Gyn Flashcards
Definition of infertility
inability to conceive x1y (can start eval >35yo at 6mo)
What age does fertility start to decline?
32yo
How dos NSAID use affect fertility?
negatively affects ovulation
How does cig use affect fertility?
rapid follicular depletion
How does obesity affect fertility?
ovulatory dysfxn - increased peripheral conversion of andrgogen to estrogen, therefore estrogen down-regulates FSH > decreased follicular development
Normal length of cycle
21-35d (although 25-35d x3-7d = likely ovulating)
How does basal body temp work?
post-ovulation, progesterone increases body temp 0.4-0.8 degrees
How do OPK tests work?
Measure urinary LH, LH surge lasts 48-50h. Ovulation normally occurs next day
How does testing progesterone work for testing for ovulation?
Test at day 21 (or 7d after ovulation) tells you if corpus luteum is making progesterone to prepare endometrial lining
What are day 3 tests
estadiol and FSH
How do day 3 tests work?
Inhibin normally inhibits FSH from being made. In decreased ov. fxn, granulosa cells make less inhibin > therefore more FSH is made. >10 is abnormal. estradiol is measured to decrease false neg (60-80 abnl)
What does AMH tell you?
Plays role in follicular recruitment, correlates with AFC. Can be falsely high in PCOS
What is a normal antral follicle count?
10-20 total
What part of the cycle should HSG be performed?
Day 5-10 of cycle
How is sperm affected by age?
decrease in motility and morphology
Prevalence of infertile couples?
10-15%
Treatment for hyper-prolactinemia?
bromocriptine (dopamine agonist)
MOA of Clomid
SERM, blocks estrogen receptors in hypothalamus> increase in FSH> more follicles stimulated
MOA of letrazole
aromatase inhibitor> blocks conversion of androgens to estrogen> increase in FSH> more follicle stimulated
How does ovarian drilling work?
Destroys ovarian stroma that is producing androgens. Decreased peripheral conversion of androgen to estrogen, increase FSH > more follicles stimulated
Treatment for chronic cervicitis
Doxycycline 100mg BID x 10 days
What value of mid-luteal progesterone indicates ovulation?
> 3
4 Most common bacteria of acute cystitis
E. Coli (75-95%), Klebsiella pneumoniae, Proteus miribilis, Staphylococcus saprophyticus
If you have one UTI, what are your chances of having another within 1 year?
50%
What is the positive predictive value of having symptoms of a UTI?
80%
What makes a UTI complicated?
Diabetes Pregnancy Immunocompromise Symptoms > 7d Post-menopausal hematuria Recurrent UTI's Recent GU surgery Urologic abnormalities Recent hospitalization Fever (100.4) Ab/pelvic pain, n/v Persistent symptoms despite treatment >3d
What amount of CFU/ml is diagnostic of UTI?
10 to the 5, 10 to the 2 if from catheter
What is leukocyte esterase?
chemical released from WBC in urine, high negative predictive value, can be falsely positive with contamination
What is nitrite?
Metabolite of gram negative bacteria
NOT PRODUCED BY PSEUDOMONAS (or gram + like staph, strep, enterococcus)
False positive with pyridium
Lifetime probability of woman getting UTI?
60%
Non-ABX ways to prevent UTI’s
Cranberry inhibits binding, methenamine > formaldehyde (bacteriostatic), vaginal estrogen in postmenopausal women
How long should treatment for Pyelonephritis be? And how soon would you expect clinical improvement?
14 days, expect response in 48-72h
ABX options for recurrent UTI’s, and how much will this decrease the risk of recurrence?
Daily macrobid, cipro, or bactrim x6-12 mo
Or post-coital
Decrease recurrence risk by 95%
What is one option for PO treatment for pyelo?
Augmentin x 14 days
What part of a vulvar lesion should you biopsy?
hypo/hyperpigmented: thickest part
ulcerative: border
Which dermatosis is characterized by the itch scratch cycle?
Lichen simplex chronicus
How do you treat lichen simplex chronicus?
Break itch-scratch cycle. Remove irritants. Topicl low potency CD
How is the diagnosis of lichen simplex chronicus made?
