gyn Flashcards
definition of primary amenorrhea
absence of menses by age 16
deginition of secondary amenorrhea
in a woman who has previously had mesnes it is the absences by 3 months
primary amenorrhea is divided into these four categories
gonadal dysgenesis (turner)
hypothalamic pit insufficiency
androgen insensitivity
imperforate hymen
in a women with normal estrogen the most likely secondary cause of amenorrhea i
asherman’s syndrome (intrauterine synechiae)
or
PCOS
in women with hypoestrogen secondary amenorrhea is most likely due to these three casues
CNS tumor
hyperprolactinemia
or
PCOS
diagnostic studies for secondary amenorrhea
first line is b HCG fr pregnancy
TSH
and prolactin
secondary tests ordered for secondary amenorrhea
FSH
estrogen
LH
and testosterone
primary dysmenorrhea is caused by
Primary is painful mensuration caused by
excess prostaglandin and leukotriene levels leading to painful uterine contractions nausea vomiting and diarrhea
onset is usually within 2 years of menarche
NO PATHOLOGICAL ABNORMALITY
Secondary dysmenorrhea (4)
painful mensuration caused by an identificale clinical condition usually of the uterus or the pelvis
endometriosis
adenomyosis (growth of endometrial tissue in the wall of the uterus)
uterine fibroids
PID
and IUD
primary dysmenorrhea usually peaks during
late teens and early 20s and incidence of secondary dysmenorrhea increases with age
what is the karyotype of turners
what are the hormones associated
45 XO
high FSH
What is the treatment for tuenr’s syndrome
cyclic estrogen and progesterone
what is the hypo pit insufficiency look like in a pt with primary dysmenorrhea
what is the treatment
NO breast development
46 XX
low FSH
low LH
give cyclic estrogen and progesterone
what does androgen insensitivity look like in a pt with primary dysmenorrhea
46 XY
normal breast development
high testosterone
what is the treatment for androgen insensitivity
remove the testes and start estrogen
how does sxs of secondary dysmenorrhea differe from sxs of primary dysmenorrhea
secondary symptoms are more likely to
include bloating
menorrhagia
dysparunia
and less likely related to the first day of lfow
primary dysmenorrhea treatmetn
start NSAIDS just before the expected menses and continue for 2-3 days
OCP vitamin B magnesium ancupuncture application of heat regular exercise also help to reduce pain
for resistant cases of primary dysmenorrhea try
tocolytic agents
CCB
progestogens
what are the tests done for evaluating secondary casuses of dysmenorrhea
hysteroscopy
D and C
larproscopy
what is PMS syndrome what is the hypothesized cause
abnormal levels of estrogen, progesteron cortisone prolactin and antidiuretic hormone as well s endogenous opiates melatonin serotinonin prostaglandins vitamin and mineral deficiencies reactive hypoglycemia menstural toxins pyschological social evolutionary and genetic factors
the reported incidence of PMS is
10-90% with 10% debilitated
prevalence is greatest during the fourth and fifth decade
association exists between PMS and
postpartum depression
perimenopausal depression
other affective disorders
clinical features of PMS
Associated with the menstrual cycle and being 1 to 2 weeks before menses during the leutal phase and end 1 to 2 days after the onset of menses
what must exist in order to have PMS
a monthly symptom free period during the follicular phase from day 1 to ovulation
most common complaints with pms are
mood changes and psychological affects
PMS symptoms outside of mood changes
fluid retention edema weight gain breast pain
backache, constipation
lifestyle modifications for PMS
caffeine reudction salt restriction low fat high complec carb intake magnesium vitamin B relaxation stress reduction
drug treatment for PMS
pyridoxine (vitamin B6) and evening primrose oil show NO BENEFIT over placebo in clinical trial but relieve breast tenderness and depression in some women
calcium carbonate
magnesium
B6 and vitamin E supplementation have been shown to benefit some women
nsaids
SSRI
what can be used to relieve breast tenderness in PMS
spironilactones
bromocroptine may relieve mastalgia
what antianxiety medications can people use from PMS
buspirone or alprazolam
vasomotor symptoms with menopause usually resolve within
2 to 3 years
3 to 6 weeks with estrogen replacement therapy
urogenital atrophy can cause what kind of incontinence
urge incontinence
can also cause atrophic cystitis and easy bleeding
other than hot flashes and vaginal atrophy what other sxs do you see with menopause
changes in sleep cycle skin becomes thin and loses elasticity increased facial hair hair lose nails become brittle confusion nloss of mempry
diagnostic studies for menopause
increased FSH greater than 30
menopause management
regular exercise
HRT but this increases the risk of cardiovascular disease breast cancer and cognitive changes
other potential risks include gallbladder disease and migraines
CI to HRT (4)
Undiagnosed vaginal bleeding
acute vascular thrombosis
liver disease
history of endometrial of breast cancer
what meds can be described for women at risk of steoperosis
Ca and vitamin D
bisphosphinates
SERMS (selective estrogen recpetor medulators)
or calcitonin
what alternative treatments are available for women in menopause
soy
black cohosh
ginseng can help relieve symptoms
DUB is defined as
abnormal bleeding in the absences of an anatomic lesion usually caused by a problem with the hypo pit ovarian system
when is DUB most liekly to occur
shortly after menarch or in peri-menopause other causes include PCOS exogenous obesity and adrenal hyperplasia
diagnostic studies for DUB
b hcg CBC PT PTT documentation of ovulation TSH serum progesterone LFT prolactin serum FSH levels
what would be done to investigate DUB
pap endometrial biopsy ultrasonography hyterosalpingography hysteroscopy and or Dand C
management of DUB
observation iron therapy and volume replacement may be needed
oral high dose estrogens might ald=so be indicated
a progesterin trial should be performed and if the bleeding stops the cycles are confirme d
OCP for DUB
older women without risk factors can be prescriped OCP SHOULD NOT be used in women who smoke have hypertension DM hx of vascular disease breast cancer liver disease focal headaches
what can you use in younger pts with DUB
cyclic progestins
refractory cases of DUB might require
endometrial ablation of vaginal hysterectomy
leiomyoma are most common during
uterine fibroids are most common in the fourth decade of life in black women and those with positive family hx
fibroids depend on
estrogen and appear with increased frequency in
women with endometrial hyperplasia,
anovulatory states,
and estrogen producing ovarian tumors
fibroids can be classified by
their location
subserous (deforming external serosa)
intramural (within uterine wall)
submucous (deforming the uterine cavity) .
