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Flashcards in Gynecology Deck (148)
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1

precocious puberty- age cut-off

before age 8 in girls
before age 9 in boys

does not always have to be treated if not serious or impactful

2

precocious puberty causes

familial/genetic (nonpathologic)

central (True) precosious puberty: early activation of hypothalamic pituitary- gonadal axis
-image the head
-continuous GnRH analog will suppress LH and FSH

pseudoprecocios puberty: autonomous excess secretion of sex steroids
-image the abdomen
-surgical tumor removal

congenital adrenal hyperplasia
-cortisol replacement

complications:
short stature
social and emotional adjustment issues

3

precocious puberty isosexual vs heterosexual

iso: premature sexual development appropriate for gender
10% due to CNS lesions/trauma
Complete- all sexual characteristics develop prematurely

incomplete- only 1 sexual characteristic develops prematurely

hetero: virilization of girls (exogenous androgens, androgen- secreting neoplasm, congenital adrenal hyperplasia)

feminization of boys

4

precocious puberty isosexual vs heterosexual

iso: premature sexual development appropriate for gender
10% due to CNS lesions/trauma
Complete- all sexual characteristics develop prematurely

incomplete- only 1 sexual characteristic develops prematurely

hetero: virilization of girls (exogenous androgens, androgen- secreting neoplasm, congenital adrenal hyperplasia)

feminization of boys

5

precocious puberty causes

familial/genetic (nonpathologic)

central (True) precosious puberty: early activation of hypothalamic pituitary- gonadal axis

pseudoprecocios puberty: autonomous excess secretion of sex steroids

6

precocious puberty isosexual vs heterosexual

iso: premature sexual development appropriate for gender
10% due to CNS lesions/trauma
Complete- all sexual characteristics develop prematurely

incomplete- only 1 sexual characteristic develops prematurely

hetero: virilization of girls (exogenous androgens, androgen- secreting neoplasm, congenital adrenal hyperplasia)

feminization of boys

7

pregesterone

pro-gestation
stimulates endometrial development
inhibits uterine contraction
increases thickness of cervical mucus
increases basal body temp
inhibits LH and FSH secretion

decrease in progesterone level leads to menstruation (simulate this by giving progesterone and then stopping it)

8

bHCG

maintains corpus luteum and progesterone secretion

9

mean age of menarch in the US

13

10

pregesterone

pro-gestation

11

True precocious puberty

high LH and FSH
GnRH will increase FSH further

treat by inducing menopause with continuous GnRH analog

12

mean age of menarch in the US

13

13

Pseudoprecocios puberty

low LH and FSH
no response when GnRH given

14

True precocious puberty

high LH and FSH
GnRH will increase FSH further

15

how long is luteal phase

13-14 days

16

FSH triggers release of which hormone from follicle?

estradiol

17

Menopause

end of menstruation due to cessation of ovarian function
Average age: 51.5 years

Premature ovarian failure: amenorrhea for at least 1 year before age 40

Labs, which are not so necessary would show
increased FSH, LH,
decreased estrogen

Menopause is diagnosed with 12 months of amenorrhea in a woman over 45yo (diagnostic and requires no additional work-up)

A woman over age 45 with irregular menses (oligoamenorrhea) and menopausal symptoms (hot flashes, mood changes, sleep disturbances) can be assumed to be going through perimenopause

Serum FSH increases in the perimenopausal period and after menopause, but this is of little diagnostic value beyong obtaining a menstrual history and history of symptoms

If younger than 45, other etiologies for oligo/amenorrhea must be excluded (TSH, serum hCG, prolactin, FSH)

18

Premature ovarian failure:

amenorrhea for at least 1 year before age 40, or high FSH + menstrual irregularity before age 40

tobacco
radiation
chemo
abdominal disorders
pelvic surgery

19

Perimenopause

ovarian response to FSH and LH decreases

FSH and LH levels increase

Estrogen levels fluctuate
irregular bleeding, sometimes heavier flow

Endometrial biopsy to r/o other causes

20

Menopause symptoms

hot flashes
breast pain
sweating
fatigue
anxiety/depression
dyspareunia
urinary frequency and dysuria
changes in bowel habits
vaginal atrophy
bladder symptoms
stress urinary incontinence

21

Menopause treatment

Women's Health Initiative- gave asx post- menopausal women estrogen and progesterone to see if it is cardioprotective, and they had more heart attacks and cardiac events so estrogen is now only used to treat symptoms

Topical estrogen is contraindicated in anyone with history of estrogen- sensitive or breast cancer

Dyspareunia can be treated with
-lubricating agents
-vaginal estrogens

Osteoporosis:
-calcium
-vitamin D
-weight-bearing exercise
-bisphosphonates
-selective estrogen receptor modulators (SERMs)

Hot flashes and mood swings:
-hormone replacement therapy at least for a little while

22

Pros and cons of hormone replacement therapy for menopause

Pro:
-control of menopause symptoms (hot flashes, vaginal dryness/atrophy, urinary incontinence, emotional lability
-reduced risk of osteoporosis
-reduced risk of colorectal cancer

CONS
-not indicated for prevention of chronic disease, stroke, heart disease, and osteoporosis (USPSTF)
-HRT doubles risk of
*invasive breast cancer (+8 per 10,000) but not noninvasive breast cancer
*endometrial cancer
*venous thromboembolism (+8 PEs per 10,000)

-increases risk of stroke by up to 32-41% (+8 per 10,000)
-increases risk of heart disease by 29% (+7 per 10,000)
-However, if taken at ages 50-59, HRT results in less coronary calcifications on CT scan. This may or may not correlate with less risk of heart disease in women taking HRT during ages 50-59.
-increases risk of biliary disease and need for biliary surgery

23

Non-hormonal options for treating hot flashes

1. Venlafaxine- a good choice if any depression, anxiety, fatigue, isolation. Good first- line drug

2. Desvenlafaxine: only non-hormonal drug that is FDA-approved for hot flashes. Also works as an antidepressant

3. Clonidine- a good choice if BP control is also needed. SE- dry mouth, constipation, drowsiness

4. Gapabentin- good choice if insomnia, restless leg syndrome, seizure d/o, neuropathy, chronic pain

5. Time- about 30-50% of women have symptoms improvement within a few months, and most have resolution within 4-5 years

6. Placebo: placebo effect is about 20-25% effective in reducing hot flashes

24

Side effects of estrogen therapy

weight gain
nausea
breast tenderness
headache
endometrial proliferation

25

Side effects of progesterone therapy

acne
depression
hypertension

26

Primary Amenorrhea

16yo with normal secondary sex characteristics but no menses

13yo with absence of both menses and secondary sex characteristics

27

Causes of primary amenorrhea

hypothalamic or pituitary dysfunction

anatomic abnormalities
-absent uterus
-vaginal septum
-imperforate hymen

chromosomal abnormalities with gonadal dysgenesis
-Turner syndrome (45XO)

28

Secondary amenorrhea

absence of menses >6 months in a patient with a prior history of menses

causes:
pregnancy
premature ovarian failure
hypothalamic or pituitary disease
acquired uterine abnormalities
polycystic ovarian syndrome
hyperprolactinemia
thyroid disease
anorexia nervosa or over-eating

29

Asherman syndrome

scarring of the uterus that follows infection or postpartum procedure

H and P
menstrual history
family history
medications
signs of masculinization
-facial hair
-voice deepening
Tanner stages

30

Labs to check in amenorrhea

1.
beta HCG
Thyroid studies (TSH and free T4)
Prolactin
FSH and LH
Androgens
-testosterone and DHEA

2.
progesterone challenge
estrogen-progesterone challenge