Women's Health GYN Flashcards
GTPAL (meaning)
G - GRAVIDITY → # of pregnancies
T - TERM → # carried to 37+ weeks
P - PRETERM → # carried to 20-26 weeks
A - ABORTION → # of losses <20 weeks
L - LIVING → # living children
(TENNESSEE POWER AND LIGHTS)
G4214 → 4 FULL TERM, 2 PRETERM, 1 ABORTION, 4 LIVING
PRIMIGRAVIDA
pregnant for the first time
Depression Scale for Postnatal Women
EDINBURGH POSTNATAL DEPRESSION SCALE
>/= 14 points = depression, < 8 = no depression
-Normal Cycle:
-When is Ovulation?
Fertility is the highest between ?
28 Days
14 days before the next cycle
Day 11-15
2 phases:
Follicular/Proliferative –> Day 1-14
Luteal/Secretory –> Day 15-28
Follicular Phase
** Hypopituitary releases GnRH → stimulate FSH/LH (from anterior pituitary) → follicle growth → estrogen secreted from follicle → NEGATIVE FEEDBACK loop (once it gets to a certain level it stops) → when estrogen get to a high enough level a POSITIVE FEEDBACK occurs with FSH/LH → Surge (bc it is released and keeps releasing) → more estrogen is released = LH spike = OVULATION
Luteal Phase
** After ovulation → follicle turns into CORPUS LUTEUM which secretes PROGESTERONE → if the patient is pregnant the progesterone continues to be produced → if the patient is NOT pregnant Corpus Luteum turns into CORPUS ALBICANS (no longer secretes estrogen and progesterone) → decreased HMs = Endometrial Sloughing/Menses ** (Starts over with follicular phase when the GnRH is secreted again by Hypothalamus)
Primary Amenorrhea
- Pathophysiology:
→ Primary: Never had a period by age 13 + absence of secondary sex characteristics
OR no period by 15 + sex characteristics
Gonadal Dysgenesis: Turners
Mullerian Agenesis: NO UTERUS OR VAGINA
HPO Axis: Anorexia, Bulimia, excessive exercise, wt loss
dx:
→ Pregnancy Test (Quantitative HCG)
→ FSH, Prolactin, TSH, T3, Free T4, Progesterone
tx:
→ No desire for Pregnancy = OCPS
→ Desire for Pregnancy = CYCLIN PROGESTERONE 10mg for 10 days or ovulation inducers
Secondary Amenorrhea
patho:
→ Secondary: Had a period, not does now (Pregnant, IUD)
No menses for 3 months + past of normal cycles
No menses for 6 months + past of irregular cycles
Causes:
-PREGNANCY
-Endometrial Atrophy: Asherman’s Syndrome→ Scarring of endometrium after termination of pregnancy or D&C
-Pituitary Dysfunction: Sheehan’s Syndrome→ hemorrhage causes bleeding into posterior pituitary
dx:
-Drugs, herbals, hormonal changes, stress, wt changes, excessive exercise
Secondary: (workup)
Pregnancy Test
TSH
Prolactin >200 → CT sella (Hyperprolactinemia = think ovulation d/o → secondary amenorrhea, oligomenorrhea)
Progesterone Challenge → Progesterone for 10 days → no bleeding → repeat HCG
FSH → >40 = ovarian failure if low or normal HPO abnormality
tx:
→ No desire for Pregnancy = OCPS
→ Desire for Pregnancy = CYCLIN PROGESTERONE 10mg for 10 days or ovulation inducers
6 Keroypical causes of Primary Amenorrhea
Turner’s syndrome: XO karyotype, webbed neck, broad chest, high FSH
Hypothalamic-pituitary insufficiency: 46, XX, low FSH, LH
Androgen insensitivity: 46, XY, High testosterone, breast development only
Imperforate hymen: 46, XX, diagnosed on PE (patient with cyclic pelvic pain), observed on speculum exam
Anorexia: 46, XX, very low weight
Mullerian agenesis – secondary sex characteristics, no uterus
Dysfunctional Uterine Bleeding
- Pathophysiology:
→ Abnormal Bleeding without cause: - POLYMENORRHEA: menses more frequently (<21 days apart)
HEMORRHAGIC/HYPERMENORRHEA: more blood loss (>7 days or >80mL) during menses
MENORRHAGIA: prolonged/heavy bleeding (>7 days, >80 mL) → REGULAR intervals
METRORRHAGIA: bleeding between menses
MENOMETRORRHAGIA: more blood loss during menses + between menses
OLIGOMENORRHEA: long periods >35 days
→ <16 → Pregnancy, Anovulation, Breakthrough bleeding, Blood dyscrasias (VWD)
→ 16-40 → Pregnancy, Anovulation, BTB on OCP, STI/PID, Endometriosis/Adenomyosis, Endometrial Cancer
→ >40: ENDOMETRIAL CANCER UNTIL PROVEN OTHERWISE, Pregnancy, Anovulation, OCPs/Hormone replacement therapy
- Diagnosis:
→ PREGNANCY TEST (#1)
→ Uterine Dilation & Curettage ( GOLD ) → dx and tx
→ Physical Exam: Thyroid, Liver, GU infx, GI problems (hemorrhoids), Polyps, Fibroids
→ Labs: FSH, LH, Prolactin, Estradiol, Testosterone, TSH, T3,T4, DHEA, coags
→ Endometrial Biopsy - Treatment:
→ Tx aims to cause cyclic bleeding/protect the endometrium
** OCPS + NSAID = TX **
PROGESTERONE (oral or IUD), OCP
14 day of Provera 10mg followed by a monophasic BCP
Mirena or Liletta (long term)
Hysteroscopy, Curettage, polypectomy, ablation
NSAID: Naproxen 500 at onset + 3-5 hours later → 250 2x/day
Ibuprofen 600 1x/day
Definitions:
1. Polymenorrhea
2.HEMORRHAGIC/HYPERMENORRHEA
3. MENORRHAGIA
4. METRORRHAGIA
5. MENOMETRORRHAGIA
6. OLIGOMENORRHEA
POLYMENORRHEA: menses more frequently (<21 days apart)
HEMORRHAGIC/HYPERMENORRHEA: more blood loss (>7 days or >80mL) during menses
