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OB/GYNE Test II

Summer 2011

Know dominant hormones during different phases!

Menstrual Cycle
(Four functional Phases of cycle)
1. Follicular Phase (pre-ovulatory) 2. OVULATORY 3. Leuteal Phase 4. Menses

(Proliferative Phase)
See Diagrams (from online)     

(Secretory Phase)

300-400 X in a lifetime Cycles normally vary from 21 40 days Bleeding normally 3 8 days (average loss of 30-80ml) >80 ml = anemia Clots small are normal, large is rapid bleeding, inability of fibrinogen to act 15% of women have classic 28 day cycle cascading event

1. Follicular Phase
o o o Days 1 o Days 5 o Days 7 o

  

Hypothalmus releases GnRH to Anterior Pituitary which releases FSH & LH FSH stimulates proliferation of granuloma cells which produce Estradiol 5 Follicles grow Increasing Estradiol and Inhibin produce Negative Feedback on FSH 7 One dominant follicle FSH decreases, non-dominant follicle recedes 14 (17) Dominant follicle matures and produces Estradiol (total phase: 10 17 days) Late Follicular Phase  LH activity causes a rise in Androgen levels (androstenedione and testosterone)  PEAK in sexual behavior

2. Ovulatory Phase
o Estradiol levels peak about 24 hours before ovulation o Pituitary surge of LH and FSH ~ Day 14 o 10-12 hours after LH peak mature follicle releases an egg o Ovulation Predictor Kit (OP kit) detect LH surge in urine See handout from online

3. Luteal Phase
     Progesterone dominance (Produces Progesterone until placenta takes over) Corpus Luteum secretes Estrogen and Progesterone (yellow body) Progesterone suppresses new follicle growth and acts on the endometrium Progesterone peaks 7 8 days after LH surge time of implantation *** Progesterone increases basal body temperature BBT (14 days long, unless pregnancy occurs)

4. Menstrual Phase
  No pregnancy, then Corus Luteum declines 9 11 days after ovulation which causes a drop in Estrogen and Progesterone MENSTRUAL FLOW

OB/GYNE Test II

Summer 2011

ENDOMETRIAL CYCLE
(Looking at same process from the angle of the uterus)

Proliferative Phase o Thin and ischemic at end of cycle o 2nd week Estrogen increase causing thickening (build-up) o Proliferative growth (deeper, wider, thicker) o Glands more active, secretory, and nutritive (increase by 8X) o Increased blood flow, increased glandular secretions Secretory Phase o Last 2 weeks o Due to Progesterone and Estrogen, glands more fluid-filled and congested o Increased blood flow MENSTRUAL/Ischemic Phase o Ischemia and cell degeneration o Cell rupture with bursting arterioles o Sloughing of uterine lining ______________________________________________

HPG/HPO axis (know well)


Gonadotropic Releasing Hormone (GnRH)Low Frequency pulses FSH release High Frequency pulses LH release

Hypothalmus

_____________________________________________

1. Follicle Stimulating Hormone (FSH)


  
Ripening of follicle Ovulation Estrogen Secretion

Anterior Pituitary

2. Luteinizing Hormone (LH)


  
Initiates Ovulation Stimulates follicle to rupture Development of Corpus Luteum

Anterior Pituitary

_____________________________________________

Estradiol = Estrogen
  
Female characteristics Helps prepare endometrium for implantation Intensifies affects of progesterone

Gonads/Ovaries

Progesterone
  
Prepares uterus Promotes Secretory endometrial cells Maintains placenta in pregnancy

Gonads/Ovaries

OB/GYNE Test II

Summer 2011

Ovulation Predictor Kit (OP kit)


Ovulation predictor kits measure the increasing amounts of luteinizing hormone in a woman's urine. The luteinizing hormone surge is what helps signal it is time for the ovaries to release an egg each month during ovulation. This luteinizing hormone surge happens between 24 and 48 hours before ovulation and is what ovulation predictor kits are highly reliable in detecting. When an ovulation predictor kit detects the hormone, a couple knows that ovulation is one to two days away, and the couple should have intercourse for the next three days to optimize the chances for conception. Types Ovulation predictor kits are widely available in drugstores and grocery stores or mass merchandisers that have a pharmacy section. Each ovulation predictor kit comes with testing strips, usually between 5 and 9, to be used each day during the middle of a woman's cycle until the luteinizing hormone is detected. Most manufacturers of home pregnancy tests also sell ovulation predictor kits, and they are available in generic brands as well. Prices for ovulation predictor kits range from $15 to $50, though cheaper versions can be found online.

