J Clin Med Gyn (Detailed)

menarche definition

onset of menstruation (lasts avg 28 days)

normal = 11-13.75 yrs, correlates w/ obesity

Day 1 = first day of bleeding

occurs 2-3 years after thelarche (tanner stage IV breast dev)

occurs anywhere from stage II-stage V for either breast/pubic hair dev (usually stage IV)

menopause definition

cessation of menses >1 year d/t loss of ovarian function

→ decreased estrogen + progesterone production

hormones in menstruation

hypothalmus releases GnRH to anterior pituitary

FSH and LH is released = growth of follicle and ovulation

→ release of progesterone during luteal phase of menstrual cycle

→ release of estrogen in follicular (before ovulation) AND luteal phase (after ovulation, when follicle → corpus luteum)

corpus luteum

white body in the ovary that secretes progesterone

formed from follicle following ovulation

progesterone role

increases blood flow/makes blood vessels

estrogen needs _, otherwise → lining w/o blood flow sloughs off → period

estrogen role

thickens the endometrial lining of uterus

replication of cells

amenorrhea definition

lack of menstrual period

dysmenorrhea definition

painful menstrual periods

polymenorrhea

cycles of < 21 days = happening often

menorrhagia definition

regular but very heavy periods or lasting for long time

→ anemia if chronic

ovulatory

metrorrhagia definition

uterine bleeding at irregular intervals

(esp between expected menstrual periods)

ovulatory or anovulatory

menometrorrhagia definition

prolonged/excessive uterine bleeding is irregular and more frequent than normal

puberty definition

developmental stage where secondary sexual characteristics appear

precocious puberty definition

onset of puberty an abnormally early age

<8 yo girls or <9 yo boys

thelarche definition

onset of female breast dev

adrenarche definition

first step in puberty!

onset of androgen-dependent body changes

(growth of axillary/pubic hair, body order, acne)

what do tanner stages correlate more with*

MSK maturity > chronological age

catamenia definition*

hx of a given female’s menstrual cycles

age of onset X # of days in cycle X duration of flow

ex: catamenia 13×28×5

PMS and neurotransmitter involved in PMS*

characterized by physical and behavioral symptoms

lack of serotonin

beta-endorphin, GABA, and ANS

luteal phase only

premenstrual dysphoric disorder (PMDD) refers to ONLY

behavioral components of premenstrual period

sx assoc. w significant distress/interference w activities

PMS/PMDD non-pharm tx

Avoid caffeine + alcohol, cigarettes, salt reduction

Get enough sleep

regular exercise

stress management (yoga, massage, etc)

NSAIDs

Vitamin B6 + E

Cognitive behavioral therapy

effective pharm tx of PMS/PMDD*

SSRIs

benzos

OCPs

agents that suppress ovulation: GnRH agonists, danazol

possible/ineffective tx of PMS/PMDD

possible: diuretics, calcium, vit b6

ineffective: progesterone, vit supps, TCAs, dietary restrictions, lithium

primary dysmenorrhea definition

painful menstruation with NO pelvic pathology

recurrent, crampy lower abdominal pain occurs during menstruation in absence of pelvic pathology

primary dysmenorrhea summary*

most common gyn complaint among adolescent females

cause: prod of of endometrial prostaglandin PGF2a AKA too much prostaglandins

dx: labs/images unnecessary unless possible pelvic dz, laparoscopy if unresponsive to 3 cycles of initial tx

tx: 1st line = NSAIDs (non steroidal anti-inflammatory drug)

2nd line: OCPs

heat compress, vit B and E, exercise

primary dysmenorrhea - cause

too much prostaglandins (PGF2a)

primary dysmenorrhea - dx

labs/imaging unnecessary UNLESS pelvic dz or unresponsive to meds → laparoscopy

primary dysmenorrhea - 1st line tx

NSAIDs

carboprost tromethamine (hemabate) is what

analog of PGF2a (prostaglandin) used to treat pp uterine atony

(makes uterine blood vessels + muscle constrict)

secondary dysmenorrhea definition

painful menstruation in presence of pelvic pathology

secondary dysmenorrhea summary*

more common among women in 4th/5th decades of life

dx: transvaginal U/S initial imaging of choice

tx the underlying factor

secondary dysmenorrhea causes (painful period w/ pelvic pathology)

gynecologic

• endometriosis

• adenomyosis

• fibroids

• ovarian cysts

• intrauterine or pelvic adhesions

• PID

• obstructive endometrial polyps

• congenital malformations

• cervical stenosis

• imperforate hymen

• use of IUD

non-gynecologic

• IBD/IBS

• ureteropelvic junction obstruction

• psych issues

primary amenorrhea definition

no menses by 13 yo with NO normal growth/2nd sex chars

OR no menses by 16 yo WITH normal growth/2nd sex chars

secondary amenorrhea definition

cessation of REGULAR menses for 3 months

or cessation of IRREGULAR menses for 6 months

prolonged amenorrhea can be the earliest sign of?

