• Shuffle
    Toggle On
    Toggle Off
  • Alphabetize
    Toggle On
    Toggle Off
  • Front First
    Toggle On
    Toggle Off
  • Both Sides
    Toggle On
    Toggle Off
  • Read
    Toggle On
    Toggle Off
Reading...
Front

Card Range To Study

through

image

Play button

image

Play button

image

Progress

1/180

Click to flip

Use LEFT and RIGHT arrow keys to navigate between flashcards;

Use UP and DOWN arrow keys to flip the card;

H to show hint;

A reads text to speech;

180 Cards in this Set

  • Front
  • Back
pelvic relaxation
uterine prolapse (grades I-IV)
cystocele
rectocele
enterocele
urinary incontinence
cystocele
postmenopausal woman
anterior vaginal wall protrussion
urinary incontinence
diagnosis --> pelvic exam
rectocele
postmenopausal woman
posterior vaginal wall protrussion
digitally assisted removal of stool
diagnosis --> pelvic exam
medical management of pelvic relaxation
used in minor relaxation
Kegel exercises --> voluntary contractions of pubococcygeus muscle
estrogen replacement --> in postmenopausal women
pessaries --> objects inserted into vagina to elevate pelvic structures
surgical management of pelvic relaxation
used when medical management fails
vaginal hysterectomy with anterior and posterior colporrhaphy (vaginal repair)
pharmacology of urinry incontincence
alpha adrenergeic --> contract urethra; ephedrine, imipramine, estrogens; phenoxibenzamine is antagonist
beta adrenergic --> relax detrusor muscle; flavoxate, progestins
cholinergic --> contract detrusor muscle; bethanecol, neostigmine; anticholinergics are oxybutynin, propantheline
cystometry
urinary catheter empties bladder then infuses saline; measures -->
residual volume --> normal 50mL
sensation of fullness --> normal 200-225mL
urge to void --> normal 400-500mL
sensory irritative incontinence
involuntary detrusor contractions stimulated by irritation from infections, stones, tumor, foreign body
presentation --> loss of urine with frequency, urgency and dysuria, suprapubic tenderness
diagnosis --> urinalysis and urine culture or cytoscopy; cystometry is usually unnecessary
management --> antibiotics for infections; cytoscopy for stones, foreing bodies and tumors
stress incontinence
from rises in intraabdominal pressure
presentation --> involuntary loss of urine with coughing or sneezing, no urine loss at night
exam --> cystocele may be present and Q-tip test is positive (rotates >30degrees)
studies --> urinalysis and culture are normal; cystometry is normal without detrusor contractions
management --> Kegel or estrogen; urethropexy or tension-free vaginal tape
motor urge hypertonic incontinence
idiopathic detrusor contractions that can't be suppressed volutarily
presentation --> loss of urine, cannot suppress urge to void, day or night
tests --> urinalysis and culture are normal; residual volume is normal but there are involuntary detrussor contractions
management --> anticholinergics and NSAIDs
overflow hypotonic incontinence
hypotonic bladder does not empty until theres excess pressure;
etiology --> denervated bladder from diabetic neuropathy or multiple sclerosis, anticholinergics
presentation --> urine loss day and night with no detrussor contractions; decreased pudendal nerve sensation
tests --> urinalysis and culture normal or infection; markedly increased residual volume without detrussor contractions
management --> self-catheterization; cholinergics, alpha blockers
bypass fistula incontinence
presentation --> history of radical pelvic or radiation surgery, continuous urine loss day and night
diagnosis --> intravenous pyelogram shows dye leakage from urinary tract fistula
management --> surgical repair
vaginal discharge diagnostic tests
speculum exam --> looking for inflammation and characteristics of discharge
vaginal pH --> normal is <4.5; nitrazine paper turns yellow when normal or dark when high pH
KOH slide --> two drops of vaginal discharge + saline + KOH are analyzed on microscope
bacterial vaginosis
high pH replaces normal flora lacbacilli
presentation and diagnosis --> fishy odor, no itching, pH>4.5, thin grayish discharge, whiff+ on KOH, clue cells on wet mount
management --> metronidazole (safe in pregnancy) or clindamycin; orally or vaginally
trichomonas vaginitis
STD; protozoan resides in seminal fluid
presentation and diagnosis -->itching, burning, pain with intercourse, green discharge, inflammation seen, erythematous cervix, pH>4.5, trichomonads and WBCs on saline
management --> oral metronidazole orally for patient and partner
candida yeast vaginitis
presentation and diagnosis --> itching, burning, pain with intercourse, normal pH, white discharge, inflammation seen, pseudohyphae on KOH
management --> single oral dose of fluconazole or vaginal azole creams
physiologic discharge
due to excess estrogen
presentation and diagnosis --> watery vaginal discharge, no itching, no inflammation, normal pH, absence of pathogens on wet mount
management --> contraception with progestins
vaginal discharge with normal pH
candida, physiologic discharge
vaginal discharge with high pH
bacterial vaginosis, trichomonas
grayish discharge
bacterial vaginosis
white discharge
candida
green discharge
trichomonas
watery discharge
physiologic discharge
differentail diagnosis of vulvar itching
vulvar carcinoma, STDs, benign vulvar dystrophy, malignant cancer; all lesions should have biopsy
vulvar dystrophy
squamous hyperplasia --> whitish, firm, cartilaginous lesions with thick kertain and epithelial proliferation on microscope; management is fluorinated corticosteroid cream

