CPD II: gynecology week 2 cont'd

the second lecture of the second week of gynecology in CPD II: vaginitis, PID, GC/chlamydia.

here are some keywords for the different conditions:
BV: risky sexual practices, clue cells, thin white discharge. gardnerella.
candida: thick cottage cheese discharge, redder tissue.
atrophic: low estrogen, thin clear discharge, thin / dry walls, high pH, basal cells.
trichomonas: copious yellow / green, tender perineum, strawberry cervix.
cytolytic: overgrowth of lactobacillus. candida symptoms. atypical clue cells, baking soda.
PID: save the tubes in 36 hours! fever / discharge. high WBC's. inguinal lymphs. fitz-hugher-curtis.
GC: greenish yellow discharge, swelling of glands, 7-21 days prodrome, increased ESR/WBC/pH.
chlamydia: similar to GC. flourescent antibody test. increased pH.

questions
vaginitis...
1. what are the signs and symptoms of vaginitis?
2. when is vaginal discharge normal?
3. what effect does progesterone have on cervical discharge?
4. what are some common etiologies for vaginitis for children?
5. vaginitis in reproductive age women is usually from...
6. what is a factor that protects against bacterial overgrowth in the vagina?
7. what are some non infectious causes of vaginitis in reproductive age women?
8. what is the pathogenesis of vaginitis in menopausal women?
9. how might crohn's disease lead to a sequelae of vaginitis?
10. what is the most likely cause of vaginitis for symptoms that occur before vs. after menses?
11. what are some distinct morphological signs for vaginitis from candidia?
12. if the WBC count on a wet prep is below 50 per HPF, vaginitis is likely due to...
13. if the WBC count on a wet prep is above 50 per HPF, vaginitis is likely due to...
14. what is a differential diagnosis for vaginitis related to dermatology?

bacterial vaginosis...
15. what is a microscopic finding that can point to BV?
16. name some risk factors for bacterial vaginosis.
17. what are the potential complications for a woman with BV?
18. what are the criteria for diagnosis of BV?
19. the WBC count is usually...
20. what is the quality of the vaginal discharge in BV?

vaginitis due to candida...
21. what are some risk factors for candida infection?
22. what is the quality of the vaginal discharge in candida?
23. what are some other symptoms of a candida infection?
24. how does symptom severity relate to time during the menses cycle in a candida infection?
25. compared to other types of vaginitis, vaginal tissue with candida infection is generally more...
26. how is the diagnosis of candida vaginitis made?
27. if there is a candida infection without the positive sign in question 26, what does this indicate? how is this treated?
28. what are some ddx's for vaginitis due to candida?

atrophic vaginitis...
29. what is the cause of atrophic vaginitis?
30. what is the quality of the vaginal discharge and vaginal walls in atrophic vaginitis?
31. what is a differential diagnosis for atrophic vaginitis?
32. what is the pH of atrophic vaginitis?
33. what is seen on the wet prep for atrophic vaginitis?

trichomonas...
34. what are the signs / symptoms of a trichomonas infection?
35. what is the morphological sign on the cervix for a trichomonas infection?
36. what is the conventional treatment for a trichomonas infection?

cytolytic vaginosis...
37. what is cytolytic vaginosis?
38. what is a common cause of cytolytic vaginosis?
39. what are the signs / symptoms of cytolytic vaginosis?
40. what might be present in the wet prep of cytolytic vaginosis?
41. what is an effective and simple treatment for cytolytic vaginosis?

PID...
42. how long is the window of time before the uterine tubes might be irreversibly damaged by a PID infection?
43. what are the common etiologies for women under 35yo with PID?
44. what are the common etiologies for women over 35yo with PID?
45. what are some risk factors for PID?
46. what are the signs/symptoms for PID?
47. what are some PE findings for PID?
48. what are three main diagnostic criteria for PID?
49. what are some complications of PID?
50. what is fitz-huges-curtis syndrome?
51. what are the differential diagnoses of PID?

