jmanderson's version from 2015-11-29 22:51

female puberty and puberty disorders


Question Answer
thelarche (onset of breast development – estrogenic) at 8-12 yofirst clinical sign of female puberty
menarche (onset of periods)2 y after thelarche (tanner stage 4)
no menses by 15 yoprimary amenorrhea
order of female pubertybreasts (10 yo), pubearche/adrenarche, peak height velocity (11.5 yo), menarche (12.5 yo), completion of puberty (14 yo)
female ethnicity order of puberty early to lateAfrican americans, Mexican americans, Caucasians
preadolescent, elevation of papilla onlytanner stage 1
areola and papilla form secondary moundtanner stage 4
preadolescent vulva (no pubes)tanner stage 1
pubic hair coarse, curly, abundant, less than in adulttanner stage 4
Endocrine changes with female pubertyDHEAS from adrenals, rise is LH/FSH, increased sensitivity of GnRH, pulsatile release of GnRH/LH/FSH, increase in androgens and estrogens from gonads
gonadotropin dependent precocious puberty labsadvanced bone age, high LH (pubertal), high LH response to GnRH
gonadotropin independent precocious puberty lab valuesadvanced bone age, low LH (prepubertal), no response to GnRH
secondary hypogadism (hypogonadotropic hypogonadism) labsFSH/LH low
primary hypogonadism (hypergonadtropic hypogonadism) labsFSH/LH high
premature thelarche (early breasts before 4 yo) managementobserve q6 mo to ensure it’s not progressing to GDPP
complete/central precocious puberty evaluation labshigh FSH/LH, estradiol, levels increase w/ GnRH stimulation test
complete/central precocious puberty evaluation MRI to r/o what?treatable CNS abnormalities (head trauma, infection, hydrocephalus, etc.)
precocious puberty, café au lait spots (coast of main shape), fibrous dysplasiaMcCune-Albright syndrome
45XTurner syndrome (primary hypogonadism)
47XXYKlinefelter syndrome (primary hypogonadism)
anosmia, GnRH def., Kal-1 gene mutKallman syndrome (secondary hypogonadism)
15q11q13 microdeletionPrader-Willi syndrome (hypogonadism)
most common cause of female pubertal delayconstitutional delay
constitutional delay of puberty labsnormal bone age, normal FSH/LH, tx generally not needed, follow-up to r/o genetic causes

menses and bleeding disorders


Question Answer
Important sections of history for women 40-64 yohx pelvic prolapse, menopausal sx
important sections of PE for women 40-64 yobreast and axilla changes
how often to do a breast exam starting at age 20q1-3 y
normal age of menarche12-13 yo
normal interval btw periods 21-35 d
normal duration of menses3-7 d (ave 5)
normal blood flow<80 cc (40cc ave)
always ask about this during the menstrual hx of female examask and document the last menstrual period
the obstetric hx includesprior pregnancies including losses, type of delivery (vag v. c-wection), M/F, birth wt, complications (HTN, DB, preterm)
GPTPAL meansGravid (total pregnancies), Para (total births after 20 wk gestation), Term (after 37 wk gestation), Preterm (before 37 wk), Abortion (loss before 20 wk), Living children
G5 P13125 pregnancies, 1 term birth, 3 preterm births, 1 abortion, 2 living children
menstrual cycle length > 35 doligomenorrhea
secondary oligomenorrhea causespregnancy, stress, HPO dysfunction, anorexia/bulimia, PCOS
most common cause of secondary oligomenorrhea?pregnancy (order bHCG test)
causes of hypogonadotropic hypogonadism primary amenorrhea?Kallman, pituitary problem
causes of hypergonadotropic hypogonadism primary amenorrhea?Turner’s (45XO), Gonadal dysgenesis (46XX), Swyer syndrome (46XY)
causes of eugonadotropic primary amenorrhea?imperforate hymen, mullerian dysgenesis, Asherman syndrome, androgen insensitivity syndrome (46XY)
anosmia, micropenis, cryptorchidism, deaf, cleft lip/palate, no production of GnRH (decreased FSH/LH)Kallman Syndrome
gonadal dysgenesis, streaked gonads, no follicles (no sex hormones), short stature, webbed neck, shield chestTurner’s
congenital disorder, dx in adolescence, menstrual blood accumulates in vagina/uterus, tx w/ incisionimperforate hymen
intrauterine scarring, adhesions/fibrosis after D&C, dx w/ hysteroscopyAsherman syndrome
menstrual flow outside of normal volume, duration, regularity or frequencyabnormal uterine bleeding
what is required to order in pt w/ postmenopausal abnormal bleeding?endometrial biopsy
1st line imaging for abnormal uterine bleedingUS
structural causes of abnormal bleeding (PALM)polyps, adenomyosis, leiomyoma, malignancy
nonstructural causes of abnormal bleeding (COEIN)coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not yet classified
increased uterine bleeding, pelvic pressure, pain bulk related sx, reproductive dysfunction, benignleiomyomas (fibroids)
mainstay definite tx of leiomyoma (but don’t do it 1st)hysterectomy
heavy periods, bleeding btw periods, irregular spotting, normal labs, often asymptomatic, polypoid mass on sonohystogramuterine polyps
Rotterdam criteria for PCOS2 of the 3 = oligo/anovulation, hyperandogenism, polycystic ovaries on US
tx for hirsuitism of PCOSshave, wax, vaniqa, contraceptive, antiandrogen
tx for endometrial protection of PCOSPO contraceptive, intermittent progestin
tx for ovulation induction of PCOSclomiphene, metformin, gonadotropins, laparoscopic surgery

