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Flashcards in Gynecology - MTB Deck (242):

Benign Breast Disease

1. Fibroadenoma
2. Fibrocystic disease
3. Intraductal papilloma
4. Fat necrosis ( trauma to breast)
5. Mastitis (inflamed, painful breast in women who are breastfeeding)


Malignant Breast Disease

1. Ductal carcinoma in situ
2. Lobular carcinomia in situ
3. Ductal carcinoma
4. Lobular carcinoma
5. Inflammatory breast cancer
6. Paget's disease of the breast/nipple


Most common cause of nipple discharge

Intraductal papilloma
** if palpable mass is also present, likelihood of caner is greater


When is further workup is needed for nipple discharge?

If nipple discharge has following characteristics:
- unilateral
- spontaneous
- bloody
- associated with mass


If patient has nipple discharge, what is the first next step?

1. Mammogram: look for underlying mass or calcifications
2. Surgical duct excision: perform for definitive diagnosis
** Cytology is not helpful and not answer for nipple discharge


Pt has bilateral milky nipple discharge. Next step?

Consider workup for prolactinoma


Fibrocystic disease

- presents with bilaeral painful breast lump(s)
- pain will vary with menstrual cycle
- simple cyst will collapse with FNA


Fibrocystic disease: tx

- OCPs/medications



- presents as a discrete, firm, nontender, and high mobile breast nodule
- mass is highly mobile on clinical exam
- FNA shows


Woman presents with breast mass. Next steps?

1. Clinical breast exam
2. Ultrasound or diagnostic mammogram (if pt < 40)
3. Fine needle aspiration


Breast mass treatment

- diagnostic and curative but not always necessart


Patient has simple cyst on clinical exam. Next step?

- Must confirm with ultrasound or FNA


39 yo w c/o of bilateral breast enlargemen and tenerenss, which flucturates with menstrual cycle. PE, the breast feels lump and there is a painful discrete 1.5cm nodule. DNA is performed and clear liquid is withdrawn. Cyst collapses with aspiration. Next step?

Clinical breast exam in 6 weeks
** if mass recurs in 6 week follow-up, FNA may be repeated and core biopsy is performed.


Patient has palpable breast mass that feels cystic. Next step?



Patient has palpable breast mass. Next step?

Fine needle aspiration
- may be done after ultrasound or instead of ultrasound


Indications for mammography (> 40 years old) and biopsy OR biopsy alone if < 40 years old

- Cyst recurs > twice within 4-6 weeks
- Bloody fluid on aspiration
- Mass doesn't disappear completely on FNA
- Bloody nipple discharge (excisional biopsy)
- If there is skin edema or erythema suggestive of inflammatory breast carcinoma (excisional biopsy)


When is cytology indicated?

When there is grossly bloody discharge


When is observation with repeat exam in 6-8 weeks?

- Cyst disappears on aspiration, and the fluid is clear
- Needle biopsy and imaging studies are negative


47 yo woman completes her yearly mammogram and is told to return for evaluaion. Mammogram reveals a "cluster" of microcalcifications in the left breast. What is the most appropriate next step?

Needle biopsy
- 15-20% of cluster of microcalcifications represent early cancer


Patient has biopsy which shows ductal carcinoma in situ. Next step?

Surgical resection with clear margins (lumpectomy)
- give radiotherapy and/or tamoxifen to prevent invasive disease


Patient has bx which shows lobular carcinoma in situ. Next step?

Tamoxifen alone
- not necessary to perform surgery
- usually seen in premenopausal women


Most common form of breast cancer

Ductal carcinoma
- 85% of all cases


Ductal carcinoma

- it is unilateral
- metastasizes to bone, liver, and brain


Lobular carcinoma

- accounts for 10% of breast carcinoma
- tends to be multifocal (within same breast) and is bilateral in 20% of cases


Inflammatory breast cancer

- uncommon, grows rapidly, and metastasizes early
- look for red, swollen, and warm breast and pitted, edematous skin (peau d'orange appearance)


Paget's disease of breast/nipple

presents with pruritic, erythematous, scaly nipple lesion
- often confuse with dermatosis like eczema or psoriasis
- look for inverted nipple or discharge


Breast cancer screening

- women > 40 years old, screening mammography every 1-2 years
- mammography has greatest benefit for >50 yrs and women with hx of premenopausal breast cancer
- BRCA genetic testing is not used for screening


Breast cancer risks

- Age > 50
- Benign breast disease (esp. cystic disease, proliferative types of hyperplasia)
- Exposure to ionizing radiation
- First childbirth after 30 or nulliparity
- Higher socioeconomic status
- Hx of breast cancer
- Hx of breast cancer in a first degree relative
- Hormone therapy
- Obesity (BMI > 30)


Invasive carcinoma tx if tumor < 5cm

If < 5cm, lumpectomy + radiotherapy +/- adjuvant therapy +/- chemotherapy
- sentinal node bx is perferred over axillary node dissection
- always test for estrogen progesterone receptors, HER2


68 y.o woman visits her PCP w/ a solid peanut shaped hard mass in the upper outer quadrant of the left breast. A bx of the lesion is done, revealing "infiltrating ductal breast cancer". What is the next step of management?

