S

Female Reproductive Health Review — Contraception, Gynecologic Disorders, and Obstetrics (Flashcards)

Hormonal Contraceptives

  • Purpose: add exogenous progesterone (and sometimes estrogen) to suppress the body's natural midcycle LH/FSH surge, preventing ovulation (pseudopregnancy state).
  • Types and principles:
    • Natural family planning / fertility awareness methods (NFP): track data points to identify fertile window and abstain or use barrier methods during that window.
    • Data points include cervical mucus, basal body temperature, cycle tracking, ovulation tests.
    • Efficacy: up to ~95% with multiple data points and proper adherence; lower with poor tracking.
    • Barrier methods: physical barriers to prevent sperm from reaching cervical canal.
    • Hormonal contraception: progestin-only or progestin + estrogen; available in multiple forms (pill, patch, ring, injection, implants, intrauterine systems).
    • Emergency contraception: Plan B (levonorgestrel) or other approved regimens; access may be prescription-based.
  • Contraindications and safety considerations:
    • Estrogen-containing products increase clotting risk; contraindicated or used with caution in patients at risk for thromboembolism.
    • Smokers >15 cigarettes/day, especially >35 years old, higher thrombotic risk; prefer progesterone-only methods when estrogen is a concern.
    • Lactating women: estrogen can suppress milk production in the initial months; progesterone-only or non-hormonal methods are preferred early postpartum.
    • Hypercoagulable states: non-hormonal methods preferred if possible.
    • Migraines with aura: higher stroke risk; prefer progesterone-only methods if needed.
    • Uncontrolled hypertension: restrict estrogen-containing regimens until BP controlled; after control, consider alternatives.
    • Diabetes: Safe in many cases; ensure no organ involvement progression (retinopathy, nephropathy, neuropathy) that would limit use.
  • Special considerations:
    • If pregnancy is not desired, hormonal contraception can be combined with metformin in PCOS or other contexts to assist ovulation suppression and metabolic effects in some patients.
    • In lactation: estrogen-containing forms may reduce milk production in the first months; progesterone-only therapies are typically preferred.
  • Practical notes:
    • When initiating or adjusting therapy, consider individual risk factors (smoking, age, BP, metabolic disease, migraine history).
    • If combination therapy is used, use the lowest effective estrogen dose to minimize thrombotic risk.

Ovarian Pathology

  • Functional ovarian cysts:
    • Follicular cysts: arise from a follicle that fails to rupture or fails to resolve; often asymptomatic and small.
    • Corpus luteum cysts: form after ovulation; usually resolve; may cause pain if ruptured.
    • Diagnosis: ultrasound preferred; small cysts often asymptomatic and self-resolve within months. Acute sharp pain suggests rupture.
  • Dermoid cysts (teratomas):
    • Germ cell tumors containing tissues from all three germ layers (e.g., hair, teeth, bone).
    • Ultrasound: often complex, solid-appearing.
    • Management: if asymptomatic and small, may observe; if large or symptomatic, surgical removal (cystectomy or oophorectomy depending on childbearing plans).
    • Most ovarian tumors are benign; malignant ovarian cancers are a leading cause of death from reproductive tract cancers; early disease often not detected on routine pelvic exam.
  • Evaluation of ovarian cancer risk:
    • BRCA1/2 mutations and Lynch syndrome raise lifetime risk.
    • Symptoms can include pelvic pressure, fullness, bloating; ultrasound may show solid masses or thick septations; CA-125 is not specific but can indicate risk or progression when epithelial carcinoma is suspected.
    • Surgical staging and treatment depend on cancer extent; may include hysterectomy with bilateral salpingo-oophorectomy, omentectomy, and lymph node assessment.
  • Ovarian torsion:
    • Acute psychiatric emergency: often presents with sudden pelvic pain; larger masses (>5 cm) increase torsion risk.
    • Ultrasound with Doppler assessing blood flow; ovaries may appear enlarged with edema; emergent surgical detorsion and assessment for viability.
  • PCOS (polycystic ovary syndrome):
    • Pathophysiology: hyperandrogenism with excess androgens (precursor to testosterone and estrogens) leading to anovulation.
    • Rotterdam criteria: requires two of three:
    • Oligo- or anovulation
    • Hyperandrogenism (clinical or biochemical; free testosterone more sensitive than total due to low SHBG from estrogen exposure)
    • Poly-cystic ovarian morphology on ultrasound (string of pearls around periphery)
    • Clinical features: irregular menses, infertility, acne, hirsutism, androgenic alopecia; acanthosis nigricans may be present.
    • Diagnostics and goals:
    • Reduce circulating androgens and unopposed estrogen exposure to protect endometrium
    • Induce ovulation if pregnancy desired (e.g., ovulation induction agents, metformin for insulin resistance)
    • Monitor for diabetes and cardiovascular risk; manage metabolic syndrome risk
    • Treatment approaches:
    • If not conceiving: hormonal contraceptives (estrogen + progestin) to suppress androgens and protect endometrium; metformin may aid in insulin resistance and cycle regulation; anti-androgens for hirsutism (e.g., spironolactone in selected cases)
    • If conceiving: weight loss, metformin may be used in some cases; consider clomiphene or letrozole for ovulation induction when appropriate

