Gynecology (Tony's) Flashcards

Question

What is a lateral episiotomy

Answer 1

Controlled incision of pelvic diaphragm

Answer 2

due to damage during childbirth in female or prostatectomy in males, increasing risk of organ prolapse in female, primary uterus and bladder prolapse organ prolapse lead to urinary and fecal incontinence in both genders

Answer 3

Inside aspect of sacrospinous ligament

Answer 4

pubococcygeus and iliococcygeal muscle form shelf like portion of pelvic floor behind the anus

Answer 5

Rectouterine pouch where pus and fluid collects, which can be drained through posterior fornix

Answer 6

Mesoosalpinx Mesometrium Mesovarium

Answer 7

Peritoneum drapes over the uterus, uterine tube and ovary superiorly

Answer 8

Covering that separates the uterus from the bladder

Answer 9

Fascial ligament that anchors side of cervix to pubic symphysis

Answer 10

Deep - underneath the broad ligament (peritoneum) that support the position of the uterus Part of the parametrium Pubocervical ligament, transverse cervical ligament, uterosacral ligament

Answer 11

Anchor side of cervix to pubic symphysis

Answer 12

aka Mackenrodt or transverse cardinal ligament Provides central cervical support and carries the uterine artery Ureter inferior to the transverse cervical ligament/uterine artery

Answer 13

Anchor cervix posteriorly to sacrum

Answer 14

Tethers ovary to uterus

Answer 15

Tethers uterus through inguinal canal to labia majora

Answer 16

Initial narrowing from body of uterus to cervix

Answer 17

4 layers from superficial to deep 1) Parametrium - supporting fibrous fascia (transverse cardinal/cervical ligament, uterosacral ligament, pubovesical ligament) 2) Perimetrium - peritoneal coat overlying uterus, continuous with mesometrium of broad ligament 3) Myometrium - smooth muscle 4) Endometrium - internal mucosa

Answer 18

Angle between vaginal and cervical axis

Answer 19

Angle between uterine body axis and cervical axis

Answer 20

Anteverted and anteflexed

Answer 21

Infundibulum --> ampulla --> isthmus --> intrauterine part --> horns of uterus

Answer 22

Ovarian fossa, medial to external iliac vessel and anterior to ureter and internal iliac artery

Answer 23

4 vaginal fornices - 1 anterior, 1 posterior, 2 lateral

Answer 24

Mesentery overlying ovarian artery and ovarian vein

Answer 25

Ovarian artery from abdominal aorta | Ovarian vein drains into IVC

Answer 26

Uterine artery from internal iliac artery | Uterine vein drains into internal iliac vein

Answer 27

Vaginal artery from internal iliac artery and internal pudendal artery from internal iliac artery (feeds distal vaginal canal in perineum) Vaginal and internal pudendal veins drain into internal iliac vein

Answer 28

Internal iliac artery with anterior and posterior division Anterior - supplies pelvic viscera Anterior division includes umbilical artery, superior vesicle artery, uterine artery, vaginal or inferior vesicle artery and middle rectal artery and internal pudendal artery Posterior division goes to body wall, lower limb muscles, perineum

Answer 29

Pass above ureter Tortuous Runs in transverse cardinal ligament

Answer 30

Feeds superior aspect of bladder and comes off umbilical artery

Answer 31

Feeds inferior aspect of bladder and superior vagina

Answer 32

Feeds rectum above pelvic diaphragm

Answer 33

Feeds distal rectum and vagina in perineum

Answer 34

Feeds rectum below pelvic diaphragm

Answer 35

Ovaries, uterus, superior vagina innervated by autonomic nerve supply Sympathetic T12-L2 to pelvic splanchnics - Synapse at pre-vertebral ganglia or abdominal aortic plexus --> travel with ovarian blood vessels to ovary - hypogastric/pelvic plexus to uterus and superior vagina Parasympathetic pelvic splanchnics S2-S4

Answer 36

Motor nerves and sensory innervation from pudendal nerve (S2-4)

Answer 37

splanchnic nerves are paired visceral nerves (nerves that contribute to the innervation of the internal organs), carrying fibers of the autonomic nervous system (visceral efferent fibers) as well as sensory fibers from the organs (visceral afferent fibers).

Answer 38

Uterine body above pelvic pain line - visceral pain travels with sympathetics to T12-L2 region Uterine cervix and upper vagina below pelvic pain line - visceral pain travels with parasympathetic to S2-4 Low vagina travels with somatic pudendal nerve S2-4

Answer 39

Spinal block - block lumbar splanchnic nerve (T12-L2), pelvic splanchnic nerve (S2-4) and pudendal nerve (S2-4) blocking all sensation from waist down Caudal epidural block from pelvic splanchnic (S2-4) and pudendal nerve S2-4 results in loss of sensation of uterine cervix and vagina Pudendal nerve block of pudendal nerve S2-4 results in loss of somatic sensation of vagina only

Answer 40

Most lymph to back body wall to chyle cistern to thoracic duct Lymph from distal vagina, labia majora and perineum drains superficially to superficial inguinal lymph nodes Some parts of uterus associated with round ligament can drain to superficial inguinal lymph nodes

Answer 41

Middle sacral artery - midline sacrum, from aorta prior to bifurcation Lateral sacral artery - feeds sacrum from lateral aspect Iliolumbar artery - ascends on back body wall Superior gluteal artery - leaves pelvis above the piriformis between lumbosacral trunk and S1 Inferior gluteal artery - leaves pelvis below piriformis Internal pudendal artery - leaves pelvis, loops around pelvic diaphragm to access perineum Obturator artery - travels with obturator nerve through obturator canal Umbilical artery - obliterated artery that gives off superior vesicle artery prior to becoming occluded

Answer 42

1. Superior vesicle artery 2. Uterine artery 3. Inferior vesicle/vaginal artery 4. Middle rectal artery 5. Internal pudendal artery (penetrates pelvic diaphragm to access perineum) 6. Inferior rectal (can alternatively branch off internal pudendal artery)

Answer 43

1. Hypothalamus secretes GnRH in pulsatilla manner 2. GnRH stimulates anterior pituitary to secrete FSH and LH in pulsation fashion 3. FSH and LH stimulate ovaries to produce estrogen and progesterone as well as ovulation

Answer 44

- amplitude and frequency of pulses determines predominant LH or FSH secretion by anterior pituitary - Follicular phase: GnRH pulses become faster to prepare for the future LH surge and high LH in literal phase - In literal phase pulses become slower to prepare for future high FSH in follicular

Answer 45

3 negative feedback loops 1. Long loop - estrogen and progesterone decrease release 2. Short loop - FSH and LH decrease GnRH release 3. Ultra short loop - GnRH inhibits its own release

Answer 46

Targets granulosa cells in ovary causing follicular growth and estrogen production

Answer 47

LH surge stimulates ovulation LH targets theca cells and corpus luteum LH stimulate thecca cells to produce testosterone, which can be converted to estrogen by granulosa cells LH stimulates corpus luteum to produce progesterone as well as estrogen

Answer 48

Estrogen and progesterone are sex steroid hormone derived from cholesterol and produced in ovarian follicles Estrogen level varies depending on stage of menstrual cycle Low (<50) at menstruation Increases with follicular development and peaks at 200 At end of literal phase, estrogen drops to menstrual levels Progesterone level varies depending on stage of menstrual cycle Low <2 before ovulation and high >5 after ovulation

Answer 49

Enclosed in germinal epithelium Outer cortex contains follicles, corpora lutes and corpora albicans Inner medulla composed of connective tissue where blood vessels, lymph vessels and nerves enter the ovaries

Answer 50

1. Produce oocytes that are ovulated into Fallopian tube | 2. Produce reproductive hormones including estrogen and progesterone

Answer 51

Cholesterol —> progesterone —> testosterone —> estrogen Progesterone produced in all major ovarian cells (granulosa, theca, interstitial, corpus luteum) Testosterone produced in theca, interstitial and corpus luteum Estrogen produced by granulosa cells and corpus luteum

Answer 52

Aromatase (lacking in the a cells)

Answer 53

Stimulate follicular development and onset of puberty

Answer 54

Estratriol

Answer 55

Determines the dominant follicle Non-dominant follicles - inability to convert T to E leading to more androgen and follicular atresia Dominant follicle - ability to convert

Answer 56

1. Activism from granulosa cells stimulates FSH secretion 2. Inhibin from granulosa cells inhibits FSH secretion 3. Follistatin from granulosa cells neutralizes activism, thereby inhibiting FSH secretion

Answer 57

1) ovarian germ cells (oogonia) multiplies by mitosis until ~20 weeks gestation 2) at birth, oogonia (2n) enter meiosis I and arrest in prophase, becoming primary oocyte (2n) in a primordial follicle 3) at start of each menstrual cycle ~15-20 primordial follicles are recruited and develop into primary follicles, which is independent of FSH 4) during follicular phase, primary follicles develop into secondary, then one follicle will mature into tertiary follicle 5) before ovulation, LH surge allows primary oocyte (2n) to complete meiosis 1, becoming secondary oocyte (1n) that is halted in meiosis 2 metaphase plus 1st polar body 6) at ovulation, secondary oocyte (1n) exits ovaries and enters fallopian tubes 7) if ovulated secondary oocyte (1n) is fertilized with sperm, then secondary oocyte completes meiosis 2 to become an ovum, which joins sperm to form zygote

Answer 58

goal of menstrual cycle is to produce a single, mature, fertilizable oocyte as well as provide right environment for it to implant and develop

Answer 59

2 cycles: ovarian and endometrial cycle normal menstrual cycle usually 28 days endometrial cycle 1. day ~1-5 menstruation, part of proliferative phase 2. day ~6-13 proliferative phase 3. day 15-28 secretory phase ovarian cycle 1. day ~1-13 follicular phase 2. day ~14 ovulation 3. day ~15-28 luteal phase during menstrual cycle, female is fertile from ovulation day -3 days to ovulation +1 day -3 days, because sperm can live in fallopian tube for 3 days +1 day, because ovulated ovum is viable for ~1 day length of follicular phase may vary, but length of luteal phase should be fixed at ~14 dayS