lichen sclerosis --> bluish-white papula that can coalesce into white plaques and show epithelial thinning; management is clobetasol cream
premalignant vulvar lesions
squamous dysplasia --> white, red or pigmented multifocal lesions with epithelium atypia not reaching BM; management is surgical excision

CIS --> same presentation with more atypia but not reaching the BM; management is laser vaporization
malignant vulvar lesions
squamous cell carcinoma --> most common; associated with HPV
melanoma --> 2nd most common; any dark or black lesion should be biopsied; prognosis related to depth of invasion
Paget disease --> red vulvar lesion
management of malignant vulvar lesions
radical vulvectomy with or without lymphadenectomy
benign vulvar lesions
molluscom contagiousum --> spontaneously regressing umbilicated tumors; observation, curettage, cryo
condylomata acuminata --> HPV 6 & 11 cauliflower lesions
Bartholin cyst --> aspiration yields sterile fluid
cervical polyps
presentation --> vaginal bleeding and smooth red or purple fingerlike projections from cervical canal
diagnosis --> biopsy shows mildly atypical cells
management --> twisting or surgical string for the polyp; electrocautery or laser for the base
nabothian cysts
mucus-filled cyst on cervix surface
presentation --> asymptomatic small white pimpli-likeelevation palpated or seen by colposcopy
management --> none necessary but can be removed by electrocautery or cryotherapy
cervicitis
presentation --> mucopurulent cervical discharge without pelvic tenderness or fever
diagnosis --> cervical culture shows chlamydia or gonorrhea
management --> oral azythromycin single dose or doxycycline 7 days
premalignant cervical lesions
are asymptomatic and 15% can progress to cancer in 8-10 years
65% regress; 20% stay the same
due to HPV 16, 18, 30s
risk factors for HPV --> early age of intercourse, multiple partners, cigarette smoking, immunosuppression
what is a pap smear
exfoliative cytology
best screening test for premalignant lesions
one specimen from T-zone and one from endocervix
conventional method --> samples are smeared and fixated onto slide
liquid-based method --> samples are rinsed into a solution
pap smear screening
start 3 years after onset of sexual intercourse or at age 21
discontinue at age 70 after >3 consecutive negative tests
if under age 30 --> screen annually with conventional or every 2 years with liquid-based
if over 30 --> screen every 2-3 years if >3 negative pap smears
pap smear classification
negative
ASC --> atypical squamous cells; undertermined significance or cannot exclude HSIL
LSIL --> low-grade squamous intraepithelial lesion; biopsy shows HPV, mild dysplasia or CIN 1
HSIL --> high-grade squamous intraepithelial lesion; biopsy shows moderate-severe dysplasia or CIN 2-3
cancer --> biopsy will show invasive cancer
ASCUS pap smear
results from inflammatory or atrophic lesions or the initial stages of HPV infection
10-15% of ASCUS paps can have a significant premalignant lesion
management --> repeat cytology in 3-6 months and HPV DNA testing (reliable patients) or colposcopy+biopsy (unreliable patients)
if high risk HPV DNA test --> colposcopy+biopsy
colposcopy
performed if there's high risk results from HPV DNA test
satisfactory or adequate --> entire T-zone is visualized and no lesions dissapear into endocervix
unsatisfactory or inadequate --> entire T-zone cant be visualized
colposcopy includes endocervical curettage and ectocervical biopsy
cone biopsy
indications:
pap smear is worst than colposcopy biopsy
abnormal endocervical curettage
lesion in endocervical canal
biopsy shows microinvasive carcinoma
cervical dysplasia management according to histology
CIN 1 --> repeat Pap in 6-12 months OR colposcopy+Pap in 12 months OR HPV DNA in 12 months
CIN 1, 2, 3 --> ablation with cryotherapy, laser or electrofulguration
CIN 1, 2, 3 --> excision by LEEP or cold-knife conization
biopsy confirmed recurrent CIN 2 or 3 --> hysterectomy
all ablations or excisions require repeat Pap, colposcopy, HPV DNA every 4-6 months for 2 years
invasive cervical cancer presentation and diagnosis
postcoital vaginal bleeding, irregular vaginal bleeding, lower extremity pain and edema
cervical biopsy --> initial diagnostic test
metastatic workup --> do if biopsy is positive; pelvic exam, chest x-ray, IV pyelogram, cystoscopy, sigmoidoscopy
CT or MRI are not used for staging
invasive cervical cancer management
stage Ia1 --> <=3mm, simple hysterectomy
stage Ia2 --> 3-5mm, modified radical hysterectomy
stage Ib --> radical hysterectomy
stages II-IV --> radio and chemo
follow-up --> pap every 3months for 2 years; then every 6 months for 3 years
cervical neoplasia in pregnancy
all abnormal pap smears should be followed by colposcopy+biopsy
no ECC is performed
cervical neoplasia in pregnancy management
