Diagnostic Procedures in Gynecology

Diagnostic procedures in gynecology are useful in identifying the presence of disease, determining the progression of disease, and monitoring the response of the organs to treatment. The major diagnostic procedures include speculum examinations, sonography (ultrasound), colposcopy, cervical biopsy and endocervical curettage, loop electrosurgical excision procedures, vulvar biopsy, endometrial biopsy, hysteroscopy, and hysterosalpingography (HSG). All of these procedures can be performed in the office setting or in a radiology suite, though in certain situations they are performed in the OR if more sedation or increased monitoring is required.

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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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Overview

The female reproductive organs are split into the lower and upper genital tracts.

Lower genital tract

  • Includes:
    • Cervix
    • Vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor
    • Vulva
  • Types of procedures used to assess the lower tract:
    • Speculum exam
    • Colposcopy
    • Cervical biopsy
    • Endocervical curettage
    • Loop electrosurgical excision procedure
    • Vulvar biopsy

Upper genital tract

  • Includes:
    • Uterus
    • Fallopian tubes
    • Ovaries Ovaries Ovaries are the paired gonads of the female reproductive system that contain haploid gametes known as oocytes. The ovaries are located intraperitoneally in the pelvis, just posterior to the broad ligament, and are connected to the pelvic sidewall and to the uterus by ligaments. These organs function to secrete hormones (estrogen and progesterone) and to produce the female germ cells (oocytes). Ovaries
  • Types of procedures used to assess the upper tract:
    • Sonography
    • Endometrial biopsy
    • Hysteroscopy
    • Hysterosalpingography (HSG)
Gross anatomy of the female reproductive system

Gross anatomy of the female reproductive system

Image by Lecturio.

Speculum Examination

Description

A speculum is a plastic or metal device used to mechanically open the vagina, allowing visualization and examination of the vaginal wall and ectocervix.

Vaginal speculum

A vaginal speculum

Image: “vaginal speculum” by Saltanat. License: Public Domain

Indications

  • Most gynecologic symptoms, including:
    • Vaginal bleeding
    • Abnormal uterine bleeding Abnormal Uterine Bleeding Abnormal uterine bleeding is the medical term for abnormalities in the frequency, volume, duration, and regularity of the menstrual cycle. Abnormal uterine bleeding is classified using the acronym PALM-COEIN, with PALM representing the structural causes and COEIN indicating the non-structural causes. Abnormal Uterine Bleeding (e.g., oligomenorrhea, amenorrhea, heavy menstrual bleeding)
    • Pelvic pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
    • Abnormal discharge
    • Vaginal itching
    • Pelvic organ prolapse
    • Mass
    • Pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care symptoms:
      • Loss of fluid
      • Concerns for preterm labor Preterm labor Preterm labor refers to regular uterine contractions leading to cervical change prior to 37 weeks of gestation; preterm birth refers to birth prior to 37 weeks of gestation. Preterm birth may be spontaneous due to preterm labor, preterm prelabor rupture of membranes (PPROM), or cervical insufficiency. Preterm Labor and Birth
      • Bleeding
  • As part of a routine wellness examination:
    • To obtain samples for cervical cancer screening Cervical cancer screening Cervical cancer is the 3rd most common gynecologic cancer. More than 90% of cervical cancer cases are associated with high-risk human papillomavirus (hrHPV), which is transmitted by sexual contact. Cervical cancer can be prevented by early detection and treatment of precancerous lesions caused by hrHPV. Cervical Cancer Screening (e.g., a Pap smear)
    • Clinical utility when woman is asymptomatic and does not need cervical cancer screening Cervical cancer screening Cervical cancer is the 3rd most common gynecologic cancer. More than 90% of cervical cancer cases are associated with high-risk human papillomavirus (hrHPV), which is transmitted by sexual contact. Cervical cancer can be prevented by early detection and treatment of precancerous lesions caused by hrHPV. Cervical Cancer Screening is controversial → joint decision-making between woman and clinician is recommended
  • To gain access to the cervix for other procedures
  • Note: A desire to initiate contraception without any other concerns does not require a speculum exam.

Contraindications

  • Preadolescent girls (if needed to evaluate for abuse or for other procedures → general anesthesia Anesthesia Anesthesiology is the field of medicine that focuses on interventions that bring a state of anesthesia upon an individual. General anesthesia is characterized by a reversible loss of consciousness along with analgesia, amnesia, and muscle relaxation. Anesthesiology: History and Basic Concepts)
  • Severe immunosuppression: ↑ risk of bacterial translocation with speculum exams

Procedure

Placing the speculum:

