GYN Flashcards
what days of cycle are optimal for fertilization
day 11-15
name the two phases (or 3)
follicular (proliferative)
luteal (secretory)
Follicular + menstruation
ovulation
luteal
Follicular phase
- days
- predominant hormone
day 1 (menstruation) to day 14 (ovulation) -new follicle is growing
HORMONES:
*GnRH–>FSH + LH–>follicle grows–>secreting estorgen–>provides (-) feedback to AP–>but then estrogen gets to a point where its very high and creates (+) feedback on FSH and LH—SURGE–. SURGE OF LH=OVULATION
what causes menstruation
progesterone withdrawal
what triggers ovulation
on day 11-14 a sugrge in LH occurs once dominant follicle is selected
corpus luteum
- progesterone production
- —-> neg feedback on FSH + LH
Luteal PHase
-hormone and its role
PROGESTERONE
- enhances endometrial lining to prepare it for implantation
- once there is no implantation– corpus luteum degenerates into corpus albicans —-> steep decr in estrogen + Progesterone
***this drop of hormones leads to menstruation and star of new cycle
MCC of secondary amenorrhea
pregnancy
ALWAYS DO PT IN EVERY PATIENT
primary vs secondary amenhorrhea
PRIMARY
- failure of menses to occur by age 15 (or 16) in presence of normal growth and secondary sexual characteristics
- ->start evaluation at age 13 if no menses + absence of secondary charactersistics
SECONDARY
*absence of menses for 3 MO in a woman with previous menses
oR
6 months in a woman with hx of irreg cycles
causes of primary amenorrhea
Turners syndrome—- XO
hypothalamic-pituitary insufficiency 46 XX
*low FSH low LH
Androgen insensitivity: 46 XY
High testosterone… breast development only
Imperforate hymen: 46, XX, diagnosed on PE
anorexia
mullerian agensis– no uterus but has secondary sex charactersitcs
Turners syndrome
XO
webbed neck, broad chest, high FSH
causes of secnoadry amenhorrhea
-what hormones to always check
pregnancy
hypothyroid
weight changes
prolactinoma
**ALWAYS CHECK BHCG, TSH and Prolactin
***progesterone challenege test–> medroxyprogesterone 5-10 mg PO once a day or another progesterone for 7-10 days—— if bleeding occurs=anouvulatory cycles
MCC of primary amenorrhea
GONADAL DYSGENSIS
- Turner syndrome– 45XO
- Mullerian dysgenesis– 46XX
- Androgen Insensitivity—46XY
a 35-year-old woman with concerns about heavy menstrual periods for the past year that occur at irregular intervals. She explains that sometimes her menses come twice a month but other times will skip two months in a row. Her menses may last 7 to 10 days and require 10 to 15 thick sanitary napkins on the heaviest days. PELVIC EXAM NORMAL NORMAL PAP no STIs
DUB
define DUB
excessive uterine bleeding with prolonged menses that is NOT CAUSED BY PREGNANCY OR MISCARRIAGE
**diagnosis of exlcusion
define Polymenorrhea
menses that occur more frequently (<21 days apart menses)
define hemorrhagic or hypermenorrhea
menses that involve more blood loss >7 days or >80 mL
menorrhagia
prolonged/heavy bleeding
>7 days or >80 ml at regular intervals
metrorrhagia
uterine bleeding that occurs frequently and irreguarly b/w cycles
menometrorrhaiga
more blood loss during menses and frequent and irregular bleeding b/w menses
oligomenorrhea
long intervals of >35 days
MCC of AUB/DUB
chronic anovulation
**corpus luteum does not form–>so noprogesterone formed—>unoppposed estrogen–>endometrial overgrowth–>irregular, unprediactable shedding
GS for diagnosis of AUB
uterine D/C
labs to order for DUB
bHCG
CBC, iron stuidies, PT, PTT,
TSH, progesterone, prolactin, FSH,
LFTs
how to confirm anovulatry cycle causing DUB
progestin trial– if the bleeding stops its from anovulation
TX for AUB
OCPs
NSAIDs
TX for AUB
OCPs
NSAIDs
TX for AUB
OCPs
NSAIDs
TX for AUB
OCPs
NSAIDs
TX for AUB
OCPs
NSAIDs
TX for AUB
OCPs
NSAIDs
TX for AUB
OCPs
NSAIDs
TX for AUB
OCPs
NSAIDs
