Gynecology - Menses, Reproduction, Infertility Flashcards
Before any phenotypic change of puberty occurs, what happens?
adrenarche occurs with regeneration of the zona reticularis in the adrenal cortex and production of androgens
—> will stimulate the appearance of pubic hair.
The pubertal sequence includes
accelerated growth,
breast development (thelarche)
development of pubic and axillary hair (adrenarche/pubarche),
growth spurt
onset of menstruation (menarche).
Usually in this order
length of time from breast bud development to menstruation is typically
2.5 years.
Adrenarche
6-8 yo —> 13-15 yo
adrenal gland begins regeneration of the zona reticularis –> increased quantities of the androgens dehydroepiandrosterone sulfate (DHEAS), dehydroepiandrosterone (DHEA), and androstenedione.
Gonadarche
starts ~ 8 yo
is independent of adrenarche
pulsatile GnRH secretion from the hypothalamus is increased —> pulsatile secretion of LH and FSH from the anterior pituitary.
Initially, these increases occur mostly during sleep and fail to lead to any phenotypic changes. As a girl enters early puberty, the LH and FSH pulsatility lasts throughout the day, eventually leading to stimulation of the ovary and subsequent estrogen release.
—> results in breast bud development and ability to ovulate
The increased rate of growth during puberty is due to
the direct effect of sex steroids on epiphyseal growth
due to the increased pituitary growth hormone secretion in response to sex steroids
What is first sign of puberty?
Thelarche (breast development)
response to increased estrogen
starts ~ 10 yo
Pubarche
Growth of pubic hair
~11 yo
Then start growing axillary hair
Usually follows thelarche
Response to increased androgens
Menarche
~12-13yo or 2.5 years after breast bud dev
inc estrogen –> endometrial prolif –> menses
adolescent menstrual cycle is usually irregular for the first 1 to 2 years after menarche, reflecting anovulatory cycles. - usually ~ 2 yrs before regular ovulatory cycles are achieved
- Failure to achieve a regular menstrual cycle after this point may represent a reproductive disorder
What can anovulation in ballet dancers or very intense exercisers be due to?
insufficient percentage of body fat that may result in hypothalamic anovulation and amenorrhea.
dec LH and GnRH —-> estrogen deficiency
Precocious puberty
Precocious puberty is defined as pubarche or thelarche before 7 years of age in Caucasian girls and before 6 years of age in African American girls.
Absent or incomplete breast development by the age of 12 years is defined as delayed puberty and also needs further workup.
How long do you have to fertilize when ovulation starts before ovum degenerates?
24 hrs
Perimenopause
- can begin 2 to 8 years prior to menopause
- irregular menstrual cycles and some of the symptoms that are associated with menopause, such as hot flashes, night sweats, and mood swings.
Dec follicular numbers —>
- dec inhibin B secretion from granulosa cells
- FSH rises
- progesterone low
Estradiol is preserved until late perimenopause when FSH and estradiol both fluctuate
Menopause
12 months of amenorrhea after the final menstrual period in the absence of any other pathological or physiological causes
Avg age ~51yo
Will have increase in both FSH and LH…just more FSH
FSH: LH ratio is > 1
Early menopause more common in women with a hx of
cigarette smoking, short menstrual cycles, nulliparity, type 1 diabetes, and family history of early menopause
Menopause characterstics
FSH > 40 IU/L is pneumonic!!!!
FSH will be elevated, estrogen decreased
Sx 2/2 decreased estrogen levels
Flushes, forgetful
Sweats at night, sad, skeletal changes, skin changes, sex dysfunction
HA, heart dz
Insomnia
Urinary sx, urogenital atrophy
Libido decreases
Dx menopause
H&P
FSH
- can be increased or decrease in perimenopausal period
- best in pts w/ combo of amenorrhea/oligomenorrhea + menopausal sx
How long to menopause sx usually last?
