guidelines for office gynecology in japan

Guidelines for office gynecology in Japan: Japan Societyof Obstetrics and Gynecology and Japan Association ofObstetricians and Gynecologists 2011 edition

Takashi Takeda1, Tze Fang Wong1, Tomoko Adachi3, Kiyoshi Ito1, Shigeki Uehara2,Yasushi Kanaoka14, Masaharu Kamada17, Hiroaki Kitagawa4, Satoshi Koseki18,Hideto Gomibuchi5, Juichiro Saito19, Kazuhiro Shirasu20, Kou Sueoka6,Mitsuhiro Sugimoto7, Mitsuaki Suzuki21, Toshiyuki Sumi15, Satoru Takeda8,Keiichi Tasaka16, Yasuyuki Noguchi22, Shunsaku Fujii23, Tsuneo Fujii24,Michihisa Fujiwara25, Tsugio Maeda26, Koji Matsumoto27, Mikio Momoeda9,Mineto Morita10, Kazuaki Yoshimura28, Yasuo Hirai11, Toshiro Kubota12,Noriaki Sakuragi29, Masakiyo Kawabata13, Hiroyuki Yoshikawa27, Hiroshi Kobayashi30

and Nobuo Yaegashi1jog_1858 615..631

Departments of 1Obstetrics and Gynecology, Tohoku University Graduate School of Medicine, 2Obstetrics and Gynecology,Kosai Hospital, Sendai, Miyagi, 3Obstetrics and Gynecology, Aiiku Hospital, 4Obstetrics and Gynecology, ToranomonHospital, 5Obstetrics and Gynecology, National Center for Global Health and Medicine, 6Obstetrics and Gynecology, KeioUniversity Graduate School of Medicine, 7Obstetrics and Gynecology, Tokyo Red Cross Hospital, 8Obstetrics and Gynecology,Jikei University School of Medicine, 9Obstetrics and Gynecology, St Luke’s International Hospital, 10Obstetrics andGynecology, Toho Medical University, 11Obstetrics and Gynecology, Tokyo Women’s Medical University, 12Obstetrics andGynecology, Tokyo Medical and Dental University, 13Obstetrics and Gynecology, Douai Memorial Hospital, Tokyo,14Obstetrics and Gynecology, Iseikai Hospital, 15Obstetrics and Gynecology, Osaka City University School of Medicine,16Tasaka Clinic, Suita, Osaka, 17Department of Obstetrics and Gynecology, Health Insurance Naruto Hospital, Naruto,Tokushima, 18Koseki Clinic, Departments of 19Obstetrics and Gynecology, St Marianna University School of MedicineYokohama Seibu Hospital, Yokohama, 20Obstetrics and Gynecology, Odawara Municipal Hospital, Odawara, Kanagawa,21Obstetrics and Gynecology, Jichi Medical University School of Medicine, Simino, Tochigi, 22Obstetrics and Gynecology,Aichi Medical University, Nagakute, Nagoya, 23Tachizaki Ladies’ Clinic, Aomori, 24Fujii Ladies’ Clinic, Hiroshima,25Department of Obstetrics and Gynecology, Kawasaki Medical University, Kurashiki, Okayama, 26Maeda Clinic, Yaizu,Shizuoka, Departments of 27Obstetrics and Gynecology, Tsukuba University Graduate School of Medicine, Tsukuba, Ibaragi,28Obstetrics and Gynecology, University of Occupational and Environmental Health, Kitakyusyu, Fukuoka, 29Obstetrics andGynecology, Hokaido University Graduate School of Medicine, Sapporo, Hokaido and 30Obstetrics and Gynecology, NaraMedical University, Kashihara, Nara, Japan

Abstract

Gynecology in the office setting is developing worldwide. Clinical guidelines for office gynecology were firstpublished by the Japan Society of Obstetrics and Gynecology and the Japan Association of Obstetricians andGynecologists in 2011. These guidelines include a total of 72 clinical questions covering four areas (Infectiousdisease, Malignancies and benign tumors, Endocrinology and infertility, and Healthcare for women). Theseclinical questions were followed by several answers, backgrounds, explanations and references coveringcommon problems and questions encountered in office gynecology. Each answer with a recommendation levelof A, B or C has been prepared based principally on evidence or consensus among Japanese gynecologists.

Reprint request to: Dr Takashi Takeda, Department of Obstetrics and Gynecology, Tohoku University Graduate School of Medicine, 1-1Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan. Email: [email protected]

doi:10.1111/j.1447-0756.2012.01858.x J. Obstet. Gynaecol. Res. Vol. 38, No. 4: 615–631, April 2012

© 2012 The Authors 615Journal of Obstetrics and Gynaecology Research © 2012 Japan Society of Obstetrics and Gynecology

These guidelines would promote a better understanding of the current standard care practices for gynecologicoutpatients in Japan.Key words: guidelines, gynecology, office practice, women’s health.

Introduction

Gynecology in the office setting is developing world-wide. It is the most frequent contact between thefemale patient and her gynecologist. It deals with awide range of areas concerning women’s health, suchas infectious disease, oncology, endocrinology, infertil-ity, health care and so on. Technological advances haveenabled the transition of inpatient operations to daysurgery procedures. Today, hysteroscopy, endometrialablation and cervical loop excision are some of themost widely performed gynecological procedures inJapan. These outpatient procedures offer quick recov-ery, less time away from work and cost-savings forpatients. In spite of its growing importance, there wasno guideline for office gynecology in the world. Underthese circumstances, Japan Society of Obstetrics andGynecology (JSOG) and the Japan Association ofObstetricians and Gynecologists (JAOG) decided topublish guidelines describing standard care practicesfor gynecologic outpatients in 2008. Subsequently, thefirst edition, ‘Guidelines for Office Gynecology inJapan 2011’, consisting of 72 Clinical Questions andAnswers (CQ&A), was published in February 2011.The original version of ‘Guidelines for Office Gynecol-ogy in Japan 2011’ contains backgrounds, explanationsand references. However, these sections have beenomitted because of space limitations.

Implications of ‘A’, ‘B’, and ‘C’Recommendation Levels

Several tests and/or treatments for gynecologic outpa-tients are presented as answers with a recommenda-tion level of A, B or C to each clinical question. Thesecriteria are essentially the same as described previouslyin ‘Guidelines for obstetrical practice in Japan: JapanSociety of Obstetrics and Gynecology (JSOG) and JapanAssociation of Obstetricians and Gynecologists (JAOG)2011 edition’. The answers and recommendation levelsare principally based on evidence or consensus amongJapanese gynecologists when the evidence is consid-ered to be weak or lacking. Thus, the answers are notnecessarily based on ‘evidence’. Answers with a recom-mendation level of A or B are regarded as current stan-

dard care practices in Japan. LevelA indicates a strongerrecommendation than level B. Consequently, informedconsent is required when office gynecologists do notprovide care corresponding to an answer with a level ofA or B. Answers with a recommendation level of C arepossible options that may favorably affect the outcomebut for which some uncertainty remains regardingwhether the possible benefits outweigh the possiblerisks. Thus, care corresponding to answers with a rec-ommendation level of C does not necessarily need to beprovided. Some answers with a recommendation levelof A or B include examinations and treatments that maybe difficult for general office gynecologists to provide.In such cases, the office gynecologists must refer thepatient to an appropriate institution.

