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No menses

Primary Amenorrhea

The absence of spontaneous menstruation by age 16

Secondary Amenorrhea

Absence of menses for >6 months

Androgen insensitivity

Breast without pubic hair

Cause of secondary amenorrhea

1. Pregnancy is the most common
2. Drug users
3. Stress
4. Excessive exercise

Asherman's Syndrome (intrauterine adhesion) or PCOS

Secondary amenorrhea with normal estrogen



Progesterone challenge

determines if estrogen levels are sufficient

Amenorrhea treatment

Treat underlying cause


Painful menstuation

Primary dysmenorrheal

1. Excessive Prostaglandin E2 (causes smooth muscle contraction)

Sx's of dysmenorrhea

1. Cramping radiating to back or thighs
2. Beginning before or at onset of menses
3. Lasting for 1-3 days


Implantation of endometrial tissue in the myometrium

Large and "boggy" uterus


Diagnosis of dysmenorrhea


Dysmenorrhea treatment

2. Oral contraceptives
3. Heat
4. Exercise

Prementrual Syndrome (PMS) Symptoms

1. Start during LUTEAL phase (1-2 weeks BEFORE menses)
2. Monthly symptom-free period during FOLLICULAR phase (day 1 of menses of obulation)
3. Mood alteration
4. Psychological affects

PMS treatment

1. Diuretics (spironolactone) for fluid retention
3. SSRIs

Menopause (climacteric)

1. Final menses
2. Lasts 3-5 years

Premature menopause

Before age 40


Post-menopausal estrogen

Menopause Complications

1. Poor vaginal lubrication
2. Bone loss
3. Cardiovascular protection declines (estrogen-related)
4. Sleep changes
5. Endometrial cancer (unopposed Estrogen)

Diagnosis of menopause

FSH of greater than 3. mIU/mL

Menopause Treatment

1. Lifestyle modifications
2. HRT - increases risk of: cardiovascular disease, breast cancer, cognitive changes
3. Ca++, Vit-D, Bisphosphonates, Calcitonin (slow Ca++ from bones)

Dysfunctional uterine bleeding (DUB)

Abnormal bleeding with an unremarkable physical examination in a very young or perimenopausal woman

DUB treatment

Oral contracetpives, but not in women who:
1. Smoke
2. HTN
3. DM
4. Hx of vascular disease
5. Hx of breast cancer
6. Hx of liver disease
7. Hx of focal headaches


Uterine fibroids - fibroids depend on estrogen

Women with fibroids have what increase of endometrial cancer


Most common presenting symptom of Leiomyomata


Treatment for Leiomyomata

1. Reduce tumor size
2. Restore fertility

Most common gynocologic malignancy

Endometrial cancer

75% of endometrial cancer pts

Postmenopausal women

Endometrial cancer may be estrogen-dependent

in younger pts

Estrogen-independent endometrial cancer

in older, postmenopausal pt


Most common type of estrogen-independent endometrial cancer

Risk factors for endometrial cancer

1. Obesity
2. Nulliparity
3. Infertility
4. Late Menopause
5. DM
6. HTN
7. White Race

Oral contraceptives have what effect on endometrial cancer


Cardinal symptom of endometrial cancer

Inappropriate uterine bleeding

Endometrial biopsy has an accuracy rate of what in diagnosing endometrial cancer


Endometial cancer treatment

1. Total hysterectomy with bilateral salpingo-oophorectomy
2. Radiotherapy (if indicated)

Endometrioses most common in who

Nulliparous women in their late 20's or 30's

Endometriosis commonly causes


Endometriosis presents with

1. Dysmenorrhea
2. Intermittent spotting
3. Pelvic pain

Endometriosis treatment

1. Symptomatic - NSAIDs (discomfort), combination oral contraceptives or progestins
2. Danazol or GnRH agonist with surgery improves fertility


Extension of endometrial glands into the uterine musculature
Not related to endometriosis

Classic Adenomyosis

Middle-aged, parous with severe secondary dysmenorrheal and menorrhagia and a symmetrically enlarged uterus