what kind of fibroids cause bleeding
submucousa
bleeding is the most common symprom
what are the clinical features of fibroids
msot have no sxs
sometimes you can feel a enlarged uterine mass
some will have symptoms of a full pelvis
menorrhagia
metrorrhagia
intermenstural bleeding
dysmenorrhea
what is the risk to pregnant women with leiomyoma
spontaneous abortion
diagnostics for fibroids
D&C
saline hysteroscopy
hysterosalpinography
laparascopy
why would you get LFTs in a pt with dub
You rule out liver disease that would cause them to not make clotting factors. So the bleeding is because of coagulopathy issues.
why are OCP CI with livr disease
The liver metabolizes estrogen, so its CI with liver disease.Is the bottom line
liver disease that happens in pregnancy
Cause also in pregnancy when estrogen levels are extremely high it can precipitate intrahepatic cholestasis of pregnancy (ICP)
managment of leiomyoma
observation
symptomatic pts can undergo myomectomy, hysterectomy or D and C
can also do endometrial ablation
how to use gnrh for leiomyoma
gnrh agonists and mifepristone may reduce tumor size in women with small leiomyoma
gnrh agonist may restore fertility
treatment is limited to 6 mo
Medroxyprogesterone acetate what is it and how do we use it in PCOS
depot medroxyprogesterone acetate (DMPA) and sold under the brand name Depo- Provera
Medroxyprogesterone acetate given on the first 10 days of each month will promote regular shedding of the endometrium. If contraception is desired, a low dose oral contraceptive can be used.
_________ is the most common type of endometrial carcinoma.
Adenocarcinoma is the most common type of endometrial carcinoma. In the US, 80% of endometrial carcinomas are of this type. Longer exposure to estrogen (i.e., early menarche, late menopause, and diabetes) is a risk factor for carcinoma.
_______ is a choice for a patient with symptomatic fibroids who would like to maintain fertility
Myomectomy is a choice for a patient with symptomatic fibroids who would like to maintain fertility and retain the uterus. There is, however, a significant risk for recurrence of leiomyomas
HSIL is associated with a high risk of ____
what is the managment
HSIL is associated with a high risk of CIN 2,3 or cervical cancer. In women 25 and older management with immediate colposcopy or LEEP is based upon these risks.
Immediate cervical ablation should not be performed because ablative procedures do not provide a specimen for diagnostic evaluation.
at what age group would you not do diagnostic procedure for HSIL
the recommendations for follow-up for abnormal cervical screening results differ for women ages 21 to 24 years from those for women 25 and older.
They advise a diagnostic excisional procedure only if abnormal results are severe or recurrent.
)________ is the safest and most effective method for termination of pregnancies up to 12 weeks. The majority of induced abortions in the US are via suction curettage.
Suction curettage is the safest and most effective method for termination of pregnancies up to 12 weeks. The majority of induced abortions in the US are via suction curettage.
when can you use misoprostil for an TAB
This patient is at 10 weeks and is therefore not eligible for medical abortion which is appropriate when a woman presents less than 49 days from LMP
first line treatment for HTN in pregnancy
methyldopa has the benefit of more research/studies and is recommended as the first-line treatment for hypertension in pregnancy.
first-line treatment for hypertension in pregnancy.
Methyldopa has the benefit of more research/studies and is recommended as the first-line treatment for hypertension in pregnancy.
how can you differentiate cervical insufficiency vs SAB
his patient presents with cervical insufficiency. This is still a viable pregnancy because she has no abdominal cramping and she is now in the 2nd trimester but she is starting to dilate. A cervical cerclage is recommended between 13-16 weeks’ gestation
when would you do a cervical cerclag
A cervical cerclage is recommended between 13-16 weeks’ gestation
what is the workup for infertility in female
In the initial evaluation of the female partner, noninvasive procedures, such as the measurement of LH and mid-luteal phase progesterone (to determine ovulatory function) and TVUS (to rule out the possibility of fibroids or polycystic ovaries), are first-line investigations.
CI to cerclage
placement include bleeding of unknown etiology, infection, labor, ruptured membranes and fetal anomalies.
In patients with irregular cycles, secondary to chronic anovulation, or oligo-ovulation, combined oral contraceptive (COC) pills help to ….
