-
Describe hormone levels through the mestral cycle
- Follicular Phase: FSH stimulates follicle; Follicle releases estradial; estradiol causes endometrial proliferation; endometrium releases FSH and LH
- Luteal Phase: LH surge causes ovulation; corpus luteum secretes estradiol and progesterone; Estradiol inhibits FSH and LH
- Menses: Corpus Luteum dies if no sperm; estradiol and progesterone decrease; endometrium degrades
- Fertilization: Endometrium produces hCG which maintains corpus luteum which produces progesterone.
-
What is next step if patient has Atypical Squamous Cell of Uncertain Significance (ASCUS) on pap smear?
Repeat pap every 4 months for 2 years
-
What is the next step if patient has Atypical Glandular Cell of Uncertain Significance?
Culposcopy, direct biopsy, and Endocervical curettage (ECC)
-
What is the next step when a Low-grade Squamous Intraepithelial Lesion (LSIL) is found on pap?
Repeat pap-smear every 4 months for 2 years.
-
What is the next step when a High-grade Squamous Intraepithelial Lesion (HSIL) is found on pap?
Culposcopy, EndoCervical Curettage, and Direct Biopsy
-
Treatment for LSIL and HSIL?
- LSIL: No treatment, most will revert
- HSIL: Cryotherapy, Laser, Loop Electric Excision Procedure (LEEP), Large Loop Excision (LLETZ), or Cold Knife Conization.
-
Treatment for AGUS?
Cold Knife Conization (CKC) and D&C
-
Differential Diagnosis for Acute Pelvic Pain.
- Pregnancy: with Corpeus Luteum bleeding, ectopic, or abortion
- Gynecologic: PID, endometriosis, cyst rupture, adnexal torsion, Mittelschmertz, Leiomyoma torsion, tumor, primary dysmenorrhea
- GI: Appendicitis, IBD, IBS, Mesenteric Adenitis, Diverticulitis
- Urinary: UTI, Calculus
-
What steps should be taken in a patient with acute pelvic pain with positive HCG?
- 1. Vaginal Ultrasound
- 2. If positive: watch and look for other sources of pain
- 3. If negative and LMP was < 5 weeks: Quant HCG (if HCG > 2000 think ectopic)
- 4. If neg and LMP was > 5 weeks: think ectopic pregnancy
-
Treatment for ectopic pregnancy
- If patient is unstable: Lap
- If pt is stable: Methotrexate or salpingostomy (if tubal)
-
Differential Dx for Amenorrhea
- Pregnancy
- Androgen Insensitivity Syndrome (no uterus)
- Pituitary Adenoma (+ Prolactin)
- Exercise Induced
- Anorexia
- PCOS
- Antipsychotics
- Previous chemo
-
Steps to evaluate amenorrhea
- HCG
- Give progesterone
- if she bleeds check LH
- if +: PCOS
- if nl: check prolactin and TSH
- if prolactin + and TSH nl: MRI
- if prolactin nl: think exercise, anorexia, etc
- if no bleeding check FSH
- if FSH +: premature menopause
- if FSH nl: MRI of brain (craniopharyngioma or other CNS tumor)
-
Differential Dx of breast mass in woman under 35
- Fibrocystic disease
- Fibroadenoma
- Mastitis / Abscess
- Fat Necrosis
-
Treatment for Fibrocystic Disease
- Under 35:Mostly just routine follow-up but
- Progesterone for 1 week at end of each month
- or Danazol can help symptoms
- Over 35: Aspiration of cyst (if bloody biopsy)
- Baseline Mammogram
-
Treatment for mastitis
- Continue breast feeding
- Analgesics
- Cephalexin or Dicloxacillin or more severe
-
Differential for breast mass in woman over 35
- Fibrocystic disease
- Fibroadenoma
- Cystosarcoma Phylloides
- Fat necrosis
- Mastitis or Abscess
- Breast Cancer
-
Treatment for Fibroadenoma
- Under 35: Watch
- Over 35: Get Baseline mammogram
- If small, benign, woman is premenopausal, and no risk factors: watch
- Otherwise: Biopsy
-
What form of breast cancer often appears like a Fibroanenoma?
Cystosarcoma Phylloides
-
When should you be highly suspicious of a br malignancy?
New mass in post-menopausal woman.
-
Causes of dysfunctional uterine bleeding
- 1. Hormonal:
- a. Anovulation (puberty, perimenopause, anorexia, extreme stress, obesity, hypothyroidism, prolactinoma, PCOD)
- b. Breakthrough bleeding on combination or progesterone-only OCP
- 2. Anatomic and Physiologic:
- a. CA (cervical, endometrial, ovarian)
- b. Polyps (cervical, endometrial)
- c. Uterine fibroids (usually submucosal)
- d. Pregnancy (miscarriage, ectopic, mole, threatened)
- e. Ovulation
- f. Postpartum (retained placental tissue, atony)
- 3. Infectious:
- a. Cervicitis
- b. Endometritis
- c. PID
- 4. Hematologic: bleeding, diathesis (ITP, hemophilia)
-
Treatment for Endometriosis
- OCP first line
- Danazol and GRH agonists second line
- Surgery is also an option esp in severe cases
-
What is Ashermans syndrome?
