Reproductive System Flashcards
Average age of menarche
Between 12 and 13
Nature of the menstrual cycle around menarche time
typically irregular, with anovulatory cycles, for the first 6 months to 1 year
2 phases of menstrual cycle
Follicular and luteal
Source of follicle stimulating hormone
pituitary gland
Ovarian follicle produces this hormone
estrogen
Effect of estrogen on uterus
Proliferation of uterine lining
Timing of lutenizing hormone spike
mid-cycle, around day 14
Action of lutenizing hormone on ovary
Release of ovum from follicle
The luteal phase of the menstrual cycle begins _____________
after release of the ovum, some time after day 14
After release of ovum, remnants of the follicle become the ________ and secrete _______
Corpus luteum, secrete progesterone
Action of progesterone on uterus during a natural menstrual cycle
maintains uterine lining in preparation for implantation of fertilized ovum
If fertilization occurs, the trophoblast synthesizes __________. This maintains _________
hCG, corpus luteum
If there is no fertilization, what does the corpus luteum do?
it degenerates, and progesterone levels start to drop
If progesterone levels drop, what happens to the endometrium?
It is sloughed off
As estrogen and progesterone drop near the end of the menstrual cycle, what hormone starts to increase?
FSH
As FSH rises near the end of the menstrual cycle, what happens in the ovary?
development of primary ovarian follicles, the start of a new follicular phase
This is a diagnosis of exclusion, when pathologic menorrhagia or metrorrhagia are ruled out.
Dysfunctional uterine bleeding
One likely cause of dysfunctional uterine bleeding
anovulation via disruption of hypothalamic-pituitary-gonadal axis, causing continuous estrogen stimulation of the endometrium that overgrows and sloughs off at irregular times in varying amounts
Common times to find dysfunctional uterine bleeding
near menarche and menopause
This is the gold standard way to determine if ovulation is occurring in the setting of dysfunctional uterine bleeding
Endometrial sampling
Definitive surgery, used in refractory cases of dysfunctional uterine bleeding
hysterectomy
First procedural treatment of choice in dysfunctional uterine bleeding (that has not responded to medical therapy)
Dilation and curettage
First line treatment for dysfunctional uterine bleeding (stable, non-hemorrhaging)
Oral contraceptives
Medical treatment for dysfunctional uterine bleeding, if bleeding is excessive
conjugated estrogens
If dysfunctional uterine bleeding is ovulatory, this medication can help to decrease menstrual blood loss
NSAIDs
Most common gynecologic cancer in the US
Endometrial cancer
Endometrial cancer, median age at diagnosis
60 years
4 most common types of endometrial cancer, listed with most common first
Adenocarcinoma–mucinous–clear cell–squamous cell
3 prognostic factors in endometrial cancer
Histologic grade–myometrial invasion–histologic type
6 risk factors for endometrial cancer
Nulliparity–Late menopause–Diabeetus–Obesity–Unopposed estrogen therapy–Tamoxifen use
Most common symptom of endometrial cancer
irregular bleeding
What does the pelvic exam typically show in endometrial cancer?
Pelvic exam is typically normal
Test of choice for endometrial cancer
endometrial biopsy
Use this diagnostic test to rule out fibroids, polyps, and endometrial hyperplasia when you suspect endometrial cancer
pelvic ultrasound
3 common treatments for endometrial cancer
total abdominal hysterectomy–bilateral salpingo-oophorectomy–radiation therapy
Define endometriosis
presence of endometrial tissue outside the endometrial cavity
most common sites for endometriosis (5)
ovary–pelvic peritoneum–round ligament–fallopian tubes–sigmoid colon
5 common symptoms of endometriosis
dysmenorrhea–dyspareunia–infertility–abnormal bleeding–chronic pelvic pain
Physical exam with disseminated endometriosis
uterosacral nodularity or a fixed retroverted uterus
Physical exam with ovary involvement in endometriosis
fixed adnexal mass
Definitive diagnosis of endometriosis
direct visualization with laparoscopy
Treatment goal in endometriosis
suppression and atrophy of endometrial tissue
Definitive surgical treatment in refractory endometriosis
hysterectomy with bilateral salpingo-oophorecomy, lysis of adhesions, removal of endometriosis lesions
3 conservative surgical treatments in endometriosis
ablation–electrocauterization–excision of visible endometriosis
4 medical treatments for endometriosis
oral contraceptives–medroxyprogesterone–danazol–GnRH
Side effects of danazol (4)
acne–edema–weight gain–hirsutism
Side effects of GnRH (2)
hot flashes–decreased bone density
Define adenomyosis
extension of endometrial glands and stroma into the musculature
Typical adenomyosis patient
parous woman, late 30s to early 40s
Adenomyosis comes with an increased risk of these 2 disorders
endometriosis–leiomyoma
2 most common symptoms of adenomyosis
dysmenorrhea–menorrhagia (though may be asymptomatic)
physical exam in adenomyosis
enlarged uterus with soft consistency
definitive diagnosis of adenomyosis
hysterectomy
this diagnostic test may help to identify adenomyosis
MRI
The only definitive treatment in adenomyosis
hysterectomy
This med may help in mild adenomyosis
analgesics
Another name for uterine fibroids
Leiomyoma
What are uterine fibroids?
