Gynecology Flashcards
Regulation by gonadal sex of the differentiation of the genital apparatus
Phenotypic or genital sex
Established by genetic inheritance at the moment of fertilization
Chromosomal sex
Establishment of gender role, role gender identity or sexual orientation
Psychological sex
Single most consistent determinant of maleness
Presence of y chromosome
Responsible for sex determination
SRY gene
One of the 2 copies of x chromosome present in females is inactivated
Lyon hypothesis
Tests to determine genetic sex
Sex chromatin test, hair root test, karyotyping
Cells that secrete anti mullerian hormone
Sertoli cells
Enlarges to become testis
Embryonic medulla
Proliferates to become the ovaries
Embryonic cortex
Mesonephric dcg
Wolffian ducts
Paramesonephric ducts
Mullerian ducts
Responsible for differentiation of wolffian ducts
Testosterone
Induces dissolution of mullerian ducts
MIF
Forms the testis
Medulla
Forms the ovaries
Cortex
Dubbed as gay gene
Xq28 of X chromosome
Part of brain larger in homosexual males
Suprachiasmatic
47 xxy
Klinefelter
Most common gynecologic problem in the prepubertal female
Vulvovaginitis
Translucent vertical line at the midline
Adhesive vulvitis
Management for adhesive vulvitis
Topical estrogen cream, BID for 3 weeks
Figure of 8 or hour glass; parchment like appearance of skin
Lichen sclerosus
Mgmt for lichen sclerosus
Sitz bath, avoid trauma; CLOBETASOL
Precocious puberty is defined by the onset of secondary sexual characteristics at what age
Before 8 in girls and 9 in boys
Managment for incomplete isosexual precocious puberty
Conservative management
Premature thelarche is associated with
Extremely low birthweights
Pseudo precocious puberty is due to
Granulosa cell tumor, mc cune albright syndrome
Tx for idiopathic precocious puberty
GnRH
Management for McCune albright syndrome
Aromatase inhibitor
3ps of mc cune albright
Precious puberty, pigmentation, polyostotic fibrous dysplasia (due to somatic mutation of neural crest cells)
Most useful diagnostic tool for premenstrual syndrome
Symtpom diary
What are the indications for endometrial biopsy for AUB
> 35yrs old, obesity, HPN, DM
Ovulatory DUB is due to what
Prostaglandin and fibrinolytic system
Medical managment for DUB
CEE 10mg/day in 4 divided doses;
Tx of choice for anovulatory DUB
Progestin
Androgenic steroid used for DUB
Danazol 200-400mg/day
Inhibits ovarian steroid production
Leuprolide- GnRH agonist
Definitive management for DUB
Hysterectomy
Primary dysmenorrhea is due to increased levels of
Protaglandin F2a
First line for primary dysme
NSAID
Isolated gonadotropin deficiency associated with anosmia
Kallman syndrome
Management for Turner syndrome
Estrogen therapy; cyclic progesterone- endometrial hyperplasia
Failure of ovaries to respond to FSH and LH secondary to receptor defect
Savage syndrome
Cessation of ovarian function in patients <40 yo
Premature ovarian failure
Management for mayer rokitansky kuster hauser syndrome
Neovagina creation
Management for androgen insensitivity
Gonad removal at 18yo; neovagina creation
Incision for imperforate hymen
Cruciate incision
Hematocolpos
Transvaginal septum
Hirsutism, amenorhea, obesity
Stein leventhal syndrome (PCOS)
Pituitary cell destruction as a result of a hypotensive episode during pregnancy
Sheehan’s syndrome
Pituitary cell destruction unrelated to pregnancy
Simmond’s disease
Management for premature ovarian failure
Irradiation, chemotherapy, autoimmunity
Intrauterine adhesions due to curettage
Asherman syndrome
Anovulation can be caused by
Hypothyroidism and prolactinoma
Menopause characterisitcs
51 yo; 12 mos after last; 3 mos with elevated FSH and LH
Menopause is earlier by how many yrs in smokers
2
Coverts androstenedione to estrone
Aromatas
Pathognomonic sign of menopause
Hot flushes/ flashes
Mgmt for hot flushes
Estrogen
Most accurate method to measure bone density
Dual energy xray DEXA
Risks regarding ERT
Heart, breast, stroke
Duration of ERT
6-12 mos, not >4 yrs
Prevents endometrial hyperplasia
Progrsin
Selective receptor modulator
Raloxifene
Herniation of the Pouch of Douglas
Enterovele
Grade: cervix descends halfway to the introitus
I
Grade: cervix descends to the introitus
II
Grade: cervix extends outside introitus
III
Grade: providential
IV
Pelvic strengthening exercise:
Keel’s maneuver
Endopelvic fascial reinforcement
Kelly placation
Obliteretion of vaginal canal
Colpocleisis/ effort procedure
Urethrovesicular suspension via abdominal apporach
Burch/ marshallarchetti krantz procedure
Elevation of bladder neck and urethra via vaginal and abdominal approaches
Sling procedure
Mgmt for rectocele
Posterior repair
Mgmt enterocele
Moschvitz repair
Mgmt for PCOS
OCP
Mgmt for late onset congenital adrenal hyperplasia
Glucocorticoid
Management for hair follicle and androgen sensitivity
Spironolactone
Double cervix, double vagina
Bicollis
Mucous retention cyst of endocervical columnar cells occuring when a cleft has been covered by squamous metaplasia
Nabothian cyst
Most common cervical cyst
Nanothiam cust
Cervical polyp
Most common lesion of the cervix
HPV types related with cervical CA
16,18,31,33
Mainstay tx for menopause
Estrogen replacement therapy
Example of a selective receptor modulator
Raloxifen
Pelvic strengthening exercise
Keel’s maneuver
Drugs for ovulation induction
Clomiphene citrate, metformin, hMG, GnRH
75% of ovarian masses in women
Functional cyst
Most common cause of complex adnexal mass
Benign cystic teratoma
Most common cause of a pelvic mass
Pregnancy
HONEYCOMB, straw colored fluid, multicystic, bilateral
Theca lutein cyst
Functional cysts include
Follicular, corpus luteum, theca lutein
Rpt ultrasound for follicular cyst and corpus luteum cyst are done when?
