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Gynecology Flashcards

0
Q

Menarche

A
  • first menstrual cycle

- onset between ages of 10 and 16

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1
Q

Thelarche

A

breast development, usually between 8 and 11

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2
Q

Thelarche process

A
  1. breast buds begin
  2. breasts and areola grow
  3. nipple and areola separate from mound
  4. areola rejoins breast contour
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3
Q

Menstrual Cycle (steps)

A
  1. Follicular phase
  2. Ovulation
  3. Luteal phase
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4
Q

Follicular phase

A
  • lasts ~13 days
  • increased FSH –> growth of follicles –> increased estrogen production
  • results in development of straight glands and thin secretions of uterine lining (proliferative phase)
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5
Q

Ovulation

A
  • day 14
  • LSH and FSH spike, leading to rupture of ovarian follicle and release of a mature ovum
  • ruptured follicular cells involute and create corpus luteum
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6
Q

Luteal phase

A
  • days 15 - 28
  • length of time (14 days) that corpus luteum can survive w/o further LH stimulation
  • corpus luteum produces estrogen and progesterone, allowing endometrial lining to develop thick endometrial glands (secretory phase)
  • in absence of implantation, corpus luteum cannot be sustained and endometrial linding sloughs off
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7
Q

Menopause

A
  • cessation of menses for a minimum of 12 months as a result of cessation of follicular development
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8
Q

Menopause: Hx and PE

A
  • average onset at 51 years

- sx include hot flashes, vaginal atrophy, insominia, anxiety/irritabiliy, poor concentration, mood changes

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9
Q

Premature menopause

A
  • cessation of menses before 40
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10
Q

Menopause: Dx

A

Labs: increased FSH then increased LH

Lipid profile: increased total cholesterol, decreased HDL

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11
Q

Menopause: tx of vasomotor symptoms

A
  • HRTs (combo estrogen/progestin)

* * increases cardiovascular morbidity

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12
Q

Contraindications of HRTs during menopause

A
  • Vaginal bleeding
  • Breast cancer (known or suspected)
  • Untreated endometrial cancer
  • Hx of thromboembolism
  • Chronic liver disease
  • Hypertriglyceridemia
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13
Q

Menopause tx: hotflashes

A

SNRIs/ SSRIs, clonidine and/or gabapentin decreases frequency of hot flashes

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14
Q

Complications of menopause

A
  • Vasomotor symptoms (tx with HRTs)
  • Hot flashes (tx with SSRIs/SNRIs, clonidine, gabapentin)
  • Vaginal atrophy (topical estrogen)
  • Osteoporosis (tx w/ daily calcium and Vitamin D)
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15
Q

For which condition should postmenopausal women be screened?

A

Osteoporosis

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16
Q

Implanon (progestin-only implant)

A
  • inhibits ovulation; increased cervical mucus viscosity
  • effective up to 3 years, immediate fertility once removed
  • side effects: weight gain, depression, irregular periods
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17
Q

IUD with progestin

A
  • foreign body results in inflammation; progesterone leads to cervical thickening and endometrial decidualization
  • effective for up to 5 years, immediate fertility once removed
  • safe with breast feeding
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18
Q

IUD: disadvntages

A
  • spotting (up to 6 months)
  • acne
  • risk of uterine puncture
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19
Q

Copper T IUD (ParaGard)

A
  • foreign body results in inflammation; copper has spermicidal effect
  • effective for up to 10 yrs, immediate fertility once removed
  • safe with breastfeeding
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20
Q

Copper IUD: disadvantages

A

increased cramping and bleeding

- risk of uterine puncture

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21
Q

Surigcal sterilization (tubal ligation, vasectomy)

A
  • permanently effective; safe with breastfeeding
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22
Q

Tubal ligation: disadvantages

A
  • irreversible

- increased risk of ectopic pregnancy

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23
Q

Depo-Provera

A
  • IM injection every 3 months

- advantages: lighter or no periods, each shot works for 3 months, and safe with breastfeeding

