{"id":37119,"date":"2026-06-26T06:06:17","date_gmt":"2026-06-26T00:36:17","guid":{"rendered":"https:\/\/atsixty.com\/?p=37119"},"modified":"2026-06-26T18:35:13","modified_gmt":"2026-06-26T13:05:13","slug":"gynaecology-summative-revision-notes","status":"publish","type":"post","link":"https:\/\/atsixty.com\/index.php\/obg\/gynaecology-summative-revision-notes\/","title":{"rendered":"Gynaecology: Summative Revision Notes"},"content":{"rendered":"\n\n\n<link href=\"https:\/\/fonts.googleapis.com\/css2?family=Playfair+Display:ital,wght@0,400;0,600;0,700;1,400;1,600&amp;family=Source+Serif+4:ital,wght@0,300;0,400;0,600;1,400&amp;display=swap\" rel=\"stylesheet\">\n<style>\n#grev01 *,#grev01 *::before,#grev01 *::after{box-sizing:border-box;margin:0;padding:0}\n#grev01{\n  --ob:#4B3A6E;--ob-dark:#362952;--ob-pale:#EFE9F5;--ob-mid:#5F4D85;\n  --acc:#A23B5C;--acc-pale:#FBEFF2;\n  --ink:#241B36;--ink-mid:#4A3D63;--ink-soft:#8A7FA0;\n  --line:#E0D8EC;--cream:#F8F6FB;--warm:#FCFBFD;\n  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var(--ob);border-radius:6px;padding:4px 13px}\n#grev01 .rv-quiz-link:hover{background:var(--ob);color:#fff}\n#grev01 .rv-footer{margin-top:32px;text-align:center;font-size:0.80rem;color:var(--ink-soft);font-style:italic;line-height:1.6}\n#grev01 .rv-footer a{color:var(--ob);font-style:normal;font-weight:600;text-decoration:none;border-bottom:1px solid var(--ob)}\n#grev01 .rv-footer a:hover{opacity:0.75}\n@media print{\n  #grev01 .rv-header{background:#4B3A6E !important;-webkit-print-color-adjust:exact}\n  #grev01{padding-bottom:20px}\n  #grev01 .rv-section{break-inside:avoid;box-shadow:none}\n}\n@media(max-width:480px){\n  #grev01 .rv-title{font-size:1.45rem}\n  #grev01 .rv-sec-title{font-size:1rem}\n  #grev01 table{font-size:0.76rem}\n  #grev01 td,#grev01 th{padding:6px 8px}\n}\n<\/style>\n\n<div id=\"grev01\">\n\n  <div class=\"rv-header\">\n    <div class=\"rv-eyebrow\">Morning Rounds \u00b7 Gynaecology Series<\/div>\n    <div class=\"rv-title\">Gynaecology<br><em>Summative Revision Notes<\/em><\/div>\n    <div class=\"rv-subtitle\">Seven topics \u00b7 NEET-PG \/ INI-CET \/ UPSC CMS \u00b7 Key facts, thresholds, classifications and traps<\/div>\n    <div class=\"rv-chips\">\n      <span class=\"rv-chip\">Physiology &amp; Consent<\/span>\n      <span class=\"rv-chip\">AUB &amp; PALM-COEIN<\/span>\n      <span class=\"rv-chip\">PCOS<\/span>\n      <span class=\"rv-chip\">Endometriosis &amp; Adenomyosis<\/span>\n      <span class=\"rv-chip\">Genital Infections &amp; PID<\/span>\n      <span class=\"rv-chip\">Menopause &amp; HRT<\/span>\n      <span class=\"rv-chip\">Gynaecological Malignancies<\/span>\n    <\/div>\n  <\/div>\n\n  <div class=\"rv-body\">\n\n    <div class=\"rv-intro\">\n      <p>These notes consolidate the seven Gynaecology Morning Rounds. They are written for rapid pre-exam revision \u2014 not first-time learning. Each section heading links to its quiz. Summative pill-badges at the end of each section capture the single-line facts most likely to appear as isolated IBQs.<\/p>\n    <\/div>\n\n    <!-- \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\n         SECTION 1 \u2014 NORMAL PHYSIOLOGY, EXAMINATION & CONSENT\n    \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550 -->\n    <div class=\"rv-section\">\n      <div class=\"rv-sec-head\">\n        <a href=\"https:\/\/atsixty.com\/index.php\/morning-rounds\/menstrual-physiology\/\">\n          <div class=\"rv-sec-num\">Topic 01 \u00b7 Gynaecology<\/div>\n          <div class=\"rv-sec-title\">Menstrual Physiology, Examination &amp; Informed Consent <span class=\"rv-arrow\">\u2197<\/span><\/div>\n        <\/a>\n      <\/div>\n      <div class=\"rv-sec-body\">\n\n        <div class=\"rv-sub\">FIGO Normal Menstrual Cycle<\/div>\n        <p><strong>Frequency 24\u201338 days \u00b7 duration \u22648 days \u00b7 no intermenstrual\/postcoital bleeding \u00b7 no flooding or large clots.