womens health Flashcards
(203 cards)
1
Q
the 5 Ps of taking a history
A
Partners Practices (what type) Prevention Protection Past hx of STI
2
Q
Special populations STI
A
Youth 15-24 MSM Pregnant HIV Correctional facility
3
Q
3 most common sx of Vaginitis
A
discharge
odor
pruritis/discomfort
4
Q
3 mosts common causes of Vaginitis
A
Yeast infection, BV, Trich
5
Q
Yeast infection
A
highest prev in reproductive years
C albicans
6
Q
Yeast infection
A
Pruritis, vulvar soreness
White, thick, curd like, adherent to vaginal walls
7
Q
Yeast infection risk factors
A
DM
Abx use
Inc estrogen levels
Immunosupp
8
Q
Dx of Yeast infection
A
Wet mount 10% KOH: budding yeast, hyphae, or pseudohyphae
9
Q
tx of Yeast infection
A
Oral Fluconazole (Diflucan) OR OTC topical azole (Clotrimazole)
10
Q
Tx for Yeast infection in pregnant
A
Need to use topical (Clotrimazole or Miconazole)
11
Q
BV
A
most common cause of discharge among women of childbearing age!***
12
Q
BV
A
Malodorous, “fishy”, thin off white d/c
13
Q
Dx criteria for BV
A
Amsel's, need at least 3 of the following: -thin, white, homo d/c -CLUE CELLS -ph >4.5 \+whiff test
14
Q
Tx of BV
A
Metronidazole (Flagyl) 500 mg BID x 7 days
OR gel or clinda cream
15
Q
What to avoid while taking Metronidazole (Flagyl)
A
drinking alcohol
16
Q
Trich
A
most common non-viral STI in the world
17
Q
Are sx common with Trich?
A
NO
most have minimal or no sx (70-85%)
18
Q
Sx of Trich
A
Purulent, frothy, thin
malodorous d/c
POSTCOITAL BLEEDING
pain w/intercourse
19
Q
Trich
A
flagellated protozoan
20
Q
PE of Trich
A
“Strawberry cervix”
vaginal ph >4.5
21
Q
Dx of Trich
A
NAAT: gold standard
22
Q
Tx of Trich
A
Metronidazole (flagyl) 2g of one single dose
can do 500 mg BID if pregnant, much weaker dose
23
Q
Chlamydia
A
most common reported BACTERIAL STD in AMERICA
24
Q
Clinical sx and PE of Chlamydia and Gon are IDENTICAL
A
Cervicitis: change in d/c, intermenstrual/post intercourse bleeding OR sx related to urethritis
PE: mucupur endocervical d/c, FRIABLE cervix, erythema, edema
25
Dx of Chlam and Gon
NAAT
26
Complication of Chlam
Conjunctivitis of Neonate
27
Gonorrhea
2nd most common reportable communicable dz in AMERICA
concern with ABX RESISTANCE
28
Complications of Gonn
Transmissable to neonate during delivery
DGI (arthritis)
29
Tx of Chlamydia
Azithro or
| Doxy
30
Tx of Gonorrhea (more)
Azithro AND
| Ceftriazone (rocephin)
31
Screening for Gon/Chlam
Yearly for all sexually active women <25YO, AND
older with risk factors
32
PID
upper genital tract (ascending)
| often a comp of Gon/Chlam or BV-assoc pathogens
33
PID
wide array of clinical sx
34
PID physical
```
Abdominal tenderness (lower quadrants)
Uterine, adnexal, or CVA tenderness "chandelier sign"
```
35
A manifestation of PID (on boards!!!)
Perihepatitis: Fitz Hugh Curtis Syndrome
inflammation of liver capsule and neighboring peritoneal surfaces
PID, RUQ pain, "violin string" lesions on liver
36
What to order if suspicous of PID
```
Pregnancy test!!
