Women's Health Flashcards
1
Q
female pelvis
A
characterized by a wide pubic arch, lighter, thinner bones, shallow false pelvis, wide and shallow pelvic cavity, round/oval pelvic inlet, large pelvic outlet, more flexible and straighter coccyx, more everted ischial tuberosities
2
Q
male pelvis
A
characterized by a narrow pubic arch, heavier, thicker bones, deep false pelvis, narrow and deep pelvic cavity, heart-shaped and smaller pelvic inlet, small pelvic outlet, more curved and less flexible coccyx, and longer ischial tuberosities that face medially
3
Q
components of the vulva
A
labia minora, labia majora, mons, clitoris, urethra, vestibular bulbs, Bartholin glands, and the vaginal opening
4
Q
function of the mons
A
fatty mound anterior to the pubic bone that functions as a cushion during intercourse and secretes pheromones
5
Q
function of the labia
A
protect the urethra and vaginal openings
6
Q
components of the vaginal vestibule
A
the urethra, vestibular gland (Bartholin gland), and the external vaginal orifice
7
Q
function of Bartholin glands
A
located below the labia minora at 4 and 8 o’clock within the vaginal vestibule and secrete mucous (lubricant) into the vaginal introitus where stimulation is increased during times of arousal - innervated by the parasympathetic nervous system
8
Q
clitoris
A
erectile tissue extending from vaginal introitus into clitoris homologous to the glans in males which is innervated by the parasympathetic nervous system and has about 8,000 nerve endings, stimulation causes dilation of arteries as a result of the release of acetylcholine and nitric oxide and results in erection of tissue
9
Q
vagina
A
musculomembranous structure about 7-9 cm in length which extends from the mid cervix to the vaginal orifice, typically sits in a collapsed position where lateral walls fall medially at the external orifice and will close internally in an anterior-posterior position
10
Q
muscular sphincters that can compress vagina
A
pubovaginalis, external urethral sphincter, urethrovaginal sphincter, and the bulbospongiosus
11
Q
blood supply to the vagina
A
uterine arteries
12
Q
sympathetic innervation of the vagina
A
deep perineal nerve branching off the pudendal nerve which sends afferent fibers to sensory ganglia at S2-S4
13
Q
cervix
A
a cylindrical, primarily fibrous (with some muscle) structure 2.5 cm in length with a supravaginal section and a vaginal section that is surrounded inferiorly by the vaginal fornix where the external os is the opening into the vaginal vault, it is supported by uterosacral ligaments which encase the vaginal vault and cervix attaching to the sacral vertebrae and some bands attach to the lateral aspect of the pelvic walls
14
Q
uterus
A
a dynamic, muscular, pear-shaped organ that is typically 7.5 cm in length (non-gravid), 5 cm wide, and 2 cm thick which is made up of the body and upper cervix (uterine isthmus), lies within the layers of the broad ligament (usually anteverted in position over bladder)
15
Q
3 components of the broad ligament
A
the mesometrium which supports the uterus, the mesosalpinx which supports the fallopian tube, and the mesovarium which supports the ovary
16
Q
3 layers of the uterine wall
A
the perimetrium is the outermost aspect that is supported by connective tissue, the myometrium is the smooth muscle layer that makes up the bulk of the uterus and contains most of the nerves and blood vessels, and the endometrium is the layer shed during monthly menses
17
Q
function of round ligament
A
supports the uterus posterior-inferior
18
Q
function of ovarian ligament
A
attaches the uterus to the ovary and contains blood vessels and nerves which supply the ovary
19
Q
fallopian tubes
A
tubes that extend posteriorly from the uterine horns which is the structure the oocyte travels along toward the uterus and beginning at the ovary
20
Q
infundibulum
A
the area within the peritoneal cavity/fallopian tube that contains fimbriae which accept the ovary during ovulation
21
Q
ampulla
A
the largest aspect of the fallopian tube which is the most common area of fertilization
22
Q
fallopian tube isthmus
A
the area where the wall of the fallopian tube is the thickest
23
Q
ovaries
A
the size/shape of an almond and are the structures that contain oocytes and produce estrogen and progesterone
24
Q
monthly cycle
A
includes both the ovarian and uterine cycles and typically lasts 28 days, begins with the release of FSH and LH from the anterior pituitary which stimulates follicular growth and estrogen secretion which causes proliferation of the endometrium, the fully developed follicle will then release the oocyte from the ovary on day 14 (at ovulation) and the corpus luteum remains in the ovary and continues to secrete estrogen and also progesterone which causes endometrial secretion, finally if no fertilization occurs, the corpus luteum stops secreting hormones and menstruation occurs (sloughing off of the endometrial lining)
25
oogenesis
the process of development of an ovum which begins as a primordial germ cell that undergoes repeated mitosis and then migrates to the ovarian cortex becoming a primordial ovum, a primordial follicle starts to develop around it (containing one layer of granulosa cells) and the oocyte begins meiosis 1, becoming a primary oocyte and stuck in prophase of meiosis 1 (which is present at birth), stimulated by FSH, a primary follicle develops and is characterized by more layers of granulosa cells which then becomes a secondary (antral) and Graafian (mature) follicle, this stimulates an LH surge which triggers completion of meiosis 1 and the onset of meiosis 2 in primary oocytes producing a secondary oocyte which becomes stuck in metaphase of meiosis 2, the secondary oocyte is released during ovulation and fertilization triggers completion of meiosis 2 producing an ovum (zygote)
26
function of granulosa cells
provide nutrients to the ovum for development and release oocyte maturation inhibiting factor until triggered by FSH and LH
27
number of primary follicles formed each month
6-12
28
function of theca cells
proliferating cells within the antral follicle that produce estrogen and progesterone which make up the follicular fluid where the estrogen acts on the follicle to upregulate FSH receptors resulting in increased FSH and, consequently, the FSH along with the estrogen upregulate LH receptors resulting in increased LH, a sudden spike in LH causes an increase in proteases to the cells surrounding the Graafian follicle and the theca cells release proteolytic enzymes leading to release of the oocyte with a single layer of granulosa cells encasing it (corona radiata)
29
atresia
