Gynecology - MTB Flashcards
1
Q
Benign Breast Disease
A
- Fibroadenoma
- Fibrocystic disease
- Intraductal papilloma
- Fat necrosis ( trauma to breast)
- Mastitis (inflamed, painful breast in women who are breastfeeding)
2
Q
Malignant Breast Disease
A
- Ductal carcinoma in situ
- Lobular carcinomia in situ
- Ductal carcinoma
- Lobular carcinoma
- Inflammatory breast cancer
- Paget’s disease of the breast/nipple
3
Q
Most common cause of nipple discharge
A
Intraductal papilloma
** if palpable mass is also present, likelihood of caner is greater
4
Q
When is further workup is needed for nipple discharge?
A
If nipple discharge has following characteristics:
- unilateral
- spontaneous
- bloody
- associated with mass
5
Q
If patient has nipple discharge, what is the first next step?
A
- Mammogram: look for underlying mass or calcifications
- Surgical duct excision: perform for definitive diagnosis
* * Cytology is not helpful and not answer for nipple discharge
6
Q
Pt has bilateral milky nipple discharge. Next step?
A
Consider workup for prolactinoma
7
Q
Fibrocystic disease
A
- presents with bilaeral painful breast lump(s)
- pain will vary with menstrual cycle
- simple cyst will collapse with FNA
8
Q
Fibrocystic disease: tx
A
- OCPs/medications
9
Q
Fibroadenoma
A
- presents as a discrete, firm, nontender, and high mobile breast nodule
- mass is highly mobile on clinical exam
- FNA shows
10
Q
Woman presents with breast mass. Next steps?
A
- Clinical breast exam
- Ultrasound or diagnostic mammogram (if pt < 40)
- Fine needle aspiration
11
Q
Breast mass treatment
A
Surgery
- diagnostic and curative but not always necessart
12
Q
Patient has simple cyst on clinical exam. Next step?
A
- Must confirm with ultrasound or FNA
13
Q
39 yo w c/o of bilateral breast enlargemen and tenerenss, which flucturates with menstrual cycle. PE, the breast feels lump and there is a painful discrete 1.5cm nodule. DNA is performed and clear liquid is withdrawn. Cyst collapses with aspiration. Next step?
A
Clinical breast exam in 6 weeks
** if mass recurs in 6 week follow-up, FNA may be repeated and core biopsy is performed.
14
Q
Patient has palpable breast mass that feels cystic. Next step?
A
Ultrasound
15
Q
Patient has palpable breast mass. Next step?
A
Fine needle aspiration
- may be done after ultrasound or instead of ultrasound
16
Q
Indications for mammography (> 40 years old) and biopsy OR biopsy alone if < 40 years old
A
- Cyst recurs > twice within 4-6 weeks
- Bloody fluid on aspiration
- Mass doesn’t disappear completely on FNA
- Bloody nipple discharge (excisional biopsy)
- If there is skin edema or erythema suggestive of inflammatory breast carcinoma (excisional biopsy)
17
Q
When is cytology indicated?
A
When there is grossly bloody discharge
18
Q
When is observation with repeat exam in 6-8 weeks?
A
- Cyst disappears on aspiration, and the fluid is clear
- Needle biopsy and imaging studies are negative
19
Q
47 yo woman completes her yearly mammogram and is told to return for evaluaion. Mammogram reveals a “cluster” of microcalcifications in the left breast. What is the most appropriate next step?
A
Needle biopsy
- 15-20% of cluster of microcalcifications represent early cancer
20
Q
Patient has biopsy which shows ductal carcinoma in situ. Next step?
A
Surgical resection with clear margins (lumpectomy)
- give radiotherapy and/or tamoxifen to prevent invasive disease
21
Q
Patient has bx which shows lobular carcinoma in situ. Next step?
A
Tamoxifen alone
- not necessary to perform surgery
- usually seen in premenopausal women
22
Q
Most common form of breast cancer
A
Ductal carcinoma
- 85% of all cases
23
Q
Ductal carcinoma
A
- it is unilateral
- metastasizes to bone, liver, and brain
24
Q
Lobular carcinoma
A
- accounts for 10% of breast carcinoma
- tends to be multifocal (within same breast) and is bilateral in 20% of cases
25
Inflammatory breast cancer
- uncommon, grows rapidly, and metastasizes early
| - look for red, swollen, and warm breast and pitted, edematous skin (peau d'orange appearance)
26
Paget's disease of breast/nipple
presents with pruritic, erythematous, scaly nipple lesion
- often confuse with dermatosis like eczema or psoriasis
- look for inverted nipple or discharge
27
Breast cancer screening
- women > 40 years old, screening mammography every 1-2 years
- mammography has greatest benefit for >50 yrs and women with hx of premenopausal breast cancer
- BRCA genetic testing is not used for screening
28
Breast cancer risks
- Age > 50
- Benign breast disease (esp. cystic disease, proliferative types of hyperplasia)
- Exposure to ionizing radiation
- First childbirth after 30 or nulliparity
- Higher socioeconomic status
- Hx of breast cancer
- Hx of breast cancer in a first degree relative
- Hormone therapy
- Obesity (BMI > 30)
29
Invasive carcinoma tx if tumor < 5cm
If < 5cm, lumpectomy + radiotherapy +/- adjuvant therapy +/- chemotherapy
- sentinal node bx is perferred over axillary node dissection
- always test for estrogen progesterone receptors, HER2
30
68 y.o woman visits her PCP w/ a solid peanut shaped hard mass in the upper outer quadrant of the left breast. A bx of the lesion is done, revealing "infiltrating ductal breast cancer". What is the next step of management?