CIN --> follow with Pap+colposcopy evrery 3 months during pregnancy; treat postpartum
microinvasion --> do cone biopsy; if confirmed, then treat postpartum
invasive cancer --> if diagnosis before 24 weeks then radical hysterectomy or radio; if after 24 weeks then cesarean at 32-33 weeks + definitive treatment
HPV vaccine
quadrivalent for types 6, 11, 16, 18 (70% of cancers and 90% of warts)
uses noninfectious particles
recommended to all women 8-26 with target age 11-12
do not test for HPV before vaccine
continue regular Paps
not recommended for pregnant, lactating or immunosuppressed
mullerian anomalies
hypoplasia/agenesis
unicornuate uterus
didelphys uterus
bicornuate uterus
septate uterus
arcuate uterus
DES uterus
uterine hypoplasia/agenesis
may lack vagina or any part of uterus except fundus
associated with urinary tract anomalies
unicornuate uterus
one Mullerian duct does not develop or develops incompletely
the incompletely developed half uterus lacks a cavity connecting to vagina which leads to pain during menses in teenagers
may have pregnancy in the bad uterus but 90% of them rupture
didelphys uterus
double uterus from failure of Mullerians to fuse
may have a single or two cervix or vaginas
bicornuate uterus
most common
failure of Mullerians to fuse at the top results in two horns sharing a cervix or two bodies sharing a cervix
septate uterus
Mullerians fused but theres no degeneration of median septum
external shape appears normal
arcuate uterus
small midline indentation at the fundus
does not have negative effects on pregnancy
DES uterus
daughters of mothers exposed to DES during pregnancy
may have hypoplastic uterus, T-shaped cavity and/or cervical defects
leiomyoma presentation
most common benign uterine tumor; outgrowth of the myometrium
intramural --> most common location within the wall of the uterus
submucosal --> beneath endometrium and can distort uterine cavity; can have meno/metro or menometrorrhagia
subserosal --> beneath the serosa and can distort the external contour and pressure the bladder, rectum or ureters
leiomyoma natural history
slow growth --> small, grow slowly and cause no symptoms except if they are massive
rapid growth --> estrogen receptors are increased and result in rapid growth specially during pregnancy
degeneration --> the size is more than blood supply resulting in ischemic with acute pain requiring hospitalization and narcotics
shrinkage --> when estrogen levels fall the leiomyoma shrinks
leiomyoma diagnosis
pelvic exam --> enlarged asymetric, nontender uterus in absence of pregnancy
sonography --> traditional for intramural or subserosal or with saline infusion for submucosal
hysteroscopy --> for submucosal myomas
confirmation of diagnosis is made by histologic exam of excised tissue
leiomyoma management
observation --> most can be managed conservatively
presurgical shrinkage --> leuprolide for 3-6 months results in 60-70% shrinkage
myomectomy --> done to conserve fertility; subsequent pregnancies should be delivered by cesarean
embolization --> catheter injects microspheres which cause ischemia and necrosis of myoma
hysterectomy --> if patient has completed childbearing
adenomyosis presentation
ectopic endoemtrial glands in myometrium
presents with secondary dysmenorrhea or menorrhagia, symmetrical diffuse uterine enlargement and tenderness during menses
adenomyosis diagnosis
mostly made clinically
ultrasound or MRI shows diffusely enlarged uterus with cystic areas in myometrium
confirmation is by histology
ademyosis management
medical --> levonorgestrel intrauterine system decreases menstrual bleeding
hysterectomy --> definitive treatment
differential diagnosis for enlarged non-pregnant uterus
leiomyoma --> asymmetric, firm, nontender
adenomyosis --> symmetric, soft, tender
differential diagnosis of postmenopausal bleeding
endometrial carcinoma (most important), vaginal or endometrial atrophy (most common), postmenopausal hormone replacement
endometrial cancer risk factors
unoppossed estrogen occurs in
obesity
hypertension
diabetes
nulliparity
late menopause
chronic anovulation (polycystic ovarian disease)
endometrial cancer diagnosis
endometrial sampling
D&C if cervical stenosis is present
hysteroscopy --> rules out cervical or endometrial polyps
ultrasound --> endometrial lining should measure <5mm thick in postmanopause
endometrial cancer management
if negative histology from sampling --> diagnosis is atrophy treated with estrogen/progesterone replacement
if positive histology from sampling --> adenocarcinoma is treated with total abdominal hysterectomy with bilateral salpingo-oophorectomy and pelvic/para-aortic lymphadenectomy; it may also require radio and chemo postoperative
endometrial hyperplasia
may cause bleeding; cells have no atypia; treat with progestin
ovarian cyst differential diagnosis
pregnancy (most common)

