Gyn Stepup Flashcards
when have all oocytes formed
20 weeks
what causes low FSH LH and androgens in 4-8 yr olds
GnRH suppression
When are initial pubertal changes
8-11 yrs
what time of day are hormones in kids highest
at night
normal events female puberty
adrenarche: adrenal androgens
gonadarche: FSH and LH activation
Thelarche: breast tissue
Pubarche: pibic hair
growth spurt
Menarche: onset menses
what happens in >50 y.o to LH and FSH
increase with onset of ovarian failure
Tanner I
raised nipple and no hair growth yet
Tanner 2
breast budding, areolar enlargement with slight growth of labial hair
Tanner 3
Further breast and areolar enlargement
more hair growth
Tanner 4
areola and nipple form above the breast
hair becomes coarse and spreads over pubic area
Tanner 5
areola recedes and nipple stays out
coarse hair extends to medial thighs
what causes central precocious puberty
early activation of hypothalamic pituitary gonadal axis
precocious puberty age in girls and boys
girls
isosexual precocious puberty
premature development appropriate for gender
heterosexual precocious puberty
virilization/,asculinization firls
feminization boys
girls with virilization is due to CAH, exposure to androgens or androgen secreting neoplasm
what is GnRH stimulation test
give GnRH:
- if LH and FSH increase then central precocious puberty
- if LH and FSH have no response then pseudoprecocious puberty ( peripheral autonomous secretion sex steroids)
labs that suggest ectopic hormone production causing precocious puberty
low LH and FSH with high estrogen
probably noeoplasm or exogenous consumption estrogen
which endocrine path can cause precocious puberty
chronic hypothyroid
what is used for Lh and FSH suppression
GnRH analogues
Tx for precocious puberty caused by CAH
cortisol replacement
complications of precocious puberty
short statures
social and emotional adjustment issues
what peaks right before ovulation
LH
when does progesterone peak
during the luteal phase or proliferative phase
which phase does ovulation occur in
right between end of follicular/proliferative and right before luteal/secretory
what peaks before LH
17B estradiol
when does body temp rise in menstrual cycle
with ovulation
which cells are regulate by LH
theca cells
which cells are regulated by FSH
granulosa cells
what stimulates endometrial proliferation
estrogens
induce the LH surge and hgih levels of Estrogen inhibit FSH secretion
role of progesterone
stimulate endometrial glands development inhibit contraction increase cervical mucus thickness increase basal body temp inhibit LH and FSH secretion maintain pregnancy
decreased levels progesterone leads to
menstruation
role of hCG
acts like LH after implantation fertilized egg
maintain corpus luteum viability
follicular phase
starts with menstruation.
FSH stimulates growth ovarian follicle (granulosa cells) which secete estradiol
role of estradiol in follicular phase
induce endometrial proliferation and increase FSH and LH
Luteal phase
the LH surge causes ovulation and the residual follicle (corpus luteum) secretes estradiol and progesterone to maintain endometrium
high levels estradiol inhibit FSH and LH
what happens when egg is notfertilized
corpus luteum degrades, progesterone and estradiol levels decrease and the endometrial lining degrades (menses)
fertilization
egg implants in endometrium and the endometrial tissue begins to secrete hCG to maintain corpus luteum
CL secretes progesterone until placenta can make it around 8-12 weeks
when does ovulation occur
14 days since 1st day of last menses
premature menopause
ovarian failure before age 40
what happens to FSH and LH in perimenopasual period
increase
but ovarian response decreases
signs of menopause
hot flashes breast pain sweting menstrual irregularity amenorrhea fatigue anxiety dyspareunia urinary frequency change in bowel habits
topical estrogen is contraindicated in what patients
any with a Hx of breast CA
what hormone is decreased in menopause
estradiol
what reduce osteoporosis and CV risks of menopause
raloxifene and tamoxifen
Selective E R modulators
what causes increased risk osteoporosis in menopause
decreased estrogen by ovaries
complications menoapuse
