Repro/Endo Flashcards
Amenorrhea (FMLD)
Primary = Failure of menarche onset by age 15 (in the presence of secondary sex characteristics) or age 13 in the absence of secondary sex characterisitics)
Secondary = Absence of menses for >3mo in a patient with previously normal menstruation or >6mo in a patient who was previously oligiomenorrhea)
MCC of Secondary amenorrhea = Pregnancy
Amenorrhea secondary to gonadal dysgenesis, turner syndrome (dx + labs)
Karotyping = Definitive dx = 45 XO
Hormonal screening = low estrogen + high FSH + high LH
Bacterial vaginosis (FMLD)
Vaginal odor worse after sex +/- itching
> 50% may be asymptomatic
Bacterial vaginosis (Dx and labs)
Amslers criteria
1. Clue cells on saline smear
2. pH >4.5
3. Thin, water grey discharge
4. (+) whiff test, fishy odor with 10% KOH
Breast cancer (health maint + prevention)
Clinical breast exam age 20-39 ; every 3 years until age 40 then annually
Mammo = age 40 or 10 years prior to age of 1st deg relative was diagnosed
Breast mass (FMLD)
Palpable single nontender firm IMMOBILE mass
MC = Upper outer quadrant and findings on mammography
Stereotactic core-needle biopsy or open biopsy = most accurate in establishing diagnosis
Cervical cancer (scientific concepts)
HPV (Most common = 16,18,31,33,45,52,58)
3rd MC gynecologic cancer
(endometrial = #1, ovarian = #2)
MC Mets = Locally (vagina, parametrium, pelvic)
MC type = Squamous, clear cell carcinoma linked to DES
MC sx = Post-coital bleeding/spotting
Cervical cancer (Dx and labs)
Screening = Pap with cytology
Dx = Colpo with biopsy
Contraception (pharm tx)
Combination OCP (estrogen + testosterone) = prevents ovulation by inhibiting mid cycle LH surge, thicken cervical mucosa, thin endometrium
Progesin only = Safe during lactation, no estrogen SE
IUD = Most effective, increase risk of PID
Dysfunctional uterine bleeding (scientific concepts)
Abnormal uterine bleeding in the absence of pelvic pathology, pregnancy
Disruption in normal cyclic pattern of ovulatory hormonal stimulation to endometrial lining
Dysfunctional uterine bleeding (Clinical intervention)
Dx of exclusion
Workup shows no evidence of organic cause and negative pelvic exam, DUB is the dx
Workup includes: hormone levels, transvaginal ultrasound, endometrial biopsy
Endometrial cancer (scientific concepts)
Endometrial cancer is a cancer that arises from the endometrium (the lining of the uterus or womb).[1] It is the result of the abnormal growth of cells that have the ability to invade or spread to other parts of the body.[8] The first sign is most often vaginal bleeding not associated with a menstrual period.[1] Other symptoms include pain with urination, pain during sexual intercourse, or pelvic pain.
Endometrial cancer occurs most commonly after menopause
Risk factor = Family hx, increased # of ovulatory cycles, infertility, nulliparity, age over 50, BRCA genes, Peutz-jeghers, Turners, HTN, DM
Estrogen-dependent cancer
MC gynecological malignancy
MC type = adenocarcinoma
MC postmenopausal (50-60)
Combination OCPs are protective against both ovarian and endometrial
Endometrial cancer (FMLD)
Postmenopausal bleeding: endometrial stripe >4mm on transvaginal US
Endometrial cancer (Dx and labs)
Dx = biopsy, pelvic exam, D&C, transvaginal US, CT, MRI
Labs = CA-125 (seen in both endometrial + ovarian cancer)
Endometriosis (FMLD)
Classic Triad (3 D’s)
Dyspaurenia
Dysmenorrhea
Dyschezia
+/- pre-post menopausal bleeding
Infertility
Endometriosis (dx + labs)
PE = usually normal; adnexal tenderness
Laparoscopy with biopsy = Definitive
Endometritis (pharm tx)
Infection post c-section = clinda + gentamicin
Group B strep coverage
Infection after vaginal delivery or chorioamnionitis = Amp + Gent
Enterocele (FMLD)
Pouch of douglas (small bowel) herniated into the upper vagina
Fibrocystic breast disorder (clinical intervention)
Ultrasound FNA reveales straw colored fluid (no blood)
Most spontanesouly resolve +/- FNA removal of fluid if symptomatic
Fragile X syndrome (dx + labs)
X-ray spine (scoliosis)
Echo = exclude MVP
Molecular testing + karotyping
Gestational diabetes (Dx and Labs)
1.Screening done at 24-28weeks = 50g 1hr glucola
- Confirmatory 3hr 100g GTT = gold standard; performed in morning after fasting
