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OBGYN Step 2 > GYN Meded > Flashcards

GYN Meded Flashcards

1
Q

ovarian cancer types

A

germ cell
stromal
endothelial

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2
Q

cervical, vaginal, and vulvar cancers are likely to be ? caused by ?
precancer lesion?
how do they present?

A 
Squamous cell carcinoma
caused by HPV exposure, smoking
precancer lesion: CIS
vulvar/vag: black pruritic lesion
cervical: post-coital bleeding and found on pap smear
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3
Q

endometrial cancer etiology, pre-cancer lesion, cancer type and how it presents

A 
estrogen exposure
dysplasia or atypia
adenocarcinoma
post-menopausal bleeding
(no screening)
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4
Q

epithelial ovarian cancer
etiology?
how it presents?

A

ovulation: trauma to epithelial layer
no screen
ascites, renal failure, SBO
presents at advanced stage late in life

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5
Q

choriocarcinoma

etiology?

A

gestational trophoblastic disease
measure B-hCG (while on OCPs)
hyperemesis gravidarum, hyperthyroid, size-date discrepancies

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6
Q

presentation of cervical cancer

A

bimodal:
30s: post-coital bleeding
60s: post-menopausal bleed

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7
Q

HPV strains that cause cancer

A

16, 18, some in 30s

6, 11 cause warts

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8
Q

HPV progression to cancer

A

HPV progresses to dysplasia, CIN I (LSIL) which affects epithelium, then will grow to affect all layers (CIS (HSIL)) then will progress to endo/ectocervical cancer (SqCC)

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9
Q

cervical cancer staging

A 
I: only involves cervix
IA: micro, IB: macro
IIA: upper 2/3 vagina
IIIA: lower 1/3 vagina
IIB: cardinal ligament involvement
IIIB: involves side wall
IVA: involves adjacent organs
IVB: distant metastasis
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10
Q

what to look for on colposcopy to suggest cervical dysplasia

what to do next

A

abnormal vessles, punctate hemorrhages, acetowhite changes, mosaicism
local ablative therapy: LEEP or cryotherapy
if endocervical: cone biopsy

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11
Q

when to get pap smear

A

begin at 21 yo q3yrs
q1 yrs if HIV+
q5 yrs if over 30 if HPV testing + pap smear
stop at 65 yo

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12
Q

pap smear results

A
  • normal
  • ASCUS: reflex HPV DNA or q6mo pap (if abnormal do colposcopy, if normal back to q3 yr paps)
  • grossly abnormal: get colposcopy (endocervical curettage and ectocervical biopsy) if + need cone biopsy (endo) + local ablation (ecto)
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13
Q

cervical cancer tx based on stage

A

IIA or better: local ablation/resection

IIB or worse: debulking, chemo/radiation (platinum-based)

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14
Q

Gardasil vaccine ages

A

F 11-26

M 11-21

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15
Q

endometrial cancer is due to

A

estrogen exposure
(adenocarcinoma)
cycles: progesterone (produced around ovulation) PROtects agains estrogen exposure
seen as dysmenorrhea or post menopausal bleeding
NO screen

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16
Q

endometrial cancer progression

A

estrogen exposure
then hyperplasia (cystic-adenomatous-atypical)
then adenocarcinoma

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17
Q

^estrogen exposure with

A

age, anovulation (PCOS), nulliparity, obesity, prolonged mentruation in life, HRT, tamoxifen, granulosa or theca tumor

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18
Q

how to tx endometrial cancer

A

TAH/BSO

+/- radiation and chemo

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19
Q

if see post menopausal bleeding, what to do next

A

endometrial sampling or D/C
negative: most likely vaginal atrophy, use estrogen cream
precancer: hyperplasia, give progesterone
if cancer: adenocarcinoma: TAH/BSH
mets: TAH/BSO +/- chemo/radiation

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20
Q

Ovarian germ cell tumors

A

teenage girls, nonmalignant
present as adnexal mass +/- weight gain, Stage I
dx: TVUS
tx: u/l Salpingo oophorectomy
-dysgerminomas (like seminomas) good px with chemo, LDH
-yolk sack: AFP
-teratoma (dermoid cyst): struma ovarii (not usually malignant)
-choriocarcinoma: B-hCG

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21
Q

Ovarian epithelial cell tumors (cystadenomcarcinoma)

A

epithelial trauma (ovulation), extremely malignant, post menopausal, more ovulations, present as Stage IIIB+: asymp and have peritoneal spread (RF, SBO, ascites)
BRCA1/2, HNPCC
dx: no screen, TVUS, CT to stage, track with CA-125
tx: TAH/BSO, paclitaxel (chemo)
mucinous
endometroid
Brenners

