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STEP 2CK Review > 17 GYN > Flashcards

17 GYN Flashcards

1
Q

You see an adnexal mass on U/S
how to think about it in:

  • premenstrual
  • reproductive age
  • postmenopausal
A
  • ovarian CA (germ cell) until proven otherwise
  • Simple cyst, vs complex cyst (many possibilities)
  • ovarian CA (epithelial) until proven otherwise
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2
Q

Types of incontinence (3) main ones

  • dx
  • tx
A
  1. stress–‘sneeze and pee,’ no nocturia. multiple births. Give pessary, surgery
  2. urge (hypertonic)–urge and nocturia. Antispasmodic–anticholinergic (oxybutynin)
  3. overflow (hypotonic)–no urge, yes nocturia. Neurogenic cause (trauma, diabetes, MS). Bethanechol/doxazosin, cath.
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3
Q

Structural abnormality causing vaginal bleeding

  • DDx
  • differences on exam
  • how to workup
A

fibroids–asymmetric enlarged uterus
polyps–normal
adenomyosis–symmetric enlarge uterus

Start with transvag U/S. Best MRI
Possible bx if r/o CA

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4
Q

MTX for ectopic, criteria (4)

A
  1. B-HCG <8000
  2. <3cm
  3. no fetal heart tones
  4. no folate supplementation

No rupture.

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5
Q

“grape-like” structure in vagina

A

2 things:
-Vaginal adenoCA from DES use in mom

-molar pregnancy can also have grape-like mass in vagina

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6
Q

Cervical CA screening

  • immunocompetent, different ages
  • immunocompromised
A

q3y 21-29
q3y or q5 PAP +HPV testing, 30-65
65 stop if no abnormal screens before

start at sex onset

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7
Q

MCC pre-menarchal bleeding in young girl

A

foreign body

do speculum exam under anesthesia

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8
Q

vulva: “porcelain-white” lesions, itchy

think what, do what

A

Think lichen sclerosis
Bx to r/o SCC
steroids

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9
Q

spontaneous abortion, completed.

-do what for patient (4)

A
  • U/S to make sure all products gone
  • track B-HCG to 0
  • give OCPs
  • give Rhogam
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10
Q

TOA

-how to tx

A

Give Abx first (Amp-Gent-MTZ)
GNR: Amp-Gent, or Cipro
Anaerobes: MTZ, or Clinda

surgery not always necessary

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11
Q

Red vulvar lesion

A

Pagets.

Bx to confirm, then Local resection

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12
Q

abortion types (5)
os
passage of products
U/S

A

Vag Bleeding
threatened–os closed, no passage, live baby
inevitable–os open (or about to), no passage, dead baby
incomplete–os open, yes passage, retained parts
complete–os closed, yes passage, empty uterus

Missed–os closed, no passage, dead baby still inside

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13
Q

Primary amenorrhea

-how to approach, DDx, big picture

A

Think 2 things: Does pt have functional axis, and does she have the anatomy to bleed from (uterus)?

yes, yes–imperforate hymen, anorexia, stress
yes, no–mullerian agenesis, AIS
no, yes–Turners, Kallmans, Craniopharyngeoma

Physical exam for axis (breast buds, axillary hair)
U/S for anatomy, looking for uterus

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14
Q

Choriocarcinoma

-where to find mets

A

lung, brain

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15
Q

Endometriosis

-3 sxs to know

A
  • dyspareunia
  • dysmenorrhea
  • infertility!
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16
Q

post-menopausal female with ascites, but no liver dz.

Think what

A

epithelial ovarian CA

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17
Q

Couple can’t have a child

  • when is it considered ‘infertility’
  • describe workup
A

infertility: >1y trying
blame man first (test for ED, semen)
then woman: bad mucus, anovulation, anatomy, endometriosis

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18
Q

Pt with Postmenopausal bleeding. you get endometrial sample. Do what for:

  • simple hyperplasia, atypia
  • complex atypia, dysplasia, or adenocarcinoma
A
  • conservative, tx with Progesterone

- TAH-BSO. If mets add chemo

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19
Q

Choriocarcinoma

  • how to dx
  • tx (2)
A

elevated B-HCG, look at U/S
stage with CT
worry about liver/brain mets!

