Ectopic Pregnancy
Sexually active female who has not had a period (or had period but light to scant bleeding) in 6 to 7 weeks complains of lower abdominal/pelvic pain or cramping (intermittent,
persistent, or acute). Pain worsens when supine or with jarring. If ruptured, p
Dominant Breast Mass/Breast Cancer
Middle-aged to older female with a dominant mass on one breast that feels hard and is irregular in shape. The mass is attached to the skin/surrounding breast tissue (or
is immobile). Among the most common locations are the upper outer quadrants of the bre
Paget's Disease of the Breast (Ductal Carcinoma In Situ)
Older female reports a history of a chronic scaly red-colored rash resembling eczema on the nipple (or nipple and areola) that does not heal. Some women complain of itching.
The skin lesion slowly enlarges and evolves to include crusting, ulceration, and/
Inflammatory Breast Cancer
Recent or acute onset of a red, swollen, and warm area in the breast of a younger woman. Can mimic mastitis. Often, there is no distinct lump on the affected breast. Symptoms
develop quickly (few weeks to months). The skin may be pitted (peau d'orange) or
Ovarian Cancer
Older women with complaints of vague symptoms such as abdominal bloating and discomfort, low-back pain, pelvic pain, urinary frequency, and constipation (e.g., frequently
blamed on benign conditions). By the time it is diagnosed, the cancer has already me
MENSTRUAL CYCLE
Follicular Phase (Days 1 to 14)
Midcycle (Day 14): Ovulatory Phase
Luteal Phase (Days 14 to 28)
Menstruation
Follicular Phase (Days 1 to 14)
Estrogen is the predominant hormone during the first 2 weeks of the menstrual cycle. It stimulates the development and growth of the endometrial lining. Follicle-stimulating
hormone (FSH) from the anterior pituitary stimulates the follicles (or the "eggs
Midcycle (Day 14): Ovulatory Phase
Luteinizing hormone (LH) is secreted by the anterior pituitary gland, which induces ovulation of the dominant follicle.
Luteal Phase (Days 14 to 28)
Progesterone is the predominant hormone during the last 2 weeks of the cycle. It is produced by the corpus luteum. Helps to stabilize the endometrial lining.
Menstruation
If not pregnant, both estrogen and progesterone fall drastically, inducing menses. Low hormone levels stimulate the hypothalamus, then the anterior pituitary (FSH), and the
cycle starts again.
Fertile Time Period
Starts about 5 days before and 1 to 2 days after ovulation (day 14 in a perfect 28-day cycle).
At this time of the menstrual cycle, there are copious amounts of clear mucus that feels thin and elastic in the vagina. It is a sign that is used in the cervic
Potassium Hydroxide Slide
Useful for helping with the diagnosis of fungal infections (hair, nails, skin). Potassium hydroxide (KOH) works by causing lysis of the squamous cells, which makes it easier
to see hyphae and spores.
Whiff Test
A test for bacterial vaginosis (BV). A positive result occurs when a strong, fishlike odor is released after one to two drops of KOH are added to the slide (or a cotton swab soaked with discharge).
ORAL CONTRACEPTIVES
Combined Oral Contraceptives
Progestin-Only Pills
Emergency Contraception ("Morning-After Pill")
Combined Oral Contraceptives: Dosed Monophasic Pills
? Loestrin FE 1/20: 21 consecutive days of estrogen/progesterone (same dose daily).
For the last 7 days of the cycle, the placebo pills contain iron supplementation (7 days of iron pills).
Combined Oral Contraceptives: Triphasic Pills
? Ortho Tri-Cyclen: Contains 21 days of active pills and 7 days of placebo pills. The dose of hormones varies weekly for 3 weeks ("tri-phasic"). Progestin used is norgestimate. Indicated for acne.
Combined Oral Contraceptives: Extended-Cycle Pills
? Seasonale: Contains 84 consecutive days (3 months) of estrogen/progesterone with a 7-day pill-free interval. This method typically results in 4 periods per year although
breakthrough bleeding is not uncommon.
Combined Oral Contraceptives: Ethinyl Estradiol and Drospirenone
? Yaz (24 active pills and 4 placebo pills)/Yasmin: Uses drospirenone (a spironolactone analog) as the progestin component. Consider for women with acne, PCOS,
hirsuitism, or premenstrual dysphoric disorder (PMDD). Higher risk of DVT and hyperkalemia.
? L
Progestin-Only Pills: Micronor
Safe for breastfeeding women. Also known as the "minipill." Use on day 1 of menstrual cycle.
