PANCE Blueprint Reproductive System (8%)

Lessons

1. Reproductive System Comprehensive Exam

2. Reproductive System Flashcards
3. Disorders of the Uterus (PEARLS)

   1. Brian Wallace PA-C Podcast: S2 Disorders of the Uterus

      Brian Wallace PA-C
   2. Dysfunctional uterine bleeding

      DUB is defined as excessive uterine bleeding with no demonstrable organic cause: Polymenorrhea (cycles with intervals of 21 days or fewer), menorrhagia (abnormally heavy or prolonged bleeding) and/or metrorrhagia (uterine bleeding at irregular intervals)

      • Diagnosis of exclusion; treat with oral contraceptives and NSAIDs
   3. Endometrial cancer

      Postmenopausal vaginal bleeding, most common GYN malignancy, usually adenocarcinoma

      • Endometrial biopsy -  vaginal bleeding in a post menopausal women is CA until proven otherwise
      • Treatment: Hysterectomy bilateral salpingo-oophorectomy +/- radiation
   4. Endometriosis

      19 mins

      Endometriosis is a benign disease related to the menstrual cycle, usually cyclical associated with the 3 D's: Dyspareunia (painful intercourse), dyschezia (difficulty in defecating), dysmenorrhea

      • Uterus is fixed and retroflexed. Tender nodularity of cul de sac and uterine ligaments.
      • Laparoscopy: Chocolate cysts observed. Definitive study
      • Treatment: Resect endometriosis, oral contraceptive therapy
   5. Leiomyoma

      Abnormal uterine bleeding; polymenorrhea, menorrhagia, intermenstrual bleeding and/or metrorrhagia along with urinary symptoms (eg, urinary frequency or urgency). Uterine mass.

      • Black women, family history, diagnose with Ultrasound
      • Intramural fibroids are most common, definitive treatment: myomectomy or hysterectomy
   6. Prolapse

      Caucasian women, after labor/delivery, chronic cough. Vaginal fullness, abdominal pain worse late in day, after prolonged standing. Relieved by lying down.

      • Prolapse of the uterus into the vaginal canal - graded by uterine descent: 0°- No descent. 1° - descent between normal and ischial spine. 2°- between ischial spines and hymen. 3°- within hymen. 4° - through hymen.
      • Prolapse of the bladder into the front wall of the vagina (cystocele) -  leads to a “reservoir effect” where the bladder is not completely emptied when the urine is passed
      • Prolapse of the rectum into the back wall of the vagina (rectocele) - complain of a sensation of bulging in the vagina when they strain to open their bowels.
4. Disorders of the Ovary (PEARLS)

   1. Brian Wallace PA-C Podcast: S2 Ovaries and PID

      24 mins

      Brian Wallace PA-C
   2. Ovarian Cysts

      Pain, menstrual delay, hemorrhagic shock from cyst rupture - Follicular cysts are most common, diagnose with ultrasound. Observe - Most resolve within 6-8 weeks (2 menstrual cycles). Persistent cysts, large cysts (>6 cm) or complex cysts can be removed

      • PCOS: Obesity, hirsutism, acne, amenorrhea or oligomenorrhea, menarche occurs at expected age. Strongly associated with obesity, acanthosis nigricans, insulin resistance and hyperinsulinemia. Ultrasound: String of pearls. Labs: LH:FSH > 2.0, increased androgens, increased testosterone. Treat with oral contraceptives, metformin
   3. Ovarian Neoplasms

      Patient in mid-50's with abdominal fullness, bloating, fatigue, weight loss and ascites

      • Tumor marker: CA 125, second most common gynecological cancer (first is endometrial)
      • Asymptomatic premenopausal patients with simple ovarian cysts < 10 cm in diameter can be observed or placed on suppressive therapy with oral contraceptives.
      • Postmenopausal women with simple cysts < 3 cm in diameter may also be followed, provided the serum CA 125 level is not elevated and the patient has no signs or symptoms suggestive of malignancy. If the cyst is > 3 cm or the CA 125 is elevated, further evaluation is necessary.
5. Disorders of the Cervix (PEARLS)

