Gynecology Flashcards
Ovotesticular Disorder of Sexual Differentiation
Previously called “true hermaphrodite”
Ambiguous or normal male genitalia
Mullerian structures absent on side of functioning testes
Bicornuate uterus if ovary/sreak gonad
5 alpha reductase deficiency
“Penis at 12”
Ambiguous genitalia at birth, increased virilization at puberty
Hirsutism
Either exces androgens or increased skin sensitivity to androgens
CAH, androgen-secreting tumor, Cushings, acromegaly, drugs
Hypertrichosis
Excess hair growth in generalized non-sexual pattern
Tx-excess hair
Lose weight
Cosmetic methods: waxing, shaving, bleaching, etc
Diannette/Yasmin
Topical eflornithine
Candida-dx
Take sample from anterior fornix/lat vaginal wall
Gram stain, KOH prep
Tx Candida (pregnant and non-pregnant)
Fluconazole if not pregnant
Clotrimazole if pregnant
Dx Trichomonas
Wet prep microscopy of discharge (women).
Culture in males.
Tx trichomonas
Metronidazole 2g PO
Tx BV
2g mentronidazole PO or 400mg BD for 5 days
Or intravaginal gel
Chlamydia serotypes A-C
Cause trachoma
Chlamydia serotypes D-K
Genital chlamydia, ophthalmia neonatorum
Chlamydia L1-L3
LGV (rectal infection, proctitis)
Tx-chlamydia
Azithromycin
Can give doxycycline for several days but not in pregnancy and less compliance than single dose azithro hence why azithro is first line
LGV
Painless rapidly healing ulcers
May cause balanitis, proctitis, cervicitis
Secondary stage-inguinal buboes, 2/3 unilateral. Slow healing with scarring
Late stage-genital elephantiasis, genital ulcers, frozen pelvis
Tx-LGV
NAAT
2/52 doxy
Gonorrhea
Increased vaginal discharge, lower abdo/pelvic pain
Contact bleeding
Endocervical swabs
Cephs ok in preg…ceftriaxone 250mg IM
Always treat automatically for chlamydia as well…which is kind of insulting when you think about it…“You’re clearly a ho. Here, have ALL the antibiotics. We think you’ll need them.”
Secondary syphilis
Arthralgia, myalgia, HA, fever
Neuro involvement–aseptic meningitis, CN palsies, optic neuritis, acute nerve deafness
Tertiary syph
2-30 years later
Gumma-SKIN, bone, mucosa
Aortitis
Neurosyph incl Argyll Robertson pupils
Congenital syph
Intrauterine death, interstitial keratitis, VIII deafness, Hutchinson teeth
Chancroid
Haemophilus ducreyi Tropical Multiple painful shallow ulcers Regional LAD Culture Tx: 2g azithro
Donovanosis/Granuloma inguinale
Klebsiella granulomatis Africa, India, Australian Aboriginal communities Painless nodule Giemsa stain--intracellular inclusions Tx-erythromycin
Herpes simplex (STI version)
Sxs
Dx
Tx
Multiple small shallow painful ulcers Febrile flu-like prodrome Swab-electron microscopy Primary outbreak-acyclovir Recurrent-5 day course acyclovir 200mg 5x/day
Facial molluscum in an adult
HIV until proven otherwise
Tx-genital warts
Podophyllin, imiquimod
Tx-PID
Ofloxacin and metronidazole 14 days
If pregnant-IM ceftriaxone + erythromycin + metronidazole
RMC-causes
Anatomical: fibroids, uterine abnormalities, cervical incompetence
Genetic
Bleeding/Clotting: Antiphospholipid, FV Lieden
Infection (late): BV
Causes dyspareunia
Vaginismus
Failure arousal and/or lubrication
Chronic UTI/urethral causes
Uterine: adenomyosis, fibroids
Extrauterine: endometriosis, chronic pelvic infection, pelvic relaxation, adhesions, vaginal shortening, tumors
GI: chronic constipation, IBD, IBS
MSK: herniated disc, femoral or abdominal hernia
Post-coital bleeding
Uterine: neoplasia, endometrial hyperplasia, polyps, fibroids
Cervical: cervicitis, erosion, ectropion, neoplasia
Vaginal: infection, atrophy, trauma
Pregnancy
Hemorrhoids
Average age breast development (puberty)
11.5
Usually 8.5-12.5
When does menarche occur in relation to puberty?
