Editing OBGYN - Review

=OBGYN Review=
*2-3 question per hour
*Majority case presentation/vignette format.
*11 lecture hours (2-3 questions per lecture).
*'''PLEASE!!! Read the question carefully.'''
*'''PLEASE!!! Read the multiple choice answers carefully.'''
*Look carefully at question / answer wording, “except”, “least”, “greatest”, “most”, “which answer is correct”, “or incorrect”.

==Putting the Guy Back in Gynecology==
 *2-3 very easy questions


*Semmelweis:
**Figured out hand washing would prevent disease.
**Ignaz Philipp Semmelweis (1818-1865)
**Figured this out in the 1850’s (before Lister and Pasteur).


*Liability:
**Failure to dx breast ca is number 1 lawsuit (lots of docs involved)
**Bad baby is #2 lawsuit
**'''Only 8.6% go to trial. 81% are won by the OB/GYN at trial.'''
**Lots of lawsuits in OB/GYN:
***76% have been sued one time
***57% have been sued two times
***41% have been sued three times
***29% have been sued four or more times
***30% have been sued for an event during residency


*Men in Gynecology:
**National studies have shown that 50% want a woman, 10% want a man, and 40% don’t care.
**2002 study out of Michigan State University asked women this same question, then had them rank the 16 most important qualities of a physician:
***Top choices were “Doctor listens to me”, “Doctor explains things clearly”, “Doctor is respectful”, “Doctor is easy to talk to”, “Doctor is caring” and “Doctor understands women.”
***Female gender was #14, Male gender was #16

==Early Pregnancy Loss==
 *1 scenario with 3-4 related quesetions


===Case#1===
*25yo G2P1001 with an LMP of 8 wks ago, presents to your ER complaining of vaginal bleeding.
*Pt reports the bleeding began earlier today and has been very brisk, without cramping.
*What’s the first test to order to evaluate this patient?
*Pregnancy test is the first test one runs for any Gyn complaint in a fertile woman.


===Know the definitions of the abortions===
*Abortion: '''termination of pregnancy before 20 weeks gestation''' ''calculated from date of onset of last menses'' or '''delivery of a fetus with a weight of less than 500 g.'''
*Threatened Abortion: any uterine bleeding from a gestation of less than 20 weeks '''without any cervical dilation or effacement'''.
*Inevitable Abortion: Uterine bleeding from a gestation of less than 20 weeks '''accompanied by cervical dilation but without expulsion of any placental or fetal tissue''' through the cervix.
*Incomplete Abortion: '''passage of some but not all fetal or placental tissue through the cervix''' before 20 weeks gestation.
*Complete Abortion: spontaneous '''expulsion of all fetal and placental tissue''' from the uterine cavity before 20 weeks gestation.
*Missed Abortion: fetal death before 20 weeks gestation '''without expulsion of any fetal or maternal tissue for at least 8 weeks thereafter'''.
*Septic Abortion: ''any type of abortion'' that is '''accompanied by uterine infection.'''
*Recurrent Spontaneous Abortion: '''loss of three or more pregnancies''' before 20 weeks gestation. 

===Cause of Abortions===
*'''70% of spontaneous abortions are because of fetal ch abnormalities.'''
*Trisomies of chr 13, 16, 18, 21, and 22 are the most common ch abnormalities.
*Ch abnormalities by frequency: trisomy > polyploidies > Monosomy X (Turner’s).
 Lecture notes say: trisomies > monosomy X > polyplodies.
*A history of 2 or 3 consecutive spontaneous early pregnancy losses (recurrent abortions) and no previous live born (RPL) is an indicator for karyotyping the couple.
**''3-8% of these couples will have some abnormality, most frequently a balanced chromosomal rearrangement or translocation.''
*'''Fetuses that abort later in gestation usually have normal chromosomes.'''
 
===Treatment of abortions===
*30-40% of human gestations have bleeding in the first 20 weeks of pregnancy.
**50% of these pregnancies result in spontaneous abortion.
**Serial HCG & uterine ultrasound aid in predicting the outcome.
**If ultrasound reveals a fetal heart, 95 % chance of a continuing viable pregnancy.
**If HCG decreases with time, pregnancy will likely result in an abortion.


*Threatened and Incomplete abortions usually occur between '''6-12 weeks gestation.'''
*Threatened and Incomplete abortions are '''characterized by profuse bleeding.'''
*'''Threatened abortions should be given "expectant management", pelvic rest, and reassurance.'''
*Inevitable abortions and Incomplete abortions should be treated with '''dilation / curettage, methergine, and anti-Rh (Rhogam).'''
**Recall that methergine constricts blood vessels ''and'' induces smooth muscle contraction so it can be used to decrease bleeding and to induce labor (as in an incomplete abortion).
*'''Complete abortions need not be hospitalized'''; complete abortions can be '''treated as outpatient with methergine''' (depending on the symptoms).
 
