First Aid for the USMLE Step 2 CK: Gynecology Flashcards
What order do thelarche, menarche, pubarche, and growth acceleration take place in female puberty?
1) Growth development
2) Thelarche
3) Pubarche
4) Menarche
The __________ triggers ovulation and stimulates the production of progesterone.
LH surge
The follicular phase comes ___________ the luteal phase.
before
The follicular phase is also called the __________ phase.
secretory
Which peaks first, estrogen of LH?
Estrogen (because of the FSH rise beforehand)
The corpus luteum can survive about __________ days without further LH or hCG.
10 - 14 days (the luteal phase, basically)
The change from _________ to ___________ causes the endometrial glands to become tortuous.
estrogen; progesterone
List the symptoms that characterize menopause.
- Hot flashes
- Vaginal atrophy (pruritus, vaginal dryness)
- Insomnia
- Anxiety/irritability
- Poor concentration
- Mood changes
- Dyspareunia
- Loss of libido
In menopause, the __________ levels rise before the _________.
FSH; LH
How does the lipid profile change during menopause?
The HDL goes down and the total cholesterol goes up.
What are some contraindications to HRT?
- Breast cancer
- Endometrial cancer
- Thromboembolism
- Liver disease
- Triglyceridemia
What drugs are used to treat vasomotor symptoms of menopause?
- Clonidine
- Gabapentin
- SNRIs
- SSRIs
Combined HRT protects against ______________.
ovarian and endometrial cancer
Primary is defined by two possible scenarios: ______________.
- Absence of menarche and secondary sexual features by age 14
- Absence of menarche by age 16 with secondary sexual features
List four causes of primary amenorrhea without secondary sexual characteristics.
- Kallman syndrome
- Hypogonadism
- Primary ovarian insufficiency (such as Turner’s)
- Constitutional growth delay
Implanon contains what?
Progestin only
What are four advantages to Implanon?
- Effective for 3 years
- Immediate fertility once removed
- Safe with breastfeeding
- Lighter periods
What is the rate of perforation in IUDs?
About 1/1,000
Hormonal IUDs are effective for ________ years, while copper IUDs are effective for ________.
5; 10
What are two disadvantages of Depo (IM medroxyprogesterone)?
- Irreversible infertility for up to ten months after discontinuation
- Weight gain
How do you use the NuvaRing?
Three weeks continuously followed by one week without
One of the major downsides of progestin-only birth control is _______________.
that you need to strictly take it every day at the same time
What are some contraindications to estrogen-containing pills?
- Undiagnosed vaginal bleeding
- Estrogen dependent cancer
- Liver failure
- Breast cancer
- History of clots
- Tobacco use in someone older than 35
List some contraindications for IUDs.
- Active pelvic infection
- Structural abnormality
- Gynecologic malignancy
- Reaction to copper
What is in the morning-after pill?
Estrogen and progestin
In addition to pills, ___________ can also be used as emergency contraception (up to 7 days post coitus).
copper IUDs
The first step of working up amenorrhea is ______________.
a pregnancy test (even in primary amenorrhea)
A woman has secondary sexual characteristics, primary amenorrhea, and no pubic hair. Diagnosis?
CAIS
List two structural and two hormonal causes of primary amenorrhea in a woman with secondary sexual characteristics.
Structural:
•Imperforate hymen
•Müllerian agenesis
Hormonal:
•CAIS
• CAH
Give a differential for secondary amenorrhea.
It’s good to think of systems-based ways, so here is a top-to-bottom outline:
•Hypothalamus: neoplasms or functional disorders (like anorexia or stress)
• Pituitary: neoplasm
•Thyroid: hypothyroidism
•Uterine: pregnancy, Asherman syndrome, cervical stenosis
•Ovarian: premature ovarian insufficiency, PCOS
Those with PCOS have ___________ progesterone.
low
The high levels of estrogen from fat inhibit the release of FSH and ovulation does not occur. Thus, progesterone remains low.
What two conditions present with absent uterus?