osteoporosis, CAD and dementia
most effective birth control
progestin implant
least effective Rx birth control
progestin OCP and regualr OCP
what birth control should be avoided in obese women
transderman contraceptive patch because diffusion into adipose tissue
how effective is lactation as birth control
95%
how effective are IUDs
99%
what is primary amenorrhea
no menses ever with normal secondary sexual characteristics age 16
13 if no sexual characteristics
secondary amenorrhea
absense of menses for 6 mo+ with prior Hx of menses
causes of secondary amenorrhea
pregnancy ovarian failure hypothalamic or pituitary disease uterine abnormalitiles PCOS anorexia malnutrtion thyroid disease
Ashermann syndrome
intrauterine adhesions from surgical procedure or possible infection
labs to order in amenorrhea
b-hCG TSH T4 T3 prolactin FSH and LH androgens
what is the progestin challenge
five progesterone and observe for bleeding for 5 days
Tx prolactinoma
dopamine agonists
XY patient with androgen insensitivity syndrome and has testicles, next step
remove testicles because of increased risk testicular cancer
primary amenorrhea with secondary sexual charcteristics
causes
look for anatomical abrnomatliies or XY genotype
steps for labs for secondary amenorrhea
check b-hCG
then check TSH, T4T3
then if normal check prolactin
then do progestin challenge
if progestin challenge is negative and have amenorrhea, now what
estrogen-progesterone challenge
if does cause bleeding check FSH and LH
if FSH and LH are hgiht- ovarian failure
if LH and FSH are low- hypothalamic pituitary dysfunction
labs for dysmenorrhea
bhCG and vaginal cultures
US for lesions
hysteroscopy if uterine pathology
Tx for dysmenorrhea
NSAIDs or OCPs
risk factor for severe pain with menses
family histroy
Tx for PMS or PMDD
exercise, Vit B6, NSAIDs, OCPs, progestines, SSRIs, alprazolam
when do mood Sx from PMS occur
second half of cycle
most common cause female infertility
endometriosis
what is endometriosis
endometrial tissue outside the uterus
causes of endometriosis
retrograde menstruation, vascular or lymphatic spread of endometrial tissue, iatrogenic from surgery or C section
risk factors fo endometriosis
FMH
infertility
nulliparity
low BMI
Signs Sx endometriosis
dysmenorrhea, dyspareunia, painful bowel movements
pelvic pain, possible infertility
uterine or adnexal tenderness
palpable adhesions
Labs in endometriosis
Bx of endometrial tissue
bhCG and UA
Ca-125 sometimes increased, but not sensitive
powder burn lesions
seen on laparascopy of uterus with endometriosis
Tx endometriosis
OCPs. progestins, danazol, GnRH agonists
ablation
hysterectomy
adenomyosis
endometrial tissue that invades myometrium causing uterine enlargement and cyclical pain
complications endometriosis
infertility
what are the parameters of defining abnormal mesnes
35 day intervals
lasting >7 days
blood loss 80 mL
labs in abnormal uterine bleeding
bhCG CBC with coag TSH LH FSH PAP smear endometrial Bx
Tx abnormal bleeding
tx underlying disorder
OCPs can help
endometrial ablation
most common cause andogen excess in women
PCOS
what is produced in PCOS
excess LH induces overproduction androgens by ovaries
some have hyperinsulinemia
labs in PCOS
increased LH LH:FSH ration >2 increased DHEA increased total testosterone \+ progestin
what causes amenorrhea and infertility in PCOS
abnomral high LH levels and FSH inhibition by high estrogen
what causes cysts in PCOS
the androgen excess
what is helpful for pregnancy in PCOS
clomiphene (antiestrogen induces follicule stimulation and maturation)
metformin
complications PCOS
infertility, increased risk DM, HTN, ischemic heart disease, ovarian torsion, endometrial CA
what is greatest contributing factor to increased risk endometrial CA in PCOS
increased estrogens
Tx gardnerella vaginalis or BV
metro or clinda
what normal flora overgrowth do you Tx partners for
trichomonas, Tx with metro
on pap exam see cervical petechiae
trichomonas
thin white fishy odor vaginal discharge
gardnerella
malodorous frothy green discharge
trichomonas
clu cells
gardnerella
motile things on slide
trichomonas
+ whiff test
gardnerella (with KOH)
pseudohyphae with KOH
candida
vaginal pH is 3.5-4.5 (normal) and has discharge
