OBGYN EOR

MCC of secondary amenorrhea

pregnancy

primary vs. secondary amenorrhea

Primary amenorrhea is the absence of menarche by 14 or 16

Secondary amenorrhea is the cessation of menstruation for 3 cycles or 6 months in females previously menstruating normally.

AUB differential

PALM COEIN

PALM-COEIN

P: Polyp

A: Adenomyosis

L: Leiomyoma

M: Malignancy/hyperplasia

C: Coagulopathy

O: ovulatory dysfunction

E: Endometrial

I: Iatrogenic

N: Not yet classified

parabasal epithelial cells

atrophic vaginitis

pH of atrophic vaginitis

>5

tx w/ topical estrogen

MC location for fibroids

intramural

intermenstrual bleeding

metrorrhagia

endometrial thickness of ____ is considered thickened in premenopausal pts

15

>____ endometrial thickness is considered thickened in postmenopausal females

>4

MCC oligohydramnios

rupture of membranes

first line tx for AUB

Combo hormonal therapy→ suppresses GnRH and pituitary FSH/LH →suppresses ovarian folliculogenesis and LH surge therefore prevents ovulation

combo OCP are protective against which cancers?

endometrial and ovarian

slight inc. risk for breast

RF for PCOS

genetics

obesity

impaired glucose tolerance/DM

metabolic syndrome

epilepsy/antiepileptic drugs

risk factors for cervical incompetence

congenital- DES exposure, bicornate uterus

acquired- inflammation, infection, cervical trauma, cone biopsy, multiple gest, late 2nd trimester abortion, LEEP

hormonal- relaxin

genetic - Ehlers Danlos, marfan

which hormone is disproportionately secreted in PCOS?

LH >> FSH

LH binds within ovaries and leads to hypersecretion of androgens

MC presentation of PCOS

oligomenorrhea

what commonly needs to be supplemented in pregnant pt with PCOS?

progesterone → plays an important role in implantation and inhibition of uterine contractions in pregnancy

Rotterdam criteria

PCOS

string of pearls on US

PCOS

how to differentiate anovulatory vs. ovulatory AUB

ovulatory is cyclic

fibrocystic breasts or fibroadenoma: fluctuates with menses?

fibrocystic

fibrocystic or fibroadenoma: tender?

fibrocystic

Most common breast cancer

IDC

ductal carcinoma with eczematous nipple lesion

paget's disease

breast cancer hormonal therapy ONLY used in post-menopausal women

aromatase inhibitors → anastrozole, letrozole

useful in ER-positive

tx indicated in HER2 overexpression

monoclonal abs

risk factors for umbilical cord prolapse

low birth weight, multiparity, polyhydramnios, prolonged labor, long umbilical cord, preterm gestation, malpresentation, pelvic deformities, and external fetal anomalies.

Malpresentation of the fetus includes transverse lie, oblique lie, breech presentation, or unstable lie.

breast cancer hormonal therapy used in pre-menopausal women

SERM → tamoxifen

adverse effects of tamoxifen

hot flashes

uterine bleeding

venous thrombosis

endometrial cancer

breast cancer screening modalities

mammogram = best in >40 y/o

US = best in <40 y/o

adverse effects of aromatase inhibitors

thromboembolism

*osteoporosis*

MI

arthralgia

why might SERMs (tamoxifen, raloxifen) be preferred in post-menopausal women for breast cancer prevention?

if they have osteoporosis

HPV vaccine schedule

<15 y/o = 2 dose series given at 0 and 6-12 months

15+ y/o = 3 dose series. Given 0,1-2, and 6 months apart.

MC etiology of breast abscess

S. aureus

treatment for breast abscess

I & D and antibiotics (e.g. cephalexin)

abx for breast abscess

dicloxacillin or cephalexin

if MRSA then TMP-SMX DS or clindamycin

MC cervical cancer

SCC

HPV strains assoc with cervical cancer

16, 18, 45

clinical manifestations of cervical cancer

usually asymptomatic

- post coital bleeding = MC sx

- irregular/heavy period

- watery discharge

- advanced dz = pelvic pain, back pain, bladder/rectal dysfunction

premature cervical dilation

incompetent cervix

tx for incompetent cervix

cerclage and bed rest

or

weekly injection of 17 alpha-hydroxyprogesterone

diagnosis of infertility

hysterosalpingography- helps evaluate tubal patency or abnormalities

first line meds for ovulation induction

letrozole or clomiphene

most effective method of emergency contraception

copper IUD → must be inserted within 5-7 days after unprotected sex

contraindications to combo OCP

- ischemic heart dz

- hx of DVT, PE, stroke

- breast cancer

- migraine w/ aura

- smokers if >35

- severe HTN

Adverse effect of depo shot

bone weakness and osteoporosis d/t calcium loss → don't use more than 2 yrs

what causes ovulation?

