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OB/GYN > Gynecology - Menses, Reproduction, Infertility > Flashcards

Gynecology - Menses, Reproduction, Infertility Flashcards

1
Q

Before any phenotypic change of puberty occurs, what happens?

A

adrenarche occurs with regeneration of the zona reticularis in the adrenal cortex and production of androgens

—> will stimulate the appearance of pubic hair.

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2
Q

The pubertal sequence includes

A

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.

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3
Q

Adrenarche

A

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.

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4
Q

Gonadarche

A

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

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5
Q

The increased rate of growth during puberty is due to

A

the direct effect of sex steroids on epiphyseal growth

due to the increased pituitary growth hormone secretion in response to sex steroids

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6
Q

What is first sign of puberty?

A

Thelarche (breast development)

response to increased estrogen
starts ~ 10 yo

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7
Q

Pubarche

A

Growth of pubic hair

~11 yo

Then start growing axillary hair

Usually follows thelarche

Response to increased androgens

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8
Q

Menarche

A

~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

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9
Q

What can anovulation in ballet dancers or very intense exercisers be due to?

A

insufficient percentage of body fat that may result in hypothalamic anovulation and amenorrhea.

dec LH and GnRH —-> estrogen deficiency

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10
Q

Precocious puberty

A

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.

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11
Q

How long do you have to fertilize when ovulation starts before ovum degenerates?

A

24 hrs

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12
Q

Perimenopause

A
  • 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

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13
Q

Menopause

A

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

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14
Q

Early menopause more common in women with a hx of

A 
cigarette smoking, 
short menstrual cycles, 
nulliparity, 
type 1 diabetes,
and family history of early menopause
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15
Q

Menopause characterstics

A

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

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16
Q

Dx menopause

A

H&P

FSH

  • can be increased or decrease in perimenopausal period
  • best in pts w/ combo of amenorrhea/oligomenorrhea + menopausal sx
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17
Q

How long to menopause sx usually last?

A

1-2 years

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18
Q

Recommendations + Contraindications for Hormone replacement therapy and estrogen replacement therapy

A

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
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19
Q

Non-hormonal tx for menopausal sx

A

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
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20
Q

Primary vs secondary amenorrhea

A

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.

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21
Q

Primary amenorrhea - categories

A 
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
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22
Q

Imperforate hymen

A

primary amenorrhea

  • no canalization of hymen across vaginal introitus
    • pelvic pain from accumulation of menses in vaginal vault (hematocolpos)
  • tx - surgery
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23
Q

Transverse vaginal septum

A

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

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24
Q

Mullerian agenesis (Mayer-Rokitansky-Kuster-Hauser)

A

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

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25
Q

Testicular feminization

A

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

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26
Q

Ovarian failure - lab characteristics

A

Primary amenorrhea - ovarian failure

Hypergonadotropic hypogonadism
High 
- GnRH
- FSH
- LH

Low
- estrogen

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27
Q

Savage syndrome

A

Primary amenorrhea - ovarian failure

Ovaries can’t respond to FSH and LSH 2/2 receptor defect

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28
Q

Turner syndrome

A

Primary amenorrhea - ovarian failure

Ovaries undergo rapid atresia

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29
Q

17-a-hydroxylase deficiency

A

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

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30
Q

Gonadal agenesis / Swyer syndrome 46 XY

A

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

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31
Q

Kallmann syndrome

A

Primary amenorrhea

HYPOgonadotropic HYPOgonadism

Congenital absence of GnRH
- neurons disrupted in travel from olfactory placode –> hypothalamus

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32
Q

Secondary amenorrhea - categories

A

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
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33
Q

Asherman syndrome

A

presence of intrauterine synechiae or adhesions, usually secondary to intrauterine surgery or infection

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34
Q

Premature ovarian failure

A

anytime menopause occurs w/o another etiology before age 35

FSH elevation + >= 3 months of amenorrhea in woman under age 40 yo

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35
Q

PCOS

A

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!!

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36
Q

What is first test for workup of secondary amenorrhea

A

B-hCG to r/o pregnancy

Will later get TSH, prolactin

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37
Q

Whcan can you tx macroadenomas/microadenomas with to resume ovulation?

A

Bromocriptine

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38
Q

In the absence of breasts and presence of a uterus, what will differentiate between hypergonadotropic and hypogonadotropic hypogonadism?

