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LMCC > Gyne > Flashcards

Gyne Flashcards

1
Q

Treatment for menorrhagia

A

NSAIDs
TXA
cOCP
IUD progesterone
Progestins on first 10-14d of each month or every 3mo if ovulatory dysfunction
Danazol (androgen)
Surgical: ablation, uterine artery embolization, hysterectomy

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2
Q

Indications for endometrial biopsy

A
  • > 40y
  • Any risk factors for endometrial CA: age, obesity, nulliparity, PCOS, diabetes, hereditary nonpolypopsis colorectal CA)
  • Failure of medical tx
  • Significant intermenstrual bleeding
  • Hx of anovulatory cycles
  • Postmenopausal woman with ET >4mm on U/S
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3
Q

Uterine ligaments

A 
Round ligaments 
Uterosacral ligaments 
Cardinal ligaments
Broad ligaments
Infundibulopelvic ligament
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4
Q

Round ligaments

A

Travel from anterior surface of uterus, through broad ligaments and inguinal canals then termiante in labia majora

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5
Q

Uterosacral ligaments

A

Arise from sacral fascia and insert into posterior inferior uterus
Supports uterus, prevents prolapse and contains autonomic nerve fibres

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6
Q

Cardinal ligaments

A

Extend from lateral pelvic walls and insert into lateral cervix and vagina
Mechanical support and prevents prolapse

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7
Q

Broad ligaments

A

Pass from lateral pelvic wall to sides of uterus

Contain fallopian tube, round ligament, ovarian ligament, nerves, vessels and lymphatics

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8
Q

Infundibulopelvic ligament

A

AKA suspensory ligament of ovary
Connects ovary to pelvic wall
Contains ovarian artery, ovarian vein, ovarian plexu s and lymphatic vessels

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9
Q

Stages of puberty

A

Boobs (thelarche)
Pubes (pubarche)
Grow
Flow (menarche)

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10
Q

Adrenarche

A

Increased secretion of adrenal androgens

usually precedes gonadarche by 2 yr

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11
Q

Gonadarche

A

Increased secretion of gonadal sex steroids

Typically around age 8

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12
Q

Premenstrual syndrome dx

A

At least one affective and one somatic symptom during the 5d before menses in each of the three prior menstrual cycles
Affective: depression, angry outbursts, irritability, anxiety, confusion, social withdrawal
Somatic: Breast tenderness, abdo bloating, headache, swelling of extremities
Symptoms relieved within 4d of onset of menses

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13
Q

Premenstrual syndrome tx

A
  • 1st line
    • Exercise
    • CBT
    • Vitamin B6
    • Combined hormonal contraception
    • Continuous or luteal phase (day 15-28) low dose SSRIs
      • Citalopram/Escitalopram 10mg
  • 2nd line
    • Estradiol patches 100ug + micronized progesterone 100mg or 200mg on days 17-28 orally or vaginally
    • LNG-IUS 52mg
    • Higher dose SSRIs continuously or in luteal phase
      • Citalopram/Escitalopram 20-40mg
  • 3rd line
    • GnRH analogues + add back HRT
  • 4th line
    • Surgical treatment +/- HRT
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14
Q

Premenstrual dysphoric disorder

A
  • At least 5 of the following during most menstrual cycles of the last year (with at least 1 of the first 4)
    • Depressed mood or hopelessness
    • Anxiety or tension
    • Affective symptoms
    • Anger or irritability
    • Decreased interest in activities
    • Difficulty concentrating
    • Lethargy
    • Change in appetite
    • Hypersomnia or insomnia
    • Feeling overwhelmed
    • Physical symptoms: breast tenderness/swelling, headaches, joint/muscle pain, bloating or weight gain
  • Symptoms affect function
  • Must be discretely related to menstrual cycle
  • Must be confirmed during at least 2 consecutive symptomatic menstrual cycles
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15
Q

Early follicular/proliferative phase

A 
Decreasing E and P 
Increased GnRH pulse frequency 
Increased FSH --> follicular growth in ovaries 
Increased LH pulse frequency 
Menses from P withdrawal
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16
Q

Mid follicular/proliferative phase

A

Increased FSH acts on ovarian granulosa cells
Increased E released from follicles
-ve feedback from E –> decreased FSH and LH
Cervical mucus clear, increasing amount, more stringy

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17
Q

Late follicular/proliferative phase

A 
Growing follicles cont to secrete E 
Increasing E from follicles, esp from dominant follicle 
Dominant follicle persists 
Remainder undergo atresia 
Granulosa cells luteinize --> produce P 
E builds up endometrium
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18
Q

Estrogen in menstrual cycle

A

Main hormone in follicular/proliferative phase
Stimulated by FSH
As level increases it acts -vely on FSH
Majority is secreted by dominant follicle
E acts on:
Follicles in ovaries to reduce atresia
Endometrium to induce proliferation
On all target tissues (decreased E receptors)

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19
Q

Progesterone in menstrual cycle

A

Main hormone in luteal/secretory phase
Stimulated by LH
Increased progesterone acts -vely on LH and is
Secreted by corpus luteum (remnant of dominant follicle)
P acts on:
Endometrium to stop build up, organize glands, prevent degradation
On all target tissues to decrease E and P receptors

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20
Q

Luteal/secretory phase

A

Fixed 14 days
Ovulation
Early-mid
Late

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21
Q

Ovulation of luteal/secretory phase

A

Sudden switch from -ve to +ve feedback (E and P cause increased FSH and LH)
E peaks –> LH surge –> ovulation
36h after LH surge, dominant follicle releases oocyte
Corpus luteum forms from dominant follicle remnant nad produces P

