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Gynecology Flashcards

1
Q

Ddx for abnormal vaginal odor

A

bacterial vaginosis *fishy odor, watery discharge

candidia yeast infection *creamy, cottage cheesy discharge

trichomoniasis (sexually transmitted) *green, vaginitis

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2
Q

How to work up abnormal vaginal discharge?

A

whiff test (add KOH) - bacterial vaginosis

wet/saline prep

KOH/wet prep

vaginal pH (nml <4.5)

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3
Q

What are signs of bacterial vaginosis?

A

postiive fishy odor on whiff test

clue cells on saline prep

pH incr above 4.5

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4
Q

How to treat bacterial vaginosis?

A

metronidazole for 7 days

don’t need to tx partner

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5
Q

How do you dx and tx vaginal caindida infection?

A

more common after abx, immunosuppresion, DM

s/sx: burning, itchy, irritation, white thick clumpy d/c

KOH prep shows pseudohyphae

pH normal

tx: 1 dose fluconazole

Azole creams - multiple day tx

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6
Q

How do you dx and tx Trichomoniasis?

A

Saline prep with motile trichomonads

ph >4.5 (elevated)

purulent, green, foul smelling discharge, strawberry cervix, vaginal pain

metronidazole orally

*treat partner as well

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7
Q

What 2 things to think about with cervical motion tenderness?

A

PID

ectopic pregnancy

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8
Q

Is a pap smear diagnotstic?

A

no - only screening!!! must have a cervical biopsy to dx

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9
Q

How do you follow up an abnormal pap smear with a ASC-H or HSIL?

A

ob/gyn consult “pap smear shows _”

colposcopy and biopsy (if you see abnormalities)

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10
Q

What are the different findings with colposcopic biopsy results of abnormal cervical tissue and how do you tx?

A

CIN 1 - 1/3 thickness affected (mild)

*can remove or f/u with another pap in 1 yr

CIN 2 - 50% affected (moderate)

CIN 3 - full thickness (advanced)

tx: loop electrosurgical excision procedure (LEEP) to remove abnormalities or ablation with cryotherapy

Pap every 3-6 months for next 2 yrs to make sure doesn’t recur

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11
Q

What part of the cervix is tested with biopsy?

A

transition zone

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12
Q

What is the normal course of HPV infection of the cervix?

A

body will clear it on its own in 1-3 years

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13
Q

What are the possible results from a pap smear?

A

NIL -negative for lesions or malignancy

Atypical squamous cells (ASC) *undetermined significance or cannot exclude HSIL)

low grade squamous intraepithelial lesion

high grade squamous intraepithelial lesion

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14
Q

How do you f/u a pap smear that is abnormal with ASC-US (atypical squamous cells of undetermined sig)?

A

HPV DNA typing - can tell you if high risk type (16 or 18)

*if neg, done with w/u

*if type 16 or 18 - colposcopy and visually directed biopsies

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15
Q

How do you follow up an abnormal pap smear with LSIL?

A

if HPV test neg and age >30- repeat HPV/Pap in 12 months

if HPV not done or positive: colposcopy with visually directed biopsies

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16
Q

What does abnormal epithelium look like on colposcopy?

A

white epithelium, mosaicism, punctation, abnormal vessels

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17
Q

How do you f/u an abnormal pap smear in pregnancy?

A

most dysplasia will spontaneously regress after pregnancy (75%)

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18
Q

How do you treat cervical cancer that has progressed to invasive cancer?

A

hysterectomy (how much is taken out depends on depth of invasion)

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19
Q

What is the Ddx of pelvic pain and fever?

A

pelvic inflammatory dz

appendicitis

cervicitis (infection just in the lower genital tract)

extopic pregnancy (get B-hcg, usually unilateral)

endometriosis (chronic pain)

ovarian cyst

inflammatory bowel dz

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20
Q

How to w/u PID?

A

b-hcg

CBC, ESR

chlamydia and gonorrhea

STD (syphilis, HIV)

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21
Q

How to manage acute PID inpt and outpt?

A

inpatient (fever)

empiric goverage

Cefotetan IV (gonorrhea) and IV doxycycline (for chlamydia)

tx until afebrile x48 hrs and no tenderness

*pull out IUD?

outpt (not febrile) (14 days abx)

IM ceftriaxone x1, PO doxycycline 14 days, PO metronidazole 14 days

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22
Q

What are complications/sequalae of PID?

A

infertility, ectopic pregnancies d/t adhesions

chronic pain d/t adhesions

pelvic and fimbrial adhesions causing “frozen pelvis”

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23
Q

What are criteria for tx PID inpatient?

