gyne
**What is one the FIRST steps in evaluating amenorrhea besides pregnancy? If they are normal, what should you perform?
#1. *order prolactin and TSH levels* (things that show that something's wrong with the HPA) #2. *progestin challenge*
In the ovarian cycle, what's going on in the ovulation stage? What day does this occur? Where is the ovum released?
(Females are both with all follicles she will ever have; Follicles are suspended in the meiotic prophase until ovulation; Final mature follicle is the primary oocyte - this is what happens during the follicle stage) When ovulation happens, it stops at the 2nd meiotic division at metaphase II; meiosis is only completed if the ovum is fertilized. This occurs around day 14 of the cycle, when there is a surge of LH from the pituitary → mature follicle ruptures (14 days BEFORE you next period) → OVUM is released in the *ABDOMINAL CAVITY* → picked up the fimbrated ends of the fallopian tube.
If a patient has hyperprolacteremia that causes secondary amenorrhea, how do you treat this issue?
(pituitary problem) Tx - bromcryptine
What are the MOST common symptoms of cervical cancers? others: later sxs:
**METRORRHAGIA** (spotting, bleeding, blood discharge, postcoital bleeding) and *CERVICAL ULCERATIONS* thin, watery discharge with odor (malodorous, nonpruritic discharge) later sxs: flank pain, dysuria/hematuria, leg pain, rectal bleeding, leg edema
What happens in the luteal phase of the ovarian cycle? How long is it?
*14 days* always it happens in the 2nd half of the ovarian cycle AFTER ovulation. ruptured follicle → fills with blood (Corpus Hemorrhagium) → turns into the corpus luteum
Ovarian cancer has an insidious onset bc it is generally asymptomatic, and most patients have non-specific GI sxs of nausea, dyspepsia, change in bowel habits, sometimes abnormal bleeding. What are the signs of symptoms of an advanced disease?
*ABDOMINAL BLOATING* or swelling w/ascites Large pelvic mass produces bladder or rectal symptoms (frequency) PE: MASS is FIXED, firm w/nodularity palpated bilaterally, LYMPH NODES (obviously will see the signs of distention)
***Where does fertilization occur?****
*Ampulla * - fertilization of egg and sperm most commonly occurs here
WHO REQUIRES BIOPSY ?!?!?
*Any women over 40 years old with uterine bleeding needs an endometrial biopsy to r/o cancer* other indications: - thickened endometrium on u/s - heavy or irregular bleeding
What are the 2 arteries that are endometrial blood supply? What does it supply? What is shed during menstuation?
*BASILAR ARTERIES* - supply the Stratum Basale (the deep layer of the endometrium) _ NOT SHED during menstruation *SPIRAL ARTERIES* - More superficial - Supply the stratum functional - *SHED during menstruation*
*What is the #1 cause of spontaneous abortions?*
*CHROMOSOMAL ABNORMALITIES*
Which estrogen is decreased after menses? What is the primary estrogen after menopause?
*Estradiol after menses* *Estrone after menopause*
What is the MOST common type of ovarian cyst?
*Follicular* others: Corpus Luteum Endometrioma Theca Lutein
What are the 4 different types of pelvic structures? Which one is the most common?
*Gyenecoid Pelvis* Android Pelvis Platypelloid Pelvis Anthropoid Pelvis
What are 3 main factors to cervical cancer? What is the big one?
*HPV* Sex (this is why its most common in women in their 20s) Smoking (+ HPV = synergistic effective) (others: multiple sex partners, early onset of sexual activity, high risk sex partners, hx of STIs, smoking, HIV, etc)
what should be asked in the GYN social history?
*Include domestic violence screening!!!* (If you have any suspicion, make sure to ask!!!)
What is the congenital abnormality that ONLY happens in males?
*Kleinfelter Syndrome* (XXY, XXXY)
What the exam, what is your next step in treating this patient?
*Pregnancy prophylaxis* - Plan B (levonorgesterl) then *STD Prophlaxis* - Gonorrhea: Rocephin 125 mg IM ; Ceftin 1g po; Vantin 400mg po - Chlamydia: Zithromax 1g po or Doxycycline 100mg BIDx7d - Trichomoniasis: Flagyl 2g po - Hepatitis B: Make sure patient has been vaccinated if not start vaccinations and give immunoglobulin - HIV (maybe) - can cause more stress
What is the most common type of vaginal cancer?
*Squamous cell* (85%)
What are the terms for the following: 1 An injury of the soft tissue resulting in ripping, crushing, overstretching, pulling apart, bending and shearing (Caused by blunt force trauma) 2 Bruises, irregular hemorrhagic areas of the skin (Caused by extravasations of blood into the skin or mucous membrane) 3 A scraping away of skin or mucous membranes from injury or mechanical means 4 Erythema: redness, a form of macula with diffuse redness, caused by capillary congestion 5 Swelling, a local or general accumulation of fluids in the tissue 6 Marks caused by belts, extension cords, lighters, and bite marks
*Tear/Laceration*: An injury of the soft tissue resulting in ripping, crushing, overstretching, pulling apart, bending and shearing (Caused by blunt force trauma) *Eccyhmosis*: Bruises, irregular hemorrhagic areas of the skin (Caused by extravasations of blood into the skin or mucous membrane) -Color is blue-black, changing from greenish to brown to yellow *Abrasion*: A scraping away of skin or mucous membranes from injury or mechanical means *Erythema*: redness, a form of macula with diffuse redness, caused by capillary congestion *Edema*: Swelling, a local or general accumulation of fluids in the tissue *Pattern Marks*: Marks caused by belts, extension cords, lighters, and bite marks
What are 5 risk factors for ovarian cancer?
*Turner's syndrome* *HNPCC* BRCA1 (45%) and BRCA 2 (25%) ↓ Fertility (Late pregnancy) Family history (5%)
What is the MOST COMMON cause of primary amenorrhea? How do you dx this condition?
*Turner's syndrome* (gonadal dysgenesis) → streak gonads (i.e. underdeveloped);Ovaries do not develop. Instead these patients have streak gonads that do not function.) dx. progestin test
Squamous cell vulvar cancer. Where is it? What does it look like? Who?
*Typically involves anterior half of vulva* • Arises in labia majora & minora (65%) Apperance varies: • Large exophytic cauliflower-like lesion • Ulceration of hypertrophic skin • Elevated red, velvety tumor Who: -women over 60
What are the 5 common symptoms of vulvar cancer? How do you dx?
*Vulvar pruritus* Vulvar Mass Abnormal/Bloody discharge Abnormal vaginal bleeding Pain (20% of vulvar cancers are found incidentally with no symptoms) *BIOPSY!!!! to dx*
What happens when a woman is exposed to unopposed estrogen without sufficient progesterone to counteract its affects?
*endometrial hypertrophy / endometrial hyperplasia* (estrogen increases uterine blood flow and builds up the endometrium)
What can be evaluated with an U/S?
- Checks size and shape of uterus (noting the presence of any fibroids) - Checks adnexal masses - Checks endometrial thickness (hyperplasia)
What is happening to the endometrium during the secretory/luteal stage?
-Endometrial glands secrete a clear, thick fluid may be noted as a change in vaginal discharge (cervical mucous) - *14 days* ALWAYS - Drop in progesterone / estrogen à vasospasm of spinal arteries -> Menses
What are the long term risks of PCOS? (3)
-Type 2 DM -Infertility/ Miscarriages -Breast/Endometrial cancer (from unopposed estrogen secretions)
What must you get consent for? (3)
1. Perform exam 2. Take photographs 3. Release evidence to law enforcement (report, photos, specimens, clothing)
What is involved with evaluating the male factor? Txt for if this is the cause?
