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Clin med I- Womens Health > menstrual cycle - cervical abnorm > Flashcards

menstrual cycle - cervical abnorm Flashcards

1
Q

Function of Follicles and Oocytes

A
  • The follicle is the basic functional unit of ovary
  • Oocytes lie inside follicles in various stages of development
  • Follicular maturation (folliculogenesis) accompanies the oocyte maturation process
  • 120 day cycle from primordial to dominant (also called a Graafian follicle)
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2
Q

How does thyroid impact the HPO Axis

A
  • Can impact the HPO axis!
  • elevated thyrotropin releasing hormone (TRH) stimulates the pituitary gland to produce prolactin
  • prolactin inhibits GnRH
  • Can cause pregnancy loss and complications in fetal development
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3
Q

Steps in normal Menstrual cycle

A
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4
Q

Describe steps in the ovarian phase of the menstrual cycle

A

describes changes that occur in the follicles of the ovary

Follicular phase (corresponds to the proliferative phase of the uterine cycle)

  • Luteal phase (corresponds to the secretory phase of the ovarian cycle)
  • Oocytes are surrounded by granulosa cells and theca cells
  • Granulosa cells contain FSH receptors and produce estrogen as well as convert androgens to estrogens
  • Theca cells contain LH receptors and produce androgens
  • Progesterone is produced by the corpus luteum
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5
Q

Oocytes are surrounded by ______ cells and _____ cells

functions of these cells?

A
  • Granulosa cells contain FSH receptors and produce estrogen as well as convert androgens to estrogens
  • Theca cells contain LH receptors and produce androgens
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6
Q

The Uterine (endometrial) Cycle consiste of

A

describes changes in the endometrial lining of the uterus.

Proliferative phase (corresponds to the follicular phase of the ovarian cycle)

  • Secretory phase (corresponds to the luteal phase of the ovarian cycle)
  • Menstruation (or pregnancy)
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7
Q

list steps in the HPO axis

A
  1. DEC estradiol levels cause hypothalamus to release GnRH to ant. pituitary
  2. anterior pituitary releases FSH and LH that stimulate granulosa cells of follicle to produce estradiol & LH stimulated theca cells to produce androgens
  3. due to INC estradiol of growing follicle FSH is suppressed
  4. INC in estrogen, progesterone and testosterone inhibit GnRH
  5. inhibin suppresses FSH
  6. INC in estrogen causes ant. pituitary to release surge of LH
  7. surge of LH = final maturation of egg and release from the follicle (ovulation)
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8
Q

FSH is suppressed by ____

A

INC estradiol of growing follicle

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9
Q

INC in estrogen, progesterone and testosterone inhibit ____

A

GnRH release from hypothalamus

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10
Q

DEC estradiol levels cause release of _____

A

GnRH from hypothalamus

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11
Q

Functions of FSH and LH

A

stimulate granulosa cells of ovarian follicle to produce estradiol

LH stimulates theca cells to produce andorgens

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12
Q

INC estrogen causes ??

A

ant. pituitary to release surge of LH

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13
Q

the final surge of LH causes?

A

final maturation of egg and release from follicle (ovulation)

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14
Q

define Amenorrhea

A

absence of menstruation

  • may be transient, intermittent, or permanent ‒
  • may result from dysfunction of the hypothalamus, pituitary, ovaries, uterus, or vagina
  • primary versus secondary
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15
Q

causes of Amenorrhea

primary vs secondary

A

PRIMARY -

Gonadal dysgenesis – 43%

Mullerian agenesis – 15%

Constitutional delay of puberty – 14%

Polycystic ovarian syndrome (PCOS) – 7%

GnRH deficiency – 5%

Transverse vaginal septum – 3%

Weight loss/anorexia nervosa – 2% § Hypopituitarism – 2%

SECONDARY

PREGNANCY!

Hypothalamic – 35%

Pituitary – 17%

Ovarian – 40%

Uterine – 7%

Other – 1%

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16
Q

questions specific to PRIMARY Amenorrhea

A
  • Completed other stages of puberty?
  • Family history of delayed or absent puberty?
  • Height in relation to family members?
  • Normal neonatal and childhood health?
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17
Q

uestions specific to SECONDARY Amenorrhea

A
  • Are there any symptoms of estrogen deficiency, including hot flashes, vaginal dryness, poor sleep, or decreased libido?
  • Is there a history of obstetrical catastrophe, severe bleeding, dilatation and curettage, or endometritis or other infection that might have caused scarring of the endometrial lining (Asherman syndrome)?
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18
Q

Workup of amenorrhea

imaging and labs

A

Primary workup

  • Evaluated most efficiently by focusing on the presence or absence of breast development, uterus, and FSH level
  • Ultrasound ‒ If needed to determine whether uterus is present

LABS

  • Human Chorionic Gonadotropin (hCG)
  • Follicle Stimulating Hormone (FSH)
  • Thyroid Stimulating Hormone (TSH)
  • Prolactin (PRL)
  • Testosterone if indicated
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19
Q

hypothalamic dysfunction is a common cause of (primary/secondary) amenorrhea?

and what may hypothalamic dysfunctuion present as?

A

SCONDARY

Constitutional delay of puberty

  • Isolated GnRH deficiency
  • Functional hypothalamic amenorrhea
  • Other ‒ infiltrative diseases and tumors of the hypothalamus ‒ systemic illnesses
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20
Q

define dysmenorrhea

what causes it?

A

recurrent crampy lower abdominal pain that occurs during menstruation in the absence of pelvic pathology

primary versus secondary

Caused by excess production of endometrial prostaglandin F2 alpha

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21
Q

si/sx of Dysmenorrhea

A

Crampy lower abdominal or pelvic pain

Back pain

Nausea / Vomiting

Diarrhea

Headache

Fatigue

Dizziness

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22
Q

tx od dysmenorrhea

first and second line

A

First line – NSAID

•Most effective when begun early in onset of symptoms

•Ibuprofen or Naproxen

  • Mefenamic acid if above not effective
  • Always take with food!
  • Acetaminophen is alternative if C/I to NSAIDs

Second Line – Hormonal

•Can also be appropriate 1st line treatment for patients who are sexually active

•OCPs prevent dysmenorrhea by suppressing ovulation, can take continuously

•Can also use transdermal patch or vaginal ring, injectable or implantable contraceptives, or levonorgestrel-releasing intrauterine devices

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23
Q

contrast PMS from PMDD

A

severe form of PMS in which symptoms of anger, irritability, and internal tension are prominent

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24
Q

tx of PMS / PMDD

A

Mild symptoms

Exercise

Stress reduction techniques such as relaxation techniques

Moderate to severe symptoms

  • 1st line (SSRIs)
  • 2nd line (OCPs) ‒ Can also consider augmentation with low-dose alprazolam
  • 3rd line (GnRH) agonist therapy with low-dose estrogen-progestin replacement)
  • 4th line surgery
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25
Q

Define Dysfunctional Uterine Bleeding (DMB)

usually caused by problem with?