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22
Q

Early-mid luteal/secretory phase

A

Switch back to -ve feedback
Increased P from corpus luteum –> decreases LH and FSH
P stabilizes endomtrium

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23
Q

Late luteal/secretory phase

A

No fertilized oocyte
Decreased P secondary to CL degeneeration –> menses
Cervical mucus: opaque, scant amount

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24
Q

Beta-hCG level at which TVUS can detect pregnancy

A

> /= 1500

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25
Q

Beta-hCG level at which transabdominal U/S can detect pregnancy

A

> /= 6500

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26
Q

Subtotal hysterectomy

A

Uterus removed only

For severe endometriosis, pt choice

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27
Q

Total hysterectomy

A

Uterus, cervix removed and uterine artery ligated

For Uterine fibroids, endometriosis, adenomyosis, heavy menstrual bleeding

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28
Q

Total hysterectomy + bilateral salpino-oophorectomy

A

Uterus, cervix, uterine artery ligated at uterus, fallopian tubes, ovaries
For endometrial CA, malignant adnexal masses, consider for endometriosis

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29
Q

Modified radical hysterectomy

A

Uterus, cervical, proximal 1/3 parametria, uterine artery ligated medial to ureter, midpoint of uterosacral ligaments and upper 1-2cm vagina
For cervical cancer

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30
Q

Radical hysterectomy

A

Uterus, cervix, entire paramtrium, uterine artery ligated at origin from internal iliac artery, uterosacral ligament at most distal attachment, upper 1/3-1/2 vagina
For cervical cancer

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31
Q

Most common causes of primary amenorrhea

A

Mullerian agenesis
Abnormal sex chromosomes (Turner’s syndrome)
Functional hypothalamic amenorrhea

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32
Q

Most common cause of secondary amenorrhea

A

Functional hypothalamic amenorrhea

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33
Q

Primary amenorrhea

A

No menses by 13 with no secondary sex characteristics

No menses by 15 with secondary sex characteristics

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34
Q

Secondary amenorrhea

A

Hx of menses with no menses for at least 3 mo who have previously had regular cycles or 6mo if irregular cycles

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35
Q

Primary amenorrhea without secondary sex characteristics

A

FSH/LH levels –> if high then hypergonadotropic hypogonadism = gonadal agenesis
If low –> hypogonadotropic hypogonadism = constitutional delay or HPA abnormality (ie. structural CNS problem or anorexia, exercise, stress)

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36
Q

Primary amenorrhea with secondary sex characteristics

A

Karyotype
XX = imperforate hymen, transverse vaginal septum, cervical agenesis, mullerian agenesis
XY = Androgen insensitivity syndrome

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37
Q

First steps of secondary amenorrhea pathway

A

b-hCG
If +ve: pregnant
If -ve: prolactin

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38
Q

Hyperprolactinemia and secondary amenorrhea

A

CT head if >100ng/dL

TSH to screen for hypothryoidism

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39
Q

Normal prolactin and secondary amenorrhea

A

Progestin challenge
If no withdrawal bleed –> primary ovarian insufficiency, uterine defect, ashermans syndrome or HPA dysfunction
If withdrawal bleed –> FSH and LH –> if high = PCOS, if normal/low = HPA dysfunction –> MRI hypothalamus, pituitary, measure other pituitary hormones (weight loss, excessive exercise, systemic dz)

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40
Q

Prolactinoma symptoms

A

Galactorrhea
Visual changes
Headache

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41
Q

Progesterone challenge to assess estrogen status

A 
Medroxyprogesterone acetate (Provera) 10mg PO OD for 10-14d 
Any uterine bleed within 2-7d after completion of Provera = +ve test/withdrawal bleed --> suggests presence of adequate estrogen to thicken endometrium 
If no bleeding occurs, may be secondary to inadeqaute estrogen, excessive androgens or progesterones or pregnancy
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42
Q

Classic hormonal workup

A 
beta hCG
TSH
Prolactin
FSH
LH
Androgens
Estradiol
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43
Q

Androgen insensitivity syndrome tx

A

Gonadal resection after puberty
Psych counselling
Creation of neovagina with dilatation

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44
Q

Mullerian dysgenesis syndrome tx

A

Counselling
Creation of neovagina with dilation
Dx study to confirm normal urinary system and spine

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45
Q

Asherman’s syndrome

A

Formation of scar tissue in uterine cavity, often after several D&Cs or severe pelvic infection
Tx: Hysteroscopy, excision of synechiae
Prevent recurrence via balloon catheter or adhesion barrier (ie. hyaluronic acid) via foley catheter for 2 wk post op

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46
Q

Premature ovarian failure tx

A

Hormonal therapy with E+P (can use OCP) to decrease risk of osteoporosis
Screen for DM, hypothyroidism, hypoparathyroidism, hypocorticolism
No tx to restore ovulation

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47
Q

Hyperprolactinemia tx

A

MRI/CT head to R/O lesion
If no lesions, bromocriptine/carbergoline if fertiltiy desired
OCP if no fertility desired

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48
Q

Ovulatory dysfunction workup

A 
beta-hCG
Ferritin
Prolactin
FSH
LH
Serum androgens (free T, DHEA)
progesterone
17-hydroxy progesterone
TSH
fT4
Pelvic U/S
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49
Q

