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Clinical Medicine Lecture - Professor Kramer > Infertility, Contraception, Breast disorders > Flashcards

Infertility, Contraception, Breast disorders Flashcards

1
Q

Infertility (Subfertility) definitions ?

A

Failure to conceive after 1 year of unprotected intercourse

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2
Q

Sterility definition ?

A

intrinsic inability to conceive

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3
Q

Fecundability definition ?

A

chance of conceiving per month (normal couples ~25%)

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4
Q

Infertility prevalence ?

A

Average of 15% of couples

Range is 7-28% by female age

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5
Q

Infertility RF ?

A

Weight gain

Smoking

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6
Q

Infertility female ovulatory etiologies ?

A

Central
Peripheral
Metabolic

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7
Q

Infertility male etiologies ?

A

Endocrine
Anatomic
Sperm abnormality
Sexual dysfunction

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8
Q

Infertility female pelvic etiologies ?

A

Infections
Structural
Endometriosis

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9
Q

Infertility female cervical etiologies ?

A

Congenital

Acquired

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10
Q

Infertility Hx ?

A

Ask about sexual practice (coitus)

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11
Q

Infertility PE ?

A

Usually normal

Findings depending on cause

  • PCOS
  • metabolic syndrome
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12
Q

Infertility DS - typical males ?

A

Semen analysis

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13
Q

Infertility DS - typical female ?

A

Basal body temperature

Progesterone levels

Luteinizing hormone

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14
Q

Infertility DS consider ?

A 
Sperm penetration assay
Sperm antibody
Post-coital sperm survival
LH level
FSH levels
Prolactin
TSH
Luteal phase endometrial biopsy
Hysterosalpingography
Laparoscopy
Pelvic ultrasound
Hysteroscopy
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15
Q

Infertility DS - Semen analysis ?

A

Excludes most male factors if normal

Checks for counts and mobility

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16
Q

Infertility DS - Sperm penetration assay ?

A

Watch capability of sperm to penetrate a hamster egg with the zona pellucida removed

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17
Q

Infertility DS - Sperm antibody ?

A

Immunobeads may be seen in lab coating sperm

see if the sperm has an AB towards itself

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18
Q

Infertility DS - Post-coital sperm survival ?

A

Check amount of sperm in the cervical fluid 6-8 hours after

Less than 10 sperm per hpf is abnormal

should occur before ovulation but not after

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19
Q

Infertility DS - Progesterone levels ?

A

Used with basal body temperature to confirm ovulation

Checked mid-luteal phase

Should be elevated (above 3ng/mL)

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20
Q

Infertility DS - Luteinizing hormone ?

A

Will surge

Ovulation occurs 24-36 hrs after initiation and 10-12 hrs after peak

Urinary kits available

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21
Q

Infertility DS FSH levels ?

A

Often elevated with ovarian causes

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22
Q

Infertility DS - Antral follicle count (AFC) ?

A

TVUS during early follicular phase, day 2-4 of menstrual cycle

Low < 4 – 10 antral follicles

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23
Q

Infertility DS - Anti mullerian hormone (AMH) ?

A

Indicator of declining ovarian function

level correlates with # of follicles you have and declines with age

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24
Q

Infertility DS - Prolactin ?

A

Evaluate for pituitary disorder

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25
Q

Infertility DS - TSH ?

A

Evaluate for thyroid (hypothyroidism, hyperthyroidism)

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26
Q

Infertility DS - Pelvic ultrasound (#1 imaging choice) ?

A

Often first imaging choice

Can identify ovarian cysts, endometriosis, structural abnormalities

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27
Q

Infertility DS - Luteal phase endometrial biopsy ?

A

Checks the maturation of the endometrial tissue

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28
Q

Infertility DS - Hysterosalpingography ?

A

Determines patency of Fallopian tubes and identifies uterine abnormalities

contrast material with steady beam of XRAY

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29
Q

Infertility DS - Laparoscopy with chromotubin ?

A

Gold standard to identify tubal abnormalities

Performed in conjunction with hysteroscopy

GS for any tubal abnormalities

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30
Q

Infertility DS - Hysteroscopy

?

A

Identify structural abnormalities such as adhesions

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31
Q

Infertility Tx. typical patient ?

A

Clomiphene

Other ovulatory agents
-Letrozole – aromatase inhibitor

IVF

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32
Q

Infertility Tx. if abdnormal postcoital test ?

