Gynecology Approaches

Pelvic Pain

Case:
A 30-year-old woman presents with lower abdominal pain for the past three months.

Approach to Pelvic Pain

1. History

Chief Complaint (CC)

History of Present Illness (HPI)

- Onset and Duration: When did the pain start? Is it acute or chronic?
- Location and Radiation: Where is the pain located? Does it radiate to the back, thighs, or other areas?
- Character and Severity: Is the pain sharp, dull, crampy, or constant? Rate the severity on a scale of 1–10.
- Timing and Cyclicity: Is the pain related to menstruation, ovulation, or intercourse?
- Aggravating/Relieving Factors: Does anything worsen (e.g., movement, menstruation) or relieve (e.g., lying down, medications) the pain?
- Associated Symptoms:
• Gynecological: Dysmenorrhea, dyspareunia, abnormal uterine bleeding, or vaginal discharge.
• Urinary: Dysuria, frequency, urgency, or hematuria.
• Gastrointestinal: Constipation, diarrhea, bloating, or rectal pain.

Gynecological History
1. Menstrual History: LMP, Age at menarche, cycle regularity, frequency, duration, amount of blood, dysmenorrhea, intermenestrual bleeding.
2. Obstetric History: Number of pregnancies, outcomes, and complications.
3. Contraceptive History: Current or past contraceptive use.
4. Sexual History: History of dyspareunia, sexually transmitted infections (STIs), or high-risk sexual behavior.
5. Pap smear

Past Medical History (PMH)

Chronic conditions: IBS, recurrent UTIs, or musculoskeletal issues.
History of pelvic infections or abdominal trauma.

Past Surgical History (PSH)

Abdominal or pelvic surgeries (e.g., appendectomy, cystectomy).

Family History
Endometriosis, gynecological cancers, or autoimmune disorders.

Drug History

Allergy History

Social History
- Lifestyle: Smoking, alcohol, or drug use.
- Occupation: Stress levels, physical strain, or sedentary work.
- Mental Health: Anxiety, depression, or impact of chronic pain.

2. Physical Examination

Vital Signs
Look for fever, tachycardia, or hypotension (signs of infection or acute abdomen).

General Appearance

Chest Examination

Abdominal Examination
- Inspection: Scars, distension, or masses.
- Palpation: Tenderness (localized or diffuse), guarding, or rebound tenderness, masses.
- Percussion: Tympany or dullness.
- Auscultation: Bowel sounds (absent in obstruction or peritonitis).

Pelvic Examination
- Inspection: Look for external genital abnormalities or discharge.
- Sterile Speculum Examination: Assess for cervical discharge, lesions, or prolapse.
- PV Examination: Check for cervical motion tenderness (CMT), adnexal masses, or uterine tenderness.
- Rectovaginal Examination (if indicated): Evaluate for rectal masses, nodularity, or tenderness.
3. Investigations and Tests

Laboratory Tests:
Beta-hCG: Rule out pregnancy or ectopic pregnancy.
Complete Blood Count (CBC)
Inflammatory markers: ESR, CRP
Urinalysis and Culture: Rule out UTI pr hematuria from stones
Cervical and vaginal swabs (NAAT, culture): detect STDs

Imaging Studies:
- Pelvic Ultrasound (Transabdominal/Transvaginal): Evaluate for ectopic pregnancy, ovarian cysts, fibroids, or adnexal masses

Specialized Tests:
- Laparoscopy: Diagnostic for endometriosis or chronic pelvic pain of unknown cause.
- Colonoscopy: If gastrointestinal causes are suspected.

4. Differential Diagnosis
1. Acute Pelvic Pain
Gynecological Causes:
1. Ectopic Pregnancy – Ruptured or unruptured.
2. Ovarian Torsion – Acute onset, severe unilateral pain.
3. Ruptured Ovarian Cyst – Sudden onset, sharp pain.
4. Pelvic Inflammatory Disease (PID) – Lower abdominal pain, fever, cervical motion tenderness.
Urinary Causes:
1. Urinary Tract Infection (UTI) – Dysuria, frequency, suprapubic pain.
2. Ureteral Stones – Flank pain radiating to the groin.
Gastrointestinal Causes:
1. Appendicitis – Periumbilical pain shifting to RLQ.
2. Diverticulitis – LLQ pain, fever, and bowel changes.
3. Bowel Obstruction – Colicky pain, distension, vomiting.
4. Perforated Viscus – Severe pain with peritoneal signs.

