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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
Q

Drug causing genital pruritis

A

OCP (progesterone)

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26
Q

REMEMBER TO ASK in chronic pelvic pain

A

Hx of sexual abuse/assault

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27
Q

1st/2nd Trimester bleeding DDx

A 
EP
Abortion
Trauma
Coagulopathy
Infection
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28
Q

1st/2nd T bleeding investigations

A

CBC
Blood group/screen
B-hCG
U/S

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29
Q

Detection of pregnancy by TVS IF B-hCG:

A

1500

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30
Q

Detection of pregnancy by transabdominal sono if beta:

A

6500

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31
Q

Indications for endometrial bleeding

A 
PMB
AUB+ age>40
AUB+ RF for endometrial cancer
AUB+ failure of medical treatment
Significant intermenstrual bleeding
AUB+ infrequent menses
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32
Q

Recovery time regarding hysterectomy approach

A

Fastest: vaginal
Then: laparoscopic
Last: abdominal

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33
Q

The most common cause of primary amenorrhea

A

Mullerian agenesis
Abnormal sex chromosomes (turner)
Functional hypothalamic amenorrhea

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34
Q

The most common cause of secondary amenorrhea

A

Functional hypothalamic amenorrhea

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35
Q

1st question in amenorrhea

A

Primary or secondary?

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36
Q

1st question in primary amenorrhea

A

Secondary sexual characteristics? (Breasts)

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37
Q

Primary amenorrhea with normal secondary sexual characteristics

A

Karyotype

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38
Q

1ْ amenorrhea + 2ْ sexual characteristics + XX karyotype

A 
*abnormal pelvis
Imperforated hymen
Transverse vaginal septum
Cervical agenesis
Müllerian agenesis
* normal pelvis
Hypothyroidism
Hyperprolactinemia 
PCOS
Hypothalamic dysfunction
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39
Q

1ْ amenorrhea + breast + XY Karyotype

A

AIS

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40
Q

1ْ amenorrhea, no breast

A

FSH/LH

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41
Q

1ْ amenorrhea, no 2ْ , high FSH

A 
Hypergonadotropic hypogonadism
Karyotype
-XO
-XX
-XY
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42
Q

1ْ amenorrhea, no 2ْ , low FSH

A 
Hypogonadotropic hypogonadism
-constitutional delay
-HPA axis abnormality
• GnRH deficiency
• kallman
• head injury
• pituitary adenoma/tumor
• DM1
• systemic disorders (IBD, JRA, chronic infection)
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43
Q

1st step in 2ْ anenorrhea

A

Beta

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44
Q

2ْ amenorrhea with negative beta

A

Prolactin

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45
Q

Normal prolactin amount

A

< 20 ng/dL

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46
Q

If high prolactin

A

> 100 ng/dL, CT head

TSH

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47
Q

2ْ amenorrhea, negative beta, normal PRL

A

Progestin challenge

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48
Q

2ْ amenorrhea, negative beta, normal PRL, no W/D bleeding with progestin challenge

A 
POI
Uterine defect
Asherman
HP axis dysfunction
Excessive androgens
Excessive progesterones
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49
Q

2ْ amenorrhea, no beta, nl PRL, W/D bleeding

A

FSH/LH

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50
Q

2ْ amen, no beta, nl PRL, W/D bleed, high FSH/LH

A

PCOS

Hyperandrogenism (androgens)

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51
Q

2ْ amen, no beta, nl PRL, W/D bleed, low/nl FSH/LH

A

HP axis dysfunction
• weight loss
• excessive exercise
• systemic disease

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52
Q

In case if HP axis dysfunction

A

MRI hypothalamus
MRI pituitary
Other pituitary hormones measurement

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53
Q

AIS Mx

A

Gonadal resection after puberty
Psychological counselling
Creation of neovagina

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54
Q

Cervical agenesis Mx

A

Suppression

Ultimately hysterectomy

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55
Q

Müllerian dysgenesis

A

Psychological counselling
Neo-vagina
Confirm normal urinary system and spine

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56
Q

Asherman Mx

A

HSG
SHG
Hysteroscopy & excision of synechiae

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57
Q

2ْ amenorrhea with HP axis dysfunction Mx

A

CHC to decrease the risk of osteoporosis

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58
Q

POF Mx

A

Screen (DM, hypothyroidism, hypocortisolism)
E+P to decrease osteoporosis
( can use OCP after induction of puberty)

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59
Q

HyperPRL

A

MRI/CT head
• if demonstrable lesion: surgery
• if no demonstrable lesion: bromocriptine, cabergoline (if fertility desired)
CHC if no fertility desired

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60
Q

Unpredictable AUB

A

Ovulatory dysfunction

Malignancy/hyperplasia

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61
Q

Regular heavy AUB

A

Adenomyosis
Leiomyoma,sm
Endometrial
Coagulopathy

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62
Q

Regular cycles, intermenstrual AUB

A

Polyp

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63
Q

1st question in AUB

A

Regular?

