Gyn

Question 1

rate of sx recurrence if ovaries left in situ for enometriosis hyst? how should they be managed instead?

Answer 1

• 60% recurrence, 30% chance re-operation
• after more conservative tx failure, hyst/BSO w/ add-back HRT results in <1% sx recurrence
• start hormone tx immediately

Question 2

describe amsel’s criteria. How much of BV is symptommatic? Tx options?

Answer 2

• 75% of women are asymptommatic
• Amsel’s: 3+ of 1.) discharge 2.) vaginal pH 4.5 or greater 3.) pos whiff test 4.) clue cells 20%+
• oral/vaginal flagyl x7 days, clinda po x7 days, secnidazole 2 g x1 (newest option)

Question 3

complex atypical hyperplasia fertility sparing options, tx results?

Answer 3

no consensus on preferred tx for progestins. Regression rates 70% PO progestin, 90% IUD. No set procedure, but EMB q3-6 mo good option

Question 4

define OAB. Describe its w/up (what needs to be ruled out). How common is it?

Answer 4

OAB = urinary urgency w/ or w/o urge incontinence in absence of metabolic or pathologic factors. Common: 1/6 women. Need to do UA and cyto to r/o dz.

Question 5

Intraoperative hypotension d/t anaphylaxis timing, tx, MC cause

Answer 5

occurs early in case (w/in 5-10 min). MC cause = abx (50%). Tx would be IV hydration, epi, hydrocorisone. Dx can be delayed when prepped and draped. perioperative mortality = 2-9%!

Question 6

OSA puts pts at higher risk for what complications? how shouldy they be managed?

Answer 6

OSA associated w/ cardiac arrythmias, acute renal failure, wound complications, postop deliurium. Continuous infusions of opioids should be avoided. try scheduled nsaids w/ prn opioids and regional anesthesia when possible.

Question 7

37 yo w/ CIN3 neg margins, next step? what if pos margins? What if <25 and neg margins? pos margins?

Answer 7

• cotest in 12 mo if neg margins, cotest in 6 mo if pos

- if <25, I think it is the same?? need to confirm

Question 8

define chronic pelvic pain. What is the name of the questionare for bladder sx, and what does it look for? name of OBS criteria and pos findings?

Answer 8

noncyclic pain 6+ mo in pelvis, ant abd wall, below umb, in L/S area or buttucks. questionnaire = PUF, looks for potassium sensitivity test. Rome criteria = IBS. needs 2+: pain relieved w/ bowel movement, onset of pain related to change in stool frequency, onset of pain is related to stool appearance change

Question 9

two types of mastalgia? how are they worked up differently?

Answer 9

cyclic mastalgia is much less concerning than non-cyclic mastalgia- does not need imaging. can start pt on NSAID trial (OCPs do NOT help)

Question 10

UAE complications? timeframe?

Answer 10

post-embolization syndrome is seen in 40% of pts and includes pain, fever, nausea, and malaise. These sx peak at 1-2 days after procedure and resolve w/in 7 days. anything longer raises suspicion of other etiology (endometritits)

Question 11

POP-Q table

Answer 11

Aa Ba C
gH pb TVL
Ap Bp D

Question 12

What percentage of BRCA1 and BRCA2 will develop ovarian ca in their lifetime? what is recommedned tx?

Answer 12

BRCA1 40%, BRCA2 20%

Risk reducins BSO @ 35-40 or when done w/ childbearing

Question 13

Define rotterdam critera

Answer 13

Need 2+

1. ) hyperandrogenism (clinical)
2. ) irregular cycles
3. ) polycystic ovaries on u/s

Question 14

what are the discriminatory bHCG levels for gestational sac, yolk sac, fetal pole?

Answer 14

99%ile probability of detection:
gestational sac = 3500
yolk sac = 17,700
fetal pole = 47,000

Question 15

what are the most common reasons for adolescent AUB?

Answer 15

cyclic, heavy bleeding- consider clotting d/o
irregular, heavy bleeding- consider HPA immaturity and PCOS (esp if other comorbidities, eg BMI, are present). CBC, UPT, STI w/up, trauma screen needs to be performed regardless of whether states is sexually active

Question 16

what is the correct mgmt for large, asymptomatic fibroids?

Answer 16

observation; consider TVUS q year

Question 17

most common reason for d/c of nexplanon? what should you do for these patients? what are other reported side effects?

Answer 17

MC reason for discontinuation = AUB
- for these pts, consider, OCPs, NSAIDs, mifepristone w/ estradiol, mifepristone + doxy, or doxy alone
Other sx include acne, amenorrhea, weight gain (all 12-20% but infrequent reason for d/c

Question 18

what is an infrequent but important item on a ddx in a pt with heavy AUB and thrombocytopenia?

Answer 18

hematologic cancer; AUB presenting sx in 3.6/1000

Question 19

following needle stick after known hep c pt, what is corret mgmt?

Answer 19

draw HCV Ab. If pos, draw HCV RNA. if neg, can test for HCV RNA again and if neg can stop (presumptive previous hx). PEP is NOT indicated or helpful.

