doi:10.1111/j.1447-0756.2012.01858.

J. Obstet. Gynaecol. Res. Vol. 38, No. 4: 615631, April 2012

Guidelines for ofce gynecology in Japan: Japan Society of Obstetrics and Gynecology and Japan Association of Obstetricians 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 Yaegashi1
jog_1858 615..631

Departments of Obstetrics and Gynecology, Tohoku University Graduate School of Medicine, 2Obstetrics and Gynecology, Kosai Hospital, Sendai, Miyagi, 3Obstetrics and Gynecology, Aiiku Hospital, 4Obstetrics and Gynecology, Toranomon Hospital, 5Obstetrics and Gynecology, National Center for Global Health and Medicine, 6Obstetrics and Gynecology, Keio University Graduate School of Medicine, 7Obstetrics and Gynecology, Tokyo Red Cross Hospital, 8Obstetrics and Gynecology, Jikei University School of Medicine, 9Obstetrics and Gynecology, St Lukes International Hospital, 10Obstetrics and Gynecology, Toho Medical University, 11Obstetrics and Gynecology, Tokyo Womens Medical University, 12Obstetrics and Gynecology, Tokyo Medical and Dental University, 13Obstetrics and Gynecology, Douai Memorial Hospital, Tokyo, 14 Obstetrics and Gynecology, Iseikai Hospital, 15Obstetrics and Gynecology, Osaka City University School of Medicine, 16 Tasaka 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 Medicine Yokohama Seibu Hospital, Yokohama, 20Obstetrics and Gynecology, Odawara Municipal Hospital, Odawara, Kanagawa, 21 Obstetrics 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, 25 Department 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, 28 Obstetrics and Gynecology, University of Occupational and Environmental Health, Kitakyusyu, Fukuoka, 29Obstetrics and Gynecology, Hokaido University Graduate School of Medicine, Sapporo, Hokaido and 30Obstetrics and Gynecology, Nara Medical University, Kashihara, Nara, Japan

Abstract
Gynecology in the ofce setting is developing worldwide. Clinical guidelines for ofce gynecology were rst published by the Japan Society of Obstetrics and Gynecology and the Japan Association of Obstetricians and Gynecologists in 2011. These guidelines include a total of 72 clinical questions covering four areas (Infectious disease, Malignancies and benign tumors, Endocrinology and infertility, and Healthcare for women). These clinical questions were followed by several answers, backgrounds, explanations and references covering common problems and questions encountered in ofce gynecology. Each answer with a recommendation level of 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, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan. Email: take@med.tohoku.ac.jp

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These guidelines would promote a better understanding of the current standard care practices for gynecologic outpatients in Japan. Key words: guidelines, gynecology, ofce practice, womens health.

Introduction
Gynecology in the ofce setting is developing worldwide. It is the most frequent contact between the female patient and her gynecologist. It deals with a wide range of areas concerning womens health, such as infectious disease, oncology, endocrinology, infertility, health care and so on. Technological advances have enabled the transition of inpatient operations to day surgery procedures. Today, hysteroscopy, endometrial ablation and cervical loop excision are some of the most widely performed gynecological procedures in Japan. These outpatient procedures offer quick recovery, less time away from work and cost-savings for patients. In spite of its growing importance, there was no guideline for ofce gynecology in the world. Under these circumstances, Japan Society of Obstetrics and Gynecology (JSOG) and the Japan Association of Obstetricians and Gynecologists (JAOG) decided to publish guidelines describing standard care practices for gynecologic outpatients in 2008. Subsequently, the rst edition, Guidelines for Ofce Gynecology in Japan 2011, consisting of 72 Clinical Questions and Answers (CQ&A), was published in February 2011. The original version of Guidelines for Ofce Gynecology in Japan 2011 contains backgrounds, explanations and references. However, these sections have been omitted because of space limitations.

dard care practices in Japan. Level A indicates a stronger recommendation than level B. Consequently, informed consent is required when ofce gynecologists do not provide care corresponding to an answer with a level of A or B. Answers with a recommendation level of C are possible options that may favorably affect the outcome but for which some uncertainty remains regarding whether the possible benets outweigh the possible risks. Thus, care corresponding to answers with a recommendation level of C does not necessarily need to be provided. Some answers with a recommendation level of A or B include examinations and treatments that may be difcult for general ofce gynecologists to provide. In such cases, the ofce gynecologists must refer the patient 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 CQ101 How do we diagnose and treat genital herpes? Answer 1 Test for antigens in samples taken directly from the lesions. Diagnosis may be possible from historytaking and clinical observation of typical clinical cases. (B) 2 Antigen test is conducted by direct immunouorescence against viral antigen and can be combined with cytology. If samples cannot be obtained directly from the lesions, patient serum can be tested for viral antibodies (enzyme-linked immunosorbent assay) or specic 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)

Implications of A, B, and C Recommendation Levels

Several tests and/or treatments for gynecologic outpatients are presented as answers with a recommendation level of A, B or C to each clinical question. These criteria are essentially the same as described previously in Guidelines for obstetrical practice in Japan: Japan Society of Obstetrics and Gynecology (JSOG) and Japan Association of Obstetricians and Gynecologists (JAOG) 2011 edition. The answers and recommendation levels are principally based on evidence or consensus among Japanese gynecologists when the evidence is considered to be weak or lacking. Thus, the answers are not necessarily based on evidence. Answers with a recommendation level of A or B are regarded as current stan-

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5 For cases with more than six recurrences within a year, or recurrences presenting with severe sympMain examples of prescription Generic name Initial episode, recurrences Mild to moderate symptoms Severe symptoms Recurrence suppression Oral acyclovir Oral valacyclovir i.v. acyclovir Oral valacyclovir

toms, prophylaxis against recurrence is advisable. (B)

Brand name Zovirax (200 mg) Valtrex (500 mg) Zovirax (5 mg/kg/session) Valtrex (500 mg)

Dosage 5 times daily for 5 days, orally Twice daily for 2 days, orally (Up to 10 days for initial episode) Every 8 h for 7 days Once daily for 1 year, orally

CQ102 How do we diagnose and treat chlamydial cervicitis? Answer 1 Diagnose by testing cervical smear for chlamydia using nucleic acid hybridization tests, nucleic acid amplication tests (NAAT) or enzyme immunoassay (EIA). (A) 2 Sample should be tested simultaneously for gonorrhea when using NAAT. (B)
Main examples of prescription Generic name Azithromycin Oral Intravenous Clarithromycin Levooxacin Minocycline Brand name Zithromax Zithromax SR Clarith, Klaricid Cravit Minomycin

