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UWS Q9 > GU Survery Exam 2 > Flashcards

GU Survery Exam 2 Flashcards

1
Q

Define neoplasm

A

atypical cell growth

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2
Q

3 classifications of ovarian neoplasms

A
  1. Benign
  2. Low malignant potential
  3. malignant
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3
Q

What are 5 complications of ovarian masses?

A
  1. torsion
  2. rupture
  3. infection
  4. hemorrhage
  5. malignant potential (exception is functional cysts)
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4
Q

3 types of functional cysyts?

A
  1. follicular cyst
  2. corpus luteum cyst
  3. theca lutein cyst
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5
Q

Are functional cysts benign or malignant?

A

benign

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6
Q

what type of mass is a dermoid?

A

neoplasm

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7
Q

besides malignancies, neoplasms or functional cysts, what are 3 other ovarian masses?

A
  1. endometrioma
  2. PCOS
  3. tubo-ovarian abscess
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8
Q

What is the most common type of functional cyst?

A

follicular cyst

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9
Q

What is the least common functional cyst?

A

corpus luteum

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10
Q

What is the most common ovarian mass?

A

theca lutein cyst

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11
Q

What are 2 causes of follicular cysts?

A
  1. dominant follicle fails to rupture (persistent follicle)
  2. immature follicle failing to undergo normal process of atresia
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12
Q

How long before the follicular cyst disappears?

A

Within 1-3 months

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13
Q

What is it called when blood fills the cavity of a follicular cyst?

A

Hemorrhagic or chocolate cyst

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14
Q

Which functional cyst is less than common than follicular but clinically more important

A

corpus luteum cyst

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15
Q

What are corpus luteum cysts associated with?

A

normal endocrine function or prolonged progesterone secretion

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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

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17
Q

When do corpus luteum cysts typically occur?

A

2-4 days post ovulation

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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

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19
Q

What is the chance of recurrence for corpus luteum cysts?

A

31% chance of recurrence

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20
Q

What is the least common functional cyst?

A

least common

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21
Q

Are theca lutein cyst usually unilateral or bilateral?

A

bilateral

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22
Q

What are the typical symptoms with theca lutein cysts?

A

usually asymptomatic

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23
Q

What causes theca lutein cysts?

A

caused by prolonged or excessive stimulation of the ovaries by endogenous or exogenous gonadotropins

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24
Q

What are some causes or endogenous or exogenous gonadotropins?

A
  1. multiple preg (twins)
  2. fertility drugs
  3. molar pregnancies
  4. choriocarcinoma
  5. diabetics
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25
Q

how long till the theca lutein cysts?

A

typically resolve spontaneously

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26
Q

When are functional ovarian cysts usually discovered?

A

routine pelvic exams

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27
Q

What are functional ovarian cysts symptoms?

A

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
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28
Q 
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
A

Functional ovarian cysts

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29
Q

What symptoms would require an immediate referral?

A 
•pain with fever and vomiting
•sudden, severe abdominal pain
•fainting, dizziness, or weakness
Adnexal Masses
•rapid breathing or heart rate (tachypnea, tachycardia)
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30
Q

What is another name for a teratoma?

A

dermoid tumor/cyst

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31
Q

What cyst contains all three germ layers?

A

dermoid/teratoma

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32
Q

what cyst is composed of skin and filled with hair, glands, muscle, bone, teeth, cartilage, respiraotry/GI epithelium, thyroid tissue

A

dermoid/teratoma

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33
Q

What is the most common ovarian neoplasm in prepubescebt girls and teens

A

dermoid/teratoma

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34
Q

age for dermoid cyst?

A

25-50

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35
Q

is there malignant potential for dermoid cyst?

A

usually removed d/t malignant potential, tho very low

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36
Q

How do you normally discover teratomas?

A

incidentally discovered on pelvic exam or imaging (50% have calcifications)

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37
Q

Who has 20% of all benign ovarian tumors?

A

postmenopausal women

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38
Q

what modality is used to dx an endometrioma?

A

US

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39
Q

pain level of endometrioma?

A

painless to severely painful?

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40
Q

Can endometriomas recur?

A

frequently recur if not completely resected

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41
Q

What is a tubo-ovarian abscess?

A

infection in the tubo-ovarian junction

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42
Q

What are the two typical causes of tubo-ovarian abscess?

A

gonorrhea and chlamydia is typical cause

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43
Q

S/Sx of tubo-ovarian abscess?

A

–Tubal/ovarian swelling/enlargement
–Pelvic pain
–Fever
–Vaginal discharge

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44
Q

What are two long term sequelae of tubo-ovarian abscesses?

A
  1. infertility (scared uterine tubes)

2. chronic pelvic pain (adhesions)

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45
Q

What is the ovarian mass malignancy risk for premenopausal women?

A

13%

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46
Q

What is the ovarian mass malignancy risk for postmenopausal for postmenopausal women?

A

45%

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47
Q

What is the 5ht leading cause of death?

A

ovarian cancer

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48
Q

what is the cause of 50% of all GYN cancer deaths?

A

ovarian cancer

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49
Q

peak age of ovarian cancer?

A

60-65

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50
Q

Risk factors of ovarian cancer?

A

•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

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51
Q

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

A

ovarian cancer

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52
Q

GI sx associated with ovarian cancer?

A

nausea, epigastric upset, gas/bloating

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53
Q

menstrual abnormalities with ovarian cancer?

A

oligomenorrhea or amenorrhea, DUB

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54
Q

hormonal changes associated with ovarian changes?

A

feminization, masculinization

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55
Q

typical cancer sx’s (5)?

A

mass, weight loss, nightsweats, anemia, ascites

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56
Q

what labs would you run for ovarian cancer?

A
  1. HCG
  2. CBC
  3. renal/LFT
  4. tumor markers Ca125
  5. CEA
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57
Q

what radiographic evaluation for ovarian cancer?

A
  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)
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58
Q

Does an elevated CA-125 mean cancer?

