OBGYN Flashcards
What are the 3 signs seen on the cervix during pregnancy
? ligament assists w/ holding fallopian tubes and ovaries?
Chadwick: early inc vascularity
Goodell: cervical softening due to edema
Hegar: isthmus/uterus softening
Broad ligament- contains arteries, veins and nerves
What part of the broad ligament are the fallopian tubes in?
What are the 4 parts of the fallopain tubes?
Mesosalpinx
Infundibulum
Ampulla
Isthmus
Interstitial/intramural
What arteries feed blood to the ovaries
Where do these arteries drain to?
Ovarian/Uterine arteries through medulla
L ovary- L renal vein
R ovary- IVC
What are the two parts of the pelvis
What is the term of the head position desired for delivery
True: immobile/constraining
False: above linea terminalis; supports pregnant uterus
Occiput anterior- back of baby head facing mother anterior
What are the 3 baby head presentation positions possible for birth
What are the 3 pelvic landmarks
Vertex- occiput anterior?
Sinciput
Brow
Interspinous diameter
Transverse inlet
Obstetrical conjugate- needs to be 11cm for delivery
What are the two hip categories favorable for vaginal delivery?
What two categories are not favorable?
Gynecoid, Arthropoid
Android, Platypelloid
What mother position may help increase pelvic outlet diameter?
Linea terminalis is AKA and includes ? structures
McRoberts maneuver: hyperflexion of legs in dorsal lithotomy, inc by 1.5-2cm
AKA Innominate line, separates false/true pelvis Pubic crest Pectineal line Arcuate line Sacral ala Sacral promontory
What makes the bony pelvis
What part contains all of the abdominal organs?
Innominate bones
Sacrum
True/lesser pelvis
The false/greater pelvis is bound in what 3 locations
Where are the superficial vascular structures in the abdomen supplied w/ blood from and travel in ? direction
Lumbar vertebrae- post
Iliac fossae- laterally
Abdominal wall- ant
Femoral artery
Diagonal towards umbilicus
What vascular structures provide blood to the muscles and fascia of the anterior abdominal wall
What is the name of the c-section incision and what strucutres may be unintentionally hit?
External iliac vessels
Maylard
Inferior epigastric artery on lateral side of rectus belly
When entering through a Pfannenstiel incision, what is the risk?
Hypothalamus releases ?
Ant Pit releases ? to take affect on ?
Severing Iliohypogastric nerve, loss of sensation over lateral gluteal/hypogastric regions
GnRH
LH/FSH on ovaries
Ovaries release ? two hormones that conduct ? two functions
What is the only female organ not changed during pregnancy?
Estrogen: proliferative; helps endometrium grow
Progresterone: secretory; helps w/ glandular processes
Ovary
What are the 3 sources of gonad tissues
Mesothelium: lines posterior abdominal wall
Mesenchyme: embryonic CT
Primordial germ cell: earliest undiff sex cells
What is the sequence of differentiation of gonad development into ovaries
When does ovary/testis differentiation begin?
Mesothelium Gonad ridge Gonad cord Indifferent gonads Ovary
Begins: 5w of gestation
Committed: 7w of gestation
? ducts develop into testes
? ducts develop into ovaries
Testes only develop from the ducts if ? is avail, otherwise ovaries develop
T: mesonephric/wolffian by 7wks
O: paramesonephric/mullerian by 12wks
TDF
How is the male phenotype made?
What hormone has no role in the gonad differentiation process?
Undifferentiated gonad + Y chromosome= TDF
Testes= MIF, T, DHT:
testes development, testosterone, mullerian inhibiting factor, fusion of labial folds, growth of phallus/prostate
Estrogen
What processes occur prior to gonadal differentiation?
Ovary can be histologically identified by ? wk but isn’t truly developed until ? wk
?wk does the cortical cords break down and into ?
Germ cells migrate to ridges/cords
10 and 12
16wk into premordial follicles
Primordial germ cells contain ? which derive from ? tissue
While still in a fetus, what replication process are the oogoniums doing?
Oogonium
Mesoderm, surface epithelium
Mitosis- diploid 46xx
By 20th wk of development, oogonium are committed and stop/rest at ? step of replication?
8-12wks of gestation, Hcg peaks and stimulates production of ? signaling the start of ?
Prophase I
Testosterone
Anti-mullerian hormone
Gonadal differentiation
What male/female organs are present at 9wks of development
11wks?
12wks?