6-8 weeks
Management for premenaechal cyst >2cm
Ex lap
Most frequent ovarian epithelial tumor
Serous cystadenoma
Resembles cells of endocervix or intestinal epithelium
Mucinous cystadenoma
Transitional tumor: coffee bean appearing nucleus
Brenner tumor
Most common neoplasm in prupubertal female
Benign cystic teratoma
Most common benign solid tumor of the ovary
Fibroma
Ovarian fibroma, ascites, hydothorax
Meig’s syndrome
Most common cause of gynecological cancer death
Malignant ovarian tumor
Gene associated with increased risk for ovarian CA
BRCA 1 gene
Most common ovarian carcinoma
Epithelial
Most frequent ovarian eptihelial tumor
Serous
Epithelial cells filled with mucin
Mucinous tumors
Hobnail cells
Clear cell
Resembles transitional cells of urinary bladder
Brenner
Epithelial cells resembling endometrium
Endometrioid
75% of patients with epithelial ovarian tumors present at what stage
III or stage IV
Phase 1 of epithelial CA managment
Debulking
Phase of 2 epithelial cancer management
Post op chemotherapy: carboplatin and taxol
Follow up for CA 125
Q 3mos for 2 yrs then q6mos for the next 2 yrs
Management for stage1a ovarian epithelial CA in young women who desire fertility
Unilateral salpingooophorecrony
Most germ cell tumors are? Benign/malignant
Benign
Most malignant germ cell tumors are what type?
Dysgerminoma
Most frequent germ cell tumor overall
Dermoid cyst
Most common ovarian neoplasm in women <30 yo
Germ cell tumor
Analogous to seminoma of testes
Dysgerminoma
Numerous hyaline droplets in yolk sac tumors
Schiller duval
Schiller duval bodies
Yolk sac tumor
Hemorrhagic highly malignant cytotrophoblast and syncytiotrophoblast
Choriocarcinoma
Mgmt for germ cell tumor
Benign- ovarian cystectony; malgnant- unilateral salpingo- oophorectony; post child bearing- TAHBSO
Sex cord stromal tumors
Granulosa theca cell and sertoli leydig cell
Resembles fetal testes
Sertoli leydig cell tumor
Coffee bean nuclei; call exner bodies
Granulosa cell tumor
Mgmnt fo sex cord stromal tumors
Young: unilateral salpingooophorectony; post menopausal: TAHBSO
Nipple projections in dermoid
Tubercle of rokitansky
Tumor marker for dysgerminoma
LDH
Tumor marker for endodermwl sinus tumor
Yolk sac tumors- AFP
Tumor marker for choriocarcinoma
HCG
Tummor marker for immature teratoma
AFP
Mgmt for labial fusion
Cortisol+ surgery
Mgmt for imperforate hymen
Cruciate incision
Dx of transverse vaginal septum
Ultrasound and MRI
Failure of urogenital sinus to contribute to the lower portion of the vagina leads to
Vaginal atresia
Mgmt for vaginal atresia
Vaginal pull through
Absence of vagina, hypoplasia of cervix, uterus and fallopian tubes
Mayer rokitansky kuster hauser
Mgmt for vaginal agenesis
Mc indole procedure; Serial vaginal dilators;
Mgmt for lichen simplex chronicus
Medium potency topical steroids BID 4-6X / week
Pruritic, polygonal, papules in external genitalia
Lichen planus
Mgmt for lichen planus
Vaginal hydrocortisone suppositories; adhesions/ surgical excision or vaginal dilators; postmenopausal atrophy: vaginal estrogen
Palpable red glandular spots and patches in the upper 1/3 of the vagina on the anterior wall
Vaginal adenosis
Vaginal adenosis is due to exposure to what
DES
Most common tumor in the vulva
Epidermal inclusion cyst
Occlusion of pilosebaceous duct
Epidermal inclusion cyst
Mgmt for epidermal inclusion cyst
Incision and drainage; complete excision
Tumor formed due to accumulation within the cyst
Sebaceous cyt
Mgmt for sebaceous cyst
Incision and drainage
Microcystic disease
Fox Fordyce disease
Due to occlusion of apocrine glands in the mons pubis and labia minora
Hidradenitis suppurativa
Mgmt for hidradenitis supparativa
Wide local excision, incision and drainage, antibiotics
Chronic inflammation of the paraurethral gland causing obstruction of the duct
Skene’s gland cyst
Mgmt for bartholin’s gland duct cyst and abscess
