GOSH Flashcards

Question

What are the Müllerian ducts

Answer 1

A pair of embryonal ducts that give rise to the fallopian tubes, uterus, cervix, and upper one-third of the vagina in a female foetus. In a male fetus, the production of Müllerian inhibiting factor by the Sertoli cells of the testes causes degeneration of the Müllerian (or paramesonephric) ducts.

Answer 2

Incidence: 3-4/100 females Pathophysiology: - defective fusion of the Müllerian ducts during embryonal development - normally functioning gonads and female karyotype results in normal development of secondary sexual characteristics (eg breast, pubic hair development)

Answer 3

Müllerian agenesis: Both of the Müllerian ducts fail to develop, leading to the absent or hypoplastic uterus, absent cervix, and vaginal agenesis (but functional ovaries) Unicornuate uterus: One of the Mullerian ducts fails to develop Didelphic uterus: Complete lack of Mullerian duct fusion resulting in double uterus, double cervix, double vagina Bicornuate uterus: Incomplete fusion of the mullerian ducts to various degrees: - - Uterus bicornis unicollis - double uterus, single cervix, and single vagina - - Uterus bicornis bicollis - double uterus and double cervix with/without a vaginal septum Septate uterus: The mullerian ducts fuse, but the septa between the two ducts persists either partially (subseptate uterus) or completely (septate uterus) DES-related abnormality: In utero exposure to diethylstilbestrol: - Vagina: adenosine, adenocarcinoma - Cervix: cockscomb cervix, cervical collar - Uterus: hypoplasia, uterine synechiae, T shaped uterine cavity - Fallopian tube: abnormal fimbriae, cornual budding

Answer 4

Asymptomatic before puberty Infertility and dyspareunia In some cases, periodic lower abdominal pain Menorrhagia Amenorrhea Associated urological (25-50% of cases) and skeletal (10-15% of cases) malformations Increased risk of these obstetric complications: - ectopic pregnancy - cervical incompetence - preterm labor - malpresentation - obstructed or prolonged labour -retained placenta leading to postpartum haemorrhage

Answer 5

A symptom of pain that occurs during or after sexual intercourse.

Answer 6

A condition of abnormally high flow of bleeding (> 80 mL of bleeding volume) or prolonged duration of bleeding (> 8 days of menstruation) during menstrual periods.

Answer 7

An obstetric term that refers to a foetus with a part other than the head overlying the maternal pelvic inlet

Answer 8

Screening tests - Transvaginal or abdominal ultrasound - Hysterosalpingography Confirmatory test: MRI

Answer 9

Surgical treatment is usually not recommended in the following situations: - Another treatable cause of infertility co-exists - The woman is asymptomatic Metroplasty: reconstruction of the uterus Septoplasty: a type of metroplasty that only involves resection of the septum in a separate uterus

Answer 10

AKA Intrauterine adhesions | Endometrial adhesions or fibrosis

Answer 11

Following uterine dilation or curettage (most common cause) | Postinflammatory (eg chlamydia)

Answer 12

``` Usually asymptomatic Abnormal uterine bleeding Secondary amenorrhea Infertility Recurrent pregnancy loss Periodic abdominal pain ```

Answer 13

Progesterone withdrawal test: bleeding does not occur following progestin withdrawal given block of the outflow tract Hysterosalpingography: honeycomb appearance of the uterus Confirmatory test: hysteroscopy to directly visualise adhesions

Answer 14

Hysteroscopic resection of the adhesions | Treatment is only indicated if patient is symptomatic

Answer 15

A hymen without an opening A congenital defect Seen in 1:1000-2000 females

Answer 16

Central cells of the Müllerian eminence in the urogenital sinus do not disintegrate → imperforate hymen → cryptomenorrhea at puberty (outflow tract obstruction leads to backup of menstrual blood) → hematocolpos (accumulation of blood in the vagina) and/or hematometra (accumulation of blood in the uterus)

Answer 17

Asymptomatic before puberty: At birth, vaginal secretions accumulate → may be detected as a swelling in the introitus → spontaneous resolution Primary amenorrhea with periodic lower abdominal pain Possible urinary retention, frequency, dysuria Possible palpable lower abdominal mass Perineal examination: tense, bulging, bluish membrane in the vulva

Answer 18

Primarily a clinical diagnosis but imaging may be conducted to rule out transverse vaginal septum

Answer 19

Excision of the imperforate hymen (hymenectomy)

Answer 20

A condition in which the vagina is abnormally closed or absent Seen in 1/5000 female individuals Caused by Müllerian agenesis

Answer 21

Agenesis or hypoplasia of the Müllerian duct → atresia of the upper-third of the vagina Normally functioning gonads and female karyotype → normal development of secondary sexual characteristics (e.g., breast, pubic hair development) Associated anomalies: - Absent or malformed uterus and cervix (in almost all cases) - Urological malformations (25–50% of cases): single kidney, pelvic kidney, horseshoe kidney - Skeletal malformations (10–15% of cases)

Answer 22

``` Asymptomatic before puberty Primary amenorrhea Infertility Dyspareunia Perineal examination: vaginal dimple and a hymenal fringe ```

Answer 23

Normal levels of LH, FSH, prolactin, estradiol, and testosterone Ultrasound: - Absent or malformed uterus (e.g., hemiuterus, rudimentary uterus) - Normal ovaries - Possible associated malformations of the kidneys or urinary tract MRI to determine if functional endometrium is present

Answer 24

Vaginoplasty

Answer 25

Abnormal development of the sinovaginal bulbs and vaginal plate

Answer 26

Primary amenorrhea | Cyclic pelvic pain

Answer 27

Vaginal dimple may be present on physical exam Palpable abdominal mass due to distention of the upper vagina Confirmatory tests: ultrasound or MRI: - Normal ovaries, uterus, cervix, and upper vagina - Measurement of the distance from introitus to obstruction

Answer 28

Surgical pull through procedure

Answer 29

Failure of recanalization of the Müllerian duct → transverse septum in the upper-third (45%), lower third (15–20%), and/or middle third (35–40%) of the vagina Associated with cervical hypoplasia or absence Cryptomenorrhea → hematocolpos

Answer 30

``` Asymptomatic before puberty Primary amenorrhea Infertility Periodic lower abdominal pain Possibly, palpable lower abdominal mass Perineal examination: normal vulva and external genitalia ```

Answer 31

Transvaginal ultrasonography | MRI

Answer 32

First-line: nonsurgical dilation over 6–12 months using graduated vaginal dilators Second-line: vaginoplasty

Answer 33

Partial or complete adhesion of the labia minora | Occurs in 2-5% of females up to 4 y/o

Answer 34

1/70,000 females

Answer 35

Absence of estrogen → predisposition to mild infection → local inflammation → raw surface epithelium of the labia minora → adhesions In rare cases: trauma (sexual abuse), congenital defect

Answer 36

Usually asymptomatic If external urethral opening is obstructed: recurrent attacks of UTI, vaginitis, vestibulitis Perineal examination: - A thin vertical midline fold in the perineum - The labia, vaginal opening, and occasionally the urethral meatus are not visible.

Answer 37

Primarily clinical diagnosis

Answer 38

Application of topical oestrogen

Answer 39

Menstrual bleeding

Answer 40

A tightly regulated process in which the coordinated release of hormones from the hypothalamus, pituitary gland, and gonads produces a single mature oocyte. These hormones are controlled by positive and negative feedback loops.

Answer 41

Menstrual cessation | No period

Answer 42

Recurrent lower abdo pain shortly before or during menstruation (in the abscence of pathological findings that could account for those symptoms)

Answer 43

AKA ABU | Increased frequency and/or volume of menstruation

Answer 44

Discomfort prior to the onset of menstruation that is accompanies by psychiatric, gastro, and/or near symptoms

Answer 45

An immature female germ cell that can undergo oogenesis to become an ovum.

Answer 46

24-38 days (28 days on average, with the first day of menstrual bleeding counted as day 1 of the cycle First few years after menarche the cycles will be irregular due to immaturity of the hypothalamic-pituitary-gonadal axis Cycles are longest at age 25-30, with younger and older individuals having shorter cycles

Answer 47

Prevalence up to 90% Most common gynaecologic condition Mainfiestes during adolescence (typically within 3 years of menarche)

Answer 48

Not completely understood Associated with risk factors: - Early menarche - Nulliparity - Smoking - Obesity - Postive family history

Answer 49

Increased endometrial prostaglandin (PGF2 alpha) production leads to vasoconstriction/ischemia and stronger, sustained uterine contractions (to prevent blood loss).

Answer 50

Usually occurs during the first 1–3 days of menstruation Spasmodic, crampy pain in the lower abdominal and/or pelvic midline (often radiating to the back or thighs) Headaches, diarrhea, fatigue, nausea, and flushing are common accompanying symptoms. Normal pelvic examination

Answer 51

Primary dysmenorrhea is a diagnosis of exclusion. Rule out conditions that cause secondary dysmenorrhea (e.g., endometriosis).

Answer 52

Symptomatic treatment: pain relief (e.g., NSAIDs), topical application of heat Hormonal contraceptives (e.g., combined oral contraceptive pill, IUD with progestogen)

Answer 53

Recurrent lower abdominal pain shortly before or during menstruation that is due to an underlying condition

Answer 54

May begin later in life than primary dysmenorrhea | Commonly affects female individuals ≥ 25 years of age

Answer 55

Uterine causes: - Pelvic inflammatory disease (PID) - Intrauterine device (IUD) - Adenomyosis - Fibroids (intracavitary or intramural) - Cervical polyps Extrauterine causes: - Endometriosis - Adhesions - Functional ovarian cysts - Inflammatory bowel disease

Answer 56

Depend on the underlying cause Secondary dysmenorrhea should be suspected in the following cases: - Abnormal pelvic examination (e.g., uterine size, cervical motion tenderness, adnexal tenderness, masses, vaginal/cervical discharge) - The pain tends to get worse over time. - No previous history of pain with menstruation - Infertility (e.g., adhesions, endometriosis, PID) - Irregular cycles - Heavy menstrual flow (e.g., adenomyosis, fibroids, polyps) - Dyspareunia or postcoital bleeding - Partial or no response to therapy with NSAIDs and/or hormonal contraceptives

Answer 57

``` Depend on the underlying cause Initial laboratory testing CBC with differential (rules out infection) Urinalysis (rules out UTIs) Other β-hCG (rules out ectopic pregnancy), Gonococcal/chlamydial swabs (rule out STDs and PID) Pelvic ultrasound ```

Answer 58

Treat the underlying cause

Answer 59

A symptom of pain that occurs during or after sexual intercourse.

Answer 60

The absence of menarche at 15 years of age despite normal development of secondary sexual characteristics or Absence of menses at 13 years of age in female individuals with no secondary sexual characteristics

Answer 61

- Constitutional growth delay - Hypogonadotropic hypogonadism - Hypergonadotropic hypogonadism - Anatomic anomalies - Receptor and enzyme abnormalities

Answer 62

Pregnancy test Check for secondary sexual characteristics and anatomical anomalies (physical examination, pelvic ultrasound): - Uterus absent: Perform karyotyping and serum testosterone to investigate for male/female genotype and androgen sensitivity - Uterus present: Test FSH and LH levels: - -Exclude imperforate hymen, vaginal atresia, and transverse vaginal septum. - -↑ FSH: primary ovarian insufficiency (e.g., Turner syndrome, Swyer syndrome, premature ovarian failure) - -Normal or ↓ FSH: constitutional growth delay, hypogonadotropic hypogonadism If galactorrhea is present: --Check prolactin and TSH levels. If symptoms of hyperandrogenism are present: - Check serum testosterone and dehydroepiandrosterone sulfate (DHEA-S) - -If high: Suspect an androgen-secreting tumor. If blood pressure is high: Suspect congenital adrenal hyperplasia.

Answer 63

Management of the underlying cause: - anatomical anomalies - surgery - Hypogonadism - hormone replacement therapy with oestrogens and progesterone Goal of treatment is the progression of normal pubertal development

Answer 64

Before menarche After menopause During pregnancy During lactation

Answer 65

Low calorie intake/ strenuous physical activity Low bone mineral density Amenorrhea

Answer 66

Formerly known as dysfunctional uterine bleeding Defined as menstrual bleeding that is abnormal and/or irregular in frequency, duration and/or intensity It may or may not be accompanied by dysmenorrhea

Answer 67

PALM -COEIN system Structural causes (PALM): - polyps - adenomysosis - leiomyomas and malignancy and hyperplasia Nonstructual causes (COEIN): - coagulopathy - ovulatory dysfunction - endometrial - iatrogenic - not otherwise classified

Answer 68

Episodic uterine bleeding, in a nonpregnant female individual of reproductive age, that is of sufficient volume to require intervention to prevent further blood loss

Answer 69

Uterine bleeding of abnormal frequency, regularity, and/or volume that has persisted for > 6 months

Answer 70

According to aetiology AUB-C: coagulopathies AUB-O: ovulation disorders (e.g., disorders of the hypothalamic-pituitary axis) AUB-E: endometrial disorders AUB-I: iatrogenic causes (e.g., estrogens, androgens, IUD) AUB-N: not otherwise classified (e.g., uterine arteriovenous malformations, cesarean scar defect)

Answer 71

Gynae history: - Age of menarche - Last menstrual period - Cycle length and regularity - Pregnancies - FH - Recent complaints - Evaluation of possible causes guided by PALM-COEIN system - Characteristics of abnormal bleeding (frequency, regularity, duration, volume) Physical Exam: - If acute bleed - ensure haemodynamic stability - Pelvic exam- Assess the severity and source of the bleeding (exclude structural abnormalities, neoplasms and trauma) - Swabs for microbiologic testing to rule out cervicitis due to gonorrhoea/ chlamydial infection Pap smear: - rule out cervical carcinoma Initial lab testing: - FBC - anaemia - Platelet count, PT, PTT, rule out bleeding disorders - B-hCG - rules out pregnancy - Additional (TFTs, Prolactin, Serum iron) Pelvic Ultrasound: - To rule out structural anomalies - Evaluation of endometrial thickness Endometrial biopsy: - Indications vary by age group and risk factor presence - Postmenopausal w/ any uterine bleeding and/or endometrial thickness ≥ 4mm - All >45y/o with frequent, heavy, and/or prolonged bleeding - <45y/o with frequent, heavy and/or prolonged bleeding who are at high risk for endometrial cancer and/or have failed medical management

Answer 72

Day 14 (counted from last menstrual period)

Answer 73

In the fallopian tube

Answer 74

Zygote to morula to blastocyst which then enters the uterine cavity

Answer 75

23 (counted from last menstrual period), starting metal maternal dialog

Answer 76

Ampulla of the Fallopian tube

Answer 77

Blastocyst implants causes release of hCG which stimulates the ovary to produce progesterone

Answer 78

Rapidly up to 10 weeks, then plateau and potentially drop

Answer 79

Basis of pregnancy test Can be detected in serum and urine 4 weeks after last menstrual period, so just 2 weeks after conception Urine +ve when conc reaches 25IU/ml

Answer 80

Main pregnancy hormone Modifies maternal physiology: -cardio (increase in HR, stroke volume, so cardiac output increase, BP drops) -resp (less lung capacity, so SOB, may make pathology difficult to identify) -Uterine quiescence (relaxation) -Immune system (immuno suppressive - so not to reject baby, but can increase infection risk) (can be a problem in those already immunosuppressed eg HIV) -smooth muscle relaxation (constipation, UTI - urinary stasis) Can be given progesterone supplementation to mothers with late miscarriage past 20 weeks previously, as will often improve current pregnancy outcome

Answer 81

Doubles in size every week from 6 until 12 weeks gestation

Answer 82

4-5 weeks: gestational sac 6mm 5-6 weeks: yolk sac 6 weeks: foetal pole 5mm 6.5-7 weeks: foetal heart activity 8 weeks: limb buds, foetal movements

Answer 83

Crown-rump length of foetus

Answer 84

Intrinsic factors: - Maternal - - height and weight (bigger mum, bigger baby) - - parity (bigger baby the more pregnancies) - - ethnic group - Foetal - - sex (boys bigger) - - genes/inherited conditions - - multiple pregnancies (twins etc will be smaller than equivalent single foetus) Extrinsic factors: - Maternal: - - social class - - nutritional status - - environment (high altitude, smaller baby) - - pre-existion disease - - pregnancy-related disease - -- hypertension (small baby), diabetes (large baby) - Fetal - - nutrition (placenta) - - Teratogenic - - Infective - -- viral (rubella, CMV)

Answer 85

When the baby is small for gestational age, not growing as expected

Answer 86

BPD: biparietal diameter HC: Head circumference AC: Abdominal circumference (T12 level) FL: Femur length This is then plotted on percentile graphs Serial scans needed, one scan cannot prove whether constitutionally small or IUGR. However, can compare the centile plotting of head circumference and abdominal circumference, and if AC

Answer 87

Indicator of how the baby is coping Fetal breathing movements Fetal movements Fetal tone Amniotic fluid volume

Answer 88

DOPPLER to assess blood flow in foetal arteries DOPPLER doesn't measure blood flow directly but this is inferred from the wave forms on the ultrasound screen to produce the pulsatility index and resistance index If high PI and RI then sign of placental insufficiency Alterations in foetal blood flow can be an eraly indication of foetal compromise

Answer 89

A high risk pregnancy is one in which the probability of an adverse outcome in the mother and/or baby is greater than that for a pregnant woman in general A pregnancy requiring medical involvement

Answer 90

``` Maternal conditions Social factors Obstetric issues in previous pregnancy Problems in this pregnancy Problems during labour ```

Answer 91

Obesity Diabetes Hypertension Chronic disease (renal, autoimmune, respiratory..) Infections Previous surgery VTE (100x more likely for VTE in this pregnancy if previous VTE)

Answer 92

``` Teenage pregnancy Maternal age >40 High parity and low interpregnancy interval (> risk of haemorrhaging) Poor socioeconomic conditions Alcohol intake Substance abuse ```

Answer 93

``` Caesarean section Preterm delivery Recurrent miscarriage (>/=3) Stillbirth Pre-eclampsia Gestational diabetes Third degree tear ```

Answer 94

Anal sphincter 3a <50% external AS involved 3b <50% external AS involved 3c internal AS involved

Answer 95

Vaginal sphincter

Answer 96

Tear of perineal muscles

Answer 97

``` Multiple Pregnancy Small for gestation age Placenta praevia (low-lying placenta) (has to have a c-section) (will bleed a lot in surgery) Gestational diabetes Pre-eclampsia ```

Answer 98

``` Meconium stained liquor Blood stained liquor Worrying features on CTG Need for oxytocin infusion Lack of progress ```

Answer 99

Midwife / GP-led - UNCOMPLICATED PREGNANCY Consultant-led shared care - HIGH RISK PREGNANCY

Answer 100

1:200 in spontaneious labour 2-3:200 in medically induced labour

Answer 101

75% in spontaneous labour with no previous vaginal deliveries 90% in spontaneous labour with previous vaginal deliveries

Answer 102

Scarring in upper uterine segment: - classical caesarean incision - - exteme prematurity/ foetal abnormality - - placential site issues - - uterine abnormality/ fibroid position - J or inverted T incision - - usually due to difficulty during previous delivery ``` Other previous surgical complications Multiple previous C sections Short inter-pregnancy interval (<1 year) Increased risk of obstructed labour - previous history -BMI -Foetal vs maternal size ``` Don't attempt VBAC if not willing for monitored hospital birth

Answer 103

Endometrium

Answer 104

Cervix or in vagina

Answer 105

12 months free of period, Red flag for potential endometrial cancer Most common cause atrophic vaginitis

Answer 106

Pain during intercourse | Can be superficial or deep

Answer 107

Gonodotrophin Releasing Hormone Decapeptide Secreted by mid basal hypothalamic neurons Hourly pulses Transported to pituitary via hypophyseal portal blood system

Answer 108

``` Bereavement Anxiety Time zone Day/night duty Exercise Weight loss/gain ```

Answer 109

AKA Follicle stimulating hormone | Stimulates follicular activity, thus promoting estradiol production from granulosa cells

Answer 110

AKA Luteinising hormone Triggers release of egg from dominant follicle Promotes development of the corpus luteum and the production of progesterone

Answer 111

``` Primordial follicle Primary/preantral follicle Secondary/antral follicle Provulatory follicle Ovulation ```

Answer 112

Lining of the uterus where a pregnancy will implant and be nourished

Answer 113

``` Oestrogen (estradiol E2) causes endometrial proliferation Endometrium thickens Increase in stromal cells Increase in glands, blood vessels By ovulation endometrium 2-3mm thick ```

Answer 114

If allowed to continually produce and so cause continuous proliferation of the endometrium, unopposed by progesterone, it can cause cancer

Answer 115

``` Progesterone dominant hormone causing: -increasing in secretion -increase in lipids and glycogen -increase in blood supply -endometrium 4-6mm thick Optimal conditions for implantation of fertilised egg (stable, vascular, nutrient rich) ```

Answer 116

Drop in prgesterone due to death of corpus luteam

Answer 117

Stringy and runny muscus type midcycle, to facillitate sperm access at ovulation

Answer 118

Columnar glands

Answer 119

Tenacious and inelastic To prevent microbial ingress so protects the developing embryo This mucus plug is critical to pregnancy (Coreo amnioitis)

Answer 120

A constant 14 days in length

Answer 121

Is the last menstrual period | Average age at menopause is ~51 years

Answer 122

Is the time after complete cessation of menstruation Can only be known with certainty after 12 months of amenorrhoea Or 6 months with high levels of FSH and LH

Answer 123

Menopause before age of 40 y/o

Answer 124

Hormone replacement therapy

Answer 125

Recent onset (usually <30 days) Lower abdominal pain – often bilateral Abnormal vaginal discharge – often purulent Deep dyspareunia Abnormal vaginal bleeding including IMB, PCB & menorrhagia Secondary dysmenorrhoea

Answer 126

``` Obesity PCOS Type 2 diabetes Tamoxifen therapy Lynch syndrome ```

Answer 127

Attain haemodynamic stability Pharmacological: - Acute AUB: - - High dose IV conjugated equine oestrogen - - Alternatives: multidose regimens of Oral contraceptive pills or oral progestins, as well as tranexamic acid - Oculatory Bleeding: - - OCP, Progestin - - NSAIDs - - Tanexamic acid - Anovulatory bleeding: - - Progestin PO for 10 days or as an IUD - - OCPs Surgical: - Uterine dilation and curettage with concomitant hysteroscopy - Endometrial ablation - Trancatheter uterine artery embolisation - Hysteroscopy - Hysterectomy

Answer 128

Severe bleeding/ hemodynamic instability Patient unresponsive to hormonal treatment Hormonal treatment contraindicated (e.g., breast cancer, endometrial cancer) Underlying medical condition requiring surgical repair

Answer 129

Onset of symptoms 5 days before menstruation Pain: dyspareunia, breast tenderness, headache, back pain, abdominal pain Gastrointestinal changes: nausea, diarrhea, changes in appetite (food cravings) Bloating and weight gain Tendency to oedema formation Neurological: migraine, increased sensitivity to stimuli Psychiatric: mood swings, drowsiness, lethargy, exhaustion, depression, anxiety, aggressiveness, social withdrawal

Answer 130

Diagnosis is based on history and self-assessment Preexisting endocrine (e.g., thyroid disorders) and psychiatric (e.g., major depressive disorder) conditions should be ruled out.

