Term
|
Definition
|
|
Term
|
Definition
women of reproductive age
black women |
|
|
Term
|
Definition
abnormal bleeding: menorrhagia, metorrhagia, Fe deficiency anemia
pain: pressure, heaviness, back and leg pain, infarct, torsion
pressure: urinary symptoms, hydroureter, hydronephrosis, constupation
infertility, spontaneous abortion
sometimes asymptomatic and found in surgeries |
|
|
Term
| how is a uterine leiomya diagnosed |
|
Definition
| U/S, CT, MRI, hysterscopy |
|
|
Term
| what do you need to rule out if your thinking uterine leiomyoma |
|
Definition
endometrial neoplasia
pregnancy
adenexal mass |
|
|
Term
| symptoms of endometrial cancer |
|
Definition
| abnormal uterine bleeding |
|
|
Term
| cause of type 1 endometrial cancer, who is it normally seen in |
|
Definition
excess estrogen unopposed by progesterone causes proliferation of endometrium
more in obese women with high estrogen from fat |
|
|
Term
| what are the two types of type 1 endometrial cancer, their prognosis and composition |
|
Definition
endometrial hyperplasia: superificially invasive precursor lesion, localized disease and generally curable
endometrial carcinoma: glands that resemble normal emdometrium, 85% 5y survival with hysterectomy and progesterone |
|
|
Term
| endometrial hyperplasia can present at different severities, what are the severities, their risk of turning into carcinoma, and their treatment |
|
Definition
simple hyperplasia with no atypia: 1%, progesterone
complex hyperplasia with no atypia: 3%, progesterone
simple hyperplasia with atypia: 8%, hysterectomy, progesterone
complex hyperplasia with atypia: 29%, hysterectomy, progesterone |
|
|
Term
| what is the cause and typical patient in type 2 endometrial cancer |
|
Definition
genetic and cellular mutations
thin, older, post-menopause, no excess estrogen |
|
|
Term
| what are the two types of type 2 endometrial cancer and their prognosis |
|
Definition
papillary serous adenocarcinoma: grade 3, 40-60% survival
clear cell carcinoma: 30-75% survival |
|
|
Term
| explain the mayo criteria for staging endometrial cancer |
|
Definition
1A: cancer is in endometrium and less than half way through the myometrium
1B: cancer is in endometrium and more than half way through myometrium
II: cancer has not spread outside uterus
III: cancer has not left pelvus
IV: cancer has spread distally |
|
|
Term
| why do you always do a pap even when a women has had a hysterectomy |
|
Definition
| vaginal cuff (hold they sewed together at blunt end at vagina) is the most common place for cancer |
|
|
Term
| symptoms of ovarian cancer |
|
Definition
abdominal bloating
increased girth
fatigue
GI disturbance
urinary symptoms
abdominal pain
menstural irregularities |
|
|
Term
| risk factors for ovarian cancer |
|
Definition
| age, family history, personal history, infertility or low parity |
|
|
Term
| what decreases risk for ovarian cancer |
|
Definition
| contraceptives, tubal ligation, hysterectomy with ovary removal, pregnancy and breast feeding |
|
|
Term
| what are the three types of ovarian cancer and their subtypes |
|
Definition
epithelial: papillary, serous, mucinous, endometroid, clear cell
germ cell: choriocarcinoma, dysgerminoma, immature teratoma
stromal cell: granulosa cell, sertoli-leydig tumors |
|
|
Term
| which type of ovarian cancer is most agressive |
|
Definition
| stromal cell: granulosa cell, sertoli-leydig tumors |
|
|
Term
| which type of ovarian cancer is seen in young women |
|
Definition
| germ cell: choriocarcinoma, dysgerminoma, immature teratoma |
|
|
Term
| which type of ovarian cancer has the best prognosis |
|
Definition
germ cell: choriocarcinoma, dysgerminoma, immature teratoma
generally curable |
|
|
Term
|
Definition
agressive surgical debulking (get out as much as you can) to decress tumor burden and allow for better chemo results
chemotherapy |
|
|
Term
| risk factors for cervical cancer |
|
Definition
sexual activity: early onset, multiple partners, high risk partners, no condom increases risk of contraction of HPV 16 and 18
supressed immune system
smoking
family history |
|
|
Term
| 3 reasons for infertility, which is most common |
|
Definition
anovulation 30%
anatomic defects 30%
abnormal spermatogenesis 40% |
|
|
Term
|
Definition
| anti-estrogen which blocks receptors at hypothalamic pituitary axis INCREASING FSH which causes ovulation induction to help with anovulation |
|
|
Term
| how is clomid administered |
|
Definition
begin 5d after menses then 5d later add progesterone
check for ovulation 14d after 1st dose |
|
|
Term
|
Definition
