Contributors: Clinical Dilemmas and Unresolved Issues in Gynecology No abstract available

Foreword: Clinical Dilemmas and Unresolved Issues in Gynecology No abstract available

Breast Cancer and the Obstetrician-Gynecologist: A Focus on Screening, Risk Assessment and Treatment of Survivors With Genitourinary Syndrome of Menopause Because of conflicting guidelines, providing appropriate breast cancer screening recommendations to our patients has become challenging. Given the high prevalence of genitourinary syndrome of menopause (GSM) overall, and among breast cancer survivors, and the understandable reluctance of physicians to prescribe effective hormonal treatments to survivors with this condition, addressing the needs of breast cancer survivors with bothersome GSM is both a common and controversial issue. In this review, we detail current breast cancer screening recommendations, breast cancer risk assessment, and management of GSM in breast cancer survivors.

Clinical Controversies in Cervical Cancer Screening Through the implementation of systematic cervical cancer screening in the mid-20th century, the United States and other developed countries have seen death rates from cervical cancer decreased by ≥70%.The purpose of this article is to address several of the most controversial issues associated with cervical cancer screening recommendations in light of historical and evolving data. In this article, we will explore the controversies around the age at which to initiate and exit screening, human papilloma virus testing alone as a primary screening approach, and the impact of human papilloma virus vaccination on cervical cancer rates.

Enhanced Recovery After Surgery and Acute Postoperative Pain Management Enhanced recovery pathways were first developed in colorectal surgery and have since been adapted to other surgical subspecialties including gynecologic surgery. Mounting evidence has shown that the adoption of a standardized perioperative pathway based on evidence-based literature reduces length of hospital stay, reduces cost, reduces opioid requirements with stable to improved pain scores, and accelerates return to normal function as measured by validated patient reported outcomes measurements. The many elements of enhanced recovery may be distilled into 3 concepts: (1) optimizing nutrition before and after surgery, recognizing that nutritional status directly impacts healing; (2) opioid-sparing analgesia, considering the current American prescription opioid crisis and the importance of pain control to regaining functional recovery; and (3) maintenance of euvolemia before, during, and after surgery. Evidence supporting enhanced recovery is presented with reference to international guidelines which were formed based on systematic reviews. Change management and the use of auditing are discussed to assure that patients derive the greatest improvement in surgical outcomes from implementation of an enhanced recovery pathway.

Updates in the Approach to Chronic Pelvic Pain: What the Treating Gynecologist Should Know Chronic pelvic is a multifaceted condition that often has both peripheral and central generators of pain. Despite its high prevalence, the evaluation and management of a pelvic pain patient often present many challenges to the practicing gynecologist. As with many other chronic pain conditions, pain severity does not always correlate with pelvic pathology and standard medical and surgical therapies are not always effective. An understanding of neurobiology and neuropsychology of chronic pelvic pain along with clinical pearls in the history and physical examination should guide management. Successful treatment of pelvic pain is typically multimodal, a combination of pharmacologic treatment strategies directed at the affected pathology and surrounding structures along with behavioral therapy. Evidence for these and other emerging therapies are presented in this article.

Management of Menopause and the Role For Hormone Therapy Hormone therapy remains the most effective treatment for menopausal symptoms but decisions are complex, requiring an assessment of benefits and risks and determination of best treatment type, dose, and duration. Benefits exceed risks for most women with bothersome menopausal symptoms or high risk for fracture if initiated under age 60 years or within 10 years since menopause. Long-term mortality and safety data from the Women’s Health Initiative is reassuring, with no increase in deaths from cardiovascular disease or cancer compared with placebo after 18 years of follow-up and a trend towards less mortality in those who initiate hormone therapy ages 50 to 59 years.

Practical Cancer Genetics and Genomics in Women’s Health There have been rapid advances in precision medicine since the Human Genome Project was completed in 2003, including several noteworthy advances in Women’s Health. This includes significant advances in predicting individualized cancer risk based on hereditary cancer genetic testing, with the number of known cancer-predisposition genes extending well beyond BRCA1 and BRCA2. This has been coupled with gene-specific management guidelines for several gynecologic cancers. In addition, genetic testing can also inform therapy selection for women with gynecologic cancers. Here we address hereditary cancer and practical cancer genetics as it relates to the practicing Obstetrician/Gynecologist.

Urinary Incontinence: Evaluation and Management Urinary incontinence is a major public health issue in the United States with physical, mental, social, and economic repercussions. History and in-office evaluation are paramount to diagnosis and formation of an appropriate treatment plan. Lifestyle modifications, which include pelvic floor muscle training and behavioral changes, are appropriate for initial management. Patients with overactive bladder syndrome whose symptoms are not adequately controlled with conservative treatment can be offered medical or procedural management. Stress urinary incontinence refractory to first-line treatment can be treated with surgical options such as mesh midurethral slings.

Office-based Approach to Evaluation and Management of Abnormal Uterine Bleeding Evaluation and management of abnormal uterine bleeding (AUB) are possible in the office. Approaching AUB evaluation from an etiology-based perspective allows the gynecologist to focus evaluation efforts on the most probable causes of AUB for a particular patient and therefore customize the management accordingly. Developing skills with imaging such as transvaginal ultrasound, saline infusion sonography, and diagnostic hysteroscopy are important for AUB etiology diagnosis. Operative hysteroscopy experience can be developed for AUB management in the office and endometrial ablation provides a minimally invasive solution for some patients.