Hacker and Moore Part 3 - Gyn

Question 1

What are the causes of female pseudohermaphroditism (masculinization inutero) (3)? What clinical sign would be evident (1)?

Answer 1

1) DDx: congenital adrenal hyperplasia, exogenous androgen ingestion by mother, Androgen producing tumors of the ovary or adrenal gland. 2) Enlarged clitoris

Question 2

What is the genetic sex of a patient with testicular feminization? What causes this disease? What anatomical structures are defective or missing? What surgery is required?

Answer 2

1) XY 2) Androgen insensitivity - genetically deficient androgen receptors 3) No mullerian tract structures - fallopian tubes, uterus 4) Abdominal testes should be removed due to malignant potential

Question 3

What is the typical cause of male pseudohermaphroditism?

Answer 3

genetic mosaicism - 45XO/46XY

Question 4

What is the appropriate treatment for labial agglutination?

Answer 4

estrogen cream and massage

Question 5

What population is most affected by urethral caruncle, what is the mechanism causing this defect?

Answer 5

1) post-menopausal women 2) contraction of vaginal epithelium leading to eversion of urethral epithelium

Question 6

Provide two common solid benign tumors of the vulva and their appropriate treatments.

Answer 6

1) fibroma and lipomas 2) surgical excision if symptomatic

Question 7

What are the SSx of Lichen sclerosis (4)? What is the appropriate treatment, why should it be treated?

Answer 7

1) SSx: dyspareunia, pruritus burning pain, skin is thin/inelastic/white 2) Treat with topical steroids (clobetasol), risk of progression to vulvar intraepithelial neoplasm (VIN)

Question 8

What is associated with acanthosis nigricans?

Answer 8

insulin resistance

Question 9

Describe a Gartner’s duct cyst, what is the appropriate intervention?

Answer 9

1) remnant of wolffian duct 2) most are asymptomatic and require no intervention

Question 10

What are the symptoms of a urethral diverticula (4)?

Answer 10

1) recurrent UTIs 2) dysuria 3) dyspareunia 4) urinary dribbling

Question 11

What is the most common vulvovaginal tumor? How is it treated?

Answer 11

1) Bartholin’s cyst 2) if infected - inflatable catheter insertion for 4-6 wks if not infected - marsupialization. treat only if symptomatic

Question 12

What structures are formed by the mullerian ducts (4)?

Answer 12

Upper vagina, cervix, uterine corpus, fallopian tubes

Question 13

Provide examples of failure of fusion (2), incomplete dissolution (1), and failure of formation (1) causing anomalies of the uterus?

Answer 13

1) failure of fusion: uterus didelphys, bicornuate uterus (rudimentary horn, with double crevix, without double cervix) 2) Incomplete dissolution: septate uterus 3) Failure of formation: unicornuate uterus

Question 14

Exposure to which drug increases the risk of uterine or cervical congenital anomalies?

Answer 14

Diethylstilbestrol (DES)

Question 15

What is the most common benign neoplastic condition of the uterus?

Answer 15

Uterine leiomyomas (fibroids)

Question 16

What are the symptoms of leiomyomas (4)?

Answer 16

1) Uterine bleeding, pelvic pressure and pain, infertility, lower back pain 2) most are asymptomatic

Question 17

What are some risk factors for developing a leiomyoma (5)?

Answer 17

1) increasing age 2) ethnicity (black) 3) nulliparity 4) FamHx 5) increased BMI

Question 18

Which hormones have an impact on leiomyomas (2)? What are their impacts?

Answer 18

1) Estrogen and progesteron 2) Leiomyomas have increase E and P receptors, thus increase in size under influence of these hormones (will increase in size during pregnancy)

Question 19

Provide the physical characteristics of leiomyomas (4)

Answer 19

1) spherical 2) well-circumscribed 3) firm 4) white

Question 20

Provide three histological changes (degenerations) that can occur to leiomyomas

Answer 20

1) hyaline degeneration - hyaline tissue replaces fibruous and muscle tissue 2) cystic degeneration - poor blood supply, follows hyaline degeneration 3) Calcification - common after menopause

Question 21

Provide the regional classification for leiomyomas (6), what risks are associated with submucosal leiomyomas?

Answer 21

1) pedunculated subserosal fibroid 2) subserosal fibroid 3) intramural fibroid 4) Submucosal fibroid 5) Pedunculated submucosal fibroid 6) Cervical fibroid 7) Submucosal can cause fertility problems, can also abort through cervical os and cause bleeding and cramping

Question 22

What is meant by ‘red degeneration’ of a fibroid? What is a symptom? When does this occur?

