Gynecology Flashcards
1
Q
What breast diseases are classified as benign?
A
Fibroadenoma Fibrocystic Disease Intraductal Papilloma Fat Necrosis (d/t trauma) Mastitis (breastfeeding women)
2
Q
What breast diseases are classified as malignant?
A
Ductal Carcinoma in situ Lobular Carcinoma in situ Invasive Ductal Carcinoma Invasive Lobular Carcinoma Inflammatory Breast Cancer Paget's Disease of the Breast/Nipple
3
Q
What should be suspected if pt presents with bilateral nipple discharge?
A
Prolactinoma
4
Q
What is included in the initial workup for Prolactinoma?
A
Serum Prolactin
Serum TSH
(check if taking any anti-dopamine medications)
5
Q
What is the most likely diagnosis in a woman presenting with non-bloody, watery, serosanguinous unilateral nipple discharge?
A
Intraductal Papilloma
6
Q
What physical exam findings should raise the suspicion for breast malignancy?
A
Bloody, spontaneous, nipple discharge associated with palpable mass, multiple ducts involved, and or axillary lymph node enlargment
7
Q
What is the first step in management for a pt presenting with unilateral breast discharge?
A
Mammogram: ck for mass/calcifications
8
Q
If mass is found on Mammogram, what is the next step in management?
A
Surgical Duct excision for definitive dx
9
Q
Which breast diseases are malignant/have malignant potential?
A
Ductal Carcinoma In situ Lobar Carcinoma In situ Invasive Ductal/Lobar Carcinoma Inflammatory Breast Cancer Paget's Disease of the Breast/Nipple
10
Q
Under what conditions should surgical excision NEVER be the next step in management?
A
Pt with Bilateral, milky nipple discharge
this suggests prolactinoma so check serum levels first
11
Q
What is the most likely diagnosis for a pt presenting with unilateral breast nodule that is discrete, firm, and HIGHLY MOBILE on exam?
A
Fibroadenoma (stromal and epithelial cells)
12
Q
What is the most likely diagnosis in a pt presenting with bilateral painful breast lump that varies in severity with her menstrual cycle?
A
Fibrocystic Disease
13
Q
What is the most likely diagnosis in a pt presenting with a sharply demarcated fluid-filled mass with posterior acoustic enhancement (deeper area of brightness) on Ultrasound that collapses with FNA?
A
Simple Cyst
14
Q
What is the treatment for Fibrocystic Disease?
A
OCPs
15
Q
What are the steps in working up any presentation of breast mass in ALL women (including pregnant)?
A
1) Clinical Breast Exam
2) Ultrasound or Mammography (>40)
3) FNA Bx
16
Q
What is the next step in management for a young woman who c/o bilateral breast enlargement and tenderness that varies with her menstrual cycle and is found to have a discrete painful nodule that produces clear fluid and completely collapses on FNA?
A
Repear Clinical breast exam (CBE) in 6 wks
17
Q
What is the next step in management for a pt with a cyctic mass that produced clear fluid aspirate and collapsed with FNA but has now returned at 6 wk f/u CBE?
A
Repear FNA or Core Bx
18
Q
When should an Ultrasound be performed in the workup of Breast mass?
A
Next step following Clinical Breast Exam for Palpable mass that feels cystic
Women
19
Q
When should Mammography be done in workup of Breast Mass?
A
Woman >50 (followed by Bx or bx alone if 2x within 4-6 wks
Bloody fluid aspirated
Mass does not fully collapse with FNA
Bloody Nipple discharge (imaging then excisional Bx)
Skin edema,erythema –>Inflammatory Ca (excisional Bx)
20
Q
When are FNA or Core Bx performed in the workup for breast mass?
A
For all Palpable Breast Masses (can do FNA after or instead of Ultrasound)
21
Q
When is cytology performed in the workup for breast mass?
A
If grossly bloody fluid is aspirated from mass
22
Q
When are observation and follow-up in 6-8wks acceptable for the management of breast mass?
A
Clear fluid is aspirated and complete collapse of mass with FNA
Needle (Core) Bx and Imaging are all negative
23
Q
What is the next step in management for a woman >40 yrs old who is found to have cluster of microcalcifications on routine mammography?
A
Core Needle Bx w/ mammographic guidance
note, cluster of microcalcifications usually represent benign disease, but some can be early malignancy
24
Q
What are the next steps in management for a pt diagnosed with DCIS on bx?
A
1) Lumpectomy (surgical resection) w/ clean margins
2) Radiation Therapy
3) Tamoxifen (5yrs)
25
What are the major effects of Tamoxifen on the body?
Estrogen Antagonism in breast tissue (decrease contralateral breast cancer incidence)
Increases Bone density/decrease fracture risk
Decrease cholesterol/cardiovascular mortality risk
Increase menopause symptoms
Estrogen Agonist at endometrium (increased risk of Endometrial Ca)
Increased Thromboembolic risk
26
What is the next step in management in a postmenopausal woman presenting w/ a h/o Tamoxifen use presenting with a chief complaint of vaginal bleeding?
Pelvic exam and Endometrial Bx
27
What is the next step in management for a pt dx'd with Lobar Carcinoma In Situ (LCIS)
Tamoxifen (5yrs)
| surgery not necessary
28
What are contraindications to Tamoxifen use?
Active Smoker
| H/o and other high risk for thromboembolism
29
What is the most common (most likely dx) form of breast cancer?
Invasive Ductal Carcinoma (unilateral)
30
What are the typical sites of metastases of Invasive Ductal Carcinoma?
Bone (blastic/lytic)
Liver
Brain
Lung
31
Which type of breast cancer has a higher tendency to be bilateral and multifocal (w/in same breast) relative to other types?
Invasive Lobar Carcinoma
32
What are some common findings on physical exam associated with Inflammatory breast cancer?
Red, swollen, warm breast with
Pitted, edematous skin (peau d'orange)
[Note: Grows fast; early mets]
33
What is findings are suggestive of Paget's Disease of the Breast/Nipple?
Pruritic, erythematous, scaly nipple lesion(looks like eczema or psoriasis)
Nipple inversion +/- Discharge
34
What are risk factors for breast cancer?
```
Age >/= 50
Ionizing Radiation exposure
Familial BRCA1/2 mutation carrier
FHx in first degree relative
First child after 30 or nulliparous
H/o breast cancer
Hormone Therapy
Obesity (BMI >/= 30)
```
35
When is BRCA1/2 genetic testing indicated?
FHx of early onset (
36
What are the treatment options for invasive breast cancers
Primary:
Lumpectomy + Radiation w/w/o Adjuvant or Chemo
Sentinel Node Bx
Pathology on all ressected tumors for Receptor Analysis (ER/PR/HER2/neu)
37
What is the primary treatment for inflammatory, metastatic, or large (>5cm) breast disease?
Systemic Therapy (ie, not surgery)
38
What is the standard of care for invasive (infiltrating) breast disease?
Lumpectomy (Breast Conserving Surgery) w/ Radiation
39
When should Lumpectomy NOT be offered?
```
Tumor >5cm
Mets in >/= 2 sites in different quadrants
Pregnancy
Prior radiation to that breast
Positive tumor margins
```
40
Who should be offered Adjuvant hormone Therapy?
ALL pt with Hormone Receptor + tumors (ER+/PR+)
41
What are the Adjuvant hormone therapy options?
