Gynecology Flashcards
Day 1 of the menstrual cycle is slated by the onset of _____?
Menses
Days 1-14 of the menstrual cycle are described as which phase?
Follicular
Day 14 is typically the day of ________?
Ovulation
Days 14-30 of the menstrual cycle are described as which phase?
Luteal
GnRH from the hypothalamus stimulate which organ?
Anterior pituitary
The anterior pituitary, once stimulated by GnRH, secretes ____ and _____?
FSH and LH
LH is responsible for which stimulating production of which hormone(s)?
Androgens and progesterone
LH stimulates what process?
Ovulation
FSH is responsible for stimulating production of which hormone(s)?
Estrogen (E2) “Estradiol”
What are signs of Estrogen excess?
- dysmenorrhea
- menorrhagia
- nausea
- edema
- enlarged uterus/fibroids
- fibrocystic breast changes
What are signs of Estrogen deficiency?
Scant menses and mid-cycle spotting
What are signs of progesterone excess?
- Edema
- Bloating
- Weight gain
- Fatigue
- HTN
- Varicose veins
“Things you would expect in a pregnant woman”
What are signs of progesterone deficiency?
- Endometriosis
- Adenomyosis
- Endometrial hyperplasia
- Prolonged/heavy menses
- Severe cramps
- Luteal spotting and BTB (breakthrough bleeding)
How many days are in a “normal” menstrual cycle?
21-35 days
Define amenorrhea
absence/abnormal cessation of menses for more than 3mo
Define oligomenorrhea
scant menses; periods occur >35 days apart
Define polymenorrhea
menses of increased frequency; periods occur <21 days apart
Define menorrhagia
AKA Hypermenorrhea; prolonged or profuse menses (>7days or 80cc)
Define metrorrhagia
any irregular uterine bleeding between cycles; spotting out of cycle
Define menometrorrhagia
both profuse bleeding during menstruation and between periods
Define dysmenorrhea
painful menses
Define mittelschmertz
pain with ovulation; “middle of month pain”
- typically unilateral, front or back
Define contact bleeding
cervix bleeding from tip of condom/penis/manual physical exam
What would contact bleeding indicate?
Cervical cancer, cervicitis (CT/Gon), period starting
What is dyspareunia?
Painful intercourse
Why could there be pain with entry at introitus (vaginal opening)?
- vaginismus mm. contractions
- infection, sores, low Estrogen
Why could there be pain with sexual friction?
- infection
- low estrogen
Why could there be pain with deep penetration?
- Pelvic pathology
- Cervix/uterus/adnexal inflammation
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
Which hormone is responsible for vaginal cornification?
Estrogen
Which hormone and contraceptives is/are responsible for decreasing cervical pH?
Progesterone
- Progesterone OCP, IUD, Prog injection
T/F: Hypothyroid disease often presents with hypermenorrhea (menorrhagia)
True
What is primary amenorrhea?
No secondary sex characteristics by age 14; no menses by age 16
What are potential causes for primary amenorrhea?
CNS hypothalamic disorder, hymen blockage, eating disorder, hypoglycemia, thyroid condition
What is secondary amenorrhea?
no menses for 3 cycles OR 6 months (whichever sooner), in a woman with previous menses
What are potential causes of secondary amenorrhea?
PREGNANCY, weight changes, stress/depression, thyroid conditions, PCOS, increased prolactin, early menopause, medications
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
Which initial labs are important to order for amenorrhea evaluation?
b-HCG, TSH, PRL;
- also r/o estrogen deficiency
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
What initial labs should you order if you suspect premature ovarian failure?
FSH, LH and E2 (rule out Estrogen deficiency)
What age category would you consider for premature ovarian failure?
<40 y.o.
What are the criteria for Dx of PCOS?
1- oligomenorrhea
2- hyperandrogenism
3- exclusion of other known disorders
**polycystic ovaries not required
What are S/Sx of PCOS?
hirsutism, anovulation, + FGT, +2hr PPGT, +insulin, increased free Testosterone,
What is the proper management of PCOS?
Meds - Progesterone, Spironolactone, Metformin
Supplements - soy/flax, saw palmetto, green tea
Other - High PRO/Low CHO diet
What are common causes of menorrhagia?
pregnancy (r/o placenta prev.), infection, IUD, fibroids/polyps, Hypothyroid, blood disorder, neoplasms
What does a workup of menorrhagia consist of?
urine pregnancy -> STI screen -> endocrine workup -> PAP -> U/S -> biopsy
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
How do you diagnose cervicitis?