Lumpectomy plus radiotherapy
| - standard of care in invasive disease
31
Indications for BRCA1 and BRCA1 gene testing
- Fam hx of early onset breast cancer or ovarian cancer
- Breast and/or ovarian cancer in the same patient
- Family hx of male breast cancer
- Ashkenaxi Jewish heritage
32
When is breast-conserving therapy not the answer?
- Pregnancy
- Prior irradiation to the breast
- Diffuse malignancy or > 2 separate quandrants
- Positive tumor margins
- Tumor > 5cm
33
When adjuvant hormonal therapy included in management?
Any hormone receptor-positive tumors, regardless of age and regardless of menopausal status, stage, or type of tumor
34
Greatest benefit of adjuvant therapy?
When tumor is both ER+ and PR+ receptors are present
| - almost as good with tumors that are ONLY ER_
35
When is adjuvant therapy least beneficial?
When tumor is only PR+
36
Tamoxifen
- competively binds to estrogen receptors
- 5 yr treatment --> 50 percent decrease in recurrent
- may be used in pre- or post-menopausal patients
37
Aromatase inhibitors (anastrozole, exemestane)
- block peripheral production of estrogen
| - standard of care in HR+ postmenopausal women (more effective in postmenopausal)
38
Concern for aromatase inhibitors
- don't cause menopausal symptoms but does increase risk of osteoporosis
39
LHRH analogues (e.g. goserelin) or ovarian ablation
- an alternative or an addition to tamoxifen in premenopausal women
40
Benefits of Tamoxifen
- decreased incidence of contralateral breast cancer
- increase bone density in postmenopausal women
- decrease fx, serum cholesterol, CV mortality risk
41
Adverse Effects of Tamoxifen
- exacerbates menopausal symptoms
| - greatly increases risk of endometrial cancer
42
Woman w/ hx of tamoxifen use presents with vaginal bleeding. Next step?
Further evaluation
| - endometrial biopsy
43
When is chemotherapy indicated in breast carcinoma?
- Tumor size > 1 cm
| - Node-positive disease
44
When is trastuzumab indicated in management?
- Metastatic breast cancer overexpressing HER2/ney
45
Trastuzumab
- monoclonal antibody directed against the extracellular domain of the HER2/neu receptor and is used to treat and control visceral metastatic sites
46
If invasive breast cancer is a HR-negative, pre- or postmenopausal women
Give chemotherapy alone
47
If invasive breast cancer is HR-positive, PRE-menopausal women. Tx?
Give chemotherapy + tamoxifen
48
If invasive breast cancer is HR-positive, POST-menopausal woman? Tx?
Give chemotherapy + aromatase inhibitor
49
Ddx: Enlarged Uterus
1. Pregnancy
2. Leiomyoma
3. Adenomyosis
50
Leiomyoma
- smooth muscle growth of the myometrium
- most common benign uterine tumor
- classically presents with African-American woman with enlarged, firm, asymetric, non-tender uterus
- B-hCG negative
51
Patient presents with leiomyoma w/ intermenstrual bleeding and menorrhagia. Location
Submucosal location w/ distortion of the uterine cavity seen on saline ultrasound
52
Pt with uterine mass complains of bladder, rectum, or ureter compression sx. Location of mass?
Subserosal
| - mass may become parasitic and obtain its bood supply from intestinal mesentary
53
Adenomyosis
abnormal location of endometrial glands and stroma within the myometrium of uterine wall
- can cause dysmenorrhea and menorrhagia
- feels soft, globular, symmetrical, and tender
54
First test to order in patient with enlarged uterus?
B-hcG test
55
Management of leiomyomas
Med tx: Serial pelvic exams & observations
Presurgical shrinkage: 3-6 mths of GnRH analog
Myomectomy: to preserve fertility
Embolization of vessels: preserves uterus & invasive radiology
56
When are hysterectomies the best treatment for leiomyomas?
When fertility is completed
| * Hysterectomy is the definitive treatment
57
Leiomyoma: pelvic exam features
ASYMMETRICALLY enlarged, firm, NONtender uterus
58
Adenomyosis pelvic exam features
SYMMETRICALLY enlarged, firm, TENDER uterus
59
Adenomyosis: Management
Medical treatment: IUS (levonorgestrel) intrauterine system may decrease heavy menstrual bleeding
Surgical (MOST definitive tx): Hysterectomy
60
Why do you always give estrogen + progestins to women with a uterus?
Estrogen alone will cause endometrial hyperplasia
61
65 year old obese patient c/o vaginal bleeding for 3 months. Last menstrual period was at age 52. She has no children. She has type 2 DM and chronic hypertension. PE is normal with normal sized uterus and no vulvar, cervical, or vaginal lesions? Next step in management?
Perform endometrial biopsy (to r/o endometrial cance)
62
Most common cause of postmenopausal bleeding
Endometrial atrophy
63
Risk factors for endometrial cacinoms
Unopposed estrogen states
- obesity
- late menopause/early menarche
- chronic anovulation
64
For reproductive age women with chronic anovulation (e.g. PCOS), what should be given to prevent endometrial hyperplasia and cancer
Progestins
65
Management of postmenopausal bleeding
1. Pelvic exam + endometrial biopsy
2. Hysteroscopy to look for endometrial or cervical polyps as sources of bleeding
3. Ultrasonography - measures thickness of endometrial lining
66
In patient w/ post-menopausal bleeding, endometrial bx reveals atrophy and no cancer. What next step?
