Women's Health 1 Flashcards
(525 cards)
1
Q
Ovulation is associated with a spike in what hormone?
A
Luteinizing Hormone (LH)
2
Q
What hormone is predominant in the follicular phase?
A
Estradiol
3
Q
What hormone is predominant in the luteal phase?
A
Progesterone
4
Q
Two anterior pituitary hormones (gonadotropins) associated with the menstrual cycle
A
- Luteinizing Hormone (LH)
2. Follicle-Stimulating Hormone (FSH)
5
Q
Two ovarian hormones associated with the menstrual cycle
A
- Estradiol
2. Progesterone
6
Q
Two phases of the ovarian cycle
A
- Folicular phase (preovulatory)
2. Luteal phase (postovulatory)
7
Q
Three phases of the uterine cycle
A
- Menses
- Proliferative phase
- Secretory phase
8
Q
Three purposes of the menstrual cycle
A
- produce an oocyte for possible fertilization
- prepare the uterus for pregnancy
- if no pregnancy, menses occurs and the cycle starts over
9
Q
What is menses?
A
shedding of the uterine mucosa
10
Q
How long does menses last?
A
3-7 days
11
Q
How much blood is lost during menses?
A
20-60 ml
one R tampon holds 5 ml
12
Q
What’s the definition of LMP?
A
the first day of bleeding
13
Q
Average age for menarche
A
12 years old
14
Q
Average age for menopause
A
51
15
Q
Average duration of the menstrual cycle
A
28 (anywhere from 21-35 days)
16
Q
Should we worry about a young woman who started her period 1 year ago and is having irregular menses?
A
No. It is normal to be irregular for the first 1-3 years, because the patient is not ovulating yet
17
Q
How long do perimenopause symptoms last?
A
3-10 years before menopause
18
Q
Definition of menopause
A
no bleeding for ONE WHOLE YEAR
19
Q
On what day in the menstrual cycle does ovulation occur?
A
day 14
20
Q
Explain the differences in the cycle before and after ovulation
A
Before:
- estrogen is the predominant steroid/ovarian hormone
- follicule
- endometrial status: menses, then proliferative
After:
- progesterone is the predominant steroid/ovarian hormone
- corpus luteum
- endometrial status: secretory
21
Q
Job of FSH
A
develops the follicles
22
Q
Job of LH
A
ovulation
23
Q
Describe the HPO axis
A
Hypothalamus performs PULSATILE GnRH secretion
GnRH acts on the pituitary, causing it to secrete gonadotropins (FSH, LH)
FSH, LH act on the ovary, causing it to secrete sex steroids (estrogen, progesterone)
24
Q
Explain the early follicular phase
A
- Low levels of sex steroids (estrogen, progesterone).
This causes FSH levels to rise.
FSH recruits more ovarian follicules, it’s trying to develop them. - Menses is happening in days 1-4
25
Explain the mid-follicular phase
- Folliculogenesis continues. This causes estrogen levels to INCREASE, which produces negative feedback on FSH & LH.
- The uterine lining is thickening (proliferative phase)
26
Explain the late follicular phase
- Dominant follicle exists. Estrogen predominates and triggers an LH surge!!
27
Explain the ovulation phase
LH surge >> LH Peak >> Oocyte released from dominant follicle >> oocyte travels into the fallopian tube for possible fertilization
28
How long before ovulation does LH surge begin?
36 hours
29
How long before ovulation does LH peak occur?
~12 hours
30
Some women feel a twinge of pain during ovulation, what's it called?
Mittelschmerz
31
Explain the luteal phase
- Follicle is converted to a corpus luteum.
Secretes progesterone, which suppresses LH/FSH through negative feedback. Follicle recruitment is inhibited
- Endometrium becomes more vascular/grandular as it prepares for implantation (secretory phase)
32
What hormone does the corpus luteum produce?
progesterone (P4)
33
Lifespan of the corpus luteum
9-11 days
34
What happens to the corpus luteum if there is no fertilization?
sharp decline in P4, which induces menses
35
What happens to the corpus luteum if fertilization occurs?
implanted zygote will secrete hCG, which sustains the corpus luteum for 6-7 more weeks
36
Definition of puberty
physical and sexual transition from childhood to adulthood
series of well-defined events and milestones representing secondary sexual maturation
37
Activation of adrenal androgen production
Adrenarche
38
Activation of ovaries
Gonadarche
39
Breast development onset
Thelarche
40
Pubic hair development onset
Pubarche
41
Onset of menses
Menarche
42
Put the puberty events in order or observation from earliest to latest
```
Adrenarche
Gonadarche
Thelarche
Pubarche
Menarche
```
43
The Hypothalamic-Pituitary-Adrenal Axis is responsible for development of 3 things:
1. hair
2. acne
3. body odor
44
At what age does the HPA Axis begin to produce increased amounts of androgens?
6-8 years
45
What hormone is secreted by the HPA axis?
DHEA
DHEA is converted to testosterone and dihydrotestosterone
46
The Hypothalamic-Pituitary-Ovarian Axis is responsible for 2 things:
1. ovarian production of estrogen and progesterone
| 2. Breast development
47
When is the HPO Axis functioning?
in utero until after newborn phase... resumes activity during puberty
48
How long does normal pubertal development take?
4 years
49
Order/sequence of the 4 major pubertal events
1. Breast budding
2. Sexual hair growth
3. Growth spurt
4. Menarche
50
At what age do the 4 major pubertal events occur?
1. Breast budding: 10-11
2. Sexual hair growth: 10.5-11.5
3. Growth spurt: 11-12
4. Menarche: 11.5-13
51
What are the major hormones associated with each of the 4 major pubertal events?
1. Breast budding: Estradiol
2. Sexual hair growth: Androgens
3. Growth spurt: Growth hormone
4. Menarche: Estradiol
52
What is the average age of menarche in the US?
12
53
Early and late timing of secondary sex characteristics
Early: before age 7-8
Late: not apparent by age 13
54
Abnormal age of menarche
No evidence of menarche by age 15-16
OR
No menses within 5 years of thelarche
55
Onset of secondary sex characteristics around or prior to age 6 (AA) or 7 (Caucasian)
Precocious puberty
56
Etiology of precocious puberty
Early sex hormone production (GnRH dependent or independent)
57
GnRH dependent precocious puberty is due to..
early activation of the HPO or HPA axes
```
idiopathic
CNS infection
inflammation
injury
neoplasm
```
58
GnRH independent precocious puberty is due to...
end organ disorders (ovary or adrenal glands)
tumors
cysts
exogenous
mutations
59
Which precocious puberty is "central" and which is "peripheral"
GnRH dependent= central
GnRH independent= peripheral
60
How to differentiate between central and peripheral precocious puberty
central: increased LH
peripheral: increased androgens
61
Treatment goals of precocious puberty
1. arrest sexual maturation until normal pubertal age
| 2. maximize adult height
62
Definition of delayed puberty
- Secondary sex characteristics not apparent by age 13
- No evidence of menarche by age 15-16
- No menses within 5 years of thelarche
63
Etiology of delayed puberty
- Endocrine (HPO Axis)
| - Anatomic
64
Two causes of delayed puberty due to HPO Axis:
1. HYPERgonadotropic HYPOgonadism (Turner Syndrome)
| 2. HYPOgonadotropic HYPOgonadism
65
FSH levels in HYPERgonadotropic HYPOgonadism
>30mlU/ml
66
What is happening in HYPERgonadotropic HYPOgonadism?
gonadal dysgenesis
(Turner Syndrome)
Have ovaries, but do not have ovarian follicules ("streak gonads")
NO SEX STEROID PRODUCTION
Lack of negative feedback upon gonadotropins, results in high FSH
Primary amenorrhea
67
Treatment for Turner Syndrome (46X)
Induce secondary sexual maturation: Estrogen therapy
Maximize adult height
68
FSH/LH levels in HYPOgonadotropic HYPOgonadism
FSH + LH = <10 mlU/mL
69
Definition of HYPOgonadotropic HYPOgonadism
disruption between hypothalamus and pituitary
GnRH stimulation is decreased
Lower than expected levels of FSH, LH
70
Etiologies of HYPOgonadotropic HYPOgonadism
- Constitutional (physiologic) delay
- Kallmann Syndrome
- Anorexia, extreme exercise
- Pituitary tumors/disorders, hyperprolactinemia
71
Three types of anatomic delayed puberty
1. Mullerian agenesis
2. Imperforate hymen
3. Transverse vaginal septum
72
What is happening in Mullerian agenesis?`
Congenital absence of upper vagina (uterus, tubes)
73
How isovarian function in Mullerian agenesis affected?
ovarian function is normal
74
What is observed in Mullerian ageneiss?
