Title:Primary Amenorrhea in the Physician's Office: Normal Coitus or Not? Always Take a Look.
|
|
- Conrad Hawkins
- 6 years ago
- Views:
Transcription
1 Author's response to reviews Title:Primary Amenorrhea in the Physician's Office: Normal Coitus or Not? Always Take a Look. Authors: Flora Bacopoulou (bacopouf@hotmail.com) George Creatsas (geocre@aretaieio.uoa.gr) George P Chrousos (chrousog@mail.nih.gov) Nikoleta Papanikolaou (nikol.papanikolaou@hotmail.com) Efthimios Deligeoroglou (edeligeo@aretaieio.uoa.gr) Version:6Date:27 January 2014 Author's response to reviews: We would like to thank the reviewers for giving us the opportunity to submit a revised version of our manuscript. We appreciate the reviewers insight and we hope that we accommodated most of their suggestions in the revised manuscript. We provide detailed responses to each of the reviewers' comments and we hope that we explain satisfactorily why we think that some comments are invalid. Reviewer: Tarek Shokeir Reviewer's report: This paper describes a case report which does not make a contribution to medical knowledge and does not have educational value or highlight the need for a change in clinical practice or diagnostic/prognostic approaches. This paper describes two cases of the very rare sexual phenomenon of urethral coitus, which is not a common medical knowledge. The aim of this report is to emphasize that a careful assessment of the external genitalia and vagina patency must always be performed in case of primary amenorrhea even if normal sexual activity is assumed and highlights the need for a change in clinical practice, as many pediatricians do not perform gynecologic examination in their current practice setting, according to a recent Clinical Report of the American Academy of Pediatrics (Braverman PK, Breech L and The Committee on Adolescence: Gynecologic examination for adolescents in the pediatric office setting. Pediatrics 2010, 126: ). Comment 1: Case reports should include relevant positive and negative findings from history, clinical examination, and investigations. There are a lot of publications and many case reports concerning the issue of primary amenorrhea in adolescents caused by Mayer-Rokitansky-Klister-Hauser syndrome (MRKH-Type II) and associated
2 with urethral intercourse. Coexistance with pituitary adenoma (micro or macro) is not a novel [Eom KS et al. (J Clin Neurosci, 2009)]. We also include relevant positive and negative findings in the description of our cases. There are a lot of publications concerning the issue of primary amenorrhea caused by Müllerian agenesis as the syndrome accounts for approximately 10% of cases of primary amenorrhea. However, urethral coitus, is a very rare sexual phenomenon; to the best of our knowledge 31 cases in the literature have been described, in women with Müllerian agenesis, as well as with other vaginal abnormalities (Sakinci M, Kokcu A, Malatyalioglu E. Satisfactory urethral coitus in a patient with vaginal stenosis: case report. Int Urogynecol J 2012;23:237-9), hymenal variations (Di Donato V, Manci N, Palaia I, Bellati F, Perniola G, Panici PB: Urethral coitus in a patient with a microperforate hymen. J Minim Invasive Gynecol 2008, 15: ), paraplegia, or even with an intact vagina (Ayan S, Gökçe G, Kiliçarslan H, Kaya K, Gültekin EY: An unusual cause of incontinence: urethral coitus. Scand J Urol Nephrol 2001, 35:254). We agree with the reviewer that coexistance of type II with pituitary adenoma (micro or macro) is not a novel. Therefore we have modified the first and fifth paragraphs of the Conclusion section of the manuscript as following: Urethral coitus, is a very rare sexual phenomenon; 31 cases in the literature have been described, most commonly in women with vaginal abnormalities and only in four adolescents. To the best of our knowledge, Case 1 also represents the second reported case of pituitary prolactinoma in association with Müllerian agenesis. Although both conditions are rare, most likely the concurrence is coincidental. When the defective genes for Müllerian agenesis are known, a possible conjecture may be then formulated. Comment 2 - For Case 1: -How did the family physician report 'normal' results on screening with Pap smears in a case with absent vagina and cervix? The family physician was obtaining Pap smears from the dilated urethra and screening was performed on the epithelium of the urethra. Along the urethra there is pseudostratified columnar and stratified columnar epithelium as well as stratified squamous cells near the external urethral orifice. There are small mucus-secreting urethral glands, that help protect the epithelium from the corrosive urine. -What were the tumor markers performed for this case? The tumor markers performed were lactate dehydrogenase (LDH), human
3 chorionic gonadotropin (HCG), alpha-fetoprotein (AFP) and cancer antigen (CA 125). They have been added in the manuscript. -What was the initial size of the microadenoma at first presentation? The initial size of the microadenoma at presentation was 9.5mm (lateral oblique diameter) and 7.1mm ((longitudinal diameter). Under Case 1 presentation the size of the microadenoma has been added: lateral oblique diameter of 9.5mm and longitudinal diameter of 7.1mm. -What was the dose and course of quinagolide given?. how was the progress with the treatment going on? Quinagolide was administered according to the British National Formulary: the adolescent was commenced 25 micrograms per day at bedtime for the first 3 days, followed by 50 micrograms/day for a further 3 days. From day 7 onwards, the maintenance dose was 75 micrograms/day. In a recent MRI of the pituitary, 2 years after initial investigation, the adenoma is undetectable and serum prolactin has reverted to normal levels 9 ng/ml. The following have been included in the revised manuscript under Case 1: She was started on oral quinagolide aiming for full cure of her prolactinoma. After two years the pituitary adenoma is undetectable on MRI and serum prolactin has reverted to normal. -A supplementation with a laparoscopic picture for the herniated inguinal gonad rather than a picture for dilated urethra would be very appreciated. Inadvertently such photos were not obtained at the time of the operation. Comment 3 - For Case 2: -We think that it is difficult to consider gradual vaginal dilatation as a first line treatment option for a case with total vaginal aplasia with no any pre-existing small vaginal pouch. We thank the reviewer for highlighting this oversight. The adolescent had indeed a vaginal dimple and this has been added in the manuscript. Our patient expressed the desire for nonsurgical management and therefore she was advised to manually place successive dilators on the vaginal dimple for 30 minutes to 2 hours per day. Nonsurgical creation of the vagina is the appropriate first-line approach in most patients as per ACOG Committee Opinion No. 562 (Müllerian agenesis: diagnosis, management, and treatment. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;121:1134-7). The above have been clarified in the manuscript under Case 2 section: The diagnosis of Müllerian agenesis was made and the adolescent expressed
