Conditions/Diseases Flashcards
Turner Syndrome Summary
Def: genetic abnormality in women
Cause: 45, XO chromosomes
Eval:
SS: amenorrhea delayed puberty webbed neck small stature poor breast development coarctation of aorta
Txt:
growth hormone
estrogen - during puberty
progestins - later to prevent endometrial hyperplasia
Excess Androgens Summary
Def: overproduction at adrenal glands, ovaries, extraglandular
Cause: Polycystic Ovary Syndrome Hormone secreting tumors Adrenal disorders - congenital adrenal hyperplasia - cushing syndrome Idiopathic Hirsutism
SS: Hirsutism Virilization structural - imperforate hymen - transverse vaginal - bicornate uterus - mullerian agenesis
Follicular phase summary
Def: onset of menses to LH surge/ovulation
Duration: variable, 14 days
Activity:
FSH increase
- follicular growth of oocytes
- emerge dominant follicle (23 chromosomes)
Menstuation
- first 3 - 7 days
- blood/desquamated superficial endometrial tissue
- prostaglandins cause cramping
Estradiol
- maintain endometrium
- start low and then increase to cause LH burst
Ovulation summary
Def: release of oocyte
Activity:
LH surge cause ovulation
oocyte released from ovary
follicle becomes corpus luteum (release progesterone)
Luteal phase summary
Activity:
Progesterone secreted by corpus luteum
- suppress FSH and LH
Fertilization:
- implanted zygote release human chorionic gonadotropin
- sustains corpus luteum until placenta take over (9 - 10 weeks)
No Fertilization:
corpus luteum involutes 9 - 10 days
- cause increase FSH
Oogenesis summary
Cause: FSH stimulation
Activity:
several primary oocytes grow
- 1 or 2 resume meiosis I
* cause secondary oocyte
primary follicle develop granolas cells around secondary oocyte
- releases 2nd oocyte and become corpus luteum
corpus luteum secrete progesterone and estrogen to support 2nd oocyte if fertilized
Amenorrhea summary
def: absence of menstruation
primary - none by 13 yrs or 15yrs with 2nd sexual development
secondary
- no menstruation 3-6 months
cause: preg hypothalamic ovarian genital outflow obstruction
Anovulation summary
def: failure to ovulate
cause:
HPO
systemic disease
medications
SS:
constant estrogen levels
irregular, unpredictable bleed
Ovulatory bleeding summary
Metorrhagia - bleed between cycles Menorrhagia - excessive bleed regular intervals Menometrorrhagia - frequent/excessive bleed Polymenorrhea - frequent bleed
Cause: Obstetric GU tract abnormal HPO axis anovulatory bleeding meds dysfunctional uterine bleeding
Fibroadenoma
Most common solid mass found in women of reproductive years (15-50)
Symptoms: firm, round, well circumscribed, mobile mass
Dgx: classic US appearance and/or needle bx
Tx: does not require excision, although most women prefer it
Mastitis/Abscess
Causes: pregnancy/lactation, injury, nipple piercing
Symptoms: pain, swollen, erythematous breast
Tx: Abx
Mammogram or US to r/o abscess
Lobular carcinoma in situ
*Misnomer-NOT a cancer, but is a risk factor for developing invasive cancer
Risk may be increased as much as 20-30%
Tx: close observation, bilateral prophylactic mastectomy. tamoxifen
ductal carcinoma in situ
Abnormal appearing microcalcifications
Proliferation of malignant cells within ducts
Stage 0
Tx: lumpectomy/Radiation therapy, mastectomy, no lymph node dissection, no chemo, possibly tamoxifen
invasive ductal/lobular carcinoma
invades beyond the normal duct/lobule into surrounding tissue
lobular carcinoma can be more diffuse and difficult to detect by mammography because it grows linearly
most common sites of metastasis: Lung, Liver, Bone, Brain
Tx: all patients need axillary lymph node bx for staging; lumpectomy/chemotherapy, mastectomy, chemotherapy/hormone therapy
