underlying coagulopathy (eg, von Willebrand’s disease); sexually transmitted
diseases; pregnancy; reproductive age—pregnancy-related complications; polycystic ovary syndrome (PCOS); sexually
transmitted infections; polyps and fibroids; malignancy (rare); perimenopause—anovulatory uterine bleeding; hypothyroidism;
fibroids and polyps; endometrial hyperplasia; endometrial cancer; postmenopause—atrophy; starting and
stopping hormone therapy; endocervical and endometrial polyps; gynecologic cancer (particularly endometrial cancer)
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| Work-up: thorough history; pelvic examination; laboratory studies—complete blood cell count; thyrotropin; pregnancy
testing; dependent on risk factors; imaging studies—not absolutely necessary; transvaginal ultrasonography
(TVUS) used to rule out other causes (eg, fibroids); use TVUS in postmenopausal women with endometrial thickness ≤4
mm to rule out endometrial cancer; saline infusion sonography can distinguish between endometrial polyps and submucosal
fibroids; magnetic resonance imaging (MRI) used (not routinely) for fibroid localization; other studies—
endometrial biopsy; dilation and curettage; hysteroscopy
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| Medical management: nonsteroidal anti-inflammatory drugs (NSAIDs)—useful in women with subjective or idiopathic
menorrhagia; give for first 3 days of menses or throughout bleeding episode; in woman with irregular bleeding,
“probably not best option”; estrogens—when used alone, useful for acute bleeding (rapidly regenerates endometrium);
intravenous (IV) or oral conjugated estrogens (Premarin) should work within first 24 hr; after bleeding stabilizes, patient
needs progesterone withdrawal; progestin therapy—stabilizes endometrium; woman can have cyclic withdrawal; not as
effective for acute bleeding as estrogen; levonorgestrel-releasing intrauterine system (Mirena) and medroxyprogesterone
(eg, Depo–Provera)—in woman with thickened lining, consider withdrawal cycles to thin lining before starting;
OCs—treatment of choice; endometrial lining becomes thin; monophasic OC effective; for acute bleeding, double dose
for 5 to 7 days; inform patients that efficacy takes several months
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| Surgical management: hysterectomy last resort for women in whom medical management fails
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| Differential diagnosis of chronic pelvic pain: irritable bowel syndrome (IBS)—Manning criteria include
chronic abdominal pain for ≥3 mo with ≥2 associated symptoms (eg, pain relieved by defecation, loose stools, abdominal
distention); perform work-up in women at risk for colon cancer or inflammatory bowel disease; interstitial cystitis—
characterized by urgency, frequency, bladder pain, and nocturia; evaluation begins with voiding diary or pelvic pain and
urinary frequency questionnaire; urinalysis to rule out urinary tract infection (UTI); potassium sensitivity test (painful);
cystoscopy under anesthesia (gold standard) shows decreased bladder capacity, characteristic glomerulations (petechiae
and fissures), and Hunter’s ulcers (in late disease); depression and history of abuse (particularly sexual abuse)—
screen by asking, “over the past 2 wk, have you felt down, depressed, or hopeless, or felt little interest or pleasure in doing
things?”; myofascial trigger points—areas of hyperirritability in muscle or fascia; injecting points with local anesthetic
results in immediate relief (diagnostic and therapeutic); fibromyalgia—pain in pelvis and other parts of body,
with tender points; abnormal pain processing disorder; endometriosis—most common cause of gynecologically related
chronic pelvic pain; other gynecologic causes—adenomyosis (growth of endometrial glands in muscle of uterus); history
of or chronic pelvic inflammatory disease (PID; empiric therapy with antibiotics may be helpful); adhesions (adhesiolysis
not better than expectant management in long term); pelvic congestion syndrome (controversial diagnosis; work up
for other causes)
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| Work-up of chronic pelvic pain: ask about symptoms of depression, sexual abuse, and bowel and bladder symptoms;
physical examination—thorough abdominal examination; pain related to old surgical sites; look for hernias and trigger
points; pelvic examination (palpate levator ani muscles for spasm and tenderness [amenable to physical therapy]); laboratory
studies dependent on differential diagnosis; pelvic US helpful; MRI useful in women with suspected adenomyosis or