  1. suction curretage (not D+C)
  2. If mets, ‘MAC” MTX, actinomycin, cyclophosphamide
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20
Q

Vulvar lesion:

what is use of acetic acid?

A

Put it on, if lesion turns white, it is HPV condyloma acuminatum.

Many tx: imiquimod, cryo, etc

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21
Q

Simple vs complex ovarian cyst

  • what is difference
  • tx
  • what if already on OCPs
A

Simple: smooth, fluid filled, <7 cm.
Complex: loculated, >7cm, already on OCPs, not resolved in 2 months

Simple: rU/S in 3-4 mo, Should resolve.
OCPs don’t really help, as previous thought

Complex: CT
If simple cyst found and pt already on OCPs, go straight to CT. Higher risk for malig. This is not simple cyst anymore, it is complex.

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22
Q

Rectocele

-what does this cause

A

rectum falls foward into vaginal space

-constipation. Pt can push finger into vagina to press on rectum to push stool. (Transvag digital compression)

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23
Q

menopause
perimenopause
menopausal transition

definitions

average age menopause
when too early

3 common sxs

What labs

A
  1. 1 year+ after last menses occured
  2. time period from onset of menstrual iregularity to start of menopause
  3. same as perimenopause

average: 51. too early:40

hot flashes, vaginal dryness, mood swings

High FSH is dx, somewhat high LH

24
Q

menopausal woman with hot flashes

-possible to tx? what to avoid

A

can use Venlafaxine (SNRI)

-avoid hormone replacement therapy (endometrail CA)