candida
vaginal pH is more alkalotic >4.5 and has discharge
gardnerella or trichomonas
Tx for gardnerella
metro
Tx for trich
metro and Tx partner
Tx for candida
topical clotrimazole, miconazole or nystatin
oral fluconazole
signs Sx TSS
vomiting, diarrhea, sore throat, HA, high fever
macular rash
hypotension, shock, resp distress
desquamation palms and soles
labs in TSS
vaginal culture shows staph aureus
dec platelets
inc AST and ALT
inc BUN and Cr
Tx TSS
clinda or penicillinase R beta lactams like oxacillin and nafcillin
vanco if MRSA
what causes cervicitis
N gon or C trach
Signs Sx cervicitis
dyapreunia, bleeding after intercourse, purulent vaginal discharge
urethritis
Dx cervicitis
gram stain for N gonn
enzyme immunoassays or PCR for both
Tx cervicitis
ceftriaxone for N gonn
doxy or azithro for chlamydia
do you T partners for cervicitis
yes
complication cervicitis
PID or septic arthritis
what reduces risk PID
barrier contraception
labs for PID
bhCG
inc WBC and ESR
gram stain
culdocentesis
Tx PID
empiric antibiotics doxy ceftriaone cefoxitin
Tx inpatient if high fever or young age
complications PID
infertility from adhesions
chronic pelvic pain
tuboovarian abscess
increased risk ectopic pregnancy
tubo ovarian abscess presentation
PID with signs of sepsis or peritonitis
Tx tuboovarian abscess
IV hydration, IV antibiotics and surgical drainage
primary syphilis
1-13 weeks post exposure
solitarty chancre that heals sponateously
secondary syphilis
as chancre heals HA, malaise, fever, maculopapular rash on palsm and soles lymphadenopathy papules in moist areas condylma lata resolve spontaneously
tertiary syphilis
1-30 years later
granulmoatous skin bone and liver lesions (gummas)
loss of 2 point discrimination (tabes dorsalis) and argyll robertson pupils
what lab will be + for life with sphyliiss
FTA-ABS
Tx syphilis
Penicilin G, doxy or tetra
IV penicillin G for severe tertiary cases
can you culture for syphilis
no
complications syphilis
destruction from gummas
CV- aortic regurg and aortitis
neuro- cerbral atrophy, tabes dorsalis and meningitis
which HPV assoc with cervical CA
16 18
acetic acid on cervix and some cells turn white
HPV
Tx HPV
podophyllin, trichloroacetic acid, topical 5-fluorouracil, alpha INF
cryotherapy
laser therapy
what strains is HPV vaccine out for
6 11 16 18
complicaitons HPV
vaginal scarring
possible increased risk cervical cancer
chancroid
H ducreyi
painful ulcer with grayish base and foul odor
possible inguinal adenopathy and bubos
gram stain of H ducreyi
gram neg rods
Tx chancroid
ceftriaxone, erythromycin, azithromycin
Lymphogranuloma venerium
L1 L2 L3 serotypes of C trachomatis
different from the one causes cervicitis
signs Sx lymphogranuloma venerium
malaise, HA, fever, formation papule at site that is painless ulcer
after 1 month have significant inguinal buboes
can progress to bubo ulceration and elephatiasis
fistula and abscess formation
labs in lymphogranuloma venereum
immunoassays for chlamydia
Tx lymphogranuloma venereum
tetracycline
erythromycin
doxycyline
what causes granuloma inguinale
Klebsiella granulmoatis
signs Sx granuloma inguinale
papule on external genitatial and becomes painless ulver with beefy red base and irregular borders
mild lymphadenopathy
Bx in granuloma inguinale
giemsa stain shows donovan bodies
red encapsulated intracellular bacteria
Tx granuloma inguinale
doxy or TMP SMX for 3 weeks
risk factors for fibroids (leiomyomas)
nulliparity african american diet high in meats alcohol FMH
signs Sx fibroids
menorrhagia, pelvic pressure or pain, urinary frequency or infertility
what imaging is used for fibroids
transvaginal US or hysteroscopy
Tx for fibroids
follow with US
FnRH agonists reduce bleeding and size but use only temporary
myomectomy for sypmotmatic
hysterectomy for those Sx and already had kids
Uterine artery embolization
endometrial CA with no relation to excess estrogen
worse prognosis
what is endometrial CA
adenocarcinoma of uterine tissue usually related to high exposure estrogen
which syndrome inc risk endometrial CA
lynch syndrome II
signs Sx endometrial CA
heavy menses, midcycle bleeding, postmenopasual bleeding, possible abdominal pain, ovaries and uterus feel fixed
