Chapter 15: Gynecology
What is the treatment plan for *Urge Incontinence/Overactive Bladder* (Detrusor Instability); in order of application of these treatments?
1. *Behavior Modification* (limiting fluid intake; avoiding caffeinated or alcoholic beverages) 2. *Bladder training* 3. *Medical therapy* = (*Anticholinergic; Oxybutynin (Ditropan XL, Oxytrol)*) 4. *SURGICAL Therapy* = *sacral neurostimulators* vs. *intravesical Botox injections*
What is the treatment for *Gestational Trophoblastic Disease*?
1. *D & C* w/ PRE-operative prep for hemorrhage w/ *two large-bore IVs, crossmatch for blood & uterotonic medications* available. POSTSURGICAL Management: > *Careful f/u Beta-hCGs levels* after D&C for possible development of *GTN*. q wkly until (-) and then monthly for 6 months. > *CONTRACEPTION plan*, this is ESSENTIAL during time of serum beta-hCG monitoring - NO exceptions! > Subsequent development of GEN is treated with *chemotherapy or hysterectomy*
What are the *'Ovarian' Phases* of the Menstrual Cycle?
1. *FOLLICULAR Phase* -- Release of *FSH & LH* from the Pituitary gland stimulates the overy & results in *Preantral follicular recruitment w/n the ovary* & eventually development of a *DOMINANT follicle* for OVULATION. 2. *LUTEAL Phase* --- About *32 hrs* after the start of the *LH surge* = *Ovulation occurs* which releases the Ovum (egg) & results in *formation of corpus luteum* from the residual follicle.
What should be done for tx in the setting of *ACUTE, profuse uterine bleeding? In order of how you would administer these.
1. *HIGH-dose Oral PROGESTERONE* or *HIGH-dose Combined OCPs* 2. *HIGH-dose IV Estrogen* 3. *Dilation & Curettage* (D&C) 4. *Uterine artery embolization* 5. *Uterine balloon tamponade*
What is the treatment plan for *Stress Incontinence* in order of application of these treatments?
1. *Pelvic Floor Strengthening Exercises* (Kegel Exercises) 2. *Weight Loss* 3. *Biofeedback* 4. *Pessaries* 5. *SURGERY* (Suburethral sling) ALL are used to restore bladder neck support.
What are the common initial steps for diagnosis of a patient's *infertility*?
1. *SEMEN Analysis* this is done first as a rule out of male factors. 2. Assessment of *ovulation status* w/ *home ovulation predictor kits* or a measurement of basal body temp. -*serum testing of androgens* -*FSH/LH* -*TSH* -*Prolactin* (important to r/o endocrine dysfunction) 3. Perform *PE, pelvic U/S & hysterosalpingography* to r/o uterin anatomical abnormalities & assess tubal patency.
what is true of the treatment of a *Fibroadenoma*?
30% will RESOLVE Spontaneously. Removal is NOT necessary. *Surgical excision* (both diagnostic & curative) *Biopsy* in HIGH-risk patients
What is the definition of *PRIMARY Amenorrhea*?
= *absence of menses* by *age 15* OR *absence of menses w/n 5 yrs of breast development*
What is the differential diagnosis for *PRIMARY Amenorrhea*?
= *absence of menses* by *age 15* OR *absence of menses w/n 5 yrs of breast development* DDx: --*Pregnancy* (ALWAYS rule this out) --*Gonadal failure* (Turner syndrome, sex chromosome mosaicism) --*Hypothalamic failure* (gonadotropin-releasing hormone [GnRH] deficiency, Kallmann syndrome, CNS neoplasm) --*Pituitary failure* (prepubertal HYPOthyroidism, early mumps infection) --*Androgen Resistance* (46 XY) --*Congenital Adrenal HYPERplasia* disorders --*ANatomic anomaly* (congenital absence of the uterus or transvers vaginal septum)
What is the most common cause of *vaginal discharge* in *PEDIATRIC Patients*?
= *retained Foreign Body* and/or *sexual abuse* Keep this as a consideration in any child w/ vulvovaginitis.
What would be a first-line treatment for the management of *HEAVY or irregular menses*?
> *NSAIDs* > *Combined OCPs* (pills, patch, vaginal ring) > *Medroxyprogesterone acetate Injections* (DEPO) > *Progestin-secreting IUDs* > Oral *tranexamic acid*
What are ALL of the common *BENIGN Breast Diseases*?
> Fibrocystic changes > Fibroadenoma > Intraductal papilloma > Mastitis > Abscess > Fat necrosis
What would some other follow up exams be to look inside the Uterus and evaluate the endometrium in a case where nothing is seen on labs or ultrasound?
>> *ENDOMETRIAL Biopsy* for women > or = to 45 yrs or if they have increased risk factors for endometrial hyperplasia. >> *Hysteroscopy* (for DIRECT visualization of the endometrial cavity)
What are the different categories of *Gestational Trophoblastic Disease*?
>> *Hydatidiform Mole* (COMPLETE or PARTIAL) >> *Gestational Trophoblastic Neoplasia* (GTN)
What are the *'Endometrial' Phases* of the Menstrual Cycle?
>> *PROLIFERATIVE Phase* (which occurs at the same time as the Follicular phase of the ovary) *Estradiol* which is produced by the ovarian follicles & induces frowth & proliferation of the Endometrium. >> *SECRETORY Phase* (which occurs at the same time as the Luteal phase of the ovary) *Corpus Luteum* secretes *progesterone* (and also estrogen, estrone) to maintain for implantation. If implantation does NOT occur then involution of the corpus luteum then abrupt drop in progesterone/estrogen will result in shedding of the endometrium.
What are the ABSOLUTE CONTRAINDICATIONS for *hormone therapy* in Menopause?
ABSOLUTE Contraindications: --*undiagnosed vaginal bleeding* --*active liver disease* --*recent MI* (myocardial infarction) --*recent/active vascular thrombosis* --Hx of *endometrial or Breast CA*
ALWAYS evaluate what on a patient with a *breast lump*?
ALWAYS evaluate *lymph nodes*
*What is the Hs/PE for an Ectopic Pregancy?
