GYNO Flashcards
is a symptom not a diagnosis; causes acronym: PALM COEIN
Abnormal uterine bleeding
PALM COEIN
structural: polyp, adenomyosis, leiomyoma, malignancy, hyperplasia then nonstructural coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not otherwise classified
Diagnostics for Abnormal uterine bleeding
GYN exam to start … followed by labs
Transvaginal ultrasound, pregnancy test, CBC, cervical cancer screening (if due), potential orders: TSH/FTF, hormone tests- prolactin, androgens estrogens, PT/PTT, bleeding disorder labs, endometrial biopsy
45+ should get a endometrial sampling or less than 45 if hx of unopposed estrogen exposure
Heavy bleeding >80mL
Tx for for Abnormal uterine bleeding
COCs, progesterone only contraceptives, TXA (Lysteda oral or IV if severe) or NSAIDs taken when pt is bleeding, endometrial ablation, Depo-Provera, Mirena
Acute emergent: ER uterine tamponade, IV, estrogen, uterine artery embolism, hysterectomy
primary vs secondary amenorrhea
Primary (never menstruation) vs secondary (previous menstruation)
Female athlete triad
amenorrhea, osteoporosis, and disordered eating
Dx for amenorrhea
hcg, FSH, LH, TSH, prolactin (Acromegaly; if elevated order MRI or CT), progesterone challenge
Tx for amenorrhea
tx underlying cause if discovered. Maintain optimum weight (by either gaining or losing). Irreversible bone loss can occur after 3 yrs of amenorrhea- calcium and vit
mastalgia/ Mastodynia
Breast pain
Cyclic vs noncyclic breast pain ?
Cyclic → usu 3rd or 4th decade; bilateral outer breasts radiating to upper arm and axilla
Noncyclic → unilateral, localized, sharp, burning. Rarely a presentation of CA
PE for breast pain. questions to ask?
mass (change w/ cycle?), nipple discharge (benign: creamy, gray, or green; abnormal: watery, serous, bloody), skin dimpling.
Skin changes that may signify cancer include erythema, edema, retraction, dimpling, peau d’orange, and nipple excoriation or crustiness.
Hx ?s: hormone therapy, breast surgery, age at menarche and menopause, prenancy and lactation, breast CA screening, family hx
dx for noncyclic breast pain
Noncyclic = unilateral, localized, sharp, burning. Rarely a presentation of CA
mammogram if postmenopausal; US for young women; CXR if trauma. Hcg
Tx for breast pain
reassurance that most pain resolved spontaneously, firm supportive bra, low-fat diet, reduced caffeine, NSAIDs, change OCP to lower estrogen and higher progesterone
What to do if no resolution of symptoms after 3-7 days of ABX for mastitis
consider inflammatory breast cancer- get mammogram/ U/S-but mammogram is not indicated in pregnant/lactating women
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what to rule out with nipple d/c & galactorrhea
pituitary adenoma
common in premenopausal and pregnant women, bilateral; only with compression; multiple ducts involved. Clear, gray, yellow, white, or dark green
Physiologic galactorrhea
spontaneous, bloody, serous fluid from breast, unilateral, involving one duct, a/w mass
Pathologic galactorrhea
Bilateral nipple discharge usually has some physiologic causes, such as_________ . Can draw a prolactin level to assess. *more concern if it’s bloody, green, and if it is spontaneous
hyperprolactinemia
Labs for nipple d/c & galactorrhea
: Prolactin, TSH, CBC, CMP, hcg- consider mammogram to assess for non palpable masses, test nipple discharge for occult blood; Periareolar US
What to do If prolactin elevated when assessing galactorrhea
MRI of brain
Is a rare form of breast cancer. Superficial skin manifestation, usually begins as ductile cancer (1-3% of breast CA cases)
Itchy, usually unilateral, well demarcated, erythematous scaly plaque that’s usually around the nipple and the areola.
