Women's Health - GYN Flashcards
Phases of menstrual cycle
- follicular phase - begins with menses, increased FSH
- ovulation
- luteal phase - corpus luteum forms
A surge in ____ causes dominant follicle to release its egg.
LH
High levels of what, are important in thickening uterine lining for implantation
estrogen
What do follicles and corpus luteum secrete?
follicles - estrogen
corpus luteum - progesterone
What hormone change specifically causes shedding of uterine lining?
dramatic drop in progesterone
What happens to corpus luteum if fertilization occurs?
keeps producing progesterone until placenta develops and takes over production
this all occurs if hCG present
corpus luteum degrades to corpus albicans
What is primary amenorrhea?
no menstruation by 16 years old even with normal development
What genetic condition common cause of primary amenorrhea?
Turner Syndrome
What is secondary amenorrhea?
no menstruation over a 6 month period
Most common cause of secondary amenorrhea
pregnancy!
Signs of polycystic ovarian syndrome
hirsutism
obesity
virilization
Possible causes of secondary amenorrhea
Pregnancy (most likely) Anorexia Stress Asherman syndrome – intrauterine adhesions and scarring Polycystic ovarian syndrome Tumor of hypothalamus or pituitary Sheehan syndrome – damage to pituitary secondary to ischemia during childbirth Hypothryoid Hyperprolactinema premature ovarian insufficiency
What is primary dysmenorrhea and what causes it?
painful menstruation without pathology; caused by excessive prostaglandin production
First and second line treatments for primary dysmenorrhea
1) NSAIDs - inhibit prostaglandins
2) OCs, IUD, Depo shot - prevent ovulation
Possible causes of secondary dysmenorrhea
Endometriosis PID Pelvic pain Cervicitis Fibroids IUD
When are PMS symptoms present and absent in cycle?
Occur in luteal phase
NO symptoms in follicular phase
Diet modifications to help PMS
Increase complex carbs, calcium, Vit D
Decrease salt
Avoid sugar, alcohol, caffeine
Medical treatment for PMS
SSRIs
Oral contraception
Diuretics – spironolactone during luteal phase
NSAIDs
Average age of menopause
51
Age of premature menopause
less than 40
Hallmark finding of menopause
hot flashes
What lab is diagnostic of menopause?
FSH > 30
What is main cause of endometrial cancer?
estrogen given without progesterone
What symptoms are improved with estrogen replacement therapy?
hot flashes, insomnia, and osteoporosis
ADRs of hormone replacement therapy for menopausal women?
breast cancer and CV disease
How can vaginal dryness and dyspareunia of menopause be treated?
vaginal estrogen cream
Menorrhagia
excessive, heavy menstrual flow
Metrorrhagia
bleeding or spotting between menses
Dysmenorrhea
menstrual pain which interferes with activities of daily living
Hypomenorrhea
extremely light menstrual flow
Oligomenorrhea
menstrual periods that occur greater than 35 days apart
Who is most likely to have dysfunctional uterine bleeding?
Menopausal woman
Very young woman
Abnormal bleeding from the uterus without any problems found in the uterus =
Dysfunctional Uterine Bleeding (DUB)
What blood work should be done for Dysfunctional Uterine Bleeding?
CBC
Iron studies
PT/PTT
Dysfunctional Uterine Bleeding treatment
Oral contraception
D&C
Endometrial ablation
Hysterectomy
African American female comes in with dysmenorrhea and bleeding in between periods. Pelvic U/S shows firm mass on uterus. Likely dx?
fibroids
Fibroid treatment
Watchful waiting
GnRH agonists help reduce size by causing hypogonadism (Depot Leuprolide, Nafarelin)
Surgery - myomectomy or hysterectomy
dyschezia =
difficulty evacuating bowels
Woman comes in with dysmenorrhea and pelvic pain related to her menstrual cycle. She also c/o dyschezia. Growth of tissue seen outside uterus on U/S. Likely dx?
endometriosis
Endometriosis treatment
NSAIDS
Oral contraception
GnRh agonist
Danazol to suppress menstruation
Surgical
Laparoscopic fulguration – destruction of tissue using high voltage electricity
Hysterectomy with bilateral salpingo oophorectomy
Best imaging for suspected endometriosis
exploratory laparoscopy
Risk factors for endometrial cancer
postmenopause FHX of colon cancer obesity never pregnant DM PCOS HTN Unopposed estrogen therapy
How is endometrial cancer dx’d?
endocervical and endometrial biopsy
*PAP smear usually negative
Post-menopausal woman with abnormal uterine bleed. What must be ruled out?
endometrial cancer
Treatment for metastatic and recurrent endometrial cancer
high dose progestins
Types of uterine prolapse
Cystocele – bladder herniating into vagina
Rectocele – rectume herniating into vagina
Enterocele – small intestine herniating into vagina
What causes uterine prolapse?
Ligaments and muscles which suspend the uterus are damaged or stretched often secondary to vaginal delivery though it may occur even to women without children
Treatment of ovarian cysts
Watchful waiting. Follow with U/S in premenopausal women with small cyst
Laparoscopic surgery for large cysts
Signs/sx’s of ovarian cancer
Nondescript GI sx’s
Pelvic pain
Pelvic pressure
Palpable mass on pelvic exam
Way to monitor progression of ovarian cancer?
