Transcript Chapter 9 Primary Care in Gynecology

Chapter 9
Primary Care in Gynecology
- Novak’s Gynecology page 199~230
Primary Care in Gynecology
 Early diagnosis and treatment of medical illnesses can
have a major impact on a woman’s health and is a key
component of primary care.
 Although timely referral is important for complex and
advanced disorders, the gynecologist initially may treat
many conditions
Primary Care in Gynecology
 Respiratory Infections
 Sinusitis
 Otitis Media
 Bronchitis
 Pneumonia
 Cardiovascular Disease
 Hypertension
 Cholesterol
 Endocrinologic Disease
 Diabetes Mellitus
 Thyroid Disease
Respiratory Infection
 Sinusitis
 Otitis Media
 Bronchitis
 Pneumonia
 Etiology
Respiratory Infection
Sinusitis
Infection : begin with a viral agent in the nose or nasopharynx that
cause inflammation that blocks the draining ostia.
 Viral agents : impede the sweeping motion of cilia in the sinus and,
in combination with the edema from inflammation,
lead to superinfection with bacteria
 Bacterial agents: S.pyogenes, S.pneumoniae, H. influenzae,
Staphylococcus aureus
α-hemolytic streptococcus species
* G(-) organism : usually limited to compromised hosts in
intensive care units
* chronic disease : polymicrobial with mixed infections consisting
of aerobic and anaerobic organisms.
Respiratory Infection
Sinusitis
 Factors to contributing the development of sinus disease
: atmospheric pollutants, allergy, tobacco smoke, skeletal deformities,
dental conditions, barotrauma from scuba diving, airline travel,
neoplasm,
# chronic sinusitis
: systemic disease (connective tissue syndrome), malnutrition
 Clinical finding
1) maxillary toothache
2) poor response to nasal decongestants
3) abnormal transillumination
4) a colored nasal discharge established by history
5) a colored nasal discharge on examination
- ≥4 : the likelihood of sinusitis↑
- none : the likelihood of sinusitis ↓
Respiratory Infection
Sinusitis
 Diagnosis
 self-diagnosed : headache, dental pain, postnasal drainage,
halitosis, dyspepsia
 Imaging studies
: not when initial episodes , but when persistent infections occur
Respiratory Infection
Sinusitis
 Treatment
 Broad antibiotic therapy
: cover common aerobes and anaerobes
patient with acute pain & purulent discharge
 Systemic decongestants: pseudoephedrine
 Topical decongestants
: < 3days d/t rebound vasodilation and worsening of symptoms
 Mucolytic agents (guaifenesin)
: help thin sinus secretions and promote drainage
 Antihistamins
: avoided in acute sinusitis d/t drying effects may lead to
thickened secretions and poor drainage of the sinuses.
 Symptomatic therapies : facial hot packs and analgesics
Respiratory Infection
Sinusitis
 Chronic sunusitis
: from repeated infection with inadequate drainage
 Sx: recurrent pain in the malar area or chronic postnasal drip
associated with chronic cough and laryngitis with intermittent
acute infection
 Treatment
- directed at the underlying etiology
: allergy control or aggressive management of infections
- Resistant cases : CT
- Endoscopic surgery : polyp remove
 Complication (- untreated sinus-)
: orbital cellulitis leading to orbital abscess, subperiosteal abscess
formation of the facial bones, cavernous sinus thrombosis, acute
meningitis, brain & dural abscess (rare)
Respiratory Infection
Otitis Media
 Serous otitis media
 Cause
: 2nd to a concurrent viral infection of the upper respiratory tract
 Diagnosis
: reveals fluid behind the tympanic membrane
 Treatment
: symptomatic Tx with antihistamines, decongestants, glucorticoids
but, little data exist supporting use of these medications
Respiratory Infection
Otitis Media
 Acute otitis media
 Cause
: bacterial infection - Streptococcus pneumoniae, H. influenzae
 Sx .
