General Gynecology, Benign Pelvic Conditions, and Gynecologic Infections
Core concepts
Benign gynecology uses systematic classification. Abnormal uterine bleeding is classified by PALM–COEIN: polyp, adenomyosis, leiomyoma, malignancy and hyperplasia; coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not otherwise classified. Fibroids are common and cause heavy bleeding, pressure, and infertility depending on location. Endometriosis presents with dysmenorrhea, dyspareunia, and chronic pelvic pain; diagnosis is clinical or laparoscopic. Pelvic inflammatory disease is diagnosed clinically with cervical motion tenderness, uterine tenderness, or adnexal tenderness, often with fever, discharge, or raised inflammatory markers. Vaginitis: bacterial vaginosis has clue cells and a fishy odor; candidiasis has itching and thick discharge; trichomoniasis has motile organisms. Ectopic pregnancy must be excluded in any reproductive-aged woman with pain and bleeding.
Traps
Do not label all heavy bleeding as “dysfunctional”; exclude structural and malignant causes, especially in women over 45. In PID, do not wait for a positive culture before treating. A normal white cell count does not exclude PID. In bacterial vaginosis, avoid treating partners routinely.
Worked example
A 28-year-old woman has lower abdominal pain, fever, and cervical motion tenderness. She meets the minimum clinical criteria for PID. Treat with a broad-spectrum regimen covering gonorrhea and chlamydia, consider anaerobic coverage, and review in 72 hours. If a tubo-ovarian abscess is suspected, arrange imaging and admission.
Rule of thumb: in a reproductive-aged woman with pelvic pain, exclude pregnancy first, then infection, then surgical emergencies.