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Flashcards in Gynecology Deck (140):
0

Thelarche

breast development, usually between 8 and 11

1

Menarche

- first menstrual cycle
- onset between ages of 10 and 16

2

Thelarche process

1. breast buds begin
2. breasts and areola grow
3. nipple and areola separate from mound
4. areola rejoins breast contour

3

Menstrual Cycle (steps)

1. Follicular phase
2. Ovulation
3. Luteal phase

4

Follicular phase

- lasts ~13 days
- increased FSH --> growth of follicles --> increased estrogen production
- results in development of straight glands and thin secretions of uterine lining (proliferative phase)

5

Ovulation

- day 14
- LSH and FSH spike, leading to rupture of ovarian follicle and release of a mature ovum
- ruptured follicular cells involute and create corpus luteum

6

Luteal phase

- days 15 - 28
- length of time (14 days) that corpus luteum can survive w/o further LH stimulation
- corpus luteum produces estrogen and progesterone, allowing endometrial lining to develop thick endometrial glands (secretory phase)
- in absence of implantation, corpus luteum cannot be sustained and endometrial linding sloughs off

7

Menopause

- cessation of menses for a minimum of 12 months as a result of cessation of follicular development

8

Menopause: Hx and PE

- average onset at 51 years
- sx include hot flashes, vaginal atrophy, insominia, anxiety/irritabiliy, poor concentration, mood changes

9

Premature menopause

- cessation of menses before 40

10

Menopause: Dx

Labs: increased FSH then increased LH
Lipid profile: increased total cholesterol, decreased HDL

11

Menopause: tx of vasomotor symptoms

- HRTs (combo estrogen/progestin)
** increases cardiovascular morbidity

12

Contraindications of HRTs during menopause

- Vaginal bleeding
- Breast cancer (known or suspected)
- Untreated endometrial cancer
- Hx of thromboembolism
- Chronic liver disease
- Hypertriglyceridemia

13

Menopause tx: hotflashes

SNRIs/ SSRIs, clonidine and/or gabapentin decreases frequency of hot flashes

14

Complications of menopause

- Vasomotor symptoms (tx with HRTs)
- Hot flashes (tx with SSRIs/SNRIs, clonidine, gabapentin)
- Vaginal atrophy (topical estrogen)
- Osteoporosis (tx w/ daily calcium and Vitamin D)

15

For which condition should postmenopausal women be screened?

Osteoporosis

16

Implanon (progestin-only implant)

- inhibits ovulation; increased cervical mucus viscosity
- effective up to 3 years, immediate fertility once removed
- side effects: weight gain, depression, irregular periods

17

IUD with progestin

- foreign body results in inflammation; progesterone leads to cervical thickening and endometrial decidualization
- effective for up to 5 years, immediate fertility once removed
- safe with breast feeding

18

IUD: disadvntages

- spotting (up to 6 months)
- acne
- risk of uterine puncture

19

Copper T IUD (ParaGard)

- foreign body results in inflammation; copper has spermicidal effect
- effective for up to 10 yrs, immediate fertility once removed
- safe with breastfeeding

20

Copper IUD: disadvantages

increased cramping and bleeding
- risk of uterine puncture

21

Surigcal sterilization (tubal ligation, vasectomy)

- permanently effective; safe with breastfeeding

22

Tubal ligation: disadvantages

- irreversible
- increased risk of ectopic pregnancy

23

Depo-Provera

- IM injection every 3 months
- advantages: lighter or no periods, each shot works for 3 months, and safe with breastfeeding

24

Depo-Provera: disadvantages

Irregular bleeding and weight gain
- decreass in BMD
- delayed fertility after discontinuation (up to 10 months)

25

Vasectomy: disadvantages

most failures due to not waiting for 2 negative sperm samples

26

Ortho Evra ("the patch")

- combined weekly estroenn and progestin dermal parch
- periods may be more regular. weekly administration

27

The patch: disadvantages

- thromboembolism risk (especially in smokers and those > 35 years)

28

NuvaRing ("the ring")

- combined low-dose progestin and estrogen vaginal ring
- can make periods more regular
- three weeks - continuous; 1 week - no ring
- safe to use continuously

29

NuvaRing: disadvantages

- may increased vaginal discharge
- spotting (first 1-2 months)