A

abnormal uterine bleeding unrelated to anatomical lesions of the uterus, pelvic pathology, pregnancy, or systemic disease; usually caused by a problem with the HPO axis

Anovulation

dx of exclusion!!! - r/o EVERYTHING else

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26
Q

Key component to evaluation of dysfunctional uterine bleeding is to determine whether _______ is occurring

A

ovulation

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27
Q

define menopause vs premature ovarian insufficiency (POI)/premature ovarian failure (POF):

A

menopause

  • permanent cessation of menstruation; defined retrospectively
  • Average age of menopause is 51.4 years old in the USA

premature ovarian insufficiency (POI)/premature ovarian failure (POF): premature menopause before age 40

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28
Q

ages to evaluate for menopause:

If patient presents with irregular menstrual cycles +/- menopausal symptoms…

A
  • If patient presents with irregular menstrual cycles +/- menopausal symptoms…
  • <40 y/o -> complete evaluation
  • 45-50 y/o -> evaluation similar to workup of oligo/amenorrhea, other causes of menstrual dysfunction must be ruled out
  • >45 y/o -> diagnostic testing not recommended
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29
Q

pathophys of menopause

A

•Decline in the quality and quantity of follicles and oocytes

_1 . Granulosa cell_s in follicles stop making estrogen and inhibin

  1. Loss of inhibin = loss of the negative feedback loop to hypothalamus and pituitary
  2. Therefore FSH and LH increase in production by pituitary
  3. Ovary cannot respond to FSH
  4. Permanent amenorrhea once all follicles are depleted
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30
Q

tx for menopause

(MHT)

A

oral 17-beta estradiol: If baseline VTE and stroke risk low

  • AVOIDED in:
  • Hypertriglyceridemia
  • gallbladder disease
  • known thrombophilias
  • migraine headaches with aura

transdermal 17-beta estradiol: Lower risk of VTE, stroke, & hypertriglyceridemia

vaginal estrogen:Will only treat vaginal atrophy, not hot flashes,

Progestin probably not needed , but maybe with vaginal creams due to higher systemic absorption

May be used indefinitely, low risk of adverse effects

  • vaginal ring (estring)
  • vaginal tablet (vagifem)
  • vaginal cream (premarin or estrace)
  • unopposed estrogen therapy (ET) for women s/p hysterectomy
  • combined estrogen- progestin therapy (EPT) for women with an intact uterus

Unopposed estrogen therapy is a risk for developing endometrial hyperplasia!

•Give estrogen and progesterone bc progesterone is protective to the Uterus

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31
Q

Unopposed estrogen therapy is a risk for developing _______ ________.

A

Unopposed estrogen therapy is a risk for developing endometrial hyperplasia!

  • Give estrogen and progesterone bc progesterone is protective to the Uterus
  • combined estrogen- progestin therapy (EPT) for women with an intact uterus
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32
Q

non hormonal tx of menopause

A

Used for women who are not candidates for MHT due to breast cancer or cardiovascular risk

  • SSRIs
  • SNRIs
  • anti-epileptics, and centrally acting drugs

low-dose paroxetine (7.5 mg/day) 1st choice because only drug that has received approval by the FDA for the treatment of hot flashes

Gabapentin (Neurontin) – especially if hot flashes occur primarily at night

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33
Q

CI of menopause hormonal therapy

A
  • Breast cancer
  • Coronary heart disease (CHD)
  • Venous thromboembolism (VTE)
  • Cerebrovascular accident (CVA)
  • Transient ischemic attack (TIA)
  • Liver disease
  • Unexplained vaginal bleeding
  • Endometrial cancer
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34
Q

•Infertility is defined as the inability to conceive after:

A

in women < 35 y/o = >12 months of regular intercourse / donor insemination without use of contraception

in women < 35 y/o = >6 months of regular intercourse or donor insemination without use of contraception

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35
Q

infertility work up female

A

Labs

TSH

Prolactin

CBC

ABO, Rh, & antibody screening

ovarian evaluation

Antral Follicle Count (AFC)

Anti-Mullerian Hormone (AMH)

Day 3 labs (FSH & estradiol) -> FSH is HIGH w/ LOW egg reserve, Measure at SAME time

Clomiphene Citrate Challenge Test (CCCT)

uterine evaluation

Hysteroscopy – look inside uterus w/ camera – no evaluation of tubes

Hysterosalpingogram (HSG) – first evaluation, looks at uterus and fallopian tubes (detect tubal lesions)

•Uncomfortable and not well tolerated

S_onohysterogram/Sonohystogram_ - saline infused into uterus w/ US guidance, can view ovaries as well

•More comfortable and well tolerated

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36
Q

tx for infertility

A

•Based on the underlying pathology

Based on the manipulation of the HPO axis via

Ovulation Induction vs. Controlled Ovarian Stimulation in combination with timed intercourse (TI), intrauterine insemination (IUI), or assisted reproductive technologies (ART)

•Lifestyle modifications and psychological/emotional support are important

Intrauterine Insemination (IUI) - Semen is spun down in the lab, washed, and injected into the uterine cavity via catheter threaded through the cervix

In Vitro Fertilization (IVF)

Cryopreservation

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37
Q

Si/Sx of PCOS

A

Irregular menstrual cycles (oligo- or anovulation)

Hyperandrogenism

Acne

Hirsutism

Male pattern (scalp) hair loss or thinning

Deeping of voice and clitoromegaly rare

Elevated serum testosterone

Obesity

Acanthosis nigricans

Mood changes

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38
Q

dx of PCOS

A

Rotterdam criteria (must have 2/3 of the following)

  1. Ovulatory dysfunction (oligo and/or anovulation)
  2. Chemical and/or biochemical signs of hyperandrogenism
  3. Polycystic “string of pearls” appearance of ovaries on transvaginal ultrasound
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39
Q

Tx of PCOS (FIRST LINE)

A

•Weight loss via diet and exercise is 1st line intervention

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40
Q

tx of PCOS in women pursing pregnancy and not pursing pregnancy

A

•In women not pursuing pregnancy

FIRST LINE - (OCPs)

SECOND LINE - Metformin

  • Antiandrogens added after 6 months of OCP use if response suboptimal… 1st line is Spironolactone 50- 100 mg twice/daily
  • GnRH agonists

•In women pursuing pregnancy

FIRST LINE - Letrozole

SECOND LINE - Clomid

•although Letrozole is not approved by the FDA for this indication

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41
Q

define vaginitis

and most likely causes

A

*General term for vag infxn, inflam, or chg in norm vag flora

Sx: Discharge change, pruritus, odor, discomfort/dyspareunia, dysuria

Majority is caused by infectious agents*:

**90%; = Gonorrhea, Chlamydia, Mycoplasma

(bacterial = MC)

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42
Q

describe vaginal ecosystem

normal pH??

A

vLactobacilli (95%)!!

Ø Other 5% includes…

  • Streptocococci sp, Staphylococcus epidermis
  • Diptheroid sp.
  • *Gardnerella vaginalis
  • Peptostreptococci sp, Bacterioides sp. , Anaerobic Lactobacillus
  • Ureaplasma urealyticum , Mycoplasma hominis

•Non keratinized, squamous epithelium, Estrogenized

•Rich in Glycogen -> substrate for Lacto, breaks down -> Lactic acid, fostering acidic envt -> pH 4.0-4.5, maintaining norm flora

•Norm pH is 4.0-4.5 = important for DX vaginal issues*

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43
Q

define BV and what causes it

A

Shift in vaginal flora from lactobacilli to diverse bacteria

•Increase production of amines by new bacteria

•pH rises- loss of lactobacilli

• Leads to overgrowth of anaerobes

•Anaerobes produce and enzyme that breakdowns vaginal peptides into amines producing the malodorous smell of BV

Most common cause of abnormal vaginal discharge in women of childbearing age (40-50%)

•50% AA

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44
Q

microbiology of BV

how is pH affected?

A

Gardnerella vaginalis

Prevotella species

Bacteroides species

Porphyromonas species

Peptostreptococcus Mycoplasma/

Ureaplasma

Resultant rise in pH to >4.5

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45
Q

si/sx of BV

A

Asymptomatic- 50-75%

Discharge (thin, off-white)

Odor (fishy)- 50%

More noticeable after intercourse

During menses

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46
Q

pt w/ BV complaining of dysuria, dyspareunia, pruritis, or vaginal inflammation:

what are you thinking?