female reproductive imaging and surgery


Question Answer
Infertility due to fallopian tube block (PID, ectopic pregnancy), what image for dx/tx?HSG
Infertility due to DES uterus (T-shaped), what image for dx?HSG
ovarian US with bilat enlarged ovaries, mult peripheral follicles, increased stromal echogenicityPCOS
hormones increased in PCOSandrostendione, estrogen, LH
functional ovarian cysts with “ring of fire” on Doppler that produces progesteronecorpus luteum cyst
most common ovarian lesionfollicular cyst
post-menopausal bleeding, order what?biopsy and transvaginal US (suspected adenocarcinoma)
endometrial stripe >5mm women not on hormone, order what?biopsy
endometrial stripe >8 mm in women on hormones, order what?biopsy
adenocarcinoma initial studyUS
adenocarcinoma imaging study for stagingMRI
infertility due to Mullerian duct abnormalities, what is dx test of choice?MRI
Mullerian duct abnormalities occur at what time of embryological development?6-8 wks
US hyperechoic nodule (Rokitanksy nodule or dermoid plug); Fluid fatteratoma
A 45 year old female presents with some mild pelvic pain and is sent for a pelvic ultrasound. The results show a thin walled, non-septated, unilocular lesion with good through transmission. There is no vascularity within the lesion. What would be the next best course of action for this patient?observation (2 cm); MRI (6 cm)
tell pt about procedure, reason, expectations, preference, alternatives, risks, expense, and decisionpre-op informed consent
first line for IDing the cause of abnormal uterine bleeding (to look for CA or hyperplasia)endometrial biopsy
looking into uterus w/ thin telescope-like device to place contraceptive devices (Essure) into fallopian tubehysteroscopy
what is the key for intraoperative safety when using hysteroscopy?fluid management
what is the most widely used means of permanent contraception in the US?laparoscopic sterilization
what is the most common method of laparoscopic sterilization?bipolar coagulation
complication of bipolar coagulation?High rate of ectopic pregnancy
most commonly performed GYN surgery?hysterectomy
most common hysterectomy approach?abdominally
ACOG hysterectomy approach of choice?vaginally
any ACOG indication for robotic hysterectomy?not yet
hysterectomy approach where cervix is left in situ and cannot be done vaginally?supracervical
hysterectomy approach where everything is removed and can be done from any approach?complete
most common complication of hysterectomy?infection
Surgery to remove the uterus, tubes, cervix and surrounding tissue, upper vagina and lymph nodes. (often ovaries are also removed)radical hysterectomy

