GYN Flashcards
AUB, adnexal mass, ectopic, molar,
Contraindications to UAE
Hypersensitivity to contrast agent used in angiography
Malignancy
Coagulation disorders which cannot be corrected
Pregnancy
Infections or inflammation of the reproductive or urinary tract
History of pelvic irradiation
Hyperthyroidism
Renal failure
Women who are not ready to accept the approximately 3-20% risk of failure and subsequent absolute need for hysterectomy due to intractable pelvic pain or infection after UAE
How to dose NSAIDS for AUB ?
- ibuproben 600mg daily
- naproxen 500mg at start of period, then 250-500mg BID for 4-5 days.
How to dose TXA for AUB?
1.3g TID up to 5 days
Vulvodynia treatment
- eliminate triggers
- topical anesthetic ointment
- amitriptyline
- pudendal nerve block
- topical steroids
- gabapentin
- botox
- PFPT
- consider bx because 60% of dermatoses
- refractory localized vulvodynia-can offer vestibulectomy.
try each one for 3-6 months
Lichen sclerosis histology
thinned epithelium, blunting of the rete ridges, chronic inflammatory infiltrate in the dermis
For which STDs does ACOG recommend expedited partner therapy?
Gonorrhea and Chlamydia
Painful ulcers DDx
Herpes
Chanchroid
Painless ulcers DDx
Lymphogranuloma venerium,
Syphillis,
granduloma inguanale
aka Donovanosis
Herpes
Exposure to onset
Symptoms
- 4-6 days
- can have fevers, myalgias that last 3-4 days
Herpes
Describe the clinical course of the first outbreak
how long is viral shedding possible?
How long until antibodies appear?
worsening symptoms for 6-7 days then gradual improvement into week 2.
viral shedding until lesions are crusted over
12 weeks until antibodies
Recurrent Herpes
Describe the clinical course
How long is viral shedding possible?
prodrome 1-2 days before lesions, then lesions for 4-5 days until the lesions crust over
Herpes
How to test for it?
viral culture swab of unroofed lesion
OR
PCR for CNS
cytology is no longer recommended
Herpes
first time treatment?
recurrent treatment?
suppression treatment?
alt options, MOA, SE
Warm soaks, sitz baths, lidocaine jelly
First
- acyclovir 400mg TID x 7-10 days
- valacyclovir 1g BID x 7-10 days
Recurrent
acyclovir 800mg BID x 5 days
Valacyclovir 1g daily x 5 days
suppression
acyclovir 400mg BID
valacyclovir 1g daily
inhibits viral DNA polymerase by inserting into viral dNA and acting as a chain terminator, n/v/d, headache, rash, itching
Herpes in pregnancy
Risks to fetus if primary outbreak is in the first trimester?
When to start suppression?
criteria for c-section?
Chance of transmission?
chorioretinitis, microcephaly, skin lesions
36 weeks
active lesions, prodromal symptoms, or outbreak in the 3rd trimester.
- 40-80% transmission if primary outbreak at delivery
- 3% transmission if recurrent lesion at delivery
Chanchroid
organism?
presentation?
how to diagnose?
How to treat?
Haemophillus ducreyi
superficial ragged edge ulcer, red halo, necrotic exudate
clinical dx-VERY painful ulcer and lymphadenopathy
can do PCR
azithro 1g PO once
CTX 250mg IM once
What is a bubo?
When does it present?
painful lymphadenophathy seen in chanchroid and LGV
7-10 days after initial chancroid lesion or by itself with LGV
Lymphogranuloma venereum
organism?
presentation?
how to diagnose?
How to treat?
Chlamydia trachomatis
painless ulcer w or w/o bubo, cervicitis, urethritis, groove sign
clinical vs. swab of ulcer or aspirate the bubo and send for chlamydia NAAT
Doxy 100 BID x 21 days
azithromycin 1g weekly x 3 weeks
Granuloma Inguinale aka donovanosis
organism?
presentation?
how to diagnose?
How to treat?
-klebsiella granulomatis
SLOW growing painless ulcer, beefy red, very vascular
-subQ granulomas, NO lymphadenopathy
-clinical of tissue smears
-azithromycin 1g weekly for at least 3 weeks and until lesions are healed
Syphilis
organism?
when to screen?
treponema pallidum
- all pregnant women in 1st and 3rd trimester
- MSM
- HIV, taking PrEP, partner with syphilis
- incarcerated, prostitution, males under 29 years
- high local prevalence
Syphilis
How to diagnose?
next step after dx?
