GU F MDT s/s and tx Flashcards
Tx for Ectopic pregnancy
Surgical
-Laparoscopy When patient is unstable or rupture has occurred
Meds
-Methotrexate 50mg/m2 IM in single or multiple doses
(Stops cells from growing ending pregnancy)
Male partner contributes about what percentage of infertility cases.
40%
S/S of what?
Early symptoms
–70% of patients present with a (usually) painless lump
—-About 90% of these are discovered by the patient
(b) Less frequent symptoms
–Breast pain
– Nipple discharge
–Erosion, retraction, enlargement, or itching of the nipple
–Redness, generalized hardness, enlargement, or shrinking of the breast
(c) Rarely
–Axillary mass or swelling
–Back or joint pain
–Jaundice
–Weight loss
Female breast carcinoma
What issue?
(a) Products of conception are completely expelled.
(b) Pain ceases, but spotting may persist.
(c) Cervical os is closed, some blood in the vaginal vault
Complete abortion ( a competed miscarriage)
Signs and symptoms of what issue?
(1) Vaginal irritation or pruritus
(2) Pain
(3) Unusual or malodorous discharge
(4) Bimanual exam may show
—(a) Pelvic inflammation
—(b) Cervical motion tenderness
—(c) Adnexal tenderness
Vaginitis
What issue?
(a) Sexually transmitted protozoal flagellate
(b) Infects the vagina, Skene ducts, and lower urinary tract in women
(c) Infects the lower genitourinary tract in men
(d) Pruritus and a malodorous frothy, yellow-green discharge occur, along with diffuse vaginal erythema.
(e) Strawberry cervix- red macular lesions on the cervix in severe cases
Trichomonas Vaginalis Vaginitis
What issue?
(a) The pregnancy has ceased to develop, but the conceptus has not been expelled.
(b) Symptoms of pregnancy disappear.
(c) There may be a brownish vaginal discharge but no active bleeding.
(d) Pain does not develop. The cervix is semi firm and slightly patulous;
(e) The uterus becomes smaller and irregularly softened;
(f) The adnexa are normal.
(g) Women may be indicated for abortifacient and correttage.
Missed abortion
PCOS patients require regular laboratory monitoring of
what?
METABOLIC SYNDROME
lipids,
glucose
Hgb A1C
Any female with vaginal bleeding, positive hCG and abdominal pain is WHAT until proven otherwise.
Ectopic Pregnancy
Treatment AUB
(1) All patients with abnormal uterine bleeding should be referred to OB-GYN
(2) For premenopausal patients treatment depends on etiology of the AUB
(3) AUB secondary to certain causes may require definitive treatment
(4) AUB-O
—(a) Treated hormonally with progestin to oppose estrogen
—(b) NSAIDS at normal doses can reduce the amount of blood loss
Treatment for breast cancer
(a) All breast masses should be referred to General Surgery for further evaluation and work up
(b) Depends on the stage of cancer
—1) Surgical resection, with axillary node dissection
—2) Radiation
—3) Systemic therapy
Treatment PMDD/PMS
Mild to moderate symptoms
Lifestyle changes
(a) Aerobic exercise
(b) Reduction of caffeine, salt and alcohol
(c) Increase in dietary calcium (1200mg/day)
(d) Vitamin D or magnesium
(e) Increase complex carbohydrates
(f) Alternative therapies (acupuncture or herbal treatments)
Signs and symptoms of what issue?
(a) Breast pain or tenderness
–1) May be asymptomatic and found on accident
(b) Discomfort often worsens during premenstrual phase of cycle as cysts are enlarging
(c) Fluctuation in size of masses
(d) Multiple or bilateral
(e) Absence of enlarged or tender lymphadenopathy
Fibrocystic condition AKA “Fibrocystic Changes”
Specific treatment for fibroids
1) Asymptomatic myomas can be managed expectantly
2) NSAIDs decrease menstrual blood loss
3) Hormonal therapies can reduce volume, size, and menstrual blood loss
4) Surgical therapy is definitive treatment and curative.
Labs to consider off ship for PCOS
-FSH
-LH
-Prolactin
-TSH
-Hemoglobin A1C (Hgb A1C)
-Lipid profile
Treatment
(1) Malignant ovarian mass
(a) Surgical evaluation and staging by a gynecologic oncologist
(b) Followed by combinations of hysterectomy and bilateral salpingooophorectomy with omentectomy and selective lymphadenectomy
(c) Postoperative chemotherapy. Or watchful waiting
Treatment PID with severe disease
Cefoxitin (Mefoxin) 2g IV Q6H and doxycycline 100mg PO or IV Q12H
——-1) Continued for a minimum of 24 hours after the patient shows significant clinical improvement.
