CNM Purple Big Book: Gynecology Normal Flashcards Preview

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Flashcards in CNM Purple Big Book: Gynecology Normal Deck (78):
1

Perineal muscles

bulbocavernosus
ischiovernosus
superficial/deep transverse

2

Pelvic floor muscles

levator ani
pubococcygeus

3

bulbocavernosus

surrounds vagina acting as a weak sphincter

4

ischiovernosus

surrounds clitoris, responsible for clitoral erection

5

superficial/deep transverse perineal muscles

converge with urethral sphincter

6

levator ani

pubococcygeus, iliococcygeus, and ischiococcygeus muscles

7

pubococcygeus

pubovainalis
puborectalis
pubococcygeus proper

8

what stimulates development of internal pelvic structures?

estrogen initiated during puberty

9

when do internal pelvic structures reach their adult size/appearnace?

by about at 16

10

why is the pH of the vagina acidic?

because of the prevalence of lactobacilli and d/t the influence of estrogen

11

what size is the non-pregnant uterus?

8 cm in length
5 cm in width
3 cm thickness

12

how long are the fallopian tubes?

~10 cm

13

gonadotropins

LH, FSH released from anterior pituritary gland in response to GnRH

14

Estrogen - where, when, etc

primarily released by ovary in response to FSH, also by adrenal cortex, corpus luteum - predominant in follicular phase;
Results in dev of seconddary sex characteristics and ultimately in maenstruation;

15

thelarche

breast development

16

adrenarche

growth of pubic and axillary hair; results from secretion fo adrenal androgens; usually starts after breast devlopment begins

17

estrone

estrogen of menopause;
converted from androstenedione produced by adrenal gland and ovarian stroma

18

estradiol

most potent; derived from ovarian follicles, partic dominant follicle'Primary estrogen of reproductive age

19

estriol

least potent; estrogen of pregnancy;
dreived from conversion of estrone and estradiol in liver, uterus, placenta and fetal adreanl gland

20

pH of vagina

<4.5

21

progesterone - from where, what, etc.

steroid hormone produced by ovarian corpus luteum and conversion of adrenal pregnenolone/pregnenolone sulfate;
Luteal phase
As supplied by ovary, level of 3ng/mL+ indicates ovulation
In the breast: subcutaneous fluid retention

22

Prostaglandin (PGE)

derived from arachidonic acid
Increased production by UTERUS as with primary dysmenorrhea
Increases uterine activity resulting in ischemia

23

Prolactin

from anteroir pituritary
Progressive release druing pregnancy
Stimulates synthesis of milk proteins in mammary tissue
Stimulates epithelial growth in breast during pregnancy

24

Adrenal hormones

Cortisol - metabolizes proteins, carbs, fats
Aldosterone - regulates Na , K; dec Na/incr K secretion by kidney
Androstenedione - converted to estrone in adipose tissue
Testosterone - can be converted to estradiol

25

LH surge

peak 10-12 hrs before ovulation

26

Ovulation

PGE and proteolytic enzymes break down follicular wall; occurs 32-44 hrs after beginning of LH surge;
Maximal prdxn of spinnbarkeit;;
increase of basal body temp 0.2-0.5 F

27

spinnebarkeit

refers to ability of cervical mucus to be stretched between examining fingers;
increased stretch = increased influence of estrogen

28

Luteal phase: corpus luteum

formed from ruptured follicle
Secretes progesterone - peak 7-8 days postovulation

29

Proliferative phase of uterine cycle

estrogen influence
endometrium grows/thickens
lasts approximately 10 days from end of menses to ovulation

30

Secretory phase of uterine cycle

progesterone influence
Av 12-16 days
Endometrial hypertrophy
Increased vascularity

31

Menstruation - of uterine cycle

declining progesterone from CL
endometrium undergoes involution, necrosis, sloughing (3-6 days)

32

screening mammography

Age 40-50:
ACS: annual; NCI: q 1-2 yrs
strong fam hx = earlier/more frequently
>50 yr: annually
10-15% false negative rate for detection of malignancies

