Gynecology Flashcards
1
Q
Day 1 of the menstrual cycle is slated by the onset of _____?
A
Menses
2
Q
Days 1-14 of the menstrual cycle are described as which phase?
A
Follicular
3
Q
Day 14 is typically the day of ________?
A
Ovulation
4
Q
Days 14-30 of the menstrual cycle are described as which phase?
A
Luteal
5
Q
GnRH from the hypothalamus stimulate which organ?
A
Anterior pituitary
6
Q
The anterior pituitary, once stimulated by GnRH, secretes ____ and _____?
A
FSH and LH
7
Q
LH is responsible for which stimulating production of which hormone(s)?
A
Androgens and progesterone
8
Q
LH stimulates what process?
A
Ovulation
9
Q
FSH is responsible for stimulating production of which hormone(s)?
A
Estrogen (E2) “Estradiol”
10
Q
What are signs of Estrogen excess?
A
- dysmenorrhea
- menorrhagia
- nausea
- edema
- enlarged uterus/fibroids
- fibrocystic breast changes
11
Q
What are signs of Estrogen deficiency?
A
Scant menses and mid-cycle spotting
12
Q
What are signs of progesterone excess?
A
- Edema
- Bloating
- Weight gain
- Fatigue
- HTN
- Varicose veins
“Things you would expect in a pregnant woman”
13
Q
What are signs of progesterone deficiency?
A
- Endometriosis
- Adenomyosis
- Endometrial hyperplasia
- Prolonged/heavy menses
- Severe cramps
- Luteal spotting and BTB (breakthrough bleeding)
14
Q
How many days are in a “normal” menstrual cycle?
A
21-35 days
15
Q
Define amenorrhea
A
absence/abnormal cessation of menses for more than 3mo
16
Q
Define oligomenorrhea
A
scant menses; periods occur >35 days apart
17
Q
Define polymenorrhea
A
menses of increased frequency; periods occur <21 days apart
18
Q
Define menorrhagia
A
AKA Hypermenorrhea; prolonged or profuse menses (>7days or 80cc)
19
Q
Define metrorrhagia
A
any irregular uterine bleeding between cycles; spotting out of cycle
20
Q
Define menometrorrhagia
A
both profuse bleeding during menstruation and between periods
21
Q
Define dysmenorrhea
A
painful menses
22
Q
Define mittelschmertz
A
pain with ovulation; “middle of month pain”
- typically unilateral, front or back
23
Q
Define contact bleeding
A
cervix bleeding from tip of condom/penis/manual physical exam
24
Q
What would contact bleeding indicate?
A
Cervical cancer, cervicitis (CT/Gon), period starting
25
What is dyspareunia?
Painful intercourse
26
Why could there be pain with entry at introitus (vaginal opening)?
- vaginismus mm. contractions
| - infection, sores, low Estrogen
27
Why could there be pain with sexual friction?
- infection
| - low estrogen
28
Why could there be pain with deep penetration?
- Pelvic pathology
| - Cervix/uterus/adnexal inflammation
29
Which hormone is responsible for reducing vaginal pH and increasing cervical pH?
Estrogen
- low vag pH to prevent infection
- high cx mucous pH to welcome sperm
30
Which hormone is responsible for vaginal cornification?
Estrogen
31
Which hormone and contraceptives is/are responsible for decreasing cervical pH?
Progesterone
| - Progesterone OCP, IUD, Prog injection
32
T/F: Hypothyroid disease often presents with hypermenorrhea (menorrhagia)
True
33
What is primary amenorrhea?
No secondary sex characteristics by age 14; no menses by age 16
34
What are potential causes for primary amenorrhea?
CNS hypothalamic disorder, hymen blockage, eating disorder, hypoglycemia, thyroid condition
35
What is secondary amenorrhea?
no menses for 3 cycles OR 6 months (whichever sooner), in a woman with previous menses
36
What are potential causes of secondary amenorrhea?