Question 20

oliguria in post op pt- what is your mgmt?

Answer 20

FENA and bladder scan (if foley is already removed). FENA <1 demonstrates pre-renal etiology, FENA>1 intra or post-renal. Consider bladder scan b/c can be d/t retention (which can be masked by pre-existing conditions and pain, eg BP, tachycardia, etc). Do not automatically give large bolus w/o known reason, especially w/ comorbid conditions.

Question 21

What medication is commonly prescribed to hormone pos breast ca pts after tx? What should they also be on d/t bone risk if postmenopausal?

Answer 21

frequently on anastrzaole, an aromatase inhibitor. they should be placed automatically on a bisphosphonate

Question 22

what route of hyst has the highest rate of cuff dehisence?

Answer 22

L/S hyst

Question 23

describe clinical findings of GSM. what is the gold standard tx?

Answer 23

pale, atrophic mucosa. parabasal cell increase. pH of vagina 5-7 (elevated). vaginal estrogen.

Question 24

correct mgmt of electrosurgical injury to bowel? what other complications would you also do this tx for?

Answer 24

• segmental bowel resection w/ EEA. A diverting colostomy is indicated in cases of large injuries without previous bowel preparation or antibiotic prophylaxis, if the injury involves the intestinal mesentery, or if the injury is not diagnosed until the postoperative period (delayed diagnosis). Two layer close if ok if injury is small (eg, trochar)

Question 25

Whatis the most common malignant ovarian germ cell tumor? what lab abnormalities are associated w/ it?

Answer 25

dysgerminoma. associated LDH, bHCG elevation.

Question 26

describe mgmt of PO DM rx as well as insulin changes pre-op for planned surgery

Answer 26

metformin and sulfonylureas should be held on the day of surgery d/t lactic acidosis and MI risk, respectively. Night time long acting insulin should be reduced (halved).

Question 27

UAE contraindications

Answer 27

asymptomatic leiomyomas, pregnanct, active infection, malignancy (or presentation suspicious for malignancy)

Question 28

according to a detailed lit review, what has shown some benefit for pts who have experienced three or more consecutive miscarriages?

Answer 28

progesterone supplementation 1st TM (no agreed upon dose, frequency, or route)

Question 29

what is the most appropriate first test to evaluate for Lynch syndrome?

Answer 29

tumor immunohistochemical testing for MLH, MSH2, MSH6, PMS2. Their ABSENCE is indicatice of Lynch possibility. For MLH do promotoer methlylation, for others germline DNA testing.

Question 30

what OAB med is contraindicated in CHTN pts? What tx is indicated if ACh meds fail?

Answer 30

mirabegron (B3 agonist)

botox bladder injections

Question 31

Other than vasomotor sx, what does HRT definitively DECREASE risk of?

Answer 31

Fractures. Heart dz is unclear, initially there was felt to be a benefit but that has been disputed. Breast and colon ca changes are dependent upon the study population.

Question 32

When is CXR indicated pre-op? EKG, echo? What age necessitates pre-op w/up?

Answer 32

CXR indicated only for acute pulmonary process (eg, PNA). EKG should be obtained for pts w/ cardiac hx. Echo should only be obtained for known LV failure or new onset suspicious sx (dyspnea). There is kno age at which pre-op testing is necessarily required, it is all based on pre-existing dz and sx.

Question 33

When should cervical ca screening begin for HIV pts? what frequency thereafteer?

Answer 33

When turn 18 or w/in one year of sexual activity. If normal, rpt in 1 year. If three consecutive normals, can do q3 y.

Question 34

which laparoscopic entry technique is recommended?

Answer 34

there is insufficient evidence to recommend one L/S ntru technique over another per 2015 Cochrane Review

Question 35

describe mgmt of incorrectly positioned IUD? what do you do if not seen on u/s?

Answer 35

if you can see the IUD w/in the cervix, should be removed. If pt is symptomatic (bleeding, pain) can discuss w/ them if they want it removed. KUB should be done if not seen on u/s. If not seen, can be assumed expelled and needs a back up method. If seen, L/S etc.

Question 36

what is the most effective emergency contraception? what is second best?

Answer 36

copper IUD is the most effective and can be placed w/in 5 days. ulipristal acetate (antiprogestin) also good for 5 days and is the 2nd most effective emergency contraception. Its MOA is inhibiting ovulation. levonorgestrel is the most commonly used b/c don’t need a rx. It’s good for 3 days and also works by inhibiting ovulation.

Question 37

Define surgical site infection. what intraoperative event/risk factor has been most closely correlated w/ surgical site infection?

Answer 37

30 days w/o foreign body, 90 days w/ foreign body (eg, mesh, sling). Blood transfusion is most closely correlated w/ SSI. Age>80 and size of incision are also RF though to a lesser degree.

Question 38

Describe the w/up of apparent vulvodynia:

Answer 38

1. Obvious etiology present? (eg, infection)
2. Q-tip swab test
3. If pos, fungual culture
4. If neg, tx as vulvodynia w/ multidimensional care
5. Increase med dose, combo neuro meds
6. last resort and pain localized to vestibule, operate

Question 39

Best endo tx option for VTE hx?

