General Gynecology Flashcards
What are absolute contraindications for UAE?
Asymptomatic
Pregnancy
Active infection
Malignancy
Can you use UAE for adenomyosis?
yes, for therapy-resistant adenomyosis
Does progesterone supplementation help pregnancy loss?
No benefit to decreasing sporadic miscarriage
Some benefit in women with 3+ losses
What is first-line treatment for gonorrhea?
ceftriaxone IM 250mg x1
1g PO azithromycin x1
In postmenopausal women without bleeding, what endometrial thickness prompts additional evaluation?
11mm (risk of malignancy 6.7%)
Who can get restrictive or diverting bariatric surgeries?
BMI >40
BMI >35 with co-morbidities
Orlistat
triacylglycerol lipase inhibitor, stops hydrolysis of triglycerides
side effects - diarrhea, flatulence
weight loss - 3%
Phentermine
noradrenergic sympathomimetic approved for weight loss
7-8% weight loss
Restrictive bariatric surgery vs malabsorption bariatric surgery
Sleeve gastrectomy - mechanical, lower weight loss, lower morbidity of surgery
Roux en Y - greater weight loss and control of comorbid conditions (diabetic)
When is breast biopsy indicated in a low risk woman?
BIRADS 4 or 5 (suspicious or suggestive of malignancy)
How do you manage BIRADS3 imaging in a low risk young woman?
Follow up in 6 months with repeat breast imaging and clinical breast exam
At what age does initial imaging of a breast mass switch from ultrasound to diagnostic mammogram?
30!
What is the work-up for persistent unilateral nipple discharge
Breast imaging - ultrasound <30, Diagnostic mammogram >30
Persistent unilateral nipple discharge + low risk BIRADS
Duct excision
Persistent unilateral nipple discharge + high risk BIRADS
Tissue biopsy
How do you initially treat a vulvar lesion not excluding invasive cancer?
wide local excision
0.5-1 margins
What are topical tx for vulvar HSIL
topical 5% imiquimod
16 weeeks
not FDA approved
other options: topical 5FU and cidofovir
What is the follow-up for VIN3 after WLE with negative margins?
6 and 12 months, then annually
Recurrence rate of VIN?
10-50%
Dovetail sign
Loss of anal skin creases anteriorly due to chronic 3rd degree lac of external anal sphincter
What is endoanal ultrasound used for?
Delineate defects of internal and external anal sphincter
How do you diagnose early syphilis?
Darkfield examination or direct fluorescent antibody testing of lesion exudate
What is the tx for syphilis?
Benzathine PCN
Non-pregnant PCN allergic - doxy alternative
Pregnant PCN allergic - desensitize
USPSTF recommendation for GC/CT screening
annually 24yo or younger
OR
older women with increased risk
What causes molluscum?
Poxvirus
Mondor disease
Superficial thrombophlebitis of veins of the anterior chest wall and breast
2/2 graumatic injury, breast surgery, or repetitive exercise
How do you treat Mondor disease?
warm compress
anti-inflammatory
Risk factors for endometriosis
mullarian anomalies, short menstrual cycles (<27 days), heavy/prolonged menstrual bleeding, and early menarche
What percent of pregnancies are unintended?
41% (as of 2011)
up to 75% among women <20 years old
What are risk factors for unintended pregnancy?
Age 18-24
income <100% of poverty level
Not completing high school
Non-hispanic black/AA
Cohabitating without marraige
What is the risk of pregnancy from a 1x unprotected intercourse?
2-5%
What are the types of emergency contraception?
Yuzpe method (COCPs)
Plan B (levonorgestrel)
Ella (ulipristal acetate)
Cu-IUD
What is one advantage of Ella over Plan B?
Ella (ulipristal) delays ovulation before or during LH surge; levonogestrel delays only prior to LH surge
Neither effective at LH peak or later
What is the dosing and efficacy of Plan B?
1 step - 1.5mg LNG x1
2 step: 0.75 LNG q12
Can give up to 72 hours (off label 5 days)
2.5% pregnancy rate
Less effective in obese women (up to 5.8% pregnancy)
What is the dosing and efficacy of Ella?
30mg ulipristal acetate x1
Can give up to 120hr
Avoid progestins x5 days
1.2-1.8% pregnancy rate
What is the Yuzpe method?
Combine OCPs to take 100-120mcg ethinyl estradiol and 0.5-0.6mg LNG
2 doses, q12h
High nausea effects
What is the effectiveness and use of Cu-IUD as emergency contraception?
Place up to 12hr after intercourse
0.1% rate of pregnancy
What is the modified for multiple procedures at the same time?
55
What is the modifier for multiple separate procedures on the same day?
25
What is the modifier for unsuccessful procedure?
53
What is the modifier for difficult procedure?
22
What is the modifier for assistant attending surgeon?
80
What are the genetics of a partial mole?
69 XXX or 69 XXY
What are the genetics of a complete mole?
46XX or 46XY
What are absolute contraindications to methotrexate?
IUP
immunodeficiency
sensitivity to MTX
active pulmonary, peptic ulcer, hepatic, or renal disease
moderate anemia/thrombocytopenia
breastfeeding
ruptured / hemodynamically unstable
unable to follow-up
What are relative contraindications to methotrexate?
cardiac activity
refusal to accept blood transfusion
ectopic >4cm
high initial hCG concentration
What is the recurrence risk of ectopic pregnancy?
1 prior - 10%
2 or more prior - 25% or more
Which medications may cause galactorrhea?