1. Semen analysis (count, pH, motility) 2. Post-coital exam (how many sperm are in the cervical mucous) Txt: intrauterine insemination IUI Donor insemination Intracytoplasmis sperm injection
Which IUD? -implanted for 10 years - implanted for 5 years -implanted for 3 years - non-hormonal
10 years: Paragard - nonhormonal 5 years: Mirena 3 years: Skyla
Menopause is a cessation of menses for a minimum of how many months? What causes menopause? Average onset? Dx?
12 months min cessation of follicular development and permanent loss of estrogen age: 51 Dx →*↑ FSH* + LH, ↓estrogen (the oocyte produce less estrogen and progesterone, and both the LH and FSH start to rise, but the gonads do not respond to this rise)
When is the recommended age of pap smears? If pap is normal, how often should you get it done? When do you test for HPV?
21 yo get it done every 3 years HPV: when there is ASCUS (atypical squamous cells); shows on positive PAP
How long is depoprovera effective for?
3 months (IM inj)
How long must the vaginal diaphragm be put in before and after intercourse?
6 hours before 6 hours after
How long is the ovarian development?
9-10 weeks
What is the prognosis of HPV?
90% of immunocompetent women will have spontaneous resolution over 2 yrs If persistent HPV- higher likelihood of developing CIN and cervical cancer
What is the first step and 2nd in the workup of a suspicious mass in postmenopausal women and in those >30yo? Premenopausal women <30yo?
>30: MAMMOGRAM → U/S, FNA (*best initial biopsy*) <30: U/S
Pt presents with **noncyclic** pain, *menorrhagia* and an *enlarged uterus* on pelvic exam. What dz? What pt population does this present in?
ADENOMYOSIS (Risk factors: endometriosis, and uterine fibroids) Older age group: parous 40-50 y/o women (vs. endometriosis which is women of reproductive age)
What are the things that MUST be included in your H&P when dealing with the female patient?
ALWAYS mention *Gs and Ps* *ALWAYS mention LMP*
what is the MOST common cause of infertility?
AMENORRHEA/ OVULATORY dysfunction (28%)
How do you dx and txt vaginal cancer?
ASX found on routine vaginal cytologic exam (pap) + bx confirms (remember neg PAP r/o cervical CA) (Endometrial biopsy r/o endometrial CA) (primary cancer from vagina cannot be diagnosed unless metastasis from another source is eliminated) Stage 1: wide excision or vaginectomy + radiation stage 2: radical surgery + radiation stage 3-4: RADIATION
What type of vulvar cancer? - rare - most commonly appears as bartholin's gland carcinoma
Adenocarcinoma
What is the #1 drug used as a date-rape drug?
Alcohol
What is involved in evaluating the cervical factor? TXT?
Anything that messes with cervical mucous abnormal pap? txt: intrauterine insemination IUI (or ultimately may need IVF)
How does the cycle continue after your period?
As estrogen ↓, there is an increase in FSH for the next cycle
If there is an abnormality noted on colposcope, how do you evaluate?
BIOPSY!!! (Apply acetic acid solution - identify abnormal areas (acetowhite epithelium, mosaicism or punctation))
Case, what dz? • positive whiff • clue cells How do you txt?
BV (bacterial vaginosis) Flagyl
What is the most common site for vulvar adenocarcinoma and 50% are squamous cell carcinoma? Who do we evaluate? Where is it located?
Bartholin's Gland carcinoma (don't get it confused with Bartholin's cyst) Biopsy any woman >40yo Location = deep in the substance of the labia (other things: Tumor may impinge on the rectum and directly spread into ischiorectal fossa. Gains access to lymphatic channels draining directly to the deep pelvic lymph nodes as well as superficial channels draining to inguinal lymph nodes)
What structure? - responsible for vaginal lubrication - can become infected (big and painful)
Bartholin's glands
What type of vulvar cancer? - Most are small elevated lesions with an ulcerated center and rolled edges. - Almost *exclusively* in the skin of the labia major. Appearance: - Looks like *small, elevated lesions with ulcerated center and rolled edges* - Pigmented tumors, moles, pruritic maculopapular eruptions
Basal cell carcinoma
What type of uterine anomaly? • Uterus with two horns and 1 cavity • Only the upper part of that part of the Mullerian system that forms the uterus fails to fuse, thus the caudal part of the uterus is NL and the cranial part is bifurcated • Heart-shaped
Bicornuate Uterus
What evidence might be found on the colposcope after a rape incident? Does it go in the kit?
Blood accumulation, etc NO, it stays in their chart (they only see if it is subpoenaed)
What is the MOST common malignancy in women? What are the risk factors?
Breast Cancer RF: Old age, Hx of personal or 1st degree relative, BRCA1-2 mutations, High-fat, low-fiber diet *↑ exposure to estrogens (nulliparity, early menarche, late menopause, first full-term pregnancy after 35)*
What is the cause of the following nipple discharge? -colostrums -spontaenous dischrage benign - bloody discharge - may be accompanied by spontaneous multiple duct discharge, more marked prior to menstruation - milky discharge in non-lacting women, usually from high prolactin level (check TSH) - purulent discharge
Breast Feeding discharge - colostrums Intraductal papilloma- spontaneous serous or serosanguinous discharge from a single duct, may or may not be a palpable mass along with it (benign) Carcinoma: bloody discharge Fibrocystic change: May be accompanied by spontaneous multiple duct discharge, more marked prior to menstruation Galactorrhea: milky discharge in non lactating women, usually from high prolactin level Subareolar abscess: purulent discharge
What is a disordered growth and development of epithelial cervical lining, pre-malignant cervical changes? When is it most commonly detected? What is the peak incidence of CIS When do patients usually see the cancer?
CIN = cervical intraepithelial neoplasia (CIN) aka dysplasia Most commonly detected in 20s - often spontaneously regresses CIS: *25-35 yo* Cancer: >40yo
What are the 3 layers of the fascia?
Camper fascia (most superficial, thin fatty layer) Scarpa's fascia (membranous; assuming no scarring) Epimysium (DEEPEST)
Case: what dz? • 26yo G1P1 • complaining of vaginal itching and discharge • discharge is white • ABX history • LMP: 1 week ago • denies urgency or frequency • negative whiff How do you txt?
Candida - yeast infection (Diflucan)
What are 6 secondary causes of dysmenorrhea? Who is it more common in? what are 3 associated symptoms?
Causes: Endometriosis, Adeomyosis Fibroids PID Ovarian Cysts IUD age: 20s + worsens w/ age assoc w/ dysparenunia, abnl bleeding, infertility
What are the 7 bacterial infections?
Chancroid Granuloma inguinale Lymphgranuloma venereum Chlamydia infections Gonorrhea BV (bacterial vaginosis) Syphilis (all are reportable except BV)
What condition? Period of time when the woman passes from reproductive to non-reproductive stage through perimenopausal transition
Climacteric
What are the 5 Viral pathogens that cause of infections?
Condyloma acuminata Herpes infection Molluscum contagiosum Hepatitis infection HIV
What the following: 1-cauliflower-like masses 2-painful ulcers 3 - Firm, dome-shaped, flesh-colored, "pearly" papules with central umbilication
Condyloma acuminata-cauliflower-like masses Genital herpes - painful ulcers Molluscum Contagiosum - Firm, dome-shaped, flesh-colored, "pearly" papules with central umbilication
Pt comes in with complaints of - local pain/tenderness - assocaited amenorrhea or delayed menstruation What dz? What might rupture cause? txt?
Corpus Luteum cyst (corpus luteum is persisting and continuing to produce progesterone, therefore causing amenorrhea) Rupture may cause INTRAPERITONEAL bleeding txt: Typically spontaneous regression
Pt comes in with complaints of vaginal fullness, pressure or something "falling out" and feeling of incomplete bladder emptying. On PE there is a reducible mass that is soft and bulges into the vagina and increases with straining or coughing. What is the condition?
