Flashcards in CM- Gynecology Deck (45):
What are the 8 parts of the gynecologic history?
1. menstrual history -menarche, LMP, cycle length/characteristics
2. pregnancy history
3. vaginal/pelvic infections
4. gynecologic surgical procedures
5. urologic history
6. pelvic pain
7. vaginal bleeding
8. sexual/contraceptive status
What are the components of the menstrual history?
2. duration of each monthly cycle
4. color, amount of flow, cramping, dysmenorrhea, backaches, diarrhea
This will help determine normal or abnormal pubertal development as well as if the person is anovulatory or ovulatory
On menstrual history, a patient says she gets her period monthly. It lasts 4-7 days and is bright red. She cramps on the first day but then it goes away.
what is her presentation characterisitic of?
On menstrual history a woman says her period is irregular. The blood is dark and painless.
Sometimes it bleeds for a really short time, and other times it bleeds for a long time.
What is this characteristic of?'
What age women are most likely to present with these symptoms?
Teens and perimenopausal women present with these symptoms
What questions should you ask when taking a pregnancy history?
1. year of the pregnancy
3. type of delivery
4. weight, gender, condition of the baby
5. complications [infertility, pregnancy, delivery]
7. onset of sexual activity, number of partners, paternity of children
When taking a history of vaginal and pelvic infections what are some risk factors you want to ask about?
What 5 STDs are screening done for?
1. IV drug use
2. coital and non-coital activity with multiple partners
3. bisexual or drug using partners
Screen for HIV, syphilis, chlamydia, gonorrhea, HSV
When taking a history of pelvic pain, what is it crucial to determine the relationship between?
Pain complex and the timing in the menstrual cycle
If pain is cyclic it is often functional and related to
1. ovulation, premenstrual tension, dysmenorrhea
If the pain is associated with urination, defacation, or coitus, you should be concerned about endometriosis.
When taking a pelvic pain history, the patient says she feels pelvic pain when urinating, defacating and during sex. What are you concerned about?
A woman is fatigued, depressed anxious and irritable. She has increased appetite breast tenderness, weight gain and headache.
When in her cycle do you think she is? What are these symptoms indicative of?
This is PMS. She is probably in the late luteal phase (5-7 days before to 4 days after menses)
What is PMDD and PMD?
How are they diagnosed?
What is the proposed biological reason for why they occur?
What is treatment?
Premenstrual dysphoric disorder and premenstrual dysphoria.
They are associated with significant psychosocial and functional impairment.
The are diagnosed with DSM-IV
It is proposed to be a problem with estrogen, porgesterone, GABA and serotonin
Treatment: SSRI, anxiolytics, oral contraceptives, PG inhibitors, duiretics and diet therapy
What are the 4 characteristics of chronic pelvic pain?
2. localized to the pelvis
3. lasts >6months
4. severe enough to affect daily functioning and relationships
What are premenarchal and postmenopausal bleeding most frequently associated with?
What is intramenstrual bleeding in the context of a regular cyclic predictable menses associated with?
Pre and Post = pathology
Intramenstrual = intrauterine pathology like leiomyoma or intrauterine polyp
What are the 6 components of a complete sexual history?
1. presence of sexual history
2. types of relationships [casual, monogamous, violent]
3. individuals involved
4. satisfaction? orgasm?
6. sexual dysfunction of patient or partner
Why is localizing pelvic pain often difficult?
A large number of non-genital and psychogenic causes exist for pelvic pain.
Pain can be subjective and dependent on cultural background, personality type, pain threshold
What are the five main stimuli that produce pain in the pelvis?
1. distention of a hollow viscus, followed by high wave contractions [ectopic pregnancy]
2. Rapid stretching of a capsule of a solid organ [cyst on the ovary]
3. chemical irritation of the parietal peritoneum [ruptured cyst]
4. tissue ischemia
5. neuritis secondary to inflammation, neoplasm, and fibrotic process in adjacent organs
Lesions in what pelvic areas locate to the lower sacral area or buttocks?
lower uterine segment
Lesions in what pelvic areas localize to the abdomen?
upper uterine segment [fundus]
dome of the bladder
adnexae [tubes and ovaries]
Nerves: hypogastric plexus
If a patient presents with sudden onset pain in the pelvis, what kind of lesions are you anticipating?
How does this differential change when the pain is gradual in onset?