Pelvic US (if unsure)
microscopy of d/c
NAAT (r/o Gon/Chlam)
HIV screen, syphillis screen
UA
CBC, ESR/CRP
```
37
Gold standard test for Gon/Chlam
NAAT
38
Criteria for presumptive clinical dz of PID
Sexual active young women
Pelvic/lower abd pain
Cervical motion, uterine, or adnexal tenderness
("Chandelier")
39
Tx for PID
Ceftriaxone (rocephin) AND
| Doxy
40
Most common STI in the WORLD
HPV- condyloma acuminata, anogenital warts
41
most common types of warts
strand 6 and 11
42
Risk factors of HPV
sexual activity
smoking
immunosuppression
43
Tx of HPV (warts)
Cyto destructive: Podoflox
Immune med: Imiquimod, Sinecatechins
Surgical: cryotherapy, laser, electrocaut
44
Types of Herpes
Primary: person HAS pre-existing antibodies
Non primary first episode: start of HSV2 in person that had HSV1 antibodies, or vice versa
Recurrent: of genital
45
Tx of Herpes
FAV drugs
"cyclovir"
start within 72 hours
1st episode: 7-10 days
Recurrent: 1-5 days
suppression: BID, daily
46
Mullerian ducts give rise to:
Fallopian tubes
Uterus
Upper vagina
47
Normal female puberty: FSH/LH stimulates production of
Estradiol from ovaries
48
Estradiol -->
breast development and growth of skeleton
49
Average age of menses and menopause
menses: 12-13 YO
menopause: 51 YO
50
Avg menstrual cycle
24-38d
51
Amount of blood loss during menses
5-80mL
52
Primary amenorrhea
Failure to reach menses (never start)
by age 15 w normal growth and secondary charac (like breasts)
OR
by age 13 w/o secondary charac (so more than just menses is missing)
53
Secondary amenorrhea
Cessation of menses (stops after it once started)
Absence for more than 3 cycle intervals
OR
6 consecutive mo
54
Most common cause of Primary amenorrhea
Gonadal dysgenesis (ovarian dysfx)
55
Gonadal dysgenesis
| most comm cause of Primary amenorrhea
Abnormal organ development
Hyper Hypogonadism (high FSH)
56
Turner syndrome
| 46 XO
Ovaries can't respond to gonadotropins
Result: premature depletion of oocytes and follicles
Woman does NOT ovulate or have periods
57
Turner syndrome clinical sx
"shield chest"
webbed neck
widely spaced nipples
"Streak ovaries" and sexual infantilism
58
Swyer Syndrome
| 46 XY gonadal dysg
"Vanishing testes"
Fibrous streak gonad can't secrete Anti'-M hormone or testosterone
Mutation of SRY gene
59
46XY Swyer
Gonads fail to diff into testes
Lack of Anti-M, testosterone, and DHT results in FEMALE INTERNAL and EXTERNAL genitalia
everything appears to be girl, but genetically a male
60
PCOS
| rare cause of primary amenorrhea
Rare cause of primary amenorrhea
Hyperandrogenism- acne, hirsutism, acanthosis nigricans, obesity
61
Female athlete triad
Not enough calorie intake
Amenorrhea
Low bone density
62
Functional hypothalamic amenorrhea
HPO axis suppressed bc not eating enough
leading to abnormal GnRH secretion --> no follicle develop/ovulation --> Low estradiol secretion --> NO LH surge
63
Idiopathic Hypo Hypo
| Congenital GnRH deficiency
if no smell, "Kallmann" synd
64
Pituitary causes of Primary amenorrhea
Micro/Macro-Adenoma (i.e. cushings)
Hyperprolactinemia (BUT this one is more associated w Secondary amenorrhea)
these two are most common
65
VERY COMMON causes of Primary: Outflow tract disorders
Uterine-Mullerian agenesis
- 46 XX with no oviducts, uterus, or upper vagina. instead have a small pouch rather than full vaginal canal.
- Normal gonadal function (estrogen = breast devel)
66
Rare cause of primary amenorrhea
Androgen Insensitivity Synd
Genetically male, looks femaile, high testosterone
Breasts, Absent upper vagina, uterus, and fallopian tubes on Pelvic US
Testes are STILLL THERE, intra abdominal or partially descended. Need to be removed d/t CA risk
67
Rare cause of Primary Amenorrhea
5-a-reductase deficiency
-46XY unable to convert DHT-->T
*ambiguous genitalia at birth*
68
17-a-hydroxylase deficiency
HTN and Lack of pubertal development
d/t decreased Cortisol synth and lack of sex steroids
69
Biggest cause of Secondary Amenorrhea
Pregnancy!
