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Physiologically most important estrogen Estradiol (E2); produced in ovary; peaks in ovulatory phase; FB to inc LH & decrease FSH
Primary estrogen in PG Estriol (E3); produced in placenta
Before menopause, primary circulating estrogen = Estradiol (E2); serum estradiol levels 30-200 pg/mL
After menopause, primary circulating estrogen = Estrone (E1); secreted by ovary; mean serum estradiol levels < 15 ng/mL
Induces glandular secretion in endometrium: Progesterone
Main role of testosterone in women estrogen precursor
Decreased testosterone levels in females cause: decline in libido, mood changes
Progesterone produced where? in corpus luteum after ovulation; by placenta in PG
Progesterone levels rise rapidly after: ovulation
FSH fn: binds to granulosa cells and stimulates estradiol secretion
In a state of estrogen deficiency, more ____ is secreted FSH
During luteal (secretory) phase, ______ are suppressed to low levels FSH and LH
Plasma LH surge precedes ovulation by 24-36 hrs
Estrogen pattern during menstrual cycle Secretion peaks just before midcycle, drops sharply with ovulation, rises again to plateau, then decreases again before menstruation
During luteal (secretory) phase, predominant hormone changes from: estradiol to progesterone
Adequate progesterone prodn is necessary to facilitate: implantation and sustain early pregnancy
Progesterone MOA Acts primarily on endometrium, initiates secretory phase
Results of hyperprolactinemia Loss of libido; Galactorrhea; Oligomenorrhea/ amenorrhea; Infertility; Decreased muscle mass; Osteoporosis
Decreased _____ levels in females cause decline in libido, mood changes testosterone
Vaginitis sxs vaginal discharge; Dyspaurenia; Dysuria; Urinary Frequency
Ectopic PG sx Missed menses/unusual menses; Lower abdominal/pelvic pain; Vaginal bleeding; Positive PG test
Ovarian cyst sx Unilateral/diffuse; Sharp; Spontaneous resolution common; Uncommon on OCPs
Ovarian torsion sx severe pain, down legs/back
PID sx Dyspaurenia; Fever; Chills; Diarrhea; Vaginal discharge
Chronic pelvic pain sx Intermittent, cyclical; Constant pain is possible; Dull, nonspecific, diffuse; Generally afebrile
Endometriosis sx Dysmenorrhea; Dyspaurenia; Adhesive dz devt possible; improved with suppression of ovulation
Uterine fibroid sx Dysmenorrhea; Dyspareunia; Urinary frequency; Lower back pain
Osteitis pubis Symphysis pain; Pelvic joint instability following childbirth
Vulvodynia Vulvar pain; Painful urination; Dyspaurenia; Vaginal and Pelvic floor symptoms
Primary dysmenorrhea: onset within: 1-2 years of menarche
Musculoskeletal pelvic pain includes: Myofascial pain; Muscle spasm; Round ligament; Spinal nerve innervation
Painful bladder syndrome = Dysuria; Negative UA; Urinary Frequency; Dyspareunia ; Dx of exclusion/ autoimmune component
Chancroid: cofactor in contracting: HIV
Chancroid: often co-infection with: HSV or syphilis
Most common symptom of endometrial neoplasia: AUB (90% of pts)
endometrial ca RF Post or late menopause; FH/PMH ca (ov, BrCa, colon, endomet); Tamoxifen; PCOS; Obesity; nulliparity; Estrogen Tx w/o progestin; Prior Endometrial Hyperplasia; DM, HTN
average uterine length = 6-8 cm
Simple/Complex Endometrial Hyperplasia: causes unopposed estrogen: Premenopause etio: Obesity; PCOS; eating disorders; Thyroid; Herbals; other anovulation
Simple/Complex Endometrial Hyperplasia: causes unopposed estrogen: Postmenopause etio: Obesity; HRT; herbals w/estrogen (soy); Ovar/ adrenal estrogen producing tumor
Postmenopausal, dyspareunia, thin vaginal discharge, atrophic vulvar changes, vaginal petechiae Atrophic vaginitis; Tx = topical estrogen
