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198 Cards in this Set
- Front
- Back
What are the physical findings in pt w/ androgen insensitivity syndrome? (pt is XY)
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Neither wolffian duct nor mullerian system develops, so no uterus, little to no axillary or pubic hair
Usually have large breasts w/ immature nipples If incomplete, there could be some pubic and axillary hair plus phallic development Note: serum testosterone levels are in normal MALE range |
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What is another name for androgen insensitivity syndrome?
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Testicular feminization
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Treatment for androgen insensitivity syndrome?
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Allow to finish sexual maturity then remove gonads (to prevent dev't of gonadoblastoma or dysgerminoma
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What are the physical findings in pt w/ mullerian agenesis?
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Sexual hair + mature nipples
No uterus Note: serum testosterone levels are in FEMALE range |
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What other physical abnormality is associated with mullerian agenesis?
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Renal anomalies
Perform renal US or intrravenous pyelography on these pts |
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15 y/o w/o breasts, yes uterus, normal wt & diet/exercise. What does HIGH LH/FSH indicate?
What is next test to do? What additional studies? |
Gonadal failure.
Get karyotype Do CXR, IV pyelogram, thyroid fxn tests |
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15 y/o w/o breasts, yes uterus, normal wt & diet/exercise. What does LOW LH/FSH indicate?
What is next test to do? What additional studies? |
Unstimulated gonads
Head MRI/CT to r/o pituitary tumors thyroid fxn tests, GH, cortisol, PRL Consider pituitary stimulation tests |
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15 y/o w/o breasts, yes uterus, normal wt & diet/exercise. What does NORMAL LH/FSH plus negative progesterone challenge indicate?
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Pituitary-CNS failure – glycoprotein hormones are immunologically but not biologically active
W/u is similar to low LH/FSH w/u |
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What are pituitary causes of amenorrhea? (4)
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1) Cells are damaged 2/2 anorexia, thrombosis, hemorrhage (Sheehan's or Simmons)
2) Neoplasms: often PRL secretors 3) Acromegaly 4) Cushing's |
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What are hypothalamic causes of amenorrhea? (5)
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1) Congenital: Kallman's (anosmia + midline facial defects) or isolated Gn deficiency
2) CNS neoplasms 3) Infiltrating disease: TB or sarcoid 4) Stress 5) Eating disorder: anorexia or bulimia |
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Secondary amenorrhea plus high FSH in pt <40?
What are some causes of this? |
Premature ovarian failure
Autoimmune disease like Hashimoto's, Addison's, DM, or Hypoparathyroidism |
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What are symptoms of premature ovarian failure?
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Hypoestrogenism
High FSH Ovarian biopsy: Generalized sclerosis or only primordial follicles (no progression past antrum stage) |
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When to check karyotype in pt with premature ovarian failure? (4)
What else to check in these pts? |
1) Pt < 30y/o (46XX/XY mosaic → remove gonads to prevent malignancy)
2) Pt <63 inches tall (Turner's) 3) Gonadal failure = uterus, no breasts, high FSH 4) Androgen insensitivity = breast, no uterus, male testosterone levels Antithyroid antibodies, antinuclear antibodies, 24-hr cortisol |
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What are other, less common or rare causes of premature ovarian failure? (5)
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1) Chemo or rads
2) Lung cancer 3) Single gonadotropin deficiency 4) Resistant or insensitive ovaries (bad or absent receptors) 5) Galactosemia (rare AR galactose metabolism dz) |
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What is MC cause, overall, of amenorrhea?
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Pregnancy!
Always get UPT first |
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Which drugs can cause amenorrhea?
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Antipsychotics (phenothiazines, haloperidol, droperidol)
TCAs Antihypertensive (reserpine, methyldopa) Anti-anxiolytics (benzos) Metoclopramide Opiates Barbiturates Estrogens Any drug that stimulate PRL excretion |
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Initial eval of amenorrhea should include which tests?
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TSH
PRL Progesterone challenge |
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What is the mechanism behind athletic amenorrhea?
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High stress levels
Energy deficit Eating disorder The 1st 2 cause increase in catechol estrogens and beta endorphins → mess w/GnRH release and hence LH & FSH |
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Treatment for athletic amenorrhea?
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Encourage pt to improve diet, decrease stress, decrease strenuous exercise
Replace estrogen and progesterone if the other changes don't help |
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Which enzyme defect can cause cause amenorrhea?
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17-α-OHlase deficiency → effects both ovarian and adrenal gland production → no sex hormones or breast development
Pts do have uterus Also have xs mineralocorticoids → HyperNa, HypoK, HTN Decreased cortisol Tx: replace cortisol and sex hormones |
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What is major cause of anovulatory amenorrhea?
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PCOS
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What percentage of reproductive age women have PCOS?
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5%
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What are 2 other names for PCOS?
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Stein-Leventhal syndrome
Chronic ovarian hyperandrogenism |
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What systemic fxns are affected in PCOS?
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Ovulation
Glycemic control XOL metabolism |
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What are possible criteria for diagnosing PCOS?