Inflammatory Breast Cancer
stage 3b, poor prognosis
Signs: swollen, usually nontender breast, erythema, peau d’orange, may not have dominant mass
Tx: preoperative chemotherapy first, mastectomy and axillary lymph node dissection, radiation, hormone therapy
Paget’s disease
signs: eczematous changes of the nipple
associated with underlying invasive cancer
dgx: with nipple bx
Tx: usually tx with mastectomy, if underlying cancer identified can do central lumpectomydysuria
Lichen sclerosus summary
Def: inflammatory condition of the valva
Cause: autoimmune
SS: vulvar pruitis vulvar pain dysuria dyspareunia white, wrinkled skin on labia
Eval:
punch biopsy
Txt: Topical steroids (2-3 mths and then weekly)
Lichen simplex chronicus summary
Def: lichenified skin reaction to chronic scratching
Cause: atopic dermatitis, cadidia, tinea
SS:
progressive pruritis
progressive burning
red papules form scaly plaques
Eval:
clinical
Txt:
underlying cause
antipruritis meds
topical steroids
Lichen planus summary
Def: inflammatory condition
Cause: autoimmune in older women
SS: chronic pruritis dyspareunia post-coital bleeding red/white, patchy, ulcerative lesions
Eval:
Clinical
Biopsy
Txt:
topical steroids
oral prednisones
Psoriasis summary
Def: genital involvement during menarche, pregnancy, menopause
Cause: autosomal dominant
SS:
pruritic
scaly, silvery patch on erythematous base
Eval:
Biopsy
Txt:
Topical steroids
Dermatitis Summary
Def: dry skin
Cause: eczema and seborrheic dermatitis
Eval:
Clinical
Txt:
offending agent
topical steroids
Vestibulitis summary
Def: localized vulvar pain without dermatitis
Cause: unknown
SS: severe pain on touch vulva
dyspareunia
small, reddened patchy areas
Eval:
light touch over vestibule recreate pain
Txt: Topical lidocaine notripyline gabapentin abstinence
Bartholin gland cyst summary
Def: obstruction of bartholin glands
Cause: bacterial cause
SS:
asymptomatic
pain and tenderness
firm swelling of posterior vaginal introitus
Eval: clinical
Txt:
word catheter
Vulvar neoplasia summary
Def: cancer of vulva
Most common vaginal intraepithelial neoplasia (from another site)
SS:
irritation
pruritus
raised lesions
Eval:
Biopsy
Txt:
Excision
Vaginal Cancer summary
Def: squamous cell, adenocarcinoma, melanoma
Not common
Cause:
HPV
Vaginal Intraepithelial Neoplasia
Cervical cancer
SS:
asymptomatic
vaginal bleed
Eval:
pap
biopsy
Txt:
radiation
hysterectomy
upper vaginectomy
Benign Cervical Tumors summary
Nabothian cysts - squamous over columnar cells in cervix
Polyps - polypectomy if symptomatic
Cervical Cancer summary
Cause: HPV but if have won’t mean get cancer
SS: precursor lesions by 10 yrs asymptomatic watery vaginal discharge spotting
Eval:
Pap test
colposcopy
conization
Txt: conization of cervix hysterectomy lymph node dissection radiation therapy
Uterine Leiomyoma Summary
Def: localized proliferation of smooth muscle cells
Cause:
Estrogen
SS:
masses in uterus
abnormal bleeding
Menorrhagia (anemia from it)
Eval:
clinical
US
Txt:
myomectomy
hysterectomy
Adenomyosis summary
Def: benign endometrial glands and stroma in uterine musculature
SS:
menorrhagia
dysmenorrhea
enlarged uterus
Eval:
MRI
histology
Txt:
hysterectomy
Endometrial polyps summary
Def: benign focal processes in perimenopausal women
SS:
abnormal bleeding
pelvic pain
Eval:
US
Txt:
polypectomy
Endometrial hyperplasia summary
def: proliferation of endometrial glands
Cause: excess estrogen exposure
SS:
abnormal uterine bleeding
Eval:
US
Txt: Dilatation and Curettage progestins medroxyprogesterone hysterectomy
Endometrial cancer summary
Def: postmenopausal cancer
SS:
postmenopausal bleeding
Eval
biopsy
US
Txt:
Hysterectomy
Benign ovarian cysts/tumors summary
