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Ovulatory (10%):
o OCPs: regulates cycle, thins endometrial lining
o Progesterone: orally or IUD (Mirena reduces bleeding in 79-94%)
o GnRH agonists: Leuprolide w/ add back progesterone reduces GnRH s/e
Surgery: done if not responsive to medical treatment
o Hysterectomy: definitive management
o Endometrial ablation: destruction of endometrium in pts who dont want a
hysterectomy
5) Amenorrhea:
- absence of menses
Primary Amenorrhea: failure of onset of menarche by age 13y/o (in the absence of
secondary sex characteristics) or age 15y/o (with secondary sex characteristics)
-Differential Diagnosis:
o Uterus present, Breasts present:
Outflow obstruction: transverse vaginal septum, imperforate hymen
o Uterus present, Breasts absent:
Elevated FSH, LH= Ovarian Causes
Premature Ovarian Failure (46XX)
o Follicular failure or follicular resistance to LH or FSH
Gonadal dysgenesis (ex Turners syndrome 45X)
o Turners Syndrome: female w/ absent/nonfunctional sex
chromosome. Rudimentary fibrosed ovaries=> primary
amenorrhea, menopause before menarche, delayed
secondary sex characteristics=> short stature, webbed
neck, edema, low hairline, low set ears, widely spaced
nipples
Normal/Low FSH, LH= Hypothalamus-Pituitary Failure
Puberty delay (ex athletes, illness, anorexia)
o Uterus Absent, Breasts present:
Mullerian agenesis (46XX)
Caused by embryologic growth failure of the mullerian duct,
with resultant agenesis or underdevelopment of the vagina,
uterus or both. Ovaries are normal in structure and function as
they have a separate embryologic source.
S/S+PE: normal height, secondary sexual characteristics, body
hair and external genitalia, absence of vagina and/or uterus
Diagnostic evaluation: transabdominal, translabial or transrectal
ultrasonography; three-dimensional ultrasonography or MRI
Management: psychosocial counseling, those with absent
vagina= nonsurgical (vaginal dilators) or surgical creation of a
neovagina
Androgen insensitivity (46XY)
A person who is genetically male (XY) is resistant to androgens
and as a result, the person has some or all of the physical traits of
a woman
S/S+PE: vagina but absence of uterus, little armpit and pubic
hair, breast develop, inguinal hernia w/ testes,
6) Premenstrual Syndrome:
Cluster of physical, behavioral, mood changes w/ cyclical occurrence during luteal phase
of menstrual cycle (7-14 days before onset of menses, relieved w/in 2-3 days of menses
onset) & at least 7 days symptom free during the follicular phase
4 phases: Menstrual (Day 1 of cycle), Follicular (1-12 days; estrogen predominates),
Ovulatory (12-14 days; LH surge causes ovulation), Luteal (Ovulation to onset of
menses; progesterone predominates)
PreMenstrual Dysphoric Disorder (PMDD): severe PMS w/ fxnl impairment
Clinical Manifestations:
o Physical: bloating, breast swelling/pain, HA, changes in bowel habits, fatigue,
muscle/joint pain
o Emotional: depression, hostility, irritability, libido changes, aggressiveness
o Behavioral: food cravings, poor concentration, noise sensitivity, loss of motor
senses
Diagnosis: sx seen in luteal phase (7-14 days before menses) w/ sx free follicular phase
(approx. 1 week)
Management:
o Nonpharmacologic: aerobic exercise, consumption of complex carbs and
frequent meals, relaxation training, light therapy, cognitive behavioral therapy,
low salt diet
o Pharmacologic:
SSRIs: for emotional sx (Fluoxetine, Sertraline, Paroxetine, Citalopram)
OCPs: induces anovulation. Drosperinone- containing OCP for PMDD
GnRH: done w. estrogen add back therapy if no response to SSRIs or
OCPs
Refractory breast pain: Danazol, Bromocriptine
Bloating; Spironolactone, calcium carbonate, low salt diet
7) Sexually Transmitted Diseases (characterized by urethritis and cervicitis)
a) Genital Herpes Simplex Virus: 90% caused by HSV II, 10% caused by HSV I (when
HSV I usually spread through oral sex)
-Risk Factors: vaginal, anal or oral sex; even spread when not an active outbreak
-S&S: painful vesicular lesions in bunches of at least 3, they break open and then heal
and go away w/in three weeks; flu-like symptoms such as fever, body aches, or
swollen glands; highly infectious when lesions are present; stress
can precipitate an outbreak
-Diagnosis: usually clinical, can take a culture of the sore if unsure
-Treatment:
First clinical episode: Acyclovir 400mg PO TID for 7-10 days
OR: Famciclovir 250mg PO TID for 7-10 days; Valacyclovir 1g PO BID for 7-10
days
Episodic Therapy for Recurrent episodes: Acyclovir 400mg PO TID for 5 days
o OR Famciclovir 1000mg PO BID for 1 day; Valacyclovir 1g PO QD for
5 days
Suppressive Therapy for Recurrent episodes: Acyclovir 400mg PO BID
o OR: Famciclovir 250mg PO BID; Valacyclovir 1g PO QD
-Complications: painful genital sores, spread to other parts of your body, pregnancy
complications such as miscarriage, early delivery, neonatal herpes which can be fatal
B) Chlamydia Trachomatis
-Risk Factors: vaginal, anal or oral sex
- S&S: may be asymptomatic, mucopurulent cervicitis, increased frequency, dysuria, abdominal
pain, PID, post coital bleeding
If Lymphogranuloma Venereum (LGV): Painless genital ulcer
-Diagnosis: Urethral, Cervical, Vaginal and Urine samples=> Ligase Chain Reaction (LCR)
Cervical and urethral samples= 97% sensitivity; Urine sample= 80% sensitivity
-Treatment:
Azithromycin 1g PO X 1 dose OR Doxycycline 100mg PO BID x 10 days
Treat for Gonorrhea!! Ceftriaxone 250mg IMx1 (co-infection likely)
Treat Partner!
