Gynecology Flashcards
Normal female vs male development
Fem: growth accel → thelarche (brst) → pubarche (pub hair) → menarche
Male: testic enlarg → penile growth → pubarche → facial hair
Menopause (PE, dg)
≤12 months; average 51yo
Hot flashes; vag atroph; insomn; anxiety/irritab; poor concent; mood chang; dyspareu; loss libido
-Premature if <40yo
Dg: clinic; ↑FSH then ↑LH; ↑tot cholest w/ ↓HDL
Menopause (ttt)
-Horm replac ttt (estro+progest): if mod-sev vasomotor sympt (SHORT term ttt); ↑R breast cancer; ↑CV morbi/morta
CI: vag bleed; breast K; unttt endomet K; Hx of thromboemb; chron liv ds; hyperTg
-Non-HRT: SSRI/SNRI; clonidine; gabapentine (↓hot flsh)
-Topical estro: vag atroph
-Supplem+/-bisphosph: osteopor (Ca/vitD/exo)
Contraception (methods)
85% pgncy in 1y if no contracept*
- Eff >99%: progest arm implant; IUD progest; copper IUD; surg steriliz (vasectomy; tubal ligat*)
- Eff 90-99%: medroxyprogest IM; patch (E+P); ring (E+P); OCP (E+P); progest pill
- Eff 75-90%: male/female condoms; diaphragm w/ spermicide; awarness (no sex during ovulat*)
- Eff 68-74%: withdrawal (before ejacul); spermicide
Contraception (CI)
-Estrog: pgncy; stroke/HTN/DVT/PE; breast K; abNl vag bld; estrog-dep K; liver neopl; abNl liv fct*; tobacco+>35yo
- IUD both: sev ut structural abNl; pgncy; gyneco inf; vag bld; gyneco malign
- IUD copper: copp allergy/Wilson ds; sev dysmenorrhea; menorrhagia
- IUD progest: levonorg allergy; breast K; acute liv ds; liv tumor
Emergency contraceptive methods
Morning-after pill (E+P) (in 120h)
Morning-after pill (progest)
Copper T IUD (in 7d)
1* amenorrhea / Delayed puberty (etiologies)
1- No menses by 16yo; presence of 2* sexual develop
- 1* ov insuff (50%): esp Turner sd; radio/chemo therapy
- Central hypogon: undernourish; stress; hyperprolac; exo; CNS tumor (pituit; radiat*); Kallmann (gonadotrop def); constitutional growth delay
2- No 2* sexual charact by 14yo (No estrog; anatom/genet probl): Mullerian agenesis; imperfor hymen; complete androgen insensitivity; congen adren hyperplasia
1* amenorrhea (dg)
Pgncy test (#1); general detailed PE; US Karyotype/testo level: if no uterus FSH/LH: if uterus present Prolact level; DHEAS If HTN: 17a-OH and 11-OH def
1* amenorrhea (ttt)
No ttt: constitutional growth delay
Hypogonadism: HRT (just estrog) then 12-18mo later, E+P
Surg: if anatomic abNl
2* amenorrhea (etiologies)
No menses for 6 consecutive months
By pgncy; ovary (PCOS, premature ov failure); hypothal (neopl, fctional/nutrit*/exo/stress, systemic ds/DM1/celiac); pituit (adenoma, mass, Sheehan); hypothyroid; uterine (Asherman, cervical stenosis)
2* amenorrhea (dg)
Hx, PE, pgncy test, TSH, prolact (if ↑, MRI)
Progestin challenge
If hyperglyc or hypoTN: 1mg DXM suppr test (CAH#Cushing#Addison)
If viriliz: level testo, DHEAS, 17-HOprogest
2* amenorrhea (ttt)
- Hypothal: underl cause; OCPs; induce ovulat* w/ gonadotropins to get pgnt
- Tumor: excision; cabergol/bromocr for prolactinoma
- Premature ov fail: combined OCPs
1* dysmenorrhea
By ut vasoconstr, anoxia, sustained contract* by ↑PGF2a
Low midline spasmodic pelvic pain; first 1-3d of menses
Ass w/ nausea, diarr, headac, flush; No pathol finding
