Female Reproductive System Flashcards

Question 1

Q

Danger Signals - Dominant Breast Mass/Breast CA Overview

Answer

A

adult/older female
has dominant mass on one breast that feels hard and irregular shaped
mass may be attached to skin/surrounding breast tissue (or is immobile)

Common locations: upper outer quadrants (tail of Spence)

Skin changes:
- “peau d’orange” (localized area of skin resembling orange peel)
- dimpling
- retraction

painless or accompanied by serous/bloody nipple discharge
nipple may be displaced or become fixed

► Order mammogram
- 15% of women w/ breast CA may have negative mammogram
► US can detect mass → Refer to breast specialist for diagnostic biopsy
► Refer to breast surgeon

Common sites for metastatic ds:
- bone (e.g., back pain)
- liver (e.g., jaundice, abdominal pain, anorexia, nausea)
- lungs (e.g., dyspnea, cough)
- brain (e.g., headache)

Question 2

Q

Danger Signals - Paget’s Disease of the Breast Overview

Answer

A

older female
hx of red-colored, scaly rash (resembling eczema) and starts on nipple and spreads to areola of one breast
may c/o itching, pain, or burning
skin lesion slowly enlarges and evolves to include crusting, ulceration, and/or bleeding on nipple
~50% of women will have breast mass
Rarely found in men

Question 3

Q

Danger Signals - Inflammatory Breast CA Overview

Answer

A

recent or acute onset of red, swollen, and warm area in breast of middle-aged woman (median age ~59 yrs)
symptoms develop quickly
may have breast tenderness or itching
can mimic mastitis
often, no distinct lump on affected breast
skin may be pitted (peau d’orange) or appear bruised
suspect in women w/ progressive breast inflammation that does not respond to antibiotics
most women w/ IBC have lymph node metastases
1/3 have distant metastases when diagnosed
more common in African Americans, usually diagnosed at younger age
Rare but very aggressive form of breast CA (1-5%)

Question 4

Q

Danger Signals - BRCA1- and BRCA2-associated Hereditary Breast and Ovarian CA Overview

Answer

A

pts w/ personal (or fam hx) of breast, ovarian, prostate, or pancreatic CA may benefit from a hereditary CA risk evaluation (genetic counseling) so that they can find out their risk for these CA
Breast CA susceptibility genes (BRCA1/2) are inherited in an autosomal dominant pattern
up to 6% of breast CA and 20% of ovarian CA cases are caused by mutations in these genes
Ashkenazi Jews (European ethnicity Jews) are at higher risk for BRCA 1/2 mutations
Men w/ BRCA mutations are at highest risk of breast/prostate CA
Women who have a high lifetime risk (~20%) should undergo annual screening mammogram, annual breast MRI, and clinical breast exams Q6-12 months beginning 10 years prior to age at diagnosis of youngest affected fam member
ask what age fam members w/ breast CA were diagnosed and screen 10 years earlier

Ex: if a sister was 35 when diagnosed w/ breast CA, then screen for breast CA by MRI can start at 25 years

Question 5

Q

Danger Signals -Ovarian Cancer Overview

Answer

A

middle-age or older woman
vague sx of abdominal bloating or discomfort, low-back pain, pelvic pain, dyspareunia, and changes in bowel habits

Other sx:
- unusual lower abdominal/back pain
- unusual tiredness or fatigue

75% are diagnosed when already spread beyond ovary → poor overall survival rate
5-year survival w/ distant metastases is 25%, but if caught at stage 1, it is >90%
Currently no lab or imaging tests that can detect at early stages
annual “CA 125” testing alone lacks sufficient specificity for screening average-risk pts
if higher risk, transvaginal US is poor in detecting early-stage epithelial ovarian CA
Look for fam hx of ≥2 1º/2º relatives (cousins, aunts, uncles) w/ hx of ovarian CA or combination of ovarian and breast CA, esp in women of Ashkenazi Jewish ethnicity w/ 1º relative (or 2º relatives on same side of fam) w/ breast/ovarian CA
Women w/ high-risk fam hx should be referred for genetic counseling and testing (e.g., BRCA 1/2, Lynch syndrome)
Screening can start 10 years before earliest age of first diagnosis of ovarian CA in fam hx

Question 6

Q

Danger Signals - Ectopic Pregnancy

Answer

A

reproductive-age sexually active female w/ pelvic pain; may be diffuse or localized to one side
sometimes accompanied by vaginal bleeding
pain may be abrupt or more gradual; can be dull or sharp (usually not cramping)
if intraperitoneal bleeding, pain may radiate from middle to upper abdomen, and/or may be referred to shoulder
may shuffle instead of walking normally to ↓ jarring of pelvis
amenorrhea to light menses in previous 6-7 weeks

RF:
- prior ectopic pregnancy
- current use of IUD
- tubal ligation
- in vitro fertilization (IVF)

~96% of ectopic pregnancies occur in fallopian tubes
definite diagnosis: serum HCG levels (quantitative chorionic gonadotropin) + transvaginal US
Leading cause of death for women in the first trimester of pregnancy → Refer to ED!

Question 7

Q

Normal Findings: Anatomy - Breasts

Answer

A

puberty in girls start w/ breast buds (Tanner stage II, ends Tanner stage V)
during puberty, common for both girls and some boys (45%) to have tender and asymmetrical breast buds and breasts (gynecomastia); one breast may be larger than other
Upper outer quadrant of breasts (called “tail of Spence”) is where majority of breast CA is located
Women w/ BRCA1 or BRCA2 gene mutation (or both) have up to 72% risk of being diagnosed w/ breast CA in their lifetime
Hard irregular mass that is not mobile → follow-up for breast CA
Postmenopausal women’s breasts will feel softer to palpation w/ less volume

Question 8

Q

Simple breast cysts

Answer

A

benign fluid-filled cysts, round/oval
- highest prevalence 35-50 years

Question 9

Q

Fibroadenomas

Answer

A

most common type of solid breast tumor
consist of fibrous tissue ranging from a few mm to 2.5 cm
US is imaging of choice
some pts may need needle biopsy to confirm diagnosis
high estrogen levels can make them grow, while low levels (e.g., menopause) can make the shrink
Most are NOT associated w/ an increase in breast CA except for COMPLEX fibroadenomas

Question 10

Q

Risk Factors for breast CA in men:

Answer

A

cryptorchidism
positive fam hx
BRCA 1/2 mutation

Question 11

Q

What is the diagnostic test for breast CA (or any type of solid tumor)?

Answer

A

Tissue biopsy

Question 12

Q

Normal Findings: Cervix

Answer

A

pink and smooth, or it might be uneven, rough or splotchy

Question 13

Q

Cervical ectropion

Answer

A

bright-red bumpy tissue w/ irregular surface on cervical surface around the os
benign finding
made up of glandular cells (same cells found inside cervical os)
more friable (bleeds easily) compared w/ squamous epithelial cells on cervix surface
Some adolescents and adult women taking birth control pills and pregnant woman may have large ectropions → normal finding (d/t high estrogen)
can change in size/shape; will disappear ore regress over time
if present, sample surface of the transformation zone (TZ) area when performing a pap test → abnormal cells are more likely to develop d/t metaplasia in PZ
Girls and teenagers have larger ectropions; some adult women on birth control pills may develop ectropion

Question 14

Q

Transformation zone (TZ)

Answer

A

area where the ectropion transitions to smooth cervical surface of squamous epithelial cells

Question 15

Q

Normal Findings: Cervical and Vaginal Mucus

Answer

A

varies from scant (“dry”), thick, white, runny white (white and clear mucus) to clear stringy mucus
after menses, vaginal discharge is scant
during midcycle, a large amount of runny, clear mucus (the mucus plug) is normal, except if pt is on hormonal contraceptives (which thickens mucus plug)
can be mixed w/ blood and appear as red-dark brownish during menstrual cycle

Question 16

Q

Normal Findings: Uterus
- fibroids

Answer

A

include uterine corpus and uterine cervix
endometrium consists of glandular epithelium and stroma
Fibroids (uterine leiomyoma or myoma) can enlarge uterus; can be asymptomatic or may cause heavy menstrual bleeding (menorrhagia), pelvic pain or cramping, and bleeding b/w periods
Fibroids (uterine leiomyoma or myoma) are usually benign; can cause urgency if fibroid is pressing on bladder
on rare occasions, fibroids can be malignant and cause uterine CA (leiomyosarcoma)

