Gynecology Flashcards
(140 cards)
0
Q
Menarche
A
- first menstrual cycle
- onset between ages of 10 and 16
1
Q
Thelarche
A
breast development, usually between 8 and 11
2
Q
Thelarche process
A
- breast buds begin
- breasts and areola grow
- nipple and areola separate from mound
- areola rejoins breast contour
3
Q
Menstrual Cycle (steps)
A
- Follicular phase
- Ovulation
- Luteal phase
4
Q
Follicular phase
A
- 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
Q
Ovulation
A
- 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
Q
Luteal phase
A
- 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
Q
Menopause
A
- cessation of menses for a minimum of 12 months as a result of cessation of follicular development
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Q
Menopause: Hx and PE
A
- average onset at 51 years
- sx include hot flashes, vaginal atrophy, insominia, anxiety/irritabiliy, poor concentration, mood changes
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Q
Premature menopause
A
- cessation of menses before 40
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Q
Menopause: Dx
A
Labs: increased FSH then increased LH
Lipid profile: increased total cholesterol, decreased HDL
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Q
Menopause: tx of vasomotor symptoms
A
- HRTs (combo estrogen/progestin)
* * increases cardiovascular morbidity
12
Q
Contraindications of HRTs during menopause
A
- Vaginal bleeding
- Breast cancer (known or suspected)
- Untreated endometrial cancer
- Hx of thromboembolism
- Chronic liver disease
- Hypertriglyceridemia
13
Q
Menopause tx: hotflashes
A
SNRIs/ SSRIs, clonidine and/or gabapentin decreases frequency of hot flashes
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Q
Complications of menopause
A
- 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
Q
For which condition should postmenopausal women be screened?
A
Osteoporosis
16
Q
Implanon (progestin-only implant)
A
- inhibits ovulation; increased cervical mucus viscosity
- effective up to 3 years, immediate fertility once removed
- side effects: weight gain, depression, irregular periods
17
Q
IUD with progestin
A
- 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
Q
IUD: disadvntages
A
- spotting (up to 6 months)
- acne
- risk of uterine puncture
19
Q
Copper T IUD (ParaGard)
A
- foreign body results in inflammation; copper has spermicidal effect
- effective for up to 10 yrs, immediate fertility once removed
- safe with breastfeeding
20
Q
Copper IUD: disadvantages
A
increased cramping and bleeding
- risk of uterine puncture
21
Q
Surigcal sterilization (tubal ligation, vasectomy)
A
- permanently effective; safe with breastfeeding
22
Q
Tubal ligation: disadvantages
A
- irreversible
- increased risk of ectopic pregnancy
23
Q
Depo-Provera
A
- IM injection every 3 months
- advantages: lighter or no periods, each shot works for 3 months, and safe with breastfeeding
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Depo-Provera: disadvantages
Irregular bleeding and weight gain
- decreass in BMD
- delayed fertility after discontinuation (up to 10 months)
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Vasectomy: disadvantages
most failures due to not waiting for 2 negative sperm samples
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Ortho Evra ("the patch")
- combined weekly estroenn and progestin dermal parch
| - periods may be more regular. weekly administration
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The patch: disadvantages
- thromboembolism risk (especially in smokers and those > 35 years)
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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
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NuvaRing: disadvantages
- may increased vaginal discharge
| - spotting (first 1-2 months)
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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
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OCPs: disadvantage
- requires daily complaince
- breakthrough bleeding (10 - 30%)
- thromboembolism risk (esp in smokers and those > 35 years)
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Progestin-only minipills
- thicken cervical mucus
| - safe with breastfeeding
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Progestin-only pills: disadvantage
requires strict complaince with daily timing
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Premenstrual Syndrome: Sx
- headache
- breast tenderness
- pelvic pain and bloating
- irritability and lack of energy
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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
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PMD: Tx
- patient should decrease consumptom of caffeine, alcohol, cigarrettes, and chocolate
- if symptoms severe, give SSRIs
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Menopause
- result of permanent loss of estrogen
| - oocytes produce less estrogen and progesterone and both LH and FSH start to rise
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Menopause: Sx
- menstrual irregularlity
- sweats and hot flashes
- mood changes
- dyspareunia (pain during sexual intercourse)