No further w/u needed
| - Give HRT (estrogen plus progesterone)
67
In patient w/ post-menopausal bleeding, endometrial bx reveals adenocarcinoma. What next step?
Perform surgery staging:
TAH and BSO, pelvic and para-aortic lympadenoecomy and peritoneal washings
+ Radiation therapy: if lymph node metastasis
+ Chemotherapy: if metastasis
68
Normal endometrial lining stripe in postmenopausal women
Less than 5mm thick
69
Simple Ovarian Cyst (Luteal or Follicular Cysts)
- most common cyst that occurs during reproductive years
| - asymptomatic unless torsion has occurred
70
Simple Ovarian Cyst: Dx
- B-hCG test: negative
| - U/S shows fluid-filled simple cystic mass
71
Simple Ovarian Cyst: Management
1. F/u exam in 6-8 weeks: steroid contraception prevents new cysts
2. Laparoscopic removal if:
- cyst is > 7 cm diameter or
- there has been previous steroid contraception w/o resolution of the cyst
72
Complex Cyst: Benign Cystic Teratoma
- benign tumors
- contain cellular tissue from all 3 germ layers
- rarely squamous cell carcinoma can develop
73
Complex ovarian cyst: diagnosis
- B-hCG is negative
| - U/S shows a complex mass
74
Complex ovarian cyst: management
Laparasopic/laparotomy removal:
- cystectomy (to retain ovarian fxn)
- oophorectomy (if fertility is no longer desired)
75
Bilateral ovarian enlargement
PCOS is associated with valproic acid
76
Ovarian hyperthecosis
- refers to nest of luteinized theca cells in ovarian stroma that produce high levels of androgens
- usually postmenopausal woman with severe hirsuitism and virilization
77
Ovarian hyperthecosis: management
OCPs (both estrogen and progestin) to suppress androgen production by reducing LH stimulation
78
Luteoma of Pregnancy
- rare, nonneoplastic, tumorlike mass of the ovary that emerges during pregnancy and regresses spontaneously after delivery
- found incidentally during C-section or postpartum tubal ligation
- can be hormonally active and produce androgens, resulting in maternal and fetal hirsutism and virilization
79
Theca Lutein Cysts
- benign neoplasms are caused by high levels of FSH and B-hCG
- associated with twins and molar pregnancies
- spontaneously regresses after pregnacy
80
Initial w/u of an ovaran mass
- B-hCG test
- Ultrasound
- Laparoscopy/laparotomy if complex or > 7 cm
81
31 y/o woman is taken to the ED c/o of severe, sudden lower abdominal pain that started 3 hrs ago. On exam, abdomen is tender, no rebound tenderness is present ands there is an adnexal mass in the cul-de-sac. U/S eval shows an 8cm left adnexal mass. B-hCG negative. Next step in management?
Laparoscopic evaluation of ovaries
- detorsioning of ovaries is needed
- if blood supply no affected, cystectomy can be done
- if there is necrosis, oophorectomy is needed
82
Ovarian enlargement is pre-pubertal or post-menopausal women is suspicious for...
Ovarian neoplasm
83
Risk factors of Ovarian Neoplasm
- BRCA1 gene
- Positive family hx
- High + of lifetime ovulations
- Infertility
- Use of perineal talc powder
84
Protective factors of ovarian neoplasm
Conditions that decrease # of ovulations
- OCPs
- Chronic anovulation
- Breast-feeding
- Short reproductive life
85
68 y/o F presents with weakness and bloated feeling in her abdomen. She is found to have abdominal distention shifting dullness and large right adnexal mass. Pelvic U/S reveals 7cm irregular and solid mass in the right ovary. Next step in management?
Abdominal CT
- to evaluate mass and confirm presence of ascites (peritoneal seeding)
- if ascites, next step step is laparotomy, oophorectomy, and surgical staging
86
9 y.o girl presents with R adnexal pain and complex cystic mass on U/S? Dx?
Germ cell tumor - common in young women and present in early stage disease
Tumor markers: LDH, B-hCG, a-FP
87
67 y/o F presents w/ progressive weight loss, distended abdomen, and left adnexal mass. Dx?
Epithelial tumor - common in postmenopasual women. most common malignant subtype is serous
Tumor markers: CA-125, CEA
88
58 y/o F presents with postmenopausal bleeding. Endometrial bx shows endometrial hyperplasia. Pelvic U/S reveals R ovarian mass.
Granulosa-theca (stromal tumor): secretes estrogen an can cause endometrial hyperplasia
Tumor markers: estrogen
89
48 y/o F c/o of increased facial hir and deepening of her voice. An adnexal mass is found on examination. Dx?
Sertoli-Leydig cell (stromal tumor): ovarian tumor secretes testosterone. Pts presents with masculinization syndromes
Tumor markers: testosterone
90
64 y.o F presents with hx of gastric ulcer and recent worsening dyspepsia presents with weight loss and abdominal pain. An adnexal mass is found. Dx?
