EOR Gyn Flashcards
define dysfunctional uterine bleeding and name the two types
abnormal frequency/intensity due to NONORGANIC causes (NOT reproductive, systemic or iatrogenic) .
- chronic anovulation
- ovulatory
describe the pathophys of dysfunctional uterine bleeding - chronic anovulatory
Disruption of hypothalamic-pituitary-ovarian axis. Seen at the extremes of age. Unopposed estrogen, without ovulation there is no progesterone = unopposed estrogen → incr endometrial growth w/ irregular, unpredictable shedding as the endometrium outgrows its own blood supply.
describe the pathophys of dysfxn uterine bleeding - ovulatory
regular cycle with prolonged progesterone secretion (due to decreased estrogen) → blood loss from endometrial vessel dilation and prostaglandins.
what is the normal frequency, duration and volume
freq: 24-38 days, duration: 4-8days, volume: 5-80mL
cryptomenorrhea vs menorrhagia
- Cryptomenorrhea: light flow/spotting
- Menorrhagia: heavy/prolonged bleeding @ normal interval
metrorrhagia vs menometrorrhagia
- Metrorrhagia: irregular bleeding between cycles
- Menometrorrhagia: irregular, excessive bleeding between cycles
oligomenorrhea vs polymenorrhea
- Oligomenorrhea: infrequent menstruation, cycle length >35 days
- polymenorrhea: frequent menstruation, cycle interval < 21 days
txt goals and options for dysfxn uterine bleeding
control acute bleed, prevent future bleeding, minimize endometrial CA risk
Acute severe bleed: high dose IV estrogen or high dose OCPs. reduce dose as bleeding improves
MC Anovulatory or Ovulatory: OCPs, progesterone if estrogen is contraindicated, GnRH agonists (leuprolide).
Sx: hysterectomy or endometrial ablation
which parts of the cycle do estradiol and progesterone dominate?
estradiol- follicular (up to day 14)
progesterone - luteal (after day 14) up to menses
when does body temperature spike in the menstrual cycle?
just after ovulation (after LH + FSH spike)
when is the proliferative and secretory phase of the cycle?
proliferative - day 5 -14
secretory- day 14- 28 –> menses
what is the MC gyn CA in US?
endometrial
what increases the risk of endometrial CA?
Estrogen-dependent CA
- risk increases with estrogen exposure (nulliparity, anovulation, PCOS, obesity, late menopause, tamoxifen, HTN, DM)
- OCPs are protective
how is endometrial CA dx - what does Bx and US show?
endometrial Bx = adenocarcinoma, US= endometrial stripe >4mm.
txt for endometrial CA : stage I, II/III, IV
Stage I: total hysterectomy + BSO +/- radiation
Stage II/III: total +BSO + lymph node excision +/- radiation
Stage IV: systemic chemo
pathophys for endometriosis
retrograde menstrual flow, hematogenous/lymphatic spread, stem cells from bone marrow, coelomic metaplasia (congenital development).
MC site of endometriosis
ovaries
uterus grows up and out of the pelvis (past pubic symphysis) at what GA?
12 wks
what does endometriosis increase the risk of ?
infertility
what is the triad of symptoms for endometriosis ?
- Cyclic premenstrual pelvic pain 2. Dysmenorrhea 3. dyspareunia . +/- dyschezia
how do you Dx endometriosis?
laparoscopy w/ Bx for definitive
what is a “chocolate cyst” ?
possible sequelae of endometriosis
= Endometrioma: involving ovaries large enough to be considered tumor
while expectant mgmt for endometriosis with minimal symptoms/trying to conceive, what are medicine txt options for more serious cases?
Medical therapy: NSAIDs, COCs, Progesterone, GnRH agonists (leuprolide), testosterone (Danazol- induces pseudomenopause by suppressing FSH/LH and midcycle surge)
Surgical options for txt of endometriosis?
endometrial ablation, TAH
islands of endometrial tissue in myometrium → diffusely enlarged uterus. = what dx?
adenomyosis
S+S of adenomyosis?
worsening menorrhagia, dysmenorrhea
tender, symmetric, enlarged “boggy uterus”
txt options for adenomyosis?
total abdominal hysterectomy (TAH). conservative used to preserve fertility (analgesics, low dose OCPs)
what race are leiomyomas MC in?
