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USMLE Step 3 - ALL > GYN > Flashcards

GYN Flashcards

1
Q

Women age <30
U/L, solitary, painless, firm, mobile mass
DOESN’T change w/ menstrual cycle
Can get increased pain or size prior to menses

A

Fibroadenoma

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2
Q

Women age 20-50
Multinodular breasts
B/L painful breast lumps
vary w/ menstrual cycle

A

Fibrocystic Disease

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3
Q

H/o recent trauma or surgery
fixed mass w/ skin or nipple retraction
mass solid on U/S
calcification on mammogram

A

Fat necrosis

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4
Q

DX and TX of Fat Necrosis

A

DX: Fine needle bx (shows foamy macrophages and fat globules)

TX: nothing just routine f/u

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5
Q

Causes of B/L nipple d/c

A

Prolactinoma
Hyperprolactinemia from MDXs
Hypothyroidism
Pregnancy

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6
Q

U/L, nonbloody nipple d/c

A

Intraductal Papilloma

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7
Q

U/L bloody nipple d/c

A

Breast Malignancy

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8
Q

Tx for Fibrocystic Disease

A

OCPs

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9
Q

Tx for Fibroadenoma

A

Reassurance in adolescents

In women ≥30 yoa –> Mammogram +/- U/S, followed by core bx if suspicious for malignancy

In women <30 yoa –> U/S +/- mammogram

  - simple cyst = needle aspiration (if pt desires) 
  - complex cyst/solid mass = image guided core bx
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10
Q

What to do if cyst aspirate is clear and cyst disappears after FNA?

A

Repeat breast exam and U/S in 4-6 wks

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11
Q

Tx for Lobar CA In Situ (LCIS)

A

tamoxifen x 5yrs

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12
Q

Tx for Ductal CA In Situ (DCIS)

A

lumpectomy + radiation + tamoxifen x 5 yrs

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13
Q

Tamoxifen MOA

A

Selective ER Modifier (SERM)

Breast ER receptor antagonist
Endometrial agonist
Bone agonist

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14
Q

SEs of Tamoxifen Use

A

Endometrial CA
Thromboembolism
Decreased osteoporosis
Hot flashes

NOTE: tamoxifen or raloxifene must be stopped 4 wks before major surgery to prevent DVTs

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15
Q

MDX to PREVENT breast cancer in pts w/ ≥ 2 first degree relatives w/ breast CA

A

Tamoxifen

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16
Q

TX for PREmenopausal woman w/ PR and ER (+) Cancer

A

Tamoxifen

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17
Q

TX for POSTmenopausal woman w/ PR and ER (+) Cancer

A

Aromatase inh. (eg. anastrozole) OR Tamoxifen

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18
Q

Aromatase Inh. MOA

A

Pure breast estrogen antagonists

bone antagonist

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19
Q

SEs of Aromatase Inh. Use

A

Increased osteoporosis

NO increased DVT risk

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20
Q

Monoclonal Ab against HER-2/NEU

A

Trastuzumab

Used in metastatic disease w/ over-expression of HER/NEU

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21
Q

SEs of Trastuzumab

A

Risk of cardiotoxicity w/ ↓ EF (do ECHO before starting MDX)

  • -> reversible after tx stopped
  • -> can use normal HF tx (eg. B-blocker, ACEI)
  • -> if get symptomatic HF, must d/c trastuzumab
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22
Q

MC form of breast cancer

A

Invasive ductal CA

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23
Q

Tx for Invasive Breast Cancer

A

Lumpectomy + radiation (breast conserving therapy)

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24
Q

When is modified radical mastectomy (NOT breast conserving) the answer?

A 
If pt pregnant 
Diffuse malignancy OR ≥ 2 sites in separate quadrants
Tumor > 5cm 
Positive tumor margins 
Prior irradiation to breast
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25
Q

When is Chemotherapy the answer for breast cancer?

A

Lesion > 1cm

Lymph node positive disease

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26
Q

When to test for BRCA 1 or 2 genes?

A

FHx of early onset (<50yoa) breast or ovarian CA
Breast and/or ovarian CA in the same pt
FHx of male breast CA
Ashkenazi Jewish heritage

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27
Q

Breast Cancer Screening Guidelines

A

Mammogram starting at age 50 then every 1-2yrs

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28
Q

Pruritic, red, scaly nipple lesion

Inverted nipple or discharge

A

Paget’s Disease of Breast

Underlying breast adenoCA present

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29
Q

Enlarged, firm, NONTENDER, ASYMMETRIC uterus
intermenstrual bleeding
menorrhagia w/ clots
dysmenorrhea
bladder, rectum or ureter compression sxs

A

Leiomyoma (uterine fibroids)

  • benign uterine tumor
  • growth of myometrium (which has smooth m)
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30
Q

Leiomyoma and relationship to estrogen

A

Size increases w/ estrogen (eg. in preg)

