Gynecology Flashcards
How long should you wait out abnormal menstruation symptoms in a patient starting Depo-Provera injections.
Abnormal bleeding symptoms typically resolve in 2-3 months with 50% of patients having amenorrhea by 1 year
Type of drug and timing of administration for emergency contraception
Levonorgestrel pills can be given 72-120 hours after intercourse
Candidates for progestin-only oral contraceptives
Thromboembolism, smoker over 35, lactating and severe nausea with combined estrogen/progestin pills.
Be wary of prescribing progestin-only oral contraceptives to these patients
History of depression
Pros and cons of combined oral contraceptives
Pros: decreased incidence of ovarian and endometrial cancer, PID, endometriosis, benign breast changes and ectopic pregnancy. Cons: possible increase in breast cancer, thromboembolism, hypertension and cervical intraepithelial neoplasia
Tubal ligation results in a decrease in incidence of what type of cancer?
Ovarian
Risks for regret in women who elect to undergo tubal ligation
Young age, not married, ligation
Patient population that will not have good contraception when using Ortho Evra ethinyl estradiol + norelgestromin patch
> 198 lbs.
Common findings in septic abortions
Fever, dilated cervix, vaginal bleeding and lower abdominal pain.
Common findings in a threatened abortion
Vaginal bleeding and closed cervix
Common findings in a missed abortion
Retention of non-viable intrauterine pregnancy for an extended period of time
Management of septic abortion
Broad spectrum antibiotics and uterine evacuation
Work up for anti-phospholipid antibody syndrome
Anti-cardiolipin and beta-2 glycoprotein antibody status. PTT. Russell viper venom time.
Definition of recurrent pregnancy loss
> 2 consecutive or > 3 spontaneous pregnancy losses before 20 weeks gestation.
Causes of recurrent pregnancy loss
Chromosome abnormalities, Lupus, APA syndrome, thyroid dysfunction, luteal phase deficiency and anatomic causes.
Drug used for prevention of preterm labor
17-OH-progesterone
Drugs used to help pregnant patients with APA syndrome
Aspirin and heparin
Medications used for medical abortions
Mifepristone (an anti-progestin that causes sloughing of decidua) followed by misoprostol (prostaglandin that stimulates uterine contraction)
Gestational age when manual vaccum aspiration is no longer appropriate? Risk of this procedure?
> 8 weeks gestation. Risk of Asherman’s Syndrome
Abortion is legal until
24 weeks gestation
D&C vs. D&E
Dilation and curettage 16 weeks gestation.
Next step if a patient presents with heavy bleeding after medical abortion with prostaglandins
Dilation and curettage
When is a hysterosonogram contraindicated?
When infection is present
What causes bacterial vaginosis? How do you treat it?
A shift from H2O2-producing lactobacilli to non-H2O2-producing lactobacilli that allow proliferation of anaerobes.
Antibiotic of choice for bacterial vaginosis
500mg oral metronidazole BID for 7 days or vaginal metronidazole .75% gel QHS for 5 days
Amsel criteria
1) Thin, gray, homogenous discharge 2) KOH whiff test w/ positive amine odor 3) Clue cells on saline wet mount 4) Vaginal pH > 4.5.
Presentation of lichen sclerosis
Vulvar pruritis, burning and pain. Introital dyspareunia. On physical exam you would see polygonal ivory papules involving the vulva and perianal areas, waxy sheen on the labia minora/clitoris, and hypopigmentation. Ultimately, scarring with loss of normal architecture, such as introital stenosis and resorption of the clitoris (phimosis) and labia minora, may occur.
Treatment for lichen sclerosis
Topical corticosteroids
Risk of transformation to squamous cell carcinoma in patients with lichen sclerosis
Less than 5%
Presentation of vaginal trichomoniasis
Diffuse, malodorous, yellow-green discharge with vulvar irritation. Wet prep has sensitivity of 70%, so you can’t rely on it to rule it out.
