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BCM > Women's Health 1 > Flashcards

Women's Health 1 Flashcards

1
Q

Ovulation is associated with a spike in what hormone?

A

Luteinizing Hormone (LH)

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2
Q

What hormone is predominant in the follicular phase?

A

Estradiol

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3
Q

What hormone is predominant in the luteal phase?

A

Progesterone

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4
Q

Two anterior pituitary hormones (gonadotropins) associated with the menstrual cycle

A
  1. Luteinizing Hormone (LH)

2. Follicle-Stimulating Hormone (FSH)

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5
Q

Two ovarian hormones associated with the menstrual cycle

A
  1. Estradiol

2. Progesterone

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6
Q

Two phases of the ovarian cycle

A
  1. Folicular phase (preovulatory)

2. Luteal phase (postovulatory)

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7
Q

Three phases of the uterine cycle

A
  1. Menses
  2. Proliferative phase
  3. Secretory phase
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8
Q

Three purposes of the menstrual cycle

A
  1. produce an oocyte for possible fertilization
  2. prepare the uterus for pregnancy
  3. if no pregnancy, menses occurs and the cycle starts over
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9
Q

What is menses?

A

shedding of the uterine mucosa

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10
Q

How long does menses last?

A

3-7 days

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11
Q

How much blood is lost during menses?

A

20-60 ml

one R tampon holds 5 ml

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12
Q

What’s the definition of LMP?

A

the first day of bleeding

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13
Q

Average age for menarche

A

12 years old

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14
Q

Average age for menopause

A

51

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15
Q

Average duration of the menstrual cycle

A

28 (anywhere from 21-35 days)

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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

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17
Q

How long do perimenopause symptoms last?

A

3-10 years before menopause

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18
Q

Definition of menopause

A

no bleeding for ONE WHOLE YEAR

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19
Q

On what day in the menstrual cycle does ovulation occur?

A

day 14

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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
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21
Q

Job of FSH

A

develops the follicles

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22
Q

Job of LH

A

ovulation

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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)

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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
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25
Q

Explain the mid-follicular phase

A
  • Folliculogenesis continues. This causes estrogen levels to INCREASE, which produces negative feedback on FSH & LH.
  • The uterine lining is thickening (proliferative phase)
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26
Q

Explain the late follicular phase

A
  • Dominant follicle exists. Estrogen predominates and triggers an LH surge!!
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27
Q

Explain the ovulation phase

A

LH surge&raquo_space; LH Peak&raquo_space; Oocyte released from dominant follicle&raquo_space; oocyte travels into the fallopian tube for possible fertilization

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28
Q

How long before ovulation does LH surge begin?

A

36 hours

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29
Q

How long before ovulation does LH peak occur?

A

~12 hours

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30
Q

Some women feel a twinge of pain during ovulation, what’s it called?

A

Mittelschmerz

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31
Q

Explain the luteal phase

A
  • 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)
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32
Q

What hormone does the corpus luteum produce?

A

progesterone (P4)

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33
Q

Lifespan of the corpus luteum

A

9-11 days

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34
Q

What happens to the corpus luteum if there is no fertilization?

A

sharp decline in P4, which induces menses

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35
Q

What happens to the corpus luteum if fertilization occurs?

A

implanted zygote will secrete hCG, which sustains the corpus luteum for 6-7 more weeks

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36
Q

Definition of puberty

A

physical and sexual transition from childhood to adulthood

series of well-defined events and milestones representing secondary sexual maturation

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37
Q

Activation of adrenal androgen production

A

Adrenarche

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38
Q

Activation of ovaries

A

Gonadarche

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39
Q

Breast development onset

A

Thelarche

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40
Q

Pubic hair development onset

A

Pubarche

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41
Q

Onset of menses

A

Menarche

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42
Q

Put the puberty events in order or observation from earliest to latest

A 
Adrenarche
Gonadarche
Thelarche
Pubarche
Menarche
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43
Q

The Hypothalamic-Pituitary-Adrenal Axis is responsible for development of 3 things:

A
  1. hair
  2. acne
  3. body odor
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44
Q

At what age does the HPA Axis begin to produce increased amounts of androgens?

A

6-8 years

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45
Q

What hormone is secreted by the HPA axis?

A

DHEA

DHEA is converted to testosterone and dihydrotestosterone

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46
Q

The Hypothalamic-Pituitary-Ovarian Axis is responsible for 2 things:

A
  1. ovarian production of estrogen and progesterone

2. Breast development

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47
Q

When is the HPO Axis functioning?

A

in utero until after newborn phase… resumes activity during puberty

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48
Q

How long does normal pubertal development take?

A

4 years

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49
Q

Order/sequence of the 4 major pubertal events

A
  1. Breast budding
  2. Sexual hair growth
  3. Growth spurt
  4. Menarche
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50
Q

At what age do the 4 major pubertal events occur?

A
  1. Breast budding: 10-11
  2. Sexual hair growth: 10.5-11.5
  3. Growth spurt: 11-12
  4. Menarche: 11.5-13
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51
Q

What are the major hormones associated with each of the 4 major pubertal events?

A
  1. Breast budding: Estradiol
  2. Sexual hair growth: Androgens
  3. Growth spurt: Growth hormone
  4. Menarche: Estradiol
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52
Q

What is the average age of menarche in the US?

A

12

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53
Q

Early and late timing of secondary sex characteristics

A

Early: before age 7-8

Late: not apparent by age 13

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54
Q

Abnormal age of menarche

A

No evidence of menarche by age 15-16
OR
No menses within 5 years of thelarche

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55
Q

Onset of secondary sex characteristics around or prior to age 6 (AA) or 7 (Caucasian)

A

Precocious puberty

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56
Q

Etiology of precocious puberty

A

Early sex hormone production (GnRH dependent or independent)

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57
Q

GnRH dependent precocious puberty is due to..

A

early activation of the HPO or HPA axes

idiopathic
CNS infection
inflammation
injury 
neoplasm
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58
Q

GnRH independent precocious puberty is due to…

A

end organ disorders (ovary or adrenal glands)

tumors
cysts
exogenous
mutations

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59
Q

Which precocious puberty is “central” and which is “peripheral”

A

GnRH dependent= central

GnRH independent= peripheral

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60
Q

How to differentiate between central and peripheral precocious puberty

A

central: increased LH
peripheral: increased androgens

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61
Q

Treatment goals of precocious puberty

A
  1. arrest sexual maturation until normal pubertal age

2. maximize adult height

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62
Q

Definition of delayed puberty

A
  • Secondary sex characteristics not apparent by age 13
  • No evidence of menarche by age 15-16
  • No menses within 5 years of thelarche
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63
Q

Etiology of delayed puberty

A
  • Endocrine (HPO Axis)

- Anatomic

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64
Q

Two causes of delayed puberty due to HPO Axis:

A
  1. HYPERgonadotropic HYPOgonadism (Turner Syndrome)

2. HYPOgonadotropic HYPOgonadism

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65
Q

FSH levels in HYPERgonadotropic HYPOgonadism

A

> 30mlU/ml

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66
Q

What is happening in HYPERgonadotropic HYPOgonadism?

A

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

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67
Q

Treatment for Turner Syndrome (46X)

A

Induce secondary sexual maturation: Estrogen therapy

Maximize adult height

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68
Q

FSH/LH levels in HYPOgonadotropic HYPOgonadism

A

FSH + LH = <10 mlU/mL

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69
Q

Definition of HYPOgonadotropic HYPOgonadism

A

disruption between hypothalamus and pituitary

GnRH stimulation is decreased

Lower than expected levels of FSH, LH

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70
Q

Etiologies of HYPOgonadotropic HYPOgonadism

A
  • Constitutional (physiologic) delay
  • Kallmann Syndrome
  • Anorexia, extreme exercise
  • Pituitary tumors/disorders, hyperprolactinemia
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71
Q

Three types of anatomic delayed puberty

A
  1. Mullerian agenesis
  2. Imperforate hymen
  3. Transverse vaginal septum
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72
Q

What is happening in Mullerian agenesis?`

A

Congenital absence of upper vagina (uterus, tubes)

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73
Q

How isovarian function in Mullerian agenesis affected?