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Menopause: PE findings
- atrophic caginitis
- decrease in breast size
- vaginal and cervical atrophy
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Menorrhagia
- heavy and prolonged menstrual bleeding
- "gushing" of blood
- clots may be seen
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Primary Amenorrhea / Delayed puberty
- absence of menses by age 16 with secondary sexual development present OR
- absence of secondary sexual characteristics by 14
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Causes of primary amenorrhea with absence of secondary sexual characteristics
- Constitutional growth delay
- Primary ovarian insufficiency
- Central hypogonadism
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Most common cause of primary amenorrhea
Constitutional growth delay
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Most common cause of primary ovarian insufficiency
Turner's syndrome
| * look for hx of radiation and chemotherapy
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Causes of central hypogonadism
- undernourishment, stress, hyperprolactinoma
- CNS tumor or cranial radiation
- Kallman's syndrome
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Kallman's syndrome
- isolated gonadotropin deficiency associated with anosmia
| - central hypogonaidms
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Primary amenorrhea w/ presence of secondary sexual characteristics
- estrogen production but other anatomic or genetic problems
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Etiology: primary amenorrhea w/ secondary sexual characteristics
- Mullerian agenesis
- Imperforate hymen
- Complete androgen insensitivity
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Mullerian agenesis
absence of 2/3 of vagina; uterine abnormalities
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Imperforate hymen
- presents with hematocolpos (blood in the vagina) that cannot escape along with bulging hymen
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Complete androgen insensitivity
- patients present with breast development (aromatization of testerone to estrone) but are amenorrheic and lack pubic hair
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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
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Short pt has primary amenorrhea w. secondary sexual characteristics but has normal growth velocity. Likely etiology?
Constitutional growth delay (most common cause)
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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
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Constitutional growth delay
- decr GnRH
- decr GnRH
- decr estrogen/progesterone (prepuberty levels)
- puberty has not started
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Hypogonadotrophic hypogonadism
* * hypothalamic or pituitary problem
- decreased GnRH
- decreased LH/FSH
- decresased estrogen
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Hypergonadotropic-hypogonadism
* ovaries have failed to produce estrogen
- increased GnRH
- increased LH/FSH
- decreased estrogen/progestrone
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Anovulatory problem
* PCOS or problem with estrogen receptors
- increased GnRH
- increased LH/FSH
- increased estrogen/progesterone production
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Anatomic problem with primary amenorrhea
* *menstrual blood cannot get out (e.g. imperforate hymen)
- normal GnRH
- normal LH/FSH
- normal estrogen production
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Pt has primary amenorrhea w/ neg pregnancy test, normal bone age. Next step?
Ultrasound to evaluate ovaries
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Pt has primary amenorrhea, neg pregnancy test, with normal breast development and no uterus. Next step?
Obtain karyotype to evaluate for androgen insensitivity syndrome
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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
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Constitutional growth delay: Tx
None necessary
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Hypogonadism: tx
- Begin HRT with estrogen at lowest dose
| - After 12 - 18 mths, begin cyclic estrogen/progesterone therapy (if uterus is present)
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Secondary amenorrhea
absence of menses for 6 consecutive months in women who have passed menarche
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Positive progestin challenge (withdrawal bleed)
- indicates anovulation that is likely due to noncyclic gonadotropin secretion pointing to PCOS or idiopathic anovulation
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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
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Negative progestin challenge (no bleed)
indicates uterine abnormalty or estrogen deficiency
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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
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If patient has secondary amenorrhea and clinical virilizationis present. Next step?
