EOR Gyn Flashcards
1
Q
define dysfunctional uterine bleeding and name the two types
A
abnormal frequency/intensity due to NONORGANIC causes (NOT reproductive, systemic or iatrogenic) .
- chronic anovulation
- ovulatory
2
Q
describe the pathophys of dysfunctional uterine bleeding - chronic anovulatory
A
Disruption of hypothalamic-pituitary-ovarian axis. Seen at the extremes of age. Unopposed estrogen, without ovulation there is no progesterone = unopposed estrogen → incr endometrial growth w/ irregular, unpredictable shedding as the endometrium outgrows its own blood supply.
3
Q
describe the pathophys of dysfxn uterine bleeding - ovulatory
A
regular cycle with prolonged progesterone secretion (due to decreased estrogen) → blood loss from endometrial vessel dilation and prostaglandins.
4
Q
what is the normal frequency, duration and volume
A
freq: 24-38 days, duration: 4-8days, volume: 5-80mL
5
Q
cryptomenorrhea vs menorrhagia
A
- Cryptomenorrhea: light flow/spotting
- Menorrhagia: heavy/prolonged bleeding @ normal interval
6
Q
metrorrhagia vs menometrorrhagia
A
- Metrorrhagia: irregular bleeding between cycles
- Menometrorrhagia: irregular, excessive bleeding between cycles
7
Q
oligomenorrhea vs polymenorrhea
A
- Oligomenorrhea: infrequent menstruation, cycle length >35 days
- polymenorrhea: frequent menstruation, cycle interval < 21 days
8
Q
txt goals and options for dysfxn uterine bleeding
A
control acute bleed, prevent future bleeding, minimize endometrial CA risk
Acute severe bleed: high dose IV estrogen or high dose OCPs. reduce dose as bleeding improves
MC Anovulatory or Ovulatory: OCPs, progesterone if estrogen is contraindicated, GnRH agonists (leuprolide).
Sx: hysterectomy or endometrial ablation
9
Q
which parts of the cycle do estradiol and progesterone dominate?
A
estradiol- follicular (up to day 14)
progesterone - luteal (after day 14) up to menses
10
Q
when does body temperature spike in the menstrual cycle?
A
just after ovulation (after LH + FSH spike)
11
Q
when is the proliferative and secretory phase of the cycle?
A
proliferative - day 5 -14
secretory- day 14- 28 –> menses
12
Q
what is the MC gyn CA in US?
A
endometrial
13
Q
what increases the risk of endometrial CA?
A
Estrogen-dependent CA
- risk increases with estrogen exposure (nulliparity, anovulation, PCOS, obesity, late menopause, tamoxifen, HTN, DM)
- OCPs are protective
14
Q
how is endometrial CA dx - what does Bx and US show?
A
endometrial Bx = adenocarcinoma, US= endometrial stripe >4mm.
15
Q
txt for endometrial CA : stage I, II/III, IV
A
Stage I: total hysterectomy + BSO +/- radiation
Stage II/III: total +BSO + lymph node excision +/- radiation
Stage IV: systemic chemo
16
Q
pathophys for endometriosis
A
retrograde menstrual flow, hematogenous/lymphatic spread, stem cells from bone marrow, coelomic metaplasia (congenital development).
17
Q
MC site of endometriosis
A
ovaries
18
Q
uterus grows up and out of the pelvis (past pubic symphysis) at what GA?
A
12 wks
19
Q
what does endometriosis increase the risk of ?
A
infertility
20
Q
what is the triad of symptoms for endometriosis ?
A
- Cyclic premenstrual pelvic pain 2. Dysmenorrhea 3. dyspareunia . +/- dyschezia
21
Q
how do you Dx endometriosis?
A
laparoscopy w/ Bx for definitive
22
Q
what is a “chocolate cyst” ?
A
possible sequelae of endometriosis
= Endometrioma: involving ovaries large enough to be considered tumor
23
Q
while expectant mgmt for endometriosis with minimal symptoms/trying to conceive, what are medicine txt options for more serious cases?
A
Medical therapy: NSAIDs, COCs, Progesterone, GnRH agonists (leuprolide), testosterone (Danazol- induces pseudomenopause by suppressing FSH/LH and midcycle surge)
24
Q
Surgical options for txt of endometriosis?
