Gynecology

Question 1

Absolute contradictions to combined hormonal contraception

Answer 1

Migraine w/ aura
Postpartum (4w BFing, 21w not BFing)
Smoker 35+ yo
Vascular disease (VTE, CAD, CVA)
HTN
Coag (thrombophilia, SLE w/ APA)
Prolonged immobilization 
Cancer 
Cirrhosis

Question 2

Absolute contradictions to hormonal IUD

Answer 2

Pregnancy 
Recent PID, STI, sepsis, septic abortion
Distorted uterine cavity 
Cervical/endometrial cancer
Breast ca w/ progesterone receptor 
Unexplained vaginal bleed

Question 3

Symptoms of endometriosis

Answer 3

Dysmenorrhea 
Dyspareunia
Dyschezia, dysuria
Low back/abdo/pelvic pain
Infertility

Question 4

Medical management of endometriosis

Answer 4

Continuous combined contraceptive
Progestin
IUD
Analgesia (NSAIDs to opioids)

Question 5

Risks of combined hormonal contraceptives

Answer 5

VTE (2-3 fold increase)
If >50 mcg estrogen: MI, CVA
Do not cause cancer

Question 6

Emergency contraception:

Options and when to use them

Answer 6

Copper IUD: best. Effective up to 7 days.

Hormonal: up to 5 days. Not effective on day of ovulation.

Question 7

Who should consider progestin-only contraceptive?

Answer 7

Smoker >35
Migraines
Breast feeding
Endometriosis
Anti-convulsivants 
Sickle cell

Question 8

How to take progestin-only contraceptive pill

Answer 8

No pill-free days
Start on 1st day of cycle (otherwise use backup x 7 days)
Same time every day (within 3h)

Question 9

Symptoms of fibroids

Answer 9

Often asymptomatic
Abnormal bleeding (menorrhagia) 
Pelvic pressure
Bowel/bladder symptoms
Pain (rarely, associated with degeneration/torsion/adenomyosis)
Infertility

Question 10

Pharmacologic management of fibroids (1st line)

Answer 10

IUD, GnRH agonist (leuprolide), progesterone modulator (ulipristal)

note: If menorrhagia, do endometrial biopsy to r/o lesion (leiomyosarcoma)

Question 11

Causes of ovulatory dysfunction (infertility)

Answer 11

PCOS
POF
prolactinoma
thyroid disease
Cushing's syndrome

Question 12

Testicular causes of male-factor infertility

Answer 12

varicocele (most common reversible cause)
infections (STI, mumps, TB)
Klinefelter
torsion

Question 13

3 things to check for all women wanting to conceive

Answer 13

Taking folic acid?
Rubella immune? (if not, vaccinate)
Varicella immune? (if not, vaccinate)

Question 14

Indications for referral for infertility

Answer 14

<35 after 1 year of trying
35-40 after 6 months
>40 immediately

Women: Hx of endometriosis, PID, STI, amenorrhea, pelvic pain
Men: abnormal semen analysis, STI, UG symptoms, varicocele

Question 15

When to assume a woman is sterile (menopause)

Answer 15

If not on contraceptive:
>50 amenorrheic x 1 year
<50 amenorrheic x 2 years

Question 16

6 main symptoms of menoapuse

Answer 16

changes in periods
hot flashes (and other vasomotor)
vaginal dryness or dyspareunia 
bladder issues, incontinence
sleep 
mood

Question 17

side effects and risks of HT for menopause

Answer 17

breast cancer (with combined, but not with estrogen only)
VTE
Stroke and other CV events
cholecystitis
liver issues
pruritus
breast pain
uterine bleeding
nausea, headache, weight change

Question 18

Two cases where HT is recommended 1st line for menopause

Answer 18

1: vasomotor symptoms in <60yo, <10y after menopause, no CI’s
2: POF or premature menopause, no CI’s (treat until expected menopause)

Question 19

HT for menopause: estrogen? progesterone? oral or transdermal?

Answer 19

Has uterus: P+E
No uterus: just E
Risk of VTE/CVD: transdermal is better

Question 20

Hormonal treatment for vaginal dryness

Answer 20

Estrogen (Premarin, Vagifem, Estring)
No need for progesterone, as minimal systemic absorption
OK even if Hx of VTE

Question 21

PCOS diagnostic criteria

Answer 21

2 out of 3:

• Clinical hyperandrogenism or biochemical (elevated total/free T)
• Oligomenorrhea/oligo-ovulation (less than 6-9 menses per year)
• Polycystic ovaries on U/S

Question 22

meds for PCOS

Answer 22

combined OCP monthly
metformin BID
(Cyclic Provera 10-14d q 2-3 months. Helps with cancer, but not with androgenism and not contraceptive)

Question 23

Meds for hirsutism in PCOS

Answer 23

Combined OCP monthly (Diane 35 is anti-androgenic)
Spironolactone
Finasteride
Flutamide