4 the desire for nonsurgical management; she was advised to manually place successive dilators on the vaginal dimple for 30 minutes to 2 hours per day. Reviewer: David Klein Major Compulsory Revisions: Comment 4: Conclusion section: Be cautious about stating that our cases highlight the need for careful assessment of external genitalia in all girls external genitalia examination can easily appear to be normal in patients with Mullerian agenesis since the distal vagina can be preserved. Similar comment with the last sentence in the conclusion regarding need for early identification of Mullerian agenesis. Are the authors also recommending a first-line bimanual or speculum exam for all adolescents with primary amenorrhea. This would be very controversial. According to AAP (Braverman PK, Breech L and The Committee on Adolescence: Gynecologic examination for adolescents in the pediatric office setting. Pediatrics 2010, 126: ) amenorrhea is an indication for a complete pelvic examination. However, many pediatricians do not have the skills and equipment in their current practice setting to perform a pelvic examination and the adolescent may be fearful, anxious, may experience pain or discomfort with a bimanual or speculum exam. Therefore, we recommend that in adolescents with primary amenorrhea, at a minimum, during assessment of external genitalia, the patency of the vagina should also be checked with gentle insertion of a saline-soaked cotton swab. We have amended the Conclusion section in the revised version of our paper as following: Our cases highlight the need for careful assessment of the external genitalia and vagina patency in all girls with amenorrhea, even if they report normal vaginal sexual activity. The American Academy of Pediatrics promotes the inclusion of the external gynecologic examination in the primary care setting as part of the annual comprehensive physical examination of children and adolescents of all ages and a complete pelvic examination for adolescents with amenorrhea. However, many pediatricians do not have the skills and equipment in their current practice setting to perform a pelvic examination and the adolescent may be fearful, anxious, may experience pain or discomfort with a bimanual or speculum exam. Therefore, we recommend that in adolescents with primary amenorrhea, at a minimum, during assessment of external genitalia, the patency of the vagina should also be checked with gentle insertion of a saline-soaked cotton swab. Despite potential negative implications (loss of patient rapport, practical barriers i.e. need for chaperone) the primary care office of the clinician who has established trust and a comfort level with the patient and often is the first to address her gynecologic issues, is the best setting to perform a gynecologic examination.
5 Comment 5: In the conclusion sections, it is difficult to tell if the authors are suggesting that the microprolactinoma and MRKH syndrome are related ( associated - i.e. syndromic) or unrelated (e.g. the microprolactinoma was incidentally found in the process of this work up, but unrelated to her presenting symptoms). Prolactinomas have an estimated prevalence of 1 per 10,000 population (Colao A, Lombardi G: Growth hormone and prolactin excess. Lancet 1998; 352: ) whereas Müllerian agenesis occurs in 1 of every 4,000-10,000 females (Müllerian agenesis: diagnosis, management, and treatment. Committee Opinion No American College of Obstetricians and Gynecologists. Obstet Gynecol 2013; 121:1134-7). The following has been included in the revised manuscript under the Conclusion section: Although both conditions are rare, most likely the concurrence is coincidental. When the defective genes for Müllerian agenesis are known, a possible conjecture may be then formulated. Comment 6: Although the authors correctly reference the AAP recommendation, it is important to acknowledge some negative outcomes from universal GU examination: a. Potential loss of rapport thus undermining the most revealing assessment of the asymptomatic adolescent the psychosocial history. b. Decreased usefulness -- with less need for cervical cytology, alternative methods for STI testing, etc. c. Issues with test sensitivity - as stated above, Mullerian agenesis can easily be missed on simple external GU examination d. Time finding chaperone and conducting the exam - universal GU exam takes valuable time away from psychosocial screening 4) Similarly, clarify that the AAP recommendation is for external exam, not pelvic/speculum exam (for which their table 1 gives specific indications). Stating gynecologic exam in the second sentence of that paragraph might be confusing to some readers. We thank the reviewer for the comment. Indeed we have to acknowledge some negative outcomes from universal GU examination. We have amended the Conclusion section in the revised manuscript as following: Our cases highlight the need for careful assessment of the external genitalia and vagina patency in all girls with amenorrhea, even if they report normal vaginal
6 sexual activity. The American Academy of Pediatrics promotes the inclusion of the external gynecologic examination in the primary care setting as part of the annual comprehensive physical examination of children and adolescents of all ages and a complete pelvic examination for adolescents with amenorrhea. However, many pediatricians do not have the skills and equipment in their current practice setting to perform a pelvic examination and the adolescent may be fearful, anxious, may experience pain or discomfort with a bimanual or speculum exam. Therefore, we recommend that in adolescents with primary amenorrhea, at a minimum, during assessment of external genitalia, the patency of the vagina should also be checked with gentle insertion of a saline-soaked cotton swab. Despite potential negative implications (loss of patient rapport, practical barriers i.e. need for chaperone) the primary care office of the clinician who has established trust and a comfort level with the patient and often is the first to address her gynecologic issues, is the best setting to perform a gynecologic examination. Minor Essential Revisions: Comment 7: Under background, second sentence: please add a pregnancy test as a first line test in primary (and secondary) amenorrhea. Pregnancy test has been added as first line test for primary amenorrhea in the Background section of the manuscript. Comment 8: Under case presentation, Case 1 (and conclusion): please change Papanicolaou smear to Papanicolaou test Papanicolaou smear has been changed to Papanicolaou test in Case 1 and Conclusion sections of the manuscript. Comment 9: Under case presentation, Case 1: please characterize the microadenoma (at least in size); and clarify the indications for treatment (size vs gonadal dysfunction vs fertility issues) as opposed to simply monitoring it over time. Also clarify marked improvement after treatment is this only in size/prolactin level or in patient oriented outcomes as well (patient feeling better, etc.). For asymptomatic patients with small lesions, size/prolactin level improvement is less important. Under Case 1 presentation the size of the microadenoma has been added: lateral oblique diameter of 9.5mm and longitudinal diameter of 7.1mm. We elected to treat the prolactinoma aiming for full cure, as per endocrine protocol of our hospital. In a recent MRI of the pituitary, 2 years after initial
