6 ⼀PREGNANCY II Flashcards
(270 cards)
1
Q
PreEclampsia = [Gestational HTN + Proteinuria]
What are the primary components for the Mechanisms of Disease in Preeclampsia? - 4
A
Ab complex mediated endovascular damage –>
- Hemolytic Anemia
- Platelet aggregation from ⬆︎Thromboxane
- Vascular constriction pervasively from ⬆︎Thromboxane
2
Q
PreEclampsia = [Gestational HTN + Proteinuria]
Describe timeline for Postpartum preeclampsia
A
PreE presents anytime between
[20WGunless 2/2 Hydatidiform Mole → PreE can present <20WG - up to 12 weeks postpartum]
_________________
PreEclampsia –> SEVERE PreEclampsia –> HELLP and at anytime, Eclampsia is possible
3
Q
Nipple discharge is pathologic if it is 1 of what 3 things?
________________
How do you workup breast nipple discharge?
A
spontaneous | uL | persistent
4
Q
The most common cause of pathologic breast nipple discharge is ⬜
A
[Intraductal papilloma (from lining of the breast duct ) ]
Papillomas are usually benign but may have associated carcinoma(atypical|DCIS|Invasive) within the lesion
5
Q
Which contraception should be given to a patient with PCOS?
_________________
why? -2
A
[Progesin IUD]
_________________
androgen excess in PCOS➜ unopposed estrogen ➜ anovulation, polycystic ovaries, irregular menses, endometrial hyperplasia/CA
Progesterone Protects the Endometrium
6
Q
What is 1st line tx for Dysmenorrhea in sexually active pts?
________________
What about non-sexually active pts?
A
Combined OCPs
_________________
NSAIDs
Combined OCPs treat dysmenorrhea by ⬇︎endometrial proliferation ➜ atrophy which –> ⬇︎prostaglandin release –> ⬇︎painful uterine contractions
7
Q
Diagnostic criteria for Primary Dysmenorrhea
_________________
etx
A
ITSO nml pelvic exampelvic cramping during first few days of menstruation
_________________
prostaglandin release from endometrial sloughing during menses
8
Q
PreEclampsia –> SEVERE PreEclampsia –> HELLP and at anytime, Eclampsia is possible
_________________
what is the treatment for HELLP? (3)
A
(g): B
(p): BM
(s|h|e): BMX
🧭B=[BP control: (when ≥ 140/90) = Labetalol | Hydralazine]
🧭M=[IVMG SULFATE (SEIZURE PX)]
🧭X=[X“baby out now!” = STAT IMMEDIATE DELIVERY]
9
Q
What is a Hydatidiform Mole? -3
_________________
How is HM related to CA?
A
★ abnormal fertilization of [empty ovum (complete mole)] by either 2 sperm or [1 sperm whose genome ultimately duplicates]
Or
★ abnormal fertilization of [normal “occupied” ovum by 2 sperm ( ➜ partial mole)]
★ Moles ➜ [hypertrophic and hydropic trophoblastic villi] that secretes βhCG > 100,000
_________________
❎HM can develop into [Gestational Trophoblastic Neoplasia]
_________________
tx = [D&C + contraception] ➜ [serial βhCG until undetectable x 6 mo]
10
Q
Hydatidiform Mole is a precursor to ⬜
How do you manage Hydatidiform Mole ? (5)
A
[Gestational Trophoblastic Neoplasia]
_________________
11
Q
Tx for Trichomoniasis is ⬜(2) . What are the precautions if female patient is breastfeeding?
A
{[2 gm metronidazole PO x 1] + [also treat sexual partner]}
_________________
after taking, breast milk should be expressed and discarded x 24h
12
Q
Give brief descriptions that differentiate Postpartum
Blues vs Depression vs Psychosis
A
- Blues = onsets PPD1, peaking at PPD5 and subsiding PPD14, worst w/lactation
- Depression = onset between [1 month - 12 months after birth] Traditional s/s. Previous Depression hx is RF
- Psychosis = RARE but onsets IMMEDIATELY after birth
13
Q
Explain how Breastfeeding is associated with iron deficiency
_________________
thalassemia< [MIX 13]< IDA
A
Breastfeeding only provides sufficient iron for first 6 months of life.
[infants ≥6 months] MUST be introducted [iron-rich solid foods (pureed meats/cereals)] to prevent iron deficiency anemia
_________________
(thalassemia < [Mentzer Index 13 (MCV/RBC)]< IRON DEFICIENCY ANEMIA)
14
Q
There are 3 types of female Urinary Incontinence
Describe [Stress Urinary Incontinence]
A
urinary leakage with INC INTRAABDOMINAL STRESS (coughing / sneezing / laughing / lifting)
15
Q
There are 3 types of female Urinary Incontinence
Describe [Urge Urinary Incontinence⼀Overactive Bladder]
A
URGE to urinate Suddenly / Overwhelmingly / Frequently
16
Q
There are 3 types of female Urinary Incontinence
Describe [Overflow Urinary Incontinence]
A
constant OVERFLOWING DRIBBLE OF URINE and bladder distension 2/2 incomplete bladder emptying
(either from mechanical outlet obstruction or DM Detrusor hypOactivity)
17
Q
There are 3 types of female Urinary Incontinence
dx for [Overflow Urinary Incontienence] -2
________________
tx for [Overflow Urinary Incontinence] -2
A
[⇪ post void residual] > 150 cc + neuropathy
________________
[intermittent self catherterization] + [correct underlying etx for incomplete bladder emptying]
18
Q
If Pap Smear testing reveals [High Grade Squamous intraepithelial lesion], what is the next step in management? -2
A
COLPOSCOPY = cervix magnified to identify and BIOPSY abnormal areas
________or________
LEEP (loop electrosurgical excision procedure) = excision of cervical transformation zone and surrounding endocervix - [only if done with childbearing]
19
Q
Trimester WG: [≤13|14-27 | ≥28]
Major causes of [1st trimester ≤14WG] bleeding - 3
A
- Spontaneous Abortion (inevitable vs threatened)
- Acute cervicitis (postcoital bleeding, Friable cervix with discharge)
- Molar Pregnancy
20
Q
Differentiate the following spontaneous abortions:
Inevitable abortion
Threatened abortion
Missed abortion
Complete abortion
spontaneous abortion = occurs < 20 WG
A
- INEVITABLE = vaginal bleeding < 20WG with cervical os dilated –>abortion will inevitably happen soon
* * * - THREATENED = vaginal bleeding < 20WG with cervical os closed is clearly a threat to a STILL LIVING FETUS
* * * - MISSED = retained Fetal death <20WG with cervical os closed…which is why we Missed it - (pt will have pregnancy sx that just suddenly disappear out of nowhere)
* * * - COMPLETE = EXPELED FETAL DEATH <20WG WITH ALL PRODUCTS OF CONCEPTION COMPLETELY EXPELED AND THEN CERVIX CLOSES BACK UP
* spontaneous = occurs < 20 WG*
21
Q
What are the 3 criteria options for diagnosing
Cervical insufficiency
A
[pp: ≥2 nonpainful {2nd trimester 14-27WG} spontaneous abortions]
OR
[Cp: Ultrasound showing short cervix ≤25 mm]
OR
[Cp: (early < 24WG ) nonpainful cervical Dilation]
_________________
pp = previous pregnancy
Cp = Current pregnancy
22
Q
[⬜ placement] ⬇︎ risk of [2T14-27WG] loss in pregnant patients with cervical insufficiency.
What is it called when [pregnancy with cervical insufficiency] fails and prolapses?
and what’s the prognosis for this?
A
Cerclage;
[Previable Prolapsing amniotic membrane];
POOR PROGNOSIS (PPAM a/w imminent delivery/high risk preterm)
23
Q
Lactational mastitis occurs ⬜(when?)
as a result of ⬜(etx -6)
A
[first 3 mo postpartum] ;
[breastfeeding difficulties(improved with lactation consultant)]➜[prolonged breast engorgement(diffuse BL TTP)]
➜ [inadequate milk drainage] ➜[clogged milk ducts & nipple pore]
➜ [Staph A Bacteria(from infant nasopharynx vs Mom skin) retrograde enter nipple pore & divide in stagnant milk]➜ Lactational mastitis
* * *
(**q**[Lies])
24
Q
Lactational mastitis occurs ⬜(when?)
and presents with what 4 symptoms?
A
[first 3 mo postpartum] ;
(**q**[Lies])
quadrant[LAD& fever/ induration / erythema / swelling & Pain]
25
Lactational mastitis
tx -4
[(**DicloxacillinPO**) or (CephalexinPO)]
+
[**KEEP BREASTFEEDING **(frequent milk drainage)]
+
**ibuprofen**
— — — — —
*+ [Needle Aspiration if ⊕abscess]*
26
Breast engorgement presents as ⬜
Tx? (3)
diffuse BL breast TTP
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
BREAST PUMPING / NSAID / Cold Compress
27
Is it safe to direct breastfeed if Lactational mastitis is present?
YES!
(*Interrupting breastfeeding can ➜ ⬇︎maternal milk production*)
28
[(*CAGS*) Condyloma Acuminata Genital Skinwarts] is caused by ⬜2.