Acute, severe AUB tx

A

Estrogen IV + gravol or antifibrinolytic (rarely used)

Tapering OCP regimen (more commonly used)

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50
Q

AUB Ddx

A 
PALMCOEIN 
Polyp
Adenomyosis 
Leiomyosis 
Malignancy
Coagulopathy 
Ovulatory dysfunction
Endometrial 
Iatrogenic
Not yet classified
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51
Q

Tx for primary dysmenorrhea

A

NSAIDs before onset of pain

OCP to suppress ovulation and reduce menstrual flow

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52
Q

Triad of endometriosis

A

Dysmenorrhea
Dyspareunia
Dyschezia

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53
Q

Laprascopic findings of endometriossis

A

Mulberry spots - dark blue/brown implants anywhere in pelvis
Endometrioma - cholocate cysts on ovaries (endometriotic cyst encompassing ovary)

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54
Q

CA-125 and endometriosis

A

May be elevated but should NOT be used in diagnostic testing

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55
Q

Endometriosis dx

A

Definitive: visualization of lesions on laparoscopy and bx/histology of specimens
If hx is suggestion even with -ve exam, should be considered adequate dx

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56
Q

Endometriosis tx

A

1st line:
OCP, progesterone or mirena IUD
2nd line:
GnRH agonist (ie. Lupron) to suppress pituitary
Danazol (weak androgen)
surgical:
Conservative lap*, electrocautery, hysterectomy/BSO
*best time to become pregnant is right after conservative sx

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57
Q

Adenomyosis

A

Extension of areas of endometrial glands and stroma into myometrium
presents ~40-50yo
Uterus symmetrically bulk, usually <14cm
Tx: NSAIDs, OCP, Depo-Provera, GnRH agonist, Mirena, danazol

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58
Q

Fibroid tx

A 
Only tx if symptomatic 
Antiprostaglandins (NSAIDs) 
GnRH agonist (Lupron) 
Ulipristal acetate* (selective progeterone receptor agonist; 5mg daily x 3mo, controls bleeding and shrinks fibroids)
*check LFTs regularly 
Uterine artery embolization
Myomectomy 
Hysteroscopy resection and endometrial ablation 
Hysterectomy
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59
Q

Yuzpe Method

A

EPC
Use within 72h of unprotected intercourse
Ethinyl estradiol + levonorgestrel (OCP high dose)
2 tabs then repeat in 12h

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60
Q

Plan B

A

EPC
Levonorgestrel q12h for 2 doses
Within 72h of intercourse up to 5d
1st line if >24h

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61
Q

Ulipristal

A

EPC
30mg PO within 5d
Selective progesterone receptor modulator (SPERM) , with primarily anti-progestin activity
May delay ovulation by up to 5d

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62
Q

Postcoital IUD

A

EPC
Copper only
Insert up to 7d postcoitus
Prevents implantation

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63
Q

Gold standard for medically induced abortion up to 9wks

A

Mifepristone + misoprostol

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64
Q

Mifepristone

A

Blocks progesterone receptor

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65
Q

Misoprostol

A

Induces uterine contractions

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66
Q

Other options for medically induced abortions

A

Misoprostol only
Methotrexate and misoprostol
Lower success rates than miso + mifepristone

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67
Q

Options for surgically induced abortions at <14wks

A

Manual vacuum aspiration (up to 8-9wks)

Suction dilatation + aspiration +/- curettage

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68
Q

Options for surgically induced abortions at 14-24wks

A

Dilatation and evacuation

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69
Q

Recurrent spontaneous abortions

A

> /=3 consecutive

Evaluate mechanical, genetic, environmental and other risk factors

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70
Q

Leading cause of maternal death in first trimester

A

Ectopic pregnancy

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71
Q

3 commonest locations for ectopic pregnancy

A
  1. Ampullary
  2. Isthmic
  3. Fimbrial
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72
Q

Risk factors for ectopic pregnancy

A 
Previous ectopics 
Current IUD use 
Hx of PID (esp with C. trachomatis infxn) 
Salpingitis 
Infertility (IVF pregnancies following ovulation induction)
Prev procedures 
Smoking
Structural anomalies
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73
Q

Normal doubling time with intrauterine pregnancy

A

1.6-2.4d

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74
Q

Surgical tx for ectopic pregnancy

A

Linear salpingostomy
Salpingectomy if tube damaged or recurrent ectopic
Must monitor bhCG titres weekly until they reach non-detectable levels
Consider Rhogam if Rh -ve

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75
Q

Medical tx for ectopic pregnancy

A

Methotrexate
Follow bhCG levels weekly until bhCG is nondetectable
Give 2nd dose if bhCG doesn’t decrease by at least 15% btwn days 4 and 7

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76
Q

C/I to MTX therapy

A 
Abnormalities in hematologic, hepatic or renal function
Immunodeficiency 
Active pulmonary dz 
PUD 
Hypersensitivity to MTX 
Heterotopic pregnancy with coexisting viable IUP 
Breastfeeding 
Unwilling to adhere to MTX protocol
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77
Q

Infertility

A

Inability to conceive or carry to term a pregnancy after one year of regular unprotected intercourse

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78
Q

Hypothalamic amenorrhea

A

Often from stress, poor nutrition, excessive exercise, hx of eating disorders

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79
Q

Ovulatory investigations for infertility

A

Day 3 LH, FSH, TSH, prolactin +/- DHEA, free T add estradiol for proper FSH interpretation
Day 21-23 serum progesterone to confirm ovulation
Basal body temperature monitoring