- Primary amenorrhea
| - normal breast development
75
What is happening in imperforate hymen?
genital plate canalization is incomplete, obstructs the outflow of menses
76
What do you think if you observe a patient with pain, bulging, bluish appearing introitus?
Imperforate hymen
77
What is happening in transverse vaginal septum?
Occurs at any level of the vagina and obstructs the outflow of menses
78
menorrhagia
excessive bleeding
79
metrorrhagia
bleeding outside/between menses
80
Menometrorrhagia
Excessive bleeding outside/between menses
81
Postcoital bleeding
bleeding after intercourse
82
Dysmenorrhea
Painful bleeding
83
Postmenopausal bleeding
ANY amount of bleeding after diagnosis of menopause
84
How to document reproductive history
GP(T-P-A-L)
G: number of pregnancies
P: pregnancy outcomes
T: Term (>37 weeks)
P: Preterm (<37 weeks, >20 weeks)
A: Abortion (<20 weeks.. elective, ectopic, or spontaneous)
L: Live births
85
How to document a woman who has 4 pregnancies- 1 term, 2 preterm, 1 first trimester spontaneous abortion, 3 living children
G4P1-2-1-3
86
“Soccer mommy” is pregnant and has three girls. She has been pregnant six times before – one elective abortion, 1 ectopic pregnancy at 9 weeks, 2 single baby deliveries at 39 weeks, one delivery at 32 weeks and another child delivered at 29 weeks who was stillborn.
G7P2-2-2-3
87
How to document reproductive history using the GPA system
G: # of pregnancies
P: pregnancies reaching viability (20 weeks)
A: pregnancies NOT reaching viability (abortions)
88
Why is age of menarche important in the PMHx?
women who start their periods younger have increased estrogen exposure, therefore increased risk of cancer
89
What's important to include when documenting GYN surgeries/proceures
Indication
90
What's the definition of sexually active
sex within the last 3 months
91
Only method to protect against STI
condoms
92
Three types of delivery
1. spontaneous vaginal delivery
2. Cesarean section
3. vaginal birth after cesarean
93
When to address infertility
Patient <35 years old: trying for >1 year
Patient >35 years old: trying for 6 months
94
What to ask about prevention/screening (3)
for each test:
1. frequency
2. outcome
3. treatment
95
Breast exams: when do you start and how often do you do them?
Start: 21 years old
Frequency: every 1-3 years
96
3 positions of breast exam inspection
1. arms at sides
2. armes pressed at hips
3. arms raised overhead
97
5 things to look for on inspection during breast exam
1. asymmetry
2. Dimpling
3. Discoloration/rash
4. Nipple retraction
5. Nipple discharge
98
How to document a breast mass
include:
- distance from areola
- diameter of mass
- position on clock (ex: 1 o'clock)
99
What is "Breast self awareness"
replacement of traditionally recommended monthly breast self-exam
Women should understand the normal appearance/feel of breasts and be aware of personal high risk factors
100
Steps of the pelvic exam
1. wet/warm the speculum
2. gentle pressure at introidus
3. insert speculum horizontally at 45 degrees
4. slight downward pressure, go all the way back until you meet resistence
5. Inspect vaginal walls, cervix
6. perform pap test (sample from transitional zone)
7. Speculum withdrawal
101
All the things you palpate during the normal bimanual exam
Cervix
Uterus
Adenexa
102
Size of a premenopausal ovary
1x2x3 cm
103
Size of a postmenopausal ovary
usually not palpable
104
Why would you do a rectovaginal bimanual exam?
Guiac
Retroverted/retroflexed uterus
Posterior mass suspicion
105
Most common imaging in OB/GYN
ultrasonography
| abominal or transvaginal
106
Indications for ultrasonography
- diagnosis of pelvic masses
- evaluate postmenopausal bleeding
- pregnancy diagnosis
107
indications for hysterosalpingography
- fallopian tube patency
- endometrial polyps
- myoma
108
How does hysterosalpingography work?
contrast medium inserted through cervix, followed by fluoroscopic observations/film
Allows to see uterine cavity and fallopian tubes
109
How does sonohysterography work?
uterine cavity filled with saline, US used to view endometrial cavity
110
Indications for sonohysterography
Diagnosis of intrauterine abnormalities (ex: polyps)
111
What type of biopsy would you perform on the vulva? Why?
punch biopsy
Ind: Eval visible lesions, persistent pruritis, burning and pain
112
What type of biopsy would you perform on the vagina? Why?
pinch forceps biopsy
Ind: suspicious masses
113
What type of biopsy would you perform on the cervix? Why?
colposcopy (directed biopsy with forceps)
ind: eval abnormal pap results, chronic cervicitis
114
What type of biopsy would you perform on the endometrium? why?
Small diameter suction catheter
Ind: eval abnormal uterine bleeding
115
What is a colposcopy?
allows for illuminated, magnified view of the cervix via binocular microscope
116
When to do a colposcopy
To further eval abnormal PAP results. While you're in there, you'll:
- get biopsy
- endocervical curettage
117
Tx for abnormal colposcopy?
Loop Electrosurgical Excision Procedure (LEEP)
118
How does LEEP work?
uses low-voltage, high frequency alternating current that limits thermal damage, but at the same time has good hemostatic properties
119
What do you use LEEP for?
excision of cervical dysplasias and cone biopsies of the cervix
120
What is hysteroscopy and when do you use it?
visual exam of the uterine cavity through fiberoptic instrument (hysteroscopy)
Ind: visualize polyps, adhesions, myoma
121
How do we inflate the abdomen for laparoscopy?
Fill with CO2 through umbillicus
122
indications for laparoscopy
| diagnostic and therapeutic
- uterine fibroids
- structural abnormalities of uterus
- endometriosis
- ovarian cysts
- adhesions
- sterilization
- hysterectomy
123
Indication for endometrial ablation
treat abnormal uterine bleeding
| not considered sterilization
124
What is dilation and curettage?
dilation of the cervix followed by curettage (scraping) of the endometrium
125
indications for D&C?
| diagnostic and therapeutic
- abnormal uterine bleeding
- incomplete abortion
- endometrial biopsy
126
Hysterectomy
surgical removal of the UTERUS
127
Total hysterectomy
removal of entire uterus (includes cervix)
128
Supracervical hysterectomy
removal of the uterine corpus only (cervix is left behind)
129
salpingo-oophorectomy
Salpingo: tubes
oophor: ovaries
May be bilateral or unilateral
May or may not be included in a hysterectomy (must ask)
130
How many pregnancies in the US are unintended?
45%
131
How many in the US use contraception?
77%
132
what percent of unintended pregnancies end in terminatino?
43%
133
4 things to take into account when considering contraceptive options
1. risk factors/tolerability
2. personal preferences
3. medical history
4. permanent sterilization regret
134
Why is it important to ask about previous birth control methods?
