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OB > General Gynecology > Flashcards

General Gynecology Flashcards

1
Q

Virchow’s Triad

A

Causes of DVT

  1. Hypercoagulable state
  2. Stasis or non-lamilar flow
  3. Irregular vessel wall (endothelial damage)
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2
Q

Risk factors for DVT?

A
  1. Age >40yo
  2. Surgery for malignancy
  3. Prolonged surgery >30 mins
  4. Obesity
  5. Delayed post-operative ambulation
  6. Medical Dz (DM, heart failure, COPD, prior DVT)
  7. Varicose veins
  8. Thrombophilias (50% of cases)
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3
Q

Mutations as etiology of DVT?

A
  1. MTHFR (Low risk of thrombosis)
  2. Leiden V (5% throm risk)
  3. Prothrombin G20210A (2-5% throm risk)
  4. Protein C (5-10% throm risk)
  5. Protein S (5% throm risk)
  6. Antitrhombin III (30-50% throm risk)
  7. Lupus anticoagulant (>5% risk)
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4
Q

Test for Anti-phospholipid Syndrome

A

(Acquired condition)

  1. Lupus anticoagulant
  2. Anti-Cardiolipin Ab
  3. Anti-b2-glycoprotein I
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5
Q

Work/up for DVT?

A
  1. Doppler u/s
    - Test of choice for major (fem/pop) veins
    - Sens/spec: 91/99%
    - Not sensitive for tibial v or at/below ankle
  2. Venography
    - Gold standard
    - invasive (use when other tests are equivocal)
  3. Impedance Plethysmography
    - highly sensitive but not specific
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6
Q

Clinical Features of PE

A
  1. dyspnea
  2. chest pain
  3. tachypnea
  4. hemoptysis
  5. tachycardia
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7
Q

Work-up for PE

A
  1. Spiral CT (sens/spec 94% for central PE)
  2. Arterial blood gas (PaO2 <90 mmHg)
  3. VQ scan- not very specific or sens
  4. ECG-nonspecific but recommended as adjunct (tachycardia & R-axis deviation)
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8
Q

Treatment of PE

A

Heparin with conversion to Warfarin

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9
Q

MOA of Heparin

A

Cofactor for Antithrombin II

Increases inhibition of thrombin and Factor Xa

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10
Q

Loading dose of Heparin for DVT vs PE?

A

DVT: 100u/kg (min 5000u)
PE: 150u/kg

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11
Q

Maintenance Dose of Heparin for DVT & PE?

A

15-25 u/kg/hr and convert to Warfarin once patient is stable (or sub Q heparin if patient is pregnant)

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12
Q

Prevention dose of Heparin?

A

5000 u BID (no effect on PTT)

5000 u every 8 hrs in pts with gyn cancers

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13
Q

Complications of Heparin

A
  1. Osteoporosis
  2. Alopecia
  3. Thrombocytopenia (long term tx)
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14
Q

Treatment protocol for DVT/PE with Heparin.

A
  1. 5000u bolus, then 1000-1200 u/hr x5d
  2. then sub Q 8000-10000 u BID
  3. establish PTT at 1.5-2.5 times normal
  4. Initiate Coumadin tx same day or after (not before)
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15
Q

Treatment protocol for DVT/PE with Lovenox.

A
  1. 1 mg/kg (generally 40-60 mg) BID or
  2. 1.5 mg/kg once daily
  3. Initiate Coumadin tx same day or after (not before)
  4. PT/PTT are normal w/ Lovenox
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16
Q

HIT- Which meds?

A

Can occur with Heparin or Lovenox

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17
Q

Repair of Bladder Injury

A
  1. Assess location of injury w/ respect to trigone
  2. Close in 3 layers if possible
    a. Non-locking continuous 3-0 vicryl through mucosa & submucosa
    b. Interrupted 3-0 vicryl to muscular layer
    c. Interrupted 2-0 vicryl to para-vesical fascia layer
  3. Instill sterile milk to assess integrity of closure
  4. Consider cystoscopy w/ or w/o indigo carmine
  5. Abx
  6. Indwelling catheter for 7 days
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18
Q

Repair of Ureteral Injury (End-to-End)

A

End-to-end anastamosis
-spatulate ends
-4-6 interrupted sutures of 4-0 chromic through full thickness of cut edge
-performed regardless of location provided no tension
-ureteric stents and bladder catheter in situ for 10 days
If end-to-end cannot be performed w/o tension consider other options

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19
Q

Ureteroneocystotomy

A

Implanting ureter into bladder

-typically if breach <5cm from bladder

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20
Q

If ureteral injury is >5cm from bladder what procedures can you try?

A

Psoas hitch
Boari flap
Ureteroureterotomy (implanting ureter into contralateral ureter)

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21
Q

Repair of Bowel Injury

A

Small bowel laceration parallel to long axis of bowel
(end-to-end closure), avoid narrowing of lumen
-mucosa/muscularis in single layer w/ interrupted vicryl 3-0
-muscularis/serosa w/ 3-0 non-absorbable suture

Small bowel laceration at right angles to long axis of bowel (side to side narrowing)

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22
Q

Bowel Prep

A

Option 1 Day -1: Golytely 1.5 L/hr till clear
Day -0:Cefoxitin 2gm iv 30 mins pre-op
Option 2 Day -1 Neomycin 1gm + Erythromycin 1gm at 2, 4, +10pm

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23
Q

Cherney

A

Excise rectus muscle off pubis, can damage inferior epigastric vessels- good exposure of lower abdomen

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24
Q

Maylard

A

Muscle cutting: must ligate inferior epigastric vessels behind lateral rectus sheath edge. Do not separate sheath off rectus muscle-good exposure of abdomen

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25
Q

Contraindication to Pfannenstiel Incision

A

Obesity

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26
Q

Considerations for closure of obese patient

A

Secure fascial closer (consider PDS or permanent suture)
Do not place prophylactic drain in sub Q tissue
Close subq tissue > 2 cm

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27
Q

Causes of Post-op Fever

A 
Winds      Bowel obstruction/ileus/Pneumonia
Water       Bladder
Wound     Ifx (ut, vag cuff, abdominal)
Walking    DVT
Wonder Drugs    Drug Allergies
Wonder Breasts  PP nursing patient
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28
Q

Work-up for post-op fever?

A

Exam: Pulse, BP, temp
Lungs
Abd Incision
Vag Incision
Extremities (evidence of DVT, thrombophlebitis)
Renal Angle Tenderness
Abdomen
Labs: CBC, Urine c&s, blood cx, CXR, Erect AXR, doppler u/s, u/s of pelvis (looking for hematoma which could be infected).
Consider drug fever
Consider thrombophlebitis (tx w/ heparin, dx and tx in cases of refractory fever of unknown cause)

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29
Q

Definition of Fever

A

> 100.4 x 2 (4 hr apart and excluding 1st 14 hrs b/c of cytokine release from tissue) or
101.5

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30
Q

Timing of Fever w/ respect to likely Dx:

A

1-3 d- Pneumonia/GI
3-7 d- DVT, Wound Infection, UTI, pneumonia, phlebitis
7+ d- Bladder/ureteric injury

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31
Q

Describe the Grades of Pelvic Organ Prolapse

A

1st Degree-down to ischial spines
2nd Degree- b/w spines & introitus
3rd Degree- Cervix below introitus
4th Degree- Uterus below introitus (procidentia)

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32
Q

Treatment of Prolapse

A 
Don't forget 
Kegel's pelvic floor exercises
Vaginal cones
Topical estrogen if atropic changes
Treat causes of chronic cough, constipation
Pessary
Surgery
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33
Q

How do you diagnose an enterocele?

