GYN Flashcards
estrogen amount in COCs is _______ than the amount of estrogen in menopausal HRT
HIGHER
If a woman is having infrequent periods, she is not ovulating frequently.
If she’s not ovulating, she’s not making a corpus luteum.
If there’s no corpus luteum, there’s no progesterone.
Know This!!
PMS occurs during the late _________ phase, cycle days ___-___
luteal, cycle days 21-28ish
structural causes of AUB
fibroids
adenomyosis
polyps
only hormonal causes of AUB cause change in:
length of the cycle
structural causes of AUB cause the period to be:
heavier and/or breakthrough bleeding b/t periods
basal body temperature increases after ovulation in response to __________ secreted by the __________
progesterone secreted by the corpus luteum
hormone that stimulates follicular growth in the ovaries and stimulates estrogen secretion (from developing follicles)
FSH
hormone that surges to cause ovulation resulting in the formation of the corpus luteum
LH
hormone that thickens the uterine lining, inhibits FSH and LH for most of the cycle, and stimulates FSH and LH release pre-ovulation
estrogen
hormone that thickens the uterine lining and inhibits FSH and LH
progesterone
FSH is secreted by the:
anterior pituitary
LH is secreted by the:
anterior pituitary
estrogen and progesterone are secreted by the:
ovaries
Endometrial Cycle includes these menstrual cycle phases:
Proliferative
Secretory
Menstrual
Ovarian Cycle includes these menstrual cycle phases:
Follicular
Ovulatory
Luteal
basal body temp increases due to increase in:
progesterone
first day of bleeding is menstrual cycle day #:
1
The ___________ phase is always 14 days long
luteal
high estrogen levels after dominant follicle has been established increase:
FSH and LH secretion
prolactin is secreted by the:
anterior pituitary
when estrogen is the dominant hormone, the endometrium:
proliferates
when progesterone is the dominant hormone, the endometrium:
thickens to prepare for implantation
leave diaphragms and cervical caps in for at least ___ hours
6
remove diaphragm by ___ hours
24
remove cervical cap by ___ hours
48
MOA of ___________:
- Supresses ovulation
- Thickens cervical mucus
- Thins asynchronous endometrial lining: decreases chance of implantation
- Slows tubal motility
COCs, Ring, Patch
MOA of ___________:
- Thickens cervical mucus for 2-4 hrs after ingestion, lasting for 22 hrs
- Inhibits ovulation (**40% ovulate normally)
POPs
MOA of ___________:
- Inhibits LH and FSH surge: suppresses ovulation, thickens cervical mucus
- Slows tubal and endometrial mobility
- Thins endometrium
Depo
MOA of \_\_\_\_\_\_\_\_\_\_\_: -Thickens cervical mucus -Inhibits ovulation x 2 yrs -Atrophies endometrium (**may rarely ovulate after 2 yrs)
etonogestrel implant (Nexplanon)
Contraindications for \_\_\_\_\_\_\_\_\_\_\_\_:
-Active gallbladder or liver disease
-Multiple CVD risk factors
HTN >/= 160/100
Current DVT or PE
Hx of thrombogenic mutations (Factor V leiden)
-Current breast cancer
-Migraines w/ aura at any age
-Migraines w/o aura if age > 35
-Hx of stroke
-Diabetes > 20 yrs w/retinopathy, nephropathy, neuropathy or other complications
-Major surgery w/prolonged immobilization
-Prior to 21 days postpartumCOCs, ring, patch
Contraindications for \_\_\_\_\_\_\_\_\_\_\_\_:
-Active liver disease
-Multiple CVD risk factors
HTN >/= 160/100
Current DVT or PE
Hx of thrombogenic mutations (Factor V leiden)
-Current or recent breast cancerPOPs, Depo, Nexplanon
most effective EC
copper IUD
most effective PO method of EC
UPA
UPA EC effectiveness: ___ pregnancies in 1000 uses
10 (1.8% chance of pregnancy after 1 act)
POPs/LNG IUDs EC effectiveness: ____ pregnancies in 1000 uses
12 (2.6% chance of pregnancy after 1 act)
COCs EC effectiveness: ____ pregnancies in 1000 uses
20-32
failure rate of copper IUD EC
