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171 Cards in this Set
- Front
- Back
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definition of menopause
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absence of menses for 12 months
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postmenopausal bleeding is a normal finding. T/F
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False
this patient must be evaluated; need to rule out endometrial hyperplasia/cancer, polyps, etc |
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lack of menarche by age __ warrants evaluation
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16
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physical symptoms of PMS
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aches, pains, bloating, breast tenderness, wt gain, swelling of hands/feet
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main cause of secondary amenorrhea
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pregnancy
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diff bt polymenorrhea and oligomenorrhea
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poly - bleeding more often than at 21-day intervals
oligo - infrequent bleeding (not ovulating) |
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risk factors for cervical cancer
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early sexual activity, multiple partners, history of STIs, no paps, poor nutrition
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cervical screening guidelines for age <21
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no screening, even with ASC-US; HPV not indicated
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cervical screening guidelines for age 21-29
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cytology alone every 3 years; HPV not indicated
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cervical screening guidelines for age 30-65
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cytology and HPV every 5 years or cytology alone every 3 years
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cervical screening guidelines for age >65
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no screening following 3 prior negative screens
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cervical screening guidelines for pts with hysterectomy
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no screening if no cervix and w/out history of CIN-2 or more severe dx in the past 20 yrs or cervical cancer ever
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what is cervical ectopy?
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when the transformation zone has grown outward
normal finding |
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cervical motion tenderness is a major sign of ___
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PID
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what are some things you palpate during the rectovaginal exam
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retroverted uterus, utero-sacral ligaments, cul-de-sac, and adnexa
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2 qualifications for primary amenorrhea
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lack of menses before 14 in absence of growth/development of secondary sex charact
or lack of menses before 16 regardless of presence of nl growth/devel of secondary sex charact |
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for regular secretion of FSH by the pit, GnRH must be secreted within a range of 1 pulse every _____
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90-180 minutes
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what imaging study is the mainstay of evaluating any abnorm of menstruation
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pelvic u/s
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what imaging study is the technique of choice in evaluating a pituitary abnorm
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MRI
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with premature ovarian failure, what diseases must you evaluate
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autoimmune (addison's, hypothyroid, hyperpara)
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management of hyperprolactinemic amenorrhea
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bromocriptine (Parlodel)
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management of anovulatory amenorrhea
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administer progestional agent OCP for younger pt
treatment for induction of ovulation is available |
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what hormone does bromocriptine counteract with
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prolactin
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dysmenorrhea: primary vs secondary
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primary: excess prostaglandins cause increased muscle contractions
secondary: more common as woman ages; processes outside the uterus, within the wall, or inside the cavity |
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most common extrauterine cause of secondary dysmenorrhea
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tubo-ovarian abscesses
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what are some extrauterine causes of secondary dysmenorrhea
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tumors, inflamm, adhesions, endometriosis, psychogenic (rare)
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what are some intramural causes of secondary dysmenorrhea
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adenomyosis - benign invasive growth of endometrium
leiomyomata - aka FIBROIDS; benign, can be small/large, firm |
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what is an adenomyosis
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benign invasive growth of the endometrium
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what is a leiomyomata? aka?