Dg of exclus; r/o 2 dysmeno
ttt: NSAIDs, topic heat, combined OCPs, progest IUD
2* dysmenorrhea
Esp by endometrios, adenomyos, fibroids, adhes, PID
Ut mass, cerv mot tender, adnex tender, vag disch
Dg: B-hCG (ectopic); CBC w/ diff (inf/neopl); UA; STD/PID
ttt: etiology
Endometriosis (PE, dg)
Endomet glds + stroma outside ut
Cyclic pelv/rect pain; dyspareun; restricted range of mot* of uterus
Dg: laparosc; blue-black/brown les*; choc cyst in ovaries (endometrioma)
Endometriosis (ttt, complications)
ttt: inhib ovul; combined OCP #1, leuprolide, danazol, NSAIDs, progest
Conserv surg: excis, cauterizat, lysis of adhes*
Defin surg: TAH/BSO +/- lysis of adhes*
Compl: infertility
Adenomyosis (PE, dg, complications)
Endomet in myometrium
Triad: pain, menorrhagia, enlarged boggy symm uterus
Dg: MRI; US; anapath
Compl: rarely progr to endometr carcinoma
Adenomyosis (ttt)
Symptom relied: NSAIDs (#1) w/ OCPs or progest
Conserv surg: resect* by hysteroscopy
Defin surg: hysterectomy
Abnormal uterine bleeding (etiologies)
Alterat* in qtty, durat*, fqcy; by PALM-COEIN
- Structur (PALM): Polyp, Adenomyos, Leiomyom, Malign/hyperplasia
- Nonstruct (COEIN): Coagulop, Ovulatory dysfct, Endometrial, Iatrogenic, Not yet classified
Abnormal uterine bleeding (PE)
Oligomeno: ↑length (35-90d) betw/ menses Polymeno: fqt menses (<21d); anovul Menorrh: ↑amount (>80mL) or prolong bld (>8d); anemia Metrorrh: bld betw/ periods Menometrorrh: excessive + irregular bld
Abnormal uterine bleeding (dg)
B-hCG; CBC (An); Pap smear (cerv K); gono/chlam; TFTs; prolact; plts/PT/PTT; US (mass, PCOS)
Endometr biopsy: if endom ≥4mm in postmenop or if >35yo w/ RF for endom hyperplasia (DM, obes)
Abnormal uterine bleeding (ttt)
-Acute heavy: high-dose estrog IV then E+P when bld stabilized. If estro CI, high-dose progest
If bld not stabil, D&C
-Ovulatory bld: NSAIDs; tranexamic acid (x5d); OCP/progest PO/inject/IUD
-Anovulatory bld: progest x10d; OCPs; progest IUD
-If all fails: D&C; hysteroscopy (biops/embolizat*); hysterectomy
Congenital adrenal hyperplasia (PE, dg, ttt)
Androg excess: gen ambig, premat pubarche, menstr irreg, infertil, hirsut, acne, palpable pelv mass
Dg: PE, Cosyntropin stimulat* test !!!; cortisol, androstened, DHEA
ttt: GC (DXM), + MC (fludrocortisone) if salt wast
Hair removal: ttt adren/ovar disorders; laser; electr
21-hydroxylase deficiency
- Classic: most sev; bb girl virilizat* +/- salt wast
- Nonclassic: late onset; androg excess or asympt
↓MC ↓Cortisol ↑Sex Hes ↓BP ↓K+ ↑Renin and 17-HOprogest
11B-hydroxylase deficiency
↓Aldost but ↑11-deoxycorticosterone ↓Cortisol ↑Sex Hes ↑BP ↓K+ ↓Renin XX: virilizat*
17a-hydroxylase deficiency
↑MC ↓Cortisol ↓Sex Hes ↑BP ↓K+ ↓Androstenedione XY: pseudo-hermaph (ambig gen, undesc testes) XX: no 2* sex dev
Polycystic ovarian syndrome (dg, PE)
Dg: ≥2 of these: PCOS on US; oligo-anovulat*; hyperandrog (clinic/biochem)
Labs: ↑estrog+testo; !r/o other causes of hyperandr (adren/ovar tumor); 2-h gluc toler test; lipid/LPL
+/- ↑LH/FSH ratio; 24-h urin cortisol (r/o CAH/Cushing)
Obes, menstr disturb, infertil (#1 in W), acne, androg alopecia, hirsutism
Polycystic ovarian syndrome (ttt, complications)
