General Gyn Flashcards
NIH diagnostic criteria for PCOS
Both required
- hyperandrogenism
- oligomenorrhea/amenorrhea
Rotterdam diagnostic criteria for PCOS
Must have 2 of 3
- Hyperandrogenism
- Oligomenorrhea/amenorrhea
- Polycystic ovaries
Androgen Excess Society diagnostic criteria for PCOS
Hyperandrogonism AND
Oligomenorrhea/amenorrhea OR polycystic ovaries
Lab tests for diagnosing PCOS
Total testosterone and sex-hormone binding globulin ( or bioavailable and free T) TSH Prolactin 17-OHP 2-hr GTT Fasting lipids
Definition of polystic ovaries
Definition of polystic ovaries
12 or more follicles measuring 2-9mm in diameter OR
Increased ovarian volume greater than 10cm3
(If there’s a follicle >10mm, repeat scan at presumed time of ovarian quiescence)
Metabolic syndrome
Elevated blood pressure (>130/85) Increased waist circumference (>35") Elevated fasting glucose levels (>100) Reduced HDL (<50) Elevated triglycerides (>150)
How does insulin resistance relate to hyperandrogenism?
Hyperinsulinemia –> decreased levels of sex hormone binding globulin –> more bioavailable androgens
Women with PCOS are also at risk for:
Metabolic syndrome Insulin resistance (--> T2DM) Nonalcoholic fatty liver disease Obesity related disorders like sleep apnea Cardiovascular disease Endometrial cancer Depression
Who should be screened for nonclassical congenital adrenal hyperplasia?
Adult women with anovulation and hirsutism
In women with PCOS who is not attempting to conceive, what is the best medical maintenance therapy to treat menstrual disorders?
Combined OCPs
Progestin (often accompanied by AUB)
Metformin (decreases circulating insulin)
In women with PCOS who are not attempting to conceive, what is the best medical maintenance therapy to reduce the risks of cardiovascular disease and DM?
Lifestyle modification
Metformin
Statins
Combined OCPs
In women with PCOS who are attempting to conceive, which methods of ovulation induction are effective?
Letrozole (aromatase inhibitor) Clomid Low-dose gonadotropins Ovarian drilling Metformin
Mechanism of action of spironolactone
Aldosterone antagonist
Also binds androgen receptor as antagonist
Flutamide mechanism of action
Androgen-receptor agonist
Finasteride mechanism of action
5-alpha-reductase inhibitor
Teratogen, need reliable contraception
Eflornithine mechanism of action
Inhibits ornithine decarboxylase
Topical
Improves outcome of laser
Can you use vaginal estrogen in patients with recent diagnosis of breast cancer or currently being treated for breast cancer?
Yes, but vaginal tablet or ring impregnated with estradiol would confer a lower systemic absorption than a cream.
Most effective form of emergency contraception
Copper IUD
Second is ulipristal acetate - SPRM
Antibodies in Graves disease
TSH receptor antibodies
can also test for increased radioactive iodine uptake
Mechanism of action of PTU/methimazole
Blocks organification of iodide –> decreases synthesis of thyroid hormon
(PTU also blocks peripheral conversion of T4 to T3)
Common supplement that can mask vitamin B deficiency
Folic acid supplementation (rule out vitamin B12 deficiency before starting supplements)
Definition of late latent syphilis
Asymptomatic, positive serologic test result greater than 12 months after infection
Treatment for primary, secondary, or early latent syphilis
Penicillin G 2.4 million units, IM x1
Treatment for late latent or tertiary syphilis or syphilis of unknown duration
Three doses of penicillin G 2.4 million units at one-week intervals
Tamoxifen mechanism of action
Selective estrogen receptor modulator
Blocks native estrogen effects on breast tissue
Stimulates estrogen receptors in endometrium
How does tamoxifen have a procoagulant effect?
Increases antithrombin III and protein C
not recommended in women with history of VTE
Who has an increased risk of endometrial neoplasia when taking tamoxifen?
Postmenopausal women
What is tamoxifen’s affect on bone?
Lower rates of osteoporosis due to antiosteoclast activity
Maybe premenopausal women have decreased bone mineral density, but no increase in fractures
Indications for laparoscopy in adolescents with pelvic pain
Chronic pain unresponsive to OCPs and NSAIDs Diagnostic dilemma (PID vs appy) Identified pelvic mass Painful irregular vaginal bleeding Progressive dysmenorrhea
Is well-controlled hypertension a contraindication to estrogen containing methods of contraception?
