Gyne Flashcards
(229 cards)
1
Q
Treatment for menorrhagia
A
NSAIDs
TXA
cOCP
IUD progesterone
Progestins on first 10-14d of each month or every 3mo if ovulatory dysfunction
Danazol (androgen)
Surgical: ablation, uterine artery embolization, hysterectomy
2
Q
Indications for endometrial biopsy
A
- > 40y
- Any risk factors for endometrial CA: age, obesity, nulliparity, PCOS, diabetes, hereditary nonpolypopsis colorectal CA)
- Failure of medical tx
- Significant intermenstrual bleeding
- Hx of anovulatory cycles
- Postmenopausal woman with ET >4mm on U/S
3
Q
Uterine ligaments
A
Round ligaments Uterosacral ligaments Cardinal ligaments Broad ligaments Infundibulopelvic ligament
4
Q
Round ligaments
A
Travel from anterior surface of uterus, through broad ligaments and inguinal canals then termiante in labia majora
5
Q
Uterosacral ligaments
A
Arise from sacral fascia and insert into posterior inferior uterus
Supports uterus, prevents prolapse and contains autonomic nerve fibres
6
Q
Cardinal ligaments
A
Extend from lateral pelvic walls and insert into lateral cervix and vagina
Mechanical support and prevents prolapse
7
Q
Broad ligaments
A
Pass from lateral pelvic wall to sides of uterus
Contain fallopian tube, round ligament, ovarian ligament, nerves, vessels and lymphatics
8
Q
Infundibulopelvic ligament
A
AKA suspensory ligament of ovary
Connects ovary to pelvic wall
Contains ovarian artery, ovarian vein, ovarian plexu s and lymphatic vessels
9
Q
Stages of puberty
A
Boobs (thelarche)
Pubes (pubarche)
Grow
Flow (menarche)
10
Q
Adrenarche
A
Increased secretion of adrenal androgens
usually precedes gonadarche by 2 yr
11
Q
Gonadarche
A
Increased secretion of gonadal sex steroids
Typically around age 8
12
Q
Premenstrual syndrome dx
A
At least one affective and one somatic symptom during the 5d before menses in each of the three prior menstrual cycles
Affective: depression, angry outbursts, irritability, anxiety, confusion, social withdrawal
Somatic: Breast tenderness, abdo bloating, headache, swelling of extremities
Symptoms relieved within 4d of onset of menses
13
Q
Premenstrual syndrome tx
A
- 1st line
- Exercise
- CBT
- Vitamin B6
- Combined hormonal contraception
- Continuous or luteal phase (day 15-28) low dose SSRIs
- Citalopram/Escitalopram 10mg
- 2nd line
- Estradiol patches 100ug + micronized progesterone 100mg or 200mg on days 17-28 orally or vaginally
- LNG-IUS 52mg
- Higher dose SSRIs continuously or in luteal phase
- Citalopram/Escitalopram 20-40mg
- 3rd line
- GnRH analogues + add back HRT
- 4th line
- Surgical treatment +/- HRT
14
Q
Premenstrual dysphoric disorder
A
- At least 5 of the following during most menstrual cycles of the last year (with at least 1 of the first 4)
- Depressed mood or hopelessness
- Anxiety or tension
- Affective symptoms
- Anger or irritability
- Decreased interest in activities
- Difficulty concentrating
- Lethargy
- Change in appetite
- Hypersomnia or insomnia
- Feeling overwhelmed
- Physical symptoms: breast tenderness/swelling, headaches, joint/muscle pain, bloating or weight gain
- Symptoms affect function
- Must be discretely related to menstrual cycle
- Must be confirmed during at least 2 consecutive symptomatic menstrual cycles
15
Q
Early follicular/proliferative phase
A
Decreasing E and P Increased GnRH pulse frequency Increased FSH --> follicular growth in ovaries Increased LH pulse frequency Menses from P withdrawal
16
Q
Mid follicular/proliferative phase
A
Increased FSH acts on ovarian granulosa cells
Increased E released from follicles
-ve feedback from E –> decreased FSH and LH
Cervical mucus clear, increasing amount, more stringy
17
Q
Late follicular/proliferative phase
A
Growing follicles cont to secrete E Increasing E from follicles, esp from dominant follicle Dominant follicle persists Remainder undergo atresia Granulosa cells luteinize --> produce P E builds up endometrium
18
Q
Estrogen in menstrual cycle
A
Main hormone in follicular/proliferative phase
Stimulated by FSH
As level increases it acts -vely on FSH
Majority is secreted by dominant follicle
E acts on:
Follicles in ovaries to reduce atresia
Endometrium to induce proliferation
On all target tissues (decreased E receptors)
19
Q
Progesterone in menstrual cycle
A
Main hormone in luteal/secretory phase
Stimulated by LH
Increased progesterone acts -vely on LH and is
Secreted by corpus luteum (remnant of dominant follicle)
P acts on:
Endometrium to stop build up, organize glands, prevent degradation
