Gynecology: Assessment, Bleeding, and Common Conditions
Core concepts
Organize gynecology around the presenting problem. For abnormal uterine bleeding, use PALM-COEIN to separate structural (polyp, adenomyosis, leiomyoma, malignancy) from nonstructural (coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not otherwise classified) causes. Know the evaluation sequence: pregnancy test first, then imaging and endometrial sampling by age and risk. Understand cervical cancer screening and HPV testing principles, and the management of abnormal results by risk. Master common conditions: fibroids (symptom-directed therapy), endometriosis (cyclic pain, dyspareunia), PCOS (Rotterdam criteria), and pelvic inflammatory disease (minimum criteria and empiric coverage).
Traps
- Always exclude pregnancy before treating abnormal bleeding.
- Endometrial sampling is indicated for postmenopausal bleeding regardless of ultrasound thickness when bleeding is present.
- PID is a clinical diagnosis; do not wait for cultures. Treat empirically with broad coverage including anaerobes.
- PCOS is a diagnosis of exclusion; exclude thyroid disease, hyperprolactinemia, and adrenal causes.
- Fibroid treatment depends on symptoms, fertility desires, and size/location, not size alone.
Worked example / rule of thumb
A 52-year-old with new postmenopausal bleeding: pregnancy test, pelvic ultrasound, and endometrial biopsy. Any postmenopausal bleeding warrants tissue sampling. Rule of thumb: structural causes need imaging; nonstructural causes need hormonal and hematologic workup.
Anchor each answer to the patient's age, reproductive goals, and acuity.