3 Treat using oral macrolides or uoroquinolone antibiotics. (A) 4 For pelvic inammatory disease (PID) or Fitz HughCurtis syndrome, oral antibiotics can be administered if the symptoms are mild. (B) 5 Post-treatment evaluation should be conducted at least 23 weeks after the completion of treatment. (B) 6 Sexual partner(s) of patient should be tested and treated. (B)

Content 250 mg/tablet 2 g/dry syrup 200 mg/tablet 500 mg/tablet 100 mg/vial

Dosage 1000 mg, single dose orally 2000 mg, single dose orally 200 mg orally, twice daily for 7 days 500 mg orally, once daily for 7 days 100 mg, twice daily, i.v. for 35 days

CQ103 How do we diagnose and treat vulva condyloma acuminatum? Answer 1 Clinical symptoms and presentation are usually sufcient for diagnosis. Biopsy and pathological evaluation can be 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) CQ104 How 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 for objective diagnosis. (C) 2 Treat locally (vaginally) or orally using chloramphenicol or metronidazole. (B)
Main examples of prescription Chloramphenicol vaginal tablet Metronidazole vaginal tablet Metronidazole tablet Chlomy vaginal tablet 100 mg Flagyl vaginal tablet 250 mg Flagyl tablet 250 mg Once daily Once daily 4 tablets twice daily Intravaginally for 6 days Intravaginally for 6 days Orally for 7 days

The duration of treatment can be prolonged as needed.

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CQ105 How do vaginitis? Answer

we

diagnose

and

treat

trichomonas

1 Check vaginal discharge microscopically for trichomonads. (B)

Main examples of prescription Antitrichomonal agents Oral formulations Vaginal tablets Metronidazole Tinidazole Metronidazole Tinidazole Brand name Flagyl Haisigyn

2 If no organisms are found microscopically, culture the sample. (C) 3 Treat systemically by giving oral metronidazole or tinidazole as ascending infection involving the upper urinary tracts cannot be ruled out. (B) 4 Sexual partner(s) must be treated simultaneously with the same oral drug. (B)

Content per tablet 250 mg 200 mg 500 mg 250 mg 200 mg

Dosage 500 mg/day, twice daily for 10 days 400 mg/day, twice daily for 7 days 2000 mg, single dose One tablet daily for 1014 days One tablet daily for 7 days If the trichomoniasis persists, withhold treatment for 1 week before repeating treatment.

Flagyl vaginal tablet Haisigyn vaginal tablet

CQ106 How do we diagnose and treat Candida vulvovaginitis? Answer 1 Diagnose by microscopic examination for yeast, or culture (agar plates with specialized medium or liquid medium with pH indicator can be used as well) of vulvovaginal discharge, in combination with clinical symptoms. (B)
Table 1 For continuous daily treatment Generic name Clotrimazole Miconazole nitrate Oxiconazole nitrate Brand name

2 For treatment, perform vaginal lavage, then intravaginal administration of antifungal medication. For vulva candidiasis, give topical creams. (A) Tables 13. 3 Treatment is considered successful if subjective symptoms disappear or vaginal discharge improves. (A)

Dosage One tablet daily One tablet daily One tablet daily

Duration 6 days 6 days 6 days

Empecid vaginal tablet 100 mg Florid vaginal suppository 100 mg Okinazol vaginal tablet 100 mg

Table 2 For patients who cannot receive regular follow ups Generic name Isoconazole nitrate Oxiconazole nitrate Brand name Adestan vaginal tablet 300 mg Okinazol vaginal tablet 600 mg Dosage 2 tablets daily One tablet daily Frequency Once a week Once a week

Table 3 For topical treatment Generic name Clotrimazole Miconazole Isoconazole nitrate Oxiconazole nitrate Brand name 1% Empecid cream 1% Florid D cream 1% Adestan cream 1% Okinazol cream Dosage 23 times daily 23 times daily 23 times daily 23 times daily Duration 57 days 57 days 57 days 57 days

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CQ107 How do we diagnose and treat gonococcus infections? Answer 1 For diagnosis of genital infection, perform gonorrhea culture or nucleic acid amplication test (NAAT) on cervical swab samples to detect for the presence of gonorrhea bacteria. (A) 2 When pharyngeal infection is suspected, perform the above tests on samples from pharyngeal swab. (C)
Main examples of prescription Generic name Injection drug Ceftriaxone Cefodizime Spectinomycin Brand name Rocephin Kenicef Trobicin

3 Samples should be tested simultaneously for chlamydia when NAAT is used. (B) 4 Single treatment using Ceftriaxone (i.v.), Cexime (i.v.) and Spectinomycin (i.m.) are rst-line therapies for genitourinary gonococcal infections. (B) Single dose of dry syrup containing 2g azithromycin can also be prescribed. (C) 5 Sexual partner(s) of patient should be tested and treated. (B)

Content 1.0 g/vial 1.0 g/vial 2.0 g/vial

Dosage 1.0g i.v., single dose 1.0g i.v., single dose 2.0g i.m. (gluteal), single dose

CQ108 How do we diagnose and treat syphilis? Answer 1 Use serologic tests for syphilis (STS), Treponema pallidum hemagglutination assay or uorescent treponemal antibody absorption test in combination for conrmatory diagnosis and determination of disease stage. (A) 2 First-line treatment with oral penicillins (amoxicillin, ampicillin). Treat primary syphilis for 24 weeks,
First-line drugs Generic name Amoxicillin Ampicillin Benzylpenicillin Abbreviation AMPC ABPC PCG Brand name Sawacillin, Pasetocin Viccilin Bicillin

secondary syphilis for 48 weeks, and tertiary syphilis for 812 weeks with oral antibiotics. (A) 3 Follow up by evaluating test results of serologic test (STS). (A) 4 When syphilis is conrmed, the physician who makes the diagnosis should report the case in accordance with the Infectious Disease Law by the Japanese government. (A)

Daily dosage 1.5 g 2.0 g 1.8 million units

Regimen 3 times daily 4 times daily 3 times daily

Duration Primary syphilis: 24 weeks Secondary syphilis: 48 weeks Tertiary syphilis: 812 weeks

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

CQ109 How do we diagnose pelvic inammatory disease (PID)? Answer Diagnosis 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 38C 2 Leukocytosis 3 Elevated C-reactive protein (Specic diagnostic criteria) (C) 1 Identication of (intrapelvic) abscess by magnetic resonance imaging (MRI) or transvaginal ultrasonography. 2 Aspiration of purulent material via the Pouch of Douglas. 3 Laparoscopic abnormalities suggestive of inammation consistent with PID.

