GYN

Question 1

ovarian cysts

Answer 1

in postmenopausal women–> consider malignancy

bening: common in reproductive age
- many resolve on own

most common type is functional ( follicular test),
- resolve in 60 days

dx: sonogram
management: observation 30-60 days
- follicular or theca lutein- surgical evaluation is present

nonfunctional: endometraiona ( chocolate cyst)– surgery

Question 2

PCOS

Answer 2

1 cause of androgen excess ad hirsutism

• bilat cysts
• presentation: hirsutism, infertility
• women with regular periods in young years and in 20s periods are very

sonogram/labs: string of pearls, oyster ovaries
elevated androgen, high FSH, LH, lipid abnormality , insulin resistant

tx: OCPs, DepoProvers, weight loss

if wants pregnancy:climid with metformin

Question 3

ovarian cysts- neoplastic masses

Answer 3

bening neoplastic process
- serous cyst adenoma- -uniloular, most common

• bening cystic teratoma- mobile on long pedicles ( have teeth and hair)
  mangement: surgery

Question 4

ovarian cancer

Answer 4

2nd gyn malignancy
- mean age 69

RF: BRCA 1 gene, fix, nulliparity, late menopause, caucuasian/ asian, diet high in sat fat

screenin: biannual pelvic exam
- sonogram not done for routine screening

tumor types: epilethial

s/s: early - most asymptomatic
later: abd distenction, pain, early satiety, urinary frequency, change in bowel habits

exam: fixed, bilat nodualr pelvic mass, abd distenion, ascities, sister mary joseph’s nodule in the umbilicus
dx: sonogram, biopsy

tumor markers: CA 125 and CEA

tx: TAH/ SBO

chemo -IV or IP

-rad tx

Question 5

Pap smear screening

Answer 5

who gets tested:

women under 21 should be tested regardless of sexual initiation
- 21-29- every 3 years
30-65- Pap and HPV every 5 years or Pap one every 3 years

over 65–> previous normal Paps- no testing

h/o pre-cancer- Paps 20 years after that dx

check for statement of adequacy: most have endocervical cells,

if adequate:
negative, atypical squamous cells, low grade spumous, or high grade , or cancer

management:
ASCUS- repeat 4-6 months, if second is same do colposcopy

ASC-H, LSIL, HSIL-colposccopy/ bx/ HPV testing

treat histology not pap results

CIN1- repeat in 6- 12 months
HPV DNA testing

CIN1 or C1N3- cryotherapy
cold knife conization, or LEEP

Question 6

cervical cancer

Answer 6

3rd most common

RF: early sex, too man sex partner, HPV, smoking
16, 18, 31, 33

squamous cell

s/sx: post-coital bleeding

exam: cervix if friable
dx: pap and bx

tx TAH
Stage 3/ 4 chemo and rad tx

Question 7

cytocele/ retocele/ uterine prolapse

Answer 7

common after menopause

• cystocele- prolapse of bladder into ant wall of vagina
• retocel- herniation of rectum into post wall

uterine prolapse- prolapse vaginal canal

sx: vaginal fullness or pressure, feeling of incomplete voiding/ defecation

tx: topical estrogen therapy ( cystocele)
- pessary
- kegel exercises
- surgcial repair

Question 8

mastitis

Answer 8

• occurs inf breastfeeding women
• caused by nipple trauma
• s. aureus

sx: unlit, erytheamt, tenderness
- fever/ child

tx: dicloxacilin, cefalexin, erythro
- continue breast feeding on affected side

Question 9

breast abscess

Answer 9

farther along mastitis

• localized mass
• f/c

management: I and D
IV abx- vancomycin
stop breastfeeding
pump and dump

Question 10

fibrocystic breast

Answer 10

• sxs: painful cystic billet breast pain, size of cyst fluctuate during menstrual cycle

exam; bilat cysts that vary in size
sonogram- fluid filled cysts

tx: conservation, reduce caffeine, increase vitamin e, tamoxifen, or bromocritpin