Treatment of vaginal trichomoniasis
Single oral dose of 2g metronidazole or 500mg metronidazole BID for 7 days. Treat partner too before resuming intercourse.
Presentation of vaginal candidiasis
Signs and symptoms of vaginitis (itching, burning, discharge, dyspareunia, dysuria), wet prep (KOH or saline), gram stain or culture demonstrate pseudohyphae or yeast.
Treatment of vaginal candidiasis
Topical azole cream for 1-3 days
Presentation of lichen planus
Inflammatory eruptions on hair-bearing skin (alopecia and rashes), nails, mouth and vulva. Vulvar symptoms include itching, burning, contact bleeding, dyspareunia and pain. Physical exam may show lacy, reticulated pattern of the labia and perineum +/- scarring, erosions and vaginal obliteration.
Presentation of vulvar vestibulitis
Rapid onset burning and rawness. Pain with tampon insertion, biking, wearing tight pants, and marked introital dyspareunia. Tenderness to light touch +/- focal or diffuse erythematous macules.
Treatment of vulvar vestibulitis
TCAs (block sympathetic afferent pain loops), pelvic floor exercises, topical anesthetics and surgery with vestibulectomy for patients who do not respond to standard therapies.
What causes lichen simplex chronicus
Chronic itching and scratching of the vulvar area that predisposes the area to infection, resulting in a scratch-itch-scratch cycle.
Presentation of lichen simplex chronicus
Thick, lichenified, enlarged and rugose labia, with or without edema.
Treatment of lichen simplex chronicus
Topical corticosteroids and antihistamines to break the scratch-itch-scratch cycle.
Tests used to diagnose chlamydia and gonorrhea infection
Culture or nucleic acid amplification test (NAAT)
Treatment for mucopurulent cervicitis
Cephalosporin (typically single dose 125mg ceftriaxone) or fluoroquinolone for gonorrhea and azithromycin or doxycycline for chlamydia. 250mg ceftriaxone if PID or upper genital tract infection.
Is HSV-1 more common in primary or recurrent genital infections?
Up to 30% of primary genital herpes infections can be HSV-1. HSV-1 is rarely seen in recurrent genital herpes.
Classification of genital HSV infections
INITIAL: no hx of herpes and seronegative, systemic symptoms (fever, headache, malaise and myalgias usually precede the onset of genital lesions), vulvar lesions begin as tender grouped vesicles that progress into exquisitely tender, superficial, small ulcerations on an erythematous base. INITIAL NON-PRIMARY: first recognized episode of genital herpes in individuals who are seropositive for HSV. Prior HSV-1 infection confers partial immunity to HSV-2 and lessens the severity of HSV-2 infection. There is less pain, fewer lesions, more rapid resolution of clinical lesions and shorter duration of viral shedding than initial infection. Systemic symptoms are rare. RECURRENT: reactivation of HSV-2 with episodic prodromal symptoms and outbreaks of lesions at varying intervals and of variable severity.
Diagnosing HSV infection
Viral culture, antigen detection and serology.
Treating HSV infection
Acyclovir, famcyclovir or valacyclovir. Sitz baths and topical xylocaine can help relieve burning and irritation.
When is transvaginal tape used as a treatment
Urinary incontinence
Primary treatment for any type of vaginal prolapse
Pessary
What percentage of people with primary syphilis will progress to secondary syphilis if left untreated
25.00%
Recommended exposure prophylaxis for patients who are unvaccinated and exposed to Hepatitis B via sexual intercourse
HBIG and start Hep B vaccine series within 14 days of exposure if source is HBsAg +, only vaccine series if source is HbsAg -. This process should be started within 7 days if exposure was blood to blood.
Ascending bacteria that can cause salpingitis
Chlamydia, gonorrhea, E. coli, Klebsiella, G. vaginalis, Prevotella, Group B streptococcus and enterococcus.
Inpatient treatment of a patient with suspected salpingitis due to chlamydia and/or gonorrhea who cannot tolerate oral medications due to nausea and vomiting.
