OB/GYN IV Flashcards
When is a pelvic exam indicated in an adolescent patient
Abnormal symptoms
sexually active
What are the common vulvovaginal lesions
- Lichen sclerosus et atrophicus
- Trauma
- Labial agglutinations
- Prolapsed Urethra
- Vaginal discharge
What is the treatment of lichen sclerosus
improved personal hygeine is the first step
What is labial agglutination
result from vulvat inflammation or skin disease, and the hypoestrogentic state. It is the adhesion of the labia minora in the midline
What is the most often malignant vaginal tumor
Sarcoma botryoides
How will sarcoma botryoides present
arises from mesenchymal tissue of the cervix or vagina, usually on the anterior wall of the upper vagina. Grows rapidly, fills the vagina, and then protrudes through the introitus
What are the 2 groups of ovarian tumors
Non germ cell (40%) Germ cell (60%)
What are the non germ cell origins tumors
lipoid cell tumors (estrogen producing)
Granulosa-theca cell tumor (Estrogen producing)
What are the germ cell origin tumors
- benign cystic teratomas
- benign cysts
- Arrhenoblastomas (androgen producing)
- Dysgerminomas and gonadoblastomas
- Endodermal sinus tumors
- Embyonal carcinomas (hCG secreting tumros)
- Immature teratomas
What is MRKH syndrome
Vaginal and uterine agenesis. Represents a failure of the caudal mullerian duct to fuse with the urogential sinus
What are some causes of amibiguous genitalia
- Congenital Adrenal Hyperplasia (CAH)
- Adrenal Tumors
- Maternal ingestion of androgenic substances
- Childhood ingestion of androgens
- Androgen insensitivity syndrome (AIS)
What is the average age of onset of puberty
9 years
What is responsible for initiation of puberty
Increased production of LH and FSH
When is the peak growth velocity
11 - 12 years, usually 1 year before menarche
When does thelarche begin
9-11
It is usually completed over a 3 year period
It is a sign of ovarian estrogen production
What is adrenarche
refers to the production of androgens from the adrenal gland
What is pubarache
the development of axillary and pubic hair that results from the adrenal and gonadal androgens.
Usually follows thelarche
What is the average age of onset of menses
12-13
What is precoious puberty
secondary sexual characteristics before 8 years of age in caucasion girls and 7 years in african americans
What is delayed puberty
characterized by the absence of breast development by age 13 or the absence of menses by age 16
what is swyner syndrome
(46, XY)
characterized by a female phenotype with amenorrhea and lack of secondary sex characteristics
Inherited as X linked recessive
At what age will menses cease to occur spontaneously
40-58
90% between 45 and 55
What is premature menopause
permanent cessation of menses ocurring before age 40
What is the hallmark of reproductive aging
elevation of FSH to greater than 10 IU/mL in the early follicular phase (between day and day 5 of the menstrual cycle)
When menses have been absent for 1 year, FSH levels are persistently greater than 30 IU/mL
Discuss the physiology of menopause
FSH receptors are absent on a cellular level which causes a decrease in estradiol levels. Estrone is also reduced, but to a lesser degree because of its ability to be converted in the periphery from androstenedione
Ovarian stromal cells still posses LH receptors and they will respond with the production of ovarian androgens
How does obesity effect levels of estrogen
Adipose tissue contains aromatase enzymes.
What is the function of the aromatase enzymes
convert androgens to estrone
What are the circulating levels of testosterone in the menopausal state.
Free and unbound circulating testosterone is increased because of a 40% reduction in the SHBG. SHBG production is stimulated by estrodiol.