2. Chronic Pelvic Pain

Gynecological Causes:
1. Endometriosis – Cyclical or continuous pain, dyspareunia, infertility.
2. Adenomyosis – Heavy, painful menses with chronic pelvic discomfort.
3. Pelvic Adhesions – Post-surgical or post-infectious.
4. Chronic PID – Recurrent lower abdominal pain.
5. Uterine Fibroids – Pressure symptoms or dysmenorrhea.
6. Primary dysmenorrhea
Urinary Causes:
1. Interstitial Cystitis – Bladder pain syndrome, worsens with filling.
2. Recurrent UTIs – Persistent or recurrent infections.
Gastrointestinal Causes:
1. Irritable Bowel Syndrome (IBS) – Pain associated with bowel habits.
2. Inflammatory Bowel Disease (IBD) – Chronic diarrhea with abdominal pain.

5. Management

1. Acute Management:
Pain Control: NSAIDs or acetaminophen, Opioids for severe cases (short term).
Treat Underlying Cause:
• Antibiotics for PID.
• Surgery for ovarian torsion or ruptured ectopic pregnancy.

2. Chronic Management:
Lifestyle Modifications: Regular exercise, weight loss, and stress reduction.
Hormonal Therapy:Combined oral contraceptives or GnRH agonists for endometriosis.
 Urinary Incontenence
Case:
A 55-year-old female presents with a complaint of leaking urine when she coughs or sneezes, which has been ongoing for six months.

Approach to Urinary Incontinence

1. History

Chief Complaint (CC)

History of Present Illness (HPI)

- Symptom Onset: When did the symptoms start?
- Duration and Progression: How long has it been happening? Is it getting worse over time?
- Pattern of Leakage: Is it continuous or intermittent?
- Triggers: Does it happen during specific activities (e.g., coughing, sneezing, laughing, exercising)?
- Volume of Leakage: Small drops or larger amounts?
- Frequency of Incontinence: How many times a day/week does it occur?
- Nocturnal Symptoms: Any nighttime incontinence or frequent waking to urinate?
- Other Urinary Symptoms: Dysuria, urgency, frequency, hesitancy, hematuria, incomplete voiding.
- Associated Symptoms: Pelvic pressure, vaginal bulge, recurrent urinary tract infections (UTIs).

Gynecological History
1. Menstrual History: LMP, Age at menarche, cycle regularity, frequency, duration, amount of blood, dysmenorrhea, intermenestrual
bleeding.
2. Obstetric History: Number of pregnancies, outcomes, and complications.
3. Contraceptive History: Current or past contraceptive use.
4. Sexual History: History of dyspareunia, sexually transmitted infections (STIs), or high-risk sexual behavior.
5. Pap smear

Past Medical History (PMH)

- Diabetes (may cause neuropathy).
- Neurological disorders (e.g., multiple sclerosis, Parkinson’s disease, stroke).
- Previous pelvic trauma or radiation.

Past Surgical History (PSH)

- Abdominal, pelvic, or urological surgeries.
- Spinal surgeries or injuries.

Family History
- Family history of urinary incontinence or pelvic floor disorders.
- Genetic conditions affecting connective tissue (e.g., Ehlers-Danlos syndrome).

Drug History
- Medications currently taking, including:
• Diuretics (may worsen frequency).
• Alpha-blockers, anticholinergics, or sedatives.

Allergy History

Social History

2. Physical Examination

Vital Signs

General Appearance:
Observe for signs of chronic illness, obesity.

Chest Exam

Abdominal Exam:
Check for bladder distention or tenderness, should rule out masses, ascites, and organomegaly, which
can influence intra-abdominal pressure.

Pelvic Exam:
- Sterile Soeculum examination: Assess for pelvic organ prolapse, evaluate for inflammation, infection, and atrophy, which can
increase bladder sensitivity and lead to urgency, frequency, and dysuria.
- PV examination: Evaluate uterine or adnexal masses.
- Stress test: Ask the patient to cough or bear down to observe for urine leakage.