Tamoxifen (pre-postmenopausal women)
Aromatase Inhibitor (Anastrazole/Exemestane)- standard
in postmenopausal women (will not cause menopausal
symptoms)
LHRH analogs (lurpolide, goserelin)/Ovarian Ablation: alternative or addition to Tamoxifen in pre-menopausal women
42
What is an adverse effect of adjuvant Aromatase inhibitors use in treatment of invasive breast cancer?
Increased risk of osteoporosis
43
When is chemotherapy indicated in treating breast cancer?
Tumor >1cm
or
+Lymph Node(s)
44
When is Trastuzumab indicated in treating breast cancer?
Metastatic cancer with HER2/neu overexpression
45
What are the most common differential dx for enlarged uterus?
Pregnancy
Leiomyoma (fibroids)
Adenomyosis
46
What is the next step in management for an African-american woman of child-bearing age presenting with enlarged, firm, asymmetric, nontender uterus?
Urine B-HCG
47
What is the most likely dx in an African-american woman of child-bearing age presenting with enlarged, firm, asymmetric, nontender uterus, and negative b-HCG?
Leiomyoma (Fibroids) -Benign tumors of the myometrium (myosin/actin filaments--> smooth muscle)
48
Under what physiologic conditions can Fibroid growth/symptoms change?
Pregnancy: Increased/Exacerbated
Menopause: Decrease/Diminished
(Fibroids are stimulated by Estrogen)
49
What symptoms can be associated with a submucosal fibroid?
Intermenstrual/breakthrough bleeding and Dysmenorrhea/Menorrhagia
(Note:Intracavitary mass on saline ultrasound)
50
What symptoms can be associated with a subserosal fibroid?
Bladder, Ureter, Rectum compression
51
What symptoms can be associated with a degenerating fibroid?
Acute onset pain during pregnancy
52
Where does a subserosal fibroid obtain its blood supply?
Abdominal Omentum or Intestinal Mesentary: Parasites
53
What is the most likely dx in a pt presenting with Dysmenorrhea, menorrhagia, and a soft, tender, globular, symmetrically enlarged uterus?
Adenomyosis
- Ectopic Endometrial glands and stroma within the
myometrium
54
What diagnostic steps should be taken for a pt with uterine enlargement?
1) Urine Pregnancy Test
2) Pelvic Exam
3) Ultrasound (with saline infusion)
4) Hysteroscopy
5) Histology
55
What steps are taken to manage uterine fibroids?
- Observation and serial pelvic exams to check growth
- Myomectomy (if fertility desired; but must deliver by c-section)
- Emolization of vessels(Uterus preserved, radiation exposure)
- Hysterectomy(best when fertility not desired/complete)
56
What are the steps to manage Adenomyosis?
Levonorgestrel Intrauterine System (IUS)-decrease menorrhagia
Hysterectomy is definitive
57
What is the first step in management of a pt who presents with postmenopausal bleeding?
Endometrial Bx
58
What is the most common cause of postmenopausal bleeding?
Endometrial Atrophy
59
What is the most important dx to r/o in a pt with postmenopausal bleeding?
Endometrial Carcinoma (most common gynecologic malignancy)
60
What is considered an acceptable thickness for the endometrial stripe in post-menopausal women?
Must be
61
What is considered an acceptable thickness for the endometrial stripe in post-menopausal women?
62
What should be suspected if pt presents with bilateral nipple discharge?
Prolactinoma
63
What is included in the initial workup for Prolactinoma?
Serum Prolactin
Serum TSH
(check if taking any anti-dopamine medications)
64
What is the most likely diagnosis in a woman presenting with non-bloody, watery, serosanguinous unilateral nipple discharge?
Intraductal Papilloma
65
What physical exam findings should raise the suspicion for breast malignancy?
Bloody, spontaneous, nipple discharge associated with palpable mass, multiple ducts involved, and or axillary lymph node enlargment
66
What is the first step in management for a pt presenting with unilateral breast discharge?
Mammogram: ck for mass/calcifications
67
If mass is found on Mammogram, what is the next step in management?
Surgical Duct excision for definitive dx
68
Which breast diseases are malignant/have malignant potential?
```
Ductal Carcinoma In situ
Lobar Carcinoma In situ
Invasive Ductal/Lobar Carcinoma
Inflammatory Breast Cancer
Paget's Disease of the Breast/Nipple
```
69
Under what conditions should surgical excision NEVER be the next step in management?
Pt with Bilateral, milky nipple discharge
| this suggests prolactinoma so check serum levels first
70
What is the most likely diagnosis for a pt presenting with unilateral breast nodule that is discrete, firm, and HIGHLY MOBILE on exam?
Fibroadenoma (stromal and epithelial cells)
71
What is the most likely diagnosis in a pt presenting with bilateral painful breast lump that varies in severity with her menstrual cycle?
Fibrocystic Disease
72
What is the most likely diagnosis in a pt presenting with a sharply demarcated fluid-filled mass with posterior acoustic enhancement (deeper area of brightness) on Ultrasound that collapses with FNA?
Simple Cyst
73
What is the treatment for Fibrocystic Disease?
OCPs
74
What are the steps in working up any presentation of breast mass in ALL women (including pregnant)?
1) Clinical Breast Exam
2) Ultrasound or Mammography (>40)
3) FNA Bx
75
What is the next step in management for a young woman who c/o bilateral breast enlargement and tenderness that varies with her menstrual cycle and is found to have a discrete painful nodule that produces clear fluid and completely collapses on FNA?
Repear Clinical breast exam (CBE) in 6 wks
76
What is the next step in management for a pt with a cyctic mass that produced clear fluid aspirate and collapsed with FNA but has now returned at 6 wk f/u CBE?
Repear FNA or Core Bx
77
When should an Ultrasound be performed in the workup of Breast mass?
Next step following Clinical Breast Exam for Palpable mass that feels cystic
Women
78
When should Mammography be done in workup of Breast Mass?
Woman >50 (followed by Bx or bx alone if 2x within 4-6 wks
Bloody fluid aspirated
Mass does not fully collapse with FNA
Bloody Nipple discharge (imaging then excisional Bx)
Skin edema,erythema -->Inflammatory Ca (excisional Bx)
79
When are FNA or Core Bx performed in the workup for breast mass?
For all Palpable Breast Masses (can do FNA after or instead of Ultrasound)
80
When is cytology performed in the workup for breast mass?
If grossly bloody fluid is aspirated from mass
81
When are observation and follow-up in 6-8wks acceptable for the management of breast mass?
Clear fluid is aspirated and complete collapse of mass with FNA
Needle (Core) Bx and Imaging are all negative
82
What is the next step in management for a woman >40 yrs old who is found to have cluster of microcalcifications on routine mammography?
Core Needle Bx w/ mammographic guidance
| note, cluster of microcalcifications usually represent benign disease, but some can be early malignancy
83
What are the next steps in management for a pt diagnosed with DCIS on bx?
1) Lumpectomy (surgical resection) w/ clean margins
2) Radiation Therapy
3) Tamoxifen (5yrs)
84
What are the major effects of Tamoxifen on the body?