AMenorrhea LOWER abdominal pain Nausea/vomiting Abnormal vaginal bleeding May have abdominal tenderness to palpation, adnexal mass or fullness. *Ruptured ectopic* may present w/ UNSTABLE vital signs, diffuse abdominal pain, rebound tenderness, guarding & SHOCK.
ABNORMAL Uterine Bleeding is characterized by what sort of alterations in *menstrual bleeding*?
AUB is considered any *abnormalities* in the *frequency, duration, volume &/or timing* of *menstrual bleeding*. Think "PALM COEIN".
What's true of the administration of *Injectable hormonal contraceptions*?
Administered *INTRAMUSCULARLY q 3 months*
What common risk factors are associated with the development of *Stress Incontinence*?
Associated Risk Factors: *Age* *Genetics* *Childbirth* *Obesity* *COPD* *Menopause*
What are the side effects assocaited with *Injectable hormonal contraceptives* (Depo-Provera)?
Associated with: *irregular spotting* *weight gain* *hair thinning* transient *decreased bone mineral density*
What is the average age-of-onset for Menopause?
Average age of onset is *51* for Menopause.
What can be used to make the diagnosis of *Menopause*?
CLinically-- this *just requires 1 yr w/o menses* w/ no other known cause. Labs: *Increased FSH* (> 30 IU/L) is SUGGESTIVE
What are the karyotype, fetal parts, beta-hCG, theca lutein cysts & malignancy features associated with *COMPLETE Mole*?
COMPLETE Moles = Most commonly, *46, XX or 46, XY* Fetal parts are ABSENT. *beta-hCG > 100,000* *Theca lutein cysts 15-25%* *HIGH risk of Malignancy @ 6-32%*
WHat are the CONTRAINDICATIONS for *combined OCPs*?
CONTRAINDICATIONS: *pregnancy* *Migraines w/ AURA* Previous or active *thromboembolic disease* *Smoking* in patients *> 35 yrs* *Undiagnosed genital bleeding* *Estrogen-dependent neoplasms* Hepatocellular carcinoma Acute Liver dysfunction POORLY controlled hypertension
How long after unprotected intercourse can you use a *Copper IUD* for Emergency Contraception?
Can be placed *w/n 5 days*. The earlier the better.
What is the common Hx of a patient with *Urge Incontinence/Overactive Bladder* (Detrusor Instability)?
Combined symptoms of: *Urge Incontinence* = which is a loss of utine *w/ urge to void* *Overactive bladder syndrome* = which is *urgency to void* w/ or w/o urge incontinence and often w/ *nocturia & frequency*.
What is the common presentation for women with *Menopause?
Common starting symptoms are: *menstrual irregularities* for > 1 yr *hot flashes* *night sweats* *sleep disturbances* *mood changes* *decreased libido* *vaginal dryness*
What should you consider about the diagnosis if the patient presents with *dyspareunia*, *pelvic pain & Dyschezia* (difficulty passing stool)?
Consider *Endometriosis*
If there is *AUB* in an older woman, what other labs tests should you consider?
Consider a *FSH/LH* An increase in BOTH of these hormones is suggestive of menopause, as the ovaries can no longer respond to hormonal signals by producing estrogen & progesterone.
What is the mechanism of action for a *Copper IUD*?
Copper IUD: causes a *sterile inflammatory response* that *prevents pregnancy implantation*
How would you treat the *diabetes/hyperglycemia* in a patient with *PCOS*?
Counsel about the following: *Weight loss* *Hypoglycemic agents* primarily METFORMIN
What is the DIFFERENTIAL diagnosis for *Ectopic Pregnancy*?
DDx: *Spontaneous abortion* (SAB) *molar pregnancy* *ruptured/hemorrhagic corpus luteum cyst* *PID* *ovarian torsion* NON-GYN DDx: *Appendicitis* *Pyelonephritis* *Diverticulitis* *Regional Ileitis* *Ulcerative colitis*
What is the definition of *Dysmenorrhea*? What are the subgroups of this?
DYSMENORRHEA - *PAIN* w/ menstrual periods that *requires medication* & *prevents normal activity*. - Primary vs. Secondary Dysmenorrhea Primary = NO detectable pelvic pathology, likely uterine prostaglandins Secondary = Pelvic pathology (endometriosis, adenomyosis or leiomyomas.
What is the definition of *Infertility*?
Defined by the following: *Inability to conceive AFTER 1 yr of unprotected intercourse* OR *after 6 months if > 35 yrs of age*
What do you need to consider when determining the treatment for a patient with *Endometriosis*?
Depends on the patient's Sxs, age, desire for future fertility & disease stage. --*extent* of *pelvic disease* does NOT correlate with the patient's symptoms.
*Urinary retention* w/ OVERFLOW can be a cause of Urinary incontinence & is diagnosed by?
Diagnosed by *ELEVATED POST-void Residual*
What type of *nipple discharge* features would be most concerning to you?
Discharge should raise concerns if it is: *bloody* *brown* *black* *unilateral* *persistent* Appears spontaneously *w/o manipulation* associated *w/ systemic signs*
What is the most common location for *Ectopic pregnancy*?
ECTOPIC Pregnancy is ANY pregnancy that is implanted OUTSIDE of the uterine cavity. Most common location = *Fallopian Tube (95%)*
What are the forms of *male & female sterilization* available?
EITHER: *fallopian tube* interruption in *women* (*Tubal ligation* or permanently implanted birth control device) or *Ligation of vas deferens* in *men*
What are the common locations for *Endometriosis*?
EMDOMETRIOSIS = growth of *endometrial tissue* in locations other than the uterus. Most common location: *Ovaries* (endometriomas or "chocolate cysts") *cul-de-sac* *uterosacral ligament*
How should emergency contraception be used?
EMERGENCY Contraception: Should be taken *immediately after unprotected intercourse*; can be taken *up to 5 days afterward*, but with *decreasing efficacy*.
What will you do for treat of *Infertility*?
ENTIRELY dependent on the cause (as there are many, and could be female or male in origin)
What are the exam and discharge features of *Bacterial vaginosis*?
EXAM - can be unremarkable except for discharge. Discharge = *Grayish or WHITE* w/ *a fishy odor*.
What are the exam and discharge features of *Yeast (Candida)*?