when a king primary follicle develops and becomes largest and dominating and will stop the progression of other follicles
30
corona radiata
a mass of granulosa cells which encases the oocyte expelled during ovulation
31
corpus luteum
the cells that remain in the ovary after the expulsion of the oocyte which begins to release progesterone and estrogen stimulated by LH and undergoes a process of enlargement followed by hormone secretion and degeneration over the course of 12 days
32
layers of the endometrium
stratum basalis and stratum functionalis
33
type of artery within the endometrial stratum basalis
straight arteries
34
type of artery within the endometrial stratum functionalis
spiral arteries which repeatedly degenerate and regenerate
35
proliferative phase of uterine cycle
begins after menstruation, leaving only a small layer of endometrial stromal cells, where estrogen levels increase causing the proliferation of the stromal and epithelial cells and increased blood supply, becomes 3-5 cm thick
36
secretory phase of the uterine cycle
begins after ovulation and is stimulated by progesterone release from the corpus luteum which causes increased glands and secretion from the endometrium and increased blood supply (spiral artery growth), becomes about 5-6 cm thick 1 week after ovulation
37
menstruation
begins when the corpus luteum no longer produces progesterone and there is no longer endometrial stimulation which results in decreased thickness of the endometrium and, vasospastic vessels, decreased blood flow to the endometrium, necrosis, vessel breaking, formation of hemorrhagic areas, and separation of necrotic tissue from the uterus - prostaglandins cause contraction of the uterus and expulsion of menstrual fluid (40 mL blood, 35 mL serous fluid, no clots typically because of it containing fibrinolysis)
38
typical GnRH release pattern
secreted in pulsatile fashion from the hypothalamus at routine intervals every 1-2 hours for 5-25 minutes, some of the neurons that control the release of GnRH are under limbic system control which may explain changes in a woman's sexual functioning based on external stimuli
39
effects of FSH/LH
activate receptors on target cells within the ovary causing increased sex hormone synthesis, stimulated by the release of GnRH and negative feedback from estrogen/progesterone typically but just before ovulation, stimulated by an estrogen/progesterone positive feedback mechanism which greatly increases FSH and LH
40
effects of estrogen (estradiol)
primarily made in the ovaries (but also made in the zona reticularis of the adrenal gland) and promotes the development of the follicle and secondary sex characteristics, will inhibit osteoclast activity, increases metabolism and fat deposition (particularly in the thigh/buttock area), softens the skin, increases vascularity of the skin, and acts on the kidneys to retain Na and H20
41
effects of progesterone
preps the uterus for implantation, assists with the development of lobules and alveoli in the breast and lactation, decreases uterine contraction to promote implantation of ovum, increases mucous production within the fallopian tubes to assist with nutrition delivery to the fertilized ovum, and is broken down quickly in the liver and released as bile or urine
42
effects of female orgasm
helps with fertilization of the ovum through perineal muscle contraction which improves the transport of sperm, the cervix dilates for about 30 minutes after orgasm, and also thought to promote oxytocin release from the posterior pituitary which may cause uterine contractions
43
physiologic changes during sexual arousal
stimulated by the parasympathetic nervous system through the sacral plexus which causes dilation of the erectile tissue within the clitoris and vestibular bulb, increased acetylcholine and nitric oxide resulting in tightening of the introitus, and increased mucus secretion from the Bartholin glands for lubrication
44
menopause
typically begins around 40-50 years old when all primordial follicles have been used up and starts with irregular ovulation with progression to anovulation resulting in decreased sex hormones and unopposed FSH/LH, eventually there will be no estrogens made in the ovaries
45
perimenopause
the transition time from typical menstruation to cessation which typically lasts 1-8 years, causes decreased length of monthly cycles because of a decrease in the follicular phase and irregular ovulation, may have thickened endometrium due to lack of shedding and/or dysfunctional uterine bleeding with metrorrhagia and irregular menses
46
true menopause
cessation of menses for 12 months where the patient has high FSH/LH and low estrogen/progesterone
47
systemic effects of menopause
lack of estrogen will cause vaginal, cervical, and uterine atrophy and fewer secretions, the tissue becomes more friable and pH increases due to lack of secretions making patients more susceptible to infections such as UTIs, dyspareunia, and pruritis, osteoporosis can develop, amount of circulating LDL will increase and tunica media pliability decreases leading to increased CVD risk, and breast tissue will atrophy
48
menopause symptoms
hot flashes, irritability, fatigue, anxiety, and increased osteoclastic activity
49
site of uterine implantation
within the stromal cells of the endometrial lining
50
function of round ligament
attaches to the uterus superiorly and the groin inferiorly and supports the uterus posteriorly and inferiorly - can cause a lot of pain during 2nd trimester of pregnancy
51
ovulation
when the developed haploid ovum, which is surrounded by the corona radiata, is expelled from the ovary into the abdomen, taken up by the fimbriae of the fallopian tubes, and transported toward the uterus by cilia movement in the fallopian tubes (stimulated by estrogen)
52
steps of fertilization
the sperm is first released into the vaginal vault and is transported to the ampulla of the fallopian tube where it migrates through the corona radiata binding to receptors in the zona pellucida of the ovum, the binding induces capacitation of the sperm releasing hyaluronidase and proteolytic enzymes into the zona pellucida, breakdown of the zona pellucida by these enzymes allows the sperm to reach the plasma membrane of the ovum, the nucleus and other components of the sperm enter the ovum, this depolarizes the ovum and cortical granules form a barrier called fertilization membrane which functions to block other sperm from getting in, calcium increases and meiosis II is completed
53
pH of semen
7.5 - 8
54
pH of vagina
4.0 - 4.5
55
location where sperm is formed
vas deferens
56
half-life of sperm
24-48 hours at body temperature
57
what makes up the bulk of semen?