Question 17

Q

Normal Findings: Ovaries

Answer

A

produces estrogen, progesterone, and a small amount of testosterone (androgens)
women w/ PCOS have multiple cysts on ovaries, which results in higher estrogen level and high androgens level (causes acne, hirsutism, oligomenorrhea, insulin resistance)
during menopause, ovaries become atrophied
palpable ovary in menopausal women is ALWAYS abnormal → R/O ovarian CA → Order pelvic/intravaginal US and refer to gynecologist

** Know female body change sin menopause: If palpable ovary (abnormal), order an intravaginal US!

Question 18

Q

Benign Variants: Supernumerary nipples

Answer

A

forms a V-shaped line on both sides of chest down the abdomen and are symmetrically distributed

Question 19

Q

Menstrual Cycle: Follicular Phase

Answer

A

based on perfect 28-day menstrual cycle

Days 1-14; - AKA proliferative phase
- each month, FSH is produced by anterior pituitary
- FSH stimulates maturation of follicles in woman’s ovary
- Estrogen is produced by developing follicles (or the “eggs”)
- estrogen is the predominant hormone during the first 2 weeks of the menstrual cycle*
- stimulates development and growth of endometrial lining

Question 20

Q

Menstrual Cycle: Ovulatory Phase

Answer

A

Day 14; Midcycle
- LH is secreted by anterior pituitary gland
- induces ovulation and the maturation of the dominant follicle on day 14 (of 28-day cycle)
- follicle migrates to fimbriae of fallopian tube
- takes ~5 days for egg to move through fallopian tube, where conception can take place

Question 21

Q

Menstrual Cycle: Luteal Phase

Answer

A

Day 14-28
- progesterone is the predominant hormone during last 2 weeks of cycle
- produced by corpus luteum
- helps to stabilize endometrial lining

Question 22

Q

Menstrual Cycle: Menstruation

Answer

A

If not pregnant, both estrogen and progesterone fall drastically → menses
low hormone levels stimulate the hypothalamus and then the anterior pituitary → (FSH)
cycle starts again

Question 23

Q

Menstrual Cycle: Fertile Time Period

Answer

A

Sexual intercourse 1-2 days before ovulation offers highest chance of pregnancy
characterized by copious amounts of clear mucus, thin and elastic in vagina
sign is used in cervical-mucus method of birth control to indicate the fertile period of the cycle
There are not ovulation kits, OTC, that can detect urinary LH, which appears within 12 hrs after it is in the serum (released by anterior pituitary)
False-positive results are possible w/ women w/ PCOS, ovarian insufficiency, and menopause

Question 24

Q

Menstrual Cycle: Conception

Answer

A

occurs when sperm fertilizes egg
as it travels down fallopian tube into uterus, fertilized egg continues to divide until it becomes sa blastocyst
blastocyst implants into endometrium → embryo
takes 3-4 days for fertilized egg to fully implant in uterus
placenta is fully formed by 18-20 weeks
estrogen and progesterone levels increase, along wit HCG, which is produced by placenta
Pregnancy lasts 280 days or ~40 weeks

Question 25

Q

Laboratory Procedures: Cervical Cytology

Answer

A

liquid-based cervical cytology (Pap test) → screen for cervical CA
have a high false-negative rate of 20-45%
liquid-based cervical cytology test ThinPrep, read by computer, is now more popular in US than Pap smear kit
If cervix bleeds easily when brush is inserted to obtain sample, may be a sign of inflammation
R/O cervicitis
some females may have slight spotting after PAP test
Do NOT perform a Pap test or liquid-based cytology during menstrual period
Best time to perform a Pap is at least 5 days after period stops
~2-3 days before PAP, pt should avoid douching, vaginal foams/medicine, tampon use, and vaginal intercourse

Question 26

Q

USPSTF (2018) and American College of Obstetricians and Gynecologists (ACOG, 2018) Guidelines on Cervical Screening for average-risk women

Answer

A

USPSTF
- does NOT recommend cervical cytology/PAP tests before 21 years
- Age 21-29 years screen w/ cervical cytology alone
- Age 30-65 years, can perform PAP test w/ cotesting/HPV testing → can space routine PAP smears Q5 years if cotesting (except if abnormal Pap)

ACOG
- HIV-positive women, hx cervical CA, or diethylstilbestrol (DES) exposure may require more frequent screening and should NOT follow routine guidelines

Question 27

Q

Laboratory Procedures: Liquid-Based Cervical Cytology Test Instructions

Answer

A

ThinPrep
- insert broom-shaped plastic brush into cervical os
- rotate in same direction for 5 turns
- if a transformative zone is present, make sure that it is included
- Place brush in liquid medium and swish gently
- remove brush and cover plastic cup
- cervical cytology test is red by computer
- abnormal results are reviewed by cytologist and/or pathologist

Question 28

Q

Laboratory Procedures: Conventional Pap Smear Instructions

Answer

A

use wooden spatula to scrape cervical surface (ectocervix)
insert brush into cervical os (endocervix)
twist gently in a circle
smear glass slide w/ both samples
spray liquid fixative on glass slide and label
By sampling ectocervix first, chances of bleeding are minimize

Question 29

Q

Screening Women w/out a Cervix

Answer

A

Stop screening if pt does NOT have a cervix as a result of hysterectomy for a benign condition

Question 30

Q

USPSTF Cervical Cancer Screening Guidelines
1. ≤ 20 years
2. 21-29 years
3. 30-65 years
4. >65 years
5. Hysterectomy (w/ cervical removal) not d/t CA

Answer

A

Do NOT screen (regardless of age of onset of sexual activity, or if person has an STD/STI or multiple sex partners)
- can perform bimanual gynecologic exam to check for pelvic inflammatory disease (PID) and test for chlamydia/gonorrhea
Liquid-based cytology or conventional Pap test
- Against routine HPV cotesting if ,30 years
- Every 3 years
Liquid based cytology OR Conventional Pap smear OR Liquid-based cytology + cotesting (for high-risk HPV)
- Every 3 years
- OR every 5 years (if cotesting)
- If NOT cotesting, needs Pap Q3years
- Can stop screening if not otherwise at high risk for cervical cancer
  - No hx of CIN stage 2/3, or cervical CA within previous 20 years
- Can stop screening if not otherwise at high risk for cervical cancer
  - No hx of CIN stage 2/3, or cervical CA within previous 20 years

Question 31

Q

The Bethesda System

Answer

A

standardized system used for reporting cervical cytology results
specimen is satisfactory if both squamous epithelial cells and endocervical cells are present, but the absence of endocervical cells is not unusual (occurs in ~10-20% of specimen and is most common in adolescents and postmenopausal women)
if woman is being treated by pelvic radiation or is pregnant, information should be included in cytology requisition
Lubricants or excessive blood can interfere w/ results

Question 32

Q

Atypical Squamous Cells of Undetermined Significance - When should you perform/repeat Pap?
1. 20 years or younger
2. 21-24 years
3. 25-29 years
4. >30 years

Answer

A

Atypical squamous cells of undetermined significance (ASC-US) → term used to describe cells that look mildly abnormal but the cause cannot be identified (infection vs irritation vs precancer)

Do NOT perform Pap if younger than 21 years
Preferred is repeat Pap test in 12 months (acceptable is reflex HPV test)
Preferred is reflex HPV test; acceptable is repeat Pap test in 12 months
Cotesting for high-risk HPV → if HPV positive, refer for colposcopy

Question 33

Q

Atypical Squamous Cells and Cannot Exclude a High-Grade Squamous Intraepithelial Lesion - What test is required for further investigation?
1. Age 21-24
2. Age 25-29
3. Age ≥30

Answer

A

ASC and cannot exclude a high-grade squamous intraepithelial lesion (ASC-H) → term used to indicate presence of cells that definitely look abnormal
- possible precancer is present
- requires more testing and possible treatment

1,2, & 3. Refer for colposcopy

Question 34

Q

Atypical Glandular Cells

Answer

A

more common in older women (ages 40-69 years)
associated w/ premalignancy or malignancy in 30% cases
risk of CA goes up w/ age
several subcategories
Follow-up tests depend on atpyical glandular cell (AGC) subcategory

