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191 Cards in this Set
- Front
- Back
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What is incidence of vaginal bleeding in 1st trimester?
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~30%
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What is DDx of vaginal bleeding in 1st trimester? (6)
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1) Threatened AB
2) Ectopic 3) Abnormal pregnancy 4) Vaginal lesions 5) Increased cervix friability 6) Infections |
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What is miscarriage risk in women w/ 1st trimester bleeding?
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~50%
Note: those who don't AB have slightly increased chance of fetal anomalies, preterm birth, fetal growth restriction |
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What % of clinically recognized pregnancies end in miscarriage?
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~15-20%
Note: up to 40% of embryos fail to implant or are lost before expected menses (= subclinical pregnancy) -> so ~50% TOTAL end in SAB |
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Definition of abortion?
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Spontaneous or induced
Pregnancy termination <20wks from LMP -OR- Delivery of fetus <500g |
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When do most clinical SABs occur?
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~80% happen in 1st trimester
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Does incidence of SABs increase or decrease with gestational age?
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DECREASE
By 6wks is 6-8% By 8wks is 2-3% |
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When can you see fetal cardiac activity on US?
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6 wks
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When can you confirm fetal viability?
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8 wks
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What accounts for majority of SABs?
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Genetic abnormalities - 50-70% of SABs
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What are genetic abnormalities that can lead to SAB? (3)
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Trisomy
Polyploidy/aneupolidy Translocations |
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Does % of SABs caused by genetic abnormalities increase, decrease, or stay the same throughout pregnancy?
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DECREASE
1st T: 70% of SABs 2nd T: 30% of SABs Birth: 3% of stillbirths |
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What are uterine or cervical causes of SABs? (4)
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Congenial uterine anomalies
Leiomyomas Intrauterine adhesions or synechiae Incompetant cervix |
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What are endocrine causes of SABs? (4)
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1) Progesterone def'cy (inadequate luteal phase)
2) Uncontrolled thyroid dz 3) Uncontrolled DM 4) LH hypersecretion |
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What are immunologic causes of SABs? (2)
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Autoimmunity: SLE or APLS
Alloimmunity |
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What are infectious causes of SABs? (10)
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Borrelia
CT/GC Herpes Listeria Mycoplasma hominis Strep agalactiae Syphilis Toxo Ureaplasma |
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What are toxins that can cause SABs? (6)
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EtOH
Caffeine Smoking Anesthetic gases High doses of rads Meds (MTX, misoprostol, tretinoin) |
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What is MC type of chromosomal abnormality found in SAB fetuses?
What does this result from? |
1) Autosomal trisomies (~50%)
T16 is mot commonly found! 2)From nondisjunction during meiosis |
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What is single MC karyotype seen in SAB fetuses?
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Monosomy X or 45,X0
~10-20% |
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What hx questions to ask when pregnant pt presents w/ vaginal bleeding?
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LMP
How much bleeding & how long Any cramping Passage of fetal tissue Fvr/chills/abdominal tenderness |
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What exam items are you looking for in pt w/ vaginal bleeding?
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Temp and v/s
Abdominal tenderness Rebound or guarding Speculum: Tissue at os? Purulent discharge? Bimanual: Cervix (closed/dilated); cervical motion tenderness; size of uterus; adnexal masses/tenderness? |
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What labs to check for pt w/ vaginal bleeding?
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CBC
Type & screen UPT (serial beta-hCG) |
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What are US guidelines for detecting intrauterine pregnancy?
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beta-hCG >1500mIU/mL should be seen by TVUS
beta-hCG >6000mIU/mL should be seen by transabdominal US |
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Definition of complete abortion?
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Spontaneous expulsion of all fetal and placental tissue from uterus prior to 20wks gestation
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Mgmt of complete abortion?
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US to confirm empty uterus, no further intervention needed.
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Definition of incomplete abortion?
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Passage of some fetal or placental tissue (NOT ALL) from uterus @ <20wks
Cervix dilated on exam |
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Mgmt of incomplete abortion?
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IVF
Type & cross/screen Immediate suction curettage |
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Definition of threatened abortion?
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Uterine bleeding @<20wks
No cervical dilation or effacement |
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Mgmt of threatened abortion?
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US to document viability
Modified activity and pelvic rest until bleeding stops |
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Definition of inevitable abortion?
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Uterine bleeding @<20wk
Plus cervical dilation NO expulsion of fetal or placental tissue thru os |
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Mgmt of inevitable abortion?
