Studied by 6 people
Date created: 12/03/2023
Vasomotor sx:
HRT (combination of estrogen and progestin) ---WHI STUDI: HRT shown to increase cardiovascular morbidity and mortality and may increase the incidence of breast and endometrial cancers. Rx HRT carefully ---Post-hysterectomy pts do not need progestin. Unopposed estrogen in pts w/ a uterus predisposes to endometrial cancer
Non-HRT: Venlafaxine and less commonly, clonidine can be given to decrease the frequency of hot flashes
Vaginal atrophy
long term: estradiol vaginal ring
short term: estrogen vaginal cream will relieve sx
Osteoporosis:
tx w/ daily calcium supplementation and exercise; possibly bisphosphonates
Take full hx, including contraceptive use, last time of coitus, condom use prior to assault, drug and alcohol use, hx of STDs, hx of mental illness or deficiency, description of the assailant, location, and time of the assault, circumstances of assault (penile penetration, use of condoms, extragenital acts, use or displays of weapons), and pt's actions since assault (douching, bathing, brushing teeth, urination/defecation, changing clothes)
Conduct complete physical exam: making note of any signs of trauma, along w/ a detailed pelvic exam, including a survey of the external genitals, vagina, cervix, and anus.
saline prep for sperm
gonorrhea and chlamydia smear/culture (including rectal if appropriate)
serologic testing for HIV, syphilis, HSV, HBV, CMV
serum pregnancy test
blood alcohol level; urine tx screen
STD tx (ceftriaxone plus doxycycline)
HIV risk assessment and possible postexposure prophylaxis
EC for pregnancy prevent
refer for psychological counseling
Arrange for follow-up w/ the same physician or w/ another provider if more appropriate
Follow-up should include repeat screening for STDs, repeat screening for pregnancy, and a discussion of coping methods w/ appropriate referrals for psychiatric care if needed
implanon
Mirena IUD
Copper IUD
Surgical sterilization
Depo-Provera
Ortho-Evra (the patch)
NuvaRing ("the ring")
OCPs (combined estrogen and progestin)
Progestin-only "minipills"
male condoms
diaphragm w/ spermicide
female condom
fertility awareness methods
withdrawal
spermicide
infectious vulvovaginitis
foreign objects
candidal infection
sarcoma botryoides (rhabdomyosarcoma)
Central precocious puberty: results from early activation of hypothalamic GnRH production. Most commonly idiopathic (also known as constitutional or true); may be related to obesity. Can also be caused by CNS tumors
Peripheral precocious puberty: aka pseudo-precocious puberty. Results from nonhypothalamic GnRH production
Signs of estrogen excess: breast development, possibly vaginal bleeding-->ovarian cysts or tumors
Signs of androgen excess: pubic and/or axillary hair, enlarged clitoris, acne, and/or increased body odor) suggest adrenal tumors or congenital adrenal hyperplasia (CAH)
radiograph of wrist and hand to determine bone age --if bone age is w/in one yr of chronological age, puberty has not started or has just recently begun --if bone age is >chronological age by >2yrs, puberty has been present for at least one year or is progressing rapidly
Conduct a GnRH agonist (leuprolide) stimulation test -- Central precocious puberty: if LH response is + obtain a cranial MRI to look for CNS tumors -----in girls 6-8yrs of age w/ signs of precocious puberty, the incidence of CNS tumor is 2% in the absence of other CNS signs -----If CNS tumors ruled out, constitutional precocious puberty is likely etiology --Peripheral precocious puberty: if LH response is neg, order the following: -----U/S of ovaries and/or adrenals to look for ovarian or adrenal cyst/tumors -----Estradiol: levels will be increased in ovarian cysts or tumors -----Androgen (DHEA, DHEAS): esp critical in setting of advanced bone age or signs of adrenarche -----17-OH progesterone: to screen for advanced bone age or adrenarche
Constitutional growth delay: the most common cause
1mary ovarian insufficiency: most commonly Turner's syndrome. Look for a hx of radiation and chemotx
Central hypogonadism: may be caused by variety of factors, including: ---undernourishment, stress, prolactinemia, or exercise ---CNS tumor or cranial irradiation ---Kallmann's syndrome (isolated gonadotropin deficiency) assoc w/ anosmia.
Mullerian agenesis: absence of 2/3 of the vagina; uterine abnormalities
Imperforate hymen: presents w/ hematocolpos (blood in vagina) that cannot escape, along w/ a bulging hymen. Requires surgical opening
Complete androgen insensitivity: pts present w/ breast development (aromatization of testosterone to estrogen) but are amenorrheic and lack pubic hair
Kallmann's syndrome (GnRH deficiency)
Tumors, infection, trauma, chronic disease
Anorexia, excess exercise, weight loss, stress
Hypothyroidism
Hyperprolactinoma
anorexia, excess exercise, weight loss, stress
Sheehan's syndrome
neoplasms
panhypopituitarism
hyperprolactinemia
hypothyroidism
Turner's syndrome
premature ovarian failure (chemotx, radiation, idiopathic)
pure gonadal dysgenesis
Savage's syndrome (gonadropin- resistant ovary syndrome)
androgen insensitivity (increase testosterone, increase estrogen)
PCOS (increase estrogen, androgen)
Enzyme deficiency (17alpha- hydroxylase or aromatase)
Normal hormone levels!
