Gynecology Flashcards
Patient with bilateral nipple discharge presents. What is on top of differential and what do you want to order?
Prolactinoma
PRL and TSH levels
What is the most common cause of unilateral, nonbloody nipple discharge?
Intraductal papilloma
What is commonly the cause of bloody nipple discharge?
Malignancy
Is cytology ever helpful for nipple discharge?
No
What is used for a definitive diagnosis of the patient with unilateral nipple discharge?
Surgical duct excision
How does fibrocystic disease present and what is tx?
Bilateral, painful breast lump which fluctuates with menstrual cycle. OCPs help
39 yo patient presents with firm, discrete, and highly mobile breast nodule. Most likley dx?
Fibroadenoma
Any woman with a breast mass should receive what work-up?
Clinical breast exam
US or mammogram (latter if >40)
Fine-needle aspiration biopsy
Do fibroadenomas need too be treated?
No, only if they’re growing quick
What patient population receives US for evaluation of a breast mass and why?
Younger woman with cystic feeling mass. US is helpful bc they often have denser breasts
In what situations is a mammogram used to evaluate a breast mass?
>50 Cyst recurring multiple times Skin erythema and consistency with malignancy Bloody nipple discharge Mass doesn't appear completely FNA
What is needed to evaluate a breast mass after US or mammogaphy?
FNA or core needle biopsy (core needle is better)
What is treatment regimen for ductal carcinoma in situ?
Lumpectomy, tamoxifen x 5yrs, radiation therapy
What is treatment regimen for lobular carcinoma in situ?
Tamoxifen x 5yrs; surgery is not necessary
What are risks of tamoxifen use? What are contraindications?
Risks: endometrial carcinoma, VTE
Contraindications: previous VTE or high risk for VTE, active smoker
What are the USPSTF’s recommendations for breast cancer screening?
No longer advised to do clinical breast exams or teach self-exam
>50 get mammogram every 1-2 years; only start before if have particularly high risk
Where does invasive ductal carcinoma metastasize?
Bone, liver, and brain; it is often unilateral
What type of lymph node biopsy preferred in invasive breast disease?
Sentinel node biopsy
When is trastuzumab indicated for mgmt of breast cancer?
When HER2/neu positive
How does treatment of HER+ cancer differ between pre- and post-menopausal women?
Premenopausal: Chemo +/- RT + tamoxifen
Posmenopausal: Chemo +/- RT + aromatase inhibitor
You feel an asymmetric, nontender uterus in an African-American woman. What is dx?
Leiomyoma
What cause of an enlarged uterus is estrogen responsive and thus may grow or change during pregnancy or menopause, respectively?
Leiomyoma
What causes symmetric enlargement of the uterus?
Adenomyosis
What is adenomyosis and how does it feel?
Endocrine glands of uterus implanted in myometrium causing dysmenorrhea and menorrhagia; not estrogen responsive; feels soft, symmetrical, globular, and tender
A patient presents with an enlarged uterus but also constipation and difficulty urinating. If this is a benign growth what may it be?
Leiomyoma
Are leiomyomas tender or nontender?
Nontender
Your patient with known adenomyosis presents with menorrhagia. What medical therapy may help?
Levonorgestrel IUD may decrease heavy bleeding
What is definitive therapy for leiomyomas and adenomyosis?
Hysterectomy
What are nondefinitive procedural methods for tx of leiomyomas?
Myomectomy
Embolization of vessels
What is the most common gynecologic malignancy?
Endometrial carcinoma
When reduced for simplicity, what is the risk factor for endometrial carcinoma?
Unopposed estrogen states
Women with anovulation due to PCOS are at high risk for what malignancy? What can be given to help reduce the odds of that malignancy?
Endometrial carcinoma due to unopposed estrogen stimulation; progestin
All postmenopausal bleeding is ______ until proven otherwise
Endometrial carcinoma
In postmenopausal patients how thick should the endometrial stripe be on ultrasound?
20 yo female presents with negative B-hCG and ultrasound showing a solitary cystic mass of adnexal region. Dx?
Simple cyst
What are indications of removal of a simple ovarian cyst?
If >7cm in diameter OR
Steroid contraception fails to allow it to resolve
Sudden onset of severe lower abdominal pain in presence of adnexal mass is …..
Ovarian torsion
Mgmt: laparoscopy and detorsioning should be done if blood supply not affected
How are complex ovarian cysts managed?
Laparoscopy/laparotomy
What are risk factors for ovarian cancer, in general terms?
Anything which increases number of ovulations and BRCA1 gene
*Thus protective factors are OCPs, breastfeeding, anovulation
What population are germ cell tumors most common? What are some markers?
young woman (dysgerminoma is most common)
presents as complex cystic mass with pain
LDH, B-hCG, and AFP
What is the most common type of ovarian cancer in postmenopausal women and what are the markers?
Epithelial type ovarian cancer
CA-125, CEA
What ovarian mass presents with excessive estrogen release?
Granuloasa-theca (stromal) tumor
What ovarian mass presents with excessive testosterone release?