Size decreases in menopause

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31
Q

Dx of Leiomyoma

A

1) Pelvic exam –> asymmetric, large, firm, nontender uterus
2) U/S
3) Hysteroscopy (direct visualization)

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32
Q

Tx of Leiomyoma

A
  • Observation
  • OCPs or progestin only contraception (progestin IUD)
  • Myomectomy –> preserved fertility; must get C-section if get preg after to prevent uterine rupture
  • Hysterectomy –> if done having babies
  • Embolization of vessels –> preserves uterus but high risks if get preg after this
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33
Q

Pt age 35-50
soft, globular, TENDER, SYMMETRIC uterus
menorrhagia
dysmenorrhea

A

Adenomyosis (no relationship to estrogen)

Location of endometrial glands/stroma within myometrium of uterus

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34
Q

Dx of Adenomyosis

A

1) Pelvic exam

2) U/S

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35
Q

Tx of Adenomyosis

A
  • Progestin IUD

- Hysterectomy –> if done having babies

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36
Q

Causes of postmenopausal bleeding and next step

A
  • vaginal or endometrial atrophy
  • endometrial carcinoma

Next step –> endometrial bx to r/o endometrial CA
NOTE: in normal postmenopausal women, endometrial lining stripe should be <5mm thick

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37
Q

RFs for Endometrial Carcinoma

A

Unopposed estrogen states:

  • obesity
  • nulliparity
  • late menopause/early menarche
  • PCOS
Tamoxifen use 
Lynch Syndrome (HNPPC)
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38
Q

Management of Endometrial CA

A

surgery staging + radiation + chemo

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39
Q

MCC of dysfunctional (unexplained) uterine bleeding

A

anovulation

(have enough estrogen but progesterone is not produced so no withdraw bleeding occurs. When endometrium can’t take it anymore, it bleeds HEAVILY and IRREGULARLY)
FSH and LH normal

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40
Q

Dx of dysfunctional uterine bleeding

A

No specific test –> dx of exclusion
BUT make sure do endometrial bx in any pt > 35 yoa w/ abnormal uterine bleeding (if <35 yoa but have persistent bleeding then also get endometrial bx)

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41
Q

Tx for dysfunctional uterine bleeding

A

Pt STABLE –> High dose PO/IV estrogen OR high dose progestin pills OR high dose OCPs

  • if pt anovulatory
  • pt >35 yoa w/ normal endometrial bx

D&C
- if need acute management of hemorrhage or if medical management fails after 24-36 hrs

Endometrial ablation/Hysterectomy
- if bleeding severe, pt not controlled w/ OCPs, pt anemic or lifestyle affected

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42
Q 
postmenopausal bleeding
pelvic pain/pressure 
abdominal distension 
uterus enlarged w/ uterine mass 
ascites (eg. fld in cul-de-sac)
A

Uterine Sarcoma

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43
Q

RFs for uterine sarcoma

A

pelvic radiation
tamoxifen use (eg. breast CA pt)
postmenopausal pts

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44
Q

Dx of uterine sarcoma

A

U/S +/- additional imaging
endometrial bx
histopathology of surgical specimen

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45
Q

Tx for uterine sarcoma

A

Hysterectomy +/- adjuvant chemo/radiation

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46
Q

MC location of metastases for uterine sarcoma?

Prognosis?

A

Lung (look for pleural effusion)

PROGNOSIS: poor; aggressive tumor that recurs

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47
Q

Sudden U/L lower abd. pain (occurs after strenuous exercise or sexual activity)
Adnexal mass
Cullen’s sign (if intraperitoneal bleeding present)
B-hCG negative

A

Ruptured Ovarian Cyst

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48
Q

Dx and Tx of ruptured ovarian cyst

A

DX:
U/S (see adnexal mass with free fld in pelvis)

TX:
Stable = analgesics; unstable = surgery

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49
Q

Sudden, U/L pelvic pain that radiates to groin/back
Adnexal mass
N/V
B-hCG negative

A

Ovarian Torsion (Right sided most common)

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50
Q

Dx and Tx of ovarian torsion

A

DX:
U/S w/ Doppler (see cyst or big ovary w/ ↓ bld flow)

TX:

  • r/o preg
  • laparoscopy w/ detorsion
  • ovarian cystectomy (if bld supply not affected)
  • oophorectomy (if necrosis or malignancy)
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51
Q

cystic mass
smooth lesion edges
few septa

A

Benign Ovarian Mass

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52
Q

irregularity
nodularity
many thick septa
solid, complex mass

A

Malignant Ovarian Mass

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53
Q 
adnexal mass on bimanual exm 
ascites
abd. pain 
w. loss
change in bowel habits 
menstrual irregularities
A

Ovarian Neoplasm

–> 2 types: epithelial (MC in postmenopausal pt) and germ cell (if pt <30 yoa)

Epithelial Tumor = CA-125, CEA tumor markers
Germ Cell Tumor = B-hCG, AFP tumor markers

