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Benign General Gyne > Miscellaneous > Flashcards

Miscellaneous Flashcards

1
Q

What proportion of women presenting with menorrhagia will ultimately prove to have an inherited bleeding disorder?

A

10-20%

70% will have VWD

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2
Q

In what group of patients with menorrhagia is it appropriate to test for bleeding disorders prior to assessing for intrauterine pathology (eg. polyps, fibroids)?

A

Adolescents - typically all gyne pathology should be ruled out first, but intrauterine pathology is so rare in adolescents that it’s not worth delaying the workup for bleeding d/o

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3
Q

What blood tests should be ordered as part of the initial assessment for an inherited bleeding disorder?

A 
CBC (platelet count)
INR, PTT
Thyroid function tests
Liver enzymes
PRL
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4
Q

What contraceptive may be contraindicated in women with severe von Willebrand disease?

A

DMPA - with very severe disease, it may be necessary to avoid the trauma of IM injection

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5
Q

How does tranexamic acid work to decrease menstrual blood loss?

A

Binds plasmin & plasminogen

Plasminogen is the precursor to plasmin, which breaks down fibrin - therefore TXA inhibits fibrin breakdown

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6
Q

How does desmopressin/DDAVP work to decrease menstrual blood loss?

A

Vasopressin analog which releases vWF from storage in endothelial cells, resulting in increased FVIII

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7
Q

Under what circumstances will desmopressin be ineffective for treatment of hemophilia-associated blood loss?

A

Hemophilia B - FIX deficiency (desmopressin has no effect on FIX concentrations)
Repeated use - tachyphylaxis

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8
Q

How would you counsel a woman who is a carrier of hemophilia A who becomes pregnant and wants to know about the risks of bleeding in pregnancy?

A

Spontaneous bleeding is exceedingly rare
FVIII levels should be measured (and treatment offered as necessary) prior to any invasive procedure, as well as in the third trimester in preparation for delivery

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9
Q

What is the minimum vWF level required to safely perform amniocentesis for a woman with type 1 vWD?

A

0.5 U/mL (actually the minimum safe level for any invasive procedure, for vaginal delivery, and for cesarean section)

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10
Q

How would you counsel a woman with moderate vWD about mode of delivery?

A

Cesarean for obstetric indications only
Minimize perineal trauma
Avoid: operative vaginal delivery, fetal scalp sampling, fetal scalp electrode

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11
Q

What are the typical symptoms of neuraxial hematoma?

A

Flaccid paralysis
Back pain
New onset numbness or weakness
Bowel or bladder dysfunction

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12
Q

If a health care provider deems a situation too sensitive to perform an intimate exam without a third party present (eg. clinic nurse), but the patient refuses to have the exam with a third party present, how should the health care provider proceed?

A

Decline to perform the examination

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13
Q

What are the clinical features of Mayer-Rokitansky-Kuster-Hauser syndrome?

A

Agenesis of vagina & uterus
Normal ovarian function
Normal secondary sex characteristics

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14
Q

What are the common renal abnormalities in women with MRKH?

A 
Unilateral renal agenesis (18%)
Pelvic kidney (11%)
Horseshoe kidney (2%)
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15
Q

You are seeing a woman with Lynch syndrome in follow-up after risk-reducing TH BSO. She is 35 years old and experiencing debilitating vasomotor symptoms. How would you counsel her regarding risks of HRT?

A

No increased risk of breast cancer with Lynch syndrome therefore this is not a contraindication to HRT
No uterus therefore can use estrogen only

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16
Q

How would you recommend a low-risk woman be surveilled for the following cancers?

Colorectal cancer
Breast cancer
Ovarian cancer
Endometrial cancer
Cervical cancer
A

Colorectal - FOBT q2 years starting at age 50 (may consider colonoscopy instead)
Breast - Breast exam q2 years starting at age 40, mammogram q2 years starting at age 50
Ovarian - no effective screening
Endometrial - no effective screening
Cervical - Pap smear q3 years starting at age 21 or coitarche (whichever comes later)

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17
Q

Sexual response is present from birth (penile erection has even been observed in utero), and parents may notice their infants touching their genitals. Around what age do children tend to begin purposeful genetic touching?

A

2-3 years

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18
Q

List two common organic causes of postpartum dyspareunia and their treatment.

A

Dyspareunia due to perineal trauma - allow time to heal (focus on non-penetrative sex), relaxation, use of lubrication

Dyspareunia due to vaginal dryness while breastfeeding (hypoestrogenic state) - use of lubrication, use of vaginal estrogen

19
Q

What is the most common reason for discontinuation of intercourse in post-menopausal women?

A

Lack of partner - divorce, partner death, etc. (not lack of interest!)

20
Q

You are planning to do a hysterectomy for menorrhagia. Your patient wants to know whether her sex life will be more satisfying if she retains her cervix. What will you counsel her?

A

Cochrane review showed no difference in sexual satisfaction between women who had total versus supracervical hysterectomies

21
Q

List one mechanism by which alcohol worsens sexual function.

A

Alcohol inhibits the HPO axis leading to lower estrogen and less vaginal lubrication

22
Q

What are the two sub-types of vulvar pain?

A

Vulvodynia - pain with no visible abnormalities

Vulvar pain - pain secondary to an underlying condition

23
Q

List two treatment options for vaginismus.

A 
CBT
Pelvic floor physiotherapy (systematic desensitization to penetration, reverse Kegels)
Benzodiazepines
Amitriptyline
Vaginal Botox
Hypnotherapy
Acupunture
24
Q

In what population is the use of testosterone for hypoactive sexual desire disorder evidence-based?

