Gynecology Flashcards

Question

Pelvic organ prolapse

Answer 1

``` Risk factors: Increased parity Vaginal deliveries Increased age Increased intraabdominal pressure - obesity, heavy lifting, chronic cough, chronic constipation ``` ``` Hx: vaginal/pelvic pressure vaginal bulge - something falling out of my vagina stress incontinence, urinary obstruction Fecal incontinence, constipation ``` Dx: physical exam ``` Tx: Observe if asx Pelvic floor muscle exercises Pessary Surgery ```

Answer 2

E.coli, S. aureus, Strep, N. gonorrhoeae, C. trachomatis, polymicrobial Presentation: vulvar pain and swelling - interfere with walking, sitting, intercourse Tender, fluctuant mass in lower labium majus Tx: I&D, cx Abx coverage Recurrent - marsupialization

Answer 3

MC cause of vaginal discharge in US Gardnerella vaginalis overgrowth Risk: sex, smoking, douching thin, white/gray discharge with fishy odor Vaginal pH >4.5 Clue cells - coccobacilli Positive whiff amine test - fishy odor with KOH Tx: Metronidazole x 7 days Clindamycin

Answer 4

Trichomonas vaginalis - flagellated protozoan ``` Greenish, frothy vaginal discharge Vaginal irritation, dysuria Strawberry cervix Vaginal pH >4.5 Wet mount: motile trichomonads Positive nucleic acid amplification test ``` Tx: metronidazole x1 (treat partner too)

Answer 5

Candida spp Risk: abx use, elevated estrogen levels, diabetes, immunosuppression Vulvar and vaginal itching/irritation Thick, white, cottage cheese like vaginal discharge normal Vaginal pH 4-4.5 Wet mount: budding yeast, pseudohyphae Tx: oral fluconazole, topical azole

Answer 6

S. aureus - exotoxin TSST-1 use of highly absorbent tampons S/S: Fever Hypotension Dysfunction of multiple organs - V, D, elevated BUN and Cr, confusion, AMS Rash: sunburn like, palms and soles involved - desquamates 1-2 weeks later Clinical Dx, vaginal cx ``` Tx: remove tampon, wound packing Supportive - IVF, vasopressors Abx: Clindamycin (decreases toxin production) + Vancomycin (covers MRSA) ```

Answer 7

MC: chlamydia, gonorrhea HSV, trichomonas ``` Features: asx Mucopurulent vaginal discharge Spotting, postcoital bleeding urethritis - WBC on UA Erythematous and friable cervix ``` Dx: Nucleic acid amplification test Gonorrhea: gram neg intracellular diplococci -culture - Thayer-martin media Tx: Chlamydia - azithromycin x1 or doxy x7 d Gonorrhea - IM ceftriaxone x1 + PO azithromycin x1

Answer 8

MC: chlamydia, gonorrhea Features: b/l lower abdominal pain Mucopurulent vaginal discharge Chandelier sign - cervical motion tenderness Fever Elevated wbc's on wet mount of vaginal fluid Elevated ESR/CRP Positive GC test RUQ pain - Fitz-Hugh-Curtis Sn - pain refers to shoulder US: tubo-ovarian abscess, thickened fluid-filled fallopian tubes Tx: Inpatient: -IV cefotetan/cefoxitin + doxy -Clindamycin + gentamicin Out pt: IM ceftriaxone x1 + doxy x14 days Long term complications: Chronic pelvic pain ectopic pregnancy infertility

Answer 9

IV cefoxitin + doxy + metronidazole until 48-72 hrs afebrile then change to oral doxy and flagyl for remaining time of 14 day course abscess larger than 8 cm - IR consult for drainage

Answer 10

HPV types 6, 11 Flesh colored, "cauliflower like" papules in genital region Turns white with acetic acid application Tx: Physical: excision, laser therapy, cryotherapy Chemical: podophyllin, trichloroacetic acid, 5-FU Immunologic: imiquimod, interferon alpha

Answer 11

HSV 1 or 2 Multiple vesicles on an erythematous base clusters of painful, shallow ulcers 1st outbreak: fever, malaise, myalgias, dysuria, LAD Latency in sensory ganglia - reactive in stress ``` Dx: Tzanck smear - multinucleated giant cells Viral cx - gold standard PCR, direct fluorescent antibody (DFA) Serology ``` Tx: acyclovir, famciclovir, valacyclovir

Answer 12

T. pallidum Primary: single papule at site of innoculation Chancre - painless, clean based ulcer with heaped-up border, indurated margins -heals spontaneously Tx: PCN G x1 ``` Secondary: Fever, malaise, LAD Rash involves palms and soles Condyloma lata - greyish raised lesions on genital mucosa Tx: PCN G x1 ``` latent: asx Early - PCN Gx1 Late - PCN G IM q1wk x3 Tertiary - 1-25 yr later - CV - aneurysms of a sending aorta, aortic valve insufficiency - Gummas - granulomatous lesions in skin, bones, internal organs tx: PCN G IM q1wk x3 Neurosyphilis -General paresis, tabes dorsalis, Argyll-Robertson pupil Tx: PCN G IM q1wk x3