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24
Q

Depo-Provera: disadvantages

A

Irregular bleeding and weight gain

  • decreass in BMD
  • delayed fertility after discontinuation (up to 10 months)
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25
Q

Vasectomy: disadvantages

A

most failures due to not waiting for 2 negative sperm samples

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26
Q

Ortho Evra (“the patch”)

A
  • combined weekly estroenn and progestin dermal parch

- periods may be more regular. weekly administration

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27
Q

The patch: disadvantages

A
  • thromboembolism risk (especially in smokers and those > 35 years)
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28
Q

NuvaRing (“the ring”)

A
  • combined low-dose progestin and estrogen vaginal ring
  • can make periods more regular
  • three weeks - continuous; 1 week - no ring
  • safe to use continuously
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29
Q

NuvaRing: disadvantages

A
  • may increased vaginal discharge

- spotting (first 1-2 months)

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30
Q

OCPs (combination estrogen and progestin)

A
  • inhibit FSH/LH, suppressing ovulation
  • thickening cervical mucus, decidualize endometriaum
  • decreases risk of ovarian and endometrial cancers
  • predictable, lighter, less painful menses
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31
Q

OCPs: disadvantage

A
  • requires daily complaince
  • breakthrough bleeding (10 - 30%)
  • thromboembolism risk (esp in smokers and those > 35 years)
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32
Q

Progestin-only minipills

A
  • thicken cervical mucus

- safe with breastfeeding

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33
Q

Progestin-only pills: disadvantage

A

requires strict complaince with daily timing

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34
Q

Premenstrual Syndrome: Sx

A
  • headache
  • breast tenderness
  • pelvic pain and bloating
  • irritability and lack of energy
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35
Q

Premenstrual syndrome: Dx

A
  • no diagnostic tests for PMD or PMDD
  • symptoms should be present for 2 consecutive ycles
  • symptom-free period of 1 week in 1st part of cycle (follicular phase)
  • symptoms must be present in 2nd half of cycle (luteal phase)
  • dysfunction in life
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36
Q

PMD: Tx

A
  • patient should decrease consumptom of caffeine, alcohol, cigarrettes, and chocolate
  • if symptoms severe, give SSRIs
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37
Q

Menopause

A
  • result of permanent loss of estrogen

- oocytes produce less estrogen and progesterone and both LH and FSH start to rise

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38
Q

Menopause: Sx

A
  • menstrual irregularlity
  • sweats and hot flashes
  • mood changes
  • dyspareunia (pain during sexual intercourse)
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39
Q

Menopause: PE findings

A
  • atrophic caginitis
  • decrease in breast size
  • vaginal and cervical atrophy
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40
Q

Menorrhagia

A
  • heavy and prolonged menstrual bleeding
  • “gushing” of blood
  • clots may be seen
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41
Q

Primary Amenorrhea / Delayed puberty

A
  • absence of menses by age 16 with secondary sexual development present OR
  • absence of secondary sexual characteristics by 14
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42
Q

Causes of primary amenorrhea with absence of secondary sexual characteristics

A
  • Constitutional growth delay
  • Primary ovarian insufficiency
  • Central hypogonadism
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43
Q

Most common cause of primary amenorrhea

A

Constitutional growth delay

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44
Q

Most common cause of primary ovarian insufficiency

A

Turner’s syndrome

* look for hx of radiation and chemotherapy

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45
Q

Causes of central hypogonadism

A
  • undernourishment, stress, hyperprolactinoma
  • CNS tumor or cranial radiation
  • Kallman’s syndrome
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46
Q

Kallman’s syndrome

A
  • isolated gonadotropin deficiency associated with anosmia

- central hypogonaidms

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47
Q

Primary amenorrhea w/ presence of secondary sexual characteristics

A
  • estrogen production but other anatomic or genetic problems
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48
Q

Etiology: primary amenorrhea w/ secondary sexual characteristics

A
  • Mullerian agenesis
  • Imperforate hymen
  • Complete androgen insensitivity
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49
Q

Mullerian agenesis

A

absence of 2/3 of vagina; uterine abnormalities

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50
Q

Imperforate hymen

A
  • presents with hematocolpos (blood in the vagina) that cannot escape along with bulging hymen
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51
Q

Complete androgen insensitivity

A
  • patients present with breast development (aromatization of testerone to estrone) but are amenorrheic and lack pubic hair
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52
Q

Primary amenorrhea: Dx

A
  1. GET A PREGNANCY TEST!

