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Gyneco Flashcards

1
Q

Sudden switch from negative to positive feedback in menstrual cycle

A

Ovulation

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2
Q

LH surge to ovulation

A

36 h

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3
Q

Duration of luteal phase

A

Fixed 14 d

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4
Q

Duration of follicular phase

A

Variable

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5
Q

Cervical spinnbarkeit in proliferative phase

A

8-10 cm

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6
Q

Cervical mucus spinnbarkeit in secretory phase

A

1-2 cm

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7
Q

Age of menarche

A

10-15 y

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8
Q

Cycle duration

A

28 +/- 7 d

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9
Q

Blood loss per cycle

A

25-80 ml

1-6 d

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10
Q

Stages of puberty

A 
Adrenarche
Gonadarche
Thelarche
Pubarche
Menarche
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11
Q

Thelarche to menarche

A

2y

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12
Q

Criteria for PMS Dx

A

1 affective + 1 somatic symptom
During the 5 d before menses
In each of the 3 prior menses
Relieved within 4 d of menses

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13
Q

1st line PMS Tx

A 
Exercise
CBT
B6
CHC
low dose SSRI during luteal phase
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14
Q

2nd line PMS Tx

A

Estradiol patch + micronized progestrone

LNG-IUS

Higher dose SSRIs (continual/luteal)

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15
Q

3rd line PMS Tx

A

GnRH analogues

+ add-back HRT

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16
Q

4th line PMS Tx

A

Surgery

+/- HRT

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17
Q

PMS symptoms

A 
1 of:
Depression
Anxiety
Irritability
Anger
Confusion
Social withdrawal
\+ 1 of:
Breast tenderness
Bloating
Limb edema
Headache
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18
Q

Premenstrual dysphoric disorder symptoms

A 
PMS symptoms +
Decreased interest in activities
Difficulty concentrating
Lethargy
Change in appetite
Hypersomnia/insomnia
Feeling overwhelmed
Joint/muscle pain
Weight gain
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19
Q

PDD criteria

A

At least 5 symptoms

Most cycles of the last year

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20
Q

Structural causes of AUB

A 
PALM
Polyps
Adenomyosis
Leiomyoma
Malignancy/hyperplasia
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21
Q

Non-structural AUB

A 
COEIN
coagulopathy
Ovulatory dysfunction
Endometrial
Iatrogenic
Not yet classified
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22
Q