seminal fluid is the bulk which is made in the seminal vesicles and helps to push the sperm from the ejaculatory duct into the vaginal vault and forms a mucoid consistency, prostatic fluid causes semen to have a white color
58
capacitation
when the acrosome of the sperm is lost after coming into contact with the zona pellucida of the ovum, must occur for fertilization to take place
59
corona radiata
remaining follicular cells after the release of the ovum from the Graafian follicle which contain glucose and hyaluronic acid for the ovum
60
zona pellucida
the layer of glycoproteins around the ovum that prevents multiple sperm from binding, initiates sperm capacitation
61
fusion
the process of genetic material from mom and dad coming together during fertilization of an ovum (46 chromosomes) where the ovum will become impenetrable to other sperm during this process
62
uterine implantation
the zygote formed during fertilization begins to divide becoming a morula and then a blastocyst which implants in the uterus about 6 days after fertilization (typically superior and posterior wall), the blastocyst contains the wall and embryonic pole which is the thickest area and will become the embryo, the blastocyst adheres to the endometrial layer and invades the stromal layer deepening implantation between day 16-22 of normal cycle, blastocyst loses zona pellucida
63
gene responsible for embryonic development of male sex characteristics
the SRY gene which is on the Y chromosome (causes Mullerian ducts to regress and Wolffian ducts to develop after week 5 of gestation)
64
effects of fertilization on the corpus luteum
hormones (hCG) produced by the fertilized ovum keep the corpus luteum active for the first trimester of pregnancy instead of degenerating as in a normal cycle
65
uterine invasion
once implanted, the blastocyte will differentiate into the embryo and placenta (trophectoderm) and decidualization of stromal cells will occur causing an inflammatory response resulting in increased blood flow and adhesion, the trophoblast (cells that will become placenta) will cause destruction and rebuilding of the spiral arteries so that blood flow can be maintained from mom to fetus during development and will secrete human chorionic gonadotropin hormone, uterine secretions will provide glucose and cellular nutrients to dividing blastocyst
66
cells supplying nutrients to the growing fetus for the first 8 weeks
decidua cells
67
components of trophoblast
the inner layer is the amnion, the outer layer is the chorion (consisting of the cellular trophoblast and mesoderm, and the syncytiotrophoblast which secretes hCG stimulating progesterone secretion from the corpus luteum during the first trimester
68
stages of implantation
apposition, adhesion, invasion, and decidualization
69
placenta releases
hCG, growth hormone, corticotropin-releasing hormone, vascular endothelial growth factor, glucocorticoids, estrogen, and progesterone
70
gestational age when fetal hypothalamus and pituitary develop
by 12 weeks - GnRH produced resulting in FSH and LH production which will be elevated in female fetuses to produce ova
71
gestational age when fetal heart begins to contract
21 days or 3 weeks (no oxygen exchange through the lungs though, mom supplies oxygen to fetus through placental diffusion)
72
fetal hemoglobin oxygen-carrying capacity
can carry 20-50% more oxygen than adult hemoglobin, has a higher affinity for oxygen and a lower affinity for carbon dioxide which increases oxygen delivery to fetal tissues (left shift)
73
blood flow rate in placenta
625 mL of blood exchanged every minute during last week of pregnancy
74
effect of progesterone during pregnancy
initially secreted by the corpus luteum but later is secreted by the placenta and develops uterine endometrium, helps with nutrition, helps keep uterine contractions low throughout pregnancy, and increases the development of the functional cells that line acini to prepare for lactation
75
effect of estrogen during pregnancy
secreted by the syncytial trophoblastic cells of the placenta and allows for appropriate enlargement of the uterus, increases breast fat deposition and lobular ductal development, increases the size of the external genitalia, increases tissue laxity, increases sodium and water retention in the kidneys leading to fluid retention, and causes vasodilation to prepare for the required demand of uterine contractions
76
amniotic fluid
fluid that the fetus floats in which is about 500-1,000 mL normally where much of it is from fetal renal function - fluid is exchanged every 3 hours and key electrolytes are exchanged every 15 hours
77
effect of pregnancy on pituitary gland
increases in size by up to 50% and increases the release of ACTH, thyrotropin, and prolactin, decreases the release of FSH/LH due to negative feedback from increased progesterone/estrogen from placenta
78
effect of pregnancy on adrenals
increase glucocorticoid release to increase amino acid levels available to be used by fetal tissues, increase aldosterone secretion causing sodium and water retention
79
effect of pregnancy on thyroid/parathyroid
thyroid gland enlarges by 50% during pregnancy due to hCG and placental demand for thyroid hormone, increased calcium demand from the fetus will cause increased PTH release and increased osteoclastic activity if calcium is not maintained through the diet
80
relaxin
a hormone secreted by the placenta and ovaries toward the end of pregnancy which will cause relaxation of ligaments, widening of the pubic symphysis, and softening of the cervix
81
effect of pregnancy on mother's uterus, vagina, and breasts
uterus will increase 22X from baseline (from 10 mL - 5 L), vaginal canal unfolds, the introitus enlarges becoming more rapid after week 20, breasts double in size
82
effect of pregnancy on mother's blood/circulation
cardiac output increases 30-60% in first trimester (may hear more murmurs or cardiac pathology during this time), systemic vascular resistance decreases resulting in decreased BP, plasma volume increases leading to relative dilutional anemia, clotting factors VII-X increase, blood volume increases 30% during third trimester
83
effect of pregnancy on mother's lungs
the uterus will elevate the diaphragm and reduce lung mobility, this will decrease TLC by 5%, minute ventilation increases, progesterone will increase sensitivity to CO2
84
average weight gain during pregnancy
25-35 lbs
85
