GYN Flashcards
Cervical cancer screening begins at? Prevention of cervical cancer?
21; HPV vaccine
3 most common cancers in women other than skin?
Breast, lung, colon
Etiology of cervical cancer?
HPV (think of cervical cancer like an STD - same risk factors)
GYN cancer with the highest mortality?
Ovarian
Mammogram breast cancer screening begins at?
50 according to USPSTF (or 40 from ACOG); family history = earlier
If you find ASCUS, what is the next step?
Do HPV DNA testing
What are excisional tx’s for cervical precancerous lesions?
local ablation: LEEP and cry
Cone
Women age 21-29 get what kind of HPV testing?
Reflex - only test for HPV if they have abnormal pap
Post-coital bleeding, dx?
cervical cancer (benign causes include: cervicitis, cervical polyp, cervical fibroid)
Tx of cervical cancer
Stage IIa or less: local resection
Stage IIb or more: chemo + radiation (usually platinum based chemo)
Risk factor for endometrial cancer? Name 8 things that contribute to that risk
unopposed estrogen; 1) age; 2) nulliparity; 3) obesity; 4) PCOS; 5) HRT; 6) tamoxifen; 7) early menarche; 8) late menopause
Surgical tx for endometrial cancer?
TAH + BSO
How do you diagnose endometrial cancer?
Biopsy: endometrial sampling or D+C
Post menopausal vaginal bleeding, what is the most common cause?
Vaginal atrophy! (not cancer)
How does a pt with cervical cancer typically present? Endometrial cancer? Ovarian cancer (3)?
post-coital bleeding; post menopausal bleeding; RF, SBO, ascites
Screening for ovarian cancer in BRCA1/2 mutations?
transvaginal U/S and Ca-125 with ppx TAH+BSO at 35
Detect choriocarcinoma by?
elevated B-HCG levels, persistent bleeding
Screening for ovarian cancer?
None (catches it too late)
Dysgerminoma - how to tx and track?
chemoreceptive + unilateral oophorectomy; use LDH to track; hCG can be elevated; often recur on contralateral side (seminoma equivalent for women)
Yolk sac tumor marker?
AFP (see Schiller-Duval bodies)
Post-menopausal female, small bowel obstruction, ascites, dx?
Ovarian cancer (can also present with weight gain and abdominal bloating)
If you find an adnexal mass, what’s the next step?
transvaginal U/S
(if simple cyst, can stop; if large, sepatated, loculated - complex cyst - use age and symptoms to determine if germ cell or epithelial)
How do you tx germ cell tumors? Epithelial ovarian tumors?
unilateral salpingo-oophorectomy; TAH + BSO and paclitaxel
Name 4 subtypes of epithelial cell ovarian cancer
1) serous; 2) mucinous; 3) endometrioid; 4) Brenner’s
these are all cystadenocarcinomas
Name 4 subtypes of germ cell ovarian cancer
1) dysgerminoma; 2) endometrial sinus/yolk sac; 3) teratoma; 4) choriocarcinoma
What is the risk factor for epithelial ovarian cancer?
Ovulation (epithelial trauma) - thing associated with it: nulliparity, post-menopausal female
Incomplete mole genetics?
69, XXY (1 egg, 2 sperm)
Complete mole genetics?
46, XX (85-90% of time) (via empty egg, 2 sperm)
What is seen on U/S of molar pregnancy?
snowstorm pattern
Grape-like mass exiting the cervix, +UPT, dx?
molar pregnancy
How do you tx a molar pregnancy?
suction curretage, follow hCG to 0 (also give OCP for 1yr)
How do you medically tx choriocarcinoma of the uterus?
low risk: methotrexate
high risk: EMA/CO (etoposide, methotrexate and dactinomycin, cyclophosphamide and vincristine)
or remember MAC backbone: methotrexate, actinomycin D (aka dactinomycin), cyclophosphamide
What do you do after molar pregnancy?
good birth control plan, and follow B-HCG to 0 (qwk)
How does a pt with a molar pregnancy present (6)?
1) size-date discrepancy; 2) B-HCG too high for dates (gt 100,000); 3) hyperthyroidism (from B-HCG); 4) hyperemesis gravidarum; 5) adnexal mass (simple cyst); 6) grape-like mass exiting cervix
How do you surgically tx choriocarcinoma?
for local disease: TAH
for more advanced: debulking - and add medical tx
DES exposure - dx?
clear cell adenocarcinoma (vaginal cancer)
Red lesion and itchy lesion on vulva, dx?
