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60 Cards in this Set
- Front
- Back
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vulvar etiologies of vaginal bleeding in the nonpregnant woman
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benign growths
trauma - rough sex/atrophic vag, FB, assault, pelvic trauma (MVA) or straddle trauma STI - ulcerations cancers systemic disease, ie bachetes disease (multisys cellulitis), Crohns, lichen planus, lymphoma, leukemia, toxic epidermal necrolysis/steven's johnson |
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how to identify lichen planus?
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plaques
often also seen in the mouth as well as the vulva |
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when do you see vulvar cancers
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often in the immunocompromised
post radiation there may be episodes of a flux of necrotic tissue that will bleed note: 3-5% of gyn cancers are vulvar |
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what are the vaginal etiologies of vaginal bleeding in the nonpregnant woman
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- benign growths, ie polyps, cysts, abberent endometrial tissue
- Vaginitis or other infection - trich, HSV, BV, VVC, atrophic vag can all cause bleeding - trauma - vaginal cancers - systemic disease and s/p radiation |
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what are the cervical etiologies of vaginal bleeding in the nonpregnant woman
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benign growths
infection, ie GC/CT, maybe trich cancer - 100% from HPV |
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what do you do with cervical polyps
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remove and send for patho study
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what are the benign growths on the cervix that can cause bleeding
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ectropion
polyps abberent endometrial tissues |
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What are the uterine etiologies of vaginal bleeding in a nonpregnant woman
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benign growths - endometrial polyps, fibroids, adenomyosis
infection - endometritis/PID, anovulatory bleed, cancer medication effects clotting disorder systemic cancer, like leukemia |
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what are the benign growths that can cause uterine bleeding in the nonpregnant woman
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endometrial polyps
fibroids adenomyosis |
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what is the management of endometrial polyps
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removal via D&C
biopsy b/c they might be cancer |
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what are the types of fibroids by locations and what is their likelihood of bleeding
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1. exo - should not bleed
2. - thickening of the uterine stripe 3. submucosal - bleed all the time, protrude in |
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what are the characteristics of adenomyosis
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endometrial lining grows into the walls of the uterus
BLEEDS constantly uterus is enlarged and boggy |
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what are the cancers that cause uterine bleeding
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adenocarcinoma
sarcoma of the uterus (fallopian and ovarian ca Rarely cause bleeding) |
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what ARE the s/s of fallopian and ovarian ca
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fallopian - watery discharge, hard to distinguish
ovarian - generally Assymptomatic |
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when do we see adenocarcinomas
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very common in women OVER 45y
rarely seen in women less than 35yo Biopsy in any woman greater than 35y |
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what medications can cause uterine bleeding
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OCP - brkthru up to 6mo is not uncommon
HRT - 1st 3mo is OK IUD- paraguard increases bleeding; mirena may cause constant bleeding up to 1 yr Depo- may cz constant bleed x1yr, also often will have some bleed ('menses') again at some point anticoags steroids chemotherapeutics psychiatric meds |
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what might you work up in a teen who has severe episodes of vaginal bleeding
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clotting disorder
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what are some non-gyn based etiologies for vaginal bleeding
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cancer (leukemia)
severe liver disease clotting disorder urethritis/bladder ca/UTI IBD/Hemorrhoids/colorectal ca (note that often vaginal bleeds will leak back and cz +hemocult) |
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where in the menstrual cycle are women who do not ovulate and what is the implication
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they are stuck in the first 1/2 of the menstrual cycle (Follicular phase)
the thick lining is building and maintained - it can break off in segments in a disorganized fashion. This can result in a severe hemorrhage |
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How to manage uterine hemorrhage (if r/t irregular menses, likely not ovulating)
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1. cycle OCP:
4 pills day 1 3 pills day 2 2 pills/day until bleeding stops then 1 pill/day 2. megase if contraindication for estrogen 3. then 3 mo of these cycles to get back on track |
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what does Lupron do?