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54
Q

Ovarian mass + endometrial hyperplasia

A 
Granulosa Theca (stromal tumor) 
--> produces estrogen = endometrial hyperplasia, feminization and precocious puberty
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55
Q

Adnexal mass + woman w/ hirsutism and deepening voice

A

Sertoli-Leydig Cell (stromal tumor)

  • -> produces testosterone = masculinization (receding hairline, deep voice, cliteromegaly, hirsutism)
  • -> ↑ testosterone and estrogen + ↓ LH and FSH
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56
Q

Protective factors against ovarian cancer

A

Breastfeeding
OCPs
short reproductive life
chronic anovulation

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57
Q

old woman w/ gastric ulcer hx and recent worsening dyspepsia presents w/ w. loss and abd pain. Adnexal mass found

A

Krukenberg Tumor (metastatic gastric Ca to ovary)

–> CEA = tumor marker

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58
Q

Ovarian fibroma + ascites + R. hydrothorax

A

Meigs Syndrome

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59
Q

Dx steps after ovarian mass found

A

U/S
–> normal = observe w/ periodic U/S
–> abn = contact gyn oncologist
Biopsy

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60
Q

Tx of ovarian mass

A 
Premenopausal = salpingo-oophorectomy  
Postmenopausal = TAH + BSO + postop chemo for malignant tissue
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61
Q

When does a preg woman need surgical intervention for adnexal mass? (3)

Tx?

A
  • mass >10 cm
  • mass has complex features
  • mass is persistent

TX:
surgical removal in early 2nd trimester –> if cancer diagnosed, can give chemo in 2nd/3rd trimesters

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62
Q

Pt presents 1-2 days after ovulation induction tx (w/ B-hCG injections). Has N/V, abd pain, B/L enlarged ovaries with multiple follicles.

A

Ovarian Hyperstimulation Syndrome
–> after ovulation induction, ovaries overexpress VEGF = increased vasc. permeability and capillary leakage = third spacing of fld

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63
Q

Other Sxs associated w/ Ovarian Hyperstimulation Syndrome

A 
Ascites
Pleural/ pericardial effusions 
Resp distress
Hemoconcentration 
Hypercoagulability 
Electrolyte imbalances 
Multiorgan failure (eg. renal failure) 
DIC
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64
Q

Evaluation of Ovarian Hyperstimulation Syndrome

A

monitor fld balance
serial CBC, electrolytes
serum hCG

pelvic U/S
CXR
Echo

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65
Q

Tx of Ovarian Hyperstimulation Syndrome

A

correct electrolytes
paracentesis/thoracentesis
DVT ppx

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66
Q

HPV types associated w/ cervical carcinoma

A

16, 18

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67
Q

HPV types associated w/ warts (benign condyloma acuminata)

A

6, 11

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68
Q

Low Grade Squamous Intraepithelial Lesion (LSIL) includes what 3 categories?

A

HPV
mild dysplasia
CIN 1

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69
Q

High Grade Squamous Intraepithelial Lesion (HSIL) includes what 5 categories?

A 
moderate dysplasia
severe dysplasia
CIS 
CIN 2
CIN 3
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70
Q

Pap screening guidelines

A
  • Start at age 21
  • Do cytology every 3 years until age 30
  • After age 30 do cytology every 3 years OR cytology + HPV every 5 years
  • Stop Paps at age 65
  • No Paps for woman w/ total hysterectomy
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71
Q

Pt b/w age 21-24 had first ASCUS or LSIL pap…what to do next?

A

Repeat pap smear in 12 mo

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72
Q

Repeated 2nd pap smear is negative or shows ASCUS or LGIL…what to do next?

A

Repeat pap smear in 12 mo

If repeated comes back negative –> do nothing; go back to routine screening
If repeated comes back as ASCUS or worse –> colposcopy and biopsy

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73
Q

Pt ≥ 25 yoa had first ASCUS pap…what to do next?

A

HPV DNA testing

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74
Q

HPV DNA negative…what to do next?

HPV DNA positive…what to do next?

A

Routine follow up –> Get pap + HPV DNA in 3 yrs

Colposcopy and biopsy

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75
Q

When to get colposcopy and biopsy?

A
  • abnormal pap (eg. HSIL)
  • 3 consecutive ASCUS paps in pt 21-24 yoa
  • ASCUS + HPV positive in pt ≥ 25 yoa
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76
Q

When to get cone biopsy?

A

Done after colposcopy if Pap smear and bx findings are inconsistent (suggests abnormal cells not biopsied)

Cone bx done in OR

77
Q

Complications of cone bx?

A

Incompetent cervix

Cervical stenosis

78
Q

Colposcopy and bx found CIN 1.. what to do next?

A

F/u w/ repeat pap smears, colposcopy + Pap smear OR HPV DNA testing every 4-6 months for 2 years

79
Q

Colposcopy and bx found CIN 2/3.. what to do next?