A

false positive are common, also fibroids, benign ovarian tumors, adenomyosis, endometriosis, PID

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59
Q

What does the USPSTF recommend for ovarian cancer screening?

A

against routine screening

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60
Q

Why does the USPSTF recommend against screening?

A

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

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61
Q

What is the take home message about ovarian cancer screening?

A

potential harms outweigh potential benefits of screening

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62
Q

Ovarian cancer stage 1: where is it, 5 yr survival rate?

A

limited to ovaries, 75-100%

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63
Q

Ovarian cancer stage 2: where is it, 5 yr survival rate?

A

pelvic extension, 45-60%

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64
Q

Ovarian cancer stage 3: where is it, survival rate? 5 yr survival rate?

A

abdominal/lymph spread, 42% survival rate, 5 year- 15-50%

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65
Q

Ovarian cancer stage 4: where is it, 5 yr survival rate?

A

malignant pleural effusion, mets to the liver, 5%

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66
Q

What is the gold standard modality for dx masses?

A

ultrasound

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67
Q

What physical exam procedures should be performed of the patient with ovarian mass?

A
  1. lymph node survery
  2. breast exam
  3. ab exam
  4. bimanual exam
  5. rectovaginal exam
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68
Q

if the mass is cystic, smooth, unilocular, unilateral, small <5cm suspicious or benign?

A

benign

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69
Q

If the mass is solid or mixed cystic/solid, multilocular, bilateral, irregular, large >10cm with internal septae or papillae suspicious or benign?

A

suspicious

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70
Q

When should you consider a laparoscopy for ovarian mass? (4)

A
  1. > 7-10cm
  2. continues to enlarge
  3. looks suspicious on US
  4. with suspicious hx, presentation, PE
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71
Q

What nutritional and lifestyle changes would you recommend for prevention of ovarian masses?

A
  1. eliminate animal fats, saturated fats
  2. eliminate alcohol esp. wine
  3. quit smoking
  4. high fruits/vegetables
  5. decrease cholesterol
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72
Q

Supplement recommendation for ovarian mass?

A
  1. beta carotene
  2. selenium
  3. Vit C/E
  4. isoflavones
  5. folic acid
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73
Q

what are some life things/med/surgeries that are preventative for ovarian mass?

A
  1. breast feeding
  2. hormonal contraception
  3. bilateral tubal ligation
  4. prophylactic bilateral oophorectomy
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74
Q

what are the common ovarian mass found in newborns?

A

small functional cysts 1-2cm that regress in months

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75
Q

what are the common ovarian mass found in premenarchal girls?

A

teratomas/dermoids

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76
Q

what are the common ovarian mass found in reproductive age?

A

functional cysts, endometriomas, tubo-ovarian abscesses, PCOS, ectopic preg, teratoma

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77
Q

what are the common ovarian mass found in post-menopausal?

A

must r/o cancer

increased risk of malignancy (both primary ovarian carcinoma and metastatic from uterus, breast or GI)

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78
Q

lymph flow starting in breast?

A

breast –> axilla –> supraclavicular

  • -> cervical nodes
  • -> opposite breast
  • -> abdominal lymphatics
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79
Q

Where is the most common site for fibrous cystic changes (benign) and/or malignant disease?

A

UOQ, upper outer

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80
Q

Where is another common site for fibrous changes besides UOQ

A

inframammary line (lower arc of the breast)

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81
Q

What about the area of fibrous tissue would make you less worrisome?

A

if symmetrical, painful, freely mobile

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82
Q

When in the cycle should clinical breast exam be performed?

A

optimal 5 days post menses, due to decreased hormonal influence

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83
Q

where does the breast lie?

A

lies between ribs 2-6, between the sternal edge and midaxillary line

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84
Q

what is the “tail” of the breast?

A

UOQ to axilla area

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85
Q

What are the 3 most common conditions for which a woman consults her doctor?

A
  1. breast pain
  2. nipple discharge
  3. palpable mass
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86
Q

what is the goal of breast evaluation?

A

to r/o cancer

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87
Q

what does the extent of breast evaluation depend on?

A
  1. natural of clinical problem
  2. age
  3. risk status
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88
Q

define mastalgia?

A

breast pain/tenderness

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89
Q

is mastalgia more common in pre or postmenopausal women?

A

MC in premenopausal

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90
Q

is mastalgia a typical symptom of cancer?

A

rarely a symptom of cancer

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91
Q

Causes of mastalgia?

A

hormonal, PMS, trauma, acute infection, M/S, cancer

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92
Q

with mastalgia when should you do and not do a mammogram?

A

physical exam finding and >35 YO consider mammogram, <35 with normal exam not indicated

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93
Q

treatment for mastalgia?

A
  1. 60-80% spontaneous remission, prospective charting

2. sx may be improved or exacerbated with hormonal tx

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94
Q

fibroadenomas malignant or benign?

A

benign

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95
Q

do fibroadenomas fluctuate with cycle?

A

yes size may

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96
Q

dx?

rubbery, firm, smooth, round, mobile, painless?

A

fibroadenoma

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97
Q

describe a fibroadenoma?

A

–Rubbery, firm, smooth, round, mobile, painless

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98
Q

Dx?

–mammography= solid, well-circumscribed, may be multilobulated/calcified (popcorn appearance)

A

fibroadenoma

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99
Q

what % of women will have multiple fibroadenomas?

A

up to 20%

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100
Q

age range for fibroadenomas?

A

15-50, no common in menopause unless on HRT

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101
Q

management of fibroadenomas?

A

CBE, mammogram, US, needle bx, tend to regress over time

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102
Q

Tx for fibroadenoma?

A

surgical excision, watch and wait

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103
Q

dx?

–Fluid filled lesion
–Soft, yet firm, mobile, well circumscribed, unilateral or bilateral, tender
–Cyclical fluctuations

A

simple cysts

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104
Q

describe the characteristics of simple cysts?

