OB-GYN

age 8 in girls - idiopathic central - premature activation of HPG axis (treat with GnRH agonists if complete to avoid premature fusion of epiphyseal plates -> prevent short stature)
age 9 in boys - most commonly due to adrenal hyperplasia

True (central - early activation of hypothalamic-pituitary-gonadal axis) = high LH/FSH & increase with GnRH stimulation
-> Next get CT/MRI of head
Pseudo (excess secretion of sex steriods) = low LH/FSH & NO response to GnRH stimulation
- next check testosterone, DHEAS, cortisol, 17-OH-progesterone, TSH (high - chronic hypothyroid) + Abdominal US

1. Cafe-au-lait spots
2. precious puberty
3. fibrous dysplasia of the bone

12.5-13yrs - tanner stage 4
growth spurt girls = 3
growth spurt boys = 4

Estradiol = ovaries
Estriol = placenta
Estrone = adipose tissue

FSH -> growth of ovarian follicle (granulosa cells) -> estradiol
LH = theca cells; (cholesterol to pregnenolone regulates) induces ovulation
hCG = similar to LH (maintains the corpus lutem (to secrete progesterone) for 8-12 weeks until placenta takes over

menopause (or absence of menses > 6 months - 1yr) before AGE 40
- high FSH

LH and FSH increase (FSH/LH > 1)
Estrogen decreases (increases risk of osteoporosis)

Progesterone
increases 24hr (1 day) before ovulation

proliferate = follicle growing; it can VARY in number of days; ESTROGEN

Secretory = SET at 13-14 days in every women; Progesterone; growing endometrial (spiral arteries) and then shed

Pros: sx control, decrease risk of osteoporotic fractures, favorable lipid profile (but NO cardioprotection), decrease risk of colorectal cancer
Cons: increased risk for (invasive) breast, endometrial cancer and DVTs (also stroke, heart disease and biliary disease)
- only indicated for treatment of SX of menopause, and patient agrees benefits outweigh S/E

women over age 45
- if less than 45 years, exclude other causes (TSH, BhCG, prolactin, FSH)

Estrogen

Progesterone
(PRO-gestation)

1. OCPs combined (4-5 pills in 24 hrs)
2. progesterone only pill - Levongesterol (plan B)
3. Anti-progesterone (Mifeprisone - RU-46)
4. Copper IUD
- all within 72 hours (3 days)

1. smoking + > 35 years
2. migraine with aura
3. uncontrolled HTN
4. Hx of thromboembolism/DVT or coagulation disorder
5. Breast/estrogen cancer
6. Preggo or breast feeding (progesterone-only pill)
7. Abnormal vaginal bleeding of unknown origin

1. Rifampin (antibiotics) + Griseofulvin
2. St. John's Wart
3. Anti-epiletic drugs (phenytoin)

1. age 14 + absence of secondary sex characteristics
2. age 16 + no menarche (has sex characteristics)

absence of menses for > 6 months (or 3 consecutive cycles if regular) in patient with prior hx of menses

scarring of the uterus that follows infection or post-partum infection (D+C - scrapping off of endometrium) -> secondary ammenorrhea

Depo-porvera IM shot or Levonorgesrel implant (DOC for MR patients)
- 50% stay infertile for 10 months after their last shot

OCPs

1. any hx of PID or recurrent STDs
2. current vaginal/cervical infection or STD
3. high risk for STDs (mult. sexual partners)
4. uterine distortion
5. uterine bleeding not worked up
6. copper allergy or WILSON's disease if copper IUD
7. Breast cancer -> avoid progesterone IUD (mirena)

1. actively breastfeeding
2. < 6 months postpartum
3. amenorrhic

local sterile inflammatory rxn within uterine wall -> sperm engulfed and destroyed (prevents fertilization and interferes with sperm transportation)
S/E = increase risk of STDs and PID (string) and causes amenorrhea (used for DUB)

B-hCG
- if primary next do US
- if secondary next do labs (TSH, prolactin +/- FSH)

cancer (endometrial)

> 4mm of of endometrial thickness (on transvaginal US)

PCOS
hirsutism = sexual hair
hypertrichosis = nonsexual hair (drug related or hereditary usually)

PCOS

Endometriosis (3D's)
laparascopy to DX
- commonly fixed or retroverted uterus

Laprascopy (for DX and to treat - ablate ectopic tissue and lyse lesions) - so she can become fertile/preggo
if post-menopause - hysterectomy with bilateral salpino-oophorectomy (TAH/BSO)

Kallmann's syndrome (congenital absence of GnRH secretion)

B-hCG first (if negative) ->
TSH (can present this way too) and prolactin
-> MRI/CT scan

OCP + NSAIDS
SSRI +/- alprazolam
excercise and Vit B6

NSAIDS +/- OCPs

high LH/FSH > 3
high DHEA
high testosterone
high estradiol (increased risk for endometrial cancer)

PCN G = DOC
if allergic = doxycycline or tetracycline

1. Weight loss (most important) + exercise
2. OCPs (or progestins) -> decrease risk of EC * (and decrease mortality**)
3. Metformin (wt loss + insulin resistance)
4. Clomiphene (for preggo)
5. Spirnolactone (not in preggo)

Clinically/PE:
lower abdominal pain or pelvic pain + 1/6:
1. cervical motion tenderness (or adnexal)
2. fever > 101F
3. high ESR or CRP
4. high WBC
5. new/unusual purulent discharge
6. WBCs on wet prep vaginal smear
(low threshold for DX and TX)