Penis Clitoris Minora
Majora Scrotum
External urethra
M: Prepuce, scrotal raphe
F: Clitoris, mons, vaginal orifice
Define Didelphys
Define Bicornuate uterus
Define Bicornuate w/ rudimentary horn
Define Septate
Define Unicornuate
Inferior duct fails to fuse, single or double vagina
Duplicated upper uterus body
Slowed growth of one duct, no fusion
Failure of resorption, septum
One duct fails to develop; PT fertile but risk of preterm delivery/loss
Define Ovotesticular DSD
What is an example of this
What can cause this example
Chromatin +
Most 46XX w/ ovotestis
M or F w/ ambiguous genital
46XX:
+ ovary, ambiguous externals
Excess androgens= virilization (fusion, hypertrophy, sinus)
+ Wolf and Muller cells
Causes:
Impair Fetal Steroidgenesis- CAH (no 21 hydroxylase)
Mother took androgens
Luteoma: masculinizing tumor
46XY DSD
D/o of testicular development= dec production of T/MIS, causes low virilization
Chromatin -
Define Androgen Insensitivity Syndrome
Kallmann Syndrome
Genotype: male
Phenotype: female
Female genital Abdominal/inguinal testis
No masculinization, menses
Partial: point mutation on androgen receptor gene
Kallman: Hypo Hypo; anosmia
Dec FSH LH and E
SECONDARY Hypogonadism
Klinefelter Syndrome
Turner Syndrome
Why is it life saving to Dx infants w/ DSD early in life
47XXY 1* hypogonadism
Dec T, Inc LH/FSH
45XO 1* Hypogonadism
Hypergonadtropic hypogonadism
Dec E, Inc FSH/LH
Avoid Adrenal crisis- Na crisis at day 4-15, death due to HypoNa/HyperK
Define Gametogenesis
What type of replication occurs here?
Development of precursors into oocytes or spermatozoa
Meiosis I: diploid to haploid
How do they replicate and into ?
Where is the transition from dip to hap and mitosis to meiosis?
Spermatogonia Spermatogonium 1* spermatocyte 2* spermatocyte, Spermatid Sperm
1* to 2= dip to hap
1 to 2*= mitosis to meiosis I
During spermatogenesis, when do sperm cells go from diploid into haploid?
One 1* spermatocyte= ? mature, mobile sperm
1* spermatocyte, diploid
Meiosis I
2* spermatocyte, haploid
1 primary= 4 mature
Define Non-Disjunction
What is the last phase of spermatogenesis?
Why is this last phase important and where does it take place?
1* spermatocyte error at first meiotic division
Spermiogenesis: spermatid into spermatozoa
Golgi body into acrosome in Sertoli cells- enzymatic penetration of zona pallucida
Development of mitochondria in middle portion of sperm tail
What type of cells line the seminiferous tubules
What are the 3 functions of these cells?
Sertoli cells
Sperm development
Spermatogenesis regulation
Passive transport from seminiferous to epididymis
Sperm mature during ? phase of development?
Where do they mature and how long does it take?
Spermiogenesis
Seminiferious tubules x 3mon: 2mon process, 1mon maturation
What are the series of hormone events prior to ovulation?
LH stimulates ? cells to make ? two products
These products are taken up by ? cell and turned into ?
Inc estrogen causes LH surge= ovulation
Theca cells: Cholestterol + LH= Androstenedione, Testosterone
Granulosa cells: Androstenedione + FSH= Estrone, Estradiol
What is the name of the scar tissue the corpus luteum turns into after ovulation?
Corpus luteum grows during ? phase under the influence of ?
This product stimulates ? cells to produce ?
Corpus albicans 7-10 days later
Luteal, LH
Granulosa cells, progesterone
Changes/variations of a woman’s period is due to ? phase of the menstrual cycle
What are the two layers of the endometrium which covers ?
Follicular, luteal is regulated more strict/less fluctuant
Functionalis, Basalis
Myometrium
The constriction of the spiral arteries deprive the ? layer is what causes ?
What happens during the Proliferative phase
What does the Secretory Phase stimulate the release of
Functionalis
Period
Estrogen, arteries lengthen, endometrial growth maxes, glands are straight/narrow due to glycogen
Glycogen/mucus
Secretory phase is occurring because ?
What hormone is high at ovulation/ferning
Prepping to implant
Estrogen
Inc amount of alkaline mucus,
Dec viscosity/spinnbarkheit
How many days after Ovulation for each to occur: Fetilization Entrance of Blastocyst Implant Trophoblast and attach Sync hCG rescue
1 4 5 6 8 10
What are the two phases of fertilization
What happens at the end of these two phases
Acrosomal reaction: penetrating zona pellucida
Zona reaction: chemical change in solubility, impermeable
Fusion of oocyte/spem= completion of Meiosis II; Ootid->zygote
What hormones effect zygote/blastocyst transit through fallopian tube?
What is the name of the 16 cell structure that precedes a blastocyst entering a uterus
Estrogen + sticking
Progesterone - sticking
Prostaglandin E + tube relax
Prostaglandin F + tube motility
Morula
What are the two layers of the blastocyst
What hormone is produced and what’s it’s purpose
Embryoblast: forms embryo, amnion, cord
Trophoblast/chorion: forms placenta, hCG
Chorion: fetus portion of placenta
hCG 7-10 days post-fertilization, preserves CL until placenta halts menses
Cause of Morning Sickness
What are the 3 phases of implantation
Define Decidua and its function
Why is this structure important
Apposition Adhesion Invasion
Maternal side of placenta, establishes embryo implantation
Endometrium of pregnancy, separates at birth
Essential for maternal blood contact w/ trophoblast
What are the 3 parts of the decidua
Trophoblast differentiates into the Cyto/Synch blast by day ?
After implantation, these further differentiate into ?
Basal Capsul* Parietal
Day 8
Extra/Villous Trophobalsts:
Extra- anchor chorionic villi to uterus
Vill- chorionic gas, nutrient, hormone exchange
Define CV Sampling
How many vessels in the umbilical cord?
What is the maternal surface of the placenta called and divided into?
