Case Scenario 1: Gynecologic Conditions Chart

Case Scenario 1: Gynecologic Conditions Chart

Diagn osis Definition Presentation / Signs

and Symptoms Management

Barth olin Cyst

Obstruction of the Bartholin duct causing fluid buildup, forming a cyst in the labia majora.

Unilateral, painless labial swelling near vaginal introitus. Can become tender and erythematous if infected.

Warm compresses or sitz baths; if symptomatic or recurrent: incision and drainage, Word catheter, or marsupialization. Antibiotics if abscessed.

Squa mous Carci noma of the Vagin a

A rare primary cancer arising from the squamous epithelium of the vaginal mucosa.

Vaginal bleeding, discharge, palpable vaginal mass, or pain, often postmenopausal.

Diagnosis via biopsy. Management includes surgical resection, radiation therapy, and/or chemotherapy based on staging. Referral to gynecologic oncology.

Aden ocarc inom a of the Vagin a

Malignant glandular tumor of the vagina, often associated with in-utero diethylstilbestrol (DES) exposure.

Vaginal spotting, watery discharge, or mass, especially in young women with DES history.

Biopsy confirms diagnosis. Treated with surgery and/or radiation. DES-exposed women require lifelong surveillance.

Liche n Scler osus

Chronic, progressive inflammatory dermatosis affecting vulvar and perianal skin, mostly in postmenopausal women.

Intense pruritus, burning, dyspareunia, thin white plaques (“cigarette paper” appearance), and skin fragility. Risk of vulvar SCC.

High-potency topical corticosteroids (e.g., clobetasol 0.05%), emollients, regular follow-up. Biopsy if suspicious for malignancy.

Liche n Planu s

Inflammatory autoimmune condition involving skin and mucosal surfaces including the vulva and vagina.

Painful erosions, white lacy striae (Wickham’s striae), vaginal discharge, dyspareunia, possible scarring.

Topical corticosteroids or calcineurin inhibitors; manage pain; treat secondary infections; possible systemic immunosuppressants for severe cases.

SOAP Note

Patient: Kelly
 Age: 19
 Gender: Female

SUBJECTIVE

Chief Complaint (CC): “Severe menstrual pain.”

History of Present Illness (HPI): 
 Kelly is a 19-year-old G0P0 female who presents to the clinic today with a chief complaint of severe, cyclical pelvic pain that has been present since menarche (age 13) but has progressively worsened over the last 2-3 years. The pain is described as a “deep, cramping, and sometimes sharp” pain located in the suprapubic area, radiating to her lower back and anterior thighs. The pain typically begins 1-2 days prior to the onset of her menses and is most severe during the first 48 hours of her period. She rates the pain as 9-10/10 at its worst, improving to a 3-4/10 after day 3 of her cycle. The pain is debilitating, causing her to miss work at her part-time job 1-2 days each month. She reports at least one episode of fainting (syncope) from the severity of the pain during her last cycle.

• Associated Symptoms:

o Gastrointestinal: She experiences severe pain with defecation (dyschezia), particularly during her menses. This leads her to avoid bowel movements, resulting in secondary constipation. She denies any blood in the stool. She also reports bloating and occasional nausea during her periods.

Liche n Simpl ex Chro nicus

Secondary skin thickening from chronic scratching or irritation of the vulva.

Thickened, leathery skin, usually unilateral. Intense itching, worse at night.

Discontinue irritants, use high- potency topical corticosteroids, antihistamines, barrier creams. Address underlying cause (e.g., infection, stress).

Vulvo dynia

Chronic vulvar pain without identifiable cause, lasting >3 months.

Burning, stinging, irritation, especially with touch or intercourse. Often no visible abnormalities.