A

Alone typically does not cause dysuria, dyspareunia, pruritis, or vaginal inflammation

•May be associated with acute cervicitis

• Presence may suggest mixed vaginitis

•Think co-infection – BV & yest commonly co-infected

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47
Q

dx of BV

A

Amsel criteria

  1. Thin, grayish-white discharge
  2. pH >4.5
  3. Positive whiff test (amine)- drop of KOH on sample of discharge with resultant fishy odor
  4. Clue cells on saline wet mount epithelial cell covered in bacteria

“crushed glass” appearance = epithelial cells surrounded in bacterial

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48
Q

tx of BV

along w/ alternatives and suppressive therapy

A

Metronidazole – do not drink alc = N/V

Metrogel

Clindamycin (avoid if pregnant / breast feeding)

Alternative:

Tinidazole

Clindamycin

Clindmycin ovules

Suppressive: recurrent BV

  • Metrogel 0.75% twice weekly for 4-6 months
  • Oral Metronidazole course, followed by boric acid 600 mg intravaginally for 21 days and suppressive metronidazole gel for 4-6 months
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49
Q

define Candidiasis

A

Characterized by inflammation in presence of Candida species (Candida albicans 80-92%)

•Present in normal flora of 25% of women

Second most common cause of vaginitis

  • As many as 50% of clinically dx women have another condition
  • Highest among women during reproductive years
  • Uncommon in postmenopausal women unless they are taking estrogen therapy and prepubertal girls
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50
Q

si/sx of yeast infection

A

Vulvar pruritis (dominant feature)

Burning, Soreness, Irritation

Dysuria

Dyspareunia

Erythema of external genitalia, vagina and cervix

Vulvar excoriation and fissures

Scant discharge

Discharge is white, thick, adherent to vaginal walls, clumpy (cottage cheese)

No or minimal odor

Cervix is usually normal

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51
Q

dx of yeast infection

A

Microscopy of vaginal dc

pH is typically normal 4-4.5 ******

• Distinguishes from BV, Trich

KOH on discharge - > Hyphae and budding

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52
Q

tx of yeast infection

simple

complicated

pregnant

A

Simple uncomplicated infection

• Fluconazole (Diflucan) 150 mg 1 dose

Complicated Infections

  • Fluconazole 2-3 sequential doses 72 hours apart
  • 7-14 days of topical if preferred
  • Clotrimazole, miconazole, terconazole

Pregnancy

• Clotrimazole, miconazole intravaginally x 7 days

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53
Q

define trich

what causes it?

A

Genitourinary infection with the protozoan Trichomonas vaginalis

The most common non-viral STD worldwide

Can be asymptomatic

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54
Q

si/sx of trich

A

Mostly asymptomatic

  • Erythema of vulva and vaginal mucosa
  • Classic green-yellow, frothy, malodorous discharge (10-30%)
  • Punctate hemorrhages on cervix (strawberry cervix) (2%)
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55
Q

tx of trich

A

5-nitroimidazole drugs are the only class that provide curative therapy

  • Metronidazole 500 mg BID x 7 days
  • Tinidazole 2 g qd x 2 days or 1 g qd x 5 days

Tinidazole better tolerated with less GI side effects but $$$

Topical therapy is ineffective

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56
Q

if a male is infected w/ trich and has si/sx…?

A

MOSTLY asymptomatic:

  • Mucopurulent or clear urethral discharge
  • Burning sensation
  • Associated with prostatitis, epididymitis, infertility, balanitis, prostate cancer
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57
Q

pH levels of:

normal vagina

BV

candidasis

Trich

A

normal pH 4.0-4.5

BV - Elevated pH to >4.7

Candidasis - pH is typically normal 4-4.5

Trich - pH is elevated >4.5

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58
Q

dx of trich

A

Nucleic acid amplification tst (NAAT)

Point of care (POCT) - AFFIRM VP III, OSOM Trich Rapid Test

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59
Q

Gonorrhea causes ____ in women and ___ in men.

A

Causes cervicitis in women and urethritis in men

Extragenital infections- pharynx and rectum

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60
Q

si/sx of gonhorrhea in women

A

Women: mostly asymptomatic

Cervicitis- most common friable cervical mucosa

If sx do develop - w_ithin 10 days post exposure_

  • Pruritis
  • Mucopurulent discharge

Pain is atypical unless PID- abdominal or dyspareunia

•10-20% of women with gonorrhea develop PID

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61
Q

si/sx of gonhorrhea in men

A

Men: Majority of men are asymptomatic

Urethritis

Incubation period 2-5 days:

Mucopurulent discharge

Dysuria

  • Epididymitis can develop if not treated
  • Rare complications include penile lymphangitis, periurtehtral abscess
  • Urethral strictures
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62
Q

dx of gonnorrhea

A

HX & PE

Genital swab-female

Urine-male (first catch)

NAAT (quicker than cx- looks for RNA test of choice for diagnosis

•But does not test for susceptibility- culture

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63
Q

tx of gonnorrhea

A

Ceftriaxone 250 mg IM x 1 plus

However also recommended is to add on Azithromycin 1 g x 1 (Even if you are only treating gonorrhea)

Alternate: for cephalosporin allergy

  • Azithromycin 2 g PO x 1 plus
  • Gentamycin 240 mg IM x 1

Pregnant women-same preferred regimen

•Coinfection with chlamydia should use azithromycin instead of doxy

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64
Q

screening for Chlamydia & gonorrhea should occur??

A

Screening: Sexually active women 25 and under- annual

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65
Q

pathogen responsible for Chlamydia

A

Gram-negative Chlamydia trachomatis – gram negative

  • Efficient disease transmission
  • Incubation period of symptomatic disease from 5-14 days
  • Long growth cycle-why treatment with antibiotics with a long half-life or a prolonged course is necessary
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66
Q

si/sx of Chlamydia in women

A

Women: majority asymptomatic, rationale for screening

•Cervix is the most common affected site

  • Nonspecific sx
  • Change in vaginal discharge
  • Mucopurulent endocervical dc
  • Cervical bleeding
  • Sexually active, young female with UA pos but cx negative, may or may not present with sx
  • Misdiagnosed as having cystitis unless specific chlamydia test is sent
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67
Q

si/sx of Chlamydia in men

A

Men: asymptomatic from 40-90%

  • Urethritis chlamydia is most common cause of nongonoccal urethritis
  • Mucoid or watery discharge which is scant
  • Dysuria
  • Incubation period is 5-10 days
  • Chlamydia frequent cause of epididymitis in men under 35
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68
Q

dx test for gonorrhea and chlamydia of throat and rectum

A

Aptima Combo 2 Assay

Xpert CT/NG- 90 minutes

•First cleared for extragenital diagnostic testing of gonorrhea and chlamydia of throat and rectum

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69
Q

tx of Chlamydia

including alternate and pregnant

A

Azithromycin

Doxycycline

Alternate

Ofloxacin

Levofloxacin

Pregnant-

Azith, no doxy

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70
Q

woman w/ Gonorrhea presenting w/ pain… what are we thinking ??

A

Pain is atypical unless PID- abdominal or dyspareunia

•10-20% of women with gonorrhea develop PID

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71
Q

pregnant women w/ gonnorrhea & Co-infection w/ Chlamydia should be treated w/ ______ instead of ______.

A

Azithromycin instead of Doxy

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72
Q

most common reported bacterial infection in US

A

Chlamydia

Gonorrhea

  • 2nd MC reported communicable DZ,
  • 2nd most prevalent STI
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73
Q

Comparing GRHEA + CHLA

  1. Extragenital infxns; pharynx + rectum > can cause invasive infxns including Endocarditis + Meningitis
  2. Long life cycle = need prolonged ABX; efficient transM of DZ, incubation PD 5-14 D
  3. Strain typing: can be done in outbreaks
  4. TX: Azithromycin 1g, Doxy 100 mg
A

GON - 1. 3.

