Several tests and/or treatments for gynecologic outpatients are presented as answers with a recommendation level of A, B or C to each clinical question. These criteria are essentially the same as described previously in ‘Guidelines for obstetrical practice in Japan: Japan Society of Obstetrics and Gynecology (JSOG) and Japan Association of Obstetricians and Gynecologists (JAOG) 2011 edition’. The answers and recommendation levels are principally based on evidence or consensus among Japanese gynecologists when the evidence is considered to be weak or lacking. Thus, the answers are not necessarily based on ‘evidence’. Answers with a recommendation level of A or B are regarded as current standard care practices in Japan. Level A indicates a stronger recommendation than level B. Consequently, informed consent is required when office gynecologists do not provide care corresponding to an answer with a level of A or B. Answers with a recommendation level of C are possible options that may favorably affect the outcome but for which some uncertainty remains regarding whether the possible benefits outweigh the possible risks. Thus, care corresponding to answers with a recommendation level of C does not necessarily need to be provided. Some answers with a recommendation level of A or B include examinations and treatments that may be difficult for general office gynecologists to provide. In such cases, the office gynecologists must refer the patient to an appropriate institution.
Chapter A. Infectious disease (CQ101 – CQ112)
Chapter B. Oncology and benign tumors (CQ201 – CQ224)
Chapter C. Endocrinology and Infertility (CQ301 – CQ314)
Chapter D. Healthcare for women (CQ401 – CQ422)
A. Infectious disease
How do we diagnose and treat genital herpes?
- 1Test for antigens in samples taken directly from the lesions. Diagnosis may be possible from history-taking and clinical observation of typical clinical cases. (B)
- 2Antigen test is conducted by direct immunofluorescence against viral antigen and can be combined with cytology. If samples cannot be obtained directly from the lesions, patient serum can be tested for viral antibodies (enzyme-linked immunosorbent assay) or specific Ig (immunoglobulin) G and IgM. In this case, evaluate the serum test carefully. (B)
- 3Treat using acyclovir or valacyclovir. (A)
- 4For mild diseases, topical acyclovir or topical vidarabine may be adequate. (C)
- 5For cases with more than six recurrences within a year, or recurrences presenting with severe symptoms, prophylaxis against recurrence is advisable. (B)
Main examples of prescription
|Initial episode, recurrences|
|Mild to moderate symptoms||Oral acyclovir||Zovirax (200 mg)||5 times daily for 5 days, orally|
|Oral valacyclovir||Valtrex (500 mg)||Twice daily for 2 days, orally|
| || ||(Up to 10 days for initial episode)|
|Severe symptoms||i.v. acyclovir||Zovirax (5 mg/kg/session)||Every 8 h for 7 days|
|Recurrence suppression||Oral valacyclovir||Valtrex (500 mg)||Once daily for 1 year, orally|
How do we diagnose and treat chlamydial cervicitis?
- 1Diagnose by testing cervical smear for chlamydia using nucleic acid hybridization tests, nucleic acid amplification tests (NAAT) or enzyme immunoassay (EIA). (A)
- 2Sample should be tested simultaneously for gonorrhea when using NAAT. (B)
- 3Treat using oral macrolides or fluoroquinolone antibiotics. (A)
- 4For pelvic inflammatory disease (PID) or Fitz–Hugh–Curtis syndrome, oral antibiotics can be administered if the symptoms are mild. (B)
- 5Post-treatment evaluation should be conducted at least 2–3 weeks after the completion of treatment. (B)
- 6Sexual partner(s) of patient should be tested and treated. (B)
Main examples of prescription
| ||Azithromycin||Zithromax||250 mg/tablet||1000 mg, single dose orally|
|Oral|| ||Zithromax SR||2 g/dry syrup||2000 mg, single dose orally|
| ||Clarithromycin||Clarith, Klaricid||200 mg/tablet||200 mg orally, twice daily for 7 days|
| ||Levofloxacin||Cravit||500 mg/tablet||500 mg orally, once daily for 7 days|
|Intravenous||Minocycline||Minomycin||100 mg/vial||100 mg, twice daily, i.v. for 3–5 days|
How do we diagnose and treat vulva condyloma acuminatum?
- 1Clinical symptoms and presentation are usually sufficient for diagnosis. Biopsy and pathological evaluation can be performed when necessary. (B)
- 2Treat with topical creams containing 5% imiquimod. (B)
- 3Surgical therapy involving direct excision, cryotherapy, electrocauterization, and laser vaporization. (C)
How do we diagnose and treat bacterial vaginosis?
- 1Nugent score on vaginal discharge; lactobacillary grade on vaginal saline lavage; or Amsel criteria can be used for objective diagnosis. (C)
- 2Treat locally (vaginally) or orally using chloramphenicol or metronidazole. (B)
Main examples of prescription
|Metronidazole vaginal tablet||Flagyl vaginal tablet 250 mg||Once daily||Intravaginally for 6 days|
|Metronidazole tablet||Flagyl tablet 250 mg||4 tablets twice daily||Orally for 7 days|
How do we diagnose and treat trichomonas vaginitis?
- 1Check vaginal discharge microscopically for trichomonads. (B)
- 2If no organisms are found microscopically, culture the sample. (C)
- 3Treat systemically by giving oral metronidazole or tinidazole as ascending infection involving the upper urinary tracts cannot be ruled out. (B)
- 4Sexual partner(s) must be treated simultaneously with the same oral drug. (B)
Main examples of prescription
|Oral formulations||Metronidazole||Flagyl||250 mg||500 mg/day, twice daily for 10 days|
|Tinidazole||Haisigyn||200 mg||400 mg/day, twice daily for 7 days|
| || ||500 mg||2000 mg, single dose|
|Vaginal tablets||Metronidazole||Flagyl vaginal tablet||250 mg||One tablet daily for 10–14 days|
|Tinidazole||Haisigyn vaginal tablet||200 mg||One tablet daily for 7 days|
| || || ||If the trichomoniasis persists, withhold treatment for 1 week before repeating treatment.|
How do we diagnose and treat Candida vulvovaginitis?