20 yo female w/ rubbery, firm, well-circumscribed, non-tender breast lesion, doesn't change w/ cycle Fibroadenoma
30 - 50yo female, painful, multiple, bilateral breast masses that increase in pain and size before menses Fibrocystic breast disease
Spontaneous bloody, serous, or cloudy nipple discharge Intraductal papilloma
Breast mass, nipple retraction, bloody nipple discharge Breast cancer (mass is most common presenting clinical manifestation)
Overweight, irregular menstrual cycles (poss. Amenorrhea), elevated blood sugar, hirsutism PCOS (stein-leventhal syndrome)
Adolescent female with midcycle pain alternating from left to right side. Relieved w/ NSAIDs Mittelschmerz
Dysmenorrhea, dyspareunia, dyschezia. Uterus is fixed, retroflexed. Cyclic pelvic pain. May have palpable pelvic mass Endometriosis
Palpable pelvic mass - "chocolate cyst" = Endometriosis
Firm irregular shaped, NONTENDER enlarged uterus Leiomyoma
Softened, tender, diffusely globular uterine enlargement Adenomyosis
6cm unilateral, mobile, tender adnexal mass Tubo-ovarian abscess
Postmenopausal vaginal bleeding Endometrial Ca - do endometrial biopsy
Postmenopausal adnexal mass Ovarian Ca
yellow creamy discharge chlamydia
primary amenorhhea = absence of menses by 16 yo
secondary amenorhhea = absence of menses x 6 mos (if h/o oligomenorrhea, 12 mos)
secondary amenorhhea: pt w/o 2nd sex characteristics = 2/2 gonad agenesis, pubertal delay, ovarian resistance syndrome, galactosemia, GnRH def, CNS mass lesion
secondary amenorhhea: pt w/ breast devt but no pubic hair = androgen insensitivity
secondary amenorhhea: normal 2nd sex characteristics = imperf hymen, transverse vaginal septum, mullerian dysgenesis
secondary amenorhhea: incomplete 2nd sex characteristics = HPA tumor, hypothyroid, hyperprolactinemia, premature ovar failure
secondary amenorrhea, not PG: Asherman syndrome (uterine synechiae) or PCOS
primary dysmenorrhea = painful menses 2/2 xs prostaglandin E2 secretion; onset near menarche, peaks in late teens
secondary dysmenorrhea = 2/2 other condition (endometriosis, adenomyosis, fibroids); usu >25 yo
Adenomyosis = implantation of endometrial tissue in myometrium; tender, symmetrically enlarged boggy uterus
PMS course 1-2 weeks before menses (during luteal phase) to 1-2 days post onset; sx-free during follicular phase
DUB causes usu increased anovulatory cycles; also PCOS, obesity, adrenal hyperplasia
endometriosis physio endomet glands & stroma outside endometrium, usu pelvis or on ovary (90%) or distant
uterine prolapse grading 0 (no descent) to 4 (thru hymen)
ovarian cysts in postmenopausal women are presumed to be: malignant until proven otherwise
OCPs are protective vs cancer of: endometrial, ovarian; not vs ovarian cysts
2 forms hereditary ovarian ca BOC (BR & ov); HNPCC
anterior vaginal prolapse includes: cystocele or cystourethrocele
apical vaginal prolapse includes: uretovaginal or vaginal vault prolapse
posterior vaginal prolapse includes: enterocele or rectocele
vulvar malig: rarest of Gyn ca; usu SCC
in utero exp to DES = risk of clear cell adenocarcinoma of vagina
vulvar malig comorbids: obesity, DM, HTN, arteriosclerosis; in younger F, also SMK & HPV
most VIN occur where: upper 1/3 of vagina; are Asx
fibroadenoma s/s round firm smooth discrete mobile nontender
Br Ca: estrogen receptors All invasive lobular and 2/3 of ductal ca are est rec pos
Br Ca typical presentations single nontender firm immobile mass; 45% in UOQ, 25% nipple
Br Ca increases risk of: endometrial ca, and vice versa
PID includes: acute salpingitis (gono or non), IUD pelvic cellulitis, TOA, pelvic abscess
Tabes dorsalis = in tertiary syphilis: loss of proprioception & vibratory sense, Argyll Robertson pupil (reacts to light but does not accommodate)