===Ectopic Pregnancy===
*'''98% of all ectopic pregnancies are in the fallopian tubes.'''


*Etiology of ectopic pregnancies is not important for the exam, but:
**Prior pelvic inflammatory disease 
**Prior tubal surgery 
**Use of assisted reproductive technology 
**Increase incidence of heterotopic (1/30,000 to 1/100) 
**Method of contraception may decrease risk of ectopic 
**Pregnancy 
**Except IUD 
**Prior ectopic pregnancy 
**Cigarette smoking 
**DES exposure 
**Increasing age


*'''Ectopic pregnancy diagnosis is via HCG and U/S.'''
**Normal rate or rise of HCG suggest normal intrauterine pregnancy.
***Recall that the syncytiotrophoblast should be making '''HCG and it should be doubling every day of pregnancy until it week 8-10''' when it reaches 50k-100k IU / L.
**If HCG is greater than 1000-1500, one should see an intrauterine pregnancy via ultrasound.
**'''If no pregnancy seen via ultrasound when the HCG is 1000-1500, suspect an ectopic pregnancy.'''


*'''Ectopic pregnancy treatment is via HCG.'''
**Declining HCG values are consistent with adequate medical or surgical treatment of an ectopic pregnancy.

===Early pregnancy loss example questions===
*A 25 yo G1P0 with an LMP 11 weeks ago presents to the ED with complaint of heavy foul smelling vaginal bleeding.
*She is febrile with a temperature 103.5, HR: 120, BP: 70/40. 
*TVUS shows a 9 wk size fetus (IUP) with no cardiac activity.
*Pelvic exam shows a cvx dilated to 1cm with blood and purulent material coming out the os.
*She experiences significant uterine tenderness on pelvic exam.
*The next best step in management is:
**A) Obtaining a stat BHCG
**B) Observation
**'''C) Suction Curretage to empty the uterus'''
**D) Performing a diagnostic laparoscopy

==Family Planning==
 *3 basic questions; 1 on pregnancy epidemiology / stats, 2 on most appropriate contraceptive choice

===Epidemiology of Pregnancy===
*'''There is an 85% chance of getting pregnant with regular intercourse and absolutely no protection.'''

===Contraindications of CHC===
*Know the contraindications to CHC (combined hormone contraception):
**'''DVT (deep vein thrombosis), prolonged immobility'''
**Smoking over the age of 35
**Migraine with aura
**Pregnancy
**Current breast or hepatic cancer
**Hypercoagulatory state (like Leiden mutation)
**Poorly controlled HTN
**Peripartum cardiomyopathy
**Vascular disease (MI, CVA)

===IUD Contraindications and Benefits===
*Contraindications for IUD:
**Pregnancy
**Unexplained vaginal bleeding
**Uterine infection or PID
**Acute discharge
**Pelvic tuberculosis
**Uterine architecture abnormalities (fibroids, septum, distortion)
**Malignant trophoblast disease
**Genital tract cancer


*Indicators for IUD:
**Highly effective
**Effective immediately
**Long-term efficacy
**Doesn't interfere with intercourse
**Immediate return to fertility
**Does not affect breastfeeding

===Hormonal Contraceptives===
*Hormonal Contraceptives 
**OCPs
**Injectable
***Combined Injectable Contraceptives (CICs)
***'''Depo-Provera (failure rate of 0.1-0.6%, slowest return to fertility of injectables)'''
***Norplant
***Implanon
**New Types
***Ring
***Patch

===Example Question===
*29 yo G0 presents to your office desiring birth control.
*She smokes 2 PPD. She states has had a strong family history significant for cervical cancer. She currently has 3 sexual partners. She has been treated for cervicitis 5 times in the last 1 years. She an extremely busy college student and also works part time.
*You discuss safer sex practices with the patient.
*What is the least appropriate contraception choice for this patient.
**A) OCP’s
**B) Deproprovera
**'''C) IUD''' (contraindications: hx of uterine infections, family hx of genital tract cancer)
**D) Contraception patch
**E) Diaphram w/ contraceptive foam


*'''Cervical cancer is not an hereditary disease but a lifestyle disease (HPV).'''
*'''IUD is an inappropriate form of birth control when the pt has an history of STI because IUDs induce  peritonitis and endometriitis upon infection.'''

==Maternal-Fetal Physiology==
 *3 questions / case presenations focused on GI, Heme, and Pulmonary physiology

===GI Physiology===
*GI physiology in pregnancy covers three primary issues: '''constipation, nausea / vomitting, and weight gain'''.