Estrogen Antagonism in breast tissue (decrease contralateral breast cancer incidence)
Increases Bone density/decrease fracture risk
Decrease cholesterol/cardiovascular mortality risk
Increase menopause symptoms
Estrogen Agonist at endometrium (increased risk of Endometrial Ca)
Increased Thromboembolic risk
85
What is the next step in management in a postmenopausal woman presenting w/ a h/o Tamoxifen use presenting with a chief complaint of vaginal bleeding?
Pelvic exam and Endometrial Bx
86
What is the next step in management for a pt dx'd with Lobar Carcinoma In Situ (LCIS)
Tamoxifen (5yrs)
| surgery not necessary
87
What are contraindications to Tamoxifen use?
Active Smoker
| H/o and other high risk for thromboembolism
88
What is the most common (most likely dx) form of breast cancer?
Invasive Ductal Carcinoma (unilateral)
89
What are the typical sites of metastases of Invasive Ductal Carcinoma?
Bone (blastic/lytic)
Liver
Brain
Lung
90
Which type of breast cancer has a higher tendency to be bilateral and multifocal (w/in same breast) relative to other types?
Invasive Lobar Carcinoma
91
What are some common findings on physical exam associated with Inflammatory breast cancer?
Red, swollen, warm breast with
Pitted, edematous skin (peau d'orange)
[Note: Grows fast; early mets]
92
What is findings are suggestive of Paget's Disease of the Breast/Nipple?
Pruritic, erythematous, scaly nipple lesion(looks like eczema or psoriasis)
Nipple inversion +/- Discharge
93
What are risk factors for breast cancer?
```
Age >/= 50
Ionizing Radiation exposure
Familial BRCA1/2 mutation carrier
FHx in first degree relative
First child after 30 or nulliparous
H/o breast cancer
Hormone Therapy
Obesity (BMI >/= 30)
```
94
When is BRCA1/2 genetic testing indicated?
FHx of early onset (
95
What are the treatment options for invasive breast cancers
Primary:
Lumpectomy + Radiation w/w/o Adjuvant or Chemo
Sentinel Node Bx
Pathology on all ressected tumors for Receptor Analysis (ER/PR/HER2/neu)
96
What is the primary treatment for inflammatory, metastatic, or large (>5cm) breast disease?
Systemic Therapy (ie, not surgery)
97
What is the standard of care for invasive (infiltrating) breast disease?
Lumpectomy (Breast Conserving Surgery) w/ Radiation
98
When should Lumpectomy NOT be offered?
```
Tumor >5cm
Mets in >/= 2 sites in different quadrants
Pregnancy
Prior radiation to that breast
Positive tumor margins
```
99
Who should be offered Adjuvant hormone Therapy?
ALL pt with Hormone Receptor + tumors (ER+/PR+)
100
What are the Adjuvant hormone therapy options?
Tamoxifen (pre-postmenopausal women)
Aromatase Inhibitor (Anastrazole/Exemestane)- standard
in postmenopausal women (will not cause menopausal
symptoms)
LHRH analogs (lurpolide, goserelin)/Ovarian Ablation: alternative or addition to Tamoxifen in pre-menopausal women
101
What is an adverse effect of adjuvant Aromatase inhibitors use in treatment of invasive breast cancer?
Increased risk of osteoporosis
102
When is chemotherapy indicated in treating breast cancer?
Tumor >1cm
or
+Lymph Node(s)
103
When is Trastuzumab indicated in treating breast cancer?
Metastatic cancer with HER2/neu overexpression
104
What are the most common differential dx for enlarged uterus?
Pregnancy
Leiomyoma (fibroids)
Adenomyosis
105
What is the next step in management for an African-american woman of child-bearing age presenting with enlarged, firm, asymmetric, nontender uterus?
Urine B-HCG
106
What is the most likely dx in an African-american woman of child-bearing age presenting with enlarged, firm, asymmetric, nontender uterus, and negative b-HCG?
Leiomyoma (Fibroids) -Benign tumors of the myometrium (myosin/actin filaments--> smooth muscle)
107
Under what physiologic conditions can Fibroid growth/symptoms change?
Pregnancy: Increased/Exacerbated
Menopause: Decrease/Diminished
(Fibroids are stimulated by Estrogen)
108
What symptoms can be associated with a submucosal fibroid?
Intermenstrual/breakthrough bleeding and Dysmenorrhea/Menorrhagia
(Note:Intracavitary mass on saline ultrasound)
109
What symptoms can be associated with a subserosal fibroid?
Bladder, Ureter, Rectum compression
110
What symptoms can be associated with a degenerating fibroid?
Acute onset pain during pregnancy
111
Where does a subserosal fibroid obtain its blood supply?
Abdominal Omentum or Intestinal Mesentary: Parasites
112
What is the most likely dx in a pt presenting with Dysmenorrhea, menorrhagia, and a soft, tender, globular, symmetrically enlarged uterus?
Adenomyosis
- Ectopic Endometrial glands and stroma within the
myometrium
113
What diagnostic steps should be taken for a pt with uterine enlargement?
1) Urine Pregnancy Test
2) Pelvic Exam
3) Ultrasound (with saline infusion)
4) Hysteroscopy
5) Histology
114
What steps are taken to manage uterine fibroids?
- Observation and serial pelvic exams to check growth
- Myomectomy (if fertility desired; but must deliver by c-section)
- Emolization of vessels(Uterus preserved, radiation exposure)
- Hysterectomy(best when fertility not desired/complete)
115
What are the steps to manage Adenomyosis?
Levonorgestrel Intrauterine System (IUS)-decrease menorrhagia
Hysterectomy is definitive
116
What is the first step in management of a pt who presents with postmenopausal bleeding?
Endometrial Bx
117
What is the most common cause of postmenopausal bleeding?
Endometrial Atrophy
118
What is the most important dx to r/o in a pt with postmenopausal bleeding?
Endometrial Carcinoma (most common gynecologic malignancy)
119
What medical therapy should all women with a uterus who are receiving hormone replacement therapy, have a h/o chronic anovulation, or other high risk conditions for unopposed estrogen exposure be given?
Progestins (to mitigate the hyperplastic effects of estrogen)
120
What is considered an acceptable thickness for the endometrial stripe in post-menopausal women?
Must be
121
What is the diagnostic work up for postmenopausal bleeding?
Pelvic Exam and Endometrial Bx
Ultrasound: measure endometrial stripe
Hysteroscopy: r/o cervical polyps
122
What are the treatment options for postmenopausal bleeding?
EMBx shows Atrophy/no cancer: Nothing further
EMBx shows Adenocarcinoma: Surgery staging (TAH/BSO, pelvic and para-aortic lymphadenectomy, and peritoneal washings)
Add radiation if:
-LN mets,
->50% myometrial invasion
-Positive margins
-Poorly differentiated
123
What is the most common type of ovarian cyst during reproductive years?
Simple Cyst
124
What diagnostic steps are taken to workup a pt thought to have an adnexal cyst?
bHCG
Pelvic Exam
Sonogram
125
What is the treatment for a simple cyst?
Observation if asymptomatic
| Laparoscopic removal if >7cm or use of OCP w/o resolution
126
What findings are associated with a complex (dermoid) cyst?
Complex Cyst on U/s
| Bhcg: Negative
127
What is a rare but significant complication of Dermoid Cysts?
Squamous Cell Carcinoma
128
What is the management for Complex Cyst?