Lumpectomy plus radiotherapy
- standard of care in invasive disease


Indications for BRCA1 and BRCA1 gene testing

- Fam hx of early onset breast cancer or ovarian cancer
- Breast and/or ovarian cancer in the same patient
- Family hx of male breast cancer
- Ashkenaxi Jewish heritage


When is breast-conserving therapy not the answer?

- Pregnancy
- Prior irradiation to the breast
- Diffuse malignancy or > 2 separate quandrants
- Positive tumor margins
- Tumor > 5cm


When adjuvant hormonal therapy included in management?

Any hormone receptor-positive tumors, regardless of age and regardless of menopausal status, stage, or type of tumor


Greatest benefit of adjuvant therapy?

When tumor is both ER+ and PR+ receptors are present
- almost as good with tumors that are ONLY ER_


When is adjuvant therapy least beneficial?

When tumor is only PR+



- competively binds to estrogen receptors
- 5 yr treatment --> 50 percent decrease in recurrent
- may be used in pre- or post-menopausal patients


Aromatase inhibitors (anastrozole, exemestane)

- block peripheral production of estrogen
- standard of care in HR+ postmenopausal women (more effective in postmenopausal)


Concern for aromatase inhibitors

- don't cause menopausal symptoms but does increase risk of osteoporosis


LHRH analogues (e.g. goserelin) or ovarian ablation

- an alternative or an addition to tamoxifen in premenopausal women


Benefits of Tamoxifen

- decreased incidence of contralateral breast cancer
- increase bone density in postmenopausal women
- decrease fx, serum cholesterol, CV mortality risk


Adverse Effects of Tamoxifen

- exacerbates menopausal symptoms
- greatly increases risk of endometrial cancer


Woman w/ hx of tamoxifen use presents with vaginal bleeding. Next step?

Further evaluation
- endometrial biopsy


When is chemotherapy indicated in breast carcinoma?

- Tumor size > 1 cm
- Node-positive disease


When is trastuzumab indicated in management?

- Metastatic breast cancer overexpressing HER2/ney



- monoclonal antibody directed against the extracellular domain of the HER2/neu receptor and is used to treat and control visceral metastatic sites


If invasive breast cancer is a HR-negative, pre- or postmenopausal women

Give chemotherapy alone


If invasive breast cancer is HR-positive, PRE-menopausal women. Tx?

Give chemotherapy + tamoxifen


If invasive breast cancer is HR-positive, POST-menopausal woman? Tx?

Give chemotherapy + aromatase inhibitor


Ddx: Enlarged Uterus

1. Pregnancy
2. Leiomyoma
3. Adenomyosis



- smooth muscle growth of the myometrium
- most common benign uterine tumor
- classically presents with African-American woman with enlarged, firm, asymetric, non-tender uterus
- B-hCG negative


Patient presents with leiomyoma w/ intermenstrual bleeding and menorrhagia. Location

Submucosal location w/ distortion of the uterine cavity seen on saline ultrasound


Pt with uterine mass complains of bladder, rectum, or ureter compression sx. Location of mass?

- mass may become parasitic and obtain its bood supply from intestinal mesentary



abnormal location of endometrial glands and stroma within the myometrium of uterine wall
- can cause dysmenorrhea and menorrhagia
- feels soft, globular, symmetrical, and tender


First test to order in patient with enlarged uterus?

B-hcG test


Management of leiomyomas

Med tx: Serial pelvic exams & observations
Presurgical shrinkage: 3-6 mths of GnRH analog
Myomectomy: to preserve fertility
Embolization of vessels: preserves uterus & invasive radiology


When are hysterectomies the best treatment for leiomyomas?

When fertility is completed
* Hysterectomy is the definitive treatment


Leiomyoma: pelvic exam features

ASYMMETRICALLY enlarged, firm, NONtender uterus


Adenomyosis pelvic exam features

SYMMETRICALLY enlarged, firm, TENDER uterus


Adenomyosis: Management

Medical treatment: IUS (levonorgestrel) intrauterine system may decrease heavy menstrual bleeding

Surgical (MOST definitive tx): Hysterectomy


Why do you always give estrogen + progestins to women with a uterus?

Estrogen alone will cause endometrial hyperplasia


65 year old obese patient c/o vaginal bleeding for 3 months. Last menstrual period was at age 52. She has no children. She has type 2 DM and chronic hypertension. PE is normal with normal sized uterus and no vulvar, cervical, or vaginal lesions? Next step in management?

Perform endometrial biopsy (to r/o endometrial cance)


Most common cause of postmenopausal bleeding

Endometrial atrophy


Risk factors for endometrial cacinoms

Unopposed estrogen states
- obesity
- late menopause/early menarche
- chronic anovulation


For reproductive age women with chronic anovulation (e.g. PCOS), what should be given to prevent endometrial hyperplasia and cancer



Management of postmenopausal bleeding

1. Pelvic exam + endometrial biopsy
2. Hysteroscopy to look for endometrial or cervical polyps as sources of bleeding
3. Ultrasonography - measures thickness of endometrial lining


In patient w/ post-menopausal bleeding, endometrial bx reveals atrophy and no cancer. What next step?

No further w/u needed
- Give HRT (estrogen plus progesterone)


In patient w/ post-menopausal bleeding, endometrial bx reveals adenocarcinoma. What next step?