70
PCOS
Androgen excess
Chronic amenorrhea or oligomenorrhea
Polycystic ovaries
Peripheral insulin resistance
71
Asherman synd
cause of Secondary amenorrhea
Scarring of endometrial lining caused by OBGYN procedure
72
Hx of weight loss, strenuous exercise, eating disorder?
Dx Sec Amenorrhea
Hypothalamic disorder
| anorexia, exercise, stress induced
73
Hx of surgical procedure or infection
Dx Sec Amenorrhea
Asherman syndrome
74
HA, visual change, Galactorrhea
Dx Sec Amenorrhea
Infiltrating Pituitary dz/tumor
Sheehan synd
75
Illness, CA, infection, RA
Dx Sec Amenorrhea
Can simply be d/t systemic illness
76
When to start evaluating for Primary amenrrhea
No menses by:
age 15
age 13 AND no breast
No menses after 3 yrs of having breasts
77
Normal order of development for women
Breast
Pubic hair
Growth spurt
Menses
78
Tests to oder when working up Amenorrhea
Pregnancy test (hcG)
FSH
TSH
Prolactin
79
What to order if pt has Short stature and elevated FSH
Karyotype
| Turner synd
80
What to order if pt has low/norm FSH, breasts, but NO uterus
```
Karyotype (Mullerian agenesis)
Total Testosterone (Androgen Insens Synd)
```
81
What to order if pt has low/norm FSH, breast, AND uterus is present
Consider endocrine: PCOS, thyroid
If hyperandrogenism: order Total Testosterone and DHEA
82
What to oder it pt has low/norm FSH, NO BREAST
Recheck FSH, LH
Consider pituitary MRI
WE NEED TO CONSIDER MRI for tumor if pt has no breasts
83
if FSH is high, consider
Primary ovarian insufficiency
ovaries are not responding like they should
84
Amenorrhea tx
catered to etiology
85
Primary ovarian insuff example
Turner syndrome
86
Breast development is a marker of:
```
Ovarian fx
(except for Androgen insensitivity synd)
```
87
4 tests to order when working up amenorrhea
Pregnancy
FSH
TSH
Prolactin
88
Pt has breasts, what is next test
Uterus?
Yes: outflow obstruction
No: Karyotype
89
Pt has NO breasts, what is next test
FSH/LH
Low: hypo hypo
High: Hyper hypo --> karyotype (Swyer, Premature failure, Turner)
90
Secondary amenorrhea
>3 mo if regular cycle
| >6 mo if irregular cycle
91
If evidence of hyperandrogenism, order
Total Testosterone
92
Abnormal bleeding
```
Abn quantity, duration, or schedule
<24 days
>38 days
duration>8 days
loss >80 mL
intermenstrual
```
93
Most common causes of abnormal bleeding:
Anovulation
Structural pathology
Bleeding disorder
Uterine neoplasia
94
PALM- COEIN for abn uterine bleeding
```
PALM= structural causes
COEIN= non structural
```
95
PALM causes of structural bleeding
Polyp
Adenomyosis
Leiomyoma (uterine fibroid)
Malignancy, endometrial hyperplasia
96
COEIN cause of NONstructural bleeding
```
Coagulopathy
Ovulatory dysfx
Endometrial
Iatrogenic (anticoags, birth control)
Not otherwise classified
```
97
What to do first when you suspect abnormal bleeding
Confirm uterus is source
Exclude pregnancy
What is pattern, severity, and cause?
