| PALM-COEIN
Polyps, Adenomyosis, Leiomyomas, Malignancy, Coagulopathy, Ovulatory dysfunction, Endometrial, Infection/Iatrogenic | What are the causes of Abnormal Uterine Bleeding? |
| Ovulatory: Regular cycles Causes: Structural & coagulation defects
Anovulatory Cause: hormonal or endocrine | Classification of AUB? |
| No periods for 3 mo ( if previous regular), or 6 mo if previously irregular
W/U : HCG, TSH, FSH, Prolactin, PaP, STI check | Amenorrhea definition and cause |
| AUB > 35 y.o or < 35 with RF ( PCOS or obesity, DM, tamoxifen), postmenopausal bleeding. | Indication for endometrial Bx: |
| Chronic amenorrhea with negative w/u to determine if there is unopposed estrogen.
Treat with medroxyprogesterone ( Provera) 10 mg/d x 10 day
Menstrual blg within a week suggest presence of estrogen. | Indication for progesterone challenge |
| Bleeding > 7 days of 2-3 days longer than usual.
Frequent bleeding < 21 d. | What is the definition of Menorrhagia? |
| 'Adolescent: Von Willebrand Dz
Young adult: an ovulation, pregnancy , infection
Adult: Fibroid, PCOS, thyroid
Postmenapausal: anticoagulation, malignancy | What are the most common causes of menorrhagia/ age group? |
| OCP ( 35 mcg estradiol) bid- qid stops bleeding in 48 hours. continue with OCP (LoOvral) x 3 mo.
If OCP contraindicated Rx Provera 10 mg x 14 d + NSAID
Consider Mirena IUD
Give FeSO4 if anemic | How do you treat menorrhagia as outpt? |
| CBC, PT, PTT, TSH, HCG, GC/Chlamydia, TSH, Prolactin, Pap
Vag exam to check for infection, polyp
If suspect Von Willebran, check Factor 8 and VW factor Ag and activity.
US | What is the W/U of menorrhagia |
| Rotterdam criteria 2/3
Ovulatory dysfunction,
Clinical androgen excess,
Polycystic ovaries on US ( not required) | PCOS Definition |
| Wt loss and exercise
OCP
Metformin | How do you treat PCOS? |
| Obesity, hydadrenitis, keratosis pillars, skin tags, Acanthosis ingrains, hirsutism, alopecia, acne, broad shoulders | What are some of the findings associated with PCOS? |
| Abnormal HPO signaling releasing excess LH over FSH.
LH triggers production of androgens.
High insulin stimulates ovary to produce androgens.
Increase androgens inhibit ovarian follicle maturation. | What causes PCOS? |
| PCOS ( most common), 21 hydroxylase deficiency, Tumor ( adrenal or ovary, Ovarian hyperthecosis ( insulin resistance in postmenaupause) Drugs ( Danzol) | What are the causes of hirsutism? |
| Total testosterone ( > 150 is abnormal)- check off OCP
If elevated check DHEA-S ( to r/o adrenal tumor > 700 abnl)
Check 17 hydroxyprogestrone to r/o 21 hydroxylase deficiency
HCG, Prolactin, US, and CT if DHEA is elevated. | What is the w/u of hisutism? |
| Wt loss, OCP ( 30-35 mcg Estradiol if < 40 y.o,) ( 20 mcg Estradiol if > 40) with low androgenic progesterone ( drosperinone)
If no response in 6 mo consider
Spironolactone 50 mg bid ( androgen receptor antagonist)
Finasteride ( 5 alpha reductase inhibitor) | Treatment of Hirsutism |
| Start at 21- 29 every 3 years with cytology alone.
