Common Gynecologic Conditions Flashcards
Physiology of the Female Repro. System
Puberty + horomes + ages and what happens
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
how the HPA and HPG systems regulate pubertythrough secondary sex characteristics and ova production
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
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
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
specific actions of LH anf FSH
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
role of relaxin
relaxin: during pregnancy: joints and ligaments become felxible to allow for passage of baby through pelvis
Ovulation and Menstration: whats occuring hormonally
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)
Ovulation and Mensturation
Cycle days in length
how the hromones impact the endometrium
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
Cervical chnges during cycle
vaginal changes
breast changes
sexual cahnges of intercourse
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
Bacterial Vaginosis
Etiology
Risk Factors
Symptoms
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
Bacterial Vaginosis
Diagnosis
Treatment
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!
Candidal Vulvovaginitis (yeast)
Etiology
Symptoms
Risk Factors
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
Candidal Albicans
Diagnosis
Treatment
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)
Trichomoniasis
Etiology
Symptoms
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
Trichomonas
Diagnosis
Treatment
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
Bartholian Gland Dysfunction
Etiology
Symptoms
Diagnosis
Treatment
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
PMS & PMDD
etiolgoy
symptoms
diagnosis of each
treatment
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
Abnoraml Uterine Bleeding
menorrhagia
metrorrhagia
hypomenorrhea
oligomenorrhea
Evaluation
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
Assessing Primary Amenorrhea
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
Assessing Secondary Amenorrhea
ashermans syndrome
GnRH pusitlie issue
prolactin
thyroid
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
premature ovarain failure: potential secondary amenorrhea
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
PCOS
Etiology
Symptoms
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
PCOS
Diagnosis
Treatent
increased risk of what
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
PCOS and contraception use
inducing the period
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
Dysmenorrhea
Etiolgoy and what is it
associated symptoms
diagnosis
treatmet
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
Endometriosis
Etiology
where they are
endometrioma
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
Endometriosis
Diagnosis
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
Endometriosis
symptoms reported by pt
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
Endometriosis
Treatment Decision
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
