Women's Health Flashcards
Workup for a vaginal pain complaint should include, at minimum:
Preg test, UA, CBC, US, pelvic exam
DDX for pelvic pain may include:
- Primary Dysmenorrhea
- Mittelshmerz- unilateral dull, aching pain that occurs mid cycle due to leakage of prostaglandin-containing follicular fluid
- Ovarian cysts- if sudden onset you should consider acute rupture
- Ovarian torsion
- Endometriosis
- Leiomyomas
Workup of ovarian cysts should include:
- Pelvic/transvaginal US
- Management- if patient has hemoperitoneum and HYPOtension- emergency surgery. If STABLE–> outpatient with NSAIDs
**Patients with unruptured cysts <5cm–> no treatment, will involute within 2-3 menstrual cycles
Acute onset of adnexal pain from ischemia w/ a history of intermittent pain, sometimes associated with exertion may be suggestive of _____.
Ovarian torsion
Some common RFs for torsion include:
- Pregnancy
- Large ovarian cysts or tumors
- Chemical induction of ovulation
Ovarian torsion workup:
US w/ doppler flow is procedure of choice but not 100% sensitive
Recurrent pelvic pain associated with menstrual cycle w/ secondary dysmenorrhea and dyspareunia is associated with ______.
Endometriosis
*US may show endometriomas, definitive dx not made in ED
Uterine fibroids are benign smooth muscle tumors, seen most commonly in women in middle-later reproductive years. They are known as:
Leiomyomas
*May develop abnormal vaginal bleeding, dysmenorrhea, bloating, backache, urinary symptoms, and dyspareunia
PE findings associated with leiomyomas:
- Bimanual exam–> mass or enlarged uterus
- Pelvic US–> confirmatory
How are leiomyomas managed:
-NSAIDs or other analgesics for pain and hormonal manipulation for excessive bleeding and referral to gyn
Key differences between dysmenorrhea and endometriosis:
Often, the pain of dysmenorrhea occurs with ovulatory cycles on the first or second day of menstruation, whereas pain from endometriosis may begin 1-2 weeks before menstruation, worsens 1-2 days before, and is relieved at or right after the onset of menstrual flow
First line treatment for dysmenorrhea is:
NSAIDs
-OCPs also a consideration
W/ secondary dysmenorrhea symptoms are secondary to an identifiable cause such as:
Endometriosis and adenomyosis, uterine fibroids, cervical stenosis, or pelvic adhesions
Primary amenorrhea is divided into 3 categories:
- Outflow tract obstruction: imperforate hymen, transverse vaginal septum, vaginal agenesis, vaginal atresia, testicular feminization
- End-organ disorders: ovarian failure, gonadal agensis (no female internal organs or breasts)
- Central-regulatory disorder: hypothalamic disorders, (defects in GnRH pulsatility with anorexia, stress, athletics, hyperprolactinemia, hypothyroidism, severe weight loss, and delayed puberty), pituitary disorders
The MC cause of secondary amenorrhea is _____.
Pregnancy
*Other causes can be categorized as anatomic abnormalities, ovarian dysfunction, prolactinoma and hyperprolactinemia, and CNS or hypothalamic disorders
Anatomical abnormalities that can cause secondary amenorrhea:
- Asherman Syndrome → the presence of intrauterine synechiae or adhesions, usually secondary to intrauterine surgery or infection
* Etiologies include D&C, myomectomy, cesarean delivery, or endometritis
•Cervical Stenosis → can manifest as secondary amenorrhea and dysmenorrhea. Usually caused by scarring of the cervical os secondary to surgical or obstetric trauma
Constellation of anovulation, oligomenorrhea or amenorrhea, hirsutism, obesity, and enlarged polycystic ovaries is associated with ________.
PCOS
Treatment of PCOS depends on the desired outcome…
•For those desiring fertility, ovulation induction using clomiphene citrate (Clomid) is begun
oPatients with PCOS are particularly resistant to ovulation induction. The probability of induction can be increased with weight loss and the concomitant use of corticosteroids. Also metformin if they have diabetes
•If not interested in fertility, cycle progestins or Depo-Provera should be used to decrease the risk of endometrial hyperplasia and cancer secondary to unopposed estrogen
Ovulation induction with ________ can be used in patients with hyperprolactinemia.
Bromocriptine
Most patients with dysfunctional uterine bleeding (DUB) are ______.
