Reproductive System Flashcards
What is the definition of secondary amenorrhea in a woman who has previously menstruated?
It is defined as the absence of menses for 3 months if previous cycles were normal
What is the definition of secondary amenorrhea in a woman with irregular menses?
Absence of menses for 6 months
In a woman with normal estrogen, what is the most likely cause(s) of secondary amenorrhea?
It is likely to be Asherman syndrome (intrauterine synechiae) or PCOS
In a hypoestrogenic woman, what are some causes of secondary amenorrhea?
CNS tumor, stress, hyperprolactinemia, hypophysitis, Sheehan syndrome, and premature ovarian syndrome
First-line test for amenorrhea
Beta-human chorionic gonadotropin (B-hCG) for pregnancy, TSH, and prolactin
What type of test will determine the presence or absence of sufficient estrogen?
Progesterone challenge test
Gonadal dysgenesis (Turner syndrome; primary amenorrhea cause) karyotyping, physical exam, labs, and management
Karyotyping: 45, X0
Physical exam: Short webbed neck, no breast development
Labs: High FSH
Management: Cyclic estrogen and progestins
Hypothalamic-pituitary insufficiency (primary amenorrhea cause) karyotyping, physical exam, labs, and management
Karyotyping: 46, XX
Physical exam: No breast development
Labs: Low FSH, low LH
Management: Cyclic estrogen and progestins
Androgen insensitivity (primary amenorrhea cause) karyotyping, physical exam, labs, and management
Karyotyping: 46, XY
Physical exam: Normal breast development
Labs: High testosterone
Management: Remove testes; start estrogen
Imperforate hymen (primary amenorrhea cause) karyotyping, physical exam, labs, and management
Karyotyping: 46, XX
Physical exam: Normal breast development
Labs: Dx on PE
Management: Surgically open
What is the predominant postmenopausal circulating estrogen?
Estrone
With menopause, the ovaries continue to produce what?
Testosterone and androstenedione
Menopause diagnostic studies
FSH of greater than 30 mIU/mL is diagnostic of menopause
Combined hormone replacement therapy his effective in reducing menopausal symptoms but appears to increase the risks of what?
Cardiovascular disease, breast CA, and cognitive changes. Other possible risks include migraine and gallbladder disease
Contraindications to hormone replacement therapy
Undiagnosed vaginal bleeding, acute vascular thrombosis, liver disease, and history of endometrial or breast CA
What is dysfunctional uterine bleeding (DUB)?
It is abnormal uterine bleeding in the absence of an anatomic lesion, usually caused by a problem with the hypothalamic-pituitary-ovarian hormonal axis
DUB clinical features
Abnormal bleeding with an unremarkable physical exam in a very young or perimenopausal woman
DUB diagnostic studies
- Urinary Beta-hCG should be done first to r/o pregnancy
- CBC, possibly iron studies, PT and PTT, documentation of ovulation, thyroid function tests, serum progesterone level, liver function tests, and prolactin and serum FSH levels are needed
- Pap smear, endometrial biopsy, pelvic U/S, hysterosalpingography, hysteroscopy, and/or D&C may be indicated based on history and physical exam
What are the types of fibroids that are classified by their location?
Subserous (deforming external series), intramural (within uterine wall), and sub mucous (deforming uterine cavity). Sub mucous is the type that causes uterine bleeding
Diagnostic procedures that may be done in fibroids
U/S, D&C, saline hysteroscopy, hysterosalpingography, and laparoscopy
In most cases of leiomyomata, what is the recommended treatment?
Observation
For symptomatic patients with leiomyomata, what type of treatment may they undergo?
Myomectomy, hysterectomy, or D&C
What type of medications may be given to reduce the tumor size of leiomyomata?
GnRH agonists and mifepristone; in women with small leiomyomata, GnRH agonists may restore fertility. Treatment is limited to 6 months
What treatment may be done in patients with leiomyomata who have no desire of future fertility?
Use of uterine arterial embolization or endometrial ablation
What is the final step of treatment if it cannot be resolved by other means?
Hysterectomy
What is the most common gynecologic cancer?
Endometrial cancer. Postmenopausal women make up 75% of the patients; median age of presentation is 58 years old
In endometrial cancers, what type makes up 75% of cancer cell types?
