Exam 4 - Chapter 18 Flashcards
Pelvic Inflammatory Disease (PID/Salpingitis)
Inflammation of the fallopian tubes, with ovaries at times
Causes: Chlamydia trachomatis (subacute), Neisseria gonorrhoeae (acute), Gardnerella vaginalis, and Trichomonas vaginalis. Occurs in young sexually active women with many partners
Pathology: Edematous tubal serosa, collection of pus forms pyosalpinx, degrading pus forms hydrosalpinx
Symptoms: High fever, lower abdominal pain, cervical motion tenderness, future ectopic pregnancy, infertility
Treatment: Antibiotics
Ectopic Pregnancy
Implantation of the ovum in the fallopian tube
Symptoms: Missed period, other signs of early pregnancy, vaginal bleeding 6 -8 weeks after last period. Upon rupture, bleeding may be excessive Lower abdominal pain may be: • Sharp unilateral • Constant • Diffuse or localized – May be referred to shoulder
Abdominal pain or unexplained hypovolemia + woman of child-bearing age = Ectopic pregnancy
Diethylstilbestrol (DES)
- Known as super-estrogen
- Nonsteroidal estrogens used from 1946–1970 to treat mothers who were prone to spontaneous abortion
- Disorders in daughters of women who received diethylstilbestrol (DES) therapy during pregnancy.
- Precocious Puberty: Puberty before the specified age
- Clear cell adenocarcinoma of the cervix and vaginal adenosis (benign condition characterized by mucosal columnar epithelium-lined changes) in areas normally lined by stratified squamous epithelium (metaplasia), may also occur in these patients
Placental Accreta
Deep penetration of the placental villi into the wall of uterus
Causes: Predisposed by previous C-section scars or endometrial inflammation
Pathology: Defective decidual layer allows placenta to attach directly to myometrium
Symptoms: Massive hemorrhage after delivery
Treatment: Hysterectomy to stop bleeding
Placental Previa
Implantation of the zygote in the lower section of the uterus
Causes: Predisposed by previous C-section scars
Pathology: Attachment of placenta to lower uterine segment of cervix
Symptoms: Painless bleeding, premature labor
Treatment: C-section, bed rest
Abruptio Placentae
Partial/complete premature separation of the placenta which is an obstetric emergency for mother and fetus
Causes: DIC, smoking, cocaine, hypertension
Pathology: Premature separation of the placenta
Symptoms: Painful bleeding with abdominal pain in third trimester. Can result in fetal death
Treatment: Immediate delivary & control bleeding
Abortion
Termination of pregnancy before the 22nd week of gestation
Causes: By physician or RU-486
Symptoms: Cramping, abdominal pain, backache, and vaginal bleeding
RU-486
RU-486 or Mifepristone competes with progesterone for the progesterone receptors.