Screen with nontreponemal test: RPR (rapid plasma reagin) or VDRL (venereal dz research lab)
^use this to direct treatment as treponemal tests are positive for life
Confirm with treponemal test: flourescent treponemal antibody absorption or t. pallidum particle agglutination
report to health department
Causes of false positive RPR or VDRL
older age, pregnancy, cardiovascular disease, malaria, leprosy, recent immunizations
primary syphilis
incubation period
symptoms
how long until they resolve
painless chancre and lymphadenopathy 10-90 days from exposure
3-6 wks regardless of treatment
Secondary syphilis
onset timing
symptoms
how long until symptoms resolve
4-8 weeks after chancre
maculopapular rash/lymphanopathy, malaise, fever, condyloma lata
resolve after 2-6 wks regardless of treatment
Early Latent Syphilis
how to diagnose?
treatment
- +serology
- no past dx of syphilis
- no evidence of primary, secondary, or late
- suspect infection was in the last 12 months
must treat because of transplacental transmission
Late Latent Syphilis
how to diagnose?
- +serology
- no past dx of syphilis
- no evidence of primary, secondary, or late
- suspect infection was over a year ago
Tertiary syphilis
symptoms
gumma,
cardiovascular,
neurosyphilis,
benign late syphilis
symptoms of neurosyphilis
meningitis
pain
paresthesia
loss of DTR
ataxia
tabes dorsalis (demylenation of the dorsal nerve roots of the spinal cord-lightening pain down the leg)
Argyll Roberston pupil (accomodate to distance, but dont react to light)
Syphilis treatment
primary, secondary, early latent, late latent without neuro sx
primary, secondary, early latent: PCN G 2.4 mil units IM once
OR
Doxycycline 100mg BID x 14 days
Late latent without neuro sx or latent of unknown duration
-PCN G 2.4 mil units IM weekly x 3 OR doxy 100 mg BID x 28 days
Neurosyphillis
dx and rx
test CSF first
aqueous crystalline PCN G
3-4 mill units IV q4hr for 10-14 days
OR procaine PCN 2.4 mil units IM daily x 10-14 days PLUS probenicid 500mg 4x daily 10-14 days
you start treating syphilis and the patient breaks out in a rash and fever in the first 2-8 hrs.
Whats the management?
jarisch-herxheimer reaction from killing the spirochete, treat with tylenol
occurs 95% of the time in primary and secondary symphilis
Syphilis
How to follow patients after initiating treatment?
Check titers at 6 and 12 months
Primary and secondary syphilis: expect to see a 4 fold drop (1:16–> 1:4) at 6 months
8-fold drop at 12 months
Early latent syphilis: check titers at 6, 12, 24 months
4-fold drop 12 months
You treat syphilis appropriately, but titers are not decreasing. next steps
check HIV, re-treat, CSF exam
your patient informs you that a previous partner was dx with syphilis within the last 90 days. What do you tell her?
treat her since her exposure was within the last 90 days.
If greater than 90 days, but we don’t have serology on her, then treat her.
Pubic lice
organism
diagnosis
treatment
pediculosis pubis
permethrin 1% cream
OR
malathion 0.5% lotion
OR ivermectin 250mcg/kg,PO, repeat in 7-14 days
Warts
organism
diagnosis
treatment
HPV 6 and 11 most commonly
clinically, can have maternal transmission up to 3 years
Pt applied: imiquimod 3.75% of 5% OR podofilox 0.5%
Doctor applied: Trichloracetic acid in the office OR cryotherapy or excision.