Adenocarcinomas
Endometrial CA risk factors (9)
- Obesity
- Nulliparity
- Infertility
- Late menopause
- Diabetes mellitus
- Unopposed estrogen stimulation
- HTN
- Gallbladder disease
- Chronic tamoxifen use
Endometrial CA diagnostic testing
- Women with postmenopausal bleeding should have a PAP smear, endocervical curettage, and endometrial biopsy.
- Other tests include fractional D&C and transvaginal U/S
Endometrial CA management
- Total hysterectomy combined with bilateral salpingo-oophorectomy is the basis of treatment and staging
- Radiotherapy may be indicated. Chemotherapy is used at advanced stages
- Recurrence is treated with high-dose progestins or antiestrogens
Endometriosis presents with what?
Dysmenorrhea, deep-thrust dyspareunia, dyschezia (difficulty passing bowel movements), intermittent spotting, pelvic pain, and infertility
Endometriosis signs
Tender nodularity of the cul-de-sac and uterine ligaments and a fixed uterus
Endometriosis diagnostic studies
Diagnostic testing for endometriosis includes U/S and laparoscopy
Endometriosis management
- In women with few symptoms, expectant management may suffice
- NSAIDs and prostaglandin synthetase inhibitors may relieve discomfort
- Combined oral contraceptives or progestins may relieve symptoms
- Surgery may be conservative or definitive; large endometriomas must be resected
- Treatment with danazol or a GnRH agonist around surgery improves fertility
Adenomyosis general characteristics
- It is an extension of endometrial glands into the uterine musculature
- It is not thought to be related to endometriosis
Adenomyosis diagnostic studies
- Pelvic U/S ma detect adenomyosis
- Pregnancy should be ruled out
- Endometrial biopsy, fractional D&C, or hysteroscopy in a patient with suspected adenomyosis will rule out endometrial cancer
Adenomyosis management
- It may be treated with D&C, a GnRH agonist, a mifepristone; hysterectomy is the definitive therapy
- Hormonal treatment has not been successful
Types of ovarian cysts
Follicular, corpus luteum, and much less commonly, theca lutein cysts
Ovarian CA diagnostic studies
- The BRCA1 gene is associated in 5% of cases; CA-125 may be used to follow treatment, particularly in postmenopausal women
- An association exists with mutations in the P53 tumor suppressor gene
- Transvaginal or abdominal U/S is useful in distinguishing benign from potentially malignant masses
Which types of HPV strains are associated with cervical neoplasia?
16, 18, 31, and 33
Which types of HPV strains are associated with condyloma acuminata?
6 and 11
What is the most appropriate technique for histologic evaluation of cervical dysplasia and neoplasia?
Colposcopy with biopsies
Preinvasive cervical neoplasia may be treated with what?
Electrocautery or cryocautery, laser therapy, conization, large loop excision of transitional zone, or LEEP procedure
Conization is used when the neoplasia is larger. What is the major risk when compared to LEEP?
Incompetent cervix
Conization is used when the neoplasia is larger. What is the major risk when compared to LEEP?
Incompetent cervix
Grading of prolapse: 0
No descent
Grading of prolapse: 1
Descent between normal position and ischial spines
Grading of prolapse: 2
Descent between ischial spines and hymen
Grading of prolapse: 3
Descent within hymen
Grading of prolapse: 4
Descent through hymen
Grading of prolapse: 4
Descent through hymen
Must vulvar malignancies are what kind and occur in which type of patient?
Squamous cell carcinomas and occur in postmenopausal women (mean age of diagnosis: 65 years)
Women with in utero exposure to DES are at increased risk of what?
Clear cell adenocarcinoma of the vagina
Women with in utero exposure to DES are at increased risk of what?
Clear cell adenocarcinoma of the vagina
Most vaginal intraepithelial neoplasms occur where?
Upper one-third of the vagina and are asymptomatic
Neoplasm of the vulva and vagina diagnostic studies
- Application of acetic acid or staining with toluidine blue may help to direct biopsies of suspicious vulvar lesions
- Vaginal biopsy for suspected vaginal invasive neoplasm should be directed by colposcopy or Lugol staining
- Clear cell adenocarcinoma is diagnosed by careful inspection and palpation of the vagina and cervix, followed by biopsies
Neoplasm of the vulva and vagina diagnostic studies
- Application of acetic acid or staining with toluidine blue may help to direct biopsies of suspicious vulvar lesions
- Vaginal biopsy for suspected vaginal invasive neoplasm should be directed by colposcopy or Lugol staining
- Clear cell adenocarcinoma is diagnosed by careful inspection and palpation of the vagina and cervix, followed by biopsies
Neoplasm of the vulva and vagina treatment
- Local excision, topical 5-fluorouracil and laser therapy are used for early vulvar lesions
- Surgical excision is required for most vaginal neoplasms; primary vaginal cancer is treated with radiotherapy
- For clear cell lesions, radical hysterectomy and vaginectomy or radiation therapy is effective.