```
Pelvic Exam
B-hCG
U/s
Laparascopy/Laparatomy removal
- Cystectomy (preserve ovarian function)
- Oopherectomy (fertility not desired)
```
129
What is the order of workup/management for a pt of reproductive age presenting with sudden onset severe lower abdominal pain with abdominal tenderness but no rebound/guarding, adnexal mass present in cul-de-sac?
BHCG
U/s (confirm mass size, location)
Laparascopic/ Evaluation of ovaries
130
What diagnosis should always be considered in prepubertal or postmenopausal females with ovarian mass?
Ovarian Cancer
131
What are some risk factors for Ovarian Neoplasm?
BRCA1 gene
FHx
High # lifetime ovulations
Infertility
132
What are some protective factors against Ovarian Neoplasm?
Conditions associated with decreasing # of Ovulations:
- OCPs
- Chronic Anovulation (PCOS)
- Breastfeeding
- Short Reproductive life
133
What is the most likely tumor associated with a very young woman/child with unilateral adnexal pain and complex cystic mass on ultrasound?
Germ Cell Tumor (most common in young women and present in early stage of disease)
134
What is the most common type of malignant epithelial cell tumor?
Dysgerminoma
135
What markers are used to track course of disease/treatment response for Germ Cell tumors?
LDH
B-hCG
a-FP (alpha fetoprotein)
136
What is the most likely tumor diagnosis in a postmenopausal woman presenting with unintentional weight loss, distended abdomen, and unilateral adnexal mass?
Epithelial Tumor (most common ovarian cancer in postmenopausal women)
137
What is the most common malignant subtype of epithelial ovarian tumor?
Serous
138
What markers are used to track course of disease/treatment response for Epithelial ovarian tumors?
CA-125
| CEA
139
What is the most likely tumor dx in a woman with postmenopausal bleeding, unilateral adnexal mass on U/S and endometrial bx showing hyperplasia?
Granulosa-theca (Stromal)Tumor (Estrogen secreting)
140
What marker(s) are used to track course of disease/treatment response for Granulosa-Theca stromal tumors?
Estrogen
141
What is the most likely tumor dignosis in a middle age premenopausal woman who c/o increased facial hair and deepening of her voice with pelvic exam revealing unilateral adnexal mass?
Sertoli-Leydig Cell (Stromal) Tumor (Testosterone secreting)
142
What marker(s) are used to track course of disease/treatment response for Sertoli-Leydig Cell Stromal Tumors?
Testosterone
143
What is the most likely tumor diagnosis in a postmenopausal woman presenting with a h/o gastric ulcer, recent worsening dyspepsia, weight loss, and abdominal pain with adnexal mass found on exam?
Metastatic Gastric Cancer (Krukenberg Tumor)
- mucin producing Adenocarcinoma
- usually bilateral mets
144
What markers are used to track course of disease/treatment response for Metastatic Gastric Cancer (Krukenberg tumor)?
CEA
145
What is the workup/management for a pt presenting with positive screening tests for ovarian tumor?
Ultrasound (CT if postmenopausal)
Biopsy (Laparoscopy if Cyst suggests malignancy but has no septations or solid components)
Check Serum markers
Removal:
-cytectomy -benign
-salpingo-oopherectomy (premenstrual)
-TAH/BSO + Chemo for malignant (postmenopausal)
146
What are the most common HPV serotypes associated with cervical cancer?
16, 18, 31, 33, 35
147
Which HPV serotypes are responsible for warts?
6, 11
148
What are risk factors for Cervical neoplasia?
Cigarette Smoking
Multiple Sexual Partners
Early age intercourse
Immunosuppression
149
At what age should females begin HPV screening?
21 (independent of age of onset of sexual activity)
150
How are females screened for HPV?
```
Liquid Prep (Pap smear)
HPV DNA testing
```
151
What is the standard schedule for HPV screening?
Female 30yo w/avg risk:
- q3yrs w/ cytology only
or
-q5yrs w/ cytology and HPV DNA testing
152
What is the next step in management for a non pregnant reliable pt who will absolutely f/u and PAP result of ASCUS?
Repeat PAP in 3-6 mos + HPV DNA typing (original liquid specimen):
-If repeat PAP/HPV typing on results are negative:
f/u q4-6 mos until 2 consecutive Neg PAPs
-If repeat PAP results show ASCUS or HPV 16, 18:
Colpo and Bx
153
What is the next step in management for a non-pregnant unreliable pt with an initial PAP result of ASCUS?
Colposcopy and Bx (ectocervical is abnormal areas visualized + Endocervical)
154
What is the next step in managemet for a non-pregnant pt with an abnormal PAP or ASCUS on repeat PAP?
Colposcopy and Bx (Ectocervical if abnormal areas visualized + Endocervical)
155
When should a pt with an abnormal PAP smear have a cone bx performed?
- If Colpo/Endocervical Bx and PAP are inconsistent
- ECC shows abnormal histology
- Endocervical lesion present
- Bx shows MICROINVASIVE cervical cancer
156
What is the next step in management for a pt with CIN1 or CIN2,3 following ablation or excision?
Observation/Follow-up with repeat PAP, Colpo w/ PAP, or HPV DNA q4-6 mos for 2 yrs
157
What is the next step in management for a pt with CIN 2,3?
Ablation: Cryo, Laser vaporization, or electrofulguration
Excision: LEEP, Cold Knife conization
Hysterectomy (Bx confirmed, recurrent CIN 2,3)
158
What is the avg age of dx of invasive cervical cancer?
45yo
159
What is the most common type of cervical cancer?
Squamous Cell Carcinoma
160
What is the next step in workup for a pt. dx with invasive cervical cancer?
Look for Mets:
- Pelvic exam
- CT
- Cystoscopy
- Proctoscopy
161
What is the treatment/management for a pt diagnosed with cervical cancer?
```
Hysterectomy (simple, modified radical)
Adjuvant therapy (radiation and chemo)
-Lymph node involvement
-Tumor>4cm
-Pooly differentiated
-Positive margins
-Local recurrence
```
162
What is the next step in management for a pregnant pt with an abnormal PAP -HGSIL?
Colposcopy and Bx (only ectocervical)
163
What is the next step in management for a pregnant pt with a bx confirmed CIN/dysplasia?
Repeat PAP +Colpo q3mos DURING pregnancy and at 6-8 wks postpartum
-If persistent lesions, follow non-preg management (remove)
164
What is the next step in management for a pregnant pt with microinvasive cervical carcinoma?
```
Cone bx (ensure no frank invasion)
Vaginal delivery
Follow-up at 2 mos post partum
```
165
What is the next step in management for a pregnant pt with invasive cervical cancer?
Diagnosed 24 wks:
-Conservative management up to 32-33 wks
-C-section followed by definitive treatment
(hysterectomy/radiation)
166
When should HPV vaccine be given?
ALL females ages 8-26 (immunization against 6,11,16,18)
| Males 9-26
167
When is HPV vaccine not recommended?
Pregnancy
Lactating
Immunosuppressed
168
What are the steps for the initial work-up of pelvic pain?
Pelvic exam
Cervical Culture (Gonorrhea/Chlamydia)
Blood tests (ESR, WBC ct, Blood Cx if fever present)
Sonogram
169
What is the most likely diagnosis when a pt presents with cervical discharge with/w/o associated symptoms?
