HOSA Reproductive Diseases and Conditions

Sexual Anatomy

Early embryonic development of sex organs not differentiated, makes gender difficult to identify; as fetus develops, organs classified into gonads (testes/ovaries) which produce germ cells and hormones, and series of ducts necessary for transportation of germ cells

Male Reproductive System

Transfers sperm to female for fertilization of ovum; produce sperm and hormones req for development and maintenance of secondary sex characteristics; sperm transported through series of ducts starting w/ epididymis, ductus deferens, and ejaculatory ducts; seminal vesicles, prostate gland, bulbourethral glands, penis accessory organs to help propel sperm to egg

Female Reproductive System

Nourishes and enables development of fertilized ovum; ovaries which contain woman’s lifetime supply of eggs prod and release egg and hormones req for secondary sex characteristics and maintenance of pregnancy; ductal system for transport, nourishment, growth of fertilized ovum includes fallopian tubes and uterus; cervix, vagina, ext genitalia; breasts accessory organs as two milk-prod glands; when pregnant, breast tissue stimulated by ovarian/placental hormones for lactation; after delivery, lactating hormones stimulate milk release

Reproduction Process

Req sperm to fertilize eggs; after release from ovary, egg progresses down fallopian; typically egg met about ⅓ way down fallopian tube by sperm cells; after fertilization, zygote travels down fallopian to uterus, attaching to uterine lining (endometrium) to nourish and grow; placenta forms within uterine wall providing mechanism for exchange of nourishment and waste w/ mother and fetus; normally gestation 38 weeks after conception, where birth process begins w/ labor and infant delivered

Menstruation

Anterior pituitary gland produces gonadotropic hormones causing ovaries to prod estrogen, progesterone, regulating menstrual cycle; during menstruation, endometrium shed via vagina, followed by ovarian prod of estrogen, causing ovum to mature and be released from ovary; corpus luteum develops, progesterone and more estrogen into bloodstream for growth of endometrium to prepare for implantation of fertilized ovum; If no pregnancy, endometrium again is shed through menses in anticipation of next cycle of possible pregnancy

STD Risk Factors

Sex w/ unknown sexual history person; drugs used by sharing needles; sex w/ many ppl; sex w/ someone diagnosed for STD or treated for STD; exposure skin-to-skin in presence of any open lesion, e.g. chancre, wart; use of alcohol clouding one’s judgement about sexual encounter; hemophilia; transfusion of blood; babies being carried by HIV-positive mother; breast-fed infants of HIV-positive mother

Sexually Transmitted Diseases (STDs)

Sometimes asymptomatic, spread by ppl unaware they are infected; a silent epidemic w/ no one immune; recurrent infections common; transmitted through bodily fluids of blood, semen, vaginal secretions during sex, some by direct contact w/ infected skin; most STDs treatable, but viral STDs (herpes, HIV) no cure; possible transmission from mother to newborn; highest in US, showing ¼ teenagers get STDs; prevention messages show high-risk sexual behavior/lifestyles can cause

Chlamydia

Most freq reported infectious disease in US, causing urethritis in men and cervicitis and urethritis in women; the silent STD, often having no symptoms and transmitted unknowingly; more often women asymptomatic, but 75% of men have symptoms 1-3 weeks after exposure; leading cause of pelvic infla disease, major cause of female sterility; female symptoms of thick vaginal discharge w/ burning sensation, itching, ab pain, dyspareunia; male symptoms discharge from penis w/ burning sensation, itching, burning sensation when peeing in latter urethritis, swollen scrotum maybe, feverish, inguinal lymph nodes often enlarged in either sex; small transient lesion, skin irritation sometimes; can be in newborns from mother during birth, causing conjunctivitis, blindness, arthritis, overwhelming infection; symptoms often 1-2 weeks post-exposure, mildly; Chlamydia trachomatis an intracellular bacterium is cause, transmitted by sexual contact; primary infection is often around genitals, but can be oral/anal, depending on sex done; organism can transmit unknowingly; lab swab cultures can reveal parasite in infected person; Giemsa stain of cell scrapings done to find potential antibodies and antigen-specific serologic studies performed; antibiotic therapy for both partners, beginning w/ single injection, followed by oral antibiotics (azithromycin, erythromycin) on 7-day regimen of doxycycline; prompt treatment can cure infection and prevent complications, e.g. PID, problem pregnancy; follow up recommended; can be completely cured, but complications more common in women; screening, reporting, and urine tests can prevent

Gonorrhea

Common STD of genitourinary tract; purulent discharge in M/F, dysuria often present varying in dysuria; 50% men asymptomatic, unknowingly spreading infection; can infect eyes, throat, or become systemic; males develop symptoms after incubation of 3-6 days; symptoms in females vary; spreads if untreated; Neisseria gonnorrhoeae bacterium results from sexual transmission; can infect newborns from birth, leading to blindness and eye infections, so erythromycin salve administered prophylactically; lab cultures of infectious body secretions and microscopic exams of exudate can identify bacteria; Ciprofloxacin, ceftriaxone, doxycycline started once diagnosis made; many strains of gonorrhoeae have become resistant to penicillin and drugs, so after antibiotic therapy, follow up culture studies ordered to ensure complete cure; neglecting treatment of gonococcal infection leads to PID, septicemia, infertility, septic arthritis; w/ early/complete treatment prognosis very good, even w/ complications; makes more likely to get HIV; abstinence best until treatment

Trichomoniasis

Protozoal infection of lower genitourinary tract, usually vaginal in women and urethral in man; about 15% of sexually active ppl have this; most infected M/F asymptomatic; initial symptoms of urethritis w/ dysuria, itching; women may have profuse greenish-yellow odorous discharge from vagina; thin whitish discharge from penis may be noticed in men; discharge can subside w/o treatment, but infection remains and becomes chronic; discomfort w/ discharge warrants screening; Trichomonas vaginalis transmitted by sex; wet prep of vaginal secretions or male urethral discharge studied for organism; urinalysis can reveal; cervix exam for presence of small hemorrhages w/ strawberry-like appearance; antiinfective drugs given, metronidazole given as single dose; prognosis good if both partners receive med treatment, follow-up exam ensuring infection cures completely; failure to treat both partners causes reinfection, a ping-pong vaginitis; avoiding sex or condoms prevents

Genital Herpes

Infection of skin of genital area, w/ ulcerations spread by direct skin contact, causing painful genital sores similar to cold sores; caused by HSV-2 virus, recurrent; incurable viral disease; large percentage of infections subclinical, so initial episodes unnoticed; more often, 1+ blisterlike lesions noticed somewhere on genitals or around anus; painful ulcers, blisters 2-30 days after sexual contact w/ infected person; influenza, swollen glands, fever, headache, painful urination may be present; infectious when sores present; some ppl “shredders” can transmit virus w/o symptoms; herpetic lesions more often women, more severe in women; subsequent outbreaks can occur for months/years as virus hides in NS; ⅕ adults carry HSV-2, transmitted sexually by viral infected body fluids during skin contact; cross-infection from oral-genital or anal sex; genital herpes can also be caused by HSV-1 esp in younger ppl; presence of open lesions inc risk of acquiring AIDS; characteristic lesions on M/F genitalia noted during phys exam; antigen test or tissue culture can identify HSV-2 to confirm diagnosis; no cure, but prescription drugs reduce duration and freq of outbreaks, e.g. Zovirax, Famvir, Valtrex; sometimes body’s own immunity makes episodes less severe; presence of sores in genital area and fear of transmitting or acquiring herpes can contribute to emotional stress or social embarrassment makes women more predisposed for cervical cancer, so Pap smear every 6 months recommended; cesarean section may be req as virus is dangerous to newborn;  recurrent herpes often prodromal symptoms (tingling, itching, burning) 1-5 days before lesions; recurrence common, but milder and triggered by fatigue/stress; generally infection has no serious problems for healthy adults; abstinence, mutual monogamy only prevention; condoms not good enough

Genital Warts (Condylomata Acuminata)

genital infection causing raised cauliflower-like growths in/near vagina/rectum or along penis; very common STD; often painless, women no obvious symptoms; lesions sometimes itch/burn; contagious lesions weeks-months after skin contact during sex w/ infected person; discomfort varies w/ size, number, location; highly contagious virus Human Papillomavirus (HPV) cause, transmitted sexually; prolonged incubation 1-6 months; infects epithelial cells; risk factors early age sex, multiple sex partners; co-infection w/ HIV causes further inc in HPV to cancer risk; many types HPV exist; can be identified by appearance, sometimes biopsy to rue out carcinoma; must be differentiated from syphilitic lesion; chem/surgical removal of wart treats, recurrence common; topical drug therapy to remove warts, e.g. keratolytic agents (podofilox, trichloroacetic acid); Imiquimod antiviral cream can stop warts from forming; cryosurgery to freeze/remove tissue; electrodesiccation uses lasers to remove larger warts; some go away w/o treatment; women w/ genital HPV infection greater risk of cervical cancer, C-section sometimes necessary occluding birth canal; no complications, can recur, pregnancy promotes growth/spread; no sex w/ infected or random ppl; vaccine against HPV prevents