~2.5 yrs after start puberty
First sign puberty in males
Testicular enlargement (>4mL)
When do males get growth spurt in puberty?
When testicular volume 12-15mL
Precocious puberty cut-offs
Females:
Gonadotrophin-dependent precocious puberty
Premature activation HPA axis Causes: Idiopathic Congenital (hydroceph) Acquired-post-radiation, infection, surgery Tumors e.g. microscopic hamartomas
Gonadotrophin-independent precocious puberty
Excess sex steroids Causes: Adrenal tumors, CAH Ovarian tumors (granulosa cell) Testicular tumors (Leydig cell) Exogeous sex steroids
Chronic pelvic pain
> 6/12
Not exclusively with menstruation or intercourse
?Estrogen mediated (rare after menopause)
Sxs suggestive of IBS, interstitial cystitis oft present, as are psych factors (depression, sleep disorders)
**Substantial number have hx childhood/ongoing sexual abuse
Chronic pelvic pain ddx
Gynae: endometriosis/adenomyosis Adhesions IBS, interstitial cystitis Pelvic organ prolapse MSK pain Nerve entrapment post-sx Other surgical
Adenomyosis
Endometrial tissue in myometrium
Uterus becomes enlarged and boggy
Menorrhagia, dysmenorrhia
RF: multiparity
Indications for hysteroscopy
PMB, IMB, PCB Irreg menstruation Persistent menorrhagia or discharge Possible uterine malformations Suspected Ashermans
Complications hysteroscopy
Perforation
Cervical damage if need to dilate
Ascent of any existing infection
Indications for laparotomy
Suspected ectopics Undx'd pelvic pain ?Tubal patency (lap and DYE) Sterilization/reversal Ovarian cystectomy Tx endometriosis
Hysterectomy: abdo vs vaginal
Vaginal has quicker recovery
Can’t do vaginal if malignancy (need to remove ovaries, look at LNs)
May be safer to do abdo if larer than 12 wks
Abdo: Pfannenstiel incision
Indications for cystoscopy
Hematuria Recurrent UTI Sterile pyuria Short hx irritative sxs Suspected bladder abnormality (fistula, diverticula, stones) Assess bladder neck
Benign epithelial ovarian tumors
Serous cystadenoma
Mucinous cystadenoma
Brenner
Malignant epithelial tumors
Serous cystadenocarcinoma
Mucinous cystadenocarcinoma
Endometrioid
Clear cell
Benign germ cell ovarian tumors
Dermoid cyst
Mature teratoma
Malignant germ cell ovarian tumors
Immature teratoma
Dysgerminoma
Benign sex cord ovarian tumors
Granulosa cell
Sertoli-Leydig
Thecomas
Fibromas
Malignant sex cord ovarian tumors
Granulosa cell
Sertoli Leydig
RFs for ovarian cancer
Increased hormone exposure (early menarche, late menopause, etc) Nulliparity/infertility Endometriosis Genetic predisposition (BRCA) **Majority have no known RFs
Uterovaginal prolapse tx in primary care
Silicon-rubber based ring pessaries (act as artificial pelvic floor)
Lichen sclerosis
Vulvar itch, white lesion, thin and crinkled skin
Labial contour slowly disappears and labial adhesions form
Tx with aqueous cream/1% hydrocortisone TDS for itching
2% Testosterone ointment BD/TDS 6/52
Vulvar squam cell hyperplasia
Thickened asymm areas (white/grey)
Lichen planus
Assoc with HCV, PBC
*Kobnerization phenomenon
Acute onset purple, polygonar pruritic papular eruption
Wickham’s striae
Dyspareunia, scar tissue. Can cause stenosis
Tx: topical ‘roids-vaginal suppositories
Vulvar vestibulitis
Reproducible exquisite pinpoint pressure tenderness.