Refer - skin biopsy needed and mammogram
Paget’s Disease of Breast
Unilateral, continuous hx with slow progression, moist or dry, irregular but distinct border, nipple always involved and disappears in advanced cases, itching common
Paget’s Disease of Breast
Usually bilateral, intermittent hx with rapid progression, moist initially, indistinct border, areola involved, nipple may be spared, itching common
Eczema of breast
Tx Paget’s Disease of Breast
Tx: mastectomy, radiation
Managed by surgical oncologist
Breast masses/ CA protective factors
childbirth before 30, multiple births, breastfeeding
Breast masses/ CA risk factors
HRT (5% increased risk per year of use; returns to baseline w/in yr of stopping), dense breasts,
Fibroadenomas and cysts do NOT increase risk
usually firm discrete mass or an area of diffuse firmness of breast tissue with or without skin thickening, cysts are rare in post menopausal women and shoulbe considered breast cancer until proven otherwise (unless on HRT)
breast cancer mass
most common; painless, freely movable, rubber feeling or hard; increase in size toward end of cycle
Fibroadenomas
Breast masses/ CA screening tools
Gail model, The Breast Cancer Risk Assessment Tool , Tyrer-Cuzick Model
Breast masses/ CA diagnostics
BRCA genetic testing if strong family hx, mammogram (USPSTF biennial 50-74), MRI, 3d mammogram (younger women with dense breasts), diagnostic mammography AND ultrasonography initially for palpable mass 25+ usually just ultrasound for <25 average risk f/u bc 15-18 percent false negative
Breast masses diagnostics if cyst ?
cyst→ aspiration and cytology, f/uin 4-6wks to determine if cyst reoccured; non cystic mass→ biopsy
Non-cancerous, usually affects both breasts. change in estrogen/ androgen ratio
Often seen in overweight boys
RT: aging, malnutrition, hypogonadism, thyroid problem, excess drinking/ cirrhosis, testical or adrenal cancer, chemo, ketoconazole, digoxin, exogenous steroids
Normal in newborn male infants due to moms hormones
Obtain family hx of breast or ovarian cancer, BRCA mutation
Gynecomastia
Usu resolves on own w/in 6 mos
Aggressive fast-growing cancer. Unilateral
May look like an infection of the breast
Refer!
Inflammatory Breast Cancer
Dx for gynocomastia?
Diag: if needed, US <25; mammogram >25yo or any age you feel a suspicious mass
extra nipples
polythelia
> 6 mo.
Patho: unclear- hyperesthesia/ allodynia and pelvic floor dysfunction
Dd: endometriosis, interstitial cystitis, painful bladder syndrome, depression, IBS, pelvic adhesions, trauma, pelvic inflammatory disease (can be comorbid)
chronic pelvic pain
Red flag findings of chronic pelvic pain
postcoital bleeding, postmenopausal bleeding, unexplained weight loss, pelvic mass, hematuria, extreme burning/ pain
chronic pelvic pain diagnostics
pelvic ultrasound r/o anatomic abnormalities, laparoscopy (severe pain), CBC, ESR, Urinalysis, chlamydia/ gonorrhea, pregnancy test
Tx of chronic pelvic pain
Meds: depot medroxyprogesterone, gabapentin, NSAIDS, gonadotropin releasing hormone agonists (Zoladex) (better for endometriosis)
Antidepressants (TCAS, SNRIs, anticonvulsants (lyrica, gabapentin)
Nonpharm: pelvic floor physical therapy, behavioral therapy cutaneous allodynia
Hysterectomy
How to dx and tx vulvar lichen sclerosis
dx with biopsy
Tx with steroids
How to dx and tx vulvar lichen sclerosis
dx with biopsy
Tx with steroids
starts 6-12 months after menarche starts, a/w low anterior pelvic pain around menstrual cycles
Primary dysmenorrhea
some years of painless menstruation then painful menstruation - not described as beginning in adolescents and usually underlying pathology
Secondary dysmenorrhea-
Red flags of dysmenorrhea
unilateral dysmenorrhea, ectopic pregnancy,
treatment of dysmenorrhea