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80
Q

Investigation for tubal and/or peritoneal/uterine factors contributing to infertility

A

HSG (can be therapeutic by opening up fallopian tube)
Sonohysterogram (can be therapeutic although less likely)
Hysteroscopy

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81
Q

Ovulation induction medications

A 
Clomiphene citrate (clomid)  
Letrozole
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82
Q

Clomiphene citrate

A

Estrogen antagonist –> perceived decreased E state –> increases GnRH –> increased FSH and LH –> induces ovulation –> bhCG for stimulation of ovum release

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83
Q

Letrozole

A

Aromatase inhibitor

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84
Q

Adult onset CAH tx

A

Dexamethasone for hyperandrogenism

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85
Q

Most common cause of infertility due to male factors

A

Varicocele

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86
Q

PCOS etiology

A

Insulin causes DECREASED FSH and INCREASED LH, which in turn causes:

  • Anovulation –> oligomenorrhea –> infertility
  • Increased ovarian secretion of androgens –> hirsutism, obesity –> increased peripheral conversion to E
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87
Q

PCOS dx

A

Rotterdam criteria: 2 of 3 required

  • oligomenorrhea/irregular menses for 6mo
  • hyperandrogenism
  • U/S evidence of polycystic ovaries (not appropriate in teens)
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88
Q

PCOS clinical features

A 
HAIR-AN 
Hirsutism 
HyperAndrogenism 
Infertility 
Insulin Resistance 
Acanthosis Nigricans
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89
Q

CAH enzyme deficiency

A

21-hydroxylase

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90
Q

Lab findings of PCOS

A

LH:FSH > 2:1
LH chronically high with FSH mid-range or low
Increased DHEA-S, androstenedione and free T, decreased SHBG

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91
Q

Tx for PCOS

A

Cycle control: OCP, metformin if T2DM or trying to get pregnant
Infertility: Clomid, Letrozole, human menopausal gonadotropins, LHRH, recombinant FSH, metformin (alone or in conjunction with clomid), ovarian drilling, bromocriptine if hyperPRL
Hirsutism: any OCP can be used, finasteride (5-alpha reductase inhibitor), flutamide (androgen inhibitor), spiro (androgen inhibitor)

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92
Q

Common infectious causes of prepubertal vulvovaginitis

A

Pinworms
Candida (if using diapers or chronic abx)
GAS, S. aureus, shigella

93
Q

Candidiasis vulvovaginitis

A

Whitish cottage cheese discharge
Pruritus, swollen/inflamed genitals, vulvar burning, dysuria, dyspareunia
pH = 4.5
KOH wetmount reveals hyphae and spores

94
Q

Bacterial vaginosis

A

Caused by Gardnerella vaginalis, mycoplasma hominis, Prevotella, mobiluncus, bacteroides
Grey, thin, diffuse discharge
Fishy odour
pH >= 4.5
>20% clue cells on wet mount (squamous epithelial cells dotted with coccobacilli)

95
Q

Candidiasis vulvovaginitis tx

A

Tx: -azole suppositories and/or creams for 1, 3, or 7d tx
Fluconazole 150mg PO in single dose can be used in pregnancy
Tx for partners not recommended

96
Q

BV tx

A

No tx if non-pregnant and asymptomatic unless scheduled for pelvic sx
Metronidazole 500mg PO BID x 7d
Metronidazole gel 0.75% x 5d OD (may be used in pregnancy)
Clindamycin 2% 5g intravaginally at bedtime for 7d
Probiotics alone or as adjuvant
Tx for partners not recommended
Need to warn pts about Flagyl and EtOH reaction

97
Q

BV associated with

A

Recurrent preterm labour, preterm birth, postpartum endometritis

98
Q

Trichomoniasis

A

Sexual transmission
Yellow-green malodorous, diffuse, frothy discharge
Petechiae on vagina, cervix
Dysuria, frequency
pH >/= 4.5
Motile flagellated organisms on saline wetmount
Many WBCs, inflammatory cells

99
Q

Trichomoniasis tx

A

Tx even if asymptomatic
Metronidazole 2g PO single dose or 500 mg BID x 7d
Symptomatic pregnant women should be treated with 2g metronidazole once
Treat partner(s)

100
Q

STIs that classify for CDC notifiable diseases

A 
Chancroid
Chlamydia
Gonorrhea
Hep A, B, C
HIV 
Syphilis
101
Q

Most common bacterial STI in Canada

A

Chlamydia

102
Q

Chlamydia features

A 
Mostly asymptomatic in women  
Muco-purulent endocervical discharge 
Urinary symptoms 
Pelvic pain
Postcoital or intermenstrual bleeding
103
Q

Chlamydia dx

A

Cervical culture or NAAT

Obligate intracellular parasite (tissue culture is definitive standard)

104
Q

Chlamydia tx

A

Doxycycline 100mg PO BID x 7d OR Azithromycin 1g PO single dose
Doxy is C/I in 2nd and 3rd trimesters
Also tx gonorrhea as often co-infection
Test of cure in pregnancy (retest 3-4wk after initiation of tx)

105
Q

Vaginal swabs for STI testing

A

Test for BV, trichomoniasis, candida

106
Q

Cervical swabs for STI testing

A

Test for Chlamydia and gonorrhea

107
Q

Gonorrhea investigations

A

Gram stain shows gram negative intracellular diplococci

108
Q

Gonorrhea tx

A

Single dose Ceftriaxone 250mg IM plus azithromycin 1g PO
Safe in pregnancy
Also tx chlamydia