A

presence of an abscess

high fever >39

septic appearance, peritonitis

IUD in place

outpt tx failure

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24
Q

How do you dx and tx cervicitis?

A

mucopurulent cervical disharge

friability of cervical epithelium (bleed when touched with a q-tip)

no systemic complaints

nucleic acid amplification testing for chlamydia and gonorrhea

empiric - 1 dose azithromycin (chlamydia) and 1 dose cefixime (gonorrhea)

*if you have gonorrhea, tx for chlamydia no matter what the test result

*if only chlamydia - just tx chlamydia

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25
Q

What are causes of secondary menorrhea (had a period, then it stopped)?

A

Pregnancy

Anovulation (missing progesterone)

Ovarian Failure (low estrogen, premature menopause)

Outflow tract obstruction (Asherman Syndrome)

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26
Q

What is the criteria for secondary amenorrhea?

A

absence of menses for 3 months with prev regular menses

or

absence of menses for 6 months with previously irregular menses

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27
Q

How to work up secondary amenorrhea?

A

Urine B-hCG (pregnancy)

TSH (cause of anovulation)

prolactin (cause of anovulation)

FSH (rule out premature menopause/premature ovarian failure)

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28
Q

When evaluating secondary ammenorrhea, what is your next step if prolactin level is elevated or if it is normal (and pt not pregnant)?

A

elevated - repeat when fasting, if still high, get MRI to r/u pituitary prolactinioma

normal - progesterone challenge test to check for correct levels of estrogen

*if pt withdrawal bleeds, dx is anovulation

*if pt does not bleed - low estrogen or outflow tract obstruction

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29
Q

When evaluating secondary ammenorrhea, how do you evaluate for low estrogen?

A

Do an estrogen-progesterone challenge test

  • if bleeds, test is positive and means low estrogen, confirm with FSH level
  • if no bleeding, test negative - outflow obstruction (not hormonal)
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30
Q

How do you evaluate for anatomic problems causing secondary amenorrhea?

A

hysterosalpingogram by IR

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31
Q

What is Asherman syndrome and how to tx?

A

intrauterine scarring/adhesions from PID or trauma (uterine currettage, myomectomy)

*surgical tx to lyse adhesions, give high dose estrogen to try to grow healthy endometrium

*intrauterine balloon allows for healing of uterine walls

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32
Q

What causes anovulation?

A

stable estrogen (low or high) - no variation means you don’t go through a normal cycle

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33
Q

How to dx (s/sx) and work up concern for ectopic pregnancy?

A

s/sx: pain, bleeding, amenorrhea

  1. serum quantitative b-hCG
  2. blood type and Rh status (if Rh neg - need to give RhoGAM)
  3. CBC
  4. Transvaginal US (show no intrauterine gestational sac)
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34
Q

At what b-hCG level should you be able to see an intrauterine gestational sac?

A

1500

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35
Q

How to tx unruptured early ectopic pregnancy?

A

Methotrexate IM to destroy pregnancy tissue (if b-hCG <5000, ectopic mass <3.5 cm, and no cardiac activity)

f/u b-hCG on days 4 and 7 (see fall by day 7) and then weekly until fall to 0

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36
Q

How do you manage a pt with bleeding, pain, and b-hCG that is <1500 and no intrauterine sac?

A

follow the p-HCG, should double every 2- 3 days and repeat US when the level is higher

*if b-hCG doesn’t maintain this rate or levels off - suggestive of ectopic

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37
Q

How do you manage an unstable ectopic pregnancy?

A

emergency laparotomy to stop hemorrhage

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38
Q

How to tx unruptured late ectopic pregnancy?

A

B-hCG >6000, ectopic mass >3.5 cm or cardiac activity

tx with laparoscopy

f/u with serial b-hCGs

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39
Q

How to work up premenstrual syndrome?

A

have pt do a 3 month diary to tell about symptoms, should be present just before period and resolve at start of menses

b-hCG

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40
Q

How to manage premenstrual syndrome?

A

mild - reassurance

eliminate coffee and caffeine, exercise, relaxation methods

SSRIs (fluoxetine) when symptoms are present

or

combo OCPs w/ drospirenone (progestin)- Yaz

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41
Q

What are the phases of the menstrual cycle?

A

follicular (first half) (FSH rises, estrogen rises)

ovulation (LH surge)

luteal (second half) (progesterone rise)

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42
Q

What is the ddx for pelvic mass pre-menopause?

A

pregnancy

functional ovarian cyst (normal, just large and will resolve)

benign ovarian neoplasm

malignant ovarian neoplasm

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43
Q

How to w/u pelvic mass in the reproductive years?

