General Gynecology Flashcards
Endometriosis
- -presence of endometrial tissue outside uterine cavity
- -cyclic pelvic pain, esp prior to menses
- -3 D’s: dysmenorrhea, dyspareunia, dyschezia
- -abnormal bleeding, infertility
- -uterosacral nodularity, retroverted uterus
Diagnostic standard?
Conservative surgical tx?
Endometriosis
Diagnostic standard: laparoscopy or laparotomy with direct visualization
Conservative surgical tx: ablation
Definitive surgical tx: TAHBSO, lysis of adhesions, removal of endometriosis lesions
Endometriosis: Medical Management
- Pain relief?
- Meds (2) to suppress ovulation and menstruation
- Meds to induce “pseudomenopause”
- -androgen derivative
- -GnRH agonists (2) to suppress LH/FSH - Tx for pts attempting to conceive?
Endometriosis: Medical Management
- NSAIDs (pain relief)
- OCPs and progestins to suppress ovulation and menstruation
- Meds to induce “pseudomenopause”
- -Danazol: androgen derivative
* androgen-related sfx
- -Leuprolide, Nafarelin: GnRH agonists
* estrogen deficiency sfx (eg, hot flashes, decreased BMD, vaginal atrophy) - expectant management in pts attempting to conceive
Adenomyosis
- -extension of endometrial tissue into myometrium
- -dysmennorrhea, menorrhagia
- -diffusely enlarged, globular, boggy uterus
Diagnostic Tools: imaging (2) and surgical (1)
Medical tx?
–pain, hormonal management (2)
Surgical tx?
Adenomyosis
Diagnostic Tools
- -imaging: ultrasound, MRI (more accurate)
- -surgical: hysterectomy
Medical Tx
- -pain: NSAIDs
- -hormonal: OCPs, progestins (not very effective)
Surgical tx: hysterectomy (definitive)
- well-circumscribed collection of endometrial tissue within uterine wall; may contain sm mm cells; may extend into uterine cavity to form polyp; not encapsulated
- cystic collection of endometrial cells on the ovary; aka “chocolate cyst”
- local proliferation of sm mm cells within uterus; surrounded by pseudocapsule; aka fibroids
- Adenomyoma
- Endometrioma
- Leiomyoma (Fibroid)
Disorders of Sexual Development
- (46, XY); normal external female genitalia; absent upper vagina and uterus; breasts present; minimal axillary/pubic hair; high T levels
- (46, XX); normal external female genitalia; absent or rudimentary upper vagina and uterus; normal ovaries; breasts present; normal axillary/pubic hair; normal T levels
- (46, XX); abnormal vagina; normal uterus and ovaries; breasts present; normal axillary/pubic hair; normal T levels; hymenal ring present
- (45, X); normal vagina and uterus; streak ovaries; lack of breasts; short stature
Disorders of Sexual Development
- Androgen insensitivity syndrome
(Testicular Feminization Syndrome)
–X-linked mut of testosterone receptor
–testes may be cryptorchid - Mullerian Agenesis Syndrome
- -hypoplastic or absent mullerian duct system - Transverse vaginal septum
- -failure of mullerian-derived upper vagina to fuse with urogenital sinus-derived lower vagina - Turner Syndrome
- -rapid ovarian atresia
DDx: dysmenorhea, menorrhagia, enlarged uterus
- uterus is soft, globular, boggy; symmetrically enlarged
- uterus is firm, irregularly enlarged; s/s of mass effect including constipation, urinary frequency
DDx: dysmenorhea, menorrhagia, enlarged uterus
- Adenomyosis
- -uterus is soft, globular, boggy, symmetrically enlarged - Leiomyoma (Fibroids)
- -uterus is firm, irregularly enlarged
- -mass effect s/s: constipation, urinary frequency
Uterine Leiomyoma (Fibroids)
- -benign proliferations of sm mm cells in myometrium
- -hormonally responsive to E and P
- -pseudocapsule
- -very common in AA women
- -menorrhagia, dysmennorhea
- -pressure-related s/s: constipation, urinary frequency, venous stasis, hydronephrosis
- -firm, nontender, irregularly enlarged uterus with “lumpy-bumpy” or cobblestone protrusions
- -dx via ultrasound
Medical tx strategy? re: hormone regulation
Definitive tx?
