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98 Cards in this Set
- Front
- Back
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What is the appropriate sexual development?
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Thelarche (breasts ~age 10)-adrenarche (increase secretion of androgens)-growth spurt-menarche (~age 11.75 first period)
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16 yo c/o primary amenorrhea. healthy, active w/ sports. Good relationship w/ family. 5'1" 84lbs. Tanner stage II. Ext Genitalia normal. Explanation?
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inadequate body weight. 3 elements of secondary sexual characteristics - body weight (85-105 lbs), sleep and exposure to sunlight.
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16 yo primary amenorrhea. 5'1" 100lbs tanner stage I. wide spaced nipples and shield chest and neck thick. No genital tract anomalies. Dx?
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Turners XO. females have failure of secondary sex characteristic.
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What is Rokitansky-Kuster-Hauser syndrome?
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uterine and vaginal agenesis.
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diagnostic test to confirm Kallman syndrome? Rx?
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Olfactory challenge. Kallman's syndrome patients will have olfactory tract hypoplasia and arcuate nucleus doesn't secrete GnRH. No breasts. Look for anosmia w/ delayed puberty. Rx: pulsatile GnRH
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7 yo w/ VB. tanner stage III breasts, tall stature. MRI normal. LH, FSH, DHEA-S and androgen normal. Dx?
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true precocious puberty. A diagnosis of exclusion after work up.
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Name CNS abnormalities associated w/ precocious puberty.
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tumors (astrocytoms, gliomas, germ cell), hypothalmic harmatoms and congenital anomalies (hydrocelphalus, arachnoid cysts, suprasellar).
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8 yo diagnosed for precocious puberty. Next step in management?
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constant GnRH (NOT PULSATILE) to suppress pituitary production of FSH and LH. Can observe if age w/in months of normal puberty.
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15 yo c/o of amenorrhea. not sexually active. Tanner stage II average height and weight. Vaginal opening is present and appears normal. Next step?
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reassurance. Normal age of menarche is b/w 9-17.
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4 yo w/ premature hair growth in pubic area. labs: high DHEA and DHEA-S, Low LH and FSH. Most likely cause of premature adrenarche?
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CAH of the 21-hydroxylase type - low cortisol 2/2 to block of 17-OH prog --> desoxycorticosteroine. thus, accumulation of adrenal androgens.
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17 yo c/o primary amenorrhea. normal breast and pubic hair. small vag opening w/ blind pouch. normal ovaries, but absence of uterus and cervix. Next study?
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renal ultrasound. renal anomalies occur in 35% of females w/ mullerian agenesis (uterus and cervix absent, w/ normal ovaries --> breasts) karyotype is 46 XX
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13 yo w/ constant abd pain worse for a week every month. bluish mass pushing the labia open. etiology?
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imperforate hymen (genital plate canalization is incomplete). menstrual blood is collecting. Rx: surgical.
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secondary amenorrhea resulting from intrauterine scarring/synechiae
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asherman's syndrome
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24 yo c/o secondary amenorrhea. Good health but stressed from medical school. BP 140/80, weight loss unintentional. pelvic exam normal. Etiology of amenorrhea?
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hypothalmic-pituitary dysfunction 2/2 to anorexia nervosa or significant weight loss. Lack of pulsatile GnRH leads to decreased LH and FSH>
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Suspect hypothalmic pituitary dysfunction. patient good health but thin and has anxiety. hCG < 5, TSH and prolactin normal. next test?
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FSH and LH levels. should be low
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Name some causes of hypothalamic-pituitary amenorrhea.
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functional (weight loss, obesity, excessive exercise) drugs (marijuana and tranquilizers), neoplasia (pituitary adenomas) psycogenic (anxiety, anorexia) and chronic medical conditions
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What are initial therapies for PCOS?
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weight loss and OCPs
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MCC of amenorrhea
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pregnancy! always consider it early in workup to avoid unnecessary tests.