7 investigation, the adenoma is undetectable and serum prolactin has reverted to normal levels 9 ng/ml. These latest results have been included in the manuscript under Case 1 presentation: She was started on oral quinagolide aiming for full cure of her prolactinoma. After two years the pituitary adenoma is undetectable on MRI and serum prolactin has reverted to normal. Comment 10: Under conclusion, both first and second paragraphs state very rare sexual phenomenon change the wording on one of the two. The phrase very rare sexual phenomenon has been deleted from the second paragraph. Comment 11: For case 2: please clarify the vaginal dilator recommendation clearly there must have been some vaginal tissue present; the reported physical exam and imaging results seem to indicate a complete absence of vaginal tissue. What did bimanual exam show? Will dilators work for this patient? We thank the reviewer for highlighting this oversight. The adolescent had indeed a vaginal dimple and this has been added in the manuscript. Rectal examination did not reveal any evidence of cervix or uterus. Our patient expressed the desire for nonsurgical management and therefore she was advised to manually place successive dilators on the vaginal dimple for 30 minutes to 2 hours per day as per ACOG Committee Opinion No. 562 (Müllerian agenesis: diagnosis, management, and treatment. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;121:1134-7). Nonsurgical creation of the vagina is the appropriate first-line approach in most patients. According to reported data, 90-95% of a series of patients with müllerian agenesis were able to achieve anatomic and functional success by vaginal dilation (Roberts CP, Haber MJ, Rock JA. Vaginal creation for mullerian agenesis. Am J Obstet Gynecol 2001;185: ; discussion ; Edmonds DK, Rose GL, Lipton MG, Quek J. Mayer-Rokitansky-Kuster-Hauser syndrome: a review of 245 consecutive cases managed by a multidisciplinary approach with vaginal dilators. Fertil Steril 2012;97:686-90). The vaginal dilator recommendation has been clarified in the manuscript under Case 2 section: The diagnosis of Müllerian agenesis was made and the adolescent expressed the desire for nonsurgical management; she was advised to manually place successive dilators on the vaginal dimple for 30 minutes to 2 hours per day. Discretionary Revisions: Comment 12:
8 Abstract and throughout text: To be consistent with reference 1 (which is commonly cited for articles on amenorrhea); the authors should consider using Mullerian Agenesis instead of MRKH syndrome, although both terms are commonly used. The term Müllerian agenesis has replaced the term MRKH syndrome throughout the manuscript. Comment 13: Under background, first sentence: consider citing reference 1 (even though cited after the following sentence), since this definition varies among experts and references. Reference 1 has been cited accordingly. Comment 14: Under case presentation, case 2: please clarify attempted sexual intercourse -did she report penetration? Also, specify that this finding, in addition to the dilated urethra, helped to confirm urethral coitus. The following have been added under Case 2 presentation: A detailed history revealed that dysuria had followed attempted sexual intercourse with penetration; the additional finding of a dilated urethra, helped to confirm urethral coitus. Comment 15: If the length of the manuscript allows, please specify the lab results (hormone panels) for case 2, even if normal. Hormonal profile lab results for both cases have been added in Table 1 of the revised manuscript. Reviewer: Karine Morcel Major Compulsory revisions: Comment 16: Many similar cases have already been reported in the literature. Recently, two similar cases associated with an interesting review of the literature were published by Rickman J et al. in J Pediatr Adolesc Gynecol. This paper is not referred by the authors. Urethral coitus, is a very rare sexual phenomenon; to the best of our knowledge
9 31 cases in the literature have been described, in women with Müllerian agenesis, as well as with other vaginal abnormalities (Sakinci M, Kokcu A, Malatyalioglu E. Satisfactory urethral coitus in a patient with vaginal stenosis: case report. Int Urogynecol J 2012;23:237-9), hymenal variations (Di Donato V, Manci N, Palaia I, Bellati F, Perniola G, Panici PB: Urethral coitus in a patient with a microperforate hymen. J Minim Invasive Gynecol 2008, 15: ), paraplegia, or even with an intact vagina (Ayan S, Gökçe G, Kiliçarslan H, Kaya K, Gültekin EY: An unusual cause of incontinence: urethral coitus. Scand J Urol Nephrol 2001, 35:254). The recently published paper of two similar cases (Ryckman J, Black A, Fleming N. Adolescent urethral coitus: 2 cases and review of the literature. J Pediatr Adolesc Gynecol 2013) has been referred in the revised manuscript (Reference no 11). We have also included the latest relevant paper of Rouzi AA: Urethral sex in a woman with previously undiagnosed Mayer-Rokitansky-Küster-Hauser syndrome. Clin Exp Obstet Gynecol 2013, 40: (Reference no 7). We have modified the first paragraph of the Conclusion section of the manuscript as following: Urethral coitus, is a very rare sexual phenomenon; 31 cases in the literature have been described, most commonly in women with vaginal abnormalities and only in four adolescents. Comment 17: The only interest of this manuscript would be to highlight that a gynaecologic exam must always be performed in case of primary amenorrhea despite a normal sexual activity, prior to dismiss an anatomic aetiology. In this case, the discussion should be rewritten to emphasize this point. The Conclusion section has been rewritten in order to emphasize this point as following: Our cases highlight the need for careful assessment of the external genitalia and vagina patency in all girls with amenorrhea, even if they report normal vaginal sexual activity. The American Academy of Pediatrics promotes the inclusion of the external gynecologic examination in the primary care setting as part of the annual comprehensive physical examination of children and adolescents of all ages and a complete pelvic examination for adolescents with amenorrhea. However, many pediatricians do not have the skills and equipment in their current practice setting to perform a pelvic examination and the adolescent may be fearful, anxious, may experience pain or discomfort with a bimanual or speculum exam. Therefore, we recommend that in adolescents with primary amenorrhea, at a minimum, during assessment of external genitalia, the patency of the vagina should also be checked with gentle insertion of a saline-soaked cotton swab. Despite potential negative implications (loss of patient rapport, practical barriers i.e. need for chaperone) the primary care office of the clinician who has established trust and a comfort level with the patient and often is the first to address her gynecologic issues, is the best setting to perform a
10 gynecologic examination. Comment 18: In last, the association between MRKH syndrome and pituitary micorprolactinemia may be random. The authors don't take into account the relative frequency of both diseases and don't discuss the possibility of a coincidental association. Prolactinomas have an estimated prevalence of 1 per 10,000 population (Colao A, Lombardi G: Growth hormone and prolactin excess. Lancet 1998; 352: ) whereas Müllerian agenesis occurs in 1 of every 4,000-10,000 females (Müllerian agenesis: diagnosis, management, and treatment. Committee Opinion No American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;121:1134-7). The following has been included in the revised manuscript under the Conclusion section: Although both conditions are rare, most likely the concurrence is coincidental. When the defective genes for Müllerian agenesis are known, a possible conjecture may be then formulated.
