Obstetrics and Gynecology Clinics of North America

A Lens into the Quality Standards of Modern-Day Colposcopy

Colposcopy is an office-based procedure performed to identify precancerous or cancerous lesions of the cervix. In 2017, colposcopy guidelines were developed by the American Society for Colposcopy and Cervical Pathology to standardize terminology, protocolize the procedure, and propose quality metrics. As a result of changes in cervical cancer screening and management guidelines, the volume of colposcopy within the United States has significantly decreased over the past 3 decades, and with the adoption of the human papillomavirus vaccination is anticipated to continue to decline. Therefore, colposcopic quality assessment and improved provider training is of increasing importance.

Common Cancers in the Pregnant Patient

In recent years, cancer has become one of the leading causes of non-accidental death among women aged 20 to 39 in the United States. Cancer in pregnancy, while rare, occurs in approximately one in every 1,000 pregnancies. The most frequently diagnosed malignancies during pregnancy include melanoma, breast cancer, cervical cancer, lymphomas, and leukemias. The primary goal is to provide effective, evidence-based care to the patient while minimizing risks to the fetus. This chapter explores the common presentations, diagnostic approaches, and management strategies for breast and cervical cancers in pregnant patients.

Cervical Cancer

American Indian/Alaska Native (AI/AN) individuals have twice the mortality rate of cervical cancer than the general US population. Participation in prevention programs such as cervical cancer screening and human papillomavirus (HPV) vaccination are under-utilized in this population. There are high rates of established cervical cancer risk factors among this community, with AI/AN people having a higher likelihood of infection with high-risk HPV strains not included in the 9-valent vaccine. There is a need for more robust and urgent prevention and treatment efforts in regard to cervical cancer in the AI/AN community.

The Current and Future States of Screening in Gynecologic Cancers

Gynecologic cancers contribute to a significant portion of cancer morbidity and mortality among women in the United States and across the globe. This article provides a comprehensive review of current screening guidelines and novel techniques that have promise in the prevention and early detection of gynecologic cancers in the future. The authors anticipate a move toward less invasive testing modalities, use of cancer biomarkers, and the prevention and treatment of high-risk factors such as human papilloma virus infection and obesity.

Bleeding from Gynecologic Malignancies

Initial assessment of vaginal bleeding in gynecologic malignancies includes a thorough history and physical examination, identification of site and extent of disease, and patient goals of care. Patients who are initially hemodynamically unstable may require critical care services. Choice of treatment is disease site specific. Cervical cancer frequently is treated with chemoradiation. Uterine cancer may be treated surgically, with radiation, or pharmacologically. Gestational trophoblastic disease is treated surgically. Alternative treatment modalities include vascular embolization and topical hemostatic agents. Patients with bleeding gynecologic malignancies should be managed as inpatients in facilities with gynecologic oncology, radiation oncology, and critical care services.

Oncofertility in Children and Adolescents

Ovarian Cysts and Tumors in Adolescents

This article aims to provide a multidisciplinary approach to ovarian/adnexal lesions in young patients. Functional cysts, torsions, benign tumors, and malignancies occur within the ovaries of children and adolescents at varying frequencies. Careful conservative management, based on the ultrasonographic sign of presence of normal ovarian tissue, in most circumstances can lead to appropriate ovarian-preserving treatments. The symptomatic ovarian cyst is often due to complications such as hemorrhage and ovarian torsion. Ovarian torsion represents surgical emergency, and a high index of clinical suspicion, based on ovarian volume and edema of the tissue, must be maintained to avoid inadvertent delay in therapy.

Fibroids and Fertility

Uterine fibroids significantly impact women's reproductive health, influencing fertility potential and pregnancy outcomes. Their growth, often facilitated by hormonal influences like estrogen and progesterone, can cause considerable disruptions in the uterus, leading to symptoms and complications that impact the quality of life and reproductive prospects of women.This article provides an exhaustive discussion of uterine fibroids, including pathophysiology, their impact on endometrial function, receptivity, fertility, and pregnancy outcomes, and the management of infertility in patients with uterine fibroids. It underlines the critical role of uterine fibroids in women's reproductive health, emphasizing the importance of effective diagnosis and treatment to promote fertility and improve pregnancy outcomes.

Prevention of Cervical Cancer in Low-Resource African Settings

Cervical cancer is a leading cause of cancer among women. Approximately 350,000 women die from cervical needlessly from cancer each year, and 85% of the global burden occurs in low- and middle-income countries (LMICs). Disparities in the incidence and mortality between LMICs and industrialized countries can be attributed to differences in access to human papillomavirus (HPV) vaccination and cervical cancer screening and treatment. The World Health Organization (WHO) is leading a renewed international effort to reduce the global burden of cervical cancer. In this article, we discuss recommendations for HPV vaccination, primary HPV screening, and treatment of precancerous lesions.

Hereditary Breast and Ovarian Cancer

This article provides an update on hereditary breast and ovarian cancer syndrome (HBOC) associated with pathogenic variants (PVs) in BRCA1/2. While many new genes have been identified and are included in testing panels, HBOC will serve as the primary example to illustrate the main concepts involved in genetic testing and management for hereditary breast and/or ovarian cancer We provide practical information regarding collecting a family history, cancer risk assessment, genetic testing and result interpretation, BRCA-associated cancer prognosis and treatment, screening recommendations, and prevention strategies. We also introduce implications of more recently identified cancer genes, polygenic risk scores (PRSs), and tumor genomic profiling. Evidence-based management strategies have been shown to reduce cancer incidence and improve survival in HBOC and other high penetrance syndromes. Obstetricians and gynecologists familiar with these concepts can identify and improve the quality of care for women and families impacted by hereditary breast and/or ovarian cancer.

Clinical Applications of Telemedicine in Gynecology and Women’s Health

Telemedicine and telehealth (TM/TH) are the 2 terms used interchangeably focusing on the delivery of health care services at a long distance using telecommunication technology. TM/TH has several gynecologic applications, including the well-woman visits, preventive care, preconception counseling, family planning including contraception and medical abortion, infertility workup, teleradiology, cervical cancer screening and colposcopy, mental health, and telesurgery. The goals of TM/TH are not only improving quality of health care in patients and building a virtual community of physicians but also increasing convenience, efficacy, and decreasing medical cost. In gynecology, TM/TH plays an important role, especially in well-woman care.

Breast, Ovarian, Uterine, Vaginal, and Vulvar Cancer Care in Low- and Middle-Income Countries

Breast, ovarian, uterine, vaginal, and vulvar cancers pose a significant risk to women's lives in low- and middle-income countries due to increasing incidence and presentation with advanced stage disease. There are challenges to screening and early detection and limitations in access to treatment and palliative care, and the current global health care workforce is insufficient. However, there is promise in development of telehealth strategies, task shifting, and increasing number of physician training programs to help address currently unmet needs.