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200 Cards in this Set
- Front
- Back
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Which STD of vulva: |
Chancroid
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Tx of chancroid?
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Erythromycin
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Chancroid causative organism?
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Hemophilus ducreyi
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Which STD of vulva:Incubation 3-10dMacule → papule → primary chancreIndurated painLESS ulcer w/ dull red baseUntreated lasts 3-8 wks then spont heals
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Syphilis
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Tx of syphilis
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PCN (all stages)
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Syphilis causative organism?
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Treponema pallidum
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Which STD of vulva:Incubation 3d-3wRare in temperate climatesSmall, painLESS papule, vesicle, or ulcer on fourchette, labia or cervix → big inguinal glands + painFUL mass that supperates and forms sinuses
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lymphgranuloma venerum (LGV)
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Tx of lymphgranuloma venerum
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TetracyclineMay need prolonged tx
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LGV causative organism?
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Chlamydia trachomatis serovar
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Which STD of vulva:Incubation 3w-8msmall, raised, rounded lzns, usually multipleMay also appear irregular, rounded, fleshy, vascular tumors that affect any part of the vulva
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Human papillomavirus“Genital warts”
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Tx of HPV
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Repeat trichloracetic acid, Podophyllin Topical imiquimod (Aldara)CryotherapyLaser surgery
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Which STD of vulva:Incubation 2-10dVesicular → rupture → single/mult/grouped shallow, tender ulcers 1-2mm diam Usu on labia majora & minora, clitoris, perineum, perianal
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Genital herpes
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Tx of genital herpes
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AcyclovirDoes not reduce recurrence rate
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Rash of secondary syphilis looks like? (on vuvlva)
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Macular, papular, papulosquamous or pustular; also may see condyloma lata
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What does condyloma lata look like?
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Confluent, spongy, gray masses w/ flat tops, broad bases
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Where is condyloma lata located?
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Periphery of vuvla
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Rash of tertiary syphilis (on vuvla) looks like?
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Gummas = squamous lesions or subQ nodules; sometimes ulcerate
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1. What is the name for irregular, rounded, fleshy, vascular tumors that affect any part of the vulva?2. Which organism causes this?
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1. Condyloma acuminata2. HPV
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Condyloma lata vs condyloma accuminata
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Syphilis vs HPV
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Which non-neoplastic epithelial disorder of the vulva:Epithelial thinning + edema + fibrosis of dermisLabial shrinkage + Introital stenosis + often pruritisSkin is edematous, white, thin, paperlikeMC in prepubertal and postmenopausal womenUsually symmetricMay cause dyspareuniaDx w/ biopsyUsually lose labia minora
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Lichen sclerosis
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Tx of Lichen sclerosis?
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High potency corticosteroids(Clobetasol or halobetasol 0.05% cream)
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Which non-neoplastic epithelial disorder of the vulva:Papulosquamous, chronic, painfulUsu inner labia minora, vagina, vestibuleMild inflammatory → severe erosive processingOften see stria at margin of lesionsMay have extreme loss of architectureDx w/ biopsy
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Lichen planus
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Tx of lichen planus?
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Vaginal hydrocortisone suppositoriesPlus estrogen creams if postmenopausal
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Which non-neoplastic epithelial disorder of the vulva:p/w vulvular pruritisthickened, white epithelium, slightly scalyUnilateral, often localizedDx w/ biopsy
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Lichen simplex chronicus
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Tx of lichen simplex chronicus
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Medium potency steroidsUsually rapid resolution
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Which benign pigmentary lesion of the vulva:Vary from 1-2mm to 1-2cm, papular, usually pigmented but can vary in colorUsually asxDx with simple excision
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Melanocytic nevi
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Which benign pigmentary lesion of the vulva:Cutaneous disorder that can affect axillae, nipples, umbilical and crural regionsPoorly defined, velvety hyperpigmentationTx is symptomatic only
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Acanthosis nigricans
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Which benign pigmentary lesion of the vulva:Complete DE-pigmentation of skin that's otherwise normalArea usu well defined & symmetricalNo effective tx
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Vitiligo
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List (3) cysts of epidermal origin
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SebaceousEpidermal InclusionHidradenoma
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One cyst of embryonic origin
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Gartner's duct(from vestigial remnant of vaginal part of Wolffian ducts)
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Duct cyst?