Cystocele (Defect in anterior vaginal wall, may be assoc w/ prolapsed) 1st degree = upper two thirds of vagina 2nd degree = comes to the vaginal introitus 3rd degree = where it comes to the vaginal opening
What type of fibroadenoma will grow *rapidly* and may grow to large size and needs *rapid excision*?
Cystosarcoma phyllodes
What type of uterine anomaly? o The uterine cavity has a "T-shape" as a result of fetal exposure to diethylstilbestrol
DES uterus
What type of cervical cancer? 1) associated with in utero exposure to DES? 2) associated with Peutz-Jegher's syndrome
DES: Adenocarcinoma (menopausal women at risk) Peutz-Jegher's: Adeno Malignum (60-70s)
What type of uterine anomaly? • Both mullerian ducts defelop but fail to fuse midline • Patient has a double uterus - 2 separate uteri • May have one or 2 vaginas or one or 2 cervices Do these patients have normal pregnancy and menses?
Didelphys Uterus • Can still have a successful pregnancy • As long as they have patent cervix and vagina, they should still have normal menses
What congenital abnormality may occur from maternal ages of *"extremes"*?
Down syndrome (35 y/o is considered advanced maternal age 45 y/o is advanced paternal age)
How do you diagnose and treat Kleinfelter's syndrome?
Dx: Excessive pituitary gonadotropin found in serum or urine Txt: NONE! :(
Overweight, smoker, over 40yo, with heavy bleeding is at great risk what disease?
ENDOMETRIAL CANCER (classic presentation: overweight, smoker, over 40yo, heavy bleeding)
What is the most common type of Endometrial cancer?
ENDOMETRIOID CARCINOMA (adenocarcinoma) (followed by serous and clear cell)
Is this an early, middle, late or metastatic findings of breast cancer? - May present as a single, contender, firm to hard mass with ill-defined margins or as mammography abnormalities with no palpable mass
Early findings
How do you dx uterine cancer? How do you txt most uterine cancers?
Endometrial bx; D+C (curettage of endocervical canal, then dilatation of canal & curettage of endometrial cavity) U/S shows a thickened endometrium leading to hypertrophy and neoplastic change (good for asxs women → signals endometrial cancer - which is a type of uterine cancer) Tx → TAH-BSO w/ pelvic washings
Women presents with vaginal bleeding post/perimenopausal, what r you suspicious for?
Endometrial cancer
What is the MOST common finding on biopsy of the uterus?
Endometrial hyperplasia (this is what causes the abnormal bleeding: menorrhagia, metrorrhagia, or post menopausal bleeding)
How do you treat if: Endometrial hyperplasia - Endometrial polyp - Cancer -
Endometrial hyperplasia - Progesterone +/- D&C Endometrial polyp - D&C Cancer - Hysterectomy
What cyst is known as a "chocolate cyst"? What are the symptoms?
Endometrioma sxs (same as endometriosis): pelvic pain, dysuria, infertility txt: surgical drainage and removal of cyst; standard endometriosis management
What is the MOST common cause of infertility in women >30yo?
Endometriosis
Pt comes in with complaint of *cyclic* pelvic and/or rectal pain and dysparenuia (painful intercourse). She states that her pain starts 1-2 weeks before and peaks 1-2 days before and ends with menstruation. Her pelvic exam reveals a "nodular uterus* and *adnexal mass*. What dz? What patient population is this more common in?
Endometriosis women of reproductive age
What dz? - I want to have a baby and I've been trying for 2 years - Never on the pill, since she was 16 - Never been pregnant before - cycle is every 28 days - No history of STI - dyspareunia
Endometriosis (USUALLY TRIAD: heavy menses, infertility, dyspareunia)
What is the difference in definition between endometriosis and adenomyosis?
Endometriosis: endometrial glands outside the uterus Adenomyosis: endometrial tissue INSIDE the myometrium of the uterus
Which uterine layer is it? - deepest layer; - stimulated by estrogen and causes menses - Layer that increases in size and sheds during menses - The deeper stratum basal provides foundation for rebuilding the stratum
Endometrium
What causes osteoporosis? Whats the gold standard?
Estrogen inhibits osteoclast and stimulates osteoblast function DEXA: T-score<-2.5 (osteoporosis) (T-score is between -1.0 and -2.5 for osteopenia)
T/F. DUB (dysfunctional uterine bleeding) is caused by neoplasm, pregnancy, inflammation, trauma, blood dyscrasia, hormone administration
FALSE!!!! NOT caused by any of those. DUB is a broad term meaning abnormal uterine bleeding *without* an obvious organic abnormality. (Usually unexplained continuous estrogen causes endometrial to bleed - no tests for dx this; Most occur at extremes of reproductive age)
What is the MOST common cause of heavy menses?
FIBROIDS
What is going on with the ovarian cycle during the follicular phase? What is the mature ovarian follicle called?
FSH from the pituitary stimulates several follicles in the ovaries - Around cycle day 6, (just after bleeding) one of the follicles becomes dominant - The mature ovarian follicle is called the graafian follicle.
*What is the MOST common type of female genital injury done during rape?* How do you describe lacerations and redness?
Female injury most commonly happens in the perineal area *Posterior fourchette- 70% -Tears* Like a clock face: "Abrasion at 3 o'clock 2cm from the anus"
Infant pt presents with ambiguous genitalia such as clitoral hypertrophy in girls and enlarged penis in boys; they have a failure to regain birth weight/weight loss. In children and adults: - very early puberty - hirsuitism - shorter than average final height -infertility What dz? dx? txt?
Female pseudohermaphroditism due to Congenital Adrenal Hyperplasia (most likely NOT on the exam) - Genotypically female - XX with a Secondary Cause - Masculinizing hormones from adrenals Dx: Dexamethasone androgen-suppression test (DAST) Treatment - Exogenous cortisol
Younger woman presents with: - a round or ovoid, rubbery, discrete, relatively mobile, nontender mass 1-3cm in diameter - usually solitary - noncylic (Typically will not change with menstrual cycle) What dz? How do you dx? Txt?
Fibroadenoma Dx: *Breast u/s* - differentiate between cystic from solid mass *Needle Biopsy or FNA* Txt: Excision (but recurrence is common)
What is the *most common breast lesion in women <30 yoa*?
Fibroadenoma (a benign, slow-growing breast tumor with epithelial and stromal components)
Pt presents with - cyclic bilateral *mastodynia* and swelling, with symptoms most prominent before menstruation. - *Rapid fluctuation* in the size of the masses is common - Other symptoms include: irregular, bumpy consistency to the breast tissue ("oatmeal with raisins") What dz?
Fibrocystic change (most common of all BENIGN breast conditions; Findings include: cysts, papillomatosis, adenosis, fibrosis and ductal epithelial hyperplasia)
What are the 2 phases of the female cycle? Which is variable in length/constant in length?
Follicular Phase - = Proliferative phase - Variable Length Luteul Phase - = Secretory phase - Constant - 14 days ALWAYS
How do you dx and txt nipple discharge? intraductal and carcinoma: Galactorrhea Subareolar abscess
For intraductal and carcinoma: -Cytologic exam -FNA -Excisional biopsy Galactorrhea: check TSH, ↑PRL, treat prolactinoma Sub-abscess: I&D (breast surgeon)
What are the 2 types of bypass incontinence, how do you dx? treat?
GU fistula (d/t poor wound healing after childbirth) - IV urography/cystoscopy - surgery Diverticulum (weakness or hernia in fascia supporting bladder or urethra) - feel suburethral mass -surgery
Greater or lesser pelvis? -Superior to pelvic inlet -L5,S1, iliac alae, pelvic brim
Greater (FALSE) pelvis
What are the 4 prominent features of menopause?