Uterine and Adnexal Pathologies

  • Endometriosis:
    • Ectopic endometrial tissue that responds to ovarian hormones; causes cyclic pain, infertility, dyspareunia; endometriomas (ovarian implant) can form known as chocolate cysts.
    • Diagnosis: laparoscopy with visualization and biopsy; ultrasound not definitive for ectopic endometrial implants.
    • Treatments: GnRH agonists (e.g., leuprolide) to suppress FSH/LH and induce a hypoestrogenic state; danazol (less common due to androgenic effects); surgical lesion ablation/lysis; hysterectomy in those who have completed childbearing.
  • Adenomyosis:
    • Ectopic endometrial tissue within the myometrium; leads to diffuse, uniform thickening of the myometrium and a globular, enlarged uterus.
    • Ultrasound helpful for differentiation; treatment similar to endometriosis with estrogen suppression; definitive treatment is hysterectomy.
  • Leiomyomas (fibroids):
    • Frequently multiple; hormonally sensitive; size can increase in pregnancy and shrink after menopause.
    • Symptoms: abnormal uterine bleeding, bulk symptoms; ultrasound to determine number, size, and location.
    • Treatments: observation if asymptomatic; medical suppression; myomectomy for those desiring future fertility; hysterectomy for definitive treatment.
  • Endometrial cancer:
    • Most common gynecologic malignancy; estrogen exposure increases risk (e.g., PCOS, unopposed estrogen after HRT, obesity-related estrogen metabolism).
    • Symptoms: abnormal uterine bleeding; postmenopausal bleeding important to evaluate.
    • Diagnostics: ultrasound to assess endometrial thickness; endometrial biopsy for histology.
    • Treatment depends on stage; surgical excision of malignant tissue, possible hysterectomy with salpingo-oophorectomy and nodal/omental assessment.
  • Cervical dysplasia and cancer:
    • Dysplasia refers to abnormal cervical cell turnover; can progress to cancer or regress.
    • Screening: Pap smear starting at age 21; HPV co-testing based on age and cytology results.
    • Age-based workup:
    • HPV16/18 are high-risk strains; DES exposure historically increases risk for adenocarcinoma; adenocarcinoma harder to detect early due to false negatives.
    • Management and staging depend on cytology results and biopsy; treatment of localized cancer may involve excision; extensive disease may require more tissue removal.
  • Bartholin glands:
    • Occlusion can lead to cysts; infection can lead to abscesses.
    • Treatment: sitz baths, antibiotics if infection; drainage often required; ward catheter may be used to keep gland open for drainage due to rapid re-epithelialization.
  • Pelvic organ prolapse:
    • Prolapse of bladder, uterus, or rectum into vaginal canal due to pelvic floor support weakness.
    • Risk factors: increased intra-abdominal pressure, fascia/muscle laxity.
    • Diagnostics: imaging with contrast to assess organ involvement and descent; exam.
    • Treatments: lifestyle changes; pelvic floor therapy; vaginal pessary; surgical mesh repair in selected cases.

