Gynecology Flashcards
Ddx for abnormal vaginal odor
bacterial vaginosis *fishy odor, watery discharge
candidia yeast infection *creamy, cottage cheesy discharge
trichomoniasis (sexually transmitted) *green, vaginitis
How to work up abnormal vaginal discharge?
whiff test (add KOH) - bacterial vaginosis
wet/saline prep
KOH/wet prep
vaginal pH (nml <4.5)
What are signs of bacterial vaginosis?
postiive fishy odor on whiff test
clue cells on saline prep
pH incr above 4.5
How to treat bacterial vaginosis?
metronidazole for 7 days
don’t need to tx partner
How do you dx and tx vaginal caindida infection?
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
How do you dx and tx Trichomoniasis?
Saline prep with motile trichomonads
ph >4.5 (elevated)
purulent, green, foul smelling discharge, strawberry cervix, vaginal pain
metronidazole orally
*treat partner as well
What 2 things to think about with cervical motion tenderness?
PID
ectopic pregnancy
Is a pap smear diagnotstic?
no - only screening!!! must have a cervical biopsy to dx
How do you follow up an abnormal pap smear with a ASC-H or HSIL?
ob/gyn consult “pap smear shows _”
colposcopy and biopsy (if you see abnormalities)
What are the different findings with colposcopic biopsy results of abnormal cervical tissue and how do you tx?
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
What part of the cervix is tested with biopsy?
transition zone
What is the normal course of HPV infection of the cervix?
body will clear it on its own in 1-3 years
What are the possible results from a pap smear?
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
How do you f/u a pap smear that is abnormal with ASC-US (atypical squamous cells of undetermined sig)?
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
How do you follow up an abnormal pap smear with LSIL?
if HPV test neg and age >30- repeat HPV/Pap in 12 months
if HPV not done or positive: colposcopy with visually directed biopsies
What does abnormal epithelium look like on colposcopy?
white epithelium, mosaicism, punctation, abnormal vessels
How do you f/u an abnormal pap smear in pregnancy?
most dysplasia will spontaneously regress after pregnancy (75%)
How do you treat cervical cancer that has progressed to invasive cancer?
hysterectomy (how much is taken out depends on depth of invasion)
What is the Ddx of pelvic pain and fever?
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
How to w/u PID?
b-hcg
CBC, ESR
chlamydia and gonorrhea
STD (syphilis, HIV)
How to manage acute PID inpt and outpt?
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
What are complications/sequalae of PID?
infertility, ectopic pregnancies d/t adhesions
chronic pain d/t adhesions
pelvic and fimbrial adhesions causing “frozen pelvis”
What are criteria for tx PID inpatient?
presence of an abscess
high fever >39
septic appearance, peritonitis
IUD in place
outpt tx failure
How do you dx and tx cervicitis?
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
What are causes of secondary menorrhea (had a period, then it stopped)?
Pregnancy
Anovulation (missing progesterone)
Ovarian Failure (low estrogen, premature menopause)
Outflow tract obstruction (Asherman Syndrome)
What is the criteria for secondary amenorrhea?
absence of menses for 3 months with prev regular menses
or
absence of menses for 6 months with previously irregular menses
How to work up secondary amenorrhea?
Urine B-hCG (pregnancy)
TSH (cause of anovulation)
prolactin (cause of anovulation)
FSH (rule out premature menopause/premature ovarian failure)
When evaluating secondary ammenorrhea, what is your next step if prolactin level is elevated or if it is normal (and pt not pregnant)?
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
When evaluating secondary ammenorrhea, how do you evaluate for low estrogen?
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)
How do you evaluate for anatomic problems causing secondary amenorrhea?
hysterosalpingogram by IR
What is Asherman syndrome and how to tx?
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
What causes anovulation?
stable estrogen (low or high) - no variation means you don’t go through a normal cycle
How to dx (s/sx) and work up concern for ectopic pregnancy?
s/sx: pain, bleeding, amenorrhea
- serum quantitative b-hCG
- blood type and Rh status (if Rh neg - need to give RhoGAM)
- CBC
- Transvaginal US (show no intrauterine gestational sac)
At what b-hCG level should you be able to see an intrauterine gestational sac?
1500
How to tx unruptured early ectopic pregnancy?
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
How do you manage a pt with bleeding, pain, and b-hCG that is <1500 and no intrauterine sac?
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
How do you manage an unstable ectopic pregnancy?
emergency laparotomy to stop hemorrhage
How to tx unruptured late ectopic pregnancy?
B-hCG >6000, ectopic mass >3.5 cm or cardiac activity
tx with laparoscopy
f/u with serial b-hCGs
How to work up premenstrual syndrome?