H-ot flashes (vasomotor instability) A-trophy of the V-agina O-steoporosis C-oronary artery disease (Menopause wreaks HAVOC) Symptoms: - menstrual irregularity -sweats and hot flashes -mood changes -dyspareunia (painful sex) PE: -atrophic vaginitis - decrease in breast size - vaginal and cervical atrophy
What is the hereditary syndrome that increases the risk of developing cancer? What is done for prevention
HNPCC (Hereditary Nonpolyposis Colon Cancer (aka Lynch syndrome) Cancer syndrome = Colon, endometrial (primary cancers), ovarian Screenings as early as the 20s
What are the risk factors to vulvar cancer?
HPV lichen sclerosus infrequent medical exam diabetes obesity htn CV disease immunosuppression
What type of HPV is Gardasil protective of?
HPV types 6, 11, 16, and 18 (may prevent development of cervical cancer)
What are the 3 risk factors for vaginal cancer? Is this a common cancer? When is it considered primary?
HPV, early hysterectomy (bc estrogen is protective), h/o pelvic radiation Rare disease (3% of gyn cancers) Primary when cancer it is found in both cervix and vagina (but it;s usually secondary to other gyn malignancies)
How does vaginal cancer spread? How is it different from others? B/c of its spread, where is it likely to metastasize to?
Hematogenous, rather than lympathic Metastasize to lungs and liver
What is recommended follow-up post sexual assault?
Hep B vaccine series (if not previous vaccinated) Testing for syphilis, Hep C, and HIV *If HIV prophylaxis started post-assault follow up with infectious disease specialist is needed
What is mainly involved in evaluating the ovulatory factors? txt?
Hormone levels FSH/LH (menstrual abnormalities) TSH (hyper/hypothyroidism) Prolactin (Galactorrhea) Progesterone test DHEAS (androgen test, too much androgen = infertility, possible PCOS) Txt: -depends on etiology - Induction of ovulation (*clomiphene*, GnRH injections) - IUI - IVF
What are the two types of endometrial hyperplasia? whats the difference?
Hyperplasia w/o atypia (overgrowth to lining of uterus) → ASX, incidental finding on hysterectomy Hyperplasia w/ atypia → pre-malignant; majority regress w/ progestin therapy; hysterectomy recommended
What condition? - Unusually light menstrual flow (spotting) How do you treat?
Hypomenorrhagia Tx → nothing, tx underlying problem
What are the effects of corpus luteum in pregnancy? No pregnancy?
If pregnant, the corpus luteum is the initial source of progesterone until the placenta forms and takes over that role. (PRO-GESTATIONAL) If pregnancy does not occur, the corpus luteum degenerates and becomes the corpus albicans (fibrous scar tissue)
Where does fertilization occur?
In the *ampulla*
What happens after the egg is excreted into the abdominal cavity, what causes the bleeding?
In the ovary, the excreted ovum leaves only the corpus hemorrhagium. corpus hemorrhagium (ruptured follicle)→ turns into corpus luteum → secretes progesterone and smaller amounts of estrogen
What structure? - opening to the vagina
Introitus
What is the MOST common type of breast cancer? (pathological)
Invasive ductal type
What is a congenital GnRH deficiency that causes amenorrhea and anosmia? What do GnRH Pulse production defects a result of? (3)
Kallman's syndrome GnRH Pulse Production defects "←hypogonadotropic hypogonadism "← anorexia/severe wt loss "← prolonged vigorous athletic exertion
What abnormality? male described as tall-statured, with breast development, psychological complaints, and infertility
Kleinfelter Syndrome
What dz? - Presents with testicular atrophy, a eunuchoid body shape, tall stature, long extremities, and gynecomastia. Etiology? What does it cause? How do you treat?
Klinefelters -Presence of an inactivated X chromosome (Barr body) - One of the most common causes of hypogonadism in males Txt: testosterone
What if the patient gets LSIL or HGSIL? What does LSIL and HGSIL represent?
LSIL: low-grade squamous intraepithelial lesion - CIN 1 (mild dysplasia of lower 1/3 of epithelial lining) →yearly or colpo HGSIL: High grade Intraepithelial lesions = CIN II (2/3 of epithelial lining) & CIN III (>2/3 of epithelial thickness) +tests -> COLPOSCOPE +/- ECC
What is the diagnostic lab finding for Turner's syndrome? How do you treat?
Lab findings: highly elevated gonadotropin production (gonads do not respond to the FSH and LH) Txt: GH (growth hormone), Estrogen therapy
How do you dx Ovarian cancer?
Labs: CA-125 (<35NL) *PELVIC U/S* - Bilateral SOLID - Multiple Septations >2-3mm THICK - ASCITES
Is this an early, middle, late (metastasis) findings or metastatic disease of breast cancer? - Ulceration, Supraclavicular lymphadenopathy; edema of the arm; metastases to the bone, lung and liver - prolonged unilateral scaling erosion of the middle with or without discharge
Late findings (metastasis) Paget's disease- prolonged unilateral scaling erosion of the middle with or without discharge
Greater or lesser pelvis? -Pelvic inlet, pelvic diaphragm -Urinary bladder, uterus, ovaries
Lesser (TRUE) pelvis
Txt for vaginal atrophy? Long term - Short term -
Long term - Estradiol vaginal ring Short term - Estrogen vaginal cream
What is mainly involved in evaluating the Pelvic Factors? TXT for is this is a cause?
Looking at the structures: TUBAL Pelvic U/S - Look for hydrosalpinx, leiomyoma, ovarian cyst (endometrioma) Hysterosalpingogram (HSG) for tubal abnormalities Laparoscopy w/chromotubation (gold standard for tubal factor - can treat at the same time for adhesions or endometriosis TXT: SURGERY May need IVF
What is the problem with mastectomies?
Lymphedema due to loss of drainage
What is the MOST common symptom associated with leiomyomas?
MENORRHAGIA!!!! (but 50-60% are asymptomatic)
What are the 3 Protective factors against ovarian cancer?
MULTIPARTY (lots of pregnancies) *OCP use* (↓ risk by 29%) Hx of Breastfeeding (pretty much, the LESS ovulation you have, the ↓↓ the risk of Ovarian cancer)
What type of vulvar cancer? Appearance: - pigmented vulvar nevi - can also be non-pigmented - typically on labia minor and clitoris - superficially spreads to urethra and vagina (metastasizes early) - raised lesion on the mucocutaneous junction
Malignant melanoma
What are the following terms: 1: forced coitus or related sexual act within a marital relationship without the consent of the partner 2: sexual assault committed by an acquaintance of the victim. Someone the victim knows. 3: when the acquaintance is a family-member 4: when the forced sexual activity occurs in the context of a dating relationship 5: sexual intercourse with a minor under the age specified by state law 6 : contact or interaction between a child and adult when the child is being used for the sexual stimulation of that adult or another person Which one must you report in every state?
Marital rape: forced coitus or related sexual act within a marital relationship without the consent of the partner Acquaintance rape: sexual assault committed by an acquaintance of the victim. Someone the victim knows. Incest: when the acquaintance is a family-member (mostly stepparents) Date rape: when the forced sexual activity occurs in the context of a dating relationship Statutory rape: sexual intercourse with a minor under the age specified by state law Child sexual abuse: contact or interaction between a child and adult when the child is being used for the sexual stimulation of that adult or another person CHILD ABUSE MUST BE REPORTED!
Female pt. post partum presents with: -fevers, chills, - breast pain, mass, itching, discharge from nipples, swelling and enlarged lymph nodes. What dz? *What is it caused by?*
Mastitis *Staph aureus*
What dz is common in women with PMS/PMDD, and has symptoms of severe + swelling of the breast usually in luteal phase and may be related to the increase in gonadotropin levels? dx? txt?
Mastodynia U/S, Mammogram Txt: Good bra - breast support (avoid caffeine)
What condition? - Bleeding at *irregular* intervals *AND* varies in amount and duration What does SUDDEN onset of irregular bleeding indicate? When is this often seen? What is it associated with?