<\/strong> A cycle meeting all four needs no further workup \u2014 the \"28-day\" figure is a population average, not a diagnostic cutoff. Pad count is a subjective proxy for blood loss, not itself a trigger for objective quantification.<\/p>\n\n        <div class=\"rv-sub\">Normal Physiology \u2014 Don't Over-Call These<\/div>\n        <p><strong>Mittelschmerz<\/strong> (brief, one-sided, mid-cycle, from follicular rupture) \u2014 benign, no imaging required. <strong>Physiologic leucorrhoea<\/strong> (cyclical, odourless, oestrogen-driven, increases around ovulation and premenstrually) \u2014 not infection. Neither is a function of age \u2014 the specific features drive the decision to investigate, not how young the patient is.<\/p>\n\n        <div class=\"rv-sub\">Baseline Gynaecological Assessment<\/div>\n        <p>Menstrual, obstetric, contraceptive, and relevant sexual history are taken <strong>as a matter of course<\/strong> \u2014 not restricted to the stated complaint. Pelvic examination is performed when <em>clinically indicated<\/em>, not reflexively at every first visit; a chaperone is offered <strong>routinely<\/strong>, not only when the patient specifically asks.<\/p>\n\n        <div class=\"rv-sub\">Informed Consent for Invasive Procedures (e.g. Endometrial Biopsy)<\/div>\n        <p>Must cover purpose and diagnostic limits, specific risks (bleeding, infection, rare perforation), voluntary nature, the alternative of hysteroscopy if inconclusive, and how results will be communicated. A strong clinical indication never abbreviates this process. A hyperplasia result does <strong>not<\/strong> pre-commit the patient to hysterectomy \u2014 management options remain hers to choose.<\/p>\n\n        <div class=\"rv-sub\">ASCUS + High-Risk HPV<\/div>\n        <p>Raises probability of dysplasia but is not itself a diagnosis \u2014 triage to <strong>colposcopy with directed biopsy<\/strong>, since histology, not the screening combination, confirms or excludes CIN.<\/p>\n\n        <p><span class=\"rv-pill\">FIGO normal cycle: 24\u201338 days, \u22648 days duration<\/span> <span class=\"rv-pill-blue\">Pad count \u2260 objective workup trigger<\/span> <span class=\"rv-pill-blue\">Chaperone offered routinely, not on request<\/span> <span class=\"rv-pill-green\">ASCUS + HPV+ \u2192 colposcopy, not repeat Pap<\/span><\/p>\n\n        <div class=\"rv-quiz-wrap\"><a class=\"rv-quiz-link\" href=\"https:\/\/atsixty.com\/index.php\/morning-rounds\/menstrual-physiology\/\">\u25b6 Open Quiz 01<\/a><\/div>\n\n      <\/div>\n    <\/div>\n\n    <!-- \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\n         SECTION 2 \u2014 AUB & PALM-COEIN\n    \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550 -->\n    <div class=\"rv-section\">\n      <div class=\"rv-sec-head\">\n        <a href=\"https:\/\/atsixty.com\/index.php\/morning-rounds\/abnormal-uterine-bleeding-palm-coein\/\">\n          <div class=\"rv-sec-num\">Topic 02 \u00b7 Gynaecology<\/div>\n          <div class=\"rv-sec-title\">Abnormal Uterine Bleeding &amp; PALM-COEIN <span class=\"rv-arrow\">\u2197<\/span><\/div>\n        <\/a>\n      <\/div>\n      <div class=\"rv-sec-body\">\n\n        <div class=\"rv-table-wrap\">\n          <table>\n            <tbody><tr><th>Category<\/th><th>Covers<\/th><\/tr>\n            <tr><td><strong>PALM<\/strong> (structural)<\/td><td>Polyp, Adenomyosis, Leiomyoma, Malignancy\/hyperplasia<\/td><\/tr>\n            <tr><td><strong>COEIN<\/strong> (non-structural)<\/td><td>Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not yet classified<\/td><\/tr>\n          <\/tbody><\/table>\n        <\/div>\n\n        <div class=\"rv-sub\">Fibroid Subtype &amp; Bleeding Risk (FIGO 0\u20137)<\/div>\n        <p>Types 0\u20132 (<strong>submucosal<\/strong>) bleed disproportionately via cavity distortion; 3\u20134 (intramural) and 5\u20137 (subserosal) more often cause bulk\/pressure symptoms or are asymptomatic for bleeding. Location, not size alone, drives both classification and management choice \u2014 though subserosal fibroids aren't <em>absolutely<\/em> incapable of any bleeding contribution either.