- No pgncy plan: OCP (E+P), progest, +/-metformin
- Pgncy plan: clomiphene (SERM), +/-metformin
- Hirsut: OCP (E+P) #1; antiandrog (spironolact/finaster); metformin
- Obes/CV RF/lipid: diet, ↓weight, exo, statins
Compl: ↑R of DM2, metabolic sd, miscarr, breast/endomet cancer (unopposed estrog)
Infertility
After 12mo of normal regular unprotected sex
1* (no prior pgncy) or 2* (prior pgncy)
-Male: testes, meds, thyroid, liv, hypoth/pituit
-Ovulatory: age, thyroid, galactorrh, menstr abNl
-Tubal/pelvic: PID, adhes, endometriosis, surg
-Cervical: cryottt, conizat, DES expo in utero
-Uterine: polyp, fibroid, congen anomalies
Cyst of Bartholin duct
Obstructed gland duct w/ mucus accum
1-3cm, unilat, asympt. If larger, painful swell+dyspareun
Mass at medial labia majora or lower vestibule
No ttt +/- warm soaks if asympt
Drain + biopsy if >40yo to r/o carcinoma
Abscess of Bartholin duct
Infected duct (polymicrob) Extreme pain, warm fluctuant mass at medial labia majora or lower vestibule
ttt: aspirat* or incis*+drain; test gonorrh/chlam
AB just if +cellulitis or STI
Vaginitis (PE, dg)
Itching, burning, irritation, abNl discharge, malodor, swelling, dyspareunia, dysuria
Exam of vulva, vagina, cervix
Dg: disch (pH, whiff test, wet mount, KOH)
If purulent + ↑WBCs + cerv friability + sympt PID → DNA/Cx gonorr/chlam to r/o cervicitis
Bacterial vaginosis
Not inf + No infl; shift in org (↑anaer/↓lactobacilli)
RF: pgncy, multi/W sex partners, fqt douch
Grayish-white disch, fish odor, mild irritat*
Clue cells; ⊕whiff
ttt: PO/vag metronid or vag clindamycin
Compl: chorioamnio/endometritis; inf; preterm; miscarr; PID
Trichomonal vaginitis
RF: unprotected sex w/ multi partn Strawb cervix; profuse malodor yellow-green disch; prurit Motile trichom (protozoa)
ttt: 1-dose PO metronidazole or tinidazole
+ ttt partners + test for other STDs
Compl: chorioamnio/endometritis; inf; preterm; miscarr; PID
Candidal vaginitis
RF: DM, AB use, pgncy, CS, HIV, OCP use, ↑sex, tight cloth
Prurit, dysuria, burn, disch (thick white, no odor), erythem vagina; Pseudohyphae
ttt: topic azole or PO fluconazole
Cervicitis
- Inf: chlam, gono, trichom, HSV
- Noninf: trauma, radiat*, malign
Yellow-green mucopur disch, ⊕cerv mot* tendern; no other signs of PID
ttt: empiric for gono+chlam (ceftriax IM and azithrom PO)
Pelvic inflammatory disease (RF, PE, complications)
Gonorrh; chlamyd trachom; endogen ae/anaer
RF: douch; smok; multi sex partners; prior STD/PID
Low abdo pain, fever, chill, menstr disturb, purul disch
Compl: recurr; chron pelv pain; dyspareun; ectop pgncy
Infertil; Fitz-Hugh-Curtis sd
Pelvic inflammatory disease (dg)
Dg: acute low abdo/pelv pain + 1 of these (ut tendern, adnex tendern, cerv mot* tendern)
B-hCG (r/o pgncy); WBCs; US
ttt: ptt and partners
Pelvic inflammatory disease (ttt)
Outptt: -Ceftiax IM 1-dose or cefoxit + probenecid + doxy x14d +/- metronid x14d
-Oflox or levoflox x14d +/- metronid x14d
Inptt: -Cefox or cefotetan + doxycy x14d
-Clindam + gentam x14d
Surg: drain abscess if persist after AB; >4-6cm
Laparo if ptt deteriorates
Toxic shock syndrome
Staph aureus toxin (TSST-1); in 5d of tampons