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64
Q

If regular bleed, 2nd question?

A

Heavy?

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65
Q

Definition of 1ْ amenorrhea

A

No menses by age 13 (if no 2ْ sexual characteristics)
No menses by age 15 (with 2ْ)
No menses 2 yr after thelarche

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66
Q

Definition of 2ْ amenorrhea

A

No menses for > 6 mo

No menses for 3 cycles

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67
Q

3 questions to ask in AUB

A

Regular?
Heavy?
Intermenstrual bleeding?

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68
Q

AUB, Polyp Dx, Mx

A

TVS
SHG
Polypectomy

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69
Q

AUB, Adenomyosis

A

TVS

MRI

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70
Q

AUB, Leiomyoma

A

TVS
SHG
Hysteroscopy

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71
Q

AUB, Malignancy/hyperplasia

A

TVS

Endometrial Bx

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72
Q

AUB, Coagulopathy

A 
CBC
Coagulation profile
vWF
Ristocetin
Factor VIII
Mx
OCP
Mirena IUD
Endometrial ablation
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73
Q

AUB, ovulatory

A 
Beta
Ferritin
FSH/LH
PRL
Androgens ( free test, DHEA, 17-oh prog)
Progesterone
TFT
Pelvic U/S
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74
Q

AUB, endometrial

A

Bx

Mx: tranex, hormonal, Mirena IUD, endometrial ablation

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75
Q

AUB, iatrogenic

A

TVS

Review meds

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76
Q

Tx of AUB

A

Resuscitate
Underlying
Medical
Surgical (endometrial ablation, hysterectomy)

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77
Q

Medication for mild AUB

A 
NSAIDs
Antifibrinolytics at time if menses
Combined OCP
Progestin (10-14d/m or q 3 mo)
Mirena IUD
Danazol
Correct anemia
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78
Q

Medication for acute, severe AUB

A 
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

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79
Q

Primary dysmenorrhea associati

A

Dyspareunia
AUB
Infertility

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80
Q

Mx of 1ْ dysmenorrhea

A

NSAIDs

OCP

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81
Q

Investigations for dyspareunia

A 
Bimanual exam +/-
U/S
Laparoscopy
Hysteroscopy
Infection screening
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82
Q

RFs for endonetriosis

A

FHx
Obstructive anomalies
Nulliparity
Age> 25

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83
Q

Triad of endometriosis

A

Dysmenorrhea
Dyspareunia
Dyschezia

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84
Q

Definite Dx of endometriosis

A

Laparoscopy and Bx (not required)

CA-125 (increased but not to be used for Dx)

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85
Q

Mainstay if endometriosis management

A

Menstrual suppression

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86
Q

1st line in suspected endometriosis

A

NSAIDs+
CHC (best continuous)
Progestin alone

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87
Q

No response to 1st line Tx of endometriosis

A 
Either:
•2nd line:
GnRH + addback 
progestin IUS
Danazol
• laparoscopic Dx and Tx
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88
Q

No response to 2nd line or laparoscopic Tx

A

Reconsider Dx

Chronic pain management

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89
Q

Definitive Tx for endometriosis

A

BSO

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90
Q

Best time to become pregnant in endometriosis

A

Immediately after laparoscopic conservative surgery

If no plan to become pregnant post-op: medical suppression

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91
Q

Size of uterus in adenomyosis

A

<14 cm

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92
Q

Halban sign

A

Adenomyosis

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93
Q

Adenomyosis Dx

A

Clinical+/-
U/S
MRI
Bx

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94
Q

Adenomyosis Tx

A 
Iron 
Analgesics, NSAIDs
OCP
MPA
GnRH
Mirena
Danazol
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95
Q

Definitive Tx for adenomyosis

A

Hysterectomy

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96
Q

Fibroid malignant potential

A

1/1000

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97
Q

Consideration of malignancy in fibroids

A

If enlarging in post-menopausal women

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98
Q

Most common symptom of fibroids

A

Asymptomatic
AUB
Most symptomatics: submucosal

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99
Q

Leiomyoma investigations

A 
CBC
U/S
SHG (to differentiate SM myoma from polyps)
Endometrial Bx (if AUB > 40)
MRI (preoperative planning)
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100
Q

Tx indications for fibroid

A

Symptomatic

Intracavitary

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101
Q

Conservative approach for myoma if

A 
Minimal symptoms
< 6-8 cm
Stable in size
Not submucosal
Pregnant
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102
Q