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CQ110 How do we treat pelvic inammatory disease (PID)? Answer Treat as stated below. 1 Outpatient treatment is usually adequate unless, as in 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 cephem or quinolone antibiotics. For moderate cases, intravenous administration of cephem (up to secondgeneration) can also be considered. (B) 3 For severe cases (with no indication for hospitalization, or where the patient is unable to receive inpatient treatment), administer intravenous third- or higher generation cephem, or carbapenem antibiotics. Combined therapy using i.v. clindamycin or minocycline is also an option. (B)
Treatment for mild to moderate PID 1. Oral cephems 1) Cefditoren (Meiact) 100 mg orally 3 times daily for 57 days 2) Cefcapene (Flomox) 100 mg orally 3 times daily for 57 days 3) Cefdinir (Cefzone)) 100 mg orally 3 times daily for 57 days 2. Oral quinolones 1) Levooxacin (Cravit) 500 mg orally once daily for 57 days 2) Tosuoxacin (Ozex) 150 mg orally 3 times daily for 57 days 3) Ciprooxacin (Ciproxan) 100200 mg orally 3 times daily for 57 days Treatment for severe PID 1. Cephems for injection 1) Cefmetazole (Cefmetazon) 12g in a single dose, i.v. twice daily for 57 days 2) Flomoxef (Flumarin) 12g in a single dose, i.v. twice daily for 57 days 3) Cefpirome (Broact) 12g in a single dose, i.v. twice daily for 57 days 4) Ceftriaxone (Rocephin) 12g in a single dose, i.v. once to twice daily for 57 days 2. Carbapenems for injection 1) Imipenem (Tienam) 0.51g in a single dose, i.v. twice daily for 57 days 2) Doripenem (Finibax) 0.25g in a single dose, i.v. 23 times daily for 57 days

CQ111 How do we screen for sexually transmitted diseases (set test)? Answer 1 The set test includes tests for four major sexually transmitted diseases: chlamydia (cervix), gonorrhea (cervix), syphilis (blood), HIV infection (blood). (B) 2 For patients at risk for pharyngeal or throat infection, test pharyngeal samples for chlamydia and gonorrhea. (C) 3 If the patient requested extra tests, tests for trichomonas (vaginal discharge), chlamydial antibody (blood), hepatitis B and C antibody (blood) can be added. (C) CQ112 How do we diagnose and treat cystitis? Answer 1 Clinical history and presentation characterized by frequent urination, burning sensation during urination or sensation of incomplete bladder emptying, and urine test ndings are useful for diagnosis. (A) Urine culture yielding more than 105 colonyforming units (CFU)/mL of one type of bacteria indicates the pathogen responsible for the infection. (C) 2 Treat with oral cephalosporins, penicillins, or quinolones. (A) 3 Differential diagnosis of other medical conditions that may present with an overactive bladder should be taken into consideration. (B) B. Oncology and benign tumors CQ201 What is the appropriate way of obtaining samples for cervical cytology? Answer Collect cervical cells with a brush or a spatula. (C) CQ202 How do we manage and treat CIN1/2 (mild to moderate dysplasia)? Answer 1 CIN1 (mild dysplasia) conrmed with biopsy should receive follow-up observation with Pap smear and colposcopy every 6 months. (B) 2 CIN2 (moderate dysplasia) conrmed with biopsy should receive careful and consistent follow up with Pap smear and colposcopy every 36 months. (B)

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3 Excluding pregnant patients, CIN2 cases that have difculty receiving proper follow up can opt for treatment. (C) CQ203 What is the indication for further testing with colposcopy-directed biopsy after a Pap smear? Answer 1 A Pap smear graded as ASC-US that revealed test results such as the following: Positive results for high-risk human papillomavirus (HPV) (B) For facilities that are unable to perform HPVtesting, if the follow-up Pap smear performed immediately or 612 months after the suspicious Pap smear is graded as ASC-US or higher. (B) (Only facilities that meet the standard requirements are allowed to perform HPV-testing by an eligible doctor under the Japanese National Health Insurance system.) 2 When a Pap smear is graded as ASC-H, LSIL, HSIL, SCC, AGC, androgen insensitivity, adenocarcinoma or other malignancies, perform a biopsy immediately. (B) CQ204 What is the indication for minimally invasive conization of the cervix procedures, such as loop electrosurgical excision procedure (LEEP) and laser vaporization? Answer LEEP is conducted as a mean of diagnosis and treatment when: 1 CIN3 (severe dysplasia or carcinoma in situ) is seen on a biopsy of the cervix, and the extent of the lesion can be identied by colposcopy and the lesions have not extended deep within the endocervix. (B) 2 CIN2 (moderate dysplasia) is seen on a biopsy of the cervix, and subsequent follow ups do not show any regression of the lesion, and when the patient shows strong determination to receive treatment. (B) Laser vaporization is conducted as a mean of treatment when: 3 CIN3 is seen on multiple biopsies of the cervix in a young female patient, and the extent of the lesion can be identied by colposcopy and the lesions have not extended within the endocervix. This is only recommended among young patients with CIN3. (C) 4 CIN2 is seen on a biopsy of the cervix, and subsequent follow ups do not show any regression

of the lesion, and when the patient shows strong determination to receive treatment. (B) CQ205 What is the clinical utility of high-risk human papillomavirus (HPV) test and HPV genotyping? Answer 1 High-risk HPV test (e.g., Hybrid Capture II or AMPLICOR HPV assay) can be used as an adjunct to cytology for cervical cancer screening to improve the accuracy of screening. (C) 2 High-risk HPV test should be used for women with ASC-US cytology to decide who needs colposcopy. (B) 3 High-risk HPV test or HPV genotyping can be used for women treated for CIN 2/3 to detect residual or recurrent diseases during post-treatment follow up. (C) 4 HPV genotyping should be used for women with histologically conrmed CIN1/2 to characterize their risk of disease progression more precisely. Women who test positive for HPV16, HPV18, HPV31, HPV33, HPV35, HPV45, HPV52, or HPV58 are considered to be at increased risk of disease progression. Therefore, they should be managed separately from women who are negative for these eight genotypes. (B) CQ206 Who should be vaccinated against human papillomavirus (HPV)? Answer 1 Girls 1014 years of age are the most highly recommended group. (A) (According to the Japanese Ministry of Health, Labor and Welfares emergency policy to promote vaccination, until the end of 2011, Japanese female students from the rst year of junior high to the rst year of high school (1316year-olds) can receive free HPV vaccination from clinics or health-care institutions receiving contracts from their respective regional administrative councils.) 2 Young women 1526 years of age are the next most highly recommended group. (A) 3 Women 2745 years of age can receive HPV vaccination. (B) 4 Women who have current evidence or history of low-grade cervical abnormalities can receive vaccination. (B) 5 HPV testing should not be used to decide whether a woman is eligible for vaccination. (B)