time at which hCG can be detected in serum
9 days after ovulation, doubles every 29-53 hours and reaches maximum level at 10-12 weeks
86
symptoms of pregnancy
loss of menses, N/V, breast enlargement and/or tenderness, fatigue, light spotting, and cramping
87
gestational age at which fetal Doppler will be positive
10-12 weeks
88
gestational age at which mother can start to feel fetal movements
20 weeks
89
trimester in which the fetus grows the most
third trimester or last 2 months
90
effects of pregnancy during the third trimester
decreased intrathoracic cavity and movement of the diaphragm, increased heat production because of increased metabolism and fetal changes, increased urination, increased swelling, Braxton-Hicks, increased breast growth - may have galactorrhea, and back pain
91
parturition
a decrease of progesterone will allow for uterine contractions, estrogen progressively increases after 7th month, and fetal secretion of cortisol, oxytocin, and prostaglandins will increase uterine contractions, mechanical stretch of the uterus and cervix from the fetus causes stimulation of smooth uterine muscles, and Braxton-Hicks contractions continue to become more frequent where regularly spaced contractions, cervical dilation, and effacement ultimately leads to birth
92
first stage of labor
the transition from more irregular contractions to regular contractions increasing in intensity and decreasing in time intervals, begins at the onset of dilation to starting typically at 1-2 cm/hour in the active phase and progressing to full dilation of 10 cm
93
second stage of labor
cervical dilation to the birth of the fetus where oxytocin maintains contractions allowing for the fetus to enter the pelvis and transition through cardinal movements to completion of delivery, lasts usually < 3 hours in nulliparous and < 2 hours in multiparous mothers
94
third stage of labor
delivery of the placenta which involves increased vaginal bleeding as the placenta separates from uterine wall, the fundus will become more rounded and expel the placenta which typically lasts 5-30 minutes after delivery of fetus
95
endometriosis
benign inflammatory process that is dependent on estrogen levels causing endometrial tissue growth outside of the uterine cavity most commonly within the pelvic structures but also can be in the intestines, urologic structures, pleura, lung, and pericardium, it is often family-linked and thought that the tissue is translocated from the uterine cavity during retrograde flow of menstrual fluid via the fallopian tubes and implants in the abdominal cavity causing inflammation and pain stimulated by circulating hormones (repair of inflammation causes fibrosis and scarring), it may also travel to more distant sites via the lymphatics and has also been potentially thought to be from embryonic development and inappropriate placement of tissue
96
endometriosis presentation
chronic abdominal pain, dysmenorrhea, dyspareunia, infertility, dysuria, pain with micturition, and pain with bowel movements
97
complications of endometriosis
infertility, ectopic pregnancy, endometrioma, nodule formation, and cyst formation
98
adenomyosis
a form of endometriosis characterized by enlargement of the myometrium due to the presence of endometrial glands in this layer of the uterus which may cause abnormal menstrual bleeding, discomfort, and dysmenorrhea, endometrial invagination of the myometrium (present in 20-35% of the population)
99
PALM-COIN causes of AUB
PALM = structural causes, COIN = nonstructural causes,
Polyps, Adenomyosis, Leiomyoma (Fibroids), Malignancy, and Coagulopathy, Ovulatory dysfunction, Iatrogenic (drugs - anticoags, antipsychotics, steroids, ginseng, HRT, IUD, SSRIs, Tamoxifen), Not otherwise classified (thyroid dysfunction - hypo/hyper)
100
anovulatory cycle
when there is not enough LH stimulation for ovulation to occur (can happen at the beginning of menarche and leading up to menopause)
101
endometrial hyperplasia
overgrowth of endometrial glands that is more common in older patients and with obesity and causes AUB, it may be without atypia (non-cancerous) or with atypia (neoplastic)
102
endometrial polyps
overgrowth of endometrial glands and stroma forming around a vascular bed and hanging in a pedunculated fashion where some can grow quite large or there may be multiple, can be due to increased endometrial aromatase, increased sensitivity to sex hormones within the tissue or unopposed estrogen causing sensitive tissue to proliferate, or Tamoxifen
103
Leiomyoma
uterine fibroid or myoma which is a benign tumor similar to a polyp but which arises from the smooth muscle layer (myometrium) of the uterus and fibroblasts which can be due to genetic disposition
104
Leiomyoma presentation
depends on their size and location but can cause AUB, infertility, menorrhagia, menometrorrhagia, and necrosis if they become twisted
105
pelvic inflammatory disease (PID)
ascending infection from the vagina and cervix which may include salpingitis, endometritis, myometritis, oophoritis, and tubo-ovarian abscess most commonly associated with gonorrhea and chlamydia although can be caused by E.coli in postmenopausal women and often thought to be polymicrobial, can cause long-term consequences as a result of scarring and adhesions (must be sexually active for PID)
106
complications of PID
ectopic pregnancy and infertility
107
chlamydia trachomatis
the most common sexually transmitted disease caused by gram-negative bacteria with no peptidoglycan layer with affinity for the columnar epithelial cells of mucous membranes including the conjunctiva, the cervix, and the lungs, it is transmitted in "elementary body" form (EB) during which it can exist outside the host cell and is inert, upon entry into the cell, it becomes an "initial body" which can replicate and disseminate and inhibits lysosome fusion which would typically break down the bacteria (some stay as EBs to transmit to other hosts), causes genital infections including non-gonococcal urethritis
108
Neisseria gonorrhea
gram-negative cocci bacteria that have pili that protect them from antibodies and vaccines, prevent phagocytosis and assist with adherence to cells, they also have protein porins PorA and PorB which help to invade epithelial cells, and Opa proteins that help with adherence and invasion, first they bind to fallopian tubes and exotoxins destroy the cilia of surrounding cells, they are then taken into cells via endocytosis where they multiply and then are released into subepithelial tissue causing systemic infection
