Lady Bits Flashcards
What causes stress incontinence in a nulliparous woman?
Leiomyomata uteri (mass effect)
Indications for endometrial biopsy >= 45 yo
AUB
Post-menopausal bleeding
Indications for endometrial biopsy < 45 yo
AUB +
Unopposed estrogen (Obesity, anovulation) Failed medical management Lynch Syndrome (HNPCC)
Indications for endometrial biopsy >= 35 yo
Atypical glandular cells on pap test
Initial workup for AUB in premenopausal women
Endocrine Evaluation (TSH, Prolactin) Pelvic Ultrasound Possible endometrial biopsy
Endometrial stripe of <=4mm
Rules out endometrial cancer in postmenopausal women
Can’t reliably rule it out in premenopausal
Irregularly-enlarged uterus
Prolonged menstrual bleeding
Labor-like pain
Prolapsing leiomyoma uteri/Aborting submucous myoma
What causes cramping during the first few days of menses?
Prostaglandin release from sloughing endometrium causes uterine contractions
What distinguishes primary dysmenorrhea from secondary?
A normal physical exam
Treatment for primary dysmenorrhea
NSAIDs (1st Line)
They work as prostaglandin synthetase inhibitors
Hormonal contraception works well too
Most patients respond to these interventions within 3 months
Bulky globular tender uterus
Usually in women >35
Adenomyosis
Tenderness along uterosacral ligaments
Nodularity in the cul-de-sac
Adnexal enlargement
Pain precedes menses by a few days
Endometriosis
Virus Strains leading to Condylomata Acuminata
HPV 6 & 11
Clinical features of Condylomata Acuminata
Multiple pink or skin-colored lesions
Lesions range from smooth, flattened papules to exophytic/cauliflower-like growths
Treatment for Condylomata Acuminata
Chemical (Podophyllin resin, tricholoracetic acid)
Immunologic (Imiquimod)
Surgical (Cryotherapy, laser therapy, excision)
Prevention for Condylomata Acuminata
Vaccination
Barrier contraception
Virus Strains leading to high grade CIN & Cervical Cancer
HPV 16 & 18
Genital Lichen Planus
Pruritic, glassy, bright red erosions & ulcerations
Affects vulva & vagina
Lichen Sclerosus
Pruritic, white, thin wrinkled skin over labia
Molluscum Contagiosum
Caused by a poxvirus
Single or multiple small pearly painless nodules
Central dimples or pits
Do not bleed on contact
Trastuzumab
Monoclonal Ab for HER2+ Breast Carcinoma
Adverse effect: Cardiotoxicity (reversible w/ discontinuation of agent)
Asymptomatic LVEF decline most common
Overt heart failure can occur
Effect amplified when used in combination with cardiotoxic chemotherapy (Doxorubicin)
Precede administration with echocardiography for baseline, and follow at regular intervals throughout therapy
Side effect of Cisplatin and Carboplatin
Ototoxicity
Peripheral neuropathy
Precede administration with baseline audiometry testing
Side effect of Anastrozole and Letrozole
Osteoporosis
Precede administration with baseline bone marrow biopsy only if administering with antimetabolite chemotherapy (5FU or MTX)
Side effect of Bleomycin
Pulmonary fibrosis
Precede administration with baseline PFTs, follow them serially throughout treatment.
Side effect of TNF-Alpha Inhibitors
Reactivation of latent tuberculosis
Precede administration PPD
How often should sexually active women <25 undergo GC/Chlam testing?
Annually (in addition to routine Pap testing)
HELLP Syndrome
Hemolysis
Elevated Liver enzymes
Low Platelets
From abnormal placentation
Triggers systemic inflammation
Activates coagulation & complement cascades
Circulating platelets rapidly consumed
Microangiopathic hemolytic anemia damages liver
Hepatic Failure in third trimester or early postpartum
Acute Fatty Liver of Pregnancy
Comes with:
Prolonged PT & aPTT
Hypoglycemia
Encephalopathy
Intrahepatic Cholestasis of Pregnancy Treatment
Ursodeoxycholic Acid
Treatment for Lactational Mastitis with no reason to suspect MRSA
Continue nursing every 2 - 3 hours, both breasts
(Milk stasis is how the bacteria ascended from baby’s nares)
NSAIDS
Dicloxacillin or Cephalexin
Treatment for Lactational Mastitis with recent Hx of antibiotic use, residence in long term care facility or incarceration
Suspect MRSA
Continue nursing every 2 - 3 hours, both breasts
(Milk stasis is how the bacteria ascended from baby’s nares)
NSAIDs
Clindamycin, TMP-Sulfa, Vancomycin
Side Effects of Medroxyprogesterone injections for long-term contraception
Weight Gain!!!!!
