Gyn Flashcards
Name most common etiologic causes of 2e amenorrhea (2)
- Ovarian causes—40%
- Hypothalamic causes—35%
Describe tx: Primary Ovarian Insufficiency (3)
- Patient education (diagnosis)
- Hormone replacement therapy until age of menopause
- Maintain age-appropriate bone density
- Cardiovascular health
- Yearly F/U of HRT, TSH levels; bone scan as needed
Describe tx: Primary dysmenorrhea (3)
- NSAIDs
- Hormonal suppression (OCPs, Depo-Provera, Mirena)
- Nonpharmacologic (i.e., physical exercise, topical heat, high- frequency transcutaneous electrical nerve stimulation (TENS))
Describe steps for primary amenorrhea (3)
- B-hcg
- Pelvic ultrasound
- Serum levels of FSH
In amenorrhea, if present + high FSH, think of what? (2)
- Gonadal dysgenesis: Turner Syndrome, Swyer syndrome
- 17 alpha hydroxylase deficiency
Describe: Gonadal dysgenesis (3)
- Present streak gonads, functionless, fribrous tissue, can’t respond to FSH stimulation
- Can’t produce sex hormones -> no 2e female sex characteristics
- Associated with Turner’s syndrome and Swyer syndrome
How to dx: Turner’s syndrome
- Karyotype: 45X or Mosaic (45X + 46XX OR 45X + 46XY)
Describe presentation: Turner’s syndrome (6)
- Short stature
- Widely spaced nipples
- Low-set ears
- Wide or webbed neck
- Broad chest
- Arms turn outward
Describe tx: Turner’s syndrome (3)
- Streak gonads surgically removed
- Estrogen therapy (low doses) + progesterone (2 yrs after) 10 days per month to induce menstrual bleeding
- Growth hormone therapy
Describe lab: 17 alpha hydroxylase defiency (3)
- high progesterone
- high deoxycorticosterone
- serum 17-alpha-hydroprogesterone < 0.2 ng/ml
Describe tx: 17 alpha hydroxylase defiency (3)
- Exogenous glucocorticoid replacement therapy (hydrocortisone or dexamethasone)
- Mineralocorticoid receptor blockade (ex: spironolactone)
- Low-dose estrogen + progestin (2 yrs later)
DDX of uterus on pelvic ultrasound + low FSH (2)
hypothalamic or pituitary disorder
- congenital GnRH deficiency (ex: Kallman syndrome)
- constitutional delay of puberty
Name DDX of anatomic abnormality in pelvic ultrasound (for amenorrhea) (2)
- Outflow tract obstruction -> surgery
- Transverse septum (inside vagina)
- Imperforate hymen
- Absent uterus
Name DDX: Absent uterus (3)
- Mullerian agenesis (46XX - genetically female)
- Complete androgen insensitivity syndrome (46 XY)
- 5-alpha reductase deficiency (46 XY)
How to differenciate DDX: Absent uterus (2)
Karyotype + serum testosterone
- Mullerian agenesis (46XX - genetically female)
- Complete androgen insensitivity syndrome (46 XY)
- 5-alpha reductase deficiency (46 XY)
Describe sx: Mullerian agenesis (5)
- 46XX - genetically female
- Short vagina
- absent/rudimentary and obstructed uterus
- ovaries N, breast N
- Development/FSH/Testosterone
Describe tx: Mullerian agenesis (3)
- Psychological counceling
- Surgical creation of vagina + vaginal dilators
- Possible to have children via assisted reproduction techniques (egg harvesting, in vitro fertilization, surrogate pregnancy) OR uterus transplantation
Describe: Complete androgen insensitivity syndrome (5)
- Defective receptor, Testosterone N
- No tissues response:
- Female external genatalia
- Sparce body hair
- Almost no pubertal acne