decline in general health

signal underlying condition ie hypothyroidism

primary amenorrhea causes

turner syndrome**, (anatomic) - gonadal dysgenesis/chromosome abnormality

androgen insensitivity, (endocrine) - disorder of HPA

constitutional delay of puberty,

abnormalities of outflow tract

turner syndrome (45 XO) stigmata**

• Short stature

• Low hairline 

• Shield-shaped thorax

• Shortened 4th metacarpal

• Small fingernails 

• Brown Nevi

• Coarctation of the aorta

• Nuchal fold (webbed neck with fold at base of neck)*

• Elbow deformity

• Rudimentary ovaries (gonadal streaks)

• No menstruation

mullerian agenesis description

mullerian duct does not grow

→ agenesis/underdev of vagina/uterus

ovaries are normal! (separate embryologic source)

#1 cause of secondary amenorrhea**

pregnancy (1st step is to exclude pregnancy/preg test!)

#2: menstruation

others (either primary/secondary): ovary, hypothalamus, pituitary, meds, thyroid, celiac dz

ovarian causes of amenorrhea

PCOS (INC androgen and estrogen = ovary dysfx)

premature ovarian failure

sole uterine cause of secondary amenorrhea

asherman’s syndrome

(presence of adhesions/synechiae that prevent endometrium from responding to estradiol)

amenorrhea is more likely with _ _ compared to ?

severe hyperthyroidism

mild hyperthyroidism/hypothyroidism

menopause occurrence

d/t genetically programmed loss of ovarian follicles → complete ovarian follicular depletion

follicle role

egg maturation

hormone production

menopause s/sx*

irregular bleeding patterns, (anovulation → progesterone def)

hot flashes, (common at night)

vaginal dryness → itching, sexual dysfunction, atrophic urethritis, (recurrent UTI)

depression,

mastodynia, (breast pain)

migraines,

insomnia,

skin changes,

joint pain,

impaired balance

how to confirm menopause

no menses for 12 months

FSH level (very high)

when ovary fx declines, FSH goes UP. estrogen is present but no ovulation = low progesterone → irregular bleeding

ovary still secretes androgens

sources of estrogen after menopause

adipose tissue

zona reticularis of adrenal gland

perimenopause

ovulatory and anovulatory cycles

1st a lengthening of interval between normal menstruation → eventually cycles are skipped

chronic anovulation → unopposed estrogen (no progesterone)

if endometrium <4 mm, good! if higher = sus b/c estrogen only can’t cause thicker endometrial layer → biopsy

T/F: once menopause starts, no amount of bleeding is acceptable

T

menopause tx*

hormone replacement therapy (HRT) - short-term

^ must be estrogen/progesterone combo HRT if they have uterus d/t risk of hyperplasia and cancer (which can occur in 6 months of unopposed estrogen therapy = no sloughing)

nonhormonal for hot flash: relaxation not effective, SSRIs/SNRIs, GABA

HRT risks for menopause*

long-term not recommended

estrogen HRT: mixed results for breast cancer, INC stroke, MI, TEP (DVT/PE), + colon cancer <70

E+P HRT: INC of breast cancer, MI, TEP, LOWER risk of colon cancer

less risk of fractures after 4-5 yrs

high risk of CV (MI/stroke) in 1st year

causes of abnormal uterine bleeding*

pregnancy*

structural uterine pathology (fibroids/polyps/adenomyosis)

anovulation

hemostasis disorder

neoplasia

trauma/infx

normal menstrual flow*

change pads >/3 hrs

fewer than 21 pads/tampons per cycle

do not change pads during night

clots <1 in in diameter

mildly/not anemic

causes of menorrhagia

1. distortion of endometrium (leiomyoma, polyp, adenomyosis)

2. menopausal transition (anovulatory cycles)

3. VWD or other clotting factor/def

causes of intermenstrual bleeding (metrorrhagia)

1. breakthrough bleeding (esp OCPs)

2. non-progesterone IUD

3. polyps or cancer

4. bloody discharge (d/t endometritis, cervicitis, vaginitis)

ovulatory abnormal uterine bleeding (AUB) summary*

regular intervals + excessive flow/duration (menorrhagia)

breast tenderness, bloating, mood changes, vaginal secretions

cause: anatomic/physical lesion (ie polyp, adenomyosis, cancer, fibroid, FB), hemostatic defect (starts menarche, d/t coagulopathy), infx, trauma

anovulatory abnormal uterine bleeding (AUB) summary*

unpredictable (metrorrhagia) w variable flow/duration

(unopposed estrogen → endometrial proliferation)

causes: HPA (menarche, menopause, stress, lactation, excessive exercise, eating disorders) PCOS, thyroid disorders, drugs (OC’s, progestins, antidepressants + antipsychotics, steroid)

(teens, >40 yo)

menorrhagia definition

excessively heavy periods (>1 pad/tampon q1-2 hr) or excessively long periods (more than 7 days)

bleeding associated with IUDs follows a pattern of _ _ BUT they tend to what?*

anovulatory bleeding

continue to ovulate

in adults, when should you do endometrial sampling when abnormal uterine bleeding (AUB)?