Contents

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

CQ101How do we diagnose and treat genital herpes?

Answer

1 Test for antigens in samples taken directly from thelesions. Diagnosis may be possible from history-taking and clinical observation of typical clinicalcases. (B)

2 Antigen test is conducted by direct immunofluores-cence against viral antigen and can be combinedwith cytology. If samples cannot be obtained directlyfrom the lesions, patient serum can be tested forviral antibodies (enzyme-linked immunosorbentassay) or specific Ig (immunoglobulin) G and IgM.In this case, evaluate the serum test carefully. (B)

3 Treat using acyclovir or valacyclovir. (A)4 For mild diseases, topical acyclovir or topical

vidarabine may be adequate. (C)

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616 © 2012 The AuthorsJournal of Obstetrics and Gynaecology Research © 2012 Japan Society of Obstetrics and Gynecology

5 For cases with more than six recurrences within ayear, or recurrences presenting with severe symp-

toms, prophylaxis against recurrence is advisable.(B)

Main examples of prescription

Generic name Brand name Dosage

Initial episode, recurrencesMild 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 daysRecurrence suppression Oral valacyclovir Valtrex (500 mg) Once daily for 1 year, orally

CQ102How do we diagnose and treat chlamydial cervicitis?

Answer

1 Diagnose by testing cervical smear for chlamydiausing nucleic acid hybridization tests, nucleic acidamplification tests (NAAT) or enzyme immunoas-say (EIA). (A)

2 Sample should be tested simultaneously for gonor-rhea when using NAAT. (B)

3 Treat using oral macrolides or fluoroquinoloneantibiotics. (A)

4 For pelvic inflammatory disease (PID) or Fitz–Hugh–Curtis syndrome, oral antibiotics can beadministered if the symptoms are mild. (B)

5 Post-treatment evaluation should be conducted atleast 2–3 weeks after the completion of treatment. (B)

6 Sexual partner(s) of patient should be tested andtreated. (B)


Generic name Brand name Content Dosage

Azithromycin Zithromax 250 mg/tablet 1000 mg, single dose orallyOral Zithromax SR 2 g/dry syrup 2000 mg, single dose orally

Clarithromycin Clarith, Klaricid 200 mg/tablet 200 mg orally, twice daily for 7 daysLevofloxacin 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

CQ103How do we diagnose and treat vulva condyloma acuminatum?

Answer

1 Clinical symptoms and presentation are usually sufficient for diagnosis. Biopsy and pathological evaluation canbe performed when necessary. (B)

2 Treat with topical creams containing 5% imiquimod. (B)3 Surgical therapy involving direct excision, cryotherapy, electrocauterization, and laser vaporization. (C)

CQ104How do we diagnose and treat bacterial vaginosis?

Answer

1 Nugent score on vaginal discharge; lactobacillary grade on vaginal saline lavage; or Amsel criteria can be used forobjective diagnosis. (C)

2 Treat locally (vaginally) or orally using chloramphenicol or metronidazole. (B)


Chloramphenicol vaginal tablet Chlomy vaginal tablet 100 mg Once daily Intravaginally for 6 days

Metronidazole vaginal tablet Flagyl vaginal tablet 250 mg Once daily Intravaginally for 6 daysMetronidazole tablet Flagyl tablet 250 mg 4 tablets twice daily Orally for 7 days

The duration of treatment can be prolonged as needed.

Guidelines office gynecology in Japan


CQ105How do we diagnose and treat trichomonasvaginitis?

Answer

1 Check vaginal discharge microscopically for tri-chomonads. (B)

2 If no organisms are found microscopically, culturethe sample. (C)

3 Treat systemically by giving oral metronidazole ortinidazole as ascending infection involving theupper urinary tracts cannot be ruled out. (B)

4 Sexual partner(s) must be treated simultaneouslywith the same oral drug. (B)


Antitrichomonalagents

Brand name Contentper tablet

Dosage

Oral formulations Metronidazole Flagyl 250 mg 500 mg/day, twice daily for 10 daysTinidazole Haisigyn 200 mg 400 mg/day, twice daily for 7 days

500 mg 2000 mg, single doseVaginal 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 daysIf the trichomoniasis persists,

withhold treatment for 1 weekbefore repeating treatment.

CQ106How do we diagnose and treat Candida vulvovaginitis?

Answer

1 Diagnose by microscopic examination for yeast, orculture (agar plates with specialized medium orliquid medium with pH indicator can be used aswell) of vulvovaginal discharge, in combination withclinical symptoms. (B)

2 For treatment, perform vaginal lavage, then intrav-aginal administration of antifungal medication.For vulva candidiasis, give topical creams. (A)Tables 1–3.

3 Treatment is considered successful if subjectivesymptoms disappear or vaginal discharge improves.(A)

Table 2 For patients who cannot receive regular follow ups

Generic name Brand name Dosage Frequency

Isoconazole nitrate Adestan vaginal tablet 300 mg 2 tablets daily Once a weekOxiconazole nitrate Okinazol vaginal tablet 600 mg One tablet daily Once a week

Table 3 For topical treatment

Generic name Brand name Dosage Duration

Clotrimazole 1% Empecid cream 2–3 times daily 5–7 daysMiconazole 1% Florid D cream 2–3 times daily 5–7 daysIsoconazole nitrate 1% Adestan cream 2–3 times daily 5–7 daysOxiconazole nitrate 1% Okinazol cream 2–3 times daily 5–7 days

Table 1 For continuous daily treatment

Generic name Brand name Dosage Duration

Clotrimazole Empecid vaginal tablet 100 mg One tablet daily 6 daysMiconazole nitrate Florid vaginal suppository 100 mg One tablet daily 6 daysOxiconazole nitrate Okinazol vaginal tablet 100 mg One tablet daily 6 days

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CQ107How do we diagnose and treat gonococcus infections?

Answer

1 For diagnosis of genital infection, perform gonor-rhea culture or nucleic acid amplification test(NAAT) on cervical swab samples to detect for thepresence of gonorrhea bacteria. (A)

2 When pharyngeal infection is suspected, perform theabove tests on samples from pharyngeal swab. (C)

3 Samples should be tested simultaneously forchlamydia when NAAT is used. (B)

4 Single treatment using Ceftriaxone (i.v.), Cefixime(i.v.) and Spectinomycin (i.m.) are first-line therapiesfor genitourinary gonococcal infections. (B)Single dose of dry syrup containing 2g azithromycincan also be prescribed. (C)

5 Sexual partner(s) of patient should be tested andtreated. (B)


Generic name Brand name Content Dosage

Ceftriaxone Rocephin 1.0 g/vial 1.0g i.v., single doseInjection 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

CQ108How do we diagnose and treat syphilis?