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aka uterine fibroids
benign; can be small/large, firm, cause heavy bleeding |
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what are some intrauterine causes of secondary dysmenorrhea
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fibroids, polyps, IUD, infection, cervical stenosis, cervical lesions
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explain the pain associated with primary dysmenorrhea
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recurrent, spasmodic lower abd pain days 1-3 of cycle; may radiate to suprapubic area or back
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meds for primary dysmenorrhea
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ibuprofen, naproxen, naproxen sodium, mefenamic acid, meclofenamate
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definition of endometriosis
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presence of endometrial glands and stroma outside the uterine cavity
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where is endometriosis typically found
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on the ovary
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is endometriosis more common in women who have or have not had children
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have not
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Sampson's theory
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theory that retrograde menstruation is the cause of endometriosis
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endometriosis: gold standard for imaging
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laparascopy
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first-line management of endometriosis
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OCPs continuously
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Depo-Provera
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OCP
administered as an injection every 3 months lots of side effects |
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Mirena
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progesterone IUD
lasts 5 years, usually after one year will not have menstruation |
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2nd line management of endometriosis
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GnRH agonists - lupron, synarel (these agents eventually decrease LH/FSH)
Others - danazol (androgenic agent), norethindrone or premarin |
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danazol
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suppresses LH and FSH
used as 2nd line management of endometriosis |
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efficacy of GnRH agonists in tx of endometriosis
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100% for 6-12 months post-therapy
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adverse effects of danazol
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acne, flushes, sweats, edema, libido changes wt gain
(danazol is an androgenic agent used for endometriosis) |
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surgical management for refractory cases of endometriosis
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hysterectomy
oophorectomy lesion ablation (10% recur) |
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2 surgical procedures used for pain management in endometriosis
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presacral neurectomy (midline pain)
laparascopic uterosacral nerve ablation |
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nulligravida
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never been pregnant
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fecundability vs fecundity
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fecundability - probability of achieving pregnancy in one cycle 20-25%
fecundity - achieving a live birth in one cycle |
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septic abortion
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type of infection that results in abortion; manifested by fever, malodorous d/c, pelvic and abd pain, and cervical motion tenderness
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what all does PID include
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endometritis, salpingitis, oophoritis, tubo-ovarian abscess, and pelvic peritonitis
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causes of PID
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usually by STIs, especially chlamydia and gonorrhea
however, normal vaginal flora can cause it |
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describe the pain in PID
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dull, continuous, bilateral, lower abd or pelvic pain that may range from indolent to severe
similar to ectopic pregnancy |
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if a patient is suspicious of PID, what must you rule out
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ECTOPIC PREGNANCY
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signs/symptoms of PID
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dull continuous pain, fever, vomiting, abnormal d/c, irregular bleeding, dyspareunia, "PID Shuffle" (similar to the Cupid Shuffle)
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minimum criteria for PID
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lower abd tenderness
adnexal tenderness (extra tender on bimanuel) cervical motion tenderness*** |
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what are some indications for hospitalization in PID
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adolescent, pregnant, N/V, fever, cannot rule out other cause, suspect TOA or pelvic abscess
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will WBCs be seen on wetprep in pts with PID
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yes
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treatment for tubo-ovarian abscess
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clindamycin or metronidazole
PLUS doxycycline |
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parenteral treatment for PID
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cefotetan or cefoxitin
PLUS doxycycline |
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oral treatments for PID
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ceftriaxone
PLUS doxycycline with or without metronidazole |
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after ovulation, the dominant follicle becomes the ____, and it secretes ____
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corpus luteum
progesterone |
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_____ prepares the lining of the endometrium for implantation of fertilized oocyte
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progesterone
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what are some causes of decreased GnRH
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anorexia, severe wt loss, stress, extreme exercise, hyperprolactinemia
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#1 cause of infertility
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hypoestrogen states
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what are 4 causes of hyperprolactinemia
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CNS tumors
hypothyroidism drugs (dopamine antagonists, methyl-dopa, serotonin agonists) spinal cord lesions |
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Sheehan's syndrome
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hypopituitary state caused by post-partum hemorrhage
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hemosiderosis
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iron deposits in pituitary impair function (decreases LH/FSH secretion)
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Savage Syndrome
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ovarian insensitivity to FSH/LH
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major feature of Turner Syndrome
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ovarian dysgenesis
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clinical findings of Turner syndrome
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ovarian dysgenesis, amenorrhea, normal IQ, webbed neck, small stature, poor hip development, absent 2nd sex charact, coarctation of aorta
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what are some uterine causes of infertility
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congenital - absence of uterus
structural - patent vagina (imperforate hymen, transvers vaginal septum) traumatic - scarring and adhesions from D&C (Asherman's syndrome) |
