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EOR Exam - Women's Health > Gynecology Part 1 > Flashcards

Gynecology Part 1 Flashcards

1
Q

Define primary and secondary amenorrhea.

A

Prim: No menses by age 14 without other pubertal development or by age 16 with other pubertal development.
Sec: Absent menses for 3 cycles or 6 months in previously menstruating woman.

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2
Q

What is the most common cause of secondary amenorrhea?

A

Pregnancy

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3
Q

List and describe anatomic causes of pathologic amenorrhea.

A

Mullerian Agenesis: congenital absence of all or part of vagina and uterus.
Imperforate Hymen or Transverse Vaginal Septum
Vaginal Atresia: lower vagina fails to develop
Intrauterine Synechiae: AKA Asherman Syndrome - endometrial scarring s/p vigorous uterine curettage
Cervical Stenosis: can be s/p D&C, cone biopsy, infection.

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4
Q

List and describe endocrine causes of pathologic amenorrhea.

A

Hypergonadotropic Hypogonadism: no synthesis of ovarian hormones s/p loss of oocytes before age 40.
Hypogonadotropic Hypogonadism: Dec LH/FSH s/p hypothalamic or pituitary disorder.
Eugonadotropic Hypogonadism: amenorrhea w/o abnormal LH/FSH levels

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5
Q

How is the diagnosis of hypergonadotropic hypogonadism made?

A

Two FSH levels > 40 drawn more than 1 month apart

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6
Q

List some causes of hypergonadotropic hypogonadism.

A

Turner Syndrome, other chromosomal abnormalities, chemotherapy, radiation, infection, autoimmune

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7
Q

What is the treatment of of hypergonadotropic hypogonadism?

A

hormone (estrogen) replacement therapy

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8
Q

List some causes of hypogonadotropic hypogonadism.

A

Hypothalamic: Kallman Syndrome, brain tumor, stress, weight loss. –> dec GnRH = dec FSh and LH
Pituitary: tumor (prolactinoma most common), metastatic tumor, Sheehan’s Syndrome
Chronic Illness: CKD, AIDS, advanced liver disease

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9
Q

What is the treatment of of hypogonadotropic hypogonadism?

A

hormone (estrogen) replacement therapy and/or tumor resection

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10
Q

List some causes of eugonadotropic hypogonadism.

A

PCOS, congenital adrenal hyperplasia, hyperprolactinemia, hypothyroidism

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11
Q

What is the treatment of of eugonadotropic hypogonadism?

A

hormone (estrogen) replacement therapy and treatment of the underlying cause

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12
Q

How is the diagnosis of secondary amenorrhea caused by hypothalamic dysfunction made?

A

Low FSH and LH, low estradiol, normal prolactin

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13
Q

How is the diagnosis of secondary amenorrhea caused by pituitary dysfunction made?

A

Low FSH and LH, high prolactin, tumor visible on imaging

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14
Q

By what mechanism does hyperprolactinemia cause amenorrhea?

A

High prolactin inhibits release of GnRH from hypothalamus causing decreased FSH/LH from pituitary.

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15
Q

Define and describe a progesterone challenge test used to assess the cause of amenorrhea..

A 
Give 10mg medoxyprogesterone (provera) for 10 days.
Withdrawal bleeding (occurs 2-7 days after progesterone withdrawn) indicates estrogen is present and cause is annovulation
No withdrawal bleeding indicates cause is low estrogen or uterine anomaly.
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16
Q

What should be included in the work-up of a patient with amenorrhea?

A 
#1 is pregnancy test
Also pelvic exam (genetic testing if no uterus), TSH, FSH, prolactin (brain MRI if elevated)
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17
Q

Describe the fertility potential in the various causes of amenorrhea.

A

Anatomic: conceive s/p correction of abnormality
Hypergonadotropic: conceive with donor egg and IVF
Hypogonadotropic: Treated with pulsatile GnRH
Eugonadotropic: fertility aid (clomiphene citrate - stimulates release of FSH/LH)

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18
Q

When a patient presenting with amenorrhea also presents with visual field defects and polyuria, what is the likely cause?