Gestational trophoblastic disease (molar pregnancy ) scientific concepts
2 MC risk factors = Prior molar pregnancy or extreme in maternal age like 20yo and 35yo
Eomplete egg with NO DNA fertilized by 1 or 2 sperm
46XXX all paternal chromosomes
Gestational trophoblastic disease (molar pregnancy ) Dx and labs
- Beta HCG elevated >100,000 very LOW serum alpha-fetoprotein
- US = Snowstorm appearance or “cluster of grapes”; Absence of fetal prats, heart sounds
Gynecomastia (clinical intervnetion)
- Supportive = depends on cause
Stop offending medsl observation if early in course will most likely resolve spontaneously
Idea tx should start within 6 mo of onset; Surgery if resistant
Limit ETOH consumption
Hydatidiform Mole (clinical intervention)
Surgical uterine evacuation is mainstay of tx to avoid choriocarcinoma
Trend weekly beta-HCG until undetectable
CXR to look for mets from possible choriocarcinoma
Hyperemesis gravidarum (pharm tx)
PO or IV fluids; Multivitamins; Bland diet = BRAT
Anitemeitcs = Doxylamine + Pyridoxine, diphenhydramine, zofran (cleft palate risk)
Hypothalmic amenorrhea (pharm tx)
Clomiphene (stimulate GnRH secretion from hypothalamus)
Hypothalmic amenorrhea (Dx + labs)
AKA when your hypothalamus causes your period to stop. Common causes include excessive exercise, stress and undereating
Normal/decreased FSH & LH
Decreased estradiol
Normal prolactin
Invasive mole (hx + pe)
Painless vaginal bleeding + preeclampsia before 20 weeks + hyperemesis
Uterine size and date discrepancies
Leiomyoma (clinical intervention)
Observation of asymptomatic
Myomectomy to preserve fertility
Hysterectomy = Definitive tx
Molar pregnancy (clinical intervention)
Surgical uterine evacuation (suction curettage)
- METS = Chemotherapy or methotrexate
Mucopurulent cervicitis (scientific concepts)
Depends on cause but start with obtaining culture
Empiric tx with Ceftriaxone + azithro + metronidazole +/- doxy while awaiting culture results
Ovarian cancer (clinical intervention)
- Early stage = TAH + lympadenectomy
- Surgery = Tumor debulking (serum CA-125 monitor tx progress)
- Chemo = Paclitaxel or Cisplatin Or Carboplatin
Ovarian cancer (FMLD)
MC in older, caucasian, nulliparous females
+/- sister mary joseph nodule
Ascites, abdominal distention, early satiety, changes in bowel habits, or fixed mass
Periop antibiotic prophy (pharm tx)
C-section up to 60 min prior
If ROM or in labor = Vaginal cleaning with povidine
PCOS (scientific concepts)
PCOS is due to insulin resistance (type 2 DM)
Associated with abnormal function of HPO axis = increase insulin and increase LH driven increase in ovarian androgen production
PCOS (dx and labs)
High androgen levels
Pelvic exam
Blood test and US can confirm
Labs = Decreased FSH, Increased LH, increased testosterone, increased estrogen,
Pre-eclampsia (Health maint + prevention)
RF= Nulliparity, control HTN
Educate pt to be aware of signs of HTN
Steroids to mature fetal lungs if >34wks
Pregnancy hypertension (hx and pe)
New onset BP 140/90 AFTER 20 weeks gestation
NO proteinuria, edema, or end-organ dysfunction
Normal findings, pregnancy (scientific concepts)
During pregnancy cardiac output INCREASES
CO peaks around 24 weeks
50% increase in the volume of plasma, 20% in RBC and WBC
Pregnancy parturition (scientific concepts)
4 phases
0 = Inhibition
1= Myometrial activation
2- Stimulation
3= Inovulation
Pregnancy, Rh Isoimmunization (clinical intervention)
RhoGam given if Rh negative @ 28wks
Rectocele (clinical intervention)
- Prophy = Kegels + weight control
- Non-surgical = Pessaries + estrogen tx
- Surgical = Hysterectomy
Transitional (gestational) HTN (FMLD)
HTN after 20 weeks gestation; no proteinuria
Resolves 12 weeks after postparum; clinically asx
Uterine leiomyoma (clinical intervention)
Observation if asx
Medical tx = decrease estrogen
Surgical = myomectomy , endometrial ablation, or hysterectomy
Acromegaly (Dx and labs)
Pituitary adenoma causing hypersecretion of GH after the closure of the epiphyses
Screening test = Exogenous (insulin like growth factor 1)
Confirmatory test = Oral glucose suppression test = increased FH levels in acromegaly
MRI of pituitary
Acromegaly (clinical intervention)