complex masses -->
dermoid cyst
benign cystic hematoma
endometrioma
tubo-ovarian abscess
ovarian cancer
ovarian cyst presentation and diagnosis
pelvic mass in reproductive years
negative betahCG (rules out pregnancy)
sonogram shows fluid-filled ovarian simple cyst
ovarian cyst management
follow-up exam in 6-8 weeks for resolution
alert patient of possibility of acute onset pain from torsion
if >7cm or prior steroid contraception --> laparoscopy
ovarian hyperthecosis pathophysiology
nests of active luteinized cells in ovarian stroma; peripheral estrogen is increased which leads to excess androgen production by ovaries; risk of endometrial hyperplasia and carcinoma are increased due to high estrogens
ovarian thecosis presentation
obesity
less severe hirsutism than PCOS
virilization (clitoral enlargement, balding, deep voice, male habitus)
amenorrhea or irregular/anovulatory cycles
can occur in postmenapause unlike PCOS
ovarian hyperthecosis management
oral contraception suppresses androgen production and free androgens
luteoma of pregnancy
non-neoplastic tumor-like mass that regresses spontaneously
asymptomatic
found incidentally
hormonally active and can produce maternal and fetal hirsutism and virilization
theca lutein cysts
benign neoplasm caused by excess FSH and beta-hCG
associated with twins and molar pregnancies
regresses spontaneously
prepubertal pelvic mass presentation and work-up
presents with sudden onset of acute abdominal pain in prepubertal female

serum tumor markers for germ cell tumors:
LDH --> dysgerminoma
beta-hCG --> chroriocarcinoma
alpha-fetoprotein --> endodermal sinus tumor
prepubertal pelvic mass diagnosis and management
if simple cyst --> diagnose with laparoscopy
if complex mass --> diagnose with laparotomy

if benign --> cystectomy+annual follow-up (pelvic exam+tumor markers)
if malignant --> unilateral S&O, staging and chemo
premenopausal complex mass
most common is dermoid cyst (benign cystic teratoma)
also endometrioma, tubo-ovarian abscess, ovarian cancer
b-hCG rules out pregnancy; ultrasound rules out simple mass (ovarian cyst)
manage with cystectomy or oophorectomy
benign cystic teratoma
complex mass with calcifications on ultrasound
ovarian torsion
presumptive diagnosis --> abrupt unilateral pelvic pain, b-hCG-, adnexal mass on ultrasound
management --> untwist ovary; if revitalization then cystectomy; if necrosis then oophorectomy
ovarian cancer presentation
postmenopausal adnexal mass
ovarian cancer risk factors
BRCA1 gene
positive family history
high number of lifetime ovulations
perineal talc powder