A

b-hCG

pelvic US

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44
Q

How to manage a functional ovarian cyst?

A

f/u exam and US in 6-8 weeks

*will go away on it’s own

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45
Q

When would you NOT expect to see a physiologic ovarian cyst?

A

if pt is on hormone contraception - should be suppressing FSH and estrogen - so woudl not be creating follicles…etc.

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46
Q

How to manage a complex mass in the pelvis?

A

most common -teratoma

REQUIRES surgical exploration!

*laparoscopic cystectomy if think benign

*staging laparotomy if think is malignant

47
Q

How to manage a solid mass in the pelvis?

A

most common - dysgerminoma (malignant)

REQUIRE SURGICAL exploration *do staging intraop

48
Q

What is the concern if young woman presents with large (>8 cm) adnexal mass and mobile with sudden onset pain?

A

Torsion!

Surgical emergency!!! to untwist or remove ovary if dead.

49
Q

What is the differential for irregular menstrual bleeding in between cycles?

A

Endometrial Polyps

Leiomyoma

Malignancy

Hyperplasia

50
Q

How to work up abnormal uterine bleeding?

A

b-hCG

CBC

menstrual hx (hormonal or anatomic)

contraception use?

pelvic exam (lower genital tract problem)

progestin trial (if withdrawal bleeds, would mean it was anovulation/unopposed estrogen)

assess the endometrium

51
Q

What are the symptoms of anovulation?

A

irregular, unpredictable vaginal bleeding without cramping

*unstable endometrium bc too much estrogen and no progeesterone effect just occasionally sloughing

52
Q

How can you assess the endometrium in irregular uterine bleeding?

A

hysteroscopy (dx and tx)

53
Q

What is the ddx of involuntary loss of urine and their characteristics?

A
  1. Irritative incontinence (infection - UA)
  2. Stress incontinence (no urine lost at night) *most common
  3. Hypertonic/ Urge incontinence (involuntary detrusor contractions)
  4. Hypotonic/overflow incontinence (overdistended bladder)
  5. Fistula or bypass incontinuence (continuous urine loss)
54
Q

How do you w/u incontinence of urine?

A

UA, culture

3-day voiding diary (intake and urine out)

q-tip test (helps look at support of bladder neck when pt bares down)

cystometry (bladder volume/pressure)

55
Q

What are normal bladder volumes?

A

residual volume 50-60 ml

sensation of fullness 250 ml

urge to void - 400-500 ml

56
Q

How to manage stress incontinence?

A

mild - kegel exercises

surgical - urethropexy (lift up urethra) or sling procedure

57
Q

How do you dx and tx irritative incontinence?

A

UA or cystoscopic visualization

tx infections, remove foreign objects…etc

58
Q

How do you dx urge incontinence?

A

cannot voluntarily be suppressed

occurs w/o warning day and night

typically large loss of urine

on cystometric studies - sensation and urge volumes reduced, presence of spontaneous detrusor muscle contractions

59
Q

How do you tx urge incontinence?

A

bladder training

anticholinergic meds (oxybutynin, tolterodine) or NSAIDs

60
Q

How do you dx hypotonic, overflow incontinence?

A

neurogenic bladder, involuntary urine loss with dribbles when bladder is so full that the pressure is higher than the urethral pressure

BLADDER NEVER EMPTIES, urinary retention

over-distended bladder and decreased pudendal nerve sensation (S2, 3, 4)

*can be due to meds

61
Q

How do you tx hypotonic, overflow incontinence?

A

intermittent self-cath

cholinergic meds

alpha adrenergic antagonists

62
Q

What are complications of hypotonic, overflow incontinence?

A

reflux of urine, recurrent infections which can eventually lead to renal failure!

63
Q

How to dx and tx fistula causing loss of urine?

A

IV pyelogram for urinary tract fistula

surgical management

64
Q

What is the first step before a sterilization procedure or birth control?

A

check to see if the pt is pregnant!

65
Q

What are options for sterilization for men and women?

A

Female - transection or occlusion of fallopian tubes

Male - vasectomy

female long-acting reverisble contraception

*progesterone or copper IUDs or Nexplanon

66
Q

What are the 4 types of contraception?

A

steroid contraceptions (OCPs, ring, dermal patch)

barrier methods (diaphragms, condoms)

IUDs

permanent contraception (tubal occlusion and vasectomy)

67
Q

Info about the copper IUD

A

can have heavier bleeding

good for 10 years

failure <1%

68
Q

Info about the levonorgestrel (mirena) IUD

A

lighter periods or amenorrhea

lasts 5 years

failure <1%

69
Q

What are risks with IUDs?

