Final Flashcards
estrogens in normal menstruation
- levels start to increase 1 week before ovulation
- rise 24 hours prior to ovulation initiates LH surge that produces ovulation
progesterone in normal menstruation
- secretory effects on endometrium
- stimulates development of lobules in breast
- withdrawal results in menses
reproductive cycle hormones
-hypothalamus releases GnRH (acts on pituitary) -pituitary releases FSH and LH (acts on ovaries) -ovaries release estrogen and progesterone
contraception interruption
- ovulation/implantation
- fertilization
- sperm function
ovulation suppression
High doses of progesterone cause negative feedback to pituitary to prevent LH surge and ovulation
why estrogen in BC
- proper estrogen/progesterone ratio needed to maintain endometrial lining
- excess estrogen = hyperplasia
- excess progestin = atrophy
estrogen containing contraception advantages
- control period timing
- cancer prevention
- reduce amount of bleeding
- decrease BP
- reduce androgens (reduce acne & PCOS)
estrogen containing contraception disadvantage
- nausea
- headache
- increase blood clot
- DVT
progestin only contraception advantages
- no estrogen S/S (headache, clot, BP)
- don’t have to worry about missing pill
progestin only contraception disadvantage
- irregular bleeding (prolonged, not heavy)
- bad mood
- weight gain
copper IUD absolute contraindications
- anatomical abnormality
- cervical cancer awaiting treatment
- current PID
- immediate postseptic abortion
- postpartum sepsis
- endometrial cancer
- suspected intrauterine disease
- pregnancy
- current cervicitis, chlamydia, or gonorrhea
- pelvic TB
- unexplained vaginal bleeding
progestin IUD absolute contraindications
- distorted uterine cavity
- current breast cancer
- cervical cancer awaiting treatment
- current PID
- postseptic abortion
- postpartum sepsis
- endometrial cancer
- suspected intrauterine disease
- pregnancy
- current cervicitis, chlamydia, or gonorhea
- pelvic TB
- unexplained vaginal bleeding
implant absolute contraindication
-current breast cancer
depot absolute contraindications
-current breast disease
progestin only pill absolute contraindication
-current breast disease
combined OC absolute contraindication
- current breast disease
- breast feeding <21 days postpartum
- severe cirrhosis
- recurrent DVT/PE risk
- acute DVT/PE
- surgery with prolonged immobilization
- HTN 160/100
- vascular disease
- current ischemic disease
- known thrombogenic disease
- peripartum cardiomyopathy <6 months
- moderate/impaired cardiac function
- <21 days postpartum
- nephropathy, retinopathy, neuropathy
- vascular disease or DM >20 yrs
- headaches with aura
- age >35 & >15 cigarettes
- complicated solid organ transplant
- lupus with positive antiphospholipid antibody
- complicated valvular heart disease
emergency contraception
- only works if ovulation has not happened
- does not cause abortions
- sperm live 5-7 days in tract
- fertile days are 5 days prior to ovulation
- large doses of progesterone can inhibit LH surge and ovulation
anatomical sources of abnormal bleeding
- polyp
- adenomyosis
- leiomyoma/fibroid
- malignancy
functional sources of abnormal bleeding
- coagulopathy
- ovulation dysfunction
- endometrium/hyperplasia
- iatrogenic, inflammatory
- not yet classified
polyp
- direct visualization is best
- ultrasound with saline
- high cancer suspicion or decreased pain tolerance gets OR biopsy
adenomyosis
- tissues that line the uterus encroach the muscles of the uterus
- difficult to diagnose w/o hysterectomy
malignancy
- cervical (visualize with speculum)
- endometrial
coagulopathy
- von willebrand disease
- thrombocytopenia
- inherited factor disorder
ovulatory dysfunction
- usually PCOS related to insulin resistance
- higher risk for endometrial cancer
- flipped LH/FSH
endometrial/hyperplasia
-no available tests to diagnose
idiopathic/inflammatory
- high doses of progesterone
- dopamine blockers increase prolactin which can cause breakthrough bleeding
- gonorrhea or chlamydia infections
excessive bleeding Tx
- lysteda/TXA
- mirena
- GnRH antagonist/agonist
- cauterize lining
- hysterectomy
amenorrhea work up
- uterus and outflow
- ovary
- pituitary
- hypothalamus
uterus and outflow amenorrhea
- imperforate hyman
- mullerian agenesis (no uterus/cervix)
- androgen insensitivity (no uterus)
- asherman’s syndrome (scarred uterus, give OCP 1 month to check endometrium)
ovaries and amenorrhea
- no progesterone = anovulation
- no estrogen = ovarian failure
administer progesterone
- bleeding occurs = anovulation
- no bleeding occurs = hypogonadism
pituitary and amenorrhea
- primary ovarian failure
- pituitary dysfunction
hypothalamus to pituitary and amenorrhea
- hard to assess because GnRH is pulsatile
- clinical diagnosis
- low body fat, stress, thyroid disease
medical contraindications for all BC
- pregnancy
- genital tract malignancy
- undiagnosed abnormal uterine bleeding
medical contraindications for oral BC
