gynecology Flashcards
1
Q
bilateral nipple discharge
- dx?
- tests?
A
prolactinoma
tests: TSH, prolactin level
2
Q
unilateral non-bloody nipple discharge
A
intraductal papilloma
3
Q
w/u of nipple discharge
A
mammogram
surgical duct excision for definitive diagnosis
4
Q
Tx, fibrocystic disease
A
OCPs
severe pain - danazol
5
Q
steps in dx of any pt with a breast mass
A
- clinical breast exam
- imaging: USG or diagnostic mammo (>40 yo)
- FNA biopsy
6
Q
Tx. fibroadenoma
A
no tx. necessary
surgical removal may be done is mass is growing
7
Q
follow-up for a cytic mass that disappears on FNA (clear fluid)
A
CBE, 6 weeks after
- if mass has recurred, get repeat USG and FNA
8
Q
bloody aspirate from cyst must be…
A
sent for cytology
9
Q
in what cases do you need to get mammography
A
cyst recurs > 2x w/in 4-6 weeks blood fluid on aspirate mass does not disappear after FNA bloody nipple discharge skin edema or erythema present
10
Q
cluster of microcalcifications seen on mammogram - next step?
A
core biopsy
11
Q
DCIS - next step in management
A
lumpectomy + RT +/- tamoxifen
12
Q
LCIS - next step
A
tamoxifen for 5 years
-not necessary to perform surgery
13
Q
risks assoc with tamoxifen
A
endometrial carcinoma
thromboembolism
14
Q
breast ca. screening guidelines
A
mammogram every 1-2 years above age 50
15
Q
BRCA1/2 gene testing indications
A
- fhx of early onset breast or ovarian ca
- breast and/or ovarian ca in same pt
- fhx male breast ca
- ashkenazi jew
16
Q
when is BCT not indicated?
A
- pregnant pt
- 2+ sites in separate quadrants
- prior irradiation to breast
- positive tumor margins
- tumor > 5 cm
17
Q
HR+ therapy for post-menopausal women with breast ca.
A
aromatase inhibitors - anastrazole, exemestane, letrozole
18
Q
when can be LHRH analogs or ovarian ablation be used in breast ca?
A
alternative or additional therapy to tamoxifen in pre-meno women
19
Q
when is chemotx included in management of breast ca.
A
tumor size > 1 cm
LN positive disease
may be neo-adjuvant
20
Q
enlarged, firm, asymmetric and nontender uterus
A
leiomyoma
21
Q
symmetric, tender uterus that feels soft. pt c/o dysmenorrhea and menorrhagia - dx?
A
adenomyosis - endometrial glands and stroma located w/in myometrium; no change in size w/ high or low estrogen states
22
Q
U/S finding in adenomyosis
A
diffusely enlarged uterus with cystic areas w/in the myometrium
23
Q
definitive diagnosis of both adenomyosis and leiomyomas
A
histology
24
Q
Management: leiomyomas
A
- serial pelvic exams and observation
- myomectomy
- next deliveries must C/S due to risk of scar rupture
- preserves fertility - embolization of vessels
- preserves uterus - hysterectomy
- best choice once fertility is completed
25
tx. adenomyosis
```
IUD placement (levonorgestrol)
definitive therapy: hysterectomy
```
26
first step in management of any pt with postmenopausal bleeding
endometrial biopsy
27
normal size of endometrial lining stripe in postmeno women on u/s
< 5 mm thick
28
if endometrial ca. if found on biopsy - when do you add on RTH? CTH?
1. RTH - if LN mets, > 50% myometrial invasion, positive surgical margins or poorly diff. tumor
2. CTH - metastasis
29
mngmt of simple ovarian cyst
U/S for initial assessment - if asx, no further tx
30
when do you do laparoscopic removal of ovarian cyst
> 7 cm in size
| previous steroid contraception w/o resolution of cyst
31
mngmt: complex (dermoid) cyst
laparoscopic/laparotomy removal (cystectomy or oophorectomy)
32
U/S dx of ovarian torsion
no blood supply seen on doppler
33
tx. ovarian torsion
emergent surgery
34
sudden severe lower abdominal pain in presence of adnexal mass
presumed to be ovarian torsion
| - laparascopy should be performed
35
initial workup of ovarian mass
BHCG
USG
laparoscopy if > 7 cm or complex
36
9 yo F presents with right adnexal pain and complex cystic mass on u/s
germ cell tumor of ovary - MC dysgerminoma
| order: LDH, B-hcg, AFP
37
67 yo F presents with progressive weight loss, distended abdomen and left adnexal mass
ovarian ca - MC serous, epithelial tumors
| order:CA125, CEA
38
58 yo F presents with post-meno bleeding. Endo biopsy shows hyperplasia. U/S shows right ovarian mass
granulosa thecal ovarian tumor
- secrete estrogen and cause endo hyperplasia
order: estrogen level
39
48 yo F complains of facial hair and hoarseness. Adnexal mass found on exam
sertoli-leydig cell tumor - secretes T and causes masculinization syndrome
measure: Testosteron levels
40
64 yo F with history of gastric ulcer and worsening dyspepsia presents with weight loss and abdominal pain. Adnexal mass present
metastatic gastric ca to ovary (Krukenberg tumor)
| marker: CEA
41
finding of ASCUS on pap in pt < 24 yo
repeat pap in 12 months
- can repeat again in 12 months if ASCUS, LSIL or negative result
- if 3x result --> get colposcopy
42
ASCUS in pt > 25 yo
get reflex HPV testing
| colpo + biopsy only if 16 or 18 present
43
endocervical curettage
all nonpregnant patients undergoing colposcopy for abnormal pap smear should undergo ECC to R/O endocervical lesions
44
when do you perform a cone biopsy
if colposcopy or ECC and pap smear findings are not consistent OR biopsy showed microinvasive carcinoma
45
mngmt of CIN 2 or 3
ablative modalities - cryotherapy, laser
| excisional modalities - LEEP, cold knife conization
46
adjuvant (CTX or RTH) for cervical ca. (indications)
```
tumor > 4 cm
mets to LN
poorly diff
positive margins
local recurrence
```
47
ASCUS finding in pregnancy - next step?
