Women's Health Flashcards
Dysfunctional uterine bleeding General
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
Dysfunctional Uterine Bleeding
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
Endometriosis
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]
Leiomyoma
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
Prolapse
Common in menopause
Post-pregnancy fo uterus to prolapse
Bothersome = surgery
Follicular ovarian cyst
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
Corpus Luteum
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
Corpus Hemorrhagicum
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
Theca Lutein
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
Cervicitis
Mucopurulent = STI Red/inflamed = vaginal candidiasis
Cervical dysplasia General
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
Cervical dysplasia Dx and Screening
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
Cervical dysplasia dx / tx
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
Incompetent cervix
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
Vaginal cystocele
Bladder bulges into vagina
Tx: support, kegals, surgery
Vaginal prolapse
Cause: weakness of pelvic and vaginal tissue, muscle
- MC in women who have had a hysterectomy
Tx: kegals, support, surgery
Rectocele
Tissue wall between vagina and rectum shrinks
Tx: kegals, surgery
Primary dysmenorrhea
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
Secondary dysmenorrhea
D/t endometriosis, adenomyosis, fibroid, adhesion
- more common later reproductive years
Dx: U/S
- Pelvic CT, dx LAP if pain persists
tx disorder
PMS
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
Menopause
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
Menopause Treatment Indications/CI
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
Menopause Treatment Options
HRT/ERT
Add progesterone if pt has uterus or if using transdermal patch
Ca / Vit D for osteoporosis
Alternatives: SSRIs, Gabapentin, Clonidine
Breast abscess
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
Fibroadenoma
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
Fibrocystic disease
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)
Mastitis
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
PID General
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
PID Dx/Tx
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
Infertility
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)
Normal L&D
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
Dystocia
labor arrest - not progressing normally for some reason
Fetal distress
baby HR increases/decreases and less reaction
dx: fetal stress test
Gestational diabetes
increased BG only during pregnancy (starts after 20wk)
- usually asx
Increased risk of T2Dm later
Tx: diet, exercise
- if too high, can start insulin
Gestational trophoblastic disease
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
Gestational vs. Chronic HTN
Gestational: transient, just during pregnancy
- after 20wk
Chronic: HTN prior to pregnancy
- before 20wk
- d/c ACE/ARB and start methyldopa
Pre-eclampsia
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
Eclampsia
Pre-eclampsia + Seizures
Sx: visual/cerebral symptoms can be a sign that a seizure is coming
Multiple gestation
- smaller babies
- at higher risk of everything
- delivered earlier than 40wks, requires close observation
Postpartum hemorrhage
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
