Flashcards in women's health Deck (299):
when should pap smears begin and end? and how frequent?
age 21 until 65
every 3 years: 21-29
every 5 years with HPV cotesting from ages 30-65
who is gardasil recommended for?
females age 9-26. intramuscular injections @ 0,2 and 6 months
when should clinical breast exam and mammogram begin?
breast exam: annually starting at age 19
mammogram: annually starting at age 45 - earlier if family history of young onset, BRCA positive
BRCA mutation increases your breast and ovarian cancer risk by how much?
BC: 50-80& compared to lifetime risk in gen population of 12%
OC: 40-50% (BRCA1), 10-20% (BRCA2) compared to lifetime risk in general population of 1.4%
what is HNPCC (lynch syndrome)
mutation involved mismatch repair genes
COLORECTAL CANCER RISK: 50-70% (compared to 2% risk in general population)
ENDOMETRIAL CANCER risk: 30-60% (compared to 2-3% in general population)
inflammation + infection of the vagina
physiological changes for vaginitis
symptoms of vaginitis
change in discharge (color and or consistency)
white, thick, curd-like discharge, adherent to vaginal walls and/or cervix with associated pruritus, dyspareunia, erythema, and edema is what?
what are risk factors for vaginitis?
diabetes (may be first sign of DM)
long-term use of broad-spectrum antibiotics
use of corticosteroid meds
heat, moisture, occlusive fabrics
diagnostic for vaginitis
we mount with spores and hyphae
how do you treat vaginitis?
ask if they prefer intravaginal agents or oral agents
intravaginal - clotrimazole, miconazole, terconasole
-creams, suppositories, and tablets
7 day regimen is recommended
oral: fluconazole (diflucan) 150 mg PO x 1 dose
if complicated, repeat dose in 72 hours
for vaginitis is therapy recommended for male partners?
what is the most common vaginitus
signs and symptoms of bacterial vaginosis
may be asymptomatic
grayish malodorous discharge
may worsen after vaginal intercourse and after completion of menses
diagnosis of bacterial vaginosis
positive amine of "whiff" test - addition of KOH releases amines causing a "fishy" odor
wet mount wiht clue cells
pH > 4.5
treatment of bacterial vaginosis
metronidazole (flagyl) 500 mg PO BID x 7 days
metronizaole gel (metrogel) 0.75% PV qhs x f days - used twice weekly for 6 months can reduce recurrences
if allergic to flagyl, then clindamycin 300mg PO BID x 7 days
therapy not recommended for male partners
patients can be asymptomatic or present with frothy gray or yellow-green vaginal discharge (copious), pruritus, cervical petechiae ("strawberry cervix")
diagnosis of trichomoniasis
women: trichomonas vaginalis
wet mount with motile lagellated anerobic protozoa (always double check) - motile trichomonads
vaginal pH > 4.5
pap smear has limited sensitivity and low specificity
men: most reliable is PCR/ culture of urine or urethral swab
treatment of trichomoniasis
metronidazole (flagyl) 2g PO x 1 dose
tinidazole 2g PO x 1 dose
does a partner have to be treated for trichomoniasis?
where is the highest incidence of chlamydia?
complications of chlamydia
neonatal transmission: conjuctivitis, pneumonitis
presents with watery to purulent discharge, cervical friability, urethritis, cervicitis may be asymptomatic
what is the incubation period for clamydia trachomatis?
how do you diagnose chlamydia?
NAAT (nucleic adcid amplification) --> women its a vaginal swab, men its urine
DNA probe with endocervical swab
when is a TOC (test of cure) recommended for chlamydia?
only in pregnancy - tests for reinfection in 3 months
treatment of chlamydia
KNOWN EXPOSURE- TREAT EMPIRICALLY
azithromycin 1 g orally in a single dose (observed) or doxycycline 100 mg orally twice a day for 7 days
**partner must be treated!!
proctitis/epidydimitis: doxy 100 mg po BID x 7 days plus ceftriaxone 250 mg IM x 1
presents with dysuria, purulent vaginal discharge, pharyngitis, and possible disseminated disease
diagnosis of gonorrhea
neisseria gonorrhoeae - incubation period of 2-8 days
DNA probe with endocervical swab
urine PCR (less sensitive)
culture other sites (pharynx, rectum)
all sexually active males with symptoms: urine testing
all sexually active females with symptoms : vaginal or endocervical swab
-treat before culture
treatment of chlamydia
ceftriaxone (recephin) 250 mg IM x 1 dose
azithromycin 1 g PO x 1 dose
does the partner have to be treated for chlamydia?
inflammation of the uterus, fallopian tubes, and/or ovaries (salpingitis, endometritis)
causes of PID
STIs (c trachomatis, n gonorrhoeae)
enteric gram negative organisms
ascending infections (G. vaginalis, H. influenzae, S. agalactiae)
risk factors for PID
multiple sex partners
age 15-24 years old
contraceptive practices (OCPs, condoms decrease risk)
history of STIs
diagnosis of PID
cervical motion tenderness (chandelier sign)
abnormal cervical or vaginal mucopurulent discharge
WBC > 10,000
when should you hospitalize someone for PID?
if surgical emergencies can't be ruled out (appendicitis, peritonitis)
can't tolerate PO regimen
failed outpatient treatment
treatment of PID
cefoxitin 2g IV q 6 hrs X 24 hours after signs of improvmenent
doxycycline 100 mg BID x 14 days
metronidazole 500 mg BID x 14 days (if BV positive or TOA)--> not in janet's
can also get same regimen outpatient but cefoxitin is IM
transition to oral abx once clinically improved . complete 14 day course
diagnosis of syphilis
genital ulcer - painless
treponemal pallidum (incubation period of 9-90 days)
non-treponemal serologic testing (RPR)
treponemal serologic testing
stages os syphilis
primary: painless chancre - well demarcated hard ulcer with raised, rolled borders. resolves in 1-5 weeks
secondary: 6-12 weeks post-exposure. maculopaular rash involving palms and soles, lymphadenopathy, mucosal pathes in mouth/genitals, condyloma lata
tertiary: late syphilis
5-20 years later, solitary gumma, cardiovascular syphilis, neurosyphilis
tx of syphilis
early latent (less than 1 year):
benzathine penicillin G 2.4 million units IM x 1 dose
primary: penicillin G 2.4 million units IM x 1 dose
secondary/tertiary: penicillin G 2.4 million units IM x 3, repeat in 1 week
tertiary, late latent
penicillin G 2.4 million units IM weekly for 3 weeks
**PARTNER MUST BE TREATED*
if they have PCN allergy, need to be desentitized
high risk HPV types
16, 18 - cause 70% of all cervical cancers; can also cause vulvar, vaginal, anal, oropharyngeal and penile cancer
what percent of sexually active adults will acquire HPV in their lifetime?