| limit use, thins cervical mucous which can decrease pregnancy |
|
|
Term
| when do you use HCG/FSH/LH in infertility |
|
Definition
| once you have a mature follicle (natural or from clomid induction) prior to intercourse |
|
|
Term
| histosalpingogram: how, why, interpertation |
|
Definition
insert speculum and shoot dye through cervix into uterus and fallopian tubes then X-ray
makes sure tubal sterilization coils are in place, looks at shape of uterus, checks for blockage
uterus should be smooth and contrast medial should spill easily and symmetrically out fimbrae |
|
|
Term
| what does estrogen contraception do to the body |
|
Definition
| STOPS FSH which stops follicle development and increases progesterone receptors which decreases ovulation |
|
|
Term
| what does progesterone contraception do to the body |
|
Definition
| STOPS LH which thickens cervical mucous and decreases endometrial lining and thus implantation |
|
|
Term
| when do you use progesterone only contraception |
|
Definition
| when estrogen is contraindicated (DVT), breast feedingm >40yo |
|
|
Term
| what are the down sides to progesterone only contrception |
|
Definition
| must take within 3h every day or use back up for 48h |
|
|
Term
| how often do you need to replace contraceptive patch, ring, depo, implanon |
|
Definition
patch: remove after 3wk, wait 1wk
ring: remove after 3wk, wait 1wk
depo: shot every 3mo
implanon: replace every 5y |
|
|
Term
|
Definition
| decreased bone mineral density (never use >5y), weight gain, abnormal bleeding |
|
|
Term
| 3 types of IUD, when do they need to be replaced, what do they do to the period |
|
Definition
paragaurd: 10y, copper, heavier
progestasert: 1y, decreased
minera: 5y, decreased |
|
|
Term
| absolute contraindications to birth control |
|
Definition
clotting: thrombophlebitis, thromboembolid disease, CV disease, coronary occlusion
GYN: undiagnosed bleeding, breast cancer, pregnancy
organ: liver disease, congenital hyperlipidemia, hepatic neoplasm
life: smoker >35 |
|
|
Term
| what is the emergency contraceptive, when should it be taken |
|
Definition
| progesterone (levonogestrel/plan B) 72h post coitus |
|
|
Term
| what is the abortifactant pill |
|
Definition
|
|
Term
| 5 forms of permanent contraception, explain each |
|
Definition
vasectomy: most safe and reversible
laproscopy/tubal: best method for no future fertility
laparotomy: post partum small infraumbilical incision, close with pomeroy technique
hysterscopy: scope places occlusive agent or device into tubal osteia BL
hysterectomy: almost 100% effective, high morbidity, perferred if multigravida |
|
|
Term
| what are the 3 types of tubal, what are the good and bad of each |
|
Definition
electrocautery: lowest failure, least reversible
ring
clip (filschie/hulka): highest failure, most reversible |
|
|
Term
| in a normal pregnancy which thyroid hormones increase, which stay the same |
|
Definition
TBG, total T4, total T3 increase
TSH, free T4, free T3 same |
|
|
Term
| in hyperthyroid which thyroid hormones increase, decrease, and stay the same |
|
Definition
TSH decrease
TBG same
total and free T4, total and free T3 increase |
|
|
Term
| 2 TX of hyperthyroid in pregnancy and indications for each |
|
Definition
thioamides: DOC
thyroidectomy: only when noncompliant or nonresponsive to DOC (never radioactive iodine) |
|
|
Term
| thioamides: MOA, goal of tx, SE |
|
Definition
decrease conversion of T4 to T3
try and keep T4 1.2-1.8 (high normal) at lowest dose to minimize fetal exposure and avoid thyroid supression and goiter in baby
fever, rash, puritis, nausea |
|
|
Term
| 2 thioamides and the difference |
|
Definition
potylthiouracil: crosses placenta less
methimazole: high fetal risk |
|
|
Term
| TX hypothyroid in pregnancy, goal of tx, how to monitor tx |
|
Definition
| levothyroxine: normalize TSH, check every 4 wk till stable then every trimester |
|
|
Term
| risk of hypothyroid on baby |
|
Definition
preeclampsia, placental abruption, low birth weight
congenital cretinism: growth failure, MR
occurs fast! |
|
|
Term
| signs of the 4 stages of syphillis |
|
Definition
1. 10-60d after infection get canchre that lasts 2-9wk, painless
2. 4-8wk later symmetrical maculopapular rash on palms and soles, infective mucous patches, lymphadenopathy, fever, malaise, sore throat, headache
latent: for 1y, non-treponenal sero tests high
tertiary: 1-10y later seroreactive (Transmission unlikley), gummas, brain abscess, damage CNS, heart, great vessels |
|
|
Term
| how do you screen for syphillis |
|
Definition
non-treponemal...