2. Obtain bone radiograph (PA left hand) to see if bone age in consitient with pubertal onset

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53
Q

Short pt has primary amenorrhea w. secondary sexual characteristics but has normal growth velocity. Likely etiology?

A

Constitutional growth delay (most common cause)

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54
Q

Pt has primary amenorrhea and has bone age > 12 yers but there are no signs of puberty. Next step?

A

Obtain LH/FSH levels to see if issues in HPA axis

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55
Q

Constitutional growth delay

A
  • decr GnRH
  • decr GnRH
  • decr estrogen/progesterone (prepuberty levels)
  • puberty has not started
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56
Q

Hypogonadotrophic hypogonadism

A
    • hypothalamic or pituitary problem
  • decreased GnRH
  • decreased LH/FSH
  • decresased estrogen
57
Q

Hypergonadotropic-hypogonadism

A
  • ovaries have failed to produce estrogen
  • increased GnRH
  • increased LH/FSH
  • decreased estrogen/progestrone
58
Q

Anovulatory problem

A
  • PCOS or problem with estrogen receptors
  • increased GnRH
  • increased LH/FSH
  • increased estrogen/progesterone production
59
Q

Anatomic problem with primary amenorrhea

A
  • *menstrual blood cannot get out (e.g. imperforate hymen)
  • normal GnRH
  • normal LH/FSH
  • normal estrogen production
60
Q

Pt has primary amenorrhea w/ neg pregnancy test, normal bone age. Next step?

A

Ultrasound to evaluate ovaries

61
Q

Pt has primary amenorrhea, neg pregnancy test, with normal breast development and no uterus. Next step?

A

Obtain karyotype to evaluate for androgen insensitivity syndrome

62
Q

Pt has primary amenorrhea w negative pregnancy test, normal bone age with normal breast development and uterus. Next step?

A

Measure prolactin and obtain MRI to assess pituitary gland

63
Q

Constitutional growth delay: Tx

A

None necessary

64
Q

Hypogonadism: tx

A
  • Begin HRT with estrogen at lowest dose

- After 12 - 18 mths, begin cyclic estrogen/progesterone therapy (if uterus is present)

65
Q

Secondary amenorrhea

A

absence of menses for 6 consecutive months in women who have passed menarche

66
Q

Positive progestin challenge (withdrawal bleed)

A
  • indicates anovulation that is likely due to noncyclic gonadotropin secretion pointing to PCOS or idiopathic anovulation
67
Q

Secondary amennorhea: Dx

A
  1. GET PREGNANCY TEST
  2. Obtain TSH (high TSH –> high prolactin)
  3. Obtain Prolactin levels
  4. Progesterone Challenge Test
  5. Estrogen Progesterone Challenge Test
68
Q

Negative progestin challenge (no bleed)

A

indicates uterine abnormalty or estrogen deficiency

69
Q

Pt has secondary amenorrhea and has signs of hyperglycemia (e.g polydipsia, polyuria) or hypotension. Next step?

A

Conduct 1-mg overnight dexamethasone suppression test to distinguish congenital adrenal hyperplasia (CAH), Cushing’s syndrome, and Addision’s disease

70
Q

If patient has secondary amenorrhea and clinical virilizationis present. Next step?

A

Measure testosterone, DHEAS and 17-hydroxyprogesterone

71
Q

56 yr old F c/o of insomnia, vaginal dryness, and lack of menses for 13 mths. Likely dx?

