Gynecology Flashcards
Discuss sex differentiation
- sex differentiation occurs through the SRY gene on the Y chromosome
- gene encodes for testis-determining factor -> mullerian inhibiting substance and testosterone which develop the male genital system
Discuss the development of the ovaries
- undifferentiated until the 7th week where develops from the paraxial mesoderm in 3rd week and develop the urogenital ridge around the nephrogenic cord in 4th week
- with no Y chromosome the indifferent gonad develop the ovary where the medullary cords degenerate, cortical cord develops (form future follicular cells) and no tunica albuginea
- ovaries descend slightly and the suspensory ligament develops from the superior genital ligament and the round ligament develops from the inferior genital ligament (gubernaculum)
Discuss the formation the genital Ducts
Indifferent Stage
- mesonephric duct is Wolfian duct
- paramesonephric duct is muellerian duct
Absence of MIS and Testosterone
- mesonephric duct degenerates
- paramesonephric duct develops to form the uterine tube, uterus and superior aspect of the vagina
- absence of testosterone forms the external genitalia and lower 1/3 of clitoris -> 5th month the vaginal plate canalizes to form the vagina
Discuss the formation of the external genitalia
Indifferent
- 3rd week mesynchymal cells migrate around cloacal membranes to form cloacal folds -> superiorly form genital tubercle and inferiorly form the urethral and anal folds
Development of External Genitalia
- genital tubercle elongates to form the clitoris
- urethral folds do not fuse to form labia majora
- urogenital groove remains open and form the vestibule
List the timing of events of the endometrial and ovarian cycles
Endometrial - day 1-5 have menstruation - day 6-13 have proliferative phase - day 15-28 have secretory phase Ovarian Cycle - day 1-13 have follicular phase - day 14 have ovulation - day 15-28 have luteal phase
Describe in-detail the ovarian cycle
Primordial
- primordial follicle develop into primary and then secondary follicle overtime and is gonadotropin independent -> larger primary oocyte with more zona pellucida + granulosa cells proliferating forming layers around oocyte + interstitial cells form theca cells around oocyte
Follicular Phase
- increase in FSH and LH lead secondary follicle to form the Graafian follicle, where fastest primary follicle to form secondary will be chosen
- tertiary follicle begin to produce estrogen which inhibits FSH causing other follicles to die
- dominant produce more estrogen leading to LH surge
Ovulation
- LH surge lead to ovulation by increasing antral fluid and release of hydrolytic enzymes so that secondary oocyte with corona radiata are release
- completion of meiosis 1
Corpus Luteam Phase
- corpus luteum produces progesterone and estrogen
- in the absence of LH the corpus luteum will degenerate into corpus albicans
- with bHCG the corpeus luteum will continue to release progesterone until taken over by placenta at 4-5 months
Describe the endometrial stages
Menstruation
- due to low estrogen and progesterone cause shedding of the endometrium
Proliferative
- high estrogen from follicle stimular endometrial cells increase its thickness
Secretory
- with high progesterone cause endometrial hypertrophy, thickening of the spiral arteries and glycogen secretion
Discuss where the major hormones of menstruation are produced
Progesterone
- produced by granulosa, theca, interstitial and corpus lutem
- LH stimulate corpus luteum to produce
- low <2 before ovulation and >5 after
- act on hypothalamus to decrease GnRH production
Testosterone
- produced by theca, interstitial and corpus luteum
- theca cells synthesize and then pass to granulosa cells via basement membrane to produce estrogen
- in non-dominant follicle cannot convert testosterone quickly enough resulting in atresia
Estrogen
- produced by granulosa and corpus luteum
- low <50 at menstruationa nd then peak at 200 during follicular development
- inhibit GnRH release
- FSH target granulosa cells to produces estrogen and stimulate follicular growth
Activin and Inhibin
- released by granulosa cells to activate or inhibit FSH release
Discuss the components, mechanism and use of oral contraceptive pill
Component