Answer 13

Screen: RPR, VDRL Confirm: FTA-Abs, MHA-TP Dark field microscopy Direct florescent antibody DFA

Answer 14

H. ducreyi Erythematous papule -> pustule -> painful ulcer with purulent base (exudative) 1-2 cm Painful inguinal LAD, bubo formation - draining Dx: Gram stain : gram-negative rod's - School of Fish pattern Tx: ceftriaxone, azithromycin

Answer 15

Tropical, MSM Chlamydia trachomatus serovals L1-L3 Primary: painless ulcer at site of inoculation - resolves spontaneously Secondary: U/L inguinalLAD -> bubo formation, groove sign (inguinal ligament bordered by LAD on either side) Proctocolitis - in anal sex -> strictures Dx: serology, NAAT Tx: doxy

Answer 16

Klebsiella granulomatis Rare in US, endemic in tropical regions Painless nodules -> shallow painless ulcers with beefy red base - bleed easily, no LAD Dx: visualization of donovan bodies (intracellular gram neg rods) on Wright-Giemsa stain of smear/bx Tx: azithromycin x3 weeks

Answer 17

MC benign tumor in women Hormonally sensitive increase in size in response to estrogen and progesterone - grow larger during pregnancy - decrease in size in menopause ``` Presentation: asx Heavy/prolonged periods -> anemia Pelvic pressure/discomfort recurrent miscarriages, infertility enlarged uterus with irregular contours ``` Dx: U/S Tx: Definitive - hysterectomy -GnRH agonist - leuprolide - 3-6 mo preop to correct anemia and decrease size Myomectomy - preserves child bearing OCP, progestin, levonorgestrel IUD - decrease bleeding, may increase size Endometrial ablation - need endometrial bx first Uterine artery embolization

Answer 18

Risk factors: Chronic unopposed estrogen stimulation - exogenous: estrogen replacement therapy without progestin -endogenous: estrogen secreting tumor (granulosa cell tumor), obesity, chronic anovulation (PCOS) Nulliparity, early menarche, late menopause FHX - Lynch syndrome DM, HTN Tamoxifen use Presentation: AUB, postmenopausal bleeding US: thickened endometrium Dx: Endometrial biopsy Tx: hyperplasia - Progestin - if low risk progression, no atypia and childbearing desired - Mirena IUD - Hysterectomy +/- b/l salpingo-oophorectomy Tx: cancer Progestin - low risk cancer and wants kids Hysterectomy + b/l salpingo-oophorectomy + LN dissection +/- radiation - local invasion +/- chemo -mets or high risk disease 5 yr survival 80-90%

Answer 19

Squamous cell carcinoma - HPV infection Clear cell adenocarcinoma - DES in utero Sarcoma botryoides (embryonal rhabdomyosarcoma - grape like tumor in infants and children

Answer 20

Squamous cell carcinoma ``` Risk: HPV 16, 33 Cervical cancer - coexist vulvar intraepithelial neoplasia (VIN) Smoking Immunosuppression Chronic inflammation - Lichen sclerosis ``` Lesion: flat plaque, raised nodule, warty, "cauliflower like", changes in pigmentation Vulvar pruritis Dx: bx Early stage: surgical resection + LN dissection +/- lymphadenectomy Local invasion: surgical resection + lymphadenectomy +/- radiation Mets - chemo

Answer 21

CIN I - mild dysplasia, 1/3 thickness involved Tx: observe CIN 2 - moderate dyplasia, 2/3 thickness involved Tx: ablation, excision - LEEP, cone CIN 3 - severe dysplasia more than 2/3 but not full thickness involved Tx: ablation, excision - LEEP, cone CIN3 - in situ carcinoma - full thickness involvement, no BM invasion Tx: ablation, excision - LEEP, cone Invasive carcinoma - invades through BM

Answer 22

initial screening at 21 unless HIV - pap 1st yr sexually active 21-29: pap q3 yr over 30: pap q3 yr or q5 with negative HPV Stop at 65 in average risk, adequately screened women Stop following total hysterectomy performed for benign indications

Answer 23

Mild dysplasia, many regress spontaneously ``` 21-24 yo - repeat Pap in one year 25-29 yo -> colposcopy over 30 - HPV testing + HPV -> colposcopy negative -> repeat Pap and HPV in 1 yr ```

Answer 24

Moderate to severe dysplasia High risk of malignancy 21-24 yo --> colposcopy Over 25 - colposcopy or LEEP

Answer 25

Abnormal cells, low risk of malignancy 21-24 yo - repeat pap 1 yr, if positive at that point -> colposcopy over 25 - test for HPV, if positive -> colposcopy

Answer 26

colposcopy for all

Answer 27

get endocervical sampling Colposcopy Endometrial biopsy for over 35 or risk factors

Answer 28