Multidisciplinary approach: pelvic floor physical therapy, topical lidocaine, low-dose antidepressants (TCAs or SNRIs), cognitive behavioral therapy, avoidance of irritants.

o Gynecologic: Her menses are heavy (menorrhagia), requiring her to change a super- absorbency tampon or pad every 1-2 hours for the first two days. Her periods last for a total of 7 days, with a gradual tapering of flow. She reports occasional deep dyspareunia (pain with deep intercourse). She denies any intermenstrual bleeding or postcoital spotting. No abnormal vaginal discharge, odor, or itching.

• Palliating/Provoking Factors: Pain is provoked by menstruation and defecation. She has tried over-the-counter Ibuprofen (400 mg) and Acetaminophen (500 mg) with minimal to no relief. Heating pads provide mild, temporary relief.

• Pertinent Negatives: Denies fever, chills, urinary symptoms (dysuria, frequency, urgency), or changes in appetite outside of her menses.

Menstrual History:

• Menarche: Age 13

• LMP (Last Menstrual Period): Began 1 week ago

• Cycle: Regular, q28-30 days

• Duration: 7 days

• Flow: Heavy for 2 days, then moderate to light for 5 days.

Gynecologic/Obstetric History:

• Gravida/Para: G0P0

• Sexual Activity: Sexually active with one male partner for the last year.

• Contraception: Reports inconsistent condom use. Has never used hormonal contraception.

• STI History: Denies any known history of STIs. Has never been screened.

• Pap Smear: None to date (age-appropriate).

Past Medical History (PMH): None. No chronic illnesses. 
 Past Surgical History (PSH): None. 
 Medications: Ibuprofen 400 mg PRN for pain, Acetaminophen 500 mg PRN for pain. 
 Allergies: No Known Drug Allergies (NKDA).

Family History: Mother has a history of “bad periods” and heavy bleeding but no formal diagnosis. No known family history of gynecologic cancers, endometriosis, or bleeding disorders.

Social History: College student, works part-time. Denies tobacco use. Reports occasional social alcohol use (2-3 drinks per weekend). Denies illicit drug use. Reports significant stress related to her symptoms and their impact on her work and daily life.

OBJECTIVE

Vitals:

• BP: 118/72 mmHg

• HR: 74 bpm

• RR: 16 rpm

• Temp: 98.6°F (37.0°C)

• SpO2: 99% on room air

• BMI: 23.9 kg/m ²

General: Patient is a well-developed, well-nourished female in no acute distress. She is alert, oriented, and cooperative.

Physical Exam:

• Abdomen: Soft, non-distended. Normoactive bowel sounds in all four quadrants. Mild suprapubic tenderness to deep palpation. No guarding, rebound tenderness, or organomegaly noted.

• Pelvic Exam:

o External Genitalia: Normal external female genitalia. No lesions, erythema, or swelling.

o Speculum: Vaginal vault is pink and without lesions. Cervix is nulliparous, pink, with no discharge, friability, or visible lesions. A small amount of old, brown blood is noted in the posterior fornix, consistent with recent menses.

o Bimanual: Uterus is of normal size, retroverted, and has limited mobility. There is significant tenderness with uterine motion (positive cervical motion tenderness). Palpation of

the posterior cul-de-sac and uterosacral ligaments elicits exquisite tenderness. Adnexa are tender to palpation, left more so than right, without distinct masses appreciated.

In-Office test:

• Urine hCG (Pregnancy Test): Negative

ASSESSMENT

1. Endometriosis, Suspected (N80.9): This is the leading diagnosis given the constellation of classic symptoms: severe, progressive dysmenorrhea since menarche, deep dyspareunia, and cyclical dyschezia. The physical exam findings of a fixed, retroverted uterus and marked tenderness of the uterosacral ligaments strongly support this diagnosis. The syncopal episode highlights the severity of the pain.

2. Menorrhagia (Heavy Menstrual Bleeding, N92.0): Patient’s report of soaking pads/ tampons every 1-2 hours for two days meets the clinical definition. This is likely secondary to underlying pathology such as endometriosis or adenomyosis.