nutrition, vitamines, heat packs, NSAIDS, oral contraceptives, Mirena IUD
pain with sexual activity
Dyspareunia-
Possible factors of Dyspareunia
RF: PID, endometriosis, postpartum, perimenopausal, psychological factors,
CM: lubrication issue, superficial issue like with lichen planus, lichen sclerosis UTI…lots of differentials, Deep pain- usually endometriosis, structural, bladder stones,
Most common cause of dyspareunia
endometriosis
diagnostics for dyspareunia
pelvic exam then KOH prep, cultures of vaginal discharge, pap, STI, Q tpvd low oxalate diet calcium citrate, ip test, CBC, ESR, HCG
Nonpharm Tx for dyspareunia
Provoked vestibulodynia/ vulvar vestibulitis: 1st line is psychological/ behavioral therapies, endometriosis: Vitamin E/C/gluten free diet, other: pelvic floor therapy, capsaicin cream, lubrication
pharm Tx for dyspareunia
estrogen cream, if estrogen CI consider ospemifene (selective estrogen receptor modulator or topical aqueous lidocaine, topical steroids for lichen sclerosus, vaginismus - botox, lidocaine injections, PVD- topical amitriptyline cream, topical estrogen 1x/day 4-8 weeks, interferon injections, endometriosis- hormonally OCP/ surgically
Vulvar area chronic pain at least 3 months
Vulvodinia
Fear reaction to any form of vaginal penetration = spasms
vaginismus
Inability to perform, lack of arousal, lack of interest, lack of orgams, pain on penetration (one or all of these)
Def: femal sexual interest/arousal disorder, femal orgasmic disorder, genito-pelvic pain/penetration disorder (req 6 mo duration of symptoms)
female sexual dysfunction
screening tools for female sexual dysfunction
sexual satisfaction scale, female sexual function index
diagnostic labs for female sexual dysfunction
guided by history/PE, if indicated- testosterone, Sex hormone binding globulin, DHEA, estradiol, calculated free testosterone, LH/FSH, pelvic ultrasound, CBC, CMP, A1C, lipid, renal liver,
Ask what meds they are on… SSRIs?
Tx options for female sexual dysfunction
Vaginal moisturizers, topical vaginal low dose estrogen, SERMS, Testosterone (off label), pelvic floor therapy
Nonpharm Tx options for female sexual dysfunction
Diet exercise, sleep, cholesterol reduction, tobacco cessation, BP/ glycemic control, psychology
PLISSIT model for addressing sexual health with women
Give permission, limited information, specific suggestions, intensive therapy
Pretty rare but most commonly seen in women in their 50s
Usually remains undetected until sx appear… more extensive
Sx: pelvic pain, urinary urgency, abdominal pain, bloating
Look into this if pt has sx t > 6 months that aren’t going away
Ovarian Cancer
RF for Ovarian Cancer
being in your 50s, having the BRCA1 or the BRCA2 gene, personal history of breast cancer, colon cancer, never having had a child.
Stages 1-4 of ovarian cancer
Stage 1= CA in 1 or both ovaries
Stage 2= spread to pelvis
Stage 3= spread to abdomen
Stage 4= beyond abdomen
hard to diagnose .. transvaginal US; Order CA-125 test (tumor marker); CT pelvis
Expensive test that looks at proteins produced by ovarian cells
Can be elevated from causes other than ovarian cancer (ex. diabetes , lupus)
Dx for ovarian cancer
Exam pearls for ovarian cancer
any evaluation of the ovary in post-menopausal women where you find an enlargement in your evaluation should signify that you want to rule out malignancy and usually requires a referral
Most common in post menopausal women btw 50-60 years of age
* post meno-pausal bleeding, fullness or pressure in pelvis
Endometrial Cancer
RF of Endometrial Cancer
Older age, never being pregnant, obesity (excess androgen is converted to estrogen), breast cancer tx meds (tamoxifen), hx of colon cancer, estrogen exposure w/o progesterone
Greater risk if family hx of colon cancer
How to dx endometrial cancer?
Stages?