We want to know if it worked and what they liked/didn't like about it. We don't want to start them on a pill they wont take for whatever reason
135
Two most important things to keep in mind when choosing a method of contraception
1. Risk factors
| 2. Reproductive desires (TIMING)
136
4 types of birth control
1. Sterilization (surgical)
2. Hormonal (pill, patch, injection, ring)
3. Non-hormonal (iud, barrier)
4. Post-coital
137
LARC
long acting reversible contraceptive
138
SARC
short acting reversible contraceptive
139
```
List the following from most to least effective:
barrier methods
hormonal methods
natural methods
no method
sterilization
intrauterine devices
implants
```
```
sterilization
implant
intrauterine devices
hormonal methods
barrier methods
natural methods
no method
```
140
Most effective
```
sterilization
Cu-IUD
LNG-IUD
implant
DMPA injection
```
141
Effective
oOCPs
patch/ring
POPs
142
Least effective
Barrier methods
| NFP
143
Most frequently used sterilization method in US
sterilization
144
When performing surgical sterilization, you counsel and document patient understanding of 3 things:
permanence
operative risks
chance of pregnancy
145
Describe vasectomy MOA
ligation of vas deference
prevents passage of sperm into ejeculate
146
10 weeks, postop from vasectomy, what do you gotta do?
confirmation by semen analysis
147
Describe bilateral tubal ligation MOA
permanent occlusion of the fallopian tubes by electrocautery, ring, or clip
prevents passage of the egg through the tubes
148
How does BTL affect woman's risks?
decreased risk of ovarian cancer
| if pregnancy does occur, increased risk of ectopic pregnancy
149
Failure rates of homonal birth control
<1-9% depending on type/method used
150
What forms does combination estrogen + progestin come in?
pills
patch
ring
151
What forms does progestin only birth control come in?
pills
injections
implants
intrauterine device
152
7 physiological effects of estrogen
- alters lipid metabolism
- potentiates Na and water retention
- increases renin substrate
- stimulates cP-450 system
- increases sex hormone-binding globulin
- decreases circulating androgens
- reduces antithrombin III
153
Contraindications for estrogen therapy
- Hx of clotting irregularities
- abnormal vaginal bleeding
- cerebral vascular disease
- pregnancy, or chance or pregnancy
- smokers >35 years
- uncontrolled HTN
- severe liver disease
- known or suspected breast malignancy
- migraine with aura (risk for stroke)
- multiple risk factors for CVD
154
Contraindications for progestin therapy
- known, suspected breast malignancy
- abnormal vaginal bleeding
- pregnancy, suspected pregnancy
- active thromboembolic disease (IF ACTIVE DVT TAKE THE PT OFF PROGESTIN)
- liver adenoma/malignancy
- migraine with aura
- vascular disease
155
combo oral contraception pills MOA:
suppression of GnRH releasing factors
- suppresses FSH, which reduces follicule maturation
- suppresses LH, which prevents ovulation
156
Role of progestin in MOA of combo oral contraception pills
Has MAJOR contraceptive effect
- prevents ovulation
- thickens the cervical mucous, which prevents sperm migration
- produces atrophic endometrium, which is less suitable for implantation
157
Role of estrogen in MOA of combo oral contraception pills
- potentiates the effects of progesterone and suppresses FSH
| - added benefit: stabilizes the endometrium, which means LESS BREAK THROUGH BLEEDING
158
Monophasic oOCPs
- standard estrogen dose (30-35mg)
| - "tradiational regimen": 3 weeks of active pills followed by one placebo week
159
Triphasic oOCPs
- dosage of either estrogen or progestin varies weekly
- "mimics" normal cycle
- slightly less hormone exposure monthly
160
Who should have low estrogen dosage? (<20 mg)
perimenopausal women
| smokers <35 years old
161
Extended regimen oOCPs
- 11 weeks of active pills followed by one placebo week
| - 4 scheduled withdrawal bleeds per year
162
Vaginal ring MOA:
same as combo OCPs
163
S/E of vaginal rings
leukorrhea, vaginal discomfort
164
What to counsel patients on with vaginal rings:
One ring stays in for 3 weeks
Remove for 1 week withdrawal bleed
Rings lose effectiveness with heat, keep refrigerated
Only one right per package, keep a back up
165
Contraceptive patch MOA
same as OCPs and ring
166
Things to think about
decreased efficacy for women >198 lbs
| potential for skin irritation
167
Directions for contraceptive patch
- place on e patch on skin for one week
- alternate patch locatino each week for 3 weeks
- one week "off" patch for withdrawal bleed
168
Indications for progestin only methods
- breastfeeding
- women >40
- patients with estrogen use contraindications
- patients with compliance issues (injection, IUDs, implants)
- reduces risk of endometrial cancer
169
Progestin only pill MOA
- thickens cervical mucous (prevents sperm migration)
- thins endometrium
- MAY inhibit ovulation
170
Most important thing about taking progestin only pills
MUST TAKE AT SAME TIME EVERY DAY
| if >3 hours late, must use back up contraception
171
Progestin injections MOA
- thickens cervical mucous (prohibits sperm mobiliy)
- decidualization of the endometrial lining (poor implantation)
- blocks LH surge (prevents ovulation)
172
Method for progestin injections
- IM injection every 3 months (maintains contraception for 14 weeks)
173
Considerations for progestin injections
irregular bleeding after first injection
amenorrhea over time
SOME WOMEN WANT WITHDRAWAL BLEEDS TO ENSURE THEY'RE NOT PREGNANT, must check personal preferences!
Takes 6-12 months to return to normal cycle after discontinuation. Not good for women who want to get pregnant in the next year
174
S/E of progestin injection
lots.
WEIGHT GAIN (~10lbs)
175
Progestin implant MOA:
- thickening of the cervical mucous
| - suppresses LH surge (inhibits ovulation)
176
How long does progestin implant last?
3 years
177
S/E of progestin implant
irregular bleeding, may achieve amenorrhea
178
Progestin only IUDs MOA
| LNG-IUD
- foreign body effect causes inflammatory response
- thickens cervical mucous
- thins the endometrial lining
179
Copper IUD MOA:
- foreign body serile inflammatory effect
| - spermicidal: inhibits sperm motility and reaction necessary for fertilization
180
Lifespan for copper IUD
10 years
181
CI for copper IUD
history of menorrhagia, dysmenorrhea
182
3 barrier methods
condoms
spermicides
diaphragm
183
Emergency contraception must be used how quickly?
within 72 hours
184
MOA of emergency contraception (Plan B pill)
delays/inhibits ovulation and prevents fertilization
185
Most effective form of emergency contraception
copper IUD
can be inserted up to 5 days after intercourse
186
What is vulvovaginitis?
disorders cauesed by infection, inflammation, or changes in the normal vaginal flora
187
3 most common organisms causing vaginal symptoms
BV
Trich
Candida
188
Name some less common causes of vaginal symptoms
```
atrophic vaginitis
FB
irritants/allergens
Cervicitis
STIs
Vulvar dermatoses
```
189
Common vaginal presenting symptoms (patient usually comes in with >1)
```
Change in vaginal discharge (color, odor, volume)
Pruritus
Burning/discomfort
Irritation
Swelling
Erythema
Spotting
Dyspareunia
Dysuria
```
190
Name the three elements of the vulvovaginal ecosystem that work together to create the environment
Microflora
Host estrogen
Vaginal pH
191
What is the predominant bacteria in the vagina?
Lactobacilli
192
What is normal vaginal pH?
3.5-4.7
193
Disruptions in the vaginal ecosystem lead to...
vaginitis
194
Name some factors that affect the vaginal ecosystem
```
Abx
FB (condom, tampons)
Hormones (pregnancy, contraceptives, phases of menstrual cycle)
Douches, Hygienic products
Sex
```
195
Describe normal vaginal secretions
white/transparent
thick or thin
NO ODOR
196
What is physiologic leukorrhea?
the normal volume of vaginal discharge increases during pregnancy and mid-cycle
197
T/F: itching, pain, irritation, mucosal friability are sometimes normal vaginal symptoms depending on the situation
False
198
3 things to do in the evaluation of a patient with vaginal Sx
1. History
2. PE
3. Test for BV, Candida, Trich....Move on to less common causes after ruling out these three
199
3 diagnostic tools for vulvovaginitis
Vaginal pH
Microscopy
Amine testing
200
How is vaginal pH tested
pH test strip applied to the vaginal wall
201
How is microscopy performed to Dx vulvovaginitis?
