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2015-03-17 20:59:17

Gynecology for PAs
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  1. Precocious Puberty
    onset of sexual development before 8 in girls and 9 in boys
  2. Gonadotropin-dependent precocious puberty
    idiopathic maturation of the hypothalamic-pituitary-gonadal axis

    ovarian tumors can be cause
  3. delayed puberty
    • primary amenorrhea is no menses at 15yo in presence of normal development of secondary sex characteristics
    • 13-no development of any secondary sex characteristics
    • cyclic pain without menses--obstruction
  4. Screening & Prevention
    Pap smear and mammography are only recognized screening tests for cancer

    No effective screening programs, ovarian, endometrial, vaginal vulvar cancers
  5. Mastalgia
    • Cyclic--pattern coinciding with leutal phase
    • Noncyclic-not following of menstrual cycle-casue by tumors, cysts, breast surgery Hx, o medication
    • Extramammary--unrelated to breast tissue
  6. Benign Breast Dz
    • fibrocyctic changes in atrophic cystic lesions which can lead to fibrosis if they rupture
    • common in 35-50yo
    • no increased risk of cancer
  7. benign breast Dz
    proliferative without atypia
    • does not typically cause palpable mass
    • increased risk of developing breast cancer 1.5-2x normal risk
    • fibroadenoma--typically occurs between 15-35
    • can enlarge and cause discomfort with pregnancy
  8. benign breast Dz
    proliferative with atypia
    • malignant cells replace epithelium in situ
    • tamoxifen has been shown to reduce CA risk
    • Follow with annul mammography and 2x annual breast exams
  9. Breast Cancer
    stats & risk factors
    • leading cause of cancer death in women
    • age and gender are risk factors
    • white, Ashkenazi Jews
    • personal hx of breast cancer
    • BRCA
    • ionizing radiation exposure
  10. Breast CA prediction
    • current age
    • age of menarche
    • age of first live birth
    • number of first degree realitives
  11. Nipple discharge
    • most nipple charge is benign, bilateral, multiductal and occurs with manipulation
    • Risk of CA increases when d/c is guaiac positive, unilateral, age over 40
    • age is predictive for CA risk in people with discharge
  12. Mammogram
    • able to detect lesions 2 years prior to becoming palpable
    • used in screening for routine evaluation and supplement an abnormal screening
  13. Breast Mass
    • u/s is first line in women who are pregnant or under 30 years old
    • MRI only used in diagnostic dilemmas, but not routine work up b/c it increase the rate of benign biposies
  14. Breast Cancer screening guidelines
    • 50-74 biennial screening
    • biennial screening mammography before age 50
    • No screening over 75
    • No breast self examinations
  15. Oligomenorrhea
    decrease frequency of menses with cycle length or > 40 days
  16. Hypomenorrhea
    reduction in the number of days or amount of menstrual flow
  17. Amenorrhea
    • chromosomal abnormality
    • hypothalamic hypogonadism
  18. Xo Turner Syndrome
    deletion of part of X chromosome
  19. Secondary Amenorrhea
    • pregnancy is number one cause
    • R/O pregnancy
    • ovary
    • hypothalamus
  20. Secondary Amenorrhea
    Signs and Symptoms
    Weight loss, excessive eating disorders
  21. Asherman Syndrome
    • the only uterine cause of secondary amenorrhea as a result of scarring from the endometrial linking.
    • Secondary Amennorhea in women with recurrent infections and/or dilation and curettage
  22. Premenstrual Syndrome PMS
    • Bx and physical symptoms that occur in 2nd half of ovarian cycle
    • Anger, irritability, and internal tension are prominent in severe forms PMDD premenstrual dysphoric disorder
    • Breast soreness and bloating DO NOT constitute PMS
    • Economic or social dysfunction needs to result
  23. PMS
    • confirmed correlation of menstrual Hx with symptoms
    • Were symptoms present before taking OC
    • R/O hypo or hyper thyroid or major depressive disorder
  24. PMS 
    • exercise and relaxation techniques
    • SSRIs
    • OCs
    • GnRH agonists for refractory cases to SSRIs and OCs
  25. Dysmenorrhea
    • painful menstruation that prevents normal activity
    • primary or secondary (endometriosis, adenomyosis, or uterine fibroids)
  26. Dysmenorrhea primary
    • 50-90% of reproductive age women experience
    • prevalence decreases with age
  27. Dysmenorrhea
    risk factors
    • age <30
    • BMI <20
    • smoking
    • menarche before age 12
    • irregular or heavy flow
    • Protective factors--younger age of 1st childbirth & high parity
  28. Dysmenorrhea
    increased uterine pressures from contractions rises higher than arterial pressure.  This leads to ischemia which produces anabolic metabolites that are sensed as pain
  29. Dysmenorrhea
    • NSAIDs given day prior or at start of menses
    • contraindications include drug reaction, nasal polyp, angioedema, and bronchospasm response to NSAIDs or those with GI ulceration
    • OCs--regulate reduce menstrual flow
  30. Secondary Dysmenorrhea
    • usually after 3rd or 4th decade
    • endometriosis, adhesions, leiomyomata, infection, IUDs
  31. Pelvic Organ Prolapse
    • Anterior-->descent of bladder (cystocele)
    • Posterior-->descent of rectum (rectocele)
    • Enterocele----herniation of intestines through vaginal wall
    • Uterine procidentia--herniation of all three compartment through vaginal wall.