over 80% - a diagnosis of HPV in one sex partner is not indicative of sexual infidelity in the other partner
physical exam for HPV
flat, papular, pedunculated growths
commonly found around the introitus
how do you diagnose HPV?
biopsy - atypical, indurated, pigmented, ulcerated. immunocompromised, refractory to therapy
HPV DNA tests
treatment of genital warts
imiquimod 5% cream (aldara) - immune enhancer that stimulates interferon and cytokine production
apply 3x per week at bedtime for up to 16 weeks
wash the tx area with soap and water 6-10 hours after the application
trichloroacetic acid (TCA) - destroys warts by chemical coagulation of proteins. apply weekly in office setting. low viscosity therefore can spread rapidly and damage adjacent tissues
cryotherapy with liquid nitrogen - destroys warts by thermal-induced cytolysis. repeat appications every 102 weeks
CO2 laser vaporization
prevention of HPV
gardasil (males and females age 9-26) - even if you have HPV, should get it
when is HSV recurrence most common?
during first year of infection
can HSV be transferred from someone who does NOT have a visible sore?
yes - can also transfer to another part of the body.
more likely for an infected male to transmit to female partner than vice versa
how do you diagnose HSV?
PCR testing (more rapid results than culture)
treatment of HSV
acyclovir 400 mg TID x 7-10 days
acyclovir 200 mg 5 times daily x 7-10 days
acyclovir 400 mg TID x 5 days, 800 mg BID x 5 days, or 800 mg TID x 2 days
initiate therapy within 1 day of lesion onset or during the prodrome that precedes outbreaks. topical therapy offers minimal clinical benefit
acyclovir 400 mg BID
famiciclovir 250 mg BID
reduces frequency of recurrences by 70-80%
what is the risk of transmission among women who acquire genital herpes near the time of delivery?
1% among women with h/o recurrent HSV at term or who acquire genital HSV during the first trimester
suppression from 26 weeks gestation through delivery
C-section if active lesion present at delivery
painful, soft, ulcer with nectrotic edges and inguinal lymphadenopathy
chancroid- diagnosis by H. ducreyi, gram stain shows "school of fish" pattern. very rare (6 cases in 2014)
treatment of chancroid
azithromycin 1 g x 1 dose
tender inguinal and/or femoral lymphadenopathy, unilateral, self-limited genital ulcer of papule, anal pain, tenesmus, proctocolitis with mucoid and/or hemorrhagic discharge. caused by chlamydia, increasing in the MSM population
lymphogranuloma venereum (LGV) - diagnosis is C. trachomatis. clinical diagnosis of exclusion
treatment of LGV
doxycycline 100 mg bid x 21 days
rare in US, painless ulcers, slowly progressive lesions without regional adenopathy, highly vascular (beefy red appearance) , anogenital infection
granuloma inguinale- difficult to culture , punch biopsy with Wright's stain exhibits donovan bodies
tx: doxycycline 100 mg BID x 3 weeks
what is the definition of infertility?
inability to conceive after 12 months or more of unprotected intercourse ( 6 months if AMA) --> 85% of couples will conceive within the first 12 cycles of trying
who should have fertility testing?
anyone unable to conceive if trying for at least one year
couples with a female partner 35 years old or older who have been unable to conceive after 6 months
what are you looking for in the history for a fertility evaluation?
chronic disease (thyroid, uncontrolled diabetes, lupus, painful menses? endometriosis?)
family hx of infertility, miscarriage
STDs- risk of tubal disease
surgical hx: abdominal surgery - risk of tubal disease
menstrual cycle history -regular vs. irregular
PMH of partner
what do you look for with the pelvic US for a fertility evaluation?
antral follicle count
what test looks at the tubes and uterine cavity?
labs for a fertility evaluation
cycle day 3 labs - FSH, estradiol
luteal phase progesterone
evaluation of FSH for a fertility evaluation
cycle day 3
FSH 10 decreased ovarian reserve - refer
must be done with estradiol (estradiol
evaluation of AMH for a fertility evaluation
antimullerian hormone: protein produced by granulosa cells in the ovary and controls the formation of primary follicles
this test is a direct reflection of follicle/egg status and is not influenced by estradiol/other hormones. it is also consistent through menstrual cycle
AMH (antimullerian hormone)
3-3.5 25 y/o
2-2.5 35 y/o
1.0 40 y/o
normal sperm parameters
volume 2.0-5.0 mL
count > 20 x 10^6/mL
motility > 50%
morphology > 14%
-stain approximately 200 sperm
fertility tx for PCP
optimize natural fertility
ovulation predictor kits
provide reassurance to anxious couples
what is the most fertile day?
day before ovulation (egg viable for 12-24 hours, sperm 72)
in general, start intercourse around CD10 and have IC every other day for a week
treatment for infertility that is an anti-estrogen that increases endogenous FSH levels
clomid - clomiphene
50 mg tablets, one tab by mouth CD3-7
try for 3 cycles then refer
who is clomid best for?
patients who are not ovulating - helps recruit an egg for ovulation. may help select the 'best' egg to ovulate in a cycle and support a "strong" follicle with better progesterone support
fertility treatment done by specialists
ovulation induction: clomid, femara, gonadotropins, ultrasound monitoring
intrauterine insemination: male factor, cervical factor, timing
donor sperm IUI
in vitro fertilization (tubal disease, endometriosis, severe male factor, unexplained infertility)
donor egg IVF
difference between primary and secondary amenorrhea
primary: absence of menses @ age 15 years in the presence of normal growth and secondary sexual characteristics or 13 years, if no menses have occurred and there is an absence of secondary sexual characteristics
-sex chromosome disorders
-H-P-O axis problem
secondary: absence of menstruation for 3-6 months in a women who previously menstruated normally
-pituitary or hypothalamic disorders (insufficiency, failure or tumors)
-ovarian disorders (dysfunction, neoplasm, PCOS)
-endocrine disorders (cushings, addisons, thyroid, diabetes)
outermost cavity of the female reproductive system and forms the lower part of the birth canal
vagina - 8-12 cm in length
area of skin between the vagina and anus
when does the menstrual cycle start?
with the removal of the endometirum and release of FSH by the anterior pituitary
what occurs during the ovarial cycle?
development of ovarian follicle
production of hormones
release of ovum during ovulation
what occurs during the uterine cycle?
removal of endometrium from prior uterine cycle
preparation for implantation of embryo under the influence of ovarian hormones
what occurs during the follicular phase?