Vaginal and Cervical Infections

  • Vaginitis:
    • BV: thin, grayish-white discharge with pH changes; wet prep shows clue cells (epithelial cells coated with bacteria).
    • Candida: thick, white, curd-like discharge; budding yeast on microscopy.
    • Risk factors: BV – pH-altering factors, multiple/new sexual partners; Candida – antibiotics use, pregnancy, hormonal birth control, diabetes.
    • Treatments: BV with metronidazole (oral or vaginal); second-line clindamycin; Candida with azoles (miconazole, clotrimazole; fluconazole for recurrence).
  • STIs: gonorrhea, chlamydia, trichomonas
    • Diagnostics: nucleic acid amplification tests (NAAT) on urine or vaginal sample; wet prep may show Trichomonas organisms.
    • Treatments: gonorrhea – ceftriaxone (IM) plus cefixime (oral) or alternative; chlamydia – doxycycline (or azithromycin if doxycycline not tolerated); trichomonas – metronidazole (or tinidazole if resistant).
    • Complications: infertility risk from PID; PID can be caused by ascending pathogens (gonorrhea, chlamydia, or other sexually transmitted pathogens).
  • Pelvic Inflammatory Disease (PID):
    • Inflammation of upper female tract; often polymicrobial; clinical diagnosis based on lower abdominal/pelvic pain with adnexal, uterine, or cervical motion tenderness.
    • Hospitalization considered for septic or failing outpatient therapy; supportive labs (white count, inflammatory markers) helpful but do not delay treatment.
    • Broad-spectrum antibiotic coverage for likely pathogens (gonorrhea, chlamydia, anaerobes, etc.).

Amenorrhea and Menstrual Disorders

  • Primary amenorrhea:
    • Criteria: no menses by age 16 with normal growth, or by age 13 with no secondary sexual characteristics.
    • Common causes arranged by presence/absence of organs and secondary attributes:
    • Breasts present, uterus present: imperforate hymen (menstrual flow blocked at vaginal opening).
    • Breasts absent, uterus present: gonadal dysgenesis (Turner syndrome) with underdeveloped ovaries.
    • Breasts present, uterus absent: androgen insensitivity syndrome; absent uterus/ovaries due to XY genotype with androgen receptor dysfunction.
    • Müllerian agenesis: congenital absence of uterus/cervix/upper vagina despite normal ovarian function and female genotype.
    • 46,XY with 17α-hydroxylase deficiency or other forms of congenital adrenal hyperplasia: genotypically female but with sexual development differences.
  • Secondary amenorrhea:
    • Definition: prior menses followed by absence of menses for a period (often >3 months or longer depending on context).
    • Initial evaluation: rule out pregnancy (urine hCG), then assess hypothalamic-pituitary-ovarian axis: prolactin, TSH, FSH, estradiol; estrogen status assessment.
    • Progesterone withdrawal test: give progesterone for 10 days, then withdraw; if withdrawal bleeding occurs, patient generally ovulates; if not, estrogen deficiency or anovulation risk.
  • Premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD):
    • Symptoms occur in luteal phase and resolve with menses; management includes symptom-directed therapies, lifestyle changes, hormonal regulation.
  • Dysmenorrhea:
    • Primary dysmenorrhea: prostaglandin-mediated; NSAIDs reduce prostaglandin activity; hormonal suppression can help by reducing ovulation and cyclical hormonal signals.
    • Secondary dysmenorrhea: may indicate endometriosis, adenomyosis, fibroids, or infections. Investigate underlying pathology.
  • Abnormal uterine bleeding (AUB): PALM-COEIN framework
    • PALM: structural causes (polyps, adenomyosis, leiomyoma, malignancy/cancer).
    • COEIN: nonstructural causes (coagulopathy, ovarian dysfunction, endocrine disturbances, iatrogenic, not otherwise classified).
  • Postmenopausal bleeding:
    • Most common benign cause is vaginal atrophy; but must evaluate for hyperplasia, polyps, adenomyosis, and endometrial cancer.
    • Workup: pelvic ultrasound to assess endometrial thickness; endometrial biopsy if thickened or inconclusive imaging.
  • Infertility:
    • Definitions: inability to conceive after 12 months of regular unprotected intercourse (younger than 35); after 6 months if older or with known risk factors.
    • Female factors: ovulatory dysfunction (e.g., PCOS), tubal/uterine factors; male partner assessed with semen analysis.
    • Diagnostic tests: day 3 FSH, day 21 progesterone, HSG (hysterosalpingogram) to assess fallopian tube patency, uterine structure.
    • Treatments tailored to cause: ovulation induction for anovulatory cycles, addressing male factor, lifestyle optimization, manage endocrine issues.
  • Menopause and perimenopause:
    • Average age around 51 years; vasomotor symptoms (hot flashes, night sweats), vaginal atrophy, dyspareunia.
    • Diagnostic clues: elevated FSH/LH, decreased estradiol; clinical diagnosis often suffices.
    • Treatments:
    • Local estrogen for vaginal atrophy without systemic exposure; non-hormonal options for most symptoms.
    • Systemic HRT for vasomotor symptoms if appropriate; estrogen-progestin combination if uterus present; estrogen-only if uterus removed.
    • Non-hormonal options: SSRIs/SNRIs for vasomotor symptoms; gabapentin for hot flashes.
    • HRT risks: increases in breast cancer risk, thrombosis, stroke, and cardiac events; minimize dose and duration.

