Uterus/FT Flashcards
PCOS- pathophysiology
Most Common endocrinopathy in females
Insulin resistance?
PCOS- S/S & PE
Abnormal menstrual cycle Terminal hair - hirsutism acne Alopecia Acanthosis nigricans Skin tags Truncal obesity
Stein Leventhal Syndrome - anovulation/hyperandrogenism, oligomenorrhea/amenorrhea, hirsutism, obesity, enlarge polycystic ovaries, infertility
Anovulation
- persistent high concentration of LH
- low concentration of FSH
- Low day 21 progesterone level
- Sonographic follicular monitoring
PCOS- diagnosis
Rotterdam criteria - 2 of 3
- Hyperandrogenism
- ovulary dysfunction
- polycystic ovaries
U/S
Ovary containing 12+ follicles sized 2-9mm OR
Ovary >10mL
PCOS- labs & imaging
Serum androgen - inc
LH - inc
FSH - dec
- inc ration 3:1
U/S - multiple cysts on ovaries
Lipids
A1C - insulin resistance
PCOS- treatment
OCP - irregular menses/acne
Metformin - hyperglycemia
Wt Loss
Clomiphene - ovulation stimulant
Chronically anovulatory
- endometrial hyperplasia - progesterone - refer to GYN
- Repeat U/S
- endometrial biopsy
Dysmenorrhea- pathophysiology
Painful menstruation
Prevents nl activity and requires meds
Associated w/ ovulatory cycles
Prostaglandin activity
Dysmenorrhea- cause
Primary - excessive prostaglandin E2 secretion in menstrual fluid -> painful cramping
- starts 3-6m after menarche
Secondary - pathologic
Dysmenorrhea- S/S & PE
History
Primary
- No specific findings
- generalized pelvic tenderness
- N/V, diarrhea
- Fatigue, low back pain, HA
- 1st day of menses
Secondary
- Pain lasts longer than a menstrual period
- starts before bleeding begins - worse throughout - persists after
- > 25yo
- blatting, menorrhagia, dyspareunia
Dysmenorrhea- labs & imaging
Labs - primary -> nl
Dysmenorrhea- treatment
NSAIDs Heat to abdomen Oral contraceptives Exercise Transcutaneous electrical nerve stimulation Surgery
Abnormal Uterine Bleeding - in reproductive aged women- pathophysiology
Abnormal menstrual bleeding and bleeding due to causes - preg, systemic, cancer
If exclude everything -> dysfunctional uterine bleeding
Abnormal Uterine Bleeding - in reproductive aged women - cause
PALM - COEIN Polyp Adenomyosis Leiomyoma Malignancy + Hyperplasia Coag Ovulatory Dysfunction Endometrial Iatrogenic Not otherwise classified
Abnormal Uterine Bleeding - in reproductive aged women - epidemiology
Any age
Abnormal Uterine Bleeding - in reproductive aged women - S/S & PE
Bleeding b/t periods, after intercourse, spotting anytime in menstrual cycle, bleeding heavier or for more days than normal, bleeding after menopause
Good Hx
- LMP, LNMP
- age of menarche/menopause
- etc
PE Speculum Bimanual Exam Eval for other bleeding sites Pap
Abnormal Uterine Bleeding - in reproductive aged women - diagnosis
Cytological exam - pap - cervical dysplasia Hysteroscopy - GOLD - direct visualization of endometrium D&C - remove tissue from uterus - diagnose and treat certain uterine conditions - heavy bleeding or clear uterine lining after miscarriage/abortion - local anesthesia
Abnormal Uterine Bleeding - in reproductive aged women - labs & imaging
"\Urine/Serum HCG CBC TSH Hormone - prolactin, androgen, estrogen Endometrial biopsy ->45 - curette, cervical dilation not always needed - small samples of tissue removed from endometrium - looked at under microscope - may need a D&C
Transvaginal U/S or Saline infusion sonohysterography
- only if palpated mass on PE
- persisting
Abnormal Uterine Bleeding - in reproductive aged women - treatment
Treat underlying problem