Answer 39

Levonorgestrel IUD

Question 40

Best initial tx for 1’ dysmenorrhea?

Answer 40

NSAIDs (80% response rate)

Question 41

At a minimum, what should be performed for incontinence w/up?

Answer 41

H&P, postvoid residual, demonstration of incontinence.

- on exam if cystocele is to hymen, can assume urethreal hypermobility

Question 42

Suggested duration and frequency of exercise for cardiovascular health per AHA?

Answer 42

30 min moderate exercise 5x per wk

Question 43

Define ovarian remnant syndrome (ORS). How can it be worked up in the office if unclear? How is it treated?

Answer 43

residual ovarian tissue following oophorectomy w/ associate pain, usually w/in 5 years of operation. TVUS should be performed. If negative findings, can consider ovarian “provocation” with clomiphene citrate for 10 days w/ rpt imaging on day 10. Can attempt suppression w/ OCPs, DMPA, lupron, though most pts will need surgery.

Question 44

Postmenopausal bleeding w/ inconclusive EMB. Next step?

Answer 44

TVUS. D&C is considered overly invasive w/o significant benefit if no u/s has been done.

Question 45

Describe difficulties w/ OCPs and antiseizure meds?

Answer 45

OCPs and antiseizure meds function bidrectionally- each affecting the serum concentration and clinical efficacy of the other. another option should be chosen for contraception. Keppra is ok though.

Question 46

ethical mgmt of unexpected intra-op findings?

Answer 46

a discussion should be held w/ health care proxy about how/if to proceed.

Question 47

describe MTX contraindications and tx protocols. What are some sfx?

Answer 47

• contraindications= IUP, ectopic pregnancy, hem/renal/hep dz, immunodeficiency, breastfeeding
• 7 day protocol- dose day one- need 15% drop between 4 and 7. If insufficient drop, dose again. If doesn’t drop after 2nd dose, consider surgery. Medical tx is 90% effective. 30% experience side effects- pain, stomatitis, N/V, diarrhea

Question 48

How should non-HIV pts be tx’d if in high risk environments?

Answer 48

Pts 13-64 should be tested at least once in their lifetime. PrEP would be tenofovir and emtricitabine for the UNAFFECTED partner.

Question 49

Contraceptive for post-bariatric pts? How long should they delay pregnancy?

Answer 49

OCPs are a poor choice d/t decreased absorptive propertives. Should delay pregnancy at least a year, maybe two. Need supplemetnation w/ protein, Fe, B12, folic acid, Ca

Question 50

What is the “female athlete triad”? What is the mechanism? Describe necessary w/up and when to perform.

Answer 50

1. ) low energy availability
2. ) irregular menstruation
3. ) diminished BMD
   - mechanism - imbalance between caloric intake and energy expenditure- HPA axis change
   - adolescents w/ 3 month period of amenrrhea should be assessed.
   - wup includes UPT, LH, TSH, prolacin, BMD
   - use the Z score for BMD!

Question 51

what is the most common reason for essure failure?

Answer 51

nonadherence in the post-procedural period. A 3-6 mo timeframe is required w/ confirmation w/ HSG using backup method.

Question 52

describe osteopenia/osteoporosis RF. What medications contribute?

Answer 52

advanced age, somking, EtOH, post-menopausal, low weight, family or personal hx, RA, vit D and Ca deficiency
- Rx: PPIs, SSRIs, thiazolidineodiones, DMPA, chemo, anticoagulants, seizure meds

Question 53

inpatient indications for PID? Inpatient tx, outpt tx regiments? what about PCN allergy?

Answer 53

inpatient indications- TOA, inability to tolerate PO abx (N/V), uncertain dx, or failure of PO abx

• cepalosporin w/ doxy +/- flagyl outpt
• PCN allergy- floroquinolone (eg, levo) + flagyl
• cefoxitin + doxy inpat

Question 54

describe timing of ovary removal by age

Answer 54

depends on indication- if overall goal is avoiding reoperation, then take ovaries. If goal is reduction of CV dz or overall mortality, remove only after 45 yo. If goal is avoidance of PD, dementia, depression remove only after 50 yo.

Question 55

RF for teratoma recurrence

Answer 55

large size (8 cm or greater), young age (<30 yo), original bilateral cysts

Question 56

describe breast surveillance for BRCA pts

Answer 56

at age 25, begin CBE 2x/year w/ MRI q
at age 30, begin CBE 2x/year w/ MRI u/s q 6 mo
35 or 40, do BSO

Question 57

when can you stop doing paps?

Answer 57

at time of hyst if no previous dz, period of 20 years total after initial dz (eg, til 70 if CIN at 50 even if hyst), 65 if last 3 normal

Question 58

describe w/up and mgmt of HSV discordant couples

Answer 58

partner should be serotype screened, if negative then the AFFECTED partner should take prophy tx