a 19-year-old nulligravid college female who complains of dull, throbbing, cramping lower abdominal pain during menses for the past three years. She reports nausea and vomiting during menses but denies irregular or heavy periods, pain with intercourse, or abdominal pain outside of menses. Pain tends to peak 24 h after the onset of menses and subsides after 2 to 3 days. A pelvic exam is norma
dysmenorrhea
define dysmenorrhea
uterine pain around time of menses
difffernece b/w primary and secondary dysmenorrhea
RF for both
tx for both
PRIMARY -no organic cause -pain from excess of prostaglandins -teens to early 20s--- declines with age -NO Pelvic pathology -N/V/D -HA "labor like pains"
RF
- menarche before 12
- nulliparity
- smoking
- fm hx
- obesity
TX= NSAIDs, OCPs
SECONDARY from pathologic cause
- endometriosis
- adenomyosis
- polyps
- fibrids
- PID
- IUD
- tumors
- adhesions
- cervical stenosis
- lesions
- psych
- *pain will increase in severity until end
- common in age 20-40s
tx=underlinyg cause
avg age for menopause
44-55
avg=51
perimenopause
transition period b/w reproductive capability and menopause
hallmark=irregular menses 3-5 years
onset of menopause <40 YO
premature ovarian failure
labs seen in menopause
elevated FSH >30 + low estradiol
**high FSH not requried tho its mainy about amenorrhea for 1 yr
tx for menopause
+uterus
-uterus
+uterus: HRT—-estrogen + progesterone
HRT=hormone replacement therapy
**Tibolone
-uterus----ERT (just estrogen) ERT=estrogen replacement therapy or SERMS-----selective estrogen receptor modulators *******raloxifine ******tamoxifen
why can you not use estrogen alone for woman in menopause with intact uterus?
incrs risk of endometrial CA
and DVT/PE
Risk of Tibolone or any HRT
BCA but its low
contraindication for HRT
hx of BCA
HRT effect on lipid profile
incrs HDL and TG levels
decrs LDL
contras for HRT
high trigs undiagnosed vag bleeding endometrial CA hx of bCA or estrogen sensitive CAs CVD hx DVT or PE
define premenstrual dysphoric disorder (PMDD)
repeated epsiode of significant depression and related s/s during week b4 menses
*****severe/debilitating PMS
DSM-5
- at least 5 symptoms in final week b4 menses
- that imrpove within few days after onset of menses
- becomes absent or minimal week post menses
S/S:
- marked lability—-mood swings, feeling suddenly sad or tearful, incrs sensitivity/rejection
- marked irriability
- depression
- severe anxiety
tx for PMDD
SSRIs
-fluoxetine or sertraline
SNRIs
-venlafaxine
low dose OCPs + diuretics
GnRH—- only as third+ line
Benzos, TCAs,
SEVERE/REFRACTORY
-ovarianectomy
when do s/s o PMS occur in cycle
-when do s/s resole
luteal phase (1-2 wks before menses)
resole at onset of menses
tx for PMS
exercise
stress reduction
1st line- SSRIs if they dont want OCPs
OCPS will be first tho before SSRIs
mucopuruelnt discharge
gram neg diplococci
gonorrhea
MC women are asympto
tx gonorrhea
IM ceftriaxone 500 mg if <300 pounds
>300 piunds= 1 gram ceftri IM
***usually tx as co infection
urethritis, vulvovaginitis (vulvar and vaginal discomfort, pain, pruritus), and inflammation of the cervix; clear vaginal discharge
chlamydia
tx for chlamydia
doxycycline 100 mg BID 7 days
alternatives
-azitrhomycin 1 g PO x1 dose
OR
-levofloxacin 500g PO x 7 days
mc sti
chlamydia
GS dx for HSV
viral culture
tx for HSV
**valcyclovir
which type of HPV MC cause for cervical CA and anal CA
16 and 18
which type of HPV causes warts
6 and 11
Gardasil covers which HPV strains
6
11
16
18
31 33 45 52 58
> 90% of cervical cancer is associated with HPV types
16 18 31 33 35
_____ is commonly seen in combination with condylomata acuminata
trichomonas
PAP shows koilocytic squamous epithelial cells in clumps
cervical warts from HPV
when does HPV vaccine start
9
oldest you can be to get HPV vaccine
45
painful sore on her vulva that first resembled a pimple. On examination, you find an ulcer with clearly demarcated borders, gray base, and foul-smelling discharge.