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Asherman's syndrome
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traumatic cause of infertility; usually due to scarring and adhesions from D&C
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treatment of amenorrhea secondary to hypothalamic causes
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tumor removal, wt gain, stress relief, exogenous GnRH
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treatment of amenorrhea secondary to pituitary causes
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tumor removal, bromocriptine to inhibit prolactin, exogenous FSH/LH
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treatment of amenorrhea secondary to ovarian causes
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clomiphene (anti-estrogen)
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treatment of amenorrhea secondary to uterine causes
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correct obstruction
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luteal phase is the "_____ phase", and occurs ___ in the menstrual cycle
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secretory
late |
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luteal phase defect is also called _____
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progesterone deficiency
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what hormone increases during the menopausal transition state
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FSH in response to decreased ovulation
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most common manifestation of decreased estrogen
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hot flashes
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menopausal women will stop having hot flashes within ___ years
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2-3
though some will have it for 10 |
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what are some causes of premature ovarian failure
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genetics
gonadotropin-resistant ovary syndrome autoimmune smoking cancer tx hysterectomy |
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therapy for hot flashes
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estrogen most effective
behavioral changes - keep temp cool, regular exercise, relaxation therapy SSRIs gabapentin - for nocturnal hot flashes |
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what drug is suggested for nocturnal hot flashes
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gabapentin
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what are some contraindications to HRT
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abnormal genital bleeding of unknown etiology
estrogen-dependent neoplasia hx of DVT or PE hypercoagulopathies/stroke/MI liver dz known/suspected pregnancy |
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the follicular phase starts ____ and ends ____
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starts on the first day
end when LH surges |
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follicles for each cycle start developing when
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in the late luteal phase of the previous cycle
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how large does the dominant follicle become by ovulation
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16-30 mm
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what happens to the dominant follicle 24-36 hrs after the LH surge
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ruptures
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the corpus luteum increases/decreases in size post-ovulation
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decreases
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at what part of the cycle does temp change happen
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couple of days prior to LH surge
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when should serum progesterone levels be taken during the cycle
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in the mid-luteal phase (normal is bt 6 and 25 ng/mL)
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release of oocyte into the fallopian tube is approx ____ after the LH surge
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36 hours
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preferred imaging to view follicles
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transvaginal U/S (doesn't require a full bladder whereas transabdominal does)
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ovarian reserve
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the capacity of the ovary to provide eggs that can be fertilized
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NIH criteria for PCOS
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chronic and unexplained hyperandrogenism
evidence of anovulation oligo-anovulation |
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Rotterdam criteria for PCOS
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chronic and unexplained hyperandrogenism
evidence of anovulation oligo-anovulation polycystic ovaries |
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diff bt Rotterdam criteria and NIH criteria for PCOS
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presence of polycystic ovaries is only included in Rotterdam
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who are some high risk groups for PCOS
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use of valproic acid (seizure pts)
oligo-ovulatory infertility obesity diabetes history of premature adrenarche 1st degree relatives |
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etiology of PCOS
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unknown
hypotheses include genetics (autosomal dominant) and precipitating factors (many) |
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PCOS patients typically have high/low serum LH concentrations
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high
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hyperthecosis
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when an area of luteinization occurs along with stromal hyperplasia
the luteinized cells produce androgens, which may lead to hirsutism and virilization |
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what is the most clearly defined environmental factor affecting the development of PCOS
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diet and its association with obesity
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how is hyperandrogenism manifested clinically
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hirsutism
acne male pattern baldness |
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what are some rare findings of PCOS
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increased muscle mass
deepening of voice clitoromegaly |
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key ovarian findings in PCOS
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multiple small follicles in a peripheral distribution and increased stroma
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key histological findings of ovaries in PCOS
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thickened and sclerotic cortex of the ovary, giving the appearance of a smooth white capsule on gross examination
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what is the Rotterdam criteria with regards to follicles in PCOS
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presence of 12 or more follicles in each ovary measuring 2-9mm in diameter
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sonographically detected polycystic ovaries are sufficient for diagnosis of PCOS. T/F
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False
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oligomenorrhea vs amenorrhea
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oligomenorrhea - fewer than 9 periods in a year
amenorrhea - no periods for 3 or more consecutive months |
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what lab is the most sensitive in establishing presence of hyperandrogenemia
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free testosterone
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treatment of PCOS
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WEIGHT LOSS
oral contraceptives clomiphene metformin or thiazolidinediones |
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abnormal uterine bleeding is ALWAYS abnormal in ______
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postmenopausal females
cancer until proven otherwise |
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what is thelarche? when does it occur?
