USMLE Step 2 Gyn focussed

Date created: 12/03/2023

Does menarche precede thelarche in women?

no
Thelarche PRECEDS menarche (8-11yrs)
Menarche (10-16yrs)

What occurs during the follicular phase of menstruation?

development of straight glands and thin secretions of the uterine lining (proliferative phase)
increased FSH--\>growth of follicles--\>increased estrogen production

What is the hormonal profile of ovulation?

LH and FSH spike

What occurs during ovulation?

rupture of the ovarian follicle and release of mature
ruptured follicular cells involute and creates the corpus luteum

What occurs during luteal phase of menstruation?

length of time that the corpus luteum can survive without further LH stimulation
the corpus luteum produces estrogen and progesterone, allowing the endometrial lining to develop thick endometrial glands w/ thick secretions (secretory phase)
In absence of implantation, the corpus luteum cannot be sustained, and the endometrial lining sloughs off

What is the definition of menopause?

cessation of menses for a minimum of 12 months as a result of cessation of follicular development

At what age is premature menopause?

ovarian failure and menstrual cessation before age 40

What are the sx of menopause?

HAVOC
Hot flashes (vasomotor instability)
Atrophy of Vagina
Osteoporosis
Coronary artery disease

Other sx: insomnia, anxiety/irritability, vaginal bleeding, poor concentration, mood changes, dyspareunia, and loss of libido

How is menopause dx?

Labs: increased FSH and increased LH
DEXA scan to follow bone density for osteoporosis
Lipid profile: increased total cholesterol, decreased HDL

How is menopause tx?

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

What are the CI of HRT?

vaginal bleeding
suspected or known breast cancer
endometrial cancer
hx of thromboembolism
chronic liver disease
hypertriglyceridemia

What are absolute CI to estrogen-containing hormonal methods (OCPs, NuvaRing, "the patch"?

pregnancy
hx of CAD or DVT
Breast cancer
undx abnormal vaginal bleeding
estrogen-dependent cancer
benign or malignant liver neoplasm
current tobacco use and age \>35yo

What are absolute CI to Mirena and Copper IUDs?

known or suspected pregnancy
unexplained vaginal bleeding until dx
current purulent cervicitis
PID that is active (w/in three mo) or recurrent
confirmed sx actinomycosis on culture (but not ASx colonization)
a bicornuate or septate uterus
cervical or uterine cancer
Pap smear w/ squamous intraepithelial lesions or two atypical Pap smears
hx of heart valve replacement or artificial joints

What are CI to Copper IUDs alone?

copper intolerance (allergy to copper, Wilson's disease)
severe dysmenorrhea and/or menorrhagia

What are the CI to Mirena alone?

Levonorgestrel allergy
breast cancer
acute liver disease or liver tumor
hx of + BRCA

What is unique about combined hormonal contraception methods?

protect against endometrial, ovarian, and breast cancer

How should sexual assault pts be approached?

- 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.

How is sexual assault dx?

- 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

How is sexual assault tx?

- 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

Which contraceptive methods have proven to be the most effective (\>99%)?

- implanon
- Mirena IUD
- Copper IUD
- Surgical sterilization

What contraceptive methods have proven to be very effective (90-99%)?

- Depo-Provera
- Ortho-Evra (the patch)
- NuvaRing ("the ring")
- OCPs (combined estrogen and progestin)
- Progestin-only "minipills"

Which contraceptive methods have proven to be moderately effective (75-90%)?

- male condoms
- diaphragm w/ spermicide
- female condom
- fertility awareness methods

Which contraceptive methods have proven to be the least effective (68-74%)?

- withdrawal
- spermicide

What are the etiologies of pediatric vaginal discharge?

- infectious vulvovaginitis
- foreign objects
- candidal infection
- sarcoma botryoides (rhabdomyosarcoma)

What organism often causes pediatric infectious vulvovaginitis?

group A strep
STDs (think possible child abuse)

What must you be concerned about if a pediatric patient presents with a candidal pediatric vaginal discharge?

worry about diabetes!