Paget’s (confirm w/bx)
Grape-like mass in vagina of a child - dx?
Rhabdomyosarcoma (sarcoma botryoides)
How do you tx melanoma on the vulva?
vulvectomy for large tumors and LN dissection
How do you tx page’s of the vulva?
local resection (no need for vulvectomy)
Hard, red, or black lesion and itchy on the vulva, dx?
squamous cell or melanoma
Which is associated with higher blood loss, surgical or medical abortion?
medical
___ is a common vulvar non-neoplastic disorder that results from chronic scratching and rubbing, which damages the skin and leads to a loss of its protective barrier. Clinical findings include thick, enlarged and rugs labia, with or without edema. Tx is?
lichen simplex chronicus; short course of high potency topical corticosteroids and antihistamines to control pruritus
Name 5 risk factors in the development of pelvic organ prolapse. Does C/S or vaginal delivery have a higher risk?
1) increasing parity; 2) increasing age; 3) obesity; 4) some CT disorders (Ehlers-Danlos); 5) chronic constipation
Vaginal delivery
Name 3 surgical options for PPH
1) uterine artery ligation; 2) internal artery ligation; 3) TAH; (also can consider embolization of arteries with IR)
Pelvic floor relaxation is usually due to stretched ___ due to multiple __. Patient can present with __, __ or on __ exam.
stretched cardinal ligaments (can’t keep things in place); large births; vaginal fullness, chronic back pain, speculum
What is the nonsurgical tx option for pelvic floor relaxation? What is the surgical tx?
Pessaries; 1) hysterectomy (uterine) 2) colporrhaphy (rectocele, cystocele)
What are the 4 grades for uterine prolapse?
Grade I: in vaginal canal
Grade II: at vaginal opening
Grade III: out of vagina but not inverted
Grade IV: inverted and out of the vagina
If there is rupture of an ectopic, you do what?
Salpingectomy
Dysmenorrhea, dyspareunia, infertility - dx?
Endometriosis
First line tx for fibroids?
OCPs and NSAIDs
How do you tx endometriosis?
OCPs (and NSAIDs)
How do you treat ovarian torsion?
Surgery to untwist the ovary
Sudden onset abdominal pain and n/v in an otherwise healthy woman, dx?
Torsion of the ovary
How do you tx a small simple cyst?
You don’t - observe only. Reimage in 12 wks if warranted (typically if it’s greater than 3cm)
If there is no rupture of an ectopic, you do what?
methotrexate if possible, if not, salpingostomy
How do you tx tubo-ovarian abscess? How do you tx PID?
inpatient IV cefoxitin + doxycycline + metronidazole (drain abscess if no improvement); cefoxitin + doxycycline
How do you tx a large dermoid cyst?
cystectomy
In addition to OCPs, how else can you shut down the HPO axis in a pt with endometriosis?
GnRH analogues and danazol
danazol will probably not be the answer ever due to androgen SEs
What are the 3 things that determine if you can use methotrexate for an ectopic pregnancy?
1) bHCG less than 5000; 2) gestational size less than 3cm; 3) no fetal heart tones
(then trend HCG to 0…due to risk of chorio)
A pt with tubo-ovarian abscess will present with abdominal/pelvic pain and at least 1 of these 3, and __ and __.
1) cervical motion tenderness; 2) adnexal tenderness; 3) uterine tenderness; fever and leukocytosis
+WBC on wet prep increases likelihood of TOA
Multiple sclerosis can induce what type of incontinence?
Overflow incontinence (due to neurogenic bladder - absence of detrusor contractions)
Q-tip test shows hyper mobility, dx?
Stress incontinence (hypermobility is of the urethra)
Sneeze and pee, dx?
Stress incontinence
Sudden urges to urinate at all times of the day, dx?
Urinary urgency, check for UTI (could be urge incontinence)
How do you diagnose urgency incontinence?
hx, bladder diary, in some cases cystometry (will show spasms of the bladder at all levels of urinary volumes)
Urgency, frequency, and dysuria - dx?
UTI
In addition to physical exam, how can you diagnose a continuous leak due to fistula?
tampon test
How do you tx stress incontinence (4)?