GC...
52. what is the quality of the discharge in a gonorrhea infection of the vagina?
53. what are some other symptoms in a gonorrhea infection?
54. how long does it take for symptoms to appear after exposure to GC?
55. what are the lab tests used to diagnose GC?

chlamydia...
56. what is the most common presentation of a chlamydia infection?
57. what is the test used to diagnose a chlamydia infection?

answers
1. abnormal vaginal discharge
irritation / swelling / pruritis
erythema
dysuria / dyspareunia
2. before ovulation due to high estrogen levels.
3. causes it to become thick and sticky, forming a plug in the cervix that can remain in place in conception occurs.
4. poor perianal hygeine
bath chemicals / soaps
foreign bodies
5. infection: trich, candida, or BV.
6. lactobaccilus (keeps pH low)
high estrogen levels (maintains wall thickness)
7. factors that raise pH in the vagina: semen, menstrual blood,
tight clothing
frequent douching
foreign bodies
8. lower estrogen levels leads to thinning of the vaginal wall which might lead to decreased lactobacillus which could lead to increased pH and greater vulnerability to infection.
9. through a fistula that connects the vaginal and the GI tracts.
10. before: chronic candida. after: BV.
11. paper cut-like fissures on the labia majora / minora.
12. normal flora imbalance.
13. staph, strep, ecoli, GC, chlamydia.
14. lichen sclerosis.

15. clue cells.
16. IUD's
risky sexual practices
uncircumcised male partner
17. PID if not pregnant
post partum, premature complications if pregnant
18. Amsel's criteria:
higher than 4.5 pH
fishy odor
gray/white discharge
clue cells
[your clue: 4.5 gray fishes]
19. below 50hpf.
20. thin, copious, white.

21. diabetes, antibiotics, pregnancy, chronic yeast infections, some contraceptives.
22. thick white cottage cheese discharge that adheres to vaginal wall.
23. pruritis, erythema, dryness
dyspareunia
24. symptoms increase before menses.
25. red.
26. the presence of hyphae / buds / spores on wet prep.
27. candida glabradae, as opposed to candida albicans. treat with boric acid.
28. contact / allergic / chemical irritation
paget's disease of the vulva

29. low estrogen levels due to menopause or primary ovarian insufficiency.
30. clear vaginal discharge, thin and dry vaginal walls.
31. erosive lichen planus.
32. greater than 6, because less lactobacillus.
33. increased WBC
decreased lactobacillus
increased parabasal cells
increased cocci

34. copious yellow / green discharge
tender perineal area
dysuria
35. "strawberry cervix".
36. antibiotics.

37. an overgrowth of the normal lactobacillus strain in the vagina.
38. increased stress.
39. similar to candida.
40. atypical clue cells.
41. baking soda.

42. about 36 hours.
43. STI, from GC and CT.
44. overgrowth of endogenous flora.
45. unsafe sex
age, economic factors
nulliparous
46. lower abdominal pain that radiates to the back / sternum
fever
discharge
abnormal bleeding
47. inguinal lymphadenopathy
fever
mucopurulent discharge
enlarged Skene's glands
easily friable, erythematous cervix
cervical motion tenderness
48. elevated wbc's on CBC
WBC's over 50hpf on wet prep
sed rate over 15mm/hr
49. fitz-hughes curtis
tuboovarian abscess
adhesions
infertility
hydrosalpinx
50. infective exudate leaving the fimbrae and travelling between liver and diaphragm.
51. endometriosis
adenomyosis
ectopic pregnancy
cysts

52. greenish mucopurulent discharge.
53. bartholin/skene gland swelling
urinary symptoms
54. 7-21 days.
55. increased ESR, WBC
increased pH
DNA probe

56. similar presentation to GC infection, or asymptomatic.
57. flourescent antibody testing, increased pH on wet prep.

CPD II: gynecology week 2- bleeding disorders

this lecture looked at some more disorders of the female reproductive tract: amenorrhea, dysfunctional uterine bleeding, PMS, PCOS, premature ovarian failure, and menopause.


questions
amenorrhea...
1. what are some signs that could indicate primary amenorrhea?
2. what are some signs in a reproductive age woman that could indicate secondary amenorrhea?
3. what are some general symptoms / signs to look for that could be correlated to amenorrhea?
4. obesity plus amenorrhea might suggest...
5. amenorrhea plus moon facies might suggest...
6. what is a maturation index and how might it help in the diagnosis of amenorrhea?
7. decreased DTR's might indicate...
8. what are the first two tests to perform on a patient with amenorrhea?
9. what are some other tests that might help with a diagnosis of amenorrhea?
10. hypothyroid is associated with amenorrhea and...
11. elevated TSH levels also cause the elevation of...
12. what can amenorrhea plus high FSH levels indicate?
13. what might amenorrhea plus low / low normal FSH levels indicate?
14. what might amenorrhea plus an elevation of free testosterone or DHEAS indicate?
15. if all the above tests are normal, what is the next diagnostic step?
16. what are the most common causes of secondary amenorrhea?