<\/p>\n\n        <div class=\"rv-sub\">Anovulatory AUB (Adolescents)<\/div>\n        <p>Immature HPO axis \u2192 no corpus luteum \u2192 <strong>unopposed oestrogen<\/strong> \u2014 usually self-limited, but persistent unopposed exposure carries a real endometrial hyperplasia risk, so cycle regulation (not just reassurance) is reasonable if the pattern persists or bleeding is heavy.<\/p>\n\n        <div class=\"rv-sub\">Adolescent Menorrhagia Since Menarche<\/div>\n        <p>Heavy bleeding present <strong>since menarche<\/strong>, plus bruising\/epistaxis \u2192 screen for von Willebrand disease <strong>alongside<\/strong> the gynaecological evaluation, not after exhausting it.<\/p>\n\n        <div class=\"rv-sub\">Management Stepwise<\/div>\n        <p>Medical first \u2014 tranexamic acid\/NSAIDs, or hormonal (COCP, LNG-IUS) \u2014 before ablation or hysterectomy. \"Objectively confirmed\" blood loss confirms the diagnosis, not the treatment tier; a normal workup still warrants symptomatic\/hormonal management if bothersome.<\/p>\n\n        <p><span class=\"rv-pill\">PALM = structural, COEIN = non-structural<\/span> <span class=\"rv-pill-blue\">Submucosal fibroids bleed most<\/span> <span class=\"rv-pill-blue\">Bleeding since menarche + bruising \u2192 screen for vWD<\/span> <span class=\"rv-pill-green\">Medical therapy before ablation\/hysterectomy<\/span><\/p>\n\n        <div class=\"rv-quiz-wrap\"><a class=\"rv-quiz-link\" href=\"https:\/\/atsixty.com\/index.php\/morning-rounds\/abnormal-uterine-bleeding-palm-coein\/\">\u25b6 Open Quiz 02<\/a><\/div>\n\n      <\/div>\n    <\/div>\n\n    <!-- \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\n         SECTION 3 \u2014 PCOS\n    \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550 -->\n    <div class=\"rv-section\">\n      <div class=\"rv-sec-head\">\n        <a href=\"https:\/\/atsixty.com\/index.php\/morning-rounds\/polycystic-ovary-syndrome-diagnosis-management\/\">\n          <div class=\"rv-sec-num\">Topic 03 \u00b7 Gynaecology<\/div>\n          <div class=\"rv-sec-title\">Polycystic Ovary Syndrome \u2014 Diagnosis &amp; Management <span class=\"rv-arrow\">\u2197<\/span><\/div>\n        <\/a>\n      <\/div>\n      <div class=\"rv-sec-body\">\n\n        <div class=\"rv-sub\">Rotterdam Criteria<\/div>\n        <p>Any <strong>two of three<\/strong> \u2014 oligo\/anovulation, clinical or biochemical hyperandrogenism, polycystic ovarian morphology on USG \u2014 after excluding other causes (thyroid, prolactin, non-classic CAH). <strong>LH:FSH ratio and insulin resistance testing are not required criteria<\/strong>, despite being commonly mistaken for diagnostic components.<\/p>\n\n        <div class=\"rv-sub\">Mechanism<\/div>\n        <p>Relatively elevated LH drives theca cell androgen synthesis; insulin resistance amplifies this and <strong>lowers<\/strong> hepatic SHBG production \u2014 more free, biologically active androgen circulates as a result. (Direction matters: insulin resistance lowers SHBG, it does not raise it.)<\/p>\n\n        <div class=\"rv-sub\">Red Flag \u2014 Not PCOS<\/div>\n        <p><strong>Rapid-onset, severe virilisation<\/strong> (voice change, clitoromegaly) over months, rather than gradual hirsutism since adolescence, should prompt evaluation for an androgen-secreting tumour or non-classic CAH \u2014 tempo of onset is the key discriminator.<\/p>\n\n        <div class=\"rv-sub\">Long-Term Risk<\/div>\n        <p>Chronic anovulation \u2192 unopposed oestrogen \u2192 endometrial hyperplasia risk, <strong>independent of fertility intentions<\/strong> \u2014 ensure regular withdrawal bleeding (cyclical progestin, COCP, or LNG-IUS) regardless of whether pregnancy is desired.<\/p>\n\n        <div class=\"rv-sub\">Goal-Directed Management<\/div>\n        <p>Fertility desired \u2192 lifestyle + letrozole (ovulation induction). Fertility not desired \u2192 COCP for cycle regulation\/endometrial protection. Metformin is an <strong>adjunct<\/strong> for metabolic features, not first-line therapy ahead of the goal-specific option.