A

–Fluid filled lesion
–Soft, yet firm, mobile, well circumscribed, unilateral or bilateral, tender
–Cyclical fluctuations

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105
Q

age for simple cyst?

A

15-50, not common in menopause

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106
Q

management of simple cysts?

A

–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.

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107
Q

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

A

fibrocystic breast changes

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108
Q

characteristics of fibrocystic breast changes?

A

–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

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109
Q

symptoms of fibrocystic breast changes?

A 
–Cyclical pain or constant
–Variation in size
–High mobility
–Multiple nodules
–Pre-menstrual aggravation
–Diffuse swelling
–Tenderness
–Heaviness
–Itching of nipple
–Usually UOQ
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110
Q

What beverages should be avoided with fibrocystic breast changes?

A

Methylxanthines

•Limiting coffee, tea, cola, chocolate and caffeinated medications

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111
Q

what dietary changes should be incorporated with fibrocystic breast changes?

A

•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)

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112
Q

What supplements may help with fibrocystic breast changes?

A

vit E and evening primrose oil

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113
Q

define mastitis?

A

infection during lactation or when skin disruption

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114
Q

mastitis presentation?

A

fever, localized erythema, pain, induration, n/v, malaise, fever, chills

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115
Q

bacterial etiology of mastitis?

A

S. aureus, S. epidermis, strep

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116
Q

Risk factors for mastitis?

A

breast feeding, trauma, breast augmentation

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117
Q

When is the most common time for mastitis?

A

most common in first 2-4 weeks postpartum

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118
Q

what is a galactocele?

A

obstruction of breast duct usually after lactation

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119
Q

Sx/s of galactocele?

A

tender and enlarged

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120
Q

tx for galactocele?

A

excise and drain

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121
Q

what is the most common cause of nipple discharge?

A

benign breast dz

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122
Q

what % of benign breast dz has Nd/c

A

10-15%

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123
Q

what % of malignant dz will have Nd/c

A

3-11%

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124
Q

what characteristics of nipple discharge or mass makes you more concerned about possible breast cancer?

A
  • discharge is bloody
  • assoc with mass
  • unilateral
  • single duct
  • spontaneous
  • postmenopausal
  • using HRT
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125
Q

what characteristics of nipple discharge or mass makes you think benign?

A 
•Often Bilateral
•Nonspontaneous
–Needs stimulation (contact, pressure)
•Multiple ducts involved
–determine quadrants when applying pressure
•Serous d/c may be caused by hormones
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126
Q

Describe pathologic discharge

A

•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

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127
Q

what is galactorrhea?

A

inappropriate lactation in the nonpuerperal woman (during/after preg), milky d/c

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128
Q

what should you evaluate for with galactorrhea?

A

evaluate for elevated prolactin levels

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129
Q

if prolactin is elevated with galactorrhea then do what?

A

order a CT to r/o pituitary tumor

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130
Q

what are some causes of galactorrhea?

A

–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.

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131
Q

what is an intraductal papilloma?

A

papillary growth inside a lactiferous duct

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132
Q

what is the #1 cause of nipple d/c

A

intraductal papilloma

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133
Q

what is the discharge like with an intraductal papilloma?

A

can be bloody or serous

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134
Q

are intraductal papillomas malignant or benign?

A

benign

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135
Q

tx for intraductal papilloma?

A

surgical excision b/c they tend to grow, breast feeding not altered if <3 ducts removed

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136
Q

causes of subareolar abscess?

A

S. aureus or anaerobic organisms

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137
Q

who is more common to have recurrent subareolar abscess?

A

recurrent in women w/ inverted nipples

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138
Q

what leads to an increase chance of subareolar abscess?

A

increased chance with/after nipple piercing

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139
Q

Tx for subareolar abscess?

A

antiobiotics, drainage, duct excision

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140
Q

what is the most common cancer in women?

A

breast cancer

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141
Q

what is the second leading cause of cancer deaths in women?

A

breast cancer, 1/3 will die from it

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142
Q

leading cause of death in women 40-55 YO?

A

breast cancer

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143
Q

What is the USPSTF recommendation for mammography screening women aged 50-74?

A

biennial, every two years

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144
Q

does the USPSTF recommend mammography for women over 75 years?

A

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.

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145
Q

what does the USPSTF recommend for breast self-exam?

A

recommends against teaching it

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146
Q

film mammography or digital or MRI for USPST recommendation?

A

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.

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147
Q

what about using US for breast cancer?

A

ineffective as a screening tool

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148
Q

PROs of mammography?

A

decrease mortality d/t earlier detection

-

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149
Q

Cons of mammography?

A

•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).

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150
Q

what can an ultrasound be used for regarding breast carcinomas?

A

detection of fluid filled vs solid mass

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151
Q

what female patients need an MRI regarding potential breast cancer?

A

•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)

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152
Q

what is a DBT?

A

digital breast tomosynthesis

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153
Q

rates of cancer with DBT?

A
  • 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.
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154
Q

when do you do needle aspirations?

A

to evaluate fluid filled lesions

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155
Q

what should you do if you have bloody aspiration?

A

biopsy is recommended

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156
Q

what should you do with cysts that reoccur within 2 weeks or require >1 aspiration

A

biopsy is recommended

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157
Q

What largely replaces a needle biopsy?

A

core biopsy

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158
Q

what is the definiitve step to determine that a mass is benign or malignant?

A

biopsy

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159
Q

what is the usual sequence before doing a biopsy?

A

mammogram –> US –> biopsy

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160
Q

avg age of breast cancer in men?

A

65

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161
Q

do men with breast cancer have any risk factors?

A

no apparent risk factors

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162
Q

what should lead to an immediate referral for men?

A

–breast lump, swelling, skin dimpling, puckering, nipple d/c, redness/scaling or skin/nipple, axillary node changes, persistent pain

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163
Q

men with breast cancer are more or less likely to have nipple d/c?

A

more likely

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164
Q

what are some breast cancer risk factors for men?