Dx: endometrial biopsy
Stage 1= only uterus
Stage 2= uterus and cervix
Stage 3= spread beyond uterus but hasn’t reached rectum or bladder
Stage 4= also affects bladder and rectum and other parts of body
Tx of endometrial cancer
Tx depends on stage of tumor/ cancer
Surgery, hysterectomy, chemo
Good survival rate if not invaded muscles
2nd most common malignancy of female GYN tract.. Decreasing due to HPV vaccine.
cervical cancer
Most common types of HPV that cause cervical cancer
HPV 16 and 18
post coital spotting, bleeding around cervix, menorrhagia; thin, watery, foul discharge
s/s of cervical cancer
RF of cervical cancer
exposure to HPV (sexual activity) , increased risk with those sexually active earlier and who have had many partners, HIV, immunocompromised, low SES, women whos moms took DES, smoking
protects against 9 types of HPV (including 16, 18, and two more types that cause warts). 3-injection series over 6 mos. Females and males can receive at 9 yrs old; routine pap
gardasil
CC= Mass on external vaginal area - very rare CA
Need biopsies … Refer out
vulvar and vaginal cancers
rare and aggressive cancer no burning, itching, or pain
Vulvar melanoma
asymptomatic, vaginal bleeding not a/w discomfort
CM vaginal CA:
lump, mass, itching, bleeding
CM vulvar CA
What to do if suspect vulvar or vaginal cancer?
CM vaginal CA: asymptomatic, vaginal bleeding not a/w discomfort
Refer to gyn for biopsy (vulvar) and colposcopy (vaginal)
Diag vaginal CA: PET and CT
Usually leave them alone if not causing a problem (large, pain, difficulty getting pregnancy, abnormal bleeding)
uterine fibroids
Cyst in Introitus… may be asymptomatic unless it’s infected
may see a larger lump on one side, very tender to touch. Often can just be treated with antibiotics.If not better may need I&D
If enlarged gland found in post-menopausal women presume it is carcinoma
bartholian cyst
how is endometriosis tx
BC and NSAIDS *
defined as inability to conceive after 1 year of regular timed, unprotected intercourse or donor insemination <35 and 6 months >35, immediate referral for 40+
infertility
Rf of infertility
obesity, cigarette smoking, underweight, shift work, occupational exposure, PCOS, varicocele (bag of worms)
Dx for male infertility
semen analysis x 2 (2-7 days of abstinence prior to sample) if + oligospermia= 8-10AM FSH, LH, testosterone; if testosterone low obtain prolactin then refer,
Dx for female infertility
pap, HPV, chlamydia, gonorrhea, imaging- hysterosalpingogram, older than 35 3 day FSH level an estradiol level, ovulation- basal body temperature charting, urinary LH home kit- LH surge 1-2 days precedes ovulation
General treatment scope for PCP related to infertility
improve nutritional status, normalize weight, eliminate cigarette, caffeine, illicit drugs NSAIDs, ETOH, toxins, fertile window- 5 days before-ovulation, intercourse 2x per week, avoid lubricants that may be spermicidal (recc raw egg white/ vegetable oil)
How to tx in preg pts?
Chlamydia
*Gonorrhea
+HIV, hepatitis B, syphilis
Chlamydia- azithromycin 1gram orally as single dose
*Gonorrhea (uncomplicated)- ceftriaxone 500mg IM as single dose for persons weighing <150kg
Refer for +HIV, hepatitis B, syphilis
Maternal genitourinary and gastrointestinal colonization is the primary risk for the leading cause of neonatal early onset disease (EOD)- eg sepsis, PNA, or meningitis.
GBS - Group Beta Strep
Who is high risk for Group Beta Strep
High risk = History of previous GBS-infected newborn, Gestational age of less than 37 weeks at time of delivery, Prolonged rupture of membranes, Very low birth weight
Diagnostics for GBS
Genito rectal swab
Screening recommended at 36 0/7-37 6/7 weeks gestation
Findings may include:
Positive genito rectal culture for GBS
Do not screen those with positive GBS bacteriuria as they will require prophylactic treatment regardless.
Tx for GBS
Intrapartum IV antibiotic recommendations: (abx in labor or after ROM)
Penicillin (PCN) G OR Ampicillin
PCN allergy alternatives include:
Cefazolin
Recommend use of Clindamycin in those with known IgE mediated events after receiving PCN and cephalosporins
Prophylaxis treatment is not necessary for those without signs of labor, with intact membranes and planned mode of delivery is cesarean section.