EXAM = *Erythema & inflammation of vulva* & *vagina* Discharge = *White, thick, curdlike*
What are the exam and discharge features of *Trichomonas vaginalis*?
EXAM = *Vagina & cervix* may be *swollen & red*, "strawberry cervix". Discharge = *Yellow-green, FROTHY, malodorous*
What are important parts of the evaluation for a newly found *breast lump*?
Evaluation should include: *assessment of general appearance* of *breast* --*inverted nipple*? --*change in size*? --*change in symmetry*? --*any skin changes*? ALWAYS include *eval of Lymph nodes* Ask about presence of lump: --if *related to menses* --if *spontaneously discovered & not gone away*
What is true of the presence of *Fibroadenomas*?
Even though these resolve spontaneously, (30%) they can be surgically excised. But keep in mind that *RECURRENCE is COMMON*
What might you see on physical exam of a patient who is starting *Menopause*?
Exam may reveal: *vaginal dryness* *decreased breast size* *genital tract atrophy*
When might you do *expectant management* for a patient with an ectopic pregnancy?
Expectant management for stable & COMPLIANT patients w/ *decreasing beta-hCG levels* or a *beta-hCG < 200 mIU/mL*, ONLY if the risk of rupture is LOW.
What is the common presentation for *Fat Necrosis*?
FAT NECROSIS -- *Firm, tender & ill-defined* w/ *surrounding erythema* -- related to *trauma or ischemia*
What are some of the common *Female* causes of Infertility?
FEMALE causes of INFERTILITY: *Ovulatory Dysfunction*: ovarian failure, prolactinoma *Uterine/tubal factors*: tubal occlusions secondary to endometriosus or PID, myomas that distort the endometrium or fallopian tube, congenital genital tract abnormalities *Endocrine Dysfunction*: THYROID/ADRENAL disease, PCOS "Unexplained infertility" other rare causes
*Fibrocystic changes* of the breast will have what kind of presentation?
FIBROCYSTIC Changes: Mild to moderate change in the breasts +/- lumps *premenstrually* *multifocal, bilateral nodularity*
What are the common characteristics of a *Fibroadenoma*?
Fibroadenomas are: *small, firm, unilateral NON-tender masses* FREELY-movable SLOW-growing
Why is the *Copper IUD* a valuable contraception?
HIGH efficacy LARC *NON-Hormonal* (good choice for women who have contraindications to hormone treatment)
What are the two types of *IUDs* which are approved for use in the US? What is the efficacy of these devices?
HIGHLY effective, with *> 99% efficacy* 1. *Levonorgestrel IUD*: progesterone-only IUD 2. *Copper IUD*
Diagnosis for an *Ectopic Pregnancy* should be made with what?
HIGHLY suspect Ectopic pregnancy in a patient w/: *Low abdominal/pelvic pain* *+ uringe or serum beta-hCG* NO intrauterine pregnancy on U/S. MEASURE serum *beta-hCG*. *U/S findings* which are concerning for ectopic include *adnexal mass* &/or complex *free fluid* & NO intrauterine pregnancy. DEFINITIVE diagnosis -- made by *laparoscopy, laparotomy or U/S visualization of pregnancy* outside of uterus.
What should be the 'key' when dosing hormones for *Menopausal symptoms?
Hormone Therapy should be prescribed for: *Shortest duration @ lowest possible dose* to treat the symptoms. Prolonged use of unopposed estrogen with increase the risk of Endometrial hyperplasia/carcinoma.
What is the hx/PE for a patient with *Pelvic Inflammatory Disease* (PID)?
Hx: *Abdominal pain* *vaginal discharge* +/- fevers Malaise PE: *tachycardia, fever, diffuse abdominal tenderness* *CERVICAL MOTION TENDERNESS* ("chandelier sign")
What are the typical complaints for a woman who has *Polycystic Ovarian Syndrome (PCOS)*?
Hx: *Hx of infrequent or irregular menstrual bleeding* *unwanted hair growth* *acne* *evidence of insulin resistance* (acanthosis nigricans) *weight gain* PE: +/- palpably enlarged ovaries
What is the Hx & PE for *Vulvovaginitis*?
Hx: *INCREASED vaginal discharge* *change in discharge odor* *vulvovaginal pruritus* & vaginal spotting PE: Complete exam of vulva, vagina & cervix. Look for *vulvar edema, erythema & discharge*.
What are the history components, PE & labs which should be performed when working up a patient's *Abnormal Uterine Bleeding*?
Hx: Take a thorough menstrual history to determine the *onset, quantity, & timing* of abnormal bleeding. PE: *Bimanual exam* fo assess the *size, shape & contour* of the uterus & ovaries. *Speculum exam* to assess for any *vaginal or cervical lesions* (eg. cervical polyps) LABS: *Beta-hCG, CBC, TSH & Prolactin* *Pelvic U/S* to determine is there are any structural abnormalities.
How Does the Age of the Patient *Affect the Workup of a New, Palpable Breast Mass*?
IN YOUNG WOMEN ...... it is reasonable to start w/ a *breast U/S* b/f going to mammography. In OLDER WOMEN ....... start with *mammography*
POST-menopausal women are at increased risk for what do condition?
INCREASED risk for: *Osteoporosis* *Heart disease*
What is the *INPATIENT management* for *PID*?
INPATIENT Management: 1. *IV Antibiotic agents* *Cefoxitin + doxycycline* *Clindamycin + gentamicin* of *Amp-sulbactam + doxycycline* 2. Transition to *PO doxycycline* 24 hrs AFTER clinical improvement. 3. Tx duration is *14 days*, if patient does NOT improve, consider IMAGING (U/S) to evaluate for a tubo-ovarian abscess that requires drainage.
Physical exam for a patient with suspected *Intraductal papilloma* . . . ?
INTRADUCTAL PAPILLOMA --patient presents with *clear, bloody or discolored fluid* from a single duct opening (*unilateral nipple*) PE: *milking* of the *breast* shows drainage from *ONE duct opening*
What is the treatment for an *Ectopic Pregnancy* in a STABLE patient?