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
How to manage premenstrual syndrome?
mild - reassurance
eliminate coffee and caffeine, exercise, relaxation methods
SSRIs (fluoxetine) when symptoms are present
or
combo OCPs w/ drospirenone (progestin)- Yaz
What are the phases of the menstrual cycle?
follicular (first half) (FSH rises, estrogen rises)
ovulation (LH surge)
luteal (second half) (progesterone rise)
What is the ddx for pelvic mass pre-menopause?
pregnancy
functional ovarian cyst (normal, just large and will resolve)
benign ovarian neoplasm
malignant ovarian neoplasm
How to w/u pelvic mass in the reproductive years?
b-hCG
pelvic US
How to manage a functional ovarian cyst?
f/u exam and US in 6-8 weeks
*will go away on it’s own
When would you NOT expect to see a physiologic ovarian cyst?
if pt is on hormone contraception - should be suppressing FSH and estrogen - so woudl not be creating follicles…etc.
How to manage a complex mass in the pelvis?
most common -teratoma
REQUIRES surgical exploration!
*laparoscopic cystectomy if think benign
*staging laparotomy if think is malignant
How to manage a solid mass in the pelvis?
most common - dysgerminoma (malignant)
REQUIRE SURGICAL exploration *do staging intraop
What is the concern if young woman presents with large (>8 cm) adnexal mass and mobile with sudden onset pain?
Torsion!
Surgical emergency!!! to untwist or remove ovary if dead.
What is the differential for irregular menstrual bleeding in between cycles?
Endometrial Polyps
Leiomyoma
Malignancy
Hyperplasia
How to work up abnormal uterine bleeding?
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
What are the symptoms of anovulation?
irregular, unpredictable vaginal bleeding without cramping
*unstable endometrium bc too much estrogen and no progeesterone effect just occasionally sloughing
How can you assess the endometrium in irregular uterine bleeding?
hysteroscopy (dx and tx)
What is the ddx of involuntary loss of urine and their characteristics?
- Irritative incontinence (infection - UA)
- Stress incontinence (no urine lost at night) *most common
- Hypertonic/ Urge incontinence (involuntary detrusor contractions)
- Hypotonic/overflow incontinence (overdistended bladder)
- Fistula or bypass incontinuence (continuous urine loss)
How do you w/u incontinence of urine?
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)
What are normal bladder volumes?
residual volume 50-60 ml
sensation of fullness 250 ml
urge to void - 400-500 ml
How to manage stress incontinence?
mild - kegel exercises
surgical - urethropexy (lift up urethra) or sling procedure
How do you dx and tx irritative incontinence?
UA or cystoscopic visualization
tx infections, remove foreign objects…etc
How do you dx urge incontinence?
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
How do you tx urge incontinence?
bladder training
anticholinergic meds (oxybutynin, tolterodine) or NSAIDs
How do you dx hypotonic, overflow incontinence?
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
How do you tx hypotonic, overflow incontinence?
intermittent self-cath
cholinergic meds
alpha adrenergic antagonists
What are complications of hypotonic, overflow incontinence?
reflux of urine, recurrent infections which can eventually lead to renal failure!
How to dx and tx fistula causing loss of urine?
IV pyelogram for urinary tract fistula
surgical management
What is the first step before a sterilization procedure or birth control?
check to see if the pt is pregnant!
What are options for sterilization for men and women?
Female - transection or occlusion of fallopian tubes
Male - vasectomy
female long-acting reverisble contraception
*progesterone or copper IUDs or Nexplanon
What are the 4 types of contraception?
steroid contraceptions (OCPs, ring, dermal patch)
barrier methods (diaphragms, condoms)
IUDs
permanent contraception (tubal occlusion and vasectomy)
Info about the copper IUD
can have heavier bleeding
good for 10 years
failure <1%
Info about the levonorgestrel (mirena) IUD
lighter periods or amenorrhea
lasts 5 years
failure <1%
What are risks with IUDs?
expulsion (low risk but can happen, usually w/in 6 wks)
uterine perforation (rare)
ectopic pregnancy (can’t prevent tubal pregnancies)
What are the contraindications for IUDs?
known or suspected pregnancy
unexplained vaginal bleeding
distorted uterine cavity
acute PID (hx of PID is fine)
What is emergency contraception?
1 dose of levonorgestrel taken within 72 hours of unprotected intercourse
What are the risks with OCPs?
venous and arterial thrombosis (low risk as we are now using lower doses than before when many of these side effects were studied initially)
What are the benefits of steroid contraception?
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)
Who should use progestin only contraceptives?
What are the types?
women with hx of DVTs, breastfeeding, PE, or stroke, smoker >35 yo
*no effect on venous or arterial thrombosis
What are contraindications for steroid contraception?
known or suspected pregnancy
acute liver dz
hormonally dependent cancer
smoker >35 yo (only for combined estrogen/progestin ones)
What are the s/sx and how to dx of endometriosis?
infertility, pain with intercourse, fixed, retroverted uterus, pain with bowel movements
dx with laparoscopic visualization and biopsy of lesions
How to clinically tell the difference between primary and secondary dysmenorrhea?
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)
What is the ddx for chronic pelvic pain?
How to w/u chronic pelvic pain?
pelvic US
cervical cx for gonorrhea/chlamydia
How to tx primary dysmenorrhea?
