GYN Flashcards
What are the hormone changes seen with Primary ovarian insufficiency?
Low estrogen, elevated LH, FSH and GnRH. Average age of onset in menopause is 51
Discuss bHCG levels after giving Methotrexate in ectopic pregnancy?
Methotrexate is day 1. It is common for bHCG to increase between day 1-4, then between day 4-7 the bHCG level must decrease by 15%!!!!!! If it decreases by 15%, then can re-check weekly until 0. If it does not decrease by 15% need to give another methotrexate if the patient is stable and there is no signs of rupture.
Describe acute pelvic inflammatory disease? Syndrome associated with this?
Lower abdominal/pelvic pain associated with pelvic tenderness and evidence of genital tract inflammation on examination
Usually, pain is bilateral, less than 2 weeks duration, can be mild to severe
Worsening with coitus or jarring movement may be the only symptoms
Abnormal bleeding occurs in 30% of patients
Usually, there is cervical motion, uterine, and adnexal tenderness on the bimanual exam
Can be severe and complicated by the diseases below:
Perihepatitis: Inflammation of the liver capsule
10% of PID
RUQ abdominal pain, pleuritic pain
AST/ALT usually minimally elevated
“Violin string” adhesions can be visible on laparoscopy
Tuboovarian abscess: Can be found on the ovary, fallopian tube or other pelvic organs
Usually associated with pain and vaginal discharge
May not be septic appearing (no fever in up to half of cases)
Consider imaging for TOA in patients with PID and:
Acute, severe illness, Significant tenderness, Adnexal mass
Poor response to antibiotic therapy
Presentation of subacute pelvic inflammatory disease?
Usually, women recall prior mild symptoms consistent with PID
An endometrial biopsy may show inflammation and signs of PID
May have subacute endometritis
May be discovered when they are noted to have infertility
Presentation of chronic pelvic inflammatory disease?
Can present with low-grade fever, weight loss, and abdominal pain
Actinomycosis and tuberculosis associated with intrauterine devices have been reported
Fairly rare
Post-menopausal woman presenting with AUB needs what evaluation and why?
This postmenopausal woman is presenting with presumed abnormal uterine bleeding as no obvious cause of vaginal bleeding is visible on the physical examination. Malignancy must be excluded in all postmenopausal women with abnormal uterine bleeding. An endometrial biopsy is an office procedure that is highly sensitive for excluding malignancy, however will not identify alternative etiologies such as polyps or leiomyoma. Biopsy findings may include benign endometrium, simple or complex hyperplasia without atypia, hyperplasia with atypia, or endometrial adenocarcinoma. A transvaginal ultrasound is a reasonable alternative to biopsy in the initial workup of postmenopausal bleeding. An endometrial thickness or “stripe” on ultrasound that is 4 mm or less has a greater than 99% negative predictive value for endometrial cancer. An endometrial stripe greater than 4mm requires follow-up with endometrial biopsy. Even with a normal initial ultrasound evaluation, patients with ongoing bleeding should undergo further testing such as hysteroscopy and dilation and curettage.
Endometrial cancer is the most common gynecologic cancer in the United States and 90% of postmenopausal women with endometrial cancer present with vaginal bleeding. Higher lifetime estrogen exposure is a major risk factor for endometrial cancer, hence those with early menarche or late menopause are at increased risk. Obesity is another major risk factor due to estrogen synthesis in adipose tissue via aromatization of androgens. A patient with abnormal uterine bleeding with any of the risk factors listed in the table below should be evaluated for endometrial malignancy.
What are the risk factors for endometrial cancer?
Postmenopausal state Advancing age Obesity Post-menopausal estrogen use Early menarche Late menopause Nulliparity Polycystic ovarian syndrome History of breast or ovarian cancer Family history of gynecologic malignancy
What are the S/S of BV?
This patient is presenting with abnormal vaginal discharge described as gray/white discharge, a positive "whiff" test, and a vaginal pH of >4.5 which are all consistent with a diagnosis of bacterial vaginosis. Bacterial vaginosis (BV) represents a change in the normal bacterial flora of the vagina. The definition of BV includes a rise in vaginal pH over 4.5, bacteria that produce certain chemicals that can be detected by smell, and a shift in the normal flora. Risk factors for BV include, but are not limited to, a history of sexually transmitted infections, smoking, sexual activity, and possibly genetic and dietary factors. About one-half of women with BV are asymptomatic. Symptomatic women may have vaginal discharge with the characteristic "fishy" odor. BV, unless in the presence of other bacterial pathogens, does not typically cause pain or burning.
The diagnosis of BV is made using the Amsel criteria, of which 3 must be present:
Gray/white discharge that coats vaginal walls
Vaginal pH >4.5
Positive “whiff” test (a fishy odor when potassium hydroxide is added to a sample of vaginal discharge)
Presence of clue cells on wet mount; clue cells are epithelium obtained from a vaginal sample that are surrounded by coccobacili; this is considered the single most reliable predictor of BV.
What is protective against developing ovarian cancer?