PREGNANCY, weight changes, stress/depression, thyroid conditions, PCOS, increased prolactin, early menopause, medications
37
Hypoestrogenic amenorrhea puts women at a higher risk for developing which condition?
osteoporosis d/t bone mineral density loss;
- also at risk for dyslipidemia, DM, breast cancer
38
Which initial labs are important to order for amenorrhea evaluation?
b-HCG, TSH, PRL;
- also r/o estrogen deficiency
39
When does exercise induced amenorrhea occur?
Body fat goes below 15-19%, BMI<18;
| - usually not just d/t exercise alone- nutrition is often a factor
40
What initial labs should you order if you suspect premature ovarian failure?
FSH, LH and E2 *(rule out Estrogen deficiency)*
41
What age category would you consider for premature ovarian failure?
<40 y.o.
42
What are the criteria for Dx of PCOS?
1- oligomenorrhea
2- hyperandrogenism
3- exclusion of other known disorders
**polycystic ovaries not required
43
What are S/Sx of PCOS?
hirsutism, anovulation, + FGT, +2hr PPGT, +insulin, increased free Testosterone,
44
What is the proper management of PCOS?
Meds - Progesterone, Spironolactone, Metformin
Supplements - soy/flax, saw palmetto, green tea
Other - High PRO/Low CHO diet
45
What are common causes of menorrhagia?
pregnancy (r/o placenta prev.), infection, IUD, fibroids/polyps, Hypothyroid, blood disorder, neoplasms
46
What does a workup of menorrhagia consist of?
urine pregnancy -> STI screen -> endocrine workup -> PAP -> U/S -> biopsy
47
What are the S/Sx of cervicitis?
* Chronic:* thick yellow d/c w. no bacterial etiology
| * Acute:* (STI- NG, CT, trick), acute trauma, polyps and cancer
48
How do you diagnose cervicitis?
Pap smear and/or biopsy
49
What is adenomyosis? What are some sx?
Endometrial glands + stroma grow into the uterine wall, creating a spongelike effect;
*Sx:* associated w/ heavy, painful periods & uterine enlargement.
50
What is Dysfunctional uterine bleeding (DUB)?
Anovulatory cycles and endometrium overgrowth
51
How do you diagnose DUB?
Dx of exclusion w/ irregular menstrual intervals
52
What are treatment options for DUB?
- Stabilize estrogen via: diet, exercise, GnRH agonist- Lupron
- Anti-inflammatory via NSAIDs
- Limit endometrial overgrowth via Progesterone in any form (cream, pill, IUD)
- Dilatation and Curretage
- Endometrial ablation
- Historectomy
53
What is the most common solid tumor in women?
Uterine fibroids AKA Leiomyomata, Leiomyoma, Fibromyoma, Myoma
54
What makes uterine fibroid removal/surgery controversial?
They are 1% malignant (leosarcoma) and the process may lead to a spread
55
T/F: Nulliparous women have increased risk of uterine fibroid.
True
56
What are Sx of uterine fibroids?
50-80% are asymptomatic
- UF are the MC cause of abnormal uterine bleeding
- Pain is NOT typical
- Urinary abnormalities
- "Pressure", bloating, heaviness
57
How do you dx uterine fibroids?
Pelvic ultrasound, however it is not definitive
58
When would surgery be an option for uterine fibroids?
- Bleeding causes severe anemia
- Unmanageable bleeding
- Severe dysmenorrhea
- Pelvic pain
- Urinary tract compression- pt tolerant level and kidney function compromised
- Infertility
- Rapid growth
- Affects adnexal evaluation
59
What is endometrial hyperplasia?
Overgrowth of endometrial cells in the endometrium.
60
What are sx of endometrial hyperplasia?
- abnormal bleeding
| - postmenopausal bleeding
61
How do you dx endometrial hyperplasia?
- Pelvic US *Endometrial stripe*
- Endometrial biopsy
- D&C
- Hysterectoscopy
62
What are treatment options for endometrial hyperplasia?
Progesterone, dietary changes, exercise, possible D&C, ablation, hysterectomy
63
What is a dangerous warning sign for endometrial cancer?