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Menstrual dysfunction (anovulation or oligo-ovulation)
PCOS on US Hyperandrogenism (clinical or biochemical) Absence of other androgen disorders or hyperPRL |
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What other syndromes can present like PCOS?
What are tests to differentiate? |
Hyperprolactinemia
Late-onset adrenal hyperplasia Ovarian and adrenal hyperplasia Cushing's syndrome Tests to differentiate: Serum PRL 17-OH progesterone Serum testosterone DHEAS 1mg o/n dexamethasone suppression test & 24hr urine free cortisol |
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MC presenting symptoms of PCOS?
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Infertility (64%)
Hirsutism (69%) Amenorrhea (51%) Obesity (41%) Dysfunctional uterine bleeding (29%) |
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Which labs may be abnormally HIGH in PCOS pts?
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Testosterone and androstenedione
E1 DHEA and DHEAS LH (often 3:1 to FSH) Hyperinsulinemia(more frequent in obese PCOS pts) |
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Which labs may be abnormally LOW in PCOS pts?
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FSH (can be normal)
Sex hormone binding globulin E2 Decreased fasting glucose:insulin (<4.5:1) |
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What are clinical findings in PCOS?
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Hirsutism
Acanthosis nigricans (often associated w/ hyperinsulinemia = HAIR-AN) Anovulation Cardiovascular disease Abnormal glucose metabolism |
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What is the inheritance pattern of inherited PCOS?
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XLD or AR (other chapter says AD!)
Theoretical 50% inheritance but is more like 40% because of genetic and environmental factors |
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How to treat PCOS if desire fertility?(4)
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Clomiphene (80% ovulaton rate, 50-60% pregnancy rate)
Human menopausal gonadotropin is 2nd-line therapy (hMG) Wedge resection/ovarian drilling Metformin Wt loss IVF |
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Treat PCOS obesity? (3)
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Diet/exercise
Anti-obesity drugs Metformin |
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Treat PCOS dysfunctional uterine bleeding? (3)
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OCPs
Progestins Dilation and curretage |
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Treat PCOS hirsutism?
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OCPs
Vaniqa (eflornithine) Progestins Spironolactone (anti-androgen) Fluatmide (anti androgen) Finasteride (5α-reductase inhibitor) GnRH analog Metformin Cimetidine Electrolysis Laser vaporization Traditional acne treatments |
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Treat PCOS recurrent miscarriage?
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hCG
progesterone supplementation |
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Best treatment for PCOS?
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Likely insulin-lowering drugs
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Who gave PMS its name?
What year? |
Dalton
1953 |
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What is the definition of PMS?
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Constellation of symptoms that occurs in a cyclic pattern, always in the same phase of the menstrual cycle, interfering with work or lifestyle and followed by a period entirely free of symptoms
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What year was 1st published description of PMS symptoms?
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1931
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What symptoms are associated with PMS?
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1) Physical:
Wt gain, breast swelling and tenderness, pelvic pain Skin changes like acne Hot flashes Diarrhea or constipation H/a craving sweets 2) Emotional: Irritability Insomnia Depression Confusion or forgetfulness Anxiety Fatigue Feeling of being “out of control” |
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What are theories of PMS's cause?
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All related to hormonal alterations:
1) Ovarian hormones (estrogen and progesterone) 2) Fluids and electrolytes (PRL, Aldosterone, RAAS, Vasopressin) 3) Neurotransmitters (monoamines, acetylcholine) 4) Others: endorphins, androgens, glucocorticoids, melatonin, insulin 5) Serotonin (since SSRIs help!) |
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Does decrease in progesterone levels trigger depression and other emotional symptoms in PMS?
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Supplementing progesterone seems to INCREASE these symptoms, so likely not. Does seem to help a small number of pts, but this might be due to placebo effect.
Note: The theory was used by Dalton in England as defense in a murder trial. |
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What is the relationship between progesterone and monoamine oxidase in PMS?
During which phase? |
Progesterone increases MAO levels in plasma
Luteal phase |
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What is role of aldosterone antagonist in PMS?
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May be related to physical symptoms of fluid retention (wt gain and breast tenderness)
Some of the emotional symptoms may be related to renin/angiotensin and aldosterone increases So spironolactone is good treatment (has antiandrogenic fx) that offers relief to many people. |
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What is thought to be the mechanism behind carb and chocolate cravings in PMS?
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Falling serotonin levels
The body ingests carbs trying to raise serotonin and l-tryptophan levels). Normally, when serotonin levels are high enough, the body craves protein which lowers serotonin to begin a new cycle. In PMS, the pt only craves carbs and chocolate, and serotonin levels never get high enough to trigger protein cravings |
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What is best diet for reducing PMS symptoms?
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Low fat, salt, and sugar
Higher in proteins and complex carbs Maybe vitamins and minerals (no definitive results) |
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Do prostaglandins help PMS symptoms?
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PGE1 may be low in some women w/ PMS (who have symptoms related to altered carb metabolism)
This can also contribute to dysmenorrhea as well Both can benefit from NSAIDs, ibuprofen, others |
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Does sterilization reduce PMS?
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Nope (if tubal or ligasure)
In extreme circumstances, TAH and BSO can help with debilitating disease |
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What is role of psychogenic meds in treatment of PMS?