A
endometrial ablation, TAH
25
islands of endometrial tissue in myometrium → diffusely enlarged uterus. = what dx?
adenomyosis
26
S+S of adenomyosis?
worsening menorrhagia, dysmenorrhea
| tender, symmetric, enlarged “boggy uterus”
27
txt options for adenomyosis?
total abdominal hysterectomy (TAH). conservative used to preserve fertility (analgesics, low dose OCPs)
28
what race are leiomyomas MC in?
African americans
29
intrauterine growth related to estrogen production - regresses after menopause. what is the Dx?
leiomyoma (fibroids)
30
what is the MC symptom of leiomyoma (apart from the most common who are asymp)?
painless bleeding
31
txt of leiomyoma
MC observation or meds (leuprolide GnRH agonist, progestins)- prior to Sx to shrink + control vascularity) + Sx (hysterectomy/myomectomy).
*- Goal is to achieve pregnancy, if this is not wanted then just hysterectomy. Ability to conceive after myomectomy is very low so this is rarely done.
32
what is endometritis? what increases the risk of it?
infection of endometrium, chorioamnionitis (fetal membrane infection), usually polymicrobial (vaginal flora, aerobic/anaerobic)
Risk: postpartum + post abortive. C section MC
33
txt of endometritis ? prophylaxis w/ c section?
post-C Section - clindamycin + gentamicin. Post-vaginal delivery or chorioamnionitis - ampicillin + gentamicin
prophylaxis w/ 1 dose 1st gen cephalosporin during C-section
34
what is the grading of uterine prolapse ?
I - descent into upper vagina ⅔ vagina.
II - cervix approaches introitus (vaginal opening)
III - outside introitus.
IV- entire uterus outside vagina (complete)
35
txt for uterine prolapse?
Txt: Pessaries, estrogen (for atrophy), Sx hysterectomy, uterosacral or sacrospinous ligament fixation.
36
what causes PID? MC organisms?
ascending polymicrobial infection caused by cervical microorganisms (Chlamydia trachomatis, Neisseria gonorrhoeae..and potentially Mycoplasma genitalium)
37
when in the cycle does PID typically show symptoms? what are S+S?
presents usually in the 1st half menstrual cycle. pelvic/abdominal pain + one of the following… adnexal tenderness, cervical motion tenderness (chandeliers sign), fundal tenderness. + vaginal discharge/friable cervix, irregular bleeding, dyspareunia, N/V, fever.
38
Dx options for PID? findings in labs, Bx, imaging
- inc WBC on microscopy of vaginal discharge, inc ESR, inc CRP, + GC/Chlamydia
- Endometrial biopsy = endometritis
- imaging : TVUS or MRI = thickened, fluid filled tubes, tubo-ovarian abscess, hyperemia on dopplers( suggest infection).
39
txt for PID? who do you hospitalize? what can untxted PID lead to?
txt underlying cause
Hospital txt: pregnancy, failure to oral therapy, severe illness w/ high fever N/V, tubo-ovarian abscess.
Prevention/Education: Untreated can lead to infertility, chronic pelvic pain, ectopic pregnancy, pelvic adhesions
40
what can help prevent the reccurence of ovarian cysts?
OCPs
41
MC cause ovarian torsion?
MC caused by ovarian cyst >5cm
42
pathophys of PCOS
Due to insulin resistance. Abnormal hypothalamic-pituitary-ovarian axis → increased insulin and increased LH driven = increase ovarian androgen production.
43
PCOS: what are the levels of testosterone and LH:FSH ratio? what does US show?
incr testosterone, LH: FSH >3:1, US - "string of pearls"
44
medical txt for PCOS
combo OCPs (normalizes bleeding and suppresses androgen), spironolactone for anti-androgen (or leuprolide, finasteride), infertility = clomiphene, metformin, lifestyle changes.
45
what are the increased risk factors for ovarian CA?
+FH, incr ovulatory cycles (infertility,nulliparity, >50yo, late menopause), BRCA
46
Dx of ovarian CA?
biopsy MC epithelial
47
how is txt of ovarian CA monitored?
Serum Ca-125 levels to monitor txt progress.
