Main routes of spread of cervical cancer
Paracervical lymphatics (also parametrial,obturator, hypogastric, external iliac, and sacral in that order)
Direct extension into parametrium
Most common germ cell tumor
Benign cystic teratomas. OCcur primarily during reproductive years, but also in childrena and PM women
Symptoms of benign cystic teratomas
Usually asymptomatic, but can cause severe pain if torsion, or if sebaceous material pills and creates a reactive peritonitis
Treatment of bartholin gland cyst
Complete excision, esp in women >40 yo who present with cystic or solid mass in this area. Incidence of adenocarcinoma of bartholin gland peaks in 60s.
STages of cervical cancer
Stage 1 - limited to cervix
Stage 1a - preclinical, microscopic
Stage 1b - Macroscopic
Stage 2 - involves vagina but not lower one third, or infiltrates parametrium but not to pelvic side wall
Stage 2a - Vaginal but not parametrial extension
Stage 2b - Parametrial extension
Stage 3 - Lower 1/3 vagina or extension to pelvic side wall
3a - Vagina but not pelvic side wall
3b - pelvic side wall, assoc with hydronephrosis or a nonfunctioning kidney caused by tumor
Stage 4 - outside the reproductive tract!
Bounds of Stage 1a cervical cancer
Lesions within 3mm of basement membrane, no wider than 7mm, with no lymph or vasc invasion, no confluent tongues
Invasive vulvar carcinoma treatment
Surgical. Radical vulvectomy and bilateral inguinal LAD...
IF inguinal nodes show sign of disease --> bilateral pelvic lymphadenectomy..
Local advanced carcinoma? Consider radiation therapy.
Most common cancer in pregnant women
Cervical cancer, mainly because this is a cancer that can affect younger, childbearing women.
Radical hysterectomy indicated for Stage 1b cervical cancer, what is taken and what can be spared
Upper 1/3 of vagina
UTerosacral and uterovesical ligamnets
Pelvic node dissection
You can spare both ovaries in a younger patient!!! Cervical cancer mets to the ovaries are pretty rare indeed.
PMB with atypical complex hyperplasia, risk of assoc endometrial carcinoma?
25-30%!!! Thus total abdominal hysterectomy is encouraged.
What if hysterectomy is not an option? Progesterone therapy can be used.
Usual cause of unilateral bloody nipple discharge
Carcinoma must be ruled out!!
OTher causes include duct ectasia and fibrocystic breast disease.
Two most common benign breast disorders
Fibroadenomas - firm, solid, well-circumscribed, nontender, freely mobile mass.
What are fibrocystic breast changes
Exaggerated response of the breast tissue to normal hormones.
Diffuse b/l nodularity is typically encountered.
Rare fibroepithelial tumors - 1% of breast malignancies.
Rapid growth, most frequent breast SARCOMA, and occur most frequently in fifth decade of life.
Fat necrosis presentation
Firm, tender mass surrounded by ecchymosis. Skin retraction can occur, which makes this hard to distinguish from cancer.
Fibroid degeneration during labor, is this common?
No. But fibroids can outgrow blood supply --> carneous degeneration, leading to preterm labor..
May also be assoc with fetal malpresentation caused by distortion of endometrial cavity. *May also contribute to postpartum hemorrhage.
Admission, IV antibiotics
Drainage via laparotomy, laparoscopy, or CT percutaneous drainage.
Antibiotics for PID, inpatient
Cefoxitin 2g IV q6h or Cefotetan 2g IV q12h + Doxy 100mg BID
Clinda 900mg q8h + Gent IV or IM
Antibiotics for PID outpatient
Cefoxitin 2g IM + Probenecid 1g in a single dose
Ceftriaxone 250mg IM + Doxy 100mg BID x14 days.
Ofloxacin + (Clinda OR Metro)
Vulvodynia, what is this
1. SEvere pain on vestibular touch or attempted vag entry
2. Tenderness to pressure localized withinthe vulvar vestibule
3. Visible findings, vulvar erythema of varying degrees
Treatment of vulvodynia
Avoid tight clothing,tampons, hot tubs, soaps --> avoid vulvar irritants!!!