local proliferation of smooth muscle cells of uterus
Leiomyoma is more common in this population
African-American women
Leiomyomas typically occur in women of what age range?
childbearing age
Most common symptoms of leiomyoma
abnormal uterine bleeding–pressure–infertility (though most patients are asymptomatic)
Physical exam in leiomyoma
nontender, irregular, masses on bimanual or abdominal exam, enlarged uterus
Diagnosis of leiomyoma
Pelvic ultrasound: hypoechoic areas among normal myometrial material
Leiomyoma treatment
Treatment is typically not required. If severe pain, infertility, growth: medroxyprogeterone, danazol, GnRH agonists. Surgical treatment includes myomectomy and hysterectomy.
Endometritis vs Endomyometritis
endomyometritis is an infection of the endometrium that invades into the myometrium
Most common causes of endometritis
C-section–vaginal delivery–dilation and evacuation or curettage–IUD insertion
3 S/Sx endometritis
Fever–uterine tenderness on bimanual exam–leukocytosis
Treatment of severe endometritis / endomyometritis
IV Clindamycin or gentamicin
Treatment of mild endometritis
cephalosporins
Treatment of chronic endometritis
doxycycline
Uterine prolapse is most common in this population
multiparous women
6 disorders that may predispose a woman to uterine prolapse
childbirth injury–pelvic tumors–sacral nerve disorders–obesity–asthma–ascites
Physical exam in uterine prolapse
descent of the cervix to the lower third of the vagina or through the introitus with bearing down or straining
4 treatments of uterine prolapse
Kegel exercises–vaginal pessary–estrogens–surgery
Two types of functional ovarian cysts
follicular and corpus luteum
Ovarian cysts most commonly occur between what two life events?
puberty and menopause
This behavior increases the risk of ovarian cysts
smoking
Symptoms of follicular cysts
Typically asymptomatic–large cysts can cause pelvic pain, dyspareunia
Larger follicular cysts can lead to this dangerous condition
ovarian torsion
Follicular cysts tend to be less than _____ in size
8 cm
Follicular cysts and Lutein cysts: which tends to be larger and more firm on palpation
Lutein
3 typical symptoms of lutein cysts
pelvic pain, amenorrhea, delayed menses
Physical exam for ruptured ovarian cyst
pain on palpation, acute abdominal pain, rebound tenderness
Presentation of polycystic ovarian disease (6)
anovulation, oligomenorrhea, amenorrhea, hirsutism, obesity, enlarged ovaries
Test of choice for workup of ovarian cysts
Pelvic ultrasound
Treatment of premenarchal patient with ovarian cyst greater than 2 cm
exploratory laparotomy
Treatment of reproductive age woman with ovarian cyst less than 6 cm
observe for 6 weeks
Treatment of reproductive age woman with cyst greater than 8 cm
exploratory laparotomy
Treatment of postmenopausal woman with palpable cyst
exploratory laparotomy
Treatment of woman with polycystic ovarian disease, desiring fertility
clomiphene citrate
Third most common cancer of female genital tract
Ovarian cancer
Primary means of spread for ovarian carcinoma
direct exfoliation of malignant cells
2 genes that increase risk of ovarian cancer
BRCA1, BRCA2
This common medication may have some protective effect from ovarian cancer
oral contraceptives
History risk factors for ovarian cancer (3)
positive family history, history of uninterrupted ovulation, breast cancer
3 types of ovarian carcinoma, listed most to least common
Epithelial tumors, germ cell, sex cord stroma
Most women with epithelial ovarian carcinoma are (this age)
in their 50s
