GU Survery Exam 2 Flashcards
1
Q
Define neoplasm
A
atypical cell growth
2
Q
3 classifications of ovarian neoplasms
A
- Benign
- Low malignant potential
- malignant
3
Q
What are 5 complications of ovarian masses?
A
- torsion
- rupture
- infection
- hemorrhage
- malignant potential (exception is functional cysts)
4
Q
3 types of functional cysyts?
A
- follicular cyst
- corpus luteum cyst
- theca lutein cyst
5
Q
Are functional cysts benign or malignant?
A
benign
6
Q
what type of mass is a dermoid?
A
neoplasm
7
Q
besides malignancies, neoplasms or functional cysts, what are 3 other ovarian masses?
A
- endometrioma
- PCOS
- tubo-ovarian abscess
8
Q
What is the most common type of functional cyst?
A
follicular cyst
9
Q
What is the least common functional cyst?
A
corpus luteum
10
Q
What is the most common ovarian mass?
A
theca lutein cyst
11
Q
What are 2 causes of follicular cysts?
A
- dominant follicle fails to rupture (persistent follicle)
- immature follicle failing to undergo normal process of atresia
12
Q
How long before the follicular cyst disappears?
A
Within 1-3 months
13
Q
What is it called when blood fills the cavity of a follicular cyst?
A
Hemorrhagic or chocolate cyst
14
Q
Which functional cyst is less than common than follicular but clinically more important
A
corpus luteum cyst
15
Q
What are corpus luteum cysts associated with?
A
normal endocrine function or prolonged progesterone secretion
16
Q
How do corpus luteum cyst form?
A
results if the sac doesnt dissolve but seals off after the egg is released –> fluid builds up inside
17
Q
When do corpus luteum cysts typically occur?
A
2-4 days post ovulation
18
Q
When do corpus luteum cysts usually resolve?
A
within a few weeks, but can grow up to 4” and may bleed or cause torison
19
Q
What is the chance of recurrence for corpus luteum cysts?
A
31% chance of recurrence
20
Q
What is the least common functional cyst?
A
least common
21
Q
Are theca lutein cyst usually unilateral or bilateral?
A
bilateral
22
Q
What are the typical symptoms with theca lutein cysts?
A
usually asymptomatic
23
Q
What causes theca lutein cysts?
A
caused by prolonged or excessive stimulation of the ovaries by endogenous or exogenous gonadotropins
24
Q
What are some causes or endogenous or exogenous gonadotropins?
A
- multiple preg (twins)
- fertility drugs
- molar pregnancies
- choriocarcinoma
- diabetics
25
how long till the theca lutein cysts?
typically resolve spontaneously
26
When are functional ovarian cysts usually discovered?
routine pelvic exams
27
What are functional ovarian cysts symptoms?
often asymptomatic
- unilateral pressure, fullness or pain in lower abdomen
- dull ache in the lower back and thighs
- pain during sex
- if producing excess hormones
1. painful periods and abnormal bleeding
2. N/V
3. breast tenderness
28
```
Dx?
•unilateral pressure, fullness, or pain in lower abd
•dull ache in the lower back and thighs
•pain during sexual intercourse
•If producing excess hormones:
–painful menstrual periods & abnormal bleeding
–nausea or vomiting
–breast tenderness
```
Functional ovarian cysts
29
What symptoms would require an immediate referral?
```
•pain with fever and vomiting
•sudden, severe abdominal pain
•fainting, dizziness, or weakness
Adnexal Masses
•rapid breathing or heart rate (tachypnea, tachycardia)
```
30
What is another name for a teratoma?
dermoid tumor/cyst
31
What cyst contains all three germ layers?
dermoid/teratoma
32
what cyst is composed of skin and filled with hair, glands, muscle, bone, teeth, cartilage, respiraotry/GI epithelium, thyroid tissue
dermoid/teratoma
33
What is the most common ovarian neoplasm in prepubescebt girls and teens
dermoid/teratoma
34
age for dermoid cyst?
25-50
35
is there malignant potential for dermoid cyst?
usually removed d/t malignant potential, tho very low
36
How do you normally discover teratomas?
incidentally discovered on pelvic exam or imaging (50% have calcifications)
37
Who has 20% of all benign ovarian tumors?
postmenopausal women
38
what modality is used to dx an endometrioma?
US
39
pain level of endometrioma?
painless to severely painful?
40
Can endometriomas recur?
frequently recur if not completely resected
41
What is a tubo-ovarian abscess?
infection in the tubo-ovarian junction
42
What are the two typical causes of tubo-ovarian abscess?
gonorrhea and chlamydia is typical cause
43
S/Sx of tubo-ovarian abscess?
–Tubal/ovarian swelling/enlargement
–Pelvic pain
–Fever
–Vaginal discharge
44
What are two long term sequelae of tubo-ovarian abscesses?
1. infertility (scared uterine tubes)
| 2. chronic pelvic pain (adhesions)
45
What is the ovarian mass malignancy risk for premenopausal women?
13%
46
What is the ovarian mass malignancy risk for postmenopausal for postmenopausal women?
45%
47
What is the 5ht leading cause of death?
ovarian cancer
48
what is the cause of 50% of all GYN cancer deaths?
ovarian cancer
49
peak age of ovarian cancer?
60-65
50
Risk factors of ovarian cancer?
•Family history (5-10%; 90% w/o FHx)
–Breast, ovarian, colon, prostate, pancreatic cancer
•Nullparity
–Uninterrupted ovulation
•Early menarche < 14
•Late menopause > 55
•Fertility promoting drugs
•Geography (higher in North Am & Europe, lowest in Japan)
•Ethnicity (higher incidence vs. mortality rates)
•Sedentary lifestyle
•High fat diet
51
Dx?
–often without symptoms until late stage
–Pressure- due to large mass size, MAY BE LBP
–Pain- may be associated with rupture, torsion or hemorrhage, cancer, functional cyst, MAY BE LBP
–GI sxs- nausea, epigastric upset, and gas/bloating
–Menstrual abnormalities- oligomenorrhea or amenorrhea, DUB
–Hormonal changes- feminization, masculinization
–Cancer sx’s- mass, weight loss, nightsweats, anemia, ascites
ovarian cancer
52
GI sx associated with ovarian cancer?
nausea, epigastric upset, gas/bloating
53
menstrual abnormalities with ovarian cancer?
oligomenorrhea or amenorrhea, DUB
54
hormonal changes associated with ovarian changes?
feminization, masculinization
55
typical cancer sx's (5)?
mass, weight loss, nightsweats, anemia, ascites
56
what labs would you run for ovarian cancer?
1. HCG
2. CBC
3. renal/LFT
4. tumor markers Ca125
5. CEA
57
what radiographic evaluation for ovarian cancer?
1. pelic US (complex mass in postmenopausal woman in highly suspicious)
2. chest x-ray, CT scan (consider d/t hx and eval and labs)
58
Does an elevated CA-125 mean cancer?
false positive are common, also fibroids, benign ovarian tumors, adenomyosis, endometriosis, PID
59
What does the USPSTF recommend for ovarian cancer screening?
against routine screening
60
Why does the USPSTF recommend against screening?
although screening with serum CA124 or transvaginal US may detect ovarian cancer at earlier stage, earlier detection would likely have a small effect on overall mortality from ovarian cancer
- due to low prevalence of ovarian cancer and the invasive diagnostic testing following a positive screen, evidence that screening could lead to harmful unneccessary procedures
61
What is the take home message about ovarian cancer screening?
potential harms outweigh potential benefits of screening
62
Ovarian cancer stage 1: where is it, 5 yr survival rate?
limited to ovaries, 75-100%
63
Ovarian cancer stage 2: where is it, 5 yr survival rate?
pelvic extension, 45-60%
64
Ovarian cancer stage 3: where is it, survival rate? 5 yr survival rate?
abdominal/lymph spread, 42% survival rate, 5 year- 15-50%
65
Ovarian cancer stage 4: where is it, 5 yr survival rate?
malignant pleural effusion, mets to the liver, 5%
66
What is the gold standard modality for dx masses?
ultrasound
67
What physical exam procedures should be performed of the patient with ovarian mass?