   1. Brian Wallace PA-C Podcast: S2 Review of Cervical and Vaginal Disorders

      Brian Wallace PA-C
   2. Cervical cancer

      Friable, bleeding cervical lesion on exam. Squamous cell carcinoma. Most caused by HPV (High risk types, 16 and 18)
   3. Cervicitis

      Usually occurs due to sexually-transmitted diseases, such as chlamydia or gonorrhea, herpes, HPV, trichomonas

      • Cervical motion tenderness. Ceftriaxone for gonorrhea + Azithromycin for Chlamydia
   4. Cervical Dysplasia

      HPV especially types 16, 18. Associated with cigarette smoking

      • Transformational zone most commonly affected, Gardasil vaccine at age 11-12 it can be administered starting at 9 years of age
      • Pap smear every 3 years starting at age 21 (regardless of sexual activity). Every 5 years if pap smear and HPV are negative starting at age 30
      • ASC-US or LSIL, CIN-1: Reflex HPV, if positive and at least 25 years old – colposcopy, if negative or under 25 years old – retest in 1 year
      • HSIL, CIN-2, CIN-3, CIS: Colposcopy. Outside cervix – LEEP or cryotherapy
   5. Incompetent Cervix

      History of cone biopsy, DES exposure. Causes 2^nd trimester abortion

      • Cervical cerclage. Placed at 14-16 weeks and removed at 36 weeks to allow for delivery
6. Disorders of the Vagina/Vulva (PEARLS)
   1. Cystocele (bladder hernia)

      Prolapse of the bladder into the front wall of the vagina -  leads to a “reservoir effect” where the bladder is not completely emptied when the urine is passed
   2. Vaginal and Vulvar Neoplasm

      • Vaginal cancer  - abnormal vaginal bleeding. Squamous cell carcinoma caused by HPV
      • Vulvar Cancer - vaginal pruritis is most common presentation. Squamous cell and melanoma – pruritic black lesions. Paget’s – pruritic red lesions
   3. Vaginal Prolapse

      Feeling of vaginal or pelvic pressure, heaviness, bulging, bowel or bladder symptoms. Common after hysterectomy.

      • Baden-Walker grades of female genital prolapse – uses the hymen as crossing point
        • Grade 1 – descent above the hymen, Grade 2 – descent to the hymen, Grade 3 – descent beyond the hymen, Grade 4 – total prolapse
   4. Rectocele

      Prolapse of the rectum into the back wall of the vagina - complain of a sensation of bulging in the vagina when they strain to open their bowels
   5. Vaginitis

      • Trichomonas: Frothy yellow, green, gray vaginal discharge and strawberry cervix. Wet mount: Flagellated protozoa. pH: Basic. Treatment: Metronidazole
      • Bacterial vaginosis: Organism: Haemophilus aka Gardnerella. Signs: Fishy odor, thin gray discharge. Wet mount: Clue cells. pH: Basic > 4.5. Treatment: Metronidazole
      • Candida: Thick white vaginal discharge. Associated with recent antibiotic use, diabetes mellitus, steroid use. KOH prep: Pseudohyphae. pH: Normal 4. Treatment: Fluconazole
7. Menstrual Disorders (PEARLS)
   1. Amenorrhea (ReelDx)

      Primary: no menses by age 16

      • Turner’s syndrome – XO karyotype, webbed neck, broad chest. Androgen insensitivity – breast development only. Imperforate hymen – observed on speculum exam. Mullerian agenesis – secondary sex characteristics, no uterus

      Secondary: previously had menses, amenorrhea for 6 months

      • Most often pregnancy. Also caused by weight changes, hypothyroid, prolactinoma
   2. Dysmenorrhea

      Pain with menses or precede menses by 1 to 3 days. Pain tends to peak 24 h after onset of menses and subsides after 2 to 3 days

      • Primary: Begins early after menarche, not associated with pelvic pathology, associated with prostaglandins, treatment with NSAIDs and oral contraceptive pills
      • Secondary: New onset in an older women, associated with a secondary pathologic (structural) cause - adenomyosis, endometriosis, fibroid, PID, IUD, treat underlying cause
   3. Premenstrual syndrome (PMS)

      Caused by an imbalance of estrogen and progesterone along with excess prostaglandin production

      • Symptoms during luteal phase (1-2 weeks before menses) - Bloating, irritability. PMDD - causes marked disruption in functioning.
      • Symptoms resolve at the onset of menses.