*Constipation:
**'''Ferrous-Sulfate in prenatal vitamins slows GI motility''' allowing for more water absorption.
**'''Give Colace as treatment for constipation.'''


*Nausea and vomitting:
**beta-HCG peaks at weeks 8-12 (at 50k-100k IU / L)
**'''Progesterone causes nause / vomitting by slowing smooth muscle.'''


*Weight gain:
**Normal: ~20 lbs
**Underweight woman: ~30 lbs
**Overweight woman: ~16 lbs
**It is not uncommon for mom to lose weight before gaining weight.

===Hematological Physiology===
*Physiologic anemia occurs in mom because '''plasma is increased by 50% but RBC count is only increased by 30%''' (more fluid increased compared to RBC increase).
*'''Hb in pregnancy is often around 11.5 mg / dL (whereas normal is 12.0-16.0).'''

===Respiratory Physiology===
*'''Progesterone is responsible for a deregulation of normal respiratory physiology.'''
**Most notably, there is a '''diminished pulmonary reserve''' in pregnancy.
*In pregnancy, it is normal to be in a state of '''respiratory alkalosis with metabolic compensation'''.
*'''Relative hyperventilation occurs in pregnancy so as to blow off CO2.'''
**That is, the increases oxygen demand goes up by 15-20% but the minute ventilation (read: the amount of CO2 blown off) goes up by more than 20%; this is the definition of hyperventilation.
**Therefore, since mom is ''hyperventilating'', her '''pCO2 is decreased''' and her '''pO2 is increased'''.
***pO2 is elevated in pregnancy (106-108) as compared to a non-pregnant state (70-100).
***pCO2 is decreased in pregnancy (27-32) as compared to a non-pregnant state (38-45).
***pH is increased in pregnancy (7.4-7.46) as compared to a non-pregnant state (7.38-7.42).

===Physiology Sample Question===
*A 26 yo G1P0 sees you for a routine pre-natal care visit at 10 weeks.
*She Googled “progesterone” the previous day and is concerned about the effects of the hormone during early pregnancy.
*Of the following symptoms that you counseled the pt to expect, which is incorrect?
**A) Mild Nausea / Vomiting
**B) Constipation
**C) GERD
**D) Bloating
**'''E) Diarrhea'''

==Pregnancy Gone Wrong==
 *3 cases; 2 focus on management, 1 focuses on diagnosis
 *Pre-elampsia, placenta previa, and placental abruption

===Definitions===
*Chronic hypertension is antedating pregnancy and post-dating pregnancy beyond 12 weeks post-partum.
*Gestational hypertension is is BP of 140/90 that ''develops after 20th week pregnancy'' in women previously known to be normotensive.
**Note that gestational hypertension occurs ''without proteinuria'' because with proteinuria makes it ''preeclampsia''.
*Chronic Hypertension with Superimposed Preeclampsia: chronic hypertension '''with proteinuria (>= 300mg in a 24 hour urine specimen)'''.
*Pre-eclampsia: BP issues (> 140/90) occurring after 20 weeks gestation '''concurrent with 300 mg proteinuria.'''
**Pre-eclampsia can occur in "mild" or "severe" forms based on proteinuria.
*Eclampsia: '''having one or more generalized convulsions and / or coma in the setting of preeclampsia''' and '''in the absence of other neurologic conditions'''.

===Eclampsia Management===
*The first thing is always to '''stabilize mom.'''
*'''The only cure for preeclampsia is delivery.'''


*Mild Eclampsia:
**The first thing is always to '''stabilize mom'''; ABCs, Oxygen.
**Rx: hypertensions in the severe malignant range (could stroke out)
**Consider expectant management until term, induce.
***Outpatient for reliable pts, inpatient for unreliable pts.
**'''Deliver baby once stable''' (vag, induce, c/s, depending on condition of mom / baby)
***To determine mode of delivery, consider fetal position, gestational age, and cervix favorability.
***Have a clear endpoint at which delivery will be achieved (i.e. within 24 hours).



*Severe Eclampsia:
**The first thing is always to '''stabilize mom'''; ABCs, Oxygen.
**'''Magnesium Sulfate and Deliver!!'''
**Rx: hypertensions in the severe malignant range (could stroke out)
**Consider expectant management for very preterm, stable patients.
***Have detailed reasoning and plan for delivery documented.
***Especially near fetal-viability grey area like 25, 26 weeks.
**'''Deliver baby once stable''' (vag, induce, c/s, depending on condition of mom / baby)
***To determine mode of delivery, consider fetal position, gestational age, and cervix favorability.
***Have a clear endpoint at which delivery will be achieved (i.e. within 24 hours).

