17 GYN Flashcards
You see an adnexal mass on U/S
how to think about it in:
- premenstrual
- reproductive age
- postmenopausal
- ovarian CA (germ cell) until proven otherwise
- Simple cyst, vs complex cyst (many possibilities)
- ovarian CA (epithelial) until proven otherwise
Types of incontinence (3) main ones
- dx
- tx
- stress–‘sneeze and pee,’ no nocturia. multiple births. Give pessary, surgery
- urge (hypertonic)–urge and nocturia. Antispasmodic–anticholinergic (oxybutynin)
- overflow (hypotonic)–no urge, yes nocturia. Neurogenic cause (trauma, diabetes, MS). Bethanechol/doxazosin, cath.
Structural abnormality causing vaginal bleeding
- DDx
- differences on exam
- how to workup
fibroids–asymmetric enlarged uterus
polyps–normal
adenomyosis–symmetric enlarge uterus
Start with transvag U/S. Best MRI
Possible bx if r/o CA
MTX for ectopic, criteria (4)
- B-HCG <8000
- <3cm
- no fetal heart tones
- no folate supplementation
No rupture.
“grape-like” structure in vagina
2 things:
-Vaginal adenoCA from DES use in mom
-molar pregnancy can also have grape-like mass in vagina
Cervical CA screening
- immunocompetent, different ages
- immunocompromised
q3y 21-29
q3y or q5 PAP +HPV testing, 30-65
65 stop if no abnormal screens before
start at sex onset
MCC pre-menarchal bleeding in young girl
foreign body
do speculum exam under anesthesia
vulva: “porcelain-white” lesions, itchy
think what, do what
Think lichen sclerosis
Bx to r/o SCC
steroids
spontaneous abortion, completed.
-do what for patient (4)
- U/S to make sure all products gone
- track B-HCG to 0
- give OCPs
- give Rhogam
TOA
-how to tx
Give Abx first (Amp-Gent-MTZ)
GNR: Amp-Gent, or Cipro
Anaerobes: MTZ, or Clinda
surgery not always necessary
Red vulvar lesion
Pagets.
Bx to confirm, then Local resection
abortion types (5)
os
passage of products
U/S
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
Primary amenorrhea
-how to approach, DDx, big picture
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
Choriocarcinoma
-where to find mets
lung, brain
Endometriosis
-3 sxs to know
- dyspareunia
- dysmenorrhea
- infertility!
post-menopausal female with ascites, but no liver dz.
Think what
epithelial ovarian CA
Couple can’t have a child
- when is it considered ‘infertility’
- describe workup
infertility: >1y trying
blame man first (test for ED, semen)
then woman: bad mucus, anovulation, anatomy, endometriosis
Pt with Postmenopausal bleeding. you get endometrial sample. Do what for:
- simple hyperplasia, atypia
- complex atypia, dysplasia, or adenocarcinoma
- conservative, tx with Progesterone
- TAH-BSO. If mets add chemo
Choriocarcinoma
- how to dx
- tx (2)
elevated B-HCG, look at U/S
stage with CT
worry about liver/brain mets!
- suction curretage (not D+C)
- If mets, ‘MAC” MTX, actinomycin, cyclophosphamide
Vulvar lesion:
what is use of acetic acid?
Put it on, if lesion turns white, it is HPV condyloma acuminatum.
Many tx: imiquimod, cryo, etc
Simple vs complex ovarian cyst
- what is difference
- tx
- what if already on OCPs
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.
Rectocele
-what does this cause
rectum falls foward into vaginal space
-constipation. Pt can push finger into vagina to press on rectum to push stool. (Transvag digital compression)
menopause
perimenopause
menopausal transition
definitions
average age menopause
when too early
3 common sxs
What labs
- 1 year+ after last menses occured
- time period from onset of menstrual iregularity to start of menopause
- same as perimenopause
average: 51. too early:40
hot flashes, vaginal dryness, mood swings
High FSH is dx, somewhat high LH
menopausal woman with hot flashes
-possible to tx? what to avoid
can use Venlafaxine (SNRI)
-avoid hormone replacement therapy (endometrail CA)
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.