- 1Diagnose by microscopic examination for yeast, or culture (agar plates with specialized medium or liquid medium with pH indicator can be used as well) of vulvovaginal discharge, in combination with clinical symptoms. (B)
- 2For treatment, perform vaginal lavage, then intravaginal administration of antifungal medication. For vulva candidiasis, give topical creams. (A) Tables 1–3.
- 3Treatment is considered successful if subjective symptoms disappear or vaginal discharge improves. (A)
Table 1. For continuous daily treatment
|Clotrimazole||Empecid vaginal tablet 100 mg||One tablet daily||6 days|
|Miconazole nitrate||Florid vaginal suppository 100 mg||One tablet daily||6 days|
|Oxiconazole nitrate||Okinazol vaginal tablet 100 mg||One tablet daily||6 days|
Table 2. For patients who cannot receive regular follow ups
|Isoconazole nitrate||Adestan vaginal tablet 300 mg||2 tablets daily||Once a week|
|Oxiconazole nitrate||Okinazol vaginal tablet 600 mg||One tablet daily||Once a week|
Table 3. For topical treatment
|Clotrimazole||1% Empecid cream||2–3 times daily||5–7 days|
|Miconazole||1% Florid D cream||2–3 times daily||5–7 days|
|Isoconazole nitrate||1% Adestan cream||2–3 times daily||5–7 days|
|Oxiconazole nitrate||1% Okinazol cream||2–3 times daily||5–7 days|
How do we diagnose and treat gonococcus infections?
Main examples of prescription
| ||Ceftriaxone||Rocephin||1.0 g/vial||1.0g i.v., single dose|
|Injection drug||Cefodizime||Kenicef||1.0 g/vial||1.0g i.v., single dose|
| ||Spectinomycin||Trobicin||2.0 g/vial||2.0g i.m. (gluteal), single dose|
How do we diagnose and treat syphilis?
- 1Use serologic tests for syphilis (STS), Treponema pallidum hemagglutination assay or fluorescent treponemal antibody absorption test in combination for confirmatory diagnosis and determination of disease stage. (A)
- 2First-line treatment with oral penicillins (amoxicillin, ampicillin). Treat primary syphilis for 2–4 weeks, secondary syphilis for 4–8 weeks, and tertiary syphilis for 8–12 weeks with oral antibiotics. (A)
- 3Follow up by evaluating test results of serologic test (STS). (A)
- 4When syphilis is confirmed, the physician who makes the diagnosis should report the case in accordance with the Infectious Disease Law by the Japanese government. (A)
|Amoxicillin||AMPC||Sawacillin, Pasetocin||1.5 g||3 times daily||Primary syphilis: 2–4 weeks|
|Ampicillin||ABPC||Viccilin||2.0 g||4 times daily||Secondary syphilis: 4–8 weeks|
|Benzylpenicillin||PCG||Bicillin||1.8 million units||3 times daily||Tertiary syphilis: 8–12 weeks|
How do we diagnose pelvic inflammatory disease (PID)?
Diagnosis should be made following the criteria as stated below.
(Minimum diagnostic criteria) (A)
- 1Lower abdominal pain, tenderness with palpation.
- 2Uterine or adnexal tenderness with palpation.
(Additional diagnostic criteria) (B)
- 1Body temperature ≥ 38°C
- 3Elevated C-reactive protein
(Specific diagnostic criteria) (C)
- 1Identification of (intrapelvic) abscess by magnetic resonance imaging (MRI) or transvaginal ultrasonography.
- 2Aspiration of purulent material via the Pouch of Douglas.
- 3Laparoscopic abnormalities suggestive of inflammation consistent with PID.
How do we treat pelvic inflammatory disease (PID)?
Treat as stated below.
- 1Outpatient treatment is usually adequate unless, as in cases as stated below, hospitalization is indicated. (B)
- • When emergency requiring surgical intervention (such as appendicitis) cannot be ruled out
- • The patient is pregnant
- • Oral antibiotics are not effective
- • The patient cannot take oral antibiotics
- • The patient has nausea, vomiting or high fever
- • The patient has a tubo-ovarian abscess.
- 2For mild to moderate cases, prescribe oral cephem or quinolone antibiotics. For moderate cases, intravenous administration of cephem (up to second-generation) can also be considered. (B)
- 3For severe cases (with no indication for hospitalization, or where the patient is unable to receive inpatient treatment), administer intravenous third- or higher generation cephem, or carbapenem antibiotics. Combined therapy using i.v. clindamycin or minocycline is also an option. (B)
|1. Oral cephems|
| 1) Cefditoren (Meiact) 100 mg orally 3 times daily for 5–7 days |
| 2) Cefcapene (Flomox) 100 mg orally 3 times daily for 5–7 days|
| 3) Cefdinir (Cefzone)) 100 mg orally 3 times daily for 5–7 days|
|2. Oral quinolones|
| 1) Levofloxacin (Cravit) 500 mg orally once daily for 5–7 days|
| 2) Tosufloxacin (Ozex) 150 mg orally 3 times daily for 5–7 days|
| 3) Ciprofloxacin (Ciproxan) 100–200 mg orally 3 times daily for 5–7 days|
|1. Cephems for injection|
| 1) Cefmetazole (Cefmetazon) 1–2g in a single dose, i.v. twice daily for 5–7 days|
| 2) Flomoxef (Flumarin) 1–2g in a single dose, i.v. twice daily for 5–7 days|
| 3) Cefpirome (Broact) 1–2g in a single dose, i.v. twice daily for 5–7 days|
| 4) Ceftriaxone (Rocephin) 1–2g in a single dose, i.v. once to twice daily for 5–7 days|
|2. Carbapenems for injection|
| 1) Imipenem (Tienam) 0.5–1g in a single dose, i.v. twice daily for 5–7 days|
| 2) Doripenem (Finibax) 0.25g in a single dose, i.v. 2–3 times daily for 5–7 days|
How do we screen for sexually transmitted diseases (set test)?
