Gyn Flashcards
Clinical signs of menopause
Sweating, hot flashes, absent or irregular menses, insomnia, headaches
Menopause and hyperthyroidism can have similar sx. What levels should you check?
FSH and TSH
Steroid tx does not have proven benefit after?
34 weeks gestation; limited benefit between 24-34 weeks
How many hours needed for steroids to have benefit?
24-48 hours
Genital warts aka. Present where? And morphology?
Condyloma acuminata. Small pink teardrop clusters in internal/external vagina or anogenital area.
Condyloma acuminata caused by?
HPV infection
Tx of condyloma acuminata?
Small lesions can be treated with trichloroacetic acid or podophyllin. Large lesions are treated with excision or fulgruation (electric current).
Condyloma lata caused by?
Syphillis. Part of secondary syphillis. Flat, velvety lesions
Lichen sclerosus, lichen planus presentation?
Lichen sclerosus in older women - white, thin, wrinkled skin over the labia. Typically affects older women, causes anogenital discomfort - causes pruritis, dyspareunia, dysuria, painful defecation. Lichen planus - middle aged women, can be hyperkeratotic, papulosquamous, or erosive.
Daugthers of women who used diethylstillbestrol (DES) are at increased risk for?
40x risk of clear cell adenocarcinoma of the vagina and cervix. Many of these women have cervical or uterine malformations (hooded cervix, T-shaped uterus, small uterine cavity, vaginal septae) as well as difficulty conceiving and maintaing pregnancy (ectopics, pre-term)
Risk factors for endometrial adenocarcinoma?
Prolonged exposure to estrogen stimulation (obesity, early menarche, late menopause, chronic tamoxifen use)
Benefits and risks of estrogen-progestin contraception
risks 1) VTE 2) HTN 3) hepatic adenoma 4) rare risk of stroke and MI. Benefits: reduce risk of endometrial and ovarian cancer
Menorrhagia
Heavy or prolonged menstruation typically lasting longer than 7 days or exceeding 80ml.
Young patients have irregular/heavy bleeding because?
Their HPA is not well developed and don’t produce FSH LH in the right ratios and up to 90% of cycles after menarche can be anovulatory. The endometrium responds to baseline estrogen which is why a lining builds and then sloughs off.
Fibroids aka
Uterine leiomyomata
Adenomyosis is?
Endometrium within the myometrum
Endometriosis?
Presence of normal endometrial mucosa (glands and stroma) in locations other than the uterine cavity
Tx for primary dysmenorrhea
NSAIDS . Inhibits prostaglandin synthetase which decreases prostaglandin production (prostaglandind released from uterus to cause contractions causes the pain)
What are the different common causes of secondary dysmenorrhea
1) uterine leimyomata 2) endometriosis 3) adenomyosis 4) pelvic infection
Pelvic exam for atrophic vaginitis
Pale, smooth and dry vaginal epithelium, scarce pubic hair, loss of fat pad in the labia
Tx for atrophic vaginitis
Initial tx for mild: lubricants, moisturizers. Moderate to severe: local low-dose vaginal estrogen replacement
Typical sx of atrophic vaginitis
Dyspareunia, dysuria, increased urinary frequency, pruritis, vaginal dryness
Stressful lives, excessive exersice dieting can cause
Hypogonadotropic hypogondadism
Laparascopy is both diagnostic and therapeutic. Allows
Visualization, ablation, excision,
Dx endometriosis when/with
When tx of suspected endometriosis with NSAIDs has failed. Tx/Dx with laparascopy
Risk factors for endometriosis
Nulliparity, early menarche, short menstrual cycles, menstrual flow obstruction
Risk factors for breast cancer
Nulliparity, postive family hx, genetic mutations (BRCA and p53), early menarche, late menopause, prolonged HRT
Risk factors for endometrial carcinoma?
Advancing age, unopposed estrogen or prolonged use of tamoxifen, obesity, nulliparty, anovulatory conditions
Pathogenesis of endometriosis
Ectopic endometrial tissue forms on or beneath pelvic mucosal or serosal surfaces, cyclic hyperplasia and degeneration occur in response to female sex hormones, chronic hemorrhaging leads to formation of fibrotic pelvic adhesions.
Presentation of endometriosis
Dysmenorrhea, dyspareunia, pelvic pain, infertility. Can have chronic pelvic pain
Exam for lichen sclerosus
Porcelain white atrophy with “cigarette paper” quality. Do biopsy to rule out vulvar SCC
Lichen sclerosus et atrophicus is considered
Premalignant, can lead to vulvar squamous cell carcinoma
1st line therapy for lichen sclerosus et atrophicus?
high potency topical steroids
Risperidone MOA, side effects
dopamine antagonist, also acts on serotonin receptors. Inhibits dopamine, causes galactorrhea, amenorrhea
Raloxifene? Most important side effect?