Dx for UTI in pregnant woman
When to screen?
Screening for all pregnant women by urine culture once early in pregnancy* (12-16 wks gestation)
UA with reflex culture
Findings may include:
Pyuria
Culture positive for 10^3 or 10^5 colony-forming units/mL (CFU)
Reported symptoms of urgency, frequency and dysuria
Common tx for UTI in pregnant woman
Amoxicillin 500mg Q8h x3-7 days
Amoxicillin-clavulanate 500mg Q12hr x3-7 days
Cephalexin 500mg Q8h x3-7 days
UTI med tx to avoid in pregnany
Avoid nitrofurantoin and sulfonamides at end of 3rd and during 1st trimester
Avoid trimethoprim in first trimester
what to do after tx UTI in pregnant woman
May also provide prescription for yeast tx to be taken at completion of ABX if needed; test of cure after tx and repeat urine cx q6-12 weeks for remainder of pregnancy.
Rare disorder consistent with severe, intractable nausea and vomiting (>3 episodes per day), dehydration, large ketonuria and >/= 5% body weight loss.
Possible DDx Gastroesophageal reflux disease (GERD)
Hyperemesis Gravidarum (HG)
Dx for Hyperemesis Gravidarum (HG)
None typically recommended in those without dehydration
May consider CMP, CBC, TSH, quantitative human chorionic gonadotropin (hCG), amylase and urinalysis
Findings may include:
Elevated liver enzymes, bilirubin and amylase
Decreased TSH
Elevated specific gravity and/or ketonuria
Tx for Hyperemesis Gravidarum (HG)
start with lifestyle modifications
Nonpharmacologic: change prenatal vitamin to folic acid only (Level A); ginger capsules 250mg QID (Level B), consider P6 acupressure wrist bands.
Pharmacologic: Vitamin B6 (pyridoxine) 10-25mg PO (alone or in combination with Doxylamine 12.5mg) 3-4 times a day. (Level A)
Low levels of iron, hemoglobin and microcytic hypochromic rbc = Hb, 11 g/dl
Recognize symptoms of fatigue, weakness, rapid heart rate, difficulty concentrating, shortness of breath, pale skin, chest pain, lightheadedness, cold hands and fe
IDA
CDC cutoffs for IDA In pregnancy
Hb 11 g/dl in 1st trimester
Hb < 10.5 g/dl in 2nd trimester
Hb 11 g/dl in 3rd trimester
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Normal for women = Female: 12.1 to 15.1 g/d
Labs for IDA in pregnancy
CBC w/ or w/out diff, Serum ferritin (low), serum iron (low), TIBC (elevated), transferrin sat (low)
Tx for IDA in pregnancy
treat underlying cause 1st
Iron and vitc rich foods
Oral iron supplementation 60-200 mg/ day elemental ion
Consider Ferrous sulfate 325 mg (65 elemental) TID btw meals if tolerable
Consider Vit C (250-500 mg BID with iron) to max absorption
Continue therapy 3-6 months after deficiency corrected to replenish stores
Educate pregnant women who are vegetarian/ Vegan
Tx asthma in pregnancy
SABA of choice: Albuterol
ICS of choice: budesonide; however continue same ICS as before preg. If possible
Salmeterol preferred over leukotriene RA or theophylline
If mom’s asthma is poorly controlled, fetus needs close monitoring (serial US with antenatal fetal testing at 32wks)
Tx of constipation during pregnancy
Tx: water, fiber, psyllium, methylcellulose (Citrucel,) , Colace.