Metastatic gastric cancer to the ovary (Krukenberg tumor)
Tumor markers: Mucin-producing tumor from the stomach
91
Management of prepubertal and post-menopausal ovarian mass
1. Sonogram (and CT scan)
2. Bx via laparoscopy for simple cysts (no septations or solid components) or postmenopausal w/o ascites
3. Tumor markers
4. Cystectomy for benign tissue
5. Premenstrual women: salpingooophorectomy
6. Postmenopausal women: TAH, BSO (and chemo for malignant therapy
92
HPV associated with cervical cancer
- HPV 16, 18, 31, 33, and 35
93
HPV associaed with benign condyloma acuminata
HPV types 6 and 11
94
Indeterminate smears
- atypical squamous cells of undetermined significance (ASCUS)
95
Abnormal Pap smears: Low-grade squamous intraepithelial (LSIL)
HPV, mild low dysplasia, CIN 1
96
High-grade squamous intraepithelial lesion (HSIL)
Moderate dysplasia, severe dysplasia, CIS, CIN 2 or 3
97
Risk factors for Cervical Dysplasia
- Early age of intercouse
- Multiple sexual partners
- Cigarette smoking
- Immunosuppression
98
When is screening started for cervical dysplasia
Three years after onset of sexual activity or age 21, whichever comes first
99
Screening used for cervical hyperplasia/cancer
Conventional method
Liquid based prep
HPV DNA testing
100
Frequency of screening
If < 30 years old, annually for conventional Pap or every 2 years for liquid based
If > 30 years old, screen every 2-3 years if > 3 consecutive negative Pap smears
101
35 y/o F is referred b/c of a Pap smear reading ASCUS. Pt states that last Pap smear, done approximately 1 yr ago, was negative. She has been sexually active, using combo OCPs from last 4 yrs. A repeat Pap smear after 3 mths again reveals ASCUS. Next step in management?
Colposcopy and ectocervical biopsy
- ASCUS is most inflammation due to early HPV infxn
- two Pap smears revealing ASCUS must be followed by colposcopy and biopsy
102
Pt has a ASCUS on Pap smear and f/u is certain. Nest step?
Repeat the Pap smear in 3-6 months or order HPV DNA typing
- if the result is negative, f/u is routine
- if repeat Pap smear is again ASCUS or HPV 16 /18 are found, then order colposcopy and biopsies
103
Pt has ASCUS on Pap smear and f/u is uncertain. Next step?
Colposcopy and biopsies
104
Endocervical curretage
- indicated for all NONpregnant patients with an abnormal Pap smear
- all nonpregnany pts undergoing colposcopy for an abnormal Pap smears must undergo an ECC to r/o endocervical lesions
105
Indications for cone biopsy
- Pap smear worse than histology (suggests abnormal cells were not bx)
- Abnormal ECC histology
- An endocervical lesion
- A biopsy showing microinvasive carcinoma of cervix
106
Management for CIN 1:
Observation and f/u
| - F/u repeat pap smears, colposcopy + Pap smear or HPV DNA testing every 4-6 months for 2 years
107
Management CIN 2 or 3
Ablative therapies: Cyrotherapy, Laser vaporization, electrofulguration
Excisional procedures: LEEP and Cold-knife conization
108
If biopsy confirmed abnormal histology
Hysterectomy
109
Invasive Cervical Cancer
- average diagnosis is 45 years
110
Invasive Cervical Cancer: Dx
Cervical bx
| Metastatic workup: pelvic exam, CXR, IV pyelogram, cystoscopy, and sigmoidoscopy
111
Most common cause of cervical bx
Squamous cell carcinoma
112
Management of invasive cervical cancer
Simple hysterectomy
113
Adjuvant therapy (Radiation therapy and chemotherapy) indications for invasive cervical caner
```
Metastasis to lymph nodes
Tumor size > 4 cm
Poorly differentiated lesions
Positive margins
Local recurrence
```
114
Management of CIN/dysplasia during pregnancy
- Pap smear and colposcopy q 3 months during pregnancy
| - Repeat Pap and colposcopy 6-8 weeks postpartum. Any persistent lesios are then definitively treated postpartum
115
Management of microinvasive cervical cancer during pregnancy
- Cone biopsy to ensure no frank invasion
| - Deliver vaginally, reevaluate and treat 2 months postpartum
116
Management of invasive cancer
Diagnosed before 24 weeks:
- Definitive treatment (radical hysterectomy)
Diagnosed after 24 weeks:
- Conservative management up to 32- 33 weeks
- C- section delivery and begin definite treatment
117
Prevention of Cervical Dysplasia by Vaccination
- Give quadrivalent HPV vaccine (Gardasil) to all females 8-26
- protects against 4 HPV types (6, 11, 16, 18)
- must still follow Pap smear recommendations
118
Initial work up for pelvic pain
1. Pelvic pain
2. Cervical culture
3. Lab: ESR (sedimentation rate), WBC (include Blood Cx if fever is present)
4. Sonogram
119
Cervicitis
- diagnosis if cervical discharge is found on routine exam, usually w/o other symtptoms
120
Management for Cervicitis
1. Get cervical cultures (chlamydia and gonorrhea)
| 2. Give single dose of oral cefexime and azithromycin
121
Acute salpingoophoritis
suspected when there is cervical motion tenderness on exam and when patient c/o of lower pelvic pain after menstruation
122
Acute salpingoophoritis
- Cervical cultures will be positive
- WBC and ESR are elevated
- R/o pelvic abscess with sonogram
123
Management of acute salpingoophoritis
Outpatient: two orabl abx (ofloxacin and metronidazole)
Inpatient: three IV abx: IV cefotoxin or cefotetan and IV doxycycline or clindamycin and gentamicin)
124
Chronic Pelvic Inflammatory Disease
- classically presents with infertility or dyspareunia
- may have hx of ectopic pregnancy or abnormal vaginal bleeding
- Cervical cx are negative
125
Patient has suspected PID. Next step
1. Cervical cultures (expected to be negative)
| 2. U/S (bilateral cystic pelvic masses - hydrosalpinges)
126
Management of PID
- Lysis of tubal adhesions, which may be helpful for infertility
- Severe, unremitting pelvic pain may require pelvic clean out (TAH, BSO)
127
Tuboovarian Abscess
- advanced from for PID
- ill-appearing women w/ severe, llower abdominal/ pelvic pain, back pain, and rectal pain
- WBC and ESR are markedly elevated
128
Lab findings of tuboovarian abscess
- WBC and ESR are elevated
- Pus on culdocentesis
- Sonogram shows unilateral pelvic mass that appears as multi-locular, cystic and complex adnexal mass
- BCx show anaerobic organisms
129
Management of tuboovarian abscess
1. Admit to hospital and give IV clindamycin and IV gentamicin
2. If no response within 72 hrs or there is abscess rupture, perform an ex-lap +/- TAH and BSO or percutaneous drainage
130
When are outpatient antibiotics the answer?