30-65: HPV and cytology q 5 years or cytology alone Q 3 years or HR HPV Q 5 years. Type 16 & 18 go to colposcopy. | Who do you screen with Pap? |
| Repeat cotest in 12 mo or test for HPV 16&18 | How do you manage + HPV and - Pap |
| Colposcopy. | How to you manage + HPV and ASCUS |
| Women > 65, or total hysterectomy | When do you stop screening for cervical cancer? |
| If pt > 40 need endometrial Bx. | How do you manage endometrial cells on Pap? |
| Screen for 20 years post treatment
Initially every year with contest x 2, If neg in 3 years, if neg in 5 years. | How often do you screen woman with hx of CIN 2 or greater? |
| Repeat in 3 years. Low risk of progression 0.28% | How do you manage ASCUS with -HPV |
| Girls: 9- 26
Men 11-26
Three doses: 0, 2, 6
Protects against HPV 6,11,16, 18, | HPV vaccine indication |
| CIN1 = HPV infection
CIN 2= High grade lesions : 40% regress
CIN 3 = Progress to cervical cancer. | Pap Classifications |
| Ovaria cyst or ectopic pregnancy | What are the causes of adenexal mass in premenopausal women? |
| Massis cystic < 10 cm with no septation or papilla.
Monitor with serial US Q 4-8 wk. Most regress
If persistent > 12 wk or if mass > 10 cm, painful, or postmenopausal referral to surgery
Treat with NSAIDS and OCP to prevent future cyst. | When can you treat cyst as outpt? |
| Azithromycin 1 mg single dose or Doxy 100 mg bid x 7 days. | What is the treatment of chlamydia? |
| Sexually active women < 25 | Who do you screen for STI? |
| Ceftriaxone 250 mg IM with Azithro 1 gm or Doxy 100 mg bidx7.
Oral option os Cefixime ( Suprax) 400 mg po in one since dose
Test for cure in 1 wk.
If PNC allergic use Azithro 2 gm in single dose. | How do you treat Gonorrhea? |
| Metronidazole 500 mg bid x 7 days or
Metrogel one applicator daily for 5 days
Clindamycin 2% cream applicator 7 days,
Clinda ovules 100 mg intravaginally x 3 days.
Partners need not to be treated. | How do you treat BV? |
| New sex partner, douche, Abx use, IUD, pregnancy. | Risk factors for BV |
| Metronidazole 2 mg single dose or 500 bid x 7 days
Treat sex partner | How do you treat Trich? |
| Fluconazole ( Diflucan ) 150 mg single dose
Miconazole cream 2% itravaginally x 7 days
Clotrimazole cream 2 % for 14 days. | How do you treat vaginal yeast infection |
| > 4 infection in a year
Fluconazole 150 mg Q 3 d for 2 wks, followed by one a week for 6 mo.
RF: Hyperglycemia, Pregnancy, OCP, Immunosuppresion, diaphragm and IUD. | How do y ou treta chronic yeast infections? |
| Ceftriaxone 250 mg IM and Doxy 100 mg bid x 14 days + Metronidazole 500 mg bid x 14 days | PID treatment |
| IUD does not post threat to PID after 20 days of insertion
IUD does not need to be removed if pt improving 72 hours after Abx started. | PID and IUD |
| Pregnant, severely ill, N/V high fever, suspect turbo-ovarian abscess, | When do you hospitalize for PID? |
| Test for cure 3 mo
Treat partner if sex active last 6 mo
Check HIV and PRP | PID Monitoring |
| Plan B ( levonorgestrel) 2 pills at once
Cefriaxone 125 mg IM + Azithromycin 1 gm or Doxy 100 bidx7d
Check GC, Chlamydia, wet prep, RPR, HIV-RNA, Hep BsAg and IgM, HCG
Recheck HIV and RPR in 6 wk, 3 and 6 mo. | What is the Prep for sexual assault? |
| Receptive anal: .5-3%
Vaginal: .1-.2%
Oral < .1% | What is HIV risk for sexual assault? |
| Tenofovir-emtricitabine (Truvada) daily for 7-10 days
Must be started within 72 hours of assault.