- Well-developed breats
Describe management: Complete androgen insensitivity syndrome (3)
- Testes in abdomen/pelvis/inguinal canal -> high risk of cancer -> surgical removal after puberty
- Counceling
- Vaginal surgery/dilation
Describe: 5-alpha reductase deficiency (3)
- Do not undergo DHT-dependent masculinization during fetal development
- at birth: female or ambiguous external genitalia
- at puberty: testosterone levels rise ++ -> male-pattern hair growth, acne, muscle mass, deeper voice
Describe management: 5-alpha reductase deficiency (2)
- Counceling
- DHT therapy (if male) or estrogen therapy (if female)
Name initial lab studies for secondary amenorrhea (5)
- FSH
- Prolactin
- Estradiol
- TSH
- If signs of virilization -> testosterone
Descrive tx, dx: Prolactinoma (2)
- IRM
- Tx: Cabergoline (Dopamine agonist) -> inhibits prolactine secretion
Describe signs and tx: Polycystic ovarian syndrome (PCOS) (6)
- Lab: Testosterone > 60 ng/dL + Signs of virilization
- Oligomenorrhea or amenorrhea
- Obesity, insulin resistance -> metformin therapy, weight loss
- Hyperandrogenism -> OCP (if no desire to be pregnant), ideally progestin w/ antiandrogen properties (ex: drospirenone) -
- spironolactone if OCP C-I
- If desire pregnancy -> clomiphene citrate
- If androgen levels +++ > 150 ng/dL -> CT Scan abdomen and pelvis to look for androgen secreting tumours
In secondary amenorrhea, what to think of if normal TSH/prolactin/androgen and:
- High FSH + low estradiol in female < 40 years old
Primary ovarian failure
Describe sx: Primary ovarian failure (2)
- Hot flashes
- Vaginal dryness
Describe tx: Primary ovarian failure (2)
Tx: Hormone replacement therapy
- Estrogen: to decrease risk osteoporosis and Cardiovasc disease
- Progesterone: to decrease endometrial hyperplasia and cancer
In secondary amenorrhea, what to think of if normal TSH/prolactin/androgen and:
- Low FSH + low estradiol in female
- Functional hypothalamic amenorrhea
- Systemic illness (ex: DB1, celiac disease)
- Large tumor that compresses FSH and LH secreting neurones -> IRM
- Pituitary gland
- CNS
In secondary amenorrhea, what to think of if normal TSH/prolactin/androgen and:
- FSH and estradiol normal
Uterus is not responding
- Asherman syndrome: scar tissue in uterine cavity
Describe dx: Asherman syndrome (2)
- golden standard: hysteroscope
- 10-day medroxyprogesterone test to access uterine function
- if bleeding -> healthy uterus
- if no bleeding -> scar tissue in uterine cavity -> hysterosalpingogram or hysteroscopy
What’s the tx of primary dysmenorrhea (2)
- Non pharmacological treatment:
- Reassurance
- Topical heat
- Physical exercise
- • High-frequency TENS
- OCP or NSAIDs
What’s the tx of leiomyomas (2)
Myomectomy or uterine artery embolization
Describe tx: PMS and PMDD
- Non pharmacologic
- Patient education
- Diet: avoid; Na+, simple sugars, caffeine, alcohol
- Supplements—CaCO3, Mg2+, Vit E
- Exercise
- Psychotherapy (CBT)
- Relaxation therapy
- Pharmacological
- NSAIDS (ex: naproxen)
- SSRIs (citalopram, fluoxetine, sertraline)
- Combined OCPs
- Spironolactone (during luteal phase only)
Name C-I for OCPs (14)
- < 6 wk postpartum if breast-feeding
- Breast CA (current)
- Smoker > 35 y.o. (> 15 cigarette/d)
