GYN study guide

The fallopian tubes, uterus, cervix, and upper 2/3s of the vagina develop from ______

2 paired mullerian ducts

What kind of abnormalities commonly accompany Müllerian duct defects due to the close proximity of development?

renal

When one or both Müllerian ducts don’t develop fully, producing abnormalities such as uterine agenesis or hypoplasia (b/l) or unicornuate uterus (u/l), this is known as ______

organogenesis

The process during which the lower segments of paired Müllerian ducts fuse to form the uterus, cervix, and upper vagina, this is known as _____

lateral fusion

Fusion of the ascending sinovaginal bulb with the descending mullerian system, resulting in a patent vagina, is referred to as ____

vertical fusion

incomplete vertical fusion results in _____

imperforate hymen

failure of lateral fusion results in _____

bicornuate or didelphys uterus

What phase of Müllerian development consists of a central septum after the lower Müllerian ducts fuse?

septal resorption

failure of septal resorption results in ____

septate uterus

What are the 3 phases of development of complete formation and differentiation of the mullerian defects?

organogenesis, fusion, septal resorption

What class mullerian defect is this?

• hypoplasia / agenesis → no reproductive potential aside from IVF of harvested ova and implantation in a host

class I

What class mullerian defect is this?

• unicornuate uterus → result of complete/almost complete arrest of development of 1 Müllerian duct

  • incomplete arrest (MC) → rudimentary horn w/ or w/o functioning endometrium

  • if horn obstructed, may need surgery, enlarging pelvic mass

• if contralateral healthy horn is almost fully developed, a full term pregnancy is believed to be possible

class II

What class mullerian defect is this?

• didelphys uterus → results from complete nonfusion of both ducts

• individual horns are fully developed and almost normal in size

• 2 cervices inevitably present

• longitudinal or transverse vaginal septum possible

• consider metroplasty (removing septum & fusing both)

• can carry pregnancy to full term since each horn is almost a fully developed uterus

class III

What class mullerian defect?

• bicornuate uterus → results from partial confusion of ducts

• demonstrates some degree of fusion b/t the 2 horns

• horns not fully developed, typically smaller

• some pts are candidates for metroplasty

class IV

What class mullerian defect?

• septate uterus → results from failure of resorption of septum b/t 2 uterine horns

• septum can be partial or complete

• uterine fundus is typically convex but may be flat or slightly concave

• highest incidence of reproductive complications

• treated by using transvaginal hysteroscopic resection of septum

class V

What class mullerian defect?

• arcuate uterus → variant of normal, no adverse impact on fertility and pregnancy outcomes

• has slight midline septum w/ minimal and often broad fundal cavity indentation

• variously classified as septate, bicornuate, or normal variant

class VI

What class mullerian defect?

• diethylstilbestrol (DES) related anomaly → synthetic form of estrogen prescribe to pregnant women to prevent pregnancy complications from 1945-1971

• seen in female offspring in 15% women exposed to DES during pregnancy

• variety of abnormal findings- uterine hypoplasia and t shaped uterine cavity; inc risk vaginal clear cell carcinoma

class VII

What are the 3 primary components of the menstrual cycle?

HPG axis (hypothalamus, pituitary gland, gonadal)

______ secretes LH and FSH to stimulate ovarian function.

anterior pituitary

Which cycle?

• follicular phase

• ovulation

• luteal phase; pregnancy

ovarian

Which cycle?

• proliferative phase

• secretory phase

• menses

uterine

What is the control center that responds to hormones and neurotransmitters and secretes GnRH every 90 minutes, pulsatile to the anterior pituitary via portal circulation?

hypothalamus

What phase of the ovarian cycle?

• initiated by lack of estrogen at end of menses

• FSH from ant pit stimulates follicle to grow & produce estrogen

• Graafian follicle chosen by day 7

• as estrogen inc, it inhibits release of FSH

• LH from ant pit in small amounts prior to ovulation, surges mid cycle in response to peak amounts of estrogen from mature follicle, stimulates ovary to produce progesterone after ovulation

• 10-14 days

follicular / phase I

Which phase of the ovarian cycle?

• estrogen peaks at 200-300 pg/ml

• GnRH inhibited by high estrogen & amt of FSH being secreted drops off

• ant pit releases LH surge ahead of ovulation

• one egg released 36-42 hours from onset of surge

• corpus luteum formed at site of follicle that hs matured and released ovum

  • secretes progesterone to ready uterus for pregnancy

  • if not fertilized, becomes inactive after 10-14 days, involutes and becomes corpus albicans (fibrous scar tissue) and menstruation occurs

ovulatory / phase II

what phase of the ovarian cycle?

• progesterone dominant (secreted by corpus luteum)

• relatively constant in length (12-14 days)

• progesterone increases and peaks (day 20 of the cycle - 6 days post ovulation)

• estrogen levels off

• corpus luteum involutes after 14 days, resulting in drop of progesterone levels

  • if implantation, progesterone levels stay up due to production of hCG, progesterone would then further inhibit FSH and new follicular recruitment

luteal / phase III

What phase of the uterine cycle?