In patients with irregular cycles, secondary to chronic anovulation, or oligo-ovulation, combined oral contraceptive (COC) pills help to prevent the risks associated with prolonged unopposed estrogen stimulation of the endometrium.
what would you do for a pt with anovulatory cycles and a CI to COC
Treatment with cyclic progestins for days 16 through 25 following the first day of the most recent menstrual flow is preferred when OCP use is contraindicated, such as in smokers older than age 35 and women at risk for thromboembolism.
how to treay leiomyoma bleeding
The heavy bleeding that typically accompanies fibroid tumors can be minimized by using intermittent progestin supplementation (depot methodroxyprogesterone acetate 150 mg IM every 28 days) and/or prostaglandin synthetase inhibitors.
treatment form chlamydial PID
One recommended outpatient treatment is Ofloxacin 400 mg once daily for 14 days; with or without metronidazole 500 mg twice daily for 14 days.
what are symptoms of a ovarian cyst and what is indicated
Symptoms associated with a functional ovarian cyst include mild to moderate unilateral pain and alteration in the menstrual cycle. On occasion, rupture of the follicular cyst causes acute pelvic pain and may need laparoscopic surgery for complete evaluation. In most cases, pain control for 4 to 5 days is what is indicated as well as the consideration of contraception to suppress future ovarian cyst formation.
A very firm ovarian mass estimated at 8 cm is found in a 33-year-old woman at her annual examination. what would you expect
The size and firmness of the ovarian mass suggests endometrioid carcinoma, a tumor in which the potential for malignancy is 100%
Based on the latest ASCCP guidelines women ages 21-24 years of age with LSIL should undergo repeat cytology at
Based on the latest ASCCP guidelines women ages 21-24 years of age with LSIL should undergo repeat cytology at 12 months. Those 25 and up with LSIL should undergo colposcopy.
what is the diagnosis of atrophy
ph
apperance
discharge
Atrophy is diagnosed by the presence of a thin, clear, or bloody discharge;
a vaginal pH of 5 to 7;
loss of vaginal rugae; and
the finding of parabasal epithelial cells on microscopic examination of a wet-mount preparation. These symptoms are all due to estrogen depletion
AUB mneumonic
PALM COEIN
structural- polyp adenomyosis Leiomyoma Malignancy
non structural - coagulopathy Ovulatory dysfunction endometrial iatrogenic not otherwise classified
what falls under the heading of irregular bleeding
any change from normal HMB HPMB IMB PMB
risk factors for endometrial can
nulliparity infertility late meno DM unopposed estrogen hypertension gallbladder disease chronic tamoxifen use
NOT RELATED TO SEXUAL HX
to OCP have protective risk factors for endometrial Ca
yes
what are the clincal features of endometrial ca aside from pmb
Obesity
htn
dm
with PMB what tests should you run
ULS (Look at stripe)
pap
EMB (endometrial biopsy)
what is the definitive choice for endometrial cancer diagnostic
endocervical curretage
but EMB has an accuracy of 90-95%
management of endometrial cancer
total hysterectomy combined with b/l salpingo-oopherectomy drives treatment and staging
radiotherapy may be indicated and chemo is used at advanced stages
reoccurrence is treated with high dose progestins and antiestrogen
how does endometriosis manifest
deep thrust dyspareunia dyschezia dysmenorrhea intermitten spotting pelvic pain infertility
signs of endometriosis
tender nodularity of the cul-de-sac and uterine ligaments and a fixed uterus
the degree of symptoms does not correlate with the degree of disease
how do you diagnose endometriosis
usually it is a diagnosis of exclusion using the ULS to rule out other pathology but you can get a definitive diagnosis laparoscopically
treatment for the relief of sxs in endometriosis
NSAIDs and prostoglandin synthesis
OCP
or progestins may relieve symptoms
surgical options for endometriosis
can resect larger endometriomas
can treat with danzol or a gnrh agonist around the time of surgery fro improved fertility
predisposing factors to prolapse
white hispanic obesity chronic cough constipation repetitive heavy lifting
(anything that increases intra abdominal pressure)
COPD
asthma
ascites
pelvic tumors
non surgical management of prolapse includes
weight reduction
smoking cessation
pelvic muscle exercises
use of vaginal pessary
surgical option for uterine prolapse
hysterectomy
name three different types of functional cysts
follicular
corpus luteum
lutein cysts
clinical features of cysts
pain with menstruation
hemorrhage secondary to rupture
or
asymptomatic
management of cysts
follow for one or two cycles if small than 8cm
with large or persistent laprascopic evaluation
cysts in postmenopausal women are
malignant until proven otherwise
PCOS pts are at increased risk for
endometrial cancer because of unopposed estrogen and endometrial hyperplasia
how people describe uLS of PCOS
String of pearls or
oyster ovaries
who is at risk of ovarian ca
family jc white older than 69 nulliparious positive hx of endometrial cancer
90% of cases are sporadic
OCP are have or have not been proven to be preventative in ovarian cancer
have been preventative
5th MCC of cancer and the 2nd most common gynecological malignancy
symptoms of ovarian cancer
ascites abdominal distention early satiety changes in bowel habits fixed mass
what is a sister mary joseph node
metastatic implant in the umbilicus can be associated with ovarian cancer