Regular menses

A

Cycle to cycle variability less than 20 days

Irregular: 20 d or more

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23
Q

Heavy bleeding

A

80 ml or more
8 d or more
Bleeding that significantly affects quality of life

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24
Q

Postmenopausal bleeding

A

Bleeding more than 1 y after menopause

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25
Drug causing genital pruritis
OCP (progesterone)
26
REMEMBER TO ASK in chronic pelvic pain
Hx of sexual abuse/assault
27
1st/2nd Trimester bleeding DDx
``` EP Abortion Trauma Coagulopathy Infection ```
28
1st/2nd T bleeding investigations
CBC Blood group/screen B-hCG U/S
29
Detection of pregnancy by TVS IF B-hCG:
1500
30
Detection of pregnancy by transabdominal sono if beta:
6500
31
Indications for endometrial bleeding
``` PMB AUB+ age>40 AUB+ RF for endometrial cancer AUB+ failure of medical treatment Significant intermenstrual bleeding AUB+ infrequent menses ```
32
Recovery time regarding hysterectomy approach
Fastest: vaginal Then: laparoscopic Last: abdominal
33
The most common cause of primary amenorrhea
Mullerian agenesis Abnormal sex chromosomes (turner) Functional hypothalamic amenorrhea
34
The most common cause of secondary amenorrhea
Functional hypothalamic amenorrhea
35
1st question in amenorrhea
Primary or secondary?
36
1st question in primary amenorrhea
Secondary sexual characteristics? (Breasts)
37
Primary amenorrhea with normal secondary sexual characteristics
Karyotype
38
1ْ amenorrhea + 2ْ sexual characteristics + XX karyotype
``` *abnormal pelvis Imperforated hymen Transverse vaginal septum Cervical agenesis Müllerian agenesis * normal pelvis Hypothyroidism Hyperprolactinemia PCOS Hypothalamic dysfunction ```
39
1ْ amenorrhea + breast + XY Karyotype
AIS
40
1ْ amenorrhea, no breast
FSH/LH
41
1ْ amenorrhea, no 2ْ , high FSH
``` Hypergonadotropic hypogonadism Karyotype -XO -XX -XY ```
42
1ْ amenorrhea, no 2ْ , low FSH
``` Hypogonadotropic hypogonadism -constitutional delay -HPA axis abnormality • GnRH deficiency • kallman • head injury • pituitary adenoma/tumor • DM1 • systemic disorders (IBD, JRA, chronic infection) ```
43
1st step in 2ْ anenorrhea
Beta
44
2ْ amenorrhea with negative beta
Prolactin
45
Normal prolactin amount
< 20 ng/dL
46
If high prolactin
> 100 ng/dL, CT head | TSH
47
2ْ amenorrhea, negative beta, normal PRL
Progestin challenge
48
2ْ amenorrhea, negative beta, normal PRL, no W/D bleeding with progestin challenge
``` POI Uterine defect Asherman HP axis dysfunction Excessive androgens Excessive progesterones ```
49
2ْ amenorrhea, no beta, nl PRL, W/D bleeding
FSH/LH
50
2ْ amen, no beta, nl PRL, W/D bleed, high FSH/LH
PCOS | Hyperandrogenism (androgens)
51
2ْ amen, no beta, nl PRL, W/D bleed, low/nl FSH/LH
HP axis dysfunction • weight loss • excessive exercise • systemic disease
52
In case if HP axis dysfunction
MRI hypothalamus MRI pituitary Other pituitary hormones measurement
53
AIS Mx
Gonadal resection after puberty Psychological counselling Creation of neovagina
54
Cervical agenesis Mx
Suppression | Ultimately hysterectomy
55
Müllerian dysgenesis
Psychological counselling Neo-vagina Confirm normal urinary system and spine
56
Asherman Mx
HSG SHG Hysteroscopy & excision of synechiae
57
2ْ amenorrhea with HP axis dysfunction Mx
CHC to decrease the risk of osteoporosis
58
POF Mx
Screen (DM, hypothyroidism, hypocortisolism) E+P to decrease osteoporosis ( can use OCP after induction of puberty)
59
HyperPRL
MRI/CT head • if demonstrable lesion: surgery • if no demonstrable lesion: bromocriptine, cabergoline (if fertility desired) CHC if no fertility desired
60
Unpredictable AUB
Ovulatory dysfunction | Malignancy/hyperplasia
61
Regular heavy AUB
Adenomyosis Leiomyoma,sm Endometrial Coagulopathy
62
Regular cycles, intermenstrual AUB
Polyp
63
1st question in AUB
Regular?
64
If regular bleed, 2nd question?
Heavy?
65
Definition of 1ْ amenorrhea
No menses by age 13 (if no 2ْ sexual characteristics) No menses by age 15 (with 2ْ) No menses 2 yr after thelarche
66
Definition of 2ْ amenorrhea
No menses for > 6 mo | No menses for 3 cycles
67
3 questions to ask in AUB
Regular? Heavy? Intermenstrual bleeding?
68
AUB, Polyp Dx, Mx
TVS SHG Polypectomy
69
AUB, Adenomyosis
TVS | MRI
70
AUB, Leiomyoma
TVS SHG Hysteroscopy
71
AUB, Malignancy/hyperplasia
TVS | Endometrial Bx
72
AUB, Coagulopathy
``` CBC Coagulation profile vWF Ristocetin Factor VIII Mx OCP Mirena IUD Endometrial ablation ```
73
AUB, ovulatory
``` Beta Ferritin FSH/LH PRL Androgens ( free test, DHEA, 17-oh prog) Progesterone TFT Pelvic U/S ```
74
AUB, endometrial
Bx | Mx: tranex, hormonal, Mirena IUD, endometrial ablation
75
AUB, iatrogenic
TVS | Review meds
76
Tx of AUB