- 1The set test includes tests for four major sexually transmitted diseases: chlamydia (cervix), gonorrhea (cervix), syphilis (blood), HIV infection (blood). (B)
- 2For patients at risk for pharyngeal or throat infection, test pharyngeal samples for chlamydia and gonorrhea. (C)
- 3If the patient requested extra tests, tests for trichomonas (vaginal discharge), chlamydial antibody (blood), hepatitis B and C antibody (blood) can be added. (C)
How do we diagnose and treat cystitis?
B. Oncology and benign tumors
What is the appropriate way of obtaining samples for cervical cytology?
Collect cervical cells with a brush or a spatula. (C)
How do we manage and treat CIN1/2 (mild to moderate dysplasia)?
- 1CIN1 (mild dysplasia) confirmed with biopsy should receive follow-up observation with Pap smear and colposcopy every 6 months. (B)
- 2CIN2 (moderate dysplasia) confirmed with biopsy should receive careful and consistent follow up with Pap smear and colposcopy every 3–6 months. (B)
- 3Excluding pregnant patients, CIN2 cases that have difficulty receiving proper follow up can opt for treatment. (C)
What is the indication for further testing with colposcopy-directed biopsy after a Pap smear?
- 1A Pap smear graded as ASC-US that revealed test results such as the following:
- • Positive results for high-risk human papillomavirus (HPV) (B)
- • For facilities that are unable to perform HPV-testing, if the follow-up Pap smear performed immediately or 6–12 months after the suspicious Pap smear is graded as ASC-US or higher. (B) (Only facilities that meet the standard requirements are allowed to perform HPV-testing by an eligible doctor under the Japanese National Health Insurance system.)
- 2When a Pap smear is graded as ASC-H, LSIL, HSIL, SCC, AGC, androgen insensitivity, adenocarcinoma or other malignancies, perform a biopsy immediately. (B)
What is the indication for minimally invasive conization of the cervix procedures, such as loop electrosurgical excision procedure (LEEP) and laser vaporization?
What is the clinical utility of high-risk human papillomavirus (HPV) test and HPV genotyping?
- 1High-risk HPV test (e.g., Hybrid Capture II or AMPLICOR HPV assay) can be used as an adjunct to cytology for cervical cancer screening to improve the accuracy of screening. (C)
- 2High-risk HPV test should be used for women with ASC-US cytology to decide who needs colposcopy. (B)
- 3High-risk HPV test or HPV genotyping can be used for women treated for CIN 2/3 to detect residual or recurrent diseases during post-treatment follow up. (C)
- 4HPV genotyping should be used for women with histologically confirmed CIN1/2 to characterize their risk of disease progression more precisely. Women who test positive for HPV16, HPV18, HPV31, HPV33, HPV35, HPV45, HPV52, or HPV58 are considered to be at increased risk of disease progression. Therefore, they should be managed separately from women who are negative for these eight genotypes. (B)
Who should be vaccinated against human papillomavirus (HPV)?
- 1Girls 10–14 years of age are the most highly recommended group. (A) (According to the Japanese Ministry of Health, Labor and Welfare's emergency policy to promote vaccination, until the end of 2011, Japanese female students from the first year of junior high to the first year of high school (13–16-year-olds) can receive free HPV vaccination from clinics or health-care institutions receiving contracts from their respective regional administrative councils.)
- 2Young women 15–26 years of age are the next most highly recommended group. (A)
- 3Women 27–45 years of age can receive HPV vaccination. (B)
- 4Women who have current evidence or history of low-grade cervical abnormalities can receive vaccination. (B)
- 5HPV testing should not be used to decide whether a woman is eligible for vaccination. (B)
- 6Pregnant women are not included in the recommendations for HPV vaccine. (B)
- 7Lactating women can receive HPV vaccine. (C)
What should vaccine recipients know before receiving the HPV vaccine?
- 1The vaccine protects against HPV16 and HPV18 infections. For girls and women not yet sexually active, the vaccine can be expected to provide 60–70% prevention against cervical cancer. (A)
- 2The vaccine does not have any therapeutic effect on existing HPV infection or cervical diseases. (B)
- 3Girls and women not yet sexually active can be expected to receive the full benefit of vaccination. (B)
- 4Vaccinated women should also have routine cervical cancer screening. (B)
- 5The three-dose schedule (0, 1–2 months, 6 months) and the cost. (A)
- 6The possible adverse events, such as pain, redness, and swelling at the injection site (the arm), headache, fainting, and shock etc. (A)
How should HPV vaccine be administered?
- 1A woman's medical fitness (conditions and circumstances) for vaccination should be assessed with comprehensive pre-vaccination health screening. (A)
- 2The vaccine should be shaken well before administration. A frozen vaccine should not be used. (A)
- 3The vaccine is injected intramuscularly (i.m.) in the deltoid muscle as a three-dose schedule at 0, 1–2 and 6 months. (B)
- 4The HPV vaccine should not be administrated for 27 days after receiving a live vaccine or for 6 days after receiving an inactivated vaccine. (A)
- 5Syncope, anaphylaxis or seizures can occur after vaccination. Therefore, vaccine providers should observe women for 30 min after they receive HPV vaccine. (A)
What is the appropriate way of obtaining samples for endometrial cytology, and who are the screening targets?
- 1Uterine endometrial samples can be obtained by scraping or by suction. (B)
- 2Women over the age of 50 or post-menopausal patients experiencing abnormal vaginal bleeding, or women with predisposing risk factors are selected for screening. (C)
How do we diagnose and treat endometrial hyperplasia without atypia?