Perform surgery staging:
TAH and BSO, pelvic and para-aortic lympadenoecomy and peritoneal washings
+ Radiation therapy: if lymph node metastasis
+ Chemotherapy: if metastasis


Normal endometrial lining stripe in postmenopausal women

Less than 5mm thick


Simple Ovarian Cyst (Luteal or Follicular Cysts)

- most common cyst that occurs during reproductive years
- asymptomatic unless torsion has occurred


Simple Ovarian Cyst: Dx

- B-hCG test: negative
- U/S shows fluid-filled simple cystic mass


Simple Ovarian Cyst: Management

1. F/u exam in 6-8 weeks: steroid contraception prevents new cysts
2. Laparoscopic removal if:
- cyst is > 7 cm diameter or
- there has been previous steroid contraception w/o resolution of the cyst


Complex Cyst: Benign Cystic Teratoma

- benign tumors
- contain cellular tissue from all 3 germ layers
- rarely squamous cell carcinoma can develop


Complex ovarian cyst: diagnosis

- B-hCG is negative
- U/S shows a complex mass


Complex ovarian cyst: management

Laparasopic/laparotomy removal:
- cystectomy (to retain ovarian fxn)
- oophorectomy (if fertility is no longer desired)


Bilateral ovarian enlargement

PCOS is associated with valproic acid


Ovarian hyperthecosis

- refers to nest of luteinized theca cells in ovarian stroma that produce high levels of androgens
- usually postmenopausal woman with severe hirsuitism and virilization


Ovarian hyperthecosis: management

OCPs (both estrogen and progestin) to suppress androgen production by reducing LH stimulation


Luteoma of Pregnancy

- rare, nonneoplastic, tumorlike mass of the ovary that emerges during pregnancy and regresses spontaneously after delivery
- found incidentally during C-section or postpartum tubal ligation
- can be hormonally active and produce androgens, resulting in maternal and fetal hirsutism and virilization


Theca Lutein Cysts

- benign neoplasms are caused by high levels of FSH and B-hCG
- associated with twins and molar pregnancies
- spontaneously regresses after pregnacy


Initial w/u of an ovaran mass

- B-hCG test
- Ultrasound
- Laparoscopy/laparotomy if complex or > 7 cm


31 y/o woman is taken to the ED c/o of severe, sudden lower abdominal pain that started 3 hrs ago. On exam, abdomen is tender, no rebound tenderness is present ands there is an adnexal mass in the cul-de-sac. U/S eval shows an 8cm left adnexal mass. B-hCG negative. Next step in management?

Laparoscopic evaluation of ovaries
- detorsioning of ovaries is needed
- if blood supply no affected, cystectomy can be done
- if there is necrosis, oophorectomy is needed


Ovarian enlargement is pre-pubertal or post-menopausal women is suspicious for...

Ovarian neoplasm


Risk factors of Ovarian Neoplasm

- BRCA1 gene
- Positive family hx
- High + of lifetime ovulations
- Infertility
- Use of perineal talc powder


Protective factors of ovarian neoplasm

Conditions that decrease # of ovulations
- OCPs
- Chronic anovulation
- Breast-feeding
- Short reproductive life


68 y/o F presents with weakness and bloated feeling in her abdomen. She is found to have abdominal distention shifting dullness and large right adnexal mass. Pelvic U/S reveals 7cm irregular and solid mass in the right ovary. Next step in management?

Abdominal CT
- to evaluate mass and confirm presence of ascites (peritoneal seeding)
- if ascites, next step step is laparotomy, oophorectomy, and surgical staging


9 y.o girl presents with R adnexal pain and complex cystic mass on U/S? Dx?

Germ cell tumor - common in young women and present in early stage disease
Tumor markers: LDH, B-hCG, a-FP


67 y/o F presents w/ progressive weight loss, distended abdomen, and left adnexal mass. Dx?

Epithelial tumor - common in postmenopasual women. most common malignant subtype is serous

Tumor markers: CA-125, CEA


58 y/o F presents with postmenopausal bleeding. Endometrial bx shows endometrial hyperplasia. Pelvic U/S reveals R ovarian mass.

Granulosa-theca (stromal tumor): secretes estrogen an can cause endometrial hyperplasia

Tumor markers: estrogen


48 y/o F c/o of increased facial hir and deepening of her voice. An adnexal mass is found on examination. Dx?

Sertoli-Leydig cell (stromal tumor): ovarian tumor secretes testosterone. Pts presents with masculinization syndromes

Tumor markers: testosterone


64 y.o F presents with hx of gastric ulcer and recent worsening dyspepsia presents with weight loss and abdominal pain. An adnexal mass is found. Dx?