  • Make sure you have all swabs, collection containers, and tools within reach prior to starting.
  • Wash your hands and wear gloves:
    • Tip: Avoid touching other items that are not part of the procedure once your hands are gloved (e.g., foot stirrups, supply drawer, etc.)
    • Unlikely to cause true harm, but your hands will touch the vagina → don’t touch something “unclean” right before you do so
  • Select a speculum of appropriate size and shape.
  • Familiarize yourself with the speculum prior to the exam.
  • Lubricate the speculum with warm water or a water-soluble lubricant (some lubricants may interfere with sampling for cervical cytology and should be avoided).
  • Let the woman know that you are about to insert the speculum.
    • Tip: Gently touch the back of your hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand to the woman’s inner thigh Thigh The thigh is the region of the lower limb found between the hip and the knee joint. There is a single bone in the thigh called the femur, which is surrounded by large muscles grouped into 3 fascial compartments. Thigh to let her adjust to the temperature/touch of your hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand before touching the labia.
  • Manually spread the labia.
  • Introduce the speculum holding it at a downward angle, then slide it inward while applying gentle downward pressure along the posterior vaginal wall
  • Once the speculum is fully inserted, open it slowly and carefully.
    • Tip: Be careful not to open the blades prematurely.
      • This is very uncomfortable.
      • Typically, the fornix of the vagina (upper portion around the cervix) is able to comfortably tolerate much larger diameters than the introitus.
  • Rotate and adjust the speculum until it cups the cervix and brings it into full view.
  • If there’s difficulty finding the cervix, partially withdraw and try again.
    • Tip: Try to find the “smooth” surface of the cervix hidden within the vaginal rugal folds → once found, use the speculum to “catch” the cervix between the speculum blades
    • Note: The cervix is often pointed directly downward.
      • May need to direct the tip of the speculum more posteriorly, then sweep upward while opening to catch the cervix. 
      • The bottom blade is longer than the top blade for this reason.
    • Less commonly, the cervix points more upward (can be seen with retroverted/retroflexed uteri).
  • Position the light until you can visualize the cervix well.
  • Maintain the open position of the speculum by tightening the thumbscrew on a metal speculum, or “clicking” it into place with a plastic speculum.

Inspection of the cervix:

On examination, note:

  • The characteristics of the surface
  • Whether the external os appears:
    • Parous (has had a vaginal delivery): larger, horizontal opening
    • Nulliparous (has not had a vaginal delivery): tight circular opening
  • Bleeding
  • Discharge (volume, color, consistency, and odor)
    • Take a sample with a cotton swab if present
  • Visible lesions:
    • Ulcerations
    • Nodules or masses
    • Describing lesions: 
      • Envision the cervix as a clock face, and describe the location of the lesion as a time.
      • E.g., a lesion in the middle of the upper cervical lip would be described as being at “12:00”

Obtain specimens for cervical cytology:

  • Obtain 1 specimen from the endocervix by:
    • Inserting a brush into the cervical canal 
    • Rotatin it several times
  • Obtain 1 specimen from from the ectocervix by:
    • Rubbing a spatula across the entire surface of the cervix
    • Placing 1 side of the spatula in the os, then rotating the spatula around like the hands on a clock
  • You can also get a combination specimen with the cervical brush (“broom”) instead:
    • Place the central, taller portion in the os.
    • Spin the brush around several times.
  • For best results:
    • The woman should not be menstruating. Note that this is not a contraindication; however, too much blood may make the sample uninterpretable.
    • Avoid intercourse, douches, or vaginal suppositories for 24–48 hours before the examination. 

Inspect the vagina:

  • Unscrew the thumbscrew and open the speculum slightly further to release the cervix.
  • Withdraw the speculum slowly while observing the vagina.
  • Maintain a slightly open position of the speculum as you withdraw it, carefully observing the mucosa as you do so, noting:
    • Color
    • Any inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation
    • Discharge (volume, color, consistency, and odor)
    • Ulcers
    • Masses
  • Close the speculum fully before it emerges from the introitus.

Colposcopy, Cervical Biopsy, and Endocervical Curettage (ECC)

Description

  • Colposcopy:
    • A colposcope (magnifying device) is used to provide an illuminated, magnified view of the ectocervix, vaginal wall, and vulva Vulva The vulva is the external genitalia of the female and includes the mons pubis, labia majora, labia minora, clitoris, vestibule, vestibular bulb, and greater vestibular glands. Vagina, Vulva, and Pelvic Floor.
    • Can be used for both diagnosis and treatment of identified lesions
  • Cervical biopsy: A tissue sample from the ectocervix and/or transformation zone is taken of any abnormal areas identified on colposcopy.
  • Endocervical curettage (ECC): 
    • A tissue sample is obtained from the endocervical canal.
    • Done at the time of colposcopy and cervical biopsies if indicated based on history, HPV HPV Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomaviridae: HPV screening, and cytology results

Indications

  • Abnormal cervical cytology (abnormal Pap smear)
  • High-risk types of HPV HPV Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomaviridae: HPV detected on cervical HPV HPV Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomaviridae: HPV testing
  • Evaluation of a palpably or visually abnormal cervix, vagina, or vulva Vulva The vulva is the external genitalia of the female and includes the mons pubis, labia majora, labia minora, clitoris, vestibule, vestibular bulb, and greater vestibular glands. Vagina, Vulva, and Pelvic Floor
  • In conjunction with treatment of cervical neoplasia, and posttreatment surveillance

Contraindications

There are very few absolute contraindications to colposcopy and biopsies. Situations in which colposcopy and biopsies are sometimes contraindicated include:

  • Acute cervicitis: may obscure results
  • Pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care
    • Colposcopy alone is often still performed in pregnancy, though physiologic changes may make interpretation more difficult.
    • Biopsies are taken only if invasive disease is highly suspected.
    • Endocervical curettage is absolutely contraindicated.
  • Life-threateningly severe immunosuppression: ↑ risk of bacterial translocation with speculum exams

Procedures

The procedure generally includes a gross examination of the vulva Vulva The vulva is the external genitalia of the female and includes the mons pubis, labia majora, labia minora, clitoris, vestibule, vestibular bulb, and greater vestibular glands. Vagina, Vulva, and Pelvic Floor, vagina, and cervix while placing the speculum, a colposcopy examination, and biopsies and/or ECC as indicated based on screening results and findings on colposcopy.