Resuscitate Underlying Medical Surgical (endometrial ablation, hysterectomy)
77
Medication for mild AUB
``` NSAIDs Antifibrinolytics at time if menses Combined OCP Progestin (10-14d/m or q 3 mo) Mirena IUD Danazol Correct anemia ```
78
Medication for acute, severe AUB
``` Fluid Consider admission •Estrogen IV q 4h x 24 h + Gravol •antifibrinolytic IV q8 h •OCP, TID x 7d, then, OD x 3wk + Gravol ``` Then Monophasic OCP x several months
79
Primary dysmenorrhea associati
Dyspareunia AUB Infertility
80
Mx of 1ْ dysmenorrhea
NSAIDs | OCP
81
Investigations for dyspareunia
``` Bimanual exam +/- U/S Laparoscopy Hysteroscopy Infection screening ```
82
RFs for endonetriosis
FHx Obstructive anomalies Nulliparity Age> 25
83
Triad of endometriosis
Dysmenorrhea Dyspareunia Dyschezia
84
Definite Dx of endometriosis
Laparoscopy and Bx (not required) | CA-125 (increased but not to be used for Dx)
85
Mainstay if endometriosis management
Menstrual suppression
86
1st line in suspected endometriosis
NSAIDs+ CHC (best continuous) Progestin alone
87
No response to 1st line Tx of endometriosis
``` Either: •2nd line: GnRH + addback progestin IUS Danazol • laparoscopic Dx and Tx ```
88
No response to 2nd line or laparoscopic Tx
Reconsider Dx | Chronic pain management
89
Definitive Tx for endometriosis
BSO
90
Best time to become pregnant in endometriosis
Immediately after laparoscopic conservative surgery If no plan to become pregnant post-op: medical suppression
91
Size of uterus in adenomyosis
<14 cm
92
Halban sign
Adenomyosis
93
Adenomyosis Dx
Clinical+/- U/S MRI Bx
94
Adenomyosis Tx
``` Iron Analgesics, NSAIDs OCP MPA GnRH Mirena Danazol ```
95
Definitive Tx for adenomyosis
Hysterectomy
96
Fibroid malignant potential
1/1000
97
Consideration of malignancy in fibroids
If enlarging in post-menopausal women
98
Most common symptom of fibroids
Asymptomatic AUB Most symptomatics: submucosal
99
Leiomyoma investigations
``` CBC U/S SHG (to differentiate SM myoma from polyps) Endometrial Bx (if AUB > 40) MRI (preoperative planning) ```
100
Tx indications for fibroid
Symptomatic | Intracavitary
101
Conservative approach for myoma if
``` Minimal symptoms < 6-8 cm Stable in size Not submucosal Pregnant ```
102
Myoma in pregnant women
Watch and wait F/U U/S if symptoms progress Best to avoid operating on it
103
If myoma with AUB
NSAIDs (anti PG) Tranex OCP MPA GnRH (often pre-myomectomy/hysterectomy, or to bridge to menopause + addback) Ulipristal acetate Uterine artery embolization (not for women considering childbirth) Myomectomy Hysteroscopic resection+ endometrial ablation (if AUB-sm) Hysterectomy
104
Ulipristal actate
Progesterone receptor antagonist | Causes endometrial changes, reversible with D/C
105
Most effective EPC
Postcoital IUD
106
Efficacy of transdermal contraceptive patches decreased in women weighing
>90 kg
107
Time of starting hormonal contraceptive
Any time during the cycle | Best: within 5 d of LMP
108
Required exams before starting hormonal contraceptives
Breast exam BP F/U at 6 wk
109
OCP on ovary
Decreased cyst decelopment | Decreased cancer
110
OCP on endometrium
Decreased cancer
111
OCP on breast
Decreased benign disease
112
OCP on bone
Osteoporosis protection
113
OCP on liver
Adenoma (est)
114
Drugs decreasing efficacy of OCP
``` Rifampin Phenobarbital Phenytoin Griseofulvin Primidone St John’s Wort ```
115
OCP in pregnancy and lactation
Absolute contra in pregnancy Not recommended until 6 wk postpartum 3 mo postpartum if breastfeeding May decrease milk production
116
Breakthrough bleeding with low-dose OCPs
If longer than 3 mo, switch to higher estrogen content
117
Progestin in Yasmin/Yas
Drospirenone: antimineralocorticoid, antiandrogenic
118
Contra of Yas/Yasmin
Renal/adrenal insufficiency (hyperkalemia) | Check K if also on: ACEI, ARB, K sparing diuretics, heparin
119
Contraceptives that must be taken at the same time everyday
POP
120
POP contra
None
121
Suitable hormonal contraceptive for postpartum women
POP
122
Hormonal contraceptives producing functional ovarian cyst
POP
123
Hormonal method with highest failure rate
POP
124
Missed 1 OCP pill in <24h
1 ASAP | The next pill at the usual
125
Miss >1 pill in a row in 1st wk
1 ASAP Continue 1 pill/d until the end of the pack + back-up contra for 7 d +/- EPC
126
Miss 2 pills in 2nd or 3rd wk
1 ASAP Continue 1 pill daily until the end of pack No placebo, No free interval Start next pack immediately
127
Miss 3 or more pills in 2nd or 3rd wk
``` 1 ASAP 1 pill daily until the end of the pack No placebo, no free interval Start the next pack immediately Back-up contra for 7 days +/- EPC ```
128
No need for back-up in case of missed OCP
Missed 1 pill in <24 h | Missed 2 pills in 2nd or 3rd wk
129
Need for back-up in case of missed OCPs