On all target tissues to decrease E and P receptors
20
Q
Luteal/secretory phase
A
Fixed 14 days
Ovulation
Early-mid
Late
21
Q
Ovulation of luteal/secretory phase
A
Sudden switch from -ve to +ve feedback (E and P cause increased FSH and LH)
E peaks –> LH surge –> ovulation
36h after LH surge, dominant follicle releases oocyte
Corpus luteum forms from dominant follicle remnant nad produces P
22
Q
Early-mid luteal/secretory phase
A
Switch back to -ve feedback
Increased P from corpus luteum –> decreases LH and FSH
P stabilizes endomtrium
23
Q
Late luteal/secretory phase
A
No fertilized oocyte
Decreased P secondary to CL degeneeration –> menses
Cervical mucus: opaque, scant amount
24
Q
Beta-hCG level at which TVUS can detect pregnancy
A
> /= 1500
25
Beta-hCG level at which transabdominal U/S can detect pregnancy
>/= 6500
26
Subtotal hysterectomy
Uterus removed only
| For severe endometriosis, pt choice
27
Total hysterectomy
Uterus, cervix removed and uterine artery ligated
| For Uterine fibroids, endometriosis, adenomyosis, heavy menstrual bleeding
28
Total hysterectomy + bilateral salpino-oophorectomy
Uterus, cervix, uterine artery ligated at uterus, fallopian tubes, ovaries
For endometrial CA, malignant adnexal masses, consider for endometriosis
29
Modified radical hysterectomy
Uterus, cervical, proximal 1/3 parametria, uterine artery ligated medial to ureter, midpoint of uterosacral ligaments and upper 1-2cm vagina
For cervical cancer
30
Radical hysterectomy
Uterus, cervix, entire paramtrium, uterine artery ligated at origin from internal iliac artery, uterosacral ligament at most distal attachment, upper 1/3-1/2 vagina
For cervical cancer
31
Most common causes of primary amenorrhea
Mullerian agenesis
Abnormal sex chromosomes (Turner's syndrome)
Functional hypothalamic amenorrhea
32
Most common cause of secondary amenorrhea
Functional hypothalamic amenorrhea
33
Primary amenorrhea
No menses by 13 with no secondary sex characteristics
| No menses by 15 with secondary sex characteristics
34
Secondary amenorrhea
Hx of menses with no menses for at least 3 mo who have previously had regular cycles or 6mo if irregular cycles
35
Primary amenorrhea without secondary sex characteristics
FSH/LH levels --> if high then hypergonadotropic hypogonadism = gonadal agenesis
If low --> hypogonadotropic hypogonadism = constitutional delay or HPA abnormality (ie. structural CNS problem or anorexia, exercise, stress)
36
Primary amenorrhea with secondary sex characteristics
Karyotype
XX = imperforate hymen, transverse vaginal septum, cervical agenesis, mullerian agenesis
XY = Androgen insensitivity syndrome
37
First steps of secondary amenorrhea pathway
b-hCG
If +ve: pregnant
If -ve: prolactin
38
Hyperprolactinemia and secondary amenorrhea
CT head if >100ng/dL
| TSH to screen for hypothryoidism
39
Normal prolactin and secondary amenorrhea
Progestin challenge
If no withdrawal bleed --> primary ovarian insufficiency, uterine defect, ashermans syndrome or HPA dysfunction
If withdrawal bleed --> FSH and LH --> if high = PCOS, if normal/low = HPA dysfunction --> MRI hypothalamus, pituitary, measure other pituitary hormones (weight loss, excessive exercise, systemic dz)
40
Prolactinoma symptoms
Galactorrhea
Visual changes
Headache
41
Progesterone challenge to assess estrogen status
```
Medroxyprogesterone acetate (Provera) 10mg PO OD for 10-14d
Any uterine bleed within 2-7d after completion of Provera = +ve test/withdrawal bleed --> suggests presence of adequate estrogen to thicken endometrium
If no bleeding occurs, may be secondary to inadeqaute estrogen, excessive androgens or progesterones or pregnancy
```
42
Classic hormonal workup
```
beta hCG
TSH
Prolactin
FSH
LH
Androgens
Estradiol
```
43
Androgen insensitivity syndrome tx
Gonadal resection after puberty
Psych counselling
Creation of neovagina with dilatation
44
Mullerian dysgenesis syndrome tx
Counselling
Creation of neovagina with dilation
Dx study to confirm normal urinary system and spine
45
Asherman's syndrome
Formation of scar tissue in uterine cavity, often after several D&Cs or severe pelvic infection
Tx: Hysteroscopy, excision of synechiae
Prevent recurrence via balloon catheter or adhesion barrier (ie. hyaluronic acid) via foley catheter for 2 wk post op
46
Premature ovarian failure tx
Hormonal therapy with E+P (can use OCP) to decrease risk of osteoporosis
Screen for DM, hypothyroidism, hypoparathyroidism, hypocorticolism