Labs for adenomyosis

1. Pelvic ultrasonography
2. Endometrial biopsy will rule out endometrial cancer

Adenomyosis treatment

1. D/C
2. GnRH agaonist or Mifepristone

Pelvic Organ Prolapse Grade 0

No decent

Pelvic Organ Prolapse Grade 1

Descent between normal position and ISCHIAL SPINES

Pelvic Organ Prolapse Grade 2

Descent between ISCHIAL SPINES and HYMEN

Pelvic Organ Prolapse Grade 3


Pelvic Organ Prolapse Grade 4


Prolapse Treatment

1. Weight reduction
2. Smoking cessation
3. Pelvic muscle exercises

Ovarian Cysts Labs


Ovarian cysts treatment

1. Persistent cysts warrant further investigation
2. Cysts in postmenopausal women are presumed to be MALIGNANT until proven otherwise

PCOS is the most common cause of

Adrogen excess and Hirsutism

PCOS underlying issue

Hypothalamic pituitary dysfunction and INSULIN RESISTANCE

PCOS pts present with

hirsutism, truncal obesity, infertility, intractable acne

PCOS ultrasound will show

"string of pearls" appearance in ovaries

PCOS treatment

1. Weight reduction
2. Oral contraceptives (hirsutism)
3. Clomiphene citrate (infertility)

Risks for ovarian cancer

1. Older
2. Nulliparous
3. White

What may be protective against ovarian cancer

Long-term oral contraceptive use

% of ovarian cancer cases are sparodic


Ovarian cancer labs

1. BRCA1 (5% of cases)
2. for treatment progress CA-125
3. Association with P53 tumor suppressor gene
4. Ultrasound helpful

Cervical dysplasia and neoplasia types 6 and 11 are linked to

Condylomata acuminate

Cervical dysplasia and neoplasia are most commonly in women

In their 20's

Carcinomai in situ (CIS)

ages 25-35

Cervical cancer

> 40 years old (47 average)
39 years old in lower socioeconomic status groups

Abnormal pap smear procedure

1. Biopsy is mandatory
2. Colposcopy with biopsy is the most appropriate technique

Cervical dysplasia and neoplasia treatment

1. Mild lesions may resolve spontaneoulsy
2. Gardasil


1. All girls aged 11-12
2. 3 injections over 6 months
3. Available to all women 9-26 years old

The rarest of gynocologic neoplasms

Neoplasm of the vulva and vagina

Most Vulvar malignancies are

Squamous cell carcinomas in postmenopausal women

Most vaginal intraepithelial neoplasms occur

in the upper 1/3 of the vagina

The most common presenting problems for neoplasms of the vulva and vagina

Postmenopausal bleeding and bloody discharge

Labs for neoplasms of the vulva and vagina

Staining with toluidine blue

Treatment for neoplasms of the vulva and vagina

1. Local excision
2. Topical 5-fluoruoracil (anit-neoplastic)

Benign breast disorders - mastitis is most often caused by


Persistent, noncyclic breast pain may suggest

Underlying cancer


Typically are ROUND, FIRM, smooth, discrete, MOBILE, and NONTENDER

When should a fibroadenomatous be biopsied

When pt is <25 years old

Treatment for Mastitis

Cephalosporin + hot compress


Genes associated with breast neoplasms (5-10%)

Risk factors for breast neoplasms

1. Nulliparity
2. Early menarche
3. Late menopause
4. Long-term estrogen
5. Delayed childbearing

Ductal carcinomas

Account for 80-85% of breast cancers
-The remainder are LOBULAR carcinomas

Paget's disease

DUCTAL carcinoma; eczematous lesion of the nipple

Presentation of breast neoplasms

1. "SNIF" lesion: Single, NONTENDER, Immobile, Firm

% of breast neoplasms that occur in the upper outer quadrant


% of breast neoplasms that occur under the nipple and areola


Treatment for breast neoplasms

1. Lumpectomy + RADIATION
2. Tamoxifen in POSTMENOPAUSAL women

Traditional methods of contraception

Abstinence from just before the time of ovulation until 2-3 days thereafter
1. Calendar method
2. Basal body temperature
3. Cervical mucous

Effectiveness of combining the calendar and basal body temp methods

Results in only 5 pregnancies per 100 couple per year

Failure rate of calendar methods of contraception

35% Failure rate

Basal body temperature method of contraception

Slight drop in temperature occurs 24-36 hours after ovulation

Symptothermal method of contraception

The MOST RELIABLE periodic abstinence method
1. Combines the cervical mucous and basal body temperature methods

Cervical mucous method of contraception

Fertile mucus resemble egg white

MOST EFFECTIVE REVERSIBLE means of contraception


Failure rates of Oral hormonal contraceptives

1% (theoretical)
4-6% (actual)