Breast exam: lymph nodes Axillary, supraclavicular, and infraclavicular lymph nodes
Polythelia = supernumerary nipples
Duct ectasia = widening of breast ducts; in pts near/past menopause; thick sticky discharge and/or itching around nipple
Fat necrosis Firm round lump; often d/t MVA or trauma
Most common breast complaint = mastalgia (benign breast pain); assoc w/hormonal changes; teens & 40s, usu ends w/menopause
Most frequent benign breast condition: Fibrocystic changes; grainy, palpable, small lumps; 30-50 y.o.; mobile, well defined; bilateral, UOQ; tender last half of cycle; dx w/bx
second most common benign breast condition: fibroadenoma; Hormone influenced abnormal growth of fibrous and ductal tissue; AA women; teens/20s; rapid growth during PG
fibroadenoma assessment discrete lump; firm, rubbery, round, mobile, non-tender, smooth, solitary; Usually UOQ, 1-5 cm
Peau d'orange is associated with: Inflammatory breast ca
Paget dz of breast: progression Begins in duct, spreads to nipple & areola; usu occurs w/ infiltrating ductal br ca; eczematous nipple lesion
Ductal BrCa types In Situ; Invasive; Inflammatory
Lobular BrCa types In situ; Invasive, predominantly in situ; Invasive
Nipple BrCa types Paget dz w/ intraductal ca; Paget dz w/ invasive ductal ca
BrCa RF BRCA 1&2; FH; prior abnormal br bx; age (60 yo ave onset); nulliparous, early menarche, late menopause, LT estrogen, delayed childbearing
Cause of characteristic odor in bacterial vaginosis Anaerobes
Bacterial vaginosis requires 3 of 4 criteria: Typical discharge, alkaline pH(5.0-5.5), positive "whiff" test, clue cells on wet prep
Bacterial vaginosis is not considered an __ STD
trichomonas vaginitis Sx/Sx Severe pruritus, malodorous (musky) discharge, dysuria, dyspareunia, may be asymptomatic, greenish-yellow/frothy discharge, petechiae or "strawberry markings on cervix
Atrophic vaginitis often masquerades as: Infection
atrophic vaginitis S/S Pruritis/burning, vaginal dryness, dyspareunia, possibly spotting, pale/thin vaginal mucosa, loss of vaginal rugation; women w/o menses (decreased estrogen)
Bilateral Bartholin abscess said to be associated with: Gonorrhea; unilateral also strep, e. coli, chlamydia, anaerobes
Organism associated with toxic shock syndrome S. aureus/endotoxins
Woman with flu like symptoms, during menses: possibly: Toxic shock syndrome
Fever >38.9 C, hypotension, diffuse erythroderma, desquamation, involvement of at least 3 organ systems = CDC case defn of: Toxic shock syndrome
Condyloma lata = secondary syphilis; Smooth, moist, flat
Pruritus, burning; cottage cheese discharge; dyspareunia Yeast vaginitis
Chronic Bartholin cyst may be mistaken for: acute abscess, esp perirectal abscess (more posterior)
TSS: Skin Erythroderma of skin / mucous mem; diffuse, red, sunburn-like rash; involves palms and soles; Conjunctival-scleral hemorrhage; later, pruritic maculopapular rash, desquamation
History of sexual intercourse with trauma increases the risk for what STD Hep B , and Hep C
3 causes of genital ulcers in US Herpes simplex virus, primary syphilis, chancroid
Herpes ulcers description: Painful, small, shallow, may have a clear exudate; secondary ulcers are smaller / less dramatic than primary lesions
Primary syphilis description: Solitary, painless, indurated, large/deep ulcer; local painless rubbery LAD
Agent responsible for chancroid H. ducreyi
Clinical presentation of lymphogranuloma venereum (LGV) Rectal ulceration or stricture, inguinal LAD
Etiology of LGV Chlamydia trachomatis
Clinical presentation of granuloma inguinale Chronic or recurrent ulcerative vulvitis. Donovan bodies on stained direct smear or biopsy of ulcer.