-Complications: PID, infertility, ectopic pregnancy, premature labor
C) Neisseria Gonorrhoeae
-Risk Factors: vaginal, anal or oral sex; presence of columnar cells on a young womans cervix
increases susceptibility
-S&S: may be asymptomatic, vaginal discharge, cervicitis, increased frequency, dysuria
-Diagnosis: Culture of cervix or urethra; gran stain of cervix and vagina could offer immediate
diagnosis
-Treatment:
Ceftriaxone 250mg IM x 1 or Cefixime
Treat for Chlamydia!! (Azithromycin 1 g PO x 1)
Treat partner!
-Complications: PID, infertility, ectopic pregnancy, chronic abdominal pain, reactive arthritis
D) Mycoplasma genitalium
-Risk Factors: vaginal, anal and oral sex
-S&S: may be asymptomatic, pelvic pain, dyspareunia, abnormal discharge, cervicitis (red,
inflamed cervix)
-Diagnosis: cervical culture (Nucleic Acid Amplification Testing NAAT)
10) Endometriosis: presence of normal endometrial tissue (stroma and gland) outside the uterine
cavity; ectopic endometrial tissue responds to cyclical hormonal changes; 15% of US population
MC sites of ectopic endometrial tissue: ovaries (MC), posterior cul de sac, broad &
uterosacral ligaments, rectosigmoid colon, bladder & distal ureter
Risk factors: nulliparity, family hx, early menarche, onset <35y/o
S&S:
o Classic triad: cyclic premenstrual pelvic pain, dysmenorrhea, dyspareunia
o Dyschezia (painful defecation)
o Pre/post menstrual spotting
o Infertility (MC cause of infertility)
o PE: usually normal; possible fixed tender adnexal masses
Diagnosis:
o Laparoscopy w/ biopsy= definitive diagnosis (used to visualize structures for
presence of tissue)
o Endometrioma: endometriosis involving the ovaries large enough to be
considered a tumor, usually filled w/ old blood appearing chocolate colored
chocolate cyst
Treatment:
o Medical: ovulation suppression
Premenstrual pain: Combined OCPs + NSAIDS
Progesterone tx: suppresses GnRH, causes endometrial tissue atrophy,
suppresses ovulation
Leuprolide: GnRH analog causes pituitary FSH/LH suppression
Danazol: testosterone (induces pseudomenopause by suppressing FSH &
LH & mid cycle surge)
o Surgical:
Conservative laparoscopy w/ ablation: used if fertility desired (preserves
uterus and ovaries)
TAH-BSO (Total Abdominal Hysterectomy w/ Salpingoophorectomy): if
no desire to conceive
-Pyelonephritis:
500 mg of oral ciprofloxacin (Cipro) twice per day for seven days; 1,000 mg of
extended-release ciprofloxacin once per day for seven days; or 750 mg of
levofloxacin (Levaquin) once per day for five days. These options are
appropriate in areas where the prevalence of resistance to fluoroquinolones does
not exceed 10 percent.