A

Perform recto-vaginal exam, ask pt to Valsalva. Feel for a bulge of the cul de sac herniation *usually containing bowel) b/w fingers

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34
Q

Ypes of enterocele repair

A

Moskowitz

McCall

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35
Q

Moskowitz

A

Serial purse string sutures obliterating the cul de sac through an abdominal incision.
No dissection of the peritoneal pouch

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36
Q

McCall

A

Plication of uterosacral ligaments in the midline
Performed vaginally
No dissection of the peritoneal pouch

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37
Q

Five compartments of possible prolapse

A 
Uterine prolapse
Anterior vaginal wall (Cystocele)
Posterior vaginal wall (Rectocele)
Enterocele 
Vaginal outlet (Perineal body)
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38
Q

3 Main types of Urinary Incontinences

A
  1. SUI
  2. Urgency Urinary Incontinence (UUI), aka OAB
  3. Mixed
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39
Q

W/up of urinary incontinence?

A 
Hx
UA
demonstration of SUI w/ + cough test
assessment of urethral mobility 
measure PVR
(Review pg 85)
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40
Q

Non-surgical treatment of SUI & Urge Incontinence

A

Pelvic floor exercises w/wo physiotherapy
Weight Loss
Dietry/Fluid modification/bladder retraining
Devices (plugs, continence pessaries & weighted cones

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41
Q

Non-surgical tx of Urge UI

A

Beta-3 adrenoreceptor agonist (Mirabegron)
SE: tachycardia, HA, diarrhea
Contraindications: uncontrolled HTN, severe
renal/liver disease
Anti-muscarinic (Oxybutinin/Tolterodine)
Blocks parasympathetic M2/M3 R to (-) involuntary
detrusor ctx
SE: dry eyes, dry mouth, constipation, gastric
retention
Contraindications: narrow angle glaucoma
Onabotulinum toxin A (100u intravesical Q6m)

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42
Q

Non-surgical tx of Urge UI

A

Beta-3 adrenoreceptor agonist (Mirabegron)
SE: tachycardia, HA, diarrhea
Contraindications: uncontrolled HTN, severe
renal/liver disease
Anti-muscarinic (Oxybutinin/Tolterodine)
Blocks parasympathetic M2/M3 R to (-) involuntary
detrusor ctx
SE: dry eyes, dry mouth, constipation, gastric
retention
Contraindications: narrow angle glaucoma
Onabotulinum toxin A (100u intravesical Q6m)
comp to anti-musc, similar dec incont episodes but
more pts w/ complete relief of Urge UI
SE: UTI, urinary retention

Sacral neuromodulation for refractory urge UI

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43
Q

Treatment options for urolithiasis?

A

Antibiotics
Anti-emetics
Analgesics
Renal decompression w/ ureteric stent, per cutanesou nephrostomy, ureteroscopic stone removal, lithotripsy (contraindicated in pregnancy)

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44
Q

Complications of Newer Surgical Procedures for Incontinence (Mid-urethral slings, needle or suture suspensions)

A
  1. Surgical site bleeding
  2. Urinary retention or persistent SUI
  3. Placement of mesh in bladder
  4. Erosion of sling material or suture into bladder
  5. Space of Retzius hematoma
  6. Local anesthetic toxicity (TVT/TOT)
  7. Injury to ureter or bowel (uncommon)
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45
Q

Mesh graft erosion complication rate?

A

5-19%

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46
Q

Complications of Mesh Graft

A
  1. Chronic pelvic pain
  2. Fistula formation
  3. Graft infection
  4. Delayed graft erosion or exposure
  5. Vaginal discharge/odor
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47
Q

Management of Mesh erosion?

A
  1. Observe, pelvic rest 6-8 weeks, vaginal estrogen (20-30% effective)
  2. Office excision of mesh (40% effective)
  3. Excision in OR, dissect overlying epithelium, excise & remove mesh, close epith, cystoscopy r/o bladder erosion (90-95% effective)
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48
Q

Timing of repair of RV fistula?

A

Immediately at time of damage or wait 3-4 m for dec in inflam/infx

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49
Q

Preop prep for RV fistula repair?

A 
Estrogen cream (if postmenopausal)
Abx
Laxatives
bowel prep
Try to reverse/treat any underlying dz (eg. IBS)
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50
Q

Bowel prep

A

Golytely 1 liter/hr till clear effluent (max 4 hr or 4 L) beginning day prior to surgery

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51
Q

Considerations for RV fistula repairs?

A
  1. Excise fistulous tract
  2. Place as many layers as feasible b/w both cavities, do not overlap suture lines
  3. Determine location of fistula
  4. If close to introitus do 3rd degree tear repair
  5. Otherwise do simple fistulectomy: close in 3 separate layers (rectal submucosa, muscularis, and vaginal mucosa)
  6. Suture material : Tension bearing- 2-0 vicryl
    Non-tension bearing- 3-0 vicryl
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52
Q

How would you determine location or type of fistula?

A

IVP

dual tampon test

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53
Q

Vesico-Vaginal Fistula management?

A
  1. Foley catheter decompression of bladder for 4-6 w minimum.
  2. If no spontaneous resolution (by 12 weeks) do 3 layer closure technique:
    -Excise fistulous tract
    -Approximate bladder submucosa
    -Approximate bladder muscularis
    -Vaginal mucosal closure
    or
  3. Latzko Technique
    -partial colpocleisis to treat fistula
    -Denudement of vaginal wall around fistual w/o
    excising it
    -concern for vaginal shortening.
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54
Q

Uretero-vaginal fistula dx?

A

Cystoscopy & IVP to identify fistula site & exclude bladder injury.

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55
Q

Management of Uretero-vaginal fistula? Lower

A
  1. Ureteral catheter stenting (30-40% healing at 3-4 w)
  2. Failure of spont healing:
    • ureteroneocystotomy
    • IVP at 3,6, 12 m
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56
Q

Management of Uretero-vaginal fistula? Upper

A
  1. Percutaneous nephrostomy for renal decompression
  2. Ureteral re-implantation at 12 w post initial operation
  3. IVP at 3,6,12 m
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57
Q

HCG units

A

mIU/ml

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58
Q

Expected HCG titer rises

A

1.3-2 times every 48 hrs until approx 6 weeks then rate slows to doubling every 72 hrs.

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59
Q

Discriminatory zones for hcg?

A

1500 mIU/ml for vag probe

6000 mIU/ml for abd probe

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60
Q

MOC of MTX

A

Folate antagonist (inhibits DHFR which converts DHF to THF)

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61
Q

Absolute Indications for MTX treatment?

A 
Hemodynamically stable 
Compliant
Desirous of fertility
Non-laparoscopic dx
No contraindications to MTX
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62
Q

Relative indications (opposite of relative contraindications) for MTX tx.

A
  1. no fetal cardiac motion
  2. size <3.5cm
  3. hcg <5000
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63
Q

Absolute contraindications of MTX tx.

A 
Liver DZ
Active pulmonary disease
Peptic ulcer disease
Blood dyscrasia
Sensitivity to MTX
Immunosuppression
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64
Q

Dosage Regimens & follow-up?

A
  1. Single dose: 50 mg/m2 BSA
  2. Multiple dose: 1mg/kg on days 1,3,5 (and 7)-recommended for cornual/cervical pregnancies when managed medically

Bhcg should drop 15% on days 3 and 7 after treatment.

