Most individuals will wish to avoid pregnancy for some part of their reproductive years. A variety of hormonal and nonhormonal contraceptive methods are available, which have different characteristics related to systemic effects, bleeding patterns, and effort required on the user’s part. The goal of contraceptive counseling is to identify a method that is safe and compatible with the individual’s preferences. Clinicians may often be able to help patients initiate contraception on the day of the initial office visit. They should remain available and supportive to patients who wish to switch methods and provide comprehensive counseling for all available contraceptive methods as well as emergency contraception options.

This review contains 8 figures, 7 tables and 51 references

Keywords: birth control, contraception, emergency contraception, Essure, hysteroscopy, interval, laparoscopy, microinserts, postpartum, salpingectomy, sterilization

For individuals who no longer desire fertility, permanent contraception options such as interrupting the vas deferens or fallopian tubes or occluding/removing the fallopian tubes are safe and effective. Clinicians should carefully counsel patients that these methods are not intended to be reversible and that they do have a small but quantifiable failure rate. Depending on personal preferences and medical comorbidities, individuals may choose to undergo procedures at or near the time of delivery or at a time remote from childbirth. We provide an overview of these different approaches as well as suggested guidelines for patient counseling.

This review contains 10 figures, 2 tables and 42 references

Key words: counseling, Essure, hysteroscopy, interval, laparoscopy, micro-inserts, permanent contraception, postpartum, salpingectomy, sterilization

Individuals may have a variety of reasons to end a pregnancy. Healthcare providers should provide support during the decision-making process and should be able to give patients basic information about their options depending on gestational age. In the United States, clinicians can offer first-trimester medical abortion with mifepristone and misoprostol up to 10 weeks’ gestation. Uterine aspiration or dilation and curettage are options throughout the first trimester. Options in the second trimester include induction abortion with medications, or a surgical procedure (dilation and evacuation) which may require cervical preparation at later gestational ages. Clinicians should assess the patient’s desire for fertility following an abortion and may offer contraception or preconception advice, as appropriate.

This review contains 13 figures, 6 tables, and 61 references.

Key Words: abortion, dilation and curettage, dilation and evacuation, mifepristone, misoprostol, pregnancy termination

The ability to diagnose early pregnancy and manage normal and abnormal findings associated with early pregnancy is important and commonly used in the medical care of women of reproductive age. The purpose of this review is to describe the evaluation of early pregnancy, discuss indications for early evaluation of pregnancy location, delineate diagnostic strategies to further evaluate pregnancy of unknown location, and review current treatment strategies for ectopic pregnancies, both tubal and nontubal in location.

This review contains 11 figures, 8 tables and 41 references

Keywords: early pregnancy, ectopic, human chorionic gonadotropin, methotrexate, pregnancy of unknown location, salpingectomy, salpingostomy, ultrasound criteria, vaginal bleeding

Early pregnancy loss is a common clinical scenario for women of reproductive age. Confirmation of pregnancy loss by pelvic ultrasonography using established criteria is crucial to ensure that potentially viable pregnancies are not interrupted. Both medical and surgical management options are effective and safe methods for the management of early pregnancy loss. Management should largely be influenced by patient preference in the hemodynamically stable patient. The purpose of this section is to describe the criteria for the diagnosis of early pregnancy loss, discuss various evidence-based treatment options for early pregnancy loss, and review current recommendations for attempts at future conception.

This review contains 4 figures, 5 tables and 41 references

Key Words: dilation and curettage, inevitable abortion, miscarriage, missed abortion, misoprostol, nonviable pregnancy, retained products of conception, threatened abortion, ultrasonography criteria

Since the Papanicolaou (Pap) smear became implemented as a screening tool for cervical cancer, the mortality from cervical cancer has sharply declined in the United States. The discovery of the human papillomavirus (HPV) as the causative agent in the progression from dysplasia of the cervix to cervical cancer has changed the types of screening offered to women and the management of abnormal Pap smears. The management of abnormal Pap smears has changed depending on the age of the woman, with women under the age of 24 years being managed more conservatively given the low rates of cervical cancer in this age group and the high rates of regression of HPV and cytologic abnormalities. Colposcopy remains the first line in evaluation of an abnormal Pap smear, with excisional treatment reserved for high-grade dysplasias with a high risk of progression to cervical cancer. Treatment for cervical dysplasia is highly effective, but even after treatment, there is an increased risk of recurrence or progression to cervical cancer for up to 25 years, and these women should be followed closely. 