Metastatic gastric cancer to the ovary (Krukenberg tumor)

Tumor markers: Mucin-producing tumor from the stomach


Management of prepubertal and post-menopausal ovarian mass

1. Sonogram (and CT scan)
2. Bx via laparoscopy for simple cysts (no septations or solid components) or postmenopausal w/o ascites
3. Tumor markers
4. Cystectomy for benign tissue
5. Premenstrual women: salpingooophorectomy
6. Postmenopausal women: TAH, BSO (and chemo for malignant therapy


HPV associated with cervical cancer

- HPV 16, 18, 31, 33, and 35


HPV associaed with benign condyloma acuminata

HPV types 6 and 11


Indeterminate smears

- atypical squamous cells of undetermined significance (ASCUS)


Abnormal Pap smears: Low-grade squamous intraepithelial (LSIL)

HPV, mild low dysplasia, CIN 1


High-grade squamous intraepithelial lesion (HSIL)

Moderate dysplasia, severe dysplasia, CIS, CIN 2 or 3


Risk factors for Cervical Dysplasia

- Early age of intercouse
- Multiple sexual partners
- Cigarette smoking
- Immunosuppression


When is screening started for cervical dysplasia

Three years after onset of sexual activity or age 21, whichever comes first


Screening used for cervical hyperplasia/cancer

Conventional method
Liquid based prep
HPV DNA testing


Frequency of screening

If < 30 years old, annually for conventional Pap or every 2 years for liquid based

If > 30 years old, screen every 2-3 years if > 3 consecutive negative Pap smears


35 y/o F is referred b/c of a Pap smear reading ASCUS. Pt states that last Pap smear, done approximately 1 yr ago, was negative. She has been sexually active, using combo OCPs from last 4 yrs. A repeat Pap smear after 3 mths again reveals ASCUS. Next step in management?

Colposcopy and ectocervical biopsy
- ASCUS is most inflammation due to early HPV infxn
- two Pap smears revealing ASCUS must be followed by colposcopy and biopsy


Pt has a ASCUS on Pap smear and f/u is certain. Nest step?

Repeat the Pap smear in 3-6 months or order HPV DNA typing
- if the result is negative, f/u is routine
-if repeat Pap smear is again ASCUS or HPV 16 /18 are found, then order colposcopy and biopsies


Pt has ASCUS on Pap smear and f/u is uncertain. Next step?

Colposcopy and biopsies


Endocervical curretage

- indicated for all NONpregnant patients with an abnormal Pap smear
- all nonpregnany pts undergoing colposcopy for an abnormal Pap smears must undergo an ECC to r/o endocervical lesions


Indications for cone biopsy

- Pap smear worse than histology (suggests abnormal cells were not bx)
- Abnormal ECC histology
- An endocervical lesion
- A biopsy showing microinvasive carcinoma of cervix


Management for CIN 1:

Observation and f/u
- F/u repeat pap smears, colposcopy + Pap smear or HPV DNA testing every 4-6 months for 2 years


Management CIN 2 or 3

Ablative therapies: Cyrotherapy, Laser vaporization, electrofulguration

Excisional procedures: LEEP and Cold-knife conization


If biopsy confirmed abnormal histology



Invasive Cervical Cancer

- average diagnosis is 45 years


Invasive Cervical Cancer: Dx

Cervical bx
Metastatic workup: pelvic exam, CXR, IV pyelogram, cystoscopy, and sigmoidoscopy


Most common cause of cervical bx

Squamous cell carcinoma


Management of invasive cervical cancer

Simple hysterectomy


Adjuvant therapy (Radiation therapy and chemotherapy) indications for invasive cervical caner

Metastasis to lymph nodes
Tumor size > 4 cm
Poorly differentiated lesions
Positive margins
Local recurrence


Management of CIN/dysplasia during pregnancy

- Pap smear and colposcopy q 3 months during pregnancy
- Repeat Pap and colposcopy 6-8 weeks postpartum. Any persistent lesios are then definitively treated postpartum


Management of microinvasive cervical cancer during pregnancy

- Cone biopsy to ensure no frank invasion
- Deliver vaginally, reevaluate and treat 2 months postpartum


Management of invasive cancer

Diagnosed before 24 weeks:
- Definitive treatment (radical hysterectomy)

Diagnosed after 24 weeks:
- Conservative management up to 32- 33 weeks
- C- section delivery and begin definite treatment


Prevention of Cervical Dysplasia by Vaccination

- Give quadrivalent HPV vaccine (Gardasil) to all females 8-26
- protects against 4 HPV types (6, 11, 16, 18)
- must still follow Pap smear recommendations


Initial work up for pelvic pain

1. Pelvic pain
2. Cervical culture
3. Lab: ESR (sedimentation rate), WBC (include Blood Cx if fever is present)
4. Sonogram



- diagnosis if cervical discharge is found on routine exam, usually w/o other symtptoms


Management for Cervicitis

1. Get cervical cultures (chlamydia and gonorrhea)

2. Give single dose of oral cefexime and azithromycin


Acute salpingoophoritis

suspected when there is cervical motion tenderness on exam and when patient c/o of lower pelvic pain after menstruation


Acute salpingoophoritis

- Cervical cultures will be positive
- WBC and ESR are elevated
- R/o pelvic abscess with sonogram


Management of acute salpingoophoritis

Outpatient: two orabl abx (ofloxacin and metronidazole)

Inpatient: three IV abx: IV cefotoxin or cefotetan and IV doxycycline or clindamycin and gentamicin)


Chronic Pelvic Inflammatory Disease

- classically presents with infertility or dyspareunia
- may have hx of ectopic pregnancy or abnormal vaginal bleeding
- Cervical cx are negative