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Double-blind, placebo controlled studies have shown significant PMS symptom reduction with SSRI fluoxetine 20mg PO qday thruout cycle
Sertraline or alprazolam may also help |
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How to treat PMS?
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Assure pt that her symptoms are real
Pt should chart her symptoms for several cycles (really premenstrual?) Stress healthy diet, exercise, sleep Consider SSRIs, spironolactone, prostaglandin inhibitors Consider progesterone therapy for non-responders OCPs |
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How to treat breast tenderness associated with PMS?
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Bromocriptine 5mg qday during luteal phase
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What is dysmenorrhea?
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Pelvic pain associated with periods
Cramping Can also be backache, headache, extemity Lightheadedness, insomnia, GI symptoms Nausea, vomiting, diarrhea |
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What difference between primary and secondary dysmenorrhea?
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Primary: aka intrinsic; not associated with identifiable pathology
Secondary: caused by gynecological condition – uterine myomas, adenomyosis, endometriosis, pelvic infection |
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What is incidence of dysmenorrhea?
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As high as 72% of women experience some discomfort
A smaller percentage experience it to a point that it interferes with activities, work, or school Is less common and less severe in women who have given birth |
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How to evaluate dysmenorrhea?
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H&P – r/o other gynecological or non-gyn causes (U or GI)
Get timing of onset and exacerbation – should be tied to menstrual bleeding |
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What is mechanism that causes pain in primary dysmenorrhea?
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Seems to be PGF2α
Causes cramping, nausea, diarrhea, headache |
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How to treat dysmenorrhea?
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Manage both primary and secondary via:
NSAIDs (decrease PGs) OCPs (atrophies endometrium – less and shorter bleeding) COX-2s help Secondary: treat underlying pathology (try medical before surgery) |
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Non-medical options to treat dysmenorrhea?
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Massage
Exercise Heating pad Acupuncture Hypnosis |
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What to do if dysmenorrhea response to medical therapy is inadequate?
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Primary: do more extensive w/u to look for underlying cause – pelvic US, sonohysterography, laparoscopy, MRI
Short-term PO narcotics for a few days of severe sx Secondary: treat underlying pathology (usually via surgery) |
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How much blood is typically lost during menses?
How much is considered abnormal? How long does bleeding typically last? |
35mL
80mL 4d (range: 1-8d) |
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What is abnormal uterine bleeding?
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Bleeding at irregular time intervals
-OR- Bleeding that is excessive but at normal time |
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Define:
1) Menorrhagia 2) Metrorrhagia 3) Menometrohagia |
1) XS bleeding at regular intervals
2) Menstrual bleeding at irregular intervals 3) XS, prolonged bleeding at irregular intervals |
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Define:
1) Intermenstrual bleeding 2) Polymenorrhea 3) Oligomenorrhea 4) Postmenopausal bleeding |
1) Bleeding btw normal cycles
2) Frequent, regular bleeding that occurs in <21d cycles 3) Infrequent, irregular bleeding that occurs in >45d intervals 4) Bleeding that occurs >1yr after menopause, or at irregular intervals while on HRT |
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What are the pregnancy related causes of abnormal uterine bleeding? (3)
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Miscarriage
Ectopic pregnancy Gestational trophoblastic disease |
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What are the infectious causes of abnormal uterine bleeding? (2)
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Cervicitis
Endometriosis |
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What are the neoplastic causes of abnormal uterine bleeding? (4)
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Cervical dysplasia/carcnioma
Endometrial hyperplasia/polyps/carcinoma Submucous leiomyomas Estrogen-producing ovarian tumors |
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What are the systemic causes of abnormal uterine bleeding? (4)
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Thyroid disease
Liver disease Coagulation disorders Sepsis |
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What are the iatrogenic causes of abnormal uterine bleeding? (5)
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Menstrual history: # days of flow, #pads/tampons used per day, impact on daily living
Hx of unusual bleeding from gums; easy bruising, prolonged bleeding after minor cuts Symptoms of wt gain, constipation, hair loss, fatigue, edema Galactorrhea Sexual hx & use of contraception |
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What should you ask in H&P of pt w/ abnormal uterine bleeding?
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Tanner stage of breast & pubic hair development
Ht & wt xs hair growth |
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What tests to order to eval abnormal uterine bleeding?
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Beta-hCG
CBC Coags TSH PRL FSH, LH, Testosterone, DHEA-S (if wondering about PCOS) |
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What is dysfunctional uterine bleeding (DUB)?
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Diagnosis of exclusion after r/o pregnancy-related, infectious, neoplastic, systemic, iatrogenic causes
Is result of anovulation or oligo-ovulation → ovary makes estrogen but no corpus luteum forms & no progesterone is secreted |
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What are major physiologic causes of anovulation? (4)
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Adolescence
Perimenopause Lactation Pregnancy |
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What are major pathologic causes of anovulation (4)
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Hyperandrogenic states
HyperPRL HypoTH Premature Ovarian failure |
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What is connection btw age and anovulation?
