ANW8024- Module 4- Well woman/ GYN/ GYN Disorders
Endometrioma/Chocolate Cyst
*Benign, blood-containing tumor that forms from implantation of ectopic endometrial tissue *Associated w/ endometriosis -An adnexal mass -Contains old blood from ectopic endometrial tissue.
What are the indications to perform a endometrial biopsy?
- Abnormal uterine bleeding (AUB) -Endometrial Hyperplasia -Lynch Syndrome
Condylomata acuminata
-Genital warts, koilocytes soft, pointed, fleshy papules that occur on the genitalia and are caused by the human papillomavirus (HPV types 6, 11)
Lichen sclerosis
-Is epithelial lining inflammation and dry skin white patches. -Usually occurs in postmenopausal women. The presentation is a severe itch and vaginal soreness. -It might progress to vaginal cancer. -Once diagnosed start superpotent steroid cream while awaiting biopsy results
luteal phase of ovarian cycle
-LH predominates during days 14-28 -LH stimulates the secretion of progesterone by the corpus luteum -is responsible for the uterine secretory phase
Types of ovarian cysts
-follicular cyst (unruptured Graafian follicle, most common in young women), -corpus luteum cyst (hemorrhage into persistent corpus luteum), -theca-lutein cyst (FHS/LH stimulation, often bilateral/multiple, associated with GTD) -hemorrhagic cyst (vessel rupture in cyst wall) -dermoid cyst (mature teratoma) -endometroid cyst/endometrioma (endometriosis → "chocolate cyst")
Functional cysts include
-follicular, -corpus luteum -hemorrhagic -theca lutein cysts TX: monitor for torsion, surgical removal
cervical polyp
-hyperplastic protrusion of the epithelium of the cervix; may be broad-based or pedunculated -Usually benign, malignancy more likely in peri or postmenopausal patients. -Visual diagnosis -May present with postcoital bleeding
Nexplanon MOA
-ovarian suppression -thickening of cervical mucous -creating an unfavorable uterine environment for implantation
secondary amenorrhea causes
1) pregnancy - UPT 2) hypothyroidism - TSH 3) prolactin - level 4) meds 5) HPO axis
5 factors to consider for infertility workup
1. Ovulatory 2. Uterine/ tubal 3. Male factor 4. Cervical factor 5. Peritoneal factor (Endometriosis)
Menstrual cycle phases
1. follicular phase 2. ovulation 3. luteal phase 4. menstruation
Cervical Polyps: Management
1.) treat them if you find them 2.) *surgically remove them in the outpatient setting*.
Depo-Provera injection
A form of contraception administered intramuscularly, approximately once every 12 weeks. intramuscular injection of progesterone every 3 months that changes uterine lining and ovum maturation Contraindicated for use greater than 2 years d/t it causing decrease in bone density
birth control pill
A hormonal pill taken orally to prevent monthly release of ovum (ovulation)
Gonorrhea
A sexually transmitted bacterial disease caused by a gonococcus bacterium that causes inflammation of the genital mucous membrane, burning pain when urinating, and a discharge
Chlamydia
A sexually transmitted disease, the most common in developed countries, caused by the bacterium Chlamydia trachomatis. Often producing no symptoms, it can cause infertility, chronic pain, or a tubal pregnancy if left untreated.
Ortho Evra Patch
A thin, peach-colored patch that sticks to the skin and time releases synthetic estrogen and progestin into the bloodstream to inhibit ovulation, increase cervical mucus, and render the uterus inhospitable; also referred to as the "patch." timed-release contraceptive worn on the skin that delivers hormones transdermal,
Bacterial Vaginosis (BV)
A vaginal infection caused by bacterial microorganisms; it is the most common form of vaginitis among U.S. women. a condition in women in which there is an abnormal overgrowth of certain bacteria in the vagina
Pap guidelines
Age 21- Initiate screenings 21-29: Pap every 3 yrs, no HPV 30-65: Pap every 3 yrs, or every 5 yrs w/ HPV 65: Stop screenings if 3+ neg in a row, no CIN2+ for 20 yrs Stop post-hysterectomy if no history of CIN2+
BV diagnosis
Any 3 of the following (Amsel's Criteria): "clue cell" on vaginal wet mount grayish discharge Whiff test Vaginal pH > 4.5
Clue cells should make you think of what diagnosis?