labs for endometrial CA
Bx to examen cells that show hyperplastic abnormal glands with vascular invasion
increased CA-125
Imaging in endometrial CA
CXR and cT to detect mets
transvaginal US to detect mass and measure wall thickness
most common cause vaginal bleeding in menopausal women
atrophic vaginitis
but still need endometrial Bx to rule out cA
Tx endometrial CA
TAH BSO and lymph node sampling
if no kids yet and limited CA to lining, can shrink with progestins and do TAH BSO after childbirth
adjuvant for endometrial CA
radiation for high grade
chemo for spread beyond uterus and cant have radiation
which hormones are good for unresectable endometrial CA
progesterone and tamoxifen
complications endometrial CA
local extension
mets to peritoneum aortic and pelvic lymph nodes, lungs and vagina
most common cervical cancer
squamous cell
risk factors cervical ca
early first intercourse tobacco HPV 16 18 31 33 multiple sexual partners and high risk history STIs
when is first pap smear
21 years old
screening with pap smears
21-29 years old every 3 years
women >30 every 5 years HPV
see abnormal lesion on pap smear, next step
punch biopsy or cone biopsy
imaging for cervical CA
CT MRI or US to determine extent
Atypical squamous cells of undetermined significance
do HPV screening and pap smears in 6 and 12 months
HPV testing in 12 months again
atypical squamous cells, cannot exclude HSIL
next step
do HPV screening, endocervical biopsy
repeat Pap in 6 and 12 months
repeat HPV in 12 months
low grade squamous intraepithelal lesion on pap
next step
this is CIN 1
repear pap in 6 and 12 months
repeat HPV in 12 months
excision loop or leepprocedure or conization/laser therapy
high grade squamous intraepithelial lesion on pap
next step
HSIL or CIN 2 or 3
excision by LEEP or conization or laster
repeat cytology every 6 months
pap shows highly atypical cells with stromal invasion
squamous cell carcinoma
cervical CA visible invasive lesions that involve uterus but to not extend into pelvic wall or lower third of vagina
Tx
radical hysterectomy with lympadenectomy or radiation and cisplatin chemo
cervical cA lesions that extend to parametrial tissue, pelvic wall, lower 3rd vagina or adjacent organs
Tx
radiation and chemo
what is a follicular cysts
from ovarian follicle and granulosa cells
may regress with cycles
have abdominal pain and gullness
Tx for follicular cyst
obsercation
corpus luteum cyst
from theca cells
or hemorrhagic corpus luteum
usually larger than follicular cysts and later in cycle
have abdominal pain and fullness but at greater risk of rupture
greater risk of torsion
Tx corpus luteal cyst
obsercation, cystectomy if does not regress or significant hemorrhage
mucinous or serous cystadenoma
from epithelial tissue resembles endometrial or tubal histo
can have psammoma bodies
Tx mucinous or serous cystadenoma
unilateral SO or TAHBSO if postmenopausal
what is an endometrioma
spread of endometriosis to ovary
abdominal pain, dyspareunia, infertility
Tx endometrioma
OCPs, GnRH agonists, progestins, danazol
cystectomy or oophorectomy frequently required because reoccur
Teratoma or dermoid cyst
from germ cells with multiple dermal tissues
rupture can cause peritonitis
Tx for dermoid cyst
cystectomy with attempted presercation of ovary
stromal cell tumor
granulosa, theca or sertoli leydig cells
secrete hormones
can cause precocious puberty or virilizaiton if sertoli leydig
Tx stromal cell tumor of ovary
unilateral SO or TAH BSO if post menopasual
most common CA of ovaries
epithelial
risk factors ovarian CA
FMH
infertility
nulliparity
BRCA1 or 2
Sx ovarian CA
abdominal pain, fatigue, weight loss, change in bowel habits, menstrual irregularity, ascites
labs in ovarian CA epithelial origin
increased CA-125 in epithelial tumors
labs in germ cell ovarian CA
increased AFP bhCG, LDH
Tx epithelial ovarian CA
TAH BSO with pelvic wall sampling, appendectomy and adjuvant chemo
Tx germ cell ovaraian CA
unilateral SP if limited
surgical debuking
chemo
complications ovarian CA
prognosis is usually poor because at time of Dx pretty advanced
US shows cystic ovarian mass with smooth lesion edges and few septa
benign