1st lifestyle, then PT and pessaries, then surgery (sling, urethral bulking agents - urethropexy = Burch procedure)
How do you tx urge incontinence (2)?
Oxybutynin, intermittent/indwelling catheter
How do you tx overflow incontinence (2)?
bethanechol, intermittent/indwelling catheter
Urge and nocturnal incontinence: stress, overactive bladder, overflow, irritative bladder
stress: no to both
overactive bladder: urge+ nocturnal+
overflow: no urge, nocturnal+
irritative: urge+, no nocturnal
Flagellated motile organisms, dx?
trichomonas
Erythematous macular body rash, desquamating rash, dx?
Toxic shock (look for tampon in question stem)
How do you tx tubo-ovarian abscess?
IV cefoxitin, doxycycline, and metronidazole, and/or drain if large
How do you dx candida? How do you tx candida?
KOH prep shows pseudohyphae; Fluconazole topical or oral
How do you tx purulent cervical discharge?
Ceftriaxone + azithromycin or doxy
Clue cells, dx?
Bacterial vaginosis
White thick vaginal discharge, dx?
Candida
How do you tx toxic shock?
Nafcillin
How do you tx trichomonas?
metronidazole po both partners!
Which two infxns are always tx together (and frequently occur together)?
Gonorrhea and chlamydia
How do you diagnose cervicitis?
Gc/Chla NAAT (NAAT=PCR), wet prep
Pt has cervical motion tenderness and cervical discharge without s/s of PID, dx?
cervicitis
T/F: there is no imaging or blood test that can confirm endometriosis
True (definitive dx is through laparascopic surgery)
How do you tx a complex cyst?
If it is greater than 7cm you should remove it laparascopically. Don’t do aspiration are you might seed it
Describe a simple cyst (6). How do you tx?
Single, fluid-filled, homogenous, cystic, unilocular, lt 7cm; can tx with OCPs
Describe a complex cyst (4). How do you tx?
loculated, lobulated, multiple septations, , gt 7cm. If it is greater than 7cm you should remove it laparascopically. Don’t do aspiration are you might seed it
___ is a chronic inflammatory condition of the bladder, which is clinically characterized by recurrent irritative voiding symptoms of urgency and frequency in the absence of objective evidence of another disease that could cause the symptoms
Interstitial cystitis
70% of women with IC have pelvic pain; women may also experience dyspareunia
GnRH agonists work by __. Danazol, a 17-alpha-ethinyl testosterone derivative, suppresses ___.
down regulating the HPO axis (decreasing release of LH and FSH, and subsequent estradiol levels); mid cycle surges of LH and FSH
Pelvic congestion syndrome is accuse of chronic pelvic pain in the setting of ___. The unique characteristics of the __ make them vulnerable to chronic dilatation with stasis leading to __.
pelvic varicosities; pelvic veins; vascular congestion
(will see enlared uterus with selective dilatation of ovarian and uterine veins - high estradiol concentrations inhibits reflex vasoconstriction of vessels)
Dysmenorrhea and heavy menstrual bleeding with progression chronic pelvic pain are typic of ___. A boggy, tender, __ uterus on examination is also characteristic.
adenomyosis; uniformly enlarged
Pts who desire lactation suppression should do these 3 things
1) wear a supportive bra; 2) avoid nipple stimulation; 3) use ice packs and analgesics (NSAIDs) to relieve associated pain
Name 4 risks of combined estrogen-progestin contraceptives
1) venous thromboembolism; 2) HTN; 3) hepatic adenoma; 4) rarely stroke and MI
What is the typical clinical presentation of ruptured ovarian cyst? U/S findings?
sudden onset, severe, unilateral lower abdominal pain immediately following strenuous activity or sexual activity; pelvic free fluid
Name 5 causes of acute abdominal/pelvic pain in women
1) mittelschmerz; 2) ectopic pregnancy; 3) ovarian torsion; 4) ruptured ovarian cyst; 5) PID (+/- TOA)
Name 3 causes of abnormal menstrual bleeding
1) fibroids; 2) adenomyosis; 3) endometrial cancer/hyperplasia
You suspect a foreign body in a child’s vagina, next step?
exam under anesthesia
Assessing bleeding post menopausal woman
history, physical exam (pelvic), U/S, endometrial bx if thickened endometrium
Birth control to tx bleeding irregularities?