1. rise of FSH during first days of the cycle, several ovarian follicles are stimulated
2. follicles compete with each other for dominance
3. dominate follicle is formed
4. as they mature, the follicles secrete increasing amounts of estrogen, which thickens the new functional layer of the endometrium in the uterus
5. estrogen also stimulates crypts in the cervix to produce fertile cervical mucus
at the end of this phase, ovulation occurs
what occurs during ovulation
during the follicular phase, estrogen suppresses production of luteinizing hormone (LH) from the pituitary gland
once estrogen levels reach a threshold stimulate production of LH
the release of LH matures the ovum and weakens the wall of the follicle in the ovary
after being released from the ovary, the ovum is swept into the fallopian tube
solid body formed in an ovary after the ovum has been released into the fallopian tube and produces significant amounts of progesterone
corpus luteum- falling levels of progesterone trigger menstruation and the beginning of the next cycle
what marks the beginning of ovulation?
average age of menarche
12.5 - begins approximately 2-3 years after initiation of puberty
when does a period become regular?
approximately after 2-2.5 years
prolonged/excessive bleeding occurring at regular intervals. often c/o large clots
irregular intervals, frequent bleeding, non-excessive amounts
metrorrhagia - often associated with dysfunctional uterine bleeding
prolonged, excessive bleeding at irregular intervals
polymennorrhea (oligomenorrhea is regular bleeding > 35 day intervals)
absence of uterine bleeding for at least 6 months or 3 cycles
how is premenstrual dysphoric disorder different from PMS?
more severe, cause both mood symptoms and functional impairment
psychological diagnosis DMS category
tx: SSRIs: fluoxitine, birtch control
difference between primary and secondary dysmennorhea
primary: no pathologic causes, hormonally due to rise in prostaglandins
secondary: due to an organic cause
-reproductive organs: endometriosis, ovarian cysts, PID, post-op adhesions
GI: constipation, IBS, IBD
causes of abnormal uterine bleeding
myomas: subserosal, intramural, submucosal
systemic diseases (thyroid, liver, coagulation disorders)
growth of extra-uterine endometrial tissue
endometriosis - endometrial tissue can be found on any intra-abdominal structures
symptoms of endometriosos
dysmennorhea : onset 2-7 days prior to menses, diminishes as menstrual flow decreases
infertility*** (3-4 times greater incidence in infertile women)
heavy and/or irregular uterine bleeding
gold standard for diagnosis of endometriosis
laparoscopy or laprotomy evaluation with tissue biopsies to confirm extra-uterine endometrial tissue
management of endometriosis
analgesics (naproxen 250 mg or 500 mg every 6-8)
danazol: suppresses menstruation
GnRH analogs: suppresses ovulation, therefore an increase in menopausal vasomotor symptoms is seen
GOAL: inhibit ovulation thus lowering hormone levels and preventing stimulation of implants and potentially shrinking their size
what accounts for 75% of primary amenorrhea?
how do you manage amenorrhea?
keep in mind that it's a symptom, so therapy is directed at the underlying cause, therefor proper evaluation and diagnosis is always required
weight loss (10% of body weight)
if endocrine problem treat underlying problem
menstrual regularity is important to maintain
what do women with PCOS exhibit?
a steady state of estrogen, androgen and LH as opposed to fluctuating levels seen in ovulating women
effects about 6% of premenopausal women
symptoms of PCOS
virilization: acne, deepening of voice, alopecia
what will a transvaginal US reveal for PCOS?
"string of pearls" on ovary
traditional evaluation of PCOS
total and free testosterone
how do you diagnose PCOS?
diagnosis of exclusion
rotterdam criteria (2/3)
-oligo or anovulation
-clinical or biochemical signs of hyperandrogenism
management of PCOS
weight reduction (7% reduction in body weight)
birth control (reduces hyperandrogenic effects and allows for normal menstrual cycles)
medroxyprogestone 10 mg/d x first 10 days of the month
insulin sensitizing therapy
definition of menopause
cessation of spontaneous menstrual bleeding for 1 year- results from loss of ovarian function which leads to a decrease in estrogen and progesterone hormones
average age is 51.5 years- premature menopause is defined as cessation of periods before age 40
what hormones rise in menopause?
LH and FSH
hormone replacement therapy for menopause
combined therapy: estrogen + progesterone - prevents endometrial hyperplasia, therefore no additional risk for uterine cancer
removal of the uterus and cervix
removing uterus without cervix
removing both tubes and ovaries
removing uterus, cervix, parametrium, and upper portion of the vagina
radial hysterectomy - doesn't include lymph nodes
patient positioning for pelvic exam
pediatrics: frog leg
degrees of uterine prolapse
1st: cervix still well within vagina
2nd: cervix at the introitus
3rd: cervix and vagina outside introitus
strawberry cervix (punctate lesions, erythematous in appearance) is a sign for what?
what is chadwick's sign?
bluish discoloration of the cervix or vaginal walls present 6-8 weeks gestation
what is hegar's sign?
softening of the cervical isthmus usually in the 2nd and 3rd trimester
what is the chandelier's sign?
pain with palpation of the cervix--> PID
what are DNA probes used for?
screening for chlyamydia and gonorrhea
what are wet mount or cultures used for?
to screen for yeast, BV, and trich
most common position of the uterus
anteverted (bent forward)
can also be:
Retroverted – bent backwards (~20%)
Anteflexed – top of the uterus folded forward
Retroflexed – top of the uterus folded backwards
where should you measure the uterus size?
