Green PANCE book- GYN Flashcards
the absence of spontaneous menstruation by age 16 years
primary amenorrhea
in a woman who has previously menstruated, an absence of menses for 3 months if previous cycles were normal
secondary amenorrhea
if a woman has irregular menses, how long until secondary amenorrhea is defined?
6 months
Most common cause of secondary amenorrhea
Pregnancy
Beta-human chorionic gonadotropin (Beta-hCG)
first line test with amenorrhea (pregnancy test)
painful menstruation caused by excess prostaglandin and leukotriene levels leading to painful uterine contractions, N/V/D
*no pathologic abnormality
primary dysmenorrhea
peaks in late teens and early 20s
painful menstruation caused by an identifiable clinical condition, usually of the uterus or pelvis (i.e., endometriosis, adenomyosis, uterine fibroids, PID or IUD)
secondary dysmenorrhea
incidence increases with age
Management for primary dysmenorrhea
- NSAIDs just before expected menses for 2-3 days
* OCPs, vitamin B, magnesium, etc.
Symptoms are associated with menstrual cycle and begin 1-2 weeks before menses and end 1-2 days after the onset of menses
*a monthly symptom free period during the follicular phase must exist
PMS
perimenopause lasts about….
3-5 years
vasomotor symptoms urogenital atrophy accelerated bone loss estrogen related CV protection declines thin, less elastic skin changes in sleep cycle confusion, memory loss, etc.
Menopause
FSH of greater than 30 is diagnostic of…
Menopause
Increase risk of:
CV disease
Breast cancer
Cognitive changes
Negative impacts of hormone therapy in menopause
abnormal uterine bleeding in the absence of an anatomic lesion, usually caused by a problem with the hypothalamic-pituitary-ovarian hormonal axis
(other causes…polycystic ovarian, exogenous obesity, adrenal hyperplasia)
Dysfunctional uterine bleeding (DUB)
most common shortly after menarche and during perimenopause
Tx depends on severity of bleeding
can use…progestin, OCP
Dysfunctional uterine bleeding (DUB)
Leiomyomata
uterine fibroids
Uterine fibroids most commonly occur in the ____ decade and more common in black women and those with a family hx
fourth
women with fibroids have a fourfold increase in the risk of…
endometrial cancer
most women have no symptoms but do have a firm, enlarged, irregular uterine mass
- some will have symptoms of pressure or fullness in pelvis
- menorrhagia, metorrhagia, intermenstrual bleeding and dysmenorrhea common
Leiomyomata (uterine fibroids)
Most common presenting symptom of leiomyomata (uterine fibroids)
Bleeding
What is the management recommended in most leiomyomata cases?
Observation
Most common GYN cancer
post menopausal women make up 75%
Endometrial cancer
mean age=58
Adenocarcinomas make up __% of endometrial cancers
75
Prognosis of endometrial cancer depends on…
age
histologic appearance
extent of spread
Obesity Nulliparity Infertility Late menopause Diabetes Unopposed estrogen stimulation HTN Gallbladder dz Chronic tamoxifen use White women
Risk factors for endometrial cancer
Cardinal symptom is inappropriate uterine bleeding***
Endometrial cancer
Tx for endometrial cancer
Total hysterectomy combined with bilateral salpingo-oophorectomy
Condition in which endometrial tissue is found outside endometrial cavity
*most sites in pelvis or on ovary
Endometriosis
Most common in nulliparous women in late 20s-early 30s
*infertility is common
Endometriosis
Dysmenorrhea Deep thrust dyapareunia Difficulty passing BM (dyschezia) Intermittent spotting Pelvic pain Infertility
Endometriosis
Tender nodularity of the cul-de-sac and uterine ligaments and a fixed uterus
*can use combined OCPs or progestins
Endometriosis
prolapse of the uterus typically occurs after…
pregnancy, labor and vaginal delivery
*risk increases after menopause
(but may occur in nulliparas)
symptoms vary but usually worse after prolonged standing or late in the day and relieved by lying down
vaginal fulless, lower abdominal aching, low back pain
uterine prolapse
Non surg: wt reduction, smoking cessation, pelvic exercises
OR surgical treatment
uterine prolapse
Most common ovarian growth
*usually functional and can include follicular, corpus luteum, theca lutein
cysts
May present as asymptomatic masses with pain and menstrual delay or with hemorrhage because of rupture
Ovarian cysts
Mobile, simple and fluid filled seen by pelvic ultrasonography
Ovarian cysts
In premenopausal women with cysts smaller than 8cm, how do you manage?