1. lymph node survery
2. breast exam
3. ab exam
4. bimanual exam
5. rectovaginal exam
68
if the mass is cystic, smooth, unilocular, unilateral, small <5cm suspicious or benign?
benign
69
If the mass is solid or mixed cystic/solid, multilocular, bilateral, irregular, large >10cm with internal septae or papillae suspicious or benign?
suspicious
70
When should you consider a laparoscopy for ovarian mass? (4)
1. >7-10cm
2. continues to enlarge
3. looks suspicious on US
4. with suspicious hx, presentation, PE
71
What nutritional and lifestyle changes would you recommend for prevention of ovarian masses?
1. eliminate animal fats, saturated fats
2. eliminate alcohol esp. wine
3. quit smoking
4. high fruits/vegetables
5. decrease cholesterol
72
Supplement recommendation for ovarian mass?
1. beta carotene
2. selenium
3. Vit C/E
4. isoflavones
5. folic acid
73
what are some life things/med/surgeries that are preventative for ovarian mass?
1. breast feeding
2. hormonal contraception
3. bilateral tubal ligation
4. prophylactic bilateral oophorectomy
74
what are the common ovarian mass found in newborns?
small functional cysts 1-2cm that regress in months
75
what are the common ovarian mass found in premenarchal girls?
teratomas/dermoids
76
what are the common ovarian mass found in reproductive age?
functional cysts, endometriomas, tubo-ovarian abscesses, PCOS, ectopic preg, teratoma
77
what are the common ovarian mass found in post-menopausal?
*must r/o cancer*
| increased risk of malignancy (both primary ovarian carcinoma and metastatic from uterus, breast or GI)
78
lymph flow starting in breast?
breast --> axilla --> supraclavicular
- -> cervical nodes
- -> opposite breast
- -> abdominal lymphatics
79
Where is the most common site for fibrous cystic changes (benign) and/or malignant disease?
UOQ, upper outer
80
Where is another common site for fibrous changes besides UOQ
inframammary line (lower arc of the breast)
81
What about the area of fibrous tissue would make you less worrisome?
if symmetrical, painful, freely mobile
82
When in the cycle should clinical breast exam be performed?
optimal 5 days post menses, due to decreased hormonal influence
83
where does the breast lie?
lies between ribs 2-6, between the sternal edge and midaxillary line
84
what is the "tail" of the breast?
UOQ to axilla area
85
What are the 3 most common conditions for which a woman consults her doctor?
1. breast pain
2. nipple discharge
3. palpable mass
86
what is the goal of breast evaluation?
to r/o cancer
87
what does the extent of breast evaluation depend on?
1. natural of clinical problem
2. age
3. risk status
88
define mastalgia?
breast pain/tenderness
89
is mastalgia more common in pre or postmenopausal women?
MC in premenopausal
90
is mastalgia a typical symptom of cancer?
rarely a symptom of cancer
91
Causes of mastalgia?
hormonal, PMS, trauma, acute infection, M/S, cancer
92
with mastalgia when should you do and not do a mammogram?
physical exam finding and >35 YO consider mammogram, <35 with normal exam not indicated
93
treatment for mastalgia?
1. *60-80% spontaneous remission*, prospective charting
| 2. sx may be improved or exacerbated with hormonal tx
94
fibroadenomas malignant or benign?
benign
95
do fibroadenomas fluctuate with cycle?
yes size may
96
dx?
| rubbery, firm, smooth, round, mobile, painless?
fibroadenoma
97
describe a fibroadenoma?
–Rubbery, firm, smooth, round, mobile, painless
98
Dx?
| –mammography= solid, well-circumscribed, may be multilobulated/calcified (popcorn appearance)
fibroadenoma
99
what % of women will have multiple fibroadenomas?
up to 20%
100
age range for fibroadenomas?
15-50, no common in menopause unless on HRT
101
management of fibroadenomas?
CBE, mammogram, US, needle bx, tend to regress over time
102
Tx for fibroadenoma?
surgical excision, watch and wait
103
dx?
–Fluid filled lesion
–Soft, yet firm, mobile, well circumscribed, unilateral or bilateral, tender
–Cyclical fluctuations
simple cysts
104
describe the characteristics of simple cysts?
–Fluid filled lesion
–Soft, yet firm, mobile, well circumscribed, unilateral or bilateral, tender
–Cyclical fluctuations
105
age for simple cyst?
15-50, not common in menopause
106
management of simple cysts?
–PE: difficult to differentiate from a solid mass
–Dx: Mammogram, U/S, Fine Needle Aspiration
–Surgical Biopsy: if bloody aspirate, palpable mass doesn’t resolve with aspiration, multiple recurrence in short period, no fluid aspirated.
–CBE after treatments, mammogram
–Recurrent large cysts have been shown to slightly inc. cancer risk in some studies, but not in others.
107
dx?
–Common, non-cancerous changes in breast tissue
–The term "disease" in this case is misleading, and many providers prefer the term "change."
–Believed to be normal variant in ~ 60% of women
–Accompanied by swelling, pain, tenderness
–Increased E, decreased P
–Often resolves with menopause
fibrocystic breast changes
108
characteristics of fibrocystic breast changes?
–Common, non-cancerous changes in breast tissue
–The term "disease" in this case is misleading, and many providers prefer the term "change."
–Believed to be normal variant in ~ 60% of women
–Accompanied by swelling, pain, tenderness
–Increased E, decreased P
–Often resolves with menopause
109
symptoms of fibrocystic breast changes?
```
–Cyclical pain or constant
–Variation in size
–High mobility
–Multiple nodules
–Pre-menstrual aggravation
–Diffuse swelling
–Tenderness
–Heaviness
–Itching of nipple
–Usually UOQ
```
110
What beverages should be avoided with fibrocystic breast changes?
Methylxanthines
| •Limiting coffee, tea, cola, chocolate and caffeinated medications
111
what dietary changes should be incorporated with fibrocystic breast changes?
•Avoid caffeine & other methylxanthines
•Avoid exogenous estrogens
•Low (animal) fat diet to 20% of calories
–reduces severity of PMS breast tenderness & swelling; studies show mixed results
•Increased dietary fiber (whole grains, legumes, veggies/fruit, flax seeds) to reduce cellular proliferation (Am J Epidemiol. 2004 Nov 15;160(10):945-60.)
•Symptoms may be improved or exacerbated with hormonal tx (i.e. OCP, HRT)
112
What supplements may help with fibrocystic breast changes?
vit E and evening primrose oil
113
define mastitis?
infection during lactation or when skin disruption
114
mastitis presentation?
fever, localized erythema, pain, induration, n/v, malaise, fever, chills
115
bacterial etiology of mastitis?
S. aureus, S. epidermis, strep
116
Risk factors for mastitis?
breast feeding, trauma, breast augmentation
117
When is the most common time for mastitis?
most common in first 2-4 weeks postpartum
118
what is a galactocele?
obstruction of breast duct usually after lactation
119
Sx/s of galactocele?
tender and enlarged
120
tx for galactocele?
excise and drain
121
what is the most common cause of nipple discharge?
benign breast dz
122
what % of benign breast dz has Nd/c
10-15%
123
what % of malignant dz will have Nd/c
3-11%
124
what characteristics of nipple discharge or mass makes you more concerned about possible breast cancer?
- discharge is bloody
- assoc with mass
- unilateral
- single duct
- spontaneous
- postmenopausal
- using HRT
125
what characteristics of nipple discharge or mass makes you think benign?