- 1When a Pap test indicates endometrial abnormalities, or when increased endometrial thickness is observed, perform endometrial biopsy for definitive diagnosis. When atypia is suspected, diagnose by performing a total endometrial curettage. (A)
- 2When treatment is indicated, administer cyclic medroxyprogesterone acetate. (B)
- 3Endometrial hyperplasia in adolescents should be treated with combined estrogen–progestin formulations. (C)
- 4For patients hoping to conceive, fertility treatment that includes ovulation induction can be started after treatment No. 2 or No. 3. (C)
- 5Among post-menopausal patients, if abnormal bleeding persists and abnormalities continue to be identified in subsequent tests, hysterectomy should be performed. (C)
How do we diagnose and manage endometrial polyps?
- 1Perform screening with transvaginal ultrasonography. (A)
- 2Diagnose using sonohysterography or hysteroscopy. (B)
- 3Perform biopsy to rule out malignancy. (C)
- 4For cases below, perform hysteroscopic surgery, or total endometrial curettage for definitive diagnosis and treatment. (B)
- • Symptomatic cases
- • An infertile patient whose infertility may be attributable to the endometrial polyp
- • Asymptomatic, but malignancy suspected.
- 5For all other cases besides those described in ‘Answer No. 4’, follow-up observation is indicated. (B)
When is hysteroscopy indicated?
- 1Diagnosis for conditions as stated below. (C)
Intrauterine adhesions (Asherman's syndrome)
Spontaneous abortion or residues after expulsion of hydatidiform mole
Residual placenta, placental polyp
Intrauterine object (IUD)
- 2Preoperative diagnosis for conditions as stated below. (B)
How do we treat endometriosis without cystic lesions?
- 1Prescribe analgesics (non-steroidal anti-inflammatory drugs [NSAIDs]) for pain. (B)
- 2When analgesics are inadequate or the patient's endometriosis requires treatment, the first-line therapy is either combined oral contraceptive (COC) or dienogest; as second-line therapy, gonadotrophin-releasing hormone (GnRH) agonist or danazol are usually chosen. (C)
- 3When medication does not work, or when the patient suffers from infertility, perform surgery to cauterize/excise endometriotic lesions and to remove adhesion. (B)
- 4To prevent recurrence of endometriosis in patients who do not wish to conceive, COC, dienogest, and GnRH agonist can be prescribed. (C)
What are the differential diagnoses and management of suspected benign ovarian cysts?
- 1To differentiate between malignant tumors, non-tumor lesions and functional cysts, history-taking, vaginal examination, ultrasonography, tumor marker tests, MRI etc. should be performed. (B)
- 2Surgery is recommended for large cysts (more than 6 cm in diameter) or when symptoms due to the cyst are observed. (B)
- 3Even for small cysts, surgery is recommended for cases whereby the existence of a tumor is confirmed. (C)
- 4If surgery is not indicated, the follow-up schedule should be arranged according to the first upcoming menstrual cycle: the first follow up being 1–3 months later, and the subsequent follow ups at 3- to 6-month intervals. (C)
- 5Explain to patients that the accuracy of the diagnosis is limited if no surgery is performed. (A)
How do we diagnose hemorrhaging corpus luteal cyst or ovarian hemorrhage?
- 1Perform a general evaluation by history-taking, basal body temperature measurement, abdominal examination, ultrasonography. (B)
- 2If the diagnosis of intraperitoneal hemorrhage is difficult in a case presenting with an ovarian mass and peritoneal fluid on ultrasonography, culdocentesis (extraction of fluid through the Pouch of Douglas) can be performed. (C)
- 3In the case of intraperitoneal bleeding, perform the necessary tests to rule out ectopic pregnancy. (B)
- 4When excessive hemorrhage is suspected, and the vital signs of the patient are not favorable, or when the hemoglobin count of the patient decreases dramatically, indicating the presence of persistent hemorrhage, emergency surgical intervention should be performed. (B)
How do we treat ovarian endometrial cyst (chocolate cyst)?
- 1The choice of treatment, which includes observation, medication or surgery, is made based on the patient's age, size of the cyst(s), and the patient's desire to conceive. Surgery is usually prioritized due to fear of rupture, infection or malignant transformation of the cyst. (B)
- 2The type of surgical procedure is chosen based on the balance between curativeness of endometriosis and preservation of ovarian function. (B)
- 3When a patient's cyst is considered to possess a high malignant potential depending on her age, cyst size and the presence of solid components within the cystic mass, she should have her diseased ovary removed surgically. (C)
How do we diagnose and treat adenomyosis?
- 1Clinical findings, internal examination, and ultrasonography can provide the appropriate diagnosis. However, for differential diagnosis against uterine fibroids or uterine sarcomas, MRI should be undertaken. (B)
- 2Treat the symptoms of adenomyosis in the same manner as endometriosis, i.e., with analgesics and hormonal treatment. (B)
- 3As a curative measure, perform hysterectomy. (B)
When do we perform operative hysteroscopy/transcervical resection (TCR) for submucosal fibroids?
- 1The usual criteria for the procedure are small uterine fibroids (less than 30 mm in size) and more than 50% protrusion in the uterine cavity. However, skilled surgeons may not be constrained by these criteria. (B)
- 2Even for patients who do not wish to become pregnant, operative hysteroscopy/TCR may be chosen for its low invasiveness. (B)
What are the considerations for a patient with intramural and/or subserosal uterine fibroids who wishes to opt for conservative therapy?
The type of treatment should be chosen based on the location and size of the fibroids, whether or not the patient has menorrhagia or anemia, age of the patient and the patient's prospects in conceiving. (A)
How do we manage patients with cervical polyps?