Miss more than 1 pill in a row in 1st wk | Miss 3 or more pills in 2nd or 3rd wk
130
Summary of 1st wk
• miss 1 pill <24h 1 ASAP + continue • miss 2 or more 1 ASAP + continue + back-up 7d +/- EPC
131
Summary of 2nd-3rd wk
• miss 1 pill 1 ASAP, + continue • miss 2 pills 1 ASAP + continue + next pack immediately • miss 3 or more 1 ASAP + continue + next pack immediately + back-up 7 d +/- EPC
134
Timing of MPA after delivery
Immediately (BF/ non-BF)
135
Timing of MPA in usual cases
Within 5 d of beginning of normal menses
136
MPA on bones
Decreased bone density(may be reversible) | Encourage vit D, Ca, daily exercise
137
Restoration of fertility after MPA
Up to 9 mo
138
Missed POP
If > 3 h, back-up for at least 48 h
139
Missed MPA + negative beta
Give next injection + back-up 7 d + • intercourse in last 5d, EPC •intercourse 5-14 d ago, beta in 3 wk •intercourse >14 d ago, nothing more
140
Yuzpe combination
Estradiol 100 Levonorgestrel 500 Can substitute with any OCP with same dose of estrogen
141
Yuzpe method
``` Within 72 h Up to 5 d 2 tabs, repeat in 12 h Contra: no absolute Caution if contra to OCP ```
142
Plan B formulation
Levonorgestrel 750
143
Plan B method
1 tab, repeat after 12 h Within 72 h Up to 5 d No caution for contra to OCP
144
Choice ECP after 24 h
Plan B
145
Plan B not recommended for
> 80 kg
146
Ulipristal method
30 mg PO within 5 d | No caution in OCP contra
147
EPC with IUD
Copper Up to 7 d Mirena cannot be used
148
1st line contraceptive for adolescents
Implants, IUDs, that do not affect BMD
149
F/U on EPC
In 3-4 wk Beta test or spontaneous mense Contra counseling
150
Gold std medical method of abortion up to 9 wk
Mifepristone + misoprostol
151
Medical methods of abortion
* mifepristone+ misoprostol * misoprostol aline * MTX+misoprostol
152
Surgical abortion methods
<14 wk •manual vacuum aspiration (up to 8-9wk) •suction dilation+ aspiration+/- curettage +/- presurgical preparation of cervix (laminaria, misoprostol) 14-24 wk •Dilatation + evacuation + presurgical cervix preparation + pain management
153
Septic spontaneous abortion Tx
IV AB 24h | Then uterine evacuation
154
Embryonic demise
CRL 7 mm or more and no cardiac activity
155
Most common location for EP
Ampullary
156
Most common etiology of EP
PID (chlamydia Trachomatis)
157
Suspected EP
Urine beta
158
Unstable EP (+ urine beta)
Surgery
159
Stable EP
TVS | Serum beta
160
Surgical management if any of:
* >3.5 cm * beta>5000 * renal/liver/hemato disease * FHR present * poor compliance * unable to F/U
161
MTX for EP if
* <3.5 cm and * beta> 5000 and * no FHR and * no renal/hepatic/hemato disease and * compliance assured and * able and willing to F/U and * no pulmonary disease/PUD/ immunodeficiency and * no pregnancy/lactation
162
Investigation for EP
Serial beta: If rise <20 %, non viable If prolonged doubling, plateau, decreasing before 8 wk, non viable U/S: Tubal ring (specific) If beta>2000-3000 and empty uterus by TVS, suspect ectopic Definitive if FHR in tube
163
Normal beta doubling time
1.6-2.4 d
164
Surgical options
•Laparoscopy: Linear salpingostomy, then weekly beta Salpingectomy if tube damaged/ipsilateral recurrence, then weekly beta * Laparotomy if unstable/extensive surgical Hx * If Rh negative, Rhogam
165
Medical Tx for EP
MTX 50/m2 IM single dose | Then weekly beta
166
2nd dose of MTX if
Beta not decreased by at least 15% between days 4-7 (in 25% of cases)
167
Tubal potency after MTX for EP
80%
168
Mx of abortion
R/O EP Check Rh Ensure stability Wait and watch or misoprostol or D&C
169
Prenatal DES exposure
Infertility with uterine factors | Clear cell adenocarcinoma of vagina
170
Infertility female tests
``` •ovulatory -Day 3: FSH,LH,estradiol, TSH, PRL, +/- DHEA, FreeTest -Day21-23: serum progesterone -basal body temperature monitoring -postcoital test (mucus:clarity, PH, spinnbarkeit/fibrosity) •peritoneal/uterine factors HSG/SHG, hysteroscopy •tubal factors HSG/SHG Laparoscopy with dye insufflation •other Karyotype ```
171
When to investigate for infertility
<35y, after 1 y 35-40, after 6mo >40, immediately
172
Earlier investigation if
``` Hx of PID Hx of infertility with previous partner Hx of pelvic surgery Hx of chemo/RT Hx of recurrent pregnancy loss Mod-severe endometriosis ```
173
Proper intercourse timing
From 2 d prior to 2 d following presumed ovulation, every other day
174
Ovulation induction methods
``` •Clomiphene citrate then beta •letrozole +/- bromocriptine (if high PRL) dexa (adult onset CAH) Metformin (PCOS) Prog supplementation during luteal Anticoagulation/ASA (Hx of recurrent spontaneous abortion, APLS) Thyroid replacement (keep TSH< 2.5) ```
175
Normal semen
``` Abstinence: 2-7d Volume: 1.5cc Count:15 million/cc Vitality:58% Motility:40% Progressive:32% Normal morphology:40% ```