===Placental Abruption===
*Placental abruption is a separation of the placenta from the uterine wall '''post-20 weeks'''.
*Placental abruption presents with '''a classic triad: bleeding, abdominal pain, and contractions.'''
**Placental abruption may or may not present with non-reassuring fetal heart rate.
*Placental abruption is '''poorly diagnosed with ultrasound.'''
*'''A history of trauma should always increase one's suspicion of placental abruption.'''
*Other causes of placental abruption include cocaine, smoking, fibroids.
**And: hypertension, prior abruption, '''trauma''', smoking, cocaine use, uterine anomaly / fibroids, multiparity, advanced maternal age, preterm premature rupture of membranes (PPROM), bleeding diathesis, rapid decompression of an over-distended uterus, polyhydramnios.

===Placenta previa===
*Placenta previa is the attachment of the placenta near or over the cervical os.
**Placenta previa come in several types: complete (covers the os completely), partial (covers the os partially), marginal (marginally covers the os), and low (placenta is near the os, within 2-3cm).


*Vaso previa is when major placental vessels lie between the fetus and the os.
**Diagnosis: assured if there is profuse bleeding after rupture of membrane along with fetal heart rate abnormalities.
**Risk: fetal exsanguination.
**Treatment: deliver by c/s immediately!


*Management of Placenta Previa:
**Conservative management, monitor mother and baby.
**If preterm, keep stable as long as possible.
**'''At 34 weeks, deliver upon bleeding or bad heart tones.'''
*'''Even a partial placental previa is an indicator for c-section.'''

===Pregnancy Gone Wrong Example Question===
*30 yo G2P0010 presents at 40 wks in active labor.
*Her pregnancy was previously uncomplicated with excellent prenatal care starting in the 1st trimester. She had 3 previous U/S performed during her pregnancy.
*The pt is dilated to 6 cm and the fetus is at a +1 station with a bulging bag. Your attending lets you artifically rupture the membranes with an amnio hook. Immediately the patient starts to hemorrhage vaginally and the fetal heart rate drops. Your attending panics and immediately wets his pants.
*The most likely dx is:
**A) Placenta previa
**B) Placental abruption with DIC
**C) Uterine rupture
**'''D) Vasa previa'''


==Normal and Abnormal Labor==
 *3 questions; focused on placenta accreta, FHR tracings, pelvimetry

===Pelvimetry===
*'''The Diagonal Conjugate is an indirect measurement of the Obstetric (True) Conjugate.'''
*The diagonal conjugate should be 11.5 cm or greater.
*The obstetric conjugate is 1.5-2 cm less than the diagonal conjugate.
*'''Adequate conjugates are: diagonal (>11.5), obstetric (>9.5)'''
*The average fetal head is about 10 cm in diameter.
*Proper pelvimetry exam includes:
**Palpation of the ischeal spines.
**Determination of the '''pelvic wall shape: convergent (bad), parallel (good), or divergent (best)'''.
**Determination of the '''bituberous diameter: 6-8cm is ideal'''
**Determination of the '''pubic arch angle: >=90 degrees'''
**Determination of the '''sacral shape: hallow (good) or shallow (bad).
*If all metrics are adequate, assume a vaginal delivery without difficulty.
*Even if the diagonal is slightly small (slightly <11.5), try a vaginal delivery.
*Ischeal spines are not usually contraindicators of vag delivery.

===Fetal monitoring===
*Baseline heart rate should be 120-160 beats per minute.
*'''Variability of the heart rate should be seen!'''
*Accelerations are good!
*'''Some decels are normal: "early" decelerations during contractions.'''


*Early and late decelerations generally present as smooth curves.
*Early decelerations occur with uterine contractions (dip with contraction) and represent vagal (head) compression.
*Late decelerations '''begin after the peak of the contraction''' and '''indicate fetal hypoxia (poor fetal reserve)'''
**For late decelerations, '''delivery quickly if not near to vaginal delivery'''.
*Variable decelerations are '''sharp changes that can occur any time''' and represent '''cord compression'''.
**Variable decelerations are '''not usually worrisome unless deep (very low heart rate) or long in duration'''.

===Cesarean Sections===
*C/s increases the risk of uterine rupture upon subsequent pregnancies.
*C/s increases the risk for ''adhesions''.
*C/s increases the risk of placenta previa.
*'''C/s increases the risk of placenta previa converting to accreta (when the placenta--and maybe even fetus--invade the myometrium).'''
**This risk increases with each subsequent c/s: 0 (5%), '''1 (24%)''', 2 (48%), 3 (67%), et cetera.
**'''In accreta, the nitty box layer is dsyfunctional''' such that the placenta can't attach and may grow into the myometrium and even into the bladder.
**Accreta is also seen after uterine rupture.