A

ovarian function is normal

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74
Q

What is observed in Mullerian ageneiss?

A
  • Primary amenorrhea

- normal breast development

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75
Q

What is happening in imperforate hymen?

A

genital plate canalization is incomplete, obstructs the outflow of menses

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76
Q

What do you think if you observe a patient with pain, bulging, bluish appearing introitus?

A

Imperforate hymen

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77
Q

What is happening in transverse vaginal septum?

A

Occurs at any level of the vagina and obstructs the outflow of menses

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78
Q

menorrhagia

A

excessive bleeding

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79
Q

metrorrhagia

A

bleeding outside/between menses

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80
Q

Menometrorrhagia

A

Excessive bleeding outside/between menses

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81
Q

Postcoital bleeding

A

bleeding after intercourse

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82
Q

Dysmenorrhea

A

Painful bleeding

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83
Q

Postmenopausal bleeding

A

ANY amount of bleeding after diagnosis of menopause

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84
Q

How to document reproductive history

A

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

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85
Q

How to document a woman who has 4 pregnancies- 1 term, 2 preterm, 1 first trimester spontaneous abortion, 3 living children

A

G4P1-2-1-3

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86
Q

“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.

A

G7P2-2-2-3

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87
Q

How to document reproductive history using the GPA system

A

G: # of pregnancies
P: pregnancies reaching viability (20 weeks)
A: pregnancies NOT reaching viability (abortions)

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88
Q

Why is age of menarche important in the PMHx?

A

women who start their periods younger have increased estrogen exposure, therefore increased risk of cancer

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89
Q

What’s important to include when documenting GYN surgeries/proceures

A

Indication

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90
Q

What’s the definition of sexually active

A

sex within the last 3 months

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91
Q

Only method to protect against STI

A

condoms

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92
Q

Three types of delivery

A
  1. spontaneous vaginal delivery
  2. Cesarean section
  3. vaginal birth after cesarean
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93
Q

When to address infertility

A

Patient <35 years old: trying for >1 year

Patient >35 years old: trying for 6 months

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94
Q

What to ask about prevention/screening (3)

A

for each test:

  1. frequency
  2. outcome
  3. treatment
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95
Q

Breast exams: when do you start and how often do you do them?

A

Start: 21 years old

Frequency: every 1-3 years

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96
Q

3 positions of breast exam inspection

A
  1. arms at sides
  2. armes pressed at hips
  3. arms raised overhead
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97
Q

5 things to look for on inspection during breast exam

A
  1. asymmetry
  2. Dimpling
  3. Discoloration/rash
  4. Nipple retraction
  5. Nipple discharge
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98
Q

How to document a breast mass

A

include:

  • distance from areola
  • diameter of mass
  • position on clock (ex: 1 o’clock)
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99
Q

What is “Breast self awareness”

A

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

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100
Q

Steps of the pelvic exam

A
  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
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101
Q

All the things you palpate during the normal bimanual exam

A

Cervix
Uterus
Adenexa

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102
Q

Size of a premenopausal ovary

A

1x2x3 cm

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103
Q

Size of a postmenopausal ovary

A

usually not palpable

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104
Q

Why would you do a rectovaginal bimanual exam?

A

Guiac
Retroverted/retroflexed uterus
Posterior mass suspicion

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105
Q

Most common imaging in OB/GYN

A

ultrasonography

abominal or transvaginal

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106
Q

Indications for ultrasonography

A
  • diagnosis of pelvic masses
  • evaluate postmenopausal bleeding
  • pregnancy diagnosis
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107
Q

indications for hysterosalpingography

A
  • fallopian tube patency
  • endometrial polyps
  • myoma
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108
Q

How does hysterosalpingography work?

A

contrast medium inserted through cervix, followed by fluoroscopic observations/film

Allows to see uterine cavity and fallopian tubes

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109
Q

How does sonohysterography work?

A

uterine cavity filled with saline, US used to view endometrial cavity

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110
Q

Indications for sonohysterography

A

Diagnosis of intrauterine abnormalities (ex: polyps)

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111
Q

What type of biopsy would you perform on the vulva? Why?

A

punch biopsy

Ind: Eval visible lesions, persistent pruritis, burning and pain

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112
Q

What type of biopsy would you perform on the vagina? Why?

A

pinch forceps biopsy

Ind: suspicious masses

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113
Q

What type of biopsy would you perform on the cervix? Why?

A

colposcopy (directed biopsy with forceps)

ind: eval abnormal pap results, chronic cervicitis

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114
Q

What type of biopsy would you perform on the endometrium? why?

A

Small diameter suction catheter

Ind: eval abnormal uterine bleeding

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115
Q

What is a colposcopy?

A

allows for illuminated, magnified view of the cervix via binocular microscope

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116
Q

When to do a colposcopy

A

To further eval abnormal PAP results. While you’re in there, you’ll:

  • get biopsy
  • endocervical curettage
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117
Q

Tx for abnormal colposcopy?

A

Loop Electrosurgical Excision Procedure (LEEP)

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118
Q

How does LEEP work?

A

uses low-voltage, high frequency alternating current that limits thermal damage, but at the same time has good hemostatic properties

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119
Q

What do you use LEEP for?

A

excision of cervical dysplasias and cone biopsies of the cervix

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120
Q

What is hysteroscopy and when do you use it?

A

visual exam of the uterine cavity through fiberoptic instrument (hysteroscopy)

Ind: visualize polyps, adhesions, myoma

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121
Q

How do we inflate the abdomen for laparoscopy?

A

Fill with CO2 through umbillicus

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122
Q

indications for laparoscopy

diagnostic and therapeutic

A
  • uterine fibroids
  • structural abnormalities of uterus
  • endometriosis
  • ovarian cysts
  • adhesions
  • sterilization
  • hysterectomy
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123
Q

Indication for endometrial ablation

A

treat abnormal uterine bleeding

not considered sterilization

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124
Q

What is dilation and curettage?

A

dilation of the cervix followed by curettage (scraping) of the endometrium

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125
Q

indications for D&C?

diagnostic and therapeutic

A
  • abnormal uterine bleeding
  • incomplete abortion
  • endometrial biopsy
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126
Q

Hysterectomy

A

surgical removal of the UTERUS

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127
Q

Total hysterectomy

A

removal of entire uterus (includes cervix)

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128
Q

Supracervical hysterectomy

A

removal of the uterine corpus only (cervix is left behind)

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129
Q

salpingo-oophorectomy

A

Salpingo: tubes
oophor: ovaries

May be bilateral or unilateral
May or may not be included in a hysterectomy (must ask)

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130
Q

How many pregnancies in the US are unintended?

A

45%

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131
Q

How many in the US use contraception?

A

77%

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132
Q

what percent of unintended pregnancies end in terminatino?

A

43%

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133
Q

4 things to take into account when considering contraceptive options

A
  1. risk factors/tolerability
  2. personal preferences
  3. medical history
  4. permanent sterilization regret
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134
Q

Why is it important to ask about previous birth control methods?