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Expectant mgmt or evacuate pregnancy (surg or med)
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Definition of missed abortion?
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Fetal death @<20wks
NO expulsion of fetal or placental tissue thru os for at least 8wks afterward |
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Mgmt of missed abortion?
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suction curettage or medical termination pf pregnancy
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Definition of septic abortion?
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Any other SAB plus uterine infection
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Mgmt of septic abortion?
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IV ABX + suction curettage
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Vaginal bleeding + closed cervix on exam could be which types of SAB (3)?
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Threatened
Complete Missed |
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Vaginal bleeding + open cervix on exam could be which types of SAB (2)?
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Inevitable
Incomplete |
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What is rate of increase of β-hCG in a normal viable pregnancy <20wks?
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Double q48H
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Which SAB pts should get RhoGAM?
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All pts who are Rh negative w/ vaginal bleeding 2/2 SAB or ectopic - give IM
If <12wks, should get MICRhoGAM (50mcg) If >12wks, get full RhoGAM (300mcg) |
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What is recurrent pregnancy loss (RPL)?
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3 or more consecutive SABs
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When should you eval RPL pt?
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Usually after the 3 consecutive losses
If pt is older and more worried, can start w/u after 2 |
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How often can we ID cause for RPL?
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50-60% of cases
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What is RPL DDx? (8)
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Genetic
Uterine anatomical anomalies Endocrine disorders Autoimmune Alloimmune Environmental Infectious Thrombophilias |
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What does initial RPL workup contain?
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Karyotype both parents
Labs: TSK, glucose, PRL, progesterone Endometrial biopsy US or hysterosalpingogram |
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What isa luteal phase defect?
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Deficient progesterone secretion by corpus luteum early in pregnancy
NOTE: Attempts to supplement progesterone in early pregnancy for RPL pts has NOT led to successful pregnancies for these pts!! |
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How is a luteal phase defect diagnosed?
How to treat it? |
1) 2 endometrial biopsies 7d after ovulation - histo shows lag of development of >2d
Can also use basal body temp chart showing luteal phase <11d OR serum progesterone <10mg/mL 1wk after ovulation 2) Progesterone replacement - no convincing evidence that this works, though! |
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What is chance of live birth after 2 consecutive SABs?
After 3 w/ previous live birth? After 3 w/o previous live birth? |
70-75%
70% 50-65% |
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What is proposed mechanism for APLA and Lupus anticoagulant in RPL?
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The antibodies block prostocyclin formation -> xs thromboxane (potent vasoconstrictor promoting platelet aggregn -> increased thrombosis & RPL risk)
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How to treat pts with APLA syndrome and lupus anticoagulant during pregnancy?
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Place on low dose ASA (75-80mg qD) +/- SQ heparin
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What are the 3 major methods used to terminate a pregnancy?
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1) Surgical evacuation w/ D&C or D&E
2) Medical AB 3) Labor induction |
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What are advantages of medical abortion?
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Avoid invasive procedure
Avoid anesthesia (usually) High success rate (~95%) |
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What are disadvantages of medical abortion?
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Need 2+ visits
May take days to wks to complete Use confined to early pregnancy Requires f/u to ensure is complete Generally multi-step process |
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What are advantages of surgical abortion?
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Can use sedation is desires
Usually needs only 1 visit Finished in a predictable time frame Use in early or later pregnancy High success rate (~99%) Single step process |
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What are disadvantages of surgical abortion?
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Invasive procedure
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What method of surgical evacuation of pregnancy to use @ <6wks?
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Suction curettage w/ smaller (6mm) canula and manual vacuum aspiration
Afterward, try to ID villi (powder puff pattern when floated in water) If can't see the villi, follow w/ serial β-hCG to r/o ectopic & confirm termination |
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What method of surgical evacuation of pregnancy to use @ 6-13wks?
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Vacuum aspiration w/ electric vacuum pump
Use suction cannulas according to GA Inspect tissue for villi, sac, fetal parts if >10wks |
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What method of surgical evacuation of pregnancy to use @ >13wks
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Use lamicel or laminaria to soften and dilate the cervix
Evacuate uterus Suction a/o sharp curettage ID fetal parts post procedure to ensure completeness |
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Over what # of weeks is considered 2nd T abortion?
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>13wks
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What meds are used for medical abortions?