Biopsy in>40 yo; no tx for 1-2 cm; sitz bath, word catheter placement ;4-6 weeks; masupialization, antibiotics for N gonorrhoeae
Also called dysontogenic cyst
Gartner’s duct cyst
Remnants of the mesonephric ducts of the wolffian system
Gartner’s duct cyst
Mgmt for gartner’s duct cyst
Excision, IVP and cystoscopy; vasopressin
Most common benign solid tumor of the vulva
Fibroma
Small fleshy outgrowth in the distal edge of urethral meatus
Urethral caruncle and prolapse
Mgmt of urethral caruncle:
Biopsy; oral topical estrogen; avoid irritation
Mass of anterior vaginal wall from the posterior urethra
Urethral diverticulum
Dysuria, dyspareunia, dribbling of urine
Urethral diverticulun
Mgmt for urethral diverticulum
Voiding cystourehtrograpjy; cystourethroscopy
Mgmt for squamous cell hyperplasia
Medium potency topical steroid BID 4-6 weeks
Risk factor for Vulvar intraepithelial neoplasia
HPV infectiom 16 and 18
Mgmt for VIN
Vulvectomy, vulvar skinning; vaporization by laser
Mgmt for vulvar carcinoma
Stage I-III: wide radical vulvar excision and bilateral inguinal femoral node dissection
Gold standard for determining sex
Karyotyping
When do the testes descend through the inguinal ring?
7-9th mo
The internal genitalia come from w/c structures
Wolffian and mullerian ducts
Analagen of external genitalia include
Genital swelling/ labioscrotal swellig; urogenital sinus; genital tubercle; genital or urethral folds
Results when phenotype and geotype do match
Pseudohermaphrodites
Grayish-white discharge 6-12 mos before menarche due to desquamation of vaginal epithelium
Physiologic discharge of puberty
Most common foreign body seen
Tissue paper
Most common cause of accidental genital trauma
Straddle injury(most common)
Management of genital warts in children
Laser therapy under inhalation anesthesia
Most common cause of peripheral precocious puberty
Granulosa cell tumor
Used to differentiate bn central and peripheral precocious puberty
GnRH stimulation test
Management for McCune Albright syndrome
Aromatase inhibitor
Management for idiopathic pecious puberty
GnRH
Management for premenstrual syndrome
Spironolactone, bromocriptine, SSRI, TAHBSO
Norma freq, duration and volume of menstrual cycle
21-35 days, 4-7 days, 30-80 ml
Excessive or prolonged menstruation
Menorrhagja
Scanty menstruation; very light flow
Hypomenorrhea
Menstruation occuring every >35 days
Oligomenorrhea
Bleeding bn normal menses
Metrorrhagia
Excessive or prolonged bleeding
Menometorrhagja
2 types of DUB
Ovulatory and anovulatory
Definitive management for DUB
Hysterectomy
Tx of choice for anovulatory DUB
Progestins
Indicated for DUB cases with acute bleeding who do not respond to Iv estrogen or women with significant hypovolemia
D and C
25% of women with breasts and uterus have
Prolactinomas or hyperprolactinemia
Initial hormonal changes signaling onset of menopause
Decrease inhibin and fah
Marker of production of ovary
Testoserone
Marker of production of adrenal gland
DHEAS
Marker of production of peripheral conversion
3a diol G
Elevated in androgen producing tumors
DHEAS
Elevated in late onset CAH
17-OHP
Elevated in cushing’s disease
Glucocoricoid and androgen
Usual fecundability rate
20%
Direct injection of a single sperm into an oocyte
Intracytoplasmic sperm injection
Sperm is added to oocytes in culture medium
In vitro fertilization
Most common presenting symptomnof vaginitis
Vaginal discharge
Fishy odor
Bacterial vaginosis
Clue cells
Bacterial vaginosis
Mgmt for vaginosis
Metronidazole
Mgmt fir candiasis
Fluconazole
Mgmt for trichomoniasis
Metronidazole
Management for enterobiasis
Pyrantel pamoate
Microscopy of enterobiasis
D shaped eggs
Microscopy for trichomonas
Trichimonads
Strawberry cervix
Trichomoniasis
Most common cause of PID
Gonorrhea
Severe cervical motion tenderness
Chandelier sign
Management for tubo ovarian abscess
Clindamycin and gentamycin
Gram negative diplococci and numerous WBC