IV cefotetan or cefoxitin PLUS doxycycline. Or clindamycin PLUS gentamicin.
Rate of infertility with each subsequent episode of PID vs. subsequent treatments with LEEP.
PID: 12% after one episode, 25% after 2 episodes and 50% after three episodes. LEEP: cervical stenosis is rare.
Most common organisms involved in acute cystitis
E. coli causes 80-85% of cases. Other major pathogens are S. saprophyticus, K. pneumoniae, E. faecalis and P. mirabilis.
Causes of overflow incontinence
Underactive detrusor muscle (neurologic disorders, diabetes) or obstruction (prolapse or post-op).
Normal post-void residual volume? What defines overflow incontinence.
50-60cc. Overflow incontinence has PVR > 300cc.
Most common causes of GSI
Genuine Stress Incontinence is urine loss due to increased abdominal pressure with normal detrusor function. The majority of GSI is caused by urethral hypermobility (straining Q-tip angle >30 degrees from horizon). Some (
Treatment for GSI due to urethral hypermobility
Retropubic urethropexy such as tension-free vaginal tape and other sling procedures
Treatment for GSI due to intrinsic sphincteric deficiency and no urethral hypermobility
Urethral bulking
Medications used to treat urge incontinence due to detrusor muscle instability
1) Oxybutinin: anti-muscarinic that blocks ACh stimulation of detrusor muscle. 2) TCAs can do the same thing, but side effects make them less desirable.
Medication that can be used to help with stress incontinence by stimulating alpha-adrenergic receptors
Pseudoephedrine
Fascial defect in rectoceles, how do you fix it?
Rectovaginal fascia. Posterior repair.
Fascial defect in cystoceles, how do you fix it?
Pubocervial fascia. Anterior repair.
What causes mixed incontinence?
Increased intra-abdominal pressure causes the urethral-vesical junction to descend causing the detrusor muscle to contract.
In what patient population is colpcleisis a good option for treatment of vaginal prolapse?
The vagina is surgically obliterated and can be performed quickly without the need for general anesthesia. Good for patients with comorbidities that prevent them from going under general anesthesia for sacrospinous fixation (cuff to sacrospinous-coccygeus complex) or sacrocolpopexy (cuff to sacral promontory using interposed mesh).
Next step in care when u/s shows a complex ovarian cyst in an asymptomatic post-menopausal female
Exploratory surgery, u/s is best imaging modality and you must take it out due to risk of ovarian cancer.
1st line treatment for endometriosis
1) NSAIDs 2) OCPs provide negative feedback to the pituitary-hypothalamic axis which stops stimulation of the ovary to produce sex hormones, such as estrogen, which stimulates endometrial tissue located outside of the endometrium and uterus. 3) Laparoscopy to clear adhesions
Definitive diagnosis for ovarian torsions
Surgical exploration, doppler u/s may be normal because ovarian blood supply can be maintained despite torsion
Presentation of patients with interstitial cystitis
Recurrent irritative voiding symptoms of urgency and frequency, in the absence of objective evidence of another disease that could cause the symptoms. Some may also have dysmenorrhea and dyspareunia.
Rome II criteria for IBS
At least 12 weeks (need not be consecutive) in the preceding 12 months of abdominal discomfort or pain that has two of three features: 1) Relief with defecation; 2) Onset associated with a change in frequency of stool; or 3) Onset associated with a change in stool form or appearance.
How does Danazol help with treatment of endometriosis?
It is a 17-alpha-ethinyl testosterone derivative, which suppresses the mid-cycle surges of LH and FSH.
What drugs are more effective than Danazol in treatment of endometriosis?
GnRH analogues. They down-regulate hypothalamic-pituitary gland production and release of LH and FSH leading to dramatic reductions in estradiol level.
40-50% of women with chronic pelvic pain may also have a history of what?
Abuse
Presentation of pelvic congestion syndrome
Pelvic fullness or heaviness that is worse premenstrually, during pregnancy, with standing, coitus and fatigue. Patients may also have pain that radiates to the vulva, vaginal discharge, backache, dysmenorrhea and urinary frequency.