176
Criteria for PCOS
Oligomenorrhea/irregular menses for 6 mo Hyperandrogenism(clinical or free test) PCO on U/S
177
PCOS in adolescence
Polycystic ovaries on U/S not an appropriate criteria | Wait 1-2 y before Dx
178
Aim of investigations for PCOS
identify hyperandrogenism Identify chronic anovulation R/O pituitary or adrenal cause
179
Tests for PCOS
LAB: PRL, TSH, Free T4, 17-oh-prog, DHEA-S, free testo (most sens), androstenedione, SHBG (decreased) LH:FSH> 2 U/S (TVS, transabdo): string of pearls (12 or more follicles) or increased ovarian volume Insuline resistance: fasting glucose:insuline <4.5 IGT: 75 g OGTT yearly
180
Cycle control in PCOS
Lifestyle: exercise, decrease BMI OCP, MPA (to prevent endometrial hyperplasia) Metformin: if DM2, trying pregnancy Tranex: menorrhagia
181
Infertility Tx in PCOS
Induction of ovulation: clomiphen citrate, letrozole, HMG, LHRH, recombinant FSH, metformin Ovarian drilling, wedge resection Bromocriptine, if hyperPRL
182
Tx of hirsutism in PCO
OCP Mechanical removal Finasteride, flutamide, spironolactone
183
Normal discharge pH
3.8-4.2
184
Prepubertal vulvovaginitis investigation
Vaginal swab for culture (state the age) | pH, wet mount, KOH (for adults)
185
Etiology of vaginal bleeding in prepubertal vulvovaginitis
GAS Shigella Endocrine abnormality Blood dyscrasia
186
Most common prepubertal gynecological problem in girls
Non-specific vulvovaginitis
187
RFs of candida vulvovaginitis
Diaper Chronic AB Chronic immunosuppression
188
Vulvovaginitis due to increased estrogen levels
Candida
189
Cottage cheese discharge
Candida
190
Asymptomatic candidiasis VV
20%
191
VV with intense pruritus
Candida
192
pH in VV candidiasis
4.5 or less
193
VV candidiasis Tx in pregnancy
Usually topical | Can use fluconazole 150 single dose
194
Prophylaxis for recurrent candidiasis VV
Boric acid Vaginal suppositories Luteal phase fluconazole
195
Partner in candidiasis?
Routine Tx not needed
196
Discharge in BV
Grey, thin, diffuse,
197
Fishy odor
BV
198
Asymptomatic BV
50-70%
199
Absence of irritation
BV
200
pH in BV
4.5 or more
201
Clue cells
BV (squamous dotted with coccobacilli) | 20%
202
Paucity of WBC in discharge
BV
203
Paucity of lactobacilli
BV
204
Positive whiff test
BV | TV
205
BV Tx indications
Pregnancy Symptomatic Pelvic surgery/procedure
206
Tx of BV
Metro 500 PO BID x 7d Metro gel OD x 5d Clinda intravaginal x7d Probiotics oral or topical (lactobacillus)
207
Tx of partner in BV?
No
208
Obstetric complications of BV
Preterm labour | Postpartum endometritis
209
BV Tx in pregnancy
Topical metro | Oral metro?
210
Missed MPA
If last injection given 13-14 wk prior, give next immediately If >14 wk prior, check beta
211
Petechiae on cervix and vagina
Trichomonas vaginalis
212
VV with sexual transmission
TV
213
Discharge in TV
Yellow-green, malodorous, diffuse, frothy
214
Asymptomatic TV
25%
215
pH in TV
4.5 or more
216
Flagellated organism on wet mount
TV
217
Many WBC/PMN
TV
218
Treatment indications
All
219
Tx of TV
Metro 2g PO single dose | Metro 500 bid x 7d
220
Tx of TV in pregnancy
Metro 2g once
221
Partner in TV
Should treat
222
Detection of HPV latent infection
DNA hybridization test
223
Subclinical HPV infection detection
Colposcopy | Pap-smear
224
Tx of HPV
``` Podofilox 0.5% bid x3d/wk in a row x 4wk Imiquimod 5% 3x/wk qhs x16 wk Podophyllin resin in tincture of benzoin weekly TCA weekly Cryo q1-2 wk Surgery/ laser Cryo IL IFN ```
225
HPV Tx in pregnancy
TCA 80-90%
226
HSV incubation
2-21d (7-10d)
227
HSV detection
Viral culture if ulcer present Tzanck HSV DNA PCR Serologic tests
228
Indication of C-section in genital wart
Obstruction of birth canal | Risk of extensive bleeding
229
Condyloma in pregnancy
Tend to get larger | Should be treated early
230
HSV Tx
Education (avoid contact since prodrome until clearance of lesions, barrier) 1st episode: acyclo, famcyclo, valacyclo 7-10 d Recurrent episode: 2-5d More than 6 recurrence/y: suppressive Tx Severe disease: IV acyclo until clinical improvement, then oral to complete 10 d
231
Most Sn/Sp test for syphilis
Darkfield microscopy
232
Syphilis tests negative after treatment:
VDRL, RPR
233
Syphilis Tx
Primary/secondary/latent of<1y duration: Benzathine penicillin G 2.4 m IM single dose Latent>1y duration: Benzathine penicillin G 2.4 m IM/wk x3 wk Neurosyphilis: Aqueous penicillin G 4m q 4h x 10-14d
234
Partner in syphilis?
Screen and treat
235
Most common genital ulcer
HSV
236
2nd most common genital ulcer
Syphilis
237
Most common bacterial STI
Chlamydia Trachomatis
238
Asymptomatic chlamydia
80% of women
239
Discharge in chlamydia
Mucopurulent, endocervical
240
Urethral symptoms
Candida TV Chlamydia HSV
241
CDC notifiable diseases
``` Chancroid Chlamydia Gonorrhea Hepatitis A,B,C HIV Syphilis ```