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6 Pregnant women are not included in the recommendations for HPV vaccine. (B) 7 Lactating women can receive HPV vaccine. (C) CQ207 What should vaccine recipients know before receiving the HPV vaccine? Answer 1 The vaccine protects against HPV16 and HPV18 infections. For girls and women not yet sexually active, the vaccine can be expected to provide 6070% prevention against cervical cancer. (A) 2 The vaccine does not have any therapeutic effect on existing HPV infection or cervical diseases. (B) 3 Girls and women not yet sexually active can be expected to receive the full benet of vaccination. (B) 4 Vaccinated women should also have routine cervical cancer screening. (B) 5 The three-dose schedule (0, 12 months, 6 months) and the cost. (A) 6 The possible adverse events, such as pain, redness, and swelling at the injection site (the arm), headache, fainting, and shock etc. (A) CQ208 How should HPV vaccine be administered? Answer 1 A womans medical tness (conditions and circumstances) for vaccination should be assessed with comprehensive pre-vaccination health screening. (A) 2 The vaccine should be shaken well before administration. A frozen vaccine should not be used. (A) 3 The vaccine is injected intramuscularly (i.m.) in the deltoid muscle as a three-dose schedule at 0, 12 and 6 months. (B) 4 The HPV vaccine should not be administrated for 27 days after receiving a live vaccine or for 6 days after receiving an inactivated vaccine. (A) 5 Syncope, anaphylaxis or seizures can occur after vaccination. Therefore, vaccine providers should observe women for 30 min after they receive HPV vaccine. (A) CQ209 What is the appropriate way of obtaining samples for endometrial cytology, and who are the screening targets?

Answer 1 Uterine endometrial samples can be obtained by scraping or by suction. (B) 2 Women over the age of 50 or post-menopausal patients experiencing abnormal vaginal bleeding, or women with predisposing risk factors are selected for screening. (C) CQ210 How do we diagnose and treat endometrial hyperplasia without atypia? Answer 1 When a Pap test indicates endometrial abnormalities, or when increased endometrial thickness is observed, perform endometrial biopsy for denitive diagnosis. When atypia is suspected, diagnose by performing a total endometrial curettage. (A) 2 When treatment is indicated, administer cyclic medroxyprogesterone acetate. (B) 3 Endometrial hyperplasia in adolescents should be treated with combined estrogenprogestin formulations. (C) 4 For patients hoping to conceive, fertility treatment that includes ovulation induction can be started after treatment No. 2 or No. 3. (C) 5 Among post-menopausal patients, if abnormal bleeding persists and abnormalities continue to be identied in subsequent tests, hysterectomy should be performed. (C) CQ211 How do we diagnose and manage endometrial polyps? Answer 1 Perform screening with transvaginal ultrasonography. (A) 2 Diagnose using sonohysterography or hysteroscopy. (B) 3 Perform biopsy to rule out malignancy. (C) 4 For cases below, perform hysteroscopic surgery, or total endometrial curettage for denitive diagnosis and 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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CQ212 When is hysteroscopy indicated? Answer 1 Diagnosis for conditions as stated below. (C) Endometrial polyps Submucosal broids Uterine anomalies Intrauterine adhesions (Ashermans syndrome) Endometrial hyperplasia Endometrial cancer Spontaneous abortion or residues after expulsion of hydatidiform mole Residual placenta, placental polyp Intrauterine object (IUD) 2 Preoperative diagnosis for conditions as stated below. (B) Endometrial polyps Submucosal broids Septate uterus Intrauterine adhesions (Ashermans syndrome) CQ213 How do we treat endometriosis without cystic lesions? Answer 1 Prescribe analgesics (non-steroidal antiinammatory drugs [NSAIDs]) for pain. (B) 2 When analgesics are inadequate or the patients endometriosis requires treatment, the rst-line therapy is either combined oral contraceptive (COC) or dienogest; as second-line therapy, gonadotrophinreleasing hormone (GnRH) agonist or danazol are usually chosen. (C) 3 When medication does not work, or when the patient suffers from infertility, perform surgery to cauterize/excise endometriotic lesions and to remove adhesion. (B) 4 To prevent recurrence of endometriosis in patients who do not wish to conceive, COC, dienogest, and GnRH agonist can be prescribed. (C) CQ214 What are the differential diagnoses and management of suspected benign ovarian cysts? Answer 1 To differentiate between malignant tumors, nontumor lesions and functional cysts, history-taking, vaginal examination, ultrasonography, tumor marker tests, MRI etc. should be performed. (B)

2 Surgery is recommended for large cysts (more than 6 cm in diameter) or when symptoms due to the cyst are observed. (B) 3 Even for small cysts, surgery is recommended for cases whereby the existence of a tumor is conrmed. (C) 4 If surgery is not indicated, the follow-up schedule should be arranged according to the rst upcoming menstrual cycle: the rst follow up being 13 months later, and the subsequent follow ups at 3- to 6-month intervals. (C) 5 Explain to patients that the accuracy of the diagnosis is limited if no surgery is performed. (A) CQ215 How do we diagnose hemorrhaging corpus luteal cyst or ovarian hemorrhage? Answer 1 Perform a general evaluation by history-taking, basal body temperature measurement, abdominal examination, ultrasonography. (B) 2 If the diagnosis of intraperitoneal hemorrhage is difcult in a case presenting with an ovarian mass and peritoneal uid on ultrasonography, culdocentesis (extraction of uid through the Pouch of Douglas) can be performed. (C) 3 In the case of intraperitoneal bleeding, perform the necessary tests to rule out ectopic pregnancy. (B) 4 When excessive hemorrhage is suspected, and the vital signs of the patient are not favorable, or when the hemoglobin count of the patient decreases dramatically, indicating the presence of persistent hemorrhage, emergency surgical intervention should be performed. (B) CQ216 How do we treat ovarian endometrial cyst (chocolate cyst)? Answer 1 The choice of treatment, which includes observation, medication or surgery, is made based on the patients age, size of the cyst(s), and the patients desire to conceive. Surgery is usually prioritized due to fear of rupture, infection or malignant transformation of the cyst. (B) 2 The type of surgical procedure is chosen based on the balance between curativeness of endometriosis and preservation of ovarian function. (B) 3 When a patients cyst is considered to possess a high malignant potential depending on her age, cyst size and the presence of solid components within the