109
Q

Most common viral STI in Canada

A

HPV

110
Q

HPV subtypes classically a/w anogenital warts/condylomata acuminata

A

6 and 11

111
Q

HPV subtypes that are the mostoncogenic

A

16 and 18
Classically a/w cervical HSIL
Others include 31, 33, 35,36,45

112
Q

Tx for HPV warts

A

1st line: salicylic acid, cryotherpay, topical cantharone
2nd line: topical imiquimod, topical 5-fluorouracil, topical trtinoin, podophyllotoxin
3rd line: curettage, cautery, surgery

113
Q

Herpes simplex virus of vulva type

A

90% are HSV-2

10% are HSV-1

114
Q

HSV dx

A

Viral culture when ulcer present
Cytologic smear (Tzank smear) - mulnucleated giant cells, acidophilic intranuclear inclusion bodies
HSV DNA PCR

115
Q

HSV tx

A

Acyclovir
Valacyclovir
Famciclovir

116
Q

HSV daily suppressive therapy

A

Consider for >6 recurrences per yr or recurrence q2mo

Acyclovir or valacyclovir

117
Q

Syphilis bacteria

A

Treponema pallidum

118
Q

Primary syphilis

A

3-4wk after exposure
Painless chancre on vulva, vagina or cervix
Painless inguinal lymphadenopathy
Serological tests usually negative, local infection only

119
Q

Secondary syphilis

A

2-6mo after initial infection
Non-specific symptoms
Generalized macuopapular rash (palms, soles, trunks, limbs)
Condylomata lata (anogenital, broad-based fleshy grey lesion)
Serological tests usually +ve

120
Q

Latent syphilis

A

No clinical manifestations
Detected by serology only
Early latent = latent of less than 1 year
Late laetnt = latent of >1yr

121
Q

Tertiary syphilis

A

May involve any organ system
Neuro: tabes dorsalis, general paresis
CV: Aortic aneursym, dilated aortic root

122
Q

Syphilis investigations

A

Aspiration of ulcer serum or node
Darkfield microscopy - look for SPIROCHETES
Non-treponemal screening tests (VDRL, RPR)

123
Q

Syphilis tx

A

Reportable disease
Tx of primary, secondary, latent syphilis <1y duration –> benzathine penicillin G 2.4 million U IM single dose
Tx of latent syphilis of >1y duration –> benzathine penicillin G 2.4 million U IM q1wk x 3 wk
Tx of neurosyphilis –> IV Aqueous penicillin G 3-4 million U IM q4h x10-14d

124
Q

Bartholin gland abscess tx

A

Cephalexin x 1wk
I&D using local anesthesia with placement of Word catheter for 2-3wks
Marsupialization under GA is more definitive tx (don’t do while actively infected)
Rarely treated by removing gland

125
Q

PID causative organisms

A

C. trachomatis
N. gonorrhoeae
Endogenous flora (E. coli, staph, strep, enterococcus, bacteroides, peptostreptococcus, H.influenzae, G. vaginalis)

126
Q

PID dx

A

Must have lower abdo pain
Plus one of cervical motion tenderness or adnexal tenderness
Plus one or more of
-High risk partner
-Temp >38C
-Mucopurulent cervical discharge
- +ve culture for N.gonorrhoeae, C. trahomatis, E. coli or other vag flora
- Cul de sac fluid, pelvic abscess or inflammatory mass on U/S or bimanual
- Leukocytosis
- Elevated ESR or CRP (not commonly used)

127
Q

Inpatient tx for PID

A

Cefoxitin IV + Doxycycline PO/IV OR
Clindamycin IV + Gentamycin IV
Continue for 24h after symptoms improved then doxy PO BID to complete 14d

128
Q

Outpatient tx for PID

A

1st line: Ceftriaxone IM + doxy PO BID x 14d OR cefoxitin IM x 1 + probenecid PO + doxy BID +/- flagyl PO BID x 14d
2nd line: Ofloxacin PO BID x 14d OR levofloxacin x14d +/- flagyl PO BID x 14d
Consider removing IUD after a minimum of 24h tx

129
Q

Toxic shock syndrome

A

Multiple organ system failure due to S. aureus exotoxin

130
Q

Menopause

A

Lack of menses for 1 yr due to loss of ovarian function

131
Q

Primary ovarian insufficiency

A

Menopause before age 40

132
Q

Perimenopause

A

Period of time surrounding menopause (2-8y preceding and 1y after last menses) characterized by fluctuating hormones, irregular cycles and symptom onset

133
Q

Hormone responsible for menopause S/E

A

Estrogen

134
Q

Menopause investigations

A

Increased FSH on day 3 and LH (FSH > LH)
not always reliable
Clinical dx

135
Q

Tx for vasomotor instability a/w menopause

A 
HRT is first line (E+P)
SSRI 
Venlafaxine
Gabapentin
Propranolol
Clonidine 
Acupuncture
136
Q

Tx for vaginal atrophy a/w menopause

A 
Local estrogen cream (premarin)
Vaginal suppository (Vagifem) 
Lubricants 
Oral or transdermal HRT 
Intravaginal laser 
SERMs (ie. Ospemifene)
137
Q