LH surge

what causes dysmenorrhea?

excess prostaglandins→ cause increased uterine wall contractions

treatment for PMDD

lifestyle mod

SSRIs

OCPs

risk factors for fibroids

-increasing age (>35)

-early menarche

- nulliparity

-obesity

-black ethnicity (5x)

-family history

sx of fibroids

pelvic pressure

bleeding

painful irregular periods

cannot lose weight

infertility/miscarriages

which GYN tumors are estrogen dependent and therefore may increase in size with relation to menstrual cycle?

fibroids

also inc. in size during pregnancy, anovulatory states

most used imaging modality for dx of fibroids

transvag US → focal heterogenic hypoechoic mass or masses with shadowing

1st line tx for fibroids

Combined estrogen-progestin contraceptives, a progestin-releasing intrauterine device, and tranexamic acid

most effective nonsurgical tx for fibroids

GnRH analogs (leuprolide, nafarelin) → usually used near menopause or to shrink fibroids prior to hysterectomy/myomectomy

HOWEVER this is 2nd line

surgical TOC for fibroids in women who want to PRESERVE fertility

myomectomy

biggest risk factor for endometritis

c-section

infection of the pregnancy endometrium (decidua)

endometritis

sx of endometritis

1. Fever > 38 (after first 24 hrs, for 2 of 10 post-partum days)

2. Uterine tenderness + abd pain

3. Foul smelling (persistent vag discharge) +/- leukocytosis

Caused by polymicrobial infection.

tx for endometritis

gentamicin + clindamycin +/- ampicillin

what abx may be given before c-section to prevent endometritis?

first gen cephalosporin → cefazolin

when are sx of endometriosis better?

estrogen stimulated → symptoms improve during pregnancy and after menopause

MC site of endometriosis

ovaries

risk factors for endometriosis

prolonged estrogen exposure → nulliparity, late first pregnancy, early menarche, short menses

other: fhx, prolonged/heavy menses

what may reduce risk of endometriosis?

- exercise >4 hrs/week

- higher parity (more kids)

- late menarche (after 14)

- longer duration of lactation

classic triad of endometriosis

Cyclic premenstrual pelvic pain, dysmenorrhea, dyspareunia

may have: dyschezia, abnormal bleeding, back/abd pain/pressure, infertility

initial imaging of choice for endometriosis

pelvic US (to rule out other dx)

definitive diagnosis of endometriosis

Laparoscopy with biopsy

first line tx for endo

- ovulation suppression → OCP

most sensitive initial test for menopause

FSH assay, >30 = menopause

LH will also be increased, estrogen decreased

raloxifene or tamoxifen: endometrium agonist

tamoxifen → therefore inc. risk of endo cancer

raloxifene is antagonist

risk factors for endometrial cancer

obesity, nulliparity, infertility, late menopause, diabetes mellitus, PCOS, unopposed estrogen stimulation, HTN, gallbladder disease, tamoxifen use.

Grades of uterine prolapse

Grade 0: Normal

Grade 1: descent into upper 2/3 of vagina

Grade 2: cervix approaches introitus

Grade 3: The lowest part is more than 1cm below the introitus, but not fully descended

Grade 4: Full descent with eversion of the vagina

pelvic organ prolapse risk factors

vaginal birth

obesity

prior pelvic surgery

advancing age

heavy lifting or straining

genetic predisposition

connective tissue disorders.

MC type of ovarian cyst

follicular

MC type of ovarian tumor

epithelial carcinoma

MC type of endometrial cancer

adenocarcinoma

tx of ovarian cyst

if <8 cm: supportive → rest, NSAIDs; may resolve

>8cm or persistent → laparoscopy/laparotomy

abrupt onset of unilateral lower quadrant abd pain; often sharp and focal and often occurring during sex or strenuous physical activity

ruptured ovarian cyst

initial test of choice for ovarian torsion

US with doppler

definitive is surgical exploration

thin, gray-white discharge

BV

what is the pH in BV?

>4.5

positive whiff test

BV

first line in BV

metro or clinda (both safe in preg)

clue cells

BV

AKA epithelial cells covered by coccobacilli

sexually transmitted flagellated protozoan

trichomonas

copious frothy yellow-green discharge

trich

cervical petechiae

Strawberry cervix→ Trichomoniasis

tx for trich

metro

treat partners

spontaneous abortion is a pregnancy that ends before ___ weeks

20

when is mifepristone/misoprostol indicated for elective abortion?

<10 weeks+6 days

When can D&C be done?

up to 12 weeks

when can D&E (evacuation) be done?

15.5-22 wks

triad of PID

1. abd tenderness

2. cervical motion tenderness

3. adnexal tenderness

PLUS 1 of the following:

- temp, wbc >10000, pelvic abnormality on bimanual/US, ESR/CRP inc. abnormal cervical or vaginal mucopurulent discharge or cervical friability

pelvic tenderness, cervical motion tenderness, purulent discharge

PID

MC etio of PID

chlamydia

fundal height measurements

12 wks - pubic symphysis

16 wks -midway between pubis and umbilicus

20-22 wks - umbilicus

38 wks - xiphoid process

how soon can urine b-hCG detect pregnancy?

14 days

which sign: uterus softening after 6 weeks

ladin's