242
Missed MPA+ positive beta
EPC | And no injection
243
Intermenstrual bleeding
Polyp Chlamydia (particularly if on OCP) Endometrial carcinoma
244
Chlamydia Dx
Cervical culture/nucleic acid amplification test Definitive std: tissue culture Urine/self vaginal tests (Urine culture negative, but pyuria)
245
Tx of Chlamydia
Doxy 100 PO bid x7d Azithro 1g PO single dose + gonorrhea Tx
246
Partner in chlamydia?
Treat
247
Chlamydia in pregnancy
Azithro | Test of cure required in 3-4 wk
248
Screening for chlamydia
When initiating OCP in sexually active High risk group Pregnancy
249
Organism that needs to be screened for when initiating OCP
Chlamydia
250
Hepatic complication of chlamydia
Fitz-Hugh-Curtis (liver capsule inflammation)
251
Gonorrhea Dx
Gram stain | Cervical/rectal/throat culture (if clinically indicated)
252
Tx of gonorrhea
Ceftriaxone 250 IM single + azithro 1g
253
Tx of gono in pregnancy
Ceftriaxone 250 + azithro 1g | Spectinomycin 2g IM + azithro 1 g
254
STI testing
Vaginal swab: candida, BV,TV | Cervical swab: gono, chla
255
Indications of test of cure for gono/chla
Symptomatic Uncertain compliance Pregnant
256
Bartholin gland abscess microorganisms
Anaerobic, polymicrobial
257
Bartholin Tx
``` Sitz bath Warm compress Cephalexin + I&D + Word cath 2-3wk Marsupialization Remiving gland ```
258
Most common cause of PID
Chlamydia | Gonorrhea
259
Cause of recurrent PID
Endogenous flora
260
Cause if PID associated with instrumentation
Endogenous flora
261
Organism associated with IUD
Actinomyces israelii (not the most common cause of course!)
262
How long does IUD increase the risk of PID?
10 d
263
Asymptomatic PID
2/3
264
Most common etiology of chronic PID
Chlamydia
265
PID investigations
``` Beta CBC B/C (if suspect septicemia) Urine R&M Vaginal swab Cervical swab Definitive Dx: endometrial Bx U/S Laparoscopy (gold std) ```
266
The must have symptom for Dx of PID
Lower abdominal pain
267
Required signs for Dx of PID
Cervical morion tenderness Or Adnexal tenderness
268
Tx of PID
polymicrobial coverage
269
Tx in case of admitted PID
Cefoxitin+ doxycycline Or Clindamycin+ gentamycin All IV until 24 h after symptoms have resolved Then, PO doxy bid to complete 14 d + percutaneous abscess drainage with U/S guide (If no response, laparoscopic drainage) If failure, surgery (TAH/BSO)
270
Outpatient Tx of PID
Ceftriaxone 250 IM x 1 + doxy 100 bid x 14 d +/- metronidazole 500 bid x14d Or Cefoxitin 2g IM + probenecid 1g PO x1 + doxy 100 bid x 14d +/- metro bid x14d Or Ofloxacin bid x14d +/- metro bid x14d Or Levofloxacin bid x14d +/- metro bid x14d F/U in 48-72 h If pt not tolerant of cephalo and Q, azithro + metro
271
IUD removal in PID
After a minimum of 24 h of treatment
272
Partner treatment in PID?
Yes
273
Report PID?
Yes
274
Re-testing for PID?
For chlamydia/gonorrhea 4-6 wk ofter treatment if documented infection
275
Foreign body duration for TSS
>24h
276
TSS Tx
``` Remove potential source of infection Debride necrotic tissue Hydration Penicillinase-resistant AB (cloxacillin) Steroid within 72 h ```
277
Pelvic cellulitis
Post hysterectomy Tx if: fever, leukocytosis Tx: clinda+genta + drain if excessive purulence/large mass
278
Dietary changes for vestibulitis
Increased citrate | Decreased oxalate
279
Menopause definition
Lack of menses for 1 y | Average age:51
280
Primary ovarian insufficiency
Before age 40
281
Menopause Dx
Use:absence of menses for 1 y FSH (day 3) > 35 Increased LH Decreased estradiol
282
Vasomotor instability Tx
1st line: HRT (low dose, short duration < 5y) | Others: SSRI, venlafaxin, gabapentin, clonidine, propranolol, acupuncture
283
Vaginal atrophy Tx
Local estrogen Lubricant HRT Laser
284
Urogenital health
Lifestyle: weight loss, bladder re-training, local estrogen, surgery
285
Osteoporosis
``` 1000-1500 mg Ca/d 800-1000 unit Vit D Weight-bearing exercise Smoking cessation Bisphosphonate SERM: raloxifene 2nd line: HRT ```
286
Raloxifene
Estrogen effect on bones | No effect on breast/uterine
287
Decreased libido
Lubrication Counseling Testosterone cream
288
CVD Tx
RF Mx | Absolute contraindication of HRT!
289
Mood and memory
1st line: anti-depressant | HRT
290
Perimenopause
2-8 y preceding to 1 y after last mense Fluctuating hormones Irregular menses Symptom onset
291
Breast cancer risk with hormonal therapy:
Increased if estrogen + progesterone | Not increased with estrogen-only HRT
292
Preferred HRT route
Transdermal | Especially if hyper TG, impaired hepatic function, smoker, headache with oral HRT
293
Bleeding episode in a post-menopausal amenorrheic woman on OCP
Endometrial Bx
294
HRT with PMS symptoms
Std dose cyclic
295
HRT and cognitive impairment
Increased cognitive impairment if taken after 65 y (combined> estrogen only) Reduced risk of dementia if taken < 65y