protective factors --> oral contraceptives, chronic anovulation, brest feeding, short reproductive life
ovarian cancer diagnosis
screening --> bimanual pelvic examination (large, solid, irregular, fixed)
tumor markers --> CEA, CA-125, LDH, AFP, hCG, testosterone
abdominal pelvic CT or pelvic ultrasound
barium enema to rule out diverticulosis
IV pyelogram for urinary tract lesions
types of ovarian tumors
epithelial --> older women; ovarian cancers (serous, mucinous, Brenner, endometrioid, clear cell)
germ cell --> younger women; dysgerminoma, endodermal, teratoma, choriocarcinoma
stromal --> granulosa-theca cells, Sertoli-Leydig cell
metastatic --> from other primary sites (endometrium, GI, breast, krukenberg)
serous ovarian carcinoma
postmenopausal woman, pelvic mass, high CEA or CA-125
choriocarcinoma
postmenopausal woman, pelvic mass, high hCG
Sertoli-Leydig tumor
postmenopausal pelvic mass, masculinization, high testosterone
endometrial carcinoma metastatic to ovaries
postmenopausal woman with bilateral pelvic masses
postmenopausal bleeding
enlarged uterus
CEA or CA-125
serous ovarian cancer
hCG as tumor marker
choriocarcinoma (ovarian germ cell tumor)
testosterone as tumor marker
Sertoli-Leydig cell ovarian stromal tumor
LDH as tumor marker
dysgerminoma
AFP as tumor marker
endodermal sinus germ cell tumor (ovary)
ovarian cancer management
laparotomy or laparoscopy with unilateral salpingo oophorectomy with histology during surgery
if benign --> USO is enough or TAH+BSO
if malignant --> TAH+BSO, omentectomy and bowel ressection if necessary + postop chemo
benign gestational neoplasia types
hydatiform mole
complete --> empty egg, paternal X, 46XX, fetus absent, grape-like vesicles
incomplete --> normal egg, maternal and paternal X, 69XXY, fetus nonviable
malignant gestational neoplasia types
nonmetastatic --> uterus only, 100%cure
good prognosis --> metastasis to pelvis or lung, 95% cure, single agent chemo
poor prognosis --> metastasis to brain or liver, 65% cure, combo chemo
gestational trophoblastic neoplasia presentation
bleeding prior to 16 weeks
passage of vesicles
hypertension
proteinuria
no fetal heart tones
hyperthyroidism
fundus larger than dates
gestational trophoblastic neoplasia diagnosis
snowstorm ultrasound shows homogenous intrauterine echoes without sac or fetus
gestational trophoblastic neoplasia management
1) baseline beta-hCG
2) chest x-ray to rule out lung metastasis
3) suction D&C
4) oral contraceptives during follow-up

if benign --> weekly b-hCG until negative for 3 consecutive weeks, then monthly until negative for 12 months
if b-hCG does not lower --> brain, thorax, abdominal and pelvic CTs for metastasis
if good prognosis metastatic --> single agent chemo + 1 year follow-up
if poor prognosis metastatic --> multiple chemo + weekly b-hCG then monthly then every three months (5 years)
cercivitis
presentation --> mucopurulent cervical discharge, without pelvic tenderness or fever
diagnosis --> nucleic acid amplification tests of cervical discharge or urine; normal WBCs and ESR
management --> single oral dose of cefixime and azithromycin
acute salpingo-oophoritis presentation and diagnosis
bilateral lower abdominal/pelvic pain
mucopurulent cervical discharge
cervical motion tenderness
high WBCs and ESR
acute salpingo-oophoritis management
certain diagnosis and no evidence of systemic infection or absecess --> ofloxacin+metronidazole 14 days
uncertain diagnosis, nulligravida, evidence of abscess or fever --> inpatient, IV cefoxitin or cefotetan + IV doxy
lower abdominal-pelvic pain differential diagnosis
acute salpingo-oophoritis
adnexal torsion
ectopic pregnancy
appendicitis
endometriosis
diverticulitis
Crohn
ulcerative colitis
tubo-ovarian abscess presentation
sepsis (tachycardia, hypotension, high fever)
severe lower abodominal-pelvic pain
peritoneal guarding and rigidity
nausea, vomit
adnexal masses may be palpated
tubo-ovarian abscess diagnosis
positive cervical cultures for chlamydia or gonorrhea
positive blood cultures for gram-
pus on culdocentesis
high WBCs and ESR
sonogram or CT show bilateral complex masses
differential diagnosis of sepsis+lower abdominal-pelvic pain
tubo-ovarian abscess
septic abortion
diverticular abscess
appendiceal abscess
adnexal torsion
tubo-ovarian abscess management
IV clindamycin and gentamicin
if no change in 72 hours or abscess rupture --> laparotomy and consider TAH+BSO
chronic PID
chronic bilateral abdominal/pelvic pain
no cervical discharge
cervical motion tenderness
negative cultures
normal WBCs and ESR
sonography may show bilateral cystic pelvic masses

