Gynecology Flashcards
Established by genetic inheritance at the moment of fertilization
Chromosomal sex
Development of primary sex organs in response to genetic sex
Gonadal sex
Regulation by gonadal sex of the differentiation of the genital apparatus
Phenotypic sex
Establishment of gender role, gender identity, or sexual orientation
Psychological sex
Plano-convex mass adherent to the inner side of the nuclear membrane in somatic cells of genetic females
Barr body
Inactivation of one of the two copies of X chromosomes in females
Lyonization
Possible specimens for sex chromatin test
buccal smear, nerve cells, blood smear, vaginal smear
Present only in 15/100 of male cells and invariably absent in females; basis for the test used in screening for large populations in sports competitions
Fluorescent body/ Y body (Hair-root test)
Gold-standard for sex determination; required for patients undergoing gender-reassignment
Karyotyping
Composed of coelomic epithelial cells; develops into the female ovaries
Outer cortex of the primitive gonads
Composed of stromal mesenchyme surrounding cords of epithelial cells; develops into the male testess
Inner medulla of the primitive gonads
AOG when primitive gonads are present
4th-6th week
AOG when testes normally descend through inguinal ring
7-9 months
Testosterone secreted by Leydig cels induces differentiation of anlagen of external genitalia. What mechanism?
Classic Endocrine Mechanism
Action of MIF on Mullerian duct; action of Testosterone on Wollfian duct. What mechanism?
Local Paracrine Regulatory Mechanism
Portion of Y chromosome that determines genetic sex
SRY gene
Which structures arise from the Wolffian ducts?
Vas deferens, epididymis, seminal vesicles
Which structures arise from the Mullerian ducts?
Uterus, fallopian tube, cervix, upper vagina
Converts testosterone to dihydrotestosterone
5-alpha-reductase
Responsible for differentiation of Wollfian ducts to male internal genitalia at 9 to 10 weeks AOG; secreted by Leydig cells
Testosterone
Glycoprotein hormone secreted by Sertoli cells; induces dissolution of Mullerian ducts, inhibiting differentiation of female internal genitalia
Mullerian Inhibiting Factor / Anti-Mullerian Hormone
Common embryonic origin of male and female external genitalia
Anlagen
Embryonic origin of glans penis, corpus cavernosum, corpus spongiosum
Genital tubercle
Embryonic origin of clitoris and vestibular bulb
Genital tubercle
Fuse around urethral groove to form the ventral shaft of the penis
Genital folds
Embryonic origin of the labia minora
Genital folds
Embryonic origin of the scrotum and prepuce
Labioscrotal swelling
Embryonic origin of the labia majora
Labioscrotal swelling
Embryonic origin of the male urethra, Cowper’s glands, prostate gland
Urogenital sinus
Embryonic origin of the urethra, female vagina, Bartholin’s glands, Skene’s glands
Urogenital sinus
Pattern of secretion of gonadotrophs in males
Pulsatile, relatively constant and sustained (tonic release)
Pattern of secretion of gonadotrophs in females
Pulsatile but cyclic
Female: coarctation of the aorta, short stature, ovarian dysgenesis, shield chest, webbed neck, normal intelligence
Turner Syndrome (45, XO)
Male: testicular atrophy, eunochoid body shape, long extremities, gynecomastia, female hair distribution
Klinefelter Syndrome (47, XXY)
Only possible detectable difference between triple X and normal females
Increased risk for menstrual irregularities and learning disorders
Genetic male lacking receptors for testosterone in target cells
Androgen Insensitivity Syndrome
Cause of androgen overproduction resulting in virilization and ambiguous genitalia in females
Congenital Adrenal Hyperplasia
Common enzyme deficiencies in CAH
21-hydroxylase; 11-beta-hydroxylase; 3-beta hydroxylase
Enzyme accumulation in 21-hydroxylase deficiency
17-hydroxyprogesterone
Most common gynecologic problem in prepubertal females; caused primarily by poor perineal hygiene
Vulvovaginits
Most common foreign body seen in pediatric gynecologic consults
Tissue paper
Pathognomonic sign of adhesive vulvitis
Translucent vertical line at the midline
Parchment-like appearance, hourglass pattern; common in prepubertal children and post-menopausal women
Lichen sclerosus
Epidermal atrophy; Hydropic degeneration of basal cells; Sclerotic strome; Dermal inflammation
Lichen sclerosus
Possible signs of sexual abuse detected during PE of a pediatric patient
Spiral fractures, cigarette burns, abrasions and bruises found at suspicious areas
Sequence of changes during female puberty
Thelarche - Pubarche - Growth Spurt - Menarche
Age of precocious puberty in males?