```
•Often Bilateral
•Nonspontaneous
–Needs stimulation (contact, pressure)
•Multiple ducts involved
–determine quadrants when applying pressure
•Serous d/c may be caused by hormones
```
126
Describe pathologic discharge
•Unilateral
•Spontaneous
–intermittent, often localized to one duct
•D/c = frank blood, serous, serosangiuneous, or greenish grey
•D/c secondary to breast carcinoma may be any color
•Etiologies:
–Intraductal papilloma (benign) is the number one cause of nipple discharge
–Breast cancer
127
what is galactorrhea?
inappropriate lactation in the nonpuerperal woman (during/after preg), milky d/c
128
what should you evaluate for with galactorrhea?
evaluate for elevated prolactin levels
129
if prolactin is elevated with galactorrhea then do what?
order a CT to r/o pituitary tumor
130
what are some causes of galactorrhea?
–excessive estrogens (OCP)
–psychotropic meds (diazepam, tricyclic antidepressants,
–afferent nerve stimulation (scars, herpes zoster lesions), stress
–primary hypothyroidism (d/t dec. T4 & elevated TRH acts as a ProInhibFactor); usually assoc with amenorrhea and menses is restored after correcting underlying problem.
131
what is an intraductal papilloma?
papillary growth inside a lactiferous duct
132
what is the #1 cause of nipple d/c
intraductal papilloma
133
what is the discharge like with an intraductal papilloma?
can be bloody or serous
134
are intraductal papillomas malignant or benign?
benign
135
tx for intraductal papilloma?
surgical excision b/c they tend to grow, breast feeding not altered if <3 ducts removed
136
causes of subareolar abscess?
S. aureus or anaerobic organisms
137
who is more common to have recurrent subareolar abscess?
recurrent in women w/ inverted nipples
138
what leads to an increase chance of subareolar abscess?
increased chance with/after nipple piercing
139
Tx for subareolar abscess?
antiobiotics, drainage, duct excision
140
what is the most common cancer in women?
breast cancer
141
what is the second leading cause of cancer deaths in women?
breast cancer, 1/3 will die from it
142
leading cause of death in women 40-55 YO?
breast cancer
143
What is the USPSTF recommendation for mammography screening women aged 50-74?
biennial, every two years
144
does the USPSTF recommend mammography for women over 75 years?
no, The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older.
145
what does the USPSTF recommend for breast self-exam?
recommends against teaching it
146
film mammography or digital or MRI for USPST recommendation?
film, The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of either digital mammography or magnetic resonance imaging (MRI) instead of film mammography as screening modalities for breast cancer.
147
what about using US for breast cancer?
ineffective as a screening tool
148
PROs of mammography?
decrease mortality d/t earlier detection
| -
149
Cons of mammography?
•False negatives
–Less of a concern if annual screening
–Less of a concern if have old films for comparison
•False positives
–Overdiagnosis, anxiety, pain (Nelson HD, 2016 ) and Unnecessary biopsies
–Especially with annual screening in women 40-49 & women with dense breast. (Nelson HD, 2016 )
–5-15% of screening mammograms require additional mammograms or ultrasound; most turn out to be normal. If abnormal, biopsy may have to be performed; most biopsies confirm that no cancer was present
–Estimated that a woman who has yearly mammograms between ages 40-49 has about a 30% chance of false-positive at some point in that decade and about a 7-8% chance of biopsy.
–Estimate for false-positive mammograms is about 25% for >50y
•Radiation exposure
–The effective radiation dose is about 0.7 mSv (70mrem vs xray pelvis/hip = 65mrem).
150
what can an ultrasound be used for regarding breast carcinomas?
detection of fluid filled vs solid mass
151
what female patients need an MRI regarding potential breast cancer?
•Patients who need MRI
–Those with current or past diagnosis of BrCa
–Those with dense breasts (determined by radiologist)
–To rectify inconclusive mammogram & U/S
–Those in high risk
•Mom with premenopausal breast cancer
•2 – 1st degree relatives with breast cancer
•May be in conjunction w/ PET-CT (PEM)
152
what is a DBT?
digital breast tomosynthesis
153
rates of cancer with DBT?
* Rates of cancer detection with DBT increased by 1.4 to 2.5 per 1000 examinations compared with mammography alone.
* Supplemental screening of women with dense breasts finds additional breast cancer but increases false-positive results. Use of DBT may reduce recall rates.
154
when do you do needle aspirations?
to evaluate fluid filled lesions
155
what should you do if you have bloody aspiration?
biopsy is recommended
156
what should you do with cysts that reoccur within 2 weeks or require >1 aspiration
biopsy is recommended
157
What largely replaces a needle biopsy?
core biopsy
158
what is the definiitve step to determine that a mass is benign or malignant?
biopsy
159
what is the usual sequence before doing a biopsy?
mammogram --> US --> biopsy
160
avg age of breast cancer in men?
65
161
do men with breast cancer have any risk factors?
no apparent risk factors
162
what should lead to an immediate referral for men?
–breast lump, swelling, skin dimpling, puckering, nipple d/c, redness/scaling or skin/nipple, axillary node changes, persistent pain
163
men with breast cancer are more or less likely to have nipple d/c?
more likely
164
what are some breast cancer risk factors for men?
factors may include the following:
–Radiation exposure
–Estrogen administration (transgender, prostate cancer)
–diseases associated with hyperestrogenism (cirrhosis or Klinefelter's syndrome)
–Heavy alcohol intake
–Definite familial tendencies:
•Increased risk in men who have a number of female relatives with breast cancer.
•An increased risk of male breast cancer has been reported in families in which a BRCA2 mutation has been identified.
165
what % of breast cancer patients have no major risk factors?
75%
166
what % of breast cancer patient do not have a primary relative with breast cancer?
90%
167
S/Sx early stage of breast cancer
–firm to hard mass
–irregular contour
–immobile
–unilateral
168
S/Sx late stage of breast cancer
```
–skin/nipple retraction, tenderness, axillary lymphadenopathy, erythema, edema, pain, fatigue
–skin retraction~ peau d’orange
Paget’s Disease of the Breast
•Adenocarcinoma of the nipple
•Signs & Symptoms
–itching/burning of skin or nipple
–nipple/skin erythema, rash, ulcerations
•Easily missed dx and tx’d as a dermatitis
```
169
what is breast cancer often dx'd as?
dermatitis
170
Breast cancer tx options?
```
•Surgery
–sentinal node dissection
–lumpectomy (breast conservation)
–mastectomy
–breast reconstruction
•Chemotherapy
•Radiation therapy
•Receptor/Hormonal blockage
•Complimentary support
–Naturopathic (dietary, nutrient and botanical support)
–IV therapy
–Acupuncture (decreases SE of chemo, surgery, radiation)
Lumpectomy
Sentinel Nodal Dissection
Lymphedema
Trans flap reconstruction
Mastectomy with Reconstruction
```
171
non-modifiable risk factors for breast cancer
```
NON MODIFIABLE Risk Factors
–Age
–Age of menarche, age of menopause
–Family history
•Especially first degree/age
–Genetic mutations: BRCA1, BRCA2, P53, P21
–Environmental exposures
```
172
modifiable risk factors for breast cancer
```
MODIFIABLE Risk Factors
–Hormone use (HRT, OC in some groups)
–Reproductive/breast feeding
–Lifestyle
•Nutrition (high fat, high alcohol)
•Exercise
–women who exercise 3.8hrs/week decreased their risk 30%
–>4hrs/wk decreased their risk 50%
•Smoking
–a woman's risk for breast cancer increases 25% if she is a smoker also depend on pack years.. 2 pack years increases her risk by 75%
–Environmental exposures?
•PCBs, ionizing radiation, chlorinated solvents
```
173
things that decrease breast cancer risk
* Menarche after 15, early menopause
* 3 or more pregnancies prior to 30
* Prolonged lactation
* Healthy diet choices
* Consistent and regular exercise
* Minimal HRT/OC use
174
list some concepts in breast cancer prevention
```
•Don’t smoke
•Reduce total fat
•Reduce animal protein
•Reduce alcohol
•Reduce exposure to carcinogens
•Reduce BMI
•Increase lignans
•Increase indoles
•Increase veggies/fruits,
•Increase green tea
•Increase olive oil
•Increase cold water fish
•Increase antioxidants
Vitamin D may heal prevent BrCa
```
175
positive correlations with breast cancer
* Animal foods
* Meats
* Total fat
* Saturated fats
* Dairy
* Refined sugar
* Total calories
* Alcohol
176
negative correlations with breast cancer
* Fish
* Whole grains
* Legumes
* Cabbage
* Vegetables
* Nuts
* Fruits
177
goals of nutritonal therapy for breast cancer
* Eat a “rainbow” selection of foods
* Reduce exposure to pesticides/herbicides
* Reduce exposure to hormones/antibiotics
* Minimally processed foods
* Eat the right types of fats/oils
* Eat low glycemic load foods
178
flax lignans and breast cancer?