Syphilis

Chronic, systemic, STD infection w/ four stages; begins painless but highly contagious local lesion chancre on genitalia; w/o early treatment during primary stage, becomes systemic, chronic involving any organ/tissue; in 1-2 months when primary lesion heals, Treponema pallidum spirochete disseminates thru body multiplying, prod lesions wherever organism most prevalent (skin, lymph nodes, CV system, brain, spinal cord); disease continues to be contagious during secondary stage w/ systemic manifestation; fever, headaches, aching of joints, mouth sores, rashes on palms/soles; latent period 1-40 years may follow, w/ infection asymptomatic; late stage sees gummas lesions invading body organs causing widespread damage, life-threatening; if fetus infected, child may die in utero or be born w/ congenital syphilis and abnormalities; syphilis must be treated early and is rising in US men, symptoms warrant screening; bacteria infection spreads w/ sex or direct contact w/ infected lesions/body fluids; congenital transmission possible w/ pregnancy; smear from primary lesion microscopically can identity bacteria; autobodies in serum can recognize as well; can easily be cured early w/ antibiotic therapy using penicillin G, or doxycycline or tetracycline if allergic to penicillin; best treated primary/secondary before irreversible damage to body; curable early, untreated can facilitate spread of HIV; If doubt, VDRL test performed to detect

Chancroid (Soft Chancre)

bacterial infection of genitalia causing necrotizing ulceration and lymphadenopathy; shallow/painless lesion on skin/mucus membrane, at site of entry 7-10 days after sex w/ infected; tender superlative inguinal adenopathy noted on phys exam; ulcer deepens, becomes purulent, spreads by autoinoculation; lesion near genitalia req prompt assessment; Haemophilus ducreyi causes; diagnosis based on clinical appearance of lesion; in lab, gram stain smears of exudate confirms infection; presence of syphilis/herpes must be ruled out; good response to antibiotics (azithromycin, clarithromycin, ceftriaxone); lesions sometimes drained surgically; good hygiene, keeping infected area clean and dry, no sex during treatment period; antibiotics often cures, but if severe can cause scarring; no vaccine available, condoms prevents

Dyspareunia

Recurrent pain/difficult sex; M/F, more in women; pain superficial or deep; amount of pain and conditions which worsen are significant as it illustrates diverse causes; in women, organic causes e.g. intact hymen, insufficient lubrication, STD, use of spermicide can cause superficial pain; deeper pelvic pain can include endometriosis, pelvic infla disease, presence of cysts/tumors in genitourinary tract or pelvis; Can have psych basis from past trauma, sexual abuse, fear of pregnancy; anxiety alone can cause vaginismus; allergic rxns to spermicidal creams/jellies or even semen can cause irritation, itching, burning; in men, anatomic abnormalities, bowed erection, tight foreskin, prostatitis, lesions on penis, urethritis secondary to STD can cause; anxiety, guild to point of psychosexual dysfunction can root problem; careful history of type/nature of pain during sex significant; phys exam, lab tests can base cause; treatment based on cause; lubricants, treating underlying infection, corrective surgery, counseling can treat; prognosis highly variable

Erectile Dysfunction (ED) / Impotence

consistent inability to maintain/achieve erection; men unable to have sex; common disorder, affecting most men at some point; temporary/chronic; sexual arousal causes arteries in penis to dilate, inc blood flow tp penis; expansion/hardening of penis compresses veins carrying blood away from penis resulting in erection; anything impeding nerve response altering req pattern of blood flow results in this; often psych basis, depression, unconscious guilt, anxiety of sex; sexual trauma, repressed inhibitions, discordant relationships can contribute, chronic fatigue; diabetes mellitus, hypertension, heart disease, hypercholesterolemia can cause; nerve insult from prostate surgery, spinal cord/pelvic/perineal trauma may interrupt impulse transmission btwn CNS and penis; meds treating hypertension/depression can have ED as side effect; alcohol, recreational drugs, antihistamines, diuretics can influence; med history, phys exam to reveal underlying causes req; history should be patient + family, any diseases, any prior surgery/trauma, all meds being taken, lifestyle, smoke/alc habits, stress levels; lab tests to rule out organic diseases, measurements of testosterone grounds diagnosis; treatment varies w/ cause; changing meds, testosterone therapy, substance abuse programs, psych counseling; psychoanalysis, discussion, behavior mods, sensate exercises to allow ability to complete full sexual response cycle; penile implants, ext vacuum devices, penile injection therapy can treat; oral drug therapy w/ Viagra can help; in sex stimulation, nitric oxide released in corpus cavernosum, causing enzymatic cascade, relaxing smooth muscle of corpus cavernosum and inflow of blood; Viagra inc effect of nitrous oxide, helping erection formation ; prognosis varies w/ cause, but most have effective therapies

Frigidity

Lack of sexual desire or response in women, seen as women being dissatisfied or frustrated; inability to experience sexual arousal/excitement or to achieve orgasm; symptoms often reflect depression; underlying med problems rarely can cause nerve damage inducing this; specific meds, chronic fatigue, stress, depression, previous rape/SA experiences; phys exam w/ med/sex histories can identify causes; if dysfunction primary, proper stimulation or use of sensate focus exercises may resolve problems by itself; inhibited female orgasm can stem from psych obstacle, e.g. troubled relationship, so counseling can help; drug therapy to inc libido helps; good results expected, no prevention known

Premature Ejaculation

Ejaculation occurs before suitable time; when a man ejaculates during foreplay or after min stimulation, he may be unable to satisfy partner or impregnate a women; typically in young men and not serious; often psych basis stemming from guilt/anxiety; troubled, negative relationship w/ sex partner can contribute; infection, degenerative neurologic conditions; diagnosis based on patient history, phys exam, lab tests to rule out pathologic factors; any underlying phys cause treated, psych factors addressed; certain techniques that help delay ejaculation of control male stimulation are suggested to female partner, allowing more time for woman to reach orgasm and enable ejaculation to occur after penetration; prognosis usually good w/ behavior mods; prevention unknown

Infertility

Involuntary inability to conceive; w/ regular unprotected intercourse, 90% of couples conceive within 1 year; inability can originate from M/F or both; 40% of time from male, 40% from female, <10% time unexplained; in a man, insufficient # of mobile sperm can cause; presence of STD or infection or blockage of genitourinary tract another cause; less often, structural anomalies, genetic diseases, endocrine disorders result; presence of varicocele can reduce sperm count; injuries affecting blood/nerve supply, radiation exposure, pollutant exposure, chronic stress, hormonal imbalances can cause; in women, STDs or other infections, ovulatory dysfunction or failure to ovulate, blocked fallopian tubes, congenital structure or chromosomal disorders, scar tissue from infection ectopic pregnancy or surgery, tumors, endometriosis, antisperm antibodies in vaginal secretions, meds compromising fertility, psych distress can cause; after phys exam and interview of both partners, cause of infertility identified; sometimes found quickly/easily, oftentimes can become time-consuming and expensive; men req complete history w/ special attention to childhood diseases, phys exam of structural abnormalities, semen analysis, and genetic/endocrine disorders to be ruled out; in women, ovulatory function established by charting menstrual cycle, hormone levels studied w/ blood tests, fallopian tubes and uterine cavity visualized w/ hysterosalpingograph to determine tubal patency, laparoscopy req to rule out endometriosis or chronic infection; treatment is individual, unless condition untreatable, course of action to achieve pregnancy includes treatment of infection, surgery to remove blockages, use of fertility drugs (chomiphene, follitropin), intrauterine insemination, vitro fertilization; half of couples who seek treatment do achieve pregnancy eventually, some can take as long as 3 years; regular exams and avoiding causative factors prevents

Epididymitis

Infla of epididymis; fever, malaise, dysuria; epididymis enlarges, tender, hard; groin/scrotal tenderness w/ severe pain to testes; relief of pain when testes elevated called Prehn’s sign; walking sometimes difficult; STDs from N. gonorrhoeae and C. trachomatis most common bacterial causes; E. coli, Staphylococcus, Streptococcus can also cause; can result from UTI, prostatitis, STDs gonorrhea syphilis; tuberculosis, mumps, prostatectomy, trauma, prolonged use of indwelling catheter may predispose; viral infection associated w/ HIV patients can cause; phys exam, urinalysis, urine culture grounds diagnosis, along w/ elevated WBC; antibiotics w/ anti-inflammatories, rest, avoidance of alcohol/spicy foods can help; scrotal support or elevation may help; scarring may occur causing sterility if delayed treatment, esp if bilateral; prognosis very good w/ early treatment; condom use, early treatment of UTIs prevent

Orchitis

Infection of testis; 1+ testes, causing swelling, tenderness, acute pain, chills, fever, nausea, vomiting, general malaise; prompt treatment to alleviate pain and begin antibiotics req; can be consequence of infection from mumps virus; other viruses/bacteria cause, may follow epididymitis; acute infection freq associated w/ STD; ½ severe cases causes atrophy of affected testicle; sterility if both affected; clinical history to see exposure to mumps, other diseases; phys exam urinalysis, serologic studies, throat cultures, serum antibodies can be used to isolate and identify causative agents; immediate differentiation of orchitis and testicular torsion done w/ Doppler ultrasonography; if bacterial, antibiotics ASAP; if mumps cause, no specific treatment besides supportive care; bed rest prescribed w/ certain adrenal steroid drugs to reduce fever, swelling in severe cases; scrotal support can help; healing follows successful treatment w/ antibiotics, scarring can compromise fertility; Risk factors for STDs avoided, mumps vaccination prevents

