Gynecology Flashcards
What is the most likely cause of infertility in a menstruating woman Under the age of 30?
PID
What is the most common cause of preventable infertility in the US?
Pelvic inflammatory disease (PID)
Female between 13-35
1-Abdominal Pain
2-Adnexal Tenderness
3-Cervical Motion Tenderness
Plus one of these: Elevated VSG C-reactive protein level Leukocytosis Fever Purulent Cervical Discharge
Pelvic inflammatory disease
Treatment for PID
For outpatients: Cefoxitin/Ceftriaxone and Doxycycline
For Inpatients: Clindamycin and Gentamicin
Most common organisms off pelvic inflammatory disease
Neisseria Gonorrheae
Chlamydia Trichomatis
Pelvic inflammatory disease, With a history of DIU
Actinomyces Israelii
Common sequelae of PID
Infertility
Rupture of tuboovarian abscess
Treatment
Emergent Laparotomy
Unilateral = excision of the affected tube
Bilateral = Histerectomy and bilateral salpingoophorectomy
The first test to perform when a woman percents with Amenorrhea
B-hCG; The most Common cause of amenorrhea is Pregnancy
Term for heavy bleeding during and between menstrual periods
Menometrorrhagia
Cause of amenorrhea with Normal Prolactin,
No response to estrogen-progesterone challenge
History of D&C
Asherman’s Syndrome
Therapy for polycystic ovarian syndrome
Weight loss and OPCs
Consider Metformin
Medication use to induce ovulation
Clomiphene citrate
Diagnostic step required in a postmenopausal woman who presents with vaginal bleeding
Endometrial biopsy
Indications for medical treatment of ectopic pregnancy
Patient stable; unruptured ectopic pregnancy of < 3.5 cm at < 6 weeks’ gestation
Medical option for Endometriosis
OPCs
Danzol
GnRH agonists
Laparoscopic findings in endometriosis.
Powder burns, “chocolate cysts”
The most common location for an ectopic pregnancy.
Ampulla of the oviduct.
How to diagnose and follow a Leiomyoma
Ultrasound
Natural history of a Leiomyoma
Regresses after menopause
A patient has > vaginal discharge and petechal patches in the upper vagina and cervix
Trichomonal Vaginitis
Treatment for bacterial vaginosis
Oral or topical Metronidazole
The most common cause of bloody nipple discharge
Intraductall papilloma
Contraceptive methods that protect against PID
OCPs and barrier contraception
Unopposed estrogen is contraindicated in which cancers?
Endometrial
or
Estrogen receptor + Breast cancer
A patient presents with recent PID with RUQ pain.
Consider Fitz-Hugg-Curtis Syndrome
Breast malignancy presenting as;
Itching, burning and erosion of the nipple
Paget’s Disease
Annual screening for women with a strong family history of Ovarian Cancer
CA-125 and Transvaginal Ultrasound
50-year-old women leaks urine when laughing or coughing.
Nonsurgical options?
Kegel exercises
Estrogen
Pressaries of stress incontinence
A 30-year-old women has unplredictable urine loss.
Examination is normal
Medical options?
Anticholinergics (oxibutynin)
B-adrenergics (metaproterenol)
For urge incontinence
Lab values suggestive of menopause
> serum FSH !
The most common cause of female infertility
Endometriosis
Two consecutive findings of atypical squamous cells of undetermined significance (ASCUS) on Pap smear.
Follow up evaluation?
Colposcopy and endocervical curettage
Breast cancer type that > the future risk of invasive carcinoma in both breast
Lobular carcinoma in situ
Endometrial glands outside the uterus (ectopic)
The most common site for ectopic endometrial glands is the
1- Ovaries (Tender adnexae in an afebrile patient)
-Others: uterosacral ligament (nodularities!) sequela: reverted uterus
-Peritoneal surface.
