MT2 Flashcards
1
Q
Infertility in >35 years
A
No conception after 12 months of intercourse without contraception
2
Q
Infertility in >35 years
A
No contraception after 6 months of intercourse without contraception
3
Q
Two types of infertility
A
1’ and 2’
4
Q
Primary infertility
A
With nulligravida
5
Q
Define nulligravida
A
No pregnancy
6
Q
Secondary infertility
A
History of prior pregnancy
7
Q
Pregnancy rates after infertility diagnosis
A
2%
8
Q
Female causes of infertility = prevalence of pelvic factors (%)
A
35%
9
Q
Pelvic factors of infertility (4)
A
Infection
Surgical history
Contraception and pregnancy history
Menstrual cycle abnormalities
10
Q
Pelvic factors of infertility: infection (5)
A
PID STI Septic abortion EndoMETRITIS Pelvic TB
11
Q
Ovulatory factor of infertility prevalence (%)
A
15
12
Q
ovulation factors of infertility (8)
A
2' amenorrhea Abnormal uterine bleeding Lateral phase defect (short cycle) Premature ovarian failure (early menopause) PCOS (high androgen) Elevated prolactin Hypothyroidism Prior use of anti-estrogens
13
Q
List some anti-estrogens (3)
A
Lupron
Depo-provera
Dana zoo
14
Q
Pelvic factors of infertility: surgical history (5)
A
D/c Ruptured appendicitis EndoMETRIOSIS Adenexal surgery Fibroids
15
Q
Pelvic factors of infertility: contraception and pregnancy history (4)
A
Prior IUD use
DES exposure in-utero
Ectopic pregnancy
Habitual abortion
16
Q
Pelvic factors of infertility: menstrual cycle abnormalities (3)
A
2’ amenorrhea
EndoMETRIOSIS
Cyclic abdominal or pelvic pain
17
Q
Other causes of infertility (not ovulatory or pelvic factors) (7)
A
Delayed childbearing Overweight (bmi>25) or underweight (<18) Insulin resistence Depression Substance abuse (alcohol, MJ, caffeine, tobacco) Malabsorption (celiac) Unexplained (15%)
18
Q
Male factors of infertility (35%) (4)
A
Varicocele (42%)
Unexplained (22%)
Obstructive azoospermia (14%)
Undescended testis (3%)
19
Q
Normal FSH levels
A
<10-15 mIU/mL
20
Q
Normal E2 level
A
<80pg/mL
21
Q
Mid cycle US to assess what? (2)
A
Follicle growth
Endometrial lining
22
Q
HSG to assess what? (1)
A
Latency of fallopian tubes
23
Q
How can you document ovulation? (3)
A
- Midluteal phase progresterone level
- Basal body temperature
- Urinary LH kits
24
Q
At what level of the midluteal phase progesterone would one need supplementation?
A
<25 = need progesterone (crinone)
D14 untilmenses or week 10-12 of pregnancy
25
Evaluation of male partner begins with what analysis?
Semen
26
When should semen analysis be performed?
After 2-5 days of abstinence
27
According to WHO criteria, what are the 4 normal factors of semen analysis?
1. Volume 2-5 mL
2. >20 million/mL sperm number
3. Motility >50% or >25% rapid, forward motility
4. 35% normal morphology
28
After diagnosis with infertility, to whom do you refer? (6)
```
Reproductive endocrinologist
Gynecologist
Urologist
Naturopathic physician
Acupuncturist
Psychologist
```
29
First step of complementary therapies to aid in infertility
Address basic issues of diet and lifestyle
30
Study of >2000 couples with successful pregnancy factors:
Longer time to pregnancy (TTP) if
- smoking, alcohol, fat, caffeine.
Those with >4 negative lifestyle variables = 7x longer TTP, conception probabilities decreased significantly, and if they did get pregnant, had more fertility issues
31
PCOS and BMI >25 notes
Lose weight = become more fertile!
| >5% restored menstrual regularity in 89%
32
High protein vs. high carb diet x 1 month in PCOS patients achieved what effect?
Significant BMI improvements, metabolic markers and ovulation/menstrual cycle.
33
Excess abdominal fat = strongly related to what
Reproductive disorders!!!'
| - related to insulin resistance, particularly in infertile women with PCOS
34
Daily exercise and whole foods diet low in processed foods, alcohol and caffeine had what effect?
Normalize weight and blood sugar!
35
CONSUMPTION OF FISH AND INFERTILITY!?!?!? (3 points)
Unexplained infertility in females = higher blood mercury
Males with abnormal sperm = higher blood mercury concentrations
Blood mercury concentrations = positively correlated with quantity of seafood consumption
36
Celiac disease causes what? Adherence to what may improve fertility?