Answer 60

0) all follicles begin as primordial follicle primordial follicle = oocyte surrounded by layer of flattened granulosa (follicular) cells ovary start with all of its primordial follicles at birth, which then slowly depletes over time primordial follicle contain a primary oocyte (2n) (primary oocyte are arrested at meiosis I prophase) 1) primordial follicles will develop into primary follicle, then secondary follicle development from primordial follicle to secondary follicle is gonadotropin (LH & FSH) independent and occurs with time at any time, only a small portion of primordial follicles are developing to become primary follicle then secondary follicle primary follicle result in: - larger primary oocyte with a zona pellucida - granulosa cells proliferating forming layers around oocyte - interstitial cells close to growing follicles form the theca cells 2) under high FSH and high LH in follicular phase, a secondary follicle develops into tertiary (Graafian or astral or pre-ovulatory) follicle high FSH stimulates many primary follicles to start development to secondary follicles the fastest primary follicle that develops into secondary follicle at first becomes the dominant follicle dominant follicle increase production of estrogen, that inhibit FSH, such that rest of the developing primary follicles die non-dominant follicles also cannot convert testosterone into estrogen resulting in high testosterone that stimulates follicular atresia dominant follicle further increase estrogen that trigger LH surge FSH stimulates proliferation, production of estrogen, increased FSH receptor and inhibin production in granulosa cells LH stimulates testosterone from theca cells, which then is converted to estrogen by granulosa cells secondary follicle has -formation of antrum, cumulus granulosa cells (surrounding oocyte) and mural granulosa cells (in the periphery) -growth of granulosa and theca cell compartments -increased vascularization of theca layer -still a primary oocyte FSH with high estrogen increase expression of LH receptor on granulosa cells, preparing the peripheral granulosa cells to become corpus luteum that is responsive to LH 3) LH surge result in ovulation the high estrogen (>200) by dominant tertiary follicle cause LH surge LH stimulates the primary oocyte (2n) to complete meiosis I to become a secondary oocyte (1n) LH stimulates progesterone production by granulosa cells LH surge results in ovulation of the tertiary oocyte into fallopian tube by increasing antral fluid and stimulating release of hydrolytic enzymes the secondary oocyte with corona radiata granulosa cells are released into peritoneal cavity to be picked up into fallopian tube the rest of follicle (peripheral granulosa and theca cell layers) remains in follicle and become vascularized with capillaries to become corpus luteum 4) corpus luteum forms and produce progesterone and estrogen in luteal phase corpus hemorrhagim -> corpus luteum -> corpus albicans corpus luteum secretes progesterone and estrogen corpus luteum contains large luteal cells (granulosa cell derived) and small luteal cells (theca cell derived) that produce progesterone and testosterone the high progesterone increases basal body temperature during luteal phase corpus luteum is temporary (lasts 14 days) and will disintegrate into corpus albicans due to decline in LH release of HCG from fertilization and implantation can rescue corpus luteum, which is them taken over by placenta after 4-5 months

Answer 61

1) menstruation at day 0-5 due to low estrogen and progesterone progesterone withdrawal results in shedding of endometrium 2) proliferative phase at day 5-14 due to high estrogen follicles produce high estrogen, which stimulate proliferation of endometrial cells increasing endometrial thickness 3) secretory phase at day 14-28 due to high progesterone corpus luteum secrete high progesterone, which cause endometrial hypertrophy, thickening of spiral arteries and glycogen secretions from glands endometrium is thickest at secretory phase the endometrium at secretory phase is optimal for implantation endometrium most optimal for implantation about ovulation + 7 days 4) return to menstruation disintegration of corpus luteum result in low estrogen and progesterone, causing endometrium to shed progesterone withdrawal is mainly responsible for normal menstrual bleeding

Answer 62

4 MOA by progesterone: 1. Inhibiting ovulation (main mechanism) 2. Change cervical mucous which blocks sperm 3. Cause pseudo decidualization of endometrium to inhibit implantation 4. Inhibit tubal peristalsis to inhibit fertilization

Answer 63

Estrogen does not contribute to mechanisms of contraception and is added to prevent breakthrough bleeding

Answer 64

1) start on 1st Sunday after menses to have period free weekends 2) start on day 1 of that month 3) quick start ASAP (recommended)

Answer 65

Can cause unscheduled bleeding

Answer 66

Any change to traditional 21/7 regimen is reasonable as long as there is no more than 7 days without hormones

Answer 67

smoker (>15 cigarettes / day) and over age 35 <6 weeks postpartum if breastfeeding history of current or past venous thromboembolism (VTE) current breast cancer uncontrolled hypertension (diastolic >100 or systolic >160) ischemic heart disease complicated valvular heart disease history of cerebral vascular accident (CVA) aka stroke migraine headache with focal neurological symptoms over age of 35 and migraine without aura (i.e. focal neurological symptoms) diabetes with end organ involvement severe cirrhosis, liver tumor, or active viral hepatitis known thrombophilia systemic lupus erythematous (SLE) with positive anti-phospholipid antibody (APLA)

Answer 68

OCP can be prescribed to anyone with family history of cancer OCP can be prescribed without a pelvic exam

Answer 69

Short term benefits - regulation of cycle - decreased bleeding - decreased dysmenorrhea, premenstual syndrome, acne, hirsutism Long term benefit - decrease risk of endometrial and ovarian cancer - decrease risk of benign breast disease - decrease risk of colorectal cancer - decrease risk of acute PID and ectopic pregnancy - dec risk of ovarian cyst - amerliorate endometriosis

Answer 70

most women using OCP report no adverse effects common adverse effects: headache, nausea, breast tenderness usually mild, transient and self resolves in few months less common adverse effects: decreased libido, unscheduled bleeding, mood changes rare adverse effects: stroke, MI, VTE, increased risk of cervical cancer

Answer 71

Thickening of cervical mucous to block sperm

Answer 72

When combined hormone contraceptive is contraindicated such as breastfeeding women, women with VTE

Answer 73

1 pill every day at same time (3 hour window) with no sugar pill week Back up contracceptive x2 days if pill was taken late Menstruation continues if baseline mensturation is regular

Answer 74

Irregular bleeding Worsening mood disorder such as depression

Answer 75

1) inhibit ovulation 2) thickening of cervical mucus to block sperm 3) pseudo-decidualization (atophy) of endometrium that inhibit implantation

Answer 76

Intramuscular injection once every 3 months breakthrough bleeding in first 3-6 months is normal, which usually can be treated with estrogen or NSAID, and can be ameliorated by shorter interval of injection 2 week forgiveness, where injection is still effective up to 14 weeks if >14 weeks since last injection, do urine pregnancy test to rule out pregnancy, give injection and use back up contraception for 7 days

Answer 77

known or suspected pregnancy (progesterone is not a teratogen, but pregnancy would make injectable progestin meaningless) unexplained vaginal bleeding current diagnosis of breast cancer

Answer 78

menstrual cycle disturbance including irregular non-stop bleeding or amenorrhea especially in first 3 months of use after 1 year of use, ~50% develop amenorrhea after 2 years of use, ~75% develop amenorrhea weight gain due to increased appetite decreased bone density delay to fertility: return to fertility after 9 months on average post discontinuation of injectable progestin

Answer 79

injectable progestin also used to treat menorrhagia, dysmenorrhea, endometriosis, chronic pelvic pain menstrual suppression, inducing amenorrhea to treat menses-related symptoms, anemia and hygienic concerns decrease risk of ovarian and endometrial cancer decrease incidence of seizure