from pubic symphysis to the uterine fundus
12 weeks – fundus rises above the pelvic brim
20 weeks – at the umbilicus
40 weeks – at the zyphoid process
what is included in the cervical cancer screening?
cervical cytology and oncogenic subtypes of human papillomavirus
Follow-up of abnormalities in screening tests with colposcopy and cervical biopsy may result in a diagnosis of
The ectocervix (surface of the cervix that is visualized on vaginal speculum examination) is covered in flat, squamous epithelial cells
-CIN refers to squamous abnormalities
The endocervix, including the cervical canal, is covered with tall, columnar or glandular epithelial cells
Glandular cervical neoplasia includes adenocarcinoma in situ and adenocarcinoma
As the squamocolumnar junction (SCJ) migrates over time, this creates the transformation zone
what is the transformation zone in the cervix?
represents the region of active cell division and therefore is the region most likely to develop abnormal growth --> where you need to sample with a pap smear
what type of HPV is thought to induce precancerous and cancerous lesions
most common high risk oncogenic or cancer-associated types
31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 69, 82
Low-risk = non-oncogenic types
Common types: 6, 11, 40, 42, 43, 44, 54, 61, 72, 81
where should a pap smear be done?
squamocolumnar junction/transition zone (where most changes begin)--> Cytologic evaluation
Primary purpose is to identify changes on the cervix related to cervical cancer
cervical cancer screening differences:
Diagnostic Testing = Cytology Only
Reflex Testing = HR-HPV added on if cytology result ASCUS ( atypical cells of undetermined significance) or above
Co-Testing = Cytology and HR-HPV
HPV Typing = Specifically looking for strains 16 and 18
Future Trends: Primary HPV Testing
who should be screened for HPV?
21-29: every 3 years with cytology. (Reflex testing every 3 years)
30-65: screening with a combination of cytology and HPV testing ("co-testing") every 5 years
over 65: negative prior screening ad no history within the last 20 years should not be screened
After a benign hysterectomy Don’t do it
HPV vaccinated: Recommended screening practices should not change on the basis of HPV vaccination status.
These guidelines do not address special, high-risk populations who may need more intensive or alternative screening, including:
History of high grade cervical dysplasia
History of invasive cervical cancer
Exposed in utero to diethylstilbestrol (DES)
Immune-compromised (HIV, s/p transplant, lupus, etc)
terminology for cytologic and histologic pap smear findings
cytologic: described with the
intraepithelial lesion (SIL)"
histologic: described with the term "cervical intraepithelial neoplasia (CIN)"
3 degrees of CIN severity
CIN 1 = low-grade lesion
refers to mildly atypical cellular changes in the lower third of the epithelium.
CIN 2 = considered a high-grade lesion
refers to moderately atypical cellular changes confined to the basal two-thirds of the epithelium (formerly called moderate dysplasia) with preservation of epithelial maturation. There is considerable variability in this category.
CIN 3 = high-grade lesion
refers to severely atypical cellular changes encompassing greater than two-thirds of the epithelial thickness and includes full-thickness lesions
direct microscopic visualization of the cervix
colposcopy- Entire cervix should be visualized including the transformation zone (squamocolumnar junction)
Abnormal areas can be biopsied to allow for diagnosis of cervical dysplasia
Endocervical curettage (ECC)
frequently performed as well
what can be used during a colposcopy that causes abnormal areas to turn white?
Lugol's iodine will stain normal vaginal tissue stains brown due to its high glycogen content, while abnormal tissues will not stain, and thus appears pale compared to the surrounding notmal tissue (called non-staining areas)
what is LEEP?
loop electrosurgical excision procedure
can be done in office or OR
diagnostic and therapeutic
cauterizes margins --> less bleeding, but pathologist unable to determine if margins positive or negative
what is CKC?
cold knife conization
always done in OR
pathologist able to give more detail about status of surgical margins
higher risk complications
what is the newest HPV vaccine?
gardasil 9- newly approved vaccine against HPV types 6, 11, 16, 18, 31, 33, 45, 52 and 58. Gardasil 9 adds protection against five additional HPV types (31, 33, 45, 52 and 58) which cause approximately 20% of cervical cancers and were not covered by previously FDA-approved vaccines. Approved for use in both males and females.
what is the latency period between HPV exposure and cervical cancer development?
benign pelvic masses
functional ovarian cyst - most common in premenopausal women
Leiomyomas (pedunculated fibroid)
what are the different physiologic cysts?
follicular cyst: Due to failure of follicle to rupture during normal ovulation
Smooth, thin walled, unilocular, round
risk factors for physiologic cysts and tx
Bilateral tubal ligation
tx: Watchful waiting
Surgery needed only if concern that brisk bleeding from a ruptured cyst may cause anemia or hemodynamic instability
what is a tubo-ovarian abscess
Usually due to PID
Occ related to endometriosis, pyelonephritis, malignancy
Associated w/ anaerobes or actinomyces
Present w/abdominal pain, +/- fever and leukocytosis
Rupture: peritonitis, fevers, chills, sepsis
Tx: antibiotics, drainage
"chocolate cyst" due to growth of ectopic endometrial tissue. Present w/ cyclic pelvic pain, dysmenorrhea, dyspareunia
this follows PID, fimbria are smooth and clubbed. Secretions collect within and distend the tube
On US, multiple hypoechoic mural nodules with incomplete septae
Benign neoplasm of smooth muscle origin. Usually originate from uterus, but can be in the broad ligament
Present in 25% of reproductive aged women
When degenerating, can appear as complex adnexal masses
Can cause elevation in CA-125
Dx – US, MRI
Symptom Treatment: OCP’s, IUD’s, Iron – “anemia”, & NSAIDS
Lupron - “Menopause” side effects
Uterine Artery Embolization
Surgery: Myomectomy vs. Hysterectomy
different ovarian tumors
Germ Cell Tumors
Arise from primordial germ cells
Sex Cord Stromal Tumors
Develop from the dividing cell population that would normally give rise to cells surrounding the oocytes, including the cells that produce ovarian hormones (the nongerm cell and nonepithelial components of the gonads)
Arise from epithelial cells
the most common benign ovarian GCT in women of reproductive age . Many asymptomatic
Can present w/pelvic pain from enlargement or torsion
10-15% are bilateral
Malignant transformation: 1-3%
teratoma (looks like hairball in the cyst)
this is diagnosed by US with a "tip of the iceberg" sign, fat-fluid levels, hair, and robitansky protuberance
what are cystadenomas?