A

FSH

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39
Q

Tx secondary amenorrhea not 2/2 hyperprolactinemia

A

Clomiphene

Gonadotropins

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40
Q

Primary dysmenorrhea

A

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
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41
Q

Secondary dysmenorrhea

A

Menstrual pain 2/2 identifiable cause

Endometriosis
Adenomysosis
Uterine fibroids
Cervical stenosis
Pelvic adhesions
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42
Q

Cervical stenosis - tx

A

Dilation of cervix

  • surgical
  • laminaria (in office)

Preggers w/ vag delivery usually leads to permanent cure

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43
Q

Pelvic adhesions - tx

A

can’t see on MRI, CT, US

Laparoscopy
NSAIDs

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44
Q

Premenstrual syndrome & Premenstrual dysphoric disorder (rare)

A

Pathophys

  • poss 2/2 serotonin + cyclic changes in ovarian steroids
  • some say nl estrogen + progesterone but have abnl response to normal hormone changes
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45
Q

Tx PMS, PMDD

A

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

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46
Q

Normal menstrual cycle/ bleeding

A

q28 days

3-5 days

30-50 mL blood loss

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47
Q

Menorrhagia

A 
Regularly timed menses
HEAVY flow (men are heavy!)

Usually 2/2

  • fibroids
  • adenomyosis
  • endometrial polyps
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48
Q

Hypomenorrhea

A

Regular timed menses
LIGHT amt of flow

Usually 2/2 hypogonadotroic hypogonadism

  • anorexia
  • athletes

Asherman’s also anotehr cause
OCPs can cause

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49
Q

Metrorrhagia

A

Bleeding occurs between regular menses

Usually 2/2

  • cervical lesions (polyps, carcionma)
  • endometrial polyps
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50
Q

Menometorrhagia

A

LOTS of bleeding at irregular intervals

2/2

  • fibroids
  • adenomyosis
  • endometrial polyps
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51
Q

Oligomenorrhea

A

Periods > 35 days apart

Most often 2/2

  • PCOS
  • chronic anovulation
  • preggers

Consider thyroid dz!

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52
Q

Polymenorrhea

A

Frequent periods

< 21 days apart

Usually caused by anovulation

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53
Q

Anovulation

A

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.

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54
Q

Amenorrhea

A

absence of a menstrual period in a woman of reproductive age

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55
Q

Lab evals of dysmenorrhea

A

Light or skipped cycles

  • preggers test
  • TSH
  • PRL
  • FSH

Heavy, frequent, or prolonged cycles

  • preggers test
  • TSH
  • CBC
  • clotting disoder labs
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56
Q

Who should get endometrial bx?

A

Woman > 40 with abnormal uterine bleeding

Obese pts w/ prolonged oligomenorrhea

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57
Q

How to distinguish adenomyosis from uterine fibroids?

A

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

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58
Q

Tx endometrial hyperplasia

A

Progestin therapy

D&C

hysterectomy

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59
Q

Dysfunctional uterine bleeding

A

Idiopathic/heavy bleeding not able to be attributed to another cause after full eval

Dx of exclusion

Most are anovulatory

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60
Q

Tx DUB

A

IV estrogen to stop acute hemorrhage

High dose oral estrogens can also control bleeding

Chronic

  • NSAIDs
  • OCPs
  • D&C
  • hysterectomy
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61
Q

Post menopausal bleeding

A

Postmenopausal bleeding, then, is any vaginal bleeding that occurs more than 12 months after the last menstrual period.

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62
Q

1 cause PMB

A

endometrial/vaginal atrophy
- thin mucosa easily traumatized –> more likely to bleed

Other causes:

  • hyperplasia
  • cancer
  • exogenous hormones
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63
Q

Eval post menopausal bleeding with

A

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

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64
Q

How good is lactational amenorrhea for birth control?

A

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

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65
Q

How long do you leave the diaphragm + spermicide in after intercourse?

A

6-8 hrs

+ more spermicide if more sex desired after first sex act

66
Q

1 cause of failure for cervical cap

A

Dislodgement

67
Q

Do spermacides protect against STIs?

A

NO!

68
Q

How do IUDs work?

A

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!

69
Q

Absolute contraindications for IUDs

Relative contraindications

A

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
70
Q

How long can you use Paragard and Mirena?

A

Paragard - 10 yrs

Mirena - 5 yrs

71
Q

Abx lowering effectiveness of pill

A

There is only 1 - Rifampin!

72
Q

Meds that reduce efficacy of oral contraceptives

A 
barbituates
Carbamazepine
Griseofulvin
Phenytoin
Rifampin
St. Johns wort
Topiramate
73
Q

Complications assoc w/ oral contraceptives

A 
DVT
PE
CVA
MI
HTN

Cholelithiasis / Cholecystitis
Benign liver adenoma
Cervical adenocarcionma
Retinal thrombosis

74
Q

Absolute Contraindications of OCP

A

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
75
Q

Ortho Evra has a decreased effectiveness in..

