Gynecology Learning Objectives and Associated Reading

PGY-1

I. Basic Science/Mechanisms of Disease a. Microbiology and immunology i. Describe the normal bacteriologic flora of the lower genital tract. ii. Describe the microbiologic principles germane to the diagnosis and treatment of gynecologic infectious diseases. iii. Describe the epidemiologic principles involved in the spread of infectious diseases in both patients and health care workers including transmission and prevention of HIV and hepatitis iv. Discuss the immunologic response to infection.

Recommended Reading: Text:  Novak’s Gynecology – Chapter 15. Genitourinary Infections and Sexually Transmitted Diseases by David Soper

Articles: 

Guidelines:  None

II. Disorders of the Urogenital Tract and Breast a. Abnormal/Dysfunctional Uterine Bleeding i. Describe the principal causes of abnormal uterine bleeding and distinguish abnormal uterine bleeding from dysfunctional uterine bleeding. ii. Elicit a pertinent history to evaluate abnormal uterine bleeding. iii. Perform a focused physical examination to investigate the etiology of abnormal uterine bleeding. iv. Perform and interpret the results of selected diagnostic tests to determine the cause of abnormal uterine bleeding: 1. Endometrial biopsy 2. Pelvic ultrasonography/saline infusion ultrasonography 3. Hysteroscopy 4. Laparoscopy v. Interpret the results of other diagnostic tests: 1. Serum/urine human chorionic gonadotropin (hCG) assay 2. Endocrinologic assays 3. Microbiologic cultures of the genital tract 4. Complete blood count 5. Coagulation profile vi. Treat abnormal uterine bleeding using both nonsurgical and surgical methods. vii. Recommend appropriate follow-up that is necessary for a patient with abnormal uterine bleeding.

Recommend Reading: Text: Clinical Gynecologic Endocrinology and (Speroff). Chapter 15. Pages 547-573. Comprehensive Gynecology. Chapter 36. Pages 1025-1042.

Articles: Munro M. Dysfunctional uterine bleeding: advances in diagnosis and treatment. Curr Opin Obstet Gynecol. 2001;13: 475-489. Montgomery BE, Daum GS, Dunton CJ. : A Review. Obstet Gynecol Surv. 2004;59(5): 368-378. Bayer SR, DeCherney AH. Clinical Manifestations and Treatment of Dysfunctional Uterine Bleeding. JAMA. 1993;269: 1823-1828. Warner PE, Critchley HO, Lumsden MA, Campbell-Brown M, Douglas A, Murray GD. Menorrhagia I: Measured blood loss, clinical features and outcome in women with heavy periods: A survey with follow-up data. Am J Obstet Gynecol. 2004;190: 1216-23. Warner PE, Critchley HO, Lumsden MA, Campbell-Brown M, Douglas A, Murray GD. Menorrhagia II: Is the 80-mL blood loss criterion useful in management of complaint of menorrhagia? Am J Obstet Gynecol. 2004;190: 1224-9. Richter HE, Learman LA, Lin F, Varner RE, Hendrix SO, Summitt RL, Washington AE. Medroxyprogesterone acetate treatment of abnormal uterine bleeding: Factors predicting satisfaction. Am J Obstet Gynecol. 2003;189: 37-42. De Kroon CD, Jansen FW, Louwe LA, Dieben SW, van Houwelingen HC, Trimbos JB. Technology assessment of saline contrast hysterosonography. Am J Obstet Gynecol 2003;188: 945-9.

Guidelines ACOG Practice Bulletin # 14. Management of Anovulatory Bleeding. Obstet Gynecol 2000;95(3). b. Vaginal and vulvar infections i. Describe the principal infections that affect the and . ii. Elicit a pertinent history in a patient with a possible infection of the vulva or vagina. iii. Perform a focused physical examination iv. Perform and interpret the results of selected tests to confirm the diagnosis of vulvar or vaginal infection, such as: 1. Vaginal pH 2. Saline microscopy (Wet mount) 3. Potassium hydroxide microscopy 4. Bacterial and viral culture 5. Colposcopic examination 6. Vulvar or vaginal biopsy v. Treat vulvar and vaginal infections vi. Describe the follow-up that is necessary for a patient with a vulvar or vaginal infection, for example: 1. Assessing and treating sexual partner(s) 2. Requirements for reporting a communicable disease 3. Assessing the patient for other possible genital tract infections 4. Counseling the patient with respect to measures that prevent re- infection.

Recommend Reading: Text: Comprehensive Gynecology. Chapter 21. Infections of the Lower Genital tract. Page 601-659.

Articles: Haefner HK. Current Evaluation and Management of Vulvovaginitis. Clin Obstet Gynecol 1999;42(2):184-195. Sobel JD. Current Concepts: . N Engl J Med 1997;337(26): 1896-1903.

Guidelines 2002 STD Guidelines. Center for Disease Control. www.cdc.gov c. Sexually transmitted diseases i. Describe the most common STDs, including causes, symptoms, and risk of transmission, such as: ii. Elicit a pertinent history in a patient with a suspected STD. iii. Perform a focused physical examination in a patient with a suspected STD. iv. Perform and/or interpret results of specific tests to confirm the diagnosis of an STD, such as: 1. Bacterial and/or viral culture 2. Endocervical aspirate for Gram stain 3. Endocervical swab for nucleic acid probe 4. Endocervical probe 5. Cervical or vaginal cytologic screening (Pap test) 6. Scraping of an ulcer or chancre 7. Serologic assays 8. Tzanck smear v. Treat STDs with appropriate antimicrobial agents. vi. Describe the long-term follow-up for patients with a STD, including assessment of the patient’s sexual partner, discussion of preventive measures, and review of serious sequelae, such as: 1. Infertility 2. Ectopic pregnancy 3. Chronic 4. Pelvic inflammatory disease (PID)

Recommend Reading: Text: Comprehensive Gynecology. Chapter 21. Infections of the Lower Genital tract. Page 601-659. Novak’s Gynecology – Chapter 15. Genitourinary Infections and Sexually Transmitted Diseases.