Most patients with germ cell carcinoma are (this age)
1-25
Diagnosis aid for epithelial ovarian carcinoma
CA-125
Notable factor of sex cord stroma ovarian cancer
hormone producing
Treatment for epithelial ovarian carcinoma
Surgery, cisplatin-based chemo
Treatment for germ cell ovarian carcinoma
Surgery, multidrug chemo
Treatment for sex cord stroma ovarian carcinoma
surgery
5 year survival rate for epithelial ovarian carcinoma
less than 20%
5 year survival rate for germ cell ovarian carcinoma
60-85%
5 year survival rate for sex cord stroma ovarian carcinoma
90%
Physical exam in ovarian carcinoma
solid, fixed, bilateral (?), nodular mass, possibly with ascites
Symptoms of ovarian carcinoma
often asymptomatic until disease is advanced, may present with vague lower abdominal pain and abdominal enlargement
Test of choice when ovarian carcinoma is suspected
Pelvic ultrasound (malignant masses tend to be greater than 8 cm, solid, multilocular, bilateral)
Tumor markers noted in ovarian carcinoma
Ca-125, alpha-fetoprotein, hCG
Primary causative agent of cervical cancer
HPV 16, 18, 31
Behaviors correlated with a higher risk of cervical cancer
early onset of sexual activity, increased number of sexual partners
Two most common types of cervical cancer, listed with most common first
squamous cell carcinoma, adenocarcinoma
This type of adenocarcinoma is linked to in utero exposure to diethylstilbestrol (DES)
Clear cell carcinoma
Classic presentation of cervical cancer, and other common symptoms
postcoital bleeding (classic), abnormal vaginal bleeding, watery discharge, pelvic pain
physical exam in cervical cancer
mass in cervix palpated on bimanual exam
Recommended frequency of Pap smears (It is now more complicated, but remember, the PANCE is kinda behind, and so is the review book)
Every 2 years beginning at age 21, then every 3 years from age 30
Treatment of microinvasion cervical carcinoma, when patient would like to maintain fertility
cone biopsy
Treatment of invasive cervical carcinoma, if not spread beyond cervix, uterine corpus, and vagina
Radical hysterectomy
These two treatments in cervical cancer have been found to be effective against “bulky stage” disease
Cisplatin-based chemo and radiation
6 most common infectious agents in cervicitis
Chlamydia trachomatis–Neisseria gonorrhoeae–Herpes simplex virus–Candida albicans–Trichomonas vaginalis–Gardnerella vaginallis
Primary symptom in acute cervicitis
purulent vaginal discharge
thick creamy vaginal discharge organism
Gonorrhea
thin gray vaginal discharge organism
Gardnerella
white, curd like vaginal discharge organism
Candida
Purulent vaginal discharge organism
Chlamydia
Foamy, greenish white vaginal discharge organism
Trichomonas
4 other symptoms in cervicitis (other than vaginal discharge)
leukorrhea, infertility, pelvic discomfort, dyspareunia
Cervicitis physical exam
acutely inflamed, edematous cervix with purulent discharge
motile flagellated whatnots on wet mount in cervicitis
Trichomonas vaginalis
Spores or hyphae with KOH prep in cervicitis
Candida
Clue cells in cervicitis
Gardnerella vaginalis
Intracellular diplococci in cervicitis
Neisseria gonorrhoeae
Trichomonas vaginalis cervicitis treatment
metronidazole
Candida cervicitis treatment
nystatin, miconazole, or clotrimazole
Gardnerella cervicitis treatment
metronidazole
Gonorrhea cervicitis treatment
ceftriaxone
Chlamydia cervicitis treatment
doxycycline or azithromycin
How long does it take cervical intraepithelial neoplasia 1 to become cervical cancer?
7 years
How long does it take CIN II to become cervical cancer?