- CAIS (46, XY)
* Müllerian agenesis (46, XX)
What do a positive and negative progestin challenge indicate?
- Positive (patient bleeds with progesterone withdrawal): PCOS or idiopathic anovulation
- Negative (patient doesn’t bleed): premature ovarian failure or uterine abnormality
What features suggest primary dysmenorrhea?
- Pain during the first three days of menstruation
- Back pain
- Absence of pathologic features on exam, lab workup, and history that would suggest other diagnosis (because primary dysmenorrhea is a diagnosis of exclusion)
True diagnosis of endometriosis and adenomyosis requires _______________.
laparoscopy to see lesions (in the case of endometriosis) and pathologic biopsy of the myometrium (in the case of adenomyosis); because this is costly and invasive, these diagnoses are usually made clinically
Although TAH is curative of endometriosis and adenomyosis, women who still want children can opt for _______________.
hysteroscopy with ablation of known lesions
Menorrhagia is ______________.
increased amount of blood
Metrorrhagia is ______________.
bleeding between periods
What things should you do to evaluate AUB?
- ß-hCG to evaluate for pregnancy
- CBC to assess anemia
- PT/PTT and bleeding time to detect coagulopathy
- Chlamydia and gonorrhea swab to test for cervicitis
- TSH to test for hyperthyroidism
- US to detect endometrial stripe thickness and uterine/ovarian masses
- Pap test
What should you do in acute heavy uterine bleeding?
- High dose estrogen or progestin can stabilize the endometrium
- If hormones fail, D&C can be done
___________ can be given during menses to stop heavy bleeding.
Tranexamic acid
____________ can help treat ovulatory and non-ovulatory bleeding.
Progestin IUDs and OCPs
Describe the classic form of congenital adrenal hyperplasia.
Defective 21-alpha hydroxylase leads to lack of glucocorticoids and aldosterone with excess androgens. Presents with hypotension and virilization.
The nonclassic form presents with normal blood pressure and later virilization.
What is cosyntropin?
Synthetic ACTH
You can give it to assess adrenal insufficiency. If the levels of cortisol fail to rise after administration of cosyntropin, then adrenal insufficiency is likely.
Explain the Rotterdam criteria for PCOS diagnosis.
Must have at least two of the following:
•Oligo/anovulation
•Clinical or biochemical evidence of hyperandrogenism
• Polycystic ovaries
Important: metabolic syndrome and obesity are common comorbidities, but are not necessary for diagnosis.
What other diseases do you need to rule out in diagnosing PCOS?
- Adrenal tumor (secreting DHEA)
- Cushing syndrome
- Nonclassic CAH
- Androgen-secreting ovarian tumors
A woman has fever and a positive chandelier sign. What should you do to further evaluate?
- Swab to test for C. trachomatous and N. gonorrhoeae (to narrow treatment)
- Ultrasound to rule out tubo-ovarian abscess
Although not necessary to diagnose PCOS, what other labs can be done to further the work up?
- LH/FSH ratio greater than 2
- TVU showing the “pearl necklace” sign in the ovary
- Metabolic testing (i.e., glucose challenge, lipids)
How should PCOS be treated?
- Clomiphene and metformin can induce ovulation (in women seeking to conceive)
- OCPs, progestin, and metformin can normalize ovulation
- Diet, weight loss, and exercise can treat obesity and metabolic syndrome
- Spironolactone can treat hirsutism
What are the complications of PCOS (things you should be screening for!)?
- Breast and endometrial cancer (due to unopposed estrogen)
- Diabetes
- Miscarriages
Women who’ve had myomectomy should never have _____________.
a subsequent vaginal delivery (must be caesarian section)
The two broad categories of clinical infertility are _______________.
primary infertility (in which the woman has never been pregnant) and secondary infertility (in which the woman has had a prior pregnancy)
What percent of infertility cases are due to problems in the woman?
58%
Bartholin cysts can cause what symptom?
Dyspareunia
Bacterial vaginosis is caused by _____________.