Up to what # of days are they used? |
Mifepristone (RU-486) - usually in combo w/ misoprostol
Methotrexate - also usually in combo w/ misoprostol Up to 49d |
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What does mifepristone (RU-486) act as?
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Progesterone-R antagonist
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What is the mechanism of MTX in preventing pregnancy?
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Inhibits syncytialization of the cytotrophoblast & therefore prevents implantation
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What might be drawback of MTX over RU-486?
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With MTX, 15-20% of pts may have to wait up to 4wks for abortion to occur
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What are major complications of medical abortion? (3)
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1) Incomplete abortion requiring surgical evacuation (~5%)
2) Hemorrhage requiring emergency d&c (<1%) 3) Post abortal endometritis (0.09-0.5%) |
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What are side effects of various methods of medical abortion?
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Bleeding & pain
Nausea (12-47%) Vomiting (9-45%) Diarrhea (7-67%) Warmth or chills (14-89%) H/a (12-27%) Dizziness (14-37%) Fatigue |
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What are major complications of surgical abortion? (4)
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1) Uterine perforation (<1%)
2) Hemorrhage (<1%) 3) Post abortal endometritis (0.4-4.7%) 4) Incomplete abortion (~1%) |
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When is labor induction performed?
What is advantage? |
Early and mid-2nd-T gestations
Allow abortion w/o fetal dismemberment |
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What are methods of labor induction for abortion?
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Intra-amniotic instillation of:
1) hypertonic saline 2) urea 3) PGF2a Or, extra-aminotic admin of PGE2 via vagina Or, high-dose oxytocin IV |
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What serious complications may occur with hypertonic salien instillation?
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Hyperosmolar coma
HyperNa DIC |
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What is preferred 2nd T termination?
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D&E or vaginal prostaglandins (safer up to 20wks)
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How did Roe v Wade (1973) change maternal mortality from pregnancy termination procedures?
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Mortality was 39% in 1972
6% in 1974 Today overall risk in <1:100k procedures |
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How many abortions are performed per year in the U.S.?
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~1.3million
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What is an ectopic pregnancy?
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Any pregnancy that develops at any site other than the endometrium
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What is ectopic pregnancy incidence?
Why has it increased? |
1) ranges from 1:64 to 1:241
Averages ~20/1000 2) Has been 4fold increase since 1985 2/2 increasing salpingitis and better ABX, so tube is now patent but has luminal dmg. |
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What is MCC of maternal death in 1st half of pregnancy?
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Ectopic pregnancy
Is 2nd MCC of death in pregnancy overall - 10-15% of maternal deaths |
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What is the cause of ectopic pregnancy?
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Major: salpingitis
Others: infection (esp w/ CT), DES exposure, prior tubal surgery, smoking during time of conception ~3% is 2/2 failure of tubal sterilization method Also, chromosomal and structural abnormalities in fetus may predispose to ectopic |
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Where do majority of ectopics occur?
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97.7% occur in fallopian tube (ampulla >isthmus >fimbriae)
1.4% are abdominal <1% are ovarian or cervical |
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What are Spiegelberg's criteria to ID ovarian pregnancy? (4)
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1) Tube + fimbria ovarica must be intact
2) Gestational sac must occupy normal ovarian position 3) sac must be connected to uterus via utero-ovarian ligament 4) Ovarian tissue must be IDed by histo in wall of gestational sac. |
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What is incidence of heterotopic pregnancies? (=IUP + ectopic)
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1:30,000 (traditional)
1:4000-15,000 (more likely, since IVF has increased the risk to up to 3% of successful transfers) |
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T or F risk of ectopics varies w/ contraceptive method
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TRUE
OCPs & diaphragm = 1% IUD = 5% Progestasert IUD = 15% |
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What is recurrence risk for women w/ 1 previous ectopic?
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btw 7-15%
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What are risk factors for ectopic pregnancy? (8)
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1) H/o tubal surgery
2) H/o PID 3) Previous ectopic 4) IUD use 5) Progestin-only OCPs 6) DES exposure 7) Endometriosis 8) Cigarette smoking |
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What is DDX of ectopic?
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1) Threatened or incomplete AB
2) gestational trophoblastic disease 3) Ruptured corpus luteal cyst 4) Salpingitis 5) Appy 6) DUB 7) Ovarian torsion 8) Degenerating fibroid 9) Endometriosis |
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What is danger in delaying diagnosis of ectopic?
