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