Tca is 1x for 4-6 weeks or until they go away
Chlamydia
presentation
diagnosis
treatment
asymptomatic, mucopurulent cervicitis, PID, endometritis
NAAT swab of cervix or urine
screen all sexually active women under 25 or older with risk factors
doxy 100mg BID x 7 days or azithro 1g once
TOC in 3 months and at next well woman
Chlamydia in pregnancy
fetal risks
treatment
chlamydia PNA, conjunctivitis
azithro 1g PO x 1 or amox 500mg TID x 7 d
TOC in 3-4 weeks
Gonorrhea
presentation
diagnosis
treatment
mucopurulent discharge, dysuria, AUB, bartolin’s/skene’s abscesses, conjuctivitis
NAAT of cervical swab, urine, or self-swab
CTX 500mg IM once (1g IM if >150kg)
OR gentamicin 240mg IM +azithromycin 2g PO
ONLY add chlamydia treatment if you have not ruled out chlamydia dx.
TOC in 2wks only if pharyngeal infection.
you treat for gonorrhea, but TOC is still positive. Next step?
send culture and get sensitivities.
Name the reportable STIs.
syphilis, gonorrhea, CMT, chanroid, and HIV,
trichomonas
presentation
diagnosis
treatment
can be asymptomatic for YEARS
strawberry cervix, yellow/green/frothy discharge
NAAT testing
metronidazole 500mg BID x 7 days OR tinidazole 2g PO once
no ex for 7 days
TOC in 3 months
Trich TOC still positive. Next steps
assess for reinfection
treat with tinadazole 2g PO daily and tinadazole 500mg BID per vagina for 14 days
if still positive, talk to CDC and ID
PID
diagnosis
treatment outpatient
lower pelvic pain PLUS
uterine tenderness or adnexa tenderness or cervical motion tenderness
CTX 500mg IM AND
Doxy 100mg BID x 14 days
Metronidazole 500mg PO BID x 14 days
OR replace CTX with cefoxitin 2g IM wi/probenecid 1g PO x 1
f/u in 2-3 days, then 1 month
PID inpatient treatment
CTX 1g IV q24hrs AND
doxy 100mg PO or IV BID AND
metronidazole 500mg PO or IV BID
OR
clindamycin 900mg IV q 8hrs
gent 2mg/kg loading dose followed by 1.5mg/kg q8hrs
PID when to operate
no improvement after 3-4 days of IV abx
ruptured abscess
acute abdomen
sepsis
consider IR for drainage
HIV
health maintenance
CD4 q 3-6 months
viral load q 3-6 months and 1 month after changing meds
check all of the following
PPD, syphilis, toxo IgG, CMV igG,
vaccine pneumococcal flu Hep B H. influenzae B Hep C
HIV
clinical course
window course
4-8 wks asymptomatic
Seroconversion
-flu-like symptoms, rash,
-abs development
-
clinical latency-asymptomatic
HIV when to section
when is vaginal delivery okay?
- viral load >1000 copies/mL or unknown viral load, section at 38 weeks
- viral load <1000 on meds you can go 39wks
Flibanserin
Use
MOA
SE
Contraindications
Female sexual interest/arousal disorder.
serotonin receptor agonist and antagonist
100mg PO Qhs
weight loss, somnolence, dizziness, nausea
contraindications post-menopausal women EtOH within 2 hours of med liver disease CYP3A4 inhibitors-erythromycin, diltiazem, verapamil, grapefruit
Bremalanotide
Use
MOA
SE
Contraindications
Female sexual interest/arousal disorder
SubQ prn 45 mins before sex, 1 dose per 24hrs
nausea/flushing/site reaction, slows gastric emptying
contraindication: HTN, post-menopausal women
treatment for post menopausal women with female sexual/arousal disorder.
short term trnsdermal testosterone can be considered per ACOG, not FDA approved
300mcg T patch, assess at 6 weeks, discontinue by 6 months if no help.
Menopausal-related sexual dysfunction medication options
- ospemefine
- Prasterone
Side effects of HRT
AUB breast tenderness nausea bloating hair loss fluid retention in arms and legs dizziness
Absolute Contraindications to HRT
Active or recent clots
undiagnosed AUB
breast cancer
estrogen dependent neoplasm
Relative contraindications to HRT
previous clot liver dz gallbladder dz endometriosis migraine with aura smoking severe hypertriglyceridemia
When to start HRT
age under 60 within 10 years of the stat of menopause
How to prescribe HRT?