Short Stature
Primary Amenorrhea
Absent Thelarche
Turner Syndrome
What are the gonadotropin levels like in Turner Syndrome?
High LH
High FSH
Streak ovaries provide no thelarche or feedback
Findings on light microscopy of patient with cervicitis from GC/Chlam
No organisms! NAATS is better test!
Clinical features of Granulosa Cell Tumor of the Ovary
Large adnexal mass
Children - Precocious Puberty
Postmenopausal - Bleeding/endometrial hyperplasia
Diagnostic findings of Granulosa Cell Tumor
Elevated Estrogen
Ovarian Mass & Thickened Endometrium on Ultrasound
Dysgerminoma
Ovarian tumor occuring in women <30
Secretes LDH or Beta-hCG
Mature Teratoma
Dermoid Cyst
Common, benign ovarian tumor
Not hormonally active
Serous cystadenomas
Most common benign ovarian neoplasm
Hormonally inactive
Sertoli-Leydig Cell Tumors
Produce androgens
Cause defeminization, then masculinization
Women of childbearing age experience: Breast flattening Scanty, irregular menstruation ending in amenorrhea Hirsutism Coarsened facial features Deepend voice Clitoral enlargement
Single most important prognostic consideration in the treatment of patients with breast cancer
Tumor burden (TNM Staging)
Features of a fibroadenoma
Rubbery Mobile Well-circumscribed Outer quadrant of breast Pre-menstrual tenderness (fluctuating estrogen & progesterone levels)
Management of adolescent patient with suspected fibroadenoma
Re-examine over at least one menstrual cycle
If it decreases in size and/or tenderness after the period, patient can be reassured
Management of non-adolescent patient with suspected fibroadenoma
Ultrasound
Excisional biopsy should be considered if patient is adult and has a very large mass
Most common beast mass in women age 35 - 50
Simple breast cyst
Indistinguishable from fibroadenoma (more likely if patient is adolescent) on physical exam
FNA diagnoses and resolves the cyst
Most common cause of vaginal bleeding in neonatal period
Maternal withdrawal of estrogen
Pregnancy is like the follicular phase of menstruation
Estrogen crosses placenta and builds fetal endometrial lining
Following delivery, neonate’s endometrium sloughs
Typically within first 2 weeks of life, may last days
Temporary breast buds & external genitalia engorgement may occur too. Brief. Physiologic. Normal.
Nodules resembling grapes protruding from the vagina in an infant
Rhabdomyosarcoma
Specifically Sarcoma Botryoides
In a patient with well-developed secondary sexual characteristics, how old can amenorrhea be considered normal?
Up to 16
In a patient with sexual characteristics absent, how old can work-up for amenorrhea be delayed
No later than 14
Patient with primary amenorrhea and no breast development. What hormone do you look at?
FSH
Patient with primary amenorrhea and no breast development with a low FSH. What do you order next?
Pituitary MRI
Patient with primary amenorrhea and no breast development with a high FSH. What do you order next?
Karyotype
When does the cervix physiologically secrete mucus?
Late follicular phase, close to ovulation
Mucus is clear, elastic, thin, like an uncooked egg white
Increase in quantity may be perceived as “discharge”
Asherman Syndrome
Intrauterine adhesions caused by uterine curettage
Presents with:
Amenorrhea & cyclic pelvic pain due to endometrial destruction & obstructed menstrual flow
How often should a woman > 30 with no history of abnormal pap be screened for cervical cancer?
Every 3 years
In an asymptomatic, average-risk patient without ovarian mass, why not do CA-125 screening?
False elevations of CA-125 can be caused by conditions such as endometriosis & leiomyomata
Indications for hospitalization for PID
Pregnancy Failed outpatient treatment Inability to tolerate oral meds Noncompliant with therapy Severe presentation (High fever, vomiting) Complications (TOA, perihepatitis)
After aspiration/drainage of simple breast cyst, how soon should patient have follow up visit?