Secondary amenorrhea,
-how to do full workup after first step of r/o 4 initial causes
Test the HPO axis, going backwards.
- Progestin challenge (can endometrium bleed?)
If bleed, then anovulation - E+P challenge
If bleed, normal uterus.
If no bleed, then endometrial dysfxn (eg Ashermans) - LH, FSH
If high, then ovarian dysfxn–menopause or Savage (check for follicles on U/S)
If low, then central issue–pit problem, MRI
Fibroids
-tx options (3)
- If mom wants to get pregnant, do surgery (myomectomy)
- TAH if mom does not want to get pregnant
- Leuprolide to shrink if too big for surgery
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
Post partum hemorrhage
- management
- what blood vessels to ligate, what order?
- massage
- meds–oxytocin, transfuse
- surgery (ex-lap)
- uterine a 1st to ligate
- then, internal iliacs
- then, TAH!
Missed abortion
-how to remove dead baby/products?
<24 weeks: D+C/suction
>24 weeks: induce
Female sexual development order, what ages?
"boobs, pubes, grow, flow" 8,9,10,11 8--breast 9--axillary hair 10--growth spurt 11--menarche
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
-Risk of ectopic:
- normal risk
- hx of ectopic
- hx of ectopic, with salpingostomy
- hx of ectopic, with salingectomy
1%
all others 15%
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)
chlamydia tx:
if can’t do doxy, use what
azithro
Vulvar cancers and their tx
(3)
what is lichen sclerosis
- SCC (MCC)
- Melanoma
both get vulvectomy and LN dissection - Paget’s –“red lesion,” local resection
Lichen sclerosis is premalignant SCC, very itchy. Also dx by bx, use steroids
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
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
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
Vaginal infections and their tx (3)
Candida–topical fluconazole (suppository), then systemic
BV–topical MTZ, then systemic
Trich–oral MTZ both partners
Ovarian CA tumor markers
Dysgerminoma
Endodermal sinus (yolk sac)
CC
teratoma
epithelial CAs
LDH
AFP
B-HCG
none
CA-125
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
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
- wrist XR: + if >2y above age
- 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)
When to work up primary amenorrhea?
if girl doesn’t:
- develop 2nd sex by age 13 (axillary hair, breast buds)
- menarche by 15
Asherman’s syndrome
Savage syndrome
Asherman’s–scarring from sloughed off endometrium
Savage–resistant ovary syndrome
PCOS
-dx
no real criteria:
LH/FSH>3
DM
high Testosterone and DHEA
Post-coital bleeding
-think what
cervical CA
in post-menopausal, probably vaginal atrophy
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.
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
adenomyosis
how is it described
enlarged, smooth, symmetrical uterus
think endometriosis of myometrium
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
Secondary amenorrhea
-What 4 causes to r/o on initial workup?
Just like prolactinoma workup
- pregnancy? UPreg
- Prolactin
- hypothyroidism (high TRH increases prolactin)
- DA blockers
UPreg, prolactin level, TSH
During TAH, what can get mistaken for ureters and get cut?
uterosacral ligaments
Menopause
- before what age pathologic
- what labs
<40 is not normal
high LH, FSH. absent follicles on U/S
Uterus: 3 ligaments to know
-their clinical correlations
- suspensory lig. Ovarian torsion–these get torsed, with the ovarian a and v contained in them
- uterosacral lig. Mistaken for ureters
- Cardinal lig. (‘Pelvic Floor’). Get loose with pregnancy and birth. Can cause: uterine, bladder, and rectal prolapse.
Endometriosis
-how to dx, what steps
1st, turn off LH/FSH axis with continuous Leuprolide. See if sxs go away
- then, dx scope laparscopy for confirm, with laser ablation