Colposcopy:

  • A vaginal speculum is placed into the vagina.
  • The colposcope is used to examine the entire surface of the visible cervix
  • Focus is on the transformation zone (TZ): 
    • The site where the squamous cells lining the ectocervix transition to the columnar cells lining the endocervix
    • The most common site for neoplasia
  • Application of acetic acid:
    • The cervix is examined 1st without acetic acid, and then with a solution of 3%–5% acetic acid. 
    • Allows improved colposcopic visualization of abnormal areas
    • Apply a generous amount of acetic acid to the cervix; wait 30‒60 seconds. 
    • Look for acetowhite changes: 
      • Cervical cells with large or dense nuclei (metaplastic, dysplastic, and HPV HPV Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomaviridae: HPV-infected cells) will turn white.
      • Acetowhite changes fade after approximately 3 minutes
  • Alternative to acetic acid: Lugol solution
    • Can be used after acetic acid if no acetowhite changes are found
    • An iodine-based solution that is taken up by normal, glycogen-containing squamous cells, causing them to turn brown
    • Abnormal cells (nonglycogenated columnar cells and high-grade lesions) do not take up the dye and remain light yellow.
  • Abnormal findings on colposcopy include: 
    • Acetowhite changes: 
      • Sharp margins on lesions suggest high-grade lesions.
      • Diffuse borders suggest low-grade lesions.
    • Mosaicism and punctation: abnormal vasculature in the TZ, suggestive of neoplasia  

Biopsy

  • Done through the speculum using a long, thin instrument that reaches the cervix.
    • Most commonly used instrument is called a Kevorkian cervical biopsy instrument.
    • Has 2 small jaws that extract a 1‒2 mm segment of tissue; known as a punch biopsy  
  • Local anesthetics Local anesthetics Local anesthetics are a group of pharmacological agents that reversibly block the conduction of impulses in electrically excitable tissues. Local anesthetics are used in clinical practice to induce a state of local or regional anesthesia by blocking sodium channels and inhibiting the conduction of painful stimuli via afferent nerves. Local Anesthetics are not typically used:
    • Cervix has relatively poor innervation to detect sharp pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain is felt more as intense visceral cramping
    • Injection of location anesthesia Anesthesia Anesthesiology is the field of medicine that focuses on interventions that bring a state of anesthesia upon an individual. General anesthesia is characterized by a reversible loss of consciousness along with analgesia, amnesia, and muscle relaxation. Anesthesiology: History and Basic Concepts is typically as uncomfortable as (or is more uncomfortable than) the biopsy itself.
  • Each specimen is individually labeled according to its location on the cervix.
  • Obtain targeted biopsies of all abnormal areas.
  • Control bleeding:
    • Usually stops spontaneously with pressure from a cotton-tipped swab
    • Can also use:
      • Silver nitrate sticks
      • Ferric subsulfate (Monsel’s solution)
      • Surgical packing
  • Pelvic rest (no intercourse/anything in the vagina) for 24‒48 hours 
Example of a cervical biopsy forceps

Example of a cervical biopsy forceps

Image by Lecturio.

Endocervical curettage (ECC)

  • Considered a “biopsy” of the endocervical canal
  • Contraindicated in pregnancy
  • Uses a curette—a long, thin instrument with a sharp metal “basket” on the end
  • The curette is introduced into the canal and moved in and out to scrape all 4 quadrants (up, down, left, and right)
  • The curette is swirled in formalin to remove the tissue.
  • An endocervical brush is then inserted and rotated to remove any additional exfoliated tissue.
  • These specimens should be collected and labeled.
Endocervical curette

Endocervical curette:
The tip is referred to as the “basket” and is used to scrape the inside of the endocervical canal.

Image by Lecturio.

Complications

Complications from colposcopy, biopsies, and ECC are all exceedingly rare, but may include:

  • Severe bleeding
  • Infection

Loop Electrosurgical Excision Procedure

Description

  • Used to diagnose and treat cervical dysplasia or very-early-stage cervical cancer
  • An electrified loop of wire is used to excise the TZ and/or pathologic area on the cervix.
  • Typically done under local anesthesia Anesthesia Anesthesiology is the field of medicine that focuses on interventions that bring a state of anesthesia upon an individual. General anesthesia is characterized by a reversible loss of consciousness along with analgesia, amnesia, and muscle relaxation. Anesthesiology: History and Basic Concepts in the office, but occasionally is done in the surgical suite under general anesthesia Anesthesia Anesthesiology is the field of medicine that focuses on interventions that bring a state of anesthesia upon an individual. General anesthesia is characterized by a reversible loss of consciousness along with analgesia, amnesia, and muscle relaxation. Anesthesiology: History and Basic Concepts
Schematic representation of cervical conization

Schematic representation of cervical conization using an electrosurgical loop

Image by Lecturio.

Indications

  • Treatment of high-grade cervical dysplasia (primary indication)
  • Diagnosis:
    • Suspicion of high-grade cervical dysplasia based on colposcopy exam with inadequate or unclear biopsy results
    • Used as an alternative when pathologic discrepancy arises between high-grade cytology on Pap smear and low-grade histology on cervical biopsy

Contraindications

  • Multiple recurrent procedures resulting in an abnormally short cervix
  • Cervicitis (e.g., active chlamydia Chlamydia Chlamydiae are obligate intracellular gram-negative bacteria. They lack a peptidoglycan layer and are best visualized using Giemsa stain. The family of Chlamydiaceae comprises 3 pathogens that can infect humans: Chlamydia trachomatis, Chlamydia psittaci, and Chlamydia pneumoniae. Chlamydia infection)
  • Pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care (strong but relative contraindication)
  • Anticoagulant use (relative)