- All cases of cervicitis
| - Acute salpingoophoritis when there is no systemic infxn or pelvic abscess
131
When are inpatient abx the answer?
- Acute salpingoophoritis in a nulligravida or adolescent patient previous outpatient treatment failure, IUD in place, presence odf fever or pelvic abscess
- All cases of tuboovarian abscess
132
21 y/o F presents ER with lower abdominal pelvic pain starting 1 day ago/ Sx began after her menstrual period completed. She is sexually active but using no contraception. Speculum exam reveals mucopurulent cervical discharge. Bimanual exam shows b/l adnexal tendernss and CMT. She is afebrile/ Her qualitative urinary B-hCG is negative. CBC shows WBC of 14K/ ESR is elevated. Most appropriate management?
Inpatient IV cefotetan, clindamycin and gentamicin
- patient has acute salpingoophoritis.
Her nulligravid status is indication for IV abx triple-therapy
133
Primary Dysmenorrhea
- diagnosis when case describes recurrent, crampy lower abdominal pain along with N/V and diarrhea during menstruationn
- Sx begin 2-5 years after onset of menstruation (ovulatory cycles)
- no pelvic abnormality
134
Etiology of primary dysmenorrhea
- excessive endometrial prostaglandin F2. which causes uterine contractions and acts on GI smooth muscle
135
Management of primary dysmenorrhea
- NSADS (first line tx)
| - Combination OCPs (second line)
136
Secondary Dysmenorrhea
- recurrent, crampy lower abdominal pain with N/V and diarrhea during menstruation
- often occurs during endometriosis, but can occur during adenomyosis or leiomyomas
137
Endometriosis
- presence of endometrial glands outside of the uterus
| - seen in women > 30 with dysmenorrhea, dyspareunia, dyschexzia (painful bowerl movements) and infertility
138
Most common site of endometriosis
Ovary
| - causing adnexal enlargement (endometriomas) also known as chocolate cysts
139
Second most common site of endometriossis
Cul-de-sac, causing uterosacral ligament nodularity and tenderness on rectovaginal examination
- associated w/ bowel adhesions and a fixed retroverted uterus
140
Endometriosis: Dx
1. U/S (may show endometrial mass)
2. Laparoscopic visualization
3. Elevated CA-125
141
Management of endometriosis
Continuous oral progesterone or OCPs (first line)
Testestorones derivatives (Danocrine or Danazol) or GnRH analogs (lupron or leuprolide)
Laparoscopic lysis adhesiosn, laser vaporization
TASH and BSO can be done for severe symptms
142
Premenarchal Vaginal Bleeding
- bleeding that occurs before menarche
| - average age at menarche is 12
143
Most common cause of premenarchal vaginal bleeding
- Presence of a foreign body
| - must r/o sarcoma botryoides
144
Sarcoma botryoides
- cancer of vagina or cervix suggested a grapelike mass arising from the vaginal lining or cervix
- tumor of the pituitary adrenal gland or ovary and sexual abuse
145
Premenarchal vaginal bleeding: diagnostic
- perform pelvic exam under sedation
- Order CT or MRI of pituitary, abdomen, and pelvis to estrogen producing tumor
- If workup is negative, it is likely idiopathic precocious puberty
146
31 y/o F c/o 6 mnths of metromenorrhagia. The patient states that she started menstruating at age 13 and that has had regular menses until the past 6 months. The pelvic exam, including a Pap smear, is normal. She has no other significant personal or family hx. What is next step in management?
Obtain B-hCG
147
Primary Amenorrhea
- diagnosed w/ absence of menses at age 14 w/o secondary sexual development OR at age 16 w/ secondary sexual development
148
Primary amenorrhea: diagnostic tests
Physical Exam and U/S
- are breasts present? Breasts indicate adequate estrogen production
- is a uterus present or absent on U/S?
Karyotype, testosterone, FSH
149
Primary amenorrhea:
- breasts present
- uterus present
Workup as secondary amenorrhea
- Imperforate hymen
- Vaginal septum
- Anorexia nervosa
- Excessive exercise
- Pregnancy before the 1st menses
150
Primary amenorrhea
- breasts present?
- uterus absent?