Answer 80

``` known or suspected pregnancy puerperal sepsis (infection and fever post childbirth or miscarriage) immediate post septic abortion current pelvic inflammatory disease, purulent cervicitis, chlamydia, gonorrhea cervical or endometrial cancer current breast cancer unexplained vaginal bleeding distorted uterine cavity anatomy malignant trophoblastic disease ```

Answer 81

unscheduled vaginal bleeding, which usually improve with time LNG-IUS tend to decrease menstrual bleeding copper IUD tend to increase menstrual bleeding pain or dysmenorrhea uterine perforation (0.1% risk) infection (relative risk of 4 in first 3 weeks after insertion then return to normal baseline) expulsion of device (5% of cases) failure resulting in pregnancy, which may have increased risk of ectopic pregnancy LNG-IUD cause hormonal side effects and functional ovarian cyst

Answer 82

Main mechanism is prevention of fertilization Other mechanisms: foreign body reaction endometrial change that adversely affects sperm transport copper directly inhibits sperm motility and reduces sperm penetration through cervical mucous inhibits implantation

Answer 83

Progesterone

Answer 84

main mechanism of action is prevention of fertilization other mechanisms of action include thickening of cervical mucus by progesterone to block sperm suppress endometrial estrogen and progestin receptor inhibit ovulation by progesterone in some women inhibit implantation induce endometrial changes

Answer 85

Contraception 3-5 years Treat heavy menstrual bleeding

Answer 86

need to use contraception for 3 months after operation and until 2 consecutive semen analysis confirms azospermia

Answer 87

insertion of alloy coil into fallopian tube via hysteroscope, which induce fibrosis and occlusion in Fallopian tube need to do hysteosalpingography radiographic imaging to confirm tubal occlusion must use contraception until occlusion is confirmed complications include failure to successfully place, perforation of fallopian tube / uterus and expulsion of coil

Answer 88

Yuzpe method (estrogen + progesterone) Plan B/Norlevo (Progestin only) Copper IUD

Answer 89

Most effective emergency contraception (effective up to 7 days post unprotected sex exposure) Then plan B then Yuzpe

Answer 90

Protesterone only

Answer 91

inhibit ovulation change endometrium to inhibit implantation disrupt luteal phase effect on tubal transport time however, does not disrupt an established pregnancy, so it is not effective with more time elapsed from sexual intercourse

Answer 92

earlier use increase effectiveness, best within 5 days of unprotected sexual intercourse plan B have 2 tablets both tablets at same time (preferred method) or one table followed by the other 12 hours later

Answer 93

absence of menstruation for at least 3 cyclic lengths

Answer 94

Cyclic length >35 days

Answer 95

failure to reach menarche (amenorrhea and no pubertal development by 14 years of age; or amenorrhea with secondary sexual characteristics by age 16)

Answer 96

previously menstruating and cessation of menses (cessation of regular menses for 3 normal menstrual cycles or 6 months), typically in patient age <40

Answer 97

causes can be classified to physiologic, other endocrinopathies, medication, hypothalamus - pituitary - ovary - uterus - outflow tract physiologic: pregnancy, breast feeding, menopause other endocrinopathies: thyroid disease (hypothyroidism, hyperthyroidism), adrenal disease (adrenal insufficiency, adrenal hyperplasia), hyper-androgenism (congenital adrenal hyperplasia, androgen secreting tumor), Cushing’s syndrome, constitutional delay of puberty medication: contraception containing estrogen and / or progesterone, anti-depressants, anti-hypertensive, anti-psychotics, opiates hypothalamus: hypothalamic tumor, functional suppression of hypothalamus, gonadotropin releasing hormone (GnRH) deficiency, infection (meningitis, TB, syphilis), traumatic brain injury functional suppression of hypothalamus-pituitary-varian axis due to physical stress on body including rapid weight loss, eating disorder, malabsorption, excessive exercise, stress pituitary: tumor (prolactinoma), empty sella syndrome, infiltrative disease (sarcoidosis), post-partum hypopituitarism (Sheehan syndrome) ovary: polycystic ovary syndrome, ovarian insufficiency, ovarian insufficiency, ovarian tumor ovarian insufficiency can be due to idiopathic causes, auto-immune destruction, chemotherapy, radiation, congenital causes (Turner’s syndrome, gonadal dysgenesis) outflow tract obstruction: congenital (complete androgen resistance, imperforate hymen, Mullerian agenesis, transverse vaginal septum), acquired (Asherman syndrome, cervical stenosis)

Answer 98

HPI menstruation history: onset of amenorrhea, previous menses if any (primary vs. secondary), previous menstrual cycle (length, pattern, consistency of pattern) hypothalamus / pituitary tumor symptoms: headache, loss of vision, vomiting, galactorrhea thyroid symptoms: temperature, heart rate, bowel movement symptoms of androgen excess: acne, hirsutism, hair thinning, deepening of voice primary ovarian insufficiency: vasomotor symptoms (hot flush, night sweats) hyperandrogenism: acne, hirsutism uterine or outflow tract obstruction symptoms: cyclic or acute pelvic pain PMH thyroid disease surgery, radiation, chemotherapy OB/GYN History GTPAL past sexually transmitted infections OB/GYN surgery Medication contraception dopamine antagonist including psychiatric medications FH age at menarche for mom and sisters family history of genetic syndrome, autoimmune disease SH eating and exercise pattern change in weight sexual history

Answer 99

general: height, weight, BMI, inspection for dysmorphic feature (Turner’s syndrome) Tanner staging skin: inspect for hyperandrogenism (hirsutism, acne, male pattern hair loss), striae (Cushing’s syndrome) head & neck: vision test (pituitary tumor), thyroid exam abdomen: palpation for mass (ovarian or adrenal tumor) genital: inspection for outflow tract obstruction, missing or malformed organ, thin vaginal mucosa (low estrogen), virilization (clitoral enlargement)

Answer 100

blood work: CBC, b-hCG, LH, FSH, prolactin, TSH, serum estrodiol pelvic ultrasound to rule out abnormal anatomy Progesterone withdrawal challenge Other: if estrogen not evidence from physical exam (normal vaginal discharge suggest normal estrogen level), then measure serum estradiol if chronic disease suspected, CBC and metabolic panel if history or physical exam suggest hyper-androgen, then serum testosterone if Turner's syndrome suspected, chromosome karyotype if hypothalamus or pituitary cause suspected, then MRI head

Answer 101

not routinely done, because it can be substituted with estradiol (E2) to measure estrogen and pelvic ultrasound to measure outflow tract progesterone for course of 10 days then stop to simulate luteal phase and see if bleeding ensues after withdrawal withdrawal bleeding confirms adequate estrogen production and functional anatomy (responsive endometrium and patent outflow tract) failure to bleed on progesterone withdrawal can be due to low estrogen from ovary, hypothalamic pituitary dysfunction, non-reactive endometrium, no uterus or anatomical abnormality with uterine outflow tract if failure to bleed, give estrogen then progesterone failure to bleed with estrogen then progesterone confirms anatomic abnormality bleeding with estrogen and progesterone confirms low estrogen, which need to be worked up to see if it is due to ovarian insufficiency or hypothalamic or pituitary disorder

Answer 102

treatment always should address underlying cause primary amenorrhea with no internal female reproductive organ usually have no viable treatment pituitary dysfunction: symptom relief with estrogen and progesterone replacement (e.g. oral contraceptive pill), LH & FSH injection for fertility hypothalamus dysfunction: if functional hypothalamic suppression, then need to correct underlying cause, otherwise symptom relief with estrogen and progesterone replacement pituitary or hypothalamus tumor: consider surgical resection, LH & FSH injection for fertility ovarian dysfunction: symptom relief with estrogen and progesterone replacement (e.g. oral contraceptive pill), egg donor and in-vitro fertilization for fertility obstructive tract should be treated with surgical repair other endocrinopathy: address and treat endocrinopathy (e.g. thyroid replacement for hypothyroidism)

Answer 103

Chromosomal abnormalities leading to primary ovarian insufficiency - Turner's syndrome, Fragile X syndrome Other genetic conditions - androgen insensitivity, congenital adrenal hyperplasia Anatomic abnormalities - Mullerian agenesis Constitutional delay Primary amenorrhea with normal breast development - androgen insensitivity syndrome, Mullerian agenesis, Mullerian uterine septum

Answer 104

45 X lacking 1 X chromosome

Answer 105

abnormal X chromosome

Answer 106

46XY karyotype with androgen receptor defect leading to female external genitalia, no uterus, no cervix, no fallopian tube, little hair growth Normal functioning testes secreting normal male testosterone

Answer 107

Excessive androgen production leading to anovulation

Answer 108

46XX karyotype, female phenotype, no uterus, no cervix, no fallopian tube Normal ovaries

Answer 109

1. History and physical Growth curve, wrist xray for bone age If normal growth and delayed wrist xray with normal work up then constitutional delay 2. TSH - fu with thyroid hormone Prolactin - MRI of head bhCG 3. Further tests depend on presence of uterus on u/s - No uterus suggests genetic syndrome (fu with karyotype and testosterone) 46XX with female range testosterone is Mullerian agenesis 46XY with male range testosterone is androgen insensitivity - Normal uterus base diagnosis on FSH level High FSH suggests primary ovarian insufficiency (repeat in 1 month to diagnose with POI, order karyotype to evaluate Turner or presence of Y chromatin, test for fragile X) Low FSH can be physiologic (functional amenorrhea, constitutional delay) or pathologic (MRI) hypothalamus pituitary disorder Normal FSH can be due to ovarian tumour, adrenal tumour or congenital adrenal hyperplasia - High 17-OH-progesterone =CAH - High testosterone =u/s for ovarian tumour - High DHEAS = adrenal imaging for tumour - Normal testosterone and DHEA consider PCOS

Answer 110

Glucocorticoid secreting tumours likely secrete cortisol, which suppresses GnRH production

Answer 111

Hypothalamic - eating disorder, stress Pituitary - prolactinoma Thyroid - hypothyroidism Ovary - PCOS, POI

Answer 112

1. History and physical - review medications including contraceptive and illicit drugs 2. TSH (thyroid hormone if abnormal), prolactin (MRI if abnormal) 3. Further tests depend on level of FSH a) high FSH suggests POI Repeat in 1 month, measure serum estradiol, order karyotype to rule out Turner's syndrome b) Normal or low FSH/LH Functional amenorrhea MRI head to rule out hypothalamus/pituitary abnormality if h/a, vomiting, vision changes Hx OB/GYN procedure do withdrawal bleed or hysteroscopy to evaluate for Asherman's syndrome Signs of hyperandrogenism (virilization such as hirsutism, acne, hair thinning, enlarged clitoris) - order serum testosterone (high PCOS, very high or rapid onset imaging for adrenal and ovarian tumour), DHEA-S and 17-hydroxyprogesterone (CAH if very high)

Answer 113

other autoimmune diseases

Answer 114

90% are idiopathic Chromosomal abnormalities Environmental insult (chemo, radiation, infection, surgery) Tumour Empty sella syndrome Autoimmune Infiltrative process

Answer 115

Inadequate follicles to sustain menses due to failure to form enough primordial follicles or accelerated loss of follicles or damage to follicle by autoimmunity or toxins

Answer 116

Primary or secondary amenorrhea Menses with cycle interval >90 days Oligo-menorrhea (<9 cycles per year)

Answer 117

Normal TSH, prolactin Can have normal anatomy on ultrasound Consistently high FSH and LH Consistently low estradiol

Answer 118

Patient diagnosed with POI if patient meets all of criteria: 1. Primary or secondary amenorrhea for 3 months or change from regular menstruation for 3 months 2. High FSH>40 on 2 occasions a month apart 3. Age <40

Answer 119

Leads to low estrogen, resulting in increased risk of osteoporosis as well as atherosclerosis and its consequent cardiovascular diseases POI lead to infertility

Answer 120

1. Pre-pubertal POI - slowly increasing estrogen for 2 years or until breakthrough bleeding - then add progesterone to induce cyclic withdrawal bleed 2. Post puberty POI Hormone therapy of estrogen for day 1-26 of menstrual cycle and progesterone for day 14-26 (OCP, patch, ring, copper + hormone replacement therapy, IUS + estrogen replacement therapy) weight bearing exercise and calcium and vitamin D supplement to prevent osteoposrosis BP, lipid monitoring to assess cardiovascular disease risk + diet, no smoking, exercise Psychosocial support for patient to deal with infertility, but recommend contraceptive if not wanting to conceive because there is still 5% chance of spontaneous pregnancy Consider egg/embryo donor or adoption if patient wants children

Answer 121

Prevent osteoporosis, CVD, vasomotor symptoms

Answer 122

4-7 days <2 days and >7 days is abnormal

Answer 123

30 mL | >80 mL is abnormal

Answer 124

24-35 days is normal | <24 or >35 days is abnormal

Answer 125

regular normal interval with excessive volume >80mL and / or duration of flow (i.e. heavy menstrual bleeding) >7 days

Answer 126

irregular intervals with normal or reduced volume and duration of flow (i.e. irregular menstrual bleeding)

Answer 127

irregular intervals and excessive volume and duration of flow (i.e. irregular heavy menstrual bleeding)

Answer 128

cyclic length <24 days

Answer 129

``` Menorrhagia Metrorrhagia Menometrorrhagia Polymenorrhea Post-menopausal bleeding Amenorrhea Oligomenorrhea ```

Answer 130

Pain with menstruation

Answer 131

Vaginal bleeding Hematuria Hematochezia

Answer 132

- - Pregnancy and its complications - Functional- Blood dyscrasia, hypothyroidism, luteal dysfunction - Pathological (PALM COEIN)

Answer 133

PALM - structural abnormalities ``` Polyps Adenomyosis Leiomyoma (ie fibroids) Malignancy Hyperplasia ``` Malignancy or hyperplasia = endometrial cancer, endometrial hyperplasia, cervical cancer COEIN are non-structural abnormalities Coagulopathy Ovulatory dysfunction - all differential diagnosis for oligomenorrhea and amenorrhea Endometrial dysfunction - endometrial hemostasis disorder, endometritis, abnormal local inflammatory response, abnormal vasculogenesis of endometrium Iatrogenic - medications, IUD Not yet classified (ie idiopathic)

Answer 134

Hormone medication - androgen, estrogen, progesterone Hormone related therapy medication - GnRH agonist, aromatase inhibitor, SERM, SPRM Other medications: SSRI, TCA, anti-psychotics, corticosteroids, anti-platelet agents, anti-coagulants

Answer 135

(PALM) | Inter menstrual bleeding

Answer 136

a) either b) either c) anovulatory d) ovulatory

Answer 137

Unpredictable and irregular menstrual cycle with prolonged or heavy bleeding

Answer 138

Predictable and cyclic menses with normal duration

Answer 139

Cervical dysplasia Polyp

Answer 140

1. Confirm uterus as source of bleeding 2. Rule out pregnancy 3. Rule out coagulopathy, ovulatory dysfunction, iatrogenic of COEIN 4. Rule out structural causes (PALM) with TVUS, saline infusion sonography and hysteroscopy 5. Determine if ovulatory or anovulatory based on history Anovulatory consider endocrinopathy and follow route for oligomenorrhea/amenorrhea Ovulatory consider endometrial dysfunction (workup with hysteroscopy and endometrial biopsy)

Answer 141

AUB in post-menopausal women is malignancy, likely endometrial cancer until proven otherwise 1) rule out cause due to medication including hormone replacement 2) rule out structural causes with endometrial biopsy, trans-vaginal ultrasound / saline infusion sonography and hysteroscopy 3) consider neoplasia elsewhere in vagina, cervix, fallopian tube, bladder / urethra and rectum 4) based on exclusion (no findings in previous steps), diagnose with post-menopausal AUB most likely due to endometrial / vaginal atrophy

Answer 142

Medication is 1st line therapy if non-structural abnormality Non-hormonal and/or hormonal for regular menorrhagia Hormonal for irregular menorrhagia

Answer 143

1. Iron supplement Indication - iron deficient anemia 2. NSAID MOA - decrease blood loss by vasoconstriction Indication - menorrhagia, pain relief for dysmenorrhea Less effective than other forms of therapy 3. Anti-fibrinolytics TXA MOA - inhibit plasminogen activator to decrease bleeding Indication - menorrhagia Contraindication - thromboembolism (DVT, PE) Side effects - nausea, GI upset, leg cramps, retinal vascular occlusion

