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174 Cards in this Set
- Front
- Back
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Describe what is happening before ovulation (hormonally) |
- Low levels of estrogen and progesterone causes hypothalamus to produce GnRH - GnRH causes anterior pituitary to release FSH (for follicular development and estrogen production from ovaries) and LH (for ovulation) |
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Describe what is happening during ovulation (hormonally) |
- Body reaches estrogen threshold and there is an abrupt LH surge - LH causes the egg to be released from ovary |
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Describe what is happening after ovulation (hormonally) |
- The corpus luteum secretes large doses of progesterone (and some estrogen) - This causes the hypothalamus to reduce production of GnRH -This causes the anterior pituitary to reduce production of FSH and LH - End of cycle plunge in estrogen and progesterone causes menstruation |
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Parameters of Endometrial cycle |
Menstrual phase: Day 1-5 Proliferative phase: Day 6-14 Secretory phase: Day 15-28 |
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Parameters of Ovarian cycle |
Follicular Phase: Day 1-14 (length variable) - Day 7 dominant follicle is established - Dominant follicle releases more estrogen which eventually stimulates FSH and LH surge (+FBL) Luteal Phase: Ovulation - end of cycle - Progesterone dominant hormone |
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How many follicles are women borne with |
1-2 million |
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How many follicles per month are recruited by rising FSH levels? |
10-20 (recruitment occurs during the late luteal phase of the preceding cycle) |
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How long after the LH surge does ovulation occur? |
12 hours |
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When does the corpus luteum go through atresia if pregnancy does not occur? |
At the end of the cycle (10-14 days after ovulation) |
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~10 years before menopause there is a gradual increase in production of LH and FSH. What level of FSH indicates ovarian compromize |
>50 MIU of FSH indicates ovarian compromise |
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Natural Family Planning Fertility Awareness Method Calendar (rhythm) Method Standard Days Method |
Monitor cycles for length for 6-12 months (1)Abstinence during fertile period (2)Barrier methods during fertile period |
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FAM Failure Rates |
Typical failure rate: 24% Perfect use failure rate: 0.4-5% Post-ovulatory only: 1% with perfect use |
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FAM When is fertile period? |
5 days prior to ovulation - 24 hours after ovulation (Days 8-19) |
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FAM When is infertile period? |
Days 1-7, Days 20-end of cycle |
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FAM Earliest fertile day = ___ |
Shortest cycle length minus 18 |
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FAM Latest fertile day = ___ |
Longest cycle length minus 11 |
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Billings Ovulation Method Cervical Mucus Ovulation Detection Method |
Woman manually checks quantity and character of cervical mucus daily for several months to learn pattern Abstinence or contraception begin as soon as there is noticeable mucus Intercourse resumes without restriction 4 days after ovulation mucus |
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Mucus Method Post menstrual mucus characteristics |
Scant or undetectable |
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Mucus Method Pre-ovulation mucus characteristics |
Cloudy, yellow or white, sticky |
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Mucus Method Ovulation mucus characteristics |
Clear, wet, stretchy, slippery spinnbarkheit |
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Mucus Method Post-ovulation mucus characteristics |
Thick, cloudy, sticky FERTILE Scant or undetectable INFERTILE |
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Basal Body Temp Method |
BBT drops just prior to ovulation and rises at least 0.4F with ovulation Fertile period is day of first temperature drop or first elevation through 3 consecutive days of elevated temp |
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Purpose of HPV DNA assay |
Determine need for colposcopy in ASC-US Co-testing for women age 30 or older |
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Normal wet mount findings |
Squamous epithelial cells Lactobacilli White blood cells Red blood cells - make sure you know source |
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Epithelial cells |
Smooth borders Few bacteria visible in the cell Single central nuclei |
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Lactobacilli |
Rod shaped Indicative of normal pH Absent or decreased in BC |
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WBCs |
Numbers approximately equal to epithelial cells Rare in BV High numbers indicate infections like: Trich Chlamydia Gonorrhea Yeast |
