Gynecology Part 4 Flashcards
1
Q
What class of medication is Ethinylestradiol?
A
Estrogen receptor agonist –> common OCP
2
Q
What is the typical dose range of PO ethinylestradiol?
A
20 - 35 mcg –> may increase dose if breakthrough bleeding
3
Q
What is the benefit of using a lower dosing strategy for PO ethinylestradiol?
A
Lessens AEs
4
Q
What is the mechanism of Progestin (progesterone) use as a birth control option?
A
Provide negative feedback to H-P axis decreasing FSH and LH inhibiting follicle development and ovulation
5
Q
What are three clinical effects of progesterone on the uterus and fallopian tubes?
A
Thickens cervical mucus
Thins endometrium
Decreases tubal peristalsis
6
Q
Why is progesterone alone effective for birth control?
A
Progesterone inhibits ovulation
7
Q
What is the risk if a patient becomes pregnant while taking progesterone birth control?
A
Ectopic pregnancy s/p progesterone decreasing tubal peristalsis.
8
Q
What hormone does estrogen most inhibit and what is the clinical effect?
A
Estrogen most inhibits FSH –> inhibits cyst growth in the ovaries
9
Q
What hormone does progesterone most inhibit?
A
LH
10
Q
Differentiate older progesterone products from newer ones and state how this is clinically relevant?
A
Older products (Yaz for ex) have more of an anti-androgen effect. Beneficial in patients with acne or PCOS
11
Q
What is the typical regimen for patients taking combination OCPs?
A
Take a pill every day. Three weeks of pills are hormonal followed by 4-7 days of placebo.
12
Q
What differentiates one combination OCP product from another?
A
They vary based on estrogen dose and type of progesterone.
13
Q
What is the typical regimen of a combination transdermal patch or vaginal ring?
A
Wear/use for three weeks then discontinue for one week. It is ok to use continuously if preferred.
14
Q
What is the most significant AE of the transdermal patch combination products?
A
Twice the risk of thromboembolism compared to OCPs
15
Q
What is the advantage of progesterone-only products compared to combination products?
A
Progesterone-only are always safer with regard to thromboembolism risk.
16
Q
What is the name of the injectable progesterone-only product and what is the injection schedule?
A
Depo Provera –> one injection every three months
17
Q
What are the most significant AEs of injectable progesterone-only products?
A
Weight gain and decrease in bone mineral density (but no increased risk of fracture has been shown)
18
Q
How long do injectable progesterone-only products disrupt menstruation after their use is discontinued?
A
Can disrupt ovulation and menses for up to one year.
19
Q
What is the brand name of the progesterone-only subdermal implant?
A
Nexplanon
20
Q
How effective is the progesterone-only implant?
A
Very effective - statistically more effective than sterilization
21
Q
How long is the progesterone-only implant effective for?
A
4 years
22
Q
What is the most significant AE of the progesterone-only implant?
A
Light, irregular bleeding for the first 3 - 12 months.
23
Q
What are the clinical effects of a progesterone releasing IUD?
A
Thickens cervical mucus, partially inhibits ovulation, thins endometrium.
24
Q
How long is the progesterone releasing IUD effective for?
A
3-7 years depending on type.
25
What are the risk factors for IUD expulsion?
Prior expulsion, Hx of menorrhagia or dysmenorrhea, post second trimester abortion, age < 25
26
What is the mechanism of action of a copper IUD?
Releases copper ions creating an inflammatory response that makes intrauterine environment very spermicidal.
27
How long is the copper releasing IUD effective for?
12 years - though copper does degrade over time
28
What are the advantages of male sterilization over female sterilization?
No general anesthesia needed and lower rates of failure
29
Define Essure and state its major AE.
Polyester coil placed in proximal fallopian tube. It stimulates a reaction that results in fibrosis and occlusion. It is rarely used because it tends to cause severe pain.
30
Differentiate tubal ligation from salpingectomy.
Lig: A small section of the tubes may be cauterized or a clip is placed on each tube.
Salp: Removal of both fallopian tubes.
31
What is the benefit of salpingectomy over tubal ligation?
Thought to be protective against ovarian cancer
32
List and describe three options for emergency contraception.