A

Hypothalamic-pituitary disease

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19
Q

When a patient presenting with amenorrhea also presents with galactorrhea, what is the likely cause?

A

Hyperprolactinemia

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20
Q

When a patient presenting with amenorrhea also presents with hot flashes and vaginal dryness, what is the likely cause?

A

Estrogen deficiency

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21
Q

What medications are known to cause amenorrhea?

A

OCPs, Danazol (suppresses FSH and LH), metoclopramide

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22
Q

What is the cause of amenorrhea seen in high performance athletes?

A

Suppression of hypothalamic GnRH release

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23
Q

Define and describe lichen sclerosus.

A

Chronic inflammatory dermatosis causing itching, irritation, and dyspareunia (pain during sex). Mostly affects post-menopausal women.

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24
Q

What is the treatment for lichen sclerosus?

A

Clobetasol (topical steroid) 1-2 times per day for 6-12 weeks followed by a maintenance topical steroid.

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25
Q

Define and describe lichen planus?

A

Chronic inflammatory condition affecting nails, scalp, and skin with chronic eruption of shiny purple papules with white striae on the vulva. Can cause vaginal adhesions and scarring over time.

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26
Q

What is the treatment for lichen planus?

A

Clobetasol 1-2 times per day for 6-12 weeks

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27
Q

Define and describe lichen simplex chronicus?

A

Thickened skin with accentuated skin markings s/p chronic itching and scratching.

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28
Q

What is the treatment for lichen simplex chronicus?

A

Medium to high potency topical steroid bid for at least 6 weeks.

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29
Q

Define and describe vulvar psoriasis?

A

Silver-red scaly patches on the genital area

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30
Q

What is the treatment for vulvar psoriasis?

A

Topical steroids and UV light

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31
Q

Describe generalized management of benign epithelial disorders of the vagina and vulva. Also list a a treatment that might be thought to work but is actually not indicated.

A

Treatment: maintain hygiene, loose fitting clothing, unscented detergent and soap, high potency topical steroid (clobetasol).
No role for topical estrogen or progesterone

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32
Q

What is the most common tumor found on the vulva and what is its cause?

A

Epidermal inclusion cysts s/p occlusion of a pilosebaceous duct or hair follicle

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33
Q

Define and describe Fox-Fordyce Disease and Hidradentitis Supparativa.

A

F-F: entrapment of apocrine sweat with resultant inflammation causing itchy, red bumps around hair follicles.
HS: Painful lumps that form under the skin that can burst open or form tunnels under the skin.

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34
Q

Define and describe Skene’s gland cysts

A

Cysts typically caused by blocked glands next to the urethral meatus. Can abscess or cause UTIs.

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35
Q

Define and describe Bartholin’s Duct cysts and abscesses.

A

Blockage of the glands/ducts that secrete mucus to the hymenal ring at the 4 and 8 o’clock positions of the vaginal ring. Treatment may include duct dilation, I&D, or marsupialization (cyst is incised and cyst wall sutured to the vaginal mucosa).

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36
Q

Define and describe lipomas of the vagina and vulva.

A

Soft tumors composed of mature fat cells and fibrous strands. Do not require removal unless large and symptomatic.

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37
Q

Define and describe cherry hemangiomas.

A

Elevated, soft red papules that contain an abnormal proliferation of blood vessels

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38
Q

Define and describe urethral caruncles.

A

Small, red, fleshy tumors found at the distal urethral meatus.

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39
Q

Define the terms menorrhagia, metrorrhagia, polymenorrhea, and oligomenorrhea associated with dysfunctional uterine bleeding.

A

Men: prolonged (7+ days), heavy (80+ ml) uterine bleeding at regular intervals
Met: variable amounts of uterine bleeding at frequent, irregular intervals
Poly: Short intervals (<21 days) of uterine bleeding
Olig: Long (35+ days) intervals of uterine bleeding

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40
Q

Describe the reproductive tract organic causes of dysfunctional uterine bleeding.