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cystic mass, she should have her diseased ovary removed surgically. (C) CQ217 How do we diagnose and treat adenomyosis? Answer 1 Clinical ndings, internal examination, and ultrasonography can provide the appropriate diagnosis. However, for differential diagnosis against uterine broids or uterine sarcomas, MRI should be undertaken. (B) 2 Treat the symptoms of adenomyosis in the same manner as endometriosis, i.e., with analgesics and hormonal treatment. (B) 3 As a curative measure, perform hysterectomy. (B) CQ218 When do we perform operative hysteroscopy/ transcervical resection (TCR) for submucosal broids? Answer 1 The usual criteria for the procedure are small uterine broids (less than 30 mm in size) and more than 50% protrusion in the uterine cavity. However, skilled surgeons may not be constrained by these criteria. (B) 2 Even for patients who do not wish to become pregnant, operative hysteroscopy/TCR may be chosen for its low invasiveness. (B) CQ219 What are the considerations for a patient with intramural and/or subserosal uterine broids who wishes to opt for conservative therapy? Answer The type of treatment should be chosen based on the location and size of the broids, whether or not the patient has menorrhagia or anemia, age of the patient and the patients prospects in conceiving. (A) CQ220 How do we manage patients with cervical polyps? Answer 1 The polyp should be resected for pathological evaluation. (B) 2 For asymptomatic patients with low risk for malignancy, instead of conducting a biopsy, the patients should receive follow-up observation. (B) 3 For pregnant patients whose polyps may be the source of cervical insufciency or chorioamnionitis, treatment should be given as necessary (resection or antibiotics). (C)

4 The method of resection depends on the size and morphology of the polyp: (i) Pull or twist the polyp to detach it using Pan forceps; (ii) ligation, and then resection; and (iii) electrocauterization, are some of the methods chosen. (B) CQ221 How do we manage Bartholins cysts? Answer 1 Asymptomatic cases with minimal swelling do not require treatment. (B) 2 Bartholins abscess presenting with acute symptoms should receive emergency treatment by drainage of purulent material (either via incision or ne-needle aspiration). Culture the infected material for bacteria and treat the infection using antibiotics. (B) 3 Perform marsupialization, a surgical treatment that preserves the function of Bartholins gland. (B) 4 Recurrent cases despite marsupialization, recurrent Bartholins abscess, and cases suspicious of carcinoma of Bartholins gland should undergo surgical resection. (B) 5 Adenocarcinoma of Bartholins gland is very rare. When malignancy is suspected, perform histopathological exploration and evaluation. (B) CQ222 What should be recommended for post-treatment follow up of patients with gynecological malignancies (cervical, endometrial or ovarian cancer)? Answer 1 The follow-up intervals are recommended as follows: every 13 months for 3 years, every 6 months for another 2 years, and then annually. (C) 2 The follow up includes interval history and physical examination (including pelvic examination), with cytology, chest X-ray, tumor markers, ultrasonography, and computed tomography scans etc. (C) CQ223 How is breast cancer screening conducted? Answer 1 All women above 50 years of age should receive mammography screening. (A) 2 Women in their 40s should receive mammography screening. (B) 3 Women above 40 years of age can receive optional screening using ultrasonography. (C)

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4 Women below 40 years of age should receive ultrasonography for breast cancer screening, or mammography in combination with ultrasonography. (C) 5 Interval in between screenings is 12 years. (B) CQ224 How is mastopathy managed? Answer 1 Clinically, mastopathy as an exclusive diagnosis for breast cancer should not be made casually. In such cases, suspicious for mastopathy should be indicated instead. (B) 2 As a rule, cases suspected for mastopathy should receive consultation from specialized institutions. (B) 3 Cases with proliferative lesions that are histologically ruled out for atypia should receive consistent screenings as the risk of breast cancer is elevated. (B) 4 Cases that are histologically conrmed with atypical proliferation (ductal, lobular) (including those with a history of proliferative atypia) have an increased risk for breast cancer. Such cases should receive follow ups in coordination with an institution specializing in breast cancer. (A) C. Endocrinology and Infertility CQ301 How do we treat functional dysmenorrhea? Answer 1 Prescribe and administer analgesics (such as NSAIDs) or low-dose combined oral contraceptive. (B) 2 Administer Japanese herbal medicine (Kampo) or anti-cramp medicine. (C) CQ302 What should we prescribe for menorrhagia without any underlying pathology? Answer 1 Administer low-dose combined oral contraceptive. (C) 2 Administer antibrinolytics (tranexamic acid, such as Transamin). (C) 3 Consider surgical treatment when pharmacotherapy is either ineffective or not a viable option. (C) CQ303 What are other treatment options besides pharmacotherapy for menorrhagia without any underlying pathology?

