1
Q
Name most common etiologic causes of 2e amenorrhea (2)
A
- Ovarian causes—40%
- Hypothalamic causes—35%
2
Q
Describe tx: Primary Ovarian Insufficiency (3)
A
- Patient education (diagnosis)
- Hormone replacement therapy until age of menopause
- Maintain age-appropriate bone density
- Cardiovascular health
- Yearly F/U of HRT, TSH levels; bone scan as needed
3
Q
Describe tx: Primary dysmenorrhea (3)
A
- NSAIDs
- Hormonal suppression (OCPs, Depo-Provera, Mirena)
- Nonpharmacologic (i.e., physical exercise, topical heat, high- frequency transcutaneous electrical nerve stimulation (TENS))
4
Q
A
5
Q
Describe steps for primary amenorrhea (3)
A
- B-hcg
- Pelvic ultrasound
- Serum levels of FSH
6
Q
In amenorrhea, if present + high FSH, think of what? (2)
A
- Gonadal dysgenesis: Turner Syndrome, Swyer syndrome
- 17 alpha hydroxylase deficiency
7
Q
Describe: Gonadal dysgenesis (3)
A
- Present streak gonads, functionless, fribrous tissue, can’t respond to FSH stimulation
- Can’t produce sex hormones -> no 2e female sex characteristics
- Associated with Turner’s syndrome and Swyer syndrome
8
Q
How to dx: Turner’s syndrome
A
- Karyotype: 45X or Mosaic (45X + 46XX OR 45X + 46XY)
9
Q
Describe presentation: Turner’s syndrome (6)
A
- Short stature
- Widely spaced nipples
- Low-set ears
- Wide or webbed neck
- Broad chest
- Arms turn outward
10
Q
Describe tx: Turner’s syndrome (3)
A
- Streak gonads surgically removed
- Estrogen therapy (low doses) + progesterone (2 yrs after) 10 days per month to induce menstrual bleeding
- Growth hormone therapy
11
Q
A
12
Q
Describe lab: 17 alpha hydroxylase defiency (3)
A
- high progesterone
- high deoxycorticosterone
- serum 17-alpha-hydroprogesterone < 0.2 ng/ml
13
Q
Describe tx: 17 alpha hydroxylase defiency (3)
A
- Exogenous glucocorticoid replacement therapy (hydrocortisone or dexamethasone)
- Mineralocorticoid receptor blockade (ex: spironolactone)
- Low-dose estrogen + progestin (2 yrs later)
14
Q
DDX of uterus on pelvic ultrasound + low FSH (2)
A
hypothalamic or pituitary disorder
- congenital GnRH deficiency (ex: Kallman syndrome)
- constitutional delay of puberty
15
Q
Name DDX of anatomic abnormality in pelvic ultrasound (for amenorrhea) (2)
A
- Outflow tract obstruction -> surgery
- Transverse septum (inside vagina)
- Imperforate hymen
- Absent uterus
16
Q
Name DDX: Absent uterus (3)
A
- Mullerian agenesis (46XX - genetically female)
- Complete androgen insensitivity syndrome (46 XY)
- 5-alpha reductase deficiency (46 XY)
17
Q
How to differenciate DDX: Absent uterus (2)
A
Karyotype + serum testosterone
- Mullerian agenesis (46XX - genetically female)
- Complete androgen insensitivity syndrome (46 XY)
- 5-alpha reductase deficiency (46 XY)
18
Q
Describe sx: Mullerian agenesis (5)
A
- 46XX - genetically female
- Short vagina
- absent/rudimentary and obstructed uterus
- ovaries N, breast N
- Development/FSH/Testosterone
19
Q
Describe tx: Mullerian agenesis (3)
A
- Psychological counceling
- Surgical creation of vagina + vaginal dilators
- Possible to have children via assisted reproduction techniques (egg harvesting, in vitro fertilization, surrogate pregnancy) OR uterus transplantation
20
Q
A
21
Q
Describe: Complete androgen insensitivity syndrome (5)
A
- Defective receptor, Testosterone N
- No tissues response:
- Female external genatalia
- Sparce body hair