3. internal hemorrhage
4. acute inflammation
Gradual onset suggests a chronic process like endometriosis or a neoplasm
What does intermittent, colicky pain in the pelvis lend to?
What about dull or throbbing pain?
Colicky - muscle contractions of a hollow viscus due to distension:
1. ectopic pregnancy
2. blood or pregnancy contents distending the uterus
3. ureteral colic or intestinal obstruction
1. chronic inflammatory disease
What is your DDx for pelvic pain of short duration?
Pelvic pain of short duration eludes to inflammation or an acute accident so:
1. ruptured ectopic
2. ruptured ovarian cyst
4. torsion of tubes/ovaries [adnexa]
What is suspected if pelvic pain presents with:
2. after missed menstrual period
3. urination or defacation
4. prior pelvuc surgery
1. inflammation and/or infection
3. GU or GI problems
4. intestinal obstruction due to adhesions
A teenager experiences abdominal discomfort at the onset of menstruation. Prior to menarche, this abdominal pain didn't occur. She misses 1-2 days of school a month because of the pain.
What is her likely diagnosis?
What percent of teens does this affect?
What is the pathophysiology behind it?
What is treatment?
30-40% of girls get it
It is due to myometrial distension and PGF2a in an immature HP axis.
The PGF2a constrict small endometrial vessels and induces myometrial contraction, tissue ischemia and endometrial disintegration
Treatment is: OCPs, NSAIDs/analgesics [to block PGs]
If this doesn't work--> pelvic US or laparoscopy
If you don't see lesions--> psychiatric
A 29 year old woman presents with new onset dysmenorrhea. The pain starts before menses and persists for a long period of time during the flow. She has been trying to conceive for 2 years and has recently developed dyspareunia.
What does this situation describe?
What are the 4 things on the DDx?
What percent of women experience this?
What is the pathology behind it?
What is treatment?
This describe secondary dysmenorrhea and can elude to:
1. PID - upper uterine infection
2. endometriosis - endometrium stroma/glands in an extrauterine location
PID is treated with antibiotics
Endometriosis is treated with OCPs and GnRH analogs. If it gets really bad, laproscopic surgery/ablation
An adolescent girl has pain on day 14 of her cycle. What is this pain suggestive of?
What is the pathology behind the pain?
How long does the pain typically last?
What is treatment?
It is mittelschmerz [mid-cycle] and suggests pain secondary to ovulation. The duration of the pain is usually a few hours
Treatment is mild analgesics or OCPs
What are the 2 broad categories of dyspareunia?
How does the pain differ in each case?
- congenital defects
- post-op adhesions
- vaginal atrophy due to estrogen deficiency
Sometimes this causes vaginismus= vaginal muscle spasms that push the penis against the vestibule exterior to the hymen or against the urethra causing pain**
- entrance dyspareunia and is a defense mechanism for women who have had bad experiences with sex
What is the pathophysiology of endometriosis?
What are the 4 theories for how it occurs?
What percent of premenopausal women are
affected? What is the avg age?
Endometriosis is endometrial glands and stroma found in extrauterine locations.
The most common site is the ovary, but it can be in peritoneum, ligaments[uterosacral/round], oviducts, etc. It can even be found in the lungs!
1. Sampson's theory- transtubal regurgitation of menstrual blood and endometrium implantation
2. tissue metaplasia of coelomic epithelium [peritoneal, pleural, pericardial cavities]
3. lymphatic/hematogenous spread
4. decreased cellular immune response to endometrial agents
5-15% of all women, avg age = 28
A 28 year old woman presents complaining of dysmenorrhea, dyspareunia and trouble conceiving. She has been getting monthly pleural effusions [catamenial hemothorax].
On PE you note:
1. pelvic tenderness with induration
2. a nodular uterosacral ligament
3. enlarged tender ovaries
4. fixed and retroflexed uterus.
What are you suspicious that this is and how do you make the diagnosis?
This presents like endometriosis.
Diagnosis is histological so you much get larparoscopy to show:
1. superficial brown/blue-black raised lesions on the peritoneum
2. ovaries with endometriomas [chocolate cysts]
And histology to show:
1. hemosiderin-laden macrophages
2. presence of endometrial glands/stroma
What is the treatment for endometriosis?
1. pharmacologically suppress ovulation with OCPs or GnRH analogs
2. laparoscopic surgery or laser surgery
What is the pathophysiology of pelvic inflammatory disease?