Answer 1 Perform dilation and curettage for acute bleeding. (C) 2 For those who do not wish to retain their uterus and/or fertility, hysterectomy or endometrial ablation can be performed. (C) CQ304 How do we manage abnormal menstrual cycle due to anovulation? Answer 1 Investigate the cause behind the abnormal menstrual cycle from patient interviews, physical ndings, endocrine tests etc. (B) 2 For those who do not wish to conceive, conduct hormonal therapy. Polymenorrhea or oligomenorrhea caused by anovulatory menstrual cycles should be treated with cyclic progestins. (B) Administer cyclic progestins for euestrogenic amenorrhea. (B) Administer cyclic estrogenprogestin for hypoestrogenic amenorrhea. (B) Administer combined estrogenprogestin, such as oral contraceptives. (C) For those who are looking forward to conceiving, induce ovulation. (B) CQ305 What are the important points when we see a woman of child-bearing age with a chief complaint of abnormal vaginal bleeding? Answer 1 Perform systematic differential diagnosis via patient interviews and physical examinations. (A) 2 Keep in mind the possibility of pregnancy when conducting patient interviews and examinations. (A) 3 When malignancy is suspected, perform cytology and biopsy. (A) 4 When pregnancy and underlying pathology are ruled out, dysfunctional uterine bleeding is diagnosed. (A) CQ306 How do we diagnose hyperprolactinemia? Answer 1 Measure serum prolactin levels when the patient presents with menstrual abnormalities or galactorrhea. (A)

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2 If serum prolactin levels are elevated, check the patients thyroid function as well. (B) 3 Interview the patient about the drugs taken (psychiatric, underlying conditions), the presence of thyroid disease symptoms, headaches, and visual eld defects. (B) 4 Check both breasts for galactorrhea. (B) 5 When serum prolactin levels exceed 100ng/mL, perform MRI to rule out prolactinoma. When necessary, refer the patient to either an endocrinologist or a neurosurgeon. (B) CQ307 How do we treat hyperprolactinemia? Answer 1 Treat using dopamine agonists in hyperprolactinemia caused by pituitary disorders. (A) 2 For drug-induced hyperprolactinemia, consult the doctor who prescribed the medication to either reduce the dosage or replace the problematic drug. (B) 3 In patients conrmed with prolactinoma, consult an endocrinologist or a neurosurgeon. Treatment using dopamine-agonist is still the main approach. (B) 4 Surgical treatment is indicated for pituitary infarction, pituitary tumors with accompanying visual eld defects, drug-resistant cases and cases that cannot tolerate pharmacotherapy. (C) CQ308 How do we diagnose and treat polycystic ovarian syndrome (PCOS)? Answer 1 Diagnose according to the 2007 diagnostic guidelines laid out by the Japan Society of Obstetrics and Gynecology. (A) 2 For women who do not wish to conceive: Advise obese patients to make lifestyle adjustments in order to lose weight (B) Induce withdrawal bleeding at consistent intervals. (B) 3 For women who wish to conceive: Advise obese patients to lose weight (B) Use clomiphene as a rst-line ovulation induction (B) For cases who did not respond to clomiphene alone, use metformin in combination with clomiphene when the patients have any of the conditions, such as obesity, glucose intolerance or insulin resistance. (C)

4 For cases with clomiphene-resistance, perform gonadotrophin treatment or laparoscopic ovarian drilling. (B) 5 Gonadotrophin treatment should be performed using either recombinant or pure FSH in a chronic low-dose method. (B) CQ309 How do we prevent the occurrence or severe progression of ovarian hyperstimulation syndrome (OHSS)? Answer 1 Use recombinant or pure FSH in a chronic low-dose method for gonadotrophin treatment in patients with PCOS or history of OHSS. (B) 2 Cancel human chorionic gonadotrophin (hCG) administration when the risk for developing OHSS is high during ovulation induction in routine infertility practice. (B) 3 When the risk of developing OHSS is high during ovarian stimulation in assisted reproductive technology 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 sufcient uids and to avoid physical exercises and sexual intercourse. (C) 5 For moderate OHSS or pregnant patients with OHSS, monitor closely and consider management at an advanced medical institution if the symptoms or the test results are not improved. (B) 6 Severe cases should receive inpatient treatment at a hospital. (B) CQ310 How do we manage premature ovarian failure (POF)? Answer 1 Perform the necessary tests, such as checking the patients endocrine prole, to identify the cause of POF. (B) 2 Choose hormone replacement therapy for patients who do not wish to conceive. (A) 3 For patients who wish to conceive, choose cyclic estrogenprogestin combination therapy. If ovulation cannot be achieved, administer high-dose human menopausal gonadotrophin (hMG) therapy. (C)

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CQ311 What are initial tests to identify the causes of the infertility? Answer Below are the recommended tests. Basal body temperature measurement. (A) Ultrasonography. (A) Endocrine tests. (B) Chlamydial antibody test or chlamydial antigen (nucleic acid identication) test. (B) 5 Hysterosalpingogram. (B) 6 Semen analysis. (B) 7 Test for cervical factors. (B) 1 2 3 4 CQ312 What are the important points for articial insemination with husbands sperm (AIH)? Answer 1 Perform AIH between the moment before and after ovulation. (B) 2 Use washed and concentrated spermatazoa suspension. (C) 3 Stimulate ovulation using clomiphene or gonadotrophin in order to increase pregnancy success rate. (C) 4 Switch to assisted reproduction technology procedures if AIH is not successful in repeated attempts. (C) 5 Explain the possible adverse events, such as bleeding, pain and infection. (B) CQ313 How do we treat male infertility? Answer 1 Pharmacotherapy for oligozoospermia. (C) 2 Perform articial insemination with husbands sperm (AIH) for mild oligozoospermia and mild asthenozoospermia. (B) 3 Choose in vitro fertilization and intracytoplasmic sperm injection for severe oligozoospermia and severe asthenozoospermia. (B) 4 Consult a urologist specializing in infertility to identify the cause of azoospermia and severe oliogozoospermia and decide on the treatment. (B) 5 If pregnancy is impossible with the husband who is diagnosed with azoospermia, articial insemination with donors sperm can be an option. (C) 6 Infertility treatment should be conducted in coordination with a urologist when the male patient presents with sexual dysfunction, such as erectile dysfunction. (C)

CQ314 How do we manage recurrent pregnancy loss in association with chromosomal anomalies? Answer 1 Provide genetic counseling to couples with a history of recurrent pregnancy loss who are taking tests for chromosomal anomalies. (B) 2 Provide genetic counseling in conjunction with karyotype test of tissues from spontaneous abortions. (C) 3 Preimplantation genetic diagnosis should be carried out in adherence to the principles laid out by the Japan Society of Obstetrics and Gynecology, and should have received ethical clearance by an internal review board. (A) D. Healthcare for women CQ401 How should we perform emergency contraception? What are the pitfalls concerning emergency contraception? Answer 1 Perform emergency contraception to reduce the probability of pregnancy in unprotected sexual intercourse. (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 coppercontaining intrauterine device can be used when necessary. (C) 5 Inform the patient that even with emergency contraception, there is still a risk of pregnancy. Ask the patient to check up at the clinic again when necessary. (B) CQ402 What should we tell the patient when prescribing oral contraceptives (OC)? Answer Provide information based on the Guidelines concerning the use of low-dose oral contraceptives (year 2007 revision). 1 Efcacy and safety: OC is the most effective reversible method of contraception available. It is also very safe. (B) 2 Additional benets: OC may ameliorate the symptoms of menstrual problems, such as dysmenorrhea, menorrhagia etc. (B) 3 Sexually transmitted diseases: OC does not prevent sexually transmitted infection. (B)