4 years
If CIN I discovered, what is the plan?
colposcopy every 3 to 4 months
If CIN II is discovered, what is the plan?
destruction or excision of the lesions, cryotherapy or laser, loop electrosurgical excision procedure (LEEP)
What’s the deal with incompetent cervix
fetal membranes are exposed to vaginal flora and risk of trauma, infection, and premature rupture of membranes is higher
What two history factors predispose a woman to incompetent cervix
surgery or cervical trauma
Common presentation and timing of incompetent cervix
painless dilation and effacement of cervix, possibly with bleeding, vaginal discharge, or rupture of membranes, often during second trimester of pregnancy
Treatment of incompetent cervix
strict bed rest–placement of a cerclage, a suture placed vaginally to close the cervix
Definition of a cystocele
descent of a portion of the posterior bladder wall and trigone into the vagina, typically due to trauma of parturition (childbirth)
symptoms of small cystocele
none
symptoms of large cystocele
vaginal pressure, protruding mass, urinary incontenence, aggravated with prolonged standing, coughing, or straining
cystocele physical exam
relaxed vaginal outlet, thin-walled, smooth bulging mass involving the anterior vaginal wall, may project through the introitus with straining
cystocele treatment (4)
Kegel exercises–vaginal pessary–estrogen therapy–surgery seldom indicated
If surgery is needed for cystocele, what is the most effective procedure?
anterior vaginal colporrhaphy
peak incidence time for vaginal neoplasia
women in their 50s
most common type of vaginal neoplasia
epithelial
Exposure to this medication increases risk of clear cell adenocarcinoma of the vagina
diethylstilbestrol (DES)
common symptoms of vaginal neoplasia
many asymptomatic–vaginal discharge–bleeding–vaginal pruritis
peak incidence time for vulvar neoplasia
women in their 60s
vulvar neoplasia symptoms
vulvar pruritis, vulvodynia (vulvar pain)
treatment of choice in vulvar neoplasia
wide local excision with regional lymphadenectomy
additional treatment (over surgery) in vulvar neoplasia with metastasis
pelvic radiation
definition of rectocele
herniation of rectum into vaginal vault
cause of rectocele
injury of endopelvic fascia of the rectovaginal septum
symptoms of small rectoceles
typically asymptomatic
symptoms of large rectoceles
vaginal pressure, rectal fullness, incomplete evacuation
rectocele physical exam
soft, thin-walled rectovaginal septum projecting into vagina
treatment of rectocele (3)
increasing fluids, laxatives, surgery: posterior colpoperineorrhaphy
most common organism in yeast vaginitis
Candida albicans
3 predisposing factors for yest vaginitis
antibiotic use, diabetes mellitus, decreased cellular immunity
What proportion of all vaginitises are caused by Candida albicans?
20-25%
symptoms of yeast vaginitis
vulvar and vaginal pruritis, burning, dysuria, dyspareunia, vaginal discharge
physical exam in yeast vaginitis
vulvar edema and erythema with a thick white vaginal discharge
yeast vaginitis treatment
topical azoles, or oral fluconazole
What proportion of all vaginitises are caused by Trichomonas vaginalis?
15-20%
Clinical manifestations of Trichomonas vaginitis (5ish)
profuse, stanky yellow or green, frothy discharge–vulvar edema–erythema–pruritis–strawberry appearance of cervix
Treatment of Trichomonas vaginitis
metronidazole for 7 days
Risk factors for Gardnerella vaginalis
low socioeconomic status, IUD usage, multiple sexual partners, smoking
What proportion of all vaginitises are caused by Garderella vaginalis
40-50%
Clinical manifestations of Gardnerella vaginitis
may be asymptomatic–profuse nonirritating discharge with a fishy odor
Burning vaginitis, thick white vaginal discharge, dysuria, dyspareunia, pruritis
think Candida
Stinky yellow or green, frothy vaginal discharge, edema, erythema, pruritis, strawberry appearance of cervix
think Trichomonas
Profuse nonirritating vaginal discharge with a fishy odor, which worsens with KOH
think Gardnerella
Wet prep of Gardnerella
clue cells: vaginal squamous epithelial cells covered with G. vaginalis, making them look granular
Gardnerella vaginitis treatment
metronidazole or clindamycin
Define primary amenorrhea
absence of menses in a woman who has not undergone menarche by age 16
3 major categories of causes of primary amenorrhea
Outflow obstruction–End-organ disease–Central regulatory disease
4 types of outflow obstruction in primary amenorrhea
Imperforate hymen–Transverse vaginal septum–Vaginal agenesis–Testicular feminization