Since the _[typical_ *_CAGS_* _tx (⬜)] is contraindicated in pregnancy,_ how is delivery managed in pregnant patients with active *CAGS*? -2
[HPV 6] & [HPV 11] ;
[PodophyllumTOPICAL]
* * *
[Vaginal delivery(*or CSection*)*]
&
{**NO** [PodophyllumTOP]}
* * *
(Unfortunately, not even CSection prevents HPV vertical transmission so (*unless large/obstructive\**) Pregnant Women with [Condyloma Acuminata Genital Skinwarts] should proceed with vaginal delivery *but WITH **NO Podophyllum Topical tx***
29
*1 of the 3 Recommended [USPSTF Guidelines for Breast Cancer Screening] is to give [Genetic test/counsel to pts with [**⊕High Risk Familyhx (breast CA)***]*
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
io\Breast CA , name 4 criteria that qualify a patient as [⊕**High Risk** Family hx]
* [**⊕High Risk Familyhx (breast CA)***] =*
* [ GOE****3******___**(1stº**or **2ndº ⼀breast)]*
* * *
* or*
* [ ****2******__**(1stº⼀breast) (1_under50yo)+ (1_anyAge)]*
* * *
* or*
* [****1******__**(1stº⼀_BILATERAL_ BREAST)]*
* * *
* or*
* [ ****1******__**(1stº**or **2ndº ⼀\< breast AND ovarian \>)]*
30
What are the 3 Recommended [*USPSTF* Guidelines for Breast Cancer Screening]? (3)
1. ⊕[(50-74yof) → mammogram q 2y](<*50 yo depends on individual*)
2. ⊕[(HRFHx)\* → Genetic test/counsel(*only if ⊕HRFHx!*)]
3. **❗️ ❗️****NO****SELF BREAST EXAMS! ❗️ ❗️ **
* * *
* \*HRFHx = [HIGH RISK(CA)⼀Family history]*
31
Postpartum endometritis cp -4
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
tx (2)
## Footnote
*RF: **CESAREAN** / GBS+ / prolonged ROM / protracted labor / operative vaginal delivery*
postpartum: [**uterine fundal tenderness**] , vaginal discharge, vaginal bleeding, fever
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Clindamycin + gentamicin
## Footnote
*polymicrobial infection*
32
In pregnancy, c/f appendicitis can be ruled out using ⬜ and presents atypically with ⬜
graded compression abd ultrasound ; [R abd pain **with NO peritoneal signs or McBurney TTP**]
33
Pt's Pap Smear reveals [Atypical Squamous Cells of Undetermined Significance]
Mngmt? - 5
* Pap smear revealing [ASCUS-(Atypical Squamous Cells of Undetermined Significance)].. →*
1st: HPV typing
* --if high risk HPV(16 or 18)---\>*
2nd: Colposcopy
* --if Colposcopy abnml --\>*
3rd: Cervical biopsy
34
There are several causes of abnormal uterine bleeding. give differentiating factors for each:
Pelvic organ Prolapse
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Cervical CA
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
endocervical polyp
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
endometritits
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
leiomyoma
eroded and bulging mass at introitus +/- incontinence, constipation, dyspareunia
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
exophytic cervical lesion
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
smooth vermiform appearance visibily protruding thru cervical os
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
uterine and cervical motion tenederness
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
enlaged **irregularly** shaped uterus
35
Urethral diverticula etx
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
s/s (3)
repeated infection and urethral trauma (vaginal delivery) ➜ distension of diverticulum with purulent fluid
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
1. ANT vaginal wall mass
2. postvoid dribbling
3. dysuria
* diagnosis confirmed with pelvic MRI or TVUS*
36
What are the 2 *medical* managements for elective spontaneous abortion
1. [miso**PROST**ol (***PROST**aglandin analogue*) 800 mcg vaginally]expels ≤2W
* * *
2. [MiFepristone antiprogestin]
37
What's the time limit for pregnant women in [Latent labor Stage 1A] if they're nulliparous?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
What about if they're multiparous?
*Labor = (LA)PD*
**1A: L**atent labor phase = Strong Contractions q3-5 min **(should be \<20 hrs for nulliparous pts and \<14 hrs for multiparous pts)**
**1B:** **A**CTIVE labor phase = Cervix is now 6 cm Dilated, [growing @ 0.5cm / hr] and effacing
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
**2** : **P**ushing Time! since Cervix is now 10cm FULLY DILATED **(should be ≤3 hrs for nulliparous and ≤2 hrs for multiparous)**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
**3 : D**elivery of Baby! and then Deliver Placenta
38
What's the time limit for pregnant women to deliver the Placenta?
*Labor = (LA)PD*
## Footnote
**3 : D**elivery of Baby! and then Deliver Placenta **(\<30 min)**
39
What is the first manifestation of pubety for females?
**BREAST** --(2.5 years later)--\> Menarche by 15 yo
40
What is the workup for Primary Amenorrhea ?-3
-**{girls of nml growth with: [no menses by 13 yo] or [no menses by 15 yo with breast]}**
## Footnote
41
What's the time limit for pregnant women in [stage**3**:"***p**USH*!"labor] if they're
Multiparous?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
What about if they're Nulliparous?
[MULTIPAROUS *≤*2h (*add 1 hour if +epidural)*]
* * *
[nulliparous *≤*3h (*add 1 hour if +epidural)*]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
* Labor = (LA)**p**d*
* 3 : PUSH! baby out ! since Cervix is now 10 cm FULLY DILATED ([MULTIparous≤2 hrs] and [nulliparous≤3 hrs] (add 1 hr if +epidural))*
42
What are the stages of Labor?
*Labor = (LA)pd*
[stage**1****: L**atentLABOR(Mn1420)]
= Strong Contractions q3-5 min ([MULTIparous≤14h] | [nulliparous≤20h])
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[stage**2****:****A**CTIVELABOR]
= Cervix 6 cm Dilated, [growing @ 0.5-(1-2) cm/hr] and effacing
* * *
[stage**3**:"***p**USH!*"labor(Mn23)]!
= pUSH out Baby since Cervix is now [**10** cm FULLY DILATED] ([MULTIparous≤2h] | [nulliparous≤3h])+epidural= add 1h
* * *
[stage**4****:**"***d**ELIVER*"labor({p0.5})]
delivery baby➜ [placenta **≤0.5h**]
* * *
https: //www.youtube.com/watch?annotation\_id=annotation\_563008&feature=iv&src\_vid=Xath6kOf0NE&v=ZDP\_ewMDxCo
43
What are the 4 clinical features for diagnosing [stage**1B****:****A**CTIVELABOR]?
* Labor = L**A**pd*
1. [stage**1****: L**atentLABOR(Mn1420)] = *[**Strong**Contractions**q 3-5 min**]*
* * *
PLUS:
2. [Cervix Dilation ≥ 6 cm]
3. [Cervix growing at 0.5-(1-2)cm/hr] {grows 1-2 cm/hr normally -- with No less than 0.5 cm/hr }
4. [Cervix effaced]
* Fetal Heart Tracing is IRRELEVANT in diagnosing [s1B *Active LABOR]*
44
For pregnant women in [stage**2ACTIVE LABOR**], when is the patient considered to be in [labor *protraction*]?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
How do you treat this? (2)
*Labor = (LA)pd*
*NORMAL s2AL: Cervix is now 6 cm Dilated, [growing @ [GOE 0.5 cm/hr and effacing]*
* * *
[_s2AL_**PROTRACTION**] = cervical dilation[LOE 0.5 cm/hr]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*[s2AL PROTRACTION] Tx* :
Oxytocin + Amniotomy
*(since most common cause of [stage 2ACTIVE LABOR *PROTRACTION*] = contraction inadequacy)*
45
Criteria for Recurrent Pregnancy Loss
[**≥3** consecutive *< 20WG* spontaneous abortions]
46
How are migraines associated with Pregnancy?
Migraines commonly start [**2T**14-27WG] of Pregnancy
*But also be suspicious of [Pseudotumor Cerebrii]*
47
How does Obesity commonly cause amenorrhea?
Obesity --\> anovulation **without affecting LH/FSH levels** which--\> Amenorrhea
48
What is Mittelschmerz?
**Mittel**schmerz = "**Middle** of the cycle" uL pelvic pain that occurs when blood released from rupture of follicle during ovulation irritates peritoneum
## Footnote
*order: LH surge --\> 36 hrs will pass --\> Ovulation*
49
How does [Pregnancy Induced Pruritus] present?- 2
1. [Benign **FOCAL** Abdominal PiP(Pregnancy Induced Pruritus)
2. WITH **NO RASH**
* * *
| {*PiP and iCP have **NO RASH*** vs [Pemphigoid Gestationis ⊕abd rash]}
## Footnote
*[Intrahepatic Cholestasis of Pregnancy] = A/W IUFD, GZD PRURITUS INCLUDING PALMS/SOLES, BUT STILL ALSO NO RASH*
50
[Pregnancy Induced Pruritus] Tx- 3
1. Oatmeal baths
2. UV light
3. Antihistamines
| {*PiP and iCP have **NO RASH*** vs [Pemphigoid Gestationis ⊕abd rash]}
51
Pemphigoid Gestationis occurs during the __ or __ trimester
CP- 3?
[2T14-27WG] OR [3T28-42WG]
## Footnote
[prodromal Pruritus]
→ [Periumbilical papules + plaques](both sparing mucus membranes)
→ [Bullae Eruption]
52
Pemphigoid Gestationis occurs during the __ or __ trimester
Dx?- 2
Tx?- 3
2nd OR 3rd
Clinical , Biopsy
Tx = [topical CTS], Antihistamines, Delivery
53
Guidelines for PAP Smear Cervical CA Screening - 3
[PAP Cervical Screening starts at 21 yo]
1. [Age 21 - 65 PAP every 3 years (cytology only)] ≥ 3x consecutively before stopping after 65
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
OR
2. [Age 30-65 can PAP every 5 years if they add HPV testing] ≥ 2x consecutively before stopping after 65
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
BUT
3. Risk Groups (immunocompro/CIN2, 3 or CA hx) need more frequent PAP screening = voids out #1 and 2 if present
54
What are the main side effects of [LevoNorgestrelprogestin IUD]- 2
1. **Breast tenderness**
2. HA
55
When does [Fetal Postmaturity Syndrome] occur?