Menometrorrhagia: Bleeding at *irregular* intervals *AND* varies in amount and duration Sudden onset of irregular bleeding may be indication of cancer or complications of pregnancy Often seen around perimenopause Mainly associated with menorrhagia or DUB (dysfunctional uterine bleeding) (other etiologies: endometrial polyps, endometrial cancer, OCPs, tumors)
What condition: ◦ Heavy, prolonged menses (> 80ml) ◦ Occurs at regular intervals ◦ Often accompanied by other symptoms What are 4 causes? How do you treat? (3)
Menorrhagia *Uterine fibroids* (most common) DUB IUD Endometrial hyperplasia Contraception, NSAIDs. Surgery: D+C, endometrial ablation, myomectomy, hysterectomy
Is this an early, middle, late or metastatic findings of breast cancer? - Back or bone pain, jaundice, weight loss - A firm or hard axillary node >1cm. - Axillary nodes that are matted or fixed to the skin ipsilateral supraclavicular or infraclavicular nodes
Metastatic Fixed axillary: stage III Supraclavicular: Stage IV
What type of vulvar cancer? -8% of vulvar cancers -Usually originates from genital tract (cervical); less commonly kidney and urethra
Metastatic cancer to Vulva
What condition? -Uterine bleeding at irregular intervals esp b/w expected menses
Metrorrhagia (Causes: - Endometrial polyps - Endometrial/cervical cancer - Exogenous estrogen administration (OCP)s)
What condition? - unopposed estrogen leading to hyperplasia of the endometrial wall and results in bleeding
Metrorrhagia from Anovulatory DUB (causes: - Disorders of the hypothalamus-pituitary-ovarian axis - Immature feedback regulation in young women (first 12-18 months after menarche in young women) - Ovarian failure in climacteric women (before onset of menopause in older women) - Other causes include: • PCOS • Hypothyroidism • Hyperprolactinemia • Excessive physical exercise)
Is this an early, middle, late or metastatic findings of breast cancer? - Skin or nipple retraction, axillary lymphadenopathy, breast enlargement, redness, edema, pain, fixation of the mass to the skin or chest wall.
Middle stage
Where is the MOST common site of endometriosis? What is the MOST common symptom?
Most common site on ovaries, then uterine cul-de-sac Pelvic Pain is the most common symptom leading up to menstruation and resolving after
Where are the common metastasizes of Ovarian cancer? How do you treat Ovarian Cancer? - Epithelial -Germ When do you fu?
Mt: Epithelial: Peritoneum, omentum, liver, lung, bone Txt: Epithelial - Surgery (tumor debalking, BSO, Hysterectomy, partial omenectomy) + Chemo Germ: Removal of adnexa + Chemo (w/dysgerminoma) FU: bc recurrence is normal... Gyn-onco q2-4 mon x 2years; q6 mons x 3yrs
Which uterine anomaly: • Uterus just doesn't form (absent) • Vagina is only rudimentary or absent • Paramesonephric ducts degenerated • Could also have kidney abnormalities Is this common?
Mullerian Agenesis (Class 1) RARE!
Which uterine layer? - thickest muscular layer; - uses this layer for uterine contractions
Myometrium
Do condoms protect you against HPV?
NOT as protective bc the labial gets scrotal contact (this is NOT covered with a condom
What is the first-line treatment of abnormal uterine bleeding?
NSAIDs to decrease blood loss
What are the S/S of PCOS needed to diagnose?
Need to have 2 of the following for diagnosis of PCOS to be made: 1. Polycystic Ovaries 2. Oligo/Anovulation 3. Clinical evidence of hyperandrogenism (hirsuitism, Acanthos Nigrants, infertility)
What is the difference between Implanon and Nexplanon?
Nexplanon is the newer version which is radiopaque. Nexplanon can found on X-ray which facilitates its removal in the event that it has migrated, cost effective.
If the prolactin and TSH levels are normal, and pt has negative progestin test, what could be the cause of their amenorrhea? (3)
OUTFLOW tract issue - imperforate hymen/abnormal cavity - *Mullerian dysgenesis* (bicornuate) - 1° - *Asherman's syndrome* (scarring of intra-uterine cavity (aka synechiae) due to repeated procedures damaging intra-uterine environment leading to adhesion formation) - 2⁰
What are the S&S of turner's syndrome? When are patients commonly diagnosed?
Often not diagnosed until puberty when female sex characteristics fail to develop • Short stature, growth retardation • Swollen hands / feet, • Wide & webbed neck • Low or indistinct hairline • Arms that turn out slightly at elbow • Absent or incomplete development at puberty, • Broad, flat chest shaped like a shield, • Heart murmur from narrowing of aorta
What condition? - Cycle more than 35 days apart - they will say they get their period "every 3 or 4 months" Can be caused by an endocrine disorder, or excessive weight loss and stress, but what are the 2 more common causes? How do you treat?
Oligomenorrhea common causes: anovulation, PCOS Tx: want pregnancy → hormones to induce ovulation; no pregnancy wanted → hormonal contraception
Ovarian Development: What do the following refer to? a) Primordial follicles within ovary develop into oogonia and primary oocytes b) The immature female germ cell forming oocytes by repeated divisions c) Sit in ovary until puberty when they're stimulated by hormones to become mature graffian follicle which gets ovulated
Ovarian Development: What do the following refer to? a) Folliculogenesis - Primordial follicles within ovary develop into oogonia and primary oocytes b) Oogonia- The immature female germ cell forming oocytes by repeated divisions c) Oocytes- Sit in ovary until puberty when they're stimulated by hormones to become mature graffian follicle which gets ovulated
What is the MOST common cause of death in women with gyn cancer?
Ovarian cancer (2nd most common gyn cancer) (highest incidence 65-74 yo)
Women presents with *abdominal pain and bloating*, a palpable mass and ascites. What are you suspicious for?
Ovarian cancer: advanced malignant disease
*What is the MOST common cause of ovulatory dysfunction among reproductive women?*
PCOS (Mechanism of PCOS is not fully understood, but there is insulin resistance that is involved. Insulin resistance leads to hyperinsulinemia which leads to increased ovarian testosterone production)
Pt of reproductive age comes in with - *amenorrhea/irregular menses* - *hirsuitism and obesity* - acne - DM type 2 What dz? What is the most severe form (hint: HAIR-AN syndrome)
PCOS HAIR-AN SYNDROME: *H*yper*A*ndrogenism, *I*nsulin *R*esistence, and *A*canthosis *N*igrans
How do you dx cervical cancer? Txt?
PE: normal (preclinical); Infiltrative: Enlarged, irregular, firm cervix, cauliflower-like proliferation and high vascular cervical tissue +/- ulceration (*looks bad*) pap, colposcopy, ECC, Bx Tx → surgery ((hysterectomy), radiation +/- chemo
Case: 18yo girl, what dz? • never had kids that presents with fever and pelvic pain • abdominal pain is diffuse • negative pregnancy • leukocyotisis with left shift • guarding and rebound tenderness • cervical purulent discharge and cervical motion tenderness
PID
A overweight woman 20-30yo comes in with complaints of headache, breast tenderness, pelvic pain, bloating, irritability and lack of energy about a week prior to menses. What dz? Dx? What is the dz that is similar to this but disrupts daily living?
PMS Dx. no tests PMDD (depression, tension, mood lability, physical symptoms; sxs removed if ovaries are removed; Risk factors: anxiety, depression, seasonal affective disorder, EtOH abuse, overwt, sedentary lifestyle, family hx)
What is the MOST common cause of amenorrhea?
PREGNANCY!
Breast prevention: - crusting, eczematous-type lesion on the breast - Itching or BURNING of the nipple What dz?
Paget's disease (MALIGNANT, uncommon form of breast cancer!) (usually an underlying mass underneath the nipple!)
