Gynecology - GU disorders + STIs Flashcards
PID will often present after
a period - blood is a good culture medium
always do cervical motion tenderness as a
1 handed exam! DO NOT put nondominant hand on abdomen when doing it!
Herpes crossing midline - is this primary or secondary infection?
Primary
Herpes DOES not cross midline in recurrences - if it does, suggests primary infection
Labial fusion
Assoc w/ excess androgens
- usually result of exogenous androgen exposure
Most common enzyme deficiency = 21 hydroxylase deficiency —> CAH
Tx = reconstructive surgery
Tx 21 hydroxylase d/o
Exogenous cortisol
Will feedback to decrease ACTH to decrease adrenal gland hormone secretion
Imperforate hymen
Central portion epithelial cells of hymenal membrane fail to degenerate and form hymenal ring
Usually dx at puberty in adolescents who p/w primary amenorrhea and cyclic pelvic pain.
Tx
- surgery to excise the extra tissue, evacuate any obstructed material, and create a normal sized vaginal opening
Transverse vaginal septum
Usually at lower 2/3 of vagina
Failure of mullerian tubercle to be cannalized
P/w primary amenorrhea and cyclical pain
Normal external genitalia
Vagina ends in blind pouch 2/2 septum
Tx = surgery
Vaginal atresia
- lower vagina fails to develop and is replaced by fibrous tissue.
- ovaries, uterus, cervix, and upper vagina are all normal.
- usually happens when urogenital sinus fails to contribute
the lower portion of the vagina - presents during adolescence with primary amenorrhea and cyclic pelvic pain.
PE
- absence of introitus
- presence of vaginal dimple
MRI/US can show large hematocolpos
Confirm nl upper repro tract
Tx
- surgery
- incise fibrous tissue and dissect until nl upper vagina ID’d
- the normal upper vaginal mucosa is then brought down to the introitus and sutured to the hymenal ring
Vaginal agenesis
aka Mayer-Rokitansky-Kuster-Hauser syndrome
Congenital absence of vagina
+
absence/hypoplasia of all or part of the cervix, uterus, and fallopian tubes
Features:
- nl external genitalia
- nl secondary sexual characteristics (breast development, axillary, and pubic hair),
- bl ovarian function.
- phenotypically and genotypically female
Usually present in adolescence with primary amenorrhea.
Tx:
- nonsurgical - create vagina using serial vaginal dilators pessed into perineal body (4mo - several yrs)
- surgery to create neovagina
Fertility
- after surgery, sex is ok
- pt can’t carry preggers - can harvest eggs for gestational surrogate though
Lichen sclerosis of vulva
Inflammatory dermatosis
Symmetric white, thinned skin on labia, perineum adn perianal region
- shrinkage and agglutination of labia minora
Usually in postmenopausal women
3-4% Inc risk vulvar cancer
Sx:
- pruritus
- dyspareunia
- usually no sx
Dx:
- always get bx to r/o vulvar SCC
Tx:
- high potency topical steroids (clobetasol or halobetasol)
Lichen planus of vulva
Multiple shiny, flat, red-purple papules usually on inner aspects of labia minora
- often erosive
Assoc w/ vaginal adhesions and erosive vaginitis
Usually in 50s-60s
Same as lichen sclerosis 3-4% inc risk of cancer
Sx:
- puruitus with mild inflammation –> severe erosions
Tx:
- high potency topical steroids (clobetasol or halobetasol)
Lichen simplex chronicus of vulva
thickened skin w/ accentuated skin markings and exocriations 2/2 chronic itching and scratching
Itching 2/2 many conditions (atopic dermatits, psoriasis, etc)
Tx:
- medium to high potency topical steroid
When do you bx benign lesions of vulva presenting with vulvar itching, irritation, burning?
Ulceration
Unifocal lesions
Uncertain suspicion of lichen sclerosis
Lesions or sx persisting after tx
Use colposcope!
1 tumor found on vulva
Epidermal inclusion cysts
- 2/2 blocked pilosebaceous duct or blocked hair follicle
Fox fordyce disease
Chronic pruritic papular eruption that localizes to areas where apocrine glands are found
Hidradenitis suppurativa
Skin dz most commonly affecting areas of apocrine sweat glands or sebaceous glands
Infected areas –> form multiple abscesses –> need I&D
Where are skene’s glands?
next to urethra meatus
Suspected bartholin’s dcut cyst - what do you do?