Articles: Peipert JF. Clinical Practice. Genital chlamydial infections. N Engl J Med 2003;349: 2424-30. Tyring SK. : The importance of early diagnosis and treatment. Am J Obstet Gynecol 2003;189:S12-S16. Yeung-Yue KA et al. The management of virus infections. Curr Opin Infect Dis 2002;15: 115-122. AMA. A Clinicians Guide to Diagnosis & Treatment: Genital Herpes. Soper D. Trichomoniasis: Under control or undercontrolled? Am J Obstet Gynecol. 2004;190: 281-290.

Guidelines 2002 STD Guidelines. Center for Disease Control. www.cdc.gov ACOG Committee Opinion # 203 Hepatitis Virus Infection in Obstetrics & Gynecology. Obstet Gynecol. 1998;92(1). ACOG Practice Bulletin # 57 Gynecologic Herpes Simplex Virus Infections. Obstet Gynecol. 2004;104: 1111-7. d. Pelvic inflammatory disease i. Describe the diagnostic criteria for PID ii. List the common infectious agents implicated in PID iii. Elicit a pertinent history from a patient suspected to have PID iv. Perform a physical exam to confirm the diagnosis of PID v. Describe the appropriate diagnostic tests to confirm PID, including indications for the tests, and how to perform and/or interpret the results. 1. Endocervical swab for culture or nucleic acid probe 2. Endometrial biopsy 3. Imaging studies 4. Laparoscopy vi. Treat PID with appropriate antimicrobial and surgical options. vii. Summarize the potential long-term effects and counsel patients regarding risks of further complications, including: 1. Chronic pelvic pain 2. Infertility 3. Ectopic pregnancy

Recommend Reading: Text: Comprehensive Gynecology. Chapter 22. Infections of the Upper Genital tract. Page 661-690. Novak’s Gynecology – Chapter 15. Genitourinary Infections and Sexually Transmitted Diseases.

Articles: Ross JD. Pelvic inflammatory disease: how should it be managed? Curr Opin Infect Dis 2003;16:37-41.

Guidelines 2006 STD Guidelines. Center for Disease Control. www.cdc.gov e. Urinary Tract Disorders i. Distinguish the types of urinary tract infection, including bacteruria, urethritis, cystitis, and pyelonephritis ii. Describe the pathophysiology related to urinary tract infection, including the organisms commonly implicated in lower and upper urinary tract disorders, and host factors, such as urinary retention, age, and pregnancy. iii. Describe the pathophysiology of the common forms of nephrolithiasis, including patient risk factors for the development of nephrolithiasis. iv. Describe the diagnostic methods and diagnostic criteria for the various types of urinary tract infections. v. Summarize the methods used for the diagnosis of nephrolithiasis. vi. Describe modes of therapy for acute, chronic, and complicated urinary tract infections, including prophylaxis for recurrent infection. vii. Summarize therapeutic options for nephrolithiasis, and strategies to prevent recurrence

Recommend Reading: Text:

Articles: Fihn SD. Acute Uncomplicated Urinary Tract Infection in Women. N Engl J Med 2003;349(3): 259-266 Dwyer PL, O’Reilly M. Recurrent urinary tract infection in the female. Curr Opin Obstet Gynecol. 2002;14: 537-543. Faro S, Fenner DE. Urinary Tract Infections. Clin Obstet Gynecol. 1998;41(3):744-754. Parmar MS. Clinical Review: Kidney stones. BMJ. 2004;328: 1420-4. Cohen RA, Brown RS. Microscopic hematuria. N Engl J Med. 2003;348(23): 2330-2338.

Guidelines:

III. First Trimester Pregnancy Loss IV. Preoperative and Postoperative Care V. Critical Care a. Cardiopulmonary Resuscitation i. Perform a rapid, focused physical examination to identify the patient who requires cardiopulmonary resuscitation and attempt to determine the cause of the patient’s decompensation. ii. Perform basic cardiac life support as per American Heart Association guidelines. iii. Describe the principles of Advanced Cardiac Life Support (ACLS), and in conjunction with an ACLS team, participate in the performance of ACLS according to American Heart Association guidelines.

Recommend Reading: Text:

American Red Cross. Basic CPR.

Preventive Ambulatory Health Care II. Special Gynecologic Conditions A. Contraception a. Define the terms: method effectiveness and user effectiveness b. Describe national policies and local policies that affect control of reproduction. c. Describe how religious, ethical, and cultural differences affect providers and users of contraception. d. Describe the impact of contraception on population growth in the United States and other nations. e. Describe the factors that influence the individual patient’s choice of contraception. f. Perform a focused physical examination to detect findings that might influence the choice of contraception. g. Interpret the results of selected laboratory tests that might influence a patient’s choice of contraception. h. Describe the advantages, disadvantages, failure rates, and complications associated with the following methods of contraception: i. Sterilization ii. Oral steroid contraception iii. Transdermal steroid contraception iv. Vaginal steroid contraception v. Implantable steroid contraception vi. Intrauterine devices vii. Barrier methods viii. Natural family planning i. Describe appropriate methods for postcoital contraception. j. Describe the appropriate follow-up for a woman using any of the aforementioned methods of contraception.