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Abnormal wet mount findings |
Trichomonads Clue cells Yeast ++WBCs Absent lactobacilli RBCs with unknown source |
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Clue cells |
Epithelial cells covered with bacteria Irregular, obscured border Salt and pepper appearance |
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Trichomonads |
Motile or dead protozoa Flagellae |
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Yeast |
Spores - clear and round Hyphae - long, tubular, branching |
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Whiff test |
KOH mixed with discharge BV Trich |
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Normal vaginal pH |
3.8-4.2 Maintained by lactobacilli >4.5 is abnormal (associated with BV or Trich) |
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Endometrial thickness requiring biopsy |
Greater than 4 requires biopsy Less than 4 does not |
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Gardasil precautions |
Higher risk of fainting and VTE Sit or rest for 15 minutes afterward Contraindicated for those with severe yeast allergy Contraindicated in pregnancy Use with caution in breastfeeding |
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Gardasil approved for |
Girls 9-26 Boys 9-15 |
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Gardasil dosing |
3 doses over 6 month period Time x x + 2 months x + 6 months |
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Bacterial Vaginosus Diagnostic Criteria |
3 or more of the following: pH > 4.5 Clue cells Positive KOH whiff test Homogenous thin white discharge |
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BV Treatment NON-Pregnant |
Metronidazole 500 mg PO BID x 7 days OR Metronidazole gel 0.75% x 5 days OR Clindamycin cream or ovules x 7 days *Should not be used with latex condoms |
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BV Treatment Pregnancy |
Oral preparations only - not vaginal Metronidazole 500 mg PO BID x 7 days OR Metronidazole 250 mg PO TID x 7 days OR Clindamycin 300 mg PO BID x 7 days (vaginal clinda cream is contraindicated in the later half of pregnancy) |
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BV Counseling |
Antabuse effect - no drinking until 24 hours after last dose Class B drug - ok for breastfeeding also Come back in 1-2 weeks if no relief |
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Trichomoniasis NON-Pregnant |
Metronidazole 2g PO in single dose OR Tinidazole (Tindamax) 2g PO in single dose Alternative: Metronidazole 500 mg PO BID x 7 days |
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Trichomoniasis Pregnant |
Metronidazole 2g PO in single dose |
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Trichomoniasis counseling |
Partner must be treated Patients taking Phenobarbital and Phenytoin may need higher doses Antabuse effect |
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Vulvovaginal Candidiasis Uncomplicated |
Treat with OTC anti-fungal: Miconazole Butoconazole Clotrimazole Nystatin Tioconazole terconazole Fluconazole |
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Recurrent VVC |
4 or more symptomatic episodes/year Obtain cultures to identify non-albicans species Tx: 7-14 days of topical therapy or 150mg PO dose of Fluconazole repeated 3 days later Maintenance anti-fungals given for 6 months |
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Severe VVC |
Extensive erythema, edema, excoriation, fisures 7-14 days of topical -azole OR PO Flucanazole in 2 sequential doses (2nd dose after 72 hours) |
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Non-albicans VVC |
optimal treatment unknown Longer duration (7-14 days) with non-fluconazole -azole drug is recommended first line For recurrence, give boric acid in a gelatin capsule vaginally for 2 weeks Maintenance of nystatin has been effective |
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Compromised host with VVC |
Longer therapy (7-14 days) |
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Pregnancy with VVC |
Only topical -azole therapies, applied for 7 days are recommended for use among pregnant women |
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Average age of menopause |
51 Retrospective diagnosis: 12 months after last period |
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Urge vs. Stress incontinence |
Urge: detrusor muscle change - clearly linked to menopause and relationship to menopause Stress: weakness of muscles secondary to obesity, multiparity, and some link with estrogen |
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Benefits of Hormone Therapy |
Decreased risk of colorectal cancer Decreased risk of hip fractures NO evidence of cardiac protection |
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Potential risks of Hormone Therapy |
Gallbladder disease Myocardial infarction Breast cancer Pulmonary emboli Stroke Endometrial cancer (ET only) |
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Contraindications for Hormone Therapy |
History of thromboembolic disorders or stroke Known or suspected breast, ovarian, or endometrial cancer Known heart disease Liver disease Pregnancy Undiagnosed vaginal bleeding |
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Primary amenorrhea |