If > 40 yo, need to do bx to rule out rare Bartholin’s gland carcinoma
Usually self resolving
If cyst is large, can lead to abscesses and need I&D or word catheter placement
Marsupialization for recurrent duct cysts/abscesses
Warm sitz baths recommended
Gartner’s duct cysts
remnants of mesonephric ducts of wolfiann system
usually in upper part of vagina
DES exposure in utero…resulting risks?
Cervical lesions (cervical hoods, cervical collars, cervical hypoplasia, etc)
Cervical insufficiency in preggers
Clear cell adenocarcionma of cervix
Most cervical cysts are
Dilated retention cysts called nabothian cysts
Caused by intermittent blockage of endocervical gland
Usually no sx
Origins of reproductive structures
All arise from mullerian system except ovaries (from genital ridge) and lower 1/3 of vagina (from urogenital diaphragm)
Many uterine abnormalities can be associated with
Inguinal hernias
Urinary tract anomalies
Uterine septae vs bicorunate uterus in preggers
Uterine septae
- usually suffer from recurrent 1st trimester loss as septae is not vascularized so placenta can’t implant
Bicornuate uterus
- second trimester pregnancy loss, malpresentation, preterm labor and delivery
Uterine leiomyoma
Benign proliferations of smooth muscle cells of myometrium
Usually happen in women of childbearing age
Regress during menopause
Hormonally response to estrogen and progesterone
Classification of leiomyomas
Characteristics
Submucosal (beneath endometrium)
- usually assoc w/ heavy or prolonged bleeding
Intramural (in muscular wall of uterus)
- most common
Subserosal (beneath uterine serosa)
Fibroids vs adenomyosis
Fibroids have pseudocapsule
- compressed areolar tissue + smooth muscle cells
- little blood vessels
- as fibroids enlarge, can outgrow blood supply, infarct, and degenerate, causing pain
Adenomyosis tends to be more diffusely organized in myometrium
MRI to distinguish between the two!
Ways to dx fibroids?
Pelvic US
Can also use HSG, saline infusion sonogram, and hysteroscopy for location and size of uterine fibroids
- good for submucosal ones
Medical therapies for Uterine Leiomyomas
GO PAN AM
GnRH agonists (leuprolide, nafarelin) OCPs
Progestins (mirena IUD, medroxyprogesterone)
Antifibrinolytics (tranexamic acid)
NSAIDs
Androgenic steroids (danazol) Mifepristone
Indications for surgical intervention for uterine leiomyomas
Abnl uterine bleeding —–> anemia
Severe pelvic pain or secondary amenorrhea
Uterine size > 12 wk obscuring eval of adnexa
Urinary freq, retention, hydronephrosis
Growth after menopause
Recurrent miscarriage or infertility
Rapid increase in size
Tx:
- uterine artery embolization (not for those wanting more fertility and large and pedunculated fibroids)
- MRI-guided high intensity ultrasound (premenopausal, done with kids)
- myomectomy (want fertility)
- hysterectomy
Endometrial polyps
Benign overgrowths of endometrial glands and stroma over vascular core
Usually in 40s-50s
Tamoxifen women at risk
Present w/ abnl vaginal bleeding
Eval w/ US, sonohysterogram, hysteroscopy
Tx - can be malignant or premalignant so remove in all postmenopausal; premenopausal remove too
Endometrial hyperplasia
Source of abnl uterine bleeding
Abnl prolif of both glandular adn stromal elements of endometrium
Can happen when endometrium exposed to continuous estrogen w/o progesterone
Risk endometrial carcionma
Dx:
- bx in office
- D&C
Risks for endometrial hyperplasia
Unexposed estrogen exposure
Obesity Nulliparity Late menopause exogenous estrogen w/o progesterone Tamoxifen use HTN DM Lynch II syndrome
Tx endometrial hyperplasia
Simple + complex atypia
- progestin therapy (depoprovera or provera)
- repeat EMB for regression
Atypical hyperplasia
- D&C eval
- hysterectomy if no kids in future
- if want kids, progestin management, repeat EMB at 3 months —–> if persistence after 9 months, hysterectomy recs
Functional cysts of the ovaries
Follicular (most common)
Corpus luteum
Follicular cysts of ovary
Most common
Happen after failure of follicle to rupture during follicular maturation phase of menstrual cycle
Usually resolve spontaneously in 2-3 months
Simple cysts < 2.5cm are physiologi
Corpus luteum cysts of ovary
Occur during luteal phase
Happen when corpus luteum fails to regress after 14d and becomes enlarged or hemorrhagic
Can rupture!
