Professional Documents
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Gynecoloy Tiki Taka
Gynecoloy Tiki Taka
___________________________
. THE BREAST:
________________
* BENIGN BREAST DISEASES:
______________________________
1 . Fibroadenoma.
2 . Fibrocystic disease.
3 . Intraductal papilloma.
4 . Fat necrosis (H/O of breast trauma).
5 . Mastitis (Inflamed, painful breast in women who are breast-feeding).
* MALIGNANT BREAST DISEASE (BREAST CANCER):
_____________________________________________________
1 . Ductal carcinoma insitu (DCIS).
2 . Lobular carcinoma insitu (LCIS).
3 . Invasive ductal carcinoma.
4 . Invasive lobular carcinoma.
5 . Inflammatory breast cancer.
6 . Paget's disease of the breast & nipple.
* NIPPLE DISCHARGE:
________________________
. H/O of bilateral nipple discharge -> Prolactinoma.
. Order prolactin levels & TSH levels (Hypothyroidism & Hyperprocatinemia).
. Surgical duct excision is NEVER the answer for bilateral, milky nipple discha
rge.
. These pts sh'd undergo workup for prolactinoma (PRL & TSH levels).
.
NIPPLE DISCHARGE
_
_____________________
|
_____________________________________
________________________
|
|
. UNI-lateral
. BI-lateral
|
|
_________________________
. PROLACTINOMA
|
|
-> Order TSH & PRL
. BLOODY
. NON-BLOODY
-> Exclude hypothyroidism & hyperprolactinemia
|
|
. MALIGNANCY
. INTRADUCTAL PAPILLOMA
. The most common cause of unilateral NON-bloody discharge is INTRA-DUCTAL PAPI
LLOMA.
. Symptoms: watery, serous or seosanguinous fluid disharge.
. Think cancer if associated e' palpable mass, involvement of more than 1 duct
or bloody discharge.
. Dx -> MAMMOGRAM -> Look for underlying mass or calcification.
. Dx -> SURGICAL DUCT EXCISION -> Definitive diagnosis.
. N.B.
. Cytology is NOT helpful & is NEVER the answer for nipple discharge.
* BREAST MASS:
_________________
{1} FIBROCYSTIC DISEASE:
____________________________
. Age -> 20 - 50 ys.
. Cyclical, bilateral, painful breast lump(s).
. Pain will vary with the menstrual cycle.
. Dx -> U/$ -> Simple cyst -> Sharp margins & posterior acoustic enhancement.
. Dx -> Fine needle aspiration (FNA) -> Cyst will collapse.
. Tx -> OCPs (Oral contraceptive pills) - Danazol may be used for severe pain.
{2} FIBROADENOMA:
_____________________
. Discrete, firm, NON tender & highly MOBILE breast nodule.
. HIGLY MOBILE MASS on clinical examination.
. Dx -> (1) -> CBE -> Clinical breast examination.
. Dx -> (2) -> U/$ & Mammography (If pt < 40 ys).
. Dx -> (3) -> FNA -> Epithelial & stromal elements.
. Tx -> Surgery (Diagnostic & therapeutic) -> Not necessary.
. N.B.
. Never diagnose a simple cyst on clinical exam alone !
. The Dx must be confirmed with either U/$ or FNA.
. N.B.
. Clinical breast examination in 6 weeks is appropriate follow up for a cystic
mass that disappears after FNA.
. If the mass recurs on the 6 week follow up, FNA may be repeated & a core biop
sy can be performed.
. N.B.
. A young pt who presents with a breast lump with NO signs of malignancy,
. can be asked to return after her menstrual period for reexamination, which ma
y reveal regression of the mass.
. Mammography is NOT useful in young pts due to density of the breast tissue.
. WHEN DO YOU ANSWER THE FOLLOWING ??
______________________________________________
(1) ULTRASOUND:
__________________
. 1st step in workup of a palpable mass that feels cystic on exam.
. Imaging test for younger women with dense breast.
(2) MAMMOGRAPHY (>50 ys old) & BIOPSY (or biopsy alone if < 40 ys old):
_______________________________________________________________________
. Cyst recurs > twice within 4-6 weeks.