Myoma in pregnant women

A

Watch and wait
F/U U/S if symptoms progress
Best to avoid operating on it

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103
Q

If myoma with AUB

A

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

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104
Q

Ulipristal actate

A

Progesterone receptor antagonist

Causes endometrial changes, reversible with D/C

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105
Q

Most effective EPC

A

Postcoital IUD

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106
Q

Efficacy of transdermal contraceptive patches decreased in women weighing

A

> 90 kg

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107
Q

Time of starting hormonal contraceptive

A

Any time during the cycle

Best: within 5 d of LMP

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108
Q

Required exams before starting hormonal contraceptives

A

Breast exam
BP
F/U at 6 wk

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109
Q

OCP on ovary

A

Decreased cyst decelopment

Decreased cancer

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110
Q

OCP on endometrium

A

Decreased cancer

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111
Q

OCP on breast

A

Decreased benign disease

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112
Q

OCP on bone

A

Osteoporosis protection

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113
Q

OCP on liver

A

Adenoma (est)

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114
Q

Drugs decreasing efficacy of OCP

A 
Rifampin
Phenobarbital 
Phenytoin
Griseofulvin
Primidone
St John’s Wort
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115
Q

OCP in pregnancy and lactation

A

Absolute contra in pregnancy
Not recommended until 6 wk postpartum
3 mo postpartum if breastfeeding
May decrease milk production

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116
Q

Breakthrough bleeding with low-dose OCPs

A

If longer than 3 mo, switch to higher estrogen content

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117
Q

Progestin in Yasmin/Yas

A

Drospirenone: antimineralocorticoid, antiandrogenic

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118
Q

Contra of Yas/Yasmin

A

Renal/adrenal insufficiency (hyperkalemia)

Check K if also on: ACEI, ARB, K sparing diuretics, heparin

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119
Q

Contraceptives that must be taken at the same time everyday

A

POP

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120
Q

POP contra

A

None

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121
Q

Suitable hormonal contraceptive for postpartum women

A

POP

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122
Q

Hormonal contraceptives producing functional ovarian cyst

A

POP

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123
Q

Hormonal method with highest failure rate

A

POP

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124
Q

Missed 1 OCP pill in <24h

A

1 ASAP

The next pill at the usual

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125
Q

Miss >1 pill in a row in 1st wk

A

1 ASAP
Continue 1 pill/d until the end of the pack
+ back-up contra for 7 d
+/- EPC

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126
Q

Miss 2 pills in 2nd or 3rd wk

A

1 ASAP
Continue 1 pill daily until the end of pack
No placebo, No free interval
Start next pack immediately

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127
Q

Miss 3 or more pills in 2nd or 3rd wk

A 
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
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128
Q

No need for back-up in case of missed OCP

A

Missed 1 pill in <24 h

Missed 2 pills in 2nd or 3rd wk

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129
Q

Need for back-up in case of missed OCPs

A

Miss more than 1 pill in a row in 1st wk

Miss 3 or more pills in 2nd or 3rd wk

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130
Q

Summary of 1st wk

A

• miss 1 pill <24h
1 ASAP + continue
• miss 2 or more
1 ASAP + continue + back-up 7d +/- EPC

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131
Q

Summary of 2nd-3rd wk

A

• 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

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134
Q

Timing of MPA after delivery

A

Immediately (BF/ non-BF)

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135
Q

Timing of MPA in usual cases

A

Within 5 d of beginning of normal menses

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136
Q

MPA on bones

A

Decreased bone density(may be reversible)

Encourage vit D, Ca, daily exercise

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137
Q

Restoration of fertility after MPA

A

Up to 9 mo

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138
Q

Missed POP

A

If > 3 h, back-up for at least 48 h

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139
Q

Missed MPA + negative beta

A

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

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140
Q

Yuzpe combination

A

Estradiol 100
Levonorgestrel 500
Can substitute with any OCP with same dose of estrogen

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141
Q

Yuzpe method

A 
Within 72 h
Up to 5 d
2 tabs, repeat in 12 h
Contra: no absolute
Caution if contra to OCP
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142
Q

Plan B formulation

A

Levonorgestrel 750

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143
Q

Plan B method

A

1 tab, repeat after 12 h
Within 72 h
Up to 5 d
No caution for contra to OCP

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144
Q

Choice ECP after 24 h

A

Plan B

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145
Q

Plan B not recommended for

A

> 80 kg

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146
Q

Ulipristal method

A

30 mg PO within 5 d

No caution in OCP contra

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147
Q

EPC with IUD

A

Copper
Up to 7 d
Mirena cannot be used

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148
Q

1st line contraceptive for adolescents

A

Implants, IUDs, that do not affect BMD

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149
Q

F/U on EPC

A

In 3-4 wk
Beta test or spontaneous mense
Contra counseling

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150
Q

Gold std medical method of abortion up to 9 wk

A

Mifepristone + misoprostol

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151
Q

Medical methods of abortion

A
  • mifepristone+ misoprostol
  • misoprostol aline
  • MTX+misoprostol
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152
Q

