GU midterm Flashcards
(134 cards)
1
Q
Phases of menstrual cycle=
A
Phases:
day 1: menses→follicular→
day 14: ovulation→luteal to day 30
2
Q
Menstrual Cycle Hormonal Sequence of Events=
A
Sequence of events:
hypothalamus secretes [GnRH] → stimulates anterior pituitary to secrete…
[LH/FSH]→ causes ovarian follicles to mature, secreting…
[estrogen/progesterone]→ ovulation→ if no fertilization→ drop in…
[progesterone]→ menses
3
Q
Name the four primary hormones of the menstrual cycle:
A
[GnRH]
[LH/FSH]
[estrogen/progesterone]
[progesterone]
4
Q
signs of estrogen excess:
A
dysmenorrhea; nausea; edema; enlarged uterus, uterine fibroids; fibrocystic breast changes; menorrhagia
5
Q
signs of estrogen deficiency:
A
scant menses; mid cycle spotting
6
Q
signs of progesterone excess:
A
edema; bloating; headache; depression; weight gain; fatigue; HTN; varicose veins
7
Q
signs of progesterone deficiency:
A
symptoms similar to those with anovulatory cycles, endometriosis, adenomyosis, endometrial hyperplasia; prolonged menses; heavy menses; severe cramps; luteal spotting; BTB
8
Q
normal menstrual cycle:
A
21-35 day cycles
9
Q
normal age of menarche:
A
in US is 12-13yo
10
Q
Amenorrhea=
A
absence or abnormal cessation of the menses for more than 3 months
11
Q
Oligomenorrhea=
A
scanty menstruation; menstrual periods occur at intervals of greater than 35 days, with only 4-9 periods in a year
12
Q
Polymenorrhea=
A
occurrence of menstrual cycles of greater than usual frequency
13
Q
Menorrhagia (hypermenorrhea)-
A
excessively prolonged or profuse menses
14
Q
Metrorrhagia-
A
any irregular, acyclic bleeding from the uterus between periods
15
Q
Menometrorrhagia-
A
irregular or excessive bleeding during menstruation and between menstrual periods
16
Q
Dysmenorrhea-
A
painful menses
17
Q
Mittelschmertz-
A
one-sided lower-abdominal pain that occurs in women at or around the time of ovulation
18
Q
Primary Amenorrhea=
A
-Primary: 0.3% prevalence; no secondary sex characteristics by age 14; no menses by age 16
19
Q
Secondary Amenorrhea=
A
Secondary: 1-3% prevalence; no menses per 3 cycles or 6 months, whichever sooner, in a woman w/ previous menses
20
Q
Primary Amenorrhea Causes=
A
CNS hypothalamic pituitary disorder; membranous blockage of vagina (hymen); drastic weight loss/ malnutrition/ eating disorder; hypoglycemia; extreme obesity; thyroid disease; anemia; congenital abnormalities of genital system
21
Q
Secondary Amenorrhea 4 most common causes=
A
- normogonadotropic anovulation
- hypogonadotropic hypogonadism
- prolactinoma
- hypergonadotropic hypogonadism
22
Q
hypergonadotropic hypogonadism:
Causes Secondary Amenorrhea
A
high LH/FSH, but unresponsive ovaries; premature ovarian failure
23
Q
prolactinoma:
Causes Secondary Amenorrhea
A
high prolactin; medications, pituitary tumor, hypothyroidism
24
Q
hypogonadotropic hypogonadism:
Causes Secondary Amenorrhea
A
low LH/FSH so lack of stimulation of ovary; psychological and physical stress
25
normogonadotropic anovulation:
| Causes Secondary Amenorrhea
normal LH/FSH, but cyclic secretion disrupted, therefore, no ovulation and low progesterone; polycystic ovarian syndrome
26
Additional causes of secondary Amenorrhea:
- pregnancy (must rule out)
- weight reduction/ drastic gain
- stress/ depression
- hypothyroidism
- PCOS (elevated estrogen and testosterone)
- obesity (elevated estrogen)
- increased prolactin (inhibits GnRH)
- premature ovarian failure (early menopause)
27
Amenorrhea Medications=
- hormonal contraception, doesn’t require intervention, may consider change to different contraception
- antipsychotics
- antidepressants, inc. tricyclics and MAOIs
- cardiovascular meds inc Ca-blockers, Aldomet, Reserpine, Digoxin
- ovarian toxins (cytoxan, fluorouracin, cisplatin)
28
Hypoestrogenic amenorrhea=
puts woman at higher risk for bone mineral density loss… osteoporosis
29
Amenorrhea evaluation physical exam=
-secondary sex characteristics; imperforate hymen/ normal anatomy; sexual maturity; weight; thyroid, hyperandrogenism signs
30
Amenorrhea evaluation initial labs=
-B-hCG; TSH; PRL; progesterone challenge test, rule out estrogen deficiency,
31
What are PCOS (PolyCystic Ovarian Syndrome) associated symptoms?