Clinical diagnosis.
Biopsy if no improvement after 1-3 weeks of treatment
How does lichen sclerosus present?
Asymptomatic, just labial changes.
What population does lichen sclerosus affect?
Postmenopausal women
How does lichen sclerosus present?
Cigarette paper lesions
Labial regression
Urethral obstruction
Introitus stenosis
How do you cure lichen sclerosis?
There is no cure
What is the treatment for lichen sclerosis?
Potent topical CS > taper
- 05% clobetasol ointment
- 05% halobetalol ointment
Which dermatosis increases the risk of vulvar squamous cell carcinoma?
Lichen sclerosus (5%)
How does lichen planus present?
Itchy and painful, vuvlvar + oral lesions
Classic finding of lichen panus
Wickham striae
Parabasal cells in vaginal discharge
How do you treat lichen planus?
high potency topical corticosteroid ointment
What is the skin change from friction in moist areas called?
Intertrigo
- dry out with cornstarch
What is the function of bartholin gland?
Makes mucus to lubricate vulva
What bacteria is most common in a bartholin gland abscess?
E. coli
Where is the bartholin gland located?
inferior labial majora or vestibule
If a postmenopausal woman has an enlarged bartholin gland what should you suspect?
Malignancy
Definition of vulvodynia
6 months of vulvar pain, diagnosis of exclusion
Likely pathophysiology of vulvodynia?
local stimulus to trauma causing a maladaptive nervous system response
Treatment of vulvodynia
topical lidocaine
topical gabapentin
TCA Antidepressants
Anticonvulsants
Typical population of desquamative inflammatory vaginitis
perimenopausal white women
How does desquamative inflammatory vaginitis present?
Copius discharge, vaginal burning, dyspareunia that is refractory to typical vaginitis treatment
What is the microscopic finding of desquamative inflammatory vaginitis?
Parabasal cells and polymorphonuclear cells
How do you treat desquamative inflammatory vaginitis?
2% vaginal clindamycin cream in vaginal hydrocortisone x4-6 weeks
What type of cancer does DES in utero cause?
Vaginal clear cell adenocarcinoma
What is a Gardner duct?
Remnant of mesonephric (Wolfian) Duct
Risk factors for POP
increased parity, vaginal deliveries Menoause- hypoestrogenism Chronically increased ab pressure (CPOD, obese) Pelvic floor trauma race (latina/white) Connective tissue disorder Spina bifida
Muscles of levator ani
Iliococcygeus
Puborectalis
Pubococcygeus
Stages of POP
0= none 1= TVL-2
Different types of POP
Distention= smooth; no loss of fascial attachments Displacement= ruggated; loff of fascial attachments
Levels of vaginal support
Level 1= cardinal/uterosacs
Level 2= Lateral vagina> ATFP
Level 3= perineal body
2 majr parts of continence
Urethral contraction and detrusor relaxtion
Which nerves and receptors are responsible for urethral contraction?
Pudendal and pelvic nerves (alpha rec)
Which nerves and receptors are responsible for bladder relaxation? And bladder contraction?
relaxation: Sympathetic nervous system (beta rec)
contraction: parasympathetic (ACh muscarinic)
Which nervous system is responsible for detrusor contraction?
Parasympathetic NS; ACh- muscarinic
How does voiding work?
Decreased sympathetic NS, increased para-sympathetic NS > detrusor contraction, urethral relaxation
Theories of SUI
Lack of support vs. sphincter deficiencies
How does SUI present in urodynamic testing?
Leak in absence of detrusor contractions
Which nerves are responsible for bulbcavernosus reflex?
S2-S4
How do TVT and TVT-O compare in terms of risk?
TVT higher risk of voiding dysfxn
TVT-O higher risk of nerve injury
How do oxybutynin, tolterodine, fesoterodine work?
Anti-cholinergics, block detrusor activity
How do vesicare and trospium work?
Selective anti-muscarinics,block detruser but should have less side effects than normal anti-cholinergics
How does mirabegron work?
beta 3 agonist, causes detrusor relaxation
What nerves are moduated in PTNS?