Answer 144

1. Combined hormone (estrogen progestin) contraceptive Indication - menorrhagia (regular or irregular), irregular menstrual cycle Most prescribed treatment for AUB MOA - progestin suppress ovulation and estrogen to support endometrium preventing breakthrough bleeding thereby decreasing blood loss (also regulate cycle, contraception, prevent hyperplasia and treat dysmenorrhea) Contraindication - heavy smoking, DVT, stroke, uncontrolled hypertension, migraine with neurological symptom, breast cancer, CAD, liver disease 2. Progestin (oral, injection, IUS) Indication - irregular menstrual cycle, menorrhagia (irregular or regular) MOA - progestin inhibits ovarian steroid synthesis causing endometrial atrophy, decreasing blood loss, cyclical withdrawal can induce endometrial shedding Oral progestin is not effective for regualr menorrhagia and less effective than NSAID and TXA IUS decrease menstrual blood loss and decrease frequency of period, which is more effective than other progestin treatment and can treat dysmenorrhea 3. GnRH agonist (Lupron) Indication - menorrhagia (regular or irregular), shrinkage of fibroid, dysmenorrhea MOA: induce reversible menopause by inducing endometrial atrophy and amenorrhea Side effects - menopausal symptoms (hot flash, mood fluctuation, vaginal dryness, bone effects)

Answer 145

Non structural - endometrial ablation or hysterectomy (definitive treatment) Structural abnormality - specific surgical management

Answer 146

Contraception - hormone contraceptives, IUD Post menopausal hormone therapy Tamoxifen Anti-coagulants Corticosteroids Chemotherapy Phenytoin Antipsychotic drugs

Answer 147

Early pregnancy - ruptured ectopic, spontaneous abortion Late pregnancy - placental abruption, placenta previa Post-partum - PPH Ovary - ruptured ovarian cyst - ovarian torsion Uterus - acute severe menorrhagia Trauma to genital tract, foreign body in genital trat Infection to genital tract including PID, salpingitis Gynecologic malignancies

Answer 148

1. Stabilize patient 2. Rule out pregnancy 3. Rule out bleeding source outside genital tract (urinary, GI) 4. Rule out vulva, vagina, cervix causes on physical exam 5. Consider ovarian, fallopian tube and uterus causes

Answer 149

Ectopic pregnanc Ruptured ovarian cyst Ovarian torsion PID

Answer 150

The ring of fire sign, also known as ring of vascularity, signifies a hypervascular lesion with peripheral vascularity on color or pulsed Doppler examination of the adnexa due to low impedance high diastolic flow 1. This sign can be seen in: corpus luteum cyst (more commonly) ectopic pregnancy

Answer 151

The double decidual sac sign (DDSS) is a useful feature on early pregnancy ultrasound to confirm an early intrauterine pregnancy (IUP) when the yolk sac or embryo is still not visualized. It consists of the decidua parietalis (lining the uterine cavity) and decidua capsularis (lining the gestational sac) and is seen as two concentric rings surrounding an anechoic gestational sac. Where the two adhere is the decidua basalis, and is the site of future placental formation.

Answer 152

Ovarian cyst (thin wall, posterior acoustic enhancement, no blood flow) Fluid in pouch of Douglas or Morrison's pouch or LUQ

Answer 153

An extension of the peritoneal cavity between the rectum and the back wall of the uterus. Also known as the rectouterine pouch

Answer 154

The hepatorenal recess (subhepatic recess, pouch of Morison or Morison's pouch) is the space that separates the liver from the right kidney

Answer 155

Enlarged ovary, ovarian mass, multiple small peripheral follicles (often in context of adnexal mass) Abnormal ovarian location Decreased/no Doppler flow in ovary

Answer 156

Immediate surgery to detorse viable ovary Otherwise salpingoophorectomy for non-viable ovary

Answer 157

Infection of upper genital tract structure (uterus, Fallopian tube, ovaries) by STI (commonly Gonorrhea or Chlamydia), which may cause endometritis, salpingitis, oophoritis, tubo-ovarian abscess, peritonitis, peri-hepatitis

Answer 158

Pelvic pain (classifcally during or shortly after menses) Vaginal discharge or bleeding Dysuria Fever, chills

Answer 159

Antibiotic therapy (ex. Ceftriaxone 250 mg IM single dose + Doxycycline 100 mg PO BID x 14 days)

Answer 160

Pelvic pain below umbilicus for >6 months duration, which causes functional disability or requiring treatment

Answer 161

History of previous sexual abuse or assault in 20%

Answer 162

1. Constitutional symptoms 2. GI symptoms - hematochezia 3. ObGyn symptoms - peri menopausal irregular vaginal bleeding, post menopausal vaginal bleeding, post coital bleeding

Answer 163

Blood work - beta-hCG (repeat in 48 h if positive), CBC, ESR Vaginal swab for STI Urinalysis r&M C&S for UTI or renal calculus

Answer 164

1. Pelvic pain dysfunction/chronic pelvic pain syndrome 2. Vestibulitis vulvodynia syndrome 3. Pelvic congestion syndrome

Answer 165

Idiopathic spasm of pelvic floor muscles (elevator ani)

Answer 166

Pelvic pain out of proportion to pathology, dyspareunia, vaginismus (spasm of vagina), dysuria, dyschezia, pain elsewhere (back, lower abdomen, groin, leg)

Answer 167

Impaired function at home/work Decreased libido -> decreased sexual activity

Answer 168

Tight, tender, band-like muscle in vagina and rectum

Answer 169

Vulvar discomfort or pain Dyspareunia (superficial —> deep) Perineal burning or rawness Urinary symptoms (urgency, frequency, dysuria)

Answer 170

Erythema of Bartholine openings and hymen Tenderness on q tip probe into vestibule, vaginismus and pelvic pain dysfunction

Answer 171

Multiparity Sedentary lifestyle Constipation Sexual dissatisfaction

Answer 172

Pelvic vein varicosities

Answer 173

Dull aching pain in pelvis and lower abdomen aggravated by standing and relieved with lying down May progress to dyspareunia, dysmenorrhea, back pain, vaginal discharge

Answer 174

Us showing pelvic veinvaricosities

Answer 175

Medication - Acetaminophen, NSAID, opioids If cyclic consider combined OCP, progesterone oral, IM or IUS, GnRH agonist (Lupron), Danazol If non-cyclic consider gabapentin or amitriptyline Surgery - laparoscopy, lysis of severe adhesions, total abdominal hysterectomy for failed medical treatment

Answer 176

1. Patients previously treated for cervical dysplasia - annual screening 2. Immune compromised - annual screening 3. Total hyserectomy including cervix for benign disease - none 4. Visual cervical abnormality on speculum exam or abnormal symptoms - colposcopy regardless of pap test cytology findings

Answer 177

Low grade squamous intraepithelial lesion Minor dysplasia not likely to become cancer, probably due to HPV infecion Equivalent to cervical intraepithelial neoplasia (CIN 1)

Answer 178

High grade squamous intraepithelial lesion Severe dysplasia that is more likely to progress to cancer Equivalent to CIN 2 or 3

Answer 179

AGC - atypical glandular cells | AIS - adenocarcinoma in situ

Answer 180

repeat Pap test cytology every 6 months x 2 if any of the Pap tests cytology every 6 months is abnormal (i.e. >ASCUS), then colposcopy if both Pap tests cytology every 6 months are negative, then return to routine screening every 3 years

Answer 181

A) HPV testing available 1) HPV testing if HPV testing is negative, then proceed to 2 if HPV testing is positive, then colposcopy 2) Repeat Pap test cytology in 1 year if repeat Pap test cytology is abnormal (i.e. >ASCUS), then colposcopy if repeat Pap test cytology is negative, then return to routine screening every 3 years B) HPV testing not avaiable follow same algorithm as ASCUS for patient age <30 with repeat Pap test cytology every 6 months x 2

Answer 182

straight to colposcopy or follow same algorithm as ASCUS for patient age <30 with repeat Pap test cytology every 6 months x 2 HSIL: straight to colposcopy ASC-H: straight to colposcopy AGC: straight to colposcopy

Answer 183

straight to colpo

Answer 184

straight to colpo

Answer 185

straight to colpo

Answer 186

Only when transformation zone between stratified squamous epithelium and glandular epithelium is visualized type 1 transformation zone = entire transformation zone visualized on colposcopy type 2 transformation zone = entire transformation zone fully visualized when cervix is opened type 3 transition zone = entire transformation zone is not visualized even when cervix is opened type 1 and 2 transformation zone is satisfactory type 3 transformation zone is not satisfactory

Answer 187

colposcopy biopsy classified by cervical intraepithelial neoplasia system (CIN 1, 2 and 3), which signify premalignant transformation and dysplasia that is not cancer but may progress to cancer

Answer 188

if any abnormal appearing tissue such as abnormal vascular pattern, mosiacism, punctate lesion, nodular lesion or turns white with acetic acid on colposcopy, then biopsy if no abnormal lesion identified, then biopsy transition zone

Answer 189

if biopsy is less than CIN 1, then return to screening protocol (Pap test very 3 years)

Answer 190

excisional biopsy mentioned above can be loop electrosurgical excision (LEEP), laser, cryotherapy or cone biopsy

Answer 191

CIN 2 or 3 have risk of cancer | CIN 2 or 3 usually treated with excisional biopsy

Answer 192

CIN 1 biopsy rarely progress to cancer a) if satisfactory (type 1 or 2 transformation zone) colposcopy, then observe with pap test at 12 months and then manage according to cytology b) if unsatisfactory (type 3 transformation zone) colposcopy, then observe with pap test and colposcopy at 6 months and 12 months i) if colposcopy and pap test at both visits are negative for CIN, then return to screening protocol ii) if CIN persist or progress, then treat by ablation c) if CIN 1 after HSIL or AGC on pap test, then review biopsy histology with pap test cytology if discrepancy, then excisional biopsy

Answer 193

if unsatisfactory (type 3 transformation zone) colposcopy and cytology was AGC or HSIL, then diagnostic excisional biopsy with LEEP or cone biopsy with endocervical curretage

Answer 194

Yeast Bacterial vaginosis Trichomoniasis

Answer 195

Chlamydia Gonorrhea

Answer 196

HIV Hepatitis B - HBSAg Hepatitis C - HCV RNA testing Syphilis - VDRL

Answer 197

Can perform immediately, but HIV, Hep B and Hep C have a latency period so need to repeat bw at 3 and 6 months

Answer 198

Urine PCR for chlamydia and gonorrhea b-hCG No voiding for 2h then beginning of 'dirty' urine (20mL)

Answer 199

Open intact vesicle with needle, then culture liquid with special swab with liquid virus transport Send to lab within hours

Answer 200

Diagnosed clinically based on warts on clinical exam

Answer 201

Testing for triage of ASCUS pap test for patient 30+ years

Answer 202

concomitant with cervical pap test with Dacron swab or cervical brush

Answer 203

Gonorrhea Insertion of regular swab and rub against posterior pharynx and tonsillar crypts

Answer 204

Testing for gonorrhea and chlamydia Insertion of regular swab 2-3 cm into anal canal pressing laterally to avoid feces Need to repeat and obtain another specimen if visible fecal contamination

Answer 205

Testing for gonorrhea and chlamydia no voiding for 2 hours then regular swab moistened with water inserted 1-2 cm up female urethra and 3-4 cm up male urethra

Answer 206

inflammation of vulva and/or vagina

Answer 207

vaginal discharge vulvo-vaginal pruritus vulvovaginal pain

Answer 208

infection (BV, vaginal candidiasis, trichomoniasis)

Answer 209

Low estrogen in follicular phase results in thick and sticky vaginal discharge high estrogen in luteal phase results in clearer, wetter and more stretchy vaginal discharge, which is more conducive to sperm travelling