Recommend Reading: Text:

Articles: Petitti DB. Combination Estrogen-Progestin Oral Contraceptives. N Engl J Med 2003;349: 1443- 50. Vandenbroucke JP, et al. Oral Contraceptives and the Risk of Venous Thrombosis. N Engl J Med. 2001;344: 1527-1535. Marchbanks PA, et al. Oral Contraceptives and the Risk of Breast . N Engl J Med. 2002;346: 2025-32. Dickinson BD, et al. Drug Interactions Between Oral Contraceptives and Antibiotics. Obstet Gynecol. 2001;98: 853-60. Gallo MF, et al. Combination Estrogen-Progestin Contraceptives and Body Weight: Systematic Review of Randomized Controlled Trials. Obstet Gynecol 2004;103: 359-73. Pfizer. Letter to Healthcare Professionals Regarding Depo-Provera and Bone Health. November 18,2004. Grimes DA. Intrauteirne device and upper genital tract infection. Lancet. 2000;356:1013-19.

Guidelines ACOG Practice Bulletin #18. . The Use of Hormonal Contraception in Women with Coexisting Medical Conditions. Obstet Gynecol. 2000;96:. ACOG Practice Bulletin #25. Emergency Oral Contraception. . Obstet Gynecol. 2001;97. ACOG Practice Bulletin #46 Benefits and Risks of Sterilization. Obstet Gynecol. 2003;102:647- 58. ACOG Practice Bulletin #59. Intrauterine Device. Obstet Gynecol. 2005;105: 223-232. FFPRHC Guidance (January 2004). The Copper Intrauterine Device as Long-term Contraception. J Fam Planning and Rep Health Care 2004;30: 29-42.

Cervical Disorders A. Preinvasive Cervical Disease a. Describe the epidemiology of cervical dysplasia. b. Elicit a pertinent history in a woman with an abnormal Pap test. c. Interpret Pap test reports using the Bethesda classification system and determine appropriate follow-up. d. Perform and interpret the results of diagnostic procedures for cervical dysplasia. e. Treat cervical dysplasia with modalities, such as: i. Cryosurgery ii. Laser ablation iii. Loop electrical excision iv. Cold knife conization f. Manage the complications resulting from treatment of cervical dysplasia. g. Establish an appropriate follow-up plan for a woman who has been treated for cervical dysplasia. h. Describe the structural changes in the that are characteristic of in-utero DES exposure. Recommend Reading: Text:

Articles: Wright TC, et al. 2001 Consensus Guidelines for the Management of Women With Cervical Cytological Abnormalities. JAMA. 2002;287: 2120-29. Stoler MH, et al. Interobserver Reproducibility of Cervical Cytologic and Histologic Interpretations: Realistic Estimates from the ASCUS-LSIL Triage Study. JAMA. 2001;285: 1500-5. Cox JT, et al. Prospective follow-up suggests similar risk of subsequent cervical intraepithelial neoplasia grade 2 or 3 among women with cervical intraepithelial neoplasia grade 1 or negative colposcopy and directed biopsy. Am J Obstet Gynecol 2003;188: 1406-12. The ASCUS-LSIL Triage Study Group. A randomized trial on the management of low-grade squamous intraepithelial lesion cytology interpretations. Am J Obstet Gynecol. 2003;188: 1393- 1400. The ASCUS-LSIL Triage Study Group. Results of a randomized trial on the management of cytology interpretations of atypical squamous cells of undetermined significance. Am J Obstet Gynecol. 2003;188: 1383-92. Wright TC, et al. Interim Guidance for the Use of Human Papillomavirus DNA Testing as an Adjunct to Cervical Cytology for Screening. Obstet Gynecol. 2004;103: 304-9. Guido R, et al. Postcolposcopy management strategies for women referred with low-grade squamous intraepithelial lesions or human papillomavirus DNA-positive atypical squamous cells of undetermined significance: A two-year prospective study. Am J Obstet Gynecol. 2003;188:1401-5.

Guidelines ACOG Practice Bulletin #45. Cervical Cytology Screening. Obstet Gynecol. 2003;102: 417-27. ACOG Practice Bulletin #61. Human Papillomavirus. Obstet Gynecol. 2005;105:905-918. ACOG Technology Assessment #2. Cervical Cytology Screening. Obstet Gynecol. 2002;100: 1423-27. ASCCP Guidelines for the Management Cervical Cytology.2002.

PGY -2

VI. Disorders of the Urogenital Tract and Breast a. Pelvic Masses i. Describe the major causes of pelvic masses, including nongynecologic sources and t hose arising from the female genital tract, such as: 1. Uterine fibroids 2. Adnexal cystic and solid masses 3. Tuboovarian abscess 4. Adnexal torsion 5. Ovarian cysts/benign neoplasms 6. Diverticulitis 7. Appendicitis ii. Elicit a pertinent history suggestive of a pelvic mass, such as: 1. Weight loss or weight gain 2. Gastrointestinal symptoms 3. Menstrual abnormalities 4. Pelvic pain or pressure iii. Perform a focused physical examination to confirm the diagnosis of a pelvic mass. iv. Perform and/or interpret tests such as endovaginal or abdominal ultrasonography to confirm the diagnosis of a pelvic mass. v. Interpret the results of other tests, such as MRI, ultrasound, or tomographic imaging, in the evaluation of a pelvic mass. vi. Discuss the role of serum markers in the evaluation and monitoring of a patient with a pelvic mass. vii. Treat benign pelvic masses, using nonsurgical or surgical methods, considering such factors as the patient’s: 1. Age 2. General Health 3. Treatment preference 4. Desire for future childbearing 5. Symptom complex viii. Describe the appropriate follow-up for patients who have been treated for a benign pelvic mass.