How does sarcoma botryoides present in the vagina?

"bunches of grapes"

What is the definition of precocious puberty?

Onset of sexual characteristics before age of 8

What are the different types of precocious puberty?

1) 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
2) Peripheral precocious puberty: aka pseudo-precocious puberty. Results from nonhypothalamic GnRH production

How does precocious puberty usually present?

- 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)

How is precocious puberty dx?

1) 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
2) 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

What are causes of central precocious puberty (GnRH-dependent)?

constitutional (idiopathic)
Hypothalamic lesions (hamartomas, tumors, congenital malformations)
Dysgerminomas
Hydrocephalus
CNS infxns
CNS trauma/irradiation
Pineal tumors (rare)
NF w/ CNS involvement
Tuberous sclerosis

What are the causes of peripheral precocious puberty (GnRH-indepedent)?

CAH
Adrenal tumors
McCune-Albright Syndrome (polyostotic fibrous dysplasia)
Gonadal tumors
Exogenous estrogen, oral (OCPs) or topical
Ovarian cysts (females)

How is central precocious puberty tx?

1st line: leuprolide
w/ tx, physical changes regress or cease to progress

How is peripheral precocious puberty tx?

Tx the cause

Ovarian cysts: no intervention is necessary, all cysts will usually regress spontaneously
CAH: Tx w/ glucocorticoids. Surgery is NOT required for the tx of ambiguous genitalia
Adrenal or ovarian tumors: require surgical resection
McCune-Albright syndrome: antiestrogens (tamoxifen) or estrogen synthesis blockers (ketoconazole or testolactone) may be effective

What is the definition of primary amenorrhea/delayed puberty?

absence of menses by age 16 w/ secondary sexual development present, or the absence of secondary sexual characteristics by age 14

What are the causes of delayed puberty (absence of secondary sexual characteristics)?

- 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.

What are the causes of primary amenorrhea (secondary sexual characteristics present)?

- 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

How is primary amenorrhea dx?

1) get a pregnancy test
2) obtain a radiograph to determine if bone age is consistent w/ pubertal onset (\>12yrs in girls)
--Constitutional growth delay: (bone age

What hormonal profile indicates constitutional growth delay?

decrease GnRH
decrease LH/FSH
decrease estrogen/progesterone at prepuberty levels
(puberty has not started yet)

What hormonal profile indicates hypothalamic or pituitary problem?

decreased GnRH
decreased LH/FSH
decrease estrogen/progesterone
(hypogonadotropic hypogonadism)

What hormonal profile indicates that the ovaries have failed to produce estrogen?

increased GnRH
increased LH/FSH
decreased estrogen/progesterone
(hypergonadotropin hypogonadism)

What hormonal profile indicates PCOS or a problem w/ estrogen receptors?

increased GnRH
increased LH/FSH
high estrogen or testosterone

In work up for primary amenorrhea, if have normal pubertal hormone levels, what does this indicate?

anatomic problem (menstrual blood can't get out)

What are causes of hypogonadotropic hypogonadism?

- Kallmann's syndrome (GnRH deficiency)
- Tumors, infection, trauma, chronic disease
- Anorexia, excess exercise, weight loss, stress
- Hypothyroidism
- Hyperprolactinoma

What are the causes of hypogonadotropic hypogonadism?

- anorexia, excess exercise, weight loss, stress
- Sheehan's syndrome
- neoplasms
- panhypopituitarism
- hyperprolactinemia
- hypothyroidism

What are causes of Hypergonadotropic hypogonadism?

- Turner's syndrome
- premature ovarian failure (chemotx, radiation, idiopathic)
- pure gonadal dysgenesis
- Savage's syndrome (gonadropin- resistant ovary syndrome)

What causes anovulatory problem?