What is the most common cause of premature menopause
women have undergone premature oocyte atresia and follicular depletion from 1 of 3 mechanisms:
- decreased initial germ cell number at birth
- Accelerated oocyte atresia after birth
- Postnatal germ cell destruction
What are the manifestation of estrogen excess
- AUB
a. Anovulatory cycles
b. Obesity
c. tumors
d. other causes not related to hormones - Endometrial hyperplasia
What should be suspected in all perimenopausal women who present with abnormal bleeding
Endometrial cancer
10% of bleeding postmenopausal is related to endometrial cancer
What are the symptoms traditionally attributed to menopause
Hot flashes Headaches Sleep disturbances Mood disturbances Sexual function changes Weight gain
What are the treatment options for menopause
Progestin supplementation for estrogen excess
Combination hormone contraception therapy for women who are normotensive nonsmokers without other risk factors
Hormone therapy in a subcontraceptive dose. Progestin is added to the dose in all women that still have their uterus
NSAIDs to reduce menstrual bleeding
What are the progestin supplementation options available for treatment of menopause
MPA (medroxyprogesterone acetate)
Norethindrone acetate
Oral micronized progesterone
Progestin containing intrauterine system
What are the target organ responses to decreased estrogen
- urogenital atrophy: vagina, urethra, bladder and pelvic floor are estrogen responsive tissue
- Uterine changes
- Breast changes
- Skin changes
- Hair changes
- CNS changes
- Cardiovascular changes
- VMSs Vasomotor symptoms
- Altered menstrual function
- osteoporosis
What is the mechanism behind VMS
the result of inappropriate stimulation of the body’s heat releasing mechanisms by the thermoregulator centers in the hypothalamus.
Characterized by progressive vasodilation of the skin over the head, neck and chest
When estrogen is contraindicated, what treatment options are available for VMS
progestogen clonidine gabapentin herbal remedies SSRI's in low dose
What is the gold standard for monitoring bone loss
Dual energy x ray absorptiometry (DEXA) scan
What is the definition of osteoporosis
DEXA scan score T of -2.5 or less
What is the definition of osteopenia
DEXA scan score T of -1 to -2.5
What can be done to help prevent osteoporosis
adequate calcium intake vitamin D weight bearing exercise reducing the risk of falling decrease smoking and alcohol consumption
What amount of calcium is recommended daily after the age of 50
1500 mg of elemental calcium daily through diet or supplements
What amount of vitamin D is recomended daily for prevention of osteoporosis in postmenopausal women
600-800 daily. Up to 2000 IU/day is considered safe
What medications are available to limit bone loss
- Bisposphonates
- SERMs (selective estrogen receptor modulators)
- Calitonin
- HT and ET
- Teriparatide
What is teriparatide
daily injection for up to 18-24 months. It has an anabolic bone effect and decreases vertebral and nonvertebral fractures
What are the risks to HT (hormone therapy)
Endometrial cancer if using estrogen only in women with a uterus. Add progestin to women with a uterus
Abnormal bleeding
Increased risk of breast cancer with progestin and estrogen combination therapy
What are the absolute contraindications to HT
- undiagnosed abnormal genital bleeding
- known or suspected breast cancer or estrogen dependent neoplasia
- active or history of thrombosis
- history of stroke or MI in the previous year
- known or suspected pregnancy
- known hypersensitivity to HT/ET
What are the common scheduling of HT
Cyclic therapy: Continuous estrogen therapy is given with progestin added for 12-14 days each month.
Continuous combined therapy
What are the availble routes of administration for HT
Systemic: transdermal patches percutaneous gel or emulsion vaginal ring oral estrogen or estrogen + progestin
Local:
topical estrogen
progestin containing intrauterine device
What are the age risk appropriate screening for post menopausal women
lipid profile: every 5 years beginning at 45
fasting blood sugar: every 3 years at 45
TSH: every 5 years at 50
Mamography: every 1-2 years at 40 then every year at 50
cervical cytology: every 1-3 years hx dependent
Osteoporosis: at age 65
Colon cancer: start at 50 with yearly fecal occult blood, 5 years for flexible sigmoid or 10 years for colonoscopy
What will latex condoms protect against
Herpes simplex Neisseria gonorrhoeae chlamydia trachomatis Ureaplasma urelyticium mycoplasma hominis Trichomonas vaginalis Treponema pallidum HIV
NOT HPV
Do natural or non latex condoms protect against most STD’s
no
What are the time constraints with using a female condom
can be inserted up to 8 hours in advance, but must be removed immediately after each act of intercourse
DO NOT USE WITH A MALE CONDOM
Is there a benefit of using a spermicide in addition to condom alone
no change in effectiveness
What are the types of barrier methods
condoms spermicides vaginal sponges diaphragms cervical caps
What is problem with prolonged or repetitive use of spermicide
damgages the vaginal epithelium and increases the risk of an HIV infection
What is the time constraint with using a diaphragm
must be left in place at least 6 hours after intercourse
What is an advantage of a cervical cap
can be left in place up to 48 hours after intercourse
What are the types of IUD
Paragard: Copper - good for 10 years
Mirena: Levonorgestrel 20 - good for 5 years
What is the mechanism of action for paragard
copper itself acts as a spermicide
IUD causes a local, sterile inflammatory reaction in the uterus and the intrauterine environment becomes spermicidal
What is the mechanism for mirena
exerts its contraceptive effect locally on the endometrium and the cervix. Progestin alters the endometrium, rendering it unfacvorable from implantation.