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Perimenarchal: teens have immature HPG axis; can't respond to E or LH surge
Perimenopausal: women have declining ovarian fxn |
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When to do endometrial biopsy when evaluating abnormal uterine bleeding?
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When suspect hyperplasia or endometrial cancer: all women over age 35 and any obese woman under 35
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What is incidence of endometrial cancer?
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Age 35: 6.1/100k
Age 40-49: 36.2/100k |
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When to do US in evaluating abnormal uterine bleeding?
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When you've ruled out organic causes of AUB and suspect a structural abnormality (e.g., fibroids or polyps)
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How to medically manage abnormal uterine bleeding in teens?
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Treat any underlying cause (like hypothyroidism)
Anovulation: Can tx w/ Provera or OCPs; Fe for anemia Acute menorrhagia: IV conjugated estrogen 25mg q4H or OCPs 35-50mcg TIDx3d → BIDx2d → QD to finish pack (2mo) |
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How to medically manage abnormal uterine bleeding in reproductive age women?
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Consider OCPs
Mirena Can induce ovulation w/ clomiphene citrate or gonadotropins |
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How to medically manage abnormal uterine bleeding in perimenopausal patient?
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Low dose OCPs if nonsmoker
Can get HRT once menopausal |
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What is non-hormonal medical therapy of abnormal uterine bleeding?
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Can use NSAIDs to reduce these women's abnormally high levels of PGI2 & PGE2:PGF2α, and EN-1
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How to treat abnormal uterine bleeding caused by fibroids?
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GnRH agonist like Lupron (leuprolide acetate) → fibroids re-grow when tx is stopped
Vaginal hysterectomy Myomectomy |
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What are surgical treatments for abnormal uterine bleeding?
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Endometrial ablation (destroys basalis layer) via:
Thermal ablation w/ rollerball or resectoscope Thermal ablation balloon (5% dextrose @87F x 8min) Hydrothermal ablation (NS 80-90C thru insulated sheath Microwave endometrial ablation (thru 8mm applicator) |
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What is success rate of endometrial ablation?
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70-97%
>85% of pts only need 1 treatment |
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If pt fails medical therapy and endometrial ablation, what is option?
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Hysterectomy
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Definition of hirsutism?
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XS body hair growth in anatomic sites in “male” pattern
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What are 3 types of body hair?
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Lanugo: light, thin, found in neonates
Vellous: fine, non-pigmented, found in most adult body regions Terminal: pigmented, coarse, found in scalp, axilla, pubic area of adult men and women, and on face and chest of men. |
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What are 3 phases of growth cycle of hair follicle?
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Anagen: growth
Catagen: involution → hair stops growth and moves up in follicle Telogen: resting phase that precedes hair loss |
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What are causes of hirsutism?
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Increased exposure to androgens 2/2:
Exogenous Increased adrenal androgen production Increased ovarian androgen production Alterations in binding globulins Increased end-organ sensitivity 2/2 increased 5α-reductase activity in skin |
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What are androgens made by body?
Where produced? |
Ovary: testosterone + androstenedione
Adrenals: DHEA, DHEAS Periphery: testosterone + DHT |
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What modulates androgen action? (2)
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1) Sex-hormone binding globulin (grabs and holds circulating androgens, decreasing their free concentration & hence action)
2) 5α-reductase (converts androgens to DHT; can only affect follicle if is DHT) |
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What is Ferriman & Gallwey Scoring System?
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Score hirsutism depending on body site
normal <8 severe >15 |
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What is DDX of hirsutism in women? (7)
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PCOS
Nonclassical adrenal hyperplasia Cushing syndrome\ Androgenic tumors (ovary, adrenals) HyperPRL Exogenous androgens Idiopathic |
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What meds have androgenic activity? (3)
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Anabolic steroids
Danazol Testosterone |
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What is significance of abrupt onset of hirsutism?
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More likely to be associated w/ tumor or exogenous hormone use
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What tests to use w/ pt w/ hirsutism?
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Total testosterone (>200ng/dL = tumor)
DHEAS (>700ug/dL = tumor) 17OH-progesterone (drawn in early morning) PRL 24 urine cortisol or o/n dexamethasone suppression test |
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What are medical treatments for hirsutism?
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OCPs (FDA approved)
Cyproterone acetate (strong progestin + estrogen) Spironolactone (blocks androgen-R) Flutamide (blocks androgen-R) Finasteride (5α-reductase blocker) GnRH analogs (suppress HPG axis) Glucocorticoids (blocks adrenal androgen production) Insulin-sensitizers (for PCOS) |
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What are adjuvant therapies for hirsutism?
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Wt loss
Bleaching/waxing/depilatories/plucking/shaving Electrolysis/laser Eflornithine Hcl cream (Vaniqa) (FDA approved) |
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How long does it take to see improvement in hirsutism after treatment has begun?
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3-6mo
|
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What is best treatment approach for hirsutism?
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Androgen suppression plus hair removal
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What are common findings in PCOS?
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Elevated LH:FSH (>2:1)
Perimenrchal onset of symptoms polycystic ovaries on US Obesity Insulin resistance in lean or obese pts |
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How do sex steroid levels affect SHGB concentrations?