Oral contraceptive pills (OCPs) have been shown to decrease the risk of epithelial ovarian cancer, with longer duration of use leading to a greater risk reduction. Studies have shown a decreased risk of 20% for every 5 years of use and up to a 50% reduction with 10 or more years of use. Some studies have suggested OCPs be used as a chemoprophylaxis in patients with BRCA gene mutations. The reason for the risk reduction is thought to be secondary to ovulatory suppression induced by OCPs. The more ovulatory cycles a woman has in her reproductive life span (each cycle leading to some ovarian damage and repair), the greater the risk of genetic mutations leading to epithelial ovarian cancer. Studies also suggest a 50% decrease in risk of endometrial cancer among OCP users versus nonusers. The risk reduction in endometrial carcinoma results from a protective effect of progestin on the endometrial lining.
Other measures that have been shown to reduce the risk of epithelial ovarian cancer include a risk-reducing bilateral salpingo-oophorectomy and opportunistic salpingectomy in patients with the highest risk.
Medical interventions that are protective against endometrial cancer?
progestin-containing contraceptives
In cases of sexual assault which area of the vagina is most likely to be damaged?
The posterior fourchette is comprised of soft tissue and inherently weak, allowing it to be easily injured by blunt trauma. This finding is not specific to sexual assault and can also be seen in consensual intercourse. However, it is more likely to occur when penetration is forced as in the case of sexual assault. Studies have shown that genital areas most commonly injured during rape include: posterior forchette (70%), labia minora (53%), hymen (29%) and fossa navicularis (25%).
Approximately 1 in 5 women in the United States report that they have been a victim of attempted or completed sexual assault in the past, with 80% of them reporting the first event prior to age 25.
If an IUD strings are not visualized what are the next steps?
If strings are not visualized on exam, then the first step should be to inform the patient of the missing IUD strings and then to use a cytobrush to attempt to sweep the strings out of the canal. This technique is often successful and should be done regardless of pregnancy status or intention to keep or remove the IUD. If it is not successful, then a pregnancy test should be performed, followed by ultrasound confirmation of the IUD location
Tamoxifen use association with endometrial cancer?
When a patient presents with postmenopausal uterine bleeding, endometrial carcinoma is the primary diagnosis of exclusion. Tamoxifen use is a known risk factor for the development of endometrial cancer. Tamoxifen is a selective estrogen receptor modulator (SERM) that behaves as either an estrogen receptor antagonist or agonist depending on the target tissue. In the breast, tamoxifen acts as an estrogen receptor antagonist by competing with estradiol. In the uterus, however, tamoxifen is known to have an estrogenic effect (agonist). Tamoxifen binds to the estrogen receptor GPR30 and stimulates cell proliferation in the endometrial tissue. Other endogenous sources of unopposed estrogen include chronic anovulation (as seen in polycystic ovary syndrome), obesity, estrogen-secreting tumors, and early menarche/late menopause.
There are numerous causes for postmenopausal vaginal bleeding that should be evaluated, including lower genital tract bleeding, vaginal atrophy, polyps, and alternative organ bleeding that mimics vaginal bleeding (urethral, rectal, etc.). Of the patients who present with postmenopausal bleeding, only 5 to 10 percent are found to have endometrial carcinoma. The prevalence of postmenopausal bleeding in those with endometrial cancer is 91%. The initial workup of postmenopausal bleeding includes an endometrial biopsy and/or transvaginal ultrasound. The most definitive diagnostic method is dilation and curettage (D&C), with or without hysteroscopy, once a uterine source is confirmed. The primary risk factor for endometrial carcinoma is long-term exposure to unopposed estrogen. Exogenous sources of unopposed estrogen include single-agent estrogen for hormone replacement therapy (without a progestin) and tamoxifen.
Atypical Squamous cells of undetermined significance next best step in screening?
This patient’s Pap smear result was atypical squamous cells of undetermined significance (ASCUS). This means that the cells are not normal, but the significance of the atypia has not be determined. According to the American Society for Colposcopy and Cervical Pathology guidelines, there are 2 options after ASCUS results: a repeat Pap smear in 1 year or human papillomavirus (HPV) testing. In the 25- to 29-year-old age group, the preferred option is HPV testing. If the HPV test is positive, then the patient should undergo colposcopy. If the HPV is negative, then the patient should have repeat cotesting with cervical cytology and HPV testing in 3 years. If the option was chosen to repeat the Pap in 1 year and the repeat Pap is normal, then the patient can resume normal testing. If the repeat Pap is abnormal (ASCUS or any other worse pathology), then the patient should undergo colposcopy.
If the patient was in the 21- to 24-year-old age group, then the guidelines give the same 2 options of repeat testing in 1 year or HPV testing. However, in this age group, the repeat testing in 1 year is the preferred method.
After age 30, routine screening involves cotesting (Pap and HPV test every 5 years) or Pap alone every 3 years. The same guidelines apply as for the 25- to 29-year-old age group for ASCUS pathology.
Common cause of HTN in young females?