GOE42WG
56
[fetal Postmaturity syndrome]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
s\s -4
* occurs GOE 42WG*
1. long fingernails
2. meconium-stained placenta
3. [wrinkled peeling skin]
4. small for gestational age
57
[Transient Tachypnea of Newborn]
cp -4
*[Retained Fetal Lung Fluid (from Cesarean/prematurity/Maternal DM)]➜*
1. [prominent Interlobar fissure fluid]
2. [Tachypnea (retractions/nasal flaring) **with clear breath sounds**]
3. lung hyperinflation
4. cardiomegaly
58
Cause of [Transient Tachypnea of Newborn] (3)
**[CESAREAN/PREMATURITY/MATERNAL DM]** ➜ [Retained Fetal Lung Fluid]
59
Tx for [transient tachypnea of newborn]
SPONTANEOUSLY RESOLVES IN 1-3d
60
risk factors for [transient tachypnea of newborn] -3
1. Cesarean
2. Maternal DM
3. Prematurity
*caused by Retained fetal lung fluid*
61
*Clinical criteria for diagnosing PMS (PreMenstrualSyndrome) relies on PMS sx*
What is the mngmt for PMS? - 5
PMS sx: [**PMS BEGIN**] --*(1 week)*→[**MENSES**] --*(*
[begin 1 week before menses]*LUTEAL*
and
[resolves during the 1 week after menses]*FOLLICULAR*
## Footnote
1st: **Sx Diary** reveal PMS sx timing occured over ≥ 2 menstrual cycles
2nd: Order **TSH** to r/o hypOthyroidism as cause
3rd: **Exercise w/NSAIDs**
4th: **SSRI**
5th: **Combined OCP** if SSRI don't work and there's no cxd
62
What are the causes of [Functional Hypothalamic Amenorrhea]?-6
*Functional hypOthalamic amenorrhea ; **these pts have low FSH** and therefore NO postmenopausal sx*
1. Excessive Exercise
2. Starvation*(very low calorie diet)*
3. underweight*(low BMI/Anorexia/Wt loss)*
4. Stress
5. Depression
6. Chronic illness
*note: these pts will NOT have normal menstrual cycles*
63
Explain how [Functional Hypothalamic Amenorrhea] causes amenorrhea
*Stress* → [(⬇︎Leptin) & (⇪**GGBNC**)] →
⬇︎GnRH → ⬇︎FSH/LH → No follicle maturation/menopausal sx/ovulation → ⬇︎Estrogen = Amenorrhea
* * *
* GGBNC = Ghrelin/GABA/BetaEndorphins/NeuropeptideY/CRH*
* Functional hypOthalamic amenorrhea ; **these pts have low FSH** and therefore NO postmenopausal sx*
* note: these pts will NOT have normal menstrual cycles*
64
# Functional Hypothalamic Amenorrhea
What's the most common long term complication for these pts?
Osteoporosis from lack of estrogen
* * *
* note: these pts will NOT have normal menstrual cycles*
***these pts have low FSH** and therefore NO postmenopausal sx*
65
What are the options for Mngmt of Spontaneous Abortion - 4
1. **Expectant**: Watchful Waiting for products of conception to expel naturally in 2-6 weeks
2. **Surgical**: [Dilitation & Curettage (D&C) (cant be done during infection)] or [Manual Vacuum Aspiration]
3. **Medical**: 800mcg Vaginal Misoprostol - takes up to 2 weeks for expel
## Footnote
*ALL REQUIRE 1 WEEK FOLLOW UP*
66
How do you anticoagulate a pregnant patient? -3
[1T < 14WG] = [LMW Enoxaparin]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
## Footnote
[2T14-27WG] = WARFARIN
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[3T28-42WG = WARFARIN
67
*Clinical criteria for diagnosing PMS (PreMenstrualSyndrome) relies on PMS sx*
What is the Clinical Criteria for PMS?
PMS sx begin 1 week before menses (luteal phase) and resolves during week after menses (follicular phase) for ≥ 2 menstrual cycles
* * *
(**IF BBC HH**)sx
68
*Clinical criteria for diagnosing PMS (PreMenstrualSyndrome) relies on PMS sx*
Name the 7 main PMS sx
**IF BBC HH**
## Footnote
- **I**RRITABILITY/MOOD SWINGS
- **F**atigue
- **B**loating
- **B**reast TTP
- **C**oncentration ⬇︎
- **H**ot Flashes
- **H**A
69
*[Polyhydramnios ( AFI ≥24 cm)] is a risk factor for Placenta Abruptio*
What are the risk factors for Polyhydramnios? - 2
1. Maternal DM - poorly controlled
2. [*swallowing*_fetal anomalies (esophageal atresia)]
70
Amniotic Fluid Index for Polyhydramnios
≥ 24cm
## Footnote
RF = Maternal DM, congenital swallowing malformation
Polyhydramnios can --\> placenta Abruptio
71
patients who are high risk for preeclampsia should receive what prophylaxis?
[12 WG ASA low dose]
72
risk factors for preeclampsia -4
1. prior severe preeclampsia
2. chronic HTN
3. DM
4. CKD
* px = [12 WG ASA low dose]*
73
*For Antepartum patients, their NST (Non Stress Test) should be **reactive***
What is the Fetal Heart Tracing criteria for this?-4
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Does this happen in pts in labor?
*reactive = appropriate [fetal cerebral oxygenation]*
1. within a **20 min period** there are
2. at least **two HR accelerations** that are
3. **15 bpm over baseline**
4. **1.5 small boxes** **long** (15 sec)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
THIS IS NOT REQUIRED FOR PTS IN LABOR
74
*Criteria for PreEclampsia is **Gestational HTN** + [**Proteinuria or End Organ Damage]***
What are the clinical requisite for ***Gestational HTN*** dx? -6
1. NO previous HTN
2. ≥ 20 WG
3. **Systolic \> 140**
4. **Diastolic \> 90**
5. At least 2 readings taken \> 6 hrs apart
6. BP taken in seated or semi-reclined position
| *requires all 6 for Gestational HTN dx*
## Footnote
*FYI: PreEclampsia can still occur superimposed on Chronic HTN*
75
# *PreEclampsia dx = [**Gestational HTN** + **Proteinuria]***
How do you clinically diagnose Proteinuria for pregnant women - 4
1.[≥300 mg protein on 24 hr urine]
OR
2.[≥ 30 mg/dL on dipstick]
OR
3.[At least 1+ on dipstick]
**OR**
4.⭐[ **Protein:Creatinine ratio \> 0.3** ]⭐
| *Must occur [(≥2x) ( each ≥6H apart)]*
76
Full term infant = 37- 42WG
How do you manage Preterm Labor 34 to 36+6 WG - 3
"***P**regnant **B**itches*"
+
(DELIVER NOW)
77
# 1
Full term infant = 37 -42WG
How do you manage Preterm Labor 32 to 33+6 WG - 4
***P****regnant **B**itches **T**ake*
+
## Footnote
(*deliver at 34WG*)
78
Gestational sacs normally implant in the \_\_\_\_\_
Describe a Cornual Interstitial ectopic pregnancy
upper uterine fundus ;
implantation in outer "cornual" areas of uterus
*dx = trans**Vaginal** US // tx = MTX or surgery if severe*
79
Name the major risk factors for Ectopic Pregnancy - 6
1. previous ectopic
2. previous Pelvic
3. previous Tubal surgery
4. PID
5. Bicornuate heart shaped uterus (causes cornual interstitial ectopic pregnancy)
6. In Vitro Fertilization (causes cornual intersitital ectopic pregnancy)
## Footnote
*tx = MTX or surgery if severe*
80
Hyperemesis Gravidarum is a normal part of pregnancy that resolves by **20 WG**
What are the risk factors for getting this? - 3
1. Multiple Gestation
2. GERD hx
3. Hydatidiform Mole (note: elevated βHCG can stimulate thyroid and --\> thyrotoxicosis of hyperemesis!)
## Footnote
*HG is usually unresponsive to PO antiemetics, and can cause Thiamine Deficiency*
81
When is a NST indicated? - 2
1. [**M**ovement from fetus ⬇︎]
OR
2. [HRp 32-34WG]
* * *
HRp: High Risk pregnancy
*the most common cause of NONreactive NST is fetal sleep cycle so be sure to allow at least 40 min testing and use vibroacoustic stimulation to wake them up!*
82
What is the most accurate method of determining gestational age?
**FIRST** trimester US with crown to rump length (since there is minimal variability of fetuses when they first start off)
83
Dx for Ovarian Torsion
**Pelvic US** revealing adnexal mass with absent Doppler flow
84
Ovarian Torsion is more common amongst \_\_\_\_\_[pre/post] menopausal women
**PRE**menopausal
## Footnote
*Untreated ovarian torsion --\> sepsis, chronic pelvic pain and infertility*
85
What is Culdocentesis? ; What is it used for?
centesis of intraperitoneal fluid thru the cul-de-sac via vaginal aspiration ; No longer used and has been replaced by US for identifying pelvic free fluid
86
How do you diagnose Endometriosis?
**LAPORASCOPY** to biopsy & remove endometriotic lesions
## Footnote
*1st, treat empirically with NSAIDs tho*
87
What is the MOST IMPORTANT intervention for preventing vertical HIV transmission from Mom to baby?
What are 2 other less important methods?
**Triple Antiretroviral therapy** (2 NRTI + [1 NNRTI or 1 PI])
*Also, [c/s if viral load is \> 1000] and [Zidovudine given to neonate for ≥6 wks after birth] are also good but not most important*
88
What is the precaution in a pregnant woman with Graves' disease?