CA 125 levels
Treatment of ovarian cancer
abd hysterectomy, bilateral salpingo oophorectomy and lymphadenectomy, and removal of any visible tumors
An obese woman comes in c/o amenorrhea and excessive hair growth. She has also had difficulties becoming pregnant. What is likely to be seen on pelvic u/s?
polycystic ovaries
What labs are part of PCOS work up?
FSH/LH - premature ovarian failure, hypogonadotropic hypogonadism
TSH - thyroid causes
DHEAS - adrenal neoplasm
Glucose tolerance test
Treatment of polycystic ovarian syndrome if patient still desires to get pregnant?
Clomiphene and Dexamethasone to stimulate ovulation
Treatment of polycystic ovarian syndrome if patient does not want to get pregnant?
Medroxyprogesterone acetate daily for 1st 10 days of each month to stimulate endometrial shedding
Oral contraception
Treat hirsutism with spironolactone, flutamide, or finasteride (all teratogenic!)
Risk factors for ovarian cancer
no children
40-60 yo
Caucasian
+ FHX
Way to manage PCOS without medication?
lose weight
neoplasia vs dysplasia
Neoplasia – abnormal growth of cells
Dysplasia – abnormal development typically with an excess of immature cells
Risk factors for cervical dysplasia and cancer
risky sexual activity
HPV exposure
long term oral contraception use
smoking
Vaccine to prevent cervical cancer? When to give?
HPV vaccine (Gardasil) recommended for children 9-26 yo
Schiller test of cervical
part of colposcopy; cervix covered with iodine and dysplastic cells that do NOT stain and should be biopsied
What are abnormal findings on routine PAP smear?
Mild cervical intraepithelial neoplasia (CIN-1) Moderate dysplasia (CIN-2) Severe dysplasia (CIN-3); most progress to cancer
What is next step if abnormal Pap smear?
refer for colposcopy and possible tissue biopsy
Most likely location of cervical cancer?
transformation zone of cervix
_______ is when the cervix begins to dilate and efface before labor.
cervical incompetence
Pap smear shows a friable cervix with mucopurulent discharge. Likely dx and cause?
cervicitis; typically caused by Chlamydia and Gonorrhea
Symptoms of vaginitis
vaginal pruritus, pain, burning, unusual discharge
Normal pH of vagina? How is this effected by bacteria?
4.0 to 4.5
over 4.5 if bacteria present
Cause of vaginitis with white cottage cheese discharge?
yeast infection
Cause of vaginitis with foul-smelling frothy, yellow/green discharge?
Trichomonas vaginosis
How is Candida dx’d?
KOH wet mount shows budding yeast and hyphae
How is Trichomonas dx’d?
wet mount shows motile flagellates of protozoa
Treatment of Candida vaginitis
Topical azoles
Oral fluconazole 150 mg oral tablet single dose
Treatment of Trichomonas vaginosis
Metronidazole 2 g x one dose
All partners should be treated
Cause of vaginitis with frothy, grey discharge and positive whiff test?
bacterial vaginosis
What is seen on wet mount of bacterial vaginosis?
clue cells = epithelial cells covered in bacteria
Treatment of bacterial vaginosis?
Metronidazole 500 mg BID x 7 days
Clindamycin
Sign of HPV virus infection
vaginitis - pruritus, pain, burning
warty growths on vagina
Treatment of HPV infection?
Remove painful warts:
Cryotherapy
Trichloroacetic acid
CO2 laser
Podofilax gel or Aldara cream
Surgical removal
A 29 year old sexually active female presents to your office complaining of mucopurelent discharge. She has had several sexual partners over the past few weeks and here last period was three weeks ago. On physical exam the vagina appears normal however there is some bleeding from the cervix. What is the most likely cause of her infection?
Chlamydia or Gonorrhea infection causing cervicitis
A 24 year old female presents to the ER complaining of strange foul smelling discharge per the vagina. You perform a wet mount and note that clue cells are present. The vaginal pH is 4.7. What is the best course of treatment.
Metronidazole 500 mg po BID x 7 day
What causes most cases of Pelvic Inflammatory Disease?
Chlamydia and Gonorrhea
PE findings of Pelvic Inflamm Disease?
Cervical motion tenderness
Purulent discharge
Why would you do U/S to help dx abdominal pain as PID?
rule out appendicitis, ectopic pregnancy, ovarian torsion
look for abscess
Culdocentesis
Placing a needle into rectovaginal space in order to culture fluid there; used to help dx PID
What test is used to dx Gonorrhea and Chlamydia?
culture
NAAT
Procedure to visualize abdominal and pelvic structures as well as obtain cultures?
Laparoscopy
Treatment of PID
Mild - outpatient abx
Severe - hospitalize with IV abx
Surgery if unresponsive to treatment or pelvic abscess seen
Treat all sexual partners!