If patient is STABLE: *Serum beta-hCG* - if this is BELOW discriminatory zone (*<1500* & U/S does NOT show *intrauterine pregnancy* then you will need to *repeat beta-hCG in 48 hrs* then repeat U/S in a week. *Confirmed Ectopic Pregnancy*: -Medical management (*methotrexate*) -Surgical intervention (*lalparoscopy*)
What is the treatment for an *Ectopic Pregnancy* in an hemodynamically UNSTABLE Patient?
If patient is hemodynamically UNSTABLE: *Immediate Surgery* will be required!!! At least a *salpingostomy* or *salpingectomy*.
Ectopic pregnancy should have the patient *typed & screened*, why?
If the mother is *Rh (-)* then they need to be given *RhoGAM*
If there is *AUB* in an adolescent, what other tests are you likely to order?
In ADOLESCENTs include: *CMP* (evaluates renal or hepatic causes of coagulopathy) *Coagulation Studies* *von Willebrand studies*
What may make the *transdermal patch* a less effective form of contraception?
In an *OBESE patient* (*weight > 90kg, 198lbs)*
When are a woman's menstrual cycle most likely to be IRREGULAR?
In the years IMMEDIATELY *following Menarche* & those *preceding Menopause*.
When are you likely to prescribe *Progesterone-only Contraceptives*?
Indicated in WOMAN for whom - *Combined OCPs are Contraindicated* Often used for *breastfeeding mothers* who have *lactational amenorrhea* Keep in mind these are LESS EFFECTIVE than combined agents.
What are some base labs that you will order on a patient that presents with *Amenorrhea*? (regardless of Primary vs. Secondary)
Labs for BOTH cases would be: *beta-hCG* *Prolactin* *TSH* w/ *reflex free T4* *LH* *FSH*
What labs & imaging tests would you order to work up a patient for suspected *Gestational Trophoblastic Disease*?
Labs: *CBC* *Type & screen* *SMP* *beta-hCG* (this will be markedly elevated for dates) Imaging: *Pelvic U/S* ("snowstorm" appearance of molar clusters on U/S) *CXR* (VERY IMPORTANT for ruling out metastases)
What else should be ordered for labs AFTER the diagnosis of PCOS has been made? (via Rotterdam criteria)
Labs: *Glucose tolerance test* *Lipid panel* B/c these patients are at increased risk for cardiac disease and diabetes.
What is length of placement for the *Levonorgestrel IUD*?
Lasts for *5 years*
How does the *Levonorgestrel IUD* work?
Levonorgestrel IUD works as a *progesterone-only IUD* which causes: --*thickening of cervical mucus* --*thinning of endometrium* --*decreased peristalsis of fallopian tubes*
How would you treat the *Infertility* in a patient with *PCOS*?
List of tx recommendations are as follows: 1. *Diet & exercise* (often infertility may improve w/ this alone) 2. Induce ovulation with *Clomiphene* or *Metformin*
What are some of the common *Male* causes of Infertility?
MALE causes of INFERTILITY: *Congenital Disorders*: include Klinefelter syndrome, androgen insensitivity, 5alpha-reductase deficiency, Kallmann syndrome, & Prader-Willi Syndrome. *Systemic disorders*: Obesity, chronic illness *Disorder of Sperm production & transport*: Ejaculatory dysfunction, decreased sperm count, abnormal morphology or decreased motility. "Unexplained infertility" other rare causes
Common presentation for *mastitis* would include what?
MASTITIS - mainly in *breastfeeding women* - presents as a *hard, red, tender, swollen area of breast* which is accompanied by *fever, myalgias & general malaise*
What is the differentiation of *Mastitis vs. Breast Abscess*?
MASTITIS - mainly in *breastfeeding women* - presents as a *hard, red, tender, swollen area of breast* which is accompanied by *fever, myalgias & general malaise* ABSCESS - usually *develops if Mastitis is INADEQUATELY treated* - exam reveals a *fluctuant mass* accompanied by *systemic symptoms* similar to those of mastitis
What is the typical dose of *Methotrexate* for an *ectopic pregnancy*?
METHOTREXATE *50 mg/m2 IM*
What is the common mechanism & etiology behind *Mixed Incontinence*?
MIXED Both *poor support /poor function of the urethral sphincter* & *involuntary detrusor m.contractions*
What is the common mechanism & etiology behind *Urge Incontinence/Overactive Bladder* (Detrusor Instability)?
Mech. is from *involuntary DETRUSOR m. contractions* These contractions can occur from the following etiologies: *Idiopathic* *Neurologic* (*Alzheimer disease, diabetes, MS*)
What is the definition of *Menopause*?
Menopause = *cessation of menstruation for 12 CONSECUTIVE months* Average *age-of-onset* is *51*.
*Fibrocystic changes* in the breast are most common in women of what age group?
Most common in women *20-50 yrs* of age.
What is the typical efficacy and use of *Subdermal Progesterone Implant*?
Most effective hormonal method. (99.9%) *implant approved for 3 yrs of use*
*Nipple discharge* is most commonly seen in women of what age group?
Most often seen in ages *20-40*
Is there a increased risk of carcinoma with *Mastitis* or *Breast abscess*?
NO
Is there an increased risk for carcinoma in a patient with *Fat necrosis*?
NO
What is the treatment for *Trichomonas vaginalis* vulvovaginitis in a non-pregnant & pregnant patient?
NON-pregnant: *Metronidazole 2 gm PO x 1-dose* *SAME as a pregnant patient* (avoid in 1st trimester)
What is the treatment for *Yeast (Candida)* vulvovaginitis in a non-pregnant & pregnant patient?
NON-pregnant: *Topical ANTI-fungal x 3-7 days* or *Oral Fluconazole x 1-dose* Pregnant: *ONLY topical ANTI-fungal x 7 days*
What is the treatment for *Bacterial Vaginosis* for non-pregnant & pregnant patients?
NON-pregnant: *Metronidazole 500 mg PO BID x 7 days* *SAME in pregnant pt.*
What is the normal length and duration of the *Menstrual Cycle*?
Normal length is *28 +/- 7 days* with *bleeding lasting 3-7 days*. First day of BLEEDING = *Day 1* of Cycle
What is the *OUTPATIENT treatment* for *PID*?