cervical and endometrial cancer


Question Answer
70% of cervical CA caused by what viruses?HPV 16, 18
risk factors for cervical dysplasia and neoplasmsSMOKING, HPV, HIV, immunocompromised, DES, CIN2 or 3, sexually active, PO contraceptive use, lack of screening, low socioeconomic status
cervical CA screening starts at what age?21 yo
most common technique for pap smear?liquid based
pap smear sample should be from what zone of cervix?TRANSFORMATION zone
ASCUS pap smear w/ neg HPVnormal, repeat in 1 y
ASCUS pap smear w/ pos HPV 16/18, order what?colposcopy if over 25 yo
ASC-H pap smear, order what?colposcopy
Gardisil vaccine covers what viruses?HPV 16, 18, 6, 11 (3 shots at 0, 2, 6 mo)
Cervarix vaccine covers what viruses?HPV 16, 18 (3 shots at 0, 1, 6 mo)
risk factors for endometrial CAUNOPPOSED ESTROGEN, obesity, lynch syndrome (HNPCC), DB, estrogen secreting tumor, PCOS
findings in endometrial CA?irregular bleeding or postmenopausal bleeding. thickened endometrial stripe
management of pt w/ endometrial CAbiopsy (to start), D&C (gold standard tx)
staging endometrial CA with what?surgery (hysterectomy)
prognosis and tx of endometrial CA depends on what? pathological review (FIGO) where high grade has worse prognosis
tx for endometrial CA if pt desires fertility and is Type 1progesterone
screen for lynch syndrome if under what age50 yo
most common tx for endometrial CAhysterectomy w/ pelvic/para-aortic nodes, pelvic cytology, BSO if over 40
4th most common CA in women (Following breast, lung, and CRC)?endometrial CA
most common, endometrioid histology, grade 1 or 2, favorable prognosis, estrogen responsive, preceded by hyperplasia sometimes, 55-65 yotype 1 (endometrioid) endometrial CA
less common, worse prognosis, grade 3, non endometrioid histology (serous, clear cell, mucinous, squamous, transitional, undifferentiated), not assoc. w/ estrogen stimulation, 65-75 yotype 2 (serous) endometrial CA
most common histology of endometrial CAadenocarcinoma
Autosomal dominant hereditaty CA w/ 40% risk of endometrial, ovarian, or colorectal CA; 9% of women <50 yo who get endometrial CA have Lynch syndrome, offer genetic testing of suspectedLynch syndrome (HNPCC)
endometrial CA post-op evaluationroutine pelvic exam q3 mo for 1st 2 y and q6 mo for 3 y and annually afterwards
leading cause of secondary amennorheapregnancy (order bHCG test)

vulvar/vaginal disease


Question Answer
yellow discharge, pain, strawberry cervix, pH >4.5trichomonas
gray/white discharge, cramping, clue cell, whiff test, pH>4.5bacterial vaginosis
most common cause of vaginitisbacterial vaginosis
white thick discharge, itching, cramping, erythema, KOH, hyphae, pH<4.5candida albicans (yeast infection)
tx yeast infectiondiflucan (antifungal PO or cream)
vaginitis in postmenopausal women, normal, low estrogen, dry vaginiaatrophic vaginitis
appears like vaginitis but with CERVICAL MOTION TENDERNESS, infections, feverpelvic inflammatory disease (PID)
risk factors for vulvar neoplasia>65 yo, HPV, smoking, HIV, lichen sclerosis
thin vulva, parchment paper, halo, figure 8, keyholelichen sclerosis
vulvar itchiness after dermatitis, hyperpigmented, diffuselichen simplex chronicus
inflammation (ulcers), whitish lacy bands of keratosis near reddish ulcerated-like lesions, chronic vulvar burning or pruritis, pain w/ intercourse, dischargelichen planus
autoimmune, involves vulvar skin, raised ovioid patches (silver scale)psoriasis
pt w/ vestibulitis, what don’t you use?speculum or pap smear! With hurt them
vulva lesion that’s warty, cauliflower-type, HPV, needs biopsycondyloma acuminata
vulvar carcinoma usually what type?squamous cell
itchy vulva, order what?biopsy (could be cancer)

ovarian masses


Question Answer
risk factors for ovarian CA?fam hx of 1st deg relative, BRCA1 or 2, HNPCC, hx of breast CA, white, low parity or nulliparity, infertility, early menarche, late menopause, hormone rerplacement w/ estrogen for >10 y
protective factors for ovarian CA?BC use for >5y, breastfeeding, full-term pregnancy, multiparity, tubal ligation, hysterectomy w/ prophylactic oophorectomy
evaluation of adnexal mass?pelvic US, if malignancy suspected get CT, staging w/ laparoscopic surgery
tumor markers for ovarian CACA125 (follow-up), CEA/CA 19-9 (mucinous/endometrioid CA)
blood filled chocolate cyst in the ovary?endometrioma
most common functional cyst in premenopausal females?follicular cysts
rare tumor from abdominal/pelvic peritoneum, often mimic GYN malignancies cystic mesothelioma
most common epithelial ovarian CApapillary serous
most common gonadal stromal cell tumorfibroma (leiomyoma)
stromal cell tumor that produces testosterone, usually large mass and virlization, low grade malignancysertoli-leydig tumor
what do you use to stage and grade ovarian CA?laparscopic surgery (more differentiated = better prognosis)

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