This review contains 18 figures, 3 tables, and 43 references.

Key words: cervical cancer screening, high-grade cervical dysplasia, human papillomavirus, low-grade cervical dysplasia, management of abnormal Pap smears, Pap smear, recurrence of cervical dysplasia, treatment of dysplasia

Vulvovaginal complaints are a common indication for women to seek gynecologic care. The most common causes of vaginitis are bacterial vaginosis, vulvovaginal candidiasis, and trichomoniasis, which account for 22 to 50%, 17 to 39%, and 4 to 35% of vaginitis, respectively. This review describes the presentation, diagnosis, and prevention strategies for the most important causes of vulvovaginitis, including characteristic findings on office microscopy and newer available diagnostic testing. It outlines treatment modalities for uncomplicated infections in healthy women, as well as nuances of treatment for recurrent and persistent infections, pregnant women, and HIV-positive women. It also explores the diagnosis and management of non-infectious vaginitis as well special consideration for vaginitis in children and adolescents.

This review contains 4 figures, 11 tables, and 58 references.

Key words: vaginitis, vulvovaginitis, bacterial vaginosis, candidiasis, trichomoniasis, vaginitis treatment

Abnormal uterine bleeding (AUB) is a common presentation that can occur in all age groups. AUB is an umbrella term for any uterine bleeding that occurs outside a woman’s normal pattern in volume, regularity, and/or timing. AUB is described by using frequency, regularity, duration, and volume or by using PALM-COEIN (Polyp, Adenomyosis, Leiomyoma, Malignancy and premalignant conditions; Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not yet classified). Workup for AUB comprises a history (with a detailed menstrual history), physical examination (including a pelvic and bimanual examination), lab tests, and imaging (primarily transvaginal ultrasonography). For treatment, medical therapies should be considered before surgical therapies, especially when fertility is desired. The decisions for treatment are based on etiology, fertility concerns, contraindications, or patient preference. Of the medical therapies, there are hormonal and nonhormonal therapies. The most common treatments for AUB are levonorgestrel intrauterine device, tranexamic acid, oral contraceptives, and nonsteroidal anti-inflammatory drugs. The most common surgical treatments are myomectomy, endometrial ablation, uterine artery embolization, and hysterectomy.

This review contains 7 figures, 11 tables and 49 references

Key words: abnormal uterine bleeding, adenomyosis, contraceptives, endometrial, fibroids, hysterectomy, menorrhagia

Chronic pelvic pain (CPP) in women is responsible for greater than 10% of referrals to gynecologists. A majority of them will remain undiagnosed or inadequately treated. Over time, CPP may lead to a syndrome that results in disability, loss of employment, and discord within relationships. This review discusses how to achieve a comprehensive assessment of CPP from a variety of causes.

This review contains 13 figures, 5 tables and 60 references

Key Words: dysmenorrhea, dyspareunia, endometriosis, interstitial cystitis, irritable bowel syndrome, pelvic floor dysfunction, pelvic pain, pudendal neuralgia, somatic pain, visceral pain

Uterine fibroids may be present in up to 80% of women and are the most common benign indication for hysterectomy. Symptoms related to fibroids can vary tremendously and depend on the number, size, and location of fibroids, as well as the patient’s hormonal status. Several different treatment options are available for fibroids. A variety of factors, such as a patient’s symptoms, age, reproductive goals, and medical comorbidities, help determine which treatment is best for each patient. 