Many different ways, pick one
estradiol 1mg PO daily OR
- 05 transdermal ethinyl estradiol daily, replace patch weekly OR
- 625mg conjugated equine estrogen PO
if she has a uterus, add progestin
PO: estradiol/drosperinone 1mg/0.5mg daily
Transdermal: estradiol 0.45mg/0.015mg oer day, replace patch weekly
or ADD: LNG-IUD (6 yrs) or prometrium 100mg PO daily
WHI
What age group?
What risk factors did patients have?
Which hormone dosing?
what was it assessing?
- 50-79 years, menopausal x 10 years
- BMI 28.5, 40% smokers, 40% HTN
- conj equine estrogen 0.625mg and medroxyprogesterone 2.5mg
- assessed for heart dz, bone frax, breast and colon cancer
- All HRT increases risk of clots/stroke and decrease risk of fracture
- E+P group: increased MI risk and breast cancer, decreased risk of colon cancer
- E only: insignificant decreases risk of breast cancer, no impact on MI and colon cancer
Do not give SSRI in combination of which chemoprevative drug
tamoxifen
give venlafaxine- SNRI is safer
paroxetine is a CYP P450 inhibitor
At what frax score do you move to a DEXA?
9.3% risk of major fracture
fracture risk assessment tool
dual energy xray absorptometry
At what, FRAX score do you start treatment
3% hip
20% overall
Treatment options for vaginal atrophy
- lubricants, conservative
- vaginal estrogen
- Ospemefine
- Prasterone
What is ospemefine?
MOA
contraindications
do you need progestin?
Pill for FDA-approved moderate-severe dyspareunia in postmenopausal women
Estrogen agonist/antagonist
CI: same as HRT
Progestin not need if under 1 year
What is prasterone?
MOA
contraindications
vaginal insert for
What is prasterone?
MOA
contraindications
vaginal insert for mod-sev dysparuenia in post menopausal women
steroid-dehydroepiandrosterone 6.5mg qhs
same CI as HRT
You have diagnosed osteoporosis.
Next step?
consider other causes of osteoporosis
order CBC, CMP, TSH, 24 hr urinary calcium level, 25-hydroxyvitamin D level
consider celiac panel, serum protein electrophoresis
Which patients should not calculate a FRAX for?
<40
already on meds
already osteoporotic
prior hip or vertebral fractures
who gets a FRAX?
low bone density or osteopenia on DEXA–>if FRAX is 3% hip or 20% major–> start med
Patient is worried, but does not meet DEXA criteria
Who gets DEXA?
65+ history of fragility frax <127lbs smoker EtOH Rheumatoid Arthritis parent with history of hip fracture
Bisphosphonates
MOA
CI
alterntives
inhibit osteoclast activity
CI: for orals, cannot sit up for 30 minutes after. esophagitis, renal impairment, hypocalcemia, hx of rous en Y gastric bypass,
alternatives: denosumab, raloxifene, tamoxifen (not FDA approved), HRT, nasal salmon calcitonin, recombinant human parathyroid hormone
- ab to RANK-L, 60mg SC q6 months
MOA and CI for the following alternative osteoporosis treatments
denosumab
raloxifene
nasal salmon calcitonin
recombinant human parathyroid hormone
Denosumab: -ab to RANK-L, 60mg SC q6 months, may be need lifelong due to relapse
Raloxifene-SERM, inhibit bone resorption, SE-VTE/vasomotor, good for ppl who need breast cancer ppx
Nasal salmon calcitonin-inhibits osteoclasts, must be at least 5 years out
rPTH-activates bone formation, can only use for 2 years, only for severe dz
What do you include in a comprehensive well women visit?
Any specific patient concerns update med/surgical hx, GYN, family hx medications tobacco, etoh, substance abuse personal safety immunizations cancer/health screening
What does BiRADs stand for?
what is the probability of malignancy with each score?
Breast Imaging-Reporting Data system
0-need more evaluation 1-0% 2-0% 3- <2% 4- 20% 5- 90% 6-100%
Who gets breast MRI?
> 20% lifetime risk of breast cancer
BRCA1 or BRCA2
first degree relative with BRCA and pt has not been tested
chest radiation therapy between 10-30 yo
Li-fraumeni
Cowden
Bannayan-Riley-Ruvalcaba
Who to refer for bariatric surgery?
BMI >40
BMI >35 with medical co-morbidities
who gets breast cancer chemo prevention?
When to use tamoxifen vs raloxifene?