African americans
intrauterine growth related to estrogen production - regresses after menopause. what is the Dx?
leiomyoma (fibroids)
what is the MC symptom of leiomyoma (apart from the most common who are asymp)?
painless bleeding
txt of leiomyoma
MC observation or meds (leuprolide GnRH agonist, progestins)- prior to Sx to shrink + control vascularity) + Sx (hysterectomy/myomectomy).
*- Goal is to achieve pregnancy, if this is not wanted then just hysterectomy. Ability to conceive after myomectomy is very low so this is rarely done.
what is endometritis? what increases the risk of it?
infection of endometrium, chorioamnionitis (fetal membrane infection), usually polymicrobial (vaginal flora, aerobic/anaerobic)
Risk: postpartum + post abortive. C section MC
txt of endometritis ? prophylaxis w/ c section?
post-C Section - clindamycin + gentamicin. Post-vaginal delivery or chorioamnionitis - ampicillin + gentamicin
prophylaxis w/ 1 dose 1st gen cephalosporin during C-section
what is the grading of uterine prolapse ?
I - descent into upper vagina ⅔ vagina.
II - cervix approaches introitus (vaginal opening)
III - outside introitus.
IV- entire uterus outside vagina (complete)
txt for uterine prolapse?
Txt: Pessaries, estrogen (for atrophy), Sx hysterectomy, uterosacral or sacrospinous ligament fixation.
what causes PID? MC organisms?
ascending polymicrobial infection caused by cervical microorganisms (Chlamydia trachomatis, Neisseria gonorrhoeae..and potentially Mycoplasma genitalium)
when in the cycle does PID typically show symptoms? what are S+S?
presents usually in the 1st half menstrual cycle. pelvic/abdominal pain + one of the following… adnexal tenderness, cervical motion tenderness (chandeliers sign), fundal tenderness. + vaginal discharge/friable cervix, irregular bleeding, dyspareunia, N/V, fever.
Dx options for PID? findings in labs, Bx, imaging
- inc WBC on microscopy of vaginal discharge, inc ESR, inc CRP, + GC/Chlamydia
- Endometrial biopsy = endometritis
- imaging : TVUS or MRI = thickened, fluid filled tubes, tubo-ovarian abscess, hyperemia on dopplers( suggest infection).
txt for PID? who do you hospitalize? what can untxted PID lead to?
txt underlying cause
Hospital txt: pregnancy, failure to oral therapy, severe illness w/ high fever N/V, tubo-ovarian abscess.
Prevention/Education: Untreated can lead to infertility, chronic pelvic pain, ectopic pregnancy, pelvic adhesions
what can help prevent the reccurence of ovarian cysts?
OCPs
MC cause ovarian torsion?
MC caused by ovarian cyst >5cm
pathophys of PCOS
Due to insulin resistance. Abnormal hypothalamic-pituitary-ovarian axis → increased insulin and increased LH driven = increase ovarian androgen production.
PCOS: what are the levels of testosterone and LH:FSH ratio? what does US show?
incr testosterone, LH: FSH >3:1, US - “string of pearls”
medical txt for PCOS
combo OCPs (normalizes bleeding and suppresses androgen), spironolactone for anti-androgen (or leuprolide, finasteride), infertility = clomiphene, metformin, lifestyle changes.
what are the increased risk factors for ovarian CA?
+FH, incr ovulatory cycles (infertility,nulliparity, >50yo, late menopause), BRCA
Dx of ovarian CA?
biopsy MC epithelial
how is txt of ovarian CA monitored?
Serum Ca-125 levels to monitor txt progress.
what strains of HPV are most common to cause cervical CA? (5)
HPV 16,18, 31, 33 and 45.
2 types of cervical cancer?