. There is bloody fluid on aspiration.
. Mass doesn't disappear completely upon FNA.
. There is bloody nipple discharge (Excisional biopsy).
. There are skin edema & erythema suggestive of inflammatory breast carcinoma (
Excisional biopsy).
. N.B.
. Mammogram sh'd be done before biopsy as biopsy distorts radiography.
(3) FINE NEEDLE ASPIRATION or CORE BIOPSY:
_________________________________________________
. Needed for a palpable mass.
. May be done after U/$ or instead of U/$.
. N.B.
. Core biopsy is superior to FNA.
(4) CYTOLOGY:
_______________
. Any aspirate that is grossly bloody must be sent for cytology.
(5) OBSERVATION WITH REPEAT EXAM IN 6-8 WEEKS:
_______________________________________________________
. Cyst disappears on aspiration & the fluid is clear.
. Needle biopsy & imaging studies are negative.
. N.B.
. A cluster of microcalcifications on mammaogram are mostly benign, however;
. approximately 15-20 % represent early cancer.
. The next step in workup is core needle biopsy under mammographic guidance.
________________________________________________________________________________
______________________________
. BREAST CANCER:
____________________
{1} PRE-INVASIVE DISEASES:
______________________________
______________________________
. Both ductal carcinoma in situ (DCIS) & lobular carcinoma in situ (LCIS) ++ th
e risk of invasive disease.
. If biopsy reveals DCIS :
-> Schedule surgical resection with clear margins (Lumpectomy; breast conserv
ing surgical resection).
-> Radiation therapy (RT).
-> Tamoxifen for 5 ys to prevent the development of invasive disease.
. It is NOT necessary to perform surgery.
. LCIS is classically seen in premenopausal women.
. N.B. Risks associated with Tamoxifen use:
-> Endometrial carcinoma.
-> Thromboembolism.
. Contraindications to Tamoxifen:
-> Patient is active smoker.
-> Previous thromboembolism.
-> High risk for thromboembolism.
{2} INVASIVE BREAST DISEASES:
__________________________________
__________________________________
(1) INVASIVE DUCTAL CARCINOMA:
_____________________________________
. is the most common form of breast cancer (85% of all cases).
. Unilateral.
. Metastatizes to bone, liver & brain.
(2) INVASIVE LOBULAR CARCINOMA:
______________________________________
. 10 % of breast carcinomas.
. Multifocal (within the same breast) & bilateral in 20 %.
(3) INFLAMMATORY BREAST CANCER:
_______________________________________
. Uncommon, grows rapidly & metastatizes early.
. Red, swollen, warm breast & pitted, edematous skin (Classic peau d'orange app
earance).
(4) PAGET's DISEASE OF THE BREAST & NIPPLE:
__________________________________________________
. Pruritic, erythematous, scaly nipple lesion.
. Often confused e' dermatosis-like eczema or psoriasis.
. Look for inverted nipple or discharge.
* ESTABLISHED RISK FACTORS FOR BREAST CANCER:
________________________________________________________
. Age > 50 ys.
. Familial BRCA1/BRCA2 mutation carrier.
. Benign breast disease, especially cystic disease, proliferative & atypical ty
pes of hyperplasia.
. Exposure to ionizing radiation.
. 1st childbirth after age 30 or nulliparity.
. Higher socioeconomic status.
. H/O of breast cancer.
. H/O of breast cancer in a 1st degree relative.
. Hormone therapy.
. Obesity (BMI > 30 Kg/m2).
* BREAST CANCER SCREENING GUIDELINES (USPSTF):
_________________________________________________________
. Mammogram every 1-2 ys recommended for ages 50-74 ys.
. Screening before age 50 is NO longer recommended.
. Women < 50 sh'd only consider mammographic screening based on high individual
risk for early onset breast cancer.
. Teaching breast-self examination is NO longer encouraged.
. Clinical breast exams are NO longer routinely advised.
* When are BRCA1 & BRCA2 gene testing indicated?
__________________________________________________
. Family H/O of early-onset (<50ys of age) breast cancer or ovarian cancer.
. Breast &/or ovarian cancer in the same pt.