- androgen insensitivity (increase testosterone, increase estrogen)
- PCOS (increase estrogen, androgen)
- Enzyme deficiency (17alpha- hydroxylase or aromatase)

What are secondary anatomic causes of amenorrhea?

Normal hormone levels!
- Asherman's syndrome due to endometritis, scarring after delivery, or D&C
- Cervical stenosis

How is primary amenorrhea tx?

- 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

What is the first step in the work-up of primary and secondary amenorrhea?

PREGNANCY TEST!

How is secondary amenorrhea dx?

absence of menses for 6 consecutive months in women who have passed menarche

How is secondary amenorrhea dx?

1) Get pregnancy test
2) 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
3) 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
4) 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
5) 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

How is secondary amenorrhea treated?

Hypothalamic: reverse the underlying cause and induce ovulation w/ gonadotropins
Tumors: excision; medical tx for prolactinomas (e.g. bromocriptine, cabergoline)
Premature ovarian failure (age

What is primary dysmenorrhea?

menstrual pain associated w/ ovulatory cycles in the absence of pathologic findings. Caused by uterine vasoconstriction, anoxia, and sustained contractions mediated by an excess of prostaglandin (PGF2alpha)

How does primary dysmenorrhea present?

- 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

How is primary dysmenorrhea tx?

- NSAIDs
- topical heat therapy
- combined OCPs
- Mirena IUD

What is secondary amenorrhea?

menstrual pain for which there is an organic cause:
- endometriosis
- adenomyosis
- tumors
- fibroids
- adhesions
- polyps
- PID

How does secondary amenorrhea present?

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)

How is secondary amenorrhea dx?

1) Obtain B-hCG to exclude ectopic pregnancy
2) 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
3) Look for pelvic pathology that causes pain

What is the difference between endometriosis and adenomyosis?

endometriosis is functional endometrial glands and stroma OUTSIDE the uterus. Adenomyosis is endometrial tissue IN the myometrium of the uterus.

How does endometriosis present?

presents w/ cyclical pelvic and/or rectal pain and dyspareunia (painful intercourse)

How does adenomyosis present?

presents w/ classic triad of noncyclical pain, menorrhagia, and an enlarged uterus

How is endometriosis diagnosed?

Requires direct visualization by laparoscopy or laparotomy
Classic lesions: blue-black ("raspberry") or dark brown ("powder-burned") appearance
Ovaries may have endometriomas (characteristic "chocolate cysts")

How is adenomyosis diagnosed?

U/S useful but cannot distinguish btw leiomyoma and adenomyosis
MRI can aid in diagnosis but is costly

How is endometriosis tx?

Pharmacologic: inhibit ovulation. First line: combo OCPs; GnRH analogs (leuprolide) and danazol.

Conservative surgical tx: excision, cauterization, or ablation of the lesions and lysis of adhesions. 20% pts can become pregnant after tx

Definitive surgical tx: TAH/BSO +/- lysis of adhesions

How is adenomyosis tx?

Pharmacologic: largely symptomatic relief. First line: NSAIDs + OCPs or progestins

Conservative surgical tx: endometrial ablation or resection using hysteroscopy. Complete eradication of deep adenomyosis is difficult and results in high tx failure

Definitive tx: Hysterectomy is the only definitive tx

What are the complications of endometriosis?

infertility (most common cause among menstruating women \>30 yrs of age)

What are the complications of adenomyosis?

rarely, can progress to endometrial carcinoma

What is the definition of abnormal uterine bleeding?

vaginal bleeding that occurs six or more months following the cessation of menstrual function is cancer related until proven otherwise.

What is menorrhagia?

increased amount of flow (\>80mL of blood loss per cycle) or prolonged bleeding (flow lasting \>8 days); may lead to anemia

What is oligomenorrhea?

an increase length of time btw menses (35-90 days between cycles)

What is polymenorrhea?

frequent menstruation (

What is metrorrhagia?

bleeding btw periods

What is menometrorrhagia?

excessive and irregular bleeding

How is abnormal uterine bleeding diagnosed?