Pap Smears Pelvic Examinations Well Woman Examinations. When should you have them performed???
Pap Smears Pelvic Examinations Well Woman Examinations. When should you have them performed??? Arlene Evans-DeBeverly, PA-C Copyright 2012 There are always ongoing changes in gynecology, including the
More informationGrand Rounds Mullerian Anomalies. Sara Schaenzer, PGY-3 9/26/18
Grand Rounds Mullerian Anomalies Sara Schaenzer, PGY-3 9/26/18 Background Congenital uterine anomalies occur in 2-4% of women Three times more common in women with recurrent pregnancy loss True incidence
More informationI have no financial interests in any product I will discuss today.
How Should We Approach Cervical Cancer Screening and Routine Pelvic Examinations in 2019? Michael Policar, MD, MPH Professor Emeritus Department of Obstetrics, Gynecology and Reproductive Sciences University
More informationI have no financial interests in any product I will discuss today.
Cervical Cancer Screening Update and Implications for Annual Exams George F. Sawaya, MD Professor Department of Obstetrics, Gynecology and Reproductive Sciences Department of Epidemiology and Biostatistics
More informationIntroduction to Colposcopy
Introduction to Colposcopy Papanicolaou smear (Pap smear) screening test Colposcopy diagnostic test Introduction to Colposcopy Acetic acid and Lugol s iodine applied Cervix examined under magnification
More informationObjectives. I have no financial interests in any product I will discuss today. Cervical Cancer Screening Guidelines: Updates and Controversies
Cervical Cancer Screening Guidelines: Updates and Controversies I have no financial interests in any product I will discuss today. Jody Steinauer, MD, MAS University of California, San Francisco Objectives
More informationI have no financial interests in any product I will discuss today.
Cervical Cancer Prevention: 2012 and Beyond George F. Sawaya, MD Professor Department of Obstetrics, Gynecology and Reproductive Sciences Department of Epidemiology and Biostatistics University of California,
More informationPrimary Amenorrhea, age 16: Recent Reflections. David A Grainger MD, MPH February 1, 2017
Primary Amenorrhea, age 16: Recent Reflections David A Grainger MD, MPH February 1, 2017 Primary Amenorrhea No menses by age 13-14 WITHOUT BREAST DEVELOPMENT No menses by age 15-16 WITH BREAST DEVELOPMENT
More informationI have no financial interests in any product I will discuss today.
Cervical Cancer Screening Update and Implications for Annual Exams George F. Sawaya, MD Professor Department of Obstetrics, Gynecology and Reproductive Sciences Department of Epidemiology and Biostatistics
More informationThe Pap Smear Test. The Lebanese Society of Obstetrics and Gynecology. Women s health promotion series
The Lebanese Society of Obstetrics and Gynecology Women s health promotion series The Pap Smear Test Since the Pap smear test started to be used the number of cases of cervical cancer was greatly reduced.
More informationMullerian duct anomalies presenting with primary amenorrhoea
International Journal of Reproduction, Contraception, Obstetrics and Gynecology Chandrayan P et al. Int J Reprod Contracept Obstet Gynecol. 2016 Feb;5(2):300-305 www.ijrcog.org pissn 2320-1770 eissn 2320-1789
More informationLEARNING OBJECTIVES. Beyond the Pill: Long Acting Contraception. Distribution Of Contraception Use By Women In The Us. Unintended Pregnancy is Common
4:15 5 pm Beyond the Pill: Long Acting Contraceptives and IUDs Presenter Disclosure Information The following relationships exist related to this presentation: Christine L. Curry, MD, PhD: No financial
More informationA Young Asian Girl with MRKH Type B Syndrome: A Case Report
A Young Asian Girl with MRKH Type B Syndrome: A Case Report Nidhi Jain 1, Pardaman Singh 2, Deepak Goel 3, Jyotsna kamra 4 1,4 Department of Obstetrics and Gynecology, Maharaja Agarsein Medical College,
More informationRemoving Unnecessary Barriers to Contraceptive Services
Title X Grantee Meeting July 31, 2013 Seattle, WA Removing Unnecessary Barriers to Contraceptive Services Michael Policar, MD, MPH Professor of Ob, Gyn, and Repro Sciences UCSF School of Medicine policarm@obgyn.ucsf.edu
More informationEvaluation of the Infertile Couple
Overview and Definition Infertility is defined as the inability of a couple to fall pregnant after one year of unprotected intercourse. Infertility is a very common condition as in any given year about
More informationHealth Literacy Assessment: Pelvic Exam Guidelines
Running head: PELVIC EXAMS Health Literacy Assessment: Pelvic Exam Guidelines Acknowledgement: Ebonie Carter, Eden Cunningham, Kimberly Hailey & Shaquira Robinson PELVIC EXAMS 1 Guideline Changes Pelvic
More informationISSN International Journal of Innovative and Applied Research (2017) Journal home page: RESEARCH ARTICLE
Journal home page: http://www.journalijiar.com RESEARCH ARTICLE MAYER-ROKITANSKY-KUSTER-HAUSER SYNDROME II (Rare Case). * Dr. Verinder Dhar 1 and Dr. Renu Hashia 2. 1. MD(Medicine), DM(Endo),Medicare Nursing
More informationClinical Standards for Service Planning in PAG
The British Society for Paediatric & Adolescent Gynaecology. Clinical Standards for Service Planning in PAG Introduction The management of young children and adolescents with gynaecological problems (aged
More informationWhat is a Pap smear?