A

expulsion (low risk but can happen, usually w/in 6 wks)

uterine perforation (rare)

ectopic pregnancy (can’t prevent tubal pregnancies)

70
Q

What are the contraindications for IUDs?

A

known or suspected pregnancy

unexplained vaginal bleeding

distorted uterine cavity

acute PID (hx of PID is fine)

71
Q

What is emergency contraception?

A

1 dose of levonorgestrel taken within 72 hours of unprotected intercourse

72
Q

What are the risks with OCPs?

A

venous and arterial thrombosis (low risk as we are now using lower doses than before when many of these side effects were studied initially)

73
Q

What are the benefits of steroid contraception?

A

improved pain with dysmenorrhea

tx of anovulatory bleeding

decr functional ovarian cysts

decr iron deficiency anemia

decr in ovarian and endometrial carcinoma (50% if used for over 10 yrs)

74
Q

Who should use progestin only contraceptives?

What are the types?

A

women with hx of DVTs, breastfeeding, PE, or stroke, smoker >35 yo

*no effect on venous or arterial thrombosis

75
Q

What are contraindications for steroid contraception?

A

known or suspected pregnancy

acute liver dz

hormonally dependent cancer

smoker >35 yo (only for combined estrogen/progestin ones)

76
Q

What are the s/sx and how to dx of endometriosis?

A

infertility, pain with intercourse, fixed, retroverted uterus, pain with bowel movements

dx with laparoscopic visualization and biopsy of lesions

77
Q

How to clinically tell the difference between primary and secondary dysmenorrhea?

A

primary always has normal pelvic exam, begins when ovulation begins in menstrual hx (~2 yrs after start of menses)

secondary always has abnormal pelvic exam (strats in 20-30s, dulla ching pain, usually anatomic cause, pain with intercourse)

78
Q

What is the ddx for chronic pelvic pain?

A
79
Q

How to w/u chronic pelvic pain?

A

pelvic US

cervical cx for gonorrhea/chlamydia

80
Q

How to tx primary dysmenorrhea?

A

1st line: NSAIDs

2nd line: OCPs

F/U in 3 months to see if helping

81
Q

How to tx endometriosis?

A

prevent progesterone withdrawal bleeding (menstrual cycle)

OCPs

anti-estrogen (danocrine) or GnRH agonists (leuprolide) - side effects: hot flashes

if fails meds: lysis of adhesions or total hysterectomy and ovary removal

82
Q

What is chronic PID and how to tx chronic PID?

A

It is pain d/t to ahdesions from past infections (NO CURRENT INFECTION)

tx: mild analgesics or surgical (TAH-BSO)

83
Q

How to dx and tx adenomyosis?

A

beingn symmetrically enlarged soft and tender uterus with cyclic pain

pelvic US with thickened myometrium

tx: total hysterectomy

84
Q

How to dx and tx leiomyomas?

A

beingn smooth muscle tumors that can enlarge with increased estrogen (Pregnancy)

can cause pelvic pain or bleeding between menses

dx: seen on salpingohysterography
tx: medical - leuprolide (gnRH agonists lowers estrogen) or surgical

85
Q

How long does someone have to try to get pregnant prior to being seen or labeled as hx of infertility?

A

12 months <35 yo

6 months >/= 35 yo

86
Q

What is the ddx of infertility?

A
  1. male factor infertility
  2. fallopian tube dz
  3. ovulatory dysfunction
87
Q

How do you w/u infertility?

A
  1. male factor infertility - semen analysis
  2. fallopian tube dz - hysterosalpingogram (HSG) to assess tubal anatomy
  3. ovulatory dysfunction - serum TSH, prolactin, progesterone level in luteal phase, day 3 FSH and estradiol level (test ovarian reserve)
88
Q

When working up infertility, what is the next step if prolactin is elevated?

A

MRI the sella turcica to look for pituitary adenoma!

tx: bromocryptine or surgery

89
Q

What is the next step if you find fallopian tube pathology when doing infertility w/u?

A

test for gonorrhea and chlamydia

tx if positive

then dx laparoscopy to try to repair or take out tubes and do IVF

90
Q

How to treat infertility due to male semen problems?

A
  1. if mildly abnormal - intrauterine insemination
  2. if severely abnormal - intracytoplasmic sperm injection and IVF and embryo transfer
  3. No viable sperm - artifical insemination by donor
91
Q

how to treat infertility due to annovulation?