Another tests
- Assess pudendal nerve innervation of the perineum with the bulbocavernosus and clitoral sacral reflex
- Perform Q-tip test to assess for hypermobility of the urethrovesical junction.
3. Investigations and Tests

- Urine Analysis and Culture: Rule out UTI and hematuria

- Post-Void Residual (PVR): Assess bladder emptying.
- Urodynamic Testing To evaluate bladder function
Tests Involved:
Cystometry: Measures bladder pressure and capacity.
Uroflowmetry: Measures the rate of urine flow.
Pressure Flow Study: Assesses the relationship between bladder pressure and urine flow, helpful in diagnosing obstruction or detrusor
underactivity.
- Pelvic Ultrasound, CT or MRI: Evaluate for masses or structural abnormalities.

4. Differential Diagnosis

1. Stress Incontinence: Involuntary leakage of urine due to increased intra-abdominal pressure (e.g., coughing, sneezing, laughing, or
physical exertion).
Causes:
- Urethral sphincter dysfunction (weakness or damage to the sphincter)
- Pelvic floor muscle weakness (e.g., after childbirth, aging, or surgery)
- Obesity (increased abdominal pressure)
- Pelvic Organ Prolapse due to altered pelvic anatomy.

2. Urge Incontinence: A strong, sudden urge to urinate followed by involuntary leakage, often due to overactive bladder muscle
contractions.
Causes:
- Detrusor overactivity (bladder muscle spasms)
- Neurological disorders: (Multiple sclerosis, Parkinson’s disease, Stroke, Spinal cord injury)
- Urinary tract infections (UTI) (irritation of bladder)
- Bladder tumors
- Bladder stones

3. Overflow Incontinence: Involuntary leakage of urine from an overfilled bladder, typically when the bladder cannot empty completely.
Causes:
- Bladder outlet obstruction (e.g., benign prostatic hyperplasia [BPH], pelvic organ prolapse, urethral stricture)
- Neurogenic bladder (e.g., diabetic neuropathy, spinal cord injury, multiple sclerosis)
- Detrusor underactivity (bladder muscle weakness)
- Medications (e.g., anticholinergics, alpha-adrenergic agents), Diuretics May increase urinary output, leading to overflow incontinence.

4. Functional Incontinence: Incontinence due to physical or cognitive impairment that prevents the person from reaching the toilet in time.
Causes:
- Physical disabilities (e.g., arthritis, musculoskeletal disorders)
- Cognitive disorders (e.g., dementia, Alzheimer’s disease)
- Sedatives, hypnotics, and narcotics: Can impair bladder control or lead to functional incontinence.
- Severe depression
- Severe obesity

5. Mixed Incontinence: A combination of stress and urge incontinence.

6. Fistulas (e.g., vesicovaginal fistula): Can cause continuous urinary leakage.

5. Management

- Conservative:
Pelvic floor muscle exercises (Kegels).
Bladder training and scheduled voiding.
Weight loss if overweight.
Avoid triggers like caffeine and alcohol.
- Pharmacological:
• Anticholinergics or beta-3 agonists for urge incontinence.
• Topical estrogen for postmenopausal vaginal atrophy.
- Surgical
 Vaginal Discharge

Case:
A 32-year-old sexually active woman presents with complaints of vaginal discharge for the past 3 weeks.

Approach to Vaginal Discharge

1. History

Chief Complaint (CC)

History of Present Illness (HPI)

- Onset: When did it start?
- Duration: How long has it been ongoing?
- Character: Describe the discharge (color, consistency, odor, amount).
- Associated Symptoms: Any itching, burning, dyspareunia, pelvic pain, fever, or dysuria?
- Cycle Relationship: Is it related to menstruation or ovulation?
- Sexual History: Recent new partners? Use of contraception? Protection methods? History of STIs?
- Triggering Factors: Recent antibiotics, douching, scented hygiene products?