1. Obtain swab of vaginal mucosa
2. Apply secretions to 2 separate slides.
3. Mix one slide with normal saline (NS wet prep)
Mix the other slide with 10% KOH (KOH wet prep)
4. Look at slides under the microscope for pathology
202
What do you do if you don't have a microscope or microscopy is inconclusive
Culture
or
DNA amplification tests/NAAT
203
What's the triple threat of vulvovaginitis?
BV, Trich, and Candidiasis often happen together
204
What is the most common cause of vaginitis?
BV: Bacterial Vaginosis (not an inflammatory condition... it's a disturbance of the ecosystem rather than a true infection of tissues)
205
Etiology of bacterial vaginosis
a reduction in lactobacilli and an increase in pH....
| leads to a polymicrobial infection (Gardnerella vaginalis is most prominent)
206
Risk factors for BV
Sexual activity
Douching
Cigarette smoking
207
Protective factors for BV
Condoms
| Estrogen-containing OCP
208
Sequelae of BV
Preterm delivery
| Risk factor for STI acquisition/transmission
209
S/S of BV
```
50% asymptomatic
Vaginal malodor (Cardinal Sx)
Abnormal discharge
No true signs of inflammation
On Exam:
- NO erythema/edema
- Thin, grey-white discharge
- NO lesions/discharge on cervix
```
210
Dx of BV
3/4 of the Amsel Criteria
211
Amsel Criteria for Dx BV
1. Adherent, grey-white, homogenous discharge
2. Vaginal pH >4.5
3. Positive whiff test
4. Presence of 20% clue cells on light microscopy
212
What's gold standard for Dx of BV?
Gram stain
213
Should you culture BV?
No. There's no way to quantify a culture
214
Amsel Criteria with the least specificity
Abnormal discharge
215
Amsel Criteria that's the most reliable predictor
Presence of clue cells
216
3 options for Tx of BV
1. Oral Metronidazole
2. Metronidazole gel
3. Clindamycin (topical)
217
Caution for Metronidazole
DO NOT DRINK EtOH
218
2nd most common cause of vaginal infections
Vaginal Candidiasis
219
Is Vaginal Candidiasis sexually transmitted?
No
220
Primary organism in Vaginal Candidiasis
Candida albicans
221
Etiology of Vaginal Candidiasis
Overgrowth of Candida >> increased penetration of superficial epithelial cells >> compromised host immunity >> enhanced estrogen state >> HOST INFLAMMATORY RESPONSE
222
Risk factors for Vaginal Candidiasis
```
DM
Abx use
Immunosuppression
Increased estrogen levels
Tight, poorly ventilated clothing
```
223
Sx of Vaginal Candidiasis
PRURITUS
Vaginal soreness/irritation, burning, dyspareunia, external dysuria
Usually no odor associated
224
Vaginal Candidiasis PE
ERYTHEMA of labia/vulva and vagina
Normal cervix
Adherent, whitish discharge... usually clumpy or COTTAGE CHEESE-like
225
Dx of Vaginal Candidiasis
Microscopy (KOH prep most sensitive) showing :
Hyphae and buds
Normal pH of 4-4.5
226
Tx for uncomplicated Vaginal Candidiasis
Topical imidazoles
or
PO Fluconazole
227
Tx for complicated Vaginal Candidiasis
Extend topicals for 7-14 days
| Increase PO Fluconazole to 3 doses instead of 1
228
Tx for recurrent Vaginal Candidiasis
Once weekly dose of oral Fluconazole for 6 months
229
Most common non-viral STI worldwide
Trichomoniasis
230
Trichomoniasis is associated with _____, so you _____ when they have it.
1. co-infection with other STIs
| 2. test for other STIs
231
Transmission of Trichomoniasis
Sexually transmitted
232
Trichomoniasis organism
Tricomonas vaginalis
233
Trichomonas vaginalis lives in the _____, so it'll produce _____.
1. vagina, urethra, paraurethral glands
| 2. UTI symptoms
234
Describe the trichomonas vaginalis organism
Flagellated protozoan
235
Sx of Trichomoniasis
Range from asymptomatic carrier to acute inflammation
Purulent, malodorous, FROTHY GREEN or yellow vaginal discharge
Pruritus
Dyspareunia, dysuria, burning
Sx of acute infection often appear during or immediately after menses
236
Trichomoniasis PE
- FROTHY GREEN/yellow discharge is classic
- Often erythematous vulva/vagina
- Punctate hemorrhages on cervix ("strawberry cervix")
Strawberry cervix only occurs in <10% of patients, but is very specific when it does occur
237
Trichomoniasis Dx
Microscopy (NS wet prep) shows ovoid, MOTILE parasites (they have flagella)
Vaginal pH >4.5
Bacterial increase the pH
238
Trichomoniasis Tx
- Oral Metronidazole
(topicals don't penetrate the urethra)
Tell pt to abstain from intercourse until 7 days after the therapy is completed and asymptomatic
- MUST treat the partner
- MUST test for other STIs
- Do NOT have to report
- Screening is recommended in high risk pts (CDC)
239
Etiology of Atrophic Vaginitis
Reduced estrogen levels
| Menopause, other hypoestrogenic states
240
Atrophic Vaginitis Sx
Dryness, burning, pruritus, discharge, bleeding, dyspareunia, UTI symptoms
241
Atrophic Vaginitis PE
- Smooth, pale, shiny vulvar skin
- Loss of elasticity and rugae
- Thinning of the skin/mucosa
- Narrowing of the introitus
- Discharge
242
Atrophic Vaginitis Dx
CLINICAL
pH >5.5 + PE findings
pH is elevated because estrogen levels are decreased so much
243
Atrophic Vaginitis Tx
Vaginal moisturizers, lubricants
Topical low-dose estrogen
244
How many new STI cases occur every year?
15-20 million
245
How many people live with an incurable STI?
65+ million
246
T/F: Reportable STIs are almost always reported.
False. Reportable STIs are often diagnosed, but not reported.
247
Young people age 15-24 make up ____% of new sexually transmitted infections.
50%
248
What are the CDC's 5 major strategies for prevention and control of STIs?
1. Risk assessment + education + counseling
- On ways to avoid STIs through changes in sexual behaviors and use of recommended prevention services
2. Pre-exposure vaccination
3. Identification of asymptomatically infected people
4. Effective diagnosis, treatment, counseling, and follow up of infected people
5. Evaluation, treatment, and counseling of sexual partners
249
Which STIs are reportable in every state? (5)
```
syphilis
gonorrhea
chlamydia
chancroid
HIV/AIDS
```
250
STIs of concern with DISCHARGE ("drips"):
Gonorrhea
Chlamydia
Other: Trichomonas (vaginitis, urethritis), BV (sexually associated), Candidiasis (not STI)
251
STIs of concern with ULCERS & LESIONS ("sores"):
```
Syphilis
Genital herpes (HSV2, HSV1)
```
Other: Chanroid, Granuloma inguinale, Lymphogranuloma
252
Other major STI concern that is not a "drip" or "sore" is....
genital HIV: cervical, oral, anal cancer
253
Describe the Neisseria gonorrhoeae organism
Gram (-) diplococci
254
Gonorrhea is most common in what age group?
15-29
255
Gonorrhea causes what type of infection/what does it mostly affect?
mucopurulent cervicitis/urethritis
256
What is the second most commonly reported STI among women/men in the US?
Gonorrhea
257
Gonorrhea transmission
UNPROTECTED oral, vaginal, and anal sexual contact
PS: penetration and ejaculation is not required (pts need to know this)
258
Gonorrhea incubation period
3-5 days
259
Most of the time, women with Gonorrhea have what symptoms?
Asymptomatic
260
If women have symptoms with gonorrhea, what are some of them?
```
MUCOPURULENT discharge
dysuria
post-coital vaginal bleeding or bleeding in between periods
abdominal pain
dyspareunia
```
261
MALE symptoms of gonorrhea
Thick, yellow-green discharge
dysuria
testicular pain
rectal pain/discharge/pruritus
262
Gonorrhea and chlamydia are associated with increased risk of contracting and transmitting ___.