2 - 4 months for clinical breast examination
If symptoms did not recur, annual screening may resume
Complex multiloculated adnexal mass
Thick walls
Internal debris
Tubo-Ovarian Abscess
Complication of PID in reproductive-age women
Presents with fever, abdominal pain
Comes with leukocytosis, elevated CRP & CA-125
Normal internal genitalia
External virilization
Undetectable serum estrogen levels
Aromatase deficiency
Transient masculinization of mother that resolves after delivery.
Female infant has normal internal genitalia nad ambiguous external genitalia due to high levels of gestational androgen
Adolescence shows delayed puberty, osteoporosis, undetectable estrogen (so no breasts)
At what level of Beta-hCG should an IUP be detectable on TVUS?
1500 - 2000
If beta-hCG is lower and no IUP is seen, re-measure hCG again in 2 days, repeating TVUS once beta-hCG is within range.
Risk factors of breast cancer
1 in 8 women have a lifetime risk in the USA
Increases with increased lifetime estrogen exposure: Chronological age Nulliparity Obesity Prolonged HRT
What is the role of hCG in normal pregnancy?
Secreted by syncytiotrophoblast
Preserves corpus luteum during early pregnancy to maintain progesterone secretion until placenta can take over.
Production of hCG begins ~8d after fetilization
Levels double every 48 hours until they peak at 6 - 8 weeks gestation
Alpha-subunit is common to hCG, TSH, LH & FSH
How do you treat vesicovaginal fistula?
Catherization in the immediate postop period
Surgical correction if you miss that window
All patients with HSIL (regardless of if they are pregnant or not, regardless of HPV status) should be evaluated how?
Colposcopy!
If efidence of invasive cancer is found, proceed to LEEP, regardless of pregnancy status
When do you do HPV testing in a gynecological visit?
ASCUS & LSIL
If positive, progress to colposcopy
Medications that commonly cause urinary incontinence in the elderly
Alpha-adrenergic antagonists (urethral relaxation)
Anticholinergics, opiates, CCBs (urinary retention/overflow)
Diuretics (excess urine production)
Reversible causes of urniary incontinence
DIAPPERS
Delirium Infection Atrophic urethritis/vaginitis Pharmaceuticals (alpha blockers, diuretics) Pscyhological (depression) Excessive urine output (DM, CHF) Restricted Mobility (Postsurgery) Stool impaction
Ideal time to examine a breast for masses
5 - 10 days after menses (follicular phase)
Fibroadenoma vs Fibrocystic changes
Fibroadenoma is one well-circumscribed lesion
Fibrocystic changes are multiple, small, cyclically tender masses (diffuse breast nodularity)
If lactation mastitis progresses to abscess
Needle aspiration
Antibiotics (Dicloxacillin, cephalexin)
Continue breastfeeding
Fluctuant, tender, palpable mass in the setting of lactation mastitis
It progressed to an abscess!
Sexually active young woman who doesn’t use contraception with lower abdominal pain, RUQ pain & a negative pregnancy test
PID progressed to Fitz-Hugh Curtis
Sjogren Syndrome
Autoimmune disorder
Inflammation of the exocrine glands
Can occur isolated or with other autoimmune disease
Dry mucous membranes
Dental caries
Dry eyes
Cough
Sicca Syndrome
From impaired function of salivary & other exocrine glands in Sjogren Syndrome
Extraglandular features of Sjogren Syndrome
Raynaud Phenomenon Arthritis Cutaneous Vasculitis Respiratory Manifestations Significant risk for non-Hodgkin Lymphoma
Respiratory Manifestations of Sjogren Syndrome
Nonallergic Rhinitis
Bronchiectasis
Large & Small Airway Disease w/ impaired mucociliary clearance
Interstitial Lung Disease
AUB that normally follows menarche
Initial menstrual cycles are irregular and anovulatory
Due to immaturity of developing HPA
Inadequate quantities & proportions of GnRH
Leads to inadequate release of LH & FSH
Ovulation skips a cycle & menstruation lacks its regular periodicity.
Between cycles, you get breakthrough bleeding because the endometrium built up too much.
Initial workup for AUB
Administer exogenous progesterone
If bleeding ensues, we can exclude primary ovarian insufficiency, endometrial abnormalities (like adhesions) & outlet tract abnormalities (like imperforate hymen).