. Family H/O of MALE breast cancer.
. Ashkenazi Jewish heritage.
. N.B.
. Primary ttt of invasive carcinoma when tumor size < 5cm is:
-> LUMPECTOMY + RADIOTHERAPY + ADJUVANT THERAPY + CHEMOTHERAPY.
. N.B.
. Sentinel node biopsy is preferred over axillary node dissection.
. ALWAYS test for E & P receptors & HER2/neu receptor protein.
. N.B.
. Primary ttt of inflammatory, tumor size > 5 cm & metastatic disease is SYSTEM
IC THERAPY.
. N.B.
. Breast conserving surgical therapy (Lumpectomy) + Radiotherapy is the standar
d of care for invasive disease.
. There is NO survival benefit with modified radical mastectomy.
* When is breast conserving therapy NOT the answer ?
___________________________________________________
. Pregnancy.
. Prior irradiation to the breast.
. Diffuse malignancy or > 2 sites in separate quadrants.
. Positive tumor margins.
. Tumor > 5 cm.
* When is adjuvant hormonal therapy included in management ?
_____________________________________________________________
. In any hormone receptor +ve (HR+) tumors regardless of age, menopausal status
, stage & type of tumor.
.
.
.
.
N.B.
There is greatest benefit when both ER+ & PR+ receprors are present.
Therapy is nearly as good when there are only ER+ estrogen receptors.
Adjuvant therapy has the least benefit when only PR+ receprors are present.
.
.
.
.
N.B.
Tamoxifen competitively binds estrogen receptors.
5 ys ttt -> 50 % -- in recurrence & 25 % -- in mortality.
May be used in pre or postmenopausal pts.
. N.B.
. Aromatase inhibitors (Astronazole - Exemestane - Letrozole) block peripheral
production of Estrogen.
. This is the standard of care in HR+ postmenopausal women (More effective than
Tamoxifen).
. Doesn't cause menopausal symptoms but doesn't ++ the risk of osteoporosis.
.
.
al
.
N.B.
LHRH analogs (Goserelin) or Ovarian ablation (Surgical oophorectomy or Extern
beam RT)
is an alternative or an addition to Tamoxifen in premenopausal women.
N.B.
The only difference between Tamoxifen & Raloxifen is the effect on endometriu
Tamoxifen -> ++ cancer.
Raloxifen -> - - cancer.
. 2ry dysm
. Symm
. Dif
. Cyst
. Hysteroscopy: . Direct visualize tumors.
/A.
. N
. Is t
. N/A.
. N/A.
______________________
PHYSICAL EXAMINATION & PELVIC ULTRASONO
GRAPHY
________________________________________
____________________
|
_______________________________________________________
_______________________
|
|
|
No ovarian mass
Bilateral solid
Bilateral cystic
Unilateral solid
|
|
|
Abdominal CT
Theca lutein cysts
Pregnancy luteoma
Laparotomy/Laparoscopy
to rule out adrenal mass
Rule out ++ B-hCG states
to rule out malignancy
. N.B.
. Postmenopausal woman with abdominal distension & ovarian mass -> Suspect Ovar
ian neoplasm.
. Dx -> CT Abdomen -> Ascites ? (No -> Laparoscopy) (Yes -> Laparotomy -> Ooph
rectomy & surgical staging).
. OVARIAN MASSES QUIZ:
__________________________
.Q. 9 yrs old girl - Rt adnexal pain - Complex cystic mass on U/$ -> GERM CELL
TUMOR
-> It is the most common in young women.
-> The most common malignant epithelial cell type -> DYSGERMINOMA.
-> Tumor markers (LDH - B-hCG - a-FP).
.Q. 67 ys old - Progressive weight loss - Distended abdomen - Left adnexal mass
-> EPITHELIAL TUMOR.
-> The most common ovarian cancer in postmenopausal women.
-> The most common malignant subtype is SEROUS.
-> Tumor markers (CA-125 - CEA).
.Q. 58 ys old - Postmenopausal bleeding - Endometrial hyperplasia - Rt ovarian
mass on U/$ -> GRANULOSA THECA
-> Granulosa theca is a stromal tumor.
