Gynecologic Pathology — Broad Survey

1. Reproductive Physiology & the Menstrual Cycle

• Follicular phase: FSH-driven folliculogenesis → estrogen → endometrial proliferation
• Luteal phase: Progesterone from corpus luteum transforms endometrium for implantation
• Cycle failure: Leads to anovulation, abnormal bleeding, and infertility

2. Uterine Pathology

Leiomyomas (Uterine Fibroids)

• Medical: Vasopressin, misoprostol (intraoperative hemostasis)
• Surgical: Myomectomy (fertility-sparing) vs. hysterectomy
• Hysterectomy (without oophorectomy) significantly lowers serum AMH compared to myomectomy, suggesting greater impact on ovarian reserve
• Myomectomy feasible even with very large uteri (up to 36 cm), with low complication rates in experienced hands
• Cesarean myomectomy is safe in selected cases

Endometrial Pathology

• Cyclic changes: Proliferative → secretory → menstrual phase
• Disruption → abnormal uterine bleeding, endometrial hyperplasia, carcinoma

3. Ovarian Pathology

Polycystic Ovary Syndrome (PCOS)

• Characterized by hyperandrogenism, anovulation, and polycystic ovaries
• Elevated LH, reduced FSH, elevated androstenedione/testosterone
• Management: Clomiphene citrate (first-line for ovulation induction); letrozole (superior in PCOS per NEJM 2014); metformin (insulin sensitization); gonadotropins; laparoscopic ovarian drilling (10–15 punctures/ovary, 73% spontaneous ovulation, 72% conception within 2 years)
• Laparoscopic drilling effects sustained up to 9 years

Ovarian Masses

• Require morphologic characterization by transvaginal ultrasound
• Surgical management: diagnostic/operative laparoscopy, ovarian cystectomy, oophorectomy

Epithelial Ovarian Cancer

• 75–80% of epithelial cancers are serous type
• Screening: Neither transvaginal ultrasound alone nor CA-125 alone (nor in combination) has proven effective at reducing mortality in average-risk women (USPSTF recommends against routine screening)
• CA-125 is elevated in 50% of stage I disease and 80–90% of advanced serous cancers — useful for monitoring, not screening
• BRCA mutation carriers: Risk-reducing salpingo-oophorectomy (RRSO) recommended; residual 2–3% risk of peritoneal carcinoma even after bilateral salpingo-oophorectomy
• Prophylactic oophorectomy in premenopausal average-risk women does not reduce long-term mortality and may increase cardiovascular and osteoporosis risk

Borderline (Low Malignant Potential) Tumors

• Serous and mucinous subtypes most common
• Lower malignant potential; fertility-sparing options applicable

4. Pregnancy-Related Pathology

Spontaneous Abortion

• 8–20% of known pregnancies; 80% occur in the first trimester
• Risk factors: advancing maternal age (>40 years → ~30% risk), prior spontaneous abortion, diabetes, smoking, closely spaced pregnancies
• After documented fetal cardiac activity at 10–13 weeks: loss rate only 0.96%
• Categories: Missed abortion (closed cervix, nonviable IUP), threatened, inevitable, incomplete, complete

Gestational Trophoblastic Neoplasia (GTN)

• Includes hydatidiform mole → persistent GTN → choriocarcinoma
• Management of GTN covered in depth (chemotherapy protocols)

5. Menopause & Endocrine Disorders

• Menopause: estrogen/progesterone decline → hot flashes, sleep disturbance, mood changes, cardiovascular/bone effects
• Depression at menopause must be distinguished from mood effects of hormonal change; SSRIs may also reduce hot flashes
• Psychiatric comorbidities common in gynecologic practice: depression, anxiety (GAD, panic disorder), substance use disorders — all requiring screening and referral

6. Pelvic Floor & Urologic Pathology

Urinary Incontinence

• Detrusor overactivity (phasic, terminal, neurogenic, idiopathic)
• Urodynamic stress incontinence: Leakage from increased abdominal pressure without detrusor contraction
• Urethral function: Normal closure maintains positive urethral pressure; incompetent closure → leakage
• Evaluated by urodynamic cystometry (compliance, capacity, detrusor pressure)

7. Sexual Dysfunction

• Sexual Interest/Arousal Disorder: Addressed with CBT, mindfulness-based cognitive therapy (MBCT), partner involvement; biologic factors (fatigue, medication, depression) and psychosocial factors both addressed
• Genito-Pelvic Pain/Penetration Disorder: Managed with behavioral, physical, and psychological therapies

8. Contraception & Fertility

• LARC methods (IUDs, subdermal implants): <1% typical-use failure rate; most effective reversible contraception
• Copper T380A, LNG-IUS, etonogestrel and levonorgestrel implants
• Lactational amenorrhea: effective for 6 months if fully breastfeeding and amenorrheic (<2.45% pregnancy rate)
• Coitus interruptus: 4–22% first-year pregnancy rate

Summary Table: Key Gynecologic Pathology