> 80 ml / cycle
duration > 7 days, > every 24 days (or less than 35 days)

Candida vaginitis

IV Premarin + Phenergan (anti-emetic)

anovulatory bleeding (dysfunctional uterine bleeding - DUB) aka cannot find pathology
- estrogen stimulation w/o adequate progesterone to stabilize growth of endometrium

threaten abortion

uterine fibroid (leiomyoma)

Endometrosis - classically there is no bleeding a/w but can have too

Endometrial hyperplasia

Hereditary bleeding disorder (vW disease)

Ectopic preggo

Endometrial or cervical polyp

Hypothyroidism (hyper can cause too but present differently)

Lactobacilli (normal on wet mount)

hypothalamic-pituitary disease with LH (main) and androgen overproduction
- androgens are peripherally converted to increase estrogens

Clamydia (frequently asymptomatic and goes unnoticed)

Outpatient = ceftriaxone (IM one dose) + metronidazole and doxycycline for 14 days
Inpatient = cefoxitin (or cefotetan) + Doxycycline
OR Clinda + Gentamycin
- have low threshold for admitting
TOTAL of 14 days (2 week tx)

Enterocele - small bowel into vagina ("feels like im sitting on an egg")

infertility, tubo-ovarian abscess (peritonitis + rebound -> surgical drainage), high risk ectopic preggo

Screen = VDRL and PRP
Dx = FTA-ABS or MHA-TP or dark-field microscopy (spirochetes swab - it cannot be cultured)
- RPR and VDRL will become negative with tx, but FTA-ABS will stay + for life

warts = 6 + 11
cancer = 16 + 18

PAINFUL ulcer (vs. syphillis painless) + much inguinal swelling (bubo formation) + grayish base and foul odor
Haemophilus ducreyi (tropical or immunocomprimised)
DX: gram stain = gram + rods
TX: ceftriaxone (or macrolide)

C. trachomatis (L-1,2,3); developing nations
Painless ulcer + inguinal lymphadenopathy (buboes) + elephantiasis (non-pitting) + FISTULA formation (common mistaken for IBD)
Dx: immunoassays for Chlamydia
Tx: tetracycline, doxycycline, erythromicin

Lymphogranuloma Venereum

Donovania granulomatis
painless ulcer w/ BEEFY red base and IRREGULAR borders
Dx: lesion biopsy on Giemsa stain shows Donovan bodies (red encapsulated intracellular bacteria)
Tx: doxy or TMP-SMX for 3 weeks

Donovan bodies - Granuloma inguinale

Uremia

Bowel obstruction

vaginal fluid CX
Blood cultrues will be negative because preformed ENDOtoxin

Fitz-Hugh-Curtis syndrome (peri-hepatitis)

NO; just do annual like every one else
most common benign neoplasm of female genital tract (smooth muscle)

Uterine fibroids (will decrease in size after menopause -> low estrogen)

increased ovulation (OCPs decrease risk) and BRCA1 > BRCA2

CA-125

AFP

AFP, hCG

hCG

LDH

Stromal cell tumors (benign)
Granulosa-theca cell = estrogen
Sertoli-Leydig cell = testosterone

Epithelial - serous cystandenocarcinoma (has psmomma bodies, calcifications)

Germ cell (seminoma)

physiological (normal) ovarian follicle - should regress by end of menstral cycle - just observation for regression (if not then suspicion for CA)

SEEDING - into peritoneum

benign (mature)
in men its immature

ONLY in POST-menopausal women

1. > age 35yrs + bleeding more frequently
2. > 18 yrs + RF
- high unopposed estrogen
-personal of FHx of breast, ovarian, colon or endometrial cancer
- tamoxifen or HRT use
- PCOS (chronic anovulation)
- obesity or DM

Radiation

chronic inflammatory condition of anogenital region (usually post-menopausal)
- ivory or porcelain-white macules and plaques with pruritis
DX: punch biopsy (R/O SCC)
TX: topical steroids (clobetasol) or pimecrolimus

Histological GRADE (over depth)

Intraductal papilloma

invasive ductal carcinoma

intraductal papilloma

Fibrocystic change

Fibroadenoma

mastitis or inflammatory cancer

CA-125

get colposcopy/biopsy -> if + LEEP/conization/laser ablation + repeat pap in 3-6 mo

repeat pap in 3-4 months (if + again then colposcopy)
get HPV testing (thin smear)

Lobectomy +/- radiation

1. Close observation lifelong +/- Tamoxifen
2. excisional biopsy (make sure its not invasive)
3. prophylatic bilateral mastectomy

spironlactone, digoxin, cimetidine, amiodarone, ketoconazole, haldol, HAART

observation - most resolves spontaneously in 6m - 2 yrs

large fibroadenoma

Breast cancer (2nd is prostate)

breast cancer
lung cancer

suspensory "cooper's ligaments" invasion or involvement
- lymphatic obstruction -> lymphadema -> skin thickening of breast

axillary node involvement!

MRI (over mammogram)

Trastuzumab (Herceptin) + anthracycline

SERM (tamoxifen)
Aromatase inhibitor

TRH and serotonin

Dopamine

increase TSH -> increase TRH -> high prolactin -> decrease GnRH and LH/FSH secretion -> amenorrhea