48
what strains of HPV are most common to cause cervical CA? (5)
HPV 16,18, 31, 33 and 45.
49
2 types of cervical cancer?
2 types: MC squamous, also adenocarcinoma (columnar cells) (clear cell carcinoma linked with DES- death sentence)
50
MC common symptom of cervical CA?
post coital bleeding/spotting MC symptom.
51
Dx of cervical cancer?
Dx: colposcopy w/ biopsy
52
txt of cervical cancer based on stage 0, I-IIa, IIb/IVa, IVb
Stage 0: carcinoma in situ: local txt (excision, ablation), TAH-BSO
Stage I - IIa: microinvasion: Sx (conization, TAH/BSO, radiation)
Stage IIb/ IVa: local advanced: radiation/chemo
Stage IVb (distant METS): palliative radiation, chemo.
53
what are the guidelines for pap smear? (starting age, stopping age + frequency of testing
Start: Age 21
Frequency: Cytology every 3 years between ages 21-29. Cytology with HPV every 5 years 30-65 → if HPV + → colposcopy
Stop: Age 65 if routine screening in last 10 years
54
what can cervicitis lead to?
PID
55
what are the two levels of cytology from a pap smear?
LSIL (low grade squamous intraepithelial lesion)
| HSIL (high grade squamous intraepithelial lesion- ALL layers of squamous epithelium w/ abnormal cells)
56
what are the 3 levels of histology from Bx of cervical dysplasia?
```
CIN I (LSIL) = mild dysplasia contained to ⅓ basal epithelium thickness
CIN 2 (HSIL) = moderate dysplasia including basal ⅔
CIN 3 (HSIL) = severe dysplasia >⅔ basal → full thickness = carcinoma in situ
```
57
what is an easy way to guess someone has cervical cancer?
Lesion w/ the naked eye = past the basement membrane = CANCER
58
txt for cervical dysplasia CIN 1 vs CIN2/3
CIN 1- observation or excision (LEEP - loop electrical excision procedure or cold knife cervical conization)
CIN2/3: excision (LOOP or cold knife) or ablation with cryocautery, laser cautery or electrocautery.
59
what is the easy classification system for abnormal uterine bleeding? what does it stand for?
PALM COEIN (Polyp, Adenomyosis, Leiomyoma, Malignancy/Hyperplasia, Coagulopathy, Ovulatory dysfxn, Endometrial, Iatrogenic, Not-yet-classified)
60
what defines primary vs secondary amenorrhea
Primary: failure of menarche onset by age 15y (w/ 2ry sex characteristics) or 13y (w/out 2ry sex characteristics)
Secondary: absence of menses for >3 months but had previous menstruation.
61
what is "central amenorrhea" ?
hypothalamus dysfxn (low FSH/LH): disruption of normal pulsatile GnRH release. Anorexia, exercise, nutritional deficiency, systemic dz, physiologic stress/psychological stress.
62
how can pituitary dysfxn cause secondary amenorrhea?
(low FSH/LH, high prolactin): prolactinoma decr GnRH
63
how can ovarian d/o cause secondary amenorrhea?
( increase FSH/LH, low estradiol): PCOS, premature ovarian failure. Turner’s syndrome.
64
how do you check for ovarian d/o causing secondary amenorrhea?
+ progesterone challenge (withdrawal) test (ovarian d/o)
=this means she has estrogen but is not ovulating
- results (no bleeding) = lacking estrogen or outflow problem
65
txt for secondary amenorrhea (hypothalamic, pituitary, uterine)
hypothalamic - stimulate gonadotropin secretion - clomiphene
Pituitary - transsphenoidal Sx tumor removal
Uterine - estrogen txt for endometrial regeneration
66
what is "dysmenorrhea" and what causes it? (primary vs secondary)
painful menstruation that affects normal activities.
Primary: not due to pelvic pathology, due to increased prostaglandins → painful uterine muscle wall activity.
Secondary: due to pelvic pathology. (endometriosis, adenomyosis, leiomyoma, adhesions, PID) increased incidence with age.
67
what organism most common causes mastitis?