Selective estrogen receptor modulalator. Mixed agonsit/antagonist. In breast and vaginal tissue it is antagonist whereas in bone tissue it is agonist. Decreases breast cancer risk. One of the first line Tx for osteoporosis though less effective than bisphosohnates and estrongen. Increased risk for VTE
PCOS also known as
Stein levanthal syndrome
How does clompihene citrate work
Estrogen analog that improves GnRH release and FSH release thereby improving chances of ovulation.
Ovulation can be induced in patients with PCOS with
Clomiphene citrate and metformin
Difference between genital ulcers seen in chancroids and herpes genitalis differ from syphillis in that
Both are painful while syphillis is not painful
presentation of primary syphillis
infection, then 2-3 weeks later, development of small painless papule => ulcerates, forms a chancre with punched-out base and raised indurated margins.
Chancroid
Ulcer with deep purulent base, and painful lymphadenopathy
Genital herpes presentation
Multiple vesicles following prodrome of burning and pruritis. Within days, vesicles become painful ulcers.
Dx of primary syphillis is best made via
spirochete ID on dark field microscopy.
Nontrepenomal serologic tests and trepenomal serologic tests
RPR, VDRL, FTA-ABS . In primary syphillis may not have yet formed antibodies against syphillis, therefore, can’t detect.
What’s going on with ovaries in Turner Syndrome?
Ovarian dysgenesis => low estrogen => high FSH
Adenomyosis a/w
multiparous women >40, early menarche, short menstrual periods, prior uterine surgery, preterm birth
Definitve dx of adenomyosis is made?
surgical pathology after hysteroectomy
Adenomysosis clinical presentation
dysmenorrhea, pelvic pain, heavy menses, bulky, globular/tender uterus (around 10 weeks size)
Midcyle pelvic pain aka
mittelchmerz
Serum inhibin B is used to measure
ovulatory reserve
Risk factors for osteoporosis
Advanced age, Caucasian/Asian ethnicity, cigarette smoking, alcohol consumption, thin body, steroid use, menopause, malnutrition, family hx
Tx / instructions for patients with trichomonas
Tx patient and sexual partner with metronidazole or tinidazole. No need to test partner but should treat, partner always has it, they can be asympomatic, it is cheap to treat. No sex till both are treated
Changes in cervical mucus during menstrual cycle
Thick, opaque and acidic in follicular phase. Thin, abundant, clear, extends 6cm in ovulatory phase, back to being thick in the luteal phase
Hallmarks of endometriosis
the 3Ds - dyspareunia, dysmenorrhea, dyschezia
Precocious puberty defined as puberty before the ages of
8 for girls or 9 for boys
Precocious puberty can be due to
Central (early activation of HPA axis) - will have high levels of FSH/LH or peripheral reasons (excess adrenal or gonadal production of hormones). Wil lhave low levels of FSH/Lh. Example of peripheral precociosu puberty is CAH.
Two main types of vaginal cancer
Squamous cell and clear cell adenocarcinoma
Clinical features of vaginal cancer
Malodorous discharge, postmenopausal or post coital vaginal bleeding; irregular mass/plaque or ulcer on vagina
Typical location of squamous cell cancer of vagina and clear cell adenocarcinoma of vagina
1) upper 1/3rd of posterior vagina wall 2) upper 1/3 or anterior vagina wall.
Risk factors for scc vaginal cancer and clear cell adenocarcinoma
1) history of hpv 16 or 18, hx of cervical dysplasia/cancer, cigs 2) in utero exposure to DES
Aromatase deficiency. Pathophysiology and presentation?
Rare genetic disorder resulting in lack or poor functioning of enzyme that converts androgens to estrogen. In utero> masculization of mother that resolves after delivery. In the child=> high levels of gestational androgens leading to normal internal genitalia but ambiguous external genitalia. clitoromegaly when excess androgens are present in utero. later in life => delayed puberty, osteoporosis, undetectable circulating estrogen, high concentration of gonadotropins and polycstic ovaries. (high FSH/LH)
Most common CAH
21 hydroxylase deficiency. Estrogen synthesized, internal genitalia normal
Mccune albright syndrome
Café au lait spots, polyostotic fibrous dysplasia, autonomous endocrine hyperfunction. Most common endocrine feature = gonadotropin independent precocious puberty.