Oral contraceptive pills (OCPs) are a well-known cause of hypertension in young females. Elevations in blood pressure attributed to OCPs are often mild and asymptomatic. The relative risk associated with patients currently using OCPs after stratification for age, weight, smoking, and family history is 1.8. This patient’s mild elevation in blood pressure is noted as stage 1 per the 2017 American College of Cardiology and American Heart Association guidelines. Her history of normal vitals with good surveillance through her pediatrician and now primary care provider with subsequent elevation as measured in the office and confirmed with ambulatory monitoring gives a clear temporal relationship with the recent addition of her combination OCP. This is an example of secondary hypertension. Secondary hypertension is defined as elevations of blood pressure attributed to an identifiable underlying cause. Although secondary causes of hypertension are uncommon, testing may be warranted if there is an unusual presentation (in this case, a very young patient), if the hypertension is drug resistent, or if there are objective clues including an audible bruit (suggestive of renovascular hypertension) or hypokalemia (suggestive of primary hyperaldosteronism).
Other infrequent complications of combination OCPs include hepatic adenomas and thrombosis. Hepatic adenomas were largely unheard of prior to the advent of hormonal contraception, and the incidence among women not taking OCPs has been reported to be around 1 per 1 million. Among those taking OCPs, the incidence has been reported to be up to 40 per 1 million women. The risk for venous thrombosis has been noted to be up to 4-fold higher among women taking OCPs than those not taking OCPs. However, the absolute risk is lower than that of pregnant and postpartum women, and with the reduction of steroid content of new OCPs, the risk of venous thrombosis from OCPs is thought to be much lower than it once was.
Although oral contraceptive-induced hypertension is not common, its recognition is important, as hypertensive oral contraceptive users appear to be at increased risk of myocardial infarction and stroke relative to nonusers. OCP use should be discontinued in these patients and an alternative form of contraception should be discussed. Contraception that does not involve the use of estrogen would likely be of the most benefit and the least risk in these cases, such as an IUD or progesterone-only contraceptive. The patient should also have her blood pressure rechecked when off of her contraceptive as she may actually have developed some other secondary hypertension. If her blood pressure remains elevated, then a more complete workup for the cause will need to be performed. If an alternative cause is found, oral contraceptives can be safely resumed.
What is BV? Symptoms? Pathophysiology? Treatment?
The patient is demonstrating signs and symptoms of bacterial vaginosis (BV) including a gray-white, thin, vaginal discharge not caused by normal sexually transmitted infections. BV is the leading cause of vaginal discharge in women of childbearing age. BV is not a true infectious or inflammatory state, but instead represents a change in the vaginal microbiome away from the predominate Lactobacillus species and toward an overgrowth of facultative anaerobic organisms, most notably Gardnerella vaginalis.
In the normal state of the vaginal microbiome, lactobacilli produce hydrogen peroxide, which is important in maintaining an acidic vaginal environment and preventing the overgrowth of anaerobes. When lactobacilli are decreased, the pH rises, allowing for a massive overgrowth of anaerobic bacteria that break down vaginal peptides into amines, causing a malodorous smell and increased squamous cell exfoliation. This process gives rise to the clinical features seen in patients with BV (copious amounts of malodorous-smelling, homogenous discharge).
While not considered a sexually transmitted infection, BV does not usually occur in women who have not had sexual contact of any kind. Multiple partners (male or female) tends the increase the risk while use of condoms tends to decrease the risk. BV is highly prevalent in women who have sex with women. Additionally, the presence of other sexually transmitted infections seems to increase the risk for BV. Higher rates of BV are reported in minority populations, but the cause for this is uncertain. Douching and cigarette smoking are additional risk factors.
Mutinous ovarian tumors typically have what presentation? What markers?
Mucinous epithelial carcinoma is the most likely tumor to present with small bowel obstruction (SBO) given its typical large growth in the pelvis. The histology, tumor markers, and age of the patient are also consistent with a mucinous neoplasm. Most mucinous epithelial tumors will show glandular architecture, with invasion being key to the diagnosis of carcinoma. Mucinous epithelial tumors often express the gastrointestinal markers CK7, CK20, and CDX2. However, cellular markers alone are insufficient to determine if this is a primary ovarian neoplasm or gastrointestinal metastasis.
Mucinous ovarian tumors can become very large and rupture, leading to the release of mucinous material into the peritoneal space. Fortunately, the tumor in this patient has not ruptured yet as this would have upstaged her cancer diagnosis and worsened her prognosis. The management of SBO varies based on the etiology of the obstruction. Most obstructions that are secondary to adhesions resolve with conservative management, including nasogastric decompression. This patient’s bowel obstruction is secondary to an ovarian malignancy, which requires removal of the mass to resolve the obstruction. Below is a table that presents the most common gynecological masses and associated common features.
A Serous epithelial carcinoma will present with?
Type of Mass Common Features
Serous epithelial carcinoma - Symptoms may consist of bloating, early satiety, urinary urgency, and abdominal/pelvic pain
- Rarely may lead to SBO