-secondary amenorrhea; metabolic dysfunction; hyperestrogenic/ androgenic state; anovulation
32
PCOS hormonal implications: androgens:
- inc levels of estrone due to conversion of ovarian and adrenal androgens to estrone in body fat
- suppress pituitary FSH
- ovary receives constant LH stimulation resulting in:
anovulation, cysts, hyperplasia of theca cells→ more
33
PCOS inc risk for:
infertility; DM; CVD; endometrial cancer
34
PCOS Diagnosing:
symptoms- hirsutism, anovulation; fasting glucose/ insulin; 2hr postprandial glucose and insulin; free testosterone, DHEA-S;
-PELVIC ULTRASOUND FOR POLYCYSTIC OVARIES NOT NECESSARY
35
PCOS Management=
-treat insulin resistance, hyperinsulinemia; address androgen excess problems; address fertility issues; address prevention of long-term PCOS complications
36
Long-term PCOS complications:
-diabetes, endometrial hyperplasia/cancer, CVD/dyslipidemia, breast cancer, obesity, fertility issues
37
PCOS Medication Treatments:
Medications
-Progesterone: normalize E:P, restore ovulation
- Spironolactone: reduce androgens and reducing abnormal hair growth
- Metformin: regulates blood sugar and dec hirsutism and anovulation
38
PCOS Treatments: Supplements
- Inc SHBG: soy, flax, nettles, green tea
- Dec androgens: saw palmetto
- Improve insulin resistance: vit C, chromium, diet
- Inc ovulation: vitex (chaste tree), rhodiola, tribulus
39
Normal menstrual bleeding=
Normal: cycle_ 21-35 days; flow_ up to 7 days (ave 3-5); amount_ up to 80ml/day (1tsp=5ml)
40
Abnormal menstrual bleeding=
-Abnormal if: 35 days, >7 days menses, spotting in between menses (BTB of metrorrhagia)
RED FLAG: POST-MENOPAUSAL BLEEDING
41
Abnormal uterine bleeding terms:
menorragia; metrorrhagia; menometrorrhagia; polymenorrhea; contact bleeding
42
-Initiators of abnormal bleeding:
infection (STI); neoplasms (fibroids, polyps); endocrine/ hormonal (PCOS, thyroid, obesity, hyperprolactinemia, menopause); malignancies (endometrial/cervical); trauma; pregnancy
43
Menorrhagia causes:
pregnancy (must rule out); infection (STI screen); intrauterine device; uterine fibroids; endometrial/ cervical polyps; hypothyroidism (TSH, fT4); coagulation disorder (PT/PTT); neoplasms (pap, U/S, EMB); dysfunctional uterine bleeding
44
Menorrhagia symptoms:
symptoms: >80-90ml/period; menstrual bleeding> 7d; unusually heavy bleeding, requiring change of protection at night, menstrual flow interfering w/ lifestyle; fatigue, dizziness, and/or SOB
45
Managing Abnormal Bleeding:
determine the cause; control bleeding; prevent/treat anemia; restore normal menstrual cycle
46
Work-up of menorrhagia:
urine pregnancy; STI screen; endocrine work-up, PRL, TSH/fT4, FSH, E, P; coagulation work-up (PT/PTT); PAP; U/S, pelvic and transvaginal; EMB/hysteroscopy and biopsy
47
Dysfunctional Uterine Bleeding (DUB)=
- If all tests are normal: DUB (diagnosis of exclusion)
- associated w/ anovulatory cycles; overgrowth of endometrium due to estrogen stimulation w/out adequate (post-ovulatory) progesterone to stabilize growth, unopposed estrogen state; associated w/ long or short cycles
48
Uterine Fibroids aka...