Surgical abortion methods

A

<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

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153
Q

Septic spontaneous abortion Tx

A

IV AB 24h

Then uterine evacuation

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154
Q

Embryonic demise

A

CRL 7 mm or more and no cardiac activity

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155
Q

Most common location for EP

A

Ampullary

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156
Q

Most common etiology of EP

A

PID (chlamydia Trachomatis)

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157
Q

Suspected EP

A

Urine beta

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158
Q

Unstable EP (+ urine beta)

A

Surgery

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159
Q

Stable EP

A

TVS

Serum beta

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160
Q

Surgical management if any of:

A
  • > 3.5 cm
  • beta>5000
  • renal/liver/hemato disease
  • FHR present
  • poor compliance
  • unable to F/U
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161
Q

MTX for EP if

A
  • <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
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162
Q

Investigation for EP

A

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

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163
Q

Normal beta doubling time

A

1.6-2.4 d

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164
Q

Surgical options

A

•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
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165
Q

Medical Tx for EP

A

MTX 50/m2 IM single dose

Then weekly beta

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166
Q

2nd dose of MTX if

A

Beta not decreased by at least 15% between days 4-7 (in 25% of cases)

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167
Q

Tubal potency after MTX for EP

A

80%

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168
Q

Mx of abortion

A

R/O EP
Check Rh
Ensure stability
Wait and watch or misoprostol or D&C

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169
Q

Prenatal DES exposure

A

Infertility with uterine factors

Clear cell adenocarcinoma of vagina

170
Q

Infertility female tests

A 
•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
Q

When to investigate for infertility

A

<35y, after 1 y
35-40, after 6mo
>40, immediately

172
Q

Earlier investigation if

A 
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
Q

Proper intercourse timing

A

From 2 d prior to 2 d following presumed ovulation, every other day

174
Q

Ovulation induction methods

A 
•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
Q

Normal semen

A 
Abstinence: 2-7d
Volume: 1.5cc
Count:15 million/cc
Vitality:58%
Motility:40%
Progressive:32%
Normal morphology:40%
176
Q

Criteria for PCOS

A

Oligomenorrhea/irregular menses for 6 mo
Hyperandrogenism(clinical or free test)
PCO on U/S

177
Q

PCOS in adolescence

A

Polycystic ovaries on U/S not an appropriate criteria

Wait 1-2 y before Dx

178
Q

Aim of investigations for PCOS

A

identify hyperandrogenism
Identify chronic anovulation
R/O pituitary or adrenal cause

179
Q

Tests for PCOS

A

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
Q

Cycle control in PCOS

A

Lifestyle: exercise, decrease BMI

OCP, MPA (to prevent endometrial hyperplasia)

Metformin: if DM2, trying pregnancy

Tranex: menorrhagia

181
Q

Infertility Tx in PCOS

A

Induction of ovulation: clomiphen citrate, letrozole, HMG, LHRH, recombinant FSH, metformin

Ovarian drilling, wedge resection

Bromocriptine, if hyperPRL

182
Q

Tx of hirsutism in PCO

A

OCP
Mechanical removal
Finasteride, flutamide, spironolactone

183
Q

Normal discharge pH

184
Q

Prepubertal vulvovaginitis investigation

A

Vaginal swab for culture (state the age)

pH, wet mount, KOH (for adults)

185
Q

Etiology of vaginal bleeding in prepubertal vulvovaginitis

A

GAS
Shigella
Endocrine abnormality
Blood dyscrasia

186
Q

Most common prepubertal gynecological problem in girls

A

Non-specific vulvovaginitis

187
Q

RFs of candida vulvovaginitis

A

Diaper
Chronic AB
Chronic immunosuppression

188
Q

Vulvovaginitis due to increased estrogen levels

189
Q

Cottage cheese discharge

190
Q

Asymptomatic candidiasis VV

191
Q

VV with intense pruritus

192
Q

pH in VV candidiasis

A

4.5 or less

193
Q

VV candidiasis Tx in pregnancy

A

Usually topical

Can use fluconazole 150 single dose

194
Q

Prophylaxis for recurrent candidiasis VV

A

Boric acid
Vaginal suppositories
Luteal phase fluconazole

195
Q

Partner in candidiasis?

