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OB/GYN > Gynecology - GU disorders + STIs > Flashcards

Gynecology - GU disorders + STIs Flashcards

1
Q

PID will often present after

A

a period - blood is a good culture medium

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2
Q

always do cervical motion tenderness as a

A

1 handed exam! DO NOT put nondominant hand on abdomen when doing it!

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3
Q

Herpes crossing midline - is this primary or secondary infection?

A

Primary

Herpes DOES not cross midline in recurrences - if it does, suggests primary infection

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4
Q

Labial fusion

A

Assoc w/ excess androgens
- usually result of exogenous androgen exposure

Most common enzyme deficiency = 21 hydroxylase deficiency —> CAH

Tx = reconstructive surgery

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5
Q

Tx 21 hydroxylase d/o

A

Exogenous cortisol

Will feedback to decrease ACTH to decrease adrenal gland hormone secretion

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6
Q

Imperforate hymen

A

Central portion epithelial cells of hymenal membrane fail to degenerate and form hymenal ring

Usually dx at puberty in adolescents who p/w primary amenorrhea and cyclic pelvic pain.

Tx
- surgery to excise the extra tissue, evacuate any obstructed material, and create a normal sized vaginal opening

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7
Q

Transverse vaginal septum

A

Usually at lower 2/3 of vagina

Failure of mullerian tubercle to be cannalized

P/w primary amenorrhea and cyclical pain

Normal external genitalia
Vagina ends in blind pouch 2/2 septum

Tx = surgery

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8
Q

Vaginal atresia

A
  • lower vagina fails to develop and is replaced by fibrous tissue.
  • ovaries, uterus, cervix, and upper vagina are all normal.
  • usually happens when urogenital sinus fails to contribute
    the lower portion of the vagina
  • presents during adolescence with primary amenorrhea and cyclic pelvic pain.

PE

  • absence of introitus
  • presence of vaginal dimple

MRI/US can show large hematocolpos
Confirm nl upper repro tract

Tx

  • surgery
  • incise fibrous tissue and dissect until nl upper vagina ID’d
  • the normal upper vaginal mucosa is then brought down to the introitus and sutured to the hymenal ring
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9
Q

Vaginal agenesis

A

aka Mayer-Rokitansky-Kuster-Hauser syndrome

Congenital absence of vagina
+
absence/hypoplasia of all or part of the cervix, uterus, and fallopian tubes

Features:

  • nl external genitalia
  • nl secondary sexual characteristics (breast development, axillary, and pubic hair),
  • bl ovarian function.
  • phenotypically and genotypically female

Usually present in adolescence with primary amenorrhea.

Tx:

  • nonsurgical - create vagina using serial vaginal dilators pessed into perineal body (4mo - several yrs)
  • surgery to create neovagina

Fertility

  • after surgery, sex is ok
  • pt can’t carry preggers - can harvest eggs for gestational surrogate though
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10
Q

Lichen sclerosis of vulva

A

Inflammatory dermatosis

Symmetric white, thinned skin on labia, perineum adn perianal region
- shrinkage and agglutination of labia minora

Usually in postmenopausal women

3-4% Inc risk vulvar cancer

Sx:

  • pruritus
  • dyspareunia
  • usually no sx

Dx:
- always get bx to r/o vulvar SCC

Tx:
- high potency topical steroids (clobetasol or halobetasol)

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11
Q

Lichen planus of vulva

A

Multiple shiny, flat, red-purple papules usually on inner aspects of labia minora
- often erosive

Assoc w/ vaginal adhesions and erosive vaginitis

Usually in 50s-60s

Same as lichen sclerosis 3-4% inc risk of cancer

Sx:
- puruitus with mild inflammation –> severe erosions

Tx:
- high potency topical steroids (clobetasol or halobetasol)

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12
Q

Lichen simplex chronicus of vulva

A

thickened skin w/ accentuated skin markings and exocriations 2/2 chronic itching and scratching

Itching 2/2 many conditions (atopic dermatits, psoriasis, etc)

Tx:
- medium to high potency topical steroid

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13
Q

When do you bx benign lesions of vulva presenting with vulvar itching, irritation, burning?