Gynecological History
1. Menstrual History: LMP, Age at menarche, cycle regularity, frequency, duration, amount of blood, dysmenorrhea, intermenestrual bleeding.
2. Obstetric History: Number of pregnancies, outcomes, and complications.
3. Contraceptive History: Current or past contraceptive use.
4. Sexual History: History of dyspareunia, sexually transmitted infections (STIs), or high-risk sexual behavior.
5. Pap smear

Past Medical History (PMH)

Previous episodes of abnormal discharge or infections?
History of diabetes, immunosuppression?

Past Surgical History (PSH)

Family History

Drug History
Use of hormonal contraception? Recent antibiotics or steroids?

Allergy History

Social History
- Smoking, alcohol use, or substance use?
- Hygiene practices (douching, use of tampons)?

2. Physical Examination

1. Vital Signs:

2. General Appearance:

3. Abdominal Examination:
- Inspect for scars, distension.
- Palpate for tenderness or masses (especially in the lower abdomen).

4. Pelvic Examination:
a. Speculum Examination:
- Inspect vaginal walls and cervix.
- Note the characteristics of the discharge: color, odor, and amount.
- Look for erythema, lesions, or cervical motion tenderness.
- Check for foreign bodies or retained products.

b. Bimanual Examination (PV):

- Assess for adnexal masses, tenderness, or cervical motion tenderness.
3. Investigations

- Vaginal pH testing.
- Whiff test (amine odor test with KOH).
- Wet mount microscopy to look for:
• Clue cells (bacterial vaginosis).
• Hyphae or pseudohyphae (candidiasis).
• Motile trichomonads (trichomoniasis).
- High vaginal and endocervical swabs for culture, Nucleic acid amplification tests (NAAT) for Chlamydia and Gonorrhea.
- Pelvic ultrasound (to evaluate for abscess, cysts, or mass).

4. Differential Diagnosis

5. Management

Specific Treatment Based on Cause:

- Bacterial Vaginosis: Oral or vaginal metronidazole or clindamycin.
- Candidiasis: Vaginal antifungals (e.g., clotrimazole) or oral fluconazole.
- Trichomoniasis: Oral metronidazole (treat sexual partners).
- Chlamydia: Azithromycin or doxycycline.
- Gonorrhea: Ceftriaxone + doxycycline or azithromycin.
- Foreign Body: Remove the foreign body and treat secondary infections if present.
- Atrophic Vaginitis: Vaginal estrogen therapy.
 Primary Amenorrhea

Case:
A 16-year-old female presents to the clinic with the complaint of no onset of menstruation despite normal breast development. She
reports normal growth in childhood and no significant medical issues. She is concerned because her peers have started their
periods.

Approach to Primary Amenorrhea

History Taking
1. Chief Complaint (CC)

2. History of Present Illness (HPI)

- Age of onset of secondary sexual characteristics (e.g., breast development, pubic hair).
- Growth pattern (normal, delayed, or accelerated).
- Associated symptoms: cyclic abdominal pain, fatigue, or galactorrhea.
- Stress, diet, or recent weight changes.

3. Gynecological History
Vaginal discharge or symptoms of obstruction (e.g., cyclic pain).
Sexual activity or contraceptive use.
4. Past Medical History (PMH)

5. Past Surgical History (PSH)

6. Family History
History of delayed puberty, amenorrhea, or genetic disorders (e.g., Turner syndrome, androgen insensitivity syndrome).

7. Drug History

8. Allergy History

9. Social History

Physical Examination
1. Vital Signs

2. General Appearance
- Tanner staging of secondary sexual characteristics.
- Signs of Turner syndrome (short stature, webbed neck).

3. Chest Exam
Are breasts present or absent?

4. Abdominal Exam
Assess for mass (e.g., hematometra in obstructive causes).

5. Pelvic Exam:
Evaluate for presence of vagina and cervix.
Look for imperforate hymen or vaginal septum.

Characteristic Features of Turner Syndrome:

- Short stature
- Webbed neck
- Low posterior hairline.
- Low-set ears.
- Broad chest with widely spaced nipples.
- Small jaw (micrognathia).
- Short fourth metacarpals.
- Cubitus valgus (increased carrying angle of the arms).
- Coarctation of the aorta.
- Bicuspid aortic valve.
- Horseshoe kidney.
- Streak gonads (primary amenorrhea, infertility)
Investigations and Tests

- Pelvic ultrasound: Assess uterus, ovaries, and any obstructive lesions. (is uterus present or absent?)
- FSH, LH: To assess ovarian function.
- Estradiol: To evaluate estrogen production.
- Prolactin: Rule out hyperprolactinemia.
- TSH: Rule out hypothyroidism.
- Karyotype: Check for Turner syndrome or other chromosomal abnormalities.
- MRI: If structural abnormalities or hypothalamic-pituitary axis issues are suspected.