Pap smear What is a Pap smear? A Pap smear is a test that checks for changes in the cells of your cervix. The cervix is the lower part of the uterus that opens into the vagina. Developed over forty years
More informationUnintended Pregnancy is Common LEARNING OBJECTIVES. Distribution Of Contraception Use By Women In The Us. Unintended Pregnancy And Contraceptive Use
3:45 4:30 pm Beyond the Pill: Long Acting Contraceptives and IUDs Presenter Disclosure Information The following relationships exist related to this presentation: Christine L. Curry, MD, PhD: No financial
More informationSexual differentiation:
Abnormal Development of Female Genitalia Dr. Maryam Fetal development of gonads, external genitalia, Mullerian ducts and Wolffian ducts can be disrupted at a variety of points, leading to a wide range
More informationClinical Practice Guidelines June 2013
Clinical Practice Guidelines June 2013 General Principles: The Papanicolaou (Pap) smear is widely credited with reducing mortality from cervical cancer, and remains the single best method for the early
More informationCervical Cancer Screening for the Primary Care Physician for Average Risk Individuals Clinical Practice Guidelines. June 2013
Cervical Cancer Screening for the Primary Care Physician for Average Risk Individuals Clinical Practice Guidelines General Principles: Since its introduction in 1943, Papanicolaou (Pap) smear is widely
More informationPreventing Cervical Cancer 2018 WHAT THIS WILL MEAN FOR PRIMARY CARE
Preventing Cervical Cancer 2018 WHAT THIS WILL MEAN FOR PRIMARY CARE DR GARY FENTIMAN, CLINICAL LEADER COLPOSCOPY, N C S P TAKE-HOME LESSONS Vaccination is Primary Prevention for Cervical Cancer Women
More informationPap Test. F r e q u e n t l y A s k e d Q u e s t i o n s
Pap Test Q: What is a Pap test? A: The Pap test, also called a Pap smear, checks for changes in the cells of your cervix. The cervix is the lower part of the uterus (womb) that opens into the vagina (birth
More informationNormal and Abnormal Development of the Genital Tract. Dr.Raghad Abdul-Halim
Normal and Abnormal Development of the Genital Tract Dr.Raghad Abdul-Halim objectives: Revision of embryology. Clinical presentation, investigations and clinical significance of most common developmental
More informationInfertility Investigations. Patient Information
Infertility Investigations Patient Information Author ID: PH Leaflet Number: Gyn 048 Version: 4 Name of Leaflet: Infertility Investigations Date Produced: March 2017 Review Date: March 2019 Please be aware
More informationGynecology Dr. Sallama Lecture 3 Genital Prolapse
Gynecology Dr. Sallama Lecture 3 Genital Prolapse Genital(utero-vaginal )prolapse is extremely common, with an estimated 11% of women undergoing at least one operation for this condition. Definition: A
More informationA National Model of Care for Paediatric Healthcare Services in Ireland Chapter 28: Paediatric Gynaecology
A National Model of Care for Paediatric Healthcare Services in Ireland Chapter 28: Paediatric Gynaecology Clinical Strategy and Programmes Division Table of Contents 28.0 Introduction 2 28.1 Current Service
More informationDisclosures. Learning objectives. George F. Sawaya, MD. I have nothing to disclose.
Well Woman Visits in 2018: How Should We Approach Cervical Cancer Screening and Routine Pelvic Examinations? George F. Sawaya, MD Disclosures I have nothing to disclose. Professor, Obstetrics, Gynecology
More informationThe Case of Mrs. Virginia Jones* Asst. Professor Division of Gyne-Oncology University of British Columbia, Department of Gynecology Vancouver, Canada
Case title: Case authors: Case synopsis: The Case of Mrs. Virginia Jones* Dr. Leslie A. Sadownik Asst. Professor Division of Gyne-Oncology University of British Columbia, Department of Gynecology Vancouver,
More informationMetoclopramide Domperidone. HYPER- PROLACTINAEMIA: the true and the false problems
Modern management of Hyperprolactinaemia Didier DEWAILLY, M.D. Department of Endocrine Gynaecology and Reproductive Medicine, Hôpital Jeanne de Flandre, C.H.R.U., 59037 Lille, France 1 Metoclopramide Domperidone
More informationStump the Professors. Professor Panelists 4/13/2015. Challenger. Kylie Fowler, MD
4/13/2015 Stump the Professors Professor Panelists Cynthia Holland-Hall MD, MPH Mary Anne Jamieson, MD Julie Strickland, MD, MPH Challenger Kylie Fowler, MD Medical degree: University of Washington School
More informationMTN-026 Clinical Management Overview
MTN-026 Clinical Management Overview Overview of Topics Physical and Genital Exams Medical and Menstrual History STI Management Concomitant Medications Prohibited Medications and Practices Physical Examination:
More informationand treating joins with the top of canal). at risk for cervical carcinomas, cervix.
CERVICAL CANCER Worldwide, cervical cancer is twelfth most common and the fifth most deadly cancer in women. It affects about 16 per 100,000 women per year and kills about 9 per 100,000 per year. Cervical
More informationPRE TEST CERVICAL SCREENING MANAGEMENT COLPOSCOPY PATHOLOGIC DIAGNOSIS AND TREATMENT
PRE TEST CERVICAL SCREENING MANAGEMENT COLPOSCOPY PATHOLOGIC DIAGNOSIS AND TREATMENT QUESTION #1 WHICH OF THE FOLLOWING IS NOT A RISK FACTOR FOR CERVICAL CANCER? A. HIGH RISK HPV B. CIGARETTE SMOKING C.
More informationSexual health screening
Sexual health screening This guideline provides screening recommendations that are based on anatomy and is inclusive of genderaffirming surgeries and hormone therapy. All patients should be screened according
More informationDisclosure. Session Objectives. I have no actual or potential conflict of interest in relation to this program/presentation.
46, XY Female: A Case of Complete Androgen Insensitivity Syndrome (CAIS) MICHELLE MCLOUGHLINMSN, CRNP, CPNP-AC THE CHILDREN S HOSPITAL OF PHILADELPHIA DIVISION OF ENDOCRINOLOGY AND DIABETES Disclosure
More informationIntroduction to GYN Specialties
Outline Introduction to GYN Specialties Gynecologic Oncology* Female Pelvic Medicine and Reconstructive Surgery* Reproductive Endocrinology and Infertility* Pediatric and Adolescent Gynecology** Family
More informationSexually Transmitted Diseases. Chlamydial. infection. Questions and Answers
Sexually Transmitted Diseases Chlamydial infection Questions and Answers What is chlamydial infection? It is a sexually transmitted infection caused by the bacteria Chlamydia trachomatis, being one of
More informationreproductive organs. Malignant neoplasms. 4. Inflammatory disorders of female reproductive organs 2 5. Infertility. Family planning.