vineral disease research lab (VDRL)
rapid plasma regin card test (RPR)
**not diagnostic and generally not positive in first stage best to check dark field for spirochetes at this time |
|
|
Term
| what tests are diagnostic for syphillis |
|
Definition
florescent treponemal antibody absorption (FTA-ABS)
microhemagglutin assay for antibody to T. pallidum (MHA-TP) |
|
|
Term
| 3 false positives for syphillis testing |
|
Definition
SLE
atypical pneumonia
CT disorders (scleroderma) |
|
|
Term
| signs of ectopic pregnancy |
|
Definition
amenorrhea
vaginal bleeding
abdominal pain
shoulder pain
back pain
syncope, dizziness, N/V, fever
breast tenderness
urge to defecate
peritoneal signs (in rupture)
cervical motion tenderness
adenexal mass on either side
uterine size 70% normal or slightly elevated |
|
|
Term
| why is there shoulder pain and urge to defecate in ectopic pregnancy |
|
Definition
shoulder: pushes on diaphragm when big enough irritating phrenic nerve. this means baby is big enough to rupture
defecation: irritation of posterior cul de sac in blood |
|
|
Term
| based on patient history how can you tell an ectopic pregnancy is not in the ampulla |
|
Definition
| if it goes 6 wk without rupturing it isnt in there |
|
|
Term
| how can you confirm an ectopic pregnancy 7 |
|
Definition
bHCG on labs 5d post conception and urine 14d
bHCG should increase by 66% in 48h failure means pregnancy isnt normal and may be ectopic
U/S
progesterone >25ng/mL indicates viable pregnancy, <5 not viable
culdocentesis: aspirate cul de sac positive if non clotting blood, negative if clear fluid
curettage of uterine cavity: only do if you highly suspect, no chorionic villi neans non-viable ectopic pregnancy
lacroscopy: direct visualization |
|
|
Term
| U/S signs in ectopic pregnancy, when can you see them, by what method |
|
Definition
transabdominal: identify sac at 5000-6000
transvaginal: identify sac at 1500-2000 and stick with heart beat at 5000 |
|
|
Term
| 4 ways to tx ectopic pregnancy |
|
Definition
surgical remova: linear salpingostomy, segmental rsection, salpingectomy
methotrexate |
|
|
Term
| methotrexate MOA, administration timeline |
|
Definition
folic acid antagonist interferes with DNA
single dose based on body surface area 50mg/m2 (usually 50-75mg)
day 0: give shot
day 4: check levels (HCG may increase)
day 7: hCG should decrease by 15% if not give second dose |
|
|
Term
| 8 indications fo methotrexate |
|
Definition
hemodynamically stable
non-laproscopic diagnosis
desires future fertility
able to return for follow up
no contrindications to med
no fetal cardiac motion
HCG <5000
unruptured mass <3.5cm |
|
|
Term
| 10 contraindications to methotrexate |
|
Definition
breast feeding
HIV
alcoholism
liver disease
blood dyscrasias
allergy
active pulmonary disease
peptic ulcer disease
renal disease
sac >3.5cm
embryonic cardiac motion |
|
|
Term
| threatened abortion: signs, prognosis |
|
Definition
vaginal bleeding, mild cramping, cervix closed
1/2 will abort |
|
|
Term
| inevitable abortion: signs, prognosis |
|
Definition
cervical changes, intense cramping, bleeding
irreversible changes |
|
|
Term
| complete abortion: define, signs |
|
Definition
<10wk entire POC passed
cramping, bleeding, passage of tissue then symptoms stop |
|
|
Term
| incomplete abortion: define, signs, tx |
|
Definition
>8-12wk
some tissue passed, cervix dilated, bleeding and cramps continue, POC seen in cervical OS
requires evacuation with suction curettage |
|
|
Term
| missed abortion: define, signs |
|
Definition
retention of failed IUP for extended period
brown discharge, feeling something wrong, loss of morning sickness, loss of brease tenderness |
|
|
Term
| absolute contraindications to hormone replacement in menopuase |
|
Definition
undiagnosed genital bleeding
