OBGYN I, Underlined Flashcards
What is the Chadwick sign?
Early blue tint to the cervix
What is goodell sign
Cervical softening due to edema
Can be an early sign of pregnancy
What is Hegarsign
Isthmus (uteral) softening
What is the ecto cervix covered by
Squamous cell epithelium
What is the Endo cervix covered by
Columnar epithelium
What are the bilateral MUSCULAR tubes that connect the uterus to the ovaries
Fallopian tubes
What type of cell lines the Fallopian tubes
Ciliated columnar
What is the most common site of ovarian cancer ?
The outer layer of the ovaries covered by epithelium
What are the most favorable hip formations for vaginal delivery
Gynecoid and anthropoid
What are the two least favorable pelvic formations for vaginal delivery
Android and Platypelloid
What is Mcroberts maneuver ?
Not underlined, but leg hyper flexion to assist in vaginal delivery for should dystocia
When do the “primordial follicles” develop in utero
At 16 weeks, gonadal cords/ Cortical cords break into cell clusters called primordial follicles
Do any oogonia form postnatally?
No
What is the hormone that suppress the formation of the uterus and uterine/ Fallopian tubes in utero
MIH/ AMH
What are the paramesonephric structures
Fallopian tubes, uterus and UPPER third of the vagina
If there is an arrest of development of utero vaginal primordium at 8 weeks what structures would not form properly?
Paramesonephric structures: Fallopian tubes, uterus, and upper third of vagina
What is the etiology of a double uterus ?
Failed fusion of the inferior paramesonephric ducts
May have single or double vagina
What is the etiology of a bicornuate uterus?
Duplication of ONLY the SUPERIOR part of the body of the uterus
Can be complete or partial
What is the etiology with a bicornuate uterus with a rudimentary horn ?
Slowed growth of 1 paramesonephric duct
- does not fuse w/ 2nd duct
Rudimentary horn may not connect w/ uterine cavity
What is the etiology of a septate uterus ?
Normal outer uterine appearance, divided internally by thin septum
Failure of resorption
Define ovotesticular DXD
When ovarian tissue AND testicular tissue is found in either same gonads or opposite gonads
Can happen in 46XX or XY
The external genitalia with ALWAYS be ambiguous
Define 46XX DSD
Ovaries present and normal, but ambiguous external genitalia
Female fetal exposure to excess androgens = external genital virilization
Clitoral hypertrophy, partial fusion of labia majora, persistent urogenital sinus
2/2 CAH (most common cause)
What is the most common cause to 46XX DSD
Congenital Adrenal Hyperplasia
Define 46 XY DSD
Inadequate virilization of the male fetus
2/2 defects in synthesis of testosterone
Disorder of testicular development
Presents with variable development of external and internal genitalia
2/2 inadequate production of testosterone and MIS by the fetal testes
Define Androgen Insenitivity Sydrome (AIS)
Normal external female genitalia; presence of testes & 46XY
Testes located in abdomen or inguinal canals
Pt is resistant to testosterone
At puberty will have normal development of breasts with no femal characteristics
NO MENSES
Can have ambiguous genitalia (partial)
2/2 point mutations in the sequence codes for androgen receptors
What is the increase Dz RSK for pts with AIS and what is the treatment approach to prevent it?
Developing malignancy By age 50
So testes are removed upon Dx
What is the big difference between AIS and 46 XY DSD
AIS has normal appearing female genitalia;
46XY ovotesticular DSD external genitalia potentially more ambiguous
A pt presetns with anosmia and poorly defines 2nd sex characteristics
With a LOW FSH, and LH
Think what syndomre
Kallman
What is 47XXY ?