CHLA - 2 , 4

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74
Q

define PID and what causes it

A

Acute infxn of upper genital tract in W

•Including uterus, ovaries, fallopian tubes, endometrium

  • Initiated by STI, *MC GRHEA or CHLA;
  • 15% of W with GRHEA and 30% (10-15%) of W with CHLA -> will go on to dvp PID
  • GRHEA PID tends to be more severe
  • Prev has DEC in U.S, 90,000 outpt visits
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75
Q

PID affects what anatomical structures?

A

Uterus

Ovaries

Fallopian tubes

Endometrium

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76
Q

microbiology of PID

A

Neisseria gonorrhoeae

Chlamydia trachomatis

Mycoplasma genitalium

E.coli (postmenopausal)

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77
Q

si/sx of PID

A

Typically acute but can be indolent and develop over weeks to months

Varying clinical syndromes

Mild vague pelvic symptoms to tubo-ovarian abscess

Rarely fatal intra-abdominal sepsis

Liver inflammation-perihepatitis (Fitz-Hugh Curtis Syndrome) 10% of women with PID

78
Q

Si/Sx of acute PID

A

-Lower ABD or pelvic pain (bilat); MC

  • Character of pain variable, can be subtle; worsens with sex
  • Onset of pain during or shortly after menses; abnorm bleeding
  • Rebound tenderness, pelvic organ tenderness, fever, decreased bowel sounds, inflamm of genital tract (CMT)
  • Uterine + adnexal tenderness on bimanual
  • Purulent cervical or vaginal discharge
79
Q

describe importance of subclinical PID?

A

_*Does not prompt W to seek car_e; SX not severe enough ->

*Sequelae can be devastating:

-Tubal factor infertility

-Many W presenting with infertility due to tubal adhesions or distal tubal occlusion, which appear PID related, gave no HX of PID!!*

80
Q

Dx of PID

A

HX: risk factors (sexual hx)

PE:

  • Pelvic – pelvic organ tenderness (CMT)
  • Purulent discharge

Imaging: CT (uncertain dx or complications), US

Additional Criteria]:

  1. Temp >101F (38.3 C)
  2. Abnormal discharge
  3. WBC on micro
  4. Documentation of GC/Ch infxn
  5. ELEV CRP
81
Q

*Sensitivity of clinical DX is 60-90%

*Presumptive DX is sufficient to warrant empiric TX of PID due to…??

A

reproductive sequelae

82
Q

PID Indications for Hospitalization:

A

Severe clinical illness – (high fever, N/V, severe ABD pain)

Complicated PID with pelvic abscess

Possible need for invasive diagnostic testing - (ex-lap)

Inability to take PO meds; Lack of response to PO meds

Concern for nonadherence

Pregnant

83
Q

tx of PID

mild-mod

inpatient

A

~ Mild to Moderate DZ:

*Ceftriaxone IM + Doxy

Cefoxtin IM + Doxy + Probenecid

~ Inpatient:

*Cefoxtin IV or Cefotetan IV + Doxy

*Clinda + Gentamycin

84
Q

cause of syphillis & transmission

A

Treponema pallidum

  • Spirochete (delicate corkscrew shaped organism), discovered 1905
  • Too small for ID on direct micro, complicates DX

*Transmission occurs from direct contact with infectious lesion during intercourse

  • Can initiate infxn wherever inoculation occurs!!!
  • Can spread via kissing, touching person’s active lesions on lips, oral cav, breasts, or genitals
  • Crosses placenta; cause fetal infxn
85
Q

si/sx of early syphillis

A

*Occurs within wks – mths after initial infxn

1°: Chancre = painless lesions @ site of inoculation

2°: Untreated = Dvp constitutional sx, rash, adenopathy, alopecia, hepatitis

Early-Latent: ASX infxn acq within prev 12 mths = considered infxnious

86
Q

si/sx of late syphillis

A

Untreated pts that go on to dvp complications from infxn

Late-Latent: untreated asyx after 12 mths = have DZ but not considered infective + are ASX

Tertiary: major complications = **Aortitis, Aortic Valve regurg, Gummatous DZ (granulomatous lesions everywhere)

87
Q

dx tests for syphillis

A

Non-Treponemal

Reagin antibodies – NON SPECIFIC

Initial screening in ASX: cheap, easy

Quantifiable: reported as titers (1:32) AB in serum diluted

Can be used to monitor TX; titers DECLINE after TX!

Treponemal:

SPECIFIC for Abs against SPECIFIC treponemal antigens

  • INCly used as initial screen, not just confirmatory (but can be used to confirm when nonT tests are reactive)
88
Q

tx of syphillis

early

late

neuro

A

Early SYP]

*Penicillin G benzathine

*Doxy

[Late SYP]

*Penicillin G benzathine

*Doxy

*Prednisone –w/ CV SYP

[NeuroSYP]

*Penicillin G cont.infusion

*Procaine penicillin IM + Probenecid

*Ceftriaxone D

*Doxy

89
Q

HPV Mucosal Types __, __, __, __ : assoc with genital warts, precancerous + cancerous lesions of the cervix, vag, vulva, anus, penis, + oropharynx

A

6, 11, 16, 18:

90
Q

transmission of HPV

A

•When SX are absent = ‘Subclinical Viral Shedding’

  • May occur quickly in new sex parts (3.5 mths)
  • Infreq condom use
  • 1° infxn incub after exposure: 4 D (2-12 range)
91
Q

si/sx of HPV

A

*Most are ASX

  • Abnormal PAP or (+) HPV test may be 1st indication
  • Vulvar/vag warts
  • Itchy + painful
  • Most HPV strain that cause cervical cancer do NOT cause warts !!!!
92
Q

vaccine reccommendations for HPV

A

Routine vacc is recommended for ALL adolescents + young adults:

Young M&W – 26

11-12: (2) shots given 6-12 mths apart

>14: (3) shots given over 6 mths

93
Q

vaccines available for HPV

A

Three vaccines available ->

  1. 9-valent (Gardasil-9): types 6,11,16,18,31,33,45,52,&58
  2. Quadvalent (Gardasil): 6,11,16,18
  3. Bivalent (Cervarix): 16,18
94
Q

ACOG reccommendations for screening for HPV

A

<21): no screening

(21-29): PAP q 3 yrs, no HPV tst

(30-65): PAP q 3 yrs & HPV tst q 5 yrs

(>65): no screening

(hyster removal of cervix): no screening

95
Q

tx of HPV

A

Self-admin

Podofilox gel

Aldara + Zyclara (Imiquimod) cream

Sinecatechins (Veregen) ointment

Office Based

Trichloroacetic acid (TCA): = remove vag warts

Cryoablation: liquid nitrogen

Laser ablation

96
Q

Herpes define :

1

non 1

reccurrent

A

1°: infxn in a pt w/o previous Ab’s

Non 1° 1st episode:

acq of gen HSV-1 in a pt with Ab’s to HSV-2

acq of gen HSV-2 in a pt with Ab’s to HSV-1

Recurrent: reactive of gen HSV in which HSV type recover from lesion = same type as Ab’s in serum

97
Q

Si/sx of herpes in

1

non 1

reccurrent

A

1° - *Painful gen ulcers = Systemic SX:

  • Dysuria, fever, HA
  • Tender inguinal LAD
  • Infxn can be mild to ASX
  • SX tend to be more severe in W