A

Overweight women > 198 lbs

This is the patch

76
Q

1 side effect of Depo-Provera (injectable)

A

Irregular menstrual bleeding

Can also get a REVERSIBLE decrease in bone mineralization

77
Q

What can progestin contraceptives lower the risk of?

A

Endometrial ca

PID

78
Q

Plan B is

A

Progestin only pill

79
Q

Most effective form of emergency contraception

A

Cu IUD

80
Q

Ulipristal (Ella, EllaOne)

A

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.

81
Q

Termination of Pregnancy options - 1st trimester

A

Suction curettage

Manual vacuum aspiration

Nonsurgical med abortion

  • mifepristone + misoprostol
  • MTX + misoprostol
82
Q

Termination of Pregnancy options - 2nd trimester

A

D&E

Med induction of labor

High dose oxytocin

Intra-amniotic installation agents

Prostaglandins

83
Q

What must you always do before an induced abortion?

A

Rh status

+ RhoGAM to all Rh negative

84
Q

What should you always do after evacuate products of conception before 6 weeks?

A
  • send to path

- float in NS to make sure there are villi. If no villi, rule out ectopic, GTD, ongoing preggers

85
Q

Mifepristone

A
  • 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)
86
Q

Methotrexate

A
  • 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
87
Q

Failed medical abortions require

A

Suction D&C

88
Q

When a second trimester termination is necessary, what is the most common and safest method of termination of pregnancy?

A

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
89
Q

Induction of labor

A
  • 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
90
Q

Infertility

A
  • 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
91
Q

Causes of female infertility:

A

the most common identifiable female factors were ovulatory disorders (32%), fallopian tube abnormalities including pelvic adhesions (34%), and endometriosis (15%).

92
Q

The most common ovulatory disorders that lead to infertility are

A

PCOS and advanced maternal age

93
Q

The primary cause of tubal factor infertility is

A

pelvic inflammatory disease

94
Q

Clomiphene citrate challenge test (CCCT)

A

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

95
Q

Measurement of a Day 3 FSH level

A

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.

96
Q

Measurement of the Day 3 estradiol level

A

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.
97
Q

Antral follicle count (AFC)

A

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

98
Q

Measurement of anti-Mullerian hormone (AMH)

A

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

99
Q

Tx PCOS

A

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
100
Q

For patients with endometriosis, fertility rates can be improved by

A

surgical ligation of periadnexal adhesions during
laparoscopy or laparotomy with excision, coagulation, vaporization, or fulguration of endometrial implants

Meds don’t help!

101
Q

1st line for infertility of unknown cause

A

clomiphene citrate +/- Intrauterine insemination

102
Q

Hirsutism

A

= increase in terminal hair along body

103
Q

Virilization

A

dev of male features like clitoromegaly, breast atrophy

104
Q

What is a marker for elevated adrenal androgen production?

A

DHEAS

105
Q

In the ovary, what increase appears to lead to excess androgen production?

A

LH or LH:FSH ratio

106
Q

Adrenal disorders leading to virilization

A

Cushings

CAH

107
Q

Cushings syndrome

A
  • 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
108
Q

CAH - what do you do if you suspect this?

A

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.

109
Q

Ovarian disorders leading to virilization

A

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
110
Q

PCOS

  • characteristics
  • dx
A
  • 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
111
Q

Theca-Lutein cysts

A
  • 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
112
Q

Stromal hyperplasia and hyperthecosis

A
  • 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
113
Q

Luteoma

A

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

114
Q

Drugs leading to virilization

A

Androgens and corticosteroids decrease SHBG, leaving a greater percentage of free testosterone circulating.

Minoxidil
Phenytoin
Diazoxide
cyclosporin

115
Q

Idiopathic Hirsutism - suspected casue?

A

cause could be increased periph androgen production due to elevated 5a-reductase activity at the level of the skin and hair follicles.

116
Q

What skin condition is often associated with PCOS?

A

Acanthosis nigricans

117
Q

Dx PCOS

RIsks

A

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
118
Q

Tx virilization

  • adrenal nonneoplastic
  • ovarian nonneoplastic
A

adrenal nonneoplastic

  • prednisone
  • Finasteride
  • Spironolactone

Ovarian nonneoplastic

  • oral contraceptives
  • progesterone
  • GnRH agonist + estrogen (will get hypo estrogen with GnRH agonist)
119
Q

What day do you measure progesterone to determine if ovulating?

A

Day 21

120
Q

Tubal ligation has not been shown to reduce the risk of

What does it reduce the risk of?