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22
Q

special tx for BRCA 1/2 in regards to ovarian cancer

A

screen annually with TVUS and CA-125

ppx TAH/BSO at 35 if done having kids

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23
Q

Ovarian stromal cell tumors

A

Granulosa-Theca: estrogen

Sertoli-Leydig: testosterone

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24
Q

what to do if find adnexal mass on exam

A

TVUS:
smooth, small cyst without septations: simple cyst

large, not smooth + septations and loculated fluid: complex cyst: biopsy

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25
if young girl with asymptomatic mass
germ cell tumor | u/l SO
26
if older F with asymptomatic mass or RF, SBO, ascites
epithelial | TAH/BSO +/- paclitaxel
27
no egg genetics but two sperm sets with 46 chromosomes
COMPLETE mole: good fertilization, bad egg presentation: size-date discrepancy, ^^B-hCG (hyperthyroidism, hyperemisis gravidarum, persistent), grape-like mass, adnexal mass dx: TVUS (snowstorm) tx: suction curretage (not D/C unless 2nd trimester) then follow B-hCG every wk for yr while on OCPs, if rises consider choriocarcinoma
28
egg + 2 sperm sets: 69 chromosomes
INCOMPLETE mole: good egg, bad fertilization | same presentation, dx, tx as complete mole
29
choriocarcinoma
after miscarriage, molar or normal pregnancy (worse px) dx: TVUS, bx with curettage, stage with CT tx: surgical: TAH: I debulking: III medical: chemo (MTX, actinomycin-D, cyclophosphamide)
30
vulvar cancer types
SqCC and melanoma: black and itchy dx: biopsy tx: vulvectomy and LN dissection Paget's: red lesion + itchy, wide local resection (better px)
31
vaginal cancer
SqCC: HPV exposure | Clear cell adenocarcinoma: "grape like mass" IN THE VAGINA: DES exposure in utero
32
PPH tx
1. uterine massage 2. meds: oxytocin, methergine, hemabate 3. balloon tamponade 4. sx: uterine artery ligation/embolization, then internal iliac artery ligation, TAH
33
uterine ligaments
uretero-sacral ligaments: cut during TAH, DON'T mistake for ureters cardinal ligament: transverse: holds to side cardinal ligament A/P: if weakened: pelvic floor relaxation: cysto/rectocele (colporophy), or uterine inversion (hysterectomy) dx: speculum exam
34
uterine inversion grades
I: into vagina, not to opening II: at opening III: outside vagina IV: full inversion
35
cysts based on ages
premenopausal: ovarian germ cell tumor reproductive: physiologic vs complex postmenopausal: ovarian epithelial cancer
36
working up ovarian cyst in reproductive age female
TVUS simple: no septations, no loculations, homogenous, anechoic (black fluid), less than 3 cm (nothing), if less than 10 cm (self-resolve) complex: septations, loculated, multiechoic, heterogenous, large (+10cm) remove complex via laparoscopy (better than laparotomy) DO NOT aspirate, OCPs do not help, MRI not needed
37
complex cysts
``` teratoma endometrioma ectopic torsion TOA cancer ```
38
teratoma
bening, in young female may present with weight gain, fullness dx: US, enormous tx: cystectomy (likely to recur) preserve fertility
39
endometrioma
path: retrograde menses estrogen-responsive, recurs with cycles presents: dysmenorrhea, dyspareunia, infertility "chocolate cyst" dx: U/S, dx laparoscopy with laser ablation
40
endometriosis tx
1. NSAIDs 2. OCP trial (poss. GnRH (lupron), or danazol) 3. laparoscopy with laser ablation if endometrioma (if only endometriosis just OCP trial
41
ectopic dx/tx
dx: B-hCG, if greater than 1500/2000 then get U/S (should see pregnancy) tx: sapingostomy, salpingectomy (if rupture) MTX
42
can use MTX + leucovorin for ectopic pregnancy
B-hCG less than 5000 gestational size less than 3cm no FHTs most fertility-sparing
43
ovarian torsion involves what ligament
suspensory ligament of the ovary, contains ovarian artery/vein
44
ovarian torsion
presents: sudden abdominal pain dx: U/S with doppler to see cyst and decreased flow tx: detorsion, remove if necrosed
45
tubo-ovarian abscess is essential the same as