under 1 in 1000 (99.9% effective)
SE of \_\_\_\_\_\_\_\_\_\_\_\_\_ (EC): Increased bleeding during periods Increased dysmenorrhea Infection during first 20 days Uterine perforation Expulsion Vasovagal or fainting w/ insertion
copper IUD
SE of \_\_\_\_\_\_\_\_\_\_\_\_\_ (EC): N+V (**most common) HA Abdominal pain Breast tenderness Fatigue Dizziness
UPA, POPs/LNG, COCs
nausea + vomiting is less severe with ______ as EC than _______ as EC
POPs/LNG less severe than COCs
POPs/LNG methods of EC
Plan B
Plan B timeframe for use
72 hours but may work up to 120 hours
ella (UPA) EC is available by __________ only
prescription
EC that is less effective in women with BMI >30
ella (UPA)
EC that delays ovulation even when LH is rising
ella (UPA)
ella (UPA) timeframe for use
120 hours
copper IUD can be inserted up to ___ days after ovulation (up to 5 days after unprotected sex that occurs mid-cycle or earlier) to prevent pregnancy
5
EC methods that delay ovulation
COCs, POPs/LNG, UPA
EC methods that have spermicidal activity
copper IUD only
EC methods that prevent implantation via uterine line effects
copper IUD
possibly UPA
type of IUD that is associated with irregular bleeding after 3 months of use
Mirena
co-test for HPV with pap for women over age:
30
start pap smears at age:
21
paps are q___ year until age 30
3
Reasons for more frequent pap smears
HIV positive
immunocompromised
DES exposure
after treatment for CIN2/3 cervical cancer
paps are q___ years after age:
30
paps are not recommended after age:
65
ASC-US
Atypical Squamous Cell of Undetermined Significance
lowest clinical concern result of pap
ASC-US
LSIL
Low-grade Squamous Intraepithelial Lesion
pap result that includes mild hyperplasia, cervical intraepithelial neoplasia (CIN) 1– probably HPV but with a high likelihood of resolution especially among young women
LSIL
pap result that includes moderate to severe dysplasia, carcinoma in situ, CIN 2 and 3– almost 100% HPV and not as likely to spontaneously resolve
HSIL
HSIL
High-grade Squamous Intraepithelial Lesion
for women > age 25 with ASC-US or LSIL pap result, order:
reflex testing for High Risk HPV
for women younger than age 25 with ASC-US or LSIL pap result:
repeat pap in 1 year
if High Risk HPV is present on reflex testing, next step is:
colposcopy
for HSIL result at any age, woman will need:
colposcopy + biopsy
___-___% of ASC-H is already cancer
5-10%
If HPV 16 or 18 is detected, even if pap is normal, woman will need:
colposcopy
negative pap with positive HPV management
repeat pap in 1 year, if same result- refer for colposcopy
if HPV is high-risk but not types 16 or 18, when should pap be repeated?
1 year
for unsatisfactory pap result on 3 month repeat pap, midwife should:
refer for colposcopy
woman < age 25 with negative pap but insufficient sampling of transformation zone, midwife should:
advise screening at regular interval
LSIL result, repeat pap in:
1 year
Type of Nipple Discharge: Lesion in duct Spontaneous (without stimulation) UNIDUCTAL UNILATERAL Bloody nipple discharge
Intraductal papilloma
Type of Nipple Discharge:
Milky discharge in someone who is not pregnant/lactating in the last 12 months
BILATERAL
MULTIDUCTAL
May occur spontaneously OR with nipple stimulation
Galactorrhea
dilation of ducts w/ surrounding INFLAMMATION and fibrosis that usually occurs in women > 50 yo, bilateral, multiductal with sticky brown/black/green discharge (can present as firm mass under nipple)
Mammary duct ectasia
Diagnostics for __________:
*depends on masses presence and discharge characteristics
If discharge black–>guaiac test for blood
If age>40 and hasn’t had a mammogram in last 6 months–>mammogram
Mammary duct ectasia
Treatment for __________:
- Advise to avoid nipple stimulation and follow up in 3-4 months
- Expectant management due to benign process