Check GFR > 60 OK, Bep b and HCG. | What is PEP for sexual assault? |
| IUD > 99 %
Implants ( Implanon and Nexpalnon)
Surgical sterilization
Abstinence | What are the most effective methods of contraception? |
| OCP, Injectables Depo Provera), Vaginal ring ( Nuvaring), Patch ( Ortho Evra) | What are the other effective methods of contraception (1-99%)? |
| Types: 52 mg ( Mirena) or Liletta: Skyla ( 13.5 mg) last 3 years and smaller.
Duration of use : up to 7 years
SE: change in bleeding pattern, spotting. 20% are amenorrmheic at one year. | Mirena IUD side effects |
| Duration 10 years. Also used as emergency contraception placed within 5 days of unprotected intercourse.
Associated with heavy periods and cramps.
Risk of uterine perforation 1/1000 | Copper IUD SE |
| Implanon or Nexplanon ( Etonogestrel)
Duration 3 years, bu effective up to 4.
SE: Change in bleeding pattern.
Decrease dysmenorrhea and pelvic pain. | Implantable contraception |
| Intravaginally for 3 wk, then leave out 1 wk or use continuously and change every 4 wk.
SE: Higher risk of DVT | Nuva Ring SE |
| Ortho Evra: Contains progesterone drospirenone which is associated with a risk of DVT 6x more than other OCP. | Patch OCP |
| Levonogestrel 3x
Drospeninone/Desogestrel 6x
Patch 7.9X
Nuvarink 6.5X | DVT risk with OCP |
| IM Q 3mo : Progesterone only.
SE: Irregular bleeding. 50% amenorrhea after 1 year.
May lower bone mineral density which reverts to normal with cessation. | Depo-Provera |
| Plan B ( levonorgestrel 0.75 mg ) 2 pill at once.
Yuzpe: 2 doses 12 hours apart: Lo/Ovral 4 pill 12 hours apart. 86% effective
No pregnancy test needed if used up to 72 hours after unprotected intecourse.
No prescription needed if > 18.
Decrease risk of pregnancy 85%
No teratogenic effects
Smoking , hypertrigliceride, and hx of DVT not contraindication. | Emergency Contraception |
| Smokers > 35, Hx of DVT, Hx of Stroke, PVD, migraine with aura, HTN, SLE with antiphospholipid Ab, DM with complication, Breast cancer | When do you avoid estrogens for contraception? |
| < 35 mcg Estradiol | OCP estrogen: what is the highest dose can use ? |
| Praroxetine ( FDA approved) Also, ecitalopram, petaline fluoxetine and gabapentin. | Post menapausal hot flash treatment? |
| DEXA: Hip T score ( standard dev. from mean in young healthy women)
T score: < -2.5
Osteopenia : T -1--2.5 | Osteoporosis Definition |
| Low BMI, postmenopausal, Asia, Hx of fx not associated with trauma, smoking, steroid use > 5 mg/d x > 3mo. , ETOH, anticonvulsant, sedentary
Comorbidities: COPD, RA, hypogonadism, hyperparathyroid, , MM, Cushing, Celiac. | Risk factors for osteoperosis |
| All women > 65, or younger with RF, evidence of osteopenia | Who do you screen for osteoporosis? |
| T score < 2.0
T score < 1.5 with RF
All with osteoporotic fx | Who do you treat for osteoporosis? |
| Ca citrate/Vit D 1500/400-800 IU and Vit K.
Biophosphanate ( Alendronate or Risendronate) decrease fx 50%
Raloxifene SERM ( hot flash and thrombosis)
Calcitonin
Smoking cessation and ETOH limit | What is the treatment for osteoporosis? |
| Renal insufficiency, Vit D deficiency, Hyperparathyroid, Hyperthyroid, Hypogonadism, Chronic liver disease, MM, Inflammatory bowel disease, Celiac | What are the secondary causes of osteoporosis? |
