Obstetrics/Gynecology Flashcards
1
Q
Definition of primary amenorrhea
A
- absence of spontaneous menstruation by 16yo WITH secondary sex characteristics or 14yo WITHOUT secondary sex characteristics
- 4 main categories based on karyotype
- Turner syndrome (Gonadal agenesis) - 45 XO
- Hypothalamic-pituitary insufficiency - 46 XX
- Androgen insensitivity - 46 XY
- Imperforate hymen - 46 XX
2
Q
Definition of secondary amenorrhea
A
- woman who has previously menstruated
- absence of menses for 3 months if previous cycles nl
- absence of menses for 6 months if previous cycles irreg
- Cause
- THE MCC 2ary amenorrhea = PREGNANCY
- Drug use, stress, significant weight change, or excessive exercise
- PCOS, CNS tumor, hyperPRL, Sheehan syndrome (causes postpartum hypopit - pituitary gland is damaged, caused by excess blood loss (hemorrhage) or extremely low blood pressure during or after labor)
- previously normal menstrual cycles and normal E, think stress or outflow obstruction (Asherman syndrome - scar tissue forms in the uterus, rare but can be a complication of multiple D&Cs)
- If galactorrhea present, prolactinemia is MCC
3
Q
Amenorrhea
A
- Primary or secondary
- women with no menstruation in presence of E stimulation of endometrium have increased risk of endometrial cancer
4
Q
Diagnostic studies for amenorrhea
A
- First line: B-hCG, TSH, PRL
- Second line: FSH, E, LH, T
- If bleeding occurs after progesterone challenge, anovulatory cycles are the cause
5
Q
Characteristics of dysfuncitonal uterine bleeding (DUB or AUB)
A
- Presents as abnormal bleeding with a generally unremarkable PE
- Abnormal uterine bleeding in non-pregnant women
- different from normal cycle in terms of regularity, flow, duration, and volume
- normally occurs right after menarche or during perimenopause
- Causes = PALM-COIEN (polyp, adenomyosis, leiomyoma, malignancy - coag, ovulatory dysFN, endometrial, iatrogenic, not otherwise classified)
- Menorrhagia = heavy or prolonged bleeding
- Metrorrhagia = irregular bleeding between menses
- PE includes speculum, evaluate for bleeding from other sources
6
Q
Diagnostic studies for DUB
A
- B-hCG, CBC, iron, PT, PTT, documentation of ovulation, thyroid, serum P, LFTs, PRL, serum FSH
- Pap, US, hysterosalpingography, hysteroscopy, and/or D&C
- endometrial bx should be done on all women over 35yo w/ obesity, HTN, or DM and on all postmenopausal pts
7
Q
management of DUB (AUB)
A
- depends on severity of bleeding - may include observation, iron therapy, and volume replacement
- progestin trial - if bleeding stops, anovulatory cylces are confirmed
- OCPs:
- older women w/o risk factors
- OCPs should NOT be used in women over 35 who smoke, have HTN, DM, or hx of vascular dz, breast CA, liver dz, or focal HA
- D&C can be dx and curative
- refractory cases may require endometrial ablation or vaginal hysterectomy
8
Q
Dysmenorrhea general characteristics
A
- PRIMARY: painful menstruation caused by increased prostaglandin and leukotriene levels - painful uterine cramping, N/V/D
- Onset: usually w/in 2yrs menarche, peak incidence = late teens/early 20s
- THERE IS NO PATHOLOGIC ABNORMALITY
- SECONDARY: painful menstruation caused by identifiable condition (usually uterus or pelvis - endometriosis, adenomyosis, fibroids, PID, IUD)
- usually affects older women (>25yo)
9
Q
clinical features of dysmenorrhea
A
