GYN Flashcards
Cervical Screening guidelines for immunocompetent vs immunocompromised:
Immunocompromised- Screen at onset of sex (even if before age 21)
Immunocompetent- No screening before age 21 (they might be able to bounce back from HPV infx)
Cervical Screening guidelines by age:
Age 21-29: Pap smear q3 years
Age 30-65: pap smear q3yrs or Pap+HPV q5yrs
Age >65- Stop screening if negative screens until this point (unless immunocompromised then continue screening)
Woman is BRCA1 (+). What cancers is she at increased risk for?
BRCA1 positive women have increased risk for ovarian, breast, and endometrial cancers.
Woman is BRCA1 (+). What can be done prophylactically for breast cancer?
Breast cancer screening is done with MRI and mammography every 6 months.
Immediate mastectomy with reconstruction is indicated at any age.
Tamoxifen chemoprevention is acceptable for women unwilling to undergo mastectomy.
Woman is BRCA1 (+). What can be done prophylactically for endometrial/ovarian cancer?
Only women who SHOULD be screened for ovarian cancer w/ transvaginal ultrasound with Ca-125 every 6 months.
Prophylactic TAH+BSO is performed at age 35.
When can you give methotrexate to terminate pregnancy?
HCG < 5000
No fetal heart tones
No folate
Size < 3 cm
snowstorm pattern
molar pregnancy
What is dysfunctional uterine bleeding?
No underlying issue to fix, just abnormal bleeding.
1st try OCPs, if they fail, try NSAIDS to “reset” the ovulation pattern
Mainstay of therapy for PCOS?
OCPs and metformin (improves hirsutism, ovulation, and insulin resistance) are the mainstay of therapy for PCOS.
Spironolactone can be used to reverse some of the hirsutism.
Woman is pregnant but has abnormal pap smear. Management?
Diagnostic excisional procedures such as cold knife cone biopsies or LEEP are recommended in pregnancy ONLY if invasive disease is suspected.
Otherwise, in cases of dysplasia treatment is postponed until after the pregnancy
What is overactive bladder/ hypertonic urge incontinence?
Bladder has random spastic detrusor contractions
Diagnose w/ cystometry (spikes at random levels of bladder volume)
Antispasmodics will bring relief (Oxybutynin)
What is the treatment for acute pelvic inflammatory disease (PID)?
If someone is septic with PID treat INPATIENT w/ IV cephalosporin and doxycycline
What is the treatment for chronic PID?
chronic PID (such as tubo-ovarian abscess) is treated with ampicillin- gentamicin and metronidazole
What is adenomyosis?
Endometrium invading uterus wall (myometrium)
Presents w/ menometrorrhagia (heavy periods) and dysmenorrhea (painful periods)
smooth but tender uterus
reason WHY a woman would not bleed AT ALL
Estrogen deficiency
Estrogen is required to build the endometrium. Without estrogen there is no building, so there is nothing to slough off even if progestin there to signal bleeding.
Pelvic ultrasound shows normal ovaries with a moderate amount of free fluid in the peritoneum. Doppler shows good blood flow to the ovary. Diagnosis?
This is pain associated with follicular rupture/ bleeding from the ovarian capsule with rupture- which then irritates the peritoneum. A rupture of an ovarian cyst leads to free fluid and good blood flow to the ovary- in the absence of other scary things (positive pregnancy test, fever, white count, etc.)
What is the associated tumor marker for Dysgerminoma?
LDH
Draw the serum marker before therapy and follow it for relapse and remission
What is the associated tumor marker for ovarian cancer?
Ca- 125
What is the associated tumor marker for yolk sac tumor?
AFP is found in yolk sac tumors and hepatocellular carcinoma
AFP is the only tumor marker which CAN be used to diagnose cancer. A characteristic lesion on ultrasound or triple-phase CT plus an elevated AFP is hepatocellular carcinoma - even without a biopsy.
What is Kallmann syndrome?
Deficient axis (low hormones including FSH, LH, and estrogen)
Normal anatomy
Anosmia (cannot smell)
Tx- Hormones (GnRH analogs, estrogen, progesterone)
Only needs a bit of hormones and she will grow into a normal woman!
Little girl with precocious puberty with onset of secondary sex characteristic development that has come too soon. Tx?
Postpone menarche until she is able to hit her growth spurt. To do that, we turn off the axis with continuous leuprolide, turning off the axis at the source—the hypothalamus.
What is savage/ resistant ovary syndrome?
Young female with menopause-like symptoms . Everything on axis is working fine (FSH, LH< estrogen, progestrone, prolactin) but no signal going to ovarian follicles for some reason
What is premature ovarian failure?
Early menopause
very high FSH level with moderately elevated LH
What is ovarian torsion?
Ovarian torsion presents with acute pain, often in conjunction with nausea and vomiting. It can spontaneously resolve- and the patient will appear completely normal- then quickly recur (torsion/detorsion). Presence of flow to the ovary on ultrasound does not rule out torsion.
Woman with previous PID now with infertility
A history of pelvic inflammatory disease significantly increases the chances of anatomic failure.
The way to diagnose this anatomic defect is by looking with a hysterosalpingogram.
Woman w/ combination of pain, bleeding, infertility, and abnormal uterine anatomy
asymmetric uterus combined with chronic pain and bleeding with her cycles is classic for fibroids
Fibroids are estrogen-responsive and get better with OCPs and after menopause.
Why does a woman w/ PCOS have irregular periods?
anovalation- no oocyte released
so estrogen builds up the endometrium of uterus but there is no progesterone to signal bleeding. Eventually so much buildup that wall will bleed on its own–> random periods
How does adrenal mass cause virilization?