- Almost no pubertal acne
- Well-developed breats
22
Q
Describe management: Complete androgen insensitivity syndrome (3)
A
- Testes in abdomen/pelvis/inguinal canal -> high risk of cancer -> surgical removal after puberty
- Counceling
- Vaginal surgery/dilation
23
Q
Describe: 5-alpha reductase deficiency (3)
A
- Do not undergo DHT-dependent masculinization during fetal development
- at birth: female or ambiguous external genitalia
- at puberty: testosterone levels rise ++ -> male-pattern hair growth, acne, muscle mass, deeper voice
24
Q
Describe management: 5-alpha reductase deficiency (2)
A
- Counceling
- DHT therapy (if male) or estrogen therapy (if female)
25
Name initial lab studies for secondary amenorrhea (5)
* FSH
* Prolactin
* Estradiol
* TSH
* If signs of virilization -\> testosterone
26
Descrive tx, dx: Prolactinoma (2)
* IRM
* Tx: Cabergoline (Dopamine agonist) -\> inhibits prolactine secretion
27
Describe signs and tx: Polycystic ovarian syndrome (PCOS) (6)
* Lab: Testosterone \> 60 ng/dL + Signs of virilization
* Oligomenorrhea or amenorrhea
* Obesity, insulin resistance -\> metformin therapy, weight loss
* Hyperandrogenism -\> OCP (if no desire to be pregnant), ideally progestin w/ antiandrogen properties (ex: **drospirenone**) -
* spironolactone if OCP C-I
* If desire pregnancy -\> **clomiphene citrate**
* If androgen levels +++ \> 150 ng/dL -\> CT Scan abdomen and pelvis to look for androgen secreting tumours
28
In secondary amenorrhea, what to think of if normal TSH/prolactin/androgen and:
* High FSH + low estradiol in female \< 40 years old
Primary ovarian failure
29
Describe sx: Primary ovarian failure (2)
* Hot flashes
* Vaginal dryness
30
Describe tx: Primary ovarian failure (2)
Tx: Hormone replacement therapy
* Estrogen: to decrease risk osteoporosis and Cardiovasc disease
* Progesterone: to decrease endometrial hyperplasia and cancer
31
In secondary amenorrhea, what to think of if normal TSH/prolactin/androgen and:
* Low FSH + low estradiol in female
* Functional hypothalamic amenorrhea
* Systemic illness (ex: DB1, celiac disease)
* Large tumor that compresses FSH and LH secreting neurones -\> IRM
* Pituitary gland
* CNS
32
In secondary amenorrhea, what to think of if normal TSH/prolactin/androgen and:
* FSH and estradiol normal
Uterus is not responding
* Asherman syndrome: scar tissue in uterine cavity
33
Describe dx: Asherman syndrome (2)
* golden standard: hysteroscope
* 10-day medroxyprogesterone test to access uterine function
* if bleeding -\> healthy uterus
* if no bleeding -\> scar tissue in uterine cavity -\> hysterosalpingogram or hysteroscopy
34
What's the tx of primary dysmenorrhea (2)
* Non pharmacological treatment:
* Reassurance
* Topical heat
* Physical exercise
* • High-frequency TENS
* OCP or NSAIDs
35
36
What's the tx of leiomyomas (2)
Myomectomy or uterine artery embolization
37
Describe tx: PMS and PMDD
* Non pharmacologic
* Patient education
* Diet: avoid; Na+, simple sugars, caffeine, alcohol
* Supplements—CaCO3, Mg2+, Vit E
* Exercise
* Psychotherapy (CBT)
* Relaxation therapy
* Pharmacological
* NSAIDS (ex: naproxen)
* SSRIs (citalopram, fluoxetine, sertraline)
* Combined OCPs
* Spironolactone (during luteal phase only)
38
Name C-I for OCPs (14)
* \< 6 wk postpartum if breast-feeding
* Breast CA (current)
* Smoker \> 35 y.o. (\> 15 cigarette/d)