A

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.

121
Q

Levonogesterol iud is protective against

A

endometrial cancer because it releases progesterone

122
Q

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

A

who weigh more than 198 pounds.

123
Q

Formerly pregnant s/p abortion

She has fever and bleeding with a dilated cervix

What is going on?

A

septic abortion

124
Q

What is associated with recurrent pregnancy loss?

Workup?

What is definition of multiple pregnancy loss?

Tx?

A

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

125
Q

Med vs surgical abortion - which has higher blood loss?

A

Medical abortion is associated with higher blood loss than surgical abortion

126
Q

vulvovaginal pruritus and erythema with or without associated vaginal discharge

A

Vulvovaginal candidiasis

Tx:
short-course topical Azole formulations (1-3 days)

127
Q

Vulvar vestibulitis syndrome

A
  • 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.

128
Q

Noonan’s syndrome

A 
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.

129
Q

McCune Albright Syndrome is characterized by

A

premature menses before breast and pubic hair development.

130
Q

True precocious puberty is manifested by

A

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.

131
Q

Threatened abortions vs missed abortions

A

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).

132
Q

Lots of hair loss during pregnancy - is this of concern?

A

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

133
Q

Hyperthecosis

A

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

134
Q

Danazol

A

is primarily used for the treatment of endometriosis

may actually worsen hirsutism and acne

135
Q

Effect of estrogen on endometrium

A

Stimulation of rapid endometrial growth,

conversion of proliferative to secretory endometrium,

regeneration of the functional layer

136
Q

Patients with anovulatory bleeding have predominantly

A

proliferative endometrium from unopposed stimulation by estrogen.

137
Q

How do progestins effect anovulatory bleeding?

A

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.

138
Q

Leiomyomas typically present in women in their

A

30s and 40s

139
Q

Management of an endometrial polyp includes the following:

A

observation,
- Observation is not recommended if the polyp is > 1.5 cm.

medical management with progestin,

curettage,

surgical removal (polypectomy) via hysteroscopy,

hysterectomy.

140
Q

Histo of endometriosis

A

Endometrial glands/stroma and hemosiderin-laden macrophages

141
Q

Adenomyosis

A

=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

142
Q

Risk factors for PMS include

A

a family history of premenstrual syndrome (PMS)

Vitamin B6, calcium, or magnesium deficiency

143
Q

Endometrial bx indicated for evaluating abnormal uterine bleeding in

A

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

144
Q

Type of fibroid often preventing pregnancy implant

A

Submucosal

145
Q

Gonadotropin-dependent precocious puberty - signs

Dx?

A

Can have elevated LH levels

If have high LH levels —> need MRI of brain with contrast

Most cases GDPP are idiopathic

146
Q

Tx idiopathic GDPP

A

GnRH agonist therapy to prevent premature epiphyseal plate fusion and max adult height potential

147
Q

Isolated amenorrhea w/ well developed secondary sexual characteristics can be normal until

A

16 yo

148
Q

Amenorrhea + absent secondary sexual characteristics, work up should not be delayed beyond age

A

14 yo

Oder FSH if no breast development

  • if decreased —> pituitary MRI
  • if increased —> karyotyping
149
Q

Precocious puberty causes

A

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
150
Q

Characteristics of steroid induced acne

A

Monomorphorous pink papules

Absence of comedones

151
Q

Female phenotype + lack normal uterus and vagina + primary amenorrhea

differential?
how do you tell apart?

A

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

152
Q

Anovulation in women shortly after menarche 2/2

A

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

153
Q

Turner syndrome hormone values

A

Low

  • estrogen
  • testosterone
  • inhibin

High
- FSH

154
Q

Aromatase deficiency

A

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

155
Q

Serum progesterone measurement to detect ovulation is peformed in

A

mid luteal phase

156
Q

Repro organs in Tfem don’t develop because

A

Testes still present and secrete mullerian inhibiting factor

157
Q

Association between hypothyroidism adn hyperprolactinemia

A

Serotonin and TRH ——–> Prolactin
- higher TRH in hypothyroidism may lead to increased prolactin (galactorrhea) and amenorrhea

Dopamine —–| Prolactin

158
Q

Med tx options for acute abnormal uterine bleeding

A

High dose IV or oral estrogen

High dose combo OCP

High dose progestin pills

Tranexamic acid

159
Q

Raloxifene

A

SERM

Antagonist

  • breast
  • vagina

Agonist
- bone

1st line to prevent osteoporosis

Increases risk of VTE

160
Q

Mucus in menstrual cycle phases

A

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

OB/GYN (7 decks)

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