  32. Pelvic Floor Defects
    risk factors
    • Childbirth
    • age > 40
    • BMI >25
  33. Pelvic floor defects
    • conservative treatment--pelvic floor muscle exercises (Kegel's)
    • Surgical Tx--reserved for symptomatic and have failed conservative treatment
  34. Vulvovaginitis
    • infection, inflammation, or changes in vaginal flora
    • change in volume, color, odor of vaginal dc
    • odor
    • pruitus
    • erythema
    • spotting
    • dysuria
    • dysparenia
  35. Vulvovaginitis
    etiology & risk factors
    • MC bacterial 40-50%
    • candida or trichomoniasis
    • MC agents--Gardnerella vaginalis, bacteroides
    • Sexual activity is risk factor especially women with women and numerous partners
    • douching and smoking increase risk
  36. Volvovaginitis
    clinical features
    • BV--asymptomatic
    • thin, offwhite fishy odor of discharge most commonly after intercourse and menses
  37. Vulvovaginitis (bacterial)
    • Gold standard is gram stain
    • Amsel criteria for clinical Dx (need 3)
    • abnormal gray d/c, pH >4.5, positive Wiff test, presence of clue cells
  38. Vulvovaginitis (bacterial)
    • metronidazole or clindamycin PO for 7 days
    • disulfiram--like effect with Metronidazole and alcohol
    • avoid metronidazole in first semester
  39. Bacterial vs Cadidiasis vs Trichomoniasis
    • BV-- >4.5pH, + wiff test, grey d/c, clue cells
    • Candidiasis--itiching, burning cottage cheese like d/c pH normal,hyphae & buds
    • Trich-- frothy maloderous d/c dysureia, dyspareunia, yellow-green d/c, >4.5pH, Trich cells
  40. Trichomoniasis vaginalis
    clinical features
    • may be asymptomatic for 3 months
    • maloderous frothy yellow-green discharge, lower abdominal pain, dysureia, post coital bleeding
    • "strawberry red cervix"
  41. Trichomoniasis vaginalis
    • left untreated can lead to urethritis or cystitis
    • PID, neoplasia, infertility
    • risk of preterm birth increases
    • In males-->prostatitis, epididymitis, and infertility and prostate cancer
  42. Trichomoniasis vaginalis
    • PCR is gold standard
    • wet mount with presence of motile trich cells
    • none of the sings and symptoms are specific or sensitive enough to make a clinical Dx
  43. Candida vaginitis
    • after BV second most common cause of vaginitis
    • not considered and STD
  44. Candida vaginitis
    risk factors
    • DM
    • ABX use
    • increased estrogen levels (OCs, pregnancy, estrogen therapy)
    • Immunosuppression
    • Contraceptive devices
  45. Candida vaginitis
    • pruitus
    • burning, soreness
    • erythema, vulvar excoriation and fissures
    • with thick clumpy cottage cheese like discharge
  46. Candida vaginitis
    • KOH prep on wet mount to show hyphae or yeast
    • Swartz-Lamkin fungal stain
    • stains can be negative in 50% of cases
  47. candida vaginitis
    • Uncomplicated--> PO and topical Fluconazole
    • Complicated--> Fluconazole 150mg every 72 hours for 2-3 doses
  48. Ovarian Neoplasms
    • second MC gynocological cancer and most common cause of death among women with gynecological cancer
    • mortality attributed to poor screening and advanced disease upon recognition
  49. Ovarian neoplasms
    • 90% are epithelial in origin
    • cells are affected by neighboring follicles which undergo transformation with every ovulation
    • repeated ovulation is associated with the histological changes
    • breastfeeding, OCs, and pregnancy can be protective
  50. Ovarian neoplasms
    risk factors
    • Fam Hx of breast or ovarian cancer or Lynch syndrome BRCA 1 BRCA2
    • MC presents in 5-6th decades of life
    • white race
    • nulliparity
    • endometriosis
    • smoking
    • Ashkenazi Jew
    • Protective-->multiparous, OCs, breastfeeding
  51. ovarian neoplasm
    symptoms & signs
    • distention, nausea, anorexia, early satiety
    • insidious onset

    • adnexal mass, abdominal ascites
    • pleural effusion
    • groin or supraclavicular lymphadenopathy
  52. ovarian neoplasms
    • 75% of cases are stage III or stage IV
    • surgical resection followed by chemotherapy
  53. Cervical CA
    • mortality has dropped 70%
    • screening women age 21-65 with pap smear every three years
    • screening starts at age 21 regardless of sexual activity
    • stop screening after 65
    • Risk decreases with age
  54. Cervical CA
    • MC type is squamous cell
    • HPV 
    • spreads by lymphatics or hematogenous
    • MC sites for hematogenous spread are lungs, liver, bone
  55. Cervical CA
    • Internation Federation of Gynecologya dn Obstetrics
    • Stage I--confined to cervix
    • Stage II--carcinoma invades beyond uterus but not to pelvic wall or to the lower third of vagina