1. hx of unopposed estrogen exposure (chronic anovulation, obesity, PCOS)

2. persistent AUB

3. med management failure

4. other risks (ie fh or tamoxifen)

tx for AUB

1. tx underlying cause

if anovulatory bleeding:

1. preg test, TSH, PLN

2. COC drugs (cause regular cycle)

3. cyclic progestins / progestin IUD

4. NSAIDs (reduce blood loss / dec prostaglandin:thromboxane ratio → hemostasis [vasodilation:vasoconstriction]

5. refractory = estrogen therapy, endometrial sampling again

6. last resort: hysterectomy, endometrial ablation (good w/ no polyps/fibroids)

endometrial hyperplasia cause

unopposed estrogen

proliferation of endometrial glands → thickened endometrium and AUB

simple → atypia (complex w atypia = INC risk of endometrial cancer)

cause of unopposed estrogen (endometrial hyperplasia)

• pharm (HRT, tamoxifen)

• endogenous = chronic anovulation (PCOS, perimenopause), obesity (adipose tissue makes estrogen), estrogen secreting tumors

indications of endometrial biopsy*

1. presence of atypical glandular cells* (AGUS) on cervical cytology (those come from the uterus)

2. >45 yo AUB or <45 yo AUB w RF (chronic anovulation, obesity, tamoxifen, DM, FH of cancer)

3. no response to tx

4. women w uterus w unopposed ERT

5. presence of endometrial cells on cervical cytology if >/40 yo (perimenopausal)

6. women w lynch syndrome (hereditary nonpolyposis colorectal cancer)

7. peutz-jehgers syndrome

lynch syndrome definition

genetic condition that INC your risk of developing cancer esp colorectal and endometrial cancer

peutz-jehgers syndrome definition

dev of hamartomatous growth in stomach and intestine

uterine cancer risk

small/dark colored spots on lips/hands/feet/mouth/anus

endometrial hyperplasia dx/tx

1. dilation & curettage (D&C) (b/c high coexistence with endometrial carcinoma)

2. no atypia = cyclic progestins / progestin IUD

3. f/u biopsy 3-6 mos

most common GYN malignancy in US*

endometrial carcinoma

RF of endometrial cancer*

1. nulliparity

2. early menarche + late menopause

3. chronic anovulation

4. obesity (endogenous estrogens), DM (IGFs), HTN (metabolic syndrome)

5. exogenous unopposed estrogens; tamoxifen

6. FH of colon, breast, ovarian, uterine cancer

7. hx of endometrial hyperplasia

8. increasing age

endometrial carcinoma protective factors*

1. smoking*

2. OC’s and combined postmenopausal HRT

3. physical activity

presentation of endometrial cancer*

Abnormal uterine bleeding – (bleeding after pre/menopause) (menorrhagia or metrorrhagia)

(one drop of blood in postmenopausal women NOT on HRT is NOT NORMAL)

dx: transvaginal U/S = thickened endometrial stripe >4 mm

endometrial cancer tx*

Hysterectomy is necessary w/ BSO (bilateral salpingo-oophorectomy) + pelvic node dissection

Stage 1 – total abdominal hysterectomy w/ BSO. May need post-op radiation

Stage 2,3 – TAH-BSO + lymph node excision w/ or w/o post-op radiation

Stage 4 – systemic chemo

Recurrence – high-dose progestin or antiestrogens

endometriosis definition

presence of endometrial glands and stroma at extrauterine sites

estrogen-dependent disorder

usually pelvis (#1 = ovaries, endometriomas = chocolate cysts - filled with old/dark/sludgy brown blood)

endometriosis presentation and progression

presentation: cyclic pelvic pain (1-2 wks before), severe dysmenorrhea, dyspareunia, infertility

