Dunphey Chapter 14
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What is AUB?
- Abnormal uterine bleeding -- 2 major categories
- organic and dysfunctional. The diagnosis of dysfunctional uterine bleeding is considered only after organic, systemic, and iatrogenic causes are limited.
What is dyspareunia?
Dyspareunia is painful sexual intercourse.
what drug is the mini pill made of?
oral contraceptives work by?
To be most effective oral contraceptives must be:
Taken at the same time every day within the same hour.
When should a postpartum woman begin oral contraceptive therapy?
Is it safe for a breast-feeding woman to begin oral contraceptives?
1. Due to the higher risk of stroke during the postpartum period oral contraceptives should be started note earlier than 4 to 6 weeks postpartum.
2. Estrogen decreases the amount and quality of breast milk, oral contraceptives are not recommended for lactating women. Progestin actually promote breast milk, so that progestin only OCs should be used in women who are breast-feeding and desire contraception.
1. What is the Depo-Provera injection?
1. Depo-Provera is an injectable form of contraception given every 3 months and has a 99.7% effective rate. Once injected it may take 8 to 9 months for fertility to be restored.
1. How long after ovulation is an ovam viable for?
2. How long after sex are sperm viable for?
1. An ovum is viable for 24 hours after ovulation.
2. Sperm are viable 48 hours after sex.
The rhythm or calendar method is based on the assumptions of the viability of the ovum and sperm.
1. Describe natural family planning methods?
A. The basal body temperature method
B. The sympatothermal method
C. The cervical mucus method
A. In the basal body temperature method the patient measures basal temperature daily and abstinence is observed from 3 days of elevated temperature.
B. In the cervical mucus method, an interruption and recognition is made of changes in the cervical mucus consistency.
C. The sympatothermal method, the fertile period as determined by calendar calculation and cervical mucus changes to decide the fertile period. Changes in mucus in basal temperature are used to decide on the end of this cycle.
(this multiple choice question has been scrambled)
1. Describe plan B.?
1. Emergency contraception, may be given as one single dose or 2 doses12 hours apart. Both of these methods must be started within 72 hours of intercourse.
1. Describe breast-cancer fast facts.
1. Cancer of the breast is the most common cancer in American women.
2. Breast cancer is 2nd only to lung cancer as the leading cause of cancer death among women.
3. The lifetime risk of a woman getting breast cancer is one in 8.
4. The median age for breast cancer diagnosis is 64 years of age.
5. The most common areas of metastasis of the regional lymph nodes, lung, skin, bone, liver, and brain.
1. Describe suspicious areas on a mammogram:
- 1. A symmetry with definitive borders or discernible masses
- 2. Architectural distortion( pulling in of breast tissue)
- 3. A radio dense nodule, irregularly shaped and unclear margins
- 4. Calcifications that are irregularly shaped clusteredand of varying sizes
- 5. skin changes such as thickening or retraction
- 6. spiculations( needlelike)
- 7. Axillary lymph nodes more than 2 cm or intra-manmarry lymph nodes more than 2 cm
1. Which breast carcinoma has the poorest prognosis of all breast cancers?
2. When comparing ductal carcinoma in situ and lobular carcinoma in situ which has a propensity for bilateralality, multicentricity, and subsequent invasive cancer?
1. Inflammatory breast carcinoma has the poorest prognosis of all breast cancers
2. lobular carcinoma in situ.
1. Describe what a sentinel node is and its importance in breast-cancer.
1. The sentinel node is the 1st lymph node along lymphatic drainage pathway. Is identified after injection with a radioisotope. If the central node is negative for metastatic disease, complete axillary lymph node dissection is not indicated.
1. Describe what mastitis is?
2. Describe the 3 general types of mastitis.
1. Mastitis is a general term that refers to inflammation of the breast.
- A. Puerperal mastitis is a cellulitis that develops in the lactating or non-lactating breast after birth.
B. None for Perl mastitis is a rare disease which is usually found in patients who are immune compromised.
C. Periductal mastitis is the inflammation that occurs proximal to the lactiferous ducts of the breasts which become filled with keratin and secretions. This occurs in older women (40 to 49 years of age), and results in the Periductal region becoming fibrotic and inflamed.