Thematic plan of lectures module iii. Diseases of female reproductive system. Family planning. Topic No of hours 1. Disturbances of menstrual function. Neuroendocrinological 2 syndromes in gynecology 1.
More informationAcute Salpingitis. Fallopian Tubes. Uterus
Acute Salpingitis Introduction Acute salpingitis is a type of infection that affects the Fallopian tubes. The Fallopian tubes carry eggs from the ovaries to the uterus. Acute salpingitis is one of the
More informationCERVICAL CANCER FACTSHEET. What is cervical cancer?
CERVICAL CANCER FACTSHEET What is cervical cancer? ENGAGe is releasing a series of factsheets to raise awareness of gynaecological cancers and to support its network to work at a grassroots level. Take-up
More informationUpdate on Medical Aspects. Mission Children s Hospital. Cindy Brown, MD. Asheville, NC. Child sexual abuse
Child sexual abuse Update on Medical Aspects Cindy Brown, MD Mission Children s Hospital Asheville, NC Objectives Genital examination Techniques Findings Examiners Sexually transmitted infections THE GENITAL
More informationInformation for Informed Consent for Insertion of a Mirena IUD
Information for Informed Consent for Insertion of a Mirena IUD What is an IUD (intrauterine Device)? An intrauterine device (IUD) is a plastic device that is placed into your uterus to prevent pregnancy.
More informationPap test results FOR WOMEN WITH AN ABNORMAL PAP TEST
Pap test results FOR WOMEN WITH AN ABNORMAL PAP TEST Introduction This booklet provides women with information about abnormal Pap test results. Many women feel anxious or worried when they are told their
More informationBen Herbert Alex Wojtowicz
Ben Herbert Alex Wojtowicz 54 year old female presenting with: Dragging sensation Urinary incontinence Some faecal incontinence HPC Since May 14 had noticed a mass protruding from the vagina when going
More informationThe Balanced Counseling Strategy Plus: A Toolkit for Family Planning Service Providers Working in High STI/HIV Prevalence Settings.
The Balanced Counseling Strategy Plus: A Toolkit for Family Planning Service Providers Working in High STI/HIV Prevalence Settings Counseling Cards Checklist to be reasonably sure a woman is not pregnant
More informationInfertility: failure to conceive within one year of unprotected regular sexual intercourse. Primary secondary
Subfertility Infertility: failure to conceive within one year of unprotected regular sexual intercourse. Primary secondary Infertility affects about 15 % of couples. age of the female. Other factors that
More informationNews. Laboratory NEW GUIDELINES DEMONSTRATE GREATER ROLE FOR HPV TESTING IN CERVICAL CANCER SCREENING TIMOTHY UPHOFF, PHD, DABMG, MLS (ASCP) CM
Laboratory News Inside This Issue NEW GUIDELINES DEMONSTRATE GREATER ROLE FOR HPV TESTING IN CERVICAL CANCER SCREENING...1 NEW HPV TEST METHODOLOGY PROVIDES BETTER SPECIFICITY FOR CERVICAL CANCER...4 BEYOND
More informationFemale Reproductive System
Female Reproductive System (Part A-1) Module 10 -Chapter 12 Overview Female reproductive organs Ovaries Fallopian tubes Uterus and vagina Mammary glands Menstrual cycle Pregnancy Labor and childbirth Menopause
More informationDepartment of Pathology, Kathmandu Medical College & Teaching Hospital, Sinamangal, Kathmandu, Nepal
Kathmandu University Medical Journal (2007), Vol. 5, No. 4, Issue 20, 461-467 Original Article Correlation of PAP smear findings with clinical findings and cervical biopsy Pradhan B 1, Pradhan SB 2, Mital
More informationCONGENITAL ABNORMALITIES OF GENITAL TRACT - VAGINAL DEFECTS
CONGENITAL ABNORMALITIES OF GENITAL TRACT - VAGINAL DEFECTS Abstract Pages with reference to book, From 256 To 261 Asif Zia Akhtar ( Department of Obstetric and Gynaecology, Abbasi Shaheed Hospital, Karachi.
More informationTRICHOMONAS VAGINALIS
TRICHOMONAS VAGINALIS What s New: There are no changes to this guideline. Introduction Trichomonas vaginalis (TV) is a flagellated protozoan that is a parasite of the genital tract. Due to site specificity,
More informationMu llerian Anomalies. Introduction
CLINICAL OBSTETRICS AND GYNECOLOGY Volume 51, Number 1, 214 222 r 2008, Lippincott Williams & Wilkins Mu llerian Anomalies LEE P. SHULMAN, MD The Anna Ross Lapham Professor in Obstetrics and Gynecology,
More informationNew Treatments for Vaginal Health. Sarah Azad, MD El Camino Women s Medical Group
New Treatments for Vaginal Health There s Hope Sarah Azad, MD El Camino Women s Medical Group The Genitrourinary Syndrome of Menopause (GSM) Problems with genital health secondary to the changes that occur
More informationBio 322 Human Anatomy Objectives for the laboratory exercise Female Reproductive System
Bio 322 Human Anatomy Objectives for the laboratory exercise Female Reproductive System Required reading before beginning this lab: Saladin, KS: Human Anatomy 5 th ed (2017) Chapter 26 For this lab you
More informationCall for Appointments
Ala Carte Pricing For Men and Women Consultation and Full Physical $60 Doctor Examination Body Height, Weight, Blood Pressure, Pulse Rate, BMI, Waist Circumference Breast examination (Women) Prostate Examination
More informationFaculty Nurse Practitioner Case Studies and Quality Assurance Review
Faculty Nurse Practitioner Case Studies and Quality Assurance Review Satellite Conference and Live Webcast Thursday, July 16, 2009 2:00-3:30 p.m. Central Time Produced by the Alabama Department of Public
More informationChronic Pelvic Pain. Bridget Kamen, MD Obstetrics and Gynecology, Confluence Health. I have no disclosures
Chronic Pelvic Pain Bridget Kamen, MD Obstetrics and Gynecology, Confluence Health I have no disclosures Objectives A little epidemiology Understand there are both gynecologic and non-gynecologic causes
More informationPRINCESS MARGARET CANCER CENTRE CLINICAL PRACTICE GUIDELINES GYNECOLOGIC CANCER CERVIX
PRINCESS MARGARET CANCER CENTRE CLINICAL PRACTICE GUIDELINES GYNECOLOGIC CANCER CERVIX Site Group: Gynecology Cervix Author: Dr. Stephane Laframboise 1. INTRODUCTION 3 2. PREVENTION 3 3. SCREENING AND
More informationDepartment of Plastic Surgery, University Hospital, Groningen, The Netherlands
SURGICAL CORRECTION OF FEMALE PSEUDOHERMA- PHRODITISM DUE TO ADRENAL HYPERPLASIA By A. J. C. HUFFSTADT, M.D. Department of Plastic Surgery, University Hospital, Groningen, The Netherlands SINCE the work
More informationGlobal HPV Disease Burden : Rationale for Vaccine
Global HPV Disease Burden : Rationale for Vaccine Muhammet Nabi Kanibir, MD Regional Medical Director Medical Affairs, MSD-Vaccines Muscat, September 2011 HPV Disease Burden Global Regional What do we
More information5/5/2010 FINANCIAL DISCLOSURE. Abnormal Uterine Bleeding. Is This A Problem? About me % of visits to gynecologist
Abnormal Uterine FINANCIAL DISCLOSURE I HAVE NO FINANCIAL INTEREST IN ANY OF THE PRODUCTS MENTIONED IN MY PRESENTATION Bryan K. Rone, M.D. University of Kentucky Obstetrics and Gynecology May 5, 2010 About
More informationTitle:The role of BRCA1 and BRCA2 mutations in prostate, pancreatic and stomach cancers.
