Gynecology Flashcards
(77 cards)
1
Q
Discuss sex differentiation
A
- sex differentiation occurs through the SRY gene on the Y chromosome
- gene encodes for testis-determining factor -> mullerian inhibiting substance and testosterone which develop the male genital system
2
Q
Discuss the development of the ovaries
A
- undifferentiated until the 7th week where develops from the paraxial mesoderm in 3rd week and develop the urogenital ridge around the nephrogenic cord in 4th week
- with no Y chromosome the indifferent gonad develop the ovary where the medullary cords degenerate, cortical cord develops (form future follicular cells) and no tunica albuginea
- ovaries descend slightly and the suspensory ligament develops from the superior genital ligament and the round ligament develops from the inferior genital ligament (gubernaculum)
3
Q
Discuss the formation the genital Ducts
A
Indifferent Stage
- mesonephric duct is Wolfian duct
- paramesonephric duct is muellerian duct
Absence of MIS and Testosterone
- mesonephric duct degenerates
- paramesonephric duct develops to form the uterine tube, uterus and superior aspect of the vagina
- absence of testosterone forms the external genitalia and lower 1/3 of clitoris -> 5th month the vaginal plate canalizes to form the vagina
4
Q
Discuss the formation of the external genitalia
A
Indifferent
- 3rd week mesynchymal cells migrate around cloacal membranes to form cloacal folds -> superiorly form genital tubercle and inferiorly form the urethral and anal folds
Development of External Genitalia
- genital tubercle elongates to form the clitoris
- urethral folds do not fuse to form labia majora
- urogenital groove remains open and form the vestibule
5
Q
List the timing of events of the endometrial and ovarian cycles
A
Endometrial - day 1-5 have menstruation - day 6-13 have proliferative phase - day 15-28 have secretory phase Ovarian Cycle - day 1-13 have follicular phase - day 14 have ovulation - day 15-28 have luteal phase
6
Q
Describe in-detail the ovarian cycle
A
Primordial
- primordial follicle develop into primary and then secondary follicle overtime and is gonadotropin independent -> larger primary oocyte with more zona pellucida + granulosa cells proliferating forming layers around oocyte + interstitial cells form theca cells around oocyte
Follicular Phase
- increase in FSH and LH lead secondary follicle to form the Graafian follicle, where fastest primary follicle to form secondary will be chosen
- tertiary follicle begin to produce estrogen which inhibits FSH causing other follicles to die
- dominant produce more estrogen leading to LH surge
Ovulation
- LH surge lead to ovulation by increasing antral fluid and release of hydrolytic enzymes so that secondary oocyte with corona radiata are release
- completion of meiosis 1
Corpus Luteam Phase
- corpus luteum produces progesterone and estrogen
- in the absence of LH the corpus luteum will degenerate into corpus albicans
- with bHCG the corpeus luteum will continue to release progesterone until taken over by placenta at 4-5 months
7
Q
Describe the endometrial stages
A
Menstruation
- due to low estrogen and progesterone cause shedding of the endometrium
Proliferative
- high estrogen from follicle stimular endometrial cells increase its thickness
Secretory
- with high progesterone cause endometrial hypertrophy, thickening of the spiral arteries and glycogen secretion
8
Q
Discuss where the major hormones of menstruation are produced
A
Progesterone
- produced by granulosa, theca, interstitial and corpus lutem
- LH stimulate corpus luteum to produce
- low <2 before ovulation and >5 after
- act on hypothalamus to decrease GnRH production
Testosterone
- produced by theca, interstitial and corpus luteum
- theca cells synthesize and then pass to granulosa cells via basement membrane to produce estrogen
- in non-dominant follicle cannot convert testosterone quickly enough resulting in atresia
Estrogen
- produced by granulosa and corpus luteum
- low <50 at menstruationa nd then peak at 200 during follicular development
- inhibit GnRH release
- FSH target granulosa cells to produces estrogen and stimulate follicular growth
Activin and Inhibin
- released by granulosa cells to activate or inhibit FSH release
9
Q
Discuss the components, mechanism and use of oral contraceptive pill
A
Component
- low dose estrogen and progestin