Question 11

fibroadenoma

Answer 11

• AA, 20 years of puberty
• painless and unlit
• mobile

s/s: painless uniat lump

dx: sonogram- smooth, uniform, solid, FNA ( no fluid)
-watched,
large- surgery

Question 12

breast cancer

Answer 12

most common cause in women, 2nd MC cause of cancer

RF: BRCA 1 and 2

• prolonged use of unopposed estrogen
• early menarche, late menopause, late first pregnancy, nulliparty, over 40
• high fat diet
• obesity
• hyperplasia with fibrocystic breast

mammogram screening: 
If average risk: 
start at 40 
40-40--> every 1-2 years
> 50-- every year

Genetic RF: 25-35
not accurate
consider MRI

tumor types 80% infiltrating ductal

• painless, stony hard unlit mass
• infiltrating lobular- 10%
• inflammatory- 2%
• Paget’s dz- 1% ( rash on her breast and tried anti-fungal cream)

sx: painless mass in URQ, nipple d/x, erosion.

dx: 90% seen on exam
u/s
mammogram
FNA
open bx 

surgery: 1 cm

hormone therapy-HR positive( tamoxifen and AI)

Zometa to dec fx

Question 13

menopause

Answer 13

mean age 51
-low estrogen

changes: cessation of sense, hot flashes, dec vaginal lubrication, depression, mood swings

late changes: CAD

• everything dries up and falls down

FHS> 30 diagnostic

tx: HRT-contervial
used for hot flashes and dryness

CI: liver dz, thrombosis, CA of breast or endometrial

alternative tx:
hot flashes- depo vera, SSRI, yoga, acupuncture

osteopsosi: calc with vitamin d

vaginal dryness

Question 14

vaginitis

Answer 14

candida: 
RF: HIV, DM, abx
s/sx:  thick white 
10% KOH pseudonyme
tx: diflucan po or single dose or azole cream

bacterial vaginosis
-smells bad, d/c worse after menses, scant/ sticky, clue cells,
flagyl 500 mg bid X 7 days
-think about cost

trichomonas - sexual awtiviy, copious d/c, green/ yellow frothy ( strawberry cervix), protozoa, flagyl 2 g po X 1 dose

flagyl- avoid ETOH and sun

Question 15

chlamydia

Answer 15

most common of STI

RF: sex

Question 16

gonorrhea

Answer 16

• vaginal itching or penile itching
• cervical motion tenderness
• dissementiated infection
• cause of septic arthritis ( wrist, elbows, knee, ankles)
• macular papular leions on hands and feet

tx: zithromax X 1 dose
or ceftrixome

tx partners

Question 17

HPV

Answer 17

most common STI in women

• subtype 6 and 11 are being
  16, 18, 31, 33- cause cervical cancer

-cauliflower -like warts on external genitalia, anus, cervical

dx: HPV DNA testing, clinical on PAP
tx: small lesions
-podophyllin, imiquimod
large lesions: cryotherapy or surgery

prevention gardais vaccine
girls and boys 9-26
16, 18,

Question 18

pelvic inflame dz

Answer 18

• bacteria starts in uterus and works its way up bilat
  pathogens: chlamydia- dos common, gonorrhea,

RF: age 20, prior PID, prior douche

sx: bilat pelvic pain, back pain down the legs

exam: mucopurlent cervical d/c
- cervical motion tenderness

dx: cervcial cx
- elevatd WBC
- sonogram

d/d: ectopic, appendicitis, pyelonephritis

tx: inpatient- pelvic access, fever above 102, pregnancy, unreliable pt
outpatient: ceftriazone IM single dose +doxcycyline po X 14 days

Question 19

contraception

Answer 19

NPF- tracking a women menstrual cycle,
avoid sex 48 hours before and after this time
- check Basal body temp and monitor cervical mucous
failure rate: 25%

barrier methods “
condoms- protects gains STI, diaphragm ( bladder irritation), cervical cap
, spermicides

advantage: low SE profile, low cost

hormonal method
estrogen and progesterone - 3 weeks and 1 week off ( get periods

monphasic- dose is stay

-advantage- in monogamous relationship

OrthoEva- path changed once a week X 3 weeks
failure rate 1%

Nuva Ring-
leave in for 3 weeks and then come out for menses

• estrogen suppress FSH so follicle won’t mature
• no ovulation
• mucous is thicker

benefits: dec endometrial can, ovarian cyst, dysmneoorhea, fiber breast

CI: pregnancy, H/o: dat, breast/ endometrial cancer, melanoma, abn liver function tests