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It is a GNRH agonist that shuts down the Ovarian hormone prdxn system (b/c its a negative feedback system)
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What are the causes of primary anovulation that can lead to vaginal bleeding
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syndromes- congen GNRH deficit, Sheehans syndrome (hypopituitary); Empty Sella turica syndrome; lymphocytic hypophycitis
tumors: tumors of the pituitary/thyroid trauma to pituitary/thyroid |
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what are the causes of secondary anovulation that can lead to vaginal bleeding
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tumors: hormone producing (ovarian and adrenal)
lactational amenorrhea stress eating disorder/severe exercise PCOS Thyroid - Hypo / Hyper Chronic Liver Disease Cushings Congenital Adrenal Hyperplasia premature ovarian failure turners syndrome androgen sensitivity synd medications (hardcore psych meds, chemo which wipes out the reproductive sys) |
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why does cushings cause anovulation
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increase in cortisol
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what is the likely cause of vaginal bleed after menopause
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endometrial cancer
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what are the criteria for PCOS
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2 of 3:
1. increased androgens 2. anovulation 3. 12+ cysts or follicles (US) there is generally also insulin resistance note there is a relationship between anovulation and increased androgens that is centered around decreased sex hormone binding enzyme from the liver (but i don't understand this) |
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what is the treatment for PCOS and why?
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OCP!
protects the endometrial lining to avoid endometrial cancer (from constant estrogen stimulation) |
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what is the recommendation for treating insulin resistance in PCOS
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generally NOT the recommendation
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what is the treatment for androgen insensitivity
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estrogen
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what labs should be ordered in the w/u of vaginal bleeding in a nonpreg woman
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CBC - how much bleeding? platelets? WBC?
PT TSH/PRolactin - anovulatory bleed? r/o tumor? PCOS - FSH/LH; free testosterone, DHEA-S - r/o ovarian or ___ neoplasm serum progesterine - rises w/ ovulation CMP & glucose OGTT - if obese or there's a fhx - OTher labs you might draw include: FSH if r/o PREMature ovarian failure <45yo US Hemocult wet mt GC/CT RPR HSV |
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what are the diagnostic tests for determining the cause of vaginal bleeding
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ULTRASOUND is the 'gold standard' - determines the thickness of the uterine stripe as well
CT - better for a tumor MRI - best for anatomical abn (fibroids) Endometrial bx - where the endometrium is at the cycle, r/o hyperplasia w/ or w/o atripsia vulvar/vag bx imaging the sella turica - likely use an MRI Disease specific scans |
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what is the management of the uterine bleed in the nonpreg womena
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1. treat acute hemmg
2. seek CAUSE 3. OCP/hormonal trt 4. D&C 5. myomectomy vs UAE (uterine arterial embolysis) 6. hysterectomy - only as really needed |
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differentiate between acute and chronic pelvic pain
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chronic is greater than 6mo
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what are the GI differential diagnoses for acute pelvic pain
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appendicitis - most severe
IBS - most common diverticulitis, cholecystitis, pancreatitis, intestinal obstruction, PUD |
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what are the GU differentials for acute pelvic pain
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UTI
renal stones |
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what are the reproductive tract disorders that are differentials for acute pelvic pain
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endometriosis - most common
salpingitis/oophoritis degenerating uterine fibroid ovarian cyst - torsion or rupture dysmenorrhea also ovulation (Mittelschmerz) or Pregnancy-related - SAB, ectopic, placental abruption, HELLP, round ligament strain, Braxton Hicks/Labor contractions |
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What are the differentials for chronic pelvic pain
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(1) functional/psychosocial
(2) adhesions from prior surgeries or PID (3) abuse -physical or sexual note: diagnosis of exclusion |
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in adolescents, what is commonly the reason for pelvic pain
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almost always GYN in origin
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What are the likely causes of pelvic pain if it is cyclical and how are they differentiated
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Mittelschmerz or dysmenorrhea
Mittelschmerz is at the time of ovulation, ie midcycle and is often unilateral Dysmenorrhea is either primary- which would come on about day 1 of bleeding - or secondary which can be attributed to another cause but is not necessarily a/w ovulation. |
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what causes mittelshmerz and how does that impact the pain
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caused by leakage of follicular fluid into the peritoneal cavity. this is the cause of the pain and means pain is generally just on one side
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what is the most common cause of cyclical pelvic pain
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dysmenorrhea
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how can timing differentiate btw primary and secondary dysmenorrhea
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primary dysmenorrhea starts about 6-12 mo after menarche b/c that's when ovulation starts.
secondary can start at any time, but generally starts after age 25 |
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what is the cause of dysmenorrhea and how does that relate to the treatments
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caused by elevated levels of uterine prostaglandins which leads to ischemia --> pain. the prostaglandins are produced by the sloughing of the uterine wall.