leiomyomata, leiomyoma, fibromyoma, myoma
49
Uterine Fibroids=
- most common solid tumor in women; typically benin
- overgrowth of muscle and connective tissue in the wall of the uterus; most common indication for major surgery in women= 30% of hysterectomies
50
Uterine Fibroids Risk factors:
inc w/ age_35-45 yo; race_African American 3x more likely; genetic predisposition; hormones_ estrogen dominance; lifestyle_ nulliparous (no children)
51
Dysfunctional Uterine Bleeding (DUB) Symptoms:
| usually asymptomatic
Symptoms: enlarged uterus; pressure, bloating; heaviness; constipation; vague feeling of discomfort; P w/ vaginal intercourse; urinary abnormalities: freq, urg, acute or chronic urinary retention, ureteral compression, hydronephrosis; pelvic pain-cramping; backache, esp during menses; abdominal enlargement; infertility, recurrent SAB
52
What is the m/c cause of abnormal bleeding?
Dysfunctional Uterine Bleeding (DUB)
53
T/F: pain is NOT a typical symptom with Dysfunctional Uterine Bleeding (DUB).
T
| majority are asymptomatic (50-80%);
54
Diagnosis of uterine fibroids:
ultrasound
55
Diagnosis of Endometrial hyperplasia:
U/S (endometrial stripe); endometrial biopsy; D+C; hysteroscopy
56
Endometrial Carcinoma Risk factors:
age_ 50-70; hyperplasia; unopposed estrogen; obesity; family history_ breast, colorectal; PCOS/anovulation; nulliparity; extended use of tamoxifen; diabetic; hypertension
57
Protective factors of endometrial cancer:
birth control pills; pregnancies; early menopause
58
Endometrial Carcinoma Signs and symptoms:
postmenopausal bleeding; postmenopausal pap w/ endometrial cells; premenopausal intermenstrual bleeding
59
Endometrial Carcinoma Stage and 5 year survival rate:
Stage I_76%; Stage II_60%; Stage III_ 30%; Stage IV_10%
PATIENTS WITH PERSISTENT SYMPTOMS DESPITE A NORMAL BIOPSY REQUIRE FURTHER EVALUATION!
60
Endometrial Carcinoma Dx imaging:
pelvic U/S (abnormal bleeding and large uterus) w/ or w/out endometrial sampling (rule out hyperplasia or carcinoma); laproscopy to evaluate and possibly remove
61
Endometriosis=
-progressive; presence of endometrial glands and stroma outside the uterus; etiological theories_ genetics, retrograde menstruation, altered immune function, environmental exposures
62
Endometriosis PREVALENCE AND EPIDEMIOLOGY:
M/C in reproductive age 25-30_ 15% of reproductive aged women; one of the leading causes of chronic pelvic P; rare in premenarche or menopausal women
63
Endometriosis Risk factors:
fam his; shorter menstrual cycles; longer menstruation flow; inc serum estrogens; obesity (excess estrogen); lack of exercise
64
Endometriosis Clinical Presentation:
pelvic P, ovulation before/during menses; dspareunia; infertility; low back/leg P; severe dysmenorrheal; irregular or heavy menstruation
65
Endometriosis Diagnosis:
- Direct visualization of pelvic and abd viscera-dx and treatment
- visually directed biopsy and removal of implant, dyspareunia, or likelihood of pregnancy following treatment
- laparoscopy is GOLD STANDARD
- serum CA-125 levels
- US or MRI (not highly sensitive)
66
Laparoscopy appearance of blue-grey “powder” burned lesions is found in what dz?