A

Uterine lesions: endometrial CA, endometrial hyperplasia, submucosal fibroid, endometrial polyps, endometritis, adenomyosis
Other causes: pregnancy, gestational trophoblastic disease (molar pregnancy, etc.), IUDs, contraception, HRT, psychotropic medications

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41
Q

Describe the systemic disease that can cause dysfunctional uterine bleeding.

A

Hypo-/hyper- thyroidism, cirrhosis, blood disorders (leukemia, Von Willebrand, prothrombin deficiency, etc)

42
Q

Differentiate between hypothyroidism and hyperthyroidism as they relate to dysfunctional uterine bleeding.

A

Hypo: Associated with menorrhagia and metrorrhagia
Hyper: associated with oligomenorrhea and amenorrhea

43
Q

Describe anovulatory causes of dysfunctional uterine bleeding.

A

Unopposed estrogen - continuous proliferation of the endometrium that eventually outgrows its blood supply sloughs off in an irregular pattern

44
Q

Describe ovulatory causes of dysfunctional uterine bleeding.

A

Mid-cycle spotting after LH surge

45
Q

Describe the steps in diagnosis of a patient with dysfunctional uterine bleeding.

A
  1. R/O pregnancy
  2. Medication reconciliation
  3. PE for thyromegaly, hepatomegaly, GU infections, GI problems (hemorrhoids), polyps, and fibroids
  4. Labs - CBC, iron, TSH, coagulation studies
  5. Eval of uterus - endometrial biopsy, hysteroscopy, pelvic US
46
Q

Describe the management options for dysfunctional uterine bleeding.

A

Surgical correction of structural problems, OCP to regularize cycles, IV estrogen for severe acute bleeding, NSAIDs reduce menstrual blood loss.

47
Q

Define dysmenorrhea.

A

Painful menses

48
Q

T/F: Dysmenorrhea is only present in women with irregular mestrual cycles.

A

False: commonly found in those who ovulate regularly

49
Q

Describe the S/S of primary dysmenorrhea.

A

Begins within 6-12 months of menarche. Severe cramps that start with menses and last 2-3 days. Pain may radiate to back or thighs. Also may have HA, nausea, or diarrhea. Normal physical exam.

50
Q

What are the three signs of dysmenorrhea associated with endometriosis.

A
  1. Pain begins prior to menses
  2. Pain not relieved by NSAIDs or OCPs
  3. Often have dyspareunia as well
51
Q

Describe the treatment for dysmenorrhea.

A

NSAIDs are first line. May use OCPs or other contraception. Endometrial resection may also be considered.

52
Q

What conditions may cause secondary dysmenorrhea?

A

Endometriosis, adenomyosis, uterine fibroids

53
Q

Describe the pathophysiology of primary dysmenorrhea.

A

PGs released from the endometrium at the beginning of menses cause intense uterine contractions.

54
Q

Define menopause.

A

Cessation of menstruation for 12 months s/p termination of ovarian follicle development and elevated FSH/LH.

55
Q

When is the averag eonset of menopause and what are the risk factors for early menopause?

A

Avg: age 51

R/F: smoking and hysterectomy

56
Q

Describe changes in serum hormone levels associated with menopause.

A

Elevated: FSH, LH, and estrone
Decrease: estradiol
Normal: TSH and prolactin

57
Q

Describe the pathophysiology of estrogen level changes associated with menopause.

A

Ovaries stop producing estrogen so only source of estrogen is peripheral conversion of androgens. Lack of estrogen causes LH and FSH to rise which causes ovarian stroma to produce androgens (testosterone and androstenedione.

58
Q

Why do women experience weight gain in perimenopausal period starting at about age 35?

A

Thought to be body’s defense mechanism to store as much estrogen as possible - estrogen is fat soluble.

59
Q

List the complications associated with hypoestrogenemia that occurs in menopause.

A

Vasomotor instability: hot flashes (worst in early menopause)
Osteoporosis: weakens bones
Genital atrophy: vaginismus, dysuria, urgency, incontinence
Mood disturbances: fatigue, anxiety, HA, insomnia, depression, irritability

60
Q

Define vaginismus.