diagnosis --> laparoscopic visualization of pelvic adhesions
management --> lysis of tubal adhesions or if unremitting TAH+BSO
primary dysmenorrhea Vs. secondary dysmenorrhea
primary --> teenagers, absence of pelvic pathology
secondary --> mature women, presence of pelvic pathology (endometriosis, adenomyosis)
primary dysmenorrhea
recurrent lower abdominal pain during menstrual periods in a teenager with absence of pelvic pathology
due to excess prostaglandin F2
treat with NSAIDs (first line) or oral contraception (2nd line)
endometriosis presentation and diagnosis
pelvic-abdominal pain
dyspareunia
painful bowel movements
infertility
exam --> cul-de-sac adhesions, uterosacral ligament nodularities, enlarged adnexa
lab --> normal WBCs and ESR, CA-125 may be elevated
diagnosis --> laparoscopy
endometriosis management
medical --> leuprolide (DOC), medroxyprogesterone, testosterone derivative
surgical --> laparoscopic lysis of tubal adhesions, cystectomies, laser vaporization or TAH+BSO
chancroid
painful ulcer with ragged edges due to Haemophilus ducreyi
confirm diagnosis with swab for gram stain and culture
treat with single dose azithromycin PO, single dose IM ceftriaxone or erythromycin 7 days
lymphogranuloma venereum
due to chlamydia trachomatis
painless vesiculopustular vaginal eruption that spontaneously heals
can have perirectal adenopathy, absecesses and fistulas within weeks
diagnosis --> postitive culture from pus aspirated from lymph node
management --> doxycylcline or erythromycin for 3 weeks + aspiration
granuloma inguinale
due to calymmatobacterium granulomatis
painless ulcer with granulation tissue and no lymphadenopathy
diagnosis --> biopsy + microscopicexam shows donovan bodies
management --> doxycycline or TMP-SMX 3 weeks
condyloma acuminatum
HPV 6, 11
generally asymptomatic but clinical lesions in 30%
pedunculated, soft papule turns into cauliflower lesion
management --> small lesions are treated topically with podophyllin, trichloroacetic acid; larger lesions with cryo, laser or surgical excision
mucopurulent discharge
chlamydia trachomatis (cervical), gonorrhea (cervical and vulvovaginal)
STDs with ulcers
chancroid (painful, ragged)
granuloma inguinale
genital herpes (painful, smooth)
lymphogranuloma venerreum
syphilis
STDs without ulcers
chlamydia
HPV
gonorrhea
HBV
HIV
ragged soft edge inflamed painful vaginal ulcer
chancroid
groove sign
lymphogranuloma venereum
beefy red painless vaginal ulcer
granuloma inguinale
rolled, hard edges, painless vaginal ulcer
syphilis
smooth edge inflamed painful vaginal ulcer
herpes
gonorrhea
vulvovaginal and cervical mucopurulent discharge
if cervicitis or PID --> pelvic pain, cervical motion tenderness, etc…
if disseminated --> petechial skin lesions, septic arthritis
management --> single dose cefixime + single dose azithromycin
estrogen-mediated effects of oral contraception
fluid retention
accelerated cholelithiasis
increased hepatic proteins
healthy lipid profile changes
progestin-mediated effects of oral contraception
mood changes and depression
androgenic --> weight gain, acne
unhealthy lipid profile changes
absolute contraindications of oral contraception
pregnancy
acute liver disease
history of vascular disease (DVT, CVA, SLE)
hormonally-dependant breast cancer
smoker >35y/o
uncontrolled hypertension
migraines with aura
diabetes
known thrombophilia
relative contraindications of oral contraceptives
migraines
depression
diabetes
chronic hypertension
hyperlipidemia
premanarchal vaginal bleeding differential diagnosis
ingestion of estrogens
foreign body (MCC)
cancer of vagina or cervix
pituitary or adrenal tumor
ovarian tumor
sexual abuse
idiopathic precocious puberty
premenarchal vaginal bleeding diagnosis
pelvic exam under sedation for foreign bodies, sexual abuse or tumors
CT or MRI of pituitary, abdomen and pelvis for tumors
abnormal vaginal bleeding work-up
1) rule out pregnancy or complications of pregnancy --> incomplete abortion, threatened abortion, ectopic pregnancy, mole
diagnosis --> b-hCG + sonogram

2) rule out anatomic lesions --> vaginal lacerations, cervical polyps, cervicitis, leiomyomas, uterine hyperplasia, adenomyosis
diagnosis --> pelvic exam, saline sonogram, endometrial sampling, hysteroscopy