- Uncontrolled HTN (systolic > 160 mm Hg or diastolic > 100 mm Hg
- Venous thromboembolism (current or Hx)
- Ischemic heart disease
- Valvular heart disease (PulmHTN, A b, Hx of SBE)
- Diabetes with retinopathy/nephropathy/neuropathy
- Migraine headaches with focal neurologic Sx
- Severe cirrhoris
- Liver tumor (adenoma or hepatoma)
- Undiagnosed vaginal bleeding
- Known thrombophilia
- Known or suspected pregnancy
Name progestin only OCPs (2)
- Progestin-only pill
- Depo-Provera injection
Name side effects: OCP (5)
Most resolve in first 3 cycles:
- Breast tenderness
- Nausea
- Irregular bleeding
- Chloasma
- No evidence for weight gain and/ or mood Ds
Name criterias for Good Candidates for p Only (8)
- CI or sensitivity to E
- > 35 yr and smoker
- Migraine headaches
- Breast-feeding
- Endometriosis
- Sickle cell disease
- Anticonvulsant Rx
- Difficulty complying with daily pill (for DMPA)
Name side effects: Copper IUD (3)
- Pelvic pain
- ↑ Menstrual ow
- Spotting
Name side effects: Levonorgestrel-releasing intrauterine system (LNG-IUS) (4)
- Pelvic pain
- Depression, headache, acne, breast tenderness (maximal in rst 3 mo of use)
- ↑ Menstrual flow or spotting in first few months then ↓ bleeding
- Functional cysts
Name benefits: Levonorgestrel-releasing intrauterine system (LNG-IUS) (4)
- Decreased menstrual flow (in over 75% of patients)
- Decreased endometrial CA
- Improved dysmenorrhea
- Prevents endometrial hyperplasia in women taking tamoxifen
Name: Emergency Contraceptions (EC) (3)
- Plan B (up to 5 days): Levonorgestrel-only method (2 doses 12h apart)
- Yuzpe Method (up to 5 days): Oral administration of 2 doses of 100 mg EE and 500 mg levonorgestrel 12 h apart
- Postcoital Insertion of Copper IUD: Can be placed up to 7 d after intercourse to prevent conception and left in place to provide ongoing contraception
Describe management: Missed abortion (3)
- D&C
- Misoprostol
- Expectant managemen
Describe: Complete abortion (1)
Spontaneous expulsion of all fetal and placental tissue before 20 wk of gestation
Describe management: Complete abortion (2)
- Ensure hemodynamic stability
- Supportive
Describe management: Incomplete abortion (3)
- D&C
- Misoprostol
Incomplete expulsion of the products of conception before 20 wk of gestation
Describe management: Threatened abortion (1)
Expectant management
Describe management: Inevitable abortion (3)
- D&C
- Misoprostol
- Expectant management
Differenciate:
- Missed abortion
- Complete abortion
- Incomplete abortion
-
Missed abortion:
- Death of the fetus occurring in utero with retention of the pregnancy
-
Complete abortion:
- Spontaneous expulsion of all fetal and placental tissue before 20 wk of gestation
-
Incomplete abortion:
- Incomplete expulsion of the products of conception before 20 wk of gestation
Differenciate:
- Threatened abortion
- Inevitable abortion
- Threatened abortion:
- Bleeding occurring during the first 20 wk of gestation without the passage of tissue or cervical dilation.
- In the presence of fetal cardiac activity, a high proportion of pregnancies continue.
- Inevitable abortion:
- Bleeding ± ROM
- Cramping
- Dilation of the cervix
Describe: Septic abortion (1)
- Infection of retained products of conception by S. aureus, GN bacilli, or gram positive cocci.
