Reproductive Flashcards
When you think of cyclical pain what do you think of?
Endometriosis
3 D’s of endometriosis
Dysmenorrhea
Dyschezia
Dyspareunia
What does endometriosis often cause in women?
Infertility
Uterine characteristics in endometriosis
Fixed retroverted uterus with decreased mobility
+/- nodules in the rectovaginal septum
Test of choice and definitive diagnostic for endometriosis
TOC = TV U/S = Ground Glass Appearance
Def = Biopsy during laparoscopy
+”powder burn” and chocolate cysts with ovarian cysts+
Management of endometriosis
NSAIDS
COCs
Progestin
Danazol
GnRH agonists = leuprolide
If you want to treat endometriosis and save fertility potential what would you do?
Laporoscopy with ablation
What 3 types of fibriods arise from the myometrium
Submucosal
Intramural
Subserosal
What are the uterine findings commonly in fibriods
Firm Nontender irregular shaped.
What hormone controls uterine fibroids
Estrogen
3 sxs that can occur in uterine fibroid ; other wise ASX
Pelvic pressure / pain
Menorrhagia
Constipation
What imaging do you use to evaluate submucosa or intramural lesions?
Infusion sonohysterogram
What is the surgical management of fibriods that preserves fertility
Myomectomy
Def = hysterectomy
When thinking risk for endometrial cancer think
Increased estrogen exposure
MC type of endometrial cancer
Adenocarcinoma
MC GYN malignancy
How does ovulation effect endometrial cancer?
If you chronically dont ovulate [PCOS] you are more at risk
Suspect endometrial cancer if a women presents how?
Postmenopausal bleeding
During pelvic U/S endometrial stripe greater than what equals time for more imaging?
4mm ; get an endometrial biopsy
What is the med management of endometrial hyperplasia and when would you use it?
Progestin and only if patient still desires to be pregnant and there is no atypia present—> otherwise hysterectomy
Describe the 3 types of ovarian cysts
Follicular
Corpus luteum cyst
Neoplastic = #1 Teratoma ; Endometrioma ; Cystadenoma
What will ruptured ovarian cyst likely have (4)
Distention
Unilateral POOP
Fever
Guarding
What is the ovarian tumor marker
CA125
Follicular ovarian cyst U/S findings:
Unilocular thin walled anechoic
Corpus luteum cyst pelvic U/S findings
Diffuse thick walled with peripheral blood flow
What are the types of physiologic ovarian cysts
Follicular and corpus luteum
What size ovarian cyst usually requires surgery
Greater 5 cm
What 2 ligaments are involved in ovarian torsion
Infundibulopelvic and ovarian ligaments
What is the definitive diagnostic for ovarian torsion and what does it show
Laporoscopy
= enlarged ovary
Absent blood flow
Peripherally displaced follicles
What is the sign associated with Doppler flow U/S for ovarian torsion
Whirlpool sign = twisting of the vascular pedicle of the enlarged ovary
Remember that PCOS has increased what?
Insulin resistance with hyperinsuinemia
Lab findings in PCOS
Incr LH / FSH
Incr estrogen / progesterone
Incr total testosterone
Pelvic U/S findings in PCOS
Enlarged ovary multiple cysts
String of pearls
Can PCOS benefit from progestin only therapy
Yes — because PCOS lacks the ability to ovulate which requires progestin ; progestin is often low
What is the most common ovarian cancer ; common in what age
Epithelial Cell common in age over 50
What sxs do you think of with ovarian cancer and what risk factors
Abdominal Distention
Bloating
Early satiety
Weight loss
Virchows node and sister Mary and Joseph node can be present in what pelvic cancer
Ovarian cancer
Size greater than what is concerning for ovarian malignancy
10cm
What cervical cancer precursor is the most common etiology
HPV 16 and 18
What is a common findings in cervical dysplasia / cancer
Post coital bleeding
Does a woman with total hysterectomy need HPV or Pap testing
NO!
HPV screening is age what?
21-65
When can you consider HrHPV[preferred] or co testing every five years
WHAT ELSE?
Age 25 +
Pap test every 3 years ; starting at 21 +
What is the acetic acid stain for HSIL
Off white dull color
Coarse vascular pattern
When should a women be referred to colposcopy
Over 25 with LSIL or ASC-H
Over 29 with ASCU-US and +HPV
Age 21-24 with ASC-US or LSIL
And
Over 29 with HPV + and NILM
Repeat Pap in 1 year
Age over 29 ASCU-US and negative HPV
Repeat Pap in 3 years
What level of tissue change requires long term follow up 25 years +
CIN 2 and CIN 3
CIN2 but desires child bearing treatment
Excisional LEEP
4 signs of PID
Previous positive NAAT [G/C]
Fever
Muco discharge
ABD Pain /‘/ Postcoital bleeding
Dont forget to look for what in PID with pelvic U/S
Tubo-ovarian abscess
Out patient management of PID
Ceftriaxone + Doxy + Metronidazole
PID + Vibreonous string + Violin string adhesions = What syndrome?