OUTPATIENT PID management: 1. *Single IM dose* + *14-day PO regimen* *IM Veftriaxone* + *PO Doxycycline* *IM Cefoxitin* + *PO probenecid* + *PO doxy* *IM cefotaxime* or *IM ceftizoxime* + *PO doxy*
What are the hormones are controlling the Endometrial changes during the Menstrual Cycle?
OVARIAN Hormones!! Proliferative Phase --*Estradiol* from the ovarian follicles will induce growth & proliferation of the endometrium. Secretory Phase --*Corpus Luteum* will secrete *Progesterone, Estrogen, Estrone* which will MAINTAIN the endometrium for implantation (until corpus incolutes and then there is an abrupt drop in those hormones)
What should the management of *Endometriosis* be, if the patient's main complaint is PAIN?
Objective will be to induve a state of ANOVULATION: 1. *NSAIDs* (first-line tx) 2. *Continuous OCPs* 3. *GnRH agonists* (to induce anovulation) 4. If medical management fails, consider *operative laparoscopy* to excise endometrial implants. 5. Definitive *Hysterectomy & BSO*
What would yo do diagnose a case of *PID*?
Often clinically, lower abdominal tenderness, adnexel tenderness or *cervical motion tenderness* in a secually active young woman is sufficient for Dx. Supportive findings; fever, *mucopurulent discharge*, *> 10 WBCs/low-power field* on gram stain or vaginal secretion. *+ STI testing* Get *vaginal cultures* which should be obtained to r/o *gonorrhea or chlamydia*
*Spermicidal gel* is a form of contraception, which is often used in combination with what other methods?
Often used in combination w/ *condoms* *diaphragm* BUT, when you use this ALONE, it is an unreliable form.
When does *Oculation* occur in terms of the *mentrual cycle*?
Ovulation occurs on *Day 10-14* (variable depending on length of the follicular phase)
What are the karyotype, fetal parts, beta-hCG, theca lutein cysts & malignancy features associated with *PARTIAL Moles*?
PARTIAL Moles = Most commonly, *69, XXX*, at times 69 XXY Usually *fetal parts PRESENT* *beta-hCG < 100,000* RARELY there is Theca Lutein cysts seen. Malignancy risk is *< 5%*
What is the definition of *Pelvic Inflammatory Disease* (PID)?
PID = infection of the *upper genital tract* that may involve *uterus, fallopian tuves &/or ovaries* w/ or w/o peritonitis.
What is true of the causative organism of *Pelvic Inflammatory Disease (PID)*?
PID is usually *POLYmicrobial*. Infection typically involves *aerobic & anaerobic organisms* from the LOWER genital tract. Patients with a lower genital infection of gonorrhea or chlamydia are at an INCREASED risk of developing PID.
What are INDICATIONS which would require *PID* to be treated on an *INPATIENT basis*?
PID should be treated INPATIENT if: *Pregnancy* *Noncompliance w/ meds* or follow-up *Inability to tolerate PO* *Tubo-ovarian ABSCESS*
*Premature menopause* occurs before what age? what is the cause?
PREMATURE Menopause occurs *before age 40*. Often due to *idiopathic Premature Ovarian Insufficiency*
What is the definition of *PRIMARY Dysmenorrhea*? What is the likely cause?
PRIMARY Dysmenorrhea = No clinically detectable pelvic pathology. Most likely due to *INCREASED uterine PROSTAGLANDIN production*.
What should you do for a diagnosis of *Stress Incontinence*?
Patient Hx + *Demonstrable leakage w/ stress* (cough) = + stress test
If Hx & exam findings do not clearly demonstrate simple stress urinary incontinence than what kind of screening should occur?
Patient should then have *screening NEUROLOGIC exam* to rule out neurologic causes as well as UROLOGIC evaluation.
What are the common presentations for *Gestational Trophoblastic Disease*? (GTN or Hydatidiform moles)
Patient will often present with Sxs: *first-trimester bleeding* *EXCESSIVE nausea/vomiting* consider, *preeclampsia or ecclampsia < 20 wks* or a *thyroid storm* PE: *uterine size > than dates*
How is a *cervical diaphragm* used for contraception?
Placed *intravaginally OVER cervix immediately BEFORE intercourse* and then *removed w/n 3 hrs afterward*.
What is the duration of placement for a *Copper IUD*?
Placement of these device lasts *10 years*
When is *Oral levonorgesterol (Plan B)* most effective?
Plan B is most effective when *used w/n 3 days*, but this can be used w/n 5 days.
What are the risk factors associated with *Pelvic Inflammatory Disease* (PID)?
RFs: *Age < 25* *Multiple secual partners8 *lack of condom/barrier use* hx of PID *STIs*
What are the risk factors for *Ectopic pregnancy*?
RFs: Hx of *prior ectopic pregnancy* *PID* *Tubal/pelvic surgery* *diethylstilbesterol exposure* in *utero*
*Menopause* is characterized by what systemic hormone levels?
RISES in *FSH* & *LH* (follicular-stimulating hormone & luteinizing hormone) LOW estrogen & progesterone
What should you do if there is a patient with confirmed *endometriosis* and *tubal occlusion* has occurred causing infertility?
Refer to a *REPRODUCTIVE ENDOCRINOLOGIST* THe whole case will likely be managed via *operative laparoscopy* or *in-vitro fertilization*.
How does a patient use a *vaginal ring* for contraception?
Ring is kept in place for *3 weeks* followed by a *1 wk holiday* during which menses occur. Contains ESTROGEN & must be used in appropriate candidates. *Similar indications*/CONTRAINDICATIONS & *Side effects* profile as combined OCPs.
What is the risk of *carcinoma* in a patient with a confirmed *intraductal papilloma*?
Risk is *2x HIGHER* than patients in a control group.
What is the risk of carcinoma in patients with *Fibroadenomas*?
Risk is *2x higher* than control patients.
What is the definition of *SECONDARY Amenorrhea*?
SECONDARY Amenorrhea: *Absence of menses* for *3 cycles* (if previously regular) or *6 months (if previously irregular)*
What is the typical differential diagnosis for *SECONDARY Amenorrhea*?