——-2) Then, an oral regimen should be given for a total course of antibiotics of 14 days.
Treatment
Trichmonas vaginalis Vaginitis
Treatment of both partners is recommended
Metronidazole (Flagyl) Dose: 2 g PO x1 or 500 mg BID x7 days
(is an antibiotic with cytotoxic effects towards anaerobic organisms)
S/S of what issue?
(1) Most women with both benign and malignant neoplasms are either symptomatic or experience only mild nonspecific gastrointestinal symptoms or pelvic pressure.
(2) Women with advanced malignant disease may experience abdominal pain and bloating, and a palpable abdominal mass with ascites is often present
Ovarian tumor
Definition of what issue?
(1) Lesion of the breast
—(a) Produces a mass (often accompanied by skin or nipple retraction)
(2) Usually indistinguishable from carcinoma even with imaging studies
(3) Commonly seen after fat injections to augment breast size or fill defects after breast surgery
(4) Trauma is presumed to be the cause
(5) Ecchymosis is occasionally present
(6) If untreated, the mass gradually disappears
Fat necrosis
What issue?
(a) Pregnancy, diabetes, and use of broad spectrum antibiotics or
corticosteroids predispose patients to this issue.
(b) Heat, moisture, and occlusive clothing also contribute to the risk.
(c) Pruritus, vulvovaginal erythema, and a white curd-like discharge that is NOT malodorous.
Vulvovaginal Candidiasis (yeast infection)
Initial testing for infertility includes what?
(1) Private consultations with each partner.
(2) Pertinent history:
(3) Gynecologic history
(4) Basic labs
PID It is most common in what demographic?
It is a leading cause of what?
-young, nulliparous, sexually active women with multiple
partners
-leading cause of infertility and ectopic pregnancy
Treatment PMS/PMDD
Medications that prevent ovulation such as _______ may lessen symptoms.
hormonal contraceptives
Imaging for Ectopic pregnancy
Transvaginal Ultrasound
_______ often presents with
–(a) Menstrual disorder
——-1) Ranging from amenorrhea to menorrhagia
–(b) Infertility
–(c) Skin disorders
——-1) Secondary to increased androgens
–(d) Insulin resistance
Polycystic ovarian syndrome (PCOS)
Treatment for
Fibrocystic condition AKA “Fibrocystic Changes”
a) NSAIDS
b) More severe pain should be referred to primary care for further evaluation.
c) Patient education
Signs and symptoms of what issue?
(1) Periodic painful swelling on either side of the introitus
(2) Dyspareunia (Pain just before, during, or after sex)
(3) Fluctuant swelling 1-4 cm in diameter lateral to either labium minus
(a) Sign of occlusion of Bartholin duct
(4) Tenderness is evidence of active infection
Bartholin’s Gland Abscess
Treatment for Carcinoma of the uterus
a) Surgery
–1) Total hysterectomy
–2) Bilateral salpingo-oophorectomy
–3) Peritoneal washings for cytology
–4) Lymph node sampling
(b) Post-operative radiation
(c) Chemotherapy
Treatment
Chlamydia
Doxycycline
Dose: 100 mg BID X 7 days
S/S of what?
(1) Amenorrhea,
(2) Nausea and vomiting,
(3) Breast tenderness and tingling,
(4) Urinary frequency and urgency,
(5) “Quickening” (perception of first movement noted at about the 18th week),
(6) Weight gain,
Pregnancy
S/S of what issue?
There are no specific symptoms or signs of this. Often asymptomatic
(a) Presumptive diagnosis is made by an abnormal Papanicolaou (PAP) smear of an asymptomatic woman with no grossly visible cervical changes.
(b) All visible abnormal cervical lesions should be referred to OB/GYN for biopsy and possible therapy
Cervical Dysplasia
Couples with unexplained infertility who do not achieve pregnancy within ____ years may be offered ovulation induction or assisted reproductive technology such as IVF.
–Women over the age of ___ are offered a more aggressive approach
3 Years
35 y/o
Treatment for abortion
(1) Stabilize and resuscitate patient if needed.
(2) MEDEVAC
(3) If products of conception are visible
–(a) Gently remove and place in a specimen bottle
(4) Analgesics
–(a) Acetaminophen 325-650mg PO Q6H PRN Pain
–(b) Can consider narcotic pain meds
Treatment Bartholin glands abscess
(1) Manual aspiration or incision and drainage of the abscess
—-(a) May reoccur
(2) Antibiotics are unnecessary unless cellulitis is present or spreading infection are present
—-(a) If STI is suspected but culture is not available presumptively treat for both Gonorrhea and Chlamydia.