Klinefelters
Low T, elevated FSH? LH
Micropenis, crytorchid
What is 45XO
Turners Syndrome
Elevated FSH/LH
Low Estrogen
“Streak gonads”
Webbed neck, low hairline, short
What is spermatogenesis
Taking primordial germ cells and making spermatids
Producing 4 mature mobile sperm from every primary spermatocyte
What is spermiogenesis
The conversion of the actual sperm
The LAST phase of spermatogensis
What is the time frame and location of spermiogenisis
2 month process + 1 month maturation
Located in the seminiferous tubules
What is the acrosome
Anterior 2/3 of the head of the sperm
Contains the enzymes to penetrate the zona pellucid a and dispersion of follicular cells of the corona radiata
What portion of the sperm contains the mitochondria
The middle of the sperm tail
What is “sperm capacitation”
Happens post ejaculation and is the process by which sperm acquire the ability to fertilize the ova
What is the function of the prostaglandins in semen
Stimulate uterine motility at time of intercourse
Aid in movement to site of fertilization in ampulla
Define the proliferative phase
Estrogen proliferates the endometrial glands
And endometrial growth is maximized
Define the secretory phase
PROGESTERONE produced by the corpus luteum stimulates the secretion of glycogen and mucus
Glands become tortuous and dilated
What is the effect of estrogen on the mucus during ovulation
Since there is high estrogen at ovulation
There is an increase in the amount of mucus that is more alkaline, with a low viscosity
FERNING appearance
What is the effect of progesterone on cervical mucus
Makes it thick and cellular
Otherwise at ovulation the mucus looks fern like
What is the differnce between an acrosomal reaction and a zona reaction
Acrosomal reaction: enzymatic penetration of zona pellucida
Zona reaction: change in solubility and binding of zona pellucida
- ovum now impermeable to other sperm
What is the stage of the fertilized egg that implants in the uterus
The blastocyst
What are the 2 cell layers of the blastocyst
Embryoblast forms embryo, amnion, umbilical cord
Trophoblast (chorion) forms placenta
-Produces hCG
What is the maternal component of the placenta
The decidua
What are the three portions of the decidua
The basalis, the capsularis, and the parietalis
Billows trophoblasts (growth support) become…
Chorionic villi
anchoring support
Define placenta accreta
When nitabuchs layer adheres to the myometrium
This is not good
Define placenta increta
When nitabuchs layer INVADES the myometrium
Really really not good
Define placenta percreta
When the placenta perforates THROUGH the myometrium
This is REALLY really bad
What is the hormone that maintains the corpus luteum
hCG
What structure produces hCG
Produced by syncytiotrophoblast during 1st trimester
What is the rate of production of hCG
Doubles every 2 days
Peaks by 60-70 days
Then declines to plateau for remainder of pregnancy
—Abnormally low in ectopic & spontaneous abortion
—High in gestational trophoblastic neoplasia (GTN)
What are the 3 advantages of gas exchange for teh fetus
- Fetal hemoglobin has a high affinity for O2
- Bohr effect, there is low o2 affinity w./ low ph
(Fetal environment is acidotic) - Fetus has a higher hgB
What are the vessels in fetal circulation
Umbilical Cord
-One vein: oxygenated & pressurized R side
-Two arteries: deoxygenated & flaccid L side
TAPup ME ?
Thelarche (1st)
Adrenacrche
Pubarche
PEak Growth Velocity
MEnarche
Order of puberty onset
What are the normal 1st signs of puberty
Thelarche is usually 1st, however some girls can presents with pubarche first
What is the pulsatile hormone around age 8 that starts the onset of puberty
PULSATILE exposure of GnRH causes anterior pituitary to release FSH/LH
(onset of puberty)
What is generally the 1st sign of secondary sexual characteristics
Thelarche, around age 10
Tanner stage 2
What is the general time frame for menarche after Thelarche onset
Typically 2.5 years after thelarche
What is the treatment for central precocious puberty
Onset will be before age 8
FSH and LH will be HIGH!!
Treat with Continuous GnRH exposure to negative feed back and inhibit LH/FSH production
What is the tx approach to PERIPHERAL precocious puberty
Pt will have onset of puberty before age 8,
FSH and LH will be LOW!!!
Treat the underlying cause
What is the most common type of delayed puberty
Constitutional Delay
Lack of thelarche by age 13 or no menses by age 16
Is the follicular phase a set number of days?
No!
Variable duration
Define the proliferative phase of the menstrual cycle
Aka the follicular phase
FSH stimulates a follicle
Granulosa cells convert androstenedione into estradiol
On day 14 LH spikes!! And starts ovulation
Increasing estradiol levels in the follicular phase of menses leads to what..
An LH surge (ovulation)
When does ovulation start after the LH surge ?