Answer 131

The onset of severe discomfort or functional impairment prior to menstruation

Answer 132

Aka PMDD | Severe affective symptoms and behavioural changes that cause clincially significant disturbance to daily life

Answer 133

Present up to 7 days prior to the onset of menstruation for the majority of cycles within one year ≥ 5 symptoms that are marked and/or persistent (e.g., depressed mood, anxiety, anger, affective lability, sleep disturbances, change in appetite, pain, headache) Significant interference in daily life (work, home, social activities, interpersonal relationships)

Answer 134

Present in the 5 days prior to the beginning of menstruation for at least 3 consecutive cycles End within 4 days after the beginning of menstruation Interfere with normal daily life activities

Answer 135

Lifestyle changes can be beneficial (e.g., regular exercise, healthy diet, avoiding individual triggers like alcohol, caffeine, or nicotine). First-line treatment - NSAIDs (e.g., naproxen) - OCPs - SSRIs (e.g., fluoxetine) in the case of severe PMS and PMDD Dietary supplements: reduce symptoms and improve mood swings - Calcium (1,200 mg/day) [16] - Vitamin E - Vitamin D In the case of water retention/bloating: - Diuretics (e.g., spironolactone) - Magnesium

Answer 136

Physiological preovulatory pain in female individuals of reproductive age Also referred to as ovulatory or midcycle pain

Answer 137

~40% of females of reproductive age

Answer 138

Enlargement and rupture of the follicular cyst and contraction of Fallopian tubes during midcycle ovulation leading to transient peritoneal irritation from follicular fluid.

Answer 139

Recurrent unilateral lower abdominal pain (can mimic appendicitis) Pain occurs during midcycle in individuals with regular menses. Dull and achy pain which can become cramp-like Can last up to 3 days Physical examination: lower abdominal pain on palpation

Answer 140

With NSAIDs as needed

Answer 141

One of the most common endocrine disorders in women It is characterized by hyperandrogenism (which primarily manifests as hirsutism, acne, and, occasionally, virilization), oligoovulation/anovulation, and/or the presence of polycystic ovaries.

Answer 142

6-12% of women in their reproductive years in the US

Answer 143

Menstrual irregularities - Primary or secondary amenorrhea - Oligomenorrhea - Menorrhagia - Infertility or difficulties conceiving Insulin resistance and associated conditions - Metabolic syndrome (especially obesity) → ↑ risk of sleep apnea - Nonalcoholic fatty liver disease Skin conditions - Hirsutism - Androgenic alopecia - Acne vulgaris - Oily skin - Acanthosis nigricans Psychiatric conditions - Depression - Anxiety disorders

Answer 144

Multiple, brown cysts arranged in a circular pattern in the subcapsular region of the ovary Cysts are relatively small and of approximately the same size.

Answer 145

``` Ovarian hypertrophy with thick capsule Stromal hyperplasia and fibrosis Multiple enlarged cystic follicles Hyperluteinized theca cells Decreased granulosa cell layer ```

Answer 146

``` PCOS Nonclassic congenital adrenal hyperplasia Congenital adrenal hyperplasia Cushing disease Hypothyroidism Hyperprolactinaemia Androgen secreting tumor Acromegaly Ovarian hyperthecosis Placental aromatase deficiency Drug induced (eg exogenous steroid and androgen intake) ```

Answer 147

A state of excess androgen levels that causes symptoms such as growth of facial hair, deepening of the voice, and male-pattern baldness

Answer 148

Virilization: the appearance of male secondary sexual characteristics in a female individual Hirsutism: excessive male pattern hair growth (e.g., chin, upper lip, mid-sternum, abdomen, back, buttocks) Male-pattern hair loss Acne Increased muscle mass Voice deepening Clitoromegaly Rapid onset of virilization is suggestive of exogenous androgen intake or androgen-secreting tumors Manifestations of the underlying condition

Answer 149

Laboratory tests to identify hyperandrogenemia: ↑ Serum total testosterone ↓ SHBG Free androgen index Investigate for the underlying cause.

Answer 150

Medication to suppress or block androgen and manage symptoms of virilization OCP Antiandrogen drugs (e.g., spironolactone, finasteride) Treat the underlying cause (e.g., surgery for androgen-secreting tumors).

Answer 151

Criteria used to diagnose PCOS Must have 2 or more of the following (and have excluded other anocrinological conditions) -Oligoovulation and/or anovulation -Hyperandrogenism (based on clinical features or laboratory studies): Examine patients for signs of acne, alopecia, and hirsutism; obtain laboratory studies as needed. [6] -Enlarged and/or polycystic ovary on ultrasound -- Ovarian volume ≥ 10 mL -- AND/OR the presence of multiple cystic follicles measuring 2–9 mm (string-of-pearls appearance) in one or both ovaries [10]

Answer 152

``` Confirm hyperandrogenism: -Obtain in all women with clinical features of PCOS, even if features are minimal or unclear: ↑ Testosterone ↑ Androstenedione ↑ dehydroepiandrosterone sulfate ``` Rule out differential diagnoses: e.g., pregnancy, endocrine disorders A clinical picture of hyperandrogenism fulfills a diagnostic criterion of pcos, even if serum androgen levels are normal An elevated LH (with LH:FSH ratio > 2:1) is a characteristic finding in most patients with PCOS but not necessary for diagnosis. Identification of cystic follicles is not mandatory to diagnose PCOS

Answer 153

Patients with PCOS are at risk of serious comorbidities, even at a young age. It is important to screen for these at the first visit and at regular intervals. Metabolic screening and monitoring: - Measure weight, height, and waist circumference; calculate BMI. - For patients with elevated BMI: Obtain a fasting lipid profile and screen for symptoms of obstructive sleep apnea. - Check blood pressure - Assess glycemic status Mental health and quality of life: -Screen for anxiety, depression, and psychosexual dysfunction.

Answer 154

Weight loss Combined oral contraceptives: - Indication: first-line treatment for hyperandrogenism and/or menstrual cycle abnormalities - Additional benefits: - - ↓ Endometrial hyperplasia → ↓ risk of endometrial carcinoma - - ↓ Menstrual bleeding - - ↓ Acne - - Treatment of hirsutism Metformin - improves menstrual irregularities, metabolic outcomes, and weight (especially when combined with lifestyle modifications) Antiandrogens: - Controversial role - Examples: spironolactone, finasteride, flutamide - Indications: can be considered for treatment of hirsutism and androgen-related alopecia in patients unable to take or tolerate COCs Additional interventions: - Antiobesity medications - Bariatric surgery, may be considered on a case-by-case basis.

Answer 155

Letrozole: - First-line therapy for ovulation induction - Improves pregnancy and live birth rates in patients with anovulatory infertility with no other causes - Mechanism of action: aromatase inhibition reduces estrogen production, stimulating FSH secretion and inducing ovulation Clomiphene: - Alternative to letrozole - May be preferred over metformin monotherapy in obese women with anovulatory infertility - Mechanism of action: inhibits hypothalamic estrogen receptors → disruption of the negative feedback mechanism governing oestrogen production → ↑ pulsatile secretion of GnRH → ↑ FSH and LH → stimulation of ovulation Exogenous gonadotropins: - The low-dose regimen is the second-line treatment for ovulation induction. - Agents: - - Exogenous FSH - - Human menopausal gonadotropin - Indication: typically used if first-line therapies are unsuccessful; occasionally used as first-line if the drug and monitoring requirements are accessible Metformin: - Can be used as second-line monotherapy for fertility treatment. - Combination with clomiphene may increase pregnancy rates, especially in obese women. - First-line therapy for insulin resistance Additional fertility interventions: - Laparoscopic ovarian drilling: - - a laparoscopic procedure in which ovarian tissue is reduced with a laser beam or surgical needle to decrease its volume and androgen production - - this hormonal shift can induce FSH secretion and improve ovarian function in patients with polycystic ovary syndrome. - - second-line treatment for ovulation induction; can be performed as a first-line treatment if other indications for laparoscopy exist In vitro fertilization: can be offered as third-line therapy Management of other PCOS manifestations - Hirsutism: - - Nonpharmacological therapy is first-line (e.g., electrolysis, light-based hair removal via laser or photoepilation) - Acne: - - Consider topical therapies (e.g., benzoyl peroxide, topical antibiotics)

Answer 156

``` Cardiovascular disease Type 2 diabetes mellitus Increased cancer risk (before menopause) -Endometrial cancer -Ovarian cancer -Pancreatic cancer -Kidney cancer -Endocrine cancers (except thyroid) Increased miscarriage rate ```

Answer 157

Definition: the time period from the first instance of climacteric symptoms caused by fluctuating hormonal levels to one year after menopause Duration: The average length of perimenopause is 4 years.

Answer 158

Definition: the time period from the first occurrence of climacteric irregular menstruation cycles to the last menstrual period Onset: usually 45–55 years of age Characterized by increasingly infrequent menstruation

Answer 159

~49–52 years (earlier in smokers)

Answer 160

The time period beginning 12 months after the last menstrual period

Answer 161

Numerical depletion of ovarian follicles with age → ↓ ovarian function → ↓ estrogen and progesterone levels → loss of negative feedback to the gonadotropic hormones → ↑ GnRH levels → ↑ levels of FSH and LH in blood (hypergonadotropic hypogonadism) → ↑ frequency of anovulatory cycles → ovarian function eventually stops permanently

Answer 162

HAVOCS: - Hot flashes/ Heat intolerance - Atrophy of Vagina - Osteoporosis - Coronary artery disease - Sleep impairment Irregular menses to complete amenorrhea Autonomic symptoms: - Hot flushes - Vertigo - Headache Mental symptoms: - Sleep impairment - Depressed mood - Mood swings - Anxiety - Irritability - Loss of libido Atrophic features (result from an age-related drop in oestrogen levels) - Breast tissue atrophy (tenderness and reduced size) - Vulvovaginal atrophy - Urinary atrophy - - urinary incontinence - - dysuria - - urinary frequency - - urgency - - increased UTIs - Osteoporosis Weight gain and bloating Hirsutism (due to relative increase in androgens Increased risk of Coronary artery disease

Answer 163

Due to removal of ovaries (commonly after hysterectomy with bilateral salpingo-oophorectomy)

Answer 164

``` Diagnosis is usually clinical. However, certain laboratory tests may help confirm the onset/presence of perimenopause: -↓ Estrogen -↓ progesterone -↓ inhibin B -↑↑ FSH -Testosterone and prolactin levels are within normal ranges. -Vaginal pH > 4.5 -Lipid profile: -- ↑ total cholesterol -- ↓ HDL ```

Answer 165

``` Treatment is not warranted for all women approaching or undergoing menopause, as it is a normal aging process. Treatment may be considered in the following cases: Symptoms are severe enough to infringe significantly on functional capacity, and hence affect quality of life. Premature menopause Surgical menopause (e.g., post-oophorectomy) ```

Answer 166

Short term treatment of menopausal symptoms Types: Estrogen therapy: for women who have had a hysterectomy Estrogen plus progestin therapy: for women with a uterus Routes: oral, transdermal Risks Cancer Unopposed estrogen can result in endometrial hyperplasia → increased risk of endometrial cancer Estrogen plus progestin therapy → increased risk of breast cancer Cardiovascular disease: coronary heart disease, deep vein thrombosis, pulmonary embolism, stroke Gallbladder disease Stress urinary incontinence Contraindications Undiagnosed vaginal bleeding Pregnancy Breast cancer/endometrial cancer Chronic liver disease Hyperlipidemia Recent DVT/stroke Coronary artery disease

Answer 167

Non-hormonal therapy is used to treat menopausal vasomotor symptoms in women who do not want to use hormonal medications or who have contraindications for HRT. Selective estrogen receptor modulators: - tamoxifen - ospemifene - raloxifene Paroxetine: -for vasomotor symptoms (i.e., hot flashes) Clonidine and/or gabapentin

Answer 168

Permanent cessation of menses before the age of 40

Answer 169

Idiopathic Primary ovarian insufficiency Bilateeral oophorectomy

Answer 170

Failure of adequate ovarian function (endocrine as well as reproductive) before the age of 40, which often leads to premature menopause

Answer 171

Ovarian insufficiency despite adequate gonadotropin stimulation (previously called premature ovarian failure)

Answer 172

Idiopathic (90% of cases) Genetic disorders associated with ovarian hypoplasia, especially in women < 30 years (e.g., Turner syndrome, Swyer syndrome, androgen insensitivity syndrome, adrenogenital syndrome, fragile X syndrome) Autoimmune diseases (e.g., autoimmune lymphocytic oophoritis, Hashimoto thyroiditis, Addison disease, type I diabetes mellitus, pernicious anemia) Toxins: Smoking is a major risk factor. Iatrogenic: radiation and/or chemotherapy, prolonged GnRH agonist therapy, induction of multiple ovulation in infertility treatment Infectious diseases (e.g., measles, mumps, tuberculosis of the genital tract)

Answer 173

Follicular dysfunction or depletion → ↓ estrogen levels → reduced feedback inhibition of estrogen on FSH and LH → ↑ FSH and LH (usually FSH > LH)

Answer 174

Climacteric symptoms such as vaginal dryness, night sweats, hot flashes, dyspareunia, and irritability Abnormal/irregular bleeding pattern that can progress to secondary amenorrhea or permanent cessation of menstruation Infertility or reduced fertility (Pregnancy is possible via in vitro fertilization.)

Answer 175

Confirmed by two high FSH levels (> 30–40 mIU/mL) and two low estradiol levels (< 50 pg/mL) at least 1 month apart after > 3 months of menstrual irregularities in a woman under age 40 Further tests help determine the underlying cause (e.g, karyotyping, thyroid function)

Answer 176

Hormone replacement therapy | Treatment of underlying causes

Answer 177

Ovarian insufficiency due to inadequate stimulation of the ovaries by the hypothalamus and/or pituitary

Answer 178

Any vaginal bleeding that occurs after menopause in women who are not taking HRT or any unscheduled bleeding in women who are taking HRT

Answer 179

Endometrial or vulvovaginal atrophy, submucous leiomyomas, and endometrial polyps are among the most common causes of postmenopausal bleeding. Approx. 10% of cases of postmenopausal bleeding are due to endometrial cancer

Answer 180

AKA POP or Female genital prolapse The protrusion of bladder, rectum, intestines, uterus, cervix, or vaginal apex into the vaginal vault due to decreased pelvic floor support.

Answer 181

Pelvic organs are only partially outside the vaginal opening

Answer 182

Pelvic organs are everted and located outside the vaginal opening

Answer 183

The anatomy which suppots the pelvic floor and consists of: - Uterosacral ligament complex (suspends the uterus and vaginal apex from the sacrum and lateral pelvis) - Paravaginal attachments - Perineal body, perineal membrane, and the perineal muscles

Answer 184

Vaginal wall prolapse: - Anterior vaginal wall prolapse: herniated anterior vaginal wall, which is often associated with a cystocele (descent of the bladder) or urethrocele (descent of the urethra); can be due to weakness of the pubocervical fascia - Posterior vaginal wall prolapse: herniated posterior vaginal wall, which is associated with a rectocele (descent of the rectum) or enterocele (herniated section of the intestines); can be due to weakness of the rectovaginal fascia Uterine prolapse: descent of the uterus Vaginal vault prolapse: descent of the apex of the vagina Apical compartment prolapse: herniated uterus, cervix, or vaginal vault Uterine procidentia: protrusion of all vaginal walls or cervix beyond the vaginal introitus

Answer 185

Common disorder in older women

Answer 186

POP is due to an insufficiency of the pelvic floor muscles and the ligamentous supportive structure of the uterus and vagina, which may be caused by: - Multiple vaginal deliveries and/or traumatic births (greatest risk factor) - Low estrogen levels (e.g., during menopause) - Increased intraabdominal pressure (e.g., obesity, cough related to chronic lung disease and/or smoking, ascites, pelvic tumors, constipation) - Previous pelvic surgery (e.g., hysterectomy) - Congenital connective tissue disorders - Diabetes mellitus

Answer 187

Feeling of pressure on or discomfort around the perineum (“sensation of vaginal fullness”) Lower back and pelvic pain (may become worse with prolonged standing or walking) Rectal fullness, constipation, incomplete rectal emptying Prolapse of the anterior (most common) or the posterior vaginal wall: - Occurs at rest and with increased abdominal pressure - Possibly with excessive vaginal discharge on inspection, bimanual examination, and speculum examination of the patient in lithotomy position Weakened pelvic floor muscle and anal sphincter tone

Answer 188

AKA POP-Q Stage 0: no prolapse Stage 1: The most distal portion of prolapse is more than 1 cm above the level of the hymen. Stage 2: The most distal portion of prolapse is 1 cm or less proximal or distal to the hymenal plane. Stage 3: The most distal portion of prolapse is more than 1 cm from the hymenal plane but no more than 2 cm less than the vaginal length. Stage 4: The vagina is completely everted or uterine procidentia has occurred.

Answer 189

Elongation of the cervix Urethral diverticulum Pelvic floor dysfunction

Answer 190

A distinct outpouching of the urethral mucosa most often located posterolaterally in the mid and distal two-thirds of the urethra

Answer 191

Acquired (most common): - Recurrent infection of the periurethral glands - Pelvic trauma (particularly involving the vagina, bladder, or urethra) - Gynecological surgery, periurethral procedures - Vaginal delivery Congenital

Answer 192

Dysuria Dyspareunia Urinary incontinence (particularly, postvoid dribbling of urine) Tender anterior vaginal wall mass during pelvic examination

Answer 193

MRI Transvaginal ultrasound if MRI is not available/feasible Urinalysis to evaluate for other conditions (e.g., urinary tract infection or malignancy)

Answer 194

A retention cyst that results from obstruction, accumulation of fluid, and cystic dilation of the ducts that drain the paraurethral glands. Manifests with dysuria, dyspareunia, and urinary overflow incontinence. Pelvic examination typically shows masses located just lateral to the external urethral meatus.