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65
Q

Side effects of MTX?

A
  1. Stomatitis
  2. Leukopenia
  3. Thrombocytopenia
  4. Elevated liver enzymes
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66
Q

Risk factors for request of tubal ligation

A
  1. Age=30
  2. Parity=2
  3. Recent decision to have tubal ligation (short time to 4. decide <6 m)
  4. Unstable marriage or unmarried
  5. Children not healthy
  6. Post-partum tubal
  7. Post-partum (neonate w/ poor apgar, premature/IUGR/diseased)
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67
Q

CREST study Failure rates at 5 years/1000 pregnancies

A 
Non PPTL- 13
PPTL-6
Copper  IUD-5
Progesterone IUD-5
Bipolar Cautery-15
Bands-10
Clips-30

Rates of ectopic higher w/ younger women
<30 27
>30 7.5

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68
Q

Risks if patient gets pregnant w/ IUD in situ

A

3x increased risk of SAB

Increased risk of septic abortion and PTL

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69
Q

Disadvantages of Robotic Surgery

A
  1. Longer operative times
  2. More surgical incisions
  3. Potential tendency to attempt laparoscopic procedures beyond one’s general skill level
  4. Extensive learning curve
  5. Increased medical cost of surgical procedures
  6. Lack of RCT to show superiority of robotic approach
  7. Possible inc risk of vaginal cuff dehiscence
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70
Q

Advantages of Robotic Surgery

A
  1. 3-D vision
  2. Use of articulated instruments -more accuracy
  3. Safer application of thermal energy devices
  4. Improved fine motor control
  5. Potential for dec in operative time and operative blood loss
  6. Permit MIS approach in more complex cases when experienced surgical assist is not available.
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71
Q 
Is Abx coverage necessary and what type for:
Hysterectomy
Laparoscopy
Laparotomy
HSG
Hysteroscopy
Induced AB &amp; D&amp;C
A

Hysterectomy- Cefazolin 1-2 g IV
Laparoscopy- No
Laparotomy- No
HSG- only w/ h/o pelvic infx- Doxy 100mg bid x 5d
Hysteroscopy- No
Induced AB & D&C- Doxy 100mg pre, 200mg post-procedure

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72
Q

PCN Allergy Classes and substitutions.

A
  1. Immediate-Anaphylaxis (IGE mediated)-may not substitute w/ cephalosporin (Flagyl, Doxy, Clinda)
  2. Delayed hypersensitivity-urticarial (cell mediated)- Cephalosporin acceptable
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73
Q

Difference between Ileus and Obstruction

A

Ileus- Pain- Distention
Post op timing 48-72 hrs
Bowel Sounds- Nil
AXR- Peripheral gas (in colon), Air in rectum
Treatment- NG tube, NPO, IV support, +
cholinergics support
SBO-Pain- Crampy
Post op timing 5-7 days
Bowel Sounds- High pitched
AXR- Central gas (in sml intest) + air fluid levels,
no air in rectum
Treatment- NG tube, NPO, IV support, +
surgery

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74
Q

Basic steps in performing an appendectomy?

A
  1. Dissect meso-appendix & ligate appendix vessels
  2. Clamp & cut base of appendix
  3. Place purse string suture around base
  4. Invert (embed) stump prior to closing purse string
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75
Q

Potential benefits of appendectomy?

A
  1. Potential to prevent a future emergency appendectomy
  2. Potential to exclude a future diagnosis of appendicitis in patients with chronic pelvic or bowel conditions
  3. When chemo/rad tx anticipated
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76
Q

Opinion on best time to gain most benefit of incidental appendectomy

A

Greatest potential <35 yo
Possible benefit at 35-50
Not recommended >50 yo

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77
Q

McBurney’s Point

A

Line from navel to ASIS, point is 2/3 down the line, point of max tenderness w/ appendicitis

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78
Q

Homan’s Sign

A

Tenderness in popliteal area when foot is actively dorsi-flexed suggesting possible thrombosis, only correct 50% of the times.

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79
Q

Alternative tx to hysterectomy:

A 
OCP's
NSAIDS
GnRH Agonist (pre-op)
Progesterone Modulators (eg. Mefipristone)
Aromatase Inhibitors
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80
Q

Repeat surgery for recurrence rate for:

  1. Single tumor
  2. Multiple tumors
A
  1. Single tumors 10%

2. Multiple tumors 25%

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81
Q

Surgical tx options for fibroids

A 
Myomectomy
        Open
        Laparoscopic Myomectomy
        Hysteroscopic Myomectomy
Uterine Artery Embolization 
Endometrial Ablation
MRI-Guided US surgery (uses US energy to denature protein w/in myoma bulk-> necrosis
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82
Q

Preoperative adjuvant tx for fibroids

A

GnRH agonist therapy

GNRH antagonist tx

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83
Q

Complications of UAE (5-8%)

A
  1. Symptomatic degeneration/pain in target lesion
  2. Myometrial infarction/necrosis
  3. Myometritis (bacterial seeding from procedure)
  4. Bacteremia from arteriotomy
  5. Uterine perforation/intraperitoneal injury
  6. Uterine artery perforation/hemorrhage
  7. Loss of ovarian function in 5-14% of cases
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84
Q

Contraindications to UAE for fibroids

A
  1. Women desiring future fertility

2. Postmenopausal women

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85
Q

Management of Gonorrhea

A

Ceftriaxone (Rocephin) 250 mg IM + Azithromycin 1gm

Treat partner w/ cefixime 400mg PO + Azithro 1gm PO

No need for TOC even if pregnant,
Reinfection- retest in 3 months

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86
Q

Subtypes of Gestational Trophoblastic Disease

A
  1. Hydatiform mole (complete and partial)
  2. Invasive mole (GTN)
  3. Choriocarcinoma (GTN)
  4. Placental site trophoblastic tumor (PSTT) (GTN)
  5. Epitheliod Trophoblastic tumor (ETT-subset of PSTT)
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87
Q

Differences between partial and complete mole?

A 
Partial Mole:
Karyotype: 69XXX or 69 XXY
Fetus: Present
Uterine size: SGA
Theca Lutein cysts: Rare
Complete Mole:
Karyotype: 46 XX or 46 XY
Fetus: Absent
Uterine size: LGA
Theca Lutein cysts: Common
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88
Q

Potential problems associated with Moles?

A
  1. Anemia
  2. Infx
  3. hyperthyroidism
  4. coagulopathy
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89
Q

Treatment of choice for molar pregnancy, follow-up?

A

Suction Curettage

Early US for future pregnancies (up to 10 fold increased risk for another mole)

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90
Q

Gestational Trophoblastic Neoplasia

A

Invasive mole
Choriocarcinoma
Placental site trophoblastic tumor

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91
Q

Most common causes of cancer death in US women

A 
Lung
Breast
Colon
Leukemia/Lymphoma
Ovary
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92
Q

Most common cause of cancer death in the world?

A

Lung

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93
Q

Most common cause of GYN cancer death in the world?

A

Breast

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94
Q

Most common cause of GYN pevlic cancer in the world?

A

cervix

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95
Q

Most common cause of GYN cancer in the USA?

A

uterine

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96
Q

Most common cause of GYN cancer death in the USA?

A

ovary

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97
Q

Most common cause of GYN pelvic tumor?

A

fibroids

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98
Q

Histopathology of Hydatiform mole.