A

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

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135
Q

Two most important things to keep in mind when choosing a method of contraception

A
  1. Risk factors

2. Reproductive desires (TIMING)

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136
Q

4 types of birth control

A
  1. Sterilization (surgical)
  2. Hormonal (pill, patch, injection, ring)
  3. Non-hormonal (iud, barrier)
  4. Post-coital
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137
Q

LARC

A

long acting reversible contraceptive

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138
Q

SARC

A

short acting reversible contraceptive

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139
Q 
List the following from most to least effective: 
barrier methods
hormonal methods
natural methods
no method
sterilization
intrauterine devices
implants
A 
sterilization
implant
intrauterine devices
hormonal methods
barrier methods
natural methods
no method
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140
Q

Most effective

A 
sterilization
Cu-IUD
LNG-IUD
implant
DMPA injection
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141
Q

Effective

A

oOCPs
patch/ring
POPs

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142
Q

Least effective

A

Barrier methods

NFP

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143
Q

Most frequently used sterilization method in US

A

sterilization

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144
Q

When performing surgical sterilization, you counsel and document patient understanding of 3 things:

A

permanence
operative risks
chance of pregnancy

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145
Q

Describe vasectomy MOA

A

ligation of vas deference

prevents passage of sperm into ejeculate

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146
Q

10 weeks, postop from vasectomy, what do you gotta do?

A

confirmation by semen analysis

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147
Q

Describe bilateral tubal ligation MOA

A

permanent occlusion of the fallopian tubes by electrocautery, ring, or clip

prevents passage of the egg through the tubes

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148
Q

How does BTL affect woman’s risks?

A

decreased risk of ovarian cancer

if pregnancy does occur, increased risk of ectopic pregnancy

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149
Q

Failure rates of homonal birth control

A

<1-9% depending on type/method used

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150
Q

What forms does combination estrogen + progestin come in?

A

pills
patch
ring

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151
Q

What forms does progestin only birth control come in?

A

pills
injections
implants
intrauterine device

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152
Q

7 physiological effects of estrogen

A
  • 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
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153
Q

Contraindications for estrogen therapy

A
  • 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
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154
Q

Contraindications for progestin therapy

A
  • 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
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155
Q

combo oral contraception pills MOA:

A

suppression of GnRH releasing factors

  • suppresses FSH, which reduces follicule maturation
  • suppresses LH, which prevents ovulation
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156
Q

Role of progestin in MOA of combo oral contraception pills

A

Has MAJOR contraceptive effect

  • prevents ovulation
  • thickens the cervical mucous, which prevents sperm migration
  • produces atrophic endometrium, which is less suitable for implantation
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157
Q

Role of estrogen in MOA of combo oral contraception pills

A
  • potentiates the effects of progesterone and suppresses FSH

- added benefit: stabilizes the endometrium, which means LESS BREAK THROUGH BLEEDING

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158
Q

Monophasic oOCPs

A
  • standard estrogen dose (30-35mg)

- “tradiational regimen”: 3 weeks of active pills followed by one placebo week

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159
Q

Triphasic oOCPs

A
  • dosage of either estrogen or progestin varies weekly
  • “mimics” normal cycle
  • slightly less hormone exposure monthly
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160
Q

Who should have low estrogen dosage? (<20 mg)

A

perimenopausal women

smokers <35 years old

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161
Q

Extended regimen oOCPs

A
  • 11 weeks of active pills followed by one placebo week

- 4 scheduled withdrawal bleeds per year

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162
Q

Vaginal ring MOA:

A

same as combo OCPs

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163
Q

S/E of vaginal rings

A

leukorrhea, vaginal discomfort

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164
Q

What to counsel patients on with vaginal rings:

A

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

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165
Q

Contraceptive patch MOA

A

same as OCPs and ring

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166
Q

Things to think about

A

decreased efficacy for women >198 lbs

potential for skin irritation

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167
Q

Directions for contraceptive patch

A
  • place on e patch on skin for one week
  • alternate patch locatino each week for 3 weeks
  • one week “off” patch for withdrawal bleed
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168
Q

Indications for progestin only methods

A
  • breastfeeding
  • women >40
  • patients with estrogen use contraindications
  • patients with compliance issues (injection, IUDs, implants)
  • reduces risk of endometrial cancer
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169
Q

Progestin only pill MOA

A
  • thickens cervical mucous (prevents sperm migration)
  • thins endometrium
  • MAY inhibit ovulation
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170
Q

Most important thing about taking progestin only pills

A

MUST TAKE AT SAME TIME EVERY DAY

if >3 hours late, must use back up contraception

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171
Q

Progestin injections MOA

A
  • thickens cervical mucous (prohibits sperm mobiliy)
  • decidualization of the endometrial lining (poor implantation)
  • blocks LH surge (prevents ovulation)
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172
Q

Method for progestin injections

A
  • IM injection every 3 months (maintains contraception for 14 weeks)
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173
Q

Considerations for progestin injections

A

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

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174
Q

S/E of progestin injection

A

lots.

WEIGHT GAIN (~10lbs)

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175
Q

Progestin implant MOA:

A
  • thickening of the cervical mucous

- suppresses LH surge (inhibits ovulation)

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176
Q

How long does progestin implant last?

A

3 years

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177
Q

S/E of progestin implant

A

irregular bleeding, may achieve amenorrhea

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178
Q

Progestin only IUDs MOA

LNG-IUD

A
  • foreign body effect causes inflammatory response
  • thickens cervical mucous
  • thins the endometrial lining
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179
Q

Copper IUD MOA:

A
  • foreign body serile inflammatory effect

- spermicidal: inhibits sperm motility and reaction necessary for fertilization

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180
Q

Lifespan for copper IUD

A

10 years

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181
Q

CI for copper IUD

A

history of menorrhagia, dysmenorrhea

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182
Q

3 barrier methods

A

condoms
spermicides
diaphragm

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183
Q

Emergency contraception must be used how quickly?

A

within 72 hours

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184
Q

MOA of emergency contraception (Plan B pill)

A

delays/inhibits ovulation and prevents fertilization

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185
Q

Most effective form of emergency contraception

A

copper IUD

can be inserted up to 5 days after intercourse

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186
Q

What is vulvovaginitis?

A

disorders cauesed by infection, inflammation, or changes in the normal vaginal flora

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187
Q

3 most common organisms causing vaginal symptoms

A

BV
Trich
Candida

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188
Q

Name some less common causes of vaginal symptoms

A 
atrophic vaginitis
FB
irritants/allergens
Cervicitis
STIs
Vulvar dermatoses
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189
Q

Common vaginal presenting symptoms (patient usually comes in with >1)

A 
Change in vaginal discharge (color, odor, volume)
Pruritus
Burning/discomfort
Irritation
Swelling 
Erythema
Spotting
Dyspareunia
Dysuria
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190
Q

Name the three elements of the vulvovaginal ecosystem that work together to create the environment

A

Microflora
Host estrogen
Vaginal pH

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191
Q

What is the predominant bacteria in the vagina?

A

Lactobacilli

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192
Q

What is normal vaginal pH?

A

3.5-4.7

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193
Q

Disruptions in the vaginal ecosystem lead to…

A

vaginitis

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194
Q

Name some factors that affect the vaginal ecosystem

A 
Abx
FB (condom, tampons)
Hormones (pregnancy, contraceptives, phases of menstrual cycle)
Douches, Hygienic products
Sex
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195
Q

Describe normal vaginal secretions

A

white/transparent
thick or thin
NO ODOR

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196
Q

What is physiologic leukorrhea?

A

the normal volume of vaginal discharge increases during pregnancy and mid-cycle

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197
Q

T/F: itching, pain, irritation, mucosal friability are sometimes normal vaginal symptoms depending on the situation

A

False

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198
Q

3 things to do in the evaluation of a patient with vaginal Sx

A
  1. History
  2. PE
  3. Test for BV, Candida, Trich….Move on to less common causes after ruling out these three
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199
Q

3 diagnostic tools for vulvovaginitis

A

Vaginal pH
Microscopy
Amine testing

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200
Q

How is vaginal pH tested

A

pH test strip applied to the vaginal wall

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201
Q

How is microscopy performed to Dx vulvovaginitis?

