GYN Flashcards by vanessa jasmin

Vaginal discharge
Red and swollen vulva
Hx of use of tampon, condom or diaphragm

Foreign body

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Bleeding at irregular intervals particularly between expected menstrual periods

examples?

Metrorrhagia or intermenstrual bleeding

Endometrial polyps,
DUB,
uterine or cervical cancer,
OCP

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When does the screening start for cervical cancer?

Screening starts at 21 independent of sexual Hx

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Extension of areas of endometrial glands and stroma into the myometrium

Mean age 40-50 yr;Common in parous women

Clinical Features
Pain:
New onset dysmenorrhea 
Pelvic pain
Dyspareunia
Heavy menstrual bleeding

Bimanual Exam: Bulky/ boggy, symmetrically enlarged, smooth*, globular, mobile, tender uterus

Adenomyosis

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What is the clinical feature of endometrial cancer?

Postmenopausal vaginal bleeding

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Pathophysiology: ↓estrogen at perimenopause and menopause
History

HX: Varying discharge; Dyspareunia; vaginal dryness
Peri/postmenopausal

PE: Pale, thin vaginal mucosa

Wet mount: folded, clumped epithelial cells

Atrophic vaginitis

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Hx of sexual contact
Whitish pink to reddish brown, fleshy/soft, painless wart-like growths on external genitalia, perineum or anus
May enlarge to form cauliflower-like lesions

Pap smear: koilocytes

Condyloma acuminatum

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Protective factor for endometrial cancer

Protective factor: OCPs ↓ risk

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Cycles occurring at intervals < 21 d

Polymenorrhea

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First infection
Fever, malaise
multiple, very painful, vesicular, ulcers
Inguinal lymphadenopathy

Viral culture
Gold standard; preferred in patients with ulcer
Direct fluorescent antigen (immunofluorescence)
Using cells scraped from ulcer bases

Genital herpes (HSV2)

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loss of the normal ligamentous support for the uterus

causes the uterus to descend into the vaginal canal

Uterine prolapse

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Watery discharge with foul odor
Dyuria and dyspareunia if severe

Profuse, frothy, yellowish, or greenish malodorous discharge; pH > 4.5; “strawberry cervix

Wet mount: round or pear-shaped protozoa

Trichomoniasis (Trichomonas vaginalis)

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Lack of organic pelvic disease

Prostaglandins

Primary dysmenorrhea

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Primary: presents 2 to 4 weeks after exposure
Painless (papule/ulcer with raised borders)
heals without Tx after 3-6 weeks
Painless bilateral inguinal lymphadenopathy
Serology usually negative

Syphilitic chancre

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Secondary: 2 to 6 months after exposure
Generalized maculopapular rash- palms, soles, trunk, limbs
Flat, round or oval papules in the perineal area covered by a gray exudate
Serology usually positive

Condyloma lata (Treponema pallidum)

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decrease in FSH/LH

increase prolactin

Prolactinoma

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Common sites of endometrial implants:

uterosacral ligaments
rectouterine pouch (pouch of Douglas)
peritoneum

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protective factors for ovarian cancer

Protective Factors (for epithelial ovarian cancers)
↓ number of ovulatory cycles
OCP use
Pregnancy and breastfeeding
Hysterectomy and salpingo-oophorectomy

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risk factors for ovarian cancer

Risk Factors
↑number of ovulatory cycles
Nulliparity, early menarche, late menopause
Age > 50
Genetic factors:
BRCA1 and BRCA-2; FHx of breast, colon, endometrial, ovarian cancer

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History:
D/C: initially watery, becoming dark brown or red
Vaginal bleeding: post-coital, postmenopausal or intermenstrual

Physical Exam
Cervical D/C
Friable, raised, reddened or ulcerated cervical mass

Colposcopy
dysplasia may show white areas with mosaic pattern
with acetic acid application

Squamous type Cervical cancer

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Uterine prolapse

3rd degree:

the cervix and vagina drop outside the introitus

highest in 25-29 yr
Clinical Findings
Infertility
Pain: dysmenorrhea, deep dyspareunia, chronic pelvic pain,

Examination:
Adnexal masses* or tenderness
Nodules/ tenderness- in the posterior vaginal fornix, uterosacral ligament, *rectovaginal septum
Fixed, retroverted uterus

Endometriosis

What age should the HPV vaccine?

(Gardasil 9): CDC recommendation
All boys and girls age from age 11
May be given up to age 21 (men), 26 (women)

Absent upper vagina and uterus; cryptorchid testes

46, XY

breast dvlpment

Complete androgen insensitivity

synrome

Abnormal bleeding: most common presenting symptom Rapid uterine enlargement Pelvic or abdominal pain

Uterine Leiomyosarcoma

2 stages: Vaginal or cervical infection Ascending infection to the upper genital tract ``` History Nausea, vomiting, fever Lower quadrant pain and cramping May be accentuated by motion or coitus Vaginal discharge or bleeding ``` Mucopurulent cervical discharge Cervical motion tenderness + adnexal tenderness

Salpingitis

HX: Partner with NGU Often no Sx + Postcoital spotting PE: +/- Purulent discharge Cervix may or may not be red or friable

Chlamydia (Chlamydia trachomatis)

Age > 40, risk factors for endometrial disease, no response to Tx what investigations and why ?