Tx for osteoporosis a/w menopause

A 
1000-1500mg Calcium OD 
800-1000 IUD Vitamin D 
Weight-bearing exercise
Smoking cessation 
Bisphosphonates (ie. Alendronate) 
Selective estrogen receptor modifiers (SERMs) ie. Raloxifene/Ospemifene, mimics E effects on bone 
HRT
138
Q

Tx for mood and memory concerns a/w menopause

A

Antidepressants (first line)

HRT (Augments effect)

139
Q

HRT and breast CA risk

A

Only a/w with estrogen + progesterone HRT use >5y, NOT with estrogen-only HRT
Only give E-only HRT if pt has no intact uterus, otherwise you need P to prevent development of endometrial hyperplasia/CA

140
Q

Absolute C/I to HRT

A 
ABCD 
Acute liver disease 
Bleeding of vagina (undx) 
Cancer (breast/uterine), CVD
DVT
141
Q

Risks a/w HRT (WHI)

A

Stroke (E > E+P)
DVT/E (E+P > E)
CHD (esp if >70yo or starting HRT >10y post-menopause)
Breast CA (>5y of E+P, no increased risk for E alone)
Dementia/MCI (if >65yo, REDUCED risk if taken before 65)

142
Q

Kallmann Syndrome

A 
AKA idiopathic hypogonadotropic hypogonadism 
Isolated GnRH deficiency 
A/w anosmia 
Failure to start or complete puberty 
Occurs in both males and females 
GH is not affected and height is normal
143
Q

Pelvic Prolapse

A

Relaxation of cardinal and uterosacral ligaments causing protrusion of pelvic organs into or out of the vagina

144
Q

Grading of pelvic organ prolapse

A 
0 = no descent during straining 
1 = distal portion of prolapse >1cm above level of hymen 
2 = distal portion of prolapse = 1cm above or below level of hymen 
3 = distal portion of prolapse >1cm below level of hymen but without complete vaginal eversion 
4 = complete eversion of total length of lower genital tract
145
Q

Cystocele

A

Protrusion of bladder into anterior vaginal wall

146
Q

Enterocele

A

Prolapse of small bowel in upper posterior vaginal wall

Only TRUE hernia of pelvis b/c peritoneum herniates with small bowel

147
Q

Rectocele

A

Protrusion of rectum into posterior vaginal wall

148
Q

Uterine prolapse

A

Protrusion of cervix and uterus into vagina

149
Q

Vault prolapse

A

Protrusion of apex of vaginal vault into vagina, post-hysterectomy

150
Q

Stress incontinence

A

Involuntary loss of urine with increased intra-abdominal pressure (cough,laugh,sneeze,walk,run)

151
Q

General conservative tx for prolapse

A

Kegel exercises
Local vaginal estrogen therapy
Vaginal pessary

152
Q

Urge incontinence

A

Urine loss a/w abrupt sudden urge to void

153
Q

Urge Incontinence tx

A

Behaviour modification (reduce caffeine, smoking cessation, regular voiding schedule)
Kegel
Anticholinergics: Oxybutinin, Tolterodine, Solifenacin
TCAs (Imipramine)
R/O neuro causes: DM, herniated disc, MS

154
Q

Incidence of malignant gyne lesions in NA

A

Endometrium > ovary > cervix > vulva > vagina > fallopian tube

155
Q

Risk factors for endometrial CA

A 
COLD NUT 
Cancer (ovarian, breast, colon) 
Obesity 
Late menopause 
DM 
Nulliparity 
Unopposed estrogen: PCOS, anovulation, HRT 
Tamoxifen: chronic use
156
Q

Abnormal endometrial thickness in postmenopausal women

A

> 5mm

157
Q

Endometrial Cancer Type I

A

Estrogen-related
80% of cases
Often presents with AUB
Better prognosis

158
Q

Endometrial Cancer Type II

A

Non-estrogen related (still related but not as much as Type I)
More aggressive, worse prognosis than type I
15% of cases
More likely to present with advanced stage of disease with symptoms like ovarian CA (Bloating, bowel dysfunction, pelvic pressure)

159
Q

Tx for endometrial cancer

A 
Hysterectomy + BSO +/- pelvic and para-aortic node diessection +/- omentectomy 
Adjuvant radiotherapy (for pts at risk for local recurrence) and adjuvant chemotherapy (for pts at risk for distant recurrence or with metastatic dz)
160
Q

Uterine sarcoma symptoms

A 
BAD-P 
Bleeding (most common) 
Abdominal distention
Foul smelling vaginal Discharge
Pelvic pressure
161
Q

Most common type of uterine sarcoma

A

Leiomyosarcoma

162
Q

Leiomyosarcoma

A

Often coexists with benign leiomyomata (fibroids)
Tx: Hysterectomy/BSO +/- chemotherapy for metastatic dz
Radiation does not improve local control or survival
Poor toucomes overall

163
Q

Less common types of uterine sarcomas

A 
Endometrial stromal sarcoma (good prognosis)  
Undifferentiated sarcoma (poor prognosis)
Adenosarcoma (rarest, mix of benign epithelium and malignant low-grade sarcoma)
164
Q

Gyne malignancy responsible for most deaths

A

Ovarian CA

165
Q

Risk factors a/w ovarian CA

A

Personal hx of breast, colon, endometrial CA
Family hx of breast, colon, endometrial, ovarian CA
use of fertility drugs