Answer 195

Conservative management - Indicated for individuals with minor symptoms - Manual compression of the suburethral mass after voiding Surgery - Indicated for individuals with persistent symptoms, urinary calculi in the diverticulum, or suspicion of malignancy - Transvaginal diverticulectomy: is a preferred procedure

Answer 196

Inability to relax and coordinate pelvic floor muscles correctly in order to urinate and/or have bowel movements

Answer 197

Urinary incontinence, urgency, and/or dysuria Fecal incontinence Dyssynergic defecation Dyspareunia Lower back or pelvic pain Feeling of pressure on the pelvic region or rectum Pelvic muscle spasms

Answer 198

Clinical features and physical examination Pelvic ultrasound Urodynamic studies Anorectal manometry

Answer 199

Pelvic floor muscle training (e.g., Kegel exercises) and physical therapy Biofeedback and electrical stimulation: probes or electrodes are placed externally or inserted into the vagina or rectum to stimulate the pelvic floor muscles Stool softeners and muscle relaxants

Answer 200

Conservative: - First line - Insertion of a vaginal pessary to support the pelvic organs: - - A silicone or latex device that is inserted into the vagina - - Pessary insertion is not a long-term treatment! - Reduction of modifiable risk factors (e.g., avoid smoking to prevent a chronic cough, weight loss, prevent constipation) - Kegel exercises: pelvic floor muscle training (also as a preventive measure) Surgery: - Indicated for symptomatic prolapse if conservative treatment fails or the patient declines it - Obliterative surgery: colpocleisis in which the vagina is closed off or narrowed to provide more support for pelvic organs. - Reconstructive surgery (abdominal or vaginal approach): to restore the original position of the descended pelvic organs - - Sacrocolpopexy (with vaginal vault suspension and hysterectomy): fixation of the vaginal apex to the sacrum for the repair of apical or vaginal vault prolapse, with suspension and hysterectomy - - Suspension techniques: prolapsed organ is fixated or suspended using native tissues such as the endopelvic fascia, iliococcygeus muscle, uterosacral ligament, or sacrospinous ligaments. - - Colporrhaphy: reinforcement of the anterior or posterior vaginal wall for the repair of cystocele or rectocele - - Sacrohysteropexy: fixation of the cervix to the sacrum for the repair of uterine prolapse

Answer 201

``` Pressure ulcers with hemorrhage Ascending infections Urinary disorders Stress incontinence - "Masked" urinary incontinence - Obstructive uropathy Defecation disorders (e.g., constipation or fecal incontinence if the anal sphincter is weakened) Sexual dysfunction Surgical complications (e.g., recurrence) ```

Answer 202

A large variety of conditions that result in inflammation of the vulva and vagina.

Answer 203

Common causes of infectious vulvovaginitis: - Bacterial vaginosis - Vaginal yeast infection - Trichomoniasis - Aerobic vaginitis Other causes of infectious vulvovaginitis: - Gonorrhea - Chlamydial genitourinary infection - Enterobius vermicularis (especially in prepubescent girls) - Scabies (seven-year itch) - Pediculosis pubis (crabs, pubic lice)

Answer 204

``` Gardnerella vaginalis (a pleomorphic, gram-variable rod) ```

Answer 205

Lower concentrations of Lactobacillus acidophilus lead to overgrowth of Gardnerella vaginalis and other anaerobes, without vaginal epithelial inflammation due to absent immune response

Answer 206

Sexual intercourse (primary risk factor, but it is not considered an STD) Intrauterine devices Vaginal douching Pregnancy

Answer 207

Commonly asymptomatic Increased vaginal discharge, usually gray or milky with fishy odor Pruritus and pain are uncommon

Answer 208

Diagnosis is confirmed if three of the following Amsel criteria are met: Clue cells - Vaginal epithelial cells with a stippled appearance and fuzzy borders due to bacteria adhering to the cell surface - Identified on wet mount preparation: A sample of vaginal fluid/discharge is transferred to a slide and mixed with normal saline. The slide is then examined under a microscope. Vaginal pH > 4.5 Positive Whiff test: an intensified fishy odor after adding 1–2 drops of 10% potassium hydroxide to a sample of vaginal fluid Thin, homogeneous gray-white or yellow discharge that adheres to the vaginal walls

Answer 209

If asymptomatic: reassurance; often resolves without treatment If symptomatic - First-line: oral metronidazole - Alternative: topical metronidazole or clindamycin Oral probiotics

Answer 210

Acquisition of STDs (e.g., HSV2, HIV, trichomonas, gonorrhea, and chlamydia infection) Miscarriage and spontaneous abortion Preterm delivery Postpartum endometritis

Answer 211

Amsel criteria Bacterial vaginosis Clue cells Discharge (gray or milky) Electrons (pH of vaginal secretions is alkaline) Fishy odor of discharge Gestation (increased risk for miscarriage) All are the most important features of bacterial vaginosis.

Answer 212

Primarily Candida albicans | in immunosuppressed patients also Candida glabrata

Answer 213

Overgrowth of C. albicans Can be precipitated by the following risk factors: - Pregnancy - Immunodeficiency, both systemic (e.g., diabetes mellitus, HIV, immunosuppression) and local (e.g., topical corticosteroids) - Antimicrobial treatment (e.g., after systemic antibiotic treatment)

Answer 214

White, crumbly, and sticky vaginal discharge that may appear like cottage cheese and is typically odorless Erythematous vulva and vagina Vaginal burning sensation, strong pruritus, dysuria, dyspareunia

Answer 215

Pseudohyphae on wet mount with potassium hydroxide (KOH) Vaginal pH within normal range (4–4.5)

Answer 216

Recommended regimens: topical azole (e.g., miconazole, clotrimazole, butoconazole) OR single-dose oral fluconazole Recommended in pregnant women: topical azole OR nystatin pessary (where available)

Answer 217

Trichomonas vaginalis Anaerobic, motile protozoan with flagella Does not encyst and, therefore, does not survive well outside the human body Under micrscope wiggles its little tail

Answer 218

Foul-smelling, frothy, yellow-green, purulent discharge Vulvovaginal pruritus Burning sensation Dyspareunia Dysuria Strawberry cervix (erythematous mucosa with petechiae)

Answer 219

Saline wet mount of vaginal smear: motile trophozoites with multiple flagella If wet mount is inconclusive, perform culture. pH of vaginal discharge > 4.5

Answer 220

Oral metronidazole OR tinidazole for the patient and sexual partner(s) [7] Check for other sexually transmitted infections

Answer 221

“After sex, Burn the Foul, Green Tree:” | burning sensation and foul-smelling, yellow-green discharge are the features of trichomonasis.

Answer 222

Atrophic vaginits Aerobic vaginits Allergic vulvovaginitis Mechanical vulvovaginitis

Answer 223

``` Decreasing labial fat pad Vaginal soreness, dryness Dyspareunia, burning sensation after sex Discharge, occasional spotting Commonly associated with receding pubic hair ```

Answer 224

primarily a clinical diagnosis, additional tests (e.g., pH test, wet mount) are often nonspecific

Answer 225

Nonhormonal vaginal moisturizers and lubricants if mild symptoms Vaginal estrogen therapy if moderate to severe symptoms Systemic hormone therapy if vasomotor symptoms

Answer 226

Low estrogen levels (e.g., after menopause, bilateral oophorectomy, radiotherapy, chemotherapy, immunological disorders) Atrophy of epithelium in vagina and vulva

Answer 227

An inflammatory vaginitis of noninfectious origin with microbiome disturbance and secondary bacterial infection

Answer 228

Gram-negative: Escherichia coli is the most common | Gram-positive: Streptococcus agalactiae, Staphylococcus aureus, and Enterococcus faecalis

Answer 229

Lower concentrations of Lactobacillus species in the vaginal flora → increase in vaginal pH → overgrowth of aerobic pathogens may trigger vaginal immune reaction

Answer 230

Copious, yellow (purulent), odorless vaginal discharge Vaginal inflammation, redness and swelling Dyspareunia, burning sensation, itching

Answer 231

``` Negative Whiff test Vaginal pH > 4.5 Leukocytes on microscopy Increased parabasal cells Culture ```

Answer 232

Adapt treatment according to the severity of each of the three disease components (infection, atrophy, and inflammation) Antibiotics - Kanamycin OR quinolones (e.g., moxifloxacin) - Ampicillin for GBS or Enterococcus faecalis infection Local steroids Local estrogens Oral probiotics reduce the risk of remission and relapse

Answer 233

Aerobic vaginitis is related to an increased risk of preterm delivery and to other severe pregnancy-related complications (e.g., ascending chorioamnionitis, PROM, miscarriage)

Answer 234

Allergies to laundry or cleaning detergents, textile fibers, sanitary pads, etc.

Answer 235

Pruritus, redness, swelling, burning sensation

Answer 236

Special allergy diagnostics (e.g. prick/puncture, intradermal test) may be indicated if symptoms persist despite treatment.

Answer 237

Avoid irritants Soothing lotions, ice packs, and sitz baths (e.g., containing chamomile) Cortisone creams if needed

Answer 238

Pruritus (e.g., due to atopic dermatitis, psoriasis, psychosomatic conditions) Friction of tight clothes, obesity Women suffering from postmenopausal estrogen deficiency or lichen sclerosis are especially at high risk.

Answer 239

Pruritus, redness, swelling, sometimes dysuria, and/or dyspareunia

Answer 240

Special dermatological or rheumatological tests to find the cause of pruritus

Answer 241

Depends on the cause | Soothing lotions/creams, ice packs, and sitz baths (e.g., containing chamomile)

Answer 242

``` Poor hygiene (most common cause) Use of perfumed soaps and bubble baths Localized skin disorders Foreign body in the genitourinary tract In some cases, sexual abuse ```

Answer 243

Estrogen levels are lower in prepubescent girls, making the vulvar skin and vaginal mucosa very thin. This makes them more susceptible to vulvovaginitis of any cause.

Answer 244

Vaginal discharge: often bloody, purulent, or foul-smelling Pain in the lower abdomen and suprapubic region Increased urinary frequency, burning on urination, and dysuria In some cases, visible segment of a foreign body at the genital opening

Answer 245

If an infectious etiology is suspected, then appropriate Gram stain, culture, prep, DNA PCR, etc. should be conducted. Direct visualization of the foreign body, either on physical examination or by means of pelvic ultrasonography, plain pelvic radiography, vaginography, or MRI

Answer 246

In the case of foreign body: removal of foreign body - First line of treatment: warm saline irrigation of the vagina in an outpatient setting - If irrigation fails, removal under general anesthesia - Antibiotics/antifungals are usually not needed if successful removal is achieved, as the vulvovaginitis would then spontaneously resolve. Topical or oral antibiotics/antifungals Conservative measures: improving hygiene, avoidance of tight clothing

Answer 247

Pelvic inflammatory disease (PID) is caused by a bacterial infection that spreads beyond the cervix to infect the upper female reproductive tract, including the uterus, fallopian tubes, ovaries, and surrounding tissue.

Answer 248

Lifetime prevalence: ~4.5% in women of reproductive age (18–44 years) > 1 million women experience an episode of PID/year. PID is one of the most common causes of infertility.

Answer 249

Most common: - Chlamydia trachomatis - Neisseria gonorrhoeae Less common (consider coinfections): - E. coli - Ureaplasma - Mycoplasma - Other anaerobes

Answer 250

``` Multiple sexual partners Unprotected sex History of prior STIs and/or adnexitis Intrauterine devices Vaginal dysbiosis ``` Risk is lower during pregnancy; -PID development during pregnancy increases the risk of maternal morbidity and preterm births

Answer 251

Infection from the lower genital tract (e.g., vagina, cervix) ascends to infect the upper reproductive tract (endometrium, fallopian tubes, ovaries) and/or peritoneal cavity.

Answer 252

``` Endometrium: endometritis Fallopian tubes: salpingitis Ovaries: oophoritis Uterine adnexa: adnexitis Surrounding pelvic structures (parametritis) The peritoneum: (peritonitis) ```

Answer 253

Lower abdominal pain (generally bilateral), which may progress to acute abdomen Nausea, vomiting Fever Dysuria, urinary urgency Menorrhagia, metrorrhagia Dyspareunia Abnormal vaginal discharge (yellow/green color)

Answer 254

Abnormal bleeding from the uterus

Answer 255

PID should always be suspected in young, sexually active women who present with lower abdominal pain and adenexal/ cervical motion tenderness Primarily based on clinical findings Important diagnostic criteria: - Patient history: most often a sexually active young woman - Lower abdominal pain - Vaginal examination - - Cervical motion tenderness: severe cervical pain elicited by pelvic examination - - Uterine and/or adnexal tenderness - - Purulent, bloody cervical and/or vaginal discharge Blood tests: - elevated ESR - leukocytosis Pregnancy test: to rule out an (ectopic) pregnancy Cervical and urethral swab: - Gonococcal and chlamydial DNA (PCR) and cultures - Giemsa stain of discharge can show cytoplasmic inclusions in Chlamydia trachomatis infections, but not in N. gonorrhoeae infection. Imaging: - Ultrasound: free fluid, abscesses, pyosalpinx/hydrosalpinx - Exploratory laparoscopy - - Indicated in ambiguous cases and if patient does not respond to treatment - - Characteristic findings include tubal edema, erythema, and purulent exudate. - Endometrial biopsy: to confirm the presence of endometritis - Culdocentesis: aspiration of intraperitoneal fluid from the pouch of Douglas: - - Reveals nature of the fluid (e.g., serous, purulent, bloody) - - Culdocentesis is no longer a routine procedure and it has been largely replaced by ultrasound.

Answer 256

``` Ectopic pregnancy PID Appendicitis Kidney stones Ovarian cyst rupture Ovarian torsion Pelvic cellulitis Cervicitis ```

Answer 257

Inflammation of the uterine cervix

Answer 258

Infectious (most common): - C. trachomatis, - N. gonorrhea, - HSV-2 - T. vaginalis Noninfectious - Localized trauma (e.g., cervical caps, diaphragms, tampons) - Chemical irritation (e.g., contraceptive creams, latex exposure) - Malignancy ``` Risk factors Young age Multiple sexual partners New sexual partner within the last 6 months Unprotected intercourse ```

Answer 259

Often asymptomatic Usually no fever Vaginal discharge: may be purulent, blood-tinged, and/or malodorous Dyspareunia Postcoital or intermenstrual bleeding Lower abdominal or pelvic pain Symptoms of the underlying condition (e.g., genital lesions in HSV infections) Physical examination Abdominal palpation: possible tenderness/discomfort (if concomitant PID is present) Bimanual examination: motion tenderness of the cervix Pelvic examination: erythematous, edematous, friable cervix; possibly visible discharge

Answer 260

Diagnosis mainly clinical: - Mucopurulent discharge - Friable cervix on pelvic examination Further tests for identification of a pathogen: - Assess vaginal secretions for appearance, pH, leukocyte count, and visible pathogens (e.g., protozoa in T. vaginalis infections) - Swab samples for bacterial culture - NAAT for N. gonorrhea and C. trachomatis

Answer 261

Antibiotics are tailored to the causative agent Evaluate sex partner(s) of patients with infectious cervicitis. Follow-up to evaluate treatment success.

Answer 262

Pelvic inflammatory disease

Answer 263

Empirical antibiotic therapy (also consider coinfections) Outpatient regimen: - One single dose of IM ceftriaxone and oral therapy with doxycycline - Signs of vaginitis or recent gynecological instrumentation: Add oral metronidazole. Inpatient regimen (parenteral antibiotics) - Indications - - No response to or inability to take outpatient oral regimen - - Non-compliance concerns (e.g., teenagers) - - Severe illness with nausea, vomiting, and/or high fever - - Tuboovarian abscess - - Pregnancy - Possible combinations (should be administered for 14 days) - - Cefoxitin or cefotetan plus doxycycline - - Clindamycin plus gentamicin - - In the case of tuboovarian abscess: Add oral metronidazole or clindamycin (to enhance anaerobic coverage). - Switch to oral therapy with doxycycline after clinical improvement. It is better to overtreat rather than delay treatment if PID is suspected

Answer 264

Short-term complications: - Pelvic peritonitis - Fitz-Hugh-Curtis syndrome (perihepatitis) - - Inflammation of the liver capsule - - Characterized by violin-string-like adhesions extending from the peritoneum to the liver - Tubo-ovarian abscess - - A confined pus collection of the uterine adnexa - - May spread to adjacent organs (e.g., bladder, bowel) Long-term complications: - Infertility: caused by adnexitis, adhesions of the fallopian tubes and ovaries, and tubal scarring, which result in impaired ciliary function and tubal occlusion - Ectopic pregnancy - Chronic pelvic pain - Hydrosalpinx/pyosalpinx: accumulation of fluid/pus in the fallopian tubes due to chronic inflammation and consequent stenosis - Chronic salpingitis

Answer 265

Located on both sides of the inner labia Primarily function to produce mucus that moisturises the vaginal mucosa This mucus is secreted into the two ducts that appear in the posterior vaginal Introits

Answer 266

Blockage of the duct by inflammation or trauma → accumulation of secretions from gland → cyst formation

Answer 267

Often asymptomatic but can cause mild dyspareunia

Answer 268

Generally a clinical diagnosis based on physical examination. Pelvic exam: unilateral, palpable mass in the posterior vaginal introitus Biopsy is indicated if any of the following apply: - > 40 years of age - Progressive, solid, and painless mass found during pelvic exam - Not responsive to treatment - History of malignancy in the labia

Answer 269

Conservative approach - Indicated for smaller, asymptomatic cysts ≤ 3 cm - Involves sitz baths to facilitate rupture of the cyst and/or warm compresses Surgery Indicated for larger cysts > 3 cm and/or infected cysts

Answer 270

``` Bartholin gland or cyst becomes infected Usually a polymicrobial infection: -E. coli (most common) -Staphylococcus species -Streptococcus species -N. gonorrhoeae -C. trachomatis ```

Answer 271

Acute unilateral pain and tender swelling Dyspareunia Pain especially while walking and sitting Fever (~20% of cases) Prompt pain relief with discharge (indicates spontaneous rupture of abscess)

Answer 272

Pelvic exam: unilateral, tender mass surrounded by edema and erythema in the posterior vaginal introitus Possible culture STD testing at the request of the patient Consider biopsy to rule out malignancy

Answer 273

Indicated in all cases of abscess formation and large cysts (> 3 cm) Involves incision and drainage followed by marsupialisation or fistulisation with a Word catheter: - Incise the vestibule longitudinally to expose the cyst or abscess - Drain cyst or abscess. Marsupialization: indicated for recurring abscesses - Evert and suture the edges of the cyst wall to the cut edges of the vestibule. - This creates a new opening that allows free drainage. Fistulization with a Word catheter - Catheter is left in the abscess cavity for four weeks - Facilitates drainage and allows for reepithelialization In case of suspected malignancy: biopsy Surgical excision: indicated in the presence of features suggestive of malignancy (e.g., invasion of surrounding tissue) or failure of less invasive measures

Answer 274

``` Bartholin gland carcinoma Folliculitis Inclusion cysts Leiomyomas Fibroma ```

Answer 275

Epidemiology: primarily found in postmenopausal women Symptoms: gradual, solid, and painless enlargement of the Bartholin gland Diagnostics: biopsy Treatment: Resection of the lesion If surgery is not possible or as adjuvant therapy: chemotherapy and radiation

Answer 276

A female sex hormone that is produced in the ovaries and, to a lesser degree, in the adrenal glands and adipose tissues. It is essential for the development of primary and secondary sex characteristics, as well as function of the reproductive organs. It also plays a role in several other processes, including bone metabolism and liver function

Answer 277

A female sex hormone produced by the corpus luteum in nonpregnant women and, in pregnant women, by the corpus luteum graviditatis until the 10th week of gestation, after which the placenta takes over production. Progesterone plays an important role in the preparation of the endometrium for implantation of a fertilized ovum and maintenance of pregnancy.