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4 Target age: any woman of reproductive age should be able to receive treatment. (C) 5 Complications: OC increases the risk of cerebral stroke and venous thromboembolism. The risk of myocardial infarction among smokers is also increased. (B) 6 Cancer risk: cervical cancer risk increases with longterm usage. Breast cancer risk is not affected. Reduces the risk of ovarian and endometrial cancer. (B) 7 Side-effects: OC may contribute to gastrointestinal symptoms 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 may be a reason for contraindication. (B) CQ403 What should we inform the patient when an intrauterine device (IUD) (including the intrauterine system) is chosen for contraception? Answer Provide 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 tted to make sure that the device is in the right position or to exchange the device. (B) 4 Possible complications, such as hemorrhage, infection, perforation etc. may occur. (B) CQ404 How do we manage Turners syndrome? Answer 1 For patients diagnosed before puberty, growth hormone may be needed for treatment. Management of patient can be carried out in coordination with a pediatrician/endocrinologist. (A) 2 For patients diagnosed before puberty, low-dose estrogen should be administered starting from puberty (from about 12 years of age). Increase the dosage in 2- to 3-year intervals. (B) 3 Hormone replacement therapy is recommended. (A) 4 Provide counseling, while taking care of the patients emotional condition, when providing explanation about her fertility. (B) 5 Provide care for patients in coordination with respective specialists for complications, such as

thyroid abnormalities, glucose intolerance, coarctation of the aorta, gonadal tumors etc. (B) CQ405 How should we provide care for XY female patients? Answer 1 After denitive diagnosis is made, provide appropriate counseling for both the patient and her parents. (B) 2 Provide careful follow up as the risk for gonadal tumor development is high. After reaching puberty, surgically remove the abnormal gonads at the appropriate timing. (A) 3 For patients with androgen insensitivity, provide estrogen replacement therapy after total gonadectomy. For XY complete gonadal dysgenesis, perform cyclic estrogenprogestin therapy as soon as the diagnosis is made. (A) CQ406 How do we provide care for patients with Mayer RokitanskyKster (Hauser) syndrome? Answer 1 Provide information for the patient regarding her medical condition in a timely and approachable manner. (A) 2 Vaginoplasty should be performed according to the patients wishes after sufcient counseling. (A) 3 Vaginoplasty should be carried out at a specialized and experienced institution. (A) CQ407 What are the important points when we perform medical examinations on an adolescent? Answer 1 Medical interviews are very important, and can be conducted with or without the accompaniment of a family member. (B) 2 Even for girls with no prior experience of sexual intercourse (virgins), physical examination, rectal examination, ultrasonography (transrectal or transabdominal) should be performed to achieve proper diagnosis. (B) 3 Peritoneal lesions caused by endometriosis should also be considered as one of the reasons of dysmenorrhea in an adolescent patient. (C) CQ408 What are the important points when treating a female adolescent?

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Answer 1 For amenorrhea, use cyclic progestins therapy or cyclic estrogenprogestin therapy once every 23 months. (C) 2 Watch out for decreased bone mass in prolonged amenorrhea. (C) 3 Do not induce menstruation in amenorrhea associated with extremely low bodyweight (less than 70% of ideal bodyweight). Such cases should be advised to regain weight through lifestyle improvement and referred for counseling. (B) 4 Dysmenorrhea that is not caused by underlying genitourinary deformities, especially cases that are associated with endometriosis, should be treated with either NSAIDs or combined oral contraceptive. (B) CQ409 What should we do when we encounter a sexual assault victim? Answer 1 Victims who have not reported their ordeal to the law enforcement authorities should be reported to the police after obtaining their consent before any medical examination takes place. (A) 2 Collection of crime evidence during medical examination of the victim(s) should be done with the victim(s) consent under the supervision of a police ofcer. (A) 3 Observe and document any physical trauma, such as external injuries, scratches, bruises etc. (B) 4 Issue a medical certicate. (B) 5 Emergency contraception should be provided. (B) 6 The medical expenses incurred from the medical examination, tests and treatment should not be charged to the victim, but should be paid by the police department. (B) CQ410 How do we help patients modify their menstrual cycle? Answer 1 To shorten the menstrual cycle, administer combined estrogenprogestin (EP) or norethisterone from the 3rd to 7th day of the menstrual cycle for 1014 days. (B) 2 To prolong the menstrual cycle, administer combined EP or norethisterone from the follicular phase until the desired period of prolongation. (B)

3 To prolong the menstrual cycle, administer moderate-dose combined EP therapy or norethisterone 57 days expected menstruation until the desired period of prolongation. (B) CQ411 What are the important points in the diagnosis of climacteric disorder? Answer 1 Suspect climacteric disorder in a woman who has already undergone menopause that comes with a myriad of complaints. (A) 2 The symptoms may be caused by estrogen withdrawal or other causes or the combination of estrogen withdrawal and other causes. Make the proper diagnosis and evaluation based on those possibilities. (C) 3 Exclude underlying pathologies that may contribute to the complaints. (B) 4 Among the differential diagnoses, watch out for depression, malignancy, and thyroid diseases due to the overlapping characteristics, such as the patients age at onset and symptoms. (C) CQ412 How should we treat climacteric disorder? Answer 1 Hormone replacement therapy is effective for symptoms caused by autonomous nervous system dysregulation, such as ushing, sweating, insomnia etc. (B) 2 As hormone-replacement therapy, estrogen only can be given to post-hysterectomy patients, otherwise, estrogen and progesterone should be given in combination. (A) 3 For non-specic complaints that encompass a myriad of symptoms, traditional Japanese herbal medicine (Kampo) can be used. (C) 4 For cases with severe mood-related disorders, counseling or psychiatric medication should be considered. (C) 5 Start the treatment for depression using antidepressants, such as selective serotonin reuptake inhibitors (SSRI) and serotoninnorepinephrine reuptake inhibitors (SNRI). (C) 6 Recommend lifestyle changes if any problems are detected. (C) 7 For other symptoms, choose the best treatment according to the case at hand. (C)