166
Q

Protective factors a/w ovarian CA

A

OCP
Pregnancy/BF
Salpingectomy
BSO

167
Q

Familial ovarian CA

A

> 1 first degree relative affected

BRCA-1 mutation

168
Q

BRCA-1 or BRCA-2 mutation prophylactic recommendation

A

Bilateral oophorectomy after age 35 or once child-bearing completed

169
Q

Common symptoms of ovarian CA

A 
Typically presents late 
Nausea, bloating, dyspepsia, anorexia, early satiety 
Increased abdo girth 
Urinary frequency
Constipation
170
Q

Functional ovarian tumours

A

Benign

  • Follicular cyst (usually regresses with next cycle, OCP can help by preventing development of new cysts, lap sx if needed)
  • Corpus luteum cyst
  • Theca-lutein cyst
  • Endometrioma
  • Polycystic ovaries
171
Q

Most common ovarian germ cell neoplasm

A

Benign cystic teratoma (dermoid)

172
Q

Benign cystic teratoma (dermoid)

A

Contains all 3 cell lines (dermal appendages, sweat and sebaceous glands, hair follicles, teeth)
Calcifications on U/S is pathgnomonic
Tx: Lap cystectomy

173
Q

Malignant germ cell tumours

A

More common in children and young women
Ex. Dysgerminoma, immature teratoma, gonadoblastoma
Tx: surgical resection, often conservative +/- Very responsive to chemotherapy

174
Q

Most common type of ovarian cancer

A

Serous epithelial ovarian tumour

Psamomma bodies on histology

175
Q

Mucinous epithelial ovarian tumour special note about tx

A

Remove appendix to rule out possible source of primary disease

176
Q

Sex cord stromal ovarian tumour examples

A

Fibroma/thecoma (benign)
Granulosa-theca cell tumours (benign or malignant)
Sertoli-Leydic cell tumour

177
Q

Granulosa-theca cell tumours tumour marker

A

Inhibin

178
Q

Sertoli-Leydig cell tumours tumour marker

A

Androgens

179
Q

Investigations to order for suspicious ovarian mass

A 
CA-125 
CBC 
LFTs
Lytes 
Creatinine 
TVUS 
CT abdo/pelvis for metastatic dz 
Bone scan or PET scan not indicated
180
Q

Majority of malignant cervical lesions

A

Squamous cell carcinoma

181
Q

Transformation zone

A

Area located between the original and current squamocolumnar junction
Area where majority of dysplasias and cancers arise

182
Q

Dx of cervical CA

A 
Colposcopy  and biopsy
Endocergical curettage if entire lesion is not visible or no lesion visible 
Diagnostic excision (LEEP) if unsatisfactory colposcopy, unable to rule out invasive dz, recurrence of lesion, suspicious for adenocarcinoma in situ, +ve findings in endocervical curettage
Cold knife conization in OR if glandular abnormality is suspected due to concern for margin interpretation
183
Q

Inadequate sample pap

A

Repeat in 3mo

184
Q

ASCUS in women <30yo or HPV testing not available

A

Repeat cytology in 6mo
If neg –> repeat in 6mo –> neg –> routine screening
if >/= ASCUS –> colposcopy

185
Q

ASCUS women >/= 30yo

A

HPV DNA testing
If neg –> repeat cytology in 12 mo
If pos –> colposcopy

186
Q

ASC-H

A

Colposcopy

187
Q

AGUS/atypical endocervical cells/atypical endometrial cells

A

Colposcopy +/- endometrial sampling

188
Q

LSIL

A

Colposcopy
OR repeat cytology in 6mo –> if >/= ASCUS –> colposcopy, if negative –> repeat cytology in 6mo; if neg –> routine screening, if >/= ASCUS –> colposcopy

189
Q

HSIL

A

Colposcopy

190
Q

Squamous carcinoma or other malignant changes

A

Colposcopy

191
Q

Gardasil viral strains covered

A

6, 11, 16, 18

192
Q

CIN I Management

A

Observation

Repeat cytology in 12mo

193
Q

CIN II and CIN III Management

A

> /= 25yo: excisional procedure
< 25yo : Observe with colposcopy at 6mo intervals for up to 24mo before tx considered
During pregnancy: repeat colposcopy and delay tx until 8-12wk after delivery

194
Q

Cervical CA tx

A

If Stage IA1 (microinvasive): LEEP if future fertility desired, simple hysterectomy if fertility not desired
Stage IA2, IBI: radical hysterectomy + pelvic lymphadenectomy
Stages IB2, II, III, IV: Primary chemoradiation therapy, hysterectomy generally NOT suggested

195
Q

Hyperplastic dystrophy/squamous cell hyerplasia

A

Pruritus most common
Typically postmenopausal women
Tx: 1% corticosteroid ointment BID x 6wk

196
Q

Lichen sclerosis

A 
Labia becomes thin, atrophic
Pruritus, dyspareunia, burning 
Figure of 8 distribution 
Most common in postmenopausal women 
Tx: Ultrapotent topical steroid clobetasol x 2-4wk then taper down, can consider long-term suppression twice a week
197
Q

Most common malignant vulvar lesion

A

SCC

198
Q

Vulvar intraepithelial neoplasia (VIN)

A

Contain HPV DNA (usually types 16, 18)
White or pigmented plaques on vulva (may only be visible on vulva)
Progression to CA rarely occurs with appropriate management
Tx: local excision, ablative therapy, local immunotherapy (imiquimod)

199
Q

T1 vulvar lesion

A

Tumour confined to vulva
No extension to adjacent perineal structures
Tx: Radical local excision

