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Family Medicine > Women's Health > Flashcards

Women's Health Flashcards

1
Q

Dysfunctional uterine bleeding General

A

Bleeding d/t anovulation or ovulation dysfunction
- problem in hypothalamic/pituitary axis, peri-menopause, chronic unopposed estrogen

Structural:

  • polyps
  • adenomyosis
  • leiomyoma (fibroid)
  • malignancy (endometrial CA)
  • cervicitis

Nonstructural/Anovulatory

  • abnormal pregnancy
  • coagulopathy
  • ovulatory dysfunction: PCO, thyroid, prolactin, perimenopause
  • chronic disease: liver, diabetes

Ages:

  • <20yo: hypothalamic immaturity, stress, wt changes
  • 20-40yo: PCOS, thyroid disease, meds, wt change, impending premature ovarian failure
  • 40-50yo: impending ovarian failure, r/o endometrial cancer

Meds: steroids, psych meds, narcotics, SERMs
- breakthrough bleeding with OCPs

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2
Q

Dysfunctional Uterine Bleeding

A

Sxs:

  • skin: hirsuitism, acne, bruising, petechiae, acanthosis nigricans
  • thyroid enlargement
  • breast: nipple d/c w/hyperprolactinemia
  • abd: masses/tenderness
  • pelvis: discharge, polyp, lesions, uterine enlargement, adnexal masses

Dx of exclusion

  • pregnancy test
  • other: CBC, Fe studies, thyroid, prolactin, FSH, Androgens, coags, LFTs, PAP, U/S, endometrial bx

Tx: correct endocrine problem
- hormones, OCPs, progesterone, surgery

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3
Q

Endometriosis

A

Normal endometrial tissue in abnormal location; responds to hormonal stimulation

  • w/d of hormones cause bleeding +/- pain and scar tissue
  • typically 20-45yo, not during menopause

RF: nulliparous women, those who struggle w/pregnancy

Sxs: pelvic pain, dyspareunia, dysmenorrhea, backache, dyschezia, dysuria, infertility, menorrhagia
- menstrual hx: short cycles, irregular or heavy flow, dysmenorrhea; improves after childbearing

Dx: clinical

  • Pelvic U/S to r/o fibroid or mass
  • pelvic CT/MRI to differentiate tumors of ovary
  • CA-125
  • Pelviscopy w/bx only way to confirm dx

Tx: sx relief

  • chronic OCPs + HD NSAIDs
  • GNRH AG (6 mo); chronic progestins, DMPA
  • surgical indications: unresponsive to meds, persistent pain/infertility, mass [ablation, deep dissection, hysterectomy]
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4
Q

Leiomyoma

A

Benign, smooth muscle tumor; estrogen-dependent*

  • growth during reproductive yrs
  • often have multiple
  • MC pelvic neoplasm in women*

RF: obesity, genetics, race, early menarche, low parity, chronic anovulation (unopposed estrogen), estrogen secreting tumor of ovary

Sx: MC asx; can have abnormal uterine bleeding

  • enlarged uterus, irregular or nodular
  • submucosal location = most symptomatic -> excess bleeding, infertility, necrosis, expulsion, infection

Dx: Transvaginal U/S*
- endometrial bx

Tx:
- indications: anemia, pain, urinary sx, growth after menopause*, infertility

Suppress estrogen:med mgmt MC

  • GNRH analogs: downregulate GNRH, suppress FSH/LH leading to “menopause state”
  • Progestins; Prostaglandin synthetase inhibitors (NSAIDs - Naproxen)

Surgical tx: uterine artery embolization, endometrial ablation, myomectomy, hysterectomy

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5
Q

Prolapse

A

Common in menopause
Post-pregnancy fo uterus to prolapse
Bothersome = surgery

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6
Q

Follicular ovarian cyst

A

MC simple cyst

  • result of unruptured follicle
  • often present mid-menses if ruptured
  • asx, possible mild/mod unilateral colicky pelvic pain if >3-5cm

Dx: HCG, pelvic U/S (benign cyst, filled with clear serous fluid)

Tx: NSAIDs; resolves after menses or w/in 6wk, repeat U/S
- surgery if >10cm d/t risk of torsion

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7
Q

Corpus Luteum

A

Post-ovulatory cyst formation of the corpus luteum exceeding >3cm; continues to produce progesterone
- rare w/OCPs

Sx: unilateral pelvic pain w/onset in late luteal phase, menses delayed up to 2wk, unilateral adnexal enlargement on exam

