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PROLOG > Gyn and Surgery > Flashcards

Gyn and Surgery Flashcards

1
Q

Regression rate of atypical endometrial hyperplasia with oral vs IUD progestin?

Surveillance of hormonal tx of hyperplasia?

A

70 vs 90%

Serial sampling every 3-6 months (can be done with IUD in place)

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2
Q

% of uterui found to have concomitant carcinoma previously diagnosed with complex atypical hyperplasia?

A

40%

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3
Q

Greatest risk for bladder cancer?

A

Tobacco use

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4
Q

Follow up for LEEP excision pathology from CIN3 for negative vs positive margins?

A

Co-testing in 12 vs 6 months

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5
Q

In addition of endometrial cancer, what uterine cancer is slightly increased with long term (>5yrs) tamoxifen use?

A

Leiomyosarcoma

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6
Q

CA125 threshold for pre vs post menopausal women

A

200 vs 35

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7
Q

Most common reaction after UAE?

A

Postembolization sydrome- fever, pain, nausea, malaise. 30-40% of pts. Usually peaks 1-2d after UAE and resolves in 7d.

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8
Q

Treatment for cyclic mastalgia

A

NSAIDs (PO and topical- diclofenac gel)

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9
Q

When do you perform risk reducing BSO for BRCA1 vs 2?

A

Between ages 35-40yo BRCA1 vs 45yo BRCA2

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10
Q

Lifetime risk of ovarian ca for BRCA 1 vs 2

Theoretical reduced risk by bilateral salpingectomy?

A

39-46% vs 12-20%

42-65%

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11
Q

When to administer pneumococcal vaccine? zoster vaccine?

A

Age 65+ (unless in special population like chronic heart disease or immunocompromised)

Age 60+ should receive one dose of zoster vaccine regardless of h/o prior shingles or chicken pox

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12
Q

Discriminatory zone to dx ectopic?

Minimal rise in hCG in 48hrs in a normal pregnancy?

A

3,510mIU/mL

>35%

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13
Q

After sexual assault, what should women be prophylactically treated for?

A

GC/CT, trich, Hep B, HIV (if assailant is known HIV+), pregnancy (plan B)

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14
Q

Next best test for AUB and low platelet count (otherwise normal labs)?

A

Bone marrow biopsy (can also do prelim with blood smear looking for immature cells).

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15
Q

Differentiate between dx for ITP v TTP v HUS?

A

ITP- megakaryocytes + normal appearing RBCs
TTP- fever, low plts, mental status changes
HUS- uremia, low plts, hematuria, sx of infection

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16
Q

What % of HCV infections will become chronic?

% risk of infection after percutaneous exposure?

Next step after negative RNA testing after (+) exposure?

A

75-80%

1.8%

Retest in 3 weeks

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17
Q

Oliguria (<17-21mL/hour) –> FENa <1 vs FENa >1

A

<1: prerenal- hypotension, hypovolemia

>1: renal/postrenal- ATN, obstruction

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18
Q

FRAX score requiring treatment

A

10yr probability of hip fracture >3% or any fracture >20%

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19
Q

Which bisphosphonate has the most data supporting its use to reduce aromatase inhibitor-initiated bone loss?

A

Zoledronic acid (IV bisphosphonate) - for patients unable to tolerate PO meds as well

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20
Q

Bazedoxifene

Raloxifene

A

SERM- blocks estrogen effects on breast and endometrium

SERM- “ “ plus pro-estrogenic effects on bone

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21
Q

Type of hysterectomy most associated with cuff dehiscence?

A

Laparoscopic- 0.64-1.3% (robotic as high as 6%) vs abdominal (02-0.3%) and vaginal (0.11%)

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22
Q

What cells would be present on cytology of atrophic vaginal epithelium?

A

parabasal cells

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23
Q

What are some standard treatments for GSM?

A

Vaginal estrogen
Ospemifene (increased risk of VTE)
Vaginal DHT (prasterone= intrarosa)- locally converted to estrogen without systemic sfx

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24
Q

What tumor markers should be ordered to rule out most common malignant masses in a 12 year old with a 15cm mass with solid components?

A

BhCG, ca125, LDH, AFP

BhCG + LDH- dysgerminoma
AFP + Ca125- immature teratoma (10-20%)