Anovulatory- most common udring adolescence, perimenopause, lactation, and pregnancy
Things to r/o with DUB:
- Structural or congenital cause
2. If > 35y then endometrial bx should be done to r/o endometrial hyperplasia or cancer
Treatment of DUB…
- Acute hemorrhage–> stop bleeding with IV estrogen
- Chronic DUB–> nonhormonal therapy with NSAIDs can decrease menstrual blood loss by 20-50%. Usually reserved for ovulatory women
- Primary treatment for anovulatory DUB= hormonal therapy! Mirena is especially useful
- Surgery may be indicated–> D&C, endometrial ablation, hysterectomy
Cyclic pelvic pain beginning 1-2 weeks before menses, peaking 1-2 days before the onset of menses, and subsiding at the onset of flow or shortly thereafter is the hallmark of _______ (condition/disease state).
Endometriosis
*Should perform PE during early menses when implants are likely to be the largest and most tender
The only way to definitively diagnose endometriosis is through a:
Laparascopy or laparotomy
Treatment options for endometriosis:
- Medical therapies (not for those trying to conceive)- NSAIDs, OCPs, progestins, Danazol
- Surgical- laparoscopy and fulguration of visible endometrial implants OR TAH/BSO, lysis of adhesions, and removal of endometrial lesions
Ovarian cysts are either: functional cysts (majority) or neoplastic growths.
Functional cysts divided into: follicular cysts (MC) and corpus luteum cysts
- Follicular cysts- asymtomatic and unilateral (typically). Can lead to ovarian torsion when >4cm. Most resolve spontaneously.
* Acute abdominal pain may result from rupture of cyst
Primary tool for ovarian cyst workup is:
Pelvic US
____ (Ovarian CA antigen) may be obtained in those at a high risk for ovarian cancer.
CA-125
A palpable ovary or adnexal mass in a premenarchal or postmenopausal patient is suggestive of _____ instead of functional cyst and should be investigated with diagnostic laparoscopy or laparotomy.
Ovarian neoplasm
*Reproductive age women with cysts > 8 cm or that persist longer than 60 days or that are solid or complex on ultrasound probably do not have a functional cyst – investigate with diagnostic laparoscopy or laparotomy
For patients of reproductive age with cysts <6cm in size, observation with close follow-up US is appropriate
:)
- Often start on OCPs to suppress ovulation in order to prevent the formation of future cysts
- *Cysts that do not resolve in 60-90 days require evaluation with cystectomy and (RARELY) oophorectomy
What are the symptoms of vaginitis (trich)?
- Severe pruritus
- Discharge, often malodorous (misty)
- Dysuria
- Dyspareunia
- May be asymptomatic (as may all vaginitis)
- Greenish-yellow, frothy (small bubbles)
How is vaginitis diagnosed?
-Motile flagellated protozoans on wet prep (saline)
oUnicellular, anaerobic
Treatment of vaginitis (trich) is:
Flagyl 2gm PO single dose or 500mg PO twice daily for 7 days
TREAT PARTNERS!
Symptoms of BV are:
- Fishy odor
- Usually heavy discharge
- Pruritus complaint not common
- “Odor after intercourse” (fishy)
- Thin, adherent, homogenous discharge
- Malodorous (fishy)
- White or gray
Dx of BV requires 3 of the following 4:
oTypical discharge
oAlkaline pH → 5.0 to 5.5 (normal 3.5 to 4.0)
oPositive “whiff” test → an amine odor noted with addition of 10% KOH
oClue cells on wet prep (saline)
•Vaginal epithelial cells that are diffusely covered with bacteria
*Treatment is the same as for trich
Symptoms of candidiasis are:
-Pruritus, burning
-“Cottage cheese” discharge
-Dyspareunia
-Vaginal erythema
oVulvar erythema
-Curdy, white discharge
-Not malodorous
-May be asymptomatic
What is seen on KOH wet prep with candidiasis?
- Pseudohyphae or budding yeast
- Not seen always so may need to treat presumptively
How is candidiasis treated?
-Oral fluconazole, topical imidazole, or intravaginal treatments
Endometritis, Salpingitis, Tubo-ovarian abscess, and pelvic peritonitis all fall under the larger umbrella of a ______ diagnosis.
Pelvic Inflammatory Disease (PID)
Some causes of PID are:
STIs!!
Polymicrobial upper genital infection (mixed aerobic and anaerobic) → gonorrhea, chlamydia*, endogenous organisms (anaerobes, H. flu, enteric gram negative rods, streptococci, mycoplasma genitalium)
PID is strongly associated with infertility and the risk of ectopic pregnancy is also increased!
:(
Incidence of PID is highest among women aged _____.
