Gyn Flashcards
Mangler fra uterine abnormalities
Absolute CI for COC
- Pregnancy and nursing
- Thromboembolism
- CAD
- Hx of CVA
- Smokers >15 cigarettes a day over 35 years
- Unexplained vaginal bleed
- Abnormal liver function
- Severe cholesterol and TG increase
Relative CI for COC
- Migraine
- Seizure disorders
- High risk for vascular disease and > 40y
- HT
- DM
What is the definition of infertility?
If no conceivement >12m, if female is >35y it is >6m
What is the fecundability?
Ability to conceive in one menstrual cycle. It is about 20-25% in the first months.
What is the most common ovulatory cause of infertility?
PCOS and advanced maternal age.
What is the primary cause of tubal factors of infertility?
PID. Others are salpingitis, tubal ligation, endometriosis, pelvic adhesion.
What test can be used to assess the ovarian reserve?
- CCCT- clomiphene citrate challenge test
- Basal FSH/estradiol testing
- Antral follicle count (AFC)
- Anti-Mullerian hormone assay (AMH)
Tx of infertility in PCOS
Clomid, metformin, weightloss, letrozole (femara)
Tx of infertility in POF
No tx, lack viable oocytes.
What is the most effective way of tx cervical cause of infertility?
IUI- Intrauterine insemination
Tx of tubal factor of infertility?
- Tuboplasty with tubal reanastomosis
- IVF
Tx of uterine cause of infertility?
Operative hysteroscopy
SE of Clomid
Hot flash, abd distention, bloating, emotional lability, depression and visual changes. Multiple gestation.
What is ovarian overstimulation sd? (OHSS)
Major complication of OI with gonadotropins. Ovarian enlargement, torsion or rupture. May be complicated by ascites, pleural effusion, hemoconcentration, hypercoagulability, electrolyte disturbance, renal failure and death.
What causes labial fusion?
Exogenous androgen exposure. Most common is 21-alpha hydroxylase def. (CAH)
What causes imperforate hymen?
Failure os embryologic hymen to degenerate and canalize
Sx of imperforate hymen
Cryptomenorrhea, primary amennorrhea, cyclical pelvic pain, central pelvic mass
What is hematocolpos?
Vagina filled with blood
What is hematometria?
Uterus filled with blood.
Tx of imperforate hymen
Hymenectomy
What is vaginal atresia?
Developmental failure of the lower 2/3 of vagina. From urogenital sinus. Replaced with fibrous tissue.
Sx of vaginal atresia?
No vagina, “vaginal dimple”. Cryptomenorrhea, hematometria.
tx of vaginal atresia
Vaginal pull through procedure
What is other name of vaginal agencies?
Mayer-Rokitansky-Kuster-Hauser sd
What is MRKH?
Failure of Mullein ducts to develop, resulting in absence in fallopian tubes, uterus, cervix and upper 1/3 of vagina. Ovaries are present, hormones are normal
Tx of MRKH sd
Frank and Ingram procedures, Serial vaginal dilators, surgery to create a neovagina (McIndoe procedure). Psychosocial
What is lichen simplex chronicus
Epidermal thickening due to excess itching. Thick and lethery. Excoriations from frequent itching.
tx of lichen simplex
Topical corticosteroids, bethamethasone. Fitz bath. Antihistamines.
What is the indications for biopsy of vulvar lesion ?
- Ulceration
- Unifocal lesion
- Uncertain suspicion
- Unindentifiable lesion
- Lesion that recur after tx
What is lichen sclerosus?
Chronic inflammatory disease, often in postmenopausal. Ass. w au.im ds. Vulvar/ anal pruritus. Dyspareunia. Crinckled cigarette paper. Figure of 8.
What is important when making dx og lichen sclerosus?
Take biopsy to exclude neoplasia. 4-6% develop vulvar cancer.
tx of lichen sclerosus
Short term high potency steroid ointment. Clobetasol. Estrogen cream w concurrent atrophy. Surgery for unresponsive case.
What is lichen planus?
atrophic inflammatory condition. Characterized by shiny white-purple papules, esp on labia minora. Is a systemic condition. Usually middle aged (30-60). sx is pruritus
tx of lichen planus
Vaginal hydrocortisone suppositories. Discontinue irritants. Adhesions w vaginal dilators or surgery. Ass. w 3-4% risk of ca.
what is a typical hx of pat w vulvar psoriasis
- pruritus ass w lesions
- ex w stress and menses
- impr. w pregnancy and summer
- often skin lesions elsewhere.
What is gartners duct cyst?
Most common benign cystic lesion of vagina. Usually asx. Rarely mass effect. Asss w GU anomalies. Located on anterolateral wall of proximal vagina. Are remnants of mesonephric ducts of Wollfian system.
Atrophic vaginitis
Thinning of vaginal epithelium due to decreased estrogen. Sx is pruritus, dyspareunia, dryness, burning, discharge. Very common in postmenopausal.
tx of atrophic vaginitis
low dose estrogen cream
What is transverse vaginal septum
Inproper fusion of Mullein ducts and urogenital sinus. Presents w primary menorrhea (cryptomenorrhea). If incomplete septa may have normal menses, but can cause dyspareunia.
What is longitudinal vaginal septum
Often asx, noticed on PE. Ass. w uterine septum or uterine didelphys. May lead to OB complications
What is epidermal inclusion cyst
Proliferation on epidermal cells within a circumcised area of the dermis. May result in plugging of pilosebaceous unit. Most are asx, but can cause pain/tenderness or bc infected (odor/pus). Flesh color, <1cm. Elective excision, I&D if infected.
What is hidradenoma
Benign cyst of the apocrine sweat gland. Often hx of similar cyst. Feature of Hidradenitis suppurativa and Fox-Fordyce ds.
Bartholins gland cyst
Obstruction and cystic dilatation of Bartholins duct. Reproductive age. Idiopathic. May be 2nd to trauma or inf. If large dyspareunia, pain. Unilateral, round ovoid at 4 or 8 o’clock. Age >40 biopsy!
Tx of Bartholins gland cyst
- Small: no mx
- Large: 1) word catheter 2) I&D w marsupialization
Skenes gland cyst
Paraurethral glands located next to urethra meatus. Caused by chronic inflammation, obstruction and eventually cystic dilation of gland. Act as reservoir for Trichomonas
Urethral carbuncle and prolapse
Small, red and fleshy. At distal urethral meatus. Postmenopausal, result of atrophy. Ectropion at posterior urethral wall. If bloody spotting use topical estrogen.
What are the cervical cysts, and which need removal?
Nabothian (majority), mesonephric, and endometriosis. Do not need removement unless symptomatic or interfere w Pap-test.
What is nebothian cyst
Clear to yellow/white elevation of endocervix/proximal ectocervix. Rarely >1cm. Contain mucus, block endocervical gland.
What is mesonephric cyst
Remnant of Wolffian ducts. Extend deeper into cervical stroma. More commonly found on ectocervix
How is endometriosis cyst on cervix
Red-purple. Ass w worsening w menses. Cyclic pelvic pain and dyspareunia.
Cervical polyps
Most are asx. Almost always bening. Presents w postcoital bleed, inter menstrual bleed. Should be removed to prevent masking bleed from other source.
Cervical stenosis
Narrowing/obliteration of cervical canal. May be congenital(segmental Mullein hypoplasia) or acquired( inf/ atrophy/ scarring). Sx may be mild or cryptomenorrhea, 2nd dysmenorrhea, infertility, OB complications, enlarged uterus
dx of cervical stenosis
inability to pass 1-2cm probe into uterine cavity.
tx of cervical stenosis
cervical dilation, misoprostol, leaving catheter
what is the most common ca in women?
Breast cancer
what is the effect of estrogen on breast
Promote ductal development and fat deposition
what is the effect of progesterone on breast
Promote lobular-alveolar development
what is the effect of prolactin on breast
Milk production
What is the effect of oxytocin on breast
Let down of milk
When is nipple discharge concerning?
- bloody or serosanguius
- unilateral
- ass w mass
- persistent
- from a singe duct
Most common cause of bloody discharge from nipple
Intraductal papilloma or sometimes invasive papillary cancer
Galactorhea causes
- pregnancy
- pit.adenoma
- hypothyroidism
- stress
- meds: OCP, antiHT, psychotropics
Serous discharge form nipple
- normal menses
- OCP
- fibrocystic change
- early pregnancy
yellow-tinged nipple discharge
fibrocystic change or galactocele
Green and sticky nipple discharge
duct ectasia
purulent nipple discharge
mastitis, breast abscess
Ovarian cause of female infertility?
PCOS and advanced maternal age. Others are POF, hypothalamic amenorrhea, hyperprolactinemia.
Uterine factors of female infertility?
- Congenital malformation
- Submucosal fibroid
- Uterine polyps
- Intrauterine synechiae (Asherman)
Cervical factors of infertility?
Mullerian duct abnormalities, cervical stenosis, cervicitis or chronic inflammation.
what is endometriosis?
Presence of endometrial glands and stroma outside the normal location, excluding adenomyosis. Hormonally dependent on estrogen.
What are the theories og pathophysiology of endometriosis
- Exact MoA has not been discerned
- Retrograde menstruation/Sampson
- Lymphatic/varscular spread/Halban
- Coelomic metaplasia/Meyer (progenitor cells)
- Induction theory( exposure to estrogen cause transformation of tissue)
- Immune dysfunction
Where is the most common site of endometriosis?
Ovary and pelvic peritoneum
risk factors for endometriosis
- 1st degree relative
- genetic mutation
- anatomic defect
- Au.imds: SLE, asthma, hypothyroidism, chronic fatigue sd, fibromyalgia, allergy
- Environment: TCDD/dioxins, caffeine, alcohol
- Nulliparity
- Early menarche
- Prolonged menses
- Mullerian anomalies
presentation of endometriosis
- Cyclical or chronic pelvic pain , peak 1-2d before mens
- dysmenorrhea
- dyspareunia (esp deep)
- dysuria
- defacatory pain
- infertility
how is PE in endometriosis
Speculum is usually normal, occasionally blue or powder-burn red lesion.
Bimanual: Uterosacral nodularity and tenderness. Fixed retroverted uterus. Enlrarged cystic adnexal mass. Fixed firm posterior cul de sac.
what is gold standard in endometriosis dx
Laparoscopy
mx of endometriosis
- Pseudopregnancy: NSAID, COCs, progestins
- Pseudomenopause: Androgen/danazol, GnRH analog/leuprolide/nafarelin
- Aromatase inh./ anastrozole, used w COCs or GnRH agonist
- Surgical: lesion ablation, resection of endometrioma, presacral neurectomy, hysterectomy w BSO (definite, done w child)