1. Topicals: Lidocaine, estrogen, steroids
2. TCAs and intralesional interferon
Thin, diffuse, whitish epithelial areas on the labia majora/minora, clitoris, and perineum. Severe cases may be difficult to identify normal anatomic landmarks.
Most common symptom --> chronic vulvar pruritus.
Raised lesions (most commonly along the posterior vulva and in the perinealbody and have a whitish cast and rough texture)
Indications for a cone biopsy
1. Unsatisfactory colpo exam (entire transformation zone cannot be seen)
2. Colpo directed cervical biopsy that indicates possibility of invasive disease
3. Neoplasm in nedocervix
4. Cells on cervical biopsy do not adequately explan cells seen on cytologic exam
PAP - HGSIL, but normal or equivocal colposcopy.
10% of colpo results will belike this. Conization of the cervix is thus required to rule out lesions higher in the endocervical canal.
Glandular pap results, assoc with what
Adenocarcinoma in situ
What is a Frei test
Used to identify lymphogranuloma inguinale. Antigen made from tserille pus produce a reaction in patients with lymphogranuloma inguinale when injected intradermally.
No longer used because gross, and also low .
How long between HIV exposure and seroconversion
2-8 months, probably retest at least 4-12 weeks or so.
What is Lymphogranuloma venereum
C. trachmatis, most commonly found in the tropics.
Begins as painless ulcer or vaginal vestibule... then develops painful adenopathy in the inguinal and perirectal areas.
Diff diagnosis for single genital ulcer
Ovarian enlargement in young woman, what is this, how should it be managed?
Return to office and recheck... because it is most likely a functional ovarian cyst.
If cyst is persistent --> CT scanning or pelvic U/s.
Functional ovarian cysts, how do they form?
Physiologically, during the normal functioning of the ovaries... Follicular cysts are usually asymptomatic, unilateral, thin walled ,filled with a watery straw colore fluid.
Corpus luteum cysts?
Less common than follicular cysts, usually unilateral but often appear complex as they may be hemorrhagic. May also be symptomatic, with dull pain on the side of the affected ovary.
Three types of functional ovarian cysts?
Follicular cysts - straw colored fluid, thin walled
Corpus luteum cysts - may look complex or be hemorrhagic
Theca lutein cyst - least comon of three types, almost always b/l and assoc with pregnancy.
CA-125 good for what
Evaluating PMW w/ pelvic mass
Assessing treatment response
PRoduced in ~80% of ovarian epithelial carcinomas.
Cystitis - diagnosed when?
Clean catch urine sample - concentration of at least 100,000 bact / mL of urine.
Conservative treatment for urge incontinence has failed, what now
- Dopamine agonists - Parlodel
Rates of vaginal vault prolapse in hysterectomy patients
Up to 18% of patients who have undergone hysterectomy.
Degrees of uterine prolapse
First degree - descent limited to upper two thirds of vagina
Second degree - just inside introitus
Third degree - out of introitus
Procidentia - completely out
What is Kelly plication
Older procedure used to suspend the urethra in stress incontinence. Has lower cure rate for stres incontinence than the burch procedure
Suspends bladder neck to Cooper ligament of the pubic bone using an abdominal approach.
Le fort procedure in whom
Vaginal vault prolapse
Poor surgical candidates
Not sexually active
Suspected ureteral injury test of choice
Renal ultrasound, noninvasive
IV pyelogram replaced by CT contrast... but contrast is CI in elevatedCI.
Urethral divercticula symptoms
OFten palpable as mass on anterior vaginal wall underneath the urethra.
Marshall Marchetti Krantz procedure
Involves attachment of the periurethral tissue to the symphysis pubis for GSUI. Long term cure rate around 80%. 1-2% will get ostetitis pubis, which is an aseptic inflammation. Course is usually chronic.
Most common cause of fecal incontinence
Obstetric trauma with inadequate repair. Generally the patient is continent of formed stool but not of flatus.
Top causes of fecal incontinence
Diabetes - 20%
Conservative measures for fecal incontinence
Bulk forming agents
Biofeedback and electrical stim of rectal sphincter
Surgery if all else fails...