Mechanism
- inhibit ovulation
- change cervical mucus
- cause pseudodecidualization of endometrium to inhibit implantatation
- inhibit tubal peristalsis to prevent fertilization
Use
- start at either 1st Sunday after menses, day 1 of month or immediately
- takes 7 days before it can work
- 21/7 method where hormone free days allow for menstruation
10
Q
List the contraindications to OCP
A
- smoker and over age of 35
- <6 weeks post partum if breastfeeding
- history of VTE
- current breast cancer
- uncontrolled hypertension
- ischemic heart disease
- complicated valvular disease
- history of stroke
- migraine headache with aura or over 35 with migraine
- severe diabetes or cirrhosis
- SLE and APLA
- thrombophilia
11
Q
List the benefits of OCP
A
Short Term
- regulation of menstrual cycle and decreased bleeding
- decreased dysmenorrhea, acne or premenstrual syndrome
Long Term
- decrease risk of endometrial, ovarian, and colorectal cancer
- decrease risk of benign breast disease
Other
- decrease risk of PID and ectopic pregnancy
- decrease risk of ovarian cyst
- improve endometriosis
12
Q
Discuss the contraceptive patch and vaginal ring
A
- same as oral contraceptive where use for 3 weeks with 1 free week
13
Q
Discuss the benefits of the progestin only pill
A
Mechanism - need to take pill everyday at same time and it increases cervical mucous - still have regular menstruation Indication - breastfeeding women or those with previous VTE Adverse Effects - irregular bleeding - worsening mood
14
Q
Discuss the benefits of injectable progestin DMPA
A
Mechanism - inhibit ovulation - thicken cervical mucous - pseudodecidualization Use - injection every 3 months where have 2 week interval at mark where still effective Contraindication - known or suspected pregnancy - unexplained vaginal bleeding - current breast cancer Adverse Effect - 50% develop amenorrhea after 1 year and 75% after 2 years - weight gain due to increase appetite - decreased bone densit - delay to fertility: require 9 months after to return Benefit - treat menorrhagia, dysmenorrhea and endometriosis - treat menses related symptoms - decrease risk of endometrial and cervical cancer - decrease seizure
15
Q
List the contraindications to an intra-uterine device
A
Contraindications - known pregnancy - puerperal sepsis - immediate post septic abortion - current PID or STI - cervical or endometrial cancer - current breast cancer - unexplained vaginal bleeding - distorted uterine cavity - malignant trophoblastic disease Adverse Effects - unscheduled vaginal bleeding - pain or dysmenorrhea - uterine perforation - infection - expulsion - failure where have increased risk of ectopic
16
Q
Discuss the benefit of copper IUD
A
Mechanism
- foreign body reaction that lead to endometrial change that adversely affect sperm transport and inhibit sperm motility directly
- best used for emergency contraception 7 days post
17
Q
Discuss the benefit of a mirena (LNG-IUS) IUD
A
- contain progesterone
- last up to 5 years
Mechanism - thicken cervical mucous
- suppress endometrial estrogen and progestin receptor
- inhibit ovulation
- inhibit implantation
- induce endometrial changes
18
Q
Discuss the use of Plan B/Norvelo
A
- progesterone only Mechanism - inhibit ovulation - change endometrium to prevent implantation - disrupt luteal phase - effect on tubal transport - does not disrupt established pregnancy
19
Q
Discuss the approach to primary amenorrhea
A
- failure to reach menarche (amenorrhea and no pubertal development by 14 or amenorrhea with secondary sexual characteristic by 16)
Pelvic Examination - if absent uterus must assess if have sexual hair -> if yes than mullerian agenesis and if no then CAIS
- if normal then assess bHCG
Negative bHCG assess prolactin, TSH and FSH
Prolactin - if increased require MRI head to assess for pituitary tumour
- treat with surgery or dopamine agonist
TSH - if elevated treat with thyroid replacement
FSH Decreased - assess if have eating disorder, over exercise or stress
- if no, then MRI for tumour -> if MRI negative than Kallman
FSH Increased - gonadal failure so must do karyotype assessing for primary ovarain insufficiency or Turner or fragile X
FSH Normal - testosterone increased than ovarian sonography for tumour
- DHEAS high then adrenal MRI for tumour
- if DHEAS and testosterone normal or high normal than PCOS