Answer

1 Use serologic tests for syphilis (STS), Treponema pal-lidum hemagglutination assay or fluorescent tre-ponemal antibody absorption test in combinationfor confirmatory diagnosis and determination ofdisease stage. (A)

2 First-line treatment with oral penicillins (amoxicillin,ampicillin). Treat primary syphilis for 2–4 weeks,

secondary syphilis for 4–8 weeks, and tertiarysyphilis for 8–12 weeks with oral antibiotics.(A)

3 Follow up by evaluating test results of serologic test(STS). (A)

4 When syphilis is confirmed, the physician whomakes the diagnosis should report the case in accor-dance with the Infectious Disease Law by the Japa-nese government. (A)

First-line drugs

Generic name Abbreviation Brand name Daily dosage Regimen Duration

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 weeksBenzylpenicillin PCG Bicillin 1.8 million

units3 times daily Tertiary syphilis: 8–12 weeks

Some formulations are not covered by national health-care insurance even if the same drugs in other formulations are.

CQ109How do we diagnose pelvic inflammatory disease(PID)?

AnswerDiagnosis should be made following the criteria as

stated below.

(Minimum diagnostic criteria) (A)1 Lower abdominal pain, tenderness with

palpation.2 Uterine or adnexal tenderness with palpation.

(Additional diagnostic criteria) (B)1 Body temperature � 38°C2 Leukocytosis3 Elevated C-reactive protein(Specific diagnostic criteria) (C)1 Identification of (intrapelvic) abscess by magnetic

resonance imaging (MRI) or transvaginal ultra-sonography.

2 Aspiration of purulent material via the Pouch ofDouglas.

3 Laparoscopic abnormalities suggestive of inflam-mation consistent with PID.



CQ110How do we treat pelvic inflammatory disease (PID)?

AnswerTreat as stated below.

1 Outpatient treatment is usually adequate unless, asin 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.

2 For mild to moderate cases, prescribe oral cephemor quinolone antibiotics. For moderate cases, intra-venous administration of cephem (up to second-generation) can also be considered. (B)

3 For severe cases (with no indication for hospitaliza-tion, or where the patient is unable to receive inpa-tient treatment), administer intravenous third- orhigher generation cephem, or carbapenem antibiot-ics. Combined therapy using i.v. clindamycin orminocycline is also an option. (B)

Treatment for mild to moderate PID

1. Oral cephems1) Cefditoren (Meiact) 100 mg orally 3 times daily for

5–7 days2) Cefcapene (Flomox) 100 mg orally 3 times daily for

5–7 days3) Cefdinir (Cefzone)) 100 mg orally 3 times daily for

5–7 days2. Oral quinolones

1) Levofloxacin (Cravit) 500 mg orally once daily for5–7 days

2) Tosufloxacin (Ozex) 150 mg orally 3 times daily for5–7 days

3) Ciprofloxacin (Ciproxan) 100–200 mg orally 3 timesdaily for 5–7 days

Treatment for severe PID

1. Cephems for injection1) Cefmetazole (Cefmetazon) 1–2g in a single dose, i.v.

twice daily for 5–7 days2) Flomoxef (Flumarin) 1–2g in a single dose, i.v. twice

daily for 5–7 days3) Cefpirome (Broact) 1–2g in a single dose, i.v. twice

daily for 5–7 days4) Ceftriaxone (Rocephin) 1–2g in a single dose,

i.v. once to twice daily for 5–7 days2. Carbapenems for injection

1) Imipenem (Tienam) 0.5–1g in a single dose, i.v. twicedaily for 5–7 days

2) Doripenem (Finibax) 0.25g in a single dose, i.v. 2–3times daily for 5–7 days

CQ111How do we screen for sexually transmitted diseases(set test)?

Answer

1 The set test includes tests for four major sexuallytransmitted diseases: chlamydia (cervix), gonorrhea(cervix), syphilis (blood), HIV infection (blood). (B)

2 For patients at risk for pharyngeal or throat infec-tion, test pharyngeal samples for chlamydia andgonorrhea. (C)

3 If the patient requested extra tests, tests for tri-chomonas (vaginal discharge), chlamydial antibody(blood), hepatitis B and C antibody (blood) can beadded. (C)

CQ112How do we diagnose and treat cystitis?

Answer

1 Clinical history and presentation characterized byfrequent urination, burning sensation during urina-tion or sensation of incomplete bladder emptying,and urine test findings are useful for diagnosis. (A)Urine culture yielding more than 105 colony-forming units (CFU)/mL of one type of bacteriaindicates the pathogen responsible for the infection.(C)

2 Treat with oral cephalosporins, penicillins, or quino-lones. (A)

3 Differential diagnosis of other medical conditionsthat may present with an overactive bladder shouldbe taken into consideration. (B)

B. Oncology and benign tumors

CQ201What is the appropriate way of obtaining samples forcervical cytology?

AnswerCollect cervical cells with a brush or a spatula. (C)

CQ202How do we manage and treat CIN1/2 (mild to mod-erate dysplasia)?

Answer

1 CIN1 (mild dysplasia) confirmed with biopsyshould receive follow-up observation with Papsmear and colposcopy every 6 months. (B)

2 CIN2 (moderate dysplasia) confirmed with biopsyshould receive careful and consistent follow up withPap smear and colposcopy every 3–6 months. (B)

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3 Excluding pregnant patients, CIN2 cases that havedifficulty receiving proper follow up can opt fortreatment. (C)

CQ203What is the indication for further testing withcolposcopy-directed biopsy after a Pap smear?

Answer

1 A Pap smear graded as ASC-US that revealed testresults such as the following:• Positive results for high-risk human papillomavi-

rus (HPV) (B)• For facilities that are unable to perform HPV-

testing, if the follow-up Pap smear performedimmediately or 6–12 months after the suspiciousPap smear is graded as ASC-US or higher. (B)(Only facilities that meet the standard require-ments are allowed to perform HPV-testing by aneligible doctor under the Japanese NationalHealth Insurance system.)

2 When a Pap smear is graded as ASC-H, LSIL, HSIL,SCC, AGC, androgen insensitivity, adenocarcinomaor other malignancies, perform a biopsy immedi-ately. (B)

CQ204What is the indication for minimally invasive conizationof the cervix procedures, such as loop electrosurgicalexcision procedure (LEEP) and laser vaporization?

Answer

LEEP is conducted as a mean of diagnosis and treat-ment when:

1 CIN3 (severe dysplasia or carcinoma in situ) is seenon a biopsy of the cervix, and the extent of the lesioncan be identified by colposcopy and the lesions havenot extended deep within the endocervix. (B)

2 CIN2 (moderate dysplasia) is seen on a biopsy of thecervix, and subsequent follow ups do not show anyregression of the lesion, and when the patient showsstrong determination to receive treatment. (B)

Laser vaporization is conducted as a mean of treatmentwhen:

3 CIN3 is seen on multiple biopsies of the cervix in ayoung female patient, and the extent of the lesioncan be identified by colposcopy and the lesionshave not extended within the endocervix. This isonly recommended among young patients withCIN3. (C)

4 CIN2 is seen on a biopsy of the cervix, and sub-sequent follow ups do not show any regression

of the lesion, and when the patient shows strongdetermination to receive treatment. (B)

CQ205What is the clinical utility of high-risk human papillo-mavirus (HPV) test and HPV genotyping?