Sertoli-Leydig cell (stromal) tumor
In a patient that presents with bilateral ovarian tumors and a history of dyspepsia what should you suspect? What is a tumor marker?
Krukenberg tumor (metastatic gastric cancer to both ovaries) CEA
In premenopausal women what is the surgical mgmt of ovarian tumors?
Salpingo-oophorectomy
Which HPV types are associated with benign condyloma acuminata?
HPV 6 and 11
What are risk factors for cervical cancer?
Smoking, multiple sexual partners, immunosuppression, early age of intercourse
When is screening for cervical cancer started?
21
At what age can cervical cancer screening be stopped if the last Pap smear was normal?
65
Is Pap smear recommended for women with hysterectomy?
No
How frequently is cervical cancer screened for?
Every 3 yrs
If >30 then can get Pap and HPV DNA screen and get tested every 5 yrs
If a women has two cervical cancer screens showing ASCUS what is the next step in mgmt?
Colposcopy and biopsy because two in a row is suggestive of cervical inflammation which may be cancer
A patient presents for cervical cancer screening and gets ASCUS what is the next step for mgmt if follow-up is certain?
What is follow-up is not certain?
Follow-up certain: repeat Pap in 3-6 months with HPV DNA testing
Follow-up uncertain: colposcopy and biopsy
Patient presents with ASCUS and f/u HPV testing shows HPV type 6. What is next step?
What if it was HPV 16 or 18?
Can follow-up with other ASCUS in 3-6 months
If high risk HPV (16 or 18) then colposcopy and biopsy
When is endocervical curettage completed in cervical cancer screening?
In nonpregnant patients with abnormal pap smears this must be done to rule out endocervical lesions
What is a longterm complication of cervical cone biopsies?
Incompetent cervix or cervical stenosis
Your patient with CIN 2 just had ablation. How should you manage long term?
Observe and f/u with Pap, colposcopy, and/or HPV every 4-6 months for 2 years
A patient presents with recurrent CIN 2 cervical cancer. What is mgmt?
Hysterectomy
How are pregnant women with HGSIL further evaluated?
They still get colposcopy and biopsy
*The only thing not done for pregnant women is endocervical curettage
How do you manage a pregnant patient with invasive cervical cancer identified at before or after 24 weeks?
Before 24 weeks: radical hysterectomy and radiation therapy
After 24 weeks: conservative mgmt until 32-33 weeks, then delivery, then mgmt
What is further mgmt of microinvasive cervical cancer in pregnant patients?
Cone bx to evaluate fr frank invasion; deliver vaginally and then re-evaluate post-partum
Gardasil is given to females of what age range?
8-26 yo
What strains does Gardasil protect against?
HPV 6, 11, 16, 18
Is Gardasil ok for use in pregnant, lactating, and immunosuppressed patients?
No
Patient presents with yellow cervical discharge in the absence of other symptoms. What is the diagnosis and tx?
Cervicitis
Treat for Chlamydia and Gonorrhea with one time dose of IV azithromycin or doxycline and IM ceftriaxone
Patient presents with lower pelvic pain after menstruation. ESR and WBC are increased and cervical cultures are positive. What is the dx and what do you want to rule out?
Acute salpingo-oophoritis
Get a sonogram to rule out pelvic abscess
Patient comes in complaining of pelvic pain but cervical cultures and ESR are negative. A sonogram demonstrates bilateral cystic pelvic masses. What is the likely dx?
Chronic PID
What is the procedural mgmt of chronic PID?
Lysis of adhesions may rid of infertility
Chronic, non-remitting pain may require TAH, BSO
Patient presents with lower pelvic pain, back/rectal pain, nausea, vomiting, and appears ill. Dx?
Tubo-ovarian abscess
What do blood cultures grow in tubo-ovarian abscess? What is seen on culdocentesis and sonogram?
Anaerobes
Culdocentesis (needle aspiration of fluid from pouch of Douglas): pus
Sonogram: unilateral pelvic mass
How is tubo-ovarian abscess managed/treated?
Admit and give IV cefoxitin and doxycycline
If the patient isn’t improving over 72 hrs then do ExLap +/- TAH/BSO or can do percutaneous drainage
What is primary dysmenorrhea?
What is cause?
What is tx?
Abdominal pain, nausea, and vomiting accompanying menstruation usually 5yrs after onset of menstruation
Caused by excessive prostaglandin F2 release which leads to additional contractions and acts on GI smooth muscle
1st line NSAIDs, 2nd line OCPs
What is the most common cause of secondary dysmenorrhea?
Endometriosis
How does endometriosis present?
Dysmenorrhea, dyspareunia, dyschezia, and infertility in patients >30
What is a chocolate cyst?
Endometriosis in an ovary
Uterosacral ligament nodularity and tenderness on rectovaginal exam is indicative of …..
Endometriosis
How is endometriosis definitively diagnosed?
Laparoscopy
What else can cause elevations of CA-125 besides ovarian cancer?