Cervicitis
170
What is the next step in management for a pt presenting with cervical discharge on routine exam?
Cervical Cultures
171
What dx should be suspected in a pt with cervical motion tenderness on exam and complaints of lower pelvic pain AFTER menstruation?
Acute Salpingo-oopheritis
172
What diagnostic lab/imaging findings will confirm the diagnosis of acute salpingo-oopheritis?
Positive Cultures
Elevated WBC/ESR
Sonogram: Negative for Tuboovarian Abscess
173
What is the treatment for acute salpingo-oopheritis?
Outpt: IM Ceftriaxone (1x) + Doxycycline
Inpt: IV Cefotetan or Cefoxitin + Doxycycline
174
What is the treatment of choice for Cervicitis?
IM Ceftriaxone (1x) + PO Azithromycin (1x) (Can substitute Doxycycline for Azithromycin)
175
What is the most likely dx in a pt presenting with infertility or dyspareunia w/w/o a h/o ectopic pregnancy or abnormal vaginal bleeding?
Chronic Pelvic Inflammatory Disease
176
What are the next steps in workup for a pt suspected of having chronic PID and the findings?
Cervical Cultures --> will be negative
Labs: WBC, ESR--> will be negative
Sonogram: Bilateral Cystic Pelvic Masses (Hydrosalpinges)
177
How is Chronic PID treated?
Lysis (tubal adhesions)
| Pelvic Clean out (if severe): TAH/BSO
178
What is a manifestation of advanced Pelvic Inflammatory disease that shhould be suspected when a pt presents ill-appearing, with severe, lower abdominal/pelvic pain, back pain, and rectal pain with systemic sx (fever, N/V, tachycardia)?
Tuboovarian Abscess
179
What diagnostic steps should be taken to work up a pt suspected of having a Tuboovarian abscess?
Labs: WBC, ESR (very elevated), Bld Cx (anaerobic orgs)
Pelvic exam ( w/ culdocentesis-->pus)
Sonogram: Unilateral Pelvic Mass (resembling a complex cyst)
180
How is Tuboovarian abscess treated?
```
Admit pt
Ab's: Cefoxitin and doxycycline
Reassess:
- if no response w/in 72 hrs or if Abscess Ruptures-->
-Ex Lap(w/w/o TAH/BSO)
OR
-Percutaneous drainage
```
181
When should a pt with pelvic pain/cervical discharge be managed as an outpt?
All cases of cervicitis
| Acute Salpingo-oopheritis w/o systemic signs or pelvic abscess
182
When should a pt with pelvic pain/cervical discharge be managed as inpt?
Prior outpt treatment failure
Pt has IUD
Systemic signs (fever, N/V, tachycardia)
Pelvic Abscess present (Tuboovarian abscess included)
183
What is the most likely dx when a female presents with recurrent, crampy lower abdominal pain with n/v and diarrhea during menstruation w/o any pelvic abnormalities?
Primary Dysmenorrhea
184
When is the onset of sx associated with primary dysmenorrhea?
2-5 yrs BEFORE menstruation onset
185
What is the underlying cause of primary dysmenorrhea?
Excessive PGF2 effects on endometrium
[Note: PGF2 causes uterine contractions and affects GI smooth muscle]
186
What is the treatment for Primary Dysmenorrhea?
```
NSAIDs (first line)
Combo OCPs (second line)
```
187
What are some common causes of secondary dysmenorrhea? (3)
Endometriosis (most common)
Adenomyosis
Leiomyomas (Fibroids)
188
What dx should be suspected when a female presents in her 30's with dysmenorrhea, dyspareunia, dyschezia, and infertility?
Endometriosis
189
What is the underlying abnormality resulting in the symptoms of Endometriosis?
Ectopic endometrial glands
190
What is the most common extra-uterine endometrial gland site in Endometriosis?
Ovaries
191
What are the ovarian manifestations of ovarian involvment in endometriosis?
Enlargement d/t Chocolate Cysts (Adnexal Endometriomas)
192
What is the second most common site for ectopic endometrial gland presence in Endometriosis?
Cul-de-sac
193
What sypmtoms are associated with Endometriosis affecting the cul-de-sac?
Uterosacral ligament nodularity
| Tenderness on rectovaginal exam
194
What 2 complications of endometriosis involving the Cu-lde-sac
Bowel Adhesions
| Fixed retroverted uterus
195
What tests/imaging should be performed to work up a pt suspected of having Endometriosis?
Sonogram (may see endometriomas)
| Definitive Dx: Laparoscopy to see the lesions
196
What serum marker can be associated with Endomentriosis?
CA-125
197
What conditions can a CA-125 be associated with?(4)
Cirrhosis
Peritonitis
Pancreatitis
Endometriosis
198
What are the steps in treating a pt confirmed to have endometriosis?
First line:
-Continuous Oral Progesterone (or OCP)
Second Line:
- Testosterone derivatives (Danazol, Danocrine)
- GnRH analogs (Lurpon or Leuprolide)
Laser vaporization of adhesions (Laparoscopically, to preserve fertility)
TAH/BSO: severe symptoms when fertility not desired
199
What is the average age of menarche?
12yo
200
What is the most likely diagnosis in a pt less than 8 yrs old who has not yet had menarche but presents with vaginal bleeding?
Premenarchal Vaginal Bleeding
201
What is the most common cause of Premenarchal Vaginal Bleeding?
Foreign Body
202
What conditions must be ruled out in a pt who presents with premenarchal vaginal bleeding? (5)
```
Sarcoma Botryoides (grape-like masses from vagina or cervix)
Pituitary Tumor
Adrenal Tumor
Ovarian Tumor
Sexual Abuse
```
203
What are the diagnostic steps involved in working up a pt with premenarchal vaginal bleeding?
```
Pelvic Exam (Anesthesia)
CT/MRI of Pituitary, abdomen, pelvis (look for tumor)
If all above is negative--> Idiopathic Precocious Puberty
```
204
What is the next step in management when a female of reproductive age presents with abdominal pain, vaginal bleeding (regardless of length of time), and/or amenorrhea?
B-hCG
205
What is the most likely dx when a female presents with absence of mensesat age 14 WITHOUT secondary sexual development or at age 16 yo WITH secondary sexual development?
Primary Amenorrhea
206
What steps are included in the diagnostic work up for a pt suspected of having primary amenorrhea?
```
Physical/Pelvic Exam:
-Breast development? (Indicator of estrogen levels)
Ultrasound:
-Uterus present?
Karyotype, Testosterone and FSH levels
```
207
What is the next step in management when a female presents with amenorrhea at age 16 but has appropriate breast development and a uterus is present on U/s?
Begin Workup for Secondary Amenorrhea:
- Check for Imperforate Hymen (pelvic exam)
- Vaginal Septum (schedule hysterosalpingogram)
- Screen for Anorexia Nervosa
- Excessive Exercise
- Pregnancy before first menses (assess sexual activity and check b-hcg)
208
What is the next step in management when a female presents with amenorrhea at age 16 but has appropriate breast development and no uterus is present on U/s?
Order Testosterone levels and so Karyotype analysis
209
What two conditions are associated with primary amenorrhea, breast development, but absent uterus?
```
Mullerian Agenesis (46XX, normal testosterone for female)
Complete Androgen Insensitivity/Testicular Feminization (46XY, normal testosterone for male)
```
210
What hormone is responsible for breast development (thelarche)?