Mom's HYPERactive **Thyroid stimulating Ab** (anti-TSH R Ab) can cross the placenta and stimulate the baby's thyroid gland --\> [*fetal* Thyrotoxicosis]
## Footnote
Baby's tx = methimazole + Beta Blcoker
89
Mode of inheritance for Hemophilia A
X-linked recessive
90
What's the time limit for pregnant women in [stage**1****: L**atentLABOR] if they're
multiparous?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
nulliparous
[stage**1****: L**atentLABOR(Mn1420)]
= Strong Contractions q3-5 min ([MULTIparous≤14h] | [nulliparous≤20h])
91
What's the time limit for pregnant women in [stage**4****:**"***d**ELIVER*"labor] ?
*Labor = LApd*
## Footnote
[stage**4****:**"***d**ELIVER*"labor({p0.5})]
*baby now pushed out* → deliver baby → deliver [placenta **≤0.5h**]
92
Why is there no use in getting a D-dimer in a pregant woman for DVT workup?
D-dimer is already **naturally elevated** in pregnant woman due to their physiological ⬆︎ fibrinogen
93
What is the disadvantage of using Progestin only OCP for contraceptive?
You have to take it every day **DOWN TO THE EXACT HOUR** or it will fail! = compliance issues
94
What's the most common cause of [unilateral breast discharge (serous or bloody])?
Intraductal Papilloma
95
CP of Fat necrosis of Breast - 4
1. s/p previous breast trauma →
2. Mass*FIRM*
3. Mass*iRREGULARLY SHAPED*
4. *Mammogram: Oil cyst +/- calcifications that appear malignant but has fat globules and foamy macrophages on bx*
96
CP for Fibroadenoma - 5
1. **nonpainful mass**
2. firm mass
3. solitary mass
4. mobile
5. ~2 cm
97
Fibrocystic changes of the breast are common in ____(*pre/post*) menopausal women
How does this typically present? - 2
**PRE**menopausal
1. cyclical bilateral breast pain
2. diffuse nodularity
*This [Fibrocystic cyclical BL breast pain] is exacerbated with caffeine!*
98
CP for Inflammatory Breast CA - 7
1. Peau d'orange appearance (superficial dimpling & pitting)
2. Diffuse breast erythema
3. breast edema
4. breast pain
5. nipple changes (retraction, flattening)
6. Axillary LAD
7. +/- nipple discharge
## Footnote
*often confused with infectious process, **but difference is IBC has NO FEVER and DOESN'T RESPOND TO ABX***
99
CP for Lobular breast carcinoma - 3
1. **FIXED** palpable mass
2. Irregular borders
3. +/- Bilateral
100
Paget Disease of the Breast is a form of ____(*type of CA*) that presents how? - 3
Ductal **ADC**
1. **crusty eczematous or ulcerating nipple & areola**
2. +/- bloody nipple discharge
3. +/- nipple retraction
*85% of Paget Disease of Breast is 2/2 underlying DCIS of glandular rissue which migrate thru mammary ducts to nipple surface. Dx = Mammogram and biopsy*
101
How do you discern pharyngitis 2/2 Neisseria Gonorrhea from pharyngitis 2/2 infectious mononucleosis?
N. Gonorrhea = non-exudative pharyngitis, and has PID lower abd pain
vs.
Mono = **exudative** pharyngitis and has fatigue
*otherwise, presentation is similar*
102
Describe Lichen Sclerosis MOD
autoimmune chronic inflammatory condition of anogenital region that affects women **of any age** that --\> vulvar squamous cell carcinoma
THIS DOES NOT AFFECT THE VAGINA!
*dx = vulvar punch biopsy*
103
Sx of Lichen Sclerosis - 5
1. Pruritus SEVERE
2. Dyspareunia
3. White Grayish pale vulva (distinguishes from postmenopausal vaginal atrophitis)
4. Cigarette paper texture of vulva (**thin**, crinkled)
5. loss of vulvar anatomy (introitus, labia minora, clitoral hood)
## Footnote
*dx = vulvar punch biopsy*
104
Risk factors for Endometrial adenocarcinoma -3
1. **EEE** - Excess Estrogen Exposure (HRT, neoplasm, [menstruation *outside* of 12-52], Nulliparity, Anovulation/PCOS)
2. **Tamoxifen**
3. **Obesity** (excess insulin--\> ⬆︎androgen release from ovarian theca --\> excess androgen is converted into estrone --\> EEE)
## Footnote
*Smoking and Progestin OCP ⬇︎Endometrial CA Risk*
105
How does Vaginal CA (SQC or Clear cell ADC) present?-4
Who usually gets Vaginal SQC?
Where does Vaginal SQC occur in the vagina?
1. Malodorous vaginal discharge
2. Vaginal irregularity aesthetically (mass, plaque, ulcer)
3. Postmenopausal bleeding
4. Postcoital bleeding
Vaginal SQC = \> 60 yo
Vaginal SQC = **POSTERIOR** Upper 1/3 of vaginal wall
106
What are the risk factors for Vaginal SQC?
same as **Cervical CA risk factors**
## Footnote
(*cervical CA migrates to vagina*)
107
In Ovarian CA, why is the specificity for CA-125 much higher in older women?
CA-125 can be elevated in younger women who have leiomyomata or endometriosis, so **elevated CA-125 is only associated w/ovarian CA in POSTmenopausal women**
108
For ovarian CA, what can CA-125 be used for? -2
*Postmenopausal women have ⬆︎risk of ovarian CA*
1. Monitors for recurrence after ovarian CA tx
2. used in initial w/u of an ovarian mass to determine if it is malignant or benign
*DO NOT DO NEEDLE ASPIRATION ON OVARIAN MASS PTS SINCE CA STATUS IS UNKNOWN AND MAY BE IATROGENICALLY SPREAD DURING ASPIRATION*
109
Pt comes in with Postmenopausal bleeding
How do you evaluate them? (4)
110
Describe the clinical progression of primary syphilis chancres
**single** papule that turns into shallow, **nonpainful**, **nonexudative ulcer** with indurated edges, accompanied with BL inguinal LAD
THESE ARE EXTREMELY INFECTIOUS!
111
What are the features of [ChancROID?]?-4
* * *
Is it painful?
* * *
What organism causes this?
1. [Deep ulcers with Exudative Grayish yellow Base]
2. **PAINFUL** inguinal coalesced bubo nodes
3. Organisms clump in long strands like a "school of fish"
* * *
**PAINFUL**
* * *
* Haemophilus Ducreyi*
112
What are the features of a Genital Herpes?-3
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Is it painful?
*"sssssSS... Ouch, GenHerpes"*
1. [Several SOUR(painful) Small Shallow Sores(ulcers) ]
2. [Sangra base (Erythematous base)]
3. [Swollen LAD}
## Footnote
**PAINFUL**
113
What are the features of [Lymphogranuloma Venereum?]?-3
* * *
Is it painful?
* * *
What organism causes this?
1. Multiple small shallow ulcers (similar to herpes)
2. Large PAINFUL coalesced inguinal lymph nodes = *Buboes*
3. Intracytoplasmic chlamydial inclusion bodies
* * *
\*\* Initial lesion is NOT painful but Buboes are \*\*
* * *
* Chlamydia Trachomatis*
114
Bechet Syndrome CP-2
Recurrent [Vasculitis-mediated aphthous and genital Ulcers]
115
What are the features of [Donovanosis granuloma inguinale]?-4
* * *
Is it painful?
* * *
What organism causes this?
1. Extensive Granulation-base ulcers
2. NO LAD
3. Deeply staining gram neg (intracytoplasmic cyst = Donovan bodies)
4. Mostly in India
* * *
**▶non**painful
* * *
▶*Klebsiella Granulomatis*
116
What do you do if a pt with clinical s/s of syphilis has a negative RPR?
Empiric **PCN G IM**!
## Footnote
*RPR false negatives are a thing so you should repeat serology in 2 weeks to see if tx reduced titers. Also, Treponemal Pallidum can NOT be cultured so don't do it!*
THESE ARE EXTREMELY INFECTIOUS!
117
What is the DDx for Stress urinary incontinence - 2
*Incontinence with coughing/lifting/sneezing*
{**⭐① vs ②a/b/c → URETHRAL HYPERMOBILITY → SUI⭐**}
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
①{[⬇︎urethral tone] < bladder neck bulking tx > } and
②.[⬇︎pelvic floor muscle]
2a. [from injury|weakening] < kegel exercise tx >
2b. →urethral prolapse < urethral sling tx >
2c. →[Pelvic Organ Prolapse *(bladder/uterus ⼀ a/w vag bulge)*] < pessary tx >
118
What is the DDx for Overflow incontinence - 2
1. DM neuropathy
2. mechanical obstruction
## Footnote
*⬇︎Detrusor activity or mechanical outlet obstruction --\> Overdistended bladder --\> involuntary dribbling and incomplete empyting (⬆︎PVR)*
119
Normal Post Void Residual for Men
\< 50 cc
120
Explain why clinicians no longer should empirically treat both Chlamydia and Gonorrhea if only one is *Positive* and the other is *negative*
Since NAAT (Nucleic Acid Amplification Test) *(as compared to culture)* is much more specific and sensitive = **little chance of NAATfalse negatives** =
empiric tx of both Gonorrhea and Chlamydia (iTSO 1 having ⊕NAAT and 1 having ⊝NAAT) ... is no longer needed = only treat the ⊕NAAT test result
| TLDR: (if using NAAT)→TRUST and TREAT only ⊕ [GC/Chlam NAAT]
## Footnote
*(empiric tx of both was done in the past either because [Culture ➜ INC delay for pending result] or because [Culture --> INC chance of false negative]*
121
Tx for Stress Urinary Incontienence - 4
1. **URETHRAL SLING**
2. **Kegel exercise physical therapy**
3. Vaginal pessary
4. Bladder neck Injectable bulking if etx is related to sphincter deficiency
122
What are bodily signs of ovulation - 3
1. **CLEAR** thick cervical mucus discharge (looks like uncooked egg white) - starts thin and then becomes thick after ovulation
2. ⬆︎temperature
3. Mittelschmerz mid-cycle (day 14) pelvic pain
*order: LH surge --\> 36 hrs will pass --\> Ovulation*
123
How does high androgen levels affect fertility for Women?