• roughly corresponds with follicular phase of ovarian cycle

• influenced by estrogen

• thickness of endometrium rapidly increases by the drawing out of the uterine glands

• dont convolute or secrete in this phase

proliferative phase

What phase of the uterine cycle?

• roughly corresponds with luteal phase of ovarian cycle

• progesterone influence from corpus luteum

• lining becomes highly vascularized, slightly edematous, glands become coiled and tortuous and begin to secrete clear fluid

secretory phase

What process occurs when the corpus luteum involutes, progesterone & estrogen dec,, PG inc & smooth muscle contraction, & endometrium loses its blood supply and sloughs its functional layer?

menstruation

What is the average length of perimenopause?

4 years; ends after 12 consecutive months w/o a menstrual cycle (menopause)

The following symptoms are associated with what condition?

• change in periods - shorter or longer, lighter or heavier, more/less time in between

• hot flashes, night sweats, trouble sleeping

• vaginal dryness

• mood swings, trouble focusing

• less hair on head, more on face and breasts

Perimenopause

What marks the permanent end of fertility with reduced functionaling of the ovaries, confirmed with the absence of menses for 12 consecutive months?

menopause

T/F: ovulation can still sporadically occur during menopause.

true

What condition might happen during menopause due to the increased loss of estrogen?

osteoporosis

What is the most common symptom of endometriosis?

pelvic pain

When does PMS regularly onset?

luteal phase - 1-2 wks before menses

must completely resolve w/ menses & cannot present before menarche

If a woman has ≥5 sx, with one being an affective sx (mood swings, anger, etc), is it more accurate to diagnose her with PMDD or PMS?

PMDD

Perimenopause or Menopause?

• transition from normal ovulatory cycling to cessation of menses

• avg age of onset - 46 y/o

• can last 2-8 yrs & be asx or sx

Perimenopause

Perimenopause or menopause?

• spontaneous amenorrhea x 1 yr due to natural ovarian failure

• age related & genetic component

• avg age - 50-52 y/o

• mildly dependent on age of menarche

Menopause

Premature menopause happens before what age?

40 y/o

What factors are protective against early menopause?

Pregnancies & breastfeeding

What is the most common first symptom of menopause?

menstrual changes; usually in this order

• heavier or lighter flow

• longer or shorter cycles

• irregularity

Are mood disturbances more associated with perimenopause or menopause?

Perimenopause

What symptoms are associated with menopause?

dude alot there’s like 3 slides on it but here’s what’s bolded

• Inc CV risk → CAD MCC of death in women

• greater central obesity (visceral fat → metabolic disturbances)

• hour glass figure → shot glass

• osteopenia, osteoporosis, inc fx risk

• atrophic vagintiis

How is menopause diagnosed?

1 year w/o period, elevated FSH & LH, decreased estradiol,

diagnostics to monitor RF (DEXA, mammogram, lipid panel, cardiac workup)

What is the most sensitive marker and best initial test for menopause?

elevated FSH (> 30 IU/mL)

Which type of HRT can be used in those without a uterus?

Estrogen only (ET or ERT)

Which HRT should be used in those with an intact uterus?

Estrogen and progesterone combo therapy

Which dosage form of ERT is preferred in those with increased triglycerides?

Transdermal- gels / creams / patches (less liver metabolism)

What are benefits to ERT for menopause treatment?

most effective for sx & dec risk of CV, stroke, osteoporosis, & dementia

not a significantly inc risk of breast cancer compared to general population

What are risks of ERT for menopause treatment?

inc risk of endometrial cancer, VTE, liver dz, gallbladder complications

What are benefits to estrogen & progesterone combined therapy for menopause?

sx relief, dec risk of CV, stroke, osteoporosis, dementia

protective against endometrial cancer

What are risks to estrogen & progesterone combined therapy for menopause?

slight increased risk of breast cancer, VTE, liver dz, gallbladder complications

What are contraindications for use of HRT?

Hx estrogen sensitive breast CA, endometrial CA, VTE, thrombophilic d/o

Undx breast lesions

Unexplained uterine/vaginal bleeding

Confirmed CVD, CAD

Active liver disease

Migraine w/ aura

Smoker

*caution w/ HTN, DM, HLD, autoimmune (SLE), obesity, Fhx breast CA

How is normal menses defined?

regular cyclical shedding secondary to successful ovulation

normal cycle length 21-35; normal menses duration 2-7 days

What causes AUB in neonates?

Estrogen withdrawal after birth

What is frequent bleeding where the internal between periods are < 24 days?

Polymenorrhea

What is infrequent bleeding where the interval between periods are > 38 days (< 12 / yr)?

Oligomenorrhea

what is considered irregular bleeding from menarche to 25 y/o and 42 y/o to menopause?

> 9 days difference between cycle lengths

What is considered irregular bleeding in ages 26-41?

>7 days difference between cycle lengths

What is prolonged menstrual bleeding?

Menses lasting > 8 days

What is considered a heavy menstrual volume?