* Uncontrolled HTN (systolic \> 160 mm Hg or diastolic \> 100 mm Hg
* Venous thromboembolism (current or Hx)
* Ischemic heart disease
* Valvular heart disease (PulmHTN, A b, Hx of SBE)
* Diabetes with retinopathy/nephropathy/neuropathy
* Migraine headaches with focal neurologic Sx
* Severe cirrhoris
* Liver tumor (adenoma or hepatoma)
* Undiagnosed vaginal bleeding
* Known thrombophilia
* Known or suspected pregnancy
39
Name progestin only OCPs (2)
* Progestin-only pill
* Depo-Provera injection
40
Name side effects: OCP (5)
Most resolve in first 3 cycles:
* Breast tenderness
* Nausea
* Irregular bleeding
* Chloasma
* No evidence for weight gain and/ or mood Ds
41
Name criterias for Good Candidates for p Only (8)
* CI or sensitivity to E
* \> 35 yr and smoker
* Migraine headaches
* Breast-feeding
* Endometriosis
* Sickle cell disease
* Anticonvulsant Rx
* Difficulty complying with daily pill (for DMPA)
42
Name side effects: Copper IUD (3)
* Pelvic pain
* ↑ Menstrual ow
* Spotting
43
Name side effects: Levonorgestrel-releasing intrauterine system (LNG-IUS) (4)
* Pelvic pain
* Depression, headache, acne, breast tenderness (maximal in rst 3 mo of use)
* ↑ Menstrual flow or spotting in first few months then ↓ bleeding
* Functional cysts
44
Name benefits: Levonorgestrel-releasing intrauterine system (LNG-IUS) (4)
* Decreased menstrual flow (in over 75% of patients)
* Decreased endometrial CA
* Improved dysmenorrhea
* Prevents endometrial hyperplasia in women taking tamoxifen
45
Name: Emergency Contraceptions (EC) (3)
* **Plan B** (up to 5 days): Levonorgestrel-only method (2 doses 12h apart)
* **Yuzpe Method** (up to 5 days): Oral administration of 2 doses of 100 mg EE and 500 mg levonorgestrel 12 h apart
* **Postcoital Insertion of Copper IUD**: Can be placed up to 7 d after intercourse to prevent conception and left in place to provide ongoing contraception
46
Describe management: Missed abortion (3)
* D&C
* Misoprostol
* Expectant managemen
47
Describe: Complete abortion (1)
Spontaneous expulsion of all fetal and placental tissue before 20 wk of gestation
48
Describe management: Complete abortion (2)
* Ensure hemodynamic stability
* Supportive
49
Describe management: Incomplete abortion (3)
* D&C
* Misoprostol
Incomplete expulsion of the products of conception before 20 wk of gestation
50
Describe management: Threatened abortion (1)
Expectant management
51
Describe management: Inevitable abortion (3)
* D&C
* Misoprostol
* Expectant management
52
Differenciate:
* Missed abortion
* Complete abortion
* Incomplete abortion
* **Missed abortion**:
* Death of the fetus occurring in utero with retention of the pregnancy
* **Complete abortion**:
* Spontaneous expulsion of all fetal and placental tissue before 20 wk of gestation
* **Incomplete abortion**:
* Incomplete expulsion of the products of conception before 20 wk of gestation
53
Differenciate:
* Threatened abortion
* Inevitable abortion
* Threatened abortion:
* **Bleeding** occurring during the first 20 wk of gestation **without** the **passage** of tissue or cervical dilation.
* In the presence of fetal cardiac activity, a high proportion of pregnancies continue.
* Inevitable abortion:
* **Bleeding** ± ROM
* Cramping
* **Dilation of the cervix**
54
Describe: Septic abortion (1)
* Infection of retained products of conception by S. aureus, GN bacilli, or gram positive cocci.