2 types of end-organ disease causes for primary amenorrhea
Ovarian failure–Gonadal agenesis
2 types of central regulatory disease causes for primary amenorrhea
hypothalamic disorders–pituitary disorders
Define secondary amenorrhea
the absence of menses for 3 menstrual cycles or 6 months in a woman who previously had normal menses
Leading cause of secondary amenorrhea
Pregnancy
4 categories of causes of secondary amenorrhea
Anatomic–Ovarian dysfunction–Hyperprolactinemia–hypothalamic disorders
2 anatomic causes of secondary amenorrhea
Asherman syndrome, Cervical stenosis
2 ovarian dysfunctional causes of secondary amenorrhea
Premature ovarian failure, polycystic ovarian disease
4 medications that can cause secondary amenorrhea via hyperprolactinemia
Dopamine agonists–tricyclic antidepressants–MAO inhibitors
2 hyperprolactinemic causes of secondary amenorrhea
Primary hypothyroidism–pituitary tumor
3 hypothalamic causes of secondary amenorrhea
Stress–Anorexia nervosa–weight loss
Causes of primary amenorrhea in women with breasts and uterus (2)
Testicular feminization–Müllerian agenesis
Causes of primary amenorrhea in women with breasts but no uterus (1)
Congenital abnormalities
Causes of primary amenorrhea in women with a uterus, but no breasts (2)
Gonadal agenesis–Enzyme deficiency in testosterone synthesis
Causes of primary amenorrhea in women with neither breasts nor uteruses (3)
Gonadal failure/agenesis–Hypothalamic-pituitary axis dysfunction–Hypothalamic, pituitary, or ovarian dysfunction
First step in diagnosis of secondary amenorrhea
pregnancy test
Next two lab tests after a pregnancy test in secondary amenorrhea
TSH and prolactin
If prolactin is normal in secondary amenorrhea, this test is next
Progesterone challenge: if the patient has withdrawal bleeding, estrogen levels are adequate and outflow tract is patent
Treatment of primary amenorrhea in women with a functional uterus and congenital abnormalities
Surgery to allow menses flow
Treatment of primary amenorrhea in women without a uterus
Estrogen replacement to effect breast development and prevent osteoporosis
Treatment of secondary amenorrhea (2)
treat underlying cause–if progesterone challenge is positive, treat with oral contraceptives to prevent endometrial hyperplasia
Define dysmenorrhea
pain and cramping during the menstrual cycle that interferes with normal daily activities
Primary vs secondary dysmenorrhea
Primary has no obvious cause (may be due to high levels of prostaglandins)–Secondary dysmenorrhea is due to endometriosis, fibroids, cervical stenosis, or pelvic adhesions
Symptoms of primary dysmenorrhea (4)
pain on first or second day of menstruation, headache, nausea, vomiting
Physical exam in primary dysmenorrhea
no abnormalities are typically noted except generalized tenderness in lower abdomen / pelvis
Symptoms of secondary dysmenorrhea due to cervical stenosis
scant menses, severe cramping pain that is relieved with increased menstrual flow
Physical exam, secondary dysmenorrhea due to cervical stenosis
scarring of external os
typical history in patients with secondary dysmenorrhea due to pelvic adhesions
pelvic infections or prior pelvic surgery
Treatment of primary dysmenorrhea
NSAIDs and oral contraceptive pills
Treatment of cervical stenosis
cervical dilation
Treatment of pelvic adhesions with dysmenorrhea
NSAIDs, oral contraceptive pills, possibly surgery
Somatic complaints in PMS
breast swelling and tenderness, bloating, headache, fatigue, constipation
Emotional complaints in PMS
irritability, depression, anxiety, libido changes
Behavioral complaints in PMS
food cravings, poor concentration, sensitivity to noise
This is necessary to confirm the diagnosis of PMS
symptom free follicular phase (about 1 week)
Treatment of PMS (3)
NSAIDs, oral contraceptive pills, maybe antidepressants
General age range of menopause in the US
between 48 and 52
If menopause occurs before this age, it is considered premature
40
2 major risks that increase with menopause
coronary artery disease, osteopenia/osteoporosis
4 major symptoms of menopause
Vasomotor flushing, sweats, mood changes, depression
physical exam in menopause (4)
decreasing breast size–vaginal, urethral, and cervical atrophy
Lab result in menopause
elevated FSH
Benefits of hormone replacement therapy in menopause
decreased risk of hip fracture, symptom improvement
Risks of hormone replacement therapy in menopause (4)
cholestatic hepatic dysfunction, increased incidence of estrogen dependent neoplasm, increased risk of thromboembolic events, undiagnosed vaginal bleeding (?)