A
  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
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202
Q

What do you do if you don’t have a microscope or microscopy is inconclusive

A

Culture
or
DNA amplification tests/NAAT

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203
Q

What’s the triple threat of vulvovaginitis?

A

BV, Trich, and Candidiasis often happen together

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204
Q

What is the most common cause of vaginitis?

A

BV: Bacterial Vaginosis (not an inflammatory condition… it’s a disturbance of the ecosystem rather than a true infection of tissues)

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205
Q

Etiology of bacterial vaginosis

A

a reduction in lactobacilli and an increase in pH….

leads to a polymicrobial infection (Gardnerella vaginalis is most prominent)

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206
Q

Risk factors for BV

A

Sexual activity
Douching
Cigarette smoking

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207
Q

Protective factors for BV

A

Condoms

Estrogen-containing OCP

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208
Q

Sequelae of BV

A

Preterm delivery

Risk factor for STI acquisition/transmission

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209
Q

S/S of BV

A 
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
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210
Q

Dx of BV

A

3/4 of the Amsel Criteria

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211
Q

Amsel Criteria for Dx BV

A
  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
Q

What’s gold standard for Dx of BV?

A

Gram stain

213
Q

Should you culture BV?

A

No. There’s no way to quantify a culture

214
Q

Amsel Criteria with the least specificity

A

Abnormal discharge

215
Q

Amsel Criteria that’s the most reliable predictor

A

Presence of clue cells

216
Q

3 options for Tx of BV

A
  1. Oral Metronidazole
  2. Metronidazole gel
  3. Clindamycin (topical)
217
Q

Caution for Metronidazole

A

DO NOT DRINK EtOH

218
Q

2nd most common cause of vaginal infections

A

Vaginal Candidiasis

219
Q

Is Vaginal Candidiasis sexually transmitted?

A

No

220
Q

Primary organism in Vaginal Candidiasis

A

Candida albicans

221
Q

Etiology of Vaginal Candidiasis

A

Overgrowth of Candida&raquo_space; increased penetration of superficial epithelial cells&raquo_space; compromised host immunity&raquo_space; enhanced estrogen state&raquo_space; HOST INFLAMMATORY RESPONSE

222
Q

Risk factors for Vaginal Candidiasis

A 
DM
Abx use
Immunosuppression
Increased estrogen levels
Tight, poorly ventilated clothing
223
Q

Sx of Vaginal Candidiasis

A

PRURITUS
Vaginal soreness/irritation, burning, dyspareunia, external dysuria

Usually no odor associated

224
Q

Vaginal Candidiasis PE

A

ERYTHEMA of labia/vulva and vagina
Normal cervix
Adherent, whitish discharge… usually clumpy or COTTAGE CHEESE-like

225
Q

Dx of Vaginal Candidiasis

A

Microscopy (KOH prep most sensitive) showing :
Hyphae and buds

Normal pH of 4-4.5

226
Q

Tx for uncomplicated Vaginal Candidiasis

A

Topical imidazoles
or
PO Fluconazole

227
Q

Tx for complicated Vaginal Candidiasis

A

Extend topicals for 7-14 days

Increase PO Fluconazole to 3 doses instead of 1

228
Q

Tx for recurrent Vaginal Candidiasis

A

Once weekly dose of oral Fluconazole for 6 months

229
Q

Most common non-viral STI worldwide

A

Trichomoniasis

230
Q

Trichomoniasis is associated with _____, so you _____ when they have it.

A
  1. co-infection with other STIs

2. test for other STIs

231
Q

Transmission of Trichomoniasis

A

Sexually transmitted

232
Q

Trichomoniasis organism

A

Tricomonas vaginalis

233
Q

Trichomonas vaginalis lives in the _____, so it’ll produce _____.

A
  1. vagina, urethra, paraurethral glands

2. UTI symptoms

234
Q

Describe the trichomonas vaginalis organism

A

Flagellated protozoan

235
Q

Sx of Trichomoniasis

A

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
Q

Trichomoniasis PE

A
  • 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
Q

Trichomoniasis Dx

A

Microscopy (NS wet prep) shows ovoid, MOTILE parasites (they have flagella)

Vaginal pH >4.5
Bacterial increase the pH

238
Q

Trichomoniasis Tx

A
  • 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
Q

Etiology of Atrophic Vaginitis

A

Reduced estrogen levels

Menopause, other hypoestrogenic states

240
Q

Atrophic Vaginitis Sx

A

Dryness, burning, pruritus, discharge, bleeding, dyspareunia, UTI symptoms

241
Q

Atrophic Vaginitis PE

A
  • Smooth, pale, shiny vulvar skin
  • Loss of elasticity and rugae
  • Thinning of the skin/mucosa
  • Narrowing of the introitus
  • Discharge
242
Q

Atrophic Vaginitis Dx

A

CLINICAL

pH >5.5 + PE findings

pH is elevated because estrogen levels are decreased so much

243
Q

Atrophic Vaginitis Tx

A

Vaginal moisturizers, lubricants

Topical low-dose estrogen

244
Q

How many new STI cases occur every year?

A

15-20 million

245
Q

How many people live with an incurable STI?

A

65+ million

246
Q

T/F: Reportable STIs are almost always reported.

A

False. Reportable STIs are often diagnosed, but not reported.

247
Q

Young people age 15-24 make up ____% of new sexually transmitted infections.

A

50%

248
Q

What are the CDC’s 5 major strategies for prevention and control of STIs?

A
  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
Q

Which STIs are reportable in every state? (5)

A 
syphilis
gonorrhea
chlamydia
chancroid
HIV/AIDS
250
Q

STIs of concern with DISCHARGE (“drips”):

A

Gonorrhea
Chlamydia

Other: Trichomonas (vaginitis, urethritis), BV (sexually associated), Candidiasis (not STI)

251
Q

STIs of concern with ULCERS & LESIONS (“sores”):

A 
Syphilis
Genital herpes (HSV2, HSV1)

Other: Chanroid, Granuloma inguinale, Lymphogranuloma

252
Q

Other major STI concern that is not a “drip” or “sore” is….

A

genital HIV: cervical, oral, anal cancer

253
Q

Describe the Neisseria gonorrhoeae organism

A

Gram (-) diplococci

254
Q

Gonorrhea is most common in what age group?

A

15-29

255
Q

Gonorrhea causes what type of infection/what does it mostly affect?

A

mucopurulent cervicitis/urethritis

256
Q

What is the second most commonly reported STI among women/men in the US?

A

Gonorrhea

257
Q

Gonorrhea transmission

A

UNPROTECTED oral, vaginal, and anal sexual contact

PS: penetration and ejaculation is not required (pts need to know this)

258
Q

Gonorrhea incubation period

A

3-5 days

259
Q

Most of the time, women with Gonorrhea have what symptoms?

A

Asymptomatic

260
Q

If women have symptoms with gonorrhea, what are some of them?

A 
MUCOPURULENT discharge
dysuria
post-coital vaginal bleeding or bleeding in between periods
abdominal pain
dyspareunia
261
Q

MALE symptoms of gonorrhea

A

Thick, yellow-green discharge
dysuria
testicular pain
rectal pain/discharge/pruritus

262
Q

Gonorrhea and chlamydia are associated with increased risk of contracting and transmitting ___.

A

HIV

263
Q

List a few complications of gonorrhea

A

Female: PID
Male: infertility (rare)
Both: disseminated gonococcal infection

264
Q

Disseminated gonococcal infection manifests as:

A 
small pustular lesions on the skin
fever
painful joints
exquisitely tender necrotic pustules
purulent arthritis
265
Q

Gold standard Dx of gonorrhea

A

Nucleic Acid Amplification Test (NAAT)

  • swab or urine
266
Q

If gonococcal infection is resistant, you should…

A

culture to determine susceptibility

267
Q

Who should be screened for gonorrhea?