Follow-up tests:
- colposcopy
- endocervical sampling
- endometrial sampling

Question 35

Q

Low-Grade Squamous Intraepithelial Lesions

When and what to retest?
1. Age 21-24
2. Age 25-29
3. Age ≥30

Answer

A

Cervical cell shows changes that are mildly abnormal
usually caused by HPV infection

Repeat Pap in 12 months
Refer for colposcopy
Preferred is repeat Pap in 12 months; acceptable for colpsocopy

Question 36

Q

High-Grade Squamous Intraepithelial Lesions

When and what to retest?
1. Age 21-24
2. Age ≥25

Answer

A

High-grade squamous intraepithelial lesions (HSILs) suggest more serious changes in cervix than low-grade squamous intraepithelial lesions (LSILs)

more likely than LSILs to be associated w/ precancer and cancer

Refer for colposcopy
Refer for immediate excisional treatment or colposcopy
- can be done by LEEP (loop electrosurgical excision procedure) w/ cervical conization or surgery of the cervix

Question 37

Q

Laboratory Procedures: HPV DNA Test + Gardasil vaccine

Answer

A

Aka Reflex HPV Testing
- HPV types 16 and 18 cause nearly all cases of cervical CA
- women are exposed to high-risk HPV through sexual intercourse
- Gardasil (males or females) is given at age 11-12 years (as young as 9-26 years); if given before 15 yo, a 2-dose series is required → 2nd dose should be given 6-12 months after first does (0, 6-12)
► If first dose of Gardasil given at age ≥15 yo, a 20dose schedule is recommended (1, 1-2, 6)

if vaccine schedule is interrupted, vaccine doses do not have to be repeated (no max interval)
Gardasil is NOT recommended for those ≥26 yo but some adults ≥27 yos may benefit from HPV immunization

Question 38

Q

Laboratory Procedures: Colposcopy

Answer

A

a colposcope → specialized “microscope” used to visualize cervix, obtain cervical biopsies, and gain access to cervix during cryotherapy or laser ablative therapy
DIAGNOSTIC tool for cervical CA is BIOPSY of the cervix, which is obtained during colposcopy
a vaginal speculum is used to expose cervix
After cervix studied, washed w/ acetic acid 3-5% (vinegar), which helps remove mucus and causes abnormal areas of cervix to turn a bright-white color, resembling leukoplakia (acetowhitening)
Biopsy samples are obtained from acetowhitened areas on cervix, cervical os (glandular cells), and squamocolumnar junction
After colposcopy, a small amount of cramping and blood spotting normal (red, brown, black) in the next few days
NSAIDs or analgesics may be used for pain PRN

** Do not confuse w/ endometrial biopsy!

Question 39

Q

Laboratory Procedures: Ablative Treatment

Answer

A

Cryotherapy or laser therapy used to treat abnormal superficial cervical cells

Question 40

Q

Laboratory Procedures: Loop Electrosurgical Excision Procedure (LEEP)

Answer

A

device used like a scalpel to cut through cervix (conization) to tx cervical CA and obtain cervical biopsy specimens
depending on resumes of biopsy (size, depth, and severity), cancerous cells can be removed by cryotherapy for mild lesions, laser ablation or surgical conization of cervix

Question 41

Q

Laboratory Procedures: Potassium Hydroxide Slide (KOH)

Answer

A

useful for helping w/ diagnosis of fungal infections (hair, nails, skin)
KOH works by lysis of squamous cells, which makes it easier to see hyphae and spores
vaginal specimens do NOT require KOH to visualize Candida

Question 42

Q

Laboratory Procedures: Whiff Test

Answer

A

test for bacterial vaginosis (BV)
positive results occurs when strong, fish-like odor is released after 1-2 drops of KOH are added to slide (or a cotton swab soaked w/ discharge)

Question 43

Q

Laboratory Procedures: Tzanck Smear

Answer

A

used as adjunct for evaluating herpetic infection (oral, genital, skin)
positive smear will show large abnormal nuclei in squamous epithelial cells
not commonly used

Question 44

Q

Exam tips: Recognize menopausal female body changes + postmenopausal

Answer

A

atrophied ovaries

If palpable ovary (abnormal) → R/O ovarian CA and order intravaginal US

palpation of postmenopausal women’s breasts will feel softer w/ less volume and may be pendulous

Question 45

Q

Clinical pearls: Consider using what to help with Pap smears?

Answer

A

use small amount of K-Y jelly to lubricate tips of speculum (in pts w/ atrophic vaginitis to reduce pain and vaginal bleeding)
will not affect Pap test results

Question 46

Q

What test should you consider obtaining for reproductive-aged females who present w/ acute abdominal or pelvic pain?

Answer

A

Always perform a pregnancy test (use good-quality urine HCG strips)

Question 47

Q

Cervical CA 5-year survival rates:
1. localized
2. regional spread
3. distant metastasis

Answer

A

92%
56%
17%

Question 48

Q

Contraception: Infertility

Answer

A

having unprotected sex for 1 year with failure to achieve pregnancy

Question 49

Q

Contraception: Overview

Answer

A

Up to 85% chance of becoming pregnant within 1 year of unprotected sexual intercourse
In US, ~50% of pregnancies are unplanned
Women seeking to prevent pregnancy have a variety of options to choose from w/ varying degrees of reported effectiveness

Exam Tip: Some questions will ask for the best birth control method for a case scenario. Remember the contraindications or adverse effects of each metho (e.g., Depo-Provera)

Question 50

Q

Contraception: Most effective method of preventing pregnancy (<1 pregnancy per 100 women in a year)

Answer

A

Implant (0.05%)
IUD (LNG 0.2%, Copper T 0.8%)
After procedure, little or nothing to do or remember
Sterilization (Vasectomy 0.15%; abdominal/Laparoscopic/Hysteroscopic 0.5%)
After procedure, use another method for first 3 months

Question 51

Q

Contraception: Methods of preventing pregnancy (<6-12 pregnancies per 100 women in a year)

Answer

A

Injectable (6%)
Repeat injections on time
Pills (9%)
take a pill each day
Patch (9%)
Keep in place, change on time
Ring (9%)
Keep in place, change on time
Diaphragm (12%)
Use correctly every time you have sex

Question 52

Q

Contraception: Methods of preventing pregnancy (≥18 pregnancies per 100 women in a year)

Answer

A

Male condom (18%)
Female condom (21%)
Withdrawal (22%)
Sponge (24% parous women; 12% nulliparous women)
Spermicide (27%)
use correctly every time you have sex
Fertility-Awareness Based Methods
Abstain or use condoms no fertile days
Newest methods (Standard Days Method or TwoDay Method) may be easiest to use and consequently more effective

Question 53

Q

Contraception: Rule Out Pregnancy; Reasonable certainties no pregnancy criterias

Answer

A

According to CDC, healthcare provider can be reasonably certain that a woman is NOT pregnant if she has no sx or signs of pregnancy and meets the following criteria:

At least ≤7 days after start of normal menses (or after an induced or spontaneous abortion)
has been correctly and consistently using a reliable method of contraception
is within 4 days postpartum
exclusively breastfeeding or for the vast majority of the time breastfeeds (>85%) and is amenorrhoeic and <6 months postpartum
Check if pregnant w/ urine pregnancy test before starting hormonal and IUD contraception

Question 54

Q

Combined Hormonal Contraception

Answer

A

combination of estrogen and progesterone
works in a synergistic manner by stopping ovulation (inhibits LH surge) and thickening the cervical mucus plug
several types such as oral contraceptives, transdermal patch, and vaginal ring
has a 9% typical use failure rate

Question 55

Q

Combined Hormonal Contraception: Dosed Monophasic Pills

Answer

A

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)

Question 56

Q

Combined Hormonal Contraception: Biphasic Pills

Answer

A

Ortho-Novum 10/11
- contains 2 different progesterone doses (2 phases)
- progesterone dose ↑ halfway through cycle
- other brands: Mircette and Jenest

Question 57

Q

Combined Hormonal Contraception: Triphasic Pills

Answer

A

Ortho Tri-Cyclen
- Contains 21 days of active pills and 7 days of placebo pills
- dose of hormones varies weekly for 3 weeks (“triphasic”)
- progestin used is norgestimate
- indicated for acne

Other brands:
- Cyclessa
- Tri-Norinyl
- Tri-Levlen
- Triphasil

Question 58

Q

Combined Hormonal Contraception: Ethinyl Estradiol and Drospirenone

Answer

A

24/4 formulation (24 days hormones/4 days placebo pills)