chancroid
YES its a STI
causative pathogen for chancroid
Haemophilus ducreyi
gram - ROD
in half of PT with chancroid there will also be?
marked lymphadenopathy in inguinal chain
tx for chancroid
single does IM ceftri 250 or azitrhomycin 1 grams PO x1 dose
serotypes of chlamydia tht cause chalmydia
D-K
serotypes of CT that cause lymphogranuloma venereum (LGV)
L1-3
RF for LGV
MSM– unprotected anal sex, HIV, HCV
painless genital ulcers or papules
lymphogranuloma vanereum
uni or bilat tender inguinal and or femoral lymphadenopathy
lymphogranuloma vanereum
strictures, fibroisis and fistulae of anogenital region
lymphogranuloma vanereum
tx for lymphogranuloma vanereum
doxycycline 100 mg PO BID for 21 days
PID involves what parts
infection ascending from cervix or vagina INTO ENDOMETRIUM AND/OR FALLOPIAN TUBES
tx for PID outpatient
ceftriaxone IIM 250 mg once + PO doxycycline 100 mg BID x14 days +/- PO Flagyl 500 mg BID x14 days
when to admit for PID
sevee n/v
if diagnosis is uncertain
ectopic preg and appendicity cant be ruled out
preg or pelvic abscess suspected
HIV+
cannot tolerate outpt meds
faiil to respond to outpt meds
inpatient tx for PID
IV second gen cephalosporin (cefoxitin or cefotetan) + IV Doxy—-then PO doxy for 14 days
clindamycin + gentamycin is alternative—– use this in pregnancy or pcn allergy—- then use PO doxy
sypgilis causative agent
spirochete Treponema pallidum
painless single ulcer (chancer)
syphilis
erythematous rash invovling palms and soles
+/- condyloma lata
secondary syphilis
what can cause a false negative syphilis test
lyme disease
tx for syphilis
Benzathine PCN G 2.4 million units IM x1 single dose
-prim and sec disease
PCN allergic= doxycycline
IV PCN G for congenital and teritary syphilis
ph for candida
acidic
<4.5
tx for candida
PO Fluconazole (diflucan) 150 mg
then repeat dose in 7 days
agent in BV
Gardnerella
anaerobic bacteria
frothy, grayish white fishy smelling dsx
BV/Gardenerella
clue cells
BV/Gardnerella
epithelial cells with bacilli attached to their surfaces
clue cells
ph for BV
basic
>4.5
tx for gardnerella
metro 500 mg PO bid 7days
also metro gel
clindamycin cream
SECOND INE TX
-clindamycin PO 300 mg bid 7days
greenish gray frothy vaginal discharge
trich
petechiae on cervix
Trich
mobile pear shaped protoxoa with flagella on wet mount
trich
tx for trich
metro 2g PO x1 dose
tx partner too
tx for atrophic vaginitis
conjugated estrogens vaginal creams for 3 wks then taper
can give oral HRT if no contraindications
non homronal vaginal crmeas too
thin pale appearing mucosa on vaginal exam in a post menopausal woman
atrophic vaginitis
causative agent for TSS
endotoxins from staph aureus
caues for TSS
tampons
non-menstrual:
- surgical and PP wound infections
- contraceptive sponge use
sudden onset of high fever + tachycardia +/- N/V/D +/- pharyngitis
TSS
tx for TSS
surrpotive
aggresive IVF replacement + IV ABX—- clindamycin + vancomycin or linezolid
mc malignancy in woan
BCA
RF for BCA
- incr age
- BRCA 1 or 2
- incr number of menstrual cycles: nulliparity, early menarche (b4 12), late menopause, late first full term preg >35yo
- incr estrogen exposure: PP HRT, prolonged unopposed estrogen, obesity, ETOH
- having endomertrial CA incrs risk of BCA and vice versa
mc type of BCA
infiltrative ductal carcinoma
eczematous nipple lesion scalling rash on nipples and areoa
pagets dz of nipple