Absolute CI to HRT
EStrogen-dependent tumors - breast or uterus
Active thromboembolic disease
Undiagnosed genital tract bleeding
*Active severe liver disease
Order of puberty
On average 4.5 years to complete, with a range of 1.5 to 6 years.
True sexual precocity
Normal gonadotropin levels (should be low)
Normal ovulatory pattern.
Represents premature activation of a normally operating hypothalamic-pituitary axis.
Usually idiopathic, can also be caused by cerebral causes such as tumors or history of encephalitis or meningitis, or hypothyroidism, POFD, NF, and others.
What is precocious pseudopuberty
Endocrine glands under neoplastic influence produce elevated aboust of estrogens creating either:
- Isosexual precocious pseudopuberty
- Heterosexual (androgens) precocious pseudopuberty --> virilizing signs
Most common cause of isosexual precocious puberty
Ovarian tumors. Some including dysgerminonomas and choriocarcinomas can produce so much gonadotropin that pregnancy tests are positive.
What is incomplete sexual precocity
Usually idiopathic, characterized by only partial sexual maturity such as premature thelarche or premature adrenarche. Gonadotropins are frequently normal.
Ovarian tumors leads to what sort of precocious puberty
Isosexual precocious pseudopuberty.
Specificially dysgermoniomas or choriocarcinomas...
HRT and uterine cancer
Does not increase risk of uterine cancer. Perhaps doe sincreas erisk of breast cancer, heart attakc, stroke, and VTE.
Hot flushes and timing of menopause
First menopausal symptoms, can occur years before the cessation of menstruation.
How long does a hot flush last
3 minutes total. Sudden sensation of heat over the chest and face that lasts b/w 1-2 minutes, then followed by a sensation of cooling or a cold sweat.
Heavy and acute bleeding in the context of an atrophic endometrium
25mg of conjugated estrogen q4h until bleeding subsides. Estrogen will helpp because it rebuilds the endometrium stimulating clotting at the capillary level.
Heavy and acute bleeding with a thickened endometrium
Hysteroscopy and D&C. D&C may be helpful in older women to r/o endometrial cancer.
Fall in BP by 20
Rise in HR by 20
Increase in weakness, dizziness, nausea or other symptoms.
First step in inducing ovulation in PCOS
Metofrmin. Insulin is thought ot act on the ovary to stimulate androgen secretion.... Additionally, hyperinsulinemia decreases SHBG
Appropriate lab tests in early menstruation dysfunctional uterine bleeding attributed to anovulation
Bleeding time - 20% of adolescents with DUB have coag defect
Blood ytle and screen
Hirsutism and irregular menses, labs worth getting
DHEA-S --> PCOS
Sertoli Leydig cell tumors
aka Androblastomas. 20-40 yo, tend to be unilateral, reaching a size fof 7-10 cm.
Very high levels of testosterone >200, rapidly developing virilizing characteristics such as temporal balding, clitoral hypertrophy, voice deepening, breast atrophy, terminal hair b/w breasts and on the back.
Idiopathic hirsutism, causes
Greater activity of 5alpha-reductase than do unaffected women. Just more hair, nothing else really.
A Biopsy for a luteal phase defect should be done when
12 days after thermogenic shift, or 2-3 days before expected onset of menses, about day 26 of a 28 day cycle.
When is the hysterosalpingogram done
Mid follicular phase, around day 8. Should not be done when the patient is menstruating or after ovulation has occurred.
Sexual precocity independent of gonadotropin functioning
Iatrogenic (ingestion of estrogens)
Normal sperm analysis
20 mil /ml
>60% with normal shape
>50% progressive forward motility
Examples of conversion of celomic epithelium into endometrium
Endometriosis in men, and in women without mullerian structures
Mullerian agenesis aka
Mayer-RokitanskyKuster-Hauser sydnrome... amenorrhea with the absente of a vagina.
Normal development in Mullerian agenesis
Normal development of breasts, sexual hair, ovaries, tubes, external genitalia. Associated skeletal and urinary tract abnormalities.
Treatment for Mullerian agenesi
McIndoe procedure, creation of an artifical vagina with split thickness skin grafts.
Testicular feminization presentation
10% of all cases of primary amenorrhea.