Yaz 28 (24 active pills and 4 placebo pills)/Yasmin
- uses drospirenone (a spironolactone analog) as the progestin component
- results in lighter menses & lower rates of unscheduled bleeding
- consider for women w/ acne, PCOS, hirsutism, or premenstrual dysphoric disorder (PMDD)
- higher risk of DVT and hyperkalemia

Labs
- check potassium if pt on ACEi, ARB, or potassium-sparing diuretic, or has kidney disease

Question 59

Q

Combined Hormonal Contraception: Extended-Cycle Oral Contraceptive Pills

Answer

A

84/7 formulation (84 days hormones/7 days placebo pills)

Seasonale
- contains 84 consecutive days (3 months) of estrogen/progesterone w/ a 7-day pill-free interval
- this method typically results in 4 periods/year
- breakthrough bleeding is not uncommon during first few months

Question 60

Q

Combined Hormonal Contraception: Non-oral Forms contraindications

Answer

A

Absolute and relative contraindications for nonoral forms of combined estrogen-progesterone method of contraception are the same as OC

Question 61

Q

Combined Hormonal Contraception: Non-oral Forms - Cervical Rings

Answer

A

7% Typical use failure rate

NuvaRing
- plastic cervical ring containing etonogestrel and ethinyl estradiol (EE)
- left inside vaginal for 3 weeks (21 days) then removed for 1 week (when woman has her period)
- educate pt on how to apply (fold in half and insert into vagina)
- ring should fit snugly around cervix
- to use it continuously, insert a ring Q21 days w/ no ring-free week in between
- Do NOT use NuvaRing if cigarette smoker aged ≥35 years

Question 62

Q

Combined Hormonal Contraception: Non-oral Forms - Ortho Evra Transdermal Contraceptive Patch

Answer

A

7% Typical Use Failure Rate

Higher risk of VTE d/t release of higher levels of estrogen compared w/ OC pills
absolute and relative contraindications for combined estrogen-progesterone method of contraception are the same as OC
Patches can be worn on buttocks, chest (except breast), upper back, arm, or abdomen
Wear a new patch 1 week at a time for 3 weeks in a row
During 4th week, do not wear a patch

Question 63

Q

Contraindications to Hormonal Contraceptive Use - ABSOLUTES!

Answer

A

► Any conditions (past or present) that ↑ risk of blood clotting
- Hx of thrombophlebitis or thromboembolic ds (e.g., DVT)
- Genetic coagulation defects, such as factor V Leiden ds
- Major surgery w/ prolonged immobilization

► Smoker >35, >15 cigs daily
- also considered a relative contraindication b/c women <35 yrs who smoke can take pill (if no other contraindications exists)

► Any condition that ↑ risk of strokes
- Migraine w/ aura
- focal neuro sx
- migraine w/out aura at ≥35
- Hx CVAs and TIAs
- HTN (if SBP >160, DBP <100)

► Inflammation and/or acute infections of the liver w/ ↑ LFTs
- in acute infection or inflammation of liver (e.g., mononucleosis) w/ ↑ LFTs → estrogen is contraindicated
- When LFTs are back to normal, can go back on birth control pills
- Hepatocellular adenomas or malignant (hepatoma)
- Cholestatic jaundice of pregnancy

► Known/suspected cardiovascular ds
- Mod-severe impaired cardiac function
- complicated valvular heart ds (risk Afib, hx of subacute bacterial endocarditis)
- CAD
- Diabetes w/ vascular component
- SLE
- HTP if SBP ≥160, DBP ≥100
- ≥2+ RF for arterial cardiovascular ds (such as older age, smoking, diabetes, HTN)

► Some reproductive system conditions/Cancers
- Known/suspected pregnancy
- Undiagnosed genital bleeding/breast mass
- Breast, endometrial, or ovarian CA (or any estrogen-dependent CA) <21 days postpartum

Question 64

Q

Contraindications for Drospirenone

Answer

A

Yaz, Yasmin, Slynd

Hyperkalemia
Kidney disease/failure
adrenal insufficiency

Answer 65

A

My - Migraines w/ focal neurological aura
C - CAD/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 aged ≥ 35 years

Answer 66

A

Migraine headaches
Migraines and >35 yrs
Migraines w/ focal neuro findings are absolute contraindication d/t ↑ risk of stroke
Smoker <35 years
Fracture or cast on LE
Adequately controlled HTN

Answer 67

A

Ovarian CA and endometrial CA decreased by 40-50%

Decreased incidence of:
- Dysmenorrhea and cramps (decrease in prostaglandins)
- Decreased pelvic pain for pts w/ endometriosis
- Acne and hirsutism (lower levels of androgenic hormones)
- Ovarian cysts (d/t suppression of ovulation)
- Heavy and/or irregular periods (d/t suppression of ovaries)

Answer 68

A

Perform thorough health hx to find out of pt has contraindication
Rule out pregnancy
Check BP (r/o HTN)

Note: A PE, Pap smear, gynecologic exam, STD/STI testing, and/or lab blood testing is NOT required for initiating contraception in most health pts
- Exception is pelvic exam before insertion of IUD (to r/o an abnormal uterus or cervicitis) and when fitting for a diaphragm

OC can be started anytime in the menstrual cycle (R/O PREGNANCY FIRST!)
ALL pts should be instructed to use “backup” (condoms) in the first weeks (7 days) during first pill pack
► Quick start → Start taking the pill on the day prescribed (give samples or prescription). RULE OUT PREGNANCY FIRST!
► Day one start → Take first pill during the first day of the menstrual period; provides the best protection
► Sunday start → Take first pill on the first Sunday after the menstrual period starts; will avoid having a period on a weekend; higher chance of ovulation happening
Follow-up visit needed within 2-3 months to check BP or any side effects and answer pt’s questions
can prescribe up to 12-13 months of refills for OC

Answer 69

A

Term used for menstrual bleeding occurring outside of usual cycle
Educate pt that spotting/light bleeding during the first few weeks after starting birth control pills, transdermal patch, or vaginal ring; for most, will ↓ 10% or less by 3rd month
Discourage pt from switching to another pill brand during first 3 months d/t spotting
advise pt that most cases resolves spontaneously within a few weeks
Pts on OC have lower estrogen doses (20 mcg EE) have higher rates of unscheduled bleeding compared w/ those on OCs w/ higher doses of 30-35 mcg of EE
if pt still has bleeding after a few weeks, an option is to switch to an OC w/ 30 mcg of EE (Lo/Ovral, Desogen, Loestrin 2, Nordette)
Check if pt is taking pills daily
takes approx. 3 months for body to adjust to hormones
Early sx can include nausea and breast tenderness a few days ater starting hormones
sx usually resolve in 1 month

Answer 70

A

take 2 pills now and continue w/ same pill pack (“doubling up”)
continue taking remaining pills at the usual time

Answer 71

A

Take most recent missed pill ASAP (even if it means taking 2 pills on the same day)
Discard any leftover missed pills.
Continue taking remaining pills at the usual time
Use backup contraceptions (e.g., condoms) or avoid sex until hormonal pills have been taken for 7 consecutive days

Answer 72

A

omit hormone-free pills (or placebo pills) by finishing the hormonal pills in the current pack and starting a new pill pack the next day
Use backup contraception until hormonal pills have been taken for 7 consecutive days
consider emergency contraception if unprotected sexual intercourse occurred in the previous 5 days

Answer 73

A

These drugs can ↓ the efficacy of OC
- Advise pts to use an alternative form of birth control (condoms) when taking these drugs and for one pill cycle afterward

Anticonvulsants: Phenobarbital, phenytoin
Antifungals (strong CYP3A4 inhibitors): Griseofulvin (Fulvicin), itraconazole (Sporanox), ketoconazole (Nizoral)
HIV/hepatitis C virus (HCV) protease inhibitors: Indinavir, boceprevir
St. John’s wort: May cause breakthrough bleeding

Answer 74

A

Thromboembolic events can happen in any organ of the body

S/s indicates a possible thromboembolic event
!! Advise pt to call 911 if symptoms of ACHES:

A - Abdominal pain
C - Chest pain
H - Headaches
E - Eye problems; change in vision
S - Severe leg pain

