***gyn

Front 1

Gyn topics

Back 1

1. Contraception
2. Gyn infections
3. Menstrual d/o & issues
4. Menstrual physio (Precocious, puberty, menopause)
5. neoplasms
6. STDs

Front 2

Precocious puberty
Dx

Back 2

1. Clinical
Complete isosexual: normal pubertal changes take place but at earlier-than normal age
Incomplete isosexual: premature breast budding (i.e., thelarche), axillary hair growth (i.e., adrenarche), or pubic hair growth (i.e., pubarche) may take place

Labs
1. Incr LH and FSH, with additional release following administration of gonadotropin-releasing hormone (GnRH) suggests pituitary gland activa-tion;
low LH and FSH with no response to GnRH suggests excess sex steroid production
2. Incr estrogen in presence of low LH and FSH suggests exogenous hormone production (neoplasm)
significantly high levels of adrenal steroids may be seen with neoplasm or congenital adrenal hyperplasia (CAH)
3. Incr TSH) with low thyroxine (T4) and triiodothyronine (T3) suggest precocious puberty in response to chronic hypothyroidism

Radiology
MRI or CT with contrast may detect cerebral or adrenal lesions

Front 3

Precocious puberty
Tx

Back 3

1. GnRH analogues are useful for LH and FSH suppression in hypothalamic-pituitary-gonadal axis pathologies
2. Precocious puberty secondary to ectopic hormone secretion should be treated by locating and removing source of hormone
3. Precocious puberty caused by CAH should be treated with cortisol replacement
4. Complete precocious puberty with an onset close to the expected start of puberty may not require treatment
Incomplete precocious puberty requires only observation to make sure that it does not become complete precocity

Front 4

Menopause
Dx

Back 4

1. Clinical
hot flashes (secondary to thermoregulatory dysfunction), breast pain
sweating
menstrual irregularity with eventual amenorrhea
possible menorrhagia
fatigue
anxiety
irritability
depression
dyspareunia (caused by vaginal wall atrophyand decreased lubrication), urinary frequency, dysuria
change in bowel habits examination detects vaginal atrophy

2. Labs
incr FSH, incr LH, decr estradiol

Front 5

Menopause
Tx

Back 5

1. Lubricating agents to treat dyspareunia (i.e., painful intercourse);
2. short-term topical vaginal estrogen used in cases of significant vaginal symptoms
3. Calcium, vitamin D, bisphosphonates, and exercise to prevent osteoporosis
4. Selective estrogen receptor modulators, such as raloxifene and tamoxifen, may serve a role in reducing osteoporosis and cardiovascular risks
5. Regular cardiovascular follow up
6. Hormone replacement therapy was mainstay of therapy for many years, but its benefits have more recently been shown to be less than previously believed, and it has been linked to increased risk for breast cancer and deep vein thrombosis

Front 6

Amenorrhea
Dx

Back 6

1. clinical
Hx should address occurrence of any previous menstruation periods (e.g., primary or secondary amenorrhea), exercise and eating habits (e.g., substantial exercise or inadequate eating), family history, medications, androgenous symptoms (e.g., facial hair, voice deepening), and known comorbidity

Examination should note Tanner stages and should check for normal sexual anatomy

Labs
1. beta-hCG test used to rule out pregnancy
2. TSH, T4, and T3-reuptake can diagnose thyroid dysfunction
3. Incr prolactin suggests prolactin-secreting tumor
4. FSH and LH levels measure hypothalamic-pituitary activity
5. Incr androgens (e.g., testosterone, dehydroepiandrosterone [DHEA]) suggest pcos
6. Progestin challenge (i.e., patient is observed for bleeding after 5-day administration of progesterone) and estrogen-progesterone challenge (i.e., patient is observed for bleeding after administration of estrogen and progesterone) can help detect anatomic abnormalities (bleeding indicates normal outflow tract), hormonal abnormalities, or hypothalamic-pituitary activity

Front 7

Amenorrhea
Tx

Back 7

1. Modify behaviors (e.g., eating disorders, exercise) to allow menstruation
2. Anatomic abnormalities require surgical correction
3. Hypothalamic-pituitary dysfunction may be treatable by GnRH or gonadotropin replacementd. Prolactinoma may be treated with dopamine agonists
4. Hormone replacement therapy may be considered in ovarian failure
5. Lysis of adhesions and estrogen administration performed for Asherman's syndrome
6. Thyroid dysfunction and Cushing's syndrome treated according to specific pathology
7. In some untreatable patients with appropriate anatomy, pregnancy may be accom
plished through egg donation, in vitro fertilization, and hormone modulation

Front 8

Dysmenorrhea
Dx

Back 8

1. Clincial
crampy lower abdominal pain associated with menstruation
n/v
headache
diarrhea
mild abdominal tenderness

Labs
beta-hCG and blood and vaginal cultures are helpful to rule out pregnancy and infection

Radiology
1. US may be used to detect ovarian and uterine lesions
2. hysteroscopy or laparoscopy may be needed to detect intrauterine pathology, intraabdominal pathology, or endometriosis

Front 9

Dysmenorrhea
Tx

Back 9

1. NSAIDs or oral contraceptive pills (OCPs) for primary disorders
2. treat underlying infection or uterine disease

Front 10

PCOS
Dx

Back 10

1. clinical
Weight gain
headache
abdominal or pelvic pain,
abdominal bloating
change in bowel habits
food cravings
mood lability
depression
fatigue
irritability
breast tenderness, edema,
abdominal tenderness
acne
2. Findings precede menses and occur at similar time points in each cycle

Front 11

PCOS
Tx

Back 11

1. exercise, vitamin B6, NSAIDs, OCPs, progestins;
2. SSRIs) ± alprazolam may improve mood symptoms in both PMS and PMDD