1) obtain B-hCG to r/o ectopic pregnancy
2) order a CBC to r/o anemia
3) 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

How is heavy uterine bleeding tx?

1) for hemorrhage, high-dose estrogen IV stabilizes the endometrial lining and stops bleeding w/in one hour
2) If bleeding is not controlled w/in 12-24hrs, a D&C is indicated

How is ovulatory bleeding tx?

Goal: decrease blood loss
1) NSAIDs to decrease blood loss
2) 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

How is anovulatory bleeding tx?

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)

What are the tx options for abnormal uterine bleeding if medical mgmt fails?

- 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.

What are the complications of abnormal uterine bleeding?

- anemia
- endometrial hyperplasia
- +/- carcinoma

What is congenital adrenal hyperplasia?

21-hydroxylase deficiency that can present in its most severe, classic form as a newborn female infant w/ ambiguous genitalia and life-threatening salt wasting. Milder forms present later in life. 11Beta-hydroxylase deficiency is a less common cause of adrenal hyperplasia.

How does CAH present?

excessive hirsutism, acne, amenorrhea and/or abnormal uterine bleeding, infertility, and rarely a palpable pelvic mass.

What is the difference btw hirsutism vs. virilization vs. defeminization?

hirsutism: male hair pattern
virilization: frontal balding, muscularity, clitoromegaly, and deepening of the voice
Defeminization: decrease brest size; loss of feminine adipose tissue

How is CAH dx?

- 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)

What is the differential to hyperandrogenism?

PCOS
21-hydroxylase deficiency (late onset, nonclassic) CAH
21-hydroxylase deficiency- (congenital, classic) CAH
Hypothyroidism
Hyperprolactinemia
Androgen-secreting neoplasm
Cushing's syndrome

How is CAH tx?

glucocorticoids (prednisone)
To remove hair growth will need: laser ablation, electrolysis, or conventional hair removal techniques must be used to remove unwanted hair

How does the most severe form of PCOS present?

hyperandrogenism
insulin
resistance
acanthosis nigricans

What is PCOS?

most common endocrine disorder in reproductive women
AKA Stein-Leventhal syndrome

What are the diagnostic criteria for PCOS?

1. polycystic ovaries
2. oligo-anovulation
3. clinical or biochemical evidence of hyperandrogenism

How does PCOS present?

High BP
BMI \> 30
Stigmata of hyperandrogenism or insulin resistance (menstrual cycle disturbances, hirsutism, obesity, acne, androgenic alopecia, acanthosis nigricans)

What conditions are patients w/ PCOS as risk for?

Type 2 DM
Insulin resistance
Infertility
Metabolic syndrome--insulin resistance, obesity, atherogenic dyslipidemia, HTN

How is PCOS dx?

Labs: (biochemical hyperandrogenemia)
- increased testosterone (total +/- free)
- DHEAS
- DHEA

What other conditions need to be excluded when dx PCOS?

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)

What other tests can be used to dx PCOS?

- 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

How is PCOS tx for women who are not attempting to conceive?

Tx w/ a combo of OCPs, progestin, and metformin (or other insulin-sensitizing agents)

How is PCOS tx for women who are trying to conceive?

Clomiphene +/- metformin is first-line tx for ovulatory stimulation

How is Hirsutism tx?

combo OCPs are first line; antiandrogens (spironolactone, finasteride) and metformin may also be used

What kind of tx can be given to PCOS pts to reduce cardiovascular risk factors and lipid levels?

advice on: diet, weight loss, and exercise plus potentially lipid-controlling medication

What are the complications of PCOS?

increase risk of early onset type 2 DM
increase risk of miscarriages
increase risk of long-term risk of breast and endometrial cancer due to unopposed estrogen secretion