HIV
263
List a few complications of gonorrhea
Female: PID
Male: infertility (rare)
Both: disseminated gonococcal infection
264
Disseminated gonococcal infection manifests as:
```
small pustular lesions on the skin
fever
painful joints
exquisitely tender necrotic pustules
purulent arthritis
```
265
Gold standard Dx of gonorrhea
Nucleic Acid Amplification Test (NAAT)
- swab or urine
266
If gonococcal infection is resistant, you should...
culture to determine susceptibility
267
Who should be screened for gonorrhea?
all sexually active women <25 years old
| women with high risk behaviors >25 years old
268
Gonorrhea Tx
Ceftriaxone 250mg IM + Azithromycin 1gm PO
Ceftriaxone 250mg IM + Doxycycline 100mg BID x 7 days\
*** The Ceftriaxone is for Gonorrhea, the others are for Chlamydia. We treat both because of the likelyhood of coinfection
269
2 special notes about Gonorrhea/Chlamydia Tx and F/U?
Notify and treat all partners within last 60 days!
ABSTINENCE during treatment!! for all 7 days OR for 7 days following single dose
270
If gonorrhea/chlamydia symptoms continue 2 weeks after Tx, what do you do? 3 months?
2 weeks: consider Test of Cure (TOC)
3 months: always RETEST
271
If a pregnant woman with gonorrhea goes untreated, the baby can develop _____ that leads to _______.
eye infection, blindness
272
T/F: Gonorrhea and Chlamydia are linked to miscarriages, premature birth, and premature rupture of membranes
True
273
If pregnant woman is Dx with gonorrhea, do NOT give _____.
Doxycycline
274
Describe the organism of Chlamydia trachomatis
Non-gonococcal
275
What does the organism of Chlamydia cause?
Mucopurulent cervicitis/urethritis
276
What is the most commonly reported STI in the US?
Chlamydia
277
What age group is chlamydia most common in?
15-24 years old
278
Do more men or women get chlamydia?
Women
279
Chlamydia transmission
UNPROTECTED oral, vaginal, anal sexual contact with infected partner
**Penetration and ejaculation not required
280
____% of patients with chlamydia are asymptomatic. If they do have symptoms, they occur _____ days after exposure
85%
| 7-14 days
281
S/S of Chlamydia
Women: mucopurulent cervical discharge (less obvious than gonorrhea), dysuria, post coital bleeding, bleeding between periods, dyspareunia, abdominal pain, ocular or rectal infection
Male: clear, watery, or milky urethral discharge, pruritus of urethra, dysuria, testicular pain, ocular or rectal infection
282
Complications of Chlamydia
Female: PID
Male: infertility
Both: Reactive Arthritis!! (eye disorders + rashes/sores/joint pain)
283
Gold standard for Chlamydia Dx
Nucleic Acid Amplification Test (NAAT)
284
Who should be screened for Chlamydia?
All sexually active women <25 years old
| Women >25 years old with high risk factors
285
Chlamydia Tx
Azithromycin 1mg PO as single dose
OR
Doxycycline 100mg BID x 7 days
Tx for gonorrhea too if index of suspicion is high
286
If a pregnant woman has chlamydia, the baby will likely contract ______ during birth
lung and eye infections!!
287
Pregnancy chlamydia Tx options (3)
Erythromycin, Azithromycin, Amoxicillin
***Consult ID for Gonorrhea pregnancy Tx
288
What is defined as a spectrum of inflammatory disorders of the upper female genital tract?
Pelvic Inflammatory Disease
289
How does PID usually occur?
direct spread from the cervix
290
```
____ includes:
endometritis
salpingitis/oophoritis
tubo-ovarian abscess
pelvic peritonitis
```
PID
291
PID is most commonly caused by what organisms? (2)
Gonorrhea and Chlamydia
292
Greatest risk factor for PID is:
Prior PID!!
293
Goal of treating PID is to prevent these 3 things:
infertility
ectopic pregnancy
chronic pelivc pain
294
Describe the pathology of PID
- STD- causing bacteria enters vagina by semen
- Causes cervicitis
- Spreads to become endometritis
- Spreads to become salpingitits, oophoritis, tubo-ovarian abscess
- Infection leaves fallopian tubes and spreads to other parts of the body >> peritonitis
295
PID Sx
- NEW ONSET PELVIC PAIN AND ABDOMINAL TENDERNESS
- dyspareunia
- vaginal discharge
- intermenstrual/post-coital bleeding
296
PID PE signs
- CHANDELIER SIGN
- CERVICAL MOTION TENDERNESS
- possible discharge
297
PID Dx
Initially presumptive based on S/S: CMT or uterine tenderness or adnexal tenderness
PLUS 1 of the following:
- fever >101
- cervical/vaginal mucopurulent discharge
- WBC on microscopy
- documented infection with NG/CT
- elevated ESR
298
If a suspected PID patient is pregnant, you must r/o:
Ectopic pregnancy!!
299
PID criteria for hospitalization
- Pregnancy
- Poor response to oral Tx
- Unable to follow outpatient Tx due to vomiting or compliance
- Severe clinical illness: fever, chills, pain, n/v, etc
- Tubo-ovarian abscess
- If surgical emergency can't be excluded
300
Outpatient PID Tx
Ceftriaxone + Doxycycline +/- Metronidazole
301
Inpatient PID Tx
Cefotetan, Cefoxitin, or Doxycycline
302
If treating someone with PID outpatient, you must ... (3)
FOLLOW UP closely with an exam in 48-72 hours
If no substantial improvement: hospitalize
Retest for NG/CT 4 weeks after therapy is complete
303
Which organism is known as the "Great Imitator"
Treponema pallidum (Syphilis)
It can present like lots of different things, esp dermatologic.
304
Describe the Treponema pallidum (syphilis) organism
spirochete
305
Name the 5 states of syphilis
1. primary
2. secondary
3. early latent
4. late latent
5. tertiary
306
How long is a syphilis patient infectious? During what stages?
1 year after contraction; early stages (primary, secondary, and early latent)
307
Syphilis transmission?
| How does it spread?
oral, vaginal or anal sex
direct contact with bacteria in syphilitic sores/rashes
spreads rapidly to the regional lymph node, then disseminates
308
Where is syphilis most commonly found in women?
vulva, vagina, cervix
309
S/S of PRIMARY syphilis
CHANCRE!! (PAINLESS ulcer with raised edges)
- occurs 10-90 days after inoculation
- heals spontaneously in 3-6 weeks
- CONTAGIOUS
310
S/S of SECONDARY syphilis
Flu-like symptoms
- begin 2-24 weeks after chancre
Diffuse maculopapular rash
- red, brown, rough
- on palms and soles most often
Lesions of genital mucus membranes (CONDYLOMA LATA)
- flat, smooth, wart-like
- highly infectious
***CONTAGIOUS
311
S/S of TERTIARY syphilis
Multi-organ effects:
- neuro
- ocular
- ophthalmic
- cardiac
GUMMAS: destructive necrotic lesions
312
1/3 of untreated syphilis leads to _____.
Tertiary syphilis (RARE)
313
How do you know when someone has latent syphilis?
positive serology, negative S/S
314
Syphilis complications (2)
Neurosyphilis: HA, AMS, dementia, meningitis
DEATH (tertiary syphilis)
increased risk of contracting/transmitting HIV
315
Syphilis definitive Dx
Dark-field microscopy: can see motile spirochetes
316
Serological SCREENING for syphilis is done with:
non-treponemal tests (VDRL, RPR)
317
Serological CONFIRMATION of syphilis is done with:
treponemal tests (FTA-ABS, TP-PA)
318
Primary and secondary stage syphilis Tx
Bicillin-LA
Benzathine Penicillin G single dose 2.4 million units
319
Early latent stage syphilis Tx
Bicillin-LA
Benzathine Penicillin G single dose 2.4 million units
320
Late latent and tertiary stage syphilis Tx
Benzathine Penicillin G 2.4 units x three weeks
321
Syphilis Tx if PCN allergy
Doxycycline or Ceftriaxone
322
Syphilis Tx if pregnant
Desensitize
323
Something you should be concerned about as a complication of Syphilis Tx... it:
- occurs in the first 24 hours of therapy
- an acute, febrile reaction
- HA and malaise often occur also
Jarisch-Herxheimer Reaction
324
Jarisch-Herxheimer Reaction Tx
antipyretics
325
Once treatment for syphilis has begun, you must follow up with quantitative _____ at 3, 6, and 12 months. Usually there is a ____ decrease by 3 months, _____ by 6 months and seronegativity in 75% of patients at _____..