``` Presentation: Irregular vaginal bleeding Postcoital bleeding New watery vaginal discharge Pelvic/back pain Urinary/bowel symptoms Speculum exam - abnormal vessels, friable tissue, Ulcerations, exophytic masses ``` Dx: Bx if lesion visible Pap test, colpo if abnl pap Tx: Microinvasive disease with invasion less than 3 mm - conization or hysterectomy Early stage confined to cervix - radical hysterectomy + lymphadenectomy +/- radiation or chemoradiation Local spread - chemoradiation first mets - chemotherapy Early detection 95% survival at 5 yrs

Answer 29

Physiologic ovarian cyst - Graafian cyst - Corpus luteum cyst Endometrioma Ectopic pregnancy Tuboovarian abscess Ovarian tumor

Answer 30

Benign: Cystic unilocular - thin septations U/l Malignant: solid components multilocularity - thick septations B/L

Answer 31

Serous Mucinous tumor marker: CA 125 elevated Presentation: Postmenopausal women with abdominal pain, early satiety, ascites Poor prognosis - late dx

Answer 32

Dysgerminoma (high LDH) Yolk sac (high AFP) Teratoma - benign (high AFP) Embryonal (high AFP, hCG) Presentation: Adolescent with abdominal pain/mass Excellent prognosis is stage one - 100% at 5 yrs

Answer 33

elevated estrogen, inhibin Presentation: Precocious puberty AUB often postmenopausal Good prognosis

Answer 34

Elevated testosterone Presentation: virilization Prognosis is good

Answer 35

95% epithelial Risk: FHx - BRCA 1/2, Lynch syndrome uninterrupted ovulatory cycles - early menarche, late menopause, nulliparity, infertility ``` Presentation: Bloating Pelvic/abdominal pain Early satiety, wt loss urinary frequency, urgency Adnexal mass ``` Dx: TVUS CA 125 Surgical exploration - bx risk seeding cavity Surgical staging and debulking -hysterectomy, bilateral salpingo-oophroectomy, LN dissection, peritoneal washings, omentectomy, diaphragmatic washings Adjuvant or neoadjuvant chemo Prog: poor - 45% survival at 5 yr Screening - not recommended of asx and average risk

Answer 36

``` puberty drugs (STACKED) Herbals - tea tree oil, lavender oil Cirrhosis hypogonadism testicular germ cell tumor hyperthyroidism HD patients ```

Answer 37

Begins as mastitis - S. aureus -> walled off MC - DM and smokers Painful breast mass Large area of redness, warmth, tenderness Purulent drainage from the mass or nipple Fever over 102F Dx: CBC: leukocytosis and bandemia US: Collection of fluid Needle aspiration - pus ``` Tx: I&D Abx: dicloxacillin, cephalexin, or amox/clav TMP-SMX if MRSA Metronidazole if suspect anaerobs - pus smell ``` Continue breast-feeding or pumping High rate of recurrence

Answer 38

Increase in fibrous tissue and benign cysts MC 35-50 yo Multiple, bilateral breast masses - often painful Hormonally sensitive - worse before/during menses U/S - r/o solid mass Tx: reduce intake of caffeine and fat OCPs to decrease stimulation of breast

Answer 39

MC benign breast tumor in women under 30 Solitary, firm, mobile breast mass Increase the size with estrogen exposure - tender in pregnancy, menses Dx: FNA, core bx, excisional bx Diagnostic mammo if over 35 Tx: may not be required if large or symptomatic - excision or cryotherapy

Answer 40

Benign - rare malignant transformation Serous - straw colored nipple discharge +/- streaked with blood Tx: excise to evaluate for cancer

Answer 41

MC in 50s Large, bulky tumor Leaf like projection on biopsy Generally benign - occasionally become malignant Tx: Close monitoring if Sxs - resect