30

OCPs (combination estrogen and progestin)

- inhibit FSH/LH, suppressing ovulation
- thickening cervical mucus, decidualize endometriaum
- decreases risk of ovarian and endometrial cancers
- predictable, lighter, less painful menses

31

OCPs: disadvantage

- requires daily complaince
- breakthrough bleeding (10 - 30%)
- thromboembolism risk (esp in smokers and those > 35 years)

32

Progestin-only minipills

- thicken cervical mucus
- safe with breastfeeding

33

Progestin-only pills: disadvantage

requires strict complaince with daily timing

34

Premenstrual Syndrome: Sx

- headache
- breast tenderness
- pelvic pain and bloating
- irritability and lack of energy

35

Premenstrual syndrome: Dx

* no diagnostic tests for PMD or PMDD
- symptoms should be present for 2 consecutive ycles
- symptom-free period of 1 week in 1st part of cycle (follicular phase)
- symptoms must be present in 2nd half of cycle (luteal phase)
- dysfunction in life

36

PMD: Tx

- patient should decrease consumptom of caffeine, alcohol, cigarrettes, and chocolate
- if symptoms severe, give SSRIs

37

Menopause

- result of permanent loss of estrogen
- oocytes produce less estrogen and progesterone and both LH and FSH start to rise

38

Menopause: Sx

- menstrual irregularlity
- sweats and hot flashes
- mood changes
- dyspareunia (pain during sexual intercourse)

39

Menopause: PE findings

- atrophic caginitis
- decrease in breast size
- vaginal and cervical atrophy

40

Menorrhagia

- heavy and prolonged menstrual bleeding
- "gushing" of blood
- clots may be seen

41

Primary Amenorrhea / Delayed puberty

- absence of menses by age 16 with secondary sexual development present OR
- absence of secondary sexual characteristics by 14

42

Causes of primary amenorrhea with absence of secondary sexual characteristics

- Constitutional growth delay
- Primary ovarian insufficiency
- Central hypogonadism

43

Most common cause of primary amenorrhea

Constitutional growth delay

44

Most common cause of primary ovarian insufficiency

Turner's syndrome
* look for hx of radiation and chemotherapy

45

Causes of central hypogonadism

- undernourishment, stress, hyperprolactinoma
- CNS tumor or cranial radiation
- Kallman's syndrome

46

Kallman's syndrome

- isolated gonadotropin deficiency associated with anosmia
- central hypogonaidms

47

Primary amenorrhea w/ presence of secondary sexual characteristics

- estrogen production but other anatomic or genetic problems

48

Etiology: primary amenorrhea w/ secondary sexual characteristics

- Mullerian agenesis
- Imperforate hymen
- Complete androgen insensitivity

49

Mullerian agenesis

absence of 2/3 of vagina; uterine abnormalities

50

Imperforate hymen

- presents with hematocolpos (blood in the vagina) that cannot escape along with bulging hymen

51

Complete androgen insensitivity

- patients present with breast development (aromatization of testerone to estrone) but are amenorrheic and lack pubic hair

52

Primary amenorrhea: Dx

1. GET A PREGNANCY TEST!
2. Obtain bone radiograph (PA left hand) to see if bone age in consitient with pubertal onset

53

Short pt has primary amenorrhea w. secondary sexual characteristics but has normal growth velocity. Likely etiology?

Constitutional growth delay (most common cause)

54

Pt has primary amenorrhea and has bone age > 12 yers but there are no signs of puberty. Next step?

Obtain LH/FSH levels to see if issues in HPA axis

55

Constitutional growth delay

- decr GnRH
- decr GnRH
- decr estrogen/progesterone (prepuberty levels)
- puberty has not started

56

Hypogonadotrophic hypogonadism

** hypothalamic or pituitary problem
- decreased GnRH
- decreased LH/FSH
- decresased estrogen

57

Hypergonadotropic-hypogonadism

* ovaries have failed to produce estrogen
- increased GnRH
- increased LH/FSH
- decreased estrogen/progestrone

58

Anovulatory problem

*PCOS or problem with estrogen receptors
- increased GnRH
- increased LH/FSH
- increased estrogen/progesterone production

59

Anatomic problem with primary amenorrhea

**menstrual blood cannot get out (e.g. imperforate hymen)
- normal GnRH
- normal LH/FSH
- normal estrogen production

60

Pt has primary amenorrhea w/ neg pregnancy test, normal bone age. Next step?