Pap smear and/or biopsy
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.
What is Dysfunctional uterine bleeding (DUB)?
Anovulatory cycles and endometrium overgrowth
How do you diagnose DUB?
Dx of exclusion w/ irregular menstrual intervals
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
What is the most common solid tumor in women?
Uterine fibroids AKA Leiomyomata, Leiomyoma, Fibromyoma, Myoma
What makes uterine fibroid removal/surgery controversial?
They are 1% malignant (leosarcoma) and the process may lead to a spread
T/F: Nulliparous women have increased risk of uterine fibroid.
True
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
How do you dx uterine fibroids?
Pelvic ultrasound, however it is not definitive
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
What is endometrial hyperplasia?
Overgrowth of endometrial cells in the endometrium.
What are sx of endometrial hyperplasia?
- abnormal bleeding
- postmenopausal bleeding
How do you dx endometrial hyperplasia?
- Pelvic US Endometrial stripe
- Endometrial biopsy
- D&C
- Hysterectoscopy
What are treatment options for endometrial hyperplasia?
Progesterone, dietary changes, exercise, possible D&C, ablation, hysterectomy
What is a dangerous warning sign for endometrial cancer?
Postmenopausal bleeding, postmenopausal pap with abnormal cells, premenopausal inter menstrual bleeding
What is the difference between primary and secondary dysmenorrhea?
Primary - no underlying pelvic pathology (dx of exclusion)
Secondary - there IS underlying pathology
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
What are common/possible etiologies for secondary dysmenorrhea?
Ovarian disorders (Endometrioma, cysts/neoplasm) Uterine disorders (Fibroids, adenomyosis, endometriosis, PID, IUD)
What are sx of secondary dysmenorrhea?
- Onset after painless menstrual cycles in past
- Pain during times other than menses
- Infertility
- Heavy flow
What are the labs to R/O secondary amenorrhea?
- Cervical culture, hCG, CBC/UA/ESR
What is the prostaglandin theory?
LH & Progesterone increases the release of local Pgs, the endometrium increases prostaglandin production as a response to progesterone withdrawal
What is the required timeframe to dx chronic pelvic pain (CPP)?
6 months
What is endometriosis?
Presence of endometrial glands and stroma outside the uterus
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
How do you dx endometriosis?
laparoscopy is gold standard
- appearance of blue-grey powder burned lesions
How do you treat endometriosis?
- Analgesics
- Endocrine therapy
- Surgery
What is PMS? (premenstrual syndrome)
Monthly recurrence of mood, cognitive or physical symptoms during the luteal phase, remits with menses
Confirmed w/ > 2 cycles
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
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
What are the different types of functional cysts?
- Follicular cyst (MC ovarian mass)
- Corpus luteum cyst
- Theca lutein cyst (rare)
T/F: Endometrioma, PCOS and tubo-ovarian abscesses are all examples of ovarian masses
True
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
Are corpus luteum cysts clinically important?
Yes, with the possibility of bleeding/torsion; whereas the other two functional cysts are not clinically important.
What are Sx of functional ovarian cysts?
- often asymptomatic & discovered during routine pelvic exam
- unilateral pressure, fullness, or pain in lower abd
Which cyst contains all 3 germ layers?
Dermoid cyst (Teratoma)
- could be benign or malignant
- “adnexal calcifications”*
What is an endometrioma?
Part of endometriosis picture, with blood-filled cysts forming on ovaries requiring laparoscopy
What is the typical cause of tubo-ovarian abscess?
Infection at the junction; d/t NG or CT
What are sx of tubo-ovarian abscess?
- Pelvic pain
- Fever
- Vaginal d/c
- Tubal/ovarian swelling
long term: CPP, infertility
At what stage in life are ovarian masses most likely malignant?
In postmenopausal women (45% malignancy risk)
What are some risk factors of ovarian cancer?
Fam Hx, Prior BRCA, Nullparity, early menarche or late menopause, fertility promoting drugs, ashkenazi jews
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
T/F: Hormonal contraceptives and breast feeding help prevent ovarian cancer
true
Where is the MC site for fibrocystic breast changes or malignant disease?
Upper outer quadrant
Why is the inframammary line important?
Common fibrous area due to bras
What is mastalgia and what are the s/sx?
Breast pain/tenderness common in premenopausal women. Can be cyclical or non-cyclical
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
What is fibroadenoma?
Fibrous stroma in breast that responds to E/P, size fluctuates with cycle.