Answer 210

Most common cause of abnormal vaginal discharge Increases risk of acquiring STIs

Answer 211

African American Changing sex partner, lesbian partner with BV, douching Change to vaginal environment: IUD, antibiotic use, co-existing STI

Answer 212

normal flora in vagina includes Lactobacillus, which produce hydrogen peroxide to prevent multiplication of other vaginal microorganism bacterial vaginosis is not an infection, but polymicrobial replacement of normal flora and multiplication in vagina without inflammation polymicrobial includes anaerobes (Prevotella, Mobiluncus, Bacteroides), Gardrerella, Ureaplasma and Mycoplasma

Answer 213

most asymptomatic increased thin, white and homogeneous vaginal discharge with a foul odor

Answer 214

Whiff test - fishy odor when alkali (10% KOH) is added to a wet mount containing vaginal discharge pH >4.5 (normal 4) Miscroscopy of wet mount containing vaginal discharge - clue cells (vaginal squamous epithelial cells coated with bateria around its edges)

Answer 215

Amsel's criteria - 3/4 of following 1. Thin white homogeneous vaginal discharge 2. pH >4.5 3. Positive Whiff test 4. Clue cells on microscopy

Answer 216

Treat only if symptomatic Treat with antibiotics (oral better than topical) 1st line - Metronidazole 500 mg PO BID x 7 days 2nd line - Metronidazole gel or Clindamycin cream If pregnant treat with metronidazole oral or clindamycin oral testing and treating sexual partner not recommended

Answer 217

2nd most common vaginal infection after BV

Answer 218

change in vagina microbiological environment: uncontrolled diabetes, systemic antibiotic use immunocompromised state high estrogen level: pregnancy, obesity, oral contraceptive pill (OCP) low estrogen (menopause, pre-puberty) decreases risk of VVC

Answer 219

candida yeast is part of normal vaginal flora, where overgrowth can cause symptoms under changed vagina environment infection of vagina and vulva by candida fungal species 95% cases are candida albicans, which respond well to usualy therapies less common infections by non-albicans candida species which is harder to treat: candida glabrata (torulopsis), candida parapsilosis, candida krusei, saccaromyces cerevisiae

Answer 220

vaginal symptoms: thick white clumpy “curdy and cottage cheese like” vaginal discharge which is usually odorless skin symptoms: vulval itch, burning, pain or soreness; skin fissures, erythema, edema or satellite lesions (sores in surrounding skin) of vulva

Answer 221

pH litmus paper test in vagina: pH usually within normal range and <4.5 (normal vaginal pH is ~4) vaginal swab KOH wet mount / culture: yeast with hyphae and spores

Answer 222

diagnosis by microbial culture of vaginal swab showing Candida (bud + hyphae) plus symptoms of vulvovaginitis

Answer 223

treat only if symptomatic oral antifungal: Fluconazole 150mg PO in single dose topical antifungals: azoles (Clotrimazole, Miconazole, Terconazole) suppository or cream for 3 days if uncomplicated cases; 7 days if complicated cases (diabetes, immunocompromised, atypical Candida) oral is preferred over topical treatment for women except when pregnant only topical treatment is recommended for pregnant women if resistant to azoles or atypical (not Candida albicans), then topical boric acid powder gentian violet is effective other alternatives treatments are not effective including Lactobacillus, probiotics, garlic tampons, tea tree oil, echinacea, golden seal, yeast guard suppositories

Answer 224

trichomoniasis is a disease caused by trichomonas vaginalis, a unicellular flagellated parasite motile protozoa transmission by genital sexual contact, which is reduced by condom trichomonas can infect vagina, bladder or urethra

Answer 225

50% of women are asymptomatic onset of symptoms usually 1 week after contact vagina symptoms: yellow-green malodorous diffuse frothy vaginal discharge, pruritus, dyspareunia urinary symptoms: dysuria, increased urinary frequency complication: rarely may cause pelvic inflammatory disease

Answer 226

vaginal discharge strawberry cervix (petechiae) due to punctate hemorrhage

Answer 227

Microscopy of vaginal swab - motile flagellated organism, many WBC, inflammatory cells (PMNs)

Answer 228

trichomoniasis diagnosed by trichomonas visualized on microscopy of vaginal swab sample

Answer 229

not a reportable disease treat even if asymptomatic oral antibiotic therapy: Metronidazole 2g PO single dose or 500mg PO BID x 7 days sexual partners should also be treated

Answer 230

post menopausal women have low estrogen, leading to atrophy of vagina atrophy of vagina usually only lead to vaginal dryness, but can cause an inflammation within the vagina resulting in vaginal discharge

Answer 231

vagina symptoms: yellowish vaginal discharge, feeling of dry and irritated vagina despite discharge, dyspareunia, pruritus, itching, burning, may cause vaginal bleeding speculum exam: vaginal petechiae

Answer 232

vaginal estrogen (ring, tablet or cream) is most effective, which need to be applied for life and achieves full effect in 3 months systemic estrogen is less effective than vaginal estrogen with more side effects and contraindications

Answer 233

excessive male-pattern hair growth in women

Answer 234

excessive development of exaggerated masculine characteristics in women usually presenting with clitoromegaly, deepening of voice, acne, hirsutism, baldness, increased muscularity

Answer 235

hirsutism and virilization are caused by excess androgen secretion (hyper-androgenemia) including testosterone and dihydrotestosterone (DHT) usually high androgen level results in hirsutism first, and very high androgen level results in virilization excess androgen may be from ovary, adrenal gland or exogenous source ovary secrete testosterone and androstenedione adrenal gland secrete dehydroepiandrosterone sulfate (DHEA-S) and androstenedione

Answer 236

1) Pituitary a) Cushing’s disease, resulting in increased ACTH that stimulate secretion of adrenal androgen b) acromegaly 2) Excess Androgen from Adrenal Gland a) neoplasm: androgen secreting adrenal tumors b) genetic: 21-hydroxylase deficiency (aka congenital adrenal hyperplasia), which stop synthesis pathway of mineral-corticoid and glucocorticoid, resulting in excess precursor converted to androgen 3) Excess Androgen from Ovary a) polycystic ovarian syndrome (PCOS) b) ovary hyperthecosis c) androgen secreting ovarian tumors: Sertoli-Leydig cell, Granulosa-theca cell, Hilus cell 4) Exogenous a) exogenous androgens: testosterone, DHEA 5) Other a) pregnancy due to luteoma or theca-lutein cyst b) severe insulin resistance syndromes c) idiopathic hirsutism

Answer 237

hirsutism: excess terminal hair growth (dark coarse hair) in androgen dependent area (upper lip, chin, mid-sternum, upper abdomen, back, buttocks) hirsutism can be graded based on Ferriman-Gallwey score, which grade 9 androgen dependent body areas from 0 (no hair) to 4 (frankly virile) hirsutism defined as >8 for black or white women, >2 for Asian women, >9-10 for Mediterranean, Hispanic and Middle Eastern Women Skin - acne Virilization - frontal balding, deepening of voice, increased muscle mass, clitoromegaly

Answer 238

body habitus inspection: hair for balding and hirsutism (Ferriman-Gallwey score), skin acne, acanthuses nigricans, Cushingoid feature (moon face, buffalo hump, striae, thin skin, bruising), muscle mass acanthosis nigricans = grey-brown discolouration of skin at neck, groin, axillae and vulva, which is marker of insulin resistance and hyper-insulinemia abdominal exam: palpate for mass (ovary) pelvic exam: inspect clitorus for clitoromegaly, bimanual pelvic exam for ovarian mass

Answer 239

blood work for amenorrhea / oligo-menorrhea: b-hCG, prolactin, TSH, FSH blood work for hirsutism: total and free serum testosterone, androstenedione, DHEA-S, 17-OH progesterone, dexamethasone suppression test or 24 hour urine for free cortisol very high 17-OH progesterone (>200) in congenital adrenal hyperplasia high cortisol despite dexamethasone suppression test or high 24 hour urine cortisol in Cushing's syndrome very high DHEA-S (>700) suggests androgen secreting adrenal tumor high total testosterone (>150) suggest androgen secreting ovarian tumor high androstenedione and high free & total testosterone suggest polycystic ovarian syndrome if high total testosterone >150, trans-vaginal ultrasound for ovarian tumor if high DHEA-S >700, abdominal CT with IV contrast for adrenal tumor

Answer 240

Oral Contraceptive Pill indication: 1st line for treatment of acne and hirsutism mechanism of action: estrogen increases steroid hormone binding globulin and progestin inhibits LH secretion, thereby decreasing ovarian androgen production takes >6 months to be effective, usually stopped after 1-2 years and observe for return of ovulatory cycles Spironolactone indication: treats hirsutism mechanism of action: inhibit ovarian and adrenal biosynthesis of androgen, androgen receptor antagonist, inhibit 5-alpha reductase activity side effects: diuresis, theoretical risk of feminizing male fetus Cyproterone Acetate indication: treats acne and hirsutism mechanism of action: inhibit androgen secretion, androgen receptor antagonist side effect: fatigue, edema, loss of libido, weight gain, mastalgia Dexamethasone indication: congenital adrenal hyperplasia mechanism of action: suppression of endogenous ACTH Flutamide mechanism of action: non-steroidal anti-androgen side effect: hepatotoxicity Finasteride mechanism of action: inhibit 5-alpha reductase Mechanical Methods plucking, waxing, shaving or exfoliants, which do not destroy dermal papillae electrolysis or laser, which destroy dermal papillae

Answer 241

common endocrine problem in women of reproductive age | affects 5-10% of women of reproductive age (12-45)

Answer 242

Family history metabolic syndrome (obesity, diabetes, dyslipidemia, hypertension)

Answer 243

insulin resistance -> decreased sex hormone binding globulin -> increased free testosterone increased testosterone production by theca cells -> follicular atresia -> anovulation anovulation results in no secretion of progesterone due to no corpus luteum, increased testosterone in ovary is converted to estrogen thus high estrogen unopposed by progesterone lead to continuous endometrial proliferation that never shed, increasing risk of endometrial cancer increased testosterone production and increased free testosterone -> secondary male sexual characteristics (hirsutism, virilization)

Answer 244

onset usually around menarche, but can be after puberty irregular menstruation or amenorrhea infertility acne, hirsutism, deepened voice weight gain vitals: hypertension body habitus: overweight or obese general: hirsutism, acne, male pattern baldness, acanthosis nigricans pelvic exam: enlarged clitoris, large ovaries on palpation

Answer 245

blood work: normal b-hCG, prolactin, TSH, FSH, normal to slightly high free & total testosterone <150, normal 17-OH progesterone, normal dexamethasone suppression test, normal 24 hour urine cortisol test high androstenedione pelvic ultrasound: polycystic ovaries