Theca lutein cysts of ovary
Large bilateral cysts filled w/ clear straw colored fluid
2/2 stim from abnormally high bhCG (eg molar preggers, choriocarcionma, ovulating induction)
Endometriomas
Ectopic endometrial tissue within ovary
Aka “chocolate cysts”
Endometriosis
1 dx in eval of infertility in couples
Endometrial tissue outside of the uterus
Sx:
cyclic pelvic pain beginning 1 or 2 weeks before menses, peaking 1 to 2 days before the onset of menses, and subsiding at the onset of menses or shortly thereafter.
Dysmenorrhea starting in 3rd decade, worsen with age…what do you worry about? Previously pain free cycles
Endometriosis
Only way to definitively dx endometriosis
Laparoscopy or laparotomy…surgery!
Tx endometriosis
No role for med therapy in those planning to conceive
NSAIDs
Suppress ovulation and menstruation:
Combo contraceptives
Progestins (suppress menstruation)
Suppress LH and FSH –> no estrogen:
Danazol
GnRH agonist
Aromatase inhibitors off label
Adenomyoma
A well-circumscribed collection of endometrial tissue within the uterine wall.
They may also contain smooth muscle cells and are not encapsulated (no pseudocapsule like fibroid)
Adenomyosis
An extension of endometrial tissue into the uterine myometrium leading to abnormal bleeding and pain.
The uterus becomes soft, globular due to hypertrophy and hyperplasia of the myometrium adjacent to the ectopic endometrial tissue
usually most extensive in the fundus and posterior uterine wall.
MRI to dx
Tx adenomyosis
Extends from the basalis layer of the endometrium, it does not undergo the proliferative and secretory changes traditionally seen in normally located endometrium or in endometriosis. adenomyosis is less responsive to
treatment with OCPs or other hormonal treatments.
Progestin-containing IUD and hysterectomy are the most effective means of treatment.
Tx UTI
Initial:
- TMP/SMX
- nitrofurantoin
- fluoroquinolone
1 cause vulvitiss
candidiasis
Syphilis
- dx
- tx
Dx
- dark field microscopy
- rpr/mha-tp
- fta-abs
Tx
- PCN
Herpes
- dx
- tx
Dx
- viral cx
- Tzanck smear but not sensitive or specific
Tx
- acyclovir
Chancroid (H. ducreyi)
- dx
- tx
Dx
- gm stain with “school of fish” appearance
Tx
- Ceftriaxone
- azithromycin
OR cipro, erythromycin
Lymphgranuloma venereum (C. trachomatis)
- dx
- tx
Dx
- complement fixation
Tx
- Doxycycline
or
- erythromycin
Lesions of syphilis
Primary
- painless
- red, round firm ulcer with raised edges = chancre
- 3 weeks after inoculation
- reginal adenopathy
Secondary
- disseminated
- 1-3 mo after primary
- flu like sx and myalgias
- maculopapular rash on palms and soles
How long do VDRL or RPR tests remain + after tx syphilis
6-12 months
Will have progressively decreasing antibody titers
Repeat these test 1 and 3 months after appearance of ulcer in compliant patient
Always confirm a positive with FTA_ABS test adn T. pallidum particle agglutination assay (TTPA)
Jarisch Herxheimer reaction
Acute febrile reaction freq accompanied by fever, chills, HA, myalgia, malaise, pharyngitis, rash
Happens after any tx for syphilis
Transient 2/2 marked systemic release of cytokines
Course of primary infection HSV
Flu like sx
Vulvar burning and pruritis precede…
Multiple vesicles persisting for 24-36 hrs
Painful genital ulcers lasting 10-22 days
Tx HPV condyloma acuminata/genital warts
Local excision
CO2 laser
Cryotherapy
Topical Trichloroacetic acid
Topical podophyllin
5-FU cream
Uncomplicated:
- imiquimod
- podofilox
Where does molluscum occur?
anywhere on skin except palms of hands and soles of feet
Usually self resolving but can remove w/ local excision, cryotherapy, or TCA
Scabies vs pubic lice
Pubic lice usually confined to pubic hair but scabies can spread throughout body!