A

Routine Tx not needed

196
Q

Discharge in BV

A

Grey, thin, diffuse,

197
Q

Fishy odor

198
Q

Asymptomatic BV

199
Q

Absence of irritation

200
Q

pH in BV

A

4.5 or more

201
Q

Clue cells

A

BV (squamous dotted with coccobacilli)

20%

202
Q

Paucity of WBC in discharge

203
Q

Paucity of lactobacilli

204
Q

Positive whiff test

205
Q

BV Tx indications

A

Pregnancy
Symptomatic
Pelvic surgery/procedure

206
Q

Tx of BV

A

Metro 500 PO BID x 7d
Metro gel OD x 5d
Clinda intravaginal x7d
Probiotics oral or topical (lactobacillus)

207
Q

Tx of partner in BV?

208
Q

Obstetric complications of BV

A

Preterm labour

Postpartum endometritis

209
Q

BV Tx in pregnancy

A

Topical metro

Oral metro?

210
Q

Missed MPA

A

If last injection given 13-14 wk prior, give next immediately
If >14 wk prior, check beta

211
Q

Petechiae on cervix and vagina

A

Trichomonas vaginalis

212
Q

VV with sexual transmission

213
Q

Discharge in TV

A

Yellow-green, malodorous, diffuse, frothy

214
Q

Asymptomatic TV

215
Q

pH in TV

A

4.5 or more

216
Q

Flagellated organism on wet mount

217
Q

Many WBC/PMN

218
Q

Treatment indications

219
Q

Tx of TV

A

Metro 2g PO single dose

Metro 500 bid x 7d

220
Q

Tx of TV in pregnancy

A

Metro 2g once

221
Q

Partner in TV

A

Should treat

222
Q

Detection of HPV latent infection

A

DNA hybridization test

223
Q

Subclinical HPV infection detection

A

Colposcopy

Pap-smear

224
Q

Tx of HPV

A 
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
Q

HPV Tx in pregnancy

A

TCA 80-90%

226
Q

HSV incubation

A

2-21d (7-10d)

227
Q

HSV detection

A

Viral culture if ulcer present
Tzanck
HSV DNA PCR
Serologic tests

228
Q

Indication of C-section in genital wart

A

Obstruction of birth canal

Risk of extensive bleeding

229
Q

Condyloma in pregnancy

A

Tend to get larger

Should be treated early

230
Q

HSV Tx

A

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
Q

Most Sn/Sp test for syphilis

A

Darkfield microscopy

232
Q

Syphilis tests negative after treatment:

233
Q

Syphilis Tx

A

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
Q

Partner in syphilis?

A

Screen and treat

235
Q

Most common genital ulcer

236
Q

2nd most common genital ulcer

237
Q

Most common bacterial STI

A

Chlamydia Trachomatis

238
Q

Asymptomatic chlamydia

A

80% of women

239
Q

Discharge in chlamydia

A

Mucopurulent, endocervical

240
Q

Urethral symptoms

A

Candida
TV
Chlamydia
HSV

241
Q

CDC notifiable diseases

A 
Chancroid
Chlamydia
Gonorrhea
Hepatitis A,B,C
HIV
Syphilis
242
Q

Missed MPA+ positive beta

A

EPC

And no injection

243
Q

Intermenstrual bleeding

A

Polyp
Chlamydia (particularly if on OCP)
Endometrial carcinoma

244
Q

Chlamydia Dx

A

Cervical culture/nucleic acid amplification test
Definitive std: tissue culture
Urine/self vaginal tests
(Urine culture negative, but pyuria)

245
Q

Tx of Chlamydia

A

Doxy 100 PO bid x7d
Azithro 1g PO single dose
+ gonorrhea Tx

246
Q

Partner in chlamydia?

247
Q

Chlamydia in pregnancy

A

Azithro

Test of cure required in 3-4 wk

248
Q

Screening for chlamydia

A

When initiating OCP in sexually active

High risk group

Pregnancy

249
Q

Organism that needs to be screened for when initiating OCP

250
Q

Hepatic complication of chlamydia

A

Fitz-Hugh-Curtis (liver capsule inflammation)

251
Q

Gonorrhea Dx

A

Gram stain

Cervical/rectal/throat culture (if clinically indicated)

252
Q

Tx of gonorrhea

A

Ceftriaxone 250 IM single + azithro 1g

253
Q

Tx of gono in pregnancy

A

Ceftriaxone 250 + azithro 1g

Spectinomycin 2g IM + azithro 1 g

254
Q

STI testing

A

Vaginal swab: candida, BV,TV

Cervical swab: gono, chla

255
Q

Indications of test of cure for gono/chla

A

Symptomatic
Uncertain compliance
Pregnant

256
Q

Bartholin gland abscess microorganisms

A

Anaerobic, polymicrobial

257
Q

Bartholin Tx

A 
Sitz bath
Warm compress
Cephalexin +
I&amp;D + Word cath 2-3wk
Marsupialization
Remiving gland
258
Q

Most common cause of PID

A

Chlamydia

Gonorrhea

259
Q

Cause of recurrent PID

A

Endogenous flora

260
Q

Cause if PID associated with instrumentation

A

Endogenous flora

261
Q

Organism associated with IUD

A

Actinomyces israelii (not the most common cause of course!)