200
Q

T2 vulvar lesion

A

Tumour of any size with extension to adjacent perineal structures
Tx: Modified radical vulvectomy

201
Q

T3 vulvar lesion

A

Extension to any of: proximal 2/3 of urethra, proximal 2/3 of vagina, bladder mucosa, rectal mucosa or fixed to pelvic bone
Tx: Chemoradiation
Node +ve dz: Adjuvant chemoradiation or radiation therapy

202
Q

Most common malignant vaginal lesion

A

SCC

203
Q

Most common location of vaginal SCC

A

Upper 1/3 of posterior wall of vagina

204
Q

Vaginal adenocarcinoma

A

Most are metastatic from ovary, cervix, endometrium or colon

If primary, most are clear cell adenocarcinomas

205
Q

Malignant vaginal lesion tx

A

Stage I: radiation and surgical excision (radical hysterectomy, upper vaginectomy, bilateral pelvic lymphadenectomy)
Stage II-IV: Chemoradiation

206
Q

Least common site for carcinoma of female reproductive system

A

Fallopian tubes

Usually serous epithelial carcinoma

207
Q

Most common type of hydatidiform Mole (Benign GTN)

A

Complete mole
46 XX or 46 XY completely of paternal origin
2 sperm fertilize an empty egg or 1 sperm with reduplication
15-20% risk of progression to malignant sequelae

208
Q

Partial or incomplete mole

A

Often triploid XXX, XYY, XXX with chromosome complement from both parents (usually single ovum fertilized by 2 sperm)
Low risk of progression to malignant sequelae (<4%)

209
Q

GTD dx

A

Quantitative b-hCG levels (tumour marker) abnormally high for gestational age
U/S Findings:
- Complete: no fetus (snow storm due to swelling of villi)
-Partial: molar degeneration of placenta +/- fetal anomalies, multiple echogenic regions corresponding to hydropic villi and focal intrauterine hemorrhage

210
Q

GTD tx

A

Suction D&C with sharp curettage and oxytocin
Rhogam if Rh -ve
Consider hysterectomy

211
Q

GTD monitoring

A

Contraception required to avoid pregnancy during entire F/U period
Serial bhCGs weekly until neg x 3 (usually takes several wk) then monthly x6-12mo prior to trying to conceive again
Increase or plateau of bhCG indicates GTN

212
Q

Invasive mole or persistent GTN

A

Dx made my rising or plateau in bhCG, development of metastases following tx of documented molar pregnancy

213
Q

Choriocarcinoma

A

Type of GTN
Often present with symptoms from metastases
May follow molar pregnancy, abortion, ectopic or normal pregnancy
If hematogenous spread is suspected, do NOT biopsy

214
Q

Placental-site trophoblastic tumour

A

Type of GTN
Rare aggressive form of GTN Abnormal growth of intermediate trophoblastic cells
Low bhCG, production of human placental lactogen, relatively insensitive to chemotherapy

215
Q

Most common metastasis location for GTN

A

Lungs

216
Q

GTN treatment

A

Mostly chemotherapy

Can consider hysterectomy if fertility not desired

217
Q

GTN monitoring

A

Contraception to avoid pregnancy during entire F/U period
Stage I, II, III: weekly bHCG until 3 consecutive normal then monthly x 12mo
Stage IV: Weekly bHCG until 3 consecutive normal then monthly x 24mo

218
Q

GTN dx

A

bhCG plateau: <10% drop in bHCG over 4 vales in 3wk OR
bhCG rise: > 20% in any two values over 2wk or longer OR
bhCG persistently elevated >6mo OR
metastases on workup

219
Q

Etiology of female infertility

A 
Ovulatory disorders (25%) 
Endometriosis (15%) 
Pelvic adhesions (12%) 
Cervical pathology (5%) 
Uterine pathology (<5%)
220
Q

Premature ovarian failure etiology

A

AI disease (most common)
Toxins (chemo)
Chromosomal (ie. Turner’s, Fragile X)

221
Q

Estrogen and coronary artery disease

A

Lower E levels (ie. women who undergo oophorectomy, premature ovarian failure, or go into early menopause) have higher rates of CAD

222
Q

Estrogen and endometrial cancer

A

Higher E levels (ie. ERT) a/w endometrial CA

223
Q

Medroxyprogesterone injection for contraception

A

Prevents ovulation, thins uterine lining
q3mo
May be used in BF women at 6wk PP
Delayed fertility after discontinuation (~10mo)
Liver dz is absolute C/I
Reduces bone mass density (each Ca and Vit D rich foods)

224
Q

Most common sites of endometriosis in pelvis

A

Ovaries > anterior/posterior cul de sac > posterior broad ligaments > uterosacral ligaments > uterus > Fallopian tubes > sigmoid colon and appendix > round ligaments

225
Q

Most common sites of endometriosis outside of pelvis

A

Liver, brain, lung and old surgical scars

226
Q

Chancroid

A

Painful ulcers
Bacterial STI caused by H ducreyi
Tx Azithro x 1 or CTX x1 or Erythromycin or Cipro

227
Q

Most common cause of outflow obstruction in secondary amenorrhea

A

Asherman syndrome

228
Q

BV often associated with infections by

A

Mycoplasma hominis

229
Q

Triad of premature ovarian failure

A

Amenorrhea
Hypergoandotropism
Hypoestrogenism

LMCC (22 decks)

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