Answer 246

1) Exclude other causes for hyperadrogenism and amenorrhea PCOS is diagnosis of exclusion hyperandrogenism differential diagnoses - normal 17-OH progesterone ruling out congenital adrenal hyperplasia - normal 24 hour urine free cortisol ruling out Cushing's syndrome - normal DHEA-S and normal abdomen ultrasound ruling out androgen secreting (adrenal or ovarian) tumor amenorrhea differential diagnoses - negative b-hCG ruling out pregnancy - normal prolactin ruling out hyperprolactinemia - normal TSH ruling out thyroid disorder - no signs of structural abnormality besides polycystic ovaries on pelvic ultrasound - normal or low FSH ruling out primary ovarian insufficiency 2) diagnose PCOS based on Rotterdam's criteria or AE-PCOS criteria a) Rotterdam Criteria patient diagnosed with PCOS if patient satisfies >2 of the 3 criteria 1. anovulation presenting as oligomenorrhea or amenorrhea 2. hyperandrogenism from clinical signs or high testosterone 3. polycystic ovaries (>12 cysts or large ovarian volume >10mL of at least one ovary) on ultrasound b) Androgen Excess PCOS (AE-PCOS) Criteria patient diagnosed with PCOS if patient satisfied all of the criteria below: 1. hyperandrogenism: hirsutism and / or hyperandrogenia 2. ovarian dysfunction: oligo or anovulation and / or polycystic ovaries on ultrasound 3. exclusion of other androgen excess disorders and related disorders note that polycystic ovary on ultrasound is not enough to diagnose PCOS and patient without polycystic ovary on ultrasound can still have PCOS

Answer 247

``` 1) Short Term Consequences infertility irregular menses hirsutism, acne, androgenic alopecia metabolic syndrome: insulin resistance, glucose intolerance, acanthosis nigricans, hypertension, obesity, dyslipidemia obstructive sleep apnea ``` ``` 2) Long Term Consequences PCOS increases risk of type 2 diabetes mellitus endometrial cancer cardiovascular disease: coronary artery disease, myocardial infarction, stroke ```

Answer 248

work up need to assess for metabolic syndrome and cardiovascular disease risk body habitus: BMI, waist circumference blood pressure diabetes screening: HbA1C and / or fasting blood glucose lipid profile: total cholesterol, LDL, HDL, triglycerides

Answer 249

1) Restore menorrhea menorrhea restored by cyclic progesterone with withdrawal to stimulate cyclic shedding of endometrium if patient does not want children, then combined oral contraceptive pill (OCP) if contraception is not needed, then cyclic progesterone 2) Contraception patients with PCOS can still get pregnancy, so need to use contraception if the patient does not want baby 3) Hyperandrogenism OCP and Cyproterone acetate can be used to treat acne and hirsutism Spironolactone can be used to treat hirsutism hirsutism can be treated by mechanical means

Answer 250

1) Metabolic Syndrome regular assessment for metabolic syndrome including fasting glucose / HbA1C; lipid profile; blood pressure healthy lifestyle: exercise, diet, weight loss address each risk factor antihypertensive if hypertensive lipid lowering medication if hyperlipidemia diabetes medication if diabetes mellitus metformin can be used to treat impaired glucose tolerance 2) Endometrial Hyperplasia and Cancer restore menorrhea by replacing progesterone to shed endometrium endometrial biopsy to screen for endometrial cancer if age >35 and abnormal uterine bleeding 3) Infertility contraception if patient does not want to get pregnant ovulation induction with SERM (selective estrogen receptor modulator) as needed when patient want to get pregnant

Answer 251

failure to conceive after 1 year of frequent unprotected intercourse (frequent ~2-3 times during fertile time window, which is at ovulation around 14 days before menstruation)

Answer 252

1. demographics: female age is single biggest risk factor for infertility, where chance of successful pregnancy dramatically decreases and miscarriage dramatically increases at age >35 increasing age -> decreased follicle cells and lower quality of oocyte with higher risk of aneuploidy 2. body habitus: very high or very low body mass index 3. OB&GYN history: oligomenorrhea, amenorrhea, pelvic inflammatory disease, endometriosis 4. past surgical history: previous abdominal or pelvic surgery 5. medication: chemotherapy

Answer 253

1. demographics: age >40 years 2. past medical history: history of undescended testes 3. past surgical history: previous urogenital surgery 4. medication: chemotherapy 5. social history: recreational drugs

Answer 254

1. Ovulation defect (oligomenorrhea or amenorrhea) in ~25% cases 2. Male factor (ie abnormal semen quantity and/or quality) in 25% cases 3. Fallopian tube defect in ~25% cases

Answer 255

cystic fibrosis carrier

Answer 256

couple in which female age <35 after 1 year of unprotected and frequent sexual intercourse couple in which female age >35 or with specific medical history after 6 months of unprotected and frequent sexual intercourse

Answer 257

1. Tubal factors- obstruction from surgery, inflammation, anatomical abnormality 2. Ovulatory dysfunction - hypothyroidism, prolactinoma, hypothalamic amenorrhia, PCOS, POI 3. Uterine structural abnormality - congenital uterine malformation, fibroids, adhesions, polyps

Answer 258

1. Abnormal semen quantity and/or quality - lube, chronic disease, surgery, chemo, testosterone, smoking, alcohol, drugs, heat, Kleinfelter, CF, chromosome Y microdleetion 2. Low or absent semen volume - failed emission, incomplete collection, short abstinence period, CBAVD, ejaculatory duct obstruction, hypogonadism, retrograde ejaculation 3. Acidic semen -CBAVD, ejaculatory duct obstruction 4. Azoospermia - obstruction, testicular failure 5. Oligospermia - variocele, hypogonadism, T-chromosome microdelection 6. Asthenospermia (poor sperm motility) - anti sperm antibodies, genital tract infection, partial obstruction of ejaculatory ducts, site of vasectomy reversal, varicele, prolonged abstinence

Answer 259

For all infertility all of the following assessment should be done: 1. Assessment of ovulation by history and serum progesterone 7 days prior to expected period 2. Ovarian reserve testing by FSH, estradial and pelvic ultrasound (us also assesses anatomy of uterus, uterine tube and rest of pelvis) 3. Uterus and uterine tube anatomy on saline infusion sonogram or hysterosalpingogram 4. Semen analysis 5. TSH for thyroid dysfunction investigation for oligo/anovulation only if positive history of olig/amenorrhea or low serum progesterone 7 days prior to expected period

Answer 260

ovulation can be assessed by history, basal body temperature charting, urine LH detection kit or luteal phase progesterone a) History on history, a regular and predictable menstrual cycle lasting 21-35 days with signs of molimina (impending period) predict ovulation in 95% of women signs of molimina include breast tenderness, cramping, mood changes and headaches 14 days before menstruation = ovulation if patient has regular predictable period on history, then ovulation can be clearly predicted and no further investigation is required b) Basal Body Temperature Testing basal body temperature charting is tracking of basal body temperature throughout menstrual cycle with an accurate digital thermometer increase of 0.3-0.5 C of body basal temperature correspond to 2-3 days after ovulation having intercourse when basal body temperature have already increased is too late because it is 2-3 days after ovulation charting of body basal temperature allows patient to track pattern of ovulation so that she can predict the next one given the same pattern c) LH Surge urine LH detection kit measures LH surge at ovulation, which can be used to detect current ovulation having intercourse at LH surge as detected by LH detection is effective d) Luteal Phase Serum Progesterone progesterone need to be measured ~7 days before the expected menstrual period, which measure the elevated progesterone at the luteal phase if ovulation

Answer 261

serum LH, FSH serum estradiol (at day 3 of menstrual cycle) serum progesterone (at 7 days before expected menstrual cycle) serum b-hCG for pregnancy serum TSH for thyroid function serum prolactin for prolactinoma pelvic ultrasound for any anatomical abnormalities

Answer 262

hypogonadotropic (low LH, FSH) hypogonadism (low estradiol, low progesterone) suggest central cause such as hypothalamic amenorrhea normagonadotropic (normal LH, FSH) satisfying Rotterdam criteria (2/3 of polycystic ovaries on ultrasound, oligo / a-menorrhea and hyperandrogenism) suggest polycystic ovarian syndrome hypergonadotropic (high LH, FSH) hypogonadism (low estradiol, progesterone) suggest primary ovarian insufficiency high TSH suggest hypothyroidism high prolactin suggest prolactinoma

Answer 263

number of eggs remaining in ovary that have potential to ovulate and be fertilized

Answer 264

FSH and estradiol on day 3 of menstrual cycle pelvic ultrasound which can count antral follicle as well as assess anatomy low ovarian reserve if high FSH and low estradiol and low antral follicle count ovarian reserve testing are not very reliable in predicting fertility potential

Answer 265

tubal patency assessed by hysterosalpingogram, saline infusion sonogram, or diagnostic laparoscopy a) Hystersalpingogram (HSG) HSG = injection of radio contrast dye into uterus and image on radiograph normal patent uterine tube lead to contrast going from uterus to tube and into abdominal cavity, making uterus, uterine tube and some of the abdominal cavity visible on radiograph in tubal obstruction, the dye cannot enter uterine tube nor the abdominal cavity, so uterine tube and abdominal cavity is invisible abnormal hysterosalpingogram leads to laparoscopic assessment HSG best done in day 2-5 after menses (to avoid blood / clot, to ensure not pregnant) with NSAID and antibiotic (Doxycycline) prophylaxis (optional) prior to HSG due to 1-3% risk of infection b) Saline Infusion Sonogram (SIS) SIS = infusion of saline into uterus, which can be visualized on ultrasound SIS can be used as substitute for hysterosalpingogram same principles and findings as hysterosalpingogram, where saline infusion in saline sonogram ~ contrast dye in hysterosalpingogram SIS is better at assessing uterine cavity, but cannot assess tube structures NSAID prior to SIS c) Laparoscopy laparoscopy is the gold standard test for assessing tubal factors diagnostic laparoscopy is laparoscopic visualization of abdominal cavity while injecting dye (indigo carmine or methylene blue) into uterus abnormal uterus / uterine tube anatomical abnormality can be visualized on laparoscopy such as fibrosis of uterus post pelvic inflammatory disease normal patent uterine tube leads to dye going through uterine tube and exiting into abdominal cavity, which is visualized on laparoscope obstructed uterine tube prevent dye from entering abdominal cavity, so it is not visualized on laparoscope laparoscopy needs to be done under general anaesthesia, so it has operative risks laparoscopic assessment indicated if patient has any of the below: 1. abnormal hysterosalpingogram 2. known endometriosis 3. previous ectopic pregnancy or tubal surgery 4. previous ruptured appendicitis 5. abnormal physical pelvic exam findings 6. previous pelvic inflammatory disease

Answer 266

uterine factor is an uncommon cause of infertility uterine factor usually already assessed by assessing for tubal patency and ovarian reserve with the following test: 1. pelvic ultrasound (3D ultrasound is better for assessing uterine malformation and space filling defects) 2. HSG or SIS (can assess for space filling masses or intra-uterine adhesions) 3. hysteroscopy, which is gold standard for definitive diagnosis of uterine abnormality

Answer 267

semen analysis is analysis of the male partner's semen sample which assess volume, concentration of sperm, sperm motility and sperm morphology semen analysis should be at least 2 properly performed semen analysis obtained at least 4 weeks apart with abstinence 2-3 days prior to semen collection, which are transported at body temperature and analyzed within an hour normal semen analysis according to WHO criteria is: 1. volume >1.5mL 2. pH >7.2 3. sperm concentration >15 million/mL of semen 4. sperm motility >40% progressive 5. sperm morphology >4% normal

Answer 268

small semen volume

Answer 269

low sperm count

Answer 270

absence of sperm in semen

Answer 271

low sperm motility

Answer 272

sperm with abnormal morphology

Answer 273

low sperm count with low motility and abnormal morphology

Answer 274

weight gain GnRH pump or gonadotropin (FSH) SC infection to induce ovulation In-vitro fertilization

Answer 275

Weight loss 1st line - Clomiphene citrate (SERM acting as estrogen antagonist thereby increasing FSH) to induce ovulation Aromatase inhibtor insulin sensitizing agent (Metformin) Laparoscopic ovarian drilling to induce ovulation Gonadotropin (FSH) SC injection to induce ovulation In-vitro fertilization

Answer 276

in-vitro fertilization donor egg adoption

Answer 277

consider tubal surgery | in-vitro fertilization

Answer 278

surgical removal of masses or adhesions within uterine cavity

Answer 279

lifestyle modification: avoid excessive heat, limit caffeine intake, stop smoking, stop marijuana and other recreational drugs, decrease alcohol intake, vitamins (C, E, Selenium, Zinc, Folic acid) abnormal sperm production: gonadotropin or exogenous pulsatile GnRH for hypothalamic dysfunction abnormal sperm function: intra-uterine insemination, in-vitro fertilization obstruction: in-vitro fertilization with testicular sperm aspiration / extraction (TESA / TESE)

Answer 280

Ovulation induction --> OI with IUI --> superovulation with IUI --> IVF

Answer 281

ovulation induction = supra-ovulation = inducing ovulation of 1 egg ovulation induction / supra ovulation stimulate ovulation followed by sexual intercourse with partner to improve chance of pregnancy ovulation induction / supra-ovulation indicated in oligo / an-ovulation ovulation / supra-ovulation should not be used in 1. premature ovarian insufficiency 2. regular menstruation and ovulation where ovulation is not the cause for infertility 3. mild male factor as cause of infertility 4. unexplained infertility ovulation / supra ovulation can be induced by clomiphen citrate, tamoxifen, letrazole, gonadotropin (FSH) or ovarian drilling

Answer 282

selective estrogen receptor modulator (SERM) that acts as an estrogen antagonist at the hypothalamus estrogen antagonism at hypothalamus remove negative feedback of estrogen, increasing FSH increased FSH stimulate follicular development and thus stimulate ovulation

Answer 283

SERM that block estrogen effect on hypothalamus to increase FSH and stimulate follicular development & ovulation

Answer 284

aromatase inhibitor that decrease synthesis of estrogen level, stimulating FSH release and triggering follicular development & ovulation

Answer 285

given as a daily subcutaneous injection in follicular phase with ultrasound monitoring of developing follicles to trigger ovulation

Answer 286

repetitive cycles of SERM >12 increase risk of ovarian and breast cancer

Answer 287

surgical caudery of tiny holes in stroma of ovary, decreasing androgen release from theca cells, stimulating ovulation ovarian drilling associated with risk of bleeding and tubal obstruction

Answer 288

superovulation = inducing ovulation of 2-4 eggs superovulation artificially induce ovulation followed by usually intrauterine insemination superovulation is a more extreme version of ovulation induction, so it is usually used in combination with intrauterine insemination when ovulation induction with intrauterine insemination fails superovulation is done with daily subcutaneous FSH injection under concomitant ultrasound to track follicular development (high FSH dose induce maturation and ovulation of >1 egg)

Answer 289

IUI usually paired with OI or SO to increase chance of conception in IUI, sperm sample is taken from the male partner, which is then washed to filter and keep only the viable and mobile sperm the washed sperm sample is then inserted via an insemination catheter into the uterus at same time as OI or SO IUI is better than natural sexual intercourse at conception because it is an optimal placement of washed sperm

Answer 290

indicated in unexplained infertility oligo / ano-ovolation where OI alone failed moderately low sperm counts disadvantages include time consuming with frequent visits, tests and procedures emotionally demanding expensive risk of multiple pregnancy and ovarian hyperstimulation

Answer 291

indicated in cases where OI with IUI failed same disadvantages as OI with IUI success rates are moderate 20% success rate in women age <35 10-15% success rate in women aged 35-39 <10% success rate in women aged 40 note that success rate of SO with IUI is greater than OI with IUI

Answer 292

in vitro fertilization is stimulation of follicle which is then retrieved and fertilized with sperm in-vitro followed by re-insertion of fertilized embryo back into uterus to be implanted indication for in-vitro fertilization 1. tubal obstruction 2. severe endometriosis 3. severe oligo-azoospermia (very low sperm count) 4. polycystic ovarian syndrome with failed medical therapy 5. failed SO with IUI at least 3 times 6. donor egg is needed (e.g. primary ovarian insufficiency) 7. advancing maternal age (>40) general procedure have 4 steps 1) FSH stimulation by subcutaneous injection to grow multiple follicles under close ultrasound and bloodwork monitoring 2) egg is aspirated with needle inserted through vagina into ovary under ultrasound guidance 3) retrieved egg is fertilized with sperm to make embryo by standard in-vitro fertilization or intra-cytoplasmic sperm injection (ICSI) a) in standard in-vitro fertilization, egg is mixed with solution of millions of sperm and one of those sperm will fertilize the egg, resulting in embryo b) in ICSI, 1 sperm is chosen and then inserted into the egg resulting in embryo c) standard in-vitro fertilization or ICSI depend on sperm count, motility and morphology where ICSI preferred if male partner sperm sample have low count, low motility and low percentage of normal morphology d) the fertilized embryo will be grown in petri-dish for 3-5 days (emulating days embryos traverse through uterine tube before implantation) e) good quality fertilized embryos can be frozen (cryoperserved) for future use 4) fertilized embryo is then inserted via catheter into uterus under ultrasound guidance, so that it can implant into uterus and start pregnancy a) in young women (<38), 1 or 2 fertilized embryos is inserted into uterus hoping 1 will implant b) in older women (>42), 5 fertilized embryos is inserted into uterus hoping 1 will implant ``` IVF have highest success rate overall success rate ~40% in all women ~50% success rate in women age <35 ~40% success rate in women age 35-39 ~20% success rate in women age >40 ```

Answer 293

Within 72h of potential exposure (contact with perpetrator's genitalia)

Answer 294

Ceftriaxone 250 mg IM 1 dose or Cefixime 400 mg PO 1 dose

Answer 295

Azithromycin 1g PO 1 dose or Doxycycline 100 mg PO q12h for 7 days

Answer 296

Metronidazole 2g PO 1 dose

Answer 297

hep b vaccine if unvaccinated (asap, then repeat doses at 1-2 months and 4-6 months after 1st dose)

Answer 298

Zidovudine (AZT) 200mg PO Q8H or 106mg/m2 per dose Q8H for 4 weeks PLUS Lamivudine 150mg per dose Q12H or 4mg/kg per dose Q12H for 4 weeks consider HIV prophylaxis if assailant is known to be HIV positive or is at high risk for being HIV positive alternative for adolescents: 300mg AZT / 150mg Lamivudine Q12H for 4 weeks

Answer 299

Levonorgestrel 0.75 mg once then repeated in 12h

Answer 300