: acute purulent otorrhea, fever, hearing loss, leukocytosis
 P. Ex
: red, bulging or perforated membrane
 Treatment
: Broad-spectrum antibiotics
- amoxicillin-clavulanic acid, cefuroxime, trimithoprim-sulfamethoxazole
* antihistamines in treatment of otitis media is unclear
Respiratory Infection
Bronchitis
 Acute bronchitis
: inflammatory condition of the tracheobronchial tree
 Causes
- viral infection and occurring in winter
: common cold viruses(rhinovirus and coronavirus), adenovirus,
influenza virus, Mucoplasma pneumoniae (nonviral pathoen)
- bacterial infections : less common and 2nd pathogens
 Sx
Period
Sx
Initial
cough, hoarseness , fever
3~4days
rhinitis and sore throat : prominent
~3wks
coughing : prominent
# coughning & sputum (prolonged in cigarette smokers) : m/c Sx
Respiratory Infection
Bronchitis
 Diagnosis
 P.Ex
: Auscultation : coarse rhonchi (rales: not usually not auscultated )
signs of consolidation and alveolar involvement : absent.
 chest x-ray : to detect the presence of parenchymal disease
 sputum culture
 Treatment
 symptomatic relief : uncomplictated cases
 antibiotics : for patients who have chest radiographic findings
consistent with pneumonia
 atitussives (containing either dextromethorphan or codeine)
: coughing (most aggravating symptom)
 expectorants : efficacy –not been proved
Respiratory Infection
Bronchitis
 Chronic bronchitis
: defined as the presence of a productive cough with excessive
secretions for 3months in a year for 2 consecutive years
 Prevalence : estimated to be 10-20% of the adult population
 Classified as a form of chronic obstructive disease (COPD)
 Causes
chronic infection and environmental pathogens found in dust
 Sx
cardinal manifestation : incessant cough,-usually in the morning ,
with expectoration of sputum
Sinusitis
Otitis media
bronchtis
Pneumonia
Respiratory Infection
Pneumonia
 Definition
: Inflammation of the distal lung that includes terminal airways,
alveolar spaces and the interstitium
 Causes
: Viral , bacterial, aspiration pneumonia
 Aspiration pneumonia
cause : depressed awareness commonly associated with use of
drugs, alcohol or anesthesia
 viral pneumonia
: multiple infection
- influenza A or B, parainfluenza, respiratory syncytial virus
: spread by aerosolization associated with coughing,
sneezing, conversation
* intubation time : short, requiring only 1~3days prior to the
acute onset of fever, chills, headache, fatigue and myalgia
Respiratory Infection
Pneumonia
* pneumonia develops in only 1% of patients who have a viral syndrome
- mortality rates
: 30% in immunocompromised individuals and the elderly
* Staphylococcal pneumoniae (2nd bacterial pneumonia)
: arising from a previous viral infection, extremely lethal
* vaccination : influenza, pneumococcal pneumonia
amantadine : used to treat individual who have not been vaccinated
(in epidemics)
* Treatment : supportive care – antipyretics and fluids
Respiratory Infection
Pneumonia
 Bacterial pneumonia
 Classification : Nosocomial or community acquired
- determine the prognosis and choice of antibiotic therapy
 Risk factors
: chronic cardiopulmonary diseases, alcoholism, DM, renal failure, malignancy,
malnutrition
 Signs and Symptoms
: depending on the infecting organism and the patient’s immune status
Typical
Atypical
Causes
Streptococcus pneumoniae. Hemophilus
influenzae, Klebsiella pneumoniae,
G(-) organisms, anaerobic bacteria
( cause 2/3 of all bacterial pneumonias)
Viruses, Mycoplasma pneumoniae, Legionella
pneumophila, Chlamydia pneumoniae …
Symptoms
Sudden onset
high fever, rigors, productive cough, chills,
pleuritic chest pain
Incidious onset
Moderate fever without the characteristic rigors and chills
Nonproductive cough, headache, myalgias, mild
leudocytosis
Radiology
disclosed infiltrates pneumonia
Bronchopneumonia with a diffuse interstitial pattern
(“bat wing distribution “)
Respiratory Infection
Pneumonia
 Laboratory studies
 Gram stain, sputum & blood culture
* sputum collection : neutrophil > 25/LPF
epithelial cell < 10/LPF
 ELISA ( indirect serologic test)
or direct fluorescent antibody staining of organisms in the sputum
: Lesionella pneumoniae