Endometriosis
extent of disease on laparoscopy does not correlate well w/ P
67
Endometriosis Treatment:
-analgesics (NSAIDS, narcotics)
Endocrine therapy...
progesterone (oral, IUD), OCP’s, GnRh agonists (LUPRON),
Danazol (synth testosterone) dec → antiproliferative effect on endometrium→ amenorrhea, Arimidex (aromatase inhibitor) dec inflammation, growth, P; Surgery
68
Dysmenorrhea Prostaglandin Theory:
progesterone dec the release of local PG’s; PG’s inc myometrial contractions, constrict small endometrial blood vessels w/ consequent tissue ischemia, endometrial disintegration, bleeding and pain
69
What is Danazols (synth testosterone) effect on the endometrium?
dec → antiproliferative effect on endometrium
70
How does Dysmenorrhea inc levels of PG across the menstrual cycle...
- follicular-luteal has 3x PG inc
- luteal-menses has 2-7x PG inc
- prostaglandins inc in luteal phase→ highest levels at the onset of menses
- higher PG levels→ uterine contractions→ cramps and P
71
DYSMENORRHEIC WOMEN MAKE ______ MORE PG THAN CONTROLS
8-13X
72
With Dysmenorrhea, most of the production and release of PG occurs in the first ______ of menstrual flow.
48hrs
73
With dysmenorrhea an excess of PG enters bloodstream affecting _______.
other smooth muscles→ headaches, dizziness, hot and cold flashes, diarrhea and nausea
74
Conventional management of dysmenorrhea:
- NSAIDS: ibuprofen; Naproxen sodium; ASA; MOA: inhibits arachodonic acid conversion to PG and leukotrienes
- Hormones: OC’s (hormonal birth control); MOA inhibitors-inhibits ovulation, dec thichness of endometrial lining and thereby fewer PG’s are made; Mirena IUD (progesterone); Depo Provera (progesterone)
75
What dysmenorrhea treatment inhibits arachodonic acid conversion to PG and leukotrienes?
NSAIDS
76
What does MOA inhibitor treatment do for dysmenorrhea?
MOA inhibitors-inhibits ovulation, dec thichness of endometrial lining and thereby fewer PG’s are made
77
PMS:
Monthly recurrence of mood, cognitive, or physical symptoms during the luteal phase
78
PMS symptoms:
symptoms peak prior to or w/ onset of flow, symptoms remit w/ menses, symptoms are not an exacerbation of an underlying disorder
79
PMDD:
Psychosocial impairment- interferes w/ work, school, relationships or social activities
80
PMDD timing:
Not an exacerbation of an underlying disorder, most prominent during last week of luteal phase, begins to remit w/ menses, absent in the week post-menses
81
PMDD Must include 5 of the following and at least one of the symptoms in 1-4:
1. depressed mood, hopelessness, self-deprecation;
2. Marked anxiety or tension;
3. Marked affective lability;
4. Anger or irritability;
5. Dec interest in usual activities;
6. Difficulty concentrating;
7. Dec energy;
8. Marked change in appitite;
9. Sleep disturbance;
10. Sense of being overwhelmed or out of control;
11. Physical symptoms generally associated w/ changes in the menstrual cycle
82
PMM has distressing physical or affective symptoms during what part of the cycle?
- THROUGHOUT the cycle
| - symptoms NEVER completely remit
83
PMM may be an exacerbation of an underlying condition, ie:
affective disorder, depression, endometriosis, substance abuse, migraines, seizure disorder, asthma, chronic fatigue, allergies or IBS
84
PMM symptoms worsen during the _____ phase
luteal phase
85
Hormonal CAUSES OF PREMENSTRUAL DISORDERS
CNS response to normal variations of hormonal changes
86
Nutritional deficiencies CAUSES OF PREMENSTRUAL DISORDERS
Vit B6, B3, C, E; Ca2+, Mg, EPO (linoleic acid/GLA); Zn; Lenoleic acid (help to synthesis PGE-1); excessive sugar, caffeine, alcohol
87
Altered PG synthesis CAUSES OF PREMENSTRUAL DISORDERS
PGs facilitates shedding of the endometrium and the bursting of the follicle @ ovulation; the withdrawal of progesterone release initiates the synthesis of PGE2-a (pro-inflammatory); dysmenorrheal is due to an imbalance of PGs, 500% inc in pro-inflam PGs (PGE2s) than anti-inflam PGs (PGE1 & 3)
88
Neurotransmitter imbalance CAUSES OF PREMENSTRUAL DISORDERS
abnormal serotonergic function and neurotransmission; in PMS pts serotonin levels were found to be lower 10 days prior to menses, while PMDD pts had lower serotonin levels all month long; SSRI shown to reduce PMDD symptoms
89
Are there Psychological factors that cause PREMENSTRUAL DISORDERS?