- Transsphenoidal surgery + Bromocriptine (increases dopamine)
- Radiation therapy if IGF-1 levels are increased post surgery
- Octreotide = somatostatin analog that supresses GH
- Pegvisomant: GH antagonist may be added to octreotide
Adrenal crisis (pharm tx)
- IV fluids (normal saline to correct hypotension + hypovolemia)
- Glucocorticoids (IV hydrocortisone if known addisons) or Dexamethasone (if unknown)
3.Reversal of electrolyte disorders
- Fludricortisone = synthetic mineralcorticoid similar to aldosterone
Adrenal crisis (scientific concepts)
MCC = abrupt withdrawl of steroids
Shock = primary manifestation (decreased BP, hypovolemia)
Adrenal insufficiency (pham tx)
Addisons disease
Addisons = Glucocorticoids + mineralocorticoids
Secondary cause = Only glucocorticoids
Adrenal insufficiency (dx and labs)
Baseline 8am ACTH, cortisol, & renin levels
- HIgh dose ACTH (cosynotropinin) stimulation test - screening test
- CRH stimulation test = differentiates causes of adrenal insufficiency
Aldosteronism, primary (scientific concepts)
Occurs independent of renin
MCC = adrenal hyperplasia
Conn syndrome = Adenoma (HTN, hypokalemia + metabolic alkalosis)
Arthropathy, Charcot (joint) FMLD
Aka diabetic foot
Joint damage & destruction as a result of peripheral neuropathy from DM, peripheral vascular disease & or other disease
Repetitive microtrauma to foot with no sensation & autonomic dysfunction leads to bone resorption & weakening
MC area = Midfoot affected with pain and swelling
Cushings (hypercortisolism) clinical intervention
3 causes; 3 different treatments
- Cushings disease (pituitary cause) = transsphenoidal surgery or radiation therapy if unresectable
- Ectopic ACTH secreting or adrenal tumor = tumor removal, ketoconazole may be used if inoperable
- Iatrogenic = steroid tx
Diabetes insipidus (clinical intervention)
- Central DI = Desmopressin/DDVAP; Carbamazepine)
- Nephrogenic (kidney doesnt detect ADH) = sodium/protein restriction use HCTZ and indoemthicin
- If symptomatic = hypotonic fluid (pure water orally)
Diabetes insipidus (Dx and Labs)
- Fluid deprivation test = Established the diagnosis of DI, continued production of DILUTE URINE (urine osmo <200 and low specific gravity <1.005)
- Desmopressin (ADH) stimulation test = Differentiate between nephrogenic and central
If central = reduction in urine output indicating response to adh
If nephrogenic = continued production of dilute urine - no response to ADH
Diabetic hypoglycemia (FMLD)
Acute altered mental status; complication of DM
MCC = Too much insulin, too little food intake, excess exercise
Autonomic: sweating, tremors, palpitations, nervousness, tachycardia
CNS: HA, confusion, slurred speech, diziness
Diabetic hypoglycemia (clinical intervention)
Mild <60mg/dl = 10-15g fast carb, fruit juice, hard candy = RECHECK every 15 minutes
Severe/unconscious = <40mg = IV bolus of D50 or inject glucagon SQ
DKA (pharm tx)
SIPS
Saline
Insulin (reg)
Potassium repletion
Search for underlying cause and treat it
INITIAL treatment = Isotonic normal saline
Diabetic nephropathy (Dx and labs)
Mircroalbuminuria = first sign of diabetic nephropathy; increased BP accelerates kidney deterioration
Albuminuria, anemia, acidosis
Kidney bx = Kimmelsteil -Wilson (nodular glomerulosclerosis = PINK HYALINE AROUND CAPILLARIES FROM PROTEIN LEAKAGE)
Graves Disease (Pharm tx)
Aka Hyperthyroidism
MC = Radioactive iodine
If not pregnant = Methimazole or PTU
If pregnant = PTU in 1st trimester then methimazole
Gynecomastia (pharm tx)
- SERM (hormone tx = Tamoxifen)
- Aromatase inhibitors blocks estrogen synthesis (anastrozole or letrozole)
- Androgens used in hypogonadism (DHEA)
Hyperaldosteronism (Dx and labs)
- Labs = Hypokalemia with met alkalosis
- Aldosterone: renin ratio screening
- Definitive test = SALINE INFUSION TEST
- CT/MRI - look for mass
5.EKG shows hypokalemia (u wave)
Hyperparathyroidism (FMLD()
signs of hypercalcemia
Bones, stones, abdominal groans, psych moans
Decreased DTR
Hyperplasia, congenital adrenal (FMLD)
Autosomal recessive disorder
Deficient in enzyme in synthesis of cortisol, aldosterone, or bone
Sex of neonate is unclear because of genital ambiguity
Hyperprolactinemia (Pharm tx)
Stop offending drug