1/3s: 1/3 better, 1/3 same, 1/3 worse

endometriosis RF*

nulliparity,

early menarche/late menopause,

short/long menstrual cycles,

FH,

mullerian anomalies,

taller/thinner/low BMI

endometriosis appearance*

laparoscopy = reddish irregularly shaped, raised patches of thickened scarring or “powder burn”,

best diagnosed by direct visualization,

elevated CA-125 if PE consistent

there is an association with endometriosis with?*

ovarian cancer

first line tx for endometriosis

analgesia

others: hormonal therapy, surgery (if severe, won’t resolve, advanced)

adenomyosis summary

endometrial glands and stroma present within uterine musculature

dx: hysterectomy, MRI

heavy period, dysmenorrhea, pelvic pain

most common pelvic tumor in women and what does it NOT turn into

leiomyoma

do NOT often turn into leiomyosarcoma

sx of leimyoma*

1. abnormal uterine bleeding (heavy or long menses, NOT inter-menstrual or postmenopausal)

2. pelvic pressure + pain (bulk, dysmenorrhea, dyspareunia, torsion/degeneration)

3. reproductive dysfx (infertility, placental abruption, fetal growth restriction, preterm labor)

leiomyoma appearance*

pelvic exam = enlarged, mobile uterus w/ irregular contour, mobile mass

transvaginal U/S: focal heterogenic hypoechoic mass w shadowing

histology: whorled pattern of smooth muscle

RF for leiomyoma*

early menarche

nulliparity

black women

red meat/beer

OC’s do NOT promote growth of fibroids

fibroid location

submucosal - in the uterus

intramural fibroid - on top of the uterus

subserosal fibroid - “stalks” , attached to fibroid

leiomyoma tx*

1. no sx = no intervention

2. hormonal tx

3. gnRH agonist (pre-op to tx anemia + shrink fibroids)

4. surgery indicated for anemia, bulk sx, fertility problems (hysterectomy, myomectomy [preserves fertility], uterine artery embolization [no fertility])

PID definition

acute infx of upper genital tract structures

→ inflammation of uterus, ovaries, and infertility

pelvic inflammatory disease (PID) pathogens*

POLYMICROBIAL

chlamydia trachomatis

n. gonorrhea

gardnerella vaginalis

mycoplasma genitalium

poststrep

bacteroides

PID sx*

variable amounts of lower abd + pelvis, b/l

abnormal uterine bleeding, esp during/after intercourse

abnormal/heavy vaginal discharge w/ unpleasant odor

urethritis

proctitis

fever/chills

dyspareunia

painful/difficult urination

ASCENDING infx = cervicitis → endometritis → salping/oophor/ovarian → peritonitis

ascending infx for ob/gyn 2n1s

pelvic inflammatory dz (PID)

RF for PID*

1. adolescence

2. hx of PID

3. gonorrhea/chlamydia

4. male partners w gonorrhea/chlamydia

5. multiple partners

6. douching

7. IUD

8. OCPs

sequelae of PID*

1. ectopic pregnancy

2. infertility

3. chronic pelvic pain

leiomyoma

diagnostic criteria for PID*

at risk for STI, pelvic/lower abd pain, no other cause AND 1 more of the following:

cervical motion, uterine, or adnexal tenderness

lab tests NOT required but INC specificity

if you have uterine/adnexal/cervical motion tenderness → empiric abx therapy

more specific: high temp, abnormal cervical discharge, WBC on salin wet prep, elevated ESR or CRP, pos gonorrhea or chlamydia

PID tx

initiate fast → hospital

should improve within 72 hrs

outpatient: ceftriaxone + doxy

inpatient: 2nd gen ceph (cefoxitin/cefotetan) + IV doxy

screen + treat for chlamydia (>25 high risk, 1st tri preg)

tx partner for both c. trachomatis and n. gonorrhoeae

endometritis summary*

inflammation of endometrium

cause: PID from STD, invasive procedure, pp, FB, uterine issues, post-abortion

tx: clinda + genta OR ampicillin OR metro

beware of toxic shock sx! (cause: s. aureus or clostridium, clos = VERY LETHAL) = hypotension, high fever, multi organ involvement

causes of adnexal masses*

ovarian causes: endometrioma,

cysts (follicular, corpus luteum),

neoplasms,

carcinoma

non-ovary: ectopic pregnancy, hydrosalpinx, tuboovarian/diverticular/appendiceal abscess, fallopian tube cancer, IBD, pedunculated fibroid, pelvic kidney

FH breast, ovarian or colon cancer increases risk of

ovarian cancer

adnexal mass + mid-cycle pain suggests?

follicular cyst

→ U/S + pregnancy test → CA-125 and laparoscopy

adnexal mass + dysmenorrhea, dysparuenia = ?

endometriosis

→ U/S + pregnancy test → CA-125 and laparoscopy

adnexal mass + pain w/ fever suggests?

infx (PID, appendicitis, diverticulitis)

→ U/S + pregnancy test → CA-125 and laparoscopy