A

Multiple islands with pale core & dark thin rim (normal villi Plus tissue proliferation of surrounding rim)

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99
Q

In which tumors would you find Schiller Duvall Bodies

A

Embryonal Carcinoma

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100
Q

Coffee Bean Nuclei

A

Granulosa Cell Tumor, Brenner Tumor

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101
Q

Call Exner Bodies

A

Granulosa Cell Tumor “Call Girl”

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102
Q

Psammoma Bodies

A

LMP tumors

Serous Tumors “body builders are serious)

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103
Q

LMP tumor

A

cellular proliferation w/ nuclear atypia

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104
Q

Describe pain

A 
Precipitating
Quality
Radiation
Severity
Timing
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105
Q

Most common Diff Dx for chronic pelvic pain

A

Endometriosis
Adhesions
IBS
IC

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106
Q

Classic triad of Interstitial Cystitis?

A

Urgency
Frequency
Pain
(in absence of objective evidence of another disease)

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107
Q

Dx of Interstitial Cystitis?

A
  1. Clinically based on Hx, PE and r/o other etioloties
  2. Potassium sensitivity test no longer done (painful & poor predictive value)
  3. Interstitial Cystitis Symptom Index-valid questionnaire
  4. Cystoscopy w/ hydrodistension-glomerulations (petechiae) or Hunner ulcer w/ bladder distention 80-100cm water pressure under anesthesia & decreased bladder capacity (<350ml) w/o anesthesia (not required)
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108
Q

Tx of Interstitial Cystitis?

A
  1. Dietary modifications
  2. Pentosan polysulfate (Elmiron)
  3. Intravesical instillations w/ various combinations of agents (DMSO, heparin, steroids, lidocaine, Marcaine, TCA, antihistamines)
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109
Q

Treatment of Vulvodynia?

A
  1. Vulvar care, local anesthetics, estrogen cream, topical TCA, trigger point injection (steroid & bupivicaine)
  2. Oral TCA’s or anticonvulsants
  3. Biofeedback, pelvic PT
  4. Vestibulectomy for refractory cases
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110
Q

Theories for etiology of endometriosis

A
  1. Retrograde menstruation
  2. Hematological spread
  3. Lymphatic spread
  4. Coelomic metaplasia-can be seen in premenarchal girls
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111
Q

Options for conservative treatment of endometriosis

A
  1. OCP
  2. Depo Medrosyprogesterone Acetate (Provera)
  3. Depo Leuprolide Acetate (Lupron)
  4. Danazol (17alpha-ethinyl testosterone)
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112
Q

SE of Depo Lupron

A

menopausal sx
osteoporosis if long term
Not 1st line tx in pts <16 yo

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113
Q

SE of Danazol

A

Androgenization in higher doses

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114
Q

If fertility is desired and disease is advanced which type of tx would be better for endometriosis?

A

Surgical

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115
Q

First annual gyn exam?

A

13-15 yo, focus on education and hx. No pelvic exam indicated until 21 yo.

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116
Q

Annual exam counseling

A

Exercise
Diet (dec Caffeine, cholesterol, calories)
(inc Calcium 700-1300mg/day, vitamins, high fiber,
folate) (>65 yo 1300 mg /d Ca++, >17 yo 1200mg/d)
STD, contraception, HRT, driving habits/seat belt use, smoking/ETOH/drugs

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117
Q

ETOH screen

A

Tolerance:(how many drinks does it take to get a high)
Annoyed:(has anyone annoyed you by questioning your drinking)
Cut down:(Has anyone told you to cut down on your drinking)
Eye opener:(Do you ever have a drink shortly after waking up)

preferable to CAGE which does not address tolerance

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118
Q

The 5 A’s of smoking cessation

A

Ask (about presence & degree of smoking)
Advise (to stop)
Assess (willingness to stop smoking)
Assist (w/ counseling, support grps, materials)
Arrange (follow-up)

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119
Q

Health effects of smoking in women

A 
lung ca
bladder
renal ca
gynecologic ca
CHD
VTE
osteoporosis
COPD
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120
Q

Health effects of smoking in pregnancy

A 
IUGR
PPROM
LBW
previa
abruption
decreased maternal thyroid function
ectopic pregnancy
increased perinatal mortality 
increased spAB and recurrent AB
(Asthma, reactive airway dz, SIDS)
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121
Q

Recommended amount of Vit D

A

600 IU/day for ages 1-70 and pregnancy; 800 IU if >70 yo

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122
Q

Pap smear Screening Recommendations

A
  • Begin age 21, every 3 years
  • Age 30-65- Pap w/ HPV testing every 5 yrs or pap alone every 3 years
  • In 2016: women 25 and up consider primary HPV screening as alternative to cytology based screening but cytology or co-testing still preferred
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123
Q

When should you stop pap smear screening?

A
  1. 65 and over
  2. Total hysterectomy for benign indications
  3. H/o hyster for CIN 2/3 or w/ h/o CIN2/3- continue pap smear alone every 3 years until 20 yrs after initial post treatment surveillance
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124
Q

Difference in sen/spec b/w conventional pap and thin prep

A

No apprciable difference in sen/spec for detection of CIN in Meta-anaylsis.

Advantages of thin prep-easier collection, improved sample adequacy, ability to do additional testing

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125
Q

NPV of combined HPV + cytology for CINII & III

A

99%

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126
Q

Sensitivity of Pap smear

A

50%

127
Q

Difference b/w LSIL & CIN2

A

LSIL-consistent w/ CIN1, not considered a precursor to cancer except in older women over extended time

CIN2-can be precursor to CIN3, therefore grouped w/ CIN3 as precursor to cancer, threshold for treatment if >24 yo

128
Q

Indication for ECC?

A
  1. if colposcopy is unsatisfactory
  2. If contemplating ablative tx (results in 10% inc in dx of CIN2,3+)
  3. if pap shows ASC-H, HSIL, AGC or AIS

contraindicated in pregnancy

129
Q

On average how long does it take for CIN 3 to progress to invasive cancer.

A

3-7 years

130
Q

Regression rate of CIN1? CIN2?

A

CIN1-60%, CIN2-40%

131
Q

Why should all cytology results be assessed?

A

Sensitivity can be low (30% w/ conventional methods)

Reproducibility of results not good (only 40-70%)

132
Q

F/up for ASC-US cytology & neg HPV?

A

cotesting in 3 years

133
Q

F/up for women 30 and, cytology neg, HPV +?

A
  1. Repeat cotest 12 mos, if pap ASCUS or higher or HPV +, colpo, if both normal cotest in 3 years
  2. Immediate HPV 16, 18, if pos-> colpo, if HPV neg cotest 12 m
134
Q

Pap-ASCUS >25 yo

A 
1. Traige testing w/ HPV preferred
   high risk HPV +--> colpo
   Negative-->routine age based testing
2. If no HPV testing done: repeat pap in 12 m
    If ASC-> colpo
135
Q

ASCUS Pap 21-25 yo

A

Pap Q 12 m
HPV and colpo NOT done routinely, only if Pap =HSIL or >, at subsequent paps even ASC gets a colpo

HPV is common due to repeat infections (not persistent infx which is a cancer risk)

136
Q

Pap-ASC-H, 25 & >

A

consider similar to HSIL, risk of CIN2,3 is 50%

COLPOSCOPY, NO HPV TESTING

137
Q

LSIL <25 yo

A

repeat pap in 12 m,

- ->    < HSIL repeat in 12 m
     - ->     If ASC or > colpo
138
Q

When should you start colon ca screening?

A
  1. Start at age 50 or 45 if African American

2. Start 10 yrs before age family member was dx w/ cancer if family hx.

139
Q

F/up after first colonoscopy?

