GYNE Flashcards
What are the SSx of Polycystic Ovarian Syndrome?
- Infertility
- menstrual irregularity, anovulation
- hirsutism
- hyperandrogenism
» acne
» alopecia
- metabolic disturbance >> obesity >> insulin resistance >> dyslipidemia >> HTN
Rotterdam diagnostic criteria of PCOS
Two out of the three of
1) clinical hyperandrogenism (Ferriman-Gallway Score >8 ) or Biochemical Hyperandrogenism (Elevated Total / Free testosterone)
2) Oligomenorrhea (less than 6-9 menses per year) or oligo-ovulation
3) Polycystic ovaries on ultrasound ( >= 12 antral follicles in one ovary or ovarian volume >= 10 cm3)
What is the most sensitive blood work to investigate PCOS?
elevated total testosterone
What are the investigations for suspected PCOS?
blood work:
- total testosterone (most sensitive) (elevated)
- DHEAS (elevated)
- androstenedione (elevated)
- SHBG (decreased)
- LH: FSH > 2:1 ( elevated LH) * NOT part of diagnostic criteria
- TSH
- prolactin
- FBG: insulin < 4.5 = insulin resistance (US units)
- OGTT/A1C/FPG, lipid
imaging:
- transvaginal u/s
** for accurate testosterone measures, pt must be OFF OCPs for at least 3 months
Management of PCOS
Non-pharmacological:
- smoking cessation
- maintain healthy BMI (decrease BMI): exercise, healthy diet
- assess psychological factors: anxiety, body image concerns, eating disorder
Pharmacological management:
Cycle control
- exercise, decrease BMI (to decrease peripheral estrogen)
- combined OCPs
- cyclic Provera (medroxyprogesterone acetate)
- oral hypoglycemic - metformin 250mg-1g BID
Infertility
- medical induction of ovulation:
> > clomiphene (30-50% pregnancy rate after 6 ovulatory cycles), hMG, LHRH, recombinant FSH
- Metformin
- Ovarian drilling
- Bromocriptine (if hyperprolactinemia)
Hirsutism
- combined OCPs
- anti-androgenic: Diane 35
- spironolactone 25mg OD up to 100mg BID
- Finasteride (5-alpha reductase inhibitor)
- Flutamide (androgen reuptake inhibitor)
Acne
- combined OCPs
- benzoyl peroxide
- topical retinoids
- systemic antibiotics
When should we r/o PCOS?
In adolescence women:
1) oligomenorrhea 3-4 yr post menarche
2) clinical/ biochemical hyperandrogenism
3) exclusion of other disorders
- If menarche < 2 years, consider pt at risk of PCOS and monitor
DDx of PCOS
- late onset congenital adrenal hyperplasia
- Cushing’s syndrome
- Ovarian +adrenal neoplasm
- hyperprolactinemia
- thyroid dysfunction
- exogeneous use of steroid hormones/ androgens
What is the definition of primary amenorrhea?
> > NO secondary sexual characteristics AND NO menarche by age 14
> > normal secondary sexual characteristics but NO menarche by age 16
What is the definition of Secondary amenorrhea?