Torsion of Testicles

One testicle twists from normal position; sudden, severe pain in one testicle, such bad pain causing nausea, vomiting, fever, urinary freq; when torsion occurs, scrotum swollen, red, tender; can cause blood vessels supplying testicle to become kinked, stopping blood flow to/from testicle; emergency treatment req; occurs when testis rotates on spermatic cord, causing sudden or extreme twist; happens spontaneously or from trauma; arteries/veins compressed, ischemia develops, swelling ensues; diagnosis based on gentle phys exam; gentle manipulation tried to untwist; no treatment needed if detorsion can be achieved; immediate relief from pain/swelling follows; if unable to work, immediate surgery to fix req; delayed surgery yields permanent damage to testicle; prognosis good if treatment prompt; even if condition corrects itself, pain is relieved, but torsion may recur; w/ surgery, no recurrence; prevention unknown

Varicocele

Veins of one testicles become abnormally distended, causing swelling around testicle expanding within scrotal sac; mild disorder more uncomfortable than painful; more uncomfortable in hot weather or after workout, relieved temporarily by lying down; inc presence of venous blood raises temp within scrotum, can contribute to lower sperm count; often asymptomatic, if vein ruptures local injury, pain, swelling; incompetent venous valves causes dilation of large scrotal veins and venous stasis; condition may be congenital, becoming symptomatic 15-25 year olds; patient history, phys symptoms, exam by physician confirms diagnosis; wearing tight-fitting underwear or use of athletic supporter supports; if affects fertility, surgery can remove distended veins, but results may not justify risk of surgery; results vary w/ degree of distention; prevention unknown

Prostatitis

Acute/Chronic infla of prostate gland; more common in men 50+; prostate enlarged, tender, sometimes pus seen at tip of penis; asymptomatic or acute symptoms in mild/sporadic forms; pain, burning sensation during urination; low back pain, fever, muscular pain or tenderness, urinary freq w/ urgency sometimes; hematuria sometimes; most times infection causes, but cause not always known; infections (non)bacterial, including gonococci from patients w/ gonorrhea, E. coli from UTI, Staphylococcus, Streptococcus, Pseudomonas; prostate gland gently palpated in phys exam; urinalysis, blood cultures, WBC ordered; ultrasound to measure postvoid residual urine may be ordered to ground diagnosis; antimicrobial penicillin therapy most common; Bactrim DS, Levaquin, Cipro for chronic; sitz baths, rest, inc fluid intake, analgesics; acutely ill are hospitalized for IV fluids and meds; chronic can develop to recurrent UTIs, urethral obstruction, acute urinary retention; prognosis for acute good w/ good treatment response; outlook less favorable for chronic, w/ complications of epididymitis, cystitis, urethritis can occur; prevention is early treatment of UTIs

Benign Prostatic Hyperplasia (BPH)

nonmalignant, noninfla hypertrophy of prostate gland; enlargement of gland common in men 50+, freq inc w/ age; often progresses to point causing compression of urethra w/ urinary obstruction causing urinary retention; difficulty in starting urination, weak stream of urine, inability to empty bladder completely, urinary freq w/ nocturia, fecal incontinence, infla and symptoms of renal disease in severe cases; cause not completely understood, but associated w/ aging process w/ hormonal/metabolic changes; as prostate enlarges, it compresses either neck of bladder or urethra, obstructing urinary flow; patient history, rectal exam for prostatic abnormalities; urinalysis, urine culture, renal function studies, urodynamic studies, cystoscopy depending on degree of symptoms; lower urinary symptoms of UTI, stones in urinary tract, possible malignancy considered; prostate specific antigen serum level lab test screens for prostatic cancer; international prostate symptom score used to determine degree of symptoms and impact on quality of life, determining therapy; treatment often waits until symptoms are not bothersome; lifestyle changes including control of fluid intake before bed, avoiding meds causing urinary retention (decongestants), drug therapy w/ alpha-adrenergic blockers (Flomax, Cardura, Hytrin) prescribed to relax prostate muscles and relieve symptoms; Proscar can shrink enlarged prostate gland prescribed sometimes; if symptoms moderate, surgery transurethral resection of prostate performed to remove obstructive part; prognosis good w/ intervention; severe untreated symptoms can reach kidneys, causing cystitis, dilation of ureters, pyelonephritis, hydronephrosis, uremia; prevention unknown

Prostate Cancer

Malignancy of small gland located below bladder and anterior to rectum of males, the prostate gland; very common cancer, but grows so slowly that only 3% afflicted will die from it; third-leading cause of cancer death in men nevertheless;often asymptomatic at diagnosis, detected clinically by abnormalities on routine digital rectal exam (DRE) or by high concentration of prostate specific antigen (PSA) in serum; asymmetric area of induration and nodules felt on DRE suggests, and malignant prostate tissue generates more PSA than normal or hyperplastic tissues do; weak/interrupted urine flow, urinary freq, difficult start/stop urine flow, urinary retention, dysuria, hematuria; new onset erectile dysfunction; risk factors includes age, heredity, lifestyle; more common 45+; much more common in Black men than white/Hispanic; risk higher in those w/ heritable mutation on BRCA1/2 genes (breast cancer susceptibility genes); diet high in animal fat, low in vegetables, low in Selenium inc risk; abnormally high PSA or abnormal DRE highly suggestive findings, but prostate biopsy req for cancer diagnosis; if PSA level >10 ng/mL should be performed; transrectal ultrasound-guided biopsy that takes samples from sussy areas, and six core tissue specimens performed; if biopsy negative but PSA level high, repeated biopsy after 6-8 weeks later; up to 25% cancers missed on initial biopsy; if biopsy found to contain carcinoma, further evaluation for staging; staged by TNM system, using DRE/PSA measurements, radionuclide bone scan, ab/pelvic CT, IV pyelogram; analysis of tumor histology (Gleason grade) leads to scoring system based on degree of glandular differentiation in structural architecture; treatment varies w/ stage, Gleason score, PSA level, age, and phys condition of patient; radical prostatectomy, radiation therapy, hormone therapy, watchful waiting all done; prostatectomy and radiation can complicate ED, urinary symptoms; hormone therapy reduces amount of androgens in body preventing body from responding to them to inhibit cancer growth; orchiectomy to remove testicle, luteinizing hormone releasing hormone antagonists to stop testosterone prod; watchful waiting w/ careful observation w/o aggressive intervention considered for 70+ w/ significant coexisting illnesses, fearing side effects;  if metastatic, hormone therapy primary treatment; eventually, all men will stop responding to hormone therapy and 2nd type of hormone therapy or chemo is tried; PSA measurement and DRE every 6-12 months to monitor efficacy of treatments req; early stage tumors offer similar 10-year survival rates; watchful waiting less successful having lower Gleason score; overall 5-year survival 96% as many are diagnosed early; survival rate declines w/ longer follow-ups, w/ 10-year survival 75%, locally advanced disease 55%, metastatic disease 15%

Testicular Cancer

One of most curable neoplasms, but still significant effect on econ/emotional status of young population it affects; almost always germ cell tumors, equality divided into seminomas and all others, nonseminomatous germ cell tumors; nodule/painless swelling of 1 testicle, w/ complaints of dull ache or heavy sensation in abdomen, perianal area, or scrotum; fewer patients have acute pain or gynecomastia; tumor may cause oligospermia, causing infertility; when advanced neck mass, dyspnea, anorexia, bone pain, lower-extremity swelling; most common 20-35, risk factors of cryptorchidism (undescended testicle), family history of testicular cancer, previous GCT, infertility, HIV infection, Downs, Klinefelter’s can predispose; diagnosis begins w/ phys exam of testes and palpation for nodal involvement; any firm/hard area in affected testes concerns; scrotal ultrasound, CT of ab/pelvis, chest radiographs, seum tumor markers grounds diagnosis; radical orchiectomy provides histologic eval of tumor and retroperitoneal lymph node dissection for metastases; baseline sperm count and sperm banking before radiographs if worry of fertility issues in men; serum tumor markers of AFP, Beta-hCG, lactate dehydrogenase helpful for initial diagnosis; TNM staged, from I-III defining good, intermediate, poor prognoses; NSGCTs highly chemosensative, so cisplatin-based combo chemo cures 80% by stopping cancer growth + metastases; if advanced, residual masses remaining after chemo req surgical resection to remove and prevent compression of adjacent structures; seminomas radiosensitive, so radiation w/(o) chemo treats, w/ residual masses followed w/ CT scans until they disappear; if elevated serum tumor marker, monitoring throughout indicates treatment success; post-treatment follow-up req part of care; I 95% 5-year  survival, II 79%, III 48%; initial serum concentration of tumor markers, time btwn diagnosis and treatment, age, extent of visceral organ involvement, # of metastases affects prognosis; males w/ unilateral postpubertal ab cryptorchidism urged to undergo prophylactic orchiectomy; if history of cryptorchidism, biopsy of testes at 18-20 for carcinoma in situ; if high risk, monthly testicular self exam can garner early treatment to prevent

Oligomenorrhea

Scanty Menstruation

Metrorrhagia

Bleeding btwn menses

Menorrhagia

Heavy or prolonged menstrual flow

Premenstrual Syndrome

Constellation of phys/emotional symptoms which may appear shortly after ovulation and subside w/ onset of menstruation or shortly after; during menstrual cycle, fluctuating hormones alter mood, sexual desire, energy levels, which may affect phys; troublesome symptoms to hormone shifts anxiety, anger, sadness, bloating, food cravings, breast pain, irritability, fatigue, sometimes edema, bloating, ab pain; if cyclic symptoms severe and fit certain psych criteria, diagnosis shifts to Premenstrual dysphoric disorder; related to fluctuations of estrogen and progesterone and their impacts on neurotransmitters dopamine, serotonin, norepinephrine; can lead to Na/fluid retention; only occurs in ovulating women; patient keeps records of symptoms during menstrual cycle to diagnose, no specific tests grounds; reduced diet of Na, inc Ca, moderate exercise, mild analgesics or diuretics, emotional support all help; sometimes low caffeine intake helps; sometimes antidepressants indicated; often resolves w/ diet fixes or menopause; no prevention