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CQ413 How should we provide information regarding the side-effects of hormone replacement therapy and the corresponding 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, coronary vascular disease, ischemic cerebral stroke, thromboembolism. 3 Provide explanation regarding relative contraindications, such as migraine, cholecystitis, cholelithiasis, uterine broids, endometrial hyperplasia etc. (B) 4 Each adverse or side-effect can be managed, taking into account factors such as the age of the patient and the number of years passed since menopause, by choosing the right drugs, opting for (or excluding) combined luteal hormone therapy, and changing the route of administration and the duration of treatment. (B) CQ414 What are the recommended traditional Japanese herbal medicines (Kampo) or alternative therapies for climacteric disorder? Answer 1 Kampo formulations, such as Tokishakuyakusan, Keishibukuryogan, Kamishoyosan etc. can be used. (C) 2 Isoavones derived from soy and red clover may be effective for menopausal hot ushes. (C) 3 Even traditional Japanese herbal medicine (Kampo) and alternative therapies have side-effects and the necessary precautions should be taken. (B) CQ415 How do we treat atrophic vaginitis? Answer 1 Prescribe vaginal estriol tablet for symptomatic cases. (B) 2 Administer estrogen systemically when topical treatment using vaginal estriol tablet is a difcult option for the patient. (B) 3 Prescribe hormone replacement therapy for patients with postmenopausal syndrome. (B)

CQ416 How do we prevent postmenopausal osteoporosis, and what are the strategies for early detection and treatment? Answer 1 Advise the patients to exercise regularly and have adequate calcium intake to prevent osteoporosis. (B) 2 Take spine X-ray or measure bone density for early detection of osteoporosis, for women over the age of 65 or for women below the age of 65 with high risk of fracture. (B) 3 Bone density measurement is usually carried out using dual X-ray absorptiometry (DXA) scan of the axial skeleton. Alternatively, peripheral DXA scan or quantitative ultrasonometry (QUS) of the calcaneus can also be performed. (C) 4 Biomarkers for bone metabolism are measured to help choose the right drugs and/or evaluate the efcacy of treatment. (C) 5 The aim of treatment is to prevent fractures, thus patients at risk may start their treatment with osteoporosis medication even if they are not fullling the diagnostic criteria for osteoporosis. (B) 6 The rst-line drugs for osteoporosis are bisphosphonates and selective estrogen receptor modulators. (A) 7 Watch out for side-effects unrelated to bone metabolism when using estrogen (conjugated estrogen, 17bestradiol). (B) CQ417 How should we treat mood-related disorders and nonspecic medical complaints? Answer 1 Prescribe hormone replacement therapy for depressive mood and symptoms associated with menopause. (B) 2 Depression associated with menopause should be treated with SSRI or SNRI. (C) 3 Patients who complain of dysmenorrhea, dyspareunia, and vulvodynia without underlying pathologies should receive psychiatric evaluation and may be treated with psychiatric medication. (C) 4 Recommend consultation with a psychiatrist or a psychosomatic medicine specialist when symptoms persist. (B) CQ418 How do we diagnose and manage premenstrual syndrome?

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Answer 1 The diagnosis of premenstrual syndrome is made based on the period of onset, physical and psychological symptoms. (A) Diagnostic guidelines set up by the American College of Obstetrics and Gynecology are used. (C) 2 For severe psychological symptoms, refer the patient to either a psychiatrist or a psychosomatic medicine specialist. (C) 3 Counseling, lifestyle management, medication (such as symptomatic treatment, sedatives, diuretics) are some of the chosen treatments. (B) 4 Use selective serotonin reuptake inhibitor (SSRI) for the treatment of moderate to severe premenstrual syndrome and premenstrual dysphoric disorder. (C) 5 Low-dose combined estrogenprogestin formulations, such as oral contraceptives, can be effective for physical symptoms. (C) CQ419 How do we diagnose urinary incontinence? Answer 1 The type of urinary incontinence is diagnosed by patient interview. (B) 2 Referral to a specialist is recommended when the residual urine volume exceeds 50100 mL after bladder voiding. (B) 3 Perform gynecological exam to check for diseases within the pelvis. If any underlying pathologies that may contribute to urinary incontinence are found, prioritize the treatment of the underlying condition. (A) 4 If hematuria is persistent or found in multiple urine tests, the patient should be referred to a urologist for a complete evaluation for diseases such as bladder cancer. (A) CQ420 How do we treat urinary incontinence? Answer 1 Perform pelvic oor muscle exercises as a behavioral therapy for stress incontinence. (B) 2 Pharmacotherapy for stress incontinence consists of either estriol or clenbuterol. (C) 3 Surgical treatment is recommended if outpatient management of urinary incontinence is deemed difcult or the patient wishes to be treated surgically. (B) 4 Urge incontinence is one of the manifestations of an overactive bladder. Hence, it is treated in the same manner as overactive bladder (refer to CQ421). (A)

CQ421 How do we manage overactive bladder in an outpatient setting? Answer 1 Diagnose overactive bladder by asking the questions in the Overactive Bladder Symptom Score (OABSS). (B) 2 Interview the patient to identify any history of neurological illnesses. (B) 3 Perform gynecological exam to check for pelvic diseases. (B) 4 Perform urine test to check for hematuria and pyuria. (B) 5 Measure residual urine volume right after voiding or micturition. (B) 6 Bladder control and pelvic oor muscle exercises as behavioral therapy. (C) 7 Anticholinergics as pharmacotherapy. (A) CQ422 How do we manage pelvic organ prolapse (POP) in an outpatient setting? Answer 1 Start initial treatment for pelvic organ prolapse when the patient complains of discomfort from symptoms, such as sagging, vaginal bulging etc. (B) 2 For patients whose lowest point of prolapse is far from the hymen (POP stage I and below), initiate treatment with pelvic oor muscle exercises. (B) 3 For patients whose lowest point of prolapse is adjacent to the hymen (POP stage II and above), initiate treatment using pessaries. (B) 4 After placing the pessary, follow up every 13 months in the rst year; and every 26 months afterwards, to check for the t and complications, such as vaginal erosions. (B) 5 Administer estriol for vaginal sores caused by pessary placing. (C) 6 If outpatient management is difcult or the patient has expressed her wish to receive surgery, after obtaining informed consent from the patient, surgical treatment is recommended. (B)

Disclosure
The authors declare that there is no conict of interest that would prejudice the impartiality of this scientic work.

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