> > in women with previous normal menstruation NO menses x 3 months
> > in women with previous oligomenorrhea NO menses x 9 months
DDX of secondary amenorrhea
> > Pregnancy
> > Hypothalamic dysfunction (decreased FSH/LH)
- Functional: anorexia, nutritional deficit, exercise - Extreme stress/ systemic illness
> > Pituitary dysfunction
- brain tumor - Sheehan syndrome (2nd postpartum hemorrhage)
> > Ovarian dysfunction
- Menopause, radiation/chemo - Turner's (XO) - PCOS, ovarian tumor
> > Endocrine
- hyperprolactinemia - hyper/ hypo- thyroidism - hyperandrogenism (PCOS, tumor) - Cushing's disease
Prophylaxis of sexually transmitted diseases (STDs) such as gonorrhea after sexual assault per CDC guidelines
3-drug regimen
Ceftriaxone 250 mg IM once, PLUS
Azithromycin 1 g PO once, PLUS
Metronidazole or tinidazole 2 g PO once
** If alcohol has been recently ingested or emergency contraception is provided, metronidazole or tinidazole can be taken by the victim at home rather than as directly observed therapy to avoid drug interactions
lifestyle causing primary hypothalamic-pituitary dysfunction and subsequent anovulation
excessive stress
excessive exercise
excessive dieting/ eating disorder
hormone disease/ conditions causing anovulatory cycles
PCOS (polycystic ovarian syndrome)
Hyperthyroidism
prolactinemia/ hyperprolactinemia
Cushing’s syndrome/ congenital adrenal hyperplasia
lifestyle modification to maximize chance of conceive naturally
- optimize body mass index (BMI)
- optimize the frequency/ timing of coitus (2-3 times per week or every 3 days)
- reduce excessive caffeine intake
- avoid overheating the testicles
dry eczematous rash on the back with mild puritic, worsened by topical cortisones, “scaling”, “scattered and spread over entire back and trunk” - DDx
- pityriasis rosea
- fungal infection/ pityriasis versicolor/ tinea corporis
- Guttate psoriasis/ psoriasis
DDx of pityriasis rosea
- Lichen planus
- medication eruption
- nummular eczema
- viral exanthems
- tinea corporis
- seborrheic dermatitis
infection associated with guttate psoriasis
strep throat or streptococcus URTI
HIV+ patient with low CD4 count (<200) and purplish lump on the dorsum of foot
Kaposi Sarcoma
Adverse reaction of Depo Provera injection
∙ Bloating ∙ Edema and weight gain ∙ Fatigue ∙ Decreased libido ∙ Dizziness ∙ Local reaction at injection site
Management of breakthrough bleeding from progesterone injection contraception
∙ Oral estrogen ∙ Tranexamic acid ∙ NSAIDS ∙ Mifepristone ∙ Increase frequency of injections
indications to undergo genetic screening for BRCA 1/2
- (BRCA1/2) breast CA < 50 y/o, especially < 35 y/o
- Ovarian CA
- bilateral breast CA
- breast + ovarian CA in the same female
- multiple breast CA on the same side of the family
- male breast CA
- Ashkenazi Jewish ethnicity
High risk of breast cancer eligible for annual mammography/MRI
30-69 y/o with ANY of the following
1) Known BRCA 1/2 carrier
2) 1st degree relative BRCA 1/2 carrier
3) Chest radiation < 30 y/o and at least 8 yrs ago
4) > 25% lifetime risk using IBIS or BOADICEA tool
Cervical cancer screening criteria
CTFPHC: starting at age 25 every 3 years if they have ever been sexually active until 70 years old and can stop if having 3 successive negatives in 10 years
risk factors of cervical cancer
- Sexually active at a young age (< 20 y/o)
- Multiple partners
- Having a partner with a number of previous intimate contacts
- Smoking
- Weakened immune system
- Long term OCP
- Giving birth to multiple children
initial assessment of female urinary incontinence
- incontinence screening questionnaires
- a three-day voiding diary
- the cough stress test
- measurement of postvoid residual
- urinalysis
first-line management for all-type (and stress incontinence) of urinary incontinence
- Pelvic floor strengthening
- lifestyle modifications:
»_space; appropriate fluid intake
»_space; smoking cessation
»_space; weight loss
FDA proved medications for stress incontinence
None
mgt: weight loss and LSM, Kegel exercise, pessaries
FDA proved medications for urge incontinence
- antimuscarinic medications
- mirabegron (Myrbetriq): for overactive bladder
- vaginal estrogen
non-pharmacological treatment for urge incontinence
- mechanical devices
- injections of bulking agents
- onabotulinumtoxin A injections
- neuromodulation
- sling procedures
- urethropexy