MENORRHAGIA: prolonged/heavy bleeding (>7 days, >80 mL) → REGULAR intervals
METRORRHAGIA: bleeding between menses
MENOMETRORRHAGIA: more blood loss during menses + between menses
OLIGOMENORRHEA: long periods >35 days
Dysmenorrhea (Primary and Secondary)
- Pathophysiology:
→ uterine pain around (1-3 days) or during menses
→ pain peaks around 24hrs after menses and stops within 2-3 days
Primary: Painful uterine muscles due to EXCESS PROSTAGLANDINS (F2a)
– Teens-20s + no associated pathology + normal pelvic exam
– Worse at the beginning of menses
– Better with age
RISK: early menarche < 1, nulliparity, smoking, fhx, obesity
Secondary: Painful periods due to an IDENTIFIABLE CAUSE
Endometriosis, Adenomyosis, Polyps, Fibroids, PID, IUD, tumor, adhesions, cervical stenosis/lesions
–WORSE AT THE END OF MENSES
–20-40s
- Diagnosis:
→ Pregnancy Test AND Pelvic US
US → sensitive for masses
Preg. Test → intrauterine and ectopic ruled out - Treatment:
→ Primary: (1st Line) NSAIDS (24 hrs before period and continued throughout period
(2nd Line) OCPs
→ Secondary: Tx underlying cause
Menopause
- Pathophysiology: Decrease in reproductive hormones (estrogen and androstenedione (DHEA) + progesterone but less)
→ >50 years old (44-55 yr old) - AVG = 51yrs
→ No menses for a year - Patient Presentation:
→ No menses for a year + hot flashes, night sweats, sleep difficulty, mood disturbances
→ After: Bone Loss (Osteopenia), Vaginal pH increases (Atrophy or Vaginitis)
PM Bleeding → Atrophic Endometrium or Atrophic Vaginitis - Diagnosis:
→ Clinical (1 yr + no menses/no cause + >40)
→ FSH + Estradiol Levels
FSH >30 + LOW estradiol - Treatment:
→ If Uterus is present → Hormone Replacement Therapy (Estrogen + Progesterone)
→ No Uterus → ESTROGEN ONLY
→ DRYNESS → OTC Vaginal Moisturizers (REPLENS 2-3x a week) + LUBRICANTS (ASTROGLIDE before sex)
** If Uterus is present NEVER use ONLY ESTROGEN = ENDOMETRIAL CANCER **
Hormone Replacement Therapy: smallest dose, shortest time
→ Estrogen: Hot Flashes
→ Progesterone: Hot flashes, increase risk of BC
*** Lipid Panel: INCREASED HDL + TG, DECREASED LDL
→ CONTRAINDICATIONS:
High Triglycerides (makes them higher)
Endometrial Cancer
Hx of BC or estrogen cancers
Hx PE, DVT, CVD
Other tx options:
Cool temps, avoid heat, alcohol, etoh, soy
VASOMOTOR TXs → PAROXETINE, ssri, snri, clonidine, gabapentin
- PEARLS:
→ Perimenopausal: transitional between reproduction + menopause = irregular menstrual function
About 3-5 years
→ PREMATURE OVARIAN FAILURE: Menopause < 40 years old
→ WHI → estrogen + progestin HM tx after menopause increased risk of HD, Stroke, clots, breast cancer and dementia
Do not use for prevention of CVD
Premenstrual Dysphoric Disorder
DISORDER:
- Pathophysiology:
→ Depression that occurs days before menses
- Diagnosis:
→ DSM5: at least 5 symptoms in the week before menses and improve within a few days of onset of menses
→ One or More MUST be present:
Affective Lability (mood swings, tearful, sad)
Interpersonal Conflicts
Depressed mood
Marked anxiety
→ (+) 4 of these:
Decreased interest
Difficult concentrating
Lethargy
Change Appetite
Hyper/Insomnia
Physical Symptoms (PMS)
- Treatment:
→ SSRIs (FLUOXETINE, SERTRALINE)
→ SNRI (Venlafaxine → especially with psych symptom)
→ OCP, Low Dose Estrogen, Diuretics, TCAs (Clomipramine)
** GnRH should be given to patients not responsive to other options *
Premenstrual Syndrome (PMS)
- Pathophysiology:
→ Physical/Emotional symptoms after ovulation and prior to menses (1-2 weeks before period) + resolve at onset of menses
IMBALANCE IN ESTROGEN AND PROGESTERONE + excess progesterone
LUTEAL PHASE
- Patient Presentation:
→ Bloating, irritability, PMDD, breast tenderness, abdominal bloating, HA, edema, - Diagnosis:
→ ACOG Criteria: Need 1 of the following within 5 days before menses and resides by 4 days post onset
Somatic: breast tenderness, abdominal bloating, HA, edema
Affective: irritable, depression, angry, anxiety, withdrawal, confusion
- Treatment:
→ EXERCISE + Reduce Stress
-1st Line (IF no OCPS wanted): SSRIs
-1st Line (If do not want to get pregnant): OCPs (stops ovulation + stabilized HMs)
3mg Drospirenone/20mcg Ethinyl Estradiol (Yazmin)
GnRH = no response to other tx
Salpingoophorectomy (surgical menopause) → last resort
Gonorrhea Cervicitis
- Pathophysiology: GRAM NEGATIVE
→ Sexually transmitted disease - Patient Presentation:
→ WOMEN: asymptomatic → can lead to PID
→ MEN: yellow, creamy, profuse, PURULENT D/C
→ Gonococcal Pharyngitis: persistent pharyngitis → can lead to Septic Arthritis of the knee or PID
→ Fitz-Hugh-Curtis Syndrome: Perihepatitis in women causing RUQ pain + fever + N/V = mimics biliary/hepatic ds - Diagnosis:
→ NAAT test:
Women: Vaginal Swab
Men: First-Catch Urine - Treatment:
→ Ceftriaxone (and Doxycycline for Chlamydia)
If allergic → Gentamicin + Azithromycin OR Cefixime
→ TREAT PARTNERS + No sex until treated!!