OCPs, levonorgestrel IUD
Post-menopausal woman bleeding - what test do you get?
u/s (if endometrial stripe thickened, endometrial biopsy)
Assessing bleeding in reproductive age
pregnancy, PALM-COEIN (polyp, adenomyosis, leiomyomata, malignancy, coagulopahty, ovulartory dysfunction, endometrial, iatrogenic, not otherwise specified)
What is the most common cause of vaginal bleeding in premenarchal, reproductive, and menopausal women
pre: foreign body
repro: pregnancy
meno: vaginal atrophy
Name 3 causes of vaginal bleeding in a premenarchal girl
1) foreign body; 2) sexual abuse; 3) precocious puberty
Name 3 causes of vaginal bleeding in a menopausal woman
1) vaginal atrophy; 2) endometrial cancer/hyperplasia; 3) HRT
How do you tx a missed abortion?
If gt 24 weeks - induce with oxytocin
If lt 24 wks - can use misoprostol
D&C if surgery is warranted
No passage of contents, cervical os open, U/S shows a dead baby, dx?
inevitable abortion
No passage of contents, closed os, dead baby, dx?
Missed abortion
UPT is positive, u/s shows nothing, B-quant is 1000, dx and next step?
pregnancy of unknown location - check B-quant in 48 hours (if it doubles, IUP, if not, ectopic)
Passage of contents, cervical os closed, no baby on u/s, dx?
Complete abortion
Abdominal pain, UPT positive, next step?
U/S and quantitative beta hCG
Passage of contents, cervical os open, retained parts on u/s, dx?
Incomplete abortion
Name 5 differential diagnoses for dysmenorrhea. Which 2 are associated with dyspareunia?
1) primary dysmenorrhea (pain during menses); 2) endometriosis (pain peaks before menses); 3) fibroids; 4) adenomyosis; 5) pelvic congestion (dull pelvic ache that worsens with standing)
endometriosis and pelvic congestion
Asymmetric uterine masses, often present with pelvic pressure or abnormal uterine bleeding - dx?
fibroids
How do you tx PCOS?
OCPs and metformin
Fat, hairy, infertility, dx?
PCOS
Severe vaginal bleeding w/o risk of DVT/PE?
IV estrogen
First step to tx a bleeding fibroid?
OCPs and NSAIDs
There is an image of a U/S of the ovaries with lots of little circles, dx?
PCOS
How do you diagnose PCOS?
1) Anovulation AND either
2) biochemical: LH/FSH gt 3:1, inc testosterone and DHEAS
OR
3) imaging - u/s follicles
Will see hyperandrogenism too
How do you tx fibroids if she wants kids? If she doesn’t want kids? If they are too big for surgery?
myomectomy; TAH; leuprolide to help shrink
List 9 possibile causes of abnormal vaginal bleeding
Polyps Adenomyosis Leiomyoma Malignancy Coagulopathy Ovarian dysfunction Endometrium Iatrogenic/IUD Not yet classified
Evaluation steps for secondary sex characteristics before 8?
obtain wrist XR (bone age), FSH, LH, and estradiol (for eval of Precocious puberty)
In precocious puberty work up, if GnRH stimulation test results in increased LH you have __ precocious puberty. Next step is __. If you have no change in LH, you have __ precocious puberty. Next step is__.
central; MRI brain (look for anterior pituitary tumor vs constitutional GnRH secretion); peripheral; U/S abdomen, adrenals, ovaries, and 17-OH progesterone test (look for CAH, adrenal or ovarian tumor, or ovarian cyst)
How do you tx central precocious puberty?
GnRH agonist (leuprolide) for prevention of premature epiphyseal plate fusion OR resect AP tumor if they have one
Delayed puberty is defined by (2)?
absence of secondary sex characteristics by 13, or the absence of menses by 16
T/F: growth hormone can help activate delayed puberty
false
Development of axillary hair or breast buds before what age warrants investigation?
8 (some research suggests younger for African Americans)
Central precocious puberty is dx’ed by what test?
GnRH stimulation test (will show LH up)
17-OH progesterone can help identify?
CAH (it is part of newborn screening, but can have late onset)
No breast development and can’t smell, dx?
Kallmann syndrome
Shield-shaped chest, broad spaced nipples, web neck; dx?
Turner syndrome (X,O)
What do you do with a pt who has androgen insensitivity syndrome?
Remove testes after puberty (due to risk of testicular cancer)
First test for primary amenorrhea?