Treatment of AUB in adolescents early in their development
If bleeding is disruptive, heavy or leads to anemia:
Progestin-only or Estrogen/Progestin OCPs
Anovulation resolves 1 - 4 years postmenarche
Hormonal abnormalities in PCOS
Excess LH Secretion
Excess Androgen
Hyperechoic nodules & calcifications on ultrasound of adnexa
Dermoid ovarian cyst (mature cystic teratoma)
Treatment = Removal of cyst
First line study to assess palpable breast mass in women >= 30
Mammography
Ultrasound can provide added characterization of it
Tissue biopsy is required to confirm
Progesterone’s normal role in menstrual cycle
Stabilizes endometrial proliferation
Causes differentiation into secretory endometrium
Cyclic withdrawal of progesterone causes menstruation
First line treatment of PCOS to restore menstruation in obese patients
Weight Loss decreases peripheral estrogen conversion
If unsuccessful, Clomiphene Citrate is second line
Clomiphene Citrate
SERM
Blocks estrogen receptors at hypothalamus
Inhibits negative feedback of pulsatile GnRH secretion
Normalizes LH & FSH levels
Creates an LH Surge
Restores ovulatory cycle, even in the presence of excess estrogen
Adverse Effects of SERMs
Hot Flashes
Venous Thromboembolism
Endometrial hyperplasia & carcinoma (Tamoxifen only)
History of Cancer
Amenorrhea
Signs of Estrogen Deficiency
Ovarian failure 2/2 Chemo
LH & FSH are high (Lack of Feedback)
Diagnostic workup of unilateral and/or bloody nipple discharge without presence of palpable breast mass
Mammogram (Often normal in intraductal papilloma)
Ultrasound (May show dilated duct in intraductal papilloma)
Diffuse breast erythema
Edema
Peau d’Orange
Inflammatory Breast Cancer
Mammogram reveals Mass, Calcification, Parenchymal Distortion
Fixed palpable breast mass
Irregular borders
Oft bilateral
Lobular Breast Carcinoma
Eczematous nipple changes that include the areola
+/- Bloody discharge
Paget Disease of the Breast
Oral levonorgestrel
Plan B (Progestin)
Delays ovulation
Efficacy decreases over the course of 72 hours
Should be administered as soon as possible after intercourse
Ulipristal
Emergency Contraception (Antiprogestin)
Delays follicular rupture Inhibits ovulation Impairs implantation More effective than levonorgestrel Can be taken up to 5 days after intercourse
Difficult to obtain in some settings
Medical emergency contraceptives
Oral levonorgestrel (progestin) - give within 3 days Ulipristal (antiprogestin) - give within 5 days
Most effective emergency contraceptive
Copper IUD
Misoprostol
Prostaglandin analog
Used with mifepristone (Progesterone blocker) for medical abortion
Stimulates uterine contractions
Risk factors for Rectovaginal Fistula
Poor intrapartum care
Long second stage of labor
(leads to ischemic pressure necrosis of rectovaginal septum)
Third or Fourth degree laceration
Presentation of Rectovaginal Fistula
Incontinence of flatus (through vagina)
Incontinence of fecal material (through vagina)
Malodorous brown/tan discharge
Diagnosis of Rectovaginal Fistula
Visual exam:
Dark red, velvety rectal mucosa on posterior vaginal wall
Treatment of Rectovaginal Fistula
Surgical repair
Lichen Sclerosus
Chronic inflammatory condition of anogenital region
Can affect women of any age
Can have autoimmune pathogenesis
Often coexists with other autoimmune conditions (DMI, Thyroid abnormalities)
Extragenital involvement is possible
“Figure of 8” pattern when perianal skin is involved too
Symptoms of Lichen Sclerosus
Intense pruritus
Dyspareunia
Dysuria
Painful defectaion
Porcelain-white polygonal patches w/ atrophy of normal genital structures
“Cigarette Paper” skin (thin, white, crinkled)
Lichen Sclerosus
Diagnosis of Lichen Sclerosus
Can be clinical
Punch biopsy is recommended for definitive diagnosis
Lichen Sclerosus can lead to
Vulvar Squamous Cell Carcinoma
Treatment of Lichen Sclerosus
High potency topical corticosteroids
Clobetasol is ultrapotent & first-line
It is not known whether corticosteroids can prevent scarring and squamous cell carcinoma
If you apply more than once daily, you increase adverse effects, including skin atrophy, discoloration, striae
Fixed Mass
Skin or Nipple retraction
Calcification on mammography
Ultrasonography demonstrates hyperechoic mass
Biopsy shows fat globules & foamy histiocytes
Fat necrosis
Often mass is excised due to concerning findings of calcifications on mammography in constellation with fixed irregular mass on physical exam
After excision, routine annual screening for breast cancer may resume normally.