- 17-OH-P increased than congenital adrenal hyperplasia
20
Q
List the differential for secondary amenorrhea
A
Hypothalmic - eating disorder or stress Pituitary - prolactinoma Thyroid - hypothyroidism Ovary - PCOS - primary ovarian insufficiency
21
Q
Discuss the presentation and management of primary ovarian insufficiency
A
- 90% are idiopathic and then Turner or chemo/radiation
Pathophysiology - inadequate follicles to sustain menses due to failure tof form enough primordial follicles or accelerated loss or damage
Presentation - primary or secondary amenorrhea
- menses interal >90 days
- oligomenorrhea
Investigation - consistently high FSH and LH
- consistently low estradiol
Diagnosis - primary or secondary amenorrhea for 3 months or changes from normal for 3 months
- high FSH >40 on 2 occassions a month apart
- age <40
Complications - increased risk of osteoporosis and atheroscleorsis
- infertility
Management - pre-puberty: increase estrogen over 2 years until breakthrough bleed -> add progesterone
- Post-Puberty: estrogen for 1-26 and progesterone for 14-26 of cycle (OCP or patch)
- prevent complications through lifestyle, monitoring and supplementation
22
Q
Discuss the presentation and management of polycystic ovarian syndrome
A
Rotterdam Diagnosis (2/3) - oligo or anovulation - clinical or biochemical hyperandrogenism - polycystic ovaries (>12 follicles) Acute Management - menstrual irregularities with oral contraceptive - acne with lifestyle changes - hirsutism with spironolactone - infertility Surveillance - impaired glucose tolerance (possible pathophysiology where theca cell insulin resistance lead to unopposed estrogen with elevated LH) - endometrial hyperplasia - hyperlipidemia
23
Q
Discuss the signs of hyperandrogensism
A
- hirsutism on androgen dependent areas of body
- acne
- clitoromegaly
- male balding
- obesity
- insulin resistance
24
Q
List the differential for abnormal uterine bleeding
A
Structural Abnormalities (PALM) - polyp - adenomyosis - leiomyoma - malignancy No Structural Abnormality (COEIN) - coagulopathy - ovulatory dysfunction - endometrial - iatrogenic - not yet classified
25
Discuss the risk factors for polyp and risk factors for polyp malignancy
```
Risk Factors
- tamoxifen
- obesity
- hormone replacement
- age
For Malignancy
- >1.5cm
- tamoxifen
- age >60
```
26
Discuss the diagnosis and treatment of polyps
```
Diagnosis
- hysteroscopy
- saline infusion sonography
Treatment
- symptomatic or post-menopausal
- asymptomatic if risk for malignancy, mulitple, prolapse, infertility
```
27
Discuss the presentation and management of adenomyosis
```
- are ectopic endometrial glands and stroma within myometrium resulting in enlarged uterus
Presentation
- heavy menstrual bleeding
- painful menstruation with chronic pelvic pain
- enlarged uterus
Treatment
- hysterectomy
- hormonal therapy
- ablation
- embolization
```
28
Discuss the presentation and management of fibroids
- is growth of myometrial smooth muscle in women of reproductive age
Presentation
- heavy and prolonged menses
- pelvic pain or pressure with 4 D’s (dysmenorrhea, dyspareunia, dyschezia, dysuria)
- infertility
- enlarged urterus
Investigations
- CBC for anemia
- transvaginal ultrasound
Treatment
- prophylactic if causing infertility, IVF or hydronephrosis
- hormonal therapy with OCP or menopause inducing drugs
29
List the risk factors for fibroids
```
Increased
- African American
- early menarche
- family history
- hypertension
- obesity
- alcohol
- red meat
Decreased
- high parity
- exercise
- smoking
- healthy diet
```
30
Discuss the screening and treatment of coagulopathy leading to AUB
Screen
- heavy menstrual bleed
- one of post-partum hemorrhage, surgery related bleed, bleeding with dental work
- two of bruising, epistaxis >=1/month, frequent gum bleeding, or family history
Treatment
- No pregnancy then contraceptive method
- pregnancy then antifibrinolytic, factor replacement, dDAVP
31
List the differential for ovulatory dysfunction
- eating disorders
- stress
- excessive exercise
- obesity
- endocrinopathy
32
List the iatrogenic causes to AUB
```
Pharmacotherapy
- exogenous gonadal steroids
- GnRH therapy
- antipsychotic
- corticosteroids
- anticoagulants
Medical
- IUD
Surgical
- D+C
- myomectomy
- C-section
```
33
List the hormone treatment principles for AUB
Combined estrogen and progestin