Amenorrhea

Absence of menstrual periods, temporary/permanent; no menses by age 16 is primary; no menses after having menstrual cycles is secondary; short periods of amenorrhea normal btwn menarche (onset of menstruation) and regular menstrual cycle, often 18+; no symptoms besides no bleeding; primary caused by late puberty, abnormality in reproductive system, hormone imbalances; conditions are not suspected unless girl is at least 16 and not having periods; obstructions of uterus/vagina or chromosomal/developmental abnormalities ruled out as cause of primary; secondary mainly hormone related; if pregnancy ruled out, thyroid disease, excess weight loss, poor nutrition, excessive athletic training, psych stress, pituitary tumors must be ruled out; premature ovarian failure ruled out in women under 40; diagnosis based on patient history, w/ etiology req blood tests, phys exam, occasional radiographs; treatment corrects underlying condition, if not possible, contraceptive hormones or  cyclic progesterone creates menstruation; prognosis excellent if underlying cause corrected; management of weight, nutrition, stress can prevent

Dysmenorrhea

Pain/cramping during menstruation, beginning shortly before/after onset of menstrual flow; primary is onset w/ initiation of menses, secondary is later after years of normal nonpainful menses; pain w/ menses common; discomfort in uterine area, diffusely throughout lower pelvis, back, thighs, buttocks; painful bowel/bladder function expected, symptoms normally lessen and abate by end of menstruation; primary caused thought be be underlying muscular structure of uterus and its reaction to various chem during cycle; secondary caused by underlying disorder, e.g. pelvic infections, fibroids, endometriosis, cervical stenosis; diagnosis made from patient history, w/ etiology determined by history, phys, pelvic ultrasounds, diagnostic laparoscopy; NSAIDs prescription or over-counter, hormonal birth control can reduce pain; heating pad on abdomen helps; if underlying organic reason, disease treated, e.g. endometriosis req birth control pills, progestins, GnRH analogs, surgery to alleviate pain; if fibroid cause, surgery to remove or reduce size w/ high freq ultrasound or embolization; prognosis good w/ resolving cause; NSAIDs, birth control pills work very well; initial onset can be prevented; if menses are eliminated, then so is dysmenorrhea

Ovarian Cysts

Fluid-filled, semisolid or solid masses originating in ovary; follicles that occur during menstrual cycle often inaccurately referred to as cysts; when small often unnoticed; size when becoming symptomatic depends on how quickly it develops, size, underlying cause, association w/ adjacent structures; rarely urinary retention can result when large cysts presses near bladder;  if cysts prod hormones, affects bodily functions; larger cysts can torsion/twist causing pain, nausea, vomiting; torsion resolved w/ surgery, sometimes req removal of ovary; two types physiologic caused by normal functioning of ovary and neoplastic cysts; neoplastic benign/malignant; occasionally cancer metastasizes to ovary; most ovarian cysts physiologic from ovarian follicle growth or corpus luteum that persists for too long; cysts that occur in postmenopausal women >10 cm in size more concerning for malignancy; mali/benign ovarian tumors cause not certain; pelvic mass noted during rectal/pelvic exams; ultrasound best assess presence and nature of cysts; MRI, CT can detect; laparoscopy w/ direct vision of ovaries may be req if cyst must be removed; benign physiologic cysts common, w/ small cysts seldom req treatment; large cysts can be drained during laparoscopy or removed, often w/o affecting ovary; cysts that are drained likely to recur; small physiologic cysts can disappear spontaneously; cancerous cysts req major surgery, often removal of uterus, omentum, appendix, or lymph nodes; if nonmalignant, outcomes excellent; if related to endometriosis, outcome depends on success of treating underlying disease’ if cancerous, prognosis depends on stage and origin and degree of abnormality; prevention unknown, but taking birth control pills may prevent

Mittelschmerz

Term applied to unilateral pain occurring in region of ovary during ovulation, often midway thru menstrual cycle; dull pain for few minutes-hour, can indicate time of ovulation for couples attempting to conceive; etiology unknown, but leakage of follicular fluid into abdomen during ovulation may be cause; pain occasionally severe enough to seek med care; history of occurrence at midpoint of menstrual cycle and elimination of other pelvic/ab causes leads to diagnosis; mild analgesics treats

Endometriosis

Chronic, charact by extrauterine endometrial tissue; implants of endometrium most commonly in pelvis, but can occur in distant sites; considered benign, can be acute/chronic; secondary dysmenorrhea, painful sex, painful defecation, infertility; cyclical infla and scarring can lead to lack of menstruation; complications of infertility, ectopic pregnancy, pelvic scarring, adhesion formation possible; retrograde menstruation most likely cause; if functioning endometrial tissue grows outside uterine cavity, it responds to ovarian hormones as endometrium (lining of uterus) does during normal menstrual cycle; cyclic swelling, infla, bleeding and scarring causes pain; risk factors of family history of disease, menstrual cycles < 28 days or lasting > 7 days, uterine structure abnormalities affecting menstrual blood loss, fibroids, diseases of immune system can associate w/ incidence; during pelvic exam, physician finds tender areas, nodules, thickened scar tissue; enlarged ovaries may represent endometriomas and retroflexed uterus that is scarred/immobile; good history, phys, ultrasound can acutely predict presence; laparoscopy can confirm diagnosis and help stage extent; treatment tailored to woman’s need, age, general health, severity of symptoms; various hormones for younger patients worried about fertility; hormonal contraception, GnRH analogs, progestin releasing IUD can resolve symptoms; Danazol rarely used to fix due to side effects;  surgery can remove endometrial impants, deep nodules, adhesions; while no cure, pregnancy, nursing a baby, menopause may bring remission of symptoms as aberrant tissue shrinks under these conditions; surgery can remove endometrial growths; in severe cases, a total hysterectomy w/ bilateral salpingo-oophorectomy sometimes; no cure, but treatment options avaiable w/ good prognosis; no prevention known

Pelvic Inflammatory Disease (PID)

infection of woman’s pelvis; tubes, ovaries, surrounding tissue involved in infection, can be self-limiting or if abscess forms life-threatening; common in young sexually active women, esp w/ 1+ partners; active infection, fever, chills, malaise, foul-smelling vaginal discharge, backache, painful tender abdomen; sometimes walking painful, and patient walks w/ shuffling gait; if abscess forms, soft tender pelvic mass can be palpated; WBC elevated; if symptoms severe, prompt med intervention req; initial infection often STD, becoming multibacterial w/ both (an)aerobic organisms; pelvic exam shows  tenderness, often bilaterally; cervix tender to manipulation/movement; cervical cultures for STD finding; ultrasound rules out abscess formation; fever, elevated WBC, phys exam usually all needed for diagnosis and to start treatment; sometimes symptoms or signs not clear, so laparoscopy can confirm; early diagnosis and prompt treatment lessens reproductive system damage; antibiotics IV/oral based on severity; infla of reproductive organs can cause scar tissue or adhesions to form, if around fallopian tubes, risks infertility and ectopic pregnancy; w/o effective treatment, complications of peritonitis in ab cavity, infection becoming blood borne, septicemia, death may occur; recurrent or severe can lead to infertility; early and aggressive therapy improves diagnosis; avoiding STDs prevents

Leiomyomas / Fibroids

Noncancerous (benign) tumors of smooth muscle of uterus; vary in #, size, location of uterus, most common tumor of female reproductive tract in up to 40% of women before menopause; often asymptomatic; if symptoms pelvic pain, pressure, constipation, urinary freq, abnormal bleeding, heavy/prolonged periods most common; severity varies w/ #, size, location of tumors; cause unknown, development stimulated by estrogen, typically regresses post-menopause; birth control pills, hormone replacement therapy do not appear to have much impact on growth; diagnosis based on pelvic exam and patient history, definitive after ultrasonography; treatment varies w/ same stuff and desire to have children; if wanting a child, surgery removes tumors; if no desire for kids, ultrasound ablation, uterine artery embolization, endometrial ablation used; hysterectomy only definitive treatments w/o recurrence; route of hysterectomy depends on many factors, but many modern techniques allow women to undergo surgery as outpatient; often no need  to remove, malignancy rate 0.5%; if removed, 10-50% recurrence rate; chance of recurrence greater w/ #; if uterine removal, no chance of recurrence; prevention unknown

Vaginitis

Infla/Infection of vaginal tissues; all ages at risk; not perilous, but irritating, painful; vaginal discharge w/ local itching/burning, odor principal symptom; depending on causative agent, discharge can be white, grey, green, absent/copious, w/(o) odor, malodorous; discharge can cause irritation, soreness of vulva; fever; symptoms req prompt appointment, diagnosis, treatment; fungal infections most common cause, but bacterial growth or infections w/ trichomonas can cause; cervical infections w/ STDs can prod discharge; in post-menopausal, absence of estrogen can thin vaginal lining, altering normal flora leading to inc susceptibility to infections, called atrophic vaginitis; after med history, pelvic exams and swabs of vagina to find bacteria or fungus and pH of discharge; cultures can ground diagnosis; based on results of cultures and wet prep exam, treatment can consist of antifungal/bacterials or for atrophic, hormonal therapy; w/ proper treatment, infla clears in a week; can be recurring problem; no STDs, good hygiene, avoiding chem irritants prevents