Author's response to reviews Title:The role of BRCA1 and BRCA2 mutations in prostate, pancreatic and Authors: Helen Cavanagh (helen21987@hotmail.com) Katherine MA Rogers (k.rogers@qub.ac.uk) Version:3Date:1
More informationName of Policy: Speculoscopy
Name of Policy: Speculoscopy Policy #: 095 Latest Review Date: September 2011 Category: Medicine/OB Gyn Policy Grade: C Background/Definitions: As a general rule, benefits are payable under Blue Cross
More informationTitle:The role of BRCA1 and BRCA2 mutations in prostate, pancreatic and stomach cancers.
Author's response to reviews Title:The role of BRCA1 and BRCA2 mutations in prostate, pancreatic and stomach cancers. Authors: Helen Cavanagh (helen21987@hotmail.com) Katherine MA Rogers (k.rogers@qub.ac.uk)
More informationPap Smear Test Cancer is one of the most feared diseases falling under the genre of lifestyle diseases. The prevalence of cancer in women has increased rapidly over the past few decades. After breast
More informationUnit 6 REPRODUCTIVE SYSTEM Reproductive System Test Bank
Unit 6 REPRODUCTIVE SYSTEM Reproductive System Test Bank Objective 6.01 Describe the basic functions of the reproductive system. 1. Which of the following is a function of the reproductive system? a. Production
More informationBy:Dr:ISHRAQ MOHAMMED
By:Dr:ISHRAQ MOHAMMED Protrusion of an organ or structure beyond its normal confines. Prolapses are classified according to their location and the organs contained within them. 1-Anterior vaginal wall
More informationF REQUENTLY A SKED Q UESTIONS. fallopian tube instead of the uterus), constant pelvic pain, and other problems.
PID can be treated and cured with Pelvic antibiotics. If left untreated, PID can lead to serious problems like infertility (not being able to get pregnant), ectopic pregnancy (pregnancy in the Inflammatory
More informationComplete Summary GUIDELINE TITLE. Cervical cytology screening. BIBLIOGRAPHIC SOURCE(S)
Complete Summary GUIDELINE TITLE Cervical cytology screening. BIBLIOGRAPHIC SOURCE(S) American College of Obstetricians and Gynecologists (ACOG). Cervical cytology screening. Washington (DC): American
More informationSamuel B. Wolf, D.O., F.A.C.O.G. Emerald Coast Obstetrics and Gynecology Panama City Florida
Making sense of the new Pap smear screening guidelines. Samuel B. Wolf, D.O., F.A.C.O.G. Emerald Coast Obstetrics and Gynecology Panama City Florida Case 17 year old G1P0010 with first sexual encounter
More informationMayer-Rokitansky-K uster-hauser syndrome: a review of 245 consecutive cases managed by a multidisciplinary approach with vaginal dilators
Mayer-Rokitansky-K uster-hauser syndrome: a review of 245 consecutive cases managed by a multidisciplinary approach with vaginal dilators D. Keith Edmonds, F.R.C.O.G., Gillian L. Rose, F.R.C.O.G., Michelle
More informationTitle:Contraceptive use and Unmet need for Family Planning among HIV Positive Women on Antiretroviral Therapy in Kumasi, Ghana
Author's response to reviews Title:Contraceptive use and Unmet need for Family Planning among HIV Positive Women on Antiretroviral Therapy in Kumasi, Ghana Authors: DENNIS O LARYEA (dlaryea@kathhsp.org)
More informationInfertility F REQUENTLY A SKED Q UESTIONS. Q: Is infertility a common problem?
Infertility (female factors). In another one third of cases, infertility is due to the man (male factors). The remaining cases are caused by a mixture of male and female factors or by unknown factors.