Answer 75

A

Chest pain (an acute MI) → Blood clot in a coronary artery
Severe headache → Stroke, TIA
Weakness on one side of the body → Ischemic stroke caused by a blood clot in the brain
Visual changes in one eye → Blood clot in the retinal artery of the affected eye
Abdominal pain → Ischemic pain of the mesenteric area caused by a blood clot
Lower leg pain (DVT) → Blood clot on a deep vein of the leg

Answer 76

A

Typical use failure rate 9%
Traditional OC have 21 days of “active” pills + 7 days of placebo pills; last 7 days are “hormone-free” days → menstrual cycle usually start within 2-3 days after the last active pill was taken (from very low levels of estrogen/progesterone)
Some brands of birth control pills (e.g., Loestrin FE) contain iron in the pills taken during last 7 days of pill cycle (instead of placebo pills) → last 7 days (hormone-free) of pill cycle are there to reinforce the habit of daily pill taking
First he FIRST pill cycle, advise pt to use “backup” (alternative form of birth control) for 7 consecutive days; the extended-cycle OC are another option to consider
All combined OC (COCs), the patch, the NuvaRing, contains both estrogen (e.g., EE) and progesterone (e.g., levonorgestrel, norethindrone, desogestrel)
Contraceptive patch (e.g., ortho Evra) results in higher levels of estrogen exposure compared w/ COCs (higher risk of blood clots, DVTs)
Estrogen in COCs can ↑ BP; BP should be checked within 4-8 weeks
Breastfeeding women can use the progestin-only pill (POP; “minipill;” e.g., Micronor, Nor-QD) or other progestin-only contraceptives → Barrier method such as condoms can also be used

Answer 77

A

4% Typical Use Failure Rate
AKA depo medroxyprogesterone acetate (DMPA)

Each dose by injection lasts 3 months
Highly effective
check for pregnancy before starting dose
Start w/in 5 days of cycle (days 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 d/t severe uterine atrophy from lack of estrogen
Do NOT recommend to women who want to become pregnant in 12 months → causes delayed return of fertility; takes up to 1 year for most women to start ovulating

BBW!!!! Avoid long-term use (>2 years)
- increases risk of osteopenia or osteoporosis that may not be fully reversible → - Recommend calcium w/ vit D + weight-bearing exercises for pts who are on this med
- Using Depo-Provera for >2 years is discouraged

Answer 78

A

Avoid Depo-Provera in this population because it will further ↑ risk of osteopenia/osteoporosis
consider testing for osteopenia/osteoporosis (dual-energy x-ray absorptiometry; DEXA scan)
Recommend calcium w/ vit D + weight-bearing exercises for pts who are on this med

Answer 79

A

0.1% Typical Use Failure Rate

Contraceptive implant containing long-acting form of progestin (etonogestrel)
- initially, unscheduled bleeding is common but when the endometrial lining atrophies, amenorrhea results
- Ovulation may not occur for a few weeks to 12 months after removal

Thin plastic rods are inserted on inner aspect of upper arm subdermally (nondominant arm)
If keloid or heavy scarring occurs, may have problem w/ removal
Special procedures, including surgery in hospital; may be needed to remove implant
Norplant II (2 rods) is effective up to 5 years
Nexplanon (1 rod) is effective up to 3 years
1/10 women stop using implant d/t unfavorable changes in menstrual bleeding

Answer 80

A

7% Typical Use Failure Rate
AKA “minipill”

Safe for breastfeeding women
most effective if woman is exclusively breastfeeding*
obese women can take POPs
Very important to take pill at the same time each day. If dose is late, ≥3 hours or a day is missed, pt should use condoms (backup contraception) or abstain from sexual intercourse for 2 days
No placebo week w/ POPs
Vomiting or severe diarrhea that occurs within 3 hrs after taking a dose → take another pill ASAP
continue taking pills daily at the same time each day
use backup contraception
Consider use of emergency contraception if unprotected sex
Micronor (Norethindrone 0.35 mg): take 1 pill daily at about the same time each day (each pack contains 28 pills); start taking pill on day 1 of menstrual cycle
POPs are slightly less effective than OC pills
An alternative for women who cannot take estrogen, such as breastfeeding mothers, older smokers, and diabetics w/ microvascular ds

Answer 81

A

“Morning-After Pill”

works best if taken within 72 hrs after unprotected sexual intercourse or if 2 consecutive days of birth control pills are skipped
women and men of all ages can get emergency contraceptive pills (except ulipristal acetate) without a prescription in US
89% effective
Ulipristal acetate (Ella): Take 1 pill within 5 days (120 hours) of unprotected sex

Levonorgestrel: Plan B One-Step my Way, After Pill, or Next Choice One Dose
- A few birth control pills that contain levonorgestrel (e.g., Triphasil) may be used as a morning-after pills but are more likely to cause nausea (d/t estrogen)
- Take 1st dose ASAP (up to 72 hrs after)
- Take 2nd dose in 12 hrs
- If pt vomits tablet within 1 hr (or less), may need to repeat dose
- OTC antiemetics (antihistamine drug class) are dimenhydrinate (Dramamine) and meclizine (Dramamine Less Drowsy)

Advise pt if she does not have a normal period in next 3 weeks, she should return for follow-up to R/O pregnancy

Answer 82

A

LNG 0.1% - 0.4%/Copper
- 0.8% Typical Use Failure Rate

IUD is the 2nd most common used method of contraception in the world
Paragard is copper-bearing (effective up to 10 years

Mirena contains the hormone levonorgestrel (LNG), which ↓ vaginal bleeding
- effective for up to 5 years
- slightly more effective than copper-bearing IUDs (Cu-IUDs)

Copper IUD can cause heavy menstrual bleeding
- also can cause cramping the first few months of use

IUD can be removed if pt desires pregnancy
not for women who plan on having a baby within 1-2 years
must be inserted by trained health provider
R/O pregnancy

Answer 83

A

Female sterilization

Answer 84

A

- Active PID or hx of PID within the past year
  - Suspected or confirmed pregnancy or has STD
  - Uterine or cervical abnormality (e.g. bicornuate uterus)
  - Undiagnosed vaginal bleeding or uterine/cervical cancer
  - Hx of ectopic pregnancy
- Endometrial and pelvic infections (first few months after insertion only)
  - Perforation of uterus
  - Heavy/prolonged menstrual periods (Cu-IUDs)
- Mirena IUD: Approx 20% of pts will have amenorrhea in 1 years
  - some have lighter periods
  - Educate pt to periodically check for missing or shortened string, esp after each menstrual period
  - if pt or clinician does not feel string, order a pelvic US

Answer 85

A

Male condoms
- 18% typical use failure rate
- More effective than female condom

Female condoms
- 21% typical use failure rate
- Do NOT use w/ any oil-based or silicone oil-based lubricants, creams, and so forth

Answer 86

A

Not as effective as hormonal forms of contraception
Cervical cap is less effective than diaphragm
after vaginal birth, failure rate ↑ 29%
can be left in vagina up to 2 days
Prentif cap, can be worn up to 48 hrs; compared w/ diaphragm, Prentif cap may cause abnormal cervical cellular change (abnormal Pap)
Diaphragm
must be used w/ spermicidal gel
after intercourse, leave diaphragm inside for at 6-8 hours (can remain inside up to 24 hours)
Need additional spermicide application before every act of intercourse
apply spermicidal foam/gel inside vagina w/out removing diaphragm

Spermidical Gel (nonoxynol-9 or N-9)
- increases risk of infection w/ STD, including HIV (may cause irritation of cervical surface; breakdown of skin barrier; af ter multiple uses

** Both diaphragm and cervical cap require a prescription and must be fitted!
- Avoid lubricants containing silicon oil; they can cause deterioration of silicone diaphragm/cap

After each pregnancy by vaginal birth or weight gain (or loss) of 20%, they need to be refitted
cervical cap and diaphragm cannot be used during menstruation

Increased risk:
- Caginal and cervical irritation (N-9) ↑ risk of HIV infection, UTIs, and TSS (rare)

Answer 87

A

OTC
made of soft foam containing spermicide
inserted inside vagina so that it covers cervix
Can be inserted up to 24 hrs before sex
should be left in place at least 6 hrs after sexual intercourse
sponge should not be worn for >30 total hours
Spermicide use (nonoxynol-9) ↑ risk of HIV infection

Increased Risk:
- vaginal and cervical irritation (nonoxynol-9) ↑ risk of HIV infection
- TSS is rare