Order testosterone levels and karyotype
- Mullerian agenesis (XX karyotype, normal testosterone for female)
- Complete androgen insensivity (testicular feminization)
- XY karyotype, normal testosterone for male
151
Primary amenorrhea
- Breast absent
- Uterus present
Order FSH level and karyotype
- Gonadal dysgenesis (Turner's syndrome) - XO karyotype, FSH elevated
- Hypothalamic-pituitary failure (XX karyotype, FSH low)
152
Primary amenorrhea
- Breast absent
- Uterus absent
Rare
| - not clinically relevant
153
17 y.o F is brought to the clinic by her mother concerned b/c her daughter has never had a menstrual period/ She reports that her daughter has good grades, studies hard but seems stressed out most of the time which is why she believed her period was delayed. On exam she seems to be well-nourished w/ adult present development and pubic hair present. Physcial exam reveals foreshortened vagina. No uterus sen on U/S. Most appropriate advice
Vaginal reconstruction may be performed
| - Patient has Mullerian agenesis (no uterus, cervix, or upper vagina)
154
Mullerian Agenesis
- karyotype reveals normal female secondary characteristics
- normal estrogen and testosterone levels (ovaries are intact)
- absence of Mullerian duct derivatives (fallopian tubes, uterus, cervic, and upper vagina)
- management involves surgical elongation of vagina
155
Androgen Insensitivity
- diagnosed when there is NO PUBIC OR AXILLARY HAIR
- karyotype reveals male karyotype
- U/S shows testes
- testes produces normal amts of estrogen for female and normal amts of testosterone for male
- involves removal of testes before age 20 b/c of risk of testicular cancer
156
Gonadal Dysgenesis (Turner Syndrome, XO)
- karyotype shows absence of one X chromosome
- absence of secondary sexual characteristics b/c 2nd X is needed for ovarian follicles
- streak gonads
- elevated FSH
- management involves estrogen and progesterone replacement for development of 2ndary sexual characteristics
157
Hypothalamic-Pituitary Failure
- diagnosed there is no sexual characteristics but uterus normal on U/S
- low FSH
- may be due to stress, excessive exercise, or anorexia nervosa
- management involves estrogen and progesterone replacement for development of 2ndary sexual characteristics
158
Kallmann syndrome
- hypothalamic-pituitary failure
| - associated with anosmia (hypothalamus doesn't produce GnRH)
159
Secondary amenorrhea
- regular menses replaced by absence of menses for 3 months
| - irregular menses replaced by absence of menses for 6 months
160
Secondary Amenorrhea: Workup
1. Pregnancy test (B-hCG)
2. TSH to r/o hypothyroidism
3. Prolactin levels to r/o elevation 2/2 pituitary tumor or meds
4. Progesterone Challenge Test
5. Estrogen-Progesterone Challenge Test
161
Why does primary hypothyroidism connect to secondary amenorrhea
An elevated TRH in primary hypothyroidism leads to increased prolactin
-
162
Prolactin: secondary amenorrhea
1. Review meds: antipsychotic and antidepressants have antidopamine leads to increased prolactin
2. CT or MRI to r/o pituitary tumor
3. Idiopathic prolactin elevation, treat w/ bromocriptine
163
Pituitary tumor: treatment
- Tumor < 1 cm; give bromocriptine (dopamine agonist)
| - Tumor > 1cm; treat surgically
164
Positive progesterone Challenge Test
Any withdrawal bleeding is diagnostic of anovulation
- treat cyclic progesterone to prevent endometrial hyperplasia.
- clomiphene ovulation induction is done if pregnancy is desired
165
Negative progesterone challenge test
Inadequate estrogen or outflow tract obstruction
166
Estrogen-Progesterone Challenge Test
- 3 weeks of oral estrogen followed by 1 week of progesterone
167
Positive Estrogen-Progesterone Challenge Test
Any withdrawal bleeding is diagnostic of inadequate estrogen. Next step is get an FSH level
- decr. FSH (HPA insufficiency). Order brain tumor via CT
168
Secondary amenorrhea:
| Positive estrogen-progesterone challenge test + incr. FSH (ovarian failure).
Y chromosome may be cause if pt < 25 yrs. Order a karyotype confirmation
169
Secondary amenorrhea:
| positive estrogen-progesterone challenge test + decr. FSH
Hypothalamic-pituitary failure
- Order brain CT/MRI to r/o a tumor.
- Give estrogen-replacement therapy to prevent osteoporosis
170
Secondary amenorrhea:
| negative estrogen-progesterone challenge test
Outflow tract obstruction or endometrial scarring (e.g. Asherman syndrome)
- Hysterosalpingogram to ID lesion
- Management: Adhesion lysis followed by estrogen stimulation
171
Premenstrual Tesnsion
- distressing physical, psych, and behaviorial symptpms recurring at same phase of menstrual cycle and disappearing during remainder of cycle
172
Premenstrual Dysphoric Disorder (PMDD)
- more severe, involving major disruptions to daily functioning and relationships
173
PMDD: treatment
- SSRIs (treatment of choice)
- low doses of Vitamin B6 (pyroxidine) may improve sx
-
174
Hirsuitism
- excessive male pattern hair growth in a woman
175
Virilization
- excessive male patter hair growtih in a woman plus masculinixing signs (cliteromegaly), baldness, lowering of voice, increasing muscle mass, and loss of female body contours
176
Initial workup in hirsutism
- Testosterone
- DHEAS
- LH/FSH
- 17-hydroxyprogesterone
177
Polycystic Ovarian Syndrome
- gradual onset hirsutism, obesity, acne, irregular bleeding, and infertilit
178
PCOS: Diagnostic Tests
- mostly clinical
- elevated LH/FSH ratio for confirmation
- bilaterally enlarged ovaries will found on exam and U/S
179
PCOS: Anovulation
- no corpus luteum production of progesterone LEADS TO
- unopposed estrogen LEADS TO
- hyperplastic endometrium and irregular bleeding LEADS TO
- predisposition to endometrial cancer
180
PCOS: Increased testosterone
- Increased LH levels LEADS TO increased theca cell production of androgens LEADS TO hepatic production of SHBG is suppressed LEADS TO increased total testosterone and increased free testosterone
181
PCOS: ovarian enlargement
U/S shows a necklacelike pattern of multiple peripheral cysts
- increased androgens LEADS TO multiple follicles in various stages of development, stromal hyperplasia
- BILATERALLY ENLARGED OVARIES
182
Anovulation: Ddx
- PCOS
- Hypothyroidism
- Pituitary adenoma
- Elevated prolactin
- Medication (e.g. antipsychotic meds)
183
PCOS: Diagnostic Tests
- LH:FSH = 3:1
- Mildly elevated testosterone level
- Pelvic U/S shows bilaterally enlarged ovaries w/ multiple subcapsular small follicles and increased stromal echogenecity
184
PCOS: Treatment
- OCPs treats irregular hirsutism and bleedng
- SPIRONOLACTONE - suppresses hair follicles
- CLOMIPHENE CITRATE or HMG treatment of infertility
- METFORMIN enhances ovulation and manages insulin resistance
185
Rapid onset hirsutism and virilization w/o family hx. Next step?