•Premenopausal women had reduced breast cancer risk with the use of dietary flax seed (lignans) compared to controls. There was no difference in post menopausal women
179
breast cancer and ALA
•The higher the level of alpha linolenic acid in breast tissue the less likely the cancer was to spread into the lymph nodes of the axillary, metastatsize or be invasive.
180
fish oil and breast cancer
•Fish oil supplementation
| –Reduced TNF alpha and interleukin beta production by 74%
181
lycopene and breast cancer
•Serum and tissue lycopene levels found to be inversely related to the incidence of several cancers (breast and prostate).
182
green tea and breast cancer
* Over 5 cups a day associated with nearly 50% reduction in recurrence after 7 years post stage I and II breast cancers.
* Contains polyphenols and catechins; capture and detoxify free radicals of various carcinogens, radiation exposure and light.
* Inhibitory actions on nearly all steps of carcinogenesis
* Suppresses proliferation of ER+ breast cancer cells
183
tumeric and breast cancer?
* Historically used as an anti-inflammatory agent, wound healing and longevity
* Chemopreventative activities
* Induces Phase II detoxification enzymes such as glutathione transferases while inhibiting procarcinogen activing enzymes.
* Inhibits the generation of reactive oxygen species (it’s an antioxidant)
184
High sugar consumption is an increase risk for several cancers:?
–breast
–Colon
–melanoma
–prostate
185
define glycemic index?
•Glycemic Index refers to the rise in blood sugar after ingesting a serving of food that provides 50grams of CHO
186
define glycemic load?
•Glycemic Load is calculated by multiplying the GI as a decimal times the amount of CHO in the ACTUAL serving size of the food
187
how does alcohol affect breast cancer?
–EtOH > Decreased folate> increased BrCa
| –Folic acid protects DNA
188
how does alcohol affect colon cancer?
–Alcohol interfers with methylation (changes in DNA)
189
majority of cervical CA in the US occur in women who: (3)
1. have never been screened
2. have not been screened within the past 5 years
3. have not received appropriate follow up after an abnormal pap smear
190
by how much has proper cervical cancer screening reduced the incidence by?
50%
191
What is the cell type on the outside of the cervix and the vagina?
squamous cells
192
what type of cells line the canal of the cervix?
columnar cells
193
what is the junction between the two cells types called?
transitional zone, SCJ
194
Where does 95% of all nervical intraepithelial neoplasia, or abnormal growth/dysplasia occur in the cervix?
transitional zone
195
define cervical dysplasia?
disordered growth
196
describe the normal cervical layer of cells. where is the young cells? where is the mature cells?
normal distribution is that the bottom layer is made of round young cells, as the cells mature, they rise to the top and flatten out
197
CIN I what is the severity of dysplasia?
mild dysplasia
198
CIN II what is the severity of dysplasia?
moderate dysplasia
199
CIN III or carcinoma in situ what is the severity of dysplasia?
severe dysplasia
200
Where are the abnormalities with dysplasia and carcinoma-in-situ
all the abnormalities are confined to the surface of the cervix
201
Where are the abnormalities with invasive cancer?
the cells are disordered throughout the entire thickness of the lining and they invade the tissue underlying the surface
202
When should regular pap smear screening for all women who are sexually active and have a cervix begin?
at age 21 or 3 years after first intercourse, whichever comes first
203
how often shoulder women less than 30 have pap smears?
annually
204
Based on USPSTF how often should women 30-65 have pap smears?
every 2-3 years after 3 consecutive normal annual paps
205
what does the USPSTF recommend for women >65 regarding pap smears?
recommends against routine screening for if patient has had adequate recent screening with normal results for the past 10 years and are not otherwise at high risk
206
Pap smears after a hysterectomy?
–discontinue screening if for benign disease and no h/o CIN
–continue screening if cervix present, h/o cervical cancer or DES exposure, unknown reason, hx of CIN until 3 normal consecutive tests
207
Post tx for CIN recommendation for pap smear
screening every 6 months X 2 then annually
208
Which has a better sensitivity conventional or liquid based pap?
liquid based aka thinprep or surepath
209
how many cervical CA cases in US each year in women with normal pap tests?
2500-3000
210
Based on bethesda classification of paps: which one has variation of normal, such as "irritation or inflammation"
atypia
211
Based on bethesda classification of paps: which one has "abnormal squamous cells of undetermined significance, benign changes that should be monitored"
ASCUS
212
Based on bethesda classification of paps: which one has mild dysplasia, aka LGSIL- low grade squamous intraepithelial lesion
CIN I
213
Based on bethesda classification of paps: which one has moderate dysplasia, HGSIL
CIN II
214
what is HGSIL
high grade squamous intraepithelial lesion
215
Which CIN has severe dysplsia with HGSIL?
CIN III
216
What is CIS?
carcinoma in situ, precancer
217
Which bethesda classification of paps is precancer
CIS
218
what is the best response to give regarding HPV dx?
this virus, like most viruses, will most likely subside and disappear
219
Name some things that increase the risk of cervical dysplasia and cancer
* Lack of cervical screening
* Sexual activity at a young age (prior to 20)
* High lifetime number of sex partners (>3)
* Smokers (2 fold)
* HPV (10 fold) present in 99.7% of cervical CA
* OC use > 5yrs
* Multiparity
* History of STI’s
* DES exposure in utero
* Steroid use
220
Name some things that decrease the risk of cervical dysplasia and cancer
* Barrier contraception use~ decreased HPV transmission & speeds regression of both penile & cervical lesions
* Quit smoking
* Stop OCP
221
Are high risk HPV strains more or less likely to result in high grade lesions that lead to cervical cancer?
more likely
222
what are low risk HPV strains more likely to result in?
cervical changes that are less likely to be precancerous altho may cause warts
223
How long does it take for HR-HPV to cause mutations?
about 3 years, hence cervical cancer in women under the age of 19 is rare
224
is HPV contagious during sex?
yes very contagious during intercourse
225
is condom use completely protective in HPV spread?
–condom use is not completely protective because the virus can spread through skin-to-skin contact beyond the genitals.
226
HPV is found in ____% of sexually active adults
>70
227
how many peeps with HPV develop visible venereal warts?
only 1%
228
in how many years in teens and early 20's, 70% HR-HPV & 90% of LR-HPV types?
regress after 3 years
229
What are a couple of early signs or symptoms of cervical cancer?
often there are NO early signs or symptoms, but can be cervical discharge or abnormal uterine bleeding
230
who is recommended to get the HPV vaccine?
girls 9-26
231
how often do you get the HPV vaccine?
series of 3 injections over 6 mnths
232
if your patient reports an abnormal pap smear... what then? what dx tests may be indicated?
Colposcopy
233
what is a colposcopy?
direct magnification and viewing of cervix, vulva, vagina, and/or perianal tissue plus biopsy of tissue
234
What are some indications for a colposcopy?