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Increased morbidity (substantial)
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What are MC symptoms of ectopic?
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>90% of pts have abdominal pain
Only 35% report completely missing a period (though usually have some abnormality) May have abnormal bleeding at time of presentation |
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What is etiology of shoulder pain with ectopics?
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Referred from diaphragmatic irritation 2/2 hemoperitoneum
Up to 25% of pts report this |
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What are MC signs of ectopic?
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Abdominal tenderness (>90%)
Palpable pelvic mass ~50% Normal uterine size in 70% Usually afebrile Orthostasis only in massive hemoperitoneum |
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What is role of hCG titers in ectopic?
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During 1st 6-7wks, hCG doubles q48H
Only 17% of ectopics meet criteria for normal doubling times Follow titers is helpful in ruling out ectopic pregnancu |
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When is US helpful in diagnosing ectopic?
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When can see fetal cardiac activity in either tube or uterus
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What is role of culdocentesis in diagnosing ectopic?
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Less frequently needed now, but useful if pt has +UPT and fluid in cul-de-sac and NO definitive intrauterine sac
Or if titers and US aren't available |
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Why is blood obtained in culdocentesis nonclotting?
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B/c is clotted blood that's been lysed already
Its hemocrit should be >15% to be significant |
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What is typical presentation of ectopic?
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Abdominal pain
Abnormal vaginal bleeding |
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What is role of progesterone levels in diagnosing ectopics?
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98% of viable pregnancies progesterone is >10ng/mL
98% of NON-viable pregnancies, progesterone is <20ng/mL So, one level <15ng/mL suggests non-viable, but doesn't distinguish btw pending SAB and ectopic Short answer: Role is limited!! |
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Pt w/ subnormal hCG rise or abnormal US BUT frozen D&C is negative, what is role of laparoscopy?
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Allows visualization of the tube
Note: false negative rate is ~4%, may be higher if done early in pregnancy |
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What is role of expectant mgmt for ectopics?
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Hospitalize pt for observation w/ surgery only for hemorrhage -> 57% of ectopics spontaneously resolve
BUT, 60% of pts are hospitalized for >4wks, so not very practical! |
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What are surgical options for ectopics?
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1) Traditional: Laparotomy w/ partial salpingectomy
2) Newer: Linear salpingostomy (laparoscopy) Note: 10% risk of persistent trophoblast, so follow until hCG is undetectable. |
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What is role of MTX in ectopic treatment?
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MC dose: 50mg/m2 IM x1
Can give multi-dose or single dose Has been reported to be successful in treating interstitial, abdominal, and cervical pregnancies Median success rate: 85% 80% tubal patency afterward |
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What is MTX mechanism of action?
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Inhibits folic acid synthesis -> blocks DNA synthesis & cell multiplication
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What are risks of MTX treatment? (5)
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Stomatitis
Dermatits Pleuritis Altered liver fxn ~60% of pts report increased abdominal pain w/ 1st few days |
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What are contraindications for MTX treatment? (7)
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Known MTX sensitivity
Breast feeding Immunodeficiency Chronic liver/lung disease Blood dyscrasias Embryonic ectopic cardiac activity Some: hCG >10,000 or sac >35mm |
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What are other, non-surgical alternatives to MTX treatment for ectopic? (3)
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Actinomycin-D (especially for more advanced)
KCl into fetal heart in advanced Possibly RU-486 + MTX (~97% success) |
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What are subsequent fertility rates following treatment for ectopic?
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Pt w/ previous term pregnancy: 80%
Nulliparous: 40% Ruptured: 65% Unruptured: 82% |
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What contraceptions methods are available in the U.S.? (7)
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1) Abstinence, withdrawal, rhythm
2) Permanent sterilizatiojn 3) Hormonal 4) IUD 5) Barrier 6) Spermicide 7) Emergency contraception |
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What are the various hormonal methods of contraception available in the U.S.? (5)
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1) OCPs: combos and progestin-only
2) Injectibles: Depot medroxyprogestesterone acetate & Lunelle (E2 cypionate + medroxyprogesterone) 3) Implant: Norplant (6 levonorgestrel rings) 4) Vaginal ring: Nuvaring (ethinyl E2 + etonorgestrel 5) Transdermal patch: Evra (ethinyl E2 + norgestimate) |
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What are the options for barrier methods in the U.S.? (3)
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1) Diaphragm
2) Cervical cap 3) Condoms (female and male) |
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What are the options for IUD in the U.S.? (2)
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1) Mirena: levonorgestrel
2) Paraguard: copper |
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With no contraception, what % of women will get pregnant in 1 yr?