Toxic Shock Syndrome

Acute, systemic infection w/ S. aureus; associated w/ menstruating females who use tampons; super-absorbent tampons can predispose women to S. aureus infection; sudden onset w/ high fever, headache, sore throat, rash; w/ progression hypotension, shock; GI symptoms, diarrhea, neuromuscular disturbances, abnormal kidney function, elevated liver enzyme; can be life-threatening w/o treatment; immediate med treatment indicated; toxins prod by bacteria causes; initial infections associated w/ single brand of tampons which have been removed from the market; can occur in women using contraceptive sponges or diaphragms; diagnosis based on clinical eval and lab tests; CDC lists specific diagnostic criteria; replacement of fluids to counteract shock and antibiotics for infection; if treatment delayed, death from overwhelming shock can occur; can result in neurologic, renal, respiratory complications; avoiding super-absorbent tampons prevents, storing them in cool dry area

Menopause

Change of life or climacteric; cessation of menstrual periods for 1 year w/ evidence of ovarian failure; average age 50-51, not considered premature unless before 40; fluctuation of menstrual cycle/flow noted, w/ periods becoming lighter, less freq; hot flashes, night sweats can be nuisance; vaginal dryness, skin changes, transient to troublesome psych symptoms from depression, poor memory, anxiety, sleep disorders, poor libido; perimenopausal when having symptoms of menopause while still menstruating; changes in ovarian prod of certain hormones creates alterations of pituitary levels of FSH, drives failing ovary to prod more follicles; altered balance btwn ovarian estrogen follicle generation, pituitary FS leads to fluctuation in menstrual cycle hormones, causing menopause; once ovarian reserve exhausted, no more eggs prod, ovulation halts and menstruation ceases; chemo, radiation for certain cancers can bring; surgican menopause (total hysterectomy) associated w/ more hot flashes and nuisance symptoms if not treated w/ hormones; patient history suggests; blood serum of follicle-stimulating hormone elevated, estrogen low; hot flashes and changes responding to estrogen withdrawal managed w/ estrogen products; patient gets final choice of hormone treatment due to potential for cancer using them; vaginal changes treated w/ local estrogen products/lubricants; bone loss treated w/ bisphosphonates, SERM’s, or salmon calcitonin; weight-bearing exercise and dietary Ca or Ca supplementation helps w/ bone loss; menopause cannot be prevented

Uterine Prolapse

Downward displacement of uterus from normal location in pelvis; if mild degree no symptoms; on occasion feeling of inc vaginal/pelvic pressure during descension; if prolapse to point where cervix is exiting vagina, woman may feel it wiping herself after urination; sometimes pain during sex or general pelvic discomfort; occurs when normal support for uterus weakens from trauma (child-birth), aging, genetic factors; weakening of supports allows uterus to move down vaginal canal, pulling vagina where cervix is attached along w/ it; when uterus completely outside vagina, termed complete procidentia; if less than complete, graded based on distance it has traveled down vagina in comparison to normal position; visible upon pelvic exam, helps when patient stands or performs Valsalva or cough to elicit prolapse; no way to reverse itself once occurring; losing weight, reduction of coughing, correction of constipation w/ excessive Valsalva can slow progression; use of pessary can help w/ symptoms but does not resolve problem, inserting itself into vagina to support uterus; surgery only way to correct; if no longer needing their uterus, hysterectomy commonly performed w/(o) reattaching vaginal apex to sacrum or to sacro-spinous ligaments; prognosis good even if surgery req; exercises strengthening pelvic floor muscles after childbirth, no smoking, reducing cough, high fiber diet w/ good fluid intake prevents

Cystocele

Downward displacement and protrusion of urinary bladder into anterior wall of vagina; pelvic pressure, urinary leakage urgency or discomfort w/ intercourse; when severe urethral/bladder neck kinking, bladder cannot be fully emptied; can cause overdistention of bladder w/ resultant nerve/muscle damage or inc incidence bladder infections; trauma to fascia, muscle, and pelvic support structures during pregnancy/delivery or from atrophy w/ age or genetic predisposition can cause; diagnosis based on clinical picture, findings from phys exam; if incontinence, Kegel exercises, surgery, or pessary use treats; surgery to return bladder to normal can be done w/(o) surgical mesh; prognosis good; exercise strengthening pelvic floor muscles after child-birth helps prevent; tissue changes w/ aging cannot be prevented; avoiding traumatic vaginal delivery prevents

Rectocele

Protrusion of rectum into posterior wall of vagina; feeling of bearing-down, fullness of vagina, back pain, pelvic pressure, difficulty evacuating rectuml occurs when posterior wall of vagina weakened, causing protrusion of rectum into vagina; often results from childbirth, aging, genetic predisposition; diagnosis based on clinical picture and phys exam findings; surgical repair of posterior wall (posterior colporrhaphy) treats, pessary used if no desire for surgery; prognosis good w/ surgery; no prevention known; reducing coughing/constipation to dec severity

Cervical Cancer

Cervix is lower part of uterus, extending from uterine isthmus into vagina, allowing sperm into uterine cavity, allowing infant to pass into birth canal; most SCC in transitional zone btwn diff epithelial types of uterus corpus and vagina, sometimes adenocarcinoma; two main symptoms are watery bloody or purulent vaginal discharge w/ heavy/foul smell, bleeding btwn menstrual periods after sex or during menopause; most common sign is abnormal Pap smear; appearance of cervical lesion varies, but often mass/ulcer on surface of cervix; if advanced, pelvic/lower back pain, hematuria, dysuria, rectal bleeding; invasive cancer considered preventable due to long premalignant stage 10+ years and effective screening; biggest  risk factors is lack of regular cervical Pap smear screening, exposure to oncogenic types of HPV (16, 18, 31, 45), more common in those w/ freq unprotected sex w/ multiple partners; HPV DNA common in 90% of invasive cancers, but not sufficient to cause neoplasia; smoking, low socioeconomic status, early/multiple parity, use of oral contraceptives, other venereal diseases risk factors; often 45-55, but significant problem in 65+ who are less likely to get a Pap smear; premalignant lesion is a CIN, involving dysplasia or atypical changes in cervical epithelium; by getting scrapings from cervical os and cervix and exam miscroscopically, cellular abnormalities can be detected; diagnosis confirmed by colposcopy and biopsy of lesion; stage determined clinically w/ phys exam of patient, chest x-ray, IV pyelogram, colposcopy, cystoscopy, proctoscopy; lymph node sampling sometimes; staged by TNM relying on clinical eval, as cervical cancer more common i n developing countires w/o access to more modern techniques; treatment varies w/ stage; low grade CIN w/ repeat cytology at 6 and 12 months; high grade CIN uses loop electrosurgical  excision procedure, though laser therapy, cryablation sometimes; radical hysterectomy to remove ovaries, oviducts, lymph nodes, lymph channels, uterus, cervix if invasive; carcinomas that have invaded pelvic wall or have distant metastases use radiation therapy; cisplatin-based chemo w/ radiotherapy used; stage determines prognosis primarily, but lymph node status, tumor volume, depth of invasion impacts; HPV subtype can affect, w/ 18 having poorer prognosis; 5-year survival 92% for women w/ stage I, 15% stage IV neoplasms; recurrence has very low prognosis, 10-15% 1-year survival; annual Pap smears and pelvic exams starting 3 years after first intercourse, no later than 21 helps prevent by early recognition; if no risk factors, can stop at 65-70

Vaginal Cancer

Rare, w/ malignancy often from metastasis of adjacent structures; most SCC, sometimes melanoma or adenocarcinoma; vaginal bleeding after sex or postmenopausal, malodorous or watery vaginal discharge, dysuria, urinary freq, constipation, melena, vaginal mass; tumor itself is a mass, plaque, or ulcer on vaginal wall; posterior wall most common site; unusual bleeding req diagnostic eval; risk factors of HPV infection, prior history of gynecologic malignancy, advanced age, multiple lifetime partners, early age of first time, smoking; vaginal intraepithelial neoplasia (VAIN), atypical squamous cells w/o invasion can be premalignant lesion, often asymptomatic, but causing postcoital spotting or discharge; SCC mean age of 60, adenocarcinoma before 20 linked to synthetic hormone diethylstilbestrol (DES); DES used in past to stop spontaneous abortions and manage diabetic pregnancies; cancer develops in daughters of DES using mothers; diagnosis difficult as lesion can be small; pap smear may discover incidentally; definitive diagnosis w/ colposcopic exam and direct biopsy of lesion; cervical biopsies can rule out primary cervical cancer; carcinomas staged by phys/pelvic exams, cystoscopy, proctoscopy, chest x-ray, bone scan; staged by TNM; treatment varies w/ location, size, clinical stage; surgery of hysterectomy, upper vaginectomy, bilateral pelvic lymphadenopathy w/ adjuvant radiation therapy; radiotherapy alone sufficient if early enough; stage determines prognosis mainly, but lymph node status, age, lesion location important; since most diagnosis done when advanced, 5-year survival SCC 44%, adenocarcinoma 75%; regular Pap smear, barrier contraceptives, limiting sexual partner number prevents; diagnosis and treatment of VAIN w/ surgery, laser ablation, or topical 5-fluorouracil can prevent progression