Unknown cause
Assoc with dyspareunia, pain on tampon insertion
Most common cause primary amenorrhea
Turners
Second most common cause primary amenorrhea
Mullerian agenesis (aka Rokitansky-Kuster-Howser syndrome)
Cervical stenosis: sxs, comps, causes, tx
Sxs: cyclical dysmenorrhea, subfertility, abn vaginal bleeding, amenorrhea
Comps: Hydrometra, hematometra, pyometra
Causes: cervical sx, radiation, infection, neoplasia, atrophic change
Tx: surgical dilation cervix
Tx-fibroids
Tranexamic acid, NSAIDs, progestogens oft ineffective if causing menorrhagia, but may be worth trying as first line
GnRH agonists + HRT to shrink (but can only use 6/12 and then they come back anyway)
TCRF=trans-cervical resection of fibroids (pre-treat with GnRH ag)
Uterine artery embolization
Fibroids-sxs
50% no sxs
30% menstrual problems (dysmenorrhea, menorrhagia)
Rarely cause pain unless torsion
May be a cause of infertility (get in way of implantation)
Types of fibroids
Intramural
Subserosal
Submucosal
Fibroid size during pregnancy
Equally likely to grow, shrink, or stay the same during pregnancy
Endometrial polyps-tx
Don’t need to remove if pre-menopausal unless sxs >3/12
Remove if post-menopausal (risk cancerous change)
Endometritis
Oft secondary to STIs, as comp sx (esp CS and intrauterine procedures) or foreign tissue (IUDs, RPC).
Post-menopause oft due to malignancy
Tender uterus +/- pelvic and systemic infection
Pyometra: pus accumulation and can’t escape
Vulval cancer-RFs
VIN Lichen sclerosis Immunosuppression Smoking Paget's disease of vulva
Exam findings-vulval carcinoma
Ulcer or mass, most commonly on labia majora or clitoris
Inguinal LNs may be enlarged, hard, immobile
Premature menopause cutoff (age)
Tx menopause
Treat vasomotor sxs. 5mg norethisterone SSRIs-hot flashes Topical estrogens for vaginal atrophy Bisphosphonates, raloxifene for osteoporosis
Raloxifene
SERM
Decreases fractures post-menopause by 30-50%
Denosumab
Monoclonal Ab to RANK-L. Decreases osteoclast activation.
HRT
Estrogen alone if hysterectomy
E + P if still have uterus
E can be given PO, transdermally, PV, SC (implant)
P can be given PO, transdermally, IUS
Tibolone: E, P, androgenic effects. Perimenopausal women who want amenorrhea. Treats vasomotor, psych, libido sxs and preserves bone mass
Urodynamic stress incontinence
Exclude OAB
>10% all women
Urethral sphincter weakness
Bladder slips below pelvic floor–no compresion
Prolapse may co-exist but not always related
RF-stress incontinence
Pregnancy, vaginal delivery
Obesity
Age (post-menopausal)
Previous hysterectomy
Tx-stress incontinence
Weight loss
Tx cough
Decrease excess fluids
Conservative: pelvic floor exercise (1st line for 3/12). 8 contractions TDS. Vaginal cones or sponges to alleviate incont
Med: duloxetine
Sx: when conservative failed. Tension free vaginal tape, trans-obturator tape=first line
OAB
Urgency with or without urge incontinence. Usually with frequency or nocturia in absence proven infection
Detrusor overactivity
35% of female incont
Usu idiopathic. May be post-USI sx, MS, spinal cord injury
OAB-history
Urgency, urge incontinence Frequency, nocturia Stress incont commonly co-exists Sometimes leaks at night, during orgasm Hx childhood enuresis or fecal urgency comm
OAB-tx
Conservative: decrease fluids/caffeine, review drugs
BLADDER TRAINING-timed voiding with systemic delay in voiding and positive reinforcement. >6/52 + anticholinergics
Med: anticholinergics, estrogens, botulinum A toxin
Sx: neuromodulation, sacral nerve stimulation
incontinence Ix
Stand and cough (over pad)-immediate loss urine=stress
Cystometry: fill bladder with 50mL H20–volume at first urge. Look for reflux
Urethrocele
Prolpase lower anterior vaginal wall, involving urethra only
Cystocele
Prolapse upper anterior vaginal wall, involving bladder
Urethrocystocele
Prolapse involving both bladder and urethra
Apical prolapse
Prolapse uterus, cervix, upper vagina
Enterocele
Prolapse lower posterior vaginal wall involving anterior wall rectum
RF-prolapse
Vaginal delivery (Esp large infant), prolonged 2nd stage, instrumetal deliveries
Congenital-EDS (collagen fuckery)
menopause (collagen again)
Iatrogenic-pelvix sx
Cervical ectropion
Columnar epith extends a bit farther.