No menses by age 14 in absence of secondary sex characteristics |
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Secondary amenorrhea |
The absence of a period for 3 cycles or 6 months duration in a woman who has been menstruating previously |
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Management of Amenorrhea |
Rule out pregnancy Check TSH and Prolactin Progesterone challenge If bleeding results anovulation is confirmed, outflow tract is patent, and woman has estrogen If TSH and Prolactin were normal further systemic evaluation is unnecessary |
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Management of Amenorrhea if progesterone challenge fails |
She either has an outflow tract problem or inadequate estrogen proliferation of the endometrium Refer for physician management |
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Treatment for amenorrhea (with successful progesterone challenge) |
Medroxyprogesterone acetate 10mg PO qd for the first 10 days of the month 3-4 times per year COCs if contraception is desired Metformin if related to PCOS - will need contraception! |
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Prolactin level that usually rules out pituitary tumor |
Prolactin <100 |
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Oligomenorrhea |
Meses occuring in intervals longer than 35 days |
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Polymenorrhea |
Menses at intervals of <21-24 days |
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Hypermenorrhea/Menorrhagia |
Regular bleeding interval Excessive in duration and flow More than 80 mL per cycle OR Longer than 7 days of bleeding |
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Metrorrhagia |
Irregular bleeding intervals |
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Hypomenorrhea |
Regular bleeding interval Less than normal amount of flow |
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Normal Menses Cycle length Bleeding length Amount |
Cycles: 24-35 days Bleeding: 2-7 days Amount: <80 mL |
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Pharmaceutical tx for menorrhagia |
Intense estrogen/progesterone therapy for 7 days. If bleeding stops, stop the COCs - she will then bleed for 2-4 days. If she desires contraception, restart COCs. If not, give MPA for first 10 days of the month 3-4 months per year. OR Motrin 800mg PO q8 hours |
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Surgical options for AUB |
D&C - not very effective, mostly for acute episodes Endometrial ablation - will still need contraception, but IUD contraindicated. 22% will need hysterectomy Hysterectomy |
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PCOS increases a woman's risk for |
Cardiovascular disease Endometrial cancer Diabetes |
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4 key features of PCOS |
-Ovulatory or menstrual dysfunction
-Hyperandrogenism -Hyperandrogenemia (however many women will have normal androgen levels) -Polycystic ovaries |
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Pathophysiology of PCOS |
LH level is higher --> stimulates follicle without releasing egg Cysts are formed in the ovaries b/c egg cannot be released --> theca cell hyperplasia Theca cells secrete androstenedione and testosterone which stays in circulation due to low levels of SHBG |
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Differential diagnosis for PCOS |
Cushing's Syndrome Adrenal hyperplasia Hyperprolactinemia Androgen-producing adrenal or ovarian tumors Hypothyroidism Idiopathic hirsutism Androgenic medications |
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Goals of PCOS treatment |
Decrease androgen levels Protect the endometrium Increase fertility Reduce long-term health risks associated with insulin resistance and hyperandrogenism |
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Treatment for PCOS |
Diet and exercise Clomid - if pregnancy is desired Spironolactone (antiandrogen) Metformin 500mg PO TID --> contraceptive! MPA 5-10mg PO qd for 1st 10 days of each mo. Or COCs |
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Most common malignant breast tumor |
Infiltrating ductal carcinoma |
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Most aggressive malignant breast tumor |
inflammatory carcinoma |
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Most common benign breast tumor |
Fibroadenoma |
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Definitive diagnosis for breast cancer |
histology |
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Greatest known risk factor for breast cancer |
Family history |
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Types of breast cancer |
Carcinoma in situ (DCIS or LCIS) Invasive or infiltrating |
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Breast Cancer Stage 0 |
DCIS or LCIS |
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Breast Cancer Stage 1 |
Tumor <2 cm No node involvement |
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Breast Cancer Stage 2 |
Tumor 2-5 cm With or without nodal involvement |
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Breast Cancer Stage 3 |
Advanced Divided into 3A, 3B |
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Breast Cancer Stage 3A |
Tumor >5cm and/or spread to nodes |