Plan B: Progesterone blocks LH surge to inhibit ovulation. Can take up to 72 hours after sex.
Ella: Anti-progesterone product inhibits ovulation and makes endometrium uninhabitable for implantation. Can take up to 5 days after sex. Px only.
Copper IUD: Can be emergency contraceptive if placed within 5 days of sex. Most effective emergency contraceptive.
33
Compare the efficacy of long acting reversible contraceptive methods to OCPs and other short-acting methods.
Long-acting methods 20x more effective. Women tend to stay on long-acting methods longer than short-acting.
34
What is MEC in relation to birth control?
Medical Eligibility Criteria for Contraceptive Use. Chart made available from the CDC to guide providers on which birth control methods can and can't be used in various medical conditions.
35
What are the 6 absolute contraindications of estrogen birth control products?
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Thromboembolic disorder
Known or suspected breast cancer
Smokers older than 35
Uncontrolled HTN
Migraine with aura
SLE with antiphospholipid antibodies
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36
What is the best birth control method for a women with SLE with antiphospholipid antibodies?
Copper IUD --> progesterone products are not indicated for this condition.
37
Define and describe endometriosis.
Endometrial tissue outside of uterus. Most common in ovary and pelvic peritoneum. May also be transported via lymph system.
38
What are thought to be possible etiologies of endometriosis?
Genetics or immune dysfunction
39
What believed to be the most likely mechanism for development of endometriosis?
Retrograde menstruation - endometrium floats back out of fallopian tubes onto ovary or cul-de-sac.
40
Describe the relationship between estrogen and endometriosis.
Endometriosis is estrogen dependent - decreased risk after menopause.
41
What might be an anatomical cause of endometriosis?
Obstructive anomaly - imperforate hymen, transverse or longitudinal septum, cervical agenesis
42
List risk factors for endometriosis.
Early menarche, short cycles, heavy or prolonged cycles, Mullerian duct anomalies, family Hx, autoimmune Hx
43
Define Mullerian duct anomalies.
Congenital abnormality in which the fetal female reproductive tract does not develop properly in
44
List protective factors against endometriosis.
Multiparity, longer lactation, regular exercise
45
What are common symptoms of endometriosis?
Many are asymptomatic - may have chronic pelvic pain, dysmenorrhea, dyspareunia, adnexal mass, infertility
46
T/F: More severe symptoms indicates a significant amount of endometriosis.
False: severity of symptoms does not correlate to amount of endometriosis.
47
How is endometriosis diagnosed?
Clinical plus laparoscopy for direct visualization. Surgery required to confirm diagnosis.
48
What imaging tests are useful in the diagnosis of endometriosis?
None - only endometriosis in the ovaries can be seen on imaging.
49
What is the surgical criteria needed to confirm endometriosis?
Two of: endometrial epithelium, endometrial glands, endometrial stroma, hemosiderin-laden macrophages
50
What are the treatment options of endometriosis?
NSAIDs, progestins, OCPs, Danazol (androgenic hormone), GnRH agonist (induces state of pseudopregnancy), surgical correction.
51
What is the mechanism of action of danazol in the treatment of endometriosis?
Shrinks displaced tissues of the uterus.
52
What OTC supplement can decrease the risk of developing endometriosis?
Omega-3 fatty acids
53
Define polycystic ovarian syndrome (PCOS).
Hormonal disorder that may cause excess androgen levels and/or infrequent or prolonged menstrual periods.
54
What are the components of the PCOS triad?
Oligo-ovulation or anovulation
Hyperandrogenism (clinical or biochemical)
Ovarian cysts (>/= 12 follicles)
55
Other than hyperandrogenism, what other hormonal abnormality results from PCOS?
Increased LH pulsatility and high LH to FSH ratio
56
What is the typical body habitus of PCOS patients?
Often overweight, but some PCOS may have lean body habitus.
57
What are the treatment options for PCOS?
Lifestyle changes for weight loss when necessary
Hormonal contraceptives
Metformin - reduces insulin resistance and androgen levels
Antiandrogenic meds may be added for hirsutism
58
Define adenomyosis.
Extension of endometrial tissue into myometrium
59
What is the cause of adenomyosis?