A

Postmenopausal women on HRT

In all other populations, testosterone is being used off-label and without great evidence of efficacy or safety

25
Q

True or false: TSH should be part of the routine work-up for heavy menstrual bleeding.

A

False

TSH should only be ordered if the patient has other signs or symptoms suggestive of thyroid disease

26
Q

What are the four structural causes of AUB?

A

Polyps
Adenomyosis
Leiomyomas
Malignancy or hyperplasia

27
Q

List three reasons to perform an endometrial biopsy in a woman with AUB.

A

> 40 years old
Risk factors for endometrial cancer present
Failure of medical management
Significant intermenstrual bleeding

28
Q

What is the appropriate next step for the following patient: a 45-year-old woman who is obese and complaining of irregular heavy bleeding suspicious for anovulation. Endometrial biopsy was negative, but ultrasound shows a focal area of cystic changes with associated increased vascularity at the uterine fundus.

A

Hysteroscopic biopsy of the abnormal area
(Focal abnormalities in women with risk factors for endometrial cancer warrant further investigation, even if the office biopsy is normal)

29
Q

Which NSAID is the most effective at decreasing menstrual blood loss?

A

They are all similarly effective

30
Q

What changes in coagulation studies would you expect to see in a woman using tranexamic acid for heavy menstrual bleeding?

A

None

31
Q

What population of women with AUB would benefit from luteal phase progesterone?

A

Women with anovulatory bleeding - MPA or norethindrone for 12-14 days/month will establish regular cycles in 50%, and protects the uterus against the effects of unopposed estrogen

Luteal phase progesterone is not an effective treatment for heavy menstrual bleeding

32
Q

What are the typical side effects of oral progestins?

A 
Breast tenderness
Water retention/bloating
Weight gain
Headaches
Acne
33
Q

What is the minimum size of endometrial cavity necessary to insert an IUD?

A

6 cm

34
Q

List four advantages and two disadvantages to non-hysteroscopic endometrial ablation (eg. NovaSure) compared with hysteroscopic endometrial ablation (eg. rollerball).

A

Advantages:

  • Lower risk of fluid overload/complications from glycine absorption
  • Lower risk of uterine perforation
  • Lower risk of cervical laceration
  • Lower risk of post-op hematometra
  • Less surgical time

Disadvantages:

  • May be unfeasible with particularly small or large cavities
  • Higher equipment cost
  • Cannot simultaneously treat uterine pathology (eg. fibroids, polyps)
35
Q

What is the pathophysiology of abnormal uterine bleeding secondary to submucosal fibroids?

A

Increased endometrial surface area
Unstable vasculature
Inability of fibroid to contract to close off bleeding vessels

36
Q

List four medications that can be used to manage acute, heavy AUB.

A

CEE 25 mg IV q6h x4 doses
OCP - 100 mcg EE po daily x5 days
TXA 1 g po/IV q6h
MPA 10-20 mg po bid or megestrol acetate 20-60 mg po bid

37
Q

True or false: the Non-Insured Health Benefits program is available to status First Nations, Metis, and Inuit women.

A

False - Metis women do not have access to the NIHB program

38
Q

What is Jordan’s Principle?

A

Child-first principle - calls on the government agency of first contact to pay for necessary services for FNIM children and seek reimbursement later, if appropriate

(Relevant because there may be disagreement between provincial and federal government agencies about which is responsible for paying for health services - in case of Jordan, led to a young child living and ultimately dying in the hospital because nobody could agree on who should pay for home care)

39
Q

A young woman comes to your office requesting “vaginal rejuvenation.” Beyond a typical medical history, what important information should you elicit? How will you counsel this woman with regards to safety and perceived benefits of surgery?

A

Important to rule out major sexual or psychiatric dysfunction, assess for coercion or exploitation, explore the role of the partner or parent in this decision (if applicable)

Counselling: “vaginal rejuvenation” is not a medical term, no evidence that surgery is beneficial for sexual satisfaction or self image, no long-term data on safety or efficacy (particularly after pregnancy or menopause), risks include dissatisfaction, infection, scarring, bleeding, dyspareunia, altered sensation, pain, wound dehiscence

40
Q

List three conservative treatments for hemorrhage following uterine perforation at endometrial ablation.

A

Intrauterine Foley tamponade
Intracervical administration of vasopressors
Rectal misoprostol

41
Q

List four absolute contraindications to endometrial ablation.

A 
Pregnancy
Desire for future fertility
Known/suspected endometrial hyperplasia or cancer
Cervical cancer
Acute pelvic infection

For non-resectoscopic ablation:
Prior classical cesarean or transmural myomectomy
Prior endometrial ablation

42
Q

List three options for endometrial preparation that will improve outcomes with subsequent resectoscopic endometrial ablation.

A

Schedule ablation for immediately after menses
Curettage prior to ablation
Pre-operative hormonal therapy: GnRH agonist or danazol

43
Q

List three signs of local anesthetic toxicity.

A

Tinnitus
Blurry vision
Perioral/facial numbness

44
Q

As a surgeon performing hysteroscopy, what is your response to being told the patient has absorbed the following volumes of fluid:

  • 500 mL glycine
  • 1 L glycine
  • 1.5 L glycine
  • 2 L NS
  • 2.5 L NS
A

500 mL glycine: notify anesthetist
1 L glycine: finish procedure as efficiently as possible, monitor u/o, consider fluid restriction or diuresis
1.5 L glycine: stop procedure regardless of whether completed, admit for monitoring (u/o, lytes, s&s of hyponatremia/fluid overload)

2 L saline: same as 1 L glycine
2.5 L saline: same as 1.5 L glycine

Benign General Gyne (4 decks)

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