endometriosis; laparoscopy may miss microscopic endometriosis; diagnosis of endometriosis difficult (normal-appearing
peritoneum can have implants); pain not dependent on severity of disease; risks associated with laparoscopy
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| Medical management of endometriosis-related pelvic pain: start with NSAIDs, OCs, or high-dose progestins
for 3 mo; gonadotropin-releasing hormone (GnRH) agonists—eg, leuprolide (eg, Lupron Depot), danazol; effective
for pain relief; good evidence for empiric therapy
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| Fibroids: common; usually small and asymptomatic but can cause heavy menses; intermenstrual bleeding or heavy irregular
bleeding uncommon and should be worked up; important to distinguish anovulatory cycles from bleeding caused by
fibroids alone; pelvic pressure, degeneration, and torsion can lead to acute pain; usually self-limited; pregnancy—
myomectomy not indicated to prevent complications unless woman has poor obstetric history due to fibroids;
infertility—usually associated with large submucosal fibroids or fibroids that distort cavity; full infertility evaluation
recommended; diagnosis—by examination; US; imaging not necessary but useful if large pelvic or adnexal mass suspected;
TVUS most common diagnostic tool; saline infusion sonography shows endometrial cavity and can distinguish
submucosal fibroids from polyps and intramural fibroids; hysterosalpingography useful for women undergoing infertility
evaluation; MRI useful in women with large fibroids and can distinguish fibroids from adenomyosis and adenomyomas;
cancer—benign fibroids do not progress to sarcomas; even in setting of rapidly enlarging uterus, incidence of sarcoma
low
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| Treatment of fibroids: OCs may be helpful for irregular bleeding and concomitant anovulatory bleeding; in woman
with menorrhagia, starting continuous OCs can help eliminate heavy bleeding; NSAIDs useful in idiopathic menorrhagia,
but not as useful in menorrhagia related to fibroids; GnRH agonists helpful in inducing amenorrhea and can shrink uterus
(maximum shrinkage occurs at 3 mo), but symptoms reappear within 1 mo of stopping therapy (useful preoperatively to
enable smaller incisions and poor surgical candidates); levonorgestrel-releasing intrauterine system can be useful in
women with abnormal uterine bleeding related to fibroids, but may be contraindicated if endometrial cavity distorted;
surgery—mainstay of therapy; important to treat abnormal bleeding not due to fibroids with hormonal management first;
hysterectomy eliminates chance of recurrence; prophylactic hysterectomy not necessary; myomectomy procedure of
choice for women who desire future childbearing (disadvantages include high recurrence rate at 5 yr and possible need for
second surgery); uterine artery embolization minimally invasive and shrinks uterine volume by 50% (women who have
large or pedunculated fibroids or submucosal fibroids may not be treated as effectively)
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| OB UPDATE —Vanessa A. Diaz, MD, Assistant Professor, Department of Family Medicine, Medical University of South
Carolina, Charleston
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| Contraception: Depo-Provera—after discontinuation, average time to return to fertility 12 to 18 mo; emergency
contraception—establish time of intercourse (most effective when taken within 72 hr); contraindicated in pregnancy
(perform pregnancy test); 1 dose taken within 72 hr after coitus, followed by second dose 12 hr later; levonorgestrel (Plan
B; 0.75 mg) causes less nausea and vomiting than OCs or estrogen-containing pills; 85% effective; OCs (2-4 pills, depending
on dose); available “behind-the-counter” (without prescription) to women and men ≥18 yr of age (available with
prescription if <18 yr of age); other options—intrauterine device (IUD) inserted within 5 to 7 days after coitus; mifepristone
effective when used ≤5 days after coitus; one dose of levonorgestrel (1.5 mg) within 3 days
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| Nutrition: encourage normal body mass index (BMI) before pregnancy; pregnant women need additional 300 calories/
day (woman of normal weight should gain ≈25 lb); folic acid (400 mg) most effective when started ≥3 mo before conception;
iron supplementation recommended; caffeine—<200 mg/day or 1 to 2 cups of coffee/day
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| Domestic abuse: often begins or escalates during pregnancy; affects ≤20% of pregnant women; risk factors include age
<20 yr, black ethnicity, and late or no prenatal care