Observe for 1-2 cycles (persistent cysts warrant further investigation)
Large or persistant cysts may require…
laproscopic eval
Cysts in postmenopausal women are considered…
Malignant
Most common cause of androgen excess and hirsutism
*bilaterally enlarged polycystic ovaries, amenorrhea or oligomenorrhea and infertility
Polycystic ovary syndrome (PCOS)
Normal puberty and adolescence, followed by progressively longer episodes of amenorrhea
*increased risk for endometrial hyperplasia and carcinoma
PCOS
Ultrasonography may have characteristic “string of pearls” or “oyster ovaries”
PCOS
Labs may show elevated androgen levels, increased LH/FSH ratio, lipid abnormalities and insulin resistance
PCOS
High risk in older women (57-63), nulliparous, white and have a positive family history
*long term OCP use may be protective because of the suppression of ovulation
Ovarian cancer
Breast and ovarian cancer (BOC) syndrome
Hereditary nonpolyposis colorectal cancer (HNPCC) syndrome
2 forms of hereditary ovarian cancer
80% of ovarian cancers are ______ tumors
epithelial
Lack of specific symptoms
May present with…
ascites, abdominal distention, early satiety, change in bowel habits or a fixed mass
Ovarian cancer
Sister Mary Joseph nodule (a metastatic implant in the umbilicus) can be associated with
Ovarian cancer
BRCA1 associated with 5%
Associated with p53 tumor suppressor gene
- transvaginal or abdominal ultrasonography to diagnose
- chemo and radiation to treat
Ovarian cancer
HPV types 16, 18, 31 and 33 are strongly linked to…
Cervical cancer
HPV exposure in addition to….
- early age at first intercourse
- early childbearing
- multiple sex partners
- high risk sex partners
- history of STDs
- low socioeconomic status
- AfroAmericans
- Cigarette smoking
all increase risk of….
Cervical Intraepithelial Neoplasia (CIN)
Atypical changes at the __________ zone of the cervix initiate CIN, the pre-invasive phase of cervical cancer
transformation
the pre-invasive phase of cervical cancer
cervical intraepithelial neoplasia (CIN)
CIN-1= mild dysplasia
CIN-2= moderate dysplasia
CIN-3=severe dysplasia
CIS= carcinoma in situ
CIN most commonly occurs in women in their…
20s
cervical cancer after age 40
Usually have abnormal pap without symptoms
May cause abnormal vaginal bleeding and vaginal discharge
Cervical cancer
Can mild cervical lesions resolve spontaneously?
YES
Loop electrosurgical excision procedure (LEEP) can be used as treatment in…
Preinvasive cervical neoplasia
All boys and girls age ______ should receive Gardasil (3 injections over 6 months)
11-12 yo
Protrusion of pelvic organs into or out of vagina
*may occur in isolation but usually combined
Pelvic organ prolapse
May result from excessive stretching of pelvic fascia, ligaments, and muscles during pregnancy, labor and delivery
*occurs from increased intra-abdominal pressure
Pelvic organ prolapse
_____ vaginal prolapse includes cystocele or cystourethrocele
Anterior
______ prolapse includes enterocele and rectocele
Posterior
0= no descent 1= descent between normal position and ischial spines 2= descent between ischial spines and hymen 3= descent within hymen 4= descent through hymen
Pelvic organ prolapse grading
tx= pelvic floor exercises, vaginal pessaries and surgical treatment
Pelvic organ prolapse
Neoplasia in this area are the rarest of GYN neoplasms
vulva and vagina
most vulvar malignancies are SQUAMOUS CELL carcinomas and occur mostly in…
post menopausal women
Usually seen in women who are…
Obese with HTN, diabetes and arteriosclerosis
Chronic hx of vulvar itching
Vulvar cancers
Local excision, topical 5-fluorouracil and laser therapy are used for early..