Thickening of the cervical mucosa makes the passage of sperm more difficult. Uterine and tubal motility are impaired
When can the types of IUD be implanted
Paragard (copper) any time in menstrual cycle
Mirena (levonorgestrel) inserted with in the first 7 days of the menstrual cycle
What is the mechanism of progestin only contraception
- diminishing and thickening cervical mucus, preventing sperm penetration
- Produces a thin, atrophic endometrium, precluding implantation
- Reduces the ciliary action of the fallopian tube, preventing sperm and egg transport
- Diminishing the function of the corpus luteum
- Occasional inhibition of ovulation by suppressing the midcycle peaks of LH and FSH
What is a benefit for a post partum progestin only contraception
no alteration of milk production and nearly 100% effectiveness in breast feeding women
What is the injectable progestin
Depo-provera: medroxyprogesterone
Deep IM injection every 12 weeks
Efficacy is less than 1 in 100
What are the implantable progestin
Implanon: 3-keto-desogestrel
serum hormone remains adequate for 3 years
Higher frequency of oligo and amenorrhea
What is the mechanism of combination oral contraceptive pills
Primary mechanism is inhibition of the LH surge
- Suppresses ovulation
- Thickening of the cervical mucus
- Alteration of tubal motility
- Alteration of endometrium to make it thin and inactive, thus hampering implantation
What specific effects does estrogen have on clotting factors
increase in serum levels of several clotting factors, especially factor VII.
Antithrombin III levels fall with in 10 days of starting OCPs
These risks are still lower than the coagulative state of pregnancy
Name the 3rd generation OCPs
gestodene
desogesterol
Name the 2nd generation OCPs
norethindrone
Levonorgesterel
What is the difference of clotting factor between the 2nd and 3rd generation OCPs
3rd generation has a greater risk
What is the problem with using OCPs in women with inherited thrombophilias
Antithrombin III, or protein C or S defects have a 6 times greater risk
Factor V leiden has a 10 times greater risk
Prothrombin mutation has a 7 times greater risk
How is hypertension affected with use of OCPs
Plasma renin activity, angiotensin levels, aldosterone section, and renal retention of sodium are all increased in OCP users
Normotensive levels return in almost all women who developed hypertension while taking OCPs when the contraception is stopped
Smoking and OCPs….
synergistic effect in the CV system, do not do it
How is the liver effected with OCP usage
greater than 5 years increases the risk of hepatocellular adenoma
What effect does progestin have on breast tissue
antagonizes the stimulating effects of estrogen
There is no increase in risk even in patients with family history of breast cancer
What effect does progestin have on the endometrium
protective effect and decreases risk of cancer by 50% up to 15 years after taking them
What effect do OCPs have on the ovaries
suppress ovarian activity and inhibit ovulation; the interuption of a significant number of ovulatory cycles in oral contraceptive users may lead to a decreased incidence of ovarian cancer.
Users of OCPs are less likely to develop ovarian cancer up to 15 years after taking them
How does OCP effect hirsutism and acne
decreasing production of androgens by the ovary and adrenal and increasing sex hormone binding globulin production by the liver
What is the NuvaRing
contraceptive device consists of a 5.4 cm flexible ring made of ethylene vinyl acetate copolymer containing ethinyl estradiol and etonogesterel. The ring is inserted into the vagina and the hormone is absorbed systemically
The ring is worn for 3 weeks and 1 week off.
What is ortho Evra
Transdermal patch. Once weekly contraceptive patch releases norelgestromin, the active metabolite of norgestimate, and ethinyl estradiol daily to systemic circulation.