using progesterone in combination with estrogen therapy for menopause decreases these two risks
endometrial hyperplasia and cancer
This breast lesion may develop with acute mastitis
breast abscess
A large portion of breast abscesses are related to this physiologic function
lactational
This is the most common bacterium in lactational breast abscesses
Staphylococcus aureus
Most common bacterial etiology in subareolar breast abscesses
mixed infection, including anaerobes, staphy, strep
Presentation in breast abscess
painful, erythematous mass in breast with occasional drainage through skin or nipple duct
Bad complication of subareolar breast abscess
fistula
Abx in lactational abscesses
nafcillin, cefazolin, vancomycin
abx in subareolar abscess
broad-spectrum abx
non-druggy treatment of breast abscesses
Incision and drainage, rule out carcinoma with biopsy
This proportion of American women will develop breast cancer during their lifetime
1:9
Most cases of breast cancer are diagnosed in this age range
after age 40
7 risk factors for breast cancer
Increasing age–Family history of gynecologic malignancies–first degree relative with breast cancer–personal history of breast cancer–exposure to ionizing radiation before age 30–significant alcohol use–BRCA1/2 gene
5 ways to reduce the risk of breast cancer
Early pregnancy–prolonged lactation–chemical or surgical sterilization–exercise–low fat diet
This complaint is rarely a symptom of breast cancer
Breast pain
Breast cancer common presentation (4)
mass–skin changes–nipple discharge–symptoms of metastatic disease
4 qualities of mass that is suspicious of breast cancer
nontender, irregular, firm, immobile
Half of all breast cancers occur in this part of the breast
upper outer quadrant
Best time to do self breast exam
5 days after menses
notable skin changes in breast cancer (4-5)
dimpling, edema, peau d’orange, nipple retraction or discharge
nonspecific (metastatic) symptoms common in breast cancer (5)
anorexia, weight loss, fatigue, dyspnea, bone pain
Who should get a mammogram and how frequently
ages 50-74, every 1-2 years
3 mammogram findings suggestive of carcinoma
spiculated mass–asymmetric local fibrosis–microcalcifications with a linear, branched pattern
Another imaging method used with breast mass
ultrasound to distinguish fluid-filled cysts from solid masses
definitive diagnosis of breast cancer
needle biopsy, FNA, or excisional biopsy
If FNA is negative in a breast mass. . .
an excisional biopsy should be done
4 types of invasive breast cancer
infiltrating ductal carcinoma–invasive lobular carcinoma–paget’s disease of nipple–inflammatory breast carcinoma
2 types of noninvasive breast cancer
ductal carcinoma in situ–lobular carcinoma in situ
DCIS breast cancer common age
50s
LCIS breast cancer common age
40s
DCIS mammogram results
clustered microcalcifications
LCIS mammogram results
not seen on mammogram
DCIS diagnosis
needle or excisional bipsy
LCIS diagnosis
frequently incidentally on biopsy for other condition
DCIS treatment
Surgical excision
LCIS treatment
Local excision
4 surgical options for breast cancer
Wide local excision or lumpectomy–Simple mastectomy–modified radical mastectomy–radical mastectomy
This surgical option can be used if breast tumor is less than 4 cm and is not fixed to underlying tissue
wide local excision or lumpectomy
4 qualities of a simple mastectomy
removal of breast tissue–removal of nipple-areolar complex–removal of skin–no axillary node dissection
5 qualities of a modified radical mastectomy
removal of breast tissue–removal of nipple-areolar complex–removal of skin–removal of pectoralis fascia–removal of axillary lymph nodes
6 qualities of radical mastectomy
removal of breast tissue, nipple-areolar complex, skin, axillary lymph nodes, pectoralis major and minor
Use for chemo in breast cancer
control micrometastases
indications for chemo in breast cancer
lymph node positive or high risk lymph node negative
3 chemotherapy agents in breast cancer
cyclophosphamide, methotrexate, 5-fluorouracil (CMF) (cure my floppies?)