-> It secretes ESTROGEN & can cause endometrial hyperplasia.
-> It may be present in children with precocious puberty.
-> Tumor marker (ESTROGEN).
.Q. 48 ys old - ++ facial hair - Deepening of voice - Adnexal mass on exam -> S
ERTOLI-LEYDIG
-> Sertoli-Leydig is a stromal tumor.
-> It secretes TESTOSTERONE.
-> Pt presents with masculinization syndromes.
-> Tumor marker (TESTOSTERONE).
.Q. 64 ys - H/O of gastric ulcer - Dyspepsia - Weight loss & abdominal pain - A
dnexal mass-> KRUKENBURG TUMOR
-> Krukenburg tumor is a matastatic gastric cancer.
-> It is a mucin producing adenocarcinoma from the stomach that has meta
statized to one or both ovaries.
-> Tumor marker (CEA).
. GENERAL MANAGEMENT OF OVARIAN MASSES:
__________________________________________________
. U/$ ( & CT for postmenopausal women).
. Biopsy via laparoscopy for simple cysts suggestive of malignancy (No septatio
ns or solid components).
. Biopsy via laparoscopy for postmenopausal without ascites.
. Tumor markers (LDH, B-hCG, a-FP, CA 125, CEA, E & P).
. PRE-menstrual women -> Salpingo-oophrectomy.
. POST-menopausal women -> TAH & BSO (Total abdominal hysterectomy & Bilateral
Salpingo-oophrectomy).
________________________________________________________________________________
______________________________
* CERVIX:
___________
___________
. CERVICAL NEOPLASIA:
__________________________
. The most common HPV types associated with cervical cancer are HPV 16, 18, 31,
33 & 35.
. HPV 6 & 11 are benign condyloma accuminata.
. PAP SMEAR CLASSIFICATION:
_________________________________
. INDETERMINATE SMEARs -> Atypical squamous cells of undetermined significance
(ASCUS).
. ABNORMAL SMEARs ->
-> Low grade squamous intraepithelial lesion (LSIL) -> HPV, mild dysplasia or
CIN 1.
-> High grade squamous intraepithelial lesion (HSIL) -> Moderate dysplasia, se
vere dysplasia, CIS, CIN 2 or 3.
-> Cancer -> Invasive cancer.
. Risk factors associated e' cervical neoplasia:
__________________________________________
. Early age of intercourse - Multiple sexual partners - Cigarette smoking - Imm
unosuppression.
. SCREENING:
______________
. Started at age 21, regardless of onset of sexual activity.
. Conventional method -> 50 % sensitivity.
. Liquid based prep. -> 75-80 % sensitivity.
. HPV DNA TEST -> Useful in management of ASCUS.
. Pt < 30 ys old -> Annually for conventional Pap or Every 2 ys for liquid base
d.
. Pt > 30 ys old -> Screen every 2-3 ys if > 3 consecutive -ve PAP smears.
. CERVICAL CANCER SCREENING GUIDELINES (USPSTF):
___________________________________________________________
. Pap screening NOT recommended for women > 65 ys with recent normal Pap smear.
. Pap smear NOT recommended for women with total hysterectomy for benign diseas
e.
. HPV testing alone is NOT suffecient for screening.
. N.B.
. ASCUS is most commonly found in women e' inflammation due to early HPV infect
ion.
. 10-15 % of pts with ASCUS have premalignant or malignant disease.
. 2 Pap smears revealing ASCUS must be followed up with colposcopy & biopsy.
. PAP at age 21 ys ==================> ASCUS: FOLLOW UP
|
_______________________________
______________________
|
|
CERTAIN
UN CERTAIN
___________
_______________
|
|
. PAP 3-6 months.
. Colposcopy & biopsy.
. HPV DNA testing.
|
____________________
|
- ve
|
Follow up
|
+ ve
(PAP -> ASCUS)
(HPV -> 16 & 18)
|
Colposcopy & biopsy
Vaginal septum.
Anorexia nervosa.
Excessive exercise.
Pregnancy before the 1st m
enses !