diagnostic studies for suspected ovarian cancer
BRCA1 gene associated in 5% of cases
cancer antigen 125 can be used to follow
p53 tumor supressor gene
transvaginal or abdominal ultrasound is useful in distinguishing benign from potentially malignant masses
definitive diagnoses of ovarian ca
biopsy but usually oophorectomy if you think it is malignant
management of ovarian cancer
surgery
chemo
radiation
what HPV strains are likely to be linked to condylomata acuminata
6 and 11
also known as genital warts
what also plays a role in the development of cervical carcinoma
intrepehtial neoplasm
risk factors for cervical cancer
early age at first intercourse multiple sexual partners or high risk sexual partner history of sexually transmitted disease low socioeconomic status cigarette smoking
stages of cervical dysplasia
mild (CIN 1
Mod CIN2
and severe CIN 3
how many pts with CIN 3 progress to frank carcinoma
about 1/3 develop microinvasive or frank carcinoma
difference between occurrence of CIN CIS and cancer
CIN 20s
CIS (in situ) 25-35
cervical cancer age 40
sxs of advance or invasive carcinoma
abnormal vaginal bleeding
abnormal vaginal discharge
visible tumor
when should you do pap smears
21 to 65
types of cervical can
ACSUS (Cannot exclude HSIL)
LSIL
HSIL and squamous cell carcinoma are all squamous cell
glandular cells include AGC endocervical cells endometrial cells glandular cell NOS
endocervical AIS
adenocacinoma (endocervical or extrauterine )
management of cervical lesions
mild may resolves spontaneously or preeinvasice can be treated with LEEP
conization is used when the neoplasm is larger (more likely to lead to an incompetent cervix than leep)
hysterectomy or lymphadenectomy is indicated for larger
when is the hpv vaccine offered
males age 13-21
females 13-26
anybody immunocompromised 22-26
11
6
16
18
these cause 70% of cervical cancers and 90% of genital warts
boosters may be needed every 5 years but that recommendation is not final
most vulvular malignancies are
SSC
and occur in OM women
who is at increased risk of vuvular malignances
women with exposure to diethylbestrol (DES) in utero
prescribed between 1940-1971 to pregnant women
what % of vaginal neoplasms are MET
80%
may arise from the urethra, bartholin gland, rectum, bladder, endometrial cavity, endocervix , kidney, or distant site
vuvular ca are most commonly found in women with these rf
obese
HTN
DM
arteriosclerosis
vuvular cancer in young women is associated with
HPV infections and smoking 25% of these pts have cervical carcinoma
most vaginal intraepithelial neoplasms occurin the
upper one third of the vagina and are asymptomatic
most common presenting problem is PM bleeding or bloody discharge
diagnostic studies for vaginal and vuvular neoplsasms
application of acetic acid or staining with toludine blue may help with biopsies of suspicious lesions
vaginal biopsy should be directed with colposcopy or lugol staining
clear cell adenocarcinoma is diagnosed by
careful inspection and palpation of the vagina and cervix followed by biopsies
management of early vulvular neoplasms
local excision
topical 5 fluorouracil
and laser therapy are used for early vuvular lesions
treatment of vaginal neoplasms
excision
primary vaginal cancer is treated with radiation
for clear cell lesions (adenocarcinoma) of the vagina what is the treatmetn
radical hysterectomy and vaginectomry or radiation therapy
mastodynia is commonly seen in women who
are taking contraceptive pills or HRT
treat with reassurance
vit B6
bromocriptine
HRT
do you culture mastitis?
no 50% of the time it is staph areus
treatment of mastitis can be with dicloxacillan or
nafcillian
cloxacillan or cephalosporin and warm or cool compress
surgical treatment may be required for abscess
it does say you can aspirate abscess
might see fever, erythema, tender fluctuant mass in one quadrant
abscess will form if untreated
fibrocystic changes are commonly seen in this gae group
30-50
usually they are bilateral pain
size fluctuatuin with cycle
multiple lesions distinguish fibrocystic changes from carcinoma
in a suspected cyst of the breast you should
FNA
diagnostic and therapeutic
usually cysts contain straw colored fluid
treatment for fibrocystic breasts
supportive bra
heat or ice on breasts
OTC analgesics
caffeine restriction is controversial
some pts respond to low salt diets
vit E
premenstrual hydrochlorothyiazide
fibroadenomas are common in
what is characteristic about them
AA women and young women
they are round firm smooth discrete, mobile, and non-tender
when should you biopsy a fibroadenoma
women younger than 25
may be excised or managed expectantly otherwise
characteristics of breast cancer
fixed, irregular, painless mass, most commonly in upper outer quadrant
other than the age what differentiates fibroadenoma from cysts
fibroadenoma are more rubbery and lobular or smooth
really mobile
cysts are sift tense or hard and ca be failru mobile
mcc in women
breast (and skin)
second leading cause of death in women
risk factors
BRCA1 and BRCA2 are really only seen in 5-10% of cases
nulliparity early menarche late menopause long term estrogen or radiation exposure delayed childbearing
first degree relative with breast cancer ESPECIALLY if it was premenopausal or bilateral in two of thos relatives
relationship between rbeast cancer and endometrial cancer
breast cancer increases the risk of endometrial cancer and vice versa
most common type of breast cancer
IDC 80-85%