what is not cancerous but assoc with incr risk of invasive BCA
lobular carcinoma in situ
BCA screening guidelines
baseline mammo every 2 years from 50-74
every 2 years starting at 40 if incr RFs——- start 10 yrs prior to the age of the 1st degree relative diagnosis
clinical breast exam every ____ yrs
every 3 yrs 20-39 YO
then annual 40+
common sites for BCA mets
bone—-vertebrae, ribs, pelvis, femur
lungs
liver
brain
TRICK: 2Bs and 2Ls
red swollen warm itchy breast + nipple retraction
inflammatory BCA
pea d’orange
assoc with poor prognosis
inflam BCA
triad for cerv CA extension to the pelvic wall
Unilateral leg edema, sciatic pain, ureteral obstruction
third MC type of CA
cervical
postmenopausal vaginal bleeding
cervical CA
MC type of cervical CA
squamous cells
RF for cervical CA
- multiple sex partners
- early age of first intercourse
- early first pregnancy
- HPV +
friable, bleeding cervical lesion
ca
at wht age should pt get first PAP regardles of sexual activity
21 YO
or at the time of intercourse under 21 who have HIV infection or on chronic immunosupp tx for SLE or organ transplant
when to discontinue pap testing
at age 65 who have had three consectiuve negative cytology tests or two consecutive HPV/pap co tests in last 10 yrs
ASC-US
atypical squamous cells of undeterminted signifiance
LSIL
low grade squamous intrapeithelial lesions
- mild dysplia
- CIN 1
HSIL
high grade squamous intraepithelial lesions
mod-seveere dysplaisa
CIN 2-3, carcioma in situ
RF for cervical dysplasia
HPV 16 18 31
they can lead to CCA
ASCUS or anything else
reflex HPV—
negative- then repeat in 1 yr
+ then send for colposcopy
MC GYN Malignancy
endometrial CA
fourth mc malignancy of women US
endometrial
postmenopasual bleeding
cervical or endometrial CA
mc type of CA for endometrial
adenocarcinoma
RF for endometrial CA
obesity nulliparity early menarche late menopause unopp estrogen
HTN
Gallbladder dz
DM
prior ovarian, endometrial or BCA
do all women who have endometrial CA have abnormal pap?
no only 50%
what is indicated in all postmenopausal women with vaginal bleeding
endometrial biopsy
mc age group for ovarian ca
40-60
ascites + abd pain
ovarian CA— advanced stage
protective factors for ovarian CA
multiparity
OCPs
breast feeding
RF for ovarian CA
nulligravidy or infertility
early menarche
late menopause
endometriosis
mc type of ovarian CA
epithelial
CA-125
ovarian CA
BRCA gene 1
BCA
Ovarian CA
RF for vaginal/vulvar CA
HPV infection, Smoking, Coexisting cervical carcinoma, In utero exposure to DES
peak age for vaginal CA
60-65
MC type of vaginal CA
squamous
—HPV
IF DES exposure then its adenocarcinoma
MC location for vaginal CA
upper one third of the posterior vaginal wall
how does vaginal CA present usually
changes in menses and/or Ab vag bleeding
mc presentation for vulvar CA
vaginal pruritus
mc type of vulvar CA
squamous
-HPV
MC types for each CA
- breast
- ovarian
- cervical
- endometrial
- vaginal
- vulvar
breast= ductal ovarian=epithelial cervical=squamous endometrial=adenocarcinoma vaginal and vulvar=squamous DES EXPOSURE=adenocarcinoma
should pt with breast abscess cont to BF on affected side?
yes—— even in the setting of I&D
a 32-year-old lactating female with breast pain, swelling, fever, chills, and a fluctuant mass of her left breast. The area directly above the lesion is warm, erythematous and tender to touch.