1-2 years
Recommendations + Contraindications for Hormone replacement therapy and estrogen replacement therapy
Recs:
- used only for tx of menopausal sx and at lowest effective dose for shortest time period
- use when there are no contraindications and:
- -vasomotor sx that are distressing (night sweats, hot flashes)
- -urogenital atrophy sx that are distressing (vaginal dryness)
Contra:
- chronic liver dz
- preggers
- breast, ovary, uterus cancer
- hx DVT, PE, CVA
- undx vaginal bbleeding
Non-hormonal tx for menopausal sx
Vasomotor sx
- clonidine
- SSRI (paroxetine)
- SNRI (venlafaxine)
- gabapentin
- SERs
Vaginal + urogenital atrophy
- lubricants
- moisturizers
- low dose vaginal estrogen
Osteoporosis
- Ca + vit D
- bisphosphanates
- calcitonin
- raloxifene, tamoxifen
- wt bearing exercise
- DEXA scan at 65 yo
Primary vs secondary amenorrhea
Primary amenorrhea
- is the absence of menarche (fi rst menses) by age 16 or no menstruation by 4 years after thelarche (the onset of breast development).
Secondary amenorrhea
- is the absence of menses for three menstrual cycles or a total of 6 months in women who have previously had normal menstruation.
Primary amenorrhea - categories
OUTFLOW TRACT ANOMALIES Normal - GnRH - LH/FSH - estrogen/progesterone
Imperforate hymen
Transverse vaginal septum
Mullerian agenesis (Mayer-Rokitansky-Kuster-Hauser)
Testicular feminization
END ORGAN DISORDERS
Ovarian failure
- Savage syndrome - ovary fails to respond to FSH and LH
- Turner syndrome
Gonadal agenesis / Swyer syndrome 46 XY
17 a-hydroxylase deficiency
CENTRAL DISORDERS Hypothalamic disorders - Kallmann syndrome - Hand-Schuller-Christian disease - tumor/trauma/sarcoid/TB/irradiation - anorexia - stress - hyperprolactinemia - hypothyroid - rapid severe wt loss - constitutionally delayed puberty
Pituitary disorders
- rare
- usually 2/2 hypothalamic dysfunction
- TB/sarcoid/irradiation/damage from surgery/hemosiderosis
Imperforate hymen
primary amenorrhea
- no canalization of hymen across vaginal introitus
- pelvic pain from accumulation of menses in vaginal vault (hematocolpos)
- tx - surgery
Transverse vaginal septum
primary amenorrhea
- failure of mullerian derived upper vagina to fuse w/ urogenital sinus derived lower vagina
- found at midvagina
- p/w primary amenorrhea w/ cyclic pelvic pain
- PE = bulging septum with hematocolpos
vs imperforate hymen - transverse vaginal septum will have hymenal ring below septum
tx - resect septum
Mullerian agenesis (Mayer-Rokitansky-Kuster-Hauser)
primary amenorrhea
Mullerian agenesis or dysgenesis
+ ovaries
- uterus, tubes, cervix
+/- cyclic pain
vs vaginal atresia - mullerian system is developed but distal vagina is composed of fibrosed tissue
tx - reconstructive surgery
Also look for anomalies in renal system
Can have children in surrogate using her ovaries
Testicular feminization
primary amenorrhea
Phenotypically female 46XY
Absence or defect of testosterone receptor
- but testosterone is produced!
Absence of pubic and axillary hair because no testosterone sensitization
Testes undescended/in labia majora
+ breasts
+ amenorrhea
+ blind pouch vagina
vs mullerian agenesis - mullerian agenesis has normal amounts of pubic hair
Tx
- gonadectomy after complete puberty to avoid risk of testicular carcionma
Ovarian failure - lab characteristics
Primary amenorrhea - ovarian failure
Hypergonadotropic hypogonadism High - GnRH - FSH - LH
Low
- estrogen
Savage syndrome
Primary amenorrhea - ovarian failure
Ovaries can’t respond to FSH and LSH 2/2 receptor defect
Turner syndrome
Primary amenorrhea - ovarian failure
Ovaries undergo rapid atresia
17-a-hydroxylase deficiency
Primary amenorrhea - ovarian failure
Defect in enzymes (17-a-hydroxylase) involved in testicular steroid production –> no testosterone!