High estrogen stimulates hyperplasia of basal layer of endometrium or metaplastic transformation
60
What is a pelvic exam finding consistent with adenomyosis?
Diffusely enlarged and globular uterus, especially in fundus and posterior wall
61
What symptoms may be present in adenomyosis?
May be asymptomatic --> may have dysmenorrhea, menorrhagia
62
List 2 risk factors for adenomyosis?
Endometriosis and uterine fibroids
63
What imaging is used in the diagnosis of adenomyosis?
US used first, but MRI is most definitive.
64
How is adenomyosis treated?
NSAIDs, OCPs, progestins, endometrial ablation, Mirena IUD (most effective temp treatment), hysterectomy
65
Define Leiomyoma.
Uterine fibroids - benign monoclonal tumors
66
What hormones stimulate growth of leiomyomas?
Estrogen and progesterone
67
What condition may exacerbate leiomyoma and what condition may stop their growth?
Pregnancy may cause fibroids to grow faster. Growth usually stops after menopause.
68
In which location is a leiomyoma most likely to cause heavy vaginal bleeding?
Submucosal - beneath the endometrium
69
In which location is a leiomyoma most common?
Intramural - within the myometrium
70
Describe the prevalence of leiomyoma and the likelihood of recurrence.
Common in about 25% of women - higher in African American population. If you have one leiomyoma, you are likely to have more.
71
What are risk factors for leiomyoma.
African American heritage, advancing age, inc estrogen, HTN, nulliparity
72
What medication is protective against leiomyoma?
Low dose OCPs
73
How is leiomyoma diagnosed?
Nontender, irregularly enlarged uterus on pelvic exam. Transvaginal US is the most common imaging used in diagnosis, but MRI may be helpful also.
74
What is the treatment for leiomyoma?
Dependent on location and if they are causing symptoms. May use NSAIDs and tranexamic acid (TXA) for bleeding. May consider hormonal therapy.
75
What hormone therapy may be used to treat leiomyoma?
Combined OCPs, progestins, mifepristone, androgenic steroids, GnRH agonists --> work to dec estrogen levels
76
What surgical options are available to treat leiomyoma?
Hysteroscopy - "shave down" leiomyoma
Hysterectomy
Artery embolization - expensive and not widely available
77
How is a GnRH agonist given to treat leiomyoma and what is its mechanism of action?
Given in a non-pulsatile fashion to shut down FSH release and decreasing HPO axis. Essentially induces menopause.
78
What GnRH agonist is most commonly used to treat leiomyoma and what are its AEs?
Leuprolide - has many AEs since it is similar to inducing menopause.
79
What is the name given to the cause of uterine bleeding after all other causes have been excluded? In what time frame is this diagnosis most common?
Abnormal uterine bleeding - most common in the peri-menopausal period.
80
List and briefly explain treatment options for abnormal uterine bleeding.
- OCPs - suppress endometrial overdevelopment and promote predictable cycles.
- Hormone-releasing IUD
- NSAIDs
- Desmopressin - in pateints with Hx of coagulation disorders
- D&C - may offer only temporary relief
- Endometrial ablation
- Hysterectomy - last resort if fertility is no longer desired
81
A pre-menopausal women presents with uterine bleeding. What condition, in particular, must be ruled out before a diagnosis of abnormal uterine bleeding is made?
Endometrial cancer
82
What are the best treatment options for severe, acute uterine bleeding?
- Stabilize with IV fluid and/or blood transfusion
- Intrauterine tamponade with packing or balloon
- Uterine curettage - treatment of choice in hemodynamically unstable patients
83
If first-line treatment options for severe, acute uterine bleeding fail, what else might be considered for management?
IV conjugated equine estrogen - stabilizes endometrial membrane and stops bleeding within 1-2 hours
84
Define endometrial polyps and state when they are most common.
Benign overgrowth of endometrial glands - most common in women age 40-50 taking tamoxifen for breast cancer prevention.
85
How might a diagnosis of endometrial polyps typically made?
US, sonohysterogram, hysteroscopy
86
When should endometrial polyps be removed?
- If they are cancerous or pre-cancerous.
- If they cause problems in pregnancy (ex, miscarriage)
- If patient can't tolerate symptoms
87
What are the 2 broad categories of ovarian cysts?