SECONDARY Amenorrhea: *Absence of menses* for *3 cycles* (if previously regular) or *6 months (if previously irregular)* DDx: --*Pregnancy* --*Hypothyroidism* --*Hyperandrogenism* (PCOS) --*Hyperprolactinemia* --*Anorexia nervosa* --STRESS --Strenuous Exercise --*Uterine Outflow Defect* (intrauterine adhesions) --*Premature Ovarian Insufficiency* ('early' menopause)
What is the definition of *SECONDARY Dysmenorrhea*? What are the likely causes?
SECONDARY Dysmenorrhea = Menstrual PAIN is due to *pelvic pathology*. Most commonly this is from *endometriosis, adenomyosis, or Leiomyomas*.
What is the common mechanism & etiology behind *Stress Incontinence*?
STRESS Incontinence: Caused by *POOR support or poor function* of the *urethral sphincter* Likely the loss of support is from *decreased elasticity of vagina*, *loss of muscle mass* of vagina & *urethral hypermobility*.
What is the common Hx of a patient with *Stress Incontinence*?
STRESS Incontinence: *loss of urine* w/ *increased intra-abdominal pressure* --*running* --*coughing* --*laughing* --*sneezing*
Is *Amenorrhea* a symptom or a diagnosis?
SYMPTOM -- you need to get at the cause of the amenorrhea, which is the diagnosis (ex. PCOS, pregnancy, Turner syndrome, GnRH deficiency, anorexia nervosa, etc.)
What are some of the potential side effects associated with *Levonorgestrel IUD*?
Side effects: *Perforation w/ placement* *Irregular menstrual bleeding* (30-70% of women experience amenorrhea) *Pelvic cramping* *Vaginal Discharge*
What are the common side effects associated with *Subdermal Progesterone Implant* (Nexplanon)?
Side effects: *irregular spotting* *local irritation @ insertion sie* (erythema, swelling)
How would you treat the *Hirsutism* in a patient with *PCOS*?
Start Tx w/: 1. *Combined OCPs* to suppress ovarian steroidogenesis & protect uterine lining from unopposed estrogen secretion. 2. May consider *Spironolactone*.
What is the flow chart of patient's for *SECONDARY Amenorrhea*?
Start with *Progestin Challenge* (after you have fuled out pregnancy) and see if there is *withdrawal bleeding*. If there is withdrawal bleeding then look into the LH levels (for possible PCOS or idiopathic anovulation) If there is NO withdrawal bleeding then check FSH. is FSH is low then try cyclic estrogen/progesterone test.
What is flow chart of patient's for *PRIMARY Amenorrhea*?
Start with presence of *secondary sex characteristics* and then determine the *presence or absence of UTERUS*. Then look at *FSH/LH* = low means this is issue with pituitary and HIGH means this is an issue with gonads
Iff a patient with an *IUD* has a *(+) pregnancy test*, what should you suspect?
Suspect an *ECTOPIC Pregnancy* -- remember, that the IUD itself does NOT increase the risk of Ectopic pregnancy.
What are the symptomatic patterns often seen in patients with *Endometriosis*?
Sxs are often associated w/ *PRE-menstrual pelvic pain* due to the *stimulation of endometrial tissue* from *estrogen & progesterone* during the menstrual cycle. Sxs: "Cyclic" pelvic pain *dysmenorrhea* *dyspareunia* *infertility*
What is the *beta-hCG monitoring* that is required following diagnosis & D&C of a *Gestational Trophoblastic Disease*?
THis monitoring is to check for any development of *GTN* (Gestational trophoblastic neoplasia). ---*Check weekly* until *beta-hCG (-)* ---*Monthly for 6 months* after neg test result. Pt. must be a *CONTRACEPTIVE* during this time of monitoring.
Are *fibrocystic changes* in the brease associated with breast carcinomas?
The ONLY time that these patients are at increased risk for breast CA is when - *cellular atypia is present* But keep in mind that breast CA must be excluded in HIGH-risk groups. Suspicious changes or + family Hx.
What is another name for the *Fertility awareness method* of BC?
*"rhythm method"* --relies on avoidance of intercourse during the ovulatory period.
*Infertility* affects what percentage of couples?
*10-15%* of couples
What percentage of women will experience *Amenorrhea* following placement of *Levonorgestrel IUD*?
*30-70%* of women
At what point should *Fetal heart motion* be detected in an embryo?
*5-6 wks GA*
What percentage of cases of gestational trophoblastic disease are *Hydatidiform moles*?
*80%* of these cases are Hydatidiform Moles.
the *pH* of vaginal fluid is *ELEVATED at > 7* . . . . . . What is most likely (w/o any other specifics)?
*Bacterial vaginosis* (Gardnerella vaginalis) *Trichomonas vaginalis* (protozoal infection)
What can be used to differentiate a *Fibroadenoma* from a cyst?
*Breast ULTRASOUND*
Which type of Hydatidiform mole will potentially have *theca lutein cysts* and have a MUCH higher risk of *malignancy* (6-32%)?
*COMPLETE Mole* Theca Lutein Cysts (15-25%) Malignancy 6-32%
What is the ONLY form of contraception which provides protection against *STIs*?
*CONDOMS* (both male & female)
What are the standard treatments for *Osteoporosis*?
*Calcium + Vitamin D* *Calcitonin* *bisphosphonates* (Alendronate) *SERMs* (selective estrogen receptor modulators; raloxifene) *Denosumab*
How can *ovulation* be *INDUCED*, in cases of infertility?
*Clomiphene* *Letrozole* Use CAUTION with these medications, as they can lead to ovarian hyperstimulation & multiple gestations.
What are the two types of *OCPs*?
*Combined OCPs* (estrogen & progesterone) *Progesterone Only*
What are the NON-hormonal contraception options?
*Condoms* (male or female* *Cervical diaphragm* *Spermicidal gel* *Copper IUD* Fertility awareness method *Male or Female sterilization*
What is the Tx for *Mastitis*?
*Continued breastfeeding* *NSAIDs* *Abx* (w/ coverage for Staphylococcus, Streptococcus, E.coli)
What is the MOST effective form of *emergency contraception*?
*Copper IUD*
What are the long-term effects of *combined OCPs*?
*DECREASED ovarian & endometrial cancers* *decreased invidence of breast disease* (but NOT breast CA) *Decreased menstrual flow* *decreased acne* *decreased dysmenorrhea*
What is the 'gold standard' for diagnosing *Endometriosis*?