More informationCoding for Fitting and Insertion of a Pessary
Coding for Fitting and Insertion of a Pessary A pessary is a device worn in the vagina for the treatment of pelvic organ prolapse or stress urinary incontinence. The pessary provides support of the vaginal
More informationCervical Screening for Dysplasia and Cancer in Patients with HIV
Cervical Screening for Dysplasia and Cancer in Patients with HIV Adult Clinical Guideline from the New York State Department of Health AIDS Institute w w w.hivg uidelines.org Purpose of the Guideline Increase
More informationTitle:The implementation of an organised cervical screening programme in Poland: an analysis of the adherence to European guidelines
Author's response to reviews Title:The implementation of an organised cervical screening programme in Poland: an analysis of the adherence to European guidelines Andrzej Nowakowski (andrzejmnowakowski@poczta.onet.pl)
More informationMechanism of hyperprolactinemia
Hyperprolactinemia Mechanism of hyperprolactinemia Causes of hyperprolactinemia Hormone-producing pituitary tumors Prolactinoma Acromegaly Hypothalamic/pituitary stalk lesion Tumors, cysts (craniopharyngeoma,
More informationRESPONSE TO DECISION LETTER
RESPONSE TO DECISION LETTER Dear Editor-in-chief, We are grateful to the editors and reviewers for their time and constructive comments on our manuscript. We have implemented their comments and suggestions
More informationChronic Pelvic Pain Case Study
Case Study Chronic Pelvic Pain Case Study Melissa, a 28 year old veteran comes to your office complaining of lower abdominal pain for the past 6 months. She has tried acetaminophen and ibuprofen but they
More informationPreventive Care Guideline for Asymptomatic Low Risk Adults Age 18 through 64
Preventive Care Guideline for Asymptomatic Low Risk Adults Age 18 through 64 1. BMI - Documented in patients medical record on an annual basis. Screen for obesity and offer intensive counseling and behavioral
More informationAdult Well Woman Screening Best Practices at CrossOver* Last updated
Health Parameter Screening Test and Frequency Reference Cervical Cancer Pap Smear Ages 21 29: Every 3 years with cytology alone Ages 30 65: Every 5 years with cytology & HPV cotesting [PREFERRED]; or Every
More informationPessaries for vaginal prolapse. Information for patients Gynaecology
Pessaries for vaginal prolapse Information for patients Gynaecology We have written this information to help explain the use of vaginal pessaries in the treatment of women with a vaginal prolapse. If you
More informationAll referrals for out-patient appointments can also be discussed with the Obstetrics and Gynaecology registrar as necessary. Presence of ascites
Gynaecology Referral Pathway for GPs to Aid Triage for Gynaecology Services in the Rotunda For acute gynaecology (suspected torsion, acute PID, etc..) or acute early pregnancy referrals please consider
More informationVaginal intraepithelial neoplasia
Vaginal intraepithelial neoplasia The terminology and pathology of VAIN are analogous to those of CIN (VAIN I-III). The main difference is that vaginal epithelium does not normally have crypts, so the
More informationCervical Cancer. Introduction Cervical cancer is a very common cancer. Nearly one half million cases are diagnosed worldwide each year.
Cervical Cancer Introduction Cervical cancer is a very common cancer. Nearly one half million cases are diagnosed worldwide each year. Most cases of cervical cancer can be prevented by getting regular
More information1) Intersexuality - Dr. Huda
1) Intersexuality - Dr. Huda DSD (Disorders of sex development) occur when there is disruption of either: Gonadal differentiation Fetal sex steroid production or action Mullerian abnormalities and Wolffian
More informationShould Progressive Perineal Dilation be Considered First Line Therapy for Vaginal Agenesis?
Should Progressive Perineal Dilation be Considered First Line Therapy for Vaginal Agenesis? Patricio C. Gargollo, Glenn M. Cannon, Jr., David A. Diamond, Phaedra Thomas, Vicki Burke and Marc R. Laufer*
More informationLABORATORY - PELVIC EXAM STUDIES COLPOSCOPY RESULTS FORM L14
LABORATORY - PELVIC EXAM STUDIES COLPOSCOPY RESULTS FORM L4 ID LABEL HERE ---> - - - VISIT #: FORM COMPLETED BY: VERSION DATE: 09/5/95 ANY MISSING OR INCOMPLETE TEST RESULTS MUST BE EXPLAINED ON THIS FORM.
More informationCamelia Davtyan, MD, FACP Clinical Professor of Medicine Director of Women s Health UCLA Comprehensive Health Program
Camelia Davtyan, MD, FACP Clinical Professor of Medicine Director of Women s Health UCLA Comprehensive Health Program A B C D USPSTF recommends the service. There is high certainty that Offer or provide
More informationCongenital Anomalies of the Genital Tract
Congenital Anomalies of the Genital Tract Prof Keith Edmonds Queen Charlotte s and Chelsea Hospital Imperial College London SSO&G Jonkoping 2015 Should Paediatric and Adolescent Gynaecology be Centralised?
More informationPelvic medical exams. Мобильный портал WAP версия: wap.altmaster.ru
Мобильный портал WAP версия: wap.altmaster.ru Pelvic medical exams A physical exam of the vagina, cervix, uterus, fallopian tubes, ovaries, and rectum. First, the area outside the vagina is checked for
More informationBursting Pelvic Inflammatory Disease.
www.infertiltysolutionsng.info/blog Disclaimer The information in this book is provided for educational purposes only and is not intended to treat, diagnose or prevent any disease. The information in this
More informationLABORATORY - PELVIC EXAM STUDIES COLPOSCOPY RESULTS FORM L14
LABORATORY - PELVIC EXAM STUDIES COLPOSCOPY RESULTS FORM L4 ID LABEL HERE ---> - - - VISIT #: FORM COMPLETED BY: VERSION DATE: 08/5/94 ANY MISSING OR INCOMPLETE TEST RESULTS MUST BE EXPLAINED ON THIS FORM.
More informationTitle:Setting priorities for mental health care in Nepal: a formative study
Author's response to reviews Title:Setting priorities for mental health care in Nepal: a formative study Authors: Mark J.D. Jordans (mark.jordans@hntpo.org) Nagendra P. Luitel (luitelnp@gmail.com) Mark
More informationMedicare Adds New Screening Services for Human Papillomavirus (HPV) and Human Immunodeficiency Virus (HIV) March 2016
Medicare Adds New Screening Services for Human Papillomavirus (HPV) and Human Immunodeficiency Virus (HIV) March 2016 On February 5, 2016, CMS released change requests announcing the addition of HPV and
More informationWhat is endometrial cancer?
Uterine cancer What is endometrial cancer? Endometrial cancer is the growth of abnormal cells in the lining of the uterus. The lining is called the endometrium. Endometrial cancer usually occurs in women
More informationCARE PRESENTATION. Diana Arriola, M.D. House Officer I
CARE PRESENTATION Diana Arriola, M.D. House Officer I CASE PRESENTATION 12 y/o F presents to ED 2 days following sexual assault by 2 male individuals (16y/o and 19 y/o) both involving penile-vaginal and
More information