Patient has suspected PID. Next step

1. Cervical cultures (expected to be negative)
2. U/S (bilateral cystic pelvic masses - hydrosalpinges)


Management of PID

- Lysis of tubal adhesions, which may be helpful for infertility
- Severe, unremitting pelvic pain may require pelvic clean out (TAH, BSO)


Tuboovarian Abscess

- advanced from for PID
- ill-appearing women w/ severe, llower abdominal/ pelvic pain, back pain, and rectal pain
- WBC and ESR are markedly elevated


Lab findings of tuboovarian abscess

- WBC and ESR are elevated
- Pus on culdocentesis
- Sonogram shows unilateral pelvic mass that appears as multi-locular, cystic and complex adnexal mass
- BCx show anaerobic organisms


Management of tuboovarian abscess

1. Admit to hospital and give IV clindamycin and IV gentamicin
2. If no response within 72 hrs or there is abscess rupture, perform an ex-lap +/- TAH and BSO or percutaneous drainage


When are outpatient antibiotics the answer?

- All cases of cervicitis
- Acute salpingoophoritis when there is no systemic infxn or pelvic abscess


When are inpatient abx the answer?

- Acute salpingoophoritis in a nulligravida or adolescent patient previous outpatient treatment failure, IUD in place, presence odf fever or pelvic abscess
- All cases of tuboovarian abscess


21 y/o F presents ER with lower abdominal pelvic pain starting 1 day ago/ Sx began after her menstrual period completed. She is sexually active but using no contraception. Speculum exam reveals mucopurulent cervical discharge. Bimanual exam shows b/l adnexal tendernss and CMT. She is afebrile/ Her qualitative urinary B-hCG is negative. CBC shows WBC of 14K/ ESR is elevated. Most appropriate management?

Inpatient IV cefotetan, clindamycin and gentamicin

- patient has acute salpingoophoritis.
Her nulligravid status is indication for IV abx triple-therapy


Primary Dysmenorrhea

- diagnosis when case describes recurrent, crampy lower abdominal pain along with N/V and diarrhea during menstruationn
- Sx begin 2-5 years after onset of menstruation (ovulatory cycles)
- no pelvic abnormality


Etiology of primary dysmenorrhea

- excessive endometrial prostaglandin F2. which causes uterine contractions and acts on GI smooth muscle


Management of primary dysmenorrhea

- NSADS (first line tx)
- Combination OCPs (second line)


Secondary Dysmenorrhea

- recurrent, crampy lower abdominal pain with N/V and diarrhea during menstruation
- often occurs during endometriosis, but can occur during adenomyosis or leiomyomas



- presence of endometrial glands outside of the uterus
- seen in women > 30 with dysmenorrhea, dyspareunia, dyschexzia (painful bowerl movements) and infertility


Most common site of endometriosis

- causing adnexal enlargement (endometriomas) also known as chocolate cysts


Second most common site of endometriossis

Cul-de-sac, causing uterosacral ligament nodularity and tenderness on rectovaginal examination
- associated w/ bowel adhesions and a fixed retroverted uterus


Endometriosis: Dx

1. U/S (may show endometrial mass)
2. Laparoscopic visualization
3. Elevated CA-125


Management of endometriosis

Continuous oral progesterone or OCPs (first line)
Testestorones derivatives (Danocrine or Danazol) or GnRH analogs (lupron or leuprolide)
Laparoscopic lysis adhesiosn, laser vaporization
TASH and BSO can be done for severe symptms


Premenarchal Vaginal Bleeding

- bleeding that occurs before menarche
- average age at menarche is 12


Most common cause of premenarchal vaginal bleeding

- Presence of a foreign body
- must r/o sarcoma botryoides


Sarcoma botryoides

- cancer of vagina or cervix suggested a grapelike mass arising from the vaginal lining or cervix
- tumor of the pituitary adrenal gland or ovary and sexual abuse


Premenarchal vaginal bleeding: diagnostic

- perform pelvic exam under sedation
- Order CT or MRI of pituitary, abdomen, and pelvis to estrogen producing tumor
- If workup is negative, it is likely idiopathic precocious puberty


31 y/o F c/o 6 mnths of metromenorrhagia. The patient states that she started menstruating at age 13 and that has had regular menses until the past 6 months. The pelvic exam, including a Pap smear, is normal. She has no other significant personal or family hx. What is next step in management?

Obtain B-hCG


Primary Amenorrhea

- diagnosed w/ absence of menses at age 14 w/o secondary sexual development OR at age 16 w/ secondary sexual development


Primary amenorrhea: diagnostic tests

Physical Exam and U/S
- are breasts present? Breasts indicate adequate estrogen production
- is a uterus present or absent on U/S?

Karyotype, testosterone, FSH


Primary amenorrhea:
- breasts present
- uterus present

Workup as secondary amenorrhea
- Imperforate hymen
- Vaginal septum
- Anorexia nervosa
- Excessive exercise
- Pregnancy before the 1st menses


Primary amenorrhea
- breasts present?
- uterus absent?

