Common GYN Conditions Flashcards
1
Q
CPPD
A
Cyclic Premenstrual Pain and Discomforts - Cluster of physical and psychological sxs
- PMDD/PMS - Pre Menstrual, psychologic sxs (luteal phase)
- Dysmenorrhea-Pain during menses
2
Q
Hallmark Sx of PMDD/PMS
A
- Depression
- Irritability
- Anxiety/Tension
- Labile Moods
- Tx with SSRI in Luteal Phase if not an exacerbation of current problem and interfere with ADLs
3
Q
PMS/PMDD Tx mild, moderate, severe
A
- Mild: Exercise, relaxation, B6, E, Calcium, Mg
- Moderate to severe: SSRI (Zoloft, Paxil, Celexa, Prozac) daily or luteal phase. OCPs containing Drosperione (Yaz)
- Severe/Unresponsive: GnRh Agonist (Lupron), Surgery (oophorectomy/hysterectomy)
4
Q
Primary Dysmenorrhea Pathophysiology
A
Increased prostaglandins in secretory endometrium –> increased uterine contraction and reduced blood flow –> pain
5
Q
Dysmenorrhea tx
A
- Prostaglandin Inhibition: NSAIDs (Ibuprofen 400-800 q4-6)
- Endometrial Suppression - HC, Depo, Mirena
- Other: Analgesics, Calcium/Mg/E, Vitamin B1 (100mg qday), Acupuncture
6
Q
First line for Dysmenorrhea?
A
Prostaglandin Inhibition: NSAIDs (Ibuprofen 400-800 q4-6)
7
Q
Endometriosis - define
A
Presence of endometrial glands and stroma outside the uterus
8
Q
Endometriosis - Etiologies
A
Genetic predisposition, retrograde menstruation, Direct transplant of endometrial tissues
- Common sites: Ovaries, anterior and posterior fornix, bowel, bladder
- Pain caused by higher concentration of nerves in endometrial implants
9
Q
Endometriosis Prevalence
A
-10%
-60-80% w/ infertility or chronic pelvic pain
Most common reason for dysmenorrhea and menorrhagia in younger patient
10
Q
Endometriosis Clinical Presentation
A
- AUB (Menorrhagia, intermenstrual bleeding)
- Asymptomatic to severe (aka cyclic or chronic) abdominopelvic pain, dysmenorrhea
- Pain on deep sex (worse during menses)
- Menstrual/sacral backache
- Cyclic bowel/bladder sx
- Infertility
- Degree of implants do not correlate with degree of sx
11
Q
Endometriosis PE
A
- FHx, Hx of infertility?
- Best during menses when pain/discomfort happening
- Pain during palpitation of posterior fornix
- Tenderness if implants in uterosacral ligaments
- Fixed retroverted uterus from posterior fornix implants
- TVUS useful
- Laparoscopy w/biopsy
12
Q
Appearance of Endometriosis?
A
“Chocolate cysts”
13
Q
Endometriosis first line management
A
- COCs: Continuous
- Progesterone: 20-100 mg po qd (Depo, Mirena)
- NSAIDs
- Danazol - Creates hypoestrogenic/hypoandrogenic state w/BC
- Aromatase inhibitors - inhibit specific protein
- GnRH agonist –> pseudomenopause (limited to 3-6 months) w/Ca++ (Inhibits cascade)
14
Q
Endometriosis Surgical Management
A
- For severe sxs that cannot be controlled
- Anatomic distortion
- Infertility
- Laprascopic or TAH with BSO
15
Q
Adenomyosis - define
A
Endometrial glands and stroma invade Myometrium causing hypertrophy via invagination
16
Q
Adenomyosis Prevalence
A
20-65% affected
More common >35
Increased risk: higher parity, prior uterine surgery, fibroids
17
Q
Adenomyosis Clinical Presentation
A
-Dysmenorrhea
-Dyspareunia
Menorrhagia (with absence of endometriosis or fibroids)
18
Q
Adenomyosis Medical Tx
A
Decreasing pain cascade - NSAIDs
Mirena - Progesterone key (implants may have higher sensitivity to estrogen, progesterone will decrease)
-Danazol - Creates hypoestrogenic/hypoandrogenic state w/BC
-Aromatase inhibitors
-OCs - Continuous
-Pain meds: NSAIDs
19
Q
Adenomyosis PE
A
- Enlarged uterus that is globular or boggy and tender (due to hypertrophy)
- Pain within uterus itself NOT ovaries/fornix/ect.