Question 20

progesterone only

Answer 20

• taken daily
• take same time every day
• good breastfeeding
• women > 40

Depo Provea- IM every 3 months
- return of ovulation up to 18 months
( good for teenagers)
SE: weight gain, mood changes, 
only use for 2 years
calcium loss

SQ Rods: left 3-5 years
cannot take oral
ovulation start promptly after removal

SE: scarring

• MOA: ovulation interrupted

CI: breast ca and liver tumors

Question 21

IUD

Answer 21

replace every 5-10 years
-wire in winning of future
-multi-parous women
- smokers > 35 y/o 
CI: pregnancy, uterine bleeding, acute gyn infection,

complications: uterine perforation,

Question 22

sterilization

Answer 22

tubal is most common

vasectomy is reliable

Question 23

infertility

Answer 23

not able to conceive w/in 12 months of unprotected sex
primary- no prior pregnancy
secondary- after previous pregnancy

causes: an-ovulation- most common
- tubal dz
- male factor
- unexplained

an ovulation
- PCOS, high prolactin, hypothalamic-pit dysfunction, hypothyroidism

dx: menstrual diary, literal phase day 21
management: bromocriptine to dx hyperpolactinemia, climid to stimulate ovulation, metformin to increase ovulation and pregnancy

Question 24

infertility- tubal dz

Answer 24

-cause: scarring/ adhesions
PID, endometriosis, h/x rupture appendix

dx: hysterosalpinogram
lapro

management: surgery/ lysis of adhesions

Question 25

infertility-male factors

Answer 25

abnormal semen analysis cause: increase scrotal temp, smoking, excessive ETOH, varicocele dx: semen analysis tx: tx etiology -IUI doner insemination

Question 26

General approach to infertility

Answer 26

- phase 1- - detailed h/o and type of coitus, ovulation tracking, semen analysis, TSH, prolatic, LH Phase 2: - hystersalpinogram - lapro - IVF if no cause

Question 27

fetus/ infant nomenclature

Answer 27

abortion: 42 weeks twins counts as 1 pregnancy

Question 28

presumption manifestations of prengnay

Answer 28

``` amenorrhea n/v quickening ( fetal movement) nulliparas 18-20 weeks multipara: 14-16 weeks ``` urinary frequency, nocturia, infection signs; chadwicks signs- bluish discoloration of vagina and cervix skin change: melasma/ chloasma ( dark patches on face) -linea nigra probable manifestation - positive pregnancy test - hagar' sign -softenging b/w fundus and cervica uterine growth- 12 weeks-symphisi pubis 20 weeks - at umbilicus after 20 weeks- 1 cm positive manifestations fetal heart tones -u/s examination of fetus labs: cholesterol increase > 200 BUN/ cr decrease

Question 29

prenatal labs

Answer 29

abc, blood type, vdrly, hep b, rubella, every visit- check maternal weight, BP, fundal height, fetal size , urine dipstick for protein,glucose, ketones

Question 30

screening tests

Answer 30

1st visit- dating sonogram -discuss screening tests 10-13 weeks-nuchal translucency 15-18 weeks- alpha-fetal protein/ quadruple screen 18-22 weeks- anatomical sonogram 24-28 weeks: glucose challenge test 28 weeks- Rhogam if woman is RH negative 32 weeks- repeat abc, VDRL, chlamydia, gonorrhea, Grp B strep

Question 31

trisomy 21

Answer 31

1st trimester- PAPP-A- low free beta hCG- high 2nd trimester- AFP -low inhibin A nuchal translucency screenin test 10- 13 weeks 10-13 weeks- CVS, not risky 15-20 - amniocentesis

Question 32

weight gain/ nutrition

Answer 32

20-35 pounds - intake 300 kc/per day - avoid ETOH, smoking, drugs, unpasteurized foot, deli meat, farm salmon

Question 33

stages of labor

Answer 33

stage 1- onset of labor to full dilated ( 10 cm ) second stage: fully dilated to birth of infant 3rd stage; - delivery of infant to delivery of placenta

Question 34

causes of slowed labor

Answer 34