Treatment of asymptomatic bartholin cyst
Observation
It may resolve on its own
Treatment of symptomatic bartholin cyst
Incision & Drainage
Placement of Word catheter
Hallmarks of Endometriosis
Dysmenorrhea
Dysparunia
Dyschezia
Also pelvic pain & infertility
First-line empiric treatment for endometriosis
NSAIDs Combined OCPs (suppression of ovulation may result in atrophy of endometriomas)
Laparoscopic evaluation for those who fail conservative treatment or have adnexal masses or infertility
Vaginal pain on insertion
No dysmenorrhea
No dyschezia
Vaginismus (involuntary contraction of vaginal musculature interfering with sexual intercourse)
Try vaginal dilators
Pathophys of Hypogonadotropic Hypogonadism
Excessive stress, weight loss or chronic illness leads to decrease in amplitude & frequency of GnRH pulses.
Pituitary LH & FSH production decreases
Ovarian estrogen production decreases
Ovulation doesn’t occur
Oligomenorrhea/amenorrhea & infertility ensue
Physical exam is typically normal (maybe low BMI)
Treatment of hypogonadotropic hypogonadism
Management of underlying cause
Reduce stress, gain weight, manage illness
At what Tanner Stage should menses be expected?
4
Premenarchal patients age < 15 with normal breast & pubic hair development require what evaluation?
None until they reach 15 and nothing has changed!
Preferred diagnostic modality for suspected gynecological tumors
Ultrasound
Phyllodes Tumor
Rare breast mass
Unilateral
Smooth
Painless
Mobile firm breast lump of variable size
Female Phenotype Normal Ovaries Abnormal Vagina (short) Absent Uterus
Mullerian Agenesis
aka Mayer-Rokitansky-Kuster-Hauser Syndrome
46 XY Genotype Male internal genitalia Female (or undermasculinized) external genitalia Experience masculinization at puberty Lack breast development
5-Alpha-Reductase Deficiency
Can’t convert Testosterone to Dihydrotestosterone (DHT)
46 XY Genotype External Female Genitalia Minimal-to-Absent Body Hair Breast Development Cryptorchid gonads
Complete Androgen Insensitivity Syndrome
Peripheral tissues unresponsive to androgen
Testosterone is aromatized to estrogen, patient develops phenotypically female, with cryptorchid testes
Orchiectomy after puberty
Why do we wait until after puberty to remove cryptorchid gonads from patients with Androgen Insensitivity Syndrome?
Risk of Dysgerminoma or Gonadoblastoma is 1 - 5% AFTER puberty.
Risk of malignancy before puberty is outweighed by benefits of gonad-stimulated puberty (attaining adult height)
Which type of breast cancer do BCRA2 carriers tend to have?
Estrogen Receptor (+)
Patient with breast cancer wants contraceptives. What do you give her?
Copper IUD
Pregnancy is contraindicated in breast cancer patients
So is hormonal birth control
Fever
Hypotension
Diffuse maculopapular rash including palms and soles
Desquamation 1 - 3 weeks after disease onset
Vomiting/Diarrhea
AMS w/o focal neuological signs
Toxic Shock Syndrome
Staph Aureus or GAS
Exotoxin release acting as superantigens
Remove foreign body, give fluids & MRSA coverage
At what age does Pap testing begin in immunocompetent patients?
21 years old, regardless of age of coitarche
Dysmenorrhea
Heavy Menstrual Bleeding
Starts later in reproductive years
Progresses to chronic pelvic pain
Boggy, tender, uniformly enlarged uterus
Adenomyosis
Endometrial glands are trapped within myometrium
Typically multiparous women > 40
Athlete’s Triad of Hypothalamic Amenorrhea
Amenorrhea
Osteoporosis
Eating Disorder
Hypothalamic Amenorrhea
Relative caloric deficiency 2/2 inadequate intake compared to energy expended.
GnRH, FSH/LH & Estrogen are all low
These women are at risk for estrogen deficiency conditions:
Infertility
Vaginal Atrophy
Breast Atrophy
Decreased bone mineral density (Stress Fractures)
Primary Ovarian Insufficiency is associated with
Concomitant Autoimmune Disorder
OR
Turner Syndrome
When do you look at a CA-125?
When pelvic ultrasonography reveals an ovarian mass in a postmenopausal patient, and you would like to classify it as malignant or benign.