1. What is the main causative organism of puerperal mastitis?
1. The main causative organism of sporadic puerperal mastitis is staph aureus.
1. Describe a subject of presentation and mastitis.
2. Describe an objective presentation of mastitis.
1. The clinical presentation is acute in nature. The patient's 1st complaint is fatigue followed by the onset of flu like symptoms. A fever, myalgia, malaise with chills can be expected. Nausea and vomiting may accompany these symptoms.
2. Nipple discharge may vary in color and contain a call blood. It is most frequently green and sticky and occur spontaneously. There are varying degrees of erythema and edema of the affected breast. The erethema is most commonly in a V shape distribution and may or may not feel hard.
1. True or false. After a diagnosis of mastitis is made it is vital that the infant continues to breast-feed.
1. True it is vital that the infant continue to breast-feed to avoid milk stasis.Because the infection is extra ductile there is no risk to the infant continuing to breast-feed.
1. Describe treatments for mastitis.
1. Treatment includes moist heat to the affected breast, pumping, massage during feeding to better drain the breast.
Pumping abreast in addition to frequent infant feeding decreases the duration of the symptoms in the sequelae of the disease.
The best responses when antibiotics are started within the 1st 24 hours of symptom onset.
1. Define infertility?
1. Infertility is defined as lack of conception despite unprotected sexual intercourse for at least 12 months as studies have shown a 93% cumulative probability of pregnancy and normal fertile couples after this time.
1. What is primary infertility vs. secondary infertility?
2. What is fecundability?
1. Primary infertility ( occurs in about one in 12 couples)refers to a woman who has never had a child, whereas secondary infertility applies to a woman who is delivered at least one child.
2. Fecundability is the probability of successful pregnancy within one menstrual cycle.
1. What effect does a woman's BMI have on her ability to get pregnant?
1. Women with a BMI of less than 20 or greater than 27 are less likely to become pregnant. Loss of just 5 to 10% of body weight in obese women with polycystic ovarian disease can restore ovulation within 6 months.
1. What is Clomid?
1. Clomid is a selective estrogen receptor modulator.with Clomid ovulation occurs in approximately 80% of selected women and conception rates approach 40%.
1. Describe primary amenorrhea.
2. Describe secondary amenorrhea
The average age at menarche in the United States today is 12.7 years.
1. Primary amenorrhea is the failure to demonstrate by age 14 and girls with no secondary sex characteristics or failure to menstruate page 16 and girls who may or may not have developed secondary sexual characteristics.
2. Secondary amenorrhea is the absence of menstruation for 3 or more consecutive months and a woman who has achieved menarche.
1. Describe Turner's syndrome and its relation to amenorrhea.
1. The most frequent cause of primary amenorrhea is dysfunction of the ovaries resulting from gonadal dysgenesis.
Turner syndrome is characterized by an XO genotype and is one of the most common chromosomal disorders. In this condition, the ovaries are placed a fibrous tissue( known as street ovaries), which have very limited capacity for estrogen production.
1. What is the only anatomic uterine etiology of secondary amenorrhea?
1. Acquired scoring in the endometrium also known as Asher-mans syndrome.
1. What is the 1st test should be performed in a patient that complains of amenorrhea?
1. A urine pregnancy test should be performed. If the test is positive serum hCG should be done.
1. What test should be performed in the patient presenting with secondary amenorrhea?
1. Test to include for secondary amenorrhea include androgen studies of total testosterone and dehydroepiandrosterone sulfate; it progesterone challenge test and the measurement of prolactin and FSH levels.
1. Describe a progesterone challenge test.
1. This test, given once the pregnancy test is negative, consists of giving medroxyprogesterone acetate (MPA) 10 mg PO for 5 to 10 days to induce withdrawal bleeding or spotting, which should occur within 14 days after the last dose.
If withdrawal bleeding occurs, this indicates to pituitary-gonadal function and amenorrhea is probably the result of anovulation. the test is negative if no withdrawal bleeding occurs in suggests low levels of estrogen or a nonpatent outflow.
1. Describe the management of amenorrhea.
1. For a patient with secondary amenorrhea whose progesterone challenge test is negative, treatment consists of oral estrogen along with oral progesterone.