- 1The polyp should be resected for pathological evaluation. (B)
- 2For asymptomatic patients with low risk for malignancy, instead of conducting a biopsy, the patients should receive follow-up observation. (B)
- 3For pregnant patients whose polyps may be the source of cervical insufficiency or chorioamnionitis, treatment should be given as necessary (resection or antibiotics). (C)
- 4The method of resection depends on the size and morphology of the polyp: (i) Pull or twist the polyp to detach it using Péan forceps; (ii) ligation, and then resection; and (iii) electrocauterization, are some of the methods chosen. (B)
How do we manage Bartholin's cysts?
- 1Asymptomatic cases with minimal swelling do not require treatment. (B)
- 2Bartholin's abscess presenting with acute symptoms should receive emergency treatment by drainage of purulent material (either via incision or fine-needle aspiration). Culture the infected material for bacteria and treat the infection using antibiotics. (B)
- 3Perform marsupialization, a surgical treatment that preserves the function of Bartholin's gland. (B)
- 4Recurrent cases despite marsupialization, recurrent Bartholin's abscess, and cases suspicious of carcinoma of Bartholin's gland should undergo surgical resection. (B)
- 5Adenocarcinoma of Bartholin's gland is very rare. When malignancy is suspected, perform histopathological exploration and evaluation. (B)
What should be recommended for post-treatment follow up of patients with gynecological malignancies (cervical, endometrial or ovarian cancer)?
- 1The follow-up intervals are recommended as follows: every 1–3 months for 3 years, every 6 months for another 2 years, and then annually. (C)
- 2The follow up includes interval history and physical examination (including pelvic examination), with cytology, chest X-ray, tumor markers, ultrasonography, and computed tomography scans etc. (C)
How is breast cancer screening conducted?
- 1All women above 50 years of age should receive mammography screening. (A)
- 2Women in their 40s should receive mammography screening. (B)
- 3Women above 40 years of age can receive optional screening using ultrasonography. (C)
- 4Women below 40 years of age should receive ultrasonography for breast cancer screening, or mammography in combination with ultrasonography. (C)
- 5Interval in between screenings is 1–2 years. (B)
How is mastopathy managed?
- 1Clinically, ‘mastopathy’ as an exclusive diagnosis for breast cancer should not be made casually. In such cases, ‘suspicious for mastopathy’ should be indicated instead. (B)
- 2As a rule, cases suspected for mastopathy should receive consultation from specialized institutions. (B)
- 3Cases with proliferative lesions that are histologically ruled out for atypia should receive consistent screenings as the risk of breast cancer is elevated. (B)
- 4Cases that are histologically confirmed with atypical proliferation (ductal, lobular) (including those with a history of proliferative atypia) have an increased risk for breast cancer. Such cases should receive follow ups in coordination with an institution specializing in breast cancer. (A)
C. Endocrinology and Infertility
How do we treat functional dysmenorrhea?
- 1Prescribe and administer analgesics (such as NSAIDs) or low-dose combined oral contraceptive. (B)
- 2Administer Japanese herbal medicine (Kampo) or anti-cramp medicine. (C)
What should we prescribe for menorrhagia without any underlying pathology?
- 1Administer low-dose combined oral contraceptive. (C)
- 2Administer antifibrinolytics (tranexamic acid, such as Transamin). (C)
- 3Consider surgical treatment when pharmacotherapy is either ineffective or not a viable option. (C)
What are other treatment options besides pharmacotherapy for menorrhagia without any underlying pathology?
- 1Perform dilation and curettage for acute bleeding. (C)
- 2For those who do not wish to retain their uterus and/or fertility, hysterectomy or endometrial ablation can be performed. (C)
How do we manage abnormal menstrual cycle due to anovulation?
- 1Investigate the cause behind the abnormal menstrual cycle from patient interviews, physical findings, endocrine tests etc. (B)
- 2For those who do not wish to conceive, conduct hormonal therapy.
- • Polymenorrhea or oligomenorrhea caused by anovulatory menstrual cycles should be treated with cyclic progestins. (B)
- • Administer cyclic progestins for euestrogenic amenorrhea. (B)
- • Administer cyclic estrogen–progestin for hypoestrogenic amenorrhea. (B)
- • Administer combined estrogen–progestin, such as oral contraceptives. (C)
- • For those who are looking forward to conceiving, induce ovulation. (B)
What are the important points when we see a woman of child-bearing age with a chief complaint of abnormal vaginal bleeding?
- 1Perform systematic differential diagnosis via patient interviews and physical examinations. (A)
- 2Keep in mind the possibility of pregnancy when conducting patient interviews and examinations. (A)
- 3When malignancy is suspected, perform cytology and biopsy. (A)
- 4When pregnancy and underlying pathology are ruled out, dysfunctional uterine bleeding is diagnosed. (A)
How do we diagnose hyperprolactinemia?
- 1Measure serum prolactin levels when the patient presents with menstrual abnormalities or galactorrhea. (A)
- 2If serum prolactin levels are elevated, check the patient's thyroid function as well. (B)
- 3Interview the patient about the drugs taken (psychiatric, underlying conditions), the presence of thyroid disease symptoms, headaches, and visual field defects. (B)
- 4Check both breasts for galactorrhea. (B)
- 5When serum prolactin levels exceed 100ng/mL, perform MRI to rule out prolactinoma. When necessary, refer the patient to either an endocrinologist or a neurosurgeon. (B)
How do we treat hyperprolactinemia?
- 1Treat using dopamine agonists in hyperprolactinemia caused by pituitary disorders. (A)
- 2For drug-induced hyperprolactinemia, consult the doctor who prescribed the medication to either reduce the dosage or replace the problematic drug. (B)
- 3In patients confirmed with prolactinoma, consult an endocrinologist or a neurosurgeon. Treatment using dopamine-agonist is still the main approach. (B)
- 4Surgical treatment is indicated for pituitary infarction, pituitary tumors with accompanying visual field defects, drug-resistant cases and cases that cannot tolerate pharmacotherapy. (C)
How do we diagnose and treat polycystic ovarian syndrome (PCOS)?