``` pelvic floors- inadequate pelvis, failure to descent, contraction factors ( tx picot ) ``` aides: episiotomy- incision to widen vulvar orifice forceps vacuum- suction cup on stop of baby's head - do first before C-seciton induction of labor: considered when prolgoned pregnancy - DM, pre-eclmapia CI: cephalospelic dispropriotn, placenta previa, uterine scar, traverse lie

Question 35

inducing labor

Answer 35

meds: early- prostaglandin gel, given vaginally to ripen the service some dilation and effacement- Piton - causes uterine contraction, given IV

Question 36

antepartum testing

Answer 36

NST- non-stress test - reactive test - 2 acceleration in 20 minutes, up 15 beast from baseline- positive test is GOOD Contraction stress test: given pitocin and watch monitor -if late decellerations- BAD vibroacoustin stiumuatlion: auditory source to wake up the baby - biophysical profile- watch sonogram for 20 minutes - check breathing, gross body movements, fetal tone, amniotic fluid index

Question 37

monitor during labor

Answer 37

120-160 normal fetal HR - if consistent decceleration- could be fetal distress external fetal monitor internal fetal monitor- dilated and ruptured if non-reassuring FHR - stop piton, scalp PH

Question 38

induced abortion

Answer 38

medical ( up to 7-9 weeks) suction curetage

Question 39

spontaneous abortion

Answer 39

-pregnancy ends befor 20 weeks gestation more than 80% of abortions RF: parity, increase with material/ paternal age 60% -caused by chromosomal abn endocrine, infection, ETOH, caffeine

Question 40

clarifications of spontaneous abortion

Answer 40

all except for missed have vaginal bleeding threatned- women w/ vaginal bleeding and pregnant, inevitable- POC have not passed incomplete vaginal bleeding, partial pass of POC habitual abortion 2-3 ore more abortions check genetic, endocrine labs

Question 41

incompetent cervix

Answer 41

-cervical weakness causing passive, painless cervical dilation results in 1st or 2nd trimester abortion or pre-term labor management: cerclage- cervical suture in 1st trimester to provide support to weak cervix

Question 42

ectopic pregnancy

Answer 42

-embryo is somewhere besides uterine cavity most common in tube cause: salpingitis ( PID) sxs: pain, vaginal bleeding, amenorrhea ( women with positive pregnancy test now having slight vaginal bleeding with pain) unruptured- more pain ruptured- pain better, hypotension, tachycardia lab: B-HCG or serum positive sonogram: absence of IU gestational sac tx: methotrexate - serum b-hcg stable, compliant has to comply surgical: salpingostomy,

Question 43

gestational trophoblastic dz

Answer 43

hydatiform mole- grape like vesicle on sonogram, no egg/ fetus presentaiotn: positive pregnancy test, vag bleeding, pre-ecamplisa , hyperemesis studies: b-hcg titer higher than gestation age sonogram: sack of grapes on snows town pattern

Question 44

pre-term labor

Answer 44

20-36 weeks triad- preterm pregnancy, uterine contractions ( 3 in 20 minutes), dilation/ effacement RF: infection, Group B strep, cocaine, heavy cig smoking sx: contraction, vag bleeding labs: fetal fibronectiven testing positive negative lower risk cervical length - if 2 cm at 20 weeks if both abn 50/50 go into labor management: observe for 30-60 minutes and hydrate her then abx to tx subclinical infection bethamethsaone to help w/ fetal lungs tocolytics- increase labor