Answer 278

Primarily takes place in the ovarian granulosa cells: - LH stimulates androgen synthesis in ovarian theca cells. - FSH stimulates conversion of androgens to oestrogens. - Conversion of androgens to oestrogens is catalyzed by the aromatase enzyme Also produced in other aromatase-containing tissues: - Fatty tissue - Placenta - Testicles - Adrenal glands

Answer 279

There are three types of oestrogen: estradiol, estrone, and estriol. Potency: estradiol > estrone > estriol During pregnancy, estrogen concentration increases: - Estradiol and estrone: 100-fold increase - Estriol: 1000-fold increase (it is secreted by the placenta as unconjugated estriol and a marker of fetal health) When oestrogen binds to its receptor in the cytoplasm, a hormone-receptor complex is formed that translocates to the nucleus.

Answer 280

Potentially due to oestrogen production in adipose tissue

Answer 281

Measurement of unconjugated estriol (uE3 or free estriol) is part of the prenatal screening for fetal anomalies (i.e., triple screen test and quad screen test). Decreased levels are associated with Down syndrome, Edward syndrome, molar pregnancy, and fetal demise.

Answer 282

Estrogen is a steroid hormone that promotes female sexual development and stimulates the growth and maturation of primary and secondary sex characteristics. GENITALIA/SEX CHARACTERISTICS: Uterus: - Endometrial proliferation - ↑ Myometrial excitability Cervix: - ↑ Production of cervical mucus: facilitates passage of sperm - Facilitates cervical dilation during labor Vagina: proliferation of epithelium Pubis: hair growth Breast: breast growth EXTRAGENITAL TISSUE: Bones: ↑ bone formation by inhibiting bone resorption (induces osteoclast apoptosis) Blood vessels: protective effect against atherosclerosis Blood clotting: ↑ risk of thrombosis Kidneys: ↑ water and sodium retention (may contribute to oedema) Protein synthesis - Slightly ↑ (anabolic effect) - ↑ Transport proteins (e.g., SHBG) Adipose tissue: female distribution of adipose tissue Liver: - ↓ Bilirubin excretion - ↑ HDL and ↓ LDL

Answer 283

Adverse effects of oestrogen can arise from high levels secondary to increased endogenous production or medication (e.g., hormone replacement therapy during menopause): - ↑ Cancer risk - - Endometrial cancer - - Breast cancer - Thrombosis - Spider nevi, gynecomastia, and testicular atrophy in individuals with cirrhosis - Breast hypertrophy, gynecomastia (in men), galactorrhea - Weight gain (oedema) - Liver toxicity - Nausea and vomiting - Depressive moods

Answer 284

Reduces risk of colon cancer

Answer 285

A condition of increased circulating oestrogen

Answer 286

↑ Estrogen production (e.g., due to ovarian tumors, obesity) Excess estrogen supplementation (e.g., due to hormone replacement therapy) ↓ Metabolism and excretion of estrogens (e.g., due to chronic liver disease)

Answer 287

Both sexes: - palmar erythema - spider telangiectasias Men: - Gynecomastia - Testicular atrophy - Reduced libido - Erectile dysfunction - Infertility - ↓ Body hair (e.g., loss of chest hair, female pattern of pubic hair distribution) Women: - Menstrual irregularities - Enlargement of the breast and uterus - Infertility - ↑ Cancer risk (e.g., endometrial cancer)

Answer 288

A condition of decreased circulating estrogen

Answer 289

Menopause Ovarian insufficiency: idiopathic or secondary to an underlying conditions (e.g., Turner syndrome, polycystic ovary syndrome) Congenital aromatase deficiency (↓ aromatase → ↑ androgens and ↓ estrogen) Hyperprolactinemia (e.g., in pituitary adenomas, hypothyroidism) GnRH agonists

Answer 290

``` Hot flashes Headaches Reduced libido Breast atrophy ↓ Bone density and secondary osteoporosis Urogenital atrophy Dyspareunia ```

Answer 291

In nonpregnant women: granulosa cells of the corpus luteum In pregnant women - Until the 10th week of gestation: corpus luteum graviditatis - From 10th week of gestation: placenta (syncytiotrophoblast)

Answer 292

The effects of progesterone are mediated via intracellular receptors. GENITALIA/SEX CHARACTERISTICS: Uterus: - Endometrial glandular secretion and spiral artery development - Inhibits endometrial hyperplasia - ↓ Estrogen receptor expression - ↓ Myometrial excitability Cervix: -↓ cervical mucus production → cervical mucus thickening (inhibits entry of spermatozoids to the uterus) Breasts: -inhibits prolactin (the decrease in progesterone levels after delivery disinhibits prolactin, triggering lactation) EXTRAGENITAL TISSUE: Hypothalamus: - ↑ Body temperature (basis of basal body temperature contraception method) - Inhibits gonadotropin secretion ROLE IN MENSTRUAL CYCLE: - After ovulation, the ruptured follicle transforms into the corpus luteum, which produces progesterone. - Progesterone induces changes in internal reproductive organs required for proper implantation of a zygote and inhibits the secretion of FSH and LH, preventing other follicles from developing.

Answer 293

Associated pathologies: low levels of progesterone are associated with infertility, premature birth, and spontaneous abortion Synthetic progesterone derivatives (progestins) are indicated for the following conditions: - Hormonal contraception - Treatment of abnormal uterine bleeding - Treatment of endometriosis - Treatment of endometrial cancer - Hormone replacement therapy (prevent endometrial proliferation induced by estrogens) - Progesterone withdrawal test

Answer 294

Absence of breast tissues and nipples

Answer 295

Presence of accessory breast tissue

Answer 296

Absence of nipples

Answer 297

Presence of accessory nipples

Answer 298

Unilateral aplasia/hypoplasia of the pectoral is muscles and breast with associated fingers abnormalities (eg brachysyndactyly) Most commonly develops on the right side

Answer 299

Disorders during the process of the mammary ridge regressing in the 7th to 8th week of embryonal development

Answer 300

``` Amastia Polymastia Athelia Polythelia Poland syndrome ```

Answer 301

Benign breast changes characterised by the formation of fibrotic and/or cystic tissue

Answer 302

Most common benign lesion of the breast Primarily in premenopausal women 20–50 years of age Up to 50% of women are affected during their lifetime.

Answer 303

Nonproliferative lesions: - Cysts: dilated, fluid-filled ducts (blue dome cysts) - Stromal fibrosis (no malignant potential) - Apocrine metaplasia Proliferative lesions (occur with or without atypical cells): - Sclerosing adenosis - - Proliferation of small ductules and acini in the lobules - - Stromal fibrosis - - Calcifications (slightly increased risk of breast cancer) - Ductal epithelial hyperplasia (ductal hyperplasia) - - Epithelial hyperplasia of terminal duct cells and lobular epithelium - - Presence of atypical cells is associated with an increased risk of breast cancer. - - Papillary proliferation (papillomatosis) is a type of ductal hyperplasia that has a papillary histopathological appearance.

Answer 304

Premenstrual bilateral multifocal breast pain Tender or nontender breast nodules Clear or slightly milky nipple discharge

Answer 305

The number of times a woman has been pregnant, regardless of pregnancy outcome (includes current pregnancy)

Answer 306

No history of pregnancy

Answer 307

History of one pregnancy (eg. currently pregnant)

Answer 308

History of two or more pregnancies

Answer 309

The number of pregnancies that a woman carries beyond 24 weeks of gestation, regardless of whether the child was born alive or was stillborn

Answer 310

No history of completed pregnancy beyond 24 weeks

Answer 311

A history of one completed pregnancy beyond 24 weeks

Answer 312

A history of multiple completed pregnancies beyone 24 weeks

Answer 313

Counted as completed weeks of gestation and completed days (0–6) of the current week of pregnancy Gestational age: estimated fetal age (in weeks and days) calculated from the first day of the last menstrual period Conceptional age: the age (in weeks and days) of the fetus calculated from the day of conception (fertilization)

Answer 314

40 weeks (280 days)

Answer 315

A pregnancy that extends beyond 42 weeks gestation

Answer 316

Live birth occurring between 20-25 weeks of pregnancy

Answer 317

Live birth before the completion of 37 weeks

Answer 318

37-42 weeks

Answer 319

``` First trimester (weeks 1–13) Second trimester (weeks 14–26) Third trimester (weeks 27–40) ```

Answer 320

``` Amenorrhea Nausea and vomiting Breast enlargement and tenderness Linea nigra: darkening of the midline skin of the abdomen Hyperpigmentation of the areola Abdominal bloating and constipation Increased weight gain Cravings for, or aversions to, certain foods Increased urinary frequency Fatigue ```

Answer 321

Goodell: - Cervical softening - First 4 weeks Telangiectasias and palmar erythema: -Small blood vessels and redness of the palms First 4 weeks Ladin: - Softening of the midline of the uterus - First 6 weeks Hegar: - Softening of the lower segment of the uterus - Between 6 to 8 weeks Chadwick: - Bluish discolouration of vagina and cervix - Between 6 to 8 weeks Chloasma: -Hyperpigmentation of the face (forehead, cheeks, nose)

Answer 322

Placental syncytiotrophoblast

Answer 323

Maintenance of the corpus luteum during the first 8–10 weeks of pregnancy (LH has a similar function) Luteal-placental shift: levels decrease after corpus luteum involution (placenta starts synthesizing its own estriol and progesterone)

Answer 324

Pregnancy test: measurement of human chorionic gonadotropin (β-hCG) Urine β-hCG test (e.g., home pregnancy test): - Qualitative test (less sensitive than serum pregnancy test) - β-hCG can be detected in urine 14 days after fertilization Serum β-hCG test: - Quantitative test (high sensitivity) - Detectable 6–9 days (on average) after fertilization

Answer 325

Confirms pregnancy At 5 weeks of pregnancy: detection of the gestational sac (corresponds with a serum β-HCG level of 1500–2000 mIU/mL) At 5–6 weeks of pregnancy: detection of the yolk sac At 6–7 weeks of pregnancy: detection of the fetal pole and cardiac activity with transvaginal ultrasound At 10–12 weeks of pregnancy: detection of fetal heartbeat with doppler ultrasound At 18–20 weeks of pregnancy: fetal movements

Answer 326

Used to calculate the expected date of delivery (due date) First day of the last menstrual period + 7 days + 1 year - 3 months

Answer 327

Inaccurate if: - The date of the last menstrual period is uncertain or unknown - The patient has irregular menstruation cycles - The patient conceived while taking contraceptive pills

Answer 328

More accurate than Naegele rule Measurement of the crown-rump length (CRL) in the first trimester Measurement of biparietal diameter, fetal femoral length, and abdominal circumference in the second and third trimesters (can be used for determining gestational age starting at 13 weeks)

Answer 329

The length from the top of the uterus to the top of the pubic symphysis: -Used to assess fetal growth and development from approx. 20 weeks' gestation onwards -Development is approx. 1 cm/week after 20 weeks Correlates with gestational age

Answer 330

Increased pressure from the uterus, lumbar lordosis, and relaxation of the ligaments supporting the joints of the pelvic girdle

Answer 331

Lower back pain - Particularly between the posterior iliac crest and the gluteal fold and in the area of the sacroiliac joint - May radiate to the thighs and hips - Worsens with weight-bearing

Answer 332

Positive pelvic pain provocation tests (e.g., posterior pelvic pain provocation test, FABER test, active straight leg raise)

Answer 333

Nonpharmacological: heat therapy, manual therapy (e.g., massage, spinal manipulation), braces, physical therapy Pharmacological: regular analgesia (paracetamol)

Answer 334

Stretching of the round ligament of the uterus as the uterus expands One of the most common conditions during pregnancy

Answer 335

Typically manifests in the second and third trimester Sharp pain in the lower abdomen and groin area (most often right-sided) Triggered by sudden and/or rapid movements (e.g., rolling over in bed, sneezing, vigorous physical activity)

Answer 336

Based on clinical history

Answer 337

Usually no treatment required | Resolves after delivery

Answer 338

Spider angioma Palmar erythema Striae gravidarum: scarring that manifests as erythematous, violaceous, and/or hypopigmented linear striations on the abdomen Hyperpigmentation: chloasma, linea nigra, hyperpigmentation of the nipples

Answer 339

Severe anemia Restrictive lung disease Hemodynamically significant heart disease Cervical insufficiency Premature rupture of membranes Gestational hypertension and preeclampsia Physical activity should be discontinued in the event of the following: - antepartum or postpartum hemorrhage - uterine contractions - amniotic fluid leakage - chest pain - dyspnea before exertion - dizziness - headaches - calf pain/swelling - and/or muscle weakness with impaired balance.

Answer 340

- Family history (medical and obstetric) of complicated pregnancies - Personal history - Advanced maternal age (> 35 years) - First pregnancy - Multiple pregnancies - Multiparity (> 5 births) - Medical conditions (e.g., antiphospholipid syndrome, hypertension, diabetes mellitus, epilepsy, malignancies) - Social and environmental factors (e.g., drug use, stress) - Preexisting gynecological conditions (e.g., uterine leiomyoma, history of uterine surgery) - Prior complicated pregnancies - Premature delivery (< 38 weeks), baby with low birth weight, or a baby born with congenital defects - Prior cesarean delivery - Rhesus incompatibility - History of > 2 abortions or placental abruption - Use of assisted reproductive technologies: in vitro fertilization, ICSI - Complications that arise during pregnancy

Answer 341

Amount of amniotic fluid is less than expected for gestational age

Answer 342

Fetal anomalies: - Urethral obstruction (e.g., posterior urethral valves) - Bilateral renal agenesis - Autosomal recessive polycystic kidney disease (ARPKD) - Chromosomal aberrations (e.g., trisomy 18) - Intrauterine infections (e.g., congenital TORCH infections) - In multiple pregnancies: twin-to-twin transfusion syndrome Maternal conditions: - Placental insufficiency - Late or postterm pregnancies (> 42 weeks of gestation) - Premature rupture of membranes - Preeclampsia Idiopathic

Answer 343

Small abdominal girth and uterine size for gestational age Ultrasound: determine amniotic fluid and assess for fetal anomalies Amniotic fluid index (AFI): a semiquantitative tool used to assess amniotic fluid volume (normal range: 8–18 cm) - Determined by dividing the uterus into 4 quadrants, holding the transducer perpendicular to the patient's spine, and adding up the deepest vertical pocket of fluid in each quadrant. - Oligohydramnios: ≤ 5 - In pregnancies < 24 weeks and multiple gestations, the single deepest pocket is used (normal range: 2–8 cm).

Answer 344

Amnioinfusion: infusion of fluid into the amniotic cavity through amniocentesis Treat underlying cause Delivery is advised if the fetus is close to term

Answer 345

Intrauterine growth restriction (due to diminished mobility of the fetus) Birth complications (e.g. umbilical cord compression) Potter sequence

Answer 346

Pulmonary hypoplasia (cause of death due to severe neonatal respiratory insufficiency) Craniofacial abnormalities (e.g., prominent epicanthal and infraorbital folds, flattened nose, receding chin, low set ears) Wrinkling of the skin Limb anomalies (e.g., bowed legs, clubbed feet)

Answer 347

POTTER sequence: Pulmonary hypoplasia (lethal), Oligohydramnios (origin), Twisted facies, Twisted skin, Extremity deformities, and Renal agenesis (classic form).

Answer 348

Excessive amniotic fluid volume expected for gestational age that results in uterine distention.

Answer 349

Typically idiopathic (∼ 70% of cases) Fetal anomalies: - Gastrointestinal (e.g., esophageal atresia, duodenal atresia and stenosis): reduced swallowing and absorption of amniotic fluid - CNS: anencephaly (leads to impaired swallowing of amniotic fluid, leakage of cerebrospinal fluid, and increased urination due to lack of fetal ADH), meningomyelocele (due to leakage of cerebrospinal fluid) - Pulmonary: cystic lung malformations - Multiple pregnancy: twin-to-twin transfusion syndrome - Fetal anemia - Chromosomal aberrations - Intrauterine infections (e.g., congenital TORCH infections) Maternal conditions: - Diabetes mellitus - Rh incompatibility (e.g., hemolytic disease of the newborn)

Answer 350

Physical examination: abdominal girth and uterine size large for gestational age Ultrasound - AFI ≥ 25 - Assess for fetal anomalies Others Rh screen Blood glucose

Answer 351

Amnioreduction: drainage of excess amniotic fluid Treat the underlying cause (e.g., glycemic control in diabetic mothers, intrauterine exchange transfusion in hemolytic disease of the newborn)