Postmenopausal bleeding, postmenopausal pap with abnormal cells, premenopausal inter menstrual bleeding
64
What is the difference between primary and secondary dysmenorrhea?
Primary - no underlying pelvic pathology (dx of exclusion)
| Secondary - there IS underlying pathology
65
What are sx of primary dysmenorrhea?
Abdominal/pelvic/Low back pain that begins with onset of menses and lasts 8-72hrs, headache, diarrhea, N/V
66
What are common/possible etiologies for secondary dysmenorrhea?
```
Ovarian disorders (Endometrioma, cysts/neoplasm)
Uterine disorders (Fibroids, adenomyosis, endometriosis, PID, IUD)
```
67
What are sx of secondary dysmenorrhea?
- Onset after painless menstrual cycles in past
- Pain during times other than menses
- Infertility
- Heavy flow
68
What are the labs to R/O secondary amenorrhea?
- Cervical culture, hCG, CBC/UA/ESR
69
What is the prostaglandin theory?
LH & Progesterone increases the release of local Pgs, the endometrium increases prostaglandin production as a response to progesterone withdrawal
70
What is the required timeframe to dx chronic pelvic pain (CPP)?
6 months
71
What is endometriosis?
Presence of endometrial glands and stroma outside the uterus
72
What is the clinical presentation fora woman with endometriosis?
- Pelvic pain @ ovulation, before/during menses
- dyspareunia
- infertility
- LB/leg pain
- severe dysmenorrhea
- irregular or heavy menses
73
How do you dx endometriosis?
laparoscopy is gold standard
| - appearance of blue-grey powder burned lesions
74
How do you treat endometriosis?
- Analgesics
- Endocrine therapy
- Surgery
75
What is PMS? (premenstrual syndrome)
Monthly recurrence of mood, cognitive or physical symptoms during the luteal phase, remits with menses
*Confirmed w/ > 2 cycles*
76
What is PMDD? (premenstrual dysphoric disorder)
Psychosocial impairment, Sx worsen in luteal phase (after ovulation) and BEGIN to remit in menses.
*7 symptom free days in follicular phase*
77
What is PMM? (premenstrual magnification)
Distressing physical or affective symptoms THROUGHOUT the cycle, symptoms may NEVER remit
*only one that may be an exacerbation of underlying condition*
78
What are the different types of functional cysts?
- Follicular cyst (MC ovarian mass)
- Corpus luteum cyst
- Theca lutein cyst (rare)
79
T/F: Endometrioma, PCOS and tubo-ovarian abscesses are all examples of ovarian masses
True
80
When would a corpus luteum cyst develop?
if the sac doesn’t dissolve, but seals off after the egg is released --> Fluid builds up inside
81
Are corpus luteum cysts clinically important?
Yes, with the possibility of bleeding/torsion; whereas the other two functional cysts are not clinically important.
82
What are Sx of functional ovarian cysts?
- often asymptomatic & discovered during routine pelvic exam
- unilateral pressure, fullness, or pain in lower abd
83
Which cyst contains all 3 germ layers?
Dermoid cyst (Teratoma)
- could be benign or malignant
* "adnexal calcifications"*
84
What is an endometrioma?
Part of endometriosis picture, with blood-filled cysts forming on ovaries requiring laparoscopy
85
What is the typical cause of tubo-ovarian abscess?
Infection at the junction; d/t NG or CT
86
What are sx of tubo-ovarian abscess?
- Pelvic pain
- Fever
- Vaginal d/c
- Tubal/ovarian swelling
long term: CPP, infertility
87
At what stage in life are ovarian masses most likely malignant?
In postmenopausal women (45% malignancy risk)
88
What are some risk factors of ovarian cancer?
Fam Hx, Prior BRCA, Nullparity, early menarche or late menopause, fertility promoting drugs, ashkenazi jews
89
What are some s/Sx of ovarian cancer?
- Non specific GI Sx
- Maybe asymptomatic
- pelvic pressure
- No spotting or other red flags for early detection
90
T/F: Hormonal contraceptives and breast feeding help prevent ovarian cancer
true
91
Where is the MC site for fibrocystic breast changes or malignant disease?