2 types: MC squamous, also adenocarcinoma (columnar cells) (clear cell carcinoma linked with DES- death sentence)
MC common symptom of cervical CA?
post coital bleeding/spotting MC symptom.
Dx of cervical cancer?
Dx: colposcopy w/ biopsy
txt of cervical cancer based on stage 0, I-IIa, IIb/IVa, IVb
Stage 0: carcinoma in situ: local txt (excision, ablation), TAH-BSO
Stage I - IIa: microinvasion: Sx (conization, TAH/BSO, radiation)
Stage IIb/ IVa: local advanced: radiation/chemo
Stage IVb (distant METS): palliative radiation, chemo.
what are the guidelines for pap smear? (starting age, stopping age + frequency of testing
Start: Age 21
Frequency: Cytology every 3 years between ages 21-29. Cytology with HPV every 5 years 30-65 → if HPV + → colposcopy
Stop: Age 65 if routine screening in last 10 years
what can cervicitis lead to?
PID
what are the two levels of cytology from a pap smear?
LSIL (low grade squamous intraepithelial lesion)
HSIL (high grade squamous intraepithelial lesion- ALL layers of squamous epithelium w/ abnormal cells)
what are the 3 levels of histology from Bx of cervical dysplasia?
CIN I (LSIL) = mild dysplasia contained to ⅓ basal epithelium thickness CIN 2 (HSIL) = moderate dysplasia including basal ⅔ CIN 3 (HSIL) = severe dysplasia >⅔ basal → full thickness = carcinoma in situ
what is an easy way to guess someone has cervical cancer?
Lesion w/ the naked eye = past the basement membrane = CANCER
txt for cervical dysplasia CIN 1 vs CIN2/3
CIN 1- observation or excision (LEEP - loop electrical excision procedure or cold knife cervical conization)
CIN2/3: excision (LOOP or cold knife) or ablation with cryocautery, laser cautery or electrocautery.
what is the easy classification system for abnormal uterine bleeding? what does it stand for?
PALM COEIN (Polyp, Adenomyosis, Leiomyoma, Malignancy/Hyperplasia, Coagulopathy, Ovulatory dysfxn, Endometrial, Iatrogenic, Not-yet-classified)
what defines primary vs secondary amenorrhea
Primary: failure of menarche onset by age 15y (w/ 2ry sex characteristics) or 13y (w/out 2ry sex characteristics)
Secondary: absence of menses for >3 months but had previous menstruation.
what is “central amenorrhea” ?
hypothalamus dysfxn (low FSH/LH): disruption of normal pulsatile GnRH release. Anorexia, exercise, nutritional deficiency, systemic dz, physiologic stress/psychological stress.
how can pituitary dysfxn cause secondary amenorrhea?
(low FSH/LH, high prolactin): prolactinoma decr GnRH
how can ovarian d/o cause secondary amenorrhea?
( increase FSH/LH, low estradiol): PCOS, premature ovarian failure. Turner’s syndrome.
how do you check for ovarian d/o causing secondary amenorrhea?
+ progesterone challenge (withdrawal) test (ovarian d/o)
=this means she has estrogen but is not ovulating
- results (no bleeding) = lacking estrogen or outflow problem
txt for secondary amenorrhea (hypothalamic, pituitary, uterine)
hypothalamic - stimulate gonadotropin secretion - clomiphene
Pituitary - transsphenoidal Sx tumor removal
Uterine - estrogen txt for endometrial regeneration
what is “dysmenorrhea” and what causes it? (primary vs secondary)
painful menstruation that affects normal activities.
Primary: not due to pelvic pathology, due to increased prostaglandins → painful uterine muscle wall activity.
Secondary: due to pelvic pathology. (endometriosis, adenomyosis, leiomyoma, adhesions, PID) increased incidence with age.
what organism most common causes mastitis?