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85%
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With spermicide only, what % of women will get unintended pregnancy in 1 yr?
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26%
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With "rhythm" method, what % of women will get unintended pregnancy in 1 yr?
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25%
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With female condoms, what % of women will get unintended pregnancy in 1 yr?
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21%
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With diaphragm/cervical cap, what % of women will get unintended pregnancy in 1 yr?
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20%
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With withdrawal method, what % of women will get unintended pregnancy in 1 yr?
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17%
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With male condoms, what % of women will get unintended pregnancy in 1 yr?
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14%
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With progestin-only OCPs, what % of women will get unintended pregnancy in 1 yr?
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7%
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With combo OCPs, what % of women will get unintended pregnancy in 1 yr?
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5%
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With vaginal ring, what % of women will get unintended pregnancy in 1 yr?
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1.2%
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With IUD, what % of women will get unintended pregnancy in 1 yr?
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0.8
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With transdermal patch, what % of women will get unintended pregnancy in 1 yr?
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0.7
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With tubal ligation, what % of women will get unintended pregnancy in 1 yr?
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0.55
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With depo-provera, what % of women will get unintended pregnancy in 1 yr?
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0.3
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With vasectomy, what % of women will get unintended pregnancy in 1 yr?
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0.15
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With norplant, what % of women will get unintended pregnancy in 1 yr?
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0.05
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What are the estrogenic effects of OCPs? (1)
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suppress FSH and LH -> inhibit ovulation
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What are the progesterone effects of OCPs? (5)
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1) Suppress LH
2) Thicken cervical mucous 3) May inhibit sperm capacitation 4) Produce decidualized endometrium with exhausted & atrophic glands 5) Alter uterus & fallopian tube motility |
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Association btw OCPs and MI?
OCPs and stroke? |
1) Weak association (RR=0.9-2.5) is current use, NONE for past use. Smoking is independent RF for MI & OCPs + smoking can increase risk of MI
2) Historical link btw high-dose OCPs; but no consistent, strong link btw them with modern dosages. *Women with other independent RFs (smoking, DM) may have slightly increased stroke risk while on OCPs |
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Association btw OCPs and DVTs?
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Slightly increased risk for 2nd and 3rd generation (~3fold vs ctrl), but this is less than risk of DVTs with pregnancy
*Factor V Leiden mutation in 3-5% of caucasians seems to be responsible for most of the DVTs... |
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What is role of combo OCPs in treatment of hyperandrogenism?
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Suppresses ovarian, adrenal, & peripheral androgen metabolism.
Estrogen part increases SHBP and blocks 5α-reductase -> less DHT |
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What is role of OCPs in treatment of menstrual disorders? (3)
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1) Can treat primary dysmenorrhea (use if NSAIDs are ineffective)
2) Can treat heavy or inter-menstrual bleeding (restore endometrial synchrony) 3) Acute menorrhagia: high doses for 3-4d then taper |
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What is role of OCPs in treatment of endometriosis?
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Reduce pelvic pain
Long-term suppression after initial medical or surgical therapy |
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What is role of OCPs in treatment of hypoestrogenic states? (3)
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1) Use as HRT for pts with hypothalamic amenorrhea
2) Or for peri-menopausal pts (treats symptoms and makes things regular) 3) Post-rads, -chemo, or -BSO HRT |
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What is role of OCPs in treatment of ovarian cysts?
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Induce cyst regression, in theory (not much evidence to support)
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What is role of OCPs in treatment of other menstrual-related disorders?
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1) Treat premenstrual dysphoric disorder
2) Menstrual migraines (minimize hormone fluctuation) |
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What is association btw OCPs and ovarian cancer?
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Users are LESS likely to develop ovarian cancer than never-users
Decreases by up to 40% with even 3-6mos of OCP use Protective effect persists up to 15 years after d/cing OCPs May help decrease hereditary ovarian cancer risk too |
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What is association btw OCPs and endometrial cancer?
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50% risk reduction vs never-users
20% reduction w/ 1yr. 40% w/ 2 yrs, 60% w/ 4+yrs Reduction persists for up to 15yrs after d/c |
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What is association btw OCPs and breast cancer?