Breast Disorders

  • Lumps and masses:
    • Fibroadenoma: common in younger patients; rubbery, round, well-circumscribed; imaging: ultrasound in younger patients due to density; mammogram if older than ~40.
    • Breast abscess: warm, tender, rapidly enlarging; often in lactating women; treat with antibiotics and drainage; continue breastfeeding if possible.
    • Mastitis: usually Staphylococcus aureus in postpartum period; treat with antibiotics and breastfeeding continuation.
    • Nonlactational cystitis and recurrent cysts management may require drainage.
  • Fibrocystic changes and nodularity: cyclical changes around menses; lifestyle measures and potential use of Danocrine (danazol) to reduce nodularity/pain in selected cases.
  • Breast cancer:
    • Most common malignant breast carcinoma is infiltrating ductal carcinoma; screening mammography recommended starting at age 40; ultrasound for younger patients and/or focal concerns; biopsy confirms diagnosis; treatment depends on stage (lumpectomy, mastectomy with/without radiation, chemotherapy, hormonal therapy).
  • Galactorrhea and hyperprolactinemia:
    • Causes include medications (dopamine antagonists), prolactin-secreting tumors (prolactinoma), hypothyroidism (increased TRH stimulates prolactin), renal failure (decreased clearance), acromegaly, etc.
    • Diagnostic approach includes checking prolactin levels and evaluating for pregnancy; address underlying cause.