• Mechanism of action: Without progesterone, the lining of the women’s uterus breaks down and sheds like normal menstrual cycle. In addition, the drug opens the cervix and influence contractions with help of prostaglandin to dislodge and expel the embryo. Ru-486 works only during the first 9 weeks of pregnancy, or up to 63 days from the start of the women’s last menstrual period. After this time, the level of progesterone goes up in a higher level where RU-486 is not effective
Complete Abortion
Spontaneous expulsion of all fetal and placental tissue from uterus prior to 20 weeks gestation. Cervix closed on examination
No further intervention necessary; ultrasound to confirm an empty uterus may be helpful
Incomplete Abortion
Passage of some fetal or placental tissue, but not all, prior to 20 weeks gestation. Cervix dilated on examination
IV hydration, type and screen/cross, immediate suction curettage
Threatened Abortion
Uterine bleeding prior to 20 weeks gestation, without any cervical dilation or effacement
Ultrasound to document fetal viability; modified activity and pelvic rest until bleeding stops
Inevitable Abortion
Uterine bleeding prior to 20 weeks gestation, accompanied by cervical dilation, but no expulsion of fetal or placental tissue through cervical os
Expectant management or evacuation of pregnancy (surgical or medical termination)
Missed Abortion
Fetal death before 20 weeks gestation without expulsion of any fetal or maternal tissue for at least 8 weeks thereafter
Suction curettage or medical termination of pregnancy
Septic Abortion
Any of the abortions above, accompanied by uterine infection
IV antibiotics, followed by suction curettage
Gestational Trophoblastic Disease
Hydatidiform mole (placental abnormality): swelling of the chorionic villi (grapelike clusters). Uterus expands as if a normal pregnancy is present, but the uterus is much larger
Causes: Chromsomal abnormalities
Pathology: Β-hCG much higher than expected for date of gestation. Classically presents in the second trimester as passage of grape-like masses through the vaginal canal. Honeycombed uterus appearance
Diagnosis: Routine ultrasound in the early first trimester. Fetal heart sounds are absent, and a ‘snowstorm’ appearance is classically seen on ultrasound
Two types:
Complete mole: Fetus can not be identified in the ammnotic fluid due to production of androgen. No maternal chromosome only paternal chromosome (46, XX)
Incomplete mole: Some the fetal parts are present. Two sperm fertilize one egg making triploid (69, XXY)
Treatment: Most abort spontaneously, or D&C
Gestational Choriocarcinoma
Malignant tumors of germ cells of the placenta. Rare
Causes: 50% develops from hydatidiform mole, 25% develops from placental cells after abortion and 25%, develops from normal placenta
Pathology: High levels of hCG, necrotic tumor
Symptoms: Excessive vaginal bleeding after removal of mole or delivery of fetus/abortant. Hemoptysis
Treatment: Surgery, chemo
Toxemia of Pregnancy (Preeclampsia and Eclampsia)
This disorder is characterized by severe hypertension that most often occurs de novo during pregnancy or complicates preexisting hypertensive disease. Toxemia characteristically occurs during the third trimester, most often in the first pregnancy
Preeclampsia: Triad of hypertension, edema, and proteinuria during the 3rd trimester. HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelets)
Eclampsia: all of the above plus seizures
Treatment:
Preeclampsia: Delivery of the fetus, bed rest, treat hypertension
Eclampsia: Medical emergency, treat with magnesium sulfate and diazepam (anti-epileptics)
Supine Hypotensive Syndrome
- Uterus compresses inferior vena cava
- Venous return to heart decreases
- Decreased venous return leads to decreased
cardiac output - BP decreases
Treatment: Place patient on left side to restore venous return
Menorrhagia
Prolonged (>7 days) and or heavy (≥80ml) uterine bleeding occurring at regular intervals
Metrorrhagia
Variable amounts of inter-menstrual bleeding occurring at irregular but frequent intervals
Polymenorrhea
An abnormally short interval (
Oligomenorrhea
An abnormally short interval (
Dysmenorrhea
Medical term for pain with menstruation
Primary Dysmenorrhea