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Decrease if testosterone is high
Increase in response to estrogens |
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How does PCOS present in teenager?
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Premature adrenarche
Persistent oligomenorrhea Hirsutism Acne Wt gain |
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What are health consequences of PCOS?
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Hyperlipidemia
Adult-onset DM Endometrial hyperplasia Infertility Obesity |
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What is acanthosis nigricans a marker of?
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Insulin resistance
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What percent of PCOS women are obese?
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50-75%
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What are the cysts in PCOS?
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Atretic follicles, usually 3-5mm in diameter
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What percentage of PCOS pts have impaired glucose tolerance?
DM? |
1) 35%
2) 10% |
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What are surgical treatments for PCOS?
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Wedge resection of ovary
Laparoscopic drilling Laparoscopic needle cautery |
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How to prevent endometrial hyperplasia in PCOS?
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Combined OCPs
Cyclic progestin therapy |
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What is a leiomyoma?
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Aka fibroid, fibromyoma, myoma
Growth of uterine muscular wall, +/- fibrous tissue Benign >99% of the time |
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Most common pelvic tumor?
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Leiomyoma
|
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Incidence of leiomyoma?
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25% caucasians
50% black women Note: 77% of post-hysto uteruses are found to have incidental myomas Account for 25-30% of hysterectomies |
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What is etiology of leiomyomas?
|
Thought to be somatic mutation of monoclonal myometrial cell line
Often occur in clusters & recur, so likely is genetic predisposition Have not been documented to occur more frequently in 1st degree relatives of probands, though. |
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What conditions cause leiomyomas to grow?
Under what conditions do leiomyomas stay the same size? Under what conditions do leiomyomas abate? |
1) During menstrual life
2) Pregnancy, OCPs, HRT 3) After menopause (if grow at this time, consider malignancy!) |
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What percent of leiomyomas are malignant?
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0.3-0.7%
|
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What are most common locations of leiomyomas? (3)
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1) Subserosal (on external surface)
2) Intramural (on uterine wall) 3) Submucosal (protrude into endometrial lining) |
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What symptoms are commonly associated w/ leiomyomas? (4)
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Dysmenorrhea
Abnormal uterine bleeding Pressure Pain (w/ menses or w/ myoma degeneration) |
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What specific symptoms are commonly associated w/ LARGE leiomyomas? (2)
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Urinary frequency
Pelvic pressure |
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What specific symptoms are commonly associated w/ SUBMUCOSAL leiomyomas?
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DUB – usually menorrhagia
|
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What specific symptoms are commonly associated w/ INTRAMURAL leiomyomas?
|
Abnormal uterine bleeding
|
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What is mechanism behind which myomas lead to DUB (dysfxnal uterine bleeding)? (5)
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1) increased endometrial surface area
2) endometrium ulcerates over myoma 3) endometrial hyperplasia at myomal-endometrial jxn 4) uterine wall can't contract & close spiral arteries during menses 5) abnormal microvascular pattern w/ stasis & change in venous drainage |
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When to remove leiomyomas?
|
1) If rapid growth or growing after menopause
2) Persistent abnormal bleeding not responsive to medical tx 3) excessive pain or pressure 4) Consider if >8cm in women who still desires childbearing |
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What are potential treatments for leiomyomas?
|
1) Surgery: hysto or myomectomy (laparotomy or -oscopy or w/ hystoscope)
2) Medical: GnRH agonist 3) IR: uterine artery embolization |
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How long does GnRH agonist take to effectively treat leiomyoma?
What is its max reduction in fibroid size? What are major drawbacks of GnRH treatment? |
1) 3-6 mo
2) 30-64% 3) Fibroid will grow back when d/c drug. Drug simulates menopausal state (but can give add-back low-dose HRT to younger pts) |
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What types of degeneration do myomas undergo?
|
1) Hyaline (65%)
2) Myxomatous (15%) 3) Calcific (10%) 4) Carneous – the most acute; 5-10% pregnancies have this complication 5) Cystic degeneration 6) Fatty degeneration |
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Relationship btw leiomyomas and infertility?
|
Not thought to be a major cause
If do have impact, is likely through uterine cavity distortion or mechanical obstruction @ cervix or tubial ostia If in posterior uterine wall might inhibit implantation |
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If no other cause for infertility is found and leiomyomas are removed, what is resultant pregnancy rate?
|
70%
|
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What is endometriosis?
|
Hormonally responsive tissue is found outside the uterus
Can see endometrial glands and stroma; macrophages w/ hemofusin and hemosiderin; & fibrosis on histology Is progressive Can have big impact on pt's quality of life via pelvic pain, dyspareunia + infertility |
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What is adenomyosis?
|
Endometrial tissue is found w/in uterine myometrium
Can cause severe menorrhagia & disabling dysmenorrhea |
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What is endometriosis prevalence?
|
Controversial
~5-15% of pre-menopausal women 20-50% in infertile women >50% in chronic pelvic pain pts Note: increased incidence amongst 1st degree relatives Affects teens. No racial preponderance |
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What is adenomyosis prevalence?
|
15-20%, usually in peri-menopausal women
May be association btw tamoxifen administration and adenomyosis |
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What are endometriosis anatomical sites?