Chorionic Villi- chromosomal abnormalities
AAV
V: oxy, high press R side
AA: de-ox, low press L side
Basal plate: divides into clefts/lobules (coutyledon)
Extends in intervillous space
Define Nitabuch Layer
What are the 3 abnormalities of this layer
What is the risk factor for these abnormalities
Maintains separation by fibrinoid degeneration of decdiuda basalis
Prevents placental invasion into uterus
P Accreta: adheres
P increta: invades
P percreta: perforates
Previous uterine surgery/c-section
How long after conception does it take for maternal blood flow to enter placenta
Placental growth is more rapid than the fetus during the first trimester, they are equal by ? wk and ? at birth
1mon: enters intervillous space from spiral arteries, bathes sync-blasts
17wks
1/6th of fetal weight
hCG levels are abnormally low during ? and high during ?
This is the hormone responsible for ? two downsides of pregnancy
Low: ectopic, spontaneous abortion
High: gestational trophoblastic neoplasia
N/V
Hyperemesis gravidarum
What part of the maternal/fetal blood transfer has higher pressure/values
Why does fetal gas exchange have a three fold advantage
Uterine artery
Fetal Hbg higher O2 affinity
Bohr effect: dec o2 affinity w/ dec pH
Fetus has higher Hgb
Chorionic villi drain nutrients/O2 from maternal blood using ? method
Fetal envirionment generally has ? pH level
Umbilical cord that wraps around a fetus’ neck is called a ?
Bohr effect
Acidic
Nuchal cord
What are the 3 modifications to fetal circulation that maintains R to L shunting
Duct Art: connect aorta and PA, diverts blood to brain/heart, away from lungs
FOvale: shunts oxygenated blood from RA to circulation
DVenosus: bypasses hepatic circulation; remnant is ligamentum venosum
Placenta previa is a risk factor for ? placental abnormality
End of video 2, labeling chart
What is the MC complaint to GYN?
P acreta
Check
Abnormal uterine bleeding
What Tanner Stage represents the onset of puberty and 2* characteristics?
What hormone controls breast development?
What hormone controls pubic hair development?
Stage 2, Thelarche
Estrogen
Androgen
During childhood, there’s no puberty due to low levels of ?
Puberty starts when the feed back inhibition of ? decreases
FSH LH Estradiol
Estradiol and GnRH
Define Thelarche and Adrenarche
What is the time span between onset of thelarche and onset of menarche
Thel: breast development; first
Adren: pubic hair growth
2.5yrs
What is the sequential acronym of puberty development stages
An earlier onset of puberty linked and due to ?
Menarche initiation can not start if female PTs weigh less than ?
TAPup Me
Thelarche Adrenarche Pubarche Peak growth velocity Menarche
Obesity, leptin as initiator hormone
106lbs/48kg
Tanner Breast Staging
Tanner Pubic Hair Staging
1: elevation of papilla
2: buds, areola diameter inc
3: enlargement, no separation
4: secondary mound
5: mature breast
2: sparse along labia
3: darker hair over pubes
4: dark/coarse hair
5: dark/coarse hair extends to thighs
What are the two types of precocious puberty and how are they Tx
Central, GnRH dependent: high LH/FSH inc estrogen levels
Tx w/ GnRH agonist- inhibits LH/FSH
Peripheral, GnRH independent: ‘precocity’; lack of HPO axis activation= low FSH/LH
Tx: ovarian tumor, CAH, exogenous exposure
What are the risks if Precocious Puberty goes UnTx
Continue Tx until ? age
Early growth plate closure
Psych distress
11/yo
What tests are done for girls w/ precocious puberty due to estrogen excess
What is the criteria for delayed puberty
What is the MC cause
Hand x-ray: bone age
FSH LH TSH
Pelvic sonogram
CNS MRI
No thelarche by 13 or,
No menarche by 16
Constitutional delay
What needs to be checked if PT presents w/ delayed puberty
How is it Tx
FSH/LH
Gonads: 1* hypogonadism; high FSH/LH (hypergonadotropic)
Hypothalamus: 2* hypogonadism; low FSH/LH (hypogonadotropic)
Monitor, possible gonad steroids
What are the 3 HyperHypo causes of Delayed Puberty
What are the 3 HypoHypo causes?
Turners, Gonad dysgenesis,
Premature Ovarian Failure
/AKA Primary Ovarian Insufficiency; cause of delayed puberty
CNS Adrenal Psychosocial
Disruption of the HPO axis can alter ? 3 functions of the menstrual cycle
How much blood loss is considered normal or excessive?
When are menstrual cycles the most irregular
Reproduction Ovulation Menstruation
20-60mL
+80mL bad
2yrs after menarche
3yrs before menopause
Females are born with ? ova, but only ? are present at start of puberty
How many ovulation are expected throughout life?
? hormone controls the follicular phase and ? effect does it have on the endometrium
1-2mill; <400K
400
Estrogen; proliferative
What is the whole purpose of the luteal phase?
“Progesterone withdrawal”= ?
Prep endometrium for implantation
Menstrual bleeding
What are the 3 forms of estrogen
Where are they secreted from
The 4 transmitters E+3/P respond to ?
Estradiol Estrone Estriol
Theca interna
Granulosa cells
Gonadotropins
What are 3 effects of FSH on ovary
Sequence of hormonal events leading to ovulation
Female who has an anovulatory menstrual cycle means there is no ? phase
E/P production
Inc LH receptors
Follicle maturation
Inc estrogen, LH surge, ovulation
Luteal
Why/how do females w/ an anovulatory menstrual cycle still have regular menses?