*DIRECT VISUALIZATION* during *Laparoscopy w/ biopsy* which will show endometrial glands.
What is the typical treatment for *Intraductal Papilloma*?
*DRAINAGE & SURGICAL exploration* of the Duct. NEED to exclude a malignant process.
What are the primary side effects associated with *Copper IUD*?
*Dysmenorrhea* *INCREASED menstrual bleeding*
What is one of the leading causes of *infertility*?
*Endometriosis* .. . . . . .another common cause is *PID*.
What is the MOST common tumor in women *< 25 yrs old*?
*FIBROADENOMA* -- this presents as a small, firm, unilateral, NON-tender mass that is freely-movable & SLOW-growing
What is the most common *benign Breast Disorder*?
*FIBROCYSTIC change*
*Day 1* of a woman's menstrual Cycle is what?
*FIRST DAY* of *Bleeding* or FIRST Day or her period.
What should you suspect if a patient with *PID* has *RUQ tenderness*?
*Fitz-Hugh-Curtis Syndrome* -- this RUQ tenderness could be from *perihepatic adhesions* which are associated with *peritonitis* resulting from the pelvic infection.
What are treatment options for *decreased libido* in Menopause?
*Flibanserin* ("female Viagra")
What is the symptomatic therapy for *Menopause*?
*HORMONE therapy* is the method for symptom management. --This is with *Estrogen* OR *combined Estrogen + Progesterone* which can be used for "short-term" relieg of the *vasomotor symptoms* (hot flashes & night sweats).
What would be ultimate management for heavy or irregular menses?
*HYSTERECTOMY* - this is if medical management is declined, contraindicated or fails.
What is the FINAL therapeutic option for the management of *Endometriosis*?
*Hysterectomy w/ bilateral salpingo-oophorectomy*
What should be done for *refractory cases* of infertility?
*In-vitro fertilization* -can be used or refer to other options for assisted reproductive technologies.
*Unilateral nipple discharge* is most commonly from what?
*Intraductal Papilloma* (rare & benign) This discharge is often sticky & clear to straw-colored.
Who will be candidates for *Surgical intervention* in the management of an *Ectopic Pregnancy*?
*Laparoscopy or Laparotomy* for *REMOVAL of ectopic pregnancy* This is indicated in the following cases: *Hemodynamically unstable pts* *NON-compliant patients* *Contraindication* to *MTX administration*
What should be performed for ANY new breast mass -- even if the patient has a recent (-) study?
*MAMMOGRAPHY* --keep in mind any 'older woman' who is already getting mammogram on a routine basis.
Who will be candidates for *medical management* of *Ectopic pregnancy*?
*METHOTREXATE* (*50 mg/m2 IM*) Can be used in the following cases: *NO fetal cardiac motion* *beta-hCG < 5000 mIU/mL* *gestational sac* diameter size *< 3.5 cm* Patient is RELIABLE to follow-up.
What are INDICATIONS which would allow *PID* to be treated on an Outpatient basis?
*Mild disease* w/o the inpatient indications.
What is the treatment for *Breast abscess*?
*NEEDLE ASPIRATION* or *SURGICAL DRAINAGE* + *Antibiotics* (still with coverage for Staphylococcus, Streptococcus, E.coli)
What is the treatment for *Fibrocystic changes* in the breast?
*OCPs*
Compare the different *Bisphosphonates* for treatment of Osteoporosis . . . . Compare Contraindications for each type.
*ORAL Bisphosphonates* = *Alendronate & Risendronate* --- *IV Bisphosphonates* -
What are some of the risk factors for *Endometrial hyperplasia* (which means there may be hyperplasia if < 45 yrs of age)?
*Obesity* *PCOS* (polycystic ovarian syndrome)
How do you make a defintive diagnosis for the cause of a patient's *vulvovaginitis*?
*Obtain SWABS* from the vagina to perform a *wet mount* & *cultures* for *GC/CT*.
What are the various options for *EMERGENCY Contraception*?
*Oral Levonorgestrel (Plan B)* *Oral Ulipristal acetate* Placement of *Copper IUD*
Which type of Hydatidiform mole will potentially have *fetal parts PRESENT*, and has a karyotype *69, XXX or 69, XXY*?
*PARTIAL mole* Beta-hCG will be < 100,000 Rarely are there Theca Lutein cysts Malignancy risk is LOW at < 5%
What is the application schedule for use of *Transdermal patch* for contraception?
*PATCH applied weekly* for *3wks* which is followed by 1-wk holiday during which menses occur. *Contains estrogen* & mUST be used in appropriate candidates. *Similar indications*/CONTRAINDICATIONS & *Side effects* profile as combined OCPs.
ANY woman with *abdominal pain* will need what?
*PREGNANCY test*
What is the most commonly diagnosed cause of *hyperandrogenism* in women?
*Polycystic Ovarian Syndrome* (PCOS) PCOS often affects adolescent women.
What are the HORMONAL contraceptives?
*Progesterone-only OCPS* *INjectable* (IM) *Subdermal Progesterone implant* *Transdermal patch* *Vaginal ring* *IUD* (levonorgestrol)
What should you do if there is a stable patient, with a *serum beta-hCG of 3000 mIU/mL* and the U/S does not show an intrauterine pregnancy?
*Repeat beta-hCG & U/S in 48 hrs* This is because there are cases in which *beta hCG of 3000 mIU/mL* will NOT show an intrauterine pregnancy -- like in the case of multiple gestations.
If there is *AUB*, and the initial U/S demonstrated a nonspecific *iintracavitary mass* . . . . what might you do prior to any biopsy to further differentiate this mass?
*SALINE infusion Sonohysterography* --- used to look for *uterine polyps* when quality of the mass is undetermined.
What testing is used to diagnose *Stress incontinence*?
*STANDING cough Stress Test*
What is the common Hx of a patient with *Mixed Incontinence*?
*Stress + Urge incontinence* presenting SIMULTANEOUSLY!
*Urinary Incontinence* is the involuntary loss of urine that negatively affects a patient's psychological, physical & social well-being . . . What are the subtypes?
