CNM Purple Big Book: Gynecology Normal Flashcards
Perineal muscles
bulbocavernosus
ischiovernosus
superficial/deep transverse
Pelvic floor muscles
levator ani
pubococcygeus
bulbocavernosus
surrounds vagina acting as a weak sphincter
ischiovernosus
surrounds clitoris, responsible for clitoral erection
superficial/deep transverse perineal muscles
converge with urethral sphincter
levator ani
pubococcygeus, iliococcygeus, and ischiococcygeus muscles
pubococcygeus
pubovainalis
puborectalis
pubococcygeus proper
what stimulates development of internal pelvic structures?
estrogen initiated during puberty
when do internal pelvic structures reach their adult size/appearnace?
by about at 16
why is the pH of the vagina acidic?
because of the prevalence of lactobacilli and d/t the influence of estrogen
what size is the non-pregnant uterus?
8 cm in length
5 cm in width
3 cm thickness
how long are the fallopian tubes?
~10 cm
gonadotropins
LH, FSH released from anterior pituritary gland in response to GnRH
Estrogen - where, when, etc
primarily released by ovary in response to FSH, also by adrenal cortex, corpus luteum - predominant in follicular phase;
Results in dev of seconddary sex characteristics and ultimately in maenstruation;
thelarche
breast development
adrenarche
growth of pubic and axillary hair; results from secretion fo adrenal androgens; usually starts after breast devlopment begins
estrone
estrogen of menopause;
converted from androstenedione produced by adrenal gland and ovarian stroma
estradiol
most potent; derived from ovarian follicles, partic dominant follicle’Primary estrogen of reproductive age
estriol
least potent; estrogen of pregnancy;
dreived from conversion of estrone and estradiol in liver, uterus, placenta and fetal adreanl gland
pH of vagina
<4.5
progesterone - from where, what, etc.
steroid hormone produced by ovarian corpus luteum and conversion of adrenal pregnenolone/pregnenolone sulfate;
Luteal phase
As supplied by ovary, level of 3ng/mL+ indicates ovulation
In the breast: subcutaneous fluid retention
Prostaglandin (PGE)
derived from arachidonic acid
Increased production by UTERUS as with primary dysmenorrhea
Increases uterine activity resulting in ischemia
Prolactin
from anteroir pituritary
Progressive release druing pregnancy
Stimulates synthesis of milk proteins in mammary tissue
Stimulates epithelial growth in breast during pregnancy
Adrenal hormones
Cortisol - metabolizes proteins, carbs, fats
Aldosterone - regulates Na , K; dec Na/incr K secretion by kidney
Androstenedione - converted to estrone in adipose tissue
Testosterone - can be converted to estradiol
LH surge
peak 10-12 hrs before ovulation
Ovulation
PGE and proteolytic enzymes break down follicular wall; occurs 32-44 hrs after beginning of LH surge;
Maximal prdxn of spinnbarkeit;;
increase of basal body temp 0.2-0.5 F
spinnebarkeit
refers to ability of cervical mucus to be stretched between examining fingers;
increased stretch = increased influence of estrogen
Luteal phase: corpus luteum
formed from ruptured follicle
Secretes progesterone - peak 7-8 days postovulation
Proliferative phase of uterine cycle
estrogen influence
endometrium grows/thickens
lasts approximately 10 days from end of menses to ovulation
Secretory phase of uterine cycle
progesterone influence
Av 12-16 days
Endometrial hypertrophy
Increased vascularity
Menstruation - of uterine cycle
declining progesterone from CL
endometrium undergoes involution, necrosis, sloughing (3-6 days)
screening mammography
Age 40-50: ACS: annual; NCI: q 1-2 yrs strong fam hx = earlier/more frequently >50 yr: annually 10-15% false negative rate for detection of malignancies
BRCA1/2
5-10% br CA is hereditary
mutated BRCA1 gene = 80% risk br CA by age 65
Test if strong fam hx or Ashkenaxi Jew
Climacteric/perimenopause
used to describe the physiologic changes associated with the change from reproductive to nonreproductive status
2-8 yrs before menopause until 1 yr after last period
Rhythmic ovarian/endometrial responses of menstrual cycle decline/eventually stop; # responsive follicles decr with resultant decr prdxn estradiol throughout climacteric. Decr estradiol = incr FSH.