262
Q

How long does IUD increase the risk of PID?

263
Q

Asymptomatic PID

264
Q

Most common etiology of chronic PID

265
Q

PID investigations

A 
Beta
CBC
B/C (if suspect septicemia)
Urine R&amp;M
Vaginal swab
Cervical swab
Definitive Dx: endometrial Bx
U/S
Laparoscopy (gold std)
266
Q

The must have symptom for Dx of PID

A

Lower abdominal pain

267
Q

Required signs for Dx of PID

A

Cervical morion tenderness
Or
Adnexal tenderness

268
Q

Tx of PID

A

polymicrobial coverage

269
Q

Tx in case of admitted PID

A

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
Q

Outpatient Tx of PID

A

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
Q

IUD removal in PID

A

After a minimum of 24 h of treatment

272
Q

Partner treatment in PID?

273
Q

Report PID?

274
Q

Re-testing for PID?

A

For chlamydia/gonorrhea 4-6 wk ofter treatment if documented infection

275
Q

Foreign body duration for TSS

276
Q

TSS Tx

A 
Remove potential source of infection
Debride necrotic tissue
Hydration
Penicillinase-resistant AB (cloxacillin)
Steroid within 72 h
277
Q

Pelvic cellulitis

A

Post hysterectomy
Tx if: fever, leukocytosis
Tx: clinda+genta
+ drain if excessive purulence/large mass

278
Q

Dietary changes for vestibulitis

A

Increased citrate

Decreased oxalate

279
Q

Menopause definition

A

Lack of menses for 1 y

Average age:51

280
Q

Primary ovarian insufficiency

A

Before age 40

281
Q

Menopause Dx

A

Use:absence of menses for 1 y
FSH (day 3) > 35
Increased LH
Decreased estradiol

282
Q

Vasomotor instability Tx

A

1st line: HRT (low dose, short duration < 5y)

Others: SSRI, venlafaxin, gabapentin, clonidine, propranolol, acupuncture

283
Q

Vaginal atrophy Tx

A

Local estrogen
Lubricant
HRT
Laser

284
Q

Urogenital health

A

Lifestyle: weight loss, bladder re-training, local estrogen, surgery

285
Q

Osteoporosis

A 
1000-1500 mg Ca/d
800-1000 unit Vit D
Weight-bearing exercise
Smoking cessation
Bisphosphonate
SERM: raloxifene 
2nd line: HRT
286
Q

Raloxifene

A

Estrogen effect on bones

No effect on breast/uterine

287
Q

Decreased libido

A

Lubrication
Counseling
Testosterone cream

288
Q

CVD Tx

A

RF Mx

Absolute contraindication of HRT!

289
Q

Mood and memory

A

1st line: anti-depressant

HRT

290
Q

Perimenopause

A

2-8 y preceding to 1 y after last mense
Fluctuating hormones
Irregular menses
Symptom onset

291
Q

Breast cancer risk with hormonal therapy:

A

Increased if estrogen + progesterone

Not increased with estrogen-only HRT

292
Q

Preferred HRT route

A

Transdermal

Especially if hyper TG, impaired hepatic function, smoker, headache with oral HRT

293
Q

Bleeding episode in a post-menopausal amenorrheic woman on OCP

A

Endometrial Bx

294
Q

HRT with PMS symptoms

A

Std dose cyclic

295
Q

HRT and cognitive impairment

A

Increased cognitive impairment if taken after 65 y (combined> estrogen only)

Reduced risk of dementia if taken < 65y

296
Q

Benefits of HRT

A

Vasomotor
Osteoporosis
Colon cancer

297
Q

Gynecological cancer whose RF in diabetes

A

Type I and II endometrial carcinoma

298
Q

Cancer with Tamoxifen

A

Endometrial, type 1

299
Q

Abn endometrial thickness in post-menopause women with AUB

A

5mm or more

300
Q

Uterus size in endometrial carcinoma

301
Q

If endometrial carcinoma suspected

A

Endometrial Bx
D&C +/- hysteroscopy
+/- pelvic U/S (if adequate sampling not feasible)

302
Q

U/S role in endometrial carcinoma

A

Not suitable for screening test

Not acceptable as alternative to pelvic exam or endometrial Bx to R/O cancer

303
Q

Endometrial carcinoma Tx

A

1st step: TAH/BSO
+ pelvic washing
+/- pelvic/para-aortic node dissection
+/- omentectomy

Better QOL if laparoscopic

304
Q

Adj RT for Endometrial carcinoma

A

If high risk of local recurrence

305
Q

Adj chemo for endometrial carcinoma

A

If mets
Or
High risk of mets (based on histologic findings)