A

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.

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165
Q

what % of breast cancer patients have no major risk factors?

A

75%

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166
Q

what % of breast cancer patient do not have a primary relative with breast cancer?

A

90%

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167
Q

S/Sx early stage of breast cancer

A

–firm to hard mass
–irregular contour
–immobile
–unilateral

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168
Q

S/Sx late stage of breast cancer

A 
–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 &amp; Symptoms
–itching/burning of skin or nipple
–nipple/skin erythema, rash, ulcerations
•Easily missed dx and tx’d as a dermatitis
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169
Q

what is breast cancer often dx’d as?

A

dermatitis

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170
Q

Breast cancer tx options?

A 
•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
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171
Q

non-modifiable risk factors for breast cancer

A 
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
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172
Q

modifiable risk factors for breast cancer

A 
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
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173
Q

things that decrease breast cancer risk

A
  • 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
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174
Q

list some concepts in breast cancer prevention

A 
•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
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175
Q

positive correlations with breast cancer

A
  • Animal foods
  • Meats
  • Total fat
  • Saturated fats
  • Dairy
  • Refined sugar
  • Total calories
  • Alcohol
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176
Q

negative correlations with breast cancer

A
  • Fish
  • Whole grains
  • Legumes
  • Cabbage
  • Vegetables
  • Nuts
  • Fruits
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177
Q

goals of nutritonal therapy for breast cancer

A
  • 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
Q

flax lignans and breast cancer?

A

•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
Q

breast cancer and ALA

A

•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
Q

fish oil and breast cancer

A

•Fish oil supplementation

–Reduced TNF alpha and interleukin beta production by 74%

181
Q

lycopene and breast cancer

A

•Serum and tissue lycopene levels found to be inversely related to the incidence of several cancers (breast and prostate).

182
Q

green tea and breast cancer

A
  • 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
Q

tumeric and breast cancer?

A
  • 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
Q

High sugar consumption is an increase risk for several cancers:?

A

–breast
–Colon
–melanoma
–prostate

185
Q

define glycemic index?

A

•Glycemic Index refers to the rise in blood sugar after ingesting a serving of food that provides 50grams of CHO

186
Q

define glycemic load?

A

•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
Q

how does alcohol affect breast cancer?

A

–EtOH > Decreased folate> increased BrCa

–Folic acid protects DNA

188
Q

how does alcohol affect colon cancer?

A

–Alcohol interfers with methylation (changes in DNA)

189
Q

majority of cervical CA in the US occur in women who: (3)

A
  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
Q

by how much has proper cervical cancer screening reduced the incidence by?

A

50%

191
Q

What is the cell type on the outside of the cervix and the vagina?

A

squamous cells

192
Q

what type of cells line the canal of the cervix?

A

columnar cells

193
Q

what is the junction between the two cells types called?

A

transitional zone, SCJ

194
Q

Where does 95% of all nervical intraepithelial neoplasia, or abnormal growth/dysplasia occur in the cervix?

A

transitional zone

195
Q

define cervical dysplasia?

A

disordered growth

196
Q

describe the normal cervical layer of cells. where is the young cells? where is the mature cells?

A

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
Q

CIN I what is the severity of dysplasia?

A

mild dysplasia

198
Q

CIN II what is the severity of dysplasia?

A

moderate dysplasia

199
Q

CIN III or carcinoma in situ what is the severity of dysplasia?

A

severe dysplasia

200
Q

Where are the abnormalities with dysplasia and carcinoma-in-situ

A

all the abnormalities are confined to the surface of the cervix

201
Q

Where are the abnormalities with invasive cancer?

A

the cells are disordered throughout the entire thickness of the lining and they invade the tissue underlying the surface

202
Q

When should regular pap smear screening for all women who are sexually active and have a cervix begin?

A

at age 21 or 3 years after first intercourse, whichever comes first

203
Q

how often shoulder women less than 30 have pap smears?

A

annually

204
Q

Based on USPSTF how often should women 30-65 have pap smears?

A

every 2-3 years after 3 consecutive normal annual paps

205
Q

what does the USPSTF recommend for women >65 regarding pap smears?

A

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
Q

Pap smears after a hysterectomy?

A

–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
Q

Post tx for CIN recommendation for pap smear

A

screening every 6 months X 2 then annually

208
Q

Which has a better sensitivity conventional or liquid based pap?

A

liquid based aka thinprep or surepath

209
Q

how many cervical CA cases in US each year in women with normal pap tests?

A

2500-3000

210
Q

Based on bethesda classification of paps: which one has variation of normal, such as “irritation or inflammation”

A

atypia

211
Q

Based on bethesda classification of paps: which one has “abnormal squamous cells of undetermined significance, benign changes that should be monitored”

A

ASCUS

212
Q

Based on bethesda classification of paps: which one has mild dysplasia, aka LGSIL- low grade squamous intraepithelial lesion

A

CIN I

213
Q

Based on bethesda classification of paps: which one has moderate dysplasia, HGSIL

A

CIN II

214
Q

what is HGSIL

A

high grade squamous intraepithelial lesion

215
Q

Which CIN has severe dysplsia with HGSIL?

A

CIN III

216
Q

What is CIS?

A

carcinoma in situ, precancer

217
Q

Which bethesda classification of paps is precancer

A

CIS

218
Q

what is the best response to give regarding HPV dx?

A

this virus, like most viruses, will most likely subside and disappear

219
Q

Name some things that increase the risk of cervical dysplasia and cancer

A
  • 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
Q

Name some things that decrease the risk of cervical dysplasia and cancer

A
  • Barrier contraception use~ decreased HPV transmission & speeds regression of both penile & cervical lesions
  • Quit smoking
  • Stop OCP
221
Q

Are high risk HPV strains more or less likely to result in high grade lesions that lead to cervical cancer?

A

more likely

222
Q

what are low risk HPV strains more likely to result in?

A

cervical changes that are less likely to be precancerous altho may cause warts

223
Q

How long does it take for HR-HPV to cause mutations?