Tx pubic lice
permethrin
Tx scabies
permethrin
or
ivermectin
Risk factors for Bacterial vaginosis
Mult sex partners Cigarettes Douching Lack of vaginal lactobacilli Fem sex partners
Dx bacterial vaginosis
3 of findings needed:
1) thin, white homogeneous discharge coating vaginal walls
2) fishy odor when + 10% KOH
3) pH > 4.5
4) Clue cells (vaginal epithelial cells covered with bacteria) on microscopy
Tx bacterial vaginsosi
Metronidazole oral
or
Clindamycin oral
Can use topical but not as effective
Dx candidiasis
Microscopy exam of KOH prep of vaginal discharge
- hyphae & spores seen better
Tx candidiasis
Topical:
- miconazole
- terconazole
Oral
- fluconazole
Dx T. vaginalis
Profuse d/c with unpleasant odor (any color) +/- frothy
Vaginal pH 6-7
Vulvar erythema
Strawberry cervix
Sx usually worse after menses b/c transient increase in vaginal pH at that time
Tx T. vaginalis
Metronidazole oral
Tinidazole oral
Tx both partners!!!!!!!!
Most common causes of cervicitis
N. gonorrhea
C. trachomatis
Dx and Tx gonorrhea
Dx
- nucleic acid amplification tests
Tx
- ceftriaxone (IM or oral)
- azithromycin or doxy for concaminant C. trachomatis infection
Tx chlamydia
Usually asymptomatic!
Azithromycin (oral)
Doxycycline (oral)
Screening for chlamydia?
Annual for sexually active women <=25yo, older women with risk factors, and all preggers
Common sites for infection = endocervix, urethra, rectum
When do you use abx as ppx to prevent endometritis?
C section
Surgical terminations of pregnancy
Hysterosalpingography & Sonohysterography if woman has hx pelvic infxn or tubes dilated
NOT RECOMMENDED IN:
- hysteroscopy
- endometrial ablation
- endometrial bx
- IUD placement
Tx endometritis or endomyometritis
Unrelated to pregnancy
- same as PID –> broad spectrum cephalosporin (cefoxitin or cefotetan) + doxycycline IV
Postpartum endomyometritis:
- clinda + gentamicin IV
Continue until clinical improvement + afebrile for 24-48 hrs
Definitive dx of PID
Laparoscopy
Endometrial bx
Pelvic imaging with PID findings
Fitzhugh Curtis syndrome
Perihepatitis from ascending infection resulting in RUQ pain and tenderness
LFT elevation
Tx PID
Inpatient
Broad spectrum cephalosporin (cefoxitin or cefotetan) IV or IV clinda + gentamycin if cephalosporin allergic
+
Doxycycline IV
Continue until clinical improvement for 24 hrs
Continue doxy oral for total 14 day course
If need to be outpatient…
IM ceftriaxone x1 + probenecid oral + oral doxy x14 days
Tuboovarian abscess
Usually 2/2 persistent PID
Usually not walled off though so more responsive to abx
Same tx as PID but may need to drain abscess
Imaging to dx tuboovarian abscess vs tuboovarian complex
US
May need CT if obese
Toxic shock syndrome
Staph aureus producing TSST-1
High fever HYPOtn Diffuse erythematous macular rash desquamation of palms adn soles GI disturbances Renal disturbance Thrombocytopenia
Blood cx often negative
Tx TSS
IV hydration
Abx only decreases risk of recurrence, not shorten length of infection
Clinda + vanco
Preexposure ppx of HIV
Tenofovir disiproxil fumarate
+
Emtricitabine
Nucleoside analogs for HIV tx
Zidovudine Lamivudine Abacavir Didanosine Stavudine
Protease inhibitors for HIV tx
Lopinavir Atazanavir Indinavir Saquinavir Ritonavir
Lowering vertical transmission rate of HIV
Ziovudine in 2nd trimester —> reduce viral load by 3rd trimester
C/s
NO breastfeeding
Sx interstitial cystitis
Pelvic pain
- usually relieved by voiding
Dyspareniua
Urinary freq, urgency
CYstoscopy - submucosal petechiae or ulcerations
Pelvic congestion syndrome
is a cause of chronic pelvic pain occurring in the setting of pelvic varicosities.