Yes
90
INFERTILITY Definition:
1. No conception after 12 months of intercourse w/out contraception in women 35
91
-FEMALE CAUSES of infertility: Pelvic factors...
~35%: infection; surgical history; contraception and pregnancy history; menstrual cycle abnormalities
92
FEMALE CAUSES of infertility: Ovulatory factors...
15%: secondary amenorrhea; abnormal uterine bleeding; luteal phase defect (short cycle, low progesterone); premature ovarian failure (early menopause)
-polycystic ovarian syndrome (high androgen); elevated prolactin; hypothyroidism; history of anti-estrogens (lupron)
93
Other causes female infertility:
delayed childbearing; overweight (BMI >25), underweight (BMI <18); insulin resistance; depression; substance use; malabsorption (celiac)
94
Male factor infertility causes=
~35%: varicocele (42% of cases); unexplained (22%); obstructive azoospermia (14%); undescended testis (3%)
95
Other male factors of infertility=
testicular surgeries or injury; genitourinary infection or STI’s; post-pubertal mumps; hypogonadism or other congenital disorder; genital radiation or chemotherapy; testicular cancer; retrograde ejaculation or other dysfunction; exposure to excessive heat, toxic chemicals, pesticides; medications or drug use- nicotine, alcohol, cocaine, steroids, marijuana, prescription meds
96
General Lifestyle affects on infertility=
- Either partner who smoked > 15 cigs/day; Alcohol >20/week; bmi>25; coffee >6cups/day if partners with > than 4 negative risks takes 7x longer, conception fell 60% 7x more likely for drugs
- Diet , exercise can both be positive and negative depending on intensity and duration, caffeine, weight to low bad to high bad
97
Ovarian masses Functional cyst
| 3 types=
- Follicular
- Corpus luteum
- Theca lutein
98
Follicular functional cysts=
most common results from dominant follicles failing to rupture persistent follicle or immature follicles failing the process of atresia usually disappears 1-3 months. Blood can fill the cyst and give a hemorrhagic/ chocolate cyst
99
Corpus luteum functional cysts=
less common clinically more important. Normal endocrine and prolonged progesterone secretion. Results from the sac not dissolving after egg is released fluid fills it. Resolves within a few weeks, can get around 4” may bleed or cause torsion 31% chance of recurance
100
Theca lutein functional cysts=
rare almost always bilateral and asymptomatic caused by excessive activation of ovaries by endogenous or exogenous gonadotropins
101
Functional cyst symptoms=
Sxs often asymptomatic found in pelvic exam, unilateral pain, fullness, pressure in lower abd. Dull ache in low abd. Or thighs. Pain while boning,
102
Functional cyst Sxs requiring immediate referral=
Pain with fever vomiting, sudden pain, fainting, dizziness weakness, tachypnea, tachycardia
103
Dermoid cyst aka teratoma Characteristics=
Large growth, contain all 3 germ layers, benign or malignant
104
Dermoid cyst aka teratoma Epidemiology:
- Most common in neoplasm in prepuberty girls and teens, 50% occur 25-50age,
- Postmenapause 20%of ovary tumors benign
- Accidental discovery most removed because of malignancy though very low.
105
Endometriom mass diagnosis, pain, and recurrence=
- Ultrasound
- Can be painless of severe pain
- Frequently recurs if not completely resected
106
Is Ovarian mass Maligancy risk more common pre or postmenopausal?