Most common benign neoplasm
Thin walled, uni- or multi-locular
5 cm to >20 cm
Multiloculated, much larger
Less frequently bilateral
what is endometriomas associated with (symptom-wise)?
dysmennorrhea or dyspareunia (pain with sex)
Physiologic cysts may be associated with what?
dull, achy pain that is localized to the size of the mass
what is suggestive of tuboovarian abscess?
fever + vaginal discharge
fallopian tube cancer is associated with what?
Serosanguinous vaginal discharge without fever
what is the most appropriate initial study for a pelvic mass workup?
Both transabdominal and transvaginal should be obtained
Best evaluation of the adnexa (parts adjoining an organ)
if yo are at all concerned about a cancer, what test should you order at a minimum?
CXR (chest CT frequently not approved by insurance without bx proven cancer)
this is a tumor marker for epithelial ovarian cancer (but also elevated in many other settings)
CA125-glcyoprotein produced by ovary, peritoneal, and pleural linings
but also for other gynceologic malignancies and benign conditions, so use in conjunction with clinical picture
elevation in which tumor markers should prompt a GI workup?
CAE or CA19-9
tumor marker for breast cancer
what are most cases of ovarian torsion associated with?
when is surgery indicated for a pelvic mass?
malignancy is suspected(allows for definitive histologic dx)
Risk associated w/mass (torsion, infection, etc)
Mass is symptomatic
when should you refer a woman with a pelvic mass?
very elevated CA 125, ascites, evidence of abdominal or distant metastases
elevated CA125 level
nodular or fixed pelvic mass
evidence of abdominal or distant mets
what contraceptive method has the best and least effectiveness towards unintended pregnancy?
best: levonorgestrel IUD, female sterilization, copper-T IUD, injectible
worst: no method, spermicide, diaphragm
difference in contraceptive effectiveness
most effective: prevents pregnancy >99% of the time
IUD/IUS implants, sterilization
very effective: prevents ~91-99% (pills, injectables, patch, ring)
moderately effective: ~81-90: condom, sponge, diaphragm
ethinyl estradiol & progestin is an example of what form of contraception?
combined contraceptive pills
*(20ug, 35ug, 50ug) )
MOA of ethinyl estradiol & progestin
progestin suppresses ovulation by preventing LH surge, thickens cervical mucus, slows tubal motility, and thins the endometrium
ehinyl estradiol augments efficacy-inhibits FSH and improves cycle control by stabilizing the endometrium
is there an increase in risk of ischemic or hemohemorrhagic stroke is associated with use of OCs containing
Breast cancer patients and immediate post-partum patients, migraines with aura (increase risk of stroke), 35 and older and smoking : don’t use BC
Obsesity is not a contraindication to BC
what are contraindications to estrogen use?
smoking AND age > 35
HTN, vascular disease, artherosclerosis (prior MI or CVA), vascular disease, cardiomyopathy
history of PE/DVT
Known thrombogenic mutations, lupus with antiphospholipid antibodies
Major surgery with prolonged immobilization
Breast cancer, hepatoma, hormonally sensitive tumors
MOA of vaginal ring
Flexible ring with ethinyl estradiol & etognogestrel
MOA of progestin only pills (mini pills)-Micronor (Norethindrone)
Thickens cervical mucus
Slows tubal motility
daily use, no hormone free week
what is the injectible contraceptive and how long does it last?
150mg IM depot medoxyprogestrone acetate
104 mg SC depot medoxyprogsterone acetate
depo-provera, 13 weeks
disadvantages of injectable contraceptive?
Many patients (up to 70%) stop using by 1 year
Irregular spotting first 6-12 months
Weight gain (average 5.4 lbs in 1st year)
Temporary bone loss/thinning (reversible)
Slow return fertility upon stopping
what is the duration for nexplanon (implant)?
Single implant 4cm long
Downside that some women can have some irregular bleeding. Doesn’t increase, just makes it more sporadic. Don’t get an actual period, more just a couple days of spotting
MOA of nexplanon (implant)
systemic progestin suppression LH/FSH thickened cervical mucous, thin endometrium. doesn't' contain estrogen
what is paragard and its MOA and its duration?
copper IUD- non-hormonal IUD
Mechanism of Action
what else can paragard be used for?
emergency contraception for up to 5 days
what is mirena, dkyla, liletta?
MOA and duration of hormonal IUD
Mechanism of Action
Thickens cervical mucus
Impairs tubal and sperm motility
duration: 5 years
contraindications for IUDs
Pelvic inflammatory disease (within 3 mos)
Purulent cervicitis or pelvic infection (delay insertion until treatment is complete)
Post-abortal sepsis (within 3 mos)
Known pelvic tuberculosis
Wilson’s disease (Copper IUD)
Distorted uterine cavity (any congenital or acquired abnormality interfering with IUD insertion, including uterine fibroids)
Unexplained vaginal bleeding
Current malignant gestational trophoblastic disease, untreated or endometrial cancer
Breast cancer, other hormone sensitive cancers (LNG-IUD)
when can hormonal emergency contraception be given?
up to 72-120 hours after unprotected sex
what are the different emergency contraception?
Plan B – (use up to 72 hours after unprotected sex)- high dose progesterone- prevents LH surge. not that effective
Ella (ulipristal) -(use up to 120 hours after unprotected sex) - more effective but need scrip
Copper IUD (up to 5 days after ovulation)
what are indications for emergency contraception?
Intercourse within past 120 hours without contraceptive protection (independent of time in the menstrual cycle) although the longer the delay of initiating treatment, the lower the efficacy.
Barrier method dislodgment/breakage
Expulsion of IUD
Missed oral contraceptive pills
Error in practicing coitus interruptus
Exposure to teratogens (e.g., cytotoxic drugs)
the majority of women having abortions are what?
in their 20s, poor, non-hispanic white, never-married, not cohabitating, protestant
methods of abortion in first trimester
medication abortion (up to 10 weeks)
-Mifepristone in the office and then go home with misoprostol which terminates pregnancy
Antiprogestin: Mifepristone 200 mg
Prostaglandin analogue: Misoprostol 800 mcg
Different from FDA approved regimen!