Ultrasound to evaluate ovaries

61

Pt has primary amenorrhea, neg pregnancy test, with normal breast development and no uterus. Next step?

Obtain karyotype to evaluate for androgen insensitivity syndrome

62

Pt has primary amenorrhea w negative pregnancy test, normal bone age with normal breast development and uterus. Next step?

Measure prolactin and obtain MRI to assess pituitary gland

63

Constitutional growth delay: Tx

None necessary

64

Hypogonadism: tx

- Begin HRT with estrogen at lowest dose
- After 12 - 18 mths, begin cyclic estrogen/progesterone therapy (if uterus is present)

65

Secondary amenorrhea

absence of menses for 6 consecutive months in women who have passed menarche

66

Positive progestin challenge (withdrawal bleed)

- indicates anovulation that is likely due to noncyclic gonadotropin secretion pointing to PCOS or idiopathic anovulation

67

Secondary amennorhea: Dx

1. GET PREGNANCY TEST
2. Obtain TSH (high TSH --> high prolactin)
3. Obtain Prolactin levels
4. Progesterone Challenge Test
5. Estrogen Progesterone Challenge Test

68

Negative progestin challenge (no bleed)

indicates uterine abnormalty or estrogen deficiency

69

Pt has secondary amenorrhea and has signs of hyperglycemia (e.g polydipsia, polyuria) or hypotension. Next step?

Conduct 1-mg overnight dexamethasone suppression test to distinguish congenital adrenal hyperplasia (CAH), Cushing's syndrome, and Addision's disease

70

If patient has secondary amenorrhea and clinical virilizationis present. Next step?

Measure testosterone, DHEAS and 17-hydroxyprogesterone

71

56 yr old F c/o of insomnia, vaginal dryness, and lack of menses for 13 mths. Likely dx?

Menopause
- may want to rule out secondary amenorrhea by ordering FSH

72

Tx of hpothalamic causes of secondary amenorrhea

Reverse underlying cause and induce ovulation with gonadoptropins

73

Premature ovarian failure (age < 40 years)

If uterus is present, treat with estrogen plus progestin replacement therapy

74

Primary Dysmenorrhea

- menstrual pain associated with ovulatory cycle in absence of pathologic findings
- caused by uterine vasoconstriction, anoxia, and sustained contractions mediated by excess PGF-1

75

Primary Dysmenorrhea: Hx and PE

- presents with low, midline, spasmodic pelvic pain that often radiates to the back or inner thighs
- cramps occur in 1st 1-3 days of menstruation and may be associated with nausea, diarrhea, and flushing
- NO PATH FINDINGS ON PELVIC EXAM

76

Primary Dysmenorrhea: Tx

- NSAIDS
- Topical heat therapy
- Combined OCPs
- Mirena IUD

77

Secondary Dysmenorrhea

- menstrual pain for which an organic cause exit

78

Ddx of secondary dysmenorrhea

- Endometriosis
- Adenomyosis
- Fibroids
- Adhesions
- Polyps
- PID

79

Secondary Dysmenorrhea: Hx and PE

- may have palpable uterine mass, cervical motion tenderness, adnexal tenderness, a vaginal or cervical discharge, or visible vaginal pathology (mucosal tears)

80

Endometriosis

- functional endometrial glands and stroma OUTSIDE the uterine

81

Endometriosis: Hx and PE

CYCLICAL pelvic and/or rectal pain and dyspareunia

82

Endometriosis: Dx

- Requires direct visualization by laparoscopy or laparotomy
- Classic lesions: blue-black ("raspberry") or dark brown ("powder-brown") appearance
- ovaries may endometriosis ("chocolate cysts")

83

Endometriosis: Pharm Tx

INHIBIT OVULATION
- combination OCPs (1st line)
- GnRH analogs (leuprolide)
- Danazol
- NSAIDS or progestins

84

Endometriosis: Surgical tx

- Excision, cauterization, or ablation of lesiosn and lysis of adhesions

85

Endometriosis: Definitive surgical tx

Total abdominal hysterectomy/bilateral salpingo-oopherectomy (TAH/BSO) +/- lysis of adhesions