 cold agglutinin c appropriate clinical symptoms
: Mycoplasma pneumoniae
Respiratory Infection
Pneumonia
Treatment
Hospitalization
Outpatient
Very ill, elderly, immunocompromised
- Oxygen therapy and hydration with
antibiotic therapy
(same protocol for outpatient therapy except
3rd –generation cephalosporin)
- Chest physiotherapy
# Switch to Oral antibiotics
: ability to eat and drink, blood culture (-),
temperature <38℃
respiratory rate ≤24bpm
pulse rate≤100bpm
# Discharge
- after switch to oral antibiotics
- WBC 12X109 /L
- comorbid illnesses are stable
- O2 saturation >90% on room air
or patient with COPD
: PO2>60mmHg and PCO2<45mmHg
Without coexisiting conditions such as
heart disease, lung disease, renal insufficiency, liver disease
or other comorbid medical illnessess in patient ≤60years
- Erythromycin(500mg, qid)
- Clarithromycin (500mg, bid) or
Azithromycin (500mg, qd for 1 day, followed by 250mg
qd for 4days) – esp. smoker or intolerance to erythmycin
- Doxicycline (100mg bid)
: for patients who are allergic or intolerant to macrolides
With coexisiting conditions such as heart disease, lung
disease,
renal insufficiency, liver disease, or other comorbid medical
illnessess in patient ≤60years
- 2nd –generation cephalosporin
or
- β-lactam-β-lactamase inhibitor
: amoxicillin-clavulanic acid
- With or without a macrolide if legionellosis is a concern
Respiratory Infection
Pneumonia
 Vaccination
 Peumococcal vaccination
- Indication
: ≥ 65, heart, lung disease, alcoholism, renal failure, DM, HIV
infection, cancer
- repeat vaccination
: recommended 5years after the 1st dose in high risk group
 influenza vaccination
- Indication
: ≥50years, serious long term health problems like heart disease,
lung disease, kidney disease, DM, immunosuppression 2nd to
long-term steroid or cancer therapy, 3rd trimester of pregnancy
during the flu season and anyone coming into close contact with
people at risk of serious influenza (physicians, nurses, family
members) * best time : October~mid November
Respiratory Infection
Pneumonia
 poor prognosis factor
: involvement >2 lobes, respiratory rate >30breaths/minute on arrival
in the health care center, severe hypoxemia (<60mmHg breathing
room air), hypoalbuminemia and septicemia
 Complication : ARDS (mortality rate : 50~70%)
Cardiovascular Disease
 Hypertesion
 Hyperlipidemia
Cardiovascular Disease
Risk factors
Cardiovascular Disease
Hypertension
 Epidemiology
-In U.S. : 15% of the population between the ages of 18 and 74 years
 Incidence
: increases with age and varies with race
>50 years : female > male
African Americans > Whites : twice
Geographic variations : higher prevalence of hypertension and
stroke in the southeastern United States regardless of race
 Definition
: blood pressure levels ≥140/90 when measured on two separate
occasions
Cardiovascular Disease
Hypertension
 Primary or essential hypertension : >95%, cause unknown
 Secondary hypertension : <5%
 Diagnosis
- Hx and P.Ex
: presence of prior elevated readings, previous use of antihypertensive
agents, a family history of death from cardiovascular disease prior to
age 55, excessive alcohol and sodium use
→ lifestyle modification is increasingly important in the therapy of
hypertension
- Laboratory evaluations
: rule out reversible causes of hypertension (secondary hypertension)
UA, CBC, S/E, Cr, fasting glucose, total cholesterol, HDL cholesterol,
EKG …
Cardiovascular Disease
Hypertension
 Measurement of Blood Pressure
<Protocols for measurement>
- patient should be allowed to rest for 5minutes in a seated position and
the right arm used for measurements
(for unknown reason, the right arm has higher readings)
- cuff should be applied 20mm above the bend of the elbow and the arm
positioned parallel to the floor
- The cuff should be inflated to 30mmHg above the disappearance of
the brachial pulse or 220 mmHg
- the cuff should be deflated slowly at a rate ≤ 2mmHg/sec
# cuff size : important
cuff hypertension : small cuffs used for obese patients
 Diastolic reading :
- Phase IV : Korotkoff’s sounds (muffled sound)
- Phase V : complete disappearance
Cardiovascular Disease
Hypertension
