Common Gynecologic Conditions

Question 1

Physiology of the Female Repro. System

Puberty + horomes + ages and what happens

Answer 1

Pubery
- around ages 8-10 the pusatile release of GnRH from teh hypothalmus begins to increase: in amount and frequency

Hypothalamus - released GnRH

triggers Pituitary (anterior) to release FSH and LH

FSH and LH trigger estrogen: which triggers follicle gorwth and secondary sex characterisitcs

leads to folliculogenesis and cyclic changes in estrogen and progesterone production

Estrogen dependent tissue become responsive to these

result:
- thelarche: breast development
- menarche: menses

Question 2

how the HPA and HPG systems regulate pubertythrough secondary sex characteristics and ova production

Answer 2

HPA
hypothalmus - CRH
pituitary - ACTH
adrenal Cortex
- androstenedione and DHEA
- net result from the adrenal cortex: creation of the axillary hair, pubic hair and acne

HGA
hygothalmus - GnRH
pituriaty - FSH and LH
act on the ovaries - production of estrogen (and some androgens which add to teh axillary and pubic hair growth)

assist in development of the breats, ovaries, uterus
creates ova and onsent of menarche

Question 3

role of adrenals
role of liver
role of thyroid
role of ovaries
role of pituitary and hypothalmus

in production of hormones which regulated female menstrual cycle

Answer 3

hypothal and pituitary: GnRH and FSH/LH to travel to the gonads
- hypothalmus: GnRH
- Pituitary: anterior (LH/FSH) posterior (oxytocinpregnancy and vasopression)

liver
- metabolizes the hormones
- makes sex hormone binding golbulin: results in allowing hormones to travel in blood

ovaries
- estrogen
- progesterone

Adrenals
- steroids for pubic hair, etc.

Thyroid
- TSH can affect fertibility and menstruation

Question 4

specific actions of LH anf FSH

Answer 4

FSH: follicle stimulation hormone
- stimulates the follicles in the ovary to grow
- the follicle grows: and has granular cells which produce estrogen
- increases production of inhibin and activing with impact the way in which FSH will impact the ovary (neg. feedback)

LH: Luteinizing Hormone
- stimulates the production of androgens in the thecal cells
- androgens converted to estrogen (in the granulosa cell)
- estrogen then “rises”” to a critical point : LH surge
- LH triggers the release of the follicle from the ovary
- remains of follicle = corpus luteum (releases progesterone)

• estrorgen and progesterone: prepare uterine lining for implantation
• FSH and LH stimulate the estrogen production from the ovary & production of inhibitn

Inhibin: suppresses FSH secretion: to prevent futher ovulation of an ova (despite estrogen promoting GnRH)
net result: increase LH and not FSH: thus the surge releasing the ovum

Question 5

role of relaxin

Answer 5

relaxin: during pregnancy: joints and ligaments become felxible to allow for passage of baby through pelvis

Question 6

Ovulation and Menstration: whats occuring hormonally

Answer 6

LH surge: releases the ovum from the follicle: resulting in a corpus luteum

corpus luteum: produces progesterone

Progesterone: inhibits further production of the gondaotropins (LH and FSH) for rest of luteal phase

once progesterone falls: leads to decrease in thicked lining: mensturation occurs
(fall of progesterone due to lack of HCG from no impanted blastocyte: no more corpus luteum: no more progresterone)

Question 7

Ovulation and Mensturation

Cycle days in length

how the hromones impact the endometrium

Answer 7

Follicular phase: days 1-14
day 14: ovulation
Luteal phase: 14-28

these cycles impact the endometrium

• estrogen proliferates the endometrieum
• high levels of estrogen + progesterone = increase thickeness in preparation for implantation

abscence of progesterone: endometral vascualture dies; shedding tissue ; menses

Question 8

Cervical chnges during cycle

vaginal changes
breast changes
sexual cahnges of intercourse

Answer 8

Cervical Changes
estrogen: thins mucus, alkaline

helps sperm mobility

progesterone: thickens, tenacious (slow and plug; assuming blastocyte is in there)
(cervical mucus testing)

Vaginal Changes
estrogen: corification of epitheilal cells (death)
progesterone: increases leukocytes

breast changes
- estrogen: causes proliferation of the mammary ducts
- progesterone: increase lobule and alveli growth
- swelling and tenderness 10 day sbefore cycle