But MIF still made –> NO female internal repro organs
+ phenotypically female
- breasts
Gonadal agenesis / Swyer syndrome 46 XY
Congenital absence of testes in XY male
LIke ovarian agenesis
MIF not released because testes never develop
+ internal and external female genitalia
- breasts 2/2 no estrogen
Kallmann syndrome
Primary amenorrhea
HYPOgonadotropic HYPOgonadism
Congenital absence of GnRH
- neurons disrupted in travel from olfactory placode –> hypothalamus
Secondary amenorrhea - categories
Most common cause is preggers
Anatomic abnormalities
- Asherman syndrome
- cervical stenosis
Ovarian dysfunction
- ovarian failure (torsion, radiation, chemo, idiopathic)
- PCOS
Prolactinoma + hyperprolactinemia
- primary hypothyroidism (increased TSH and TRH —> cause hyperprolactinemia)
- D anatagonists
- TCAs
- estrogen
- MAOIs
- opiates
- pituitary adenoma
- empty sella syndrome
- preggers
- breastfeeding
CNS or hypothalamic disorders
- disruption of HPA
- stress
- exercise
- anorexia
- wt loss
- Kallmann
- Sheehan syndrome
Asherman syndrome
presence of intrauterine synechiae or adhesions, usually secondary to intrauterine surgery or infection
Premature ovarian failure
anytime menopause occurs w/o another etiology before age 35
FSH elevation + >= 3 months of amenorrhea in woman under age 40 yo
PCOS
Chronic anovulation –> increased estrogen + androgen
Increased androgens from ovaries and adrenals
- causes increased estrogen conversion in adipose tissue
- causes decreased SHBG so increased free testosterone
Increased estrogen from increased androgen
- increased LH: FSH ratio –> atypical follicular dev –> anovulation –> increased androgen production –> ongoing cycle!!
What is first test for workup of secondary amenorrhea
B-hCG to r/o pregnancy
Will later get TSH, prolactin
Whcan can you tx macroadenomas/microadenomas with to resume ovulation?
Bromocriptine
In the absence of breasts and presence of a uterus, what will differentiate between hypergonadotropic and hypogonadotropic hypogonadism?
FSH
Tx secondary amenorrhea not 2/2 hyperprolactinemia
Clomiphene
Gonadotropins
Primary dysmenorrhea
Idiopathic menstrual pain w/o ID pathology
Usually happens < 20 yo
Poss 2/2 increased levels of endometrial prostaglandin production
Tx:
- NSAIDs
- COX2 inhibitors
- OCPs (poss work b/c stop ovulation or decrease endometrial prolif –> dec prostaglandin production)
- heating pads, exercise, massage
Secondary dysmenorrhea
Menstrual pain 2/2 identifiable cause
Endometriosis Adenomysosis Uterine fibroids Cervical stenosis Pelvic adhesions
Cervical stenosis - tx
Dilation of cervix
- surgical
- laminaria (in office)
Preggers w/ vag delivery usually leads to permanent cure
Pelvic adhesions - tx
can’t see on MRI, CT, US
Laparoscopy
NSAIDs
Premenstrual syndrome & Premenstrual dysphoric disorder (rare)
Pathophys
- poss 2/2 serotonin + cyclic changes in ovarian steroids
- some say nl estrogen + progesterone but have abnl response to normal hormone changes
Tx PMS, PMDD
SSRIs (fluoxetine)
SNRI (venlafaxine)
Benzos (alprazolam)
Leuprolide
Danazol
Spironolactone
Contraceptives DO NOT help much EXCEPT Yaz
- Mild symptoms of PMS often improve by suppressing the hypothalamic-pituitary-ovarian axis with oral contraceptive pills.
Carbs
Vitamins A, E and B6
Normal menstrual cycle/ bleeding
q28 days
3-5 days
30-50 mL blood loss
Menorrhagia
Regularly timed menses HEAVY flow (men are heavy!)
Usually 2/2
- fibroids
- adenomyosis
- endometrial polyps
Hypomenorrhea
Regular timed menses
LIGHT amt of flow
Usually 2/2 hypogonadotroic hypogonadism
- anorexia
- athletes
Asherman’s also anotehr cause
OCPs can cause
Metrorrhagia
Bleeding occurs between regular menses
Usually 2/2
- cervical lesions (polyps, carcionma)
- endometrial polyps
Menometorrhagia
LOTS of bleeding at irregular intervals
2/2
- fibroids
- adenomyosis
- endometrial polyps
Oligomenorrhea
Periods > 35 days apart
Most often 2/2
- PCOS
- chronic anovulation
- preggers
Consider thyroid dz!