DUB...
17. what is dysfunctional uterine bleeding?
18. what is the most common age for DUB?
19. what is the etiology of DUB?
20. what are the signs / symptoms of DUB?
21. what are some tests that might aid in the diagnosis of DUB?
22. what is the salivary progesterone good for detecting?

dysmenorrhea...
23. what are the characteristics of primary dysmenorrhea?
24. what are the most common causes of secondary dysmenorrhea?
25. what are the signs and symptoms of dysmenorrhea?
26. how might primary and secondary dysmenorrhea be distinguished based on treatment?

PMS...
27. what are the theories of etiology for PMS?
28. diagnosis of PMS is made by...
29. what are some differential diagnoses of PMS?

PCOS...
30. how common is PCOS?
31. PCOS is characterized by...
32. what is a test that can aid in the diagnosis of PCOS?
33. what are the "cysts" in PCOS?
34. what are the possible sequelae for PCOS?
35. what are some common symptoms for PCOS?
36. what is a good lab test to diagnose PCOS?
37. what would be seen in the TVUS for a PCOS patient?
38. what is a hormone that further increases estrogen sensitivity in the uterus?

premature ovarian failure...
39. what is premature ovarian failure?
40. what are the etiologies for premature ovarian failure?
41. what are the signs / symptoms of premature ovarian failure?
42. what are labs that can aid in the diagnosis of premature ovarian failure?

menopause...
43. physiologic menopause occurs when menses stops for how long?
44. what is the average age for physiologic menopause in the US?
45. what is the hallmark symptom for the perimenopausal period?
46. describe the hormonal shifts that occur during the perimenopausal period.
47. what are some causative factors for premature menopause?
48. what is the most common reason that women with menopause seek treatment? what is the cause of this symptom?
49. what are some other common symptoms related to menopause?
50. if a patient comes in with symptoms of menopause, what is an important test to perform first?
51. what are the potential issues in menopause related to osteoporosis?
52. what are some factors that can increase a menopausal woman's risk for osteoporosis?
53. what are some tests to screen for the potential CV disease that might be associated with menopause?

answers
1. no signs of puberty before 13
menarche 16yo
2. negative pregnancy test, missed menses for over 3 months, have less than nine menses per year.
3. hypo or hyperthyroid symptoms
virilization (hypertrichosis, hirsuitism)
obesity
4. PCOS
5. Cushing's.
6. a microscopic assessment of (endometrial?) cells that looks at the stage of development of cells present which is an indication of the degree of estrogen influence. (superficial cells: high estrogen influence. basal cells: low estrogen influence)
7. hypothyroid.
8. thyroid panel and prolactin.
9. pregnancy test
CMP
CBC, sed rate
celiac panel
bone age
10. infertility.
11. prolactin levels.
12. primary ovarian insufficiency.
13. hypothalamic amenorrhea.
14. pituitary tumor, ovarian, adrenal tumor.
15. TVUS to see any structural abnormalities.
16. PCOS and hypothalamic.

17. abnormal bleeding in the absence of signs of structural abnormality, inflammation or pregnancy.
18. puberty and perimenopause.
19. related to anovulation, can be caused by PCOS or idiopathic.
20. polymenorrhea, menorrhagia, metrorrhagia.
21. thyroid panel
TVUS
progesterone test
EMB
22. good for detecting if patient is ovulating in general: test on day 21.

23. due to prostaglandin excess, pain related to excess contraction, begins in menarche and has consistent episodes.
24. structural abnormality: endometriosis, adenomyosis, fibroids.
25. colicky pain that begins 1-3 days prior to menses and lasts until 2-3 days after.
26. NSAID's and OCP's will alleviate symptoms of primary dysmenorrhea and not secondary dysmenorrhea.

27. fluctuations of estrogen / progesterone levels, increased sensitivity of tissues to E/P levels, fluid retaining effects of estrogen.
28. PMS journals.
29. thyroid disease
other hormonal disorders
affective disorders

30. 5-10% of women.
31. anovulation plus androgen excess symptoms.
32. test FSH/LH levels on day 3 of cycle, can be 1:3 instead of 3:1. high LH levels indicate chronic anovulation.
33. follicles that have not ovulated.
34. CV disease
diabetes
endometrial carcinoma
35. irregular menses
hirsuitism, acne, alopecia
mild to severe obesity
36. salivary hormone levels: estrogen, testosterone, progesterone, DHEA, cortisol
37. polycystic ovary; string of pearls morphology.
38. hyperinsulinemia.