U/S to look for adnexal mass
| CT scan to look for adrenal tumor
186
Rapid onset hirsutism and virilization w/o family hx. Likely dx?
```
Adrenal tumor (elevated DHEAS)
Ovarian tumor (elevated testosterone)
```
187
Congenital Adrenal Hyperplasia
- gradual onset hirsutism w/o virilization in teens and 20s associated w/ menstrual irregularities and anovulation
- elevated 17-hydroxyprogesterone
- management involved in corticosteroid replacement to stop androgenicity and restore ovulatory cycles
188
Idiopathic Hirsutism
- hirsutism and no virilization
- all lab tests are normal
- most common cause of hirsutism
189
Idiopathic Hirsuitism: Treatment
- Spironolactone (1st line treatment)
| - Eflornithine (Vaniqa) -1st line topical drug for unwanted facial hair and chin hair
190
Pt c/o hirsutism with elevated testosterone, normal DHEAS, increased LH, decreased FSH, and normal 17-hydroxyprogesterone. Next step?
U/S to r/o other disorders/tumors
- likely PCOS
- screen lipids and fasting blood glucose
191
Pt c/o hirsutism w/ normal testosterone, normal DHEAS, normal LH/FSH, and very elevated 17-hydroxyprogesterone. Next step?
ACTH stimulation
- likely congenital adrenal hyperplasia
- confirms the diagnosis
192
Pt c/o hirsutism w/ very elevated testosterone, normal DHEAS, normal LH/normal FSH, and normal 17-hydroxyprogesterone. Next step?
U/S and CT to image tumor
| - likely ovarian tumor
193
Pt c/o hirsutism w/ elevated testosterone, very elevated DHEAS, normal LH, normal FSH, and normal 17-hydroxyprogesterone. Next step?
U/S or CT to image tumor
| - likely adrenal tumor
194
Menopause
- 12 months of amenorrhea w/ elevation of FSH and LH
- mean age of 51 years old
- smokers experence menopause up to 2 years earlier
195
Menopause: Diagnostics
- serial levels of elevated gonadotropins (FSH > 50 IU/ml)
196
Early menopause
- occurs between 40 and 50
| - often idiopathic but can occur after radiation therapy or surgical oophorectomy
197
Premature ovarian failure
- occurs before 30
| - associated w/ autoimmune disease or Y chromosome mosaicism
198
Amenorrhea during menopause
- menses become anovulatory and decrease in 3-5 years period known as perimenopause
199
Hot flashes during menopause
- unpredictable, profuse sweating and heat that occurs in 75% in women
- obese less likely to undergo hot flashes (due to peripheral conversion of androgens to estrone)
200
Reproductive tract during menopause
- decreased vaginal lubrication, increased vaginal pH, and increased vaginal infections can occur
201
Urinary tract during menopause
- increased urgency, frequency, nocturia, and urge incontinence
202
Most common cause of mortality in postmenopausal women
Cardiac disease
203
Osteoporosis
- common in postmenopausal thin, white women with positive family history
- treat w/ calcium and Vitamin D, weight-bearing exercise
204
Most common site of symptomatic osteoporosis
Vertebral bodies leading to crush fracture, kyphosis, and decreased height
- hop and wrist fractures are next frequent sites
205
Osteoporosis: Diagnostic Testing
- DEXA scan to assess bone density (T >/= -2.5)
| - 24 urine hydroxyproline or NTX to assess calcium loss
206
Osteoporosis: Treatment
Bisphosphonates and SERMS (1st line therapy)
- Bisphosphonates inhibits osteoclastic activity
- SERMS increase bone density
Calcitonin, denosumab
Teraparatide is a PTH analog
207
SERMS use in osteoporosis
protective against heart and bones but not effective for vasomotor symptoms
208
Tamoxifen (Nolvadex) in osteoporosis
endometrial and bone agonist effects but breast antagonist effects
209
Raloxifene (Evista) in osteoporosis
bone agonist effects but endometrial antagonist effects
210
Indications for HRT
- Menopausal vasomotor symptoms (hot flashes)
- Genitourinary atrophy
- Dyspareunia
211
Contraindications for HRT
```
Tx of osteoporosis
Describes hx of:
- estrogen-sensitive cancer
- liver disease
- active thrombosis
- unexplained vaginal bleeding
```
212
Which postmenopausal women can be given continuous estrogen for hormone therapy?