A

LEEP OR cold knife conization

80
Q

Keep getting recurrent CIN 2/3.. what to do next?

A

Hysterectomy

81
Q

Pregnant woman w/ abnormal Pap.. what to do next?

A

Do colposcopy and bx

Preg. pts managed same as non-preg pts EXCEPT NEVER perform endocervical curretage on preg pt

82
Q

Preg woman has CIN or dysplasia on colposcopy and bx.. what to do next?

A

Repeat pap + colposcopy every 3 months during preg

Then get repeat pap + colposcopy 6-8 wks postpartum (even if pap and colposcopy were normal during preg)

83
Q

Preg woman has microinvasive cervical cancer on colposcopy and bx.. what to do next?

A

Cone bx

Deliver vaginally and then reevaluate 6-8 wks postpartum

84
Q

Preg woman has invasive cancer on colposcopy and bx.. what to do next?

A

Dx before 24 wks = radical hysterectomy or radiation

Dx after 24 wks = conservative management upto 32-33 wks then do C-section and hysterectomy

85
Q

when to get HPV vaccine?

A

Females: 8-26 yoa
Males: 9-26 yoa

86
Q

who CAN’T get HPV vaccine?

A

Preg pt
Lactating pt
IC pt

87
Q

Inflammation of cervix + cervical d/c + friable cervix

A

Cervicitis

Causes: Gonorrhea + Chlamydia

88
Q

Tx for cervicitis

A

IM ceftriaxone + PO Azithromycin

89
Q 
lower abd. pain 
tenderness
fever
cervical motion tenderness 
mucopurulent vaginal d/c
↑ WBC 
↑ ESR, CRP
A

Acute PID

Causes: Gonorrhea + Chlamydia

90
Q

RFs for acute PID

A 
multiple sexual partners (HIGHEST RISK) 
inconsistent barrier contraception use 
age 15-25
sex partner w/ Gono/Chlam
prev. PID
91
Q

Dx of acute PID

A

first r/o preg

Initial: cervical cx and NAAT
Accurate: laparoscopy (ONLY for recurrent infxns)

92
Q

Tx for acute PID

A

Outpatient: IM ceftriaxone single dose + PO doxycycline x14d
Inpatient: IV cefoxitin OR cefotetan + IV doxycycline

93
Q

Inpatient admission criteria for acute PID

A 
Fever > 102.2F
failure to respond to PO MDXs
pt can't take PO MDXs (eg. vomiting) 
pt not complaint w/ tx 
pregnancy
94
Q

Complications of acute PID

A 
infertility 
ectopic preg
chronic pelvic pain 
tuboovarian abscess
pelvic peritonitis 
sepsis
95
Q

Sxs of chronic PID

U/S findings?
Tx?

A

infertility
dyspareunia

cervical cx (-) 
U/S --> B/L cystic pelvic masses (hydrosalpinges)

TX:
lysis of tubal adhesions to improve fertility
for unremitting pelvic pain –> TAH, BSO

96
Q 
ill appearing woman 
severe lower abd/pelvic pain 
back pain 
rectal pain 
N/V
fever
tachycardia 
↑ WBC
↑ ESR 
Pus on culdocentesis
A

Tuboovarian abscess

97
Q

Dx of Tuboovarian abscess

A

U/S:
U/L pelvic mass (multinodular, cystic, complex adnexal mass)

Bld cx:
anaerobic bacteria

98
Q

Tx of Tuboovarian abscess

A

Admit to hospital
IV Cefoxitin + IV doxycycline

No response w/in 72 hrs or if abscess ruptures –> percutaneous drainage OR exploratory laparatomy +/- TAH and BSO

99
Q

thin, vaginal d/c w/ fishy odor
gray/white d/c
no itching or inflammation
vaginal pH >4.5

A

Bacterial Vaginosis (Gardnerella)

MCC of vaginitis

100
Q

Dx and Tx of Bacterial Vaginosis

A

DX:
saline wet mount –> clue cells (obscured edges of cells)

TX:

  • PO metronidazole x 7 days OR vaginal clindamycin
  • only tx symptomatic preg pts
101
Q

Complications of Bacterial Vaginosis

A
  • ↑ risk of preterm birth
  • ↑ risk for acquisition of HIV, HSV 2, gonorrhea, chlamydia, Trichomonas infxns
  • preterm PROM
  • chorioamnionitis
102
Q

white, cheesy vaginal d/c
vaginal inflammation and itching
vaginal pH: 3.5-4.5 (normal)

A

Candidiasis (Candida albicans)

103
Q

Dx and Tx of Candidiasis

A

DX:
KOH shows pseudohyphae

TX:

  • PO fluconazole
    - -> CI in preg pts
  • vaginal miconazole, clotrimazole, econazole, or nystatin
    - -> can use in preg pts
104
Q 
profuse, green, frothy vaginal d/c 
urinary frequency, dysuria, dyspareunia
vaginal inflammation and itching 
cervical petechiae ("strawberry cervix") 
vaginal pH > 4.5
A