Differential Diagnosis (DD)

1. Gonadal Dysgenesis (e.g., Turner Syndrome)

2. Müllerian Agenesis (Mayer-Rokitansky-Küster-Hauser syndrome)
3. Androgen Insensitivity Syndrome
4. Hypothalamic Axis failure (e.g., stress, weight loss, Kallman Syndrome)
5. Transverse Vaginal Septum
6. Imperforate Hymen

Management

- Turner Syndrome: Growth hormone and estrogen and progesterone replacement therapy.
- Müllerian Agenesis: Vaginal dilators or surgical intervention if needed.
- Androgen Insensetivity Syndrome: Removal of testes, estrogen replacement therapy
- Hypothalamic Axis failure: Address underlying stress or nutritional issues.
- Kallman Syndrome: estrogen and progesterone replacement therapy
- Obstructive Causes: Surgical correction (e.g., hymenectomy).
 Secondary Amenorrhea

Case:
A 28-year-old female presents with a complaint of no menstrual periods for 6 months. She previously had regular cycles.

Approach to Secondary Amenorrhea

History Taking
1. Chief Complaint (CC)

2. History of Present Illness (HPI)

- Onset and duration of amenorrhea.
- Prior menstrual cycle characteristics (regularity, flow, duration).
- Associated symptoms:
• Hot flashes or vaginal dryness (suggesting low estrogen).
• Galactorrhea (suggesting hyperprolactinemia).
• Stress, weight loss, or excessive exercise.
• Symptoms of hypothyroidism (e.g., fatigue, weight gain) or hyperthyroidism (e.g., weight loss, palpitations).

Gynecological History
1. Menstrual History: LMP, Age at menarche, cycle regularity, frequency, duration, amount of blood, dysmenorrhea, intermenestrual bleeding.
2. Obstetric History: Number of pregnancies, outcomes, and complications.
3. Contraceptive History: Current or past contraceptive use.
4. Sexual History: History of dyspareunia, sexually transmitted infections (STIs), or high-risk sexual behavior.
5. Pap smear

4. Past Medical History (PMH)

5. Past Surgical History (PSH)

Pelvic or abdominal surgeries (e.g., uterine surgeries, C-section).

6. Family History
Early menopause or other reproductive disorders in family members.

7. Drug History

8. Allergy History

9. Social History

Physical Examination
1. Vital Signs

2. General Appearance

3. Chest Exam

4. Abdominal Exam

5. Pelvic Exam
- Sterile speculum examination
- PV examination

Investigations

- hCG: Rule out pregnancy (always first).

- TSH, Free T4: Screen for thyroid dysfunction.
- Prolactin: Check for hyperprolactinemia.
- Progesterone Challenge Test (PCT)
- Estrogen–Progesterone Challenge Test (EPCT).
- FSH, LH: Evaluate ovarian function.
- Estradiol: Assess estrogen levels.
- Serum testosterone and DHEAS: If signs of hyperandrogenism (e.g., hirsutism).
- Pelvic ultrasound: Evaluate for PCOS, endometrial thickness, or structural abnormalities.
- hysterosalpingogram (HSG)
- MRI of the pituitary: If prolactin levels are elevated or other pituitary dysfunction is suspected.
Differential Diagnosis
1. Pregnancy (most common cause).
2. Hypothalamic dysfunction: Stress, excessive exercise, or eating disorders.
3. Hyperprolactinemia: Prolactinoma or medication-induced.
4. Thyroid dysfunction: Hypothyroidism or hyperthyroidism.
5. Polycystic Ovary Syndrome (PCOS).
6. Premature Ovarian Insufficiency (POI).
7. Asherman’s Syndrome: Uterine scarring post-surgery or infection.
8. outflow tract obstruction

Management

- Pregnancy: Provide antenatal care.