? Micronor: Take one pill daily at about the same time each day (each pack contains 28 pills). Start taking pill on day 1 of menstrual cycle.
Progestin-Only Pill: Emergency Contraception ("Morning-After Pill")
Rule out preexisting pregnancy fi rst. Effective up to 72 hours after unprotected sex. Most effective if taken within the first 24 hours.
Progesterone Only (Plan B, Levonorgestrel 0.75 mg Tabs)
? Effective up to 89%.
? Oral contraceptive pills with levono
Oral Contraceptive Pills
Traditional oral contraceptive pills have 21 days of "active" pills and 7 days of placebo pills.
? The last 7 days are the "hormone-free" days. The menstrual period usually starts within 2 to 3 days after the last active pill was taken (from very low leve
Drug Interactions of Oral Contraceptives
These drugs can decrease the effi cacy of oral contraceptives. Advise patients to use alternative form of birth control (condoms) when taking these drugs and for one pill cycle afterwards.
? Anticonvulsants: Phenobarbital, phenytoin.
? Antifungals: Griseo
Absolute Contraindications Mnemonic: "My CUPLETS
My Migraines with focal neurologic aura
C CAD or CVA
U Undiagnosed genital bleeding
P Pregnant or suspect pregnancy
L Liver tumor or active liver disease
E Estrogen-dependent tumor
T Thrombus or emboli
S Smoker age 35 or older
Pill Danger Signs
Thromboembolic events can happen in any organ of the body. These signs indicate a possible thromboembolic event. Advise patient to report these or to call 911 if symptoms
of ACHES:
? Abdominal pain
? Chest pain
? Headaches
? Eye problems; change in vision
Intrauterine Device
The second most commonly used method of contraception in the world (female sterilization is the first). Paragard is copper-bearing (effective up to 10 years) and Mirena contains the hormone levonorgestrel, which decreases vaginal bleeding. Mirena intraute
Depo-Provera (6% Typical Failure Rate)
Each dose by injection lasts 3 months. Check for pregnancy before starting dose. Start in first 5 days of cycle (day 1-5) because females are less likely to ovulate at these times.
Women on Depo-Provera for at least 1 year (or longer) have amenorrhea beca
Diaphragm With Contraceptive Gel and the Cervical Cap
(13% Failure Rate)
? The diaphragm must be used with spermicidal gel. After intercourse, leave diaphragm inside vagina for at least 6 to 8 hours (can remain inside vagina up to 24 hours).
? Need additional spermicide before every act of intercourse. Apply the spermicidal fo
Condoms
Male Condoms (18% Failure Rate)
? More effective than the female condom.
Female Condoms (21% Failure Rate)
? Do not use with any oil-based lubricants, creams, and so on.
Nuvaring (9% Failure Rate)
? Plastic cervical ring that contains etonogestrel and ethinyl lestradiol and is left inside the vagina for 3 weeks, then removed for 1 week (has period). Educate patient on how to apply and remove (the ring should fi t snugly around cervix).
Absolute and
Ortho Evra Contraceptive Patch (9% Failure Rate)
? Higher risk of VTE (releases higher levels of estrogen) compared to oral contraceptive pills. Absolute and relative contraindications for combined estrogen-progesterone method of contraception are the same as oral
contraceptives.
Contraceptive Implants (<1% Failure Rate)
? Contains long-acting form of progestin (etonorgestrel). Results in amenorrhea, which is reversible when the implants are removed. May take a few weeks to 12 months to ovulate. Thin plastic rods are inserted on the inner aspect of the upper
arm subdermal
Fibrocystic Breast
Monthly hormonal cycle induces breast tissue to become engorged and painful. Symptoms occur 2 weeks before the onset of menses (luteal phase) and are at their worst right before the menstrual cycle. Resolves after menses start. Commonly starts in women in
Polycystic Ovary Syndrome (PCOS)
? Hormonal abnormality marked by anovulation, infertility, excessive androgen production, and insulin resistance.
Classic Case
Obese teen or young adult complains of excessive facial and body hair (hirsutism 70%), bad acne, and amenorrhea or infrequent pe
Polycystic Ovary Syndrome (PCOS) Treatment
Treatment Plan
? Transvaginal ultrasound: Enlarged ovaries with multiple small follicles (sizes vary).
? Serum testosterone, DHEAs, and androstenedione are elevated. FSH levels normal or low.