Non 1 *Fewer lesions, Less systemic SX

-AB’s from one HSV offer some protection against the other

Recurrent - *Less severe than either 1° or Non1°

  • Mean duration of lesions = shorter than 1°
  • Systemic SX infrequent

-Approx 25% of recurrent episodes are ASX

98
Q

dx of herpes

A

Choice of test may vary with clin presentation

  • Active lesions can be ‘unroofed’ for fluid (sent for viral cx & PCR)
  • Serologic testing
99
Q

reccommendtions for screening for herpes virus

A

Even though it is one of the MC STI’s, it is NOT recommended in ASX adolescents & adults

100
Q

tx of herpes

1

non 1

reccurrent

A

1° HSV Infxn: *b/c DZ tends to be more severe;

all pts should be _started on antivirals w/I 72 hrs of onset of clinical SX (_Usu duration = 7-10 D)

Famciclovir 250 mg TID

Acyclovir 400 mg TID, or 200 mg 5x daily

Valacyclovir 1000 mg BID

Recurrent DZ: Chronic Suppressive Therapy -

Acyclovir 400 mg BID

Famciclovir 250 mg BID

Valacyclovir 500 mg QD, or 1000 mg QD

Episodic Therapy ->

Acyclovir

Famciclovir

Valacyclovir

101
Q

Most common cause of the benign breast disorders

A

Fibrocystic Breast Changes

102
Q

compare/ contrast

Fibrocystic Breast Changes vs fibroadenoma

A

fibrocystic

Hormone induced breast changes -cyclic in nature

Painful bilateral breasts,

Freely moving in regard to adjacent structures

“Lumpiness” fluctuates with the menstrual cycle

fibroadenoma

noncyclic, Painless, Increase size with pregnancy

•Round, oval, Hard or rubbery

103
Q

imaging modalities for looking at breast cycts

A
  • Ultrasound = Distinguishes cystic from solid mass
  • Fine Needle Aspirate = US is done before a fine needle aspirate with cyst.
  • Mammogram = Further evaluation of clinically suspicious masses & Further evaluation of solid masses
  • Core Needle Biopsy (CNB) = for solid mass, definitive dx for fibroadenoma
104
Q

qhat is the BI-RADS score and how is it used in regards to fibrocystic breast changes

A

It’s a scoring system radiologists use to describe mammogram results.

Simple – reassurance

Complicated: risk of cancer directly related to findings on bx

  • BI-RADS 2 – benign
  • BI-RADS 3 – repeat imaging in 6 mo, FNE can be performed instead of 6mo imaging to Confirm lesion is benign.

Complex: BI-RADS 4/5

  • Require ultrasound guided CNB to Dx benign vs malignant.
  • FNE is NOT sufficient
105
Q

•Core Needle Biopsy (CNB) - Definitive Dx for??

A

fibroadenomas

106
Q

cause of mastitis and how we tx

A

Blockage of duct and reduced drainage

Offending organism: S. aureus, MRSA -> grows in stagnant milk

Antibiotics:

dicloxacillin or cephalexin

Get rid of milk

107
Q

how to tx Breast Abscess:

in pregnant women?

abx?

A

Breastfeeding or pumping is important for resolution of infection and relief of discomfort.
Reduces duration & Improves outcomes

I&D

Empiric therapy against S. aureus

  • Dicloxacillin
  • Cephalexin
  • trimethoprim-sulfamethoxazole
108
Q

Benign proliferation of the glandular tissue of the male breast is called??

caused by???

A

Gynecomastia

Caused by an increase in the ratio of estrogen to androgen activity

109
Q

si/sx of Gynecomastia

A

concentric, rubbery-to-firm disk of tissue

often mobile

located directly beneath the areolar area

110
Q

when assessing Gynecomastia make sure you differentiate it from what 2 conditions???

& what can you NOT miss??

A

Be careful to differentiate from:

pseudogynecomastia = (fat)

from breast carcinoma = (commonly unilateral, non-tender, fixed masses)

Don’t miss a testicular cancer! *

111
Q

age affected by & give short description of lesions:

fibroadenoma

fibrocystic changes

cancer

cancer until proven otherwise

A

fibroadeonma - 10-30

s_mooth, rubbery_, round, NONTENDER, PAINLESS

fibrocystic & cancer - 30 - 50

“lumpy” rope-like, tender, size fluctuation w/ menses / premenstraul pain is worse, cysts are round and mobile

cancer until proven otherwise - >50

firm, hard, non-tender, irregular borders, fixed to usrrounding tissue

112
Q

Breast cancer:

Most common non-invasive:

Most common invasive:

A

Most common non-invasive: Ductal carcinoma in situ

Most common invasive: infiltrating ductal

113
Q

Leading cause of cancer death in women worldwide

A

breast cancer

2nd most Dx malignancy behind lung cancer

114
Q

si/sx of breast cancer

early and late

A

Early

  • Immobile, fixed, ill-defined margins
  • Linear calcifications on mammography

•Painless mass

Late

  • Mass fixed to skin/chest wall
  • Skin/nipple retractions
  • Asymmetrical breast enlargement
  • Breast edema, erythema, and pain
  • Bloody nipple discharge
  • Jaundice

•Bone pain

•Weight loss

•Peau D’ orange - Resemblance to the skin of an orange due to lymphedema

115
Q

define inflammatory breast cancer vs lymphadenopathy

A

Inflammatory: Rapidly progressing, tender, firm, and enlarged breast with thickening of the underlying skin

  • Require full-thickness skin biopsies
  • Presence of dermal lymphatic invasion = Inflammatory Breast Cancer
  • It is important to rule out inflammatory breast cancer if a suspected breast infection does not respond to antibiotics

Lymphadenopathy:

  • Normal lymph nodes are movable, non-tender <5 mm
  • Nodes affected by malignancy, Matted, hard, firm, immovable
  • Fixed to skin or deeper tissues
  • >1cm denote metastases

•Axillary LN involvement and/or Supra/infraclavicular nodes (think metastatic disease)

•Sentinel nodes are first lymph nodes targeted by tumor invasion

•Sampled 1st in surgery to check for spread

116
Q

tx of breast cancer w:

Her 2+

ER/PR+, HER -

A

Her 2+ = herceptin

ER/PR+, HER - = tamoxifen, aromatase inhibitors

117
Q

what is tamoxifen used to tx?

side effects?

A

•ER/PR+, HER2-) = premenopausal women

side effects: DVT, uterine cancer, vasomotor sx

•Given for 5-10 yrs then switch to AI

dec reccurrence by 40-50%, dec mortality by 25%

caution w/ strong CYP2D6 inhibitors

118
Q

what is aromatase inhibitors used to tx?

side effects?

A

ER/PR+, HER2-) - CI in premenopausal women

side effects: Less DVT / uterine ca B_UT more bone loss, myalgia and arthralgia_

superior to SERM

anatrozole

exemestane

letrozole

119
Q

what is Herceptin used to tx?

side effects?

A

•HER2+ w/ chemo regimen

  • Against HER-2 oncogene (+) ‘over-expression’
  • Dramatically improved survival
120
Q

breast cancer is MOST likely to spread to:

A

Bone

  • Liver
  • Lung
  • Brain
121
Q

first LN affected by breast cancer

A

sentinel LN

122
Q

imaging modalities to screen for breast cancer and when they should be used

A

mammo - For women at average risk, screening mammograms should be performed annually beginning at age 40

US- diagnostic follow-up of an abnormal screening mammogram

  • can differentiate a solid mass from a cyst
  • to provide guidance for biopsies and other interventions

•Ultrasound is the first line of imaging in a woman who is pregnant or less than 30 years old with focal breast symptoms or findings

123
Q

US is first line imaging modality to screen for breast cancer IF ????