A
  1. Every 10 years if normal.
  2. colonic polyp, benign 3-5 years
  3. Polyp w/ atypia, every 3 years
140
Q

F/up if family h/o colon cancer

A

One 1st degree relative, Q 5 years

2 or more 1st degree relatives, Q 3 years

141
Q

Breast Cancer Screening

A

Beginning at 40

142
Q

Lung Cancer

A

Low dose chest CT annually
Adults 55-80 w/ smoking hx (30 pk year hx & current smoker or quit <15 yrs ago, stop screening once pt >15 yrs quit smoking)

143
Q

Glucose/FBS:

A

annually if high risk, every 3 years beginning at age 45

144
Q

Lipid profile

A

5 yearly beginning age 45

145
Q

TSH

A

5 yearly beginning at age 50

146
Q

DEXA

A

beginning at age 65 or sooner w/ risk factors, repeat no sooner than 2 years

147
Q

UA

A

yearly after age 65

148
Q

HIV

A

consider testing annually for ages 13-64 if high risk (>1%), otherwise routinely x1, use clinical judgement

149
Q

Incidence of BRCA I & II

A

1:300-800

150
Q

Inheritance patter for BRCA

A

Autosomal dominant inheritance w/ high penetration

151
Q

What % of all ovarian cancers are associated w/ BRCA?

A

10%

152
Q

What % of all breast cancers are associated w/ BRCA?

A

5%

153
Q

Risk of breast and ov ca w/ BRCA I?

A

Breast Ca risk- 65-74% (65-75%)

Ovarian Ca risk- 39-46% (40-45%)

154
Q

Risk of breast and ov ca w/ BRCA II?

A

Breast Ca risk- 65-74% (65-75%)

Ov Ca risk- 12-20% (10-20%)

155
Q

What other ca are associated w/ BRCA gene mutations?

A
  1. prostate
  2. pancreatic
  3. gastric ca
  4. melanoma
156
Q

Lynch II and risk of ovarian cancer

A

15 fold risk of ovarian cancer

157
Q

What types of ovaria cancers are associate w/ hereditary cancers?

A

High Grade Serous or endometroid

158
Q

Relationship of hereditary breast cancers to timing of cancers

A

10 years earlier than sporadic cancers

159
Q

Risk of male breast ca w/ BRCA?

A

6%

160
Q

Chemoprophylaxis options for BRCA

A

OCP’s to decrease ovarian cancer

Tamoxifen for BRCA 2

161
Q

Risk Reducing Surgeries for BRCA carriers?

A

BSO by age 40 or when childbearing complete
Prophylactic mastectomy
80-90% reduction in cancer

162
Q

Tetenus Vaccine

A

Substitute 1 time dose of Tdap
Then Td every 10 years
Tdap during EACH pregnancy b/w 27-36 weeks EGA

163
Q

MMR

A

One time dose unless high risk
Give 2
High Risk: healthcare workers
beginning college students
International travelers
Rubella negative PP patients

164
Q

Hepatitis A

A

International travelers

illicit drug users

165
Q

Hepatitis B

A

Pts aged 13-18
Healthcare workers
Those dealing w/ or receiving blood products
IV drug users
More than 1 sexual partner/recent or current STD
Hepatitis B household contacts

166
Q

Influenza

A

Annually after age 6

167
Q

Pneumoccal Schedule

A

Once only after 65 (unless w/ chronic medical conditions)
Immuno-compromised
Slenectomy
Chronic medical illness

168
Q

Meningococcal Schedule

A

by age 15 or prior to high school/military service-90% effective

169
Q

Varicella Schedule

A

All adults w/o evidence of immunity

NOT IN PREGNANCY

170
Q

Zoster Schedule

A

Single dose 60 and over

171
Q

HPV Schedule

A 
9-26 yo 
3 shots (0,2, 6m)
172
Q

Contraindications to HPV vaccine?

A

Pregnancy
Guil Bar
Severe yeast allergy

173
Q

Nine Valent HPV covers which strains

A

6, 11, 16, 18 (& 31, 33, 45, 52, 58)

174
Q

When should statins be prescribed?

A
  1. Clinical ASCVD
  2. LDL >190
  3. DM age 40-75 w/ LDL 70-189 mg/dl & w/o clinical ASCVD
  4. LDL 70-189 mg/dL &10 yr ASCVD risk >7.5% based on Framingham Risk Score (FRS)
175
Q

Elements of Framingham Risk Score

A
  1. Age
  2. Gender
  3. total cholesterol
  4. HDL
  5. Smoking status
  6. systolic BP
176
Q

Target cholesterol and LDL?

A

Total cholesterol <200

LDL <130

177
Q

Example and MOA of Bile Acid Resins?

A

Colestid

MOA: Increase cholesterol breakdown + excretion

178
Q

Example and MOA of Niacin?

A 
Nicotinic acid (Vit B3)
MOA: Lowers TG, tot chol + LDL, raises HDL
179
Q

Example and MOA of Fibrates?

A

Lopid
MOA: Lowers TG & raises HDL
DO NOT USE W/ STATINS, INC RISK OF MYOLYSIS

180
Q

Example and MOA of Statins?

A

Lipitor, Crestor, Zocor, Prevachol

MOA: Lowers TG, tot chol, LDL (20-60%), raises HDL

181
Q

Risk factors for CAD?

A
  1. Fam h/o premature CHD
  2. HTN
  3. DM
  4. Female >55 yo w/o HRT
  5. Current cigarette smoking
  6. Low HDL (<35)
182
Q

CAD in women, how are sx different than in men?

A
  1. Sx more typically atypical

2. Stress testing

183
Q

When should DEXA screening begin?

A

Age >65 or w/ 1 or more risk factors or FRAX >9.3%

184
Q

How often should DEXA be repeated?

A

No sooner than Q2 yrs unless new risk factors-no tx

On tx: Q2 yrs until stable, do not repeat once stable or improved

185
Q

Difference between the T-score and the Z-score

A

T-score: standard deviations from mean peak bone density of a normal young adult.

Z-score: Standard deviations from mean peak bone density of the same age, sex and race

186
Q

Interpretation of T-Scores?

A

Noramal >/= -1 SD below young adult peak bone mass
Low Bone Mass -1 ot -2 1/2 (formerly Osteopenia)
Osteoporosis = -2 1/2 SD below young adult peak BM

187
Q

Risk Factors for Osteoporosis?

A
  1. Personal h/o major frx
  2. 1st degree relative w/ frx
  3. Caucasian race
  4. Current cigarette smoker
  5. Low Ca++ intake
  6. Drugs: Anticonvulsants, steroids, chronic heparin,
    TPN, long acting progesterone, lithium
  7. Frail
  8. Inadequate physical activity
  9. Estrogen deficiency
  10. Alcoholism
  11. RA
188
Q

Normal bone loss?

A

pre-menopausal- 0.5%/yr

post-menopausal- 5%/yr

189
Q

W/up of osteoporosis

A
  1. Ca++, Vitamin D
  2. Chemistry profile
  3. 24 hr urine ca++
  4. PTH
  5. TSH (if on thyroid replacement tx)
190
Q

Utility of FRAX

A

Fracture risk screening tool (women >40 yo)
Predicts risk for osteoporotic frx in next 10 yrs
Use in decision to tx for low bone mass or to do DEXA on pt <65 yo (if FRAX >9.3%)

191
Q

Indications for treatment based on T-score?