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Slight increase in relative risk associated with current or recent use vs never use
FHx of breast cancer doesn't influence this association Duration, dose, formulation don't influence This increase does NOT persist beyond 4 yrs post-d/cing OCPs |
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What are non-contraceptive benefits of OCP use? (8)
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1) Reduce cancer risk for: ovarian, endometrial, possibly colorectal cancer
2) Reduce risk for benign breast disease (fibroadenomas, fibrocystic changes) 3) Less symptomatic PID 4) Less risk of ectopic 5) Increase bone mineral density 6) Decrease hirsutism & acne 7) May improve RA symptoms 8) Decrease menstrual flow, anemia, dysmenorrhea |
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What are contraindications to OCP use?
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1) H/o DVT or PE
2) H/o CVA, CAD, ischemic heart dz 3) DM with microvascular complications or >20yrs of DM 4) H/o estrogen-dep't cancer or breast cancer 5) Current pregnancy 6) Migraines w/ focal neuro symptoms 7) HTN (>160/100) or vascular dz 8) Active liver dz (viral, growth, cirrhosis) 9) Major surgery w/ prolonged leg immobilzation 10) H/o or FHx of hypercoagulable disorder |
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What are potential side effects of long-acting hormonal contraception?
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1) Menstrual (esp w/ progestin-only) - irregular bleeding, spotting, amenorrhea
2) headaches 3) decrease bone mineral density (w/ depo-provera) |
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What emergency contraception methods are available?
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1) Yupze (200mcg E2 + 1mg levonprgestrel q12h x2)
2) Preven: another combo method 3) Plan B: progestin-only 4) Copper IUD - can insert up to 7d after ovulation (failure rate 0.1%) |
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When to use emergency contraception?
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best w/in 72h of unprotected intercourse
IUD: up to 7d after ovulation |
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What is IUD mechanism of action? (3)
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1) Causes foreign-body reaction -> alter sperm motility and integrity
2) Alters tubal fluids -> alters ova & sperm transport 3) Alters uterine lining -> unfavorable for implantation |
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What are contraindications for pregnancy? (6)
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1) Confirmed or suspected pregnancy
2) Known or suspected pelvic malignancy 3) Undiagnosed vaginal bleeding 4) Acute or chronic pelvic infection 5) High risk behavior for STDs 6) Hyperbilirubinemia 2/2 Wilson's dz (for copper IUDs only) |
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What are major risks associated w/ IUDs? (4)
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1) Displaced string
2) Uterine perforation 3) difficult removal 4) Pelvic infection (w/ copper IUD) if STD exposure |
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When to insert IUD?
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Mirena: 7d after menses onset or immediately after early pregnancy loss
Paraguard: insert at any point as long as pt is not pregnant Can insert immediately postpartum, pastabortion, or w/in 6wks postpartum |
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What are advantages of barrier method contraception? (4)
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Protect vs STDs
Don't need much prior planning Easy access No systemic side effects |
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What are disadvantages of barrier method contraception?
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Need high motivation to use
Discomfort Latex allergies Diaphragm: Increased UTI risk |
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What is role of permanent sterilization in contraception?
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One of most widely used methods worldwide
Most common method in U.S. female >30y/o <1% pts will get pregnant after procedure in 1st yr Risk of failure does persist, and varies by method & age. |
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What are normal physiological changes seen in sexual response?
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Vasoconstriction & increased tone in genitals, breasts, skin
Elevation in pulse, BP, respiration |
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What are phases of sexual response cycle? (4)
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1) Excitement
2) Plateau 3) Orgasm 4) Resolution |
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Who describes the phases of the sexual response cycle?
What year? |
1) Masters & Johnson
2) 1966 |
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What are Kaplan's phases of sexual response? (3)
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Desire
Arousal Orgasm |
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What are normal initial female sexual physiological responses?
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1) Vaginal lubrication w/ transudate from vaginal walls 2/2 vasoconstriction
2) Expansion of upper 2/3 of vaginal walls 3) Cervix and uterus elevate 4) Clitoris and labia enlarge 5) Breast size increases & nipples become erect |
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What are physiological changes seen in the female "orgasmic platform"?
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1) Lower 3rd of vagina vasoconstricts
2) Vaginal lubrication slows 3) The shaft and glans of clitoris contracts 4) Sex flush along chest wall and back (50-75% of women) |
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What is prevalence of female sexual dysfunction?
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10-63%
Average is 41% |
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What factors are associated with increased risk for sexual dysfunction?