Yes, use progesterone-only
Number needed to treat (NNT)
100 / (exposure with desired outcome) - (no exposure with desired outcome)
Absolute risk reduction
An quantity by which some outcome is reduced
Not a ratio
(exposure with desired outcome) - (no exposure with desired outcome)
Relative risk reduction
Absolute risk reduction / baseline rate of event in question
Relative risk
100 - relative risk reduction
Which lower genital tract anomalies should be transected in the OR?
Imperforate hymen (semiperforate hymen, septums can be done in the office)
Which lifestyle modification decreases blood pressure the most?
Weight loss
In order to be considered eligible for Medicaid EHR program, the proportion of the OBGYN’s private practice patient volume covered by Medicaid must be:
30%
Does Depo decrease bone mineral density?
Yes 5% after 5 years of use
But this is recoverable after Depo is discontinued
What is the single dose regimen treatment for bacterial vaginosis?
Secnidazole 2g PO x1 (oral granules)
First line treatment for cyclic nonfocal mastalgia
Supportive bra and NSAIDs
Danazol
Androgen that suppresses pituitary gonadotropin release
Only FDA approved drug for cyclic mastalgia
(but not first line due to side effects - weight gain, menstrual irregularity, hot flashes, voice deepening, acne, hirsutism)
Postembolization syndrome
30-40% of embolizations, results from tissue ischemia and necrosis leading to an inflammatory reaction
Pain, nausea, fever, elevated WBC
Peaks 1-2 days after procedure and resolves within 8 days
Fractional excretion of sodium < 1
Prerenal etiology of oliguria (decreased renal perfusion)
Ovarian mass with elevated LDH and b-hCG
Dysgerminoma
What should patients do with their basal (long-acting) insulin preoperatively
Decrease dose the night before to prevent hypoglycemia while NPO
Helpful to prevent pregnancy loss in women with recurrent (>3 consecutive) pregnancy loss
Progesterone supplements
Treatment for fibroids in a smoker that wants to delay surgery
Leuprolide acetate
Age when varicella is given
First dose 12-15 months
Second dose 4-6 years
7 and older who do not have evidence of immunity
Treatment for exposure to varicella, still asymptomatic
Vaccination
First line for GERD treatment
PPI
When should DEXA scan be performed
Age 65
Or if FRAX 10yr fracture risk is 9.3% or greater
Treatment of osteoporosis should be initiated when:
T-score of -2.5 or less
FRAX score with 10yr risk of 3% or greater for hip fracture
FRAX score with 10yr risk of 20% or greater for major osteoporotic fracture
Used for the prevention of osteoporotic fractures AND reduction of breast cancer risk
Raloxifene
Omnibus Final Rule
Addresses provisions of HITECH act
Attempt to standardize EHR capabilities across platforms and provide funding for “meaningful use” of EHR
Primary risk of tamoxifen and raloxifene
Thromboembolic events
Why is raloxifene better than tamoxifen for menopausal patients
Tamoxifen has increased risk of VTE, endometrial neoplasia, and cataracts
She had positive blood cultures in the hospital, but she’s on oral antibiotics and feeling much better now, would you repeat the blood cultures?
No
Do you biopsy a thick endometrium in an asymptomatic postmenopausal woman?
No
The first step in creating an office safety program is to
Designate a medical director for safety
Pap screening for HIV+ women
Initiate a year after starting sexual activity, if normal then yearly cytology
Most effective emergency contraception
Copper IUD
then ulipristal - antiprogestin, then oral levonorgestrel
After obturator sling, patient can’t rotate hip outward
Obturator internus injury
Risks for surgical site infections
Abdominal»_space; laparoscopic»_space; vaginal
Length of procedure > 3 hours
Blood transfusion
Next test for “burning” or tender vulvar pain with swab test
Fungal culture
Next step after insufficient sample on EMB (for single episode PMB)
TVUS for endometrial stripe
Postprocedure contraceptive recommendation after hysteroscopic sterilization
Contraception for at least 3 months until HSG or targeted ultrasound confirms bilateral occlusion
Best treatment for vasomotor symptoms of menopause in women with a uterus
Combined estrogen and progesterone
Risk of copper IUD
Irregular bleeding
PID (and subsequent tubal damage) in patients with multiple sex partners
How long is ulipristal acetate effective as emergency contraception after intercourse
5 days
A hospital surgical proctor:
Receives institutional compensation for protctoring
Completes written evaluation of new faculty
Can recommend termination of a procedure if unsafe
Nonviable pregnancy of unknown location, but not enough information to warrant methotrexate?