Procedure

  • A speculum is inserted.
  • Colposcopy is performed: 
    • Acetic acid is applied and the cervix is visualized using a colposcope.
    • Extent of dysplasia is noted.
  • Smallest wire needed to excise the entire lesion should be selected.
  • Local anesthesia Anesthesia Anesthesiology is the field of medicine that focuses on interventions that bring a state of anesthesia upon an individual. General anesthesia is characterized by a reversible loss of consciousness along with analgesia, amnesia, and muscle relaxation. Anesthesiology: History and Basic Concepts is injected creating a cervical block; typically:
    • 1%–2% lidocaine with epinephrine
    • Approximately 10 mL (total) is injected at least at 5:00 and 7:00, and often at 11:00 and 1:00 as well.
    • Note: Direct injection at 3:00 and 9:00 should be avoided in order to avoid the cervical vessels.
  • The loop is activated (typically blended cutting and coagulation current at a relatively low voltage) 
  • The loop is carefully passed around and under the TZ, ideally in one continuous movement, thus excising it.
    • Moving too fast: the loop drags or sticks to the tissue and doesn’t adequately cut it
    • Moving too slowly: excessive thermal damage causing the loop to stick within the tissue, making additional passes necessary
  • Endocervical curettage is typically performed following removal of the loop electrosurgical excision procedure specimen.
  • Both loop electrosurgical excision procedure and ECC specimens are sent for histologic evaluation.
  • Control bleeding:
    • Electrocautery at the base of the lesion
    • Monsel’s solution
    • Suture if needed

Complications

  • Bleeding
  • Infection
  • Cervical stenosis due to epithelial changes.

Vulvar Biopsy

Description

A sample of tissue is taken from the vulva Vulva The vulva is the external genitalia of the female and includes the mons pubis, labia majora, labia minora, clitoris, vestibule, vestibular bulb, and greater vestibular glands. Vagina, Vulva, and Pelvic Floor.

Indication

Vulvar biopsies are indicated in the evaluation of any abnormal-appearing vulvar lesions to rule out (or identify) neoplasia and to assist in the diagnosis of vulvar dermatitis.

  • Vulvar pruritus that is not due to infections vulvovaginitis Vulvovaginitis The term vulvovaginitis is used to describe an acute inflammation of the vulva and vagina. Vulvovaginitis can be caused by several infectious and non-infectious etiologies, and results from disruption of the normal vaginal environment. Common signs and symptoms include pain, pruritis, erythema, edema, vaginal discharge and dyspareunia. Vulvovaginitis (e.g., candida Candida Candida is a genus of dimorphic, opportunistic fungi. Candida albicans is part of the normal human flora and is the most common cause of candidiasis. The clinical presentation varies and can include localized mucocutaneous infections (e.g., oropharyngeal, esophageal, intertriginous, and vulvovaginal candidiasis) and invasive disease (e.g., candidemia, intraabdominal abscess, pericarditis, and meningitis). Candida/Candidiasis infection)
  • Worrisome visible lesions (similar to the “ABCDEs” of melanoma Melanoma Melanoma is a malignant tumor arising from melanocytes, the melanin-producing cells of the epidermis. These tumors are most common in fair-skinned individuals with a history of excessive sun exposure and sunburns. Melanoma):
    • Symmetry
    • (Irregular) Borders
    • Color variation
    • Diameter (larger lesions are more concerning)
    • Evolution (lesion is changing)
    • Others:
      • Underlying skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin retraction
      • Changes in the surrounding vulvar architecture
      • Nonhealing ulcers
      • Lesions that do not respond to standard therapy
      • Abnormal vasculature (Note: Do not attempt to biopsy a highly vascular lesion in the office.)

Contraindications

  • None 
  • If risk of bleeding is high, biopsies should be done in the OR instead of the office.

Procedure

  • Perform vulvar colposcopy:
    • Generously apply acetic acid to the vulva Vulva The vulva is the external genitalia of the female and includes the mons pubis, labia majora, labia minora, clitoris, vestibule, vestibular bulb, and greater vestibular glands. Vagina, Vulva, and Pelvic Floor with soaked cotton balls.
    • Observe with a colposcope.
  • Avoid taking a biopsy sample near the clitoris or the urethral or anal openings.
  • Prepare the area with antiseptic (e.g., povidone–iodine)
  • Inject 1‒2 mL of local anesthetic (typically 1%‒2% lidocaine with or without epinephrine)
  • Obtain the biopsy sample:
    • Punch biopsy: A tool with a 3‒5 mm sharp circular tip is twisted around the site to be excised.
    • Lift the lesion and cut the base with scissors.
  • Control bleeding:
    • May stop with pressure alone
    • Can also use:
      • Silver nitrate
      • Monsel’s solution
      • Electrocautery
      • Suture
  • Keep the site clean and dry until healed
Performing pu

A punch biopsy tool is used to take an excisional biopsy of the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin:
This tool is commonly used for vulvar biopsies.