Staph aureus (also strep or candida)
68
mastitis: infectious vs congestive vs abscess (S+S)
Infection: unilateral pain, tender, warmth, nipple discharge
Congestive: bilateral pain/swelling, low grade fever and axillary lymph
Abscess: induration w/ fluctuance (pus). RARE
69
txt for mastitis: infectious vs congestive vs abscess
Infection: supportive (warm compress, breast pump) + anti-staph abx (dicloxacillin,nafcillin, cephalosporin) fluconazole if fungal. Continue to FEED
Congestive: if mom does not want to breastfeed = ice packs, tight bras, analgesics, avoid breast stimulation. If breastfeeding = manually empty breast completely after baby is done feeding.
Abscess: I&D, discontinue breast feeding from affected breast
70
what two types of breast CA are most common
ductal and lobule
71
incr # menstrual cycles and increased estrogen = increased or decreased risk of breast CA ?
increased
72
" in situ" means what?
An in situ tumor is one that is confined to its site of origin and has not invaded neighboring tissue or gone elsewhere in the body
73
what is inflammatory breast CA show?
peau d’orange (lymph obstruction)= WORSE prognosis
74
mammogram of breast CA shows what?
calcifications and/or spiculated mass
75
what is the initial Dx modality to evaluate a breast mass in someone <40yo (dense breast tissue)?
US
76
what is the staging of breast CA?
T(size), N (nodes) M (METS)
0: precancerous, DCIS or LCIS
I-III: w/in breast/regional lymph nodes
IV: METS
77
what endocrine therapy (medications) are options for adjunctive therapy for breast CA pts with E/P-receptive or HER2 positive CA?
anti-estrogen - tamoxifen.
aromatase inhibitors -letrozole, anastozole
monoclonal Ab
78
prophylaxis meds for breast CA (for post-menopausal or women >35yo with high risk).
SERM (tamoxifen/raloxifene) Tamoxifen preferred but higher risk DVT.
79
mammogram screening guidelines: ACOG, ACS, USPTF
ACOG: >40y annual
ACS: >45yo annual; >54yo biannual
USPTF: >50 biannual
80
when do you stop mammogram screening?
when life expectancy is <10years
81
pap smear guidelines
<21 no testing, 21-29 Q 3 years, 30-65 Q five years with pap (or w/out HPV Q 3 years).
>65 stop testing if no abnormal in 20yrs
82
what is a fibroadenoma? what age pt is it most common in?
benign breast lump, nontender/mobile/rubbery. MC younger females.
does NOT wax and wane w/ hormone levels
83
txt for fibroadenoma
nothing - observation
84
breast - fluid-filled cyst due to exaggerated response to hormones. (may be tender, wax + wane w/ hormone levels) VERY COMMON: what is the Dx ?
fibrocystic changes
85
Dx of fibrocystic changes in breast: FNA will show what kind of fluid? what is the txt for this?
straw-colored
| Txt: observe or FNA to drain (if symptomatic)
86
medical txt options for galactorrhea
txt underlying cause (synthroid (for hypothyroid) or dopamine agonists (cabergoline or bromocriptine) (for hyperprolactinemia)
87
txt for gynecomastia. What are medications used? what is the ideal timeframe of txt?
supportive- stop offending meds, observe (most regress spontaneously), ideal txt in the first 6mo (>12 months tissue may turn fibrous).
Meds: SERM (tamoxifen) or aromatase inhibitors (blocks estrogen synthesis) or androgens (for hypogonadism)
88
what are 3 clinical screening tools to Dx menopause-depression?
PRIME-MD (primary care eval of mental health d/o), PHQ-2, MRS (menopause rating scale)
89
relative contraindications to hormone therapy for menopause include what?
Hx breast or endometrial CA, active liver dz, hypertriglyceridemia, porphyria (buildup of porphyrins), thrombolic d/o (CAD + stroke Hx), undiagnosed vaginal bleeding, endometriosis, fibroids
90
three alternatives to hormone replacement therapy for menopause?