Polymenorrhea
Frequent periods
< 21 days apart
Usually caused by anovulation
Anovulation
An anovulatory cycle is a menstrual cycle during which the ovaries do not release an oocyte
Can be anovulatory 2/2 too little estrogen (exercise)
Can have too much estrogen like in PCOS
Can have not enough progesterone being produced, but ok estrogen. FSH and LH ok too. This is in obesity.
Amenorrhea
absence of a menstrual period in a woman of reproductive age
Lab evals of dysmenorrhea
Light or skipped cycles
- preggers test
- TSH
- PRL
- FSH
Heavy, frequent, or prolonged cycles
- preggers test
- TSH
- CBC
- clotting disoder labs
Who should get endometrial bx?
Woman > 40 with abnormal uterine bleeding
Obese pts w/ prolonged oligomenorrhea
How to distinguish adenomyosis from uterine fibroids?
MRI
Both have similar presentation
Adenomyosis typically features globular uterus < 12 weeks size
vs
Fibroids have irregular enlargement with variable sized uterus 8wks-35 wks or more
Fibroids tend to present w/ sx of mass effect (constipation, urinary freq) vs adenomyosis have pelvic pain more often
Tx endometrial hyperplasia
Progestin therapy
D&C
hysterectomy
Dysfunctional uterine bleeding
Idiopathic/heavy bleeding not able to be attributed to another cause after full eval
Dx of exclusion
Most are anovulatory
Tx DUB
IV estrogen to stop acute hemorrhage
High dose oral estrogens can also control bleeding
Chronic
- NSAIDs
- OCPs
- D&C
- hysterectomy
Post menopausal bleeding
Postmenopausal bleeding, then, is any vaginal bleeding that occurs more than 12 months after the last menstrual period.
1 cause PMB
endometrial/vaginal atrophy
- thin mucosa easily traumatized –> more likely to bleed
Other causes:
- hyperplasia
- cancer
- exogenous hormones
Eval post menopausal bleeding with
Endometrial bx
Pelvic exam
Pap smear _ high risk HPV screen
Pelvic US - eval endometrial striped and uterine cavity
- endometrial stripe should be thin and < 4mm in postmenopausal
- bx if > 4 mm
Hysteroscopy
D&C is therapeutic and dx
How good is lactational amenorrhea for birth control?
15-55% become preggers
50% of mothers will begin to ovulate between 6-12 mo after delivery, even while BF
Return of ovulation happens BEFORE return of menstruation
How long do you leave the diaphragm + spermicide in after intercourse?
6-8 hrs
+ more spermicide if more sex desired after first sex act
1 cause of failure for cervical cap
Dislodgement
Do spermacides protect against STIs?
NO!
How do IUDs work?
Mirena
- progesterone in this thickens cervical mucus + atrophies the endometrium to prevent implantation
Copper
- hampers sperm motility + capitation so rarely reach fallopian tube
THEY DO NOT PREVENT OVULATION!
Absolute contraindications for IUDs
Relative contraindications
Absolute
- known/suspected preggers
- undx vaginal bleeding that is abnl
- acute cervical, uterine, or salpingeal infection
- Cu allergy
- Wilson’s disease (paragard only)
- Current breast cancer (for Mirena only)
Relative
- Prior ectopic
- Hx STIs in past 3 mo
- Uterine anomaly
- fibroid distorting uterine cavity
- menorrhagia or dysmenorrhea (paragard only)
- STI
How long can you use Paragard and Mirena?
Paragard - 10 yrs
Mirena - 5 yrs
Abx lowering effectiveness of pill
There is only 1 - Rifampin!
Meds that reduce efficacy of oral contraceptives
barbituates Carbamazepine Griseofulvin Phenytoin Rifampin St. Johns wort Topiramate
Complications assoc w/ oral contraceptives
DVT PE CVA MI HTN
Cholelithiasis / Cholecystitis
Benign liver adenoma
Cervical adenocarcionma
Retinal thrombosis
Absolute Contraindications of OCP
Smokers > 35 yo smoking > 15 cigs/day
- progestins raise LDL and lower HDL
- estrogens do the opposite! increase HDL and lower LDL
Thomboembolism PE CAD CVA Breast/endometrial ca Abnl liver function Known/suspected preggers Severe hypercholesterolemia Severe hypertriglyceridemia
Ortho Evra has a decreased effectiveness in..