Answer 352

``` Fetal malposition Umbilical cord prolapse Premature birth Premature rupture of membranes Premature uterine contractions ```

Answer 353

Advanced maternal age (≥ 35 years) Previous multiple pregnancy Use of assisted reproductive technology Maternal family history of dizygotic twins

Answer 354

Monozygotic: - ie identical - 1/3 of all twin pregnancies - Division of the fertilised oocyte into two embryonic layers - Genetically identical - Can share amniotic sac and placenta in various ways: - - Monochorionic-diamniotic: The twins share a single chorionic sac (the twins share a placenta) but have a separate, individual amniotic sac - - Monochorionic-monoamniotic: The twins share a single chorionic sac (the twins share a placenta) and a single amniotic sac - - Monochorionic-monoamniotic (conjoined twins): The twins share a single chorionic sac (the twins share a placenta) and a single amniotic sac and are conjoined Dizygotic: - ie fraternal - 2/3 of all twin pregnancies - Fertilisation of two oocytes with two mature spermatozoa - Genetically different - Dichorionic-diamniotic: The twins have separate chorionic sacs (separate placentas) and separate amniotic sacs.

Answer 355

A FOUR-wheeler has SPACe for twins. 1st four days (0–3): Separate placenta and amniotic sac 2nd four days (4–7): shared Placenta 3rd four days (8–11): shared Amniotic sac Day 12 and beyond: Conjoined twins.

Answer 356

Physical examination: - Fundal height and abdominal girth are unusually large for the gestational age. - Two or more fetal heart rates can be heard on auscultation. Ultrasound: - Evidence of more than one fetus - Differentiation between monochorionic and dichorionic twins during early pregnancy - - Dichorionic twins: lambda sign: Both chorionic cavities are separated from one another. Separation of the chorionic and amniotic sacs resembles the Greek symbol λ (lambda) on ultrasound. - - Monochorionic twins: T-sign: One chorionic cavity is present and each twin has an individual amniotic sac. Separation of the amniotic sacs resembles the letter T on ultrasound.

Answer 357

Almost all complications associated with normal pregnancies are more likely in multifetal pregnancies. Maternal illnesses: - Preterm labor and birth (most common complication) - Hyperemesis gravidarum - Gestational diabetes - Preeclampsia, eclampsia, pregnancy-induced hypertension - Cervical incompetence, premature rupture of membranes - Placental insufficiency, hypotrophy, and intrauterine malnutrition of at least one fetus - Uterine atony - Miscarriage or loss of one fetus during the first trimester - Placenta previa - Increased risk of maternal morbidity Birth complications: - prolonged first stage of labor - premature placental abruption after birth of the first fetus - prolapsed cord Fetal illnesses: -Spontaneous reduction or vanishing twin syndrome: can occur during the first trimester -Twin-to-twin transfusion syndrome: -- Affects 10–15% of monochorionic twin pregnancies -- Blood is continuously shunted from one twin to the other through vascular anastomoses on the shared placenta, posing a risk to both fetuses. -- (Recipient twin: Polycythemia Hypervolemia Polyhydramnios in diamniotic pregnancies) -- (Donor twin: Anemia Growth retardation Hypovolemia, dehydration (stuck twin or cocooned appearance) Oligohydramnios in diamniotic pregnancies) -Cord entanglement: can occur only in monoamniotic twin pregnancies -Increased risk of neonatal morbidity (growth restrictions, prematurity, cerebral palsy, congenital abnormalities) and mortality

Answer 358

Indications for Cesarean delivery: - Monochorionic-monoamniotic twin pregnancies between 32–34 weeks' gestation - Breech presentation - Significant difference in fetal weight Indication for vaginal delivery: -Diamniotic twins ≥ 32 weeks with one fetus in vertex presentation - Indication for induction of labor: - Dichorionic-diamniotic twin pregnancy at 38 weeks gestation

Answer 359

A pregnancy in which the fertilised egg attaches in a location other than the uterine endometrium

Answer 360

A pregnancy that occurs within the fallopian tube

Answer 361

A pregnancy that occurs within the interstitial portion of the fallopian tube (ie the bit that connects the tube to the endometrial cavity)

Answer 362

A rare condition involving multiple gestations in which one is intrauterine and another is ectopic Occurs more frequently in patients undergoing infertility treatments (eg IVF)

Answer 363

Fallopian tube (∼ 95% of cases): - Ampulla (∼ 70%) - Isthmus (∼ 15%) - Fimbriae (∼ 8%) - Interstitial/cornual pregnancy (∼ 2%): implantation of gestational sac in the cornua of a bicornuate or septate uterus Ovary (∼ 3% ) Abdomen (∼ 1%) Cervix (< 1%)

Answer 364

Anatomic alteration of the fallopian tubes: - History of PID (e.g., salpingitis) - Previous ectopic pregnancy - Surgeries involving the fallopian tubes - Endometriosis - Ruptured appendix - Kartagener syndrome - Exposure to diethylstilbestrol (DES) in utero - Bicornuate uterus Nonanatomical risk factors: - Smoking - Advanced maternal age - Pelvic inflammatory disease - Intrauterine device - In vitro fertilization - Hormone therapy

Answer 365

Patients usually present with signs and symptoms 4–6 weeks after their last menstrual period. Lower abdominal pain and guarding (ectopic pregnancy is often mistaken for appendicitis due to the similarity of symptoms) Possibly, vaginal bleeding Signs of pregnancy: - Amenorrhea - Nausea - Breast tenderness - Frequent urination Tenderness in the area of the ectopic pregnancy Cervical motion tenderness, closed cervix Enlarged uterus Interstitial pregnancies tend to present late, at 7–12 weeks of gestation, because of myometrial distensibility.

Answer 366

Acute course with sudden and severe lower abdominal pain (acute abdomen) Signs of hemorrhagic shock (e.g., tachycardia, hypotension, syncope) (In some cases acute hemorrhage may lead to bradycardia) More common in interstitial pregnancy

Answer 367

Indication: best initial imaging test for determining the location of the pregnancy Supportive findings: - Empty uterine cavity in combination with a thickened endometrial lining - Possible free fluid within the pouch of Douglas (unspecific) - Additional findings in tubal pregnancy: - - Possible extraovarian adnexal mass - - Tubal ring sign (blob sign): an echogenic ring that surrounds an unruptured ectopic pregnancy - Additional findings in interstitial pregnancy - - Interstitial line sign: an echogenic line that extends from the gestational sac into the upper uterus (thought to be the echogenic appearance of the interstitial portion of the tube) - - A thin myometrial layer (< 5 mm) surrounding the gestational sac Additional considerations Ultrasound findings in normal pregnancy: In an intrauterine pregnancy at 5–6 weeks' gestation, a gestational sac and yolk sac are visible in the uterus. If the gestational sac cannot be seen at all on ultrasound, the patient is diagnosed with pregnancy of unknown location.

Answer 368

Exploratory laparoscopy

Answer 369

Stabalise patient Refer immediately to obs and gynae for emergnecy surgery If stable, determine whether medical, surgical or expectant management Supportive management: - pain relief - prenatal and contraceptive counselling following treatment - anti-D immunoglobulin for Rh-neg patients with bleeding ``` Medical therapy: Methotrexate (first line) -Mechanism of action: inhibits folate-dependent steps in DNA synthesis to terminate the rapidly dividing ectopic pregnancy. -Indications: -- Uncomplicated ectopic pregnancies -- Hemodynamically stable patients -- Unruptured mass -- β-hCG ≤ 2,000–5,000 mlU/mL -- Mass size < 3.5 cm -- No fetal heartbeat -Absolute contraindications: -- Chronic conditions --- Pulmonary (e.g., severe asthma) --- Renal (e.g., creatinine clearance < 50 mL/min/1.73 m2) Hepatic (e.g., alcohol use disorder or chronic liver disease) --- Hematologic (e.g., leukopenia, thrombocytopenia, severe anemia) --- Intrauterine pregnancy --- Breastfeeding --- Methotrexate sensitivity --- Immunodeficiency --- Peptic ulcer disease --- Ruptured ectopic pregnancy ``` Non-urgent surgical management: - Indications for nonurgent surgery - - Contraindications for MTX - - Unsuccessful medical treatment - - A concurrent surgical procedure (e.g., bilateral tubal blockage) is necessary. - - The patient has indicated a preference for surgical treatment. - Approach Laparoscopy (preferred) - Procedure: salpingostomy, i.e., removal of ectopic pregnancy without removing the affected fallopian tube (tube‑conserving operation) - - Preferred in patients with unruptured tubal pregnancy who do not meet the criteria for conservative treatment - - Complications - -- Risk of persistent ectopic pregnancy - -- Risk of repeat ectopic pregnancy - -Additional considerations - -- Patients require serial hCG measurement. - -- Consider a prophylactic dose of MTX if there is concern for incomplete resection. - - Salpingectomy may be required in select cases (e.g., large ectopic mass). Expectant management: Asymptomatic patients with very low β-hCG levels may experience spontaneous resolution of ectopic pregnancy -Indications -- Minimal symptoms -- No evidence of ectopic mass on TVUS -- Confirmed plateauing or decreasing serial β-hCG levels -Considerations during expectant management -- Provide extensive counseling on the risks of complications in addition to general counseling. -- Arrange close surveillance and serial β-hCG measurement (e.g., every 2–7 days). -Conversion to medical or surgical therapy -- Increasing symptoms, e.g., pain, signs of ruptured ectopic pregnancy -- Insufficient decrease, persistent plateau, or increase in β-hCG levels

Answer 370

ABCDE approach for patients with obvious signs of rupture and those at high risk of impending rupture. Suspect ruptured ectopic pregnancy in patients in their first trimester with any of the following: - Clinical features of shock: e.g., tachycardia, hypotension, pallor - Severe abdominal or pelvic pain - Peritoneal signs on examination - Significant vaginal bleeding - Clinical deterioration after receiving MTX therapy Acute stabilisation: - Start immediate IV fluid resuscitation. - Rapidly deliver blood transfusion as soon as blood products are available. - If hypotension persists, start vasopressors Surgical management: - Indications for emergency surgery - - Hemodynamic instability - - Symptoms of impending rupture (e.g., severe pelvic pain) - - Signs of intraperitoneal bleeding: e.g., peritonitis, POCUS positive for free fluid - - Risk factors for rupture - Approach: Laparotomy is preferred for large intraperitoneal bleeding or critically unstable patients, otherwise a laparoscopic approach is typically performed. - Procedure: - - Salpingectomy, i.e., partial or complete removal of the affected fallopian tube (does not preserve tube function) - - Preferred approach for: - -- Ruptured tube - -- Heavy bleeding - -- Large ectopic mass - -- Severe damage to the fallopian tube - -Additional considerations - -- If the patient desires future pregnancies: Evaluate the status of the contralateral fallopian tube before salpingectomy. - - If the patient does not desire future pregnancies: Bilateral salpingectomy may be performed.

Answer 371

The condition is fatal for the fetus. Maternal mortality rate: ∼ 0.6/100,000 in the US Future fertility: depends primarily on the fertility status prior to the ectopic pregnancy Recurrence: Approx. 10% Risk factors: - History of previous spontaneous miscarriage - Tubal damage - Age > 30 years

Answer 372

AKA pregnancy induced hypertension Pregnancy-induced hypertension with onset after 20 weeks' gestation without proteinuria or end-organ dysfunction Defined as a systolic blood pressure ≥ 140 mmHg or diastolic blood pressure ≥ 90 mmHg on 2 separate measurements at least 4 hours apart When hypertension is diagnosed < 20 weeks' gestation, the diagnosis is chronic hypertension and is not due to pregnancy.

Answer 373

New-onset gestational hypertension with proteinuria or end-organ dysfunction

Answer 374

Pre-eclampsia that occurs in a patient with chronic hypertension

Answer 375

A life-threatening form of pre-eclampsia characterized by Hemolysis, Elevated Liver enzymes, and Low Platelets May occur without hypertension or proteinuria

Answer 376

Occurrence of new-onset hypertension, proteinuria, or end-organ dysfunction at < 20 weeks gestation

Answer 377

A severe form of pre-eclampsia with convulsive seizures and/or coma

Answer 378

Persistent hypertension after delivery that generally resolves within 12 weeks If hypertension lasts > 12 weeks postpartum, a secondary cause should be considered.

Answer 379

The three primary features of PREeclampsia are - Proteinuria - Rising blood pressure (hypertension) - End-organ dysfunction.

Answer 380

Hypertensive pregnancy disorders occur in 6–8% of pregnancies. Preeclampsia: 5–7% of pregnancies Eclampsia: < 0.1% of all deliveries HELLP syndrome: 0.5–0.9% of all pregnancies

Answer 381

General risk factors: - Thrombophilia (e.g., antiphospholipid syndrome) - < 20 or > 35 years of age - African-American descent - Diabetes mellitus or gestational diabetes - Chronic hypertension - Chronic renal disease (e.g., SLE) - Obesity (BMI ≥ 30) Pregnancy-related risk factors: - Nulliparity - Multiple gestation (e.g., twins) - Hydatidiform mole - Previous preeclampsia - Chromosomal anomalies or congenital structural anomalies - Family history

Answer 382

``` Asymptomatic hypertension Nonspecific symptoms (e.g., morning headaches, fatigue, dizziness) can occur. ```

Answer 383

Preeclampsia without severe features: - Usually asymptomatic - Nonspecific symptoms may include: - - Headaches - - Visual disturbances - - RUQ or epigastric pain - - Rapid development of oedema - Hypertension - Proteinuria Preeclampsia with severe features: - Severe hypertension (systolic BP ≥ 160 mmHg or diastolic BP ≥ 110 mmHg) - Proteinuria - Oliguria - Headache - Visual disturbances (e.g., blurred vision, scotoma) - RUQ or epigastric pain - Pulmonary edema - Cerebral symptoms (e.g., altered mental status, nausea, vomiting, hyperreflexia, clonus)

Answer 384

Onset: most commonly > 27 weeks' gestation (∼ 30% occur postpartum) Preeclampsia usually present (∼ 85%) Nonspecific symptoms: nausea, vomiting, diarrhea RUQ pain (liver capsule pain; liver hematoma) Rapid clinical deterioration (DIC, pulmonary edema, acute renal failure, stroke, abruptio placentae)

Answer 385

Onset: The majority of cases occur intrapartum and postpartum. Most often associated with severe preeclampsia Eclamptic seizures: generalized tonic-clonic seizures (usually self-limited)

Answer 386

Disseminated intravascular coagulation A condition characterized by systemic activation of the clotting cascade, platelet consumption, and subsequent exhaustion of clotting factors that leads to widespread thrombosis and hemorrhage. Often associated with trauma, shock, and sepsis.

Answer 387

Deterioration with headaches, RUQ pain, hyperreflexia, and visual changes

Answer 388

A common benign and chronic disease in women of reproductive age that is characterised by the occurrence of endometrial tissue outside of the uterus

Answer 389

Age of onset: 20–40 years Incidence: 2–10% of all women Ethnicity: In the US, endometriosis is more common in white and Asian women than in black and Hispanic women

Answer 390

When a woman's menstrual flow moves in the wrong direction, so backwards through the fallopian tubes rather than out through the vagina

Answer 391

Not fully understood Retrograde menstruation seems to play a major role in pathogenesis Other contributing factors: - Coelomic metaplasia - Iatrogenic implantation - Haematogenic and lymphogenic dissemination of endometrial cells - Hereditary component

Answer 392

Pelvic organs: - Ovaries (most common site, often affected bilaterally) - Rectouterine pouch - Fallopian tubes - Bladder - Cervix Peritoneum Extrapelvic organs (less commonly affected): - Lung - Diaphragm

Answer 393

Regardless of location, it reacts to the hormone cycle, much the same as the endometrium and proliferates under the influence of oestrogen

Answer 394

``` Increased production of inflammatory and pain mediators Nerve disfunction Altered anatomy (eg pelvic adhesions) which can lead to infertility ```

Answer 395

Up to a third of patients are asymptomatic Chronic pelvic pain that worsens before onset of menses Uterosacral tenderness, uterosacral nodularity Dysmenorrhea Pre-or postmenstrual bleeding Dyspareunia Infertility Dyschezia

Answer 396

Painful or difficult defection

Answer 397

Patient history Physical exam: - rectovaginal tenderness - adnexal masses Transvaginal ultrasound (best initial test): - Uterus is generally not enlarged - Evidence of ovarian (chocolate) cysts - Nodules in bladder or rectovaginal septum Laparoscopy (confirmatory test): -May show endometriotic implants and adhesions Normally severity of the findings does not correlate with the severity of symptoms

Answer 398

Endometrium: -Endometrial implants that present as yellow-brown (sometimes reddish-blue) blebs, islands, or pinpoint spots Ovaries: - Gunshot lesions or powder-burn lesions - -Black, yellow-brown, or bluish nodules or cystic structures - -Seen on the serosal surfaces of the ovaries and peritoneum - Ovarian endometriomas or chocolate cysts: cyst-like structures that contain blood, fluid, and menstrual debris Fallopian tubes: salpingitis isthmica nodosa -Nodular tube changes, resulting in: ↑ Risk of sterility and ectopic pregnancy ↓ Transmittance

Answer 399

Normal endometrial glands Normal endometrial stroma Preponderance of hemosiderin laden macrophages due to cyclic hemorrhages into endometriomas

Answer 400

Benign disease characterised by the occurrence of endometiral tissue within the myometrium due to hyperplasia of the endometrial basal layer

Answer 401

Peak incidence at 35-50 years

Answer 402

The exact etiology is unknown, though some risk factors have been identified: - Endometriosis - Uterine fibroids - Parity

Answer 403

May be asymptomatic Dysmenorrhea Abnormal uterine bleeding Chronic pelvic pain, aggravated during menses Globular, uniformly enlarged uterus that is soft but tender on palpation

Answer 404

Diagnosis is clinical May be supported by transvaginal ultrasound and MRI findings: - Asymmetric myometrial wall thickening - Myometrial cysts Histology serves to confirm the diagnosis.

Answer 405

Conservative: - Combined oral contraceptives , - Progestin-only contraception (e.g., IUD, continuous-use contraceptive pill) - NSAIDs for pain relief - GnRH agonists Surgical: - Hysterectomy is the definitive treatment. - Excision of single, organized adenomyomas.

Answer 406

Medical therapy: - Mild to moderate pelvic pain without complications - - Empirical medical therapy with NSAIDs and continuous hormonal contraceptives - - NSAIDs alone if pregnancy is desired - - Synthetic androgens (e.g., danazol) - Severe symptoms - - GnRH agonists (e.g., buserelin, goserelin) and estrogen-progestin OCPs Surgical therapy: - First-line: laparoscopic excision and ablation of endometrial implants - - To confirm the diagnosis and exclude malignancy - - If there is a lack of response to medical therapy - - Treat expanding endometriomas and complications (e.g., bowel/bladder obstruction, rupture of endometrioma, infertility) - Second-line: open surgery with hysterectomy with or without bilateral salpingo-oophorectomy - - Treatment-resistant symptoms - - No desire to bear additional children

Answer 407

Anemia Endometriosis in the uterotubal junction inhibits implantation of the zygote: ↑ risk of ectopic pregnancy Endometriosis → fibrous adhesions → strictures and entrapment of organs: - Intestines: constipation or diarrhea; in rare cases, intestinal obstruction, ileus, or intussusception may occur - Ureter: urine retention

Answer 408

AKA Fibroids | A benign, hormone-sensitive smooth muscle tumor of the uterus

Answer 409

Nulliparity Early menarche (< 10 years old) Age: 25–45 years -Fibroids are largely found in women of reproductive age -Influenced by hormones (i.e., estrogen, growth hormone, and progesterone) -During menopause, hormone levels begin to decrease and leiomyomas begin to shrink Increased incidence in African American individuals Obesity Family history

Answer 410

Leiomyomas are classified according to their location. Subserosal leiomyoma: located in the outer uterine wall beneath the peritoneal surface Intramural leiomyoma (most common): growing from within the myometrium wall Submucosal leiomyoma: located directly below the endometrial layer (uterine mucosa) Cervical leiomyoma: located in the cervix Diffuse uterine leiomyomatosis: The uterus is grossly enlarged due to the presence of numerous fibroids.

Answer 411

Most women have small, asymptomatic fibroids. Symptoms depend on the number, size, and location of leiomyomas. Abnormal menstruation: - hypermenorrhea - heavy menstrual bleeding - metrorrhagia (possibly associated anemia) - dysmenorrhea Features of mass effect: - Enlarged, firm and irregular uterus during bimanual pelvic examination - Back or pelvic pain/discomfort - Urinary tract or bowel symptoms (e.g., urinary frequency/retention, constipation, features of hydronephrosis) Reproductive abnormalities - Infertility (difficulty conceiving and increased risk of miscarriage) - Dyspareunia

Answer 412

Ultrasound (best initial test) - Concentric, hypoechoic, heterogeneous tumors - Calcifications or cystic areas suggest necrosis - Saline-infused sonography: can be used to better visualize submucosal and intramural fibroids Hysteroscopy: to assess submucosal fibroids MRI: to evaluate the uterus and ovaries for potentially complicated surgical cases and visually differentiate between leiomyomas, adenomyomas, and adenomyosis

Answer 413

Macroscopic: - Grayish-white surface - Homogeneous; tissue bundles on cross-section partly in a whorled pattern - Some leiomyomas may involve regressive changes: scar formation, calcification, and cysts Microscopic: - Smooth muscle tissue in a whorled pattern with well-demarcated borders - Consisting of monoclonal cells interspersed with connective tissue

Answer 414

Only treat symptomatic patients Treatment depends on patient's desire to preserve fertility, personal preference, comorbidity which contraindicates surgery, and severity of symptoms Fertility preserving treatments: Medical: - First line (to reduce heavy bleeding and symptom management) - - COCP and mini pill (control bleeding and pain but may promote growth of fibroids) - - Mirena coil (controls heavy bleeding but does not treat fibroids themselves) - - Antifibrinolytics (eg tansexamic acid) (reduce heavy bleeding and used when desired no hormonal contraceptives) - - NSAIDs (for dysmenorrhea) - Second line (to reduce tumor sixe and decrease tumor vascularisation) - - GnRH agonists - -- (optimal prior to surgery but not for long term (>6months) use due to risk of odteoporosis, hot flushes and depression) - -- (decrease size of fibroids) - -- (suppress growth of new ones) - -- (decrease tumor vascularisation) - -- (induce amenorrhea, so improve anaemia) - -- (rebound growth of fibroids after discontinuation of GnRH therapy) - - GnRH antagonists - - Androgenic agonists (suppress growth of fibroids but have high side effect profile (acne, oedema, hair loss etc)) - - Selective progesterone receptor modulators Myomectomy: Surgical removal of fibroids -preferred in rapidly growing fibroids, recurrent refactory bleeding secondary to medical therapy and in severe symptoms -Approach: -- Hysteroscopic myomectomy: submucosal fibroids and some intramural fibroids that are primarily intracavitary -- Abdominal myomectomy (laproscopic or open incision): subserosal and intramural fibroids Fertility affecting treatments: Interventional therapy: - Uterine artery embolization: a percutaneous, radiologic procedure in which an embolic agent is injected into the uterine artery in order to block the blood supply to the fibroid(s) - - Procedure - -- Injection of polyvinyl alcohol (PVA) into the arteries that supply the fibroid, causing it to shrink - -- 25% of patients require further invasive treatment (e.g., hysterectomy) due to failed embolization or recurrent symptoms - - Indications - -- Recurrent refractory heavy bleeding and/or severe pain unresponsive to medical treatment - -- Contraindications to surgery or personal preference to avoid surgery - -- No desire to preserve fertility, but wish to preserve the uterus -Magnetic resonance-guided focused ultrasound surgery (MRgFUS): a procedure that utilizes MRI and ultrasound waves to destroy fibroids Surgery: hysterectomy with/without bilateral salpingo-oophorectomy (definitive treatment)

Answer 415

Infertility Iron deficiency anemia (due to heavy menstrual bleeding) Fibroid torsion Thromboembolism Very rare: malignant transformation to uterine leiomyosarcoma

Answer 416

Elevated concentrations of progestin and estrogen foster the growth of leiomyomas. Pain may be caused by: - Mass effect - Necrosis - Peritoneal irritation Premature contractions Depending on location and size: - Fetal malpresentation - Fetal growth retardation - Prematurity and miscarriages - Extrauterine pregnancy - Placental abruption Cervical leiomyoma: obstruction of the birth canal is an indication for cesarean delivery Postpartum: atonic hemorrhages Puerperium: fibroid regression accompanied by calcification

Answer 417

Ovarian tumors are the most common ovarian mass in women > 55 years of age. Lifetime prevalence of malignant ovarian cancer: 1–2% Ovarian cancer is the second most common gynecological cancer (after endometrial cancer) but causes the most deaths (with endometrial cancer causing the second most). Median age at diagnosis of ovarian cancer: 63 years Incidence rates highest in non-Hispanic white women

Answer 418

Risk factors: General: - Age: Incidence of ovarian cancer increases with age. - Asbestos exposure Genetic predisposition: - BRCA1/BRCA2 mutation - - The lifetime risk of developing ovarian cancer is up to 44% for BRCA1-positive women and 17% for BRCA2-positive women. - - Positive family history and/or the occurrence of breast cancer at a younger age (i.e. < 30 years) increase the likelihood of carrying a mutation in these genes. - HNPCC syndrome: The lifetime risk of developing ovarian cancer is ∼ 10%. - Family history - Peutz-Jeghers syndrome Hormonal factors: - Elevated number of lifetime ovulations - - Infertility/low number of pregnancies - - Early menarche and late menopause - Endometriosis Protective factors: Surgical intervention: - Bilateral salpingo-oophorectomy - Hysterectomy - Tubal ligation Hormonal factors: - Oral contraceptives - Breastfeeding - Parity

Answer 419

Hereditary nonpolyposis colorectal cancer syndrome AKA Lynch syndrome A hereditary cancer syndrome caused by a mutation in mismatch repair genes. Individuals have a significantly higher risk of developing colorectal, gastric, and endometrial cancer

Answer 420

An autosomal dominant, hamartomatous polyposis syndrome Characterized by the presence of polyps (typically < 20) throughout the gastrointestinal tract (mainly the jejunum). Associated with mutation of the STK11 gene on chromosome 19p13.3. Manifests with hematochezia, constipation, diarrhea, mucocutaneous hyperpigmentation, and an increased risk of colorectal, ovarian, breast, and pancreatic cancer.

Answer 421

Epithelial ovarian tumors - Arise from ovarian surface epithelium - Most commonly benign Germ cell ovarian tumors - Arise from the primordial germ cells (e.g., oocytes) - Can be benign or malignant - Subtypes are determined by structural differentiation - - Extraembryonic differentiation: yolk sac tumor - - Somatic differentiation: teratoma - - No differentiation: dysgerminoma Sex cord and stromal ovarian tumors - Arise from sex cord cells (e.g., Sertoli or granulosa cells) or stromal cells (e.g., fibroblasts or primitive gonadal stroma) - May be benign or malignant Krukenberg tumor: - Secondary ovarian tumor that most commonly arises from metastatic spread of gastric carcinoma - Often bilateral - Characteristic mucin secreting signet ring cells on histology - Route of metastatic spread is still debated

Answer 422

Traditionally asymptomatic But ~90% of patients do present with symptoms before diagnosis Subacute symptoms: - Most common manifestations - Nonspecific and difficult to attribute to ovarian cancer - Adnexal mass - - Can be asymptomatic - - Often found on routine pelvic examination or imaging - Pelvic and abdominal symptoms - - Changes in urination (e.g., frequency or urgency) - - Bloating/abdominal distention - - Early satiety - - Nonspecific pelvic pain - Abnormal bleeding - - Postmenopausal bleeding - - Rectal bleeding - Paraneoplastic syndromes - - Polyneuritis - - Cerebellar degeneration - - Dermatomyositis - - Hemolytic anemia Acute symptoms: - Occur in advanced disease - Indication for immediate evaluation and treatment - Extrapelvic symptoms - - Ascites - - Malignant pleural effusion - - Bowel obstruction - Hematologic complications - - venous thromboembolism - Intrapelvic symptoms - - ovarian torsion - Metastatic dissemination - - Liver: nausea, jaundice, ascites - - Brain: headaches, seizures, focal motor deficits - - Omentum: omental caking (i.e., disease infiltration of omental fat) resulting in abdominal pain - - Distant lymph nodes: supraclavicular or inguinal lymphadenopathy

Answer 423

Pelvic ultrasound - Imaging test of choice for evaluation of adnexal masses and suspected ovarian cancer - Both TA and TV used - Assess: - - Size and structural characteristics - - Laterality - - Mass margins - - Vascularity - - Pelvic fluid MRI: - Not routinely recommended - May be helpful in determining origin of pelvic masses that are not clearly arising from the ovary - Useful for assessing feasibiltiy of surgical resection CT: - Not recommended in initial evalution of adnexal masses - Useful for determining th eextent of ovarian mets Tumor markers: - Epithelial ovarian tumors: CA-125 is elevated in ~80% of malignant tumors - In premenopausal: elevated CA-125 points to benign process - In postmenopausal: elevated CA-125 >35 should raise malignancy concerns - Should only be used to monitor disease progression or recurrence after treatment Germ cell tumors: - Dysgerminoma: LDH, B-hCG - Yolk sac tumor: AFP - Immature teratoma: AFP, LDH, CA-125 - Choriocarcinoma: B-hCG - Embryonal carcinoma: AFP, b-hCG Sex cord-stromal tumors: - Granulosa cell tumor: inhibin - Other types: none Tissue diagnosis: - Noninvasive biopsy (fine needle aspiration): not recommended due to the risk of tumor seeding and, as a result, advancing the stage of disease - Fine needle aspiration is absolutely contraindicated in ovarian tumors because it may directly spread tumor cells to the peritoneum - Surgical evaluation: - - Recommended method for diagnosing ovarian cancer - - Should only be utilized in patients with a high probability of a malignant ovarian mass - - If a malignancy is found, it can be staged and cytoreduction can be performed

Answer 424