Bacterial vaginosis
Yeast infections are caused by
Candida albicans
Psuedohyphae
Candida- chains of yeast Buds may not separate but instead form a chain of cells
PID treatment
Ceftriaxon (IM) and doxy (PO) with or without Metronidazole 500mg bid for 14days
multiphasic pills examples
Combination Pills that vary the dosage of these hormones across the menstrual cycle to reduce the overall dosages to which the woman is exposed and possible side effects.
Genital warts treatment
Cryotherapy (weekly until resolved) OR Podophyllotoxin (0.5% paint or 0.15% cream - apply bd with plastic applicator for 3 days; repeat in 4 days, then weekly for 4-6 cycles if necessary) OR Imiquimod (Aldara cream applied to each wart by patient 3x a week at bedtime - wash off after 6-10 hours, until warts disappear - may take 16 weeks). Refer all females (including partners of males with warts) to specialised clinic where colposcopy is available due to risk of cervical cancer (Murtagh).
What is PCOS associated with?
Cushing's syndrome, acromegaly, premature ovarian failure, simple obesity, congenital adrenal hyperplasia, thyroid disease
Bartholin cyst
Cystic dilation of Bartholin gland
ovulation phase of ovarian cycle
Day 14 1. Peak in LH induces ovulation 2. LH peak + FSH slight rise produces cascade that stimulates ovulation (Oocyte release from mature follicle)
Chlamydia diagnosis and treatment
Diagnosis • Urine (first stream) is collected and PCR (polymerase chain reaction) evaluation detects genetic material from Chlamydia • Culture of purulent material Treatment: • Azithromycin by mouth • Doxycycline by mouth
Birth control- Diaphram?
Diaphragm must stay in place 6 hours after intercourse. They are also fitted so must be refitted if you lose or gain a significant amount of weight.
ASCUS on pap smear
Do hpv testing -if neg, routine f/u every year , -if positive colposcopy---cin2/cin3--tx; -if CIN1--repeat pap in 6/12 months -two negative smear--- f/u routine screening, if ASCUS again--colposcopy
CA125 tumor marker can be elevated in what conditions
Endometriosis PID Other non-gyn malignancies The first trimester of pregnancy during menstrual
follicular phase of ovarian cycle
FSH predominates during days 1-13, the ovarian follicles develop and estrogen secretion by follicles is stimulated FSH promotes the development of a follicle that secretes estrogen. An estrogen spike leads to a surge in LH and ovulation around day 14 in the 28-day cycle.
Bartholin's glands
Glands located on either side of the vaginal opening that secrete mucus for vaginal lubrication.
Gonorrhea treatment
Gonorrhea TX: IM Ceftriaxone Cover Chlamydia with: azithromycin : 1 g orally as a single dose doxycycline : 100 mg orally twice daily for 7 days
Vasomotor menopause Sx
HA, palpitations, night sweats, insomia
HIV treatment
HAART (Highly Active AntiRetroviral Therapy): using a combination of drugs to reduce viral load A decreased viral load indicates a positive response to prescribed HIV treatment, because viral load testing measures the presence of HIV viral genetic material
Vasomotor menopause treatment
HRT's- oral, transdermal, topical Estrogen versus Combined (estrogen & progestin) If woman has not uterus she does not need the progesterone.
Bartholin cyst tx
I&D Placement of word catheter
Monophasic Oral Contraceptives
Identical amounts of estrogen and progestin throughout the pack Examples: Aviane, Alesse, Loestrin 24 Fe, Ortho Novum, Ovcon, Ovral, Ortho-Cept, Sprintec, Yasmin, Yaz
What tests should you obtain for PCOS diagnosis?
