What are the essential gynecological topics to learn in real-world practice?

Essential Gynecological Topics for Real-World Practice

Master the management of common menstrual disorders, contraception counseling, early pregnancy complications, and gynecologic emergencies, as these constitute the foundation of daily gynecologic practice and directly impact patient morbidity and quality of life.

Core Clinical Competencies

Menstrual Disorders Management

Dysmenorrhea represents one of the most frequent presenting complaints and requires systematic treatment protocols. 1, 2

• First-line therapy consists of NSAIDs (ibuprofen 600-800 mg every 6-8 hours or naproxen 440-550 mg every 12 hours) taken with food for 5-7 days during bleeding. 2
• Approximately 18% of patients fail NSAID therapy and require hormonal contraceptive methods as second-line treatment. 2
• Adjunctive non-pharmacological approaches include heat therapy to the abdomen/back, acupressure at LI4 (dorsum of hand) and SP6 (4 fingers above medial malleolus) points, and peppermint essential oil. 2
• When NSAIDs fail, evaluate for structural causes (fibroids, polyps, adenomyosis, endometriosis) and consider hormonal contraceptives or progestins. 2

Hypomenorrhea requires systematic evaluation to identify functional hypothalamic amenorrhea (FHA), polycystic ovarian morphology (PCOM), or endocrine disorders. 1

• Assess stress levels, exercise patterns, weight changes (BMI <18.5 kg/m² warrants nutritional intervention with 1800-2000 kcal daily), and eating disorders—these account for 50% of FHA cases. 1
• Laboratory workup includes pregnancy test (99% sensitivity/specificity), FSH (normal 1.4-9.6 IU/L), LH (normal 1.9-12.5 IU/L), estradiol, prolactin (normal 2-18 ng/mL), and TSH (normal 0.4-4.5 mU/L). 1
• LH:FSH ratio >2 suggests PCOS (85% diagnostic accuracy); ratio <1 suggests FHA (80% diagnostic accuracy). 1
• Prolonged hypoestrogenic states require hormone replacement therapy (0.3-0.625 mg conjugated estrogens daily) to prevent bone loss, with bone density monitoring every 2 years. 1

Prolonged menses evaluation follows the PALM-COEIN classification system to distinguish structural from non-structural causes. 3

• Structural causes include endometrial polyps, adenomyosis, leiomyomas (fibroids), and malignancy/hyperplasia—all require imaging with transvaginal ultrasound, sonohysterography, or hysteroscopy. 3
• Non-structural causes include ovulatory dysfunction (adolescence, perimenopause, PCOS, hypothalamic dysfunction), endometrial disorders, and iatrogenic factors (hormonal contraceptives, IUDs). 3
• Endometrial biopsy is indicated in women over 40 or those with risk factors to exclude hyperplasia or malignancy. 3
• Laboratory evaluation includes pregnancy test, thyroid function, prolactin levels, and coagulation studies when appropriate. 3

Contraception and Family Planning

Comprehensive contraceptive counseling requires discussing effectiveness, correct use, noncontraceptive benefits, side effects, and STD protection for each method. 4

• Use the "5 P's" framework: Partners (number, gender, concurrency), Practices (types of sexual activity), Protection from STDs (condom use patterns), Past STD history, and Prevention of pregnancy. 4
• Method effectiveness based on typical use is the most important consideration—long-acting reversible contraceptives (implants, IUDs) have the highest effectiveness rates. 4
• Dual protection (condoms plus another method) is essential for patients at STD risk, including those with multiple or potentially infected partners. 4
• For patients who have completed childbearing, discuss permanent sterilization (female or male) but counsel that highly effective reversible methods (implants, IUDs) may be alternatives if uncertain about future fertility. 4

Infertility evaluation should begin simultaneously for both partners after 12 months of unprotected intercourse (6 months if woman >35 years, oligomenorrhea, known tubal/uterine disease, or male subfertility suspected). 4

• Female evaluation includes reproductive history (gravidity, parity, pregnancy outcomes), menstrual cycle characteristics, sexual history including STDs, and physical examination focusing on BMI, thyroid, breast, pelvic organs, and signs of androgen excess. 4
• Male evaluation includes reproductive history, systemic illnesses (diabetes), prior surgeries/infections, medications, lifestyle exposures, gonadal toxin exposure, and physical examination of penis, urethral meatus location, and testicular examination. 4
• Refer to specialists (reproductive endocrinology, urology) when basic evaluation identifies abnormalities or after 6-12 months of unsuccessful basic interventions. 4

Early Pregnancy Complications

Ectopic pregnancy requires prompt sonographic diagnosis and risk stratification to determine medical versus surgical management. 5, 6

• Transvaginal ultrasound is the crucial diagnostic tool—all major guidelines (RCOG, RCPI, SOGC, ACOG, NICE) agree on its central role. 5
• Methotrexate is appropriate for hemodynamically stable patients meeting specific criteria: β-hCG levels, absence of fetal cardiac activity, and patient reliability for follow-up. 5
• Laparoscopy is preferred over laparotomy for hemodynamically stable patients requiring surgery; laparotomy is reserved for emergency conditions with hemodynamic instability. 5
• Post-treatment surveillance with serial β-hCG measurements is essential regardless of treatment modality. 5

Early pregnancy loss management offers three evidence-based options: expectant, medical, or surgical management. 7

• Differentiate between viable and nonviable pregnancies using serial β-hCG measurements and ultrasound findings. 7
• Present all three management options to patients, as each has distinct advantages: expectant management avoids intervention, medical management avoids surgery, and surgical management provides definitive resolution. 7
• Earlier diagnosis through improved ultrasound technology allows more conservative outpatient or day-care treatment approaches. 6