A

all sexually active women <25 years old

women with high risk behaviors >25 years old

268
Q

Gonorrhea Tx

A

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
Q

2 special notes about Gonorrhea/Chlamydia Tx and F/U?

A

Notify and treat all partners within last 60 days!

ABSTINENCE during treatment!! for all 7 days OR for 7 days following single dose

270
Q

If gonorrhea/chlamydia symptoms continue 2 weeks after Tx, what do you do? 3 months?

A

2 weeks: consider Test of Cure (TOC)

3 months: always RETEST

271
Q

If a pregnant woman with gonorrhea goes untreated, the baby can develop _____ that leads to _______.

A

eye infection, blindness

272
Q

T/F: Gonorrhea and Chlamydia are linked to miscarriages, premature birth, and premature rupture of membranes

A

True

273
Q

If pregnant woman is Dx with gonorrhea, do NOT give _____.

A

Doxycycline

274
Q

Describe the organism of Chlamydia trachomatis

A

Non-gonococcal

275
Q

What does the organism of Chlamydia cause?

A

Mucopurulent cervicitis/urethritis

276
Q

What is the most commonly reported STI in the US?

A

Chlamydia

277
Q

What age group is chlamydia most common in?

A

15-24 years old

278
Q

Do more men or women get chlamydia?

A

Women

279
Q

Chlamydia transmission

A

UNPROTECTED oral, vaginal, anal sexual contact with infected partner

**Penetration and ejaculation not required

280
Q

____% of patients with chlamydia are asymptomatic. If they do have symptoms, they occur _____ days after exposure

A

85%

7-14 days

281
Q

S/S of Chlamydia

A

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
Q

Complications of Chlamydia

A

Female: PID

Male: infertility

Both: Reactive Arthritis!! (eye disorders + rashes/sores/joint pain)

283
Q

Gold standard for Chlamydia Dx

A

Nucleic Acid Amplification Test (NAAT)

284
Q

Who should be screened for Chlamydia?

A

All sexually active women <25 years old

Women >25 years old with high risk factors

285
Q

Chlamydia Tx

A

Azithromycin 1mg PO as single dose
OR
Doxycycline 100mg BID x 7 days

Tx for gonorrhea too if index of suspicion is high

286
Q

If a pregnant woman has chlamydia, the baby will likely contract ______ during birth

A

lung and eye infections!!

287
Q

Pregnancy chlamydia Tx options (3)

A

Erythromycin, Azithromycin, Amoxicillin

***Consult ID for Gonorrhea pregnancy Tx

288
Q

What is defined as a spectrum of inflammatory disorders of the upper female genital tract?

A

Pelvic Inflammatory Disease

289
Q

How does PID usually occur?

A

direct spread from the cervix

290
Q 
\_\_\_\_ includes:
endometritis
salpingitis/oophoritis
tubo-ovarian abscess
pelvic peritonitis
A

PID

291
Q

PID is most commonly caused by what organisms? (2)

A

Gonorrhea and Chlamydia

292
Q

Greatest risk factor for PID is:

A

Prior PID!!

293
Q

Goal of treating PID is to prevent these 3 things:

A

infertility
ectopic pregnancy
chronic pelivc pain

294
Q

Describe the pathology of PID

A
  • 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&raquo_space; peritonitis
295
Q

PID Sx

A
  • NEW ONSET PELVIC PAIN AND ABDOMINAL TENDERNESS
  • dyspareunia
  • vaginal discharge
  • intermenstrual/post-coital bleeding
296
Q

PID PE signs

A
  • CHANDELIER SIGN
  • CERVICAL MOTION TENDERNESS
  • possible discharge
297
Q

PID Dx

A

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
Q

If a suspected PID patient is pregnant, you must r/o:

A

Ectopic pregnancy!!

299
Q

PID criteria for hospitalization

A
  • 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
Q

Outpatient PID Tx

A

Ceftriaxone + Doxycycline +/- Metronidazole

301
Q

Inpatient PID Tx

A

Cefotetan, Cefoxitin, or Doxycycline

302
Q

If treating someone with PID outpatient, you must … (3)

A

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
Q

Which organism is known as the “Great Imitator”

A

Treponema pallidum (Syphilis)

It can present like lots of different things, esp dermatologic.

304
Q

Describe the Treponema pallidum (syphilis) organism

A

spirochete

305
Q

Name the 5 states of syphilis

A
  1. primary
  2. secondary
  3. early latent
  4. late latent
  5. tertiary
306
Q

How long is a syphilis patient infectious? During what stages?

A

1 year after contraction; early stages (primary, secondary, and early latent)

307
Q

Syphilis transmission?

How does it spread?

A

oral, vaginal or anal sex
direct contact with bacteria in syphilitic sores/rashes

spreads rapidly to the regional lymph node, then disseminates

308
Q

Where is syphilis most commonly found in women?

A

vulva, vagina, cervix

309
Q

S/S of PRIMARY syphilis

A

CHANCRE!! (PAINLESS ulcer with raised edges)

  • occurs 10-90 days after inoculation
  • heals spontaneously in 3-6 weeks
  • CONTAGIOUS
310
Q

S/S of SECONDARY syphilis

A

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
Q

S/S of TERTIARY syphilis

A

Multi-organ effects:

  • neuro
  • ocular
  • ophthalmic
  • cardiac

GUMMAS: destructive necrotic lesions

312
Q

1/3 of untreated syphilis leads to _____.

A

Tertiary syphilis (RARE)

313
Q

How do you know when someone has latent syphilis?

A

positive serology, negative S/S

314
Q

Syphilis complications (2)

A

Neurosyphilis: HA, AMS, dementia, meningitis

DEATH (tertiary syphilis)

increased risk of contracting/transmitting HIV

315
Q

Syphilis definitive Dx

A

Dark-field microscopy: can see motile spirochetes

316
Q

Serological SCREENING for syphilis is done with:

A

non-treponemal tests (VDRL, RPR)

317
Q

Serological CONFIRMATION of syphilis is done with:

A

treponemal tests (FTA-ABS, TP-PA)

318
Q

Primary and secondary stage syphilis Tx

A

Bicillin-LA

Benzathine Penicillin G single dose 2.4 million units

319
Q

Early latent stage syphilis Tx

A

Bicillin-LA

Benzathine Penicillin G single dose 2.4 million units

320
Q

Late latent and tertiary stage syphilis Tx

A

Benzathine Penicillin G 2.4 units x three weeks

321
Q

Syphilis Tx if PCN allergy

A

Doxycycline or Ceftriaxone

322
Q

Syphilis Tx if pregnant

A

Desensitize

323
Q

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
A

Jarisch-Herxheimer Reaction

324
Q

Jarisch-Herxheimer Reaction Tx

A

antipyretics

325
Q

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 _____..

A

VDRL/RPR titers; 4 fold; 8 fold; 2 years

326
Q

Which confirmatory tests for syphilis are qualitative?

A

Trepomonal tests

327
Q

Which confirmatory test s for syphilis are quantitative?

A

NON-Trepomonal tests (RPR/VRDL)

328
Q

Syphilis may be transmitted to a baby by an infected mother ______, which leads to a serious multisystem infection known as ______.

A

during pregnancy; congenital syphilis

329
Q

Transmission of Genital Herpes Simplex Virus

A

by someone unaware they have it, during viral shedding

330
Q

Describe a primary outbreak of HSV. How are non-primary and recurrent episodes different?

A

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
Q

HSV Dx

A
  • PCR swab OR culture of the VISIBLE LESION

- Serological testing: IgG based, type specific

332
Q

HSV Tx (1st episode)

A

Valacyclovir 1gm q day x 7-10 days

Other options: Acyclovir, Famciclovir

333
Q

HSV Tx (recurrent episode)

A

Start Tx during prodrome: Valtrex (valcyclovir) 500mg bid x 3-5 days

334
Q

HSV recurrent episodes tend to occur _____

A

during illness or stress

335
Q

If HSV outbreaks occur >6 times per year:

A

give suppressive therapy: daily Valtrex (1g

336
Q

Does suppressive HSV therapy eliminate viral shedding?