US cystic mass show irregularity nodularity, multiple septa and pelvic extension
malignancy
how to properly stage ovarian malignancy
surgical resection and histo staging
what causes breast abscess
S aureus or strep or anaerobic subareolar infections
breast abscesses are more common in which women
smokers
painful mass in breast, fever with plapable red warm breast mass
breast abscess
labs in breast abscess
increased WBCs, fine needle aspiration confirms
Tx breast abscess
oral or IV antibiotic
incision and drainage of fluctuant masses
continue breast feeding
what would a Bx of fibrocystic changes of breast show you
epithelial hyperplasia
when should you start mammos
age 40 or 50 depending
suspicious lesions on mammos are what
hyperdense regions or calcifications
Tx for fibrocystic changes
caffeine and diet reduction
OCPs
progesterone
tamoxifen
what is most common benign breast tumor
fibroadenoma from proliferation of single duct
usually
fibroadenoma findings
solitary solid and mobile
well defined edges
Bx FNA will confirm
Tx for fibroadenoma
surgical excision or US guided crytotherapy
nonbloody nipple disharge
noncancerous pathology
bloody or nonbloody discharge from nipple on stimulation
breast pain and palpable mass behind areola
intraductal papilloma
Tx intraductal paiplloma
surgical excision
most common malignant neoplasm of breast
fuctal CA
risk Fx for breast CA
FMH BRCA 1 or 2 ovarian CA endometrial CA prior breast CA increased estrogen exposure early menarche, late menopause, nulliparity, late first pregnancy increased age, obesity, alcohol, DES, industrial chemicals or pesticides
palpable solid immobile breast lumo
breast CA
peau dorange
lymhatic obstruction causing lympedema and skin thickening that makes breast look like orange peel
most common site breast cancer
upper outer quadrant
next step when find breast mass
biopsy FNA with US
core Bx is more definitive and determines if invasive
most breast CA are detected how
screening mammos
DCIS of breast
ductal carcinoma in situ
malignant cells in ducts without stromal invasion
LCIS of breast
lobular
malignant cells in lobules without stromal invasion
can be multifocal
increased risk CONTRAlateral malignancy
invasice ductal carcinoma
malignant cells in ducts with stromal invasions and microcalcifications
fibrotic response in breast tissue
most common invasive breast CA!!!!!!!
findings in invasive ductal carcinoma
firm palpable mass with skin dimpling, nipple retraction
peau d’orange or nipple discharge
invasive lobular carcinoma
malignant cells in breast lobules with infiltration and less fibrotic response in breat
bilateral and multifocal
slower mets
assoc with hormone replacement!!!!!!!
paget disease of breast
malignant adenocarcinoma infiltrate epithelium of nipple and areola
usually ductal carcinoma
signs of pagets of breast
scaly eczematous or ulcerated lesion on nipple and areola
preceded by pain, burning or itching
inflammatory carcinoma of breast
subtype ductal characterized by rapid progression and angioinvasive behavior, poor prognosis
signs inflammatory carcinoma of breast
breast pain, tenderness, erythema, warmth, pearu d’orange, lymphadenopathy
medullary carcinoma of breast
well cicrumscribed rapid growth
better prognosis
mucinous carcinoma of breast
well circumscribed slow growth
more common in older women
gelatinous in palpation
tubular carcinoma of breast
tubular structures invading the stroma
usually in 40s
good prognosis
what is used to determine extend of breast lesion
MRI
what is used to determine possible mets of breast lesion
bone scan and cT
Tx DCIS of breast
lumpectomy
maybe radiation
mastectomy in hight risk
Tx LCIS of breast
close observation and tamoxifen or raloxifene
Tx invascve carcinoma of breast
lumpectomy if early and focal
mastectomy for multifocal and radiation if > 5cm
sentinel lymph node Bx always
hormone or chemo for all node + cancers > 1cm and aggressive tumors
negative FNA on solid breast mass
need more definitive Bx because 20% false negative
Mab used in breast CA
trastuzumab anti Her 2 neu
Tx inflammatory breast CA
mastectomy, radiation and chemo
mets of breast CA
bone, thoracic cavity, brain and liver
tumors with + Estrogen or progesterone R or her2neu
better prognosis