What part of the pubis: -upper crest of the pubis and promontory sacrum - transversely the ischial tuberosity
Pelvic Inlet-upper crest of the pubis and promontory sacrum Pelvic Outlet- transversely the ischial tuberosity
What is the loss of support of pelvic organs from the pelvic floor commonly caused by chronic elevation of intra-abdominal pressure (pregnancy, heavy lifting, chronic coughing, atrophic changes, smoking and obesity)? What organs does it effect?
Pelvic Relaxation affects: bladder, uterus and rectum
What condition? Irregular bleeding leading up to menopause Usual age of onset? Average duration?
Perimenopause age: 45 duration: 5 years
What structure? -Network of muscles between and surrounding the vagina and the anus -gets stretched/torn during vaginal delivery
Perineum
What condition: - shortening of the follicular phase; shortening of the luteal phase - Menses occur at regularly but cycles fewer than 21 days What type of women is this more typical in? How do you dx? How do you txt?
Polymenorrhagia dx: hx or measure basal temp over mons Tx → find cause; and treat it anemia → iron; short follicular phase or anovulation -→ estrogen or ovulation induction; short luteal phase - HCG 14th day, progestin 15th day, ovulation induction
A 29 yo gets her pap it comes out positive for ASCUS, and she gets the HPV test done. What happens if it is positive? What happens if it is negative?
Positive: Colposcopy Negative: repeat HPV in 1 year - if this is normal after 1 year, get normal pap every 3 years - this is abnormal after 1 year, do colposcopy
What dz? Bleeding that occurs after 12 months of amenorrhea in a middle-aged woman Most common cause? Dx? txt?
Post-Menopausal bleeding MC cause: exogenous hormones (HRT) (others: vaginal atrophy; organic causes) Dx: U/S, Biopsy, Hysteroscopy with D&C txt: depends on the source
How do you treat PCOS?
Pregnancy wanted → anti-estrogen (clomiphine); insulin lowering agents (metformin) Pregnancy unwanted → OCP; anti-androgens; progestin; insulin lowering agents (metformin)
What is defined as ovarian failure and menstrual cessation before age 40?
Premature menopause is defined as ovarian failure and menstrual cessation
How do you prevent, txt cystocele?
Prevention = Kegel exercises!!! txt: Pessary- hold everything up and hold and support the vagina. Estrogen—postmenopausal women Anterior colporrhaphy aka sling
What is the difference between primary and secondary amenorrhea?
Primary - an absence of menses in which the woman has never menstruated (usually by age 16) Secondary - absence of menses for 6 months in a previously menstruating female
Pt presents with: - Colicky pain in abdomen radiated to lower back, labia and thighs - Typically starts with onset of bleeding, but may not be present until 2nd day of menses - Associated N/V/D - Associated Headaches - Physical Exam shows *no significant pelvic disease* What dz? How do you treat?
Primary Dysmenorrhea txt: Naproxen (before onset of pain) OCPs heating pad exercise
What happens to the endometrium during the follicular phase? What is the length? Whats going on with the hormones?
Proliferative: - endometrium is proliferating/thickening - Approximately: days 5 - 16; but this varies (days 1-5 are menses) - preparing for possible implantation
What is the abortion pill that will disrupt the actual pregnancy within 6 weeks of conception?
RU486
Pt comes in complaining of vaginal fullness or falling out, and has a flat, weak perineal body. She says she has difficulty defecating and gets very constipated. She admits to just having a baby in where there was a big tear. What dz? Who is this MC in? txt?
Rectocele (Wall between the vagina and the rectum gets loose) MC associated with a patient who had a fourth degree tear during delivery. Tx → fiber, water, stool softeners; laxative; posterior colpoperineorrhaphy
What are the 2 effect of Relaxin?
Relaxes the Pubic symphysis, & pelvic joints (to make joints more reflexible and make room during pregnancy) Relaxes myometrium (inhibits uterine contraction during pregnancy, overcome during labor; softens and dilates the cervix to facilitate delivery)
What incontinence? urine loss: -after ↑ intra-abdominal pressure - strong unexpected urge to void -chronic urinary retention - reasons outside bladder urinary tract (impairment) -constant dribbling or dampness, positional loss of urine without urge or forewarning
STRESS-after ↑ intra-abdominal pressure URGE- strong unexpected urge to void OVERFLOW-chronic urinary retention FUNCTIONAL- reasons outside bladder urinary tract (impairment) BYPASS - constant dribbling or dampness, positional loss of urine without urge or forewarning
What type of vulvar cancer? - appears as a subcutaneous nodule or exophytic (growing outward beyond the surface epithelium) & fleshy -poor prognosis
Sarcoma of the Vulva (i.e. Lieomyosarcoma)
Case: what dz? • 16yo • itching • no sex How do you txt?
Scabies - permethrin
What type of uterine anomaly? o The two Mullerian ducts have fused, but the partition between them is still present splitting the system in two parts o Partial or complete - Usually the septum affects on the cranial part of the uterus Common? What does it cause? How is it fixed?
Septated Uterus o Most common uterine malformation and a large cause for miscarriages o Discovered sometimes in infertility work-up or after recurrent miscarriages o Septum can be easily surgically removed
What are the 3 layers of the uterus?
Serosa Myometrium Endometrium
Which uterine layer? - most external; - visceral peritoneum
Serosa - perimetrium
What is the most common type of cervical cancer? What is HPV 16 mostly found in? What is HPV 18 mostly found in? What is the average of of diagnosis of CANCER?
Squamous cell *16: Squamous cell* *18: Adenocarcinoma (glandular elements)* 51yo (bc these women never got screened before)
What is the most common type of vulvar cancer? Wht is the second type?
Squamous cell carcinoma Malignant Melanoma (2nd) (followed by adenocarcinoma → sarcoma → Bartholin's gland tumor → metastatic)
Describe the following stage of breast cancer: Stage 0: Stage 1:
Stage 0: Tis (tumor in situ) Stage 1: Tumor size <2cm A- or tumor <2cm B- no tumor in the breast, but some cluster cancer cells found in lymph nodes +/- <2cm tumor
Describe the following stage of breast cancer: Stage 2:
Stage 2: Stage A: Tumor size <2-5 cm Stage B: Tumor size <2-5 cm + cancer cells in lymph nodes +/- near breastbone or >5 with no lymph nodes
Describe the following stage of breast cancer: Stage 3:
Stage 3: Axillary node involvement A, B, C
Describe the following stage of breast cancer: Stage 4:
Stage 4: Distant metastasis
What layer of the endometrium is shed during menstruation?
Stratum functionale - superficial 2/3 of endometrium; shed during menstruation (Stratum basale - deep layer of endometrium; not shed)
What are the 4 classifications of fibroids by location? - below endometrium - into vagina through cervix, endometrial cavity, or abdominal cavity - within uterine wall - under serous surface of uterus
Submucosal- below endometrium Pedunculated- into vagina through cervix, endometrial cavity, or abdominal cavity Intramural- within uterine wall Subserous- under serous surface of uterus
Txt for menopause?
Supportive Care Herbal Supplements
T/F. Combined hormonal contraception or progestin ↓ the risk of endometrial hyperplasia/carcinoma among women with PCOS.
TRUE
What medication helps decrease cancer size and recurrence by shutting down the ovaries but increases the risk of uterine cancer?
Tamoxifen (must do endometrial biopsy prior!)
What are the 5 stages of tanner development? Age?
Tanner I: no glandular tissue; areola follows the skin contours of the chest (prepubertal) [typically age 10 and under] Tanner II: breast bud forms, with small area of surrounding glandular tissue; areola begins to widen [age 10-11.5] Tanner III: breast begins to become more elevated, and extends beyond the borders of the areola, which continues to widen but remains in contour with surrounding breast [age 11.5-13] Tanner IV: increased breast size and elevation; areola and papilla form a secondary mound projecting from the contour of the surrounding breast [age 13-15] Tanner V: breast reaches final adult size; areola returns to contour of the surrounding breast, with a projecting central papilla. [age 15+]
What type of cyst is the least common of the functional ovarian cysts, and is caused by ↑ levels of chorionic gonadotropins; and is seen in pts with hydatidform mole, choriocarcinoma, or patients using Clomid or chorionic gonadotropins? What color are these cysts? symptoms?