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Bartholin's gland
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Cysts of urethral and paraurethral origin (2)
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Skene's ductUrethral or suburethral diverticulum
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Benign solid vulvar/vaginal tumor of epithelial origin (2)
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Seborrheic keratosisHidradenoma
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Benign solid vulvar/vaginal tumor of mesodermal origin (5)
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FibromaLipomaLeiomyomaHemangiomaVulvovaginal polyps
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Benign solid vulvar/vaginal tumor of urethral origin (1)
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Caruncle
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Diffuse vulvular pain occuring w/ or w/o provocationUsually constant and unremittingDull, burning painUsually no abnormalities of skin or architecture
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Vulvodynia
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Tx of vulvodynia?
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TCAAnticonvulsantsPain mgmt programs
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Entry dyspareuniaVestibular erythemaVestibular tenderness w/o active dermatosis or disorders that would otherwise explain Sx
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Vestibulitis
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Tx of vestibulitis?
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5% lidocaine ointmentTCAs may helpSurgery only in extreme, refractory cases
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Developmental issue in vagina/vulva leading toHematocolpos, Hematomtetra, HematosalpinxExam reveals bulging fluid mass in vagina, “no way out”
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Imperforate hymen
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Developmental issue in vagina/vulva:Complete or partialSoft tissue septum running from introitus to cervixMay have 1-2 cervices
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Septate vaginaMay need no tx if asx
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Developmental issue in vagina/vulva:Rare congenital defectSeptum divides vagina into upper and lower compartmentsComplete or incompletePregnancy may occur, Partial menstrual flow if incomplete
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Transverse vaginal septumtx by resecting septum
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Normal vaginal fluid characteristics?
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pH 4.0squamous epithelial cells + normal bacterial floraFluid is white + not malodorous
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Normal vaginal bacteria?
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Lactobacilli (aerobic gram variable rods)GN bacteriaAnaerobes
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Another name for lactobacilli?
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Doderlein's bacilli
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Type of vaginitis with:white, thick discharge4.0 pHBudding hyphae on KOH prepNegative Whiff test
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Candidiasis
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Type of vaginitis with:thin, gray-white discharge>4.5 pHClue cells & few wbcs on microPositive Whiff test (amide odor)
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Bacterial vaginosis
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What causes bacterial vaginosis?
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Imbalance of normal flora – anaerobic bacteria
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Type of vaginitis with:thick, milky, grey-white or green discharge>4.5 pHmotile trichomonadsNegative Whiff test
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Trichomoniasis
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What organism causes trichomoniasis?
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Parasite named trichomonas vaginalis (an STD)
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What causes atrophic vaginitis?
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Irritation + inflammation 2/2 atrophy of vaginal mucosa
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General symptoms of vaginitis?
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Increased vaginal dischargeMalodorous dischargeVaginal or vulvar pruritis or burning, edema, erythemaDyspareunia
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How to distinguish causes of vaginitis from one another?
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Pex of vagina & vulvaDetermine fluid pHMicro eval of fluid w/ saline & KOHWhiff test
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Positive Whiff test means?
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Bacterial vaginosis
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Thick, white “cottage cheese” appearance of vaginal fluid?
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Candidiasis
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See the organism under the microscope when examining vaginal fluid sample in which 2?
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Candidiasis and Trichomoniasis
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Can see clumping of bacteria onto epithelial cells in micro eval of vaginal fluid in which disease?
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Bacterial vaginosis
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Which 3 species causes candidiasis?
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C. albicans (budding hyphae)C. tropicalis (budding hyphae)C. glabrata (spores)
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Symptoms of candidiasis?
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Vulvar itching/burning+/- Bladder sx (may be misdiagnosed as cystitis)Thick, white discharge
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Tx candidiasis?1 PO5 topical
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po: fluconazole (diflucan)top: miconazole (monistat) clotrimazole (mycelex, lotrimin) tioconazole (vagistat) terconazole (terazol) butoconazole (femstat)
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What is thought to be the mechanism behind recurrent yeast infections?