Cause of pelvic congestion syndrome
Vasodilatation occurs when pelvic veins are exposed to high concentrations of estradiol, which inhibits reflex vasoconstriction of vessels, induces uterine enlargement with selective dilatation of ovarian and uterine veins resulting in pelvic varicosities.
Where is the iliohypogastric nerve at risk for damage and what symptoms would patients have?
The iliohypogastric nerve travels on top of the psoas until it reaches the ASIS when courses medially between the internal and external oblique muscles, becoming cutaneous 1 cm superior to the superficial inguinal ring. It supplies cutaneous sensation to the groin and the skin overlying the pubis.
Where is the ilioinguinal nerve at risk for damage and what symptoms would patients have?
The ilioinguinal nerve travels on top of the psoas beneath the iliohypogastric and also courses between the internal and external obliques until it becomes cutaneous 1cm superior the the superficial inguinal ring. It supplies cutaneous sensation to the groin, symphysis, labium and upper inner thigh.
Major risk factors for breast cancer
Gail model: Old age, Early age at menarche, Late age at 1st childbirth, 1st degree relative, previous breast biopsy, biopsies with atypical hyperplasia, race/ethnicity
Test to do if a woman presents with bloody nipple discharge
Ductogram
Test to do if a post-menopausal woman presents with white nipple discharge
Fasting prolactin levels, if elevated do brain MRI to r/o pituitary tumor. If MRI is normal move on to r/o other causes of elevated prolactin levels like hypothyroidism, hypothalamic disorders, chest lesions (breast implants, thoracotomy scars, and herpes zoster) and renal failure.
What breast disease would you recommend a decrease in caffeine intake
Fibrocystic changes. Caffeine elevates cortisol levels, cortisol alters sex hormone levels and changes breast composition.
Next step if breast FNA reveals bloody fluid from a mass
Excisional biopsy to r/o cancer. If fluid were, clear follow up in 2 months
Most common cause of “nipple itch”
Chemical irritants such as laundry detergents, soaps, and perfumes
Most common time for women to get mastitis
Weeks 2-4 after delivery
Abx for mastitis
Dicloxacillin is first line, erythromycin if patient is allergic to PCN
Next step in a patient with cervical LSIL on pap smear
Colposcopy and biopsy to confirm. 20% of patients with LSIL on pap smear will have HSIL on biopsy and 50% of patients with LSIL on pap smear will have a negative colposcopy.
LEEP
Loop electrosurgical excision procedure. Cervical transition zone and area affected by squamous neoplasia are removed and sent to pathology, diagnostic and therapeutic in most cases.
Progression rate of HSIL to invasive cervical cancer
12.00%
When do you recommend radical hysterectomy to a patient with cervical cancer?
Stages Ia2-IIa (confined to cervix and uterus).
ASCUS
Atypical Squamous Cells of Undetermined Significance on pap smear
ACOG mammogram recommendations
Every year starting at 50, biannual between 40-50
Next step in a patient with cervical LSIL on colposcopy and biopsy
Pap smears at 6 and 12 months or HPV DNA testing at 12 months. Excisional procedures are not indicated for LSIL
Indications for cold knife conization
Positive endocervical curettage, HSIL lesion too large for LEEP, patient not tolerant of examination in office, lesion extending into the endocervical canal beyond vision and ruling out invasive cancer.
Next step in a patient with a genital condyloma not responsive to imiquimod (TLR-7 activator) or trichloroacetic acid
Biopsy to r/o cancer. If not cancer, vaporize it with a laser.
Definitive treatment for patients with pelvic pain due to endometriosis
Hysterectomy + bilateral salpingo-oophorectomy
Stages of endometriosis
Staged based on location, extent, and depth of endometriosis implants; presence and severity of adhesions; and presence and size of ovarian endometriomas. Stages I and II have superficial implants and mild adhesions. Stages III and IV have severe adhesions, chocolate cysts and infertility.