- low dose estrogen and progestin
Mechanism
- inhibit ovulation
- change cervical mucus
- cause pseudodecidualization of endometrium to inhibit implantatation
- inhibit tubal peristalsis to prevent fertilization
Use
- start at either 1st Sunday after menses, day 1 of month or immediately
- takes 7 days before it can work
- 21/7 method where hormone free days allow for menstruation
List the contraindications to OCP
- smoker and over age of 35
- <6 weeks post partum if breastfeeding
- history of VTE
- current breast cancer
- uncontrolled hypertension
- ischemic heart disease
- complicated valvular disease
- history of stroke
- migraine headache with aura or over 35 with migraine
- severe diabetes or cirrhosis
- SLE and APLA
- thrombophilia
List the benefits of OCP
Short Term
- regulation of menstrual cycle and decreased bleeding
- decreased dysmenorrhea, acne or premenstrual syndrome
Long Term
- decrease risk of endometrial, ovarian, and colorectal cancer
- decrease risk of benign breast disease
Other
- decrease risk of PID and ectopic pregnancy
- decrease risk of ovarian cyst
- improve endometriosis
Discuss the contraceptive patch and vaginal ring
- same as oral contraceptive where use for 3 weeks with 1 free week
Discuss the benefits of the progestin only pill
Mechanism - need to take pill everyday at same time and it increases cervical mucous - still have regular menstruation Indication - breastfeeding women or those with previous VTE Adverse Effects - irregular bleeding - worsening mood
Discuss the benefits of injectable progestin DMPA
Mechanism - inhibit ovulation - thicken cervical mucous - pseudodecidualization Use - injection every 3 months where have 2 week interval at mark where still effective Contraindication - known or suspected pregnancy - unexplained vaginal bleeding - current breast cancer Adverse Effect - 50% develop amenorrhea after 1 year and 75% after 2 years - weight gain due to increase appetite - decreased bone densit - delay to fertility: require 9 months after to return Benefit - treat menorrhagia, dysmenorrhea and endometriosis - treat menses related symptoms - decrease risk of endometrial and cervical cancer - decrease seizure
List the contraindications to an intra-uterine device
Contraindications - known pregnancy - puerperal sepsis - immediate post septic abortion - current PID or STI - cervical or endometrial cancer - current breast cancer - unexplained vaginal bleeding - distorted uterine cavity - malignant trophoblastic disease Adverse Effects - unscheduled vaginal bleeding - pain or dysmenorrhea - uterine perforation - infection - expulsion - failure where have increased risk of ectopic
Discuss the benefit of copper IUD
Mechanism
- foreign body reaction that lead to endometrial change that adversely affect sperm transport and inhibit sperm motility directly
- best used for emergency contraception 7 days post
Discuss the benefit of a mirena (LNG-IUS) IUD
- contain progesterone
- last up to 5 years
Mechanism - thicken cervical mucous
- suppress endometrial estrogen and progestin receptor
- inhibit ovulation
- inhibit implantation
- induce endometrial changes
Discuss the use of Plan B/Norvelo
- progesterone only Mechanism - inhibit ovulation - change endometrium to prevent implantation - disrupt luteal phase - effect on tubal transport - does not disrupt established pregnancy
Discuss the approach to primary amenorrhea
- failure to reach menarche (amenorrhea and no pubertal development by 14 or amenorrhea with secondary sexual characteristic by 16)
Pelvic Examination - if absent uterus must assess if have sexual hair -> if yes than mullerian agenesis and if no then CAIS
- if normal then assess bHCG
Negative bHCG assess prolactin, TSH and FSH
Prolactin - if increased require MRI head to assess for pituitary tumour
- treat with surgery or dopamine agonist
TSH - if elevated treat with thyroid replacement
FSH Decreased - assess if have eating disorder, over exercise or stress
- if no, then MRI for tumour -> if MRI negative than Kallman
FSH Increased - gonadal failure so must do karyotype assessing for primary ovarain insufficiency or Turner or fragile X
FSH Normal - testosterone increased than ovarian sonography for tumour
- DHEAS high then adrenal MRI for tumour