Menarche mean onset is 12.7 years of age =


onset of menses  Ovulation often inconsistent for 1-2 years leading to irregular cycles o Puberty  Thelarche Breast budding  Pubarche/adrenarche Pubic/armpit hair  Growth spurt  Menarche/ovulation last phase of the process Characteristics of cycling Puberty Tanner Stages
    

I - Prepub Elevated papilla only. No pubic hair II Breasts and papilla are elevated and appear as small mound with enlarging areola diameter.
Sparse long, pigmented hair along labia majora (range 8-13 years, median age 10.5 years) III - Further breast enlargement without separation of breast and areola (median age 11.2 years). Dark coarse, curled pubic hair is sparsely spread over mons (median age 11.4 years) IV Secondary mound of areola and papilla develop above the breast (median age 12.1 years) Adulttype pubic hair is abundant but limited to the mons pubis (median age: 12) V Recession of areola occurs (median age 14.6 years, range 12 18). Pubic hair is adult type in both quantity and distribution onto thighs

 

PROCOCIOUS PUBERTY occurs before 8 y/o DELAYED PUBERTY Menarche absent at age 18

All terms used in describing menstruation:

OB/GYNE Test II

Summer 2011

* Oligomenorrhea Infrequently occurring menses at >35 days (Classic sign of PCOS) * Amenorrhea absence of menses * Primary Amenorrhea no initial menses during puberty changes
 
No menses by age 16 regardless of normal growth & 2ndary growth characteristics, OR Absence of menses by age 14 when normal growth & 2ndary sexual characteristics are absent.

Etiology: anatomic deviations, endocrine abnormalities (hypothyroid), autoimmune disease, eating disorders, excessive exercise.
S/S : Absence of menses, lack of 2ndary sexual characteristics DIFFERENTIALS: Pregnancy, Defect in H-P-O axis (gonadotropin deficiency, extreme exercise, stress, pituitary tumor, PCOS, premature ovarian failure, thyroid disorders, primary gonadal disorder) o Physiological findings: Wgt, Hgt, visual fields, thyroid, nipple discharge, pelvic exam, hirsutism, vaginal appearance (check for congenital absence of ovaries), vagina, imperforate hymen) o Diagnostic tests: Start with hCG, TSH, T4, prolactin, FSH, LH, Estradiol, Pelvic U/S to check anatomy  MRI to check for pituitary tumor if prolactin is elevated. o Management: Refer to gynecological or endocrinology for further evaluation. FUNCTIONAL HYPOTHALMIC AMMENORRHEA ATHLETES HORMONES ARE NORMAL: o Chronic illness, stress, delayed puberty, chemo, O.C., Psych meds, Gonadotropin Hormone Deficiency, PCOS If LH/FSH elevated Primary ovarian failure (chromosomal, autoimmune, structural such as transverse vaginal septum)

o o

 

* Secondary Amenorrhea
  Absence of menses for 3 cycles or 6 mos in women who have previously menstruated regularly. Occurs in 3-5% of women. o Etiology: See Primary Amenorrhea o S/S: As per definition o DIFFERENTIALS: Pregnancy, annovulation d/t defect in H-P-O axis, use of OCPs, use of Progesterone-only contraception, Adrenal disorder, medication cause. o Diagnostic tests: hCG, prolactin, TSH, T4, LH, FSH, Estradiol o Management: Encourage withdrawal bleed every 3 months ***  Progesterone Challenge Test Progesterone in oil 100-200mg/IM or Prometrium 300mg X 7-10 days after concluding med.  If bleeding occurs after Progesterone Challenge, Estrogen is adequate, cervix is patent, and endometrium is functional.  If NO bleeding occurs, add 1.25 mg Premarin (conjugated Estrogen) for 21 days to prime lining and add Provera 10mg X last 5 days. OCPs X1pack as option too.  IF NO BLEED, check FSH to rule out Premature Ovarian Failure  Long-term cycling management with OCPs cyclic Progesterone, or HRT