Sexual changes
- increased lubrication, strecthing, sensation

average age of menarche: 12.7, menopause 51.4

Question 9

Bacterial Vaginosis
Etiology
Risk Factors
Symptoms

Answer 9

Etiology
- overgrowth of normal vaginal flora due to a change in the pH of the vagina: increases the anaerobic bacteria while decreasing lactobacilli
- gardenlla vaginalis is the MOST COMMON IN WOMEN WHO HAVE SEX WITH WOMEN

RIsk Factors
- vaginal douching
- multiple sex partners
- recent abx. use
- cigarette smoking
- IUD
- soaps/lotions
- lubricants

Symptoms
- increased dischage: grey/white and thin with ODOR
- dysuria, dyspareunia and vaginal puritis
- can be asymptomatic

Question 10

Bacterial Vaginosis
Diagnosis
Treatment

Answer 10

Diagnosis
Wet Mount slide: clue cells
- addition of the KOH prep results in fishy odor

Treatment
- untreated BV = increased risk of STIs, HIV, gon/chalmydia
- BV in pregnancy = increased risk of preterm labor

Medications: abx.
- clindamycin & can be used in pregnancy (right before sleeping so it doesnt seep out
- Metronidazole: watch disulfram reaction: no alcohol with this!

Question 11

Candidal Vulvovaginitis (yeast)
Etiology
Symptoms
Risk Factors

Answer 11

Etiology
- a yeast infection: MC candida albicans

Risk factors
- abx. use
- warm moist environment
- DM
- HIV
- always check HIV and DM in those with recurrent yeast infections

Symptoms
- external dysuria and vulvar puritius!!!
- pain swelling and redness
- external vulvar edema, fissure
- discharge: thick, white and curdy like cottage cheese

Question 12

Candidal Albicans
Diagnosis
Treatment

Answer 12

Diagnosis
- WET MOUNT: with addition of KOH prep: see the hyphae and budding
- will have normal pH (compared to BV)

Treatment
- pt. edu: preventin this with proper hygeine & use of a probiotic

Medications
vaginal creams: OTC
- clotrimazole, miconazole
- warn pt: these meds can weaken latex condoms, etc.

oral preps Rx.
- fluconazole (1 dose)

Question 13

Trichomoniasis
Etiology
Symptoms

Answer 13

Trichomoniasis Etiology
- a parasitic sexually transmitted infection: the trichomnas vaginalis

Symptoms
- most (70%) are asymptomatic
- can appear later: ithcy, odor, burning iwth urination or sex
- thin, yellow/green discharge, frothy
- “strawberry cervix” petechiae on cervix

Having Trich: increased the risk of having other STIs (HIV!!)
can increase risk of having low birth weight baby if pregnant

Question 14

Trichomonas
Diagnosis
Treatment

Answer 14

Diagnosis
- WET MOUNT: visable trichomonads on the slide; swimming with the flagella
- can have odor with KOH

Treatment
Metroniadozole
- MUST TREAT PARTNERS: tell them to see a PCP to get treatment
- if recurrent infection: can use more

Question 15

Bartholian Gland Dysfunction
Etiology
Symptoms
Diagnosis
Treatment

Answer 15

Etiology
- barholian galnd: produces lubrication for sexual activity in the vagina
- blockage of the duct (usually unilateral) due to a variety of reasons
- trauma
- childbirth
- can get infected: leading to abcess formation

Symptoms
- unilateral lump/buldge in teh vulva
- can be painful or painless
- can impacte the ability to urinate

Abcess formation : infected cyst of the gland
- painful, redness and swelling +/- fever

Diagnosis
- clinical

Treatment
- can resolve on its own; depends on severity
- sitz baths to help
- if abcess: I & D the abcess & give abx.
- if recurring abcess: consider word catherter to let it drain over some time
- if recurrent abcess: can do a marsupialization: remove gland and evert edges to prevent recurrance

Question 16

PMS & PMDD
etiolgoy
symptoms
diagnosis of each
treatment

Answer 16

PMS: Premenstrual syndrome
PMDD: premenstrual dysphoric disorder

Etiology
- a continumum of symptoms collected together into syndromes : a psychoneuroendocrine disorder
- hormonal influences with psychosocial factors interplaying
- a role in ovarian function: as suppression of ovarian function (contraception) decreases symptoms