With 36-40 hours
What is the only phase of menses with a defined duration .?
The luteal phase
9-10 days long
If no corpus luteum is produces in an a ovulatory cycle
What happens?
Lots of estrogen
(not cyclically produced), but no corpus luteum
(no progesterone surge to balance)
“Unopposed estrogen” can lead to ↑ uterine lining (proliferation)
What is the second most common cause of 2* amenorrhea after pregnancy
Anovulatory cycle
Define primary amenorrhea
No menses by age 16 in presence of normal secondary sexual characteristics
No menses by age 14 in absence of secondary sexual characteristics
No menses w/in 3 yrs of thelarche
Define 2* amenorrhea
Absence of menses for at least 3 months in women who were previously menstruating regularly
What is the evaluation process for Amenorrhea
Progesterone withdrawal test
Give progesterone x 10 days
If bleeding ensues, assume 2 things:
- Nml estrogen production to have developed endometrium
- Patent outflow tract intact
What is the DDx for AUB
PALM NOICE
Polyps
Adenomyosis
Leiomyoma
Malignancy
Not yet classified Ovulatory Dysfunction Iatrogenic Coagulopathy Endometrial
What is the marker in mm for Endometrial thickness in post menopausal AUB
EMT less than 4 mm and abNML
EMT less than 4 mm w risks of cancer
Greater than 4mm
Or EMT not clearly seen
All lead to a Bx
What is the tx for acute stable menorrhagia ?
Combined OCPs
If unstable or no response within 12-24 hours
Send for surgery!
What is the tx approach to chronic recurrent menorrhagia
Levonorgestrel IUD is often the most effective 1st line tx
NSAIDs for pts that are mild and not already taking NSAIDs
What is the tx for primary dysmenorrhea
NSAIDs
OCPS
What are the Ds of endometriosis
Dysmenorrhea
Dyspareunia
Dyschezia
Infertility D
What is the definitive Dx for Endometriosis
Laparoscopy
What is the tx approach to endometriosis
If minimal: watchful waiting
Mild: NSAIDs
-if ineffective try cyclic hormones (progesterone/ OCPs)
-if above still unaffective, then send to OBGYN for lap Dx
What are danazol and Leuprolide
Danazol is a androgen analog that inhibits FSH/LH and can be used in endometriosis Tx in pts older than 16
Leuprolide is a GnRH agonist that can decrease estrogen production and used in pts of adult age
What is Premenstrual Dysphroic Disorder
DSM-5: at least 5 symptoms w/ significant psychosocial or functional impairment
How do you DDx PMDD
Pt presents with s/s min the luteal phase and is s/s free for at least 7 days in the 1st Half of the menstrual cycle for at least 3 consecutive cycles
What is the primary treatment for PMS/PMDD
SSRi
2* long anovulatory agents
-OCPs, GnRH Agonist
What is FSHIUL for menopause s/s
FSH-
Flashes, Flushes, forgetful
Sad, Skin, skeleton, stroke
Headaches, HDz
IUL-
Insomina
Urinary S.s
Libido decrease
What is the increased risk factor in all age groups taking hormone therapy
Increase stroke risk
Why should you not give unopposed estrogen to women with uteruses
↑ risk of endometrial hyperplasia, neoplasia, and endometrial cancer
If a pt has an intact uterus, and menopause symptoms
What topical agent can be used .?
Low dose topical estrogen
What are the osteoporosis risk factors
SHATTERED
Steroids Hyperthyroid, HyperCa+, hyper parathyroid Alcohol Tobacco Low Test Thin Early Menopause Renal or liver failure Erosive bone Dz Dietary low Ca
Family Hx
What scan should be done for all menopausal women
DEXA scan
For 65 y/o with 1 RSK fx for Osteoporisis or sustained fxs
Or is perimenopausal with a RSK fxs and low BMI or meds known to accelerate bone loss
A z score less than what requires a workup for osteoporosis ?
