gyne test 2

8/6/2019 GYNE TEST 2

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OB/GYNE Test II Summer 2011

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Know dominant hormones during different phases!

Menstrual Cycle(Four functional Phases of cycle)

1. Follicular Phase (pre-ovulatory) 2. OVULATORY 3. Leuteal Phase 4. Menses

(Proliferative Phase) (Secretory Phase)

See Diagrams (from online)

300-400 X in a lifetime Cycles normally vary from 21 40 days

Bleeding normally 3 8 days (average loss of 30-80ml) >80 ml = anemia

C lots small are normal, large is rapid bleeding, inability of fibrinogen to act 15% of women have classic 28 day cycle

1. Follicular Phase cascading event

o Hypothalmus releases GnRH too Anterior Pituitary which releases FSH& LH

o FSH stimulates proliferation of granuloma cells which produce Estradiol Days 1 5 Follicles grow

o Increasing Estradiol and Inhibin produce Negative Feedback on FSH Days 5 7 One dominant follicle

o FSH decreases, non-dominant follicle recedes Days 7 14 (17) Dominant follicle matures and produces Estradiol (total phase: 10 17 days)

o Late Follicular Phase LH activity causes a rise in Androgen levels (androstenedione and test osterone) PEAK in sexual behavior

2. Ovulatory Phaseo Estradiol levels peak about 24 hours before ovulationo Pituitary surge of LH and FSH

~ Day 14o 10-12 hours after LH peak mature follicle releases an egg

o Ovulation Predictor Kit (OP kit) detect LH surge in urine

See handout from online

3. Luteal Phase

Progesterone dominance (Produces Progesterone until placenta takesover) Corpus Luteum secretes Estrogen and Progesterone (yellow body) Progesterone suppresses new follicle growth and acts on the endometrium Progesterone peaks 7 8 days after LH surge time of implantation *** P rogesterone increases basal body temperature BBT (14 days long, unless pregnancy occurs)

4. Menstrual Phase

No pregnancy, then Corus Luteum declines 9 11 days afterovulation which causes a drop in Estrogenand Progesterone

MENSTRUAL FLOW




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ENDOMETRI AL CYCLE(Looking at same process from the angle of the uterus)

Proliferative Phaseo Thin and ischemic at end of cycleo 2nd week Estrogen increase causing thickening (build-up)o

Proliferative growth (deeper, wider, thicker)o Glands more active, secret ory, and nutritive (increase by 8X)o Increased blood flow, increasedglandular secretions

Secretory Phaseo Last 2 weekso Due to Progesterone and Estrogen, glands more fluid-filled and congestedo Increased blood flow

MENSTRUAL/Ischemic Phaseo Ischemia and cell degenerationo Cell rupture with bursting arterioles

o Sloughing of uterine lining

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HPG/HPO axis (know well)

Gonadotropic Releasing Hormone (GnRH)- Hypothalmus

Low Frequency pulses FSH release

High Frequency pulses LH release

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1. Follicle Stimulating Hormone (FSH) Anterior Pituitary

Ripening of follicle

Ovulation

Estrogen Secretion

2. Luteinizing Hormone (LH) Anterior Pituitary

Initiates Ovulation

Stimulates follicle to rupture

Development of Corpus Luteum

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Estradiol = Estrogen Gonads/Ovaries

Female characteristics

Helps prepare endometrium for implantation

Intensifies affects of progesterone

Progesterone Gonads/Ovaries

Prepares uterus Promotes Secretory endometrial cells

Maintains placenta in pregnancy




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Ovulation Predictor Kit (OP kit)

Ovulation predict or kits measure the increasing amounts of luteinizing hormone in a woman's urine. Theluteinizing hormone surge is what helps signal it is time f or the ovaries t o release an egg each monthduring ovulation. This luteinizing hormone surge happens bet ween 24 and 48 hours bef ore ovulationand is what ovulation predict or kits are highly reliable in detecting. When an ovulation predict or kit detects the hormone, a couple knows that ovulation is one t o t wo days away, and the couple shouldhave intercourse f or the next three days t o optimize the chances f or conception.