Symptoms
- bloating
- breast tenderness
- fatigue insomnia
- irritability
- poor concentration
- changes in appetite

Diagnosis : PMS
- technically: symptoms during luteal phase, 7 days of no symptoms during first 1/2 of the follicular phase
- ensure its not just a psych. issue: and that its actaull cyclically related

Diagnosis& Symptoms: PMDD
- a severe and more debilataing presentation of PMS
- mood disturbances are severe: depressed, anxiety, easily crying, etc.
- debiliating and impacting daily life

no CLEAR indication when it goes from PMS to PMDD

Treatment
- lifestyle cahnges can help : diet, exercise, destress
- B vitamins: E for breast tenderness
- decrease carbs., simple sugars, etc.
- contraception to suppress ovaries
- SSRIs canbe helpful

Question 17

Abnoraml Uterine Bleeding
menorrhagia
metrorrhagia
hypomenorrhea
oligomenorrhea

Evaluation

Answer 17

Definitions
menorrhagia: heavy bleeding
metrorrhagia: frequent bleeding
hypomenorrhea: light
oligmenorrhea: infrequent: spread out periods (menses)

Evaluation
history: LMP, amoutn, frequency, infection, preg hx., last pap
physical: cytology (PAP), bimanual

Ultrasound
- evaluate uterus and adenxa, endometrium thickness

endometrial biopsy
- can be done in office for those 40+ or those with risk factors
sonohistogram
- under anethesia: US with fluid to get better look at the uterus and can do D&C with this

D & C : dlation and curretage
- removing endometrial tissue: can be a complete uterine sample or can be treatment

Question 18

Assessing Primary Amenorrhea

Answer 18

need a working uterus, an exit and proper hormone control to have a period

Primary Amenorrha
- NEVER had first period: by age 13 with no normal growth or by age 15 with normal secondary sex cahracteristic growth

if age 13: no secondary sex characteristic develop: look towards genetic testing (could have underlying syndrome)

if age 15: with secondary sex characters: think outflow issue or hormone issue: could be other disorder

Outflow Issue
- without a proper “exit” : no menses
- imperforated hymen: cant flow
- abnormal uterine cavity: absent: meullarian dysgenesis

Hormone Issue
- check LH/FSH
- normal FSH/LH: think hypothalamic cause
- high FSH’LH: PCOS or resistant ovaries
- prolactin high; pituitary adenoma

Question 19

Assessing Secondary Amenorrhea
ashermans syndrome
GnRH pusitlie issue
prolactin
thyroid

Answer 19

RULE OUT PREGNANCY FIRST ALWAYS!!

secondary amenorrhea: absent period for more than 6 months in female who previously menstrated

First labs: b-HCG, TSH, Prolactin
- looking for pregnancy, hypothyroid, or pituitary adenoma

Ashermans Syndrome: interuterine scarring due to repeated procedures: leads to adhesions and distrubtion of the lining

GnRH Pulsatile issue: hypogonadism
- anoerxia, weight loss, severe stress, atheletic exertion : aspect of teh female athlete triad (anoerxia, amenorrhea, OP)

hyperprolactinoma: due to pituitary adenoma
- treat with bromocriptine (decrease the prolactinoma, stop the suppression of the hormones and period should return)

hypothyroid: elevated TSH, decrease T3/T4: actaully increase prolactin which suppresses

Question 20

premature ovarain failure: potential secondary amenorrhea

Answer 20

premature ovarian failure
- failure of the follicles to mature before the age of 40
- prolactin and TSH are normal: need to test this
- given progesterone : progesteron SHOULD produce a withdraw bleed after stopping the progesteron: since the progesterone triggered gorwht of endometrium, then the lack of it should induce a period

+ withdraw bleed: they are making enough estrogen (to help bulk the endomet)

• withdraw bleeD: give estrogen/progestin combo course (like birht control) and see if endometrium responds to the estrogen

Question 21

PCOS
Etiology
Symptoms

Answer 21

Etiology
- MCC of ovulatory dysfunction in reproducitve age women
- a disorder of oligomenorrhea, anovulation and hyperandrogenism
- genetic, environmental and metabolically influenced
- insulin resistance plays a role : increased production of androgens from the ovaries:

Symptoms
- typical presentation: amenorrhea, infertilitiy and hirsutism
- hirsutism: increased androgens: increased facial hair
- acanthosis nigracans: insulin resistance
- obese/overweight: insulin resistance
- infertility: could br the only reason they discover

Question 22

PCOS
Diagnosis
Treatent
increased risk of what

Answer 22

Diagnosis
- clincial picture : histrustiam, increased weight, etc.
- oligo/amenorrhea
- elevated testosterone
- 2:1 LH:FSH ratio
- US: see “strign of pearl” cysts on imaging: but not exclusive to PCOS and not diagnostic

Treatment
- depends on clincial picture
- often times lifestyle changes: weight loss: will induce periods to return
- overweight/obese: metformin can help with insulin resistance: and therefore help weight loss and induce menses by lowering testosterone
- infertility treatments

Risks
- T2Dm because of the insulin resistance

Question 23

PCOS and contraception use
inducing the period

Answer 23

Amenorrhea = rule out preg
US: assess endometrium thickness
then try to induce a period: progestin withdraw bleed test

if they withdraw bleed and have a thin ( < 10mm) endometrium = advise to treat with contraception options to decrease risk of endometrial hyperplasia (and risk of endomet. CA) combined OCP or IUD

if they dont withdraw bleed and thick endotrium
- refer for enmet. biopsy to rule of hyperplasis and CA

Question 24

Dysmenorrhea
Etiolgoy and what is it
associated symptoms
diagnosis
treatmet

Answer 24

Etiology
- painful menstruation
- due to prostoglandins: cramping

Symptoms
- N/V and Gi upset
- menstrual HA

Diagnosis
- always rule out other cuases of pelvic pain
- is there a pattern? look at when in cycle is occuring
- endometriosis, polps, etc.
- pathologic cause of the pain?

Treatment
- NSAIDS (anti-prostiglandins)
- heating pads, exercise
- combnined OCPs: can help suppress ovarian function and decrease flow to decrease pain

Question 25

Endometriosis
Etiology
where they are
endometrioma

Answer 25

Etiology
- abnormal growth of tissue that is histologically simialr to teh endometirum; but for some reason leaves or grows outside theuterus
- retrograde menstruation posisbel theory
- hematogenous spread
- instrumentation disruption
- in those of reproductive age : women
- extremely common in infertile women: maybe nbeause theyre getting worked up for infertibiltiy and found this way

Where are they and what they do
- lesions found can be smal to huge
- leads to pelvic adhesions and causes inflammatoyr responses
- they are anywhere in the peritoneal cavity (or anywhere else) but they shed and scar like a normal cycle
- dark brown, blue or black

endometrioma: choclate cyst
- irritating to perineum, if popped: old blood
- if ruptured: need to copious irrigate

• peritoneal cavity & on pelvic structures: MC location is on the ovaries or in the cul-du-sac (space between rectum and uterus

Question 26

Endometriosis
Diagnosis

Answer 26

Diagnosis
- a dx. of esculsion usually : rule out other cuases for teh pelviv pain, etc.
- history, presentation and exam findings can lead to dx.
- mc diagnosis that leads to hospitalization of women

only way to confirm dx. is direct visualization of the masses: diagnostic laproscopy
- see red,brown and dark masses on teh peritoneal structures, pelvic structures (ovaries)
- can have scarringa nd inflamamtion/thickeing

Rarely
- found in lung, liver and kidney and brain

Question 27

Endometriosis
symptoms reported by pt

Answer 27

Symptoms
- PAIN: generalized pelvic pain
- cyclical pain usually: worse 2-3 weeks leading up to menstruation and resolves for some time
- infertility: adhesions of the organs, scarring and inability to be fertile
- Fixed Uterus: immbolie, due to adhesions and scarring

ovarian mass : large endometrioma

Question 28

Endometriosis
Treatment Decision

Answer 28

Treatment: depends on womens desire to get pregnant
- pain control with NSAIDS
- OCPs helpful

Fertilitiy Desired
- NO OCPs
- pain control
- move tosurgical appraoch: dx. with laproscopy & get rid of adhesions

No Fertility Desired
NSAIDS
OCPs: suppress ovaries anda void the endometrial proliferation
- depo shot
- lupron (GnRH agonist) : can created menopasusal side effects

definiative treatment is hysterectomy with oophroectomy