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Colonization of the GI tract which serves as a repository
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Tx recurrent yeast infections?
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Prolonged course of PO antifungals (fluconazole or ketoconazole)Vaginal applicants of boric acid, gentian violet
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Tx bacterial vaginosis?
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PO or vaginal metro or clinda (flagyl, metrogel, cleocin)Treat sexual partners if recurrent infections
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T or F Metro or Clinda are safe throughout pregnancy
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TRUE
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Trichomonads are unicellular or multicellular?
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Unicellular
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Cause of atrophic vaginitis?
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Inadequate estrogenAssociated with menopause, breastfeeding
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Tx of atrophic vaginitis?
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Supplemental estrogen (locally in vagina or systemic)NO ABX needed
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Most common STDs? (5)
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ChlamydiaGenital herpesGonorrheaSyphilisTrichomoniasis
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Gonorrhea primarily infects upper or lower genital tract
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Upper
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Diagnose syphilis via?
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RPR or VDRLConfirm with fluorescent-labeled treponema Ab test (FTA)Or Microhemagglutination assay of Ab to T.pallidum (MHA-TP)
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Diagnose chlamydia via?
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PEx (characteristic discharge)Culture of d/cmRNA
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Tx chlamydia?
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DoxycyclineazithromycinA quinolone
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Which organism causes genital herpes?
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HSV-2 > HSV-1Infection is chronic!
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What disease has this presentation:small vesicles → shallow, painful ulcers on labia, cervix, vaginal mucosa, perineum; may be clusters+/- inguinal adenopathy+ vaginal dischargePain so severe it may require narcotics, topical anesthetics, hospitalization, bladder cath+/- fever & malaise
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Genital herpes
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Difference between primary and recurrent herpes outbreak?
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Primary usu more severe, lasts 12-21dRecurrent usu 2-5d, more mild
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When is genital herpes contagious?
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In days prior to and during recurrent outbreak
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What are prodrome symptoms of genital herpes?
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Tingling or burning in affected region+/- mild systemic symptoms
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Tx genital herpes? (3)
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AcyclovirFamciclovirValacyclovirTx recurrent for 3d
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Who should get suppressive tx for recurrent genital herpes?
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Pt's decision. Usually recommended for pts with >2-3 outbreaks a yearSingle daily dose is effective to reduce frequency of secondary outbreaks
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When should you c-section with HSV?
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If woman has prodrome or active lesion at time of delivery
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Prevent need for c-section with HSV?
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Place on antivirals at 36w
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What is Bartholin's gland cyst caused by?
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Dilation of Bartholin's gland DUCTGland secrets mucin → gets obstructed, dilates, fills w/ fluidBecomes a soft tissue mass in vulvaIs sterile, NOT an infection
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Difference between Bartholin's gland cyst vs abscess vs malignancy
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Cyst: sterile, clear fluidAbscess: polymycrobial (maybe nessie gonorrhea), purulentMalignancy: Can present as a cyst, most are benign (biopsy in women >40y)
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Tx Bartholin's cyst?
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Usu tx only if symptomaticIncision and drainage (leave Ward catheter in place)Marsupialization (open widely & suture back edges to keep open)Excision (take whole gland and duct out)
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What is Fitz-Hugh-Curtis syndrome?
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PID that has spread along upper peritoneum to the liver capsule, causing perihepatic adhesions
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What is pelvic inflammatory disease (PID?)
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Spectrum of infection and inflammation involving varying degrees of (depending on severity):Upper genital tract (endometrium, tubes, ovaries)Surrounding peritoneum
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Cause of PID?
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Polymicrobial - Infection with STD organism such as GC or CT
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Mechanism of microbial invasion in PID? (2 ways)
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1. Infection of cervix breaks down cervix barrier → infxn ascends → endogenous superinfection of upper tract by aerobic + anaerobic organisms than normally inhabit lower tract2. Mechanical instrumentation during procedure (e.g., D&C, hysteroscopy, endometrial/cervical biopsy, IUD insertion)(#2 is less common)
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PID w/GC vs w/CT?
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GC: More acute and severeCT: Often silent & diagnosed only retrospectively
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Is there a relationship btw bacterial vaginosis and PID?