Dg: abrupt >38.9C, hypoTN, diffuse rash, vomit, watery diarrh; desquamat palms/soles in 1-2wks in recovery
Bld Cx ⊖bcz ds by preformed toxin
ttt: emergent rehydrat*, remov foreign body; drain; Clinda+vanco (if MSSA, clinda+oxac/nafcill) (if MRSA, clinda+vanco/linezo)
Compl: morta (cardio, ARDS, DIC)
Uterine leiomyoma / fibroids (PE, complication)
Benign; multiple tumors; black>white
Hormone sensitive (↑ in pgncy; ↓ at menop)
Rare malign transfo
Asympt; menometrorr; mass effect (bladd/rect); pain (dysmeno, dyspareun); firm nontend irregul Ut
Compl: infertility
Uterine leiomyoma / fibroids (dg, ttt)
Dg: TV US; MRI (prep surg; r/o cancer); CBC (anem)
ttt: if asympt, annual pelv exam + CBC
OCPs (E+P); medroxyprog/danazol (↓bld)
Leuprolide (↓size+Vx); NSAIDs (↓pain)
Surg: myomectomy (W wants child); hysterectomy (if not); Ut artery embolizat; emergent surg if tors
Endometrial cancer (types, PE)
Type I: unopp estro (tamoxi/estro) → typ/atyp hyperplasia; 55yo; favorable pg
Type II: unrelat to estro; p53 mutat*; 67yo; poor pg
Vag bld (early); pain (late); metab sd
Endometrial cancer (dg, ttt)
Dg: pgncy test if premenop; TV US (endom ≥4mm); endom/endocerv biopsy
ttt: high-dose progestins (W wants child)
TAH/BSO +/- radiat* (postmenop)
TAH/BSO w/ adj chemoth (adv-stage cancer)
Cervical cancer (RF)
Endocervix (column); Ectocervix (squam)
↓pH → metapl of endocerv to squam
Junct* exposed to carcinogens → CIN
RF: HPV DNA in ~all (16 in squam K; 18 in adenoK); immsuppr; HIV; STDs; tobac; high parity; OCPs
Gardasil V: ag 6-11 (gen warts) and 16-18 (cancer)
Cervical cancer (PE, screening)
Metrorrh; postcoital spot; bld/purul malodor nonprurit disch (after invas*)
Screen: starting 21yo regardless of sexual activ
(21-29yo Pap/3y; 30-65yo Pap/3y or Pap+HPV/5y)
Stop at 65yo if all previous ⊖ and if No DES expo and if No HIV/immsuppr
Cervical cancer (dg, ttt, pg)
Dg: read the book (too complicated)
ttt: read the book (too complicated)
Pg: 5-y survival 68% caucasian; 55% black W
Vulvar cancer (RF, PE)
RF: HPV (16/18/31); lichen sclerosus; infqt exams; DM; obes; HTN; CV ds; smok; high-R sex; immsuppr
VIN: vulvar intraepith neoplasia (precancerous)
Prurit, pain
Early: white, pigment, raised, thick, nodul, ulcer
Late: large, cauliflower-like, hard ulcer
Vulvar cancer (dg, ttt)
Dg: punch biopsy (if suspic* or persist prurit esp postmenop)
ttt: high-grade VIN (chemoth, laser ablat*, vulvectomy)
Invasive: radical vulvectomy + LNectomy +/- preop radiation/chemoth/both
Vaginal cancer (RF, types)
RF: immsuppr; chron irritat; prolapse; low SES; radiat; hysterectomy; multi sex partners; DES expo
Postmenop: squam cell carcinoma
Young: adenoK; clear cell adenoK from DES
Vaginal cancer (PE, dg, ttt)
AbNl vag bleed; abNl discharge; post-coital bleed
Usually upper 1/3 of vag
Dg: cytology, colposcopy, biopsy
ttt: local excis; partial/complete vaginectomy; if invasive then radiat or radical surg
Ovarian cancer (RF)
#1 death from gynec cancers RF: age; low parity; ↓fertility; delayed childbearing; ⊕fam Hx; BRCA1 (45% R); BRCA2 (25% R); HNPCC sd
!!! OCPs taken for ≥5y ↓R by 29%
Ovarian cancer (PE, dg)
Asympt; mild GI/pelvic pressure/pain
