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OB/GYN Midterm
OB/GYN Midterm Review
| Question | Answer |
|---|---|
| External genital organs | Vulva: external genital organs Consists of: mons pubis, labia majora, labia minora, hymen, clitoris, vestibule, urethra, Skene’s glands, Bartholin’s glands, vestibular bulbs |
| Labia Majora | cutaneous folds of adipose and fibrous tissue Outer surface covered in hair follicles Inner surface has sebaceous glands Both have sweat glands Homologous to scrotum in male Size related to fat content; atrophy after menopause |
| Labia Minora | cutaneous folds located between labia majora Dense connective tissue with erectile tissue and elastic fibers Sebaceous glands but no hair follicles (as are the breasts) Homologous to penile urethra Relatively more prominent in children and postmenopausal |
| Clitoris | a short, cylindrical erectile organ at superior portion of vestibule (area within labia minora) Distal 1/3rd is glans, contains many nerve endings Homologous to penis in male |
| Urethra | a conduit for urine from the urinary bladder to the vestibule Approximately 3.5 to 5 cm in length (male urethra is 17.5 cm in length Length is one of the factors in frequency of UTIs in females vs. males |
| Skene’s glands | branched, tubular glands adjacent to distal urethra Secrete lubrication Highly variable anatomy Homologous to prostate in males |
| Bartholin’s glands | vulvovaginal glands located beneath fascia, 4 and 8 o’clock Ducts open into a groove between labia minora and hymen Secrete mucus for vaginal lubrication Homologous to Cowper’s glands in men Both Bartholin’s and Skene’s glands may become infected |
| Introitus | vaginal opening (technically any opening into a cavity or canal) |
| Anus | rectal outlet or opening |
| Internal anatomy terms | Vagina, cervix, uterus, broad ligament, ovaries, fallopian tubes, bladder, rectum |
| Broad Ligament | a thin, double layer of peritoneum that envelopes Fallopian tubes, ovarian and round ligaments, uterus, ovarian and uterine arteries and veins |
| Is the bladder anterior to the uterus? | Yes |
| Cervix location | between vagina and uterus |
| Pre-pubertal changes | Adrenarche: maturation of adrenal cortex Ages 6-10 average Development of pubic and axillary hair Sweat composition changes (body odor) Skin oiliness and acne |
| Adrenarche | maturation of adrenal cortex |
| Pre- pubertal changes | Gonadarche: gradual maturation of interactions between GnRH (gonadotropin- releasing hormone), pituitary hormones, and ovaries Earliest gonadal changes in puberty Growth of gonads (ovaries and testes), increase in sex steroid hormones in response to pitui |
| Gonadarche | gradual maturation of interactions between GnRH (gonadotropin- releasing hormone), pituitary hormones, and ovaries. |
| Puberty | sequence of events by which a child reaches sexual maturity |
| Early puberty | decreased sensitivity of hypothalamus to sex hormones |
| Thelarchy | postnatal breast development 60% of the time this is the first stage of puberty Breast bud development occurs on average 2 years prior to menarche |
| Menarche | onset of menstruation, which is a bloody vaginal discharge that occurs as a result of endometrial shedding after ovulation, when fertilization has not occurred In US, average age 12.5 years Time influenced by environment, genetics, nutritional status |
| Menarche (2) | Critical weight, body fat % needed Obesity- earlier menarche Malnourishment or athletes- delayed menarche |
| Menarche (3) | During adolescence/ menarche, more common to have annovulatory cycles, leading to irregular or heavy bleeding It is possible for ovulation to occur prior to or after menarche |
| Menarche (4) | Ovaries secrete estrogen in response to pituitary hormones Pituitary hormones released by stimulation from GnRH from hypothalamus Effects: growth in stature, breast growth, increase in adipose tissue, pelvic widening |