12) Cervical Cancer (3rd MC gynecologic CA; 1st= endometrial CA. 2nd= ovarian CA)
Risk Factors:
o Early onset of sexual activity, increased # of partners, smoking, CIN (Cervical
Intraepithelial Neoplasm), DES exposure, Immunosuppression, STDs
2 Types:
o Squamous (90%)
o Adenocarcinoma (10%)
Clear cell carcinoma linked w/ DES exposure
Takes on average 2-10 years for carcinoma to penetrate the basement membrane
Clinical Manifestations:
o Post coital bleeding/spotting (1st symptom)
o Metorrhagia
o Pelvic pain
o Watery vaginal discharge
Diagnosis: Colposcopy w/ biopsy
o Screening= PAP smear w/ cytology
Management:
o Stage O: Carcinoma in situ
Local treatment:
Excision (LEEP, Cold knife conization)
Ablation tx (cryotherapy or laser)
TAH-BSO (total abdominal hysterectomy-bilateral salpingooophorectomy)
o Stage Ia1: microinvasion
Surgery: Conization, TAH-BSO, XRT
o Other stage I, IIA
TAH-BSO; XRT+ Chemo tx (Cisplatin)
o Stage IIb-Iva: Locally advanced; II- extends locally beyond cervix, III- lower 1/3
of vagina, IV- Local METS (bladder, rectum)
XRT+ Chemo (Cisplatin w/ 5FU)
o Ivb or recurrent: Distant Mets
Palliative XRT, Chemo (surgery is not likely to be curative)
Prevention: Gardasil vaccine vs HPV 6, 11, 16, 18; 3 doses in 6 mos; age 11-26; CI if
immunosuppressed, pregnant or lactating
Screening Guidelines:
o 21-29 y/o: PAP and HPV every 3 years
o 30-65 y/o: PAP and HPV every 5 years
13) Rectocele/Cystocele:
Rectocele: distal sigmoid colon into posterior distal vagina
Cystocele: posterior bladder herniating into the anterior vagina
Uterine prolapse: uterine herniation into the vagina
Enterocele: pouch of douglas (small bowel) into the upper vagina
Risk Factors:
o Weakness of pelvic support structures (MC after childbirth)
o Increased pelvic floor pressure due to:
Multiple vaginal births
Obesity
Repeated heavy lifting
Grades:
o I: descent into upper 2/3 of vagina
o II: cervix approaches introitus
o III: outside introitus
o IV: entire uterus outside of vagina= complete prolapse
Clinical Manifestations:
o Pelvic Fullness, heaviness falling out sensation
o Lower back pain (esp w/ prolonged standing)
o Vaginal bleeding, purulent discharge
o Urinary frequency, urgency, stress incontinence
PE: bulging mass esp w/ increased intrabdominal pressure (such as Valsalva)
Management:
o Prophylactic: Kegel exercises, weight control
o Nonsurgical: pessaries, estrogen treatment (improves atrophy)
o Surgical: hysterectomy; uterosacral or sacrospinous ligament fixation
Diagnosis:
o Pelvic US: vessels crossing os
APT test: blood from vagina, add sodium hydroxide. Fetal blood stays pink,
maternal blood brown/yellow
Management:
o Immediate C-Section
o
Management:
Await for spontaneous labor or induction of labor (with oxytocin or
prostaglandin gel)
Monitor for infection (infection is MC complication of PROM)
Placental abruption (done w/ placenta previa)
o
Types:
o Complete Molar pregnancy: egg with no DNA fertilized by 1 or 2 sperm.
46XX all paternal chromosomes.
Associated with higher risk of malignancy
o Partial Molar pregnancy: an egg is fertilized by 2 sperm (or 1 sperm that
duplicates its chromosomes). There may be development of the fetus but it is
always malformed and never viable
Risk Factors: prior molar pregnancy or extremes of age <20y or
>35 y; Asian
Pathophysiology:
o Abnormal pregnancy in which a nonviable fertilized egg implants in uterus with
a nonviable pregnancy which will fail to come to term => abnormal placental
development
Clinical Manifestations:
o Painless vaginal bleeding may begin @ 6 weeks- 4th/5th months MC. Possible
brownish discharge
o Uterine size/date discrepancies (ex larger than expected)
o Preeclampsia before 20 weeks
o Hyperemesis Gravidarum: due to significant hormonal changes
Diagnosis:
o B-HCG: markedly elevated (>100,000)
o Very low maternal serum a-fetoprotein
o Ultrasound: snowstorm or cluster of grapes appearance & absence of fetal
parts & heart sounds.
Cluster of grapes= enlarged cystic chorionic villi
Complete: no products of conception seen
Partial: gestational sac seen
Management:
o Uterine Suction curettage: as soon as possible to avoid risk of choriocarcinoma
development; pts followed weekly until B-HCG levels fall to an undetectable
level
o If METs: chemotherapy which destroys trophoblastic tissue. Suspect if B-HCG
rises or plateaus after tx, continue hemorrhage after tx, vaginal tumor or pelvic
mass presence
2) Invasive mole
o Same histopathologic characteristics of a hydatidiform mole, but invasion of the
myometrium with necrosis and hemorrhage occurs or pulmonary METs are
present
3) Choriocarcinoma
Ruptured:
Laparoscopic salpingostomy (surgical incision into a fallopian tube): 1 st
choice
May need to do reparative procedure to save reproductive organs
OR Salpingectomy (removal of fallopian tube)
Give RhoGAM if mother Rh-