1st line: NSAIDs
2nd line: OCPs
F/U in 3 months to see if helping
How to tx endometriosis?
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
What is chronic PID and how to tx chronic PID?
It is pain d/t to ahdesions from past infections (NO CURRENT INFECTION)
tx: mild analgesics or surgical (TAH-BSO)
How to dx and tx adenomyosis?
beingn symmetrically enlarged soft and tender uterus with cyclic pain
pelvic US with thickened myometrium
tx: total hysterectomy
How to dx and tx leiomyomas?
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
How long does someone have to try to get pregnant prior to being seen or labeled as hx of infertility?
12 months <35 yo
6 months >/= 35 yo
What is the ddx of infertility?
- male factor infertility
- fallopian tube dz
- ovulatory dysfunction
How do you w/u infertility?
- male factor infertility - semen analysis
- fallopian tube dz - hysterosalpingogram (HSG) to assess tubal anatomy
- ovulatory dysfunction - serum TSH, prolactin, progesterone level in luteal phase, day 3 FSH and estradiol level (test ovarian reserve)
When working up infertility, what is the next step if prolactin is elevated?
MRI the sella turcica to look for pituitary adenoma!
tx: bromocryptine or surgery
What is the next step if you find fallopian tube pathology when doing infertility w/u?
test for gonorrhea and chlamydia
tx if positive
then dx laparoscopy to try to repair or take out tubes and do IVF
How to treat infertility due to male semen problems?
- if mildly abnormal - intrauterine insemination
- if severely abnormal - intracytoplasmic sperm injection and IVF and embryo transfer
- No viable sperm - artifical insemination by donor
how to treat infertility due to annovulation?
- Give Clomiphene citrate on day 5 of cycle to increase FSH and estrogen and will stimulate ovulation
- if this fails, can use human menopausal gonadotropin to induce ovulation
*both create high risk for multiple gestations!
What is the ddx for postmenopausal bleeding?
- Endometrial carcinoma (adenocarcinoma)
*higher risk in obese women, women who have never been pregnant or on OCPs
- Endometrial hyperplasia (benign or pre-malignant)
- Endometrial polyps (that are bleeding)
- Vaginal atrophy (low estrogen and low BMI)
- cervical cancer (can see with speculum exam)
How to work up postmenopausal bleeding?
MUST HAVE ENDOMETRIAL TISSUE!
- endometrial biopsy (office) or D&C (outpt surgery)
*more recently can look at US and endometrial lining thickness
What is the next step in work up when you dx endometrial carcinoma?
staging laparotomy!
TAH - BSO (total abd hysterectomy and bilateral salpingo-oophorectomy)
lymphadenectomy if affected/enlarged
1, What is the most common gyne cancer in the US?
- What is the most deadly gyne cancer in US?
- endometrial
- ovarian
What are risk factors for endometrial cancer?
ANYTHING WITH INCREASED ESTROGEN
- unopposed estrogen replacement therapy
- obesity
- granulosa cell tumor of ovary (estrogen producing)
- tamoxifen (selective estrogen receptor modulator)
how do you tx endometrial hyperplasia?
- simple hyperplasis without atypia
- benign, tx with progestins - complex hyperplasia with atypia
high potential to become malignant
- tx with TAH-BSO or high dose progestin if can’t do surgery
What is the average age of menopause?
51 (40-60 yo)
What are the criteria for menopause?
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)
How to work up menopause?
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
How do you treat symptoms of menopause?
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)
What complication of menopausal are women at risk for?
osteoporosis
What is the best way to tx osteoporosis?
bisphosphonates
hormone replacement will do it as well, but have increased risk of heart/breast cancer-so don’t just give for osteoporosis
What are contraindications to hormone replacement for menopausal women?
breast/endometrial cancer
active thrombophlebitis
undx vaginal bleeding
active liver dz
What is the differential for pelvic mass in post-menopausal women?
Ovarial cancer
uterine mass/fibroid uterus
metastatic tumor (from endometrium of uterus or GI - usually bilateral)
old tubo-ovarian abscess (adhesions)
How do you w/u, dx and tx pelvic mass in post-menopausal woman?
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)
What is the typical natural hx of ovarian cancer?
picked up late, surgery and chemo, eventually will relapse and succumb to dz
How to work up a vulvar lesion?
biopsy!
What is the ddx for vulvar itching/lesion?
squamous hyperplasia
lichen sclerosis
vulvar intraepithelial neoplasia
vulvar cancer (progression of the above VIN)
paget’s disease
What is the most common vulvar carcinoma?
squamous cell carcinoma
How to tx vulvar cancer?
vulvectomy
lymph node dissection if <1 mm invasion of basement membrane for staging
What is lichen sclerosis and how to tx?
epidermal thinning with “parchment-like” appearance
tx: clobetasol cream (testosterone cream)
What is squamous hyperplasia of vulva and tx for it?
hyperplasia and hyperkeratosis of epithelium
firm and white appearing
tx: fluorinated corticosteroid cream