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A cause and effect relationship is not provenThey are caused by similar organismsBac vag is more common in women with PID
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PID presentation (history)?
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Can be acute pelvic pain & fever (GC), often during or after a period in a sexually active female. Or gradual and less severe (CT)Often nausea & vomiting
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What is the classic physical exam finding for PID?
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Chandelier sign (cervical motion tenderness)Also can get varying degrees of LQ, uterine, and adnexal tenderness
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Pt with PID, on exam you palpate a unilateral adnexal or cul-de-sac mass is suspicious for?
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Tubo-ovarian abscess (TOA)
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PID findings on speculum exam?
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Mucopurulent discharge coming from cervixIf is more advanced in course, this may have resolved since Nessie or Chlam often will have been eliminated by this point.
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Lab findings in PID?In Fitz-Hugh-Curtis?In TOA?
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1) Often positive cervical culturesElevated wbcs, ESR, CRP2) Fitz-Hugh-Curtis: elevated LFTs 3) TOA: may see complex adnexal mass
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Why does PID often present during or after a period?
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Blood is a good culture medium for PID-causing organismsCervical barrier to ascending infection has broken down
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Other things in DDx for PID?
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GI: appy, diverticulitis, IBDU: kidney stone, UTIGYN: ectopic pregnancy, septic SAB, endometriosis, degenerating fibroids, ovarian torsion, ruptured ovarian cyst
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Tests to r/o or r/i PID?
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UPT, cervical gram stain/wet mount, US, laproscopy (“gold standard” for diagnosis but used infrequently)
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Clinical criteria for diagnosis of PID? (4 minimum and 6 supporting)
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Minimum: Sexually active or recent h/o instrumentationLower abdominal painAdnexal and cervical motion tendernessSupporting: >101F (38.3C)Abnormal cervical/vaginal dischargeElevated ESR/CRP & wbcsPositive GC or CTUS shows TOA or hydro/pyosalpinxLaproscopy shows tubal inflammation &/o pyosalpinx
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Which groups are at higher risk for PID?
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Women in late teens and early 20sLower socioeconomic statusAfrican/Afro-CarribeanWomen w/ h/o prior PIDHistory of douchingRecent sex w/ new partner or multiple partners
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What are the potential long-term consequences of PID?
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Infertility (20% incidence with 1, increased with each new episode)Chronic pelvic pain (20% incidence)TOAIncreased ectopic pregnancy risk (10%, 6-10x greater than no PID)May pass STDs on to sex partnersDeath (rare) (usu 2/2 ruptured TOA)
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How many cases of PID diagnosed/yr?How many outpt visits from PID?How many inpt admissions from PID?
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~1 million 2.5 million outpt visits 250k-300k inpt admissions/yr → most cmn reason for gynecological admissions in US!
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Best PID prevention?
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Consistent condom useAggressive GC/CT screening → tx positive pts & partnersHigh suspicion for STDs and early PID in sexually activePromote monogamy, condom use, esp in teens
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Best PID recurrence prevention?
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OCP use after first diagnosisPromote consistent condom use and monogamy
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Once PID is diagnosed, which other tests should be performed?
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HIVSyphilisHep B & CSpeculum exam: check for bac vaginosis and trichomoniasisOffer Hep B vaccine
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What are criteria for hospitalization for PID?
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Can't tolerate PO meds> 101F or 38.3CEvidence of TOATeen or pregnant ptNo response to PO meds after 48 hrsNulliparityPt has HIV/AIDSConcerned that pt will/can not comply w/ meds or follow upSigns of peritoneal irritation on PEx IUD (?)Diagnosis is uncertain (and surgical emergency like appy is factor)
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Relation btw PID and IUDs?
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Uncertain; Some studies show increased PID after insertion of copper IUD. 60m study showed 2.2 PID per 100 for copper IUD vs 0.8 PID per 100 for levonorgestrel IUD
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If diagnose PID in pt w/ an IUD, what to do?
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Standard of care says to remove foreign bodyBut studies show that response to ABX was similar w/ and w/o IUD removal
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What should ABX for PID cover?
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GC, CT plus anaerobes, GN anaerobes, and streptococci
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What are PO tx for PID?