A

Ultrasound is the first line of imaging in:

a woman who is pregnant

_<30 years ol_d with focal breast symptoms or findings

124
Q
A
125
Q

Most common pelvic tumor in women:

define this tumor

A

Leiomyoma (Fibroids)

Benign tumor arising from smooth muscle cells of the myometrium

  • Resemble normal tissue
  • Feel firm and smooth
126
Q

locations of Leiomyoma (fibroids)

A

Locations:

•Intramural Myoma

  • Subserosal Myoma
  • Submucosal Myoma
  • Cervical Myoma
  • Pedunculated (Stemmed)
127
Q

dx of Leiomyoma (Fibroids)

A

Enlarged Uterus

Irregular Uterus

+/- Tender uterus

Transvaginal Ultrasound

Saline Infused Sonography (sonohysterography)

Hysteroscopy

MRI

Hysterosalpingography (HSG)

128
Q

tx of Leiomyoma (Fibroids)

A

Goal: Symptomatic relief

Studies have found menopause causes fibroids to shrink → relief of symptoms

Treatment options: Watchful waiting

Medical Management

  • NSAIDS – only for dysmenorrhea
  • OCPS
  • Levonorgestrel IUD (Mirena/Skyla)
  • Gonadotropin releasing hormone (GnRH)
  • Danazol

Surgery: Mainstay of treatment

•Indications for treatment: AUB, bulk related symptoms, infertility, recurrent miscarriages

129
Q

define Adenomyosis

A

Ectopic endometrial tissue within the myometrium

  • Ectopic tissue induces hypertrophy and hyperplasia in the myometrium
  • Diffusely enlarged uterus → “Boggy Uterus”

Resemble fibroids

130
Q

dx of Adenomyosis

A

Definitive diagnosis only via histology s/p hysterectomy

Transvaginal ultrasound and MRI very helpful

MRI better but more expensive –

KEY WORDS:

  • “Asymmetric thickening of the myometrium”
  • “Linear striations”
  • “Loss of clear endomyometrial border”
  • “Increased myometrial heterogeneity”
131
Q

Tx of Adenomyosis

A

Hysterectomy – only guaranteed treatment

Uterine artery embolization – some success (not well studied)

OCPs/IUD – Can attempt to help decrease bleeding and pain. –> Not FDA approved for Adenomyosis

_Gonadotropin releasing hormone analogs (Lupron) and Aromatase Inhibitors (Anastrozole, Letrozol_e

•May decrease dysmenorrhea and menorrhagia symptoms, Temporary

132
Q

contrast pathophys of

Leiomyoma (Fibroids) vs Adenomyosis

A

Leiomyoma (Fibroids) - Benign tumor arising from smooth muscle cells of the myometrium

•Resemble normal tissue, Feel firm and smooth

Adenomyosis: Ectopic endometrial tissue within the myometrium

  • Ectopic tissue induces hypertrophy and hyperplasia in the myometrium
  • Diffusely enlarged uterus → “Boggy Uterus”
133
Q

contrast si/sx of

Leiomyoma (Fibroids) vs Adenomyosis

A

Leiomyoma (Fibroids) : Most are small and asymptomatic,

Heavy or prolonged menstrual bleeding

Adenomyosis: Diffusely enlarged uterus → “Boggy Uterus

  • Heavy Menstrual Bleeding – 65%
  • Dysmenorrhea- 25%
  • Chronic pelvic pain
134
Q

define endometreosis and what causes it

A

Presence of normal endometrial mucosa abnormally implanted in locations other than the uterine cavity

Ectopic areas respond to cyclical hormonal fluctuations similar to intrauterine endometrium

Including release of prostaglandins leading to inflammatory process and scarring of ectopic areas

Estrogen dependent disease – Menopause leads to resolution of symptoms

135
Q

most common locations for endometriosis

A

•Ovaries (MOST COMMON)

  • Uterus (Perimetrium)
  • Posterior cul-de-sac
  • Broad ligament/Uterosacral ligament
  • Rectosigmoid colon
  • Bladder
136
Q

si/sx of endometriosis

A

Severity of symptoms do not always correlate to extent of disease

Asymptomatic

Dysmenorrhea

Heavy or irregular bleeding

Lateral displacement of the cervix

Localized tenderness in the posterior culde-sac (Pouch of Douglas)

Palpable tender nodule in the posterior cul-de-sac (Endometrioma)

137
Q

dx endometriosis

A

Laparoscopy with biopsy – Primary diagnostic modality

•Classic blue black or powder burned appearance

Transvaginal or Endorectal ultrasonagraphy

Pelvic Ultrasound

• first line study to help rule out other pathology and identify findings suggestive of endometriosis

MRI

138
Q

complication of endometriosis

A

Endometrioma – “Chocolate Cyst”

•Most common on ovaries

139
Q

tx endometriosis

A

95% response to medical management – 50% will have return of symptoms after 5 years of medical management

Hormonal Contraceptive:

Combined (Estrogen/Progestin)

•Progestin only

(GnRH) analogues (Lupron)

• Restricted to 6 months –> Risk osteoporosis and lots of menopause type side effects

Danazol (Androgenic Steroid)

Surgical Options:

Hysterectomy with or without bilateral oophorectomy – Hysterectomy with BSO considered definitive therapy

Laparoscopic uterine nerve ablation – Resection of nerve bundles

Drainage and laparoscopic cystectomy

L_aparoscopy and surgical endometrial implant ablation_ – Reoperation rate high 50%

140
Q

define ovarian cysts and name the types of them

A

Cyst: sac filled with liquid or semiliquid material

Occur in women of all ages including neonatal/infancy phases

• Most prevalent during infancy, adolescence, and childbearing years

Functional ovarian cysts → Most common cystic ovarian lesion – Occur most commonly in women of reproductive age

  • Follicular
  • Corpus luteal cyst
  • Theca lutein cyst
  • Endometrioma

Simple cyst: Simple fluid, thin wall. E.g: Follicular, Luteal, serous cystadenoma

Complex cyst: debris, blood, varied wall thickness, septations, hemorrhagic

141
Q

name the functional ovarian cysts

A
  • Follicular
  • Corpus luteal cyst
  • Theca lutein cyst
  • Endometrioma
142
Q

contrast follicular cyst vs corpus luetal cyst

A

Follicular Cysts

  • Balloon does not pop / NO RUPTURE – cyst is formed
  • Resolve spontaneously 2-3m -> 70-80% resolve on their own

On ultrasound, present as simple unilocular, anechoic cysts with a thin, smooth wall

Corpus Luteal Cyst

•Occurs after ovulation– it pops but corpus luteum

does not dissolve and becomes cyst

•Thicker walls

“Ring of Fire” Doppler appearance = ring of blood flow

143
Q

Theca Lutein Cysts cause?

appearance?

A

•Hormonal Overstimulation by βhCG – hyperstimulation ovaries and cysts created

bilateral

Gestational Trophoblastic Disease;

Hormonal therapy (E.g. infertility treatment); - seldom in singleton pregnancy

Septations do not show enhancement on ultrasound

144
Q

define endometrioma

si/sx?

A
  • Cyst formed with endometrial tissue → “Chocolate Cyst”
  • Most common during reproductive years

Chronic pelvic pain

Hormonally responsive

145
Q

PCOS AKA Stein-Leventhal Syndrome appearance on US?

A
  • 10 or more peripheral simple cysts
  • Characteristic “string-of-pearls” appearance
146
Q

name the 3 Benign Ovarian Tumors

A

Mature Cystic Teratoma

Cystadenoma

Cystadenofibroma

147
Q

benign ovarian tumor that appears in 70% in women of reproductive age

&

Appears cystic → calcifications, fat, sebaceous tissue, hair, and/or teeth

complications???