- 1Diagnose according to the 2007 diagnostic guidelines laid out by the Japan Society of Obstetrics and Gynecology. (A)
- 2For women who do not wish to conceive:
- • Advise obese patients to make lifestyle adjustments in order to lose weight (B)
- • Induce withdrawal bleeding at consistent intervals. (B)
- 3For women who wish to conceive:
- • Advise obese patients to lose weight (B)
- • Use clomiphene as a first-line ovulation induction (B)
- • For cases who did not respond to clomiphene alone, use metformin in combination with clomiphene when the patients have any of the conditions, such as obesity, glucose intolerance or insulin resistance. (C)
- 4For cases with clomiphene-resistance, perform gonadotrophin treatment or laparoscopic ovarian drilling. (B)
- 5Gonadotrophin treatment should be performed using either recombinant or pure FSH in a chronic low-dose method. (B)
How do we prevent the occurrence or severe progression of ovarian hyperstimulation syndrome (OHSS)?
- 1Use recombinant or pure FSH in a chronic low-dose method for gonadotrophin treatment in patients with PCOS or history of OHSS. (B)
- 2Cancel human chorionic gonadotrophin (hCG) administration when the risk for developing OHSS is high during ovulation induction in routine infertility practice. (B)
- 3When the risk of developing OHSS is high during ovarian stimulation in assisted reproductive technology procedures:
- • Do not use hCG for luteal support (A)
- • Reduce or delay (coasting) treatment using hCG administration alternative to LH surge (B)
- • Cancel embryo transfer and freeze all embryos. (B)
- 4For mild OHSS, direct patients to take sufficient fluids and to avoid physical exercises and sexual intercourse. (C)
- 5For moderate OHSS or pregnant patients with OHSS, monitor closely and consider management at an advanced medical institution if the symptoms or the test results are not improved. (B)
- 6Severe cases should receive inpatient treatment at a hospital. (B)
How do we manage premature ovarian failure (POF)?
- 1Perform the necessary tests, such as checking the patient's endocrine profile, to identify the cause of POF. (B)
- 2Choose hormone replacement therapy for patients who do not wish to conceive. (A)
- 3For patients who wish to conceive, choose cyclic estrogen–progestin combination therapy. If ovulation cannot be achieved, administer high-dose human menopausal gonadotrophin (hMG) therapy. (C)
What are initial tests to identify the causes of the infertility?
Below are the recommended tests.
- 1Basal body temperature measurement. (A)
- 2Ultrasonography. (A)
- 3Endocrine tests. (B)
- 4Chlamydial antibody test or chlamydial antigen (nucleic acid identification) test. (B)
- 5Hysterosalpingogram. (B)
- 6Semen analysis. (B)
- 7Test for cervical factors. (B)
What are the important points for artificial insemination with husband's sperm (AIH)?
- 1Perform AIH between the moment before and after ovulation. (B)
- 2Use washed and concentrated spermatazoa suspension. (C)
- 3Stimulate ovulation using clomiphene or gonadotrophin in order to increase pregnancy success rate. (C)
- 4Switch to assisted reproduction technology procedures if AIH is not successful in repeated attempts. (C)
- 5Explain the possible adverse events, such as bleeding, pain and infection. (B)
How do we treat male infertility?
- 1Pharmacotherapy for oligozoospermia. (C)
- 2Perform artificial insemination with husband's sperm (AIH) for mild oligozoospermia and mild asthenozoospermia. (B)
- 3Choose in vitro fertilization and intracytoplasmic sperm injection for severe oligozoospermia and severe asthenozoospermia. (B)
- 4Consult a urologist specializing in infertility to identify the cause of azoospermia and severe oliogozoospermia and decide on the treatment. (B)
- 5If pregnancy is impossible with the husband who is diagnosed with azoospermia, artificial insemination with donor's sperm can be an option. (C)
- 6Infertility treatment should be conducted in coordination with a urologist when the male patient presents with sexual dysfunction, such as erectile dysfunction. (C)
How do we manage recurrent pregnancy loss in association with chromosomal anomalies?
- 1Provide genetic counseling to couples with a history of recurrent pregnancy loss who are taking tests for chromosomal anomalies. (B)
- 2Provide genetic counseling in conjunction with karyotype test of tissues from spontaneous abortions. (C)
- 3Preimplantation genetic diagnosis should be carried out in adherence to the principles laid out by the Japan Society of Obstetrics and Gynecology, and should have received ethical clearance by an internal review board. (A)
D. Healthcare for women
How should we perform emergency contraception? What are the pitfalls concerning emergency contraception?
- 1Perform emergency contraception to reduce the probability of pregnancy in unprotected sexual intercourse. (C)
- 2A single dose of levonorgestrel is administered. (B)
- 3Use the Yuzpe method. (C)
- 4For women with a history of pregnancy, a copper-containing intrauterine device can be used when necessary. (C)
- 5Inform the patient that even with emergency contraception, there is still a risk of pregnancy. Ask the patient to check up at the clinic again when necessary. (B)
What should we tell the patient when prescribing oral contraceptives (OC)?
Provide information based on the ‘Guidelines concerning the use of low-dose oral contraceptives (year 2007 revision)’.
- 1Efficacy and safety: OC is the most effective reversible method of contraception available. It is also very safe. (B)
- 2Additional benefits: OC may ameliorate the symptoms of menstrual problems, such as dysmenorrhea, menorrhagia etc. (B)
- 3Sexually transmitted diseases: OC does not prevent sexually transmitted infection. (B)
- 4Target age: any woman of reproductive age should be able to receive treatment. (C)
- 5Complications: OC increases the risk of cerebral stroke and venous thromboembolism. The risk of myocardial infarction among smokers is also increased. (B)
- 6Cancer risk: cervical cancer risk increases with long-term usage. Breast cancer risk is not affected. Reduces the risk of ovarian and endometrial cancer. (B)
- 7Side-effects: OC may contribute to gastrointestinal symptoms but is not associated with weight gain. (B)
- 8Caution and contraindication: hypertension, smoking (more than 15 cigarettes per day), obesity (BMI > 30), advanced age (more than 40 years old) are some of the criteria that call for caution and may be a reason for contraindication. (B)
What should we inform the patient when an intrauterine device (IUD) (including the intrauterine system) is chosen for contraception?