A

Artificial insemination

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33
Q

Infertility Tx. consider ?

A

Other ovulatory induction agents

  • Post-menopausal gonadotropin
  • Recombinant FSH

In vitro fertilization

  • Gamete intrafallopian transfer
  • Zygote intrafallopian transfer

Surrogate options

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34
Q

Selective estrogen receptor modulator ?

35
Q

Infertility Tx. patient education ?

A

Could be male or female causes

Treat structural or other underlying causes

36
Q

Infertility Tx. pharmacology ?

A

Clomiphene (Clomid)

  • Best first choice for anovulatory
  • Promotes ovulation
  • 50-100mg for 5 days on day 5 of menstrual cycle

Post-menopausal gonadotropin

Recombinant FSH

37
Q

Infertility Tx. Artificial insemination ?

A

Best choice for abnormal post coitus testing

Highly motile sperm selected

Transcervically injected in uterus

38
Q

Infertility Tx. Gamete intrafallopian transfer (GIFT) ?

A

Ova retrieved from mature follicle with laparoscopy

Ova placed in fallopian tube

Sperm placed in Fallopian tube

39
Q

Infertility Tx. Zygote intrafallopian transfer (ZIFT) ?

A

Ova removed

Fertilized with sperm

Zygotes placed in fallopian tube within 24 hours

40
Q

Infertility Tx. consider ?

A

Surrogate options

41
Q

Contraception methods ?

A 
Traditional
Barrier
Oral hormonal
Injected, implanted, transdermal hormonal
Intrauterine devices
Abortion
Sterilization
42
Q

Contraception method - traditional - symptothermal ?

A

Most reliable of the abstinence methods

Combines mucus and basal body temperature

43
Q

Contraception method - traditional - cervical mucus ?

A

Daily evaluation

Fertile mucus looks like egg white

44
Q

Contraception method - traditional - body temperature ?

A

Slight increase in body temperature indicates ovulation

45
Q

Contraception method - traditional - calendar ?

A

Predicts day 14 for ovulation

35% failure rate

46
Q

Contraception method - traditional - lactational amenorrhea ?

A

May be effective for up to 6 months

Must continuously breast feed and anovulatory

47
Q

Contraception method - traditional - postcoital douching ?

A

Ineffective and unreliable

48
Q

Contraception method - traditional - Coitus interrupt us ?

A

Ineffective and unreliable

49
Q

Contraception method - barrier ?

A

Male condom

Female condom

Cervical caps

Diaphragms

-May contain spermicidals
Nonoxynol-9 or oxtoxynol-3

50
Q

Contraception method - oral hormones - Most effective reversible means ?

A

Theoretical failure rate 1%

Actual failure rate 4-6%

51
Q

Contraception method - oral hormones - Contain combinations of estrogen and progesterone ?

A

Typically 21 days of active hormones with 7 days of placebo or no pill

Bleeding often occurs 3-5 days after last active pill

52
Q

Contraception method - oral hormones - Additional benefits ?

A

Less benign breast disease, iron deficiency anemia, DUB, and PID

Reduced ovarian and endometrial cancer

Ectopic pregnancy protection

Improves hirsutism, acne, and endometriosis

53
Q

Contraception method - oral hormones - Disadvantages ?

A

Increased thromboembolic disease

Abnormal lipids

Increase in ovarian, endometrial and cervical cancer

No STI protection

54
Q

Contraception method - IM injection ?

A 
Medroxyprogesterone acetate (Depo-Provera)
-IM injection every 90 days

Failure rate only 0.3%

Fertility rates may take 18 months to normalize after DC

55
Q

Contraception method - Implantation ?

A

Levonorgestrel (Nexplanon)

Implant rods

Efficacy good

Effective 3 years

56
Q

Contraception method - Transdermal ?

A

Applied once weekly for 3 weeks

Reduced efficacy for women >200lb

57
Q

Contraception method - Vaginal ring ?

A

Inserted for 3 weeks and then removed

Will induce menstruation

Best for nulliparous females

58
Q

Contraception method - Intrauterine devices, very common - general information ?

A

Believed to produce environment hostile for fertilized ovum

Failure rates 1-5%

Placed during menstruation

59
Q

Contraception method - Intrauterine devices - considered most for ?

A

Multiparous

Smokers who do not desire permanent contraception

60
Q

Contraception method - Intrauterine devices - formulations ?