Obstetrics: Normal Pregnancy Timeline and Safety

  • Initial prenatal visits:
    • Comprehensive history and physical to identify high-risk features; baseline prenatal labs; pap smear early in pregnancy; dating ultrasound for gestational age confirmation.
  • First trimester (weeks 10–12): assess fetal heart tones; discuss early screening options (cell-free DNA or serologic serum screening with ultrasound correlation).
  • Second trimester (weeks 18–22): fundal height measurement (cm should approximate gestational age +/- 2 cm); anatomy ultrasound; second-trimester genetic screening if not done earlier.
  • 24–28 weeks: 1-hour glucose challenge test (screening for gestational diabetes); if abnormal, proceed to diagnostic 3-hour oral glucose tolerance test.
  • Third trimester: increased visit frequency; assess fetal presentation via palpation and ultrasound; screen for infections and anemia; GBS status assessed; monitor for complications.
  • Safe medications in pregnancy:
    • Avoid NSAIDs (risk of closing fetal patent ductus arteriosus); acetaminophen preferred for pain.
    • Antibiotics safe in pregnancy: penicillins, cephalosporins (category B); metronidazole (category B) for BV or trichomonas; doxycycline avoided.
    • Anticoagulants: avoid warfarin (category X); use LMWH (e.g., enoxaparin) if anticoagulation necessary.
    • Nausea and vomiting: doxylamine and do not use certain agents; antiemetics include dimenhydrinate and ondansetron (category B); many acid-reflux medications (H2 blockers, PPIs) considered safe; inhalers generally safe; inhaled corticosteroids for asthma management if needed.
  • Labor and delivery:
    • Stages of labor: latent (prolonged, ends at 4–6 cm), active (rapid dilation to 10 cm), second stage (cervix fully dilated to delivery), third stage (delivery of placenta).
    • Cesarean section indications: failure of labor to progress, prior C-section, abnormal fetal presentation (e.g., transverse/occipital malpresentation), placenta previa, or other obstetric concerns.
    • Length of hospital stay varies by mode of delivery and complications; typical 1–3 days with uncomplicated vaginal delivery.
  • Postpartum care:
    • Postpartum visits at 1–2 weeks (telehealth) and 6–7 weeks (in-person) to reassess cycles, contraception, lactation, mood, and recovery.
    • Lactation considerations: assess latch and milk supply; address breastfeeding challenges.
    • Postpartum mood disorders: baby blues are common and self-limiting; postpartum depression may require SSRI therapy and support; postpartum anxiety can present with OCD-like behaviors and panic; postpartum psychosis is rare but severe and requires immediate intervention.

Pregnancy Complications and Emergencies

  • Pregnancy loss (miscarriage):
    • Types vary, but common symptoms include vaginal bleeding and cramps before 20 weeks; aneuploidy is a leading cause.
    • Diagnostics: speculum exam for bleeding; serial beta-hCG and ultrasound for reassurance or to confirm miscarriage; management includes medical (misoprostol) or surgical (D&C) evacuation as indicated.
  • Ectopic pregnancy:
    • Most commonly tubal; risk increased with tubal scarring (PID, prior ectopic, tubal surgery).
    • Presentation: unilateral lower abdominal pain with possible vaginal bleeding; pregnancy test should be done in reproductive-age females with pelvic pain.
    • Diagnostics: transvaginal ultrasound; serial beta-hCG (doubling approximately every 48 hours; sometimes up to 60% increase is possible).
    • Management: stable small ectopic pregnancy may be treated with methotrexate; larger or ruptured ectopics require surgical intervention (laparoscopic salpingostomy or salpingectomy).
  • Cervical insufficiency:
    • Cervical length shortening increases risk of preterm birth; transvaginal ultrasound surveillance at 14–16 weeks if risk factors present; cerclage or vaginal progesterone may be used to prevent preterm birth in high-risk individuals.
  • Rhesus (Rh) incompatibility:
    • Rh-negative mother with Rh-positive fetus can develop anti-D antibodies; prophylaxis with Rho(D) immune globulin (RhoGAM) at 28 weeks and after any bleed, and postpartum if baby is Rh-positive.
  • Gestational diabetes mellitus (GDM):
    • Two-step approach common: 1-hour screening with 50 g glucose; if >125 mg/dL, proceed to 3-hour diagnostic test with 100 g glucose.
    • Most cases managed with diet and exercise; insulin is the main pharmacologic therapy if needed; some cases allow metformin.
    • Macrosomia risk: fetal overgrowth; serial growth ultrasounds to monitor.
  • Hypertensive disorders of pregnancy:
    • Chronic hypertension: diagnosed when BP > 140/90 before 20 weeks or persists postpartum; management includes low-dose aspirin 81 mg/day starting 12–14 weeks, home BP monitoring, and pharmacologic control if BP > 160/110 (beta-blockers and calcium channel blockers are first-line; hydralazine as alternative but with tachycardia concerns).
    • Gestational hypertension: new onset BP > 140/90 after 20 weeks; similar management to chronic hypertension; ultrasound monitoring in late third trimester; higher risk for preeclampsia.
    • Preeclampsia: new-onset hypertension after 20 weeks with proteinuria or end-organ dysfunction; delivery is definitive treatment; magnesium sulfate used for seizure prophylaxis; monitor with ultrasound and labs; aspirin for prevention in high-risk individuals.
    • HELLP syndrome: hemolysis, elevated liver enzymes, low platelets; may occur with or without severe HTN; delivery often indicated due to maternal risk.
    • Eclampsia: preeclampsia with seizures; management includes seizure control, stabilization, and delivery.
  • Trophoblastic disease (molar pregnancy):
    • Hydatidiform mole produces high hCG and can resemble pregnancy; ultrasound shows snowstorm pattern; treatment is suction curettage (D&C) with careful follow-up of hCG to zero; pregnancy attempts discouraged for ~6 months due to risk of recurrence; potential for malignant GTD with metastasis (e.g., pulmonary nodules).
  • Placental abnormalities:
    • Placental abruption: premature separation of placenta; presents with painful vaginal bleeding and abdominal pain; diagnose with ultrasound but may be clinical; management focuses on maternal stabilization and delivery if fetal distress.
    • Placenta previa: placenta implanted low in the uterus and may cover the cervical os; presents with painless vaginal bleeding; management includes avoiding intercourse and planning cesarean delivery around 36–37 weeks to prevent bleeding.
  • Complications of labor and delivery:
    • Shoulder dystocia: baby’s shoulder becomes stuck; managed with rapid maneuvers (e.g., McRobert’s position, suprapubic pressure) to facilitate delivery; risk of brachial plexus injury and postpartum hemorrhage.
    • Umbilical cord prolapse: cord descends before the baby; risk of cord compression and fetal distress; delivery urgency increases when cord presenting.
    • Postpartum hemorrhage: uterine atony, coagulopathy, lacerations, or retained products; management includes uterine massage, uterotonics (oxytocin), and possible surgical intervention; blood products as needed; monitor for DIC.
  • Postpartum pituitary (Sheehan) syndrome:
    • Pituitary necrosis due to severe hemorrhage/shock; presents with lactation failure (agalactorrhea) or secondary hypopituitarism; diagnosis via anterior pituitary hormone panel and MRI showing empty sella; treat with hormone replacement as needed.