Diagnosis and management are based on the classification of blood pressure readings
Cardiovascular Disease
Hypertension
Cardiovascular Disease
Hypertension
 Treatment
- General guidelines in assessing individuals for therapy
Cardiovascular Disease
Hypertension
Medication
mechanism
Indication
Contra Ix
Side effect
Reduce plasma and ECF
vol
•→ decreanse peripheral
• resistance, initially
• decrease of cardiac
• output
•→ then normalize
•m/c used medication for
• initial BP reduction
• Cr level <2.5g/L
•+NSAIDs →limits the
effectiveness of thiazides
•Acute gout, DM (glucose
intolerance) hyperlipidemia
•Hyperuricemia
•Hyperglycemia
•Hyperlipidemia
•hypokalemia
•Better than tiazide
diuretics at lower GFR
and higher Scr
•Thiazides +Loop diuretics
•: cause profound diresis →lead
to renal impairment
•Same as above
•hypocalcemia
1) Diuretics
Thiazides
(eg.hydrochlorthiazide)
Loop diuretics
(eg. furosemide)
* Potassium-sparing diuretics (spironolactone, triamterene or amiloride)
2) Adrenergic Inhibitors
Β-blockers
•Propranolol
•Β1 selective
•(atenolol)
•Decreasing cardiac
output and plasma renin
activity c some increase
in total peripheral
resistance
•Migraine
•Angina, MI
•tachycardia
•Asthma, DM, COPD, sick
sinus syndrome,
bradyarrhythmia,
•NSAIDs → decrease the
effectiveness of β-blockers
•Depression
•Sleep
disturbaces(nightmares
in the elderly)
•constipation
•Metabolic change
(similar to those of
thiazides)
•AMI(by rebound
phenomenom)
α1-adrenergic
Prazosin
doxazosin
Promote vascular
relaxation
Total cholesterol LDL
cholesterol ↓ HDL
cholesterol↑
•Males
•(minimal effects on
potency)
•Stress urinary
incontiness
•+diuretics →hypotension
exacervated
•Elder
Orthostatic
hypotension tachcardia,
weakness, dizziness,
mild fluid retension
Medication
Mechanism
Angiotensin-converting
Enzyme Inhibitors(ACEi)
•Captopril
•Enalapril
•Enalprilat
Indication
ContraIx
Side effect
Asthma, COPD,
depression ,DM,
Peripheral vascular
disease
•* combination with
diuretics, CCB, β-blockers
•Pregnancy
•+ NSAIDs: decrease
the effectiveness
•+diuretics :
hypovolemia
• Chronic cough
• Hypotension
• blooddyscrasias, rashes, loss
of taste , fatigue, headaches
hyperK
•Heart failure,
conduction
disturbance
•Headache, dizziness,
constipation, peripheral edema
Angiotensin Receptor
Antagonists
•Losartan
•Calsatan
•Interfere with the
binding of angiotensin II
to AT-I receptor
•Protecting the heart and
kidney
Calcium-channel
Blockers
•Verapamil
•Nifedipine
•Nicardipine
•Block Ca movement
across smooth m.
→promoting vessel wall
relaxation
•CAD,
•elder
•Direct Vasodilators
•Hydralazine
•Minoxidil
(limited use to the
gyecologist d/t side effect
–beard growth)
•Direct relaxation of
vascular smooth m.
primarily arterial
•Preeclampsia, eclampsia
•Central-acting Agents
•Metyldopa
•clonidine
•Inhibit the sympathetic
nervous
system→peripheral
vascular relaxation
•Headaches, Tachycardia
(→β –blocker)
• fluid (Na) retension
(→diuretics)
Drug-induced lupus
erythematousus
•Taste disorder
•Dry mouth
•Suddent withdrawal of
clonidine: hypertensive crisis
and induce angina
Cardiovascular Disease
Hypertension
 Choice of drugs
 migraine headache : β-blockers or CCB
 DM : ACEi
 MI : β-blockers
 African Americans: diuretics + CCB
 Monitoring Therapy
 Lifestyle modification (slightly elevated BP)
- Interval : 1~2 week
 With other disease (i.e.cardiovascular or renal)
- lifestyle modification alone is successful
: close monitoring - interval 3~6month
- lifestyle modification is unsuccessful: medication
Cardiovascular Disease
Hyperlipidemia
Cholesterol : esterized form with various proteins and glycerides that
chrarcterize the stage of metabolism
 Important lipid particles in cholesterol metabolism
 Chylomicrons
: large lipoprotein particles - dietary triglycerides + cholesterol
secreted in the intestinal lumen, absorbed in the lymph, and then
passed into general circulation
adhered to binding sites on the capillary wall and are metabolized
for energy production. (in adipose tissue and skeletal muscle )
 Lipoprotein Particle
: consisted three major component
- core : consists of nonpolar lipids (triglycerides & cholesterol ester)