colposcopy and biopsy
| if CiN 2/3 --> repeat colposcopy each trimester and 6-12 weeks postpartum
48
finding of microinvasive cervical ca. in pregnancy
cone biopsy to ensure no frank invasion
| deliver vaginally, reevaluate and tx. 2 mos postpartum
49
finding of invasive cervical ca in pregnancy
< 24 weeks: definitive treatment
| >24 weeks: conservative until 32-33 weeks, then delivery by C/S with definite treatment
50
initial work-up for pelvic pain
1. pelvic exam
2. cervical culture
3. labs: ESR, WBC, bcx if fever
4. sonogram
51
outpatient mnmgt of acute salpingo-oophoritis
1x IM ceftriaxone + PO doxycycline
52
inpatient mnmgt of acute salpino-oophoritis
IV cefotetan or cefoxitin + doxycycline
53
young woman presents with severe, lower abdominal pain, back pain, rectal pain. She has a fever, NV and tachycardia. On labs: WBCs very elevated. Pus on culdocentesis - Dx?
tuboovarian abscess
- USG shows unilateral pelvic mass
- bcx: anaerobic organisms
54
Tx. tuboovarian abscess
cefoxitin + doxycycline
| - if no response w/in 72 hours, may require laparotomy
55
primary dysmenorrhea
recurrent, crampy lower abdominal pain with NVD during menstruation; caused by excessive PGF2 which acts on both uterine and GI smooth mm
56
tx. primary dysmenorrhea
NSAIDs
| 2nd line: OCPs
57
dysmenorrhea, dyspareunia, dyschezia and infertility in a mid 20s female
endometriosis - endometrial glands outside the uterus
58
MC sites of endometriosis
ovary - adnexal enlargements
| cul de sac - painful rectovaginal exam, uterosacral nodularity
59
diagnosis of endometriosis
laparoscopy
60
tx. endometriosis
first line: OCP
| 2nd line: androgen derivative (danocrine, danazol) or GnRH analogs (leuprolide)
61
MCC of premenarchal bleeding
foreign body
62
what needs to be ruled out in premenarchal bleeding
1. abuse
2. sarcoma botyroides
3. tumor of pituitary or ovary
63
Dx. testing premenarchal bleeding
1. pelvic exam under sedation
2. CT/MRI of pituitary, abdomen and pelvis to look for E-prod tumor
3. if w/u is negative: idiopathic precocious puberty
64
first test to do in eval of irregular bleeding in reproductive aged woman
pregnancy test - Bhcg
65
primary amenorrhea
absence of menstruation at age 14 w/o secondary sexual characteristics or age 16 w/ secondary sexual development
66
amenorrhea: breasts present, uterus present
secondary amenorrhea --> imperforate hymen, vaginal septum, AN, excessive exercise, pregnancy
67
amenorrhea: breasts absent, uterus present
1. FSH level and karyotype
FSH elevated - Turners
FSH low - hypothalamic pituitary failure, normal karyotype
68
amenorrhea: breasts present, uterus absent
1. order Test levels and karyotype
Mullerian agenesis: XX, normal testosterone for female
testicular feminization: XY, normal test for male
69
normal female secondary sexual characteristics, normal estrogen and testosterone levels (ovaries are intact), but have asbence of fallopian tubes, uterus, cervix and upper vagina - dx? tx?
Dx. Mullerian agenesis
| Tx. surgical reconstruction of vagina for intercourse, infertility counselling
70
pt presents with primary amenorrhea. On exam she has breasts, but no pubic hair, vagina ends in blind pouch; b/l inguinal masses present. Labs show normal estrogen and testosterone levels. Dx. Tx
Dx. androgen insensitivity
Tx. removal of testes prior to age 20
estrogen replacement
71
mngmt of primary amenorrhea in Turner's syndrome
E and P4 replacement
72
pt presents with primary amenorrhea, no secondary sexual characteristics. FSH levels are low.