Fitz Hugh Curtis
Dont forget what in BV
Usuallllllyyyyyy white copious discharge with odor due to increase in amines [FISHY]
3 of 4 criteria for BV include :
Thin white/gray discharge
Clue cells
pH of vaginal fluid greater than 4.5
Fish after whiff test 10% POTASSIUM HYDROXIDE
FIRST CHOICE for BV management
Metro by mouth BID x 7 days
2 important risk factors for yeast infection
Diabetes
Recent antibiotic use
Wet mount for yeast infection shows what
Psuedohyphe or spores
What would make a yeast infection complicated? (5)
Not infected by C. Albicans
Pregnant
Immune comp = Diabetes
Greater than 3 episodes per year
Severe sxs
How can you treat complicated yeast infection
Oral FLUCONAZOLE every 72 hours in 3-4 doses
Topical azole 7-14 days
Topical clotrimazole or Miconazole for 7 days if pregnant
Describe PE for Trichomonaisis
Frothy yellow-green discharge
Malodorous
Strawberry punctuate hemm cervix
Talk about TRICH treatment
Metro PO is first line ; 7 days
Tinadzole = 2nd
MUST TREAT PARTNER
Will amines be positive in TRICH?
Yes, bitch!
PALM COIEN for AUB
Polyp
ADENOMYOSIS
LEIOMYOMA
Malignancy
Coagulopathy
Ovulatory dysfunction
Endometrial
Iatrogenic
NOT CLASSED
Postcoital bleeding suggests what?
Cervical pathology
First line imaging for AUB
Pelvic U/S
What is hormonal vs non hormonal way to treat acute AUB ?
Hormonal = IV estrogen
Non hormonal = TXA ;; intrauterine Tamponade
3 thins common if no menarche before 15 with secondary sex characteristics
Outflow obstruction
Mullerian agenesis
Androgen sensitivity
3 etiologies of no menarche by 13 with no sex characteristics
Turner syndrome 45 XO
Illness, anorexia
Athletes
Dont forget what if your patient presents with amenorrhea
Check for pregnancy
What is ASHERMAN s syndrome
Intrauterine adhesions with fibrous tissue bands by trauma to the basal layer or INFECTION
What two heart complications are assoc with Turner’s syndrome
Coarctation of the aorta
And
Bicuspid aortic valves
Describe Turner’s syndrome 45XO
Low set ears
Wide set nipples
Web Neck
Minimal breast buds
Amenorrhea with which signs would make me concerned for pregnancy
Chadwicks and Hegars
What are the results of progesterone challenge in PCOS
Administer progesterone and get a withdrawal bleed, suggesting low levels of progestin
If there is no withdrawal bleed after progesterone challenge what can you do
Estrogen + progestin challenge
After estrogen progestin challenge if there is a withdrawal bleed what do you suspect
Primary ovarian failure
HYPOTHALMIC amenorrhea
After estrogen + progestin test is there is a withdrawal bleed what do you suspect
Primary ovarian failure
HYPOTHALMIC amenorrhea
If there is no withdrawal bleed after estrogen + progestin testing then what do you suspect?
ASHERMAN syndrome
Cervical stenosis
Lactational mastitis is most often due to what microbe?
Staph A.
Periductal non lactational mastitis can occur if patient has what 2 risk factors
Tobacco use
Squamous Metaplasia
Imaging studies for mastitis are only indicated when?
If patient is not lactating
What are the PO ABX of choice for mastitis
Dicloxacilin and cephalexin
MRSA txm think:
Bactrim
Unilateral fluctuant tender breast mass with fever think ;
Breast Abscess
U/S results of breast abscess are often
Ill defined borders with septations
Age most at risk for fibroadenoma
15-35
Firm round rubbery discrete non tender mobile breast mass is a ;
Fibroadenoma
What size fibroadenoma usually gets excised
Greater than 5 cm
What is the effect of E and P on fibrocystic breast changes
E= stimulates the ducts
P= stimulates the stroma
Describe fibrocystic breast changes
Usually BILATERAL and PAINFUL mobile smooth changes in size.