Women w/o uterus
213
Why are women w/ uterus given progestin therapy for hormone replacement therapy?
Must be given progestin to prevent endometrial hyperplasia
214
Benefits of HRT
- Decreases risk of osteoporotic fractures
| - Decreases rate of colorectal cancer
215
Risks of HRT
- increases risk of CVT
- increases risk of heart attacks and breast cancer
* * risks occur w/ therapy > 4 years
216
Guidelines for HRT
- only use for vasomotor symptoms in menopause
- never use to prevent CV symptoms
- use lowest dose of HRT
- use shortest duration of HRT to treat symptoms
- don't exceed 4 yrs of therapy
217
Barrier contraception
- protective against STDs
218
Steroid contraception (e.g. estrogen + progesterone) Contraindications
- pregnancy
- acute liver disease
- hormone dependent cancer
- Smoker > 35
- Migraines w/ aura
- DM w/ vascular disease
- Thrombophilia
- Uncontrolled HTN
219
Steroid contraceptive benefits
- Decreased ovarian and endometrial CA
- Decreased dysmenorrhea
- Decreased DUB
- Decreaed ectopic pregnancy
220
Intrauterine Device (e.g. levonorgestrel)
- effective and avoids side effects of hormonal atherapy
221
Absolute contraindications of IUD
- pelvic malignancy
- salpingitis
- pregnancy
222
35 y.o woman comes to GYN's office c/o infertility for 1 yr. She and her husband has been trying to achieve pregnancy for 1 year and have been unsuccessful/ No hx of PID and has used OCPs for 6 years. Semen analysis is low and shows decreased sperm density and low motility. Next step in management?
Repeat semen analysis
| - abnormal semen analysis is repeated in 4-6 weeks
223
Infertility
- inability to achieve pregnancy after 12 months of unprotected and frequent intercourse
224
Infertility workup
1. Semen analysis
2. If semen analysis is normal, work up for anovulation
3. If semen analysis is normal and ovulation is confirmed, then work up for fallopian tube abnormalities
225
Normal semen analysis
- Volume: > 2m:
- pH 7.2 - 7.8
- sperm density: > 20 million/mL
- sperm motility: 50%
- sperm morphology: > 50% normal
226
If patient submitted 2 abnormal semen samples 4-6 weeks apart, next step?
Pursue fertility options such as:
- intrauterine insemination
- intracytoplasmic sperm injection
- IVF
227
Anovulation workup
- Basal body temperature: no midcycle temp elevation
- Low progesterone
- Proliferative histology on endometrial bx
228
Common causes of anovulation
- Hypothyroidism
| - Hyperprolactinemia
229
Ovulation induction
- Clomiphene citrate
- Human menopausal gonadotropin (used if clomiphene fails)
- Monitor for ovarian hyperstimulation leads to increased ovarian size
230
Diagnosing tubal abnormalities
1. Check for chlamydia IgG antibody test to r/o infection induced tubal adhesions
2. Hysterosalpingogram ( HSG ) to check for normal anatomy
3. Laparoscopy: if HSG is abnormal to visualize oviducts and attempt tuboplasty
231
Unexplained infertility
- normal semen analysis, ovulation confirmed, and no tubal abnormalities
- no treatment indicated
- 60% patients achieve spontaneous pregnancy within 3 years
232
iVF
1. Eggs aspirated from ovarian follicles using U/S guided transvaginal approach
2. Fertilied w/ sperm in lab, resulting in embryos
3. Multiple embryos transferred into uterine cavity
233
Gestational Trophoblastic Disease
- abnormal proliferation of placental tissue involving both cytotrophoblast and/or syncytiotrophoblast
234
GTN
- most common in Taiwan and Phillipines
| - risk factors include age extremes (< 20 years old and > 35 yerars old) and folate deficiency
235
GTN: Presentation
- Bleeding < 16 weeks gestation
- Passage of vesicles from vagina
- may see HTN, hyperthyroidism, and hyperemesis gravidarum and no fetal heart tones appreciated
236
GTN: Signs
- Fundus larger than dates
- Absence of fetal heart tones
- Bilateral cystic enlargement of ovaries (theca-lutein cysts)
237
Most common site of distant metastasis for GTN
lungs
238
Complete molar pregnancy
- empty egg
- 46, XX
- fetus absent
- 20% are malignant
- treat w. no chemotherapy but serial B-hCG until negative
- F/u for 1 year on OCP
239
Partial molar pregnancy
- Normal Egg
- 69, XXY (triploidy)
- fetus nonviable
- 10% are malignant
- treat w/ no chemotherapy but serial B-hCG until negative
- F/u for 1 year on OCP
240
32 y.o Filipino woman is 15 weeks' pregnant by dates. She presents w/ painless vaginal bleeding associated w/ severe nausea and vomiting. Her uterus extends to umbilicus but no fetal heart tones appreciated. Her blood pressure is 162/98 mm Hg. Dipstick urine shows 2+ proteinurisa. Which of the following is likely diagnosis?
Molar pregnancy
241
GTN: Diagnostic Testing
U/S
- reveals homogenous intrauterine echos w/o a gestational sac or fetal parts
- "snowstorm" ultrasound
242
GTN: Management
- Baseline qualitative B-hCG titer
- Chest X-ray (r/o lung metastasis)
- Suction dilation and curretage (D&C)
- Place patient on effective contraception to ensure no confusion w/ recurrent disease or pregnancy