the remainder are lobular
what predisposes pts to IDC
lobular CIS and ductal hyperplasia predispose to cancer
pagets is a
DUCTAL disease that presents as eczematous lesion of the nipple
what % of breast cancers are estrogen recptor positive
ALL ILCS
2/3 DCIS
most common presentation of breast cancer
single nontender firm mobile mass in
45% upper outer quadrant
25% under the nipple and areola
most guidelines recommend mammograms
1-2years between 50-75
screening women earlier is controversial because of the high rate of positives and should be individualized
daignostic studies for suspected breast cancer
fine needle
stereotactic core needle biospy is highly accurate
might need open biopsy
all should undergo recptor analysis testing and histological anaylsis
oncotype DX test is used to help determine the need fro chemotherapy in women with stage I or II hormone receptor positive cancer and looks at 21 genes with the tumor to determine the likelihood of the cancer reoccurring or spreading
METS workup is recommended for these stages of breast cancer
III and above
what is tamoxifen used for
to treat women with estrogen receptor positive disease and postmenopausal women
if someone wanted to use periodic abstinence as a contraceptive method how would you instruct them to do so
abstinence from 4 to 5 days before ovulation until 2-3 days after ovulation
high level of motivation required to track basal bofy temperature and ovulation cycle
failure rate 25%
calendar mehtods are based on the predictably of the lutal phase which has a 35% failure rate
when is the patch CI
in women over 200lb
vaginal ring can only be used in
nulliparious women
how long can it take for ovulation to return after depot injection
can take up to 18 months
when do you usually see withdrawl bleeding with the pill `
3 to 5 days after the last pill
how does measuring basal body temperature work as a method of contraception
need to measure your temperature before undertaking any activity at all
a slight drop in temperature will occur 24 to 36 hours after ovulation THEN a rise of .3 to .48 degrees occurs remaining at a plateau for the rest of the cycle
fertile mucus resembles a
egg white
what is the most reliable “natural’ method of famil planning
symptothermal combining cervical mucus and basal body temperature
what are the advantages of combo birth control
lower rates of benign breast disease, IDA, and PID as well as fewer ovarian cysts (dysmenorrhea and menorrhagia )
improvements in hirsutism acne and symptoms of endometriosis
may also protect against RA
disadvantages of COC
abnormal lipids potential increase in breast cancer RARELY HTN cholelithiasis benign liver tumors
adverse reactions to COC
missed periods intermenstrual bleeding bloating acne nausea HA weight gain
msot resolve within the first few months and are rare with low dose
most common injection
medroxyprogesterone acetate 150mg Q 90 days
black box warning for medroxy p
may lead to calcium loss, bone weakness, osteoperosis, and should only be used for 2 years
after 2 years need to give Ca
after 5 years need DEXA
when can you expect return to fertility with medroxyp
18 months
CI to IUD
salpingitis hx
undiagnosed AUB
acute infection
and suspected gyn malignancy
what are the relative CI to the IUD
immunosupression previous ectopic pregnancy or sexually transmitted disease multiple sexual partners sever dysmenorrhea uterine abnormalities anemia valvular heart disease and youg age
name of common spermacides
nonoxynol-9
octoxynol-3
ovulatory factors for infertility are defined by
central
peripheral
metabolic
pelvis factors in infertility
infection
sturctural
endometeriosis
cervical factors in infertility
congenital
aquired
most common cause of infertility
ovulatory disorders
diagnostic workup for infertility
semen analysis before anything
then
basal body temp
ovulation prediction tests
and progesterone level
after the initial hormone tests what is the workup for infertility
luteal phase endometrial biopsy
FSH levels
prolactin
thyroid stimulating hormone tests may be helpful
how does hysterosalpingography determine infertitlity
looks at tubal abnormalities
treatments for infertitlity
clomiphene citrate 50-100 mg for 5 days beginning on day 3,4, or 5 of the cycle
should be given to anovulatory women to promote ovulation
when would you use artificial insemination
for couples with abnormal postcoital tests
different types of assisted technologies for infertility
in vitro
gamete intrafallopian transfer
zygote intrafallopian trasnfer
surrogate
PID incompasses
acute salpingiits
IUD relate pelvic cellulitis
TOA
pelvic abscess
clinical presentation of PID
lower abdominal pain b/l nausea with or without V HA lower back pain \+/- fever
adnexal mass with pain think
TOA
other than cervical motion tenderness what would you expect to see in a pt with PID
can see bartholin or skene glands abscess
what should you do in a PID workup
DNA probes for gonorrhea and chlamydia
trans vag YLS help differentiate acute from chronic inflammation in the presence of adnexal mass
diagnostic culdocentesis or laparoscopy may be required
treatment for PID- outpatient
women with mild disease can be treated as outpatients
A single intramuscular dose of a long-acting cephalosporin plus doxycycline (100 mg orally twice daily for 14 days)
inpatient treatment of PID
Cefoxitin (2 g intravenously every six hours) or cefotetan (2 g intravenously every 12 hours) plus doxycycline (100 mg orally or intravenously every 12 hours).