Age of precocious puberty in females?
9 in boys; 8 in girls
Precocious puberty with normal LH, FSH and estrogen; levels are increased with GnRH stimulation; usual cause is idiopathic or a CNS lesion
Central precocious puberty (GnRH dependent)
Precocious puberty with decreased LH and FSH but highly elevated estrogen; levels do not change with GnRH; most common etiologies are Granulosa Cell tumor and McCune-Albright syndrome
Peripheral precocious pubery (GnRH dependent)
Treatment of choice for idiopathic precocious puberty
GnRH agonist administered chronically until puberty
Precocious puberty, cafe au lait spots, polyostotic fibrous dysplasia
McCune-Albright syndrome
Requisites for diagnosis of premenstrual syndrome
Symptoms present in last 3 consecutive cycles; absent in pre-ovulatory phase; resolve with onset of menses; interfere with normal daily functioning
First step in workup of abnormal uterine bleeding
Pregnancy test
AUB work-up to check for disorders of coagulation, endocrine dysfunction or chronic disease
CBC with pc/dc; Coagulation profile; TSH; prolactin
AUB work-up to check for reproductive tract abnormalities or anatomic defects
Pelvic examination; Pelvic UTZ;
Indications for endometrial biopsy in the work-up of AUB
Post-menopausal; >35 years old; Obese; Hypertensive
DUB: post-menarchal; dysfunctional HPO axis; unstable, frequent, haphazzard; no elevation of body temperature; proliferative changes in endometrial biopsy
Anovulatory DUB
DUB: mid-reproductive life; due to local endometrial factors; orderly tissue breakdown; self-limited bleeding; mid-cycle body temperature elevation; secretory changes in endometrial biopsy
Ovulatory DUB
Treatment of choice for anovulatory DUB
Progestin
Treatment for acute excessive uterine bleeding in hemodynamically stable patients
Conjugated equine estrogen (CEE) 10mg/day in 4 doses for 14-21 days; medroxyprogesterone for 7-10 days
Treatment for acute excessive uterine bleeding in hemodynamically unstable patients
IV estrogen (causes rapid proliferation of denuded endometrium)
Irreversible complication of Danazol
Deepening of the voice
Treatment for chronic ovulatory DUB for patient desiring contraception
OCP and levonogestrel-releasing IUD w or w/o NSAIDs and Tranexamic acid
Menstrual pain associated with ovulatory cycles in the absence of pathologic findings; mediated by excess of prostaglandins; diagnosis of exclusion
Primary dysmenorrhea
Excessive menstrual pain and cramping arising in the mid-reproductive years with identifiable anatomic pathology
Secondary dysmenorrhea
Primary amenorrhea
No menses by 14 years in the absence of secondary sexual characteristics; No menses by 16 years if with secondary sexual characteristics
Secondary amenorrhea
No menses for 3 months (if previous menses were regular); no menses for 6 months (if previous menses were irregular)
Primary amenorrhea: no breasts ; low FSH and LH. Likely etiology?
CNS tumor (hypogonadotrophic hypogonadism)
Primary amenorrhea: no breasts; high FSH and LH; normal karyotyping. Likely etiology?
Ovarian failure
Primary amenorrhea: no breasts; high FSH and LH; abnormal karyotyping. Likely etiology?
Turner’s syndrome
Hypogonadotropic hypogonadism with insufficient GnRH; anosmia
Kallman syndrome
Primary amenorrhea: breasts present; uterus absent; abnormal karyotyping. Likely etiology?