(3) Frequent warm soaks
(4) Marsupialization may be required for frequent reoccurrence. Done by OB/GYN
(5) Women under 40 years of age, asymptomatic cysts do not require therapy unless large or cause problem with intercourse
Treatment for endometriosis
(a) NSAIDS
(b) Hormonal therapy
—Inhibit ovulation for 4-9 month preventing cyclic stimulation of
endometriotic growths inducing atrophy
(c) Surgical
—Laparoscopic ablation of endometrial implants
—Hysterectomy, with bilateral salpingooophorectomy
definitive diagnosis of endometriosis is made only by what?
histology of lesions removed at surgery.
(Laparoscopy)
Signs and symptoms of what issue?
(1) Bloating
(2) Breast pain
(3) Ankle swelling
(4) A sense of increased weight
(5) Skin disorders
(6) Irritability
(7) Aggressiveness
(8) Depression
(9) Inability to concentrate
(10) Libido change
(11) Lethargy
(12) Food cravings
PMS/PMDD
What surgical intervention of endometriosis is effective in reducing pain and promoting fertility?
Laparoscopic ablation of endometrial implants
Treatment Bacterial Vaginosis (BV)
(a) Metronidazole (Flagyl) 500 mg BID x7 days
(b) Clindamycin vaginal cream (Clindagel, Cleocin T lotion) –
—1) Dose: 2%, 5g once daily for 7 days
(c) Metronidazole gel (0.75%, 5g vaginal twice daily for 5 days)
S/s of what issue?
(1) Severe lower quadrant pain
–(b) Sudden in onset,
–(c) Stabbing
–(d) Intermittent
–(e) Does not radiate
(2) Backache may be present during attacks.
(3) Adnexal tenderness on physical exam.
(4) Shock may occur in about 10%, often after pelvic examination
(5) At least two-thirds of patients give a history of
–(a) Abnormal menstruation;
–(b) Many have been infertile
Ectopic
Signs and symptoms of what issue?
(1) Dysmenorrhea
(2) Chronic pelvic pain
(3) Dyspareunia
(4) Abnormal uterine bleeding
(5) Infertility
(6) May be asymptomatic
(7) Physical exam may show
—(a) Tender nodules in the cul-de-sac or rectovaginal septum
—(b) Cervical motion tenderness
—(c) Adnexal mass or tenderness
Endometriosis.
Tx for mastitis
1( Symptomatic tx
2) MSSA antibiotics
vs
3) MRSA antibiotics
1) Symptomatic tx
Regular emptying of the breast
(a) Either with breastfeeding, pumping, or hand expression
(b) Nursing of the infected breast is safe for the infant
NSAIDS
1) Motrin is preferred and safe in lactation
2) MSSA Antibiotics
–Cephalexin (Keflex) 500mg PO QID 10-14
–Clindamycin 300 mg PO TID for 5-14 days
3) MRSA antibiotics
–Trimethoprim/sulfamethoxazole (Bactrim) PO q 12 hours for 5-14 days
–Clindamycin 300-450mg PO TID 5-14 days
What issue?
(a) Terminal episode of naturally occurring menses
(b) Retrospective diagnosis
(c) Usually after 6 months of amenorrhea
Menopause
Laboratory workup for Vaginitis
-KOH
-Wet prep
-NAAT urine testing for chlamydia and gonorrhea
-Vaginal pH
Leiomyoma of the uterus (fibroid tumor) is usually asymptomatic what are some symptoms for which females will seek treatment?
1) Pelvic pressure
2) Abnormal uterine bleeding
3) Pain
Treatment considerations for fibroadenoma
(a) All breast masses should be referred to General Surgery for further evaluation and work up
(b) Once confirmed by biopsy, no treatment is usually necessary
(c) Excision may be necessary for large or rapidly growing fibroadenomas
—1) Larger than 3-4 cm
—2) Rule out phyllodes tumor
—–a) A rare malignant fibroadenoma like tumor
Menopause
-Normal age is what?
48-55 yo
Gynecologic history to ask for infertility
(a) Menstrual pattern
(b) Contraceptive use history
(c) Family history of infertility and spontaneous abortions
Signs and symptoms of what issue?
(1) May have painful menstrual cramping
(2) May be asymptomatic except for spotting
(3) Depending on the amount of blood, you could have signs of anemia
—(a) Fatigue
—(b) Pallor
—(c) Lightheadedness or dizziness with exertion
—(d) Pica (craving or chewing substances that have no nutritional value, such as ice, clay, soil, or paper) owing to low iron
(e) Weakness
(f) HA
AUB
S/S of what issue?