Pharm management for fibrocystic breast changes
Danazol
Tamoxifen
What is the most common type of breast cancer
Infiltration duct carcinoma
4 important risk factors for breast cancer
Early menarche
Late menopause
Birth of a child after age 35
Nulliparity
Describe a breast cancer lump
Fixed non tender firm lump with IRREGULAR BOARDERS
What location on the breast is most concerning for cancer
Upper outer margin
Hallmark of Paget’s disease
A scaly raw burning lesion that begins on the nipple then spreads to the Areola
Almost all women with inflammatory breast cancer have what and what is the characteristic sign
LAD
Peau De Orange
What is the effect on ALP in Breast Cancer
Increased
What 4 things are often decreased for a mom during pregnancy
Peripheral vascular resistance
And
Blood pressure
And
Esophageal sphincter tone
And
Gastric motility
When should you expect to hear fetal heart tones
10-12 weeks
When should you expect to hear fetal heart tones
10-12 weeks
What is a Chadwick’s and Hegars and when should you expect them?
7 weeks = CHADWICKS = Blue Violet appearance of cervix
12th week = HEGARS = upper uterus enlarged lower part is empty
Define Naegles Rule
Take LMP + 7 days - 3 months + 1 year = EDD
What med can cause neural tube defects
Valproate
What markers are high in Down syndrome for quad screen
Inhibin and HCG
When do you administer anti D IG
If Rh - negative ; at 28 weeks! // and within 72 hours if hemmorhage
What is an important test at 35 weeks gestation
GBStrep
What is the best estimate of age around 20 weeks gestation
Crown rump length
PROM is defined as
Premature rupture after 37 weeks gestation
Most common cause of PPROM
Genital tract infection
What is the color of nitrazine paper for PROM or negative test. Also what can test for PROM
PROM positive = BLUE ; also positive FERN TEST of amniotic fluid
Intact = Orange
How can you manage PROM if no contraindications to labor or vaginal delivery
Oxytocin
What two medications can aid in cervical ripening
Misoprostol and PGE2
What is the benefit of cervical ripening
It helps the cervix soften and thin out so that cervix can be made suitable for delivery within 24 hours
If the AFI shows olyghydraminos you need to be thinking
PROM // PPROM
What is the acronym for remembering the different tocolytics
It’s Not My Time
Indomethacin
Nifedipine
Mag Sulfate
Terbutaline
PROM in less than 34 weeks don’t forget to administer what 2 tings
Antenatal corticosteroids
Magnesium sulfate at less than 32 WEEKS
PROM over 34 weeks gets what
HOSPITALIZE
MC of spontanous abortion
Genetic defects not compatible with life
What 4 abortion types occur specifically in the first 20 weeks
Threatened
Inevitable
Complete
Incomplete
Missed [ALL TYPES]
Management for Spont abortion
Mifepristone then misoprostol with ion 24 hours
D&C if no improvement = surgery
Define abruptio placentae ; can cause what kind of bleeding
-Prelabor separation of the implanted placenta from the uterine wall
-Rupture of maternal vessels in decidua basalis
3rd TRI VAG BLEEDING + PAIN + CONTRACTIONS
External Bleed = if lower uterus
Internal Bleed = if superior uterus
Previas are what
Painless BRIGHT RED BLOOD after 20 weeks gestation ;; placenta down and implanting over the cervical os
What is the thing to know about previa management
No speculum until after U/S
3 risk factors for placenta previa
Hypertension
Cocaine
Trauma
When is it safe to deliver placenta previa
36-37 weeks gestation
What is the #1 risk factor for ectopic pregnancy
Previous ectopic pregnancy
What is the preferred therapy for ectopic and what does it do and when given ?
Methotrexate 1mg/kg
Inhibits folic acid metabolism
Gestational sac less than 4cm and Hemodynamically stable
What is the acronym for HELLP in Preeclampsia
Need greater than 2 in Hemolysis
Hemolysis [Hgb , elevated bilirubin , blood smear weird, low hatpoglobin]
Elevated Liver Enzymes
Low Platelet Count
What type of surgery is indicated in complicated ectopic pregnancy
Salpingostomy or ectomy
Definition of chronic HTN in pregnancy
High Bp persists 12 weeks postpartum ;; transient if returns to normal but he 12 th week
3 monitoring tips for gestational hypertension
Weekly NSTs
Weekly maternal blood pressure measurement
Patient education on signs and sxs
First line Bp management med
IV Labetalol
Measurements significant for Proteinuria that you need to know [6]
BP PITC
Bp over 140/90 on 2 occasions 4 hours apart or 160 / 110 confirmed twice
Proteinuria = creatine ration greater than 0.3 ;; serum creatine greater than 1 = kidney insufficiency
Thrombocytopenia = less 100,000K
Impaired liver function
Pulmonary edema
Cerebral disturbance = headaches, convulsions, vision disturbance
What does mag sulfate do in preeclampsia
Seizure prophylaxis
How long do you give mag sulfate for pre eclampsia
Continued until 24 hours PP
When is screening for gestational diabetes
24 to 28 weeks
Fasting
1 hr
2 hr
3 hr
Glucose in pregnancy testing values?