Dx: HCG, pelvic U/S

Tx: spontaneous resolution
- complication - may fill with blood

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8
Q

Corpus Hemorrhagicum

A

Blood in corpus luteum - rapidly enlarges

  • late menses
  • rapid progression of pain

Dx: HCG
- Pelvic U/S: cystic structure w/internal echos and densities, irregular borders; possible blood in pelvis

Tx: spontaneous resolution
- analgesics, rest, repeat U/S

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9
Q

Theca Lutein

A

Hyperactive luteal cells in response to high levels of gonadotropins and HCG in early pregnancy

  • often bilateral
  • may be a/w molar pregnancy (precancerous)
  • may be caused by ovarian hyperstimulation from fertility drugs

Dx: HCG, pelvic US

Tx: stable = no intervention; resolves when hormones stabilize
- may take up to 6-12wk in early pregnancy

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10
Q

Cervicitis

A 
Mucopurulent = STI
Red/inflamed = vaginal candidiasis
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11
Q

Cervical dysplasia General

A

Develop from precancerous lesion (CIN: cervical intraepithelial neoplasia)

  • MC cause: HPV infection
  • MC type: SCC (80%)
  • Sexual transmission

RF: HPV infection, smoking, early age of first sex, multiparty, STIs, longterm OCPs, low SES, I/C, HIV

Sxs:

  • asx
  • post-coital bleeding
  • watery foul d/c
  • advanced disease: back pain, hematuria, hematochezia
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12
Q

Cervical dysplasia Dx and Screening

A

ID w/pap smear but dx w/bx

Transformation zone = squamo-columnar junction

  • columnar epithelium is slowly replaced w/squamous epithelium = squamous metaplasia
  • results in INC cellular activity and vulnerability to carcinogens and HPV integration

First screening age 21

  • 21-29: pap smear cytology q 3yr w/no h/o abn
  • 30-65: pap smear cytology w/HPV co-testing q 5y w/no h/o abn
  • > 60: discontinue screening if no h/o neoplasia in past 20y

Screening: cytology
Diagnosis: histology

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13
Q

Cervical dysplasia dx / tx

A

ASC-US (atypical squamous cell - undetermined)
ASC-H (cannot exclude high grade lesion)
- DNA HPV + colp if >25yo, repeat in 1yr if younger; regular screening q 3y

LSIL: CIN I (mild dysplasia)
- <25yo repeat pap in 1y; 25-30 colp; >30 HPV + colp, repeat pap/HPV in 1y

HSIL: requires management

  • CIN II: mod/severe dysplasia
  • CIN III: CA in-situ

Tx options: ablation, excision (LEEP), excisional cone biopsy, surgery

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14
Q

Incompetent cervix

A

Cervix open and dilated earlier than it should have during pregnancy
- weak cervical tissue causes premature birth or loss of an otherwise healthy pregnancy

RF: h/o cervical bx, congenital conditions, cervical trauma, D&C

Sx: sensation of pelvic pressure, cramps, light vaginal bleeding

Dx: pelvic exam, transvaginal U/S

Tx: weekly progesterone supplementation

  • serial U/S
  • possible cervical cerclage to close cervix
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15
Q

Vaginal cystocele

A

Bladder bulges into vagina

Tx: support, kegals, surgery

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16
Q

Vaginal prolapse

A

Cause: weakness of pelvic and vaginal tissue, muscle
- MC in women who have had a hysterectomy

Tx: kegals, support, surgery

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17
Q

Rectocele

A

Tissue wall between vagina and rectum shrinks

Tx: kegals, surgery

18
Q

Primary dysmenorrhea

A

D/t prostaglandins from the endometrium
- common in adolescents

Sx: pain w/menses; occurs only w/ovulatory cycles
- normal exam

Dx: normal labs, dx w/hx
- U/S and LAP if pain persists

Tx: NSAIDs - Naproxen, Mefenamic acid
- add OCPs

19
Q

Secondary dysmenorrhea

A

D/t endometriosis, adenomyosis, fibroid, adhesion
- more common later reproductive years

Dx: U/S
- Pelvic CT, dx LAP if pain persists

tx disorder

20
Q

PMS

A

Distressing physical, psych, behavioral sxs appearing regular in luteal phase and resolve with menses

  • triggered by changes in gonadal steroids during luteal phase
  • luteal phase symptoms only** w/relief by day 3 of menses; reccurs monthly
  • hallmark: symptom free follicular phase