   4. Menopause

      Menopause is a clincal diagnosis and is defined by cessation of menses for at least 12 months

      • Average age is 51.5. Definitive diagnosis: FSH > 30 mIU/mL
      • Women who have a uterus should be given a progestin in addition to estrogen because unopposed estrogen increases risk of endometrial cancer.
      • Know the contraindications for HRT: ↑ triglycerides, Undiagnosed vaginal bleeding, Endometrial cancer, history of breast CA or estrogen sensitive cancers, CVD History, DVT or PE history
8. Disorders of the Breast (PEARLS)
   1. Breast abscess

      Often is a complication of mastitis - symptoms are the same with the addition of localized mass and systemic signs of infection

      • Staphylococcus aureus is the most common cause. Incision and drainage + antibiotics (nafcillin/oxacillin IV or cefazolin PLUS metronidazole)
   2. Breast Cancer

      Most common malignancy in women. Risk factors (increased exposure to estrogen): Menarche before age 12, old age of first full term pregnancy, no pregnancies, menopause after age 52

      • Mammogram every 2 years from age 50-74. Every 2 years beginning at age 40 if increased risk factors – 10 years prior to the age the 1'st degree relative was diagnosed. Clinical breast exam: every 3 years in women age 20-39 y/o then annually after age 40. Breast self exam – monthly beginning at age 20 – immediately after menstruation or on days 5-7 of the menstrual cycle.
   3. Fibroadenoma

      Young adult female with painless, firm solitary (rubbery feeling) well defined mobile breast mass. No changes with menstrual cycle
   4. Fibrocystic disease

      Multiple bilateral breast masses that increase in size and pain before menses, usually resolves with the start of the menstrual cycle. Aspiration of cysts- straw colored fluid with no blood
   5. Gynecomastia

      Physiologic gynecomastia: affects pubescent boys. Watch and wait, typically resolved in 1 year

      • Drugs: particularly spironolactone, anabolic steroids, and antiandrogens
      • Klinefelter’s syndrome- XXY karyotype, tall, thin, long limbs. Hypogonadism. Treatment: Danazol
   6. Galactorrhea

      Bilateral milky breast secretions that occur in a non-lactating patient

      • Rule out prolactin-secreting pituitary adenoma, TSH, CT or  MRI. Treat with dopamine agonist - bromocriptine
   7. Mastitis

      Occurs in breastfeeding mothers. Organism: S. aureus, treat with Dicloxacillin, warm compresses. Continue to breastfeed

      • Infectious (unilateral) - Unilateral, fever, chills and color change
      • Congestive (bilateral) - Bilateral breast engorgement that usually occurs in primigravidas
      • Inflammatory breast cancer presents with breast tenderness and color change, but fever and chills are not usually present
9. Pelvic inflammatory Disease

   Causative agents include Gonorrhea and Chlamydia. Chandelier sign (cervical motion tenderness). Complications: infertility, ectopic pregnancy, tubo-ovarian abscess (adnexal mass)
10. Contraceptive Methods

