GYN Meded Flashcards
ovarian cancer types
germ cell
stromal
endothelial
cervical, vaginal, and vulvar cancers are likely to be ? caused by ?
precancer lesion?
how do they present?
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
endometrial cancer etiology, pre-cancer lesion, cancer type and how it presents
estrogen exposure dysplasia or atypia adenocarcinoma post-menopausal bleeding (no screening)
epithelial ovarian cancer
etiology?
how it presents?
ovulation: trauma to epithelial layer
no screen
ascites, renal failure, SBO
presents at advanced stage late in life
choriocarcinoma
etiology?
gestational trophoblastic disease
measure B-hCG (while on OCPs)
hyperemesis gravidarum, hyperthyroid, size-date discrepancies
presentation of cervical cancer
bimodal:
30s: post-coital bleeding
60s: post-menopausal bleed
HPV strains that cause cancer
16, 18, some in 30s
6, 11 cause warts
HPV progression to cancer
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)
cervical cancer staging
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
what to look for on colposcopy to suggest cervical dysplasia
what to do next
abnormal vessles, punctate hemorrhages, acetowhite changes, mosaicism
local ablative therapy: LEEP or cryotherapy
if endocervical: cone biopsy
when to get pap smear
begin at 21 yo q3yrs
q1 yrs if HIV+
q5 yrs if over 30 if HPV testing + pap smear
stop at 65 yo
pap smear results
- 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)
cervical cancer tx based on stage
IIA or better: local ablation/resection
IIB or worse: debulking, chemo/radiation (platinum-based)
Gardasil vaccine ages
F 11-26
M 11-21
endometrial cancer is due to
estrogen exposure
(adenocarcinoma)
cycles: progesterone (produced around ovulation) PROtects agains estrogen exposure
seen as dysmenorrhea or post menopausal bleeding
NO screen
endometrial cancer progression
estrogen exposure
then hyperplasia (cystic-adenomatous-atypical)
then adenocarcinoma
^estrogen exposure with
age, anovulation (PCOS), nulliparity, obesity, prolonged mentruation in life, HRT, tamoxifen, granulosa or theca tumor
how to tx endometrial cancer
TAH/BSO
+/- radiation and chemo
if see post menopausal bleeding, what to do next
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
Ovarian germ cell tumors
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
Ovarian epithelial cell tumors (cystadenomcarcinoma)
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
special tx for BRCA 1/2 in regards to ovarian cancer
screen annually with TVUS and CA-125
ppx TAH/BSO at 35 if done having kids
Ovarian stromal cell tumors
Granulosa-Theca: estrogen
Sertoli-Leydig: testosterone
what to do if find adnexal mass on exam
TVUS:
smooth, small cyst without septations: simple cyst
large, not smooth + septations and loculated fluid: complex cyst: biopsy
if young girl with asymptomatic mass
germ cell tumor
u/l SO
if older F with asymptomatic mass or RF, SBO, ascites
epithelial
TAH/BSO +/- paclitaxel
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
egg + 2 sperm sets: 69 chromosomes
INCOMPLETE mole: good egg, bad fertilization
same presentation, dx, tx as complete mole
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)
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)
vaginal cancer
SqCC: HPV exposure
Clear cell adenocarcinoma: “grape like mass” IN THE VAGINA: DES exposure in utero
PPH tx
- uterine massage
- meds: oxytocin, methergine, hemabate
- balloon tamponade
- sx: uterine artery ligation/embolization, then internal iliac artery ligation, TAH
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
uterine inversion grades
I: into vagina, not to opening
II: at opening
III: outside vagina
IV: full inversion
cysts based on ages
premenopausal: ovarian germ cell tumor
reproductive: physiologic vs complex
postmenopausal: ovarian epithelial cancer
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
complex cysts
teratoma endometrioma ectopic torsion TOA cancer
teratoma
bening, in young female may present with weight gain, fullness
dx: US, enormous
tx: cystectomy (likely to recur) preserve fertility
endometrioma
path: retrograde menses
estrogen-responsive, recurs with cycles
presents: dysmenorrhea, dyspareunia, infertility
“chocolate cyst”
dx: U/S, dx laparoscopy with laser ablation
endometriosis tx
- NSAIDs
- OCP trial (poss. GnRH (lupron), or danazol)
- laparoscopy with laser ablation if endometrioma (if only endometriosis just OCP trial
ectopic dx/tx
dx: B-hCG, if greater than 1500/2000 then get U/S (should see pregnancy)
tx: sapingostomy, salpingectomy (if rupture)
MTX
can use MTX + leucovorin for ectopic pregnancy
B-hCG less than 5000
gestational size less than 3cm
no FHTs
most fertility-sparing
ovarian torsion involves what ligament
suspensory ligament of the ovary, contains ovarian artery/vein
ovarian torsion
presents: sudden abdominal pain
dx: U/S with doppler to see cyst and decreased flow
tx: detorsion, remove if necrosed
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
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
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)
OAB (hypertonic)
random spasms of detrusor muscle
URGE, NOCTURNAL, will leak
dx: cystometry: random spikes representing spasms
tx: antispasmodics, oxybutinin
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
irritative bladder
stones, cancer, UTI frequency, urgency, dysuria \+URGE, NO NOCTURNAL dx: U/A tx: underlying condition
risk for fistulas
surgery, cancer, IBD constant leak, still normal function dx: physical exam "tampon test" using blue dye in bladder tx: fistulotomy
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)
PID orgs?