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| Psychosocial screening: ask, “do you have problems keeping appointments?”; ask about transportation, safety, food
supply, substance abuse, alcohol use, tobacco use, stress, and timing of pregnancy
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| Immunizations: preconception screening for hepatitis B and rubella; women should wait >1 mo after receiving live vaccines
to conceive; avoid live attenuated vaccines; if exposure occurs, immune globulin may be given; influenza—
vaccine recommended in any trimester; do not use intranasal (live) vaccine; if pregnant woman develops influenza, antiviral
medications not recommended; postpartum period—give diphtheria and tetanus toxoids, combined vaccine (Td) if
woman immunized >10 yr earlier; tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis, adsorbed (Tdap)
vaccine recommended for pregnant adolescents (give ≤5 yr after Td )
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| Previous births: vaginal birth after cesarean delivery (VBAC)—overall success rate, 73%; in women with spontaneous
labor, risk for uterine rupture <1.0%; if woman needs induction and had previous vaginal delivery, risk <1.0% (1.5%
if no previous vaginal delivery); with successful trial of labor, risk for rupture low (if woman failed trial of labor, ie, required
cesarean delivery, risk for uterine rupture 2.3%); according to American College of Obstetricians and Gynecologists
(ACOG), VBAC safest in women with one previous low transverse cesarean delivery, adequate pelvis, no history of
additional uterine surgeries, and with availability of physician and anesthesiologist to perform immediate emergency cesarean
delivery, if necessary; women who had >1 cesarean delivery, may undergo trial of labor if they had ≥1 previous
vaginal delivery; VBAC not recommended for women with 2 previous births both by cesarean deliveries; informed consent
essential
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| Genital herpes: ACOG recommendations—treat primary infections with antiviral therapy as soon as possible; cesarean
delivery if active lesions present to prevent neonatal herpes; consider antiviral therapy starting at 36 wk (concerns
about asymptomatic shedding of virus); for recurrent episodes, daily suppressive therapy (use higher doses of valacyclovir
with greater number of recurrences)
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| Depression: 43% of women with history of depression relapse during pregnancy (risk higher if patient being treated and
medication discontinued); adverse effects of depression include low birth weight and developmental delays; selective serotonin
reuptake inhibitors (SSRIs)—concerns about persistent pulmonary hypertension of newborn with use during
third trimester (6-fold increase in risk if used after 20 wk gestation); concerns about poor neonatal adaptation (eg, feeding
problems, respiratory distress, jitteriness), low birth weight, preterm birth, and neonatal seizures; in 2005, FDA warned
that use of paroxetine during first trimester increases risk for birth defects (recent studies show sertraline associated with
similar risks); risks associated with citalopram unclear; management—weigh risks of medications against risk for relapse;
avoid medications during first trimester; consider bupropion (more safety data than SSRIs); if using SSRI, use fluoxetine
(eg, Prozac)
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| Prenatal visits: 10 wk—fetal heart tones audible (cardiac activity seen earlier with US); 11 to 14 wk—consider first
trimester screening; 16 to 18 wk—triple or quadruple screening; 28 wk—give RhO (D) immune globulin (RhO [D]
IGIM; eg, RhoGAM] if mother Rh negative; 1-hr glucose tolerance testing; recheck hemoglobin and hematocrit; in high-
risk patients, retest for syphilis; 35 to 37 wk—check for group B streptococci; repeat gonorrhea and Chlamydia testing
in high-risk patients; 41 wk—discuss induction
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| Gestational diabetes: 2-step approach recommended; 1-hr glucose tolerance test generally performed at 28 wk, but
performed earlier if patient has risk factors (eg, obesity, personal history of gestational diabetes, glucosuria); if negative,
repeat at 24 to 28 wk; if positive, proceed with 3-hr test; with 1-hr test (50-g oral glucose load), using cut-off of
130 mg/dL identifies 90% of women with gestational diabetes; with 3-hr test (100-g oral glucose load) use conservative
cutoffs (fasting, 95 g/dL; 1 hr, 180 mg/dL; 2 hr, 155 mg/dL; 3 hr, 140 mg/dL)
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| Preterm labor: <34 wk; occurs in ≈10% of pregnancies; can be due to, eg, group B streptococci, bacterial vaginosis, incompetent