F = 95
1 hr = 180
2 hr = 155
3hr = 140
Treatment of choice for medical management of gestational diabetes
Insulin
What 3 type of insulin do not cross the placenta
Regular
Insulin Lispro
Insulin Aspart
Physio overview of the menses cycle
Negative feedback
Hypothalamus —> GnRH to Pit Gland
Ovaries receive FSH and LH from Pit Gland
Ovaries secrete E and P which turn off the hypothalamus and pit gland
Duration of menses that is considered normal
8 days
MENSTRAUL phase
Day 1-7 ; FSH begins to rise
Follicle begins to form
Ovulatory phase
7-14 day
Day 14 = LH surge for ovulation
Luteal phase
14 - 28
Prepare the lining for fertilization
High levels of progesterone
When should women have had menses
13 no secondary characteristics
Or 15 with secondary sex characteristics
Amenorrhea with irregular cycles is defined as what time frame
6 months at least
Common reasons for GnRH production insufficiency : 4
Eating disorders
Weight loss
Excessive exercise
Stress // Idiopathic
[delayed sex character // short stature ]
Turner’s syndrome
XO
Ovary Dysgenesis
Dropper eyelids
Crowding of teeth
Web neck
Mullerian dysgenesis think
No uterus or upper 2/3 of vagina BUT has ovaries
; some times missing other body parts
Androgen insensitivity
XY ; Get Karyotype
Absent menses
Well developed breasts
Little pubic hair
Short depth vagina
[No uterus or ovaries//Atrophic testes internally]
What is the most common cause of secondary amenorrhea in a young women
Pregnancy
Ashemranns syndrome is usually due to
Several D &C previously
Labs normal not pregnant with amenorrhea think what diagnostic
Progesterone challenge
Regulate menses trying to get pregnant
Dopamine Agonist
Clomid
Elevated prolactin
Referral to specialist
INTERMENSTRUAL bleeding think what causes
Polyps
Cervical CA
Birth control
Vaginal trauma
AUB
PALM
Polyp , ADENOMYOSIS , leiyomama , malignancy
COEIN
Coagulopathy , ovulatory dysfunction , endometrial , iatrogenic , Not yet classified
MC type of polyp
Cervical ; lobular red / pink pop out of the cervix
ADENOMYOSIS is what
Enlarged uterus
Heavy prolonged periods
Fibroids is what type of tumor
Smooth muscle
E and P receptors
Heavy and prolonged bleeding
MC : Submucous = deform uterine cavity ; heavy bleeding
Subserous uterus = mishappen ; asymmetrical
What type of surgery preserves fertility in fibroids
Myomectomy
Endometrial cancer think
Prolonged estrogen exposure
DIABETES
Dx for endometrial cancer
Next step
Definitive
Next step = EMBx
Definitive = Endometrial curettage
Iatrogenic AUB
BC // IUD
Anticoag drugs
TCAs SSRIs
HRT
MC Molar Preg
Complete = 2 sperms ;
Grape like ; ground glass uterus ; vag bleeding l severe hyperemesis ; large uterus ; no fetal heart rate
TXM = D and C ; OCs for at least 1 year
AUB with progesterone challenge should do what
Stop the bleeding
Primary dysmenorrhea causes
Increased prostaglandins
Increased leukotriene levels
MC cause of secondary dysmenorrhea
Endometriosis
What is a way to decrease risk of endometriosis
Longer duration of lactation
Higher parity
Regular exercise
Bimanual exam for endometriosis
Nodularity
Retroverted uterus
ADE of danazol
Deepening of the voice that may be permanent
When do PMS sxs occur
Second half of the menses cycle
PMDD has what two things
Social impairment and prospective charting
5 total sxs from each group of sxs
Dietary modifications proven for PMS / PMDD
[5]
Small frequent meals
More complex carbs
Fruits and Veggies
More Ca2+
Decrease caffeine , alcohol, tobacco, chocolate , sodium
Medications 1st line PMS PMDD
Fluoxetine
-NSAIDS-
Non pharmaceuticals : calcium , B6, St Johns wort
Ovarian cysts in what presentation = MC pathologic
Post menopausal
Ovarian cysts are commonly
Follicular —> unilateral
Excessive response to NML function
Mobile small firm U/S
PCOS presents with type of cysts
Bilateral cysts
PCOS usually has a hx of what
Infertility
Increased LH/FSH ratio then you think what
Endocrine dysfunction
String of pearls =
PCOS
What medication in addition to clomid can increase pregnancy outcomes
Metformin
RF for ovarian cancer [5]
NULLIPAROUS
Late menopause
Diet in high fat
BRCA1/BRCA2
Family history
Vague GI sxs with early satiety think
Ovarian cancer
Ovarian cancer tumor markers ; management and if early stage high risk management ?
