++Gyn Suts2

Front 1

Define precocious puberty

Back 1

girls<8
boys <9

Front 2

Gyn topics

Back 2

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

Front 3

What is the most common cause of precocious puberty

Back 3

adrenal hyperplasia

Front 4

Precocious puberty
Dx

Back 4

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 5

What is the cause of Precocious of puberty

Back 5

1) early activation of the hypothalamic-pituitary- gonadal axis
2) excess secretion of sex steroids

Front 6

Precocious puberty
Tx

Back 6

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 7

How is Precocious puberty diagnosed

Back 7

1) Pituitary gland: High LH,FSH w/ incr w/ GnRH administration
2) Excess sex steroid: low LH,FSH w/ no response to GnRH administration
incr estrogen w/ low LH,FSH ->
tumor or CAH
3) chronic hypothyroidism: incr TSH w/ low T3,T4
4) MRI or CT w/ contrast (cerebral or adrenal lesions)

Front 8

Menopause
Dx

Back 8

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 9

Treatment for Precocious puberty

Back 9

1) LH, FSH suppression: GnRH analogues
2) ectopic hormone: remove source
3) CAH: cortisol replacement

Front 10

Menopause
Tx

Back 10

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 11

Define Menopause

Back 11

One year of amenorrhea because of ceasing ovarian function

Front 12

Amenorrhea
Dx

Back 12

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 13

What is premature menopause

Back 13

ovarian failure before 40 yr/old

Front 14

Amenorrhea
Tx

Back 14

1) Modify behaviors
2) surgical correction
3) Hypothalamic-pituitary dysfunction: GnRH or gonadotropin replacement.
4) Prolactinoma: dopamine agonists
5) Ovarian failure: Hormone replacement
6) Asherman: Lysis of adhesions and estrogen administration
7) Tx Thyroid dysfunction and Cushing's syndrome
8) in vitro fertilization

Front 15

causes of premature menopause

Back 15

Tobacco
radiation/chemo
autoimmune d/o
abdominal or pelvic surgery

Front 16

Dysmenorrhea
Dx

Back 16

1) beta-hCG
2) blood and vaginal cultures (r/o infection)
3) U/S
4) hysteroscopy or laparoscopy

Front 17

Symptoms of menopause

Back 17

hot flashes
menstrual irrgeularities
amenorrhea
dysparenunia (2/2 vaginal atrophy & decr lubrication)

Front 18

Dysmenorrhea
Tx

Back 18

1. Primary D/O: NSAIDs or OCPs
2. treat underlying infection or uterine disease

Front 19

How is menopause diagnosed

Back 19

incr FSH, LH
decr estradiol

Front 20

What are the clinical features of PCOS

Back 20

1) obesity
2) Hirsutism
3) virilization
4) amenorrhea
5) infertility
6) bilateral ovarian enlargement

Front 21

How is menopause treated

Back 21

1) dysparunia: lubricating agents, estrogen cream

2) osteoporosis: Ca, vit D, bisphoshonates, exercise, SERM (raloxifene, tamoxifen)

3) hormone replacement

Front 22

PCOS
Tx

Back 22

1) clomiphene (induce follicle stimulation)
2) OCPs, progestins (regulate cycle and tx symptoms)

Front 23

What is the cause of increased osteoporosis risk in menopausal women

Back 23

decreased estrogen production by the ovaries

Front 24

endometriosis
Dx

Back 24

1) biopsy (shows endometrial tissue)
2) beta-hCG (r/o pregnacy)
3) urinalysis (r/o UTI)
4) incr CA-125
5) laparoscopy: ("powder-burn" lesions and cysts) optimal diagnostic tool

Front 25

What are causes of Amenorrhea

Back 25

NO CATCHUP
Nutrition (Anorexia)
Ovarian dz
Cushing syn
Anatomic abnormalities
Thyroid dz
Chromosone abnorm
Hypothalamic-pit dysfxn
Uterine dz
Pregnancy

Front 26

endometriosis
Tx

Back 26

1. symptom journal
2. symptom relief
OCPs, progestins, danazol, or GnRH agonists
3. Laparoscopic ablation: (remove lesions while maintaining fertility)
4. Severe cases
Hysterectomy, lysis of adhesions, or salpingo-oophorectomy

Front 27

What is Asherman's Syndrome

Back 27

scarring of the uterus that follows infection or post partum infection

Front 28

abnormal uterine bleeding
Dx

Back 28

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 29

What is the difference between primary and secondary amenorrhea

Back 29

Primary: never having menses in 16 y/o with normal secondary sex characteristics or 13 y/o w/ no secondary characteristics

Secondary: absence of menses for 6 mths in patient with prior menses

Front 30

abnormal uterine bleeding
Tx

Back 30

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 31

What is the first step in work-up of amenonorhhea

Back 31

B-hcg pregnancy test

Front 32

PCOS
Dx

Back 32

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 33

How is amenorrhea diagnosed

Back 33

1) B-hCG test
2) TSH, T4, T3 reuptake
3) incr prolactin-> tumor
4) FSH, LH levels
5) incr androgens -> PCOS
6) Progestin challenge (observed for bleeding after 5 day administration of progesterone)
7) Estrogen & progesterone challenge (observed for bleeding after administration of estrogen & progesterone)
6&7 can help detect anatomic abnormalities

Front 34

PCOS
Tx

Back 34

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 35

What is the treatment for amenorrhea

Back 35

1) modify behavior
2) surgery
3) Hyp-Pit dysfxn
4) Prolactinoma -> DA agonists
5) Ovarian failure-> hormone replacement
6) Asherman -> Lysis & estrogen
7) in vitro fertilization

Front 36

Vaginitis
Dx

Back 36

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 37

What is the concern if testicles are present in XY patient w/ androgen insensitivity syndrome

Back 37

testicles should be removed early because of increased risk of testicular cancer

Front 38

Vaginitis
Tx

Back 38

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

Front 39

Toxic shock syndrome
Dx

Back 39

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 40

Toxic shock syndrome
Tx

Back 40

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 41

Cervicitis
Dx

Back 41

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 42

Cervicitis
Tx

Back 42

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

Front 43

What is endometriosis

Back 43

endometrial tissue outside the uterus

Front 44

What is the most common cause of female infertility

Back 44

endometriosis

Front 45

What is the most common cause of androgen excess in women

Back 45

PCOS

Front 46

What do patient with PCOS have to worry about?

Back 46

increased risk of endometrial cancer due to high estrogen levels

Front 47

what is the cause of ovarian cysts in PCOS

Back 47

androgen hypersecretion

Front 48

Clinical features of endometriosis

Back 48

1) dysmenorrhea
2) dyspareunia,
3) dyschezia (painful bowel movements),
4) uterine or adnexal tenderness

Front 49

What is the cause of PCOS

Back 49

Hypothalamic-pituitary disease with excess LH secretion-> overproduction of androgen

Front 50

How is PCOS diagnosed

Back 50

1) incr LH, LH:FSH ratio >3
2) incr DHEA
3) incr androstenedione
4) positive progestin challenge
5) U/S (enlarged ovaries w/ cysts)

Front 51

How can you tell the difference between primary and secondary dysmenorrhea symptoms

Back 51

1) primary occur at the beginning of cycle
2) secondary occur mid-cycle before menstruation and incr in severity until conclusion of menstruation