Adhesions in the uterus caused by scarring
-
Medical treatment for infertility
- 1. Clomiphene
- 2. If hypoestrogen use human menopausal gonadotropin also
-
Organisms causing PID?
- N Gonorrhea
- Chlamydia
- E coli
- Actinomyces Israelii (IUD)
-
Rx for PID
- Outpatient: Cefoxitin or Ceftriaxone and Doxycycline
- Inpatient: Clindamycin and Gentamycin
-
Obese woman with hirsutism, amenorrhea, and infertility
PCOS
-
Lab findings of PCOS
- + testosterone and androstenedione
- LH:FSH > 2:1
-
Rx for PCOS?
- Oral contraceptives or
- Cyclic progesterone
-
Cottage cheese vaginal discharge; pseudohyphae on KOH; hx of DM, abx, or pregnancy
Candida Albicans
-
Dysuria, positive culture or antibody test
Chlamydia trachomatis
-
Maloderous discharge, fishy smell on KOH, Clue cells
Garderella Vaginalis
-
Multiple shallow painful ulcers, recurrence
Herpes
-
Venereal warts, koilocytosis on pap smear
HPV
-
Venereal warts, koilocytosis on pap smear
HPV
-
Characteristic appearance of lesions, intracellular inclusions
Molluscum contagiousum
-
Mucopurulent cervicitis; gram negative bugs
N Gohorrhoeae
-
Crabs; itching, lice
Pediculosis
-
Painless chancre, spirochete on dark field microscopy
Primary Syphilis
-
Condyloma lata, maculopapular rash on palms, serology positive
Secondary Syphilis
-
Bugs swimming under microscope; pale green, frothy, watery discharge, strawberry cervix
Trichomonas vaginalis
-
Rx for candida albicans
Antifungal
-
Rx for Chlamydia trachomatis
- Doxycycline, azithromycin
- if pregnant: erythromycin or amoxicillin
- if non-compliant: 1 g azithromycin once
-
Rx for Gardnerella Vaginalis
Metronidazole
-
Rx for Herpes
Acyclovir or Valacyclovir
-
Rx for N Gonorrhoeae
Ceftriaxone or Ciprofloxacin
-
Rx for Pediculosis
Permethrin cream
-
Rx for syphilis
Penicillin
-
Rx for Trichomonas vaginalis
Metronidazole
-
Child with ambiguous genitalia
First think congenital adrenal hyperplasia (usually 21-hydroxylase deficiency)
-
8 year old boy who is starting puberty
Adrenal hyperplasia (21-hyroxylase deficiency)
-
Signs and symptoms of 21-hyroxylase deficiency
- 1. ambiguous genitals in XX; precocious puberty in boys
- 2. low Na
- 3. high K
- 4. low BP
- 5. high 17-hydroxyprogesterone
-
Rx for 21-hydroxylase deficiency
Corticosteroids and fluids
-
5 yo child with bunch of grapes protruding from vagina
Sarcoma Botryoides (rhabdomyosarcoma)
-
Rx for idiopathic precocious puberty
- gonadotropin-releasing hormone analogue
- (leuprolide)
-
Woman with loss of urine during coughing, laughing, lifting, or standing (if severe). Treatment?
- Stress Incontinence
- Treat:
- Kegel Exercises
- Meds: ERT, Pseudoephedrine
- Pessaries
- Surgery
-
Woman unable to reach bathroom in time regardless of amount in bladder, dribbling, urgency, frequency, nocturia; possible neuro symptoms, previous sx, or hematuria.
Treatment?
- Urge Incontinence
- Treat:
- Meds-anticholinergics, B agnoists, Sm muscle relaxants, and TCA's
- Bladder training
-
Woman with dribbling, having to run to bathroom, losing urine on coughing or laughing; remaining urine on PVR test. Hx of neuro disease possible.
Treatment?
- Overflow Incontinence
- Treatment:
- 1. Rx-prazosin, terazosin, phenoxybenzamine; diazepam, dantrolene; bethanechol
- 2. Intermittent catheterization
-
Girl Tanner staging signs and exptected ages.
- Stage I: Prepubescent
- Stage II: (9-13) Br buds appear, areola enlarges; hair on labia
- Stage III: (10-14) elevation of breast, areola enlarges; hair on pubis, pits; acne
- Stage IV: (10.5-15) areola makes second mound; adult hair
- Stage V: (over 16) no further growth; areola same contour as breast; adult hair
-
7 yo girl, tanner stage 3, LH raises when GnRH given. Rx?
- Central precocious puberty
- Treat with GnRH and look for CNS lesion
-
Treatement for Dysfuntional Uterine Bleeding?
- Mild: Fe
- Moderate: Progestin
- Severe or Active bleed: Estrogen
-
Post menopausal woman with vulvar pruritis, dyscomfort, dyspareunia, dysuria, painfull defecation. On PE has porcelin white macules and papules and atrophic labia minora and clitoris. Dx? Next step? Rx?
- Dx: Lichen Sclerosis
- Next: biopsy to rule out SCC
- Rx: Topical steroids
-
16 yo girl comes in with amenorrhea, nl uterus and ovaries, no other pubic hair and can't smell. Dx?
Kallman's Syndrome (No GnRH secretion)
-
What are the tests for Syphillis?
- RPR or VDRL initially
- FTA ABS to confirm
|
|