A

Spasm of the vaginal muscles when something is entering it. Leads to dyspareunia.

61
Q

List treatment options for the complications of menopause.

A

Vasomotor instability: estrogen+progesterone, clonidine
Osteoporosis: bisphosphonates, Ca supplements
Genital atrophy: topical estrogen (premarin), vaginal ring (estring), lubrication
Mood disturbances: counseling, antidepressants

62
Q

Describe the pros and cons of hormone replacement therapy in menopause.

A

Pros: treat hot flashes, osteoporosis, genital atrophy, mood disturbances, dec risk of: Alzheimer’s osteoarthritis, colon CA
Cons: inc risk of endometrial CA (if given w/o progesterone), breast CA, and thromboembolism/stroke

63
Q

What are the AEs of hormone replacement therapy?

A

nausea, erratic vaginal bleeding, HA, breast tenderness

64
Q

Describe two regimens for hormone replacement therapy.

A
  1. Premarin on days 1-25 plus Provera on days 13-25

2. Continuous Premarin, estradiol, or transdermal estrogen plus Provera

65
Q

Describe the use of selective estrogen receptor modulators (SERMs) in menopause.

A

Estrogen agonist affects on bones and cholesterol but estrogen antagonist on breasts and endometrium.

66
Q

Name 3 medications used as adjunct therapy for hot flashes.

A

Gabapentin, paroxetine (SSRI), vanlafaxine (SNRI)

67
Q

Describe the HPOU axis that stimulates menses and reproduction.

A

Hypothalamus releases GnRH –> Pituitary releases LH and FSH –> ovaries and uterus stimulated

68
Q

State the effects of LH, FSH, estrogen, and progesterone.

A

FSH: stimulates growth of eggs in the ovaries
LH: causes rupture of the follicle and release of ovum
Estrogen: helps build endometrium
Progesterone: stabilizes uterine lining

69
Q

Describe the result of chronic estrogen exposure that isn’t balanced by progesterone.

A

Endometrial lining becomes unstable and is at risk for developing CA

70
Q

Describe the steps of ovulation.

A

FSH causes follicle to develop into dominant follicle
LH surge causes follicle to rupture
Ovum released from ruptured follicle
Remainder of ruptured follicle becomes the corpus luteum (CL)
CL releases progesterone

71
Q

Describe what happens to the corpus luteum if fertilization occurs or if it does not occur.

A

Fert: CL persists for 13 weeks to support the pregnancy

No fert: with no hCG, CL gets reabsorbed leading to decrease in estrogen and progesterone causing menstruation.

72
Q

Describe the follicular and luteal phases of ovulation.

A

Fol: follicle develops and grows. Estrogen release causes endometrium to thicken.
Lut: CL releases progesterone to enhance uterine lining

73
Q

Describe the four phases of each menstrual cycle.

A

Menstrual Phase: shedding of the endometrium –> days 0-5
Proliferative Phase: uterine lining grows in response to estrogen –> days 5-13
Ovulation: day 14
Secretory Phase: uterine lining growth stabilizes in response to progesterone –> days 14-28

74
Q

What results from long term exposure to progesterone?

A

Thinning of the uterine lining

75
Q

What is considered to be a normal amount of bleeding during menstruation?

A

20-80 ml –> changing one super tampon or pad every hour is considered heavy bleeding.

76
Q

What are the S/S of premenstrual syndrome?

A

Bloating, weight gain, constipation, anxiety, breast tenderness, depression, irritability, sugar/salt cravings

77
Q

Describe the DSM-5 definition of premenstrual dysmorphic disorder.

A

Mood swings, anger, irritability, sense of hopelessness, anxiety associated with severe PMS symptoms. Must be present for most of the menstrual cycles for one year. Must also be associated with significant distress or interfere with ADLs.

78
Q

Describe the S/S of chlamydia.

A

Usually asymptomatic. If symptoms…
Females: purulent discharge, post-coital bleeding, friable cervix, urinary symptoms
Males: dysuria, urethral discharge

79
Q

What is the CDC recommendation for screening of chlamydia?