109
gonorrhea presentation
most commonly as urethritis causing dysuria and discharge, can also infect the epididymis, prostate, and rectum, and cause septic arthritis typically in 1 or 2 joints where inflammatory reaction will cause significant joint destruction (synovial fluid culture will show gram-negative diplococci in WBCs), rarely causes bacteremia (fever, joint pain, skin eruption on extremities), women with gonococcal urethritis are more likely to be asymptomatic
110
endometritis
inflammation of the intrauterine lining most commonly associated with PID but can also be associated with transcervical procedures such as hysteroscopy but still thought to be GC driven from preoperative infection, idiopathic endometritis may cause chronic disease state and increase risk of spontaneous abortions, and issues with implantation
111
salpingitis
inflammation of fallopian tube that can lead to scarring and may be unilateral or bilateral, most commonly due to PID
112
tubo-ovarian abscess
complication of PID that develops in 15% of patients with salpingitis due to infection causing inflammation and collection of purulent fluid within the fallopian tube (pyosalpinx) and ovary which blocks the structure preventing drainage and causing increased pressure and tissue necrosis, if it ruptures it can cause septicemia with a mortality of 50% (most commonly polymicrobial)
113
tubo-ovarian abscess presentation
acute pelvic/abdominal pain, fever/chills, discharge, and adnexal tenderness, uterine tenderness, and cervical motion tenderness during bimanual pelvic exam (Chandelier sign)
114
polycystic ovarian syndrome (PCOS)
cylindrical syndrome hallmarked by ovarian cysts, obesity, alteration in menses, and increased androgen production which appears to be genetically linked and associated with CVD and DM (first-degree relative = 20-40% link, twins = 70% link), some identified genetic links include P450c alteration, LH receptor gene abnormalities, DENND1A alteration causing theca cells abnormalities, and thyroid adenoma gene, patients typically start with insulin resistance leading to increased insulin levels which disrupts hypothalamic-gonadal axis causing increased levels of LH compared to FSH secretion resulting in increased androgen secretion from theca cells which can lead to disrupted ovulation (oligoanovulation or oligomenorrhea), ovarian cysts caused by unruptured ovarian follicles filling with fluid, thickened endometrium causing menorrhagia when menses occurs, and hirsutism due to androgen excess and metabolic syndrome
115
PCOS phenotypes associated with insulin resistance, glucose intolerance, and DM risk
type A and B (classic PCOS)
116
ovarian torsion
most commonly associated with previously enlarged ovary (ovarian cysts) and typically > 4 cm which causes the ovary to twist around the ligament of ovary which encases the vascular supply, initially causes venous congestion and increased swelling which can eventually lead to arterial obstruction and ischemia (necrosis), it is more common to occur on the right side and also in pregnancy
117
ovarian torsion presentation
severe, sudden onset of adnexal pain and vomiting and need to go to the OR immediately for detorsion
118
DO NOT MISS diagnoses in the setting on pelvic pain
tubo-ovarian abscess, ovarian torsion, PID
119
blood supply to cervix
a branch off the uterine artery
120
squamocolumnar junction
where the portio vaginalis which is lined with squamous epithelium and the cervical os and canal which are lined with glandular columnar cells meet - the transitional zone where neoplasia is most likely to occur
121
estrogen causes glandular columnar cells of the cervical canal to produce
a thin watery, slippery, and stretchy mucous which helps sperm move through the cervix into uterus
122
progesterone causes glandular columnar cells of the cervical canal to produce
a thick mucous
123
leukorrhea
normal monthly vaginal discharge of about 1-4 mL per day which is odorless, thin, white/transparent or more yellow and have some odor in some individuals and still be considered normal (pH = 4-4.5)
124
normal vaginal flora
acidic because of lactobacilli which cause the conversion of glycogen to lactic acid facilitated by estrogen (without estrogen the pH would be 7)
125
vulvovaginitis
inflammation of the vulva and vagina due to STI, antibiotic use, hormonal and/or pH imbalance, douching, and sexual activity which leads to erythema, pruritis, burning, dyspareunia, and friability of vaginal and cervix which can cause spotting
126
most common causes of vulvovaginitis
candidiasis, bacterial vaginosis, and trichomoniasis
127
findings associated with BV
white/grey discharge with a fishy odor, elevated pH, clue cells, and Gardnerella vaginalis
128
findings associated with vaginal candidiasis
white cottage cheese-like discharge, normal pH, and yeast buds and pseudohyphae
129
findings associated with vaginal trichomoniasis
frothy/bubbly discharge with elevated pH, motile, pear-shaped flagella, and a strawberry cervix
130
non-infectious vulvovaginitis
most commonly associated with decreased estrogen levels and vaginal atrophy (menopause) but can also be caused by topical irritants or allergens and systemic disorders like SLE and RA
131
cervicitis
inflammation of the cervix most commonly at the columnar cells due to STI infection such as gonorrhea or chlamydia or non-infection associated with inserted foreign bodies such as pessaries, tampons, contraceptives, condoms, or diaphragms
132
cervicitis presentation
spotting, dyspareunia, pruritis, vaginal discharge, and cervical tissue friability (strawberry cervix - trichomoniasis or ulcerative lesions - HSV)
133
condyloma acuminata
anogenital warts associated with HPV infection most commonly caused by low-risk subtypes 6 and 11 which are transmitted sexually and the most common STI globally (effects 58-64% exposed to these strands), they are typically painless (may be pruritic) and their shape and appearance can vary where they may be white, hyperpigmented, skin-colored, or pink and may be flat, cauliflower-like, pedunculated, plaque-like, or smooth, they can involve the cervix or urethra and can spontaneously subside over the course of months (more likely to reappear with irritation or immunosuppression)
134
human papilloma virus (HPV)