- clot
- HTN
- complicated migraine
- liver disease
- ischemic heart disease
medical contraindication for IUD
- current PID/cervicitis
- misshapen uterine cavity
- copper allergy (paragard)
bacterial vaginosis examination findings
- thin, off white discharge with fishy odor
- no inflammation
bacterial vaginosis treatment
metronidazole
trichomoniasis examination findings
- thin, yellow-green, malodorous, frothy discharge
- vaginal inflammation
trichomoniasis treatment
- metronidazole
- treat sexual partner
candida vaginitis examination findings
- thick cottage cheese discharge
- vaginal inflammation
candida vaginitis treatment
fluconazole
herpes
- painful
- infects dorsal root ganglia
syphilis
- not painful
- single lesion that is large and hard
PID diagnostic criteria
- cervical motion tenderness or uterine tenderness or adnexal tenderness
- from untreated gonorrhea or chlamydia
PID treatment for uncomplicated
-outpatient unless can’t comply with keeping ABX down
PID treatment for tuboovarian abscess
- always treat inpatient
- sepsis work up
- drainage
genital warts
- caused by HPV
- worsens when cell mediated immunity suppressed
- aldara only non destructive treatment that takes weeks to months
- can do cryo or laser therapy
fibroids (leiomyomata uteri)
- rarely malignant
- benign tumors in smooth muscle that are hormone dependent
- 50% have aneuploidy
- clonal expansion
fibroids management
- 80% require no treatment
- bleeding/pain treated symptomatically
- GnRH agonists/antagonists used for temporary (6 month) relief
- myomectomy (conservative)
- uterine fibroid embolization (conservative)
- hysterectomy
pelvic organ prolapse cause
- failure of ligaments
- cardinal ligaments support cervix and prevent vaginal prolapse
pelvic organ prolapse risk factors
- genetic
- menopause
- parity
- aging
- previous hysterectomy
- obesity
- smoking
anterior compartment pelvic organ prolapse symptoms
bladder prolapse
- urinary symptoms
- pelvic pain
- intercourse difficulty
apical compartment pelvic organ prolapse symptoms
vagina/uterus prolapse
- urinary symptoms
- pelvic pain
- intercourse difficulty
posterior compartment pelvic organ prolapse symptoms
rectum prolapse
- constipation
- pelvic pain
- intercourse difficulty
pelvic organ prolapse management
- kegel
- don’t smoke
- stool softener
- lose weight
- pessary
- surgery to reinforce vaginal wall
stress incontinence
due to increased abdominal pressure under stress
-weak abdominal floor muscles
urge incontinence
- due to involuntary contraction of bladder muscles
- treat with Rx
overflow incontinence
due to blockage of urethra
neurogenic incontinence
due to impaired nervous system function
adenocarcinoma of the endometrium
- most common gyn malignancy
- not the most deadly
- good outcomes due to early detection
- early symptom of abnormal bleeding
estrogen dependent endometrial cancer
- obesity
- anovulation/PCOS
- exogenous estrogen
- tamoxifen
- good prognosis
less estrogen dependent endometrial cancer
- poor prognosis
- mismatch repair gene failure
- serous and clear cell subtype
endometrial hyperplasia and endometrial cancer
- complex hyperplasia with atypia has 30% chance to progress to endometrial cancer
- should be treated as well differentiated adenocarcinoma
endometrial hyperplasia treatment
- progestin to combat unopposed estrogen
- hysterectomy
endometrial cancer staging
- always done surgically with hysterectomy
- majority of cases stage I
endometrial cancer treatment stage 1
surgery
endometrial cancer treatment stage 2
surgery and chemo/radiation
endometrial cancer treatment stage 3 and 4
surgery and palliative
uterine sarcoma presentation
- not common
- postmenopausal uterine growth
- pain
- pressure
- vaginal bleeding
uterine sarcoma diagnosis
- endometrial biopsy, but many false negative
- most incidentally diagnosed at hysterectomy
uterine sarcoma prognosis
- poor
- high stage at diagnosis
- poor response to chemo
uterine sarcoma treatment
- hysterectomy
- lymph node removal not helpful because it spreads hematologically
- radiation/chemo for inoperable
cervical cancer
- 3rd most common gyn cancer in US
- # 1 cancer killer in underdeveloped due to lack of widespread effective screening
- caused by HPV
subtypes of ovarian cancer
- epithelial: most common
- germ cell: typically teenagers
- stromal: 20s-30s
- metastatic
ovarian cancer symptoms
- typically at stage 3 or 4
- ABD pain, bloating, distention
- constipation
- back pain
ovarian cancer risk factors
- age 50 or older #1 risk
- familial (BRCA gene)
- anything that increases number of ovulations in a lifetime
ovarian cancer prevention
- ovulation suppression
- no good means to screen
ovarian cancer treatment
- surgery typically regardless of stage
- no consensus on optimal chemotherapy
- radiation not primary but may be used to treat symptomatic metastatic disease
adnexal mass
- any mass >5cm = referral to gyn
- a simple cystic mass <5cm should be reimaged in 6-12 weeks