3 weeks on and 1 week off
May be associated with greater risk of VTE than OCPs
What are the options for emergency contraception
Morning after pill:
- Yuzpe method (combination of ethinyl estradiol 100 microgram and 1 mg norgestrel)
- Progestin only (more effective) 1.5 mg single dose; less effective 0.75 mg 2 doses over 12 hours
- Plan B (OTC for over 18)
Copper IUD
Mifepristone: Single oral dose of 600 mg has 100% efficacy
What is the basis of natural family planning to prevent conception
must restrict sexual intercourse from the end of menses to 1-2 days after the in increase of basal body temperature of 0.4 to 1.0 degrees
What are the markers used in natural family planning
Fertility awareness
Basal body temperature
Menstrual calendar
Cervical secretions
Based on cervical secretions when is a woman most fertile
secretions are abundant, clear or white, slippery and stretchy
What are the bacterial sexually transmitted diseases
Gonorrhea chlamydia chancroid Granuloma inguinale Bacterial vaginosis Lymphogranuloma venereum
Where does neisseria gonorrhoeae have a predilection for
columnar and transitional epithelium
Women: cervicitis urethritis PID acute pharyngitis
Men:
urethritis
prostatis
epididymitis
What is the problem with gonorrhea effecting newborns at birth
blindness
infection of the joints
sepsis
Are men or women typically more symptomatic with a gonorrhea infection
men
When will symptoms present with a gonorrhea infection
2-5 days after exposure, but may not be evident for 30 days.
what culture medium is selective for N. gonorrhoeae
Thayer-Martin culture medium
What are the diagnostic testing options available for diagnosing N. gonorrhoeae
Thayer-Martin culture medium
gram stain
(NAAT) Nucleic acid amplification test
What should be considered when choosing a treatment option for gonorrhea
it is often with a coinfection of chlamydia trachomatis. Consider using a treatment plan that covers both options
What are the treatment options for gonorrhea
- Cephalosporins:
a. cefixime 400 mg PO
b. ceftriaxone 125 mg IM (pharyngeal infection) - Quinolones (No prego or under 18)
a. Ciporfloxacin 500 mg PO
b. Ofloxacin 400 mg PO
c. levofloxacin 500 mg PO - Spectinomycin 2g IM
- Azithromycin 2g PO single dose
What treatment options are recomended for coinfection of gonorrhea and chlamydia
add either:
azithromycin 1g PO or
doxycycline 100 mg PO BID for 7 days
What is the problem with using NAAT to follow up on treatment success
can remain positive for up to 3 weeks post treatment
What is chlamydia
a genus of obligatory gram negative intracellular bacteria
most commonly reported STD
Are women typically symptomatic with a chlamydia infection
no
What is the clinical presentation of a woman with a chlamydia infection
mucopurulent cervicitis urethritis pyuria negative urine culture Fever and lower abdominal pain (PID)
How is chlamydia diagnosed
culture from endocervix in women an urethral swab in men (gold standard)
NAAT: PCR or LCR
What are the treatment options for chlamydia
- doxycycline 100 mg PO BID for 7 days
- Azithromycin 1 g PO
- Ofoxacin 400 mg PO BID for 7 days
- Erythromycin base 500 mg PO QD 7 days
- Levofloxacin 500 mg PO 7 days
What causes chancroid
Haemophilus ducreyi
What is chancroid
a known cofactor in HIV transmission
lesions begin as small papules and progress to painful genital ulcers in 2-3 days.
What is the incubation time for chancroid
3-5 days
How is the diagnosis of chancroid determined
Probable diagnosis is made when painful genital ulcers are present without eveidence of herpes (culture) or syphilis (darkfield examination and serologic study)
What is the treatment of chancroid
- Azithromycin 1 g PO
- Ceftriaxone 250 mg IM
- Ciprofloxacin 500 mg PO BID for 3 days
- Erthromycin base 500 mg PO TID 7 days
What is granuloma inguinale
genital ulcerative disease, which is also known as donovanosis, is caused by klebsiella granulomatis, a gram negative intracellular bacterium
What is the clinical presentation of granuloma inguinale
affected individuals present with a painless, beefy red, friable ulcerative lesion without regional lymphadenopathy, but with accompanying inguinal join swelling caused by subcutaneous spread of granuloma
What are the treatment options for granuloma inguinale
- Doxycycline 100 mg PO BID 21 days
- TMP-SMX 160mg/800mg PO BID 21 days
- Ciprofloxacin 750 mg PO BID 21 days
- Erythromycin base 500 mg PO QD 21 days
- Azithromycin 1 g PO 21 days
What causes Bacterial Vaginosis
the replacement of the normal H202 producing lactobacillus with high concentrations of other bacteria, such as Garnerella vainalis, mobiluncus, Bacteroides, and mycoplasma.