Neisseria gonorrhea
definitive diagnosis for PID
Endometrial biopsy, TVS/ MRI,laparoscopic
TVS or MRI showing thickened, fluid filled tubes, with or without free pelvic fluid or tubo ovarian complex
Acute PID
Management for cervical stenosis
Gentle dilatation
Examples of ablative therapy for CIN II-III
Cryotherapy, CO2 laser ablation, Loop electrosurgical excision, Cold knife conization
HPV 6,11 causes what
Genital warts
Most common cervical CA tumor type
Squamous
Most common symptom of cervical CA
Vaginal bleeding
Stage of cervical CA confined to cervix
I
Stage of cervical CA invading the uteus
II
Stage if cervical CA extending to the pelvic wall
III
Stage of cervical CA that extends beyond the true pelvics
IV
Management for stage IA and IIA
Extrafascial hysterectomy
Management for highly advanced cervical CA
Chemoradiatiob
Most common cause of death of cervical CA
Uremia
Most common Mullerian anomaly
Category V. Septate uterus
Most common type of myoma
Intramural
Myoma associated with prolonged bleeding
Submucosal
Most common symptom of myoma
AUB
Most common symptom of endometrial polyp
Metorrhagia
Presence and growth of glands and stroma of the lining of the uterusnin aberrant location
Endometriosis
Theories in endometriosis
Metastatic theory(retrograde menstruation- most wideley accepted); metaplastic theory
Adenomyosis is growth of endometrial glands and stroma where
Uterine myometrium with a depth of at least 2.5
Most common site for adenomyosis
Ovaries
Chocolate cysts or powder burn lesions in the pelvis
Adenomyosis
3 cardinal features of adenonyosis
Gland, stroma, hemorrhage
Mid 30s, nulliparous, infertile, secondary dysme,pelvic pain
Adenomyosis
Classic symtpom of adenomyosis
Dysmenorrhea and menorrhagis
Laparosxopy
Diagnosis of endometriosis is via
Most common sx of endrometrial hyperplasia
Bleeding (long periods of oligomenorrhea/amenorrhea followed by irregular excessive uterine bleeding)
Most important determinant of pre malginant potential(endometrial hyperplasia)
Cytologic atypia
Most common cause of post menopausal bleeding
Endometrial atrophy
Most common gynecologic malignancy
Endometrial cancer
Most common site of mets in endometrial cancer
Lungs
Most common subtype of endometrial CA
Endometrioid
basic tx for endometrial CA
Tahbso, node sampling, peritoneal washing
Most common cause of simple cystic adnexal mass in reproductive years
Functional cyst
Most common cause of complex adnexal mass
Benign cystic teratoma
Persistence of dominant follicle
Follicular cyst
Arise from prolonged or excessive stimulation by endo/exogenous gonadotrophins
Theca lutein cysts
Management for adnexal mass during reproductive years
8cm ex lap
Typical size of malignant pelvic masses
> 8cm
Ovarian CA types
EGS(epithelial, germ cell, stromal)
Epithelial ovarian tumors that resemble fallopian tubes
Serous tumors
Epithelial ovarian tumor that resembles cells of the GIT
Mucinous
Hobnail cells are found in
Clear cell CA
Analogous to seminoma of the testes
Dysgerminoma
Schiller Duval bodies are found in
Yolk sac tumors
Malignant germ cell tumors:
Dysgerminoma, endodermal sinus/yolk sac tumor, choriocarcinoma, immature teratoma
Sex cord stromal tumors include
Granulosa theca cell and sertoli leydig cell tumors
Failure of mullerian tubercle to canalize
Transverse vaginal septum
Failure of the urogenital sins to contribute to lower portion of vagina
Agenesis of lower vagina
Liquefaction degeneration at the basal layer; well defined band like infiltrate below the basal layer
Lichen planus
Related to exposure to DES in utero
Vaginal adenosis
Most common symptom of vulvar intraepithelial neoplasia
Itching
Risk factor for VIN
HPV 16 and 18
Most common sx of vulvar CA
Itching
Most common type of vulvar CA
Squamous
Mngmt for stage I to stage III Vulvar Ca
Wide radical vulvar excision and bilateral inguinal femoral node dissedtion