2. For primary amenorrhea, estrogen therapy is indicated for patients who develop secondary sex characteristics and prevent osteoporosis
1. Describe the timing of PMS.
1. PMS symptoms arise during the 2nd or luteal phase of the menstrual cycle, starting at day 14 after menses, immediately following ovulation and the midcycle LH and FSH gonadotropin surge.
1. Describe the diagnosis of PMS.
1. Using a diary of at least 2 menstrual cycles if the intensity of symptoms increases at least 30% in the 6 days before the onset of menses and if the symptoms occur in 2 consecutive months, a diagnosis of PMS is made.
2. One of the most important assessment parameters in making a diagnosis of PMS is that the symptoms occur only during the luteal phase of the menstrual cycle. If the symptoms appear during the follicular phase, this may reflect the mood or anxiety disorder.
1. What lifestyle changes are beneficial to women who suffer with PMS.
1. Lifestyle changes include regularly scheduled meals that are relatively high in complex carbohydrates and low in salt, sugar, and caffeine; most importantly regular aerobic exercise.
1. What is the drug of choice for treating PMS
1. SSRIs such as Prozac Zoloft Paxil and Celexa are all effective in treating PMS.
Follow up should be within 2 months.
1. What does PMDD stand for?
Premenstrual dysphoric disorder or PMDD is a condition associated with severe emotional and physical problems that are linked closely to the menstrual cycle.
1. What is primary dysmenorrhea and secondary dysmenorrhea?
1. Primary dysmenorrhea is painful menses with no pelvic pathologyand begins 1 to 2 years after the onset of menstruation.
Secondary dysmenorrhea is painful menses secondary to pelvic pathology and women tend to be in their 30s or 40s. If a complaint of painful intercourse is present a diagnosis of secondary dysmenorrhea should be explored.
1. What is the pathophysiology of uterine cramping in dysmenorrhea?
1. Elevated resting tone and dysrhythmic contractions compromises blood supply and oxygenation to uterine muscle thus causing cramping.
1. What agents are most effective in treating dysmenorrhea?
1. Aspirin 325 mg 2 tablets PO started the day or 2 performance tradition is helpful in reducing prostaglandin levels.
The NSAID ibuprofen remains the mainstay of dysmenorrhea therapy is considered the most effective OTC pain reliever once cramps have been initiated
heat therapy in NSAIDs have been shown to be counterproductive when used together.
1. What is the most common cause of secondary dysmenorrhea?
1. In the physical exam what is the most common symptom in endometriosis?
1. Tenderness in the posterior fornix is the most common symptom.
1. What is the preferred diagnostic method to diagnose endometriosis?
1. Direct visualization of endometrial implants through laparoscopy is the preferred diagnostic method, as most implants are located on the pelvic organs.
1. Differentiate metrorrhagia and menorrhagia.
Metorrhagia - irregular uterine bleeding
Menorrhagia - post menapausal bleeding.
1. What is the treatment for endometriosis.
1. There is no for endometriosis oral contraceptives and NSAIDs usually provide adequate relief and mild disease.
1. Describe the treatment for moderate to severe endometriosis
1. Medical treatment alone is inappropriate for moderate to severe disease. Only surgical intervention is shown to improve fertility.
1. Described leiomyomas.
1. Leiomyoma is our most commonly called uterine fibroids. Fibroids are benign tumors most common tumor of uterus. Most are small and asymptomatic. The most common symptom is uterine bleeding, pain during intercourse, if the fibroid is large enough it can cause pressure on the bladder causing urinary symptoms.
1. Describe conservative and surgical management of leiomyomas.
1. No treatment is necessary for small and asymptomatic leiomyomas.
If the patient is severely anemic due to bleeding, progesterone given IM every 28 days and 300 mg of iron will help.
For very large leiomyomas surgical removal is necessary.
1. What type of cancers are most endometrial cancers?
1. The majority are pure adenocarcinomas. Endometrial cancer accounts release 20% of cases of post menopausal uterine bleeding.
Cancer of the endometrium is the most common of all gynecological cancers.
The overall five-year survival rate is 80 to 85%.
OC pills have been shown to have a protective mechanism against ovarian and endometrial cancer.
What is typically the only presenting patient complaint and endometrial cancer?
Abnormal bleeding in 80% of cases.