Estrogen
211
What is the next step in management when a female presents with amenorrhea at age 16, has no breast development but a uterus is present on U/s?
Order FSH and Karyotype analysis
212
What two conditions are associated with amenorrhea, absent breast development, but a uterus is present on U/s?
```
Gonadal Dysgenesis (Turner's Syndrome):
-XO, High FSH--> Streaked ovaries
```
Hypothalamus-Pituitary Failure
-XX, Low FSH-->inadequate ovarian stimulation
213
What reproductive structures are derived from the embryological Mullerian Ducts?
Fallopian Tubes
Uterus
Cervix
Upper Vagina
214
What is the next step in management for a 17 yo female who c/o never getting her period and constantly being stressed out who is found to have adult breast development, pubic hair, a shortened vagina on exam, and no uterus seen on ultrasound?
Karyotype and Testosterone levels
215
What is the most likely diagnosis when a pt presents with amenorrhea, breast and pubic hair development, normal ovarian function (estrogen and testosterone levels normal) but no uterus, fallopian tubes, or cervix or upper vagina seen and karyotype reveals 46XX genotype?
Mullerian Agenesis
216
What is the management for a pt with Mullerian Agenesis?
Surgical Elongation of Vagina (to aid in sexual intercourse)
| Infertility Counseling
217
What is the most likely diagnosis when a female pt presents with amenorrhea, breast development, no pubic or axillary hair, no uterus, tubes or cervix and testes seen on U/S and karyotype confirms 46XY genotype?
Androgen Insensitivity
(Note: This pt will have normal female estrogen levels and normal male testosterone levels, however, receptors do not respond to androgen presence)
218
What is the management for a pt with Androgen Insensitivity?
Surgical removal of undescended tested BEFORE age 20
| Estrogen Replacement Therapy
219
Why is it necessary to remove the tested in a pt with Androgen Insensitivity syndrome?
Increased risk of Testicular Cancer if not removed
220
What is the most likely diagnosis when a pt presents with amenorrhea, absent secondary sex characteristics, elevated FSH, streak ovaries, and karyotype analysis confirming a 45,XO genotype?
```
Gonadal Dysgenesis (TURNER SYNDROME)
(Note: Second X is necessary for normal ovarian follicular development , so when absent result is streak ovaries)
```
221
What is the management for a pt with Turner Syndrome?
Estrogen and Progesterone replacement (facilitate secondary sexual characteristic development)
222
What is the most likely diagnosis when a pt presents with amenorrhea, no breast development, but uterus seen on U/S and FSH is low?
Hypothalamic-Pituitary Failure
223
What are some of the causes associated with Hypothalamic-Pituitary Failure?(3)
Stress
Excessive Exercise
Anorexia Nervosa
224
What is the next step in management when a pt presents with amenorrhea, no breast development, but uterus seen on U/S and FSH is low
CT/MRI head (to r/o brain tumor)
225
What is the management for a pt with Hypothalamic-Pituitary Failure?
Estrogen and Progesterone replacement (for secondary sexual development)
226
What is the most likely diagnosis when a pt presents with amenorrhea, no breast development, but uterus seen on U/S, FSH is low, and anosmia?
Kallmann Syndrome (Hypothalamus fails to produce GnRH)
227
What is the most likely dx when a pt presents with previously regular or irregular menstrual cycles now c/o an absence of menses for at least 3 and 6 months, respectively?
Secondary Amenorrhea
228
What is the next step in management when a female of reproductive age presents with amenorrhea currently but reports she used to get her period?
B-hCG
229
What is the next step in management for a pt who presents with amenorrhea currently but reports she used to get her period and BhCG is negative?
TSH (r/o hypothyroidism)
230
What is the next step in management for a pt who presents with amenorrhea currently but reports she used to get her period and BhCG is negative and TSH is high?
Administer Levothyroxine to correct hypothyroidism and menses should return
231
What is the next step in management for a pt who presents with amenorrhea currently but reports she used to get her period and BhCG is negative and TSH is normal?
Check prolactin Level
( Note: will be high in primary hypothyroidism d/t absence of negative feedback on hypothalamus -->elevated TRH which can stimulate prolactin release from ant pituitary)
232
What is the next step in management for a pt who presents with amenorrhea currently but reports she used to get her period and BhCG is negative, TSH is normal, and Prolactin is elevated?
```
Review medications (antipsychotics/antideppressants)
Head CT/MRI (r/o pituitary tumor)
```
233
What is the next step in management for a pt who presents with amenorrhea currently but reports she used to get her period and BhCG is negative, TSH is normal, Prolactin is elevated, and a pituitary tumor is detected on imaging?
Tumor Bromocriptine (dopamine agonist)
Tumor >1cm --> Surgical removal
234
What is the most likely dx and next step in management for a pt who presents with amenorrhea currently but reports she used to get her period, BhCG is negative, TSH is normal, prolactin is elevated but no tumor detected on imaging and no medications are being used with anti-dopamine effects?
Dx: Idiopathic Prolactinemia
| Treat with Bromocriptine
235
What is the next step in management for a pt who presents with amenorrhea currently but reports she used to get her period and BhCG is negative, TSH is normal, and Prolactin is normal?
Progesterone Challenge Test
236
What is the most likely dx for a pt who presents with amenorrhea currently but reports she used to get her period and BhCG is negative, TSH is normal, and Prolactin is normal, and there is bleeding following progesterone withdrawal?
Dx: Anovulation
237
What is the next step in management for a female dx with Anovulation?
Cyclic Progesterone
Clomiphene Induction (for ovulation if pregnancy desired)
238
What is the next step in management for a pt who presents with amenorrhea currently but reports she used to get her period and BhCG is negative, TSH is normal, and Prolactin is normal, and there is NO bleeding following progesterone withdrawal?
Estrogen-Progesterone Challenge Test
| -3wks of estrogen + 1 week progesterone
239
What is themost likely diagnosis and next step in management for a pt who presents with amenorrhea currently but reports she used to get her period and BhCG is negative, TSH is normal, and Prolactin is normal, and there is bleeding following estrogen-progesterone withdrawal?
Dx: Inadequate Estrogen
| Check FSH
240
What is the most likely dx and next step in management for a pt who presents with amenorrhea currently but reports she used to get her period and BhCG is negative, TSH is normal, and Prolactin is normal, there is bleeding following estrogen-progesterone challenge, and FSH is elevated?
Dx: Premature Ovarian Failure
If pt Karyotype Analysis (look for Y chromosome mosaicism)
241
What is the most likely dx/next step in management for a pt who presents with amenorrhea currently but reports she used to get her period and BhCG is negative, TSH is normal, and Prolactin is normal, there is bleeding following estrogen-progesterone challenge test and FSH is low?
Dx: Hypothalamic-Pituitary Insufficiency
1) Head CT/MRI (r/o tumor)
2) Give Estrogen with cyclic Progesterone HRT to prevent osteoporosis and endometrial hyperplasia, respectively
242
What is the most likely dx/ next step in management for a pt who presents with amenorrhea currently but reports she used to get her period and BhCG is negative, TSH is normal, and Prolactin is normal, and there is NO bleeding following estrogen-progesterone challenge?
