Endometriosis, Infertility, Cysts, Sexual Assault, Urinary Incontinence Flashcards
24 yo nulligravid f w. 18 mo hx of painful intercourse, difficulty defacating, and dysmenorrhea - sx are cyclical and occur w. menses - her menses are regular but very heavy - she has no hx of STI and is monogamous w. her husband
endometriosis
2 PE findings of endometriosis
-retroverted uterus w. nodularity
-ttp of uterosacral ligaments and cul-de-sac
endometriosis is a condition in which ectopic endometrial tissue implants are found in extrauterine sites, mc the _ (4)
ovaries
fallopian tubes
cul-de-sac
uterosacral ligaments
3 d’s of endometriosis
dyspareunia
dyschezia
dysmenorrhea
also infertility
20% of women w. endometriosis will have what sx
chronic stomach pain
definitive dx for endometriosis is _,
which is confirmed w. _
laparoscopy confirmed w. bx
t/f: US, barium enema, IV urography, CT, and MRI are all acceptable for dx of endometriosis
f!
they are not specific or adequate
6 tx options for endometriosis
NSAIDs
OCPs
danazol
depo-provera
GnRH agonists
surgery
first line tx for endometriosis
OCP
moa for combined OCP and progesterone analogs in endometriosis tx
combined OCP: ovarian suppression
progesterone analogs: inhibit growth of endometrium
name 2 progesterone analogs
medroxyprogesterone
levonorgestresl
how do GnRH antagonists tx endometriosis
pituitary GnRH suppressed -> decreased estrogen
moa for donazol
steroid -> inhibits mid-cycle FSH/LH surge
2 surgical options for endometriosis
-lapraoscopic ectopic endometrial tissue removal
-hysterectomy
definition of infertility
inability to conceive w.in 12 mo of unprotected intercourse
primary infertility is defined as infertility in the absence of
previous pregnancy
secondary infertility is defined as infertility after a
previous pregnancy
fertility is _% female
and _% male
female: 65%
male: 20-40%
unknown: 15%
mc cause of infertility
anovulation
4 causes of infertility
anovulation
tubal dz
male factor
idiopathic/multifactorial
steps in work up of infertility
- detailed hx - type of coitus, when, where, how often
- ovulation tracking
- semen analysis
- labs
- hysterosalpingogram vs laparoscopy
variables in ovulation tracking
-menstrual diary
-luteal phase progesterone level
-basal body temp
if progesterone level is < _ on day 21 of the luteal phase, you know your pt did not ovulate
3 ng/ml
body temp indication of female infertility
no mid-cycle basal body temp increase
4 labs useful in dx of female infertility
TSH
prolactin
LH
FSH
3 meds used in tx of female infertility
-clomiphene citrate
-metformin
-bromocriptine
moa for clomiphene citrate
hyperstimulates ovulation
when is metformin used for infertility
if PCOS is the cause
increases ovulation
when is bromocriptine used to tx female infertility
hyperprolactinemia
39 yo AA f w. hx abnormally heavy menstrual bleeding and increased pelvic pressure - no pain - enlarged uterus
leiomyoma
PE finding of leiomyoma
enlarged uterus w. asymmetric contours
benign smooth muscle cell tumors
leiomyoma
6 sx of leiomyoma
polymenorrhea
menorrhagia
intermenstrual bleeding/metorrhagia
pelvic presure
increased abd girth
uterine mass
what pt pop do you think of when you see leiomyoma
AA
fam hx
3 types of leiomyoma
subserosal
intramural
submucosal
what type of leiomyoma projects into the pelvis and may be pedunculated
subserosal
what type of leiomyoma is contained w.in the uterine wall
intramural
what type of leiomyoma projects into the uterine cavity
submucosal
dx for leiomyoma
US
MRI if uterine mass
symptomatic tx for leiomyoma
NSAIDs
OCPs
danazol
leuprolide
what medication shrinks leiomyomas pre operatively
leuprolide
definitive tx for leiomyoma
myomectomy
endometrial ablation
hysterectomy
mc surgical tx for fibroids
hysterectomy
22 yo nulligravida f w. pelvic pain and irregular menstrual bleeding - not sexually active or pregnant - never been on OCPs - uniltateral ttp on left side of pelvis
ovarian cyst
most cysts are asymptomatic, but can cause
bloating
low abd pain
dyspareunia
lbp
how are ovarian cysts classified
functional (normal menstrual cycle)
non-functional (abnormal menstrual cycle)
mc type of ovarian cyst
follicular
3 types of functional ovarian cyst
-follicular
-corpus luteum
-theca lutein
ovarian cyst caused by dominant follicle failing to rupture
follicular
ovarian cyst caused by dominant follicle rupturing but then closing again -> does not dissolve
corpus luteum
type of ovarian cyst caused by overstimulation of HCG produced by placenta -> only seen in pregnancy
theca lutein
5 types of non-functional ovarian cysts
PCOS
endometriomas
dermoid
ovarian serous
mucinous cystadenoma
3 characteristics of non-functional ovarian cysts
> 10 cm
irregular borders
internal septations
3 main complications of ovarian cysts
hemorrhagic
rupture
torsion
ovarian cyst hemorrhage is mc w. what 2 types of cysts