98
Most common cause of Abn Uter Blee in 13-18 YO
Persistent anovulation d/t immature HPO axis
99
Most common cause of Abn Uter Blee in 19-39 YO
Structural lesion (fibroid, leiomyoma, polyp)
100
Most common cause of Abn Uter Blee (AUB) in over 40 YO
Anovulatory bleeding
| Endometrial hyperplasia and CA
101
Molimia sx
related to cycle
| Breast tender, bloating, change in cervical mucus
102
Menorrhagia
| heavy
Think:
Structural lesion (polyp, hyperplasia, fibroid)
Coagulation disorder
Liver/Kidney failure
103
Intermenstrual bleeding
d/t Cervical pathology (dyslasia or infection) or an IUD
104
Perimenopause
Abn bleeding 5-10 years before menopause, common
Anovulation d/t declining # of Ovarian follicles
105
Bleeding that is frequent, heavy, or prolonged should be evaluated with
EMB- Endometrial Biopsy to r/o Endometrial hyperplasia or CA
106
Is bleeding AFTER menopause ever normal?
NO
Concerning for Endometrial CA
Do Pelvic US OR EMB- Endometrial biopsy
107
Abn Uter Blee physical exam
Signs of bleeding disorder (skin, pallor, bruising)
Thyroid!
Hyperandrogen (acne, hirsutism, male balding)
108
If anovulatory bleeding with AUB,
check CBC
then TSH, Prolactin, Androgen
109
If ovulatory bleeding with AUB, suspect
CBC and other labs
Pelvic US
EMB-endometrial bx
110
Intermenstrual bleeding, what tests?
Pap smear
| Cervical cultures
111
Who should get EMB- Endometrial Bx?
>45YO with AUB
| ANY postmenopausal women with uterine bleeding
112
If you are younger than 45, when should you get EMB- Endometrial bx?
with Abnormal Uterine Bleeding (AUB) AND
Risk factor for unopposed estrogen
Persistent bleeding
Failed med tx for AUB
113
Inpatient mgmt for Acute AUB
Admit if heavy and sx of hemodynamic instability
Tx: IV estrogen or possible Dand C
114
Outpatient mgmt of AUB
COC (birth control)
Medroxyprogesterone (provera) , prog only
High dose estrogen
Tranexamic acid (non hormonal)
115
Two most common outpatient tx for AUB
COC (monophasic pill w ethinyl estradiol)
AND
Medroxyprogesterone (provera)
116
Most common Tx for CHRONIC AUB
Levonorgestral (mirena) IUD
117
Tx for Chronic AUB (surgical options)
Endometrial ablation
| Hyesterectomy (extreme cases)
118
Other tx options for chronic AUB
Depo-provera
Estrogen/progestin
Tranexamic acid
NSAIDs
BUT keep in mind, Levonorgestrel (Mirena) IUD is most common!
119
Anovulatory AUB
unpredictable bleeding
120
Ovulatory AUB
regular cycle length + sx associated w ovulation
121
Heavy AUB bleeding likely d/t
Fibroid
Adenoma
Coagulopathy
122
Intermenstrual bleeding likely d/t
polyp
birth control
PID
cervical issue
123
Irregular (anovulatory) bleeding likely d/t
PCOS
Thyroid
Hyperprolactinemia
124
If pt is hemodynamically unstable with AUB, what is tx?
IV Estrogen
125
Primary dysmenorrhea
Painful menses, No dz
17-22 YO common
126
Secondary dysmenorrhea
Painful menses d/t PRESENCE of Dz
older women
127
Prostaglandins are released from endometrium during cell lysis -->
uterine contractions and ischemia --> PAIN
128
When do primary dysmenorrhea sx onset
few hours b4 or just after onset of menses
129
Workup for primary amenorrhea
Pregnancy test
| Consider pap smear and vaginal cultures, but not always nec
130
Tx of Primary dysmenorrhea
1st line: NSAIDs!!!!