*Stress Incontinence* *Urge Incontinence/Overactive Bladder* *Mixed Incontinence*
Why is it important for longer hormonal therapy to be COMBINED estrogen + progesterone?
*UNOPPOSED Estrogen* (w/o progesterone) can lead to: *ENDOMETRIAL Hyperplasia* &/or *carcinoma*.
What should you do for a diagnosis of *Urge Incontinence/Overactive Bladder (Detrusor Instability)*?
*URODYNAMICS/CYSTOMETRY* ---reveals involuntary Detrusor m. contraction that is associated with urinary leakage.
What needs to be ruled out in ALL women who present complaining of *urinary incontinence*?
*Urinary Tract Infection (UTI)*
What testing is used to diagnose *Urge incontinence*?
*Urodynamics/Cystometry*
If the patient has completed childbearing and she continues to have very HEAVY menses; what are some of the *less invasive surgical management* options?
*Uterine Artery embolization* *Endometrial ablation*
What is a good recommendation for helping a patient with *urinary incontinence* who is having difficulty quantifying the frequency their involuntary losses of urine?
*VOIDING Diary* -- this will help quantify *BOTH frequency & volume of urine lost*, *circumstances of leakage* (to diagnose type of incontinence), *voiding patterns* & the amount & type of fluid taken in.
the *pH* of vaginal fluid is *normal or < 7*, there are still sxs of vulvovaginatis . . . . . . what is the most likely cause (w/o any other specifics)?
*Yeast (Candida albicans)*
The *Gestational Sac* maybe visualized on a transvaginal U/S when the *beta-hCG levels* are at what?
*beta-hCG* that is *1500-3000 mIU/mL* is known as the "discriminatory zone": b/c there will be a *gestational sac* that should be visualized.
What is the *"discriminatory zone"* for *serum beta-hCG*?
*beta-hCG* that is *1500-3000 mIU/mL* is known as the "discriminatory zone": b/c there will be a *gestational sac* that should be visualized.
Why is *Levonorgestrel IUD* a good choice of contraception for a patient with *HEAVY menstrual bleeding*?
This IUD is associated with: *Decreased menstrual bleeding* *Decreased symptoms of Dysmenorrhea*
When does *surgical menopause occur*?
This occurs following *removal or IRRADIATION* of the *ovaries*.
What is the treatment plan for *Mixed Incontinence*?
Treat *URGE INCONTINENCE* as the *FIRST* condition. --So think of behavior, bladder training, medical therapy (anticholinergic) & surgical therapy (sacral & botox). In general though treatments will be geared toward the patient's worst symptoms; & some treatment OVERLAP (ex. *kegel exercises*)
What kinds of symptoms are treated by *hormone therapy* in Menopause?
Treating for *VASOMOTOR Symptoms* which are primarily hot flashes & night sweats.
What is the typical treatment for *Fat Necrosis*?
Tx: *Analgesia* +/- Excisional Biopsy (can be done to r/o malignancy)
What is the *FSH/LH* ratio in *PCOS*?
Typically this is *INCREASED* by a *ratio > 2*
What is the typical discharge associated with an *Intraductal Papilloma*?
UNILATERAL discharge that is *sticky & clear-to-straw-colored*. But keep in mind this is still a common cause of bloody nipple discharge.
Why should you use inducers of ovulation (like Clomiphene or Letrozole) w/ caution?
USE with caution b/c these medications can lead to --*OVARIAN HYPERSTIMULATION* and therefore increases the risk of *multiple gestations*.
How can *fertility rates* in *endometriosis* be improved?
Use of *operative laparoscopy* to *lyse scar tissue* & *endometriomas* which are causing tubal occlusion.
What criteria is used for the diagnosis of *Polycystic Ovarian Syndrome* (PCOS)
Uses "Rotterdam Criteria", in which you will need the presence of two of the following three: > *Oligo-* or *Anovulation* > *Hyperandrogenism* (clinical evidence by hirsutism or laboratory by elevated free or total testosterone) > *Polycystic ovaries* on *U/S* If you are working up for amenorrhea then you may also get *FSH/LH* which will be *INCREASED at ratio of > 2*, but this is not required for diagnosis.
What are alternative treatment for *vaginal atrophy* (associated with menopause)?
VAGINAL ATROPHY: *vaginal lubricants* *topical estrogens*
What are alternative treatments for *vasomotor instability* (which are NOT hormonal therapy)?
VASOMOTOR Instability: *Venlafaxine* *SSRIs* *Clonidine*
What is the most common cause of *Vulvovaginitis*?
VULVOVAGINITIS --most commonly caused by *bacterial vaginosis* (Gardnerella vaginalis)
What are the top 3 causes of *Vulvovaginitis*?
VULVOVAGINITIS -- commonly caused by: 1. *Bacterial Vaginosis* (Gardnerella vaginalis) 2. *Fungal infection* (*Candida* albicans) 3. *Protozoal infection* (*Trichomonas vaginalis*) But this can be caused by other STIs (*gonorrhea or chlamydia*)
*Bilateral nipple discharge* will require workup for what?`
Will need workup for *PROLACTINOMA*
Up to what point can you use *Oral Ulipristal acetate*?
You can use this for emergency contraception: *up to 5 days afterward*.
What should you do for a diagnosis of *Mixed Incontinence*?
You will need BOTH: *+ cough stress test* (w/ leakage on stress) & *Urodynamics/Cystometry*.
What are the Microscopy & pH features of *Bacterial vaginosis*?
on *Wet Mount*: *> 20% epithelial cells* w/ indisctinct cell margins, *"clue cells"* on KOH prep: *(+) whiff test* fishy odor when placed on a slide. *pH > 7*
What are the Microscopy & pH features of *Trichomonas vaginalis*?
on *Wet mount*: *Motile, flagellated protozoans* on KOH prep: nothing *pH ELEVATED at > 7*
What are the Microscopy & pH features of *Yeast (Candida albicans)*?
on Wet Mount: No characteristic findings will be present. on *KOH prep*: *Pseudohyphae & budding yeast cells* (sportes) of Candida albicans. pH is *normal or < 7*
What is really the ONLY method of prevention of Ectopic pregnancies?
the PREVENTION & Tx of *STIs*