. IF THE BREATS ARE PRESENT & THE UTERUS IS ABSENT:
_____________________________________________________________
. Order Testrosterone levels & Karyotyping:
. {MULLERIAN AGENESIS} XX karyotype, Normal testosterone for FEMALE.
. {ANDROGEN ISNENSITIVITY = TESTICULAR FEMINIZATION} XY karyotype, Normal testo
sterone for MALE.
. IF THE BREASTS ARE ABSENT & THE UTERUS IS PRESENT:
______________________________________________________________
. Order FSH & Karyotype.
. {GONADAL DYSGENESIS = TURNER'S $} XO karyotype, FSH ELEVATED.
. {HYPOTHALAMIC - PITUITARY FAILURE = KALLMAN'S $} XX karyotype, FSH LOW.
. ABSENT BREASTS & UTERUS -> Not cilinically relevent !!
. N.B. In pts e' Mullerian agenesis, with absent uterus, cervix & upper vagina,
intact ovaries with normal estrogen
levels, VAGINAL RECONSTRUCTION
sh'd be performed to elongate the vagina for satisfactory intercourse.
. N.B. In cases with ABSENT BREASTS WITH UTERUS PRESENT, FSH levels are ordered
1st:
. FSH ++ -> Do KARYOTYPING to detect TURNER'S $ (XO).
. FSH -- -> Do CRANIAL MRI to detect HYPOTHALAMIC-PITUITARY FAILURE.
* MULLERIAN AGENESIS:
___________________________
. Normal female 2ry sex characters.
. Normal testosterone levels (Intact ovaries).
. Absence of all Mullerian duct derivatives (Fallopian tubes, uterus, cervix &
upper vagina).
. Tx -> Surgical elongation of the vagina for satisfactory intercourse & counse
ling about infertility.
* ANDROGEN INSENSITIVITY $ = TESTICLAR FEMINIZATION = PSEUDOHERMAPHRODITE MALE:
________________________________________________________________________________
___________________
. No public or axillary hair.
. Karyotyping -> Male genotype XY.
. Ulrasound -> TESTES.
. The testes produce BOTH NORMAL levels of ESTROGEN for a FEMALE & TESTOSTERONE
for a MALE.
. Tx -> Removal of testes before age 20 due to ++ risk of testicular cancer.
. Estrogen replacement will then be needed.
. N.B. Androgen insensitivity $ (46 XY) is a MALE with 1ry amenorrhea, bilatera
l inguinal masses, breast
development, no pubic or axillar
y hair.
. The peripheral tissues are unresponsive to androgens, with normal and
rogen concentrations.
. No mullerian structures (No uterus - No fallopian tubes).
. The vagina ends with a blind pouch.
. Tx -> Gonadectomy AFTER puberty to avoid testicular carcinoma AFTER c
ompletion of breast development
& end of height spurt.
. N.B. Andogen insensitivity $ -> PRESENCE of Mullerian inhibiting factor.
* GONADAL DYSGENESIS = TURNER'S $:
_________________________________________
. Karyotyping -> 45 XO .. Absence of one X chromosome (45,XO).
. Absence of 2ry sex characters.
. ++ FSH.
. Because the second X chromosome is essential to the development of normal ova
rian follicles, streak gonads develop.
. Tx -> Estrogen & Progesterone replacement for development of 2ry sex characte
rs.
. N.B. Other manifestations of Turner's $ -> Aortic coarctation & upper BP > lo
wer BP.
* HYPOTHALAMIC PITUITARY FAILURE = KALLMAN'S $:
__________________________________________________________
. Karyotyping 46 XX.
. U/$ -> Normal uterus.
. LOW FSH.
. It may be due to stress, excessive exercise or anorexia nervosa.
. ANOSMIA (Hypothalamus doesn't produce GnRH).
. CT head will rule out any brain tumor.
. Tx -> Estrogen & Progesterone replacement for development of 2ry sex characte
rs.
________________________________________________________________________________
______________________________
* SECONDARY AMENORRHEA:
_______________________________
. Regular menses are replaced by an absence of menses for 3 months.
or
. Irregular menses are replaced by an absence of menses for 6 months.