Types

Ovulation predict or kits are widely available in drugst ores and grocery st ores or mass merchandisers that have a pharmacy section. Each ovulation predict or kit comes with testing strips, usually bet ween 5 and9, t o be used each day during the middle of a woman's cycle until the luteinizing hormone is detected.Most manufacturers of home pregnancy tests also sell ovulation predict or kits, and they are available ingeneric brands aswell. Prices f or ovulation predict or kits range from $15 t o $50, though cheaperversions can be f ound online.

Menarche mean onset is 12.7 years of age =onset of menses

Ovulation often inconsistent for 1-2 years leading to irregular cycles

o Puberty

Thelarche Breast budding Pubarche/adrenarche Pubic/armpit hair Growth spurt

Menarche/ovulation last phase of the process

Characteristics of cycling

Puberty Tanner Stages

I - Prepub Elevated papilla only. No pubic hair

II Breasts and papilla are elevated and appear as small moundwith enlarging areola diameter.Sparse long, pigmented hair along labia majora (range 8-13 years, median age 10.5 years)

III - Further breast enlargement without separation of breast and areola (median age 11.2 years).

Dark coarse, curled pubic hair is sparsely spreadover mons (median age 11.4 years)

IV Secondary mound of areola and papilla develop above the breast (median age 12.1 years) Adult-type pubic hair is abundant but limited t o the mons pubis (median age: 12)

V Recession of areola occurs (median age 14.6 years, range 12 18). Pubic hair is adult type in bothquantity and distribution ont o thighs

PROCOCIOUS PUBERTY occurs before 8 y/o DELAYED PUBERTY Menarche absent at age 18

All terms used in describing menstruation:




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* Oligomenorrhea I nfrequently occurring menses at >35 days (Classic sign of PCOS)

* Amenorrhea absence of menses

* P rimary Amenorrhea no initial menses during puberty changes

N o menses by age 16 regardless of normal growth & 2ndary growth characteristics, OR

Absence of menses by age 14 when normal growth & 2ndary sexual characteristics are absent. Etiology: anat omic deviations, endocrine abnormalities (hypothyroid), aut oimmune

disease, eating disorders, excessive exercise.o S/S : Absence of menses, lack of 2ndary sexual characteristics

o DIFFERENTI ALS: Pregnancy,Defect in H-P-O axis (gonadotropin deficiency, extreme exercise,

stress, pituitary tumor, PCOS, premature ovarian failure, thyroid disorders, primary gonadal disorder)

o Physiological findings: W gt, Hgt, visual fields, thyroid, nipple discharge, pelvic exam, hirsutism,

vaginal appearance (check for congenital absence of ovaries), vagina, imperforate hymen)

o Diagnostic tests: Start with hCG, TSH, T4, prolactin, FSH, LH, Estradiol, Pelvic U/S to check anatomy

MRI to check for pituitary tumor if prolactin is elevated.

o M anagement: Refer t o gynecological or endocrinology f or further evaluation.

FUNCTIONAL HYPOTH ALMIC AMMENORRHEA ATHLETES HORMONES ARE NORMAL: o Chronic illness, stress, delayed puberty, chemo, O.C., Psych meds, Gonadotropin Hormone Deficiency,

PCOS

If LH/FSH elevated Primary ovarian failure (chromosomal, aut oimmune, structural such as transversevaginal septum)

* Secondary Amenorrhea

Absence of menses for 3 c y cles or 6 mos in women who have previously menstruated

regularly. Occurs in 3-5% of women.

o Etiology: See Primary Amenorrhea o S/S: As per definition o DIFFERENTI ALS: Pregnancy, annovulation d/t defect in H-P-O axis, use of OCPs,

use of Progesterone-only contraception, Adrenal disorder, medication cause. o Diagnostic tests: hCG, prolactin, TSH, T4, LH, FSH, Estradiol o Management: Encourage withdrawal bleed every 3 months ***

Progesterone Challenge Test Progesterone in oil 100-200mg/IM or

Prometrium 300mg X 7-10 days after concluding med. I f bleeding occurs after Progesterone Challenge, Estrogen is adequate,

cervix is patent , and endometrium is functional. I f N O bleeding occurs, add 1.25 mg Premarin (conjugated Estrogen) f or

21 days t o prime lining and add Provera 10mg X last 5 days. OCPs X1pack as option t oo.