Mifepristone 600 mg and Misoprostol 400 mcg
Dilation & Curettage
-Manual vacuum aspiration (MVA)
-Electrical vacuum aspiration
methods of abortion in second trimester
Dilation & Evacuation (12-13+ wks up to viability)
what is MVA?
Vacuum aspiration abortion, most generally through ~11 weeks LMP among U.S. providers
Evacuation of incomplete SAB’s or other pregnancy loss
Completion of incomplete or failed medical abortion
Suction component of D&E at 14-18 weeks LMP
Removal of amniotic fluid or as security curettage in D&E and induction abortion
second most reported STI in the US, usually has a higher incidence in men
neisseria gonorrhea- relationship with HIV - presences of NG infection facilitates transmission and acquisition of HIV
4 stages of infection of gonorrhea
local inflammatory response with or w/out systemic dissemination (typically infections of urogenital but can become systemic)
clinical presentation of uncomplicated vs complicated gonorrhea infection
uncomplicated: most are asymptomatic, can present with cervicitis/urethritis in females (generally infects the columnar epithelial cells of the cervix) or urethritis/epidydimitis in males
complicated: tenosynovitis (can affect multiple tendons), dermatitis, polyarthralgias (fever, chills, malaise at onset), purulent arthritis, often preceded by urogenital infection
-should sample joint fluid if have inflammatory arthritis
treatment of uncomplicated gonorrhea
ceftriaxone 250 mg IM x 1
azithromycin 1 g po x 1 (to cover for C. trachomatis)
what is not recommended for treating GC?
quinolones - because they have so much resistance
most commonly reported bacterial infection in the US
chlamydia trachomatis (more common in women)
complications in trichomonas in men
prostate CA if not treated, epididymitis, infertility
how should you treat trichomonas in pregnant women?
SYMPTOMATIC pregnant women should be treated AFTER THE FIRST TRIMESTER to reduce risk of preterm birth
ASYMPTOMATIC pregnant women - don't treat
which HSV can cause genital infection?
both but most recurrent genital herpes is cased by HSV 2
clinical features of primary infection of HSV
painful genital ulcers, fever, HA, tender local LAD, local pain and itching , dysuria . acute urinary retention can occur in severe infection and should be differentiated from urinary hesitation
diagnosis of HSV
viral culture of vesicle contents
cell culture and/or PCR swab for denuded lesions
tzanck smear - less sensitive and specific, only helpful if +, doesn't differentiate between types
HSV serology has limited value because positive serology can mean present or past infection
treatment of primary HSV infection
oral antivals - acyclovir, famcyclovir, valacyclovir for 7-10 days
what is the treatment for recurrent HSV?
shorter, episodic course antiviral dosing taken at first prodrome and at least within 48 hours of first lesion appearance
HSV suppressive therapy for very frequent attacks or multiple sexual partners
which HPV types account for most cervical CA
16 and 18
type 6 and 7 often cause benign genital warts
what is the test to diagnose HPV in males?
no FDA approved test
what occurs in primary syphilis
painless chancre (shanker) at inoculation site 3-6 weeks after non tender regional LAD occurs. resolves 4-6 weeks without scarring
what is secondary syphilis?
untreated patients enter a bactermic stage approximately 6 weeks after primary chancre heals. the bacteria multiply and spread via blood throughout the body
rash - macular lesions, symmetrically distributed- palms, soles, mucous membranes (also on palms and soles --> rocky mountain fever, endocarditis)
any organ system can be infected
what is tertiary syphilis?
develops over 6-40 years
slow inflammatory damage to small blood vessels and neurons
1. gummatous syphilis - granulomatous lesions become nectrotic and fibrotic - skin and bone
2. cardiovascular syphilis - aneurysm in ascending aorta or aortic arch due to chronic inflammation
3. neurosyphilis - asymptomatic, subacute meningitis, meningovascular syphilis, Tabes dorsalis, general paresis. CSF should be tested
screening for syphilis
utilizes a non-treponemal test -RPR and vDRL. based upon reactivity of patients blood with syphilis to a cardiolipin-chilerstol-lecithin Ag --> syphilis causes cellular damage and release of cardiolipin and lecithin, the body produces antibodies against these antigens. less sensitive and specific for primary disease
confirm: utilize a treponemal test - FTA-ABS, TP-PA, MHA-TP
-this will detect the antibody to the spirochete itself. confirmatory
how do you treat neurosyphilis?
benzathine PCN G 18-24 million units per day, administered as 3 to 4 million units IV every four hours x 10-14 days-> doesn't make it go awawy, but symptoms may improve
IF PCN allergy, desensitize
highest risk factor for PID
females with multiple sex partners, age less than 25, sti exposure, previous sti/pid
most common causes of PID
N. gonorrhoeae and C trachomatis
rare during pregnancy after 12 weeks due to mucous plut
perihepatitis due to ascending infection that causes inflammation of hepatic capsule. presents with RUQ pain radiating to the shoulder (similar to gallbladder), but they have normal liver labs. LAPARASCOPY- PATCHY PURULENT AND FIBRINOUS EXUDATE ("VIOLIN STRING" ADHESIONS)
fitz hugh-curtis syndrome
what weeks is the first trimester?
Start trimester on the date of the LMP
what weeks is the second trimester?
what weeks is the third trimester?
when is a fetus viable?
23-24 weeks gestation
preterm verse term
preterm: prior to 37 weeks gestation
labs to diagnose pregnancy
urine BhCG- doubles every 72 hours in pregnancy
A level of > 1500 with no sonographic evidence of a fetus is highly indicative of ectopic pregnancy
how do you determine the fundal height during pregnancy?
Palpate the uterine fundus with bimanual exam up to 12 weeks.
Palpate uterine fundus with abdominal exam after 16 weeks. (MacDonald Maneuver)
how much weight should a normal weight woman gain during pregnancy?
Gains by Trimester
-2 to 5 pounds total for 1st trimester.
- ~0.5 lbs per week for the first 28 weeks.
- ~1.0 lb every week after 28 weeks
72% of weight gain is due to physiologic changes (~9lbs)
- fetus, placenta, amniotic fluid, uterus, maternal blood volume, breasts, edema
what supplements should pregnant women be taking?