Labs: Prolactin, Fasting lipid panel, 2hr gtt, free testosterone Procedures: endometrial biopsy, Pelvic US,
What appears leathery, hypertrophic, lichenified plaques on the neck, ankles or perineum, patches are rectangular, thickened and hyperpigmented, skin lines are exaggerated?
Lichen Simplex Chronicus
Trichomonas treatment
Metronidazole (Flagyl) 2 grams orally (single dose)
Are palpable ovaries normal in a postmenpausal woman?
NO! this indicates further evaluation, r/o CA
Uterine Fibroids (Leiomyomas)
Non-cancerous tumors of uterus. Most common benign tumor in women
PCOS treatment
OCP, spironolactone, clomiphene, HMG, metformin
HIV treatment goals
Primary treatment goals: • reduce HIV-related morbidity and prolong survival • improve quality of life • restore and preserve immunologic function • maximally and durably suppress viral load • prevent vertical HIV transmission AT THIS TIME, ERADICATION OF HIV IS IMPOSSIBLE
Lichen Planus
Pruritic, purple, polygonal planar papules and plaques (6 P's)
NSAIDs MOA
Reversibly inhibit COX-1 & COX-2 Block prostaglandin synthesis
Bartholin cyst can be causes by
STI's - Gonorrhea most common
Chlamydia signs and symptoms
Signs/symptoms: -Sometimes asymptomatic! -Increased vaginal discharge usually white/yellow -Urinary urgency/frequency, suprapubic pressure -Diffuse low abdominal pain (usually mild at first) -Bright red (light amount) bleeding after intercourse -Vaginal odor -Strawberry looking cervix -Men clear to white discharge -Infection can go upward and feel like a bladder infection
spinnbarkeit sign
The ability for the cervical mucus to stretch between the fingers during ovulation, which facilitates sperm movement into the uterus
Vulvocandidiasis
Thick, curdy white vaginal discharge C/o itching dysuria, dyspareunia Risk: DM, HIV, *recent abx use* Dx: KOH - branch chain hyphae and spores pH < 4.5 Rx: Fluconazole
Dysmenorrhea treatment
Treat underlying cause Analgesics, NSAIDs, Aspirin, heat, oral contraceptives. Whole grains, legumes, fruit, vegetables, and nuts. Avoid sugars, alcohol, caffeine, dairy products, and salt.
HPV diagnosis
Warts: Visual insepction. Cervix: routine pap, HPV typing by PCR or NA hybridization assay.
HPV (human papilloma virus)
a group of viruses that can cause genital warts in males and females and can cause cervical cancer in females
Nexplanon
a hormone implant with a single progestin-releasing rod that is effective for 3 years
Trichomonas
a parasite causing an STD
HPV Vaccine (Gardasil)
a vaccine that can prevent cervical cancer, pre-cancerous genital sores, and genital warts caused by genital HPV infection
HSV-2 treatment
acyclovir, valacyclovir, famciclovir
Lynch syndrome
an autosomal dominant disease caused by abnormal nucleotide mismatch repair. Mutations in MSH2 (codes for MutS) and MLH1 (MutL) are most common. Colorectal cancer Endometrial cancer Ovarian cancer
Teratoma (dermoid cyst)
benign (in girls) germ cell tumor of ovary Tx- cystectomy, methotrexate, serial HCG's
fertility awareness methods
birth control methods that use the signs of cyclic fertility to prevent or plan conception
extended-cycle pill
birth control pill that reduces menstrual periods to four times a year Examples: Jolessa, Amethia Lo, Seasonique, Quartette
ovarian cysts
collections of fluid within a sac (cyst) in the ovary
Causes of primary amenorrhea
congenital defects of gonadotropin-releasing hormone production, genetic disorders, trauma, infection and tumors, Thyroid dysfunction 1- delayed puberty (normal to delay up to 2-3 yrs) 2- imperforate hymen (vaginal canal not open) 3- vaginal atresia (vagina does not develop, still see rugae) 4- labial adhesions (sex abuse, no rugae) 5- gonadal dygenesis (turner's sydnrome) 6- mullerian agenesis
intrauterine device (IUD)
contraceptive device inserted into the uterus that prevents implantation of a fertilized egg
COX-1 and COX-2
cyclooxyrgenase 1 & 2 are enzymes that convert arachidonic acid to prostaglandin, resulting in pain and inflammation. COX-1 is known to be present in most tissues and maintains the normal lining of the stomach / GI tract. The enzyme is also involved in kidney and platelet function. COX-2 is primarily present at sites of inflammation.