A

Menopause

- may want to rule out secondary amenorrhea by ordering FSH

72
Q

Tx of hpothalamic causes of secondary amenorrhea

A

Reverse underlying cause and induce ovulation with gonadoptropins

73
Q

Premature ovarian failure (age < 40 years)

A

If uterus is present, treat with estrogen plus progestin replacement therapy

74
Q

Primary Dysmenorrhea

A
  • menstrual pain associated with ovulatory cycle in absence of pathologic findings
  • caused by uterine vasoconstriction, anoxia, and sustained contractions mediated by excess PGF-1
75
Q

Primary Dysmenorrhea: Hx and PE

A
  • presents with low, midline, spasmodic pelvic pain that often radiates to the back or inner thighs
  • cramps occur in 1st 1-3 days of menstruation and may be associated with nausea, diarrhea, and flushing
  • NO PATH FINDINGS ON PELVIC EXAM
76
Q

Primary Dysmenorrhea: Tx

A
  • NSAIDS
  • Topical heat therapy
  • Combined OCPs
  • Mirena IUD
77
Q

Secondary Dysmenorrhea

A
  • menstrual pain for which an organic cause exit
78
Q

Ddx of secondary dysmenorrhea

A
  • Endometriosis
  • Adenomyosis
  • Fibroids
  • Adhesions
  • Polyps
  • PID
79
Q

Secondary Dysmenorrhea: Hx and PE

A
  • may have palpable uterine mass, cervical motion tenderness, adnexal tenderness, a vaginal or cervical discharge, or visible vaginal pathology (mucosal tears)
80
Q

Endometriosis

A
  • functional endometrial glands and stroma OUTSIDE the uterine
81
Q

Endometriosis: Hx and PE

A

CYCLICAL pelvic and/or rectal pain and dyspareunia

82
Q

Endometriosis: Dx

A
  • Requires direct visualization by laparoscopy or laparotomy
  • Classic lesions: blue-black (“raspberry”) or dark brown (“powder-brown”) appearance
  • ovaries may endometriosis (“chocolate cysts”)
83
Q

Endometriosis: Pharm Tx

A

INHIBIT OVULATION

  • combination OCPs (1st line)
  • GnRH analogs (leuprolide)
  • Danazol
  • NSAIDS or progestins
84
Q

Endometriosis: Surgical tx

A
  • Excision, cauterization, or ablation of lesiosn and lysis of adhesions
85
Q

Endometriosis: Definitive surgical tx

A

Total abdominal hysterectomy/bilateral salpingo-oopherectomy (TAH/BSO) +/- lysis of adhesions

86
Q

Endometriosis: Complications

A

Infertility (most common cause among menstruating women > 30 yrs)

87
Q

Adenomyosis

A

endometrial tissue in the myometrium of the uterus

88
Q

Adenomyosis

A

Classic triad:

  • NONCYCLICAL pain
  • Menorrhagia
  • Enlarged uterus
89
Q

Adenomysos: Dx

A
  • Usually path diagnosis
    U/S is useful but can’t distinguish btwn leiomyoma and adenomyosis
  • MRI can aid but costly
90
Q

Adenomyosis: Pharm Tx

A

Largely symptomatic relief with NSAIDS (1st line) plus OCPs or progestins

91
Q

Adenomyosis: Conservative surgical tx

A

Endometrial ablation or resection using hysteroscopy

- Complete eradication of deep adenomyosis is difficult and results in high tx failure

92
Q

Adenomyosis: definitive surgical tx

A

Hysterectomy is only definitive tx

93
Q

Adenomyosis: Complications

A

can rarely progress to endometrial carcinoma

94
Q

Secondary Amenorrhea: Dx

A
  1. Obtain B-hCG to r/o ectopic pregnacy
  2. Order following:
    • CBC to r/o infxn
    • UA to r/o UTI
    • Gonoccocal/chlamydial swabs to r/o STIs/PID
95
Q

Dysfunctional uterine bleeding (DUB)

A

Diagnosis of exclusion

  • abnormal uterine bleeding w/o evidence of an underlying cause
  • may be ovulatory or anovulatory
96
Q

What is postmenopausal bleeding?