Upper outer quadrant
92
Why is the inframammary line important?
Common fibrous area due to bras
93
What is mastalgia and what are the s/sx?
Breast pain/tenderness common in premenopausal women. Can be cyclical or non-cyclical
94
What is fibrocystic breast changes?
Benign condition w/ bilat diffuse changes with hormone fluctuation.
- Masses that don't reduce with menses should be evaluated further
95
What is fibroadenoma?
Fibrous stroma in breast that responds to E/P, size fluctuates with cycle.
- rubbery, firm, smooth, round, mobile, painless
96
Which age do women get fibroadenoma and simple cysts?
15-50 yrs, NOT common in menopause unless on HRT
97
What are characteristics of simple cysts?
- Fluid filled breast lesions
- Soft, firm, mobile, well-circumscribed, uni/bilat, TENDER
- cyclical fluctuations
98
What is mastitis?
- infection with lactation or skin disruption
| - MC in 2-4wks post partum
99
What are s/sx of mastitis?
fever, erythema, pain, induration, N/V, malaise, chills
100
What is the etiology of mastitis?
S. aureus, S. epidermis, strep
101
What is a galactocele and how do you treat?
Obstruction of breast duct, becomes tender and enlarged.
| Tx- excise and drain
102
What is the MC cause of nipple discharge?
benign breast disease
103
What is the MC pathologic cause of nipple discharge?
intraductal papilloma (still benign but pathologic)
104
What characteristics of nipple discharge seem pathologic?
- unilateral
- spontaneous
- frank blood, serous, green/grey
- any other color (d/t carcinoma)
105
What is galactorrhea and what is commonly the cause?
Inappropriate lactation in non puerperal woman
- uni OR bilateral
- evaluate for elevated PROLACTIN levels (r/o pituitary tumor)
106
What is intraductal papilloma?
papillary growth inside lactiferous duct, d/c may be bloody or serous
Tx- surgical excision
107
What causes subareolar abscess?
s. aureus or anaerobic organisms
- common in women w/ inverted nipples or nipple piercings
Tx- antibiotics, drainage, excision
108
What is MC cancer in women?
Breast cancer
109
What is leading cause of cancer deaths in women?
Lung cancer (Breast is second, cause there are two boobs)
110
When would you order MRI instead of US if you suspected breast cancer?
- current or past dx of BrCa
- dense breasts
- high risk with fam hx
111
What are s/sx of early stage BrCa?
- firm/hard mass
- irregular contour
- immobile
- unilateral
112
What are s/sx of late stage BrCa?
- skin/nipple retraction
- tenderness
- axillary
lymphadenopathy
- erythema/edema/ulcer
- pain
- fatigue
- PEAU D'ORANGE
113
Risk factors for BrCa?
- Age (older)
- Sex (Female)
- Race (white)
- Genetic mutations
- Hormone use
- Breast feeding (decr. risk)
- Years of exposure to ovarian estradiol
114
How do you diagnose BrCa?
Biopsy
| Screen w/ self and clinical breast exams and mammography
115
What is Paget's disease of the breast?
- Adenocarcinoma of the nipple
"Itching or burning of the nipple"
- May also be erythema, rash and ulcer
116
How is cervical dysplasia graded?
- Mild (CIN 1)
- Mod (CIN 2)
- Severe (CIN 3)
CIN = cervical intraepithelial neoplasia
SIL = (low or high) squamous intraepithelial lesion
117
T/F: Family history is not a risk factor for cervical cancer.
True
118
What are RF for cervical cancer?
- Early age of first intercourse
- Multiple sex partners
- HPV infection
- Smoking
- Hormonal contraception > 5yrs
- exposure to DES
119
When is a colposcopy performed?
To identify abnormal areas that require biopsy after the Pap smear screening test showed abnormal cells
120
What is the recommended pap smear frequency?
Screening starts within 3 years after having vaginal intercourse or by age 21; every 1-2 years
121
What is LEEP?
Fine wire loop with electrical energy to remove tissue
122
What is conization?