A

Mature Cystic Teratoma

•Do not resolve spontaneously

•Associated with ovarian torsion if >5cm

•10% of all ovarian neoplasms – can turn into cancer

148
Q

describe the 2 types of Cystadenoma

A

Serous – older women (40-50 yo)

  • Benign ovarian tumors
  • 15-25% bilateral

Mucinous - less frequent than serous, younger women (20-40 yo)

  • Can be very large
  • Filled with mucinous material
  • 5-10% bilateral
149
Q

Surface epithelial tumor of ovary that resembles malignant tumor

age group?

Tx?

A

Cystadenofibroma: Rare & Benign

•Surface epithelial tumor of ovary

Common in 15-65 yo

  • Complex cystic to solid appearing mass
  • Tx: Oophorectomy (ovary removal)
150
Q

Benign Ovarian Tumors that appear in women of:

reproductive age

40-50

20-40

15-65

A

reproductive age - Mature Cystic Teratoma

40-50 - Cystadenoma (serous)

20-40 - Cystadenoma (Mucinous)

15-65 -Cystadenofibroma

151
Q

si/sx of a ruptured cyts

A

Sudden onset sharp pain

152
Q

Ovarian Cysts & Benign Tumors imaging modalities

A

Ultrasound – First line method of choice

•Helps distinguish complex, simple or solid lesions

CT Pelvis - Only for malignancy staging

MRI - Done after u/s if needed

  • Can evaluate for complex masses
  • Use with caution as may delay care if neoplasm is of concern
153
Q

Ovarian Cysts & Benign Tumors US Management of reproductive age

simple vs hemhorragic

A

Reproductive Age

Simple:

  • <5 cm observe
  • 5-7cm f/u annually
  • >7 cm either MRI or surgery

Hemorrhagic:

• >5cm f/u ultrasound 6-12 weeks

154
Q

Ovarian Cysts & Benign Tumors US Management of post-menopausal

A

•>1cm-7cm ultrasound annually +/- CA-125

155
Q

Ovarian Cysts & Benign Tumors US Management of dermoid & endometriomas

A

Dermoid

  • U/S q6-12 months
  • Cystectomy

Endometrioma

  • Initial f/u ultrasound 6-12 weeks
  • U/S annually
  • Cystectomy
156
Q

Tx of Ovarian Cysts & Benign Tumors

A

Analgesia management

_Hormonal Contraceptio_n - Recurrent Functional Cysts

Indications for ovarian cystectomy or oophorectomy

  • Symptomatic cysts – Persistent 5-10cm cysts (esp. symptomatic)
  • Ovarian Torsion or Suspected malignancy

Surgery not indicated required for

  • Follicular or Corpus Luteal Cyst
  • unless very large or hemorrhagic with rupture
157
Q

define pelvic organ prolapse and anatomy involved

A

Herniation of pelvic organs to or beyond the vaginal walls

Anatomic support of pelvic organs via pelvic floor and connective tissues.

  • Levator ani muscle complex – primary support
  • Pubococcygeus
  • Puborectalis
  • Iliococcygeus
158
Q

define these locations of POP

Cystocele

rectocele

enterocele

A

•Anterior Compartment Prolapse (Cystocele) –Hernia of anterior vaginal wall with descent of bladder

_•Posterior Compartment Prolapse (Rectocele) -_Hernia of posterior vaginal segment with descent of the rectum.

•Enterocele –Hernia of the intestines to or through the vaginal wall.

159
Q

si/sx of POP

A

Sitting on egg or balloon

Prolapse does NOT cause pain ***

Defecatory Symptoms: Constipation – most common*

  • Fecal urgency
  • Fecal incontinence, e.g. during intercourse
  • Incomplete emptying

Urinary symptoms

  • Slow urine stream
  • Sensation of incomplete emptying
  • Overactive bladder (urgency, frequency, incontinence)
  • 2-5x increase risk

Sexual

  • Avoidance, shame
  • +/- dyspareunia
160
Q

define stages of POP and what is the staging system called

I-IV

A

Simplified Pelvic Organ Quantitation System (POP-Q)

Stage 0- No prolapse

Stage I –Prolapse 1cm above hymenal plane

Stage II – Prolapse descends to introitus

Stage III – Prolapse greater than 1cm past hymenal remnant, but does not cause complete vaginal vault eversion or complete uterine procidentia.

Stage IV – Complete vaginal vault eversion or complete uterine procidentia,

  • i.e. vagina and/or uterus are maximally prolapsed with entire extent of vaginal mucosa everted
161
Q

tx for POP

A

Indicated only for symptomatic (urinary, bowel, or sexual dysfunction)

•Do NOT have to treat if patient is asymptomatic or if they are not bothered by their symptoms

Conservative:
Pessary - Silicone devices vary size and shape

  • 50% discontinue use after 1-2 years
  • Must be removed and cleaned regular basis

P_elvic Floor Muscle Exercise (PFME)_ - Physical Therapy

Surgical:

Anterior vaginal wall prolapse repair - Anterior colporrhaphy (highly recurrent)

Posterior vaginal wall prolapse repair - Posterior colporrhaphy

Apical defect

  • Sacral colpopexy
  • Hysterectomy with Uterosacral or Sacrospinous Ligament Suspension
162
Q

complications of Ovarian Cysts & Benign Tumors

A

Ovarian torsion – 70% women 20-39yo age, Mature Cystic Teratoma

  • Adnexa and ovary typically involved
  • Most cases involve ovarian masses measuring 6-10cm

•Typical symptoms –sharp sudden, then waxing/waning pain, n/v

•Goal of emergent surgery: laparoscopic detorsion for adnexa and ovary salvage → TIME IS OVARY

Hemorrhagic cyst - Rupture and internal bleeding

• Common – Corpus luteal cyst day 20-26 of cycle

Persistent pain or pressure

163
Q

POP does NOT cause _____.

main concerns w/ POP are: ____ & _______

A

Prolapse does NOT cause pelvic pain *****

•Main concerns are:

  • inability to empty bladder (incr. risk for infections)
  • and defecatory dysfunction
164
Q

Cervical Squamous Intraepithelial Lesions -> CSIL are divided into???

A
  • Low-grade squamous intraepithelial lesion (LSIL)
  • High-grade squamous intraepithelial lesion (HSIL)
165
Q

Cervical Intraepithelial Neoplasia -> CIN are categorized by?

A

CIN 1 -> LSIL (condyloma/cervical intraepithelial lesion)

•CIN 2

  • p16-negative are referred to as LSIL
  • p16-positive are referred to as HSIL

CIN 3 -> HSIL

166
Q

Pathogenesis of Cervical Intraepithelial Neoplasia

A

Role of human papillomavirus - HPV infection is necessary for development of cervical neoplasia

  • HPV alone is not sufficient to cause these disorders

HPV types/persistence

Cervical “transformation zone” (T-zone)- of the cervix is the site of carcinogenesis by infection with oncogenic subtypes of HPV

Sexual transmission

167
Q

name low risk and high risk HPV subtypes ?

Squamous cell carcinoma & Adenocarcinoma are HPV types ???

