Gyn Disorders Flashcards
____ is the MC gyn malignancy in the US and is MC in what age population?
Endometrial Cancer
-peaks at 50-60 years (POST-menopausal)
Endometrial cancer is an ______ - dependent cancer and the risk for getting it increases with _____ exposure.
Estrogen
*increased estrogen exposure associated with nulliparity, chronic anovulation, PCOS, obesity, estrogen replacement therapy, late menopause, Tamoxifen, HTN, DM
_____ is definitive dx of endometrial cancer.
Endometrial bx (Adenocarcinoma is MC- 80%)
Treatment options for endometrial cancer by stage…
Stage I: Hysterectomy (TAH +/- BSO) +/- post-op radiation tx
Stage II/III: TAH-BSO + LN excision +/- post-op radiation therapy
Stage IV: Advance–> Chemo
_____ is MC site of endometriosis.
Ovaries
*Endometriomas= Chocolate cysts
A big RF for endometriosis is _____. Its onset is usually before the age of ____.
Nulliparity
-onset before 35 y/o
This classic triad is associated w/ what diagnosis?
- Cyclic premenstrual pelvic pain
- Dysmenorrhea
- Dyspareunia
(+/- Dyschezia)
Endometriosis
The definitive diagnostic tool of endometriosis is _____.
Laparoscopy w/ bx
*PE usually normal with fixed, tender adnexal masses
Treatment ladder for Endometriosis:
- Combined OCPs (ovulation suppression) + NSAIDs
- Progesterone, Lupron (GnRH analog causes pituitary FSH/LH suppression), Danazol (testosterone–> induces pseudomenopause and suppresses FSH and LH)
- Conservative Laparoscopy w/ Ablation (if fertility is desired)
- TAH-BSO (if no desire to conceive)
2 main types of functional ovarian cysts are ____ & _____.
Follicular and Corpus Luteul
Most patients presenting with this dx are asymptomatic however some may have unilateral RLQ or LLQ pain. There may also be a mobile, palpable adnexal mass. These usually spontaneously resolve.
Functional Ovarian Cyst
Functional ovarian cysts are diagnosed by ____.
Pelvic US
- Follicular= smooth, thin-walled unilocular
- Luteal= complex, thicker-walled with peripheral vascularity
Mainstay of treatment for functional ovarian cysts is ____.
Supportive care: rest, NSAIDs, repeat US after 6 weeks
- Most cysts <8cm usually spontaneously resolve
- IF >8cm, persistent, or found post-menopause then +/- laparoscopy or laparotomy
Common RFs for ovarian cancer include:
Family history, increased number of ovarian cycles (infertility, nulliparity, >50 years at menopause), BRCA1 /BRCA2
*Protective factors= OCPs, high parity, or TAH
Ovarian cancer usually presents between ___ and ___ years of age.
40-60
_____ node= METS to the umbilical lymph node.
Sister Mary Joseph’s Node
Definitive dx tool for ovarian cancer is:
Biopsy (90% epithelial)
*Transvaginal US is a useful screening tool
What lab value is taken to monitor treatment progress of ovarian cancer?
CA-125
_____ is the MC benign ovarian cyst.
?? unsure of this
Dermoid Cystic Teratoma
*Management= removal due to potential risk of torsion or malignant transformation
What endocrine syndrome is characterized by the following triad:
- Amenorrhea
- Obesity
- Hirsutism
PCOS
*Due to insulin resistance= increased risk of HTN, DM, and atherosclerosis
What lab values are affected in patients with PCOS?
- Increased testosterone
- LH:FSH ratio > 3:1 (normal 1.5:1)
What is the trademark US finding in a patient with PCOS?
String of pearls= bilateral enlarged ovaries with peripheral cysts
Mainstay of treatment for PCOS is _____.
Combined OCPs (normalizes bleeding)
_____ is an anti-androgenic agent for hirsutism.
Spironolactone- blocks T receptors
Teratogenic–> must be used with OCPs!!
____ in patients with abnormal LH:FSH ratios may improve menstrual frequency by reducing insulin.
Metformin
Long utero-ovarian ligaments predisposes what age group to ovarian torsion?
Prepubertal girls
Benign uterus smooth muscle tumors are known as _____.
Leiomyomas (Fibroids)
If a suspected growth continues to enlarge after menopause it is likely not a fibroid as fibroids are related to ESTROGEN production!
FYI
A 35 year old African American patient presents with a large, irregular hard palpable mass in the pelvis during bimanual exam. She complains of menorrhagia. What is her most likely diagnosis?
Leiomyoma- fibroid!
Treatment options for leiomyomas…
- Observation
- Inhibit estrogen: LUPRON (causes GnRH inhibition when given continuously)- it shrinks the uterus temporarily until menopause. Usually used near menopause or pre-op
- Progestins: cause endometrial atrophy
- Surgical: Hysterectomy, Myomectomy Endometrial ablation, Artery embolization
Islands of endometrial tissue within the myometrium are known as ____. It causes a DIFFUSELY enlarged uterus.
Adenomyosis
A patient comes in with progressively worsening menorrhagia, dysmenorrhea, and a TENDER, SYMMETRICALLY “BOGGY” UTERUS on PE. Her most likely dx is ____.
Adenomyosis
The only effective therapy for adenomyosis is ____.
TAH
Pap Smear cervical cytology results and recommendations
SEE STUDY GUIDE!!