Neoplasm of the vulva and vagina treatment
- Local excision, topical 5-fluorouracil and laser therapy are used for early vulvar lesions
- Surgical excision is required for most vaginal neoplasms; primary vaginal cancer is treated with radiotherapy
- For clear cell lesions, radical hysterectomy and vaginectomy or radiation therapy is effective.
What is the most frequent benign condition of the breast?
Fibrocystic changes-this includes things like cysts, papillomatosis, fibrosis, adenosis, and ductal epithelial hyperplasia
What is the most frequent benign condition of the breast?
Fibrocystic changes-this includes things like cysts, papillomatosis, fibrosis, adenosis, and ductal epithelial hyperplasia
In suspected breast cysts, what is considered to be both diagnostic and therapeutic?
Fine-needle aspiration; cysts usually contain straw-colored fluid
Treatment of fibrocystic changes of the breast
- Many types of fibrocystic breast problems need no treatment other than a supportive bra
- The role of caffeine restriction in the treatment of fibrocystic changes is controversial; some patients respond to a low-salt diet, vitamin E supplementations, or HCTZ premenstrually
What is considered to the be the second most common benign breast disorder?
Fibroadenomas; occur most frequently in young women
Fibroadenomas clinical features
They are round, firm, smooth, discreet, mobile, and nontender
Fibroadenomas diagnostic studies
In a woman younger than 25 years of age, a fibroadenomatous mass should be biopsied
Fibroadenomas treatment
They may be excised or managed expectantly
Types of breast neoplasms
- Infiltrating ductal carcinomas (make up 80-85% of the breast CA)
- Lobular carcinomas
What two things predispose to breast CA?
Lobular CIS and atypical ductal hyperplasia
What two things predispose to breast CA?
Lobular CIS and atypical ductal hyperplasia
What is Paget disease of the breast?
It is a ductal carcinoma presenting as an eczematous lesion of the nipple
A breast biopsy specimen should undergo what tests?
Estrogen and progesterone receptor analysis as well as histologic analysis
What is oncotype DX test?
It is a test used in breast CA to help determine the need for chemotherapy for women with stage I or II hormone receptor-positive CA. The test looks at 21 genes within the tumor to determine the likelihood of the cancer recurring or spreading
Breast CA treatment
- Staging should occur before treatment begins
- Treatment with the intent to cure most likely occurs for patients with stage I, IIA, or IIB cancer
- Lumpectomy with sentinel node biopsy is often preferred with early-stage CA. Modified radical mastectomy and partial mastectomy have equivalent survival rates when surgery is followed by radiation therapy
- Adjuvant chemotherapy and/or hormonal manipulation benefit some women
- Tamoxifen is used to treat women with estrogen receptor-positive disease and postmenopausal women
What is the most reliable periodic abstinence method?
Symptothermal method combined with the cervical mucus and basal body temperature method
Minipills (progestin only)
- They are half as effective as combination pills and may cause amenorrhea
- They are most useful in lactating women, those over 40 years of age, and those who cannot tolerate estrogen in the combination pills
Advantages of contraceptives
- Less benign breast disease, iron deficiency anemia, and pelvic inflammatory disease as well as fewer ovarian cysts
- Protection against ectopic pregnancy; reduced risk of ovarian and endometrial CA; reduced dysmenorrhea and menorrhagia; and improvements in hirsutism, acne, and symptoms of endometriosis. It may also protect against RA
Advantages of contraceptives
- Less benign breast disease, iron deficiency anemia, and pelvic inflammatory disease as well as fewer ovarian cysts
- Protection against ectopic pregnancy; reduced risk of ovarian and endometrial CA; reduced dysmenorrhea and menorrhagia; and improvements in hirsutism, acne, and symptoms of endometriosis. It may also protect against RA
Disadvantages of contraceptives
- Increased risk of thromboembolic disease, particularly in smokers over 35 years of age, and abnormal lipids
- Possible increased risk of breast CA and, rarely, HTN, cholelithiasis, and benign liver tumors
What is the most common depot formulation?