Transvaginal ultrasound Assess endometrial thickness and other pathologies Endometrial biopsy To r/o endometrial hyperplasia and cancer

breast dvlpment variable (depending on ovarian function) Vagina: normal Uterus: normal Ovaries: streak 45, XO

Turners Syndrome

Cyclic bleeding with diminished flow or shortening of menses

Hypomenorrhea

Risk factors for Endometrial cancer ?

``` Risk factors: ↑ estrogen exposure** Obesity Chronic anovulation; PCOS Nulliparity Early menarche/ late menopause unopposed postmenopausal estrogen replacement ```

a hernia of the bladder wall into the vagina | causes a soft, anterior fullness

Cystocele

Cycles occurring at intervals > 35 d

Oligomenorrhea

What can you find expect to find during a Bimanual exam for Ovarian CA?

Premenopause: enlarged ovary Postmenopause: palpable ovary Solid, irregular, or fixed pelvic mas

Absent or rudimentary upper vagina and uterus

Mullerian agenesis

Uterine prolapse | 2nd degree:

the cervix is at the introitus

Rotterdam Criteria- must meet 2 of 3: Oligo/anovulation menstrual cycles > 35 days apart or Signs of hyperandrogenism Clinical: hirsutism (less common- alopecia); acne Biochemical: ↑DHEA-S, *free testosterone, SHBG Polycystic ovaries by ultrasound >10 small antral follicles are seen in each ovary

PCOS

PE: Purulent cervical discharge; Skene/ Bartholin gland inflammation +/- Inflammation of cervix and vulva

Gonorrhea (Neisseria gonorrhea)

complication of sexually transmitted infections Pain: dyspareunia, dysuria, RUQ abdominal pain Vaginal discharge + foul odor Risk Factors: age < 25, risky sexual behavior, early age at first intercourse PE Acute: fever; cervical motion tenderness; very tender uterus and adnexae Chronic: bilateral tender, irregular, fairly fixed adnexae Abnormal cervical discharge or bleeding can cause Fitz-Hugh-Curtis (perihepatitis) syndrome

PID

Secondary dysmenorrhea

``` Endometriosis* Adenomyosis* Leiomyomas* PMS) IUD ```

HX: Intense pruritus, swollen, inflamed genitals, vulvar burning, dysuria, dyspareunia Hx of immunosup-pression, recent ATB use, ↑estrogen levels PE: White, curdy discharge; pH < 4.5 Cervix may be red + Erythema of perineum or thighs Tests: KOH: spores; mycelia, budding, branching yeast; pseudohyphae

Moniliasis / Candida vulvovaginitis (Candida albicans)

Hx of sexual contact Painless, dimpled or umbilicated flesh-colored or pearly papules several millimeters in diameter in genital area resolve spontaneously within months of appearance cytoplasmic inclusion bodies

Molluscum contagiosum

Most common benign tumor of the pelvis 40-50% of pre-menopausal woman > 35 yr Heavy menses + clots Dysmenorrhea Bimanual exam Firm, regular/irregular, nontender nodules + enlarged uterus asymmetric/nodular

Leiomyomata (Fibroids)

Any bleeding that presents > 1 yr after menopause

Post-menopausal bleeding

Uterine prolapse | 1st degree:

the cervix remains within the vagina

Risk Factors for Cervical Cancer

HPV infection: Types 16, 18 highest risk > 99% of cervical cancers contain one of the high risk HPV types High risk behaviors: Multiple sexual partners, other STI, early age at first intercourse, high risk male partner History of STI Smoking Immunosuppression

Use of new hygiene products

Allergic vaginitis

leading cause of gynecological cancer deaths

Ovarian cancer

Cyclic bleeding that is heavy (> 80 ml blood loss) and prolonged (>7d) examples ?

Menorrhagia or heavy menstrual bleeding (HMB) ``` Endometrial polyps, DUB, adenomyosis, leiomyomas, IUD ```

Clinical: Absence of menses x 1 yr ↑ levels of FSH on day 3 of cycle Average age of onset: 52 years Hot flushes/flashes, night sweats, sleep disturbances, palpitations

Menopause

Swelling on the introitus Dyspareunia Discomfort when walking on adducted thighs Fluctuant mass on either labium Acute: Hot and tender swelling Chronic: Non-tender

Bartholin cyst and abscess Acute- abscess: Hot and tender swelling Chronic- cyst: Non-tender