I F N O BLEE D , check FSH t o rule out Premature Ovarian Failure Long-term cycling management with OCPs cyclic Progesterone, or HRT

Premature Ovarian Failure

Low Estrogen Elevated LH and FSH working t o produce Estrogen, but not working (< 40 y/o) Causes Gonadal dysgenesis (ovaries shut down), genetic abnormalities, aut oimmunedisorders, infection, cancer tx

* Hypermenorrhea/ M enorrhagia Ex cessive duration & flow (>7d, or 80mL)

Metorrhagia irregular, excessive flow or length of timeMenometrorrhagia Irregular, heavy bleeding Hypomenorrhea Regular bleeding in less than normal amount




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* P ost-coital bleeding after sexual inter course infection or PG

* P olymenorrhea Bleeding at short intervals (<21 days) too frequent

* Hypermenorrhea/ M enorrhagia Ex cessive duration & flow (>7d, or 80mL)or irregular y Organic gynecological disease PG, PG-related complications, cervicitis, endometriosis, polyps,

leiomyoma, adenomyosis, o endometrial hyperplasia (not good)/carcinoma,o cervical carcinoma.

y Systemic thyroid dysfunction, liver cirrhosis, active hepatitis, adrenal hyperplasia, renal failure, hypersplenism, bleeding disorders, leukemia, severe sepsis, DIC

y Medications, IUDs, foreign bodies, trauma

Dysfunctional Uterine Bleeding (DUB) Prolonged or ex cessive bleeding due to

endometrial shedding in the absence of pelvic structural disorders. C hronic anovulation is the

leading cause.

y Etiology: Hormonal disturbancewith dysfunction of the H-P-O axis, resulting in continuous Estrogen

stimulation of endometrium.o Seen in adolescence and perimenopause frequently.

y S/S: irregular bleeding, light t o heavy flow

y DIFFERENTI ALS: Pregnancy, ect opic pregnancy, cervical or uterine polyps, blood dyscrasia, perimenopause, thyroid disorder, pituitary tumor, cervicitis

y Physical findings: thyroid exam, pelvic exam

y Diagnostics: CBC, pap, cultures, TSH, prolactin, pelvic U/S, testing f or blood dyscrasias (VonWillibrands), endometrial bx, hysteroscopy (looking at lining and bx taken).

y Management: OCPs, progesterone tx usually 10-14 days/month, Depo-provera, Mirena, Lysteda, HSC/D&C

y If severe bleeding: refer f or surgical intervention, Endometrial ablation is an option destruction of the endometrium via heated liquidor electrocaudery

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Oligomenorrhea infrequent menses at intervals >35 days ***y On a continuum bet ween normal ovulat ory cycling and secondary amenorrhea (milder f orms) y Etiology: Peri-menopause, PCOS, majorweight gain or loss, Estrogen suppressors vs. unopposed (OCP)

Dysmenorrhea painful menstruation (Different from PMS)

y Etiology: Primary increased prostaglandin produced by endometriumo Secondary pelvic or uterine pathologic cause such as endometriosis

y S/S: Primary Usually occurs in women <20 y/o. Pain in lower back , pelvis, thighs. Cycle day 1 or 2o Secondary Occurs in women 25 40 w/ sx of increasingly painful menses. May note

dyspareuniawith new onset (red flag f or endometriosis)

y DIFFERENTI ALS: Endometriosis, adenomyosis, PID, obstructive defects, bowel disorder (IBS)

y Mgt: NSAIDS, OCPs including cycle suppression, Depo-provera. If failure of these measures, surgical

intervention.

PMS/PMDD (Premenstrual Syndrome and Premenstrual Dysphoric Disorder) T hey ARE different!

y Physical, cognitive, affective, and behavioral sx that occur in a cyclic fashion during the luteal phaseof menstrual cycle and resolve with menstruation

y PMS International classification of diseases

y PMDD American Psychological Association more criteria met

T OXIC SH OC K rare, associated with tampon use & vaginal staph aureus-produced endotoxins

y Etiology releaseof inflammat ory mediat ors in response t o a relatively minor infection