known or suspected estrogen dependent neoplasia
active DVT, pulmonary emboli, hx of these
active or recent arterial thromboembolic disease (stroke, MI)
liver dysfunction or disease
known or suspected pregnancy
hypersensitivity to hormone therapy preperations |
|
|
Term
| define hypoactive sexual disorder |
|
Definition
| persistent or recurrent deficiency or absence of sexual fantasies thoughts or desire for receptivity to sexual activity with personal distress |
|
|
Term
| define female sexual arousal disorder |
|
Definition
| persistent or recurrent inability to attain or maintaint sufficient sexual excitement causing personal distress |
|
|
Term
| 3 types of female sexual arousal disorder |
|
Definition
missed arousal disorder: lack of subjective mental excitement
genital arousal disorder: lack of physiological response
general arousal disorder: both |
|
|
Term
| what is the most common female sexual disorder |
|
Definition
| hypoactive sexual disorder |
|
|
Term
| 3 sexual pain disorders, describe each |
|
Definition
dysparenuria: recurrent or persistent genital pain associated with intercourse
vaginismus: recurrent or persistent involuntary spasm of muscle in 1/3 upper vagina that interferes with vaginal penitration and causes personal distress
non-coital sexual pain disorder: recurrent persistent genital pain associated with non coital sexual stimulation |
|
|
Term
| 4 theories on endometrosis and the basis of each |
|
Definition
sampsons: retrograde flow
halbans: vascular and lymphadic dissemination
meyers: mullerian metaplasia of multipotential cells in peritoneal cavity, changes allow cells to develop into functional endometrial tissue
immunologic: immune complex found in menstural fluid, induces changes in some susceptible people causing endometrosis |
|
|
Term
| classic symptoms of endometrosis |
|
Definition
dysmenorrhea
dyspartenuria
inferitility
abnormal bleeding
pelvic pain |
|
|
Term
| non-classic symptoms of endometrosis |
|
Definition
| rectal bleeding, dyschezia, difficulty with defecation, hematuria, uterosacral nodularity, uterus fixed, ovarian enlargement, thick rectovaginal septum |
|
|
Term
| diagnosis of endometrosis |
|
Definition
H and P
laproscopic: DIRECT VISUALIZATION
biopsy of endometrial glands, stroma
presence of hemoserdin laiden macrophages
pelvis u/S
colonoscopy
MRI/CT |
|
|
Term
| what are the 5 heart diseases that cause mortality in pregnancy |
|
Definition
previous MI: 30% mortality in 3rd trimester
uncorrected tertaology of fallot
esimenger syndrome: 50% mortality due to thromboembolism (recommend termination)
mitral stenosis: never have mom push in pregnancy, too much pressure on valve
peripartum cardiomyopathy: 50% mortality, suggest termination?? |
|
|
Term
| define peripartum caridomyopathy, 4 causes |
|
Definition
cardiac failure in last 4wk gestation or 5-6mo post partum
myocarditis, preeclampsia, twins, hyperthyroid
**Dx of exclusion |
|
|
Term
| what are normal changes of the blood in pregnancy |
|
Definition
volume expands 40-50%
plasma > RBC mass
decreased hematocrit |
|
|
Term
| what are the #1 and 2 causes of anemia in pregnancy what type of anemia |
|
Definition
Fe deficiency: low MCV, MCHC, ferritin, microcytic hypochromatic
folate deficiency: megaloblastic |
|
|
Term
| what are the 5 causes of anemia that are not the two most common, what type of anemia |
|
Definition
hereditary spherocytosis: hemolytic
G6PDH deficiency: hemolytic
pyruvate kinase deficency: hemolytic
thalassemia: microcytic hypochromatic
sickle cell: hemolytic |
|
|
Term
| what are the normal changes of urine flow in pregnancy |
|
Definition
| increased GFR, renal plasma flow, CR clearance |
|
|
Term
| causes of cystitis in pregnancy, how does it cause complications |
|
Definition