Esp present advanced: abdo pain/ascites/palpable mass
Dg: ↑CA-125 (epith cell K if postmenop; maybe endometriosis if premenop; only for progr/recurr) TV US (screen high-R W or if sympt)
Ovarian cancer (markers)
Epithelial: CA-125 Endodermal sinus: AFP Embryonal carcinoma: AFP, B-hCG Choriocarcinoma: B-hCG Dysgerminoma: LDH Granulosa cell: inhibin
Ovarian cancer (ttt, prevention)
Surg: TAH/BSO w/ omentectomy + pelvic and paraAo LNectomy
Postop chemoth: except if early-stage or low-grade
Radiation: for dysgerminomas
Prev: BRCA1 mut (screen/y w/ US + CA-125 then prophyl oophorectomy at 40yo or if no more children)
OCPs ↓R; No routine screening for general pop
Pelvic organ prolapse (RF, PE)
RF: vaginal birth; genet predisp; adv age; prior pelv surg; connect T ds; ↑intra-abdo pressure (obes/constip)
Sensat* of bulge in vagina
Urin/fecal incontin; incomplete bladd empty; dyspareun
Pelvic organ prolapse (dg, ttt)
Dg: degree of prolapse (by Valsalva while in lithotomy)
ttt: support (↑fiber diet; ↓weight; limit straining/lifting)
Pessary; surgery (hysterectomy w/ vaginal vault suspens*)
Urinary incontinence
Bladder dysfct or sphincter dysfct
R/o fistula (if total incont); neuro abNl (if urge incont); distended bladd (overflow incont)
Dg: UA; ur Cx; void diary; urodynamic test; creat; cystogram
Urinary incontinence w/o genital pathology
Delirium/confus* Infect* Atrophic urethritis/vaginitis Pharmaceutical Psychiatric causes Excessive urine output Restricted mobility Stool impact*
Types of urinary incontinence
- Total: all times + all positions; ttt w/ surg
- Stress: ↑intra-abdo P; ttt w/ Kegel/pessary or vag vault suspens
- Urge: unrelated to posit*; ttt w/ anticholin or TCAs or behavior
- Overflow: chron urin retent*; ttt w/ urethral cath in acute; ttt underl ds; timed voiding
Pediatric vaginal discharge
Nl but r/o sexual abuse
- Infec vulvovaginitis: malodo, yellow-green, purul disch; Grp A strep; Candida (recent AB, immsuppr); STDs
- Foreign body
- Noninf vulvovaginits: contact dermatitis; eczema
- Sarcoma botryoides: malign
Precocious puberty (etiologies)
- Central: early activat* of hypoth GnRH product*
- Periph: GnRH-independent
Signs of ↑estrog: brst dev, vag bld (ovar cyst/tumor)
Signs of ↑androg: pub/axill hair, ↑clitoris, acne (adr tumor/CAH)
Precocious puberty (dg)
Bone age: pub not started or started >1y or rapid progr
GnRH agon stimulat* test w/ LH resp: ⊕ (central: CNS tumor or idiop); ⊖ (periph: US adren/ovar; cyst, tumor, exog estrog, CAH)
Precocious puberty (ttt)
Central: leuprolide (#1)
Periph: ttt cause: cyst (regress spont); CAH (GC); adr/ov tumor (surg); McCune-Albright (antiestrog tamoxifen; estrog blockers ketoconazole)
Nonproliferative breast lesions (types, RF)
No ↑R of breast cancer (unless complex cyst)
Esp simple cysts w/ fluid (↑resp to Hes/growth fact)
Or papillomatosis, adenosis, fibrosis, ductal epithelial hyperplasia
30-50yo; ass w/ trauma and caffeine
Nonproliferative breast lesions (PE, dg, ttt)
Cyclic bilat mastalgia, swell, esp prior to menses
Rapid fluctuat* in size; irreg bumpy consistency
Dg: re-examine after menses; if unchang then US (liqu/solid); FNA (if cyst, ↓pain+dg); excis* biopsy (if no fluid or if bld on aspir); mammo? maybe if >35yo