RF: late 20s onset; worse after childbirth
- Fhx, depression, PPD, anxiety

Sxs: (emotional component) uncontrolled anger, irritability, severe internal tension w/min coping, impaired QOL

Dx: symptom calendar for 2-3 mo

Tx:

  • mild: diet, exercise, sleep aid, NSAIDs
  • mod/severe: CBT

Gold standard: SSRI
Other: drospirenone OCPs, Venlafaxine (SNRI), Alprazolam (BZD), GHRN Ag

21
Q

Menopause

A

Definition: amenorrhea for 12mo

  • hypoestrogen <20; high FSH
  • before 40yo: primary ovarian insufficiency

Sxs: hot flash, night sweats, sleep disturbances, decreased vaginal lubrictaion, dyspareunia, decreased arousal, overactive bladder, recurrent UTI, irritability, anxiety, poor concentration, decreased libido

  • short term: GU atrophy, vaginal dysfunction, urinary dysfunction
  • long term: CVD, osteoporosis, dementia
22
Q

Menopause Treatment Indications/CI

A

HRT: women w/uterus
ERT: women whose uterus is removed

Indications:

  • GU atrophy
  • osteoporosis
  • vasomotor sxs

CI:

  • women 10y post-menopause
  • h/o clotting, risk of clotting, CVD, stroke risk
  • breast cancer risk, h/o breast or endometrial cancer
  • acute liver or gallbladder disease
  • prolapse or vaginal ulcerations
23
Q

Menopause Treatment Options

A

HRT/ERT

Add progesterone if pt has uterus or if using transdermal patch

Ca / Vit D for osteoporosis

Alternatives: SSRIs, Gabapentin, Clonidine

24
Q

Breast abscess

A

Collection of pus in breast w/assoicated cellulitis

Sxs: cellulitis, erythema, peau d’orange
- pain, pus, fevers

Dx: clinical
- U/S: adjacent interstitial fluid, presence of hypoechoic rim

Tx: abx
- percutaneous needle drainage or surgical I/D

25
Q

Fibroadenoma

A

Stromal overgrown of the breast tissue, common < 40

Sx: solid, mobile, palpable, pain

Dx: mammogram; core bx if suspicious
- U/S: well-defined borders, wider than tall, homogenous w/isoechoic

Tx:

  • excision biopsy if suspicion, large in size
  • surgical intervention unnecessary in most patients
26
Q

Fibrocystic disease

A

Cysts are well loculated fluid-filled sacs

Sx:

  • changes in size w/hormone changes
  • soft to palpation
  • +/- pain

Dx: U/S (well-defined borders, anechoic texture)
- FNA

Tx: no intervention vs. aspiration via FNA
(cyst will collapse if serous)

27
Q

Mastitis

A

Infection/cellulitis of breast most commonly seen in women who are breastfeeding
- may develop into abscess

Sx: erythema, warmth, pain, fever

Dx: U/S if concern for abscess

Tx: abx (Keflex), I/D abscess

28
Q

PID General

A

Clinical dx of upper genital tract infection and inflammation
Minimal criteria:
- All: uterine tenderness, adnexal tenderness, CMT
- +1: fever, mucopurulent d/c (cervicitis), high WBC, elevated ESR

RF: <25yo, multiple partners, non-barrier method, previous PID, h/o STD, recent pelvic procedures

  • condoms and OCPs = protective
  • MC: gonorrhea, chlamydia
  • often concurrent BV

Sx: lower abd/pelvic pain, possible rebound tenderness

  • acute or insidious onset w/INC pain, worse w/menstruation
  • vaginal d/c, possible fever, dysuria
  • CMT**

Complications:

  • chronic pelvic pain/dyspareunia
  • adhesions
  • infertility
  • ectopic pregnancy
  • pelvic abscess
  • death d/t ruptured TOA
29
Q

PID Dx/Tx

A

Dx:

  • cervical wet mount - trich, leukocytes, BV
  • cervical NAAT (GC)
  • other STI screening
  • UA/HCG
  • U/S if palpable mass; CT for abscess or sepsis
  • blcx if septic

Tx:

  • outpatient: Ceftriaxone 250mg IM + Doxy 100mg BID x14d [add metro to cover anaerobes, BV, recurrent]
  • f/u 72hr and 3,4d; abstinence

inpatient: Ceftriaxone 2g IV + doxy 100mg IV/PO [consider adding clinda or metro]