15-25y
Clinical features of PID are:
oLower abdominal and pelvic pain typically is bilateral
oNausea (± vomiting), headache, lassitude are common
o± Fever
oExamination reveals lower abdominal and pelvic pain and cervical motion tenderness (chandelier sign)
oPurulent and/or malodorous discharge and inflammation of Bartholin’s or Skene’s glands may be present
oAn adnexal mass may indicate a tubo-ovarian abscess
Lab studies for PID include:
oDNA probes for gonorrhea and chlamydia
oTransvaginal ultrasonography is helpful in differentiating acute and chronic inflammation or the presence of adnexal masses
oDiagnostic culdocentesis or laparoscopy may be required
Treatment of PID includes:
- Ceftriaxone IM x 1 dose PLUS Azithromycin (or doxycycline) for 2 weeks
- May add metronidazole BID for 2 weeks (to cover for anaerobes)
- Remove IUD if present!
- *If disease is severe woman should be hospitalized- on doxy for 14 days PO
Persistent PID can lead to development of _____.
TOA
*usually accompanied by fever and increase in WBCs
Imaging of choice for TOA is:
US
*May need pelvic CT in obese women
Treatment of TOA involves:
oFirst step is frequently broad-spectrum antibiotics
oUnless the abscess is ruptured and causing peritoneal signs or is impenetrable by antibiotics, surgery can often be avoided
oTreatment of choice is often ampicillin (2g IV q4h), gentamicin, plus clindamycin or metronidazole
*If more SERIOUS:
•Drainage of TOA using ultrasound guidance or laparoscopy if no response within 48 hours of medical therapy
- Unilateral salpingo-oophorectomy is considered as a curative therapy for unilateral TOA
- For bilateral TOAs, often a TAH/BSO may be necessary
____ is often associated with lactation and presents as focal tenderness, erythema, and differences in temp from one region of the breast to another.
Mastitis
*Complicated by abscess formation
Women with mastitis _____ (should/should NOT) continue to breastfeed.
Should :) - prevents intraductal accumulation of infected material
- If not breastfeeding you should pump
- *Treat with ABX- cephalexin
The MC cause of spontaneous abortions is:
Chromosomal abnormalities- 60%
_____ is the termination of pregnancy, by any means, before 20 weeks gestation, less than 500g, or less than 25cm.
Abortion
Risk factors for a spontaneous abortion are:
Smoking, infection, maternal systemic disease (DM, thyroid, PCOS), immunologic parameters, drug use, maternal/paternal age, increasing parity, high BMI, heavy caffeine use, submucosal fibroids, uterine abnormality (septum, bicornuate), Asherman’s (uterine synechiae/atresia), history of prior SAB
Classifying spontaneous abortions:
- Threatened: Bleeding + Unopened cervix + Product not passed
- Inevitable: Bleeding + Opened cervix + Product not yet passed but no way to maintain pregnancy
- Incomplete: Bleeding + Opened cervix + Partial product passage
- Complete: Bleeding + Opened cervix + Product passed
- Missed: NO bleeding + Unopened cervix + No passage of product (fetal demise has occurred without symptoms).
“Treatment” of spontaneous abortion involves:
oIf the pregnancy has been definitively determined to be no longer viable, the uterus must be emptied
oIf the pregnancy is early and the patient is managed expectantly (allow the products of conception to pass naturally), careful follow-up with pelvic examinations, serial hCG titers, and transvaginal ultrasonography can be used to determine whether the abortion is complete
oDilation and curettage also may be necessary to ensure complete emptying of the uterus or as one form of induced abortion. Morbidity is caused by uterine perforation or cervical laceration
Rhogam necessary when mother is Rh negative and:
- At any time in a pregnancy if she has vaginal bleeding
- If she miscarries or has an ectopic pregnancy
- If she undergoes a procedure such as an amniocentesis
- At 28 WEEKS and at delivery is baby is Rh positive
Large placental separations may result in:
-Premature delivery, uterine tetany, DIC, and hypovolemic shock
Classic presentation of placental abruption is:
Third-trimester vaginal bleeding associated with severe abdominal pain and/or frequent, strong contractions
*Dx is mainly clinical. Few picked up on US. May use US to rule out previa.
Treatment of placental abruption involves:
- Delivery in severe cases
- Stabilize the patient and hospitalize with continuous fetal monitoring. Prepare for possible hemorrhage with placement of large bore IVs, infusion of LR, preparation of whole blood or PRBCs)
_____ is a pregnancy that implants outside the uterine cavity.
Ectopic
*Usually fallopian tube
PE for ectopic reveals:
Adnexal mass that is often nontender, a uterus that is SGA, and bleeding from cervix.
