Gynecology

Question 1

What bacteria cause vaginal infections in prepubertal females?

Answer 1

Shigella
Strep pyogènes

Question 2

In what populations is trichomonas found?

Answer 2

Infants
Sexually active people

Question 3

What is the most common vaginal pathogen?

Answer 3

Candida albicans

Question 4

What is the treatment for bacterial vaginosis?

Answer 4

Metronidazole
500 mg orally bid for 7 days

Metronidazole gel 0.75%
One full applicator vaginally daily for 5 days

Clindamycin 300 mg PO BID x 7: days

Question 5

What is the treatment of vulvovaginal candidiasis?

Answer 5

Clotrimazole 1% cream
5 g intravaginally for 7–14 days

Clotrimazole 100-mg vaginal tablet
One vaginally daily for 7 days

Or 2 tablets vaginally for 3 days

Oral agent: fluconazole 150 mg
Once orally

Question 6

What is the treatment of trichomoniasis?

Answer 6

Metronidazole
2 g orally as single dose

Tinidazole
2 g orally as single dose

Question 7

How is trichomoniasis transmitted?

Answer 7

Vertically or by sexual contact

Question 8

What is the presentation of trichomoniasis (postpubertal)?

Answer 8

pruritic, frothy, and yellowish discharge

“strawberry cervix” with multiple punctate areas of hemorrhage is pathognomonic

Question 9

How is trichomoniasis found?

Answer 9

Antigen testing (NAAT)

Question 10

What is the treatment of infant trichomoniasis?

Answer 10

PO metronidazole 15 mg/kg/day orally in two to three divided doses for 7 days

Question 11

What are the characteristics of bacterial vaginosis?

Answer 11

(i) a homogeneous, white adherent vaginal discharge; (ii) vaginal pH above 4.5; (iii) a fishy, amine-like odor released when 10% potassium hydroxide solution is added to a sample of the discharge; and (iv) the presence of clue cells (Amsel criteria)

Question 12

What are the bacteria that are overgrown in bacterial vaginosis?

Answer 12

Gardnerella vaginalis, Mobiluncus species, other anaerobes, and Mycoplasma hominis

Question 13

What symptoms go AGAINST the diagnosis of bacterial vaginosis?

Answer 13

Dysuria
Pruritis

Question 14

What are clue cells?

Answer 14

epithelial cells that are studded with large numbers of small bacteria giving them a granular appearance with shaggy borders

Question 15

What are the most common causes of cervicitis?

Answer 15

Neisseria gonorrhoeae and Chlamydia trachomatis and potentially Mycoplasma genitalium

Question 16

What are the symptoms of cervicitis

Answer 16

purulent vaginal discharge, intermenstrual bleeding, postcoital bleeding, and dyspareunia

Question 17

Treatment of cervicitis

Answer 17

empiric therapy for gonorrhea and chlamydia while awaiting test results. This can be treated with ceftriaxone (250 mg intramuscularly or intravenously + azithromycin (1 g orally), or doxycycline (100 mg orally twice a day for 7 days)

Question 18

What are the minimum diagnostic criteria for PID?

Answer 18

Sexually active patient with pelvic or lower abdominal pain, no cause other than PID identified, and one of the following:
Cervical motion tenderness or
Uterine tenderness or
Adnexal tenderness

Question 19

What is perihepatitis Fitz-Hugh–Curtis syndrome

Answer 19

right upper quadrant pain and tenderness produced by inflammation of the liver capsule in association with PID

Question 20

What is the treatment of PID?