Define criteria for 1* Amenorrhea
Estrogen break through- loses ability to maintain endometrium
No menses by 16 w/ normal 2* characteristics
No menses by 14y/o and no 2* characteristics
No menses by 3yrs of thelarche
Define Criteria for 2* Amenorrhea
All causes of 2* amenorrhea can also cause ?
Cessation of menses x 3mon and previously regular
Primary amenorrhea
PT w/ AIS would have ? type of amenorrha
Hypergonadotropic Hypogonadism can be causes by what two d/os?
Primary
Turners
46XX and 46XY
Define Hypothatlamic Amenorrhea
What can cause this
Low GnRH/FSH secretion
Non-ovulatory
Stress/exercise
Weight loss
Celiac Dz
Define Kallman syndrome
What is the first and second MC cause of 2* amenorrhea
Congenital GnRH deficiency w/ anosmia
1st: Pregnancy
2nd: anovulatory cycles
Functional hypothalamic amenorrhea
What effect would hyperprolactinemia have on a PT?
After initial exam and labs, what test is done for assessing amenorrhea
Dec GnRH, low LH/FSH
Progesterone withdrawal test: give exogenous progesterone
+ bleeding= estrogen developed endometrium or; PT outflow tract in tact
- bleed= unsure if proliferative phase occurred or if estrogen is functional
What are the primary tests ordered for amenorrhea evaluation
What are the 3 radiological tests ordered
hCG FSH Prolactin Estradiol TSH/fT4
Transvaginal US: PCOS, uterine agenesis, ovarian tumor
Hysterosalpingogram- mullerian anomalies/uterine adhesion
MRI: mullerian anomalies, hypothalamic pituitary Dz
If progesterone challengne test doesn’t cause bleeding, what is the next step
E/P challenge
+ bleed= FSH check
FSH >40: ovarian failure
FSH>5: stress, CNS tumor, Sheehan (post-partum necrosis/ischemia)
-bleed= obstruction/Ashermann
Frequent menstrual bleeding is a cycle that is ? days while infrequent cycles is ? days
Amenorrhea is a menstrual cycle absent for ? months or more and irregular bleeding is a cycle varying more than ? days
<21
>35
6mon
>20 days
How many days is classified as prolonged or shortened menstrual bleeding
How much blood is considered heavy or light flow
> 8 days
<2 days
> 80cc
<5cc
What is the MC complaint seen in GYN?
Abnormal uterine bleeding
PALM COINE
Structure:
Polyp Adenomyosis Leiomyoma Malignancy/hyperplasia
Non-structural:
Coagulopathy Ovulatory dysfunction Iatrogenic Not classified Endometrial
What is the magic number of double endometrium thickness?
How is acute menorrhagia Tx if the PT is stable?
How are they Tx if unstable or don’t respond to non-surg Tx in first 24hrs
4mm
Combo OCP
Medroxypreogesterone acetate
Both @ higher dose than for contraception
Surgery: D&C Balloon tamponade Uterine artery embolization Hysterectomy
How is chronic recurrent menorrhagia Tx
Stable:
1: Normalize prostaglandins, not effective if taking NSAID
2: Coordinate sloughing- medroxyprogesterone, combo OCP
3: Endometrial suppression- Progestin only OC Extended cycle OC DMPA Levonorgestrel- most effective
4: Antifibrinolytic therapy- for PTs w/ fibrinolytic activity
Tranexamic acid
When are PTs surgical candidates for abnormal uterine bleeding?
Dysmenorrhea is a ? mediated problem causing
Failed medical therapy
Child bearing completed
Prostaglandin- inc severity= inc prostaglandin levels
Back pain, N/V/D, HA
When are prostaglandins highest
How is primary dysmenorrhea Tx
First 2 days of menstruation
NSAIDs
Possible combo w/ OCPs, progestin only (Levo, Depo, Nexplanon)
PTs w/ migraine and aura can’t get ? type of OCPs
What is the MC location for endometrial tissue to be found in PTs w/ endometriosis
This is a cause of _ dysmenorrhea
Estrogen containing
Pelvic peritoneum
Ovaries, Uterosacral ligament
2*
What are the Sxs of endometriosis
This condition may cause the uterus to take on ? shape
Dysmenorrhea
Dyspareunia
Dyschezia
Chronic pelvic pain
Retroverted
If endometrial tissue is found in the thorax, where is it MC found
How is endometriosis Dx and what imaging is not recommended
R side w/ chest/shoulder pain
Laparoscopy, allows simultaneous Tx w/ ablation
US- lacks sensitivity
How can endometriosis be differentiated from dysmenorrhea
How is mild endometriosis Tx
Endometriosis occurs 1-2 days prior to menses
NSAIDs
Cyclic hormones: Progesterone/OCPs
NSAID + OCP failure=referral
What androgen analog is used during endometriosis Tx to inhibit LH/FSH
What is the GnRH agonist used?
How is severe recalcitran Dz cases Tx
Danazol- adverse acne/hair growth
Leuprolide- initiates pseudomenopause
Total hysterectomy w/ bilateral salpingo-oophorectomy
What NSAIDs are used during endometriosis Tx
Endometriosis frequently co-exists w/ ? and ?
