OBGYN Precision & Pearls Flashcards
Azospermia means _______ and what percentage of male infertility does this account for?
Absence of sperm to ejaculate
20% of male infertility cases
Bacterial Vaginosis is the MCC of vaginitis. Explain the pathophysiology of this condition (why it occurs)
-overgrowth of Gardnerella Vaginalis
-Decreased lactobacillus acidophilus (normally maintains pH of vagina)
What are some things to tell a patient to avoid BV?
Avoid douching
Condom use helps prevent
No need to treat the partner
Symptoms of Bacterial Vaginosis and Treatment
-Malodorous vaginal discharge worse after sex
-Vaginal itching
-Dyspareunia
-May be asymptomatic (>50%)
Metronidazole or Clindamycin
What criteria is used for BV and what are the components?
Amsel Criteria
-Copious, thin, homogenous gray/white fishy odor discharge
-Vaginal pH > 4.5
-Positive whiff amine test (fishy)
-Clue cells on wet saline mount
-few WBC’s
MC type of cervical cancer and the strains of HPV that cause it most times.
Squamous cell carcinoma
16 & 18 most common types
Others: 31, 33, 45, 52, 58
What type of cervical cancer is linked with DES exposure?
Clear cell carcinoma
MC symptom of cervical cancer
MC lymph nodes involved with cervical cancer
Post-coital bleeding or spotting
Paracervical lymph nodes
Explain the different treatment modalities for cervical cancer based on staging (Stage 0-4)
Stage 0 (in situ): Local excision (LEEP, conization), Ablation (cryotherapy or laser), TAH-BSO
Stage 1: Surgery (conization), TAH-BSO + Chemo (Cisplatin)
Stage 2-4a (locally advanced): XRT + Chemo (Cisplatin +/- 5FU)
Stage 4b (Distant METS): Palliative radiation + Chemo
What are risk factors associated with cervical cancer?
What is one prevention method?
-HPV**
-Early onset sexual activity, increased number of partners
-Smoking
-STI’s
-DES exposure
-Immunosuppression
HPV Vaccine (Gardasil 9) and screen with PAP smear and cytology
Best diagnostic for cervical cancer?
Where does the malignant transformation most commonly occur in the cervix?
Colposcopy with biopsy
Squamocolumnar junction
What are the screening recommendations for cervical cancer with a pap smear?
-Ages 21-29: PAP every 3 years
-Ages 30 or above and HPV neg: HPV and Pap every 5 years
-Ages 30 or above and HPV pos: Co-testing in 1 year
-Age 65: Stop testing if negative so far
DO NOT SCREEN IF BELOW 21 YEARS OLD
What is dysfunctional uterine bleeding (DUB) defined as?
What are some diagnostics that are done if no pathologic cause is found for the bleeding?
Unexplained abnormal bleeding in a non pregnant woman
Beta HCG, Transvaginal US, Endometrial biopsy if stripe is > 4mm to rule out endometrial cancer
What is the treatment for DUB?
- Acute hemorrhage: IV high dose estrogen, NSAIDs for pain
-Chronic: Estrogen-Progestin OCP’s, IUD, Hysterectomy definitive
Explain the following terms:
-Menorrhagia
-Metrorrhagia
-Menometrorrhagia
-Oligomenorrhea
-Polymenorrhea
-Menorrhagia: heavy bleeding at normal intervals
-Metrorrhagia: bleeding between cycles
-Menometrorrhagia: irregular intervals with excessive bleeding
-Oligomenorrhea: infrequent cycles > 35 days
-Polymenorrhea: frequent cycles < 21 days
Risk factors for endometrial hyperplasia/carcinoma
-Chronic, unopposed estrogen: chronic anovulation, estrogen only therapy, PCOS, early menarche, late menopause, Tamoxifen use
-BRCA1 and BRCA2
-Age > 50 years old (Postmenopausal)
-Peutz-Jehger’s: polyps in intestines disorder
Endometrial cancer is the MC gynecological cancer in the US. What is the MC type, what is something that is protective against it, and what is one common symptom of this condition?