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Ofloxacin 400mg + Metro 500mg BID x 14dCefloxin 2g + probenacid 1g (one dose) Ceftriaxone 250mg IM (one dose) + Doxy 100mg PO BID x 14d
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What are IV or IM tx for PID?
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Cefotetan 2g IV q12H or cefoxitin 2g IV q6H + Doxy 100mg IV or PO q12HClinda 900mg IV q8H + Gent IV/IM 2mg/kg LD then 1.5 mg/kg q8H MDOfloxacin 400mg IV q12H + Metro 500mg IV q8HAmp/Sulbactam 3g IV q6H + Doxy IV/PO q12HCipro 200mg IV q12H + Doxy IV/PO 100mg q12H + Metro 200mg IV q8H
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How to test for GC/CT
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GC: Thayer Martin media culture or PCRCT: PCR is best (since is intracellular)
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Principles to remember with PID? (9)
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Consider in all sexually active women of reproductive age p/w pelvic painR/o pregnancyErr on side of overdiagnosisStart treatment ASAPReassess in 48-72 hrs to ensure responseRefer or treat all partnersScreen for asx GC/CT in sexually active men and womenEncourage condom use and monogamyScreen for additional STDs once PID is diagnosed
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What is mean age of menarche and menopause?
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12.7yrs51.4 yrs
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What is the mean duration of menses?
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5.2d 3-8d range
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What is the mean interval for menses?
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28d21-35d rangeOnly 15% of women have 28d cycle
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What 2 times have the greatest variability in menstrual cycle?
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1) 1st 2yrs after menarche (anovulatory in 6% of these cycles)2) 3yrs before menopause (anovulatory in 34% of these cycles)
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Basal vs functional layers in terms of 1) hormone responsiveness and 2) presence thruout cycle
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1) Basal = pretty unresponsive; Fxnal = very responsive2) Basal = intact thruout cycle; Fxnal = most is lost during menses
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What part of cycle are prostoglandins max?What are they good for in the cycle?
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Max just prior to mensesCause spiral arteries to constrict → initiate menstrual flow; stimulate myometrial contrxns
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How many germs cells during:PrenatalBirthPuberty
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1) 6-7 million @ 20wks2) 2 million @ birth3) 300k @ puberty
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What is a primordial follicle?
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Oocyte arrested in the diplotene stage of Prophase 1Surrounded by 1 layer of granulosa cellsGrowth = independent of gonadotropin stimulation
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What is a preantral follicle?
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Oocyte surrounded by zona pellucidaSeveral layers of granulosa cellsTheca layerGrowth = becomes dependent on gonadotropins
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Which hormones do you need for granulosa cell accumulation and progressive follicular growth?
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Which hormone signals follicular recruitment?When in the cycle does this start?FSH induces LH-R and aromatase enzyme → convert androgens to estrogens w/in developing follicleEstrogen + FSH increase # of FSH-R on the cells + increase granulosa cell mitosis → granulosa cell layer proliferation
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Which hormone signals follicular recruitment?When in the cycle does this start?
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FSHIn the late luteal phase of the preceding cycle
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What does LH do in the follicular phase?
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Interacts w/ theca cells → androgen production (get aromatized to estrogen BUT cause follicular atresia in non-dom't follicles)
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In which cells does androgen aromatization occur?
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Granulosa cells (adjacent to theca cells)
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Which hormones decrease follicular maturation?Why?
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Androgens in high concentration Become 5α reduced to become more potent androgensNote: Premature LH increases can also decrease granulosa cell mitosis → degeneration
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The surge of which hormone predicts impending ovulation?
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LHOvulation occurs 34-36h after the start of the surge or 10-12h after its peak
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What two things dictate the lifespan of the corpus luteum?
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Tonic LH secretionStimulation by hCG
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What are the phases of the menstrual cycle for the:Ovary?Endometrium?
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Ovary: follicular, ovulation, lutealEndometrium: Proliferative, secretory, menstrual
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When is the dominant follicle selected during the cycle?
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Days 5-7
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What causes atresia of non-dominant follicles?