dx?
1/3 of each: Gc, Chlamydia, vaginal flora
tx: clinical, TVUS, TOA (free fluid)
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
life-threatening uterine bleed treatment
- 2 large bore IVs
- IVF boluses
- T/C, transfuse prn
- IV estrogen (shuts off acute uterine bleeding)
- surgical intervention
life-threatening uterine bleed surgical interventions
intracavitary tamponade
D/C
uterine artery embolization
TAH
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)
medical/sx management of abortion
misoprostol (1st trimester)
oxytocin (induce delivery of dead baby)
D/C
don’t forget to give Rh- moms RhoGAM
criteria for MTX (+leucovorin) in ectopic
B-hCG less than 5000
size less than 3.5 cm
no FHTs
mom not on folate
PALM (structural)
COEIN (nonstructural)
causes of abnormal uterine bleeding
polyps
adenomyosis
leiomyomas
malignancy
coagulopathy ovarian dysfunction endometrial probs iatrogenic (IUD) not yet classified
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)
fibroid treatment
tx: OCPs, NSAIDS
sx: myomectomy (fertility sparing less successful), TAH, may do leuprolide first to shrink fibroids
cycle timeline
days 0-14 cycle: estrogen predominant (proliferative)
14-28: progesterone (decrease proliferation)
dysfunctional uterine bleeding tx
OCPs = IUD
NSAIDs
sx: ablation, TAH
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
PCOS tx
metformin (helps push into ovulation)
OCPs = IUDs
clomiphene if wants to ovulation
spironolactone to reduce androgenism
puberty timeline
breast - 8
axillary - 9
growth - 10 (before menarche)
menarche - 11 (estrogen levels spike, growth spurt ends)
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
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
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
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
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
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
secondary amenorrhea causes
pregnancy, hypothyroidism, prolactinemia/prolactinoma (inhibit GnRH), medications, then consider HPO axis
how hypothyroid causes amenorrhea
disinhibits TRH which causes ^prolactin
how physiologic stress (intense exercise, anorexia) causes secondary amenorrhea
affects hypothalamic axis
secondary amenorrhea at the ovary
savage syndrome (ovarian resistance), POF, menopause tx: HRT
Asherman’s
endometrial scarring (procedures)
secondary amenorrhea
no periods in 3 months
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
tx for anovulation
clomiphene, pergonal
if infertile but ovulating normally, what to get next
hysterosalpingogram looking for anatomical defects: PID, fibroids, mullerian problems
if infertile but ovulation and anatomy if fine, what to do next?
suspect endometriosis get diagnostic laparoscopy
tx: laser ablation, OCPs, estrogen
DHEAS vs testosterone
testosterone from ovaries (U/S)
DHEAS from adrenal (CT/MRI)
if ^^^ and unilateral: cancer
if ^ and systemic: not cancer
PCOS presentation
hirsutism, ^testosterone, NORMAL DHEAS, b/l ovaries
Sertoli-Leydig presentation
virulization, ^^^testosterone, NORMAL DHEAS, tumor in u/l ovary on u/s, tx with resection
adrenal tumor presentation
^^^DHEAS, NORMAL TESTOSTERONE, virilization, u/l adrenal tumor on CT/MRI, dx: adrenal vein sampling (to pick which side to resect)
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)
labs/imaging in menopause
don’t do but will see decreased estrogen, ^^FSH, lack of follicles on imaging
premature ovarian failure
s/s of menopause before age 40
menopause tx
venlafaxine (effexor- SSRI) for hot flashes estrogen creams for vaginal atrophy questionable efficacy: phytoestrogens (soy) for hot flashes HRT: ^risk breast cancer
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