Surgical evacuation of the uterus
Best treatment for c.diff in patients who are at high risk of recurrence (on concomitant antibiotic therapy, severe infection, advanced age)
Fidaxomicin
Safest mood stabilizer for breastfeeding
Valproic acid
Minimum evaluation for low back pain
Neuro exam
Primary amenorrhea, no breast development or pubic hair, next test?
FSH
Concern in older adults wiht ibuprofen
Renal injury
Medications with bone loss/fracture risk
DMPA
SSRIs
PPIs
Antiepileptics
Absolute contraindications to endometrial ablation
Pregnancy
Known endometrial cancer
Active pelvic infection
Desire to maintain fertility
Relative contraindications to endometrial ablation
Congenital uterine anomalies
Enlarged uterine cavity
Conditions that create myometrial thinning (previous uterine surgery, myomectomy, cesareans)
Conditions that may increase the risk of future endometrial cancer or hyporplasia
Reasons to perform BSO during benign hysterectomy
Decreases risk of ovarian cancer
Decreases risk of reoperation (moreso than cancer)
Vaginismus
Involuntary contraction of the pelvic floor, inhibiting entry into the vagina
Hysterectomy for CIN, how often and how long to do vaginal cytology?
Every three years until 20 years post-hyst
Osteoporosis treatment for women in their 50s
Estrogen agonist/antagonist while in their 50s
Then switch to bisphosphonates in their 60s (decreases amount of time exposed to these drugs because of bad side effects)
Improves MI risk perioperatively in high risk patients
Beta blockers
Stop hysteroscopy if fluid deficit is greater than
1000mL
Treatment for DCIS
Lumpectomy
Mastectomy felt to be too aggressive despite lower recurrence rate
AIS treatment in patients who have completed childbearing
Hysterectomy
How often should lipid screening be performed
Every 5 years after 45
How often should diabetes screening be performed
Every three years after 45
Treatment for bone loss in adolescents with functional hypothalamic amenorrhea
Transdermal estradiol with cyclic oral progestin
Risk factors for vitamin D deficiency
Darker skin Vegetarian diet Obesity Bariatric surgery Limited sun exposure
Common method of confirming completion of medical management of miscarriage
Ultrasound 7-14 ays after misoprostol: absence of GS and endometrial thickness <30mm
Medication that has shown possible association with vulvodynia
OCPs
How to evaluate acute diverticulitis
CT
Most common (75%) of all cases of pediatric vulvovaginitis
Nonspecific vaginitis
Requirements of the American Institute of Ultrasound in Medicine (AIUM)I
If you’ve completed residency more than 3 years ago, in the last 36 months, must have attained:
- at least 30 AMA Physicians Recognition Award Category 1 Credits
- Supervised, interpreted, and reported at least 300 diagnostic obstetric US exams
65 yo with lifetime negative cervical cancer screening, cytology is negative but insufficient cells
Do HPV testing
Exemptions to Physician Payments Sunshine Act
CME Buffet meals Samples for patient use Educational materials for patient use Loan of medical devices <90 days Transfer of anything of value to a physician when physician is a patient Discounts Charity care Anything less than $10 unless aggregate amount exceeds $100
When should colon cancer screening begin in African Americans
45 years old
When should colonoscopies be discontinued
75 if normal in last 10 years
Pneumococcal vaccine recommendation for vaccine naive individuals 65 and older
PCV13 at 65, then PPSV23 6-12 months later
Pneumococcal vaccine recommendation for individuals who previously received PPSV23 at 65 years or older
PCV13 after one year from PPSV23
Pneumococcal vaccine recommendation in individuals who previously received PPSV23 before age 65 and who are now 65 or older
Wait at least a year and do PCV13 at 65, then PPSV23 6-12 months later
Pulmonary changes during Trendelenberg positioning
Airway resistance increases Chest wall compliance decreases Functional residual capacity decreases Functional vital capacity decreases Total lung volume decreases
First step i evaluation of nonpalpable contraceptive implant
Urine pregnancy test
Advantage of bazedoxifene in patients taking estrogen
Prevents bone loss and protects endometrium
When should post-exposure prophylaxis for HIV be given in sexual assault victims?