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Increasing estrogen concentrations from the dominant follicle → negative feedback inhibition of FSH → w/d gonadotropin support for non-dominant folliclesNote: the dominant follicle has greater #s of FSH-R (2/2 more granulosa cells), so survives. Also, theca layer has increased vascular dev't, so better delivery of FSH
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What hormone signal is needed to get an adequate LH surge? What is the minimal concentration needed?How long does this need to last?What other hormone facilitates the positive feedback needed to get the LH surge?
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Estradiol>200 pg/mL~50hLow levels of progesterone
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What does the LH surge do? (3)
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Re-starts meiosis in the oocyteCauses granulosa cell luteinizationMakes PGs and progesterone needed for follicular rupture
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What is thought to be the mechanism behind the follicle rupturing?
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Likely is degenerative changes in the follicular wall → collagen destruction → passive expansion of follicle → ruptureIs probably NOT 2/2 increased antral fluid volume + increased hydrostatic pressure
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When is the first polar body extruded from the oocyte?
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During ovulation → 1st meiotic division + 1st p.b. extrusion
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What causes the degenerative changes leading to follicular rupturing and extrusion of the oocyte from the follicule? (2)
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ProstaglandinsLysosomal enzymes
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Normal corpus luteum functioning is dependent on which hormone?What else is needed for its normal functioning?
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1. LH (tonic secretion) 2. Optimal preovulatory follicular development (which is dependent on adequate FSH stimulation)
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Which hormone is needed to sustain the corpus luteum of pregnancy?
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Human chorionic gonadotropin (hCG)
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Which day in the cycle does progesterone peak?
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Day 8, after the LH surge
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What does the progesterone peak accomplish?
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Mediates maturity of secretory endometrium & suppresses new follicular growth
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What influence does tonic LH secretion have on progesterone?
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Causes sustained progesterone output
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T or F: Light microscopic changes in the glands and stroma of the endometrium are so characteristic and uniform that one can tell which luteal phase day it is just by looking?
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TRUE
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On which day is implantation likely to occur?
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22-23This coincides with peak intracellular apocrine secretory activity
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What causes luteal phase defects?
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Corpus luteal insufficiencyIs difficult to diagnose, and its role in infertility is unclear.
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What is often said to be the 1st sign of puberty in girls?What age does it occur?What event precedes it by 1-2 years?
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Thelarche = breast budding10.8 +/- 1.1yrsIncrease in linear growth velocity
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What puberty event comes after thelarche?At what age?
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Pubarche = pubic hair growth11.0 +/- 1.2yrs
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What puberty event follows pubarche?At what age?
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Maximum growth velocity12.1 +/- 0.88 yrs
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What is the final event of puberty?At what age?
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Menarche = first period12.9 +/- 1.2yrs
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How long on average after thelarche does menarche occur?
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2.5 years
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What is 1st hormonal sign of puberty?
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Increase in LH pulsatility at night
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What is the 2nd hormonal sign of puberty?What does this lead to?
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LH and FSH pulses occurring thruout the dayThis leads to increasing estrogen levels from the growing ovarian follicle → positive feedback from E2 finally initiates LH surge and ovulation → elevated progesterone levels + luteal phase
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Why do many teens have irregular periods?
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Because ovulation is often inconsistent 1-2 yrs after menarche
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If teenagers continue to have irregular periods >2yrs after menarche, what might this indicate?
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A reproductive disorder
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What non-androgen hormone does estrogen stimulate?
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Growth hormone → IGF-I → increased somatic growth
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What non-androgen hormone does estrogen stimulate?
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Growth hormone → IGF-I → increased somatic growth
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What is adrenarche?What is produced?At what age does it occur?
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1) Increased androgen production by the adrenal glands. It is NOT essential for normal ovarian function, and gonadal function is NOT essential for proper adrenal function.2)The adrenals produce increased quantities of DHEA, DHEAS, and androstenedione3) 6-8 yrs old
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What effect does estrogen have on bone? What is the difference between estrogen and growth hormone on bones?
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1) Increases bone growth (esp axial skeleton); promotes epiphyseal plate fusion (precocious puberty = grow early, but are short)2) Growth hormone has more effect on long bones
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What is the body type of a hypogondal pt?Of a GH-deficient pt?