Kallman’s syndrome
Hypogonadotropic hypogonadism with anosmia.
Treatment for stress incontinence
Kegel exercises and then urethopexy (restoration of urethovesical angle)
uretheral hypermobility can be diagnosed by?
Inserting cotton swab into urethral orifice and demonstrating angle > 30 degrees upon increase in intra-abdominal pressure
Treatment for chlymadia
1 dose azithromycin or 7 day course of doxyclycine
Treatment for gonorrhea
Ceftriaxone
Endometrial hyperplasia classification and tx
Endometrial hyperplasia gets categorized as simple (mildly crowded and cystically dilated) or complex (more crowded and disorganized) and without atypia or with atypia. Hyperplasia without atypia ( hysterectomy
Candida vaginitis tx
Oral fluconazole (over intravaginal agents) due to comfort. Pseudohyphae seen in wet-mount prep. Cttage cheese discharge, vaginal inflammation. No need to treat partner. Ph = 3.8-4.5
PID diagnosis criteria
Fever >38, leukocytosis, elevated ESR, purulent cervical discharge, adnexal tenderness, CMT, lower abdominal tenderness
Most common cause of infertility in women
PID
Tx for PID
If high fever, failure to respond to antibiotics, N/V, pregnancy => inpatient hospitalization and wide spectrum abx. Regimens: cefoxitin or cefotetan/doxycycline, clinda/gentamycin. No not delay abx tx until ucx results come out.
PID can lead to
tubo-ovarian abscess, abscess rupture, pelvic peritonitis, and sepsis
Diagnosis of primary ovarian failure
FSH elevation in the setting of >3 months of amenorrhea in a woman under 40
Causes of premature ovarian failure
Chemotherapy, radiation, autoimmune ovarian failure, Turney’s syndrome, fragile X syndrome.
What are athe FSH and LH levels like in premature ovarian failure
no folicular development -> no estrogen => elevated FSH AND LH. FSH elevated more because of slwoer clearance from the system
Patients with secondary amenorrhea should get
FSH, prolactin and pregnancy test
Women with excessive exercise, low caloric intake have amenorrhea due to
Decreased LH and GnRH
Syncytiotrophoblast
Outer layer of the trophoblasts. Epithelial covering of the embryonic placental villi which invades the wall of the uterus
Role of HCG in pregnancy
HCG secreted by the syncytiotrophoblasts to preserver the CL during pregnancy, so that it can continue to secrete progesteerone until the placenta starts making its own progesterone and takes over. Production of hCG starts around 8 days after fertilization and the levels of hcG doubles every 48 hours
Alpha unit of hCG is common with
TSH, FSH, LH. Beta unit is specific to hCG and is the basis of home pregnancy tests.
Morning after pill is what?
Levonorgestrol, Works by delaying ovulation
Abnormal uterine bleeding definition
Menstrual bleeding with abnormal duration, quality, or schedule
Ovarian cyst rupture presentation
Mostly in young women of reproductive age, asymptomatic or develop sharp sudden onset unilateral pain esp after strenuous activity or sex. May have slight bleeding due to drop in hormones after ovarian cyst rupture. Pelvic u/s shows free fluid near the cyst
Differential diagnosis for acute pelvic pain
1) Ovarian cyst rupture 2) ovarian torsion 3) ectopic pregnancy 4) mittelschmerz 5) ectopic
Ovarian torsion presentation
Acute onset uniliateral abdominal pain, n/v, pelvic u/s with doppler shows enlarged ovary veins with decreased blood flow
Initial workup for adnexal mass in postmenopausal woman
Trans vag u/s, CA 125 level. In post menopausal women, elevated CA125 has high sensitivity and specificity.
Mgmt of asymptomatic women with adnexal mass
if U/S not concerning and CA125 low, observe patient with periodic U/S. if U/S concerning, or if CA125 elevated, refer to gyn onc
Common STDS and tx
1) chlamydia trochamitis cervicitis (most common cause of cervicitis)-azithromycin 2) neisseria gonorrhea - ceftriaxone 3) herpex - acyclovir 4) trichomonoas vaginitis - metronidazole
What testing is recommended to differentiate GC?
Nucleic acid ampflicfication testing
Tx for Neisseria gonorrhea
Ceftriaxone + azithro or doxy. Second agent to cover cephalosporin resistant gonococci as well as concoitant chlamydia infection
Most common cystic ovarian neoplasm
Serous cystadenomas, accounts for 30% of ovarian tumors. 25% are malignant, about half are bilateral. Do not produce androgens or estrogens.