most common hormone therapy in breast cancer
tamoxifen
overall 5 year disease-free survival rate in breast cancer
94%
prognosis in patients with estrogen and progesterone receptor positive cancer
more favorable than others
define breast fibroadenoma
benign tumors most commonly noted in women younger than 40 years of age
breast fibroadenoma physical exam (6)
round, well circumscribed, rubbery, nontender, mobile, firm lesion
breast fibroadenomas never have (2)
axillary involvement or nipple discharge
breast fibroadenomas may change with these events
menstural cycle, pregnancy
breast fibroadenoma size
1-5 cm
Breast fibrocystic disease is common in women in this age
between 30 and 40
Breast fibrocystic disease etiology
exaggerated stromal response to hormones
breast fibrocystic disease presentation
breast swelling, pain, tenderness
breast fibrocystic disease physical exam
multiple, well demarcated, mobile masses, may involve both breasts
breast fibrocystic disease never has (2)
axillary lymph node involvement or nipple discharge
decreasing intake of ____ and _____ may reduce symptoms of breast fibrocystic disease
nicotine and caffeine
treatment for severe breast fibrocystic disease
danazol, an androgen
mastitis is typically seen in these women, and caused by this
lactating women, skin flora or oral flora of infant
mastitis organism enters breast through
erosion or crack in nipple
mastitis clinical presentation (6)
fever, chills, malaise–red, tender, warm breast mass
mastitis treatment
dicloxacillin
mastitis possible complication
breast abscess
patients with mastitis should do this
continue to breastfeed or use breast pump to prevent accumulation of infected material
This is a serious complication in women infected with N gonorrhoeae and C trachomatis
Pelvic inflammatory disease
PID increases risk for these two bad things
infertility, ectopic pregnancy
Age with highest incidence of PID
15-19 year old women
4 risk factors for PID
smoking, nonwhite ethnicity, unmarried, IUD (only if insertion during STD infection)
primary symptom of PID
abdominal or pelvic pain (bilateral or unilateral, burning, cramping, or stabbing)
other symptoms of PID (other than pelvic pain) (5)
vaginal discharge–abnormal bleeding–dyspareunia–GI symptoms–urinary symptoms
PID physical exam (4)
lower abdominal tenderness–cervical motion tenderness (Chandelier’s sign)–purulent cervical discharge–fever
PID lab results
elevated white count, cultures
definitive diagnosis of PID
laparoscopy
PID treatment (3)
hospitalize–broad spectrum cephalosporins (cefotetan, cefoxitin)–doxycycline (clinda and genta may be used if allergic to cephalosporins)
4 methods of ovulation assessment
basal temperature–menstrual cycle tracking–evaluation of cervical mucus–monitoring for premenstrual or ovulatory symptoms
Failure rate of periodic abstinence as a method of contraception
20-40%
Define coitus interruptus
A spell Harry Potter uses to render his enemies instantly flaccid. No. Withdrawal of the penis from the vagina before ejaculation
Failure rate of coitus interruptus
15-25%
Define lactational amenorrhea
After delivery, ovulation is delayed due to hypothalamic suppression of ovulation secondary to nursing and lactation
Failure rate of lactational amenorrhea as a contraceptive method
15-55%
How can the failure rate of lactational amenorrhea be reduced to 2%?
Method not used for more than 6 months, breast-feeding is the only form of nutrition for the infant
Least effective category of contraception
natural methods
Failure rate of male condom with perfect use and normal use
perfect: 2%–normal: 10-15%
Failure rate of female condom
15-20%
This is the only method of contraception that protects against HIV transmission
Condoms
Disadvantage of female condom
more costly than male condoms
How long must a diaphragm be in place after intercourse, and what is a special consideration for a diaphragm
6-8 hours, spermicide must also be used
failure rate of diaphragm as contraceptive
5-20%
If a diaphragm is left in place for too long. . .
the patient could become colonized with S. aureus and develop toxic shock syndrome
common side effects of contraceptive diaphragm
bladder irritation and cystitis
Contraceptive diaphragm logistics
must be fitted and replaced every 5 years or when patient gains or loses more than 10 pounds
3 special considerations regarding cervical cap contraception
can be left in place for 1-2 days–must be fitted–requires use of spermicide
failure rate of cervical cap contraception
5-20%
mechanism of action of spermicide
disrupt cell membrane of sperm, act as a mechanical barrier of sperm to cervical canal
When and how to use spermicide
placed in vagina 30 minutes BEFORE intercourse. May be used alone, but more effective in conjunction with condoms, diaphragms, or cervical caps.