Labial/Vulvar Cancer

Vulva is area of female external genitalia; any condition that affects skin or other part of body can affect vulva; 90%+ vulvar malignancies are SCC; most have nodule/ulcer on labia majora/minora or clitoris; lesion pruritus; less common is vulvar bleeding, discharge, dysuria, enlarged lymph node in groin; most often postmenopausal, 65 year average; risk factors of smoking, HPV, HIV, HSV2 infection, multiple sex partners, prior cervical/endometrial/breast cancer, Northern European ancestry; vulval intraepithelial neoplasia (VIN), noninvasive epithelial dysplasia of vulva is premalignant lesion for invasive carcinoma; diagnosis req biopsy of lesion, colposcopy can define areas to biopsy; after diagnosis confirmed, phys exam of regional lymph nodes req; for metastasis, chest radiograph, cystoscopy, proctoscopy, IV pyelogram; Pap smear to check for cervical cancer; staged by TNM; surgical removal of growth and surrounding skin or all of vulva treats, vulvectomy; inguinofemoral lymphadenectomy often performed; radiation sometimes w/ surgery; distant metastases or recurrences treated w/ systemic chemo, but rate of response typically low, prognosis poor; inguinofemoral lymph node status indicates prognosis; 5-year survival 0-77% based on stage; barrier contraceptives, regular gynecologic exams, treatment of VIN w/ excision, laser therapy, topical 5-fluorouracil prevents progression

Ovarian Cancer

More deaths than any other gynecologic malignancy; often asymptomatic until advanced due to ovaries location deep in pelvis; derive from epithelial cells; neoplasms induce nonspecific symptoms lower ab discomfort, bloating, constipation, lower back pain, irregular menstrual cycles, urinary freq, dyspareunia; most common sign enlargement of abdomen from accumulation of fluid, often indicates advanced disease; persistent vague digestive disturbances (discomfort, gas, distention) that cannot be explained may be ovarian cancer; 40-65, etiology mainly unknown; pregnancy, breast-feeding, prolonged use of oral contraceptives, tubal ligation may reduce risk of developing; breast cancer, family history of breast/ovarian cancer inc risk; mutations on BRCA1/2 genes, the breast cancer susceptibility genes may be present; hereditary nonpolyposis colon cancer inc risk; early stage diagnosed sometimes on palpation of abnormal adnexal mass during routine pelvic exam; due to deep anatomic location of ovary, most early not discovered; finding of pelvic mass leads to transvaginal ultrasound and use of serum tumor markers to distinguish benign/malignant; if not malignant, mass followed for 2 months to see if it resolves; Serum CA 125, a glycoprotein tumor marker elevated > 65 U/mL in more than 80% of cancers; tumors staged by TNM, based on surgical eval and diagnostic, often laparotomy; therapeutic cytoreduction to reduce tumor volume performed here; ab/pelvic CT to find metastases; treatment varies w/ extent of disease at diagnosis and size/lcoation of residual tumor; early stage I/II treated w/ surgical removal of ovaires and fallopian tubes, bilateral salpingo-oophorectomy, and uterus hysterectomy, although if cancer diagnosed in very early stage and wishes to have children, one ovary only may be removed; risk of relapse reduced w/ adjuvant chemo and platinum-based compounds (carboplatin plus paclitaxel) treatment for advanced is aggressive surgical cytoreduction w/ chemo; efficacy of treatment evaluated thru radiographic testing indicated by decline in serum CA-125 level, w/ regular follow up exams; 5-year survival 50% as more than 75% of cancers have spread beyond ovaries at time of diagnosis; stage I 89% 5-year survival, w/ metastatic disease 13%; young age, absence of ascites, low volume of residual disease improves prognosis; periodic pelvic exams important for women, screening of BRCA1/2 gene mutations, transvaginal ultrasound and serum CA 125 measurements every 6-12 months at ages 25-35 can detect early

Endometrial Cancer

Most common gynecologic malignancy; often begins w/ endometrial thickening (hyperplasia), abnormal tissue development (dysplasia), and carcinoma in situ; ulcerations of endometrium develop as blood vessels erode, vaginal spotting or bleeding occurs; most common presenting symptom is abnormal perimenopausal or postmenopausal uterine bleeding in early stages of disease; late manifestations of cancer include pain, systemic symptoms; can be revealed by Pap smear; two types, most common is related to high cumulative exposure to estrogen, presenting as low-grade adenocarcinoma; excess estrogen from estrogen replacement therapy for postmenopausal women, tamoxifen for breast cancer, obesity, early onset menarche, late menopause, never having children, chronic anovulation; endometrial hyperplasia w/ cellular atypia caused by endometrial exposure to cont estrogen unopposed by progesterone, a precursor lesion for this type of carcinoma; second type unrelated to estrogen or hyperplasia as high-grade papillary serous or clear cell carcinoma w/ poorer prognosis; primarily postmenopausal, median age 61; hereditary nonpolyposis colorectal cancer at high risk; pregnancy, use of oral contraceptives for 12 months offers protective effect; endometrial biopsy performed on all women w/ abnormal uterine bleeding or abnormal cells on Pap smear; dilation, curettage remains gold standard and performed for nondiagnostic biopsy; after diagnosis, preoperative eval of CBC, renal/liver function tests, urinalysis, chest x-ray, ECG; staged by TNM system, req total hysterectomy w/ bilateral salpingo-oophorectomy to fully evaluate extent of disease; lymph nodes evaluated surgically; serum tumor marker CA-125 measured to predict spread beyond uterus; very early stage treated w/ surgery alone, whereas adjuvant radiation therapy recommended for those w/ more advanced disease; radioactive implant inserted into vagina and left for duration of treatment while patient in hostpital; combo chemo used if metastatic; risk of recurrent disease greatest within 3 year of diagnosis; follow-up to detect recurrence and measure Ca-125 and vaginal cytology; prognosis based on stage and tumor grade; early 5-year survival 96%, regionally advanced 66%, metastatic 25%; routine screening not recommended as no sensitive or specific tests are available; those at risk should have annual endometrial biopsy starting at age 35 to prevent; prophylactic hysterectomy after childbearing considered

Amniocentesis

Small amount of amniotic fluid extracted in lab analysis

Chorionic Villus Sampling (CVS)

a biopsy to excise placental tissue for lab analysis

Doppler Ultrasonography

Noninvasive, real-time, 3-D fetal imaging

Morning Sickness

Nausea, vomiting associated w/ pregnancy; common, 80% women; may begin before first missed menses, resolving 12-16 weeks by itself; only 1% pregnant women have persistent morning sickness beyond 20th week; if severe, excess weight loss, metabolic imbalance, then called hyperemesis gravidarum affecting ½-3% women; sometimes nausea in waves, sometimes hours at a time; if dehydrated, urine dark, ketones may be present; if vomiting severe, blood tests show electrolyte/metabolic abnor; rapid pulse, poor skin turgor, dec urine output, constipation signs of dehydration; etiology not yet defined; believed to be human chorionic gonadotropin or isoforms and estrogen responsible; psych problems can make symptoms worse; underlying GI conditions can experience worse symptoms GI; diagnosis based on symptoms and positive pregnancy test; simple hydration, rest, eating small amounts of food can get women thru; avoiding food, smells, env triggers benefit; ginger, hypnosis, wrist bands, vitamin B6/12 can help lower severity; over-the-counter sleep aid Unisom, vitamin B6 can help, a combo safe for fetus and effective most times; additional drugs safe if all else fails; often self-limiting, gradually resolves; if severe, can lead to esophageal tears, peripheral neuropathies, encephalopathy, death; prevention unknown

Hyperemesis Gravidarum

more severe morning sickness that doesn’t respond to over-the-counter remedies, normally req prescription meds, hospitalization; weight loss >5% associated w/ metabolic disturbances, dehydration; excessive vomiting in pregnancy; freq severe episodes of nausea, weight loss, dehydration, unable to keep food/liquid in stomach; if untreated, fluid/electrolyte imbalances cause A/B disturbances in baby/mother; abnormal urine osmolality w/ high ketones in urine noted; blood may be hemoconcentrated w/ mild elevations in WBC, abnor in blood chemistries; abnormal liver enzymes, thyroid labs may be present; etiology unknown, but elevated estrogen, hCG levels believed to be responsible; emotions may play part in onset and severity; inability to ingest food/liquid w/o vomiting; underlying emotional disturbances (abuse) have higher incidence; diagnosis based on symptoms, weight loss, dehydration disturbing electrolyte balance; when severe, hospitalization where reversal of dehydration w/ IV fluids occurs; electrolyte imbalance fix w/ salt infusions; antiemetics IV until women able to take oral liquids; once tolerating oral agents w/o vomiting, snet home w/ weight loss stabilizing her; home nursing IV can continue; prognosis excellent, resolving spontaneously w/ progression of pregnancy; complications of dehydration, excessive electrolyte disturbances should be avoided; if not treated, profound maternal/fetal complications; timely intervention can prevent complications