Admit:

  • pregnancy
  • abscess
  • tubo-ovarian mass
  • severe illness w/systemic sxs
  • no response to OP
  • severe I/C
30
Q

Infertility

A

Definition

  • no pregnancy after 1y of trying
  • no pregnancy after 6mo of trying if >35yo or suspicion of pre-existing problem
  • recurrent miscarriage

Factors:

  • male: low/no sperm, low motility [H/P, semen analysis]
  • female: ovulatory dysfunction, endometriosis, tubal disease* [H/P, cultures, endocrine labs, HSG]

Tx:

  • DA Ag: suppress prolactin
  • SERMs: negative feedback so more FSH produced
  • Aromatase inhibitors
  • Metformin for PCOS or IR
  • Wt loss
  • HCG injection midcycle to stimulate LH surge

Assistive reproductive techniques

  • IVF
  • IUI (intrauterine insemination)
  • ICSI (intracytoplasmic sperm injection)
31
Q

Normal L&D

A

General:

  • to term at 37wk
  • labor: regular uterine contractions leading to cervical change
  • regular contractions q8-10min + water breaks or significant vaginal bleeding
  • effacement and dilation* of cervix: 4-5cm dilated and 100% effaced when labor generally begins

First Stage (getting ready)

  • latent phase: hrs-days, 0-4cm dilation
  • active phase: more rapid cervical change
  • end: cervix completely dilated

Second stage (pushing baby out)

  • start: complete cervical dilation, pt starts pushing
  • end: baby delivered
  • 3-5min between contractions
  • successive pregnancies are quicker

Third stage (delivery of placenta)

  • start: delivery of baby
  • end: delivery of placenta
  • involution* - uterus shrinks to size of grapefruit
  • abnormal if > 30min* (avg 7-8min)

Fourth stage

  • start: delivery of placenta
  • end: 24hr later, postpartum, start breastfeeding
32
Q

Dystocia

A

labor arrest - not progressing normally for some reason

33
Q

Fetal distress

A

baby HR increases/decreases and less reaction

dx: fetal stress test

34
Q

Gestational diabetes

A

increased BG only during pregnancy (starts after 20wk)
- usually asx

Increased risk of T2Dm later

Tx: diet, exercise
- if too high, can start insulin

35
Q

Gestational trophoblastic disease

A

Diseases arising from the placenta

Trophoblast: lining of cells of the developing blastocyte providing nourishment that develops into the placenta

Hydatidiform mole*

  • rare: abnormal growth of placental cells caused by fertilization of empty ovum or 2 sperm + 1 ovum
  • sx: vaginal bleed, hyperemesis

Dx: HCG very High

  • enlarged uterus
  • U/S: grape-like clusters or snow-storm apperance*
  • bx to confirm

Tx: surgical evacuation by hysteroscopy + Rhogam

  • no pregnancy for 1yr
  • follow HCG until negative for 1yr
  • start on OCPs
36
Q

Gestational vs. Chronic HTN

A

Gestational: transient, just during pregnancy
- after 20wk

Chronic: HTN prior to pregnancy

  • before 20wk
  • d/c ACE/ARB and start methyldopa
37
Q

Pre-eclampsia

A

HTN + 1 of the following:

  • proteinuria
  • thrombocytopenia
  • renal insufficiency
  • impaired LFTs
  • pulmonary edema
  • cerebral/visual sx

After 20wk

Sxs: 
w/out severe features
- BP < 160/100
- no CNS
- normal serum
- no pulmonary edema

Severe symptoms all opposite

38
Q

Eclampsia

A

Pre-eclampsia + Seizures

Sx: visual/cerebral symptoms can be a sign that a seizure is coming

39
Q

Multiple gestation

A
  • smaller babies
  • at higher risk of everything
  • delivered earlier than 40wks, requires close observation
40
Q

Postpartum hemorrhage

A

Lacerations: cervix, trauma, vaginal wall

Still placenta inside: didn’t come out intact, get it out! D&C

Baggy, soft uterus, not involuting
- give meds to make uterus involute, smooth muscle contraction (misoprostol, prostaglandin, epinephrine)

Try to tamponade the bleeding: use balloon catheter for uterus, stuff uterus with sponges
- blood transfusion or other blood products

IR: place catheter, uterine artery embolization

Late effort: hysterectomy
- pt usually in shock or DIC at this point

Family Medicine (17 decks)

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