+ supportive- exercise, stop smoking, heat, yoga
2nd line pharm: Birth control (COC, Depo provera, IUD)
131
Consider laparoscopy or GnRH analog tx in Primary Amenorrhea if
Resistant cases
132
When to f/u or Refer out with primary amenorrhea
```
pain worsening each cycle
last longer than first 2days
meds not working
increasingly heavy
pain with FEVER
abnormal d/c
pain unrelated to menses
```
133
Secondary dysmenorrhea
bc of a disease
may be worse during menses
134
Secondary dysmen sx often associated with other sx like
Dyspareunia (pain w sex)
| Infertility or AUB
135
Secondary dysmenn sx usually age
30-40
136
Common cause of secondary dysmenn (a disease)
```
Endometriosis
Adenomyosis
Adhesions
PID
Fibroids
```
137
Tx of Seconday dysmen
Underlying cause
COC
Pelvic surgery perhpas
138
PMS relationship to
LUTEAL phase
occurs i most cycles
resolve w onset of mense
139
PMDD
PMS w more severe emotional sx
140
PMDD possible cause
abnormal Serotonin response
141
Not enough Serotinin in Luteal phase
PMS, and other sx caused by:
Progesterone increases MAO
which reduces Serotinin availability
142
PMS diagnostic criteria
1-4 sx that are physical, behavioral, or psychological OR
>5 sx that are physical or behavioral
at least ONE sx during Luteal phase
Sx remit at menses
143
PMDD
| DSM5 criteria
At least one must be present:
- mood swing, sudden sad, sens to rejection
- hopelessness, depressed
- anger/irritable
- tension,anxiety
AND
at least one of these (together totallying 5)
- cant concentrate
- appetite change
- anheydonia
- fatigue
- overwhelmed
- sleep changes
- breast tender, wt gain, bloating
144
PMDD Criteria ctd
must be present in most cycles over the PREVIOUS YEAR
145
Non pharm tx for PMS
```
decrease salt, caffeine
exercise
calcium, MG
stress reduce
CBT
```
146
Pharm tx of PMDD
First line tx: SSRI (fluoxetine (prozac), sertraline (zoloft) escitalprom (lexapro)
147
Fluoxetine and Sertraline are best tx for
PMDD
both are SSRIs
148
Menopause
permanent cessation of menses for 12 months in a row
149
Perimenopause (transition to menopause)
4 years before Final Menstrual Period (FMP)
150
Clinical sx of Perimenopause (menopausal transition)
the time period b4
Irregular menses
Hot flashes/night sweats
Anxiety/depression
Vaginal dryness
Change in lipid/bone
151
FSH value is suggestive of Perimenopause (transitional period b4)
FSH > 25
152
Menopause before age ___ is abnormal
40 YO
153
Labs to suggest you are officially Menopausal
FSH > 70
154
Postmenopause sx
Hot flashes (usually stop within 4-5 YEARS of onset)
Vaginal dryness
Inc risk Osteoporosis, CVD, and Dementia
Anxiety/Depression
155
Vasomotor (hot flashes)
Usually in upper body, face, neck, chest
1-5 min
Narrowing of Thermoregulatory zone
156
Who has hot flashes the worst in menopause?
African american
What about the least? Asians
157
Tx for Hot flashes
```
Lifestyle
Estrogen vs. Estrog/Prog
SSRI, SNRI
Clonidine
Gabapentin
Herbal
```
158
NOT recommended for hot flashes
Prog only meds
Testosterone
Compounded bio-identical hormones
159
Most effective tx for Menopausal sx
Systemic Hormone Therapy (HT)
160
Estrogen only
for Women who have had Hysterectomy
161
Why do we usually give the Progesterone component of the Estrog/Prog combo therapy?
to protect the uterus from Hyperplasia and Endometrial CA
162
Estrog/Prog combo
Women w intact uterus
163
How long to give Hormone Therapy?
Lowest dose for shortest possible amt of time.
No more than 5 years and not beyond age 60
164
Do not use Hormone Therapy
For more than 5 years
| for Woman >60 YO
165
SE of Hormone Therapy
Tender breasts
Vaginal bleeding
Bloating
HA
166
Risk of Hormone Therapy
Clots and Breast CA
167
Lower risk of clots when using Estrogen only if you use what route
Transdermal
168
Different than combo therapy, Estrogen alone does not raise a risk of what
no risk of CVD or Breast CA
still clots though
169
CONTRA to Hormone Therapy
```
Breast CA
CHD
Previous Clot or Stroke
Active Liver dz
Unexplained vag bleed
High risk Endomet CA
TIA
```
170
Testosterone is not recommended for vasomotor sx, but what can it HELP with?