Adenocarcinoma
Combination (Estrogen + Progestin) OCP’s
Postmenopausal bleeding/AUB
What are 5 symptoms associated with endometrial cancer?
1) Cyclic premenstrual pelvic pain/low back pain, 2) dyspareunia, 3) dyschezia, 4) AUB, and 5) infertility
What diagnostics are done for endometrial cancer?
Transvaginal US (screening)
-Thickened endometrial stripe > 4 mm
Endometrial biopsy (definitive)
CA-125 seen in both endometrial and ovarian cancer
Treatment for endometrial cancer
Hysterectomy + BSOOP +/- Radiation/Chemo
Endometriosis is the MCC of infertility in women > 30 years old. What is this condition defined as? Where is the MC site?
Implantation of endometrial tissue outside of the uterus
Ovaries
Risk factors for endometriosis
Prolonged estrogen exposure (nulliparity, late first pregnancy, early menarche, < 35 years old)
Triad of symptoms for endometriosis
What is another symptom of this condition (what does the uterus appear as)?
-Cyclical premenstrual pelvic pain + dyspareunia + dysmenorrhea
May have fixed, tender adnexal mass or fixed retroverted uterus
What diagnostic is initially done for endometriosis? What is the definitive diagnostic?
US initially
Laparoscopy with biopsy is definitive
Explain what an endometrioma looks like on laparoscopy
Ovary tumor filled with old blood, called a chocolate cyst
Treatment for endometriosis
-Ovulation suppression: OCP’s + NSAIDs for pain
-Progesterone, Leuprolide, Danazol
-Surgical: Laparoscopy with ablation if fertility desired. TAH-BSO if no desire to conceive
Endometritis is an infection of the decidua (uterine endometrium). What is the biggest risk factor and what’re OTHER risk factors?
Biggest: C-section delivery
Others: PROM > 24 hours, vaginal delivery, D&C for evacuation, multiple pelvic exams
Symptoms of endometritis
Fever, tachycardia, abdominal pain and tenderness 2-3 days after C section or post-abortion. May have vaginal bleeding or foul smelling lochia
What is the treatment for endometritis if post C-section? How about post vaginal delivery?
What is given prophylactically during the C-section to avoid this infection?
Clindamycin + Gentamicin (C section)
Ampicillin + Gentamicin (Vaginal)
Cefazolin x 1 dose during C section to avoid infection
What is the pathophysiology of PCOS (ie: why does it occur)?
Due to insulin resistance (such as DM Type II), associated with abnormal function of H-P-Ovarian axis –> increase of insulin and LH-driven increase in ovarian androgen production.
Increased LH –> Increased testosterone
Decreased FSH –> cystic ovaries
What is the triad of symptoms associated with PCOS? What do the ovaries feel/appear as?
What is one other symptom that can occur with this condition that should be remembered?
Triad: amenorrhea (chronic anovulation), obesity, hirsutism (androgen excess)
Ovaries appear bilaterally smooth, enlarged
Acanthosis nigricans (due to insulin resistance)
What are 5 things patients with PCOS are at increased risk for?
HTN and atherosclerosis due to insulin resistance, endometrial hyperplasia, endometrial cancer, infertility
What is seen on labs for a patient with PCOS?
Increased testosterone (DHEA)
Increased LH: FSH ratio (> 3:1)
What diagnostic study, besides labs, is usually done to evaluate for PCOS and what is seen?
Pelvic US: multiple ovarian cysts with a “string of pearls” appearance
Treatment choices for PCOS
-Combination OCP’s (Mainstay)
-Lifestyle changes: diet, exercise, weight loss
-Spironolactone for hirsutism (blocks testosterone), but it is teratogenic so must be used with OCP’s
-Clomiphene to fix infertility
What is the MC benign breast disorder in reproductive age women?
