Day 13 - Gyn1 Flashcards
Menopause dx
12 mo. amenorrhea; If 45+ yo woman, No need to check FSH or LH - Clinical dx of menopause; If 40+ yo woman, also no need - assume perimenopausal; If under 40, labs required to exclude other etiologies - serum TSH, bHCG, prolactin, FSH, LH
Type of incontinence assoc w/ menopause & Tx
Stress incontinence due to lack of estrogen causing vaginal atrophy & lack of tone around urethra; Tx w/ Kegel exercises &/or vaginal estrogen cream
Next step if menorrhagia in perimenopausal period
Endometrial bx (concern for endometrial hyperplasia at this age & given sx - should be less frequent bleeding)
Pros/Cons of hormone replacement for menopause
PROS: control variable menopausal sx, reduce risk of osteoporotic fractures, reduce colon cancer risk, favorable lipid profile (not necessarily translate into cardioprotection though); CONS: no longer indicated for prevention of CV/Stroke/Osteoporosis, doubles risk of invasive breast cancer (not increase risk of non-invasive), doubles risk of endometrial cancer, double risk of DVT/PE, increasing risk of stroke, increasing risk of CV disease overall (less calcification, but unsure what that means), increases risk of biliary disease & need for biliary surgery
Indication(s) for hormone replacement therapy (HRT)
Tx menopausal sx ONLY (if pt feels benefits outweight side effects)
Non-hormonal tx options for menopausal hot flashes
Desvenlafaxine (only FDA approved drug), Clonidine, Gabapentin; Time; Placebo effect 20-25%
Absolute contraindications to OCPs
Pregnancy (if on once become pregnancy, stop but not assoc w/ congenital anomalies), History of thromboembolism (DVT, PE, inherited - e.g., Factor V Leiden), History of estrogen-feeding tumor (e.g., breast or endometrial cancer), History of CVD/Stroke/CAD, poorly controlled HTN, Smoker > Age 35, Hepatic disease/neoplasm, Abnormal vaginal bleeding of unknown etiology (may be endometrial or cervical cancer), Migraine w/ aura/neuro sx/vascular involvement (all increase risk of stroke w/ OCPs)
Advantages/Disadvantages of OCPs
ADV: Reliable, Reduce risk of endometrial (ovulation is greatest risk) and ovarian cancer, decreases incidence of ectopic pregnancy (and pregnancy overall), menses more predictable/lighter/less painful, help w/ acne; DIS: daily dosing, not protect against STDs, breakthrough bleeding, estrogen side effects (bloating, weight gain, breast tenderness, nausea, headaches - different dosages available to deal with this), progesterone side effects (depression, acne, HTN - different progesterones, some highly adrogenic & some less), increase DVT risk, increase TGs
Type of liver pathology assoc w/ OCP use
Reversible liver cholestasis, hepatic adenoma (benign liver tumor which may undergo malignant transformation - also caused by anabolic steroids), Budd-Chiari syndrome, IVC syndrome, veno-occlusive disease of terminal hepatic venules &/or sinusoids, HCC, cirrhosis, portal HTN, or liver failure above
Meds known for reducing combined estrogen-progesterone OCP effectiveness
Antibx (specifically Rifampin - revs up cP450), Griseofulvin, Antiepileptics, St. John’s wort
Contraindications for IUD
Current vaginal or cervical infx, High risk STDs or PID (including multiple sexual partners or history of recurrent STDs), Known pregnancy or desire to be pregnant in near future, Severe uterine distortion, Uterine bleeding not yet worked up, Copper allergy or Wilson’s disease, Breast cancer (avoid progesterone IUD),
1st steps w/u of F w/ primary amenorrhea
Thorough H & P; Congenital defects identified - imperforate hymen, transverse vaginal septum, vaingal agenesis; If signs of hyperadrogenism (suggesting excess testosterone), serum testosterone & DHEA-S (ovaries make DHEA not DHEA-S, which is made by adrenals) to check for androgen-secreting tumor; If galactorrhea, serum prolactin & if positive, MRI to assess for prolactinoma; If uterus not appear to be present or difficult to assess, pelvic sonogram; If uterus absent, karyotype and serum testosterone level (if androgen insensitivity, 46XY & elevated testosterone OR if abnormal mullerian development, 46XX & normal female testosterone level); If uterus present, check B-HCG (if high, pregnancy) & serum FSH (if high, check karyotype for Turner syndrome; if low, cranial MRI for hypothalamic or pituitary disease; if normal, check serum prolactin & thyrotropin, again looking for prolactinoma)
15 yo p/w eval for primary amenorrhea, PE shows bluish bulge where vaginal opening should be - Dx
Imperforate hymen
1st steps in w/u F w/ secondary amenorrhea
Thorough H & P; Serum B-HCG (pregnancy); Serum prolactin (prolactinoma/hyperprolactinemia), TSH (thyroid disease), FSH (ovarian failure - high); If signs of hyperandrogenism, serum DHEA-S & total testosterone… if testosterone high but DHEA-S normal, indicates PCOS… if both high, androgen-secreting tumor from adrenal; If all the above normal or hx or D & C, progesterone withdrawal test… if cannot bleed w/ progesterone withdrawal, then Ashermann syndrome (i.e., uterus not capable of making blood)