|
Posterior cul-de-sac
Uterosacral ligament surface peritoneum Bilateral ovarian fossa + ovarian surfaces Broad ligament Fallopian tubes Anterior cul-de-sac May see peritoneal defects (usu lateral to uterosacral ligs) Has been reported in lung, nasal mucosa, bladder, kidney, incisional sites |
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What is metastatic theory of endometriosis?
|
Implantation after retrograde menstruation into peritoneal cavity, lymphatic dissemination, or hematogenous spread of endometrial tissue
Or, iatrogenic dissemination via procedures |
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What factors support the metastatic theory of endometriosis?
|
Endometriosis location in dependent parts of body
Endometrial cells can implant Increased incidence of endometriosis in pts w/ outflow obstruction IDing endometriosis in sites distant to abdominal cavity |
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What is embryonic cell rest and coelomic metaplasia theory of endometriosis?
|
Is de novo development of endometrial tissue outside uterus
|
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What factors support the embryonic cell rest and coelomic metaplasia theory of endometriosis?
|
NONE
|
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What is thought to be the true mechanism behind endometriosis?
|
Altered macrophage capacity to induce cytolysis of ectopic endometrial cells
Plus increased ability of this tissue to survive, proliferate, invade, and induce angiogenesis Plus impaired endometrial cell apoptosis Are more MPs in endometriosis, along w/ peritoneal MPs making increased synthesis of growth factors, cytokines, angiogenic factors These MPs have impaired cytotoxic ability No one knows why this happens, though. |
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What is clinical presentation of endometriosis? (5)
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1) Pelvic pain
2) Infertility 3) Dypareunia 4) Rectal discomfort and tenesmus 5) Abnormal uterine bleeding |
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What is clinical presentation of adenomyosis?
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Abnormal uterine bleeding (usually prolonged)
Severe dysmenorrhea |
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What are characteristics of pelvic pain associated w/ endometriosis?
|
Usually cyclic, occurring prior to or w/ menses
Unilateral or bilateral in lower quadrants Progression: increased pain week before menses |
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What is thought to be the etiology behind the pelvic pain of endometriosis?
|
Tissue edema
Blood extravasation These stimulate A-delta and C primary afferent fiber mechanoreceptors |
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What is the relationship between pelvic pain and extent of endometriosis spread?
|
NONE!
|
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What is the mechanism behind infertility caused by endometriosis?
|
Scarring and adhesions distort pelvic architecture and affect oocyte transportation from ovary to tube
Peritoneal environment affects oocytes and sperm Peritoneal fluid inhibits sperm function |
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What percent of women w/ endometriosis are affected by infertility?
|
30-40%
|
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What is the mechanism behind dyspareunia in endometriosis?
|
An immobile, fixed uterus, usually present w/ severe disease
Note: there's an association btw endometriosis and pain in specific coital positions |
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What is the mechanism behind rectal discomfort and tenesmus in endometriosis?
|
Posterior cul-de-sac scarring & immobility
|
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What are physical findings in endometriosis? (6)
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VARIABLE! Can have:
1) Diffuse lower abdominal tenderness in various locations 2) Nodularity and tenderness along uterosacral ligaments 3) Immobility of pelvic viscera → pain w/ manipulation 4) Fixed, retroverted uterus 5) Narrowing of posterior vaginal fornix 6) Adnexal tenderness and immobility |
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What are physical findings in adenomyosis? (2)
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Mobile uterus, often top-normal size or enlarged
No evidence of leiomyomas |
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How to diagnose endometriosis?
What are you looking for? |
Laparoscopy or laparotomy
Macroscopic black&blue lesions + red, red/pink, yellow/brown, white, & clear vesicular lesions + peritoneal defects, fibrosis, & scarring +/- microscopic implants (do histological exam of biopsies of normal-appearing tissue) |
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What are endometriomas?
What causes them? How to diagnose? |
1) Ovarian chocolate cysts
2) Endometriosis w/in ovary 3) US, MRI, CT |
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What possible future studies can be used to diagnose endometriosis?
What studies should to avoid? |
1) Possibilities include peritoneal fluid markers like cytokines, growth factors, angiogenic factors
2) For surface endometriosis, avoid imaging (useless). Also, avoid CA-125, anti-endometrial antibodies (not specific or reproducible) |
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Which part of uterus is adenomyosis usually more extensive?
What does the myometrium look like? |
Posterior wall
Trabeculated |
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What system is used to stage endometriosis?
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Revised American Society for Reproductive Medicine Classification of Endometriosis
Done post-op, documenting extent & location of implants & adhesions |
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What are medical management options for endometriosis? (6)
What is rational behind treatment? Which of the treatments are used as adjuncts? |
1) OCPs, Danazol, Progestins, GnRH agonists, anti-inflammatories, antidepressants
2) Suppress ovarian E2 production → decrease stimulus for endometrial growth and proliferation 3) anti-inflammatories, antidepressants |
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What are surgical mgmt options for endometriosis?