1. What tests as ordered in a post menopausal patient that presents with abnormal uterine bleeding?
1. Endometrial biopsy. Pap smear alone is not a reliable indicator for endometrial cancer.
When should an endometrial biopsy be performed in a postmenopausal woman?
Biopsy is done at the endometrial thickness is greater than 4 mm or any woman with persistent uterine bleeding regardless of endometrial thickness.
1. What is most important in the management of endometrial cancer?
2. Described the phases of endometrial cancer.
1. The primary principle of management is to obtain a correct diagnosis as early as possible, as the cure rate for endometrial cancer is high if treated early.
2. 5 total stages, stage one is confined to the uterine body, stage V is spread outside the palace.
1. Describe menopause.
1. Menopause has occurred when the patient has not menstruated for one year. This takes place between the ages of 48 to 55 years. Always perform a pregnancy test or the patient resents with amenorrhea.
. The most common symptoms of menopause hot flashes, night sweats and insomnia.
Vaginal dryness or atrophy is a common complaint due to loss of estrogen.The most effective treatment for vaginal dryness is topical vaginal application of an estrogen product.
Osteoporosis is a major concern of menopause.
1. Describe the use of hormone replacement therapy.
1. HRT is not a first-line treatment for menopausal symptoms. HRT is only for women with moderate to severe menopausal symptoms particularly hot flashes and sleep disturbances, but only for short., No longer than 5 years.
Estrogen only therapy is usually limited to women who no longer have a uterus.
- Exogenous estrogen is contraindicated in patients with estrogen dependent cancers, such as breast, and endometrial and ovarian cancers, or on diagnosed vaginal bleeding.
- Patients with liver disease, active thrombosis or history of stroke should not take estrogen. Pregnancy and migraine headache are other contradictions to taking estrogen.
1. Describe the 3 main classifications of ovarian cancer.
1. Ovarian cancer has 3 main classifications; surface epithelial- stromal tumors( by far the most common life-threatening represent 80 to 90% over wearing tumors), sex cord - stromal tumors, and germ cell tumors.
Ovarian cancer is quantitatively the rarest but the most deadly form of gynecological cancers.
Ovarian cancers have been associated with the number populations in a woman's lifetime; therefore nulli-parity increases the number of ovulations and thereby the risk of a cell mutation occurring.
1. Describe the symptoms of ovarian cancer.
2. Describe objective findings of ovarian cancer.
1. Symptoms include back pain bloating and constipation. As a tumor enlarges public pressure, discomfort urinary frequency abdominal swelling bloating and nausea.
2. During a pelvic exam, a public Mass, decreased mobility of the cervix and uterus, pain untold patient of the ovaries, and a digital rectal exam may confirm a pelvic mass. Malignant ovarian tumors are usually large with irregular contour and decreased mobility, unlike benign tumors and cysts.
1. Describe ovarian cancer staging.
1. Ovarian cancer staging a staged 1 through 4, one being confined to the ovaries and 4 representing distant metastasis.
1. Describe management of ovarian cancer.
1. Unlike other cancers, surgical resection for optimal reduction is the standard of care both for early and advanced ovarian cancer. Surgical removal usually include hysterectomy and bilateral oophorectomy with appendectomy.
1. Describe the grading of cervical intraepithelial neoplasia.
1. The greatest severity are CIN I ( Mild dysplasia), CIN II ( mod dysplasia), and CIN III ( severe dysplasia to carcinoma in situ).
1. When should Pap smears or screening for cervical cancer begin?
1. Screening should begin at age 21 regardless of sexual history and is recommended every 2 years.
1. What is the clinical presentation of patients with premalignant and invasive cervical cancers?
1. Premalignant presentations will be a history of risk factors and no gynecological exam for number of years, while invasive cancers present with a history of a brownness discharge or abnormal vaginal bleeding occurring spontaneously or after intercourse
Describe common STIs and their treatment.
1. CHLAMYDIA - Azithromycin
2. GONORRHEA -Ceftriaxone
3. TRICHOMONIASIS - Metronidazole
4. BACTERIAL VAGINOSIS - Metronidazole
5. CHANCROID - Azithromycin
6. SYPHILIS - Benzathine penicillin G
7. ANOGENITAL HERPES - Acyclovir
8. Molluscum Contagiosum - No TX heal on own
9. Candidiasis - Fluconazole (Diflucan)
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