Trichomonas (Trichomonas vaginalis)

MC non-viral STD

105
Q

Dx and Tx of Trichomonas

A

DX:
saline wet mount shows motile pear-shaped flagellates

TX:

  • single dose PO metronidazole
  • tx both pt and sexual partners
106
Q

Complications of Trichomonas

A

metronidazole enters breast milk
–> to avoid infant exposure, breast milk should be expressed and discarded for 24 hrs after metronidazole administration

107
Q

recurrent crampy lower abd pain
N/V
diarrhea
ALL DURING MENSTRUATION

A

Primary Dysmenorrhea

  • -> from excessive endometrial prostaglandin F2
  • -> no pelvic abnormality
108
Q

Tx for Primary Dysmenorrhea

A

First line: NSAIDs x 2-4 mo

Second line: OCPs

109
Q 
Woman >30 yoa
3 D's: 
-dysmenorrhea 
- dyspareunia 
- dyschezia 
Cyclical pelvic pain
Cervical motion tenderness
Uterus normal in size but immobile
Infertility
A

Endometriosis

  • cause of secondary dysmenorrhea
110
Q

MC sites of endometriosis

A

MC site = ovary –> see adnexal enlargements (chocolate cysts)

2nd MC site = cul-de-sac (space b/w uterus and rectum)

  • -> get nodularity and tenderness on rectovaginal exam
  • -> can get bowel adhesions
111
Q

Dx of Endometriosis

A

U/S –> shows endometriomas (“homogeneous cystic-appearing mass in ovary)

Definitive dx = laparoscopic visualization

112
Q

Tx of Endometriosis

A

First line:
NSAIDs + OCPs OR
NSAIDs + PO progesterone

Second line:
Danazol (testosterone derivatives) OR
Leuprolide (GnRH analog)

To improve fertility –> laparoscopic lysis of adhesions

113
Q 
vulvovaginal dryness, itchiness, irritation
dyspareunia 
vaginal bleeding 
urinary incontinence and recurrent UTIs
pelvic pressure
A

vulvovaginal atrophy

–> common in post-partum pts due to breastfeeding

114
Q

Physical exam findings of vulvovaginal atrophy

A 
narrowed introitus 
pale mucosa
decreased elasticity and rugae of mucosa 
petechiae, fissures
loss of labial volume 
vaginal pH >5
115
Q

Tx of vulvovaginal atrophy

A

vaginal moisturizer and lubricant

topical vaginal estrogen

116
Q

grapelike mass protruding from vaginal lining or cervix

A

Sarcoma botryoides (cancer of vagina or cervix)

117
Q

Primary amenorrhea definition

A

pt 14 yoa and still no menses or secondary sexual characteristics OR
pt 16 yoa and still no menses BUT has secondary sexual characteristics

118
Q

Workup of primary amenorrhea

A 
Physical exam 
U/S 
Karyotype 
Testosterone 
FSH
119
Q

DDX for amenorrhea + presence of breasts + uterus

A

secondary amenorrhea:

  • -> imperforate hymen
  • -> transverse vaginal septum
  • -> anorexia nervosa
  • -> excessive exercise
  • -> pregnancy before first menses
120
Q

cyclic, pelvic or abd pain w/ primary dysmenorrhea
small suprapubic mass can be palpated sometimes
on perineal exam see bulging bluish membrane b/w the labia

A

Imperforate Hymen

121
Q

malformations of urogenital sinus and Mullerian ducts
normal uterus, breasts, ovaries, body hair
abnormal vagina

A

Transverse vaginal septum (46, XX)

122
Q

DDX for amenorrhea + presence of breasts but NO uterus

A

Mullerian agenesis

Complete androgen insensitivity

123
Q

normal female secondary sexual characteristics
breast development and body hair present
normal estrogen + testosterone levels (b/c ovaries are intact)
absence of all Mullerian duct derivatives (fallopian tubes, uterus, cervix, upper vagina)
short vagina

A

Mullerian Agenesis (46, XX)

TX:

  • surgical elongation of vagina for sex
  • counseling about infertility
124
Q

breasts present
no pubic hair
“B/L inguinal masses” –> actually testes
no Mullerian structures (“vagina ends in blind pouch”)

U/S shows testes

A

Complete Androgen Insensitivity (46, XY)

–> mutation of androgen receptor gene

TX:

  • remove testes before age 20 b/c of increased risk of testicular cancer
  • estrogen replacement
125
Q

DDX for amenorrhea + NO breasts but have uterus

A 
Gonadal dysgenesis (Turner's syndrome) 
Hypothalamic-pituitary failure
126
Q

no secondary sexual characteristics
streak gonads
↑ FSH

A

Gonadal dysgenesis (Turner’s syndrome, 45, XO)

