Women's Health Flashcards
Key Points to the menstrual cycle
1) Follicular phase/Proliferative (14 days): presence of estrogen thickens the endometrium until a dominant follicle is produced-leads to ovulation
2) Luteal phase/Secretory phase: AFTER ovulation, progesterone prepares uterus lining for implantation, if the corpus leuteum doesn’t implant, then you will decrease both hormones and menstruation happens
On what days in the menstrual cycle does ovulation occur?
Days 12-14
What causes ovulation? (the release of the egg)
LH surge
Heavy or prolonged bleeding @ normal menstrual intervals
menorrhagia
Irregular bleeding between normal menstrual cycles
Metorrhagia
Infrequent menstruation
Oligomenorrhea
Painful menstruation
Dysmenorrhea
What is the cause of primary dysmenorrhea?
Non-pelvic etiology:
- Caused by increased prostaglandin secretions which causes increased uterine wall contractility
- Treat with NSAID
What is the cause of secondary dysmenorrhea?
A pelvic etiology:
-Caused by something such as endometriosis, leiomyoma, PID
At what point in the menstrual cycle do the symptoms of Premenstrual syndrome occur?
- They occur in the luteal phase
- They are relieved within 2-3 days of the onset of menses
- Must be symptom free at least 7 days during the follicular phase
**Treat with SSRI
What is the definition of primary amenorrhea?
- Failure of menarche onset before the age of 15 if 2ry sex characteristics present
- Failure of menarche onset before the age of 13 if NO 2dy sex characteristics
Etiologies of primary amenorrhea
1) A uterus & breasts present and there is outflow obstruction
2) There is no uterus (Mullein agencies, androgen insensitivity)
3) Ovarian causes of too much FSH, LH-there would be no breasts present (premature ovarian failure, gonadal dysgenesis)
4) HPA axis failure causes low FSH. LH
What is the definition of secondary amenorrhea?
absence of menses for >3 months in a patient with previously normal menstruation
Etiologies of secondary amenorrhea
1) Pregnancy (MC)
2) Hypothalamus dysfunction ( low FSH, LH)
3) Pituitary dysfunction (high prolactin)
4) Ovarian dysfunction (PCOS, POF
Amenorrhea workup
1) pregnancy test
2) estrogen stimulation
3) Progesterone challenge test
- If withdrawal bleeding there is an ovarian issue
- If no withdrawal bleeding there is not enough estrogen or an outflow obstruction
What is the influence of estrogen and progesterone replacement on endometrial cancer?
Unapposed (only estrogen) replacement = INCREASED risk
Estrogen & Progesterone combo = protective
What is the best lab to order when menopause is suspected?
FSH! The levels will surge greater than 30
-Later you will see decreased estrogen
Consequences of menopause (loss of estrogen protection)
1) osteoporosis
2) increased lipids
3) increased cardiovascular risk
What is a leiomyoma?
Benign smooth muscle tumor of the uterus
MC presenting symptom of leiomyoma?
Bleeding
Treatment of leiomyoma
GhRH agonist (Leuprolide)
-Hysterectomy is definitive
What is the MC cause for a hysterectomy?
Leiomyoma
Cystocele
Prolapse of the posterior bladder into the anterior vagina
Rectocele
Prolapse of the rectum in the posterior vagina
Enterocele
Prolapse of the pouch of douglas into the upper vagina
Grading of Pelvic organ prolapse
I. descent into upper 2/3 of vagina
II. cervix aproaches introitus
III. outside introitus
IV. complete prolapse outside vagina
Pelvic organ prolaspe management
- prevent with Kegal exercises
- Pessaries
- Ligament fixation surgeries
What is the triad of PCOS?
1) Amennorrhea
2) obesity
3) Hirstuism
*all from insulin resistance
Pathophysiology of PCOS
Abnormal HPA axis, leading increased insulin (insulin resistance) and increase LH leading to ovarian androgen production
-High testosterone and high LH levels found
Treatments for PCOS
- OCP
- Spirinolactone (tetragenic), decreases androgens
- Clomiphene; if desiring pregnancy
- Metformin
99% of cervical cancer is caused by what?