A
  1. T-score of -2.5 w/o risk factors

2. T-score of -1.0 or below and FRAX score >/=3 for hip fx or >/=20 for major fx

192
Q

Prevention of Osteoporosis

A

weight bearing exercise
sunlight
Ca++ supplementation
Vit D supplementation

193
Q

Recommendations for Ca supplementation

A

Ages 9-18- 1300 mg/d
19-50 yo- 1000 mg/d
Over 50 yo- 1200 mg/d

194
Q

How much Ca++ does average diet contain?

How much Ca++ does glass of milk have?

A

600-900mg

tall glass of milk: 500 mg of Ca++

195
Q

Recommendations for Vit D supplementation?

A

Ages 1-70: 600 IU daily

>70 yo: 800 IU daily

196
Q

Treatment of Osteoperosis?

A

Bisphosphonates-1st line
HRT
SERM’s
Calcitonin

197
Q

Bisphosphonates MOA? Eg?

A

Inhibits bone resorption by osteoclasts

Fosomax 70mg / week

198
Q

Contraindications to Bisphosphonates

A 
esophageal abnormalities (incl reflux) 
renal failure
199
Q

How do you instruct to take Bisphosphonates?

A

Take on empty stomach

Remain upright for 30 mins

200
Q

Benefits of HRT for osteoporosis?

A

5 fewer fx/10,000 women

33% hip fx reduction

201
Q

MOA and Benefits of SERM’s for osteoporosis?

A

MOA: Pro-estrogenic on bone, anti-estrogenic on endometrium

Reduces vertebral fx rate by 50%

202
Q

Calcitonin dosage?

A

200 IU/day nasal spray
sub Q injection
effective on vertebral fx but expensive, no hip data

203
Q

Risk Reduction for Bone Fx?

A

No free rugs
Slip on shoes (avoid laces and bending down, shifting center of gravity)
Store objects at eye level (avoids bending)
Optimize vision & lighting

204
Q

Definition of Obesity? Classes?

A

BMI >30
Class I: 30-35
Class II: 35-39
Class III: >40

205
Q

US obesity rate/state?

A

> 20%

206
Q

What % of of women in US are obese?

A

35%

207
Q

Management of obesity?

A
  • see pt 1x/month
  • behavioral support including support grps
  • Medical tx if BMI >30 (>27 w/ med risks)
  • Surgical tx if BMI >40 (>35 w/ med risks)
  • Exercise min of 30 min brisk walk every other day
  • Daily diet: folic acid, calcium, protein (50g), energy 2200 kcal
208
Q

Incidence of rape

A

1:5 women

209
Q

Rape exam? When and how should it be done?

A 
Within 48-72 hrs optimal
Hx
PE
Tests: scalp hair, saliva, comb pubic hair
Cervical Cx
Blood work: HCG, STS, HIV, Hepatitis 
Wet smear (trich)
Stains on clothes
Vaginal/Rectal swabs
Fingernail scrapings
Photography when available
Maintain chain of custody of evidence
Emergency contraception
F/up in 6 weeks (std, psych, preg)
210
Q

Prophylaxis for rape?

A 
250mg ceftriaxone IM
1gm azithromycin
2gm metronidazole
HAART w/in 72 hrs if known HIV pos
If HIV unknown and <72 hrs call HIV hotline
211
Q

Abx coverage of GC/Cl

A

Ceftriaxone 250 mg IM PLUS Azithromycin 1gm

212
Q

Abx for Endometritis/PID Outpatient

A

Ceftriaxone (Rocephin) 250mg IM PLUS

Doxycycline 100mg BID x 14 d w/ or w/o metronidazole 500mg BID x14d

213
Q

Abx for PID/Endometritis Inpatient

A

Cefoxitin (Mefoxin) 2g IV Q6 hr OR
Cefotetan 1g IV Q12 hr

PLUS

Clindamycin 900mg IV Q8 hr
Gentamycin 2 mg/kg load, then 1.5 mg/kg maintenance IV or IM

PLUS

Doxycycline 100mg BID x 14 days

214
Q

Regimens for BV?

A 
Clindamycin cream 5gm x 7 d PV
OR
Flagyl 5gm QD PV x 5 d
OR
Flagyl 500mg PO BID x7 days
215
Q

Abx Regimen for UTI? Cystitis

A 
Trimethoprim 100mg BID x 3 days OR
Trimethoprim + Sulfamethoxazole 100/800mg BID x3 d
  (PREFERRED)   OR
Nitrofurantoin 100mg BID x 7 d
Give Quinolones if resistant
216
Q

Abx Regimens for Pyelonephritis?

A

Bactrim 100/800 mg IV Q12 OR
Ceftriaxone 2gm IV Q24 hrs, change to PO meds for total of 14 d total
Outpatient: ciprofloxacin 500mg po BID x 7 d

217
Q

Abx Regimens for Primary Syphilis

A

Benzothaine PCN 2.4 mil u IM x1

218
Q

Abx Regimens for Unknown Syphilis (secondary)?

A

Benzothaine PCN 2.4 mil u IM Q week x 3 if prior negative status not confirmed

219
Q

Dx of PID

A

Lower abd/pelvic pain in sexually active female, r/o other causes and ONE other of the MAJOR criteria:

  1. Adnexal tenderness
  2. Uterine tenderness
  3. Cervical motion tenderness

MINOR criteria:

  1. fever >38.0
  2. Mucopurulent vaginal discharge
    • Gc/Cl
  4. Gramp + diplococci on gram stain
  5. WBC >10
220
Q

Criteria for In-patient tx for PID

A

Cannot exclude surgical emergencies (eg. appendicitis)
pregnant
no response clinically to orals
unable to follow or tolerate outpatient oral regimen
severe illness, nausea, vomiting or high fever
TOA

221
Q

Long term sequela of PID?

A

Chronic pelvic pain
Infertility
Inc risk of ectopic pregnancy

222
Q

Incubation period of syphilis?

A

9-90 days

223
Q

Primary lesion of syphilis?

A

Primary canchre (cold painless ulcer w/ clear margins & punched out crater-like appearance)

224
Q

Secondary lesion of syphilis? What does it look like? When does it appear?

A 
6 w to 6 m after primary chancre
condylomata lata 
maculopapular rash (torso, palms, soles)
225
Q

Tertiary Syphilis

A

Gumma
Cardiac lesions
Tabes Dorsalis
Argyll-Robinson pupil

226
Q

Serology of Syphilis

A

Non-specific testing: VDRL, RPR-screening tests (can have false pos), usually returns to negative but may remain weakly pos for life
Specific testing:FTA-Abs, TPI- Confirmatory, typically remains positive

227
Q

How long does sero-conversion take?

A

4-6 weeks

228
Q

Causes of false positive RPR

A 
Auto-immune disease (classically SLE)
Smallpox vaccination
malaria
Mycoplasma pneumonia
Debilitation (aging)
Pregnancy
229
Q

Result of toxin release from dying spirochetes of syphilis?

A

Jarisch-Herxheimer Rxn

Acute febrile illness, can cause PTL

230
Q

Tx of syphilis if PCN allergic?

A

Erythromycin
If pregnant: desensitize since Tetracyclines contraindicated (causes yellow teeth) and Erythromycin does not adequately treat fetus

231
Q

Differences b/w syphilis and chancroid?

A 
Syphilis: 
Single
Painless
Clear Margins (crater-like)
Rubbery painless nodes
Treponema Pallidum
Cold
Chancroid:
Multiple
Painful
Vague Margin
Painful nodes
Hemophilus Ducreyi
Hot
232
Q

Differential Dx of vulvar ulcer?