Mature cystic teratomas (Dermoid cyst) account for 50%

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25
Benefits of HT for post menopausal women
Decrease bone fracture in >60yo Decrease vasomotor sx Some evidence for cardioprotection if initiated prior to 60yo
26
Risk of breast malignancy in post menopausal women using HT
Increase from 0.19 to 0.3
27
Intervals for cervical ca screening in HIV+ women
Starting within 1 yr of intercourse or at 21yo. Q1yr x3 if negative of cytology alone then q3yrs thereafter with contesting. The interval does not increase at age 30.
28
Management of nonfundal IUD
Obtain transvaginal US-> if IUD stem is below internal is, remove it; if above internal os detailed counseling depending on sx (likely to migrate to fundal position over time particularly if shortly after insertion)
29
MoA of ulipristal acetate
Antiprogestin- prevent LH surge and therefore delaying ovulation
30
List the structures at a transobturator sling passes (out to in)
Skin, subQ fat, gracilis, adductor mm, obturador externus, obturador membrane, obturator internus, periurethral endopelvic fascia
31
Difference between mature vs immature teratoma
Immature- contains all three germ cell layers, grade of tumor is determined by the quantity of immature neural elements Mature- contains at least two of the three germ cell layers
32
What is a risk factor for surgical site infection with hysterectomy which is independent of route?
Blood transfusion
33
%age of ovarian and breast cancer that is related to BRCA1 or 2
10% and 3-5%
34
Screening and prophylactic BSO timing for prevention of ovarian ca in BRCA carriers
Screening with CA125 and TVUS starting at 30-35 or 5-10yrs prior to earliest ovarian ca dx in the family And to continue until BSO Prophylactic BSO immediately after childbearing or by age 40
35
What are the two types of VIN, their associations and association with cancer
LSIL and HSIL VIN- HPV persistence (exacerbated by smoking and immunocompromise), low risk for cancer Differentiated-type VIN- associated with lichen sclerosis (or derm conditions), higher association with cancer
36
Minimum criteria for dx of SUI needed before proceeding with surgery:
H&P, PVR, normal urinalysis, demonstration of SUI
37
Urodynamics is useful to rule out ISD in the setting of SUI. What are some risk factors you can use when deciding whether or not to get urodynamic testing?
Smoking, hypoestrogenism, prior urologic surgery
38
General exercise recommendations:
30min of moderate intensity activity 5x per week OR 25min of high intensity activity 3x per week ;With weight training 2x per week
39
Rate of IUD expulsion: Rate of IUD perforation:
2-3%, up to 30% if placed immediately postpartum 1 per 1000 IUD insertions
40
Diagnosis and rx of ovarian remnant syndrome
Clomiphene citrate to stimulate ovarian tissue growth Surgical excision with hidrológico confirmation
41
Histology of an EMB for post menopausal bleeding is “scant tissue, insufficient”, what is the next step?
TVUS, 4mm of less does not require further histology workup
42
Nosy anti epileptic meds have what affect on OCP efficacy? Why? What two anti epileptic meds have decreased efficacy because of OCPs?
Increased enzyme metabolism and SHBG levels decrease the serum levels of OCPs, therefore decrease their efficacy OCPs decrease available levels of Lamotragine and Valproate, therefore increasing seizures
43
Explain the pathophysiology behind recurrent UTIs in genitourinary syndrome of menopause:
Urethra contains glycogen-storing cells crucial to the survival of lactobacilli -> lack of estrogen leads to less glycogen -> loss of lactobacilli -> path changes from acidic to basic allows more virulent bacteria to infect
44
Time frame woman should wait to get pregnant after gastric bypass surgery? Why?
12-24 months Most rapid weight loss in first year
45
Describe female athlete triad and its pathophysiology
Low energy availability (with or without disordered eating), irregular menstruation, decreased BMD Imbalance of caloric intake v expenditure -> loss of gnrh pulsatility -> decreased FSH -> decreased estrogen Workup with Preg test,FSH, LH, TSH, PRL
46
List at least three medications which can decrease BMD
PPI’s, SSRI’s, thiazolidinedione, anticonvulsants, DMPA, hormone suppressive therapy, calcineurin inhibitors, chemo agents, anti coagulation
47
Distinguish between vulvodynia and vaginismus
Vulvodynia is pain of the vulva lasting at least 3 months without an identifiable cause, either provoked or unprovoked Vaginismus is involuntary contraction of pelvic floor muscles inhibiting entry to the vagina
48
Risk factors for recurrence of mature teratoma
Young age (<30), large (>8cm), bilateral 3-4% recur
49
Describe breast surveillance for BRCA carriers
2x yearly breast exam and annual MRI starting at age 25 30yo+ annual mammo and MRI, 2x yearly exam
50
Screening for VAIN after hysterectomy with CIN2+
Screening at 1 and 2 years then, if negative, every 3 years for 20 years
51
When to initiate dexa scans before 65yo
``` Medical history of fragility fracture Body weight <127lbs Medical causes of bone loss Parental history of hip fracture Current smoker Alcoholism RA ```
52
Supplementation of calcium and vitamin d
1200mg and 600 IU daily (800IU >70yo)
53
When to treat osteopenia
FRAX of 3% hip fracture or 20% rush of major osteoporotic fracture in 10yrs
54
At what endometrial thickness should you consider biopsy for post menopausal patients without bleeding?