No tx to restore ovulation
47
Hyperprolactinemia tx
MRI/CT head to R/O lesion
If no lesions, bromocriptine/carbergoline if fertiltiy desired
OCP if no fertility desired
48
Ovulatory dysfunction workup
```
beta-hCG
Ferritin
Prolactin
FSH
LH
Serum androgens (free T, DHEA)
progesterone
17-hydroxy progesterone
TSH
fT4
Pelvic U/S
```
49
Acute, severe AUB tx
Estrogen IV + gravol or antifibrinolytic (rarely used)
| Tapering OCP regimen (more commonly used)
50
AUB Ddx
```
PALMCOEIN
Polyp
Adenomyosis
Leiomyosis
Malignancy
Coagulopathy
Ovulatory dysfunction
Endometrial
Iatrogenic
Not yet classified
```
51
Tx for primary dysmenorrhea
NSAIDs before onset of pain
| OCP to suppress ovulation and reduce menstrual flow
52
Triad of endometriosis
Dysmenorrhea
Dyspareunia
Dyschezia
53
Laprascopic findings of endometriossis
Mulberry spots - dark blue/brown implants anywhere in pelvis
Endometrioma - cholocate cysts on ovaries (endometriotic cyst encompassing ovary)
54
CA-125 and endometriosis
May be elevated but should NOT be used in diagnostic testing
55
Endometriosis dx
Definitive: visualization of lesions on laparoscopy and bx/histology of specimens
If hx is suggestion even with -ve exam, should be considered adequate dx
56
Endometriosis tx
1st line:
OCP, progesterone or mirena IUD
2nd line:
GnRH agonist (ie. Lupron) to suppress pituitary
Danazol (weak androgen)
surgical:
Conservative lap*, electrocautery, hysterectomy/BSO
*best time to become pregnant is right after conservative sx
57
Adenomyosis
Extension of areas of endometrial glands and stroma into myometrium
presents ~40-50yo
Uterus symmetrically bulk, usually <14cm
Tx: NSAIDs, OCP, Depo-Provera, GnRH agonist, Mirena, danazol
58
Fibroid tx
```
Only tx if symptomatic
Antiprostaglandins (NSAIDs)
GnRH agonist (Lupron)
Ulipristal acetate* (selective progeterone receptor agonist; 5mg daily x 3mo, controls bleeding and shrinks fibroids)
*check LFTs regularly
Uterine artery embolization
Myomectomy
Hysteroscopy resection and endometrial ablation
Hysterectomy
```
59
Yuzpe Method
EPC
Use within 72h of unprotected intercourse
Ethinyl estradiol + levonorgestrel (OCP high dose)
2 tabs then repeat in 12h
60
Plan B
EPC
Levonorgestrel q12h for 2 doses
Within 72h of intercourse up to 5d
1st line if >24h
61
Ulipristal
EPC
30mg PO within 5d
Selective progesterone receptor modulator (SPERM) , with primarily anti-progestin activity
May delay ovulation by up to 5d
62
Postcoital IUD
EPC
Copper only
Insert up to 7d postcoitus
Prevents implantation
63
Gold standard for medically induced abortion up to 9wks
Mifepristone + misoprostol
64
Mifepristone
Blocks progesterone receptor
65
Misoprostol
Induces uterine contractions
66
Other options for medically induced abortions
Misoprostol only
Methotrexate and misoprostol
Lower success rates than miso + mifepristone
67
Options for surgically induced abortions at <14wks
Manual vacuum aspiration (up to 8-9wks)
| Suction dilatation + aspiration +/- curettage
68
Options for surgically induced abortions at 14-24wks
Dilatation and evacuation
69
Recurrent spontaneous abortions
>/=3 consecutive
| Evaluate mechanical, genetic, environmental and other risk factors
70
Leading cause of maternal death in first trimester
Ectopic pregnancy
71
3 commonest locations for ectopic pregnancy
1. Ampullary
2. Isthmic
3. Fimbrial
72
Risk factors for ectopic pregnancy
```
Previous ectopics
Current IUD use
Hx of PID (esp with C. trachomatis infxn)
Salpingitis
Infertility (IVF pregnancies following ovulation induction)
Prev procedures
Smoking
Structural anomalies
```
73
Normal doubling time with intrauterine pregnancy
1.6-2.4d
74
Surgical tx for ectopic pregnancy
Linear salpingostomy
Salpingectomy if tube damaged or recurrent ectopic
Must monitor bhCG titres weekly until they reach non-detectable levels
Consider Rhogam if Rh -ve
75
Medical tx for ectopic pregnancy
Methotrexate
Follow bhCG levels weekly until bhCG is nondetectable
Give 2nd dose if bhCG doesn't decrease by at least 15% btwn days 4 and 7
76
C/I to MTX therapy
```
Abnormalities in hematologic, hepatic or renal function
Immunodeficiency
Active pulmonary dz
PUD
Hypersensitivity to MTX
Heterotopic pregnancy with coexisting viable IUP
Breastfeeding
Unwilling to adhere to MTX protocol
```
77
Infertility
Inability to conceive or carry to term a pregnancy after one year of regular unprotected intercourse
78
Hypothalamic amenorrhea