Common menstrual cramps that are recurrent and are not due to other diseases. Cramps usually begin one to two days after a woman starts getting her period. Pain usually begins 1 or 2 days before or when menstrual bleeding starts and is felt in the lower abdomen, back, or thighs and can range from mild to severe. Pain can typically last 12 to 72 hours and can be accompanied by nausea, vomiting, fatigue, and even diarrhea. Common menstrual cramps usually become less painful as a woman ages and may stop entirely if the woman has a baby
Secondary Dysmenorrhea
Pain that is caused by a disorder in the woman’s reproductive organs, such as endometriosis, uterine fibroids, or infection. Pain from secondary dysmenorrhea usually begins earlier in the menstrual cycle and lasts longer than common menstrual cramps. The pain is not typically accompanied by nausea, vomiting, fatigue, or diarrhea. Treatment: Aspirin, other anti-inflammatory drugs and oral contraceptive pills
Seasonal Oral Contraceptive Pill
It contains two female hormones, an estrogen called ethinyl estradiol, and a progestin called levonorgestrel
Amenorrhea
An abnormal absence of menstruation
Primary Amenorrhea
Failure to have a period during puberty. Patients usually have birth defects like Turner Syndrome or other congenital defects
Secondary Amenorrhea
When a woman has normal menstrual cycles but stopped having her period for 6 months or longer. Exception-women who are pregnant, breastfeeding or in menopause. Common factors contributing are: drugs (chemotherapy), anti-depressants, low body weight, hormonal problems
5 types: Psychogenic Amenorrhea Lactational Amenorrhea Anorexia Nervosa Exercise Amenorrhea Runner's Amenorrhea
Psychogenic Amenorrhea
Menstrual cycle stops in young female (non-pregnant) without any evidence of abnormalities with pituitary or ovaries. Common with college freshmen (stress) or usage of opiates
Lactational Amenorrhea
Increased of PRL due to nursing a baby
Anorexia Nervosa
Decreased body weight (body fat)»_space; decreased FSH and LH»_space; decreased estrogen production
Exercise Amenorrhea
Delayed menarche, luteal phase dysfunction and amenorrhea are known as female athletic triad (decreased FSH & LH)
Runner’s Amenorrhea
Long distance female runners produce Beta endorphins which inhibit GnRH production. Treatment: diet, decrease exercise and birth control pills
Turner’s Syndrome
Pubertal delay in girls due to low estrogen
Causes: An absent or structurally abnormal second chromosome characterizes Turner Syndrome (45 or 46 XO chromosomes)
Pathology: In absence of second functional X chromosome, oocyte degeneration happens because of primary gonadal failure, which causes FSH and LH rise and are elevated at birth and again at puberty
Symptoms: 10 – 20% Turner girls, some ovarian functions at puberty that allow for slight breast development, short stature, neck, webbed neck, abnormal upper to lower segment ratio, primary amenorrhea
Treatment: Estrogen and progesterone and height with Growth hormone
Endometriosis
Deposits of endometrium outside its normal location, most often located on the ovary and pelvic peritoneum
Causes: Idiopathic, affects 10% of women, especially between 20-30
Pathology: Retrograde flow of endometrial fragments (non-neoplastic) through fallopian tubes during menstruation, with implantation on the ovary or other peritoneal structures
The condition is characteristically responsive to hormonal variations of the menstrual cycle. Menstrual-type bleeding occurs into the ectopic endometrium, resulting in blood filled, or so-called “chocolate,” cysts
Symptoms: Severe menstrual-related pain (dysmenorrhea), pelvic pain, and pain during intercourse (dyspareunia). Infertility
Diagnosis: Visualizing the ectopic deposits within the pelvis with a laparascope
Treatment: Birth control pills, and drugs that suppress output of gonadotropins from the pituitary gland
Endometritis
Inflammation of the endometrium or uterine lining by bacterial infection
Causes: Acute - trauma, STDs, Staphylococcus and Streptococcus, after delivery or miscarriage. Chronic - PID, TB
Symptoms: Malaise, fever, constipation. Chronic - abnormal vaginal bleeding, pelvic pain, discharge, infertility
Treatment: Antibiotics
HPV
Sexually transmitted DNA virus that infects the lower genital tract, especially the cervix
• Infection is usually eradicated by acute inflammation & persistent infection leads to an increased risk for cervical dysplasia (cervical intraepithelial neoplasia, CIN).
• Risk of CIN depends on HPV type (determined by DNA sequence).