End of clim, ovary contains no follicles & endometrium atrophies = reproductive capabilities terminated
premature menopause
premature ovarian failure
cessation of menses before age 40
menopause
after menopause, LH & FSH both increased
Generally rely on cessation of menses, hypoestrogenic sx, age and consistently elevated FSH for dx of menopause
Lab findings of menopause
FSH: >40 mIU/mL
LH: 3-fold elevation (20-100 mIU/mL)
estradiol: <20 pg/mL
vaginal pH in climacteric
pH 5.0 or more
Some vaginal sx of climacteric
may have pruritis, leukorrhea, friability, increased susceptibility to infectino, dyspareunia
Urinary tract changes with climacteric
Decreased muscle tone: urethra/trigone area
Atrophic changes in urethra/periurethral tissue = stress incontinence may occur
Hypoestrogenic effects in trigone area; lowered sensory threshold to void = sensory urge incontinence may occur
Urinary urgency, frequency, dysuria d/t atrophic changes in urethra and periurethral tissue
Vasomotor sx of climacteric: hot flashes
75% of women get them
generally cease w/i 2-3 yrs after menopause
CV effects of climcateric
Lipid levels:
incr in LDL (ideal 60)
Cognitive fxn in menopause
memory impairment may be indirectly r/t decr estrogen secondary to hot flashes and sleep disturbance
Rish of demetia incr in healthy women 65-79 yr using ET or EPT
screening for cholesterol and HDL
Age 20:
Q 5 yrs
screening for plasma glucose
Age 45 (& younger women with risk factors): q 3 yrs
Thyroid function/TSH screening
Age 65:
q 3-5 yrs
begin earlier if presence of autoimmune condition or strong family hx of thyroid dz
hearing screening
Age 65 & older
screening for visual acuity/glaucoma by opthalmologist
Age 40-64:
q 2-4 yrs
Age 65+:
q 1-2 yrs
Contraception >40yr
COC: safe for healthy, non-smoking, non-obese perimenopausal women. Non-contraceptive benefits may be esp attractive: relief of vasomotor sx, menstrual regulation
POP also safe option
IUD: good option, LNG may help with heavy bleeding
Barrier methods acceptable
Sterilization: most prevalent method in US among married women
Fertility awareness less effective during perimenopause with irregular cycles
Deciding when to stop contraception
Reaching age 55 (90% have reached menopause by then) vs 2 FSH levels while off hormonal contraceptives and using a nonhormonal contraceptive
HT Indications
relief of menopausal sx r/t estrogen deficiency: vasomotor instability, vulvar/vaginal atrophy
Prevention of osteoporosis
Potential reduction of risk for colon CA
C/I to HRT
thrmoboemobolic disorders or thrombophlebitis Known or suspected creast cancer Estrogen dependent CA Liver dysfunction or dz Undiagnosed abnormal uterine bleeding Known or suspected pregnancy
Potential risks of HRT
endometrial hyperplasia/CA
Breast CA (relationship w HT inconclusive; possilbe small but signif incr witih long-term HRT)
Gallbladder dz
Thromboembolic disorders
Followup after HT initiation
Reevaluate in 3 months; if no problems, annually after that
Evaluate sx each time; discontinue as appropriate
Consider nonhormonal drugs for osteoporosis prevention if longterm therapy needed
HT regimen options
0.625 mg conjugated E or equivalent prevents osteoporosis in 90% menopausal women
10-14 days q month: 10 mg of MPA or equiv or daily doses of 2.5-5.0 mg for prevention of endometrial hyperplasia
Continuous combined: E/P daily (may have unpredictable bldg for a while before amenorrhea)