ENDOMETRIOSIS
Nulliparous and >30 with the following symptoms;
- Dysmenorrhea (painful menstruation)
- Dyspareunia (painful intercourse)
- Dyschezia (painful defecation)
&/or= perimenstrual spotting
ENDOMETRIOSIS
Gold Standart for diagnosis of Endometriosis
Laparoscopy with visualization of the endometriosis
Treatment of Endometriosis
First and second line agents
Surgery
Older patients
*First-line= birth control pills( if acceptable)
Second-line= Danzol; GnRH agonists
- Surgery and cautery will destroy the endometriomas !
- Older patient, Hysterectomy and bilateral salpingoophorectomy for SEVERE symptoms!
What is the most likely cause of infertility in a menstruating woman over the age of 30 without a history of PID ?
ENDOMETRIOSIS
“Cottage cheese” pseudohyphae on KOH preparation
History of -DBT
-ATB treatment
-Pregnancy
Candida sp.
Tx: topical or oral antifungal
Bugs can be seen swimming under microscope; pale green, frothy, watery discharge; “Strawberry” cervix.
T. Vaginalis
Tx: metronidazole
Malodorous discharge; FISH SMELL on KOH preparation
CLUE CELLS
G. Vaginalis
Tx: metronidazole
Veneral wats, koilocytosis on Pap smear
Human Papillomavirus
Tx: - acid
- cryo therapy - laser - podophyllin
Multiple shallow, painful ulcers; recurrence and resolution
Herpes virus
Tx: Acyclovir
Painless chancre, spirochete on dark-field microscopy
Syphilis ( stage I)
Tx: Penicillin
Condyloma lata, maculopapular rash on palms, serology
Syphilis (stage II)
Tx: Penicillin
Most common SDT; dysuria, + culture and antibody tests
C. Trachomatis
Tx: Doxycycline
Azithromycin*( for compliance issue; one single dose 1mg orally)
Chlamydia in pregnancy: eritromycin!
-gonorrhea should be treated as presumed chlamydial coninfection. ( but the opposite is not true)
Mucopurulent cervicitis; gram - bug on Gram stain
Neisseria Gonorrheae
Tx: Ceftriaxone
Fluoroquinolone
Treat for chlamydial coninfection !
Characteristic apearence of lesions, intracellular inclusions
Molluscum
Tx: curette
cryotherapy
electrocauterization
coagulation
“Crabs”’ look for Itching; lice can bee seen on pubic hairs
Pediculosis
Tx: permethrin cream
Seek and treat the patients’s sexual partners
T. Vaginalis Human Papillomavirus Herpes virus Syphilis Chlamydia Trachomatis Neisseria Gonorrheae Molluscum Pediculosis
( gardenella and candida they are not typically sexual transmitted disease)
Patients with Gonorrhea usually are treated for presumed chlamydial infection
CEFTRIAXONE (Gonorrhea)
DOXYCYCLINE ( Chlamydia)
But, do NOT give Gonorrhea treatment to chlamydia infection!
> 40-y-o.
Dysmenorrhea Menorrhagia
Large Boggy uterus on physical exam
Endometrial glands within the uterine musculature
Adenomyosis
Management of Adenomyosis
1-Dilatation and curettage first rule out endometrial cancer.
- Hysterectomy: To relieve Severe symptoms
- GnRH.
The most common tumors in woman
The most common indication of hysterectomy
Fibroids -Leiomyomas-
BENIGN!
40% of women have Fibroids by the age of 40!
Leiomyomas of the uretus are estrogen-dependent
They grow during pregnancy and oral contraceptive pills.
They me
Ay cause;
Infertility, pain, And Menorrhagia or metrorrhagia.
Anemia—–> indication of hysterectomy
Dilate tigon and curettage are needed to rule out endometrial cancer if >35y
First test to order in any woman of reproductive age with abnormal uterine bleeding?
A pregnancy test!
Abnormal uterine bleeding not associated with tumor, inflammation or pregnancy
Dysfunctional Uterine Bleeding (DUB)
Is the most common cause of abnormal uterine bleeding.
>70 associates with anovulatory cycles.