high Androgen (such as PCOS) --\> ⬇︎GnRH release from feedback inhibition --\> ⬇︎FSH --\> ⬇︎ovarian maturation --\> 2°follicle atresia --\>
1. Anovulation chronically
2. Amenorrhea
3. Polycystic Ovaries
124
Adenomyosis CP - 3
1. **symmetrically enlarged TENDER uterus (\> 12 weeks in size)**
2. Menorrhagia
3. Dysmenorrhea eventually --\> Chronic Pelvic Pain
## Footnote
*etx: glands invade uterine myometrium --\> blood deposition inside myometrium during cycle --\> dysmenorrhea from irregular contractions and menorrhagia from extra deposited blood*
125
Adenomyosis dx
True dx = pathological exam of tissue after hysterectomy
## Footnote
*etx: glands invade uterine myometrium --\> blood deposition inside myometrium during cycle --\> dysmenorrhea from irregular contractions and menorrhagia from extra deposited blood*
126
What's the most common sign of Endometrial Polyps
**nonpainful** intermenstrual bleeding
127
Most common causes of **Intermenstrual** bleeding - 5
## Footnote
*"I'm seeing some spotting in between my periods"*
1. Endometrial Polyps - nonpainful and light
2. Endometrial ADC/hyperplasia - Older women
3. Adenomyosis
4. Cervicitis(from PID)
5. Cervical CA
128
Leiomyomata uterine Fibroids CP - 5
1. Pelvic pressure --\> urinary incontinence/incomplete voiding/constipation
2. **irregularly enlarged NONTENDER uterus**
3. Menorrhagia (especially with submucosal)
4. Dysmenorrhea (especially with submucosal)
5. Progressively longer menses due to deformity of the uterus from fibroids
## Footnote
*Submucosal and Pedunculated are the worst!*
129
Clinical definition of Primary Amenorhhea
**girls with no menses by age 15** but who have normal growth and secondary sex characteristics
130
Why do pts with Androgen Insensitivity Syndrome have NO ovaries/fallopian tubes/uterus/cervix but DO have breast?
they actually have functioning Testes that secrete **AntiMullerian Hormone** **& Testosterone** and this --\> regression of Mullerian ducts. Breast comes from the aromatization of testosterone into estrogen
## Footnote
Wolffian ducts also degenerate and fetal urogenital sinus does not differentiate into a penis and scrotum --\> default of external female genitalia
131
CP of congenital 5α reductase deficiency
ambiguous genitalia at birth 2/2 undervirilization
## Footnote
*these pts can not convert Testosterone --\> DHT*
132
Difference in CP between Androgen insensitivity syndrome and Mullerian agenesis pts
**AIS pts will have NO pubic or axillary hair** since they don't respond to testosterone (which is what causes axillary/pubic hair in both sexes!)
but
Mullerian agenesis pts have normal testosterone levels so will have pubic and axillary hair
*Both obvi have no mullerian duct organs*
133
What are the common side effects of OCPs - 6
1. HTN
2. Breast Tenderness
3. ⬆︎TriAcylGlycerides
4. Bloating with Nausea
5. **Breakthrough bleeding** = **most common (usually with lower estrogen doses)**
6. Venous thromboembolism (Migraine w/aura is a ctd for Combined OCPs)
## Footnote
*Wt Gain is NOT a side effect of combined OCPs and OCPS actually ⬇︎risk of Endometrial and Ovarian CA*
134
Why is Intrauterine Copper device relatively contraindicated in dysmenorrhea pts
its uterine inflammatory rxn actually --\> ⬆︎pain
135
Why is Medroxyprogesterone depot relatively contraindicated in young pts - 2
1. it causes ⬇︎ of bone mineral density
2. it ⬆︎body fat and ⬇︎lean muscle mass
## Footnote
*in addition to Breast tenderness and bleeding for 1st 6 months*
136
Why can pts with PID sometimes present with RUQ pain?
uterine infxn extends from fallopian tubes (salpingitis) --\> diffuse abd --\> Liver capsule--\> RUQ pain exacerbated with deep inspiration = **Fitz Hugh Curtis perihepatitis**
## Footnote
PID causes salpingitis and cervicitis
137
What's the gold standard method to diagnose Cervical Intraepithelial Neoplasia? ; What's tx for this?
Colposcopy (**even if they're pregnant! - DO IT**) ; Cervical Conization (via cold knife conization or loop electrosurgical excision procedure)
## Footnote
*conization inevitably --\> short cervix and cervical stenosis due to scar tissue*
138
What is Asherman syndrome
**INTRAUTERINE ADHESIONS** (could be from infxn or uterine surgery)
this can cause 2° Amenorrhea (normal ovulation and hormone levels but mechanical amenorrhea)
139
CP for [Bartholin gland Duct] cyst-4
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
What causes this?
1. **4 or 8 o'clock** position - base of labium majora
2. **egg shaped**
3. **CYSTIC mass**
4. nonpainful
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[*Bartholin gland Duct*] obstruction
*can develop into abscess which presents with fluctuance*
140
Describe Gartner duct cyst
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Where do they come from?
single or multiple submucosal cyst on the lateral aspects of the upper ANT vagina
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
incomplete regression of Wolffian duct
141
Tx for
*asymptomatic* Bartholin duct cyst
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*symptomatic* Bartholin duct cyst? -2
**OBSERVATION** if asx since it will spontaneously drain :-)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
If symptoms are present --\> Incision and Drainage f/b word catheter ⬇︎ recurrence
142
What would you expect symptom presentation for this to be?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
What would you expect pelvic US to reveal?
**Mature dermoid cystic teratoma of ovary**
mostly asx but sometimes with long standing lower abd/pelvic pain
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
hyperechoic ovarian cyst with calcifications(from teeth and bone)
143
What are the 4 CA associated with Lynch Syndrome
1. proximal Colorectal
2. Ovarian
3. Endometrial
4. Skin
## Footnote
*Germline mutation in mismatch repair protein*
144
Mngmt for [Epithelial Ovarian Carcinoma (ovarian CA)]- 2 steps
1st: **XLap** to remove pelvic mass, dissect pelvic and paraAortic lymph nodes, inspect entire abd cavity
2nd: **Platinum based Chemotherapy**
* this comes from ovarian, tubal or peritoneal abnormal proliferation*
145
What is Choriocarcinoma?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
What other organ does it involve?
aggressive form of [gestational trophoblastic neoplasia]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
metastasizes to **LUNGS** --\> cp/dyspnea/hemoptysis
146
When does [GTNChoriocarcinoma] occur?
| *Choriocarcinoma is an aggresive subtype of GTN*
occurs after ANY TYPE OF PREGNANCY
| *Choriocarcinoma is an **aggresive subtype** of GTN*
## Footnote
*🔎GTN = [Gestational Trophoblastic Neoplasia]*
147
*BRCA mutation is associated with Breast _and_ Ovarian CA(Epithelial Ovarian Carcinoma)*
How can pts reduce their risk of developing [Epithelial Ovarian Carcinoma]?-5
1. **BL Salpingo-Oophorectomy**
2. OCP (only ⬇︎ovarian CA but actually ⬆︎breast CA risk)
3. 1st gestation \< 30 yo
4. Breastfeeding
5. Tubal ligation
## Footnote
*Epithelial Ovarian Carcinoma comes from Ovarian, Tubal or Peritoneal abnormal proliferation*
148
What is the most common complication of an untreated [Mature dermoid cystic teratoma of ovary]?
**OVARIAN ISCHEMIA 2/2 TORSION**
* * *
mass on the ovary --\> ⬆︎risk for torsion around its support ligaments which contain ovarian blood supply
*It is NOT common for [Mature dermoid cystic teratoma of ovary] to rupture*
149
Pt has just been hospitalized for PID
Now that she's hospitalized, what are the **inpatient** abx options for PID?-3
Inpatient:
1. CeFOXitin IV + Doxy PO
2. Cefotetan IV + Doxy PO
3. [Clindamycin IV + Gentamicin IV]
*Remember: PID is actually POLYmicrobial*
150
What is the **outpatient** abx regimen for treating PID (2)
IMCefTriaxone
+
PODoxy
## Footnote
*make sure these pts can tolerate and comply with PO abx*
151
What are the risk factors for Cervical CA? - 6
1. Smoking (impairs immunity)
2. STI hx
3. HPV 16/18(early/frequent sex)
4. ImmunoCompro
5. [VaginalSQC CA] hx(Vaginal SQC CA) and (Cervical CA) share SAME RISK FACTORS
6. Vulvar CA hx
| *(Vaginal SQC CA) and (Cervical CA) share **SAME RISK FACTORS***
152
What are the risk factors for Toxic Shock Syndrome - 3
*organisms = staphA and GASP*
1. **T**ampons
2. [**S**inus/Nasal Surgery]
3. [**S**kin lesions or Burns]
153
CP for Toxic Shock Syndrome - 5
*organisms = Staph A and GASP*
1. **Generalized “*****sunburn*****” macular rash INVOLVING palms & soles**
2. hypOtension
3. Fever
4. Vomiting
5. Diarrhea
154
[*CAGS -*Condyloma Acuminata Genital Skinwarts] are caused by _____ & _____.
Describe its appearance - 2
HPV 6 & 11
Could Either be:
1.multiple skin-colored exophytic*(cauliflower-like)* lesions +/- friability
OR
2.multiple skin colored smooth sessile(broad & flat) papules +/- friability
155
Condyloma Lata is caused by ⬜ .