===Labor Example Question===
*MG is a 20 yo G3P2002 who presents to L&D in active labor.
*She is 7 cm dilated and progressing well.  Her contractions every 1 - 2 minutes. You notice repetitive early decelerations in the fetal heart tracing.  The Nurse starts screaming for help when she see’s the FHR tracing. The next act in management should be.
**A) Emergency C/S
**B) Emergency Forceps Delivery
**'''C) Expectant Labor Mgmt and calm the nurse''
**D) Increase oxytocin administartion and calm the nurse.

==Embryology==
 *3 questions; 1 focuses on the type of anomaly, 1 on incidence of congenital anomalies

===Definitions===
*Malformations are abnormalities that result from ''intrinsically abnormal development processes that have been wrong from the beginning.''
**"Intrinsic" implies from the beginning such as a chromosomal anomaly present at fertilization.
*Disruptions are abnormalities that '''result from interference with previously normal development.'''
**'''Disruptions include teratogens, viruses, and ''amniotic bands''.'''
*Deformations are abnormaliteis of form or shape because of mechanical disturbance that keep normal development from progressin.
**Deformities include oligohydraminos (low amniotic fluid levels) which results in a smushed face (like wearing a pair of lady's hose over one's head); also called "Potter's sequence".
*Dysplasias are abnormal cellular formations.
**'''Dysplasia is the process and the consequence of “dyshistiogenesis” (abnormal tissue formation).'''
**'''Dysplasias include renal issues due to obstruction of flow.'''

===Incidence of Anomalies===
*Single minor anomalies are very common: '''14% of live births have a minor anomaly.'''
**Examples of minor anomales include: ear tags, single umbilical anomaly, hemangiomas
**Minor anomalies are ''of no serious medical significance'' but may alert clinician to the presence of a major anomalies.
**90% of infants with 3 or more minor anomalies will have 1 or more major defects.
*Single major anomalies are not uncommon: '''3% of live births have a major anomaly.'''
**Major developmental defects are much more common in early embryos (10-15%) than newborn infants (3%) but most of the early embryos with major defects abort spontaneously


*'''Chromosomal anomalies are present in 50-56% of spontaneously aborted fetuses.'''
*'''75% of all pregnancies are aborted.'''

===Teratology===
*The most critical period for a fetus-teratogen interaction is when cell division, cell differentiation, and morphogenesis at are their peak.
*The first two weeks of gestation is the "all or nothing" stage in which teratogen exposure results in fetal abortion (nothing).
**In this all or nothing period, the '''teratogen is interfering with implantation and cleavage'''.
*Most of the development during this time is concerned with the formation of the extra embryonic structures (amnion, chorion, yolk sac, etc).

===Embryology Example Questions===
*27 yo gravida 1 para 0 at 20 weeks gestation was found to have a fetus with amniotic band syndrome which has caused complete amputation of the lower fetal arms and legs.
*This type of anomaly would be classified as:
**a. Malformation
**'''b. Disruption'''
**c. Deformation
**d. Dysplasia
**e. None of the above 

==Abnormal Uterine Bleeding==
 *3 questions; cover causes of AUB

===Know the uterine / ovarian cycle!===
*Leading up to ovulation is the follicular phase (estrogen dominated) of the ovarian cycle and the proliferative phase of the uterine cycle.
*Post-ovulation is the luteal phase (progesterone dominated) of the ovarian cycle and the secretory phase of the uterine phase.
http://upload.wikimedia.org/wikipedia/commons/c/cd/MenstrualCycle2.png

===Abnormal uterine bleeding===
*Dysfunctional uterine bleeding: The term dysfunctional uterine bleeding has classically been used to describe excessive noncyclic endometrial bleeding unrelated to anatomical lesions of the uterus or to systemic disease; thus, '''it is a diagnosis of exclusion'''.
**It is more useful to think of dysfunctional uterine bleeding as anovulatory bleeding, since this is the primary cause.
**Anovulation may be related to a systemic medical disease or may be due to a variety of factors which affect the hypothalamic pituitary axis.


*Anovulation is the most common cause of abnormal uterine bleeding.
*When a woman doesn't ovulate, there is no corpus luteum and therefore no progesterone.
*Recall that progesterone causes the endometrium to become secretory.
*Without ovulation / progesterone, the endometrium just keeps proliferating.
*Initially, there will be a lack of bleeding as the endometrium doesn't get the progesterone signal drop that causes menses.
*Once the excessively-proliferating endometrium outgrows its blood supply, it will bleed--heavily.

