Reproductive Flashcards
Palpable breast mass
A firm palpable breast mass with ill-defined borders is concerning for malignancy. Additional clinical features suggestive of malignancy include an immobile mass with associated LAD, expressed nipple discharge, skin changes, or new-onset nipple inversion. H and P is not enough though. Need imaging
If you have a palpable breast mass
- age less than 30
- US with/without mammogram
- simple cyst - needle aspiration (if patient desires
- complex cyst/mass (solid mass) - image-guided core biopsy
- US with/without mammogram
- age at least 30
- Mammogram with/without US
- suspicious for malignancy - core biopsy
- Mammogram with/without US
Mammogram findings that are suspicious
Spiculated soft tissue mass with calcifications. Additional concerning findings are architectural distortion and linear branching calcs.
Infertility definition
Couple’s inability to conceive after at least 12 months of appropriately timed intercourse without contraception.
For women 35 and older, evaluation occurs after at least 6 months of infertility
Male factor infertility is a common cause. The most common etiologies are testicular or genetic defects (Klinefelter, varicocele). Klinefelter is number 1 chromosomal cause of male infertility.
A semen analysis is gold standard in evaluation of male partner and is the first step in an infertility evaluation. Sperm volume, pH, concentration, motility and morphology are assessed.
For most women, ovulation and fertility return within a month of discontinuing OCPs. If it’s been 12 months, evaluation regardless of prior contraception.
Differential diagnosis of vaginitis
1) Bacterial vaginosis (gardnerella vaginalis)
- Thin, off white discharg with fishy odor
- no inflammation
- pH over 4.5
- clue cells
- positive whiff test (amine odor with KOH)
- Tx with metronidazole or clindamycin
2) Trichomoniasis (trichomonas vaginalis)
- thin yellow-green malodorous frothy discharge
- vaginal inflammation
- ph over 4.5
- motile trichomonads
- Tx with metronidazole. Treat sexual partner.
3) candida vaginitis (candida albicans)
- thick, cottage cheese discharge
- vag inflammation
- normal ph (3.8-4.5)
- pseudohyphae
- tx with fluconazole
clinical features of vaginitis are nonspecific. Always get wet mount or NAAT to avoid inappropriate treatment.
retrograde urethrography
indicated when urethral injury suspected. Blood at tip of meatus, hematuria
Acute epididymitis
Etiology
- age less than 35 - sexually transmitted (chlamydia, gonorrhea)
- age over 35 - bladder outlet obstruction (coliform bacteria)
Manifestatons
- unilateral, posterior testicular pain
- epididymal edema
- pain improved with testicular elevation
- dysuria, frequency (with coliform infection)
Diagnosis
- NAAT for chlamydia and gonorrhea
- UA/UCx
If gonorrhea can’t be ruled out give CTX/Doxy. Fluoroquinolones (levofloxacin) are appropriate for patients with low risk of gonococcal infection but should not be used if gonorrhea is still a possibility due to increasing resistance.
Causes of recurrent pregnancy loss
Structural
- uterine - fibroids, adhesions, polyps
- cervical insufficiency
Chromosomal
- aneuoploidy
- translocations/rearrangements
- mosaicism
immunologic/heme
- hypercoagulable disorders (antiphospholipid)
- alloimmune intolerance
endocrine
- thyroid
- PCOS
- diabetes
- hyperprolactinemia
Other
- advanced age
- defective endometrial receptivity
- decreased ovarian reserve
- celiac disease
Filling defect on hyserosalpingogram
Due to intracavitary leiomyoma, intrauterine adhesions (asherman), or a uterine anomaly (Septum, bicornuate, didelphys)
Uterine septum is the uterine anomaly most commonly associated with recurrent pregnancy loss
Septa have low blood supply so when embryo implants it is abnormal and poorly vascularized leading to pregnancy loss. Hysteroscopic resection of the septum is treatment of choice to decrease recurrence risk of spontaneous abortion
vaginal progesterone
Indicated for prevention of preterm delivery in patients diagnosed with a short cervix (25mm or less) via transvaginal ultrasound at 18-24w gestation.
B-hCG discriminatory zone
- This is when you can see the embryo on US.
If it is below 1500 and can’t see it yet then it can be either ectopic or too early. In stable peeps, bhcg should be repeated every 48h to determine if increase is consistent with normal pregnancy (at least 35% increase every 48h). US repeated when we reach 1500.
Treatment of ectopic pregnancy
Hemodynamically stable - methotraxate.
Not - surgery
Symptoms usually start 6-8 weeks after LMP. Vaginal bleeding, lower abdominal pain and amenorrhea.
Risks
- prior ectopic
- hx of pelvic surgery
- tobacco use
- PID
- infertility
- IVF
Positive hcG, lower abdominal pain and/or vaginal bleeding.
- hemodynamically unstable
- immediate surgical consult
- stable
- TVUS
- adnexal mass - treat ectopic pregnancy
- IUP
- Nondiagnostic
- serum hcg
- over 1500 - repeat B and TVUS in 2d
- under 1500 - repeat B in 2 days
- serum hcg
- TVUS
Threatened abortion
vaginal bleeding, closed cervix and IUP with normal fetal cardiac activity
Absolute contraindications to combined hormonal contraceptives
- migraine with aura (bc of slightly increased stroke risk)
- 15 cigs/day PLUS age 35 and up
- HTN over 160/100
- heart disease
- diabetes with end organ damage
- history of DVT/PE
- antiphospholipid antibody
- history of stroke
- breast cancer
- cirrhosis and liver cancer
- major surgery with prolonged immobilization
- use less than 3 weeks postpartum
Constiutional delay of growth and puberty
clinical
- FHx of late bloomers
- delayed puberty
- short stature, normal growth velocity
- delayed bone age
Management
- reassurance, watchful waiting
- maybe hormone therapy
prognosis
- puberty onset correlates with family members
- normal expected adult height
puberty is delayed if no secondary sex characteristics (testicular enlargement beyond 4ml or breast development) by age 14 in boys or 12 in girls
normal growth velocity is 4-6cm/h
Kallmann Syndrome
Anosmia and hypogonadotropic hypogonadism. Affected males often have cryptorchidism and micropenis