Answer 88

A

20-35 mcg

Answer 89

A

Desogen
Ortho-TriCyclen
Yaz/Yasmin

Answer 90

A

Anorexic and/or bulimic patients
- very high risk of osteoporosis

Answer 91

A

Seasonale (84 days hormones + 7 days placebo pill)

Answer 92

A

Mefenamic acid (Ponstel)

Answer 93

A

Cu-IUD → 10-12 years

Mirena (progesterone IUD) → 5 years

Answer 94

A

Blood clots → stroke, heart attacks, and hyperkalemia

Answer: Yaz or Yasmin

Answer 95

A

women who want to become pregnant in 12-18 months because it may cause delayed return of fertility
- can take up to 1 year for some women to start ovulating

Answer 96

A

Medical conditions such as:
- diabetes
- smoker for >35 years
- on anticonvulsant or antiretroviral therapy
- ovarian cancer
- ischemic heart disease
- liver tumors

Answer: Cu-IUD

Answer 97

A

Menstrual Cramps
1. Refers to recurrent crampy pain in pelvic area caused by menstruation; not caused by disease

same type of pain caused by a disease such as endometriosis
- Endometriosis is a/w heavy menstrual periods (menorrhagia) w/ severe cramping
- pelvic area cramping
  - heavy periods
- NSAIDs
  - acetaminophen (paracetamol)
  - hormonal methods

ALL NSAIDs are probably effective:
- Mefenamic acid (Ponstel): 250 mg Q6hr for pain PRN
- Naproxen sodium (Aleve): 275 mg Q6-8 hr for pain PRN
- Ibuprofen (Advil): 400-600 mg Q4-6 hrs for pain PRN
- Ketoprofen (Orudis): 25-50 mg Q6-8 hr for pain PRN
- Acetaminophen (Tylenol): 1-2 tablets Q4-6 hr for pain PRN (if NSAIDs contraindicated)

→ If poor/no relief, consider extended-cycle OCs such as Yaz (24/4) or extended-cycle OCs (seasonale)
- Progestin-only methods may also be effective
- Refer to gynecologist to R/O endometriosis if severe menstrual cramp pain w/ heavy menses (can cause iron-deficiency anemia)

Answer 98

A

heavy menstrual periods

Answer 99

A

Absence of menses
- can be transient, intermittent, or permament
absence of menarche by age 15 years (or older)
absence of menses for >3 months in girls/women who previously had regular menstrual cycles or if irregular cycles, it is missing menses for 6 months
- Most common cause of secondary amenorrhea is pregnancy

Answer 100

A

- nonmalignant breast lesions, which are either nonproliferative (benign) or proliferative (fibroadenomas, fibrosis, papillomas, and mild-to-mod hyperplasia, others)
  - very common condition found in reproductive-aged women (30-50 years)
  - previously called fibrocystic breast disease

women w/ proliferative lesions have a slightly ↑ risk of breast CA
many have cyclic monthly breast changes occurring in premenstrual period (breast engorgement + breast pain [mastodynia]), which improve after menses starts

- 30-50 years
  - cycle onset of bilateral breast tenderness and breast lumps starting from a few days (up to 2 weeks) before period for many years
  - once menstruation starts, tenderness disappears + breast lumps ↓
  - may report lesion or mass has grown in size
  - during breaset exam, breast may feel lumpy, nodular, or cystic
  - if mass present, it is mobile w/ discrete edge, not attached to skin, and feels rubbery to firm texture (not hard)
  - nipples and/or breast may feel tender

Multiple mobile and rubbery to firm (not hard) masses on 1-2 breasts

- Stop caffeine intake
  - take vitamin E and evening primrose capsules daily
  - wear bras w/ good support
  - Referral needed if dominant mass, skin changes, fixed mass

Answer 101

A

breast pain

Answer 102

A

** Most common type of CA in women
- 2nd most common cause of death in women in US (leading cause 8is heart disease)
- most causes are diagnosed by abnormal mammogram but up to 15% of women have breast mass not detected on mammogram (mammographically occult ds)
** - GOLD STANDARD: biopsy of breast/axillary mass
- > 50 years, older age
  - genetic mutations (BRCA 1/2)
  - early menarche (before age 12)
  - late menopause (after age 55)
  - dense breast
  - personal or fam hx of breast CA
  - radiation therapy to chest/breast before age 30 (treated for Hodgkikin’s lymphoma)
  - mother took diethylstilbestrol (DES; 1940-1071)
- not being physically active
  - overweight or obese after menopause
  - hormones (estrogen and progesterone) taken during menopause for >5 years
  - pregnancy at age 30 or older
  - not breastfeeding
  - nulliparity
  - mod-high alcohol intake
- Ductal carcinoma in situ (DCIS)
  - infiltrating lobar carcinoma (CA)
  - infiltrating ductal CA
  - mixed lobar and ductal CA
  - PDB
  - inflammatory breast CA
  - phyllodes tumor
  - breast sarcoma (rare)
- Estrogen receptors (ER)
  - progesterone receptor (PR)
  - HER2 (human epidermal growth factor receptor)
  - Most breast CA (80%) are hormone-receptor positive (ER and/or PR)
USPSTF: Biennial screening mammography for women 50-74 years
- Insufficient evidence for digital breast tomosynthesis (DBT) as screening method for breast CA

** Know physical exam findings and follow-up for breast cancer
→ hard irregular mass that is NOT mobile

Answer 103

A

- pt or clinician detects dominant breast mass, painless
  - mass feels hard, has irregular edges, not mobile
  - may have axillary adenopathy
  - may have skin changes (dimpling or peau de orange, thickening) or erythema (IBC)
  - may have nipple discharge; bloody or erosion
  - scaling on nipple and/or areola → sign of PDB

Sx of metastases:
- bone → back pain, leg pain
- liver → nausea, jaundice, anorexia, pain
- lungs → SOB, cough
- brain → headache

- Mammogram → grouped microcalcifications, spiculated high-density mass
  - Breast US/sonography → Distinguish if mass is cystic or solid/malignant (e.g., calcifications)
  - MRI of breast (w/ gondolium) → Used to screen women at high risk of breast CA; most invasive breast CA are enhanced on gondolium-contrast MRI
- ≥30 years w/ dominant breast mass
  * Order diagnostic mammogram + breast US (to determine if cystic or solid)
  * If abnormal mammogram → refer to breast specialist

Age ≤ 30 years
Order breast US w/ or w/out diagnostic mammogram/breast biopsy
If low clinical suspicion, may observe for 1-2 menstrual cycles
Skin changes (peau de orange, dimpling)
order diagnostic mammogram w/ biopsy of underlying mass
If fam hx of breast and/or ovarian CA (first-degree includes parents/siblings & second-degree relatives are aunts/uncles/cousins
refer to geneticist
Ashkenazi Jews are at higher risk of BRCA 1/2 mutations
Physical Exam
Breast exams such for masses, axillary, supraclavicular, and cervical adenopathy
Secondary prevention
Aspirin use at least once per week (associated w/ up to 50% reduction in death from breast CA)
tamoxifen for certain pts at higher risk at ≥ 35 years

Answer 104

A

- Hormonal abnormality marked by anovulation or oligo-anovulation (infrequent ovulation), infertility, excessive estrogen, high androgen production (acne, hirsutism), and insulin resistance
  - higher risk for DM2, dyslipidemia, metabolic syndrome, endometrial hyperplasia, obesity, nonalcoholic fatty liver disease, depression, and OSA
- obese teen/young adults
  - c/o excessive facial and body hair (hirsutism 70%)
  - bad acne
  - amenorrhea or infrequent periods (oligomenorrhea)
  - dark thick hair (terminal hair) seen on face, cheek, and beard areas
  - may have male-pattern baldness when older
- Transvaginal US → enlarged ovaries seen w/ multiple small follicles (“ring of pearls” appearance)
  - ↑ serum testosterone, dehydropiandrosterone (DHEA), and anderostenedione
  - FSH are normal or ↓
  - FBG and 2-hour oral glucose tolerance test (OGTT) → abnormal