TX:
- estrogen + testosterone replacement

127
Q

no secondary sexual characteristics
uterus present
↓ FSH and LH

A

Hypothalamic Pituitary Failure

TX:
- estrogen + testosterone replacement

Kallmann’s Syndrome –> same presentation + anosmia (due to lack of GnRH)

128
Q

genetically male but when born external genitalia looks like female
male internal genitalia
at puberty get masculinization due to increased testosterone
no breast development

A

5- alpha-reductase deficiency (46, XY)

  • can’t convert testosterone –> DHT
129
Q

get gestational maternal virilization (resolves after birth of baby) AND virilization of XX fetuses

normal internal genitalia but ambiguous external genitalia (virilization) 
clitoromegaly 
↑ FSH, LH w/ ↓ estrogen
primary amenorrhea 
tall stature 
risk of osteoporosis
A

Congenital Aromatase Deficiency

  • can’t convert androgens –> estrogens
130
Q

scarring of uterus after infxn OR postpartum procedure (eg. D&C)

A

Asherman syndrome

TX: lysis of adhesions + estrogens

131
Q

amenorrhea at age <40
hypoestrogenic sxs (hot flashes, ↓ bone mass, ↑ fx)
↑FSH, LH
↓ estrogen

A

Primary Ovarian Insufficiency

132
Q

Causes of Primary Ovarian Insufficiency

A
  • anticancer drugs
  • pelvic radiation
  • galactosemia
  • autoimmune oophoritis (ovary inflammation)
  • Turner syndrome
  • Fragile X syndrome
  • ** Associated w/ autoimmune disorders (eg. pernicious anemia, Addison’s disease)
133
Q

Tx of Primary Ovarian Insufficiency

A

PO or transdermal estrogen therapy w/ progestin in women w/ intact uterus to ↓ risk of endometrial CA
–> continue estrogen until age 50

NOTE: To get pregnant, pt needs IVF w/ donor oocytes

134
Q

Definition of Secondary Amenorrhea

A

regular menses replaced by absence of menses for 3 months OR
irregular menses replaced by absence of menses for 6 months

135
Q

Causes of Secondary Amenorrhea

A

pregnancy
premature ovarian failure
hypothyroidism (TRH increases prolactin)
PCOS
anorexia nervosa/ excessive exercise
hyperprolactinemia (MDXs or pituitary tumor)
obesity
–> causes anovulation (FSH and LH normal; no progesterone = no menses)
acq’d uterine abn
hypothalamic or pituitary disease

136
Q

Hormone Values and Tx of Anorexia Nervosa

A

↓ GnRH
↓ LH, FSH
↓ estrogen

TX: 
pulsatile GnRH 
estrogen 
vit D and Ca2+ 
increase caloric intake
137
Q

Long term consequences of anorexia nervosa

A

osteoporosis

increased cholesterol and TGs

138
Q

Interpretation of Progesterone Challenge Test (PCT)

A

(+) PCT = pt bleeds

  - -> pt has enough estrogen 
  - -> means pt has anovulation 
  - -> tx w/ cyclic progesterone to prevent endometrial hyperplasia + clomiphene if want to get pregnant

(-) PCT = pt DOESN’T bleed

  - -> pt DOESN'T have enough estrogen  OR
  - -> pt has outflow tract obstruction
139
Q

Interpretation of Estrogen - Progesterone Challenge Test (EPCT)

  • 3 weeks of estrogen followed by 1 week of progesterone
  • done to distinguish if underlying problem is inadequate estrogen OR outflow tract obstruction
A

(+) EPCT = pt bleeds

  - -> pt DOESN'T have enough estrogen 
  - -> get FSH level 
             - ↑ FSH level = ovarian failure 
             - ↓ FSH level = hypothalamic-pituitary insufficiency (get brain CT/MRI to r/o tumor; give estrogen to prevent osteoporosis and cyclic progestin to prevent endometrial hyperplasia)

(-) EPCT = pt DOESN’T bleed

  - -> pt has outflow tract obstruction or endometrial scarring (eg. Asherman syndrome) 
  - -> order hysterosalpingogram to identify lesion (tx is adhesion lysis)
140
Q 
sxs occur days before menses and go away after period: 
breast tenderness 
pelvic pain and bloating 
irritability 
lack of energy 
headache
A

Premenstrual syndrome

DX: pt should keep menstrual diary

141
Q

Severe form of premenstrual syndrome

affects daily functioning and relationships

A

Premenstrual dysphoric disorder

142
Q

Tx for premenstrual syndrome OR premenstrual dysphoric disorder

A

SSRIs

–> if first SSRI ineffective, try another SSRI OR combined OCP

143
Q

pts w/ premenstrual syndrome OR premenstrual dysphoric disorder are at increased risk of what?