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y Can occur after surgery, postpartum, with skin & bone infections, burns, derm. Lesions, and resp. tract infections

y Subjective: abrupt onset , high fever, chills, vomiting, watery diarrhea, myalgia, headaches, abdominalpain in a previously healthy young woman during or shortly after menstruation

y Objective: Multisystem involvement fever, hypotension, orthostatic hypotension, sunburn-like rashwithin 24-48 hours onset , conjunctival hyperemia, oropharyngeal erythema, strawberry t ongue, vaginal

hyperemia, Non-specific abdominal tenderness, general confusion & disorientationy DIFFERENTI AL: Rocky Mountain S. F., Legionnaires, t oxic epidermal necrolysis, rheumatic fever,

let ospironsis, rubeola, lyme disease, Epstein-Barrvirus, or disseminated fungal infections

y PLAN: Admission to ICU, B/P support (fluids & pressors), IV ABx

PCO S Poly c ystic Ovarian Syndrome- hyperandrogenism and oligo-ovulation or annovulation (infrequent or

absent menses)

y Oligomenorrheic, hirsute, obese, and infertile

y Insulin resistence and hyperinsulinemia o BMI > 27 o Waist t o hip ratio > 0.85

o Waist > 100 cm o Acanthosis nigricans (neck dark pigmented and leathery) Pits, groin, f olds o Skin tags

y PCOS

o What it is multiple inactive f ollicular cysts. Androgen excess & chronicanovulation

o What to look for Associated with greater LH and GnRH dysfuction withabnormal estradiol levels that fail t o stimulate a normal FSH reaction. Obesity, hirsutism,

o Testing glucose/diabetic type sympt oms

Acanthosis Nigricans Results from insulin resistance, predisposed t o NIDDM and CAD.

y Increased insulin production contributes t o excess androgen production and chronic annovulation.y Subjective: Hirsutism, mental Hx, danazol use *, progestins, glucocorticoids, anabolic steroids,

phenyt oin, or monoxidil use

y Objective: male hair patterns, increased muscle mass, clit oral enlargement , decreased breast size, voicechanges, obesity, acanthosis nigricans, ovarian masses

y DI AGNOSTICS: FSH low or normal Dexamethasone suppression or R/O CushingsLH Elevated Glucose Tolerance Test LH FSH ratio > 3 Fasting insulinTest osterone BUN/creat DHEA-S 17 Hydroxy-progesterone

y DIFFERENTI AL: Ovarian Disorders, Congenital Adrenal Hyperplasia, Androgen-producing tumors, Cushings, Drug related, Obesity, Post-menopause

y PLAN: Weight loss, Refer t o endocrinology, Review Risks of CA, NIDDM, HTN, CAD;

o Discuss fertility issues (desire f or kids?), o For increased cholesterol do diabetic diet.

y MEDS: Metf ormin 500mg q HS X 1 week , BID X 1 week , TID and then evaluate.o Corrects hyperinsulinemia, reduces LH sex hormone binding globulin & ovarian androgenso Monit or BUN/creatinine

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1st initial GYNE EXAM Care/gentle sets tone for all future exams/contact




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y Indication: Gynacologic Sx, sexual activity, age 21.y Chaparone may or MAY NOT put patient at ease. y Talk about rules of confidentialityy Consent NOT in Illinois: no need f or parent consent f or STDs, PG dx, PG care, contraceptiony Emancipated Minor, no consent needed y EDUCATE on Anat omical norms, exam expectations, what we look f or, menarche, tampon use.y GIVE LOTS OF INFORMATION THE MORE THE BETTER!

Adolescent care

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Eating disorders/Nutrition

Safe sex/Abstinence

Safety

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Menopause

Changes that occur expectations see diagram

Options for treatment HRT is risky educate and give written information

Goals of treatment Limit caffeine, ETOH, smoking




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Osteoporosis & Osteopenia low bone mass leading t o fragility/increased fractures. Femoralneck and lumbar vertebrae (composed of the trabecular bone) are the most susceptible.

What is normal? balance bet ween osteoclast and osteoblast production. T-score on a Dexa Scan of >/= (-1.0)

Osteopenia - T-score on a DXA Scan of (-1.0 t o -2.5)Osteoporosis - T-score on a DXA Scan of < (-2.5)Treatment basics diet , exercise, health and medication regimens no smoke, no E T OH

y W eight bearing exercise walking 30 minutes 3XW minimum

y C alcium + Vitamin D 1000mg age 19-50, 50-65 not on ERT need 1500mg, 1500mg > age 65

y Elimiate

y Ralozifene & estrogen (pg 413)

y Two biophosphates alendronate, risedronate) etidronate not USDA approved

HRT/ERT weigh the risks and benefits!!!