Endometriosis
Cirrhosis
Peritonitis
Pancreatitis
What are first and second line treatment options for endometriosis? Why do they work?
1st line: progestins or OCP; progestin inhibits endometrial tissue growth
2nd line: testosterone (danazol) or GnRH analogs (leuprolide)
Can also do lysis of adhesions or TAH/BSO for severe disease
What is the most common cause of premenarchal vaginal bleeding? What must you rule out?
Presence of foreign body
Rule out: sarcoma botryoides, tumor of ovary/pituitary, sexual abuse. Do a pelvic exam under sedation and get CT/MR imaging to rule out the other issues
What is Mullerian agenesis and what is mgmt?
Absence of Mullerian duct derivatives (fallopian tubes, uterus, upper vagina, cervix). Ovaries present and E and T levels are normal
Vaginal reconstruction
Patient presents with scant axillary and pubic hair development and complains of ever having a period yet. US reveals testes. Dx and mgmt?
Androgen insensitivity syndrome
Removal of testes before age 20 bc of heightened risk of cancer and estrogen replacement
What is Kallmann syndrome?
Anosmia and hypothalamic-pituitary failure leading to primary amenorrhea
Patient presents with primary amenorrhea and uterus is present on US but you find low FSH. Dx? Mgmt?
Hypothalamic-pituitary failure
Mgmt: estrogen and progesterone replacement
What are part of the steps of working up secondary amenorrhea?
B-hCG
TSH
Medications
Progesterone or estrogen-progesterone challenge test
Premenstrual dysphoric disorder is treated with ….
SSRI, vitamin B6 (pyridoxine)
What happens to LH/FSH ratio in PCOS?
Increases (usually to 3:1)
Why are patients with PCOS at heightened risk of endometrial cancer?
Anovulation leads to failure of corpus luteum to form and thus no progesterone release. Unopposed estrogen can then increase risk of cancer
Patients with PCOS are managed with what medical therapies? (Hint: 4)
OCPs help irregular bleeding and hirsutism
Clomiphene citrate helps in those wanting pregnancy
Spironolactone has anti-androgenic effects
Metformin for insulin resistance
A patient presents with rapid onset virilization and hirsuitism. What two tumors are on your differential and how can you differentiate them via labs?
Adrenal tumor: elevated DHEAS
Ovarian tumor: elevated testosterone
What is elevated in congenital adrenal hyperplasia? What is another name for the disorder?
What is tx?
Also called 21-hydroxylase deficiency
17-hydroxyprogesterne is elevated
Treat with corticosteroid replacement
What is the most common cause of hirsuitism and what is dx?
Idiopathic hirsuitism
Spironolacone and eflornithine (Vaniqa; topical drug for treatment of unwanted facial and chin hair)
What test confirms the diagnosis of CAH/21-hydrooxylase deficiency?
ACTH stimulation test
Menopause before 30 years of age =
Premature ovarian failure
What are T score cutoffs for osteopenia and osteoporosis on DEXA?
Osteopenia is T score -1.5 to 2.5
Osteoporosis is T score > -2.5
How do biphosphonates work?
Inhibit osteoclastic bone formation
SERMs are helpful in posmenopause by reducing what symptoms?
They reduce osteoporosis and cardiovascular disease
Tamoxifen has agonist effects where? antagonist where?
Agonist at bone and endometrium
Antagonist at breast
Raloxifene is a SERM with what agonist and antagonist effects?
Agonist at bone
Antagonist at endometrium
What is denosumab?
RANKL inhibitor which inhibits osteoclast function
When biphosphonates fail what is used for osteoporosis?
Teriparatide (PTH analog)
When providing HRT to a postmenopausal woman with a uterus what else must you administer and why?
Progestins because of the endometrial growth qualities of estrogen
What are some absolute contraindications for OCPs?
Smoking, uncontrolled HTN, migraines with aura, VTE, hormonal responsive cancer, pregnancy, acute liver disease, thrombophilia
OCPs reduce the risk of what cancers?
Ovarian and endometrial
What are the steps for evaluating infertility in a couple?
1) Semen analysis
2) Anovulation work-up
3) Fallopian tube abnormality work-up
What are risk factors for gestation trophoblstic disease?
Age extremes, folate deficiency, Taiwanese/Philipines
Bleeding before 16 weeks gestation, hyperemesis gravidarum, and passage of vesicles should raise suspicion of what?
Gestational Trophoblastic Disease
Where can GTN spread?
Distant mets to lungs
What is more likely to form malignancy, complete or incomplete hydatiform mole?
What are the karyotype of each?
Complete more likely to form malignancy
Complete is a dizygote
Incomplete is triploid
Sonogram showing homogenous intrauterine echoes without a gestational sac or intrauterine parts should raise suspicion for ….
Gestational trophoblastic disease (“snowstorm” appearance)
What is mgmt of GTN?
CXR to rule out malignancy
Quantiative B-hCG levels
Suction D&C
Place on effective OCPs to be able to ensure if rising B-hCG levels in the future are recurrence rather than pregnancy