PID (pathogen and tx) present/dx: abd/pelvic pain, no other cause, 1/3: cervical motion, adnexal, or uterine tenderness +/- fever, leukocytosis WBCs on wet prep tx like PID
46
if TOA is treated like PID and does not improve
``` get u/s, will see abscess needs inpatient IV abs: cefoxitin + doxy + metro OR clindamycin and gentamicin if no improvement, drain ```
47
incontinence unique to women
stress: stretched cardinal ligament after multiple births, get cystocele leaks when ^abd. pressure (sneeze, cough) NO URGE, NO NOCTURNAL SYMPTOMS dx: cystocele, "q tip test" showing mobility no U/A, no cystometry tx: Kegel, pessaries, sling (MMK, Birch)
48
OAB (hypertonic)
random spasms of detrusor muscle URGE, NOCTURNAL, will leak dx: cystometry: random spikes representing spasms tx: antispasmodics, oxybutinin
49
overflow/neurogenic bladder (hypotonic)
absences of detrusor contractions MS, trauma, antispasmodic meds pt will leak before they "explode" NO URGE, +NOCTURNAL SYNDROME dx: distended bladder, focal neuro def., cystometry (no contractions) tx: bethanechol (intitiate contractions), catheterization
50
irritative bladder
``` stones, cancer, UTI frequency, urgency, dysuria +URGE, NO NOCTURNAL dx: U/A tx: underlying condition ```
51
risk for fistulas
``` surgery, cancer, IBD constant leak, still normal function dx: physical exam "tampon test" using blue dye in bladder tx: fistulotomy ```
52
cervicitis organisms | dx, tx
same ones as vulvovaginitis (BV, trich, candida) + Gc/Chlamydia dx: NAAT = PCR, wet prep, may treat empirically tx: ceftriaxone x 1 doxy or azithro (or for vv orgs)
53
PID orgs? | dx?
1/3 of each: Gc, Chlamydia, vaginal flora | tx: clinical, TVUS, TOA (free fluid)
54
PID tx
inpatient if toxic, pregnant, cannot tolerate PO: IV cefoxitin and doxy (back up: clinda and gent) outpt: ceftriaxone IM, doxy + metro DO NOT use FQs or PO cephs
55
life-threatening uterine bleed treatment
1. 2 large bore IVs 2. IVF boluses 3. T/C, transfuse prn 4. IV estrogen (shuts off acute uterine bleeding) 5. surgical intervention
56
life-threatening uterine bleed surgical interventions
intracavitary tamponade D/C uterine artery embolization TAH
57
intrauterine pregnancy to abortion
IUP->threatened(bleeding)->inevitable (no passage, os open, dead baby)->incomplete(passage of contents, os open, retained parts)->complete(passage, closed os, nothing on u/s) missed (no passage, closed os, dead baby)
58
medical/sx management of abortion
misoprostol (1st trimester) oxytocin (induce delivery of dead baby) D/C don't forget to give Rh- moms RhoGAM
59
criteria for MTX (+leucovorin) in ectopic
B-hCG less than 5000 size less than 3.5 cm no FHTs mom not on folate
60
PALM (structural) COEIN (nonstructural) causes of abnormal uterine bleeding
polyps adenomyosis leiomyomas malignancy ``` coagulopathy ovarian dysfunction endometrial probs iatrogenic (IUD) not yet classified ```
61
fibroids
estrogen responsive asymptomatic or may present with anemia, pain (nodular), infertility, visceral obstruction dx: TVUS (MRI and biopsy are better but don't do)
62
fibroid treatment
tx: OCPs, NSAIDS sx: myomectomy (fertility sparing less successful), TAH, may do leuprolide first to shrink fibroids
63
cycle timeline
days 0-14 cycle: estrogen predominant (proliferative) | 14-28: progesterone (decrease proliferation)
64
dysfunctional uterine bleeding tx
OCPs = IUD NSAIDs sx: ablation, TAH
65
PCOS
anovulation (estrogen predominant), atretic follicles (produces testosterone) dx: hx of anovulation and 1 of 2: biochemical evidence of androgenism (^DHEAS, ^testosterone, LH:FSH >3:1) or imaging evidence of atretic follicles
66
PCOS tx
metformin (helps push into ovulation) OCPs = IUDs clomiphene if wants to ovulation spironolactone to reduce androgenism
67
puberty timeline
breast - 8 axillary - 9 growth - 10 (before menarche) menarche - 11 (estrogen levels spike, growth spurt ends)
68
precocious puberty work up (secondary sexual characteristics less than 8 yo)