When used Reduction of osteoporosis and/or menopausal Sx that are int olerableContraindications CAD, DVT/PE, Breast/Uterine/Ovarian CA, liver dysfunction

Uterine CA - EndometrialHyperplasia Biopsy for abnormal uterine bleedingy Endometrial/uterine cancer is the most common gynecological malignancy in

women >45 years of age (caused by high levels of estrogen)What, where, when concerns

y Risk factors: Unopposed estrogen replacement , HRT, obesity, nulliparity/low parity, diabetes, HTN, Monopause, Chronic anovulation, tamoxifen use

y Screen: unexplained menopausal bleeding, premenopausal with PCOS, Obese, nulliparous clients with diabetes and HTN

Incontinence

Types

o Urge detruser instability from neuro disorder or aging o Anticholinergics: Ditropan, Detrol

o Stress urethral hypermobility or displacement of the urethra from pressureo Treat: Imipramine 10-25mg BID-QID o Estrogen tx o Sling procedure o

B

ladder surgery o Overflow over distention of the bladder

o DO NOT use anticholinergics or tricyclics

o Meds usually ineffective o Urecholine 10-25mgBID-QID

Treatment/interventions

o Test: UA, Cough stress test, Post-void Residual




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o Treat:

o Behavioral Habit training

Bladder training

Pelvic muscle exercise

Vaginal devices Biofeedback

o Lifestyle changes

Weight loss

Caffeine reduction

Fluid management

Smoking cessation

Reduce constipation

Modify physical activity

HTN

Lipids

Cancer

Is CXR appropriate to screen for lung cancer?

Prolapse(s)

Types

STDs and Vaginosis Slides: What to look for

B.V. Causes and treatment for B. V.

Yeast

S/S

STDs




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Trichimosis Fishy order yellow greendysuriastrawberry cervix

Wet Mount No reportingneeded

Sex Metronidazol 2GM in asingle dose or 500 mg po bidX 7D

Partner Txreoccurentinfection

HIV Incubation30-6 months

Flu likesymptomslymphadopathyWt loss nocsweats fevers

Elisa X 2confirm withwestern Blot

Yesreporting isneeded toIDPH

Blood bodyfluids

Mom-baby

HAARTTB medicationimmunizations

Partner tx infected

GC2-10 days

Mucopurlent vagdischargeBartholinitisSkenesCervical motiontendernessdysuria

UrineCervicalswabDNA rapidantigen

Yes reportto IDPH

Body fluidsSex and oraltransmission

Mom -baby

Metronidazol250 IM and

Azythromycin1 Gm or docycline 100bid X 7D

Yes

Chlamydia

7-21 d

Mucopurlent vag

dischge PIDdysparunia

Rieder syndrome3-6 p

Urine cervical

swab

Wk p infec

Yes report

to IDPH

conjunctivitisurethritis

Sex body

fluidsMom-baby

Skin lesionslasts 2-6 m

Azythromycin

1 Gm poOr Doxcycline100 mg bid X7

Yes

Reider syncan last 2-infection txNSAIDS

Syphyllis

10-90 days

Chanchrepainlessmaculopap rashon hands andfeet patchalopecia

RPR/VDRLIf + thenTrepocmaltest toconfirm dx

Yes reportto IDPH

Sex

Mom-baby

PCN-G 2.4 IM Yes

HSV Burning itching

tingling andvesicular lesions

Culture

weepinglesionsIgg-HSV

no Sex body

fluids

Mom-baby

Acylovir 400

mg po TID X7-10 dayPrevent ion400 mg TID x5

Gardasil va

the partne

Hep B Flu likesymptomsmalaise, fever fatigue liver enlarges

LFT HbgABimmunoessay

no blood Tx symptoms Vaccinate to prevent

Hep C Flu likesymptoms

Diarrhea malaisefatigue liver enlarges

Immuneessay hep-c

antibody

no BloodBody fluid

Mom-baby

Interferon IM

Reportable?

Care/Counseling




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Bartholinitis

Pregnancy testing throughout

Visit Schedule:

4-28 weeks: See every 4 weeks28-36 weeks: See every 2 weeks

>36 weeks: See every week

y SIS I 11-13 weeks

y SIS II at 16 weeks

y 1 Hr GTT, Hbg 28 weeks

y GBS 36 weeks

gyne test 2

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