A

about 3 years, hence cervical cancer in women under the age of 19 is rare

224
Q

is HPV contagious during sex?

A

yes very contagious during intercourse

225
Q

is condom use completely protective in HPV spread?

A

–condom use is not completely protective because the virus can spread through skin-to-skin contact beyond the genitals.

226
Q

HPV is found in ____% of sexually active adults

A

> 70

227
Q

how many peeps with HPV develop visible venereal warts?

A

only 1%

228
Q

in how many years in teens and early 20’s, 70% HR-HPV & 90% of LR-HPV types?

A

regress after 3 years

229
Q

What are a couple of early signs or symptoms of cervical cancer?

A

often there are NO early signs or symptoms, but can be cervical discharge or abnormal uterine bleeding

230
Q

who is recommended to get the HPV vaccine?

A

girls 9-26

231
Q

how often do you get the HPV vaccine?

A

series of 3 injections over 6 mnths

232
Q

if your patient reports an abnormal pap smear… what then? what dx tests may be indicated?

A

Colposcopy

233
Q

what is a colposcopy?

A

direct magnification and viewing of cervix, vulva, vagina, and/or perianal tissue plus biopsy of tissue

234
Q

What are some indications for a colposcopy?

A
  • 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
Q

which type of cellular changes of the cervix usually go away without tx?

A

ascus, atypia, CIN I

236
Q

when should someone with ascus, atypia or CIN I have pap smears?

A

every 4 months in 1st year, every 6 months in 2nd year, CIN II tx for persistent lesions

237
Q

what are some tx for CIN II

A

–Cryotherapy
–Loop Excision (LEEP)
–Pap test every 4 months in 1st year, every 6 months in 2nd

238
Q

is tx recommended for CIN II?

A

yes, most don’t go away

239
Q

what kind of treatment is recommended for CIN III and CIS

A

–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
Q

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

A

cryotherapy

241
Q 
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
A

Leep , loop electrosurgical excision procedure

242
Q

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

A

conization

243
Q

list 3 types of vaginal suppositories for CIN

A
  1. green tea
  2. vit A and herbal compound
  3. riboflavin B2, have been shown to cause regression of CIN
244
Q

supplements for CIN?

A 
–Antioxidants reduce risk of CIN &amp; cancer
–Folic acid and beta carotenes
–Pyridoxine (B6)
–Selenium
–Zinc
245
Q

what is DES?

A

Diethylstilbestrol
–synthetic non-steroidal estrogen
–used to prevent miscarriage & other pregnancy complications from 1938-1971.

246
Q

what are the effects of DES?

A

–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
Q

Suggested screening for interval for DES daughters?

A
  • 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
Q

average age of first intercourse?

A

16.5

249
Q

what percentage of all unintended pregnancies occur in women who are using birth control?

A

60%

250
Q

how does hormonal contraception work?

A

•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
Q

what is another name for “the patch”

A

ortho-evra

252
Q

what does the patch release?

A

eithnyl estradiol 20 mcg/ 150mcg progestin every 24 hrs

253
Q

how often do you have to change the patch?

A

changed each week for 3 weeks then one week off, don’t apply to breasts

254
Q

what is the patient compliance % for the patch? for the pill users?

A

88%- patch

77%- pill users

255
Q

what are the advantage of the patch?

A

–avoids gastrointestinal/hepatic interference

–compliance

256
Q

what are the disadvantages of the patch?

A 
–Dysfunctional uterine bleeding
–Dysmenorrhea, breast tenderness
–No STD protection
–Application site reactions ~ 17%
–Higher risk of pregnancy &amp; DUB if >198 #
–TOO MUCH HORMONE???
257
Q

Efficacy of the patch?

A

99%

258
Q

how much eithnyl estradiol is released with the NuvaRing?

A

15mcg EE (120mcg progestin) daily

259
Q

how often do you change nuvaring?

A

vaginal insertion 3 weeks and 1 week out for menses (ok for continuous use)

260
Q

advantage of nuva ring?

A

–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
Q

disadvantage of nuvaring

A

–Comfort and possible side effects : headache, vaginitis, but >40% report no side effects
–no STD protection

262
Q

how much DMPA is in DMPA?

A

150 mg, injected quarterly

263
Q

how much DMPA is in lunelle?

A

25mg DMPA + 5mg estradiol, injected monthly with a max of 33 days

264
Q

advantage of DMPA or lunelle/injections?

A

–longer term birth control, compliance

–decreased risk of endometrial cancer

265
Q

disadvantage of DMPA or lunelle/injections

A

–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
Q

what is implanon?

A

progestin only contraception, rod injected underneath the skin of upper arm like Norplant

267
Q

mechanism of implanon?

A

–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
Q

side effects of implanon?

A

Irregular menses, weight gain, acne, headaches, breast tenderness, hair loss, changes in mood and libido, abdominal/pelvic pain, HTN

269
Q

what is the most commonly used reversible contraceptive method?

A

oral contraceptives

270
Q

who should take progestin only pills?

A

for women who shouldnt or cant take estrogen

  • breast feeding
  • risk blood clots
271
Q

is there a placebo with progestin only?

A

taken daily, no placebo, ALL pills contain hormone

272
Q

advantage of progestin?

A 
•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
Q

does ovarian cancer prevention increase with oral contraceptive use?

A

yes OC > 4 yrs = 30%

OC x 12+ = 80%

274
Q

does endometrial cancer prevention increase with OC use?

A

yes

275
Q

what cancer might have an increased risk with OC?

A

breast cancer

276
Q

how long till after discontinuation of OC does the number of breast cancer cases become same as non user?

A

10-20 years after discontinuation

277
Q

disadvantages of hormonal contraception

A 
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
Q

Possible side effects of hormonal contraception?

A 
•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
Q

what should you warn a girl about OC in regards to antibiotic use?

A

it might make it less effective so use barrier methods

280
Q

what are some drugs that OC can have interactions with?