VDRL/RPR titers; 4 fold; 8 fold; 2 years
326
Which confirmatory tests for syphilis are qualitative?
Trepomonal tests
327
Which confirmatory test s for syphilis are quantitative?
NON-Trepomonal tests (RPR/VRDL)
328
Syphilis may be transmitted to a baby by an infected mother ______, which leads to a serious multisystem infection known as ______.
during pregnancy; congenital syphilis
329
Transmission of Genital Herpes Simplex Virus
by someone unaware they have it, during viral shedding
330
Describe a primary outbreak of HSV. How are non-primary and recurrent episodes different?
PAINFUL vesicular or ulcerated lesions
last up to 2 weeks
first episode usually accompanied by flu-like symptoms
Non-primary are less severe, recurrent have less Sx
331
HSV Dx
- PCR swab OR culture of the VISIBLE LESION
| - Serological testing: IgG based, type specific
332
HSV Tx (1st episode)
Valacyclovir 1gm q day x 7-10 days
Other options: Acyclovir, Famciclovir
333
HSV Tx (recurrent episode)
Start Tx during prodrome: Valtrex (valcyclovir) 500mg bid x 3-5 days
334
HSV recurrent episodes tend to occur _____
during illness or stress
335
If HSV outbreaks occur >6 times per year:
give suppressive therapy: daily Valtrex (1g
336
Does suppressive HSV therapy eliminate viral shedding?
NO, just reduces it
337
Must counsel HSV patients on 3 things:
1. recurrence
2. asymptomatic viral shedding
3. risk of transmission
338
80-90% of neonatal herpes infections occur from ____.
vaginal delivery
339
Must use _____ for pregnant women with history of HSV and _____ for pregnant women with current, active HSV
suppressive therapy for last 4 weeks of pregnancy; C-section
340
What are the high-risk strains of HVP and the low-risk strains of HPV?
High: 16, 18
Low: 6, 11
341
HVP transmission
direct contact to mucous membranes/fluids
342
HPV genital warts are called _____.
condyloma accuminata
343
HVP vaccine has demonstrated effectiveness in _____ persistent HPV vaccinations impacting CIN II-III rate by covering _____. It is most effective in _______.
preventing; high-risk HPV 16, 18; not yet infected (prior to sexual debut)
344
Describe the appearance of HPV genital warts
soft, fleshy growths with "cauliflower" apperance (narrow base, heaped up)
345
HPV gental warts Dx
based on clinical findings
acetic acid will usually turn them a whitish color
biopsy if uncertain
346
HPV genital warts Tx (patient applied)
```
Podofilox solution/gel
or
Imiquimod cream (Aldara)
- may weaken condoms/diaphragms
```
347
HPV genital wards Tx (provider administered)
Cryotherapy
Trichloroacetic acid (TCA): best for mucosal lesions
Surgical
348
T/F: HPV gental warts do not require follow up
True
349
Two most common GYN disorders in reproductive-age women
abnormal uterine bleeding
| amenorrhea
350
general phrase for bleeding at irregular, unpredictable intervals
Abnormal Uterine Bleeding
351
failure to ovulate
anovulation
352
less frequent ovulation
oligoovulation
353
heavy or prolonged menstrual flow
menorrhagia
354
intermenstrual bleeding
metrorrhagia
355
prolonged uterine bleeding occurring at irregular intervals
menometrorrhagia
356
bleeding more often than every 21 days
polymenorrhea
357
How is uterine bleeding classified? (FIGO standards)
pattern and etiology
| structural (PALM) and non-structural (COEIN)
358
Structural causes of AUB are:
PALM
Polyp
Adenomyosis
Leimyoma (submucosal or other)
Malignancy and hyperplasia
359
Non-structural causes of AUB are:
COEIN
```
Coagulopathy
Ovulatory dysfunction
Endometrial
Iatrogenic
Not yet classified
```
360
Women enter and exit reproductive lifespan similarly. Explain.
```
Amenorrhea >>
AUB, anovulatory periods >>
Ovulatory periods >>
AUB anovulatory periods >>
Amenorrhea
```
361
Explain how estrogen predominance causes AUB
Estrogen produced by adipose tissue
Lack of corpus luteum formation due to low P4
Unopposed estradiol stimulates the endometrium
Continuous proliferation that can cause:
- amenorrhea (no switch to luteal phase)
- necrosis and irregular sloughing from outgrowing the blood supply
- Menometrorrhagia
362
Other than estrogen predominance, what are 3 other etiologies that may cause AUB?
HPO axis dysfunction
oligo-ovulation
with ovulation
363
A cause of structural AUB: usually focal, benign hyperplastic process within the endometrium
endometrial polyps
364
Pathophys of endometrial polyps
ovary produces unopposed estrogen due to chronic anovulation, predominance of estrogen leads to overgrowth of the endometrium
365
Endometrial polyps are most common ____, so a Sx could be ______.
perimenopausal or "newly" postmenopausal; postmenopausal bleeding
366
Endometrial Polyp Tx
scheduled P4
| OCPs
367
A cause of structural AUB: islands of endometrium growing into myometrium
Adenomyosis
368
Pelvic exam of adenomyosis
"boggy" tender uterus
369
Adenomyosis Dx
clinical Dx of exclusion
| definitive by hystology only
370
Adenomyosis Tx
OCPs
| surgical
371
A cause of structural AUB: benign overgrowth of the myometrium
uterine fibroids
372
A woman with AUB describing a "heaviness" or "fullness" of her pelvic pain might have
fibroids
373
Uterine fibroids Dx
pelvic exam
pelvic US
both show irregularly enlarged uterus
374
Uterine fibroids Tx
GnRH agonist (Leuprolide)
Myomectomy
Hysterectomy
375
A cause of NON-structural AUB: caused by Von Willebrand's Dz, herbal remedies (ginseng, gingko, motherwort), anticoagulants (coumadin, heparin, aspirin)
coagulopathy
376
A cause of NON-structural AUB: due to endocrine d/o, thyroid disorder, hyperprolactinemia, DM, PCOS
ovulatory dysfunction
377
A cause of NON-structural AUB: due to OCPs, HRT, IUD, other meds
Iatrogenic
378
Amenorrhea definition
the absence of menstruation for at least 3-6 consecutive months
379
Oligomenorrhea definition
less frequent menstruation interval >35 days, but <3-6 months
380
Primary amenorrhea definition
never menstruated
381
Secondary amenorrhea
absence of menstruation (positive history of previous menstruation)
382
4 etiologies of amenorrhea to consider
1. pregnancy
2. HPO dysfunction
3. ovarian dysfunction
4. alteration of the genital outflow tract
383
EVERY WOMAN is ______ until proven otherwise.
pregnant
384
Amenorrhea can be due to HPO dysfunction when there is ______
disruption of pulsatile secretion of GnRH
385
Name some things that can cause HPO dysfunction with resulting amenorrhea
```
weight change
marijuana
pituitary adenoma
hypothyroidism
anxiety
chronic medical illness
```
386
Estrogen deficiency and androgen excess are signs of amenorrhea caused by _____.
ovarian dysfunction/failure
387
two types of ovarian dysfunction
premature ovarian failure
| ovarian follicles resistant to FSH/LH stimulation
388
alteration of the genital outflow tract can be due to these 2 things
1. congenital obstruction of the uterus, cervix, or vagina
| 2. scarring of endometrium (Asherman's syndrome)
389
4 routine tests for amenorrhea
pregnancy
prolactin
TSH
FAH/LH, estrogen/progesterone
390
If there is withdrawal bleeding on a progesterone challenge test, you know the patient has _____ (3), so amenorrhea must be due to either ____ or _____.
patent outflow tract, adequate estrogen, and functional endometrium
anovulatory, oligo-ovulatory
391
If patient does not have withdrawal bleeding on a progesterone challenge test, amenorrhea is due to ____ (2)
hypoestrogenic
or
genital outflow tract
392
two anovulatory/oligo-ovulatory conditions
1. pituitary adenoma: suppresses GnRH pulsatility, antiestrogenic effect on endometrium. Get MRI.