39. premature menopause that results from insufficient estrogen production from ovaries despite high gonadotropin hormone levels.
40. autoimmune
chemotherapy / pelvic irradiation
congenital thymic aplasia
galactosemia
gonadal dysgenesis
41. amenorrhea plus estrogen deficiency symptoms.
42. high serum FSH combined with low serum estradiol.

43. one year.
44. 51.
45. increased menses frequency followed by oligomenorrhea.
46. estrogen and progesterone production decrease while testerone stays the same.
47. smoking, high altitude, malnutrition.
48. hot flashes, caused by low estrogen / high gonadotropin levels.
49. vaginal dryness / atrophic vaginitis / dyspareunia
neuropsychiatric changes
night sweats
urinary frequency or incontinence
Gi disturbances
musculoskeletal changes
decreased libido
50. thyroid function to rule out hypothryoid.
51. decreased estrogen levels causes increased bone resorption by osteoclasts which increases likelihood for fractures, etc.
52. alcohol/cigarettes
caucasian/asian race
family history of osteoporosis
GI malabsorption issues
53. lipid profile
glucose
BMI
inflammatory markers

CPD II: gynecology- pelvic pain, pelvic mass, abnormal bleeding

this week we began the gynecology section in CPD, taught by Dr. Windstar. we went over some of the anatomy and physiology from last year, then talked about diagnosis of various abnormalities: pelvic pain, pelvic mass, and abnormal bleeding disorders.

questions
introduction...
1. what is the characteristics of a normal menses in terms of color, how long the flow lasts, average blood loss?
2. what is menorrhagia?
3. how much blood does a saturated pad or tampon usually hold?
4. what is the connection between constipation and gynecological conditions?
5. what are rectoceles and cystoceles?
6. Skene's glands are palpated if what is suspected?
7. what are the 4 possible positions of the uterus?
8. what is the normal size of the uterus?
9. what is the normal size of a reproductive age ovary?
10. what is the normal size of a menopausal age ovary?
11. what is the most common place that endometriosis develops?
12. name three pregnancy tests.
13. what is the advantage to the serum qualitative test?
14. what is the serum quantitative test used for?
15. what is the normal pH of cervical secretions?
16. what is the most common imaging technique used when masses are suspected?

pelvic masses...
17. what are hematocolpos?
18. what is the most common benign neoplasm in women?
19. what are hydrosalpinges?
20. TVUS might be preferred over CT because...
21. what is the most common tumor marker elevated in ovarian cancer?

pelvic pain...
22. what are the four systems that must be assessed with the presentation of pelvic pain?
23. what might syncope or hemorrhagic shock suggest?
24. describe the quality of pelvic pain in adnexal torsion.
25. tenderness in the anterior abdominal wall might indicate...
26. describe the quality of pelvic pain in perirectal abscess.
27. what are some sources of pain that would require immediate referral to ER?
28. what are some concomitant symptoms that should always be asked when a patient presents with pelvic pain?
29. 70% of patients with chronic pelvic pain have...
30. what are some labs that would aid in the diagnosis of pelvic pain?
31. if source of pelvic pain cannot be determined with PE and labs, consider...

abnormal vaginal bleeding...
32. what is menorrhea?
33. what is polymenorrhea?
34. what is metrorrhagia?
35. what is oligomenorrhea?
36. what is amenorrhea?
37. how long after menopause does bleeding need to persist in order to be considered abnormal?
38. what are the common ages for anovulation and why?

what are the most common causes of abnormal vaginal bleeding for...
39. infants.
40. children.
41. women of reproductive age with syncope or hemorrhagic shock.
42. women of reproductive age with positive pregnancy test.
43. women of reproductive age with negative pregnancy test.

44. what are the labs and imaging tests that would aid in the diagnosis of abnormal vaginal bleeding?
45. what is a south american herb that can aid in estrogen imbalances?

female reproductive endocrinology...
46. how does weight affect onset of puberty?
47. how does blindness affect onset of puberty?
48. what is the most common cause of precocious puberty?
49. what is the average age of menarche in the US?
50. describe the levels of FSH and LH after birth and in early childhood.
51. what hormonal change triggers the beginning of the menstrual cycle?
52. what is the hormone that stimulates FSH and LH production and where is it produced?
53. what is the hormonal change that triggers ovulation?
54. corpus luteum makes which hormone?
55. why does body temperature rise during the luteal phase?
56. when do progesterone levels peak?
57. if implantation occurs, how long does the corpus luteum continue to produce progesterone?
58. what are the hallmarks of the endometrial proliferative stage? what stage of ovarian development does this correspond to?
59. what are the hallmarks of the endometrial secretory stage? what stage of ovarian development does this correspond to?
60. when during the lifetime is estrone (E1) highest? what demographic is it higher in?
61. when during the lifetime is estradiol (E2) highest? what is it produced by?
62. when is estriol (E3) highest? what is it produced by?
63. E3 is the breakdown product of...