Absent uterus, blind vaginal canal. Sexual hair is decreased (sign of androgens).
Abnormal luteal phase
Ovulation with poor progestational effect in the second half of the cycle.
This is evaluted at the endometrium, with a biopsy around day 22-26. Midluteal progesterone levels <10 are suggestive but not diagnostic.
Pregnanediol is a metabolic product of progesteroene, and this may be helpful.
Most common reason for amenorrhea in women of reproductive age
Chronic endometritis or scarring of endometrium
Emotional stress, extreme weight loss, and adrenal cortical insufficiency
OCPs in PCOS
Directly suppress estrogen production
Clinical improvement may take up to 6 months to manifest.
Conservative measures for treating dysmenorrhea
SEdatives or antispasmodics
Biochemical makeup of primary dysmenorrhea
Higher than normal concentration of prostaglandins in the endometrium and menstrual fluid.
Thus, prostaglandin synthase inhibitors: INdomethacin, naproxen, ibuprofen, and mefenamic acid (Ponstel).
Also OCPs --> minimize endometrial prostaglandin production during concurrent administration of estrogen and progestin.
REserve narcotics for those that fail other therapies.
Anorexia nervosa hormone concentraitosn
PRL, TSH, and thyroxine are normal
FSH and LHa re low
What decreases PIF
EStrone, from peripheral conversion of androstenedione to estrone in adipose tissue.
Semen analysis in varicocele
Decrease in number with decrease in motility and increased abnormal forms.
Normal males but with uterus and fallopian tubes
Failure of MIF. Karyotybe is 46,XY, testes are present, and testosterone production is normal.
Danazol, what is this
Progestatinal compound derived from testsoterone used to treat endometriosis.
Induces pseudomenopause, but does not alter basal Gn levels. Appears to act as an antiestrogen and causes endometrial atrophy.
Danazol post pregnancy
Endometrium is atrophied. Although cyclic menses return almost immediately, it is felt that endometrium is too atrophied to avoid SAB. Thus, three or so cycles should pass before they try.
Abnormal uterine bleeding who do not respond to standard therapy (e.g. OCPs, antiprostaglandins)
Hysteroscopy, looking for small polyps or fibroids.
Bicornuate uterus due to what
Failed fusion of the Mullerian ducts. Main risk is obstetric, such as a increase in rate of second trimester abortion and premature labor. Term --> increase in breech and tranverse lie.
Mullerian anomalies, what additional investigations are mandatory
Approx 30% of patients with mullerian anolamies have coanomalous uterine abnormalities.
Dysmenorrhea and menorrhagia
Tender, symmetrically enlarged uterus w/o adenexal tenderness
Fixed, retroverted uterus
Adnexal tenderness and scarring
Tenderness along uterosacral ligaments
Clomiphene does what
Blocks normal negative feedback of the endogeous estrogens ---> stimulates release of endogenosu GnRH
Genitalia - feminine on outside, MIF works though so no internal genitalia.
Tall stature, normal rbeast development with absence of axillary and pubic hair
Kallman syndrome, suspect when
Amenorrheic patient of normal stature, with delayed or absent pubertal develoment, esp with anosmia. Olfactory screening can work.
Kallman syndrome, defect
Structural defect in area of the brain by their olfactory bulbs and arcuate nucleus, which does not secrete GnRH in normal pulsatile fashion.
Non-Kallman causes of minimal or absent pubertal development iwth normal stature
Severe systemic disease
Intensive athletic training --> ballet and running.
Breast bud to menarche development
1-2 years beteween.
If menarche delayed beyond 16 to 17, delayed puberty should be investigated.
Normal pelvic exam
Other symptoms: Nausea, fatigue, diarrhea, headache, which may be related to excess of prostaglandin F2alpha
Two major drugs: OCPs, and antiprostaglandins
Therapy of Chlamydia infection in pregnancy
Oral EES or amoxicillin for seven days
Azithromycin one time dose
Doxy and other TCNs CI in pregnancy
Why treat chlamydia infections in pregnancy
Neonatal pneumonia or conjunctivitis later on if untreated.
NOT assoc with preterm labro or PPROM.