L4-S3
What causes endometrial hyperplasia and what is this a precursor to?
Estrogenic stimulation
Precursor to adenocarcinoma (type 1)
What is the best way to sample endometrial lining when concern for ECa?
hysteroscopy is best
then in office EBx = D&C
What progestin therapy can be used for endometrial hyperplasia?
Provera 10mg x 12-14 days/month or 100 mg megace same way or IUD
If using progestin therapy for hyperplasia, how often should you sample the lining?
q 3-6 months
How is hyperplasia classified?
WHO schema outdated, now EIN schema
- benign
- pre-malignant
- malignant
If pre-malignant on biopsy, what percentage will have concurrent ECa on hyst specimen?
40%
In a patient with PMB, what ES warrants a EBX?
> 4mm or if bleedinr recurrent/persistent
What is the most commonly diagnosed gyn malignancy?
ECa
At what stage does ECa normally present?
70% type 1, stage 1 at dx
mean age of ECa dx?
63 yo
What is type 1 endometrial cancer?
Endometrioid
75% of cases
normally low grade at dx
white women
What is type 2 endometrial cancer?
Clear Cell, pap serous, Carcinosarcoma
high grade with risk of extra-uterine spread at time of dx
women of color
What percentage of ECa is Pap serous, and what percentage of death d/t ECa does this cause?
10% of all ECa are pap serous, they cause 40% of ECa deaths
Risk factors for endometrial cancer
age north american/northern european high education/income/white nulliparity- h/o infertility early menarche, late menopause Tamoxifen Obesity (T2DM, HTN) Lynch syndrome
What is Cowden syndrome? genes and cancers
genes: PTEN
Cancers: thyroid, breast, endometrial
What is lynch syndrom? genes and cancers
genes: MLH1, MSH2, PMS2, MSH6
Cancers: colorectal, ovarian, type 1 endometrial
What can cause increased estrogen?
obesity
chronic anoulation (PCOS)
estrogen producing tumors (granulosa cell)
How much does increased estrogen increase the risk of ECa?
20x the risk
How is ECa staged?
surgically: hyst-BSO, para-aortic LN, pelvic LN, washing
When are LND not needed?
grade 1
grade 2 if <50% myometrium
if tumor <2 cm
Stages of ECa
I: confined to uterus
IA: <50% myometrium
IB: >50% myometirum
II: cervical stroma
IIIA: serosa/adnexa
IIIB: vaginal/parametrium
IIIC: pelvic/para-aortic LN
IVA: bladder/bowel mucosa
IVB: distant mets
How often is Surveillance after surgery for ECa?
first 2 years: every 3-6 months
then 3 years of q 6 months
then annually
When do patients need adjuvant radiation?
if 70+ yo with one of the following:
if 50+ yo with 2 of the following:
any age with all three of the following:
+LVSI
grade 2 or 3
outer 1/3 of myometrium
What chemo do we use?
carboplatin and paclitaxel
How do we screen for VIN?
We don’t!
What are risk factors for VIN?
HPV
Smoking
Immunocompromised
What are the two different types of VIN?
Differentiated: starts from Lichen sclerosis
Usual: HPV associated
Who needs a biopsy of a wart?
all post-menopausal women, those refractory to topical treatment
If vulvar cancer is suspected, what is the treatment?
Wide local excision with margins of 0.5-1 cm
If vulvar cancer is not suspected, but patient has VIN what is the treatment?
Laser ablation, excision, topical imoquimod
How does laser ablation for VIN work?
Burn around lesion 0.5-1 cm
Use colposcope to see
How deep does laser need to burn for VIN?
In hair bearing areas: 3mm into subcutaneous fat
In non-hair bearing: into dermis (2mm)
How do patient’s use imiquimod for VIN?
Apply weekly x 12-20 weeks, with colpo q 406 weks
not FDA approved
What is one factor that makes colposcopy of vulva difficult?
Keratinization
What is the recurrence rate of VIN?
9-50%
What surveillance is needed after treatment of VIN?
Appointment in 6 months, then 12 months, then annually