* WORK UP FOR SECONDARY AMENORRHEA:
______________________________________________
{1} PREGNANCY TEST (B-hCG) !!
{2} THYROTROPIN (TSH) (RULE OUT HYPOTHYROIDISM):
_________________________________________________________
. An elevated TRH in primary hypothyroidism -> ++ prolactin.
. -- TSH -> ++ TRH -> ++ PRL.
. Treart hypothyroidism with thyroid replacement for rapid restoration of menst
ruation.
{3} PROLACTIN (RULE OUT HYPERPROLACTINEMIA):
______________________________________________________
. If elevaed:
. 1. Review medications ( Antipsychotics & Antidepressants have ANTI-DOPAMINE s
ide effect -> ++ PRL).
. 2. CT or MRI HEAD (To rule out pituitary tumor).
.. Tumor < 1 cm -> Give bromocrptine (Dopamine agonist).
.. Tumor > 1 cm -> Surgical ttt.
. 3. If the cause of ++ PRL is idiopathic -> Tx -> Bromocriptine.
{4} PROGESTERONE CHALLENGE TEST (PCT):
______________________________________________
. +ve PCT -> Any withdrawal bleeding is diagnostic of ANOVULATION !
. Tx -> CYCLIC PROGESTERONE to prevent endometrial hyperplasia.
. CLOMIPHENE ovulation induction is done if pregnancy is desired.
. -ve PCT -> Inadequate Estrogen or Outflow tract obstruction.
{5} ESTROGEN-PROGESTERONE CHALLENGE TEST (EPCT):
____________________________________________________________
. 3 weeks of oral estrogen followed by 1 week of progesterone.
. +ve EPCT -> Any withdrawal bleeding is diagnostic of INADEQUATE ESTROGEN !!
----------------. Next step is -> Get FSH level:
.. ++ = OVARIAN FAILURE. Y chromosome mosaicism may be
the cause if pt < 25 ys. Order karyotyping
.. ---- = HYPOTHALAMIC PITUITARY INSUFFECIENCY. Order B
RAIN CT or MRIto rule out a tumor.
.. Give Est replacement therapy to prevent osteoporosis
& cyclic progestins to prevent end. hyperplasia.
. -ve EPCT -> Diagnostic of outflow tract obstruction or endometrial scarring (
Asherman $).
---------------. Next step is -> Order a HYSTEROSALPINOGRAM to identify the
lesion.
. Tx -> Adhesion lysis follwed by Estrogen stimulation of th
e endometrium.
. N.B. TRH -> ++ PRL.
. Hypothyroidism -> Hyperprolactinemia.
. N.B. Pregnancy & thyroid states:
. ++ TBG - T3 - T4
. NORMAL TSH - Free T3 & T4.
. N.B. Vigrous atheletes have -- LH & -- GnRH -> Estrogen defeciency -> 2ry ame
norrhea -> Infertility.
. These atheletes have -- BMI with thin well defined musculature.
. N.B. Acquired hypogonadotrophic hypogonadism is a cause of amenorrhea seen mo
st commonly in association with
significant stressors, eating diso
rders & excessive exercise.
. Tx -> PULSATILE GnRH therapy can induce ovulation.
. N.B. The cause of amenorrhea in lactating mothers is INHIBITION of GnRH by +
+ circulating PROLACTIN
. NOT human placental lactogen xxx (Common mistake).
. N.B. The main cause of irregular menstrual cycles in women shortly after mena
rche is:
. IMMATURE HYPOTHALAMIC PITUITARY GONADAL AXIS & ANOVULATION
. This leads to insuffecient gonadotropins secretions.
. Dx -> Give progesterone -> Withdrawal bleeding.
________________________________________________________________________________
______________________________
* PRE-MENSTRUAL $YNDROME:
_________________________________
{1} PRE-MENSTRUAL TENSION:
________________________________
. Distressing physical, psychological & behavioral syms recurring at the same p
hase of the menstrual cycle.
. Disappear during the remainder of the cycle.
{2} PRE-MENSTRUAL DYSPHORIC DISORDER (PMDD):
______________________________________________________
. More severe, involving major disruptions to daily functioning & relationships
.
. Dx -> Menstrual diary.