- Primary: sxs are central lower abdomen or pelvis radiating to back or thighs, beginning before or at onset of menses, lasting 1-3 days
- PE, labs, radiologic tests = nl
- Secondary: similar sxs as above but may also include bloating, heavy menstrual bleeding, and dyspareunia
- less related to first day of flow
10
Q
diagnostic studies for dysmenorrhea
A
- dx of primary dysmenorrhea based on hx, use of menstrual diary, PE
- specific tests for secondary dysmenorrhea - hysteroscopy, D&C, laparoscopy
- all allow both dx and tx
11
Q
management of dysmenorrhea
A
- Primary:
- start NSAIDs right before expected menses, continue 2-3 days
- OCPs, vit B (B1, thiamine; B6, pyridoxine), magnesium, acupuncture, heat, regular exercise
- Secondary:
- underlying conditions should be treated
- sx treatment may be sufficient
12
Q
Pelvic Inflammatory disease etiology and sxs
A
- etiology: infxn ascends from cervix to involve endometrium and/or fallopian tubes
- MCC = gonorrhea, chlamydia, genital mycoplasmas
- RF: endocervical infxn, BV, hx of PID, vaginal douching, IUD insertion, D&C or C-section
- signs and sxs:
- mucopurulent malodorous vaginal discharge
- abd pain
- abnl vaginal bleeding
- bilateral lower abdominal and pelvic pain
- N/V
- urethritis, proctitis
- Fever
- yellow endocervical discharge, easily induced bleeding
- uterine or adnexal tenderness and swelling, CMT
- rebound/guarding
13
Q
Pelvic inflammatory disease dx and tx
A
- Dx: ESR elevated, leukocytosis, B-hCG, NAATs, gram stain
- US: enlarged fallopian tubes with fluid in cul-de-sac
- laparoscopy - last line, rule out appy, ectopic, tumor
- endometrial bx
- outpt: ceftriaxone IM and doxy PO x14d
- +/- flagyl BID x 14d
- inpt: hosp if: dx uncertain, pregnant, abscess suspected, severely ill or N/V preclude outpt management, HIV pos
- Doxy + IV cefotetan or cefoxitin x 48h, then PO doxy BID x14d
- clindamycin + gentamicin qh x48h, then PO doxy BID x14d
14
Q
bacterial vaginosis
A
- MCC vaginitis
- RF: new partner, smoking, IUD, douching, pregnancy
- signs, sxs: mostly asx
- increased vag d/c
- dysuria, frequency, dyspareunia
- noticeable fishy discharge after menses or intercourse, no itching
- thin ivory/gray d/c
- dx: amsel criteria (3 of 4)
- thin, gray, homogenous d/c
- positive whiff
- clue cells
- elevated pH >4.5 (basic)
- tx: metronidazole BID x7d
- Or vaginal metronidazole
15
Q
atrophic vaginitis
A
- postmenopausal women, thinning of vag epithelium
- signs, sxs: dyspareunia, thin vag d/c, vag pruritis, burning, soreness
- atrophic vulvar changes (smooth, shiny, pale, dry, thin), scattered vag petechia, thin clear or brown d/c (leukorrhea)
- UTI, urge incontinence may be associated
- Dx: clinical dx
- vaginal cytology (greater % of parabasal cells)
- vaginal pH: 5-7
- tx: H2O soluble lubes, topical vaginal estrogens, oral estrogens
16
Q
candidiasis
A
- 2nd MCC vaginitis
- RF: high dose OCP, diaphragm use, DM, abx, pregnant, immune suppression, tight clothes
- signs, sxs: vulvar or vag itching, burning, external dysuria, dyspareunia, odorless thick cottage cheese curd-like d/c
- erythema of vulva, excoriations from scratching
- dx: wet mount - budding yeast
- gram stain - pseudohyphae
- vaginal culture (+) for yeast
- pH <4.7 (acidic)
- tx: fluconazole 150 PO once
- tx uncircumcised partners
- short-course topical azole
- recurrent: weekly topical /PO
- resistant: boric acid TID x7d