Answer

1 High-risk HPV test (e.g., Hybrid Capture II orAMPLICOR HPV assay) can be used as an adjunctto cytology for cervical cancer screening to improvethe accuracy of screening. (C)

2 High-risk HPV test should be used for women withASC-US cytology to decide who needs colposcopy.(B)

3 High-risk HPV test or HPV genotyping can be usedfor women treated for CIN 2/3 to detect residual orrecurrent diseases during post-treatment follow up.(C)

4 HPV genotyping should be used for women withhistologically confirmed CIN1/2 to characterizetheir risk of disease progression more precisely.Women who test positive for HPV16, HPV18,HPV31, HPV33, HPV35, HPV45, HPV52, or HPV58are considered to be at increased risk of diseaseprogression. Therefore, they should be managedseparately from women who are negative for theseeight genotypes. (B)

CQ206Who should be vaccinated against human papillomavi-rus (HPV)?

Answer

1 Girls 10–14 years of age are the most highly recom-mended group. (A) (According to the JapaneseMinistry of Health, Labor and Welfare’s emergencypolicy to promote vaccination, until the end of 2011,Japanese female students from the first year ofjunior high to the first year of high school (13–16-year-olds) can receive free HPV vaccination fromclinics or health-care institutions receiving con-tracts from their respective regional administrativecouncils.)

2 Young women 15–26 years of age are the next mosthighly recommended group. (A)

3 Women 27–45 years of age can receive HPVvaccination. (B)

4 Women who have current evidence or history oflow-grade cervical abnormalities can receivevaccination. (B)

5 HPV testing should not be used to decide whether awoman is eligible for vaccination. (B)



6 Pregnant women are not included in the recommen-dations for HPV vaccine. (B)

7 Lactating women can receive HPV vaccine. (C)

CQ207What should vaccine recipients know before receivingthe HPV vaccine?

Answer

1 The vaccine protects against HPV16 and HPV18infections. For girls and women not yet sexuallyactive, the vaccine can be expected to provide60–70% prevention against cervical cancer. (A)

2 The vaccine does not have any therapeutic effecton existing HPV infection or cervical diseases.(B)

3 Girls and women not yet sexually active can beexpected to receive the full benefit of vaccination.(B)

4 Vaccinated women should also have routine cervicalcancer screening. (B)

5 The three-dose schedule (0, 1–2 months, 6 months)and the cost. (A)

6 The possible adverse events, such as pain, redness,and swelling at the injection site (the arm), head-ache, fainting, and shock etc. (A)

CQ208How should HPV vaccine be administered?

Answer

1 A woman’s medical fitness (conditions and circum-stances) for vaccination should be assessed withcomprehensive pre-vaccination health screening.(A)

2 The vaccine should be shaken well beforeadministration. A frozen vaccine should not be used.(A)

3 The vaccine is injected intramuscularly (i.m.) in thedeltoid muscle as a three-dose schedule at 0, 1–2 and6 months. (B)

4 The HPV vaccine should not be administrated for27 days after receiving a live vaccine or for 6 daysafter receiving an inactivated vaccine. (A)

5 Syncope, anaphylaxis or seizures can occur aftervaccination. Therefore, vaccine providers shouldobserve women for 30 min after they receive HPVvaccine. (A)

CQ209What is the appropriate way of obtaining samples forendometrial cytology, and who are the screeningtargets?

Answer

1 Uterine endometrial samples can be obtained byscraping or by suction. (B)

2 Women over the age of 50 or post-menopausalpatients experiencing abnormal vaginal bleeding, orwomen with predisposing risk factors are selectedfor screening. (C)

CQ210How do we diagnose and treat endometrial hyperpla-sia without atypia?

Answer

1 When a Pap test indicates endometrial abnormali-ties, or when increased endometrial thicknessis observed, perform endometrial biopsy for de-finitive diagnosis. When atypia is suspected, diag-nose by performing a total endometrial curettage.(A)

2 When treatment is indicated, administer cyclicmedroxyprogesterone acetate. (B)

3 Endometrial hyperplasia in adolescents should betreated with combined estrogen–progestin formula-tions. (C)

4 For patients hoping to conceive, fertility treatmentthat includes ovulation induction can be startedafter treatment No. 2 or No. 3. (C)

5 Among post-menopausal patients, if abnormalbleeding persists and abnormalities continue to beidentified in subsequent tests, hysterectomy shouldbe performed. (C)

CQ211How do we diagnose and manage endometrialpolyps?

Answer

1 Perform screening with transvaginal ultrasonogra-phy. (A)

2 Diagnose using sonohysterography or hysteros-copy. (B)

3 Perform biopsy to rule out malignancy. (C)4 For cases below, perform hysteroscopic surgery, or

total endometrial curettage for definitive diagnosisand treatment. (B)• Symptomatic cases• An infertile patient whose infertility may be

attributable to the endometrial polyp• Asymptomatic, but malignancy suspected.

5 For all other cases besides those described in‘Answer No. 4’, follow-up observation is indicated.(B)

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CQ212When is hysteroscopy indicated?

Answer

1 Diagnosis for conditions as stated below. (C)Endometrial polypsSubmucosal fibroidsUterine anomaliesIntrauterine adhesions (Asherman’s syndrome)Endometrial hyperplasiaEndometrial cancerSpontaneous abortion or residues after expulsion ofhydatidiform moleResidual placenta, placental polypIntrauterine object (IUD)

2 Preoperative diagnosis for conditions as statedbelow. (B)Endometrial polypsSubmucosal fibroidsSeptate uterusIntrauterine adhesions (Asherman’s syndrome)

CQ213How do we treat endometriosis without cysticlesions?

Answer

1 Prescribe analgesics (non-steroidal anti-inflammatory drugs [NSAIDs]) for pain. (B)

2 When analgesics are inadequate or the patient’sendometriosis requires treatment, the first-linetherapy is either combined oral contraceptive (COC)or dienogest; as second-line therapy, gonadotrophin-releasing hormone (GnRH) agonist or danazol areusually chosen. (C)

3 When medication does not work, or when thepatient suffers from infertility, perform surgery tocauterize/excise endometriotic lesions and toremove adhesion. (B)

4 To prevent recurrence of endometriosis in patientswho do not wish to conceive, COC, dienogest, andGnRH agonist can be prescribed. (C)

CQ214What are the differential diagnoses and management ofsuspected benign ovarian cysts?

Answer

1 To differentiate between malignant tumors, non-tumor lesions and functional cysts, history-taking,vaginal examination, ultrasonography, tumor markertests, MRI etc. should be performed. (B)

2 Surgery is recommended for large cysts (more than6 cm in diameter) or when symptoms due to the cystare observed. (B)

3 Even for small cysts, surgery is recommended forcases whereby the existence of a tumor is confirmed.(C)

4 If surgery is not indicated, the follow-up scheduleshould be arranged according to the first upcomingmenstrual cycle: the first follow up being 1–3 monthslater, and the subsequent follow ups at 3- to 6-monthintervals. (C)

5 Explain to patients that the accuracy of the diagnosisis limited if no surgery is performed. (A)

CQ215How do we diagnose hemorrhaging corpus luteal cystor ovarian hemorrhage?