Overweight women > 198 lbs
This is the patch
1 side effect of Depo-Provera (injectable)
Irregular menstrual bleeding
Can also get a REVERSIBLE decrease in bone mineralization
What can progestin contraceptives lower the risk of?
Endometrial ca
PID
Plan B is
Progestin only pill
Most effective form of emergency contraception
Cu IUD
Ulipristal (Ella, EllaOne)
is a derivative of 19-norprogesterone, and acts as a selective progesterone receptor modulator (SPRM) with agonist/antagonist effects at progesterone receptor sites.
Its primary mechanism of action is to delay ovulation (follicular rupture) and inhibit implantation into the endometrial lining.
Termination of Pregnancy options - 1st trimester
Suction curettage
Manual vacuum aspiration
Nonsurgical med abortion
- mifepristone + misoprostol
- MTX + misoprostol
Termination of Pregnancy options - 2nd trimester
D&E
Med induction of labor
High dose oxytocin
Intra-amniotic installation agents
Prostaglandins
What must you always do before an induced abortion?
Rh status
+ RhoGAM to all Rh negative
What should you always do after evacuate products of conception before 6 weeks?
- send to path
- float in NS to make sure there are villi. If no villi, rule out ectopic, GTD, ongoing preggers
Mifepristone
- synthetic progesterone receptor antagonist that binds to
progesterone receptors in the uterus, thus blocking the stimulatory effects of progesterone on endometrial growth. - disrupts the pregnancy by making the endometrial lining unsuitable to sustain the pregnancy.
- can be used up to 63 days from the last menstrual period
- more effective when used with misoprostol (both together are gold std for med abortion)
Methotrexate
- dihydrofolate reductase inhibitor that works by interfering with DNA synthesis
- prevents placental villi proliferation
- use is off label
- use within 49 days of LMP
- use with misoprostol as well
Failed medical abortions require
Suction D&C
When a second trimester termination is necessary, what is the most common and safest method of termination of pregnancy?
D&E
- This method of termination is very similar to first trimester D&C
except that wider cervical dilation is required. - f/u with US to make sure all products evacuated
Induction of labor
- uses cervical ripening agents, amniotomy, and high-dose IV oxytocin infusion.
- Vaginal or oral prostaglandins (prostaglandin E2, misoprostol) can be used to ripen the cervix and augment labor in second trimester termination
- Induction of labor is a longer process than D&E. It requires an inpatient admission and can potentially become a multiday process.
- However, induction of labor allows for the potential delivery of an intact fetus
Infertility
- Infertility is defined as the failure of a couple to conceive after 12 months of unprotected sex
- If the female partner is 35 year of age or older, evaluation should be initiated after 6 months of unprotected sex
Causes of female infertility:
the most common identifiable female factors were ovulatory disorders (32%), fallopian tube abnormalities including pelvic adhesions (34%), and endometriosis (15%).
The most common ovulatory disorders that lead to infertility are
PCOS and advanced maternal age
The primary cause of tubal factor infertility is
pelvic inflammatory disease
Clomiphene citrate challenge test (CCCT)
clomiphine citrate = Partial agonist at estrogen receptors in hypothalamus.
Prevents normal feedback inhibition and increase release of LH and FSH from pituitary, which stimulates ovulation.
CCCT can test for decreased ovarian reserve
- small elevations in FSH levels correlate with decreased
fecundity (ability to reproduce).
Not used as much anymore
Measurement of a Day 3 FSH level
Fertility test
good ovarian reserve will make enough ovarian hormone early in the menstrual cycle to provide inhibition of FSH, thus keeping it at a low level.
Measurement of the Day 3 estradiol level
Fertility test
may be indicative of premature follicle recruitment that can occur in women with poor ovarian reserve
- higher Day 3 estradiol level is suggestive of diminished reserve
- lower level is suggestive of adequate ovarian capacity.
Antral follicle count (AFC)
assess ovarian reserve
US test
- measures the number of antral follicles (2 to 10 mm in
diameter) present between Days 2 and 4 of the menstrual cycle.
- presence of 4 to 10 antral follicles is a sign of good
ovarian reserve
Measurement of anti-Mullerian hormone (AMH)
used in predicting ovarian reserve.
measurement of AMH from the primordial follicle pool.
When the pool is robust, a high level of AMH is detected.