- for regular or irregular menorrhagia or irregular cycle
- progestin suppress ovulation
- estrogen support endometrium preventing breakthrough bleeding
Progestin Only
- for irregular menstrual cycle
- inhibit ovarian steroid synthesis leading to endometrial atrophy and decrease bleeding
GnRH Agonist (Lupron)
- for regular or irregular menorrhagia, shrinkage of fibroid and dysmenorrhea
- induce reversible menopause
34
List the mechanism of non-hormonal treatment of AUB
```
Iron Supplementation
NSAID
- cause vasoconstriction and reduce pain
Anti-fibrinolytics (TXA)
- inhibit plasminogen activator in order to decrease bleeding
```
35
List the life-threatening differential for vaginal bleeding
```
Early pregnancy: ectopic or spontaneous abortion
Late pregnancy: abruption or previa
Post-partum: PPH
Ovary: torsion or rupture of cyst
Uterus: severe menorrhagia
Trauma
Infection: PID or salpingitis
Malignancy
```
36
Discuss the presentation and management of an ectopic pregnancy
```
Presentation
- pelvic pain
- vaginal bleeding
- palpable adnexal mass
- peritoneal signs
Investigation
- postive bHCG that is not doubling every 48hrs
- trans-vaginal ultrasound show ectopic or no pregnancy intra-uterine pregnancy with bHCG >1500
Management
- surgery if complicated
- medical abortion if not complicated
```
37
Discuss the presentation and management of ruptured ovarian cyst
```
Presentation
- pelvic pain
- vaginal bleeding
- nausea and vomiting
- tenderness to palpation
- peritoneal signs
Investigations
- negative bHCG
- ultrasound show free fluid in pelvis
Management
- uncomplicated get conservative with possible fluid resuscitation
- surgical for source control if unstable or deteriorating
```
38
Discuss the presentation and management of ovarian torsion
```
Presentation
- pelvic pain
- vaginal bleeding
- fever, nausea and vomiting
- palpable mass
Investigations
- negative bHCG
- ultrasound show enlarged ovary/mass/peripheral follicles or no doppler flow
Management
- immediate surgery with possible salpingooophorectomy
```
39
Discuss the presentation and management of pelvic inflammatory disease
```
Pathophysiology
- infection of upper genital tract by STI
Presentation
- prior STI or sexual activity
- pelvic pain during or after menses
- vaginal discharge or bleeding
- fever
- dysuria
- cervical motion tenderness
Investigations
- positive culture
- abscess
Management
- ceftriaxone 250mg IM + doxycyline 100mg BID for 14 days
```
40
Discuss the presentation of Chronic Pelvic Pain Syndrome
```
Pathophysiology
- idiopathic spasm of pelvic floor muscle
Presentation
- pain out of proportion
- dyspareunia
- vaginismus
```
41
Discuss the presentation of vestibulitis vulvodynia syndrome
Presentation
- vulvar discomfort
- superficial dyspareunia
- perineal burning
- erythema of Bartholine opening and hymen
- tenderness to Q-tip probe
42
Discuss the presentation of pelvic congestion syndrome
- pelvic pain varicosities
Presentation
- dull achin pain in pelvis made worse by standing
- ultrasound with pelvic varicosities
43
Discuss the cervical screening
- begin screening at 21 if ever sexually active and repeat every 3 years
- if never, can wait until sexually active
- stop at 70 if have 3 previous normal results
44
List the different pap test results
ASC-US: atypical squamous cell of undetermined significance
ASC-H: atypical squamous cell that cannot exclude high grade lesion
LSIL: low grade squamous intraepithelial lesion
HSIL: high grade squamous intraepithelial lesion
Squamous cell carcinoma
45
List the follow up testing for pap test results
```
ASC-US <30
- repeat every 6 months x2 -> if abnormal then colposcopy
ASC-US >30 with HPV testing
- if positive then colposcop
- if negative then repeat PAP in 1 year
- if no HPV than same as <30
LSIL
- colposcopy or repeat PAP at 6 months
HSIL/ASC-H/AGC
- colposcopy
```
46
Discuss the use of colposcopy
```
Diagnosis
- uses acetic acid to turn white the areas of dysplasia which can be biopsied
- if nothing than do transition zone
Management
- CIN 1 than repeat PAP at 12 months
- CIN 2 or 3 perform LEEP excision
```
47
Discuss the presentation and management of bacterial vaginosis
- most common cause of increase discharge
- increase risk of acquiring STI
Amsel's criteria (3/4):
- thin white discharge
- pH >4,5
- positive Whiff test: fishy odor when alkali is added