Image: “Proper technique of holding the punch for performing punch biopsy” by Nischal U. License: CC BY 2.0

Endometrial Biopsy

Description

  • A thin pipelle is used to sample the endometrium for direct histologic evaluation.
  • Done in the office, usually without anesthesia Anesthesia Anesthesiology is the field of medicine that focuses on interventions that bring a state of anesthesia upon an individual. General anesthesia is characterized by a reversible loss of consciousness along with analgesia, amnesia, and muscle relaxation. Anesthesiology: History and Basic Concepts

Indication

  • Evaluation for precancerous and neoplastic conditions of the endometrium
    • Abnormal uterine bleeding Abnormal Uterine Bleeding Abnormal uterine bleeding is the medical term for abnormalities in the frequency, volume, duration, and regularity of the menstrual cycle. Abnormal uterine bleeding is classified using the acronym PALM-COEIN, with PALM representing the structural causes and COEIN indicating the non-structural causes. Abnormal Uterine Bleeding (AUB) in women with risk factors for neoplasia
    • Postmenopausal bleeding
  • Follow-up and surveillance of endometrial hyperplasia Endometrial Hyperplasia Endometrial hyperplasia (EH) is the abnormal growth of the uterine endometrium. This abnormal growth may be due to estrogen stimulation or genetic mutations leading to uncontrolled proliferation. Endometrial Hyperplasia and Endometrial Cancer

Contraindication

  • Pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care
  • Acute infection (pelvic inflammatory, cervical, or vaginal)
  • Cervical cancer Cervical cancer Cervical cancer, or invasive cervical carcinoma (ICC), is the 3rd most common cancer in women in the world, with > 50% of the cases being fatal. In the United States, ICC is the 13th most common cancer and the cause of < 3% of all cancer deaths due to the slow progression of precursor lesions and, more importantly, effective cancer screening. Cervical Cancer
  • Cervical stenosis

Procedure

  • The woman is placed in the lithotomy position, and a bimanual examination is done to determine the uterine size and position.
  • Insert a speculum and identify the cervix.
  • Prepare the cervix with antiseptic (e.g., povidone–iodine)
  • Insert the endometrial pipelle through the cervical os until resistance is felt at the uterine fundus:
    • Pipelles have rulers on them → note the length of the cavity (average length: 6‒8 cm) 
    • If the pipelle is unable to be advanced through the cervical canal (either because of a tight internal os or a significant uterocervical angle):
      • Place a forceps (tenaculum) on the anterior lip of the cervix.  
      • Provide gentle outward traction to straighten the uterocervical angle and keep the cervix in place during insertion of the pipelle.
    • The cervical canal can be dilated with cervical dilators if still unable to advance the pipelle.
  • Pull the piston back on the pipelle to generate suction within the tube
  • Slide the pipelle in and out several times (while keeping the tip within the endometrial cavity), rotating the pipelle to obtain the most comprehensive sample possible.
  • Empty the sample into a labeled specimen container.
  • Control bleeding:
    • Small amounts of bleeding from the os and tenaculum sites are common and usually respond to pressure.
    • Severe bleeding would be suspicious for malignancy or an underlying bleeding disorder.

Complications

  • Cramping
  • Uterine perforation (uncommon with modern plastic pipelles)
  • Infection
Endoemtrial biopsy

Schematic depiction of an endometrial biopsy using a pipelle device:
The pipelle is inserted to the fundus of the uterus; then the piston on the opposite end is pulled back, creating space and generating suction within the tube. This suction pulls endometrial tissue into the tube, which can then be sent for histologic evaluation.

Image by Lecturio.

Sonography (Ultrasound)

Ultrasound is the most common diagnostic procedure used to visualize the internal female reproductive organs.

Types of studies

  • Transvaginal ultrasound (TVUS):
    • Allows for the best visualization of female reproductive structures located within the pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 "hip" bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis
    • Transducer is placed inside the vagina.
    • Transducer is typically:
      • At or below the cervix 
      • Angled slightly upward to visualize the reproductive organs
  • Transabdominal ultrasound (TAUS):
    • Transducer is placed on the lower abdomen.
    • Best for visualizing structures above the true pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 "hip" bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis, for example:
      • An enlarged uterus (e.g., during pregnancy)
      • Large cysts or fibroids extending out of the pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 "hip" bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis
    • Useful in people who cannot tolerate transvaginal exams
  • Saline infusion sonography (SIS):
    • A catheter is placed into the endometrial cavity (same procedure as placing an endometrial pipelle).
    • Once the catheter is in place, a balloon is inflated to keep the catheter in place and the speculum is removed.
    • A TVUS probe is inserted into the vagina and the uterus identified.
    • While observing on TVUS in real time, sterile saline is injected into the endometrial cavity
      • This fluid distends the cavity, allowing for evaluation of intracavitary lesions.
      • Although the fluid does efflux through the fallopian tubes, the tubes are too thin for this to be observed on TVUS (HSG is required; see below)
    • After images are taken, the balloon is deflated and the catheter and probe are removed.

Indications

TAUS/TVUS:

The indications for TVUS and TAUS are the same and generally include bleeding and/or pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain. Both are typically performed during the same exam to ensure a complete evaluation of the female reproductive organs.

  • Suspected ovarian or fallopian tube masses:
    • Cysts
    • Malignancy
    • Ectopic pregnancy
  • To assess the uterus in cases of abnormal bleeding  (including menstrual bleeding, postmenopausal bleeding, and bleeding in pregnancy), looking especially for:
    • Endometrial thickness → may indicate hyperplasia (if thick) or atrophy (if thin)
    • Presence of leiomyomas:
      • Hypoechoic, well-circumscribed, round mass
      • May be anywhere in the myometrium
    • Signs of adenomyosis Adenomyosis Adenomyosis is a benign uterine condition characterized by the presence of ectopic endometrial glands and stroma within the myometrium. Adenomyosis is a common condition, affecting 20%-35% of women, and typically presents with heavy menstrual bleeding and dysmenorrhea. Adenomyosis:
      • Enlarged uterus
      • Asymmetrical thickening of the myometrium
      • Myometrial cysts
      • Linear striations radiating out from the endometrium
      • Loss of a clear endomyometrial border
  • Pelvic pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain (looking for structural causes)
  • Evaluation of congenital anomalies
  • Infertility Infertility Infertility is the inability to conceive in the context of regular intercourse. The most common causes of infertility in women are related to ovulatory dysfunction or tubal obstruction, whereas, in men, abnormal sperm is a common cause. Infertility assessments
  • Assess the presence and location of intrauterine devices (IUDs).
  • Pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care assessments:
    • Dating
    • Cervical length
    • Anatomic, fluid, and growth assessments of the fetus
  • Visually assist with other invasive procedures, including:
    • Aspiration of ova for in vitro fertilization Fertilization To undergo fertilization, the sperm enters the uterus, travels towards the ampulla of the fallopian tube, and encounters the oocyte. The zona pellucida (the outer layer of the oocyte) deteriorates along with the zygote, which travels towards the uterus and eventually forms a blastocyst, allowing for implantation to occur. Fertilization and First Week 
    • Aspiration of pelvic fluid
    • Obstetric uses, including:
      • Amniocentesis
      • Chorionic villus sampling