Order testosterone levels and karyotype
- Mullerian agenesis (XX karyotype, normal testosterone for female)
- Complete androgen insensivity (testicular feminization)
- XY karyotype, normal testosterone for male


Primary amenorrhea
- Breast absent
- Uterus present

Order FSH level and karyotype
- Gonadal dysgenesis (Turner's syndrome) - XO karyotype, FSH elevated
- Hypothalamic-pituitary failure (XX karyotype, FSH low)


Primary amenorrhea
- Breast absent
- Uterus absent

- not clinically relevant


17 y.o F is brought to the clinic by her mother concerned b/c her daughter has never had a menstrual period/ She reports that her daughter has good grades, studies hard but seems stressed out most of the time which is why she believed her period was delayed. On exam she seems to be well-nourished w/ adult present development and pubic hair present. Physcial exam reveals foreshortened vagina. No uterus sen on U/S. Most appropriate advice

Vaginal reconstruction may be performed
- Patient has Mullerian agenesis (no uterus, cervix, or upper vagina)


Mullerian Agenesis

- karyotype reveals normal female secondary characteristics
- normal estrogen and testosterone levels (ovaries are intact)
- absence of Mullerian duct derivatives (fallopian tubes, uterus, cervic, and upper vagina)
- management involves surgical elongation of vagina


Androgen Insensitivity

- diagnosed when there is NO PUBIC OR AXILLARY HAIR
- karyotype reveals male karyotype
- U/S shows testes
- testes produces normal amts of estrogen for female and normal amts of testosterone for male
- involves removal of testes before age 20 b/c of risk of testicular cancer


Gonadal Dysgenesis (Turner Syndrome, XO)

- karyotype shows absence of one X chromosome
- absence of secondary sexual characteristics b/c 2nd X is needed for ovarian follicles
- streak gonads
- elevated FSH
- management involves estrogen and progesterone replacement for development of 2ndary sexual characteristics


Hypothalamic-Pituitary Failure

- diagnosed there is no sexual characteristics but uterus normal on U/S
- low FSH
- may be due to stress, excessive exercise, or anorexia nervosa
- management involves estrogen and progesterone replacement for development of 2ndary sexual characteristics


Kallmann syndrome

- hypothalamic-pituitary failure
- associated with anosmia (hypothalamus doesn't produce GnRH)


Secondary amenorrhea

- regular menses replaced by absence of menses for 3 months
- irregular menses replaced by absence of menses for 6 months


Secondary Amenorrhea: Workup

1. Pregnancy test (B-hCG)
2. TSH to r/o hypothyroidism
3. Prolactin levels to r/o elevation 2/2 pituitary tumor or meds
4. Progesterone Challenge Test
5. Estrogen-Progesterone Challenge Test


Why does primary hypothyroidism connect to secondary amenorrhea

An elevated TRH in primary hypothyroidism leads to increased prolactin


Prolactin: secondary amenorrhea

1. Review meds: antipsychotic and antidepressants have antidopamine leads to increased prolactin
2. CT or MRI to r/o pituitary tumor
3. Idiopathic prolactin elevation, treat w/ bromocriptine


Pituitary tumor: treatment

- Tumor < 1 cm; give bromocriptine (dopamine agonist)
- Tumor > 1cm; treat surgically


Positive progesterone Challenge Test

Any withdrawal bleeding is diagnostic of anovulation
- treat cyclic progesterone to prevent endometrial hyperplasia.
- clomiphene ovulation induction is done if pregnancy is desired


Negative progesterone challenge test

Inadequate estrogen or outflow tract obstruction


Estrogen-Progesterone Challenge Test

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


Positive Estrogen-Progesterone Challenge Test

Any withdrawal bleeding is diagnostic of inadequate estrogen. Next step is get an FSH level

- decr. FSH (HPA insufficiency). Order brain tumor via CT


Secondary amenorrhea:
Positive estrogen-progesterone challenge test + incr. FSH (ovarian failure).

Y chromosome may be cause if pt < 25 yrs. Order a karyotype confirmation


Secondary amenorrhea:
positive estrogen-progesterone challenge test + decr. FSH

Hypothalamic-pituitary failure
- Order brain CT/MRI to r/o a tumor.
- Give estrogen-replacement therapy to prevent osteoporosis


Secondary amenorrhea:
negative estrogen-progesterone challenge test

Outflow tract obstruction or endometrial scarring (e.g. Asherman syndrome)
- Hysterosalpingogram to ID lesion
- Management: Adhesion lysis followed by estrogen stimulation


Premenstrual Tesnsion

- distressing physical, psych, and behaviorial symptpms recurring at same phase of menstrual cycle and disappearing during remainder of cycle


Premenstrual Dysphoric Disorder (PMDD)

- more severe, involving major disruptions to daily functioning and relationships


PMDD: treatment

- SSRIs (treatment of choice)
- low doses of Vitamin B6 (pyroxidine) may improve sx



- excessive male pattern hair growth in a woman



- excessive male patter hair growtih in a woman plus masculinixing signs (cliteromegaly), baldness, lowering of voice, increasing muscle mass, and loss of female body contours


Initial workup in hirsutism

- Testosterone
- 17-hydroxyprogesterone


Polycystic Ovarian Syndrome

- gradual onset hirsutism, obesity, acne, irregular bleeding, and infertilit


PCOS: Diagnostic Tests

- mostly clinical
- elevated LH/FSH ratio for confirmation
- bilaterally enlarged ovaries will found on exam and U/S


PCOS: Anovulation

- no corpus luteum production of progesterone LEADS TO
- unopposed estrogen LEADS TO
- hyperplastic endometrium and irregular bleeding LEADS TO
- predisposition to endometrial cancer