Gardnerella vaginalis
Thick white secretions that adhere to the vaginal wall are normal in what two physiologic states?
- Pregnancy
* Luteal phase
How are the ulcers from HSV different from those in H. ducreyi?
- HSV: shallow, painful, multiple
* H. ducreyi: deep, painful, single
What organisms cause PID (by incidence)?
- N. gonorrhoeae (1/3)
- C. trochomatis (1/3)
- Endogenous aerobes/anaerobes (1/3)
What is the chandelier sign?
CMT that makes the patient “jump for the chandelier”
Explain the mnemonic A ROPE for acute pelvic pain.
- Appendicitis
- Ruptured ovarian cyst
- Ovarian torsion
- PID
- Ectopic pregnancy
What are the diagnostic criteria for PID?
- Pelvic pain
* Uterine, cervical, or adnexal tenderness
What are two important components of treating toxic-shock syndrome?
- Antibiotics against S. aureus
* Rehydration
A woman presents with fever, vomiting, diarrhea, nonpurulent conjunctivitis, desquamating rash on the palms and soles, and a macular erythematous rash. What is the likley diagnosis?
Toxic shock syndrome (clindamycin and vancomycin)
Bacterial cultures typically show __________ in toxic shock syndrome.
nothing (because the syndrome is caused by a preformed toxin)
Although most fibroids are asymptomatic, they can present with the following symptoms: _________________.
- Dysmenorrhea
- Heavy periods
- Dyspareunia
- Firm, nontender, enlarged and irregular uterus
Myomas can be in three places: ______________.
subserosal, intramural, and submucosal
You’ve done a physical exam on a woman with suspected fibroids. What three tests/labs/images might you order next?
- TVU
- MRI (often just used in preparation for surgery)
- CBC (to assess for anemia)
How should you manage an asymptomatic fibroid patient?
Yearly pelvic exams and CBCs
List three medications that can treat the bleeding from fibroids.
- Medroxyprogesterone acetate (also Megace)
- Leuprolide
- Danazol
What are the two kinds of endometrial cancer?
- I: endometrioid
* II: serous, papillary, and squamous
True or false: both kinds of endometrial cancer are associated with estrogen exposure.
False
Only type I is.
Type II is associated with the p53 mutation.
Which endometrial cancer presents at an older age?
Type II
Go through the treatment options for endometrial cancer.
- Women who may want future children: high-dose progestins
- Women who don’t want future children: TAH BSO with radiation
- Women with advanced cancer: TAH BSO with radiation and chemotherapy
Cervical cancer has two tissue subtypes. List each and the type of HPV that is most common in each.
- Squamous (16)
* Adenocarcinoma (18)
What are the most common symptoms of cervical cancer?
Metrorrhagia and postcoital bleeding
How do LSIL and HSIL correlate with CIN?
- LSIL = CIN I
* HSIL = CIN II and III
For ASC-US and LSIL in women younger than 24, ACOG recommends ____________.
repeat cytology in one year
For HSIL and ASC-H, ACOG recommends ____________.
colposcopy
For ASC-US and LSIL in women older than 24, ACOG recommends ____________.
DNA testing
What should you do for AGC?
Colposcopy with endocervical sampling
If you do a colposcopy for HSIL or ASC-H and it is negative, then ___________.
do colposcopy and cytology every 6 months for two years or until negative
How should you treat CIN I on colposcopy?
Repeat cotesting at 12 and 24 months
How should you treat CIN II and III on colposcopy?
LEEP or cone excision
A common cause of death in cervical cancer is ______________.
uremia from blocked ureters
B in the staging of cervical cancer means ___________.
lateral growth
Lynch syndrome raises the risk of which gyn cancers?
Ovarian and endometrial
CA-125 is associated with which type of ovarian cancer?
Epithelial cell
Elevated CA-125 in a premenopausal woman can be caused by ___________________.
endometriosis
What pelvic masses produce AFP?
Choriocarcinoma and endodermal sinus
Granulosa cell tumors secrete ____________.
inhibin
Dysgerminoma produces _______________.
LDH