Ibu/ketoprofen
Naproxen/Na
Mefenamic acid
Adenomyosis and Fibroids
S/Sxs of PMS
Criteris for Pre-Menstrual Dysmorphic D/o
Fatigue Mood Tender Bloat
5 Sxs w/ significant Psych/Social impairment
Mood swings of PMS coincide w/ ? phase
Why are there mood swings w/ PMS
Luteal: dec serotonin
Impact on CNS: Serotonin Noradrenaline GABA
Why is there bloating/weight gain during PMS
PMDD Dx requires a Sx free period of 7 days that coincides w/ ?
Progesterone (antimineralcorticoid) + estrogen (+ RAAS)= altered E+ balance
First half of cycle x 3 cycles
Follicular phase- onset of menses
What are the top two PE Sxs of PMS
What is the top behavioral health Sx
Fatigue Bloating
Labile mood
How is PMS/PMDD Tx
What anovulatory agent is used second line and why is this step done?
SSRIs: Fluoxetine Sertraline Paroxetine
Cramp/HA: NSAID
Bloat: Diuretic (HCTZ, spironolactone)
Combo OCPs
GnRH agonist- Leuprolin
Places body in false menopause to relieve Sxs
When are Sxs of PMS/PMDD worse
What is the definition of menopause
End of cycle during switch of p/e
Dx at 12mon after final menses
Avg age: 52
Menopause transition is AKA ?
Define Premature Ovarian Failure
What is the acronym for the Sxs of menopause
Perimenopause/Climacteric
No menses <40y/o due to high FSH/low E/P
FSHIUL
Flashes Sad HA Insomnia Urinary sxs Libido
The vasomotor Sxs of menopause can start as early as ? before FMP
How is estrogen a cardio protector?
This protection is gone and equal to male risk factors by age ?
2yrs
High HDL, Lower TC
70
Hormone therapy can be beneficial to PTs but loses the protection if started ?
PTs on hormone therapy need to be evaluated every ?
Don’t give ? type of estrogen to females w/ uterus due to ? risks
Over 60y/o
+10yrs after FMP
Q6-12mon
Unopposed, endometrial hyperplasia, neoplasia, endometrial cancer
What estrogen combo hormone therapy can be given to females w/ uterus
? part of hormone therapy causes females to be at inc risk for DVTs
Estrogen + Beazedoxifine
Estrogen
What is the SHATTERED Family acronym for
Osteoporosis Risk factors
Steroid Hyperthyroid/Ca/parathyroid Alcohol/tobacco Testosterone, low Thin, low BMI Early menopause Renal/liver failure Erosive bone dz Diet low in Ca/DM-1 FamHx
When do women get DEXA scans
When do perimenopausal women get DEXA scans
+65y/o
One or more RF for osteoporosis
Sustained Fxs
Specific RFs
Low BMI <18.5
Meds accelerating bone loss
What is a normal DEXA criteria?
Define T Score
Define Z score
Normal: +2.5–1.0
Penia: -1–2.5
Porosis:
When is osteoporosis medical therapy started?
What meds are used to prevent, treat or both
Which ones work faster at vertebrae than hip?
T score < -2.5
Vertebral/hip Fx
-1 - 2.5 w/ 1+ RF
Prevent: estrogen, Vit D
Treat: denosumab, calcitonin/PTH 2nd line
Both: SERM, bisphosphonates
Prevention
MOA of bisphosphonates
What are the a/e of using?
Inhibit osteoclast resorption
Take on empty stomach and stay upright x 30min due to esophageal erosion
Osteonecrosis of jaw
Atypica femur Fx
Prolonged use is worse
Take drug holidays
Loss of estrogen increases ? activity
Loss of ?” of height needs to have a compression Fx considered
Where is most Ca lost from
Osteoclast
> 1.5”
Trabecular bone of spine, femoral neck
What initial labs are ordered to work up amenorrhea
Why is primary ovarian failure a concern?
hCG FSH/LH TSH Prl
Estrogen= leads to severe osteoporosis
What microbe causes Erythrasma
What does it look like under a woods lamp
How is it Tx
Corynebacterium
Red
Local: clindamycin
Wide: erythromycin
Normal vaginal pH is ?
Why is this level needed?
What are two causes of non-inflammatory vaginitis
4.5
Lactobaccili- creates lactic acid and hydrogen peroxide as defenses
BV- gardnerella
Candidiasis
What is the MC cause of vaginal d/c
What is the criteria used for Dx
BV- grey/milky d/c w/ fishy odor
Amsel’s Criteris:
pH >4.5 D/c Odor Clue
How is vaginal pH tested
How is BV Tx
Nitrazine paper turns blue
Metronidazole
Clindamycin cream
Alt: Secnidazole, Tinidazole, Clindamycin ovules
How are recurrent BV infections Tx
No prior extended Tx:
Vaginal Metrogel, Clindamycin
PO Metronidazole Tinidazole
Prior Hx of Tx: Same as above x 2wks then, Suppression therapy w/ Metronidazole gel x 1wk Metronidazole PO x 2wks Tinidazole x 6mon
What are the adverse outcomes of unTx BV in pregnancy
What is the 2nd MC cause of vaginitis
PROM
Pre-term delivery
Intra-amniotic infection
Post-partum endometritis
Candidiasis albicans or Glabrata- resistant to -azoles
What are the RFs for a candidiasis infection
How is it Tx
ImmSupp DM Environmental Estrogen ABX use
Clotrimazole x 7 days**
PO Metronidazole x 1 dose
Chronic recurrent candidiasis infections are a ? issue
What can cause these repeats?