- if DHEAS and testosterone normal or high normal than PCOS
- 17-OH-P increased than congenital adrenal hyperplasia
List the differential for secondary amenorrhea
Hypothalmic - eating disorder or stress Pituitary - prolactinoma Thyroid - hypothyroidism Ovary - PCOS - primary ovarian insufficiency
Discuss the presentation and management of primary ovarian insufficiency
- 90% are idiopathic and then Turner or chemo/radiation
Pathophysiology - inadequate follicles to sustain menses due to failure tof form enough primordial follicles or accelerated loss or damage
Presentation - primary or secondary amenorrhea
- menses interal >90 days
- oligomenorrhea
Investigation - consistently high FSH and LH
- consistently low estradiol
Diagnosis - primary or secondary amenorrhea for 3 months or changes from normal for 3 months
- high FSH >40 on 2 occassions a month apart
- age <40
Complications - increased risk of osteoporosis and atheroscleorsis
- infertility
Management - pre-puberty: increase estrogen over 2 years until breakthrough bleed -> add progesterone
- Post-Puberty: estrogen for 1-26 and progesterone for 14-26 of cycle (OCP or patch)
- prevent complications through lifestyle, monitoring and supplementation
Discuss the presentation and management of polycystic ovarian syndrome
Rotterdam Diagnosis (2/3) - oligo or anovulation - clinical or biochemical hyperandrogenism - polycystic ovaries (>12 follicles) Acute Management - menstrual irregularities with oral contraceptive - acne with lifestyle changes - hirsutism with spironolactone - infertility Surveillance - impaired glucose tolerance (possible pathophysiology where theca cell insulin resistance lead to unopposed estrogen with elevated LH) - endometrial hyperplasia - hyperlipidemia
Discuss the signs of hyperandrogensism
- hirsutism on androgen dependent areas of body
- acne
- clitoromegaly
- male balding
- obesity
- insulin resistance
List the differential for abnormal uterine bleeding
Structural Abnormalities (PALM) - polyp - adenomyosis - leiomyoma - malignancy No Structural Abnormality (COEIN) - coagulopathy - ovulatory dysfunction - endometrial - iatrogenic - not yet classified
Discuss the risk factors for polyp and risk factors for polyp malignancy
Risk Factors - tamoxifen - obesity - hormone replacement - age For Malignancy - >1.5cm - tamoxifen - age >60
Discuss the diagnosis and treatment of polyps
Diagnosis - hysteroscopy - saline infusion sonography Treatment - symptomatic or post-menopausal - asymptomatic if risk for malignancy, mulitple, prolapse, infertility
Discuss the presentation and management of adenomyosis
- are ectopic endometrial glands and stroma within myometrium resulting in enlarged uterus Presentation - heavy menstrual bleeding - painful menstruation with chronic pelvic pain - enlarged uterus Treatment - hysterectomy - hormonal therapy - ablation - embolization
Discuss the presentation and management of fibroids
- is growth of myometrial smooth muscle in women of reproductive age
Presentation - heavy and prolonged menses
- pelvic pain or pressure with 4 D’s (dysmenorrhea, dyspareunia, dyschezia, dysuria)
- infertility
- enlarged urterus
Investigations - CBC for anemia
- transvaginal ultrasound
Treatment - prophylactic if causing infertility, IVF or hydronephrosis
- hormonal therapy with OCP or menopause inducing drugs
List the risk factors for fibroids
Increased - African American - early menarche - family history - hypertension - obesity - alcohol - red meat Decreased - high parity - exercise - smoking - healthy diet
Discuss the screening and treatment of coagulopathy leading to AUB
Screen
- heavy menstrual bleed
- one of post-partum hemorrhage, surgery related bleed, bleeding with dental work
- two of bruising, epistaxis >=1/month, frequent gum bleeding, or family history
Treatment
- No pregnancy then contraceptive method
- pregnancy then antifibrinolytic, factor replacement, dDAVP
List the differential for ovulatory dysfunction
- eating disorders
- stress
- excessive exercise
- obesity
- endocrinopathy
List the iatrogenic causes to AUB
Pharmacotherapy - exogenous gonadal steroids - GnRH therapy - antipsychotic - corticosteroids - anticoagulants Medical - IUD Surgical - D+C - myomectomy - C-section
List the hormone treatment principles for AUB