A

psychiatric disorders (lifetime risk 80%)

  • anxiety
  • depression
  • mood disorders
144
Q 
obesity
acne
graudual onset hirsutism 
irregular bleeding 
infertility
A

Polycystic Ovarian Syndrome (PCOS)

145
Q

Dx of PCOS

A

↑ LH: FSH ratio (3:1)
↑ testosterone

U/S –> B/L enlarged ovaries w/ multiple subcapsular small follicles and increased stromal echogenicity

146
Q

Tx of PCOS

A

Weight loss (1st line in woman trying to get pregnant)
OCPs
Spirinolactone
Clomiphene citrate OR human menopausal gonadotropin (HMG) for infertility
–> if doesn’t work, give FSH and LH
Metformin

147
Q

Comorbidities of PCOS

A 
metabolic syndrome (DM, HTN) 
obstructive sleep apnea
nonalcoholic steatohepatitis 
endometrial hyperplasia/cancer
148
Q

how to dx DM II in PCOS?

A

must use glucose tolerance test

–> CAN’T use HgA1C or fasting glucose

149
Q 
sever form of PCOS: 
temporal balding 
clitoral enlargement 
deepening of voice 
hirsutism 
acne
A

Hyperthecosis

–> ↑ testosterone, androstenedione = virilization

150
Q

RAPID onset hirsutism and virilization

No FHx

A

Adrenal OR Ovarian Tumor

Adrenal Tumor = –> ↑ testosterone AND DHEAS
Ovarian Tumor = –> ↑ testosterone

DX:
U/S (ovarian mass) or CT (adrenal mass)

TX:
surgical removal of tumor

151
Q

Avg age of menopause

FSH and LH levels in menopause

A

Avg age = 51
↑ FSH and LH (b/c ↓ estrogen)

NOTE: obese pts have mild menopause sxs b/c their adipose tissue helps to convert adrogens –> estrogens

152
Q

MCC of mortality in postmenopausal women

A

cardiovascular disease

153
Q

Ca requirement in menopause women

A

1200 mg Ca/day

154
Q

menopause sxs looks similar to what disease?

A

Hyperthyrodism –> so get FSH and TSH levels

155
Q

Benefits of Combined Estrogen/Progesterone Menopausal Hormone Therapy

A 
Menopausal sx control 
Bone mass/fx
Colon CA 
DM II
All-cause mortality (<60 yoa)
156
Q

Detrimental Effects of Combined Estrogen/Progesterone Menopausal Hormone Therapy

A 
DVTs
Breast CA (ok if pt <60) 
CAD (age ≥ 60) 
Stroke 
Gall bladder disease
157
Q

MC reason for why women stop menopausal hormone therapy

A

irregular bleeding (common in 1st 6 months of use)

158
Q

recommendations for menopausal hormone therapy dose and length?

A

use lowest dose for shortest time (3-5yrs)

159
Q

RFs for Osteoporosis

A 
Increased age (MOST IMPT RF) 
\+ FHx in thin, white woman
steroid use
low Ca intake (eg. vegan diet) 
sedentary lifestyle 
smoking 
alcohol (>3 drinks/day)
Celiac D 
Vit D def
hyperparathyroidism 
hyperthyroidism
160
Q

MDXs that predispose to osteoporosis

A

glucocorticoids
anti-androgens
anti-convulsants

161
Q

DX of osteoporosis

A

DEXA scan
–> T score ≤ -2.5 = osteoporosis

PTH, Ca, Phos = NORMAL

162
Q

Tx of osteoporosis

A

First Line: Ca (1200 mg/d), Vit D (800 IU/d), bisphosphonates, SERMs (eg. tamoxifene, raloxifene)

Second Line:

  • calcitonin
  • denosumab
  • teriparatide (PTH analog)

NOTE: if pt doesn’t respond to therapy or has rapidly progressing osteoporosis, look for secondary causes (eg. multiple myeloma)

163
Q

Emergency Contraception (Most –> Least Effective)

A

Copper IUD (MOST EFFECTIVE EMERGENCY CONTRACEPTION)
Ulipristal (antiprogestin)
Levonorgesteral pill (plan B)
OCPs

164
Q

Regular Contraception (Most –> Least Effective)

A

Progestin Implant (Nexplanon) –> >99% efficacy
IUD –> 99% efficacy
–> first line in adolescents b/c easy to use and effective
IM injection (Depo)
OCP
–> lactating mom = progestin ONLY OCP
Condoms

165
Q

CIs to IUD use

A 
acute pelvic infxn
cervicitis (friable cervix) 
pelvic malignancy 
undiagnosed vaginal bleeding 
pregnancy 
wilson disease/copper allergy (if considering Copper IUD)
166
Q

SEs of Progestin vs Copper IUD

A

Progestin:

  • irregular bleeding
  • amenorrhea
    - -> b/c of this SE, progestin IUD preferred over copper IUD in pts w/ SCD (b/c get decreased bld loss over time)

Copper:

  • heavier menses
  • dysmenorrhea
167
Q

MDX that decrease OCP effect

A

rifampin
anti-epileptics (eg. phenytoin)
St. John’s wart

168
Q

SEs of OCPs

A 
breakthrough bleeding (tx by giving OCP w/ higher dose of estrogen)
reversible cholestasis 
hepatic adenoma
Budd-Chiari syndrome 
HCC

w. gain DOESN’T occur w/ OCP use

169
Q

OCPs protect against what cancers?