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Low income
Lower educational level Unmarried Prior h/o emotional or psychological stressors |
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What are main types of disorders seen in female sexual dysfunction?
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1) Sexual desire disorders
2) Sexual arousal disorders 3) Orgasmic disorders 4) Sexual pain disorders |
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What are subtypes of disorders seen in female sexual dysfunction?
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1) Lifelong vs acquired
2) Generalized vs situational 3) Specific etiologies |
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What are types of sexual desire disorders?
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1) Hypoactive: deficiency of sexual thoughts &/or desire for or receptivity to sexual activity
2) Sexual aversion: phobia w/ avoidance of sexual activity + severe anxiety associated w/ thinking about sexual activity These pts have normal physiological sexual response |
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What is sexual arousal disorder?
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Can't generate or keep sufficient sexual excitement (anatomical and physiological).
Decreased vasoconstriction Lack of lubrication Subjective diminution of excitement Examples: pts w/ pelvic floor dysfunction + incontinence |
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What is orgasmic disorder?
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Absence of or difficulty attaining orgasm despite sufficient sexual stimulation & arousal
Can be primary or situational |
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What are types of sexual pain disorders? (2)
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1) Dyspareunia: genital pain associated w/ intercourse. Often a/w vaginal atrophy, dryness, pelvic adhesions, endometriosis, myomas, vaginitis, vulvitis, & vestibulitis. Can also be impacted by prior abuse, lack of enough stimulation time, & cultural perceptions about female sexuality
2) Vaginismus: Pt w/ normal physiologic sexual response but can't psychologically engage in penetration. Muscles of lwr 1/3 of vagina + introitus constrict. May be 2/2 h/o sexual trauma or abuse |
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What are the etiologies of sexual dysfunction?
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Multifactorial! (organic & psychosocial)
1) Decreased vascularity 2/2 heart dz, HXOL, smoking, DM 2) Neurogenic: injury, hormonal (POF) 3) Underlying depression/anxiety disorder 4) Meds: antidepressants (SSRI or TCAs), H2 blockers, beta blockers, thiazides, spironolactone 5) Psychosocial: religious, cultural issues; prior h/o abuse or trauma; fear of rejection, fear of intimacy, body images issues |
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Which antidepressant increases sexual desire?
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Trazodone
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How to eval sexual dysfunction?
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Perform sexual history routinely, after rapport has been established.
Ask: sexual orientation, type & freq of sexual activity, partners past & present, sexual satisfaction Pt must feel that complete confidentiality will be kept at all times!! |
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What meds to treat sexual dysfunction?
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1) PO and intravaginal estrogen for vaginal dryness, atrophy, dyspareunia
2) Estrogen + methyltestosterone for libido decrease 3) Sildenafil: help increase genital blood flood & smooth muscle relaxation (for pts w/ sexual arousal disorder) |
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What devices to treat sexual dysfunction?
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Clitoral vacuum device (enhances blood flow in sexual arousal disorder)
Vibrators? |
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What other treatments for female sexual dysfunction?
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Correct underlying conditions
Treat adhesions or endometriosis Antifungals, steroid creams Therapist referral Usually include pt's partner in the therapy process |
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What is menopause?
What is "natural" menopause vs premature ovarian failure? |
1) Permanent cessation of menses resulting from loss of ovarian follicular activity
2) Natural = 12 months of amenorrhea w/o pathologic cause; avg age = 51.4 POF: Menopause <40y/o |
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What is perimenopause?
What is avg age & how long it lasts? |
Period immediately prior to menopause & after 1st yr of menopause
Avg age = 47.5, lasts ~4yrs |
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What is the climacteric?
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Phase that makes transition btw reproductive and non-reproductive state in women
Includes decreased fertility & extends beyond menopause |
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What endocrine changes are seen in menopause?
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1) Declining inhibin levels from granulosa cells -> increased FSH form pituitary
2) This accelerates follicular phase 3) See high E2 levels during menses +/- follicular cysts 4) Granulosa cells gradually lose ability to make E2 + increased FSH & LH 5) Post mp: androgen levels decline by 50%, but still androgen>estrogen so can get hirsutism & alopecia |
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Which form of estrogen is dominant after menopause?
How is is produced? |
E1
Made by aromatization of androstenedione in adipose tissues |
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What are major symptoms of menopause?