SIS:

By distending the uterus, SIS allows identification of intracavitary pathology (in addition to everything seen on routine TVUS). A standard TVUS is typically performed before the SIS procedure.

  • Can identify:
    • Polyps
    • Submucosal leiomyomas
    • Adhesions
    • Septa
    • Contour of the endometrial cavity
  • Typically done to evaluate:
    • Infertility Infertility Infertility is the inability to conceive in the context of regular intercourse. The most common causes of infertility in women are related to ovulatory dysfunction or tubal obstruction, whereas, in men, abnormal sperm is a common cause. Infertility
    • Abnormal uterine bleeding Abnormal Uterine Bleeding Abnormal uterine bleeding is the medical term for abnormalities in the frequency, volume, duration, and regularity of the menstrual cycle. Abnormal uterine bleeding is classified using the acronym PALM-COEIN, with PALM representing the structural causes and COEIN indicating the non-structural causes. Abnormal Uterine Bleeding with suspected endometrial pathology
    • Intrauterine surgical planning
Normal hysterosonography

Saline infusion sonogram (SIS):
The sterile saline instilled into the cavity of the uterus is anechoic (visible as the dark central portion of the image) and delineates the shape of the endometrial cavity. This image shows a normal endometrium (the hyperechoic/brighter band around the cavity), without any focal changes. The endometrium is surrounded by the myometrium, which stretches almost to the right border of the image.

Image: “Normal hysterosonography” by Mikael Häggström. License: Public Domain

Contraindications

  • TAUS: none
  • TVUS: preadolescent girls
  • SIS: pregnancy

Hysteroscopy (HSC)

Description

  • A scope is introduced into the endometrial cavity through the cervix. 
  • Used to diagnose and/or treat intrauterine pathologies
  • It is a gold standard diagnostic tool for assessment of:
    • Endometrial cavity
    • Tubal ostia (where the tubes enter the endometrial cavity)
    • Endocervical canal
  • Can be performed in the office or in a surgical suite

Indications

From a diagnostic standpoint, HSC has similar indications as for SIS. The primary advantage of HSC over SIS is the ability to directly visualize lesions and treat them simultaneously. HSC is performed to:

  • Diagnose and investigate causes of:
    • Abnormal uterine bleeding Abnormal Uterine Bleeding Abnormal uterine bleeding is the medical term for abnormalities in the frequency, volume, duration, and regularity of the menstrual cycle. Abnormal uterine bleeding is classified using the acronym PALM-COEIN, with PALM representing the structural causes and COEIN indicating the non-structural causes. Abnormal Uterine Bleeding
    • Thickened endometrium seen on sonography; can distinguish between:
      • Diffusely thickened endometrium (a concern for hyperplasia)
      • Polyps
    • Submucosal fibroids
    • Intrauterine adhesions
    • Endocervical lesions
    • Infertility Infertility Infertility is the inability to conceive in the context of regular intercourse. The most common causes of infertility in women are related to ovulatory dysfunction or tubal obstruction, whereas, in men, abnormal sperm is a common cause. Infertility
    • Postmenopausal bleeding
    • Dislocation of IUDs
  • Treat lesions via:
    • Adhesiolysis
    • Myomectomy/polypectomy
    • Endometrial ablation (or resection)
    • Removal of intrauterine foreign bodies

Contraindications

  • Viable intrauterine pregnancy
  • Active pelvic infection
  • Known cervical or uterine cancer

Procedure

  • Cervix and vagina are prepared with antiseptic (e.g., povidone–iodine)
  • A speculum is inserted and the cervix identified.
  • The anterior lip of the cervix is grasped with a tenaculum forceps to:
    • Provide countertraction during dilation and advancement of the scope
    • Straighten the uterocervical angle with gentle outward pressure
  • The cervix is dilated up to the diameter of the scope.
  • The hysteroscope (usually about 4‒5 mm in diameter) is introduced through the cervix.
  • The uterus is distended with a gas or fluid medium (most often, normal saline).
  • Images are taken.
  • Surgical treatments (e.g., myomectomy) are performed
    • Camera is contained within a sheath.
    • These sheaths can also contain operative ports—channels through which surgical instruments can be introduced.

Complications

  • Uterine perforation
  • Injury to internal organs
  • Hemorrhage 
  • Infection
  • Complications from distention media:
    • Air embolism 
    • Fluid overload
    • Hyponatremia Hyponatremia Hyponatremia is defined as a decreased serum sodium (sNa+) concentration less than 135 mmol/L. Serum sodium is the greatest contributor to plasma osmolality, which is very tightly controlled via antidiuretic hormone (ADH) release from the hypothalamus and by the thirst mechanism. Hyponatremia
Hysteroscopy
Hysteroscopy

Schematic depiction of hysteroscopy

Image by Lecturio.