It is an infection of the upper reproductive tract organs thought to be caused by the upward migration of lower tract bacteria enhanced during menstruation due to the loss of cervical barriers.
What are the 2 main bacteria that cause PID? How does the presentation differ between them?
1. N. gonorrhea - true pathogen of fallopian tube epithelial cells inciting direct and acute inflammation
2. C. trachomatis- does not cause acute inflammation in the fallopian tubes, however, multiple infections from chlamydia result in tube destruction and infertility from delayed hyperimmune response
A woman presents with constant pelvic pain. It started unilateral but has progressed to bilateral.
She has malaise, fever, and a purulent yellow discharge.
On PE, you note uterine tenderness, bilateral ovarian tenderness.. The chandelier sign is positive.
What does this patient have?
What is the most likely cause?
What will labs show?
ACUTE PID- gonorrhea
Labs will show leukocytosis and ESR. cervical culture may be positive OR negative
How does the presentation differ from acute PID and chronic PID?
Acute- pain is constant
Chronic - pain is intermittent and associated with menstrual function. Dyspareunia is present
What are the 2 most serious complications of PID?
1. tubo-ovarian abscess
A person with prior cases of acute PID that resolved now presents with pressure-like, persistent pain. What does this describe and how do you verify your suspicion?
US can identify the abcess
The diagnosis of endometriosis is made _____________ while the diagnosis of PID is made ________________.
Endometriosis is a clinical diagnosis while PID is a clinical diagnosis
What is the treatment for PID?
What 3 sequelae of PID does the treatment hope to prevent?
antibiotics or in servere cases surgery for persistant TOA
Treatment is in hopes of preventing:
2. ectopic pregnancy
3. chronic pelvic pain
Describe premenarche in women.
By 16-20 wks in utero, the female has the max oogonal content for her life [6-7 million].
80% are lost by birth and then each cycle she loses more until the store is lost at menopause
What are the 2 stages of the menstrual cycle?
Which hormone drives each cycle?
Which is most consistent in length?
1. Follicular phase [proliferative]
-can slightly vary in length
-estrogen formed from follicular growth causes growth and proliferation of the endometrium [primary to secondary to Graffian follicle]
--OVULATION and RUPTURED FOLLICLE---
2. Luteal phase [secretory]
- always 14 days
-progesterone from the corpus luteum causes secretory changes in uterine glands/stroma
Describe the levels of LH, FSH, estrogen and progesterone during the menstrual cycle.
1. LH constantly rises during follicular phase to a huge peak just before ovulation and then dramatically goes down for the luteal phase
2. FSH descreases during follicular phase, but then has a little surge just before ovulation and then decreases again in luteal.
3. Estrogen rises to peak before ovulation, dips a little and then rises again in luteal
4. Progesterone is low all through follicular and then rises dramatically in luteal
When does the menstrual cycle start? Describe the uterine changes throughout the cycle.
Menstrual cycle begins on day 1 of the period.
1. Menstruation = loss of outer layers of the endometrium [1-5]
2. Follicular phase= denuded epithelium is reformed by estrogen influence. Mitotic influence results in thickened mucosa and lengthening of endometrial glands [5-14]
3. luteal phase = progesterone from the ovarian corpus luteum stimulates further thickening of endometrium, increased tortuosity of the glands, growth of the spiral arteries, reduction of mitotic activity, secretion of lumen of glands
If not fertilized, estrogen and prgesterone levels fall and the mucosa gets necrotic
What are the vaginal changes associated with the menstrual cycle?
1. Proliferative [follicular] =endocervical glands secrete watery elastic mucus with a fern pattern on slides due to salt content
2. Luteal = rise in progesterone thickens cervical mucus to become tacky
When does basal body temperature change during the menstrual cycle?
Progesterone elevates basal body temp so during luteal phase
What are the 3 main types of condom currently on the market?
What are the benefits and drawbacks of each?
1. Latex - most common
-PROS = protect against STIs and HIV, odorless, greater sensitivity, resistant to deterioration from storage/lube
-CONS = breakage and slippage more common
3. Natural skin [lamb intestine] = greater sensitivity but NO STI protection [porous to bacteria and viruses]
What is the "typical" failure rate of condoms?
What does typical failure rate mean?
It is 12 % and typical use means
-put on wrong
- not in time