    • Stage III--Tumor extends to the pelvic wall or involves lower thrid of the vagina and/or causes kidney dysfunction
    • Stage IV--Carcinoma has extended beyond the true pelvis rectal mucosa or bladder
  56. Cervical CA
    risk factors
    • sex with multiple partners
    • early coitus
    • smoking Hx
    • HIV infection
    • Hx of STI
    • sex with male who had sex with partner with cervical CA
  57. Cervical CA
    cervical lymphadenopathy, LE edema, ascites, decreased breath sounds (mets)
  58. Cervical CA
    surgical resection and chemotherapy
  59. Endometriosis
    patho, clinical features, Dx
    • presence of endometrial glands and stroma at extrauterine sites
    • usually located about the pelvis
    • common, benign, chronic, estrogen dependent
  60. Endometriosis
    • 25-35 yo
    • uncommon in pre or post menarchal girls
    • 7-10% of females have it
  61. Endometriosis
    risk factors
    • nulliparity, early menarche, late menopause
    • caucasians and Asians
    • protective factors--multiple births, breast feeding, late menarche
  62. Endometriosis
    • dysmenorrhea
    • pelvic pain
    • dyspareunia
  63. Endometriosis
    Dx and Tx
    • Laparoscopy with visual inspection of lesions
    • or histology
  64. Endometrial CA
    • endometrial biopsy is gold standard
    • U/s or TVUS
  65. Endometrial CA
    postmenopausal bleeding
  66. Endometrial CA
    Tx and staging
    • FIGO
    • Surgery alone is curative for low risk
    • adjuvant therapy for med to high risk
    • hysterectomy with bilateral salpingooophorectomy and paraaortic lymph dissection
  67. Uterine Leiomyomas (Fibroids)
    • benign monoclonal tumors from myometrium
    • shrink at menopause
  68. Uterine Leiomyomas (Fibroids)
    risk factors
    • 2-3x greater risk in AA
    • early menarche
    • nulliparity
    • increased BMI
    • smoking decreases risk
  69. Menopause
    permanent cessation of menstrual periods (amenorrhea for >12months)
  70. Perimenopause
    • transistion time where ovarian estrogen production fluctuates
    • typically begins 4 years prior to menopause
  71. Menopause
    • hot flashes
    • sleep disturbances
    • depression
    • vaginal dryness
    • lack of concentration
    • arthralgias
  72. Menopause 
    • symptomatic relief
    • transdermal estrogen has fewest risk for thromboembolism
    • progestin therapy must be added to those with intact uterus to prevent endometrial CA
  73. Contraindications to hormone therapy
    • DVT
    • MI
    • stroke
    • liver dysfunction
    • pregnancy
    • undiagnosed genital bleeding
  74. Osteoporosis
    bone demineralization occurs after estrogen production stops
  75. Osteoporosis
    Risk Factors
    • advanced age
    • Hx of fractures
    • smoking
    • EtOH intake
    • FRAX assessment tool
  76. Osteoporosis
    • women > 65
    • or women whose risk factors equal that of a 65 yo caucasian
  77. Osteoporosis 
    • hormone replace3ment therapy, Ca supplementation, and weight-bearing exercise
    • smoking cessation
    • 1200mg.d of Ca
    • Bisphosphonates (low Dexa score or Hx of fractures)
  78. Combination Oral Contraceptives
    • estrogen regularizes the menstrual cyccle and progestin is the contraceptive affect
    • LH and FSH levels are suppressed and LH surge is absent
  79. Oral contraceptives
    reduction of dysmenorrhea, pelvic pain, PMS, benign breast disease, ovarian CA, acne, hirsutism, endometrial CA, Fe deficient anemia
  80. Patch and Ring contraception
    • Patch--synthetic progestin and estrogen-decreased efficacy with obese
    • Ring--inserted at beginning of menses and remains 3 weeks
  81. Oral Contraception, Rings, patch
    • Hx of DVT
    • uncontrolled HTN
    • CAD
    • Complicated DM
    • Hx CVA
    • Severe liver disease
    • > or equal to 35 and > or equal to 15 cigarettes/day
  82. Injectable Hormonal Contraceptives (DMPA)
    • IM Q3mo within first 5 days of menses
    • maintains circulating levels of progestin therefore blocking the LH serge
    • No contraindication for smoking or HTN
  83. barrier contraception
    • best protection against STIs
    • effectiveness based on proper use
  84. IUD
    • Levonorgestrel and Copper
    • 5 years and 10 years
    • Insert during menses b/c confirms no pregnancy and cervix is slightly relaxed
  85. IUD 
    side effects
    • + decreased menstrual blood loss, pain relief, 
    • - expulsion (primarily during first year)
  86. IUD 
    • Levonorgestre--breast CA, DVT Hx
    • Levonorgestre and Copper--severe liver Dz, endometrial CA, spesis
  87. Emergency Contraception
    • used up to 72 post intercourse
    • Copper ring can work if pt is not pregnant
    • Levonorgestrel oral emergency delays ovulation