55
Describe: Lab investigations for recurrent miscarriages
TIE GAME
* Thrombophilic
* Immunologic: Antiphospholipid antibodies
* Endocrine: Fasting glucose or Hb(A1c), TSH (hypothyroidism), PRL
* Genetic/chromosomal: Cytogenetic analysis of both partner
* Anatomic: Hysteroscopy, Hysterosalpingography
* 6. Environmental/toxicologic
56
Name methods of abortion (5)
First trimester:
* Vacuum curettage
* Misoprostol
Second trimesteR:
* D&E
* Labor induction
* Oxytocin
57
Describe labs of menopause (4)
* ↑ Serum FSH
* ↑ Serum LH
* ↓ Serum estradiol
* ↑ Vaginal pH \> 6
58
Name: Indication for Spine XR in Postmenopausal women (3)
* Historic height loss \> 6cm
* Prospective height loss \> 2 cm (↑kyphosis)
* Acute, incapacitating back pain: to R/O vertebral #
59
Describe the management of Vasomotor Sx in menopause (5)
Resolves within 5 yr
* Reassurance and lifestyle Ds: Use fans to keep cool, dress in layers, quit smoking, exercise, weight loss if overweight, avoid hot food, caffeine, and EtOH
* Alternative medicine: Evidence lacking for long-term safety/efficacy for black cohosh, dietary soy, phytoestrogens clover, Vit E, kava, evening primrose oil, Chinese herbs
* **Nonhormonal Rx: venlafaxine/SSRIs, gabapentin, clonidine, bellergal**
* **Nonestrogenic hormonal Rx: Ps**
* **Systemic HRT: Estrogen therapy (ET), estrogen/progesterone therapy (EPT)**
60
Describe the management of Urogenital Sx in menopause (3)
Generally, Worsen with age
* Reassurance, patient education, and smoking cessation
* Vaginal moisturizer (polycarbophil gel/Replens)
* **Local ET: intravaginal E is the Rx of choice for isolated vaginal Sx (e.g., Vagifem).** At recommended dose/frequency do not need to add P
61
Describe the management of Osteoporosis Sx in menopause (7)
Generally Worsens with age
* Patient education: exercise, healthy diet, and smoking cessation
* Osteoporosis RF assessment
* **Vit D (800 IU/d) and Ca2+ supplementation**
* **Bisphosphonates (alendronate, risedronate)**
* **Selective estrogen receptor modulators (SERMs)**
* **Calcitonin**: approved for Rx, not prevention of osteoporosis
* **E**
62
Name C-I to estrogen therapy (4)
CULT
* Cancer (breast or uterine)
* Undx vaginal bleeding
* Liver disease (acute)
* Thromboembolic disease (active)
63
Name C-I to progesterone therapy (4)
PUB
* Pregnancy
* Undx vaginal bleeding
* Breast CA
64
Describe presentation: Bacterial vaginosis (5)
* odor
* Amsel criteria (3 of 4)
* Thin homogeneous vaginal discharge
* Clue cells on N/S wet mount or Gram stain
* Positive Whiff test on KOH wet mount
* Vaginal pH \> 4.5
65
Describe tx: Bacterial vaginosis (2)
* Metronidazole
* Clindamycin
66
Describe: Vaginal candidiasis (6)
* pruritus
* edema, fissures excoriations, dysuria
* thick flocculent white discharge
* DX criteria:
* Normal vaginal pH (4–4.5)
* Hyphae and buds on saline wet mount (yeast)
* Positive yeast culture from the vagina
67
Describe tx: Vaginal candidiasis (2)
* Fluconazole
* Clotrimazole
68
Describe: Vaginal trichomoniasis (6)
* Dyspareunia, pruritus
* « Strawberry cervix »
* Dx criteria:
* Trichomonas (motile agellum) seen on N/S wet mount
* High number of Polymorphonuclear leukocytes (PMNs) on saline microscopy
* Positive culture
* Vaginal pH 5 – 6
69
Describe tx: Vaginal trichomoniasis (2)
* Metronidazole
* Tx partner
70
Describe tx: Gonorrhea (5)
* **(Cefixime** or **Ceftriaxone) + (Azithromycin or** **Doxycycline)**
* Alternative: Azithromycin or Spectinomycin
## Footnote
**Co-treatment for chlamydia**
71
Describe tx: Chlamydia (3)
* **Doxycycline**
* **Azithromycin**
* Alternative: Erythromycin
72
Name indications for Repeat screening for Gonorrhea (2)
* **All cases 6 mo post-Rx**
* Test of cure with culture **3 to 7 d after** initiation of treatment when:
* **gono pharyngeal infx**
* tx with nonrec regimen
* suspected tx failure
* uncertain compliance
* reexposure to untreated partner
* **PID or disseminated infx**
* **pregnancy**
73
Name indications for repeat testing of C.TRACHOMATIS (2)
* **All cases 6 mo post-Rx**
* **Test of cure in 3 to 4 wk recommended when:**
* Uncertain compliance
* non recommended regimen
* **Pregnancy**
74
Describe: Syphilis (4)
* 1°:
* **painless chancre** (genital ulcer), regional LAD
* Resolves in 2-8 wk
* 2°:
* **symmetric maculopapular rash (palms and soles**)
* fever, malaise, LAD, mucous lesions, condyloma lata, alopecia, meningitis, headaches, uveitis, retinitis
* Latent: axp
* 3°: aortic aneurysm, aortic regurgitation, coronary artery ostial stenosis
* **Neurosyphilis** (form of 3°): Argyll-Robertson pupil
* **Gumma** (form of 3°): tissue destruction in any organ.