circular double-stranded DNA that belongs to the papillomaviridae family that infects the host through the basal layer of the epidermis and causes genital warts (subtypes 6 and 11) and increases the risk of cervical cancer (subtypes 16 and 18), it is transmitted sexually and also through fomites with high transmission rates where it invades the basement membrane usually through a break in upper layers of mucous membranes and replicates intracellularly stimulating unnecessary cellular division, higher risk subtypes are able to enter our genome intracellularly and express proteins that suppress tumor suppressor gene P53 which can lead to cancer, the immune system clears 90% of these infections in about 1 year
135
cervical dysplasia
indicator of cellular changes concerning for early cancer associated with HPV infection (subtypes 16 and 18 cause 70% of cervical cancers) most commonly affecting the squamocolumnar junction
136
stages of cervical dysplasia
starts as an infection of the epithelial basement membrane, then progresses to CIN 1 and CIN 2 (intraepithelial neoplasia 1 and 2) which have a 90% clearance rate, if not cleared it progresses to CIN 3 which has a 70% regression rate, if no regression then cancer forms and it can invade into deeper structures
137
condylomata lata
painless anogenital warts found within skin folds such as in the vagina and anal regions associated with secondary syphilis which can be flat or cauliflower-like papules that contain spirochete and are very infectious (usually develop within weeks-months of initial infection), patient is able to transmit syphilis during this time and can progress to tertiary syphilis if not treated (condylomata will resolve spontaneously but syphilis will remain)
138
pelvic organ prolapse
herniation of the bladder, rectum, or uterus into or beyond the vaginal walls which are all supported by fascia and perineal muscles, the pelvic floor loses supportive functioning and will become weak typically as part of aging, but also increases with a history of previous trauma such as childbirth, surgical intervention, neurologic dysfunction (pudendal nerve), obesity, heavy lifting, repetitive increased abdominal pressure as with coughing, and family history
139
Levator ani
composed of the iliococcygeus and puborectalis and is the primary support structure for pelvic organs
140
anterior vaginal wall prolapse
cystocele = bladder descending to impair vaginal canal
141
posterior vaginal wall prolapse
rectocele = rectum descending to impair vaginal canal
142
enterocele
pelvic organ prolapse involving the intestines descending to impair vaginal canal
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apical vaginal wall prolapse
uterine and vaginal vault herniation
144
pelvic organ prolapse presentation
severity can vary from a small descent of the cervix to a complete prolapse of the uterus into the vaginal canal, symptoms may include positional pressure, difficulty with urination or control of urination, change in bowel habits including constipation or fecal urgency, and decreased sexual satisfaction or sexual discomfort
145
Bartholin cyst
when a lubricating Bartholin gland becomes blocked so that fluid accumulates causing vulvar edema, typically sterile but can be associated with infection and can become an abscess
146
endocervical polyps
thought to be caused by chronic inflammatory change and can also be hormonally mediated, typically < 3 cm, teardrop-shaped, with varying color visualized with speculum hanging from cervical os
147
anovaginal fissure
a tract that forms between the rectum or anus and vagina most commonly associated with childbirth and prolonged labor causing necrosis from prolonged pressure on the rectovaginal wall, complication of 3rd and 4th-degree tearing, and presents with fecal drainage through vaginal orifice
148
location of breast tissue bed
extends horizontally from the lateral sternum to the midaxillary line and vertically from ribs 2-6
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retromammary space
contains adipose and bursal tissue allowing for movement and sits anterior to pectoral muscles
150
breast tissue contains
glandular tissue which includes ducts and lobules, fibrous tissue which contains ligaments and supportive tissue, and adipose tissue
151
lactiferous ducts
ducts that carry the milk produced in the breast lobules to the lactiferous sinuses which then carry it to the nipple
152
breast lobules
modified sweat glands within the breasts that have grapelike alveoli clusters that produce milk, each breast typically has 15-20 lobes which each contain 12-25 lobules
153
nipple
fissured with ductal openings (9-10) and is made of primarily smooth muscle that can compress the ducts and become erect, contains sebaceous glands that produce oily secretions that protect during breastfeeding
154
breast venous drainage
primarily the axillary vein and also the internal thoracic vein
155
blood supply to breast
external mammary artery (lateral thoracic artery) and the internal mammary artery (internal thoracic artery)
156
breast lymphatic drainage
lymphatic fluid from the nipple, areola, and lobules collect in the subareolar lymphatic plexus and 75% drains into the axillary lymph nodes, this then drains into clavicular nodes and subclavian lymphatic trunk, remaining fluid will drain into parasternal and abdominal lymph nodes
157
breast innervation
anterior and lateral branches off intercostal nerves
158
acini
functional units of the breast which are lined with epithelial cells that secrete milk and dump into interlobular collecting system, myoepithelial cells underly the acini which can contract to cause milk ejection
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time required for full breast development
takes about 4 years for full development (breast growth continues until age 35)
160
colostrum
the first milk produced after delivery that contains immunologic components and is produced in small quantities over the first few days postpartum, during this time prolactin will disrupt typical HPA that would otherwise stimulate ovulation
161
fibrocystic breasts
the most common benign condition of the breast characterized by the proliferation of ductal breast tissue thought to be associated with an alteration in estrogen/progesterone or an increase in prolactin resulting in fibrocystic changes and more dense breast tissue that occurs under normal hormonal monthly changes, it affects 30-60% of women and is most common in women of childbearing age or premenopausal women commonly palpated in the upper/out quadrant of the breast (most are < 1 cm and asymptomatic but can be painful and have accompanying straw-colored or green discharge)