Gail model 5 yr risk >/= 1.7% or lifetime risk of >/= 20%
anybody can get tamoxifen, but only postmenopausals can get raloxafene
REMEMBER -raloxafene is good for osteoporosis.
Lipid screening by age
9-11- once
18-21 once
40-75- every 5 yrs.
consider starting a low-moderate dose statin based on elevated risk
Went to stop pap?
65 with negative paps for the last 10 years
When to start pap in the following populations?
DES
HIV
Cancer/immunocompromised
- DES, annual cytology starting at age 21
- HIV-within one year of being sexually active, start with cytology alone and if normal for 3 years, then you can mov to standard testing.
cancer/immuno…treat like HIV
HNPCC
when to do risk reducing surgery and what are you doing?
hyst BSO at 35-40 after childbearing
alternative to colonscopy
flex sig q 5 years
stool guiac-2 samples from 3 consecutive BMs
When to give pneumococcal vaccine
65+
pneumococcal conjugate vaccine (PVC13)
pneumococcal polysaccharide vaccine (23)
give PVC13 then PPSV23 6-12 months later, ok in pregnancy
When to give zoster vax?
2 doses 2-6 months apart in every 50+ regardless of natural immunity.
How long is liletta FDA approved for?
6 yr
OCPs
Patient wants control of acne. which progesterone class do you give?
third gen because it has fewer androgen side effects
ex desogestrel, norgestimate
OCPs
Patient has PMS. which progesterone class do you give?
4th gen
Drosperonone bc FDA for PMS
OCPs
Patient missed one pill.
recs?
Take the missed pill now, take the next pill at the usual time and use condoms for 7 days
OCPs
Patient missed two pills.
recs?
Take two pills now. take another two pills tomorrow at the usual time, continue with the pack and use condoms for 7 days.
OCPs
Patient missed three pills.
recs?
toss the pack and start a new pack, use condoms for 7 days.
Contraception failure rates
Etonogestrel implant Hormonal IUD Copper IUD vasectomy Combination OCP Tubal ligation Male Condom
Etonogestrol implant 0.05% Copper IUD 0.08% Hormonal IUD 0.2% Vasectomy 0.15% Combination OCP 9% Tubal ligation 18-37/1000 Male condom 18%
relative CI to MTX for ectopic
4+cm
heartbeat present
hcg 5000+
jehovahs witness or anemic
Diagnostic features of failed IUP
CRL 7mm without HB
GS 25mm + without HB
no embryo with HB 2 wks after GS with no yolk sac
no embryo with HB 11 days after GS WITH yolk sac
Absolute contraindications to endometrial ablation
pregnancy, known or suspected endometrial hyperplasia or cancer, desire for future fertility, active pelvic infection, IUD currently in situ, and being post-menopausal
histology of squamous cell hyperplasia of the vulva
gross appearance
age
treatment
thickened epithelium, no inflammatory infiltrate
grossly-leathery appearance
age 30-60
triamcinolone and antihistamines
Top three causes of death by age
1-19
accidents
cancer
suicide
Top three causes of death by age
20-44
accidents
cancer
heart dz
Top three causes of death by age
45-64
cancer
heart dz
accidents
Top three causes of death by age
65-85
cancer
heart dz
chronic lung disease
painless bleeding, 6 year old, chronic constipation and asthma, presents with a mass at the introitus
most likely dx
urethral prolapse
rx underlying cause, sitz baths, estrogen cream BID for 1-4 weeks
IBS Rome criteria
recurrent abdominal pain
- onset 6 months ago
- 1 day/wk for 3 months
- associated with 2 or more of the following:
- relation to defecation
- associated with change in stool frequency
- associated with change in stool appearance
describe the bristol stool form scale
1 to 7
1 hard
4 is normal
7 watery
IBS subtypes
Diarhea
conspit
mixed
untyped
IBS work up
CBC
chem for volume depletion
WBC, stool cx, ova and parasite, c. diff
rule out colon cancer symtpoms
IBS D meds
antimotility
loperamide, diphenoxylate
anticholinergics
belladonna, dicyclomine, hycosamine for bloating and gas
HIGH fiber diet (25-35 grams/day)
IBS C meds
lubiprostone, linaclotide
HIGH fiber diet (25-35 grams/day)