> 80 mL or volume that interferes with quality of life

What is considered a light menstrual volume?

< 5 mL

What is abnormal genital bleeding?

Generic term used when source of bleeding is not yet identified

What organs are involved in bleeds from the lower genital tract?

Cervix, vagina, vulva

What organs are involved in upper genital tract bleeding?

Uterus, ovary, fallopian tube

What is abnormal uterine bleeding (AUB)?

Indicated uterine source but not yet classified as anatomic, hormonal, systemic dz or cancer

What is excessive non cyclic endometrial bleeding unrelated to anatomical lesions of the uterus or systemic dz (dx of exclusion; outdated term)?

Dysfunctional uterine bleeding (DUB)

What is anovulation that may be related to a disease state vs other factors that effect the HPG-A; irregular menses from no ovulation?

Anovulatory bleeding

What is the MC type of AUB?

Anovulatory

Who is anovulatory AUB MC in?

extremes of age

What is the pathophys of anovulatory AUB?

Disruption of HPG-A → ovulation failure → lack of CLC formation → failure of normal progesterone secretion → unopposed estrogen causes endometrium to outgrow blood supply → necrosis & abnormal bleeding

what does Anovulatory AUB increase the risk for?

Hyperplasia w/ atypia or or dysplasia which can lead to malignancy

What is heavy and/or prolonged bleeding at normal intervals (cyclic, ovulatory)?

Menorrhagia

What causes menorrhagia?

Hormonal imbalance (estrogen > progesterone [MC] or progesterone + PG > estrogen)

structural (PALM- polyps, adenomyosis, leiomyoma, malformations)

liver dz, pregnancy comp, VWD, IUDs, meds

what is bleeding that occurs bt menses aka intermenstrual bleeding?

Metrorrhagia

What is heavy bleeding and intermenstrual bleeding/spotting?

Menometrorrhagia

What is bleeding that occurs after contact with cervix or vaginal walls, commonly after sex (post coital)?

Contact bleeding

What should contact bleeding be considered until proven otherwise?

Cervical cancer

What is the term for light periods?

Hypomenorrhea / cryptomenorrhea

What is the absence of menses / uterine bleeding?

Amenorrhea

Primary or secondary amenorrhea?

• failure of onset of menarche

• by age 13 if no secondary sex characteristics

• by age 15 if characteristics are present

Primary

Primary or secondary amenorrhea?

• New absence of menses but has menstruated for atleast 6 mos prior to

• > 3 mos if regular before onset

• > 6 mos if oligomenorrhea or irregular before onset

Secondary

What are causes of primary amenorrhea if the breast and uterus are absent?

Mullerian agenesis, androgen insensitivity (genetically male but resistant androgen effects - presents like prepubertal female)

What are causes of primary amenorrhea if breasts are absent and uterus is present with high FSH/LH?

Ovarian problems - premature ovarian failure, gonadal dysgenesis (Turney’s syndrome MC)

What are causes of primary amenorrhea if breasts are absent and uterus is present with normal to low FSH or LH?

Hypothalamic pituitary failure, pubertal delay (athletes, illness, anorexia(

What are causes of primary amenorrhea with breasts and uterus present?

Outflow obstruction - transverse vaginal septum, imperforate hymen

What are causes of primary amenorrhea if breasts are present and uterus is absent?

Defect in testosterone synthesis, presents like adolescent female but has intra-abdominal tests

What is the MCC of secondary amenorrhea?

Pregnancy

What are causes of secondary amenorrhea?

Pregnancy, Hypothalamic dysfunction, pituitary dysfunction, ovarian disorders (MC PCOS), uterine disorder, uterine outflow tract problem

What is bleeding occurring after confirmed menopause (1 full year w/o bleeding)?

Postmenopausal AUB

What is postmenopausal AUB considered until proven otherwise?

Endometrial cancer

Does the following correlate with ovulatory AUB or anovulatory AUB?

• regular cycles days 21-35

• PMS- bloating, breast pain, irritability

• Dysmenorrhea (1st/2nd day)

• Basal body temp (BBT) inc when ovulating

• cervical mucus changes to clear & stretchy

Ovulatory

What should always be done first when evaluating a patient presenting with AUB?

Pregnancy test

What should be included in the PE for an AUB patient?

Speculum & bimanual exam, general exam to look for systemic signs

What diagnostic testing should be considered for AUB?

Pregnancy test, Pap/cervical cultures, endometrial sampling (esp if risk for endometrial hyperplasia), U/S, MRI ± contrast, hysterosalpingogram, progesterone challenge

What labs should be considered for AUB?

CBC, CMP, TFTs, Testosterone, Insulin, Prolactin, 17hydrogyprogesterone, FSH/LH/Estradiol/Progesterone

What is a normal endometrial thickness in premenopausal females?

10-14mm

What endometrial thickness is considered thickened in premenopausal females?

≥ 15 mm

What endometrial thickness is normal in postmenopausal females?

≤ 4 mm

What endometrial thickness is considered thickened in postmenopausal females?

≥ 5 mm