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onset of breast development (occurs 2 years before menarche)
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definition of abnormal uterine bleeding
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abnormal menstrual bleeding unrelated to anatomic lesions; usually caused by hormonal imbalances
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2 major classes of AUB
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ovulatory and anovulatory
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anovulatory vs. ovulatory AUB
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anovulatory - most common; constant endo proliferation w/out progest-mediated maturation and shedding; overgrown endo continually shreds
ovulatory - inadequate progest secretion by corpus luteum causes a luteal-phase defect; often presents with polymenorrhea and metrorrhagia |
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common causes of anovulatory AUB
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PCOS
obesity unopposed exogenous estrogen |
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what are 4 diff manifestations of abnormal bleeding
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less than 21 days
more than 36 days lasting longer than 7 days blood loss >80 mL |
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what is menorrhagia? regular/irregular intervals?
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menses that are too long in duration (more than 7 days) and/or with excessive blood loss (more than 80 mL) occurring at normal intervals
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most common anemia associated with menstruation
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iron-deficiency anemia
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what is metrorrhagia? regular/irregular intervals?
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intermenstrual bleeding
irregular intervals |
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what is polymenorrhea? regular/irregular intervals?
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occurs too frequently (less than 21 days)
regular intervals |
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what age groups are anovulatory cycles most common to occur?
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during adolescence and perimenopause
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menometrorrhagia
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bleeding that occurs at irregular intervals, too long in duration, or excessive blood loss
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what is oligomenorrhea? increased/decreased amount of blood?
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periods occur more than 35 days apart
decreased |
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systemic causes of oligomenorrhea
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excessive wt loss (anorexia nervosa)
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what are some causes of contact bleeding
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sex
cervical eversion cervical polyps infection atrophic vaginitis cervical cancer |
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main skin abnormality associated with hypothyroidism
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acanthosis nigricans
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placenta previa vs abruptio placentae
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placenta previa - placenta implants too close to the cervix; 3rd trimester bleed; is painLESS
abruptio placentae - placental lining separates from the uterus; its the most common pathological cause of late pregnancy bleeding; can cause massive bleeding; very painful, typically in 3rd trimester |
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what type of thermometer can predict time of ovulation
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BBT (basal body temp thermometer)
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diff bt transvaginal and transabdominal U/S
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transvaginal - empty bladder; enables closer look with greater details of pelvic organs
transabdominal - full bladder; enables a wider but less discriminative exam of the pelvis; better for evaluating fibroids |
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sonohysterography
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saline instilled into uterine cavity via catheter to provide enhanced visualization during transvaginal U/S
can detect polyps, hyperplasia, ca, fibroids, and adhesions |
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when is D&C indicated
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if bleeding persists, no cause can be found, or tissue is inadequate for diagnosis
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what are some causes of AUB
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immature hyp-pit axis
lack of estrogen feedback hypo/hyperthyroidism systemic illness weight loss |
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Novasure
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one time, 5-minute procedure that lightens/ends heavy period
basically the endometrium is burned by electrical energy |
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what is the most frequent indication for hysterectomy in premenopausal women
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uterine fibroids
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what percent of fibroid pts require treatment
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10-20%
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most common symptoms of fibroids
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menometrorrhagia, +/- clots, anemia
also can have pelvic pain/pressure, back pain, lower ext pain, dyspareunia, infertility |
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subserosal fibroids: location? appearance? sxs? can become?