Gynecologic Emergencies

Pelvic inflammatory disease (PID) requires early recognition and appropriate antibiotic treatment to prevent long-term sequelae including infertility, chronic pelvic pain, and ectopic pregnancy. 6

• Maintain high index of suspicion in sexually active women with lower abdominal pain, cervical motion tenderness, or adnexal tenderness. 6
• Initiate empiric antibiotic therapy immediately when PID is suspected—do not delay treatment waiting for culture results. 6
• Screen for and treat STDs (gonorrhea, chlamydia) in the patient and sexual partners. 2

Ovarian torsion presents as acute pelvic pain and requires urgent surgical intervention to preserve ovarian function. 8

• Suspect in patients with sudden-onset severe unilateral pelvic pain, nausea, and vomiting. 8
• Ultrasound with Doppler may show enlarged ovary with decreased or absent blood flow, but normal Doppler does not exclude torsion. 8
• Surgical detorsion via laparoscopy should be performed urgently—ovarian preservation is possible even with apparent necrosis. 8

Common Benign Conditions

Adnexal masses, leiomyomata (fibroids), endometriosis, and PID constitute the majority of benign gynecologic presentations. 9

• Adnexal masses require risk stratification based on patient age, ultrasound characteristics (simple versus complex, size, septations, solid components), and tumor markers (CA-125) to determine malignancy risk. 9
• Leiomyomata management depends on symptoms (bleeding, pain, pressure, infertility) rather than size alone—asymptomatic fibroids require only observation. 9
• Endometriosis diagnosis is clinical based on cyclic pelvic pain, dysmenorrhea, dyspareunia, and dyschezia; empiric medical management with NSAIDs, hormonal contraceptives, or progestins is appropriate without surgical confirmation. 9
• Surgical diagnosis via laparoscopy is reserved for patients failing medical management or requiring fertility treatment. 9

Special Populations

Pediatric and Adolescent Gynecology

Prepubertal girls present with specific conditions requiring specialized knowledge: vulvovaginitis, lichen sclerosus, labial adhesions, and ovarian torsion. 8

• Use the separation and traction technique for painless genital inspection in children—this is effective and easy to perform. 8
• Speculum examination, vaginoscopy, swabs, ultrasound, or blood sampling should only be performed for specific diagnostic questions, not routine screening. 8
• Vulvovaginitis is the most common prepubertal gynecologic complaint and typically responds to improved hygiene and topical treatments. 8
• Lichen sclerosus requires high-potency topical corticosteroids and long-term monitoring for response and potential malignant transformation. 8

Pregnancy-Associated Gynecologic Conditions

Gynecologic cancers diagnosed during pregnancy require multidisciplinary management balancing maternal treatment with fetal safety. 4

• The incidence of cancer during pregnancy is rising due to delayed childbearing and increased use of noninvasive prenatal testing that may reveal asymptomatic malignancies. 4
• Imaging during pregnancy should avoid radiation exposure >100 mGy—MRI without gadolinium is preferred for staging gynecologic cancers. 4
• Chemotherapy administered during the second and third trimesters has not been associated with significant fetal defects, but avoid administration beyond week 33 of gestation to prevent delivery during nadir. 4
• Allow a 3-week period between last chemotherapy dose and expected delivery date to avoid nadir-related complications. 4

High-Risk Obstetric Patients

Women with reproductive complications (preterm birth, pre-eclampsia, gestational diabetes, premature ovarian insufficiency) have increased cardiovascular disease risk requiring long-term monitoring. 4

• Preterm birth increases stroke risk (effect size 1.71,95% CI 1.53-1.91) and cardiovascular disease risk through accelerated atherosclerosis. 4
• Obstetricians and gynecologists should take thorough reproductive histories and refer high-risk patients for cardiovascular screening and follow-up with primary care or cardiology. 4
• Postpartum contraception counseling should begin during pregnancy and continue throughout the interpregnancy period, using patient-centered approaches that avoid coercion. 4
• Women at increased risk of maternal morbidity and mortality require multidisciplinary care involving obstetricians, maternal-fetal medicine specialists, primary care, and relevant medical subspecialists. 4

Survivorship Care

Gynecologic cancer survivors require comprehensive long-term management addressing sexual health, menopausal symptoms, genitourinary/digestive disorders, and chronic pain. 4

• Hormone replacement therapy for endometrial cancer survivors remains controversial—short-term use can be discussed individually for symptomatic patients, particularly those with early/premature menopause. 4
• Vaginal stenosis following radiotherapy requires early intervention with topical estrogens, moisturizers, lubricants, and vaginal dilators plus regular sexual activity to prevent complete occlusion. 4
• Sexual health assessment should use validated questionnaires (FSFI, FSDS, SQF) to facilitate communication, though face-to-face meetings remain essential. 4
• Pelvic floor disorders (urinary incontinence, fecal incontinence, pelvic organ prolapse) are common after pelvic surgery and require early detection with referral to specialists for pelvic floor physical therapy, biofeedback, pessaries, or surgery. 4

Immunotherapy in Gynecologic Oncology

Immune checkpoint inhibitors targeting PD-(L)1 have improved outcomes in advanced cervical and endometrial cancers, requiring understanding of biomarker testing and patient selection. 4

• Features suggesting immunotherapy responsiveness include elevated PD-L1 expression, POLE mutations with ultra-mutated TMB, HPV infection, tumor-infiltrating lymphocytes, and mismatch repair deficiency. 4
• Biomarker testing is crucial to identify patients who may benefit from immunotherapy, as not all gynecologic tumors respond to immune checkpoint inhibitors. 4
• Management requires nuanced understanding of treatment selection, response evaluation, surveillance, immune-related adverse events, and quality of life considerations. 4