breast abscess
**progression from mastitis—s/s are same but addition of localized mass + systemic s/s infection
tx for breast abscess
I&D
anti-staph abx
-Nafcillin/oxacillin IV or cefazolin + metronidazole
alt is vanco
dicloxacillin
- cephalexin
- clinda
- MRSA=bactrim or clinda
The most common type of noncancerous breast tumor that most often occurs in young women
firboadenoma
dx for fibroandeoma
diagnostic mammo + US
-if indeterminant– FNA + pathology
<25 should be biopsied
a 42-year-old woman with breast masses that changes in size, especially during her menstrual cycles. These masses are usually painful and pain radiates into the axillae. She reports that her breasts often feel full and heavy. Occasionally she has a small amount of greenish-brown nipple discharge. An ultrasound exam shows cystic masses within the breasts.
fibrocystic dz
multiple bilateral breast masses
fibrocystic
solitary mobile mass of breast
fibroadenoma
breast cyst aspiration shows straw colored fluid with no blood
fibrocystic
tx for fibrocystic
nsaids heat ice supporitve bra, decr caffeienc, fat, chocolate
OCPS
a 45-year-old female complaining of pressure in the pelvis and vagina along with discomfort when straining. She also feels that her bladder hasn’t fully emptied after urinating.
cystocele
dx for cystocele
POP-Q
-pelvic organ prolapse quantification—- mesured extent and location of defects
US or MRI
prophlaxs for cystocele
kegels
estrogen tx after menopause
a 50-year-old female with pelvic pressure reports and a sensation of a mass present in the vagina. She reports chronic constipation and a sensation that the rectum is not completely emptied following a bowel movement. Occasionally, she experiences episodes of fecal incontinence.
rectocele
pelvic pressure + bowels s/s
rectocele
sudden onset of sharp and usually unilateral lower abdominal pain,
ovarian torsion
70% also have N/V
dx test of choice for ovarian torsion
gold standard
abd US with doppler flow
GS= laparoscopy
a 63-year-old, G5P5, Hispanic woman with a three-day history of increased pelvic pressure and a “bulge” that is felt in her vagina when she coughs. Additionally, she complains of incomplete emptying of her bladder, constipation and has noticed a recent worsening of lower back pain.
uterine prolapse
**many kids is key
how do OCPS prevent ovulation
inhibits the mid cycle LH surge
thicken cervical mucus
thins endometrium
what are OCPS protective factor for?
ovarian and endometrial CA
acne
contras to OCPS
> 35 + smoker
hx of blood clots, BCA, migraines WITH aura
a 24-year-old nulligravid woman comes to your office with an 18-month history of painful intercourse, difficulty defecating, and dysmenorrhea. These symptoms are cyclical and come and go with her menses. Her menses are regular and heavy, requiring 10 to 15 thick pads on the days of heaviest flow. She denies ever being diagnosed with a sexually transmitted infection (STI). She and her husband have been engaging in regular intercourse without contraception for 1 year in an attempt to conceive. On pelvic examination, you find a normal-sized, immobile, retroverted uterus with nodularity and tenderness on palpation of the uterosacral ligaments.
endometriosis
mc sites for endometriosis tissue to be implanted
ovaries
FTs
cul-de-sac
uterosacral ligaments
dyspareunia define
painful sex
dyscheciz define
difficult defacating
dysmenorrhea define
painful periiods
three Ds for endometriosis
dyschezia
dysmenorrhea
dyspareunia
def dx for endometriosis
laparoscopy
Imaging tests (eg, ultrasonography, barium enema, IV urography, CT, MRI) are not specific or adequate for diagnosis
fixed and retroverted uterus
endometriosis
tx for endometriosis
-1st
nsaids OCPs Danazol (steroid)----inhibs mid cycle surge of FSH + LH Depo shot GnRH Surigcal
FIRST LINE=OCPs
- estrogen does the ovulation suppresion
- progesterone analogs will inhibit growth of endometrium
difference b/w primary and secondary infertility
primary= infertility in absence of previous pregnancy
secon=infert after a previous pregnancy
mcc of infertility
annovulation—-amenorrhea and abnormal periods
what does it mean when a luteal phase progeterone level is less than 3
she did not ovulate
if PCOS is the cause of infertility what can we give pt to help with ovulation
metformin—increases ovulation
tx for hyperprolactinemia causing infertility
bromocpriptine
fixed and retroverted uterus
endometriosis
mc benign GYN tumor
leiomas
list types of leiomas
-which is MC
intramural–within uterine wall (MC)
submucosal–projects into uterine cavity
subserosal–projects into uterine cavity–can be pedunculated
parasitic–
a 39-year-old African American woman with abnormally heavy menstrual bleeding along with increased pelvic pressure. She denies pain and is not using any hormonal contraception. She uses multiple sanitary pads per day. On pelvic examination, there is an enlarged uterus with asymmetric contours. The uterus is non-tender to palpation.