Hypothalamic pituitary failure due to stress, excessive exercise or anorexia nervosa
73
tests to order in w/u of secondary amenorrhea
1. B-hcg
2. TSH level - hypothyroidism
3. PRL level - if high: look for meds, CT/MRI head
4. progesterone challenge test
5. estrogen-P4 challenge test
74
progesterone challenge test
1. any withdrawal bleeding = anovulation
tx. cyclic progesterone
2. no withdrawal bleeding = estrogen inadequate or outflow obstruction --> order EPCT
75
estrogen-progesterone challenge test (EPCT)
1. withdrawal bleeding = inadequate estrogen
- get FSH level
increased FSH - ovarian failure
decreased FSH - hypothalamic-pituitary insuff
2. no withdrawal bleeding = outflow obstruction or endometrial scarring
- order hysterosalpingogram
76
tx. of choice for PMDD
SSRIs - fluoxetine
| - if no effect, trial 2nd SSRI, if that fails = OCP
77
which vitamin may improve symptoms of PMDD
vit B6 - pyridoxine
78
Tx. PCOS
OCP
spironolactone - for hirsutism
clomiphene citrate - for infertility
metformin- for insulin resistance
79
rapid onset hirsutism and virilization w/o a family history - dx? next step?
consider ovarian or adrenal tumor
1. USG or CT
Tx. surgical removal of tumor
80
gradual onset hirsutism w/o virilization in 2nd-3rd decade assoc. with menstrual irregularities and anovulation. May present as precocious puberty with short stature.
CAH
- elevated serum 17 OH P4
- positive fhx
81
tx. CAH
corticosteroid replacement
82
Tx. idiopathic hirsutism
spironolactone
83
Eflornithine (vaniqa)
first line topical drug for tx. of unwanted facial and chin hair
84
confirmatory test for CAH
ACTH stimulation test
85
prevention of osteoporosis in menopausal women
weight bearing exercise
| 1200 mg Ca and 400-800 IU vit D
86
Dx. menopause
```
12 mos of amenorrhea
elevated FSH (>50) and LH (not as valuable)
```
87
menopause < 30 yo
POF
| - could be secondary to autoimmune disease or Y chromosome mosaicism
88
MC site of osteoporosis
vertebral bodies --> crush fractures, kyphosis and decreased height
89
Dx. osteoporosis
DEXA bone scan
- T score > -2.5
(-1 to -2.5 = osteopenia)
90
First line therapy: osteoporosis
bisphosphonates
| SERMS
91
second line therapy for osteoporosis
calcitonin
denosumab - RANKL inhibitor (inhibits osteoclast fxn)
teriparatide - PTH analog used if bisphosphonates fail
92
benefits of HRT
decreased rate of osteoporotic fractures
decreased rate of CRC
decreased serum lipid levels
93
risks of HRT
thromboembolic events
increased risk of dementia
increased risk of MI in combo therapy
increased risk of breast ca with combo therapy > 4yrs
94
effect of HRT on CV disease
not effective for either primary or secondary prevention
95
C/I to IUD placement
```
pregnancy
pelvic malignancy
salpingitis
active infection - vaginal cx prior to placement
abnormal uterine size/shape
immune suppression
```
96
steps in w/u of infertility
1. semen analysis
2. if semen analysis normal --> w/u for anovulation
3. if above WNL --> fallopian tube abnormalities
97
next step - abnormal semen analysis
repeat in 4-6 weeks to confirm findings
98
normal semen analysis values
```
volume > 2 ml
ph 7.2-7.8
sperm density > 20 million/ml
sperm motility > 50%
sperm morphology > 50 % normal
```
99
findings consistent with anovulation
basal body temp - no midcycle temp elevation
P4 low
endometrial histology: proliferative
100
ovulation induction
clomiphene citrate
| s/e: ovarian hyperstimulation (monitor ovarian size during induction)
101
work-up for tube abnormalities
1. Chlamydia IgG - neg ab test r/o tubal adhesions due to infection
2. HSG - if normal, no further w/u
3. laparoscopy - with abnormal HSG to visualize tube and perform tuboplasty
102
RF: gestation trophoblastic disease
Taiwan/Phillipines
maternal extremes in age
folate deficiency
103
CF: gestational trophoblastic disease
```
bleeding from vagina < 16 weeks gestation
passage of vesicles from vagina
HTN
hyperthyroidism
hyperemesis
no fetal heart tones
bilateral theca-lutein ovarian cysts
```
104
management: gestational trophoblastic disease
initial eval: B-hcg, TFT, usg
CXR - r/o lung mets
suction D&C
for 6-12 mos - pt on OCP and gets weekly HCG level