A

NO, just reduces it

337
Q

Must counsel HSV patients on 3 things:

A
  1. recurrence
  2. asymptomatic viral shedding
  3. risk of transmission
338
Q

80-90% of neonatal herpes infections occur from ____.

A

vaginal delivery

339
Q

Must use _____ for pregnant women with history of HSV and _____ for pregnant women with current, active HSV

A

suppressive therapy for last 4 weeks of pregnancy; C-section

340
Q

What are the high-risk strains of HVP and the low-risk strains of HPV?

A

High: 16, 18
Low: 6, 11

341
Q

HVP transmission

A

direct contact to mucous membranes/fluids

342
Q

HPV genital warts are called _____.

A

condyloma accuminata

343
Q

HVP vaccine has demonstrated effectiveness in _____ persistent HPV vaccinations impacting CIN II-III rate by covering _____. It is most effective in _______.

A

preventing; high-risk HPV 16, 18; not yet infected (prior to sexual debut)

344
Q

Describe the appearance of HPV genital warts

A

soft, fleshy growths with “cauliflower” apperance (narrow base, heaped up)

345
Q

HPV gental warts Dx

A

based on clinical findings
acetic acid will usually turn them a whitish color
biopsy if uncertain

346
Q

HPV genital warts Tx (patient applied)

A 
Podofilox solution/gel
or
Imiquimod cream (Aldara)
- may weaken condoms/diaphragms
347
Q

HPV genital wards Tx (provider administered)

A

Cryotherapy
Trichloroacetic acid (TCA): best for mucosal lesions
Surgical

348
Q

T/F: HPV gental warts do not require follow up

A

True

349
Q

Two most common GYN disorders in reproductive-age women

A

abnormal uterine bleeding

amenorrhea

350
Q

general phrase for bleeding at irregular, unpredictable intervals

A

Abnormal Uterine Bleeding

351
Q

failure to ovulate

A

anovulation

352
Q

less frequent ovulation

A

oligoovulation

353
Q

heavy or prolonged menstrual flow

A

menorrhagia

354
Q

intermenstrual bleeding

A

metrorrhagia

355
Q

prolonged uterine bleeding occurring at irregular intervals

A

menometrorrhagia

356
Q

bleeding more often than every 21 days

A

polymenorrhea

357
Q

How is uterine bleeding classified? (FIGO standards)

A

pattern and etiology

structural (PALM) and non-structural (COEIN)

358
Q

Structural causes of AUB are:

A

PALM

Polyp
Adenomyosis
Leimyoma (submucosal or other)
Malignancy and hyperplasia

359
Q

Non-structural causes of AUB are:

A

COEIN

Coagulopathy
Ovulatory dysfunction
Endometrial
Iatrogenic
Not yet classified
360
Q

Women enter and exit reproductive lifespan similarly. Explain.

A 
Amenorrhea >>
AUB, anovulatory periods >>
Ovulatory periods >>
AUB anovulatory periods >>
Amenorrhea
361
Q

Explain how estrogen predominance causes AUB

A

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
Q

Other than estrogen predominance, what are 3 other etiologies that may cause AUB?

A

HPO axis dysfunction
oligo-ovulation
with ovulation

363
Q

A cause of structural AUB: usually focal, benign hyperplastic process within the endometrium

A

endometrial polyps

364
Q

Pathophys of endometrial polyps

A

ovary produces unopposed estrogen due to chronic anovulation, predominance of estrogen leads to overgrowth of the endometrium

365
Q

Endometrial polyps are most common ____, so a Sx could be ______.

A

perimenopausal or “newly” postmenopausal; postmenopausal bleeding

366
Q

Endometrial Polyp Tx

A

scheduled P4

OCPs

367
Q

A cause of structural AUB: islands of endometrium growing into myometrium

A

Adenomyosis

368
Q

Pelvic exam of adenomyosis

A

“boggy” tender uterus

369
Q

Adenomyosis Dx

A

clinical Dx of exclusion

definitive by hystology only

370
Q

Adenomyosis Tx

A

OCPs

surgical

371
Q

A cause of structural AUB: benign overgrowth of the myometrium

A

uterine fibroids

372
Q

A woman with AUB describing a “heaviness” or “fullness” of her pelvic pain might have

A

fibroids

373
Q

Uterine fibroids Dx

A

pelvic exam
pelvic US

both show irregularly enlarged uterus

374
Q

Uterine fibroids Tx

A

GnRH agonist (Leuprolide)
Myomectomy
Hysterectomy

375
Q

A cause of NON-structural AUB: caused by Von Willebrand’s Dz, herbal remedies (ginseng, gingko, motherwort), anticoagulants (coumadin, heparin, aspirin)

A

coagulopathy

376
Q

A cause of NON-structural AUB: due to endocrine d/o, thyroid disorder, hyperprolactinemia, DM, PCOS

A

ovulatory dysfunction

377
Q

A cause of NON-structural AUB: due to OCPs, HRT, IUD, other meds

A

Iatrogenic

378
Q

Amenorrhea definition

A

the absence of menstruation for at least 3-6 consecutive months

379
Q

Oligomenorrhea definition

A

less frequent menstruation interval >35 days, but <3-6 months

380
Q

Primary amenorrhea definition

A

never menstruated

381
Q

Secondary amenorrhea

A

absence of menstruation (positive history of previous menstruation)

382
Q

4 etiologies of amenorrhea to consider

A
  1. pregnancy
  2. HPO dysfunction
  3. ovarian dysfunction
  4. alteration of the genital outflow tract
383
Q

EVERY WOMAN is ______ until proven otherwise.

A

pregnant

384
Q

Amenorrhea can be due to HPO dysfunction when there is ______

A

disruption of pulsatile secretion of GnRH

385
Q

Name some things that can cause HPO dysfunction with resulting amenorrhea

A 
weight change
marijuana
pituitary adenoma
hypothyroidism
anxiety
chronic medical illness
386
Q

Estrogen deficiency and androgen excess are signs of amenorrhea caused by _____.

A

ovarian dysfunction/failure

387
Q

two types of ovarian dysfunction

A

premature ovarian failure

ovarian follicles resistant to FSH/LH stimulation

388
Q

alteration of the genital outflow tract can be due to these 2 things

A
  1. congenital obstruction of the uterus, cervix, or vagina

2. scarring of endometrium (Asherman’s syndrome)

389
Q

4 routine tests for amenorrhea

A

pregnancy
prolactin
TSH
FAH/LH, estrogen/progesterone

390
Q

If there is withdrawal bleeding on a progesterone challenge test, you know the patient has _____ (3), so amenorrhea must be due to either ____ or _____.