Describe: Lab investigations for recurrent miscarriages
TIE GAME
- Thrombophilic
- Immunologic: Antiphospholipid antibodies
- Endocrine: Fasting glucose or Hb(A1c), TSH (hypothyroidism), PRL
- Genetic/chromosomal: Cytogenetic analysis of both partner
- Anatomic: Hysteroscopy, Hysterosalpingography
- Environmental/toxicologic
Name methods of abortion (5)
First trimester:
- Vacuum curettage
- Misoprostol
Second trimesteR:
- D&E
- Labor induction
- Oxytocin
Describe labs of menopause (4)
- ↑ Serum FSH
- ↑ Serum LH
- ↓ Serum estradiol
- ↑ Vaginal pH > 6
Name: Indication for Spine XR in Postmenopausal women (3)
- Historic height loss > 6cm
- Prospective height loss > 2 cm (↑kyphosis)
- Acute, incapacitating back pain: to R/O vertebral #
Describe the management of Vasomotor Sx in menopause (5)
Resolves within 5 yr
- Reassurance and lifestyle Ds: Use fans to keep cool, dress in layers, quit smoking, exercise, weight loss if overweight, avoid hot food, caffeine, and EtOH
- Alternative medicine: Evidence lacking for long-term safety/efficacy for black cohosh, dietary soy, phytoestrogens clover, Vit E, kava, evening primrose oil, Chinese herbs
- Nonhormonal Rx: venlafaxine/SSRIs, gabapentin, clonidine, bellergal
- Nonestrogenic hormonal Rx: Ps
- Systemic HRT: Estrogen therapy (ET), estrogen/progesterone therapy (EPT)
Describe the management of Urogenital Sx in menopause (3)
Generally, Worsen with age
- Reassurance, patient education, and smoking cessation
- Vaginal moisturizer (polycarbophil gel/Replens)
- Local ET: intravaginal E is the Rx of choice for isolated vaginal Sx (e.g., Vagifem). At recommended dose/frequency do not need to add P
Describe the management of Osteoporosis Sx in menopause (7)
Generally Worsens with age
- Patient education: exercise, healthy diet, and smoking cessation
- Osteoporosis RF assessment
- Vit D (800 IU/d) and Ca2+ supplementation
- Bisphosphonates (alendronate, risedronate)
- Selective estrogen receptor modulators (SERMs)
- Calcitonin: approved for Rx, not prevention of osteoporosis
- E
Name C-I to estrogen therapy (4)
CULT
- Cancer (breast or uterine)
- Undx vaginal bleeding
- Liver disease (acute)
- Thromboembolic disease (active)
Name C-I to progesterone therapy (4)
PUB
- Pregnancy
- Undx vaginal bleeding
- Breast CA
Describe presentation: Bacterial vaginosis (5)
- odor
- Amsel criteria (3 of 4)
- Thin homogeneous vaginal discharge
- Clue cells on N/S wet mount or Gram stain
- Positive Whiff test on KOH wet mount
- Vaginal pH > 4.5
Describe tx: Bacterial vaginosis (2)
- Metronidazole
- Clindamycin
Describe: Vaginal candidiasis (6)
- pruritus
- edema, fissures excoriations, dysuria
- thick flocculent white discharge
- DX criteria:
- Normal vaginal pH (4–4.5)
- Hyphae and buds on saline wet mount (yeast)
- Positive yeast culture from the vagina
Describe tx: Vaginal candidiasis (2)
- Fluconazole
- Clotrimazole
Describe: Vaginal trichomoniasis (6)
- Dyspareunia, pruritus
- « Strawberry cervix »
- Dx criteria:
- Trichomonas (motile agellum) seen on N/S wet mount
- High number of Polymorphonuclear leukocytes (PMNs) on saline microscopy
- Positive culture
- Vaginal pH 5 – 6
Describe tx: Vaginal trichomoniasis (2)
- Metronidazole
- Tx partner
Describe tx: Gonorrhea (5)
- (Cefixime or Ceftriaxone) + (Azithromycin or Doxycycline)
- Alternative: Azithromycin or Spectinomycin
Co-treatment for chlamydia
Describe tx: Chlamydia (3)
- Doxycycline
- Azithromycin
- Alternative: Erythromycin
Name indications for Repeat screening for Gonorrhea (2)
- All cases 6 mo post-Rx
- Test of cure with culture 3 to 7 d after initiation of treatment when:
- gono pharyngeal infx
- tx with nonrec regimen
- suspected tx failure
- uncertain compliance
- reexposure to untreated partner
- PID or disseminated infx
- pregnancy
Name indications for repeat testing of C.TRACHOMATIS (2)
- All cases 6 mo post-Rx
-
Test of cure in 3 to 4 wk recommended when:
- Uncertain compliance
- non recommended regimen
- Pregnancy
Describe: Syphilis (4)
- 1°:
- painless chancre (genital ulcer), regional LAD
- Resolves in 2-8 wk
- 2°:
- symmetric maculopapular rash (palms and soles)
- fever, malaise, LAD, mucous lesions, condyloma lata, alopecia, meningitis, headaches, uveitis, retinitis
- Latent: axp
- 3°: aortic aneurysm, aortic regurgitation, coronary artery ostial stenosis
- Neurosyphilis (form of 3°): Argyll-Robertson pupil
- Gumma (form of 3°): tissue destruction in any organ.