follicular
corpus luteal
rupture of ovarian cysts commonly occurs after
sexual intercourse
risk of ovarian torsion 2/2 to ovarian cyst increases if cyst is > _ cm
5
what type of ovarian cyst is mc larger but asymptomatic
follicular
what type of ovarian cyst mc causes localized pelvic pain, amenorrhea, or delayed menses
corpus luteum
4 sx of ruptured ovarian cyst
pain
hypotn
abd pain radiating to shoulder
tachycardia
what do you think when you see hx of ovarian cyst plus waxing/waning pain, n/v, and low grade fever
ovarian torsion
first line imaging for suspected ovarian torsion
US abd/pelvis
definitive dx for ovarian torsion
direct visualization during surgery
work up for ovarian cysts
- transvaginal/abd US
- MRI if indeterminate
- CA125
- US guided aspiration
lab for ovarian cyst work up
CA-125
most ovarian cysts resolve w.in
1 month
when is f/u imaging required for incidentally discovered simple ovarian cysts in women of reproductive age
> /= 5 cm
management of simple ovarian cysts > 5 cm but < 7 cm in premenopausal females
annual imaging
management of simple ovarian cyst > 7 cm
MRI
surgical assessment
indication for further work up for ovarian cysts (3)
-persist beyond 2-3 menstrual cycles
-post menopausal woman
-fam hx ovarian ca
sexual assault is defined as
-any involuntary sexual act in which a person is coerced or physically forced to engage against their will
-any non consensual sexual touching of a person
t/f: physical contact needs to occur for dx of sexual assault
f!
rape constitutes both a _ (2)
psychiatric emergency
legal situation
considerations for management of rape victim (3)
-document all procedures
-save clothes
-take samples
work up for rape victim should include cultres from the (3)
vagina
anus
pharynx
what tests to order for rape victim (7)
gonorrhea
chlamydia
syphilis
hepatitis
HIV
UA
pregnancy (regardless of contraception)
pharm for for rape victim
-abx prophylaxis: rocephin PLUS doxy
-tetanus
-emergency contraception
f/u for rape victim
-24-48 hr after d.c
-one week
-six weeks
-+/- 12-18 weeks
when are repeat cultures performed for rape victim
six week f.u
when would 12-18 week f/u be required for rape victim
repeat HIV titers
when should category of “spouse or partner neglect/violence” be used
-non accidental acts of physical force that result in physical harm to intimate partner
-or have potential to result in physical harm or evoke significant fear
non accidental acts of physical force include
shoving
slapping
hair pulling
pinching
restraining
shaking
throwing
biting
kicking
hitting w. fist or object
burning
poisoning
choking
holding head under water
when should the category of “spouse or partner violence, sexual” be used
-forced or coerced sexual acts w. intimate partner
-sexual violence, physical force, or psychological coercion
-whether or not sexual act is completed
-sexual acts w. partner who is unable to consent
when should category of “spouse or partner neglect” be used
-egregious act or omission by one partner that deprives a dependent partner of basic needs
-or has reasonable potential to result in physical or pschological harm to dependent partner
-one partner is extremely dependent on the other for care/assistance
5 major types of urinary incontinence
urge
stress
overflow
functional
mixed
urge incontinence is caused by _ overactivity
detrusor
urge incontinence is characterized by
-frequent, small amt of urine
-occurs at night/disrupts sleep
urge incontinence is mc seen in what pt pop (2)
elderly
nursing home
tx for urge incontinence
- kegels
- anticholinergics/TCAs
what anticholinergic is mc used for urinary incontinence
oxybutinin
what TCA is mc used for urinary incontinence
imipramine
stress incontinence is caused by
weakness of pelvic floor
stress incontinence occurs w.
sneezing
coughing
laughing
bending
lifting
if pt experiences _, you can probs rule out stress incontinence
nocturnal incontinence
tx for stress incontinence
- kegels
- vaginal estrogen
- pessary
- surgery: mid urethral sling
overflow incontinence is caused by
impaired detrusor contractility -> bladder distension
overflow incontinence commonly occurs in what 2 pt pops
diabetics
neuro d.o
hallmark sign of overflow incontinence
elevated postvoid residual volume
tx for overflow incontinence
- intermittent self catheterization
- cholinergics
- alpha blockers
what cholinergic is used for overflow incontinence
bethanechol -> increase bladder contractions
what alpha blockers are used for overflow incontinence
terazosin
doxazosin
decrease sphincter resistance
normal voiding sx but difficulty reaching the toilet due to physical/mental disabilities
functional incontinence
tx for functional incontinence
scheduled voiding times
mc type of urinary incontinence
mixed: stress PLUS urge
tx for mixed incontinence
- lifestyle mods/kegels
- treat predominant sx