Answer

1 Perform a general evaluation by history-taking,basal body temperature measurement, abdominalexamination, ultrasonography. (B)

2 If the diagnosis of intraperitoneal hemorrhage is dif-ficult in a case presenting with an ovarian mass andperitoneal fluid on ultrasonography, culdocentesis(extraction of fluid through the Pouch of Douglas)can be performed. (C)

3 In the case of intraperitoneal bleeding, perform thenecessary tests to rule out ectopic pregnancy. (B)

4 When excessive hemorrhage is suspected, and thevital signs of the patient are not favorable, or whenthe hemoglobin count of the patient decreases dra-matically, indicating the presence of persistent hem-orrhage, emergency surgical intervention should beperformed. (B)

CQ216How do we treat ovarian endometrial cyst (chocolatecyst)?

Answer

1 The choice of treatment, which includes observation,medication or surgery, is made based on thepatient’s age, size of the cyst(s), and the patient’sdesire to conceive. Surgery is usually prioritized dueto fear of rupture, infection or malignant transfor-mation of the cyst. (B)

2 The type of surgical procedure is chosen based onthe balance between curativeness of endometriosisand preservation of ovarian function. (B)

3 When a patient’s cyst is considered to possess a highmalignant potential depending on her age, cyst sizeand the presence of solid components within the



cystic mass, she should have her diseased ovaryremoved surgically. (C)

CQ217How do we diagnose and treat adenomyosis?

Answer

1 Clinical findings, internal examination, and ultra-sonography can provide the appropriate diagnosis.However, for differential diagnosis against uterinefibroids or uterine sarcomas, MRI should be under-taken. (B)

2 Treat the symptoms of adenomyosis in the samemanner as endometriosis, i.e., with analgesics andhormonal treatment. (B)

3 As a curative measure, perform hysterectomy. (B)

CQ218When do we perform operative hysteroscopy/transcervical resection (TCR) for submucosal fibroids?

Answer

1 The usual criteria for the procedure are small uterinefibroids (less than 30 mm in size) and more than50% protrusion in the uterine cavity. However,skilled surgeons may not be constrained by thesecriteria. (B)

2 Even for patients who do not wish to become preg-nant, operative hysteroscopy/TCR may be chosenfor its low invasiveness. (B)

CQ219What are the considerations for a patient with intramu-ral and/or subserosal uterine fibroids who wishes toopt for conservative therapy?

AnswerThe type of treatment should be chosen based on the

location and size of the fibroids, whether or not thepatient has menorrhagia or anemia, age of the patientand the patient’s prospects in conceiving. (A)

CQ220How do we manage patients with cervical polyps?

Answer

1 The polyp should be resected for pathological evalu-ation. (B)

2 For asymptomatic patients with low risk for malig-nancy, instead of conducting a biopsy, the patientsshould receive follow-up observation. (B)

3 For pregnant patients whose polyps may be thesource of cervical insufficiency or chorioamnionitis,treatment should be given as necessary (resection orantibiotics). (C)

4 The method of resection depends on the size andmorphology of the polyp: (i) Pull or twist the polypto detach it using Péan forceps; (ii) ligation, and thenresection; and (iii) electrocauterization, are some ofthe methods chosen. (B)

CQ221How do we manage Bartholin’s cysts?

Answer

1 Asymptomatic cases with minimal swelling do notrequire treatment. (B)

2 Bartholin’s abscess presenting with acute symptomsshould receive emergency treatment by drainage ofpurulent material (either via incision or fine-needleaspiration). Culture the infected material forbacteria and treat the infection using antibiotics.(B)

3 Perform marsupialization, a surgical treatmentthat preserves the function of Bartholin’s gland.(B)

4 Recurrent cases despite marsupialization, recurrentBartholin’s abscess, and cases suspicious of carci-noma of Bartholin’s gland should undergo surgicalresection. (B)

5 Adenocarcinoma of Bartholin’s gland is very rare.When malignancy is suspected, perform histopatho-logical exploration and evaluation. (B)

CQ222What should be recommended for post-treatmentfollow up of patients with gynecological malignancies(cervical, endometrial or ovarian cancer)?

Answer

1 The follow-up intervals are recommended asfollows: every 1–3 months for 3 years, every6 months for another 2 years, and then annually.(C)

2 The follow up includes interval history and physicalexamination (including pelvic examination), withcytology, chest X-ray, tumor markers, ultrasonogra-phy, and computed tomography scans etc. (C)

CQ223How is breast cancer screening conducted?

Answer

1 All women above 50 years of age should receivemammography screening. (A)

2 Women in their 40s should receive mammographyscreening. (B)

3 Women above 40 years of age can receive optionalscreening using ultrasonography. (C)

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4 Women below 40 years of age should receive ultra-sonography for breast cancer screening, or mam-mography in combination with ultrasonography. (C)

5 Interval in between screenings is 1–2 years. (B)

CQ224How is mastopathy managed?

Answer

1 Clinically, ‘mastopathy’ as an exclusive diagnosis forbreast cancer should not be made casually. In suchcases, ‘suspicious for mastopathy’ should be indi-cated instead. (B)

2 As a rule, cases suspected for mastopathy shouldreceive consultation from specialized institutions.(B)

3 Cases with proliferative lesions that are histologi-cally ruled out for atypia should receive consistentscreenings as the risk of breast cancer is elevated. (B)

4 Cases that are histologically confirmed with atypicalproliferation (ductal, lobular) (including those witha history of proliferative atypia) have an increasedrisk for breast cancer. Such cases should receivefollow ups in coordination with an institution spe-cializing in breast cancer. (A)

C. Endocrinology and Infertility

CQ301How do we treat functional dysmenorrhea?

Answer

1 Prescribe and administer analgesics (such asNSAIDs) or low-dose combined oral contraceptive.(B)

2 Administer Japanese herbal medicine (Kampo) oranti-cramp medicine. (C)

CQ302What should we prescribe for menorrhagia withoutany underlying pathology?

Answer

1 Administer low-dose combined oral contraceptive.(C)

2 Administer antifibrinolytics (tranexamic acid, suchas Transamin). (C)

3 Consider surgical treatment when pharmacotherapyis either ineffective or not a viable option. (C)

CQ303What are other treatment options besides pharmaco-therapy for menorrhagia without any underlyingpathology?

Answer

1 Perform dilation and curettage for acute bleeding.(C)

2 For those who do not wish to retain their uterusand/or fertility, hysterectomy or endometrial abla-tion can be performed. (C)

CQ304How do we manage abnormal menstrual cycle due toanovulation?