- Histopathology from hysterectomy specimen (definitive)
- Imaging - MRI (More sensitive and specific)
20
Q
Adenomyosis MRI
A
- Cystic appearance
- Heterogeneity of myometrium
- Asymmetric myometrial thickness
21
Q
Adenomymosis Surgical Tx
A
- Hysterectomy
- Excision of implants (Difficult)
- Uterine Artery Embolism
22
Q
Leiomymoma (Fibroids, myoma, leiomyomata, fibromyoma) Define
A
- Benign growth/tumor
- Etiology unknown (single cell cloned, genetic, over expression of growth factors, hormone receptors)
- Malignant = sarcoma (
23
Q
Classification of fibroids (Leiomymoma)
A
- Submucosal - Protruding into uterine cavity
- Intramural - Within myometrium
- Subserosal - On serous surface of uterus
- Pedunculated - On stalk
24
Q
fibroids (Leiomymoma) Prevalence
A
- 20-50% reproductive age have symptomatic
- Increased risk with obesity and Fx, African American, nullips, early menarche and infertility
25
fibroids (Leiomymoma) Clinical Presenation
- Asymptomatic (incidental)
- Menorrhagia - cyclic due to larger surface area
- Menometrorrhagia
- Dysmenorrhea, cyclic
- Dyspareunia
- Non cyclic pelvic pain
- Urinary frequency/bladder pressure
- Constipation
- Anemia, infertility, SAB
- Common to have more than one
- Range from
26
Endometriosis vs Adenomyosis vs fibroids (Leiomymoma)
- Bogginess of adenomyosis
- Pain during menses of endometriosis
- Fibroids are firm
27
fibroids (Leiomymoma) Testing
TVUS allows you to identify and measure (MRI, CT
| HSG - Use dye and X-ray for patency of tubes and identify disruptions of architecture of tubes
28
fibroids (Leiomymoma) PE
- Non-tender on exam
| - Enlarged, bulky, irregular FIRM uterus
29
fibroids (Leiomymoma) Tx (Asymptomatic)
- Expectant
| - Sono 6mo-1yr to r/o rapid growth especially post menopausal
30
fibroids (Leiomymoma) Tx (Symptomatic)
- Consider size, location, severity, age, reproductive plans
- Expectant w/ sono 6mo-1yr
- OCs and Mirena best
- GnRH agonists, aromatase inhibitors
- Pain relief - NSAIDs
- Infertility - Remove submucosal and intramural
- Surgery is mainstay of Tx w/ BC for preventative tx
31
Myomectomy (Types)
- MR guided US surgery - Non invasive, out pt, 1-3 day recovery
- Abdominal myomectomy - Horizontal or vertical, 4-6 wk recovery
- Laproscopic - via abd or vagina, GA, 1-2 wk recovery
- Hysteroscopy myomectomy - GA, vaginal removal, 1-3 day recovery
- Laser - GA, 1 week recovery
- UAE - Injection of polyvinal beads into uterine artery, block blood flow --> necrosis of fibroid, out pt, 1-2 week recovery
- Hysterectomy - GA, 4-6 weeks recovery (total or partial)
32
Physiological Ovarian Cysts types/causes
- Follicular - Follicle isn't released --> fluid filled sac
- Corpus Luteum - Doesn't regress and is filled with fluid
- Theca Lutein (increased hCG) - Molar pregnancy, early pregnancy
- All can be hemorrhagic
33
Complex Cysts/Benign Ovarian Neoplasms
-Overgrowth, not just normal cyclic hormonal changes
-Serous and mucinous cystadenomas
Endometrioma - Chocolate cysts (Endometriosis)
-Matura Teratoma (Dermoid cyst) - Germ cell w/hair, bone teeth
34
Ovarian Cyst Incidence
- Reproductive age: 70% functional, 10% endometriomas (resolve in a cycle or two)
- Post menopausal: 50% malignant
35
Ovarian Cyst Clinical Presentation
- Unilateral dull ache - sharp pain
- Pressure
- Increased abd girth, increased urinary freq
- Follicular - Mild lower abd discomfort, pelvic pain, dyspareunia
- Corpus Luteum - Pelvic irritation, delayed menses
- Luteal can be bilateral
- Functional are unilateral because you ovulate from one side or another
36
Ovarian Torsion Sxs
Sudden onset acute unilateral pain w/ N/V
37
Ovarian Cysts PE
- R/O ectopic, rupture, abscess/infection, pregnancy (UPT. GC/CT, CBC)
- Abd guarding or rebound, dullness on percussion
- Functional cysts 3-7cm, mobile, unilateral, non tender
- Post menopausal - C1A125
- TVUS shows if it's solid or fluid filled, locate and measure
- Laparoscopy for diagnosis
38
Ovarian Cysts malignant charicteristics
- Solid component
- Septations, Focal wall thickening
- Send to radiology for f/u
39
Ovarian Cysts risk of malignancy
- Prepubescent or post menopausal >1cm
- Complex or solid mass on imaging
- Genetic predisposition to CA
- Presence in pt with non-gynecological CA
40
Ovarian Cysts to Refer
- Pre-menarche or post menopausal with masses refer for f/u
- Acute pain, unstable: ER for r/o rupture, ectopic
- Main cause is functional cycling, if not cycling refer for f/u
41
Simple Ovarian Cysts Tx
5-7cm (premenopausal), >1-7cm (Menopausal): consult, f/u annually
> 7cm refer for eval
-Medical - COCs for functional cysts
-Surgical - Depends on growth/Family planning
-Cystectomy
-USO, BSO, TAH w/BSO