Host issue w/ 4 repeats/year
Dec mannose binding lecting
Inc of IL-4
What is used for recurrent VVC Tx
What is used for suppression therapy?
PO Fluconazole: day 1 4 and 7
After completing Tx regime:
PO Fluconazole x 6mon
What meds are used for non-albican species of VVC
What med can be used for external irritaiton/inflammation
Boric acid x 2wks
Fluconazole Q72hrs
Mild potency steroid
What is the 3rd MC cause of vaginal d/c
How is it Dx
Trichomoniasis- frothy green/yellow d/c w/ musty odor
Frothy d/c Strawberry cervix pH >4.5 Trichomonads on wet prep (mobile w/ flagella) NAAT* gold standard
How is Trichomoniasis Tx
How are PTs w/ BV and Trichomonas infections Tx
Metronidazole 2g PO or,
500mg BID x 2wks if compliant PT
Tinidazole 2g x once
Tx BV
Test of Cure at 1mon and 6on
What are the causes of vulvar pruritis w/ white lesions
What are the causes of pruritis w/ red lesions
Dystrophies:
Lichen sclerosus
Squamous hyperplasia
Dermatoses: Contact/Atopic dermatitis Psoriasis Vestibulitis Lichen planus
Define Squamous Hyperplasia
Define Lichen Sclerosus
Vulvar pruritis that used to be called leukoplakia
Lichen simplex chronicus
Inflammation of dermis in post-menopause w/ wax/wane itching/late burning
Skin appears paper/crinkled
Lichen Sclerosus has an increased risk for PTs to develop ?
How is it Tx
Squamous Ca of vulva
Topical CCS- Clobetasol
Retinoids if unremitting
Phototherapy and 5-aminolevulinic acid if severe
Define Lichen Simplex Chronicus
How is it Tx
Non neoplastic alteration of vulvar skin due to chronic irritation from itch/scratch cycle
MC at L Majora
Lube: petroleum jelly, veg oil Sitz bath PO antihistamine Wear cotton gloves at night Topical steroid
Unresolved in 1-3wks= biopsy
Atopic Dermatitis
How is it Tx
Hx of allergy/eczema w/ atypical location
Scaly patches w/ fissuring
Topical steroids
ImmunModulators- Tacrolimus
Where is Psoriasis uncommonly seen in females?
Define Koebnerization
How is it Tx
Mons pubis
Labia
Trauma on vulva as inticing factor
Emollient/Steroids
Dovonex after
What meds can cause Lichen Planus
How does it appear
NSAIDs BB Methyldopa PCN Quinine
Cutaneous and mucosal surfaces w/ red erosion/white border
D/c Pruritis Burning
Post-intercourse bleeding
What are the 3 variants of Lichen Planus
What does it look like
How is it Tx
Erosion Papulosquamous Hypertrophic
Purple erosive pruritic polygon papules/plaques- can affect gingiva
Clobetasol
Vaginal hydrocortisone
Suppository
How does Intertrigo present
How is it Tx
Crease friction from bacterial/fungal infection
Burning/itching
Hyperpigmentation
Corn starch
Mild steroid: inflammation
Antifungal: Nystatin/Cotrimazole
What is the MC cause of vaginal irritation after menopause?
How does it present
How is it Tx
Atrophic vaginitis
Clear/yellow/blood tinged d/c w/ dysparunia
Loss of rugae/pale mucosa
Topical estrogen
Bartholin cyst is a concern for CA in women over ? y/o
If the cyst is located ?, the PT presents w/ no pain
How are these Tx
40
Cyst in duct
ASx= none, unless >40
Don’t do I&D
Word catheter
Marsupialization after 2 failures
What usually follows a bartholin cyst
Women w/ this follow on presentation need ? screening
Abscess- polymicrobial w/ correlation to G/C infection
STD panel: G/C
When are ABX used for Barthlin abscess Tx
What ABX are used
Recurrent/High risk PT: Pregnant Cellulitis Systemic infection ImmSupp
TMP/SMX
Amox/Clav
What microbe causes Toxic Shock Syndrome
When does it start and how does it present
How/why do PTs die of this
Staph A
2days after surgery/onset of menses
Macular rash w/out pain/itch
ARDS, DIC or HOTN leading to myocardial failure
What are the major criteria for Dx Toxic Shock
What are the minor criteria
HOTN OHOTN syncope BP <90 Macular erythroderma Temp >38.8*C Skin desquamation 1-2wks later
3 needed: Diarrhea/Vomit Membrane erythema Elevated Cr Inc platelet count/bilirubin AMS
What increases the chances of vulvar Ca?
These are usually caught and Dx in ? stage
Age, HIV
1 or 2
Vulvar Ca is usually ? type
What is the 2nd MC type
Squamous on Hart line
Malignant melanoma, poor prognosis
What are the risk factors of vulvar Ca in women <55y/o
What risk factors affect >55y/o
Women have a 35x inc risk of Ca if they have ? 2 RFs
HPV, smoking
Same risk as cervical Ca
15% have HPV
Long standing lichen sclerosis
Smoker + HPV
How does Vulvar Ca usually present
What procedure is done for exam?