Consider physiologic.
The most common non physiologic cause is Polycystic ovary syndrome (PCOS).
DUB > 35 y-o:
DUB in all women age:
DUB > 35 y-o: dial attain and curettage —> to rule out Endometrial Cancer!
DUB in all women age: look for Anemia!
Causes of DUB:
Infections
Endocrine disorders
Coagulation defects
Estrogen-producing neoplasms
Treatment of DUB
NSAIDs = First line
Oral contraceptive pills = First line for DUB and Dysmenorrhea
(And if the patient does not desire pregnancy
Progesterone monotherapy = severe bleeding!
Overweight
Hirsutism
Amenorrhea
Infertility
PCOS
>LH
< or normal FSH
Ultrasound= multiple peripheral-oriented cysts
What is the most likely cause for infertility in a woman under 30 with abnormal menstruation ?
PCOS
Tx of PCOS
Risk.
Oral contraceptive pills
If desire pregnancy= clomiphene to induce ovulation
> risk of Endometrial Cancer!
Is infertility usually a male or a female problem?
2/3 cases are due to Female problem.
1/3 male.
First step evaluating a couple for infertility.
Physical exam no clues.
Semen analysis
Cheap, easy, non invasive!
Characteristics of normal semen
Ej volume= >1 ml
Sperm concentration= > 20 million/ml
Inicial foward motility = > 50% of sperm
Normal morphology = > 60% of sperm
Next step after semen evaluation;
Documentation of ovulation
Basal body temperature
Progesterone levels
Endometrial Bx
Radiologic test to examine the Fallopian tubes.
Histerosalpingogram
Previous dilatation and curettage that cause intrauterine synechiae
History of Fibroids
Simptoms of Endometriosis
Lead you to suspect uterine problem
PID
Previous ectopic pregnancy
Lead to suspect tube problem
Last resort in the work up of infertility?
Laparoscopy= in a patient of history suggestive of Endometriosis
Lysis of adhesions and destruction of endometriosis often restore fertility
Medications to try restore female fertility
-Woman with adequate production of estrogen:
CLOMIPHENE
-Woman hipoestrogenic:
hMG Menopausal Gonadotropin! ( LH & FSH)
-In vitro fertilization
What is the risk associated with medical induction of ovulation?
Multiple-Gestation pregnancies.
Distinguish between primary and secondary amenorrhea
Primary amenorrhea : patient has NEVER menstruated
Secondary amenorrhea: patient used to menstruate but has STOP
What is the cause of secondary amenorrhea Ina previously menstruating women of reproductive age?
Pregnancy ! Until proved otherwise!
Order hCG in order to rule out pregnancy as first step!
Excessive exercise may cause amenorrhea
True
Athlets
Common causes of secondary amenorrhea:
PCOS
Anorexia (amenorrhea is required for diagnosis of anorexia)
Endocrine disorders:
-headaches, /
-galactorrhea, /-> PITUITARY TUMOR
-visual field defects./
Antipsychotics: due to > Prolactin.
Previous Chemotherapy ( 1* ovarian failure)
( keep in mind = menopause, although is not 2* amenorrhea )
Secondary Amenorrhea
1) Rule out pregnancy
Next step?
2) Progesterone challenge
2.A)Vaginal bleeding (Enough estrogen)
-look LH:
> LH = PCOS
< LH = Ideopathic. ( PRL & TSH)
Hypothyroidism : > TSH >PRL
Pituitary Prolactinoma : MResonance
PRL normal= ask for GnRH (stress;exercise;drugs)
CLOMIPHENE
2.B) No Vaginal Bleeding( inadequate estrogens)
-FSH
FSH > = OVARIAN FAILURE
-Autoinmune disorders
-Karyotype abnormalities
-Chemotherapy
FSH < = BRAIN TUMOR ( craneopharyngioma)
-Order MRI
CLOMIPHENE INEFECTIVE !
Pregnancy can present as primary amenorrhea
True! Always check hCG in any amenorrhea !