86

Endometriosis: Complications

Infertility (most common cause among menstruating women > 30 yrs)

87

Adenomyosis

endometrial tissue in the myometrium of the uterus

88

Adenomyosis

Classic triad:
- NONCYCLICAL pain
- Menorrhagia
- Enlarged uterus

89

Adenomysos: Dx

- Usually path diagnosis
U/S is useful but can't distinguish btwn leiomyoma and adenomyosis
- MRI can aid but costly

90

Adenomyosis: Pharm Tx

Largely symptomatic relief with NSAIDS (1st line) plus OCPs or progestins

91

Adenomyosis: Conservative surgical tx

Endometrial ablation or resection using hysteroscopy
- Complete eradication of deep adenomyosis is difficult and results in high tx failure

92

Adenomyosis: definitive surgical tx

Hysterectomy is only definitive tx

93

Adenomyosis: Complications

can rarely progress to endometrial carcinoma

94

Secondary Amenorrhea: Dx

1. Obtain B-hCG to r/o ectopic pregnacy
2. Order following:
- CBC to r/o infxn
- UA to r/o UTI
- Gonoccocal/chlamydial swabs to r/o STIs/PID

95

Dysfunctional uterine bleeding (DUB)

Diagnosis of exclusion
- abnormal uterine bleeding w/o evidence of an underlying cause
- may be ovulatory or anovulatory

96

What is postmenopausal bleeding?

Is cancer until proven otherwise

97

Oligomenorrhea

increased length of time between menses (35 - 90 days between cycles)

98

Polymenorrhea

Frequent menstruation (< 21 days between cycles)
- often anovular

99

Menorrhagia

- increased amt of flow (> 80 cc of blood loss per cycle) or prolonged bleeding (flow lasting > 8 days)
- may lead to anemia

100

Metorrhagia

- bleeding between periods

101

Menometrorrhagia

- excessive and irregular bleeding

102

Most common cause of abnormal uterine bleeding

Pregnancy

103

Abnormal Uterine Bleeding: WorkUp

1. B-hCG to r/o pregnancy
2. CBC to evaluate for anemia
3. Pap smears to r/o cervical cancer
4. TFTs to r/o thyroid ssie
5. Platelet, PT/PTT to r/o von Willebrand's dizease and factor XI
6. U/S to look for endometriosis

104

Indication for endometrial biopsy

1. If endometrium is at least 4 mm in POSTMENOPAUSAL woman
2. If pt is > 35 yrs with risk factors of endometrial hyperplasia (e.g. diabetes, obesity)

105

First line tx of abnormal uterine bleeding

NSAIDS - decrease blood loss

106

Heavy bleeding: tx

- High dose estrogen IV stabilizes endometrial lining and typically stops bleeding w/in 1 hr
- If bleeding isnt controlled w/in 12-24 hrs, a D&C is often indicated

107

Ovulatory bleeding: tx

- NSAIDS to decrease blood loss
- If patient is hemodynamically stable, give OCPs or Mirena IUD

108

If unable to medically tx abnormal uterine bleeding, next step?

- D & C
- Hysteroscopy: to ID endometrial polyps or peform directed biopsies
- Hysterectomy

109

Congenital Adrenal Hyperplasia

deficiency of at least one enzyme for synthesis of cortisol from cholesterol

110

21-hydroxylase deficiency

most severe, classic form presents as newborn female infant w/ ambiguous genetalia and life-threatening salt wasting

111

11B-hydroxylase deficiency

less common cause of adrenal hyperplasia

112

Congenital Adrenal Hyperplasia: Hx and PE

- excessive hirsuitism
- acne
- amenorrhea
- abnormal uterine bleeding
- infertility
- palpable pelvic mass

113

Congenital Adrenal Hyperplasia: Dx

- increased androgens (testosterone > 2ng; DHEAS > micrograms)
- increased serum testosterone
- increased DHEAS
- incresased 17-OH progesterone levels

114

Congenital Adrenal Hyperplasia: Tx

Glucocorticoids
- prevents new terminal hair growth but doesn't get rid of hirsuitism

115

Polycystic ovarian disease

Diagnosis requires at least 2 criteria:
1. polycystic ovaries
2 oligo-/anovulation
3. clinical evidents of hyperandrogenism

116

PCOS: Hx and PE

- High BP and obesity
- Stigmata of hyperandrogenism or insulin resistance: menstrual cycle abnormalities, acne, hirsuitism, obesity

117

Women with PCOS are at increased risk for which conditions?

