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
Bacterial vaginosis
MC cause of vaginal discharge in US
Gardnerella vaginalis overgrowth
Risk: sex, smoking, douching
thin, white/gray discharge with fishy odor
Vaginal pH >4.5
Clue cells - coccobacilli
Positive whiff amine test - fishy odor with KOH
Tx:
Metronidazole x 7 days
Clindamycin
Trichomoniasis
Trichomonas vaginalis - flagellated protozoan
Greenish, frothy vaginal discharge Vaginal irritation, dysuria Strawberry cervix Vaginal pH >4.5 Wet mount: motile trichomonads Positive nucleic acid amplification test
Tx: metronidazole x1 (treat partner too)
Vulvovaginal candidiasis
Candida spp
Risk: abx use, elevated estrogen levels, diabetes, immunosuppression
Vulvar and vaginal itching/irritation
Thick, white, cottage cheese like vaginal discharge
normal Vaginal pH 4-4.5
Wet mount: budding yeast, pseudohyphae
Tx: oral fluconazole, topical azole
Toxic shock syndrome
S. aureus - exotoxin TSST-1
use of highly absorbent tampons
S/S:
Fever
Hypotension
Dysfunction of multiple organs - V, D, elevated BUN and Cr, confusion, AMS
Rash: sunburn like, palms and soles involved - desquamates 1-2 weeks later
Clinical Dx, vaginal cx
Tx: remove tampon, wound packing Supportive - IVF, vasopressors Abx: Clindamycin (decreases toxin production) + Vancomycin (covers MRSA)
Cervicitis
MC: chlamydia, gonorrhea
HSV, trichomonas
Features: asx Mucopurulent vaginal discharge Spotting, postcoital bleeding urethritis - WBC on UA Erythematous and friable cervix
Dx:
Nucleic acid amplification test
Gonorrhea: gram neg intracellular diplococci
-culture - Thayer-martin media
Tx:
Chlamydia - azithromycin x1 or doxy x7 d
Gonorrhea - IM ceftriaxone x1 + PO azithromycin x1
Pelvic inflammatory disease
MC: chlamydia, gonorrhea
Features:
b/l lower abdominal pain
Mucopurulent vaginal discharge
Chandelier sign - cervical motion tenderness
Fever
Elevated wbc’s on wet mount of vaginal fluid
Elevated ESR/CRP
Positive GC test
RUQ pain - Fitz-Hugh-Curtis Sn - pain refers to shoulder
US: tubo-ovarian abscess, thickened fluid-filled fallopian tubes
Tx:
Inpatient:
-IV cefotetan/cefoxitin + doxy
-Clindamycin + gentamicin
Out pt: IM ceftriaxone x1 + doxy x14 days
Long term complications:
Chronic pelvic pain
ectopic pregnancy
infertility
Tubo-overian abscess treatment
IV cefoxitin + doxy + metronidazole until 48-72 hrs afebrile
then change to oral doxy and flagyl for remaining time of 14 day course
abscess larger than 8 cm - IR consult for drainage
Condyloma acuminata
HPV types 6, 11
Flesh colored, “cauliflower like” papules in genital region
Turns white with acetic acid application
Tx:
Physical: excision, laser therapy, cryotherapy
Chemical: podophyllin, trichloroacetic acid, 5-FU
Immunologic: imiquimod, interferon alpha
Genital herpes
HSV 1 or 2
Multiple vesicles on an erythematous base
clusters of painful, shallow ulcers
1st outbreak: fever, malaise, myalgias, dysuria, LAD
Latency in sensory ganglia - reactive in stress
Dx: Tzanck smear - multinucleated giant cells Viral cx - gold standard PCR, direct fluorescent antibody (DFA) Serology
Tx: acyclovir, famciclovir, valacyclovir
Syphilis
T. pallidum
Primary: single papule at site of innoculation
Chancre - painless, clean based ulcer with heaped-up border, indurated margins
-heals spontaneously
Tx: PCN G x1
Secondary: Fever, malaise, LAD Rash involves palms and soles Condyloma lata - greyish raised lesions on genital mucosa Tx: PCN G x1
latent: asx
Early - PCN Gx1
Late - PCN G IM q1wk x3
Tertiary - 1-25 yr later
- CV - aneurysms of a sending aorta, aortic valve insufficiency
- Gummas - granulomatous lesions in skin, bones, internal organs
tx: PCN G IM q1wk x3
Neurosyphilis
-General paresis, tabes dorsalis, Argyll-Robertson pupil
Tx: PCN G IM q1wk x3
Diagnosis of syphilis
Screen: RPR, VDRL
Confirm: FTA-Abs, MHA-TP
Dark field microscopy
Direct florescent antibody DFA
Chancroid
H. ducreyi
Erythematous papule -> pustule -> painful ulcer with purulent base (exudative) 1-2 cm