Androgen insensitivity
Primary amenorrhea: breasts present; uterus absent; normal karyotyping
Mullerian agenesis (Mayer-Rokitansky-Küster-Hauser syndrome)
Primary amenorrhea: breasts present; uterus present
Outflow obstruction
Outflow tract abnormalities causing secondary amenorrhea
Imperforate hymen, Transvaginal septum, Vaginal agenesis
CNS-hypothalamic causes of secondary amenorrhea
Decreased leptin, weight loss, anorexia nervosa, exercise, stress
Hirsutism, amenorhea, obesity
Polycystic Ovarian Syndrome
Pituitary cell destruction as a result of hypotensive episode during pregnancy
Sheehan syndrome
Treatment for hyperprolactinemia
Bromocriptine, TCA, MAOI
Cessation of ovarian function before the age of 40; may be caused by irradiation, chemotheraphy, autoimmunity
Premature ovarian failure
Progesterone challenge test: withdrawal bleeding within 7 days. Possible causes?
Anovulation (most common); prolactinoma, hypothyroidism, endometrial CA with unopposed estrogen
Progesterone challenge test: no withdrawal bleeding. Possible causes?
Outflow obstruction, inadequate estrogen (do EPCT)
Indirect means of determining sufficient estrogen to produce endometrial growth that will slough after the progesterone level falls
Progesterone challenge test
Intrauterine adhesions most frequently caused by endometrial curettage associated with pregnancy; cause of DUB
Asherman syndrome
Timeframe required to diagnose menopause
12 months amenorrhea from final period; 3 months amenorrhea with elevation of gonadotropins
Mean age of menopause for Filipinos
47-48 years
Median age of onset and length of perimenopausal (climacteric) period
47.5 years; may take as long as 4 years
Initial hormonal change signalling onset of menopause
Decreased ovarian inhibin production with increased pituitary FSH
Less likely to develop hot flushes, osteoporosis; more likely to develop endometrial hyperplasia during menopause
Obese women
More likely to develop hot flushes; more likely to develop osteoporosis; less likely to develop endometrial hyperplasia and cancer
Non-obese women
Recommendations for prevention of osteoporosis during menopause
Calcium supplementation (1500mg/day)
Vitamin D supllementation (1500mg/day)
Weight-bearing exercises
Smoking cessation
Benefits of hormone replacement therapy during menopause
Decreases vasomotor symptoms
Stabilizes trabecular bone formation
Acidifies vaginal pH, decreases atrophic vaginitis
Thickens vaginal epithelium, decreases dyspaerunia
Risks of hormone replacement therapy during menopause
Increased risk for heart disease, breast cancer, stroke, endometrial cancer and gallbladder disease
Risk of breast cancer increases after how many years of ERT
4 years
Contraindications to ERT for menopause
Undiagnosed vaginal bleeding Active thrombophlebitis Chronic impaired liver function History of thromboembolic disease Hormonally-dependent carcinoma
Alternative for those with contraindications to ERT for menopause
Selective receptor modulators (SERM)
Raloxifene Tamoxifen
Anterior pelvic organ prolapse
Cystocele
Posterior pelvic organ prolapse
Rectocele
Pelvic organ prolapse through Pouch of Douglas
Enterocele
POP wherein entire uterus as well as the anterior and posterior vaginal walls extend outside the introitus at all times
Procidentia (Grade IV POP)
Excess of nonsexual hair
Hypertrichosis
Rapid onset of virilizing and hirsutism symptoms; elevated DHEAS levels; palpable abdominal mass
Androgen-producing tumor
Gradual onset of virilizing and hirsutism symptoms; elevated 17-OHP; presents with premature pubarche, acne, accelerated bone age, menstrual irregularities
Late-onset CAH (21-hydroxylase deficiency)
Gradual onset of symptoms; increased glucocorticoids and androgens; exhibits central obesity, dorsal neck pad, abdominal striae
Cushing’s disease (ACTH-secreting pituitary adenoma)
Gradual onset of hirsutism after puberty with long duration; normal testosterone, DHEAS, 17-OHP; common in Mediterranean family background
Hair follicle androgen sensitivity (5-alpha reductase sensitivity)
Management of androgen-producing tumors
Surgery
Management of late-onset CAH
Glucocorditoids
Management of Cushing’s disease
Surgery, hormone replacement
Required duration of unprotected, frequent intercourse to consider infertility
12 months
Management of hair follicle androgen sensitivity
Spironolactone
Likelihood of conception occurring with one cycle of appropriately-timed midcycle intercourse; rate usually is 20%
Fecundity
Ovulatory causes of female factor infertility
PCOS Advanced maternal age Premature ovarian failure Hyperprolactinemia Hypothyroidism
Tubal causes of female factor infertility
PID
Tubal ligation
Pelvic adhesions
Endometriosis
Uterine causes of female factor infertility
Congenital malformation Submucosal fibroids Uterine polyps Asherman syndrome Luteal phaes defect
Cervical causes of female factor infertility
Cervical stenosis
Cervicitis
Unfavorable mucus
Phase 1 workup for infertility
Ovulation documentation
Semen analysis
Ovarian reserve
Pelvic UTZ
Normal semen analysis values
Volume: 2-5mL Concentration: >20 million/mL Motility: >50% with forward progression Normal forms: >30% with normal form pH: 7.2-7.8
Treatment for hypothalamic-pituitary failure causing male factor infertility
Human Menopausal Gonadotropins (hMG)
Weak estrogen; competes with endogenous estrogen for binding sites; induces ovulation by further enhancing GnRH release
Clomiphene
Alternative treatment for ovulation induction; reduces insulin resistance
Metformin
Used for ovulation-induction when estrogen levels are low
hMG (or alternatively, GnRH)
Characteristic of normal vaginal secretion during midcycle estrogen surge
clear, elastic, mucoid
Characteristics of normal vaginal secretion during luteal phase / pregnancy
thick, white, adherent to vaginal wall
Grayish-white discharge, fishy odor, (+)clue cells, pH >4.5, (+) whiff test. Common etiology and DOC?