306
Q

Chemo for endometrial cancer

A

If recurrent disease (if high grade)

307
Q

Hormonal therapy for endometrial carcinoma

A

Progestin

For recurrent disease (if low grade)

308
Q

Most important prognostic factor in endometrial carcinoma

A

FIGO stage

309
Q

Post-menopausal woman with rapidly enlarging uterus

A

Consider leiomyosarcoma

Perform an endometrial Bx

310
Q

Tx differences between leiomyosarcoma and endometrial carcinoma

A

No routine LND

No role for RT

311
Q

Cancer increased by fertility drugs

A

Ovarian epithelial carcinoma

312
Q

Drug reducing risk of ovarian cancer

313
Q

Marker of epithelial cell tumor

314
Q

Granulosa cell tumor marker

315
Q

Sertoli-Leydig tumor marker

316
Q

Dysgerminoma marker

317
Q

Yolk sac tumor marker

318
Q

Choriocarcinoma

319
Q

Immature teratoma marker

320
Q

Embryonal cell marker

321
Q

Omental cake

A

Ovarian cancer

322
Q

Mass screening for endometrial cancer

323
Q

Mass screening for ovarian cancer

324
Q

Indications of screening for ovarian cancer

A
  • > 1 1st degree relative with ovarian cancer, BRCA1 mutation
  • Hx of endometrial/breast/colon cancer
  • BRCA1/2 mutation
325
Q

Method of screening

A

CA-125
TVS
Starting age:30

326
Q

If BRCA1/2 mutation

A

Prophylactic bilateral oophorectomy after age 35/after completed child bearin

327
Q

Symptomatic/suspicious adnexal mass

A

Sugical exploration

328
Q

Follicular mass U/S

A

4-8 cm

Unilacular

329
Q

Follicular mass Mx

A

If not suspicious/asymptomatic and <6cm :
Wait 6 wk + OCP
If no regression: laparoscopy

330
Q

Corpus luteum vs follicular cyst

A

Corpus luteum more likely to cause pain, may delay onset of next period, larger(10-15cm) , firmer

331
Q

Mx of corpus luteum cyst

A

Same as follicular

332
Q

Cyst generated by abn beta levels

A

Theca-Lutein

eg: molar pregnancy, clomiphene

333
Q

Drug causing theca-lutein cyst

A

Clomiphene

334
Q

Mx of theca-lutein cyst

A

Conservative

Treat high beta levels

335
Q

The most common ovarian germ cell neoplasm

A

Dermoid (cystic teratoma)

336
Q

Pathognomonic finding in benign teratoma

A

Calcification

337
Q

Tx of dermoid cyst

A

Laparoscopic cystectomy

338
Q

Tumors for which total resection is not necessary due to high response rate to chemo

A

Dysgerminoma

Immature teratoma

339
Q

Most common ovarian tumor

340
Q

Psamomma body

341
Q

Pseudyxoma peritonitis

342
Q

Enormous size

343
Q

Need to remove appendix

344
Q

Poor response to chemo

345
Q

Meig’s syndrome (benign ovarian tumor and ascitis and pleural effusion)

A

Fibroma/thecoma

346
Q

Ovarian tumor associated with endometrial cancer

A

Granulosa-theca cell tumor

347
Q

Precocious puberty

A

Granulosa-theca (estrogen)

348
Q

Postmenopausal bleeding

A

Granulosa-theca

349
Q

Menorrhagia

A

Granulosa-theca

350
Q

Call-exner bodies in histology

A

Granulosa-theca

351
Q

Virilizing effects

A

Sertoli-Leidig

352
Q

Krukenberg

A

Metastatic ovarian tumor from stomach/colon/breast source

Signet ring cells

353
Q

Investigations for ovarian cancer

A

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
Q

Nabothian cyst

A

Benign cervical ct

355
Q

Gynecological malignancy with smoking RF

356
Q

Barrel-shaped cervix

A

Adenocarcinoma

357
Q

Normal Pap

A

Repeat in 1-3 yr

358
Q

Inadequate sample

A

Repeat in 3 mo

359
Q

Pap: ASCUS

A

Age?
30 or higher: HPV-DNA testing
Less than 30: repeat pap in 6 mo

360
Q

ASCUS, above 30, positive HPV-DNA test

361
Q

ASCUS, below 30, repeated in 6 mo: ASCUS

362
Q

ASCUS, above 30, negative HPV

A

repeat cytology in 12 mo

363
Q

ASCUS, below 30, negative repeated cytology after 6 mo, next step?