Premature Ovarian Failure    Low Estrogen Elevated LH and FSH working to produce Estrogen, but not working (< 40 y/o) Causes Gonadal dysgenesis (ovaries shut down), genetic abnormalities, autoimmune disorders, infection, cancer tx

* Hypermenorrhea/Menorrhagia Excessive duration & flow (>7d, or 80mL) Metorrhagia irregular, excessive flow or length of time Menometrorrhagia Irregular, heavy bleeding Hypomenorrhea Regular bleeding in less than normal amount

OB/GYNE Test II

Summer 2011

* Post-coital bleeding after sexual intercourse infection or PG * Polymenorrhea Bleeding at short intervals (<21 days) too frequent

* Hypermenorrhea/Menorrhagia
y

Excessive duration & flow (>7d, or 80mL)or irregular

y y

Organic gynecological disease PG, PG-related complications, cervicitis, endometriosis, polyps, leiomyoma, adenomyosis, o endometrial hyperplasia (not good)/carcinoma, o cervical carcinoma. Systemic thyroid dysfunction, liver cirrhosis, active hepatitis, adrenal hyperplasia, renal failure, hypersplenism, bleeding disorders, leukemia, severe sepsis, DIC Medications, IUDs, foreign bodies, trauma

Dysfunctional Uterine Bleeding (DUB) Prolonged or excessive bleeding due to endometrial shedding in the absence of pelvic structural disorders. Chronic anovulation is the leading cause.
y Etiology: Hormonal disturbance with dysfunction of the H-P-O axis, resulting in continuous Estrogen stimulation of endometrium. o Seen in adolescence and perimenopause frequently. S/S: irregular bleeding, light to heavy flow DIFFERENTIALS: Pregnancy, ectopic pregnancy, cervical or uterine polyps, blood dyscrasia, perimenopause, thyroid disorder, pituitary tumor, cervicitis Physical findings: thyroid exam, pelvic exam Diagnostics: CBC, pap, cultures, TSH, prolactin, pelvic U/S, testing for blood dyscrasias (Von Willibrand s), endometrial bx, hysteroscopy (looking at lining and bx taken). Management: OCPs, progesterone tx usually 10-14 days/month, Depo-provera, Mirena, Lysteda, HSC/D&C If severe bleeding: refer for surgical intervention, Endometrial ablation is an option destruction of the endometrium via heated liquid or electrocaudery ________________________________________________

y y y y y y

Oligomenorrhea infrequent menses at intervals >35 days ***


y y y y On a continuum between normal ovulatory cycling and secondary amenorrhea (milder forms) Etiology: Peri-menopause, PCOS, major weight gain or loss, Estrogen suppressors vs. unopposed (OCP) painful menstruation (Different from PMS) Etiology: Primary increased prostaglandin produced by endometrium o Secondary pelvic or uterine pathologic cause such as endometriosis S/S: Primary Usually occurs in women <20 y/o. Pain in lower back, pelvis, thighs. Cycle day 1 or 2 o Secondary Occurs in women 25 40 w/ sx of increasingly painful menses. May note dyspareunia with new onset (red flag for endometriosis) DIFFERENTIALS: Endometriosis, adenomyosis, PID, obstructive defects, bowel disorder (IBS) Mgt: NSAIDS, OCPs including cycle suppression, Depo-provera. If failure of these measures, surgical intervention.

Dysmenorrhea

y y

PMS/PMDD
y y y y

(Premenstrual Syndrome and Premenstrual Dysphoric Disorder) They ARE different! Physical, cognitive, affective, and behavioral sx that occur in a cyclic fashion during the luteal phase of menstrual cycle and resolve with menstruation PMS International classification of diseases PMDD American Psychological Association more criteria met rare, associated with tampon use & vaginal staph aureus-produced endotoxins Etiology release of inflammatory mediators in response to a relatively minor infection

TOXIC SHOCK

OB/GYNE Test II
y y y

Summer 2011

y y

Can occur after surgery, postpartum, with skin & bone infections, burns, derm. Lesions, and resp. tract infections Subjective: abrupt onset, high fever, chills, vomiting, watery diarrhea, myalgia, headaches, abdominal pain in a previously healthy young woman during or shortly after menstruation Objective: Multisystem involvement fever, hypotension, orthostatic hypotension, sunburn-like rash within 24-48 hours onset, conjunctival hyperemia, oropharyngeal erythema, strawberry tongue, vaginal hyperemia, Non-specific abdominal tenderness, general confusion & disorientation DIFFERENTIAL: Rocky Mountain S. F., Legionnaires, toxic epidermal necrolysis, rheumatic fever, letospironsis, rubeola, lyme disease, Epstein-Barr virus, or disseminated fungal infections PLAN: Admission to ICU, B/P support (fluids & pressors), IV ABx