- Hypothalamic Causes: Nutritional counseling, psychotherapy for eating disorders.
- Hyperprolactinemia: Dopamine agonists (e.g., bromocriptine, cabergoline), depend on cause.
- Thyroid Dysfunction: Treat hypothyroidism or hyperthyroidism.
- PCOS: Lifestyle changes, oral contraceptives for menstrual regulation, metformin if insulin resistance is present.
- Premature Ovarian Insufficiency: Hormone replacement therapy (HRT) for symptom relief and bone protection.
- Asherman’s Syndrome: Hysteroscopic adhesiolysis.
 Abnormal Vaginal Bleeding

Case:
A 42-year-old female presents to the clinic with complaints of abnormal vaginal bleeding for the past three months.
Approach to Abnormal Vaginal Bleeding

History
1. Chief Complaint (CC)

2. History of Present Illness (HPI)

- Onset: When did the bleeding start?
- Duration: How long does the bleeding last?
- Frequency: How often does the bleeding occur?
- Volume: Heavy/light bleeding? Any clots?
- Pattern: Postcoital, intermenstrual, or continuous?
- Associated symptoms: Pain, fever, fatigue, weight loss, dizziness, or vaginal discharge?

Gynecological History
1. Menstrual History: LMP, Age at menarche, cycle regularity, frequency, duration, amount of blood, dysmenorrhea, intermenestrual bleeding.
2. Obstetric History: Number of pregnancies, outcomes, and complications.
3. Contraceptive History: Current or past contraceptive use.
4. Sexual History: History of dyspareunia, sexually transmitted infections (STIs), or high-risk sexual behavior.
5. Pap smear

4. Past Medical History (PMH)

History of bleeding disorders, anemia, or thyroid disease

5. Past Surgical History (PSH)

6. Family History

7. Drug History

8. Allergy History

9. Social History

Physical Examination
1. Vital Signs

2. General Appearance

3. Chest Exam

4. Abdominal Exam
Look for tenderness, masses, or organomegaly.

5. Pelvic Exam
- External genitalia: Signs of trauma, lesions, or discharge?
- Speculum exam: Visualize the cervix for lesions, bleeding source, or discharge.
- Bimanual exam: Assess uterine size, mobility, tenderness, or adnexal masses.

Investigations and Tests

- Serum β-hCG: Rule out pregnancy.

- CBC: Check for anemia and Platelet count
- Coagulation profile: Rule out bleeding disorders.
- Anovulation assesment
- Pelvic ultrasound (transvaginal): Assess for endometrial thickness, fibroids, or ovarian pathology.
- Saline Sonogram, Hysteroscopy
- Pap smear or HPV testing: If indicated.
- Endometrial biopsy: If endometrial hyperplasia or malignancy is suspected.
Differential Diagnosis

1. Structural Causes (PALM)

These are often identifiable through imaging or biopsy.
P: Polyp (endometrial or cervical)
A: Adenomyosis
L: Leiomyoma (fibroids)
M: Malignancy and hyperplasia
• Endometrial cancer
• Cervical cancer
• Vaginal or vulvar cancer
2. Non-Structural Causes (COEIN)
These are typically systemic or functional.
C: Coagulopathy
• Von Willebrand disease
• Platelet dysfunction
O: Ovulatory dysfunction
• Anovulation (e.g., polycystic ovary syndrome, thyroid dysfunction)
E: Endometrial
• Primary endometrial causes (e.g., chronic endometritis)
I: Iatrogenic
• Hormonal contraceptives
• Anticoagulants
• IUDs
N: Not yet classified

Management

1. Acute Management (if bleeding is heavy): Hemodynamic stabilization: IV fluids or blood transfusion if necessary.

2. Chronic Management
- Address underlying cause (e.g., fibroid removal, treat thyroid dysfunction).
- Hormonal management (e.g., progesterone therapy, LNG-IUD).
- Consider surgical options for refractory cases (e.g., hysteroscopy, endometrial ablation, hysterectomy).