SSRI antidepressants, herbal supplements (black cohosh, evening primrose - not as effective)
91
what is the timing of PMS symptoms
```
luteal phase (1-2 weeks before menses) and resolve 2-3 days after the period starts
*and at least 7 symptom free days in the follicular phase
```
92
how is PMDD different from PMS?
it is severe PMS with a functional impairment
AND presence of at least five symptoms, including one affective symptom, such as mood swings, irritability, and/or depression
93
what is "metal shmurz" ?
pain felt when ovulating (burst of follicle)
94
medical txt for PMDD? (2)
OCPs- containing drosperidone along with estradiol (aka Yaz)
| and/or SSRIs
95
timeline of postpartum blues vs postpartum depression ?
blues: starts 2-3 days postpartum, lasts 10 days
depression: starts 2 wks-12mo postpartum, resolves 3-14 months
96
conservative txt for PMS symptoms?
lifestyle (exercise/diet, caffeine/salt restriction, vitamin B6 +E),
97
candida albicans: pathophys
yeast (MC opportunistic pathogen) - decrease in lactobacillus that usually prevent the overgrowth of yeast.
98
causes of urogenital candida albicans
Abx, pregnancy, uncontrolled DM, impaired immune system, OCPs or hormone therapy
99
txt for yeast infection ?
oral azole
100
4 manifestations of chlamydia infection?
1. Urethritis: mucopurulent discharge, purritis, dysuria, dyspareunia, hematuria. 40% asymptomatic
2. PID: abd pain + cervical motion tenderness
3. Reactive arthritis (reiter’s syndrome): urethritis, uveitis, arthritis - autoimmune rxn
4. Lymphogranuloma venereum: genital/rectal lesion w/ softening, suppuration, lymphadenopathy
101
Dx of chlamydia
nucleic acid amplification (vaginal swab or first-catch urine
(also can do a culture or blood antigen detection)
102
txt for chlamydia infection
Azithromycin (1gm 1dose) or Doxycycline (100mg 10days). Retest in 10 days to ensure clearance + txt for gonorrhea
103
2 manifestations of gonorrhea
Urethritis: anal, vaginal, pharyngeal discharge. PID
Dissemination: arthritis/dermatitis, rash
104
txt for gonorrhea
ceftriaxone 250mg IM + txt for chlamydia. Cefixime as alternative
105
3 most common organisms that cause cystitis?
MC E coli also Staph saprophyticus (sexually active women) enterococci (indwelling catheter)
106
what differentiates pyelonephritis from cystitis on UA?
WBC casts
107
what bladder analgesic turns your pee orange? (txt for cystitis) what is the ADR of this?
phenazopyridine (bladder analgesic- turns urine orange) - DONT USE >24 hrs cause of methemeglobinemia, hemyolytic anemia
108
txt options for uncomplicated cystitis?
nitrofurantoin (macrobid), FQs, TMP-SMX
109
what makes cystitis "complicated"? what are the txt options for this?
symptoms >7 days or underlying condition/elderly/males: FQs PO or IV, aminoglycosides 7-10 days
110
txt for cystitis in pregnancy
amoxicillin or macrobid 7-14 days.
111
txt for pyelonephritis?
FQ PO or IV, aminoglycosides 14 days (7 days in healthy young women)
112
Dx of herpes?
PCR (best), tzank smear = multinucleated giant cells + inclusion bodies
113
prevention/education for herpes in pregnancy
give acyclovir + Csection, breastfeeding not contraindicated unless lesion on the breast.
114
can mom transfer HIV/AIDs to baby? how?
yes through birth or breastfeeding
115
Dx of HIV (screening, definitive and monitoring txt)
antibody test- ELISA (screening), rapid test (blood or saliva). Western blot (confirmatory). HIV RNA viral laid (monitor infectivity and txt)
116
pathophys of HPV
infects keritanized skin causing excessive proliferation + retention of stratum corneum ⇒ papula formation
117
vaginal -tiny, painless papules evolve into soft, fleshy cauliflower-like lesions. Occur in clusters. Persist for months and may spontaneously resolve. Dx ?
condyloma accuminata - HPV
118
HPV (condyloma accuminata)
whitening of lesion w/ acetic acid, histology = koilocytic squamous cells w/ hyperplastic hyperkeratosis
119
5 txt options for removal of condyloma accuminata warts
chemical, salicylic acid, cryotherapy, laser, podophyllin (cytotoxic agent).
120
HPV vaccine schedule
For Male + female 9-45yo. 3 doses (0,2,6mo) or 2 doses (0,6mo) for ages 9-14. Target age 11-12yo.