Often from stress, poor nutrition, excessive exercise, hx of eating disorders
79
Ovulatory investigations for infertility
Day 3 LH, FSH, TSH, prolactin +/- DHEA, free T add estradiol for proper FSH interpretation
Day 21-23 serum progesterone to confirm ovulation
Basal body temperature monitoring
80
Investigation for tubal and/or peritoneal/uterine factors contributing to infertility
HSG (can be therapeutic by opening up fallopian tube)
Sonohysterogram (can be therapeutic although less likely)
Hysteroscopy
81
Ovulation induction medications
```
Clomiphene citrate (clomid)
Letrozole
```
82
Clomiphene citrate
Estrogen antagonist --> perceived decreased E state --> increases GnRH --> increased FSH and LH --> induces ovulation --> bhCG for stimulation of ovum release
83
Letrozole
Aromatase inhibitor
84
Adult onset CAH tx
Dexamethasone for hyperandrogenism
85
Most common cause of infertility due to male factors
Varicocele
86
PCOS etiology
Insulin causes DECREASED FSH and INCREASED LH, which in turn causes:
- Anovulation --> oligomenorrhea --> infertility
- Increased ovarian secretion of androgens --> hirsutism, obesity --> increased peripheral conversion to E
87
PCOS dx
Rotterdam criteria: 2 of 3 required
- oligomenorrhea/irregular menses for 6mo
- hyperandrogenism
- U/S evidence of polycystic ovaries (not appropriate in teens)
88
PCOS clinical features
```
HAIR-AN
Hirsutism
HyperAndrogenism
Infertility
Insulin Resistance
Acanthosis Nigricans
```
89
CAH enzyme deficiency
21-hydroxylase
90
Lab findings of PCOS
LH:FSH > 2:1
LH chronically high with FSH mid-range or low
Increased DHEA-S, androstenedione and free T, decreased SHBG
91
Tx for PCOS
Cycle control: OCP, metformin if T2DM or trying to get pregnant
Infertility: Clomid, Letrozole, human menopausal gonadotropins, LHRH, recombinant FSH, metformin (alone or in conjunction with clomid), ovarian drilling, bromocriptine if hyperPRL
Hirsutism: any OCP can be used, finasteride (5-alpha reductase inhibitor), flutamide (androgen inhibitor), spiro (androgen inhibitor)
92
Common infectious causes of prepubertal vulvovaginitis
Pinworms
Candida (if using diapers or chronic abx)
GAS, S. aureus, shigella
93
Candidiasis vulvovaginitis
Whitish cottage cheese discharge
Pruritus, swollen/inflamed genitals, vulvar burning, dysuria, dyspareunia
pH = 4.5
KOH wetmount reveals hyphae and spores
94
Bacterial vaginosis
Caused by Gardnerella vaginalis, mycoplasma hominis, Prevotella, mobiluncus, bacteroides
Grey, thin, diffuse discharge
Fishy odour
pH >= 4.5
>20% clue cells on wet mount (squamous epithelial cells dotted with coccobacilli)
95
Candidiasis vulvovaginitis tx
Tx: -azole suppositories and/or creams for 1, 3, or 7d tx
Fluconazole 150mg PO in single dose can be used in pregnancy
Tx for partners not recommended
96
BV tx
No tx if non-pregnant and asymptomatic unless scheduled for pelvic sx
Metronidazole 500mg PO BID x 7d
Metronidazole gel 0.75% x 5d OD (may be used in pregnancy)
Clindamycin 2% 5g intravaginally at bedtime for 7d
Probiotics alone or as adjuvant
Tx for partners not recommended
Need to warn pts about Flagyl and EtOH reaction
97
BV associated with
Recurrent preterm labour, preterm birth, postpartum endometritis
98
Trichomoniasis
Sexual transmission
Yellow-green malodorous, diffuse, frothy discharge
Petechiae on vagina, cervix
Dysuria, frequency
pH >/= 4.5
Motile flagellated organisms on saline wetmount
Many WBCs, inflammatory cells
99
Trichomoniasis tx
Tx even if asymptomatic
Metronidazole 2g PO single dose or 500 mg BID x 7d
Symptomatic pregnant women should be treated with 2g metronidazole once
Treat partner(s)
100
STIs that classify for CDC notifiable diseases
```
Chancroid
Chlamydia
Gonorrhea
Hep A, B, C
HIV
Syphilis
```
101
Most common bacterial STI in Canada
Chlamydia
102
Chlamydia features
```
Mostly asymptomatic in women
Muco-purulent endocervical discharge
Urinary symptoms
Pelvic pain
Postcoital or intermenstrual bleeding
```
103
Chlamydia dx
Cervical culture or NAAT
| Obligate intracellular parasite (tissue culture is definitive standard)
104
Chlamydia tx
Doxycycline 100mg PO BID x 7d OR Azithromycin 1g PO single dose
Doxy is C/I in 2nd and 3rd trimesters
Also tx gonorrhea as often co-infection
Test of cure in pregnancy (retest 3-4wk after initiation of tx)
105
Vaginal swabs for STI testing
Test for BV, trichomoniasis, candida
106
Cervical swabs for STI testing
Test for Chlamydia and gonorrhea
107
Gonorrhea investigations