Recommend Reading: Text: Surgery for Benign Diseases of the Ovary. TeLinde’s Operative Gynecology. Chapter 26. 639-660.

Articles: Oyelese Y, Kueck AS, Barter JF, Zalud I. Asymptomatic Postmenopausal Simple . Obstet Gynecol Surv. 2002;57(12): 803-9. Templeman CL, Fallat ME, Lam AM, Perlman SE, Hertweck SP, O’Conner DM. Managing Mature Cystic Teratomas of the Ovary. Obstet Gynecol Surv. 2000;55(12): 738-45. Van Nagell JR, Ueland FR. Ultrasound evaluation of pelvic masses: predictors of malignancy for the general gynecologist. Curr Opin Obstet Gynecol. 1999;11(1):45-49. DePreist PD, et al. A Morphology Index Based on Songraphic Findings in Ovarian Cancer. Gyn Onc. 1993;51: 7-11.

Guidelines ACOG Committee Opinion # 280 The Role of the Generalist Obstetrician- Gynecologist in the Early Detection of Ovarian Cancer. Obstet Gynecol. 2002;100: 1413-6. b. Benign Breast Disorders i. Describe the clinical history and principal pathophysiologic conditions that affect the breast, such as: 1. Breast mass 2. Nipple discharge 3. Pain 4. Infection (mastitis) 5. Asymmetry 6. Excessive size 7. Underdevelopment ii. Perform a focused physical examination to evaluate for an abnormality of the breast. iii. Describe the indications for the following procedures to assess breast disorders. Be able to perform and/or interpret the results of each of them: 1. Needle aspiration of a cyst or abscess 2. Collection of nipple discharge for cytologic examination and/or culture 3. Fine needle aspiration of a mass 4. Needle localization biopsy 5. Excisional biopsy 6. Mammography 7. Ultrasonography

Recommend Reading: Text: Breast Diseases: Diagnosis and Treatment of Benign and Malignant Disease. Comprehensive Gynecology. Chapter 13. 353-388.

Articles: Hindle WH. Breast Mass Evaluation. Clin Obstet Gynecol. 2002;45(3): 750-7. Zylstra S. Office Management of Benign Breast Disease. Clin Obstet Gynecol. 1999;42(2):234-248.

Guidelines ACOG Committee Opinion @ 186. Role of the Obstetrician-Gynecologist in the Diagnosis and Treatment of Breast Disease. September 1997. ACOG Committee Opinion # 272. Follow-up of Abnormal Screening Mammography. Obstet Gynecol. 2002;99: 869. ACOG Practice Bulletin # 42 Breast Cancer Screening. Obstet Gynecol 2003:101: 821-32.

VII. First Trimester Pregnancy Loss a. Spontaneous abortion i. Describe the principal causes of, or predisposing factors for, spontaneous first-trimester abortion. ii. Describe the differential diagnosis of early spontaneous abortion. iii. Describe the usual symptoms and findings experienced by a patient with an early pregnancy loss. iv. Perform a focused physical examination to confirm the diagnosis of spontaneous abortion. v. Perform and/or interpret the results of selected tests used in the diagnosis and management of early pregnancy loss: 1. Quantitative serum hCG titer 2. Ultrasonography (abdominal and endovaginal) 3. Serum progesterone 4. Complete blood count vi. Treat a patient with an early spontaneous abortion, using nonsurgical or surgical methods. vii. Describe and treat the complications that may develop as a result of treatment of a spontaneous abortion, for example: 1. Genital tract infection 2. Uterine perforation 3. Retained products of conception viii. Describe the indications for anti-D immune globulin in patients experiencing a spontaneous abortion. ix. Counsel patients regarding future fertility issues and risk of recurrent pregnancy losses depending on the etiology. x. Summarize signs and symptoms, diagnosis, treatment, and potential sequelae of septic abortion.

Recommend Reading: Text: Spontaneous and Recurrent Abortion: Etiology, Diagnosis, and Treatment. Comprehensive Gynecology. Chapter 15. 403-430. Management of Abortion. TeLinde’s Operative Gynecology. Chapter 21. 483- 506.

Articles: Oates-Whitehead RM, Haas DM, Carrier JAK. Progestogen for preventing miscarriage. Cochrane Database. 2005;1. Ballagh SA, Harris HA, Demasio K. Is curettage needed for incomplete spontaneous abortion. Am J Obstet Gynecol. 1998;179(5): 1279-82.

Guidelines ACOG Practice Bulletin # 26. Medical Management of Abortion. Obstet Gynecol. 2001;97(4).

b. Ectopic pregnancy i. Describe the major factors that predispose to ectopic pregnancy ii. Elicit a pertinent history in a patient with a suspected ectopic pregnancy. iii. Perform a focused physical examination in a patient with a suspected ectopic pregnancy. iv. Describe the differential diagnosis of ectopic pregnancy. v. Perform and interpret the results of tests to confirm the diagnosis of ectopic pregnancy, such as: 1. Endovaginal ultrasonography 2. Uterine curettage or aspiration 3. Laparoscopy vi. Interpret the results of other diagnostic tests, such as: 1. Quantitative serum hCG titer 2. Serum progesterone 3. Complete blood count vii. Describe the indications and contraindications for, and complications of, medical management of ectopic pregnancy. viii. Describe the indications for, and complications of, surgical management of an ectopic pregnancy. ix. Treat an affected patient using appropriate nonsurgical or surgical methods. x. Describe the indications for anti-D immune globulin in patients’ wit an ectopic pregnancy. xi. Describe the follow-up that is indicated for a patient treated for an ectopic pregnancy. xii. Counsel patients about the recurrence risk for an ectopic pregnancy and prognosis for a normal intrauterine pregnancy.