Answer 20

1. Mild
   CTX 250mg IM + doxycycline 100mg PO BID X 14 days
2. Moderate-severe (abscess, systemically unwell, not responding to tx)
   CTX 1-2g daily + doxycycline 100mg BID + metronidazole 500mg BID

OR
Cefoxitin + doxycycline

Question 21

Treatment for primary HSV infection

Answer 21

Acyclovir 400 mg po tid for 7–10 days
OR
Acyclovir 200 mg po five times daily for 7–10 days
OR
Famciclovir 250 mg po tid for 7–10 days
OR
Valacyclovir 1 g po bid for 7–10 days

Question 22

Treatment for suppression of HSV infection

Answer 22

Acyclovir 400 mg po bid
OR
Famciclovir 250 mg po bid
OR
Valacyclovir 500 mg po once a day
OR
Valacyclovir 1 g po once a day

Question 23

Treatment of recurrent HSV infection

Answer 23

Acyclovir 400 mg po tid for 5 days
OR
Acyclovir 800 mg po bid for 5 days
OR
Acyclovir 800 mg po tid for 2 days
OR
Famciclovir 1,000 mg po bid for 1 day
OR
Valacyclovir 500 mg po bid for 3 days
OR
Valacyclovir 1 g po once daily for 5 days

Question 24

How should OCP be prescribed for abnormal uterine bleeding?

Answer 24

On a taper from q6h to once daily

Question 25

What are contraindications to estrogen therapies

Answer 25

migraine with aura, deep venous thromboembolism or pulmonary embolism, inherited prothrombotic disorders, systemic lupus erythematosus with positive or unknown antiphospholipid antibodies, hypertension (SBP >160 mm Hg or DBP >100 mm Hg), certain heart conditions (ischemic heart disease, complicated valvular heart disease, peripartum cardiomyopathy), certain liver conditions (hepatocellular adenoma, liver malignancy, severe cirrhosis), postpartum <21 days, stroke, current diagnosis of breast cancer, or history of complicated solid organ transplant

Question 26

Treatment of lichen sclerosis

Answer 26

topical, high-potency corticosteroids (clobetasol 0.05% ointment) applied to the affected area twice daily for 2 weeks. Patients should be reexamined at 2 weeks to assess for response. Patients usually require 6 to 12 weeks of treatment with topical steroids until symptoms and visible findings have resolved.

Question 27

What is the definition of oligomenorrhea?

Answer 27

an interval of more than 6 weeks between two menstrual periods.

Question 28

What is the definition of infrequent menstrual bleeding

Answer 28

one to two episodes of menstrual bleeding in a 90-day period

Question 29

What are the reportable STIs in canada?

Answer 29

Chlamydia
Gonorrhea
Syphilis

Question 30

Risk factors for ectopic pregnancy

Answer 30

• Previous ectopic
• Tubal surgeries
• PID
• Tubal abnormalities
• Assisted reproduction
• IUD

Question 31

Risk factors for PID

Answer 31

young age
large number of sexual partners
nonbarrier contraceptive methods

cigarette smoking
recent douching
bacterial vaginosis
previous gynecologic surgery
HIV infection

Question 32

What are the serious potential complications of PID?

Answer 32

tuboovarian abscess
infertility
chronic pelvic pain
ectopic pregnancy

Question 33

Specific/definitive criteria for PID

Answer 33

endometrial biopsy with evidence of endometritis
Laparoscopic abnormalities consistent with PID
Transvaginal US or MRI showing thickened, fluid-filled tubes or tuboovarian complex
Doppler studies showing tubal hyperemia

Question 34

Which has higher risk of infertility in PID - chlamydia or gonorrhea?

Answer 34

chlamydia

Question 35

Non STI bugs that can cause PID

Answer 35

anaerobes, Gardnerella vaginalis, Gram-negative rods, cytomegalovirus (CMV), M. genitalium

Question 36

Ddx vaginal bleeding pre-pubertal

Answer 36

• trauma
• Foreign body
• Genital warts
• Vulvovaginitis
• Lichen sclerosis
• Shigella vaginitis* (but can also happen with GAS, gonorrhea and chlamydia vaginitis)
• Tumour – endodermal sinus tumor, rhabdomyosarcomas, sarcoma botryoides)
• Vascular anomalies/malformations – eg. Infantile hemangioma
• Urethral prolapse with irritation

Question 37

What is a sarcoma botryoides?

Answer 37

presents as a polypoid, “grape-like” mass protruding from the introitus and often has metastasized to the lungs, pericardium, liver, kidney, and bones when initially diagnosed. Peak incidence is 2 years of age but this can present between 1 and 5 years old.