Improve sexual function for postmenopausal women
171
Bio-identical hormones
plant derived hormones similar to those produced by body
often advocates recommend salivary testing
172
SSRIs used for Menopause
SSRI:
Paroxetine
Citalopram
Escitalpram
173
SRNIs used for menopause
Venlaxafine (effexor)
| Desvenlafaxine (pristiq)
174
Loss of estrogen with menopause often leads to
Vulvovaginal and bladder-urethral atrophy
vaginal dryness, pain w sex, itching
sexual dysfx
urinary frequency
recurrent UTI
175
Treating solely Vulvovaginal atrophy
Estrogen- local (cream, ring, tablet)
176
Ospemifene rx for
Dyspareunia d/t vulvar atrophy
| a SERM
177
Risk factors for Osteoporosis
Older age
Female
```
White or Asian
Long term steroids
Low body weight
Excessive alc intake
Cig smoking
FH Osteoporosis
Vit D def
Secondary osteoporosis
```
178
How much Ca and Vit D should you have to prevent osteoporosis?
1200 Ca
| 800 Vit D
179
Diagnosing Osteoporosis
DEXA gives you a T score
OR
Fragility Fracture
180
Fragility Fracture
Spine, hip, wrist, humerus, rib, pelvis
from STANDING HEIGHT or less
181
Osteoporosis Dx with T Score
< or equal to -2.5
182
Low bone mass (osteopenia)
T score:
| between -1 and -2.5
183
T score:
| Greater than -1.0
Normal
184
When to screen normal healthy women for Osteoporosis?
65 YO
185
Usually start bone screening at 65YO, but if women has risk factors, screen earlier:
```
Hx of fragility fracture
weight <127
Med cause of bone loss
Parental med hx of Hip fx
Smoker
Alcoholism
RA
FRAX calculator 10 yr risk is >9.3%
```
186
Candidates for Pharm therapy for Osteoporosis
Post menopause hx of HIP or VERTEBRAL fracture
T score
187
1st line therapy for Osteopenia
Bisphosphonates
| zoledronic acid, risedronate, alendronate
188
Other tx for Osteoporosis
SERMS
(Evista/Raloxifene)
reduce risk of Breast CA
189
Monitoring for Osteoporosis
Normal T score: 5-15 yrs
Osteopenia (-1.5 to -2): 5 years
Bad osteopenia (-2 to -2.49): 1 year
190
Monitoring after you legit have Osteoporosis, for tx reasons
1-2 years after starting tx, then every 2 yrs after
191
Anterior compartment POP
Cystocele (bladder)
192
Posterior compartment POP
Rectocele
193
Prolapse sx
```
Heaviness, pressure
Urinary sx
Defecatory sx
Splinting
Pain and irritation
```
194
Risk factors for Prolapse
Vaginal births
Obesity
Chronic dz (constipation, COPD)
195
Racial effect on Prolapse
Hispanic women highest risk
African american lowest risk
196
Conservative mgmt of prolapse
Pessary (donut thing)
| Kegel exercises
197
Surgical tx of prolapse
for those who have sx or declined conservative mgmt
198
Advantage of Pessary:
safe
effective
Disadvantage of Pessary:
odor, d/c, vagina ulcer
have to remove for sex
199
Surgery for Prolapse, can take ligament from:
Sacrospinous
| Uterosacral
200
Sacrocolpopexy surgery
Attach vagina or cervix to Anterior longitudinal ligament of the SACRUM
201
Anterior and posterior repair surgery of prolapse both do what?
PLICATION TO VAGINAL TISSUE TO MIDLINE e to reduce Bulging bladder or Bulging rectum
202
Obliterative procedures
Best, safe, effective
| but can never have sex again
203
When is Prolapse emergent?
Almost never, but exceptions are:
Urinary retention
Obstructive Nephropathy
UroGyn consult for Pessary or Surgery