[Link]
 Postmenopausal Bleeding

Case:
A 62-year-old woman presents with vaginal bleeding for 1 week. She reached menopause 10 years ago and has had no bleeding since.

Approach to Postmenopausal Bleeding

History
1. Chief Complaint (CC)
2. History of Present Illness (HPI)
- Onset: When did the bleeding start?
- Duration: How long does it last?
- Amount: Is it spotting or heavy?
- Nature: Color and consistency of the blood.
- Associated symptoms: Pelvic pain, vaginal discharge, weight loss, fatigue.
- Exacerbating/relieving factors: Relation to physical activity, trauma, or intercourse.
- Menstrual history: Age of menopause, any prior abnormal bleeding postmenopause.
3. Past Medical History (PMH)
History of gynecological issues (fibroids, endometrial hyperplasia, or cancers).
4. Past Surgical History (PSH)
Previous uterine or pelvic surgeries (e.g., hysterectomy, endometrial ablation).
5. Family History
History of cancers (especially breast, ovarian, or endometrial).
6. Drug History
- Use of hormone replacement therapy (HRT).
- Medications like anticoagulants or tamoxifen.
7. Allergy History
8. Social History

Physical Examination
1. Vital Signs
2. General Appearance
Pallor (suggesting anemia), weight loss, or cachexia.
3. Chest Examination
Look for signs of metastasis (lung masses).
4. Abdominal Examination
Inspect for masses, distension, tenderness, or ascites.
5. Pelvic Examination
- Inspect external genitalia for trauma, lesions, or signs of atrophy.
- Speculum examination: Evaluate vaginal mucosa, cervical lesions, or blood source.
- Bimanual exam: Assess uterus size, mobility, adnexal masses, tenderness.

Investigations
- Complete blood count (CBC) for anemia.
- Transvaginal ultrasound (TVUS): First-line imaging to assess endometrial thickness.
Normal endometrial thickness: ≤5 mm in postmenopausal women without HRT.
- Endometrial biopsy: Indicated if endometrial thickness >5mm.
- Pap smear: To screen for cervical abnormalities.
- Hysteroscopy: For direct visualization of the uterine cavity, often with biopsy.
- Coagulation profile.

Differential Diagnoses
- Endometrial cancer.
- Atrophic vaginitis.
- Endometrial hyperplasia.
- Hormone replacement therapy (irregular bleeding may occur with HRT especially during the first few months of use
- Cervical cancer or polyps.
- Vaginal cancer
- Coagulopathy
- infection
- Trauma.

Management
- Stabilize if there is hemodynamic instability (IV fluids, transfusion if needed).
- Endometrial cancer: Surgical staging (hysterectomy + lymphadenectomy) ± chemotherapy/radiotherapy.
- Endometrial hyperplasia: Progestins or surgery if atypia is present.
- Atrophic vaginitis: Vaginal estrogen therapy.
- Polyps: Hysteroscopic polypectomy.
 Precocious Puberty

Case:
A 6-year-old girl presents with her mother, concerned about breast development and pubic hair growth over the past 4 months.

Approach to Precocious Puberty

1. History
Chief Complaint (CC)
History of Presenting Illness (HPI)
- Onset, progression, and duration of symptoms.
- Presence of:
• Vaginal bleeding or discharge.
• Growth spurt or advanced height.
• Acne or body odor.
• Systemic symptoms (headaches, vision changes, bone pain).
Past Medical History (PMH)
Past Surgical History (PSH)
Family History
- Age of puberty onset in parents or siblings.
- Genetic conditions (e.g., McCune-Albright syndrome, neurofibromatosis).
Drug History
Use of hormonal creams, medications, or supplements.
Allergy History
Social History

2. Physical Examination
1. Vitals
2. General Appearance
- Tanner staging for breast and pubic hair development.
- Look for café-au-lait spots, acne, or advanced height for age.
3. Chest Exam
4. Abdominal Exam
Palpate for organomegaly or masses (e.g., adrenal or ovarian tumor).
5. Pelvic Exam
- Inspect for external genitalia changes (e.g., clitoromegaly, discharge).
- Consider imaging instead of a speculum or bimanual exam in children.