Provide information as below.
- 1It does not prevent pregnancy without fail. (A)
- 2Visit the doctor as soon as a pregnancy is suspected. (A)
- 3Receive consistent follow up after the IUD has been fitted to make sure that the device is in the right position or to exchange the device. (B)
- 4Possible complications, such as hemorrhage, infection, perforation etc. may occur. (B)
How do we manage Turner's syndrome?
- 1For patients diagnosed before puberty, growth hormone may be needed for treatment. Management of patient can be carried out in coordination with a pediatrician/endocrinologist. (A)
- 2For patients diagnosed before puberty, low-dose estrogen should be administered starting from puberty (from about 12 years of age). Increase the dosage in 2- to 3-year intervals. (B)
- 3Hormone replacement therapy is recommended. (A)
- 4Provide counseling, while taking care of the patient's emotional condition, when providing explanation about her fertility. (B)
- 5Provide care for patients in coordination with respective specialists for complications, such as thyroid abnormalities, glucose intolerance, coarctation of the aorta, gonadal tumors etc. (B)
How should we provide care for XY female patients?
- 1After definitive diagnosis is made, provide appropriate counseling for both the patient and her parents. (B)
- 2Provide careful follow up as the risk for gonadal tumor development is high. After reaching puberty, surgically remove the abnormal gonads at the appropriate timing. (A)
- 3For patients with androgen insensitivity, provide estrogen replacement therapy after total gonadectomy. For XY complete gonadal dysgenesis, perform cyclic estrogen–progestin therapy as soon as the diagnosis is made. (A)
How do we provide care for patients with Mayer–Rokitansky–Küster (–Hauser) syndrome?
- 1Provide information for the patient regarding her medical condition in a timely and approachable manner. (A)
- 2Vaginoplasty should be performed according to the patient's wishes after sufficient counseling. (A)
- 3Vaginoplasty should be carried out at a specialized and experienced institution. (A)
What are the important points when we perform medical examinations on an adolescent?
- 1Medical interviews are very important, and can be conducted with or without the accompaniment of a family member. (B)
- 2Even for girls with no prior experience of sexual intercourse (virgins), physical examination, rectal examination, ultrasonography (transrectal or transabdominal) should be performed to achieve proper diagnosis. (B)
- 3Peritoneal lesions caused by endometriosis should also be considered as one of the reasons of dysmenorrhea in an adolescent patient. (C)
What are the important points when treating a female adolescent?
- 1For amenorrhea, use cyclic progestins therapy or cyclic estrogen–progestin therapy once every 2–3 months. (C)
- 2Watch out for decreased bone mass in prolonged amenorrhea. (C)
- 3Do not induce menstruation in amenorrhea associated with extremely low bodyweight (less than 70% of ideal bodyweight). Such cases should be advised to regain weight through lifestyle improvement and referred for counseling. (B)
- 4Dysmenorrhea that is not caused by underlying genitourinary deformities, especially cases that are associated with endometriosis, should be treated with either NSAIDs or combined oral contraceptive. (B)
What should we do when we encounter a sexual assault victim?
- 1Victims who have not reported their ordeal to the law enforcement authorities should be reported to the police after obtaining their consent before any medical examination takes place. (A)
- 2Collection of crime evidence during medical examination of the victim(s) should be done with the victim(s)' consent under the supervision of a police officer. (A)
- 3Observe and document any physical trauma, such as external injuries, scratches, bruises etc. (B)
- 4Issue a medical certificate. (B)
- 5Emergency contraception should be provided. (B)
- 6The medical expenses incurred from the medical examination, tests and treatment should not be charged to the victim, but should be paid by the police department. (B)
How do we help patients modify their menstrual cycle?
- 1To shorten the menstrual cycle, administer combined estrogen–progestin (EP) or norethisterone from the 3rd to 7th day of the menstrual cycle for 10–14 days. (B)
- 2To prolong the menstrual cycle, administer combined EP or norethisterone from the follicular phase until the desired period of prolongation. (B)
- 3To prolong the menstrual cycle, administer moderate-dose combined EP therapy or norethisterone 5–7 days expected menstruation until the desired period of prolongation. (B)
What are the important points in the diagnosis of climacteric disorder?
- 1Suspect climacteric disorder in a woman who has already undergone menopause that comes with a myriad of complaints. (A)
- 2The symptoms may be caused by estrogen withdrawal or other causes or the combination of estrogen withdrawal and other causes. Make the proper diagnosis and evaluation based on those possibilities. (C)
- 3Exclude underlying pathologies that may contribute to the complaints. (B)
- 4Among the differential diagnoses, watch out for depression, malignancy, and thyroid diseases due to the overlapping characteristics, such as the patient's age at onset and symptoms. (C)
How should we treat climacteric disorder?
- 1Hormone replacement therapy is effective for symptoms caused by autonomous nervous system dysregulation, such as flushing, sweating, insomnia etc. (B)
- 2As hormone-replacement therapy, estrogen only can be given to post-hysterectomy patients, otherwise, estrogen and progesterone should be given in combination. (A)
- 3For non-specific complaints that encompass a myriad of symptoms, traditional Japanese herbal medicine (Kampo) can be used. (C)
- 4For cases with severe mood-related disorders, counseling or psychiatric medication should be considered. (C)
- 5Start the treatment for depression using antidepressants, such as selective serotonin reuptake inhibitors (SSRI) and serotonin–norepinephrine reuptake inhibitors (SNRI). (C)
- 6Recommend lifestyle changes if any problems are detected. (C)
- 7For other symptoms, choose the best treatment according to the case at hand. (C)
How should we provide information regarding the side-effects of hormone replacement therapy and the corresponding strategies for treatment?