<\/p>\n\n        <p><span class=\"rv-pill\">Rotterdam: any 2 of 3, no required LH:FSH ratio<\/span> <span class=\"rv-pill-blue\">Insulin resistance lowers SHBG, raises free androgen<\/span> <span class=\"rv-pill-blue\">Rapid virilisation \u2260 PCOS<\/span> <span class=\"rv-pill-green\">Letrozole if fertility desired; COCP if not<\/span><\/p>\n\n        <div class=\"rv-quiz-wrap\"><a class=\"rv-quiz-link\" href=\"https:\/\/atsixty.com\/index.php\/morning-rounds\/polycystic-ovary-syndrome-diagnosis-management\/\">\u25b6 Open Quiz 03<\/a><\/div>\n\n      <\/div>\n    <\/div>\n\n    <!-- \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\n         SECTION 4 \u2014 ENDOMETRIOSIS & ADENOMYOSIS\n    \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550 -->\n    <div class=\"rv-section\">\n      <div class=\"rv-sec-head\">\n        <a href=\"https:\/\/atsixty.com\/index.php\/morning-rounds\/endometriosis-adenomyosis\/\">\n          <div class=\"rv-sec-num\">Topic 04 \u00b7 Gynaecology<\/div>\n          <div class=\"rv-sec-title\">Endometriosis &amp; Adenomyosis <span class=\"rv-arrow\">\u2197<\/span><\/div>\n        <\/a>\n      <\/div>\n      <div class=\"rv-sec-body\">\n\n        <div class=\"rv-sub\">Diagnosis \u2014 Endometriosis<\/div>\n        <p>An endometrioma on ultrasound is highly suggestive but <strong>laparoscopy with histological confirmation<\/strong> remains the definitive standard, particularly for peritoneal\/superficial implants that imaging cannot see. CA-125 is non-specific and not a required diagnostic marker.<\/p>\n\n        <div class=\"rv-table-wrap\">\n          <table>\n            <tbody><tr><th>Feature<\/th><th>Adenomyosis<\/th><th>Leiomyoma (Fibroid)<\/th><\/tr>\n            <tr><td>Uterine shape<\/td><td>Symmetric, globular, \"boggy,\" tender<\/td><td>Irregular enlargement, discrete masses<\/td><\/tr>\n            <tr><td>MRI<\/td><td>Thickened, ill-defined junctional zone<\/td><td>Well-circumscribed mass with capsule<\/td><\/tr>\n            <tr><td>Course<\/td><td>Progressive dysmenorrhea, late 30s\u201340s<\/td><td>Often painless or pressure symptoms<\/td><\/tr>\n          <\/tbody><\/table>\n        <\/div>\n\n        <div class=\"rv-sub\">Stage-Pain Discordance<\/div>\n        <p>ASRM <strong>stage correlates poorly with pain severity<\/strong> \u2014 deep infiltrating lesions and local inflammatory\/nerve involvement matter more than total visible disease burden. Minimal disease can be severely painful; extensive disease can be relatively painless. This is recognised disease biology, not a diagnostic error.<\/p>\n\n        <div class=\"rv-sub\">Infertility Mechanism (Minimal Disease)<\/div>\n        <p>Without adhesions or distorted anatomy, infertility is driven by an <strong>altered peritoneal\/inflammatory environment<\/strong> (cytokines, prostaglandins impairing oocyte quality, fertilisation, implantation) \u2014 not mechanical blockage, which becomes dominant only in moderate-to-severe disease.<\/p>\n\n        <div class=\"rv-sub\">GnRH Agonist Therapy<\/div>\n        <p>Induces a hypoestrogenic state \u2014 long-term use risks <strong>accelerated bone mineral density loss<\/strong>. \"Add-back\" therapy (low-dose oestrogen-progestin) mitigates this and allows longer treatment durations beyond the otherwise limited window.<\/p>\n\n        <p><span class=\"rv-pill\">Laparoscopy + histology = definitive diagnosis<\/span> <span class=\"rv-pill-blue\">Stage \u2260 pain severity<\/span> <span class=\"rv-pill-blue\">Minimal disease infertility = inflammatory, not mechanical<\/span> <span class=\"rv-pill-green\">GnRH agonist + add-back protects bone<\/span><\/p>\n\n        <div class=\"rv-quiz-wrap\"><a class=\"rv-quiz-link\" href=\"https:\/\/atsixty.com\/index.php\/morning-rounds\/endometriosis-adenomyosis\/\">\u25b6 Open Quiz 04<\/a><\/div>\n\n      <\/div>\n    <\/div>\n\n    <!