? Fasting blood glucose and 2-hour oral glucose tolerance test
Candida Vaginitis
Overgrowth of Candida albicans yeast in the vulva/vagina. Considered as normal vaginal flora, but can also be pathogenic. Diabetics, HIV-positive, on antibiotics (i.e., amoxicillin), or any type of immunosuppression are at higher risk. (The male penis can
Candida Vaginitis Treatment
Medications
? Miconazole (Monistat), clotrimazole (Gyne-Lotrimin) for 7 days (over the counter).
? Prescription: Difl ucan 100 mg tab � 1 dose, terconazole (Terazol-3) vaginal cream/suppository.
? If patient is on an antibiotic such as amoxicillin, recomm
Bacterial Vaginosis (BV)
Caused by an overgrowth of anaerobic bacteria in the vagina. Risk factors include sexual activity, new or multiple sex partners, and douching. Not an STD. Therefore, sexual
partner does not need treatment. Pregnant women with BV are at higher risk for int
Bacterial Vaginosis (BV) Treatment
Medications
? Metronidazole (Flagyl) BID � 7 days or vaginal gel at HS (bedtime) � 5 days.
? Watch for disulfuram (Antabuse) effect if combined with alcohol (severe nausea, headache, etc.).
? Clindamycin (Cleocin) cream at HS � 7 days.
? Oil-based creams
Trichomonas Vaginitis (Trichomoniasis)
Unicellular protozoan parasite with flagella that infects genitourinary tissue (both males and females). Infection causes inflammation (pruritus, burning, and irritation) of
vagina/urethra.
Classic Case
Adult female complains of very pruritic, reddened vu
Trichomonas Vaginitis (Trichomoniasis) Treatment
Medications
? Metronidazole (Flagyl) 2 g PO � 1 dose (preferred) or metronidazole 500 mg BID � 7 days.
? Treat sexual partner because trichomoniasis is considered an STI. Avoid sex until both partners complete treatment.
Atrophic Vaginitis
Chronic lack of estrogen in estrogen-dependent tissue of the urogenital tract; results in atrophic changes in the vulva and vagina of menopausal women.
Classic Case
Menopausal female complains of vaginal dryness, itching, and pain with sexual intercourse
Osteoporosis
A gradual loss of bone density secondary to estrogen defi ciency and other metabolic disorders.
Most common in older women (White or Asian descent) who are thin and with small body frames, especially if positive family history. Treat postmenopausal women
Bone Density Test Scores
? Use DXA to measure the bone mineral density (BMD) of the hip and spine. Do baseline and repeat in 1 to 2 years (if on treatment regimen) to assess the effi cacy of
the medicine. If not on treatment, repeat DXA in 2 to 5 years.
? Osteoporosis: T-scores o
Osteoporosis Treatment
Bisphosphonates (First Line)
Selective Estrogen Receptor Modulator (SERM) Class
Miacalcin (calcitonin salmon, derived from salmon)
HRT/ERT (estrogen-replacement therapy)
Bisphosphonates (First Line)
? First-line drug for treating postmenopausal osteoporosis, osteoporosis in men, andglucocorticoid-induced osteoporosis (men and women).
? Potent esophageal irritant (advise patients to report sore throat, dysphagia, midsternalpain). May cause esophagitis
Selective Estrogen Receptor Modulator (SERM) Class
Evista (raloxifene). Blocks estrogen receptors. A Category X drug.
? Approved for use after menopause.
? Do not use to treat menopausal symptoms (aggravates hot fl ashes).
? Does not stimulate endometrium or breast tissue.
? Increases risk of venous throm
Other Hormones
Miacalcin (calcitonin salmon, derived from salmon)
? Not a first-line drug.
? Stops bone loss and maintains BMD (but does not rebuild bone).
? May reduce spinal fracture risk.
HRT/ERT (estrogen-replacement therapy)
? Increases bone density and treats menopausal symptoms.
? Increases risk of heart disease, DVT, breast and endometrial cancer.
Exam Tips Birth Control
? Some brands of birth control pills (e.g., Loestrin FE) contain iron during the last 7 days of the pill cycle (instead of a placebo pill).
? Low-dose birth control pills contain 20 mcg to 25 mcg of ethinyl estradiol.
? Desogen, Ortho-Tricyclen, and Yaz/Y
Exam Tips Other
? There will be questions on all the types of vaginitis (bacterial vaginosis [BV], trichomonas, candida, atrophic vaginitis). The questions range from diagnosis, workup/lab tests, to
treatment.
? Become familiar with BV. "Clue cells" are squamous epitheli
Clinical Tips
? Birth control pills can elevate total T4 levels (but not free T4) and triglycerides/lipids.
? Do not recommend Depo-Provera for women who want to become pregnant in 12 to 18 months because it may cause delayed return of fertility. It can take up to 1 ye