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
How would you describe these lesions?-2
Treponema Pallidum **SECONDARY** syphilis
1. **FLAT**
2. **VELVETY**
* * *
“**CLTS** get *syph*!”
[**C**ondyloma **L**ata **T**reponemaPallidum **S**yphilis]
156
Which hormone prepares the endometrium for implantation of a fertilized egg?
**P**rogesterone **P**repares endometrium via decidualization
157
Which hormone induces prolactin production during pregnancy?
*postpartum DROP of***E**strogen
158
Which hormone is responsible for myometrium relaxation during pregnancy?
**P**rogesterone
159
How should pts with PCOS go about restoring ovulatory cycles 1st?
What's the next 2 options if that doesn't work?
1st: **WEIGHT LOSS!**
2nd:[**C**lomiphene citrate (GnRH🟢)]
3rd: **so_k**
| PCOS Tx = [*Wt loss →so**C**k]
160
Why do women who've recently delivered and are breastfeeding have no menstrual cycles?
Elevated Prolactin (responsible for mammogenesis and galactogenesis) **inhibits GnRH release** --\> anovulation and amenorrhea for ≤ 6 months
## Footnote
*after 6 months, even with breastfeeding women will start to ovulate again and even before then, this is not a reliable form of contraception*
161
Lichen Sclerosus and Atrophic Vaginitis can present similarly
What is the major distinguishing feature?
*Both have thin & pale tissue*
Lichen Sclerosus does **NOT** affect the vagina
Atrophic Vaginitis affects both and can be a result of menopause (2/2 natural, chemotherapy, radiation, surgical or lack of estrogen replacement therapy)
162
Describe the appearance of Lichen Planus
Ulcerated Glazed Erythematous Vulva
163
Who should be the only demographics to receive BRCA/HER2 testing - 3
1. Women with Breast CA \< 50 yo
2. Women with Ovarian CA at any age
3. Women with first degree relatives with #1 or #2
164
CP of ovarian CA - 3
1. early satiety (from ascities)
2. abd/pelvic pressure (from ascities)
3. GI sx (constipation/diarrhea/bloating/anorexia) - (from ascities)
165
What is the most common pelvic tumor in women?
Leiomyomata uterine fibroids
## Footnote
*Submucosal and Pedunculated are the worst!*
166
[T or F] Posterior Cul-De-Sac fluid accumulation in a pregnant woman is an abnormal finding
**FALSE**
## Footnote
(this is a normal finding for preggos along with corpus luteum ovarian cyst UNLESS IT'S IN THE SETTING OF ECTOPIC. THEN IT MEANS HEMOPERITONEUM FROM RUPTURE OR OVARIAN CYST RUPTURE)
167
DDx for Free fluid in the pelvis of a woman - 3
1. Normal pregnancy change
2. Ruptured Ectopic --\> hemoperitoneum
3. Ruptured Ovarian cyst
168
[T or F] Combined OCPs ⬆︎ risk for Endometrial CA ; Explain
FALSE ; **Combined** OCPs ⬇︎risk for Endometrial CA because the progestin differentiates endometrial cells
169
[T or F] Combined OCPs ⬇︎ risk for Ovarian CA ; Explain
TRUE ; **Combined** OCPs ⬇︎risk for Ovarian CA because it suppresses chronic ovulation which causes chronic damage to surface
170
Why are Combined OCPs **contraindicated in pts with [Migraine with aura] hx**?
There is a rare but serious **RISK OF STROKE** with use of combined OCs in women with migraine/HA hx, especially if they smoke or are \> 35 yo
171
What's the first steps in w/u for Bilateral breast discharge with no lumps, LAD or nipple changes?-4 ; Why?
**Hyperprolactinemia** **is most common cause of galactorrea**
1. PROLACTIN levels - Prolactinoma could --\> Hyperprolactinemia
2. TSH levels - hypOthyroidism could --\> ⬆︎TRH & TSH --\> Hyperprolactinemia since TRH stimuales prolactin release
3. PREGNANCY test - Pregnancy could --\> Hyperprolactinemia since TSH shares same α-subunit Is this as bHCG
4. MED REVIEW - D2🟥Antidepressants/Opioids all --\> Hyperprolactinemia
172
When should the HPV **3 dose** vaccine be given to females?
Between 11-26 yo regardless of anything
## Footnote
\*they receive 3 doses spread out\*
**\*\*this INCLUDES women with genital warts, positive HPV and abnormal cytology hx!!!!\*\***
173
When should the HPV **3 dose** vaccine be given to males?
Between 9-21 (or 26 if HIV+ and/or gay) yo
## Footnote
\*they receive 3 doses spread out\*
174
In a +bHCG pt who comes in with RLQ pain, vaginal bleeding and a negative Transvaginal US
why would we wait and repeat the bHCG & transvaginal US in 2 days if at the time it was already 1000
Intrauterine pregnancy is not detectable via transvaginal US until **1500-2000** bHCG. There should be SOMETHING on transvaginal US at that time (whether normal pregnancy or ectopic)
175
βhCG levels have to be ____ for pregnancy to be detected via trans*vaginal* US, and usually _____ when trans*abdominal* US can finally detect it
What are βhCG levels during:
A: Ectopic Preg/Miscarriage
B: Molar Pregnancy
βhCG levels have to be **1500-2000** for conclusive pregnancy detection via transvaginal US and usually **\>5000** for transABDominal US to finally detect it
A: Ectopic Preg/Miscarriage = low βhCG
B: Molar Pregnancy = \> 100,000 βhCG!!!
*βhCG should double every 2 days in normal pregnancy for first 7 weeks*
176
How does Obesity commonly cause amenorrhea?
Obesity --\> anovulation **without affecting LH/FSH levels** which--\> Amenorrhea
177
Selective Estrogen Receptor Modulators (SERMs) are used for _______(*indications*)-3 ; What are the main side effects of SERMs? - 3
1.[Breast CA px]
2.[Breast CA tx *adjuvant* (Tamoxifen)]
3.[Postmenopausal Osteoporosis (Raloxifene)]
SIDE EFFECTS
A: **Hot Flashes**
B: Venous Thromboembolism (all estrogen agonist ⬆︎resistance to protein C)
C: Endometrial Hyperplasia/ADC
*note: SERMs not only modulate estrogen receptors but they actually block estrogen binding competitively*
178
🄰 What would you expect the following hormones *(prior to hypothalamus shut down)* to be in PCOS (polycystic ovarian syndrome)?
GnRH
FSH
Estrogen
| 🄱 . Explain each
*PCOS= [⇪GnRH] , [nml FSH], [⇪⇪⇪Estrogen]*
## Footnote
*PCOS (initially)*=
*🍟[⇪GnRH]* **(from [*DM/Obesity*HYPERinsulinemia] stimulating ([**HYPER GnRH⼀LHwsx] ...
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*🍟[nml FSH]* ...(whilst FSH secretion stays normal/unchanged)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*🍟[⇪Estrogen]* ([**HYPER GnRH⼀LHwsx ] → ⇪ ⇪HYPERandrogen secretion from Ovarian Theca → converted into ⇪ ⇪ ⇪HYPEREstrone** (*HYPEREstrone eventually → GnRH _hypothalamus shut down_ via neg feedback)*
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_x\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*{🔎wsx = Weighted secretion = [(**LH**>FSH) or (FSH>LH) ]secretion}*
*[🔎BSX = BALANCED SECRETION = (LH **=** FSH)]*secretion*
179
What would you expect the following hormones to be in Hypothalamic hypogonadism (functional hypothalamic amenorrhea)?
GnRH
FSH
Estrogen
180
What would you expect the following hormones to be in [Primary Ovarian Insufficiency]?
GnRH
FSH
Estrogen
*POI main sx = [amenorrhea ≤40 yo(unless POI cause = Menopause)]*
181
How does estrogen deficiency cause stress AND URGE incontinence? -5
▶⬇︎estrogen --\> [ atrophy**V**ulvoVagina
▶and atrophy[**BUM**(**B**ladder trigone/ **U**RETHRA/**M**uscles of PelvicFloor)] --\>
[atrophy**U** → Urethral closure --\> ⬆︎bladder pressure]*→ URGEi *
[(atrophy**M** → ⬇︎Urethral compliance) →UTI] → *URGEi (rule this out first!)*
[atrophy**M** → ⬇︎Urethral compliance]*→ STRESSi*
“ estrogen maintains her **VBUM**”
182
What are the causes of Primary Ovarian Insufficiency? - 8
1. Menopause
2. [Chemotherapy - targets rapidly dividing granulosa/theca cells]*can cause Premature POI*
3. [Radiation - targets rapidly dividing granulosa/theca cells]*can cause Premature POI*
4. oophorectomy
5. Turner syndrome
6. fragile X syndrome
7. hypOthyroidism
8. adrenal insufficiency
183
List the numerous contraindications to Combined OCPs - 11
1. Migraine with aura
2. Smokes ≥15 cig/day and ≥35 yo
3. HTN ≥160/100
4. Heart disease
5. DM with end organ damage
6. Breast CA (estrogen AND progesterone may have proliferative effects on breast tissue)
7. Liver Cirrhosis/CA
8. Thromboembolism hx
9. Prolonged immobilization
10. Antiphospholipid syndrome hx
11. ≤3 wks postpartum
184
What is [***PGVD*** -(Penetration Genitopelvic Vaginismus Disorder)]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
tx?-2
pain with any vaginal penetration (penis, tampon, gyne exams)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
tx = Vaginal Dilators, Kegel exercises
*this is AKA Vaginismus*
185
In pts with Pudendal neuralgia, where do they have superficial pain? - 3
1. Vulva
2. Perineum
3. Rectum
## Footnote
*these are the pudendal n distribution areas*
186
What are the causes of Hydrosalpinx (fluid accumulation in fallopian tubes) - 2
1. Adhesions (PID, surgery)
2. Tubal ligation
187
What is the 1st line tx for Postmenopausal hot flashes? ; What can you use if that doesn't work?