Combined estrogen and progestin
- for regular or irregular menorrhagia or irregular cycle
- progestin suppress ovulation
- estrogen support endometrium preventing breakthrough bleeding
Progestin Only
- for irregular menstrual cycle
- inhibit ovarian steroid synthesis leading to endometrial atrophy and decrease bleeding
GnRH Agonist (Lupron)
- for regular or irregular menorrhagia, shrinkage of fibroid and dysmenorrhea
- induce reversible menopause
List the mechanism of non-hormonal treatment of AUB
Iron Supplementation NSAID - cause vasoconstriction and reduce pain Anti-fibrinolytics (TXA) - inhibit plasminogen activator in order to decrease bleeding
List the life-threatening differential for vaginal bleeding
Early pregnancy: ectopic or spontaneous abortion Late pregnancy: abruption or previa Post-partum: PPH Ovary: torsion or rupture of cyst Uterus: severe menorrhagia Trauma Infection: PID or salpingitis Malignancy
Discuss the presentation and management of an ectopic pregnancy
Presentation - pelvic pain - vaginal bleeding - palpable adnexal mass - peritoneal signs Investigation - postive bHCG that is not doubling every 48hrs - trans-vaginal ultrasound show ectopic or no pregnancy intra-uterine pregnancy with bHCG >1500 Management - surgery if complicated - medical abortion if not complicated
Discuss the presentation and management of ruptured ovarian cyst
Presentation - pelvic pain - vaginal bleeding - nausea and vomiting - tenderness to palpation - peritoneal signs Investigations - negative bHCG - ultrasound show free fluid in pelvis Management - uncomplicated get conservative with possible fluid resuscitation - surgical for source control if unstable or deteriorating
Discuss the presentation and management of ovarian torsion
Presentation - pelvic pain - vaginal bleeding - fever, nausea and vomiting - palpable mass Investigations - negative bHCG - ultrasound show enlarged ovary/mass/peripheral follicles or no doppler flow Management - immediate surgery with possible salpingooophorectomy
Discuss the presentation and management of pelvic inflammatory disease
Pathophysiology - infection of upper genital tract by STI Presentation - prior STI or sexual activity - pelvic pain during or after menses - vaginal discharge or bleeding - fever - dysuria - cervical motion tenderness Investigations - positive culture - abscess Management - ceftriaxone 250mg IM + doxycyline 100mg BID for 14 days
Discuss the presentation of Chronic Pelvic Pain Syndrome
Pathophysiology - idiopathic spasm of pelvic floor muscle Presentation - pain out of proportion - dyspareunia - vaginismus
Discuss the presentation of vestibulitis vulvodynia syndrome
Presentation
- vulvar discomfort
- superficial dyspareunia
- perineal burning
- erythema of Bartholine opening and hymen
- tenderness to Q-tip probe
Discuss the presentation of pelvic congestion syndrome
- pelvic pain varicosities
Presentation - dull achin pain in pelvis made worse by standing
- ultrasound with pelvic varicosities
Discuss the cervical screening
- begin screening at 21 if ever sexually active and repeat every 3 years
- if never, can wait until sexually active
- stop at 70 if have 3 previous normal results
List the different pap test results
ASC-US: atypical squamous cell of undetermined significance
ASC-H: atypical squamous cell that cannot exclude high grade lesion
LSIL: low grade squamous intraepithelial lesion
HSIL: high grade squamous intraepithelial lesion
Squamous cell carcinoma
List the follow up testing for pap test results
ASC-US <30 - repeat every 6 months x2 -> if abnormal then colposcopy ASC-US >30 with HPV testing - if positive then colposcop - if negative then repeat PAP in 1 year - if no HPV than same as <30 LSIL - colposcopy or repeat PAP at 6 months HSIL/ASC-H/AGC - colposcopy
Discuss the use of colposcopy
Diagnosis - uses acetic acid to turn white the areas of dysplasia which can be biopsied - if nothing than do transition zone Management - CIN 1 than repeat PAP at 12 months - CIN 2 or 3 perform LEEP excision
Discuss the presentation and management of bacterial vaginosis
- most common cause of increase discharge
- increase risk of acquiring STI
Amsel’s criteria (3/4): - thin white discharge
- pH >4,5
- positive Whiff test: fishy odor when alkali is added
- clue cells