(1) Classic
–(a) Sudden onset severe unilateral lower abdominal pain
–(b) May develop after episodes of exertion or athletics
(2) Atypical
–(a) Half of patients
–(b) Gradual onset of intermittent pain
–(c) Nausea and vomiting – 70% of cases
3) Physical pain
–(a) Unilateral lower abdominal tenderness with guarding
–(b) Unilateral adnexal tenderness on bimanual exam
—–1) About 30% of patients are bilaterally tender
–(c) Possible palpable adnexal mass
Ovarian Torsion
TX for PCOS
1) Weight loss and exercise are often effective in inducing ovulation
(2) Metformin therapy
(3) If attempting fertility
—(a) Ovarian stimulation with medications or surgery
(4) If not attempting fertility
—(a) Combined contraceptive (pill, ring, patch)
—(b) LNG IUD
(5) Treatment of hirsutism
Lab considerations for infertility
(a) CBC
(b) Gonorrhea testing
(c) Chlamydia testing
(d) TSH
(e) Semen analysis
Definition of what issue?
(a) Most common benign neoplasm of the female genital tract.
(b) Discrete, round, firm, often multiple uterine tumor composed of smooth muscle and connective tissue.
(c) May cause miscarriage and pregnancy complications because they interfere with implantation.
Leiomyoma of the uterus (fibroid tumor)
Signs and symptoms of what issue?
1) Lower abdominal pain
(2) Chills and fever
(3) Menstrual disturbances
(4) Purulent cervical discharge
(5) Cervical and adnexal tenderness
(6) Many women may have subtle or mild symptoms such as
—(a) Postcoital bleeding
—(b) Urinary frequency
—(c) Low back pain
PID
Treatment for nipple discharge
(1) Would discuss with your supervising physician and refer to a breast clinic, OB/GYN, or General surgery depending on what type of discharge is present.
(2) Dependent on underlying cause
(3) Most discharge is benign especially if bilateral.
—(a) Annoying or disconcerting to patients
(b) Duct excision can be offered
What can help decrease bleeding associated with fibroids?
LNG IUD
What issue?
(a) Polymicrobial disease that is NOT sexually transmitted; chronic in nature
(b) An overgrowth of Gardnerella and other anaerobes
(c) Increased malodorous discharge without obvious vulvitis or vaginitis
Bacterial Vaginosis (BV)
Treatment
Vulvovaginal Candidiasis
(a) Fluconazole (Diflucan) is an antifungal
1) Dose: 150 mg daily for 1 day
S/s of what issue?
(1) Frequently begins within 3 months after delivery.
(2) Starts with an engorged breast and a sore or fissured nipple.
(3) Cellulitis is typically unilateral.
(a) Affected area of breast being red, tender, and warm.
(4) Fever and chills are common.
Mastitis
Treatment
Gonorrhea
Ceftriaxone (Rocephin)
Dose: 500 mg IM x 1 dose
Initial operational labs for secondary amenorrhea
hCG
What issue?
(a) The cervix is dilated.
(b) Some portion of the products of conception remains in the uterus.
(c) Only mild cramps are reported,
(d) Bleeding is persistent and often excessive.
Incomplete abortion
What is Pertinent history to ask for infertility?
(a) History of STI
(b) Prior pregnancies
(c) Alcohol use
(d) Tobacco use (specifically cigarettes)
(e) Recreational drug use
(f) Prescription medications
(g) Use of saunas or hot tubs
(h) Tight underwear(Males)
Definition of what issue?
(a) Abnormal uterine bleeding is the presenting sign in 90% of cases
—1) ALL post-menopausal bleeding requires evaluation
(b) Pap smear is frequently negative
(c) Pain is usually a late symptom
(d) After a negative pregnancy test, endometrial tissue is required to confirm diagnosis.
Most often 50-70 years of age
Carcinoma of the endometrium
What issue?
(increased risk of miscarriage)
(a) Bleeding or cramping occurs, but the pregnancy continues.
(b) The cervix is not dilated.
Threatened abortion
Disposition AMENORRHEA
(1) Any patient found to be pregnant should be _______
(2) Any non-pregnant patient who presents with secondary amenorrhea should be ______
1) MEDEVAC to Obstetrics.
2) routine referred to physician supervisor or gynecology for further evaluation.
Signs and symptoms of what mass?
(a) Round or ovoid
(b) Rubbery
(c) Discrete
(d) Relatively movable
(e) Nontender mass 1-5 cm in diameter
Fibroadenoma
Disposition AMENORRHEA
(1) Any patient found to be pregnant should be _______
(2) Any non-pregnant patient who presents with secondary amenorrhea should be ______
1) MEDEVAC to Obstetrics.
2) routine referred to physician supervisor or gynecology for further evaluation.