- PEARLS:
→ Treat for both Chlamydia and Gonorrhea
→ Test for HIV, Chlamydia, and Syphillis
Chlamydia Cervicitis
- Pathophysiology:
→ Sexually transmitted disease - Patient Presentation:
→ WOMEN: cervicitis, urethritis, PID
Vaginal d/c, bleeding, cervical redness and friable
UTI symptoms
→ MEN: MUCOID/WATERY/CLEAR D/C + dysuria
Can lead to epididymitis - Diagnosis:
→ NAAT - Treatment:
→ Doxycycline (and Ceftriaxone for Gonorrhea)
Alternative: Azithromycin or Levofloxacin
→ Treat partners and No sex for 7 days after therapy is completed
** PREGNANT + CHLAMYDIA = AZITHROMYCIN OR AMOXICILLIN **
- PEARLS:
→ Treat for both Chlamydia and Gonorrhea
→ TX for Neonatal Conjunctivitis = Oral Erythromycin
** Leading cause of infertility in the US **
** Chlamydia and Gonorrhea Screening:
→ Sexually Active Women (including pregnant):
24 years or younger
25 years or older if at risk
Cervicitis HSV
- Pathophysiology:
→ Sexually Transmitted
HSV1 = “above the waist” (oral)
HSV2 = “below the waist” (genitals)
→ Contagious when lesions are present
→ Reside in the sensory neurons (trigeminal and sacral) for LIFE and are activated by stress, skin damage, or viral illness - Patient Presentation:
→ “Dew Drops on a rose petal”
Grouped VESICLES on an erythematous base
Burning/stinging - Diagnosis:
→ Viral Culture (GOLD), PCR, Direct Fluorescence Antibody, Type-Specific Serology testing
Tzanck Smear skin scrapings: Multinucleated Giant Cells - Treatment:
→ Valacyclovir
Acyclovir - PEARLS:
→ Herpes Labialis: “Cold Sores”, perioral
→ Herpetic Whitlow: Fingers
→ Herpes Gladiatorum: Wrestlers → trunk/extremities
→ Keratoconjunctivitis: Eyes → Blanching Dendritic Lesions
→ HSV in CNS = Meningitis/Encephalitis
→ Neonatal HSV: mother-baby
Cervicitis HPV
- Pathophysiology:
→ Genital Warts from HPV 6 and 11
→ Cancer from 16, 18, 31, 33, 35 - Patient Presentation:
→ Condylomata Acuminata = soft, skin-colored, fleshy lesions
→ Cervical Cancer - Diagnosis:
→ Shave/Punch BIOPSY
KOILOCYTIC squamous epithelial cells in clumps on PAP SMEAR
Cervical Swab can show HPV DNA - Treatment: Spontaneous Remission
→ Symptoms tx: PODOPHYLLIN or TRICHLOROACETIC
IMIQUIMOD (Aldara)
Surgery/Cryotherapy with Liquid Nitrogen
→ Vaccine:
HPV 9 (GARDASIL-9) →
9-45 YR OLD MALES AND FEMALES
All pts 11-12 = 2 doses
Catch up for unvax 13-26 regardless of risk factors
Quadrivalent Vax (Gardasil) → HPV 6,11, 16,18
Bivalent (16, 18)
- PEARLS:
→ Trichomoniasis is commonly seen with condylomata acuminata
Chancroid
- Pathophysiology:
→ STD leading to PAINFUL genital ulcers
→ HAEMOPHILUS DUCREYI (Gram-Negative rod)
VERY CONTAGIOUS (but rare in US) - Patient Presentation:
→ Painful genital ulcers on erythematous base with sharply demarcated borders
GRAY BASE + FOUL D/C
Ulcer covered in purulent exudate + BLEEDS EASY WHEN SCRAPED
Areas most susceptible to friction
→ LYMPHADENOPATHY - Diagnosis:
→ Serology testing for Syphilis: RPR/VDRL
Gram Stain, Culture, Biopsy - Treatment:
→ Ceftriaxone
Or Azithromycin
Lymphogranuloma Venereum
- Pathophysiology:
→ Ulcerative STD of the genitalia
→ Caused by CHLAMYDIA TRACHOMATIS L1, L2, L3 (GRAM-NEGATIVE)
→ Primary infx of lymphatics/lymph nodes - Patient Presentation:
→ 3 Stages:
Primary Stage: PAINLESS genital ulcers
Secondary Stage: INGUINAL/FEMORAL LYMPHADENOPATHY (aka Buboes)
Late Stage: Angiogenital structures, fibrosis, fistulas - Diagnosis:
→ Clinical → Serologic testing for Syphilis (RPR, VDRL)
→ Definitive Dx: Serology Testing (for chlamydia)
→ Consider HIV Testing - Treatment:
→ DOXYCYCLINE FOR 21 DAYS
Erythromycin or Azithromycin
→ PREGNANT → ERYTHROMYCIN
Aspirate node if buboes (I&D are CI bc it causes a decline in healing) - PEARLS:
→ Risk Factors: MSM (unprotected), HIV, HCV
Pelvic Inflammatory Disease
- Pathophysiology:
→ Infection that ascends from cervix/vagina that involves the ENDOMETRIUM and/or the FALLOPIAN TUBES
→ PMH of STD (Chlamydia/Gonorrhea) - Patient Presentation:
→ Cervical Motion Tenderness (Chandelier Sign)
→ Pelvic Pain + Fever (may have D/C)
**HOSPITALIZE IF:
Unable to exclude a surgical cause
Pregnant