Medroxyprogesterone acetate, 150mg every 90 days
Depot shots black box warning
May lead to calcium loss, bone weakness, and osteoporosis; use should be limited to 2 years
When do fertility rates return to normal with the depot shot
Within 18 months
Nexplanon
Relies on the implantation of rods that release levonorgestrel for 3 years. Efficacy is very good, but side effects are common, including menstrual irregularity, HA, and weight gain
2 types of IUD devices
- Levonorgestrel-releasing IUD (Mirena); usable for 5 years
2. Copper T (ParaGard); usable for 10 years
Disadvantages of IUD devices
Uterine perforation; higher incidence of spontaneous abortion if pregnancy occurs; increased risk of ectopic pregnancy, cramping, or bleeding with menses; and risk of pelvic infection
Disadvantages of IUD devices
Uterine perforation; higher incidence of spontaneous abortion if pregnancy occurs; increased risk of ectopic pregnancy, cramping, or bleeding with menses; and risk of pelvic infection
Absolute contraindications to IUD devices
Current pregnancy, undiagnosed vaginal bleeding, acute infection, past salpingitis, and suspected gynecologic malignancy
Relative contraindications to IUD devices
Nulliparity, previous ectopic pregnancy or STD, multiple sexual partners, severe dysmenorrhea, uterine abnormalities, anemia, valvular heart disease, and young age
Common spermicides
Nonoxynol-9 and octoxynol-3
What is the most common cause of infertility?
Ovulatory disorders (central, peripheral, metabolic)
Male factors to infertility
Endocrine and anatomic disorders, abnormal spermatogenesis or motility, and sexual dysfunction
What is the first test that should be done for infertility?
Semen analysis
What tests help to determine ovulation?
Basal body temperature, ovulation prediction tests, and progesterone levels
What does postcoital testing measure?
Sperm survival
What tests may be helpful in infertility?
Luteal phase endometrial biopsy, FSH levels, prolactin, and thyroid-stimulating hormone tests
What does hysterosalpingography determine in infertility?
Tubal patency and uterine abnormalities
Treatments in infertility currently have a success rate of about 85%. What do they include?
- Clomiphene citrate, 50-100 mg for 5 days beginning on day 3, 4, or 5 of the cycle, should be given to anovulatory women to promote ovulation
- Artificial insemination is an alternative for couples with abnormal postcoital tests
- Other treatments depend on the cause of the infertility, the couple’s resources, and the age of the woman
What are some assisted reproductive technologies for infertility?
In vitro fertilization, gamete intrafallopian transfer, zygote intrafallopian transfer, and surrogate options
What are some assisted reproductive technologies for infertility?
In vitro fertilization, gamete intrafallopian transfer, zygote intrafallopian transfer, and surrogate options
What does pelvic inflammatory disease include?
Acute salpingitis (gonococcal or nongonococcal), IUD-related pelvic cellulitis, tubo-ovarian abscess, and pelvic abscess
What may an adnexal mass indicate?
A tubo-ovarian abscess
PID diagnostic studies
- DNA probes for gonorrhea and chlamydia (most common cause of PID) have largely replaced Gram staining and culture of any discharge
- Transvaginal ultrasonography is helpful in differentiating acute and chronic inflammation or the presence of adnexal masses
- Diagnostic culdocentesis or laparoscopy may be required
PID treatment
- Women with mild disease can be treated as outpatients with antibiotics, antipyretics, analgesics, and bed rest; if present, an IUD should be removed
- Women with severe disease should be hospitalized for IV antibiotic therapy and possible surgery
- Sex partners should be evaluated and treated
PID treatment
- Women with mild disease can be treated as outpatients with antibiotics, antipyretics, analgesics, and bed rest; if present, an IUD should be removed
- Women with severe disease should be hospitalized for IV antibiotic therapy and possible surgery
- Sex partners should be evaluated and treated
Obstetric visits
The initial visit should take place 6-8 weeks after the LMP. Generally a woman is examined every 4 weeks until the 32nd week of gestation, every 2 weeks up to 36 weeks of gestation, and then weekly thereafter