A

Ulceration
Unifocal lesions
Uncertain suspicion of lichen sclerosis
Lesions or sx persisting after tx

Use colposcope!

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14
Q

1 tumor found on vulva

A

Epidermal inclusion cysts

- 2/2 blocked pilosebaceous duct or blocked hair follicle

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15
Q

Fox fordyce disease

A

Chronic pruritic papular eruption that localizes to areas where apocrine glands are found

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16
Q

Hidradenitis suppurativa

A

Skin dz most commonly affecting areas of apocrine sweat glands or sebaceous glands

Infected areas –> form multiple abscesses –> need I&D

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17
Q

Where are skene’s glands?

A

next to urethra meatus

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18
Q

Suspected bartholin’s dcut cyst - what do you do?

A

If > 40 yo, need to do bx to rule out rare Bartholin’s gland carcinoma

Usually self resolving

If cyst is large, can lead to abscesses and need I&D or word catheter placement

Marsupialization for recurrent duct cysts/abscesses

Warm sitz baths recommended

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19
Q

Gartner’s duct cysts

A

remnants of mesonephric ducts of wolfiann system

usually in upper part of vagina

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20
Q

DES exposure in utero…resulting risks?

A

Cervical lesions (cervical hoods, cervical collars, cervical hypoplasia, etc)

Cervical insufficiency in preggers

Clear cell adenocarcionma of cervix

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21
Q

Most cervical cysts are

A

Dilated retention cysts called nabothian cysts

Caused by intermittent blockage of endocervical gland

Usually no sx

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22
Q

Origins of reproductive structures

A

All arise from mullerian system except ovaries (from genital ridge) and lower 1/3 of vagina (from urogenital diaphragm)

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23
Q

Many uterine abnormalities can be associated with

A

Inguinal hernias

Urinary tract anomalies

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24
Q

Uterine septae vs bicorunate uterus in preggers

A

Uterine septae
- usually suffer from recurrent 1st trimester loss as septae is not vascularized so placenta can’t implant

Bicornuate uterus
- second trimester pregnancy loss, malpresentation, preterm labor and delivery

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25
Q

Uterine leiomyoma

A

Benign proliferations of smooth muscle cells of myometrium

Usually happen in women of childbearing age
Regress during menopause

Hormonally response to estrogen and progesterone

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26
Q

Classification of leiomyomas

Characteristics

A

Submucosal (beneath endometrium)
- usually assoc w/ heavy or prolonged bleeding

Intramural (in muscular wall of uterus)
- most common

Subserosal (beneath uterine serosa)

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27
Q

Fibroids vs adenomyosis

A

Fibroids have pseudocapsule

  • compressed areolar tissue + smooth muscle cells
  • little blood vessels
  • as fibroids enlarge, can outgrow blood supply, infarct, and degenerate, causing pain

Adenomyosis tends to be more diffusely organized in myometrium

MRI to distinguish between the two!

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28
Q

Ways to dx fibroids?

A

Pelvic US

Can also use HSG, saline infusion sonogram, and hysteroscopy for location and size of uterine fibroids
- good for submucosal ones

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29
Q

Medical therapies for Uterine Leiomyomas

A

GO PAN AM

GnRH agonists (leuprolide, nafarelin)
OCPs

Progestins (mirena IUD, medroxyprogesterone)
Antifibrinolytics (tranexamic acid)
NSAIDs

Androgenic steroids (danazol)
Mifepristone
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30
Q

Indications for surgical intervention for uterine leiomyomas

A

Abnl uterine bleeding —–> anemia

Severe pelvic pain or secondary amenorrhea

Uterine size > 12 wk obscuring eval of adnexa

Urinary freq, retention, hydronephrosis

Growth after menopause

Recurrent miscarriage or infertility

Rapid increase in size

Tx:

  • uterine artery embolization (not for those wanting more fertility and large and pedunculated fibroids)
  • MRI-guided high intensity ultrasound (premenopausal, done with kids)
  • myomectomy (want fertility)
  • hysterectomy
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31
Q

Endometrial polyps

A

Benign overgrowths of endometrial glands and stroma over vascular core

Usually in 40s-50s

Tamoxifen women at risk

Present w/ abnl vaginal bleeding

Eval w/ US, sonohysterogram, hysteroscopy

Tx - can be malignant or premalignant so remove in all postmenopausal; premenopausal remove too

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32
Q

Endometrial hyperplasia

A

Source of abnl uterine bleeding
Abnl prolif of both glandular adn stromal elements of endometrium

Can happen when endometrium exposed to continuous estrogen w/o progesterone

Risk endometrial carcionma

Dx:

  • bx in office
  • D&C
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33
Q

Risks for endometrial hyperplasia

A

Unexposed estrogen exposure

Obesity
Nulliparity
Late menopause
exogenous estrogen w/o progesterone
Tamoxifen use
HTN
DM
Lynch II syndrome
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34
Q

Tx endometrial hyperplasia

A

Simple + complex atypia

  • progestin therapy (depoprovera or provera)
  • repeat EMB for regression

Atypical hyperplasia

  • D&C eval
  • hysterectomy if no kids in future
  • if want kids, progestin management, repeat EMB at 3 months —–> if persistence after 9 months, hysterectomy recs
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35
Q

Functional cysts of the ovaries

A

Follicular (most common)

Corpus luteum

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36
Q

Follicular cysts of ovary

A

Most common

Happen after failure of follicle to rupture during follicular maturation phase of menstrual cycle

Usually resolve spontaneously in 2-3 months

Simple cysts < 2.5cm are physiologi

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37
Q

Corpus luteum cysts of ovary

A

Occur during luteal phase

Happen when corpus luteum fails to regress after 14d and becomes enlarged or hemorrhagic

Can rupture!

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38
Q

Theca lutein cysts of ovary

A

Large bilateral cysts filled w/ clear straw colored fluid

2/2 stim from abnormally high bhCG (eg molar preggers, choriocarcionma, ovulating induction)

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39
Q

Endometriomas

A

Ectopic endometrial tissue within ovary

Aka “chocolate cysts”

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40
Q

Endometriosis

A

1 dx in eval of infertility in couples

Endometrial tissue outside of the uterus

Sx:
cyclic pelvic pain beginning 1 or 2 weeks before menses, peaking 1 to 2 days before the onset of menses, and subsiding at the onset of menses or shortly thereafter.

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41
Q

Dysmenorrhea starting in 3rd decade, worsen with age…what do you worry about? Previously pain free cycles

A

Endometriosis

42
Q

Only way to definitively dx endometriosis

A

Laparoscopy or laparotomy…surgery!

43
Q

Tx endometriosis

A

No role for med therapy in those planning to conceive

NSAIDs

Suppress ovulation and menstruation:
Combo contraceptives
Progestins (suppress menstruation)

Suppress LH and FSH –> no estrogen:
Danazol
GnRH agonist

Aromatase inhibitors off label

44
Q

Adenomyoma

A

A well-circumscribed collection of endometrial tissue within the uterine wall.

They may also contain smooth muscle cells and are not encapsulated (no pseudocapsule like fibroid)

45
Q

Adenomyosis

A

An extension of endometrial tissue into the uterine myometrium leading to abnormal bleeding and pain.

The uterus becomes soft, globular due to hypertrophy and hyperplasia of the myometrium adjacent to the ectopic endometrial tissue

usually most extensive in the fundus and posterior uterine wall.

