GYN Flashcards
1
Q
Women age <30
U/L, solitary, painless, firm, mobile mass
DOESN’T change w/ menstrual cycle
Can get increased pain or size prior to menses
A
Fibroadenoma
2
Q
Women age 20-50
Multinodular breasts
B/L painful breast lumps
vary w/ menstrual cycle
A
Fibrocystic Disease
3
Q
H/o recent trauma or surgery
fixed mass w/ skin or nipple retraction
mass solid on U/S
calcification on mammogram
A
Fat necrosis
4
Q
DX and TX of Fat Necrosis
A
DX: Fine needle bx (shows foamy macrophages and fat globules)
TX: nothing just routine f/u
5
Q
Causes of B/L nipple d/c
A
Prolactinoma
Hyperprolactinemia from MDXs
Hypothyroidism
Pregnancy
6
Q
U/L, nonbloody nipple d/c
A
Intraductal Papilloma
7
Q
U/L bloody nipple d/c
A
Breast Malignancy
8
Q
Tx for Fibrocystic Disease
A
OCPs
9
Q
Tx for Fibroadenoma
A
Reassurance in adolescents
In women ≥30 yoa –> Mammogram +/- U/S, followed by core bx if suspicious for malignancy
In women <30 yoa –> U/S +/- mammogram
- simple cyst = needle aspiration (if pt desires) - complex cyst/solid mass = image guided core bx
10
Q
What to do if cyst aspirate is clear and cyst disappears after FNA?
A
Repeat breast exam and U/S in 4-6 wks
11
Q
Tx for Lobar CA In Situ (LCIS)
A
tamoxifen x 5yrs
12
Q
Tx for Ductal CA In Situ (DCIS)
A
lumpectomy + radiation + tamoxifen x 5 yrs
13
Q
Tamoxifen MOA
A
Selective ER Modifier (SERM)
Breast ER receptor antagonist
Endometrial agonist
Bone agonist
14
Q
SEs of Tamoxifen Use
A
Endometrial CA
Thromboembolism
Decreased osteoporosis
Hot flashes
NOTE: tamoxifen or raloxifene must be stopped 4 wks before major surgery to prevent DVTs
15
Q
MDX to PREVENT breast cancer in pts w/ ≥ 2 first degree relatives w/ breast CA
A
Tamoxifen
16
Q
TX for PREmenopausal woman w/ PR and ER (+) Cancer
A
Tamoxifen
17
Q
TX for POSTmenopausal woman w/ PR and ER (+) Cancer
A
Aromatase inh. (eg. anastrozole) OR Tamoxifen
18
Q
Aromatase Inh. MOA
A
Pure breast estrogen antagonists
bone antagonist
19
Q
SEs of Aromatase Inh. Use
A
Increased osteoporosis
NO increased DVT risk
20
Q
Monoclonal Ab against HER-2/NEU
A
Trastuzumab
Used in metastatic disease w/ over-expression of HER/NEU
21
Q
SEs of Trastuzumab
A
Risk of cardiotoxicity w/ ↓ EF (do ECHO before starting MDX)
- -> reversible after tx stopped
- -> can use normal HF tx (eg. B-blocker, ACEI)
- -> if get symptomatic HF, must d/c trastuzumab
22
Q
MC form of breast cancer
A
Invasive ductal CA
23
Q
Tx for Invasive Breast Cancer
A
Lumpectomy + radiation (breast conserving therapy)
24
Q
When is modified radical mastectomy (NOT breast conserving) the answer?
A
If pt pregnant Diffuse malignancy OR ≥ 2 sites in separate quadrants Tumor > 5cm Positive tumor margins Prior irradiation to breast
25
When is Chemotherapy the answer for breast cancer?
Lesion > 1cm
| Lymph node positive disease
26
When to test for BRCA 1 or 2 genes?
FHx of early onset (<50yoa) breast or ovarian CA
Breast and/or ovarian CA in the same pt
FHx of male breast CA
Ashkenazi Jewish heritage
27
Breast Cancer Screening Guidelines
Mammogram starting at age 50 then every 1-2yrs
28
Pruritic, red, scaly nipple lesion
| Inverted nipple or discharge
Paget's Disease of Breast
Underlying breast adenoCA present
29
Enlarged, firm, NONTENDER, ASYMMETRIC uterus
intermenstrual bleeding
menorrhagia w/ clots
dysmenorrhea
bladder, rectum or ureter compression sxs
Leiomyoma (uterine fibroids)
- benign uterine tumor
- growth of myometrium (which has smooth m)
30
Leiomyoma and relationship to estrogen
Size increases w/ estrogen (eg. in preg)
| Size decreases in menopause
31
Dx of Leiomyoma
1) Pelvic exam --> asymmetric, large, firm, nontender uterus
2) U/S
3) Hysteroscopy (direct visualization)
32
Tx of Leiomyoma
- Observation
- OCPs or progestin only contraception (progestin IUD)
- Myomectomy --> preserved fertility; must get C-section if get preg after to prevent uterine rupture
- Hysterectomy --> if done having babies
- Embolization of vessels --> preserves uterus but high risks if get preg after this
33
Pt age 35-50
soft, globular, TENDER, SYMMETRIC uterus
menorrhagia
dysmenorrhea
Adenomyosis (no relationship to estrogen)
Location of endometrial glands/stroma within myometrium of uterus
34
Dx of Adenomyosis
1) Pelvic exam
| 2) U/S
35
Tx of Adenomyosis
- Progestin IUD
| - Hysterectomy --> if done having babies
36
Causes of postmenopausal bleeding and next step
- vaginal or endometrial atrophy
- endometrial carcinoma
Next step --> endometrial bx to r/o endometrial CA
NOTE: in normal postmenopausal women, endometrial lining stripe should be <5mm thick
37
RFs for Endometrial Carcinoma
Unopposed estrogen states:
- obesity
- nulliparity
- late menopause/early menarche
- PCOS
```
Tamoxifen use
Lynch Syndrome (HNPPC)
```
38
Management of Endometrial CA
surgery staging + radiation + chemo
39
MCC of dysfunctional (unexplained) uterine bleeding
anovulation
(have enough estrogen but progesterone is not produced so no withdraw bleeding occurs. When endometrium can't take it anymore, it bleeds HEAVILY and IRREGULARLY)
FSH and LH normal
40
Dx of dysfunctional uterine bleeding
No specific test --> dx of exclusion
BUT make sure do endometrial bx in any pt > 35 yoa w/ abnormal uterine bleeding (if <35 yoa but have persistent bleeding then also get endometrial bx)
41
Tx for dysfunctional uterine bleeding
Pt STABLE --> High dose PO/IV estrogen OR high dose progestin pills OR high dose OCPs
- if pt anovulatory
- pt >35 yoa w/ normal endometrial bx
D&C
- if need acute management of hemorrhage or if medical management fails after 24-36 hrs
Endometrial ablation/Hysterectomy
- if bleeding severe, pt not controlled w/ OCPs, pt anemic or lifestyle affected
42
```
postmenopausal bleeding
pelvic pain/pressure
abdominal distension
uterus enlarged w/ uterine mass
ascites (eg. fld in cul-de-sac)
```
Uterine Sarcoma
43
RFs for uterine sarcoma
pelvic radiation
tamoxifen use (eg. breast CA pt)
postmenopausal pts
44
Dx of uterine sarcoma
U/S +/- additional imaging
endometrial bx
histopathology of surgical specimen
45
Tx for uterine sarcoma
Hysterectomy +/- adjuvant chemo/radiation
46
MC location of metastases for uterine sarcoma?
Prognosis?
Lung (look for pleural effusion)
PROGNOSIS: poor; aggressive tumor that recurs
47
Sudden U/L lower abd. pain (occurs after strenuous exercise or sexual activity)
Adnexal mass
Cullen's sign (if intraperitoneal bleeding present)
B-hCG negative
Ruptured Ovarian Cyst
48
Dx and Tx of ruptured ovarian cyst
DX:
U/S (see adnexal mass with free fld in pelvis)
TX:
Stable = analgesics; unstable = surgery
49
Sudden, U/L pelvic pain that radiates to groin/back
Adnexal mass
N/V
B-hCG negative
Ovarian Torsion (Right sided most common)
50
Dx and Tx of ovarian torsion
DX:
U/S w/ Doppler (see cyst or big ovary w/ ↓ bld flow)
TX:
- r/o preg
- laparoscopy w/ detorsion
- ovarian cystectomy (if bld supply not affected)
- oophorectomy (if necrosis or malignancy)
51
cystic mass
smooth lesion edges
few septa
Benign Ovarian Mass
52
irregularity
nodularity
many thick septa
solid, complex mass
Malignant Ovarian Mass
53
```
adnexal mass on bimanual exm
ascites
abd. pain
w. loss
change in bowel habits
menstrual irregularities
```
Ovarian Neoplasm
--> 2 types: epithelial (MC in postmenopausal pt) and germ cell (if pt <30 yoa)
Epithelial Tumor = CA-125, CEA tumor markers
Germ Cell Tumor = B-hCG, AFP tumor markers
54
Ovarian mass + endometrial hyperplasia
```
Granulosa Theca (stromal tumor)
--> produces estrogen = endometrial hyperplasia, feminization and precocious puberty
```
55
Adnexal mass + woman w/ hirsutism and deepening voice
Sertoli-Leydig Cell (stromal tumor)
- -> produces testosterone = masculinization (receding hairline, deep voice, cliteromegaly, hirsutism)
- -> ↑ testosterone and estrogen + ↓ LH and FSH
56
Protective factors against ovarian cancer
Breastfeeding
OCPs
short reproductive life
chronic anovulation
57
old woman w/ gastric ulcer hx and recent worsening dyspepsia presents w/ w. loss and abd pain. Adnexal mass found
Krukenberg Tumor (metastatic gastric Ca to ovary)
--> CEA = tumor marker
58
Ovarian fibroma + ascites + R. hydrothorax
Meigs Syndrome
59
Dx steps after ovarian mass found
U/S
--> normal = observe w/ periodic U/S
--> abn = contact gyn oncologist
Biopsy
60
Tx of ovarian mass
```
Premenopausal = salpingo-oophorectomy
Postmenopausal = TAH + BSO + postop chemo for malignant tissue
```
61
When does a preg woman need surgical intervention for adnexal mass? (3)
Tx?
- mass >10 cm
- mass has complex features
- mass is persistent
TX:
surgical removal in early 2nd trimester --> if cancer diagnosed, can give chemo in 2nd/3rd trimesters
62
Pt presents 1-2 days after ovulation induction tx (w/ B-hCG injections). Has N/V, abd pain, B/L enlarged ovaries with multiple follicles.
Ovarian Hyperstimulation Syndrome
--> after ovulation induction, ovaries overexpress VEGF = increased vasc. permeability and capillary leakage = third spacing of fld
63
Other Sxs associated w/ Ovarian Hyperstimulation Syndrome
```
Ascites
Pleural/ pericardial effusions
Resp distress
Hemoconcentration
Hypercoagulability
Electrolyte imbalances
Multiorgan failure (eg. renal failure)
DIC
```
64
Evaluation of Ovarian Hyperstimulation Syndrome
monitor fld balance
serial CBC, electrolytes
serum hCG
pelvic U/S
CXR
Echo
65
Tx of Ovarian Hyperstimulation Syndrome
correct electrolytes
paracentesis/thoracentesis
DVT ppx
66
HPV types associated w/ cervical carcinoma
16, 18
67
HPV types associated w/ warts (benign condyloma acuminata)
6, 11
68
Low Grade Squamous Intraepithelial Lesion (LSIL) includes what 3 categories?
HPV
mild dysplasia
CIN 1
69
High Grade Squamous Intraepithelial Lesion (HSIL) includes what 5 categories?
```
moderate dysplasia
severe dysplasia
CIS
CIN 2
CIN 3
```
70
Pap screening guidelines
- Start at age 21
- Do cytology every 3 years until age 30
- After age 30 do cytology every 3 years OR cytology + HPV every 5 years
- Stop Paps at age 65
- No Paps for woman w/ total hysterectomy
71
Pt b/w age 21-24 had first ASCUS or LSIL pap...what to do next?
Repeat pap smear in 12 mo
72
Repeated 2nd pap smear is negative or shows ASCUS or LGIL...what to do next?
Repeat pap smear in 12 mo
If repeated comes back negative --> do nothing; go back to routine screening
If repeated comes back as ASCUS or worse --> colposcopy and biopsy
73
Pt ≥ 25 yoa had first ASCUS pap...what to do next?
HPV DNA testing
74
HPV DNA negative...what to do next?
HPV DNA positive...what to do next?
Routine follow up --> Get pap + HPV DNA in 3 yrs
Colposcopy and biopsy
75
When to get colposcopy and biopsy?
- abnormal pap (eg. HSIL)
- 3 consecutive ASCUS paps in pt 21-24 yoa
- ASCUS + HPV positive in pt ≥ 25 yoa
76
When to get cone biopsy?
Done after colposcopy if Pap smear and bx findings are inconsistent (suggests abnormal cells not biopsied)
Cone bx done in OR
77
Complications of cone bx?
Incompetent cervix
| Cervical stenosis
78
Colposcopy and bx found CIN 1.. what to do next?
F/u w/ repeat pap smears, colposcopy + Pap smear OR HPV DNA testing every 4-6 months for 2 years
79
Colposcopy and bx found CIN 2/3.. what to do next?
LEEP OR cold knife conization
80
Keep getting recurrent CIN 2/3.. what to do next?
Hysterectomy
81
Pregnant woman w/ abnormal Pap.. what to do next?
Do colposcopy and bx
Preg. pts managed same as non-preg pts EXCEPT NEVER perform endocervical curretage on preg pt
82
Preg woman has CIN or dysplasia on colposcopy and bx.. what to do next?
Repeat pap + colposcopy every 3 months during preg
| Then get repeat pap + colposcopy 6-8 wks postpartum (even if pap and colposcopy were normal during preg)
83
Preg woman has microinvasive cervical cancer on colposcopy and bx.. what to do next?
Cone bx
| Deliver vaginally and then reevaluate 6-8 wks postpartum
84
Preg woman has invasive cancer on colposcopy and bx.. what to do next?
Dx before 24 wks = radical hysterectomy or radiation
Dx after 24 wks = conservative management upto 32-33 wks then do C-section and hysterectomy
85
when to get HPV vaccine?
Females: 8-26 yoa
Males: 9-26 yoa
86
who CAN'T get HPV vaccine?
Preg pt
Lactating pt
IC pt
87
Inflammation of cervix + cervical d/c + friable cervix
Cervicitis
Causes: Gonorrhea + Chlamydia
88
Tx for cervicitis
IM ceftriaxone + PO Azithromycin
89
```
lower abd. pain
tenderness
fever
cervical motion tenderness
mucopurulent vaginal d/c
↑ WBC
↑ ESR, CRP
```
Acute PID
Causes: Gonorrhea + Chlamydia
90
RFs for acute PID
```
multiple sexual partners (HIGHEST RISK)
inconsistent barrier contraception use
age 15-25
sex partner w/ Gono/Chlam
prev. PID
```
91
Dx of acute PID
first r/o preg
Initial: cervical cx and NAAT
Accurate: laparoscopy (ONLY for recurrent infxns)
92
Tx for acute PID
Outpatient: IM ceftriaxone single dose + PO doxycycline x14d
Inpatient: IV cefoxitin OR cefotetan + IV doxycycline
93
Inpatient admission criteria for acute PID
```
Fever > 102.2F
failure to respond to PO MDXs
pt can't take PO MDXs (eg. vomiting)
pt not complaint w/ tx
pregnancy
```
94
Complications of acute PID
```
infertility
ectopic preg
chronic pelvic pain
tuboovarian abscess
pelvic peritonitis
sepsis
```
95
Sxs of chronic PID
U/S findings?
Tx?
infertility
dyspareunia
```
cervical cx (-)
U/S --> B/L cystic pelvic masses (hydrosalpinges)
```
TX:
lysis of tubal adhesions to improve fertility
for unremitting pelvic pain --> TAH, BSO
96
```
ill appearing woman
severe lower abd/pelvic pain
back pain
rectal pain
N/V
fever
tachycardia
↑ WBC
↑ ESR
Pus on culdocentesis
```
Tuboovarian abscess
97
Dx of Tuboovarian abscess
U/S:
U/L pelvic mass (multinodular, cystic, complex adnexal mass)
Bld cx:
anaerobic bacteria
98
Tx of Tuboovarian abscess
Admit to hospital
IV Cefoxitin + IV doxycycline
No response w/in 72 hrs or if abscess ruptures --> percutaneous drainage OR exploratory laparatomy +/- TAH and BSO
99
thin, vaginal d/c w/ fishy odor
gray/white d/c
no itching or inflammation
vaginal pH >4.5
Bacterial Vaginosis (Gardnerella)
MCC of vaginitis
100
Dx and Tx of Bacterial Vaginosis
DX:
saline wet mount --> clue cells (obscured edges of cells)
TX:
- PO metronidazole x 7 days OR vaginal clindamycin
- only tx symptomatic preg pts
101
Complications of Bacterial Vaginosis
- ↑ risk of preterm birth
- ↑ risk for acquisition of HIV, HSV 2, gonorrhea, chlamydia, Trichomonas infxns
- preterm PROM
- chorioamnionitis
102
white, cheesy vaginal d/c
vaginal inflammation and itching
vaginal pH: 3.5-4.5 (normal)
Candidiasis (Candida albicans)
103
Dx and Tx of Candidiasis
DX:
KOH shows pseudohyphae
TX:
- PO fluconazole
- -> CI in preg pts
- vaginal miconazole, clotrimazole, econazole, or nystatin
- -> can use in preg pts
104
```
profuse, green, frothy vaginal d/c
urinary frequency, dysuria, dyspareunia
vaginal inflammation and itching
cervical petechiae ("strawberry cervix")
vaginal pH > 4.5
```
Trichomonas (Trichomonas vaginalis)
MC non-viral STD
105
Dx and Tx of Trichomonas
DX:
saline wet mount shows motile pear-shaped flagellates
TX:
- single dose PO metronidazole
- tx both pt and sexual partners
106
Complications of Trichomonas
metronidazole enters breast milk
--> to avoid infant exposure, breast milk should be expressed and discarded for 24 hrs after metronidazole administration
107
recurrent crampy lower abd pain
N/V
diarrhea
ALL DURING MENSTRUATION
Primary Dysmenorrhea
- -> from excessive endometrial prostaglandin F2
- -> no pelvic abnormality
108
Tx for Primary Dysmenorrhea
First line: NSAIDs x 2-4 mo
| Second line: OCPs
109
```
Woman >30 yoa
3 D's:
-dysmenorrhea
- dyspareunia
- dyschezia
Cyclical pelvic pain
Cervical motion tenderness
Uterus normal in size but immobile
Infertility
```
Endometriosis
- cause of secondary dysmenorrhea
110
MC sites of endometriosis
MC site = ovary --> see adnexal enlargements (chocolate cysts)
2nd MC site = cul-de-sac (space b/w uterus and rectum)
- -> get nodularity and tenderness on rectovaginal exam
- -> can get bowel adhesions
111
Dx of Endometriosis
U/S --> shows endometriomas ("homogeneous cystic-appearing mass in ovary)
Definitive dx = laparoscopic visualization
112
Tx of Endometriosis
First line:
NSAIDs + OCPs OR
NSAIDs + PO progesterone
Second line:
Danazol (testosterone derivatives) OR
Leuprolide (GnRH analog)
To improve fertility --> laparoscopic lysis of adhesions
113
```
vulvovaginal dryness, itchiness, irritation
dyspareunia
vaginal bleeding
urinary incontinence and recurrent UTIs
pelvic pressure
```
vulvovaginal atrophy
--> common in post-partum pts due to breastfeeding
114
Physical exam findings of vulvovaginal atrophy
```
narrowed introitus
pale mucosa
decreased elasticity and rugae of mucosa
petechiae, fissures
loss of labial volume
vaginal pH >5
```
115
Tx of vulvovaginal atrophy
vaginal moisturizer and lubricant
| topical vaginal estrogen
116
grapelike mass protruding from vaginal lining or cervix
Sarcoma botryoides (cancer of vagina or cervix)
117
Primary amenorrhea definition
pt 14 yoa and still no menses or secondary sexual characteristics OR
pt 16 yoa and still no menses BUT has secondary sexual characteristics
118
Workup of primary amenorrhea
```
Physical exam
U/S
Karyotype
Testosterone
FSH
```
119
DDX for amenorrhea + presence of breasts + uterus
secondary amenorrhea:
- -> imperforate hymen
- -> transverse vaginal septum
- -> anorexia nervosa
- -> excessive exercise
- -> pregnancy before first menses
120
cyclic, pelvic or abd pain w/ primary dysmenorrhea
small suprapubic mass can be palpated sometimes
on perineal exam see bulging bluish membrane b/w the labia
Imperforate Hymen
121
malformations of urogenital sinus and Mullerian ducts
normal uterus, breasts, ovaries, body hair
abnormal vagina
Transverse vaginal septum (46, XX)
122
DDX for amenorrhea + presence of breasts but NO uterus
Mullerian agenesis
| Complete androgen insensitivity
123
normal female secondary sexual characteristics
breast development and body hair present
normal estrogen + testosterone levels (b/c ovaries are intact)
absence of all Mullerian duct derivatives (fallopian tubes, uterus, cervix, upper vagina)
short vagina
Mullerian Agenesis (46, XX)
TX:
- surgical elongation of vagina for sex
- counseling about infertility
124
breasts present
no pubic hair
"B/L inguinal masses" --> actually testes
no Mullerian structures ("vagina ends in blind pouch")
U/S shows testes
Complete Androgen Insensitivity (46, XY)
--> mutation of androgen receptor gene
TX:
- remove testes before age 20 b/c of increased risk of testicular cancer
- estrogen replacement
125
DDX for amenorrhea + NO breasts but have uterus
```
Gonadal dysgenesis (Turner's syndrome)
Hypothalamic-pituitary failure
```
126
no secondary sexual characteristics
streak gonads
↑ FSH
Gonadal dysgenesis (Turner's syndrome, 45, XO)
TX:
- estrogen + testosterone replacement
127
no secondary sexual characteristics
uterus present
↓ FSH and LH
Hypothalamic Pituitary Failure
TX:
- estrogen + testosterone replacement
Kallmann's Syndrome --> same presentation + anosmia (due to lack of GnRH)
128
genetically male but when born external genitalia looks like female
male internal genitalia
at puberty get masculinization due to increased testosterone
no breast development
5- alpha-reductase deficiency (46, XY)
- can't convert testosterone --> DHT
129
get gestational maternal virilization (resolves after birth of baby) AND virilization of XX fetuses
```
normal internal genitalia but ambiguous external genitalia (virilization)
clitoromegaly
↑ FSH, LH w/ ↓ estrogen
primary amenorrhea
tall stature
risk of osteoporosis
```
Congenital Aromatase Deficiency
- can't convert androgens --> estrogens
130
scarring of uterus after infxn OR postpartum procedure (eg. D&C)
Asherman syndrome
TX: lysis of adhesions + estrogens
131
amenorrhea at age <40
hypoestrogenic sxs (hot flashes, ↓ bone mass, ↑ fx)
↑FSH, LH
↓ estrogen
Primary Ovarian Insufficiency
132
Causes of Primary Ovarian Insufficiency
- anticancer drugs
- pelvic radiation
- galactosemia
- autoimmune oophoritis (ovary inflammation)
- Turner syndrome
- Fragile X syndrome
* ** Associated w/ autoimmune disorders (eg. pernicious anemia, Addison's disease)
133
Tx of Primary Ovarian Insufficiency
PO or transdermal estrogen therapy w/ progestin in women w/ intact uterus to ↓ risk of endometrial CA
--> continue estrogen until age 50
NOTE: To get pregnant, pt needs IVF w/ donor oocytes
134
Definition of Secondary Amenorrhea
regular menses replaced by absence of menses for 3 months OR
irregular menses replaced by absence of menses for 6 months
135
Causes of Secondary Amenorrhea
pregnancy
premature ovarian failure
hypothyroidism (TRH increases prolactin)
PCOS
anorexia nervosa/ excessive exercise
hyperprolactinemia (MDXs or pituitary tumor)
obesity
--> causes anovulation (FSH and LH normal; no progesterone = no menses)
acq'd uterine abn
hypothalamic or pituitary disease
136
Hormone Values and Tx of Anorexia Nervosa
↓ GnRH
↓ LH, FSH
↓ estrogen
```
TX:
pulsatile GnRH
estrogen
vit D and Ca2+
increase caloric intake
```
137
Long term consequences of anorexia nervosa
osteoporosis
| increased cholesterol and TGs
138
Interpretation of Progesterone Challenge Test (PCT)
(+) PCT = pt bleeds
- -> pt has enough estrogen
- -> means pt has anovulation
- -> tx w/ cyclic progesterone to prevent endometrial hyperplasia + clomiphene if want to get pregnant
(-) PCT = pt DOESN'T bleed
- -> pt DOESN'T have enough estrogen OR
- -> pt has outflow tract obstruction
139
Interpretation of Estrogen - Progesterone Challenge Test (EPCT)
- 3 weeks of estrogen followed by 1 week of progesterone
- done to distinguish if underlying problem is inadequate estrogen OR outflow tract obstruction
(+) EPCT = pt bleeds
- -> pt DOESN'T have enough estrogen
- -> get FSH level
- ↑ FSH level = ovarian failure
- ↓ FSH level = hypothalamic-pituitary insufficiency (get brain CT/MRI to r/o tumor; give estrogen to prevent osteoporosis and cyclic progestin to prevent endometrial hyperplasia)
(-) EPCT = pt DOESN'T bleed
- -> pt has outflow tract obstruction or endometrial scarring (eg. Asherman syndrome)
- -> order hysterosalpingogram to identify lesion (tx is adhesion lysis)
140
```
sxs occur days before menses and go away after period:
breast tenderness
pelvic pain and bloating
irritability
lack of energy
headache
```
Premenstrual syndrome
DX: pt should keep menstrual diary
141
Severe form of premenstrual syndrome
| affects daily functioning and relationships
Premenstrual dysphoric disorder
142
Tx for premenstrual syndrome OR premenstrual dysphoric disorder
SSRIs
| --> if first SSRI ineffective, try another SSRI OR combined OCP
143
pts w/ premenstrual syndrome OR premenstrual dysphoric disorder are at increased risk of what?
psychiatric disorders (lifetime risk 80%)
- anxiety
- depression
- mood disorders
144
```
obesity
acne
graudual onset hirsutism
irregular bleeding
infertility
```
Polycystic Ovarian Syndrome (PCOS)
145
Dx of PCOS
↑ LH: FSH ratio (3:1)
↑ testosterone
U/S --> B/L enlarged ovaries w/ multiple subcapsular small follicles and increased stromal echogenicity
146
Tx of PCOS
Weight loss (1st line in woman trying to get pregnant)
OCPs
Spirinolactone
Clomiphene citrate OR human menopausal gonadotropin (HMG) for infertility
--> if doesn't work, give FSH and LH
Metformin
147
Comorbidities of PCOS
```
metabolic syndrome (DM, HTN)
obstructive sleep apnea
nonalcoholic steatohepatitis
endometrial hyperplasia/cancer
```
148
how to dx DM II in PCOS?
must use glucose tolerance test
| --> CAN'T use HgA1C or fasting glucose
149
```
sever form of PCOS:
temporal balding
clitoral enlargement
deepening of voice
hirsutism
acne
```
Hyperthecosis
--> ↑ testosterone, androstenedione = virilization
150
RAPID onset hirsutism and virilization
| No FHx
Adrenal OR Ovarian Tumor
Adrenal Tumor = --> ↑ testosterone AND DHEAS
Ovarian Tumor = --> ↑ testosterone
DX:
U/S (ovarian mass) or CT (adrenal mass)
TX:
surgical removal of tumor
151
Avg age of menopause
| FSH and LH levels in menopause
Avg age = 51
↑ FSH and LH (b/c ↓ estrogen)
NOTE: obese pts have mild menopause sxs b/c their adipose tissue helps to convert adrogens --> estrogens
152
MCC of mortality in postmenopausal women
cardiovascular disease
153
Ca requirement in menopause women
1200 mg Ca/day
154
menopause sxs looks similar to what disease?
Hyperthyrodism --> so get FSH and TSH levels
155
Benefits of Combined Estrogen/Progesterone Menopausal Hormone Therapy
```
Menopausal sx control
Bone mass/fx
Colon CA
DM II
All-cause mortality (<60 yoa)
```
156
Detrimental Effects of Combined Estrogen/Progesterone Menopausal Hormone Therapy
```
DVTs
Breast CA (ok if pt <60)
CAD (age ≥ 60)
Stroke
Gall bladder disease
```
157
MC reason for why women stop menopausal hormone therapy
irregular bleeding (common in 1st 6 months of use)
158
recommendations for menopausal hormone therapy dose and length?
use lowest dose for shortest time (3-5yrs)
159
RFs for Osteoporosis
```
Increased age (MOST IMPT RF)
+ FHx in thin, white woman
steroid use
low Ca intake (eg. vegan diet)
sedentary lifestyle
smoking
alcohol (>3 drinks/day)
Celiac D
Vit D def
hyperparathyroidism
hyperthyroidism
```
160
MDXs that predispose to osteoporosis
glucocorticoids
anti-androgens
anti-convulsants
161
DX of osteoporosis
DEXA scan
--> T score ≤ -2.5 = osteoporosis
PTH, Ca, Phos = NORMAL
162
Tx of osteoporosis
First Line: Ca (1200 mg/d), Vit D (800 IU/d), bisphosphonates, SERMs (eg. tamoxifene, raloxifene)
Second Line:
- calcitonin
- denosumab
- teriparatide (PTH analog)
NOTE: if pt doesn't respond to therapy or has rapidly progressing osteoporosis, look for secondary causes (eg. multiple myeloma)
163
Emergency Contraception (Most --> Least Effective)
Copper IUD (MOST EFFECTIVE EMERGENCY CONTRACEPTION)
Ulipristal (antiprogestin)
Levonorgesteral pill (plan B)
OCPs
164
Regular Contraception (Most --> Least Effective)
Progestin Implant (Nexplanon) --> >99% efficacy
IUD --> 99% efficacy
--> first line in adolescents b/c easy to use and effective
IM injection (Depo)
OCP
--> lactating mom = progestin ONLY OCP
Condoms
165
CIs to IUD use
```
acute pelvic infxn
cervicitis (friable cervix)
pelvic malignancy
undiagnosed vaginal bleeding
pregnancy
wilson disease/copper allergy (if considering Copper IUD)
```
166
SEs of Progestin vs Copper IUD
Progestin:
- irregular bleeding
- amenorrhea
- -> b/c of this SE, progestin IUD preferred over copper IUD in pts w/ SCD (b/c get decreased bld loss over time)
Copper:
- heavier menses
- dysmenorrhea
167
MDX that decrease OCP effect
rifampin
anti-epileptics (eg. phenytoin)
St. John's wart
168
SEs of OCPs
```
breakthrough bleeding (tx by giving OCP w/ higher dose of estrogen)
reversible cholestasis
hepatic adenoma
Budd-Chiari syndrome
HCC
```
w. gain DOESN'T occur w/ OCP use
169
OCPs protect against what cancers?
Ovarian and endometrial (remember breastfeeding protected against ovarian and breast CA)
170
CIs to OCP use
```
Migraine w/ aura
Smokers ≥ 35 yoa
HTN ≥ 160/110
pregnancy
acute liver disease, cirrhosis, liver CA
DVT/CVA/SLE
Heart disease
breast CA
Antiphospholipid syndrome
DM w/ vascular disease
thrombophilia
```
171
Infertility Definition
Age <35: no preg in ≥ 12 months
| Age ≥ 35: no preg in ≥ 6 months
172
Causes of Infertility in Following Cases:
<30 yoa, normal period
<30 yoa, abnormal period
>30 yoa, normal period
<30 yoa, normal period = PID
<30 yoa, abnormal period = PCOS
>30 yoa, normal period = endometriosis
173
Workup for Infertility
1) Semen analysis
- -> if abnormal, repeat in 4-6 wks
- -> repeat sample also abnormal, need IVF or intracytoplasmic sperm injection
2) Anovulation
- -> hypothyroidism and hyperprolactinemia = reversible causes
- -> ovulation induction via clomiphene citrate (if have enough estrogen) OR human menopausal gonadotrophin (if pt has ↓ estrogen)
- -> look out for ovarian hyperstimulation syndrome
3) Fallopian Tube Abnormalities
- -> hysterosalpingogram (HSG) - if normal, no more workup
- -> laparoscopy (if HSG abnormal)
174
```
bleeding in preg pt <16 wks gestation
passage of vesicles from vagina ("grapes")
HTN
hyperthyroidism
hyperemesis gravidarum
no fetal heart tones
fundus larger than dates
```
Gestational Trophoblastic Disease
175
Complete Hydratiform Mole Characteristics
Empty Egg
46, XX
Fetus absent
20% progress to malignancy (chorioCA)
176
Incomplete Hydratiform Mole Characteristics
Normal Egg
69, XXY
Fetus nonviable
10% progress to malignancy (chorioCA)
177
Dx of Gestational Trophoblastic Disease
urine B-hCG (+)
U/S --> homogenous intrauterine echoes w/o gestational sac or fetal parts ("snowstorm")
178
Tx of Gestational Trophoblastic Disease
Baseline B-hCG
CXR (r/o metastases)
D&C
--> then measure B-hCG weekly till 6-12mo
--> give OCPs so pt doesn't get preg during f/u period
--> discontinue B-hCG measurement if get 3 (-) consecutive results
--> no preg for 6 mo after B-hCG normal
179
MC sites of metastases in pt w/ Gestational Trophoblastic Disease
1) Lungs
| 2) Vagina
180
Tx for Choriocarcinoma
Chemotherapy (methotrexate) + hysterectomy
181
```
pelvic P and heaviness
low back pain
posterior vaginal mass that increases w/ valsalva maneuver
obstructed voiding
urinary retention
urinary incontinence
constipation
fecal urgency/incontinence
sexual dysfunction
```
Pelvic Organ Prolapse
--> due to injury of pelvic floor muscles (eg. during delivery)
182
RFs for Pelvic Organ Prolapse
obesity
multiparity
hysterectomy
postmenopausal age
183
Tx for Pelvic Organ Prolapse
vaginal pessary
| surgery (if pessary fails)
184
Postexposure PPX for sexual assault
- HIV (3 drug tx; offer upto 72 hrs after assault)
- Hep B (Hep B vaccine + IG --> not needed if prev. vaccinated)
- Chlamydia (azithromycin)
- Gonorrhea (ceftriaxone)
- Trichomonas (metronidazole; not needed if asymptomatic)
185
Pain, tendernes on lateral sides of vulva (3 and 7 o'clock)
| Dyspareunia
Bartholin Gland Cyst
Tx: I&D (fld should be cx)
---> if it occurs in woman > 40, do excision b/c might be cancer
186
Causes of True (Central) Precocious Puberty
Female <8, Male <9
early activation of hypothalamic-pituitary-gonadal axis
--> see testicular/clitoral enlargement
187
Causes of Pseudo (Peripheral) Precocious Puberty
CAH
exogenous hormones
adrenal tumors
--> see virilization of girls
188
McCune -Albright Syndrome
precocious puberty + bone lesions + cafe-au-lait spots