The cause of pelvic vein congestion is unknown.
Hormonal factors contribute to vasodilatation when pelvic veins are exposed to high concentration of estradiol, which inhibits reflex vasoconstriction of vessels, induces uterine enlargement with selective dilatation of ovarian and uterine veins.
Pain worse premenstrually and during pregnancy, and is aggravated by standing, fatigue and coitus.
The pain is often described as a pelvic “fullness” or “heaviness,” which may extend to the vulvar area and legs.
Associated symptoms include vaginal discharge, backache and urinary frequency. Menstrual cycle defects and dysmenorrhea are common. No signs of pelvic floor relaxation were noted on exam.
Nerves at risk for nerve entrapment syndrome 2/2 surgery from low transverse incision include
iliohypogastric nerve (T-12, L-1) - cutaneous sensation to the groin and the skin overlying the pubis
ilioinguinal (T-12, L-1) nerve.
- cutaneous sensation to the groin, symphysis, labium and upper inner thigh.
These nerves may become susceptible to injury when a low transverse incision is extended beyond the lateral border of the rectus abdominus muscle, into the internal oblique muscle.
Damage to the obturator nerve, which can occur during lymph node dissection would result in the inability of the patient to adduct the thigh.
Best time to obtain prolactin level
Stimulation of the breast during the physical examination may give rise to an elevated prolactin level.
Accurate prolactin levels are best obtained with patients fasting.
Any solid dominant breast mass on exam should be evaluated
cytologically, with a fine needle aspiration (FNA), or histologically, with an excisional biopsy
Blood discharge breast mass…what do you do?
excisional biopsy be performed to rule out breast cancer, even if aspriation (bloody) drains the mass
If clear discharge is obtained on aspiration and the mass resolves, reexamination in two months is appropriate to check that the cyst has not recurred.
Definitive surgery for endometriosis
Hysterectomy + BSO
Need BSO or continued pain will happen and re-op needed!
best way to begin a workup for an incidental finding of an adnexal mass
transvaginal ultrasound
BV vs T. vaginalis vs. candida
Trich
- inflammation
- pruritus
- white SMELLY discharge
BV
- no inflammation
Candida
- thick discharge, white
Tx vaginismus
relaxation
Kegels
Insertion of dilators, fingers, etc to desensitize
Atrophic vaginitis
usually in post-menopausal fem 2/2 decreased estrogen levels
Tx:
- moisturizers and lubricants
- low dose vaginal estrogen therapy
Young woman p/w breast lump, no obvious signs of malignancy, what do you do next?
Ask to return after menstrual period for reexam - may have shrunk mass
Benign likely if mass shrunk
If not, can do US, FNA, and/or excisional bx
Abdominal pain in young female in middle of her cycle w/ benign hx and clinical exam most likely…
Mittelschmerz (midcycle pain)
Pain lateralizes (unilateral) to ovary that produced mature ovum Sudden onset not too severe pain Nonradiating No N/V/F/C
vs PID which is bilateral
vs ovarian torison which is sudden onset, radiates to groin or back, + N/V, +/- adnexal mass
Copious vaginal d/c
White or yellow
NOT malodorous
No other sx or findings on vaginal exam
PHysiologic leukorrhea
No tx necessary, reassure
What side torsion of ovary more common
Right
2/2 longer length of R utero-ovarian ligament
L rectosigmoid colon occupies space around L ovary
Vaginal bleeding is uncommon!!!!
Physiologic galactorrhea
Usually b/l
Most commonly milky; can be yellow, brown, gray, green
Hyperprolactinemia is most commono cause
Eval with Prolactin, TSH, possible brain MRI
1 cause mucopurulent cervicitis
Chlamydia
