dec 1 Flashcards
what causes anovulatory periods vs ovulatory? (i.e. in terms of hormones)
initially have anovulatory cycles, which don’t hurt, for up to 2-5 years, irregular, due to estrogen withdrawal (can be prolonged and heavy, but should be painless)
as HPA matures then ovulatory cycles - periods are from progesterone withdrawal
Casuses of gynecomastia
Idiopathic
hypogonadism - primary or secondary
liver dissease
renal disease
hyperthyroidism
neoplasms
drugs - anti androgens, antibiotics (isoniazid, ketoconazole, metronidazole) , antacids (H2 blockers), cancer (alkylating agents) chemotherapy, CV drugs
drugs - alcohol, amphetamines, heroin, marijuana
hormones
psychoactive agents - diazepam, phenothiazine, tricyclic
Definition of primary amenorrhea
no periods by 16 with breast development
no periods by 14 without breast development
most common causes: physiologic immaturity, stress, excessive exercise, dieting
also think of the anatomical abnormalities (i.e. imperforate hymen)
if they have secondary characteristics, think of imperforate hymen with hematocolpos
if no secondary characteristics - think of endocrine causes - will have elevated FSH/LH in primary ovarian failure, should do a karyotype
Secondary amenorrhea
no periods for 3 months after having periods
chromosomal abnormalities in primary amenorrhea without secondary sex characteristics
Turner syndrome
fragile X carriers
autoimmune
primary amenorrhea with low FSH and LH
physiologic immaturity
isolated gonadotropin deficiency
hypogonadotropic hypogonadism (chronic illness, low body weight, stressful life events)
TSH and proaction should also be considered
Secondary amenorrhea - most common causes
pregnancy
anorexia/stress (will have low LH, FSH and estradiol)
PCOS - androgen excess symptoms and insulin resistance
if have hirsutism/virilization, think of late onset CAH
Patient has amnorrhea, normal secondary sex characteristics, negative pregnancy test, normal prolactin and TSH and no evidence of outflow tract obstruction , what investigation to do
progesterone withdrawal test - will help you ono if the uterus is primed by estrogen
if normal and primed, then should have bleeding within 1 week after the last progesterone tablet
if no withdrawal bleeding, then there is a then systemic estrogen deficiency
Treatment of amenorrhea
should be directed at the causes
anovulation - can manage with cyclic progesterone, withdrawal or combined hormonal contraceptives
PCOS = weight loss, exercise, progesterone withdrawal or OCP (will help to remove some of the androgen effect)
Spritonolactone - will help to treat hirsutism , and metformin can help with ovulatory cycles in PCOS
Definition of Primary dysmenorrhea and most common causes
pelvic pain during menstruation in the absence of pelvic pathology
is a feature of ovulation - so happens 1-3 years after menarche
secondary dysmenorrhea
menstrual pain associated with pelvic pathology
most frequent causes: endometriosis or PID
Investigations of dysmenorrhea
to rule out obstructing genital tract lesions - ultrasound is the usual initial screen, for endometriosis and PID - need to do laparxopy but usually only done if fail medical therapy (i.e. try it out then do the other tests)
Treatment of dysmenorrhea
Primary dysmenorrhea:
1st line - NSAIDS before or as soon as periods start, and need for 2-3 days, if don’t work, then may add OCP or long-acting reversible contraceptives; if you need contraception, then OCP can be primary
If it persists despite 4 months of OCP, then consider an alternative diagnosis
Alternative treatments: Depo, IUD (levonorgestrel releasing)
What tests should you do after sexual assault?
histoy and physical
forensic material - within 72 hours of the assault
put clothes in a paper bag f drying
examine for bruising bites, and oral, genital and ana trauma
photographs to document injuries
specimens from fingernails, mouth, vagina, pubic hair and anus
DNA from semen, saliva, blood, fingernail scrapings and pubic hair
wet mount of vaginal fluids show the presence or absence of sperm under the microscope
STI cultures (but need 72 hours for the bacterial load to be sufficient for culture)
baseline HIV and syphillis test
Therapy: prophylaxis for emergency contraception and STI and hepatitis Immune Globulin and hepatitis vaccine if indicated
option: cefixime + azithromycin
metronidazole (for BC and trichomonas)
in 3 weeks - do repeat cultures, wet mounts and a pregnancy test
then do serology for syphilis, hepatitis and HIV at 12 weeks
think about counselling
Signs that substance is being abused (and no just used)
can use CRAFT questionnaire, suggests excessive use
Car - driving under the influence
Relax - using drugs to relax, fit in, feel better
Alone - using while alone
Forgetting - forgetting things as a result of drugs/alcohol
Family/Friends - telling teen to cut down
Trouble - getting into trouble because of drugs/alcohol