Antipsychotics
Metoclopromide
Verapamil
COCPs
methyldopa
Cigarette paper skin on the vulva
Loss of architecture
Lichen sclerosus
Violaceous papules and plaques on the vulva
w/ erosions or ulcerations
Lichen planus
Amsel criteria
pH >4.5
Clue cells
Thin white-grey discharge
Positive whiff test
Which treatments for condyloma are safe in pregnancy?
cryotherapy
trichloroacetic acid
When is peak bone density for women?
19 years old
What’s the difference between a T score and a Z score?
T score = bone marrow density compared to young healthy cohort
Z score = bone marrow density compared to age-matched women
What is the T-score criteria for osteopenia and osteoporosis?
Osteopenia: less than -1 to -2.5
Osteoporosis: less than -2.5
Who merits treatment for low bone density?
Osteoporosis (T20% risk of major fracture in next 10 years or >3% risk of hip fracture)
History of low trauma fracture
What is the first line treatment for osteoporosis?
Bisphosphonates
What are second-line tx for osteoporosis?
Raloxifene - good for younger pts or high breast cancer risk
Denosumab - RANK-L inhibitor
Hormone therapy
Calcitonin
PTH
How often do you screen for cervical cancer in HIV+ women?
Yearly, w/in 1 year of first sexual activity or w/in 1 year of HIV dx if sexually active
Continue through lifetime
How often do you screen women who had DES exposure in pregnancy
Annually
When should you sample the endometrial lining in a post-menopausal women?
AUB and stripe >4mm
incidental finding and stripe >11mm
When is bariatric surgery recommended?
BMI >40 or >35 with medical comorbidities with diet/exercise/meds unsuccessful
What is the most common endometrial abnormality in a woman on tamoxifen?
endometrial polyps (incidence 8-36%) followed by hyperplasia (1.3-20%)
What genetic abnormalities cause primary ovarian insufficiency?
45X Turner
Fragile X
17-alpha-hydroxylase def
aromatase deficiency
galactosemia
What are defining features of moderate ovarian hyperstim?
mild features (nausea/vomiting, enlarged ovaries, diarrhea, abd distension)
+ ultrasound evidence of ascites
+ hematocrit >41%
+ WBC >15
What are features of severe OHSS?
moderate features plus:
- clinical evidence of ascites or hydrothorax
- end-organ damage: dyspnea, oliguria, intractable n/v, tense ascites, low BP, syncope, severe pain
- Hct >51
- WBC > 25
- Electrolyte abnormalities: elevated Cr >1.6, Na < 135, K > 5, elevated LFTs
How long after bariatric surgery should you wait to attempt pregnancy?
12-18 months
What genetic complication is unique to ICSI?
Imprinting disorders
Especially Beckwith-Wiedemann syndrome
What are indications for ICSI?
Moderate-severe male factor infertility
Surgical retrieved sperm
Pre-implantation genetic diagnosis / aneuploidy screening
Cryopreserved oocytes
Prior failed fertilization
How do you treat hydrosalpinx prior to IVF?
Salpingectomy
Should you treat an endometrioma surgically to improve fertility?
Surgical tx reduces ovarian reserve - HOWEVER surgical removal of Stage I/II improves fertility by RCTs
What is the most common complication of hysteroscopy?
uterine perforation (0.7-3%)
Painful ulcer with tender unilateral suppurative lymph nodes
Chancroid (haemophilus ducreyi)
Nonpainful ulcer with unilateral tender suppurative lymph nodes
LGV - chlamydia trachomatis L1-3
Nonpainful ulcer with firm non-suppurative bilateral lymph nodes
Syphilis
Painful ulcers with firm non-suppurative lymph nodes
HSV
Donovan bodies
Granuloma inguinale / Klebsiella granulomatous
What is the likelihood that endometrium is covering an Essure and it is not visible hysteroscopically?
25%
Which is better for fertility, endometrioma drainage or removal?
Unclear, unless if >4cm then cystectomy is better than drainage
What gives false positive serum hCG?
heterophile antibodies
especially in women with exposure to animals (lab workers, farms).
Get a urine hCG to compare
Why would someone undergo gamete intra-fallopian transfer?
Fertilization occurs in vivo
For patients with objection to IVF
Involves laparoscopy, live birth rates are lower than IVF
Chronic endometritis
AUB, abdominal pain, CMT/uterine tenderness
Histology: plasma cells on embx/hysteroscopy
Tx: doxy 100mg BID x10-14 days or azithro 500mg x1 + 250mg x4 days
Mirabegron
Beta3 adrenergic receptor agonist
Side effecct - HTN
Coaptite
Urethral bulking agent
used to tx stress urinary incontinence
Frankenhauser plexus
uterovaginal plexus
4 and 8 o’clock at cervical base
Add back progestin therapy with GnRH agonists
Reduces bone loss and vasomotor symptoms
Norethindrone acetate 5mg PO daily (only FDA approved regimen)
Ok to start with initiation of GnRH in young patients
Steps of implantation
Apposition - embryo contact with endometrium
Adhesion - embryo adheres to endometrium
Invasion - embryo embeds in endometrium
When is DXA scan for bone mineral density recommended?
65+ years
<65 years, post-menopausal, and if FRAX is >8.4%
Which measurements are most accurate for DXA scans?
Hip
Lumbar spine
Who should you calculate a FRAX score for?
Post-menopausal patients
<65 years old
One risk factor for osteoporosis
What is the recommended daily allowance for calcium?
1000mg/day 19-50yo
1200mg/day 51yo+
What is the daily recommended allowance for vitamin D?
600 IU/day up to 70
800 IU/day >70