| Hormones involved in Menstruation ~ GnRH... | gonadotropin- releasing hormone Released by hypothalamus in pulsatile manner Acts upon pituitary |
| Hormones involved in Menstruation ~ LH... | Leutinizing hormone Released by anterior pituitary Acts upon ovary: Tells theca cells to make steroid hormones Induces “leutinization” of granulosa cells– make progesterone |
| Hormones involved in Menstruation ~ FSH... | Follicle stimulating hormone Secreted by anterior pituitary Acts on granulosa cells of ovary to stimulate follicular growth |
| Hormones involved in Menstruation ~ Estrogen (E1/E2/E3)... | Secreted by ovarian follicle |
| Hormones involved in Menstruation ~ Progesterone... | Secreted by ovarian corpus luteum |
| Hypothalamic-pituitary- ovarian axis | Refers to interactions between hormones secreted by hypothalamus, pituitary, and ovaries Positive and negative feedback interactions Separate from HPA (adrenal) and HPT (thyroid) axes, although entire endocrine system interconnected |
| Mestruation Cycle and Blood Loss | Cyclic vaginal discharge of sloughed endometrium (lining of uterus) Normal cycle considered between 25-36 days Only 10-15% of women have exact 28 day cycle (moon cycle) Average of 130mL of blood loss Pads/tampons absorb approx. 20-30mL |
| Beginning of Menstrual Cycle ~ Follicular Phase | Follicular/ pre-ovulatory phase Variable in duration (average 14 days) First few days: slight increase in FSH, stimulates follicular growth One growing follicle recruited for ovulation, starts producing estrogen LH slowly rising |
| Follicular Phase (cont.) | Estrogen levels peak, produces positv feedback on LH LH levels surge, resulting in ovulation (the release of ovum from the follicle) Rising estrogen levels inhibit FSH Progesterone levels rise Endometrium thickens w/rising E levels Incr. in cervical mucus |
| Ovulatory phase | Begins with LH surge LH released in pulses for about 36-48 h Ovum released from follicle 16-32 h after LH surge External cervical os opens from 1 to 3mm in diameter Elastic cervical mucus forms “superhighway” for sperm |
| Luteal/ post-ovulatory phase | Follicle reorganizes, becomes corpus luteum Functional life of corpus luteum is 14 days, less variation in duration of this phase Corpus luteum secretes progesterone, which supports process of implantation of fertilized ovum FSH and LH levels are low |
| Luteal phase Effects of progesterone | Rise in basal body temperature Thickening, loss of elasticity of cervical mucus |
| Menopause | The cessation of menses due to decreased ovarian function for a period of 12 consecutive months In US, average age is 50 As ovaries age, decrease in their response to LH and FSH Perimenopause: shorter and irregular cycles, decrease in ovulation |
| Menopause (2) | Eventually ovaries stop producting E Lack of E feedback causes LH and FSH levels to rise Adrenal glands and fat cells can still produce small amount of estrogen (convert androgen hormones) Only slight decrease of testosterone production by ovaries |
| Premature menopause | ovarian failure due to unknown cause before the age of 40 |
| Artificial menopause | cessation of menses due to surgical removal of uterus (hysterectomy) and/or ovaries (oopherectomy), chemotherapy, or radiation to pelvis |
| Signs & Symptoms of Menopause | General: Hot flashes due to vasomotor instability, fatigue, insomnia Mental/emotional: irritability, decrease in concentration, anxiety, nervousness Cardiovascular: palpitations, tachycardia, increase for risk of stroke and heart disease Gastro: nause,con |
| Musculoskeletal signs of Menopause | joint pain, muscle pain, osteoporosis Loss of bone mass 1-2%/ year Highest risk for bone mass loss in Caucasians, slender or small frame body habitus, regular consumption of alcohol and tobacco, steroid use, levothyroxine (thyroid hormone replacement) us |