-2.0
What are the ADE of Bisphosphonates ( Rx used to treat osteoporosis)
ONJ AFF
GI inflammation/bleeding
Take on empty stomach, remain upright 30m
Adverse effects:
ONJ: osteonecrosis of the jaw
AFF: atypical femur fracture, often bilateral
What type of bacteria are responsible for BV
Overgrowth of anaerobic species:
-Gardnerella vaginalis, Ureaplasma urealyticum, Mobiluncus spp, Mycoplasma hominis, & Prevotella spp
What is the Rx for BV
Metronidazole
(500 x 7days or 5g intravag x 5 days)
Or
Clindamycin cream 5g intravag for 7 days
What medication do you add on for chronic./ recurrent BV
Use Metro and clinda as regular and add 30d PV boric acid suppository
If more than 3 episodes of BV in last 12 months?
Maintenance regimen.
Metrogel or PO nitroimidazole x 7-10d, then metrogel 2 x weekly for 4-6m
What are two risk factors for Candida infections
Pregnancy and Immunosupporesion
What is the treatmetn for Recurrent candida infections
If acute then Oral Fluconazole q 72 hours or Vaginal azole x for 7-14 days
Suppressive therapy is fluconazole weekly for 6 months
May need to tx indefinitely
What is the Rx for non albicans canidida infections
Not as responsive
Fluconazole q 72 hours
Boric Acid PV every day for 2 weeks
Why would you give a steroid for a candida infection
Symptomatic treatment for external irritation
Topical mid-potency steroid can help symptoms associated w/ external inflammation
A pt presents with forthy green yellow D/c and a strawberry cervix
Trichomoniasis
Can BV and Trich present together ?
Yes both have high pH
If together treat the BV as well
Metro or clinda
Inflammation of the vaginal dermis
Is called
Lichen sclerosus
What is the major ADE of having lichen sclerosus
Increased risk of cancer
What is the cause of lichen simplex chronicus
Itch scratch cycle
A pt presents with excoriations w/ background erythema
With a thickening of the skin. Leathery grey appearance
Think
Lichen Simplex Chronicus
If lichen simplex chronicus doesnt heal in 3 weeks…
Get a Bx
How does psoriasis present in skin folds
more red w/ fine scale = inverse psoriasis
What is the most common form of Lichen Planus?
Erosive
What are the major criteria for Toxic shock Syndrome
HOTN
(Ortho Syncope, or BPP less than 90)
Macular erythoderma
Fever
Skin desquamation (1-2 weeks post rash onset)
What are the minor criteria for toxic shock syndrome
GI upset: Diarrhea or Vomiting
Mucos Membranes
Muscular S/s
Renal (BUN/ Cr 2x greater than NML)
Platelets less than 100,000
Hepatic: Elevated ALT/ AST
AMS
Most common vulvar cancer
Squamous cell that arrises predominantly on the vestibule
What are the risk factors for vulvar cancer in women over 55+
Tend to be nonsmokers w/out STD
HPV related to only 15% of cases in this age group
Related to long-standing lichen sclerosus
A pt presents with pruritus and visible lesion
With pain, bleeding and ulceration
That is chronic
Think
Vulvar cancer
How does SCC of the vagina present
Presents as vaginal bleeding
Usually from metastatis
Where do nearly all cervical neoplasias develop
With in the T zone
What is nearly always the cause of cervical neoplasia
HPV
What are the high risk HPV strains
Types 16, 18
Persistent HPV infections lead to..
Cervical Cancer
What is the role of the HPV vaccine and who should get it
Prevents cancer
And age 9-45
How often should pap testing be done for HPV screening
q 3 years
How often should primary HPV testing be conducted
Q 5 years
Do cotesting together
When can you discontinue screening in cervical dysplasia and HPV
Older than 65 AND
NO history of CIN 2+ in last 20 years AND
-Two consecutive negative primary HPV tests within 10y (most recent in past 5y)
OR
Two consecutive negative co-tests within past 10y (most recent in past 5y)
OR
Three consecutive negative Pap tests within 10y (most recent in past 5y)
What do you do if a pt has AGC
If atypical endometrial cells: endometrial and endocervical sampling + colposcopy
All other types: colposcopy + endocervical sampling
(if pregnant – no endocervical sampling)
If also 35+: colposcopy + endocervical and endometrial sampling
What is the follow up for cervical cancer
Every 3 months for 2 years
Then every 6 months for 5 years post treatment
Then annually