Reproductive Medicine: Infertility Evaluation and Management

  • Two primary infertility scenarios:
    • Inability to conceive after one year of unprotected intercourse in women <35 or after six months in women ≥35.
    • Infertility due to PCOS, early ovarian dysfunction, endometriosis, or other endocrine factors.
  • Male factor and female factors:
    • Male: semen analysis to assess number and quality of sperm.
    • Female: evaluate ovulatory function and tubal/peritoneal factors (HSG to assess tubal patency; assess ovulation with cycle tracking and hormone tests).
  • Diagnostic approach requires correlating cycle patterns with hormonal status and anatomic findings.

Practical Notes and Study Aids

  • PALM-COEIN framework for abnormal uterine bleeding – structural vs non-structural etiologies.
  • Rotterdam criteria for PCOS: 2 of 3 criteria (ovulatory dysfunction, hyperandrogenism, polycystic ovarian morphology).
  • Key thresholds and rules:
    • Ectopic pregnancy risk increases when beta-hCG > 2000 mIU/mL without intrauterine gestation on ultrasound.
    • hCG doubling every 48 hours is the classic teaching; can vary by up to ~60% increase in some cases.
    • GDM diagnosis via 3-hour glucose tolerance test after a positive 1-hour screen (two or more abnormal values define GDM).
    • Pre-eclampsia defined by hypertension after 20 weeks with proteinuria or end-organ dysfunction; HELLP is a severe variant.
    • Rh prophylaxis (RhoGAM) at 28 weeks and after any bleeding event; postpartum testing of the newborn’s Rh status guides additional prophylaxis.
  • Clinical judgment emphasized: many conditions require imaging, labs, and sometimes surgical confirmation or intervention; ultrasound is a first-line tool for many pelvic conditions but not definitive for all (e.g., endometriosis).