In the first 72 hours
Postexposure prophylaxis for sexual assault
28 day course of three drug regimen (tenofovir, emtricitabine, and raltegravir)
Prophylaxis for recurrent UTI in postmenopausal women
Daily antibiotic
not enough evidence for estrogen yet
HPV vaccine before age 15
Two doses, 6-12 months apart
HPV after age 15
Three dose regimen, second dose 1-2 months after the first and the third given 6 months after the first
HPV vaccine not FDA approved for individuals over
26 years old
Vulvar itching that began with an inciting fungal infection or other event
Scaling and lichenified plaques
Erosions and ulcers
Hyper and hypo pigmentation
Biopsy shows thickened rete ridges, thickened granular layer, hyperkeratosis
Lichen simplex chronicus
Vaginal pruritis, irritation
Thinned, crinkly white skin
Figure of eight appearance
Biopsy shows markedly thinned epithelium and blunting of rete ridges, sometimes hyperkeratosis
Lichen sclerosus
Inflammatory of mucosa and genital tract
White reticulate lacy, fernlike
Adhesions of labia
Biopsy shows degeneration of basal layers, lymphocytic infiltrate of the dermis, epidermal acanthosis
Lichen planus
Elevated in granulosa cell tumors
Inhibin B
Yolk sac tumor presentation
Acute abdominal pain and a huge pelvic mass
Elevated in yolk sac tumor (endodermal sinus tumor)
AFP
Dysgerminoma presentation
Abdominal pain, fever, ascites
Elevated in dysgerminoma
LDH, hCG
Screening for prostate cancer in transgender females
Offer PSA screening after age 50 if they transitioned after 20
Class 1 recommendation for contraception in patients with SLE, APLS, etc
Copper IUD
What medication is most likely employed for adolescent obesity which is not responding to lifestyle changes?
Tetrahydrolipstatin
What are the most likely organisms implicated in genital pruritis and vaginal discharge
Respiratory organisms
How many milliliters does a super plus tampon hold
15-18
Medical treatments for acute menstrual bleeding in adolescents
Conjugated equine estrogen
Medroxyprogesterone acetate
Tranexamic acid
Combined oral contraceptives
Type of suture for Pomoroy
0-plain catgut
Poliglecaprone type of suture
Monofilament absorbable
Most common treatment/procedure for endometrioma
Excision/stripping
What drug should be avoided in patients receiving a full opioid agonist
Butorphanol
Androgen sensitive skin areas
Thighs Face Back Sternum (NOT AXILLARY)
Relative risk for what cancer is increased when taking OCPs
Cervical
Medication for chronic neuropathic pain
Gabapentin and pregabalin
Factor that has been associated with later menopause
High parity
Medication for osteoporosis that increases osteoblasts and stimulates bone formation
Recombinant PTH
What is most valuable in detecting a gas embolus intraoperatively
End tidal CO2
Mood stabilizer that is most likely to result in bone resorption
Lithium
Treatment of a flat dome shaped umbilicated lesion of the vulva
Intralesional interferon
Podofilox
Imiquimod
Curettage
Hormone that increases only in mid lutéal cycle
Inhibin A
HLA-DR4
Rheumatoid arthritis
Colposcopic finding most indicative of invasive cervical carcinoma
Atypical vessels
Most common presentation of erosive lichen plan is
Dyspareunia
Next step in management of 9yo with mass posterior to the areola
Observation
Goal LDL
Less than 100
Treatment for breast budding after giving estrogen for labial adhesions in a child
Bêta méthadone créma
What age does a woman gain maximum bone density
19
Most important treatment in panhypopituitarism
Cortisol
Chronic pelvic pain with history of DV, extra screening?
Depression
Antibiotic that decreases serum concentration of OCPs
Rifampin
Components in the treatment of thyroid storm
PTU
Iodine
Beta blocker
Dexamethasone
Extraintestinal manifestations of Crohns
VTE
Renal calculi
Osteoporosis
B12 deficiency
Androgens produced by the ovary
Testosterone
Androstenedione
DHT
DHEAS
Which phase of cell cycle does protein synthesis, RNA synthesis, and DNA repair occur
G1
VIN III with 0.9mm invasive carcinoma and clear margins?
Observation
E6
P53
E7
Rb
Bone formation markers
Osteocalcin
Bone specific alk phos
Procollqgen type 1
N terminal pro peptide
Other pathology you might find at time of surgery for endometriosis
Unicornuate uterus
Most likely side effect of paroxetine
Neuro
Urogénital sinus gives rise to
Urinary bladder
Hymen
Lower vagina
Paraurethral glands
Progestins derived from 19-nortestosterone
Levonorgestrel
Norethindrone
Norgestimate
Desogesterol
Risk factors for HIT
Heparin >4days
UFH
Female
Surgery
Most frequently encountered problems associated with TPN
Catheter tip infections
Most common sex hormone aneuploidy
Klinefelters XXY
Mechanism of action of heparin
Inactivation of thrombin