33

BRCA1/2

5-10% br CA is hereditary
mutated BRCA1 gene = 80% risk br CA by age 65
Test if strong fam hx or Ashkenaxi Jew

34

Climacteric/perimenopause

used to describe the physiologic changes associated with the change from reproductive to nonreproductive status
2-8 yrs before menopause until 1 yr after last period
Rhythmic ovarian/endometrial responses of menstrual cycle decline/eventually stop; # responsive follicles decr with resultant decr prdxn estradiol throughout climacteric. Decr estradiol = incr FSH.
End of clim, ovary contains no follicles & endometrium atrophies = reproductive capabilities terminated

35

premature menopause

premature ovarian failure
cessation of menses before age 40

36

menopause

after menopause, LH & FSH both increased
Generally rely on cessation of menses, hypoestrogenic sx, age and consistently elevated FSH for dx of menopause

37

Lab findings of menopause

FSH: >40 mIU/mL
LH: 3-fold elevation (20-100 mIU/mL)
estradiol: <20 pg/mL

38

vaginal pH in climacteric

pH 5.0 or more

39

Some vaginal sx of climacteric

may have pruritis, leukorrhea, friability, increased susceptibility to infectino, dyspareunia

40

Urinary tract changes with climacteric

Decreased muscle tone: urethra/trigone area
Atrophic changes in urethra/periurethral tissue = stress incontinence may occur
Hypoestrogenic effects in trigone area; lowered sensory threshold to void = sensory urge incontinence may occur
Urinary urgency, frequency, dysuria d/t atrophic changes in urethra and periurethral tissue

41

Vasomotor sx of climacteric: hot flashes

75% of women get them
generally cease w/i 2-3 yrs after menopause

42

CV effects of climcateric

Lipid levels:
incr in LDL (ideal 60)

43

Cognitive fxn in menopause

memory impairment may be indirectly r/t decr estrogen secondary to hot flashes and sleep disturbance
Rish of demetia incr in healthy women 65-79 yr using ET or EPT

44

screening for cholesterol and HDL

Age 20:
Q 5 yrs

45

screening for plasma glucose

Age 45 (& younger women with risk factors):
q 3 yrs

46

Thyroid function/TSH screening

Age 65:
q 3-5 yrs
begin earlier if presence of autoimmune condition or strong family hx of thyroid dz

47

hearing screening

Age 65 & older

48

screening for visual acuity/glaucoma by opthalmologist

Age 40-64:
q 2-4 yrs
Age 65+:
q 1-2 yrs

49

Contraception >40yr

COC: safe for healthy, non-smoking, non-obese perimenopausal women. Non-contraceptive benefits may be esp attractive: relief of vasomotor sx, menstrual regulation
POP also safe option
IUD: good option, LNG may help with heavy bleeding
Barrier methods acceptable
Sterilization: most prevalent method in US among married women
Fertility awareness less effective during perimenopause with irregular cycles

50

Deciding when to stop contraception

Reaching age 55 (90% have reached menopause by then) vs 2 FSH levels while off hormonal contraceptives and using a nonhormonal contraceptive

51

HT Indications

relief of menopausal sx r/t estrogen deficiency: vasomotor instability, vulvar/vaginal atrophy
Prevention of osteoporosis
Potential reduction of risk for colon CA

52

C/I to HRT

thrmoboemobolic disorders or thrombophlebitis
Known or suspected creast cancer
Estrogen dependent CA
Liver dysfunction or dz
Undiagnosed abnormal uterine bleeding
Known or suspected pregnancy

53

Potential risks of HRT

endometrial hyperplasia/CA
Breast CA (relationship w HT inconclusive; possilbe small but signif incr witih long-term HRT)
Gallbladder dz
Thromboembolic disorders

54

Followup after HT initiation

Reevaluate in 3 months; if no problems, annually after that
Evaluate sx each time; discontinue as appropriate
Consider nonhormonal drugs for osteoporosis prevention if longterm therapy needed