A

Annual testing of sexually active women < 26 and all others at risk

80
Q

What is the treatment for chlamydia? What medication is also given for a presumed coinfection?

A

Chlamydia treated with PO doxycycline

Gonorrhea treated simultaneously with IM ceftriaxone

81
Q

How should a patient with chlamydia be counseled with regard to their sexual partners?

A

Treat all sexual partners in the past 6 months

82
Q

T/F: S/S of gonorrhea are the same as chlamydia.

A

True

83
Q

Which HSV is associated with genital herpes?

A

Either HSV-1 or HSV-2 can cause oral or genital but majority of STIs are HSV-2. HSV-1 more commonly associated with cold sores.

84
Q

T/F: Herpes patients can only transmit the disease when they are symptomatic.

A

False: asymptomatic shedding occurs. More shedding occurs after recent acquisition or in frequent outbreaks.

85
Q

What are S/S of herpes infection.

A

malaise, myalgias, nausea, diarrhea, fever, vulvar burning and pruritis precede multiple vescicles

86
Q

What are the most common triggers of a recurrent herpes outbreak?

A

Stress, trauma, menses

87
Q

What testing options are available for HSV?

A

Viral culture from scraping of sore
PCR from sore tissue, blood, or spinal fluid
Blood test for HSV antibodies - tests for prior infection

88
Q

How is herpes treated?

A

Primary infection: valacyclovir 1g bid for 10 days

Recurrent HSV: topical lido plus valacyclovir x 5 days

89
Q

When is suppressive therapy for HSV used? What is the treatment regimen? What are the benefits?

A

For patients experiencing > 4-6 episodes per year
Valacyclovir 500mg qd
Makes outbreaks less frequent and severe as well as decreasing the transmission rate (still non-zero)

90
Q

Describe a chancroid and state the causative organism.

A

STI that results in painful genital ulcers. Caused by H. Ducreyi.

91
Q

T/F: Chancroid is one of the most common STIs in the US.

A

False: uncommon in the developed world.

92
Q

State the four diagnostic criteria of chancroid.

A

One or more painful genital ulcers
Negative PCR for HSV
Negative test for syphilis
Clinical S/S consistent with chancroid

93
Q

Describe the progression of a chnacroid.

A

Begins as an erythematous papule –> progresses to pustules –> pustules ulcerate to form painful open sores. Ulcers have an erythematous base with a gray or yellow purulent exudate. Half of patients will also have inguinal lymphadenopathy.

94
Q

What abx are used to treat chancroid?

A

Ceftriaxone 250mg IM or Azithromycin 1g PO

95
Q

Describe the three stages of Lymphogranuloma Venereum (LGV).

A

Primary: Genital ulcer 3-12 days after exposure which heals in a few days/
Secondary: “Groove Sign” produced by mass caused by severe inflammation of femoral and inguinal lymph nodes –> appears 2-6 weeks after primary
Late: Fibrosis and strictures in the anogenital region

96
Q

What is the treatment of LGV?

A

Doxycycline 100mg PO bid x 21 days

97
Q

Compare the incubation periods of syphilis, herpes, chancroid, and LGV.

A

Syphilis: 7-14 days
Herpes: 2-10 days
Chanchroid: 4-7 days
LGV: 3-12 days

98
Q

Compare the primary lesion of syphilis, herpes, chancroid, and LGV.

A

Syphilis: papule
Herpes: vesicle
Chanchroid: papule/pustule
LGV: papule/vesicle

99
Q

Compare the number of lesions of syphilis, herpes, chancroid, and LGV.

A

Syphilis: single
Herpes: multiple
Chanchroid: 1-3, sometimes more
LGV: single

100
Q

State whether each of syphilis, herpes, chancroid, and LGV are painful or not painful.

A

Syphilis: not painful
Herpes: painful
Chanchroid: painful
LGV: not painful

101
Q

Compare the incubation periods of syphilis, herpes, chancroid, and LGV.

A

Syphilis: PCN
Herpes: valacyclovir
Chanchroid: ceftriaxone or azythromycin
LGV: doxycycline

EOR Exam - Women's Health (7 decks)

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