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Breast Cancer Stage 3B |
Tumor any size with spread to skin or chest wall |
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Breast Cancer Stage 4 |
Metastasis |
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Tumors requiring systemic therapy |
Tumors larger than 2 cm warrant systemic therapy |
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Tumors requiring mastectomy |
Tumors >4 cm warrant mastectomy |
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Sxs of Lichen Sclerosus |
Adhesions between labia minor and clitoral structures Itching Epithelial thinning with cigarette paper appearance |
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Management of Lichen Sclerosus |
Biopsy Estrogen cream for labial agglutination Betamethasone Valerate (Valisone) 2-3 weeks Taper to Clobetasol BID Testosterone propionate in petroleum F/U q6 months Lifetime maintenance |
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Vitiligo |
Lack of skin pigmentation Etiology unknown Autosomal dominant disorder Associated with thyroid dysfunction, pernicious anemia, and DM |
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Leukoderma |
Temporary or permanent loss of cutaneous pigment due to physical trauma Look for cause of trauma No treatment is indicated |
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Behçet's Syndrome |
Recurret oral and genital ulcerations Monoarticular arthritis and CNS manifestations occur when severe Unknown etiology, palliative treatment only Topical and systemic corticosteroids provide most dependable relief, also Colchicine |
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Vulvodynia |
Pain of the vulva Chronic vulvar discomfort with burning, stinging, irritation, and rawness Encompasses many conditions |
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Vulvar Vestibulitis Syndrome |
Type of Vulvodynia 1) Entry dyspareunia 2) Erythema or inflammation of vestibule 3) Pain produced by pressure with Q-tip on vestibule |
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Cyclic vulvovaginitis |
Pain worse just before or during menses, exacerbated by intercourse Hx of frequent use of abx Diflucan 150mg weekly x 2 months, then bi-weekly x 2-4 months |
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Dysesthetic vulvodynia |
Typically occurs in peri- or post-menopausal Pudendal neuralgia - diffuse, unremitting, burning pain that is not cyclic. Less point tenderness. Urethral or rectal discomfort Usually not erythematous Tricyclic antidepressants |
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Pediculosis Pubis |
Pubic Lice Permethrin 1% creme rinse applied for 10 minutes and then washed off Pregnancy category B Lindane shampoo not recommended for pregnancy, lactating women or children under 2 |
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Scabies |
Lindane lotion |
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Itching variations of the vulva |
Lichen sclerosus Fox-Frdyce Pediculosis pubis Scabies |
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White variations of the vulva |
Lichen sclerosus Vitiligo Leukoderma |
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Ulcerative variations of the vulva |
Herpes Behçet's disease Lichen planus Syphilis |
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Pigmented variations of the vulva |
vulvar intraepithelial neoplasia nevi lentigo |
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Papules/cysts variations of the vulva |
Epidermal cysts Bartholin's cyst Folliculitis Hidradenitis suppurativa Inclusion cysts Skene's duct cyst |
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Muscles of pelvic diaphragm |
Coccygeus and levator ani Support the urethra, anus, and abdominal contents |
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Muscles of urogenital diaphragm |
Bulbocavernosus, ischiocavernosus |
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Urethrocele |
Weakening of pubocervical fascia and herniation of urethra into vagina |
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Cystocele |
Same as urethrocele except the bladder herniates into the vagina Stress incontinence, complaints of urgency, incomplete emptying, pelvic fullness |
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Rectocele |
Protrusion of the rectum into the posterior vaginal lumen Constipation, rectal fullness, incomplete emptying |
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Enterocele |
Herniation of the small bowel into the vaginal lumen |
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Non-operative therapy for cystocele, enterocele, and rectocele |
Estrogen therapy Kegal exercises Pessaries Reevaluation every 3-4 months |
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Urinary Incontinence Tests |
Residual urine (<50mL is normal) Bladder capacity (400-500 mL) First urge (150-200 mL) Stress test (300 mL volume in bladder - cough in lithotomy and then upright - urine leakage with cough suggests stress incontinence - delayed or persistent leak suggests detrusor instability) |
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Stress Incontinence Non-pharmaceutical Tx |
Reduce caffeine weight loss Stop smoking Prevent constipation Use tampons for exercise-induced incontinence Kegels Pelvic floor muscle training Bladder training Referral to women's health physical therapist |