Recommend Reading: Text: Ectopic Pregnancy: Etiology, Pathogenesis, Diagnosis, Management. Comprehensive Gynecology. Chapter 16. 431-466. Ectopic Pregnancy. TeLinde’s Operative Gynecology. Chapter 22. 507-536.

Articles: Sowter MC, Farquhar CM. Ectopic pregnancy: an update. Curr Opin Obstet Gynecol. 2004;16: 289-93.

Guidelines ACOG Practice Bulletin # 3 Medical Management of Tubal Pregnancy. Obstet Gynecol. 1998;92(6).

VIII. Preoperative and Postoperative Care a. Preoperative Care i. Conduct detailed preoperative assessment with consideration given to the needs of special patient groups, such as: 1. Children and adolescents 2. The elderly 3. Patients with coexisting medical conditions, such as cardiopulmonary disease or coagulation disorders. ii. Describe the indications for and perform appropriate preoperative evaluation and/or referral, including laboratory tests, radiographic imaging, and EKG. iii. Summarize indications and compose appropriate preoperative preparation plans for patients undergoing gynecologic surgery, including: 1. Mechanical bowel preparation 2. Antibiotic use 3. Thromboembolism prophylaxis iv. Choose appropriate suture and surgical instruments as dictated by the procedure v. Describe the options for intraoperative pain control.

Recommend Reading: Text: Preoperative Counseling and Management: Patient Evaluation, Informed Consent, Infection Prophylaxis, Avoidance of Complications. Comprehensive Gynecology. Chapter 23. 691-718. Preoperative Care. TeLinde’s Operative Gynecology. Chapter 6. 103-122.

Articles: Grocott MP, Mythen MG, Gan TJ. Perioperative Fluid Management and Clinical Outcomes in Adults. Anesth Analg 2005;100: 1093-106. Fleisher LA, Eagle KA. Lowering Cardiac Risk in Noncardiac Surgery. N Engl J Med. 2001;345(23): 1677-1682 Monahan EG. Medical clearance for gynecologic surgery. Obstet Gynecol Surv. 1998;53(2): 117-126. Goodnough LT. Risks of blood transfusion. Crit Care Med. 2003;31(12):

Guidelines ACOG Practice Bulletin # 21. Prevention of Deep Venous Thrombosis and Pulmonary Embolism. Obstet Gynecol. 2000;94(4). ACOG Practice Bulletin #23. Antibiotic Prophylaxis for Gynecologic Procedures. Obstet Gynecol. 2001;97(1). b. Postoperative Care i. Choose appropriate pain control based on the surgical procedure, degree of patient discomfort, and patient discomfort, and patient characteristics, including age and presence of coexisting morbidities. ii. Manage and counsel patients about normal postoperative recovery. Include the following topics: 1. Advancement of diet and return to normal dietary and bowel function 2. Ambulation 3. Management of urethral catheterization and return to normal urinary function 4. Thromboembolism prophylaxis 5. Wound care 6. Return to normal activity levels and/or appropriate restrictions, including sexual activity iii. Elicit appropriate history, perform a physical examination, perform and/or interpret appropriate tests, and manage common postoperative complications, such as: 1. Fever 2. Gastrointestinal ileus/obstruction 3. Infection 4. Wound complications 5. Fluid or electrolyte imbalances, including abnormalities of urinary output 6. Respiratory problems 7. Thromboembolism

Recommend Reading: Text: TeLinde’s Operative Gynecology. Preoperative Care. Pages 103-122. . Articles: Geerts WH, et al. Prevention of Venous Thromboembolism: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126: 338S-400S. Al-Took S. Platt R. Tulandi T. -related small-bowel obstruction after gynecologic operations. Am J Obstet Gynecol. 1999;180(2): 313-315. Steed HL, et al. A randomized controlled trial of early versus traditional postoperative oral intake after major abdominal gynecologic surgery. Am J Obstet Gynecol. 2002;186(5): 861-5.

Guidelines:

IX. Critical Care a. Hemodynamic assessment i. Describe the conditions most likely to cause cardiovascular dysfunction in obstetric and gynecologic patients. ii. Perform a focused physical examination to detect signs of hemodynamic derangements, such as: 1. Hypotension or hypertension 2. Bradycardia or tachycardia 3. Apnea or tachypnea 4. Signs of poor tissue perfusion (e.g., oliguria, delayed capillary refill) 5. ARDs 6. Myocardial failure 7. Altered mental status iii. Explain the indications for central hemodynamic monitoring iv. Interpret the results of central hemodynamic monitoring and describe management of patients in whom central monitoring is being performed based on hemodynamic parameters obtained. v. Describe the complications of central hemodynamic monitoring and consult with an appropriate specialist, as needed, when managing the complications.

Recommend Reading: Text:

Articles:

Guidelines

b. Allergic drug reactions i. List the drugs most likely to produce allergic reactions in obstetric and gynecologic patients. ii. Describe the typical symptoms associated with a drug reaction. iii. Describe the varying degrees of severity of a drug reaction, including anaphylaxis. iv. Perform a focused physical examination to confirm the diagnosis of a drug reaction and assess the severity of the reaction. v. Describe the differential diagnosis of a drug reaction. vi. Describe the principles of treatment of a drug reaction. Manage a patient with a drug reaction, in consultation with an appropriate specialist, as needed.