42
Pelvic Organ Prolapse define
- Herniation of pelvic contents through vaginal canal
| - More common in postmenopausal women
43
Pelvic Organ Prolapse Prevalence
40% of women >60
| -Mostly asymptomatic
44
Pelvic Organ Prolapse Etiology
- Atrophic nature and decrease in estrogen
- Pelvic muscles and connective tissue get less strong
- Vaginal childbirth stresses structures
- Surgeries to any pelvic organs
45
Risk for Pelvic Organ Prolapse
- Hispanic/Low SES
- Menopause
- Chronic cough caused by smoking, straining with constipation, heavy lifting
- Pregnancy, prolonged labor, large baby
46
Pelvic Organ Prolapse Clinical presenation
- More symptomatic through course of day
- Difficulty urinating/defecating
- Stress incontinence
- Splinting - press on perineum to empty bowel
- Dyspareunia
- Hysterectomy common cause - often do partial and leave cervix
47
Pelvic Organ Prolapse Assessment
- Valsalva as you remove speculum
- Valsalva with two fingers inserted anterior and posterior
- Single posterior speculum bill
48
Pelvic Organ Prolapse Staging
- 0 - No prolapse
- 1 is > 1 cm above hymen
- 2 is 1 cm below plane of hymen, protrudes no further then 2cm less then length
- 4 is Eversion of lower genital tract complete
49
Pelvic Organ Prolapse 1st line tx
- Lifestyle changes: Wt loss, stop smoking, exercise, prevent osteoporosis
- Biofeedback: Replace stress with relaxation. TENS is nerve stimulation
- Pelvic Floor Training: Kegals
- Mechanical: Pessary inserted to provide support and occupy space (change q3 months)
- Surgical
50
Indications for Vulvar Derm Biopsy
- Lesions suspicious for malignancy
- Inability to make dx by visual inspection
- Lack of resolution after therapy
- Patient concern
51
Types of Vulvar Derm Bipsies
- Punch - Most common. Full thickness, amy do multiple. Dx not theraputic. Keye's punch 3-4 cm
- Shave - Horizontal Shave. Not full thickness. Mostly dx, can tx
- Excisional - Complete removal, beyond margins. Dx and Tx.
52
Inclusion/Epidermal/Sebaceous cysts
- Redness, itching
- Common
- In internal mucosa you can see vascular aspect
- Self-limiting
- Many different presentations
53
Vulvovaginal Candidiasis
- Most common cause of sudden onset itching
- Red, puffy mucous membranes with skin fold fissures
- Many tx, yeast prophylaxis
54
Contact Dermatitis
- Edema of labia minora
- Superficial erosions
- Lube can cause this, also latex, tea tree, KY Jelly
- Contact derm will start immediately, allergic rxn can take time to develop
55
Vulvar Psoriasis/Eczema/Atopic Derm
- Scaly or non-scaly plaques
- Psoriasis - Silvery and scaly
- Eczema - Bright red and scaly
56
Lichen
- Large range of atopic skin reactions
- Pain with sex --> lidocaine
- Melatonin to sleep through itch
- Tx with corticosteroid or ointment provide diflucan for yeast
57
Lichen Planus
- Red, moist areas
- Itch, pain, burning
- Uncomfortable, raw, red patches
58
Lichen sclerosis
- White epithelium, reabsorption of labia
- Scarring over clitoral hood
- Itch
- Atropic manifestation, more common in elderly
59
Lichen Simplex Chronic
Thickening of skin from scratching all the time
Intractable itch
-Tx with high potent corticosteroid topically
60
Tx for Lichen Simplex Chronicus
- Topical high potency corticosteroid -->taper
- Minimize scratching with sleep supplements and antihistamines
- Lidocaine jelly for comfort
- Difulcan with corticosteroid tx
- Careful skin care - warm water only finger tips. Icepacks PRN
- Avoid hot water, harsh soap, washcloths, medications, rough fabric, tight clothes, heat, perfumes
61
Pelvic Pain NOS
- Pelvic, Urinary, Neuro, MSK, Psychogenic
- Main things to ask: Acute/Chronic, Cyclic/Non-Cyclic
- 10-40% patients
62
Acute Pelvic Pain
63
Chronic Pelvic Pain
3-6 months
- Localized to pelvis, anterior abd wall below umbilicus, lower back, butt
- Functional long term disability
64
Pelvic Pain PE
- Pain mapping (q-tip test on vulva)
- Single digit exam of musculature
- R/O Appendicitis
- Assess for prolapse
- CBC, Pap, UPT, FOBT, EMBx, TVUS/MRI/CT
65
Pelvic Pain Management
- Expectant, Medical, Complementary, PT, Psychotherapy, Surgery
- Level of pain, associated sx, desire for pregnancy/future fertility
66
Pelvic Floor Muscle/Neuropathic Dysfxn
-Muscles of pelvic floor are weak, tight
OR impairment of sacroiliac joint, low back, coccyx, hip joint
-Tissues or nerves surrounding pelvic organ increased or decreased sensitivity or irritation
67
Pelvic Floor Muscle/Neuropathic Dysfxn Tx
-External and internal soft tissue mobilization
-Biofeedback
-Deep Tissu Massage
-Connective tissue manipulation
-Electrical stimulation
TENS
-Visceral manipulation
-Trigger point release
-Heat and cold therapy
