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
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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
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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)
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4
Q

Primary Dysmenorrhea Pathophysiology

A

Increased prostaglandins in secretory endometrium –> increased uterine contraction and reduced blood flow –> pain

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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
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6
Q

First line for Dysmenorrhea?

A

Prostaglandin Inhibition: NSAIDs (Ibuprofen 400-800 q4-6)

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7
Q

Endometriosis - define

A

Presence of endometrial glands and stroma outside the uterus

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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
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9
Q

Endometriosis Prevalence

A

-10%
-60-80% w/ infertility or chronic pelvic pain
Most common reason for dysmenorrhea and menorrhagia in younger patient

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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
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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
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12
Q

Appearance of Endometriosis?

A

“Chocolate cysts”

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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)
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14
Q

Endometriosis Surgical Management

A
  • For severe sxs that cannot be controlled
  • Anatomic distortion
  • Infertility
  • Laprascopic or TAH with BSO
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15
Q

Adenomyosis - define

A

Endometrial glands and stroma invade Myometrium causing hypertrophy via invagination

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16
Q

Adenomyosis Prevalence

A

20-65% affected
More common >35
Increased risk: higher parity, prior uterine surgery, fibroids

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17
Q

Adenomyosis Clinical Presentation

A

-Dysmenorrhea
-Dyspareunia
Menorrhagia (with absence of endometriosis or fibroids)

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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

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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)
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20
Q

Adenomyosis MRI

A
  • Cystic appearance
  • Heterogeneity of myometrium
  • Asymmetric myometrial thickness
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21
Q

Adenomymosis Surgical Tx

A
  • Hysterectomy
  • Excision of implants (Difficult)
  • Uterine Artery Embolism
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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 (
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23
Q

Classification of fibroids (Leiomymoma)

A
  • Submucosal - Protruding into uterine cavity
  • Intramural - Within myometrium
  • Subserosal - On serous surface of uterus
  • Pedunculated - On stalk
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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

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25
Q

fibroids (Leiomymoma) Clinical Presenation

A
  • 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
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26
Q

Endometriosis vs Adenomyosis vs fibroids (Leiomymoma)

A
  • Bogginess of adenomyosis
  • Pain during menses of endometriosis
  • Fibroids are firm
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27
Q

fibroids (Leiomymoma) Testing

A

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
Q

fibroids (Leiomymoma) PE

A
  • Non-tender on exam

- Enlarged, bulky, irregular FIRM uterus

29
Q

fibroids (Leiomymoma) Tx (Asymptomatic)

A
  • Expectant

- Sono 6mo-1yr to r/o rapid growth especially post menopausal

30
Q

fibroids (Leiomymoma) Tx (Symptomatic)

A
  • 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
Q

Myomectomy (Types)

A
  • 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
Q

Physiological Ovarian Cysts types/causes

A
  • 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
Q

Complex Cysts/Benign Ovarian Neoplasms

A

-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
Q

Ovarian Cyst Incidence

A
  • Reproductive age: 70% functional, 10% endometriomas (resolve in a cycle or two)
  • Post menopausal: 50% malignant
35
Q

Ovarian Cyst Clinical Presentation

A
  • 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
Q

Ovarian Torsion Sxs

A

Sudden onset acute unilateral pain w/ N/V

37
Q

Ovarian Cysts PE

A
  • 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
Q

Ovarian Cysts malignant charicteristics

A
  • Solid component
  • Septations, Focal wall thickening
  • Send to radiology for f/u
39
Q

Ovarian Cysts risk of malignancy

A
  • Prepubescent or post menopausal >1cm
  • Complex or solid mass on imaging
  • Genetic predisposition to CA
  • Presence in pt with non-gynecological CA
40
Q

Ovarian Cysts to Refer

A
  • 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
Q

Simple Ovarian Cysts Tx

A

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
Q

Pelvic Organ Prolapse define

A
  • Herniation of pelvic contents through vaginal canal

- More common in postmenopausal women

43
Q

Pelvic Organ Prolapse Prevalence

A

40% of women >60

-Mostly asymptomatic

44
Q

Pelvic Organ Prolapse Etiology

A
  • Atrophic nature and decrease in estrogen
  • Pelvic muscles and connective tissue get less strong
  • Vaginal childbirth stresses structures
  • Surgeries to any pelvic organs
45
Q

Risk for Pelvic Organ Prolapse

A
  • Hispanic/Low SES
  • Menopause
  • Chronic cough caused by smoking, straining with constipation, heavy lifting
  • Pregnancy, prolonged labor, large baby
46
Q

Pelvic Organ Prolapse Clinical presenation

A
  • 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
Q

Pelvic Organ Prolapse Assessment

A
  • Valsalva as you remove speculum
  • Valsalva with two fingers inserted anterior and posterior
  • Single posterior speculum bill
48
Q

Pelvic Organ Prolapse Staging

A
  • 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
Q

Pelvic Organ Prolapse 1st line tx

A
  • 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
Q

Indications for Vulvar Derm Biopsy

A
  • Lesions suspicious for malignancy
  • Inability to make dx by visual inspection
  • Lack of resolution after therapy
  • Patient concern
51
Q

Types of Vulvar Derm Bipsies

A
  • 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
Q

Inclusion/Epidermal/Sebaceous cysts

A
  • Redness, itching
  • Common
  • In internal mucosa you can see vascular aspect
  • Self-limiting
  • Many different presentations
53
Q

Vulvovaginal Candidiasis

A
  • Most common cause of sudden onset itching
  • Red, puffy mucous membranes with skin fold fissures
  • Many tx, yeast prophylaxis
54
Q

Contact Dermatitis

A
  • 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
Q

Vulvar Psoriasis/Eczema/Atopic Derm

A
  • Scaly or non-scaly plaques
  • Psoriasis - Silvery and scaly
  • Eczema - Bright red and scaly
56
Q

Lichen

A
  • 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
Q

Lichen Planus

A
  • Red, moist areas
  • Itch, pain, burning
  • Uncomfortable, raw, red patches
58
Q

Lichen sclerosis

A
  • White epithelium, reabsorption of labia
  • Scarring over clitoral hood
  • Itch
  • Atropic manifestation, more common in elderly
59
Q

Lichen Simplex Chronic

A

Thickening of skin from scratching all the time
Intractable itch
-Tx with high potent corticosteroid topically

60
Q

Tx for Lichen Simplex Chronicus

A
  • 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
Q

Pelvic Pain NOS

A
  • Pelvic, Urinary, Neuro, MSK, Psychogenic
  • Main things to ask: Acute/Chronic, Cyclic/Non-Cyclic
  • 10-40% patients
62
Q

Acute Pelvic Pain

A
63
Q

Chronic Pelvic Pain

A

3-6 months

  • Localized to pelvis, anterior abd wall below umbilicus, lower back, butt
  • Functional long term disability
64
Q

Pelvic Pain PE

A
  • 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
Q

Pelvic Pain Management

A
  • Expectant, Medical, Complementary, PT, Psychotherapy, Surgery
  • Level of pain, associated sx, desire for pregnancy/future fertility
66
Q

Pelvic Floor Muscle/Neuropathic Dysfxn

A

-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
Q

Pelvic Floor Muscle/Neuropathic Dysfxn Tx

A

-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