Since primary vaginal carcinomas are rare, found cases are usually ? Ca
Pruritis w/ lesion
Vulvoscopy- coposcopic exam of vulva w/ biopsy
Metastatic to vagina
What are the types of vaginal Ca
Squamous- HPV, bleeding
Adenocarcinoma- metastatic, DES exposure
Mesenchymal
What is the MC type of vaginal malignancy in kids under 5y/o
What may be the most rare form?
Rhabdomyosarcoma (mesenchuymal tumor)
Leiomyosarcoma
What is the MC Complaint of PTs w/ vaginal Ca
What is the MC region?
What if the Ca is on the anterior wall
What if it’s on the posterior wall?
Vaginal bleeding
Upper third of wall
Dysuria Urgency Hematuria
Constipation
What are the four types of benign cervical dzx
Polyp Cervicitis Nabothian cyst Stenosis
S/Sxs of Cervical stenosis
How is it Tx
Contracting scar issue on endocervical canal blocks os=
Dysmenorrhea Infertility Amenorrhea
Dilators
Vaginal estrogen x 4wks if Post-monopause
Cervical os needs to be at least _mm for blood to exit
Define Nabothian cyst
5mm
Columnar cell trapped under squamous during metaplasia, continue secreting mucus
Rarely Sx= no Tx
If Sx= cautery/excision
How does cervicitis present
What can cause it
What part of the cervix creates mucus
Bleeding cervical epithelium
G/C HSV Trichomonas BV
Endocervix from glandular columnar cells
SCJ can regress into endocervix during what 3 low estrogen times?
Immature metaplastic cells in the T-zone are vulnerable to the oncogenic effects of ?
What other 2 RFs increase these chances
Menopause
Lactation
Progestin only OCPs
HPV
Early intercourse and 1st pregnancy
What is the primary method of detecting pre-cancers
Cervical Ca is not considered to be sensitive to ?
Colposcopy
Estrogen
What are the risk factors for cervical neoplasms
Age, inc
Low status
Ethnicity
Male w/ multiple partners
Early coitus
Tobacco/diet
Parity ImmSupp Exogenous hormones Cervical HPV Screenings poor
HPV vaccine is ? prevention while Pap screenings are ?
What lab/pap finding is a “surrogate” for cervical Ca
Vaccine- primary
Pap- secondary
CIN 3: squamous epithelial lesion
What are the different grades of CIN
1: mild; abnormal cells in lower 1/3, HPV, most regress
2: moderate; abnormal cells to middle 1/3
3: severe; abnormal cells to upper 1/3
Carcinoma in situ- full thickness involvement
HPV is the MC STI in the US, what type is the most oncogneic worldwide
What are the low risk strands of HPV
Where does the infection reside in the body
16: ano/oropharyngeal cancers
6 and 11- genital warts, laryngeal papillomas
Basal cells
Since HPV can spontaneously resolve, what is it’s key factor to develop in Ca?
PTs w/ HPV 16/18 w/ lesions lasting longer than 6mon develop ?
Persistence
Squamous Intraepithelial lesion
Define Pap Co-Testing
Define Reflex Testing
Pap Cyto sample tested for HPV in PTs +30y/
<30y/o w/ abnormal cells on Pap trigger additional tests
What Pap screenings are needed for the following ages: <21 21-29 30-65 >65 Post-Hysterectomy
<21: no screening
21-29: Q3yrs w/ Reflex testing
30-65: Co-test Q5yrs, only Pap=Q3yrs
> 65= 3 consecutive neg Paps
Post-Hys, no CIN2 past 20yrs:
+ cervix= continue screening
- cervix= no screening
CNI2+ Dx in 20yrs= vaginal swabs x 20yrs past Dx
Co-test/Reflex test only give you ? data
HPV HR DNA test gives you ?
Presence of HPV
Sub type of HPV
HPV results are given using ? criteria
What info is given
Bethesda
Specimen type Adequacy Interpretation Description ancillary testing Notes/recommendations
What are the 5 categories of resutls that can come back on a pap smear
ASCUS- atypical squamous cells undetermined significance
LSIL- low grade squamous intraepithelial lesion
ASC-H- atypical squamous cells, can’t exclude HSIL
HSIL- high grade squamous intraepithelail lesion
AGC- atypical glandular cells
+HPV PTs are managed the same as ?
How are they managed
LSIL
Colsposcopy
What is the next step for:
>30y/o LSIL, -HPV
LSIL but no HPV test
LSIL w/ +HPV
PT w/ ASC-H
PT w/ HSIL
Repeat Co-test in 1yr
Colposcopy
Colposcopy
Colpo regardless of HPV
Loop or Colpo
Pap is a ? tool, Colpo is a ? tool
Colpo offers what 3 tools
What has to be done prior to procedure
Screen, Dx
Biopsy Sampling Visualization
Qualitative pregnancy test
If Colpo is unsat due to T-zone can’t be seen, whats then ext step
Cervical Ca is #_ of malignancy in females
4, usually from HPV
LEEP- loop electrosurgical excision procedure
CKC- cold knife cone
How often are Cervical Ca Pts f/u
How often are cervical/vaginal cuff paps performed
Q3mon x 2yrs
Q6mon until 5yrs Post-Tx
Annually
Annually x 20yrs post-Tx
What are the estrogen dependent abnormalities of the uterus?
