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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
Q

if young girl with asymptomatic mass

A

germ cell tumor

u/l SO

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26
Q

if older F with asymptomatic mass or RF, SBO, ascites

A

epithelial

TAH/BSO +/- paclitaxel

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27
Q

no egg genetics but two sperm sets with 46 chromosomes

A

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

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28
Q

egg + 2 sperm sets: 69 chromosomes

A

INCOMPLETE mole: good egg, bad fertilization

same presentation, dx, tx as complete mole

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29
Q

choriocarcinoma

A

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)

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30
Q

vulvar cancer types

A

SqCC and melanoma: black and itchy
dx: biopsy
tx: vulvectomy and LN dissection
Paget’s: red lesion + itchy, wide local resection (better px)

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31
Q

vaginal cancer

A

SqCC: HPV exposure

Clear cell adenocarcinoma: “grape like mass” IN THE VAGINA: DES exposure in utero

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32
Q

PPH tx

A
  1. uterine massage
  2. meds: oxytocin, methergine, hemabate
  3. balloon tamponade
  4. sx: uterine artery ligation/embolization, then internal iliac artery ligation, TAH
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33
Q

uterine ligaments

A

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

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34
Q

uterine inversion grades

A

I: into vagina, not to opening
II: at opening
III: outside vagina
IV: full inversion

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35
Q

cysts based on ages

A

premenopausal: ovarian germ cell tumor
reproductive: physiologic vs complex
postmenopausal: ovarian epithelial cancer

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36
Q

working up ovarian cyst in reproductive age female

A

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

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37
Q

complex cysts

A 
teratoma
endometrioma
ectopic
torsion
TOA
cancer
38
Q

teratoma

A

bening, in young female may present with weight gain, fullness

dx: US, enormous
tx: cystectomy (likely to recur) preserve fertility

39
Q

endometrioma

A

path: retrograde menses
estrogen-responsive, recurs with cycles
presents: dysmenorrhea, dyspareunia, infertility
“chocolate cyst”
dx: U/S, dx laparoscopy with laser ablation

40
Q

endometriosis tx

A
  1. NSAIDs
  2. OCP trial (poss. GnRH (lupron), or danazol)
  3. laparoscopy with laser ablation if endometrioma (if only endometriosis just OCP trial
41
Q

ectopic dx/tx

A

dx: B-hCG, if greater than 1500/2000 then get U/S (should see pregnancy)
tx: sapingostomy, salpingectomy (if rupture)
MTX

42
Q

can use MTX + leucovorin for ectopic pregnancy

A

B-hCG less than 5000
gestational size less than 3cm
no FHTs
most fertility-sparing

43
Q

ovarian torsion involves what ligament

A

suspensory ligament of the ovary, contains ovarian artery/vein

44
Q

ovarian torsion

A

presents: sudden abdominal pain
dx: U/S with doppler to see cyst and decreased flow
tx: detorsion, remove if necrosed

45
Q

tubo-ovarian abscess is essential the same as

A

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
Q

if TOA is treated like PID and does not improve

A 
get u/s, will see abscess
needs inpatient IV abs: 
cefoxitin + doxy + metro
OR clindamycin and gentamicin
if no improvement, drain
47
Q

incontinence unique to women

A

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
Q

OAB (hypertonic)

A

random spasms of detrusor muscle
URGE, NOCTURNAL, will leak
dx: cystometry: random spikes representing spasms
tx: antispasmodics, oxybutinin

49
Q

overflow/neurogenic bladder (hypotonic)

A

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
Q

irritative bladder

A 
stones, cancer, UTI
frequency, urgency, dysuria
\+URGE, NO NOCTURNAL
dx: U/A
tx: underlying condition
51
Q

risk for fistulas

A 
surgery, cancer, IBD
constant leak, still normal function
dx: physical exam
"tampon test" using blue dye in bladder
tx: fistulotomy
52
Q

cervicitis organisms

dx, tx

A

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
Q

PID orgs?

dx?