Question 45

premature rupture of membranes

Answer 45

- most common dx leading to NICU admission ``` Risks: vaginal/ cervical infection -cervical incompetence - multiple pregnancy - cig smoking ``` sxs: gush of fluid from vagina - every time she cough or strains--> feels a squirt signs: sterile speculum exam, pooling, nitrazine paper, ferning test, visual leakage treatment: 34 weeks for lung mature- bethamethsone > 35 weeks - induce under 34- immature lungs - keep baby in mom, check NST, CBC, bed rest until she is 35 weeks then deliver

Question 46

maternal RH isoimmuniation

Answer 46

mom produces ab again foreign red blood cells antigen in maternal circulation - risk is present only if mom is RH negative and dad id RH + and baby is RH + tx: Rhogam - 28 weeks protective -

Question 47

multiple gestation

Answer 47

- more severe s/sx of pregnancy - high risk ``` complications: spontaneous abortion - pre-eclampsia -increas of death for fetus, -cord prolapse - incr risk for placenta separation ```

Question 48

gestational diabetes

Answer 48

DM during pregnancy RF: AA, hispanic, indian correlation with pre-eclampsia, traumatic birth fetal risK : macrosomia, prematurity, still birth, delayed fetal lung maturity 24-28 week- GCT - non fasting 50 g glucose load - check maternal glucose after 1 hour - if > 140 mg/ dl move to GTT GTT- fasting testing take blood and then given 100 gm oral glucose at 1, 2, and 3 hours - 2 abn values fasting: 95 don't use h A1c during DM A1: diet controlled A2: insulin tx: diet and exercise finger stick X qid keep BS

Question 49

HTN in pregnant

Answer 49

chronic HTN- HTN before 20 weeks before gestation 140/ 90- 179/109 - no end organ damage check monthly sonogram- to make sure baby growing -stat weekly NST and biophysical profile serial BP and urine protein medication 150/100 methoadopa

Question 50

preeclampsia/ eclampsia

Answer 50

- proteinuria, edema, HTN eclampsia- above pause seizures after 20 weeks and moslty near term - can occur up to 2 weeks post part No incr risk for HTHn later in life ** most common risk factor is nulliparity multiple gestation DM chronic HTN complications: ecclmpia , renal failure, HELP, DIC prevention: 1 gm calcium daily mild and severe classification mild tx: BP high, proteinuria, and no other sx --> tx: deliver baby before 37 weeks--: bed rest and check BP and urine dips - if not reliable--> admit them and deliver at 37 weeks severe: BP higher 160-180/ 100, ++ proteinuria, and have sxs ( HA, blurred vision, RUQ pain, elevated creatinine) ``` tx: hospitalize , ICU given betamethasome over 34 weeks --> induced not stable--> immediate C-section mag sulfate- to dec seizures hydralazien and labetolol ```

Question 51

placental abruption

Answer 51

placenta becomes detached from side of uterine most common cause of 3rd trimester bleeding RF: HTH, cocaine, cig smoking, trauma external form: blood drains through the cervix - more common, less serious concealed- hemorrhage is confined - less common, more serious sx: abd pain ( searing) fetal distress labs/test: clinical, sonogram, H/H, PT/PTT tx: if large and fetal distress- emergency C-seciton if small- watchful waiting complications: fetal demise, maternal hemorrhage, maternal DIC and death

Question 52

placenta previa

Answer 52

placenta over the cervical os - may be partial or complete RF: advanced mat age, multiple gestation, previous previa, scarred endometrium sx: painless, bright red bleeding may have contractions ( no prenatal care, easily seen on sonogram) signs: sonogram , no vaginal exam tx: if little spotting- bed rest if full gush of blood- delivered C-section complications: embolism, prematurity, hypoxia

Question 53

post part hemorrhage

Answer 53

uterine atony - uterus continues to contact after baby born RF: later is short or long or infection findings: soft uterus tx: piton and uterine manage Genital laceration - suture it Retained placenta- see on the placenta missing or go in do manual exploration

Question 54

endometritis

Answer 54

infection in the endometrium ruptured membrane > 24 hours 2-3 days post part fever , uterine tenderness labs: elevated WBC UA tx: clindamycin and gentamicin