2. hypothyriodism
393
Androgen excess is idiopathic _____% of the time
50%
394
Pathologic etiology of androgen excess is most commonly due to:
PCOS
395
Hirsutism is defined as:
| and is due to:
excess of terminal hair in male pattern of distribution
increased androgens
396
Virilization is defined as:
| and is due to:
masculinization of a woman
increased testosterone
397
```
The adrenal glands produce most of our ____.
The ovaries produce most of our ____.
Extraglandular sites (adipose) produce most of our ____.
```
DHEA-S
Androstenedione
Testosterone
398
PCOS definition
anovulation/oligo-ovulation, increased androgen levels, and enlarged ovaries (>12 follicles)
399
Name some clinical features of PCOS
OBESITY
infertility
hirsutism/virilization/acne
menstrual irregularities
400
Patients with PCOS most commonly have _____ (bleeding pattern)
oligomenorrhea= amenorrhea with complaints of occasional, heavy menses
401
Name some possible etiologies of PCOS
obesity
androgen excess
estrogen excess
metabolic syndrome
402
Hypothesis about why hyperinsulinemia might cause PCOS
peripheral insulin resistance may cause increased insulin signaling in the ovary, leading to enhanced ovarian steroidgenesis
ovarian follicle development is arrested, annovulation results
403
5 lab tests to Dx PCOS
| PCOS panel
```
LH:FSH ratio (>2:1)
total/free testosterone (elevated)
DHEA-S (elevated)
Prolactin
TSH
```
***clinical eval and patient history are cornerstone of Dx though
404
PCOS ultimate Tx goal
suppress the source of androgen excess or block androgen action at receptor site
405
PCOS Tx
diet and exercise for ALL patients!
```
OCPs
cyclic progesterone withdrawal
clomiphene
metformin
spironolactone
```
406
What is the most frequent pelvic tumor? When do they usually come about?
Fibroids
| 5th decade of life
407
What's a fibroid?
a benign tumor of muscle cell origin
408
Each individual myoma is ______.
Monoclonal
409
Myomas have receptors for ______ and _____.
Estrogen; progesterone
410
What is the growth of myomas related to?
estrogen production... fibroids regress after menopause
411
Name the four types of myomas. How are they classified
Pedunculated, intramural, subserosal, submucosal
They're classified into subgroups by relationship to layers of the uterus
412
Describe the appearance of fibroids
glistening, pearl-white appearance with smooth muscle arranged in a whorled configuration
413
How is the blood supply to fibroids?
relatively poor.
| usually only have 1-2 arteries at the base
414
As fibroids grow, they outgrow the blood sypply and degenerate. How does this manifest in the patient?
severe pain and localized peritoneal irritation
415
How many myomas progress to malignancy?
<1%
416
MC presentation of fibroids
Most are asymptomatic, but menorrhagia is MC presentation
417
Fibroids on physical exam
Large, irregular hard palpable mass in the abdomen or pelvis during bimanual exam
418
Fibroids Dx
Pelvic US (focal heterogenic masses with shadowing)
Abnormal pelvic exam
419
Fibroids Tx (most)
Observation for most
420
Medical Fibroids Tx
inhibit estrogen
Leuprolide is most effective medical Tx (GnRH agonist that causes GnRH inhibition when given continuously)
GnRH antagonists
NSAIDs
Hormonal Therapy
421
Definitive Tx for Fibroids
Hysterectomy
422
Most common cause for hysterectomy
Fibroids
423
When would you perform a myomectomy (removal of JUST the fibroids) as treatment for fibroids?
to preserve fertility
424
Other, less common surgical treatments for fibroids?
endometrial ablation, artery embolization
425
3 most common conditions most frequently associated with hysterectomy
1. uterine leiomyomata
2. endometriosis
3. uterine prolapse
426
Most commonly used embolization particles in artery embolizations
polyvinyl alcohol
427
Artery embolization results in a ____% volume reduction
40%
428
________ is a complication of artery embolization that is due to reaction to contrast media resulting in necrosis, lasts 2-7 days, and causes cramping, pelvic pain, N/V, fever, malaise. Has VERY infrequently lead to PE, sepsis, ovarian cancer
Post embolization syndrome
429
____% of UAE patients will require an additional procedure. Although, UAE has shorter hospitalizations, reduced pain scores and quicker return to daily activity than hysterectomy initially.
25%
430
What type of fibroid is found centered in the muscular wall of the uterus?
Intramural
431
What type of fibroid is found beneath the uterine serosa (outer wall)?
Subserosal
432
Which types of fibroids are primarily associated with AUB & where are they located?
Submucosal; located within the endometrial cavity
433
Explain menopause physiologically
permanent termination of menses due to cessation of ovarian response to pituitary stimulation
434
Explain menopause clinically
no menses for >1 year with elevation of serum FSH levels
435
Average age of menopause?
| Normal range for menopause?
51 yo; 44-59 yo
436
premature menopause may occur in patients with/who...
DM
smoking
vegetarians
malnourishment
437
3 types of Sx in menopause
1. vasomotor
2. urogenital atrophy
3. psychological
438
Vasomotor Sx of menopause are triggered by _____.
estrogen withdrawal
439
Name some vasomotor Sx of menopause
```
hot flashes
night sweats
hair/skin/nail changes
mood changes
HLD
osteoporosis
CV events
```
440
Loss of elasticity of the vagina due to decreased mucosal blood flow is called...
urotenital atrophy
441
Name some urogenital atrophy Sx of menopause
```
irritation
pruritis
dryness
dyspareunia
gray discharge
bleeding
```
442
Name some psychologic Sx of menopause
```
fatigue
irritability
anxiety
memory loss ?
depression ?
```
443
Menopause Dx
FSH assay is most sensitive initial test!!
increased serum FSH >30IU/mL
444
What happens to the following three hormones in menopause (can be used for diagnosis):
FSH
LH
Estrogen
FSH increased
LH increased
Estrogen decreased
445
Menopause PE
decreased bone density, thin and dry skin, decreased skin elasticity, atrophied vagina
446
3 important complications of menopause due to loss of estrogen's protective effects
1. increased CV risk
2. increased osteoporosis
3. HLD
447
Tx for vasomotor Sx of menopause
estrogen therapy is #1 (95% relief)
Progestin (70% effective)
Antidepressants
Clonidine
Gabapentin
448
Tx for urogenital atrophy in menopause
transdermal/topical estrogen
449
3 options for hormone therapy in menopause
1. estrogen
2. combination estrogen/progestin
3. testosterone
450
Benefits of estrogen only HRT in menopause
- MOST effective symptomatic Tx (hot flashes, mood changes, vaginal atrophy)
- no increased risk of breast cancer
451
Risks of estrogen only HRT in menopause
- increased risk of endometrial cancer (SO, often used in patients s/p hysterectomy)
- THROMBOEMBOLISM
- liver Dz
452
Benefits of estrogen + progesterone HRT in menopause
- Protective against endometrial cancer (SO, often used in patients who still have a uterus)... progestin protects against the unopposed estrogen that may lead to endometrial cancer
- decreased symptoms, CV risk, osteoporosis, and dementia
453
Risks of estrogen + progesterone HRT in menopause
- venous thromboembolism
| - slightly increased risk of breast cancer??
454
Two options for frequency of HRT
continuous
| cyclic (pts will bleed almost like a normal period cycle)
455
Best advice for HRT
use the lowest dose for the shortest duration needed
456
decreased bone mineral density and loss of micro architecture in osteoporosis most frequently cause what two ortopedic injuries?
hip fracture and vertebral compression fractures
457
How to eval bone density in osteoporosis?
DEXA scan:
458
When to screen for osteoporosis?