Staph aureus (also strep or candida)
mastitis: infectious vs congestive vs abscess (S+S)
Infection: unilateral pain, tender, warmth, nipple discharge
Congestive: bilateral pain/swelling, low grade fever and axillary lymph
Abscess: induration w/ fluctuance (pus). RARE
txt for mastitis: infectious vs congestive vs abscess
Infection: supportive (warm compress, breast pump) + anti-staph abx (dicloxacillin,nafcillin, cephalosporin) fluconazole if fungal. Continue to FEED
Congestive: if mom does not want to breastfeed = ice packs, tight bras, analgesics, avoid breast stimulation. If breastfeeding = manually empty breast completely after baby is done feeding.
Abscess: I&D, discontinue breast feeding from affected breast
what two types of breast CA are most common
ductal and lobule
incr # menstrual cycles and increased estrogen = increased or decreased risk of breast CA ?
increased
” in situ” means what?
An in situ tumor is one that is confined to its site of origin and has not invaded neighboring tissue or gone elsewhere in the body
what is inflammatory breast CA show?
peau d’orange (lymph obstruction)= WORSE prognosis
mammogram of breast CA shows what?
calcifications and/or spiculated mass
what is the initial Dx modality to evaluate a breast mass in someone <40yo (dense breast tissue)?
US
what is the staging of breast CA?
T(size), N (nodes) M (METS)
0: precancerous, DCIS or LCIS
I-III: w/in breast/regional lymph nodes
IV: METS
what endocrine therapy (medications) are options for adjunctive therapy for breast CA pts with E/P-receptive or HER2 positive CA?
anti-estrogen - tamoxifen.
aromatase inhibitors -letrozole, anastozole
monoclonal Ab
prophylaxis meds for breast CA (for post-menopausal or women >35yo with high risk).
SERM (tamoxifen/raloxifene) Tamoxifen preferred but higher risk DVT.
mammogram screening guidelines: ACOG, ACS, USPTF
ACOG: >40y annual
ACS: >45yo annual; >54yo biannual
USPTF: >50 biannual
when do you stop mammogram screening?
when life expectancy is <10years
pap smear guidelines
<21 no testing, 21-29 Q 3 years, 30-65 Q five years with pap (or w/out HPV Q 3 years).
>65 stop testing if no abnormal in 20yrs
what is a fibroadenoma? what age pt is it most common in?
benign breast lump, nontender/mobile/rubbery. MC younger females.
does NOT wax and wane w/ hormone levels
txt for fibroadenoma
nothing - observation
breast - fluid-filled cyst due to exaggerated response to hormones. (may be tender, wax + wane w/ hormone levels) VERY COMMON: what is the Dx ?
fibrocystic changes
Dx of fibrocystic changes in breast: FNA will show what kind of fluid? what is the txt for this?
straw-colored
Txt: observe or FNA to drain (if symptomatic)
medical txt options for galactorrhea
txt underlying cause (synthroid (for hypothyroid) or dopamine agonists (cabergoline or bromocriptine) (for hyperprolactinemia)
txt for gynecomastia. What are medications used? what is the ideal timeframe of txt?
supportive- stop offending meds, observe (most regress spontaneously), ideal txt in the first 6mo (>12 months tissue may turn fibrous).
Meds: SERM (tamoxifen) or aromatase inhibitors (blocks estrogen synthesis) or androgens (for hypogonadism)
what are 3 clinical screening tools to Dx menopause-depression?
PRIME-MD (primary care eval of mental health d/o), PHQ-2, MRS (menopause rating scale)
relative contraindications to hormone therapy for menopause include what?
Hx breast or endometrial CA, active liver dz, hypertriglyceridemia, porphyria (buildup of porphyrins), thrombolic d/o (CAD + stroke Hx), undiagnosed vaginal bleeding, endometriosis, fibroids
three alternatives to hormone replacement therapy for menopause?