This review contains 11 figures, 4 tables and 55 references

Key Words: abnormal uterine bleeding, fibroids, FIGO fibroid classification, hysterectomy, leiomyoma, myomectomy, uterine artery embolization

Endometriosis is a chronic, gynecologic disease affecting 6 to 10% of reproductive age women. Pelvic pain, dyspareunia, and infertility are the most common symptoms of endometriosis that can have a significant impact on patients’ lives. Although the etiology remains largely unknown, the role of estrogens in the development and growth of endometriosis is well characterized. Medical and surgical therapies are the two cornerstones of endometriosis management. Following diagnosis of endometriosis, treatment options will be dependent on patient preference (i.e, seeking pain relief versus fertility treatment). Future research aimed at targeting altered molecular pathways in patients with endometriosis will hopefully help mitigate the burden of this debilitating disease.

This review contains 5 figures, 9 tables, and 78 references.

Key Words: aberrant gene expression, altered immunity, endometriosis, infertility, medical and surgical therapy, pelvic pain, retrograde menstruation, stem cells

Prenatal genetic testing offers patients and providers the opportunity to screen for aneuploidy, genetic syndromes, and congenital malformations during pregnancy. Screening options include taking a clinical history, evaluation of maternal serum markers or noninvasive cell-free DNA, and ultrasound evaluation during the first and second trimesters. Invasive diagnostic testing such as amniocentesis or chorionic villus sampling allows for further investigation of positive screening results and a directed test to identify aneuploidy as well as specific gene mutations and gain, loss, or rearrangement of genetic information. Laboratory methods for testing fetal samples differ by types of genetic abnormalities that can be detected and turnaround time for results; these methods include karyotype, fluorescence in situ hybridization, and microarray.

This review contains 5 figures, 5 tables and 43 references

Key words: amniocentesis, aneuploidy, cell-free DNA, chorionic villus sampling, karyotype, microarray, prenatal genetic screening, ultrasonography

Sexual assault affects as many as one-third of women around the world. Sexual assault includes individual traumatic events as well as chronic sexually abusive relationships, and can involve a partner, acquaintance, or stranger. Many women who have experienced sexual assault develop long-term mental and physical effects of their sexual trauma, including post-traumatic stress disorder, alcohol abuse, and dyspareunia. OBGYNs are able to have long-lasting impacts on the many survivors of sexual assault by screening effectively and providing compassionate, trauma-informed care.

This review contains 10 figures and 33 references.

Keywords: human trafficking, intimate partner violence, primary care, rape, sexual assault, sexual violence, trauma-informed care, women

Human sex trafficking, often referred to as modern-day slavery, is a major global human rights problem with at least 4.5 million people trafficked for commercial sex annually. Many of these women interface with the medical system regularly, often in women’s health clinics and the emergency departments. Therefore, it is important for healthcare providers to be able to identify red flags for human trafficking, to be able to screen effectively, and to know how to connect patients with resources in the community. It is also important for healthcare providers to be aware of the many long-term health effects related to sexual trauma that victims of human trafficking may develop. OBGYNs are able to have long-lasting impacts on the many survivors of human sex trafficking by screening effectively and providing compassionate, trauma-informed care.

This review contains 4 figures, and 3 tables, and 40 references.

Keywords:  Sexual assault, sexual violence, Intimate partner violence, Human trafficking, Rape, Trauma-informed care, Women, Primary Care, Obstetrics and Gynecology.

Premenstrual syndrome (PMS) is a recurrent constellation of affective and physical symptoms that begin during the luteal phase of the menstrual cycle and resolve completely or almost completely during the follicular phase. Symptoms range in severity from mild to severe. The pathophysiology of PMS is discussed in this chapter, and potential causes are listed in a table. The diagnosis and differential diagnosis are reviewed. To warrant medical attention, evaluation, and intervention, premenstrual symptoms must be recurrent and sufficiently severe to interfere with daily work and social activities. Mild cases of PMS can be treated with lifestyle modification (e.g., good sleep patterns, regular exercise) and nonpharmacologic therapy (e.g., bright-light therapy, stress management, behavioral therapy). More severe cases warrant aggressive intervention, with pharmacologic therapy and even surgery in women who respond very well to a gonadotropin-releasing hormone (GnRH) agonist and have completed childbearing.