Front 12

endometriosis
Dx

Back 12

1. clinical
dysmenorrhea
dyspareunia,
painful bowel movements (i.e., dyschezia),
pelvic pain
possible infertility
uterine or adnexal tenderness
palpable adhesions on uterus or ovaries

Labs
1. biopsy of lesions shows endometrial tissue;
2. beta-hCG and urinalysis helpful to rule out pregnancy and urinary tract infection
3. CA-125 marker frequently increased but not a highly sensitive test

Radiology
1. laparoscopy will show "powder-burn" lesions and cysts on involved areas and is optimal diagnostic tool

Front 13

endometriosis
Tx

Back 13

1. Recording a journal of symptoms is useful for defining treatment
2. OCPs, progestins, danazol, or GnRH agonists may supply symptomatic relief
3. Laparoscopic ablation may successfully remove lesions while maintaining fertility potential
4. Hysterectomy, lysis of adhesions, or salpingo-oophorectomy may be required in severe cases

Front 14

abnormal uterine bleeding
Dx

Back 14

1.clinical
1) Uterine bleeding that does not follow usual menstrual cycle or occurs in postmenopausal women
2) Menses with <21-day or >35-day intervals, lasting >7 days, or blood loss >80 mL are considered abnormal
3) Assoc symptoms (e.g., fever, abdominal pain, vaginal discharge, acne, changes in bowel or bladder function), family history, history of medical conditions useful to making diagnosis
4. Visualization of bleeding site (e.g., cervix, vagina, anus, vulva), palpation of pelvic masses important

Labs =
1. beta-hCG used to rule out pregnancy
2. CBC, coagulation studies, TSH, FSH, and LH are used to rule out anemia, coagulopathy, and endocrine abnormalities
3. Pap smear and endometrial biopsy (possibly obtained during dilation and curettage [D&C]) used to rule out cancer
5. Testing for STDs used to rule out infection

Radiology
1. US may detect uterine lesions
2. hysteroscopy frequently indicated to visualize lesions and perform D&C

Front 15

abnormal uterine bleeding
Tx

Back 15

1. Treat underlying disorder (e.g., coagulopathies, thyroid disease, infection)
2. OCPs can be used for cycle irregularity
3. Endometrial ablation may be performed for severe or recurrent bleeding

Front 16

PCOS
Dx

Back 16

1. clinical
Obesity (frequently initial sign)
Hirsutism: excess growth of facial, chest, and abdominal hair
Virilization: balding, increased muscle mass, voice deepening, clitoral enlargement
Menstrual dysfunction: amenorrhea, oligomenorrhea, breakthrough bleeding
Infertility
Bilateral ovarian enlargement on bimanual examination

Labs
1. incr LH, LH:FSH ratio >3, incr DHEA, incr androstenedione; positive progestin challenge

Radiology
1. US shows enlarged ovaries with multiple cysts

Front 17

PCOS
Tx

Back 17

1. Clomiphene (antiestrogen) induces follicle stimulation and maturation to allow pregnancy
2. OCPs or progestins can be used to regulate menstrual cycles, treat hirsutism and virilization, and decrease endometrial cancer risk
3. Management of glucose intolerance required to avoid complications of diabetes mellitus (DM)

Front 18

Vaginitis
Dx

Back 18

1. Clinical
vaginal irritation or pruritus
vaginal discharge

Labs
1. wet mount (i.e., smear of vaginal fluid examined under microscope) with saline or potassium hydroxide (KOH) and
2. vaginal pH testing useful to distinguish cause
3. diagnostic cards are available for testing vaginal fluid samples when microscopy is unavailable

Front 19

Vaginitis
Tx

Back 19

1. metronidazole (G. vaginalis or Trichomonas)
2. clindamycin (G. vaginalis)
3. fluconazole (C. albicans)

Front 20

Toxic shock syndrome
Dx

Back 20

1. clinical
vomiting
diarrhea
sore throat
headache
high fever
generalized macular rash
severe cases develop hypotension, shock, respiratory distress, and desquamation of palms and soles

Labs
1. vaginal fluid culture shows S. aureus
2. decr platelets, incr alanine aminotransferase (ALT) and aspartate aminotransferase (AST), and incr blood urea nitrogen (BUN) and creatinine

Front 21

Toxic shock syndrome
Tx

Back 21

1. Remove tampon or other intravaginal objects
2. Supportive care for hypotension; pressors may be required
3. Clindamycin or penicillinase-resistant P-lactam antibiotics (e.g., oxacillin, nafacillin); vancomycin required for methicillin-resistant strains

Front 22

Cervicitis
Dx

Back 22

1. clinical
Possibly asymptomatic (>50% of cases in chlamydial infection)
Dyspareunia, bleeding after intercourse, purulent vaginal discharge (milder for Chlamydia)
Urethritis associated with purulent discharge and dysuria
Rectal and pharyngeal infections are frequently asymptomatic
Examination detects inflammation of cervix with associated purulent discharge

Labs
1. Gram stain of cervical scraping shows gram-negative diplococci with N. gonorrhoeae (usually nothing seen with Chlamydia infection)
2. Culture on Thayer-Martin agar detects N. gonorrhoeae
3. Enzyme immunoassays useful for detecting both pathogens
4. DNA probes and DNA amplification testing (i.e., polymerase chain reaction [PCR] ) are highly sensitive means of detecting either pathogen on swabs of cervical fluid

Front 23

Cervicitis
Tx

Back 23

1. ceftriaone or fluoroquinolones (not in pregnancy) for N. gonor¬rhoeae, doxycycline (not in pregnancy) or azithromycin for Chlamydia; both antibiotics often given together because of frequent dual infection
2. sexual partners must be treated to reduce risk of reinfection