Endometriosis, Infertility, Cysts, Sexual Assault, Urinary Incontinence Flashcards by Lauren Cunningham

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

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2 PE findings of endometriosis

-retroverted uterus w. nodularity
-ttp of uterosacral ligaments and cul-de-sac

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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

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3 d’s of endometriosis

dyspareunia
dyschezia
dysmenorrhea

also infertility

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20% of women w. endometriosis will have what sx

chronic stomach pain

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definitive dx for endometriosis is _,
which is confirmed w. _

laparoscopy confirmed w. bx

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t/f: US, barium enema, IV urography, CT, and MRI are all acceptable for dx of endometriosis

they are not specific or adequate

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6 tx options for endometriosis

NSAIDs
OCPs
danazol
depo-provera
GnRH agonists
surgery

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first line tx for endometriosis

OCP

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moa for combined OCP and progesterone analogs in endometriosis tx

combined OCP: ovarian suppression
progesterone analogs: inhibit growth of endometrium

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name 2 progesterone analogs

medroxyprogesterone
levonorgestresl

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how do GnRH antagonists tx endometriosis

pituitary GnRH suppressed -> decreased estrogen

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moa for donazol

steroid -> inhibits mid-cycle FSH/LH surge

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2 surgical options for endometriosis

-lapraoscopic ectopic endometrial tissue removal
-hysterectomy

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definition of infertility

inability to conceive w.in 12 mo of unprotected intercourse

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primary infertility is defined as infertility in the absence of

previous pregnancy

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secondary infertility is defined as infertility after a

previous pregnancy

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fertility is _% female
and _% male

female: 65%
male: 20-40%

unknown: 15%

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mc cause of infertility

anovulation

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4 causes of infertility

anovulation
tubal dz
male factor
idiopathic/multifactorial

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steps in work up of infertility

detailed hx - type of coitus, when, where, how often
ovulation tracking
semen analysis
labs
hysterosalpingogram vs laparoscopy

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variables in ovulation tracking

-menstrual diary
-luteal phase progesterone level
-basal body temp

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if progesterone level is < _ on day 21 of the luteal phase, you know your pt did not ovulate

3 ng/ml

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body temp indication of female infertility

no mid-cycle basal body temp increase

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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

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

1. transvaginal/abd US 2. MRI if indeterminate 3. CA125 4. 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

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

1. kegels 2. 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

1. kegels 2. vaginal estrogen 3. pessary 4. 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

1. intermittent self catheterization 2. cholinergics 3. 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

1. lifestyle mods/kegels 2. treat predominant sx