296
Benefits of HRT
Vasomotor Osteoporosis Colon cancer
297
Gynecological cancer whose RF in diabetes
Type I and II endometrial carcinoma
298
Cancer with Tamoxifen
Endometrial, type 1
299
Abn endometrial thickness in post-menopause women with AUB
5mm or more
300
Uterus size in endometrial carcinoma
Normal
301
If endometrial carcinoma suspected
Endometrial Bx D&C +/- hysteroscopy +/- pelvic U/S (if adequate sampling not feasible)
302
U/S role in endometrial carcinoma
Not suitable for screening test | Not acceptable as alternative to pelvic exam or endometrial Bx to R/O cancer
303
Endometrial carcinoma Tx
1st step: TAH/BSO + pelvic washing +/- pelvic/para-aortic node dissection +/- omentectomy Better QOL if laparoscopic
304
Adj RT for Endometrial carcinoma
If high risk of local recurrence
305
Adj chemo for endometrial carcinoma
If mets Or High risk of mets (based on histologic findings)
306
Chemo for endometrial cancer
If recurrent disease (if high grade)
307
Hormonal therapy for endometrial carcinoma
Progestin | For recurrent disease (if low grade)
308
Most important prognostic factor in endometrial carcinoma
FIGO stage
309
Post-menopausal woman with rapidly enlarging uterus
Consider leiomyosarcoma | Perform an endometrial Bx
310
Tx differences between leiomyosarcoma and endometrial carcinoma
No routine LND | No role for RT
311
Cancer increased by fertility drugs
Ovarian epithelial carcinoma
312
Drug reducing risk of ovarian cancer
OCP
313
Marker of epithelial cell tumor
CA-125
314
Granulosa cell tumor marker
Inhibin
315
Sertoli-Leydig tumor marker
Androgens
316
Dysgerminoma marker
LDH
317
Yolk sac tumor marker
AFP
318
Choriocarcinoma
Beta
319
Immature teratoma marker
None
320
Embryonal cell marker
AFP | Beta
321
Omental cake
Ovarian cancer
322
Mass screening for endometrial cancer
No
323
Mass screening for ovarian cancer
No
324
Indications of screening for ovarian cancer
* >1 1st degree relative with ovarian cancer, BRCA1 mutation * Hx of endometrial/breast/colon cancer * BRCA1/2 mutation
325
Method of screening
CA-125 TVS Starting age:30
326
If BRCA1/2 mutation
Prophylactic bilateral oophorectomy after age 35/after completed child bearin
327
Symptomatic/suspicious adnexal mass
Sugical exploration
328
Follicular mass U/S
4-8 cm | Unilacular
329
Follicular mass Mx
If not suspicious/asymptomatic and <6cm : Wait 6 wk + OCP If no regression: laparoscopy
330
Corpus luteum vs follicular cyst
Corpus luteum more likely to cause pain, may delay onset of next period, larger(10-15cm) , firmer
331
Mx of corpus luteum cyst
Same as follicular
332
Cyst generated by abn beta levels
Theca-Lutein | eg: molar pregnancy, clomiphene
333
Drug causing theca-lutein cyst
Clomiphene
334
Mx of theca-lutein cyst
Conservative | Treat high beta levels
335
The most common ovarian germ cell neoplasm
Dermoid (cystic teratoma)
336
Pathognomonic finding in benign teratoma
Calcification
337
Tx of dermoid cyst
Laparoscopic cystectomy
338
Tumors for which total resection is not necessary due to high response rate to chemo
Dysgerminoma | Immature teratoma
339
Most common ovarian tumor
Serous
340
Psamomma body
Serous
341
Pseudyxoma peritonitis
Mucinous
342
Enormous size
Mucinous
343
Need to remove appendix
Mucinous
344
Poor response to chemo
Mucinous
345
Meig’s syndrome (benign ovarian tumor and ascitis and pleural effusion)
Fibroma/thecoma
346
Ovarian tumor associated with endometrial cancer
Granulosa-theca cell tumor
347
Precocious puberty
Granulosa-theca (estrogen)
348
Postmenopausal bleeding
Granulosa-theca
349
Menorrhagia
Granulosa-theca
350
Call-exner bodies in histology
Granulosa-theca
351
Virilizing effects
Sertoli-Leidig
352
Krukenberg
Metastatic ovarian tumor from stomach/colon/breast source | Signet ring cells
353
Investigations for ovarian cancer
Bimanual exam Risk of Malignancy Index (RMI, used for referral) CA-125, CBC, LFT, lytes, creatinine TVS CT abdomen, pelvis If suspicious of other primary sources: FOB, if positive, endoscopy +/- barium enema If gastric symptoms: gastroscopy +/- upper GI series If AUB: endometrial Bx If abn cervix: cervix Bx If breast lesion/RF: mammogram
354
Nabothian cyst
Benign cervical ct
355
Gynecological malignancy with smoking RF
Cervical
356
Barrel-shaped cervix
Adenocarcinoma
357
Normal Pap
Repeat in 1-3 yr
358
Inadequate sample
Repeat in 3 mo
359
Pap: ASCUS
Age? 30 or higher: HPV-DNA testing Less than 30: repeat pap in 6 mo
360
ASCUS, above 30, positive HPV-DNA test
Colpo
361
ASCUS, below 30, repeated in 6 mo: ASCUS
Colpo
362
ASCUS, above 30, negative HPV
repeat cytology in 12 mo
363
ASCUS, below 30, negative repeated cytology after 6 mo, next step?
Repeat cytology in 6 mo
364
ASCUS, below 30, negative repeated cytology, negative again after another 6 mo