SS: asymptomatic mass pelvic pain dyspareunia dysmenorrhea
Eval: pelvic exam US CBC UPT
Txt:
Removal
Malignant Ovarian Neoplasms Summary
Highest mortality rate
SS;
bloating, pain, satiety, eating issues
fixed solid mass
Eval:
US
histo
Txt:
Hysterectomy and Ovarial removal
Protective: OCP use breastfeeding multiparity tubal ligation
Ovarian torsion summary
Def: twisting of ovary
SS:
new onset pelvic pain
N/V
adnexal mass
Eval:
US
Candidiasis Vaginosis
Yeast Infection-candida albicans or glabrata
Predisposed by: DM, recent abx use, OCPs, pregnancy, CS therapy, occlusive clothing
SS: white, thick discharge, intense Pruritis, dysruria
vulvar/labial erythema, excoiation, edema, white discharge *often without odor
Dgx: characteristic s/s; *Normal pH, hyphae/spores on KOH, wet prep or culture
Tx: Oral fluconazole 150mg PO for 1 dose; vaginal hygiene
Bacterial vaginosis
common cause of vaginal discharge in women of childbearing age
overgrowth of largely anaerobic bacteria (*mainly gardnerella vaginalis) and a decrease in lactobacilis
SS: nonirritating, discharge, thin, gray white/yellow discharge, foul vaginal odor
Dgx: Amsel criteria: must have 3 of these: abnormal discharge, *abnormal pH >4.5, positive whiff test with KOH, wet prep shows *clue cells
DNA probe
Tx: metronidazole 500mg PO bid fro 7 days
Trichomoniasis vaginosis
STI
SS: persistent, profuse, frothy discharge, vulvar pruritis/foul odor, dysuria, inflamed labia, perineum, vagina, small petechiae (strawberry spots)
Dgx: wet mount shows increase in PMNs with *motile flagellate, KOH whiff, *pH >4.5
DNA probe, screen for other STIs
Tx: systemic metronidazole 2 gm PO x 1 or 500 mg PO bid for 7 days, must tx partner
Human papillomavirus
Warts/condyloma acuminata types 6 and 11; very common STI
SS: numerous, discrete fleshy lumps, smooth velvety surface, symmetric, may coalesce into cauliflower like regions, may be hidden in rectum or vaginal canal
mass, pruritis, burning, bleeding
Dgx: visual inspection (may require acetic acid wash to visualize affected skin), pathology
Tx: often difficult
Surgical: cryotherapy, electrocautery, laser,surgery
Chemical destruction: TCA acid, topical podofliox, topical imiquimod
Expectant management
Herpes simplex virus
type 2 > type 1
Primary (first) outbreak-most severe
SS: small, painful, grouped vesicles develop at site of contact>pustules>erosions/ulcers, erythema, swelling
dysuria, flu-like symptoms, lymphadenopathy
Secondary outbreak: less severe, fewer lesions, prodrome likely, heal faster
Dgx: clinical presentation, viral culture, tzanck smear, PCR, serology
Tx: primary: acyclovir 200mg PO 5 times/day x 7-10 days
relapse is common 3-5 days of tx
Chlamydia
SS: often asx; mucopurulent discharge with cercitis, dysuria, postcoital bleeding, pelvic pain, fever, urethritis
Complications: PID: tubal occlusion, infertility, extopic pregnancy risk, increases with each infection
Dgx: DNA assay, cervical culture, screen annually
Tx: azithromycin 1 gm x 1; doxycycline 100mg bid x 7 days; treat partner and report
Gonorrhea
SS: can be asx; copious mucopurulent discharge, dysuria, pelvic pain, fever, urethritis, usually affects other sites like oropharyngeal
Complications: PID
Disseminated: arthritis, tenosynovitis, dermatitis,
Dgx: DNA assay, culture, screening guidelines
Tx: ceftriaxone 250mg IM x 1 and azithromycin 1gm x1 for chlamydia
Syphilis
Primary-painless, hard, indurated ulcer forms at site of inoculation (chancre)-hidden, chancre heals in 3-6 weeks without scar
Secondary-skin rash on palms and soles, flu like illness, condyloma lata, systemic, hepatitis, GI, musculoskeletal, renal, neuro, resolves 2-6 weeks to latent infection