amenhorrhea...
64. what is meant by primary and secondary amenhorrea?
65. what are causes of anovulatory amenhorrhea related to hypothalamic dysfunction?
66. what are causes of anovulatory amenhorrhea related to pituitary dysfunction?
67. what are causes of anovulatory amenhorrhea related to ovarian failure?
68. what are causes of anovulatory amenhorrhea related to other endocrine dysfunction?
69. what is ovulatory amenhorrhea?
70. what are examples of anatomical abnormalities that might cause ovulatory amenhorrhea?

answers
1. medium/dark red
3-7 days of bleeding
30mL blood loss
2. greater than 80mL blood loss during a cycle or bleeding for more than 7 days.
3. 5-15mL.
4. constipation can cause more estrogen to return from the GI back into the blood stream, via beta glucoronidase, causing an estrogen dominance state.
5. rectoceles are bulges of the posterior vaginal wall and cystoceles are bulges of the anterior vaginal wall due to wall laxity.
6. chlamydia.
7. retroverted, retroflexed, anteverted, anteflexed.
8. 6cm * 4cm.
9. 3 * 2 * 2cm.
10. 1 * 0.7 * 0.5cm.
11. pouch of douglas.
12. urine ßHCG
serum qualitative ßHCG
serum quantitative ßHCG
13. more specific and sensitive than urine.
14. miscarriage or ectopic pregnancy.
15. 3.5-4.5
16. ultrasound: transvaginal or abdominal.

17. accumulation of blood in the vagina due to imperforate hymen.
18. fibroids / leiomyomas.
19. uterine tubes filled with fluid due to blockage at the distal end.
20. because of the radiation from a CT.
21. CA-125.

22. gyn, GI, GU, MS.
23. ruptured ectopic pregnancy, ovarian cyst.
24. severe, colicky, unilateral pain which reaches peak intensity in seconds or minutes.
25. bladder / urethral pain due to a lower urinary disorder.
26. painful defecation, localized tender mass.
27. ectopic pregnancy
tubo-ovarian abscess
ovarian cyst rupture or torsion
appendicitis
bowel perforation
28. fever, chills, nausea, vomiting, dizziness, dyspnea, night sweats.
29. endometriosis.
30. UA
wet prep
CBC
pregnancy test
31. TVUS, laparoscopy.

32. see question 2.
33. menses that are too frequent (less than 21 days before menses).
34. bleeding that occurs not in relation to menses (including spotting).
35. infrequent menses (more than 35 days between menses)
36. no menses.
37. 6 months.
38. puberty and perimenopause due to the lack of progesterone.

39. in utero stimulation of endometrium via placental estrogens.
40. trauma, precocious puberty / premature menses, urethral meatus prolapse.
41. see question 23.
42. spontaneous abortion, ectopic pregnancy, gestational trophoblastic disease, endometritis.
43. hormonally related cause, or structural abnormality.

44. pregnancy, CBC, ferritin, TVUS, EMB, coagulation tests, vulvar biopsy, pap smear.
45. maca.

46. overweight girls have earlier puberty and underweight girls have later puberty.
47. earlier onset for unknown reasons.
48. hypothyroidism.
49. 12.5.
50. very high at birth but low in childhood.
51. drop in estrogen and progesterone.
52. GnRH, produced in the hypothalamus.
53. spike in LH.
54. progesterone.
55. because of the thermogenic effects of progesterone.
56. about day 21.
57. until the placenta takes over.
58. endometrial vascularization and proliferation, fertile mucous from cervix. corresponds to follicular phase.
59. stabilization and formation of secretory elements in endometrium. corresponds to luteal phase.
60. highest during menopause, obese women.
61. highest in childbearing years, produced by follicles.
62. pregnancy, placenta.
63. E1 and E2 in the liver.

64. primary: period never started. secondary: menses stop for over 3 months.
65. anorexia nervosa
excess exercise
66. galactorrhea
benign pituitary adenoma
67. autoimmune disorders
chemotherapy, pelvic irradiation
methyltrexate
68. cushing's
hypo/hyperthyroid
obesity
PCOS
69. a rare form of amenhorrhea that is marked by normal ovulation but abnormal anatomy.
70. acquired endometrial lesions
cervical stenosis
imperforate hymen
male pseudohermaphroditism
transverse vaginal septum
vaginal and uterine aplasia