===Terminology of AUB===
*Menorrhagia means ''heavy, prolonged bleeding''.
*Metorrhagia means '''light, irregular bleeding'''.
*Menotorrhagia means '''heavy, irregular bleeding'''.
*Amenorrhea is defined as absent bleeding '''for 3 or more cycles'''.
*Eumeorrhea has a cycle of 21-35 days.
*Oligomenorrhea is an interval over 35 days.
*Polymenorrhea is an interval less than 24 days.
*Intermenstrual bleeding is bleeding between regular menses.
*Prementstrual spotting refers to light bleeding just before menses begins.
*Post-coital spotting refers to bleeding ''within 24 hours of vaginal intercourse''.


*Intermenstrual cycle bleeding (bleeding between menses):
**Causes of intermenstrual bleeding include mechanical issues or ovulation.
***'''polyps, cervical cancer, IUD issues, and infection.'''
***'''drop in estrogen just before ovulation'''


*Menorrhagia (regular, heavy):
**Causes of menorrhagia include anatomical issues and coagulation issues.
***'''fibrionids, polyps'''
***'''vWf deficiency'''


*Menotorrhagia (irregular, heavy):
**Causes of menotorrhagia are ''anovulatory''
**PCOS, thyroid deficiency


*Etiology of abnormal uterine bleeding includes:
**Hormonal: anovulation
**Anatomical: coagulopathies

===Differentiating between Hormonal AUB and Anatomic AUB===
*Hormonal AUB:
**Anovulation
**Hyperplasia / Cancer
**Postmenopausal
**Thyroid dysfunction
*Anatomical:
**Polyps
**Fibroids
**Coagulopathy

===AUB Example Question===
*67 yo AA female presents to you with postmenopausal bleeding.
*The most likely cause of her bleeding is?
**'''A) Atrophic vaginitis'''
**B) Atrophic endometrium
**C) Anovulatory bleeding
**D) Trauma
**E) Endometrial cancer

==Menopause and Hormone Replacement Therapy==
 *3 questions; 1 on s&s c/w menopause, 1 on HRT indications / contraindications, 1 on workup of menopause s&s.

===Endocrine Menopause===
*Hormonal changes in menopause:
**'''FSH is increased'''
**Decreasing inhibin (decreasing negative feedback on FSH)
**Variable levels of estradiol levels
***Estrone replaces estradiol as the predominant estrogen
**Testosterone gradually declines with age
*Checking estrogen doesn't help to diagnose menopause.

===�Menopause: Symptomatology===
*Menstrual cycle changes
*'''Declining fertility, though not absolute.'''
**One can still get pregnant after the onset of menopause.
**Be sure to talk to menopause pts about birth control.
*Neuroendocrine complaints
*Multiple organ system changes

===Contraindications to estrogen replacement therapy===
*Contraindications for estrogen replacement therapy:
**Undiagnosised abnormal genital bleeding
**Active thrombosis or hx of estrogen-dependent thrombotic events
**Pregnancy
**'''Endometrial cancer and breast cancer'''
**Known or suspected estrogen-dependent neoplasia


*Reservations about HRT:
**See the contraindications
**May increase risk of endometrial cancer
**May increase risk of breast cancer 
**May increase risk of cardiovascular disease
**May increase risk of thromboembolic events

===Evaluation of the post-menopausal pt===
*Hx and PE:
**Determine the menopausal stage.
**Do a mammogram
**Symptoms, impact on QOL
**Medical diagnoses, medications
**Relevant risks, contraindications


*Labs, Imaging:
**Mammogram
**Pregnancy test: '''be sure to rule out pregnancy!'''
**Evaluate abnormal bleeding
**Evaluate relevant risks 


*S&S of Menopause:
**Loss of concentration
**Loss of libido
**Decreased vaginal lubrication
**Depression

===Example Menopause Question===
*Ms T. is a 51 yo G3P2012. Presents to your office with complaints of worsening hot flashes.
*She also says it has been 3 months since her last normal menses but she currently is spotting. She complaints of difficulty concentrating and increased vaginal dryness with intercourse.
*What factor in her medical history would contraindicate the use of HRT.
**A) Hx of gall stones
**B) recent dx of benign breast cyst
**'''C) Suspected endometrial cancer'''
**D) Hx of cervical cancer


*All the rest are not contraindications
**Loss of concentration is a s/s of menopause.

==Infertility==
 *3 questions; center on evaluation and diagnositics for infertility

===Definition of Infertility===
*The definition of infertility is '''1 year of regular coitus without conception'''.
*Infertility can be the result of a single factor or several factors.
*'''Because of the expense involved it is not practical to do every test on every couple.'''
**The two most important variables are '''age and duration of infertility.'''
**Therefore, we work up from easiest / most-likely / cheapest / least invasive.
*A careful history and physical exam is important for narrowing the tests to be ordered for a given case.