Theca Lutein cyst Straw-colored Pelvic heaviness (rupture may cause intraperitoneal bleeding)
What is the most common complication associated with ovarian cysts?
Torsion (functional ovarian cysts must be >3cm in size)
What are the Protoaz, Fungal, Ectoparasite cause of infections? (4)
Trichomonas vaginitis Vulvovaginal candidiasis Pediculosis pubis Scabies
What two chromosomal abnormalities: • Both lead to severe MR and a lot of congenital anomalies • If they survive to delivery, post-natal survival is not good • Often electively terminated pregnancies
Trisomy 18: Edwards Syndrome Trisomy 13: Patau Syndrome
Pt presents with Ovotestis, what dz? How do you dx? Txt?
True Hermaphroditism (Ovarian and testicular tissue) dx: Karyotype Treatment is Surgical
What are the surgical methods to contraception? WOTF is NOT permanent
Tubal sterilization Essure - stent in the tubes *Male Vasectomy* - not permanent
What is the syndrome in which the patient *just has one X chromosome and none other*?
Turner Syndrome (hormones are NOT produced)
What dz? - Short stature, shield chest, widely spaced nipples, webbed neck, *coarctation of the aorta*, and/or bicuspid aortic valve. ay present with lymphedema of the hands and feet in the neonatal period. May have horseshoe kidney Etiology? What does it cause?
Turner's syndrome due to gonadal dysgenesis causes: MOST common cause of 1° amenorrhea
How do you treat endometrial cancer? Txt for recurrent disease? When do you follow/up?
Tx → hysterectomy + BSO + bx of para-aortic LN; radiation; chemo; In Recurrence→ hormonal tx w/ a progestational agent, + chemo F/u → routine surveillance q 3-4 mons for 1st 2 yrs; intervals q6 mons for next 3 yrs, then annually
What are the 2 most common types of Ovarian Cancer? Which is more common in older women? younger women? Which is better prognosis? Which type of ovarian cancer is the MOST common overall?
Types: - Epithelial neoplasm (older 60s) - Germ Cell Neoplasm (younger 20-30s, better prognosis) Epithelial neoplasm → Serous Cystadenocarcinoma (usually bilateral)
What are the diagnostic labs (4) and U/S results of PCOS?
U/S: string of pearls Labs: ↑ serum androgen; LH/FSH >3; hyperinsulinemia;
What is the ONLY article of clothing that goes in the rape kit?
UNDERWEAR
Where is the MOST common location of breast cancer?
UOQ (45%)
What type of uterine anomaly? • Only one side of the Mullerian duct forms • The uterus has a single horn shape
Unicornuate Uterus
How do vaginal cancers present?
Usually asymptomatic and found on routine exam - Postmenopausal vaginal bleeding and/or bloody discharge. - Advanced tumors may impinge upon rectum or bladder or extend into pelvic wall causing pain or leg edema (late finding); -Bimanual exam w/ palpation of entire length of vagina can detect small submucosal nodules not visualized during exam
Pt. AA woman presents asymptomatic or with the following symptoms: - *bleeding*: long, heavy periods.→ anemia - *pressure* pelvic and bloating; constipation; frequency or retention - *Pain* 2° dysmenorrhea, dyspareunia - *pelvic sxs*: a firm, nontender, irregularly enlarged ("lumpy-bumpy*), or cobblestone uterus. What dz?
Uterine Leimyoma (Fibroids)
What dz? descent of cervix + uterus through vaginal canal sometimes past vaginal opening; caused by: obesity, large uterine/ovarian tumor What is the complete one called? Who is it most common in? Txt?
Uterine Prolapse Procidentia MC in Multiparous women Txt: Pessary, estrogen, hysterectomy with vaginal vault suspension
What is the MOST common GYN malignancy? Who? Risk factors?
Uterine cancer! 75% post-menopausal women ↑'d Risks: PCOS, obesity, smoking, age, nulliparous, late pregnancy, unopposed estrogen, tamoxifen, hereditary (remember for unopposed estrogen, you need progestin to neutralize the risk; tamoxifen has a stimulating effect on the endometrium; hereditary - HNPCC- colon thing)
What are the four ligaments of the uterine? Which is the primary support of the uterus?
Uterosacral *cardinal* Round Broad *Cardinal* - primary suport, attaches from cervix to pelvic sidewalls
What is the MOST COMMON symptom of uterine cancer?
Vaginal Bleeding! → anemia (80% of women with endometrial cancer have vaginal bleeding, but only 5-10% of women with abnormal vaginal bleeding have endometrial cancer; Consider: when there is post menopausal bleeding, peri-menopausal DUB - dysfunctional uterine bleeding)
Pt presents with abnormal vaginal bleeding, an abnormal discharge or postcoital bleeding. Prsents in the upper 1/3 of the vagina in 75% of all patients. What dz?
Vaginal cancer
What is the rare variants of squamous cell vulvar cancer? What does it look like?
Verrucous carcinoma It looks like a large wart and is a slow growing tumour that rarely spreads to other parts of the body. It is usually curable with surgery. = condylomatous growth
What do the following mean? a. Infertility → b. Primary infertility → c. Secondary infertility → d. Infecundity → e. Fecundity → f. Fecundability →
What do the following mean? a. Infertility → inability to achieve a recognized pregnancy after trying to conceive for 1 year b. Primary infertility → never able to conceive c. Secondary infertility → absence of a live birth > 5 years in persons w/ prior births d. Infecundity → inability to achieve a live birth e. Fecundity → the probability of achieving a live birth in 1 menstrual cycle f. Fecundability → likelihood of conception after a month of unprotected intercourse
What type of vaginal cancer: 1) Located on the posterior wall of upper 1/3 of vagina - Appears ulcerative, exophytic 2) Located on the anterior surface and lower half of the vagina - Apperance of nevi 3) seen in children <5yo and women in their 50-60s - presents like a grape-like structure that protrudes the vagina - located upper anterior wall
What type of vaginal cancer: 1) SQUAMOUS CELL: Located on the posterior wall of upper 1/3 of vagina - Appears ulcerative, exophytic 2) MELANOMA Located on the anterior surface and lower half of the vagina - Apperance of nevi 3) SARCOMA seen in children <5yo and women in their 50-60s - presents like a grape-like structure that protrudes the vagina - located upper anterior wall
Which type of endometrial cancer? A) - develops independently of estrogen -assocaited with endometrial atrophy - poorly differentiated tumor - high risk of relapse and poor prognosis B) - associated with endogenous or exogenous unopposed estrogen exposure - typically low-grade, well differentiated tyomr - favorable prognosis
Which type of endometrial cancer? A) TYPE 2 - develops independently of estrogen -assocaited with endometrial atrophy - poorly differentiated tumor - high risk of relapse and poor prognosis B) TYPE 1 - associated with endogenous or exogenous unopposed estrogen exposure - typically low-grade, well differentiated tyomr - favorable prognosis
Male with Kleinfelter's syndrome: Do they have normal male external genitalia and sexual function?
Yes normal genital and function but NO SPERM!!! (azoospermia!)
What are the 2 complications of abnormal uterine bleeding?
anemia endometrial hyperplasia +/- carcinoma
If the patient has the following, how do you fix? -anemia → - short follicular phase or anovulation - short luteal phase
anemia → iron; short follicular phase or anovulation→ estrogen or ovulation induction; short luteal phase → HCG 14th day, progestin 15th day, ovulation induction
Txt for osteoporosis?
bisphosphonates + calcium supplements
What organs are commonly affected in metastatic cervical cancer?
bladder or rectum
Again, *MOST common symptom* of endometrial cancer? How do you dx?
bleeding: post-menopausal bleeding + endometrial bleeding = think endometrial cancer! BIOPSY!