Answer

1 Investigate the cause behind the abnormal men-strual cycle from patient interviews, physical find-ings, endocrine tests etc. (B)

2 For those who do not wish to conceive, conducthormonal therapy.• Polymenorrhea or oligomenorrhea caused by

anovulatory menstrual cycles should be treatedwith cyclic progestins. (B)

• Administer cyclic progestins for euestrogenicamenorrhea. (B)

• Administer cyclic estrogen–progestin forhypoestrogenic amenorrhea. (B)

• Administer combined estrogen–progestin, suchas oral contraceptives. (C)

• For those who are looking forward to conceiving,induce ovulation. (B)

CQ305What are the important points when we see a womanof child-bearing age with a chief complaint of abnor-mal vaginal bleeding?

Answer

1 Perform systematic differential diagnosis via patientinterviews and physical examinations. (A)

2 Keep in mind the possibility of pregnancy whenconducting patient interviews and examinations.(A)

3 When malignancy is suspected, perform cytologyand biopsy. (A)

4 When pregnancy and underlying pathology areruled out, dysfunctional uterine bleeding is diag-nosed. (A)

CQ306How do we diagnose hyperprolactinemia?

Answer

1 Measure serum prolactin levels when the patientpresents with menstrual abnormalities or galactor-rhea. (A)



2 If serum prolactin levels are elevated, check thepatient’s thyroid function as well. (B)

3 Interview the patient about the drugs taken (psychi-atric, underlying conditions), the presence ofthyroid disease symptoms, headaches, and visualfield defects. (B)

4 Check both breasts for galactorrhea. (B)5 When serum prolactin levels exceed 100ng/mL,

perform MRI to rule out prolactinoma. When neces-sary, refer the patient to either an endocrinologist ora neurosurgeon. (B)

CQ307How do we treat hyperprolactinemia?

Answer

1 Treat using dopamine agonists in hyperprolactine-mia caused by pituitary disorders. (A)

2 For drug-induced hyperprolactinemia, consult thedoctor who prescribed the medication to eitherreduce the dosage or replace the problematic drug.(B)

3 In patients confirmed with prolactinoma, consult anendocrinologist or a neurosurgeon. Treatment usingdopamine-agonist is still the main approach. (B)

4 Surgical treatment is indicated for pituitary infarc-tion, pituitary tumors with accompanying visualfield defects, drug-resistant cases and cases thatcannot tolerate pharmacotherapy. (C)

CQ308How do we diagnose and treat polycystic ovarian syn-drome (PCOS)?

Answer

1 Diagnose according to the 2007 diagnostic guide-lines laid out by the Japan Society of Obstetrics andGynecology. (A)

2 For women who do not wish to conceive:• Advise obese patients to make lifestyle adjust-

ments in order to lose weight (B)• Induce withdrawal bleeding at consistent inter-

vals. (B)3 For 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 clomi-phene when the patients have any of the condi-tions, such as obesity, glucose intolerance orinsulin resistance. (C)

4 For cases with clomiphene-resistance, performgonadotrophin treatment or laparoscopic ovariandrilling. (B)

5 Gonadotrophin treatment should be performedusing either recombinant or pure FSH in a chroniclow-dose method. (B)

CQ309How do we prevent the occurrence or severe progres-sion of ovarian hyperstimulation syndrome (OHSS)?

Answer

1 Use recombinant or pure FSH in a chronic low-dosemethod for gonadotrophin treatment in patientswith PCOS or history of OHSS. (B)

2 Cancel human chorionic gonadotrophin (hCG)administration when the risk for developing OHSSis high during ovulation induction in routine infer-tility practice. (B)

3 When the risk of developing OHSS is high duringovarian stimulation in assisted reproductive tech-nology 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)

4 For mild OHSS, direct patients to take sufficientfluids and to avoid physical exercises and sexualintercourse. (C)

5 For moderate OHSS or pregnant patients withOHSS, monitor closely and consider management atan advanced medical institution if the symptoms orthe test results are not improved. (B)

6 Severe cases should receive inpatient treatment at ahospital. (B)

CQ310How do we manage premature ovarian failure (POF)?

Answer

1 Perform the necessary tests, such as checking thepatient’s endocrine profile, to identify the cause ofPOF. (B)

2 Choose hormone replacement therapy for patientswho do not wish to conceive. (A)

3 For patients who wish to conceive, choose cyclicestrogen–progestin combination therapy. If ovula-tion cannot be achieved, administer high-dosehuman menopausal gonadotrophin (hMG) therapy.(C)

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CQ311What are initial tests to identify the causes of theinfertility?

AnswerBelow are the recommended tests.

1 Basal body temperature measurement. (A)2 Ultrasonography. (A)3 Endocrine tests. (B)4 Chlamydial antibody test or chlamydial antigen

(nucleic acid identification) test. (B)5 Hysterosalpingogram. (B)6 Semen analysis. (B)7 Test for cervical factors. (B)

CQ312What are the important points for artificial insemina-tion with husband’s sperm (AIH)?

Answer

1 Perform AIH between the moment before and afterovulation. (B)

2 Use washed and concentrated spermatazoa suspen-sion. (C)

3 Stimulate ovulation using clomiphene or gonadotro-phin in order to increase pregnancy success rate. (C)

4 Switch to assisted reproduction technology proce-dures if AIH is not successful in repeated attempts.(C)

5 Explain the possible adverse events, such as bleed-ing, pain and infection. (B)

CQ313How do we treat male infertility?

Answer

1 Pharmacotherapy for oligozoospermia. (C)2 Perform artificial insemination with husband’s

sperm (AIH) for mild oligozoospermia and mildasthenozoospermia. (B)

3 Choose in vitro fertilization and intracytoplasmicsperm injection for severe oligozoospermia andsevere asthenozoospermia. (B)

4 Consult a urologist specializing in infertility to iden-tify the cause of azoospermia and severe oliogozo-ospermia and decide on the treatment. (B)

5 If pregnancy is impossible with the husband who isdiagnosed with azoospermia, artificial inseminationwith donor’s sperm can be an option. (C)

6 Infertility treatment should be conducted in coordi-nation with a urologist when the male patient pre-sents with sexual dysfunction, such as erectiledysfunction. (C)

CQ314How do we manage recurrent pregnancy loss in asso-ciation with chromosomal anomalies?

Answer

1 Provide genetic counseling to couples with a historyof recurrent pregnancy loss who are taking tests forchromosomal anomalies. (B)

2 Provide genetic counseling in conjunction withkaryotype test of tissues from spontaneous abor-tions. (C)

3 Preimplantation genetic diagnosis should be carriedout in adherence to the principles laid out by theJapan Society of Obstetrics and Gynecology, andshould have received ethical clearance by an inter-nal review board. (A)

D. Healthcare for women

CQ401How should we perform emergency contraception?What are the pitfalls concerning emergencycontraception?

Answer

1 Perform emergency contraception to reduce theprobability of pregnancy in unprotected sexualintercourse. (C)

2 A single dose of levonorgestrel is administered. (B)3 Use the Yuzpe method. (C)4 For women with a history of pregnancy, a copper-

containing intrauterine device can be used whennecessary. (C)

5 Informthepatient thatevenwithemergencycontracep-tion, there is still a risk of pregnancy. Ask the patient tocheck up at the clinic again when necessary. (B)

CQ402What should we tell the patient when prescribing oralcontraceptives (OC)?