A

Ovarian and endometrial (remember breastfeeding protected against ovarian and breast CA)

170
Q

CIs to OCP use

A 
Migraine w/ aura 
Smokers ≥ 35 yoa 
HTN ≥ 160/110 
pregnancy 
acute liver disease, cirrhosis, liver CA
DVT/CVA/SLE 
Heart disease 
breast CA
Antiphospholipid syndrome 
DM w/ vascular disease 
thrombophilia
171
Q

Infertility Definition

A

Age <35: no preg in ≥ 12 months

Age ≥ 35: no preg in ≥ 6 months

172
Q

Causes of Infertility in Following Cases:

<30 yoa, normal period
<30 yoa, abnormal period
>30 yoa, normal period

A

<30 yoa, normal period = PID
<30 yoa, abnormal period = PCOS
>30 yoa, normal period = endometriosis

173
Q

Workup for Infertility

A

1) Semen analysis
- -> if abnormal, repeat in 4-6 wks
- -> repeat sample also abnormal, need IVF or intracytoplasmic sperm injection

2) Anovulation
- -> hypothyroidism and hyperprolactinemia = reversible causes
- -> ovulation induction via clomiphene citrate (if have enough estrogen) OR human menopausal gonadotrophin (if pt has ↓ estrogen)
- -> look out for ovarian hyperstimulation syndrome

3) Fallopian Tube Abnormalities
- -> hysterosalpingogram (HSG) - if normal, no more workup
- -> laparoscopy (if HSG abnormal)

174
Q 
bleeding in preg pt <16 wks gestation 
passage of vesicles from vagina ("grapes") 
HTN
hyperthyroidism
hyperemesis gravidarum 
no fetal heart tones 
fundus larger than dates
A

Gestational Trophoblastic Disease

175
Q

Complete Hydratiform Mole Characteristics

A

Empty Egg
46, XX
Fetus absent
20% progress to malignancy (chorioCA)

176
Q

Incomplete Hydratiform Mole Characteristics

A

Normal Egg
69, XXY
Fetus nonviable
10% progress to malignancy (chorioCA)

177
Q

Dx of Gestational Trophoblastic Disease

A

urine B-hCG (+)

U/S –> homogenous intrauterine echoes w/o gestational sac or fetal parts (“snowstorm”)

178
Q

Tx of Gestational Trophoblastic Disease

A

Baseline B-hCG
CXR (r/o metastases)
D&C
–> then measure B-hCG weekly till 6-12mo
–> give OCPs so pt doesn’t get preg during f/u period
–> discontinue B-hCG measurement if get 3 (-) consecutive results
–> no preg for 6 mo after B-hCG normal

179
Q

MC sites of metastases in pt w/ Gestational Trophoblastic Disease

A

1) Lungs

2) Vagina

180
Q

Tx for Choriocarcinoma

A

Chemotherapy (methotrexate) + hysterectomy

181
Q 
pelvic P and heaviness 
low back pain 
posterior vaginal mass that increases w/ valsalva maneuver 
obstructed voiding 
urinary retention 
urinary incontinence 
constipation
fecal urgency/incontinence 
sexual dysfunction
A

Pelvic Organ Prolapse

–> due to injury of pelvic floor muscles (eg. during delivery)

182
Q

RFs for Pelvic Organ Prolapse

A

obesity
multiparity
hysterectomy
postmenopausal age

183
Q

Tx for Pelvic Organ Prolapse

A

vaginal pessary

surgery (if pessary fails)

184
Q

Postexposure PPX for sexual assault

A
  • HIV (3 drug tx; offer upto 72 hrs after assault)
  • Hep B (Hep B vaccine + IG –> not needed if prev. vaccinated)
  • Chlamydia (azithromycin)
  • Gonorrhea (ceftriaxone)
  • Trichomonas (metronidazole; not needed if asymptomatic)
185
Q

Pain, tendernes on lateral sides of vulva (3 and 7 o’clock)

Dyspareunia

A

Bartholin Gland Cyst

Tx: I&D (fld should be cx)
—> if it occurs in woman > 40, do excision b/c might be cancer

186
Q

Causes of True (Central) Precocious Puberty

Female <8, Male <9

A

early activation of hypothalamic-pituitary-gonadal axis

–> see testicular/clitoral enlargement

187
Q

Causes of Pseudo (Peripheral) Precocious Puberty

A

CAH
exogenous hormones
adrenal tumors

–> see virilization of girls

188
Q

McCune -Albright Syndrome

A

precocious puberty + bone lesions + cafe-au-lait spots

USMLE Step 3 - ALL (9 decks)

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