* Persistent AS-CUS, LGSIL, 2 consecutive abn. Paps
* ASCUS/LGSIL in pt unlikely to return for adequate follow up care
* Persistent cervical inflammation on pap smear
* AGCUS atypical glandular cells on pap smear
* Persistent cervical bleeding
* Hx DES exposure (DES daughter)
* HIV + pt
235
which type of cellular changes of the cervix usually go away without tx?
ascus, atypia, CIN I
236
when should someone with ascus, atypia or CIN I have pap smears?
every 4 months in 1st year, every 6 months in 2nd year, CIN II tx for persistent lesions
237
what are some tx for CIN II
–Cryotherapy
–Loop Excision (LEEP)
–Pap test every 4 months in 1st year, every 6 months in 2nd
238
is tx recommended for CIN II?
yes, most don't go away
239
what kind of treatment is recommended for CIN III and CIS
–Treatment/follow-up often provided by GYN oncologist
–Surgical treatment recommended
–LEEP
–Conization or laser beam treatment
–Hysterectomy (advanced stages)
–Pap tests every 4 months in 1st year, every 6 months in 2nd
240
what tx option is this?
•A probe is placed against cervix, which damages the cells by freezing them. These are then shed over the next month in a heavy watery discharge.
•Depth is hard to control
•Has had high failure rate for treating large areas of dysplasia & areas that extend into the cervical canal
cryotherapy
241
```
what tx option is this?
•Uses a fine wire loop with electrical energy flowing through it
•Tissue that is removed is sent to lab
•Good for treatment and diagnosis
•Done under local anesthesia
•Causes little discomfort
```
Leep , loop electrosurgical excision procedure
242
what tx option is this?
•Removes a cone-shaped piece of the cervix
•Better for diagnosing, but may have removed all of the undamaged tissue as well
•High success rate, may interfere with future childbearing
conization
243
list 3 types of vaginal suppositories for CIN
1. green tea
2. vit A and herbal compound
3. riboflavin B2, have been shown to cause regression of CIN
244
supplements for CIN?
```
–Antioxidants reduce risk of CIN & cancer
–Folic acid and beta carotenes
–Pyridoxine (B6)
–Selenium
–Zinc
```
245
what is DES?
Diethylstilbestrol
–synthetic non-steroidal estrogen
–used to prevent miscarriage & other pregnancy complications from 1938-1971.
246
what are the effects of DES?
–Women who took DES during pregnancy have a slightly higher risk of breast cancer
–Women who were exposed to DES in utero have higher rates of:
•structural reproductive tract anomalies
•vaginal/cervical dysplasia and adenocarcinoma
•infertility
•poor pregnancy outcomes
•autoimmune disorders
–Males who were exposed to DES in utero have higher rates of:
•structural reproductive tract anomalies
•infertility
247
Suggested screening for interval for DES daughters?
* First pap at onset of menses, 14 y.o. or onset of intercourse
* Baseline colposcopy after onset of intercourse
* Vaginal and cervical paps every 6-12 months until 30 y.o.
* Thereafter, yearly cervical and vaginal paps
248
average age of first intercourse?
16.5
249
what percentage of all unintended pregnancies occur in women who are using birth control?
60%
250
how does hormonal contraception work?
•Synthetic versions of estrogen &/or progesterone
–Suppresses FSH and LH surge
–Inhibit follicular maturation; no ovulation
–Thicken cervical mucus
•barrier to sperm
–Alters endometrial lining
•so implantation unlikely
251
what is another name for "the patch"
ortho-evra
252
what does the patch release?
eithnyl estradiol 20 mcg/ 150mcg progestin every 24 hrs
253
how often do you have to change the patch?
changed each week for 3 weeks then one week off, don't apply to breasts
254
what is the patient compliance % for the patch? for the pill users?
88%- patch
| 77%- pill users
255
what are the advantage of the patch?
–avoids gastrointestinal/hepatic interference
| –compliance
256
what are the disadvantages of the patch?
```
–Dysfunctional uterine bleeding
–Dysmenorrhea, breast tenderness
–No STD protection
–Application site reactions ~ 17%
–Higher risk of pregnancy & DUB if >198 #
–TOO MUCH HORMONE???
```
257
Efficacy of the patch?
99%
258
how much eithnyl estradiol is released with the NuvaRing?
15mcg EE (120mcg progestin) daily
259
how often do you change nuvaring?
vaginal insertion 3 weeks and 1 week out for menses (ok for continuous use)
260
advantage of nuva ring?
–avoids gastrointestinal/hepatic interference- lower hormone dosages than OC
–no fittings required
–left in place for 21 days
–may be taken out for up to 3 hours
261
disadvantage of nuvaring
–Comfort and possible side effects : headache, vaginitis, but >40% report no side effects
–no STD protection
262
how much DMPA is in DMPA?
150 mg, injected quarterly
263
how much DMPA is in lunelle?
25mg DMPA + 5mg estradiol, injected monthly with a max of 33 days
264
advantage of DMPA or lunelle/injections?
–longer term birth control, compliance
| –decreased risk of endometrial cancer
265
disadvantage of DMPA or lunelle/injections
–irreversible
–quarterly or monthly doctor visits
–delayed return to fertility (4months- 2years)
–side effects; weight changes, DUB, mood swings
–Osteopenia with prolonged use of DMPA
–no STD protection
266
what is implanon?
progestin only contraception, rod injected underneath the skin of upper arm like Norplant
267
mechanism of implanon?
–thickens cervical mucus prevents sperm from fertilizing egg and from allowing egg that does happen to get fertilized from implanting
–inhibits the ovulation during the first 2y and continues to do so during the 3rd y, but less effectively.
268
side effects of implanon?
Irregular menses, weight gain, acne, headaches, breast tenderness, hair loss, changes in mood and libido, abdominal/pelvic pain, HTN
269
what is the most commonly used reversible contraceptive method?
oral contraceptives
270
who should take progestin only pills?
for women who shouldnt or cant take estrogen
- breast feeding
- risk blood clots
271
is there a placebo with progestin only?
taken daily, no placebo, ALL pills contain hormone
272
advantage of progestin?
```
•Prevention
–unwanted pregnancy
–osteoporosis
–colorectal cancer
•Improves
–DUB
–Mood/PMS
–Dysmenorrhea (92% improve)
–Menorrhagia
–Acne/Hirsuitism/PCOS
•inc. SHBG/dec. testosterone; some forms better than others (Alesse, Yasmin)
- ovarian cancer prevention
- endometrial cancer prevention
–relief of migraines (?)
–lessens fibrocystic breast changes (?)
–endometriosis(?)
–functional ovarian cysts (?)
–emergency contraception
```
273
does ovarian cancer prevention increase with oral contraceptive use?
yes OC > 4 yrs = 30%
| OC x 12+ = 80%
274
does endometrial cancer prevention increase with OC use?
yes
275
what cancer might have an increased risk with OC?
breast cancer
276
how long till after discontinuation of OC does the number of breast cancer cases become same as non user?
10-20 years after discontinuation
277
disadvantages of hormonal contraception
```
Disadvantages of hormonal contraception
•No STI protection
•Not tolerated by all women; side effects
•Risks of using hormones out weighs individual benefits
•Compliance
•Expense
•Unwanted menstrual cycle changes
Possible Side effects:
```
278
Possible side effects of hormonal contraception?
```
•Cardiovascular:
–Increase incidence MI
–HTN
–DVT
–CVA-cerebrovascular accident
–Decrease HDL; increase total cholesterol
•Decrease glucose tolerance
•BTB, amenorrhea
•Vaginitis/ Abnormal PAPs
•Nausea/Vomiting
•Leg cramps
Weight gain (?)
Headaches/migraines; dizziness
•Decrease serotonin --> depression
•*Decrease Zn, Mg, Vit. C, B1, B2, B6, B12, FA
If side effects; different formulation may help
* concurrent use of prenatal vitamin advisable
```
279
what should you warn a girl about OC in regards to antibiotic use?
it might make it less effective so use barrier methods
280
what are some drugs that OC can have interactions with?
•Antibacterials/ antivirals/ antifungal (diflucan; cipro)
- alcohol
- St. Johns Wort
281
contraindications to hormonal contraception?
•Liver disease
•Pregnancy
•History/current HTN or heart/vascular disease
–stroke risks (>35, inc. lipids,HTN, CAD in a family member <45yoa, diabetes, obesity, smoking)
•Migraine with focal neurological sxs
•Breast cancer
•Smoking >15 cigs and >35yoa
–500% increased risk of fatal MI; particularly among women >35 who face greater risk of death due to stroke.