- rubbery, firm, smooth, round, mobile, painless
Which age do women get fibroadenoma and simple cysts?
15-50 yrs, NOT common in menopause unless on HRT
What are characteristics of simple cysts?
- Fluid filled breast lesions
- Soft, firm, mobile, well-circumscribed, uni/bilat, TENDER
- cyclical fluctuations
What is mastitis?
- infection with lactation or skin disruption
- MC in 2-4wks post partum
What are s/sx of mastitis?
fever, erythema, pain, induration, N/V, malaise, chills
What is the etiology of mastitis?
S. aureus, S. epidermis, strep
What is a galactocele and how do you treat?
Obstruction of breast duct, becomes tender and enlarged.
Tx- excise and drain
What is the MC cause of nipple discharge?
benign breast disease
What is the MC pathologic cause of nipple discharge?
intraductal papilloma (still benign but pathologic)
What characteristics of nipple discharge seem pathologic?
- unilateral
- spontaneous
- frank blood, serous, green/grey
- any other color (d/t carcinoma)
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)
What is intraductal papilloma?
papillary growth inside lactiferous duct, d/c may be bloody or serous
Tx- surgical excision
What causes subareolar abscess?
s. aureus or anaerobic organisms
- common in women w/ inverted nipples or nipple piercings
Tx- antibiotics, drainage, excision
What is MC cancer in women?
Breast cancer
What is leading cause of cancer deaths in women?
Lung cancer (Breast is second, cause there are two boobs)
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
What are s/sx of early stage BrCa?
- firm/hard mass
- irregular contour
- immobile
- unilateral
What are s/sx of late stage BrCa?
- skin/nipple retraction
- tenderness
- axillary
lymphadenopathy - erythema/edema/ulcer
- pain
- fatigue
- PEAU D’ORANGE
Risk factors for BrCa?
- Age (older)
- Sex (Female)
- Race (white)
- Genetic mutations
- Hormone use
- Breast feeding (decr. risk)
- Years of exposure to ovarian estradiol
How do you diagnose BrCa?
Biopsy
Screen w/ self and clinical breast exams and mammography
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
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
T/F: Family history is not a risk factor for cervical cancer.
True
What are RF for cervical cancer?
- Early age of first intercourse
- Multiple sex partners
- HPV infection
- Smoking
- Hormonal contraception > 5yrs
- exposure to DES
When is a colposcopy performed?
To identify abnormal areas that require biopsy after the Pap smear screening test showed abnormal cells
What is the recommended pap smear frequency?
Screening starts within 3 years after having vaginal intercourse or by age 21; every 1-2 years
What is LEEP?
Fine wire loop with electrical energy to remove tissue
What is conization?
Removes a cone-shaped piece of the cervix, may interfere with future childbearing
What is DES and side effects?
Diethylstilbestrol; synthetic estrogen
- high risk of BrCa, infertility, cx dysplasia, autoimmune disorders, reproductive anomalies
What is endometrial adenocarcinoma?
Uterine cancer
What is the typical presenting complaint with endometrial adenocarcinoma?
abnormal bleeding
What are the RF for endometrial adenocarcinoma?
Age 50-70, Fam hx and unopposed estrogen
- nulliparity, PCOS, tamoxifen, diabetes, HTN
How many pregnancies are unintended in USA?
50%, MC 20-24yrs
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
T/F: Nonoral methods of contraception have lower user failure rates and thus greater reliability
True; less human error
What hormone does “the patch” use?
Progestin, changed weekly for 3 weeks
What hormone does NuvaRing use?
Progestin, take out for menses.
may cause bacterial vaginosis
What was the major issue with injectable hormones (lunelle, depo-provera)?
difficulties getting pregnant quickly after stopping, osteopenia
The Mirena IUD secretes which hormone?
levonorgestrel, a synthetic similar to progesterone
- spotting is MC side effect
What are contraindications to taking P/E HCPs?
Liver disease, pregnancy, HTN, neurological migraines, breast cancer, smokers
What are drug interactions with HCPs?
Tylenol, Alcohol, Antibiotics, St Johns wort, antidepressants, CS, bronchodilators, rifampin
When would you take progestin only pills?
women who can’t take estrogen (breast feeding and risk for blood clots)
What is Norplant?
Silicone rods w/ progesterone placed subcutaneously for 5yrs
What is the minipill?
Prog only OC
What element does a non-hormonal IUD use?