``` Peritoneum Pelvic viscera Endopelvic fascia Elevator ani muscle Perineal membrane Superficial genital muscles Vulvar subcutaneous fascia Fat Skin ```

Answer 301

Oval opening between the levator crura through which passes the vagina and urethra

Answer 302

vaginal uterine axis is parallel to long axis of body when supine, but when standing, lower 1/3 vagina is parallel to the long axis of body but the upper 2/3 vagina & uterus are perpendicular to long axis of body

Answer 303

Structural Support anterior support: lower 1/3 vagina supported by pubouretral and urethropelvic ligament, which contains elastin and collagen with smooth muscle lateral support: lower 1/3 vagina supported by endopelvic fascia which attaches to the arcus tendineus; upper 2/3 vagina & uterus supported by cardinal (Mackenrodt’s) ligament posterior support: uterus supported by uterosacral ligament apical support: uterosacral ligament and upper support of arcus tendons 2) Mechanical Support constant levator ani muscles contraction activity pulls rectum anteriorly & superiorly, help maintain urinary & fecal incontinence (levator ani muscle involuntarily contracts during cough) cardinal and uterosacral ligaments, pubo-cervical fascia flap valve closure: upper vagina covers opening in levator plate once one of the supports fails, then progressive damage to other supports over time due to extra strain, leading to pelvic organ prolapse

Answer 304

syndrome of urgency, frequency, nocturia, urinary incontinence

Answer 305

Immobility

Answer 306

Chronic valsalva maneuvers Pelvic floor relaxation Pregnancy and childbirth

Answer 307

Medication Smoking Obesity

Answer 308

Neurologic problems Medication

Answer 309

a) detrusor overactivity - neurologic (spinal cord injury) - inflammation (cystitis, stone, tumour) - structural (bladder neck obstruction tumour stone, BPH) - idiopathic b) decreased bladder compliance - fibrosis of bladder - non-functioning bladder neck or proximal urethra: neurological disease, trauma, surgery, aging

Answer 310

a) Urethral hypermobility - childbirth - pelvic surgery - aging - levator muscle weakness b) intrinsic sphincter deficiency - aging - hypoestrogen state - pelvic surgery - neurologic problem

Answer 311

weakened pelvic floor allowing bladder neck and urethra to descend with increased intra abdominal pressure

Answer 312

Supra-pubic pressure Over distended bladder Continuous incontinence

Answer 313

``` anti-histamine anticholinergics ACE inhibitor, diuretics anti-depressants, antipsychotics alpha agonists, alpha 1 blockers ```

Answer 314

for urinary incontinence insert cotton swab into urethra, where positive test = movement of swab by >30 degrees with straining which suggest urethra hyper mobility causing stress urinary incontinence

Answer 315

(S2-4): anal sphincter contraction with squeezing of clitoris, bulb penis or tugging of Foley catheter

Answer 316

(S2-4): ipsilateral contraction of anal sphincter upon stroking of the peri-anal skin

Answer 317

Urine analysis R&M, C&S Suspected overflow - post void residual u/s suspected urgency - cystometry to diagnose detrusor overactivity severe voiding symptoms - urine flow rate and urodynamic testing suspected structural disease within urethra or bladder - cystoscopy

Answer 318

Based on history and urodynamics study

Answer 319

History and positive stress test on physical

Answer 320

bladder u/s showing PVR > 200 cc

Answer 321

1st line = lifestyle modification, weight loss, pelvic floor exercises (Kegel, vaginal cones, biofeedback, electrical stimulation), bulking agents, estrogen replacement therapy 2nd line = pessary for female (medical device to provide structural support of vagina) last line = surgical treatments open or laparoscopic Burch Retropubic Urethropexy (RPU), where placing surgical suture at bladder neck and tying it to Cooper ligament pubo-vaginal sling procedures, where a band of sling is placed under bladder neck that tightens (closing urethra) during Valsalva maneuver mid-urethral slings, which can be retropubic tension-free vaginal tape (TVT) or obturator TVT, where a sling is placed around mid urethra that tightens (closing urethra) during Valsalva maneuver surgical treatments have 80-90% cure rate at 5 years

Answer 322

1st line = lifestyle modification (decrease fluid intake, limit caffeine intake, smoking cessation, weight loss), bladder habit training, estrogen replacement therapy 2nd line = medication: anti-cholinergics (Tolterodine, Oxybutynin, Trospium, Solifenacin, Darifenacin, TCA) last line = Botulinum toxin, sacral neuromodulation no role for surgery

Answer 323

combination of management for urgency and stress incontinence

Answer 324

lifestyle changes catheterization treat underlying cause

Answer 325

herniation of pelvic organs to or beyond the vaginal walls

Answer 326

herniation of anterior vaginal wall often associated with descent of bladder (cystocele) and urethra (urethrocele)

Answer 327

herniation of posterior vaginal wall often associated with descent of rectum (rectocele) and / or intestines (enterocoele)

Answer 328

descent of apex of vagina (uterus and cervix, cervix alone or vaginal vault) into lower vagina to hymen or beyond vaginal introitus, can be associated with enterocele

Answer 329

anterior, posterior and apical compartment prolapse

Answer 330

demographics: age OB&GYN history: pregnancy, vaginal childbirth (which stretches pelvic muscle and fascia that may cause permanent damage) body habitus: obesity past medical history: previous pelvic surgery other: hypo-estrogenic state (post-menopause), connective tissue disorder social history: smoking

Answer 331