| E. coli infects lower UTI and makes phospholipase A which makes PGE which causes contractions and perterm labor |
|
|
Term
| symptoms and lab signs of cystitis |
|
Definition
frequency
urgency
dysuria
bladder discomfort
afrebile
urianlysis: WBC, bacteria, nitrates, leukocyte esterase |
|
|
Term
| tx of cystis and pyelonephritis in pregnancy, complicatios, DOC |
|
Definition
ampicillin and cephtriaxone: safe, DOC
TMP/SMX: hyperbilirubinemia, worse 3rd trimester
nitrofuratonin: hemolysis, worse 3rd trimester |
|
|
Term
| how do you monitor tx for pyelonephritis |
|
Definition
pt should respond in 48-72h, if not change antibiotics, culture, and make changes as needed
check for obstructions and stones |
|
|
Term
| trisomy 21 levels of: AFP, E3, hCG, inhibin A, PAPA A |
|
Definition
AFP decreased
E3 decreased
hCG: increased
inhibin A increased
PAPA A increased |
|
|
Term
| trisomy 13 levels of: AFP, E3, hCG, inhibin A, PAPA A |
|
Definition
AFP no change
E3 no change
hCG no change
inhibin A no change
PAPA A decrease lots |
|
|
Term
| trisomy 18 levels of: AFP, E3, hCG, inhibin A, PAPA A |
|
Definition
AFP decrease
E3 decrease
hCG decrease
inhibin A no change
PAPA A decrease |
|
|
Term
| how can you identify the epidural space |
|
Definition
potential space around meninges
high resistance ligamentum flavum (pushing through makes pop)
low resistance epidural space |
|
|
Term
| what are the layers of penetration to get into epidural space |
|
Definition
| skin > spuraspinous lig > intraspinsou lig > lig flavum > subudural space |
|
|
Term
| autonomic dysreflexia: cause, signs |
|
Definition
trauma, bladder, distension, bowel sores, sex
anxiety, nausea, tachycardia, bradycardia, HTN crisis, HTN |
|
|
Term
| MOA of autonomic dysreflexia |
|
Definition
if pt had spinal cord injury above T7 it causes disease
cant sense pain of labor
body senses pain though and raises BP too high |
|
|
Term
|
Definition
sit pt upright
remove clothes
remove painful stimuli
all pt with injuty above T6 need to get epidural |
|
|
Term
| bartholian gland cyst/abscess: location, signs, tx |
|
Definition
base of each labia majora
cyst: soft painless
abscess: soft of firm, painful, erythema
TX: incision, include inside incision, world catheter, marspulization |
|
|
Term
| explain the path of fetal circulation |
|
Definition
oxgenation at placenta > ductus venosis > vena cava > two options
highly oxygenated blood > RA > foramen ovale > LA > mitral > aorta > brain and upper body
low oxygenated blood > RA > tricuspid > pulmonary artery > ductus arterosis > aorta > lower half of body |
|
|
Term
| rules for steroid tx in preterm labor |
|
Definition
| never give after 34wks (recommended 24-34 wks |
|
|
Term
| SE steroids in preterm labor |
|
Definition
flushing
headache
hypotension
not teratogenic |
|
|
Term
| what do you do if mom ruptures at 24-24 wks |
|
Definition
steorids
prophylactic antibiotics
MgS
delay only until pulmonary maturity then deliver vaginally if able |
|
|
Term
| what do you do if mom ruptures 34wks-up to term |
|
Definition
induce and deliver
infection risk > preterm delivery risk |
|
|
Term
| how can preterm labor be prevented |
|
Definition
weekly progesterone injections (16-36 wks only)
quick attention to complaints: pelvic pressure, discharge, cramps
education to signs and symptoms |
|
|
Term
| explain the normal hormone secretion process and timing of puberty |
|
Definition
hypothalamus secretes GNRH which stimulates pituitary to make FSH/LH which acts on adrenal glands to make progesterone and estrogen
6-8yo adrenal glands begin secreting dehydroepiandrosterone
2y later gonads begin secreting gonadal sex hormones
4y later complete |
|
|
Term
| how is pubirty timing controlled |
|
Definition
body fat: need 85-106lbs within 16-24% body fat (delay in athletes, premature in obesity)