25
CAH congenital adrenal hyperplasia -what test -which type MCC, how present
screening test: 17 OH Progesterone 21 OH-lase def. neonate with hypoNa, hyperK, hypotension. Both aldo and cortisol shunted.
26
Secondary amenorrhea, | -how to do full workup after first step of r/o 4 initial causes
Test the HPO axis, going backwards. 1. Progestin challenge (can endometrium bleed?) If bleed, then anovulation 2. E+P challenge If bleed, normal uterus. If no bleed, then endometrial dysfxn (eg Ashermans) 3. LH, FSH If high, then ovarian dysfxn--menopause or Savage (check for follicles on U/S) If low, then central issue--pit problem, MRI
27
Fibroids | -tx options (3)
1. If mom wants to get pregnant, do surgery (myomectomy) 2. TAH if mom does not want to get pregnant 3. Leuprolide to shrink if too big for surgery
28
Pap smear comes back: - ASCUS - Abnormal -do what
ASCUS: get HPV test or rPAP in 3 mo if age21-24. If either abnormal, do colpo Abnormal: do colpo
29
Post partum hemorrhage - management - what blood vessels to ligate, what order?
1. massage 2. meds--oxytocin, transfuse 3. surgery (ex-lap) - uterine a 1st to ligate - then, internal iliacs - then, TAH!
30
Missed abortion | -how to remove dead baby/products?
<24 weeks: D+C/suction | >24 weeks: induce
31
Female sexual development order, what ages?
``` "boobs, pubes, grow, flow" 8,9,10,11 8--breast 9--axillary hair 10--growth spurt 11--menarche ```
32
DUB dysfunctional uterine bleeding - tx in emergency - tx
Anovulation. Even without firm dx, if life threatening bleeding, use IV estrogen. OCPs and NSAIDs (paradoxical. NSAIDs block prostglandins) -endometrial ablation possible too
33
-Risk of ectopic: - normal risk - hx of ectopic - hx of ectopic, with salpingostomy - hx of ectopic, with salingectomy
1% all others 15%
34
female with LMP 4 weeks ago. Has had N/V for past 3 weeks and can't keep anything down. UPreg+, TSH normal, orthostatics+ Think what
Hyperemesis gravidarum | -Do U/S, look for possible mole (snowstorm)
35
chlamydia tx: | if can't do doxy, use what
azithro
36
Vulvar cancers and their tx (3) what is lichen sclerosis
1. SCC (MCC) 2. Melanoma both get vulvectomy and LN dissection 3. Paget's --"red lesion," local resection Lichen sclerosis is premalignant SCC, very itchy. Also dx by bx, use steroids
37
Cystocele - what does this cause - dx - how to tx
bladder falls into vaginal space Stress incontinence Q-tip sign or anterior prolapse Kegels and Pessary to strengthen pelvic floor, eventual surgery
38
Cervical CA screening finds CA - what txs - what if pregnant
If only ectocervical, not endo, can do local destruction only: LEEP, Cryo, laser If both ecto and endo, do both local destruction and Cone Bx If pregnant, no cone bx (wait til after pregnancy). can still do LEEP, cryo
39
PCOS | -tx (4 meds)
These 2 first line: OCPs--reset axis, induce regular cycles metformin--this improves PCOS in addition to the DM. mech unknown why spironolactone--androgen i clomiphene--induce ovulation
40
Vaginal infections and their tx (3)
Candida--topical fluconazole (suppository), then systemic BV--topical MTZ, then systemic Trich--oral MTZ both partners
41
Ovarian CA tumor markers Dysgerminoma Endodermal sinus (yolk sac) CC teratoma epithelial CAs
LDH AFP B-HCG none CA-125
42
Young female with hx of Hodgkin's presents with urinary incontinence. Think what how to dx
Crohn's fistula? from radiation treatment | Inject dye into bladder to see where it ends up
43
Precocious puberty in female - when to suspect, what is danger? - how to workup?
You see breast buds or axillary hair <8y Danger: misses growth spurt if early menarche 1. wrist XR: + if >2y above age 2. Leuprolide stim test. If LH/FSH increase, then central cause. MRI for pit tumor. If no tumor, then "constitutional"and give continuous leuprolide If LH/FSH no change, look outside HPO axis for estrogen production. (ovaries, adrenal, etc)
44
When to work up primary amenorrhea?
if girl doesn't: - develop 2nd sex by age 13 (axillary hair, breast buds) - menarche by 15
45
Asherman's syndrome | Savage syndrome
Asherman's--scarring from sloughed off endometrium | Savage--resistant ovary syndrome
46
PCOS | -dx
no real criteria: LH/FSH>3 DM high Testosterone and DHEA
47
Post-coital bleeding | -think what
cervical CA in post-menopausal, probably vaginal atrophy
48
which type of ovarian CA category worst? - how present? what 3 sxs to know? (3) - who at risk, what to do for them
epithelial ovarian CA -peritoneal seeding. can present with renal fail, SBO, ascites. usu present late stage. BRCA1/2 at risk. Screen with CA-125 and transvag U/S q6mo. Do ppx TAH-BSO at 35. PPx mastectomy at any age. HNPCC also at risk.
49
Young female, sex worker, presenting with abd pain x12h. High fever, N/V, SIRS+. Exam has CMT+, left adnexal tenderness, no mass. -do what
Acute PID. Inpatient because toxic. Ceftriaxone/cefotetan and doxy. Outpt if not SIRS/toxic Why not TOA? in real life would do U/S to r/o. If TOA or chronic PID, use amp-gent-mtz
50
adenomyosis | how is it described
enlarged, smooth, symmetrical uterus think endometriosis of myometrium
51
Toxic shock syndrome | -what 2 signs to remember about it
In addition to high fever, N/V/Diarrhea: - erythematous macular rash - desquamation of palms/soles
52
Secondary amenorrhea | -What 4 causes to r/o on initial workup?
Just like prolactinoma workup 1. pregnancy? UPreg 2. Prolactin 3. hypothyroidism (high TRH increases prolactin) 4. DA blockers UPreg, prolactin level, TSH
53
During TAH, what can get mistaken for ureters and get cut?
uterosacral ligaments
54
Menopause - before what age pathologic - what labs
<40 is not normal | high LH, FSH. absent follicles on U/S
55
Uterus: 3 ligaments to know | -their clinical correlations
1. suspensory lig. Ovarian torsion--these get torsed, with the ovarian a and v contained in them 2. uterosacral lig. Mistaken for ureters 3. Cardinal lig. ('Pelvic Floor'). Get loose with pregnancy and birth. Can cause: uterine, bladder, and rectal prolapse.
56
Endometriosis | -how to dx, what steps
1st, turn off LH/FSH axis with continuous Leuprolide. See if sxs go away 2. then, dx scope laparscopy for confirm, with laser ablation

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