Gram stain shows gram negative intracellular diplococci
108
Gonorrhea tx
Single dose Ceftriaxone 250mg IM plus azithromycin 1g PO
Safe in pregnancy
Also tx chlamydia
109
Most common viral STI in Canada
HPV
110
HPV subtypes classically a/w anogenital warts/condylomata acuminata
6 and 11
111
HPV subtypes that are the mostoncogenic
16 and 18
Classically a/w cervical HSIL
Others include 31, 33, 35,36,45
112
Tx for HPV warts
1st line: salicylic acid, cryotherpay, topical cantharone
2nd line: topical imiquimod, topical 5-fluorouracil, topical trtinoin, podophyllotoxin
3rd line: curettage, cautery, surgery
113
Herpes simplex virus of vulva type
90% are HSV-2
| 10% are HSV-1
114
HSV dx
Viral culture when ulcer present
Cytologic smear (Tzank smear) - mulnucleated giant cells, acidophilic intranuclear inclusion bodies
HSV DNA PCR
115
HSV tx
Acyclovir
Valacyclovir
Famciclovir
116
HSV daily suppressive therapy
Consider for >6 recurrences per yr or recurrence q2mo
| Acyclovir or valacyclovir
117
Syphilis bacteria
Treponema pallidum
118
Primary syphilis
3-4wk after exposure
Painless chancre on vulva, vagina or cervix
Painless inguinal lymphadenopathy
Serological tests usually negative, local infection only
119
Secondary syphilis
2-6mo after initial infection
Non-specific symptoms
Generalized macuopapular rash (palms, soles, trunks, limbs)
Condylomata lata (anogenital, broad-based fleshy grey lesion)
Serological tests usually +ve
120
Latent syphilis
No clinical manifestations
Detected by serology only
Early latent = latent of less than 1 year
Late laetnt = latent of >1yr
121
Tertiary syphilis
May involve any organ system
Neuro: tabes dorsalis, general paresis
CV: Aortic aneursym, dilated aortic root
122
Syphilis investigations
Aspiration of ulcer serum or node
Darkfield microscopy - look for SPIROCHETES
Non-treponemal screening tests (VDRL, RPR)
123
Syphilis tx
Reportable disease
Tx of primary, secondary, latent syphilis <1y duration --> benzathine penicillin G 2.4 million U IM single dose
Tx of latent syphilis of >1y duration --> benzathine penicillin G 2.4 million U IM q1wk x 3 wk
Tx of neurosyphilis --> IV Aqueous penicillin G 3-4 million U IM q4h x10-14d
124
Bartholin gland abscess tx
Cephalexin x 1wk
I&D using local anesthesia with placement of Word catheter for 2-3wks
Marsupialization under GA is more definitive tx (don't do while actively infected)
Rarely treated by removing gland
125
PID causative organisms
C. trachomatis
N. gonorrhoeae
Endogenous flora (E. coli, staph, strep, enterococcus, bacteroides, peptostreptococcus, H.influenzae, G. vaginalis)
126
PID dx
Must have lower abdo pain
Plus one of cervical motion tenderness or adnexal tenderness
Plus one or more of
-High risk partner
-Temp >38C
-Mucopurulent cervical discharge
- +ve culture for N.gonorrhoeae, C. trahomatis, E. coli or other vag flora
- Cul de sac fluid, pelvic abscess or inflammatory mass on U/S or bimanual
- Leukocytosis
- Elevated ESR or CRP (not commonly used)
127
Inpatient tx for PID
Cefoxitin IV + Doxycycline PO/IV OR
Clindamycin IV + Gentamycin IV
Continue for 24h after symptoms improved then doxy PO BID to complete 14d
128
Outpatient tx for PID
1st line: Ceftriaxone IM + doxy PO BID x 14d OR cefoxitin IM x 1 + probenecid PO + doxy BID +/- flagyl PO BID x 14d
2nd line: Ofloxacin PO BID x 14d OR levofloxacin x14d +/- flagyl PO BID x 14d
Consider removing IUD after a minimum of 24h tx
129
Toxic shock syndrome
Multiple organ system failure due to S. aureus exotoxin
130
Menopause
Lack of menses for 1 yr due to loss of ovarian function
131
Primary ovarian insufficiency
Menopause before age 40
132
Perimenopause
Period of time surrounding menopause (2-8y preceding and 1y after last menses) characterized by fluctuating hormones, irregular cycles and symptom onset
133
Hormone responsible for menopause S/E
Estrogen
134
Menopause investigations
Increased FSH on day 3 and LH (FSH > LH)
not always reliable
Clinical dx
135
Tx for vasomotor instability a/w menopause
```
HRT is first line (E+P)
SSRI
Venlafaxine
Gabapentin
Propranolol
Clonidine
Acupuncture
```
136
Tx for vaginal atrophy a/w menopause
```
Local estrogen cream (premarin)
Vaginal suppository (Vagifem)
Lubricants
Oral or transdermal HRT
Intravaginal laser
SERMs (ie. Ospemifene)
```
137
Tx for osteoporosis a/w menopause
```
1000-1500mg Calcium OD
800-1000 IUD Vitamin D
Weight-bearing exercise
Smoking cessation
Bisphosphonates (ie. Alendronate)