sleep: increase in FSH/LH
optic light: blind adolescents have delayed secondary sex development, sunlught helps with delease of gonadotropins |
|
|
Term
| order of body changes in puberty |
|
Definition
| thelarche > pubarche > adrenarche > growth spurt > menarche > growth spurt |
|
|
Term
| turner syndrome: cause, 7 signs |
|
Definition
45XO
hypoergonadotrophic hypogonadism
webbed neck
shield chest
wide spaced nipples
coarctation of aorta
rudimentary ovaries - gonadal streak
multiple pigmented nevi |
|
|
Term
| normally how is testosterone/DHEA/deoxycorticosterone made |
|
Definition
DHEA --> testosterone + andostenedione
progesterone + 12a-hydroxylase + 21a-hydroxylase --> deoxycorticosterone
testosterone + 5a-reductase --> dihydroxytestosterone (DHT) |
|
|
Term
| cause of congenital adrenal hyperplasia |
|
Definition
AR altered 21-hydroxylase gene on CH6
21-hydroxylase deficiency > increased progesterone and 17a-hydroxyprogesterone > DHEA > androstendione and testosterone
OR
11b-hydroxylase deficiency catalizes conversion od deoxycorticosterone to cortisol which increases androgens |
|
|
Term
| signs of congenital adrenal hyperplasia |
|
Definition
early: ambigous gneitalia, virilized newborn, salt wasting
late: puberty andrenarche precedes thelarche |
|
|
Term
| diagnosis of congenital adrenal hyperplasia |
|
Definition
DHEAS and androstendione and 17-hydroxyprogesteone in follicular phase
mild HTN and histurism |
|
|
Term
| tx congenital adrenal hyperplasia |
|
Definition
DOC deoxycorticosterone
adrenals decreased cortisol production so to maintain control you increase ACTH causing over secretion of precursor and increased androgens
glucicorticoids + prednisone > ACTH secretion |
|
|
Term
| what hormones do adrenal glands, ovaries, and adipose make |
|
Definition
adrenal glands: DHEA, androstendione, testosterone
ovaries: androstendione, testosterone
adipose: testosterone from conversion of androstendione |
|
|
Term
| what is the basis of constitutional histuism |
|
Definition
| dihydrotestosterone (more potent) is made within hair follicle and genital skin via conversion of testosterone and 5a-reductase |
|
|
Term
| how is the ovary ocntrolled by androgens |
|
Definition
| LH > theca lutein cells > androstenedione + testosterone > granulosa cells of ovarian follicles > estrogen |
|
|
Term
| cause of polycystic ovarian disease |
|
Definition
excess LH stimulates ovarian theca lutein cells > increase androstendione > aromatized to estrone in fat cells > esterone positive feedback on LH and cycle continues
with increase in androstendione there is increase in testosterone which causes histurism and acne |
|
|
Term
|
Definition
2/3
1. oligo-ovulation or anovulationm irregular menses or amenorrhea
2. hyper androgenism: clinical or biochemical
3. polycystic on U/S STRING OF PEARLS |
|
|
Term
| hormones changes in polycystic ovarian disease |
|
Definition
increased LH:FSH
estrone > estradiol
androstendione increase
testosterone increase |
|
|
Term
| symptoms of polycystic ovarian |
|
Definition
oligomenorrhea/amenorrhea
acne, histurism
infertility, chronic anovulation
40% impaired glucose tolerance with 8% class II screen with diabetes
increased TG/LDL
decreased HDL
HTN
obesity
metabolic syndrome |
|
|
Term
| tx of polycystic ovarian if pregnancy not desired |
|
Definition
weight reduction
contraceptives: supress LH > decreases ovarian production of testosterone and androstendione > decreases acne, histurism and androgen stimulation of existing follicles
spironolactone: stops steroid enzymes, binds androgenic receptors at hair follicle
shaving, electrolysis, depliatories |
|
|
Term
| tx of polycystic ovarian syndrome if pregnancy desired |
|
Definition
weight reduction
clomid to induce ovulation
metformin insulin sensitizer |
|
|