A

•Antibacterials/ antivirals/ antifungal (diflucan; cipro)

  • alcohol
  • St. Johns Wort
281
Q

contraindications to hormonal contraception?

A

•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
Q

if you take OC the first sunday after the first day of menses do you need back up BC?

A

yes, needs one week back up BC

283
Q

if you take OC the first day of menstraul cycle, do you need back up BC?

A

no backup required

284
Q

what is cyclical or continuous OC?

A

“seasonal” is an 84 day OC

285
Q

what is a missed pill?

A

a pill not taken within 6 hrs from its normal time is considered a missed pill

286
Q

if you miss 1 pill what should you do?

A

take missed pill asap

287
Q

if you miss 2 pills in a row what should you do?

A

READ Directions, in pill pack or contract prescribing provider or pharmicist, may consider use of barrier protection or EC

288
Q

Contraindation for Copper T IUD

A 
–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
Q

another name for the Copper T IUD?

A

paraguard

290
Q

What are some early IUD danger signs for Copper T IUD?

A 
•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
Q

risks of Copper IUD

A

–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
Q

advantages of copper IUD?

A

–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
Q

Potential complications of copper IUD

A 
–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
Q

Name 3 receptacles for spermicide?

A
  1. condoms
  2. diaphragm
  3. cervical cap
295
Q

how does spermicide work?

A

destroy sperm cell membranes

296
Q

disadvantage of spermicide?

A

Insertion necessary 30 minutes PRIOR to intercourse
Additional insertions with each additional act of intercourse
May increase risk for UTI, vaginitis
“Messy”
Compliance

297
Q

advantage of spermicide?

A

reversible

298
Q

efficacy of spermicide?

A

as low as 79% with typical use, increased with barrier

299
Q

what can male condom prevent spread of?

A

•Fluid –transmiting STI protection
–HIV,GT, CT
–(latex and polyurethane only)

300
Q

advantage of male condom?

A

afforable and easy access

301
Q

disadvantage of male condoms

A

–Little to no protection from skin to skin STI like HPV, HSV

302
Q

contraindications for male condoms

A

–Allergy to spermicide, latex (use avanti and trojan supra)

303
Q

theoretical vs actual effectiveness of male condom with spermicide?

A

98%- theory

85%- actual

304
Q

what is a diaphragm?

A

latex intravaginal, reversible method

305
Q

contraindications for diaphragm

A

–severe prolapse
–allergy to latex or spermicide
–vaginal septa or fistula
–recurrent/chronic UTI

306
Q

disadvantage of diaphragm?

A

–compliance/efficacy
–vaginal irritation, infections, odor
–comfort self or partner

307
Q

where is the cervical cap placed?

A

suctions directly over the cervix

308
Q

does the cervical cap require proper fitting by physician?

A

yes

309
Q

risks of cervical cap?

A

–vaginal/cervical abrasion, infection, TSS, odor, allergy, discomfort
–4% of users will develop an abnormal pap smear so repap in 3months

310
Q

contraindication of cervical cap?

A

Abnormal PAP
Allergy to rubber; spermicide
Acute cervicitis; vaginitis

311
Q

what is NFP?

A

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
Q

What does successful NFP depends on?

A

–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
Q

is tubal sterilization is permanent?

A

Tubal sterilization is intended to be a permanent method of birth control

314
Q

what is the failure rate in 10 yrs for tubal sterilization?

A

2%

315
Q

what is a vasectomy?

A

•surgical procedure severing the vas deferens - the tubes that carry sperm from the testes

316
Q

describe how a vasectomy surgery goes?

A

•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
Q

after how many months should you check to make sure no sperm are present after a vasectomy?

A

2-3 mnths

318
Q

how many ejaculations post-op vasectomy to flush remaining sperm?

A

15-20

319
Q

what is a vasovastotomy?

A

a reversal of the vasectomy

320
Q

what is the possible side effects of vasectomy?

A

•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
Q

any evidence that a vasectomy decreases tesosterone levels or sex drive?

A

no evidence

322
Q

any association between vasectomy and prostate CA?

A

no association

323
Q

what might ED associated with vasectomy be due to?

A

mostly psychological in nature, may exacerbate previous difficulties and problems between sexual partners; counseling may be required to resolve difficulties

324
Q

what is the morning after pill?

A

emergency contraceptions, a way to PREVENT PREGNANCY after unprotected intercourse

325
Q

what are two names for the morning after pill?

A

plan B or preven

326
Q

what is another alternative to the morning after pill?

A

OCP/hormones taken in high doses within 5 days of unprotected sex

327
Q

Can an IUD be used as EC

A

yes, inserted within 120 hrs/5 days of unprotected sex, 99% effective in preventing pregnancies

328
Q

what is in preven?

A

.25mg levonorgesterl & 0.5mg EE, take twice daily, 75% risk reduction

329
Q

what is in plan B?

A

0.75mg levonorgestrel (1bid) 89% risk reduction

330
Q

will EC affect an established pregnancy?

A

does not effect it

331
Q

MOA of EC?

A 
–Inhibits/delays ovulation
–Alter endometrium
–Thicken cervical mucus
–Alter sperm or ovum transport
–Does not affect an established pregnancy
332
Q

What is the dosing of Plan B?

A

–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
Q

Side effects of plan B

A 
Side effects:
–nausea and may have vomiting
–dizziness, tired, breast tenderness
–may delay menses
–trigger HSV outbreak if HSV +
334
Q

What is mifepristone/ RU486 used for?

A

non surgical method that mimics SAB/miscarriage

335
Q

what is in mifepristone?

A

antiprogesterone

336
Q

when should mifepristone be taken?

A

less than 49 days since LMP

337
Q

Side effects of mifepristone?

A

–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
Q

Contraindications of mifepristone

A

–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
Q

contraceptive risk of death on OC non smoker < 35 YO

A

1/200k

340
Q

contraceptive risk of death on OC smoker 35-44 YO

A

1/700

341
Q

what is the least effect contraceptive method?

