Gyn 2 Quiz Flashcards
What 3 conditions constitute primary amenorrhea?
lack of menarche at age of 16, >2 years after onset of puberty or no signs of puberty by age 14
Define secondary amenorrhea.
menses cease >3-6 and the woman is not pg, lactating or menopausal
What are the most common cause of anovulatory amenorrhea?
functional causes (endocrine or genetic)
What is generally occurring with ovulatory amenorrhea?
anatomical genital abnormality with normal hormonal function
Give 3 examples of acquired uterine abnormalities causing ovulatory amenorrhea?
asherman’s syndrom
endometrial tb
obstructive fibroids and polyps
yes
Give 3 examples of congenital genital abnormalities that may result in ovulatory amenorrhea?
cervical stenosis
imperforate hymen
transverse vaginal septum
Give 4 examples of hypothalamic dysfunction that may result in anovulatory amenorrhea?
anorexia nervosa
excessive exercise
hypothalamic chronic anovulation
chronic undernutrition
Give 2 examples of pitutary dysfunction that may result in anovulatory amenorrhea?
galactorrhea (hyperprolactinemia)
benign pituitary adenoma
What are 3 potential disorders involving ovarian failure/dysfunction that may result in anovulatory amenorrhea?
autoimmune d/o
chemo
viral infection
What are 3 potential disorders involving endocrine dysfunction that may result in anovulatory amenorrhea?
PCOS
Cushing’s Syndrome
Hyper/hypothyroidism
What are some signs during hx taking that might suggest hypothalamic anovulation?
change in weight
dietary deficiencies
excessive exercise
environmental stress
What, in hx, might make you think Asherman’s?
Hx of D&C or uterine surgery
meds that might cause virilism or galactorrhea
What are some hx signs of endocrine d/o?
thyroid sxs
virilization: hirsutism, temporal balding, deepening voice
sxs of estrogen deficiency: hot flashes, vag dryness
obesity in hirsute women (PCOS)
What are 4 PEs you would want to do with amenorrhea?
vitals
thyroid
breast exam (looking for nipple d/c)
pelvic (looking for structural abnormalities)
What are some red flags for amenorrhea?
delayed puberty
virilization
visual field defects (prolactinoma)
What are the top three labs to run when someone presents with amenorrhea?
pregnancy test
thyroid study
Prolactin (increase may indicate pituitary tumor)
What are the most common causes of primary amenorrhea?
physiological delay of puberty
functional hypothalamic chronic anovulation
Name 5 common causes of secondary amenorrhea?
pregnancy PCOS Obesity Thyroid dys. hypothalamic dys.
If your pt. is taking drugs that affect dopamine, what might be the possible cause of her amenorrhea?
hyperporlactinemia
If your pt. is taking hormones and/or is on drugs that affect the balance of estrogenic/androgenic effects, what might be the possible cause of her amenorrhea? You may also see signs of virilization with this.
drug-induced virilization
If someone has high BMI (>30) and virilization, what might be the cause of her amenorrhea?
PCOS
Estrogen excess
If someone has low BMI (<18.5) and has risk factors such as a chronic d/o, dieting or an eating d/o, what might be the cause of her amenorrhea?
functional hypothalamic anovulation secondary to eating d/o
If your pt is of short stature and has a webbed neck, primary amenorrhea and widely spaced nipples, what might you consider as the cause?
turner’s syndrome (rare)
Your pt has warm, moist skin, tachycardia and a tremor, what might you be thinking is the cause of her amenorrhea?
hyperthyroidism
Your pt. has course, thick skin, loss of eyebrow hair, bradycardia, delayed DRTs, weight gain and constipation along with her amenorrhea. what might be the cause?
hypothyroidism
Pt. present with acne and signs of virilization along with amenorrhea. What might be the cause?
Androgen excess due to PCOS, an androgen secreting tumor, cushing’s syndrome, adrenal virilism or drugs
You notice striae, moon face, tuncal obesity and thin extremities in your pt. with amenorrhea. What might be the cause?
Cushing’s Syndrome
Your patient has acanthosis nigricans, amenorrhea, virilization and obesity. What might be the cause?
PCOS
You notice vitiligo or hyperpigmentation of the palm as well as orthostatic hypotension in your patient with amenorrhea. What does this pattern suggest?
Addison’s dz
A patient has amenorrhea and sxs of estrogen deficiency (hot flashes, night sweats, etc) and has risk factors such as oophorectomy, chemo or pelvic irradiation. What might be going on?
premature ovarian failure
A young woman comes in with primary amenorrhea, hirsuitism and virilism. What are some possibilities for the cause?
androgen excess due to hermaphroditism, an androgen-secreting tumor, adrenal virilism, gonadal dysgenesis.