75
Describe tx: Syphilis (3)
* 1°, 2°, early latent: Benzathine Penicillin G, Doxycycline
* Neurosyphilis: Penicillin G
* Gumma: Benzathine Penicillin G
76
Describe tx: Herpes (2)
* Acyclovir
* Famciclovir
77
Describe: Chancroid (3)
* **Painful** genital ulcers with granulomatous bases
* **H. ducreyi**
* May progress to inguinal ulcers, painful inguinal LAD
78
Describe tx: Chancroid (4)
* Ciprofloxacin
* Eryhtromycin
* Azithromycin
* Ceftriaxone
## Footnote
**Must empirically treat all individuals with sexual exposure in the last 2 wk from onset**
79
Describe: HPV Condyloma Acuminata (2)
* Frequently asx
* Lesion: external genital warts (condyloma acuminata)—multifocal **cauli ower-like exophytic fronds** → ± pruritus or local discharge
80
Describe tx: HPV Condyloma Acuminata (7)
* Patient applied:
* **Imiquimod**
* **Podophyllotoxin**
* Provider-based:
* **Cryotherapy**
* **Bi- or trichloroacetic acid**
* **CO2 laser ablation, excision**
* Extensive or resistant lesions:
* Excision with electrosurgery
* CO2 laser removal
81
Describe: PID Minimum Triad
Lower abdo pain + one of the following:
* Adnexal tenderness
* Cervical motion tenderness
* Utrine tenderness
82
Describe: Fitz-Hugh-Curtis Syndrome
Perihepatitis resulting in adhesions between the liver capsule and the abdo wall. Perihepatitis resolves with Rx of PID.
83
Describe inpatient tx: PID (4)
* Cefotetan + doxycycline then continue with doxycycline
* Cefoxitin + doxycycline, then continue with doxycycline
* Clindamycin + gentamicin then doxycycline or clindamycin
Note: consider adding metronidazole
84
85
Describe outpatient tx: PID (4)
* Ceftriaxone + (doxycycline or azithromycin)
* Cefixime + (doxycycline or azithromycin)
* Levofloxacin
Note: consider adding metronidazole
86
Name gold standard dx: PID
Laparoscopy
87
Describe population screening (3)
* There are slight differences among each province
* Should begin within 3 yr of initiating sexual activity or over age 21, whichever is later
* Should be conducted annually until three consecutive negative Pap tests
88
Describe: Approach to cervical CA screening (Figure)
* Unsatisfactory/inadequate sample
* Normal
* Benign atypia (infection, reactive Ds)
* Atypical Squamous Cells - Uncertain Significance (ASCUS)
* Low-grade Squamous Intraepithelial Lesion (LSIL)
* Colposcopy
* Atypical Glandular Cells of Uncertain Signifi- cance (AGUS)
* High-grade Squamous Intraepithelial Lesion (HSIL)
* Invasive cervical cancer (rarely)
* Carcinoma in situ (CIS)
* Atypical Squamous Cells - Possible HSIL (ASC-H)
* Cervical Intraepithelial Neoplasia (CIN)
\_\_\_\_\_\_\_
* If these Pap tests are normal → continue screening q2–3 yr
* Should continue until the age of 69 yr, if there has been adequate screening over the past 10 yr
* If there has been no Pap smear for 5 yr, begin annual Pap tests until three consecutive negative Pap tests, then should continue q2–3 yr
* Discontinue screening at age 70 if \> 3 normal Pap tests in the last 10 yr
89
Describe HPV screening for:
* HIV/immunocompromised
* Total hysterectomy
* Subtotal hysterectomy
* Pregnancy
* Women who have sex with women
* HIV/immunocompromised: annual screening.
* Discontinue screening for women who have undergone a total hysterectomy for benign reasons and no Hx of cervical dysplasia or HPV.
* Subtotal hysterectomy (i.e., cervix intact): continue routine screening.
* Screening frequency in pregnancy is the same as in nonpregnant women.