Ovarian mass in a postmenopausal patient
Ultrasound shows simple cyst
CA-125 is normal
Observe
Ovarian mass in a postmenopausal patient
Ultrasound shows large size, septations or solid components
Undergo further imaging (MRI/CT) to assess extent of disease
Ovarian mass in a postmenopausal patient
CA-125 is elevated
Undergo further imaging (MRI/CT) to assess extent of disease
Recurrent oral aphthous ulcers (painful)
Systemic Manifestations
Genital Ulcers (Painful)
Behcet Syndrome
Thought to be a vasculitis
Multiple deep ulcers (Painful)
Base has grey-to-yellow exudate
Organisms clump in long parallel strands (“School of Fish”)
Chancroid
H. Ducreyi
Multiple small grouped ulcers (Painful)
Shallow w/ erythematous base
Multinucleated giant cells & Intranuclear inclusions (Cowdry Type A)
Herpes Simplex 1/2
Extensive & progressive ulcerative lesions (Painless) without lymphadenopathy
Base may have granulation-like tissue
Deeply staining gram-negative introcytoplasmic cysts (Donovan bodies)
Granuloma Inguinale (Donovanosis)
Klebsiella Granulomatis
Single, indurated, well-circumscribed ulcer (Painless)
Clean base
Bilateral inguinal lymphadenopathy
Thin, delicate, corkscrew-shaped organisms on darkfield microscopy
Syphilis
Treponema Pallidum
Small & shallow ulcers (Painless)
Large, painful, coalesced inguinal lymph nodes (“Buboes”)
Intracytoplasmic inclusion bodies in epithelial cells & leukocytes
Lymphogranuloma Venereum
Chlamydia Trachomatis
Most common cancer in the vagina
Metastatic direct spread from cervix, vulva, or endometrium
Type of cancer in primary vaginal cancer
Squamous Cell Carcinoma (commonly upper 1/3)
Diagnose: Biopsy
Symptoms: Bleeding, malodorous vaginal discharge
Risk factors: Smoking, HPV
Evaluation of refractory endometriosis
Laparoscopy
Definition of Menopause
Absent menses for 12 months
Management of uncomplicated ovarian cyst rupture with no fever, hypotension, tachycardia or signs of hemoperitoneum/infection
Outpatient analgesics
Patient presents for infertility & endometriosis is diagnosed. How do we improve her fertility?
Surgical resection of endometriomas
When was DES widely used?
1938 - 1971
It’s a synthetic estrogen given for prevention of Spontaneous Abortion, Premature Delivery & Postpartum Lactation Suppression
Effects of in-utero exposure to DES
Women are at risk of:
Clear Cell Adenocarcinoma of vagina & cervix (40-fold risk increase)
Men are at risk of: Cryptorchidism Microphallus Hypospadias Testicular hypoplasia
Irregular polypoid mass on anterior vaginal wall
Clear Cell Adenocarcinoma of the Vagina & Cervix
Think DES exposure in-utero
When do we stop Pap testing?
Age 65 or Hysterectomy
PLUS
No history of CIN2 or higher
AND
3 consecutive negative Pap tests OR 2 consecutive co-testing results
What malignancy are PCOS patients most likely to develop?
Endometrial
Chronic anovulatory cycles lead to decreased progesterone secretion (no corpus luteum), and overproliferation of endometrium
Treat with cyclic progesterone, combined OCPs or progesterone IUD to reduce cancer risk
What syndrome are adrenocortical malignancies associated with?
Li-Fraumeni
Malodorous, thin white vaginal discharge
In absence of inflammation
Bacterial Vaginosis
Amine odor on KOH whiff test
Clue Cells on microscopy
Treat with metronidazole or clinda
What causes anovulation in PCOS?
High estrone (increased peripheral conversion & decreased sex hormone binding globulin) provides negative feedback to the hypothalamus, so GnRH is not released.
FSH is low, so follicle doesn’t mature
LH is low, so follicle doesn’t release
Gonadotropin levels in Primary Ovarian Insufficiency
GnRH is elevated
FSH is elevated
Estrogen is low
Failure is at the level of the ovaries, so the rest of the pathway is trying to rev them up.
Origin site of Epithelial Ovarian Carcinoma
Ovary
Fallopian Tube
Peritoneum
Can start with any of these! Metastasizes all over abdomen regardless of primary origin.
Definition of preeclampsia
New-onset hypertension
And/or
Signs of end-organ damage at >= 20 weeks gestation