Painful inguinal LAD, bubo formation - draining
Dx:
Gram stain : gram-negative rod’s - School of Fish pattern
Tx: ceftriaxone, azithromycin
Lymphogranuloma venereum
Tropical, MSM
Chlamydia trachomatus serovals L1-L3
Primary: painless ulcer at site of inoculation - resolves spontaneously
Secondary: U/L inguinalLAD -> bubo formation, groove sign (inguinal ligament bordered by LAD on either side)
Proctocolitis - in anal sex -> strictures
Dx: serology, NAAT
Tx: doxy
Granuloma inguinale (Donovanosis)
Klebsiella granulomatis
Rare in US, endemic in tropical regions
Painless nodules -> shallow painless ulcers with beefy red base - bleed easily, no LAD
Dx: visualization of donovan bodies (intracellular gram neg rods) on Wright-Giemsa stain of smear/bx
Tx: azithromycin x3 weeks
uterine fibroids (leiomyomas, leiomyomata uteri)
MC benign tumor in women
Hormonally sensitive increase in size in response to estrogen and progesterone
- grow larger during pregnancy
- decrease in size in menopause
Presentation: asx Heavy/prolonged periods -> anemia Pelvic pressure/discomfort recurrent miscarriages, infertility enlarged uterus with irregular contours
Dx: U/S
Tx:
Definitive - hysterectomy
-GnRH agonist - leuprolide - 3-6 mo preop to correct anemia and decrease size
Myomectomy - preserves child bearing
OCP, progestin, levonorgestrel IUD - decrease bleeding, may increase size
Endometrial ablation - need endometrial bx first
Uterine artery embolization
Endometrial hyperplasia and endometrial cancer
Risk factors:
Chronic unopposed estrogen stimulation
- exogenous: estrogen replacement therapy without progestin
-endogenous: estrogen secreting tumor (granulosa cell tumor), obesity, chronic anovulation (PCOS)
Nulliparity, early menarche, late menopause
FHX - Lynch syndrome
DM, HTN
Tamoxifen use
Presentation: AUB, postmenopausal bleeding
US: thickened endometrium
Dx:
Endometrial biopsy
Tx: hyperplasia
- Progestin - if low risk progression, no atypia and childbearing desired - Mirena IUD
- Hysterectomy +/- b/l salpingo-oophorectomy
Tx: cancer
Progestin - low risk cancer and wants kids
Hysterectomy + b/l salpingo-oophorectomy + LN dissection
+/- radiation - local invasion
+/- chemo -mets or high risk disease
5 yr survival 80-90%
Vaginal neoplasms
Squamous cell carcinoma - HPV infection
Clear cell adenocarcinoma - DES in utero
Sarcoma botryoides (embryonal rhabdomyosarcoma - grape like tumor in infants and children
Vulvar cancer
Squamous cell carcinoma
Risk: HPV 16, 33 Cervical cancer - coexist vulvar intraepithelial neoplasia (VIN) Smoking Immunosuppression Chronic inflammation - Lichen sclerosis
Lesion: flat plaque, raised nodule, warty, “cauliflower like”, changes in pigmentation
Vulvar pruritis
Dx: bx
Early stage: surgical resection + LN dissection +/- lymphadenectomy
Local invasion: surgical resection + lymphadenectomy +/- radiation
Mets - chemo
Staging and treatment of cervical dysplasia and cancer
CIN I - mild dysplasia, 1/3 thickness involved
Tx: observe
CIN 2 - moderate dyplasia, 2/3 thickness involved
Tx: ablation, excision - LEEP, cone
CIN 3 - severe dysplasia more than 2/3 but not full thickness involved
Tx: ablation, excision - LEEP, cone
CIN3 - in situ carcinoma - full thickness involvement, no BM invasion
Tx: ablation, excision - LEEP, cone
Invasive carcinoma - invades through BM
Cervical cancer screening guidelines
initial screening at 21 unless HIV - pap 1st yr sexually active
21-29: pap q3 yr
over 30: pap q3 yr or q5 with negative HPV
Stop at 65 in average risk, adequately screened women
Stop following total hysterectomy performed for benign indications
Low-grade squamous intraepithelial lesions (LSIL)
Mild dysplasia, many regress spontaneously
21-24 yo - repeat Pap in one year 25-29 yo -> colposcopy over 30 - HPV testing \+ HPV -> colposcopy negative -> repeat Pap and HPV in 1 yr
High grade squamous intraepithelial lesion (HSIL)
Moderate to severe dysplasia
High risk of malignancy
21-24 yo –> colposcopy
Over 25 - colposcopy or LEEP