As women age and the pool declines, a lower amount is found
Tx PCOS
Clomiphine
Letrozole (aromatase inhibitor)
Pulsatile GnRH
Metformin
- best in PCOS for insulin resistance
- helps prevent DM 2
- helps lose weight
- helps induce ovulation
- modest effect in suppressing androgen production
For patients with endometriosis, fertility rates can be improved by
surgical ligation of periadnexal adhesions during
laparoscopy or laparotomy with excision, coagulation, vaporization, or fulguration of endometrial implants
Meds don’t help!
1st line for infertility of unknown cause
clomiphene citrate +/- Intrauterine insemination
Hirsutism
= increase in terminal hair along body
Virilization
dev of male features like clitoromegaly, breast atrophy
What is a marker for elevated adrenal androgen production?
DHEAS
In the ovary, what increase appears to lead to excess androgen production?
LH or LH:FSH ratio
Adrenal disorders leading to virilization
Cushings
CAH
Cushings syndrome
- most common cause is due to cushings disease caused by pituitary adenoma hypersecreting ACTH
- can also be due to paraneoplastic secretion, adrenal gland tumors
Dx
- use dex suppression test to dx.
- also can use am cortisol
CAH - what do you do if you suspect this?
get 17-hydroxyprogesterone (OHP) because 21-a-hydroxylase deficiency is most common etiology.
Dx confirmed with ACTH stimulation test.
- Marked increase in 17OHP indicates CAH.
Ovarian disorders leading to virilization
Nonneoplastic
- PCOS
- Theca lutein cysts
- stromal hyperplasia and hyper thecosis
Neoplastic
- Sertoli-Leydig cell tumors (arrhenoblastoma), granulosa-theca cell tumors, hilar (Leydig) cell tumors, and germ cell tumors (gonadoblastomas)
- luteoma
PCOS
- characteristics
- dx
- Hirsutism, virilization, anovulation, amenorrhea, and obesity, and DM2
- increased LH stimulation causes cystic changes in ovaries and increased ovarian androgen secretion
Dx
- testosterone level
- LH:FSH level. DO NOT DO ONLY ONE (LH or FSH) - will not help
Theca-Lutein cysts
- theca cells stim by LH of the ovary are stimulated by LH to produce androstenedione and testosterone.
- androgens are normally shunted to the granulosa cells for aromatization to estrone and estradiol.
- Theca lutein cysts produce an excess amount of androgens that are secreted into the circulation.
- These cysts may be present in either normal or molar pregnancy
- Diagnosis is made by ovarian biopsy
Stromal hyperplasia and hyperthecosis
- Stromal hyperplasia is common between ages 50 and 70 and can cause hirsutism. The ovaries are uniformly enlarged.
- Stromal hyperthecosis is characterized by foci of utilization within the hyperplastic stroma
Luteoma
a benign tumor in preggers that grows in response to hCG.
This tumor can result in high levels of testosterone and androstenedione and virilization in 25% of patients.
Usually resolve in the postpartum period
Drugs leading to virilization
Androgens and corticosteroids decrease SHBG, leaving a greater percentage of free testosterone circulating.
Minoxidil
Phenytoin
Diazoxide
cyclosporin
Idiopathic Hirsutism - suspected casue?
cause could be increased periph androgen production due to elevated 5a-reductase activity at the level of the skin and hair follicles.
What skin condition is often associated with PCOS?
Acanthosis nigricans
Dx PCOS
RIsks
2/3 of the following:
- secondary amenorrhea/oligomenorrhea
- evidence of hyperandrogenism
- evidence of polycystic ovaries on US (classic string of pearls appearance)
Risk of developing:
- dyslipidemia
- insulin resistance
- type 2 DM
- –> get 2hr OGTT to ID impaired glucose tolerance
Tx virilization
- adrenal nonneoplastic
- ovarian nonneoplastic
adrenal nonneoplastic
- prednisone
- Finasteride
- Spironolactone
Ovarian nonneoplastic
- oral contraceptives
- progesterone
- GnRH agonist + estrogen (will get hypo estrogen with GnRH agonist)
What day do you measure progesterone to determine if ovulating?
Day 21
Tubal ligation has not been shown to reduce the risk of
What does it reduce the risk of?
breast, cervical, or endometrial cancers
NO decrease in menstrual blood flow in women who have undergone a tubal ligation.