Deficiency in number of nutrients.
| Adherence to gluten free diet may improve fertility
37
News on caffeine and fertility?
Pretty much, just don't.
38
Each hour of vigorous activity associated with what
7% lower risk of ovulation infertility
39
Regular exercise before IVF may do waht
may negatively affect outcomes
40
Women who exercise >4h / week x 1-9 years (3 factors)
40% less likely to have live birth
3x more likely to cancel cycle
2x's as likely to have implantation failure or SAB
41
Women who participated in aerobic exercise =
30% less likely to have live brith vs. nonexercisers
42
Past or current stress, especially depression may be the cause of what?
Many cases of unexplained infertility
43
Stress hormones have what effect on the reproductive system
Inhibitory effects, thus stress needs to be addressed in anyone receiving fertility svcs.
44
Techniques for stress reduction (8)
```
Biofeedback
Individual.couple therapy
Progressive muscle relaxation
Acupuncture
Yoga
Tai chi
Qi gong
Meditation
```
45
Improvement 2 fold vs. no accupuncture is seen where?
IMPROVEMENT OF PREGNANCY RATES!
46
Pelvic US confirms that what modality can improve pelvic flow and thus improve fertility rates?
Acupuncture!!!!
47
Acupuncture may also be helpful with what 6 other conditions?
1. Improving sperm
2. Menstrual cycle regulation
3. Ovulation
4. Stress
5. Anxiety
6. Depression
48
Effects of acupuncture may be mediated through where?
Endogenous opioid peptides in CNS, particularly through beta-endorphin
49
Prenatal vitamins should include
Folic acid and iron
50
B12 deficiency may be associated with ? Thus causing what (2)
Menstrual cycle dysfunction; recurrent miscarriages and infertility
51
What has been shown to improve uterine blood flow and fertilization rates with prior failed IVF?
ARGININE!
52
ROS = increases risk for what and how? (4)
Infertility; negative effect on OOCYTE maturation, fertilization, embryo development and pregnancy
53
What deadly habit can increase ROS?
SMOKING!
54
Smokers had significantly lower levels of what compared to non=smokers
Follicular fluid beta-carotene
55
Smokers showed a significantly lower __ rate in comparison to non smokers
Fertilization
56
Follicular depletion of AO betacarotene occurs in response to oxidative stress imposed by ??
Cigarette smoke!
57
Overall, low AO has been found in?
WOMEN WITH INFERTILITY
58
Low magnesium/selenium = associated with
Infertility
59
What botanical may help lengthen lateral phase, decrease prolactin and restore ovulation?
Vitex = chaste tree
60
Green tea = related to reduced (3)
Food intake
Body weight
Blood levels of testosterone, estradiol, lepton, insulin, insulin-like growth factor I, LH, glucose, cholesterol and TG
61
Lower levels of testosterone, estradiol, lepton, insulin, insulin-like growth factor I, LH, glucose, cholesterol and TG were seen with consumption of what yummy stuff?
Green tea
62
These two botanicals help to stimulate ovulation and improve ovarian function
Tribulus and rhodiola
63
Combination of tribulations and rhodiola =
Pregnancy prep by vitanica
64
Phytoestrogen supplementation for ? = ? (3)
luteal phase support resulted in higher values for implantation rate, clinical pregnancy and ongoing pregnancy/delivered rate
65
Phytoestrogens supplementation increased __, __ and ___ plasma concentrations but were also found to reverse the deleterious effects of clomid on ___ ____ leading authors to conclude that the combo may increase pregnancy rates
FSH, LH and 17 beta-estradiol;
| Endometrial thickness
66
Topical, oral or vaginal natural progesterone was found to (4)
1. Normalize menstrual cycle
2. Improve implantation rates
3. Maintain pregnancy in women with history of repeated miscarriages
4. D21 <25 may benefit from PT progesterone after ovulation until menses starts or week 10-12 of pregnancy
67
What - IF DEFICIENT - may improve ovarian function?
DHEA
68
Treatments for sperm (5)
Vit C, E, glutathione, lycopene and coQ10
69
AO's improve what
Sperm quality and quantity
70
How do AO's improve sperm quality and quantity?
Decreasing ROS
71
In suboptimal sperm, what AO's are have beneficial effects?