    • Barrier methods: 
      • Failure rates are as high as 40%, offer STI protection, safe for patients with contraindications to hormones
      • Male condoms: 20% failure rate, offers STI protection
      • Female condoms: 21% failure rate, offers STI protection
      • Diaphragm: 15% failure rate, must remain in place 6-24 hours after intercourse, requires pelvic exam and fitting
    • Spermicides Nonoxynol-9
      • Destroys sperm - often used with other forms of BCP such as condoms
      • 27% failure rate
      • Slight increased risk for HIV
    • OCP's
      • 9% failure rate, 0.3% failure rate when used correctly
      • Improves dysmenorrhea and controls menstrual cycle
      • Combined estrogen and progesterone - not used in women > 35 years of age that are smokers, patients with history of blood clots, breast cancer or migraines with aura
      • 35 and younger who smoke OK
    • Progestin-only mini pill
      • 9% failure rate, 0.3% failure rate when used correctly
      • Safe in lactation - can be used in breastfeeding woman
      • No estrogenic side effects (headache, nausea, HTN)
    • Transdermal patch
      • The contraceptive efficacy of the transdermal patch is comparable to that of combined OCP's
      • The failure rate is 0.3 percent with perfect use and 9 % with typical use
    • NuvaRing
      • Flexible plastic vaginal ring
      • 7% failure rate
      • Applied every week for 3 weeks then 1 week off
    • IUD
      • Most effective form of birth control. Reversible.
      • Copper IUD (Paragard) -  0.8% failure rate, women who cannot have hormones that want children later in life (replaced every 10 years)
      • Progestin-only IUD (Mirena)- 0.2% failure rate, replaced every 3-5 years
    • Depo-Provera
      • Long-acting progesterone injection
      • 5% failure rate
      • lasts 3 months
    • Implanon
      • Long-acting progesterone implanted in the upper arm
      • 0.05% failure rate
      • lasts 3 years
    • Emergency contraception
      • Up to 25% failure rate
      • Levonorgestrel emergency contraceptive (Plan B One-Step, etc) within 3 days of unprotected sex or prescribe Ella (ulipristal) within 5 days
      • Consider a copper IUD within 5 days if the woman also wants long-lasting contraception. It's the most effective emergency contraceptive
      • Recommend backup for 7 days after levonorgestrel...and for 14 days or until the next period after Ella, whichever comes first.
    • Sterilization
      • Tubal ligation - 0.5% failure rate, permanent
      • Essure - chemicals or coils to scar fallopian tubes - 0.5% failure rate, can be done in office
      • Vasectomy - 0.15% failure rate - vas deferens from each testicle is clamped, cut, or otherwise sealed. This prevents sperm from mixing with the semen that is ejaculated from the penis.
11. Infertility

    Failure to conceive after 1 year of unprotected intercourse

    • First step: Test male sperm, anovulation is the most common cause - amenorrhea and abnormal periods - 65% female, 20-40% male, 15% unknown. Treatment for anovulatory women: Clomiphene citrate
12. Uncomplicated Pregnancy

    1. Brian Wallace PA-C Podcast: S2 OB Prenatal Care & Active vs Passive Studying

       26 mins

       Brian Wallace PA-C
    2. Normal labor/delivery

       Cervical examination:

       • Dilation – up to 10 cm.
       • Effacement (softening) – up to 100%.
       • Station (position of the baby the head) – 0 is at ischial spine.

       Stages of labor:

       • Stage 1: Onset contractions to full dilation (primi- 6-20 hours ) (multi- 2-14 hours).
       • Stage 2: Full dilation to baby delivery (primi- 30 mins-3 hours) (multi- 5-6 minutes).
       • Stage 3: After baby delivery to expulsion of placenta (0-30 mins).
         • Placenta should have 2 arteries and 1 vein.

       APGAR score:

       • Activity (2=active movement), Pulse (2= >100 BPM), Grimace (2= pulls away, sneeze), Appearance (2=pink), Respiration (2=crying).
       • Score > 6 is good.
       • A score of 4 necessitates resuscitation.
    3. Prenatal diagnosis/care

       G_ P_ or G_ P _ _ _ _

       • G is the number of pregnancies.
       • P is the number of deliveries.
       • Or P is full-term deliveries, premature deliveries, abortions, living children.

       Nagel’s rule for due date: LMP + 7 days - 3 months.