A

spermicide alone

342
Q

what is the most effective contraceptive method, top 2?

A

Vasectomy/Tubal ligation
Abstinence
Most effective

343
Q

list the least effective most effective contraceptive methods

A 
Least effective
Spermicide alone
Diaphragm/cervical cap plus spermicide
Condom plus spermicide
Oral contraception
IUD
Vasectomy/Tubal ligation
Abstinence
Most effective
344
Q

Define infertility

A
  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
Q

what is primary infertility?

A

nulligravida

346
Q

what is secondary infertility?

A

infertility without history of prior pregnancy

347
Q

what is the importance of intervention with infertility?

A
  • 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
Q

What are 4 major pelvic factors that affect female infertility?

A
  1. infection
  2. surgical hx
  3. contraception and preg hx
  4. menstraul cycle abnormalities
349
Q

What are some examples of infection that can affect female infertility?

A

pelvic inflammatory disease, sexually transmitted disease, septic abortion, endometritis, pelvic tuberculosis

350
Q

what are some examples of surgical hx that can cause female infertility?

A

dilation and curettage, ruptured appendicitis, endometriosis, adnexal surgery, fibroids

351
Q

what are some examples of contraception and preg hx that can cause female infertility?

A

prior IUD use, DES exposure in utero, ectopic pregnancy, habitual abortion

352
Q

what are some examples of menstrual cycle abnormalities that can cause female infertility?

A

secondary amenorrhea, endometriosis, cyclic abdominal or pelvic pain

353
Q

What are some ovulatory factors that affect female fertility?

A
  • 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
Q

can being overweight, depression, substance use, celiac dz or insulin resistance affect female fertility?

A

yes

355
Q

what are 4 male factors that cause infertility?

A
  1. varicocele
  2. unexplained
  3. obstructive azoospermia
  4. undescended testis
356
Q

What is azoospermia

A

absence of motile sperm

357
Q

what are some other male factors that can cause infertility?

A
  • 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
Q

what is a normal D3 FSH level?

A

<10-15 mIU/ml

359
Q

what is a normal D3 E2 level?

A

<80 pg/ml

360
Q

when can you do an ultrasound to assess follicle growth and endometrial lining for infertility?

A

midcycle

361
Q

what would a HSG evaluate?

A

to assess patency of fallopain tubes

362
Q

how can ovulation be documented?

A
  • 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
Q

what should be evaluated with irregular cycles?

A 
–Testosterone
–Dehydroepiandrosterone sulfate (DHEAS)
–17-OH progesterone
–Cortisol
–Prolactin (PRL)
–Thyroid function tests
364
Q

what should the evaluation of the male partner start with?

A

with a semen analysis

365
Q

when should a semen analysis be performed?

A

2-5 days of abstinence

366
Q

what is normal volume for semen analysis?

A

2-5 ml

367
Q

what is the normal sperm # for a semen analysis?

A

> 20 million/ml

368
Q

what is normal motility in a semen analysis?

A

motility >50% or >25% rapid, forward motility

369
Q

what is the normal % for normal morphology of semen analysis?

A

35% normal morphology

370
Q

What is the first step to address for infertility?

A

address basic issues of diet and lifestyle

371
Q

significant longer time to pregnancy (TTP) if?

A
  • 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
Q

do overweight individuals have increased rates of infertility?

A

yes, PCOS and BMI >25

373
Q

Can fish consumption affect fertility?

A
  • 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
Q

can celiac disease affect infertility?

A

–May cause deficiency in a number of nutrients requires special consideration if present in either partner
- adherence to GF diet may improve fertility

375
Q

Can caffeine affect the risk for not achieving a live birth?

A

–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
Q

Should a women exercise before IVF?

A

although exercise is typically associated with a 7% lower risk of ovulatory infertility, but Regular exercise before IVF may negatively affect outcomes

377
Q

Name some stress reduction techniques

A

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
Q

What about acupuncture for infertility?

A
  • 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
Q

What vitamin deficiency can be associated with menstraul cycle dysfunction, recurrent miscarriages and infertillty?

A

B12

380
Q

what supplement has been shown to improve uterine blood flow and fertilization rate with prior failed IVF

A

arginine

381
Q

how might vitex/chaste tree help with infertility?

A

may help lengthen the luteal phase, decrease prolactin and restore ovulation

382
Q

what supplements can help to stimulate ovulation and improve ovarian function

A

Tribulus and rhodiola

- combo product called pregnancy prep

383
Q

how might progesterone help in someone with repeated miscarriages?

A

maintain pregnancies in women with history of repeated miscarriages

  • normalize menstraul cycle
  • improve implantation rates
384
Q

Name some supplement that may improve sperm quality and quantity

A

Vit C and E, glutathione, lycopene, and CoQ10, phytoestrogens

385
Q

Name 4 substances that have been correlated with poor sperm quality/quantity

A
  1. caffeine
  2. nicotine
  3. marijuana
  4. alcohol
386
Q

T/F: Women typically suffer more severe and longer term consequences than men

A

True

387
Q

T/F:For women many RTIs are asymptomatic or unrecognized as serious

A

T

388
Q

T/F: women are more liekly to acquire STIs from any single sexual encounter

A

T

389
Q

What are the 5 major concepts prevention and control of STIs are based on?

A
  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
Q

What is the common complaint with vaginitis?

A

itching, burning, dishcarge, odor, pain

391
Q

Dx?

itching, burning, discharge, odor, pain

A

vaginitis

392
Q

What is the most infectious agents of vaginitis?

A
  1. bacterial vaginosis 40-50% (gardnerella)
  2. candidiasis
  3. strep spp
  4. trichomonas (STI)
    (first 3 are normal flora)
393
Q

What is the most common gynecologic complaint?

A

vaginitis

394
Q

what is normal vaginal pH?

A

<4.7

395
Q

what is the name of the normal vaginal flora that maintains the pH?