Failed/Inability to tolerate OP treatment
Severely ill (High fever, N/V)
Tubo-Ovarian Abscess
- Diagnosis:
→ Clinical: Abd. Tenderness + CMT + Adnexal Tenderness + one or more:
Temp
WBC >10k
Pelvic Abscess
→ NAAT test for Chlamydia/Gonorrhea - Treatment:
INPATIENT:
→ IV CEFOTETAN (Cefoxitin) + DOXY
IV CLINDAMYCIN + IV GENTAMYCIN
OUTPATIENT:
→ Ceftriaxone and Doxycycline (May add Metronidazole)
IM Cefoxitin + Probenecid + Doxy (May add Metronidazole) - PEARLS:
→CAN CAUSE INFERTILITY, ectopic pregnancies, tubo-ovarian abscess (adnexal mass)
Syphilis
- Pathophysiology:
→ STD caused by SPIROCHETE TREPONEMA PALLIDUM
→ Risk if IVDU - Patient Presentation:
→ 3 Stages:
Primary Syphilis: PAINLESS ULCER (CHANCRE) in genital/groin for 3-6 weeks
Secondary: NON-ITCHY maculopapular RASH + PALMS/SOLES or condyloma latum, lymphadenopathy, constitutional symptoms for 2-6 weeks
Tertiary: Widespread systemic infx + PERMANENT CNS CHANGES (NEUROSYPHILIS_ or Gummas (painless, soft, tumor-like masses from skin, bones, liver, etc) - Diagnosis:
→ Serology: RPR/VDRL (Rapid Plasma Reagin or Venereal Disease Research Laboratory Test)
Confirmed by: FTA-ABS (Treponemal Antibody Absorption Test)
FALSE POS with LYMES DZ - Treatment:
→ BENZATHINE PCN 2.4 MILLION UNITS IM 1 DOSE
DOXY = if PCN allergy
IV PEN G for Gummas (Congenital/Late Ds)
Vaginitis - Trichomoniasis
- Pathophysiology:
→ STD: PROTOZOA w/ Flagella
→ Sexual Active Women - Patient Presentation:
→ YELLOW-GREEN, malodorous, thin discharge
→ Itchy, burning, dysuria, LA Pain
** STRAWBERRY CERVIX ** - Diagnosis:
→ Wet Mount - Treatment:
→ METRONIDAZOLE for 7 days
(or TINIDAZOLE)
→ Treat Partner
VAGINITIS - BACTERIAL VAGINOSIS
- Pathophysiology:
→ GARDNERELLA (anaerobic) - Patient Presentation:
→ Grey D/C + Fishy Odor - Diagnosis:
→ Clue Cells on Wet Mount
+Whiff Test (Fishy Odor)
→ PH >4.5 (BACTERIA = BASIC) - Treatment:
→ METRONIDAZOLE
2nd Line → Clindamycin - PEARLS:
- NO ALCOHOL WITH METRONIDAZOLE*
Atrophy Vaginitis
- Pathophysiology:
→ Post-menopausal women - Patient Presentation:
→ Thin, clear, bloody d/c + loss of vaginal rugae
→ Recurrent UTIs (increased urgency/frequency) - Diagnosis:
→ Clinical/Vaginal Exam: clear,pale mucosa
→ PH 5-7 - Treatment:
→ Topical Estrogens
CONJUGATED ESTROGEN VAGINAL CREAM
Use (3 weeks) then taper to lowest dose
If not CI → Oral HRT
Vaginitis - Candidiasis
- Pathophysiology:
→ Candidiasis Albicans
→ RF: DM, OCPs, ABX - Patient Presentation:
→ White, clumpy, cheesy discharge
→ Itchy, dysuria, burning, pain with sex, vaginal/vulvar edema - Diagnosis:
→ KOH Prep
Hyphae
→ pH <4.5 (ACIDIC) - Treatment:
→ Oral Fluconazole (Diflucan) x1 then repeat in 7 days
Topical Clotrimazole
Topical Tioconazole
SEVERE → AMP B, Caspofungin, Voriconazole
pH of D/C
→ Normal pH: 4-4.5 (Acidic)
→ BV: >4.5 (Bacteria = Basic)
→ Vulvovaginal Candidiasis: 4-4.5 (ACIDIC)
→ Trichomoniasis + Atrophy: 5-6
Breast Cancer
- Pathophysiology:
→ MC malignancy in women
→ RF: Menarche before 12, Advanced maternal age, No pregnancy, Menopause after age 52, >65, Obesity, ETOH
** MC = Infiltrating Intraductal Carcinoma (IIC) ** - Patient Presentation:
→ Breast mass → IMMOBILE, IRREGULAR
→ Nipple Retraction + Bloody Nipple D/C
→ 3 Types:
Infiltrating Lobular → BILATERAL
Paget’s Disease → Eczematous itchy, scaling rash on nipple and areola
Inflammatory Breast Cancer → Red, swollen, warm, itchy breast + nipple retractions + PEAU D’ORANGE (NO LUMPS) - Diagnosis:
→ ESTROGEN RECEPTOR (ER) → 75%
→ PROGESTERONE (PR) → 65%
→ HER2 (25%)
→ Aspirate (if Cystic)
→ MAMMOGRAM = MICROCALCIFICATIONS
→ US = Delineating Cysts
→ BIOPSY = DEFINITIVE Dx
** → BRCA Gene: INHERITED GENETIC MUTATION = INCREASED RISK OF BREAST AND OVARIAN CANCER **
- Treatment:
→ SEGMENTAL MASTECTOMY (LUMPECTOMY) followed by BREAST IRRADIATION in ALL patients
If (+) nodes = Chemo
→ TAMSULOSIN = Tumors ER positive
reduces/blocks estrogen receptor in breast tissue
→ AROMATASE INHIBITORS = Postmenopausal ER (+) patients
Anastrozole, Exemestane, Letrozole
Reduced estrogen PRODUCTION
→ Monoclonal AB tx: HER2 positive (Human Epidermal Growth Factor Receptor) - PEARLS:
*** SCREENING: Used risk calculators (The Gail Model, Tyrer-Cuzick, BC Surveillance Consortium Risk Calc.)
→ MAMMOGRAM:
40-74: ANNUAL or EVERY OTHER YEAR (BIENNIAL)
75 & older: No evidence risk/reward
→ High Risk Patients:
(+ BRCA, chest radiation, risk >20%)
Refer to high risk screening clinic
PREVENTATIVE THERAPY:
SERMs: Selective Estrogen Receptor Modulators:
Tamoxifen or Aromatase Inhibitors reduce risk
BRRMs: Bilateral Risk Reduction Mastectomy
→ Metastases: Bone, Lung, Liver
Cervical Cancer
- Pathophysiology:
→ HPV = MCC (99%) → 16,18 = MC
→ 80% = Squamous Cell
Arising from the squamocolumnar junction of the cervix (Transformational Zone)
→ RF: Multiple sex partners, early age of first intercourse, early first pregnancy, + HPV, Smoking - Patient Presentation:
→ POSTMENOPAUSAL ABNORMAL VAGINAL BLEEDING
→ Friable Cervix
→ Post-Coital Bleeding
** CERVICAL CANCER that extends into the Pelvic Wall: UNILATERAL LEG SWELLING, SCIATIC PAIN, URETERAL OBSTRUCTION **
- Diagnosis:
→Friable, Bleeding Cervical Lesions on exam
→ BIOPSY of lesions and colposcopy - Treatment:
→Resect and/or Chemo and Radiation
Stage 1: Conservative, simple, radical hysterectomy
Stage 2: Chemo +/- Radiation
Cervical Cancer that extended to Pelvic Wall =
UNILATERAL LEG SWELLING, SCIATIC PAIN, URETERAL OBSTRUCTION
Cervical Dysplasia Risk Factor
(Dysplasia = Abnormal Development)
Early age of intercourse
Early childbearing
Multiple sex partners
History of STI
Low socioeconomic status
Smoking
*HPV
Cervical Dysplasia: PAP requirements
→ 1st Pap: AGE 21 regardless of sexual activity
+ at the time of initial intercourse if <21 who have HIV infx or on chronic immunosuppressive therapy for LUPUS or post organ transplant
→ 21-29: ONLY CYTOLOGY every 3 years
→ 30 or older: Cytology + HPV every 5 years OR cytology every 3
→ Annual screening if HIGH RISK: HIV, Immunosuppression, in utero DES exposure, or women treated for CIN2, CIN3, or Cervical Cancer
→ Discontinue PAP if =
Total Hysterectomy
Age 65 (if 3 consecutive negative cytology tests or 2 neg HPV/PAP tests in the 10 years before stopping).
CD - PAP Pathology Report –> Next step?
→ ASC-US: Atypical Squamous Cells of undetermined significance
→ LSIL: Low-grade squamous intraepithelial lesions that are MILD DYSPLASIA
CIN I
→ HSIL: High-grade squamous intraepithelial lesions that are MODERATE - SEVERE DYSPLASIA
CIN II-III, Carcinoma in SITU
-Tx:
→ HPV POSITIVE + NEGATIVE cytology = repeat PAP in 12 months
→ ASC-US and up = REFLEX HPV TESTING
If ASC-US + negative HPV = Continue routine screening
IF NEGATIVE = repeat in 12 months
IF POSITIVE = send for COLPOSCOPY
→ ASC-US, LSIL, CIN-I:
Reflex HPV:
If (+) or 25/>: COLPOSCOPY
If (-) or < 25: RETEST 1 year
→ HSIL, CIN-2, CIN-3, CIS:
COLPOSCOPY
Outside cervix - LEEP (Loop Electrosurgical Excision Procedure) or Cryotherapy
Inside cervix - Cone Biopsy
→ Squamous Cell Carcinoma:
RESECT and/or CHEMO + RADIATION
AGC (atypical glandular cells) → Colposcopy with Endocervical Sampling (regardless of HPV)
HPV related to Cervical Dysplasia
HPV Vaccination
→ Types 16, 18, 31 = increase risk for Cervical Cancer
-HPV Vaccination:
→ NOT GIVEN DURING PREGNANCY
→ 9-Valent Vaccine (only vax available in US)
→ Males & Females recommended at 11-12 years old, but can be given at 9 years old
Catch-up vaccinations: 13-26 yrs
MSM = 22-26 yrs old = Catch up HPV vaccinations recommended
→ DOSING:
<15 = 2 DOSES, 6 MONTHS APART
>15 = 3 DOSES, 1-2 months and at 6 months
Immunocompromised = 3 doses
Endometrial Cancer
- Pathophysiology:
→ Most common GYN malignancy
→ Adenocarcinoma (MC)
RF: Obesity, nulliparity, early menses, late menopause, HTN, gallbladder ds, FM, prior cancer, unopposed estrogen stimulation
(smoking DOES NOT increase risk) - Patient Presentation:
→ POSTMENOPAUSAL BLEEDING**
→ On US the endometrium is >4mm (should be <4 in PMW) - Diagnosis:
→ ENDOMETRIAL BIOPSY = ALL POSTMENOPAUSAL WOMEN W/ VAGINAL BLEEDING
→ Usually have an abnormal PAP - Treatment:
→Total Hysterectomy and bilateral Salpingo-oophorectomy
+ radiation (possibly chemo) in stages II, III
VAGINAL Cancer
- Pathophysiology:
→ RARE
RF: HPV, Smoking, Cervical cancer, In utero exposure to DES
→ SQUAMOUS CELL caused by HPV!!!