etiologic agent of granuloma inguinale Klebsiella granulomatis (formerly Calymmatobacterium granulomatis)
Etiologic agent of condyloma acuminata HPV 6 & 11
Clinical appearance of condyloma acuminata Papillomatous, white, cauliflower like
Chancroid causative organism Haemophilus ducreyi
Chancroid is most often a co-infection with what Herpes and or syphilis
Test for trichomonas Wet prep
Risk factors for cervical cancer Smoker, hormones, multiple sexual partners, sex before 18, HIV, poor SES, age, multiple pregnancies, chlamydia infection, diet low in fruit and vegetables
Effective methods to prevent cervical cancer Routine pap tests, avoid smoking, condom use, limit partners, HPV vaccine
Low risk HPV strains HPV-6, and HPV-11 (cause genital warts)
High risk strains of HPV HPV-16 & 18; 31, 33, 45
Offer __ testing for all patients evaluated for STIs HIV
Acute HIV symptoms Fever, mono-like illness, diarrhea
Which hepatitides are commonly sexually transmitted A, B, and C (especially B)
Males voiding within __ before urethral culture washes secretions away 1-2 hours
What is herpetic whitlow Herpes on the fingers (especially around the nail bed)
Characteristic of primary HSV outbreak 2-7 day course, systemic symptoms possible, local symptoms (painful), first outbreak is the worst
Precipitants of HSV recurrent outbreaks Sun, wind, trauma, fever, menses, stress
Multiple, vesicular, pruritic, painful, recurrent rash Herpes simplex
Gonorrhea s/s Vaginal discharge, abdominal pain, 50% asymptomatic
Female complications of gonorrhea PID, infertility, ectopic pregnancy, tubo-ovarian abscess, perihepatitis (Fitz-Hugh-Curtis syndrome), septic arthritis, vertical transmission, ophthalmia neonatorum
Common co-infxn with Gonorrhea: Chlamydia
Violin string adhesions between liver and parietal peritoneum, RUQ pain may be prominent symptom especially in young women, PID complication Fitz-Hugh-Curtis syndrome
Secondary syphilis usual duration: A few weeks
Clinical appearance of secondary syphilis Bilaterally symmetrical papulosquamous rash, condyloma, alopecia, denuded tongue, lymphadenopathy (firm, rubbery, non-tender)
Secondary syphilis is contagious by: Skin on skin contact (any portion of the body)
Latent syphilis = period after secondary stage, no clinical manifestation
Tertiary syphilis is __ infectious rarely
Etiology of syphilis (bug) Treponema pallidum spirochete
How many stages of syphilis are there 4
Acute syphilis: chancre develops on skin near infection site about __ after inoculation 3-6 weeks
Characteristic of secondary syphilis Maculopapular rash often on palms and soles, generalized LAD, typically lasts about 3 months
How long does the acute syphilitic chancre last 5-6 weeks
How long may syphilis remain inactive Up to 5 years
tertiary syphilis = End organ manifestation (CNS, cardiovascular, ocular); gummatous lesions of skin, bones, viscera
Single, heaped up or rolled edge, textbook case never painful Syphilitic chancre
Bilateral papulosquamous rash on palms and soles Secondary syphilis
What type of bacterium is chlamydia trachomatis Intracellular obligate bacteria
If you are treating a patient for chlamydia do you need to also treat for gonorrhea Not necessarily
Clinical course of chlamydia Asymptomatic or minor symptoms in majority, vaginal discharge, dysuria, mucopurulent cervicitis, acute urethral syndrome, pelvic pain, lower abdominal pain
Perinatal transmission of chlamydia can cause __ Ophthalmia neonatorum, pneumonia
Female chlamydia complications PID, infertility, ectopic pregnancy, perihepatitis, perinatal transmission
Common condition in which microorganisms spreads from lower genital tract, infect & inflame upper genital tract structures including endometrium, tubes, ovaries & peritoneum PID
Symptoms of PID Abd pain, dyspareunia, possibly fever/chills, possibly RUQ pain
Besides 3 CDC minimum criteria, additional criteria for PID dx Elevated oral temp (>101), abnormal cervical or vaginal discharge, elevated ESR, Elevated C-reactive protein, positive GC or chlamydia, increased WBC
Created by: duanea00