-- \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\n         SECTION 5 \u2014 GENITAL INFECTIONS & PID\n    \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550 -->\n    <div class=\"rv-section\">\n      <div class=\"rv-sec-head\">\n        <a href=\"https:\/\/atsixty.com\/index.php\/morning-rounds\/genital-tract-infections-pelvic-inflammatory-disease\/\">\n          <div class=\"rv-sec-num\">Topic 05 \u00b7 Gynaecology<\/div>\n          <div class=\"rv-sec-title\">Genital Tract Infections &amp; Pelvic Inflammatory Disease <span class=\"rv-arrow\">\u2197<\/span><\/div>\n        <\/a>\n      <\/div>\n      <div class=\"rv-sec-body\">\n\n        <div class=\"rv-table-wrap\">\n          <table>\n            <tbody><tr><th>Infection<\/th><th>Key wet mount \/ sign<\/th><th>pH<\/th><\/tr>\n            <tr><td>Trichomoniasis<\/td><td>Motile flagellates; strawberry cervix<\/td><td>\u2191 (overlaps BV)<\/td><\/tr>\n            <tr><td>Bacterial vaginosis<\/td><td>Clue cells; fishy odour\/whiff test<\/td><td>\u2191 (overlaps Trich)<\/td><\/tr>\n            <tr><td>Candidiasis<\/td><td>Pseudohyphae\/budding yeast; itching<\/td><td>Normal\u2013low<\/td><\/tr>\n          <\/tbody><\/table>\n        <\/div>\n        <p>pH overlaps between trichomoniasis and BV \u2014 the actual discriminator is <strong>wet mount morphology<\/strong>, not pH.<\/p>\n\n        <div class=\"rv-sub\">PID \u2014 Empirical Treatment Threshold<\/div>\n        <p>CDC minimum criteria: cervical motion, uterine, or adnexal tenderness in a sexually active woman with pelvic pain. <strong>Treat now<\/strong> \u2014 do not wait for culture or imaging given the reproductive stakes of delay. Many cases are afebrile; fever is not required.<\/p>\n\n        <div class=\"rv-sub\">Fitz-Hugh-Curtis Syndrome<\/div>\n        <p>Perihepatitis from transperitoneal\/lymphatic spread of pelvic pathogens \u2014 \"violin-string\" capsular adhesions, not parenchymal disease, hence normal gallbladder\/LFTs. A specifically recognised PID complication, not coincidental cholecystitis.<\/p>\n\n        <div class=\"rv-sub\">Tubo-Ovarian Abscess<\/div>\n        <p>Drainage decision is driven by <strong>clinical response<\/strong> (failure after 48\u201372h, rupture, instability\/sepsis) \u2014 not abscess size alone. Don't stop antibiotics just because fever resolves; full course (often ~14 days) prevents relapse.<\/p>\n\n        <div class=\"rv-sub\">Cumulative Reproductive Risk<\/div>\n        <p>Even adequately treated PID leaves <strong>cumulative tubal scarring<\/strong> \u2014 risk of tubal factor infertility and ectopic pregnancy increases with each episode and does not plateau after the first.<\/p>\n\n        <p><span class=\"rv-pill\">Trich vs BV: wet mount discriminates, not pH<\/span> <span class=\"rv-pill-blue\">PID: treat on clinical criteria, don't wait<\/span> <span class=\"rv-pill-blue\">Fitz-Hugh-Curtis: capsular, not parenchymal<\/span> <span class=\"rv-pill-green\">TOA decision = response, not size<\/span><\/p>\n\n        <div class=\"rv-quiz-wrap\"><a class=\"rv-quiz-link\" href=\"https:\/\/atsixty.com\/index.php\/morning-rounds\/genital-tract-infections-pelvic-inflammatory-disease\/\">\u25b6 Open Quiz 05<\/a><\/div>\n\n      <\/div>\n    <\/div>\n\n    <!-- \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\n         SECTION 6 \u2014 MENOPAUSE & HRT\n    \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550 -->\n    <div class=\"rv-section\">\n      <div class=\"rv-sec-head\">\n        <a href=\"https:\/\/atsixty.com\/index.php\/morning-rounds\/menopause-hormone-therapy\/\">\n          <div class=\"rv-sec-num\">Topic 06 \u00b7 Gynaecology<\/div>\n          <div class=\"rv-sec-title\">Menopause &amp; Hormone Therapy <span class=\"rv-arrow\">\u2197<\/span><\/div>\n        <\/a>\n      <\/div>\n      <div class=\"rv-sec-body\">\n\n        <div class=\"rv-sub\">Diagnosis<\/div>\n        <p>Clinical diagnosis \u2014 <strong>12 consecutive months of amenorrhea<\/strong> at the expected age. FSH testing is reserved for atypical scenarios (suspected POI, post-hysterectomy uncertainty, contraception masking cycles) \u2014 not for confirming a typical presentation. FSH fluctuates, it does not rise smoothly, through perimenopause.