===Normal Fertility===
*The requirements for normal fertility include:
**Regular ovulation
**Patent fillopian tubes
**Receptive endometrium, with hormone cascasde
**Cervical mucus in a favorable state
**Spermatogenesis
**Erectile and ejaculatory competence

===Anovulation associated with ovarian failure===
*Most of the details of ovarian failure are in excess.


*Common causes of ovarian failure and subsequent anovulation:
**Turner syndrome
**46XX Gonadal dysgenesis (depicted )
**X chromosome rearrangements
**Chromosomal mosaicism
**True hermaphroditism
**Iatrogenic associated with chemotherapy or radiation for neoplasia
*Pregnancy may be possible with donated oocytes and in vitro fertilization if an intact uterus is present.


*Turner syndrome is one cause of ovarian failure.
**'''Turner syndrome is characterized by primary amenorrhea, ovarian streaks, no secondary sexual characteristics (because of primary gonadal failure).'''

====Anovulation with Primary Gonadotropin Deficiency====
*Anovulation with primary gonadotropin deficiency demonstrates ''isolated gonadotropin deficiency''.
**No GnRH / LH / FSH;
*Anovulation with primary gonadotropin deficiency '''may present with anosmia''' and / or '''panhypopituitarism'''.
*''In obese patients pectoral fat may be misinterpreted as breast development.''
*Patients with primary gonadotropin deficiency will begin to ovulate again with gonadotropin therapy.

====Functional Chronic Anovulation====
*Stress suppresses gonadotropic release at hypothalamus.
**This response to stress is good for a state of famine (don't make more eaters when there's little eating to be done).
**Probably a mild form of anorexia nervosa
*Serum cortisol levels tend to be elevated
*May be associated with emotional or physical stress
**Commonly seen in athletes, anorexics, high stress situations, and physical-appearance-success coupling.
*Part of the problem in functional chronic anovulation is that '''a certain amount of body fat needed to maintain LH / FSH levels''' and these women lack that fat threshold.
*'''Although FSH and LH levels are both low, FSH is usually slightly higher than LH'''

====Polycystic ovarian disease====
*'''POCD is the most common cause of anovulation.'''
*POCD '''presents as hirsuitism, high BMI, oligo- / a-menorrhea, and insulin resistance.'''
**Insulin resistance found in >50% of cases.
*'''May be found in many lean women with anovulation, e.g., competition athletes.'''

===Anovulation Workup===
*Workup for the anavulating patient:
**Chemistries: FSH, LH, prolactin, testosterone, DHEA-S, 17-OH progesterone, fasting glucose, insulin.
***Recall that prolactinemia / prolactinomas can cause anovulation by hyperplasticizing the pituitary.
***Recall that insulin resistance is common in PCOD.
**Imaging:
***CT of the sela tercica to identify a prolactinoma.
***U/S of ovaries to be sure they exist and do not have cysts ("string of pearls").

===Pathophysiology Male Infertility===
*There are three major classifications of male infertility:
**Azoospermia: no sperm
**Oligo-asthenospermia: reduced or warped
**Erectile and ejaculatory dysfunction

====Semen Analysis====
*Obtain the sample after 3-5 days of abstinence
*Normal semen characteristics:
**Volume: 2-5 cc
**Concentration: 20 million/cc or 25 million/total ejaculate
**Motility: 50-70% with rapid forward progression
**Morphology: 30% normal forms using strict criteria


*We need to know when to attain a semen analysis:
*Semen analysis workup:
**Chemistries: FSH, testosterone, TSH, prolactin
**Imaging studies:
***Vasogram
***Sonogram of the scrotum and groin
***CT or MRI of the sella turcica (if prolactin is elevated)
**Testicular biopsy (indicated for azoospermia or severe oligospermia with normal FSH and LH)

===Infertility Example Question===
*CT is a 25 yo Para 0 comes to see you for evaluation for infertility.
*She has normal 28 day menstrual cycles. Her husband has farthered 2 children in a previous affair. His recent semen analysis was normal with a very good sperm count. CT had developed severe PID 3 years ago.
*Which study would be the preferable test to perform next.
**A) Endometrial bx
**B) Post coital test
**'''C) Hysterosalpingogram'''
**D) Serum progesterone


*Your Pt’s hubby is a 25 year old former college baseball player who now works as a preschool teacher. He works out lifting weights three times a week. He has a history of a scrotal injury with testicular torsion in college. His younger brother has cystic fibrosis and has has survived into his early 20’s with therapy but has required numerous hospitalizations. You perform a post-coital test followed by a semen analysis, neither of which reveals any sperm.
*Which of the following tests is most likely to identify the cause of the azoospermia?
**FSH
**Testicular biopsy
**Prolactin
**'''Vasogram'''
***Recall that cystic fibrosis pts often have agenesis of the vas deferens.
***Recall that damage may have severed his vas in his college days.

