Gynecology Flashcards
Tanner stages - breast development
1 - prepubertal
2- bud with elevation of breast and papilla, areola enlarges
3 - further enlargement
4- areola and papilla form secondary bound above level of the breast
5 - mature - only papilla projects as areola recesses
Tanner stages - pubic hair (both sexes)
1 - prepubertal 2- sparse long, slightly pigmented hair 3 - darker, coarser and more curled 4 - adult hair type, covering smaller area 5 - adult type, spread to medial thigh
Precocious puberty
girls under 8
boys under 9
Categories:
Familial/genetic
Central - premature activation of HPG axis
Peripheral - autonomous secretion of excess sex steroids by gonads or adrenal glands
Dx:
Bone age - normal suggests benign variant
elevated LH in central
low LH in peripheral
elevated DHEA-S suggests CAH or adrenal neoplasm
elevated TSH - hypothyroidism
CT/MRI - r/o hypothalamic or pituitary lesion
CT abd/pelvis - r/o adrenal tumor or ovarian tumor
Tx: most observe
Continue GnRH agonist - leuprolide for central
Resect tumor
Heterosexual precocious puberty
Develop secondary sex characteristics normally seen in opposite sex
Girls: virilization/ masculinization
-CAH, exogenous androgens, androgen-secreting neoplasm
Boys: feminization - gynecomastia
-excess estrogens
Isosexual precocious puberty
Complete - all secondary sex characteristics develop prematurely
Incomplete: development of characteristic isolated from others
FSH
Stimulates ovarian follicle to develop
Follicular phase of cycle
Estrogen (estradiol)
Stimulates endometrial proliferation
induces midcycle LH surge
high levels inhibit FSH secretion - negative feedback
LH
induces ovulation
Progesterone
Stimulates endometrial gland development Inhibits uterine contraction Increases cervical mucus thickness Increase basal body temperature inhibits secretion of FSH and LH Decrease in progesterone level leads to menstruation
b-hCG
Maintains the corpus luteum and progesterone secretion
Menopause
Permanent end of menstruation because of ovarian failure
Amenorrhea at least 1 year in over 40
Sxs: Hot flashes Sweating Sleep disturbances Anxiety, depression, labile mood Breast pain Dyspareunia, atrophy of the vaginal wall, decreased vaginal lubrication Urinary frequency Stress incontinence
high FSH
if younger than 45 other causes must be excluded - TSH, serum hCG, prolactin, FSH
Primary ovarian insufficiency
Amenorrhea or menstrual irregularity + high FSH before age 40
Perimenopause
Ovaries are progressively less responsive to FSH -> high FSH and fluctuating estrogen levels
Menstrual periods may become heavier or irregular
Dysmenorrhea
Pain with menses
Primary: cause inflammation and physical trauma of the shedding endometrial lining and uterine contractions
-starts with menses, resolves over several days
Secondary: endometriosis, PID, fibroids, adenomyosis
-midcycle pain increases until conclusion of menses
Risk: menorrhagia Menarche before 12 BMI less than 20 PID sexual asault smoking PMS
Tx:
NSAIDs
Estrogen-progestin OCP
PMS and PMDD
luteal phase
PMS: physical syndrome
PMDD - mood disorder
Risk: FHx
Presentation: Waking Headache Abdominal or pelvic pain Bloating Change in bowel habits Food cravings mood lability, depression Fatigue Irritability Breast tenderness Edema abdominal tenderness acne
Tx: NSAIDs exercise and relaxation SSRIs during luteal phase or continuously OCP GnRH agonists
Adenomyosis
endometrial tissue inside muscle of uterus
Endometrosis
endometrial tissue outside of the uterus - ovaries, broad ligament, bowel, bladder, lungs, brain
Risk: nulliparity, FHx, infertility
Presentation: Pelvic pain beginning 2- 7 days prior to menses and lasting throughout menses Dyspareunia Constipation, diarrhea, bowel pain Infertility
Exam:
Tenderness of vaginal fornix
Lateral displacement of cervix
Tenderness in posterior cul-de-sac or rectovaginal septum
Palpable tender nodules in posterior cul-de-sac, uterosacral ligaments, rectovaginal septum
Pain with movement of the uterus
Uterus fixed in retroverted position
Labs: elevated CA125
Pelvic US - r/o other path
Laparoscopy - dark blue, powder burns - black, red, white, yellow, brown lesions
-endometromas
Tx: NSAIDs OCPs GnRH agonists Danazol - inhibits gonadotropin secretion from pituitary Ablation during laparoscopy Hysterectomy with salpingo-oophorectomy
Causes of abnormal uterine bleeding
PPALM-COEIN
Pregnancy - intrauterine, ectopic Polyps of the endometrium Adenomyosis Leiomyomas Malignancy - endometrial hyperplasia, carcinoma, sarcoma
Coagulation - von Willebrand disease, immune thrombocytopenia, platelet function defect
Endometrial infection - endometriosis and PID
Iatrogenic - anticoagulants, progesterone only OCP, IUD
Not yet classified
Primary amenorrhea
Absence of menses and secondary sexual characteristics by age 13
If secondary sexual characteristics present, absence of menses by age 15
Secondary amenorrhea
Absence of menses for at least six months or three cycles and patient previously menstruated
Hormonal abnormalities in PCOS
Elevated LH - LH:FSH >2:1
Elevated androgens
Elevated insulin
Elevated estrogens
Low sex hormone-binding globulin
Insulin causes elevated androgens, aromatase converts androgens to estrogen, estrogen stimulates endometrium and negative feedback to pituitary suppressing FSH release
Clinical features of PCOS
At least 2 of 3:
Oligoovulation or anovulation - menstrual irregularities
Hyperandrogenism - elevated testosterone and DHEA-S, acne, male pattern baldness, hirsuitism
Polycystic ovaries on U/S - string of pearls
Additional features: Obesity Insulin resistance Infertility Increased risk endometrial hyperplasia/cancer
Management of PCOS
Diet and exercise first line
OCPs - 1st line
-cycle regulation, decreased androgen production, elevated SHBG, endometrial protection (progesterone)
Cyclic progestins
Spironolactone
Clomiphene - ovulation if desire pregnancy
Metformin -2nd line - restores ovulatory cycle
Causes of female infertility
Ovulatory dysfunction - MC
-functional hypothalamic amenorrhea, PCOS, primary ovarian insufficiency, thyroid disease, hyper prolactinemia
Endometriosis
Tubal disease - PID, tubal surgery
Uterine abnormalities - fibroids, congenital mullerian anomalies, Asherman syndrome
Cervical factors
Pelvic organ prolapse
Risk factors: Increased parity Vaginal deliveries Increased age Increased intraabdominal pressure - obesity, heavy lifting, chronic cough, chronic constipation
Hx: vaginal/pelvic pressure vaginal bulge - something falling out of my vagina stress incontinence, urinary obstruction Fecal incontinence, constipation
Dx: physical exam
Tx: Observe if asx Pelvic floor muscle exercises Pessary Surgery
Bartholin duct abscess
E.coli, S. aureus, Strep, N. gonorrhoeae, C. trachomatis, polymicrobial
Presentation:
vulvar pain and swelling - interfere with walking, sitting, intercourse
Tender, fluctuant mass in lower labium majus
Tx: I&D, cx
Abx coverage
Recurrent - marsupialization