(3 initial, 1 rare, 1 definitive) |
1) Excision or destruction w/ laser vaprorization
2) Electrocoagulation or thermocoagulation 3) Lysis of adhesions 4) Rare: Presacral neurectomy or uterosacral ablation to manage pain 5) Definitive: TAH + BSO + Lyse adhesions + Excise all peritoneal surface lesions & endometriomas |
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What is Danazol?
What is its effect on endometriosis? |
1) Synthetic 17-α-ethinyl-testosterone derivative
2) It inhibits multiple enzymes in steriodogenesis and cytosolic hormone receptors Causes high androgen, low estrogen environment → reduces endometrial tissue activity |
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What type of bone loss is associated with long term (>6mo) GnRH agonist treatment for endometriosis?
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Trabecular
Note: Avoid this with add-back estrogen/progestin therapy!! |
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Which is the best treatment for endometriosis symptoms:
Medical, surgical, or combined? |
Combined!
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What is treatment for adenomyosis? (2)
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1) OCPs + NSAIDs or GnRH agonist
2) Definitive: TAH if pt fails medical treatment |
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Define chronic pelvic pain in women
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Nonspecific pelvic pain >6mo
May or may not be relieved by analgesics Pain is associated w/ laparoscopically evident pathology, occult somatic pathology, and nonsomatic disorders. |
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How common is chronic pelvic pain in women?
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Up to 10% of outpt gyn consults
Responsible for 10-35% of laparoscopies & 12% of hysterectomies in U.S.A. |
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What is innervation of major pelvic organs? (overall)
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From ANS – both PSNS and SANS
Afferent pain: thru SANS w/ cell bodies in thoracolumbar distribution PSNS is involved to a lesser extent & transmit painful stimuli |
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What are spinal cord levels of the mullerian-derived organs?
(i.e., uterus, tubes, upper vagina) Transmit via PSNS or SANS? |
1) T10, T11, T12, L1
2) SANS |
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What is innervation FROM the uterus?
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Uterus → uterosacral ligaments → uterine inferior plexus → hypogastric plexus @ level of rectum & vagina
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What are spinal cord levels of the lower vagina, cervix, and lower uterine segment?
Transmit via PSNS or SANS? |
1) S2-S4
2) PSNS |
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What are spinal cord levels of ovaries and distal fallopian tubes?
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T9 + T10
Have own nerve supply |
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What are spinal levels of bladder, rectum, perineum, and anus?
Transmit via PSNS or SANS? |
S2-S4
SANS and PSNS |
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Fibers from the perineum and anus combine to form branches of which pelvic nerve?
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Pudendal
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What mechanisms can cause visceral pain? (6)
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1) Distention of hollow viscera
2) Sudden stretching of solid organ's capsule 3) Hypoxia or necrosis of viscera 4) Prostanoid production 5) Chemical irritation of visceral nerve endings 6) Inflammation |
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What is difference btw splanchnic pelvic pain and referred pelvic pain?
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1) Splanchnic: irritable stimulus is appreciated in specific organ 2/2 tension (stretching, distention, pulling) or peritoneal irritation/inflammation
2) Referred: autonomic impulses from diseased visceral organ → irritable response w/in spinal cord. Pain is sensed in dermatomes corresponding to cells getting the impulses. |
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What is DDx of gyn causes of chronic pelvic pain? (7)
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1) PID
2) Endometriosis 3) Pelvic adhesions 4) Pelvic relaxation 5) Ovarian cysts 6) Mittelschmerz 7) Adenomyosis |
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What is DDx of ortho/MSK causes of chronic pelvic pain? (3)
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1) Psoas muscle pain
2) Stress fracture of pelvis 3) Abdominal wall pain |
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What is DDx of urinary tract causes of chronic pelvic pain? (5)
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1) Interstitial cystitis & urethral syndrome (UTI symptoms w/o bacteruria)
2) UTI/pyelo/cystitis 3) Bladder spasms 4) Ureteral obstruction (stone) 5) Perinephric abscess (usually caused by staph) |
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What is DDx of GI causes of chronic pelvic pain or lower abdominal pain? (5)
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1) IBS, IBD
2) Constipation/bowel obstruction 3) Appy, diverticulitis 4) Strangulated hernia 5) Cholecystitis, cholangitis, GD ulcers, pancreatitis |
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What are the 11 most common causes of acute pain related to reproductive organs?
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1) mittelschmerz
2) Fxnal ovarian cysts 3) Intrauterine pregnancy 4) Ectopic pregnancy 5) Pelvic infections 6) Uterine tumors 7) Adnexal neoplasia 8) Ovarian torsion 9) Endometriosis 10) Adenomyosis 11) Dysmenorrhea |
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What is mittelschmerz?
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Dull pressure or aching during mid-cycle in RLQ or LLQ 2/2 ovulation, ovarian capsule distention, or mild bleeding associated w/ ovulation
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What are fxnal ovarian cysts (2)?