- surface coat of phospholipids : made of apoproteins & structural
proteins
 Apoprotein : attached to all lipoprotein particles have specific
receptors and demarcate the stage of cholesterol metabolism
Cardiovascular Disease
Hyperlipidemia
 Lipoprotein classes
:determined by the separation of lipids in an electrophoretic field
 Prehepatic metabolites : CM and Remnants
 Posthepatic metabolites : VLDL , IDL, LDL., HDL
 Metabolism
Cardiovascular Disease
Hyperlipidemia
 Hyperlipoproteinemia
 TG:choesterol > 5:1
- predominant fractions are chylomicrons and VLDL
 TG : cholesterol < 5:1
- problem of VLDL and LDL fraction
 Initial classification
Cardiovascular Disease
Hyperlipidemia
 Laboratory testing
multiple environmental causes of variation in cholesterol measurements
< major sources of variation >
- diet, obesity, smoking, ethanol intake, effects of exercise
- clinical conditions
: hypothyroidism, DM, acute or recent MI, recent weight changes
- other
: fasting state, position while the sample is drawn, use and duration of
venous occlusion . Anticoagulant and storage and shipping conditions
Cardiovascular Disease
Hyperlipidemia
 Intraperson variation
 Age and sex
< 50years, in women lower lipid values than men
> 50 years, women lipid value increase d/t exogenous oral conjugated estrogens
 Seasional variation
 Diet and obesity
 Alcohol and cigarette smoking
: moderate (defined as approximately 2ounces of absolute alcohol/day)
sustained alcohol intake is noted to HDL ↑ LDL ↓, TG ↑
- this effect is negated with higher quantities
 Smoking : LDL cholesterol and TG ↑, HDL cholesterol ↓
(critical number : 15~20 / day)
 Exercise : TG and LDL↓ HDL↑
 Caffeine mixed effect on lipoprotein measurements, avoid in the
12hours prior to blood collection

* Blood sample : collected in the morning after a 12-hour fast
Cardiovascular Disease
Hyperlipidemia
 Disease States and Medication Effects
- Diuretics, propranolol: TG↑, HDL cholesterol↓
(esp. Diuretics : total cholesterol ↑)
- DM : TG & LDL↑ HDL cholesterol↓
- Pregnancy
: total serum cholesterol ↓in 1st trimester, continuous increases of all
fractions in 2nd~3rd trimester
- Hypothyroidism : total cholesterol and LDL cholesterol ↑
Cardiovascular Disease
Hyperlipidemia
 Management
 Once hyperlipidemia is confirmed on at least two separate
occasions, 2nd causes should be diagnosed or excluded by taking a
detailed medical and drug history, measuring Scr, fasting glucose
level, performing thyroid, LFT
 obese patients : diet and weight loss (1st)
 Exercise and cigarette cessation
Figure 9.4 Treatment decisions based on the LDL cholesterol level
Cardiovascular Disease
Hyperlipidemia
Medication
Bile acid-binding
resins
effect
cholestyramine and
colestipol
Nicotinic acid
Fibric acid
derivatives
Clofibrate,
gemfibrozil
HMG-CoA reductase
inhibitors
(-statin)
Atorvastatin,
fluvastatin,
lovastatin,
pravastatin
simvastatin
Adverse effect
LDL↓HDL↑
Constipation, bloating , nausea,
heartburn
TG, LDL, lipoprotein(a)↓
HDL↑
Flushing, pruritus, G-I distress
c aspirin or ibuprofen : minimize the
facial flushing
TG↓, HDL↑
LDL↑(some pts)
Effect in cardiovascular
disease
Severe myalgias, muscle weakness c
increases in creatine phosphokinase
levels, rarely hhabdomyolysis leading
to renal failure
Endocrinologic Disease
Diabetes Mellitus
 Definition
: chronic disorder of altered carbohydrate, protein and fat metabolism
from deficiency in the secretion or function of insulin
: defined by either fasting hyperglycemia or elevated plasma glucose
levels after an oral glucose tolerance test (OGTT)
 Risk factors
- age >45years
- adiposity or obesity
- a family history of diabets
- Race and ethnicity
- Hypertension (≥140/90)
- HDL cholesterol ≤35mg/dL with or without a TG level ≥ 250mg/dL
- History of gestational diabetes or delivery of baby >9 pound
Endocrinologic Disease
Diabetes Mellitus
 Classification
 Type 1 DM
: The major metabolic disturbance of type 1 diabetes is the absence of insulin
from destruction of β cells in the pancreas
 Type 2 DM
: heterogeneous form of disbetes that commonly occurs in older age groups
(>40 years) and is more frequently noted to have familial tendency than type 1
diabetes.