Selective estrogen receptor modifiers (SERMs) ie. Raloxifene/Ospemifene, mimics E effects on bone
HRT
```
138
Tx for mood and memory concerns a/w menopause
Antidepressants (first line)
| HRT (Augments effect)
139
HRT and breast CA risk
Only a/w with estrogen + progesterone HRT use >5y, NOT with estrogen-only HRT
Only give E-only HRT if pt has no intact uterus, otherwise you need P to prevent development of endometrial hyperplasia/CA
140
Absolute C/I to HRT
```
ABCD
Acute liver disease
Bleeding of vagina (undx)
Cancer (breast/uterine), CVD
DVT
```
141
Risks a/w HRT (WHI)
Stroke (E > E+P)
DVT/E (E+P > E)
CHD (esp if >70yo or starting HRT >10y post-menopause)
Breast CA (>5y of E+P, no increased risk for E alone)
Dementia/MCI (if >65yo, REDUCED risk if taken before 65)
142
Kallmann Syndrome
```
AKA idiopathic hypogonadotropic hypogonadism
Isolated GnRH deficiency
A/w anosmia
Failure to start or complete puberty
Occurs in both males and females
GH is not affected and height is normal
```
143
Pelvic Prolapse
Relaxation of cardinal and uterosacral ligaments causing protrusion of pelvic organs into or out of the vagina
144
Grading of pelvic organ prolapse
```
0 = no descent during straining
1 = distal portion of prolapse >1cm above level of hymen
2 = distal portion of prolapse = 1cm above or below level of hymen
3 = distal portion of prolapse >1cm below level of hymen but without complete vaginal eversion
4 = complete eversion of total length of lower genital tract
```
145
Cystocele
Protrusion of bladder into anterior vaginal wall
146
Enterocele
Prolapse of small bowel in upper posterior vaginal wall
| Only TRUE hernia of pelvis b/c peritoneum herniates with small bowel
147
Rectocele
Protrusion of rectum into posterior vaginal wall
148
Uterine prolapse
Protrusion of cervix and uterus into vagina
149
Vault prolapse
Protrusion of apex of vaginal vault into vagina, post-hysterectomy
150
Stress incontinence
Involuntary loss of urine with increased intra-abdominal pressure (cough,laugh,sneeze,walk,run)
151
General conservative tx for prolapse
Kegel exercises
Local vaginal estrogen therapy
Vaginal pessary
152
Urge incontinence
Urine loss a/w abrupt sudden urge to void
153
Urge Incontinence tx
Behaviour modification (reduce caffeine, smoking cessation, regular voiding schedule)
Kegel
Anticholinergics: Oxybutinin, Tolterodine, Solifenacin
TCAs (Imipramine)
R/O neuro causes: DM, herniated disc, MS
154
Incidence of malignant gyne lesions in NA
Endometrium > ovary > cervix > vulva > vagina > fallopian tube
155
Risk factors for endometrial CA
```
COLD NUT
Cancer (ovarian, breast, colon)
Obesity
Late menopause
DM
Nulliparity
Unopposed estrogen: PCOS, anovulation, HRT
Tamoxifen: chronic use
```
156
Abnormal endometrial thickness in postmenopausal women
>5mm
157
Endometrial Cancer Type I
Estrogen-related
80% of cases
Often presents with AUB
Better prognosis
158
Endometrial Cancer Type II
Non-estrogen related (still related but not as much as Type I)
More aggressive, worse prognosis than type I
15% of cases
More likely to present with advanced stage of disease with symptoms like ovarian CA (Bloating, bowel dysfunction, pelvic pressure)
159
Tx for endometrial cancer
```
Hysterectomy + BSO +/- pelvic and para-aortic node diessection +/- omentectomy
Adjuvant radiotherapy (for pts at risk for local recurrence) and adjuvant chemotherapy (for pts at risk for distant recurrence or with metastatic dz)
```
160
Uterine sarcoma symptoms
```
BAD-P
Bleeding (most common)
Abdominal distention
Foul smelling vaginal Discharge
Pelvic pressure
```
161
Most common type of uterine sarcoma
Leiomyosarcoma
162
Leiomyosarcoma
Often coexists with benign leiomyomata (fibroids)
Tx: Hysterectomy/BSO +/- chemotherapy for metastatic dz
Radiation does not improve local control or survival
Poor toucomes overall
163
Less common types of uterine sarcomas
```
Endometrial stromal sarcoma (good prognosis)
Undifferentiated sarcoma (poor prognosis)
Adenosarcoma (rarest, mix of benign epithelium and malignant low-grade sarcoma)
```
164
Gyne malignancy responsible for most deaths
Ovarian CA
165
Risk factors a/w ovarian CA
Personal hx of breast, colon, endometrial CA
Family hx of breast, colon, endometrial, ovarian CA
use of fertility drugs
166
Protective factors a/w ovarian CA
OCP
Pregnancy/BF
Salpingectomy
BSO
167
Familial ovarian CA
>1 first degree relative affected
| BRCA-1 mutation
168
BRCA-1 or BRCA-2 mutation prophylactic recommendation