- Type 2 DM
- Insulin resistance
- Infertility
- Metabolic syndrome

118

PCOS: Dx

- LH:FSH = 3:1 (normal is 1.5:1)
- testosterone level is mildly elevated
- Pelvic U/S shows bilaterally enlarged ovaries w/ multiple subcapsular small follicles and increased stromal echogenecity

119

PCOS: Management

- OCP treats irregular bleeding and hirsuitism
- SPIRONOLACTONE- used to suppress hair follicles
- CLOMIPHENE CITRATE or human menopausal gonadotropin treats infertility
- METFORMIN enhances ovulation and manages insulin resistance

120

Pt has 2ndary amenorrhea with elevated prolactin levels. Next step?

1. Review meds for antipsychotics esp those with anti-dopamine effects
2. CT or MRI of head to r/o pituitary tumor
- Tumor < 1 cm: give bromocriptine (dopamine agonist)
- Tumor > 1cm: treat surgically
3. If cause of elevated prolactin is idiopathic tx with bromocriptine

121

Estrogen Progesterone Test

- 3 weeks of oral estrogen followed by 1 week of progesterone

122

Positive Estrogen Progesterone Test

- withdrawal bleeding is diagnostic of inadequate estrogen
** Get FSH level
- if FSH is high, may be due to Y mosaicism so get karyotype
- if FSH is low, may 2/2 to HPA insufficiency so get brain CT/MRI

123

Negative Estrogen Progesterone Test

Diagnostic of outflow obstruction or endometrial scarring (e.g. Assmeran syndrome)
** Order hysterosalpingogram to identify lesion and lyse adhesions

124

Anovulation

- classically presents w/ hx of amenorrhea followed by unpredictable bleeding (prolonged unopposed estrogen stimulates endometrium)

125

Idiopathic Hirsuitism

- diagnosis when there is no virilization and all lab tests are norma
- most common cause of hirsuitism

126

Management of Idiopathic Hirsuitism

- Spironolactone: tx of choice
- Eflornithine - 1st line tx for unwanted facial and chin hir

127

Common sites of osteoporosis

- Vertebral bodies leading to crush fx, kyphosis, and decreased height

128

Common risk factors for osteoporosis

- Positive family hx in a thin white female
- Steroid use
- Low Ca intake
- Sedentary lifestyle
- Smoking
- Alcohol

129

Osteoporosis: Dx

- DEXA scan assesses bone density (T score > -2.5)
- 24 hr urine hydroxyproline or NTX to assess calcium loss

130

Osteoporosis: Management

First line therapy: bisphosphonates and SERMS
- bisphosphonates inhibit osteoclastic activity
- SERMS (selective estrogen recept modulators) increase bone density
Second line therapy: Calcitonin and fluoride

131

SERMS (e.g. Tamoxifen and Evista(

- protective against heart and bos but not for vasomotor sx

132

Tamoxifen

- SERM
- bone and endometrial agonist effects but breast antagonist effects

133

Raloxifen

- SERM
- has bone agonist effects but endometiral antagonist effects

134

Indications for Hormone Replacement Therapy

Treatment of:
- Menopausal vasomotor symptoms (hot flashes)
- Genitourinary atrophy
- Dyspareunia

135

Contraindications for HRTs

Tx of
- osteoporosis
If there is a history of:
- estrogen sensitive breast cancer
- liver disease
- active thrombosis
- unexplained vaginal bleeding

136

If indicated, what HRT should women without uterus receive ?

Continuous estrogen

137

If indicated, what HRT(s) should women with a uterus receive

Estrogen WITH progestin therapy to prevent endometrial hyperplasia

138

Benefits of HRT

- decreases rate of osteoporotic fx
- decreases rate of colorectal cancer

139

Risks of HRT

- increases risk of DVT
- increases risk of heart attacks and breast cancer in combo therapy
** risk of breast cancer associated w/ therapy > 4 yrs**