MRI to dx

46
Q

Tx adenomyosis

A

Extends from the basalis layer of the endometrium, it does not undergo the proliferative and secretory changes traditionally seen in normally located endometrium or in endometriosis. adenomyosis is less responsive to
treatment with OCPs or other hormonal treatments.

Progestin-containing IUD and hysterectomy are the most effective means of treatment.

47
Q

Tx UTI

A

Initial:

  • TMP/SMX
  • nitrofurantoin
  • fluoroquinolone
48
Q

1 cause vulvitiss

A

candidiasis

49
Q

Syphilis

  • dx
  • tx
A

Dx

  • dark field microscopy
  • rpr/mha-tp
  • fta-abs

Tx
- PCN

50
Q

Herpes

  • dx
  • tx
A

Dx

  • viral cx
  • Tzanck smear but not sensitive or specific

Tx
- acyclovir

51
Q

Chancroid (H. ducreyi)

  • dx
  • tx
A

Dx
- gm stain with “school of fish” appearance

Tx
- Ceftriaxone
- azithromycin
OR cipro, erythromycin

52
Q

Lymphgranuloma venereum (C. trachomatis)

  • dx
  • tx
A

Dx
- complement fixation

Tx
- Doxycycline
or
- erythromycin

53
Q

Lesions of syphilis

A

Primary

  • painless
  • red, round firm ulcer with raised edges = chancre
  • 3 weeks after inoculation
  • reginal adenopathy

Secondary

  • disseminated
  • 1-3 mo after primary
  • flu like sx and myalgias
  • maculopapular rash on palms and soles
54
Q

How long do VDRL or RPR tests remain + after tx syphilis

A

6-12 months

Will have progressively decreasing antibody titers

Repeat these test 1 and 3 months after appearance of ulcer in compliant patient

Always confirm a positive with FTA_ABS test adn T. pallidum particle agglutination assay (TTPA)

55
Q

Jarisch Herxheimer reaction

A

Acute febrile reaction freq accompanied by fever, chills, HA, myalgia, malaise, pharyngitis, rash

Happens after any tx for syphilis

Transient 2/2 marked systemic release of cytokines

56
Q

Course of primary infection HSV

A

Flu like sx

Vulvar burning and pruritis precede…

Multiple vesicles persisting for 24-36 hrs

Painful genital ulcers lasting 10-22 days

57
Q

Tx HPV condyloma acuminata/genital warts

A

Local excision

CO2 laser

Cryotherapy

Topical Trichloroacetic acid

Topical podophyllin

5-FU cream

Uncomplicated:

  • imiquimod
  • podofilox
58
Q

Where does molluscum occur?

A

anywhere on skin except palms of hands and soles of feet

Usually self resolving but can remove w/ local excision, cryotherapy, or TCA

59
Q

Scabies vs pubic lice

A

Pubic lice usually confined to pubic hair but scabies can spread throughout body!

60
Q

Tx pubic lice

A

permethrin

61
Q

Tx scabies

A

permethrin

or

ivermectin

62
Q

Risk factors for Bacterial vaginosis

A 
Mult sex partners
Cigarettes
Douching
Lack of vaginal lactobacilli
Fem sex partners
63
Q

Dx bacterial vaginosis

A

3 of findings needed:

1) thin, white homogeneous discharge coating vaginal walls
2) fishy odor when + 10% KOH
3) pH > 4.5
4) Clue cells (vaginal epithelial cells covered with bacteria) on microscopy

64
Q

Tx bacterial vaginsosi

A

Metronidazole oral

or

Clindamycin oral

Can use topical but not as effective

65
Q

Dx candidiasis

A

Microscopy exam of KOH prep of vaginal discharge

- hyphae & spores seen better

66
Q

Tx candidiasis

A

Topical:

  • miconazole
  • terconazole

Oral
- fluconazole

67
Q

Dx T. vaginalis

A

Profuse d/c with unpleasant odor (any color) +/- frothy

Vaginal pH 6-7

Vulvar erythema
Strawberry cervix

Sx usually worse after menses b/c transient increase in vaginal pH at that time

68
Q

Tx T. vaginalis

A

Metronidazole oral

Tinidazole oral

Tx both partners!!!!!!!!