<\/p>\n\n        <div class=\"rv-sub\">Vasomotor Symptom Mechanism<\/div>\n        <p>A <strong>narrowed hypothalamic thermoneutral zone<\/strong> from oestrogen withdrawal \u2014 the thermoregulatory centre overreacts to trivial temperature changes; core temperature itself is not genuinely elevated.<\/p>\n\n        <div class=\"rv-sub\">HRT \u2014 Window of Opportunity &amp; Uterine Status<\/div>\n        <p>Starting HRT <strong>within ~10 years of menopause or before age 60<\/strong> carries a more favourable cardiovascular risk profile than starting later. Intact uterus \u2192 combined oestrogen-progestin (oestrogen-only is for post-hysterectomy women only).<\/p>\n\n        <div class=\"rv-sub\">Contraindications<\/div>\n        <p>Personal history of <strong>oestrogen receptor-positive breast cancer<\/strong> is an absolute\/near-absolute contraindication to systemic HRT regardless of years disease-free; adding a progestin protects the endometrium but does <strong>not<\/strong> neutralise this specific risk.<\/p>\n\n        <div class=\"rv-sub\">Genitourinary Syndrome of Menopause (GSM)<\/div>\n        <p><strong>Local vaginal oestrogen<\/strong> is first-line for isolated GSM \u2014 minimal systemic absorption, a different risk category from oral\/transdermal therapy, generally usable even with some systemic HRT contraindications.<\/p>\n\n        <p><span class=\"rv-pill\">Menopause = clinical diagnosis, 12 months amenorrhea<\/span> <span class=\"rv-pill-blue\">HRT window: &lt;10 yrs post-menopause \/ &lt;60 yrs<\/span> <span class=\"rv-pill-blue\">ER+ breast cancer hx = HRT contraindication<\/span> <span class=\"rv-pill-green\">Local oestrogen for GSM \u2260 systemic risk<\/span><\/p>\n\n        <div class=\"rv-quiz-wrap\"><a class=\"rv-quiz-link\" href=\"https:\/\/atsixty.com\/index.php\/morning-rounds\/menopause-hormone-therapy\/\">\u25b6 Open Quiz 06<\/a><\/div>\n\n      <\/div>\n    <\/div>\n\n    <!-- \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\n         SECTION 7 \u2014 GYNAECOLOGICAL MALIGNANCIES\n    \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550 -->\n    <div class=\"rv-section\">\n      <div class=\"rv-sec-head\">\n        <a href=\"https:\/\/atsixty.com\/index.php\/morning-rounds\/gynaecological-malignancies\/\">\n          <div class=\"rv-sec-num\">Topic 07 \u00b7 Gynaecology<\/div>\n          <div class=\"rv-sec-title\">Gynaecological Malignancies <span class=\"rv-arrow\">\u2197<\/span><\/div>\n        <\/a>\n      <\/div>\n      <div class=\"rv-sec-body\">\n\n        <div class=\"rv-sub\">HPV Risk Stratification<\/div>\n        <p><strong>HPV 16\/18<\/strong> \u2014 high-risk, oncogenic, drive the large majority of cervical cancers. <strong>HPV 6\/11<\/strong> \u2014 low-risk, cause genital warts, not malignancy. Vaccines target the oncogenic types specifically.<\/p>\n\n        <div class=\"rv-sub\">Endometrial Cancer \u2014 Unifying Risk Mechanism<\/div>\n        <p><strong>Unopposed oestrogen<\/strong> connects obesity (peripheral aromatization in adipose tissue), nulliparity (fewer progesterone-dominant pregnancy periods), and PCOS (chronic anovulation \u2014 lack, not excess, of progesterone).<\/p>\n\n        <div class=\"rv-sub\">Ovarian Cancer Screening<\/div>\n        <p>No validated population screening strategy (CA-125 + USG) reduces mortality in average-risk women \u2014 CA-125 is non-specific (fibroids, endometriosis) and insensitive in early disease. Screening is reserved for high genetic risk (e.g. BRCA).