MOST common cause of miscarriage?
chromosomal defects
What happens to the corpus luteum if there is no fertilization?
corpus luteum → turns into corpus albicans and secretions of progesterone and estrogen ends ↓progesterone and ↓ estrogen → vasospasm of spinal arteries → No blood flow to endometrial lining → sloughing off of the lining
How do you dx and txt endometriosis?
def. dx: *DIRECT visualization via laparoscopy*. Ovaries have endometriomas that looks like "chocolate cysts" Classic lesions: have blue-black "raspberry" or dark brown "powder-burned" appearance Txt: Pregnancy desired → NSAIDS, laparoscopy to remove adhesions Pregnancy undesired → NSAIDs; *combined OCP*; Lupron (GNRH agonist); laparoscopy; definitive → hysterectomy + oophorectomy
How do you dx and txt PCOS?
dx: -PEARL NECKLACE sign of U/S - ↑androgens, ↑ testosterone (+/- free) - ↑LH/FSH ratio (LH secretion while inhibiting FSH) ~2:1 txt: no baby: OCP - first line + metformin yes baby: Clomiphene +/- metformin
How do you dx and treat fibroids?
dx: CBC -anemia U/S: uterine myomas (excludes ovarian masses) Txt: GnRH agonists Mirena IUD Surgery (myomectomy, hysterctomy, Embolization of uterine arteries, Ablation)
How do you dx and txt adenomyosis?
dx: *MRI is the most accurate test* curative txt: Hysterectomy
Case: What dz? • discharge • boyfriend • painful sex • lots of frothy discharge Txt?
dx: Trichomoniasis treatment: flagyl
How do you dx and txt mastitis?
dx: exam, biopsy, mammogram (if not breastfeeding) txt: warm compress, ABX, frequent feeding if breastfeeding. Surgical drainage if necessary
What does estrogen do during the endocrine cycle?
estrogen → *endometrial lining to thicken* and *cervical mucous thin* → positive feed back to hypothalamus to release LH
Pt has urinary incontinence, what are the steps in diagnosis and treatment?
first step: obtain UA and urine culture to r/o UTI Next: - voiding diary; urodynamic testing - serum creatinine to r/o renal dysfunction - cystogram to demonstrate fistula sites and descensus of bladder neck
If fertilization occurs, where does it occur?
in the ampulla (Ovulation occurs around day 14 of the cycle, when there is a surge of LH from the pituitary → mature follicle ruptures (14 days BEFORE you next period) → OVUM is released in the *ABDOMINAL CAVITY* → picked up the fimbrated ends of the fallopian tube)
Uterine myomas are benign but can cause what 2 things?
infertility or menorrhagia (malignant ones, leimyosarcomas, are rare 0.1-0.5%)
What is the most common cause of bloody discharge?
intraductal papilloma
What are the 4 benefits to oral contraceptions other than contraception?
lowers pain helps acne decreases menstrual blood loss lowers ovarian cancer risk
What are the 4 main factors in regards to the cause of infertility?
male factor (ex: sperm/ejaculation) ovulatory factor (ex: anovulatory, HPA issue, age) pelvic factor (ex: PID, Endometriosis, Uterine problems) cervical factor (ex: Müllerian duct abnormality)
What is the *only intra-abdominal organ bc it's NOT surrounded by peritoneum*?
ovary
*Where does the ovum mature and release?*
ovum *Matures and is released in the ABDOMINAL CAVITY*
What is going on in the endocrine cycle?
pituitary → FSH & little LH FSH → follicles form → ↑ estrogen estrogen → endometrial lining to thicken → positive feedback → stimulate hypothalamus → LH release ↑↑ LH→ ↓estrogen → egg is excreted into abdominal cavity
Fallopian tube, where is the proximal end and *distal end*?
prox: opening into the uterus through the fundus *distal*: to the *peritoneal cavity*
What is the txt for PMS/PMDD?
psych eval; *lifestyle - diet, exercise, no caffeine/EtOH, ↓ stress;* hormonal contraceptives; diuretics; nutritional supplements; *antidepressants;* congenital behavior therapy; NSAIDs
If a patient come in with a presentation of aching pelvic pain and dyspareunia, you do an u/s and see fluid in the cup-de-sac, what should you assume? How would you txt?
ruptured follicular cysts (sxs: pelvic pain, can be asymptomatic) txt: Most spontaneously regress OCPs can be given (if there is no follicle, there should be no cyst)
What are the sxs, dx and txt for CIN?
sxs: NONE dx: BIOPSY (with positive pap) txt: Ablation or excision
What are the common signs(2) and symptoms (3) of breast cancer?
symptoms: "lump" Breast Pain Nipple discharge Sign: palpable mass Poorly defined margins on breast
What is the breast tissue extends up into axillary region ?
tail of Spence
What happens to the cycle in menopause? What happens to FSH? What happens to the ovary?
the ovary no longer responds to LH/FSH (Ovarian failure) Ovarian failure → causes ↑↑ FSH by 40% → no longer secretes estrogen and progesterone
What do kegel exercise strengthen?
vaginal wall
Pt. presents with pruritus, pain, or ulcerations of mass. She states that initial the lesions were white, pigmented, raised and thickened, and ulcerative. But later progressed into large, cauliflower-like ulcerated lesions in the vulva. What does this pt have? Common cancer? average age?
vulvar cancer Rare 1-4% 65 yo (younger 20-40yo: the cancer is HPV)
How do you treat vulvar cancer for the following stages: - Stage 1 < 2cm - Stage 2 > 2 cm - Stage 3 + lymph node involvement - Stage 4 pelvic involvement - Stage 5 distant involvement
vulvectomy, lymphadenoctomy +/- radiation
Within how many days must a rape kit be done?
within 5 days! (>5 days, no rape kit, but a full extensive comprehensive history and exam can still be taken!; but you MUST know if the patient had sex with anyone else during that 5 day as well)
Fibrocystic change: primarily affects women of what ages? rare in what age? associated with what use? txt?
women 30-50 yo rare: post menopausal (thought to be hormonal) associated: *CAFFEINE* txt: dietary modifications (↓caffeine & salt, vit E)
How long can a sperm live inside the uterus? How long is there ovum fertilizable? When r women most fertile?
~72 hours ~30 hours 1-2 days before ovulation and day of ovulation
What are the 6 Uterine abnormalities? MOST COMMON? RARE?
• Class 1: Mullerian a genesis (RARE) • Class 2: Unicornuate uterus • Class 3: Uterus didelphys • Class 4: Bicornuate uterus • Class 5: Septate uterus (MOST COMMON) • Class 6: DES uterus
Endogenous estrogen: most potent: primary estrogen after menopause least potent:
• Estradiol (most potent), • Estrone (primary estrogen after menopause), • Estriol (least potent)
What do the following hormones do? FSH: LH: FSH & LH in males: Prolactin: Oxytocin:
• FSH - stimulates follicle development • LH surge - stimulates ovulation • FSH & LH in men controls the testes function •Prolactin -Stimulates milk secretion in the breasts - Inhibits the effects of FSH & LHà -Why breastfeeding women don't ovulate (mostly) • Oxytocin - stimulates uterine contractions during labor - Synthetic form of this is given IV to induce labor - Pitocin
***What is a definitive test for menopause?***
↑↑ FSH by 40%
What are the adverse effects of Depo?
↓ bone density weight gain
When can women be d/c from pap screenings? Who gets it lifelong?
≥70 you who had 3+ normal paps Lifelong: Women w/ DES exposure Immunocompromised (HIV/AIDS)