Easy bleeding (post-coital, smears, colposcopy)
Indistinguishable from early cervical cancer so need to do smear
Common in high estrogen states, e.g. on the pill
Bartholin cyst
Cyst (usu U/L) in lower vestibule
Arises due to inflamm and obstruction of gland, usu in women reproductive age
Condyloma
Genital warts. HPV 6, 11 (covered by Gardasil quadrivalent vaccine)
Koilocytic change
Extramammary Paget’s disease
Malignant epith cells in epidermis vulva
Erythematous, pruritic, ulcerated vulvar skin
Carcinoma in situ
Must distinguish from melanoma
Clear cell adenocarcinoma of vagina
Complication of female fetuses exposed to DES
Exocervix-histology
Lined by squamous epith
Endocervic-histology
Lined by columnar epith
High risk HPV
16, 18, 31, 33 and more
16 and 18 covered by Gardasil vaccine
CIN-histology
Koilocytic change, disordered cellular maturation, nuclear atypia, increased mitotic activity
Referral for colposcopy
Borderline and mild tested for HPV. if positive for high risk–referral
Moderate and severe-automatic referral
Three inadequate smears
Cervical carcinoma
Average age 40-50
Presents as PCB or cervical discharge
RF: High risk HPV, smoking, immunodeficiency
80% are squamous cell; 15% adenocarc
Limitation pap smear
Doesn’t pick up adenocarcinoma
Asherman syndrome
Secondary amenorrhea due to loss basalis and scarring. Often from overaggressive dilation and curettage
Anovulatory cycle
Estrogen-driven proliferative phase without subsequent progesterone-driven secretory phase. (NB unopposed estrogen)
Common cause dysfunctional uterine bleeding, esp during menarche and menopause
Endometrial hyperplasia
As consequence unopposed estrogen
Postmenopausal uterine bleeding
Most important predictor for progression to endometria carcinoma is cellular atypia
Endometrial carcinoma
Most common invasive carcinoma of female genital tract
*Post-menopausal bleeding
75% from hyperplasia pathway
25% sporadic pathway–more aggressive
Unopposed estrogen–causes
PCOS/anovulatory cycles
Obesity
Estrogen replacement
PCOS
5% women of reproductive age
Increased LH:FSH
Increased LH induces excess androgens from theca cells causing hirsutism
Androgen converted in adipose to estrone (unopposed estrogen(
Classic presentation: obese young woman with infertility, oligomenorrhea, hirsutism.
Some pts have insulin resistance and may develop TII DM 10-15 years later
Management ovarian cyst in post-menopausal woman
Risk assessment: pre or post-menopausal, CA 125, simple?
If simple,
Treatment endometriosis
Danazol 3-6m
Triptorelin up to 6/12
Lap
1st line HMB
Mirena
2nd line HMB
Tranexamic acid, mefanamic acid
Mefanamic has more side effects
1st line severe PMS
SSRIs Vit B6 Diet and exercise CBT yasmin or Cilest
Management of significant and symptomatic prolapse
Surgery
Festoterodine
Urge incontinence
Solifenacin
Urge incontinence
OAB management
Start trial therapy and reassess before urodynamic studies
Bladder diary and bladder retraining
Oxybutynin
Causes and Ix for vesicovaginal fistula
Causes: worldwide is obstructed labor. First world is pelvic surgery
Ix: Methylene blue into bladder, then speculum into vagina
Emergency contraception options
1.5mg levonorgesterol. Up to 72 hrs
Ulipristal up to 5 days
Copper coil up to 5 days
Rokitansky’s
Mullerian agenesis
Ovaries fine
No Fallopian tubes or uterus; may have shortened vagina
Indications for colposcopy
Three borderline Three insufficient Two mild Borderline or mild + high-risk HPV Any moderate or severe
Wertheim’s hysterectomy
Cervical cancer
Removes uterus, upper 1/3 vagina, parametrium
Subtotal hysterectomy
Leaves cervix
Cytoreduction surgery
Debulking.
Can be used before chemo
Meig’s syndrome
Pleural effusion (classically on right) and ovarian fibroma
RMI calculation
concerning things on USS x CA 125 x 3 (if post-menopausal)
Most common adverse effect POP
Irregular bleeding
Length of contraception after menopause
50: 12 months
Primary dysmenorrhea
No pelvic pathology
Increased prostaglandins
Up to 50% women
Secondary dysmenorrhea–causes
Endometriosis, adenomyosis, PID, IUD, fibroids
Cerazette
3rd generation POP
Can take up to 12 hours late (as opposed to three hours with earlier pills)
proliferative phase
Aka follicular phase
Secretory phase
Aka luteal phase