**WEIGHT LOSS** ; Combined OCPs
## Footnote
HEY! HRT IS NO LONGER RECOMMENDED FOR [CAD, DEMENTIA OR OSTEOPOROSIS POSTMENOPAUSE PX]!!!!!!!
188
How does the Levonorgestrel progestin IUD work as a contraceptive? - 3
1. thickens cervical mucus
2. thins the endometrium when present outside of pregnancy which --\> implantation impairment AND ⬇︎menstrual bleeding
3. prevents withdrawal bleeding altogether --\> **amenorrhea**
189
What is the main side effect of Copper IUD
Menorrhagia
190
What is the main side effect of Medroxyprogesterone injections
Weight Gain
191
Pelvic US reveals
*Hyperechoic ovarian cyst with calcifications*
Dx?
[Mature dermoid cystic teratoma of ovary]
192
Pelvic US reveals
*Homogenous cystic ovarian mass*
Dx?
[*Endometrioma* (Endometriosis of ovary)]
193
Ovarian hyperThecosis is usually diagnosed in \_\_\_\_[pre/post] menopausal women
What is it?
**POST**menopausal;
⬆︎Theca cell activity --\>
⬆︎androgen --\> virilization,
and ⬆︎insulin resistance → hyperglycemia, acanthosis nigricans
*this does NOT affect LH and FSH and ovaries are enlarged but not cystic*
194
DDx for Menorrhagia (abnormal uterine bleeding) - 10
*"Bleed Uteri in the* [**C**oagulopathic **COVE** **PLACE**]!
**C***oagulopathic*
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
**C**ervical CA
**O**vulatory dfxn
**V**aginal CA
[**E**ndometrial hyperplasia/ADC (get bx if risk factors present)]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
**P**regnancy
**L**eiomyomata uterine fibroids
**A**denomyosis
**C**opper IUD
**E**ndometrial Polyps
| *Pregnancy, Structural, NonStructural, Meds*
195
What does [Fat necrosis of breast] show on mammography -2
[oil cyst +/- calcifications ]
that may initially appear to be malignant*(until malignancy r/o by bx revealing fat globules and foamy macrophages)*
196
What does [Fat necrosis of breast] show on core biopsy - 2
fat globules and foamy macrophages
197
When is MRI of the breast indicated? - 5
1. [breast CA BRCA carrier]
2. [breast CA BRCA carrier ... *in 1st degree relative*]
3. [breast CA **Dz** assessment]
4. [breast CA **Tx** assessment]
5. breast/chest radiation between 10-30 yo
198
In a woman with normal menstrual cycles, what is usually the cause of infertility if she is \> 35 yo?
diminished Ovarian reserve
*oocytes are of _finite_ number and quality*
199
What is an ovarian Fibrothecoma
sex cord-stromal tumor that secretes both but Estrogen \> testosterone
200
[inclusion cyst of Vulva] usually result because of ⬜, whereas [epidermal cyst of Vulva] result from ⬜
**i**njury local*→ [**i**nclusion* cyst of Vulva]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
**e**xit duct of sebaceous gland obstructed*→ [**e**pidermal* cyst of Vulva]
| *of Vulva*
201
What are 4 major s/s of Pregnancy
**FAWN**
1. **F**atigue +/- insomnia
2. **A**menorrhea
3. **W**eight gain
4. **N**V
*these sx can overlap with Perimenopausal sx so be careful not to quickly dismiss an older pt who's actually pregnant!*
202
Tx for Condyloma Acuminata - 5
1. **Trichloroacetic acid**
2. [Cryotherapy c liquid nitrogen or cryopr obe]
3. [Imiquimod 5% cream {pt application}]
4. [Podophyllum resin] *Pregnancy C❌D*
5. [PodoFilox 0.5% gel{pt application}]*Pregnancy C❌D*
| [(HPV6 & HPV11)*CAGS*-Condyloma Acuminata Genital Skinwarts]
203
[T or F] It is ok to perform a Colposcopy in a pregnant woman whose pap recently resulted abnormal
TRUE (**Colposcopy is indicated when pap is abnormal** **even if pt is pregnant! - DO IT**) ; So is Cervical bx if a lesion has high-grade features
## Footnote
*Endocervical curettage is contraindicated*
204
[T or F] It is ok to perform a Cervical biopsy on a pregnant woman whose pap recently resulted abnormal
TRUE - **after Colposcopy**, if lesion has high-grade features
## Footnote
*Endocervical curettage is contraindicated*
205
[Atypical Glandular Cells] on a Pap may be due to either [\_\_\_\_ CA] OR [\_\_\_\_ CA]
What should you do to work this up? - 3
Endometrial ; [cervical(from Endometrial glands migrating to cervical area)]
*perform…*
1. Colposcopy*(evaluates **Ectocervix**)*
2. Endocervical curettage*(evaluates **endocervix**)*
3. Endometrial biopsy*(evaluates **Endometrium**)*
* * *
* With AGC on Pap you need to evaluate Ectocervix, endocervix and Endometrium*
206
What is Ovarian hyperstimulation syndrome
Ovulation inducing medications --\> excessive follicle development --\> ovarian enlargement, ascities, SOB and abd pain
207
Secondary Amenorrhea occurs when women stop having menses for ≥6 months
What is the full workup for Secondary Amenorrhea?
Evaluate **F**LA**T** **P**iG for 2° Amenorrhea
208
In a _pt with hypothyroidism_, why do you need to \_\_\_\_\_[decrease/increase] her [levothyroxine T4] when she becomes pregnant? -3
**INCREASE** (with monitoring of T4);
* Estrogen from pregnancy usually ⬆︎Thyroid binding globulin AND bHCG stimulates thyroid --\> ⬆︎total thyroid hormone in mom for the baby.
* BUT _hypOthyroid_ Moms won't produce adequate thyroid hormone and this can --\> congenital hypOthyroidism.
* So **give _hypOthyroid Moms_ more** [**Levothyroxine T4**] **when pregnant**
*Levothyroxine = T4 / Liothyronine = T3*
209
A friable cervix is one that easily _____ when touched. This is usually a sign of **cervicitis** secondary to \_\_\_\_\_
bleeds "crumbles" ; [N. Gonorrhea PID]
210
bHCG shares an \_\_\_subunit with which other 3 hormones?
ALPHA;
1. FSH
2. LH
3. TSH--\> Pregnant woman naturally have more T3 and T4 (also because Estrogen ⬆︎thyroid binding globulin which ⬆︎total thyroid levels) - these pts are still *clinically* euthyroid
211
How do you confirm a *female* pt has urinary retention?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*male*?
urinary catheterization [≥150ccFEMALE] [≥50ccmale]
*Bladder can hold up to 400 cc*
212
Indications for Pessary - 2
1. Pelvic organ prolapse
2. Stress urinary incontinence
213
What are risk factors for Osteoporosis? - 9
*Bone Mineral Density (T-score) ≥ 2.5 SD BELOW the YAM*
1. **OSTEOPOROTIC FX HX(personal OR family)**
2. ⬇︎Estrogen (postmenopause)
3. LOW BMI (malnutrition/malabsorption)
4. Sedentary lifestyle
5. Poor Ca+ intake (body needs [1**_0_**00mg/day*PREmenopausal*] and [1200 mg/day*POSTmenopausal*])
6. Smoking
7. EtOH abuse
8. White race
9. CTS
214
What are the major risk factors for PreMenstrual Syndrome? - 5
1. **FAMILY HX OF PMS**
2. [Pyridoxine VitaminB6] deficiency
3. Ca+ deficiency
4. Mg deficiency
5. Age \> 30
215
Dx for [Functional Hypothalamic Amenorrhea]?
⬇︎FSH
216
Which substance actually exacerbates the cyclical bilateral pain associated with Fibrocystic changes of breast?
Caffeine
217
Raloxifene MOA
Indications-2
[SERM-(Selective Estrogen R Modulator)]
1. Breast CA
2. Osteoporosis
* * *
* SE = Venous Thromboembolism*
218
Why do [pt \< 21 yo] NOT require PAP Smear Cervical CA screening?
Immune System in patients \< 21yo clears HPV on its own
219
CP for TTP -3
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
When does this occur during pregnancy?
*“preggos can always get the TTP**TAN**!”*
## Footnote
1. **T**hrombocytopenia ➜ Petechial Rash
2. **A**nemia hemolytic
3. **N**eurologic ∆
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
In pregnancy can occur [ANYTIME (even Postpartum)]
220
What's Major difference between TTP and HELLP during pregnancy?
TTP*TAN* = can occur anytime from [1st trimester \<-thru-\> PostPartum]
vs
HELLP (and [Acute Fatty Liver of Pregnancy]) = [3rd Trimester 28-42WG] ONLY
221
CP for Acute Fatty Liver of Pregnancy - 3
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
When does this occur?
[**3rd** trimester 28-42WG]
1. ⬆︎LFTs
2. hypOglycemia
3. NV
222
Gestational sacs normally implant in the \_\_\_\_\_
upper uterine fundus
223
# Gestational sacs normally implant in the \_\_\_\_\_
What is the "typical" triad for Ectopic Pregnancy? - 3
upper uterine fundus ;
*i\⊕UPT***VAL** had an ectopic the other day!
1. **V**aginal bleeding/spotting
2. **Adnexal Tenderness** **(if implanted in tube)**
3. **L**ower abd pain
*dx = trans**Vaginal** US / tx = MTX or [surgery if severe]*
| *(in the setting of ⊕UPT)*
224
Preeclampsia is typically diagnosed ____ weeks gestation.