Iron: Supplement 30 mg FeSO4 daily
Folic Acid: 400 mcg daily
what dietary avoidances are in pregnancy?
Soft cheeses: Listeria (crosses placenta can lead to bacteremia.)
-Raw meats/fish: toxoplasmosis & salmonella
-Deli Meats: Listeria
-Fish: mercury levels can impact brain development
what are the ToRCH infections?
Toxoplasmosis (cat feces, no changing litter boxes)
what is the prenatal evaluation schedule?
Visits every 4 weeks until ~ 28 weeks
Visits every 2 weeks until ~ 36 weeks
Visits every week from ~ 36 weeks until delivery.
initial pregnancy labs
Urinalysis: w/culture & sensitivity
-proteinuria: sign of pre-eclampsia
-glucosuria: sign of gestational diabetes
Type & Screen
-Rh type: determine maternal/fetal incompatibilities
Pap follow established pap guidelines
HIV, Hep B (surface Ag), Syphilis (RPR)Rubella titer, gonorrhea, Chlamydia
Carrier screening (optional)
Eastern European Jewish decent
what pain med should you NOT use during pregnancy?
motrin -affects development of fetal heart
what is PICA in pregnancy a sign of?
craving for non-food items, often ice. - anemia
what lab should be repeated at every pregnancy visit?
Repeat H/H ~28 weeks
If positive GC/Chlamydia, repeat 3rd trimester
when does genetic testing begin in pregnancy?
trisomy 21 (quad screen) - 10 weeks
Free fetal DNA
Screens for T21,T18, T13 and sex chromosome aneuploidy
amnioentesis - 16 weeks
treatment of UTI during pregnancy
Nitrofurantoin 100 mg BID x 3-7 days
-Cephalexin 500 mg BID x 3-7 days
-Ampicillin 500 mg BID x 3-7 days
-Fluoroquinolones: teratogenic to fetal cartilage
-Sulfas: neonatal hyperbilirubinemia
-Trimethoprim: folic acid antagonist
treatment for Rh incompatibility
Rhogam at 28 weeks and within 72hours postpartum
1 vein- carries oxygenated blood originating from the placenta to the fetus’s portal system.
- blood enters the ductus venous shunt (liver)
- then enters into right heart
-foramen ovale: allows blood to enter left heart; closes with baby’s first breath following delivery
- left heart delivers blood to rest of fetal body
*opposite of what you would think
2 arteries - Removes waste from fetal circulation
normal fetal heart rate
what is quickening?
when mother can first detect fetal movement
-occurs ~18 weeks
-described as a fluttering in the abdomen
-conduct daily at approximately 28 weeks
-tallying 10 movements within the course of 2 hours
maneuvers for palpating fetal lie- Determine presenting part at every visit after 36 weeks.
stages of labor
-begins with cervical effacement & dilation.
-ends with complete dilation.
-Latent phase: contrations may occur at regular intervals
-Active phase: begins with 4 cm dilation.
-from complete dilation
-average duration: primigravida ~50 minutes, multigravida ~20 minutes
-From birth of the neonate to placental delivery. (usually within 60 minutes)
-The first hour immediately post-partum
Relationship to presenting fetal part to ischial spines
Station –3: at pelvic inlet, “floating”
Station 0: level of the ischial spine, “engaged”.
Station +3: level of the perineum (usually baby is crowing)
ways to induce labor
(Indications- maternal medical conditions (many )
-fetal conditions (many)
***perineal tear degrees
- only mucosa or skin injury
Second Degree (most common)
-first degree tears plus disruption of the superficial fascia & the transverse perineal muscle.
-first & second degree tears plus the external anal sphincter
-all of the above plus laceration extending into the rectal mucosa.
Incision intended to decrease the extent of perineal tears.
episiotomy - NOT recommended
indications for a c section
breech or transverse lie
multiples (not all)
placenta previa or abruption
Higher incidence of PE
Damage to maternal organs
important things to watch for during post-partum care
Excessive blood loss
-CBC, lightheadedness, tachycardia, hypotension
when does the post-partum visit occur
pregnancy loss at less than 20 weeks gestation
Pregnancy loss is most common in the first trimester – 80% occur by 12 weeks gestation
bleeding & cramping, no cervical dilatation, pregnancy still viable.
cervical dilation, bleeding but no passage of products of conception yet occurred.
fetus & placenta are expelled. Pain absent, bleeding/spotting may persist.
cervical dilation, retained products of conception, usually the placenta. Cramping & persistent bleeding, which is often excessive.
Pregnancy which ceases to develop but no products of conception have been expelled. No bleeding, no pain, cervix remains firm and closed
3 or more consecutive spontaneous abortions.
workup for suspected misscarriage
BhCG: Baseline, then repeat in 48-72 hours to determine trend.
in a normal pregnancy levels should double every 72 hours
look for products of conception
management for incomplete, inevitable, or missed abortion
dilation and curettage
Gestational Trophoblastic Disease- abnormal fertilization of a pregnancy, non-viable at any point
No pregnancy for minimum of 1 year: patients need to be on contraception.
complete molar pregnancies are at an increased risk for development of what?
higher than normal BhCG levels are indicative of what?
also Protrusion or expulsion of grape-like vesicles from cervical os or vagina
-trophoblasts; edematous villi
With or without vaginal bleeding
when should you have a high suspicion for ectopic pregnancy?
any pregnant patient with new onset, severe pain
causes of ectopic pregnancy
Any condition that interferes with migration of fertilized ovum to the uterus
PID-scarring of the uterus & fallopian tubes secondary to sexually transmitted infections
IUD in place
pregnancy after tubal ligation
Sudden, severe lower quadrant pain that typically remains unilateral
Pain may radiate to shoulder (but rarely will present with this)
due to phrenic nerve irritation
Irregular vaginal bleeding or spotting
Pelvic exam may be normal
Abdominal exam positive for pain
if several days have gone by since onset you may see distention due to bleeding into the peritoneum
palpable mass may be found
when does an ectopic usually occur?
usually around 6 weeks but can happen as late as 12
workup for ectopic
BhCG (beta HCG)- may be lower than IUP of same gestational age. serial hCG may be slower to rise, or plateau
anemia may be present
leukocytosis may be seen
Ultrasound-to evaluate for signs of intrauterine pregnancy (IUP)
abdominal U/S with no IUP & hCG level of >6500 or transvaginal U/S with no IUP & hCG level >2000-3000 diagnostic of ectopic.
management of ectopic
Medical therapy -- Methotrexate 50 mg/m2
Surgical therapy – Laparoscopic salpingostomy (opening the tube but it’s not removed) or salpingectomy (taking out whole tube)
Emergent surgical therapy- most people get salpingectomy
Provide RhoGam for Rh negative patients.
false labor. uterine contractions that occur at irregular intervals and consists of mild cramping and contraction of uterine wall
braxton hicks contractions
adequate water intake
lay down/change position
Systolic BP ≥ 140 or Diastolic BP ≥ 90 taken twice at least 6 hours apart.