162
fibroadenoma
benign breast mass typically 1-3 cm in diameter caused by overgrowth of glandular epithelial and fibrous supporting structural tissue typically causing a well-circumscribed, round, mobile, and painless mass that is slow-growing which can often spontaneously resolve, can change in association with monthly hormonal fluctuations
163
non-infectious mastitis
inflammation of breast tissue typically from breastfeeding and associated with blocked milk duct, infrequent feedings, damage to the nipple, stress/fatigue, oversupply of milk, and rapid weaning that most commonly occurs in the first 3 months of lactation - typically resolves in 12-24 hours with breastfeeding and breast massage (if seen in non-breastfeeding patient need to think about underlying immunocompromise or inflammatory breast cancer)
164
infectious mastitis
most commonly caused by staph aureus when mastitis persists for more than 12-24 hours or with a chaffed nipple allowing bacteria to enter and multiply in stagnant milk causing infection, may have associated fever, malaise, and lymphadenopathy
165
breast abscess
complication of mastitis or cellulitis causing formation of a purulent fluid pocket most commonly causes by staph aureus
166
galactorrhea
inappropriate lactation or production on milky discharge which can occur in men due to hormonal disturbances most commonly associated with hypothalamic-pituitary disorders (hyperprolactinemia, hypothyroidism causing increased TRH), pituitary tumors (prolactinomas), paraneoplastic syndrome (SCLC, bronchogenic cancers, islet cell tumors) trauma, chronic stress, or medications (antipsychotics, spironolactone)
167
gynecomastia
excess breast tissue development in males (hyperplasia of stromal and ductal tissue behind the nipple) most commonly in adolescents and men > 50 years old caused by an alteration of estrogen/testosterone ratio due to elevated estrogen but normal testosterone or normal estrogen but low testosterone where breast tissue increases responsiveness to estrogen, can be due to medications, paraneoplastic syndrome, weight gain, stress, hypogonadism, CKD, liver dysfunction, testicular, adrenal, or pituitary tumors
168
spontaneous abortion
the unexpected loss of pregnancy before 20 weeks (AKA miscarriage) where many are associated with genetic abnormality and some are associated with maternal age, infection, maternal uterine structural abnormalities, placental abruption, PROM, poorly controlled DM, ETOH, smoking, drug use, obesity, thyroid dysfunction, and medications
169
missed abortion
fetal demise (no fetal heart beat) without expulsion from the uterine cavity
170
threatened abortion
symptoms of abortion (bleeding/cramping) but fetus remains viable with closed cervical os
171
inevitable abortion
cervical os is open, products of conception will be passed
172
incomplete abortion
when some of the products of conception have been released through the cervical os but some remain in the uterus (may have heavy bleeding)
173
recurrent abortion
2-3 spontaneous abortions
174
septic abortion
induced or spontaneous abortion where an infectious pathogen enters the endometrium and/or myometrium, risk is increased with unsafe abortion techniques, prolonged bleeding, and surgical intervention and most commonly associated with vaginal bacteria including Enterobacteriaceae, strep, and staph
175
septic abortion presentation
vaginal bleeding (POC), PID symptoms, purulent vaginal discharge, fever, and evidence of septicemia
176
trophoblast function
composed of 3 layers - the amnion, the chorion, and the syncytiotrophoblast which secretes human chorionic gonadotropin (hCG) which causes continued stimulation to the corpus luteum to secrete progesterone preventing menses (the syncytiotrophoblast will eventually become the placenta by embedding trabeculae cells into the uterine wall to create villous tress)
177
yolk sac function
develops the second week of gestation along with amnion and helps provide nutrients to the embryo until the placenta is formed, develops primordial germ cells, and encourages the development of vasculature and fetal RBC production
178
germ cell lines within the embryo
ectoderm, mesoderm, and endoderm
179
placenta development
initially formed from trophoblastic cords from the blastocyst that develop into blood vessels and attach the fetus to the uterus, diffusion begins to occur between mom and fetus and oxygenated blood plasma travels from mom to fetus through the umbilical vein where deoxygenated blood plasma travels to mom from fetus through the umbilical artery, as the placenta grows, the surface area increases, tissue thins and diffusion occurs more easily (once developed, very vascular with 625 mL of blood per minute being exchanged during last week of pregnancy)
180
placenta releases
estrogens and progestins as well as oxygen, nutrients, water, and hormones from the maternal circulation
181
permeability of placental membrane
actively or passively transports molecules and nutrients necessary for the fetus but does not allow fetal and maternal blood to mix
182
placental abruption
partial or complete premature separation of the placenta from the endometrial lining causing pain during separation and bleeding (venous or arterial), arterial bleeding will have higher pressure and an increased risk of spreading/worsening of the separation and can be life-threatening, lower pressure bleeding most commonly occurs along the edge of placenta and is often self-limited but can increase the risk for intermittent bleeding and growth restriction
183
placenta previa
when the placenta develops over the cervix which is thought to be associated with poor vascular supply in the typical upper uterine cavity attachment area or with a larger placenta seen in multiple gestation, risk increases with previous c-section or trauma which decreases the vascularity of the decidua within the optimal region of the uterine cavity
184
complications of placenta previa
structures of the pelvis can put shearing pressure on the inferiorly placed placenta causing slight detachment and vaginal bleeding, sexual intercourse and intravaginal exam can also cause bleeding later in pregnancy (most commonly in the 3rd trimester)