PCOS: Increased testosterone

- Increased LH levels LEADS TO increased theca cell production of androgens LEADS TO hepatic production of SHBG is suppressed LEADS TO increased total testosterone and increased free testosterone


PCOS: ovarian enlargement

U/S shows a necklacelike pattern of multiple peripheral cysts
- increased androgens LEADS TO multiple follicles in various stages of development, stromal hyperplasia


Anovulation: Ddx

- Hypothyroidism
- Pituitary adenoma
- Elevated prolactin
- Medication (e.g. antipsychotic meds)


PCOS: Diagnostic Tests

- LH:FSH = 3:1
- Mildly elevated testosterone level
- Pelvic U/S shows bilaterally enlarged ovaries w/ multiple subcapsular small follicles and increased stromal echogenecity


PCOS: Treatment

- OCPs treats irregular hirsutism and bleedng
- SPIRONOLACTONE - suppresses hair follicles
- CLOMIPHENE CITRATE or HMG treatment of infertility
- METFORMIN enhances ovulation and manages insulin resistance


Rapid onset hirsutism and virilization w/o family hx. Next step?

U/S to look for adnexal mass
CT scan to look for adrenal tumor


Rapid onset hirsutism and virilization w/o family hx. Likely dx?

Adrenal tumor (elevated DHEAS)
Ovarian tumor (elevated testosterone)


Congenital Adrenal Hyperplasia

- gradual onset hirsutism w/o virilization in teens and 20s associated w/ menstrual irregularities and anovulation
- elevated 17-hydroxyprogesterone
- management involved in corticosteroid replacement to stop androgenicity and restore ovulatory cycles


Idiopathic Hirsutism

- hirsutism and no virilization
- all lab tests are normal
- most common cause of hirsutism


Idiopathic Hirsuitism: Treatment

- Spironolactone (1st line treatment)
- Eflornithine (Vaniqa) -1st line topical drug for unwanted facial hair and chin hair


Pt c/o hirsutism with elevated testosterone, normal DHEAS, increased LH, decreased FSH, and normal 17-hydroxyprogesterone. Next step?

U/S to r/o other disorders/tumors
- likely PCOS
- screen lipids and fasting blood glucose


Pt c/o hirsutism w/ normal testosterone, normal DHEAS, normal LH/FSH, and very elevated 17-hydroxyprogesterone. Next step?

ACTH stimulation
- likely congenital adrenal hyperplasia
- confirms the diagnosis


Pt c/o hirsutism w/ very elevated testosterone, normal DHEAS, normal LH/normal FSH, and normal 17-hydroxyprogesterone. Next step?

U/S and CT to image tumor
- likely ovarian tumor


Pt c/o hirsutism w/ elevated testosterone, very elevated DHEAS, normal LH, normal FSH, and normal 17-hydroxyprogesterone. Next step?

U/S or CT to image tumor
- likely adrenal tumor



- 12 months of amenorrhea w/ elevation of FSH and LH
- mean age of 51 years old
- smokers experence menopause up to 2 years earlier


Menopause: Diagnostics

- serial levels of elevated gonadotropins (FSH > 50 IU/ml)


Early menopause

- occurs between 40 and 50
- often idiopathic but can occur after radiation therapy or surgical oophorectomy


Premature ovarian failure

- occurs before 30
- associated w/ autoimmune disease or Y chromosome mosaicism


Amenorrhea during menopause

- menses become anovulatory and decrease in 3-5 years period known as perimenopause


Hot flashes during menopause

- unpredictable, profuse sweating and heat that occurs in 75% in women
- obese less likely to undergo hot flashes (due to peripheral conversion of androgens to estrone)


Reproductive tract during menopause

- decreased vaginal lubrication, increased vaginal pH, and increased vaginal infections can occur


Urinary tract during menopause

- increased urgency, frequency, nocturia, and urge incontinence


Most common cause of mortality in postmenopausal women

Cardiac disease



- common in postmenopausal thin, white women with positive family history
- treat w/ calcium and Vitamin D, weight-bearing exercise


Most common site of symptomatic osteoporosis

Vertebral bodies leading to crush fracture, kyphosis, and decreased height
- hop and wrist fractures are next frequent sites


Osteoporosis: Diagnostic Testing

- DEXA scan to assess bone density (T >/= -2.5)
- 24 urine hydroxyproline or NTX to assess calcium loss


Osteoporosis: Treatment

Bisphosphonates and SERMS (1st line therapy)
- Bisphosphonates inhibits osteoclastic activity
- SERMS increase bone density
Calcitonin, denosumab
Teraparatide is a PTH analog


SERMS use in osteoporosis

protective against heart and bones but not effective for vasomotor symptoms


Tamoxifen (Nolvadex) in osteoporosis

endometrial and bone agonist effects but breast antagonist effects


Raloxifene (Evista) in osteoporosis

bone agonist effects but endometrial antagonist effects


Indications for HRT

- Menopausal vasomotor symptoms (hot flashes)
- Genitourinary atrophy
- Dyspareunia


Contraindications for HRT

Tx of osteoporosis
Describes hx of:
- estrogen-sensitive cancer
- liver disease
- active thrombosis
- unexplained vaginal bleeding


Which postmenopausal women can be given continuous estrogen for hormone therapy?