A 
HSV
Syphilis
Chancroid
LGV
Granuloma Inguinale
Bechet's
Vulvar Carcinoma
233
Q

If unsure of cause of vulvar ulcer what is best choice of medication for treatment until dx made?

A 
Erythromycin  (assuming not pregnant) will cover 
Syphilis
Chancroid
Granuloma Inguinale
Lympho Granuloma Venarium
234
Q

Important to remember what key follow-up for any single positive STI result?

A

Full STD panel work-up!!!!

235
Q

Which form of erythromycin is safe in pregnancy? Which is not?

A

Erythromycin succinate is acceptable in pregnancy

Erythromycin estolate IS NOT ACCEPTABLE in pregnancy.

236
Q

Bartholin’s Gland Management?

A

Excise gland in pts >40 y/o to r/o adenocarcinoma or in pts w/ recurrent cysts or infections.

237
Q

Bartholin’s Abscess Management?

A

I&D then Word catheter, 4-6 weeks, preferable

Culture abscess to r/o MRSA.

238
Q

Normal pH of vagina?

A

<4.7

239
Q

Dx of vaginitis?

A

hx & sx
pH
10% KOH (yeast)
normal saline wet prep slide

240
Q

Tx of recurrent yeast infx?

A

> /= 4 attacks/yr
Diflucan 150mg days 1,3,5 and weekly x 6 mos
OR
Boric Acid 600mg BID x 2 weeks.

241
Q

Dx of BV?

A

pH >4.5
+amine test
>20% of clue cells

242
Q

Complications of BV in pregnancy? Post hyster?

A

PTL and PPROM, vag cuff cellulitis/PID

243
Q

Dx of Trich?

A

Increase pH

244
Q

Complications of Trichomonas?

A

PTL

PPROM

245
Q

Dx of Tuberculosis?

A
  1. PPD intradermally (Wait 48 hrs to interpret, Positive induration >10mm)
  2. IGRA blood test for latent TB, detects immune response to TB bacteria, requires only one visit, not effected by prior BCG vaccine
  3. CXR: Apical cavitation, hilar lyphadenopathy
246
Q

Treatment of TB?

A

6-9 months of

  1. Isoniazid 5mg/kg/day
  2. Rifampin (interferes w/ OCP) 10mg/kg/day
  3. Ethambutol (if Isoniazid resistence) 15mg/kg/day
  4. Pyrazinamide 20mg/kg/day
  5. Supplement w/ Vit B 12 as above treatment reduces B12 levels
247
Q

Basic principles of Ethics:

A
  1. Autonomy: pt has right of choice
  2. Beneficence: promote health and welfare
  3. Nonmalificence: do no harm
  4. Justice: Equal service to everyone
248
Q

Most common cause of ambiguous genitalia?

A

Congenital Adrenal Hyperplasia (CAH)

249
Q

Which enzyme deficiency accounts for 90% of CAH?

A

21 Hydroxylase deficiency (obstructs cortisol production & thus there is no negative feedback to switch off ACTH) leading to more androgen production, salt wasting b/c of inadequate aldosterone production.

250
Q

Order of adolescent development?

A

Growth Spurt (GR)
Breast (Therlarche)
Pubarche
Andrenarche (Independent of HP maturation)
Menarche (Tanner IV or 2-3 yrs after Thelarche)

GRaB PAM

251
Q

Time for development of normal Cycle?

A

6 years

252
Q

When would you evaluate amenorrhea in teen?

A
  1. No 2/ sexual development by 13
  2. Age 14 w/ hirsutism
  3. Age 15 regardless of development or 4 years after onset of puberty
  4. > 90 days without menses in menstruating adolescent
253
Q

Definition of Precocious Puberty

A

2.5 standard deviations earlier than mean age
7 yo in white American girls
6 yo in black American girls

254
Q

Life cycle of hair follicle?

A

Anagen-active phase of hair growth
Catagen-involution of epithelial cells surrounding dermal papilla
Telogen-resting phase

ACT

Hair falls out w/ initiation of anagen

255
Q

Differential Dx of Hirsutism

A 
PCO
CAH
Ovarian or Adrenal Tumor
Familial
Drugs (androgens, danazol)
256
Q

Lab w/up of hirsutism

A
  1. Total T (r/o abnormal ovarian/adrenal fx)
  2. DHEAS (r/o abn adrenal fx,most adrenal tumors excrete excess testosterone)
  3. 17 OH progesterone (r/o CAH)
257
Q

Treatment of Hirsutism?

A
  1. OCP
  2. Spironolactone
  3. Finasteride
  4. Flutamide
  5. Vaniqua
  6. Cosmetic removal
258
Q

MOA of Spironolactone?

A

blocks androgen R & inhibits 5-a-Reductase

259
Q

MOA of Finasteride?

A

5-a-reductase inhibitor (inhibits testosterone ->DHT)

260
Q

MOA of Flutamide?

A

Blocks ornithine decarboxylase

261
Q

MOA or Vaniqua?

A

Blocks ornithine decarboxylase

262
Q

MOA of OCPs for Hirsutism?

A

dec androgen production & inc SHBG levels–> inc binding and less free androgen

263
Q

Causes of secondary amenorrhea

A
  1. Pregnancy
  2. Hypo/hyperthyroidism
  3. Hyperprolactinemia
  4. PCOS
  5. CAH
  6. Stress/exercise
  7. Weight loss/anorexia
  8. Medications (eg. psychotropics)
  9. Premature ovarian failure (consider autoimmune)
  10. Androgen secreting tumors
  11. ACTH/GH secreting tumors
  12. Other hypothalamic lesions (craniopharyngiomas/sarcoid/TB)
  13. Ashermans Syndrome
  14. Androgen secreting tumors
264
Q

Primary Ovarian Insufficiency
Definition
Causes

A

Cessation of menses by age 40
Causes: Chromosomal
Chemotherapy/Radiation
Endocrinopathies: hypoparathyroidism,
hypoadrenalism
Autoimmune
Prior pelvic surgery–> damage to ovaries

265
Q

W/up for amenorrhea or h/o regular menses w/ 3 or more m of menstrual irregularities

A

FSH, LH, E2 (2 random tests at least 1 m apart)
Pregnancy test
PRL, TSH

If dx confirmed:
Karyotype
FMR-permutation
Andrenal Ab (if + get yearly corticotrophin stim test)
Pelvic US
TSH & TPO ab Q 1-2 yrs (20% develop Hashimotos)

266
Q

Tx of Primary Ovarian Insucfficiency

A

.1mg/d Transdemral Estradiol plus cyclic progesterone x 10-14 d

267
Q

Causes of Abnormal Uterine Bleeding

A 
Structural: (AUB-PALM)
Polyp
Adenomyosis
Leiomyoma
Malignancy &amp; Hyperplasia
Non-structural: (AUB-COEIN)
Coagulopathy 
Ovulatory Dysfunction
Endometrial
Iatrogenic
Not yet classified
268
Q

Differential Dx for AUB age 13-18?

A 
Anovulation -immature HPO axis
Hypothalamic dysfxn (stress, excess exercise)
Coagulopathis
Hormonal contraceptives
Infx
Pregnancy
Tumor
269
Q

Differential Dx for AUB age 19-39?

A 
Pregnancy
Anovulation (PCOS)
Anatomic lesions (fibroids/polyps)
Hormonal contraception
Hyperplasia/malignancy
270
Q

Differential Dx for AUB age >40?

A

Anovulation (declining ov fx)
Fibroids
Hyperplasia/Malignancy
Atrophy

271
Q

Dx evaluation for AUG?