Uterine Leiomyoma (Fibroids)
- -more common in AA women
- -decrease estrogen levels (eg, medroxyprogesterone, danazol, GnRH agonists)
- -definitive tx: hysterectomy
Adnexal Mass
- cystic; multi-loculated; chocolate-containing material
- -context: pelvic pain, dyspareunia, dysmennorhea, infertility - contiguous with other structures; complex; thick-walled; air-fluid levels
- -context: PID
Adnexal Masses
- Endometrioma
- -cystic, multi-loculated, chocolate-containing material in context of pelvic pain, dyspareunia, dysmennorhea, infertility - Tubo-Ovarian Abcess
- -mass contiguous with other structures; complex and thick-walled; air fluid levels in context of STI, PID
Dx:
urine loss with exertion or straining that leads to increase in intra-abdominal pressure; associated with pelvic relaxation and urethral hypermobility
–cotton swab test reveals urethral straining angle of at least 30 degrees
Stress incontinence
–urine loss with exertion or straining that leads to increased intra-abdominal pressure;
–Pathophysiology: urethral hypermobility due to weak pelvic floor musculature
Dx:
- -urine leakage due to involuntary or uninhibited bladder contractions (detrusor overactivity);
- -urinary urgency and frequency, nocturia;
- -often associated with UTIs, bladder stones, bladder cancer, foreign bodies, urethral diverticulum, neurologic disease, diabetes
Tx – three drug types?
Urge incontinence
- -urine leakage due to involuntary or uninhibited bladder contractions; urgency and frequency; nocturia
- -often associated with UTIs, bladder stones, bladder cancer, foreign bodies, urethral diverticulum, neurologic disease, diabetes
Pathophysiology: destrusor overactivity
Tx:
- anticholinergics
- smooth muscle relaxants (eg, tolterodine)
- anti-spasmodic (eg, oxybutynin)
Dx:
incontinence due to poor or absent bladder contractions (detrusor insufficiency/areflexia) that lead to urinary retention with bladder overdistension; constant urinary dribbling
Tx:
- rx to increase bladder contractility
- rx to reduce bladder outlet resistance
- mechanical tx
Overflow incontinence
–incontinence due to poor or absent bladder contractions that lead to urinary retention with bladder overdistension; constant urinary dribbling
Tx:
- cholinergic agents (eg, bethanecol)
- -increase bladder contractility - striated muscle relaxants (eg, diazepam, dantrolene)
- -reduce bladder outlet resistance - self-catheterization
DDx: acute pelvic pain
- recurrent; mild; unilateral; mid-cycle; normal US
- amenorrhea; crampy abdominal pain; vaginal bleeding; no intrauterine pregnancy on US; (+) b-hCG, usually low for GA and doesn’t increase as expected
- acute, severe, unilateral abdominal pain; n/v; unilateral, tender adnexal mass; Doppler shows enlarged ovary with decreased blood flow
- acute, severe, unilateral abdominal pain following sexual intercourse or strenuous physical activity; US shows cystic mass with free fluid
- fever, chills; vaginal discharge; lower abdominal pain; dysuria; painful defecation; cervical motion tenderness; hx of PID; US shows complex multilocular fluid
DDx: acute pelvic pain
- Mittelschmerz
- -recurrent; mild; unilateral; mid-cycle; normal US - Ectopic pregnancy
- -amenorrhea; crampy abdominal pain; vaginal bleeding; no intrauterine pregnancy on US; (+) b-hCG, usually low for GA and doesn’t increase as expected - Ovarian torsion
- -acute, severe, unilateral abdominal pain; n/v; unilateral tender adnexal mass; Doppler shows enlarged ovary with decreased blood flow - Ruptured ovarian cyst
- -acute, severe, unilateral abdominal pain immediately following sexual intercourse or strenuous physical activity; US shows cystic mass with free fluid - Tubo-Ovarian abscess
- -fever, chills; vaginal discharge; lower abdominal pain; dysuria; painful defecation; cervical motion tenderness; hx of PID; US shows complex multilocular fluid
GnRH Agonists
–pulsatile, continuous
- Which type is used to increase FSH, LH and induce ovulation?
- Which type is used to suppress FSH, LH and inhibit ovulation?
GnRH Agonists
Pulsatile GnRH
–increases FSH, LH; induces ovulation
(uses pump; actual GnRH)
Continuous GnRH
–decreases FSH, LH; inhibits ovulation
–by downregulating GnRH receptors
(Leuprolide, Nafarelin, Gosarelin)
4 ABX which can be used for prophylaxis against recurrent UTIs?
Recurrent UTI prophylaxis
- Trimethoprim-sulfamethoxazole
- -contraindicated in pregnancy - Nitrufurantoin
- -contraindicated “at term” in pregnancy
3.. Cephalexin (Cephalosporin)
- Ciprofloxacin (Fluoroquinolone)
- -contraindicated in pregnancy
NB: these are reasonable options in non-pregnant patients
Puberty
What is the correct order of the 5 events of puberty?
Puberty
- Adrenarche/Gonadarche (age 6-8)
- -increased androgen and GnRH secretion
- -initially no phenotypic changes
- -GnRH secretion becomes pulsatile, leading to pulsatile FSH/LH, and then estrogen - Thelarche (age 10)
- -development of breast buds
- -first phenotypic sign of puberty
- -due to estrogen - Pubarche (age 11)
- -growth of pubic/axillary hair
- -due to increased androgens - Peak Growth Spurt (age 12)
- Menarche (age 12-13)
- -2.5 years after thelarche