Describe tx: Syphilis (3)
- 1°, 2°, early latent: Benzathine Penicillin G, Doxycycline
- Neurosyphilis: Penicillin G
- Gumma: Benzathine Penicillin G
Describe tx: Herpes (2)
- Acyclovir
- Famciclovir
Describe: Chancroid (3)
- Painful genital ulcers with granulomatous bases
- H. ducreyi
- May progress to inguinal ulcers, painful inguinal LAD
Describe tx: Chancroid (4)
- Ciprofloxacin
- Eryhtromycin
- Azithromycin
- Ceftriaxone
Must empirically treat all individuals with sexual exposure in the last 2 wk from onset
Describe: HPV Condyloma Acuminata (2)
- Frequently asx
- Lesion: external genital warts (condyloma acuminata)—multifocal cauli ower-like exophytic fronds → ± pruritus or local discharge
Describe tx: HPV Condyloma Acuminata (7)
- Patient applied:
- Imiquimod
- Podophyllotoxin
- Provider-based:
- Cryotherapy
- Bi- or trichloroacetic acid
- CO2 laser ablation, excision
- Extensive or resistant lesions:
- Excision with electrosurgery
- CO2 laser removal
Describe: PID Minimum Triad
Lower abdo pain + one of the following:
- Adnexal tenderness
- Cervical motion tenderness
- Utrine tenderness
Describe: Fitz-Hugh-Curtis Syndrome
Perihepatitis resulting in adhesions between the liver capsule and the abdo wall. Perihepatitis resolves with Rx of PID.
Describe inpatient tx: PID (4)
- Cefotetan + doxycycline then continue with doxycycline
- Cefoxitin + doxycycline, then continue with doxycycline
- Clindamycin + gentamicin then doxycycline or clindamycin
Note: consider adding metronidazole
Describe outpatient tx: PID (4)
- Ceftriaxone + (doxycycline or azithromycin)
- Cefixime + (doxycycline or azithromycin)
- Levofloxacin
Note: consider adding metronidazole
Name gold standard dx: PID
Laparoscopy
Describe population screening (3)
- There are slight differences among each province
- Should begin within 3 yr of initiating sexual activity or over age 21, whichever is later
- Should be conducted annually until three consecutive negative Pap tests
Describe: Approach to cervical CA screening (Figure)
- Unsatisfactory/inadequate sample
- Normal
- Benign atypia (infection, reactive Ds)
- Atypical Squamous Cells - Uncertain Significance (ASCUS)
- Low-grade Squamous Intraepithelial Lesion (LSIL)
- Colposcopy
- Atypical Glandular Cells of Uncertain Signifi- cance (AGUS)
- High-grade Squamous Intraepithelial Lesion (HSIL)
- Invasive cervical cancer (rarely)
- Carcinoma in situ (CIS)
- Atypical Squamous Cells - Possible HSIL (ASC-H)
- Cervical Intraepithelial Neoplasia (CIN)
_______
- If these Pap tests are normal → continue screening q2–3 yr
- Should continue until the age of 69 yr, if there has been adequate screening over the past 10 yr
- If there has been no Pap smear for 5 yr, begin annual Pap tests until three consecutive negative Pap tests, then should continue q2–3 yr
- Discontinue screening at age 70 if > 3 normal Pap tests in the last 10 yr
Describe HPV screening for:
- HIV/immunocompromised
- Total hysterectomy
- Subtotal hysterectomy
- Pregnancy
- Women who have sex with women
- HIV/immunocompromised: annual screening.
- Discontinue screening for women who have undergone a total hysterectomy for benign reasons and no Hx of cervical dysplasia or HPV.
- Subtotal hysterectomy (i.e., cervix intact): continue routine screening.
- Screening frequency in pregnancy is the same as in nonpregnant women.