CA 125
CEA
Management = total hysterectomy and bilateral salpingo-oopherectomy
Early stage high risk = chemo / IV or intraperitoneal
Management for cystic adnexal mass
Functional cysts = may diseasappear
Repeat sonogram in 6 weeks
Solid adnexal mass management
Laparoscopy
Ages 21-29 gets what PAP screening
PAP along every 3 years
30-65 gets what PAP screening
PAP and HPV = every 5 years
PAP alone = every 3 years
Over 65 years hx of pre cancer = what pap screening
PAP screening Q 3 years // 20 years after dx
ASCUS vs HSIL management
ASCUS =
Repeat PAP in 1 year or HPV test ; AGE 21-24
HPV test alone = AGE 24-29
HPV + —> Colposcopy ; AGE 30 or older
HSIL =
Colposcopy / Bx
Histology comes from what
Colposcopy
CIN 1 do what
CIN 2/3
?
CIN1 = repeat pap in 6-12 months
CIN2/3 = cryotherapy CO2 laser
Cold knife conization ADE vs. LEEP
Incompetent cervix
LEEP = less likely
RF for cervical cancer ; MC
HPV 16 and 18
Smoking
Increased sex partners
MC : Sq Cell Cancer
POST COITAL BLEEDING
Breast feeding warmth and discomfort
S Aureus
Mastitis
—> dicloxacilin
can lead to abscess localized PAIN
—> vancomycin
Painful cyclic bilateral changes in shape or size ? And what treatment?
Fibrocystic breast disease
Vit E / Dec Caffiene // OCPs // Severe = Bromocriptine
Fibroadenoma
Rubbery solid smooth breast mass
Mobile
MGMT = observe for small // large surgical
RF for breast carcinoma
Prolonged estrogen
+/- Endometrial cancer
High fat / High BMI
Painless stony hard unilateral mass
MC : infiltrating ductal carcinoma
Starts as ductal carcinoma [DCIS]
pruritic scaly rash on nipple ; ABX/Fungals do not resolve
Pagets Disease
Stepwise breast cancer Diagnostics
Mammo —> U/S —> Bx
P and E positive breast cancer can be treated with
HRT
POST menopausal think : Letrozole
Pre menopausal think : Tamoxifen
Fluid filled cysts =
Bilateral fibrocystic breast changes
Treatment for prolapse // uterus , rectum , bladder
Cystocele = estrogen therapy
Pessary
Kegel exercises
Make sure any one starting menopause requesting HRT have no hx of
Cancer , breast cancer, endometrial
Common pH of candida vaginitis
4.0 - 5.0
BV treatment
Metronidazole 7 days
IVag = 5 days [Metro]
Clindamycin IVag = 7 days
Trichomonas ;
TXM
Protozoa
Metronidazole = single dose
Tinadazole 2 g
Single dose
AVOID ETOH
Do females with Chlamydia have CMT
YES!
C/G Test of choice
NAAT
Preferred Chlamydia with pregnancy
TXM
Azithromycin x 1 dose
Chlamydia txm non pregnant no G
Doxy
MUCOPURULENT DISCHARGE
1 cause of septic arthritis in young , sexually active adults
Gonorrhea : DISSEMINATED INFXN
Skin lesions for gonorrhea
Maculopapular lesions on the hands//feet
Gonorrhea treatment
IM Ceftriaxone
Genital warts HPV serotype
6 and 11
Cauliflower like warts on external genitalia think
HPV
HPV management : for warts
1st Line = podophyllotoxin -topical
Imiquimod
Pregnant = TCA ; acid
Clinician administered : Cryo ; surgical excision ; laser
Vaccine recommendation for HPV
Girls an Boys
9-26
Rec age : 11-12
Up through age 45.
Dosing = 2 for less than 15 yrs; 3 for over 15 yrs
