Describe hormone levels through the mestral cycle
- Follicular Phase: FSH stimulates follicle; Follicle releases estradial; estradiol causes endometrial proliferation; endometrium releases FSH and LH
- Luteal Phase: LH surge causes ovulation; corpus luteum secretes estradiol and progesterone; Estradiol inhibits FSH and LH
- Menses: Corpus Luteum dies if no sperm; estradiol and progesterone decrease; endometrium degrades
- Fertilization: Endometrium produces hCG which maintains corpus luteum which produces progesterone.
What is next step if patient has Atypical Squamous Cell of Uncertain Significance (ASCUS) on pap smear?
Repeat pap every 4 months for 2 years
What is the next step if patient has Atypical Glandular Cell of Uncertain Significance?
Culposcopy, direct biopsy, and Endocervical curettage (ECC)
What is the next step when a Low-grade Squamous Intraepithelial Lesion (LSIL) is found on pap?
Repeat pap-smear every 4 months for 2 years.
What is the next step when a High-grade Squamous Intraepithelial Lesion (HSIL) is found on pap?
Culposcopy, EndoCervical Curettage, and Direct Biopsy
Treatment for LSIL and HSIL?
- LSIL: No treatment, most will revert
- HSIL: Cryotherapy, Laser, Loop Electric Excision Procedure (LEEP), Large Loop Excision (LLETZ), or Cold Knife Conization.
Treatment for AGUS?
Cold Knife Conization (CKC) and D&C
Differential Diagnosis for Acute Pelvic Pain.
- Pregnancy: with Corpeus Luteum bleeding, ectopic, or abortion
- Gynecologic: PID, endometriosis, cyst rupture, adnexal torsion, Mittelschmertz, Leiomyoma torsion, tumor, primary dysmenorrhea
- GI: Appendicitis, IBD, IBS, Mesenteric Adenitis, Diverticulitis
- Urinary: UTI, Calculus
What steps should be taken in a patient with acute pelvic pain with positive HCG?
- 1. Vaginal Ultrasound
- 2. If positive: watch and look for other sources of pain
- 3. If negative and LMP was < 5 weeks: Quant HCG (if HCG > 2000 think ectopic)
- 4: . If neg and LMP was > 5 weeks th ink ectopic pregnancy
Treatment for ectopic pregnancy
- If patient is unstable: Lap
- If pt is stable: Methotrexate or salpingostomy (if tubal)
Differential Dx for Amenorrhea
- Androgen Insensitivity Syndrome (no uterus)
- Pituitary Adenoma (+ Prolactin)
- Exercise Induced
- Previous chemo
Steps to evaluate amenorrhea
- Give progesterone
- if she bleeds check LH
- if +: PCOS
- if nl: check prolactin and TSH
- if prolactin + and TSH nl: MRI
- if prolactin nl: think exercise, anorexia, etc
- if no bleeding check FSH
- if FSH +: premature menopause
- if FSH nl: MRI of brain (craniopharyngioma or other CNS tumor)
Differential Dx of breast mass in woman under 35
- Fibrocystic disease
- Mastitis / Abscess
- Fat Necrosis
Treatment for Fibrocystic Disease
- Under 35:Mostly just routine follow-up but
- Progesterone for 1 week at end of each month
- or Danazol can help symptoms
- Over 35: Aspiration of cyst (if bloody biopsy)
- Baseline Mammogram
Treatment for mastitis
- Continue breast feeding
- Cephalexin or Dicloxacillin or more severe
Differential for breast mass in woman over 35
- Fibrocystic disease
- Cystosarcoma Phylloides
- Fat necrosis
- Mastitis or Abscess
- Breast Cancer
Treatment for Fibroadenoma
- Under 35: Watch
- Over 35: Get Baseline mammogram
- If small, benign, woman is premenopausal, and no risk factors: watch
- Otherwise: Biopsy
What form of breast cancer often appears like a Fibroanenoma?
When should you be highly suspicious of a br malignancy?
New mass in post-menopausal woman.
Causes of dysfunctional uterine bleeding
- 1. Hormonal:
- a. Anovulation (puberty, perimenopause, anorexia, extreme stress, obesity, hypothyroidism, prolactinoma, PCOD)
- b. Breakthrough bleeding on combination or progesterone-only OCP
- 2. Anatomic and Physiologic:
- a. CA (cervical, endometrial, ovarian)
- b. Polyps (cervical, endometrial)
- c. Uterine fibroids (usually submucosal)
- d. Pregnancy (miscarriage, ectopic, mole, threatened)
- e. Ovulation
- f. Postpartum (retained placental tissue, atony)
- 3. Infectious:
- a. Cervicitis
- b. Endometritis
- c. PID
- 4. Hematologic: bleeding, diathesis (ITP, hemophilia)
Treatment for Endometriosis
- OCP first line
- Danazol and GRH agonists second line
- Surgery is also an option esp in severe cases
What is Ashermans syndrome?