- Surgically treated with removal of the subareolar duct system if imaging shows focal thickening of the duct wall or if symptoms are severe
Mammary duct ectasia
small WART-LIKE (solitary or multiple) benign growth in the duct usually occurs in women 40-50 years of age with unilateral, uniductal bloody/serosanguinous discharge…may or may not have palpable mass
Intraductal papilloma
Treatment for __________:
Without atypia, single papilloma and < 1 cm: Do not remove
Multiple papillomas or single papilloma > 1 cm: duct excision
Intraductal papilloma
Treatment for __________:
-Decrease breast/nipple stimulation to decrease discharge
-Outside of pregnancy/lactation:
Pituitary tumors → expectant management, medication, and/or surgery
Meds: bromocriptine and cabergoline
Discontinuation of meds → recurrence of galactorrhea, therefore lifelong therapy required
Discontinuing medication causing galactorrhea
Galactorrhea
dense epithelial and fibroblastic tissue, usually nontender, encapsulated, round or oval, smooth, mobile, firm, rubbery, can be large
Fibroadenoma
incidence of this breast mass decreases with increased age- commonly benign usually singular mass in younger women
Fibroadenoma
treatment for Fibroadenoma
expectant management
fluid-filled mass most common in 35-50 yo women
*Discrete, tender, mobile, size may fluctuate with menstrual cycle
cyst
area of fatty tissue may occur in the breast or other areas - usually in later reproductive years
**Discrete, soft, nontender, may or may not be mobile
Lipoma
Poorly defined, firm, nontender, nonmobile mass that is usually result of trauma or surgical manipulation of the tissue that resolves spontaneously
Fat necrosis
Glandular tissue, fat and fibrous connective tissue mass
- Discrete, nontender, nonmobile, may be nonpalpable with incidental dx on imaging studies
- Average age of diagnosis: 45 yo
Hamartoma
Milk-filled cysts that usually occur during or after lactation
- Discrete, firm, sometimes tender
- Duct dilation often have an inflammatory component
Galactocele
Treatment for Galactocele
aspiration for diagnosis and appropriate treatment
Suspicious for \_\_\_\_\_\_\_\_\_: skin changes lesion is hard painless/ non-tender irregular borders immobile mass fixed to the skin or surrounding tissue gritty enlarged axillary cervical and supraclavicular lymph nodes
Breast CA
Risk Factors for \_\_\_\_\_\_\_\_\_\_: BRCA 1 or 2 mutation smoking age female sex personal hx family hx genetic mutations breast lesions with atypia dense breast tissue high-dose radiation to chest (esp during puberty) menarch before age 12 menopause after age 55 nulliparity first full-term pregnancy after age 30 current use of COC use of COC after menopause weight gain after age 18 physical inactivity alcohol consumption Jewish ancestry Born in North America, North Europe, Asia, or Africa
Breast CA
ACS recommends yearly mammograms starting at age:
45
ACOG recommends yearly mammograms starting at age:
40
USPSTF recommends biennial mammograms starting at age:
50
Normal physiological process that occurs at the squamocolumnar junction or transformation zone
initiated by the eversion of the columnar epithelium onto the ectocervix - occurs under the influence of estrogen and its ensuing exposure to acidic vaginal pH
squamous metaplasia
Squamous metaplasia may arise through reproductive years but is most active during:
adolescence and first pregnancy
Breast mass that occurs in ages 30-50 that may cause skin stretching due to rapid growth
Phyllodes tumor
woman whose depression being treated with fluoxetine (Prozac) who reports a decrease in libido should be prescribed:
buproprion (Wellbutrin)
HRT regimen for women WITHOUT a uterus; sometimes called unopposed estrogen which would increase the risk of endometrial cancer if a postmenopausal woman with a uterus used them.