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1) Short trunk + long arms/legs2) Long trunk + short arms/legs
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What factors determine when puberty begins?
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Family historyRace (African American = earlier)Altitude (lower = earlier)Distance to equator (closer = earlier)Urban vs rural (urban = earlier)Obese or blind = earlier
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What are factors that can lead to delayed puberty?
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DiabetesExtreme obesityPoor nutritionExcessive stressOver-exercise
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What is Frisch's critical body fat theory?
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Pt needs 17-22& body fat to initiate puberty (good for anorexic or obese teens)But, this does not explain all teens
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At what age is the HPG axis functional?
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20 WEEKS of life (prenatal)
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When do LH and FSH levels first peak?When do they first flare?
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20wks gestational ageFirst 1-2 years of life
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What is the accepted age range for onset of puberty?
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8-14 yrsAfrican American girls may start before 8 (this is normal)
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What two ages are markers for delayed puberty needing workup?
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No secondary sexual characteristics by 14Secondary sexual characteristics but no menarche by 16
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Should we workup isolated breast or pubic hair development in absence of other puberty signs?
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Usually warrants observation to exclude precocious puberty
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What is premature adrenarche thought to be an early sign of?
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PCOS later in life
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Which gender more commonly gets precocious puberty? (ratio?)Delayed puberty?
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Girls (5:1)Boys
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How long (average) does puberty take in girls vs boys?
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Girls: 3yrsBoys: 5yrs
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Isosexual vs heterosexual precocious puberty?
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Iso: Premature puberty compatible with individual's genetic sex Iso is way more common type!!Hetero: premature puberty with changes OPPOSITE of individual's genetic sex In girls this means xs androgen production from adrenals or ovaries
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GnRH-dependent vs GnRH-independent precocious puberty?Please give 3 alternate terms for each name
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Dependent: Premature re-activation of HPG axis → the hypothalamic pulse generator starts up too early AKA: True, Complete, CentralIndie: Early sex steroid production NOT from HPG axis AKA: Pseudo-puberty, Incomplete, Partial
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What is “mixed picture” GnRH precocious puberty?
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Peripheral hormone production leading to HPG activation
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What percent of precocious puberty is idiopathic in girls?In boys?
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Girls: 75%Boys: 40%More MRI use might help find subtle changes that reduce these figures!!
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What causes GnRH dependent precocious puberty? (2)How to treat each?
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Idiopathic; tx w/ GnRH agonists (leuprilide acetate)Tumors (hamartomas = MC); tx w/ surgery, rads, GnRH agonists
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What causes GnRH independent precocious puberty? (7)How to treat each?
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1) Functional ovarian cyst; surgery(?)2) Granulosa cell tumor; surgery3) Adrenal steroid producing tumor; surgery4) McCune-Albright (aka polyostotic fibrous dysplasia)5) Genetic mutation in gonadotropin-R, causing autonomous ovarian estrogen production (constitutional activation); tx = testolactone (inhibits aromatase)6) Hypothyroidism; hormone replacement7) Exogenous drug ingestion; stop taking drug!
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In female, what is order of puberty? (4)
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Thelarche (breast bud) Pubarche (pubes)Max growth velocityMenarche
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What is only form of precocious puberty in which bone growth is delayed rather than advanced?
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Primary hypothyroidism
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What should you ask in H&P of pt w/ precocious puberty?5 H, 6P
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H: Growth & puberty milestonesFamily history (reproductive anomalies?)Any exogenous drug ingestion?Symptoms of thyroid disease?Neuro symptoms or hx of CNS insults?PEx: Ht, wt, %tle for ageTanner stagingNeuro + thyroid examSkin (cafe au lait spots?)Abdominal examPelvic & rectal exam (masses?)
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What labs and rads for precocious puberty w/u?
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Serum E2, LH, FSH, TSH, hCGHetero: Add DHEAS, 17-OH progesterone, testosteroneLeft wrist bone agePelvic US or CT (ovarian or adrenal masses?)Head MRI (tumors?)Skull XR (cystic lesions of McCune-Albright?)
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What is McCune-Albright syndrome characterized by?