ASA/NSAIDS are used first line to treat dysmen. because they decrease prostaglandin prodxn (by decreasing the activity ofhte cyclo-oxygenase pathways). Ca Channel blockers are also used for dysmen b/c they decrease prostaglandins by decreasing myometrial activity. Exercise and low fat diet also help to relieve dysmenn |
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What is the duration of primary dysmennorhea and when does it start r/t the cycle
What are the accompanying s/s |
starts on day 1 with bleeding
Lasts 8-72 hrs a/w: back/thigh pain, HA, N/V/D |
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What "cures" most women's primary dysmenorrhea
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pregnancy and delivery of a baby!
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what are the components of the diagnostic w/u for dysmenorrhea
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cervical cx
CBC / ESR (note that ESR will often be elevated in PID) PT Laparoscopy - gold standard but is invasive and rarely done initially Pelvic US - much more common Also possible are the UA, wet mount, and stool guiac depending on s/s |
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What are the pharmacologic treatments for dysmenorrhea
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ASA/NSAIDS - reduce cyclooxygenase pathways/decrease prostaglandin prdxn
COC - inhibit ovulation Mirena (Levonorgestrel IUD) - induces endometrial atrophy Danazol/Gonadotropin releasing hormones - for more severe, short term use - long term fx Ca Channel Blockers - decrease prostaglandins by decreasing myometrial activity |
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How do ASA/NSAIDS work for dysmenorrhea
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only works for primary and should be taken 1 day before onset of bleeding QID through day 2
work by reducing activity of the cyclo-oxygenase pathways thereby reducing the prostaglandin production |
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How does the Mirena (Levornogestrel IUD) help with dysmenorrhea
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induces atrophy of the endometrial lining
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How does Danazol used for dysmenorrhea
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Danazol is a gonadotropin releasing hormone.
it is used only short term because it pulls Ca, but it has long term effects. Danazol or other gonadotropin releasing hormones are only for very severe dysmenorrhea |
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How do Ca Channel blockers work for dysmenorrhea
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decrease prostaglandins by reducing myometrial activity
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What are some alternative tx options for dysmenorrhea
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EXERCISE
HEAT - QID Acupuncture Thiamine 100mg QD vitamin E Pyridoxine Mg Low Fat Veg diet TENS |
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What are surgical options for dysmenorrhea
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uterine nerve ablation
presacra neurectomy |
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Define PID and explain locations
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infx anywhere in the upper female genital tract (above the internal cervical os)
- endometrium - fallopian tubes - ovaries - myometrium - parametria - pelvic peritoneum |
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What are the general causes of PID
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1. STI complication
2. procedure 3. spontaneous in sexually active females |
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S/S of PID (criteria)
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Abdominal pain
PLUS 1 of the following: - adnexal tenderness - uterine tenderness - cervical motion tenderness can also have: temp >38C Discharge (vag or cervical) chills bleeding elevated ESR/CRP Lab documentation of cervical infection s/p procedure |
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What is the 1st line treatment for PID
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Ceftriaxone 250mg IM OR Cefoxitin 2 grams IM and Probenecid PO
PLUS Doxy 100mg PO BID x14days PLUS/MINUS Metronidazole 500mg PO x14days |
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What are possible complications of PID
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infertility
increased risk ectopic chronic pelvic pain / dyspareunia Fitz-Hugh and Curtis Syndrome |
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Fitz-Hugh and Curtis Syndromes
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development of fibrous adhesions as a consequence of PID
there is acute RUQ pain/tenderness but NO alterations of Liver enzymes |
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What is the F/U for PID
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48hrs - determine improvement and consider admission
2 wks - s/s improvement/decline |