Recommend Reading: Text:

Articles: Gruchalla RS. Drug Allergy. J Allergy Clin Immunol. 2003;11(2):548-559. Kemp SF, Lockey RF. Anaphylaxis: A review of causes and mechanisms. J Allergy Clin Immunol. 2002;110(3): 341-48.

Guidelines

Procedure Related Reading

Sterilization  Peterson HB. et al. The risk of pregnancy after tubal sterilization: Findings from the U.S. Collaborative Review of Sterilization. Am J Obstet Gynecol. 1996;174(4): 1161-1168.  Jamieson DJ, et al. Complications of Interval Laparoscopic Tubal Sterilization: Findings from the U.S. Collaborative Review of Sterilization. Obstet Gynecol. 2000;96: 997-1002.  Peterson HB, et al. The Risk of Ectopic Pregnancy after Tubal Sterilization. N Engl J Med. 1997;336(11): 762-767.  Hillis SD, et al. Poststerilization Regret: Fidnings from the U. S. Collaborative Review of Sterilization. Obstet Gynecol. 1999;93: 889-95.  Hillis SD, et al. Higher Hysterectomy Risk for Sterilization than Nonsterilized Women: Findings from the U.S. Collaborative Review of Sterilization. Obstet Gynecol. 1998;91: 241-6.  Peterson HB, et al. Pregnancy after Tubal Sterilization with Bipolar Electrocoagulation. Obstet Gynecol. 1999;94: 163-7.  Peterson HB, et al. The Risk of Menstrual Abnormalities after Tubal Sterilization. N Engl J Med. 2000;343(23): 1681-*87.

Laparoscopy  Chandler JG, et al. Three Spectra of Laparosocpic Entry Access Injuries. J Am Coll Surg. 2001;192: 478-491.

Hysterectomy  Kjerulff KH, et al. Effectiveness of Hysterectomy. Obstet Gynecol. 2000;95(3): 319-26.  Hilliis SB, et al The Effectiveness of Hysterectomy for Chronic Pelvic Pain. Obstet Gynecol. 1995;86: 941-5.  Learman LA, et al. Hysterectomy Versus Expanded Medical Treatment for Abnormal Uterine Bleeding: Clinical Outcomes in the Medicine or Surgery Trial. Obstet Gynecol. 2004;103: 824-33.  Kupperman M, et al. Effect of Hysterectomy vs Medical Treatment on Health-Related Quality of Life and Sexual Functioning. JAMA. 2004;291: 1447-1455.  Kovac SR. Transvaginal Hysterectomy: Rationale and Surgical Approach. Obstet Gynecol. 2004;103: 1321-5.  Kovac SR. Clinical Opinion: Guidelines for hysterectomy. Am J Obstet Gynecol. 2004;191: 635-40.  Farrell SA, Kieser K. Sexuality after Hysterectomy. Obstet Gynecol. 2000;95: 1045-51. 

PGY -3

X. Disorders of the Urogenital Tract and Breast a. Vulvar Dystrophies and Dermatoses i. Describe the principal types of vulvar dystrophies and dermatoses, such as: 1. Squamous cell hyperplasia 2. 3. 4. 5. Atrophic ii. Elicit a pertinent history in a patient with a suspected vulvar dystrophy or dermatosis. iii. Perform a focused physical examination in a patient with a suspected vulvar dystrophy or dermatosis. iv. Perform and/or interpret the results of selected diagnostic tests to confirm the diagnosis of a vulvar dystrophy or dermatosis, for example: 1. Colposcopy 2. Staining with dyes to localize the affected area. 3. Vulvar biopsy v. Treat common vulvar dystrophies and dermatoses medically and surgically. vi. Describe follow-up for a patient with a vulvar dystrophy or dermatosis, including the risk, if present, for malignant change.

Recommended Reading: Text: Surgical Conditions of the Vulva. TeLinde’s Operative Gynecology. Chapter 33. 865-892. Fitzpatrick: Color Atlas and Synopsis of Clinical Dermatology.

Articles: Edwards, L. New concepts in . Am J Obstet Gynecol. 2003;189(3 Suppl): S24-30. Foster DC. Vulvar Disease. Obstet Gynecol. 2002;100: 145-63.

Guidelines: Haefner H, et al. The Vulvodynia Guideline. J Lower Genit Tract Dis. 2005;9(1): 40-51.