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33 yo c/o amenorrhea x 12mo. +dyspareunia. menarche @ age 15. Good health. 5'4" 130 lbs. TSH and prL normal. Etiology of amenorrhea?
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premature ovarian failure. dyspareunia 2/2 to vaginal dryness (estrogen deficiency)
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17 yo c/o primary amenorrhea. good health. +cyclic cramping, not sexually active. 5'6" 120 lbs. Tanner stage IV. suprapubic tenderness. normal ext gen but difficulty w/ speculum exam but normal anatomy. hCG negative. dx?
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obstruction of the genital outflow tract. patient's symptoms point to an anatomical cause which prevents bleeding. DDx: imperforate hymen (obstruction of genital outflow) and mullerian agenesis (no vag or uterus or FT)
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amenorrhea secondary to extensive exercise is under what category?
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hypothalamic amenorrhea. (think Olympic gymnasts)
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31 yo G3P0 c/o amenorrhea x 6mo. miscarriage 7 mo ago complicated by infection and req'd abx and D&C. Examination and labs normal. etiology of amenorrhea?
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asherman's syndrome 2/2 curettage or endometritis which can cause synechiae or adhesions from trauma to endometrium
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What are the labs that should be ordered in pre-menopausal patient c/o amenorrhea w/ normal H&P?
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hCG, TSH and PrL
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22 yo G0 c/o of amenorrhea x 6 mo s/p discontinuing OCPs. good health normal physical exam. Appropriate next question in history?
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Hx of oligo-ovulatory cycles. history of this may increase risk of amenorrhea upon discontinuation. "post pill amenorrhea"
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35 yo asian w/ irregular menses and hirsutism x 3 mo. No FHx. DHEA-S elevated. Dx?
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adrenal tumor.
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What is the lab to order to diagnose 21-hydroxyprogesterone deficiency? What labs will be normal?
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17-hydroxyprogesterone. Normal labs: TSH, prL, testosterone and DHEA-S
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22 G0 c/o hirsutism since menarche. normal menses, sexually active on OCPs, not overweight. normal exam and labs. dx?
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idiopathic.
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lab(s) to diagnose Cushing's syndrome?
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dexamethasone suppression test or a 24hr urinary cortisol.
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26 yo c/o hirsutism and irregular menses. terminal hair and gray-brown velvety discoloration on back of neck. next test?
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fasting insulin. lesion is consistent w/ acanthosis nigricans which is associated w/ increased androgens levels and hyperinsulinemia.
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36 yo c/o hair loss. delivered 3 mo ago. Hx of hair loss and thinning in parents. testosterone and TSH normal cause for alopecia?
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high estrogen levels in pregnancy increase synchrony of hair growth, therefore they fall out together.
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24 yo c/o facial hair, worsening acne and deepening voice and amenorrhea x 2mo. enlarged clitoris and right sided adnexal mass. dx?
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sertoli-leydig cell tumor. MC diagnosed in ages 20-40 and are unilateral. Labs will show decreased FSH and LH and elevated testosterone.
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what types of tumors secrete estrogen?
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granulosa cell tumors
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34 yo c/o hirsutism, irregular menses and weight gain. labs show slightly elevated testosterone. etiology?
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PCOS
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26 yo c/o irregular menarche and hirsutism. +acne and acanthosis nigricans and temporal balding. serum testosterone elevated. Dx? Other symptoms?
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hyperthecosis (severe PCOS). associated w/ virilization 2/2 to high androstenedione and testosterone. look for clitoral enlargement and deepening of voice.
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21 yo treated w/ OCPs for irregular menses, acne and hirsutism. All but hirsutism remain. next step?
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add spironolactone. Aldosterone receptor antagonist diuretic w/ androgen receptor blocking.
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32 yo c/o irregular menses q6-8w x 8mo. MPA used to treat. Mechanism of medroxyprogesterone acetate in anovulatory bleeding?
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converts endometrium to secretory phase. anovulatory bleeding 2/2 unopposed stimulation by estrogen. progestins convert to secretory phase and withdrawal then mimics involution of CL = sloughing.