• High-risk—HPV types 16, 18, 31, and 33
• Low-risk—HPV types 6 and 11
• High-risk HPV produce E6 and E7 proteins which result in increased destruction of p53 and Rb (tumor suppressor proteins) which increases the risk for CIN
Treatment: Vaccines like Gardasil (for types 6, 11, 16, 18)
Cervical Intraepithelial Neoplasia (CIN)
Most physicians regard cervical dysplasia and in situ carcinoma as very closely related, constituting different stages in a progressive spectrum of epithelial abnormalities, classifying them under the general term, cervical intra-epithelial neoplasia (CIN). Disordered epithelial growth manifested by loss of polarity and nuclear hyperchromasia, beginning at the basal layer and extending outward, is characteristic. It is graded into three categories:
• Grade I: CIN 1Mild dysplasia
• Grade II: Moderate dysplasia
• Grade III: Severe dysplasia (carcinoma in situ)
- The goal of screening is to catch dysplasia (CIN) before it develops into carcinoma
- Progression from CIN to carcinoma, on average, takes 10-20 years. Screening begins at age 21 and is initially performed yearly
- Pap smear is the gold standard for screening
- Cells are scraped from the transformation zone using a brush and analyzed under a microscope
- Dysplastic cells are classified as low grade (CIN I) or high grade (CIN II and III)
High-grade dysplasia is characterized by cells with hyperchromatic (dark) nuclei and high nuclear to cytoplasmic ratios
• Hybrid Capture 2 Technology: new test based on RTPCR
• Treatment: Dysplasia and in situ carcinoma: cryocautery (freezing), surgical excision of abnormal area, hysterectomy (removal of uterus)
• Invasive carcinoma: radiation or radical hysterectomy (resection of uterus, fallopian tubes, ovaries, and adjacent tissues)
Uterine Myometrial Tumors (Leiomyoma)
Leiomyoma (benign, common): This is the most common uterine tumor and the most common of all tumors in women; the incidence is increased in women of African lineage. The tumor is a benign neoplasm; malignant transformation is rare
• Leiomyomas occur in multiple separate foci in most cases. The tumors are estrogen-sensitive. They often increase in size during pregnancy, and they almost always decrease in size following menopause
• Leiomyosarcoma (malignant, rare)
Staging 5-Year Survival Rates: I (Localized to cervix): 85% II (Body of the uterus): 75% III (Ovaries): 35% IV (Other sites): 10%
Endometrial Carcinoma
Endometrial hyperplasia leads to adenocarcinoma in endometrium. Most common gynecological malignancy. Affects women 55-65
Causes: Unopposed estrogen use, obesity, diabetes, HTN
Symptoms: Postmenopausal vaginal bleeding, pyometra (pus in cervix), hematometra (blood in cervix)
Treatment: Variable prognosis - depends on the stage and to a lesser extent on the grade of the tumor. Sometimes total hysterectomy
Staging 5-Year Survival Rates: I (Localized to endometrium): 90% II (Cervix): 50% III (Pelvic spread): 20% IV (Other sites): 5%
Ovarian Cancer
Malignant neoplasm (abnormal growth) located on the ovaries
- 5th Leading cause of cancer death in ♀ and leading cause of death from gynecological malignancies
- Older ♀ @ higher risk (post-menopasual)
- Ovarian cancer prognosis is poor. Symptoms are vague and non-specific conditions
- Symptoms: Pelvic heaviness, abdominal discomfort, vaginal bleeding, weight gain or loss, abnormal menstrual cycles
- Thus, 50% of ♀ with ovarian cancers are diagnosed in the advanced stages of the disease
- Factors protecting ♀ from ovarian cancer: Early age pregnancy, use of oral contraceptives (birth control pills)
- Risk Factors: Presence of BRCAI and BRCAII (mutated) genes increase breast and ovarian cancers, higher dietary fat content, smoking
- Testing: Blood chemistry, CA 125, ultrasound, CT, MRI, pelvic exam, and PAP smear (♀ over 20 yrs old). If diagnosed in early stages, survival rate is higher
- Treatment: Taxol (yew tree derivative) Regression of ovarian cancer by disrupting the cellular structures of tumor. Anti-estrogens
Serous Cystadenoma
Fallopian tube-like epithelium
Serous Cystadenocarcinoma
Malignant cysts with psammoma bodies
Mucinous Cystadenoma
Tumor epithelium resembles mucus-secreting epithelium of endocervix
Mucinous Cystadenocarcinoma
Malignant tumor with mucus-secreting epithelium