HPV 16, 18 MC
What is the MC type of cervical cancer?
squamous cell
MC presenting symptom for cervical cancer?
Post coital bleeding/spotting
How do you diagnose cervical cancer?
Colposcopy with bx
What strands of HPV does the Gardasil vaccine cover
HPV 6,11,16,18
- given between 11-26 years old.
- If under 15: get 2 doses 6 months apart
- If over 15: get 3 doses over 6 months
What type of breast disease changes with menstruation?
Fibrocystic breast disease
Hallmarks of fibrocystic breast disease
Fluid-filled breast cyst due to exaggerated response to hormones
- MC in 30-50 y/o & MC breast disorder
- Mobile and tender
- Straw colored fluid on FNA
Hallmarks of breast fibroadenoma
-Late teens to early 20s
-nontender, mobile, rubbery mass that DOES NOT change with menstruation
-
Hallmarks of inflammatory breast cancer
- Peau d’orange apperance due to lymphatic obstruction
- red swollen, warm itchy breast
Neoadjuvant Endocrine Therapy for ER positive breast cancer?
- Anti-estrogen: Tamoxifen
- Aromatase Inhibitors: Letrozole, Anastrozole
- Can also be used in high risk patients to prevent breast cancer
Neoadjuvant Endocrine Therapy for HER2 positive breast cancer
Trastuzumab (Herceptin)
MC causative organisms of Pelvic Inflammatory Dz
N. gonorrhoeae & Chlamydia
Treatment of PID
Outpatient: Doxy + Ceftriaxone
Inpatient: Doxy + 2nd gen cephalosporin
Diagnosis of PID
1) Abdominal tenderness
2) Adnexal tenderness
3) Cervical motion tenderness (Chandelier sign)
PLUS 1 of the following:
- fever
- WBC
- positive gram stain
- pus
- ESR, CRP
Hallmarks of bacterial vaginosis
- Caused by an overgrowth of natural bacteria (Gardnerella vaginalis) as the PH increases
- MC cause of vaginitis
- Whiff test with fishy order and thing, grey watery discharge
- Clue cells on microscope
- Metronidazole x 7 days
- Do not need to treat partner
Hallmarks of Trichomoniasis vaginitis
- Flagellated protozoa
- Itching, erythema, dysuria
- Malodorous frothy yellow green discharge, STRAWBERRY CERVIX
- Treat with metronidazole and treat partner
Hallmarks of Canndida vaginitis
- Candida albicans overgrowth
- Curd-like cottage cheese discharge
- Hyphae yeast on KOH
- Treat with 1 dose fluconizole
- Can also use anti fungal creams such as clotrimazole
Chlamydia hallmarks
MC cause of Cervicitis
- Dysuria, mucopurulent cervix, frequency
- Diagnose with Nucleic acid PCR
- Treat with Azithromycin 1g x 1 dose OR doxycycline 100mg PO x 10 days
Gonorrhea hallmarks
- May be asx with vaginal discharge, dysuria, frequency
- Dx with nucleic acid PCR
- Tx is with Ceftriaxone 250 mg IM
Chancroid Hallmarks
- Caused by Haemophilus Ducreyi
- Appear as a PAINFUL genital ulcer with inguinal lymphadenopathy
- Treat with Azithromycin
How does HPV present
- Precursor to cervical cancer
- Flat, pedunculate flesh-colored growths
- “CAULIFLOWER LESIONS”
- Cells whiten with 4% acetic acid application
How do Oral contraceptive pills work?
- Prevent ovulation by inhibiting the LH surge
- Thickens cervical mucus
- Thins endometrium
Pros of OCP
- controls dysmenorrhea
- Protects against osteoporosis, endometrial and ovarian cancer
Cons and contraindications of OCP
- Smokers over 35 y/o SHOULD NOT USE
- Increased risk for gallstones, DVT/PE, fluid retention
- Caution in diabetic
What is the “mini pill”?
Progestin only birth control:
- inhibits ovulation and thickens cervical mucosa
- safe during lactation
- can have menstrual irregularities
2 examples long lasting progestins
1) Implanon (etonogestrel): implantable rod that lasts 3 years; increases osteoporosis
2) Depo Provera: injection lasting 3 months
What is ortho evra?