Mirena - IUD OCA - estrogen + progestin PO progestin Tranexamic acid - safe when trying to get preog Myomectomy and uterine artery emboization Polypectomy Hysterectomy Endometrial ablation
Postmenopausal bleeding- pathophysiology
Menopause - 12m of amenorrhea
- FSH>30
- estradiol <20
Postmenopausal bleeding- epidemiology
Exogenous hormones
PMS- S/S & PE
Mood symptoms - irritability, mood swings, depression, anxiety
Physical symptoms - bloating, breast tenderness, insomnia, fatigue, hot flashes, changes in appetite
Cognitive symptoms - confusing and poor concentration
Symptoms must occur in sec half of menstrual cycle - luteal phase
PMS- diagnosis
5days prior and 4 days after menses
S/S consistent
PMS- labs & imaging
CBC
TSH
Pregnancy
PMS- treatment
Do all mammograms post cycle
Psych hx
Premenstrual dysphoris disorder (PMDD)- diagnosis
5 or 11present
- marked dpressed mood, feelings of hopelessness
- marked anxiety, tension, feelings,
- affective lability
- persistent/marked anger
Premenstrual dysphoris disorder (PMDD)- treatment
SSRI - GOLD
- Fluoxetine - Prozac
- Sertraline - Zoloft
- Paroxetine controlled-release - Paxil CR
- daily 14d prior to menses
CBT
NSAID
Vit
Bromocriptine
OCA
Benzos
Spironolactone
Lifestyle mod - caffeine, dec ETOH, smoking etc, salt restriction, inc exercise
Leiomyoma (Uterine Fibroid)- pathophysiology
Common, benign uterine tumor
Smooth muscle and connective tissue
Depend on estrogen
Classified by location - subserous, intramural, submucous, intraligamentous, pedunculated, parasitic
Leiomyoma (Uterine Fibroid) - S/S & PE
Discrete, round firm uterine mass
Asymptomatic
Menorrhagia, metrorrhagia, intermenstrual bleeding, dysmenorrhea
Bleeding - most common presenting S/S
anemia
Infertility - distort uterine cavity
Leiomyoma (Uterine Fibroid) - labs & imaging
Pelvic U/S D&C Saline Hysteroscopy Hysterosalpingography - die injected into uterus and fallopian tubes Lapaorscopy Pelvic MRI/CT
Leiomyoma (Uterine Fibroid) - treatment
Observation - mild symptoms
Myomectomy or D&C - symptomatic
Depo-provera - medroxyprogesterone acetate
- 150mg IM every 28d
- can have bleeding at times
Danazol - synthetic modified testosterone - 400-800mg daily - put pt in amenorrhea, usually before surgery
Uterine arterial embolization or endometrial ablation - if they don’t want kids
Hysterectomy - final step
Endometriosis- pathophysiology
Endometrial tissue found outside of endometrial cavity
Common locations
- ovaries
- uterosacral ligament
- GI tract
- lungs/brain
3 theories
- Retrograde menstruation - reflux of endometrial cells -> peritoneum -> ovary
- Vascular & lymphatic dissemination
- Transformation of peritoneal cells -> endometrial cells
Genetic
- 7-9% have 1st deg relative
- HLA-B7 allele
Stimulated by hormones
Endometriosis- cause
Early - implants are red, petechial lesions on peritoneal surface
Older - dark brown, blue, black implants
- filled w/ menstrual debris
Surround tissue - thick and scarred
Adhesions developed -> bowel obstruction
On ovaries - endometriomas ““Chocolate Cysts””
- old menstrual blood
- grow in several cm
- erodes into underlying tissue
Endometriosis - epidemiology
20-30
Infertile W
Fmhx Early menarche Long duration of menstrual flow Heavy bleeding Shorter cycles
Endometriosis- S/S & PE
3Ds - Dysmenorrhea, Dyspareunia, dyschezia
Asymptomatic -> severe pelvic pain
- deep pain from infiltrating lesions
Infertility
PE
- tender nodules in posterior vaginal fornix
- pain w/ uterine motion
- Tender adnexal masses
- nothing