determine bone age (wrist XR): if 2 yrs greater than chronologic age, determine where stimulation is coming from: GnRH stim test, if + (^LH) get MRI, if + for tumor, resect, if -: constitutional, give leuprolide continuously if - GnRH stim test: peripheral: U/S of abdomen, ovaries, and adrenals, get DHEAS, testosterone, 17-OHP if CAH: give steroids if tumor: resect if cyst: reassurance
69
delayed puberty (no secondary sex characteristics by 13, no bleeding by 15)
determine bone age (wrist XR) and get FSH, LH if both ^: hypergonadotropic hypogonadism (axis on, ovaries not responding), do karyotype if levels not elevated: hypogonadotropic: PRL, TSH, FT4, UCG, CBC, LFT, ESR, MRI if all negative: constitutional delay: just wait (no GH), check fam hx of delay
70
conditions that cause primary amenorrhea due to a deranged axis but anatomy is intact ?
Kallmann's syndrome (hypothalamus, lose pulsatile GnRH + anosmia) Craniopharyngioma (ant pit, no FSH/LH produced)-resect Turner's (ovaries, X,O, ^FSH, LH) tx: give E+P to all
71
Mullerian agenesis
no uterus, tubes, upper 1/3 vagina X,X : has ovaries, secondary sex characteristics, has female external genitalia, normal hormone levels tx: elevate vagina
72
androgen insensitivity syndrome
X,Y, testosterone is converted to estrogen: has secondary sex characteristics, external female genitalia (default, and no response to testosterone to develop penis/scrotum), no uterus/tubes (due to MIF) dx: X,Y, ^testosterone, normal LH, FSH, testes on U/S tx: elevate vagina, do orchiectomy after puberty
73
Turner's
streak ovaries (X,O) or (X,X) coarctation, bicuspid aortic valve has uterus and external genitalia, will NOT develop secondary sex characteristics, will have external genitalia, uterus ^^^FSH, LH (unresponsive ovaries, disinhibited axis) tx: give E+P, f/u ECHO
74
secondary amenorrhea causes
pregnancy, hypothyroidism, prolactinemia/prolactinoma (inhibit GnRH), medications, then consider HPO axis
75
how hypothyroid causes amenorrhea
disinhibits TRH which causes ^prolactin
76
how physiologic stress (intense exercise, anorexia) causes secondary amenorrhea
affects hypothalamic axis
77
secondary amenorrhea at the ovary
``` savage syndrome (ovarian resistance), POF, menopause tx: HRT ```
78
Asherman's
endometrial scarring (procedures)
79
secondary amenorrhea
no periods in 3 months
80
if bleeds with progesterone challenge, probably ? | if doesn't bleed?
PCOS (no ovulation so no progesterone) if no bleed: give E+P, if still doesn't bleed its an endometrial problem (i.e. Asherman's) if bleeds with E+P, signal problem
81
tx for anovulation
clomiphene, pergonal
82
if infertile but ovulating normally, what to get next
hysterosalpingogram looking for anatomical defects: PID, fibroids, mullerian problems
83
if infertile but ovulation and anatomy if fine, what to do next?
suspect endometriosis get diagnostic laparoscopy | tx: laser ablation, OCPs, estrogen
84
DHEAS vs testosterone
testosterone from ovaries (U/S) DHEAS from adrenal (CT/MRI) if ^^^ and unilateral: cancer if ^ and systemic: not cancer
85
PCOS presentation
hirsutism, ^testosterone, NORMAL DHEAS, b/l ovaries
86
Sertoli-Leydig presentation
virulization, ^^^testosterone, NORMAL DHEAS, tumor in u/l ovary on u/s, tx with resection
87
adrenal tumor presentation
^^^DHEAS, NORMAL TESTOSTERONE, virilization, u/l adrenal tumor on CT/MRI, dx: adrenal vein sampling (to pick which side to resect)
88
CAH
^DHEAS, NORMAL TESTOSTERONE, hirsutism (may present with virilization), b/l adrenal hyperplasia on CT/MRI, 17-OHP in urine, tx: cortisol and fludricortisone (aldo)
89
labs/imaging in menopause
don't do but will see decreased estrogen, ^^FSH, lack of follicles on imaging
90
premature ovarian failure
s/s of menopause before age 40
91
menopause tx
``` venlafaxine (effexor- SSRI) for hot flashes estrogen creams for vaginal atrophy questionable efficacy: phytoestrogens (soy) for hot flashes HRT: ^risk breast cancer ```
92
osteoporosis
``` dexa scan at 65 (60 if smoker) if osteoporosis: tx with bisphosphonates ppx: vitamin D and Ca2+ if vit D deficiency 50,000 units/wk encourage exercise ```

OBGYN Step 2 (5 decks)

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