A

•Low-risk types (HPV 6 and 11)

• High-risk types (HPV 16 and 18)

  • Squamous cell carcinoma – HPV 16 (59%), 18 (13%)
  • Adenocarcinoma – HPV 16 (36%), 18 (37%)
168
Q

HPV persistence is caused by

A

The reason HPV infection persists in some women and not in others is unknown

•Older age - 50% high-risk HPV infections persist in women older than 55 years of age

20% rate of persistence in women under age 25

•Duration of infection - The longer an HPV infection has been recognized, the longer it will take to clear

•High-risk HPV subtype - More likely to persist than low oncogenic types

169
Q

define the transformation zone and its clinical significance

A

•The area when glandular epithelium replaces squamous epithelium is called transformation zone (T-zone)

Cervical neoplasia originates within the T-zone

170
Q

primary vs secondary Prevention of Cervical Lesions

A

Primary prevention - vaccination

•condoms are only partially protective

Secondary prevention - aimed at cervical cancer rather than CIN itself

•CIN -> appropriate monitoring and treatment

171
Q

types of HPV vaccines

A

•Quadrivalent vaccine (Gardasil) targets HPV types 6, 11, 16, and 18. - targets all 4 subtypes

•9-valent vaccine (Gardasil 9) targets HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58. - Targets high risk HPV

Bivalent vaccine (Cervarix) targets HPV types 16 and 18.

172
Q

19 Advisory Committee on Immunization Practices (ACIP) Recommendation for Vaccination (HPV)

Children and adults aged 9‐26 yo

Adults aged >26 yo

Special populations

A

Children and adults aged 9‐26 yo

  • routinely recommended at age 11 or 12 y;
  • vaccination can be given starting at age 9 yo.

Adults aged >26 yo

  • Catch‐up HPV vaccination is not recommended for all adults

Special populations

pregnant - delayed until after pregnancy.

breastfeeding or lactating - can receive HPV vaccine.

173
Q

HPV testing after atypical squamous cells: (2)

A

Cervical cancer screening co-testing

Testing with both cervical cytology (Pap test) and high-risk HPV infection

Reflex HPV testing aka HPV triage

The collection of a specimen for HPV testing when the cytology sample is collected, but performing the HPV test only if the cytology results are ASC-US

174
Q

define ASC-US vs ASC-H

A

ASC-US - Atypical squamous cells of undetermined significance

More marked than simple reactive changes but do not show LSIL abnormalities

Reflex HPV testing aka HPV triage

ASC-H - Atypical squamous cells: cannot exclude high-grade squamous intraepithelial lesion

Cells that likely consist of a mixture of true high-grade SIL and other findings that mimic such lesions

require further HPV testing - Cervical cancer screening co-testing

175
Q

Tx of Cervical cancer

A
  • The mainstays of treatment of HSIL are excision and ablation of the transformation zone of the cervix
  • Hysterectomy is an option for women who are
  • incompletely treated with excision or ablation
  • who have recurrent CIN
176
Q

define excisional vs ablative tx for cervical cancer

A

Excisional treatments are referred to as cone biopsies or cervical conization

•LEEP, Loop electrosurgical excision procedure, also called large loop excision of the transformation zone (LLETZ)

•Laser conization is another technique

Ablative treatments use an energy source (eg, cryotherapy, laser) to destroy the transformation zone

177
Q

According to US Professional Organizations Pap Test Starts at Age ____

A

21

178
Q

define expeditied tx of cervical cancer.

when is Expedited treatment neccessary for tx cervical cancer

A

Expedited treatment - treatment with excision (usually in the form of loop electrosurgical excisional procedure [LEEP]) without having first doing a colposcopy

•SKIP CULPOSCOPY!!!*** if immediate CIN3+ risk _>_4%

179
Q

•Clinical Manifestations of cervical cancer

A
  • Irregular or heavy vaginal bleeding
  • Post-coital bleeding - most specific presentation of cervical cancer, may also result from cervicitis
180
Q

progression of cervical cancer

A
  1. Oncogenic HPV infection at the cervical transformation zone
  2. Persistence of the HPV infection
  3. Progression from persistent viral infection to pre-cancer
  4. Development of carcinoma and invasion
181
Q

tx of cervical cancer

microinvasive disease (stage IA1) with no evidence of intermediate- or high-risk features

stage IA2 and IB1 cervical cancer

IB2 stage

early-stage cervical cancer with intermediate-risk features

early-stage cervical cancer with high-risk features

A

microinvasive disease (stage IA1) with no evidence of intermediate- or high-risk features - conization or extrafascial hysterectomy – preferred

stage IA2 and IB1 - modified radical hysterectomy

IB2 stage - radical hysterectomy

early-stage cervical cancer with intermediate-risk features - adjuvant chemoradiation rather than RT alone

early-stage cervical cancer with high-risk features - adjuvant chemoradiation rather than RT alone

182
Q

Origins of Ovarian Cancer: The majority of ovarian malignancies (95%) are derived from ______ cells

A

epithelial

•Ovarian cancer is the second most common gynecologic malignancy and the most common cause of gynecologic cancer death

183
Q

risk factors for ovarian cancer

A

Genetic predisposition

  • The Lynch syndrome
  • BRCA gene mutations

Age - The incidence of ovarian cancer increases with age

184
Q

The risk of ovarian cancer appears to be decreased in women with a history of

A

Previous pregnancy

Use of OCPs

Breastfeeding

ALL result in less ovulation = less chance to damage ovary

185
Q

e risk of ovarian cancer may be increased in patients with a history of

A

Infertility

Endometriosis

PCOS

Cigarette smoking

ALL result in INCREASED ovulation = more likely to damage ovaries

186
Q

acute vs subacute presentations of ovarian cancer

A

Acute presentations

Pleural effusion

Bowl obstruction

Subacute presentations

Adnexal mass – palpate mass in abdominal region

Pelvic or abdominal pain

Bloating

GI symptoms

187
Q

early symptoms of ovarian cancer

& the Role of early detection

A

Presence of early symptoms

Advanced epithelial ovarian cancer typically presents with

abdominal distention

Nausea

Anorexia

or early satiety due to the presence of ascites and bowel metastases

Most women with epithelial ovarian cancer have pelvic or abdominal symptoms prior to their diagnosis

Role of early detection: The goal of early detection is to reduce epithelial ovarian cancer mortality

188
Q

evaluation for ovarian cancer consists of:

decribe the 2 phase process

A

Tumor markers - CA 125 ( most common biomarker used to detect ovarian cancer)

Pelvic ultrasonography

Pelvic exam

1. initial evaluation

  • If there is no indication for diagnostic surgery -> an evaluation for other etiologies
  • If an adnexal mass is found and based upon the initial evaluation, there is a suspicion of EOC -> surgical evaluation

2. Surgical evaluation

189
Q

dx of ovarian cancer

A

•Histopathologic examination of excised tissue – GOLD STANDARD

•Evaluate pelvic mass

•Serum CA 125 is for the evaluation of adnexal masses

  • OVA1 and Overa (aka OVA2) are serum biomarkers for evaluation of malignancy
  • includes CA 125, HE4, and three additional markers
190
Q

when to refer pelvic masses to gyn oncologist

premonopausal

postmenopausal

A

Refer if ANY are present:

premonopausal

elevated CA 125 level

ascites

evidence of abdominal or distant metastases

postmenopausal

all above +

nodular or fixed pelvic mass

191
Q

tx for ovarian camcer

A

The novel immunotherapeutic vaccine DSP-7888 (ombipepimut-S or adegramotide/nelatimotide), in combination with pembrolizumab (Keytruda)

  • The anti-cancer vaccine t_argets the Wilms Tumor 1 (WT1) protein_
  • DSP-7888 induces WT1-specific cytotoxic T lymphocytes and helper T cells to attack WT1-expressive cancer cells
192
Q

reccomendations on screening for ovarian cancer

A

No North-American expert groups recommend routine screening for ovarian cancer.

The US Preventive Services Task Force (USPSTF) recommends against screening for ovarian cancer, except for the known carriers of genetic mutations that increase ovarian cancer risk.

Clin med I- Womens Health (2 decks)

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