>11mm, 6.7% risk of being malignant
55
What % of EIN on curettage are found to have carcinoma on hysterectomy specimen?
40% (EIN = complex hyperplasia with stylus)
56
If endometrial cells are present on cervical cytology, what detail is most important in her history?
Is she pre or post menopausal
57
Diagnosis of intrinsic sphincter deficiency?
Urodynamics- maximum urethral closure pressure <20mm h2o or a valsalva leak point pressure <60cm h2o
58
What are the risks and max fluid deficit for electrolyte poor vs rich hysteroscopic distending media?
Electrolyte poor: at 750cc, stop procedure if comorbidities. 1000cc is absolute upper limit. Risks hyponatremia leading to cerebral edema, seizures, and death. Electrolyte rich: 2500cc is absolute upper limit. Pulmonary edema and CHF
59
What antiretroviral HIV medication should not be combined with contraceptives or HRT due to decreased levels it with concomitant use?
Fosamprenavir
60
What is the best management to prevent bone loss related to amenorrhea secondary to anorexia?
Weight recovery and Ca (1300mg) and Vit D (400-1000 IU) supplementation daily
61
Criteria for gestational trophoblastic neoplasia when following hCG levels after D&C for molar pregnancy:
HCG levels plateau for 4 consecutive values over 3 weeks Hcg levels increase by 10% or greater for 3 values over 2 weeks HCG levels persistent for 6 months after evacuation Histopathology of chorio carcinoma Mets on CXR
62
List the procedures commonly performed by gynecology which require antibiotics
Hysterectomy, urethral sling, hysterosalpingogram, D&E
63
How to avoid ilioinguinal and iliohypogastric n injury during laparoscopy:
Avoid placing ports below the level of the ASIS
64
Management of women with AIS in setting of excisional procedure for HSIL:
Preferred is hysterectomy If child bearing still desired: Margins+: reexcision or reassess in 5mo with colpo and ecc Margins neg: long term follow up in 6 months
65
If a partner reveals a clinical dx of HSV without testing to their partner without a h/o of HSV, what should the management approach be?
Type specific serologic testing of partner to verify clinical dx. Then test other partner. If discordant, offer suppression to prevent transmission
66
Management of a non-palpable Etonogestrel implant:
Obtain pregnancy test XR of arm to localize implant Use alternative contraception until implant is located
67
Describe action of bazedoxifene-conjugated equine estrogen
Bazedoxifene- SERM with positive effects on bone density and antagonist effects on breast and endometrium. conjugated equine estrogen (CEE)- relieves hot flashes, decreased BMD loss Combo has shown reduction in hot flashes and breast pain compared to CEE-progestin combo Ideal for a patient with increased risk of osteoporosis, having hot flashes and breast pain, who has a uterus
68
USPSTF HCV screening
One time screen of HCV for asx individuals born 1945-1965 who have not had prior screening. Otherwise for IV drug use, exposure, chronic hemodialysis, received transfusion prior to 1992 or clotting factors prior to 1987, HIV+
69
Why is clindamycin and gentamicin an ecceptable alternative to cephazolin?
Clindamycin covers gram+ and anaerobic orgs. Gentamicin covers gram- aerobes Acceptable- clinda + quinolone or aztreonam
70
Why should you treat adolescent heavy menstrual bleeding with OCPs ONLY AFTER testing for coagulation defects?
Estrogen increases Von Willibrand factor, thus making lower baseline levels
71
What should be tested for in the case of assault? What should be treated prophylactically?
Trich, CG/CT, HIV, syphilis, hepatitis. Repeat testing for HIV at 6wks, 3 and 6 months.
72
If a victim presents with __ hrs of an assault from an assailant known to be HIV +, what is the regimen recommended?
72hrs Three drug regimen- tenofovir, emtricitbine, raltegravir- x28 days
73
Who is an endometrial biopsy recommended for? Sensitivity/ specificity of test?
AUB >45yo or <45yo with additional risk factors of unopposed estrogen or chronic anovulation
74
Dx recurrent UTI First line tx
2+ UTIs in 6months or 3+ in 1yr Daily prophylactic abx x6-12 months and reassess
75
What is the 9 valent vaccine schedule?
Ideally initiated in 11-12 to but now up to age 46 <15yo: 2 doses, second dose 6-12 months after first >15yo: 3 doses, second dose 1-2 months after first, third dose 6 months after first If interrupted, no need to start over, just complete it late
76
Non hormonal initial medications for hot flashes: 1. She doesn’t want it to effect libido or cause weight gain 2. She is on tamoxifen for DCIS 3. She has chronic pelvic pain
1. Paroxetine (50% decrease) 2. Venlafaxine (40-60% decrease- doesn’t block CYP2D6 as much a paroxetine which decreases efficacy of tamoxifen) 3. Gabapentin (40-60% decrease)
77
A patient had an ex-lap for an ectopic and now has burning on her mons, labia, inguinal area, and upper leg- what nerve was damaged?
The ilioinguinal
78
Describe main characteristics of these familial cancer syndromes (autosomal dominant) 1. Li-Fraumeni 2. Cowden 3. Peut-Jeghers
1. Tp53. Soft tissue sarcomas, osteosarcomas, premenopausal breast cancer, brain tumors 2. PTEN mutations. Thyroid, breast, endometrial ca. Macrocephaly, skin lesions of face and mucous membranes 3. Stk11. Hamartomatous polyps in GI tract. Muccocutaneous hyperpigmentation. Breast, ovarian, uterine, GI, sex cord stromal tumors

PROLOG (5 decks)

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