Miscarriage

naturally occurring loss of fetus before 20th week; classified as missed (no tissue passed), incomplete (some tissue passed), or complete (all tissue passed); (in)complete has vaginal bleeding and pelvic cramping; excessive bleeding leads to hypovolemia, rapid pulse, low BP; in hospital CBC verifies extent of blood loss; when severe hemorrhage, shock ensues; positive pregnancy test w/ urine/blood req to verify patient was pregnant; exam of cervix may reveal blood in vagina w/(o) visible products of conception; similar symptoms to ectopic pregnancy; prompt med care req; etiology unknown, w/ 10-15% pregnancies affected; majority from abnormal chromosomes; infection, metabolic disturbances, maternal antibody prod (lupus, clotting disorders) associated w/ inc risk; drugs, most prescribed meds do not normally cause; travel, exercise, intercourse not associated w/ miscarriage; women who work as anesthesiologists noted to have higher risk; diagnosis based on clinical picture and pelvic ultrasonography; ultrasound can determine fetal viability or amount of remaining tissue in uterus; based on level of serum hCG, can rule out ectopic pregnancy; if bleeding not severe, mother treated conservatively allowing products of conception to pass on their own;  meds to expedite passage of fetal/placental tissue given sometimes; if complete abortion, no need for meds; if bleeding severe or expulsion of ceontents incomplete, surgery (D&C) indicated; in instances of missed abortion, woman may elect to have sugery to remove products to avoid uncertainty/discomfort of spontaneous passage; knowing blood type as RhoGAM req esp if Rh negative; prognosis of all types excellent; good prenatal care, no alc, tobacco, abuse of inhalants, drugs, herbs can prevent; prescription drugs taken w/ caution

Ectopic Pregnancy

Fertilized ovum implants and grows outside endometrial canal, most often fallopian; pos pregnancy test and pelvic pain common, can be no pain and neg pregnancy test; if pain, often one sided; cramping w/(o) bleeding can occur; if bleeding into abdomen, diffuse pelvic pain; if large amount int bleeding, hypotensive and shock can occur; if not treated promptly, bleeding can cause death; serum beta-hCG >1500-2000 units w/ empty uterus on transvaginal ultrasound sussy for ectopic; abnormal rise in beta-hCG over 48 hours can be early sign; sudden/severe lower ab pain w/ vaginal bleeding req prompt med evaluation; any fertilized egg that cannot make it into uterus and implants and grows will become ectopic; cause of most unknown; pelvic adhesions, damaged fallopian tubes, progesterone contraception, previous tubal ligation, previous pelvic infection, prior pelvic surgery, IUD’s all inc incidence; diagnosis difficult; if not ruptured or no pain, serial ultrasounds w/ serial blood pregnancy tests can help ground diagnosis; when ruptured, diagnosis less difficult, w/ transvaginal ultrasound mainstay in diagnostic imaging; if diagnosis unclear or no ultrasound, frozen D&C can look for evidence of intrauterine gestational tissue; culdocentesis (placing needle into space behind uterus) can be used in unusual cases if diagnosis uncertain; if diagnosis remains in question, laparoscopy to directly visualize pelvis, fallopian tubes; if early unruptured, methotrexate causes placenta to die and products reabsorbed by body; laparoscopic surgery common way to treat; if unruptured, tubal conservation possible; many times tubes are sacrificed, rarely removal of ovary; if int bleeding, surgery w/ laparoscope possible; if fallopian tube preserved, inc risk for recurrence; if ectopic w/ falling beta-hCG, close observation w/o use of methotrexate or surgery w/ later treatment done; prognosis good w/ prompt med intervention; chance of conception w/ normal intrauterine pregnancy excellent; if underlying tubal disease or extensive pelvic adhesions, chance of pregnancy reduced; prior ectopic pregnancies inc risk of subsequent ectopic; preventing PID can reduce risk

Premature Labor

Contractions leading to cervical change before 37 weeks completed; contractions changing size of cervical opening or length of cervix; sometimes contractions are unfelt, only evident on fetal monitor; may have inc vaginal discharge, spotting; vaginal exam shows cervical changes; ultrasound can show changes in length and ab P; premature contractions req immediate instructions from nurse; most time unknown etiology; predisposing is maternal infection, uterine abnor, uterine fibroids, uterine bleeding, previous preterm births, multifetal pregnancy, advanced maternal age, gum disease, vaginal colonization, certain bacteria, no prenatal care, preterm cervical dilation, effacement, smoking, stress, domestic violence; diagnosis made by demonstrating cervical change by contractions; fetal fibronectin can help predict risk; cervical length change on ultrasound, pelvic exam grounds diagnosis; no effective treatment can be delayed by 48-72 hours; terbutaline, indocin, NSAIDs can deal w/ preterm contractions; Ca channel blockers, magnesium sulfate potential treatment; intramuscular injections of steroids can help reduce complications; weekly intramuscular progesterone injections if previous history preterm birth, reducing incidence by 30%; outcome of baby depends of age it is born, underlying presence of infection, birth defects, cause of labor; earlier gestational age more guarded prognosis; steroids before birth can improve outcomes; treated infection, bed rest, judicial use of tocolytics to inhibit contractions, use of steroids when appropriate, enhanced fetal surveillance may help prevent; only proven agent for prevention is intramuscular progesterone

Toxemia / Eclampsia

Preeclampsia/Toxemia is serious disease of pregnancy w/ hypertension, proteinuria, often in third trimester but anytime after 20 completed weeks; eclampsia is seizure in patient w/ preeclampsia; preceded by weight gain, peripheral swelling, edema sometimes; BP >140/90 clear sign; if >300 mg protein in urine, diagnosis present; persistent headache, visual disturbances, epigastric pain sometimes present; deep tendon reflexes can be more exaggerated when severe, clonus may be present; if seizure, often grand mal, having usual postictal manifestation of confusion, disorientation; patients inc risk of stroke, central neurologic nature may need eval for presence of stroke; seizures req emergency intervention; etiology preeclampsia unknown, w/ 7% women in US affected, more common in first pregnancies, younger women, women w/ multiple fetuses, 35+, underlying hypertension or vascular disease (diabetes, lupus); causative agent unknown, but presence of placenta req; once placenta delivered, condition improves after 24-48 hours; cases can be persistent, lasting 7+ days postdelivery; diagnosis based on clinical picture, history, elevated BP, possible lab abnors; delivery of infant/placenta treats; if child and woman remote from due date, bed rest, freq monitoring of fetus/mother, monitoring blood tests, delay of delivery until fetal lung maturity req; if more severe, immediate delivery sometimes; if fetus <34 weeks, steroids to accelerate lung maturity; laboring women may req meds (magnesium sulfate) to reduce seizure chance; after delivery, disease can remit, often immediately worsen 24-48 hours before improving; early diagnosis/treatment best, prognosis poorer if severe due to maternal/fetal death; Ca supplementation, lose dose aspirin therapy, good nutrition may prevent

Abruptio Placentae

Premature detachment of normally positioned placenta during pregnancy; hemorrhage, ab pain, fetal distress, fetal death maybe; degree of bleeding variable, w/ most mild/moderate; uterus often contracts during abruption, w/ painful contractions very closely spaced or sudden; monitoring fetal heart rate may show abnor, but early on can be normal; if abruption extensive, fetal death, large clot forming under placenta leading to massive blood loss in moth and consumption of clotting factor, causing coagulopathy; when severe, mother’s blood unable to clot; some abruptions no bleeding, only signs are fetal heart rate abnor or death; large abruptions can be found w/ ultrasound; med emergency; often cause unknown; hypertension, preeclampsia, trauma, maternal vascular disease, infection, drug use (cocaine), multiple gestation predisposes; diagnosis made by constellation of risk factors, fetal heart rate pattern, mother’s systems, contraction pattern, presence of bleeding; diagnosis confirmed/refuted at time of delivery; ultrasound rarely helps for smaller abruptions, but can find large ones; treatment depends on degree separation, proximity to delivery, maternal/fetal stability; when mild, labor can continue w/ anticipated vaginal delivery, operating room ready in case clinical picture rapidly deteriorates; in more severe cases, immediate surgical delivery; treatment of massive blood loss, coagulopathy treated w/ blood, clotting factor replacement; prognosis depends on degree abruption, gestational age; if abruption small, fetus >34 weeks, outlook excellence; good prenatal care w/ individualized attention to risk factors can prevent

Placenta Previa

When placenta covers opening of cervix; partial version where majority of placenta is away from opening; complete version = central previa when more central portion of placenta covers os; patient experiences painless, bright vaginal bleeding, often 1st/2nd trimester; sometimes painless vaginal bleeding in third; abdomen soft, nontender; when excessive bleeding, vital signs may indicate shock, rapid thready pulse, falling BP; fetal heart rate may  show compromised blood supply to fetus; low implantation of blastocyst in uterine cavity causes; prior C-section, previous childbirth, multiple gestation can inc risk; diagnosis based on pelvic ultrasonogram shows placenta implanted shows placenta implanted over cervical os; as os begins to dilate, vessels tear loose and placenta bleeds; critical that cervical exam not done until location of placenta verified by ultrasound; oftentimes daily life continues normally if no bleeding; no exercise, intercourse as they can cause bleeding; if bleeding stops and fetus stable, patient followed as outpatient w/ restricted activity and regular visits; if bleeding more significant, hospitalization may be req until fetus deemed mature; in stable previas, delivery done 36th week to avoid potential catastrophic bleeding in labor; any massive hemorrhage w/ fetal/maternal compromise req immediate delivery by C-section; there is not time where vaginal delivery alowed w/ viable fetus if placenta previa present; most times outcomes excellent; prognosis guarded w/ compromise or blood loss or infant premature; prevention unknown

Fetal Presentations

Most fetuses are in cephalic/vertex presentation, head first facing opening; some present in other manners, e.g. footling breech (feet first), frank breech (buttocks), transverse lie (across uterus); if abnormal presentation, delivery done via C-section