65 years old per NOF
| Earlier, age 50, if RF other than menopause
459
Osteoporosis Tx (4 options)
Estrogen
Bisphosphonates
Raloxifene
Parathyroid hormone
460
Name some ways to prevent osteoporosis
```
Calcium
Vit D
Weight bearing exercise
Estrogen
Bisphosphonates
Raloxifene
Reduce RF
```
461
Breast cancer is primarily a malignancy of the _____.
milk ducts or lubules (which produce the milk)
462
4 components of breast tissue
1. adipose tissue
2. connective tissue
3. lobules (make milk)
4. ducts (transport milk)
463
Most breast tumors occur in what quadrant?
upper outer quadrant
464
blood supply to the lateral breast?
3rd, 4th, 5th intercostals
465
blood supply to the medial breast?
internal mammary perforators
466
blood supply to the lower breast?
thoracoacromial trunk
467
The central and peripheral breast drains into a what lymphatics?
into a large plexus below the areola that then drains into the axillary nodes
468
What is fibrocystic breast disorder?
a BENIGN breast disease
| = a fluid-filled breast cyst due to exaggerated response to hormones
469
what is the most common of ALL breast conditions?
fibrocystic breast disorder
470
How prevalent are fibrocystic breast changes?
affect 30-50% of postmenopausal women
471
Fibrocystic breast disorder S/S:
CYCLIC, bilateral engorgement and nodularity during menstrual cycles!!
PE: diffusely TTP, lumpy-bumpy breasts
472
Fibrocystic breast disorder Tx
supportive
473
Fibrocystic breast disorder Dx
US
Fine Needle Aspiration (FNA) reveals straw-colored fluid (no blood)
474
What is the second most common type of BENIGN breast disease?
fibroadenoma
475
What patients does fibroadenoma mostly effect?
Young women, teens-20s
476
Fibroadenoma S/S:
firm, mobile, well-defined, usually solitary lump in breast
DOES NOT wax and wane with menstruation
477
Fibroadenoma Tx
excision if >3cm (or clinical judgement)
observation for most
478
What's a fibroadenoma?
a BENIGN breast lump made of glandular and fibrous tissue (collagen arranged in swirls)
479
What's an Intraductal Papilloma?
a BENIGN tumor arising from the ducts
480
intraductal papilloma S/S:
NIPPLE DISCHARGE: bloody, serous, cloudy (MC cause of bloody, serous nipple discharge!!)
Non-palpable usually
481
intraductal papilloma Tx
Excision of atypical, symptomatic, or large lesions
482
What's a Phyllodes Tumor?
a (usually) BENIGN breast tumor
483
What does Phyllodes Tumor look like on biopsy?
fibro-epithelial lesions
484
Phyllodes tumor probably arise from _____.
intra-lobular stroma
485
What's the limit for benign, borderline, and malignant phyllodes tumors?
mitoses per HPF:
Benign: <4
Borderline: 4-9
Malignant: 10+
486
Phyllodes Tumor Tx
Excise with ample margin
Stage the malignant ones
Mets to: lung, mediastinum, bone
487
What is Mastitis?
inflammation of the breast. can be infectious or congestive
488
Breast Dz mostly seen in lactating women secondary to nipple trauma (especially primagravida)
infectous mastitis
489
Breast Dz of bilateral breast enlargement occuring usually 2-3 days postpartum
congestive mastitis
490
MC organism in mastitis infection
S.aureus
491
Tx for infectious mastitis
Bactrim, Clindamycin
Mothers should continue to breast feed
492
Compare/contrast S/S of infectious mastitis, congestive mastitis, and breast abscess
infectious mastitis: UNILATERAL breast pain, tenderness, warmth, swelling, nipple discharge
congestive mastitis: BILATERAL breast pain and swelling
breast abscess: induration with fluctuance. purulent.
493
Breast abscess Tx
I&D
| Discontinue breastfeeding from the affected breast
494
2 types of invasive breast cancer
Ductal (80%)
| Lobular (10%)
495
3 types of non-invasive breast cancer
ductal carcinoma in situ, lobular carcinoma in situ, Pagets
496
4 important tumor markers
ER
PR
Her2
Ki67
497
Name some risk factors for breast cancer
```
BRCA1 & BRCA2
AGE >40
1st degree relative with breast cancer
Menarche: <12 yo
>40 menstrual years
First live birth after 35 years old
Nulliparous
previous biopsy
Caucasian
Female
EtOH use (once per day)
```
498
Breast cancer staging:
T (tumor) - N (nodes) - M (mets)
499
Stage 0 breast cancer
precancerous, DCIS, LCIS
500
Stage I-III breast cancer
within breast/regional lymph nodes
501
Stave IV breast cancer
metastatic
502
MC CC of pts coming in with breast cancer
lump
503
breast cancer Sx
painless, hard, fixed breast mass (MC in upper outer quadrant)
unilateral nipple discharge (bloody, purulent, green)
504
breast cancer PE
ASYMMETRIC redness, discoloration, ulceration, skin retraction, nipple inversion, skin thickening, or changes in breast size/contour
505
Paget's disease of the nipple on PE
chronic eczematous, itchy, scaling rash on the nipples and areola (may ooze)
506
inflammatory breast cancer on PE
red, swollen, WARM, itchy breast
| often with nipple retraction, usually no lump
507
What is the term for skin changes that look like the peel of an orange? What are they due to? What does it mean for prognosis?
Peau d'orange; lymphatic destruction; poor prognosis
508
How to perform breast exam
inspect size, skin findings
palpate, start with axilla and hold arm
palpate mass location, size, qualities
509
4 tools for breast cancer Dx
1. mammogram
2. US
3. biopsy
4. MRI
510
What findings on mammogram are highly suspicious for malignancy?
microcalcifications and spiculated masses
511
what is the recommended initial modality to evaluate breast masses in patients >40 years old?
US
512
Mammogram screening recommendations (USPSTF, ACOG, ACS)
USPSTF: age 50-74 every 2 years
ACOG: age 40-49 every 1-2 years, age 50+ every year
ACS: age 40+ every year
513
3 important things about US in breast cancer Dx
1. it's adjunct for mammogram
2. solid vs. cystic
3. better study for younger, denser breasts
514
When do you use a mammogram for breast cancer Dx?
adjunct study for high risk patients
515
Recommendations for clinical breast exams as part of screening
age 20-39: every 3 years
| age 40+: every year
516
When should patients perform self breast exams?
every month starting at age 20
should be done immediately after menstruation or on days 5-7 of menstrual cycle...less fluid retention and hormonal influence at this time
517
All discrete, palpable, suspicious masses should be _____ and _____!!!!
imaged; biopsied
518
primary breast cancer Tx (3)
1. lumpectomy (followed by radiation therapy)
2. mastectomy
3. removal of regional (axillary) lymph nodes to determine if METs present
519
When is radiation therapy used as adjunctive breast cancer treatment?
- after lumpectomy
| - maybe after mastectomy to destroy residual microscopic tumor cells
520
When is chemotherapy used as adjunctive breast cancer treatment?
stage II-IV breast cancer and inoperable disease (esp ER negative)
521
What types of breast tumors benefit from neoadjuvant endocrine therapy (3)
Estrogen receptor positive
Progesterone receptor
HER2 positive
522
What neoadjuvant endocrine therapy would be used for ER (+) tumors?
Tamoxifen: anti-estrogen, binds and blocks receptor in breast tissue
(ER positive tumors are dependent on estrogen for growth)
523
What neoadjuvant endocrine therapy would be used for postmenopausal patients with an ER (+) tumor?
Letrozole, Anastrozole: reduces the production of estrogen
524
What neoadjuvant endocrine therapy would be useful against HER2 (human epidermal growth factor receptor) positive tumors?
Trastuzumab (Herceptin): Monoclonal Ab Tx, HER 2 receptors stimulate cancer growth and are associated with more aggressive tumors
525
What 2 agents can be used for prevention in high-risk patients?
Tamoxifen or Raloxifene
**for postmenopausal women or women >35 years old with high risk
usually used for 5 years