       • Chadwick’s sign: blue cervix.
       • Hegar's sign - cervical softening.
       • Advanced maternal age is 35 - offer testing for genetic abnormalities.
       • Total weight gain range should be 25–35 lb, except in obese women, for whom weight gain should be <15 lb.
       • Folic acid supplementation (0.4–0.8 mg) prior to conception; 4 mg for secondary prevention.
       • Monthly visits to a healthcare professional for weeks 4–28 of pregnancy
       • Visits twice monthly from 28 to 36 weeks
       • Weekly after week 36 (delivery at week 38–40)

       First trimester (weeks 1-12)

       • Fetal heart tones: 10-12 weeks
       • Screening:
         • PAPP-A
         • Free beta HCG
         • Nuchal translucency- ultrasound (10-13 weeks) - >3.5 mm – trisomy or neural tube defect
         • CVS (10-13 weeks)

       Second trimester (weeks 13-27)

       • Fetal movement:
         • Nullipara: 18-20 weeks
         • Multipara: 14-16 weeks
       • Uterine growth
         • At umbilicus – 20 weeks
         • Weeks gestation should equal fundal height in cm.
       • Screening
         • Maternal AFP.
           • Increased- neural tube defects.
           • Decreased- trisomy.
         • Inhibin A.
         • Unconjugated estriol.
         • Ultrasound (18-20 weeks) - anatomy scan, gender reveal.
         • Amniocentesis (15-18 weeks).

       Third trimester (weeks 28- birth)

       • Full term is 37 weeks. Plan for induction after 40 weeks.
       • Vaccines:
         • Tdap (28 weeks).
         • Rhogam (28 weeks) – for Rh-negative mothers only.
       • Screening:
         • Gestational diabetes (24-28 weeks): 50g non fasting 1-hour test followed by 3-hour GTT if > 130 mg/dl on 1-hour
         • Rh antibodies for Rh-negative mothers (28 weeks).
         • Vaginal-rectal culture for Group B strep (35 weeks) - If positive, treat with IV penicillin during delivery.
         • Nonstress test: 20-minute monitoring -  should see two accelerations (15 BPM above baseline, for 15 seconds), and no decelerations.
         • Biophysical profile: NST, amniotic fluid level, fetal movements, fetal tone, fetal breathing.
13. Complicated Pregnancy (PEARLS)

    1. Brian Wallace PA-C Podcast: S2 Complicated Pregnancy Parts 1-5

       Brian Wallace PA-C

    2. Abortion

       • Threatened – vaginal bleeding, closed cervical os
       • Inevitable – vaginal bleeding, open cervical os, no passage of tissue
       • Incomplete – vaginal bleeding and tissue passage from open cervical os
       • Complete – complete passage of fetal tissue
    3. Abruptio placentae

       When you see painful vaginal bleeding in the third trimester think abruptio placenta

       • Delivery of the fetus and placenta is definitive treatment, blood type, cross-match and coag studies as well as placement of large bore IV line, Cesarean section most often is the preferred route for delivery
    4. Cesarean section

       C-sections constitute about 32% of deliveries in the United States

       • most common reasons for cesarean are a previous cesarean, dystocia or failure to progress, breech presentation and fetal distress
    5. Dystocia

       Dystocia is defined as an abnormal labor progression  - macrosomia ( big baby),  small pelvis, poor contractions.

       • Shoulder Dystocia: failure of the shoulders to deliver spontaneously after delivery of the fetal head - Turtle Sign – retraction of the delivered head against the maternal perineum McRoberts maneuver and Woods “Corkscrew”
    6. Ectopic pregnancy

       Most often in ampulla. Serial quantitative Beta HCG and transvaginal ultrasound

       • Ring of fire sign (hypervascular lesion with peripheral vascularity on Doppler). HCG is > 1,500, but no fetus in utero. Normal pregnancy HCG increases by 66% every 48 hours 

        
    7. Fetal distress

       Non-stress testing

       • GOOD- Reactive NST - > 2 accelerations in 20 minutes, with increased fetal heart rate 15 bpm lasting > 15 seconds, indicates fetal well being
       • BAD - Nonreactive NST - No fetal heart rate accelerations or < 15 bpm lasting < 15 seconds, get contraction stress test

       Contraction stress test - measures fetal response to stress at times of uterus contraction

       • GOOD - Negative CST - No late decelerations in the presence of 2 contractions in 10 minutes, indicates fetal well being, repeat CST as needed
       • BAD - Positive CST - Repetitive late decelerations in the presence of 2 contractions in 10 minutes, worrisome especially if nonreactive NST, prompt delivery

       APGAR - Appearance, Pulse, Grimace, Activity, Respiration (view scoring system)

