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