who gets admitted for PID
lack of response or tolerance
PREGNANCY
inability to take oral medications due to nausea or illness
complicated PID (TOA or abscess)
possible need for surgical intervention or diagnostic exploratory
primary syphillis is characterized by
chancre which is a PAINLESS ulcer with e CLEAN base and firm indurated margins
develops at the site of inoculation most commonly genital area
associated with rubber discrete non tender lymphadenopathy
secondary syphillis
involves skin mucuous membrane eye bone kidneys CNS or liver
there maybe relapsing lesions during early latency
late or tertiary syphilis
includes hummatous lesions involving skin, bones and viscera
cardiovascular disease
nervous system
and opthalmic lesions
neruosyphilis
neruosphyilis can result in asymptomatic disease, meningovascular syphilis (chronic meningitis)
generalized paresis or tabes dorsalis (chronic progressive degeneration of parenchyma )
tabes dorsalis
manifests with impaired proprioception, loss of vibratory sense, argyll robertson pupil (reacts to life but does not accommodation )
or tabes dorsalis crises (sever pain and neurological decompensation)
if not treated congenital syphilis may develop
interstitial keratitis hutchinson teeth saddle nose deafness CNS abnormalities
diagnostic studies for syphilis
T. pallidum may be identified using dark field microscopy but the technique is difficult
IMMUNOFLUORESCENT staining techniques are more reliable and the organism CAN’T be cultured
SEROLOGICAL TESTING is the recommended methor for diagnosis
Specific testing for tertiary syphilis includes
LP
joint fluid analysis
biopsy
treatment for syphilis
PCN g 2.4 million units IM
late and latent and tertiary syphilis requires weekly THREE weekly injections
treat neurosyphilis with
aqueous PCN q 4 hours for 10-14 days may be followed with three weekly doses of PCN G
what is the Jarisch Herxheimer reaction
fever and toxic state that may occur after sudden massive destruction of spirochetes
to prevent this antipyretics should be administered during the first 24 hours of treatment
what do you need to do after discovering a pt has syphillis
careful f/u
report
incubartion period of gonorrhea
2-8 days after exposure
highest incidence of gonorrhea is in
15 to 29 year olds
male complaints with gonorrhes
burning with urination
serous or milky discharge
1 to 3 days later urethral pain is more pronounced and discharge becomes yellow, creamy, profuse, and occasionally tinged with blood
without treatment of gonorrhea in men
infection may regress and become chronic or progress to involve the prostate, epididymis, and periurethral glands with acute, painful inflammation
and result in prostatitis and urethral strictures
symptoms of gonorrhea in women
many remain asymptomatic or may develop dysuria, urinary frequency and urgency and a purulent urehtral discharge
vaginitis and cervicitits are common
honococcal bacteremia is associated with
peripeheral skin lesions
septic arthritis of the knee, ankle, or wrist
gonococcal conjunctivitis looks like
unilterla copious purulent discarge
at risk of globe rupture
diagnostic studies for gonorrhea
gram stain of urethral discharge shows diploccoci
smears are less often positive in women
cultures are essential
treamtnet of gonorrhea
iM Ceftriazone OR
oral cefixime
doxy or azithro NEED to be administered simultaniously regardless of chlamydial infection
NEED TO REPORT
LYMPHANGRUNULOMA venerum
starts withs a vesciular or ulcerative lesion (may go unnoticed)
this infection spreads to the lymph nodes causing inguinal buboes
may fuse and break down resulting in mutliple draining sinuses and scarring
dx of chlamydia
usually clinical
can do ELISA or DNA
trichamonas affects the
vagina
skene gland
lower urinary tract of femals AND genitourinary tract of males
yellow frothy discharge and vaginal erythema and red macular lesions on cervix thing
trichomonas
dose of metronidazol for trich
2 G
may need to be repeated
Dose of metronidazol for trich
2 G
May need to be repeated
treatment of Lymphogranuloma venereum
LGV proctitis should be treated with doxy +ceftriaxone
if anorectal chlamydia continue with doxy
pregnant pts with LGV treat with
erythromyocin or azithromyocin
risk factors for vaginal candidiasis
age extremes pregnanct uncontrolled DM corticosteroids HIV disease
symptoms of candidiasis
pruririts burning dysparunia and white flocullent discharge
two treatments for bac vag in non pregnant pt
clindamycin or metronidazole
500 mg twice daily for seven days
single dose has lower efficacy
symptomatic pregnant women treatment
metronidazole 500mg 2 times daily for 7 days
250 mg three times daily for seven days
clindamycin 300 mg twice daily for seven days
what is premenstrual dysmorphic disorder
According to the American Psychiatric Association DSM-5, mood swings, anger, irritability, sense of hopelessness or tension, and anxiety or feeling on edge associated with severe premenstrual syndrome symptoms is defined as premenstrual dysphoric disorder.
why can’t you give BC with estrogen to pts with hx of seizure disorder
Certain antiepileptic drugs induce hepatic metabolism of estrogen (carbamazepine, oxcarbazepine, phenobarbital, phenytoin, and topiramate)
This can potentially lead to failure of any contraceptive that contains estrogen. Therefore progestin only birth control methods would be beneficial to this patient.
complaint of painful vulvar ulcers and a swollen inguinal lymph node
Gram negative coccobacillus
canchroid
management of canchroid
zithro
ceftriaxone
cipro
Which organism causes condyloma latum?
Treponema pallidum (syphilis).
Enterocele what is it and what is the managment
is the descending of the small intestine into the lower pelvic cavit
Operative management of an enterocele with an anterior colporrhaphy
rectocele tx
rectocele with a posterior colporrhaphy
In addition to gabapentin, what are some medications useful in treating the vasomotor symptoms of menopause?
Answer: Selective serotonin reuptake inhibitors and clonidine have some utility in managing vasomotor symptoms during menopause.
what is intrahepatic cholestasis of pregnancy and how does it present what are the risks
characterized by pruritus which is often concentrated in the palms of the hands and soles of the feet. Serum bile acids are almost always elevated and there is a significant increase in intrauterine fetal demise.