Management - flagyl 500mg PO BID for 7 days
- do not need to treat partner
Discuss the presentation and management of vulvovaginal candidiasis
- 2nd most common with 75% having at least one episode
Risk Factors - uncontrolled diabetes or system antibiotic use
- immunocompromised
- high estrogen level (pregnancy, obesity, OCP)
Presentation - thick, white clumpy discharge
- vulval itch with erythema and satellite lesions
Investigation - pH litmus paper <4.5
- vaginal KOH swab show yeast with hyphae and spores
Management - fluconazole 150mg PO
- topical cream for 3 days if uncomplicated and 7 if complicated (topic preferred only if pregnant)
Discuss the presentation and management of trichomoniasis
- symptoms one week after contact Presentation - yellow-green, frothy malodorous discharge with pruritis and dyspareunia - strawberry cervix Investigation - motile flagellated organism Management - treat even if asymptomatic with flagyl 2g PO single or 500mg PID x7
Discuss the presentation and management of post menopausal atrophic vaginitis
- low estrogen leading to atrophy of the vagina Presentation - yellow vaginal discharge - dry and irritation of vagina - dyspareunia - vaginal petechiae Management - vaginal estrogen applied for life
List the female risk factors for infertility
- age >35
- low or high body mass
- history of oligo/amenorrhea, PID or endometriosis
- previous pelvic surgery
- previous chemotherapy
List the male risk factors for infertility
- age >40
- cryptochordism
- previous surgery or chemotherapy
- recreational drug use
Discuss the inter-relationship between infertility and sexual dysfunction
- sexual dysfunction when health, relationship or idea regarding sex cause problems with function (desire, arousal, orgasm) -> leads to infertility which contributes to worsening dysfuncion
- for men most common is erectile dysfunction
- for women it is low desire/arousal, dyspareunia or difficulty reaching orgasm
List the indications for further testing with infertility
- female age <35 and have attempted for 1yr of unprotected and frequent (2-3x per fertile window)
- female age >35 or specific history after 6 months of attempt
List the investigations for infertility
- assessment of ovulation by history and serum progesterone 7 days prior to expected period
- ovarian reserve testing by FSH, estradiol, and ultrasound
- uterus and uterine tube anatomy by saline infusion sonogram
- semen analysis
- TSH
Discuss the methods for assessing ovulation
History
- should have ovulation 14 days before expected period if regular
- have signs of molimina
Basal Body Testing
- increase by 0.3-0.5 2-3 days after ovulation
LH Surge
- can measure LH surge at ovulation
Luteal Phase Serum Progesteron
- assessment of progesterone 7 days before expected period
How do you confirm low ovarian reserve
- measure FSH and estradiol on day 3 of menstrual cycle along with pelvic ultrasound for follicles
- high FSH and low estradiol suggest low reserve along with low follicle count
Discuss methods for assessment of tubal patency
Hysterosalpingogram
- dye put into uterus to assess patency of tubes
- due 2-3 days after menses to avoid clot and pregnancy
Saline Infusion Sonogram
- infusion of saline into uterus to assess patency
Laproscopy
- gold standard
- indication: abnormal hystersalpingogram, endometriosis, previous ectopic or surgery, previous ruptured appendicitis, abnormal pelvic exam, PID
List the normal semen findings
- volume >1.5mL
- pH >7.2
- sperm concentration >15million
- > 40% progressive motility
- > 4% normal
Discuss the management for ovulation dysfunction infertility
Hypogonodotropic hypogonadism - weight gain - GnRH or FSH injections - IVF Normogonodotropic normoestrogen (PCOS) - weight loss - clomiphene citrate which is selective estrogen receptor modulator to increase FSH - metformin for insulin sensitization - FSH injection - IVF Hypergonodatropic hypogonadism (POF) - IVF - donor - adoption
Discuss management of male infertility
- lifestyle modification: avoid heat, limit caffeine, stop alcohol, smoking, drugs
- abnormal sperm get GnRH
- abnormal sperm function get IVF
- obstruction require IVF
Discuss the methods of treatment for induction