<\/p>\n\n        <div class=\"rv-table-wrap\">\n          <table>\n            <tbody><tr><th>Cancer<\/th><th>Staging method<\/th><\/tr>\n            <tr><td>Cervical<\/td><td>Clinical \u2014 examination, biopsy, imaging<\/td><\/tr>\n            <tr><td>Endometrial<\/td><td>Surgical-pathological<\/td><\/tr>\n            <tr><td>Ovarian<\/td><td>Surgical-pathological<\/td><\/tr>\n          <\/tbody><\/table>\n        <\/div>\n\n        <div class=\"rv-sub\">Postmenopausal Bleeding<\/div>\n        <p><strong>Any<\/strong> amount or duration, including a single resolved episode, warrants endometrial workup before attributing to atrophy \u2014 endometrial cancer is the most common gynaecological malignancy presenting this way.<\/p>\n\n        <p><span class=\"rv-pill\">HPV 16\/18 = cancer; 6\/11 = warts<\/span> <span class=\"rv-pill-blue\">Endometrial cancer risk = unopposed oestrogen<\/span> <span class=\"rv-pill-blue\">No effective ovarian cancer screening test exists<\/span> <span class=\"rv-pill-green\">Postmenopausal bleeding always gets worked up<\/span><\/p>\n\n        <div class=\"rv-quiz-wrap\"><a class=\"rv-quiz-link\" href=\"https:\/\/atsixty.com\/index.php\/morning-rounds\/gynaecological-malignancies\/\">\u25b6 Open Quiz 07<\/a><\/div>\n\n      <\/div>\n    <\/div>\n\n    <!-- \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\n         EXAMINER'S FAVOURITES \u2014 CROSS-SERIES RAPID RECALL\n    \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550 -->\n    <div class=\"rv-section\">\n      <div class=\"rv-sec-head\">\n        <div class=\"rv-sec-num\">Cross-Series \u00b7 Gynaecology<\/div>\n        <div class=\"rv-sec-title\">Examiner's Favourites \u2014 Rapid Recall<\/div>\n      <\/div>\n      <div class=\"rv-sec-body\">\n\n        <div class=\"rv-sub\">Classifications to know cold<\/div>\n        <div class=\"rv-table-wrap\">\n          <table>\n            <tbody><tr><th>Classification<\/th><th>What it grades<\/th><th>Key anchor<\/th><\/tr>\n            <tr><td>PALM-COEIN<\/td><td>Cause of AUB<\/td><td>PALM = structural; COEIN = non-structural<\/td><\/tr>\n            <tr><td>Rotterdam criteria<\/td><td>PCOS diagnosis<\/td><td>Any 2 of 3, after excluding other causes<\/td><\/tr>\n            <tr><td>FIGO fibroid subtype (0\u20137)<\/td><td>Fibroid location<\/td><td>0\u20132 submucosal bleed most<\/td><\/tr>\n            <tr><td>ASRM stage (I\u2013IV)<\/td><td>Endometriosis extent<\/td><td>Does not correlate with pain severity<\/td><\/tr>\n            <tr><td>CDC PID criteria<\/td><td>Threshold for empirical treatment<\/td><td>Cervical motion\/uterine\/adnexal tenderness alone suffices<\/td><\/tr>\n          <\/tbody><\/table>\n        <\/div>\n\n        <div class=\"rv-sub\">Eponymous \/ named signs &amp; mechanisms \u2014 one-liners<\/div>\n        <p>\n          <span class=\"rv-pill\">Mittelschmerz: brief, one-sided, mid-cycle \u2014 benign, no workup<\/span>\n          <span class=\"rv-pill\">Fitz-Hugh-Curtis: violin-string capsular adhesions, not parenchymal liver disease<\/span>\n          <span class=\"rv-pill-blue\">Strawberry cervix: trichomoniasis, not bacterial vaginosis<\/span>\n          <span class=\"rv-pill-blue\">Window of opportunity: HRT timing hypothesis for cardiovascular risk<\/span>\n          <span class=\"rv-pill-green\">Add-back therapy: protects bone during GnRH agonist use<\/span>\n        <\/p>\n\n        <div class=\"rv-sub\">Number anchors<\/div>\n        <p>\n          <span class=\"rv-pill\">FIGO normal cycle: 24\u201338 days, \u22648 days duration<\/span>\n          <span class=\"rv-pill\">Rotterdam: any 2 of 3 criteria<\/span>\n          <span class=\"rv-pill\">Menopause: 12 consecutive months amenorrhea<\/span>\n          <span class=\"rv-pill-blue\">TOA: 48\u201372 hr antibiotic trial before drainage decision<\/span>\n          <span class=\"rv-pill-blue\">HRT window: within ~10 yrs of menopause \/ before 60<\/span>\n          <span class=\"rv-pill-blue\">HPV 16\/18: oncogenic; 6\/11: low-risk\/warts<\/span>\n          <span class=\"rv-pill-green\">ASCUS + HPV+ \u2192 colposcopy threshold<\/span>\n          <span class=\"rv-pill-green\">Endometrial sampling: indicated for ANY postmenopausal bleeding<\/span>\n        <\/p>\n\n        <div class=\"rv-sub\">Sequence rules \u2014 act in