Functional and Neoplastic Growth
88
Where do functional ovarian cysts arise from and which is most common?
Follicular (most common) and Corpus Luteum
89
What condition may result from an ovarian cyst and how is it diagnosed?
Ovarian torsion - US is imaging study of choice. Definitive Dx is direct observation during surgery.
90
If ovarian torsion is suspected, what is the management priority and why?
Prompt surgical evaluation to preserve ovarian function.
91
What determines how an ovarian cyst (that has not caused torsion) should be managed?
Size: > 7cm = regular monitoring with MRI
< 7cm = regular monitoring with US
Patients may be prescribed OCPs to suppress ovulation
92
List 9 key components of caring for a sexual assault victim.
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Treat life threats
Obtain informed consent
Obtain and document patient's recollection of events
Head to toe exam for trauma
Inspect and photograph external genitalia
Speculum exam
Test blood and vaginal swabs for STIs
Abx and ARV prophylaxis
Counsel and arrange for follow up exam
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93
How many providers should be involved in the exam of and specimen collection from a sexual assault victim?
There should always be a witness. The provider collecting the specimens should deliver them personally. If the witness is to deliver specimens, they must sign a chain of custody form.
94
List 7 risk factors for sexual assault.
```
Drug/alcohol use
Impulsive tendencies
History of abuse
Hostility toward women
Poverty
Tolerance of violence in the community
Societal norms around male sexual dominance
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95
List 4 warning signs of intimate partner violence.
Partner overly attentive or critical
Psych changes - anxiety, sleep disturbances
Suspicious bruises
Sexually active but difficulty with pelvic exam
96
List and define three acronyms that can be used as screening tools for intimate partner violence.
HITS: how often does partner Hit, Insult, Threaten, or Scream?
STaT: have you ever been Slapped, Threatened, or Thrown?
RADAR: Remember to Ask, Document, Assess, and Refer
97
List 7 risk factors for being a victim of intimate partner violence.
```
Age 16 - 24
Low SES
Low education
Immigrant
Hx of violence
Transgender
Hx of alcohol or drug use
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98
T/F: If a provider suspects or discovers a patient is a victim of intimate partner violence, they are mandated to report their findings to the police?
False: If it involves a child, yes. If it involves an adult, the victim must be the ones to call the police.
99
Describe the physiologic process of normal micturition.
Bladder fills --> sensation to void --> detrusor relaxes while urethra and pelvic floor contracts --> desire to void --> detrusor contracts while urethra and pelvic floor muscles relax.
100
What physiologic components are required for a person to remain continent?
Requires healthy fascia, attachments, and strength, connection, and coordination of levator ani muscles.
101
List and describe the 4 types of incontinence.
Urge: uninhibited detrusor contraction - leak without provocation.
Stress: increased intra-abdominal pressure and laxity of internal urethral sphincter.
Mixed: A mix between stress and urge
Other: Can be - overflow (retention to the point urine leaks out), a fistula (connection between urinary tract and vagina/rectum), urethral diverticula, insensible (leakage with no trigger or sensation), functional (physical/mental impairments), or psychogenic.
102
What is the classic triad of symptoms associated with urethral diverticula?
Dysuria, dribbling, and discharge
103
List three circumstances when urinary incontinence should be referred to a specialist.
Acute onset with no UTI
Abnormal neuro exam
Hematuria with no UTI
104
What is the first line treatment/counseling for urge incontinence?
Avoid caffeine and alcohol
105
List some non-pharmacological methods to treat stress incontinence.
PT OTC devices, Pessary, Midurethral sling
106
List pharmacologic and invasive options for managing urge incontinence.
Antimuscarinics - inhibit detrusor contractions
Mirabegron - blocks beta receptor in detrusor to relax it and increase capacity
Posterior tibial nerve stimulation
Intravesicular Botox - blocks release of Ach
Interstim - pacemaker for the bladder
107
List diagnostic findings of a UTI.
On UA --> hematuria, leukocytes, leukocyte esterase, nitrate in absence of vaginal infection
108
List abx options for treating UTI.
Bactrim, fluoroquinolones, nitrofurantoin, ampiciliin, cephalexin