Gardnerella vaginalis. Metronidazole
Pruritus, burning, erythema, cottage-cheese-like discharge, (+)hyphae, pH < 4.5. Common etiology and DOC?
Candida albicans. Fluconazole
Green-yellow frothy discharge, pruritus, malodorous, (+)strawberry cervix, pH > 4.5. Common etiology and DOC?
Trichomonas. Metronidazole
No discharge, (+)erythema and excoriations, pruritus, normal pH, (+)D-shaped eggs. Common etiology and DOC?
Enterobius vermicularis. Pyrantel pamoate
Polymicrobial ascending infection of the upper genital tract; increased risk with STDs, IUD use and douching; (+)chandelier sign. Common etiologies?
C.trachomatis, N. gonorrhoeae, other endogenous aerobes and anaerobes
Violin-string adhesions from chronic pelvic inflammation
Fitz-Hugh-Curtis syndrome
Outpatient regimen for empiric PID treatment
Ceftriaxone 250mg IM SD, Doxycycline 100mg BID PO x 14 days, with or without Metronidazole 500mg BID PO x 14 days
Indications for in-patient treatment of PID
Surgical emergency not excluded Pregnant Poor response to oral regimen Unable to follow outpatient regimen Severe illness, nausea, vomiting, high-fever Tubo-ovarian abscess
In-utero exposure causes increased risk of clear cell adenocarcinoma
DES
Double cervix usually arising from uterine didelphys with double vagina
Bicollis
Mucous retention cyst of endocervical columnar cells; Most common cervical cyst. No treatment required.
Nabothian cyst
Most common lesion of the cervix; associated with intermenstrual or post-coital spotting; not premalignant
Cervical polyp
Exists between the squamous epithelium of the vagina and ectocervix and the columnar epithelium of the endocervix; site of collecting specimens for Pap smere
Transformation zone
When to begin screening for cervical cancer
3 years after onset of sexual activity or at 21 years of age (whichever comes first)
Pap smear: within normal limits. Intervention?
Continue routine testing
Pap smear: inflammation without atypia.Intervention?
Treat inflammation
Pap smear: inflammation with atypia. Intervention?
Treat inflammation first, then repeat pap smear
Pap smear: atypical squamous cells of uncertain significance. Intervention?
Colposcopy and biopsy, OR repeat pap smear after 3 months
Pap smear: Low Grade SIL (CIN 1, Koilocytosis). Intervention?
Colposcopy and biopsy
Pap smear: High grade SIL (CIN 2, CIN 3). Intervention?
Colposcopy and biopsy
Possible indications for diagnostic conization
T-zone difficult to evaluate
Uncertainty regarding disease presence
Extension to ectocervix
Biopsy suggestive of microinvasive disease
Most frequent malignancies in females, in decreasing order
Endometrial CA
Ovarian CA
Cervical CA
HPV strains which conver high risk for cervical CA
16, 18, 31, 33
Most common histologic type of cervical CA
Squamous cell (85%-90%)
Most common symptom of cervical CA
Vaginal bleeding