Dgx: spirochete seen on dark microscopy, screening and confirmation serology
Tx: PenG 2.4 million units IM x1
*repeat titers at 3, 6, 12 and 24 months post tx to ensure eradication
PID
acute ascending pelvic infection involving the upper genetial tract; often d/t gonorrhea and chlamydia
SS: often asx; low *bilateral abdominal pain, vaginal discharge, dysuria, dyspareunia, N/V/F/C, irregular bleeding
fever, abd tenderness, endocervical discharge, cervical motion tenderness, uterine tenderness
Dgx: clinical, imaging, laparoscopy
Labs: pregnancy test, UA, CBC, microsopy on vaginal discharge, STI testing
Tx: inpatient: doxycycline 100mg PO q12 hours plus cefoxin 2gm IV q6hours
outpatient: ceftriaxone 250mg IM x 1 plus doxy 100mg PO bid continue for 14 days
Threatened Abortion
Def: vaginal bleeding through a closed cervical os, pregnancy may still be viable
S/s: vaginal bleeding, painless or mild suprapubic pain, closed cervical os, products of conception not visualized, uterine size appropriate for gestational age
Reassuring factors: serum hcG doubling every 48 hours, detectable cardiac activity
Adverse outcomes: preterm labor, premature rupture of membranes
Tx: Supportive management
Inevitable abortion
Spontaneous abortion is imminent
S/s:vaginal bleeding, pelvic cramping, cervical os open, gestational products may or may not be visible, uterus may still be apropriately sied
Tx: supportive care, pain meds for cramping, f/u to make sure they did pass the products
Complete abortion
Most common abortion
Def: a spontaneous abortion in which the entire contents of the uterus are expelled; common
Incomplete abortion
Def: spontaneous abortion with retained products; common >12 weeks
S/s: heavy vaginal bleeding, severe cramps, cervical os open, retained products, uterus small for gestational age (we want this to be contracted to stop the bleeding)
Tx: surgical management-D&C = scraping of all tissue in uterus
Missed abortion
Def: retention of a failed intrauterine pregnancy
S/s: mild vaginal bleeding/spotting, cervical os closed, products of conception not visable, uterus small for gestational age
Tx: surgery or meds to induce abortion
Septic abortion
Def: spontaneous abortion complicated by uterine infection
Causes: staph aureus, gram neg bacilli, gram positive cocci
Risks: invasive procedures, foreign bodies, incomplete or illegal induced abortions
S/s: vaginal bleeding, pelvic tenderness, cervical os open, uterus tender and boggy, fever, chills, tachycardia, vaginal discharge, peritonitis, septicemia
Tx: stabilize pt, blood and endometrial cultures, broad spectrum abx (clinda, gentamicin, amp)
surgical management of DNC or may need hysterectomy
Recurrent pregnancy loss
3 or more losses before 20 weeks
Causes: uterine abnormalities, chromosomal, endocrine, immunologic, hematologic
Ectopic pregnancy
Implantation of the embryo outside the uterine cavity
MUST r/o in any woman of reproducing age with abd/pelvic pain or irregular bleeding
Hemorrhage from ectopic pregnancy is the leading cause of maternal death in first trimester
S/s: abd pain, abnormal uterine bleeding, pregnancy sx, dizziness, amenorrhea, abd tenderness, peritoneal signs, adnexal tenderness, cervical motion tenderness* (unilateral), adnexal mass, uterus normal size
Eval: UPT, hcG, transvaginal US, CBC
Tx: methotrexate, surgery is preferred
IUGR summary
def: intrauterine fetal growth
cause:
HTN
diabetes
smoking
SS:
weight gain
fundal height low
Txt:
supplements
smoking cessation
Premature rupture of membranes
Rupture of membranes before onset of labor
Generally followed by prompt onset of spontaneous labor and delivery
Etiology: infection, low SES, 2nd and 3rd tri bleeding, low BMI, nutritional deficiencies, smoking, uterine over distension