Bilateral oophorectomy after age 35 or once child-bearing completed
169
Common symptoms of ovarian CA
```
Typically presents late
Nausea, bloating, dyspepsia, anorexia, early satiety
Increased abdo girth
Urinary frequency
Constipation
```
170
Functional ovarian tumours
Benign
- Follicular cyst (usually regresses with next cycle, OCP can help by preventing development of new cysts, lap sx if needed)
- Corpus luteum cyst
- Theca-lutein cyst
- Endometrioma
- Polycystic ovaries
171
Most common ovarian germ cell neoplasm
Benign cystic teratoma (dermoid)
172
Benign cystic teratoma (dermoid)
Contains all 3 cell lines (dermal appendages, sweat and sebaceous glands, hair follicles, teeth)
Calcifications on U/S is pathgnomonic
Tx: Lap cystectomy
173
Malignant germ cell tumours
More common in children and young women
Ex. Dysgerminoma, immature teratoma, gonadoblastoma
Tx: surgical resection, often conservative +/- Very responsive to chemotherapy
174
Most common type of ovarian cancer
Serous epithelial ovarian tumour
| Psamomma bodies on histology
175
Mucinous epithelial ovarian tumour special note about tx
Remove appendix to rule out possible source of primary disease
176
Sex cord stromal ovarian tumour examples
Fibroma/thecoma (benign)
Granulosa-theca cell tumours (benign or malignant)
Sertoli-Leydic cell tumour
177
Granulosa-theca cell tumours tumour marker
Inhibin
178
Sertoli-Leydig cell tumours tumour marker
Androgens
179
Investigations to order for suspicious ovarian mass
```
CA-125
CBC
LFTs
Lytes
Creatinine
TVUS
CT abdo/pelvis for metastatic dz
Bone scan or PET scan not indicated
```
180
Majority of malignant cervical lesions
Squamous cell carcinoma
181
Transformation zone
Area located between the original and current squamocolumnar junction
Area where majority of dysplasias and cancers arise
182
Dx of cervical CA
```
Colposcopy and biopsy
Endocergical curettage if entire lesion is not visible or no lesion visible
Diagnostic excision (LEEP) if unsatisfactory colposcopy, unable to rule out invasive dz, recurrence of lesion, suspicious for adenocarcinoma in situ, +ve findings in endocervical curettage
Cold knife conization in OR if glandular abnormality is suspected due to concern for margin interpretation
```
183
Inadequate sample pap
Repeat in 3mo
184
ASCUS in women <30yo or HPV testing not available
Repeat cytology in 6mo
If neg --> repeat in 6mo --> neg --> routine screening
if >/= ASCUS --> colposcopy
185
ASCUS women >/= 30yo
HPV DNA testing
If neg --> repeat cytology in 12 mo
If pos --> colposcopy
186
ASC-H
Colposcopy
187
AGUS/atypical endocervical cells/atypical endometrial cells
Colposcopy +/- endometrial sampling
188
LSIL
Colposcopy
OR repeat cytology in 6mo --> if >/= ASCUS --> colposcopy, if negative --> repeat cytology in 6mo; if neg --> routine screening, if >/= ASCUS --> colposcopy
189
HSIL
Colposcopy
190
Squamous carcinoma or other malignant changes
Colposcopy
191
Gardasil viral strains covered
6, 11, 16, 18
192
CIN I Management
Observation
| Repeat cytology in 12mo
193
CIN II and CIN III Management
>/= 25yo: excisional procedure
< 25yo : Observe with colposcopy at 6mo intervals for up to 24mo before tx considered
During pregnancy: repeat colposcopy and delay tx until 8-12wk after delivery
194
Cervical CA tx
If Stage IA1 (microinvasive): LEEP if future fertility desired, simple hysterectomy if fertility not desired
Stage IA2, IBI: radical hysterectomy + pelvic lymphadenectomy
Stages IB2, II, III, IV: Primary chemoradiation therapy, hysterectomy generally NOT suggested
195
Hyperplastic dystrophy/squamous cell hyerplasia
Pruritus most common
Typically postmenopausal women
Tx: 1% corticosteroid ointment BID x 6wk
196
Lichen sclerosis
```
Labia becomes thin, atrophic
Pruritus, dyspareunia, burning
Figure of 8 distribution
Most common in postmenopausal women
Tx: Ultrapotent topical steroid clobetasol x 2-4wk then taper down, can consider long-term suppression twice a week
```
197
Most common malignant vulvar lesion
SCC
198
Vulvar intraepithelial neoplasia (VIN)
Contain HPV DNA (usually types 16, 18)
White or pigmented plaques on vulva (may only be visible on vulva)
Progression to CA rarely occurs with appropriate management
Tx: local excision, ablative therapy, local immunotherapy (imiquimod)
199
T1 vulvar lesion
Tumour confined to vulva
No extension to adjacent perineal structures
Tx: Radical local excision
200
T2 vulvar lesion
Tumour of any size with extension to adjacent perineal structures