Transdermal birth control patch
-applied weekly for 3 weeks with 1 week off
What is the most effective form of contraception (other than sterility and abstinence) ?
Intrauterine devices:
1) Mirena: lasts 5 years
2) Paraguard: copper IUD, lasts 10 years
Clomiphene
Partial estrogen receptor agonist (stimulates ovulation via hypothalmus)
-Induces ovulation in patients with Infertility and PCOS
Leuprolide
GnRH analog:
- If given PULSATILE; treats infertility
- If given CONTINUOUS; treats fibroids, prostate cancer, DUB, PMS
How long after conception can a serum b-hcg be positive?
5 days
How long after conception can a urine b-hcg be positive?
14 days
What is Goodell’s sign?
Cervical softening due to increased visualization at 4-5 weeks gestation
What is chadwicks sign?
bluish coloration of the cervix at 8-12 weeks gestation
How do you estimate the date of deliver?
Naegele’s rule:
7 days after start of LMP subtract 3 months
Triple screening measured at 15-20 weeks (2nd trimester)
- alpha-feto protein
- B-hcg
3) estradiol
A 2nd trimester screening test with the following results indicate what dx?
AFP: low
B-hCG: High
Estradiol: Low
Down Syndrome (Trisomy 21)
A 2nd trimester screening test with the following results indicate what dx?
AFP: High
B-hCG: n/a
Estradiol: n/a
Open neural tube defects such as spina bifida
A 2nd trimester screening test with the following results indicate what dx?
AFP: Low
B-hCG: Low
Estradiol: Low
Trisomy 18: often born stillborn or die within first year
When is gestational diabetes screened for?
24-28 weeks
When are fetal heart tones heard on doppler?
10-12 weeks
Who gets RhoGAM and when is it given?
RH - mothers who are unsensitized
Given @ 28 weeks, and within 72 hrs after childbirth
What is the definition of a spontaneous abortion ?
loss of pregnancy before 20 weeks
What is the MC cause of first trimester bleeding?
Threatened abortion
Hallmarks of threatened abortion
- Pregnancy may be viable
- Bleeding or spotting
- Nothing is expelled
- Bed rest and monitor B-hCG
Hallmarks of an inevitable abortion
- nothing is expelled
- progressive cervical dilation, possible ROM
- D&C if 1st trimester
- D&E (evacuation) if after 1st trimester
Hallmarks of incomplete abortion
- some contents expelled
- dilated cervix
- heavy bleeding with retained tissue
- Give ptocin, D&E
Hallmarks of a complete abortion
- all contents expelled
- give rhogam if indicated
Hallmarks of missed abortion
Fetal demise but still retained in uterus
- nothing expelled
- closed cervical os
- misoprostol, D&E
What is placenta previa?
Abnormal placental placement on or close to the cervical os
How does placenta previa present?
PAINLESS 3rd trimester bleeding, do an u/s to determine placenta placement
-You then need to monitor fetal heart rate and induce steroids for lung development if past 24 weeks. If complete previa you must do C-section
What is a placental abruption ?
Premature separation of placenta from uterine wall
How does placental abruption present?
Severe PAINFUL distended uterus with dark red profuse 3rd trimester bleeding
- The fetal heart rate is likely to to be bradycardia and in distress
- Immediate delivery is needed
Average length of menstrual cycle
24-38 days with 4.5-8 days of menstruation
Etiologies of dysfunctional uterine bleeding
1) chronic anovulation (90 %)
- unopposed estrogen without ovulation means no progesterone is produced, which means the uterus will shed irregular and unpredictably as overgrowth occurs rather than when progesterone should have stimulated it to.
2) ovulatory
- Prolonged progesterone secretion after ovulation causes increased endometrial vessel dilation and prostaglandins
Workup of dysfunctional uterine bleeding
Diagnosis of exclusion!!
-must find no organic cause even after all the following has been evaluated:
Hormone levels, TVUS, endometrial bx (if >4mm)
Treatment for acute/ severe dysfunctional uterine bleeding
- high dose IV estrogens
2. hysterectomy is definitive
Treatment for anovulatory and ovulatory causes of dysfunctional uterine bleeding
OCP