``` Gynecologic Benign causes: -Ovarian cysts -Pelvic inflammatory disease -Tuboovarian abscess -Hydrosalpinx -Leiomyoma -Endometrioma Malignant cause -metastatic cancer ``` ``` Nongynecologic Benign causes -Appendiceal abscess -Pelvic kidney -Complicated diverticulitis -Bladder diverticulum Malignant causes -Retroperitoneal sarcoma -Gastrointestinal cancer -Metastatic cancer ```

Answer 425

Surgical: For best outcomes -Surgical staging: used to obtain pathologic specimens and evaluate the extension of cancer spread -- Peritoneal cytology -- Hysterectomy with bilateral salpingo-oophorectomy -- Pelvic and paraaortic lymph node dissection -- Omentectomy -Surgical debulking: whenever possible, maximal cytoreduction (ie removal of visible tumor) should be completed to imprive long term outcomes -- Residual disease <1cm defines optimal debulking -- Utilised in disease stages 1-3 ``` Chemotherapy: -Indications: -- Early stage disease --- Those with high risk disease (stage 1C, stage 2) --- Only used as adjucant therapy after initial debulking surgery -- Advance stage disease (stages 3-4) --- All patients after initial cytoreductive surgery -Preferred regimens -- Carboplatin/ paclitaxel (first line) -- 5-FU/ oxaliplatin -- Carboplatin/ paclitaxel/ bevacizumab -Route of administration --IV Intraperitoneal ``` Targeted molecular therapy: - Indications: - - BRCA1 or BRCA2 postive disease - - Maintenance therapy after surgical debulking and chemotherapy - Targeted agents: Poly (ADP-ribose) polymerase inhibitors - - Olaparib - - Niraparib - - Veliparib Radiation therapy: -Reserved as symptomatic treatment for recurrent or metastatic disease

Answer 426

Very poor overall prognosis as a result of late diagnosis | 5-year survival rate of all stages: ~50%

Answer 427

Indications: - Routine screening with CA-125 or transvaginal ultrasound is not recommended in individuals with an average risk of ovarian cancer - In high-risk individuals: - - familial risk assessment should be performed - - after which genetic counseling and subsequent genetic testing for hereditary cancer syndromes (e.g., BRCA1, BRCA2, or Lynch syndrome) may be indicated. - -- Some of the tools used for familiar risk stratification include the Ontario Family History Assessment Tool, the Manchester Scoring System, the Referral Screening Tool, and the Pedigree Assessment Tool - - In patients with high-risk mutations: - -- Risk-reducing bilateral salpingo-oophorectomy (rrBSO) is a preventive treatment option for patients who do not wish to conceive in the future - -- Periodic screening for ovarian cancer (e.g., annual transvaginal ultrasound, pelvic exam, and CA-125 levels) is an alternative to rrBSO Potential benefits - Reduction in mortality - Diagnosis of ovarian cancer at an earlier stage Potential harms - False positives - Psychological distress - Morbidity or mortality from surgery

Answer 428

Pregnancy luteoma - Definition: rare, benign tumors that arise in response to elevated hormone levels (e.g., β-hCG) during pregnancy - Clinical features: - - The majority of patients are asymptomatic. - - Occasionally, they are functionally active (i.e., cause androgen hypersecretion) and manifest with symptoms of virilization of the mother or the fetus. - Diagnostics: - - Pelvic ultrasound - -- Solid adnexal mass - -- Can be unilateral or bilateral - -- Significant venous or arterial flow - -- 4–10 cm in diameter - - Luteomas are often diagnosed incidentally during cesarean delivery. - Treatment - - Observation - - Most regress spontaneously post partum. Theca lutein cysts Corpus luteum cyst If surgical removal of an ovarian tumor is indicated during pregnancy, surgery should, if possible, be scheduled for after the 10th week of gestation, as the secretion of progesterone by the corpus luteum is essential for the maintenance of the pregnancy. The placenta takes over this function from approximately the 10th week of pregnancy onwards.

Answer 429

Human papilloma virus causes infections of the skin and mucus membranes There are many strains which result in varying presentations Double stranded, circular, nonenveloped DNA virus with an icosahedral capsid

Answer 430

``` Types 6 and 11 Cause: -Anogenital warts -Mild cervical cell abnormalities -Tumors of nongenital mucosal membranes (eg respiratory tract, oral cavity, oesophagus, eye) ```

Answer 431

Types 16, 18, 31, 33 Cause: -cervical cancer (responsible for 70% of cases) High risk of anogenital, oral and oropharyngeal squamous cell carcinoma

Answer 432

Skin warts, such as common warts (verruca vulgaris) and plantar warts (myrmercias)

Answer 433

Transomission occurs between two epithelial surfaces Close personal contact: cutaneous warts Sexual contact: anogenital lesions

Answer 434

Damaged skin/mucous membranes (e.g., maceration, trauma, herpes simplex virus infection) Immunodeficiency (e.g., HIV infection, chemotherapy) Additional risk factors for genital/mucosal HPV infections include: - Unprotected sex - Number of lifetime sexual partners - Early age at first sexual activity - Uncircumcised males

Answer 435

Most common sexually transmitted infection (STI) Approx. 50% of new infections affect individuals between 15–24 years of age. Prevalence: ∼ 79 million in the US Incidence: ∼ 14 million annually in the US

Answer 436

Cervical intraepithelial neoplasia (CIN) and cervical cancer Vulvar intraepithelial neoplasia (VIN) and vulvar cancer Vaginal intraepithelial neoplasia (VAIN) and vaginal cancer Squamous cell carcinoma of the penis Anal cancer

Answer 437

AKA condylomata acuminata Pathogen: HPV types 6 and 11 (responsible for ∼ 90% of genital warts) Location: ♀: vulvar, cervix, anal region, urethra (rare) ♂: glans penis, foreskin, urethra, anal region Clinical features - Exophytic, cauliflower-like lesions - Often asymptomatic; may cause pruritus, tenderness, or bleeding in rare cases Diagnostics: - Visual inspection - Application of 5% acetic acid turns lesions white (not a specific finding) - Biopsy indications - - Immunodeficiency (e.g., HIV infection) - - Warts with atypical features (e.g., affixed to underlying tissue, pigmented, indurated, bleeding) - - Warts refractory to treatment Treatment: - Pharmacotherapy: local cytostatic treatment (e.g., 5-FU, trichloroacetic acid, podophyllin, salicylic acid) or immune response modifiers (e.g., imiquimod, interferon alpha) - Cryotherapy: freezing external warts with CO2, N2O, or N2 - In case of numerous warts: curettage, laser surgery, or electrocoagulation

Answer 438

Pathogen: particularly HPV types 3 and 10 Clinical features: flat, white-brown, slightly elevated, scattered plaques in the anogenital region Differential diagnosis: condylomata lata (usually flat, smooth, and moist) in syphilis Treatment: - Curettage or laser surgery - Regular checks are necessary because of the high risk of malignancy

Answer 439

Description: transitional stage between a genital wart and Bowen disease (a squamous cell carcinoma in situ) Pathogen: most commonly HPV-16 Clinical features: Multiple, flat, red-brown pigmented papules on the external genitalia (particularly the penile shaft, glans, foreskin, vulva, and perianal region) Treatment: - Re-examination every 3–6 months (lesions often regress spontaneously) - If persistent: - - local destructive therapy(same as for anogenital warts) - - followed by surveillance (annual examinations), since lesions may recur Prognosis: malignant transformation occurs in 2.6% of cases

Answer 440

AKA Buschke-Löwenstein tumor Pathogen: primarily HPV types 6 and 11 Clinical features: exophytic, verrucous, locally invasive squamous cell carcinoma without a tendency to metastasize Treatment: surgical excision

Answer 441

Most common in infancy, childhood, and adolescence Prevalence: ∼ 7–12% in the US Sex: ♀ = ♂

Answer 442

AKA verruca vulgaris Pathogen: particularly low-risk HPV types 2 and 4 Clinical features - Lesions are plaques or papules - - Skin-colored or whitish - - Usually firm, often with a rough and scaly surface - - Sometimes have a cauliflower-like appearance - - Located on the elbows, knees, fingers, and/or palms - Often asymptomatic but may cause tenderness (depending on the location) and pruritus → scratching → bleeding Treatment - Initially watchful waiting (most skin warts regress within 2 years) - Topical agents (e.g., salicylic acid), cryotherapy, or surgical interventions

Answer 443

AKA verruca plantaris Pathogen: HPV type 1 Clinical features: - Rough, hyperkeratotic lesions on the sole of the foot - Often grow inwardly and cause pain while walking

Answer 444

AKA verruca plana Pathogen: particularly HPV types3 and 10 Clinical features Multiple small, flat patches or plaques Localized on the face, hands, and shins

Answer 445

HPV types that cause mucosal manifestations in the genital area may also lead to nonanogenital mucosal manifestations, such as: - Oral warts and oropharyngeal carcinomas - Laryngeal papilloma: benign tumor of the laryngeal epithelium caused by HPV infection of the throat - - Associated with HPV type 6 and 11 - - Appear as white, exophytic cauliflower-like lesions located in the larynx, trachea, and on the vocal cords - - Usually single lesions in adults and multiple in children - - Can cause voice changes (e.g., hoarseness) and, in more severe cases, airway obstruction - Laryngeal carcinoma - Respiratory papillomatosis and squamous cell carcinoma (SCC) of the lung - Conjunctival papillomas and conjunctival carcinoma

Answer 446

Benign tumors, e.g., fibroids, papillomatous dermal nevi Molluscum contagiosum Malignant tumors, particularly squamous cell carcinomas

Answer 447

There is no treatment for the infection itself. In most cases the infection clears up without any treatment Several factors guide the choice of the treatment of anogenital warts, including wart characteristics (i.e., size, number, and anatomic site), patient preference, and potential adverse effects. Treatment options of HPV–related anogenital warts are: - Routine clinical monitoring - Local treatment with one of the following: - - Podophyllotoxin - - Imiquimod - -- Toll-like receptor 7 agonist; activates immune cells - -- Indications include actinic keratoses, superficial basal cell carcinomas, herpes simplex infections, and genital warts. - - Trichloroacetic acid - Cryotherapy - Surgical removal (e.g., tangential scissor, shave excision, curettage, laser, electrosurgery) Evidence of malignancy should always be excluded on HPV–related cervical lesions via cytological and histological monitoring. For treatment options of HPV–related cervical lesions, see cervical cancer treatment

Answer 448

High rate of recurrence | Infection with high-risk types may transition to precancerous or malignant lesions after several years

Answer 449

Education about risk factors HPV vaccination Use of condoms (decrease risk of infection but do not provide full protection as uncovered areas may still be infected

Answer 450

Vertical transmission to the fetus is rare but may lead to: - Laryngeal papillomatosis → airway obstruction - Conjunctival papillomatosis Treatment/prevention: - Vaccination should be avoided during pregnancy. - Trichloroacetic acid is preferred - Cryotherapy and surgical interventions are also safe. - Podophyllin, 5-FU, and interferon are teratogenic and contraindicated in pregnancy. Delivery: - Cesarean section does not prevent vertical transmission of HPV. - Cesarean section is indicated only if the birth canal is obstructed by large genital warts.

Answer 451

3rd most common gynae malignancy after endometrial and ovarian and 3rd most common one to cause death Incidence is higher in countries without screening programs and HPV vaccination Incidence has declined in. recent times due to screening and vaccine Peak incidence 35-44 years Mortality is highest in those aged 55-64 Cervical intraepithelial neoplasia (CIN), a precursor of cervical cancer, typically occurs in young adults (aged 25-35 years)

Answer 452

Infection with high risk HPV types: - HPV 16: most common in squamous cell carcinoma - HPV 18: most common in adenocarcinoma Risk factors: Associated with HPV infection: - Multiple sexual partners (strongest risk factor) - Early-onset of sexual activity - Multiparity - Immunosuppression (e.g., HIV infection, post-transplantation) - History of sexually transmitted infections (e.g., herpes simplex, chlamydia) Environmental risk factors: - Cigarette smoking and/or exposure to second-hand smoke (for squamous cell cancer types only) - In-utero exposure to diethylstilbestrol (DES) - Low socioeconomic status

Answer 453

Patients are usually asymptomatic in the early stages and develop symptoms later in the course of the disease. Always consider cervical cancer as a cause of postcoital bleeding Early symptoms: - Abnormal vaginal bleeding: irregular vaginal bleeding, heavy, irregular menstrual bleeding, postcoital spotting - Abnormal vaginal discharge: blood-stained or purulent malodorous discharge (not necessarily accompanied by pruritus) - Dyspareunia - Pelvic pain Late symptoms: - Hydronephrosis - Lymphedema - Fistula formation Cervical examination: - Ulceration - induration - or an exophytic tumor

Answer 454

Direct complications of invasive cervical cancer: - Local infiltration of organs - - Infiltration and compression of ureter → urinary obstruction → hydronephrosis → kidney failure (bilateral obstruction is a potentially fatal complication) - - Other organs often affected by the spread of cervical cancer include the rectum, bladder, and vagina. - Fistula formation in locally advanced disease (e.g., rectovaginal, vesicovaginal, urethrovaginal fistula) - Compression of veins or lymphatic vessels in the lesser pelvis → lymphedema of the lower extremities - Metastasis - - Bone metastasis: bone pain, pathologic fractures, spinal compression, hypercalcemia - - Liver metastasis: abdominal pain, abdominal distention, nausea, jaundice - - Lung metastasis: cough, hemoptysis, dyspnea, chest pain - - Brain metastasis: headaches, seizures, cognitive deficits, focal neurological deficits - Cancer anorexia-cachexia syndrome (CACS) Complications of radiation therapy: - Vaginal stenosis - Postirradiation vaginitis (e.g., vaginal dryness, dyspareunia) - Radiogenic cystitis/proctitis - Radiation may increase the risk of cancer complications such as fistula formation

Answer 455

Cervical cancer has the best prognosis out of the three main gynecological cancers (ovarian, endometrial, and cervical cancer). ``` The survival rates decrease with increasing FIGO stage: Stage 0: > 93% Stage I: 93% Stage II: 63% Stage III: 35% Stage IV: 16% ``` Patients without lymph node involvement have a very good prognosis, regardless of FIGO stage. Main cause of death: uremia, often occurs secondary to bilateral ureteral obstruction.

Answer 456

Type I endometrial cancer: endometrioid adenocarcinomas (grade 1 and 2) derived from atypical endometrial hyperplasia Type II endometrial cancer: endometrioid adenocarcinomas (grade 3) and tumors of nonendometrioid histology (serous, clear cell, mucinous, squamous, transitional, and undifferentiated cells)

Answer 457

Type I endometrial cancer - Directly related to long-term exposure to increased estrogen levels - Some genetic mutations (e.g., in the PTEN gene or mismatch repair genes) are also associated with this type of cancer. Type II endometrial cancer - Mostly estrogen-independent - Associated with endometrial atrophy (especially in postmenopausal women) - Strongly associated with a genetic predisposition Risk factors for estrogen-dependent tumors - Nulliparity - Early menarche and late menopause - Polycystic ovary syndrome - Metabolic syndrome (esp. obesity and diabetes mellitus type 2 ) - Hypertension - Unopposed estrogen replacement therapy (e.g., for menopausal symptoms) - History of breast cancer and tamoxifen treatment - Lynch syndrome (hereditary nonpolyposis colorectal cancer) ``` Protective factors: Low estrogen and high progestin or progesterone levels have a protective effect. -Multiparity -Combination oral contraceptive pills -Regular physical exercise -Lifelong soy-rich diet ```

Answer 458