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Stress Incontinence Pharmaceutical and Surgical Tx |
Estrogen 0.625 mg/day Topical estrogen cream Pseudoephedrine 15-30 mg PO TID (not for HTN) Surgery to elevate bladder neck Pelvic floor electrical stimulation |
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Kegel Exercises |
10-20 per day Each for 10 seconds 30 per day 6 weeks needed to achieve beneficial effects |
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Pelvic Floor Muscle Training |
More specific than Kegels Daily minimum of 30-45 contractions Each for 10 seconds Relax 10 seconds between Sets can be divided into 2-3 times Correct technique demonstrated by descent of clitoris and an upward, inward contraction of anus |
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Urge Incontinence |
Due to instability of detrusor muscle More than 7x per day |
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Urge Incontinence Non-Pharmaceutical Tx |
Bladder training |
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Urge Incontinence Pharmaceutical Tx |
Oxybutynin 2.5-5.5 mg TID-QID |
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Pathognomonic for Endometriosis |
tender nodule at uterosacral ligament |
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Definitive Dx for Endometriosis |
Made only by surgery with subsequent histology confirmation of endometrial tissue |
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Tx for Endometriosis |
Oral contraceptives NSAIDs for dysmenorrhea (palliative) Laparoscopy with laser treatment of lesions or adhesions Other treatments for more severe disease may cause drug-induced menopause or hormone reaction |
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Syphilis incubation period |
10-90 days |
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Primary syphilis |
3-8 weeks Early testing may be negative Chancre Discharge from chancre highly infectious |
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Secondary syphilis |
1-2 years Testing usually accurate Blood borne bacteria spread to all major organs Hair loss, lymphadenopathy, rash on palms and soles, patches in mouth and anogenital area, malaise, arthralgia, headache, sometimes liver/kidney dysfunction, condylomata lata (flat warty lesions - highly contagious) |
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Latent syphilis |
May last entire life Probably non-infectious after 4 years, but still able to transmit through placenta Asymptomatic Diagnosis by blood test |
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Tertiary Syphilis |
Most severe stage and least common All the bad stuff |
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Syphilis Testing Nontreponemal |
VDRL RPR May have false positives - including undiagnosed Lupus |
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Syphilis Testing Treponemal |
Diagnosis with Treponema-specific test TPHA MHATP FTA-ABS |
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Syphilis Tx Non-pregnant |
Benzathine PCN G 2.4 million units IM Single dose Doxycycline 100mg BID x 14 days |
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Syphilis Tx Pregnant |
PCN only! If allergic to PCN, must desensitize. Warn pt. about Jarisch Herxheimer Reaction which may cause early labor |
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Syphilis Treatment of sex partners |
All sex partners within 90 days should be treated, even if they test negative |
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Gonorrhea Incubation period |
3-4 days |
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Gonorrhea Presentation |
Most women are asymptomatic (may have discharge, dysuria or frequency) May have redness and swelling at point of contact, purulent exudate Disease may remain local or can spread to uterus, fallopian tubes, and ovaries, causing PID |
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Gonorrhea Diagnosis |
Gram stain of discharge (takes 24-48 hours) Swab from cervix or urine sample |
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Gonorrhea Tx Non-pregnant |
Ceftriaxone 250mg IM single dose PLUS Azythromycin 1g PO single dose |
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Gonorrhea Tx Pregnant |
Ceftriaxone 250 mg IM Single dose PLUS Azythromycin 1g PO Single dose |
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Gonorrhea Treatment of sex partners |
All partners within 60 days should be treated If no partners within 60 days, most recent partner should be treated Abstain from sex until 7 days after tx EPT available: Ceftriaxone 400mg/Azythro 1g |
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Chlamydia Incubation Period |
1-3 weeks |
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Chlamydia Risk factors |
Age less than 25 Multiple sex partners (or partners with mult.) History of STI Use of non-barrier contraception Gonorrhea infection |
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Chlamydia Presentation |
May be Asymptomatic! Cervicitis Urethritis PID Perihepatitis |
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Chlamydia Complications |
Infertility Reiter's syndrome Can't see, Can't pee, Can't climb a tree Cervical erosion Salpingitis Transmission to newborns |