A
  1. Give Clomiphene citrate on day 5 of cycle to increase FSH and estrogen and will stimulate ovulation
  2. if this fails, can use human menopausal gonadotropin to induce ovulation

*both create high risk for multiple gestations!

92
Q

What is the ddx for postmenopausal bleeding?

A
  1. Endometrial carcinoma (adenocarcinoma)

*higher risk in obese women, women who have never been pregnant or on OCPs

  1. Endometrial hyperplasia (benign or pre-malignant)
  2. Endometrial polyps (that are bleeding)
  3. Vaginal atrophy (low estrogen and low BMI)
  4. cervical cancer (can see with speculum exam)
93
Q

How to work up postmenopausal bleeding?

A

MUST HAVE ENDOMETRIAL TISSUE!

  • endometrial biopsy (office) or D&C (outpt surgery)

*more recently can look at US and endometrial lining thickness

94
Q

What is the next step in work up when you dx endometrial carcinoma?

A

staging laparotomy!

TAH - BSO (total abd hysterectomy and bilateral salpingo-oophorectomy)

lymphadenectomy if affected/enlarged

95
Q

1, What is the most common gyne cancer in the US?

  1. What is the most deadly gyne cancer in US?
A
  1. endometrial
  2. ovarian
96
Q

What are risk factors for endometrial cancer?

A

ANYTHING WITH INCREASED ESTROGEN

  1. unopposed estrogen replacement therapy
  2. obesity
  3. granulosa cell tumor of ovary (estrogen producing)
  4. tamoxifen (selective estrogen receptor modulator)
97
Q

how do you tx endometrial hyperplasia?

A
  1. simple hyperplasis without atypia
    - benign, tx with progestins
  2. complex hyperplasia with atypia

high potential to become malignant

  • tx with TAH-BSO or high dose progestin if can’t do surgery
98
Q

What is the average age of menopause?

A

51 (40-60 yo)

99
Q

What are the criteria for menopause?

A

no period for 12 months

most common complaint - vasomotor symptoms w/ hot flashes, sleep disturbances, chang ein sexual fx (less likely in obese pts because have more estrogen from their fat)

100
Q

How to work up menopause?

A

urine b-hcg (just make sure that is not why hasn’t had period)

clinical dx

(FSH, LH, GnRH elevated) *FSH best lab test if going to do it

101
Q

How do you treat symptoms of menopause?

A

hormone replacement therapy (estrogen daily + progestin (medroxyprogesterone acetate 1 wk per month) until symptoms go away (at most 4 yrs)

*estrogen to decr symptoms

*progestin to protect against endometrial hyperplasia (if no uterus, can just do estrogen)

102
Q

What complication of menopausal are women at risk for?

A

osteoporosis

103
Q

What is the best way to tx osteoporosis?

A

bisphosphonates

hormone replacement will do it as well, but have increased risk of heart/breast cancer-so don’t just give for osteoporosis

104
Q

What are contraindications to hormone replacement for menopausal women?

A

breast/endometrial cancer

active thrombophlebitis
undx vaginal bleeding

active liver dz

105
Q

What is the differential for pelvic mass in post-menopausal women?

A

Ovarial cancer

uterine mass/fibroid uterus

metastatic tumor (from endometrium of uterus or GI - usually bilateral)

old tubo-ovarian abscess (adhesions)

106
Q

How do you w/u, dx and tx pelvic mass in post-menopausal woman?

A

pelvic US

CA-125 level (baseline)

CBC, metabolic panel (liver enzymes for metasteses)

surgery to reduce tumor load and stage

chemo for advanced dz (spread)

107
Q

What is the typical natural hx of ovarian cancer?

A

picked up late, surgery and chemo, eventually will relapse and succumb to dz

108
Q

How to work up a vulvar lesion?

A

biopsy!

109
Q

What is the ddx for vulvar itching/lesion?

A

squamous hyperplasia

lichen sclerosis

vulvar intraepithelial neoplasia

vulvar cancer (progression of the above VIN)

paget’s disease

110
Q

What is the most common vulvar carcinoma?

A

squamous cell carcinoma

111
Q

How to tx vulvar cancer?

A

vulvectomy

lymph node dissection if <1 mm invasion of basement membrane for staging

112
Q

What is lichen sclerosis and how to tx?

A

epidermal thinning with “parchment-like” appearance

tx: clobetasol cream (testosterone cream)

113
Q

What is squamous hyperplasia of vulva and tx for it?

A

hyperplasia and hyperkeratosis of epithelium

firm and white appearing

tx: fluorinated corticosteroid cream

Step 3 (15 decks)

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