# type 1 : an absence of insulin
type 2 : resulting in insulin resistance
Endocrinologic Disease
Diabetes Mellitus
 Diagnosis
1. FBG (fasting blood glucose) ≥ 126mg/dL
2. Random blood glucose ≥200mg/dL with classic signs and symptoms
of diabetes
(polydipsia, polyuria, polyphagia and weight loss)
3. 2-hour OGTT (fasting sample, 60 and 120 minute samples) after a
75g load of glucose
→ 2-hour OGTT should not be performed if the first two criteria are
present.
* Diagnostic criteria for imparied glucose intolerance (IGT)testing
: 110mg/dL≤FRG<126mg/dL
Endocrinologic Disease
Diabetes Mellitus
 Indication of DM testing
- Age ≥45years (repeat at 3-year intervals)
- Classic signs and symptoms of diabetes
(i.e. polyuria, polydipsia, polyphagia and weight loss)
- Ethnic groups at high risk
(Pacific Islanders, Native Americans, Africal Americans, Hispanic
Americans, Asian Americans)
- Obesity
- First-degree relative with diabetes
- Gestational diabetes or birth of a baby over 9 pound
- Hypertension (≥ 140/90)
- HDL cholesterol levels≥35mg/dL or triglyceride level ≥250mg/dL
- Impaired glucose tolerance based on previous testing
Endocrinologic Disease
Diabetes Mellitus
Endocrinologic Disease
Diabetes Mellitus
 Treatment
Endocrinologic Disease
Diabetes Mellitus
 Complication
 Acute complication
- Diabetic ketoacidosis (DKA)
- Nonketotic hyperosmolar diabetic coma (NKHC)
- Hypoglycemia
- Lactoacidosis
 Chronic complication
- Macroangiopathy: accelerated atherosclerosis (CHD, MI, CVA…)
- Microangiopathy : retinopathy, nephropathy, neuropathy
- Other : infection, skin lesion
Endocrinologic Disease
Thyroid Disease
 Thyroid disorders are more common in women and some families,
although the exact inheritance is unknown.
 In geriatric populations, the incidence ≒5%
 Thyroid function tests may be misleading in women receiving
exogenous sources of estrogen because of altered binding
characteristics (i.e. hormonal replacement therapy, pregnancy)
 Hypothyroidism
 Hyperthyoidism
 Thyroid Nodules and cancer
Endocrinologic Disease
Hypothyroidism
 Incidence
- overt hypothyroidism :2% of women, and at least an additional 5%
develop subclinical hypothyroidism
( subclinical hypothyroidism : defined as an elevated serum TSH
concentration with a normal serum free T4 level)
Endocrinologic Disease
Hypothyroidism
 Causes
- Autoimmune thyroiditis (Hashimoto’s thyroiditis)
- incidence increases with age
- associated with other endocrine (e.g. type 1DM, primary
ovarian failure, adrenal insufficiency and hypoparathyroidism)
and nonendocrine disorders (e.g. vitiligo and pernicious
anemia)
- Familial predisposition
( specific genetics or environmental trigger is unknown)
- Iatrogenic cause : after surgical removal or radioactive iodine
therapy for hyperthyroidism of thyroid cancer
- Secondary to pituitary or hypothalamic diseases from TSH or
TRH deficiency
Endocrinologic Disease
Hypothyroidism
 Clinical Features
- Fatigue, lethargy, cold intolerance, nightmares, dry skim, hair loss,
constipation, periorbital carotene deposition (causing a yellow
discoloration), carpal tunnel syndrome and weight gain(<5~10kg)
menstrual dysfunction (menorrhagia or amenorrhea
- Infertility (d/t anovulation)
: exogenous thyroid hormone is not useful for women who are
anovulatory and euthyroid
- Neuropsychiatric symptoms
: depression, irritability, impaired memory and dementia in the elderly
- Not cause of premenstrual syndrome (PMS), but worsening PMS may
be a subtle manifestation of hypothyroidism
- Precocious or delayed puberty
Endocrinologic Disease
Hypothyroidism
 Diagnosis
: confirmed with laboratory studies
- Serum TSH↑, s-T4 or free T4 index ↓,