- clue cells
Management
- flagyl 500mg PO BID for 7 days
- do not need to treat partner
48
Discuss the presentation and management of vulvovaginal candidiasis
- 2nd most common with 75% having at least one episode
Risk Factors
- uncontrolled diabetes or system antibiotic use
- immunocompromised
- high estrogen level (pregnancy, obesity, OCP)
Presentation
- thick, white clumpy discharge
- vulval itch with erythema and satellite lesions
Investigation
- pH litmus paper <4.5
- vaginal KOH swab show yeast with hyphae and spores
Management
- fluconazole 150mg PO
- topical cream for 3 days if uncomplicated and 7 if complicated (topic preferred only if pregnant)
49
Discuss the presentation and management of trichomoniasis
```
- symptoms one week after contact
Presentation
- yellow-green, frothy malodorous discharge with pruritis and dyspareunia
- strawberry cervix
Investigation
- motile flagellated organism
Management
- treat even if asymptomatic with flagyl 2g PO single or 500mg PID x7
```
50
Discuss the presentation and management of post menopausal atrophic vaginitis
```
- low estrogen leading to atrophy of the vagina
Presentation
- yellow vaginal discharge
- dry and irritation of vagina
- dyspareunia
- vaginal petechiae
Management
- vaginal estrogen applied for life
```
51
List the female risk factors for infertility
- age >35
- low or high body mass
- history of oligo/amenorrhea, PID or endometriosis
- previous pelvic surgery
- previous chemotherapy
52
List the male risk factors for infertility
- age >40
- cryptochordism
- previous surgery or chemotherapy
- recreational drug use
53
Discuss the inter-relationship between infertility and sexual dysfunction
- sexual dysfunction when health, relationship or idea regarding sex cause problems with function (desire, arousal, orgasm) -> leads to infertility which contributes to worsening dysfuncion
- for men most common is erectile dysfunction
- for women it is low desire/arousal, dyspareunia or difficulty reaching orgasm
54
List the indications for further testing with infertility
- female age <35 and have attempted for 1yr of unprotected and frequent (2-3x per fertile window)
- female age >35 or specific history after 6 months of attempt
55
List the investigations for infertility
- assessment of ovulation by history and serum progesterone 7 days prior to expected period
- ovarian reserve testing by FSH, estradiol, and ultrasound
- uterus and uterine tube anatomy by saline infusion sonogram
- semen analysis
- TSH
56
Discuss the methods for assessing ovulation
History
- should have ovulation 14 days before expected period if regular
- have signs of molimina
Basal Body Testing
- increase by 0.3-0.5 2-3 days after ovulation
LH Surge
- can measure LH surge at ovulation
Luteal Phase Serum Progesteron
- assessment of progesterone 7 days before expected period
57
How do you confirm low ovarian reserve
- measure FSH and estradiol on day 3 of menstrual cycle along with pelvic ultrasound for follicles
- high FSH and low estradiol suggest low reserve along with low follicle count
58
Discuss methods for assessment of tubal patency
Hysterosalpingogram
- dye put into uterus to assess patency of tubes
- due 2-3 days after menses to avoid clot and pregnancy
Saline Infusion Sonogram
- infusion of saline into uterus to assess patency
Laproscopy
- gold standard
- indication: abnormal hystersalpingogram, endometriosis, previous ectopic or surgery, previous ruptured appendicitis, abnormal pelvic exam, PID
59
List the normal semen findings
- volume >1.5mL
- pH >7.2
- sperm concentration >15million
- >40% progressive motility
- >4% normal
60
Discuss the management for ovulation dysfunction infertility
```
Hypogonodotropic hypogonadism
- weight gain
- GnRH or FSH injections
- IVF
Normogonodotropic normoestrogen (PCOS)
- weight loss
- clomiphene citrate which is selective estrogen receptor modulator to increase FSH
- metformin for insulin sensitization
- FSH injection
- IVF
Hypergonodatropic hypogonadism (POF)
- IVF
- donor
- adoption
```
61
Discuss management of male infertility
- lifestyle modification: avoid heat, limit caffeine, stop alcohol, smoking, drugs
- abnormal sperm get GnRH
- abnormal sperm function get IVF
- obstruction require IVF
62
Discuss the methods of treatment for induction
```
Ovulation Induction
- add selective estrogen receptor modulator or FSH to act as antagonist at hypothalamus to increase FSH