A

patent outflow tract, adequate estrogen, and functional endometrium

anovulatory, oligo-ovulatory

391
Q

If patient does not have withdrawal bleeding on a progesterone challenge test, amenorrhea is due to ____ (2)

A

hypoestrogenic
or
genital outflow tract

392
Q

two anovulatory/oligo-ovulatory conditions

A
  1. pituitary adenoma: suppresses GnRH pulsatility, antiestrogenic effect on endometrium. Get MRI.
  2. hypothyriodism
393
Q

Androgen excess is idiopathic _____% of the time

A

50%

394
Q

Pathologic etiology of androgen excess is most commonly due to:

A

PCOS

395
Q

Hirsutism is defined as:

and is due to:

A

excess of terminal hair in male pattern of distribution

increased androgens

396
Q

Virilization is defined as:

and is due to:

A

masculinization of a woman

increased testosterone

397
Q 
The adrenal glands produce most of our \_\_\_\_.
The ovaries produce most of our \_\_\_\_.
Extraglandular sites (adipose) produce most of our \_\_\_\_.
A

DHEA-S
Androstenedione
Testosterone

398
Q

PCOS definition

A

anovulation/oligo-ovulation, increased androgen levels, and enlarged ovaries (>12 follicles)

399
Q

Name some clinical features of PCOS

A

OBESITY
infertility
hirsutism/virilization/acne
menstrual irregularities

400
Q

Patients with PCOS most commonly have _____ (bleeding pattern)

A

oligomenorrhea= amenorrhea with complaints of occasional, heavy menses

401
Q

Name some possible etiologies of PCOS

A

obesity
androgen excess
estrogen excess
metabolic syndrome

402
Q

Hypothesis about why hyperinsulinemia might cause PCOS

A

peripheral insulin resistance may cause increased insulin signaling in the ovary, leading to enhanced ovarian steroidgenesis
ovarian follicle development is arrested, annovulation results

403
Q

5 lab tests to Dx PCOS

PCOS panel

A 
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
Q

PCOS ultimate Tx goal

A

suppress the source of androgen excess or block androgen action at receptor site

405
Q

PCOS Tx

A

diet and exercise for ALL patients!

OCPs
cyclic progesterone withdrawal
clomiphene
metformin
spironolactone
406
Q

What is the most frequent pelvic tumor? When do they usually come about?

A

Fibroids

5th decade of life

407
Q

What’s a fibroid?

A

a benign tumor of muscle cell origin

408
Q

Each individual myoma is ______.

A

Monoclonal

409
Q

Myomas have receptors for ______ and _____.

A

Estrogen; progesterone

410
Q

What is the growth of myomas related to?

A

estrogen production… fibroids regress after menopause

411
Q

Name the four types of myomas. How are they classified

A

Pedunculated, intramural, subserosal, submucosal

They’re classified into subgroups by relationship to layers of the uterus

412
Q

Describe the appearance of fibroids

A

glistening, pearl-white appearance with smooth muscle arranged in a whorled configuration

413
Q

How is the blood supply to fibroids?

A

relatively poor.

usually only have 1-2 arteries at the base

414
Q

As fibroids grow, they outgrow the blood sypply and degenerate. How does this manifest in the patient?

A

severe pain and localized peritoneal irritation

415
Q

How many myomas progress to malignancy?

A

<1%

416
Q

MC presentation of fibroids

A

Most are asymptomatic, but menorrhagia is MC presentation

417
Q

Fibroids on physical exam

A

Large, irregular hard palpable mass in the abdomen or pelvis during bimanual exam

418
Q

Fibroids Dx

A

Pelvic US (focal heterogenic masses with shadowing)

Abnormal pelvic exam

419
Q

Fibroids Tx (most)

A

Observation for most

420
Q

Medical Fibroids Tx

A

inhibit estrogen

Leuprolide is most effective medical Tx (GnRH agonist that causes GnRH inhibition when given continuously)

GnRH antagonists
NSAIDs
Hormonal Therapy

421
Q

Definitive Tx for Fibroids

A

Hysterectomy

422
Q

Most common cause for hysterectomy

A

Fibroids

423
Q

When would you perform a myomectomy (removal of JUST the fibroids) as treatment for fibroids?

A

to preserve fertility

424
Q

Other, less common surgical treatments for fibroids?

A

endometrial ablation, artery embolization

425
Q

3 most common conditions most frequently associated with hysterectomy

A
  1. uterine leiomyomata
  2. endometriosis
  3. uterine prolapse
426
Q

Most commonly used embolization particles in artery embolizations

A

polyvinyl alcohol

427
Q

Artery embolization results in a ____% volume reduction

A

40%

428
Q

________ 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

A

Post embolization syndrome

429
Q

____% 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.

A

25%

430
Q

What type of fibroid is found centered in the muscular wall of the uterus?

A

Intramural

431
Q

What type of fibroid is found beneath the uterine serosa (outer wall)?

A

Subserosal

432
Q

Which types of fibroids are primarily associated with AUB & where are they located?

A

Submucosal; located within the endometrial cavity

433
Q

Explain menopause physiologically

A

permanent termination of menses due to cessation of ovarian response to pituitary stimulation

434
Q

Explain menopause clinically

A

no menses for >1 year with elevation of serum FSH levels

435
Q

Average age of menopause?

Normal range for menopause?

A

51 yo; 44-59 yo

436
Q

premature menopause may occur in patients with/who…

A

DM
smoking
vegetarians
malnourishment

437
Q

3 types of Sx in menopause

A
  1. vasomotor
  2. urogenital atrophy
  3. psychological
438
Q

Vasomotor Sx of menopause are triggered by _____.

A

estrogen withdrawal

439
Q

Name some vasomotor Sx of menopause

A 
hot flashes
night sweats
hair/skin/nail changes
mood changes
HLD
osteoporosis
CV events
440
Q

Loss of elasticity of the vagina due to decreased mucosal blood flow is called…

A

urotenital atrophy

441
Q

Name some urogenital atrophy Sx of menopause

A 
irritation
pruritis
dryness
dyspareunia
gray discharge
bleeding
442
Q

Name some psychologic Sx of menopause

A 
fatigue
irritability
anxiety
memory loss ?
depression ?
443
Q

Menopause Dx

A

FSH assay is most sensitive initial test!!

increased serum FSH >30IU/mL

444
Q

What happens to the following three hormones in menopause (can be used for diagnosis):
FSH
LH
Estrogen

A

FSH increased
LH increased
Estrogen decreased

445
Q

Menopause PE

A

decreased bone density, thin and dry skin, decreased skin elasticity, atrophied vagina

446
Q

3 important complications of menopause due to loss of estrogen’s protective effects

A
  1. increased CV risk
  2. increased osteoporosis
  3. HLD
447
Q

Tx for vasomotor Sx of menopause

A

estrogen therapy is #1 (95% relief)

Progestin (70% effective)
Antidepressants
Clonidine
Gabapentin

448
Q

Tx for urogenital atrophy in menopause

A

transdermal/topical estrogen

449
Q

3 options for hormone therapy in menopause

A
  1. estrogen
  2. combination estrogen/progestin
  3. testosterone
450
Q

Benefits of estrogen only HRT in menopause

A
  • MOST effective symptomatic Tx (hot flashes, mood changes, vaginal atrophy)
  • no increased risk of breast cancer
451
Q

Risks of estrogen only HRT in menopause

A
  • increased risk of endometrial cancer (SO, often used in patients s/p hysterectomy)
  • THROMBOEMBOLISM
  • liver Dz
452
Q

Benefits of estrogen + progesterone HRT in menopause

A
  • 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
Q

Risks of estrogen + progesterone HRT in menopause

A
  • venous thromboembolism

- slightly increased risk of breast cancer??

454
Q

Two options for frequency of HRT

A

continuous

cyclic (pts will bleed almost like a normal period cycle)

455
Q

Best advice for HRT

A

use the lowest dose for the shortest duration needed

456
Q

decreased bone mineral density and loss of micro architecture in osteoporosis most frequently cause what two ortopedic injuries?

A

hip fracture and vertebral compression fractures

457
Q

How to eval bone density in osteoporosis?

A

DEXA scan:

458
Q

When to screen for osteoporosis?

A

65 years old per NOF

Earlier, age 50, if RF other than menopause

459
Q

Osteoporosis Tx (4 options)

A

Estrogen
Bisphosphonates
Raloxifene
Parathyroid hormone

460
Q

Name some ways to prevent osteoporosis

A 
Calcium
Vit D
Weight bearing exercise
Estrogen
Bisphosphonates
Raloxifene
Reduce RF
461
Q

Breast cancer is primarily a malignancy of the _____.