There is a slight reduction in the risk of ovarian cancer, but the mechanism is not yet fully understood.
Levonogesterol iud is protective against
endometrial cancer because it releases progesterone
The patch has comparable efficiency to the pill in comparative clinical trials, although it has more consistent use. It has a significantly higher failure rate when used in women
who weigh more than 198 pounds.
Formerly pregnant s/p abortion
She has fever and bleeding with a dilated cervix
What is going on?
septic abortion
What is associated with recurrent pregnancy loss?
Workup?
What is definition of multiple pregnancy loss?
Tx?
Antiphosphospholipid antibodies are associated with recurrent pregnancy loss.
Workup:
- anticardiolipin and beta-2 glycoprotein antibody status
- PTT
- Russell viper venom time.
recurrent pregnancy loss = > two consecutive or > three spontaneous losses before 20 weeks gestation.
Tx with heparin and Asa during preggers
Med vs surgical abortion - which has higher blood loss?
Medical abortion is associated with higher blood loss than surgical abortion
vulvovaginal pruritus and erythema with or without associated vaginal discharge
Vulvovaginal candidiasis
Tx:
short-course topical Azole formulations (1-3 days)
Vulvar vestibulitis syndrome
- severe pain on vestibular touch or attempted vaginal entry,
- tenderness to pressure and erythema of various degrees.
Symptoms often have an abrupt onset and are described as a sharp, burning and rawness sensation.
Women may experience pain with tampon insertion, biking or wearing tight pants, and avoid intercourse because of marked introital dyspareunia.
Often, a primary or inciting event cannot be determined.
Tx: TCA pelvic floor rehabilitation biofeedback topical anesthetics.
Surgery with vestibulectomy is recommended for patients who do not respond to standard therapies and are unable to tolerate intercourse.
Noonan’s syndrome
short stature, webbed neck, heart defects, abnormal faces delayed puberty.
Individuals with Noonan’s syndrome have a normal karyotype.
VS TURNERS
failure to establish secondary sexual characteristics,
short stature
characteristic physical features: pterygium colli, shield chest and cubitus valgus.
McCune Albright Syndrome is characterized by
premature menses before breast and pubic hair development.
True precocious puberty is manifested by
premature secretion of GnRH hormone in a pulsatile manner.
Tx:
GnRH agonist to suppress pituitary production of follicular-stimulating hormone and luteinizing hormone.
Observation is acceptable if the precocious puberty is within a few months of the routinely expected puberty.
The process should be treated if the bone age or puberty is advanced by several years.
Threatened abortions vs missed abortions
Threatened abortion:
vaginal bleeding,
a positive pregnancy test
a cervical os closed or uneffaced,
Missed abortion:
retention of a nonviable intrauterine pregnancy for an extended period of time (i.e. dead fetus or blighted ovum).
Lots of hair loss during pregnancy - is this of concern?
High estrogen levels in pregnancy increase the synchrony of hair growth.
Therefore, hair grows in the same phase and is shed at the same time.
Occasionally, this can result in significant postpartum hair loss.
In the non-pregnant state, asynchronous hair growth occurs such that a portion of hair is in one of the three hair growth cycles at all times
Hyperthecosis
is a more severe form of polycystic ovarian syndrome (PCOS).
It is associated with virilization due to the high androstenedione production and testosterone levels.
In addition to temporal balding, other signs of virilization include clitoral enlargement and deepening of the voice.
Hyperthecosis is more difficult to treat with oral contraceptive therapy.
It is also more challenging to achieve successful ovulation induction
Danazol
is primarily used for the treatment of endometriosis
may actually worsen hirsutism and acne
Effect of estrogen on endometrium
Stimulation of rapid endometrial growth,
conversion of proliferative to secretory endometrium,
regeneration of the functional layer
Patients with anovulatory bleeding have predominantly
proliferative endometrium from unopposed stimulation by estrogen.
How do progestins effect anovulatory bleeding?
Progestins inhibit further endometrial growth, converting the proliferative to secretory endometrium.
Withdrawal of the progestin then mimics the effect of the involution of the corpus luteum, creating a normal sloughing of the endometrium.
Leiomyomas typically present in women in their
30s and 40s
Management of an endometrial polyp includes the following:
observation,
- Observation is not recommended if the polyp is > 1.5 cm.
medical management with progestin,
curettage,
surgical removal (polypectomy) via hysteroscopy,
hysterectomy.