-If ruptured patient may be HYPOtensive, unresponsive, or show signs of peritoneal irritation secondary to hemoperitoneum
Labs in ectopics:
The classic finding is a β-hCG level that is low for gestational age and does not increase at the expected rate
- In patients with a normal intrauterine pregnancy, the trophoblastic tissue secretes β-hCG in a predictable manner that should lead to doubling (or at least an increase of ≥⅔) approximately every 48 hours
- An ectopic pregnancy has a poorly implanted placenta with less blood supply than in the endometrium, thus the level of β-hCG does not double every 48 hours
US for ectopic may reveal adnexal mass
A gestational sac with a yolk sac seen in the uterus on ultrasound indicates an IUP
For patients that cannot be definitively diagnosed with an ectopic v. IUP should receive serial hCGs q 48h
As a guideline, an IUP should be seen on transvaginal ultrasonography with a β-hCG between 1,500-2,000 mIU/mL. A fetal heartbeat should be seen with β-hCG > 5,000 mIU/mL
Treatment of ectopic involves:
oIf a patient presents with a ruptured ectopic pregnancy and is unstable, the first priority is to stabilize the patient with IV fluids, blood products, and pressors if necessary
oThen take to the OR where exploratory laparotomy can be done to stop the bleeding and remove the ectopic pregnancy
oIf the patient is stable with a likely ruptured ectopic pregnancy, the procedure of choice is exploratory laparoscopy that can be performed to evacuate the hemoperitoneum, coagulate any ongoing bleeding, and resect the ectopic pregnancy
If patient has an unruptured ectopic, an option other than surgery is:
Methotrexate therapy for treatment of the ectopic pregnancy is usually used for uncomplicated, nonthreatening, ectopic pregnancies.
_______ is defined as abnormal implantation of the placenta over the internal cervical os.
Placenta previa
oComplete Previa = the placenta completely covers the internal os
oPartial Previa = the placenta covers a portion of the internal os
oMarginal Previa = the edge of the placenta reaches the margin of the os
oLow-Lying Placenta = implanted in the lower uterine segment in close proximity but not extending to the internal os
oRarely, a fetal vessel may lie over the cervix known as a vasa previa
Placenta previa fetal risks:
Preterm delivery and its complications, PPROM, IUGR, malpresentation, vasa previa, congenital abnormalities
_____ is the abnormal invasion of the placenta into the uterine wall.
Placenta Accreta
In patients with known or suspected previa, _____ sonography is avoided
Transvaginal
How is placenta previa managed?
oCommonly managed with strict pelvic rest (i.e., no intercourse) and modified bed rest
•Some clinicians wont institute this until the patient presents with sentinel bleed
• However, 70% of patients with placenta previa have recurring bleeding episodes and will require delivery before 36 weeks
•Prepare for preterm delivery:
*Prior to 34 weeks gestation, betamethasone is given to promote fetal lung maturity
**Tocolysis is also used to assist in prolonging the pregnancy up to 34 weeks of gestation. Occasionally it is used past 34 weeks to help control bleeding
Rupture of membranes before ___ weeks is considered preterm rupture of the membranes. Rupture of the membranes occurring before the onset of labor is termed premature rupture of the mebranes.
37
*If the 2 occur together it is called preterm premature rupture of the membranes- PPROM
Prolonged PPROM has been associated with increased risk of:
Chorioamnionitis, abruption, and cord prolapse
Diagnosis of ROM is done by:
History of leaking vaginal fluid, pooling on speculum exam, and positive Nitrazine and fern tests
Treatment of PPROM involves consideration of risks of prematurity v. infection.
Thus, ampicillin with or without erythromycin is recommended in the setting of PPROM
-Corticosteroids also currently recommended
oCommonly, if ROM occurs any time after 34-36 weeks, labor is induced/augmented
Some preterm facts…
- Infants born on the cusp of viability at 24 weeks have a greater than 50% mortality rate
-Tocolysis → the attempt to prevent contractions and the progression of labor
oOnly RITODRINE – a beta-mimetic agent – is FDA-approved for this purpose
oThe principal benefit from gaining 48 hours in a pregnancy is to allow treatment with steroids to enhance fetal lung maturity and reduce the risk of complications associated with preterm delivery
•Betamethasone, a glucocorticoid, can reduce the incidence of RDS and other complications from preterm delivery. Thus, prior to 34 weeks gestation, the advantage of treating with steroids need to be weighed against the risk of prolonging the pregnancy
oChorioamnionitis, nonreassuring fetal testing, and significant placental abruption are absolute indications to allow labor to progress,
Non-reassuring patterns indicating fetal distress…
o Increased or decreased FHR, especially during and after a contraction
• Normal is 110-160 bpm