Endometriosis- diagnosis
Tissue biopsy - laparoscopy
- direct visualization
Endometriosis- treatment
Depends on severity, location, desire for prego Observation NSAIDs - for discomfort Surgery - conservative or definitive Med treatment - OCP - IUD - Progesterone therapy - Danazol - 19-nortestosterone derivative - GnRH agonist - lupron
Pregnancy
- dec/improved symptoms
- doesn’t cure
Hysterectomy
Endometriosis- prognosis
Dec risk
- > 4hr/wk exercise
- higher parity
- longer duration of lactation
Adenomyosis- pathophysiology
Endometrial tissues exist w/in and grows into muscular wall of uterus
Adenomyosis - epidemiology
Middle age, severe dysmenorrhea, hx of childbearing, symmetrically enlarged uterus, menorrhagia
Adenomyosis - S/S & PE
Asymptomatic Severe dysmenorrhea Abdominal pressure + bloating Symmetrically enlarged uterus - can palpate Heavy bleeding
Adenomyosis - diagnosis
Pelvic US
MRI
Hysterectomy - DEFINITIVE
- look at cells under microscope
Adenomyosis- treatment
NSAIDs
Hormones
Hysterectomy
Uterine Prolapse- pathophysiology
Post pregnancy, labor, vaginal delivery
Uterine Prolapse- cause
Any condition that inc intra-abdominal pressure
- obesity, chronic cough, heavy lifting, pelvic tumors, ascites, constipation
Uterine Prolapse- epidemiology
> 50% post menopause
White women
Uterine Prolapse- S/S & PE
Vaginal fullness Lower abdo pain Low back pain ""falling out"" sensation Relief w/ lying down
W/ - cystocele, rectocele, enterocele
Uterine Prolapse- diagnosis- grade
Graded 0-4
Grade 0 - no prolapse
Grade 1 - Descent >1cm above hymen
Grade 2 - Descent to hymen
Grade 3 - protrudes but no less than 2cm total vag length
Grade 4 - total eversion of lower genital tract
Uterine Prolapse- treatment
Pessary
Refer to GYN
Wt reduction, smoking cessation, kegels
Surgery
Functional Cysts- pathophysiology
Monthly follicle keeps growing
Follicular Cyst- pathophysiology
Most common functional cyst
Failure in ovulation - 2nd to disturbances in release of pituitary gonadotropins
- failure to ovulate and fluid fails to be reabsorbed
3-8cm
Lined by inner layer of granulosa cells and outer layer of theca interna cells
Follicular Cyst- S/S & PE
Asymptomatic
Large cysts - aching pelvic pain, dyspareunia, occasional abnormal uterine bleeding
Complications - ovarian torsion and bleeding
- >6cm - turn on stalk -> torsion
Follicular Cyst- treatment
Watch and Wait - disappear spontaneously in 60d w/out treatment Reeval in 6w by U/S Benign vs Mal Sugery eval OCP - help establish nl rhythm
Corpus Luteum Cyst- pathophysiology
Thin walled uniocular cysts from after ovulation when corpus luteum fails to regress
3-11cm
Less common
Corpus Luteum Cyst- epidemiology
Amenorrhea
Delayed menstruation
Corpus Luteum Cyst- S/S & PE
Localized pain, tenderness
Amenorrhea
Delayed menstruation
Corpus Luteum Cyst
Watch and Wait
- regress in 1-2m
OCP - recom, but maybe not beneficial
Laparoscopy or laparotomy - required to control hemorrhage to perform detorsion of ovary
Ovarian Torsion- pathophysiology
2nd to enlarged ovary by mass
Ovarian Torsion - S/S & PE
Severe abdominal pain
Pelvic pain
N/v
Ovarian Torsion- treatment
Surgical Emergency
Hydrosalpinx- pathophysiology
Distally blocked fallopian tube, filled w/ fluid
Distended -> sausage appearance
Hydrosalpinx- cause
Hematosalpinx - filled w/ blood
Pyosalpinx - filled w/ pus
PID
Endometriosis
surgery
Ruptured appendix
Hydrosalpinx- S/S & PE
Asymptomatic
Pelvic pain
Abd pain
Infertility
Hydrosalpinx- labs & imaging
U/S
Hysterosalpingogram
Laparoscopy