121
primary syphillis
chancre- painless ulcer w/ raised indurated edges (papule that ulcerates) . heal spontaneously 3-4 wks + nontender lymphadenopathy nearby
122
secondary syphillis
maculopapular rash, involve the palms + soles.
| Condyloma lata + Systemic symptoms
123
when does tertiary syphillis come up?
1-20yrs after inoculation
124
tertiary syphillis: derm, neuro + cardiac symptoms
1. Gumma (granulomas on skin/body tissues/bones.
2. Neurosyphillis (HA, meningitis, dementia, vision/hearing loss, incontinence.
3. CV = aortitis, aortic regurg + aneurysm.
125
what is latent syphillis?
asymp infection + normal exam but positive serologic testing.
126
early latent vs late latent syphillis
Early latent <1yr (highly infectious), late latent >1yr (less infectious)
127
Dx of syphillis: screening vs confirmatory
Screening- RPR + VDRL
| Confirmatory: FTA-ABS (fluorescent treponemal antibody absorption) or microagglutination test for T. pallidum antibodies
128
what is the "jarisch-herkheimer" rxn? how do you txt it?
acute febrile response to rapid lysis of syphillis spirochetes from txt w/ PCN G.
Myalgia+ HA. Txt with anti-pyretics in first 24hrs reduces incidence
129
after txt of syphillis, what is the followup schedule? how do you know there has been adequate txt?
at 6months and 12 months after txt for clinical + serologic test. 4-fold reduction in titer = adequate mgmt.
130
txt for trichomonas
metronidazole, tinidazole + MUST txt partner
131
what contraceptive can reduce transmission of trichomonas?
spermicidal agents reduce transmission
132
perinatal complications of trichomonas and BV
PROM, preterm labor, etc
133
terbultaine is used how in OBgyn?
its a B2 agonist that helps relax smooth muscle (bronchial + uterine) - stops spasm. Helps slow down the process of labor
134
what are prostoglandins used in the txt of postpartum hemorrhage?
misoprostol, methergine or hemabate
135
MC cause of vaginitis, what is its pathophysiology?
BV: decreased lactobacilli (maintains pH) → overgrowth of normal flora (gardinella vaginalis). MC cause of vaginitis
136
what is included in "Amsel's Criteria" for BV?
- Abnormal gray vaginal discharge
- Vaginal pH greater than 4.5
- Positive amine test
- More than 20% of epithelial cells are clue cells
137
Dx of BV
KOH prep = fish smell, clue cells + few WBCs, few lactobacilli
138
Txt of BV
metronidazole, clindamycin
139
vaginal CA - what is the most common type and location?
squamous cell
| in posterior wall of the upper ⅓ of the vagina
140
MC sign of vaginal CA
bleeding
141
txt of vaginal CA based on staging
stage I = excision, Stage II+ = chemo
142
txt of rectocele
standard posterior colporrhaphy or site-specific repair over crosslinked porcine small intestine graft augmented repair
143
what are the different types of urinary incontinence? (5)
1. Stress: leak w/ incr abdominal pressure (laugh, cough) [from laxity of pelvic floor muscles]
2. Urge/overactive: sudden urge + involuntary loss of urine
3. Overflow: bladder doesn’t empty completely → dribbling/leaking [CNS dz or BPH]
4. Functional: physical/mental impairments causes pt to not reach the toilet in time
5. Mixed: stress + urge
144
medical txt options for incontinence (stress, urge, overflow)
stress- alpha agonists (psuedophed, midodrine)
Urge - anticholinergics (oxybutinin, tolterodine), Tricyclic antidepressants, Mirabegron
Overflow: cholinergics or alpha blockers (tamsulosin)
145
non-pharm txt of stress incontinence
stress: Sx- incr. Urethral outlet resistance or artificial sphincter, vaginal cones to incr. Pelvic floor muscle strength, estrogen cream
146
non-pharm txt of overflow incontinence
Urge: botox injection or bladder augmentation, Diet - avoid spicy foods, citrus, chocolate + caffeine
147
Fitz-Hugh-Curtis syndrome
PID + perihepatitis
148
MC cause of PID
chlamydia trachomatis
149
classic pelvic finding of endometriosis
fixed retroverted uterus, with scarring, and tenderness posterior to the uterus.