- any pelvic mass found on CT should be followed up with pelvic U/S
fallopian tube cancer
- thought to be rare but some ovarian cancer may actually be tubal
- presents with water vaginal discharge
- same treatment as epithelial ovarian cancer
vulvar cancer types
- HPV associated: young, smoking, VIN associated
- lichen sclerosis associated: more common, older
vulva intraepithelial neoplasia characteristics
- elevated
- irregular borders
- warty
- itchy
- multicentric
vulva intraepithelial neoplasia diagnosis and treatment
- direct visualization
- colposcopy
- biopsy
- treatment is ablative
paget disease of vulva
- erythematous plaque with white scaling
- itching, burning pain
- wide local excision
- recurrence is common
fecundability
-likelihood of conception per cycle
fecundity
likelihood of live birth per cycle
fertility
likelihood of live birth over some period of time
subfertility
no pregnancy after 6 cycles
infertility
no pregnancy after 1 year
causes of infertility
- male factors
- female factors
- combination of factors in both partners
- all 1/3 responsibility
male infertility
easiest and cheapest to test for with semen analysis
couples factor and infertility
- coital frequency and timing
- smoking
- alcohol
- illicit drugs
- antisperm antibodies
female infertility causes
- ovulation disorders
- tubal obstruction
- endometriosis
- uterine disorders
- idiopathic
endometriosis
histologically normal endometrial glands and stroma with hemosiderin laden macrophages outside the endometrial cavity
endometriosis symptoms
- painful periods
- painful sex
- infertility
endometriosis treatment
- symptom related: NSAIDs
- hormonal: progestins, GnRH suppression
- surgery
adenomyosis
- enlarged globular, tender uterus without focal mass
- treat symptoms
- primarily histological diagnosis
pelvic pain differential
GI, GU, reproductive organs, ABD wall pain, bony pelvis
bleeding in 1st trimester
- 50/50 on normal vs abnormal
- all need a workup
pain in 1st trimester
- nearly everyone has pain
- most pain without bleeding is not pathological
- pain and bleeding is possibly pathological
threatened abortion
- vaginal bleeding with or without pain
- has normal, live pregnancy
incomplete abortion
- partially passed products of conception
- open cervix
- increasing pain
complete abortion
- passage of all products of conception
- subsiding pain
missed abortion
no passage of tissues and asymptomatic
septic abortion
secondary infection of incomplete abortion
why do ectopic pregnancies cause vaginal bleeding
does not produce enough progesterone or hCG to maintain endometrium so irregular bleeding occurs
why do ectopic pregnancies cause pain
fallopian tube stretch and blood in tube causes irregular pain
complete molar pregnancy
-egg with no nucleus that 1 sperm that duplicates or 2 sperm
partial molar pregnancy
normal egg fertilized by 2 sperm
discriminatory zone
gestational sac expected at hCG >2000
yolk sac
presence of is conclusive of intrauterine pregnancy
fetal pole
- should grow at least 2 mm per day
- heartbeat should be detectable within 1 week of pole development
ectopic pregnancy
- number 1 finding is empty uterus
- free fluid concerning for ruptured ectopic
- can treat with methotrexate or surgery
variations from baseline
- general rule all variations from baseline are reflexes designed to maintain homeostasis, particularly oxygen delivery
- can’t manage vascular beds, can only manage HR
variability
- increases in HR due to increase in O2 demand via sympathetic nervous system
- implies intact CNS
absent variability
- sleep (no more than 45 minutes)
- meds (opioids, mag)
- CNS injury (diagnosis of exclusion)
accelerations
- reflex increase in HR due in increased O2 demand and implies intact CNS
- less than 32 weeks, increase HR 10 BPM for 10 seconds
- 32 weeks and greater, increase HR 15 BPM for 15 seconds
Early decelerations
- start with initiation of contraction, bottom out at contraction peak, and end with contraction
- thought to be vagal response
- not associated with hypoxemia/acidemia
variable decelerations
- hypoxemic event
- > 15 BPM drop reaching peak in <30 seconds
- lasting at least 15 seconds but no more than 2 minutes
- possibly due to cord occlusion
- can result in secondary hypoxemia
late decelerations
- hypoxemic event
- symmetric, gradual decrease in HR
- onset at peak of contraction, nadir at contraction termination, termination after contraction ends
- during contraction lactic acidosis occurs
pre-eclampsia
blood pressure >140/90 with at least 300 mg protein without end organ damage
pre-eclampsia with severe features
BP>160/110 or with end organ damage
acute HTN emergency
- BP >160/110 for >15 minutes
- labetalol and hydralazine
- goal is BP <160/110
eclamptic seizure phases
- facial automatisms
- tonic/clonic seizures
- post-ictal
don’t abolish the seizure with benzos, give mag
isoimmunization
-Rh negative mother and Rh positive fetus