Adhesions in the uterus caused by scarring
Medical treatment for infertility
- 1. Clomiphene
- 2. If hypoestrogen use human menopausal gonadotropin also
Organisms causing PID?
- N Gonorrhea
- E coli
- Actinomyces Israelii (IUD)
Rx for PID
- Outpatient: Cefoxitin or Ceftriaxone and Doxycycline
- Inpatient: Clindamycin and Gentamycin
Obese woman with hirsutism, amenorrhea, and infertility
Lab findings of PCOS
- + testosterone and androstenedione
- LH:FSH > 2:1
Rx for PCOS?
- Oral contraceptives or
- Cyclic progesterone
Cottage cheese vaginal discharge; pseudohyphae on KOH; hx of DM, abx, or pregnancy
Dysuria, positive culture or antibody test
Maloderous discharge, fishy smell on KOH, Clue cells
Multiple shallow painful ulcers, recurrence
Venereal warts, koilocytosis on pap smear
Venereal warts, koilocytosis on pap smear
Characteristic appearance of lesions, intracellular inclusions
Mucopurulent cervicitis; gram negative bugs
Crabs; itching, lice
Painless chancre, spirochete on dark field microscopy
Condyloma lata, maculopapular rash on palms, serology positive
Bugs swimming under microscope; pale green, frothy, watery discharge, strawberry cervix
Rx for candida albicans
Rx for Chlamydia trachomatis
- Doxycycline, azithromycin
- if pregnant: erythromycin or amoxicillin
- if non-compliant: 1 g azithromycin once
Rx for Gardnerella Vaginalis
Rx for Herpes
Acyclovir or Valacyclovir
Rx for N Gonorrhoeae
Ceftriaxone or Ciprofloxacin
Rx for Pediculosis
Rx for syphilis
Rx for Trichomonas vaginalis
Child with ambiguous genitalia
First think congenital adrenal hyperplasia (usually 21-hydroxylase deficiency)
8 year old boy who is starting puberty
Adrenal hyperplasia (21-hyroxylase deficiency)
Signs and symptoms of 21-hyroxylase deficiency
- 1. ambiguous genitals in XX; precocious puberty in boys
- 2. low Na
- 3. high K
- 4. low BP
- 5. high 17-hydroxyprogesterone
Rx for 21-hydroxylase deficiency
Corticosteroids and fluids
5 yo child with bunch of grapes protruding from vagina
Sarcoma Botryoides (rhabdomyosarcoma)
Rx for idiopathic precocious puberty
- gonadotropin-releasing hormone analogue
Woman with loss of urine during coughing, laughing, lifting, or standing (if severe). Treatment?
- Stress Incontinence
- Kegel Exercises
- Meds: ERT, Pseudoephedrine
Woman unable to reach bathroom in time regardless of amount in bladder, dribbling, urgency, frequency, nocturia; possible neuro symptoms, previous sx, or hematuria.
- Urge Incontinence
- Meds-anticholinergics, B agnoists, Sm muscle relaxants, and TCA's
- Bladder training
Woman with dribbling, having to run to bathroom, losing urine on coughing or laughing; remaining urine on PVR test. Hx of neuro disease possible.
- Overflow Incontinence
- 1. Rx-prazosin, terazosin, phenoxybenzamine; diazepam, dantrolene; bethanechol
- 2. Intermittent catheterization
Girl Tanner staging signs and exptected ages.
- Stage I: Prepubescent
- Stage II: (9-13) Br buds appear, areola enlarges; hair on labia
- Stage III: (10-14) elevation of breast, areola enlarges; hair on pubis, pits; acne
- Stage IV: (10.5-15) areola makes second mound; adult hair
- Stage V: (over 16) no further growth; areola same contour as breast; adult hair
7 yo girl, tanner stage 3, LH raises when GnRH given. Rx?
- Central precocious puberty
- Treat with GnRH and look for CNS lesion
Treatement for Dysfuntional Uterine Bleeding?
- Mild: Fe
- Moderate: Progestin
- Severe or Active bleed: Estrogen
Post menopausal woman with vulvar pruritis, dyscomfort, dyspareunia, dysuria, painfull defecation. On PE has porcelin white macules and papules and atrophic labia minora and clitoris. Dx? Next step? Rx?
- Dx: Lichen Sclerosis
- Next: biopsy to rule out SCC
- Rx: Topical steroids
16 yo girl comes in with amenorrhea, nl uterus and ovaries, no other pubic hair and can't smell. Dx?
Kallman's Syndrome (No GnRH secretion)
What are the tests for Syphillis?
- RPR or VDRL initially
- FTA ABS to confirm