–Risks may be even greater among those patients with a history of migraines.
282
if you take OC the first sunday after the first day of menses do you need back up BC?
yes, needs one week back up BC
283
if you take OC the first day of menstraul cycle, do you need back up BC?
no backup required
284
what is cyclical or continuous OC?
"seasonal" is an 84 day OC
285
what is a missed pill?
a pill not taken within 6 hrs from its normal time is considered a missed pill
286
if you miss 1 pill what should you do?
take missed pill asap
287
if you miss 2 pills in a row what should you do?
READ Directions, in pill pack or contract prescribing provider or pharmicist, may consider use of barrier protection or EC
288
Contraindation for Copper T IUD
```
–Abnormal uterine anatomy
–Enlarged uterus
–Nulliparous
–Current/ past PID
–Known or suspected Pg
–Hx of ectopic pg
–DUB of unknown cause
–Suspected malignancy
–Copper allergy or Wilson's disease
```
289
another name for the Copper T IUD?
paraguard
290
What are some early IUD danger signs for Copper T IUD?
```
•Early IUD danger signs
–Late/missed period (r/o preg)
–Abdominal pain
–Fever, chills
–Increased discharge
–Odorous discharge
–Big changes in bleeding: breakthrough bleeding, heavy periods, clots
```
291
risks of Copper IUD
–Uterine/ tubal infection is limited to time of insertion & is < 1% & reduced to < 0.1% with proper insertion technique
–Perforated uterus, low risk with proper insertion
–No protection from STIs
292
advantages of copper IUD?
–10 years of contraception, easy and often no hassle
–Just as effective as surgical sterilization
–Most cost-effective when cost is over 10 years
–Can be used as emergency contraception
–Efficacy Theoretical 98.5% Actual 96%
293
Potential complications of copper IUD
```
–Spotting, bleeding, hemorrhage, anemia
–Cramping/ pelvic pain
–IUD expulsion: partial or complete
–Lost IUD strings
–Difficult removal
–Pregnancy (failed IUD)
–Uterine perforation
–Pelvic Inflammatory Disease
```
294
Name 3 receptacles for spermicide?
1. condoms
2. diaphragm
3. cervical cap
295
how does spermicide work?
destroy sperm cell membranes
296
disadvantage of spermicide?
Insertion necessary 30 minutes PRIOR to intercourse
Additional insertions with each additional act of intercourse
May increase risk for UTI, vaginitis
“Messy”
Compliance
297
advantage of spermicide?
reversible
298
efficacy of spermicide?
as low as 79% with typical use, increased with barrier
299
what can male condom prevent spread of?
•Fluid –transmiting STI protection
–HIV,GT, CT
–(latex and polyurethane only)
300
advantage of male condom?
afforable and easy access
301
disadvantage of male condoms
–Little to no protection from skin to skin STI like HPV, HSV
302
contraindications for male condoms
–Allergy to spermicide, latex (use avanti and trojan supra)
303
theoretical vs actual effectiveness of male condom with spermicide?
98%- theory
| 85%- actual
304
what is a diaphragm?
latex intravaginal, reversible method
305
contraindications for diaphragm
–severe prolapse
–allergy to latex or spermicide
–vaginal septa or fistula
–recurrent/chronic UTI
306
disadvantage of diaphragm?
–compliance/efficacy
–vaginal irritation, infections, odor
–comfort self or partner
307
where is the cervical cap placed?
suctions directly over the cervix
308
does the cervical cap require proper fitting by physician?
yes
309
risks of cervical cap?
–vaginal/cervical abrasion, infection, TSS, odor, allergy, discomfort
–4% of users will develop an abnormal pap smear so repap in 3months
310
contraindication of cervical cap?
Abnormal PAP
Allergy to rubber; spermicide
Acute cervicitis; vaginitis
311
what is NFP?
natural family planning, helps to identify which days of the month pregnancy is likely by observing and charting physical changes, information can be used to avoid or encourage pregnancy
312
What does successful NFP depends on?
–Regular menstrual cycles
–Compliance with charting & accurate observation
–Able to keep track of various bodily signals that indicate ovulation
–Times with abstinence, mutual partner motivation
- circumstances altering physiology can alter ovulation as well as sx used to track ovulation
313
is tubal sterilization is permanent?
Tubal sterilization is intended to be a permanent method of birth control
314
what is the failure rate in 10 yrs for tubal sterilization?
2%
315
what is a vasectomy?
•surgical procedure severing the vas deferens - the tubes that carry sperm from the testes
316
describe how a vasectomy surgery goes?
•30 minutes under local anesthetic:
–Incision: scrotum numbed w/ local anesthetic, two small cuts in scrotum, lift out each tube, cutting and blocking them so the sperm cannot reach the penis.
–No-incision: freeze skin & nerves to vas deferens, hold VD in place with clamp, tiny puncture is made w/ forceps which stretch the opening so the tubes can be reached, lifted out, and blocked by cutting, cauterizing & applying 2 titanium clips. Tubes are released back into scrotum. Minimal bleeding, no stitches, in-office
317
after how many months should you check to make sure no sperm are present after a vasectomy?
2-3 mnths
318
how many ejaculations post-op vasectomy to flush remaining sperm?
15-20
319
what is a vasovastotomy?
a reversal of the vasectomy
320
what is the possible side effects of vasectomy?
•Pain.
–should stop within a week.
–will respond well to mild analgesics.
•Infection
–watch for fever, persistent swelling/pain
•Granulomas
–benign lump may develop as a result of leakage of sperm from the cut end of the vas into the scrotal tissues resulting in an inflammatory reaction.
–may be painful or sensitive to touch or pressure
–generally treated with anti-inflammatory agents.
•Epididymitis
–inflammation at the site of the vasectomy can causes swelling of the epididymus
–should subside within about one week.
•Abscesses
–rare; the result of infection from the operation, or may be picked up post-operatively.
•Erectile dysfunction
–in the form of impotence, premature ejaculation or painful intercourse.
–may be mostly psychological in nature; vasectomy may exacerbate previous difficulties and problems between sexual partners; counseling may be required to resolve difficulties.
–no evidence that vasectomy decreases testosterone levels or sex drive
•Prostate cancer
–New Zealand study recently published in JAMA has found no association with prostate CA
321
any evidence that a vasectomy decreases tesosterone levels or sex drive?
no evidence
322
any association between vasectomy and prostate CA?
no association
323
what might ED associated with vasectomy be due to?
mostly psychological in nature, may exacerbate previous difficulties and problems between sexual partners; counseling may be required to resolve difficulties
324
what is the morning after pill?
emergency contraceptions, a way to PREVENT PREGNANCY after unprotected intercourse
325
what are two names for the morning after pill?
plan B or preven
326
what is another alternative to the morning after pill?
OCP/hormones taken in high doses within 5 days of unprotected sex
327
Can an IUD be used as EC
yes, inserted within 120 hrs/5 days of unprotected sex, 99% effective in preventing pregnancies
328
what is in preven?
.25mg levonorgesterl & 0.5mg EE, take twice daily, 75% risk reduction
329
what is in plan B?
0.75mg levonorgestrel (1bid) 89% risk reduction
330
will EC affect an established pregnancy?
does not effect it
331
MOA of EC?
```
–Inhibits/delays ovulation
–Alter endometrium
–Thicken cervical mucus
–Alter sperm or ovum transport
–Does not affect an established pregnancy
```
332
What is the dosing of Plan B?
–The sooner EC is initiated the more effective
| –Take tablet(s) with in 120 hrs of unprotected sex followed by second pill(s) 12 hours later
333
Side effects of plan B
```
Side effects:
–nausea and may have vomiting
–dizziness, tired, breast tenderness
–may delay menses
–trigger HSV outbreak if HSV +
```
334
What is mifepristone/ RU486 used for?
non surgical method that mimics SAB/miscarriage
335
what is in mifepristone?
antiprogesterone
336
when should mifepristone be taken?
less than 49 days since LMP
337
Side effects of mifepristone?