A

Medical Hx (si/sx of coagulopathy)
PE
Labs: hcg, PRL, TSH, CBC, PT/PTT (if indicated), cvx cx, endo bx
Imaging:U/S, SHG, Hysteroscopy, MRI

272
Q

When is endo bx indicated?

A

Women >45 yo
Women <45 yo w/ AUB & unopposed E
Failed medical management
Persistent AUB

273
Q

Treatment for AUB?

A

Consider NSAIDs, OCPs, transxemic acid, Levonorgestrel IUD

If anovulatory: OCPs, MPA, IUD

Acute/severe bleeding: Estrogen (Premarin 25 mg IV, repeat Q4 hrs up to 6 hrs), OCP taper, progestins, Curettage if unable to treat medically

Surgical Management for chronic bleeding- endometrial ablation (if not chronic anovulation), UAE (fibroids), hysterectomy

274
Q

Dx of PMDD?

A

Non-focal, >7-10 d

Sx don’t consistently resolve upon onset of menses

275
Q

Dx of PMS?

A

Sx Focal 3-5 days prior to menses

Sx resolve at onset of menses

276
Q

Tx of PMS/PMDD?

A

Vit B6
Ca/Mg
Exercise
Stress Reduction

Dec: caffeine, ETOH, salt, fat

Meds: SSRI for mood swings
Danazol, GnRH agonist to suppress Ovulation

277
Q

What affects Prolactin levels and how?

A

Prolactin:
Inhibited by Dopamine, PIF (Prolactin Inhibitory Factor)

Stimulated by: TRH, Nipple Stim

278
Q

W/up for Galactorrhea?

A

Medication hx (antipsychotics, emtoclopramide, SSRI’s, oral E)
Breast Exam
Look at D/c under microscope-fat droplets
Cytological smear (for malignancy if concerned)
Prolactin level, TSH
Visual field test
MRI of pituitary foss

279
Q

Considerations for Prolactin blood testing?

A

early AM
prior to breakfast
prior to exercise
no intercourse or nipple stim

280
Q

Treatment of Galactorrhea

A
  1. Dopamine agonists: Carbergoline (long act), bromocriptine (Carbergoline preferred)
  2. Parlodel (bromocryptine)
281
Q

Advantages vs Disadvantages of Dopamine agonists?

A

Advantages: Long acting dopamine agonist, side effects less severe than parlodel, twice weekly dosage

Disadvantages: Cost

282
Q

Side Effects of Parlodel?

A

Postural hypotension
Nausea
Headache

If severe SE do dosage 2.5mg BID vaginally instead of PO

283
Q

Units for Progesterone

A

ng/Ml

284
Q

Units for Androgens

A

ng/ml

285
Q

Prolactin

A

ng/ml

286
Q

Estrogens

A

pg/ml

287
Q

FSH/LH, HCG

A

mIU/ml

288
Q

TSH

A

micU/ml

289
Q

Normal DHEAS

A

96-512

290
Q

Normal total T

A

2-45

291
Q

Prolactin

A

<26

292
Q

TSH

A

0.3-5

293
Q

When do you start work-up for infertility?

A
  1. Anytime if anovulatory/male h/o infertility
  2. Age <35 after 12 m of trying
  3. Age >35 after 6 m of trying
294
Q

Discussion of history for infertility?

A

Pattern of menses
Confirm adequate intercourse
PMH
Family Hx

295
Q

W/up testing for infertility

A 
Tests: Mid-luteal progesterone
           Ovulatory kits/Urinary LH kit
Tubal status: HSG/Laparoscopy w/ chromopertubation
Semen Analysis
Ovarian Reserve- If >35 w/ no conception in 6 m
-Day 2-3 FSH/E2 (high FSH, low E2 abnl)
-AMH
-Antral Follicle count  D2-5
-Clomid Challenge Test D10 FSH
296
Q

Risk Factors for Decreased Ovarian Reserve

A 
Age> 35
FHx early menopause
genetic condition (ie 45 XO mosaic)
FMR-1 Permutation
previous ov surgery (ie endometrioma)
oophorectomy
h/o chemo or XRT
smoking
297
Q

Onset of LH surge to ovulation

A

36 hrs

298
Q

LH peak to ovulation

A

12 hrs

299
Q 
Clomiphene:
MOA
Dose
Cost
Multiple reganancy rate
Hyper stim rate
A 
MOA of clomid- Anti-Estrogen
Dose- 50mg day 5-9
Cost- cheaper than gonadotrophins
Multiple pregnancy rate- 7%
Hyper stim rate- low
300
Q 
Gonadotropin:
MOA
Dose
Cost
Multiple reganancy rate
Hyper stim rate- Lower than gonadotropin
A 
MOA- FSH + LH
Dose- 1-2 amps IM day 7-14
Cost-More expensive than clomid
Multiple pregnancy rate- 21%
Hyper stim rate- higher than clomid
301
Q

How soon before a surgery should OCP’s be discontinued?

A

1 month

302
Q

SLE and OCP’s

A

Ok if mild & w/o antiphospholipid antibodies

If vascular dz present consider IUD

303
Q

Absolute contraindications for OCPs

A 
Breast cancer
Any estrogen sensitive tumor
Pregnancy
Unexplained vaginal bleeding
Thrombosis
Smoker over 35 yo
Liver disease
CHD/CVA
304
Q

Extended cycle oral contraceptives
MOA
Content
Eg

A

84 d of active pill followed by 7 d placebo
Contains levonorgestrel 0.15 mg & ethinyl estradiol 0.03mg
Eg. Seasonale

305
Q

Emergency Contraceptive Options

A
  1. Combined E/P pill- 100 micrograms Estrogen & 0.5 mg Levonorgestrel x 2 doses 12 hr apart
  2. Progestin only 1.5 levonorgestrel (Plan B)- more effective and less SE than OCP w/in 72 hrs
  3. Copper IUD inserted w/in 5 d of unproteceted inercourse (99% effective)
  4. RU-486
306
Q

Depression in pregnancy

  • how often should you screen
  • incidence
  • name of postpartum depression screen
  • Treatment
A
  • At least once during pregnancy w/ standardized tool
  • 1:7
  • Edinburgh Postnatal Depression Screen
  • Fluoxitene (low dose used for PMDD), Zoloft ( Sertraline)
307
Q

HRT (Estrogen)- Contraindications

A
  1. Pregnancy
  2. Breast CA
  3. Estrogen Sensitive tumor
  4. Undiagnosed vag bleeding
  5. Severe Liver Disease
  6. H/o DVT
308
Q

Risks of HRT (Estrogen)

A

VTE

Breast CA

309
Q

Benefits of HRT

A 
Alleviation of Hot flashes
Possible improvement of memory
Feeling of general well being
Slight improvement  in urinary incontinence
Less dyspareunia (local effect)
NOT cardio protective
310
Q

WHI findings on Estrogen Replacement Tx

A

Incr Risk of DVT, strokes
Dec Risk of CHD *not statistically sig
Dec risk of Inv Breast Dz (not statistically sig)??
Dec risk of Fracture rates

311
Q

WHI findings of Combination HRT

A

Inc risk of stroke
DVT
Breast ca
CHD

312
Q

When is HRT therapy indicated?

A

Menopausal vasomotor sx
vaginal dryness
prevent early osteoporosis bone loss

SHOULD NOT BE USED FOR PREVENTION OF HEART DZ OR STROKE

313
Q

Formulations of localized estrogen

A

Premarin, Estring, Vegifem

OB (5 decks)

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