failure rate of spermicide
3-20%
Common side effect of spermicide
vaginal irritation
Failure rate of IUDs
1-3%
6 absolute contraindications to IUD use
Current pregnancy–Abnormal vaginal bleeding–Gynecologic cancer–Acute cervical or uterine infection–History of PID (according to board review book, but not true)–Uterine fibroids with distortion of uterine cavity (not in review book, but in more reliable sources)
4 relative contraindications to IUD use
Nulliparity–prior ectopic pregnancy–history of STD–moderate to severe dysmenorrhea (all 4 are according to review book, but aren’t entirely true)
Hormones used in contraception
Progesterone alone or progesterone and estrogen
Hormonal contraception MOA
interfere with pulsatile release of FSH and LH, suppress ovulation, change endometrium to not allow for implantation
Hormonal contraception failure rate
thoretically 1%, actually about 3%
Ways that hormonal contraception effectiveness may be decreased (6 drugs)
PCN, tetracycline, sulfonamides, rifampin, phenytoin, barbiturates
Hormonal contraception increases risk of (4ish)
increased coagulability, so: thromboembolus, PE, stroke, MI
Which hormone in hormonal contraception is directly related to coagulability
estrogen (higher estrogen=higher coagulability)
7 absolute contraindications to oral contraceptive pills
Thromboembolism–PE–MI–stroke–Breast/endometrial cancer–hepatic tumor or abnormal liver function–Smokers over 35
4 relative contraindications to oral contraceptive pills
Uterine fibroids–Lactation–Diabetes mellitus–hypertension (according to review book, other sources don’t mention fibroids)
5 things that oral contraceptive pills decrease the risk of
ovarian cancer–endometrial cancer–ectopic pregnancy–anemia–PID
Depo-provera duration of action
3 months
Depo-provera hormone
progestin
depo-provera mechanism of action
suppression of ovulation, thickening of cervical mucus, makes endometrium unsuitable for implantation
depo-provera failure rate
0.3%
4 common side effects of depo-provera
irregular vaginal bleeding–depression–breast tenderness–weight gain
long term use side effects of depo-provera
loss of bone mineral density–osteoporosis–fracture
how long after discontinuation of depo-provera might normal ovulation be delayed
up to 18 months
Failure rate of tubal sterilization
0.2-0.4%
Success rate of tubal sterilization reversal
40-80%
How long should contraception be used after vasectomy?
4-6 weeks
failure rate of vasectomy
less than 1%
success rate of vasectomy reversal
60-70%
hormones in emergency contraception
ethinyl estradiol and/or levonorgestrel
MOA emergency contraception
inhibition or delay in ovulation and insufficient corpus luteum function
failure rate of emergency contraception
15-25%
emergency contraception is most effective when used. . .
within 72 hours of intercourse
What does emergency contraception do in an established pregnancy
no effect on fetal development
Percentage breakdown of causes of infertility (male, female, unidentifiable)
male: 40%, female: 40%, unidentifiable: 20%
4 categories of causes of male infertility
Endocrine, Anatomic defects, abnormal sperm production or motility, sexual dysfunction
3 risk factors for male infertility
exposure to chemicals, radiation, excessive heat
4 endocrine causes of male infertility
Hypothalamic dysfunction, anabolic steroids, thyroid disease, hyperprolactinemia
2 anatomic defect / abnormal spermatogenisis causes of male infertility
varicocele, cryptorchidism
history questions for male infertility (5)
previous pregnancies fathered by patient, chemical or toxin exposure, history of STDs, mumps, trauma to genitalia
physical exam for male infertility (3)
sx of testosterone deficiency, varicocele, patency of urethral meatus
lab tests for male infertility (5)
semen analysis, thyroid, testosterone, prolactin, fsh
5 categories of female infertility causes
cervical, uterine, tubal, peritoneal, ovulatory
2 cervical causes of female infertility
cervical stenosis, cervicitis
3 uterine causes of female infertility
malformations, leiomyoma, Asherman’s syndrome
3 tubal causes of female infertility
PID, tubal ligation, endometriosis
2 peritoneal causes of female infertility
adhesions, endometriosis
5 ovulatory causes of female infertility
pituitary insufficiency, hyperprolactinemia, polycystic ovarian disease, ovarian tumor, thyroid disease, obesity
diagnostic tests for female infertility (9)
laparoscopy, eval for evidence of ovulation, endometrial biopsy, progestin challenge, FSH, LH, prolactin, thyroid function, pelvic examination
ovulation induction drug
clomiphene citrate
major side effect of clomiphene citrate
multiple-gestation pregnancy