Estrogen-only therapies (ET)
HRT regimen for women WITH a uterus; the progestogen is really only for the purpose of endometrial protection
Estrogen plus Progestogen therapies (EPT)
Contraindications for \_\_\_\_\_\_\_\_\_\_: Hx breast cancer CHD Hx venous thromboembolic (VTE) event Hx stroke active liver disease unexplained vaginal bleeding high-risk endometrial cancer transient ischemic attack
Menopausal HRT
SYSTEMIC vaginal therapy of HRT
Femring
vaginal therapy that is local only
Estring
SE of ________:
reflux exacerbation
GERD
esophageal ulceration
biophosphonates (Alendronate)
If a HT option is low estrogen for local vaginal symptoms only, you do not need to:
add progesterone
DEXA scans are recommended for all women over age:
65
tool used to estimate risks to make decision on whether to screen a woman early for osteoporosis
FRAX
compares a woman’s bone mass to peak bone mass of the average woman aged 30
T-score
normal bone density T-score
> -1
osteopenia T-score
-1.1 – -2.49
osteoporosis T-score
-2.5 or less
recommended daily calcium intake for women over 50
1200 mg
recommended daily calcium intake for premenopausal women under age 50
1000 mg
recommended daily calcium intake for postmenopausal women on estrogen under age 65
1000 mg
recommended daily calcium intake for postmenopausal women not taking estrogen
1500 mg
recommended daily calcium intake for premenopausal women over age 50
1200 mg
Treatment of chlamydia for non-pregnant women
Azithromycin 1 g orally in a single dose OR
Doxycycline 100 mg orally twice/day x 7 days
retest for chlamydia (test of cure) in ___ months
3
Treatment for \_\_\_\_\_\_\_\_\_\_\_: Acyclovir 400 mg TID x 7-10 days OR Acyclovir 200 mg 5 times/day x 7-10 days Valacyclovir 1 g BID x 7-10 days OR Famciclovir 250 mg TID x 7-10 days
1st clinical episode of HSV
Treatment for __________:
Acyclovir 400 mg BID OR
Valacyclovir 500 mg QD OR 1 g QD OR
Famciclovir 250 mg BID
suppressive therapy for HSV
“strawberry cervix” is a sign of:
trich
Treatment for _____________:
Metronidazole 2 g orally in a single dose OR
Tinidazole 2 g orally in a single dose
Trich
Treatment for _____________:
PO metronidazole* (Flagyl) 500 mg bid x 7 d OR Topical metronidazole (Metrogel), qhs x 5 d OR
Topical clindamycin vaginal cream (Cleocin Vaginal) 5 gm qhs x 7d
BV
- Homogenous, thin white discharge that smoothly coats vaginal walls
- Clue cells
- pH of vaginal fluid > 4.5
- Fishy odor of discharge before or after adding KOH ***Must have 3 out of 4 to diagnose:
BV
Gonorrhea is diagnosed with:
NAAT or culture on Thayer Martin media
Chlamydia is diagnosed with:
NAAT
trich is diagnosed with:
wet mount
Treatment of gonorrhea in nonpregnant women:
ceftriaxone 250 mg IM once with azithromycin
Syphyllis is treated with:
benzathine Pen G 2.4 million units
Risk Factors for \_\_\_\_\_\_\_\_\_\_\_\_\_: Pregnancy Diabetes Previous history of cystitis Use of spermicides Use of diaphragm for contraception Sexual activity History of UTI
UTI (cystitis)
least expensive effective treatment available for the treatment of cystitis and should be recommended unless the patient is allergic or the community has high levels of resistance to this regimen.
Trimethoprim/sulfasmethoxazole
choose SSRI w/ long half-life for PMS/PMDD such as:
fluoxetine (Prozac)
sertraline (Zoloft)
gonadotropin hormones
FHS and LH
gonadism
ovarian estrogen production
type of amenorrhea with normal levels of FSH and LH (ex: outflow obstruction, cervical stenosis, chronic anovulation, hyperandrogenism, PCOS)
normogonadotropic amenorrhea
type of amenorrhea with decreased levels of FSH and LH where ovaries don’t produce enough estrogen (ex: anorexia, chornic illness, excessive exercise, weight loss)
hypogonadotropic/ hypogonadism amenorrhea
type of amenorrhea with increased levels of FSH and LH where ovaries don’t produce enough estrogen (ex: premature ovarian failure due to autoimmune, chemotherapy, etc.)