Dgx: H and P, avoid digital exam, confirm with Amnisure, US, pH
Risks: Maternal intrauterine infection
Fetal umbilical cord compression and/or ascending infection
Tx: if at TERM: induce labor with oxytocin and intravaginal PGE2
Shoulder dystocia
failure of the shoulders to spontaneously traverse the pelvis after delivery of the fetal head
Turtle sign
Obstetric emergency-have pt stop pushing, McRoberts maneuver is used
Decreased variability on EFM
fetal hypoxia, acidemia, drugs, fetal tachycardia, fetal CNS and cardiac abnormalities, prolonged uterine contractions, prematurity, fetal sleep
Uterine prolapse
sagging of the uterus; various stages
S/s: pressure, feeling of something bulding, urinary incontinence, retention, cramping, low back pain
Tx: nothing, pessary, hysterectomy
Cystocele
bladder becoming prolapsed first
S/s: pressure, feeling something bulging, urinary incontinence, retention, frequent UTIs
Tx: pessaries, Kegel exercises, double voiding; anterior colporraphy, burch suspension, sling procedures
Rectocele
posterior part of pelvic wall is beginning to prolapse and bring the uterus with it
S/s: pressure, feeling something bulging, stool incontinence
Tx: pessaries, manual splinting, posterior colporraphy
Fistulae
Abnormal connection between two organs (a hole that shouldn’t be there)
Cause: childbirth injuries (lacerations, necrosis), previous surgery, Crohn’s disease
S/s: incontinence, gas from the vagina, foul smelling discharge: all depends on where it is
Tx: easy to repair; Foley
Menopausal transition summary
Def: time frame due to when menstrual cycle length changes to end of LMP
SS:
Stages:
-2 = variable cycle length diff from normal
-1 = > 2 skipped cycles and amenorrhea > 60 days
FSH increases
inhibin B decline
estadriol same
Intermenstrual interval increases to 40 - 50 days
Eval:
diary
Txt:
symptomatic
Menopause summary
Def: permanent cessation of menstrual periods, > 12 months
Avg age 51 yrs
Criteria: FSH > 30 mlU/ml and cessation of menstrual period
Txt:
symptoms
osteoporosis prevention
Postmenopause summary
Def: 12 months after LMP
Stage:
1 - First 5 years after the final menstrual period
* accelerated bone loss
2 - begin 5 years after final period to death
* vaginal symptoms
Txt:
Estrogen/Progesterone
SERMs
Postmenopausal bleeding summary
Cancer until proven otherwise
Eval:
transvag US
Endometrial biopsy
Osteoporosis summary
Def: decrease in bone mass with increased risk for fracture
Risks: Age Sex Fhx caucasian/asian alcohol smoking small build low weight sedentary low calcium and vit D Steroids
SS: asymptomatic fragility fracture dowager's hump height loss
Eval: CBC Vit D Serum Xray followed by CT FRAX DEXA T > -2.5
Txt: Nonpharm - Diet - smoking - alcohol - weight bearing exercise - fall prevention
Pharm
- Vit D
- Calcium
- SERMS
- Bisphosphonates
- Calcitonin
- Teriparatide
- Denosumab
Primary Amenorrhea
Absence of menses by age 15 with normal growth and development of secondary sex characteristics
Causes: chromosomal abnormalities, hypogonadism, absence of certain gyn organ, pituitary disease
Premenstrual syndrome
Etiology: unknown
Cyclic occurrence for >2 months and symptom free >7 days
S/s: HA, fatigue, mastalgia, abdominal bloating, irritable, restless, low mood, tension
These diminish after onset of menses
Dgx: no objective test, solely based on documentation.
Keep a menstrual diary
Tx: SSRI, SNRI, anxiolytics, OCPs, NSAIDs, spironolactone
calcium, vit D, and B6
increase exercise, diet changes (decrease caffeine, EtOH, Na, chocolate, sugar)
Premenstrual Dysphoric Disorder
More severe PMS-type syndrome; also known as late luteal dysphoric syndrome.