uterine fibroids aka leiomyoma
inital TOC for leiomyomas
transvaginal US
focal heterogenic hypoechoic mass of masses with shadowing on transvag US
fibroids
tx for firboids
- medical
- NSAIDs
- OCPS
- Danazol
- Leuprolide– can be used to shrink before surgery - DEFINITIVE:
- myomectomy–to preserve fertility
- endometrial ablation
- Hyerestcomy— mc
what type of ovarican cysts is mc
follicular—follicle fails o rupture and continues to grow
22-year-old nulligravida presents with pelvic pain and irregular menstrual bleeding. She denies sexual activity, and her β-hCG urine test is negative. She has never been on oral contraceptives. On pelvic examination, unilateral tenderness on the left side and a palpable cystic mass approximately 4 to 5 cm in size are present.
ovarain cyst
list three types of functional ovarian cysts
follicular– MC–dominat follicle fails to rupture
corpus luteum—– usually 2-3 cm, can get as big as 10 cm–dominant follicle ruptures but closes again and doesnt dissolve
Theca Lutein cysts– overstimulation of HCG prod by placenta so only seen in preggo
list non-functional ovarian cysts
also called neoplastic cysts
- PCOS
- endometriomas aka chocolate cysts
- dermoid cysts aka teratomas
- ovarian serious and mucinous cystadenoma
US shows a cyst that is smooth, thin walled and unilocular
follicular
US shows a yst that is complex, thick walled and with peripheral vascularity
corpus luteum
anechoic unilocular fluid filled cysts are low or hgh risk for malignancy
low
solid, nodular, thick septation cysts are low or high risk for malignancy
high
what labs to order if concerned baout ovarian CA
ca-125
beta HCG
alpha-fetoprotein
three main complications from ovarian cysts
- hemorrhagic
- mc with follicular and coprus luteum cysts - rupture
- releases contents into peritoneal cavity
- mc after sex - torsion
- ovary twists around suspensory ligaments
- cuts off blood suppy to the ovary
- this is a risk if cyst is >5 cm
waxing and waning pain
ovarian torsion
+/- N/V
low grade fever
first imaging choice for ovarain torsion
US
CT is more $$$$$$ and will give same results as US
simple cyst in a premenopausal woman is b/w 5-7 cm what is tx
follow up yearly
simple cyst grearer than 7cm tx/plan
further imaging with MRI
surgical assessment
rophylactic antibiotic therapy for rape victim
- Rocephin 250 mg followed by PO doxy twice daily x7 days
- tetanus toxoid if indicated
- emergency contraception
- councesling
list typses of incontinence
urge
stress
ovrflow
functional
mixed
urge incontinence
detrusor overactivity
-frequent small amts of urine
MC in old,
-assoc with UTI
***at night + disrupts sleep
tx=bladder training exercised
if unsuccessful
1. oxybutin—– anticholingeric
2. imipramine–TCA
stress incontienence
pelvic floor weakness
-urine leaks due to abrupt incr in intra abd pressure—- cough, sneeze, laugh, bending or lifting
- **multiple deliveries
- **NO URINE LOSS AT NIGHT
tx
- kegel
- vaginal estrogen
- pessary
- surgery
urine loss at night
urge incontience
overflow incontience
impaired detrusor contractility
-urinary retention leads to bladder distention and overflow of urine
- common in DM and neurlogic disordrs
- elevated postvoid residual volume*******
tx
- self cath best one
- MEDS
1. cholinergic agents— bethanechol to incr bladder contractions
2. alpha blockers to decr sphincter resistance
functional incontiencne
normal voiding systems but who have difficulty reaching toilet bc of physical or mental disability
mc type of incontience
mixed
urge + stress
tx=life style mods
pelvic flor exercies