``` contributing factors lead to weakness in pelvic floor that hold pelvic organs in place including aging declining quality of collagen estrogen withdrawal constipation chronic cough ``` weakness in pelvic floor structures lead to prolapse of organs herniating into vaginal wall, which descends into what was originally vaginal canal

Answer 332

sensation of fullness, pressure or bulge in vagina organs falling out of vagina urinary symptoms: urinary incontinence or retention (may be complicated by urinary tract infection or renal impairment) -- pelvic organ prolapse may mask stress urinary incontinence by organ compressing on urethra, which is important, because any surgery fixing pelvic organ prolapse will create new problem of stress incontinence GI symptoms: constipation OB&GYN symptoms: vaginal bleeding or discharge from erosions or ulcerations

Answer 333

grade 0 = no prolapse grade 1 = prolapse descending to upper 1/3 of vagina grade 2 = prolapse descending to mid vagina grade 3 = prolapse descending to level of hymenal ring or introitus grade 4 = prolapse descending past hymenal ring

Answer 334

treatment is indicated for any symptomatic pelvic organ prolapse 1st line = pelvic floor exercises (Kegels, vaginal cones, biofeedback, electrical stimulation of pelvic floor), estrogen replacement therapy (systemic or local) 2nd line = pessary (medical device inserted into vaginal canal to provide structural support to return and hold prolapsed organ to its original place) last line = surgery

Answer 335

urinary retention due to organ prolapse (which may lead to hydronephrosis and renal failure), otherwise all other surgeries are elective procedures

Answer 336

surgery can be reconstructive or obliterative reconstructive aims to correct and restore normal anatomy, which can be via open or vaginal approach in reconstructive surgery, supporting structures (uterosacral ligament, sacrospinous ligament) are reattached or shortened; or organs are pexed (tethered) to other internal pelvic structures to prevent prolapse via mesh vault prolapse: sacralcolpopexy, sacrospinous fixation, uterosacral ligament suspension cystocele: anterior colporrhaphy (plication of pubovervical fascia), may use graft to provide support which can be sutured to cardinal uterosacral ligament, endopelvic fascia or obturator fascia rectocele: posterior colporrhaphy (posterior repair), plication of endopelvic fascia and perineal muscle approximated in midline to support rectum and perineum enterocele: contents reduced, neck of peritoneal sac ligated, uterosacral ligament and levator ani muscle approximated obliterative removes and / or closes off all or portion of vaginal canal by colpocleisis (closure of vagina) or colectomy to reduce viscera back into pelvis, which is only via vaginal approach

Answer 337

urinary incontinence, dyspareunia, recurrence of relapse (30% risk)

Answer 338

Obstetric Iatrogenic Local disease causing inflammation

Answer 339

obstetric fistula usually result from prolonged, obstructed labour without timely medical intervention 1) prolonged, obstructed labour result in sustained pressure of baby’s head on mother’s pelvic bone, damaging pelvic soft tissue 2) damage of pelvic soft tissue result in fistula from vagina to bladder or rectum

Answer 340

vesicovaginal or rectovaginal fistula: recurrent vaginitis, irritation of vulva, vagina and perineum, dyspareunia vesicovaginal fistula: uncontrolled leakage of urine into vagina (“urinary incontinence” or “increased vaginal discharge” by patient), recurrent urinary tract infection, abnormal urinary stream, hematuria rectovaginal fistula: uncontrolled leakage of feces into vagina (“fecal incontinence” or “foul smelling vaginal discharge” by patient), flatus into vagina

Answer 341

A) Vesicovaginal fistula if small fistula, then trans-urethral or supra-pubic catheter to drain bladder, allowing fistula to heal if large fistula, then surgical repair (lysis of fistula and then closure of fistula with sutures), which can be via vaginal or abdominal open approach B) Rectovaginal fistula surgical repair (lysis of fistula and then closure of fistula with sutures), which can be via vaginal or abdominal open approach

Answer 342

last natural menstrual period, defined as 12 months of amenorrhea after the last natural menstrual period, typically occurring at age 45-55

Answer 343

40-45 years

Answer 344

menopause before age 40

Answer 345

after 55 years

Answer 346

transition period of altered ovarian hormone leading up to menopause and 1 year after menopause

Answer 347

progression from regular cycles to shortened cycles to irregular cycles then to menopause peri-menopause can start as early as mid 30s and last 2-8 years up to menopause

Answer 348

in time around menopause, there is narrowing of thermoneutral zone, which result in regulatory response of sweating or shivering in response to small change in temperature loss of estrogen lead to atrophy of vagina and bladder incontinence low estrogen lead to dyslipidemia, increase plaque development and inhibit vasodilation, thereby increasing risk of cardiovascular disease

Answer 349

symptoms can be throughout peri-menopause and post-menopause there is spectrum of symptoms, where menopause can range from asymptomatic to symptomatic severely affecting quality of life Symptoms vasomotor: hot flashes, night sweats affect ~60% of menopausal women majority of post-menopausal women will experience hot flashes <7 years, but hot flashes can persist for >15 years exacerbated by obesity, smoking usually have trigger such as alcohol, warm ambient environment, hot drinks cognitive: poor memory, poor concentration psychiatric: depression, irritability, emotional lability, sleep disturbance menopause can initiate de novo psychiatric disorder or worsen existing psychiatric disorder urogenital: vaginal dryness, urinary frequency & urgency, diminished libido vaginal dryness often 1st sign of menopause and progressive with time, leading to discomfort, dyspareunia, bleeding, post-coital bleeding or discharge general: fatigue, myalgia & athralgia complication due to low estrogen in post-menopause: increased risk of cardiovascular disease, osteoporosis, colorectal cancer

Answer 350

hormone dependent cancer: breast cancer, endometrial cancer arterial thromboembolic disease: myocardial infarction, angina venous thromboembolism: deep vein thrombosis, pulmonary embolism cardiovascular disease: coronary artery disease, myocardial infarction, stroke severe active liver disease un-investigated abnormal uterine bleeding due to possible endometrial cancer and hormone replacement worsening uterine bleeding

Answer 351

FSH, LH, and E2 tend to fluctuate during menopause and usually not used, also due to the fact that peri-menopause and menopause are clinical diagnoses usually menopause have high FSH, high LH and low E2

Answer 352

cardiovascular disease risk factors: lipid profile, blood glucose / HbA1C cancer risk factor: mammogram osteoporosis risk factor: BMD pelvic ultrasound as baseline, which can be used to compare and detect endometrial hyperplasia post hormone replacement

Answer 353

clinical retrospective diagnosis which rarely requires investigation - diagnosed if amenorrhea for 1 year and in normal age range (45-55)

Answer 354

lifestyle modification recommended for everyone reducing core body temperature (fan, reduce room temperature, lighter clothing) regular exercise weight loss smoking cessation avoid known trigger such as hot drinks or alcohol for vasomotor symptoms, consider prescribing systemic hormonal therapy (HT) 45 for urogenital atrophy, prescribe local vaginal estrogen

Answer 355

Estrogen and progesterone if patient has an uterus OR estrogen only if patient does not have an uterus

Answer 356

HT is not equivalent to OCP HT is at a lower dose which only partially replaces the estrogen and progesterone hormone level to a level below normal whereas OCP is at a higher dose which increases estrogen and progesterone hormone to a level above normal HT is safer than OCP due to lower doses contraindication for HT and OCP are not the same

Answer 357

indication: menopausal symptoms (vasomotor, vaginal dryness) that is negatively impacting quality of life to be started in critical window (3-5 years after last menstrual period) for maximum of 5 years therapy in patients with premature ovarian failure, HT should be used up until normal menopause age (i.e. age 50) for its cardio-protective effect HT is not recommended for prevention of coronary heart disease or osteoporosis due to risk of breast malignancy and cardiovascular disease

Answer 358

cardiovascular disease: stroke, coronary artery disease, myocardial infarction VTE related: smoking, previous VTE including DVT, PE malignancy: previous breast cancer, endometrial cancer acute liver disease

Answer 359

hormonal therapy replaces low estrogen in menopause, negating menopausal symptoms as well as negating health risks associated with low estrogen progesterone is added to lower risk of endometrial cancer from unopposed estrogen estrogen only HT can be considered in patients with total hysterectomy

Answer 360

types of estrogen oral conjugated equine estrogen (CEE/premarin), which is not bio-identical oral estrase, which is bio-identical transdermal estradiol, which is bioidentical types of progesterone oral micronized progesterone, which is bio-identical progestin, which is a synthetic drug and not bio-identical

Answer 361

estrogen can be delivered orally or transdermally (gel, patch) oral estrogen is inferior to transdermal, because it increases risk of VTE the transdermal patch bypass liver to avoid VTE risk, are relatively stable in blood and permit measurement of serum estradiol for dose adjustment transdermal estrogen route includes gel and patch progesterone is usually delivered orally

Answer 362

no convincing evidence that HT increase risk of CVD in newly menopausal women starting HT HT started in critical window (3-5 years after last menstrual period) do not increase CVD risk HT initiated outside critical window (>5 years after last menstrual period) can increase CVD risk

Answer 363

HT only increase VTE risk by a minimal amount (2-3 additional cases per 10,000 users) with greatest risk in 1st year of use risk of VTE decreases with lower dose and transdermal route of estrogen

Answer 364

HT as risk for stroke and dementia is unclear risk factors for stroke should be addressed HT should be on the lowest dose

Answer 365

longer duration of HT increases risk of breast cancer (8 additional cases per 10,000 person years) usually breast cancer risk increases after 5 years of HT patients taking HT should undergo regular screening for breast cancer

Answer 366

start HT with a low dose and then slightly increase until menopausal symptoms improve thus to be at minimally effective dose while on HT, reassess risk for CVD, VTE and breast cancer regularly stop HT by age of 60 or after 5 years of HT due to increased risk for CVD and breast cancer if possible, use transdermal estradiol to decrease risk of VTE if patient have uterus, add micronized progesterone

Answer 367

mood symptoms breast soreness bloating vaginal bleeding

Answer 368

if hormonal therapy is contraindicated or not desired, then 2nd line treatments may be considered for vasomotor symptoms anti-depressant: venlafaxine (Effexor), desvenlafaxin anti-epileptics: gabapentin anti-hypertensives: clonidine venlafaxine and gabapentin are most commonly used complementary and alternative therapy is not recommended due to lack of evidence for efficacy and safety

Answer 369

1st line treatment for vaginal atrophy in absence of vasomotor symptoms can be added to HT if HT does not resolve vaginal atrophy

Answer 370

cream: premarin vaginal cream, estragyn cream vaginal suppository: vagifem vaginal ring: estring

Answer 371

Due to only local effect, local vaginal estrogen not associated with CVD, VTE nor breast cancer

Answer 372

local vaginal estrogen need to be taken life-long

Gynecology (Tony's) Flashcards

(406 cards)