This review contains 1 figure, 5 tables and 51 references

Key Words: Premenstrual syndrome, premenstrual dysphoric disorder, selective serotonin reuptake inhibitors, anxiogenic progesterone metabolites, estrogen, progesterone.

The healthcare community and lay public have become more aware of transgender (TG) people in the past decade as celebrities have publicly transitioned and activists have pushed back against restrictive laws. Movies, television, nonfiction books, and novels increasingly represent the experience of people who are TG. News organizations and entertainment outlets have given attention to the lives, needs, and challenges of TG and gender-nonconforming individuals. Nonetheless, TG individuals are often fearful when seeking healthcare. Experiences of shame, judgment, and rejection with providers lead to anxiety in future encounters. The number of clinical providers who feel prepared to offer care for TG individuals is limited. Many TG individuals have been denied basic primary and preventive healthcare as a result of their TG status. Understanding the concepts of TG and gender nonconformance expands the skill set of the healthcare professional for providing culturally competent care to all patients and their family members.

This review contains 26 figures, and 59 references.

Key Words: cis-sexual, gender binary, gender confirmation surgery, gender dysphoria, gender nonconforming, intersex, LGBTQ, queer, transgender, WPATH

Vulvar symptoms are a common reason for a gynecologic visit. A variety of conditions impact the vulva, including dermatologic conditions, hormonal changes, vulvar pain, and sexually transmitted or other infections. History and physical exam, focused on the symptoms and the vulvovaginal area, are crucial to identifying the etiology of the symptoms. A full evaluation may include vulvar biopsies and testing for infections. The treatment of the symptoms depends on the etiology; therefore, an accurate and thorough determination of the cause of the patient’s symptoms is of primary importance. Treatment can include antibiotics, antifungals, steroids, antidepressants, hormones, and pelvic floor physical therapy. In this chapter, we summarize common conditions affecting the vulvar, their evaluation, and their treatment.

This review contains 7 figures, 10 tables, and 40 references.

Keywords: Bartholin gland, candidiasis, dermatitis, eczema, hidradenitis suppurativa, lichen planus, lichen sclerosus, sexually transmitted infections, vulva, vulvodynia, vulvovaginal atrophy

22q11.2 deletion syndrome (22q11.2DS) is the most common chromosomal microdeletion syndrome with an incidence of 1/3,000-1/4,000 live births. Common manifestations of 22q11.2DS include congenital heart defects, hypocalcemia, immune deficiency, cleft palate, cognitive deficits, and psychiatric disturbances. As childhood management of 22q11.2DS has improved, these individuals are living into adulthood and may have children of their own. Thus, it is imperative for the clinician to have an understanding of both the physical and psychiatric complications that may be seen in the adult with 22q11.2DS and how this may affect a pregnancy. Here we review the common features of 22q11.2DS in the adult and pregnancy management recommendations for the obstetrician. 

This review contains 4 figures, 1 tables, and 27 references.

Keywords: 22q11.2 Deletion Syndrome; DiGeorge Syndrome; Velocardiofacial Syndrome; 22q11.2 Deletion Syndrome Adult; 22q11.2 Deletion Syndrome pregnancy; DiGeorge Syndrome pregnancy; DiGeorge Syndrome adult. 

Sexually transmitted infections (STI’s) are relatively common. Their presentations range from symptom-free to highly painful, debilitating and life-threatening. The approach to each type of infection varies, and depends on the ability to screen, the availability and effectiveness of treatment, and the likelihood of long-term sequelae. For many infections, prophylaxis is possible; other infections are more challenging to prevent. Unless sexual partners are also treated, re-infection is a concern, as is the further spread of disease to subsequent sexual contacts. Some infections, once effectively treated, lead to an asymptomatic carrier state that may or may not re-emerge as an active problem and/or cause sexual contacts to become ill. 

This review contains 10 tables, and 44 references.

Key Words: sexually transmitted infections, chlamydia, gonorrhea, syphilis, HIV, herpes simplex, granuloma inguinale, lymphogranuloma venereum, chancroid, trichomoniasis