Atypical squamous cell of undetermined significance (ASCUS)
Abnormal cells, low risk of malignancy
21-24 yo - repeat pap 1 yr, if positive at that point -> colposcopy
over 25 - test for HPV, if positive -> colposcopy
Atypical squamous cell - cannot exclude high-grade SIL (ASC-H)
colposcopy for all
Atypical glandular cells (AGC)
get endocervical sampling
Colposcopy
Endometrial biopsy for over 35 or risk factors
Invasive cervical cancer
Presentation: Irregular vaginal bleeding Postcoital bleeding New watery vaginal discharge Pelvic/back pain Urinary/bowel symptoms Speculum exam - abnormal vessels, friable tissue, Ulcerations, exophytic masses
Dx: Bx if lesion visible
Pap test, colpo if abnl pap
Tx:
Microinvasive disease with invasion less than 3 mm - conization or hysterectomy
Early stage confined to cervix - radical hysterectomy + lymphadenectomy +/- radiation or chemoradiation
Local spread - chemoradiation first
mets - chemotherapy
Early detection 95% survival at 5 yrs
ddx for adnexal mass
Physiologic ovarian cyst
- Graafian cyst
- Corpus luteum cyst
Endometrioma
Ectopic pregnancy
Tuboovarian abscess
Ovarian tumor
US findings in benign vs malignant ovarian mass
Benign:
Cystic
unilocular - thin septations
U/l
Malignant:
solid components
multilocularity - thick septations
B/L
Epithelial ovarian tumors
Serous
Mucinous
tumor marker: CA 125 elevated
Presentation:
Postmenopausal women with abdominal pain, early satiety, ascites
Poor prognosis - late dx
Germ cell tumors
Dysgerminoma (high LDH)
Yolk sac (high AFP)
Teratoma - benign (high AFP)
Embryonal (high AFP, hCG)
Presentation:
Adolescent with abdominal pain/mass
Excellent prognosis is stage one - 100% at 5 yrs
Granulosa cell ovarian tumor
elevated estrogen, inhibin
Presentation:
Precocious puberty
AUB often postmenopausal
Good prognosis
Sertoli-Leydig cell ovarian tumor
Elevated testosterone
Presentation: virilization
Prognosis is good
Ovarian cancer
95% epithelial
Risk:
FHx - BRCA 1/2, Lynch syndrome
uninterrupted ovulatory cycles - early menarche, late menopause, nulliparity, infertility
Presentation: Bloating Pelvic/abdominal pain Early satiety, wt loss urinary frequency, urgency Adnexal mass
Dx: TVUS
CA 125
Surgical exploration - bx risk seeding cavity
Surgical staging and debulking
-hysterectomy, bilateral salpingo-oophroectomy, LN dissection, peritoneal washings, omentectomy, diaphragmatic washings
Adjuvant or neoadjuvant chemo
Prog: poor - 45% survival at 5 yr
Screening - not recommended of asx and average risk
ddx of gynecomastia
puberty drugs (STACKED) Herbals - tea tree oil, lavender oil Cirrhosis hypogonadism testicular germ cell tumor hyperthyroidism HD patients
Breast abscess
Begins as mastitis - S. aureus -> walled off
MC - DM and smokers
Painful breast mass
Large area of redness, warmth, tenderness
Purulent drainage from the mass or nipple
Fever over 102F
Dx:
CBC: leukocytosis and bandemia
US: Collection of fluid
Needle aspiration - pus
Tx: I&D Abx: dicloxacillin, cephalexin, or amox/clav TMP-SMX if MRSA Metronidazole if suspect anaerobs - pus smell
Continue breast-feeding or pumping
High rate of recurrence
Fibrocystic changes
Increase in fibrous tissue and benign cysts
MC 35-50 yo
Multiple, bilateral breast masses - often painful
Hormonally sensitive - worse before/during menses
U/S - r/o solid mass
Tx:
reduce intake of caffeine and fat
OCPs to decrease stimulation of breast
Fibroadenoma
MC benign breast tumor in women under 30
Solitary, firm, mobile breast mass
Increase the size with estrogen exposure - tender in pregnancy, menses
Dx:
FNA, core bx, excisional bx
Diagnostic mammo if over 35
Tx: may not be required
if large or symptomatic - excision or cryotherapy
Intraductal papilloma
Benign - rare malignant transformation
Serous - straw colored nipple discharge +/- streaked with blood
Tx: excise to evaluate for cancer
Phyllodes tumor
MC in 50s
Large, bulky tumor
Leaf like projection on biopsy
Generally benign - occasionally become malignant
Tx: Close monitoring
if Sxs - resect
