Gynecology Flashcards
Absolute contradictions to combined hormonal contraception
Migraine w/ aura Postpartum (4w BFing, 21w not BFing) Smoker 35+ yo Vascular disease (VTE, CAD, CVA) HTN Coag (thrombophilia, SLE w/ APA) Prolonged immobilization Cancer Cirrhosis
Absolute contradictions to hormonal IUD
Pregnancy Recent PID, STI, sepsis, septic abortion Distorted uterine cavity Cervical/endometrial cancer Breast ca w/ progesterone receptor Unexplained vaginal bleed
Symptoms of endometriosis
Dysmenorrhea Dyspareunia Dyschezia, dysuria Low back/abdo/pelvic pain Infertility
Medical management of endometriosis
Continuous combined contraceptive
Progestin
IUD
Analgesia (NSAIDs to opioids)
Risks of combined hormonal contraceptives
VTE (2-3 fold increase)
If >50 mcg estrogen: MI, CVA
Do not cause cancer
Emergency contraception:
Options and when to use them
Copper IUD: best. Effective up to 7 days.
Hormonal: up to 5 days. Not effective on day of ovulation.
Who should consider progestin-only contraceptive?
Smoker >35 Migraines Breast feeding Endometriosis Anti-convulsivants Sickle cell
How to take progestin-only contraceptive pill
No pill-free days
Start on 1st day of cycle (otherwise use backup x 7 days)
Same time every day (within 3h)
Symptoms of fibroids
Often asymptomatic Abnormal bleeding (menorrhagia) Pelvic pressure Bowel/bladder symptoms Pain (rarely, associated with degeneration/torsion/adenomyosis) Infertility
Pharmacologic management of fibroids (1st line)
IUD, GnRH agonist (leuprolide), progesterone modulator (ulipristal)
note: If menorrhagia, do endometrial biopsy to r/o lesion (leiomyosarcoma)
Causes of ovulatory dysfunction (infertility)
PCOS POF prolactinoma thyroid disease Cushing's syndrome
Testicular causes of male-factor infertility
varicocele (most common reversible cause)
infections (STI, mumps, TB)
Klinefelter
torsion
3 things to check for all women wanting to conceive
Taking folic acid?
Rubella immune? (if not, vaccinate)
Varicella immune? (if not, vaccinate)
Indications for referral for infertility
<35 after 1 year of trying
35-40 after 6 months
>40 immediately
Women: Hx of endometriosis, PID, STI, amenorrhea, pelvic pain
Men: abnormal semen analysis, STI, UG symptoms, varicocele
When to assume a woman is sterile (menopause)
If not on contraceptive:
>50 amenorrheic x 1 year
<50 amenorrheic x 2 years
6 main symptoms of menoapuse
changes in periods hot flashes (and other vasomotor) vaginal dryness or dyspareunia bladder issues, incontinence sleep mood
side effects and risks of HT for menopause
breast cancer (with combined, but not with estrogen only) VTE Stroke and other CV events cholecystitis liver issues pruritus breast pain uterine bleeding nausea, headache, weight change
Two cases where HT is recommended 1st line for menopause
1: vasomotor symptoms in <60yo, <10y after menopause, no CI’s
2: POF or premature menopause, no CI’s (treat until expected menopause)
HT for menopause: estrogen? progesterone? oral or transdermal?
Has uterus: P+E
No uterus: just E
Risk of VTE/CVD: transdermal is better
Hormonal treatment for vaginal dryness
Estrogen (Premarin, Vagifem, Estring)
No need for progesterone, as minimal systemic absorption
OK even if Hx of VTE
PCOS diagnostic criteria
2 out of 3:
- Clinical hyperandrogenism or biochemical (elevated total/free T)
- Oligomenorrhea/oligo-ovulation (less than 6-9 menses per year)
- Polycystic ovaries on U/S
meds for PCOS
combined OCP monthly
metformin BID
(Cyclic Provera 10-14d q 2-3 months. Helps with cancer, but not with androgenism and not contraceptive)
Meds for hirsutism in PCOS
Combined OCP monthly (Diane 35 is anti-androgenic)
Spironolactone
Finasteride
Flutamide