3. Investigations
- Bone Age Assessment: X-ray of the left hand and wrist, advanced bone age suggests true precocious puberty.
- Hormonal Studies: FSH, LH, and estradiol.
Elevated LH and FSH in a pubertal pattern suggests central precocious puberty (CPP).
Low LH and FSH suggest peripheral precocious puberty (PPP).
- TSH and free T4: Rule out hypothyroidism.
- Brain MRI: Indicated in girls under 6 years with CPP to rule out CNS lesions.
- Pelvic Ultrasound: Evaluate for ovarian cysts or tumors.

4. Differential Diagnosis
1. Central (Gonadotropin-Dependent):
- Idiopathic central precocious puberty.
- CNS tumors (e.g., hypothalamic hamartoma).
- CNS infections or trauma.
2. Peripheral (Gonadotropin-Independent):
- McCune-Albright syndrome.
- Granulosa cell tumor or other ovarian tumors.
- Exogenous estrogen exposure.

5. Management
 Infertility

Case:
A 29-year-old female presents with a complaint of inability to conceive after trying for 15 months with her husband.

Approach to Infertility

1. History Taking

Chief Complaint (CC)

History of Present Illness (HPI)

- Duration of trying to conceive
- Frequency of intercourse
- Menstrual history
- Contraception history: None in the past year.
- Symptoms suggestive of ovulatory dysfunction (e.g., oligomenorrhea, amenorrhea)
- Symptoms suggestive of tubal or uterine pathology (e.g., chronic pelvic pain, abnormal vaginal discharge)
- Partner history

Gynecological History
1. Menstrual History: LMP, Age at menarche, cycle regularity, frequency, duration, amount of blood, dysmenorrhea, intermenestrual bleeding.
2. Obstetric History: Number of pregnancies, outcomes, and complications.
3. Contraceptive History: Current or past contraceptive use.
4. Sexual History: History of dyspareunia, sexually transmitted infections (STIs), or high-risk sexual behavior.
5. Pap smear

Past Medical History (PMH)

- Any known chronic illnesses (e.g., diabetes, hypothyroidism, PCOS).
- Previous pelvic inflammatory disease (PID)

Past Surgical History (PSH)

Family History
- History of infertility, early menopause, or genetic disorders in the family.

Drug History

Allergies

Social History

2. Physical Examination

Vital Signs

General Appearance

Chest Exam

Abdomenal examination

Pelvic Exam
- External genitalia
- Speculum exam
- Bimanual exam: No adnexal masses or tenderness, uterus normal in size and mobility.

3. Investigations

Male Partner
- Semen Analysis: Volume, concentration, motility, and morphology.
- Hormonal Testing: Testosterone, FSH, LH, and prolactin.
Female Partner
- Ovulation Assessment: progesterone levels on day 21
- Hormonal Testing: LH, FSH, estradiol, prolactin, TSH, and testosterone.
- Pelvic ultrasound to evaluate ovaries and uterus.
- Hysterosalpingography (HSG) to assess tubal patency and uterine abnormalities.
- Ovarian Reserve Testing
Day 3 FSH level
Anti-Müllerian Hormone (AMH).
Antral follicle count on ultrasound.
4. Differential Diagnoses

1. Anovulation
- Polycystic Ovary Syndrome (PCOS).
- Hypothalamic Amenorrhea: Stress, weight loss, or excessive exercise.
- Primary Ovarian Insufficiency (POI)
- Hyperprolactinemia.
- Thyroid Disorders.
- Obesity: Can lead to hormonal imbalance.
2. Tubal Factor Infertility
3. Uterine Factor
- Fibroids
- congenital uterine anomalies.
4. Male Factor Infertility
5. Unexplained Infertility: Diagnosis of exclusion.

5. Management

- Ovulation Induction: Clomiphene citrate or HMG

- Tubal Factor Management: Laparoscopic surgery if tubal obstruction or adhesions are confirmed.
- Assisted Reproductive Techniques (ART):
• Intrauterine insemination (IUI) if mild male factor infertility or unexplained infertility.
• In vitro fertilization (IVF) if ART is required for tubal or severe male factor issues.