SSRI antidepressants, herbal supplements (black cohosh, evening primrose - not as effective)
what is the timing of PMS symptoms
luteal phase (1-2 weeks before menses) and resolve 2-3 days after the period starts *and at least 7 symptom free days in the follicular phase
how is PMDD different from PMS?
it is severe PMS with a functional impairment
AND presence of at least five symptoms, including one affective symptom, such as mood swings, irritability, and/or depression
what is “metal shmurz” ?
pain felt when ovulating (burst of follicle)
medical txt for PMDD? (2)
OCPs- containing drosperidone along with estradiol (aka Yaz)
and/or SSRIs
timeline of postpartum blues vs postpartum depression ?
blues: starts 2-3 days postpartum, lasts 10 days
depression: starts 2 wks-12mo postpartum, resolves 3-14 months
conservative txt for PMS symptoms?
lifestyle (exercise/diet, caffeine/salt restriction, vitamin B6 +E),
candida albicans: pathophys
yeast (MC opportunistic pathogen) - decrease in lactobacillus that usually prevent the overgrowth of yeast.
causes of urogenital candida albicans
Abx, pregnancy, uncontrolled DM, impaired immune system, OCPs or hormone therapy
txt for yeast infection ?
oral azole
4 manifestations of chlamydia infection?
- Urethritis: mucopurulent discharge, purritis, dysuria, dyspareunia, hematuria. 40% asymptomatic
- PID: abd pain + cervical motion tenderness
- Reactive arthritis (reiter’s syndrome): urethritis, uveitis, arthritis - autoimmune rxn
- Lymphogranuloma venereum: genital/rectal lesion w/ softening, suppuration, lymphadenopathy
Dx of chlamydia
nucleic acid amplification (vaginal swab or first-catch urine
(also can do a culture or blood antigen detection)
txt for chlamydia infection
Azithromycin (1gm 1dose) or Doxycycline (100mg 10days). Retest in 10 days to ensure clearance + txt for gonorrhea
2 manifestations of gonorrhea
Urethritis: anal, vaginal, pharyngeal discharge. PID
Dissemination: arthritis/dermatitis, rash
txt for gonorrhea
ceftriaxone 250mg IM + txt for chlamydia. Cefixime as alternative
3 most common organisms that cause cystitis?
MC E coli also Staph saprophyticus (sexually active women) enterococci (indwelling catheter)
what differentiates pyelonephritis from cystitis on UA?
WBC casts
what bladder analgesic turns your pee orange? (txt for cystitis) what is the ADR of this?
phenazopyridine (bladder analgesic- turns urine orange) - DONT USE >24 hrs cause of methemeglobinemia, hemyolytic anemia
txt options for uncomplicated cystitis?
nitrofurantoin (macrobid), FQs, TMP-SMX
what makes cystitis “complicated”? what are the txt options for this?
symptoms >7 days or underlying condition/elderly/males: FQs PO or IV, aminoglycosides 7-10 days
txt for cystitis in pregnancy
amoxicillin or macrobid 7-14 days.
txt for pyelonephritis?
FQ PO or IV, aminoglycosides 14 days (7 days in healthy young women)
Dx of herpes?
PCR (best), tzank smear = multinucleated giant cells + inclusion bodies
prevention/education for herpes in pregnancy
give acyclovir + Csection, breastfeeding not contraindicated unless lesion on the breast.
can mom transfer HIV/AIDs to baby? how?
yes through birth or breastfeeding
Dx of HIV (screening, definitive and monitoring txt)
antibody test- ELISA (screening), rapid test (blood or saliva). Western blot (confirmatory). HIV RNA viral laid (monitor infectivity and txt)
pathophys of HPV
infects keritanized skin causing excessive proliferation + retention of stratum corneum ⇒ papula formation
vaginal -tiny, painless papules evolve into soft, fleshy cauliflower-like lesions. Occur in clusters. Persist for months and may spontaneously resolve. Dx ?
condyloma accuminata - HPV
HPV (condyloma accuminata)
whitening of lesion w/ acetic acid, histology = koilocytic squamous cells w/ hyperplastic hyperkeratosis
5 txt options for removal of condyloma accuminata warts
chemical, salicylic acid, cryotherapy, laser, podophyllin (cytotoxic agent).
HPV vaccine schedule
For Male + female 9-45yo. 3 doses (0,2,6mo) or 2 doses (0,6mo) for ages 9-14. Target age 11-12yo.
primary syphillis
chancre- painless ulcer w/ raised indurated edges (papule that ulcerates) . heal spontaneously 3-4 wks + nontender lymphadenopathy nearby
secondary syphillis
maculopapular rash, involve the palms + soles.