Copper
What is the mechanism of a copper IUD?
reduces sperm motility (copper is its kryptonite), prevents fertilization
When would IUD be contraindicated?
abnormal uterine anatomy, nulliparous, pregnancy, DUB of unknown cause, malignancy, allergy to copper
Which receptacles are suitable for spermicide?
condoms, diaphragm, cervical cap
What are possible side effects of vasectomy?
pain, infection, granulomas, epididymitis, abscesses, ED,
What is Preven?
emergency contraception similar to plan B
What methods are used for natural family planning?
cervical mucous, BBT, calendar, symptothermal
T/F: IUD can be used as an emergency contraceptive
True
What is non surgical abortion RU486?
Mimics SAB via Mifepristone (Antiprogesterone)
- Must be < 49d since LMP
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
What hormonal changes occur during perimenopause?
- Rising FSH = marker of perimenopause*
- Ovaries become sporadically responsive to pituitary FSH/LH, with decreased gonadal hormone output
What signifies the onset of menopause?
Absent menses for 12 months and elevated FHS/LH with low Estrogen
What is the average age of menopause?
50-51yo
What are the symptoms of vulvar cancer?
- itching, burning, soreness
- lump/mole/growth
- color change (white/erythematous)
What are symptoms of vulvodynia/vulvar vestibulitis?
Chronic perineal discomfort (burning, stinging, irritation), altered cutaneous perception
Describe what occurs with cystocele
Herniation of the bladder wall causing an outpouching of anterior vaginal wall
- may be asymptomatic or cause incontinence
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
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
Describe what occurs with a urethrocele
Round doughnut-shaped mucosa is observed protruding from the urethral opening.
- Vaginal bleeding is MC symptom
What is procidentia?
Complete uterine prolapse (3rd degree)
T/F: Many RTIs are asymptomatic, even serious ones requiring treatment
True
What is the most common gynecologic complaint?
Vaginitis
What are the common infectious agents for vaginitis?
- Bacterial vaginosis
- Trichomonas vaginitis
- Candida vaginitis
- Atrophic vaginitis (STI)
Which organism is responsible for maintaining a healthy vagina?
Lactobacillus
Describe bacterial vaginitis.
Overgrowth of normal bacteria
- not sexually transmitted!!
- gardnerella, haemophilus, GBS
What are the clinical criteria for bacterial vaginitis?
- amine “fishy” odor; whiff test
- elevated pH
- clue cells
- discharge
What are s/sx of trichomonas vaginalis?
- Frothy yellow-green discharge*
- Strawberry cervix
- may be malodorous
- erythema
Which organs does trichomonas vag. infect?
Vagina, scene’s ducts, lower urinary tract
What are s/sx of candida albicans aka yeast infection?
Pruritis, erythema, WHITE CURD-LIKE DISCHARGE :s
What RTI is caused by low estrogen?
Atrophic vaginitis
Which organisms infect the upper reproductive tracts?
Gonorrhea, Chlamydia trachomatis
What are s/sx of CT?
May be asymptomatic
- cervicitis, urethritis, PID
- Reiter’s syndrome
What are s/sx of NG?
May be asymptomatic
- cervicitis, urethritis, PID
- pharyngitis and arthritis
Which conditions would cause mucopurulent cervicitis?
NG and CT; and PID
What are s/sx of PID?
- mucopurulent cervicitis
- adnexal tenderness
- disturbed menses
- chills and fever
- elevated ESR and WBC
Which infection is caused by treponema pallidum?
syphilis by the spirochete itself!
Describe primary syphilis
- Within 3 weeks
- Highly contagious
- CHANCRE (Painless ulcer w/ firm borders)
- regional lymphadenopathy
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)
Describe tertiary syphilis
- May begin as early as 1 year after infection
- Gummata (sores) develop
- Cardiovascular and neuro effects occur
How do you dx syphilis?
Antibody testing (VDRL) and MHA-TP
What STI is caused by haemophilus ducreyi?
Chancroid
Describe chancroid
MUCHO painful lesion with ulceration of lymph node in the groin
What should be your DDX for genital ulcers?
HSV, Syphilis, Chancroid, Lymphogranuloma venereum (LGV)-CT
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)
Describe primary herpes progression
- erythematous papule
- vesicle
- pustule
- ulceration
- encrustation
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
T/F: HSV may cause unilateral keratitis (cornea), blepharitis and keratoconjunctavitis
True
HPV is also known as _________________
Condyloma accuminata
How do you treat HPV?
- Podophyllin resin
- Freezing via cryoprobe/nitrogen
- CO2 laser- anesthesia