Tx: Modified radical vulvectomy
201
T3 vulvar lesion
Extension to any of: proximal 2/3 of urethra, proximal 2/3 of vagina, bladder mucosa, rectal mucosa or fixed to pelvic bone
Tx: Chemoradiation
Node +ve dz: Adjuvant chemoradiation or radiation therapy
202
Most common malignant vaginal lesion
SCC
203
Most common location of vaginal SCC
Upper 1/3 of posterior wall of vagina
204
Vaginal adenocarcinoma
Most are metastatic from ovary, cervix, endometrium or colon
| If primary, most are clear cell adenocarcinomas
205
Malignant vaginal lesion tx
Stage I: radiation and surgical excision (radical hysterectomy, upper vaginectomy, bilateral pelvic lymphadenectomy)
Stage II-IV: Chemoradiation
206
Least common site for carcinoma of female reproductive system
Fallopian tubes
| Usually serous epithelial carcinoma
207
Most common type of hydatidiform Mole (Benign GTN)
Complete mole
46 XX or 46 XY completely of paternal origin
2 sperm fertilize an empty egg or 1 sperm with reduplication
15-20% risk of progression to malignant sequelae
208
Partial or incomplete mole
Often triploid XXX, XYY, XXX with chromosome complement from both parents (usually single ovum fertilized by 2 sperm)
Low risk of progression to malignant sequelae (<4%)
209
GTD dx
Quantitative b-hCG levels (tumour marker) abnormally high for gestational age
U/S Findings:
- Complete: no fetus (snow storm due to swelling of villi)
-Partial: molar degeneration of placenta +/- fetal anomalies, multiple echogenic regions corresponding to hydropic villi and focal intrauterine hemorrhage
210
GTD tx
Suction D&C with sharp curettage and oxytocin
Rhogam if Rh -ve
Consider hysterectomy
211
GTD monitoring
Contraception required to avoid pregnancy during entire F/U period
Serial bhCGs weekly until neg x 3 (usually takes several wk) then monthly x6-12mo prior to trying to conceive again
Increase or plateau of bhCG indicates GTN
212
Invasive mole or persistent GTN
Dx made my rising or plateau in bhCG, development of metastases following tx of documented molar pregnancy
213
Choriocarcinoma
Type of GTN
Often present with symptoms from metastases
May follow molar pregnancy, abortion, ectopic or normal pregnancy
If hematogenous spread is suspected, do NOT biopsy
214
Placental-site trophoblastic tumour
Type of GTN
Rare aggressive form of GTN Abnormal growth of intermediate trophoblastic cells
Low bhCG, production of human placental lactogen, relatively insensitive to chemotherapy
215
Most common metastasis location for GTN
Lungs
216
GTN treatment
Mostly chemotherapy
| Can consider hysterectomy if fertility not desired
217
GTN monitoring
Contraception to avoid pregnancy during entire F/U period
Stage I, II, III: weekly bHCG until 3 consecutive normal then monthly x 12mo
Stage IV: Weekly bHCG until 3 consecutive normal then monthly x 24mo
218
GTN dx
bhCG plateau: <10% drop in bHCG over 4 vales in 3wk OR
bhCG rise: > 20% in any two values over 2wk or longer OR
bhCG persistently elevated >6mo OR
metastases on workup
219
Etiology of female infertility
```
Ovulatory disorders (25%)
Endometriosis (15%)
Pelvic adhesions (12%)
Cervical pathology (5%)
Uterine pathology (<5%)
```
220
Premature ovarian failure etiology
AI disease (most common)
Toxins (chemo)
Chromosomal (ie. Turner's, Fragile X)
221
Estrogen and coronary artery disease
Lower E levels (ie. women who undergo oophorectomy, premature ovarian failure, or go into early menopause) have higher rates of CAD
222
Estrogen and endometrial cancer
Higher E levels (ie. ERT) a/w endometrial CA
223
Medroxyprogesterone injection for contraception
Prevents ovulation, thins uterine lining
q3mo
May be used in BF women at 6wk PP
Delayed fertility after discontinuation (~10mo)
Liver dz is absolute C/I
Reduces bone mass density (each Ca and Vit D rich foods)
224
Most common sites of endometriosis in pelvis
Ovaries > anterior/posterior cul de sac > posterior broad ligaments > uterosacral ligaments > uterus > Fallopian tubes > sigmoid colon and appendix > round ligaments
225
Most common sites of endometriosis outside of pelvis
Liver, brain, lung and old surgical scars
226
Chancroid
Painful ulcers
Bacterial STI caused by H ducreyi
Tx Azithro x 1 or CTX x1 or Erythromycin or Cipro
227
Most common cause of outflow obstruction in secondary amenorrhea
Asherman syndrome
228
BV often associated with infections by
Mycoplasma hominis
229
Triad of premature ovarian failure
Amenorrhea
Hypergoandotropism
Hypoestrogenism