. Tx -> SSRI (Fluoxetine) & Vit. B 6.
________________________________________________________________________________
______________________________
. ENDOCRINE DISORDERS:
___________________________
. Hirsutism -> Excessive male pattern hair growth in a woman.
. Verilization -> Hirsutism + Masculinizing signs
(Clitoromegaly - Baldness - Low voice - ++ muscle ma
ss - loss of female body contour).
. Almost all cases of hirutism are either PCOS or IDIOPATHIC.
. More serious causes of hirsutism (ANDROGEN SECRETING TUMORS) need to be exclu
ded in work up.
. WORK UP -> TESTOSTERONE - DHEAS - LH/FSH - 17 HYDROXYPROGESTERONE.
{1} POLYCYSTIC OVARIAN $YNDROME (PCOS):
_______________________________________________
. It is considered as OVARIAN cause of infertility.
. Gradual onset of hirsutism, obesity, acne, irregular bleeding & infertility.
. Chronic anovulatory cycles -> Infertility.
. Dx -> LH / FSH -> +++++++++ !
. Dx -> U/S -> Bilaterally enlarged ovaries.
. Anovulation -> No corpus
->
->
->
|
NEGATIVE
POSITIVE -> PREGNANCY
|
|
_______________________________________________________________
________________________
|
|
|
|
|
++ PROLACTIN
++ FSH
++ TESTOSTERONE
++ TSH & -- T4
H/O of uterine procedures
|
|
|
|
|
Normal TSH
Ovarian failure
PCO
Hypothyroidism
Normal FSH
No PRL ++ medications
Normal TSH
Normal creatinine
Normal PR
L
|
|
MRI brain with pituitary focus
E/P stimulation
No withd
rawal bleeding
|
Hysteroscopy or HSG
to rule out
ASHERMAN $
________________________________________________________________________________
______________________________
* OSTEOPOROSIS:
__________________
. The most common affected site is VERTEBRAL BODIES -> Crush #s, kyphosis &
-height.
. Hip & wrist #s are the next most common sites.
. The most common risk factor is +VE FAMILY H/O in a THIN WHITE FEMALE.
. Other risk factors: Steroid use, low Ca intake, SMOKING & ALCOHOL.
. PREVENTION with Ca & Vit. D, weight bearing exercise & elinination of cigaret
tes & alcohol.
. Dx -> DEXA SCAN (Dual energy x-ray absorptiometry) to assess BONE DENSITY.
-> Results in the form of T-score -> >- 2.5 = Osteoporosis.
. Ca loss is assessed with a 24 hour urine hydroxyproline or NTX (N-telo-peptid
e, a bone breakdown ptn product).
. Tx -> BIPHOSPHONATES & SERMs are the 1st line of therapy.
-> Biphosphonates (Alendronate - Risedronate) INHIBIT OSTOCLASTIC ACTIVI
TY.
-> SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERMs) INCREASE BONE DENSITY.
. SERMs are protective against the heart & bone AGONIST effects but br
east ANTAGONIST effects.
. RALOXIFENE has bone AGONIST effects but endometrial ANTAGONIST effec
ts.
prevents endometrial cancer.
. N.B. Estrogen is NEVER the 1ry ttt of osteoporosis bec. of ass. risks of clot
s & endometrial cancers.
. N.B. DEXA SCAN -> T-score -> 1.5 - 2.5 -> OsteoPENIA.
-> > 2.5
-> OsteoPOROSIS
.
________________________________________________________________________________
______________________________
* HORMONE REPLACEMENT THERAPY (HRT):
______________________________________________
. HRT is used to ttt the following:
. HRT is NOT used in the following:
_________________________________
___
______________________________
. Menopausal vasomotor symptoms (Hot flashes).
osis.
. Genitourinary atrophy.
. Estrogen sensitice cancer (Breast or endometrial).
. Dyspareunia.
. Liver disease.
. Osteopor
. Active thrombosis.
. Unexplained vaginal bleeding.
. BENEFITS of HRT:
. RISKS of HRT:
____________________
________________
. -- rate of osteoporotic #s.
. ++ risk of DVT.