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When is inhibin increased?
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luteal phase
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Test or procedure most useful to evaluate heavy menstrual periods.
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get a pelvic ultrasound to image endometrium to r/i or r/o polyps.
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14 yo G0 w/ heavy menstrual flow refractory to OCPs. H/H 9.1/27.8%, hCG negative. most likely etiology?
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coagulation disorder. look for vW disease. Leiomyomas can cause this but age range is typically 30-40s
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Most definitive treatment for DUB (menorrhagia refractory to OCP)?
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endometrial ablation.
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Why should leuprolide not be used long term?
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risk of osteoporosis. GnRH receptor agonist
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35 yo G0 c/o irregular menstrual periods and daily bleeding x 4w. morbidly obese, sexually active w/ normal exam. Most appropriate next step?
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endometrial bx to r/o endometrial hyperplasia or carcinoma given h/o irregular bleeding and morbidly obese.
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34 yo G2P2 p/w intermentrual bleeding x 1y. on OCPs normal physical. upreg negative, endometrial bx negative for neoplasia. next test?
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pelvic u/s to look for structural anomalies like myomas, polyps or malignancy.
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Why is free testosterone elevated in PCOS?
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because sex hormone binding globulin is decreased by elevated androgens (abnromal FSH:LH ratio). LH increased in response to increased estrogens fed by elevation of androgens. insulin resistance and chronic anovluation are hallmarks of PCOS.
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Define DUB
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irregular or increased menstrual bleeding w/o identified etiology (after complete work-up: TSH, prL, U/S, endometrial bx)
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Incidental 2cm simple cyst found on ovulatory patient. next step.
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functional cyst. observation and reassurance.
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35 yo smoker G2P2 c/o heavy menstrual bleeding. Dx submucosal leiomyoma. Best option if patient still wants children?
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hysteroscopy w/ myoma resection to preserve uterus while removing pathology. ablation destroys endometrium and create asherman's. OCPs would help, but she is over 35 and a smoker!
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19 yo w/ dysmenorrhea taking 600mg ibuprofen. exam normal next step?
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OCPs. relive dysmenorrhea.
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How do OCP relieve primary dysmenorrhea?
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create endometrial atrophy. less endometrium = less prostaglandins = reduced pain
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Guidelines for chlamydia and gonorrhea screening?
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all sexually active patients age 25 y and younger. PID is a cause of secondary dysmenorrhea.
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19 yo w/ dysmenorrhea refractory to OCPs and depo. next step?
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diagnostic laparoscopy. it can confirm endometriosis and exclude other causes of secondary dysmenorrhea. Can try GnRH short course.
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During ex lap for dysmenorrhea, blue-black powder burn lesions seen in the pelvis. What would be seen in pathology analysis?
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endometrial glands or stroma and hemosiderin laden macrophages classic for endometriosis.
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42 yo G4P4 p/w hx of severe menstrual pain w/ regular but heavy cycles. pelvic exam shows enlarged soft, boggy uterus. no masses palpated and prego test negative. H/H 9.8/28.3%. Dx?
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adenomyosis. gland tissue in the muscle which grows w/ cycle but cannot slough because trapped in uterine muscle. Less likely is endometrial carcinoma because she still has menses.
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Definitive treatment for adenomyosis.
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hysterectomy is 80% effective in eliminating pain and abnormal bleeding. GnRH agonists are 1st choice for medical management.
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Pathologic diagnosis of adenomyosis
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invasion of endometrial glands into the myometrium
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41 yo G2P2 diagnosed w/ fibroids. Next step in mangement?
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endometrial bx in all owmen over 40 w/ irregular bleeding to r/o endometrial carcinoma.
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pathology diagnosis of fibroids?
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well-circumscribed, non-encapuslated myometrium confrims diagnosis of fibroids (develops in myometrium)
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Between Vaginal bleeding, HTN, type 2 DM and hyperthyroidism, which is a contraindication to treatment of menopausal symptoms w/ hormone therapy.