Hysterosalpingography (HSG)

Description

  • A fluoroscopic examination that allows assessment of the uterine cavity shape and patency of the fallopian tubes
  • A catheter is inserted into the uterine cavity → dye is injected → x-ray images are taken

Indications

  • Assess tubal patency:
    • Usually as part of an infertility evaluation
    • Note: The tubal canal is very thin and not visible with other imaging methods.
  • Suspected congenital uterine anomalies

Contraindications

  • Pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care
    • These procedures are typically done after menses but prior to ovulation in order to avoid interruption of early viable pregnancies.
    • For unclear reasons, there is an increased chance of conception during cycles in which HSG is performed.
  • Active undiagnosed vaginal bleeding
  • Active pelvic infection

Procedure

  • A speculum is inserted and the cervix identified.
  • A balloon-tipped catheter is inserted through the cervical canal into the uterine cavity:
    • Balloon is inflated to hold the catheter in place and to prevent leakage of dye.
    • A tenaculum can be used if needed.
  • The contrast material is injected slowly and observed on fluoroscopy in real time.
  • Images are taken.
  • The balloon is deflated; a final image is usually taken of dye filling the vaginal cavity while the catheter is withdrawn.

Findings

Normal: 

  • Normal uterine cavity contour
  • Fallopian tubes fill with dye → dye is seen spilling out the ends of both tubes into the pelvic cavity (“bilateral fill and spill”)

Abnormal:

  • Absence or partial filling of the tubes, or absence of spill → fallopian tube obstruction
  • Dilated fallopian tube → hydrosalpinx
  • Intracavitary filling defects → submucosal leiomyomas or polyps
  • Abnormal uterine cavity contour → congenital uterine anomaly
Hysterosalpingographic evaluation of primary and secondary infertility

Normal HSG examination:
This radiograph shows a normal uterine contour with bilateral fill and spill of dye from the fallopian tubes.

Image: “Hysterosalpingographic evaluation of primary and secondary infertility” by Muhammad Usman Aziz, MBBS, FCPS (Radiology). Senior Registrar, Department of Radiology, Liaquat National Hospital. License: CC BY 3.0

Complications

  • Cramping
  • Leaking contrast material
  • Vaginal bleeding
  • Fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever
  • Severe pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain

Clinical Relevance

The following conditions are some of the most common gynecologic conditions diagnosed with the procedures discussed on this page:

  • Cervical cancer Cervical cancer Cervical cancer, or invasive cervical carcinoma (ICC), is the 3rd most common cancer in women in the world, with > 50% of the cases being fatal. In the United States, ICC is the 13th most common cancer and the cause of < 3% of all cancer deaths due to the slow progression of precursor lesions and, more importantly, effective cancer screening. Cervical Cancer: 3rd most common cancer in women in the world. Owing to effective screening, diagnosis, and treatment, however, most disease can be caught and treated at an early, preinvasive stage. Diagnosis is made using cervical Pap smears with assessing cytology, HPV HPV Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomaviridae: HPV testing, colposcopy, and biopsies. Preinvasive disease is typically managed with loop electrosurgical excision procedures, while invasive disease requires more significant surgeries.
  • Abnormal uterine bleeding Abnormal Uterine Bleeding Abnormal uterine bleeding is the medical term for abnormalities in the frequency, volume, duration, and regularity of the menstrual cycle. Abnormal uterine bleeding is classified using the acronym PALM-COEIN, with PALM representing the structural causes and COEIN indicating the non-structural causes. Abnormal Uterine Bleeding (AUB):  collective term for abnormalities in the frequency, volume, duration, and/or regularity of the menstrual cycle Menstrual cycle The menstrual cycle is the cyclic pattern of hormonal and tissular activity that prepares a suitable uterine environment for the fertilization and implantation of an ovum. The menstrual cycle involves both an endometrial and ovarian cycle that are dependent on one another for proper functioning. There are 2 phases of the ovarian cycle and 3 phases of the endometrial cycle. Menstrual Cycle. Etiologies include Polyps, Adenomyosis, Leiomyomas, Malignancy/hyperplasia, Coagulopathy, Ovulatory dysfunction, Endometritis and atrophy, Iatrogenic causes (official acronym: PALM-COEIN). Diagnosis is done by extensive history taking, exam, lab workup, sonography, and/or endometrial biopsy. Treatment is based on the underlying etiology. 
  • Uterine leiomyoma Uterine leiomyoma Uterine leiomyomas (or uterine fibroids) are benign tumors arising from smooth muscle cells in the uterine myometrium. Leiomyosarcomas, however, are malignant tumors, arising de novo (not from fibroids). Uterine Leiomyoma and Leiomyosarcoma: benign tumors arising from smooth muscle cells in the uterine myometrium. Uterine leiomyomas are usually easily identified as a hypoechoic, well-circumscribed, round masses on pelvic sonography. Treatment for leiomyomas may include surgical resection or medical options to reduce bleeding and/or bulk symptoms. 
  • Endometrial polyps Endometrial polyps Endometrial polyps are pedunculated or sessile projections of the endometrium that result from overgrowth of endometrial glands and stroma around a central vascular stalk. Endometrial polyps are a few millimeters to a few centimeters in size, can occur anywhere within the uterine cavity, and, while usually benign, can be malignant, particularly in postmenopausal women. Endometrial Polyps: pedunculated or sessile projections of the endometrium that result from overgrowth of endometrial glands and stroma around a central vascular stalk. Endometrial polyps Endometrial polyps Endometrial polyps are pedunculated or sessile projections of the endometrium that result from overgrowth of endometrial glands and stroma around a central vascular stalk. Endometrial polyps are a few millimeters to a few centimeters in size, can occur anywhere within the uterine cavity, and, while usually benign, can be malignant, particularly in postmenopausal women. Endometrial Polyps are a few millimeters to a few centimeters in size and can occur anywhere within the uterine cavity. These polyps can become malignant in postmenopausal women. Endometrial polyps Endometrial polyps Endometrial polyps are pedunculated or sessile projections of the endometrium that result from overgrowth of endometrial glands and stroma around a central vascular stalk. Endometrial polyps are a few millimeters to a few centimeters in size, can occur anywhere within the uterine cavity, and, while usually benign, can be malignant, particularly in postmenopausal women. Endometrial Polyps are suspected on a sonogram showing a thickened endometrium and are more definitively diagnosed on SIS, HSG, and/or hysteroscopy and are usually treated with hysteroscopic resection. 
  • Adenomyosis: benign uterine condition characterized by the presence of ectopic endometrial glands and stroma within the myometrium. Adenomyosis typically presents with heavy menstrual bleeding and dysmenorrhea. Diagnosis is often made during history taking, with numerous findings suggestive of adenomyosis Adenomyosis Adenomyosis is a benign uterine condition characterized by the presence of ectopic endometrial glands and stroma within the myometrium. Adenomyosis is a common condition, affecting 20%-35% of women, and typically presents with heavy menstrual bleeding and dysmenorrhea. Adenomyosis on ultrasound. Management is based on the woman’s preference regarding future childbearing and may include hysterectomy (definitive treatment), other surgical options, or medical hormonal suppression.
  • Ovarian cysts Ovarian cysts Ovarian cysts are defined as collections of fluid or semiliquid material, often walled off by a membrane, located in the ovary. These cysts are broadly categorized as either functional or neoplastic. Neoplastic ovarian cysts are subcategorized as either benign or malignant. Ovarian Cysts: collections of fluid or semiliquid material, often walled off by a membrane, located in the ovary. When the cysts occur as a result of normal physiologic processes, they are called functional, whereas if there is abnormal growth of ovarian cells, the cyst is referred to as neoplastic. Neoplastic ovarian cysts are subcategorized as either benign or malignant and are categorized according to their cell of origin (e.g., epithelial, germ cell, or stromal cells).
  • Vulvar dermatoses:
    • Lichen sclerosis (LS): chronic, progressive dermatologic condition of the vulva Vulva The vulva is the external genitalia of the female and includes the mons pubis, labia majora, labia minora, clitoris, vestibule, vestibular bulb, and greater vestibular glands. Vagina, Vulva, and Pelvic Floor that is characterized by inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation and epithelial thinning, visible as porcelain-white “parchment-like” vulvar plaques; as LS progresses, scarring can distort the anatomy. Lichen sclerosis itself is benign, but it is associated with an increased risk for vulvar squamous cell carcinoma Squamous cell carcinoma Cutaneous squamous cell carcinoma (cSCC) is caused by malignant proliferation of atypical keratinocytes. This condition is the 2nd most common skin malignancy and usually affects sun-exposed areas of fair-skinned patients. The cancer presents as a firm, erythematous, keratotic plaque or papule. Squamous Cell Carcinoma (SCC). Diagnosis is clinical, but definitive diagnosis requires vulvar biopsy, which shows a thinned epidermal layer and homogenization of collagen in the upper dermis.
    • Lichen simplex chronicus: benign vulvar skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin disorder characterized by hyperkeratosis (thickening of the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin) that occurs secondary to chronic vulvar irritation. Lichen simplex chronicus presents with intense pruritus, often worse at night, and well-demarcated, dry patchy plaques; the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin is usually thick, scaly, and firm and may appear similar to some vulvar malignancies. Diagnosis is usually clinical (but a biopsy may be needed to rule out malignancy) and shows a hypertrophic epidermal layer.

References

  1. Feltmate, C. M., Feldman, S. (2020). Colposcopy. UpToDate. https://www.uptodate.com/contents/colposcopy#H17
  2. Lee, S. I., Kilcoyne, A. (2021). Hysterosalpingography. UpToDate. Retrieved December 14, 2021, Retrieved December 14, 2021,from https://www.uptodate.com/contents/hysterosalpingography#H1381205198
  3. Moore, J.F., Carugno, J. (2021). Hysteroscopy. StatPearls. Retrieved December 14, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK564345
  4. Bradley, L. D. (2021). Overview of hysteroscopy. UpToDate. Retrieved December 14, 2021, from https://www.uptodate.com/contents/overview-of-hysteroscopy?topicRef=3262&source=see_link#H47
  5. Carusi, D. A. (2021). The gynecologic history and pelvic examination. UpToDate. Retrieved December 14, 2021, from https://www.uptodate.com/contents/the-gynecologic-history-and-pelvic-examination?search=speculum%20exam&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H7
  6. Hoffman, M. S., Mann, W. J. (2021). Cervical intraepithelial neoplasia: Diagnostic excisional procedures. UpToDate. Retrieved December 14, 2021, from https://www.uptodate.com/contents/cervical-intraepithelial-neoplasia-diagnostic-excisional-procedures?search=LEEP&source=search_result&selectedTitle=1~36&usage_type=default&display_rank=1#H5
  7. Will, A.J., Sanchack, K.E. (2020). Endometrial Biopsy. StatPearls. Retrieved December 14, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK541135/

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