Dx: Genital Outflow Tract Obstruction or Endometrial Scarring
1)Order Hysterosalpingogram
-Adhesions present--> lyse then give estrogen for
endometrium stimulation
-Can place stent to prevent re-adhesions
243
What is the most likely dx in a female who presents with distressing physical, psychological, and behavioral sx that do not really interfere with her ability to carry out daily activities but they occur and resolve at the same phases of each menstrual cycle?
Premenstrual Syndrome
244
What is the most likely dx for a female pt who presents
with severe, debilitating physical, psychological, and behavioral disruptions occurring and resolving during the same phases of menstrual cycle each month?
Premenstrual Dysmorphic Disorder (PMDD)
245
What is the treatment for PMDD?
SSRI (increase extracellular Serotonin)
Low dose Vit B6 (Pyridoxine)
[Note : +/- Diuretics for fluid retention (results are mixed)]
246
What is the most likely dx in a female who presents with excessive male-pattern hair growth?
Hirsutism
247
What is the most likely dx in a woman presenting with excessive male-pattern hair growth and clitoromegaly, baldness, lowering of voice, increasing muscle mass, or loss of female contours (ie: masculinizing features)?
Virilization
248
What are the common causes of Hirsutism?
Polycystic Ovarian Syndrome (PCOS)
| Idiopathic
249
What is a less common but significant cause of Hirsutism that must be excluded in all cases females presenting with excessive male-pattern hair growth?
Androgen-secreting Tumor
250
What are the initial steps in the workup of a pt presenting with excessive male -pattern hair growth?
Testosterone Level (can be elevated in PCOS and Ovarian tumor)
DHEAS (Longer t1/2 so used to determine appropriate DHEA levels; elevated in Adrenal tumor)
LH/FSH (ratio will be high in PCOS)
17-Hydroxyprogesterone (will be high in 21-OHlase def)
251
What is the most likely dx in a pt who presents with hirsutism, obesity, metrorrhagia/oligomenorrhea/amenorrhea, acne, infertility
Polycystic Ovarian Syndrome (PCOS)
(to dx, only need 2/3:
Irregular bleeding/Anovulation
Bilateral Cystic Ovaries
Evidence of Increased Testosterone levels)
252
What are the next steps in management for a pt suspected of having PCOS?
LH/FSH ratio (>3:1, LH increased but FSH decreased)
Testosterone levels
Pelvic U/S
-(bilateral enlarged ovaries w/ multiple subcapsular
follicles (small) and increased stromal echogenicity)
Lipid panel
Fasting Glc
253
What conditions are women with PCOS at increased risk of getting?
Endometrial Cancer (unopposed estrogen production bc no corpus luteum--> no progesterone)
Insulin Resisitance--> Diabetes
Dyslipidemia
Infertility
254
What is the treatment for a pt with PCOS?
OCP: manage irregular bleeding, progestin mitigated estrogen effects on endometrium
Spironolactone: suppress hair follicles
Clomiphene Citrate or human Menopausal Gonadotropin (hMG): for infertility
Metformin: enhances ovulation, manages insulin resistance
255
What is the next step in management for a female who presents with RAPID onset hirsutism, virilization, with no family history?
Check testosterone and DHEAS
256
What is the next step in management for a female who presents with RAPID onset hirsutism, virilization, with no family history, and elevated Testosterone?
Pelvic U/s to r/o/i Ovarian Tumor
257
What is the next step in management for a female who presents with RAPID onset hirsutism, virilization, with no family history, and DHEAS is markedly elevated?
CT-Abdomen/Pelvis (r/o/i adrenal mass)
258
What is the next step in management for a female who presents with rapid onset hirsutism, virilization, with no family history, and DHEAS or testosterone are markedly elevated and adrenal or ovarian mass confirmed on imaging?
Surgical Removal of tumor
259
What is the most likely dx in a patient presenting with menstrual irregularities and anovulation, Gradual onset hirsutism WITHOUT virilization in the second/third decade of life, elevated 17-hydroxy-Progesterone, +/- precocious puberty, short stature and positive family hx?
Congenital Adrenal Hyperplasia (21 hydroxylase Def)
260
What is the management for pts diagnosed with CAH-21-hydroxylase deficiency?
```
Corticosteroid replacement (will decrease androgenicity and restore ovulatory cycles)
Fludracortisone (aldosterone) replacement
```
261
What is the most likely dx in a female presenting with excessive male pattern hair growth, no virilization, and normal labs (testosterone, DHEAS, 17-hydroxy-progresterone)
Idiopathic Hirsutism
262
What is the most common cause of Hirsutism?
Idiopathic Hirsutism
263
What is the treatment for Idiopathic Hirsutism?
Spironolactone (first choice)
| Eflornithine (Vaniqua): first line topical for unwanted facial hair
264
What hormone(s) will typically be elevated in PCOS?
LH
LH/FSH ratio
Testosterone (High LH-->increased theca cell androgen production-->suppression of Hepatic SHBG--> increased Free and Total testosteron)e
265
If LH, LH/FSH ratio, Testosterone are elevated, what is the next step in management for a pt presenting with hirsutism and irregular menstrual cycle/anovulation?
Abdominal/Pelvic U/S
| Lipid and Fasting glucose screen
266
What is the next step in management for a pt with markedly elevated 17-hydroxyprogesterone and gradual onset hirsutism, anovulation/irregular bleeding?
ACTH stimulation test (give cosyntropin and get no change in cortisol level)
267
What is the next step in management for a pt with markedly elevated Testosterone, rapid onset hirsutism and irregular menses/anovulation?
U/S or CT (visualize tumor)
268
What is the next step in management for a pt with markedly elevated DHEAS, rapid onset hirsutism and irregular menses/anovulation?
CT or U/S (visualize tumor)
269
What is the most likely dx in a female with elevated FSH and LH and amenorrhea for at least 12 months?
Menopause
270
What is the average age of a pt presenting with menopause?
51yo
271
How is Menopause dx in a female pt in her mid 50's presenting with amenorrhea for at least 12 months?
Check Serial levels of LH and FSH (>50 IU/mL)
272
What age is considered early onset for menopause?
Between 40-50yo
273
What is the most likely dx in a pt
Premature Ovarian Failure
274
What two conditions may be associated with premature ovarian failure?
Y Chromosome Mosaicism
| Autoimmune Disease
275
What are the most common underlying factors associated with Premature Ovarian Failure?
Idiopathic
Radiation
Surgery (oophorectomy)
276
Which menopausal symptoms are related to the reduction in Estrogen? (7)
1) Amenorrhea (3-5 yrs prior to menopause menses become less frequent = perimenopause)
2) Hot Flashes (less likely in obese women)
3) Mood Changes (emotional lability, depression, sleep issues)
4) Osteoporosis (increased osteoclast activity)
5) Cardiovascular Disease (most common cause of death in postmenopausal women)
6) Urinary Tract Changes (Increased urgency, frequency, nocturia, urge incontinence
7) Reproductive Tract Changes (decreased lubrication, increased vaginal pH, increased infection risk)
277
What the 3 most common sites of osteoporotic pathologic fractures in descending order?
Vertebral Bodies
Hip
Wrist
278
What are the musculoskeletal results of osteoporosis-related vertebral fractures? (2)
Kyphosis
| Decreased Height
279
What risk factors are associated with developing osteoporosis? (8)
Positive Fam Hx
Thin
Caucasian
```
Steroid Use
Low Calcium intake
Sedentary Lifestyle
Smoking
Alcohol
```
280
What are some ways to prevent osteoporosis?