Premenopausal 13%
Post 45%
107
5 leading cause of cancer deaths=
Ovarian cancer
108
50 % of all gyn cancer deaths
| (Peak age 60-65)=
Ovarian cancer
109
How to diagnose Ovarian cancer:
- Labs, CBC, renal/lft, tumor markers-ca125
| - Radiographic, Pelvic us, chest xray ,ct scan
110
Stage of Ovarian cancer diagnosis in order of percentage found:
- stage 3 15-50% 5 yr survival rate
- stage 1 75 -100%
- stage 4 5%
- stage 2 45-60%
111
Is CA- 125 a reliable ovarian cancer test?
CA -125 is unreliable at best can give false positives with fibroids, benign ovarian tumors, adenomyosis, endometriosis, PID
112
Cervical Dysplasia & cancer Screening Guidelines=
- Reg paps for all women who are sexual active and have a cervix at age 21 or 3 years after first boning which ever comes first.
- 65 against routine screening if 10 yr history is clean and not high risk
113
HPV Tests=
thin prep . sure path transmission sexually, high risk hpv cancer, low risk warts
114
Vocabulary for PAPs:
Atypia; variation of normal
Ascus; abnormal squamous cells of undetermined significance watch it.
CIN I; cervical intraepthalial neoplasia mild aka LGSIL low grade intraepithelial lesion
CIN II; moderate aka HGSIL high grade
CIN III; severe AKA hgsil
CIS; carcinoma in situ pre-cancerous
Cervical cancer
115
Ascus=
abnormal squamous cells of undetermined significance watch it.
116
CIN I;
cervical intraepthalial neoplasia mild aka LGSIL low grade intraepithelial lesion
117
CIN II;
moderate aka HGSIL high grade
118
CIS;
carcinoma in situ pre-cancerous
119
Management of abnormal paps;
| Atypia, ASCUS, CIN I=
most go away without treatment paps every 4 months 1 yr every 6 moths 2 yr
120
Management of abnormal paps CIN II=
treatment recommended, cryo, LEEP, pap test every 4 months 1 yr 6mths 2 yr
121
Management of abnormal paps CIN II, CIS, Cancer=
treatment by gyn oncologist, surgery, LEEP, Conization or laser beam treatment, Hysterectomy in late stages, same pap testing as above
122
Breast Health Upper Outer Quadrant (UOQ) –
most common site for fibrous cystic changes (benign) and/or malignancies.
123
Fibrous areas of the breast are of less concern if _______.
symmetrical, pain-free & mobile.
124
Mastalgia –
breast pain: must differentiate cyclic from non-cyclic
125
Nipple Discharge –
most common will be benign, but be concerned if: bloody, associated with mass, unilateral, single duct, spontaneous, post-menopausal, hormone replacement therapy (HRT), prolactinoma
126
Fibrocystic Breast Changes should resolve with _______.
menopause
127
Mammogram every ______ after age 40.
1-2 years
128
T/F with fibrocystic breast changes 75% of patients have no major risk factors
T
129
___% of Pt with Fibrocystic Breast Changes do NOT have a primary family member with breast cancer
90%
130
hypothalamus secretes [GnRH] → stimulates anterior pituitary to secrete...
[LH/FSH]
131
What dz has the following symptoms: menstrual cycle irregularities and infertility; appearance, weight (obesity), excessive hair growth, acne, hair loss (alopecia); metabolic issues-hypoglycemic, insulin resistant, hyperlipidemia, hypertension?
PCOS
132
Complete Gynecological History Taking:
```
History of Present Illness:
o Menstrual History
o Discharge
o Pelvic Pain
o Pelvic Relaxation
OB History
Contraceptive History
Sexual History
ROS
FMHx
PMHx
Psych/Social Hx
Medications
Supplements
Lifestyle
```
133
LH:
FSH:
LH: androgens, progesterone, ovulation
FSH: estrogen
134
Effects of Estrogen:
```
o Endometrial proliferation
o Myometrial cell growth
o Vaginal cornifcation
o Reduced vaginal pH (why important?)
o Increased cervical mucus pH
Other: breast, fat, skin, bone, brain
Feed back loop on hypothalamic-pituitary
```