Answer 22

1) it is an acute infarct of a fribroid 2) associated with severe pain 3) occurs during pregnancy

Question 23

How is heavy menstruation due to leiomyomas treated medically (3)?

Answer 23

1) Progestin-only therapies 2) Combination hormonal OCPs 3) GnRH agonists (short term use only, pre-surgical)

Question 24

How is menorrhagia due to leiomyomas treated surgically, how does the fertility concerns of the patient affect treatment (3)?

Answer 24

1) desired fertility - myomectomy or uterine artery embolization (used if size and number of fibroids limited) 2) desired uterine preservation - uterine artery embolization or endometrial ablation 3) no desired fertility - endometrial ablation or hysterectomy

Question 25

What is the most common symptom of endometrial polyps? What is concerning about endometrial polyps?

Answer 25

1) menorrhagia and spontaneous bleeding 2) risk of conversion to endometrial carcinomas

Question 26

What is a Nabothian cyst? Comment on the cell types present.

Answer 26

1) mucus retaining cyst on the cervix 2) squamous metaplasia occurs and squamous cells cover secreting columnar cells of the cerix (benign)

Question 27

What is a symptom of cervical polyps? How are they treated? What should be included in the work-up and why?

Answer 27

1) post coital bleed 2) twisting of polyp or cautery 3) Send for pathology - could be squamous cell or adenocarcinoma (risk is low)

Question 28

What causes endometrial hyperplasia (5)? What are the malignant potential?

Answer 28

1) unopposed estrogen - PCOS, granulosa-thecal cell tumors, obesity, exogenous estrogens, tamoxifen 2) complex atypical hyperplasia has malignancy risk of 20-30% for endometrial cancer

Question 29

How is endometrial hyperplasia treated depending on the pathological findings (3)

Answer 29

1) simple hyperplasia without atypia - treat with 3 months cyclic progestin 2) complex hyperplasia - treat with daily progestin for 3-6 months 3) complex hyperplasia with atypia - hysterectomy

Question 30

Describe Asherman’s syndrome. What is a common causes?

Answer 30

1) endometrium is denuded and covered with scar tissue 2) Curretage following high-risk procedure. Endometrial ablation.

Question 31

What is the prevalence of ectopic pregnancies? How do IVF and ART affect the rate of ectopics?

Answer 31

1) 1 in 80
2) Increased in IVF and ART, and location changes

Question 32

What is the most common cause for tubal ectopics?

Answer 32

Damage to the tubal cilia due to infections (chlamydia and gonorrhea)

Question 33

Provide the risk factors for ectopic pregnancy (6)

Answer 33

1) Hx of tubal infection 2) Cigarette smoking 3) prior ectopic 4) tubal sterilization or surgery 5) pregnancy with IUD, Depo, or emergency contraceptive pill 6) ARTs

Question 34

What is the triad of symptoms for ectopic pregnancy?

Answer 34

1) missed menses 2) vaginal bleed 3) lower abdominal pain

Question 35

What are the SSx of an acutely ruptured ectopic pregnancy (6)? What is the appropriate management?

Answer 35

SSx: intraperitoneal hemorrhage, abdominal pain, dizziness, hypotension, ipsilateral shoulder pain, tachycardia, diaphoresis

Tx: Surgical emergency, fluid resuscitation, laparotomy

Question 36

Discribe the different tests that faciliate the diagnosis of an ectopic with reference to specific lab values.

Answer 36

1) hCG rise less than 50% in 48 hours -> abnormal IUP or ectopic
2) hCG decline slower than 20% in 48 hours -> ectopic
3) hCG > 1000 with no gestational sac on U/S

Question 37

Provide the surgical options available for treating ectopic pregnancy, their impacts on fertility, and the associated risks (4).

Answer 37

1) Salpingectomy - impacts fertility
2) Partial salpingectomy - fertility sparing. Used for mid-ampulla implantation
3) Salpingotomy and Salpingostomy - Very good fertility sparing, risk of residual trophoblastic tissue

Question 38

What drug is used for the medical management of ectopic pregnancies? What is its mechanism of action? How is treatment followed?

Answer 38

1) Methotrexate 2) Folic acid antagonist 3) Serial hCG until undetectable, repeat therapy

Question 39

What hCG level is appropriate for expectant management of an ectopic pregnancy?

Answer 39

hCG less than 200