In intrahepatic cholestasis of pregnancy the number of adverse fetal outcomes increase as serum bile acid levels rise
What is the first line intravenous antibiotic therapy for patients with endometritis?
Clindamycin and gentamicin.
most common symptom of vaginal cancer
Vaginal bleeding
multiple 0.5 cm to 1.5 cm oval ulcers with sharply defined borders and a yellowish-white membrane.
Behçet’s syndrome included recurring genital and oral ulcerations and relapsing uveitis. The genital and oral ulcers are classically painful with a necrotic center and surrounding red rim.
more common in Japan, Korea, and the Eastern Mediterranean area, and affects primarily young adults
whiff test is done by
potassium hydroxide wet preparation of a sample.
ovarian cancer in post menopausal women is usually
epithelial
ovarian cancer in pre mensstrual is usually
germ
women of any age can get this type of ovarian cancer
stromal
The diagnosis of cervical insufficiency is usually based on
The diagnosis of cervical insufficiency is usually based on history of recurrent midtrimester loss, risk factors, and a transvaginal ultrasound measurement of cervical lengt
what is the difference between the treatment for bacterial vaginosis and
Metronidazole 2 g PO (D) is therapy for trichomonas vaginitis. Although metronidazole is an appropriate medication for treatment of BV, the one time dosing is not sufficient.
for BV can also do
CLINDA 300 x 1o days
suboptimally cytoreduced disease after surgical cytoreduction for epithelial ovarian cancer
what is the treatment
Carboplatin and paclitaxel intravenously is the preferred first-line chemotherapy in women who have suboptimally cytoreduced disease after surgical cytoreduction for epithelial ovarian cancer.
The color varies; warts may be white, skin-colored, erythematous (pink or red), violaceous, brown, or hyperpigmented. Anogenital warts are usually soft to palpation and can range from 1 mm to more than several centimeters in diameter. The warts are typically asymptomatic but can occasionally be pruritic.
flat dome shaped or cauliflower appearance
rst-line patient-applied therapies include imiquimod, podophyllotoxin, and sinecatechins. First-line clinician-administered treatments are cryotherapy, trichloroacetic acid, surgical excision, electrosurgery, and laser therapy.
dense breast tissue, with rope-like or cobblestoning texture to the bilateral breasts with cyclical pain that is associated with menstruation
Fibrocystic breast changes
rare and usually present as firm, mobile, well-circumscribed, rapidly growing masses that usually involve one breast.
Phyllodes tumors
test for gonorrhea
Gram stain of the ulcer exudate showing gram-negative rods
______is the treatment of choice in hemodynamically unstable patients with heavy uterine bleeding. If bleeding persists, the next step in treatment would be the use of intravenous conjugated_______
Uterine curettage is the treatment of choice in hemodynamically unstable patients with heavy uterine bleeding. If bleeding persists, the next step in treatment would be the use of intravenous conjugated equine estrogen.
how do you distinguish premenstural dysmorphic disorder
rm of PMS in which symptoms of anger, irritability, and internal tension are prominent. Symptom onset is usually in the early 20s. Premenstrual irritability is the most common symptom. DSM-5 diagnostic criteria for premenstrual dysphoric disorder requires prospective documentation of physical and behavioral symptoms (using diaries) being present for most of the preceding yea
symptoms must be present for more of than a year
what is the treatment fo rtwin to twin transfer
As the mother is 20 weeks pregnant, the best intervention would be fetoscopic laser ablation.
A 24-year-old woman presents with fever, chills, and painful lumps to the groin area for the past three weeks
what is the treatment
Lymphogranuloma venereum
doxy
how do you diagnose syphilis
Initial screening is performed with a nontreponemal test (eg, RPR). This is a quantitative test (reported as a titer of antibody) and reflects the activity of the infection.
FTA-ABS is used to confirm but will give FALSE POSITIVE
if already infected
Rapid plasma reagin (RPR) (D) are nonspecific tests that reflect the activity of the infection. Titers are followed after treatment to monitor therapeutic response.
initial visit what is the most accurate way to date the preganncy
CRL
when would you use cytotoxic chemotherapy for ER positive tumors
cytotoxic chemotherapy (A). Chemotherapy may also be used for ER-positive tumors with high-risk characteristics, such as a high-grade tumors, large size (≥ 2 cm)
otherwise endocrine therapy
Tamoxifen, an estrogen receptor modulator, significantly reduces the risk of recurrence and death in patients with ER-positive disease
A 42-year-old woman with a history of hypertension and a body mass index of 32 presents to the office with her fourth incidence of vaginal candidiasis in the past year. Besides a wet mount and fungal culture, which of the following screening test should be ordered?
Glycated hemoglobin (also called A1C)
A 32-year-old woman presents to the ED at 39 weeks of gestation in active labor. Her axillary temperature is 98.6°F, pulse is 88 beats per minute, and blood pressure is 120/80 mm Hg. Upon vaginal examination, an umbilical cord is noted to be protruding from the cervix which is dilated to five centimeters. While awaiting a surgical suite for an emergency cesarean section, which of the following agents would be most appropriate to administer?
umbilial cord prolapse —>
Emergency cesarean section is the standard obstetrical management. If a delay in cesarean section is anticipated, such as waiting for an open surgical suite or transporting the patient from a remote location, the tocolytic terbutaline 0.25 mg can be given subcutaneously to decrease uterine contractions and alleviate pressure on the cord.