–Discomfort (cramps)
–Nausea
–Bleeding for 9 to 13 days ~ up to 67 days
–Heavy bleeding
–Retained tissue
–Surgical abortion due to incomplete termination of pregnancy
•Efficacy 92-97%
338
Contraindications of mifepristone
–Confirmed or suspected ectopic Pg or undx adnexal mass
–IUD in place
–Chronic adrenal failure
–Current long term systemic corticosteroid therapy
–Hx of allergy to mifepristone, misoprostol or other prostaglandins
–Hemorrhagic disorders or concurrent anticoagulant therapy
339
contraceptive risk of death on OC non smoker < 35 YO
1/200k
340
contraceptive risk of death on OC smoker 35-44 YO
1/700
341
what is the least effect contraceptive method?
spermicide alone
342
what is the most effective contraceptive method, top 2?
Vasectomy/Tubal ligation
Abstinence
Most effective
343
list the least effective most effective contraceptive methods
```
Least effective
Spermicide alone
Diaphragm/cervical cap plus spermicide
Condom plus spermicide
Oral contraception
IUD
Vasectomy/Tubal ligation
Abstinence
Most effective
```
344
Define infertility
1. no conception after 12 months of intercourse without contraception in women under 35 years of age
2. no conception after 6 months of intercourse without contraception in women over age 35 years of age
345
what is primary infertility?
nulligravida
346
what is secondary infertility?
infertility without history of prior pregnancy
347
what is the importance of intervention with infertility?
* Pregnancy rates are approximately 2% after the 12th (under age 35) or 6th (over age 35) month without intervention.
* This point underscores the importance of timely specialty referrals to reproductive endocrinologists for evaluation for assisted reproductive therapies.
* Many OB-GYN’s, primary care physicians and complementary care providers may do couples a disservice by waiting too long make these referrals.
348
What are 4 major pelvic factors that affect female infertility?
1. infection
2. surgical hx
3. contraception and preg hx
4. menstraul cycle abnormalities
349
What are some examples of infection that can affect female infertility?
pelvic inflammatory disease, sexually transmitted disease, septic abortion, endometritis, pelvic tuberculosis
350
what are some examples of surgical hx that can cause female infertility?
dilation and curettage, ruptured appendicitis, endometriosis, adnexal surgery, fibroids
351
what are some examples of contraception and preg hx that can cause female infertility?
prior IUD use, DES exposure in utero, ectopic pregnancy, habitual abortion
352
what are some examples of menstrual cycle abnormalities that can cause female infertility?
secondary amenorrhea, endometriosis, cyclic abdominal or pelvic pain
353
What are some ovulatory factors that affect female fertility?
* Secondary amenorrhea
* Abnormal uterine bleeding
* Luteal phase defect (short cycle)
* Premature ovarian failure (early menopause)
* Polycystic ovarian syndrome (high androgen)
* Elevated prolactin
* Hypothyroidism
* Prior use of anti-estrogens (lupron, depo-provera, danazol)
354
can being overweight, depression, substance use, celiac dz or insulin resistance affect female fertility?
yes
355
what are 4 male factors that cause infertility?
1. varicocele
2. unexplained
3. obstructive azoospermia
4. undescended testis
356
What is azoospermia
absence of motile sperm
357
what are some other male factors that can cause infertility?
* Testicular surgeries or injury
* Genitourinary infection or STD’s
* Post-pubertal mumps
* Hypogonadism or other congenital disorder
* Genital radiation or chemotherapy
* Testicular cancer (<0.1% of cases)
* Retrograde ejaculation or other dysfunction
* Exposure to excessive heat (hot tubs, saunas)[?], toxic chemicals, pesticides
* Medications or drug use: nicotine [first- or second-hand], alcohol, cocaine, steroids, marijuana; prescription medications
358
what is a normal D3 FSH level?
<10-15 mIU/ml
359
what is a normal D3 E2 level?
<80 pg/ml
360
when can you do an ultrasound to assess follicle growth and endometrial lining for infertility?
midcycle
361
what would a HSG evaluate?
to assess patency of fallopain tubes
362
how can ovulation be documented?
* midluteal phase progesterone level (<25 may benefit from pv progesterone – Crinone- d14 until menses or week 10-12 of pregnancy)
* basal body temperature
* urinary luteinizing hormone (LH) kits
363
what should be evaluated with irregular cycles?
```
–Testosterone
–Dehydroepiandrosterone sulfate (DHEAS)
–17-OH progesterone
–Cortisol
–Prolactin (PRL)
–Thyroid function tests
```
364
what should the evaluation of the male partner start with?
with a semen analysis
365
when should a semen analysis be performed?
2-5 days of abstinence
366
what is normal volume for semen analysis?
2-5 ml
367
what is the normal sperm # for a semen analysis?
>20 million/ml
368
what is normal motility in a semen analysis?
motility >50% or >25% rapid, forward motility
369
what is the normal % for normal morphology of semen analysis?
35% normal morphology
370
What is the first step to address for infertility?
address basic issues of diet and lifestyle
371
significant longer time to pregnancy (TTP) if?
* the woman or partner smoked >15 cigarettes/day
* the partner consumed>20 alcohol units/week
* the woman's body mass index was >25
* the woman’s coffee and/or tea intake was >6 cups/day
372
do overweight individuals have increased rates of infertility?
yes, PCOS and BMI >25
373
Can fish consumption affect fertility?
* Females with unexplained infertility had higher blood mercury concentrations than fertile counterparts.
* Males in with abnormal sperm had higher blood mercury concentrations
* Blood mercury concentrations were positively correlated with quantity of seafood consumption.
* Frequency of recent fish consumption was associated with an increased risk for delay in pregnancy
374
can celiac disease affect infertility?
–May cause deficiency in a number of nutrients requires special consideration if present in either partner
- adherence to GF diet may improve fertility
375
Can caffeine affect the risk for not achieving a live birth?
–Risk for not achieving a live birth was significantly increased by caffeine consumption of 2-50 mg/day compared with 0-2 mg/day "usually" or during the week of the initial visit.
–Gestational age decreased by 3.8 for women who consumed >50 mg/day of caffeine "usually" or during the week of the initial visit.
–Odds of multiple gestations increased by 2.2-3.0 for men who increased their "usual" intake or intake during the week of the initial visit by an extra 100 mg/day.
376
Should a women exercise before IVF?
although exercise is typically associated with a 7% lower risk of ovulatory infertility, but Regular exercise before IVF may negatively affect outcomes
377
Name some stress reduction techniques
biofeedback, individual/couple therapy, progressive muscle relaxation, acupuncture, yoga, tai chi, qi gong, & meditation should be part of the treatment.
•Medications for anxiety & depression that are safe for use in pregnancy are available for women with more severe symptoms.
378
What about acupuncture for infertility?
* Has been supported in the research in terms of improving pregnancy rates in women undergoing fertility treatment
* Can also be helpful in improving sperm, menstrual cycle regulation, ovulation, and stress, anxiety, and depression
379
What vitamin deficiency can be associated with menstraul cycle dysfunction, recurrent miscarriages and infertillty?
B12
380
what supplement has been shown to improve uterine blood flow and fertilization rate with prior failed IVF
arginine
381
how might vitex/chaste tree help with infertility?
may help lengthen the luteal phase, decrease prolactin and restore ovulation
382
what supplements can help to stimulate ovulation and improve ovarian function
Tribulus and rhodiola
| - combo product called pregnancy prep
383
how might progesterone help in someone with repeated miscarriages?
maintain pregnancies in women with history of repeated miscarriages
- normalize menstraul cycle
- improve implantation rates
384
Name some supplement that may improve sperm quality and quantity
Vit C and E, glutathione, lycopene, and CoQ10, phytoestrogens
385
Name 4 substances that have been correlated with poor sperm quality/quantity
1. caffeine
2. nicotine
3. marijuana
4. alcohol
386
T/F: Women typically suffer more severe and longer term consequences than men
True
387
T/F:For women many RTIs are asymptomatic or unrecognized as serious
T
388
T/F: women are more liekly to acquire STIs from any single sexual encounter
T
389
What are the 5 major concepts prevention and control of STIs are based on?