PCOS Polycystic Ovarian Syndrome- hyperandrogenism and oligo-ovulation or annovulation (infrequent or absent menses) y Oligomenorrheic, hirsute, obese, and infertile y Insulin resistence and hyperinsulinemia o BMI > 27 o Waist to hip ratio > 0.85 o Waist > 100 cm o Acanthosis nigricans (neck dark pigmented and leathery) Pits, groin, folds o Skin tags y PCOS
o What it is multiple inactive follicular cysts. Androgen excess & chronic anovulation o What to look for Associated with greater LH and GnRH dysfuction with abnormal estradiol levels that fail to stimulate a normal FSH reaction. Obesity, hirsutism, o Testing glucose/diabetic type symptoms

Acanthosis Nigricans
y y y y

Results from insulin resistance, predisposed to NIDDM and CAD.

y y

Increased insulin production contributes to excess androgen production and chronic annovulation. Subjective: Hirsutism, mental Hx, danazol use *, progestins, glucocorticoids, anabolic steroids, phenytoin, or monoxidil use Objective: male hair patterns, increased muscle mass, clitoral enlargement, decreased breast size, voice changes, obesity, acanthosis nigricans, ovarian masses DIAGNOSTICS: FSH low or normal Dexamethasone suppression or R/O Cushings LH Elevated Glucose Tolerance Test LH FSH ratio > 3 Fasting insulin Testosterone BUN/creat DHEA-S 17 Hydroxy-progesterone DIFFERENTIAL: Ovarian Disorders, Congenital Adrenal Hyperplasia, Androgen-producing tumors, Cushings, Drug related, Obesity, Post-menopause PLAN: Weight loss, Refer to endocrinology, Review Risks of CA, NIDDM, HTN, CAD; o Discuss fertility issues (desire for kids?), o For increased cholesterol do diabetic diet. MEDS: Metformin 500mg q HS X 1 week, BID X 1 week, TID and then evaluate. o Corrects hyperinsulinemia, reduces LH sex hormone binding globulin & ovarian androgens o Monitor BUN/creatinine

______________________________ 1st initial GYNE EXAM


Care/gentle sets tone for all future exams/contact

OB/GYNE Test II
y y y y y y y

Summer 2011

Indication: Gynacologic Sx, sexual activity, age 21. Chaparone may or MAY NOT put patient at ease. Talk about rules of confidentiality Consent NOT in Illinois: no need for parent consent for STDs, PG dx, PG care, contraception Emancipated Minor, no consent needed EDUCATE on Anatomical norms, exam expectations, what we look for, menarche, tampon use. GIVE LOTS OF INFORMATION THE MORE THE BETTER!

Adolescent care

_______________________________ Eating disorders/Nutrition

Safe sex/Abstinence

Safety

_______________________________
Menopause Changes that occur expectations see diagram Options for treatment HRT is risky educate and give written information Goals of treatment Limit caffeine, ETOH, smoking

OB/GYNE Test II

Summer 2011

Osteoporosis & Osteopenia low bone mass leading to fragility/increased fractures. Femoral
neck and lumbar vertebrae (composed of the trabecular bone) are the most susceptible.