``` 1-2% of population Most common cancer of female genital tract Fourth most common cancer in women (after breast, lung and colorectal) Type 1 ~80% of endometrial cancers Type 2 ~10-20% of cases Primarily affects postmenopausal women Peak incidence 65-74 years Type 1 onset usually nearer to menopause Type 2 usually in older ladies ```

Answer 459

Tumor-related: Abnormal uterine bleeding is the main symptom. -Postmenopausal: any amount of vaginal bleeding, including spotting or staining -Perimenopausal/premenopausal: metrorrhagia, menometrorrhagia -Vaginal bleeding usually does not occur in type II cancer. Later stages may present with pelvic pain, palpable abdominal mass, and/or weight loss. Pelvic exam is often normal, Possible findings include: -Abnormal cervix -Enlarged uterus -Evidence of local metastases Metastases: - Localized metastasis: contiguous spread to the cervix and vagina, fallopian tubes, and ovaries (25% of cases) - Lymphogenic metastasis: Seen in late stage cases - - Retroperitoneal spread, or involvement of the pelvic and/or para-aortic lymph nodes - Hematogenic metastasis: - - Rare - - Occurs at a very late stage and usually in the lungs

Answer 460

Procedures: - Endometrial sampling: most commonly performed as part of a pelvic exam - Hysteroscopy-guided biopsy - Dilatation and curettage Results: - Endometrial hyperplasia, with or without atypia - Pronounced proliferation of disorganized glandular tissue (characteristic of endometrial adenocarcinoma) - If there is no detectable pathology on biopsy and if no further symptoms occur, endometrial cancer can be ruled out. Imaging: Transvaginal ultrasonography - Considered to be the first diagnostic step by some experts since it is noninvasive and enables initial assessment - Findings: - - Thickening of the endometrium - - Cystic changes, variable echogenicity - - Possibly visible tumor infiltration into neighboring organs - Regular monitoring required in postmenopausal women with endometrial thickening ≥ 5 mm Abdominal ultrasonography: -A complete abdominal ultrasound is indicated to exclude metastasis. Chest x-ray, CT, MRI: -assessment of metastatic spread (lungs, pelvis) Laboratory tests: FBC - anaemia Coagulation studies to assess for other possible causes of heavy uterine bleeding Ther is no routine screening test for endometrial cancer

Answer 461

Prevalence: most frequent form of endometrial cancer Types: - Type I endometrial carcinoma includes estrogen-dependent endometrioid adenocarcinoma (grade 1 and 2; the most common) - Type II endometrial carcinoma includes estrogen-independent endometrioid adenocarcinoma (grade 3; rare, poor prognosis) Histology findings: - Pronounced glandular proliferation, which presents as atypical glandular tubes - The glands are positioned, in part, back-to-back ("dos-à-dos") with no separating stroma - Lined with pseudostratified epithelial cells, the nuclei of which are enlarged in an atypical vesicular form. - These glandular cells frequently demonstrate mitosis. - Tumor cell nests may also be observed and infiltrate the myometrium in high-grade tumors.

Answer 462

Serous adenocarcinoma (contains psammoma bodies and papillary structure with tufts) Clear cell adenocarcinoma Mucinous adenocarcinoma Squamous cell carcinoma Undifferentiated carcinoma

Answer 463

Surgical management: - Indication: women with endometrial cancer who are postmenopausal, perimenopausal, or do not intend to become pregnant - Procedures: - - Total hysterectomy with bilateral salpingo-oophorectomy (TAH/BSO) with or without lymph node removal - - Advanced radical hysterectomy and removal of the upper vagina according to Wertheim-Meigs additional Nonsurgical management: - Progestins: Indicated for women with early stage endometrial carcinoma (well-differentiated and progesterone and estrogen receptor positive), who would prefer to avoid TAH-BSO and preserve fertility, or as adjuvant therapy - Radiotherapy and/or chemotherapy (adjuvant or palliative)

Answer 464

Pyometra: - An accumulation of pus in the uterine cavity - Caused by infection resulting from obstruction of the cervical opening by the tumor and secondary blood stasis (hematometra) - Can develop in patients with duplication of the cervix or as an uncommon complication of gynecological malignancy - Presented with purulent vaginal discharge, lower abdominal pain, and enlarged uterus - Diagnosed by imaging studies (e.g., abdominal ultrasound or CT scan) - Treated with drainage and dilation of the cervical lumen

Answer 465

Endometrial cancer has the 2nd best prognosis (after cervical cancer) of all gynecological cancers in the US. Cancer stage at diagnosis determines the 5-year survival rate: - Localized endometrial carcinoma: > 90 % - Metastasized endometrial cancer: 16.8 % Death rate: 4.9 per 100,000 women per year Types of endometrial carcinomas that are well-differentiated and possess estrogen receptors (type I) have a more favorable prognosis. Clear cell and papillary serous carcinomas (type II) have an aggressive course and a poor prognosis.

Answer 466

Think of a CEOs decline Cervical, Endometrial, Ovarian have a progressively worse prognosis

Answer 467

A malignancy of the outer female genitalia

Answer 468

Malignancy that is closely related to vulvar cancer in terms of aetiology and histology but it occurs inside the vagina, typically the posterior third of the vaginal wall, rather than the vulva

Answer 469

Incidence: rare Age: -HPV-related vulvar cancer: 35–65 years -Non-HPV related types: 55–85 years

Answer 470

Infection with HPV 16, 18, 31, and 33 (16 and 33 account for 55% of HPV-related cases of vulvar cancer) Vulvar dystrophy and vulvar or cervical intraepithelial neoplasia (VIN/CIN) Smoking Precancerous lesions (e.g., lichen sclerosus) Immunosuppression

Answer 471

Squamous cell carcinoma (> 80% of cases) Basal cell carcinoma Melanoma Paget disease of the vulva

Answer 472

Pathology - Adenocarcinoma; carcinoma in situ - Low risk (< 15%) of underlying invasive Paget disease/ invasive adenocarcinoma (unlike Paget disease of the breast which is always associated with underlying carcinoma) Clinical features - Eczematoid lesions - Raised, well-demarcated borders - Erythematous patches with white scaling - Crusting and ulcerations - Local pruritus

Answer 473

May initially be asymptomatic Local pruritus, possibly with burning sensation and pain Reddish, blackish, and/or whitish patches of discoloration Lumps or growths of various shapes, often wart-like lesions or ulcers Vulvar bleeding or discharge (less common) Dysuria, dyspareunia Lymphadenopathy in the groin area

Answer 474

Pelvic exam Colposcopy Biopsy

Answer 475

Vulvar dermatoses | Vulvar intraepithelial neoplasia

Answer 476

Vulvar dermatoses are not inherently precancerous, but they do increase the risk of squamous cell carcinoma. Subtypes: - Lichen sclerosus: epidermal atrophy and loss of vulvar architecture - Lichen simplex chronicus: squamous cell hyperplasia - Genital lichen planus (hypertrophied skin with purple lesions) Etiology: unclear Epidemiology: -postmenopausal women and, less commonly, prepubescent girls Clinical features: - Parchment-like, thin, shiny vulvar skin - Narrow, atrophic vaginal introitus resulting in dyspareunia - Burning pain, pruritus, bleeding vulvar ulcers - Lichen simplex chronicus is characterized by chronic pruritus, which provokes persistent scratching of the vulva and so causes lichenification of the skin. Diagnosis: Colposcopy and biopsy of suspicious lesions are required to rule out malignancy. Histology - Epidermal atrophy, localized hyperkeratosis, degeneration of the basement membrane - Loss of collagenous and elastic connective tissue - Presence of an inflammatory infiltrate Therapy - Without atypical cellular morphology: local therapy with glucocorticoid-containing creams - In the event of malignancy: surgical resection of the lesion

Answer 477

Definition: precancerous lesion caused by dysplasia of squamous cells Classification: - VIN, usual type (most common) - - Associated with HPV - - Commonly multifocal - VIN, differentiated type - - Associated with lichen sclerosis and other dermatoses - - Commonly unifocal - VIN, unclassified type Diagnosis: tissue biopsy Treatment: depending on severity, excision or ablation may become necessary Prognosis: may progress to vulvar carcinoma despite treatment (in < 10% of cases)

Answer 478

First-line treatment: local excision and surgical resection (radical vulvectomy) Radiotherapy and/or palliative chemotherapy: when disease metastasizes to peripheral lymph nodes or other organs

Answer 479

The average 5-year survival rates range from 30–50%. | Survival rates vary greatly depending on the stage of the disease.

Answer 480

Squamous cell carcinoma - Most common type - Usually occurs secondary to cervical squamous cell carcinoma, primary carcinoma is rare Clear cell adenocarcinoma - Usually occurs secondary to vaginal adenosis (the presence of glandular columnar epithelium within the upper two-thirds of the vaginal wall) - Seen in daughters of women who received diethylstilbestrol during pregnancy Sarcoma botryoides - Rare, highly malignant embryonal rhabdomyosarcoma that arises most commonly, but not exclusively in the genitourinary system - Epidemiology: peak incidence in childhood (< 4 years) - Pathology - - Gross: clear, polypoid masses that resemble a bunch of grapes protruding through the vagina - - Microscopy: pleomorphic spindle-shaped cells - - Immunohistochemical staining: desmin positive

Answer 481

Vaginal bleeding Leukoplakia, vaginal ulceration with contact bleeding Malodorous discharge Possibly urinary frequency

Answer 482

Pelvic exam Colposcopy: if abnormal cytology results without a clearly visible lesion during peliv exam Biopsy of mass to determine histopathology

Answer 483

Radiotherapy - Indicated in squamous cell carcinomas - Preserves external genitalia Surgical therapy

Answer 484

The number out of every 100 women who become pregnant within the first year of typical use of the method of contraception

Answer 485

The number of unintended pregnnacies in 100 women per year with perfect use of the method of contraception The PI is the most common measure of contraceptive efficacy used in clinical studies

Answer 486

Coitus interruptus Fertility awareness base methods Vaginal douche Lactational amenorrhea

Answer 487

AKA the withdrawal method Method: penis is withdrawn from the vagina before ejaculation ~22% failure rate

Answer 488

Avoidal of sexual intercourse during the ovulation period Calendar method: - The fertility period is estimated by documenting the timing of ovulation - Based on 3 points: - - (i) an egg can be fertilized for ∼ 24 hours after ovulation - - (ii) the lifespan of sperm is 48 hours following ejaculation - - (iii) ovulation occurs 12–16 days before onset of the next menses. - Fertilization can occur anytime from 3 days before to 1 day after ovulation. - The fertility period is calculated after recording 6 menstrual cycles Cervical mucus method: - The fertility period is estimated by evaluating the abundance and consistency of cervical mucus throughout the cycle. - During the days leading to ovulation, cervical mucus becomes stringy/elastic, thick, and abundant due to an increase in progesterone. - Conception is more probable up to 4 days after cervical mucus reaches its maximum abundance and elasticity; intercourse should be avoided during this time. - Contraindicated in: - - breastfeeding women < 6 weeks postpartum - - non-breastfeeding women < 4 weeks postpartum - - in women with irregular menstrual cycles Basal body temperature method: - The body temperature is measured throughout the cycle. - The increase in progesterone concentration after ovulation triggers an increase in basal body temperature, thus indicating the fertility period. Symptothermal method: -Including a combination of the basal body temperature method and the cervical mucus method

Answer 489

Unreliable method of contraception, although still practiced by over 20% of women in the US. Not a recommended form of contraception, but many women in the US still have this misconception Risk of promoting unintentional pregnancy by pushing semen into the cervical canal Method: The vagina is flushed with water or other products immediately after male ejaculation during intercourse in an attempt to theoretically flush semen out

Answer 490

Amenorrhea is induced by exclusively breastfeeding for up to 6 months immediately postpartum Method Suckling at the breast → ↑ prolactin and ↓ gonadotropin-releasing hormone → suppression of ovulation FSH levels are normal/high → follicle growth; however, ↓ LH leads to inhibited follicular maturation and the absent LH surge prevents ovulation

Answer 491

A T-shaped device wrapped in copper wire that is inserted into the uterus Approved for 5 or 10 years of continuous use; may be effective for longer Mechanism of action: altered tubal motility and a sterile inflammatory reaction of the endometrium → spermicidal effect and prevention of implantation Indications: - Emergency contraception (most effective type) - Long-acting contraception - Contraception in patients with contraindications for estrogen-based contraceptives Contraindications: - Uterine abnormalities (i.e. bleeding, malignancy, infection, abnormal anatomy) - Cervical infections - Known or suspected pregnancy - Menorrhagia - Dysmenorrhea - Copper hypersensitivity Complications: - Menorrhagia - Dysmenorrhea - Uterine perforation - Ectopic pregnancy - Pelvic inflammatory disease

Answer 492

``` Condom Diaphragm Cervical cap Sponge Spermicide ```

Answer 493

Description: A thin sheath that is placed over the shaft of the penis (male condom) or in the vaginal canal (female condom) prior to sexual intercourse Acts as a physical barrier between penile, vaginal, and/or anal secretions Contraindication: latex allergy for latex condoms Complications: unintentional pregnancy or infection due to breakage (usually related to incorrect use)

Answer 494

Description: Dome-shaped latex, metal, or plastic device that holds spermicide Placed into the anterior and posterior fornix of the vagina prior to sexual intercourse; must be kept in place for 6 hours after intercourse Prevents passage of semen into the cervix Contraindications: cervical anomalies or abnormalities (e.g., infection, malignancy), spermicide or latex allergy Complication: toxic shock syndrome (use for ≥ 24 hours is not recommended)

Answer 495

Description: Cup shaped latex, metal, or plastic device that holds spermicide Placed over the base of the cervix; inserted up to ∼ 8 hours before sexual intercourse and must be removed after 48 hours Prevents passage of semen into the cervical canal Contraindications: - cervical anomalies or abnormalities, - spermicide or latex allergy Complication: toxic shock syndrome, -cervical erosion (resulting in spotting)

Answer 496

Description: Foam disk containing spermicidal fluid; activated by moistening with tap water and gently squeezing before inserting into the vagina Inserted up to 24 hours before intercourse; should not be worn > 30 hours Prevents entry of semen into the cervix and has spermicidal effects Contraindications: - cervical anomalies or abnormalities, - spermicide allergy Complication: vaginal irritation, -toxic shock syndrome (rare)

Answer 497

Description: Foams or jellies that are inserted into the vagina prior to sexual intercourse The active ingredient disrupts surface membranes → spermicidal effect Contraindication: spermicide allergy Complication: vaginal irritation

Answer 498

Female sterilization: Description: surgical interruption of the fallopian tubes Methods: - Tubal ligation with or without partial salpingectomy - Partial destruction of oviduct with electrocoagulation - Clipping or banding of the fallopian tubes Can be performed under neuraxial or general anesthesia Vasectomy: Description: division and removal of a section of the vas deferens Can be performed under local anesthesia Complications: - Hematoma - Surgical site infection - Sperm granulomas: a collection of sperm due to leakage from the vas deferens into the surrounding interstitium - Postvasectomy pain syndrome - - A condition characterized by a chronic, dull, aching pain in the testes in patients who have had a vasectomy - - Caused by the accumulation of testicular fluid in the epididymis - Failure - - Patients should be counseled about potential post-vasectomy pregnancies (approx. 1 in 2,000 cases) - - Follow-up sperm sample test at three months after surgery to verify azoospermia

Answer 499

Inability to achieve pregnancy after 12 months of unprotected sex in women < 35 years and 6 months in women ≥ 35 years of age Primary infertility: infertility in persons who have never achieved pregnancy Secondary infertility: infertility in persons who have previously achieved at least one pregnancy

Answer 500

The inability of a woman to carry to live birth even if conception is possible (e.g., due to uterine myomas, antiphospholipid syndrome)

Answer 501

Infertility affects approx. 10–15% of couples of reproductive age Approx. 5% of women in the US aged 15–44 years old are infertile Approx. 5–10% of men in the US aged 15–44 years old are infertile

Answer 502

Ovary-related causes: - Premature ovarian failure - Menstrual cycle abnormalities (e.g., functional hypothalamic amenorrhea) - Hyperprolactinemia - Thyroid disorders - Systematic conditions: - - diabetes mellitus - - hypertension - - obesity - - chronic diseases (e.g., hepatic or renal) - Pituitary adenoma - Diminished ovarian reserve - - A decline in functioning oocytes (either reduced number or impaired development) - - A normal consequence of age, but can also be caused by an underlying disorder (e.g., endometriosis) - Hypogonadotropic hypogonadism - Cushing syndrome - PCOS Tubal/pelvic causes - PID - Endometriosis - Fallopian tube adhesions and/or obstruction - - Following tubal or pelvic surgery - - Following infections: - -- appendicitis - -- chronic chlamydia infection - -- acute salpingitis - -- inflammatory bowel disease Uterine causes: - Anatomical anomalies (e.g., septate uterus, bicornuate uterus, Mayer‑Rokitansky-Kuster‑Hauser syndrome) - Uterine leiomyoma - Endometrial polyps - Asherman syndrome - - Mostly iatrogenic (scarring, fibrosis, and/or adhesions of the endometrium caused by curettage) - - Reduces the sensitivity of the endometrium to progestogens Cervical causes: -Cervical anomalies (e.g., insufficient cervical mucus production) -Trauma (e.g., following cryotherapy, conization) Immune factors (e.g., antisperm antibodies in the cervical mucus) -DES exposure in utero Psychiatric causes: - Vaginismus - Sexual arousal disorder

Answer 503

Sperm disorders (e.g., reduced sperm count, impaired motility, reduced ejaculate volume) Testicular damage (e.g., scrotal injuries, testicular torsion, infections such as mumps, gonorrhea) Scrotal hyperthermia (varicocele) Medication (e.g., anabolic steroids, spironolactone, corticosteroids, cimetidine) Thyroid disorders Chronic diseases (e.g., liver cirrhosis, renal insufficiency) Inherited disorders - Klinefelter syndrome - Kallmann syndrome - - Often associated with structural/developmental abnormalities: - -- cryptorchidism - -- cleft palate - -- scoliosis - -- renal agenesis - - Characterized by delayed onset of puberty and hyposmia/anosmia - - More common in men Sexual dysfunction (e.g., impaired libido, anejaculation) Pituitary and hypothalamic tumors Hyperprolactinemia Cryptorchidism

Answer 504

Medical history of both partners, especially gynecological history Assess ovulatory function - Menstrual history - Body temperature analysis to monitor menstrual cycle - Hormone tests (between the 3rd and 5th day of the menstrual cycle ) - - Midluteal serum progesterone levels: progesterone should increase shortly after ovulation → failure of progesterone levels to rise indicates anovulation - - Ovulation prediction test (detect LH levels) - - Androgen levels: elevated levels induce negative feedback to the hypothalamus → inhibition GnRH secretion → decreased estrogen levels and suppression of ovulation - - Ovarian reserve - -- Early follicular FSH levels: elevated in ovarian insufficiency and indicate reduced ovarian reserve - -- Early follicular estradiol levels - -- Anti-Müllerian hormone levels - - TSH levels: elevated levels in hypothyroidism - - Prolactin levels: hyperprolactinemia - Ovarian sonography: antral follicle count - Endometrial biopsy - - Usually performed 1–3 days before menstruation to determine thickness of endometrium - - A flat endometrial lining indicates a defect in the luteal phase of the menstrual cycle. Imaging: assess the patency of fallopian tubes and uterus - Indications: - - If the initial workup does not reveal any abnormalities and no history suggestive of tubal obstruction - - Screen for tubal occlusion and structural uterine abnormalities (e.g., septate uterus, submucous fibroids, intrauterine adhesions) - Hysterosalpingography: an imaging technique involving the injection of contrast dye into the cervical canal and serial radiographs to evaluate the uterine cavity and morphology/patency of the fallopian tubes - Sonohysterosalpingography: an ultrasound technique in which fluid is inserted into the uterus via the cervix to examine the uterine lining - Hysteroscopy and/or laparoscopy - - Indicated if there is evidence of intrauterine abnormalities or tubal occlusion. - - Can also be used therapeutically to remove small adhesions or mucous plugs obstructing the tubal lumen Examine cervix: - Physical examination - Pap smear - Testing for antisperm antibodies in cervical mucus

Answer 505

Lifestyle modifications: cessation of alcohol, nicotine, and recreational drug use as they contribute to subfertility. Treatment of underlying causes: (e.g., levothyroxine for hypothyroidism, bromocriptine for hyperprolactinemia, metformin for PCOS) [10] Ovulation induction - Clomiphene citrate - GnRH (pulsatile): stimulation of FSH and LH release → follicle maturation - Gonadotropins (e.g., recombinant hCG, recombinant LH): stimulate final oocyte maturation → ovulation - Tamoxifen (selective estrogen receptor modulator) - GnRH-antagonists Assisted reproductive technology: - In vitro fertilization - - The most common form of assisted reproduction technology - - Involves hormonal follicular stimulation followed by a transvaginal follicular puncture for oocyte retrieval with ultrasound monitoring - - The recovered oocytes are mixed with processed spermatozoa and incubated. - - Two (in young women) to a maximum of five embryos (in women over 40 years of age) are transferred into the uterus. - Intracytoplasmic sperm injection: a type of assisted reproductive technology, in which a single spermatozoon is introduced into an oocyte under a microscope using an injection pipette Intrauterine insemination (IUI): a procedure in which washed and concentrated sperm are introduced directly into the uterine cavity Oocyte donation Surgery: removal of tubal, cervical, or uterine adhesions, myomas, and/or scar tissue

Answer 506

A potentially life-threatening complication of ovulation induction with exogenous human chorionic gonadotropin (hCG)

Answer 507

Exogenous hCG is thought to be responsible for the massive luteinization of the ovarian granulosa cells. Formation of multiple ovarian follicles and corpus luteum cysts with rapid ovarian enlargement ↑ Release of vasoactive mediators (e.g., VEGF) that induce an increase in capillary permeability and consequent third spacing into the abdominal cavity

Answer 508

Onset: between 3 days (early onset) and ≥ 9 days (late onset) after hCG administration ``` Abdominal pain and distention Nausea and/or vomiting Weight gain Severe features Pleural effusion Acute kidney injury with oliguria/anuria Venous or arterial thromboembolic events ```

Answer 509

Laboratory analysis: - Leukocytosis, ↑ Hct - Serum electrolyte concentrations and renal function tests - Liver function tests Transvaginal ultrasound: ascites and ovarian enlargement

Answer 510

Mild and moderate cases (usually early onset): manage on an outpatient basis: - Limit physical activity - Pain management with acetaminophen - Daily monitoring of body weight (should not increase by > 1 kg/day) and urine output - Sufficient hydration (1–2 L/day) - Paracentesis to relieve symptoms of ascites Severe cases (usually late onset) - Hospitalization - Multidisciplinary management approach: - - supportive care - - monitoring - - prevention of complications (e.g., prophylactic anticoagulation)

Answer 511

Medical history of both partners Semen analysis Mixed antiglobulin reaction test for antisperm antibodies - Antisperm antibodies form in disruption of the blood-testis barrier (composed of Sertoli cell tight-junctions) - The antibodies can lead to immobilization and agglutination of sperm or have a spermatotoxic effect. TSH levels Prolactin levels Karyotype test (Kallmann syndrome, Klinefelter syndrome)

Answer 512

Treatment of underlying cause Modification of lifestyle factors such as alcohol, nicotine, and recreational drug use Medical therapy: clomiphene citrate, tamoxifen Assisted reproductive technology - Intrauterine insemination - In vitro fertilization - Intracytoplasmic sperm injection Surgical treatment of testicular anomalies and/or defects

Answer 513

Physical exam Ultrasound and mammogram (first-line) - Ultrasound: - - Findings range from normal appearance to focal regions of thick parenchyma. - - Сysts may be present. - Mammogram (not recommended for women < 30 years): - - Round or oval masses with clear borders - - In some cases, dispersed calcifications Fine-needle aspiration (after imaging confirms a cystic lesion): indicated if the patient is symptomatic and/or requests the procedure Biopsy: confirms diagnosis if imaging is inconclusive

Answer 514

If symptoms are mild, treatment is not required. In case of severe symptoms: - oral contraceptives - tamoxifen - progesterone Fine-needle aspiration or surgery: - If a cyst causes severe pain, discomfort, or disfiguration - In the case of proliferative lesions with atypical cells Reevaluate the cyst after 4–6 weeks.

Answer 515

Depends on the histologic subtype: - Nonproliferative lesions do not increase the risk of cancer. - Proliferative lesions with atypical cells (e.g., ductal epithelial hyperplasia) are associated with an increased risk of cancer

Answer 516

Inflammation of the breast parenchyma

Answer 517