* Women who have sex with women should follow the same screening protocol as women who have sex with men.
90
Describe staging and rx of cervical CA
91
Describe: Approach to the management of ovarian cysts (Figure)
92
Describe: Approach to the management of uterine leiomyomas (Figure)
93
Describe: Characteristics of benign vers s ma ignant ovarian masses
94
Name first choice imagerie for pelvic masses (1)
U/S
95
Name lab markers for ovarian masses (4)
* **CA-125 (N \< 35 U/mL): ovarian tumors**
* AFP (N \< 5.4 ng/mL): Germ cell tumors (endodermal sinus), dermoids, pregnancy, Hepatocellular Carcinoma
* LDH (N \< 250 U/L): Dysgerminomas
* hCG (N \< 5 mlU/mL): germ cell tumors GTD (choriocarcinoma), pregnancy, marijuana
96
Describe PHARMACO tx of chronic pelvic pain (5)
* **1. Analgesics:**
* First line - NSAIDs (ibuprofen, ASA, naproxen)
* Second-line - opioids (avoid long-term use)
* **2. Combined OCPs**
* **3. GnRH agonists (i.e., leuprolide/Lupron)** ± add back Estrogen
* **4. Progestins** (i.e., MPA suspension/Depo Provera/Visanne)
* Adjuncts:
* ± SSRIs (fluoxetine, paroxetine, or sertraline)
* ± Neuro modulators (gabapentin, amitriptyline or nortriptyline)
* ± Trigger point injections
* ± Peripheral nerve blocks
97
Describe SURGERY tx of chronic pelvic pain (5)
If poor response to other tx
1. Laparoscopic laser ablation
2. Laparoscopic adhesiolysis
3. Presacral neurectomy (superior hypogastric plexus excision)
98
Name common locations of ectopic pregnancy (3)
* **Ampullary**
* Isthmic
* Fimbrial
99
Describe the approach to ectopic pregnancy (Figure)
100
Describe the management of ectopic pregnancy (2)
* Methotrexate (MTX)
* Monitoring: serial (weekly) b-hCG levels until undetectable
* Laparoscopic surgery or laparotomy. Indications:
* Failed or contraindication to MTX Rx
* Previous EP in same fallopian tube
101
Name C-I to methotrexate (5)
* Breast-feeding
* Chronic liver disease (alcoholism, fatty liver, etc.)
* Known sensitivity to MTX
* Blood dyscrasias (i.e., thrombocytopenia, significant anemia)
* Hepatic, renal, or hematologic dysfunction
102
Describe investigations for prolapse (4)
* No specific tests for prolapse
* Imaging not usually necessary (unless procidentia to R/O urinary retention)
* Biopsy all suspicious persistent vulvovaginal lesions
* Cystocele evaluation:
* a. UTI screen
* b. Postvoid residual (PVR)
* • ± Refer to gynecologist for urodynamic testing
103
Describe pessaries for prolapse (5)
* Device placed in vagina to provide support and/or fill space
* **Support pessaries (the ring) for earlier stages (II and III)**
* **Space-filling pessaries (Gellhorn) for more advanced prolapse**
* Ideally changed and rinsed weekly with F/U q3mo
* Lubricants or vaginal E (if atrophy) is often employed with pessaries in postmenopausal women
104
Name indications for surgery for prolapse (4)
* not recommended if asx
* Advanced and asx: must assess efficiency of bladder emptying due to risk for complications of urinary retention (recurrent UTI, urosepsis) and assess exposed vaginal epithelium for erosions at risk for infection
* More frequent F/U (q3 mo) if decided against surgery
* Patient fails conservative management, is unable or unwilling to use pessary, or desires surgical management
105
106
Describe the management of OVULATORY DYSFUNCTION in infertility (4)
* (A) Anovulation:
* **Clomiphene citrate (Clomid)**
* Gonadotrophins (hMG) ± IUI
* Lifestyle/weight ∆ ± metformin (if PCOS)
* IVF/intra-cytoplasmic sperm injection
* Donor oocytes
* (B) Hyperprolactemia: **Bromocriptine** (dopamine agonist)
* (C) Thyroid dysfunction
* (D) Functional hypothalamic amenorrhea: (appropriate behavioral or psychologic interventions)
Revision LMCC
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