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Vaginal bleeding. concern for endometrial cancer. Get an endometrial bx and pelvic ultrasound w/ strip <4mm before HRT.
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47yo G2P2 c/o amenorrhea x 3mo. No menopausal sx. hCG and TSH WNL. Dx?
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perimenopause. Avg age 51.3y. At age extremes, irregular menses is normal.
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optimal daily calcium intake for a post-menopausal women?
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1200-1500mg. absorption decreases w/ age because of a decrease in active Vit D. A positive calcium balance is necessary to prevent osteoporosis.
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In a post-menopausal woman, what risk factors put her at increased risk for developing osteoporsis?
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hx of facture, low body weight, smoking, alcohol consumption lack of adequate vit D and calcium intake.
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58 yo G3P1 postmenopausal w/ Hx of distal radius (colles) fracture, +TOB, otherwise normal exam, gyn screening completed. Next step in management
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get DEXA and begin treatment of bisphosphonates (regardless of T score, since she has a risk factors)
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Most effective treatment of severe menopausal symtpoms.
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HRT
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ACOG guidelines for HRT.
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smallest effective dose for shortest time period.
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T/F: HRT is recommended as prophylaxis of CVD.
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False, per WHI, increased risk of breast cancer, MI, CVD and TE events.
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What is an anatomical contraindication of estrogen-only therapy for menopausal symptoms?
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intact uterus. At risk for endometrial cancer.
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what is the MC side effect that causes peri/post-menopausal to stop HRT?
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vaginal bleeding. most irregular bleeding occurs in first 6 mo. Its disturbing.
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what is the most effect treatment for hot flashes in a women whose PSHx includes hysterectomy.
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estrogen therapy. combined therapy if she has a uterus
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HRT has what effect on lipid/cholesterol profile.
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increases HDL and decreases LDL. estrogen increases TG and increases LDL catabolism. HRT block hepatic lipase activity and prevent conversion of HDL2 to HDL3, which increases HDL!
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what is the circulating estradiol level in a postmenopausal women?
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10-20 pg/ml
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What is the most likely source of circulating estrogens in a 54 yo G4P4 postmenopausal women in good health who has never experienced menopausal symptoms.
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aromatization of circulating androgens (conversion of androstenedione and testosterone into estrone)
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27 yo G0 c/o not getting pregnant in last 3 mo. She and her husband healthy. Next step?
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reassurance and observation. only been trying for 3 mo. After 12 mo, healthy couples have 90% conception rate.
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define primary infertility
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inability to conceive after 1 year w/o contraception.
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Most likely diagnostic test for infertility in 27 yo G0 healthy woman w/ PMHx of "pelvic infection"
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Hysterosalpingogram. hx of tubal disease (PID) can cause adhesion and obstruction.
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what are the limitations of a hysteroscopy v HSG?
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hysteroscopy will only give info on uterine cavity and not tubes.
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In a woman w/ suspected PCOS, what test will most likely identify PCOS as a cause of infertility?
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testosterone levels. PCOS - irregular cycles, habitus, hirsutism. testosterone should be slightly elevated and confirm diagnosis. A combined LH/FSH test would help.
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In a woman diagnosed w/ PCOS. what test would help to see if she is ovulating?
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progesterone levels (evidence of corpus luteum)
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In addition to weight loss and starting metformin, what is the most appropriate treatment for PCOS infertility?
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ovulation induction agents (clomiphene citrate - which inhibits estrogen receptor in hypothalamus --> blocking negative feedback --> increasing GnRH --> LH and FSH)
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37 yo G2P1 c/o infertility x 1y. good health except for depression treated w/ imipramine. PrL is elevated. Next step in management?
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wean off imipramine. hyperprolactinemia 2/2 to imipramine. Premature to begin bromocriptine or obtain an MRI w/o doing this first.
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27 yo G0 c/o of infertility. irregular menses q2-3months w/ spotting. no meds. exam normal. labs: elevated TSH, low T4, increased PrL. Next step in management?
