Gynecology

Question 1

Indications for BRCA Screening (7)

Answer 1

• family member with ovarian, Fallopian tube or primary peritoneal cancer
• 2 family members with breast cancer under 50
• 2 or more primary breast cancers
• personal history of breast cancer before 50
• personal history of triple negative diagnosed before 60
• male family member with breast cancer
• 2 relatives with breast, prostate or pancreatic cancer

Question 2

Definition and Work-Up of Primary Amenorrhea

Answer 2

No menses by age 15

• beta hCG
• TSH
• prolactin
• FSH
• pelvic US

Question 3

Definition and Steps in Secondary Amenorrhea Work-Up

Answer 3

Defined as … 3 months without period if regular, 6 months without period if irregular

1 - pregnancy test
2 - if neg, TSH - if abnormal follow up with T4 and treat accordingly
3 - if normal, prolactin (review meds, MRI, bromocriptine)
4 - if normal, FSH - elevated FSH means ovarian insufficiency
5 - If FSH is low or normal check estradiol, low estradiol and low FSH means hypogonadotropic hypogoadism
6 - If estradiol normal, check testosterone for PCOS
7- Progesterone withdrawal test - if bleed after test then anovulation
8 - if no bleeding with estrogen - progesterone challenge then outflow problem - hysteroscopy (example - asherman syndrome)

Question 4

Hormone Replacement Therapy Guidelines

Answer 4

Used for short-term symptom relief and osteoporosis prevention

Use < 5 yrs (due to risk of endometrial cancer)

Contraindications - breast or endometrial cancer, history of PE or DVT

Question 5

2 IUDS

Answer 5

Copper - can be used as emergency contraception, 10 yrs

Mirena - PROG only, 3-5 years

Question 6

Levonorgestrel

Mifepristone / Ulipristal

Answer 6

EMERGENCY CONTRACEPTION

Levo - progesterone receptor agonist, work up to 3 days

Mifepristone - progesterone receptor modulator, works up to 5 days

Question 7

Lichen Sclerosis v. Lichen Planus

Answer 7

Sclerosis - white, thin, inc cancer risk because of chronic inflammation (vulvar biopsy if suspicious lesions)

Planus - violet, flat papules OR erosive type, erythematous (w/ oral gingiva involvement as well)

BOTH TREATED WITH STEROIDS

Question 8

Tx of TOA

Answer 8

If suspect, do transvaginal US or CT

CBC, culture for gonorrhea and chlamydia

Tx - IV cefoxitin and doxy (clindamycin + gentamicin if PCN allergy)

If ruptured (hypotension, peritoneal signs) –> surgery

If no improvement after 48-72 hrs abx or > 9 cm –> percutaneous drainage

Question 9

What do you do if you have a negative PAP but pos HPV test?

Answer 9

Do HPV DNA testing for 16 and 18 strains

OR

Repeat HPV test in 1 yr

Question 10

Mgt of ASCUS, LSIL and HSIL by Age

Answer 10

If 21 - 25 … if ASCUS or LSIL just repeat PAP in 1 yr

If 25+ … if ASCUS do HPV test … if neg repeat PAP in 3 yrs, if pos do colposcopy and ECC

If 25-30 w/ LSIL do colposcopy and ECC

If 30+ w/ LSIL do HPV test …if neg repeat PAP in 1 yr, if pos colposcopy and ECC

HSIL any age - colposcopy and ECC

Question 11

Differential for Abnormal Uterine Bleeding (8)

Answer 11

PALM-COIN - E

P - polyp (remove - 95% benign)

A - adenomyosis (endometrial glands in myometrium - boggy and painful)

L - leiomyoma (fibroids - ENLARGED)

M - malignancy (endometrial or cervical)

C - coagulopathy

O - Ovulation dysfunction (no corpus luteum so no withdrawal bleeding until endometrium outgrows blood supply)

I - iatrogenic (OCPs, anticoagulation, IUD) or infection

N - not classified

E - endometriosis

Question 12

What should you immediately exclude in post-coital bleeding? In postmenopausal bleeding?

Answer 12

Post-coital is cervical cancer until proven otherwise

Post-menopause is endometrial cancer until proven otherwise - endometrial biopsy

Question 13

Indications for Endometrial Biopsy (4)

Answer 13

Any post-menopause bleeding

abnormal uterine bleeding in women > 45

abnormal uterine bleeding in women < 45 with BMI > 30, chronic unopposed estrogen exposure, failed medical mgt or high risk cancer

Atypical glandular cells on pap

Question 14

Treatment of Endometriosis

Answer 14

NSAIDs
Hormonal contraceptives
GnRH agonists
Aromatase inhibitors 
ALL EQUAL EFFICACY

If moderate to severe, danazol (androgen) or leuprolide (continuous GnRH) to dec FSH and LH

Surgery if infertile or severe - attempt to remove implanted glands and restore normal anatomy

Question 15

What is the LH:FSH in PCOS?

Answer 15

> 3:1 because high androgens –> estrogen production outside ovary –> feedback to hypothalamus leads to LH surge without increase in FSH

Question 16

Clomiphene

Answer 16

Binds estrogen receptors at hypothalamus –> inhibit estrogen negative feedback –> more pulsatile GnRH –> LH and FSH

Used in PCOS patients that wish to conceive

Question 17

Mgt of Bartholin Gland Cyst

Answer 17

I&D - culture fluid for chlamydia and gonorrhea

If recurrence - marsupilization, stitch walls down to keep cyst open

Question 18

Androgen Insensitivity v. 5 Alpha Reductase Deficiency

Answer 18

AIS - genotype is male, phenotype is female, no peripheral testosterone for external male genitalia, get breast development because androgen receptors not able to block peripheral estrogen from working on breasts

5ARD - genotype is male, phenotype is female, cannot convert testosterone to DHT (no external genitalia as embryo), NO breast development because testosterone able to block at breast