hypergonadotropic/ hypogonadism amenorrhea
type of amenorrhea where there is presence of secondary sex characteristics without menses by age 16 or absence of secondary sex characteristics by age 14
primary amenorrhea
prolactin may be increased by:
medications
benign pituitary tumor
breastfeeding
breast stimulation
women with PCOS or excess adipose tissue have ________ estrogen
normal to high estrogen
conditions that cause _____ estrogen:
anorexia
chronic disease
prolactemia
low
conditions that cause ______ estrogen and ______ FSH+LH:
menopause
premature ovarian failure
low estrogen, high FSH+LH
without sufficient levels of estrogen, progesterone challenge test will:
NOT result in a withdrawal bleed
with sufficient levels of estrogen, progesterone challenge test will:
result in a withdrawal bleed
condition in which the endometrial tissue invades the uterine muscle tissue most common in women aged 35-50 and sometimes asymptomatic but can cause dysmenorrhea, non-cyclic uterine cramping, deep dyspaurenia, menorrhagia (often contributed to perimenopause)
adenomyosis
Symptoms of __________:
large, boggy, tender uterus
irregular contour of uterus
myometrial lesions that look like fibroids
adenomyosis
Treatment of \_\_\_\_\_\_\_\_\_\_\_: NSAIDs narcotics hormonal contraceptives hysterectomy
adenomyosis
benign uterine smooth muscle tumors
fibroids (aka leimyomas, myomas)
symptoms of \_\_\_\_\_\_\_\_\_\_: **asymptomatic often menorrhagia dysmenorrhea pelvic pressure increased abdominal size irregular contour of uterus usually non-tender
fibroids
Treatment of \_\_\_\_\_\_\_\_\_\_\_\_: expectant management/symptom relief COCs anti-estrogen therapies (leuprolide) LNG_IUS surgery (myomectomy, hysterectomy) uterine artery embolization
fibroids
causes painless bleeding
cervical polyp
painless, white, firm nodules visible on the cervix
Nabothian cysts
full development of breast tissue occurs during:
pregnancy and lactation
approximate number of oocytes that are left when a female reaches puberty
200,000
acts as a sling for the vagina and the vaginal sphincter
pubovaginalis band of the pubococcygeus perineum muscle
pelvic type that poses difficulty for SVB and increases the likelihood of OP position and forceps-assisted delivery
heart-shaped
stretching of the _______ may occur during the 2nd stage, & can result in rectal prolapse
levator ani muscle
sling and accessory sphincter for the rectum.
puborectalis band of the pubococcygeus perineum muscle
muscle that controls defecation
pubococcygeus proper band of the pubococcygeus perineum muscle
female sexual response that may cause vasocongestion to occur in 50% to 75% of women
desire
average range for the menstrual cycle
21-34 days
____% of women report a 28-day menstrual cycle
15
amount of blood loss during menstruation, if reported by a woman, the NP documents as abnormal
> 80 mL
discomfort during ovulation
mittleschmerz
endocrine disorder that causes amenorrhea
ovarian tumor
pituitary disorder that causes amenorrhea
Cushing’s disease
HSV-1 and HSV-2 can cause genital infection but typically______ causes more genital pain, & outbreaks are more frequent
HSV-2
most common symptom of endometriosis
dysmenorrhea
migration of endometrial tissue into the peritoneal cavity via the fallopian tubes during menses
retrograde menstruation
breast assessment method recommended for subsequent examinations for an individual with dense breasts
ultrasound
tamoxifen increases risk of __________ cancer
endometrial
SE of \_\_\_\_\_\_\_\_\_: **Dangerous: abnormal vaginal bleeding or discharge pain or pressure in the pelvis leg swelling or tenderness chest pain shortness of breath weakness, tingling, or numbness in face, arm, or leg difficulty speaking or understanding vision problems dizziness sudden severe headache ***Most common: increased tumor or bone pain hot flashes nausea fatigue mood swings depression headache hair thinning constipation dry skin loss of libido
tamoxifen
SE of \_\_\_\_\_\_\_\_\_\_\_\_: hot flushes night sweats nausea vomiting loss of appetite constipation diarrhea heartburn stomach pain changes in weight muscle, joint, or bone pain **most common excessive tiredness headache dizziness weakness swelling of the hands, feet, ankles, or lower legs difficulty falling asleep or staying asleep vaginal bleeding or irritation breast pain hair loss blurry vision
letrozole
administration route for trastuzumab (Herceptin) for breast CA
IV
Pelvic inflammatory disease consists of pelvic or lower abdominal pain and at least one of these 3 signs:
uterine tenderness
cervical motion tenderness
adnexal tenderness
category of medical eligibility for contraceptive use where there is an advantage of using this method that outweighs any risk
Category 2
category of medical eligibility for contraceptive use where There is no restriction for the use of the contraceptive method.
Category 1
category of medical eligibility for contraceptive use where there is a risk that outweighs the advantages of the contraceptive method
Category 3
category of medical eligibility for contraceptive use where there is an unacceptable health risk if the contraceptive method is used
Category 4
For a couple that uses no contraception, ___ of every 100 couples will experience an unintended pregnancy within 1 yr
85
spermicide that can be used immediately before sex
foam
typical users of spermicides, during the 1st year of use, approximately ____% will have an unintended pregnancy.
28%
sponges work for ___ hours
3
to remove the female condom, __________ the ring
squeeze and twist
absolute contraindication for COCs
acute viral hepatitis
absolute contraindication for Depo
Long-term corticosteroid use with history of nontraumatic fracture
factor that has been associated with spontaneous menopause that occurs earlier than the avg age of 51 yrs
smoking