A

lactobacillia acidophilus

396
Q

what is the etiology of vaginitis?

A

imbalance in normal flora –> allows for overfrowth of microorganisms –> sx

397
Q

Name some common risk factors for vaginitis?

A

•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
Q

What produces the fishy odor of bacterial vaginitis?

A

amine-induced

399
Q

dx?

fishy odor?

A

bacterial vaginitis?

400
Q

agents for bacterial vaginitis?

A

gardnerella, haemophilus, group B strep: not considered STI, but may be sexually associated (lesbian)

401
Q

is bacterial vaginitis considered an STI?

A

considered STI, but may be sexually associated (lesbian)

402
Q

What are the clinical criteria for dx bacterial vaginitis?

A 
3 out of the 4 findings
1. –pH >4.5
2. –Positive “whiff” test (KOH alkalinizes d/c &amp; releases gas
FISHY)
3.–Positive clue cells
4.–Homogenous discharge
•Be aware of patient self-diagnosing
403
Q

Pathogenesis of BV?

A

•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
Q

What are the 2 antibiotics for tx of BV?

A

metronidazole or clindamycin; topical and oral.

405
Q

what are some more natural tx for Bacterial vaginitis?

A
  1. lactobacilli
  2. lactic acid gel
  3. boric acid vaginally
  4. use condoms before and after tx, dont douche
406
Q

dx?

pruritis, white-yellow d/c, erythematous tissue, often vulvar component ?

A

candida vulvovaginitis VVC mc d/t candida albicans

407
Q

describe the sx of yeast infection?

A

Pruritis, white-yellow d/c, erythematous tissue, often vulvar component (fissures)

408
Q

How do you dx VVC?

A

with wet mount/or culture

  1. 10% KOH wet mount
    - pseudohyphae
    - budding yeast
    - pH 3.8-4.5 (normal)
409
Q

What are some predisposing factors for VVC?

A 
•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
Q

Tx for VVC?

A

•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
Q

Is trichomoniasis vaginalis a STI?

A

yes

412
Q

what is the protozoal that causes trichomoniasis vaginalis?

A

trichomonas vaginalis

413
Q

can Trich vaginalis faciliate the transmission and acquisitiion of HIV and other STI?

A

yes

414
Q

how do you dx trich vaginalis?

A

fresh normal saline wet mount

  1. motile organisms with flagella
  2. increased PMNs WBC
415
Q

What can trich vaginalis infect?

A

vagina, skene’s ducts, & lower urinary tract in men and women

416
Q

what color is the typical discharge with trich vaginalis?

A

yellow/green frothy

417
Q

dx? yellow/green frothy discharge

A

trich vaginalis

418
Q

what does the cervix look like with severe trich vaginalis infection?

A

strawberry cervix, with red macular spots

419
Q

dx? strawberry cervix?

A

trich vaginalis

420
Q

tx for trich vaginalis?

A
  1. Empirically treat partner(s) even if asymptomatic
  2. Metronidazole or tinidazole is treatment of choice
  3. Adequate lactobacilli may prevent infections
421
Q

What cells are infected with chlamydia or gonorrhea?

A

genital columnar epithelium

422
Q

what might someone present with sx wise with chlamydia?

A

asx, cervicitis, urethritis, PID, Reiter’s syndrome

423
Q

how might someone present with gonorrhea infection?

A

asx, cervicits, urethritis, PID, pharyngitis, arthritis

424
Q

Since 1988 what has been the most commonly reported communicable dz in oregon?

A

chlamydia trachomatis

425
Q

who had the most positive gonorrhea tests?

A

2.5x higher among younger women, african americans had 5x higher prevalence

426
Q

what % of men with Neisseria gonorrhea were asx?

A

22%

427
Q

How do women usually present with CT or GC?

A 
•Asymptomatic
•Vaginal discharge
•Dysuria
•Dyspareunia
•Low abdominal pain, CPP
•Unusual bleeding
–metrorrhagia
–menorrhagia
428
Q

how do men usually present with CT or GC

A
  • Asymptomatic
  • Penile discharge
  • Dysuria
  • Burning/pruritus around urethral meatus
  • Pain with ejaculation
  • Pain and swelling in the testicles
429
Q

Are GC and CT reportable disease in oregon

A

yes

430
Q

Signs of CT or NG?

A
  • Mucopurulent cervicitis
  • Urethritis
  • Gonorrheal Conjunctivitis
  • Gonorrheal Opthalmia Neonatorum
431
Q

How to test for NG and CT?

A

•Cervical/urethral culture or via urine
–DNA Probe Culture is GOLD STANDARD
•Can be tested with liquid-based pap
•Test/treat partner(s)

432
Q

What is the gold standard for NG and CT testing?

A

DNA probe culture

433
Q

What is the CDC screening recommendations of Ct/NG?

A
  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
Q

Who should you screen for NG/GT

A
  • Clinical symptoms
  • New prenatal patients
  • Before inserting an IUD
  • Multiple partners in last 60 days
  • Sexual assault victim
435
Q

Tx for NG?

A
  • 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
Q

What supplement may prevent NG/CT infections?

A

lactobacillus

437
Q

Tx for CT?

A

–A single dose of azithromycin or a week of doxycycline (twice daily) are the most commonly used treatments.
–Also, tetracyclin, erthyromicin

438
Q

Sx of epididymitis?

A

•Scrotal pain
•Scrotal swelling
•Fever
•Penile discharge

  • Chills
  • Abdominal pain
  • Pelvic pain
  • Frequent urge to urinate
  • Dysuria
  • Hematuria
  • Painful ejaculation
439
Q

What are you looking for in the first void urine with epididymitis?

A

WBCs

440
Q

dx procedure for epididymitis?

A

DNA probe

  • intraurethral culture ofr GC and CT
  • LCR urine test
441
Q

What organisms are responsible for epididymitis?

A

GC and CT

UWS Q9 (3 decks)

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