UPT
Karyotype of mullerian agenesis?
XX (idiopathic loss of mullerian ducts)
Primary amenorrhea: HPO axis intact and uterine anatomy intact, dx (4)?
1) pregnancy; 2) anorexia; 3) weight loss; 4) imperforate hymen
Primary amenorrhea: HPO axis intact and uterine anatomy not intact, dx (2)?
Mullerian agenesis (XX, normal testosterone) and androgen insensitvity syndrome (XY female appearing, increased testosterone)
Primary amenorrhea: HPO axis not intact and uterine anatomy intact, dx (3)?
Craniopharyngioma, Kallmann syndrome, Turner syndrome
first two have no FSH, LH; Turners has increased FSH, LH
What 3 tests should you order in diagnosing primary amenorrhea?
1) urine pregnancy test; 2) wrist xray; 3) u/s of the uterus
Why does hypermagnesemia cause hypocalcemia?
due to temporary suppression of PTH secretion
First test for secondary amenorrhea?
UPT
What medications should you look for in secondary amenorrhea?
Anti-psychotics (dopamine antagonists increase prolactin)
What tests should you get to assess secondary amenorrhea, and in which order?
UPT, then TSH, prolactin, FSH
A woman stops bleeding, runs a lot, training for a marathon, dx?
hypothalamic causes
A woman with multiple elective abortions/D&Cs has amenorrhea, dx?
Asherman’s syndrome
If a woman has savage syndrome, what would the following tests show: progestin challenge, E+P challenge, FSH and LH, U/S
savage = unresponsive ovaries progestin negative (since no estrogen phase on endometrium) E+P induces bleed FSH, LH both increased U/S would show follicles
Name 3 hypothalamic causes of 2ndary amenorrhea. Name 3 AP causes.
1) stress; 2) anorexia; 3) exercise
1) adenoma; 2) Sheehan; 3) apoplexy
Name 3 ovarian causes of 2ndary amenorrhea. Name 2 endometrial causes.
1) savage syndrome; 2) premature ovarian failure; 3) menopause
1) asherman syndrome; 2) ablation
What’s the difference btwn primary and secondary amenorrhea?
Primary has never had a period while 2ndary has in the past
In 2ndary amenorrhea, once TSH, UPT, and prolactin have all been ruled out, what are the next tests (and the order)
Think about HPO Axis problems: 1) progesterone challenge; 2) E+P challenge; 3) FSH, LH and FSH/LH; 4) MRI; 5) DOE = hypothalamus
In 2ndary amenorrhea, once TSH, UPT, and prolactin have all been ruled out and you bleed with a progesterone challenge, what’s the dx? Don’t bleed w/P or E+P challenge?
PCOS; Asherman’s or ablation
How do you tx vaginal atrophy?
vaginal estrogen creams
What are symptoms of menopause (4)?
hot flashes, vaginal atrophy, irritability, and mood swings
How do you tx hot flashes?
venlafaxine
What is primary care for women after menopause?
Ca + Vit D, dexa at 65
If CAD put on statin
3 things necessary for fertility?
1) ovulation; 2) normal anatomy; 3) normal semen
How do you tx infertility from anovulation?
clomiphene
Infertility and fibroids, desires children, next step?
myomectomy
What is the ovarian androgen? Adrenal androgen?
Testosterone; DHEA-S
How do you dx a tumor in a young woman causing virilization?
U/S
How do you dx congenital adrenal hyperplasia?
17-OH-progesterone in the urine
What are 3 ways you can tell if a woman is ovulating?
1) basal temp rises 1 degree on ovulation; 2) endometrial bx day 14-28 showing secretory uterus; 3) can measure progesterone level at day 22
What is the order of puberty development?
Tits, pits, mits, lips
breast, axillary hair, growth spurt, menarche
What are six causes of precocious puberty (think about each level)?
1) Hypothalamus constitutionally on; 2) AP LH/FSH secreting tumor; 3/4) Ovary: cyst, granulosa theca tumor; 5/6): adrenals: CAH, tumor
__ syndrome is characterized by premature menses before breast and pubic hair development
McCune-Albright syndrome
__ anomalies occur in 25-35% of pts with mullerian agenesis.
renal
What are the 3 D’s of endometriosis?
Dysmenorrhea (painful periods), dypareunia (painful sex), and dyschezia (painful defecation)