A

Is cancer until proven otherwise

97
Q

Oligomenorrhea

A

increased length of time between menses (35 - 90 days between cycles)

98
Q

Polymenorrhea

A 
Frequent menstruation (< 21 days between cycles)
- often anovular
99
Q

Menorrhagia

A
  • increased amt of flow (> 80 cc of blood loss per cycle) or prolonged bleeding (flow lasting > 8 days)
  • may lead to anemia
100
Q

Metorrhagia

A
  • bleeding between periods
101
Q

Menometrorrhagia

A
  • excessive and irregular bleeding
102
Q

Most common cause of abnormal uterine bleeding

103
Q

Abnormal Uterine Bleeding: WorkUp

A
  1. B-hCG to r/o pregnancy
  2. CBC to evaluate for anemia
  3. Pap smears to r/o cervical cancer
  4. TFTs to r/o thyroid ssie
  5. Platelet, PT/PTT to r/o von Willebrand’s dizease and factor XI
  6. U/S to look for endometriosis
104
Q

Indication for endometrial biopsy

A
  1. If endometrium is at least 4 mm in POSTMENOPAUSAL woman

2. If pt is > 35 yrs with risk factors of endometrial hyperplasia (e.g. diabetes, obesity)

105
Q

First line tx of abnormal uterine bleeding

A

NSAIDS - decrease blood loss

106
Q

Heavy bleeding: tx

A
  • High dose estrogen IV stabilizes endometrial lining and typically stops bleeding w/in 1 hr
  • If bleeding isnt controlled w/in 12-24 hrs, a D&C is often indicated
107
Q

Ovulatory bleeding: tx

A
  • NSAIDS to decrease blood loss

- If patient is hemodynamically stable, give OCPs or Mirena IUD

108
Q

If unable to medically tx abnormal uterine bleeding, next step?

A
  • D & C
  • Hysteroscopy: to ID endometrial polyps or peform directed biopsies
  • Hysterectomy
109
Q

Congenital Adrenal Hyperplasia

A

deficiency of at least one enzyme for synthesis of cortisol from cholesterol

110
Q

21-hydroxylase deficiency

A

most severe, classic form presents as newborn female infant w/ ambiguous genetalia and life-threatening salt wasting

111
Q

11B-hydroxylase deficiency

A

less common cause of adrenal hyperplasia

112
Q

Congenital Adrenal Hyperplasia: Hx and PE

A
  • excessive hirsuitism
  • acne
  • amenorrhea
  • abnormal uterine bleeding
  • infertility
  • palpable pelvic mass
113
Q

Congenital Adrenal Hyperplasia: Dx

A
  • increased androgens (testosterone > 2ng; DHEAS > micrograms)
  • increased serum testosterone
  • increased DHEAS
  • incresased 17-OH progesterone levels
114
Q

Congenital Adrenal Hyperplasia: Tx

A

Glucocorticoids

- prevents new terminal hair growth but doesn’t get rid of hirsuitism

115
Q

Polycystic ovarian disease

A

Diagnosis requires at least 2 criteria:
1. polycystic ovaries
2 oligo-/anovulation
3. clinical evidents of hyperandrogenism

116
Q

PCOS: Hx and PE

A
  • High BP and obesity

- Stigmata of hyperandrogenism or insulin resistance: menstrual cycle abnormalities, acne, hirsuitism, obesity

117
Q

Women with PCOS are at increased risk for which conditions?