69
Q

Most common causes of cervicitis

A

N. gonorrhea

C. trachomatis

70
Q

Dx and Tx gonorrhea

A

Dx
- nucleic acid amplification tests

Tx

  • ceftriaxone (IM or oral)
  • azithromycin or doxy for concaminant C. trachomatis infection
71
Q

Tx chlamydia

A

Usually asymptomatic!

Azithromycin (oral)
Doxycycline (oral)

72
Q

Screening for chlamydia?

A

Annual for sexually active women <=25yo, older women with risk factors, and all preggers

Common sites for infection = endocervix, urethra, rectum

73
Q

When do you use abx as ppx to prevent endometritis?

A

C section
Surgical terminations of pregnancy
Hysterosalpingography & Sonohysterography if woman has hx pelvic infxn or tubes dilated

NOT RECOMMENDED IN:

  • hysteroscopy
  • endometrial ablation
  • endometrial bx
  • IUD placement
74
Q

Tx endometritis or endomyometritis

A

Unrelated to pregnancy
- same as PID –> broad spectrum cephalosporin (cefoxitin or cefotetan) + doxycycline IV

Postpartum endomyometritis:
- clinda + gentamicin IV

Continue until clinical improvement + afebrile for 24-48 hrs

75
Q

Definitive dx of PID

A

Laparoscopy
Endometrial bx
Pelvic imaging with PID findings

76
Q

Fitzhugh Curtis syndrome

A

Perihepatitis from ascending infection resulting in RUQ pain and tenderness

LFT elevation

77
Q

Tx PID

A

Inpatient

Broad spectrum cephalosporin (cefoxitin or cefotetan) IV or IV clinda + gentamycin if cephalosporin allergic
+
Doxycycline IV

Continue until clinical improvement for 24 hrs

Continue doxy oral for total 14 day course

If need to be outpatient…
IM ceftriaxone x1 + probenecid oral + oral doxy x14 days

78
Q

Tuboovarian abscess

A

Usually 2/2 persistent PID

Usually not walled off though so more responsive to abx

Same tx as PID but may need to drain abscess

79
Q

Imaging to dx tuboovarian abscess vs tuboovarian complex

A

US

May need CT if obese

80
Q

Toxic shock syndrome

A

Staph aureus producing TSST-1

High fever
HYPOtn
Diffuse erythematous macular rash
desquamation of palms adn soles
GI disturbances
Renal disturbance
Thrombocytopenia

Blood cx often negative

81
Q

Tx TSS

A

IV hydration

Abx only decreases risk of recurrence, not shorten length of infection

Clinda + vanco

82
Q

Preexposure ppx of HIV

A

Tenofovir disiproxil fumarate
+
Emtricitabine

83
Q

Nucleoside analogs for HIV tx

A 
Zidovudine
Lamivudine
Abacavir
Didanosine
Stavudine
84
Q

Protease inhibitors for HIV tx

A 
Lopinavir
Atazanavir
Indinavir
Saquinavir
Ritonavir
85
Q

Lowering vertical transmission rate of HIV

A

Ziovudine in 2nd trimester —> reduce viral load by 3rd trimester

C/s

NO breastfeeding

86
Q

Sx interstitial cystitis

A

Pelvic pain
- usually relieved by voiding

Dyspareniua

Urinary freq, urgency

CYstoscopy - submucosal petechiae or ulcerations

87
Q

Pelvic congestion syndrome

A

is a cause of chronic pelvic pain occurring in the setting of pelvic varicosities.

The cause of pelvic vein congestion is unknown.