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Chlamydia Tx Non-pregnant |
Azithromycin 1g PO x 1 dose OR Doxycycline 100mg PO BID x 7 days re-test in 3 months |
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Chlamydia Tx Pregnant |
Azythromycin 1g PO x 1 dose (doxy is contraindicated) re-test in 3 months |
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Chlamydia Treatment of sex partners |
All partners within 60 days of infection EPT provided Abstain from sex for 7 days after tx |
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How long does it take after transmission for the HIV antibody to be detectable? |
25 days Detectable in at least 95% within 3 months of infection |
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Herpes Incubation period |
1-45 days |
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Herpes Primary Infections |
Local inflammation and pain, fever, headache, malaise, myalgia, dysuria; purulent discharge with cervical lesions; lymphadenopathy Primary lesions are usually present for 17-20 days |
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Herpes Diagnosis |
Primarily a clinical diagnosis Confirmed by culture and type-specific serologic tests |
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Herpes Tx Primary outbreak (episodic) |
Acyclovir 400mg PO TID x 7-10 days *Valacyclovir 1g PO BID x 7-10 days *Famciclovir 250mg PO TID x 7-10 days *better absorbed Topical drugs not recommended |
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Herpes Tx Episodic outbreaks |
Same drugs, different doses |
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Herpes Tx Suppression |
Same drugs, different doses If more than 6 doses per year |
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Herpes Tx Pregnancy |
Suppression starting at 36 weeks Acyclovir 400mg PO TID Valacyclovir 500mg PO BID |
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Genital Warts Treatment Non-pregnant |
Patient-applied Imiquimod Podofilox Sinecatechins Provider-administered Cryotherapy with liquid nitrogen Surgical removal Trichloroascetic acid |
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Genital Warts Treatment Pregnant |
TCA/BCA preferred NO podofilox NO imiquimod |
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Pelvic Inflammatory Disease Diagnosis |
Direct observation of inflamed fallopian tube on laparoscopy, laparotomy, or biopsy evidence of salpingitis Presumptive diagnosis can be made on clinical grounds |
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Pelvic Inflammatory Disease Lab findings helpful in diagnosis |
+ gc/ct elevated WBCs elevated ESR |
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Pelvic Inflammatory Disease Parameters for outpatient treatment |
Temp less than 100.4 (38 C) WBCs less than 11,000 Bowel sounds present Able to tolerate nourishment and treatment No evidence of peritonitis |
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Pelvic Inflammatory Disease When to initiate treatment |
Pelvic/lower abdominal pain without identifiable cause AND ONE OF THE FOLLOWING ON EXAM: Cervical motion tenderness Uterine tenderness Adnexal tenderness |
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Pelvic Inflammatory Disease Treatment IV |
Cefotetan 2g IV q12 hours PLUS Doxycycline 100mg IV q12 hours |
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Pelvic Inflammatory Disease Treatment IM/PO |
Ceftriaxone 250mg IM single dose PLUS Doxycycline 100mg PO BID x 14 days PLUS Metronidazole 500mg PO BID x 14 days |
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BRCA-1 is associated with which cancers? |
Breast Ovarian Colon |
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What reduces the risk for ovarian cancer? |
Every pregnancy reduces risk by 10% Breastfeeding Tubal ligation Oral contraceptives |
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Screening tests for ovarian cancer |
NONE |
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Tests used to aid in the diagnosis of ovarian cancer |
CA-125 (80% of women with ovarian cancer will have elevated levels, but it is not sensitive as a screening test) TVUS is better for diagnosis than for screening |
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Treatment of ovarian cancer |
Surgical excision and chemotherapy |
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Adenomyosis Definition |
Growth of endometrial tissue in myometrium |
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Adenomyosis Presentation |
Usually over 40 years old Menorrhagia (heavy or prolonged bleeding) Dysmenorrhea - up to 1 week before period Enlarged uterus Soft, tender uterus Anemia is possible |
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Adenomyosis Management |
NSAIDS Iron OCPs for control of bleeding Menstrual suppression with progestins Possible hysterectomy if severe |
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Infertility |
Failure to conceive after 12 months of frequent unprotected sex if 35 or younger or 6 months if over 35 |
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Most common form of infertility for women |
Ovulatory disorder |
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Review Infertility |
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