What do each result from? What are findings in each? What are symptoms or complications in each? |
1) Follicular or corpus luteum
2) Follicular: 2/2 failure of egg release from mature follicle during ovulation → aching in RLQ or LLQ Corpus luteum: cyst persisting in center of corpus luteum; may be fxnal or non, so may delay menses. Rare except in pregnancy 3) F: Enlarged cystic ovary on exam CL: Cyst in center of CL. 4) F: Torsion w/ pain, rupture w/ pain, rupture w/ hemorrhage, or nothing (spontaneous resolution) CL: Torsion, rupture, hemorrhage; treat w/ OCPs or laparoscopy |
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How can an intrauterine pregnancy cause pelvic pain?
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Stretching the visceral peritoneum via the enlarging uterus, early uterine contractions, ovarian capsule stretching from the corpus luteum cyst, corpus luteum rupture, and threatened abortion
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How can ectopic pregnancy cause pelvic pain?
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Before and after rupture 2/2 stretching of the fallopian tube hollow viscus or peritoneal irritation from a hemoperitoneum
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Where might an ectopic pregnancy be located? (5)
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Tubes
Cervix Ovary Intramural Abdominal |
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How can uterine tumors (like leiomyomas or leiomyosarcomas) cause pelvic pain?
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Via torsion, necrosis, visceral peritoneum stretching, or pressure against surrounding intra-abdominal structures.
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How can adnexal neoplasia cause pelvic pain? (4)
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Hemorrhage, necrosis, torsion, or rupture
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What is the pathogenesis of pelvic pain in ovarian torsion?
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Twists → venous blood flow ceases → ovary enlarges → arterial blood flow ceases → necrosis
Pain is usually acute, severe, and constant or intermittent. May also include n/v & diaphoresis |
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What is pathogenesis of pelvic adhesions?
What is MCC of these? |
1) Adhesions happen 2/2 trauma to visceral or parietal peritoneum (2/2 operation, endometriosis, or infxn)
Can also happen w/ ischemic damage to peritoneum occurs → no fibrin lysis → fibrous adhesions occur Foreign body granulomas can occur 2/2 talc or gauze/suture material → adhesions 2) Surgical intervention (~70%) |
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How do pelvic adhesions cause pelvic pain?
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Theories include pain via mechanical stimulation (i.e., stretching) of visceral nociceptors
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How to treat pelvic adhesions?
What percent of pts see improvement of pelvic pain from this? |
1) Laparoscopic lysis
2) 65-85%. 75% of pts see continued improvement 6-12 mos after surgery |
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What are causes of deep vaginal pain?
What makes it worse? How to treat? |
1) Tender trigger points in the paracervical region or margins of the vaginal cuff after hysterectomy; pain is diffuse
2) Coitus, menses, examination 3) Inject w/ 1% procaine or 0.25% bupivacaine w/ min 3-5mm penetration of vaginal mucosa – may need to repeat 3x per week. Use diagnostic laparoscopy to r/o adhesions & endometriosis. Laser therapy for fulgurate endometriosis, lyse adhesions, transect uterosacral ligaments. |
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Myofascial trigger point vs abdominal wall trigger point?
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MFTP: hyperirritable spot, usually w/in taut band of SKM or muscle fascia
AWTP: in fat or fascial planes above the aponeurosis on needle localization |
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How to detect myofascial trigger points?
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Points are painful on compression (=jump sign)
May give rise to characteristic referred pain to arm, leg, or back Tenderness Autonomic phenomena: tearing, coryza, visual disturbances, tinnitus |
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How to treat myofascial trigger points?
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Hyperstimulation
Analgesics: stretch, cold spray Needle w/ local injection Transcutaneous electrical nerve stimulation (TENS) Acupuncture |
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What diagnostic method can be used to distinguish visceral pathologic conditions from chronic abdominal pain of neurologic origin?
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Careful neuro assessment w/ palpating small areas of tissue:
Place needle into tissue either abdominally or vaginally Inject saline into local tissue & reproduce same pain w/ needle tip |
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T or F: Sexual abuse is associated w/ chronic pelvic pain
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TRUE
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Best approach to pt w/ chronic pelvic pain?
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1) Complete medical, social, sexual history and PEx.
2) ID trigger points & use analgesia to improve accuracy 3) Differentiate btw somatic and visceral foci of pain 4) Consider US, CT, MRI, AbdXR & Renal rads to help diagnose 5) Use minimal am't of meds 6) Limit surgery to severe, refractory cases 7) Avoid removing normal tissue 8) Offer psych consultation – multidisciplinary therapy is key! |
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Which meds to use w/ chronic pelvic pain, & what are benefits or side effects?
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1) Analgesics; may be addicting
2) Antidepressants; may potentiate analgesics 3) Anxiolytics: may potentiate analgesics but may be addicting 4) GnRH agonists for endometriosis; bone loss (add back tx) |
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What are the success rates for laparoscopic conservative surgery in endometriosis associated pelvic pain?
For hysterectomy for chronic pelvic pain? For presacral neurectomy for difficult, non-responsive cases? |
1) Relief up to 6mos in 40-70% of women
2) Up to 78% (even w/o uterine pathology) 3) 50-75%, but recurrence rate is >50% |
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What is laparoscopy's role in treatment for chronic pelvic pain?
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40% of laparoscopy is done to treat chronic pelvic pain
40% have diagnosable abnormalities 50% may be helped with this procedure, though |