``` Staphylococcus aureus (most common) Other pathogens (e.g., Streptococcus, Escherichia coli) are rare. ```

Answer 518

Occurs in up to 10% of nursing mothers (2-4 weeks postpartum)

Answer 519

Nipple fissures facilitate the entry of bacteria located in the nostril and throat of the infant or on the skin of the mother into the milk ducts during breastfeeding. Prolonged breast engorgement (due to overproduction of milk ) or insufficient drainage of milk (e.g., due to infrequent feeding, quick weaning, illness in either the baby or mother) result in milk stasis, which creates favorable conditions for bacterial growth within the lactiferous ducts.

Answer 520

Tender, firm, swollen, erythematous breast (generally unilateral) Pain during breastfeeding Reduced milk secretion Flu-like symptoms, malaise, fever, and chills In some cases, reactive lymphadenopathy

Answer 521

Clinically | Breast milk cultures or imaging may be required if there is no response to intitital treatment

Answer 522

In nursing mothers, breastfeeding with alternate breasts is recommended every 2–3 hours. Patients with mastitis should continue to breastfeed to reduce risk of breast abscess Analgesics (e.g., ibuprofen) Cold compresses Antibiotic treatment -Oral penicillinase-resistant penicillin or cephalosporin (e.g., dicloxacillin or cephalexin) -In the case of methicillin-resistant Staphylococcus aureus (MRSA): clindamycin or trimethoprim-sulfamethoxazole (TMP-SMX) or vancomycin for severe cases In the case of inadequate response to initial treatment: - Initiate treatment according to breast milk culture results. - Consider an underlying breast abscess, which requires surgical drainage.

Answer 523

Anticipatory lactational counseling To prevent recurrence: oral Lactobacillus probiotic

Answer 524

An encapsulated accumulation of pus within the breast tissue | The main complication of mastitis

Answer 525

``` Breast pain, erythema, and edema Purulent discharge from the nipple of the affected breast Fluctuating mass on palpation Possibly overlying skin necrosis Fever Nausea ```

Answer 526

Needle aspiration: for abscesses with intact overlying skin Incision and drainage: if overlying skin necrosis is present Antibiotic treatment (samer as for mastitis)

Answer 527

Benign nonsuppurative inflammatory lesion affecting adipose tissue of the breast

Answer 528

Incidence: < 3% of all breast lesions | Peak incidence: 50 years

Answer 529

Nontender periareolar mass with irregular borders | Breast skin retraction, erythema, or ecchymosis

Answer 530

Mammogram and/or ultrasound: - Fluid-filled oil cyst - Coarse rim calcifications Biopsy (if any suspicious or inconclusive imaging findings) - Foam cells and multinucleated giant cells - Necrotic fat cells - Hemosiderin deposition and chronic inflammation

Answer 531

No treatment required

Answer 532

Subareolar periductal chronic inflammatory condition defined by dilated mammary ducts which are eventually clogged

Answer 533

Most common in perimenopausal women | Peak incidence: 40–50 years

Answer 534

Inspissated luminal secretion stasis leading to periductal inflammation and fibrous obliteration

Answer 535

Unilateral greenish or bloody discharge (most common cause of greenish nipple discharge) Nipple inversion Firm, stable, painful mass under the nipple (may mimic breast cancer) May progress to a breast abscess

Answer 536

Mammogram and/or ultrasound: can be used to determine mammary duct diameter Biopsy (if any suspicious or inconclusive imaging findings) can show the following: - Central cavity filled with neutrophils and secretion - Pericentral inflammation and/or fibrotic breast parenchyma - Obliteration of the ducts

Answer 537

Usually not necessary (most cases resolve spontaneously) Antibiotic therapy if infected Surgical excision for persistent lesions

Answer 538

Fibroadenoma Phyllodes tumor Intraductal papilloma Lobular carcinoma in situ (LCIS)

Answer 539

Bengin breast tumor with fibrous and glandular tissue

Answer 540

Most common breast tumour in women <35 years | Peak incidence 15-35 years

Answer 541

Unknown, but a hormonal relationship has been established (increased estrogen, e.g., during pregnancy or before menstruation, may stimulate growth)

Answer 542

Usually, a well-defined, mobile mass Most commonly solitary Non-tender Rubbery consistency

Answer 543

Ultrasound: well-defined mass Mammogram: well-defined mass that may have popcorn-like calcifications Core needle biopsy or fine needle aspiration to confirm the diagnosis: fibrous and glandular tissue

Answer 544

Regular check ups

Answer 545

Goo | Most not associated with increased risk of breast cancer

Answer 546

Rare fibroepithelaial tumor with histology similar to that of fibroadenoma

Answer 547

Peak incidence: 40–50 years Most commonly benign Approx. 0.4% of all breast tumors Of unknown aetiology

Answer 548

Painless, smooth, multinodular lump in the breast, with an average size of 4–7 cm Variable growth rate: may grow slowly over many years, rapidly, or have a biphasic growth pattern

Answer 549

Ultrasound and mammogram findings are similar to fibroadenoma, but phyllodes tumors tend to be larger and grow faster than fibroadenomas. Despite the fact that the lesion is typically benign, a suspected phyllodes tumor should be considered a suspicious mass until proven otherwise. If a phyllodes tumor is suspected, perform a core needle biopsy - Leaf-like architecture with papillary projection of epithelium-lined stroma - Connective tissue and cysts - Varying degrees of atypia and hyperplasia

Answer 550

Surgical excision | In case of recurrence: total mastectomy

Answer 551

After excision of benign tumors: excellent prognosis Lesions that show signs of malignancy on histology may recur and metastasize.

Answer 552

Microcalcifications or production of a mass are rare (usually incidental biopsy finding). Lower risk of subsequent invasive carcinoma (equal predisposition in both breasts) compared to DCIS Multifocal localisation

Answer 553

Decreased E-cadherin expression Lobules filled with monomorphic cells Intact basal membrane Diffuse growth pattern

Answer 554

After core needle biopsy: - Clinical and imaging follow-up - Usually no treatment necessary After surgical excision: - Classic LCIS: no further surgery is necessary - Nonclassic LCIS (e.g., pleomorphic LCIS): evaluation of surgical margins and re-excision is recommended

Answer 555

Benign proliferation of mammary gland tissue in male individuals or infants of either sex (neonatal gynecomastia)

Answer 556

Increased oestrogen:testosterone ratio

Answer 557

Neonatal: - Occurs in up to 90% of neonates due to placental transfer of maternal estrogens - Gynecomastia is bilateral, sex independent, and spontaneously resolves within a few weeks or months Pubertal: - Epidemiology: occurs in up to 50% of adolescent boys - Pathophysiology: caused by pubertal estrogen/androgen imbalance - Clinical features: - - Small, mobile, firm plaques of breast tissue in the subareolar region that develop during puberty - - Can be tender, unilateral/bilateral, and associated with fatty development around the nipple - - Spontaneously resolve by 17 years of age - Management - - Reassurance of benign nature of the condition - - Surgical removal of the breast glandular tissue is indicated for pubertal gynecomastia which persists after 17 years of age (persistent pubertal gynecomastia). Senile: -Occurs in ~50% of men over 50 years of age

Answer 558

Due to estrogen excess: - Malignancies - - Leydig cell tumor - - Sertoli cell tumor - - Ectopic hCG-producing tumors (e.g., lung cancer, hepatocellular carcinoma) - - Adrenocortical tumors - Liver cirrhosis: due to increased conversion of adrenal androgen precursors to estrogen - Hyperthyroidism: due to ↑ peripheral conversion of androgens to estrogens and ↑ hepatic production of sex hormone binding globulin (SHBG), which has a higher affinity for testosterone → ↓ free testosterone and a relative increase in estrogen - Refeeding (after prolonged starvation) [36] Due to decreased testosterone: - Klinefelter syndrome - Chronic kidney disease - Testicular disorders (e.g., mumps orchitis, castration, trauma to both testes) - Starvation Due to drugs - Inhibitors of testosterone receptors - - Antiandrogens (e.g., finasteride, bicalutamide, cyproterone acetate, flutamide) - - High-dose cimetidine (H2 receptor blocker) - - Spironolactone - Inhibitors of testosterone synthesis - - Ketoconazole - - Spironolactone - - Chemotherapy drugs (e.g., cyclophosphamide, methotrexate, bleomycin, cisplatin, vincristine) - Exogenous androgens and androgenic steroids - - Exogenous testosterone - - Androgen precursors (e.g., DHEA, androstenedione) - - Androgenic steroids - Estrogen receptor stimulators - - Estrogens - - Digitalis compounds - - Marijuana - - HAART drugs Idiopathic: -25% of patients

Answer 559

Firm, concentric mass at the nipple-areolar complex that may be tender In pathological gynecomastia: possible features of undervirilization, hyperthyroidism, liver/kidney disease, etc.

Answer 560

Laboratory studies: - Serum levels of testosterone, estradiol, luteinizing hormone, and hCG: indicated in patients with pathological/idiopathic gynecomastia - Other tests based on history and examination findings: - - Liver function tests - - Renal function tests - - Thyroid hormone assay Imaging: - Mammography and ultrasound-guided biopsy - - Indicated in patients with suspected breast cancer - - Gynecomastia appears as normal breast tissue behind the nipple on mammography. - Testicular ultrasound: - - indicated in patients with abnormal findings on testicular examination, signs of undervirilization, features of primary hypogonadism, or ↑ hCG levels

Answer 561

Pseudogynecomastia Male breast cancer Mastitis Lipoma

Answer 562

Treat the underlying cause. - Discontinue the offending drug (if possible). - Treat hyperthyroidism, hypogonadism, chronic liver or kidney disease. Observation: indicated in physiological and recent-onset (< 6 months) pathological gynecomastia Medical therapy: - indicated for cosmesis or tender gynecomastia in select patients - Testosterone replacement: in patients with hypogonadism - Selective estrogen receptor modulators (e.g., tamoxifen): in patients with severe pubertal gynecomastia or idiopathic gynecomastia > 3 months that causes substantial breast enlargement with tenderness and/or psychosocial distress Surgery (subcutaneous mastectomy): -indicated for cosmesis in persistent gynecomastia (> 1 year)

Answer 563

A milk retention cyst located in the mammary gland

Answer 564

Frequently occurs during or after lactation | Most common benign breast lesion in lactating women

Answer 565

Obstruction of lactiferous duct → distention of the duct due to collection of milk and epithelial cells → cyst formation

Answer 566

Firm, nontender mass, typically located in the sub-areolar region Pain suggests secondary infection.

Answer 567

Primarily a clinical diagnosis Fine needle aspiration: milky substance (diagnostic and therapeutic) Ultrasound - Complex mass - Findings depend on the fat and water content of the cyst Mammography (rarely indicated): Galactoceles may appear as an indeterminate mass or a mass with the classic fat-fluid level.

Answer 568

Pseudolipoma Cystic mass with fat fluid level Pseudohamartoma

Answer 569

Usually not necessary as most spontaneously resolve | Repeated needle aspiration or surgical excision for symptomatic cysts

Answer 570

Usually good | No increased risk of subsequent breast cancer

Answer 571

AKA Mondor disease | Thrombophlebitis of the superficial veins of the breast and/or anterior chest wall

Answer 572

Idiopathic Iatrogenic (e.g., breast surgery, breast biopsy, radiation therapy) Traumatic (e.g., tight brassiere use, strenuous exercise)

Answer 573

Sudden onset Painful, thickened, cord-like lump or mass Overlying erythema of the superficial veins of the breast and/or anterior chest wall

Answer 574

Clinical features and history | Imaging: ultrasound and/or mammography to rule out other underlying conditions

Answer 575

Conservative measures: - Warm compressed - NSAIDs - Avoidance of irritating clothes

Answer 576

Benign and self-limited disease

Answer 577

A well-circumscribed collection of fluid within the breast that is influenced by hormonal changes

Answer 578

25% of all breast masses Most common in premenopausal women Peak incidence: 35–50 years of age

Answer 579

Solitary breast cyst (most common): a single, circumscribed collection of fluid within the breast Multiple breast cysts: multiple, circumscribed collections of fluid within the breast Simple breast cysts: smooth, thin, regularly shaped walls that are completely filled with fluid Complicated breast cysts: thin-walled cysts filled with fluid and debris Complex breast cysts : thick-walled or septated masses, with intracystic or other solid components

Answer 580

Single or multiple breast masses May be painful or tender Variable size (microcysts, gross cyst, clusters) and texture (smooth, soft, firm) Usually movable

Answer 581

The preferred initial study depends on the woman's age. Breast ultrasound and/or mammography: - Simple cyst - - Imperceptible wall, well-defined, round, anechoic lesion with posterior acoustic enhancement and no solid components - - Up to 1–2 inches (2.5–5 cm) in size - - Other findings include peripheral calcifications and reverberation artifacts - Complicated cysts: - - Thin-walled, homogeneous hypoechoic mass or fluid levels, with or without posterior acoustic enhancement - Complex cysts: - - Thick-walled, thickly septated, or intracystic mass with irregular or lobulated margins and posterior acoustic enhancement due to the presence of cystic components Other: MRI

Answer 582

Simple and complicated cysts: - Mostly benign; do not require intervention - If the cyst is large, painful, and/or has signs of infection: ultrasound-guided fine-needle aspiration - Rarely, complicated cysts are diagnosed as probably benign: clinical follow up in 6 months and repeat imaging Complex cysts: - May develop into breast cancer - Ultrasound-guided core needle biopsy

Answer 583

Breast discomfort or tenderness caused by physiological changes (e.g., hormonal effects) or disease (e.g., breast cancer).

Answer 584

Peak age: 30–50 years of age | Approx. 70% of women are affected during their lifetime.

Answer 585

Cyclical mastalgia: - Primary breast pain associated with the menstrual cycle - Aetiology: hormonal fluctuations of the menstrual cycle, postmenopausal hormone therapy, and oral contraceptive use Noncyclical mastalgia: - Primary breast pain not associated with the menstrual cycle - Aetiology: breast lesions or cysts, chest wall trauma, hormone replacement therapy, pendulous breasts, previous breast surgery Extramammary pain: - Secondary breast pain referred from extramammary locations - Aetiology: chest wall or spinal disorders and trauma

Answer 586

Cyclical mastalgia: - Often bilateral, diffuse breast pain - Typically, most severe in the upper outer quadrant of the breasts - May radiate to the medial aspect of the upper arm - Usually worsens the week prior to the onset of menstruation Noncyclical mastalgia: - Unilateral or bilateral breast pain, usually located over the costal cartilages - Sharp or burning pain and/or soreness Extramammary pain: -Depends on the underlying condition

Answer 587

Medical history (e.g., hormone therapy, trauma, surgical history, risk factors for breast cancer) Physical examination: - Focused breast examination - Look for signs of infection (e.g., erythema, swelling, pain) - Rule out signs suggestive of breast malignancy (e.g., skin changes, mass, nipple discharge) Imaging: - Breast ultrasound and/or mammography - Indications: depend on the patient's age and the presence of findings suggestive of malignancy - - Women with cyclical breast pain usually do not require imaging. - - Women with noncyclical or focal breast pain that is not extramammary should undergo breast imaging. - -- < 30 years of age: ultrasound - -- 30–39 years of age: ultrasound and/or mammography - -- ≥ 40 years of age: ultrasound and/mammography

Answer 588

``` First-line treatment: Conservative -Provide reassurance -Recommend well-fitting sports bra -Use of warm or cold compresses -Analgesia (e.g., acetaminophen, NSAIDs) ``` Second-line treatment: for patients with persistent (> 6 months of conservative treatment) or severe symptoms - Tamoxifen - Postmenopausal hormone therapy should be decreased or discontinued if it is the cause of breast pain.

Answer 589

Cyclical mastalgia: - Usually resolves spontaneously within 3 months of onset - Typically relapses and remits Noncyclical mastalgia: - Resolves spontaneously in approx. 50% of patients - Usually responds poorly to treatment

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