A
  • Type 2 DM
  • Insulin resistance
  • Infertility
  • Metabolic syndrome
118
Q

PCOS: Dx

A
  • LH:FSH = 3:1 (normal is 1.5:1)
  • testosterone level is mildly elevated
  • Pelvic U/S shows bilaterally enlarged ovaries w/ multiple subcapsular small follicles and increased stromal echogenecity
119
Q

PCOS: Management

A
  • OCP treats irregular bleeding and hirsuitism
  • SPIRONOLACTONE- used to suppress hair follicles
  • CLOMIPHENE CITRATE or human menopausal gonadotropin treats infertility
  • METFORMIN enhances ovulation and manages insulin resistance
120
Q

Pt has 2ndary amenorrhea with elevated prolactin levels. Next step?

A
  1. Review meds for antipsychotics esp those with anti-dopamine effects
  2. CT or MRI of head to r/o pituitary tumor
    • Tumor < 1 cm: give bromocriptine (dopamine agonist)
    • Tumor > 1cm: treat surgically
  3. If cause of elevated prolactin is idiopathic tx with bromocriptine
121
Q

Estrogen Progesterone Test

A
  • 3 weeks of oral estrogen followed by 1 week of progesterone
122
Q

Positive Estrogen Progesterone Test

A
  • withdrawal bleeding is diagnostic of inadequate estrogen
    • Get FSH level
      • if FSH is high, may be due to Y mosaicism so get karyotype
      • if FSH is low, may 2/2 to HPA insufficiency so get brain CT/MRI
123
Q

Negative Estrogen Progesterone Test

A

Diagnostic of outflow obstruction or endometrial scarring (e.g. Assmeran syndrome)
** Order hysterosalpingogram to identify lesion and lyse adhesions

124
Q

Anovulation

A
  • classically presents w/ hx of amenorrhea followed by unpredictable bleeding (prolonged unopposed estrogen stimulates endometrium)
125
Q

Idiopathic Hirsuitism

A
  • diagnosis when there is no virilization and all lab tests are norma
  • most common cause of hirsuitism
126
Q

Management of Idiopathic Hirsuitism

A
  • Spironolactone: tx of choice

- Eflornithine - 1st line tx for unwanted facial and chin hir

127
Q

Common sites of osteoporosis

A
  • Vertebral bodies leading to crush fx, kyphosis, and decreased height
128
Q

Common risk factors for osteoporosis

A
  • Positive family hx in a thin white female
  • Steroid use
  • Low Ca intake
  • Sedentary lifestyle
  • Smoking
  • Alcohol
129
Q

Osteoporosis: Dx

A
  • DEXA scan assesses bone density (T score > -2.5)

- 24 hr urine hydroxyproline or NTX to assess calcium loss

130
Q

Osteoporosis: Management

A

First line therapy: bisphosphonates and SERMS
- bisphosphonates inhibit osteoclastic activity
- SERMS (selective estrogen recept modulators) increase bone density
Second line therapy: Calcitonin and fluoride

131
Q

SERMS (e.g. Tamoxifen and Evista(

A
  • protective against heart and bos but not for vasomotor sx
132
Q

Tamoxifen

A
  • SERM

- bone and endometrial agonist effects but breast antagonist effects

133
Q

Raloxifen

A
  • SERM

- has bone agonist effects but endometiral antagonist effects

134
Q

Indications for Hormone Replacement Therapy

A

Treatment of:

  • Menopausal vasomotor symptoms (hot flashes)
  • Genitourinary atrophy
  • Dyspareunia
135
Q

Contraindications for HRTs

A 
Tx of
- osteoporosis
If there is a history of:
- estrogen sensitive breast cancer
- liver disease
- active thrombosis
- unexplained vaginal bleeding
136
Q

If indicated, what HRT should women without uterus receive ?

A

Continuous estrogen

137
Q

If indicated, what HRT(s) should women with a uterus receive

A

Estrogen WITH progestin therapy to prevent endometrial hyperplasia

138
Q

Benefits of HRT

A
  • decreases rate of osteoporotic fx

- decreases rate of colorectal cancer

139
Q

Risks of HRT

A
  • increases risk of DVT
  • increases risk of heart attacks and breast cancer in combo therapy
    • risk of breast cancer associated w/ therapy > 4 yrs**

First AId 2CK (22 decks)

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