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under outside covering of uterus
knobby appearance typically doesnt affect menses, but can cause pelvic and back pain, and generalized pressure can develop a stalk, and become pedunculated |
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most common type of fibroids
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intramural
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symptoms of intramural fibroids
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menorrhagia, pelvic pain, back pain, or generalized pelvic pressure, if you will
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where do intramural fibroids develop
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within lining of uterus
expand inward, if you will |
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least common type of fibroids
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submucosal
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which fibroids cause the most menstrual problems, anemia, and hospitilization
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submucosal
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hormone therapy for fibroids
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Lupron (GnRH agonist)
Danazol (synthetic androgen) Progestins (anti-estrogen) |
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definitive procedure for tx of sympto fibroids
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hysterectomy
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alternative procedure for tx of fibroids
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myomectomy
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2 categories of uterine cysts
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functional - which includes follicular, corpus lutein, theca lutein
neoplastic growths |
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how does a follicular cyst arise
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after the failure of the follicle to rupture during follicular maturation or failure of ovulation
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what is mittelschermz
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sharp pain that occurs mid-cycle
can be caused by follicular cyst rupture |
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pathophys of corpus lutein cysts
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occurs after egg has been released from a follicle
follicle becomes corpus luteum, usually breaks down/disappear if fertilization doesnt occur; however it may fill with fluid or blood and persist on the ovary....thus becoming a corpus lutein cyst, if you will |
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theca lutein cysts
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small, bilateral cysts filled with clear, straw-colored fluid
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what causes theca lutein cysts
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stimulation from abnormally high gonadotropins (especially B-HCG)
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cyst management - pts of reproductive age with cysts less than 6 cm
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observation with a follow up U/S
or could start patient on OCPs to suppress gonadotropin stimulation |
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adenomyosis
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extension of endometrial glands and stroma into uterine musculature
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effect of adenomyosis on uterus
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becomes diffusely enlarged and globular dye to hypertrophy/plasia
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diff bt fibroids and adenomyomas
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adenomyomas have no distinct capsular margin
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what does parous mean
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have had atleast one child
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medical and surgical treatment of adenomyosis
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medical - GnRH agonists (lupron)...however this is limited to 6 mths due to elevated LDLs
surgical - hysterectomy |
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why is Lupron limited to 6 months
|
osteoporosis
elevated LDLs |
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most common cause of endometritis
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after delivery or instrumentation/disruption of the uterine cavity
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most common cause of fever during the post-partum period
|
endometritis
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clinical sxs of endometritis
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uterine tenderness
fever elevated WBC foul smelling lochia abnl bleeding/discharge dyspareunia malaise |
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treatment for endometritis
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combination of IV clindamycin and gentamicin
can also do 2nd/3rd generation cephalo + metronidazole po abx not usually necessary |
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most common cause of Tubo-Ovarian Abscess
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spread of anaerobic bacteria from the lower genital tract
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what are some GI conditions that can cause TOA
|
diverticulitis
appendicitis |
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typical ultrasonographic appearance of a TOA
|
multilocular, cystic, complex adnexal mass often with debris and thick septations
.....whatever that means |
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treatment of TOA
|
IV triple antibiotic regimen: ampicillin, clindamycin, and flagyl
if no improvement, surgical intervention |
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Douching is ____
|
BAD
|
|
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what are the 5 anti-muscarinic drugs approved for OAB
|
tolterodine (Detrol)
oxybutynin (Ditropan) trospium (Sanctura) solifenacin (Vesicare) darifenacin (Enablex) |