==Gynecological Cancers==
 *3 questions; 1 on diagnosis of endometrial (uterine) cancer, 1 on risk factors of cervical and prevention of cancer, 1 on appropriate evaluation for pelvic mass

===Gynecological Cancers===
*Ovarian Cancer / Fallopian tube cancers
*Cervical cancer
*Endometrial cancer (AKA uterine cancer)
*Rarer cancers:
**Vulvar cancer
**Vaginal cancer
**Trophoblastic cancer

===Endometrial (uterine) cancer===
*'''Most common gynecologic cancer (41k new cases each year)'''
**1/38 lifetime risk (cervical is 1/135)
*'''Second most common gynecological cancer killer'''
*Risk factors: age, null-gravis, ''atypical hyperplasia'', unopposed hormone replacement, '''obesity, hypertension, and diabetes.'''
**Recall that the highest risk for ''cervical cancer'' is ''high grade dysplasia''.
**75% of cases of endometrial cancer are found in post-menopausal women
*Presentation of endometrial cancer includes '''abnormal bleeding, post-menopausal bleeding''', pre-menopausal bleeding.
*'''Known etiologies of endometrial (uterine) cancers include prolonged unopposed estrogen stimulation.'''

====Endometrial (uterine) cancer: Diagnosis====
*For all gynecological problems, consider a pregnancy test as the first diagnostic.
*Upon suspecting uterine cancer, '''take a biopsy'''.
**'''Biopsy is via pipelle.'''
**Biopsies have a 98% sensitivity for uterine cancer.
**Dilation and curettage (D&C) may need to be 

*For diagnosing uterine cancer, '''histeroscopy is the gold standard.'''
**Hysteroscopy can reveal cancer lesion for direct biopsy.
**Hysteroscopy should not be used for known uterine cancer cases as the fluid used can push malignant cells to new locations

*Suspicion of a uterine cancer can also indicate an U/S.
**The endometrium in non-malignant cases should be less than 6mm thick.
**Endometrium over 6mm is an indication for biopsy.

===Cervical Cancer Epidemiology===
*Cervical cancer screening via Pap smears:
**Screening is now recommended to begin at 21 yo--not based on time of first coitus.
**Pap smears should be repeated every 2 years if normal and low-risk from age 21-29.
***Low risk: No history of high grade dysplasia, HIV, or other immune suppression.
**After age 30, and 3 consecutive negatives, and low-risk, pap smears can be reduced to every 3 years.
**May stop pap smears after age 70 or after total hysterectomy.
**'''Pap smears catch most cervical cancer cases: 60% are caught in stage 1.'''


*''If an abnormal Pap smear occurs or if the cervix appears or feels abnormal:''
**'''Colposcopy'''
**'''Directed Biopsy'''
***LEEP excisin
***Cold knife cone (microscopic or suspicion of invasion)


*Cervical cancer risk factors: minorities / underserved, multiparity, early parity, early coitus, '''smoking'''.
*HPV strains 16, 18, 31, 33 are associated with cervical cancer.
*Some cases of HPV infection (especially in the young, with their highly proliferative cervical epithelium) resolve spontaneously.

===Evaluation of an Adnexal Masses===
*Good prognostic indicators of adnexal masses: being asymptomatic, cystic nature (fluid filled, means it is benign), being young (15-45 yo), spontaneous resolution
*Bad prognostic indicators of adnexal masses: having associated pain, solid / complex nature, ascites, omental caking quality, lymphadenopathy


*The differential diagnosis for an adnexal mass should include:
**Physiologic
**Gestational
**Inflammatory
***PID can form a pretty big, complex mass on the ovary with fallopian tube involvement.
**Congenital
**Traumatic
**Neoplastic


*Adnexal mass workup:
**Pelvic exam
**CA 125 as triage, be ready to call in gyncological oncology as backup
**Imaging:
***U/S is superior to CT


*Adnexal mass Treatment:
**Operate on large masses.
**Operate on masses with many bad indicators (old age, ascites, etc.)

===Gynecological Cancer Example Question===
*Which disease; treatment dyad is correct?
**A) Endometrial adenocarcinoma: HPV vaccine (total hysterectomy)
**B) Cervical squamous carcinoma: Tamoxifen (chemo, radiation, sx, depending on grade / location)
**'''C) Ovarian epithelial carcinoma: operation and chemotherapy (platinum based chemo)'''
**D) Cervical dysplasia: Chemotherapy (no treatment if mild / moderate, severe moves into cervical carcinoma treatment options)