ttt: reassure; aspirat* if pain; ↓caffeine; OCP (↓fluctuat*)
Proliferative breast lesions without atypia
FIbroadenomas, intraductal papillomas, sclerosing adenosis, ductal hyperplasia
Ass w/ small ↑R of breast cancer
- Intraduc papill: papill cells from wall of cyst into lumen; Dg w/ core biop; ttt w/ excis* bcz ass w/ atypia/DCIS
- Sclerosing adenosis + ductal hyperpl: no ttt
Fibroadenoma (PE, dg)
Prolif les* w/o atypia; benign; epith+stroma
Esp <30yo; round rubbery mobile 1-3cm
Solitary or 20% multiple
No chang during menses; ↑in pgncy/He ttt; ↓in menop
Dg: US (liq/solid); needle biopsy/FNA; excis* if uncertain
ttt: excis* curative but recurrence common
Phyllodes tumor
dg: fibroadenoma
Larger, ↑meta ability than fibroad
Papillary project* of stroma, lined w/ epith
Ass w/ hyperplasia + atypia
Atypical hyperplasia
Ductal or lobular Similar to low-grade DCIS or LCIS ↑R of breast cancer Dg: biopsy after mammo ↓R w/ mammo/year + Tamoxifen or aromatase inh
Breast cancer (RF)
#1 W cancer #2 cancer death in US 60% in upper outer quadrant
RF: W; older; caucasian; personal Hx; fam Hx (1st); genetic (BRCA1-2); alcoh; cigaret; radiat; fibrocystic chang w/ cell atypia; ↑expo to estrog (nullipa, early menarch, late menop, 1st pgncy >35yo)
Breast cancer (PE)
-Early: single, nontender, firm/hard, immovable
Ill-defined margins; mammo abNl
-Later: axill LN, brst enlarg, pain, peau d’orange, fixat*
-Late: ulcer; supraclav LN; arm edema; scaling eros*
-Meta: bone (pain); lung (dyspn/cough); liver (pain/N/jaund); hard axill LN >1cm; supra/infraclav LN
Breast cancer (screening, dg)
- Screen: postmenop (mammo); premenop (US if <30yo)
- Suspic les*: biopsy (mammo guided FNA; core needle; open)
- Receptor status: ER, PR, HER2/neu
- Tumor markers if recurr: CEA, CA 15-3, CA 27-29
- Meta: ↑ESR, ↑ALP (liv/bon meta), ↑Ca; CXR, CT CAP, brain MRI, PET CT
Breast cancer (ttt)
- Early-stage: conserv surg + radiat* or mastectomy +/- radiat*; w/ sentinel LN + adjuvant ttt
- Locally adv: neoadj chemo + trastuzumab (if HER2⊕); conserv surg or mastectomy w/ sentinel + adjuvant ttt
-Adjuvant ttt: all ER/PR⊕ give tamoxifen or aromatase inh (if postmenop); all HER2⊕ give trastuzumab
Triple⊖ give chemoth if >0.5cm (Not if already got neoadj)
-CI to conserv surg: large, subareolar, multifocal, fixed to chest, prior radiat* to chest, nipple/skin involv
-Stage IV: radiat* + hormon ttt +/- mastectomy
Breast cancer (prognosis, complications)
Pg: TNM stage (I-IV) most reliable; ER⊕/PR ⊕ favorable pg; localized (75-90% cure); spread (40-50% 5y-survival)
Compl: pleural effusion; edema arm
Sexual assault (PE, dg)
#1 crime in US Full Hx (last time, condom, OCP, drug/alcoh, STD), descript* of assailant, locat*/time; act* since assault (douch, ...)
Dg: complete PE; gono/chlam/trichom smear/Cx/wet mount; HIV/syphilis/HSV/HBV/CMV; pgncy test; bld alcoh; urine toxicology
Sexual assault (ttt)
ttt traumatic injuries
STD ttt + prophyl (ceftriax + azithrom +/- metronid)
Hep B vaccine if not received
HIV prophyl
Emergency contracept*
Psychological counseling
Follow-up (repeat STD/pgncy screening, psychiatric care)