Routine screen in 3 year
365
ASCUS, below 30, negative ctopogy in 6 mo, ASCUS in 3rd cytology in 6 mo
Colpo
366
ASC-H
Colpo
367
AGUS
Colpo +/- endometrial Bx
368
LSIL
Either colpo or repeat cytology in 6 mo
369
LSIL, negative after 6 mo
Repeat in 6 mo
370
LSIL, if ASCUS or more after 6 mo
Colpo
371
LSIL, negative in 6 mo, again negative in 6 mo
Routine screening in 3 years
372
LSIL, negative in 6 mo, but ASCUS or more in 2nd repeat in 6 mo
Colpo
373
HSIL
Colpo
374
Any malignant changes on Pap
Colpo
375
Marker for monitoring ovarian cancer response to treatment
CA-125
376
Cold knife conization indication
Suspicion of glandular abnormality
377
Indications for LEEP
Unsatisfactory colpo Discrepancy between cyto/colpo/histo Glandular abnormality in endocervical curettage Suspicious of adenocarcinoma in situ Recurrence of lesion post-ablation/excision Inability to R/O invasive disease
378
Gardasil age
Females: 9-45 Males: 9-26
379
Cervarix age
Females 10-25
380
Conception after HPV vaccin
Avoided until 30 days
381
Endocervical curettage indication
No lesion on colpo | Entire lesion not visible
382
Pap in pregnancy
At all initial prenatal visits
383
Time of diagnostic conization during pregnancy
2nd trimester
384
Dysplasia Mx during pregnancy
Deferred until completion of pregnancy
385
Delivery mode in presence of dysplasia
Vaginal
386
Invasive cervical cancer in pregnancy
Mx depends on prognosis, fetal maturity, pt wishes T1: termination+ radical surgery or chemoradio T2/T3: delay therapy until viable fetus, then C/S + concurrent radical surgery or subsequent chemoradio
387
CIN I Mx
Observation | Repeat assessment and cytology in 12 mo
388
If cytology: HSIL/AGC | And then: CIN
Review of cytology and histology | If discrepancy remains, excisional Bx
389
If CIN II/III
Age 25 or higher: treat ( excision preferred for CIN III) Positive margin: F/U with colpo +/- Bx/endocervical curettage Age <25: observe with colpo q 6 mo for 24 mo (then consider Tx) Pregnancy: treatment and repeat colpo 8-12 wk after delivery
390
Age of hyperplastic dystrophy of vulva
Post menopausal
391
Tx of hyperplastic dystrophy
CS oint
392
Most common age of lichen sclerosis
Post menopausal
393
VIN Tx
Local excision Ablation Imiquimod
394
Most important predictor of prognosis in vulvar cancer
Nodal involvement | 2nd most important: tumor sizea
395
Schiller test
For Dx of abn squamous epithelium of vagina (doesn’t take up Lugol)
396
Most common site of vaginal SCC
Upper 1/3 of posterior wall
397
Vitamin deficiency implicated in mole formation
Vit A | B-carotene
398
The most common symptom of complete mole
Vaginal bleeding
399
Complete mole chromosome
XX, XY
400
Incomplete mole chromosome
XXX, XXY, XYY
401
Risk of malignant sequelae for complete mole
15-20%
402
Risk of malignant sequelae for incomplete mole
<4%
403
Presentation of incomplete mole
Threatened/spontaneous/missed abortion
404
Mole investigation
Beta U/S CXR
405
U/S of complete mole
Snow storm
406
U/S of incomplete mole
Degeneration of placenta Multiple echogenic regions Fetal abnormalities
407
High risk of persistent GTN following mole evacuation
Uterine invasion as high as 31% Beta >100000 Excessive uterine size Prominent theca-lutein cyst
408
Mole Tx
Suction D&C with sharp curettage +oxytocin +Rhogam Consider: histerectomy
409
F/U of mole
Contraception during entire F/U period Serial beta, weekly, until negative x3, then monthly for 6-12 mo If increase or plateau of beta, chemol
410
HTN <20 wk in pregnancy
Think GTD/GTN
411
GTN with relative insensitivity to chemo
Placental site trophoblastic tumor
412
Features of bad prognosis in metastatic GTN
``` Long duration from pregnancy (>4mo) Beta>100,000/24h urine Beta>40,000/ blood Brain/liver mets Prior chemo Following term pregnancy ```
413
GTN investigation
CBC, lytes, Cr, beta, TSH, LFT | CXR, U/S pelvis, CT abdo/pelvis, CT brain
414
If suspect brain mets, but negative CT
LP: | If plasma beta/CSF beta <60: mets
415
Stage 1 GTN Tx Confined to uterine corpus Stage 2: mets to genital Stage 3: mets to lungs
•if low risk: pulsed actinomycin (1st line) Alternative: MTX •if high risk: combination chemo
416
Stage 4 GTN | Mets to brain, liver, kidney, GI tract
Combination chemo + surgical resection of sites of disease persistence, resistance to chemo +/- RT for brain mets
417
No1 place for GTN mets
Lungs
418
F/U for GTN
Contraception during entire f/u period Stage1,2,3: weekly beta until 3 negative, then monthly x12 mo Stage4: weekly beta until 3 negative, Then monthly x 24mo
419
GTN Dx
Plateau: <10% drop over 4 values in 3wk Rise: >20% in any two values over 2wk or longer Persistent elevation >6 mo Mets on w/u

Med (25 decks)

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