Removes a cone-shaped piece of the cervix, may interfere with future childbearing
123
What is DES and side effects?
Diethylstilbestrol; synthetic estrogen
| - high risk of BrCa, infertility, cx dysplasia, autoimmune disorders, reproductive anomalies
124
What is endometrial adenocarcinoma?
Uterine cancer
125
What is the typical presenting complaint with endometrial adenocarcinoma?
abnormal bleeding
126
What are the RF for endometrial adenocarcinoma?
Age 50-70, Fam hx and unopposed estrogen
| - nulliparity, PCOS, tamoxifen, diabetes, HTN
127
How many pregnancies are unintended in USA?
50%, MC 20-24yrs
128
By what mechanism do E/P hormonal contraceptives work?
- Suppress FSH/LH surge, inhibiting follicular maturation- no ovulation, Prog thickens Cx mucous, alters endometrial lining
129
T/F: Nonoral methods of contraception have lower user failure rates and thus greater reliability
True; less human error
130
What hormone does "the patch" use?
Progestin, changed weekly for 3 weeks
131
What hormone does NuvaRing use?
Progestin, take out for menses.
| *may cause bacterial vaginosis*
132
What was the major issue with injectable hormones (lunelle, depo-provera)?
difficulties getting pregnant quickly after stopping, osteopenia
133
The Mirena IUD secretes which hormone?
levonorgestrel, a synthetic similar to progesterone
- spotting is MC side effect
134
What are contraindications to taking P/E HCPs?
Liver disease, pregnancy, HTN, neurological migraines, breast cancer, smokers
135
What are drug interactions with HCPs?
Tylenol, Alcohol, Antibiotics, St Johns wort, antidepressants, CS, bronchodilators, rifampin
136
When would you take progestin only pills?
women who can't take estrogen (breast feeding and risk for blood clots)
137
What is Norplant?
Silicone rods w/ progesterone placed subcutaneously for 5yrs
138
What is the minipill?
Prog only OC
139
What element does a non-hormonal IUD use?
Copper
140
What is the mechanism of a copper IUD?
reduces sperm motility (copper is its kryptonite), prevents fertilization
141
When would IUD be contraindicated?
abnormal uterine anatomy, nulliparous, pregnancy, DUB of unknown cause, malignancy, allergy to copper
142
Which receptacles are suitable for spermicide?
condoms, diaphragm, cervical cap
143
What are possible side effects of vasectomy?
pain, infection, granulomas, epididymitis, abscesses, ED,
144
What is Preven?
emergency contraception similar to plan B
145
What methods are used for natural family planning?
cervical mucous, BBT, calendar, symptothermal
146
T/F: IUD can be used as an emergency contraceptive
True
147
What is non surgical abortion RU486?
Mimics SAB via Mifepristone (Antiprogesterone)
| - Must be < 49d since LMP
148
What are the contraindications and side effects of RU486?
SE- cramps, nausea, bleeding, retained tissue, need to undergo surgical abortion
Contra- ectopic pg or adnexal mass, IUD, CS therapy, hemorrhagic disorders
149
What hormonal changes occur during perimenopause?
* Rising FSH = marker of perimenopause*
| - Ovaries become sporadically responsive to pituitary FSH/LH, with decreased gonadal hormone output
150
What signifies the onset of menopause?
Absent menses for 12 months and elevated FHS/LH with low Estrogen
151
What is the average age of menopause?
50-51yo
152
What are the symptoms of vulvar cancer?
- itching, burning, soreness
- lump/mole/growth
- color change (white/erythematous)
153
What are symptoms of vulvodynia/vulvar vestibulitis?
Chronic perineal discomfort (burning, stinging, irritation), altered cutaneous perception
154
Describe what occurs with cystocele
Herniation of the bladder wall causing an outpouching of anterior vaginal wall
- may be asymptomatic or cause *incontinence*
155
Describe what occurs with rectocele
Herniation of rectal wall causing an outpouching of posterior vaginal wall
- constipation or the need to apply digital pressure in the vagina in order to defecate
156
Describe what occurs with an enterocele
Weakening of the rectovaginal septum allowing the small intestine to herniate down between layers of the septal wall (pouch of douglas)
- usually asymptomatic
157
Describe what occurs with a urethrocele
Round doughnut-shaped mucosa is observed protruding from the urethral opening.