Presenting feature of serous cysteadenoma
Ovarian mass and abdominal pain
Granulosa cell tumors. Epi, presenting feature
Fairly common. 10% of all solid malignant ovarian tumors. Tumor produces excess estrogen. Occur at any age but follow bimodal distrubition. If occuring young, will show as precocious puberty (breasts, hair, hyperplasia of uterus). If occuring post menopausal, wont have the tx menopausal sx like vaginal dryness.
Dysgerminomas, epi and presentation
Arise in younger women, average incidence age 20. usually unilateral and undergo torsion. Tumor is neutral and does not secrete male or female sex hormone.
Sertoli-Leydig cell tumors presentation
Produce testosterone, causes defeminazation followed by masculinization. Altered body contour, scanty breasts,
Mature teratomas aka
Dermoid cysts. Don’t produce any hormones
Examples of emergency contraceptions and efficacy
1) copper iud - causes inflammation, toxic to ova/sperm (99%) 2) levonorgestral pill - progestin, delays ovulation (85%) 3) ulipristal pill - anti-progestin, delays ovulation (>=85%) 4) OCPs (75%) - progestin, delays ovulation
Abnormal uterine bleeding in adolescents typically due to
immature hypothalamus pituitary ovarian axis. Endometrium builds up during anovulatory cycles and if ovulation occurs, heavy menses ensue
First line tx for AUB in adolescents
high dose estrogen, high dose OCPs, high does progestin, and if those are contraindicated transexemic acid (antifibrinolytic)
Side effects of combined OCPs
Breast tenderness, amenorrhea, bloating, breakthrough bleeding, decreased risk for ovarian and endometrial cancer, increased risk for cervical cancer, VTE, hypertension, liver disorders, elevated triglycerides
Amsel criteria for bacterial vaginosis
When 3 of 4 criteria are met, dx 1) positive whiff test 2) clue cells on wet mount (vaginal epithelial cells with adherent coccobacilli) 3) vaginal pH >4.5 4) thin, gray-white vaginal discharge. ITCHING AND BURNING ARE NOT USUAL. VAGINAL EPITHELIUM/CERVIX NOT INFLAMED
Premature ovarian failure
amenorrhea>3 months, high gonadotropin levels, low estrogen in women
Obesity is a common cause of amenorrhea
There is anovulation secondary to obesity. Ovaries still producing estrogen, but progesterone not being produced at normal post ovulation levels. Therefore, progesterone withdrawal menses at the end of the cycle do not occur
Steroid acne presentation
monomorphous pink papules and absence of comedones. Distributed on face, arms, and extremities.
Patients taking metronidazole should avoid?
Alcohol - be cautious against disulfiram like reaction - acetaldehyde accumulates in the blood stream. Flushing, N/V, hypotension.
Cervical cancer screening guidelines
No screening under 21 unless immunocompromised, HIV+/SLE. 21-29: cytology every three years, 30-64: cytology every 3 years or cytology+hpv testing every 5 years. 65 and over: no screening if hx of negative screens and not at high risk for cervical cancern pts with hysterectomy/cervix removal: no screening is no hx of high grade precancerous lesions, cervical cancer, DES exposure
Fibroids presentation
Irregular uterus, pregnancy difficulties, difficulty conceiving, mass issues (causes constipation, urinary frequency, pelvic pressure/pain), heavy menses with clots
Tx of fibroids
observation if asymptomatic, hormonal contraception, embolization, surgery if symptomatic
First line diagnostic work up for fibroids
U/S has high sensitivity for uterine fibroids and ovarian pathology.
Most common cause of decreased fertility in women in their fourth decade who are still experiencing menstrual cycle
Decreased ovarian reserve
Inferitility due to aging can be assessed by?
Using early follicular phase FSH level, clomiphene challenge test, inhibin B level
In patient with primary amenorrhea and uterus, what should be done next?
FSH level. If FSH is high => karyotyping. If FSH is low => pituitary MRI
Forms of effective contraception for breastfeeding moms
Barrier method, sterilization, IUD, progstin only contraceptives. Don’t give combined pills - may decrease production and get into the milk
Most common pelvic tumor found in women
Fibroids
Risks and benefits of tamoxifen
SERM. Antagnositic on breast and vaginal tissue but agonist on endometrium, increasing risk for endometrial cancer. Has overall mortality benefit, also decreases risk for osteoporosis by acting as a estrogen recept agonist on osteoclasts, inhibiting bone turnover.