Continuous cyclic: E daily, P for 10-14 days/mo; withdrawal bleed when P done
Cyclic: E days 1-25; P last 10-14 days; then 3-6 days of nothing
S/E oral estrogen:
increased HDL/triglycerides;
first-pass metabolism determines results
effects E/EP patch
no significant impact on HDL/triglycerides;
may have less adverse effects on gallbladder and coagulation factors than oral E
Vaginal estrogen creams
tx vulvar/vaginal atrophy;
will NOT provide relief from vasomotor sx;
some systemic absorption
NEED cyclic progestin with intact uterus
Estring
little/no systemic absorption;
90 days duration
Do not need cyclic progestin
Femring
SYSTEMIC absorption
tx vasomotor & vulvar/vaginal atrophy
90 day duration
Requires added progestin if intact uterus
Topical sprays/gels/emulsions (17B-estradiol)
SYSTEMIC absorption
NO sig effect on HDL/triglycerides
May have less adverse effects on gallbladder and coag factors tahn oral E
Need cyclic progestin with intact uterus
Topical may not provide sufficient endometrial protection
Progestin-only HRT
effective in relieving vasomotor sx
May have +impact on Ca balance
NOT effective on vulvovaginal sx
MAY have adverse effect on lipid profile
Testosterone in HRT
oral/transdermal/injections/subQ
may use if E not effective enough on extreme vasomotor sx
may incr energy level, feeling of well-being, libido
S/e: acne, hirsutism, clitoromegaly
Does not appear to have neg lipid effect
S/E of HRT
breast tenderness (E/P; usually only few weeks)
Nausea (E; relieved if taken AC/HS)
Skin irritation w patch
Fluid retention/bloating (E/P)
Alterations in mood (E/P)
TX of S/E: lower dose, dif route, dif formulation
Bleeding on HT
Continuous cyclic: usually some bleeding; starts last few days P or just after. If bldg is earlier/heavy/persistent may indicate endometrial hyperplasia = eval
Continuous-combined: erratic spotting and light bldg 1-5 days in first yr; endometrial biopsy if heavier or longer than usual
Nonhormonal mgmt of vasomotor sx
Antidepressants (ssri, srni) gabapentin, clonidine
Avoid caffeine, alcohol, cigarettes, spicy foods, big meals
Regular, mod exercise
Vit E - anecdotal reports of relief
Soy foods, isoflavine supplements
False positive nontreponemal tests for syphilis
VDRL, RPR (become + by 1-2 wks after chancre)
False positives assoc with mononucleosis, collagen vascular dz, some other med conditions
Usually see low tieter 1:8
Treponemal tests for syphilis
FTA-ABS
TPI
reported as +/- not quantitative
Usually remain + indefinitely after tx
Genital herpes simplex
Gold standard: tissue culture of lesion
other tests: PCR, DNA probe, direct flourescent antibody/enzyme assay
Serum antibody test for HSV 1/2: may take 4-12 wks for seroconversion
trich
wet mount: motile, flagellated protozoa
Greater than 10 WBC/high power field
vag pH >4.5
HIV testing
Sensitive screening test: enzyme immunoassay EIA or rapid test: 99% sensitive at 12+ wks postexposure
Must be confirmed with highly specific tests: Western blot, IFA
HIV antibody detectable in 95% people by 6 months
Estradiol levels
Follicular: 20-150
Midcycle: 150-750
Luteal: 30-450
Postmenopause; <20
FSH levels
Follicular: 5-25
Midcycle: 20-30
Luteal: 5-25
Postmenopause 40-250
LH levels
follicular: 5-25
midcycle: 75-150
luteal; 5-40
postmenopause:30-200
Progesterone levels
follicular: <0.2
Normal Bone Mineral Density T score
BMD w/i 1 standard deviation of young normal adult
T-score above -1
Osteopenia
T-score between -1 and -2.5
Osteoporosis
T-score at or below -2.5