order<\/div>\n        <p>\n          <span class=\"rv-pill\">PID: treat empirically first, never wait for culture\/imaging<\/span>\n          <span class=\"rv-pill\">AUB: medical therapy before ablation\/hysterectomy<\/span>\n          <span class=\"rv-pill-blue\">PCOS: confirm fertility goal before choosing first-line therapy<\/span>\n          <span class=\"rv-pill-blue\">Postmenopausal bleeding: workup before attributing to atrophy<\/span>\n          <span class=\"rv-pill-green\">Endometriosis: laparoscopy + histology before calling it definitive<\/span>\n          <span class=\"rv-pill-green\">Adolescent menorrhagia since menarche: screen for vWD alongside, not after, gynae workup<\/span>\n        <\/p>\n\n      <\/div>\n    <\/div>\n\n    <!-- Footer -->\n    <div class=\"rv-footer\">\n      Gynaecology Summative Revision \u00b7 atsixty.com \u00b7 Morning Rounds Series<br>\n      <a href=\"https:\/\/atsixty.com\/index.php\/morning-rounds\/index-to-gynaecology-morning-rounds-series\">\u2190 Return to Gynaecology Series Index<\/a>\n    <\/div>\n\n  <\/div>\n<\/div>\n\n\n<ul class=\"wp-block-latest-posts__list wp-block-latest-posts\"><li><a class=\"wp-block-latest-posts__post-title\" href=\"https:\/\/atsixty.com\/index.php\/obg\/gynaecology-summative-revision-notes\/\">Gynaecology: Summative Revision Notes<\/a><\/li>\n<li><a class=\"wp-block-latest-posts__post-title\" href=\"https:\/\/atsixty.com\/index.php\/obg\/gynaecological-malignancies\/\">Gynaecological Malignancies<\/a><\/li>\n<li><a class=\"wp-block-latest-posts__post-title\" href=\"https:\/\/atsixty.com\/index.php\/obg\/menopause-hormone-therapy\/\">Menopause &amp; Hormone Therapy<\/a><\/li>\n<li><a class=\"wp-block-latest-posts__post-title\" href=\"https:\/\/atsixty.com\/index.php\/obg\/genital-tract-infections-pelvic-inflammatory-disease\/\">Genital Tract Infections &amp; Pelvic Inflammatory Disease<\/a><\/li>\n<li><a class=\"wp-block-latest-posts__post-title\" href=\"https:\/\/atsixty.com\/index.php\/obg\/endometriosis-adenomyosis\/\">Endometriosis &amp; Adenomyosis<\/a><\/li>\n<\/ul>","protected":false},"excerpt":{"rendered":"<p>Morning Rounds \u00b7 Gynaecology Series GynaecologySummative Revision Notes Seven topics \u00b7 NEET-PG \/ INI-CET \/ UPSC CMS \u00b7 Key facts, thresholds, classifications and traps Physiology &amp; Consent AUB &amp; PALM-COEIN PCOS Endometriosis &amp; Adenomyosis Genital Infections &amp; PID Menopause &amp; HRT Gynaecological Malignancies These notes consolidate the seven Gynaecology Morning Rounds. They are written for&hellip;&nbsp;<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"neve_meta_sidebar":"","neve_meta_container":"","neve_meta_enable_content_width":"","neve_meta_content_width":0,"neve_meta_title_alignment":"","neve_meta_author_avatar":"","neve_post_elements_order":"","neve_meta_disable_header":"","neve_meta_disable_footer":"","neve_meta_disable_title":"","footnotes":""},"categories":[74,55],"tags":[82,93,83],"class_list":["post-37119","post","type-post","status-publish","format-standard","hentry","category-morning-rounds","category-obg","tag-cms","tag-gynaecology","tag-neet-pg"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.9 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Gynaecology: Summative Revision Notes - atsixty<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/atsixty.com\/index.php\/obg\/gynaecology-summative-revision-notes\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Gynaecology: Summative Revision Notes - atsixty\" \/>\n<meta property=\"og:description\" content=\"Morning Rounds \u00b7 Gynaecology Series GynaecologySummative Revision Notes Seven topics \u00b7 NEET-PG \/ INI-CET \/ UPSC CMS \u00b7 Key facts, thresholds, classifications and traps Physiology &amp; Consent AUB &amp; PALM-COEIN PCOS Endometriosis &amp; Adenomyosis Genital Infections &amp; PID Menopause &amp; HRT Gynaecological Malignancies These notes consolidate the seven Gynaecology Morning Rounds. 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