S/s: Mood sx predominate (anxiety, affective lability, anhedonia-loss of interest, low mood), markedly intereferes with school or work or social life; STILL have a sx free period
Dgx: CC of irritability, tension, dysphoria, mood lability AND 5 out of 11 consistent sx
Tx: SSRIs-fluoxetine, sertraline, paroxetine; Alprazolam; OCPs
Dysmenorrhea
the pain associated with onset of menses
S/s: uterine cramps, D, N, V, HA; most common complaint seen in OB/GYN
Primary: excess prostaglandins/contractions; assoc with ovulatory cycles
Secondary: pathologic cause present; etiology is from other gyn disease-mainly endometriosis/endometriosis
Dgx: hx-pain specific, no specific PE findings; could do US to r/o other pathologies
Tx: NSAIDs, hormones/OCPs/LARCs, surgical (TAH, cervical dilation, neurectomy), Adjuvent (heat, exercise, TENS)
Acute pelvic pain-MC etiologies and eval
GYN-dysmenorrhea, endometriosis, mittelschmerz, ovarian torsion, ovarian cyst/abscess, PID
Pregnancy-related- ectopic
GI-appendicitis
GU-cystitis, nephrolithiasis
Evaluation: UPT, wet prep, chl/gon, CBC, ESR, FOBT, US, CT, laparoscopy
Chronic pelvic pain-MC etiologies and eval
endometriosis, adenomyosis, adhesions, cystitis, IBS, vastibulitis, pelvic congestion
Eval: never dx without reason, lab studies, behavioral assessment, laparoscopy
Endometriosis
abnormal growth of endometrial type tissue outside of uterus; commoly occurs in the ovaries
S/s: pain 1-2 weeks before menses, relieved at onset of menses, variety of sx: dysmenorrhea, dyspareunia, infertility, hematuria, dysuria
Dgx: careful hx, PE: retroverted, fixed uterus, enlarged ovaries, overt lesions
Only laparoscopy and histology can definitively dgx; US, MRI, colonoscopy, and cystoscopy
Tx: hormones/OCPs, pain meds, discuss future fertility, observation and counseling; unresponsive may require hyst-BSO
Secondary Amenorrhea
absence of menses for more than 3 months in girls or women who previously had regular menstrual cycles or six months in girls or women who had regular menses
Causes: pregnancy, hypothalamic dysfunction (eating disorders, exercise, stress), systemic illness (DM, celiac, thyroid), ovarian disorders ( PCOS, premature ovarian failure)
Polycystic ovarian syndrome
An intrinsic hypothalamic-pituitary axis abnormality in the ovary that leads to an increased release of GnRH; increase in LH and a higher LH:FSH ratio triggers an ovarian production of testosterone
S/s: irregularities, infertility, hypertension, central obesity, male pattern alopecia, hirsutism, acne vulgaris, acanthosis nigricans, insulin resistence and hyperinsulinemia
Rotterdam Criteria: Must have 2/3
- Oligo-ovulation or anovulation
- Clinical hirsutism or hyperandrogenism
- Morphologic polycystic ovaries
Dgx: Clinical, US for string of pearls, Labs
Tx: menstrual abnormalities-OCP and metformin
Infertility-Clomid
Hirsutism and Acne-estrogen-progestin contraception, anti-androgen, mechanical hair removal, topical retinoids, abx
Abnormal Uterine Bleeding
vaginal bleeding of abnormal quantity, duration, and schedule
work up depends on age and reproductive hx
Causes: pregnancy, Polyp, Adenomyosis, Leiomyomas, Malignancy/hyperplasia; Coagulopathy, Ovulatory dysfunction, Endometrial polyps, Iatrogenic problems, Non-classified chronic endometritis
Female Athlete Triad
disordered eating, menstrual irregularities, low bone mineral density
Dgx of exclusion: R/o pregnancy, premature ovarian failure, thyroid dysfunction, osteopenia, uterine outflow tract abnormalities
Tx: increasing caloric deficiency relative to energy expenditure; using OCP to regulate menses; tx of decreased bone density