AnswerProvide information based on the ‘Guidelines

concerning the use of low-dose oral contraceptives(year 2007 revision)’.

1 Efficacy and safety: OC is the most effective revers-ible method of contraception available. It is also verysafe. (B)

2 Additional benefits: OC may ameliorate the symp-toms of menstrual problems, such as dysmenorrhea,menorrhagia etc. (B)

3 Sexually transmitted diseases: OC does not preventsexually transmitted infection. (B)



4 Target age: any woman of reproductive age shouldbe able to receive treatment. (C)

5 Complications: OC increases the risk of cerebralstroke and venous thromboembolism. The risk ofmyocardial infarction among smokers is alsoincreased. (B)

6 Cancer risk: cervical cancer risk increases with long-term usage. Breast cancer risk is not affected. Re-duces the risk of ovarian and endometrial cancer. (B)

7 Side-effects: OC may contribute to gastrointestinalsymptoms but is not associated with weight gain.(B)

8 Caution 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 maybe a reason for contraindication. (B)

CQ403What should we inform the patient when an intrauter-ine device (IUD) (including the intrauterine system) ischosen for contraception?

AnswerProvide information as below.

1 It does not prevent pregnancy without fail. (A)2 Visit the doctor as soon as a pregnancy is suspected.

(A)3 Receive consistent follow up after the IUD has been

fitted to make sure that the device is in the rightposition or to exchange the device. (B)

4 Possible complications, such as hemorrhage, infec-tion, perforation etc. may occur. (B)

CQ404How do we manage Turner’s syndrome?

Answer

1 For patients diagnosed before puberty, growthhormone may be needed for treatment. Manage-ment of patient can be carried out in coordinationwith a pediatrician/endocrinologist. (A)

2 For patients diagnosed before puberty, low-doseestrogen should be administered starting frompuberty (from about 12 years of age). Increase thedosage in 2- to 3-year intervals. (B)

3 Hormone replacement therapy is recommended.(A)

4 Provide counseling, while taking care of thepatient’s emotional condition, when providingexplanation about her fertility. (B)

5 Provide care for patients in coordination withrespective specialists for complications, such as

thyroid abnormalities, glucose intolerance, coarcta-tion of the aorta, gonadal tumors etc. (B)

CQ405How should we provide care for XY female patients?

Answer

1 After definitive diagnosis is made, provide appro-priate counseling for both the patient and herparents. (B)

2 Provide careful follow up as the risk for gonadaltumor development is high. After reaching puberty,surgically remove the abnormal gonads at theappropriate timing. (A)

3 For patients with androgen insensitivity, provideestrogen replacement therapy after total gonadec-tomy. For XY complete gonadal dysgenesis, performcyclic estrogen–progestin therapy as soon as thediagnosis is made. (A)

CQ406How do we provide care for patients with Mayer–Rokitansky–Küster (–Hauser) syndrome?

Answer

1 Provide information for the patient regarding hermedical condition in a timely and approachablemanner. (A)

2 Vaginoplasty should be performed according tothe patient’s wishes after sufficient counseling.(A)

3 Vaginoplasty should be carried out at a specializedand experienced institution. (A)

CQ407What are the important points when we performmedical examinations on an adolescent?

Answer

1 Medical interviews are very important, and can beconducted with or without the accompaniment of afamily member. (B)

2 Even for girls with no prior experience ofsexual intercourse (virgins), physical examination,rectal examination, ultrasonography (transrectal ortransabdominal) should be performed to achieveproper diagnosis. (B)

3 Peritoneal lesions caused by endometriosis shouldalso be considered as one of the reasons of dysmen-orrhea in an adolescent patient. (C)

CQ408What are the important points when treating a femaleadolescent?

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Answer

1 For amenorrhea, use cyclic progestins therapy orcyclic estrogen–progestin therapy once every2–3 months. (C)

2 Watch out for decreased bone mass in prolongedamenorrhea. (C)

3 Do not induce menstruation in amenorrhea associ-ated with extremely low bodyweight (less than 70%of ideal bodyweight). Such cases should be advisedto regain weight through lifestyle improvement andreferred for counseling. (B)

4 Dysmenorrhea that is not caused by underlyinggenitourinary deformities, especially cases that areassociated with endometriosis, should be treatedwith either NSAIDs or combined oral contraceptive.(B)

CQ409What should we do when we encounter a sexualassault victim?

Answer

1 Victims who have not reported their ordeal to thelaw enforcement authorities should be reported tothe police after obtaining their consent before anymedical examination takes place. (A)

2 Collection of crime evidence during medical exami-nation of the victim(s) should be done with thevictim(s)’ consent under the supervision of a policeofficer. (A)

3 Observe and document any physical trauma,such as external injuries, scratches, bruises etc.(B)

4 Issue a medical certificate. (B)5 Emergency contraception should be provided. (B)6 The medical expenses incurred from the medical

examination, tests and treatment should not becharged to the victim, but should be paid by thepolice department. (B)

CQ410How do we help patients modify their menstrual cycle?

Answer

1 To shorten the menstrual cycle, administer com-bined estrogen–progestin (EP) or norethisteronefrom the 3rd to 7th day of the menstrual cycle for10–14 days. (B)

2 To prolong the menstrual cycle, administer com-bined EP or norethisterone from the follicularphase until the desired period of prolongation.(B)

3 To prolong the menstrual cycle, administermoderate-dose combined EP therapy or norethister-one 5–7 days expected menstruation until the desiredperiod of prolongation. (B)

CQ411What are the important points in the diagnosis of cli-macteric disorder?

Answer

1 Suspect climacteric disorder in a woman who hasalready undergone menopause that comes with amyriad of complaints. (A)

2 The symptoms may be caused by estrogen with-drawal or other causes or the combination ofestrogen withdrawal and other causes. Make theproper diagnosis and evaluation based on thosepossibilities. (C)

3 Exclude underlying pathologies that may contributeto the complaints. (B)

4 Among the differential diagnoses, watch out fordepression, malignancy, and thyroid diseases due tothe overlapping characteristics, such as the patient’sage at onset and symptoms. (C)

CQ412How should we treat climacteric disorder?

Answer

1 Hormone replacement therapy is effective for symp-toms caused by autonomous nervous system dys-regulation, such as flushing, sweating, insomnia etc.(B)

2 As hormone-replacement therapy, estrogen only canbe given to post-hysterectomy patients, otherwise,estrogen and progesterone should be given in com-bination. (A)

3 For non-specific complaints that encompass amyriad of symptoms, traditional Japanese herbalmedicine (Kampo) can be used. (C)

4 For cases with severe mood-related disorders,counseling or psychiatric medication should beconsidered. (C)

5 Start the treatment for depression using antidepres-sants, such as selective serotonin reuptake inhibitors(SSRI) and serotonin–norepinephrine reuptakeinhibitors (SNRI). (C)

6 Recommend lifestyle changes if any problems aredetected. (C)

7 For other symptoms, choose the best treatmentaccording to the case at hand. (C)



CQ413How should we provide information regarding theside-effects of hormone replacement therapy and thecorresponding strategies for treatment?