Answer 105

A

- First-Line: OC → used to suppress ovaries
  - Spironolactone is used to ↓ and control hirsutism
  - If pt does not want OC, give medroxyprogesterone tablets (Provera) 5-10 mg daily for 10-14 days (repeat Q1-2 months to induce menses)
  - Metformin (Glucophage) → induce ovulation (if desires pregnancy); warn reproductive-aged diabetic females (who do not want to become pregnant) to use birth control
  - weight loss ↓ androgen and insulin levels
PCOS pts are at ↑ risk for:
- CAD/CHD
- DM2 and metabolic syndrome
- CA of breast and endometrium
- Central obesity
- Infertility
- Nonalcoholic fatty liver disease

Answer 106

A

- USPSTF: screen wo9men ≥ 65 years
  - Osteopenia and osteoporosis caused by a gradual loss of bone density 2º to estrogen deficiency and other metabolic ds
  - Most common in older women (white or Asian descent) who are thin w/ small body frames, esp if positive family hx
  - Treat postmenopausal women (or men ≥ 50 years) who have osteoporosis T-score ≤ -2.5) or hx of hip/vertebral fracture
Other risk groups:
- Chronic steroid use (e.g., severe asthma, autoimmune ds) at high risk for glucocorticoid-induced osteoporosis → R/O osteoporosis in older women/men on chronic steroids esp if accompanied by other RF (lower testosterone, small frame, thin, white, or Asian)
- Anorexia nervosa/bulimia
- Long-term use of PPIs, such as omeprazole (Prilosec)
- Gastric bypass, celiac dis, hyperthyroidism, ankylosing spondylitis, RA, etc
- “Female athlete triad” → combination of low weight w/ hx of amenorrhea or menstrual dysfunction and low bone density; at higher risk for osteoporosis
- Low calcium intake (*low intake of dairy), vit D deficiency, inadequate physical activity
  - Alcohol consumption (≥ 3 drinks daily), high caffeine intake
  - Smoking (active or passive)

Answer 107

A

- DEXA to measure bone mineral density (BMD) of hip/spine → obtain baseline and repeat in 2 years (if on tx regimen) to assess the efficacy of med

Osteoporosis: T-score of -2.5 or lower SD at lumbar spine, femoral neck, or total hip region → Pharmacologic therapy if osteoporosis or postmenopausal w/ hx of fragility fracture, hx of hip fracture, or recent fracture

Osteopenia: T-score -1.5 and -2.4 SD

- Weight-bearing exercises 30 mins TID
  * Swimming and biking are not considered weight-bearing exercise (but good for severe arthritis)
  * Weight-bearing exercises are walking, jogging, aerobic dance clases, most sports, yoga, tai chi
  * Isometric exercises are not considered weight-bearing
  - Calcium w/ vit D 1,200 mg/daily w/ vit D 800 IU daily
  - Smoking cessation if smoker (smoking cigarettes accelerates bone loss)
  - FRAX (Fracture RIsk Assessment Tool) will give 10-year probability of hip fracture and major osteoporotic fracture (spine/forearm/shoulder)

Answer 108

A

Bisphosphonates
Selective Estrogen Receptor Modulator Class
Tamoxifen (Nolvadex)
Parathyroid Hormone Analog
Other: Miacalcin and Calcitriol

Answer 109

A

First-line drugs for treating postmenopausal osteoporosis, glucocorticoid-induced osteoporosis (women/men) and osteoporosis in men
Potent esophageal irritant → Advise pt to report sore throat, dysphagia, midsternal pain
may cause esophagitis, esophageal perforation, gastric ulcers, reactive/bleeding peptic ulcer ds (PUD)
↑ BMD and inhibits bone resorption

Ex:
- Fosamax (alendronate) PO daily or weekly
- Aetonel (risedronate) PO daily weekly, or monthly
► Take immediately in AM w/ full glass (6-8 oz) of plain water (do not sue mineral water)
► Take tabs sitting or standing and wait at least 30 mins before lying down
► Do not crush, split, or chew tablets; swallow tablets whole
► Never take w/ other meds, juice, coffee, antacids, vitamins
► will cause severe esophagitis or esophageal perforation if lodged in esophagus
- Consider prophylaxis for high-risk postmenopausal women w/ osteopenia
- Repeat DEXA after 2 years of therapy

Contraindications
- Inability to sit upright
- esophageal motility disorders
- hx of PUD or hx of GI bleeding
- CKD
- certain types of bariatric surgery (e.g., Roux-en-Y gastric bypass)

Osteonecrosis of the jaw (mandible or maxilla) more likely if on IV/IM bisphosphonates; pt c/o jaw heaviness, pain, swelling, and loose teeth

Answer 110

A

Approved for use in postmenopausal women w/ osteoporosis who are higher risk for breast CA
drugs ↓ risk of breat CA (if taken long term, up to 5 years)
Selective estrogen receptor modulators (SERMs) are option for pts who cannot tolerate or have contrainidcations to bisphosphonates
Used as adjunct tx for estrogen-receptor-positive breast CAs

Ex:
- Raloxifene (Evista) → category X drug

Do NOT stimulate endometrium or breast tissue since it blocks ERs
Do NOT use to treat menopausal sx (aggravates hot flashes)

BBW!
- ↑ risk for DVTs
- pulmonary embolisms
- endometrial/uterine CA
- ↑ risk of death from stroke (postmenopausal women w/ hx of heart disease)

Answer 111

A

category X drug
use for tx of breast CA that is hormone-receptor positive and for prophylaxis in women at high risk for breast CA; can be taken up to 5 years
↑ risk of DVT, endometrial CA, strokes, and PE

Common SEs (SERMs):
- hot flashes
- white/brownish vaginal discharge
- weight gain/loss

Answer 112

A

Teriparatide (Forteo) → injection recombinant human parathyroid hormone (PHT) for tx of osteoporosis
comes as prefilled injector

WARNING: ↑ incidence of osteosarcoma in rats

Answer 113

A

Calcitonin salmon, derived from salmon → weak antifracture efficacy compared w/ bisphosphonates and PTH

Calcitriol → Vit D analog
- must be on a low-calcium diet
- monitor pt for hypercalcemia, hypercalciuria, and renal insufficiency
- may be effective in preventing glucocorticoid and posttransplant-related bone loss

Answer 114

A

Avg age of menopause for women in US is 51 years
WHI showed that combined estrogen-progestin replacement therapy (ERT) ↑ risk of stroke, heart ds, VTE, breast CA, and PE
USPSTF does NOT recommend combined estrogen-progestin or unopposed estrogen for prevention of chronic conditions (heart ds, osteoporosis)
→ Does not apply to women who want hormone therapy for relief of menopausal sx
→ Experts recommend duration of therapy of <5 years d/t ↑ risk of breast CA
→ Many experts consider it safe for healthy women within 10 years of menopause (younger than 60 years_ w/ no contraindications for estrogen
→ Women who have a uterus need both estrogen and progesterone d/t ↓ risk of endometrial CA
→ use unopposed estrogen for women w/ hysterectomy
Estrogen can alleviate dyspareunia and vaginal/urethral atrophy
Estrogen always ↑ risk of developing or exacerbating SLE (bitch control pills are contraindicated in women w/ lupus)

Answer 115

A

- 5th most common CA in women in UA
  - seldomly diagnosed in early stages; usually metastasized at diagnosis
  - for certain women w/ BRCA1 and BRCA 2 mutations
  - USPSTF does NOT recommend routine screening for ovarian CA in general pop. but high-risk women w/ suspected BRCA 1/2 mutations should be referred for genetic counseling and testing
  - Screening statrts at 30 years (or 5-120 years before earliest age of first diagnosis in family member)
Vague symptoms → frequently blamed on benign conditions)
- abdominal bloating
- abdominal discomfort
- low-back pain
- pelvic pain
* Symptoms of metastasis depends on area affected, including:
- bone pain
- abdominal pain
- headache
- blurred vision
- If ovarian CA screening → transvaginal US w/ serum cancer antigen (CA-125)
- some experts recommended risk-reducing bilateral salpingo-oophorectomy (BSO) between 35-40 years (after childbearing is complete) for certain women w/ BRCA/2 mutations

Answer 116

A

- caused by overgrowth of anaerobic bacteria in vagina
  - NOT an STD → partner does NOT need treatment
  - Tx is esp. important for pregnant women
  - Pregnant women w/ BV are at higher risk for premature labor or low birth-weight babies