- Women who have sex with women should follow the same screening protocol as women who have sex with men.
Describe staging and rx of cervical CA
Describe: Approach to the management of ovarian cysts (Figure)
Describe: Approach to the management of uterine leiomyomas (Figure)
Describe: Characteristics of benign vers s ma ignant ovarian masses
Name first choice imagerie for pelvic masses (1)
U/S
Name lab markers for ovarian masses (4)
- CA-125 (N < 35 U/mL): ovarian tumors
- AFP (N < 5.4 ng/mL): Germ cell tumors (endodermal sinus), dermoids, pregnancy, Hepatocellular Carcinoma
- LDH (N < 250 U/L): Dysgerminomas
- hCG (N < 5 mlU/mL): germ cell tumors GTD (choriocarcinoma), pregnancy, marijuana
Describe PHARMACO tx of chronic pelvic pain (5)
-
1. Analgesics:
- First line - NSAIDs (ibuprofen, ASA, naproxen)
- Second-line - opioids (avoid long-term use)
- 2. Combined OCPs
- 3. GnRH agonists (i.e., leuprolide/Lupron) ± add back Estrogen
- 4. Progestins (i.e., MPA suspension/Depo Provera/Visanne)
- Adjuncts:
- ± SSRIs (fluoxetine, paroxetine, or sertraline)
- ± Neuro modulators (gabapentin, amitriptyline or nortriptyline)
- ± Trigger point injections
- ± Peripheral nerve blocks
Describe SURGERY tx of chronic pelvic pain (5)
If poor response to other tx
- Laparoscopic laser ablation
- Laparoscopic adhesiolysis
- Presacral neurectomy (superior hypogastric plexus excision)
Name common locations of ectopic pregnancy (3)
- Ampullary
- Isthmic
- Fimbrial
Describe the approach to ectopic pregnancy (Figure)
Describe the management of ectopic pregnancy (2)
- Methotrexate (MTX)
- Monitoring: serial (weekly) b-hCG levels until undetectable
- Laparoscopic surgery or laparotomy. Indications:
- Failed or contraindication to MTX Rx
- Previous EP in same fallopian tube
Name C-I to methotrexate (5)
- Breast-feeding
- Chronic liver disease (alcoholism, fatty liver, etc.)
- Known sensitivity to MTX
- Blood dyscrasias (i.e., thrombocytopenia, significant anemia)
- Hepatic, renal, or hematologic dysfunction
Describe investigations for prolapse (4)
- No specific tests for prolapse
- Imaging not usually necessary (unless procidentia to R/O urinary retention)
- Biopsy all suspicious persistent vulvovaginal lesions
- Cystocele evaluation:
- a. UTI screen
- b. Postvoid residual (PVR)
- • ± Refer to gynecologist for urodynamic testing
Describe pessaries for prolapse (5)
- Device placed in vagina to provide support and/or fill space
- Support pessaries (the ring) for earlier stages (II and III)
- Space-filling pessaries (Gellhorn) for more advanced prolapse
- Ideally changed and rinsed weekly with F/U q3mo
- Lubricants or vaginal E (if atrophy) is often employed with pessaries in postmenopausal women
Name indications for surgery for prolapse (4)
- not recommended if asx
- Advanced and asx: must assess efficiency of bladder emptying due to risk for complications of urinary retention (recurrent UTI, urosepsis) and assess exposed vaginal epithelium for erosions at risk for infection
- More frequent F/U (q3 mo) if decided against surgery
- Patient fails conservative management, is unable or unwilling to use pessary, or desires surgical management
Describe the management of OVULATORY DYSFUNCTION in infertility (4)
- (A) Anovulation:
- Clomiphene citrate (Clomid)
- Gonadotrophins (hMG) ± IUI
- Lifestyle/weight ∆ ± metformin (if PCOS)
- IVF/intra-cytoplasmic sperm injection
- Donor oocytes
- (B) Hyperprolactemia: Bromocriptine (dopamine agonist)
- (C) Thyroid dysfunction
- (D) Functional hypothalamic amenorrhea: (appropriate behavioral or psychologic interventions)