Histo of endometriosis
Endometrial glands/stroma and hemosiderin-laden macrophages
Adenomyosis
=presence of endometrial glands and supporting tissues in the muscle of the uterus
The gland tissue grows during the menstrual cycle and, at menses, tries to slough, but cannot escape the uterine muscle and flow out of the cervix as part of normal menses.
This trapping of the blood and tissue causes uterine pain in the form of monthly menstrual cramps.
enlarged, soft, boggy uterus
Hysterectomy is nearly 80% effective in eliminating pain and abnormal bleeding, if she is willing to undergo surgery
GnRH agents are the first choice for medical therapy for the pain, but the problem is that the adenomyosis seems to recur after discontinuing the therapy
Risk factors for PMS include
a family history of premenstrual syndrome (PMS)
Vitamin B6, calcium, or magnesium deficiency
Endometrial bx indicated for evaluating abnormal uterine bleeding in
Women >=45 and all postmenopausal women
Women < 45 with persistent sx or risk factors for endometrial cancer (obesity, DM, unopposed estrogen, PCOS, early menarche, late menopause)
Unopposed estrogen exposure
Prolonged amenorrhea w/ anovulation
Type of fibroid often preventing pregnancy implant
Submucosal
Gonadotropin-dependent precocious puberty - signs
Dx?
Can have elevated LH levels
If have high LH levels —> need MRI of brain with contrast
Most cases GDPP are idiopathic
Tx idiopathic GDPP
GnRH agonist therapy to prevent premature epiphyseal plate fusion and max adult height potential
Isolated amenorrhea w/ well developed secondary sexual characteristics can be normal until
16 yo
Amenorrhea + absent secondary sexual characteristics, work up should not be delayed beyond age
14 yo
Oder FSH if no breast development
- if decreased —> pituitary MRI
- if increased —> karyotyping
Precocious puberty causes
Central
- result of early activation of HPO axis
- FSH and LH levels HIGH
- all should get brain CT or MRI
- Tx GnRH agonist
Peripheral
- FSH and LH LOW
- ovarian cysts producing estrogen, excess periph conversion of testosterone —> estrogen, CAH
Characteristics of steroid induced acne
Monomorphorous pink papules
Absence of comedones
Female phenotype + lack normal uterus and vagina + primary amenorrhea
differential?
how do you tell apart?
Mullerian agenesis
AIS
5-a reductase deficiency
Genotype tells apart some!
XX for mullerian agenesis
XY for AIS adn 5-a reductase deficiency
5-a-reductase deficiency show virilization at puberty
Anovulation in women shortly after menarche 2/2
HPO axis immaturity
- does not make adequate quantities of LH and FSH to induce ovulation
Endometrium builds up under influence of estrogen. Without progesterone, cue to slough endometrium is lacking and menstrual like bleeding occurs due to estrogen breakthrough bleeding
Turner syndrome hormone values
Low
- estrogen
- testosterone
- inhibin
High
- FSH
Aromatase deficiency
Can’t convert androgen –> estrogens as well
XX
Nl internal genitalia
Ambiguous external genitalia (clitoromegaly)
High
- FSH
- LH
- testosterone
- androstenedione
Low
- estradiol
- estrone
Polycystic ovaries
In utero
- placenta can’t make estrogens —> masculinzation of mom resolving after delivery
Serum progesterone measurement to detect ovulation is peformed in
mid luteal phase
Repro organs in Tfem don’t develop because
Testes still present and secrete mullerian inhibiting factor
Association between hypothyroidism adn hyperprolactinemia
Serotonin and TRH ——–> Prolactin
- higher TRH in hypothyroidism may lead to increased prolactin (galactorrhea) and amenorrhea
Dopamine —–| Prolactin
Med tx options for acute abnormal uterine bleeding
High dose IV or oral estrogen
High dose combo OCP
High dose progestin pills
Tranexamic acid
Raloxifene
SERM
Antagonist
- breast
- vagina
Agonist
- bone
1st line to prevent osteoporosis
Increases risk of VTE
Mucus in menstrual cycle phases
Ovulatory phase
- profuse
- clear
- thin
- pH 6.5 (more basic_ to allow sperm to come in
Follicular, luteal phase
- thick
- acidic
- no penetration by sperm