Brenner Tumor
Benign tumor resembling bladder transitional epithelium
Endometroid Tumor
Malignant tumor resembling endometrium
Clear Cell Tumor
Rare, malignant tumor composed of sheets of clear cells
Ovarian Tumors (Germ Cells)
Occur in women younger than 25 years old
• Common germ cell tumor: Teratoma (Mature: benign)
• Contain teeth or calcified parts
• Mature teratoma presents a hairy structure and teeth: it is known as dermoid cyst
• Malignant tumors (immature teratoma: rapidly metastasize) may secrete AFP and hCG
Ovarian Tumors (Other Tumors)
- Granulosa cell tumor: Hormonally inactive and may produce estrogen which cause mentrual irregularities
- Theca cell tumor: are solid tumors and produce estrogen. They are benign in nature and often cause endometrial hyperplasia
- Sertoli-Leydig cell tumor: are solid tumors and produce androgens which cause masculine characteristics
Metastatic Ovarian Tumors
- Tumors metastatic to the ovary account for approximately 5% of all ovarian tumors
- These tumors are frequently of gastrointestinal tract, breast, or endometrial origin
- They are called Krukenberg tumors when ovaries are replaced bilaterally by mucin secreting signet ring cells and the site of origin is often the stomach
Polycystic Ovary Syndrome (PCOS)
- Involves enlarged ovaries, which contain many fluid-filled sacs (cysts), and a tendency to have high levels of male hormones (androgens). Not all women with PCOS have cysts
- A main underlying problem with PCOS is a hormonal imbalance. In women with PCOS, the ovaries make more androgens than normal. High levels of these hormones affect the development and release of eggs during ovulation
- Researchers also think insulin may be linked to PCOS. Many women with PCOS have too much insulin in their bodies because they have problems using it. Excess insulin appears to increase production of androgen. High androgen levels can lead to: acne, hirsutism, weight gain and ovulation problems
- Blood tests to measure levels of LH and male hormones are performed, and ultrasonography of the ovaries may be performed
PCOS Treatment
- No ideal treatment is available. The choice of treatment depends on the type and severity of symptoms, the woman’s age, and her plans regarding pregnancy
- Women who do not wish to become pregnant may take a progestin by mouth or a combination oral contraceptive (which contains estrogen and a progestin)
- The medicine metformin (Glucophage) is used to treat type 2 diabetes. It also has been used in PCOS, but not approved by FDA for this use. Metformin affects the way insulin controls blood glucose (sugar) and lowers testosterone production. It slows the growth of abnormal hair and, after a few months of use, may help ovulation to return. Recent research has shown metformin to have other positive effects, such as decreased body mass and improved cholesterol levels. Metformin will not cause a person to become diabetic
- Lack of ovulation is usually the reason for fertility problems in women with PCOS. Several medications that stimulate ovulation can help women with PCOS become pregnant. For example Clomiphene, gonadotropins. In vitro fertilization (IVF) offers the best chance of becoming pregnant in any given cycle. It also gives doctors better control over the chance of multiple births. IVF is very costly
- “Ovarian drilling” is a surgery that may increase the chance of ovulation. It’s sometimes used when a woman does not respond to fertility medicines. The surgeon punctures the ovary via laparoscopy with a small needle carrying an electric current to destroy a small portion of the ovary. This procedure carries a risk of developing scar tissue on the ovary. This surgery can lower male hormone levels and help with ovulation. But, these effects may only last a few months
Toxic Shock Syndrome
- Estimated 10-15 cases per 100,000 menstrual age women per year
- This condition was initially associated with the use of highly absorbent tampons. It is caused by exotoxin produced by Staphylococcus aureus, which grows in the tampon
- Use of tampons promotes development
- Characteristic features include skin peeling, fever, vomiting, and diarrhea, sometimes followed by renal failure and shock. A generalized rash often seen in patients.