Gonorrhea diagnosis and treatment
diagnosis is made by nucleic acid amplification tests (NAAT) or culture. Treatment can be with IM ceftriaxone, oral cefixime, or IM spectinomycin in cases where cephalosporins cannot be tolerated. azithromycin or amoxicillin for presumed Chlamydial infection
Most common cause of dysmenorrhea
endometriosis, which can only be diagnosed with surgical exploration
postcoital test
examines the interaction between sperm and cervical mucous; sperm agglutination, and reduced motility suspicious for antisperm antibodies
ovarian cycle
follicular phase, ovulation, luteal phase
Cystadenoma
glandular tumors that are filled with cysts, these are the most common benign tumors in the pancreas
HRT
hormone replacement therapy (estrogen and progesterone)
HIV
human immunodeficiency virus A virus that attacks and destroys the human immune system and causes AIDS
secondary infertility
inability to conceive after a previous pregnancy
primary infertility
inability to conceive after one year of engaging in unprotected sex
pelvic inflammatory disease (PID)
inflammation and infection of organs in the pelvic region; salpingitis, oophoritis, endometritis, endocervicitis
Lichen Simplex Chronicus
lichenification --long-term atopic dermatitis -- repetitive scratching/rubbing well-circulated plaque tx: stop the itch-scratch cycle; dressing/topical steroids, tar, anti-histamine
BV treatment
metronidazole or clindamycin
thelarche
onset of breast development
menarche
onset of menstruation
CA125 marks what cancer?
ovarian and endometrial cancers
dysmenorrhea
pain caused by uterine cramps during a menstrual period
Pap guidelines, age 30-65
q3 years OR q5 years with HPV
Pap guidelines, age 21-29
q3 years, no HPV
punch biopsy
removal of a small oval core of skin for laboratory analysis using a sharp, hollow instrument
secondary amenorrhea
the absence of menstruation after a period of normal menses
Primary amenorrhea
the failure to begin menstruating at puberty by age 15-16
perimenopause
the term used to designate the transition phase between regular menstrual periods and no periods at all
menopause
the time of natural cessation of menstruation; also refers to the biological changes a woman experiences as her ability to reproduce declines
lichen planus tx
topical steroids w/ occlusive dressing intralesional steroids (severe) topical tretinoin (severe) systemic therapy (severe, painful cases) -cyclosporine (mouthwash for oral lesions) -retinoids -methotrexate PUVA (generalized eruptions) antihistamines
uterine fibroids diagnosis
ultrasound Endometrial biopsy
herpes simplex virus type 2
virus that causes ulcer-like lesions of the genital and anorectal skin and mucosa; after initial infection, the virus lies dormant in the nerve cell root and may recur at times of stress
Trichomonas diagnosis
wet mount
Gonorrhea symptoms
women-greenish-yellow discharge from the cervix of the uterus or discomfort wile urinating, fever, lower abdominal cramping, pain, vaginal bleeding men- inflammation of the urethra and the sides around the opening of the urethra, yellowish-white or yellowish-green discharge from the penis, burning while urination
What is Gibrata when found on the wet prep?
yeast buds only
HRT contraindications
•Women with breast ca or those at high risk •Hx of ovarian or uterine ca •Hx of CVD or stroke •Hx of clotting disorder •Undiagnosed uterine bleeding