A

Levonorgestrel (Mirena) releasing– works for 5 years

Copper T (Para Gard)– works for 10 years

61
Q

Contraception method - Intrauterine devices - risks ?

A

Uterine perforation

Ectopic pregnancy

62
Q

Contraception method - Intrauterine devices - contraindications ?

A

Current infection

Hx PID

63
Q

Contraception method - abortion - emergency contraception ?

A

Progesterone (with possible estrogen) immediately following intercourse

Levonorgestrel common

  • Most effective within 72 hours
  • Taken twice in 12 hours
64
Q

Contraception method - sterilization ?

A

Hysterectomy

Bilateral salpingoophorectomy

Uterine ablation

NO LONG WANT TO CONCIEVE

65
Q

Sexual assault (Rape) definition ?

A

any sexual act performed by one person on another without the person’s consent

66
Q

Sexual assault (Rape) prevalence ?

A

Estimated 700k-1 million females yearly in US

67
Q

Sexual assault (Rape) demographic ?

A

20% of adult women

15% of college-age women

12% of adolescent girls (increased incidence)

Higher incidence in African American

68
Q

Sexual assault (Rape) etiologies and RF ?

A

Alcohol

flunitrazepam (Rohypnol)

gamma-hydroxybutyrate (GHB)

69
Q

Sexual assault (Rape) Hx ?

A

Often will not admit sexual assault
-Must ask!

May just say “assaulted” or “mugged”

May have concern for STI

May complain of injuries

Psychological disturbance

  • “Rape trauma” syndrome
  • -Acute phase– usually 2 weeks
  • -Delayed phase
  • -PTSD
70
Q

Sexual assault (Rape) PE ?

A

Psychological findings

Evaluate for

  • Bite marks
  • Scratches
  • Pelvic injury
  • Bleeding

May not perform complete pelvic exam

  • Send to facility with Sexual abuse nurse examiner (SANE)
  • -Will collect legal forensic specimens
71
Q

Sexual assault (Rape) DS ?

A

GC/chlamydia PCR

Wet mount

Baseline panels

Evidence

72
Q

Sexual assault (Rape) DS - baseline panels ?

A

Hepatitis
HIV
Syphilis

73
Q

Sexual assault (Rape) DS - evidence ?

A

Pap test

Vaginal saline swabs

Acid phosphatase

Pubic hair combings

Fingernail scrapings

Woods lamp
-Dried semen fluoresce under light

74
Q

Sexual assault (Rape) DS - forensic evidence seen - mobile sperm ?

A

Vagina 8 hours

Cervical mucous 2-3 days

75
Q

Sexual assault (Rape) DS - forensic evidence seen - immotile sperm ?

A

Vagina and Rectum 24 hours

Cervical mucous up to 17 days

76
Q

Sexual assault (Rape) DS - forensic evidence seen - acid phosphatase ?

A

High levels in seminal fluid

77
Q

Sexual assault complications ?

A

40% have injuries

1% need hospitalization or
major repair

0.1% are fatal

PTSD

78
Q

Sexual assault Tx. ?

A

Treat acute injuries

SANE nurse transfer

STI treatment

Emergency contraceptive, check serum HCG 1st

Gynecology follow up in 2 weeks

79
Q

Sexual assault Tx. STI treatment ?

A

Ceftriaxone 125 mg intramuscularly in a single dose, plus

Metronidazole 2 g orally in a single dose, plus

Doxycycline 100 mg orally 2 times a day for 7 days

Hepatitis B immunoglobulin IM ASAP
-3 dose immunization series (if not done previous 0, 1, 6 months)

Consider HIV prophylaxis

80
Q

Sexual assault Tx. Emergency contraceptive, check serum HCG 1st ?

A

Levonorgestrel twice 12 hours apart

81
Q

Sexual assault Tx. Gynecology follow up in 2 weeks ?

A

Repeat STI tests

Reassess psychological Sx

82
Q

Sexual assault Tx. physiological counseling ?

A

Victims internalize fears

Assess for referrals for further counseling

83
Q

Sexual Assault facts ?

A

All 50 states require physicians/providers to report child sexual abuse

Nearly half of states require physicians report statutory rape

  • Sexual intercourse with female under an age specified by state law (14-18 years of age)
  • -Adolescent of this age is unable to con

Clinical Medicine Lecture - Professor Kramer (28 decks)

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