Measure testosterone, DHEAS and 17-hydroxyprogesterone
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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
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Tx of hpothalamic causes of secondary amenorrhea
Reverse underlying cause and induce ovulation with gonadoptropins
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Premature ovarian failure (age < 40 years)
If uterus is present, treat with estrogen plus progestin replacement therapy
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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
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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
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Primary Dysmenorrhea: Tx
- NSAIDS
- Topical heat therapy
- Combined OCPs
- Mirena IUD
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Secondary Dysmenorrhea
- menstrual pain for which an organic cause exit
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Ddx of secondary dysmenorrhea
- Endometriosis
- Adenomyosis
- Fibroids
- Adhesions
- Polyps
- PID
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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)
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Endometriosis
- functional endometrial glands and stroma OUTSIDE the uterine
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Endometriosis: Hx and PE
CYCLICAL pelvic and/or rectal pain and dyspareunia
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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")
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Endometriosis: Pharm Tx
INHIBIT OVULATION
- combination OCPs (1st line)
- GnRH analogs (leuprolide)
- Danazol
- NSAIDS or progestins
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Endometriosis: Surgical tx
- Excision, cauterization, or ablation of lesiosn and lysis of adhesions
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Endometriosis: Definitive surgical tx
Total abdominal hysterectomy/bilateral salpingo-oopherectomy (TAH/BSO) +/- lysis of adhesions
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Endometriosis: Complications
Infertility (most common cause among menstruating women > 30 yrs)
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Adenomyosis
endometrial tissue in the myometrium of the uterus
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Adenomyosis
Classic triad:
- NONCYCLICAL pain
- Menorrhagia
- Enlarged uterus
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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
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Adenomyosis: Conservative surgical tx
Endometrial ablation or resection using hysteroscopy
| - Complete eradication of deep adenomyosis is difficult and results in high tx failure
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Adenomyosis: definitive surgical tx
Hysterectomy is only definitive tx
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Adenomyosis: Complications
can rarely progress to endometrial carcinoma
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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
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What is postmenopausal bleeding?
Is cancer until proven otherwise
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Oligomenorrhea
increased length of time between menses (35 - 90 days between cycles)
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Polymenorrhea
```
Frequent menstruation (< 21 days between cycles)
- often anovular
```
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Menorrhagia
- increased amt of flow (> 80 cc of blood loss per cycle) or prolonged bleeding (flow lasting > 8 days)
- may lead to anemia
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Metorrhagia
- bleeding between periods
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Menometrorrhagia
- excessive and irregular bleeding
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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)
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First line tx of abnormal uterine bleeding
NSAIDS - decrease blood loss
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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
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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
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Congenital Adrenal Hyperplasia
deficiency of at least one enzyme for synthesis of cortisol from cholesterol
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21-hydroxylase deficiency
most severe, classic form presents as newborn female infant w/ ambiguous genetalia and life-threatening salt wasting
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11B-hydroxylase deficiency
less common cause of adrenal hyperplasia
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Congenital Adrenal Hyperplasia: Hx and PE
- excessive hirsuitism
- acne
- amenorrhea
- abnormal uterine bleeding
- infertility
- palpable pelvic mass
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Congenital Adrenal Hyperplasia: Dx
- increased androgens (testosterone > 2ng; DHEAS > micrograms)
- increased serum testosterone
- increased DHEAS
- incresased 17-OH progesterone levels
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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
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PCOS: Hx and PE
- High BP and obesity
| - Stigmata of hyperandrogenism or insulin resistance: menstrual cycle abnormalities, acne, hirsuitism, obesity
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Women with PCOS are at increased risk for which conditions?
- Type 2 DM
- Insulin resistance
- Infertility
- Metabolic syndrome
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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
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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
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Common sites of osteoporosis
- Vertebral bodies leading to crush fx, kyphosis, and decreased height
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Common risk factors for osteoporosis
- Positive family hx in a thin white female
- Steroid use
- Low Ca intake
- Sedentary lifestyle
- Smoking
- Alcohol
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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
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Raloxifen
- SERM
| - has bone agonist effects but endometiral antagonist effects
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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
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Benefits of HRT
- decreases rate of osteoporotic fx
| - decreases rate of colorectal cancer
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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**