Multiple Pregnancies

Infertility treatment contributes to inc as drugs (Clomid) stimulate ovulation, causing several ova to be released at ovulation, and sperm multiple opportunities for fertilization; during process of vitro fertilization, several fertilized ova implanted in hope that at least one success will occur; ovaries sometime release 1+ ovum naturally; fertilized zygote sometimes divides prod identical twins; greater risk toxemia, dyspnea, urinary freq, constipation, edema of feet and legs, heartburn early in pregnancy relative to single fetus mothers; those expecting triplets+ hospitalized at start of third trimester, restricted to bed rest; fetuses monitored freq and often delivered by C-section; size of multiple pregnancies generally prevents pregnancy from continuing to term; can result in small, immature infants who need intensive nursing care 

Hydatidiform Mole

Abnor proliferation of placental tissue taking on charact of malignancy; placenta has “cluster of grape” like appearance on ultrasound or diagnosis may come from pathologic eval after miscarriage or pregnancy termination; experiences symptoms like other pregnant women, sometimes more nausea/vomiting, vaginal bleeding; on phys exam uterus may feel larger than expected on last menstrual period; in cases of complete molar pregnancy, no fetus develops, ultrasound shows empty or absent sac of abnor appearing placenta; incomplete mole occurs in living fetus, difficult to detect; if blood hCG performed, may be greatly elevated out of proportion from what expected at gestational age; if pregnant w/ vaginal bleeding, ultrasound appointment needed; genetic anomaly during fertilization where placenta develops abnor as mass of clear grape-like vesicles w/ no fetus present causes; diagnosis based on clinical picture, absence of FHTs (in a complete mole), abnor elevated hCG levels, ultrasound of placenta; sometimes diagnosis made by microscopic exam of placenta by pathologist after delivery, pregnancy termination, or miscarriage; mole normally not expelled spontaneously, so surgery req, w/ usual being D&C; observation for hemorrhage key; if molar tissue persists post-op, chemo to prevent further growth; on occasion, persistent trophoblastic tissue which chemo doesn’t work may req hysterectomy; if uterine evacuation, serial beta-hCGs req until values fall below detectable amounts; pregnancy should be avoided for 6 months after removal; most do not persist, prognosis good w/ early treatment; complications of infection, bleeding can occur; if fetus present, preeclampsia if before 20 weeks, concerning an incomplete mole; can be precursor to choriocarcinoma; prevention unknown affecting 1/1500 pregnancies in US

Fibrocytic Breast Condition

Common, benign breast disorder; female w/ mammary fibroplasia has uncomfortable feeling in breasts; lumps, cysts, single/multiple, smooth/rounded, can be palpated in 1+; breasts tender on palpation, shooting pains in breast; tenderness more intense premenstrually; after menopause, condition less of problem; 1+ breast lumps warrants screening; etiology unknown; inc formation of fibrous tissue and hyperplasia of epithelial cells of ducts/glands, resulting in dilation of ducts; cystic disease most common disease of female breast, often 30-50, related to normal hormonal variation; prompt diagnosis based on palpation and mammogram to differentiate this from malignant neoplasm; ultrasonography performed to determine whether lump solid/hollow, distinguishing cysts from tumors; no specific treatment known; sometimes aspiration of cysts w/ needle; antiinflammatory meds, oral contraceptives sometimes; patient advised to wear firm bra and restrict caffeine; often benign, mostly never resulting in malignancy; microscopic findings showing atypical cells or hyperplasia inc risk of cancer; prevention unknown, but improvement seen w/ restricting caffeine

Mastitis

infla of 1+ mammary glands; acute puerperal (postdelivery) version is infla during lactation postpartum; nursing mother has sudden pain, redness, heat in breasts at start/end of lactation; breasts hot, doughy, tough; axillary lymph nodes may be enlarged; discharge from nipple, fever, malaise; req same-day appointment w/ symptoms; caused by streptococcal or staphylococcal infection; bacteria invades milk ducts, inducing infla and occlusion; milk stagnates in lobules, prod dull pain; baby, nursing staff, mother’s own body can be source of infection; diagnosis based on clinical picture; firm, supportive bra should be worn, heat supplied to area, progesterone Rx, drug therapy (antibiotics); palliative care of rest, analgesia, warm soaks; breast-feeding need not to be discontinued if patient improves; prognosis good w/ treatment; abscesses may form w/ inadequate treatment; anyone in contact w/ nursing mother should avoid infection to prevent

Breast Fibroadenoma

Nontender benign tumor of breast; most freq breast tumor in adolescents, young women, often late teens early 20s; firm, round, encapsulated, movable mass in breast; no pain or tenderness; breast exam warranted; etiology unknown; hormonally responsive, growing in size during late menstrual phases; diagnosis based on palpation, clinical picture, mammogram; fine needle biopsy is highly specific in breast masses to ensure no malignancy; treatment of benign tumor is surgical removal under local anesthetic; pathology confirms diagnosis; prognosis good w/o complication; prevention unknown

Breast Cancer

Often arises from terminal ductal lobular unit (TDLU) of breast, the functional unit of breast tissue, very hormonally responsive; lump, swelling, tenderness of breast; irritation, dimpling of breast skin (peau d’orange); pain, ulceration, retraction of nipple; visual exam shows breast asymmetric; earliest sign is abnor on mammogram, appearing before physician can feel lump; if untreated, nodules become fixed to chest wall, axillary masses, ulcerations develop; breast pain not common factor early; woman (or man) presenting lump, abnor nipple discharge, change in shape w/(o) pain req diagnostic eval, esp if abnor mammogram findings; most common cancer, 2nd leading cause of cancer death in women; mortality highest in those <35 (more aggressive tumors) >75 (body less able to fight cancer); inc age, female gender greatest risk factors, 100x more common women; prolonged exposure to high concentration of endogenous estrogen inc risk; younger age of menarche, older age of first full-term pregnancy, older age at menopause risk factors; long-term (>5 year) use of combined estrogen/progesterone hormone replacement therapy inc risk, but tamoxifen use reduces risk; presence of atypical ductal hyperplasia inc risk, as does prior personal history of breast cancer; alc use inc risk; family history important but not great correlation; 5% associated w/ mutations on BRCA1/2; ductal carcinoma in situ (DCIS) is malignant cells lacking capacity to invade thru basement membrane, a precursor lesion for breast cancer; can spread thru duct system to involve entire sector of breasts, migrating to nipple skin leading to Paget’s of breast; presence of DCIS inc risk of invasive carcinoma 8-10x; risk lower in males as breast less sensitive to hormones, male breasts no lobules; Klinefelter’s gynecomastia, testicular dysfunction, BRCA2 gene mutation risk factor for men; 90% diagnosed thru abnormal mammogram findings, w/ remained detected by phys exam; diagnostic mammography, ultrasound can determine need for biopsy; ultrasound differentiates solid from cystic masses to determine if malignant; contrast-enhanced MRI may be needed if breasts are dense; biopsy taken of all sussy lumps for definitive diagnosis; staged by TNM system; after diagnosis, work-up includes phys exam, blood tests; staging mammography of both breasts req when considering breast-conserving treatment; if advanced, chest x-ray, CT of ab/pelvis, bone scan done; tumor estrogen receptor and progesterone receptor status and expression of oncogene c-erbB-2 and protein prod HER2/neu measured as they have prognostic value; DCIS treated w/ local excision, radiation, and/or tamoxifen to prevent invasive neoplasm development; if invasive, stage/patient preference taken into account; lumpectomy, mastectomy w/ removal of axillary lymph nodes, radiation therapy, hormone therapy (based on estrogen/progesterone receptor of tumor), chemo; Herceptin is humanized monoclonal antibody directed against c-erbB-2 may be effective against tumors overexpressing oncogene; axillary lymph node positivity important to prognosis; presence of estrogen/progesterone receptors better prognosis and tumor responsiveness to hormone therapy, but expression of c-erbB-2 lower prognosis; localized 5-year survival 96%, regional spread 78%, distant metastasis 21%; some may report post-breath therapy pain syndrome post-op, developing weeks-years after surgery due to nerve damage; having child before 25, breast-feeding for min 6 months, avoiding weight gain, limiting alcohol; if high risk, taking tamoxifen can reduce; regular mammography can reduce risk of death, identifying breast cancer early, esp for 40+

Paget’s Disease of Breasts

Charact breast lesion signifying presence of malignant adenocarcinoma cells; underlying carcinoma in breasts present in 97%; skin of nipple develops erythematous, eczematous, scaly, or ulcerated lesion; lesion, often unilateral, can heal spontaneously, or topical treatments can mask infla; if more advanced, crusting, serous/bloody discharge from nipple, nipple retraction; some have persistent pain or pruritus at nipple; can have breast mass or mammogram abnor; unknown whether Paget’s cells arise from underlying mammary adenocarcinoma (accepted theory) or whether they represent a carcinoma in situ independently; peak age 50-60; diagnosis established by means of biopsy or nipple scrape cytology; any breast masses or mammogram abnor req eval; treatment is simple mastectomy, but breast conserving surgeries to treat now used; axillary lymph node dissection should be performed; whole-breast irradiation may be performed w/ surgery; prognosis affected by presence of palpable breast mass and metastasis to axillary nodes; if palpable mass, 5-year survival 20-60%, w/o mass 75-100%; monthly breast self-exam may aid in detection early