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Multiple cystic bone lesionscafe-au-lait spotsprecocious puberty
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What is w/u & ddx of pt w/ delayed puberty and primary amenorrhea?Pt has NO breasts, YES uterus, High FSH
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High FSH? Hypergonadotropic hypogonadism Get karyotype 45 XY = Swyer's 45X = Turner's syndrome or mosaicism 46XX = Many things (see other card)
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No breasts, yes uterus, high FSH, 46XX pt differential? (6)
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1) Pure gonadal dysgenesis2) 17-OHase deficiency3) X chromosome deletion4) FSH-R defect5) Ovarian destruction: rads/chemo, viral, autoimmune (schmidt's), galactosemia6) Myotonic dystrophy or Kennedy's disease.
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What is w/u and ddx of pt w/ delayed puberty and primary amenorrhea?Pt has NO breasts, YES uterus, Low/Normal FSH
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Low FSH? Hypogonadotropic hypogonadism Image CNS Tumor: Pituitary or hypothalamic (craniopharyngioma) No tumor: Many things (see other card)
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No breasts, yes uterus, low FSH, CNS image shows no tumor differential? (7)
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1) Kallman's2) Gonadotropin deficiency3) Constitutional: anorexia, xs exercise, systemic disease4) GnRH-R defect5) Histiocytosis X6) Pituitary insufficiency7) Hypothyroidism
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What is w/u & ddx of pt w/ delayed puberty and primary amenorrhea?Pt has NO uterus, YES breasts
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Take karyotype + Testosterone levelsXY: Androgen insensitivityXX: Uterovaginal agenesis
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What are MC causes of primary amenorrhea AND delayed puberty?
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1) Gonadal dysgenesis (usually Turner's)2) Uterovaginal agenesis3) Androgen insensitivtity4) Anorexia nervosa or extreme exercise
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What is the incidence of primary amenorrhea?
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<1%
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What is secondary amenorrhea?
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No menses >6mNo menses for a total of 3 previous cycle intervals
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What is the incidence of secondary amenorrhea?
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~0.7%
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What questions to ask in H&P of amenorrhea?
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History of coitus?Nature and sequence of other pubertal events (primary)Hx of severe systemic illness or stress?Changes in sleep, thirst, appetite, smell?Headaches? Vomiting? Visual field defects? Fatigue? Galactorrhea?Pt on meds or chemo/rads?Ht? Wt? Pulse? BP?Evidence of low estrogen or hirsuitism?See normal reproductive tract on PEx?
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What initial blood tests should be performed for pt w/ amenorrhea?
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Thyroid fxn testsPRL level
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Pt w/ galactorrhea and amenorrhea should have which test?
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Head MRI or thin-section coronal CT w/ contrast
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What is a progesterone challenge test?
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200mg IM progesterone in oil OR 300mg PO micronized progesterone OR 10mg PO medroxyprogesterone acetate for 5 dPositive test = bleeding or spotting w/in 2-7 days of test.
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What does a positive progesterone challenge test indicate? (4)
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Serum estrogen level > 40pg/mLThe anterior pituitary is making LH and FSHEndometrium and outflow tract are fxningIf Thyroid fxn tests and PRL are normal, pt is anovulatory
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What does a negative progesterone challenge test indicate? (7)
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1) Outflow tract defect, e.g. Asherman's fibrosis 2/2 severe endometriosis cervical stenosis uterine agenesis imperforate hymen transverse vaginal septum2) Hypoestrogen state
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Pt has amenorrhea, normal TH/PRL, NO withdrawal bleeding on progesterone challenge – what tests and what do they indicate?
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LH & FSHLow FSH = hypothalamic causes of amenorrheaHigh FSH = ovarian failure
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What are MC causes of primary amenorrhea?
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1) Gonadal failure: Turner's; gonadal agenesis (1/3 of all cases)2) Mullerian anomalies: Uterovaginal agenesis (1/5 of all cases)
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What condition occurs in Mayer-Rokitansky-Kuster-Hauser syndrome?
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Uterovaginal agenesis
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Primary amenorrhea WITH breasts and WITH uterus? (5)
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Hyperandrogenic amenorrhea (PCOS)Hypothalamic dysfunctionHypothyroidHyperprolactinemiaObstruction (imperforate hymen os transverse vaginal septum)
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