b. Urogynecology (See Attached AUGS objectives) i. Explain the normal anatomic supports of the vagina, rectum, bladder, urethra, and (or vaginal cuff in the setting of prior hysterectomy), including the bony pelvis, pelvic floor nerves and musculature, and connective tissue. ii. Describe the static and dynamic interrelationships and function of the pelvic organs and support mechanisms. iii. Summarize the normal function of the lower urinary tract during the filling and voiding phases, and the mechanisms responsible for urinary continence. iv. Summarize the potential psychological, social, and sexual consequences of urogynecologic disorders. v. Describe the principal etiologies of pelvic support defects, urinary incontinence, and fecal incontinence, including effects of pregnancy and delivery. vi. Identify the anatomic defects associated with various aspects of pelvic support disorders. vii. Characterize the major types of urinary incontinence. viii. Describe abnormal urethral conditions, including urethral syndrome, urethritis, and diverticuli. ix. Describe the possible etiologies, diagnostic strategies, and treatment approaches for interstitial cystitis. x. Characterize and explain various types of urinary voiding disorders. xi. Describe the etiologies, prevention, diagnostic techniques, and approaches to repairing various fistulae that may involve the pelvic organs. xii. Describe the symptoms that may be experienced by a patient with pelvic support defects, urinary incontinence, or fecal incontinence. xiii. Elicit a pertinent history in a patient with a suspected pelvic support defect, urinary incontinence, or fecal incontinence. xiv. Perform a focused physical examination to identify and characterize specific pelvic support defects, including: 1. Anterior compartment 2. Urethral hypermobility 3. Posterior compartment 4. Apical compartment (cervix/uterus or vaginal cuff) xv. Perform a focused physical exam in a patient with urinary and/or fecal incontinence, including assessment of: 1. Bladder and urethral support 2. Perineal, levator, and anal sphincter strength 3. Neurologic status xvi. Perform and interpret the results of selected tests to characterize urinary incontinence disorders, including: 1. Assessment of residual urine volume 2. Simple cystometry 3. Q-tip test xvii. Describe the indication for, and interpret the results of other diagnostic tests, such as: 1. Urinalysis 2. Urine culture 3. Cystourethroscopy 4. Multi-channel cystometry 5. Urethral profilometry 6. Uroflowmetry 7. Radiologic tests 8. Electromyography 9. Assessment of anal sphincter integrity (e.g. manometry, radiologic imaging studies, neurologic testing) xviii. Treat urogynecologic disorders by both nonsurgical (e.g. pelvic floor exercise regimens, physical therapy, pessary) and surgical methods. xix. Describe the types of injuries or complications that may occur related to medical and surgical treatments of urogynecologic disorders, and the approaches to managing them. xx. Describe appropriate follow-up for a patient who has been treated for an urogynecologic disorder. xxi. Summarize and counsel patients regarding risks, benefits, and expected outcomes of surgical and nonsurgical approaches to management of pelvic support and incontinence disorders.

Recommended Reading: Text:

Articles: Clark AL, Gregory T, Smith VJ, Edwards R. Epidemiologic evaluation of reoperation for surgically treated and urinary incontinence. Am J Obstet Gynecol 2003;189:1261-7. Clemons JL, Aguilar VC, Tillinghast TA, Jackson ND, Myers DL. Risk factors associated with an unsuccessful pessary fitting trial in women with pelvic organ prolapse. Am J Obstet Gynecol. 2004;190:345-50. Ouslander JG. Management of overactive bladder. N Engl J Med 2004;3508:786-99.

Guidelines:

See attached guidelines by the American Urogynecologic Society. c. Chronic pelvic pain i. Define chronic pelvic pain. ii. Outline the principal gynecologic and nongynecologic causes of chronic pelvic pain, and describe the pathophysiology of each cause. iii. Elicit a pertinent, detailed medical, menstrual, and sexual history to characterize the patient’s chronic pelvic pain, including signs/symptoms emanating from non-reproductive organs. iv. Elicit an appropriate social and mental health history in a patient with chronic pelvic pain. v. Perform a focused physical examination, including attempts to localize the pain and an evaluation of neurologic and musculoskeletal components. vi. Perform and/or interpret the results of the following selected diagnostic tests to determine the cause of chronic pelvic pain. 1. Microbiologic cultures of the genitourinary tract. 2. Radiologic imaging studies 3. Hysteroscopy 4. Laparoscopy 5. Injection of anesthetic agent at a specific trigger point 6. Mental health examination, including screening for depression or dysphoria. vii. Treat patients with chronic pelvic pain, using nonsurgical and surgical methods. viii. Summarize indications and approximate success rates for interventions for chronic pelvic pain, such as laparoscopy, presacral neurectomy, uterosacral nerve ablation, adhesiolysis, and extirpative procedures. ix. Describe the indications for referral of a patient to a specialist in urology or gastroenterology. x. Describe the indications for referral to a multidisciplinary group, including pain management specialists and behavioral and/or mental health. xi. Describe the appropriate long-term goals and follow-up for a patient with chronic pelvic pain.

Recommended Reading: Text: Persistent or Chronic Pelvic Pain. TeLinde’s Operative Gynecology. Chapter 27. 661-674.

Articles: Howard FM. Chronic Pelvic Pain. Obstet Gynecol. 2003;101: 594-611. Howard FM. The Role of Laparoscopy in the Chronic Pelvic Pain Patient. Clin Obstet Gynecol. 2003;46(4):749-66. Gunter J. Chronic Pelvic Pain: An Integrated Approach to Diagnosis and Treatment. Obstet Gynecol Surv. 2003;58(9): 615-23. Mertz HR. Irritable bowel syndrome. N Engl J Med. 2003;349: 36-46. Butrick CW. Interstitial Cystitis and Chronic Pelvic Pain: New Insights in Neuropathology, Diagnosis, and Treatment. Clin Obstet Gynecol. 2003;46(4): 811-23.

Guidelines: ACOG Practice Bulletin #XX. Chronic Pelvic Pain 2004 Obstet Gynecol. 2004;51: 589-605.

d. (In conjunction with REI) i. Summarize the theories of the pathogenesis of endometriosis. ii. Describe the typical history of a patient with endometriosis. iii. Perform a focused physical examination in a patient with suspected endometriosis and identify the principal abnormal clinical findings. iv. Perform and interpret the results of selected tests to confirm the diagnosis of endometriosis, for example: 1. Endovaginal ultrasonography 2. Laparoscopy with/without biopsy v. Describe various features of endometriosis on visual inspection with laparoscopy or laparotomy. Compare the sensitivity of visual inspection with laparoscopy or laparotomy in diagnosing endometriosis. vi. Describe the staging system for endometriosis according to the American Society for Reproductive Medicine Classification of Endometriosis. vii. Treat endometriosis medically and surgically. viii. Describe the appropriate long-term follow-up and outcome in patients who have endometriosis, including infertility.