| Gynecology and Menopause | Thinning of vaginal mucosa and vulvar skin Loss of pelvic muscle tone, leading to incontinence, vaginitis, cystitis Change in vaginal flora Decrease in libido |
| Hormone replacement therapy in Menopause, rationale | to decrease risk of heart disease, stroke, osteoporosis; make women more comfortable if highly symptomatic |
| Hormone replacement therapy in Menopause | Estrogen must be given with progesterone or else there is an increased risk for endometrial cancer Combination therapy: Premarin/ Provera or Prempro Ok give unoppos E if hysterectomy HRT contraindicated in E- sensitive cancers, hist. of thromboembolism |
| Hormone replacement therapy (HRT) Benefits (according to studies) | decrease in osteoporosis, colorectal cancer, and heart disease (when taken early in the menopausal years) |
| Risks (according to other studies, such as by Women’s Health Initiative): HRT | heart disease, breast cancer, stroke, blood clots; risks according to these studies considered small. Also elevated CRP. |
| Forms of HRT | oral pills, transdermal patch, vaginal cream or suppository |
| Bio-identical hormone replacement therapy | Hormones synth in lab mimick exact struct as in body; suggest that this makes “natural” and proces bet by the body (no conclusive studies) Combined compound pharmacy; dose can be individualstudies done w synthesized hormone All exogenous hormones take a t |
| To HRT or not? | Decision is individual. Women need to be informed of ALL options. Depends on individual medical history, symptoms, comfort level, compliance (taking a pill is easier than boiling herbs and taking various nutritional supplements). We can provide sup |
| Abnormal Uterine Bleeding | Also known as Dysfunctional Uterine bleeding Excessive uterine bleeding with no demonstrable organic cause. Most frequently due to abnormalities of endocrine origin |
| Abnormal Bleeding Patterns: Menorrhagia | aka hypermenorrhea, is prolonged (over 7 days) or excessive (greater than 80mL) uterine bleeding occurring at regular intervals |
| Dysmenorrhea | painful menstruation |
| Metrorrhagia | Uterine bleeding occurring at irregular but frequent intervals, the amount being variable |
| Menometrorrhagia | Prolonged uterine bleeding occurring at irregular intervals. |
| Polymenorrhea | uterine bleeding occurring at regular intervals of less than 21 days |
| Oligomenorrhea | infrequent uterine bleeding; intervals between bleeding episodes vary from 35 days to 6 months |
| Abnormal Bleeding includes | Menses that are too frequent (more often than every 26 d) Heavy periods (esp. if with egg-sized clots) Any bleeding that occurs at the wrong time, including spotting Any bleeding lasting longer than 7 days Extremely light periods or no periods at all |
| Organic causes of abnormal bleeding | Systemic disease Disorders of blood coagulation, e.g. von Willebrand’s disease, leukemia, sepsis, Idiopathic thrombocytopenic purpurea Hypothyroidism > hyperthyroidism Liver cirrhosis |
| Reproductive Tract Diseases | Abortion (threatened, incomplete, or missed) Ectopic pregnancy Malignancies of the reproductive tract Endometrial hyperplasia Cervical lesions (erosions, polyps, cervicitis) Myomas (uterine fibroid) Traumatic vaginal lesions Foreign bodies (IUD) |
| Iatrogenic causes of bleeding | Oral/ injectable steroids (birth control pill, HRT) Tranquilizers/ psychotropic drugs Always ask about medications!!!! |
| Dysfunctional Uterine Bleeding | Once organic, systemic and iatrogenic causes are ruled out, then the diagnosis of dysfunctional uterine bleeding (DUB) can be made Most common at either end of reproductive age spectrum Actual cause not completely clear |
| Annovulatory DUB | Continuous estradiol production without corpus luteum formation/ progesterone production Estrogen stimulates endometrial proliferation; endometrium may outgrow blood supply, necrose, and slough off irregularly |