. -- rate of colorectal cancer.
. ++ risk of heart attacks & breast cancer.
(Risk of breast cancer is only ass. e' therapy > 4ys).
. N.B.
. Women withOUT a uterus can be given CONTINOUS ESTROGEN.
. All women WITH a uterus must also receive PROGESTIN therapy to prevent endome
trial hyperplasia.
. GUIDELINES for HRT:
_______________________
. Only start HRT for vasomotor symptoms.
. Never give HRT for the prevention of CVS disease.
. Use the lower dose of HRT to ttt syms.
. Use the shortest duration of HRT to ttt syms; reevaluate annually.
. Don't exceed 4 ys of ttt (++ risk of breast cancer after 4 ys of ttt).
. N.B. On HRT, the requirement of L-thyroxine is ++ in ttt of menopausal women.
________________________________________________________________________________
______________________________
* CONTRACEPTION:
_____________________
{1} BARRIER METHODS:
________________________
. Condoms, vaginal diaphragm & spermicides.
. Protective agaisnt STDs.
{2} STEROID CONTRACEPTION:
________________________________
. Combination of E + P.
. Progestin only pill called "mini-pill".
. ABSOLUTELY CONTRAINDICATED in:
-> Pregnancy.
-> Acute liver disease.
-> Vascular disease (thromboembolism, DVT, CVA & SLE).
-> Hormone dependent cancer (Breast carcinoma).
-> Smoker > 35 ys.
-> Uncontrolled HTN.
-> Migraines with aura.
-> DM with vascular disease.
. RELATIVELY CONTRAINDICATED in:
-> Migraines.
-> Depression.
-> DM.
-> Chronic HTN.
-> Hyperlipidemia.
. BENEFITS:
-> -- Ovarian & endometrial cancer.
-> -- Dysmenorrhea.
-> -- DUB.
-> -- Ectopic pregnancyy.
{3} INTRA-UTERINE DEVICE (IUD):
____________________________________
. Levonorgestrel impregnated.
. Copper banded.
. ABSOLUTELY CONTRAINDICATED in:
-> Pregnancy.
-> Pelvic malignancy.
-> Salpingitis.
. RELATIVELY CONTRAINDICATED in:
-> Abnormal uterine size or shape.
-> Immunosuppression.
-> Nulligravity.
-> Abnormal Pap smear.
-> H/O of ectopic pregnancy.
. BENEFITS:
-> Effective & avoids side effects of hormonal therapy.
. N.B.
. Low dose OCPs don't ++ the risk of cancer, heart disease or thromboembolic ev
ents in women with no ass. risk factors
as HTN, DM or smoking.
.
RACEPTIVE PILLs
ORAL CONT
|
_______________________________________
________________________
|
|
SERIOUS SIDE EFFECTS
PROTECT AGAINST
__________________________
_____________________
1 . Venous thromboembolism.
1 . Ovarian cysts & cancer.
2 . Cardiovascular events & stroke.
2 . Endometrial cancer.
3 . ++ Triglycerides.
3 . Benign breast disease.
4 . Cholestasis or cholecystitis.
4 . Dysmenorrhea -> Anemia.
5 . DM.
6 . HTN.
. N.B. OCPs does NOT cause weight gain (Common mistake).
. N.B. Emergency contraception -> LEVONORGESTREL !
________________________________________________________________________________
______________________________
* INFERTILITY:
_________________
. Inability to achieve pregnancy after 12 months of unprotected & frequent inte
rcourse.
. INFERTILITY WORK UP STEPS:
1
2
3
up
->
->
->
is
* MALIGNA
|
|
_______________________
______________________________________
|
|
|
|
COMPLETE
i"N"complete
tic
Good P. Mets
Bad P. Mets
|
__
|
NON metasta
|
|
|
Empty egg
Pevis or lungs
nly
"N"ormal egg
Brain or liver
46 XX
00 % cure
69 XXY
65 % cure
Triploidy
> 95 % cure
Dizygotic ploidy
Fetus Absent
ENT CHEMOTHERAPY
MULTIPLE agents
Uterus o
SINGLE AG
10 % malignancy
FOLLOW UP FOR