GYN Flashcards
Vaginal discharge
Red and swollen vulva
Hx of use of tampon, condom or diaphragm
Foreign body
Bleeding at irregular intervals particularly between expected menstrual periods
examples?
Metrorrhagia or intermenstrual bleeding
Endometrial polyps,
DUB,
uterine or cervical cancer,
OCP
When does the screening start for cervical cancer?
Screening starts at 21 independent of sexual Hx
Extension of areas of endometrial glands and stroma into the myometrium
Mean age 40-50 yr;Common in parous women
Clinical Features Pain: New onset dysmenorrhea Pelvic pain Dyspareunia Heavy menstrual bleeding
Bimanual Exam: Bulky/ boggy, symmetrically enlarged, smooth*, globular, mobile, tender uterus
Adenomyosis
What is the clinical feature of endometrial cancer?
Postmenopausal vaginal bleeding
Pathophysiology: ↓estrogen at perimenopause and menopause
History
HX: Varying discharge; Dyspareunia; vaginal dryness
Peri/postmenopausal
PE: Pale, thin vaginal mucosa
Wet mount: folded, clumped epithelial cells
Atrophic vaginitis
Hx of sexual contact
Whitish pink to reddish brown, fleshy/soft, painless wart-like growths on external genitalia, perineum or anus
May enlarge to form cauliflower-like lesions
Pap smear: koilocytes
Condyloma acuminatum
Protective factor for endometrial cancer
Protective factor: OCPs ↓ risk
Cycles occurring at intervals < 21 d
Polymenorrhea
First infection
Fever, malaise
multiple, very painful, vesicular, ulcers
Inguinal lymphadenopathy
Viral culture
Gold standard; preferred in patients with ulcer
Direct fluorescent antigen (immunofluorescence)
Using cells scraped from ulcer bases
Genital herpes (HSV2)
loss of the normal ligamentous support for the uterus
causes the uterus to descend into the vaginal canal
Uterine prolapse
Watery discharge with foul odor
Dyuria and dyspareunia if severe
Profuse, frothy, yellowish, or greenish malodorous discharge; pH > 4.5; “strawberry cervix
Wet mount: round or pear-shaped protozoa
Trichomoniasis (Trichomonas vaginalis)
Lack of organic pelvic disease
Prostaglandins
Primary dysmenorrhea
Primary: presents 2 to 4 weeks after exposure
Painless (papule/ulcer with raised borders)
heals without Tx after 3-6 weeks
Painless bilateral inguinal lymphadenopathy
Serology usually negative
Syphilitic chancre
Secondary: 2 to 6 months after exposure
Generalized maculopapular rash- palms, soles, trunk, limbs
Flat, round or oval papules in the perineal area covered by a gray exudate
Serology usually positive
Condyloma lata (Treponema pallidum)
decrease in FSH/LH
increase prolactin
Prolactinoma
Common sites of endometrial implants:
uterosacral ligaments
rectouterine pouch (pouch of Douglas)
peritoneum
protective factors for ovarian cancer
Protective Factors (for epithelial ovarian cancers) ↓ number of ovulatory cycles OCP use Pregnancy and breastfeeding Hysterectomy and salpingo-oophorectomy
risk factors for ovarian cancer
Risk Factors
↑number of ovulatory cycles
Nulliparity, early menarche, late menopause
Age > 50
Genetic factors:
BRCA1 and BRCA-2; FHx of breast, colon, endometrial, ovarian cancer
History:
D/C: initially watery, becoming dark brown or red
Vaginal bleeding: post-coital, postmenopausal or intermenstrual
Physical Exam
Cervical D/C
Friable, raised, reddened or ulcerated cervical mass
Colposcopy
dysplasia may show white areas with mosaic pattern
with acetic acid application
Squamous type Cervical cancer
Uterine prolapse
3rd degree:
the cervix and vagina drop outside the introitus
highest in 25-29 yr
Clinical Findings
Infertility
Pain: dysmenorrhea, deep dyspareunia, chronic pelvic pain,
Examination:
Adnexal masses* or tenderness
Nodules/ tenderness- in the posterior vaginal fornix, uterosacral ligament, *rectovaginal septum
Fixed, retroverted uterus
Endometriosis
What age should the HPV vaccine?
(Gardasil 9): CDC recommendation
All boys and girls age from age 11
May be given up to age 21 (men), 26 (women)
Absent upper vagina and uterus; cryptorchid testes
46, XY
breast dvlpment
Complete androgen insensitivity
synrome
Abnormal bleeding: most common presenting symptom
Rapid uterine enlargement
Pelvic or abdominal pain
Uterine Leiomyosarcoma
2 stages:
Vaginal or cervical infection
Ascending infection to the upper genital tract
History Nausea, vomiting, fever Lower quadrant pain and cramping May be accentuated by motion or coitus Vaginal discharge or bleeding
Mucopurulent cervical discharge
Cervical motion tenderness + adnexal tenderness
Salpingitis
HX: Partner with NGU
Often no Sx + Postcoital spotting
PE: +/- Purulent discharge
Cervix may or may not be red or friable
Chlamydia (Chlamydia trachomatis)
Age > 40, risk factors for endometrial disease, no response to Tx
what investigations and why ?
Transvaginal ultrasound
Assess endometrial thickness and other pathologies
Endometrial biopsy
To r/o endometrial hyperplasia and cancer
breast dvlpment variable (depending on ovarian function)
Vagina: normal
Uterus: normal
Ovaries: streak
45, XO
Turners Syndrome
Cyclic bleeding with diminished flow or shortening of menses
Hypomenorrhea
Risk factors for Endometrial cancer ?
Risk factors: ↑ estrogen exposure** Obesity Chronic anovulation; PCOS Nulliparity Early menarche/ late menopause unopposed postmenopausal estrogen replacement
a hernia of the bladder wall into the vagina
causes a soft, anterior fullness
Cystocele
Cycles occurring at intervals > 35 d
Oligomenorrhea
What can you find expect to find during a Bimanual exam for Ovarian CA?
Premenopause: enlarged ovary
Postmenopause: palpable ovary
Solid, irregular, or fixed pelvic mas
Absent or rudimentary upper vagina and uterus
Mullerian agenesis
Uterine prolapse
2nd degree:
the cervix is at the introitus
Rotterdam Criteria- must meet 2 of 3:
Oligo/anovulation
menstrual cycles > 35 days apart or
Signs of hyperandrogenism
Clinical: hirsutism (less common- alopecia); acne
Biochemical: ↑DHEA-S, *free testosterone, SHBG
Polycystic ovaries by ultrasound
>10 small antral follicles are seen in each ovary
PCOS
PE: Purulent cervical discharge; Skene/ Bartholin gland inflammation
+/- Inflammation of cervix and vulva
Gonorrhea (Neisseria gonorrhea)
complication of sexually transmitted infections
Pain: dyspareunia, dysuria, RUQ abdominal pain
Vaginal discharge + foul odor
Risk Factors: age < 25, risky sexual behavior, early age at first intercourse
PE
Acute: fever; cervical motion tenderness; very tender uterus and adnexae
Chronic: bilateral tender, irregular, fairly fixed adnexae
Abnormal cervical discharge or bleeding
can cause Fitz-Hugh-Curtis (perihepatitis) syndrome
PID
Secondary dysmenorrhea
Endometriosis* Adenomyosis* Leiomyomas* PMS) IUD
HX: Intense pruritus, swollen, inflamed genitals, vulvar burning, dysuria, dyspareunia
Hx of immunosup-pression, recent ATB use, ↑estrogen levels
PE: White, curdy discharge; pH < 4.5 Cervix may be red
+ Erythema of perineum or thighs
Tests: KOH: spores; mycelia, budding, branching yeast; pseudohyphae
Moniliasis / Candida vulvovaginitis (Candida albicans)
Hx of sexual contact
Painless, dimpled or umbilicated flesh-colored or pearly papules several millimeters in diameter in genital area
resolve spontaneously within months of appearance
cytoplasmic inclusion bodies
Molluscum contagiosum
Most common benign tumor of the pelvis
40-50% of pre-menopausal woman > 35 yr
Heavy menses + clots
Dysmenorrhea
Bimanual exam
Firm, regular/irregular, nontender nodules
+ enlarged uterus
asymmetric/nodular
Leiomyomata (Fibroids)
Any bleeding that presents > 1 yr after menopause
Post-menopausal bleeding
Uterine prolapse
1st degree:
the cervix remains within the vagina
Risk Factors for Cervical Cancer
HPV infection: Types 16, 18 highest risk
> 99% of cervical cancers contain one of the high risk HPV types
High risk behaviors:
Multiple sexual partners, other STI, early age at first intercourse, high risk male partner
History of STI
Smoking
Immunosuppression
Use of new hygiene products
Allergic vaginitis
leading cause of gynecological cancer deaths
Ovarian cancer
Cyclic bleeding that is heavy (> 80 ml blood loss) and prolonged (>7d)
examples ?
Menorrhagia or heavy menstrual bleeding (HMB)
Endometrial polyps, DUB, adenomyosis, leiomyomas, IUD
Clinical: Absence of menses x 1 yr
↑ levels of FSH on day 3 of cycle
Average age of onset: 52 years
Hot flushes/flashes, night sweats, sleep disturbances, palpitations
Menopause
Swelling on the introitus
Dyspareunia
Discomfort when walking on adducted thighs
Fluctuant mass on either labium
Acute: Hot and tender swelling
Chronic: Non-tender
Bartholin cyst and abscess
Acute- abscess: Hot and tender swelling
Chronic- cyst: Non-tender