55

HT regimen options

0.625 mg conjugated E or equivalent prevents osteoporosis in 90% menopausal women
10-14 days q month: 10 mg of MPA or equiv or daily doses of 2.5-5.0 mg for prevention of endometrial hyperplasia
Continuous combined: E/P daily (may have unpredictable bldg for a while before amenorrhea)
Continuous cyclic: E daily, P for 10-14 days/mo; withdrawal bleed when P done
Cyclic: E days 1-25; P last 10-14 days; then 3-6 days of nothing

56

S/E oral estrogen:

increased HDL/triglycerides;
first-pass metabolism determines results

57

effects E/EP patch

no significant impact on HDL/triglycerides;
may have less adverse effects on gallbladder and coagulation factors than oral E

58

Vaginal estrogen creams

tx vulvar/vaginal atrophy;
will NOT provide relief from vasomotor sx;
some systemic absorption
NEED cyclic progestin with intact uterus

59

Estring

little/no systemic absorption;
90 days duration
Do not need cyclic progestin

60

Femring

SYSTEMIC absorption
tx vasomotor & vulvar/vaginal atrophy
90 day duration
Requires added progestin if intact uterus

61

Topical sprays/gels/emulsions (17B-estradiol)

SYSTEMIC absorption
NO sig effect on HDL/triglycerides
May have less adverse effects on gallbladder and coag factors tahn oral E
Need cyclic progestin with intact uterus
Topical may not provide sufficient endometrial protection

62

Progestin-only HRT

effective in relieving vasomotor sx
May have +impact on Ca balance
NOT effective on vulvovaginal sx
MAY have adverse effect on lipid profile

63

Testosterone in HRT
oral/transdermal/injections/subQ

may use if E not effective enough on extreme vasomotor sx
may incr energy level, feeling of well-being, libido
S/e: acne, hirsutism, clitoromegaly
Does not appear to have neg lipid effect

64

S/E of HRT

breast tenderness (E/P; usually only few weeks)
Nausea (E; relieved if taken AC/HS)
Skin irritation w patch
Fluid retention/bloating (E/P)
Alterations in mood (E/P)
TX of S/E: lower dose, dif route, dif formulation

65

Bleeding on HT

Continuous cyclic: usually some bleeding; starts last few days P or just after. If bldg is earlier/heavy/persistent may indicate endometrial hyperplasia = eval
Continuous-combined: erratic spotting and light bldg 1-5 days in first yr; endometrial biopsy if heavier or longer than usual

66

Nonhormonal mgmt of vasomotor sx

Antidepressants (ssri, srni) gabapentin, clonidine
Avoid caffeine, alcohol, cigarettes, spicy foods, big meals
Regular, mod exercise
Vit E - anecdotal reports of relief
Soy foods, isoflavine supplements

67

False positive nontreponemal tests for syphilis

VDRL, RPR (become + by 1-2 wks after chancre)
False positives assoc with mononucleosis, collagen vascular dz, some other med conditions
Usually see low tieter 1:8

68

Treponemal tests for syphilis

FTA-ABS
TPI
reported as +/- not quantitative
Usually remain + indefinitely after tx

69

Genital herpes simplex

Gold standard: tissue culture of lesion
other tests: PCR, DNA probe, direct flourescent antibody/enzyme assay
Serum antibody test for HSV 1/2: may take 4-12 wks for seroconversion

70

trich

wet mount: motile, flagellated protozoa
Greater than 10 WBC/high power field
vag pH >4.5

71

HIV testing

Sensitive screening test: enzyme immunoassay EIA or rapid test: 99% sensitive at 12+ wks postexposure
Must be confirmed with highly specific tests: Western blot, IFA
HIV antibody detectable in 95% people by 6 months

72

Estradiol levels

Follicular: 20-150
Midcycle: 150-750
Luteal: 30-450
Postmenopause; <20

73

FSH levels

Follicular: 5-25
Midcycle: 20-30
Luteal: 5-25
Postmenopause 40-250

74

LH levels

follicular: 5-25
midcycle: 75-150
luteal; 5-40
postmenopause:30-200

75

Progesterone levels

follicular: <0.2

76

Normal Bone Mineral Density T score

BMD w/i 1 standard deviation of young normal adult
T-score above -1

77

Osteopenia

T-score between -1 and -2.5

78

Osteoporosis

T-score at or below -2.5