RF:
- sexual activity
- new or multiple sex partners
- douching

- Sexually active female c/o:
  - unpleasant and fish-like vaginal odor; worse after intercourse (if no condom used)
  - discharge is copious, milk-like consistency
  - Speculum ex reveals off-white/light-gray discharge coating vaginal walls
  - no vulvar or vaginal redness or irritation (vaginal anaerobic bacteria do not cause inflammation)
Wet Smear Microscopy
- Findings: Clue cells, very few WBCs
- may see Mobiluncus bacteria (82%), gram- anaerobic rod-shaped bacteria
* Clue cells: made up of squamous epithelial cells w/ large amount of bacteria coating the surface that obliterates edges of squamous epithelial cells

Whiff Test
- apple one drop of KOJ to cotton swab, soaked w/ vaginal discharge
POSITIVE: a strong “fishy” odor is released

Vaginal pH
- Alkaline vaginal pH >4.5
- Normal vaginal pH is 4.0-4.5 (acidic)

- Metronidazole (Flagyul) BID x 7 days
  - Alternative: Metronidazole vaginal gel one applicator at bedtime for 5 days
  - Watch for disulfiram (Antabuse) effect if combined w/ alcohol (e.g., severe nausea, headache)
  - Prescribed clindamycin (Cleocin) cream at HS x 7 days (oil based)
  - Oil-based creams can weaken condoms
  - Sex partners: Tx NOT recommended by CDC because BV is not an STD
  - Abstain from sexual intercourse or use condoms until treatment is done (↑ cure rate by 50%)

Answer 117

A

- Overgrowth of Candida albicans yeast in vulva/vagina
  - Considered normal vaginal flora, can also be pathogenic
  - Diabetics, as well as those w/ HIV, on antibiotics (e.g., amoxicillin), or have an type of immunosuppression at higher risk
  - Male penis can be infected (balanitis)
  - Asymptomatic women & sex partners do NOT need treatment
- white cheese-like (“curd-like”) vaginal discharge
  - severe vulvovaginal pruritus, swelling, redness (inflammatory reaction)
  - may have external pruritus of vulva and vagina
- Wet smear microscopy
  - Swipe cotton swab w/ vaginal discharge in middle of a glass slide
  - Add a few drops of normal saline (to the discharge)
  - Cover sample w/ cover slip and examine it under microscope (set it a high power)
  - Findings: Pseudohyphae & spores w/ large number of WBCs are present
- Miconazole (Monistat); clotrimazole (Gyne-Lotrimin) x 7 days
  - Lactobacillus (oral or vagina) does NOT prevent postantibiotics vulvovaginitis

Prescriptions:
- Fluconazole (Diflucan) 150 mg tablet x 1 dose
- terconazole (Terazol-3) vaginal cream/supository

Severe sx or immunocompromised:
- Fluconazole (Diflucan) 150 mg in 2 sequential doses given 3 days apart
- Do NOT use oral fluconazole in pregnancy (teratogenic)

Answer 118

A

- unicellular protozoan parasite w/ flagella infecting GU tissues (both male/female)
  - causes inflammation (pruritis, burning, and irritation) of vagina/urethra
  - most common sites are: urethra (dysuria) and vagina
  - can also affect paraurethral glands, Bartholin glands, cervix, bladder, and prostate
- c/o of very pruritic, redden vulvovaginal area
  - may complain of dysuria
  - Copious grayish-green and bubbly vaginal discharge
  - Male partners may have dysuria, frequency (urethritis) or may be asymptomatic

Objective Findings:
- “Strawberry cervix” - small points of bleeding on cervical surface (punctate hemorrhages)
- Swollen and reddened vulvar and vaginal area; vaginal pH >5.0
- Dysuria (burning) w/ urination, copious foamy purulent vaginal discharge

- Microscopy (use low power): Mobile unicellular organisms w/ flagella (flagellates) and a large amount of WBCs; Trichomonads will remain motile for only 10-20 mins after collection
  - NAAT for T. vaginalis (vaginal samples better than first-voided urine)
- Metronidazole (Flagyl) 2 g PO x 1 dose or 500 mg BID x 7 days
  - Tinidazole 2 g PO x 1 dose
  - Treat sexual partner because trichomoniasis is STI; AVOID sex both partners complete treatment

Answer 119

A

- chronic lack of estrogen in estrogen-dependent tissue of urogenital tract
  - results in atrophic changes in vulva and vagina of menopausal women
  - estrogen is most effective treatment for mod-severe vaginal atrophy
  - low-dose topical estrogen therapy is preferred d/t low systemic absorption
- Menopausal female c/o vaginal dryness, itching, pain w/ sexual intercourse
  - dyspareunia
  - may have vulvar/vaginal bleeding (fissures) after intercourse
  - a great deal of discomfort w/ speculum exams (e.g., PAP tests); PAP usually “abnormal” 2º atrophic changes
  - worsens over time w/ age
  - >50% women do NOT report symptoms

Objective findings:
- Atrophic labia w/ ↓ rugae, vulva or vagina may have fissures
- dry, pale pink color to vagina

- Initial therapy: nonhormonal vaginal moisturizers and lubricants
  - Vaginal moisturizers (e.g., Replens) intended for use 2-3 days/wk routinely
  - Lubricants can be water-based (e.g., K-Y Jelly), silicone-based, or oil-based ( can break down latex condoms)

Mod-severe symptoms:
- Topical conjugated estrogen preferred
- comes in several forms → cream, tablet, capsule, or vaginal ring
- Progesterone supplementation is required (if intact uterus) if using long term to ↓ risk of endometrial hyperplasia

Tablet or capsule vaginal estradiol inserts:
- 4 mcg (Imvexxy)
- 10 mcg (Vagifem, Uvafem, Imvexxy)
- Insert into vagina daily for 2 weeks, then use weekly thereafter

Ring form of estradiol:
- Estring designed to release 7.5 mg of estradiol in vagina daily
- Effective for 90 days only then replace w/ new ring
- If pap shows atrophic smear → needs to be repeated in 3 months d/t atrophic smears are difficult to analyze and can be misinterpreted
- Estrogen can change vaginal cytology back to premenopausal state
- can be used for 2-3 months only, then repeat Pap or it can be used for longer periods for consistent relief of mod-severe vaginal sx

Answer 120

A

- previously known as lichen sclerosus et atrophicus
  - chronic inflammatory disorder of skin in vulva and labia seen in children, adolescents, and adults
  - can be asymptomatic or cause severe sx (e.g., pruritis or skin fissures that are painful)
  - Other lesions can be located in axillae, inframammary folds, antecubital fossae, waist, and other locations
- early skin lesions appear as flat-topped and slightly scaly hypopigmented, white, or mildly red polygonal papules; may coalesce to form larger plaques w/ peripheral erythema
  - Over time, when inflammation lessens, lesion resembles cigarette paper (wrinkled appearance)

Answer 121

A

- Pathogenesis is not clear; one theory is may be d/t retrograde menstruation where endometrial cells leave uterus and start growing on ovaries, pelvis, uterine ligaments, bowel, bladder, or thorax
  - lesions are stimulated by estrogen (just like endometrium where cells originate)
  - can result in infertility (25-35% infertile women have it)
- reproductive-aged woman b/t age 25-35 w/ hx of mod-severe pelvic pain during menses
  - heavy cramping
  - dyspareunia
  - dysmenorrhea may start approx. 1-2 days before menses, during menses or a few days after menses
  - ectopic endometrial tissue (endometriomas) can grown on pelvis, ovary, peritoneum, bladder, bowel, abdominal wall, or thorax

Objective Findings:
- nodules in posterior fornix
- adnexal masses
- pain w/ manipulation of pelvic organs
- pelvic exam may be normal
- large lesion smay show up in pelvic-intravaginal US

3.

→ Refer to gynecologist
- Estrogen/progesterone contraceptives (birth control pills, patch, or vaginal ring) or progestin-only therapy will suppress ovary and prevent ovulation and hormonal levels
- NSAIDs for dysmenorrhea pain
- Gonadotropin-releasing hormone (GnRH) analogues (e.g., leuprolide/Lupron Depot) and aromatase inhibitors for severe cases (anastrozole/Arimidex)

Answer 122

A

T score of > -2.5 SD

Answer 123

A

T score of -1.5 to -2.4 SD

Answer 124

A

squamous epithelial cells that have blurred edges d/t large # of bacteria on cell’s surface

Answer 125

A

underlying glucose metabolism disorders and diabetes

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Female Reproductive System Flashcards

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