A woman comes in with primary amenorrhea, enlarged ovaries, hirsuitism and virilism. What are some possibilities for the cause?
androgen excess due to 17-hydroxylase deficiency
PCOS
androgen-secreting ovarian tumor
A pt. has amenorrhea, galactorrhea, nocturnal ha and visual field defects. What might be the cause.
hyperprolactinemia
pituitary tumor
A baby has fused labia and clitoral enlargement at birth. What might be the cause?
androgen exposure during the 1st trimester
drug-induced virilization
What is the most common population to get DUS?
women >45 or in puberty
What percentage of cases of DUS are anovulatory?
90%
What is the classic presentation of DUS?
polymenorrhea
menorrhagia
metrorrhagia
What is the difference in presentation between anovulatory DUB and ovulatory DUB?
anovulatory tends to occur at unpredictable times and not related to the menstrual cycle
ovulatory tends to cause excessive bleeding during menstrual cycle and has signs of ovulation
What are some things you want to r/o with DUB in your hx/PE/Dx?
pregnancy anemia coagulation d/o thyroid problems structural abnormalities hormone imbalance
In which patients would you want to r/o hyperplasia with EMB?
women >35 obese PCOS DM HTN endometrial thickness >4mm
When would you run a GC/CT in the case of DUB?
if PID endometritis or cervicitis is suspected.
What is the pattern and quality of pain with dysmenorrhea?
occurs with or before menses by 1-3 days
peaks 24 hours after onset of menses
subsides in 2-3 days
sharp or cramping, throbbing or dull, constant ache
Where does the pain of dysmenorrhea radiate and what are some concomitant sxs?
radiates to the legs
HA, N/D, constipation, LBP, urinary frequency
When does primary dysmenorrhea usually begin?
in adolescence
When does secondary dysmenorrhea usually begin?
in adulthood
What is the difference in cause for primary vs secondary dysmenorrhea?
primary is not due to underlying gyn structural d/o.
(increased uterine contractions, passage of tissue through os, narrow os, lack of exercise)
secondary is usually due to underlying pelvic AbN (endometriosis, fibroids, adenomyosis)
What are some good questions to ask to differentiate btw primary and secondary dysmenorrhea?
age of onset nature and severity factors that relieve/worsen degree of disruption of daily life presence of pelvic pain unrelated to menses effects of contraceptive on pain
red flags: dysmenorrhea
new/sudden onset of pain
unremitting pain
fever
vaginal d/c
What are the first tests to do for dysmenorrhea? And what if those come out inconclusive?
Pg, TVUS, culture
then, SIS or HSG
then, MRI
if all of above inconclusive….hysteroscopy
What is the pattern of PMDD?
sever PMS sxs occurring only during the 2nd half of cycle and ending with onset of menses or shorty after
What are some key sx features of PMDD?
suicidal thoughts
decreased interest in daily activities
sxs are severe enough to interfere with daily activities
How do you Dx PMS or PMDD?
clinically
PMS: 2-3 month PMS diary
PMDD: diary for at least 2 cycles
Must have: feelings of sadness/hopelessness, anxiety, emotional liability with frequent tearfulness, irritability/anger, loss of interest in daily activities
DDX: PMDD
thyroid disease
other hormonal d/o’s
affective d/o’s
What is the underlying issue with PCOS?
the woman’s inability to process insulin in the liver and muscles due to probable genetic susceptibility that causes hyperinsulinemia
When do sxs start with PCOS?
menarche and worsen with time
What is the classic PCOS presentation?
irregular menses hirsutism, acne, temporal balding acanthosis nigricans obesity m/b enlarged ovaries/cystic ovaries
What are some serious sequelae if PCOS goes untreated?
CVD DM metabolic syndrome endometrial carcinoma m/b breast CA
What does PCOS look like on TVUS?
string of pearls: multiple follicles 2-9mm on periphery of ovary
What is require for DX of PCOS?
2 of 3:
ovulatory dysfunction = menstrual irregularity
clinical/biochemical evidence of hyperandrogenism
more than 10 follicles per ovary on TVUS
What two tests would you do to r/o Cushing’s Syndrome and adrenal virilism when you suspect PCOS?
serum cortisol
fasting serum 17-hydroxyprogesterone
What are some etiologies of premature ovarian failure?