Women w/o uterus


Why are women w/ uterus given progestin therapy for hormone replacement therapy?

Must be given progestin to prevent endometrial hyperplasia


Benefits of HRT

- Decreases risk of osteoporotic fractures
- Decreases rate of colorectal cancer


Risks of HRT

- increases risk of CVT
- increases risk of heart attacks and breast cancer
** risks occur w/ therapy > 4 years


Guidelines for HRT

- only use for vasomotor symptoms in menopause
- never use to prevent CV symptoms
- use lowest dose of HRT
- use shortest duration of HRT to treat symptoms
- don't exceed 4 yrs of therapy


Barrier contraception

- protective against STDs


Steroid contraception (e.g. estrogen + progesterone) Contraindications

- pregnancy
- acute liver disease
- hormone dependent cancer
- Smoker > 35
- Migraines w/ aura
- DM w/ vascular disease
- Thrombophilia
- Uncontrolled HTN


Steroid contraceptive benefits

- Decreased ovarian and endometrial CA
- Decreased dysmenorrhea
- Decreased DUB
- Decreaed ectopic pregnancy


Intrauterine Device (e.g. levonorgestrel)

- effective and avoids side effects of hormonal atherapy


Absolute contraindications of IUD

- pelvic malignancy
- salpingitis
- pregnancy


35 y.o woman comes to GYN's office c/o infertility for 1 yr. She and her husband has been trying to achieve pregnancy for 1 year and have been unsuccessful/ No hx of PID and has used OCPs for 6 years. Semen analysis is low and shows decreased sperm density and low motility. Next step in management?

Repeat semen analysis
- abnormal semen analysis is repeated in 4-6 weeks



- inability to achieve pregnancy after 12 months of unprotected and frequent intercourse


Infertility workup

1. Semen analysis
2. If semen analysis is normal, work up for anovulation
3. If semen analysis is normal and ovulation is confirmed, then work up for fallopian tube abnormalities


Normal semen analysis

- Volume: > 2m:
- pH 7.2 - 7.8
- sperm density: > 20 million/mL
- sperm motility: 50%
- sperm morphology: > 50% normal


If patient submitted 2 abnormal semen samples 4-6 weeks apart, next step?

Pursue fertility options such as:
- intrauterine insemination
- intracytoplasmic sperm injection


Anovulation workup

- Basal body temperature: no midcycle temp elevation
- Low progesterone
- Proliferative histology on endometrial bx


Common causes of anovulation

- Hypothyroidism
- Hyperprolactinemia


Ovulation induction

- Clomiphene citrate
- Human menopausal gonadotropin (used if clomiphene fails)
- Monitor for ovarian hyperstimulation leads to increased ovarian size


Diagnosing tubal abnormalities

1. Check for chlamydia IgG antibody test to r/o infection induced tubal adhesions
2. Hysterosalpingogram ( HSG ) to check for normal anatomy
3. Laparoscopy: if HSG is abnormal to visualize oviducts and attempt tuboplasty


Unexplained infertility

- normal semen analysis, ovulation confirmed, and no tubal abnormalities
- no treatment indicated
- 60% patients achieve spontaneous pregnancy within 3 years



1. Eggs aspirated from ovarian follicles using U/S guided transvaginal approach
2. Fertilied w/ sperm in lab, resulting in embryos
3. Multiple embryos transferred into uterine cavity


Gestational Trophoblastic Disease

- abnormal proliferation of placental tissue involving both cytotrophoblast and/or syncytiotrophoblast



- most common in Taiwan and Phillipines
- risk factors include age extremes (< 20 years old and > 35 yerars old) and folate deficiency


GTN: Presentation

- Bleeding < 16 weeks gestation
- Passage of vesicles from vagina
- may see HTN, hyperthyroidism, and hyperemesis gravidarum and no fetal heart tones appreciated


GTN: Signs

- Fundus larger than dates
- Absence of fetal heart tones
- Bilateral cystic enlargement of ovaries (theca-lutein cysts)


Most common site of distant metastasis for GTN



Complete molar pregnancy

- empty egg
- 46, XX
- fetus absent
- 20% are malignant
- treat w. no chemotherapy but serial B-hCG until negative
- F/u for 1 year on OCP


Partial molar pregnancy

- Normal Egg
- 69, XXY (triploidy)
- fetus nonviable
- 10% are malignant
- treat w/ no chemotherapy but serial B-hCG until negative
- F/u for 1 year on OCP


32 y.o Filipino woman is 15 weeks' pregnant by dates. She presents w/ painless vaginal bleeding associated w/ severe nausea and vomiting. Her uterus extends to umbilicus but no fetal heart tones appreciated. Her blood pressure is 162/98 mm Hg. Dipstick urine shows 2+ proteinurisa. Which of the following is likely diagnosis?

Molar pregnancy


GTN: Diagnostic Testing

- reveals homogenous intrauterine echos w/o a gestational sac or fetal parts
- "snowstorm" ultrasound


GTN: Management

- Baseline qualitative B-hCG titer
- Chest X-ray (r/o lung metastasis)
- Suction dilation and curretage (D&C)
- Place patient on effective contraception to ensure no confusion w/ recurrent disease or pregnancy