A

Repeat cytology in 6 mo

364
Q

ASCUS, below 30, negative repeated cytology, negative again after another 6 mo

A

Routine screen in 3 year

365
Q

ASCUS, below 30, negative ctopogy in 6 mo, ASCUS in 3rd cytology in 6 mo

366
Q

ASC-H

367
Q

AGUS

A

Colpo +/- endometrial Bx

368
Q

LSIL

A

Either colpo or repeat cytology in 6 mo

369
Q

LSIL, negative after 6 mo

A

Repeat in 6 mo

370
Q

LSIL, if ASCUS or more after 6 mo

371
Q

LSIL, negative in 6 mo, again negative in 6 mo

A

Routine screening in 3 years

372
Q

LSIL, negative in 6 mo, but ASCUS or more in 2nd repeat in 6 mo

373
Q

HSIL

374
Q

Any malignant changes on Pap

375
Q

Marker for monitoring ovarian cancer response to treatment

376
Q

Cold knife conization indication

A

Suspicion of glandular abnormality

377
Q

Indications for LEEP

A

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
Q

Gardasil age

A

Females: 9-45
Males: 9-26

379
Q

Cervarix age

A

Females 10-25

380
Q

Conception after HPV vaccin

A

Avoided until 30 days

381
Q

Endocervical curettage indication

A

No lesion on colpo

Entire lesion not visible

382
Q

Pap in pregnancy

A

At all initial prenatal visits

383
Q

Time of diagnostic conization during pregnancy

A

2nd trimester

384
Q

Dysplasia Mx during pregnancy

A

Deferred until completion of pregnancy

385
Q

Delivery mode in presence of dysplasia

386
Q

Invasive cervical cancer in pregnancy

A

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
Q

CIN I Mx

A

Observation

Repeat assessment and cytology in 12 mo

388
Q

If cytology: HSIL/AGC

And then: CIN

A

Review of cytology and histology

If discrepancy remains, excisional Bx

389
Q

If CIN II/III

A

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
Q

Age of hyperplastic dystrophy of vulva

A

Post menopausal

391
Q

Tx of hyperplastic dystrophy

392
Q

Most common age of lichen sclerosis

A

Post menopausal

393
Q

VIN Tx

A

Local excision
Ablation
Imiquimod

394
Q

Most important predictor of prognosis in vulvar cancer

A

Nodal involvement

2nd most important: tumor sizea

395
Q

Schiller test

A

For Dx of abn squamous epithelium of vagina (doesn’t take up Lugol)

396
Q

Most common site of vaginal SCC

A

Upper 1/3 of posterior wall

397
Q

Vitamin deficiency implicated in mole formation

A

Vit A

B-carotene

398
Q

The most common symptom of complete mole

A

Vaginal bleeding

399
Q

Complete mole chromosome

400
Q

Incomplete mole chromosome

A

XXX, XXY, XYY

401
Q

Risk of malignant sequelae for complete mole

402
Q

Risk of malignant sequelae for incomplete mole

403
Q

Presentation of incomplete mole

A

Threatened/spontaneous/missed abortion

404
Q

Mole investigation

A

Beta
U/S
CXR

405
Q

U/S of complete mole

A

Snow storm

406
Q

U/S of incomplete mole

A

Degeneration of placenta
Multiple echogenic regions
Fetal abnormalities

407
Q

High risk of persistent GTN following mole evacuation

A

Uterine invasion as high as 31%
Beta >100000
Excessive uterine size
Prominent theca-lutein cyst

408
Q

Mole Tx

A

Suction D&C with sharp curettage
+oxytocin
+Rhogam
Consider: histerectomy

409
Q

F/U of mole

A

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
Q

HTN <20 wk in pregnancy

A

Think GTD/GTN

411
Q

GTN with relative insensitivity to chemo

A

Placental site trophoblastic tumor

412
Q

Features of bad prognosis in metastatic GTN

A 
Long duration from pregnancy (>4mo)
Beta>100,000/24h urine
Beta>40,000/ blood
Brain/liver mets
Prior chemo
Following term pregnancy
413
Q

GTN investigation

A

CBC, lytes, Cr, beta, TSH, LFT

CXR, U/S pelvis, CT abdo/pelvis, CT brain

414
Q

If suspect brain mets, but negative CT

A

LP:

If plasma beta/CSF beta <60: mets

415
Q

Stage 1 GTN Tx
Confined to uterine corpus

Stage 2: mets to genital

Stage 3: mets to lungs

A

•if low risk: pulsed actinomycin (1st line)
Alternative: MTX

•if high risk: combination chemo

416
Q

Stage 4 GTN

Mets to brain, liver, kidney, GI tract

A

Combination chemo
+ surgical resection of sites of disease persistence, resistance to chemo
+/- RT for brain mets

417
Q

No1 place for GTN mets

418
Q

F/U for GTN

A

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
Q

GTN Dx

A

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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