Superovulation
- induce 2-4 eggs and then intra-uterine insemination
- daily FSH injections
Intrauterine Insemination
- male sperm washed and placement in uterus
IVF
- tubal obstruction
- severe endometriosis
- low sperm count
- PCOS
- failed SO
- donor egg needed
- age >40`
```
63
Discuss the procedure of IVF
- FSH stimulate egg production which is aspirated by needle
- inseminated with sperm
- fertilized egg inserted into uterus
- <38 1-2 eggs inserted and >42 then 5
64
List the red flags for domestic abuse
```
Being Abused
Situational
- planning on leaving or recent termination
- pregnancy
Demographics
- <30
- low SES
Physical or mental disability
Past History
```
Abuser
- history of aggression
- low SES or unemployment
- substance use
65
List the risk factors for pelvic organ prolapse
- age
- pregnancy
- obesity
- previous surgery
- hypo-estrogen
- connective tissue disorder
- smoking
66
Discuss the presentation and management of pelvic organ prolapse
```
Pathophysiology
- weakness in pelvic floor lead to prolapse of vaginal walls along with organs surrounding
Presentation
- fullness, pressure or bulge from vagina
- urinary incontinence
- constipation
- vaginal bleeding or discharge
Investigations
- urodynamics
Management
- pelvic floor exercises and estrogen replacement
- pessary
- surgery
```
67
Discuss the grading of pelvic organ prolapse
```
Grade 1
- prolapse descending to upper 1/3 of vagina
Grade 2
- prolapse descending to mid vagina
Grade 3
- prolapse descending to hymenal ring
Grade 4
- prolapse past hymenal ring
```
68
Discuss the different causes of obsterical fistuals
```
Obstetric
- due to prolonged, obstructed labor without timely intervention
Iatrogenic
- pelvic surgery or radiotherapy lead to injury
Local disease Causing Inflammation
- local inflammatory disease
- IBD
- local cancer
```
69
Discuss the presentation and management of pelvic fistula
Presentation
- recurrent vaginitis and irritation
- vesicovaginal: uncontrolled leakage of urine with recurrent UTI
- rectovaginal: leakage of stool and flatus from vagina
Management
- vesico: small get catheter in order to heal or large get surgical repair
- recto: surgical repair
70
What is the definition of menopause
- 12 months of amenorrhea typically occuring between 45-55
- peri-menopause is transition period of altered hormones that leads up to and last for 1 year after
- is the shortenin of cycles with greater time in between
71
Discuss some of the physiologic changes with menopause
- narrowing of thermoneutral zone leading to regulatory response of sweating or shivering
- low estrogen lead to atrophy of vagina and bladder incontinence
- low estrogen lead to dyslipidemia, increase plaque and vasodilation
72
Discuss the clinical symptoms of menopause
- vasomotor: hot flashes and night sweats
- poor memory and concentration
- depression and sleep disturbance
- vaginal dryness and increased urinary frequency
- decreased libido
- fatigue and myalgia
Increased Risk of
- osteoporosis
- cardiovascular disease
- colorectal cancer
73
Discuss the conservative management of menopause
- reduce core body temperature
- avoid triggers such as alcohol, warm environment and drinks
- regular exercise and weight loss
- smoking cessation
74
List the indications and contraindications for hormone therayp
```
Indications
- menopausal symptoms that negatively impact quality of life within 3-5 years of menopause for a max of 5 years
- those with premature ovarian failure should be used until 50 for cardioprotective benefits
Contraindication
- cardiovascular disease
- breast or endometrial cancer
- venous thromboembolism
- acute liver disease
```
75
List the option for medical therapy of menopause
- lower dose than OCP, so have lower risk
- have both estrogen and use progesterone if have uterus
- transdermal better as bypass liver so lower risk of DVT
Types
- oral conjugated equine estrogen
- oral esterase
- transdermal estradiol
- oral micronized progesterone
- progestin
76
Discuss the use of vaginal estrogen therapy
- first line for vaginal atrophy without vasomotor symptoms
- reduced risk of complications of HT
- require lifelong therapy
77
List the histological findings of endometriosis
>=2 of
- endometrial epithelium
- endometrial gland
- endometrial stroma
- hemosiderin-laden macrophage
