PCOS - insulin resistance and anovulation

thyroid disese

nonclassical congenital adrenal hyperplasia - get early morning serum 17-hydroxygrosterone level

androgen-secreting tumor- if testosterone exceeds 2 ng/ml

cushing syndrome

hyperprolactinemia

intermittent progestins

provera

contraceptive steroids - pills, patch, ring

reduce insulin resistance - metformin + rosiglitazone

ovulation induction - clomid + aromatase inhibitor

check for fertility factors

birth control pills or patch or ring

antiandrogens - aldactone, propecia

diet and exercise

metformin

lipid abnormalities

cv disease

insulin resistance

endometrial carcinoma

sleep apnea

1. hypothalamic or pituitary problem

- loss of GnRH (stress, low body fat, congenital) or hyperprolactinemia (pituitarm adenoma, hypothyroidism, drug-induced, idiopathic)

2. ovarian problem

- congenital - Turner's

- premature menopause (ovarian failure)

3. uterine problem

- intrauterine adhesions (synechiae)

- congenital- mullerian agenesis, outflow problems

4. metabolic/endocrine abnormality

-hypothyroidism

- hyperprolactinemia

- chronic illness/cancer

- inuslin resistance (PCOS)

exam - uterus normal? scarring?

hormone challenge

- give provera (progestin). bleeding = intact uterus + somewhat fxnal ovaries

- if provera doesn't work, then give extrace + provera. bleeding = intact uterus but non-fxnal ovaries

Labs: HCG, FSH, LH, TSH, prolactin, testosterone, chromosomal analysis

dx:

tx:

1. if she DOES want more kids:

- GSH or GnRH + fertility drugs

2. if she Does NOT want more kids:

- birth control pills to fix estrogen problem

submucous leiomyoma

tx: surgery, stop periods, GnRH agonist (lupron) to shrink fibroids temporarily

submucous leiomyoma - "fibroids"

PCOS - irregular, heavy periods

coagulopathy

benign ovarian cyst

ovarian malignancy

pedunculated leiomyoma

benign: unilateral

mobile

cystic

small (<5 cm)

malignant:

bilateral

fixed

solid or semi-cystic

large >5 cm

ascites

benign cystic teratoma (dermoid)

tx: excision

cystadenoma

tx: excision

complications:torsion, mucinous peritonitis if rupture, death due to compression of other organs

PID

ovarian torsion

ruptured endometrioma

ectopic pregnancy

spontaneous abortion

PID (acute salpingitis)

tx: remove IUD, supportive care

doxycycline, azythromycin

ovarian torsion

us: mass with no arterial flow

tx: spontaneous reversion (knee-chest position)

operative laparoscopy (untwist if not necrotic), oophorectomy if  necrotic

endometriosis

laparoscopy - resection/destruction of endometrioma

try to get pregnant

consider fertility tx if doesn't get pregnatn

priamry: young age, ovulatory menstrual cycle, congenital uterine abnormalities, abnormal prostaglandin metabolism

secondary: pelvic pathology, endometriosis, adenomyosis, leiomyoma, outflow obstruction

endometriosis

tx: expectant, symptomatic, ovarian suppression, surgery (TAH or BSO)

pregnancy/fertility tx

continuous steroid contraceptives

GnRH agonists (Lupron)

adenomyosis

tx: symptomatic (NSAIDS), ovarian suppression, hysterectomy, segmental resection, endometrial ablation

leiomyomata (fibroids)

tx: expectant

- ovarian suppression (lupron)

- anti-progestational (RU-486)

- radiologic embolization

- surgery - myomectomy or hysterectomy

mullerian fusion abnormalities

vaginal formation problems

cervical stenosis

uterine prolapse

tx: reduce abdominal pressure (lose weight, tx COPD), estrogen replacement, kegels, surgical sling procedure

NOT hysterectomy

candida - yeast infection - monilia

tx: oral or topical fungicides, topical cream (monistat)

other causes: HIV, hormonal changes (pregnancy, bcp), summer (sweat, swimsuits)

trichomoniasis

oral or topical metronidazole

bacterial vaginosis

oral or topical metronidazole

topical clindamycin

vasectomy

gonadotropin suppression via testosterone injection every 3-6 weeks but has 8-12 week "waiting' period

estrogen: 14-50 mcg

progestin: 0.15-1 mg

contraceptive patch with norgestimate and ethinyl estradiol

risk: higher risk of DVT and PE

n/v

breakthrough bleeding

breast tenderness

dysphoria

oily skin/acne

complications:

HTN, hypercoagulation, lipid profile changes, stroke, mi,

contraception

reduced mentstrual bleeding, cramping

predictable or no periods

reduced risk of uterine and ovarian cancer (NOT cervical)

injectible progestin

not very user friendly because lots of side effects (breakthrough bleeding, weight gain, dysphoria), lipid/cv concerns, bone loss, sexual dysfunction

once every 3 mos

depo-provera + estrogen

once monthly

IUDs

once every 3-5 years

PID risk

 but less systemic effects because it delivers a lower dose of progestin straight to uterus

good for heavy periods

elecrtical current that coagulates pathches on uterus to destroy endometrium

used for menorrhagia -- still need contraception

plan b - cuts risk of pregnancy by 75% - doesn't mean still 25% risk of being pregger because risk wasn't 100% to begin with

insert IUD

barrier contraceptives

IUD

progestin-only pills

depo-provera

injectible progestin

sperm problems: 35%

tubal problems: 35%

egg/ovulation: 15%

unusual: 5%

idiopathic: 10%

<35 - after 1 year of unprotected intercourse

35-40: after 6 mos

>40: immediately

health

- pelvic exam

- HIV, HEP B & C tests

- immune status  rubella, hep

- TSH

- genetic tests

eggs

- day 2-3 of menstrual cycle - FSH (should be <10), E2 (should be <80)

- post-ovulation day 6-8 serum progesterone (should be >9)

sperm

- semen analysis

tubes

- hysterosalpingogram

- laparoscopy

10-17 - pregnancy is possible but treatment will improve changes

17-25 - pregnancy is possible (but unlikely) but treatment is of no value

concentration:

normal >20 mil/ml

mild/mod 10-19 mil/ml

severe 5-9 mil/ml

very severe <5 mil/ml

motility:

Normal >40%

mild/mod 20-39%

severe 10-19%

very severe <10%

volume:

<1 ml or >10 ml

TMC: volume x conc x motility: should be >35 mil

mild/mod: might consider intrauterine insemination IUI

severe/very: basically need IVF

enhancing ovulation

ex: gonadotropin injections (have "gonal" in them), clomiphene citrate, clomid

fertility drug

increased rate of twins/triplets

if it will work, it will work in the first 3-4 mos. no value continuing past 6 mos

yes, or close to it

tx: estrogen, SSRIs

reduce/prevent vasomotor flushes: estrogen, SSRIs

improve sleep (by treating hot flashes)

prevent bone loss (estrogen, ca, ssri, bisphosphonate)

large study of HRT

results: HRT has some bad side effects and shouldn't be used on everyone

estrogens

combined with progestin for any women that still has uterus. cannot give estrogen alone because of increased risk for cancer

endometrial hyperplasia

endometrial carcinoma

selective estrogen receptor modulators

prevent breast cancer and improve bone health

tamoxifen and raloxifene

women wtih significant hot flushes

3-5 years post-menopause

increased risk of:

breast cancer

cv disease

thromboembolism

uterine cancer (unless progestin is added)

surgery (TAH, BSO)

adjunctive chemo

cervical intraepithelial neoplasia - cervical cancer precursor

mild/moerate/severe dysplasia

screened via pap smear

begin 3 years afer becoming sexually active or 21 y/o

every 3 years if results are normal

stop age 65 or 70

normal: no intraepithelial lesions or malignancy

atypical squamous cells: ASC

- undetermined significance (ASC-US) - could just be inflammatory reaction - treat infection, repeat in a few mos

- cannot exclude HSIL  (ASC_H) - basically same as high grade

low grade squamous intraepithelial lesions (LGSIL)

high grade squamous intraepithelial lesions (HGSIL)

for anything other than normal or ACS US, do colposcopy

loop electrosurgical excision procedure (LEEP)

cervical cryotherapy

cold knife cone biopsy

local spread and destruction- occlusion of ureters, penetration into bladder/rectum

lymphatic spread

distant metastasis rare

radical hysteretomy and lymph node dissection

radiation - often via implant therapy

chemo

pelvic exenteration - take out all organs in the pelvis

increased: unopposed estrogen (PCOS, Rx)

genetics

decreased: oral contraceptives, progestin

hyperplasia w/o atypia

hyperplasia w/ atypia

CIS

endometrial carcinoma until proven otherwise

postcoital: cervical polyp or cervical ca

abnorma;: endometrial hyperplasia or ca

eval: transvag US, endometrial bioosy, dilation and curettage

radiation - implants to endometrium and vag, lymph nodes

surgery: TAH, BSO

hormonal: progestin, tamoxifen

chemo

vulvar

vaginal

uterine