Hormonal factors contribute to vasodilatation when pelvic veins are exposed to high concentration of estradiol, which inhibits reflex vasoconstriction of vessels, induces uterine enlargement with selective dilatation of ovarian and uterine veins.

Pain worse premenstrually and during pregnancy, and is aggravated by standing, fatigue and coitus.

The pain is often described as a pelvic “fullness” or “heaviness,” which may extend to the vulvar area and legs.

Associated symptoms include vaginal discharge, backache and urinary frequency. Menstrual cycle defects and dysmenorrhea are common. No signs of pelvic floor relaxation were noted on exam.

88
Q

Nerves at risk for nerve entrapment syndrome 2/2 surgery from low transverse incision include

A 
iliohypogastric nerve (T-12, L-1) 
- cutaneous sensation to the groin and the skin overlying the pubis

ilioinguinal (T-12, L-1) nerve.
- cutaneous sensation to the groin, symphysis, labium and upper inner thigh.

These nerves may become susceptible to injury when a low transverse incision is extended beyond the lateral border of the rectus abdominus muscle, into the internal oblique muscle.

Damage to the obturator nerve, which can occur during lymph node dissection would result in the inability of the patient to adduct the thigh.

89
Q

Best time to obtain prolactin level

A

Stimulation of the breast during the physical examination may give rise to an elevated prolactin level.

Accurate prolactin levels are best obtained with patients fasting.

90
Q

Any solid dominant breast mass on exam should be evaluated

A

cytologically, with a fine needle aspiration (FNA), or histologically, with an excisional biopsy

91
Q

Blood discharge breast mass…what do you do?

A

excisional biopsy be performed to rule out breast cancer, even if aspriation (bloody) drains the mass

If clear discharge is obtained on aspiration and the mass resolves, reexamination in two months is appropriate to check that the cyst has not recurred.

92
Q

Definitive surgery for endometriosis

A

Hysterectomy + BSO

Need BSO or continued pain will happen and re-op needed!

93
Q

best way to begin a workup for an incidental finding of an adnexal mass

A

transvaginal ultrasound

94
Q

BV vs T. vaginalis vs. candida

A

Trich

  • inflammation
  • pruritus
  • white SMELLY discharge

BV
- no inflammation

Candida
- thick discharge, white

95
Q

Tx vaginismus

A

relaxation

Kegels

Insertion of dilators, fingers, etc to desensitize

96
Q

Atrophic vaginitis

A

usually in post-menopausal fem 2/2 decreased estrogen levels

Tx:

  • moisturizers and lubricants
  • low dose vaginal estrogen therapy
97
Q

Young woman p/w breast lump, no obvious signs of malignancy, what do you do next?

A

Ask to return after menstrual period for reexam - may have shrunk mass

Benign likely if mass shrunk

If not, can do US, FNA, and/or excisional bx

98
Q

Abdominal pain in young female in middle of her cycle w/ benign hx and clinical exam most likely…

A

Mittelschmerz (midcycle pain)

Pain lateralizes (unilateral) to ovary that produced mature ovum
Sudden onset
not too severe pain
Nonradiating
No N/V/F/C

vs PID which is bilateral

vs ovarian torison which is sudden onset, radiates to groin or back, + N/V, +/- adnexal mass

99
Q

Copious vaginal d/c

White or yellow

NOT malodorous

No other sx or findings on vaginal exam

A

PHysiologic leukorrhea

No tx necessary, reassure

100
Q

What side torsion of ovary more common

A

Right

2/2 longer length of R utero-ovarian ligament

L rectosigmoid colon occupies space around L ovary

Vaginal bleeding is uncommon!!!!

101
Q

Physiologic galactorrhea

A

Usually b/l

Most commonly milky; can be yellow, brown, gray, green

Hyperprolactinemia is most commono cause

Eval with Prolactin, TSH, possible brain MRI

102
Q

1 cause mucopurulent cervicitis

A

Chlamydia

OB/GYN (7 decks)

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