3) rule out dysfunctional uterine bleeding --> anovulation (hypothyroidism, hyperprolactinemia)
diagnosis --> history of irregular unpredictable menstrual bleeding without cramps; clear thin watery cervical mucus; no midcycle temperature rise; endometrial biopsy shows proliferative endometrium
primary amenorrhea diagnosis
absence of menses at age 14 without 2dary sexual characteristics or
absence of menses at age 16 with secondary sexual characteristics
primary amenorrhea, breasts+, uterus-
Mullerian agenesis --> 46XX, create a vagina
androgen insensitivity --> 46XY but looks female, absent pubic hair, high testosterone; give estrogen, create vagina and remove testes
primary amenorrhea, breasts-, uterus+
gonadal dysgenesis --> Turner, high FSH, no follicles, streak ovaries
HP axis failure --> low FSH, normal ovaries, diagnose with brain scan
Kallman --> +anosmia
secondary amenorrhea diagnosis
absence of menses for 3 months if previously regular
absence of menses for 6 months if previously irregular
first step in evaluation of secondary amenorrhea
b-hCG to rule out pregnancy
etiology of secondary amenorrhea
anovulation --> PCOS, hypothyroidism, pituitary adenoma, hyperprolactinemia, antipsychotics, antidepressants
hypoestrogenic --> absence of functional ovarian folliclles, HP insufficiency
outflow tract obstruction
secondary amenorrhea work-up
1) b-hCG; if negative -->
2) TSH (primary hypothyroidism causes high TRH and hyperprolactinemia); if negative -->
3) prolactin (antipsychotics or pituitary tumor); do MRI tu rule out adenoma; if negative -->
4) progesterone challenge test; if positive then anovulation; if negative then inadequate estrogen -->
5) estrogen-progesterone challenge test;
if positive --> inadequeate estrogen; if high FSH then ovarian failure; if low FSH then HP insufficiency
if negative --> outflow tract obstruction or endometrial scarring; order hysterosalpingogram
idiopathic/constitutional precocious puberty
too much gonadotropins
all puberty changes are seen
6y/o girl
normal MRI

treat with leuprolide to avoid premature closure of epiphysis
McCune-Albright syndrome
autonomous aromatase activation with excess estrogen
complete precocious puberty
6 y/o
café au lait spots
multiple cystic bone lesions

management --> aromatase enzyme inhibitor
granulosa cell tumor
precocious complete puberty
6 y/o girl
pelvic mass

management --> surgery
premenstrual syndrome (PMS) diagnosis
based on diary of symptoms throughout 3 menstrual cycles; must meet all criteria -->

recurrent in at least 3 consecutive cycles
absent in preovulatory phase
present in the 2 postovulatory weeks
intereferes with normal functioning
resolves with onset of menses
premenstrual syndrome management
yaz (drospirenone/estradiol)(low-dose combo OCP, 4-day hormone free)
drospirinon (DRSP)(spironolactone analogue with antimineralocortocoid effects)
SSRIs (for emotional symptoms)
alprazolam (for emotional symptoms)
GnRH agonists
hirsutism due to adrenal tumor
rapid onset virilization
abdominal/flank mass on CT or MRI
markedly elevated DHEAS
remove surgically
hirsutism definition
excessive male-pattern hair growth with or without virilization (clitorimegaly, baldness, deep voice, increased muscle)
hirsutism due to Sertoli-Leydig tumor
rapid onset virilization
adnexal pelvic mass on exam and ultrasound
markedly elevated testosterone
remove surgically
hirsutism due to congenital adrenal hyperplasia
21-hydroxylase deficiency
gradual onset hirsutism without virilization
normal exam
markedly increased 17OH progesterone
treat with corticosteroid replacement
hirsutism work-up
sudden onset --> testosterone and DHEAS levels, pelvic exam, abdominal CT or MRI, pelvic ultrasound
gradual onset --> serum 17OH progesterone levels, testosterone, pelvic ultrasound (PCOS)
differential diagnosis of hirsutism
21-hydroxylase deficiency
stromal ovarian tumor
PCOS
idiopathic (MCC)
adrenal tumor
idiopathic hirsutism
due to 5-alpha reductase overactivity
gradual onset hirsutism
normal DHEAS, 17-OH progesterone and testosterone
treat with spironolactone or eflornithine
polycystic ovarian syndrome presentation
irregular menstrual bleeding (from anovulation/unopposed estrogen; gonadotropins arent pulsatile)
hirsutism (increased LH stimulates androgens which also decrease SHBG)
obesity
infertility
ovarian enlargement with multiple cysts
polycystic ovarian syndrome diagnosis
suspected with --> irregular menstrual bleeding, obesity, hirsutism, infertility
confirmed with --> LH/FSH ratio 3:1 (normal is 1.5:1)
polycystic ovarian syndrome management
OCPs (normalize bleeding and suppress LH)
spironolactone (suppresses 5-alpha reductase)
if pregnancy is desired --> clomiphene
semen analysis for infertility
normal values:
volume >2ml
pH 7.2-7.8
sperm density >20million/ml
motility >50%
morphology >50% normal