What are the symptoms associated with this condition?
Fibrocystic breast disorder
Multiple, painful or painless, breast masses that may increase in size with menses. Often worse prior to menstruation. Multiple, smooth, mobile, and round.
Diagnostics done for fibrocystic breast changes. What is seen?
US initially
FNA: straw colored or green fluid
Treatment for fibrocystic breast changes
Most spontaneously resolve
May aspirate fluid if symptomatic
What is gynecomastia and what is the cause of it?
Breast development in boys/men
Due to increase in effective estrogen or decrease in androgens (testosterone)
-Can be hormonal (in infants it is due to maternal estrogen), idiopathic, or medications (spironolactone, theophylline, thiazides)
Three pharm treatments for gynecomastia
Clomiphene (induces ovulation)
Tamoxifen (estrogen antagonist)
Danazol
What are two other things that should be remembered as treatment for gynecomastia?
Limit EtOH
Treatment should be started within 6 months of onset
What is the MC benign breast lesion in those < 30 years old?
Explain what it feels like
Fibroadenoma of the breast
Doesn’t change in size with menstruation. Firm, contender, solitary, mobile, rubbery lump in breast
What diagnostics are done for fibroadenoma of the breast and what is seen?
US (initial)
FNA: collagen arranged in a swirl
What is amenorrhea (primary vs secondary)?
What is the MCC of secondary amenorrhea?
Primary amenorrhea: failure of onset of menarche by age 15 with sex characteristics or age 13 without sex characteristics.
Secondary amenorrhea: absence of menses > 3 months in a patient with previously normal menstruation
MCC secondary: pregnancy
What are some other causes of secondary amenorrhea?
Pituitary dysfunction (prolactinoma), hypothalamus dysfunction (amenorrhea, eating disorder, osteoporosis = female athlete triad), ovarian dysfunction (decreased estrogen, increased LH and FSH), uterine dysfunction
Explain Asherman’s Syndrome and how it relates to secondary amenorrhea
Uterine dysfunction: acquired endometrial scarring after D&C
What labs should be drawn if the patient has amenorrhea?
HcG, FSH, TSH, Prolactin levels, LH
Explain dysmenorrhea, what primary is caused by, and the symptoms with time frame in which this condition occurs.
Dysmenorrhea is painful menstruation that affects normal activities
Primary is due to increased prostaglandins
Crampy lower abdominal or pelvic pain 1-2 days before onset of menses and diminishes over 12-72 hours
Pelvic organ prolapse is weakness of the pelvic floor muscles due to vaginal birth, surgery, obesity, etc. Explain the grades 0-4 of uterine prolapse.
Grade 0: no descent
Grade 1: uterus descent into upper 2/3 of vagina
Grade 2: cervix approaches introitus
Grade 3: cervix outside introitus
Grade 4: entire uterus outside vagina
Explain the following words:
-Cystocele
-Enterocele
-Rectocele
Cystocele: Posterior bladder herniating into anterior vagina
Enterocele: (Pouch of Douglas) small bowel into upper vagina
Rectocele: rectum into posterior vagina
Clinical interventions for Pelvic Organ Prolapse
-Kegel Exercises
-Pessaries
-Topical Estrogen
-Hysterectomy of sacrospinous ligament fixation if no improvement
What is likely on a history of a patient with Paget’s Disease of the breast?
-Chronic eczematous itchy, scaling rash on the nipples and areola (may ooze)
- A lump is often present
-May have bloody nipple discharge
The male being the cause of infertility accounts for what percentage of infertility cases? What diagnostic should be done for this? What is the normal ejaculate volume and stats?
40%
semen analysis
Normal volume: 1.5-5mL and pH > 7.2
If amenorrhea is secondary to a hypothalamus problem, what labs are seen?
Normal/decreased FSH/LH
Decreased Estradiol
Normal Prolactin
The menstrual cycle varies from _______ and the average time is ______. Menstruation is considered what “day” of the cycle? Ovulation occurs________
Varies from 20-25 days
Average is 28 days
Menstruation is day 1
Ovulation occurs 14 days before menstruation
Explain the H-P-O axis and the hormones that control each phase.
