Certification Exam

Endometriosis refers to the growth of endometrial glands and stroma outside of the uterus, particularly in the pelvis and ovaries. It is characterized by chronic pain and infertility and is most prevalent in women with a mean age of 25 to 35 years. It is rare in young girls and postmenopausal women. Women with endometriosis classically present with the triad of dysmenorrhea, dyspareunia, and dyschezia. They may also present with cyclical pelvic pain and urinary symptoms such as dysuria, hematuria, urgency, or frequency. Physical exam findings suggestive of endometriosis include tenderness on vaginal exam, nodules in the posterior fornix, adnexal masses, and immobility or lateral displacement of the cervix or uterus. The physical exam may also be normal but the absence of findings does not exclude the disease. Imaging is of limited value and is only useful if a pelvic or adnexal mass is present. A transvaginal ultrasound may demonstrate a hypoechoic, vascular, or solid mass. Pelvic MRI should be reserved for equivocal cases of suspected rectovaginal or bladder endometriosis. The definitive diagnosis of endometriosis requires exploratory laparoscopy and biopsy. Treatment of mild to moderate endometriosis consists of the use of nonsteroidal anti-inflammatory drugs and oral contraceptives. Leuprolide with oral contraceptives, laparoscopy, and hysterectomy with bilateral salpingo-oophorectomy (definitive treatment) are reserved for severe endometriosis.

Atrophic vulvar changes (B) are usually seen in postmenopausal women with atrophic vaginitis, a disorder characterized by dyspareunia, thinning of the vaginal epithelium after menopause, and vaginal pruritus. Cervical motion tenderness (C) is classically seen in patients with pelvic inflammatory disease, an infection (most commonly caused by Neisseria gonorrhoeae or Chlamydia trachomatis) that involves the cervix, vagina, endometrium, and possibly the fallopian tubes. Patients would present with mucopurulent malodorous vaginal discharge, pelvic pain, fever, and vomiting. A Bartholin abscess may present as a tender introital mass (D), usually located at the posterior aspect of the vagina opening. Bartholin abscess is a complication of an obstructed Bartholin duct, which is then colonized by microorganisms such as Escherichia coli (most common), Staphylococcus aureus, N. gonorrhoeae, and C. trachomatis.