Adenocarcinoma = DES - Patient Presentation:
→ UPPER ⅓ OF POSTERIOR VAGINAL WALL
→ Changes in menstrual period and/or abnormal bleeding (changes in bleeding) - Diagnosis:
→ Mass may be found on exam
→ BIOPSY → squamous cell carcinoma (MC) - Treatment:
→ Stage 1: hysterectomy, vaginectomy, and bilateral pelvic lymphadenectomy
→ II-IV: Radiation - PEARLS:
→ Stage 1:
→ Stage II: Invasive Carcinoma confined to vaginal mucosa
→ Stage III: Extension of lesion to the pelvic wall
→ Stage IV: Lesions involving the bladder or rectum
VULVAR Cancer
- Pathophysiology:
→ SQUAMOUS cell & MELANOMA
RF: HPV, Smoking, Cervical cancer, In utero exposure to DES - Patient Presentation:
→ Vaginal itching +/- red/white ulcerative crusted lesions ON vulva - Diagnosis:
→ ACETIC ACID/STAIN WITH TOLUIDINE BLUE → BIOPSY (the stain helps direct biopsy) - Treatment:
→ VULVECTOMY + lymph node dissection - Surgical Excision, chemo, laser therapy
BREAST ABSCESS
- Pathophysiology:
→ STAPH AUREUS
Pus-filled lump that grows under the skin due to an infection
Can come from Mastitis, blocked milk duct
Common in non-lactating women - Patient Presentation:
→ Fever, Chills, pain, FLUCTUANT MASS
Warm, red, tender (signs of inflammation) - Diagnosis:
→ Breast US + Mammogram (Non-Lactating women) - Treatment:
→ Incision & Drainage + ABX → DICLOXACILLIN or Cephalexin
Beta Lactam Allergy = Clindamycin
MRSA risk = Bactrim or Clinda
Severe = Vancomycin - PEARLS:
MILK MUST BE EXPRESSED TO REDUCE ENGORGEMENT
** CONTINUE BREAST FEEDING EVEN IF I&D OCCURS **
Breast Fibroadenoma
BREAST FIBROADENOMA:
- Pathophysiology:
→ Benign Breast Tumor
Glandular and fibrous tissue
15-35 years old
- Patient Presentation:
→ PAINLESS MASS in the breast that is not cancerous (2-3 cm)
Smooth, well-circumscribed, mobile
Firm, solitary/rubbery feeling
Wax & Wane with menstruation (increase in size during pregnancy)
Upper & outer quadrants - Diagnosis:
→ Clinical
US or Mammogram (Not in adolescents)
If well-defined, solid mass and negative images → Core Needle Biopsy or short term follow up (3-6 months)
Definitive Dx: Core Needle Biopsy - Treatment:
→ Careful watch:
<5cm without concerns = OBSERVE 1-2 month intervals
Mass regression = 3-4 month intervals
Persistence → US
>5cm = Excisional BIOPSY
Biopsy confirms fibroadenoma + asymptomatic = leave it
Some women choose to have it removed or CRYOABLATION
Fibrocystic Disease
- Pathophysiology:
→ Lumps in breasts that come and go
→ DOES NOT INCREASE RISK OF BREAST CANCER
→ 30-50 years of age - Patient Presentation:
→ Breast pain BEFORE menses, resolving with the start of the period
→ BILATERAL, painful, swollen, lumpy breasts - Diagnosis:
→US/Mammogram (Mam may show thickening)
→ Definitive Diagnosis: BREAST CYST ASPIRATION
STRAW-COLORED FLUID with NO BLOOD - Treatment:
→ Symptomatic Tx with NSAIDS, ICE/HEAT, supportive bra, decrease caffeine, fat and chocolate
OCPs w low estrogen, potent progestin, medroxyprogesterone acetate
Monthly self-breast exams 1 week after a period
Mastitis
- Pathophysiology:
→ Staph Aureus infection of the breast through milk ducts/fissure in the skin caused by BF
→ Common during lactation (especially early on)
**INFECTIOUS = Unilateral, Fever/Chills, Red
**CONGESTIVE = Bilateral (Primigravidas) - Patient Presentation:
→ Usually unilateral, swollen, red, tender breast
→ FEVER
→ No “lump” (that would indicate abscess) - Diagnosis:
→ Clinical
US if suspect Abscess
Culture Breast Milk (help w/ ABX)
Severe = Blood Cultures - Treatment:
→ DICLOXACILLIN x 10 days
→ KEEP BREASTFEEDING!!!!
Water/cold compresses, NSAIDs - PEARLS:
→ INFLAMMATORY BREAST CANCER: tenderness and color change BUT NO FEVER/CHILLS
Cystocele
CYSTOCELE:
- Pathophysiology:
→ Bladder prolapse (Posterior bladder into the Anterior Vaginal Wall)
→ Bulge of bladder into vaginal wall
→ Supportive connective tissue separating the bladder and vagina weaken → Weak pelvic floor
→ After childbirth or lifting heavy objects
- Patient Presentation:
→ Bulge of bladder into vaginal wall + Urinary symptoms
→ Pelvic pressure and discomfort
→ “something falling out of my VAGINA”
→ Incomplete emptying, frequency/urgency - Diagnosis:
→ Pelvic Exam + Urodynamic Studies + UA
POP-Q, Q-tip test, Voiding Cystourethrogram
Tissue bulge int vagina = pelvic organ prolapse - Treatment:
→ Kegel Exercises, Pelvic Floor retraining
→ Pessary
→ Estrogen therapy = after menopause to maintain ton and vitality of the tissue
Surgery if really bad
Rectocele
- Pathophysiology:
→ Prolapse of the Rectum into the POSTERIOR Vaginal Wall
→ Childbirth - Patient Presentation:
→ Feeling like something is falling out of vagina
→ Pelvic pressure + Bowel Symptoms (Constipation, straining, incomplete emptying)
→ Worse when bearing down - Diagnosis:
→ Pelvic Organ Prolapse Quantification (POP-Q)
Colonoscopy (rule out cancer) - Treatment:
→ Kegel Exercises/Pelvic Floor
→ Pessary
Ovarian Torsion
- Pathophysiology:
→ Ovary rotating at the pedicle that occludes blood flow - Patient Presentation:
→ Sudden onset of severe SHARP lower quadrant pain + N/V
→ Adnexal tenderness WITHOUT cervical motion tenderness - Diagnosis:
1st → Pregnancy Test
→Abdominal US with Doppler Flow
Doppler flow is not always absent in torsion - Treatment:
→ Emergent Surgery to uncoil the ovary
Uterine Prolapse
- Pathophysiology:
→ Uterus descends towards/into vagina
→ Pelvic floor or ligaments becomes weak - Patient Presentation:
→ Uterus can protrude out of vagina