What are fibroids AKA
Adenomyosis
Leiomyomata
Endometrial hyperplasia
Leiomyomata- MC pelvic tumor of women
What is a common presenting Sxs of fibroids
What is the preferred Dx
These commonly lead to ? Tx
Bleeding
US
Hysterectomy
What is used to reduce/slow bleeding from leiomyomas
Define Adenomyosis
What is the first image ordered?
Contraceptives
IUD
Endometriosis w/in myometrium, usually ASx
US
What is the gold standard Tx for Adenomyosis
What meds may be tried prior to Tx
Hysterectomy
GnRH agonist Danazol IUD COC
What is the MC Sx of Polyps
How are they viewed?
Metrorrhagia
US, sonohysterography
How does endometrial hyperplasia present
Who is is MC seen in
How is it Dx
Abnormal uterine bleeding
Post-menopause women
Biopsy- gold standard
How is endometrial hyperplasia classified for malignancy potential
Trans-Vag US is the first Dx step for endometrial hyperplasia only in ? PTs
Greatest= complex hyperplasia w/ atypia Least= simple hyperplasia w/out atypia
Post-menopause, 4mm or less= low risk
How are PTs w/ endometrial hyperplasia w/ atypia but want to retain fertility managed?
How are PTs w/ endometrial hyperplasia w/out atypia managed
Progestin w/ endometrial biopsy q3mon
Then hysterectomy and salpingectomy
Pre-Meno:Low progestin x 6mon or
COC w/ endometrial biopsy
Post-Meno: SAME
What is the MC Gyn in Ca
What are the MC presentations
Endometrial Ca
Vaginal bleeding
Pelvic pressure
Early satiety
How is endometrial Ca Tx
Define Lynch Syndrome
Hysterectomy w/ bilateral salpingoophrectomy and lymph node staging
Multiple Ca, usually sentinel
Tx w/ prophylactic hysterectomy
How is endometrial Ca Dx
What would be seen on TVUS
Endometrial Biopsy
Post-Meno: 4mm or small, ok
5 or more, biopsy
What tumor marker may be seen in endometrial cancer
This responds to ? hormone
CA125, monitor tool
May help w/ ovarian masses in Post-Meno PTs
Progestin- Tamoxifen
What are the two types of functional ovarian masses
Define endometrioma
Follicular cyst- follicle doesn’t rupture, >3mm
Lutein cyst- corpus luteum doesn’t regress
Metaplastic ovarian mass from endometriosis
How doe functional cysts present
How are they dx and Tx
Pain Dull sensation Heavy
Bimanual exam, US
Tx w/ surgery
What are sizes of simple cysts and f/u
Pre-Men: 3 or less: norm variant 5 or less: no Tx >5 <7: repeat TVUS 12wks, persists= annual TVUS >7: MRI/surg eval
Post-Meno:
1 or less: norm variant
5 or less: Norm CA125= repeat US 12wks, persists= annual TVUS
7 or more: MRI, surg eval
What steroid hormones cause male-ness
DHEA- adrenal gland; weak
Androstenedione- adrenal gland and ovary, weak
T- adrenal gland, ovary and adipose, potent
DHT- follicles and genital skin, most potent
Define Hypertrichosis
Dfeine Hirsutism
Dfein Virilizaiton
Non-sexual hair not due to androgens
Terminal thick male pattern hair on female, due to androgens
Acne Male baldness Deep voice
Due to androgens
PCOS
Dx req’s ? 2 things
What are the 5 MC presentations
High androgen/estrogen
Hyperandrogenism
Oligo/anovulation
Hirsutism Abnormal bleeding PC ovary Infertility Obesity
What is NOT a required finding for Dx of PCOS
Define Ovarian Hyperthecosis
How do they present
Poly cystics ovaries
Sever PCOS- nest of lutenized theca cells in ovarian stroma
Balding Hypertrophy Deep voice
Acanthosis nigrans
HAIRAN Syndrome
Hyper Androgenic Insulin Resistant Acanthosis Nigricans
PCOS variant w/ severe insulin resistance
What causes idipathic hirsutism
How is PCOS Tx
Variant
Inc 5-alpha reductase activity
Mild form of PCOS
COCs: progestin only or Clomiphene if pregnancy desired
Metformin
How is the hirsutism of PCOS Tx
Androgen blockers: Spirinolactone, Flutamide 5-alpha reductase: Finasteride Eflornithine- slows growth
What causes the most deaths than any other Gyn malignancy
Why is this so deadly
Ovarian cancer
No screenings
What is the primary mechanism of ovarian cancer
What are some protective steps that can be done
Uninterrupted ovulation
Breast feeding
OCPs
Ligation/hysterectomy
Diet high fiber, low fat
What factors can falsely elevate CA125
What PE finding + a pelvic mass is indicative of ovarian cancer
What pulm finding is concern
Premenopause w/ endometriosis, fibroids
Ascites
Pleural effusion
What lab findings will be seen in PTs w/ ovarian Ca
How is ovarian cancer staged
What does BRCA mutation do to prognosis
Thrombocytosis
HypoNa
Surgery
Improves, better response to chemo