Fibrocystic disease of breasts includes:
cysts, papillomatosis, adenosis, fibrosis, ductal epithelial hyperplasia
Age for fibrocystic disease
30-50
Sx’s of fibrocystic disease
palpable breast mass (usually multiple and bilateral)
+/- pain
Size changes with menstrual cycle
Nipple discharge
Diagnostic imaging for breast masses
Breast U/S Mammogram Biopsy Fine-needle aspiration cytology Gram stain or culture any discharge
Most common breast lesion
Fibrocystic Disease
Treatment of Fibrocystic Disease
Monitor
Aspiration of cysts reduce pain
Reduce caffeine?
1-5 cm rubbery, movable, and non-tender breast mass is likely what?
fibroadenoma
Treatment of fibroadenoma
Reassurance
Cryoablation
Breast pathology commonly seen within 3 months of delivery or women who are nursing for the first time?
mastitis and breast abscess
Common pathogen of in nipple discharge of mastitis
staph aureus
Next step in non-lactating women with mastitis who does not respond to antibiotics?
incision and biopsy
Treatment of mastitis and breast abscess
Abx to cover staph - Augmentin, Dicloxacillin
Mechanical emptying of breast
Abscess may need I&D
Ok to continue breastfeeding
What is the most common female malignancy?
breast cancer
2 types of breast malignancies? Which is more common?
Ductal carcinomas (85%) Lobular carcinomas (15%)
How is invasive ductal carcinoma (IDC) and ductal carcinoma in situ (DCIS) treated?
IDC: Mastectomy or lumpectomy with radiation
DCIS: increased risk of IDC and therefore requires lumpectomy or mastectomy followed by radiation
How is invasive lobular carcinoma (ILC) and lobular carcinoma in situ (LCIS) treated?
ILC: Lumpectomy or mastectomy
LCIS: monitor; not cancer but does increase risk of developing cancer
What is Paget’s Disease?
cancerous skin cells around nipple that indicate underlying breast cancer
Risk factors of breast cancer
Advanced age (avg 60) Nulliparity Older at first pregnancy Early menarche 50 Long term estrogen exposure Genetics FHX Caucasian
Gene that is involved in breast cancer?
BRCA 1 or 2
PE of breast mass that is malignant
firm, poorly defined, immobile, non-tender
most often in upper outer quadrant
may have overlying peau d’orange (orange peel skin)
Mammogram recommendations for breast cancer screening
every 2 years after age 50 if no risk factors
stop at age 75
Imaging if cancer has become metastatic
CT
PET scan
How can estrogen-receptor positive breast cancer be treated medically?
Tamoxifen - estrogen receptor antagonist
Procedures and therapies to treat breast cancer
Lumpectomy
Mastectomy
Chemo/radiation
Tamoxifen
Main sign of pituitary prolactinoma
galactorrhea
Lab work-up of galactorrhea
Prolactin levels
hCG
Meds that can reduce galactorrhea
Cabergoline and bromocriptine
What is gynecomastia?
male developing female breasts
Possible causes of gynecomastia?
endocrine d/o chronic liver or kidney disease neoplasm medications puberty
What imbalances in hormones are seen in gynecomastia?
low testosterone
increased estradiol
+/- elevated prolactin
genetic disorder that causes gynecomastia in men?
Klinefelter’s syndrome
Gynecomastia treatment
generally self-limiting
stop offending meds
treat underlying cause
surgical removal
Gram stain for Gonorrhea
G- diplococci
Breast exam shows multiple well defined masses which are tender
fibrocystic disease
Basics of why are synthetic estrogen and progestin combinations used as contraceptives?
suppress ovulation
What is Minipill?
progesterone only oral contraceptive
not as effective as combination pills but have different side effect profiles
Non-contraceptive benefits of OCPs
Improve benign breast disease
Decrease anemia
Improve dysmenorrhea, acne, and hirsutism
Decrease development of myomas
Decrease risk of endometrial cancer and ovarian cysts
ADRs of oral contraception
Increased risk of stroke, DVT, and breast cancer
ADRs of IUD
uterine perforation
increased risk of ectopic pregnancy and pelvic infection
Clinical definition of infertility
inability to conceive after 1 year of sexual activity without use of contraceptive
Female causes of infertility
Problems with ovulation Cervical Problem Infection (Chlamydia) Scarring of tubes or uterus Endometriosis
Male causes of infertility
Smoking or alcohol
Recreational or rx’d drug use
Scrotal hyperthermia
Abnormal spermatogenesis
Lab work to find cause of infertility
Semen analysis
FSH, LH, TSH, progesterone and estrogen levels
Ovulation prediction tests
Imaging to find cause of infertility
pelvic u/s
hysterosalpingography
laparoscopy
Infertility treatment
Clomiphene citrate 50-100 mg to promote ovulation
Resolve any infections or endocrine disorders
Surgical - fulguration of endometriosis, disruption of scarring and adhesions
Artificial insemination
In vitro fertilization
The theoretical failure rate of oral contraception is _____ but the typical failure rate is _____.
0.3%, 8.0%
A patient calls to tell you that she has missed her pill yesterday. Upon further questioning she has not had intercourse in the past week. What is her best course of action?
recommendation is to take both pills today and use a barrier method for 7 days