- Autoimmune thyroiditis
: confirmed by the presence of serum antithyroid peroxidase
(antimicrosomal) antibodies
* Central hypothyroidism
: low or low-normal serum free T4 with either a low or inappropriately
normal serum TSH concentration
Endocrinologic Disease
Hypothyroidism
 Treatment
- L-thyroxine(T4), levothyroxine (Synthroid of Levothroid)
: absorption may be poor when taken in combination with aluminum
hydroxide (common in antacids), cholestyramine, ferrous sulfate or
sucralfate because of binding or chelation
- Normal daily dosage : 0.1~0.15mg
(maintain TSH levels within the normal range)
Endocrinologic Disease
Hyperthyroidism
 Incidence
: affects 2% of women during their lifetimes most often during their
childbearing years
* Graves’ disease represents the most common disorder
 Causes
- Graves’ disease
- Transient thyrotoxicosis
: result of unregulated grandular release of thyroid hormone in
postparum (painless, silent or lymphocytic) thyroiditis and
subacute (painful) thyroiditis
- Other
: hCG-secreting choriocarcinoma, TSH-secreting pituitary adenoma,
and struma ovarii
- Factitious ingestion or iatrogenic overprescribing
Endocrinologic Disease
Hyperthyroidism
 Clinical feature
- Fatigue, diarrhea, heat intolerance, palpitations, dyspnea, nervousness,
and weight loss.
(In young patients : paradoxical weight gain from an increased appetite)
- Vomiting in pregnant women- confused with hyperemesis gravidarum
- P/Ex ) Tachycardia, lid lag, tremor, proximal m. weakness and warm,
moist skin
- Dramatic physical change : ophthalmologic and lid retraction ,
periorbital edema and proptosis, : 1/3 of women
- In elderly adults : symptoms are often more subtle with presentations
of unexplained weight loss, atrial fibrillation or new-onset angina
pectoris
- Menstrual abnormalities
: regular menses, light flow, anovulatory menses and associated
infertility
Endocrinologic Disease
Hyperthyroidism
- Goiter : in younger women (m/c) c Graves’ disease
- Toxic nodular goiter is associated with nonhomogeneous glandular
enlargement while in subacute thyroiditis the gland is tender, hard and
enlarged
 Diagnosis
- Total and free T4 and T3 ↑
(measured by radioimmune assay[RIA])
- in thyrotoxicosis , S-TSH concentrations: undetectable
- Radioiodine uptake scans
: useful in the differential diagnosis of established hyperthyroidism
* Thyroiditis and medication-induced thyrotoxicosis
: glandular radioisotope concentration↓
Endocrinologic Disease
Hyperthyroidism
 Treatment
 Antithyroid medication
: PTU ( 50~300mg q6~8hours) or methimazole(10~30mg/day)
: relapse rate : 50% over a lifetime
- minor side effects : fever, rash or arthralgias
- major toxicity (<1%) : hepatitis, vasculitis, agranulocytosis
 Radioiodine
 Surgical resection
 Iodine-131
: permanent cure of hyperthyroidism in 70~80%of patients
 β-blocker (propranolol)
: control of sympathomimetic symptoms (tachycardia), peripheral
conversion of T4→T3
Endocrinologic Disease
Hyperthyroidism
 Thyroid storm
:started immediately PTU, β-blockers, glucocorticoids
and high-dose iodine preparations (SSKI or intravenous
sodium sodium iodide)
Endocrinologic Disease
Thyroid Nodule and Cancer
 Incidence : common and found on P.Ex in ≥5% of patients
 Character
: most nodules- asymptomatic and benign
- Malignant tendency
: irradiation in childhood,
 Diagnosis
- TFT→ FNA→thyroid scan
- Biopsy: provides a diagnosis in 95% of cases
 Malignanacy
- Papillary thyroid carcinoma (m/c)
:75% of cases associated cervical lymph node metastasis, usually cured
- Aplastic tumors
: poor prognosis and progress rapidly despite therapy
 Treatment
: Radioiodine therapy or surgical ablation