Dopamine agonists (Bromocriptine, cabergoline)
Hyperthyroid (scientific concepts)
- Graves disease = MCC; autoimmune
- Toxic multinodular goiter (plummer dz) autonomous functioning nodules; MC in elderly
- Toxic adenoma = one autonomous functioning nodule
- TSH secreting pituitary adenoma
Hypoparathyroidism (dx and labs)
Caropedal spasms, trosseaus and chovsteks sign, increased DTR
Triad: Hypocalcemia, decreased PTH, increased phosphate
Hypopituitarism (scientific concepts)
Pituitary destruction or deficicent hypothalamic pituitary stimulation
Congenital
Or
Acquired (tumor, infiltrative disease, bleeding into pituitary like Sheehans), pituitary infarction, XRT
Hypothyroidism (myxedema) Dx and Labs
Decreased T3/T4
Increased TSH
Sx = bradycardia, hypothermia, hypoventilation, hypotensive, hypoglycemia, hyponatremia, delayed T3/T4
Hypothyroidism (myxedema) FMLD
Myxedema crisis = Extreme form of hypothyroidism
Sx = fatigue, cold intolerance, weight gain, constipation, dry skin, mylagia, menstrual irregularities, goiter, bradycardia, delayed DTR
Klienfelter syndrome (dx and labs)
47XXY karyotype
Low serum tesosterone
Klienfelter syndrome (dx and labs)
47XXY karyotype
Low serum tesosterone
Klinefelter syndrome (FMLD)
Patients appear normal until puberty
Tall, thin,stature, long limbs
In adulthood = scoliosis, ataxia, developmental delays, hypogonadism, small testicles, infertility, scarce pubic hair
Pheochromocytoma (scientific concepts)
Catecholamine secreting adrenal tumor (Chromaffin cells)
Secretes Epi + Norepi
90% benign; may be associated with MEN type 2
Pituitary adenoma (FMLD)
In females = Hypogonadism, amenorrhea, galactorrhea, HA, visual changes
In men = Hypogonadism, decreased libido, infertility, HA, visual changes
Pituitary adenoma (pharm tx)
Prolactinoma = Dopamine agonists (cabergoline, bromocriptine)
Somatotroph adenoma = Somatostatin analog (octreotide, lanreotide)
Primary adrenal insufficiency (scientific concepts)
Addisons disease
Adrenal gland destruction (lack of cortisol and aldosterone)
Etiologies:
1. Autoimmune (MC)
2.Infection (MCC worldwide) like TB, HIV, fungal, CMV
3.Vascular (thrombosis or hemorrhage in adgren gland known as Waterhouse-fredrichsen)
4.Metastatic disease or medications (ketoconazole, rifampin, phenytoin, barbituates)
Primary hyperaldosteronism (Scientific concepts)
Renin-independent (autonomous)
Conn syndrome = adrenal adosteronoma in the zona glomerulosa
Primary hyperparathyroidism (clinical intervention)
- Surgery = Parathyroidectomy
- Vitamin D/Ca supplementation if this is a secondary problem
- Tx of hypercalcemia if symptomatic (IV fluids, furosemide)
SIADH (dx and labs)
Syndrome of inappropriately HIGH ADH
- Isovolemic hypotonic hyponatremia = decreased BUN
- Urine = Increased urine osm
- Dx made in absence of renal, adrenal, pituitary, thyroid disease, or diuretic use
SIADH (pharm tx)
Moderate = ADH receptor antagonists (conivaptan, tolvaptan)
Chronic = Demeclocycline (tertracycline)
SIADH (clinical intervention_
Tx underlying cause when possible
Fluid restriction
If severe hyponatremia = IV hypertonic saline
Avoid rapid correction to prevent central pontine myelinolyusis
SIADH/malignancy (FMLD)
Neuro sx of hyponatremia and cerebral edema = confusion, lethargy, disorientation, seizures
Normovolemic, hypotonic, hyponatremic = Decreased serum osmolarity
Subacute thyroiditis (clinical intervention)
Aspirin (no anti-thyroid drugs)
Thyroglossal duct cysts (FMLD)
Often presents as midline neck cysts closely associated with hyoid bone
Asx but can have symptoms
Mass will elevate with tongue protrusion or swallowing
Thyroidtoxicosis (FMLD)
Thyrotoxicosis is condition due to excess thyroid hormone of any cause
Increased T3 + T4 with decreased TSH
Sx = anxiety, emotional lability, weakness, tremor, palpitations, heat intolerance, weight loss, a.fib
Can progress into coma, hypotension
MCC = Event like surgery, trauma, infection, illness, pregnancy
Type 1 DM (Scientific concepts)
Pancreatic beta cell destruction
Patient no longer able to produce insulin; MC in childhood
Type 1A = Autoimmune beta cell destruction triggered by 1 or more environmental factors
Type 1B = Nonautominnue beta cell destruction