Recommended Reading: Text: Endometriosis and . Comprehensive Gynecology. Chapter 18. 517- 546. Endometriosis. Clinical Gynecologic Endocrinology and Infertility. Chapter 29. 1103-1134.

Articles: Winkel CA. Evaluation and Management of Women With Endometriosis. Obstet Gynecol. 2003;102:397-408. Moore J, Kennedy S, Prentice A. Modern combined oral contraceptives for pain associated with endometriosis. Cochrane Database. 2005;1. Olive DL, Pritts EA. Drug Therapy: Treatment of Endometriosis. N Engl J Med. 2001;345(4): 266-75. Jacobson TZ, Barlow DH, Koninckx P. Laparoscopic surgery for pelvic pain associated with endometriosis. Cochrane Database. 2005;1. Prentice A. Regular review: Endometriosis. BMJ. 2001;323: 93-5.

Guidelines: ACOG Practice Bulletin # 11. Medical Management of Endometriosis. December 1999.

XI. Critical Care a. Toxic shock i. Describe the pathogenesis and microbiology of toxic shock syndrome (TSS) ii. Describe the typical signs and symptoms of a patient with TSS and distinguish signs/symptoms according to the infectious agent. iii. Perform a focused physical examination to confirm the diagnosis of TSS, and assess the severity of the patient’s illness. iv. Interpret the results of diagnostic tests to evaluate TSS. v. Describe the principles of treatment of TSS, and the possible need for consultation with a critical care or infectious disease specialist. vi. Counsel affected patients about the risk of recurrence and the value of preventive measures.

Recommended Reading: Text:

Articles:

Guidelines: b. Septic shock i. Explain the pathophysiology of septic shock. ii. Describe the usual causes of septic shock in obstetric and gynecologic patients. iii. Describe the typical symptoms experienced by a patient with septic shock. iv. Perform a focused physical examination to confirm the diagnosis of septic shock, attempt to determine the etiology of the disorder, and assess the severity of the patient’s illness. v. Describe indications for, and interpret the results of, the following diagnostic tests: 1. Microbiologic cultures 2. Complete blood count and white cell differential 3. Liver function tests 4. Renal function tests 5. Coagulation profile 6. Chest x-ray 7. MRI and CT scan of the abdomen and pelvis 8. Ultrasonography of the pelvis 9. Arterial blood gases 10. Central hemodynamic monitoring vi. Describe the principles of management of septic shock, including antimicrobial and supportive therapy vii. Manage a patient with septic shock, consulting an appropriate specialist as needed.

Recommended Reading: Text: Shock in the Gynecologic Patient. TeLinde’s Operative Gynecology. Chapter 10. 209-232.

Articles: Hotchkiss RS, Karl IE. The Pathophysiology and Treatment of Sepsis. N Engl J Med. 2003;348(2): 138-150. Sessler CN, Perry JC, Varney KL. Management of severe sepsis and septic shock. Curr Opin Crit Care 2004;10: 354-63. Annane D, Bellissant E, Bollaert PE, Briegel J, Keh D, Kupfer Y. Corticosteroids for treating severe sepsis and septic shock. Cochrane Database. 2005;1. Guidelines: Dellinger RP, et al. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med 2004;32(3): 858-73.

c. Adult respiratory distress syndrome i. Identify the principal causes of adult respiratory distress syndrome (ARDS). ii. Explain the pathophysiology of ARDS depending on the etiology. iii. Describe the usual signs and symptoms manifested by a patient with ARDS. iv. Perform a focused physical examination to aid in the diagnosis of ARDS and assess the severity of the condition. v. Interpret the results of diagnostic tests such as: 1. Chest x-ray 2. Pulse oximetry 3. Arterial blood gases 4. Pulmonary function tests 5. Central hemodynamic monitoring vi. Describe the principles of treatment of ARDS. vii. Manage a patient with ARDS, consulting an appropriate specialist as needed.

Recommended Reading: Text:

Articles: Marini JJ. Advances in the understanding of acute respiratory distress syndrome: summarizing a decade of progress. Curr Opin Crit Care. 2004;10: 265-71.

Guidelines:

XII. Surgical Care of the Geriatric Patient ( In conjunction with Gyn/Onc) a. Surgical Care of the Geriatric Patient i. Explain surgical options for a given indication in a geriatric patient, accounting for the patient’s medical condition and functional status. ii. Assess the impact of the proposed surgical intervention on a patient’s capacity for independent living, including assessment of availability of assistance, or need for assistance during treatment or the recovery period. iii. Summarize complications of anesthesia that are more common in the elderly patient. iv. Assess the geriatric patient’s capacity for independent decision making related to surgical consent. v. Counsel patients and family members about advance directives, living wills, DNR orders, power of attorney, and surrogate decision-making. vi. Describe the appropriate preoperative evaluation for a geriatric patient, including consultation with other medical disciplines as indicated. vii. Describe the unique considerations related to preoperative, intraoperative, and postoperative care of the geriatric patient, such as: 1. Entrapment (pressure) neuropathies 2. Hypothermia 3. Fluid and electrolyte imbalances 4. Thromboembolism 5. Pain management 6. Adverse drug events 7. Mental status changes 8. Incontinence 9. Infection 10. Nutrition 11. Stress-induced gastrointestinal ulceration 12. Pressure ulcers 13. Ambulation difficulties 14. Prevention of falls 15. Functional decline 16. Possible referral to an assisted-living facility or possible need for assistance within the home.

Recommended Reading: Text:

Articles:

Guidelines: