GYN OB Flashcards
Absence of menstruation by age 16
Primary Amenorrhea
What is the lab workup for primary amenorrhea?
- Quantitative Beta-HCG (pregnancy exam) 2. FSH, LH, prolactin, TSH(T3/T4), 3. May consider genetic testing
What imaging studies are order for primary amenorrhea?
Abdominal/Pelvic U/s, MRI or CT to r/o out CNS, abdominal or pelvic mass
What are the causes for primary amenorrhea?
- Gonadal agenesis or dysgenesis
- GNRH Deficiency
- Constitutional pubertal delay
- Hyperprolactinemia
- Ovarian resistance syndrome (PCOS)
- Stress
- CNS Mass
What is the max age for failure of menarche onset in the presence of 2nd sex characteristics ?
15/16
What is the age for failure of menarche onset in the absence of 2ry sex characteristics?
13
What are the etiologies of 1ry amenorrhea with uterus present and breast present ?
Outflow obstruction
Outflow obstruction consists of ?
Transverse vaginal septum, imperforate hymen
What are the etiologies of 1ry amenorrhea with uterus absent and breast present ?
Mullerian agenesis (46XX) Androgen insensitivity (46XY)
What are the etiologies of 1ry amenorrhea with uterus present and breast absent ?
Elevated:FSH/LH=Ovarian Causes
1. Premature ovarian failure 2. Gonadal dysgenesis (Turner’s 45X0)
Normal /Low: FSH/LH=
- Hypothalamus-Pituitary Failure
- Puberty delay (ex athletes, illness, anorexia)
What is Dysfunction uterine bleeding?
abnormal uterine with no underlying cause -no organic or anatomic
What is the normal menstrual cycle
24-35 days
Heavy bleeding at normal intervals
menorrhagia
bleeding between cycles
metrorrhagia
Irregular intervals with excessive bleeding
menometrorrhagia
What is oligomenorrhea ?
Infrequent cycle >35years
What is polymenorrhea
frequent cycle <21 days
How is dysfunction uterine bleeding diagnosis?
Dx of exclusion
What is the treatment of DUB?
NSAIDS, OCP/IUD, ablation/sx if persistent
What is 2nd amenorrhea ?
Cessation of menses of 6 (3) months with previous normal menses or >6 months of pets with oliogmenorrhea
what is the MC of 2nd amenorrhea
Pregnancy
What is the evaluation of 2nd amenorrhea
- Quantitative Beta-HCG (pregnancy exam) 2. FSH, LH, prolactin, TSH(T3/T4)
- Progestin Challenge
Ectopic endometrial tissue outside of the uterus
Endometriosis
What is the MC site for endometriosis ?
Ovaries MC Site
Posterior cul de sac, broad and uterosacral ligaments, recto sigmoid colon, bladder
What are the risk factors of Endometriosis?
NULLIPARITY, fm hx, early menarche,
Onset age of endometriosis
<35
Most common cause of infertility >30
Endometriosis
Endometriosis triad classic presentation?
triad of cyclic premenstrual pelvic pain + dysmenorrhea +
dyspareunia; ± low back pain, dyschezia, spotting
What is definitive dx for endometriosis ?
laparoscopy
Overall Treatment for Endometriosis?
hormonal, NSAIDs, ablation, TAH & bilateral salpingo-oophrectomy (BSO)
Treatment for endometriosis if fertility is desired?
Conservative Laparoscopy with ablation to preserve uterus and ovaries
What medical treatment suppress ovulation ?
Progesterone,,
Leuprolide and danazol
What Suppress GnRH, causes endometrial tissue atrophy and suppress ovulation?
Progesterone
Testosterone (induces pseudomenopause-suppresses FSH & LH, mid cycle surge)
Danazol
GnRH analog causes pituitary FSH/LH suppression and causes GnRh inhibition when given continuously
Leuprolide-used for ovulation suppression and shrinks uterus put to 50%, will rtc to size once medication therapy is stop.
Ectopic endometrial tissue within myometrium
Adenomyosis
triad of non-cyclical pain + menorrhagia + enlarged uterus
Adenomyosis
How is Adenomyosis diagnosis?
MRI, post-total abdominal hysterectomy (TAH) examination of uterus
What is treatment of Adenomyosis?
TAH - only effective therapy; NSAIDs & hormones for symptomatic relief
When does adenomysosis presents ?
Later in reproductive years
What is PE of adenomyosis ?
Tender “symmetrically” enlarged “Boggy uterus”; Symmetric soft and tender.
What is Leiomyoma ?
AKA Uterine Firboids, Fibromyoma; Uterine smooth muscle tumor, “Benign Bleeders”
What hormone is responsible for Leiomyoma ?
Estrogen: Growth related to estrogen production, regresses after menopause; May increase with pregnancy in size with the menstrual cycle.
Leiomyoma is most common on what age? What ethnicity?
In 30’s, especially >35; 5x more common in African Americans
Pelvic exam of Leiomyoma?
irregular, hard palpable mass(es)
non tender
What are Leiomyoma CM?
MC -Bleeding/menorrhagia and dysmennorrhea; May present with increase bladder frequency and urgency
How is Leiomyoma (AKA: Uterine Fibroids) DX?
Pelvic US
Medical Treatment for Leiomyoma (AKA: Uterine Fibroids)
hormones, inhibition of estrogen(decrease endometrial growth); Leuprolide and Progestins (causes endometrial atrophy)-decreases bleeding
Definitive Treatment for Leiomyoma (AKA: Uterine Fibroids)
TAH, Fibroids are the MC cause for hysterectomy
What surgical treatment is used if trying to perserve fertility for uterine fibroids ?
Myomectomy; Endometrial ablation, artery embolization-both may affect the ability to conceive
What is endometrial Hyperplasia?
Precursor to endometrial adenocarcinoma (type 1); endometrial gland proliferation cytologic atypia,
What hormone is responsible for Endometrial Hyperplasia
Unopposed estrogen (unopposed by progesterone)
Common causes/etiologies that results in endometrial hyperplasia?
Chronic anovulation, PCOS, perimenopause, obesity (conversion of androgen-estrogen in adipose tissue)
When is endometrial hyperplasia mc?
Postmenopausal women
Presentation of Endometrial Hyperplasia?
menorrhagia, metrorrhagia, postmenopausal bleeding
Endometrial Hyperplasia is diagnosis?
TVUS -ENDOMETRIAL STRIPE >/OR EQUAL 4MM (SCREENING TEST)
What is Endometrial Hyperplasia definitive diagnosis?
Endometrial BX
What is Endometrial Hyperplasia screening test?
TVUS with endometrial stripe >/or equal to 4mm
What is the tx for What is Endometrial Hyperplasia?
Hyperplasia without atypia: progestin
o Hyperplasia with atypia: TAH (if not sx candidate or if pt wishes to perceive fertility)
What is the MC benign gynecologic lesion?
Leiomyoma /Fibromyoma
4th most common female cancer (breast>lung>colon)
Endometrial Cancer
risk factors for the development of endometrial cancer
is an estrogen dependent cancer so the main risk factors are anything that increases estrogen exposure- nulliparity, chronic anovulation, PCOS, estrogen replacement therapy, late menopause, obesity, Tamoxifen. These along with DM, family history, previous h/o breast/ovarian cancer are the most commonly listed risk factors.
due to unopposed estrogen, hyperplasia
Type 1 adenocarcinoma (75%) of Endometrial cancer
unrelated to estrogen, p53 mutation in 90%
Type 2 serous (25%):Endometrial Cancer
Endometrial Cancer Presentation?
Postmenopausal bleeding: abnormal vaginal bleeding; Pre or perimenopausal -menorrhagia or metrorrhagia
Endometrial Cancer is dx?
endometrial biopsy
Endometrial Cancer Treatment if trying to perceive fertility?
high dose progestin(stops estrogen from being unopposed, limits endometrial growth)
Endometrial Cancer Tx for postmenopausal ?
TAH/BSO, ± radiation/chemotherapy depending upon
staging
Endometrial Cancer Tx for stage 1?
TAH/BSO +/- post op radiation therapy
Endometrial Cancer Tx for stage II/III?
TAH-BSO + lymph node excision+/- post op radiation therapy
Endometrial Cancer Tx for stage IV (advanced)
systemic chemotherapy
What are the screening guidelines for endometrial cancer for asymptomatic women?
No current screening guidelines
MC age for endometrial cancer?
50-60; perimenopausal 25%
What hormone is dependent for Endometrial cancer
estrogen
HPV 16 =? what type of cancer
Squamous cell 90%
HPV 18
adenocarcinoma 10%
Cervical cancer risk factors?
Sex =risk ; HPV, early onset of sexual activity, increase # of partners, smoking, CIN, DES exposure, immunosiuppresions, STI’s
S/S of cervical cancer
Post-coital spotting/bleeding, metrorrhagia
Cervical cancer dx?
biopsy cytology
Cervical cancer prevention ?
HPV vaccine against 6, 11, 16,18
What is the 3rd MC gynecologic Cancer ?
cervical cancer
Cervical cancer is associated to which virus?
HPV 99.7% especially 16, 18
When is HPV vaccine CI?
Immunospressed, pregnant and lactating
ACOG guidelines for ages 21-29?
every 3 years (pap smear)
ACOG guidelines for ages 30-65?
Q 3 years or Pap + HPV testing Q 5 years
ACOG guidelines for age >65?
Stop screening if negative (within the last 10 years)
Atypical squamous cells of undetermined significance (ASC-US):
21-24 yo: repeat PAP in 1 yr or HPV test
o ≥25 yo: HPV test or repeat PAP in 1 yr
§ HPV positive → colposcopy
§ HPV negative → repeat PAP & HPV in 3 yrs
Atypical squamous cells, cannot exclude HSIL (ASC-H):
All nonpregnant women → colposcopy
o Higher risk of cancer than ASC-US
Low-grade squamous intraepithelial lesion, includes cervical intraepithelial
neoplasia I [CIN I] (LSIL
Most common cause: transient HPV infection o 25-29 yo: colposcopy with biopsy o ≥30 yo: HPV testing § HPV negative → repeat cytology in 1 yr HPV positive → colposcopy with biopsy o Progression to cancer: 7 yrs
High-grade squamous intraepithelial lesion, includes CIN II, III & carcinoma in
situ (HSIL
Colposcopy with biopsy in all ages
Atypical glandular cells of undetermined significance (AGC
Colposcopy with biopsy in all ages
Malignant transformation is most common at what site in the cervix?
squamocolumnar junction
Common Causes for Cervicitis?
MC is infections and other causes;
STI: Neisseria gonorrheae , Chlamydia, HSV, syphilis, Trichomonas
● Non-infectious: Trauma, XRT exposure
Cervicitis clinical presentation and s/s?
S/S: Pain, vaginal discharge, bleeding, dyspareunia
● PE: Cervical discharge, odor, “strawberry cervix” (Trich), absence of other
PID signs
Cervicitis treatment?
Tx: Week of abstinence after treatment started AND:
○ Gonorrhea/Chlamydia: Always treat for both
■ Ceftriaxone 250mg IM x1 + azithromycin 1g PO x 1 or Doxy
BID x7d
○ Syphilis: Pen G IM
○ Trichomonas: Metronidazole
○ HSV: Acyclovir; 1 st episode 7-10 days; recurrent episodes 5 days
What is vaginal cancer?
Rare, usually 2° to another cancer
● 95% squamous cell carcinoma
● Diethylstilbestrol (DES) exposure ↑ risk for clear cell carcinoma
Symptoms of vaginal cancer?
abnormal vaginal bleeding, vaginal discharge, typically asymptomatic
Treatment for vaginal cancer?
Xray therapy, surgery
What is vulvar cancer?
90% squamous cell
● Risks: HPV 16, 18, 31
S/S of vulvar cancer ?
pruritus (MC presentation), pain, red/white ulcerative lesion; post-coital bleeding (20%)
Vulvar Cancer dx?
Biospy
Most common cause of vaginitis
Bacterial Vaginosis
BV organism?
Gardnerella vaginalis
BV s/s?
Discharge: thin, homogenous, grayish-white, fishy odor, odor worse after sex, +/-pru
How is BV dx? What type of cells?
Dx: + whiff test on potassium hydroxide (KOH) prep,CLUE CELLS on wet mount
BV treatment?
metronidazole PO/PV (SAFE in pregnancy), clindamycin PO/PV
What are BV complications?
Pregnancy-PROM, preterm labor, chorioamnionitis
Trichomoniasis PE ?
“Strawberry cervix” on exam
● Discharge: copious, yellow-green, frothy, malodorous; PH >5
Trichomoniasis microscopic?
motile trichomonads (protozoa) on wet saline prep
Trichomoniasis tx?
metroniadazole
Does trichomoniasis needs treatment for sexual partner?
True
Fungal Vaginitis organism?
Candida albicans
Risk factors of candida albicans?
diabetes mellitus (DM), recent antibiotic or steroid use, pregnancy
Candida PE?
Discharge: thick, white, “cottage cheese” texture with no odor
Candida microscopic?
hyphae, yeast on KOH prep
What is Bartholin Cyst / Abscess?
Duct obstruction → enlarged gland
What causes Bartholin Cyst / Abscess?
infections(E. coli, Staphylococcus auerus, Neisseria gonorrhoeae) or trauma
S/S of Bartholin Cyst / Abscess?
Infectious: tenderness, redness, unilateral mass
o Non-infectious: non-tender, unilateral mass
DX of Bartholin Cyst / Abscess?
cultures, cbc
TX of Bartholin Cyst / Abscess?
Infectious: incision & drainage (I & D) with Word catheter, warm
compresses, antibiotics may be warranted
o Non-infectious: self-limited, usually no treatment required (consider biopsy
for age >40 yo)
What uterus disorder may presents <35 y/o ?
Endometriosis and Leiomyoma
What are Ovarian Cysts?
Common in reproductive years, usually unilateral
● Follicular - associated with ovulation
● Corpus luteum - may be hemorrhagic upon rupture
Dx of Ovarian cysts?
U/S, r/o pregnancy
TX of Ovarian cysts?
NSAIDs, most resolve on their own, repeat U/S, may need surgery if recurrent
● BEWARE: large cysts > 5 cm can lead to ovarian torsion
o Emergent surgical detorsion
When is a emergent surgical detorsion for an ovarian cyst done/required?
> 5 cm can lead to ovarian torsion
Highest mortality of all gynecologic cancers
Ovarian Cancer
Risks of Ovarian Cancer?
Risks: ↑ # of ovulatory cycles, BRCA1 & 2, FHx, Lynch II syndrome (hereditary
nonpolyposis colorectal cancer [HNPCC])
What decreases risk of Ovarian cancer?
OCPs taken >5 yrs
S/S of ovarian cancer?
S/S appear late in disease, vague pain/pressure, bloating, early satiety,
constipation
PE of ovarian cancer ?
Solid fixed abdominal mass on exam, ascites
o Sister Mary Joseph node: metastasis to umbilical lymph nodes
Dx of Ovarian Cancer?
U/S, CT
o 90% are epithelial tumors
o Tumor marker CA-125
TX of Ovarian Cancer?
TAH/BSO + post-op chemotherapy
Prevention in ovarian cancer?
in women who are BRCA 1 positive - annual U/S, CA-125 screening
● Consider prophylactic oophorectomy when childbearing complete
Diagnostic triad: polycystic ovaries + oligo-/anovulation + evidence of
hyperandrogenism
PCOS
PCOS cause ?
Exact cause not known, but associated with ban function of hypothalamus-pituitary -ovarian axis(increase insulin and increase LH-Driven -Increase in ovarian androgen production. Insulin resistance common
● Obesity, acanthosis nigricans
DX of PCOS?
testosterone, dehydroepiandrosterone sulfate (DHEA-S), LH:FSH ratio >2x
normal
o Rule out other causes of hyperandrogenism
o U/S optional - may show “string of pearls
TX of PCOS:
OCPs, antiandrogens
What has increase risk of infertility and endometrial cancer?
PCOS
Pelvic Organ Prolapse?
Weakness of pelvic floor musculature due to vaginal birth, previous surgery,
obesity
● Uterine: herniation into vagina
● Cystocele: posterior bladder into anterior vagina
● Enterocele: small bowel into upper vagina
● Rectocele: rectum into posterior vagina
S/S of Pelvic organ prolapse
pelvic fullness, “falling out” sensation, urinary frequency/incontinence
DX of Pelvic organ prolapse?
bulging mass on exam with Valsalva
TX of Pelvic organ prolapse?
Kegel exercises, pessaries, surgery(hysterectomy; Uterosacral or sacrospinous ligament fixation?
Pelvic Inflammatory Disease (PID)?
Polymicrobial infection; associated with STIs
Risk factors for PID?
Multiple sex partners, unprotected sex, prior PID, age 15-19, nulliparous, IUD placement
S/S and PE for PID?
S/S: pain, fever, purulent cervical discharge, “chandelier sign” on exam
● Dx: high suspicion from exam, U/S for abscess, cervical motion tenderness, adnexal tenders plus +grain stain, temperature >38 C, WBC >10,000, pus on culdocentesis
Treatment for PID?
doxycycline + ceftriaxone to cover chlamydia & gonorrhea
Complications for PID?
infertility, Fitz-Hugh-Curtis syndrome (right upper quadrant [RUQ]
pain, perihepatitis)
Toxic
Fitz-Hugh Curtis syndrome?
hepatic fibrosis/scarring & peritoneal involvement. May radiate to the right shoulder. Infertility, turbo ovarian abscess, ectopic pregnancy and chronic pelvic pain ?
Toxic shock Syndrome etiology?
exotoxins produced by Staphylococcus aureus
Most Common cause of Toxic Shock Syndrome?
tampon use
S/s of Toxic Shock Syndrome?
abrupt onset of high fever, vomiting, diarrhea, diffuse macular red rash
DX of Toxic Shock Syndrome?
clinical, labs, organism isolation is not required
Tx of Toxic Shock Syndrome?
hospital admission, aggressive rehydration, anti-staphylococcal antibiotics (clindamycin + vancomycin (mrsa)
What is mastitis?
Infectious (unilateral; lactating women 2° nipple trauma) vs congestive (bilateral;
2-3d postpartum)
● Staphylococcus aureus is the most common infectious agent
TX for mastitis?
anti-staphylococcal antibiotics, warm compresses, continue to breast feed
Breast abscess:
rare, fluctuant, needs I & D, stop breast feeding from affected side
What is dx for Fibrocystic changes?
U/S, straw colored fluid on fine needle aspiration (FNA)
What is tx for fibrocystic changes
usually none needed
What is fibrocystic changes?
Most common benign breast disorder
● Cysts, ductal epithelial hyperplasia, fibrosis
● Associated with caffeine use
● S/S: cyclic breast tenderness in luteal phase, multiple mobile masses which
fluctuate in size due to hormone levels
Fibroadenoma?
Most common benign breast lesion <30 yo
● S/S: round, rubbery, mobile, nontender mass on exam, no cyclical fluctuation in
size
Dx of fibroadenoma?
U/S, FNA to distinguish from cyst
Tx of fibroadenoma?
± excision