A

1/3 of each: Gc, Chlamydia, vaginal flora

tx: clinical, TVUS, TOA (free fluid)

54
Q

PID tx

A

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
Q

life-threatening uterine bleed treatment

A
  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
Q

life-threatening uterine bleed surgical interventions

A

intracavitary tamponade
D/C
uterine artery embolization
TAH

57
Q

intrauterine pregnancy to abortion

A

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
Q

medical/sx management of abortion

A

misoprostol (1st trimester)
oxytocin (induce delivery of dead baby)
D/C
don’t forget to give Rh- moms RhoGAM

59
Q

criteria for MTX (+leucovorin) in ectopic

A

B-hCG less than 5000
size less than 3.5 cm
no FHTs
mom not on folate

60
Q

PALM (structural)
COEIN (nonstructural)
causes of abnormal uterine bleeding

A

polyps
adenomyosis
leiomyomas
malignancy

coagulopathy
ovarian dysfunction
endometrial probs
iatrogenic (IUD)
not yet classified
61
Q

fibroids

A

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
Q

fibroid treatment

A

tx: OCPs, NSAIDS
sx: myomectomy (fertility sparing less successful), TAH, may do leuprolide first to shrink fibroids

63
Q

cycle timeline

A

days 0-14 cycle: estrogen predominant (proliferative)

14-28: progesterone (decrease proliferation)

64
Q

dysfunctional uterine bleeding tx

A

OCPs = IUD
NSAIDs
sx: ablation, TAH

65
Q

PCOS

A

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
Q

PCOS tx

A

metformin (helps push into ovulation)
OCPs = IUDs
clomiphene if wants to ovulation
spironolactone to reduce androgenism

67
Q

puberty timeline

A

breast - 8
axillary - 9
growth - 10 (before menarche)
menarche - 11 (estrogen levels spike, growth spurt ends)

68
Q

precocious puberty work up (secondary sexual characteristics less than 8 yo)

A

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
Q

delayed puberty (no secondary sex characteristics by 13, no bleeding by 15)

A

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
Q

conditions that cause primary amenorrhea due to a deranged axis but anatomy is intact ?

A

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
Q

Mullerian agenesis

A

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
Q

androgen insensitivity syndrome

A

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
Q

Turner’s

A

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
Q

secondary amenorrhea causes

A

pregnancy, hypothyroidism, prolactinemia/prolactinoma (inhibit GnRH), medications, then consider HPO axis

75
Q

how hypothyroid causes amenorrhea

A

disinhibits TRH which causes ^prolactin

76
Q

how physiologic stress (intense exercise, anorexia) causes secondary amenorrhea

A

affects hypothalamic axis

77
Q

secondary amenorrhea at the ovary

A 
savage syndrome (ovarian resistance), POF, menopause
tx: HRT
78
Q

Asherman’s

A

endometrial scarring (procedures)

79
Q

secondary amenorrhea

A

no periods in 3 months

80
Q

if bleeds with progesterone challenge, probably ?

if doesn’t bleed?

A

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
Q

tx for anovulation

A

clomiphene, pergonal

82
Q

if infertile but ovulating normally, what to get next

A

hysterosalpingogram looking for anatomical defects: PID, fibroids, mullerian problems

83
Q

if infertile but ovulation and anatomy if fine, what to do next?

A

suspect endometriosis get diagnostic laparoscopy

tx: laser ablation, OCPs, estrogen

84
Q

DHEAS vs testosterone

A

testosterone from ovaries (U/S)
DHEAS from adrenal (CT/MRI)
if ^^^ and unilateral: cancer
if ^ and systemic: not cancer

85
Q

PCOS presentation

A

hirsutism, ^testosterone, NORMAL DHEAS, b/l ovaries

86
Q

Sertoli-Leydig presentation

A

virulization, ^^^testosterone, NORMAL DHEAS, tumor in u/l ovary on u/s, tx with resection

87
Q

adrenal tumor presentation

A

^^^DHEAS, NORMAL TESTOSTERONE, virilization, u/l adrenal tumor on CT/MRI, dx: adrenal vein sampling (to pick which side to resect)

88
Q

CAH

A

^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
Q

labs/imaging in menopause

A

don’t do but will see decreased estrogen, ^^FSH, lack of follicles on imaging

90
Q

premature ovarian failure

A

s/s of menopause before age 40

91
Q

menopause tx

A 
venlafaxine (effexor- SSRI) for hot flashes
estrogen creams for vaginal atrophy
questionable efficacy:
phytoestrogens (soy) for hot flashes
HRT: ^risk breast cancer
92
Q

osteoporosis

A 
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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