A

milk ducts or lubules (which produce the milk)

462
Q

4 components of breast tissue

A
  1. adipose tissue
  2. connective tissue
  3. lobules (make milk)
  4. ducts (transport milk)
463
Q

Most breast tumors occur in what quadrant?

A

upper outer quadrant

464
Q

blood supply to the lateral breast?

A

3rd, 4th, 5th intercostals

465
Q

blood supply to the medial breast?

A

internal mammary perforators

466
Q

blood supply to the lower breast?

A

thoracoacromial trunk

467
Q

The central and peripheral breast drains into a what lymphatics?

A

into a large plexus below the areola that then drains into the axillary nodes

468
Q

What is fibrocystic breast disorder?

A

a BENIGN breast disease

= a fluid-filled breast cyst due to exaggerated response to hormones

469
Q

what is the most common of ALL breast conditions?

A

fibrocystic breast disorder

470
Q

How prevalent are fibrocystic breast changes?

A

affect 30-50% of postmenopausal women

471
Q

Fibrocystic breast disorder S/S:

A

CYCLIC, bilateral engorgement and nodularity during menstrual cycles!!

PE: diffusely TTP, lumpy-bumpy breasts

472
Q

Fibrocystic breast disorder Tx

A

supportive

473
Q

Fibrocystic breast disorder Dx

A

US

Fine Needle Aspiration (FNA) reveals straw-colored fluid (no blood)

474
Q

What is the second most common type of BENIGN breast disease?

A

fibroadenoma

475
Q

What patients does fibroadenoma mostly effect?

A

Young women, teens-20s

476
Q

Fibroadenoma S/S:

A

firm, mobile, well-defined, usually solitary lump in breast

DOES NOT wax and wane with menstruation

477
Q

Fibroadenoma Tx

A

excision if >3cm (or clinical judgement)

observation for most

478
Q

What’s a fibroadenoma?

A

a BENIGN breast lump made of glandular and fibrous tissue (collagen arranged in swirls)

479
Q

What’s an Intraductal Papilloma?

A

a BENIGN tumor arising from the ducts

480
Q

intraductal papilloma S/S:

A

NIPPLE DISCHARGE: bloody, serous, cloudy (MC cause of bloody, serous nipple discharge!!)

Non-palpable usually

481
Q

intraductal papilloma Tx

A

Excision of atypical, symptomatic, or large lesions

482
Q

What’s a Phyllodes Tumor?

A

a (usually) BENIGN breast tumor

483
Q

What does Phyllodes Tumor look like on biopsy?

A

fibro-epithelial lesions

484
Q

Phyllodes tumor probably arise from _____.

A

intra-lobular stroma

485
Q

What’s the limit for benign, borderline, and malignant phyllodes tumors?

A

mitoses per HPF:
Benign: <4
Borderline: 4-9
Malignant: 10+

486
Q

Phyllodes Tumor Tx

A

Excise with ample margin
Stage the malignant ones

Mets to: lung, mediastinum, bone

487
Q

What is Mastitis?

A

inflammation of the breast. can be infectious or congestive

488
Q

Breast Dz mostly seen in lactating women secondary to nipple trauma (especially primagravida)

A

infectous mastitis

489
Q

Breast Dz of bilateral breast enlargement occuring usually 2-3 days postpartum

A

congestive mastitis

490
Q

MC organism in mastitis infection

A

S.aureus

491
Q

Tx for infectious mastitis

A

Bactrim, Clindamycin

Mothers should continue to breast feed

492
Q

Compare/contrast S/S of infectious mastitis, congestive mastitis, and breast abscess

A

infectious mastitis: UNILATERAL breast pain, tenderness, warmth, swelling, nipple discharge

congestive mastitis: BILATERAL breast pain and swelling

breast abscess: induration with fluctuance. purulent.

493
Q

Breast abscess Tx

A

I&D

Discontinue breastfeeding from the affected breast

494
Q

2 types of invasive breast cancer

A

Ductal (80%)

Lobular (10%)

495
Q

3 types of non-invasive breast cancer

A

ductal carcinoma in situ, lobular carcinoma in situ, Pagets

496
Q

4 important tumor markers

A

ER
PR
Her2
Ki67

497
Q

Name some risk factors for breast cancer

A 
BRCA1 &amp; 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
Q

Breast cancer staging:

A

T (tumor) - N (nodes) - M (mets)

499
Q

Stage 0 breast cancer

A

precancerous, DCIS, LCIS

500
Q

Stage I-III breast cancer

A

within breast/regional lymph nodes

501
Q

Stave IV breast cancer

A

metastatic

502
Q

MC CC of pts coming in with breast cancer

A

lump

503
Q

breast cancer Sx

A

painless, hard, fixed breast mass (MC in upper outer quadrant)

unilateral nipple discharge (bloody, purulent, green)

504
Q

breast cancer PE

A

ASYMMETRIC redness, discoloration, ulceration, skin retraction, nipple inversion, skin thickening, or changes in breast size/contour

505
Q

Paget’s disease of the nipple on PE

A

chronic eczematous, itchy, scaling rash on the nipples and areola (may ooze)

506
Q

inflammatory breast cancer on PE

A

red, swollen, WARM, itchy breast

often with nipple retraction, usually no lump

507
Q

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?

A

Peau d’orange; lymphatic destruction; poor prognosis

508
Q

How to perform breast exam

A

inspect size, skin findings
palpate, start with axilla and hold arm
palpate mass location, size, qualities

509
Q

4 tools for breast cancer Dx

A
  1. mammogram
  2. US
  3. biopsy
  4. MRI
510
Q

What findings on mammogram are highly suspicious for malignancy?

A

microcalcifications and spiculated masses

511
Q

what is the recommended initial modality to evaluate breast masses in patients >40 years old?

A

US

512
Q

Mammogram screening recommendations (USPSTF, ACOG, ACS)

A

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
Q

3 important things about US in breast cancer Dx

A
  1. it’s adjunct for mammogram
  2. solid vs. cystic
  3. better study for younger, denser breasts
514
Q

When do you use a mammogram for breast cancer Dx?

A

adjunct study for high risk patients

515
Q

Recommendations for clinical breast exams as part of screening

A

age 20-39: every 3 years

age 40+: every year

516
Q

When should patients perform self breast exams?

A

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
Q

All discrete, palpable, suspicious masses should be _____ and _____!!!!

A

imaged; biopsied

518
Q

primary breast cancer Tx (3)

A
  1. lumpectomy (followed by radiation therapy)
  2. mastectomy
  3. removal of regional (axillary) lymph nodes to determine if METs present
519
Q

When is radiation therapy used as adjunctive breast cancer treatment?

A
  • after lumpectomy

- maybe after mastectomy to destroy residual microscopic tumor cells

520
Q

When is chemotherapy used as adjunctive breast cancer treatment?

A

stage II-IV breast cancer and inoperable disease (esp ER negative)

521
Q

What types of breast tumors benefit from neoadjuvant endocrine therapy (3)

A

Estrogen receptor positive
Progesterone receptor
HER2 positive

522
Q

What neoadjuvant endocrine therapy would be used for ER (+) tumors?

A

Tamoxifen: anti-estrogen, binds and blocks receptor in breast tissue

(ER positive tumors are dependent on estrogen for growth)

523
Q

What neoadjuvant endocrine therapy would be used for postmenopausal patients with an ER (+) tumor?

A

Letrozole, Anastrozole: reduces the production of estrogen

524
Q

What neoadjuvant endocrine therapy would be useful against HER2 (human epidermal growth factor receptor) positive tumors?

A

Trastuzumab (Herceptin): Monoclonal Ab Tx, HER 2 receptors stimulate cancer growth and are associated with more aggressive tumors

525
Q

What 2 agents can be used for prevention in high-risk patients?

A

Tamoxifen or Raloxifene

**for postmenopausal women or women >35 years old with high risk

usually used for 5 years

BCM (8 decks)

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