- Vaginal bleeding is MC symptom
158
What is procidentia?
Complete uterine prolapse (3rd degree)
159
T/F: Many RTIs are asymptomatic, even serious ones requiring treatment
True
160
What is the most common gynecologic complaint?
Vaginitis
161
What are the common infectious agents for vaginitis?
- Bacterial vaginosis
- Trichomonas vaginitis
- Candida vaginitis
- Atrophic vaginitis (STI)
162
Which organism is responsible for maintaining a healthy vagina?
Lactobacillus
163
Describe bacterial vaginitis.
Overgrowth of normal bacteria
- not sexually transmitted!!
- gardnerella, haemophilus, GBS
164
What are the clinical criteria for bacterial vaginitis?
- amine "fishy" odor; whiff test
- elevated pH
- clue cells
- discharge
165
What are s/sx of trichomonas vaginalis?
* Frothy yellow-green discharge*
- Strawberry cervix
- may be malodorous
- erythema
166
Which organs does trichomonas vag. infect?
Vagina, scene's ducts, lower urinary tract
167
What are s/sx of candida albicans aka yeast infection?
Pruritis, erythema, WHITE CURD-LIKE DISCHARGE :s
168
What RTI is caused by low estrogen?
Atrophic vaginitis
169
Which organisms infect the upper reproductive tracts?
Gonorrhea, Chlamydia trachomatis
170
What are s/sx of CT?
May be asymptomatic
- cervicitis, urethritis, PID
- Reiter's syndrome
171
What are s/sx of NG?
May be asymptomatic
- cervicitis, urethritis, PID
- pharyngitis and arthritis
172
Which conditions would cause mucopurulent cervicitis?
NG and CT; and PID
173
What are s/sx of PID?
- mucopurulent cervicitis
- adnexal tenderness
- disturbed menses
- chills and fever
- elevated ESR and WBC
174
Which infection is caused by treponema pallidum?
syphilis by the spirochete itself!
175
Describe primary syphilis
- Within 3 weeks
- Highly contagious
- CHANCRE (Painless ulcer w/ firm borders)
- regional lymphadenopathy
176
Describe secondary syphilis AKA the great mimicker
- 2-8wks after chancre, they develop a RASH on palms and soles
- CONDYLOMA LATA
- fever, sore throat, weakness, wt loss, hair loss (patchy)
177
Describe tertiary syphilis
- May begin as early as 1 year after infection
- Gummata (sores) develop
- Cardiovascular and neuro effects occur
178
How do you dx syphilis?
Antibody testing (VDRL) and MHA-TP
179
What STI is caused by haemophilus ducreyi?
Chancroid
180
Describe chancroid
MUCHO painful lesion with ulceration of lymph node in the groin
181
What should be your DDX for genital ulcers?
HSV, Syphilis, Chancroid, Lymphogranuloma venereum (LGV)-CT
182
Number off the herpes viruses
```
HSV 1 = herpes simplex
HSV 2
VZV (type 3)
EBV (type 4)
CMV (type 5)
HHV roseola (type 6)
HHV (type 7)
HHV Kaposi's sarcoma (type 8)
```
183
Describe primary herpes progression
- erythematous papule
- vesicle
- pustule
- ulceration
- encrustation
184
What are the s/sx of primary herpes?
golden crusty ulceration, may be asymptomatic, Blisters/vesicles, pain/itching, local/systemic symptoms; sexual hx with partner known to have herpes; new partner
185
T/F: HSV may cause unilateral keratitis (cornea), blepharitis and keratoconjunctavitis
True
186
HPV is also known as _________________
Condyloma accuminata
187
How do you treat HPV?
- Podophyllin resin
- Freezing via cryoprobe/nitrogen
- CO2 laser- anesthesia