GC vs chlamydial pregnancy infections
GC may cause pregnancy problems, including aboriton, preterm labor, PPROM, chorio, neonatal sepsis, disseiminated gonoccal disease is more common in pregnant women, etc etc. Chlamydia generally just causes neonatal problems.
HIV serostatus when in pregnancy
As early as possible
Repeat near delivery time.
Vertical transmission has dramatically decreased.
Risk of vertical transmission with combo therapy
If no C-delivery, IV zidovudine during labor. breast feeding discouraged. Neonate generally also gets oral ZDV syrupt.
CDC recommendation for L&D
Rapid HIV for those women whose HIV status is unknown. HIV infection can be identified and measures may be taken to reduce risk of vertical transmission
What erythromycin is CI in pregnancy
Erythromycin estolate salt can lead to liver dysfunction in pregnancy.
When can a cesarean decrease vertical transmission of HIV
Only before rupture or membranes or even labor to effectively reduce transmission.
IV ZDV and minimizing trauma to the baby is advisable. Neonate also gets ZDV syrup.
Best treatments for chlamydial cervicitis in pregnancy
Erythromycin (NOT estolate)
Parvo virus in adults
Myalgias and low grade feverm maybe malaise, and perhaps a reticular rash that comes and goes. Up to 20% of adults will have no symptoms.
Neg IgM and IgG for parvo, cutoff time to worry
20 days. If more than exposure, then doesnt have to worry. If before that, then perhaps antibodies have yet to show up.
FHT sinusoidal heart rate pattern
Sine wave of 3-5 minute cycles. Indicative of severe fetal anemia or asphyxia
Pregnant woman with parvo infection, how to manage
Weekly FUS for 10 weeks assessing for hydrops, with possible referral for intrauterine transfusion. Luckily less than 5% of susceptible infected pregnant women will have fetuses complicated by anemia.
Pregnancies <20 weeks at the most risk.
Excess fluid located in two or more fetal body cavities, many times is associated with hydramnios.
Causes of hydramnios
FEtal CNS anomalies
Fetal GI anomalies
Fetal chromosomal anomalies
Fetal nonimmune hydrops
Fetal cardiac weirdness
Fetal cardiac arrhythmias present how
A nonimmune hydrops that does not usually affect blood counts.
Causative agents behind endomyometritis
Ascending infeciton of vaginal organisms (anaerobic predominance but also GNRs)
Post c-del fever ddx
Atelectasis (uncommon, most are regional)
Criteria for adequate uterine contractions
Contractions q2-3 minutes, firm on palpation, lasting for at least 40-60 seconds.
ACitive phase of labor, nul vs mul
>= 1.5 cm/h
Arrest of active phase, if no progress for at least 2 hours.
Stages of labor
1st - onset of labor to complete cervical dilation of cervix
2nd - Dilation to infant expulsion
3rd - infant to placenta
Septic pelvic thrombophlebitis
Bacterial infection of pelvic venous thrombi, usually involving the ovarian vein
Treatment for endomyometritis
IV Gent + Clinda - 90% of cases effective
Extended PCNs or cephalosporins as well
Endometritis after vaginal delivery?
Usually does not need anaerobic coverage, and thus ampicillin and gent are just fine.
What happens if endomyometritis does not respond after 48 h to clinda and gent therapy
POssible enterococcal infection.
If fever persists for 48-72hours beyond this, CT scan of abdomen and pelvis may reveal an abscess or infected hamartoma.
FEver of wound infection, when
If in first day, possible GAS --> Flesh eating bacteria. Immediate and extensive surgical debridement is indicated.
Pathogenesis of septic pelvic thrombophlebitis
PLacental implantation site bacteria spread to ovarian venous plexus, causing thrombophlebitis. SPT women may look well, or sometimes may have a palpable pelvic mass.
Diagnosis by CT or MRI
Firm, nontender, 1cm ulcerated lesion of the vulva, with raised borders and an indurated base
Primary chancre of syphilis. Usuallyalso has painless inguinal LAD
If older, perhaps consider SCC of the vulva.
Primary chancre of syphilis, how to diagnose
RPR or VDRL
if negative, as it may be...