A male child born at 40 weeks of gestation has an Apgar score of 4 at birth. He is gasping for air and has a pulse of 68. Which of the following would be the best choice for initial clinical intervention in this patient?
pp vrntilation
Neonates who persistently show respiratory distress and a heart rate under 60 beats per minute despite positive airway pressure or intubation should receive chest compressions and may also need intravenous epinephri
An 18-year-old woman presents to the clinic for her annual preventive health examination. She is asymptomatic. There is a new palpable left-sided adnexal mass on pelvic exam. Which of the following imaging modalities is best to initially characterize the mass?
MRI for teratoma
A 32-year-old woman is having abnormal uterine bleeding for several weeks after a normal vaginal delivery. Serum human chorionic gonadotropin (hCG) levels are tested and found to be elevated. They remain elevated at persistently low levels when retested after two months. A pelvic ultrasound reveals a hyperechoic intrauterine mass. Which of the following is the most likely diagnosis?
Placental site trophoblastic tumors cause very low, persistent levels of hCG. These are malignant tumors that most commonly occur after a non-molar abortion or pregnancy.
She states she does not remember the date of her last menstruation and that her cycles are irregular. A home pregnancy test this morning was negative as is the in-office urine pregnancy test. Which of the following is the best next step in confirming pregnancy?
A urine pregnancy test 14 days after last intercourse would minimize the possibility of a false negative. False negatives are most likely caused by performing the test too soon after conception. A serum test is the most sensitive test, but results are not immediately available and there is an increased cost associated with the serum test. A repeat urine test is readily available and may eliminate the need for the serum test.
hormones in menopause
A decrease in estrone, decrease in estradiol, and an increase in testosterone
trichimonas pH.
Trichomoniasis presents with vulvar pruritus and a profuse, frothy, greenish, foul-smelling vaginal discharge with a pH usually exceeding 5.0.
Bacterial vaginosis presents with malodorous, gray-white discharge. The pH is typically 5.0-5.5.
A 35 year-old female presents with a solitary breast mass. Fine needle aspiration reveals bloody fluid with no malignant cells. What is the next best step in the care of this patient?
Excisional biopsy is the next step in cases of bloody fluid, residual mass or thickening.
progesterone controls the growth of what in the breasrt
growth of the lobules and alveoli is under the influence of progesterone.
estrogen controls the growth of what in the breast
proliferation of the mammary ducts Proliferation of the mammary ducts is under the influence of estrogen.
PAINLESS papule
shallow ulceration/erosion
NONindurated
primary LGV
what is secondary LGV
10-30 days after exposure secondary LGV leads to buboes (grossly enlarged tender nodes) and can lead to the GROOVE SIGN
what is the groove sign
seperation of the lymph nodes by the inguinal ligament seen with LGV which is causes by chlamydia trachomatis
how do you confirm LGV
through titers
what is the treatment for lGV
Doxy
soft PAINFUL ulcer of the vulva
tender with ragged edges on a necrotic base and tender lymphadenopathy
cancroid
what is the organism that causes cancroid
Haemophilusducreyi small gram negative rod
gram stain seen as “school of fish”
after ruiling out syphilis and herepes you can biopsy or culture to help establish the diagnoses
treatment for cancroid
azithromyocin or intramuscular cerftriaxone
primary syphilis generally presents as
RAISED borders indurated (hard) base
NON TENDER chancre
papule
usually arise 3 weeks after exposure and disapear spontaneously
what are the painful genital ulcesr
chancroid and HSV
what are the painless genital ulcers
syphilis(indurated)
LGV (non indurated with lymphadenopathy)
granuloma inguinale (beefy red bleeds easily)
what would you do if you suspected syphilis but the VDRL and RPR were negative
might be early do darkfield microscopy
what is the treatment for syphilis
IM PNC
if latent or unknown do IM q 3 wks
All postmenopausal women above the age of ___ should be screened for osteoporosis (i.e., using the DEXA scan to measure bone mineral density).
All postmenopausal women above the age of 65 should be screened for osteoporosis (i.e., using the DEXA scan to measure bone mineral density).
what is carbaprost and what are the CI
Carboprost, a prostaglandin analog that stimulates uterine contractility, may cause significant bronchospasm and is contraindicated in patients with asthma.
What is methylergonovine and what are the contraindications
Hypertension (C) and coronary artery disease (B) are contraindications to the use of methylergonovine, another common uterotonic agent which causes vasospasm
treatment for a patient with a TOA
Cefoxitin and doxycycline are an appropriate antibiotic regimen for a patient with a tubo-ovarian abscess
firm uterus with PPH think
what is the tx
retained placenta
D and C
hysterectomy
nml uterus with PPH think…
what is the tx
think laceration
pressure–>
sutures
absent uterus and pph
what is the treatment
uterine involution
first try to replace
tocolytics then oxytocin
what if you have a pph that can not be resolved
2 large bore IVS
IV estrogen
uterine artery ligation (OB)
uterine artery embolization (IR)
TAH (OB)
in women over 45 and older with AUB
only in pos
difference between adenomyosis and leimyoma
adenomyosis is sift and tender with a globular boggy uterus
leiomyoma is non tender and irregular firm
inpatient mngmt of PID
Ceft +doxy
or Clindamycin and \gentamycin