What is normal? balance between osteoclast and osteoblast production. T-score on a Dexa Scan of >/= (-1.0) Osteopenia - T-score on a DXA Scan of (-1.0 to -2.5) Osteoporosis - T-score on a DXA Scan of < (-2.5) Treatment basics diet, exercise, health and medication regimens no smoke, no ETOH y Weight bearing exercise walking 30 minutes 3XW minimum y Calcium + Vitamin D 1000mg age 19-50, 50-65 not on ERT need 1500mg, 1500mg > age 65 y Elimiate y Ralozifene & estrogen (pg 413) y Two biophosphates alendronate, risedronate) etidronate not USDA approved HRT/ERT weigh the risks and benefits!!! When used Reduction of osteoporosis and/or menopausal Sx that are intolerable Contraindications CAD, DVT/PE, Breast/Uterine/Ovarian CA, liver dysfunction Uterine CA - Endometrial Hyperplasia Biopsy for abnormal uterine bleeding y Endometrial/uterine cancer is the most common gynecological malignancy in women >45 years of age (caused by high levels of estrogen) What, where, when concerns y Risk factors: Unopposed estrogen replacement, HRT, obesity, nulliparity/low parity, diabetes, HTN, Monopause, Chronic anovulation, tamoxifen use y Screen:  unexplained menopausal bleeding,  premenopausal with PCOS,  Obese, nulliparous clients with diabetes and HTN Incontinence Types o Urge detruser instability from neuro disorder or aging o Anticholinergics: Ditropan, Detrol o Stress urethral hypermobility or displacement of the urethra from pressure o Treat: Imipramine 10-25mg BID-QID o Estrogen tx o Sling procedure o Bladder surgery o Overflow over distention of the bladder o DO NOT use anticholinergics or tricyclics o Meds usually ineffective o Urecholine 10-25mg BID-QID Treatment/interventions o Test: UA, Cough stress test, Post-void Residual 8

OB/GYNE Test II

Summer 2011

o Treat: o Behavioral  Habit training  Bladder training  Pelvic muscle exercise  Vaginal devices  Biofeedback o Lifestyle changes  Weight loss  Caffeine reduction  Fluid management  Smoking cessation  Reduce constipation  Modify physical activity

HTN

Lipids

Cancer Is CXR appropriate to screen for lung cancer?

Prolapse(s) Types

STDs and Vaginosis Slides: What to look for B.V. Causes and treatment for B. V. Yeast S/S STDs

OB/GYNE Test II
Trichimosis Fishy order yellow green dysuria strawberry cervix Flu like symptoms lymphadopathy Wt loss noc sweats fevers Mucopurlent vag discharge Bartholinitis Skenes Cervical motion tenderness dysuria Mucopurlent vag dischge PID dysparunia Rieder syndrome 3-6 p Syphyllis 10-90 days Chanchre painless maculopap rash on hands and feet patch alopecia Burning itching tingling and vesicular lesions

Summer 2011
Wet Mount No reporting needed Sex Metronidazol 2 GM in a single dose or 500 mg po bid X 7D HAART TB medication immunizations Partner Tx only if reoccurent infection

HIV Incubation 30-6 months

Elisa X 2 confirm with western Blot

Yes reporting is needed to IDPH Yes report to IDPH

Blood body fluids Mom-baby Body fluids Sex and oral transmission Mom -baby

Partner tx only if infected

GC 2-10 days

Urine Cervical swab DNA rapid antigen

Metronidazol 250 IM and Azythromycin 1 Gm or docycline 100 bid X 7D Azythromycin 1 Gm po Or Doxcycline 100 mg bid X7

Yes

Chlamydia 7-21 d

Urine cervical swab

Yes report to IDPH conjunctivitis urethritis Yes report to IDPH

Sex body fluids Mom-baby Skin lesions lasts 2-6 m Sex Mom-baby

Yes Reider syndrome can last 2-6 mon p infection tx with NSAIDS

Wk p infec RPR/VDRL If + then Trepocmal test to confirm dx Culture weeping lesions Igg-HSV

PCN-G 2.4 IM

Yes

HSV

no

Sex body fluids Mom-baby

Acylovir 400 mg po TID X 7-10 day Prevent ion 400 mg TID x 5 Tx symptoms

Gardasil vaccine to the partner

Hep B

Hep C

Flu like symptoms malaise, fever fatigue liver enlarges Flu like symptoms Diarrhea malaise fatigue liver enlarges

LFT HbgAB immunoessay

no

blood

Vaccinate partner to prevent spread

Immune essay hep-c antibody

no

Blood Body fluid Mom-baby

Interferon IM

Reportable? Care/Counseling

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OB/GYNE Test II

Summer 2011

Bartholinitis

Pregnancy testing throughout


Visit Schedule: 4-28 weeks: See every 4 weeks 28-36 weeks: See every 2 weeks >36 weeks: See every week y y y y SIS I 11-13 weeks SIS II at 16 weeks 1 Hr GTT, Hbg 28 weeks GBS 36 weeks

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