Ovulation Induction - add selective estrogen receptor modulator or FSH to act as antagonist at hypothalamus to increase FSH Superovulation - induce 2-4 eggs and then intra-uterine insemination - daily FSH injections Intrauterine Insemination - male sperm washed and placement in uterus IVF - tubal obstruction - severe endometriosis - low sperm count - PCOS - failed SO - donor egg needed - age >40`
Discuss the procedure of IVF
- FSH stimulate egg production which is aspirated by needle
- inseminated with sperm
- fertilized egg inserted into uterus
- <38 1-2 eggs inserted and >42 then 5
List the red flags for domestic abuse
Being Abused Situational - planning on leaving or recent termination - pregnancy Demographics - <30 - low SES Physical or mental disability Past History
Abuser
- history of aggression
- low SES or unemployment
- substance use
List the risk factors for pelvic organ prolapse
- age
- pregnancy
- obesity
- previous surgery
- hypo-estrogen
- connective tissue disorder
- smoking
Discuss the presentation and management of pelvic organ prolapse
Pathophysiology - weakness in pelvic floor lead to prolapse of vaginal walls along with organs surrounding Presentation - fullness, pressure or bulge from vagina - urinary incontinence - constipation - vaginal bleeding or discharge Investigations - urodynamics Management - pelvic floor exercises and estrogen replacement - pessary - surgery
Discuss the grading of pelvic organ prolapse
Grade 1 - prolapse descending to upper 1/3 of vagina Grade 2 - prolapse descending to mid vagina Grade 3 - prolapse descending to hymenal ring Grade 4 - prolapse past hymenal ring
Discuss the different causes of obsterical fistuals
Obstetric - due to prolonged, obstructed labor without timely intervention Iatrogenic - pelvic surgery or radiotherapy lead to injury Local disease Causing Inflammation - local inflammatory disease - IBD - local cancer
Discuss the presentation and management of pelvic fistula
Presentation
- recurrent vaginitis and irritation
- vesicovaginal: uncontrolled leakage of urine with recurrent UTI
- rectovaginal: leakage of stool and flatus from vagina
Management
- vesico: small get catheter in order to heal or large get surgical repair
- recto: surgical repair
What is the definition of menopause
- 12 months of amenorrhea typically occuring between 45-55
- peri-menopause is transition period of altered hormones that leads up to and last for 1 year after
- is the shortenin of cycles with greater time in between
Discuss some of the physiologic changes with menopause
- narrowing of thermoneutral zone leading to regulatory response of sweating or shivering
- low estrogen lead to atrophy of vagina and bladder incontinence
- low estrogen lead to dyslipidemia, increase plaque and vasodilation
Discuss the clinical symptoms of menopause
- vasomotor: hot flashes and night sweats
- poor memory and concentration
- depression and sleep disturbance
- vaginal dryness and increased urinary frequency
- decreased libido
- fatigue and myalgia
Increased Risk of
- osteoporosis
- cardiovascular disease
- colorectal cancer
Discuss the conservative management of menopause
- reduce core body temperature
- avoid triggers such as alcohol, warm environment and drinks
- regular exercise and weight loss
- smoking cessation
List the indications and contraindications for hormone therayp
Indications - menopausal symptoms that negatively impact quality of life within 3-5 years of menopause for a max of 5 years - those with premature ovarian failure should be used until 50 for cardioprotective benefits Contraindication - cardiovascular disease - breast or endometrial cancer - venous thromboembolism - acute liver disease
List the option for medical therapy of menopause
- lower dose than OCP, so have lower risk
- have both estrogen and use progesterone if have uterus
- transdermal better as bypass liver so lower risk of DVT
Types
- oral conjugated equine estrogen
- oral esterase
- transdermal estradiol
- oral micronized progesterone
- progestin
Discuss the use of vaginal estrogen therapy
- first line for vaginal atrophy without vasomotor symptoms
- reduced risk of complications of HT
- require lifelong therapy
List the histological findings of endometriosis
> =2 of
- endometrial epithelium
- endometrial gland
- endometrial stroma
- hemosiderin-laden macrophage