- 1The minor side-effects are: (A)
Abnormal vaginal bleeding, mastalgia (breast pain), breast swelling.
- 2Rare adverse effects that may occur are: (B)
Breast cancer, ovarian cancer, lung cancer, coronary vascular disease, ischemic cerebral stroke, thromboembolism.
- 3Provide explanation regarding relative contraindications, such as migraine, cholecystitis, cholelithiasis, uterine fibroids, endometrial hyperplasia etc. (B)
- 4Each adverse or side-effect can be managed, taking into account factors such as the age of the patient and the number of years passed since menopause, by choosing the right drugs, opting for (or excluding) combined luteal hormone therapy, and changing the route of administration and the duration of treatment. (B)
What are the recommended traditional Japanese herbal medicines (Kampo) or alternative therapies for climacteric disorder?
- 1Kampo formulations, such as Tokishakuyakusan, Keishibukuryogan, Kamishoyosan etc. can be used. (C)
- 2Isoflavones derived from soy and red clover may be effective for menopausal hot flushes. (C)
- 3Even traditional Japanese herbal medicine (Kampo) and alternative therapies have side-effects and the necessary precautions should be taken. (B)
How do we treat atrophic vaginitis?
- 1Prescribe vaginal estriol tablet for symptomatic cases. (B)
- 2Administer estrogen systemically when topical treatment using vaginal estriol tablet is a difficult option for the patient. (B)
- 3Prescribe hormone replacement therapy for patients with postmenopausal syndrome. (B)
How do we prevent postmenopausal osteoporosis, and what are the strategies for early detection and treatment?
- 1Advise the patients to exercise regularly and have adequate calcium intake to prevent osteoporosis. (B)
- 2Take spine X-ray or measure bone density for early detection of osteoporosis, for women over the age of 65 or for women below the age of 65 with high risk of fracture. (B)
- 3Bone density measurement is usually carried out using dual X-ray absorptiometry (DXA) scan of the axial skeleton. Alternatively, peripheral DXA scan or quantitative ultrasonometry (QUS) of the calcaneus can also be performed. (C)
- 4Biomarkers for bone metabolism are measured to help choose the right drugs and/or evaluate the efficacy of treatment. (C)
- 5The aim of treatment is to prevent fractures, thus patients at risk may start their treatment with osteoporosis medication even if they are not fulfilling the diagnostic criteria for osteoporosis. (B)
- 6The first-line drugs for osteoporosis are bisphosphonates and selective estrogen receptor modulators. (A)
- 7Watch out for side-effects unrelated to bone metabolism when using estrogen (conjugated estrogen, 17β-estradiol). (B)
How should we treat mood-related disorders and non-specific medical complaints?
- 1Prescribe hormone replacement therapy for depressive mood and symptoms associated with menopause. (B)
- 2Depression associated with menopause should be treated with SSRI or SNRI. (C)
- 3Patients who complain of dysmenorrhea, dyspareunia, and vulvodynia without underlying pathologies should receive psychiatric evaluation and may be treated with psychiatric medication. (C)
- 4Recommend consultation with a psychiatrist or a psychosomatic medicine specialist when symptoms persist. (B)
How do we diagnose and manage premenstrual syndrome?
How do we diagnose urinary incontinence?
- 1The type of urinary incontinence is diagnosed by patient interview. (B)
- 2Referral to a specialist is recommended when the residual urine volume exceeds 50–100 mL after bladder voiding. (B)
- 3Perform gynecological exam to check for diseases within the pelvis. If any underlying pathologies that may contribute to urinary incontinence are found, prioritize the treatment of the underlying condition. (A)
- 4If hematuria is persistent or found in multiple urine tests, the patient should be referred to a urologist for a complete evaluation for diseases such as bladder cancer. (A)
How do we treat urinary incontinence?
- 1Perform pelvic floor muscle exercises as a behavioral therapy for stress incontinence. (B)
- 2Pharmacotherapy for stress incontinence consists of either estriol or clenbuterol. (C)
- 3Surgical treatment is recommended if outpatient management of urinary incontinence is deemed difficult or the patient wishes to be treated surgically. (B)
- 4Urge incontinence is one of the manifestations of an overactive bladder. Hence, it is treated in the same manner as overactive bladder (refer to CQ421). (A)
How do we manage overactive bladder in an outpatient setting?
- 1Diagnose overactive bladder by asking the questions in the Overactive Bladder Symptom Score (OABSS). (B)
- 2Interview the patient to identify any history of neurological illnesses. (B)
- 3Perform gynecological exam to check for pelvic diseases. (B)
- 4Perform urine test to check for hematuria and pyuria. (B)
- 5Measure residual urine volume right after voiding or micturition. (B)
- 6Bladder control and pelvic floor muscle exercises as behavioral therapy. (C)
- 7Anticholinergics as pharmacotherapy. (A)
How do we manage pelvic organ prolapse (POP) in an outpatient setting?
- 1Start initial treatment for pelvic organ prolapse when the patient complains of discomfort from symptoms, such as sagging, vaginal bulging etc. (B)
- 2For patients whose lowest point of prolapse is far from the hymen (POP stage I and below), initiate treatment with pelvic floor muscle exercises. (B)
- 3For patients whose lowest point of prolapse is adjacent to the hymen (POP stage II and above), initiate treatment using pessaries. (B)
- 4After placing the pessary, follow up every 1–3 months in the first year; and every 2–6 months afterwards, to check for the fit and complications, such as vaginal erosions. (B)
- 5Administer estriol for vaginal sores caused by pessary placing. (C)
- 6If outpatient management is difficult or the patient has expressed her wish to receive surgery, after obtaining informed consent from the patient, surgical treatment is recommended. (B)