       • Score from 1-10 with > 7 normal, 4-6 fairly low, 3 and under critically low
       • Test is done at 1 and 5 minutes after birth
    8. Gestational diabetes

       13 mins

       Most common complication: macrosomia. Glucose tolerance test between 24 and 28 weeks of gestation - 50 g (1 hour) glucose challenge test (non-fasting). Positive if blood glucose is > 130 mg/dL

       • If ≥ 130 mg/dl after 1 hour then get a 3 hour 100 g glucose tolerance test (GOLD STANDARD)
       • Results are positive if - One hour > 180, Two hour > 155, Three hour > 140
       • Insulin is considered first line therapy, glyburide, dietary management
    9. Gestational trophoblastic disease

       Beta HCG higher than expected, size-date discrepancy, hyperemesis

       • Mole Types: Complete mole - no fetal parts “Grape-like” mass or “snowstorm” on transvaginal ultrasound.
       • Incomplete mole - fetal parts
       • Choriocarcinoma - cancer of gestational contents
    10. Hypertension disorders in pregnancy

        Treatment goal: < 140/90. Treat with Methyldopa, Hydralazine, metoprolol

        • Contraindicated: ACE inhibitors, ARBs, diuretics, calcium channel blockers
        • Preeclampsia - Classic triad: HTN, + Proteinuria and edema after 20 weeks GA
        • Eclampsia - HTN, +Proteinuria + seizures or coma. TX magnesium  and delivery
        • HELLP syndrome is a manifestation of preeclampsia with hemolysis, elevated liver enzymes, and low platelets.
    11. Multiple gestation

        One in 80 births, 3% chance of twins, monitor for complications

        • Elevated beta-HCG. Two or more fetuses observed on ultrasound
        • Monozygotic: identical, Dizygotic: fraternal
    12. Placenta previa

        Painless vaginal bleeding *bright red in 3rd trimester (versus painful, dark red vaginal bleeding in placenta abruptio) usually no abdominal pain

        • No pelvic/cervical digital exam, no intercourse, no vigorous exercise
    13. Postpartum hemorrhage

        Blood loss: > 500 mL of blood within the first 24 hours after vaginal delivery or 1,000 ml with cesarean

        • Uterine atony - defined as a boggy and enlarged uterus - 90% of postpartum hemorrhages.
          • Treatment: Uterotonic agents (contracts the uterus down): Oxytocin IV, Misoprostol, bimanual uterine massage, last resort hysterectomy.
        • Genital Track Trauma - precipitous labor, operative vaginal delivery (forceps, vacuum extraction).
          • Treatment: Laceration greater than 2 cm are repaired surgically.
        • Retained Placental Tissue - Occurs when separation of the placenta from uterine wall or expulsion of the placenta is incomplete.
          • Treatment: Surgery.
        • Coagulation Disorders -DIC associated with severe preeclampsia, amniotic fluid embolism, placental abruption.
    14. Premature rupture of membranes (PROM)

        Clinical definition: rupture of membranes at ≥ 37 weeks gestation prior to the start of uterine contractions.

        • Preterm premature rupture of membranes (PPROM) describes PROM < 37 weeks gestation.
        • Diagnosis: Need to confirm that this is truly amniotic fluid
          • Speculum - fluid pulling in posterior fornix
          • Nitrazine test - blue (due to elevated pH) determine if this is amniotic fluid - PH > 7.1 means it is positive
          • Microscope examination - ferning - take a specimen of the fluid put it on a slide and let it air dry will see "fern pattern" crystallization of the amniotic fluid (crystallization of estrogen and amniotic fluid)
        • Treatment depends on gestational age:
          • > 34 weeks – induce labor
          • 32-34 weeks collect fluid and check for lung maturity – then induce
          • < 32 weeks stop contractions and start 2 doses of steroid injection then deliver the baby – give antibiotics
    15. RH incompatibility

        Rh negative mother, Rh positive fetus - 1'st pregnancy is always unaffected Give Rhogam at 28 weeks, within 72 hours of delivery and during any uterine bleeding throughout pregnancy

        • Given if Rh negative mother and father Rh positive or unknown. Risk of hydrops fetalis