if sperm density is low --> intrauterine insemination
if severely abnormal --> intracytoplasmic sperm injection or in-vitro fertilization
causes of infertility
primary hypothyroidism
hyperprolactinemia
PCOS
pituitary adenoma
antipsychotics
PH insufficiency
ovarian insufficiency
semen abnormalities
PID
infertility work-up
1) initial step is semen analysis
2) rule out anovulation with history, progesterone levels, endometrial biopsy and temperature chart
3) if semen is normal and anovulation is ruled out --> hysterosalpingogram
if positive --> attempt laparoscopic correction OR in-vitro fertilization
if negative --> unexplained infertility; spontaneous pregnancy occurs in 60% at 3 years OR treat with clomiphene+intrauterine insemination
premature ovarian failure
hot flashes and sweats
>30 y/o
high FSH
menopause presentation and diagnosis
presentation --> amenorrhea, hot flashes, cardiovascular disease, osteoporosis
diagnosis --> 3 months of amenorrhea with elevation of gonadotropins
osteoporosis presentation and diagnosis
vertebral crush fractures, hip and wrist fractures
diagnosis --> dual-energy x-ray absoprtiometry (DEXA scan)
osteoporosis management
lifestyle changes --> Ca+ and vitamin D, weight-bearing exercise, stop cigarettes and alcohol
medications --> biphosphonates and/or SERMs (raloxifene)
risks of hormone replacement therapy
estrogen+progestin --> breast cancer, heart disease, stroke
estrogen alone --> risk of stroke; no change in risk of breast cancer or heart disease
both groups --> DVT
benefits of hormone replacement therapy
improves -->

vaginal dryness
hot flashes
vasomotor symptoms
osteoporois
indications of hormone replacement therapy
only indication is vasomotor symptoms
if only need to treat osteoporosis consider SERMs
cystic breast mass diagnosis and management
diagnosis --> cyst aspiration and fine-needle aspiration with pathology exam
management --> preaspiration mammography then aspiration; if benign, no further work-up
fibrocystic breast change presentation
bilateral breast enlargement which fluctuates with menstrual periods (cyclic mentrual mastalgia)
may have palpable painful nodules
fibrocystic breast change diagnosis and management
aspiration and complete drainage
mass dissapears and fluid is clear --> discard fluid; reexamine in 4-6 weeks
mass dissapears and fluid is bloody --> send for cytologic exam; reexamine in 4-6 weeks
mass persists after aspiration --> wait 2 weeks after aspiration then mammography + excisional biopsy
fibroadenoma presentation
most common in adolescents and young women
discrete, smoothly contoured, rubbery, nontender, movable mass
fibroadenoma diagnosis and management
diagnose with ultrasound or fine needle aspiration showing a solid mass that does not collapse after aspiration
treat conservatively or elective excisional biopsy
mammographic calcifications
nonpalpable; most are benign but 15-20% are early cancer; requires steoretactic needle localization and biopsy under mammographic guidance; treatment depends on histology
indications of excisional biopsy of the breast
cellular bloody cyst on fluid aspiration
failure of a suspicious mass to dissapear completely upon aspiration
bloody nipple discharge with or without palpable mass
skin edema and erythema and needle biopsy cannot be performed
bloody nipple discharge
requires excisional needle biopsy
usually results from intraductal papilloma
management based on histology
breast cancer management
determine prognostic factors
stages I and II do breast-conserving therapy with wide excision + axillary node dissection or sentinel node biopsy + radiotherapy
breast cancer prognostic factors
lymph node status --> most important; inversely proportional to survival
tumor size --> correlates with lymph node involvment but 15% of small tumors have positive node involvement
receptor status --> estrogen and progesterone receptor status is needed before surgical therapy; it's prognostic and predictive factor
DNA ploidy --> determines diploid or aneuploidy (worse); it's unclear wether this is an independent risk factor
infiltrating ductal carcinoma
80% of breast cancers
starts as atypical ductal hyperplasia --> ductal carcinoma in situ --> invasive
mas is stony hard and increases in size
infiltrating lobular carcinoma
10% of breast cancers
better prognosis than infiltrating ductal carcinoma
inflammatory breast cancer
uncommon
rapid growth with early metastasis
skin is erythematous, swollen, warm, edematous and orange
paget disease
uncommon
lesion is pruritic, red and scaly, located in nipple and areola
nipple may become inverted
discharge may occur
breast cancer risk factors
BRCA 1 or 2 gene mutation (RR 15)
ductal or lobular carcinoma in situ (RR 15)
atypical hyperplasia (RR 4)
breast irradiation age < 20 (RR 3)
positive family history (RR 3)
sentinel node biopsy
first lymph node to ehich cancer cells are likely to spread from primary tumor
dye is injected into tumor which flows into the sentinel node
biopsy is performed to determine stage and if removal of nodes is necessary
adjuvant treatment for node positive breast cancer
premenopausal, ER or PR positive --> chemo +- ovarian ablation +- tamoxifen
premnopausal, ER and PR negative --> chemo
postmenopausal, ER or PR positive --> tamoxifen + chemo
postmnopausal, ER and PR negative --> chemo
elderly --> tamoxifen or chemo