| Ovulatory DUB | Most commonly after adolescent years, prior perimenopausal years Is heavy menses in women who ovulate &who don't have a coagulopathy, uterine abnormality Circulat hormon level aresame as thos in wom w/o DUB Decreased prostaglandin synthesis&endometrial p |
| Diagnosis of Dysfunctional Bleeding | Detailed history (easy bruising/ bleed, meds, contraceptimethods, symptoms pregnancy&systemic diseases, pain? Labs: hemoglo, serum iron, serum ferritin, TSH, beta-HCG, liver function, PAP smear, CBC, FSH, LH, STD test Imaging: hysteroscopy, pelvic ultraso |
| Managing Uterine Bleeding | Estrogen: rapid growth endomet over denuded&raw endo (in high doses stops acute bleed) Progest: added to estr aft bleed stopped; organizes endo so that sloughing off process (when horm are stop) is organized, less heavy Bcontrol: long-t manage Mirena: pro |
| Managing Uterine Bleeding w/Non-steroidal antiinflammatory drugs | reduce menstrual blood loss in women who ovulate (inhibit prostaglandins) by 20-50% |
| Surgical therapy for dysfunctional uterine bleeding | ilatation and Curettage Endometrial Ablation: laser photovaporization of endometrium (may cause scarring, adhesions, uterine contraction) Hysterectomy (only if DUB persistent) |
| Menorrhagia Therapy | Birth control pills: tend to reduce heaviness of flow If heavy flow may result in anemia; decreasing heaviness may restore normal iron levels |
| Iron replacement therapy | Pills nausea, consitpation Need to be taken with food and with something acidic (OJ) May be found in liquid preparations that are easier to assimilate Standard Process: Ferrum food (whole food based iron) Homeopathic: Ferrum phos 6X cell salt |
| Iron replacement therapy | Pills nausea, consitpation Need to be taken with food and with something acidic (OJ) May be found in liquid preparations that are easier to assimilate Standard Process: Ferrum food (whole food based iron) Homeopathic: Ferrum phos 6X cell salt |
| Foods high in iron | Molasses Dried figs Meat Liver Lentils Dark leafy greens (need to be cooked) |
| Inhibit absorption of iron | Oxalates Tannins Phytates Carbonate Hypochlorhydria Infection or inflammation Other divalent minerals (Ca2+, Mg2+, etc.) |
| Metrorrhagia | If periods too freqbut reg, insuff ovarian prod of progest may be respon If periods inconsist, annovulatory bleeding may be respo If spotting in bet regular periods, suspect mech problem such as fibroids or polyps Need ultrasound or sonohysterography (fl |
| Irregular periods | Irregular but otherwise “normal”, low-dose birth control pill helps establish regularity If flow is inconsistent (sometimes heavy or light), cycles are likely annovulatory; birth control pill used to establish regularity Screen for PCOS, thyroid disease |
| Constant bleeding | Uterine lining denuded; need high dose estrog than that available in BCP to restore endometrial lining. It is usually given PO or IV until bleeding stops Progesterone given when bleeding stops to organize endometrium Long-t BCP for manag Screen for anemia |
| Natural management of DUB | Tissue tonification– bleeding may be sign of poor tissue tone of mucus membranes, uterus Stress reduction– endocrine sys advers aff by stress, mis-t of release of horm Reduce inflam– omega-3 Correct nutritional def: Vit A, B complex, C, K, bioflavonoids |
| Botanical management approaches of DUB | Chaste tree/ Vitex agnus castus: balance est-prog rat to norm and reg men cycle Ginger/ Zingiber officinale: anti-inflamatory (inhibits prost and leuko synth), helps red menflow Astring herbs: Sheperd’s purse/ Capsella bursa pastoris, Yarrow/ Achillea mil |
| Natural management approaches to DUB | Botanical uterine tonics: Dong quai, Raspberry leaves Uterine stim: Vitex, Achillea, Squaw vine/Mitchella repens, Blue cohosh/ Caulophyllum thalictroides Stop semi-acute blood loss: Cinnamon, Fleabane/ Erigeron spp. (tincture and essential oil), Shepherd’ |