185
ectopic pregnancy
implantation of a fertilized ovum outside of the typical intrauterine site most commonly in the fallopian tube (can also be in the cervix, ovary, abdominal cavity, or site of scar tissue) which can be associated with previous inflammation or scarring due to PID, surgical changes, fertility procedures, advanced maternal age, IUD, and douching but also can be idiopathic (smoking can increase risk of PID and ectopics) - a leading cause of death for women in the first trimester of pregnancy
186
ectopic pregnancy presentation
POOP typically 6-8 weeks after LMP, pain along one of the lower quadrants, vaginal bleeding, shock, and syncope
187
death can occur in ectopic pregnancy due to
rupture of the fallopian tube or implantation of previous c-section scar which can rupture uterine wall and cause patient exsanguination/hemorrhage
188
cord prolapse
when the umbilical cord presents prior to delivery of the head and gets compressed in the pelvis which leads to the occlusion of key vasculature and fetal ischemia, the risk is increased with obstetric procedures such as fetal manipulation, rush of amniotic fluid when membranes rupture, multiples, premature delivery, malformations of the uterus, low attached placenta, prolonged labor, long umbilical cord, and abnormal fetal presentation
189
preeclampsia
maternal hypertension developing after 20 weeks of pregnancy where defective spiral arteries remain narrow (rather than enlarging and becoming straighter) causing placenta hypoperfusion causing it to release substances that alter maternal vascular functioning decreasing renal blood flow and causing activation of RAAS, increased BP, and proteinuria, thought to be multifactorial and possibly immune-mediated, genetically linked, related to vascular abnormalities, or environmental exposures
190
eclampsia
the extreme of preeclampsia which causes diffuse vasospasm as a result of placental ischemia leading to severe hypertension impeding autoregulation of cerebral circulation causing seizures (cerebral edema and cerebral vascular spasm), decreased level of consciousness, low urine output, hypertensive emergency, and poor liver functioning
191
HELLP
complication of eclampsia causing Hemolysis, Elevated Liver enzymes, and Low Platelets
192
amniotic sac
fibrous tissue made up of collagen and laminin where metalloproteases will start to degrade it as mother gets closer to delivery (AKA membranes)
193
amniotic fluid function
normally about 500-1000 mL of fluid that the fetus floats in within the amniotic sac which helps with protection, wiggle room, and fetal temperature maintenance and is exchanged every 3 hours (key electrolytes are exchanged every 15 hours)
194
premature rupture of membranes (PROM)
rupture of membranes < 37 weeks gestation allowing for the release of amniotic fluid prior to beginning contractions which is commonly caused by genital tract infection resulting in inflammation and prostaglandin release and weakening and leads to oligohydramnios (can cause sudden or intermittent leaking), risk factors include trauma, genetics, inflammatory disorders, and cigarette smoking
195
time at which membranes normally rupture
when the cervix is fully dilated (beginning of 2nd stage of labor)
196
amount of blood loss expected with delivery of placenta
350 mL
197
Rh incompatibility
occurs when the mom is negative for Rhesus D antigen but the baby is positive causing the mom to develop anti-D antibodies in the case there is fetomaternal bleeding, antibodies can then cross the placenta and destroy fetal RBCs, particularly in subsequent pregnancies
198
complications of Rh incompatibility
phagocytosis of fetal RBCs which can be asymptomatic or lead to fetal hemolytic anemia, hydrops fetalis, or fetal demise
199
primary postpartum hemorrhage
bleeding that causes hypovolemia within the first 24 hours after delivery > 500 mL if vaginal delivery
200
secondary postpartum hemorrhage
bleeding that causes hypovolemia that occurs after 24 hours-12 weeks after delivery > 500 mL if vaginal delivery
201
most common causes of postpartum hemorrhage
the 4 T's: uterine atony (tone), tissue, trauma, and thrombus also increased risk with retained placenta, lacerations, use of instrumentation, large newborn, HTN, prolonged labor, placenta previa, placental abruption, and coagulopathy
202
risk of PE increases during pregnancy due to
most common during postpartum time because of increased venous stasis, hormonal changes, endothelial injury, hypercoagulability, and increased estrogen (increased fibrinogen)
203
amniotic embolism
when amniotic fluid enters the maternal venous circulation and then pulmonary circulation most commonly occurring during labor or immediately postpartum where there is an increased risk if delivery is premature, advanced maternal age, abnormal attachment site of the placenta, preeclampsia, c-section, and polyhydramnios
204
peripartum dilated cardiomyopathy
heart failure that is typically seen in the third trimester or after delivery causing LV EF of < 45% due to increased blood volume, increased preload, dilutional anemia, increased placenta demand for large volumes of blood, pro-inflammatory state, genetic disposition, and hormonal alterations that change vascular functioning and lead to enlargement of the left ventricle and increased risk for MI
205
risks for peripartum cardiomyopathy
advanced maternal age, multiple gestation, hypertension, and cocaine use
206
risk of arterial/aortic dissection increases during pregnancy due to
increased abdominal pressure and hormonal changes in vasculature during pregnancy, risk is compounded if collagen disorder present or cardiac malformation
207
aortic dissection
separation in the wall of the aorta allowing for the accumulation of blood between the tunica intima and tunica media which creates a false lumen that will progressively increase in size as blood spreads in the false tract that can rupture, create downstream reentry site connecting with true lumen, enlarge to compress or occlude the true lumen causing hypoperfusion, or form a hematoma within the intimal defect
208
intracerebral hemorrhage
typically associated with preeclampsia/eclampsia where angiogenic and hemodynamic shifts cause an increase in the size of aneurysms and can lead to subarachnoid hemorrhage, highest risk during 3rd trimester of pregnancy but can also occur during the postpartum period