Adequate VitD3 and Calcium intake
Weight-Bearing Exercise
Smoking Cessation
Alcohol Cessation
281
What test is used to screen/dx Osteoprorsis?
Bone mineral Density (DEXA) scan
282
What is the next step in management if a pt has an abnormal DEXA result?
Assess Calcium loss-24 hr Urine Hydroxyproline or NTX (N-telopeptide, a bone metabolite)
283
What are first-line treatments for osteoporosis?
First line: Bisphosphonates (inhibit osteoclasts)
SERMs (increase bone density and cardio
protective, ex Tamoxifen and Raloxifene)
284
What are other treatments for osteoporosis and when are they used?
Calcitonin (Increases Ca uptake by bone)
Denosumab (RANK L inhibitor--> Inhibits Osteoclasts)
Teriparatide (PTH analog; when bisphosphonates fail)
285
How do Tamoxifen and Raloxifen differ?
Tamoxifen:
- Bone and Endometrial Estrogen Agonism
- Breast Estrogen Antagonism
Raloxifene:
- Bone Estrogen Agonism
- Endometrial Antagonism
286
What is T-score value correlates to Osteoporosis?
T>/= -2.5
[Note: Osteopenia = -1.5 - -2.5]
287
When can Hormone Replacement Therapy (HRT) be used in postmenopausal women?
Treat Vasomotor Sx of Menopause
Genitourinary Atrophy
Dyspareunia
288
When is it acceptable to prescribe continuous/unopposed Estrogen?
In women who DO NOT have a Uterus
289
What are indications against HRT use in postmenopausal women?
```
To treat Osteoporosis
H/o Estrogen-sensitve cancer (breast/endometrial)
Liver Disease
Active Thrombosis
Unexplained Vaginal Bleeding
```
290
If a woman still has her uterus, what additional hormone needs to be given if when she is on Hrt?
Progestin
291
What are the benefits of HRT?
Decrease osteoporotic fracture risk
| Decrease the rate of Colon Cancer
292
What are the risks associated with HRT?
Increased DVT risk
Increased risk of heart attack
Increased risk of Breast Cancer (if HRT for >4yrs)
293
What are the guidelines for HRT?
Only start HRT for vasomotor symptoms
Use lowest dose possible
Use for the shortest duration (reevaluate annually)
Do not use for >4yrs
Never start is for Cardio-protection
294
What risk factors associated with OCP use can increase the chances of adverse effect even with low-dose contraception?
Active Smoking
HTN
Diabetes
(Without these, no increased risk of heart disease, cancer, or thromboebolism/event)
295
What are absolute contraindications against Steroid Contraception use?
```
Pregnancy
Acute Liver Disease
Active Smoker >35
Vascular Disease
Hormone dependent Cancer
Uncontrolled HTN
Migraines w/ Aura
DM w/ vascular disease
Thrombophilia
```
296
WHat are benefits of Sterroid Hormone contraceptive methods?
Decreased ovarian/endometrial cancer risk
Decease Dysmenorrhea
Decrease dysfunctionall uterine bleeding
Decrease risk of Ectopic Pregnancy
297
What are absolute contraindications to IUD use for contraception?
Pregnancy
Pelvic Malignancy
Salpingitis
(note: abnormal uterine size/shape is only a relative contraindication)
298
What is the next step in management for a 35 yo woman who presents with infertility after 1 yr of trying to conceive after stopping OCP use, no h/o PID, and a normal pelvic exam?.
Semen Analysis
299
What is the most likely dx when a pt presents with inability to conceive after 12 months of unprotected, frequent intercourse?
Infertility
300
What is the next step in management for a couple dx with infertility and the initial semen analysis is abnormal?
Repeat Semen Analysis in 4-6 wks
301
What is the next step in management for a couple dx with infertility and the repeat semen analysis is abnormal?
Refer to fertility specialist for IVF including ICSI and other fertility options
302
What is the next step in management for a couple dx with infertility and the the semen sample shows no viable sperm?
Discuss Artificial Insemination by donor
303
What is the next step in management for a couple dx with infertility and the semen analysis is normal?
Female workup for anovulation
304
What should be included in the anovulation workup for an infertile couple with a normal semen analysis?
Track Basal Body Temperature
Check Progesterone levels
Endometrial Bx ( to assess for proliferative histology)
305
If there is no mid cycle elevation in Basal Body Temperature when working up a female for infertility secondary to anovulation, what is the next step in management?
Check TSH, Prolactin --> if these are normal--> Progesterone Challenge Test --> If w/drawal bleeding:
Dx Anovulation and
Start Ovulation induction with Clomiphene (if this fails use hMG)
306
What is the most common side effect of Ovulation Induction therapy and what should be done?
Ovarian Hyperstimulation (Monitor ovarian size during induction)
307
What is the next step in management for a couple dx with infertility and the semen analysis is normal, and ovulation is confirmed?
Work up for Fallopian Tube Abnormality:
| -Check Serum Chlamydia IgG Antibody (negative test r/o infection-related adhesions)
308
What is the next step in management for a couple dx with infertility and the semen analysis is normal, and ovulation is confirmed and Chlamydia IgG is negative?
Hysterosalpingogram:
- if normal anatomy--> no further testing
- if abnormal-->laparoscopy check tubes and attept
reconstruction (tuboplasty) if needed.
- If severe--> discuss IVF
309
What is the dx/treatmment in a pt with inability to conceive for a yr or more with normal semen analysis, confirmed ovulation, and normal reproductive anatomy?
Unexplained Infertility--> No treatment
310
What is the average number of cycles attempted in IVF prior to successful pregnancy?
appx 4 Cycles
311
What cell layers are involved in Gestational Trophoblastic Disease?
Trophoblast and/or Syncytiotrophoblast
312
In what countriesis GTN most common?
Taiwan
| Philippines
313
What risk factors are associated with GTN?
Asian
Age extremes in maternity (35)
Folate Deficiency
314
What is the most common symptom associated with GTN?
Bleeding at
315
What are the most common physical exam findings/signs of GTN?
Fundal Height > dates
Markedly High B-hCG
Absence of Fetal Heart tones
Bilateral Cystic Enlargement of ovaries (theca-lutein cysts)
316
What is the most common site of distal mets with GTN
Lungs
317
What are the features associated with a complete molar pregnancy
```
No fetus
Fertilization of empty egg by 1 sperm cell
46XX (all paternal) dizygotic
20% become malignant
No Chemo required
```
318
What are the features of a Partial Molar Pregnancy?
```
Nonviable Fetus present
Fertilization of a normal egg by 2 sperm cells
69XXY (triploidy)
10% become malignant
No Chemo required
```
319
What is the distinguishing feature between molar pregnancy and a pt who presents with hypertension -related complications in pregnancy?
No viable fetus in Molar Pregnancy
| Viable Fetus in all other HTN conditions associated with pregnancy
320
How is Molar pregnancy diagnosed?
U/s showing intrauterine echoes w/o gestational sac or fetal parts (Snowstorm)
321
What is the management for Molar pregnancy?
Baseline quantitative B-hCG
CXR (to r/o lung mets)
Suction D&C
Contraception (OCP) -1 yr with serial BhCG