cervix, fundal abnormalities, fetal anomalies, or maternal factors (eg, thermal injury, autoimmune disease, hypertension);
no effective screening method for primiparous women; for multiparous women, if fetal fibronectin negative,
risk for delivery within next 7 days low (positive results not as helpful); look at cervical length with TVUS probe (<30
mm indicates higher risk for early delivery); Bishop scoring—assess position, consistency, effacement, and dilatation of
cervix and station of head; score >7 higher likelihood of early delivery; treatment—tocolysis not effective long term;
steroids at <34 wk gestation (multiple doses may be harmful); consider antibiotics for rupture of membranes
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| Preeclampsia: mild—generally does not require medication, just monitoring; bed rest; severe—address immediately;
hospitalization; medications (eg, magnesium, hydralazine)
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| Postdate pregnancy: higher perinatal mortality at 42 wk; potential complications (eg, oligohydramnios, perinatal hypoxia,
death); induction in wk 41; >41 wk, perform biweekly nonstress test or biophysical profile to assess fetal well-being
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| Postpartum depression: consider if “baby blues” not resolved by tenth day; have high index of suspicion; use Edinburgh
Postnatal Depression Scale (10 questions scored from 0 to 3; score >10 red flag; score >12, sensitivity 100%, specificity
95.5%); all psychotropic medications excreted in breast milk; SSRIs recommended for breast-feeding women
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| Other common conditions: morning sickness—advise small frequent meals; many medications available;
heartburn—H2 -receptor antagonists and proton pump inhibitors class B drugs; constipation—start with high volume
of fluids; do not use stimulant laxatives; hemorrhoids—use conservative treatment; usually regress after pregnancy;
pain—acetaminophen (eg, Tylenol) and narcotics most commonly used; aspirin and NSAIDs not recommended;
UTIs—first-line therapy usually ampicillin or nitrofurantoin
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| Complications and future health risks: gestational diabetes—perform oral glucose tolerance test 6 to 8 wk after
pregnancy and repeat every 3 yr; preeclampsia—increases risk for cardiovascular disease and cerebrovascular accidents
(higher risk if preeclampsia led to preterm delivery); thrombophilia—risk doubles during pregnancy (increases 7- to 10-
fold in postpartum); when traveling, advise new mothers to stop every 15 min to walk; test to identify hereditary thrombophilia
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Suggested Reading
Agdi M et al: Endoscopic management of uterine fibroids. Bes Pract Res Clin Obstet Gynaecol 22:707, 2008; Apgar
BS et al: Treatment of menorrhagia. Am Fam Physician 75:1813, 2007; Chen BH et al: Dysfunctional uterine bleeding.
West J Med 169:280, 1998; Crosignani PG et al: Levonorgestrel-releasing intrauterine device versus hysteroscopic
endometrial resection in the treatment of dysfunctional uterine bleeding. Obstet Gynecol 90:257, 1997; Deave T
et al: The impact of maternal depression in pregnancy on early child development. BJOG 115:1043, 2008; Dick ML:
Chronic pelvic pain in women: assessment and management. Aust Fam Physician 33:971, 2004; Harper LM et al: Predicting
success and reducing the risks when attempting vaginal birth after cesarean. Obstet Gynecol Surv 63:538, 2008;
Hirst A et al: A multi-centre retrospective cohort study comparing the efficacy, safety and cost-effectiveness of hysterectomy
and uterine artery embolisation for the treatment of symptomatic uterine fibroids. The HOPEFUL study. Health
Technol Assess 12:1, 2008; Lethaby AE et al: Progesterone or progestogen-releasing intrauterine systems for heavy
menstrual bleeding. Cochrane Database Syst Rev:CD002126, 2005; Meadows E: Treatments for patients with pelvic
pain. Urol Nurs 19:33, 1999; Morgan MA et al: Obstetrician-gynecologists' screening and management of preterm
birth. Obstet Gynecol 112:35, 2008; Nemeroff CB: Understanding the pathophysiology of postpartum depression: implications
for the development of novel treatments. Neuron 59:185, 2008; Ortiz DD: Chronic pelvic pain in women. Am
Fam Physician 77:1535, 2008; Phaloprakarn C et al: Use of oral glucose tolerance test in early pregnancy to predict
late-onset gestational diabetes mellitus in high-risk women. J Obstet Gynaecol Res 34:331, 2008.
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