→ Vaginal fullness, abdominal pain WORSE LATE IN THE DAY or after standing
**GRADES:
0 Degree = NO descent
1st Degree = to the upper vagina/descent between normal and ischial spine
2nd = To the introitus/between ischial spines and hymen
3rd = Cervix is OUTSIDE the introitus/within hymen
4th = PROCIDENTIA - Entirely OUTSIDE
- Diagnosis:
→ Pelvic Exam
- Treatment:
→ Asymptomatic, 1st, 2nd:
No treatment
PESSARY
→ Severe, persistent, 3rd, 4th:
SURGERY
Hysterectomy
Barrier Contraceptive
BARRIER:
Failure rates 40% + STI protection
Male Condoms: 20% failure
Female: 21% failure
Diaphragm: 15% failure
Spermicide Nonoxynol-9
SPERMICIDES NONOXYNOL-9:
Destroys the sperm and is usually used with condoms
27% failure rate
INCREASED risk of HIV
OCPs
Prevents ovulation by inhibiting the LH surge mid-cycle
Thickens cervical mucus and thins the endometrium
9% failure rate, if used correctly 0.9%
HELPS with: Dysmenorrhea and controls cycle, Ovarian cyst, ovarian and endometrial cancer, and acne
First 3 cycles you may expect breakthrough bleeding, nausea, breast tenderness
COMBINED ESTROGEN & PROGESTERONE = NOT in women > 35 if smokers, history of blood clots breast cancer, Migraines with Aura
Risk of DVT
OCP Protocol
Typical Start: (Start the FIRST SUNDAY after Menses)
Use contraceptive for the first 7 days
Quick Start: (start at a time other than post-menses)
- LMP </= 5 days: start OCP NOW + 1 week backup
- LMP >5 days: Preg test
NO UPSex: Start OCP + 1 week backup - UPSex >5 days: Urine Preg isn’t accurate (can start without fetal harm)
- UPSex < 5 days: Plan B
Missed Pill:
- After 1st cycle = start new pack 7 days after last pill
- Pill missed:
1 pill: take it, take next pill as scheduled
2 or more in a row:
Take pill asap + backup for 7 days (PlanB if needed)
Last week in cycle: Skip placebo and start new pack + back up for 7 days
Vomiting within 2 hours: Repeat pill + backup
>48 hours: Backup until after V/D resolves and til 7 active pills are taken
TRANSDERMAL PATCH:
→ TRANSDERMAL PATCH:
Very effective (FT 0.3% with perfect use and 9% in typical use)
Risk of VTE (small)
Started first day of period and patch changed weekly
NuvaRing
→ NuvaRing: Flexible plastic vaginal ring
7% failure rate
1 ring for 3 weeks each month
Insert on day 5 of cycle
Remove for 1 week then insert a new ring
Progestin-Only Mini Pill
→ Progestin-Only Mini Pill:
SAFE IN LACTATION
Decreased risk of Ovarian/Endometrial Cancer
No estrogenic side effects: HA, Nausea, HTN
IUD
→ IUD:
Highly effective and reversible
COPPER: Paragard → every 10 years (0.8 failure rate)
PROGESTIN: Mirena → every 3-5 years (0.2 failure rate)
Emergency Contraceptive
LEVONORGESTREL (Plan B) within 3 days of UNPROTECTED sex or Ella within 5 days
Copper IUD within 5 days
Drug rxn with CYP3A4 inducers (carbamazepine, topiramate, st john wart)
OCPs → start pack asap after plan B
Backup for 7 days after
DEPO-PROVERA SHOT
→ DEPO-PROVERA SHOT:
Long-acting injection (5% failure rate)
Lasts 3 months
May cause menstrual regularities
NEXPLANON
→ NEXPLANON:
Long acting PROGESTERONE implanted in the arm (0.1% FR)
Lasts 3 years
STERILIZATION
→ STERILIZATION:
Tubal Ligation = 0.5% FR – Permanent
Vasectomy = 0.15%
Vas deferens from each testes is clamped, cut, or sealed to prevent sperm from mixing with semen that is ejaculated from the penis
Endometriosis
- Pathophysiology:
→ Endometrial tissue implants in areas outside the uterus
Most common: Ovaries, Fallopians tubes, cul-de-sac, uterosacral ligament
→ Can lead to infertility - Patient Presentation:
→ THREE D’s: Dyspareunia (pain with sex), Dyschezia (difficulting defecating) and Dysmenorrhea (painful periods)
→ Pelvic pain just before or during menses
***** PHYSICAL EXAM:
Uterus is FIXED and RETROFLEXED!!!!
Tender nodularity of cul de sac and uterine ligaments - Diagnosis:
→ Definitive Diagnosis: LAPAROSCOPY confirmed with BIOPSY
→ Uterus is FIXED and RETROFLEXED!!!!
→ Images: US, Barium Enemia, IV Urography, CT, MRI (These may show extent of endometriosis) - Treatment:
→ NSAIDS, OCP, Danazol, Depo, GnRH, Surgery
Oral Contraceptives: FIRST LINE
Estrogen-Progesterone OCP = Ovarian Suppression
Progesterone Analogs (Medroxyprogesteron and Levonorgestrel) = Endometrium growth suppression
- PEARLS:
Infertility
- Pathophysiology:
→ Inability to conceive after 1 year of actively trying
PRIMARY: Infertility without a previous pregnancy
SECONDARY: Infertility with a previous pregnancy
→ Cause: ANOVULATION (amenorrhea and abnormal periods)
Tubal Ds, Male Factor (20-40%), Unexplained/multifactorial - Diagnosis:
→ Pap, HM levels, US, Hysterosalpingogram, Semen Analysis, Ovulation check
→ Ovulation Tracking:
Luteal Phase (Day 21) Progesterone Level → Progesterone < 3 on day 21 = PT DID NOT OVULATE
Core Temp (No mid cycle basal)
Body Temp. with increase
→ Semen Analysis
→ LABS: TSH, Prolactin, LH, FSH > 35
If no Dx from tests above then try:
→ Hysterosalpingogram (evaluate for tubal factors)
→ Laparoscopy
- Treatment:
→ Based on cause:
CLOMIPHENE CITRATE: hyperstimulates ovulation
Surgery (lysis of adhesions in tubal ds)
Assisted Reproductive Tech. (IVF)
METFORMIN: Increases ovulation and pregnancy rates in PCOS pts
BROMOCRIPTINE: treats Hyperprolactinemia
Leiomyoma
- Pathophysiology:
→ Uterine Fibroids
Benign smooth muscle tumors
→ MC: black women, fhx - Patient Presentation:
→ Polymenorrhea, menorrhagia, intermenstrual bleeding, metrorrhagia
→ Pelvic Pressure and Increased Abdominal Girth (Uterine Mass may be present)