What is the exception to the rule?
**GOE20WG**! ; Preeclampsia as a complication of Hydatidiform mole (which may occur \< 20WG)
225
* PreEclampsia --\> SEVERE PreEclampsia --\> HELLP and at anytime, Eclampsia is possible*
* \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_*
Tx -2
1. STAT DELIVERY
2. MgIV
226
*PostMenopause [Hormone Replacement Therapy] ⇪ DVT/PE risk*
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
What are 2 alternative tx for Postmenopause sx?
1. **SSRI**
2. SNRI
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*50-70% f endorse sx reduction*
227
how long after discontinuing contraception does it take for ovulation to return?
LOE1month
228
What's the **FIRST** step in working up Infertility?
SEMEN ANALYSIS
229
definition of
Infertility ?
[GOE12mo timely unprotected intercourse] ➜ still no conception
230
Endometriosis
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
physical exam findings -2
1. immobile uterus
2. [pelvic nodules (w/chronic pelvic pain)]
231
# primary ovarian insufficiency
main presenting sx
[secondary amenorrhea ≤40 yo]
*(for all POI causes except Menopause)*
232
Source of Estrogens (3)
1. Ovaries
2. Liver (from Estriol)
3. Peripheral tissue (from androgens)
233
Source of Progestins (4)
1. Ovaries
2. Testis
3. Adrenal Gland
4. Placenta during pregnancy
## Footnote
*comes from Cholesterol*
234
List the natural estrogens (3). Which is most estrogenic?
- Estrone (E1)
- **Estradiol (E2) = MOST ESTROGENIC**
- Estriol (E3) = not very active
235
List the [synthetic steroidal estrogens] (3)
* Ethinyl estradiol
* Mestranol
* Quinestrol
236
Aromatase MOA (2)
Converts...
- Androstenedione --\> e1*e1 can transform to [eE3 estriol]* (think: A is 1st letter)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
- Testosterone --\> E2 (like :"test-es")
| *only can e1 possibly later convert to Ee3*
## Footnote
*Ee3 = E3 = EsTriol*
237
How do Steroid Hormones molecularly work?
Hormone diffuses into target cell and binds to receptor. [Hormone-receptor complex dimerizes in nucleus] and binds to specific DNA regions (activators/repressors) --\> Gene tx
238
Describe the **Name** and **Hormone levels** during the Menstrual cycle
A: Days 1-14
B: Day 14
C: Days 14-28
A: [Follicular Proliferative Phase] = low E2 with INC FSH and LH receptors on Dominant follicle
B: Ovulation (FSH & LH peak with LH surge)
C: [Luteal Secretory Phase]= Progesterone INC
239
Reproductive actions of Estrogen (5)
1. Female Secondary Sex characteristics
2. Puberty & Adolescent changes (epiphyseal closure)
3. Menstrual cycle (gonadotropin secretion)
4. Uterine Endometrial **proliferation**
5. [Thin Cervical Mucus] secretion for sperm facilitation
240
Metabolic actions of Estrogen (7)
1. [INC HDL] :-)
2. INC Bile saturation into cholesterol --\> DEC cholelithiasis
3. Stimulates Renin substrate release --\> INC BP
4. INC Clotting
5. DEC Bone Resorption
6. DEC LDL
7. DEC free thyroid hormone *(via INC TBG)*
241
CNS actions of Estrogen (2)
1. Positive mood, cognition, memory
2. Protects against Neurodegenerative DO
242
Estrogen Clinical Indication (5)
"We Use Estrogen for **OPRAH**"
1. **O**CP component (ethinyl estradiol)
2. [**H**RT Menopausal (Premarin)]
4. [**P**erimenopause/Oligomenorrhea/Dysmenorrhea]
5. [**R**eally behind *(♀delayed Puberty | ♀hypOgonadism)*]
6. **A**cne (Estrostep)
243
Estrogens SE (6)
**B**eware of **E**strogen's **CAVE**
1. **B**reast tenderness
2. **V**enous Thrombosis
3. **C**onstitutional (HA/NV)
4. **E**dema
5. [**E**ndometrial Hyperplasia/Carcinoma (**Estrogen when taken alone**)]
6. **A**denocarcinoma in offspring of pts who've taken DES
244
SERM = \_\_\_\_. What is its MOA (2)
SERM = **S**elective **E**strogen **R**eceptor **M**odulator
* Estrogen BLOCKER in some tissues
* Estrogen Agonist in other tissues
245
Tamoxifen Indication
Pre AND POSTMenopausal Breast CA that are (ER/PR +). Serves as [Adjuvant Hormonal Therapy]
246
Tamoxifen Contraindications (2)
1. DVT/PE Hx
2. Pregnancy
247
Drug class of Clomiphene
SERM
248
Clomiphene Indication
Female Infertility 2° to ovulation DO
249
Clomiphene MOA (2)
SERM*"[❌ at TOP] ... [tickles down below]"*
* Estrogen Blocker @ hypothalamus & pitutiary--\> INC LH & FSH
* Partial agonist @ ovaries
## Footnote
1. [hypOthalamus& ANT Pit*Estrogen🟥*] →"tricks" hypOthalamus into thinking Estrogen is low → ⇪ LH & FSH [used for IVF]
2. OVARY *[Estrogen PARTIAL🟢]*
250
Raloxifene Indication (2)
Osteoporosis & [Postmenopausal Breast CA **Px**] only
251
Raloxifene MOA (2)
* Estrogen R Agonist @ Bone
* Estrogen R BLOCKER @ Uterus & Breast
252
Name the [Aromatase inhibitors] (4)
Anastrozole
Letrozole
Exemestane - (Covalently Irreversible)
Formestane - (Covalently Irreversible)
253
[Aromatase inhibitors] indication (2)
[**ER⊕** Breast CA (Tx and Px)]
254
[Aromatase inhbitors] SE (8)
"**D**on't **FETCH** **V**ile a**R**omas"
1. [**F**ractures & Arthralgia]
2. **T**hrombophlebitis
3. **H**ypercholesterolemia
4. **V**aginal Bleeding (profuse)
5. **E**dema-Peripheral
6. **C**onstitutional (HA/Nausea)
7. **D**yspnea
8. **R**ash
255
Physiological actions of Progesterone (7)
1. Menstrual cycle: Negative feedback during [Luteal secretory phase]
2. Endometrial transformation --\> [Luteal Secretory phase]
3. Reverts [thin cervical mucus] back to [THICK cervical mucus] which inhibits any further sperm transport
4. INC body temp at Ovulation
5. Maintains Pregnancy: Inhibits Uterine contraction and suppresses immune system
6. Mammogenesis
7. Blocks and enhances actions of estrogens
256
Progestin Indication (6)
1. OCP alone or [OCP componenent]
2. Menopausal Endometrial Protection (medroxyprogesterone)
3. Oligomenorrhea
4. Amenorrhea
5. PCOS
6. Endometriosis
257
Name the [**Progestin only** OCP] (5)
1. Levonorgestrel
2. Norgestrel
3. Norethindrone
4. Medroxyprogesterone (injectable)
5. Etonogestrel (Implant)
258
How do [Progestin only OCP] perform their action (4)
Alters ...
1. GnRH pulsation and DEC ANT Pit responsiveness to GnRH
2. Tubal Peristalsis
3. Cervical Mucus Secretions
4. Endometrial Receptiveness
259
[Progestin only OCP] SE (3)
* Irregular periods
* Breast tenderness
* Constitutional (HA / Nausea / Dizziness)
260
**Name** the [Progestin only OCP] and its **dosage** given for [spotting, irregular periods, oligomenorrhea]
Medroxyprogesterone given via injection q3 mo.
261
Which [Progestin only OCP] is used for Emergency contraception (morning after)
Levonorgestrel (Blocks LH surge and impairs surge transport)
262
[Combined OCP] MOA (2)
1. Negative feedback on Gonadotropin secretion --\> No ovulation
2. Progestin thickens Cervical mucus
263
[Combination OCP] SE (9)
**B**irthControl **G**ives **L**adies **A** **H**ome **W**ithout **T**errible, **B**awling **B**abies
1. **B**reast Tenderness (don't use in Breast CA)
2. **G**allbladder Dz
3. **L**iver Neoplasm
4. **A**bnormal Menstruation
5. **H**TN
6. **W**eight change
7. **T**hromboembolism
8. **B**loating
9. **B**reakthrough Bleeding
264
Why is estrogen always coadministered with progestin in [women with uterus]
Estrogen, **given** **alone**, --\>Endometrial CA
265
# MiFepristone
[MOA] -2
1. [Progesterone R Blocker] and
2. [Glucocorticoid R blocker at high dose]
266
# MiFepristone
Indication (2)
1. Abortion (only with pregnancy ≤49 days)
2. Refractory Cushing's Syndrome
267
**Name** and **Describe** which drug MiFePriStone is co-adminstered with for [Abortions LOE49d]
mi(S)o*PROS*tol = (S)imulates *PROS*taglandin = [*PROS*taglandin analogue] that (S)Timulates uTerus ➜ [uTerus contraction w/ NVD]
"(S)imulates *PROS*taglandin to (S)queeze the uTerus "
268
Dosage Regimen for Emergency Contraceptive
1st: Within 72 hours of intercourse **take 2 T [0.75 mg of levonorgestrel**]
2nd: Wait 12 Hours
3rd: Repeat Step 1
269
Menopause Dx (2)
1 year since last menses + [FSH \> 25]
270
Menopause sx come from ___ deficiency and includes what 4 main EARLY sx?
Menopause sx come from **Estrogen** deficiency:
1. Mood Changes (95%) (HRT Tx indicated)
2. Fatigue (95%)
3. Vasomotor instability --\> Hot Flashes (70%) (HRT Tx indicated)
4. Insomnia (55%)