Pulsatile GnRH from Hypothalamus –> FSH and LH from anterior pituitary –> control ovary follicles
Explain what happens in the pre-ovulatory phase (2 weeks leading up to ovulation). Give both names, explain the hormones, what occurs, etc.
Ovarian Follicular Phase & Endometrial Proliferative Phase
Estrogen predominates and builds up endometrium
-GnRH –> increases FSH and follicle/egg maturation in ovary. Increased LH causes follicle to produce estrogen. Ovulation occurs on day 12-14 and then positive feedback causes more GnRH, more estrogen, LH and FSH
At the last step in the pre-ovulatory phase, what causes ovulation (Days 12-14)?
Sudden LH surge
Explain what happens in the next phase (Post-Ovulatory) which is Days 14-28. What are the two names, what hormones do what, etc.
Ovarian Luteal Phase and Endometrial Secretory Phase
Progesterone predominates
LH surge causes follicle to become corpus lute which secretes estrogen and progesterone to maintain endometrium.
If the follicle is NOT fertilized, corpus luteum deteriorates and the fall of estrogen and progesterone leads to menstruation. Process starts all over.
What is infertility in a female defined as? What medication can be used to treat this (as an option)?
Failure to conceive after 1 year of regular, unprotected sex
Clomiphene induces ovulation. Encourage diet and exercise to correct endocrine problems that may be causing this as well.
What is the karyotype of Turner Syndrome and what is one thing it can cause related to OBGYN?
Female 45, XO
Amenorrhea
karyotyping gives the definitive diagnosis
What is menopause defined as? What is the average age? What is considered premature? Explain some symptoms of this condition.
Cessation of menses > 1 year due to loss of ovarian function
Average: 50-52
Premature if < 40 years old
Hot flashes, vaginal atrophy, incontinence, osteoporosis, CV risk increases, decrease in breast size, sleep changes
What is the most sensitive assay for menopause and what does it show?
What is the predominant estrogen AFTER menopause?
FSH assay ( >30 is diagnostic)
Estrone is predominant
What do the other labs show with menopause?
Increased FSH
Increased LH
Decreased Estrogen
What is a leiomyoma? One important risk factor that should be remembered (a population that is at increased risk for this condition).
And what is the most common symptom of this.
Benign uterine smooth muscle tumor (MC benign gynecologic tumor)
African Americans at 5x more risk for this
Bleeding MC symptom
What is one thing to remember about a leiomyoma in regards to the pathophysiology?
Growth is estrogen dependent so it may wax and wane in size with menstruation
How do you diagnose a leiomyoma? What is the treatment?
Transvaginal US: hypo echoic mass with shadowing
Treatment: Observation, Leuprolide (shrink before surgery), Myomectomy, Hysterectomy
What is seen on exam in a patient with a leiomyoma?
Firm, contender asymmetric mobile mass(es) in abdomen or pelvis on bimanual exam
How does Clomiphene stimulate ovulation in those with amenorrhea?
Stimulates GnRH from the hypothalamus
Ovarian torsion is characterized by what symptoms?
acute, sudden onset of unilateral pelvic pain
Abdominal tenderness or adnexal mass
Diagnostics that should be done if you suspect ovarian torsion?
US with Doppler: decreased ovarian blood flow
Surgical exploration: definitive diagnosis
What is the treatment for ovarian torsion?
Laparoscopy with detorsion
What are the two options for sterilization (in both genders)?
Male: vasectomy
Female: tubal ligation: TAH-BSO
Clinical Intervention for a contusion of the breast
Avoid rubbing/massaging area
Apply heat
NSAIDs
What is considered Chronic or Pre-existing HTN in pregnancy?
HTN before 20 weeks gestation or before pregnancy
Persists > 6 weeks postpartum