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start synthroid for hypothyroidism. hypothyroidism predisposes patients for hyperprolactinemia (etiology unknown).
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23 yo marathon runner c/o amenorrhea x 2y. irregular for 1 year prior, regular before that. No hx of Pelvic infections. tall and skinny. exam and labs normal. next step?
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get estrogen levels. most likely excercise-induced hypothalamic amenorrhea, characterized by normal FSH and low estrogen. best treatment is weight gain, increased caloric intake and decreasing excercise.
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45 yo G3P3 c/o infertility x 2 y. previously on IUD. Kids > 10yo. Normal cycles, good health, normal exam. Next step?
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clomiphene challenge test - given days 5-9 of cycle and checking FSH on days 3 and 10 can determine ovarian reserve (given her age).
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What test should you get prior to beginning ovarian stimulation or IVF in woman > 40yo.
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clomiphene challenge test to gauge ovarian reserve.
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When is semen analysis not appropriate as an initial test in completely healthy female with a normal exam?
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when she has previous conceived with that person previously.
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A 28 yo G0 airline pilot wants to conceive. she travels a lot but wants to know when is it best to have itnercourse during cycle to maximize her changes of pregnancy. advice?
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use ovulation predictor kits and bone after it turns positive. Since sperm can live up to 3 days, sex days 11-17 have a good chance of resulting in pregnancy as egg only viable 24h. in women w/ variable cycles, predictor kits work well.
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in a couple w/ primary infertility and no hx of children together. If completely normal exam and labs in female, what is next step?
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semen analysis. male factor plays a role in ~35% of cases. If this is normal get a HSG.
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Define diagnosis of Premenstrual dysphoric disorder (PMDD).
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psychiatric disorder, describing severe form of premenstrual syndrome that include 5 of 11 symptoms, functional impairment and prospective charting of symptoms. All three areas need to be represented for diagnosis. Cyclic occurrence of a minimum symtpoms and interference of social functioning.
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What is the initial treatment for premenstrual syndrome (PMS)?
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excercise and Vitamins A, E and B6 (deficiency associated w/ increase in PMS).
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42 yo G2P3 c/o bloating, mood swings and irritability the week prior to menses. In addition to complete physical exam, which diagnostic tool would allow to accurately determine diagnosis?
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prospective symptom calendar. it will clarify if there is a cyclic or constant nature of symptoms.
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22 yo G0 returns for f/u of mood swings and difficulty concentrating week prior to menses x 12 mo. PMHx and PE nromal. appropriate treatment option?
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mild symptoms usually suppressed by OCPs. diet excercise and vitamins.
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what disease can mimic PMS? What is a good way to distinguish the two?
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hypothyroidism (bloating, weight gain, fatigue). Get a prospective symptom calendar.
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Why isn't a hysterectomy a recommended treatment for severe PMS?
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it would only resolve the menstrual bleeding component. hormonal shifts are controlled by hypothalamic-pituitary-ovarian axis.
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T/F: In a woman who has complained of mood swings and fatigue in the week prior to menstrual period should still be recommended to have a symptom diary for 2 months prior to therapy?
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true. before beginning pharmacologic therapy, make sure symptom-free during follicular phase.
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37 yo G1P1 diagnosed w/ PMS has only had minor relief w/ diet and exercise. Next step?
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SSRI (floxetine, setraline, paroxetine) increase amt of serotonin in brain and effective in alleviating PMS and PMDD symptoms. Regiment qDay or for 10 days during luteal phase.
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How does regular exercise help PMS symptoms (mood and bloating)?
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increases circulating endorphins int he brain whic are "feel good" hormones and act similar to serotonin.
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Is PMS inheritable?
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yes. FHx, Vit B6 def, calcium def, mag def.
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T/F: previous anxiety, depression and other mental health problems are significant risk factors for PMDD
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true.
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T/F: PMS is associated w/ obesity and IDDM
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true.
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