| Acupoints to regulate bleeding | Sp-1: strengthens Sp function of keeping blood in vessels; esp. good for uterine bleeding BL-17, Sp-10, K-8, Lr-1 |
| Herbs to stop bleeding? | Pao Jiang (fried ginger), Ai ye San qi, Qian cao gen, Pu huang Da ji, Xiao ji |
| Amenorrhea | No menstrual flow for at least 6 months Physiologic: during pregnancy or post-partum (eg during lactation) Pathologic: due to endocrine, genetic, and/or anatomic disorders Failure to menstruate is a symptom of these disorders; ameno not a final diagnosis |
| Amenorrhea (2) | Lack of menstrual flow in it of itself is not harmful to the body If woman is not pregnant or breastfeeding, amenorrhea is NOT normal and underlying cause must be investigated |
| Primary amenorrhea | absence of menses in a woman who has never menstruated by the age of 16.5 years |
| Secondary amenorrhea | absence of menses for an arbitrary time period, usually longer than 6- 12 months |
| Primary amenorrhea characteristics | Various etiologies Etiologies grouped on the basis of whether secondary sex characteristics (breasts) and female internal genitalia (uterus) are present or absent |
| Primay amenorrhea causes | Breasts Absent/ Uterus Present Gonadal Failure: Most common cause of primary amenorrhea Chromosomal disorders: Two X chromosomes needed for ovarian development Turner syndrome (45,X) 46,X, abnormal X Mosaicism (X/ XX; X/XX/XXX) |
| Primary amenorrhea causes... hypothalamic failure | Breasts absent/ uterus present Hypothalamic failure secondary to inadequate GnRH release Neurotransmitter defect: not enough GnRH is secreted Kallman syndrome: not enough GnRH is synthesized Congenital anatomic defect in CNS CNS neoplasm |
| Primary amenorrhea causes... pituitary failure | Breasts absent/ uterus present Pituitary Failure Isolated gonadotrophin insufficiency (thalassemia major, retinitis pigmentosa) Pituitary neoplasia Mumps, encephalitis Newborn kernicterus Prepubertal hypothyroidism |
| Primary amenorrhea... genetically transmitted disorder | Genetically transmitted disorder Absence of androgen receptor synthesis or action XY karyotype; normally functioning male gonads, normal levels of testosterone Lack of receptors on target organs so there is a lack of male differentiation of external and i |
| Primary amenorrhea... congenital absence of uterus | Second most frequent cause of primary amenorrhea Occurs in 1 in 4000-5000 female births Also may have congenital kidney and cardiac defects |
| Primary amenorrhea... breast development & uterus present | Breast development/ Uterus present Second largest category (approx. 1/3) Due to problems in: Hypothalamus Pituitary Ovaries Uterus |
| Primary amenorrhea...diagnosis | Labs: estradiol, FSH, progesterone, serum prolactin Chromosomal testing Imaging: cranial CT scan or MRI |
| Primary amenorrhea... treatment | Hormone replacement Pulsatile GnRH for fertility if disorder of CNS-hypothalamus- pituitary Removal of gonads in XY androgen resistance due to malignant potential |
| Primary amenorrhea... facts | Likely already diagnosed and worked up by the time they get to your office Acupuncture and herbs will not restore menses if no uterus present! May help with secondary symptoms |
| Secondary amenorrhea... uterine causes | Intrauterine adhes Adhesion: post-inflammatory scar tissues Most com due to endometrial curettage Evac of live or dead fetus by mech means Postpartum or post abortal curettage Diagnostic curettage (D&C) Severe endometritis or fibrosis following myectomy o |
| Secondary amenorrhea... CNS hypothalamic causes | Hypothalamic lesions (due to neoplasm or sequelae of infections) Drugs: antihypertensives, phenothiazine derivatives, postpill amenorrhea (no longer than 6 months) Stress Strenuous exercise Weight loss |
| Secondary amenorrhea... CNS hypothalamic causes (2) | |
| Primary amenorrhea... absent breast and uterine development | Rare Male karyotype Due to enzyme deficiencies |
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