AI
chemo
cigarette smoking
Sxs: premature ovarian failure
amenorrhea/irregular bleeding
sx of estrogen deficiency
Which tests are diagnostic for premature ovarian failure?
serum FSH, estradiol (if FSH is >20)
What is considered premature menopause? Give 3 reasons why this might occur
before the age of 40
high altitude, smoking, undernutrition
What is the hallmark of perimenopause?
changes in bleeding patterns with menses usually beginning in 40s
Ssx: menopause
hot flashes/sweating vaginal dryness neuropsychiatric changes night sweats light-headedness, palpitations, numbness, tingling atrophic changes GI disturbances lack of libido
What are 3 health problems associated with menopause?
osteoporosis
CVD
breast CA
What are three risk factors for osteoporosis?
smoking
sedentary lifestyle
wt. less than 127lbs. or BMI<21
What is the classic presentation of vaginitis?
abnormal vaginal d/c
irritation
pruritis
erythema
What makes d/c AbN?
offensive odor
prutitis
burning/pain
copious
What does d/c look like when cancerous?
watery, bloody or both
3 causes of vaginitis in young girls
chemicals
foreign bodies
infection
what is the main cause of vaginitis in reproductive age women?
infection
When is inflammatory or atrophic vaginitis most common?
in menopausal women
What do you want to know, specifically, when a woman comes in with vaginits?
Antibx use
immunosuppressive d/os
hx of fistulas
sexual practices and hx
What 4 PEs should you do for vaginitis?
palpate inguinal LNs
external genital exam
bimanual
vaginal pH
red flags: vaginitis
trichomonal vaginitis in children
fecal d/c (fistula)
What else could cause sxs that look like vaginitis? Name 4
UTI
allergy/irritation
derm dz
paget’s dz
Risk factors for BV. Name 5
IUD Low vit. D poor nutrition douching no condom use anal sex before vaginal sex spermicides smoking
What are the hallmark sxs of BV?
fishy odor to d/c
profuse, thin white gray d/c that coats tissue
pruritis and irritation
What is uncommon with BV?
erythema and edema
What are the dx criteria for BV?
gray d/c
pH >4.5
fishy odor
clue cells
Do WBCs go up with BV?
no
Risk factors for candida.
antibx use pregnancy constrictive undergarments UD DM
What is the d/c like with candida?
thick, white, cottage-cheese like
adheres to vaginal wall
pH<4.5
When do sxs often increase with candida?
a week before menses
How do you dx atrophic/inflammatory vaginitis?
ph>6
wet prep: increased WBCs, decrease lactobacillus, parabasal cells
m/b increased cocci
What are the sxs of atrophic/inflammatory vaginitis?
clear or purulent d/c
dyspareunia, dysuria, irritation
itching, erythema, burning, minor bleeding
thin dry mucosa
What is the d/c like with trich?
copious yellow/green and frothy!
What might the walls and surface of the cervix look like with trich?
strawberry/punctate red
how does one dx trich?
pH: >5.5
wet prep: increased WBCs, flagellated trichomod
What are the sxs of cytolytic vaginosis?
burning, pruritis rawness vulvovaginitis dyspareunia erythematous and excoriated tissue
Dx of cytolytic vaginosis
pH normal or <3.5
wet prep: small amount of WBCs, increased rods, false/atypical clue cells
What are the two most common causes of PID?
Neisseria Gonorrhea (GC) Chlamydia trachomatis
What is the most common cause of PID in women >35?
overgrowth of anaerobic/aerobic bacteria in vagina that ascend
What are common risk factors for PID in adolescents?
with older sexual partners
hx of child protective sercives involvement
hx of attempted suicide (wah???)
Of gonorrhea and chalmydia, which causes more severe PID sxs?
gonorrhea
Sxs: PID
low ab pain that radiates to the back fever d/c AUB onset during or after menses dysuria N/V
What will you find on PE with PID?
inguinal LAD, tender fever 101 or greater increased pulse rate speculum: red cervix, easily friable mucopurulent d/c, yellow/green from os CMT, guarding/rebound tenderness, enlarged skene's glands, uterine and adenexal tenderness
how would you confirm/negate PID?
wet prep: >10 WBCs/hpf
CBC: elevated WBCs
ESR: increased >15mm/hr
If all negative, not likely PID
What are the main complications of PID (know these fo’ reals)?
Tubal scarring and adhesions: chronic pelvic pain, menstrual irregularities, infertility and increased risk for ectopic pg
3 DDx for PID
endometriosis
appendicitis
ectopic pg
What does the d/c of gonorrhea look like?
yellow/green mucopurulent
What is the pattern of labs associated with gonorrhea?
inc. pH
inc. WBCs
inc. ESR
positive culture, of course.