Avoid mineral oil, castor oil, saline, and PEG
d/t progesterone effect on bowel motility (decreased)
Early pregnancy Bleeding diagnostics
Transvaginal ultrasound
Labs: HCGs, CBC, Coags,
monitor closely… could move back into right position spontaneously. 95% resolve prior to birth, don’t do digital exam, refer to OB
placenta previa
3rd-trimester non-obstetric bleeding causes
Cervicitis Vaginitis Trauma Polyps Malignancy
3rd-trimester obstetric bleeding causes -
Lots of blood- placenta previa, abruptio placentae, vasa previa, uterine rupture
not as much blood- bloody show, intercourse
3rd-trimester non-vaginal bleeding causes
hemorrhoids, hemautira
early vs late postpartum hemorrhage
Early= > 500 ml in first 24 hours (blood loss underestimated)
Late= > 500 cc after first 24 hours
Major causes of postpartum hemorrhage
retained placental fragments, infection, hematomas, sub involution
How to manage postpartum hemorrhage
D&C , Antibiotics
Fertilized ovum implants anywhere outside the uterus
RF: PID, chlamydia, OCP,
ectopic pregnancy
Ectopic pregnancy triad
pelvic pain, amenorrhea, irregular bleeding
unruptured- abdominal pain with or without vaginal spotting/bleed, dizziness, shoulder pain (more common in ruptured), amenorrhea for 1-2 months, nausea, fatigue, breast heaviness, unilateral pelvic/abd pain, speculum: bluish coalition of cervix, budging culdesac, highly indicative findings: adnexal mass, involuntary guarding peritoneal signs
CM of Ectopic pregnancy
Diagnostics for ectopic pregnancy
HCG, CBC, transvaginal U/S
Low rising HCG
What to do if you suspect ectopic pregnancy
send to ER
How is ectopic pregnancy treated
ER : methotrexate with or without leucovorin or mifepristone, surgical laparoscopy or laparotomy: only treatment option for ruptured; rh negative blood type women should receive RhoGAM
What to educate after women received methotrexate for ectopic pregnancy
after methotrexate- women should refrain from Sexual activity, ETOH, folic acid vitamins until after resolution of ectopic pregnancy (3 months)
Frequent feeding/pumping, augmentin, dicloxacillin, or cephalosporin for staph or strep. Flu-like sx. Can progress to abscess
mastitis
Screening tools for perinatal mood disorders
Beck, Edinburgh, PHQ-9, PPD Screening Scale
Dx for perinatal mood disorders
assess for thyroid abnormalities and SI
Tx of perinatal mood disorders
CBT, pharm
Low dose SSRI 5-7 days and refer
SSRIs, vit d, DHA, CBT, massage, acupuncture, yoga
first 2-3 mos through first year. Affects entire family (child/partner)
Assess: guilt, fatigue, sleep disturbance, loss of interest/concentration, appetite change, agitation, SI
PPD
occurs around 2-4 weeks pp delusions, hallucinations, hopelessness → emergency
PP Psychosis
What qualifies as preterm labor
labor before 37 weeks gestation
RF: SES, genetic conditions, periodontal disease, multiple gestation, substance use, maternal infections, preeclampsia
Injectable steroids at 24-34 wks gestation to mature fetal lungs
new onset HTN with proteinuria
S/S: dizziness, headache, seeing spots, RUQ discomfort, swelling of face and hands.
Refer
preeclampsia
Mild vs Severe Preeclampsia
Mild : 140/90, Protein 1+
Severe : > 140/90, and 3+ urine, may have elevated LFTS
Short term vs long term tx of preeclampsia
Short term: Nifedipine, IV Labatelol, Hydralazine
Long term: labetaloal, methyldopa
Baby aspirin, calcium
Delivery at 37 wks
Diagnostics for preeclampsia
Twice weekly BP and once weekly CBC, liver enzyme, and creat
High BP causes seizures
Mag sulfate for seizure prevention
If less than 34 wks gestation need antenatal corticosteroids
Requires emergent delivery
Eclampsia
HELLP Syndrome
develops in preeclampsia H= hemolysis E= elevated L= liver enzymes L= low P= platelets
Goal BPs during pregnancy
Gestational Hypertension
Primary care can manage GH just needs to be monitored carefully
Want BP 120-160/80-105
Low dose Aspirin
FDA guidelines Unplanned pregnancy
FDA guidelines: medication abortion is avialable up to 10 weeks with mifepristone and misoprostole
Adoption