→ Uterus with asymmetric contours
→ SINGLE or MULTIPLE
Subserosal: projects into pelvis
Intramural: within the uterine wall (MC)
Submucosal: into the uterine cavity - Diagnosis:
→ US (and/or MRI)
Well-Defined, HYPOECHOIC mass in myometrium
→ Biopsy confirms - Treatment:
→ Symptomatic treatment: NSAIDs, OCPS, Danazol, Leuprolide (shrinks fibroids pre-op too)
→ DEFINITIVE: MYOMECTOMY, HYSTERECTOMY, Endometrial Ablation
Ovarian Cysts
- Pathophysiology:
→ Fluid-filled sac within the ovary
Functional Cysts: Normal physiological fnx of the ovaries (3)
2-3cm (<10cm), clear liquid, smooth internal lining
→ FOLLICULAR CYSTS = Most Common
Dominant follicle fails to rupture
→ Corpus Luteum Cyst
Dominant follicle ruptures + closes again without dissolving
→ Theca Lutein Cyst (Ovarian Cyst in PREGNANCY)
Overstimulation of HCG produced by the PLACENTA
Non-Functional Cysts/Neoplastic Cysts:
→ PCOS, Endometriomas (Chocolate Cysts), Dermoid Cysts (teratomas), Ovarian Serous and Mucinous Cystadenoma
> 10cm, Irregular Borders, Internal Septations
- Patient Presentation:
→ Asymptomatic
→ Bloating, Lower Abdominal Pain, Dyspareunia, or Low Back Pain
→ Follicular: Asymptomatic
→ Corpus Luteum: Localized Pelvic Pain, Amenorrhea, Delayed Menses - Diagnosis:
→ TRANSVAGINAL US (or abdominal)
→ MRI (if US is indeterminate)
Rule out Ovarian Cancer: CA-125
→ Definitive: US guided Aspiration - Treatment:
→ Most resolve ~1 month
→ Follow up imaging NOT NEEDED until 5cm - Follow ups:
→ <5/>7cm = yearly follow-up
→ >7cm = image with MRI or Surgery
→ Cysts that persist >⅔ cycles OR postmenopausal women = US/Laparoscopy, possibly biopsy - COMPLICATIONS: (3)
Hemorrhagic: Follicular and Corpus Luteal
Rupture: Release of contents into peritoneal cavity
After Sex
PAIN + HYPOTENSION, ABD/SHOULDER PAIN + TACHY
Torsion: Ovary twists around suspensory ligament, cutting off blood supply to the ovary
At higher risk if >5cm
WAXING/WANING PAIN + N/V + LOW-GRADE FEVER
ABD/PELVIC US = 1ST
URGE INCONTINENCE:
- Pathophysiology:
→ Detruser muscle is OVERACTIVE
→ ELDERLY/SNF (Maybe associated w/ UTI) - Patient Presentation:
→ Frequent, Small amounts of urine
→ OCCURS @ NIGHT + Disrupts Sleep - Diagnosis:
→ Postvoid Residual Urine Volume = normal/low (peeing all the time = nothing left)
→ Urodynamic studies: Increased bladder contractions during filling - Treatment:
→ Bladder-Training Exercises
2nd Line: Oxybutynin (anticholinergic) or TCAs (Imipramine)
STRESS INCONTINENCE:
- Pathophysiology:
→ Weak Pelvic Floor
→ PREGNANCIES - Patient Presentation:
→ Urine leakages when intra-abdominal pressure is increased:
Coughing, sneezing, laughing, bending, lifting
→ NO URINE LOSS @ NIGHT - Diagnosis:
→ Postvoid Residual Urine Volume = normal/low
→ Urodynamic studies: NORMAL bladder contractions during filling - Treatment:
→ Kegel Exercises
Vaginal Estrogens
Pessary
Surgery → Mid-Urethral Sling
OVERFLOW INCONTINENCE:
- Pathophysiology:
→ Impaired Detrusor Contractility
Urinary retention → Bladder Distention → Overflow of urine through urethra
→ DIABETIC Patients, BPH, or Neurologic D/O - Patient Presentation:
→ Frequent dribbling and incomplete emptying sensation - Diagnosis:
→ Postvoid Residual Urine Volume = ELEVATED!!!! (Not emptying badder)
→ Urodynamic studies: NORMAL bladder contractions during filling - Treatment:
→ Intermittent self-catheterization
→ Cholinergic Agents (Bethanechol) = Increases bladder contractions
→ Alpha-Blockers (Terazosin, Doxazosin) = Decrease sphincter resistance
FUNCTIONAL INCONTINENCE:
- Pathophysiology:
→ Pts with normal voiding but have a difficult time reaching the toilet due to disability - Patient Presentation:
→ Increased urine loss and inability to time urination - Treatment:
→ Scheduled voiding times
MIXED:
→ Combo or Stress & Urge
→ Lifestyle mods + Pelvic floor = first line
Sexual Assault
- Pathophysiology:
→ Involuntary sexual act while person is coerced or physically forced to engage against their will or without consent
→ 1 in 3 are sexually assaulted - Presentation:
→ Physical contact (Not necessary: ex. forced to watch sexual act) - Diagnosis:
→ Rape: Psych evaluation and legal situation
Explain the purpose of everything
RAPE KIT: ensures proper evidence is secured
Cultures from VAGINA, ANUS, PHARYNX for Gonorrhea, Chlamydia + RPR for syphilis, hepatitis, HIV
UA, Pregnancy Test
- Treatment:
→ Prophylactic ABX
ROCEPHIN + DOXY X7
TETANUS
PLAN B
COUNSELING ASAP
→ FOLLOW-UP:
Within 24-48 hrs
1 week
6 weeks: repeat STI cultures/RPR
12-18 weeks: Repeat HIV
Spouse/Partner Violence
→ Physical:
Nonaccidental acts of physical force that results or has the potential to cause physical harm to an intimate partner or evoke significant fear in the partner within THE PAST YEAR
Shoving, slapping, hair pulling, pinching, restraining, shaking, throwing, biting, hitting, kicking, burning, etc…
→ Sexual:
Forced/coerced sexual act within a intimate partner THIS PAST YEAR
Physical force, psychological coercion, unable to consent
→ Neglect:
Egregious act or omission in the past year by one partner that deprives a dependent partner of basic needs resulting in physical and psychological harm
Partner is incapable of self-care owing to physical, psychological.intellectual or cultural limitations
40 year old with pelvic pain with diffuse uterus enlargement
Adenomyosis
40 year old with prolonged heavy periods with palpable smooth, round, firm masses on uterus
Leiomyoma (Fibroids)