Condyloma lata + Systemic symptoms
when does tertiary syphillis come up?
1-20yrs after inoculation
tertiary syphillis: derm, neuro + cardiac symptoms
- Gumma (granulomas on skin/body tissues/bones.
- Neurosyphillis (HA, meningitis, dementia, vision/hearing loss, incontinence.
- CV = aortitis, aortic regurg + aneurysm.
what is latent syphillis?
asymp infection + normal exam but positive serologic testing.
early latent vs late latent syphillis
Early latent <1yr (highly infectious), late latent >1yr (less infectious)
Dx of syphillis: screening vs confirmatory
Screening- RPR + VDRL
Confirmatory: FTA-ABS (fluorescent treponemal antibody absorption) or microagglutination test for T. pallidum antibodies
what is the “jarisch-herkheimer” rxn? how do you txt it?
acute febrile response to rapid lysis of syphillis spirochetes from txt w/ PCN G.
Myalgia+ HA. Txt with anti-pyretics in first 24hrs reduces incidence
after txt of syphillis, what is the followup schedule? how do you know there has been adequate txt?
at 6months and 12 months after txt for clinical + serologic test. 4-fold reduction in titer = adequate mgmt.
txt for trichomonas
metronidazole, tinidazole + MUST txt partner
what contraceptive can reduce transmission of trichomonas?
spermicidal agents reduce transmission
perinatal complications of trichomonas and BV
PROM, preterm labor, etc
terbultaine is used how in OBgyn?
its a B2 agonist that helps relax smooth muscle (bronchial + uterine) - stops spasm. Helps slow down the process of labor
what are prostoglandins used in the txt of postpartum hemorrhage?
misoprostol, methergine or hemabate
MC cause of vaginitis, what is its pathophysiology?
BV: decreased lactobacilli (maintains pH) → overgrowth of normal flora (gardinella vaginalis). MC cause of vaginitis
what is included in “Amsel’s Criteria” for BV?
- Abnormal gray vaginal discharge
- Vaginal pH greater than 4.5
- Positive amine test
- More than 20% of epithelial cells are clue cells
Dx of BV
KOH prep = fish smell, clue cells + few WBCs, few lactobacilli
Txt of BV
metronidazole, clindamycin
vaginal CA - what is the most common type and location?
squamous cell
in posterior wall of the upper ⅓ of the vagina
MC sign of vaginal CA
bleeding
txt of vaginal CA based on staging
stage I = excision, Stage II+ = chemo
txt of rectocele
standard posterior colporrhaphy or site-specific repair over crosslinked porcine small intestine graft augmented repair
what are the different types of urinary incontinence? (5)
- Stress: leak w/ incr abdominal pressure (laugh, cough) [from laxity of pelvic floor muscles]
- Urge/overactive: sudden urge + involuntary loss of urine
- Overflow: bladder doesn’t empty completely → dribbling/leaking [CNS dz or BPH]
- Functional: physical/mental impairments causes pt to not reach the toilet in time
- Mixed: stress + urge
medical txt options for incontinence (stress, urge, overflow)
stress- alpha agonists (psuedophed, midodrine)
Urge - anticholinergics (oxybutinin, tolterodine), Tricyclic antidepressants, Mirabegron
Overflow: cholinergics or alpha blockers (tamsulosin)
non-pharm txt of stress incontinence
stress: Sx- incr. Urethral outlet resistance or artificial sphincter, vaginal cones to incr. Pelvic floor muscle strength, estrogen cream
non-pharm txt of overflow incontinence
Urge: botox injection or bladder augmentation, Diet - avoid spicy foods, citrus, chocolate + caffeine
Fitz-Hugh-Curtis syndrome
PID + perihepatitis
MC cause of PID
chlamydia trachomatis
classic pelvic finding of endometriosis
fixed retroverted uterus, with scarring, and tenderness posterior to the uterus.