Asherman's syndrome due to endometritis, scarring after delivery, or D&C
Cervical stenosis
Constitutional growth delay: No tx
Hypogonadism: Begin HRT w/ estrogen alone at the lowest dose. 12-18mo later, begin cyclic estrogen/progesterone therapy (if the uterus is present)
Anatomic: requires surgical intervention
Get pregnancy test
If neg B-hCG: measure TSH and prolactin
increased TSH= hypothyroidism
increased prolactin = (inhibits release of LH and FSH) points to a thyroid pathology. Order an MRI of the pituitary to rule out tumor
very increased prolactin = suggests a prolactin-secreting pituitary adenoma
If normal B-hCG: initiate progestin challenge (10 days of progestin)
positive progestin challenge (withdrawal bleed): indicates anovulation that is likely due to noncyclic gonadotropin secretion-->PCOS or idiopathic anovulation. Check LH levels and if LH is moderately high, etiology is likely PCOS. Marked elevation of LH can indicate premature menopause
neg progestin challenge (no bleed): indicates uterine abnormality or estrogen deficiency. Check FSH levels --increased FSH: indicates hypergonadotropic hypogonadism/ovarian failure --decreased FSH: obtain a cyclic estrogen/progesterone test. A positive withdrawal bleed points to hypogonadotropic hypogonadism; a neg withdrawal bleed suggests an endometrial or anatomic problem
Look for signs of hyperglycemia (polydipsia, polyuria), or hypotension: conduct a 1mg overnight dexamethasone suppression test to distinguish CAH, Cushing's syndrome, and Addison's syndrome
Look for clinical virilization: measure testosterone, DHEAS, and 17-hydroxyprogesterone --mild pattern: PCOS, CAH, or Cushing's syndrome --moderate to severe pattern: look for an ovarian or adrenal tumor
low, midline, spasmodic pelvic pain that often radiates to the back or inner thighs
cramps occur in the first 1-3 days of menstruation and may be associated w/ nausea, diarrhea, headache, and flushing
no pathologic findings on pelvic exam
NSAIDs
topical heat therapy
combined OCPs
Mirena IUD
menstrual pain for which there is an organic cause:
endometriosis
adenomyosis
tumors
fibroids
adhesions
polyps
PID
Similar to primary dysmenorrhea, but look for pathology.
palpable uterine mass
cervical motion tenderness
adnexal tenderness
vaginal or cervical discharge
visible vaginal pathology (mucosal tears, masses, prolapse)
Obtain B-hCG to exclude ectopic pregnancy
Order:
CBCPD to r/o infxn or neoplasm
UA to r/o UTI
gonococcal/chlamydial swabs to rule out STDs/PID
Stool guaic to r/o GI pathology
Look for pelvic pathology that causes pain
obtain B-hCG to r/o ectopic pregnancy
order a CBC to r/o anemia
Check the following:
pap smear to r/o cervical cancer
TFTs to r/o hyper/hypothyroidism and hyperprolactinemia
obtain plt count, bleeding time, PT/PTT to r/o von Willebrand's disease and factor XI deficiency
order u/s to evaluate the ovaries, uterus, and endometrium. Look for uterine masses, polycystic ovaries, and thickness of the endometrium
If endometrium is >4mm in a postmenopausal woman, obtain an endometrial biopsy. An endometrial biopsy should also be obtained if the pt is >35 yo, obese (BMI>35yo) and diabetic
for hemorrhage, high-dose estrogen IV stabilizes the endometrial lining and stops bleeding w/in one hour
If bleeding is not controlled w/in 12-24hrs, a D&C is indicated
Goal: decrease blood loss
NSAIDs to decrease blood loss
If pt is hemodynamically stable, tx w/ OCPs or Mirena IUD to thicken the endometrium and control the bleeding. If not effective w/in 24hrs, look for alternative dx
Goal: convert proliferative endometrium to secretory endometrium
give progestins x 10 days to stimulate withdrawal bleeding
for young pts w/ anovulatory bleeding who may also have a bleeding disorder, give desmopressin followed by a rapid increased in von Willebrand's factor and factor VIII (lasts roughly six hrs)
D&C: an appropriate diagnostic/therapeutic option
Hysterectomy: can help identify endometrial polyps as well as aid in the performance of directed uterine biopsies
Hysterectomy or endometrial ablation: appropriate in women who fail or do not want hormonal tx, have symptomatic anemia, and/or experience a disruption in their quality of life from persistent, unscheduled bleeding.
anemia
endometrial hyperplasia
+/- carcinoma
increased androgens (testosterone > 2ng; DHEAS > 7 ug/mL): r/o adrenal or ovarian neoplasm
increased serum testosterone: suspect ovarian tumor
increased DHEAS: suspect an adrenal source (adrenal tumor, Cushing's syndrome, CAH)
increased 17-OH progesterone levels (either basally or in response to ACTH stimulation)
polycystic ovaries
oligo-anovulation
clinical or biochemical evidence of hyperandrogenism
Labs: (biochemical hyperandrogenemia)
increased testosterone (total +/- free)
DHEAS
DHEA
Other causes of hyperandrogenism:
TSH, prolactin
17-OH progesterone to r/o nonclassical CAH
Consider screening in the setting of clinical sx of Cushing's syndrome (moon facies, buffalo hump, abd striae) or acromegaly (increased head size)
Other causes of metabolic abnormalities:
2hr oral glu tolerance test
fasting lipid and lipoprotein levels (total cholesterol, HDL, LDL, triglycerides)
U/S: look for >8 small, subcapsular follicles forming a "pearl necklace" sign
Gonadotropins: Increased LH/FSH ratio (>2:1)
Fasting insulin levels
24hr urine for free cortisol: adult-onset CAH or Cushing's syndrome