vulvar lesions
surgical excision is required for most vaginal neoplasms
What diagnostic can distinguish between solid and cystic breast masses
Ultrasonography
Mastodynia (matalgia)
breast tenderness
Breast infection/breast abscess most often caused by staph aureus (primarily occurs in lactating women)
*unilateral tenderness, heat, significant fevers, chills and other flu like symptoms
Mastitis
usually 1 quadrant or lobule of breast is affected
tx= penicillinase resistant antibiotic and hot compresses
Mastitis
Most benign condition of breasts…include cysts, papillomatosis, fibrosis, adenosine and ductal epithelial hyperplasia
Fibrocystic changes
Diagnostic and therapeutic procedure to do if you suspect cysts
Fine needle aspiration
Round, firm, smooth, discrete mobile and nontender..benign
Fibroadenomas
Most common cancer in women, Second leading cause of death in women
increased risk with... Nulliparity Early menarche Late menopause Long term estrogen or radiation Delayed childbearing
Breast cancer
Does breast cancer increase the risk of endometrial cancer (and vice versa)
YES
Infiltrating ductal carcinomas
make up the majority of breast cancers
the remainder are lobular carcinomas
_____ disease is a ductal carcinoma presenting as an eczematous lesion of the nipple
Paget
The majority (2/3) of ductal carcinomas are estrogen receptor…
positive!
Single, nontender, firm, immobile mass
- 45% occur in UPPER OUTER QUADRANT
- 25% under nipple and areola
breast cancer
Best SCREENING tool for breast cancer?
Mammograms
Lumpectomy with sentinel node biopsy if preferred for….
early stage breast cancer
______ is used to treat women with estrogen receptor positive disease and post menopausal women
Tamoxifen
Lactational amenorrhea may be effective in delaying contraception for….
6 months after birth (if the woman is breast feeding exclusively and amenorrhea is maintained)
What is the failure rate for the calendar method of contraception
35%
predicts the day of ovulation based on average menstrual patterns
*are based on the relative constancy (14 days) of the luteal phase
calendar method
what happens to the temperature of the vagina 24-36 hours after ovulation
temperature drops, then rises and plateaus for the rest of the cycle
most effective reversible means of pregnancy prevention
oral hormonal contraceptives
ethinyl estradiol or mestranol
estrogen component of OCP
withdrawal bleeding occurs _____ days after the last active OCP pill
3-5 days
most useful in lactating women, women over 40, those who cannot tolerate estrogen
Progestin only pills (“mini pills”)
What should the first test be when evaluating infertility
Semen analysis
Clomiphene citrate can be used in…
“infertile” women to promote ovulation
Acute salpingitis
IUD related pelvic cellulitis
Tubo ovarian abscess
Pelvic abscess
pelvic inflammatory disease (PID)
- usually polymicrobial
* most bacterial!
PID
Lower abdominal and pelvic pain, typically bilaterally
Nausea, HA, lower back pain
+/- fever
PID
Exam reveals lower abdominal and pelvic pain and cervical motion tenderness (chandelier sign)
Purulent discharge and inflammation of Bartholin or Skene glands may be present
PID
most common causes of PID
Chlamydia
Gonorrhea
This diagnostic is helpful in differentiation acute and chronic inflammation of PID
transvaginal ultrasonography
Mild dz treated outpatient with antibiotics, antipyretics, analgesics and bed rest
Severe dz should be hospitalized for IV abx and possibly surgery
PID