1. Progestin only (are HALF as effective as COC

Disadvtages of oral hormonal contraceptives

1. Increased risk of thromoboembolic diseas and abnormal lipids
2. Possible increased risk of breast cancer and HTN, cholelithiasis

DEPOT formulation inhibits

Anterior pituitary function

DEPOT failure rate


After discontinuation of DEPOT fertility rates return to normal

within 18 months

Transdermal patch is applied

Once a month

Trans dermal patch is not effective

In women who weight >200 lbs


Failure to conceive after 1 year of unprotected intercourse

First step in testing infertility

Semen analysis should precede any other testing

Expected Date of Confinement (EDC) - Nagele's Rule

LMP - 3 months + 1 week

1st trimester testing can detect what 5 of Trisomy 21 and other genetic disorders

1. Low PAPP-A
2. High free beta-hCG
3. Nuchal translucency

Chadwick's sign

Bluish discoloration of vagina and cervix
Sign of pregnancy

Chorionic villus sampling is performed when

10-13 weeks
1. Option of a 1st trimester termination if a major malformation is detected
2. Risk of spontaneous abortion after CVS is slightly higher than that after amniocentesis

During the 2nd trimester abnormally high levels of AFP

Indicate increased risk for neural tube defects

Amniocentesis is performed

At 15-18 weeks

Nonstress Test (NST)

1. 2 accelerations of fetal heart rate in 20 minutes
2. 3rd trimester test

Contractions will have what effect on blood flow to the placenta

Decrease blood flow to the pelacenta


A decline in fetal heart rate of 15 bpm, or lasting more than 15 seconds, or a slow return to baseline

Ectopic Pregnancy 95% occur

In the fallopian tube

Most common cause of ectopic pregnancy

Occlusions to the tube secondary to adhesions

Ectopic pregnancy presentation

1. Unilateral adnexal pain
2. Amenorrhea or spotting
3. Tenderness or mass on pelvic exam

Ectopic pregnancy labs

1. Serial increases of hCG are LESS THAN EXPECTED (normally 2x/48hrs)
2. Transvaginal ultrasound

Ectopic pregnancy treatment


Spontaneous abortion

Loss of pregnancy BEFORE 20 weeks

Spontaneous abortion occurs in what % of clinically recognized pregnancies


80% of spontaneous abortions occur during

The 1st trimester

Missed spontaneous abortion

Cervix1. is CLOSED
2. No bleeding
3. No products of conception
Fetal demise has occurred WITHOUT symptoms

Threatened abortion

Cervix is CLOSED

Inevitable abortion

Cervix is OPEN, NO PRODUCTS of conception

Incomplete abortion

Cervix is OPEN, SOME products of conception

Complete abortion

Cervix is OPEN, PRODUCTS of conception

% of complete hydatidiform moles progress to malignancy


Partial hydatidiform moles have

Have a fetus present

Gestational trophoblastic disease (GTD) labs

1. Persistently ELEVATED levels of hCG
2. Ultrasound - "grape-like vesicles" or "snowstorm"

Gestational trophoblastic disease (GTD) treatment

1. Suction curettage
2. Monitor with serial hCG
3. Contraception for 6-12 months

With Multiple gestation symptoms of pregnancy

Are more severe
Prenatal visits should occur more frequently

2/3 of twins are

Dizygotic (fraternal; formed by fertilization of 2 ova)

Gestational diabetes increase lifetime risk of DM

to 50%

Gestational diabetes effects what races


Gestational diabetes labs

1. Screening high-risk women at 1st prenatal visit
2. Repeat screening at 24-28 weeks
3. Screening: Non-fasting glucose challenge with serum glucose 1 hour later

If non-fasting glucose challenge is >103

Then conduct a 3-hour glucose tolerance test

HgbA1c for gestational diabetes

Is NOT recommended

For a diagnosis of gestational diabetes to be made

>/= 2 abnormal labs

Gestational diabetes treatment

1. Diet & Exercise
2. Insulin: fasting >105, or postprandial >120


Delivery before 37 weeks

Preterm Labor

Regular uterine contractions (>4-6/hour) between 20-36 weeks

Treatment for preterm labor

Tocolytics: Mag sulfate, Terbutaline

Premature rupture of membranes (PROM) AVOID what

Digital Exam should be AVOIDED unless delivery is imminent

PROM treatment after 37 weeks

Induction with Oxytocin (Pitocin)

PROM treatment 20-36 weeks

1. Admit to hospital
2. If <34 weeks, steroids (betamethasone) for fetal lung development
3. NST and BPP daily

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