3. Dysmenorrhea, Secondary (N94.5): The patient’s severe menstrual pain, associated with other symptoms and physical findings, is indicative of a secondary cause rather than primary (physiologic) dysmenorrhea.

4. Constipation (K59.00): Secondary to pain avoidance with defecation (dyschezia) during menses.

5. Contraception Counseling / Health Maintenance (Z30.011): Patient is sexually active with inconsistent barrier method use, placing her at risk for unintended pregnancy and STIs.

Differential Diagnoses:

• Adenomyosis: Overlaps significantly with endometriosis symptoms (menorrhagia, dysmenorrhea). It is less common in this age group but remains a strong possibility. Ultrasound may provide clues.

• Primary Dysmenorrhea: Unlikely given the severity, focal tenderness on exam, and associated GI symptoms.

• Pelvic Inflammatory Disease (PID): Less likely given the cyclical nature of the pain, lack of fever, and absence of purulent cervical discharge. However, chronic PID can cause adhesions and pain, so STI screening is warranted.

• Uterine Fibroids (Leiomyoma): Can cause heavy bleeding and pain, but less likely to cause the specific dyschezia and uterosacral tenderness seen here. Less common in a 19-year-old.

PLAN

1. Diagnostics:

a. Pelvic Ultrasound (Transvaginal & Abdominal): Ordered to evaluate for structural abnormalities, specifically looking for endometriomas (“chocolate cysts”), signs of adenomyosis, uterine fibroids, and to assess uterine mobility/potential adhesions.

b. Labs: CBC to assess for anemia from menorrhagia. Gonorrhea/Chlamydia NAA (urine or swab) to screen for STIs.

c. Symptom Diary: Patient provided with a diary to track pain levels, bleeding, bowel symptoms, and medication use in relation to her menstrual cycle.

2. Therapeutics (Empiric Treatment):

a. Pain/Inflammation: Discontinue PRN OTC use. Prescribed Naproxen 550 mg, 1 tablet by mouth twice daily with food, to be started 2 days before expected onset of menses and continued through the first 3 days of bleeding.

b. Hormonal Suppression: Initiated treatment with a continuous combined oral contraceptive (COC).

i. Rx: [e.g., Drospirenone/Ethinyl Estradiol 3mg/0.02mg], 1 tablet by mouth daily.

ii. Instructions: Instructed patient to take pills continuously, skipping the placebo week, to induce amenorrhea. Explained that this is the first-line treatment for suspected endometriosis to suppress endometrial tissue growth, reduce bleeding, and alleviate pain. Discussed risks, benefits, and common side effects (e.g., breakthrough bleeding initially).

3. Patient Education:

a. Diagnosis: Discussed the suspected diagnosis of endometriosis in detail, explaining that it is a condition where uterine lining-like tissue grows outside the uterus, causing inflammation and pain.

b. Treatment Goal: Explained that the goal of the current plan is to manage symptoms, reduce pain to a tolerable level, control bleeding, and allow her to maintain normal daily activities.

c. Constipation: Advised increasing fluid and dietary fiber intake. Suggested Miralax or docusate sodium PRN if constipation persists despite pain control.

d. Non-pharmacologic: Encouraged continued use of heating pads. Advised light exercise like walking or stretching as tolerated.

e. Red Flags: Instructed to call or return if she experiences pain unresponsive to the new medication regimen, fever >100.4°F, or menstrual bleeding that soaks through a pad/tampon every hour for more than two consecutive hours.

4. Health Maintenance:

a. Counseled on safe sex practices and the importance of consistent condom use for STI prevention, even while on OCPs.

5. Follow-up:

a. Will call the patient with lab and ultrasound results within one week.

b. Schedule a follow-up appointment in 3 months to evaluate her response to the empiric treatment regimen.

c. If symptoms are not significantly improved, a referral to a Gynecologist for further evaluation and consideration of diagnostic laparoscopy (the gold standard for diagnosis) will be made.