1. educate and counsel towards safer sex behavior
2. ID asx ppl and sx pp unlikely to seek dx/tx services
3. dx and tx infected ppl
4. evaluate, tx and counsel sex partner who have STI
5. pre-exposure vaccination for at risk ppl
390
What is the common complaint with vaginitis?
itching, burning, dishcarge, odor, pain
391
Dx?
| itching, burning, discharge, odor, pain
vaginitis
392
What is the most infectious agents of vaginitis?
1. bacterial vaginosis 40-50% (gardnerella)
2. candidiasis
3. strep spp
4. trichomonas (STI)
(first 3 are normal flora)
393
What is the most common gynecologic complaint?
vaginitis
394
what is normal vaginal pH?
<4.7
395
what is the name of the normal vaginal flora that maintains the pH?
lactobacillia acidophilus
396
what is the etiology of vaginitis?
imbalance in normal flora --> allows for overfrowth of microorganisms --> sx
397
Name some common risk factors for vaginitis?
•Antibiotics (reduce normal protective (lactobac) bacteria)
•Tight-fitting garments, synthetic fabrics
•Decrease in lactobacillus (low estrogen)
•Douches, chlorinated pools, perfumed toilet paper, diet
•Medical conditions (DM and candidiasis)
•Unprotected sex, numerous partners, new male partner
–pH semen = 7.5
•IUD users (string = vector for upper RTI)
•Women w/ STI’s especially NG, CT, Trich, HIV, HSV (Why?)
•Smokers
•Oral contraceptives
398
What produces the fishy odor of bacterial vaginitis?
amine-induced
399
dx?
| fishy odor?
bacterial vaginitis?
400
agents for bacterial vaginitis?
gardnerella, haemophilus, group B strep: not considered STI, but may be sexually associated (lesbian)
401
is bacterial vaginitis considered an STI?
considered STI, but may be sexually associated (lesbian)
402
What are the clinical criteria for dx bacterial vaginitis?
```
3 out of the 4 findings
1. –pH >4.5
2. –Positive “whiff” test (KOH alkalinizes d/c & releases gas
FISHY)
3.–Positive clue cells
4.–Homogenous discharge
•Be aware of patient self-diagnosing
```
403
Pathogenesis of BV?
•Lactobacilli hydrogen peroxide inhibits growth of anaerobes & other organisms.
•Lactobacilli control the environment;
–if low other bacteria (gardnerella, Group B strep) overgrow amino acids production increase vaginal pH squamous cell desquamation classic discharge
•Elevated pH kills normal flora (lactobacilli) while anaerobes and other bacteria flourish
404
What are the 2 antibiotics for tx of BV?
metronidazole or clindamycin; topical and oral.
405
what are some more natural tx for Bacterial vaginitis?
1. lactobacilli
2. lactic acid gel
3. boric acid vaginally
4. use condoms before and after tx, dont douche
406
dx?
| pruritis, white-yellow d/c, erythematous tissue, often vulvar component ?
candida vulvovaginitis VVC mc d/t candida albicans
407
describe the sx of yeast infection?
Pruritis, white-yellow d/c, erythematous tissue, often vulvar component (fissures)
408
How do you dx VVC?
with wet mount/or culture
1. 10% KOH wet mount
- pseudohyphae
- budding yeast
- pH 3.8-4.5 (normal)
409
What are some predisposing factors for VVC?
```
•Diabetes
•Pregnancy
•Antibiotic use
•Corticosteriods
•Unprotected intercourse (semen pH); spermacides; lubricants; oral sex
•HIV infection
•Douching
•Menses/hormones
•Occlusive clothing
•Dietary choices
–can increase risk if susceptible
```
410
Tx for VVC?
•Treat underlying cause if known
–Pre-treatment if during menstrually-associated
•Antifungal: ~azoles (i.e.clotrimazole, miconazole), nystatin
•Boric acid suppositories
•OTC topical steroids for sx relief
•Oral/vaginal acidophilus
•Sitz baths
•Diet: may eliminate sugar, alcohol, processed food
•Treatment of partner not necessary
411
Is trichomoniasis vaginalis a STI?
yes
412
what is the protozoal that causes trichomoniasis vaginalis?
trichomonas vaginalis
413
can Trich vaginalis faciliate the transmission and acquisitiion of HIV and other STI?
yes
414
how do you dx trich vaginalis?
fresh normal saline wet mount
1. motile organisms with flagella
2. increased PMNs WBC
415
What can trich vaginalis infect?
vagina, skene's ducts, & lower urinary tract in men and women
416
what color is the typical discharge with trich vaginalis?
yellow/green frothy
417
dx? yellow/green frothy discharge
trich vaginalis
418
what does the cervix look like with severe trich vaginalis infection?
strawberry cervix, with red macular spots
419
dx? strawberry cervix?
trich vaginalis
420
tx for trich vaginalis?
1. Empirically treat partner(s) even if asymptomatic
2. Metronidazole or tinidazole is treatment of choice
3. Adequate lactobacilli may prevent infections
421
What cells are infected with chlamydia or gonorrhea?
genital columnar epithelium
422
what might someone present with sx wise with chlamydia?
asx, cervicitis, urethritis, PID, Reiter's syndrome
423
how might someone present with gonorrhea infection?
asx, cervicits, urethritis, PID, pharyngitis, arthritis
424
Since 1988 what has been the most commonly reported communicable dz in oregon?
chlamydia trachomatis
425
who had the most positive gonorrhea tests?
2.5x higher among younger women, african americans had 5x higher prevalence
426
what % of men with Neisseria gonorrhea were asx?
22%
427
How do women usually present with CT or GC?
```
•Asymptomatic
•Vaginal discharge
•Dysuria
•Dyspareunia
•Low abdominal pain, CPP
•Unusual bleeding
–metrorrhagia
–menorrhagia
```
428
how do men usually present with CT or GC
* Asymptomatic
* Penile discharge
* Dysuria
* Burning/pruritus around urethral meatus
* Pain with ejaculation
* Pain and swelling in the testicles
429
Are GC and CT reportable disease in oregon
yes
430
Signs of CT or NG?
- Mucopurulent cervicitis
- Urethritis
- Gonorrheal Conjunctivitis
- Gonorrheal Opthalmia Neonatorum
431
How to test for NG and CT?
•Cervical/urethral culture or via urine
–DNA Probe Culture is GOLD STANDARD
•Can be tested with liquid-based pap
•Test/treat partner(s)
432
What is the gold standard for NG and CT testing?
DNA probe culture
433
What is the CDC screening recommendations of Ct/NG?
1. annual screening of all sexually active women <25 years
2. annual screening of all sexually active women >25 years with risk factors
3. rescreen women 3-4 months after tx d/t high prevalence of repeat infection
434
Who should you screen for NG/GT
* Clinical symptoms
* New prenatal patients
* Before inserting an IUD
* Multiple partners in last 60 days
* Sexual assault victim
435
Tx for NG?
* Ciprofloxacin 500 mg orally in a single dose,
| * Ofloxacin 400 mg orally in a single dose, PLUS Azithromycin 1 g orally in a single dose
436
What supplement may prevent NG/CT infections?
lactobacillus
437
Tx for CT?
–A single dose of azithromycin or a week of doxycycline (twice daily) are the most commonly used treatments.
–Also, tetracyclin, erthyromicin
438
Sx of epididymitis?
*•Scrotal pain
•Scrotal swelling
•Fever
•Penile discharge*
* Chills
* Abdominal pain
* Pelvic pain
* Frequent urge to urinate
* Dysuria
* Hematuria
* Painful ejaculation
439
What are you looking for in the first void urine with epididymitis?
WBCs
440
dx procedure for epididymitis?
DNA probe
- intraurethral culture ofr GC and CT
- LCR urine test
441
What organisms are responsible for epididymitis?
GC and CT