Adrenals make DHEA– excess DHEA–> virilization (facial hair, acne, clitoromegaly, and a deepened voice)
How does breastfeeding prevent amenorrhea?
breastfeeding–> Increased prolactin levels–> Inhibition of GnRH–> Decreased FSH/LH–> Decreased estrogen/progestrone
How to diagnose PCOS?
PCOS is an endocrine diagnosis—Get LH:FSH ratio
Ultrasound is NOT part of the diagnostic workup for PCOS. - it will just show many cysts on ovaries
What causes incomplete moles?
incomplete chromosomal structure- part fetus part not
Caused by a normal egg fertilized by two sperm (dispermy)
Woman exposed to DES during pregnancy
Vaginal Adenocarcinoma of her daughter
Cancer will resemble a bag of grapes in vagina
What causes complete mole?
Completely molar (no fetal parts)
caused by dysfunctional oocyte (egg has no nucleus)- only paternal DNA is expressed
How will condyloma acuminatum present?
Growths/warts in genital area that are not itchy
Application of acetic acid changes the color of the lesions to white
What causes condyloma acuminatum?
Anogenital warts caused by human papillomavirus (HPV)
Most common strains of HPV that cause anogenital warts are 6 and 11
What is the treatment for condyloma acuminatum?
Treatment is with either imiquimod, podophyllin or trichloroacetic acid (if they are small)
Excision/fulguration (if they are large).
ow do you treat lichen sclerosis?
Porcelain-white lesions and a narrowing of the introitus
Lichen sclerosis is an inflammatory condition, use anti-inflammatories (i.e. topical steroids)
It should first be biopsied to rule out cancer.
How to diagnose Premature ovarian failure?
To diagnose menopause (or premature ovarian failure), look for an elevated FSH, decreased AMH, and antral follicle count.
AMH is a marker for follicles, it gradually decreases over a woman’s life; it is undetectable at menopause
What is treatment for vaginal candida infection?
Treatment starts with topical fluconazole, progressing to po only if there is a failure of topical.
What is treatment for RUPTURED ectopic pregnancy?
Exploratory laparotomy with a salpingectomy (the diseased pregnancy and the tube in which it is stuck come out)
Girls exposed to Diethylstilbestrol (DES) in utero are at increased risk of?
Vaginal clear cell adenocarcinoma
Breast cancer
squamous cell cervical cancer
Exposed women should have an annual gynecologic exam
Most common risk factor for ectopic pregnancy?
Pelvic inflammatory disease (PID)
Sex cord stromal tumors
Leydig cell tumor
Leydig cell tumor
Granulosa cell tumor
Leydig cell tumors
Hyperestrogenism- cause gynecomastia, decreased libido, testicular mass
eosinophilic cytoplasmic Reinke crystals
Klinefelter syndrome
chromosomal aneuploidy XXY
Small and firm testes
severely subnormal sperm count and most are infertile
Elevated serum FSH and LH
Dysgerminomas
Rapid growth on the ovary with elevated Lactate dehydrogenase and alkaline phosphatase
Abdominal enlargement and pain due to rupture with hemoperitoneum or torsion
Fitz-Hugh–Curtis (FHC) syndrome
Extrapelvic manifestation of pelvic inflammatory disease (PID) caused by an ascending infection from the pelvis to the liver via the lymphatics of the pericolic gutter. This leads to patchy inflammation of the liver capsule
String-like adhesions
Bicornuate uterus
Incomplete fusion of the paramesonephric (müllerian) ducts, resulting in 2 uterine cavities
Recurrent abortions, dysmenorrhea, dyspareunia, cyclic pelvic pain, and infertility
Septate uterus
septate uterus has a normal external surface but 2 endometrial cavities
Tx: Surgical repair with resection of the septum hysteroscopically
Unicornuate uterus
asymmetric lateral fusion defect
One cavity is usually normal, with a fallopian tube and cervix, while the failed müllerian duct has various configurations
Duplication of the haploid genome of a single sperm following fertilization of an ovum without maternal genetic material
Complete molar pregnancy
46 XX or 46 XY
Snowstorm or Swiss cheese pattern
Very elevated typically >100,000 mIU/mL
Fertilization of an ovum by two sperm where maternal genetic material is present
Partial molar pregnancy
69 XXX, 69 XXY, 69 XYY
Beta-hCG slightly elevated or within normal limits
Evaluating a patient with an imperforate hymen.
Pelvic ultrasound is not only important when confirming the diagnosis of imperforate hymen, but additionally important to evaluate for other uterovaginal abnormalities
If this is the case, further imaging studies are indicated, typically with MRI.
pelvic inflammatory disease (PID) treatment
Cultured Chlamydia trachomatis: Treat with azithromycin only
Cultured Neisseria gonorrhoeae: Treat with ceftriaxone AND azithromycin
Unknown etiology of sexually transmitted infection: Treat with ceftriaxone AND azithromycin
PID: Treat with doxycycline AND cefoxitin
Fitz-Hugh–Curtis syndrome: Treat with doxycycline AND cefoxitin
placental abruption
Suspect placental abruption in all patients complaining of painful vaginal bleeding with uterine contractions.
maximum recommended adult daily dose of acetaminophen
maximum recommended adult daily dose of 4000 mg (4 g).
Toxicity typically doesn’t occur unless an adult ingests doses greater than 10–12 grams.
Conjunctival injection and pain in eye when looking at light
Corneal abrasion
Dx: Fluorescein staining exam
Tx: Erythromycin ointment, ciprofloxacin liquid drops