How is the clinical diagnosis of BV determined
3 of the following criteria
- Homogenous, grayish, noninflammatory discharge that adheres to vaginal walls
- saline preparation of vaginal secretions that reveals squamous cells whose borders are obscured by coccobacillary forms, known as clue cells.
- pH of secretions greater than 4.5
- fishy odor after addition of 10% KOH (whiff test)
- DNA probe test
What is the treatment for BV
- Metronidazole 500 mg BID 7days
- Metronidalzole gel one applicator intravaginally per day for 7 days
- Clindamycin cream one applicator intravaginally QHS
What is lympgranuloma venereum (LGV)
rare in US
requires a 21-34 day incubation period and primary genital ulcers appear at the site of inoculation
diagnosis made by exclusion
What is the treatment for LGV
- doxycycline 100 mg BID for 21 days
2. Erythromycin 500 mg QD for 21 days
What is the cause of syphilis
Treponema pallidum
What are the signs and symptoms of primary syphilis
THE GREAT IMITATOR
Initial lesion of primary syphilis is a painless, ulcerated, hard chancre, usually on the external genitalia.
What is the incubation period for primary syphilis
10-90 days for the lesion
lesions usually resolve in 2-6 weeks
What is secondary syphilis
Untreated patients, the chancre is followed in 6 weeks to 6 months by a secondary or bacteremic stage in which the skin and mucous membranes are affected.
A maculopapular rash of the palms, soles and mucus membranes occur. Condyloma latum and generalized lymphadenopathy are seen as well. Lesions usually resolve with in 2-6 weeks.
What is tertiary syphilis
33% of untreated patients develop tertiary syphilis with multiple organ involvement.
Endarteritis leads to aortic aneurysm and aortic insufficiency, tabes dorsal is, optic atrophy and meningovascular syphilis as well as granulamotous lesions.
What is tabes dorsalis
slow degeneration (specifically, demyelination) of the sensory neurons that carry afferent information. The degenerating nerves are in the dorsal columns (posterior columns) of the spinal cord (the portion closest to the back of the body) and carry information that help maintain a person’s sense of position (proprioception), vibration, and discriminative touch.
What is the problem with congenital syphilis
stillbirth, nonimmune hydrops, jaundice, infant hepatosplenomegal and skin rash and pseudoparalysis of an arm or leg
How is syphilis diagnosed
Darkfield examination detects spirchetes in the primary and secondary stage
Serologic testing
- Nontreponemal:
a. RPR (rapid plasma reagin)
b. VDRL (Venereal Disease Research Lab) - Treponemal antibody tests
a. can remain positive for life
b. FTS-ABS (fluorescent treponemal antibody absorption)
c. TP-PA (T. Pallidum Particle agglutination)
What is Jarisch-Herxheimer reaction
an acute febrile reaction that may be accompanied by myalgias, headache, and other systemic symptoms, can occur within 24 hours after treatment of syphilis at any stage, especially early disease
What is the treatment of early syphilis
- Benazthine penicillin G 2.4 million units IM
- Doxycycline 100 mg BID 14 days
- Tetracycline 500 mg PO QD 14 days in nonpregnant penicillin allergic patients
What should be used in pregnant patients with syphilis and a penicilin allergy
Skin testing following penicillin desensitization. All other medications are contraindicated
What is the clinical presentation of HIV
80-90% are asymptomatic
Initial exposure of HIV results in a retroviral syndrome in 70%
- febrile phayngitis
- fever
- sweats
- myalgia
- arthralgia
- headache
- photophobia
Hos is HIV diagnosied
ELISA
enzyme linked immunosorbent assay
Positive ELISA followed by a western blot analysis
Viral load for acute retroviral syndrome cases
When should a patient be referred for treatment with HIV
asymptomatic: CD4 counts less than 300
symptomatic: CD4 counts less than 500
What is the incubation period for HPV
6 weeks to 18 months with a mean of 3 months
What types of HPV are strongly associated with CIN
16, 18, 31, 33, and 35
On colposcopy, what will the lesions look like for HPV
flat, small and acetowhite, with a vascular punctuation or mosaicism.
Histologically, these lesions reveal koilocytosis, acanthuses, ad variable nuclear atypia
What is the treatment of HPV warts
Patient applied methods
- Podofilox solution or gel
- Imiquimod cream
Provider applied methods
- Cyrotherapy
- Podophyllin resin
- Bicholor or tricholoracetic acid
- Surgical excision or ablation