Answer

1 The minor side-effects are: (A)Abnormal vaginal bleeding, mastalgia (breast pain),breast swelling.

2 Rare adverse effects that may occur are: (B)Breast cancer, ovarian cancer, lung cancer, coro-nary vascular disease, ischemic cerebral stroke,thromboembolism.

3 Provide explanation regarding relative contraindi-cations, such as migraine, cholecystitis, cholelithi-asis, uterine fibroids, endometrial hyperplasia etc.(B)

4 Each adverse or side-effect can be managed, takinginto account factors such as the age of the patientand the number of years passed since menopause,by choosing the right drugs, opting for (or exclud-ing) combined luteal hormone therapy, and chang-ing the route of administration and the duration oftreatment. (B)

CQ414What are the recommended traditional Japanese herbalmedicines (Kampo) or alternative therapies for climac-teric disorder?

Answer

1 Kampo formulations, such as Tokishakuyakusan,Keishibukuryogan, Kamishoyosan etc. can be used.(C)

2 Isoflavones derived from soy and red clover may beeffective for menopausal hot flushes. (C)

3 Even traditional Japanese herbal medicine (Kampo)and alternative therapies have side-effects and thenecessary precautions should be taken. (B)

CQ415How do we treat atrophic vaginitis?

Answer

1 Prescribe vaginal estriol tablet for symptomaticcases. (B)

2 Administer estrogen systemically when topicaltreatment using vaginal estriol tablet is a difficultoption for the patient. (B)

3 Prescribe hormone replacement therapy for patientswith postmenopausal syndrome. (B)

CQ416How do we prevent postmenopausal osteoporosis,and what are the strategies for early detection andtreatment?

Answer

1 Advise the patients to exercise regularly and haveadequate calcium intake to prevent osteoporosis. (B)

2 Take spine X-ray or measure bone density for earlydetection of osteoporosis, for women over the age of65 or for women below the age of 65 with high riskof fracture. (B)

3 Bone density measurement is usually carried outusing dual X-ray absorptiometry (DXA) scan of theaxial skeleton. Alternatively, peripheral DXA scan orquantitative ultrasonometry (QUS) of the calcaneuscan also be performed. (C)

4 Biomarkers for bone metabolism are measured tohelp choose the right drugs and/or evaluate the effi-cacy of treatment. (C)

5 The aim of treatment is to prevent fractures, thuspatients at risk may start their treatment withosteoporosis medication even if they are not fulfill-ing the diagnostic criteria for osteoporosis. (B)

6 The first-line drugs for osteoporosis are bisphospho-nates and selective estrogen receptor modulators.(A)

7 Watch out for side-effects unrelated to bone metabo-lism when using estrogen (conjugated estrogen, 17b-estradiol). (B)

CQ417How should we treat mood-related disorders and non-specific medical complaints?

Answer

1 Prescribe hormone replacement therapy for depres-sive mood and symptoms associated with meno-pause. (B)

2 Depression associated with menopause should betreated with SSRI or SNRI. (C)

3 Patients who complain of dysmenorrhea, dyspareu-nia, and vulvodynia without underlying pathologiesshould receive psychiatric evaluation and may betreated with psychiatric medication. (C)

4 Recommend consultation with a psychiatrist or apsychosomatic medicine specialist when symptomspersist. (B)

CQ418How do we diagnose and manage premenstrualsyndrome?

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Answer

1 The diagnosis of premenstrual syndrome is madebased on the period of onset, physical and psycho-logical symptoms. (A)Diagnostic guidelines set up by the AmericanCollege of Obstetrics and Gynecology are used. (C)

2 For severe psychological symptoms, refer thepatient to either a psychiatrist or a psychosomaticmedicine specialist. (C)

3 Counseling, lifestyle management, medication (suchas symptomatic treatment, sedatives, diuretics) aresome of the chosen treatments. (B)

4 Use selective serotonin reuptake inhibitor (SSRI) forthe treatment of moderate to severe premenstrualsyndrome and premenstrual dysphoric disorder. (C)

5 Low-dose combined estrogen–progestin formula-tions, such as oral contraceptives, can be effectivefor physical symptoms. (C)

CQ419How do we diagnose urinary incontinence?

Answer

1 The type of urinary incontinence is diagnosed bypatient interview. (B)

2 Referral to a specialist is recommended when theresidual urine volume exceeds 50–100 mL afterbladder voiding. (B)

3 Perform gynecological exam to check for diseaseswithin the pelvis. If any underlying pathologies thatmay contribute to urinary incontinence are found,prioritize the treatment of the underlying condition.(A)

4 If hematuria is persistent or found in multiple urinetests, the patient should be referred to a urologist fora complete evaluation for diseases such as bladdercancer. (A)

CQ420How do we treat urinary incontinence?

Answer

1 Perform pelvic floor muscle exercises as a behavioraltherapy for stress incontinence. (B)

2 Pharmacotherapy for stress incontinence consists ofeither estriol or clenbuterol. (C)

3 Surgical treatment is recommended if outpatientmanagement of urinary incontinence is deemed dif-ficult or the patient wishes to be treated surgically. (B)

4 Urge incontinence is one of the manifestations of anoveractive bladder. Hence, it is treated in the samemanner as overactive bladder (refer to CQ421). (A)

CQ421How do we manage overactive bladder in an outpa-tient setting?

Answer

1 Diagnose overactive bladder by asking the ques-tions in the Overactive Bladder Symptom Score(OABSS). (B)

2 Interview the patient to identify any history of neu-rological illnesses. (B)

3 Perform gynecological exam to check for pelvic dis-eases. (B)

4 Perform urine test to check for hematuria andpyuria. (B)

5 Measure residual urine volume right after voidingor micturition. (B)

6 Bladder control and pelvic floor muscle exercises asbehavioral therapy. (C)

7 Anticholinergics as pharmacotherapy. (A)

CQ422How do we manage pelvic organ prolapse (POP) in anoutpatient setting?

Answer

1 Start initial treatment for pelvic organ prolapsewhen the patient complains of discomfort fromsymptoms, such as sagging, vaginal bulging etc.(B)

2 For patients whose lowest point of prolapse is farfrom the hymen (POP stage I and below), initiatetreatment with pelvic floor muscle exercises.(B)

3 For patients whose lowest point of prolapse is adja-cent to the hymen (POP stage II and above), initiatetreatment using pessaries. (B)

4 After placing the pessary, follow up every1–3 months in the first year; and every 2–6 monthsafterwards, to check for the fit and complications,such as vaginal erosions. (B)

5 Administer estriol for vaginal sores caused bypessary placing. (C)

6 If outpatient management is difficult or the patienthas expressed her wish to receive surgery, afterobtaining informed consent from the patient, surgi-cal treatment is recommended. (B)

Disclosure

The authors declare that there is no conflict of interestthat would prejudice the impartiality of this scientificwork.



guidelines for office gynecology in japan

Documents

administer combined estrogenprogestin

combined oral contraceptive

abnormal vaginal bleeding

subsequent follow ups

highly recommended group

advise obese patients

receive mammography screening

risk human papillomavirus