Diagnosed at >20 weeks gestation
Occurs after 20 weeks gestation and up to 6 weeks post-partum.
Thrombocytopenia, Renal insufficiency, Impaired liver function, Pulmonary edema, Cerebral or visual symptoms
> +1 is positive, consider 24 hour urine collection (> 300 mg is positive) gold standard
previous history or family history of GHTN
African American race
AMA (advanced material age), but also a risk factor if you’re very young, so “extremes of materal age”
Preeclampsia with severe features
Systolic BP > 160 or diastolic >110
Elevated Liver transaminases
Low Platelets: thrombocytopenia
management of severe preeclampsia
34-37: deliver immediately
Preeclampsia with severe features at EGA
what is eclampsia
50% of seizures develop prior to labor
Maternal & fetal risks
higher risk of placental abruption
higher risk of DIC
how do you treat eclampsia?
Turn patient to side to prevent aspiration
Immediately IV bolus
Magnesium sulfate 6 g IV (loading dose)
Diazepam 5-10 mg over 4 minutes or until seizure ceases.
Continuous IV infusion of magnesium sulfate at 2 g/hr
measure urine output
measure for signs of magnesium toxicity
loss of DTR’s, decreased RR
calcium gluconate for reversal
when should you screen for gestational diabetes?
Perform 24-28 weeks gestation (or at initial prenatal visit in high risk women)
interpretation of GTT
fasting > 95
1 hour >180
2 hrs > 155
3 hrs > 140
positive if elevated in any 2 of the 3 hour tests.
if one abnormal, close monitoring and possible retesting
Complications of GDM
Fetal macrosomia – with associated delivery complications
Intrauterine fetal demise
may lead to neonatal death
Fetal Heart rate tracing abnormalities
loss of variability
repetitive severe variable decelerations or late decelerations.
potential causes: umbilical cord compression (variable decelerations), uteroplacental insufficiency (late decelerations)
too little amniotic fluid
too much amniotic fluid
AFI > 19
Implantation of the placenta in the lower uterine segment covering the internal cervical os
More common in multiparous women & women with prior c-section.
intrauterine growth restriction
signs and symptoms of placenta previa
Painless bleeding as early as 20 weeks
Intrauterine growth restriction (IUGR)
Diagnosis is made on ultrasound.
18-24 weeks, repeat U/S in 3rd trimester
if previa is
33 week G6P7 (all C-section)
delivered presents with severe
abdominal pain and bleeding. What is
the likely diagnosis?
Up to 30% of mild abruptions have no pain
The fetus can tolerate up to 40% separation without long term effects
Once approach 50% abruption typically outcome is fetal demise.
management of placenta abruption
Continuous maternal & fetal monitoring
Delivery-vaginal delivery not contraindicated if maternal/fetal stability present. 50% deliver vaginally.
Blood products: high risk for hemorrhage
RhoGam for Rh negative mothers
most common cancer of female reproductive system? most lethal cancer of female reproductive system?
common: endometrial ( uterine)
cancer arising from epithelial tissue
cancer arising from connective tissue (bones, tendons, cartilage, muscle, and fat)
cancer arising from plasma cells of bone marrow
what is present in 99.7% of cervical cancer?
Normal Immune System - takes 15 to 20 years for cervical cancer to develop
Weakened Immune System (such an untreated HIV infection) – can take only 5 to 10 years for cervical cancer to develop
All new cervical cancers pts should be tested for HIV, if positive this is an AIDs defining illness
most common histology of cervical cancer?
squamous cell carcinoma
what is the first line chemo therapy for almost all gyn cancers?
vulvar cancer most often affects what?
labia majora- Often present with a prurtitic or painful lesion
post menopausal bleeding is what until proven otherwise?
Also, any change in bleeding habits after age 35 needs to be worked up
Treatment of hyperplasia:
Do not desire future fertility Total Hysterectomy +/- BSO (no LND); This is Definitive treatment
Desire to retain fertility Treat with progestins and monitor with serial EMBs (Provera, Megace, Mirena IUD)
biggest risk for endometrial cancer
followed by age, obesity
This is a genetic mutation, which is
autosomal dominant and causes
endometrial cancer and increased risk of colon cancer
umbilical nodule associated with malignancy
sister mary joseph nodule
what is the frequent breast lesion, Most common in women 30-50, Asymptomatic or painful breast mass
fibrocystic breast disease
what is mastalgia
Mild mastalgia is a normal physiologic cyclical change during late luteal phase
Result from variation in plasma concentration of gonadotrophic and ovarian hormones
what is the workup of a breast mass?
-Mammogram and/or Ultrasound (Approx.10% of cancers are mammographically occult. Age cutoff for mammogram: >30 years old)
Biopsy (required for any solid mass)
-FNA, Core needle biopsy vs. surgical
what is the preferred method for initial diagnosis of a breast mass?
core needle biopsy
painless, well circumscribed, freely mobile tumors
Rounded, lobulated or discoid shape
10% will regress spontaneously
Most tend to stop growing at 2-3 cm
Rapid growth during
Hormone Replacement Therapy
May involute in postmenopausal women
t or f: fibroadenoma is considered to have malignant potential
However, because they contain an epithelial tissue, neoplasia can occur
Most common mass during pregnancy and postpartum
lactating adenoma - distinct mobile mass
Most common cause of spontaneous serous or serosanguinous drainage.Most common cause of nipple discharge
intraductal papilloma - not a premalignant lesion
benign tumor growing from lining of duct
Microcalcifications (clustered, stellate, pleomorphic)
New or evolving findings
Prompts a biopsy or short term follow-up
most common breast cancer