Post coital bleeding/spotting is the most common sx of what diagnosis?
Cervical carcinoma
*Avg age of dx is 45 years
Cervical cancer treatment based on stage:
Stage 0 (CIS): Local treatment- excision (LEEP, Cold Knife Colonization), ablation, TAH-BSO
Stage I-IIA (Microinvasion): Surgery (conization, TAH-BSO, XRT) +/- Chemo
Stage IIB-IVA (Locally advanced): XRT + Chemo
Stage IVB or Recurrent (Metastatic): Palliative XRT +/- Chemo
HPV vaccination given between 11-26 (Gardasil and Gardasil 9)
If <15 y/o then 2 doses at least 6 mos apart
If >15 y/o then 3 doses usually at day 0, 2 mos, and 6 mos
MC cause of cervicitis is _____.
Chlamydia
Patient presents with increased urinary frequency, dysuria, abdominal pain, and post coital bleeding. What should be on the differential?
Chlamydia
How is chlamydia diagnosed?
Nucleic Acid Amplification–> PCR more specific and sensitive though
-Cultures and DNA probe as well
How is gonorrhea diagnosed?
Nucleic Acid Amplification–> PCR more specific and sensitive though
-Cultures and DNA probe as well
Patient presents with ulcerated vulvar lesion. She also complains of a low-grade fever for the last week. What should be on the differential?
Herpes Simplex
How is herpes diagnosed?
Viral culture & PCR
-See enlarged, multi-nucleated cells with ground-glass cytoplasm and nuclei containing inclusion bodies
Patient presents with a flat, pedunculated flesh-colored growth (“cauliflower-like” lesion) with post-coital bleeding. What should be on the differential?
HPV (Cervicitis)
Patient presents with a painful genital ulcer with some foul smelling discharge. Painful inguinal LAD also present. What is the most likely diagnosis and treatment?
Dx- Chancroid
Tx- Azithromycin 1g x 1 dose
Patient presents with PAINLESS genital lesion with softening and tender, unilateral inguinal LAD. What is a possible dx and treatment?
Dx- Lymphogranuloma Venereum
Tx- Doxycycline 100mg PO BID x 21 days
Rectal exposure can result in proctocolitis in patients with LGV. Can have mucoid and/or hemorrhagic rectal discharge and pain.
This can lead to chronic, colorectal fistulas and strictures, which can involve the entire sigmoid :(
The presence of LGV is strongly associated with what other diagnosis?
HIV
-Positive HIV in 75% of cases
Patient presents with painless ulcer with raised, indurated edges. Diffuse, bilateral maculopapular lesions on the palms and soles are noted. Also, multiple wart-like lesions near the ulcer are noted. What should be on the differential for this patient?
Syphilis
How is syphilis diagnosed?
- darkfield microscopy: allows for direct visualization of the spirochete (used in patients with chancre or condylomata lata)
- RPR: titer; non-specific and must be confirmed by treponemal testing (FTA)
What is the treatment for syphilis?
Penicillin G (even in PCN allergic)
*May have Jarisch-Herxheimer Rxn: acute febrile response due to rapid lysis of many spirochetes, assoc with myalgias and HAs
**ALL patients must be reexamined clinically and serologically at 6 & 12 months after tx
***ALL patients w/ syphilis should be tested for HIV
Cervical motion tenderness associated with PID is known as a ______ sign.
Chandelier
19 year old patient presents w/ lower abd tenderness, fever, purulent cervical discharge and CMT. She states that she does not use protection and has multiple sexual partners. What should be on your differential?
PID- most commonly gonorrhea and/or chlamydia
Hepatic fibrosis/scarring and peritoneal involvement related to PID is known as ______ Syndrome.
Fitz-Hugh Curtis
(RUQ pain due to perihepatitis which may radiate to the right shoulder)
*Violin strings on anterior surface of liver
How is PID treated?
Outpatient: Doxy 100mg BID x 14 days + Rocephin 250mg IM x 1
Inpatient: IV Doxy + 2nd Gen Cephalosporin (Cefoxitin or Cefotetan)
Vaginal and vulvar pruritus with red/white ulcerative, crusted lesions on exam is associated with what cancer diagnosis?
Vulvar
*Treatment- surgical excision, radiation therapy, chemotherapy
Patient presents with some vaginal itching and states that she notices a strange “fishy” odor, especially after sex. She also states that she has noticed a greyish, white discharge. What is at the top of your differential?
BV
What do you see on a microscopic evaluation of BV sample?
Clue cells
How do you treat BV?
Flagyl x 7 days (gel or PO)
Patient presents with vulvar itching, redness, and pain with intercourse. She also states she has a greenish discharge. What may be near the top of your differentials?
Trichomoniasis
What is a common finding on speculum examination of a patient with Trich?
Strawberry cervix (cervical petechiae)
What is found on microscopic examination of a Trich specimen?
Mobile protozoa on wet mount
How is Trich treated?
Flagyl 2g x 1 dose OR
Flagyl 500mg BID oral x 7 days
*MUST treat partner too!!
Patient presents with vaginal burning and itching. She also notes dysuria and dyspareunia. She says a few days ago she noted a thick, curd-like/cottage cheese discharge. What is at the top of your differential list?
Candida- Yeast Infxn
What is seen on a microscopic examination of a yeast specimen?
HYPHAE, YEAST
How is Candida treated?
Fluconazole PO X 1 dose or
Intravaginal antifungals