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1) Irregular menses - shorter cycle then missed periods 2/2 anovulation
2) Hot flashes (~70% of pts) 3) Sleep disturbances 4) Mood disturbances 5) UG atrophy: dyspareunia, vulvar pruritis, in continence |
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How to treat irregular menses at menopause?
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1) Low dose OCPs (20ug ethinyl E2) in nonsmokers w/o HTN/vascular dz
2) Monthly withdrawal progestins 3) Combo OCPs |
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What is a hot flash?
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Sudden sensation of warmth + flushed sensation of upper body + face
Usually 1-5 mins Can occur 5-7 yrs after mp |
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What is etiology of hot flashes?
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2/2 alterations in hypothalamic thermoregulation 2/2 steroid & peptide hormone level fluctuations
A/w increases in serum LH, but this doesn't seem to be causative |
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What is osteopenia?
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2.5 > bone mineral density <1.0 SD below T score (young adult mean)
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What is a T score in assessing bone mineral density?
A Z score? |
1) BMD compared to young adult mean
2) BMD compared to pt's own age group |
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What is osteoporosis?
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BMD >/= 2.5 SD below young adult mean
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How to assess bone mineral density (BMD)?
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Via dual-energy x-ray absorptiometry (DEXA)
Can also look at bone remodeling markers (osteocalcin, bone-specific ALkP, precollagen extension peptides) and urinary markers of bone resorption (pyridinoline cross-link peptides, N telopeptides, OH-proline, OH-lysine) -> increased usu means increased bone turnover |
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How common is osteoporosis?
How many fractures/yr does it account for? |
1) 25 million in U.S.; 15% females >50y/o have osteoporosis (~50% >65y/o have osteopenia)
2) 50% of women over age 65 -> 25% lead to death in 1yr, 25% stay bedridden |
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Where do fractures of osteoporosis occur in old people?
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Vertebrae (spinal compression)
Hip (at femur) Distal radius (Colles) |
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What is primary osteoporosis (type 1)?
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2/2 estrogen deprivation, advancing age, xs smoking and EtOH, poor nutrition, not enough wt-bearing exercise, & hereditary factors (Asian or Caucasian)
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What is secondary osteoporosis (type 2) owing to? (3)
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2/2 another factor:
1) endocrine abnormalities, e.g., PTH, TH, and cortisol xs; DM, hypogonadism 2) GI abnormalities (malabsorption, anorexia) 3) Meds: anticonvulsants, cyclosporine, GCs, GnRH agonists, heparin, isonizaid, Li, MTX, Thyroid hormone |
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What treatments are available for osteoporosis? (10)
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1) Wt-bearing exercise
2) Stop smoking/drinking EtOH 3) Calcium (500mg if on E2, 1000mg if not) 4) Vit D (esp if ltd sunlight exposure) 5) E or P replacement 6) Bisphosphonates 7) Calcitonin 8) SERMs 9) Tibolone 10) PTH |
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Is Sodium Fluoride recommended from treatment of osteoporosis?
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No - increases BMD< but may increase fracture risk.
Slow release formulations may be better. |
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What are benefits of HRT in menopause? (6)
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1) 70-80% improvement in vasomotor sx & UG atrophy
2) 2-5% BMD increase 3) 25-50% decrease in vertebral and hip fractures 4) Possible 20% decrease in CRC & AD 5) 25% reduction in tooth loss risk 6) Possible reduction in age-related macular degeneration |
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What are risks of HRT in menopause?
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1) Elevated risk of cardiac and stroke risk
2) Thromboembolic events 3) Breast cancer |
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What are recommendations in HRT nowadays?
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Risk outweighs benefits for any given woman
Reserve HRT treatment for menopausal symptoms for as short a time as possible |
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What are currently available HRT estrogen preparations (generally)? (7)
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1) 17β E2 (PO, vaginal, transdermal)
2) Ethinyl E2 (PO) 3) Conjugated Equine (PO, IV, vaginal) 4) Synthetic conjugated 5) Estropipate (PO and vaginal) 6) Esterified 7) Others: estrogen combos, E3 valerate, black cohash extract |
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What are currently available HRT progesterone preparations (generally)?
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MPA
Norethindrone Micronized progesterone Note: use these for women with uteri. |
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What are advantages of SERMs in treatment of osteoporosis?
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Have differential agonistic and antagonistic properties.
Raloxifene is approved for osteoporosis; does not promote endometrial hyperplasia, may reduce risk of breast neoplasms. |