```
Vit C
Vit E
Glutathione
Lycopene
CoQ10
```
72
What can decrease sperm DNA damage and improve motility
AO's
73
200mg ____ improved fertilization rate of fertile Norma's per ic males with low fertilization rates after 1 month treatment by reducing lipid peroxidation potential
Vitamin E
74
DNA fragmented sperm treated with (2)
VIt C and Vit E
75
Sperm motility problems treated with
L-acetyl carnitine alone or in combo with L-carnitine
76
Carnations may be of benefit post abx in __ or __
Bacterial prostatitis or post NSAID in abacterial prostatitis
77
Sperm count treatment (2)
Folic acid and zinc sulfate
78
Men with severe oligospermia
Phytoestrogens
79
In males, caffeine, nicotine, marijuana and alcohol have been correlated with
Poor sperm quality and quantity
80
Oligospermia correlated with low intake of
Fruit.vegetables
81
Neoplasm definition
Atypical cell growth
82
What classifications of neoplasms can you have (3)
Benign
Low malignant potential
Malignant
83
Complications of ovarian mass (5)
```
Torsion
Rupture
Infection
Hemorrhage
Malignant potential (- functional cysts)
```
84
Functional cysts (3)
Follicular cyst
Corpus luteum cyst
Theca leutein cyst
85
Neoplasms (1)
Desmond
86
Other ovarian masses (3)
Endometrioma
PCOS
Turbo-ovarian abscess
87
MC functional cyst
Follicular
88
Least common functional cyst
Corpus luteum
89
Rare functional cyst
Theca lutein
90
MC ovarian mass (also benign)
Functional cyst
91
This results from dominant follicle's failing to rupture (1 of two causes)
Follicular cyst
92
This results from immature follicle's failing to undergo normal process of atresia (1 of two causes)
Follicular cyst
93
How long do follicular cysts last
1-3 months
94
What are hemorrhagic/chocolate cysts?
Blood filling cavity of follicular cyst
95
What cysts are less common but more clinically important?
Corpus luteum cysts
96
Which cyst may be associated with normal endocrine function or prolonged progesterone secretion?
Corpus luteum cyst
97
This results if the sac doesn't dissolve, but seals off after egg is released, thus fluid builds up inside
Corpus luteum cysts
98
When do corpus luteum cysts occur?
2-4 days post ovulation
99
How long do corpus luteum cysts last?
Resolve within a few weeks but can grow to 4 inches and may bleed or cause torsion
100
What is the chance of recurrence with corpus luteum cysts?
31%
101
These are almost always bilateral and asymptomatic
Theca lutein cysts
102
What is the cause of the ca lutein cysts?
Prolonged or excessive stim of ovaries by endogenous or exogenous gonadotropins
103
What are some examples of prolonged or excessive stimulation of ovaries by endogenous or exogenous gonadotropins? (5)
```
Multiple pregnancies (twins)
Fertility drugs
Molar pregnancies
Choriocarcinoma
Diabetics!!
```
104
Do theca lutein cysts resolve spontaneously?
Yes
105
How do you Discover functional ovarian cysts?
These are asymptomatic so they're discovered during routine pelvic exam
106
What would you feel when doing a routine pelvic exam and discover a functional ovarian cyst?
Unilateral pressure, fullness or pain in lower abd.
107
What would the patient report with a functional ovarian cyst? (2)
Dull ache in lower back and thighs
| Pain during sex
108
If producing excess hormones in a functional ovarian cyst, what are 3 symptoms?
Painful menstrual periods and abnormal bleeding
N/V
Boob tenderness
109
What are some immediate referral symptoms of functional cyst? (5)
```
P w/ fever/vomiting
Sudden,severe abd. Pain
Fainting, dizzy, weak
Rapid breathing or herat rate (tachypnea, tachycardia)
SHOCK
```
110
Desmond tumor/cyst AKA
Teratoma
111
Characteristics of teratoma? (4)
Monstrous growth
Has all 3 germ layers
Has skin, hair, glands, muscle, bone, teeth, eww, cartilage, respiratory/GI epithelium,, thyroid tissue
Benign OR MALIGNANT
112
Would we remove a teratoma?
Yes! Potentially also the ovary or both ovaries. This means they'll go into menopause. She would also need estrogen and progesterone HRT.
113
Teratomas are rare?
VERY rare, but still a possibility
114
Teratoma epidemiology (5)
MC ovarian neoplasm in prepubescent girls and teens
50% 25-50 years old
Postmenopausal women 20% of all benign ovarian tumors
Incidentally discovered on pelvic exam or imagining (50% have calcification)
Removed due to malignant potential, although very low.
115
Endometrioma diagnostic tool
ULTRASOUND
116
Are endometriomas painful?
Can be painless to severely painful
117
If not resected, endometriomas frequently recur?
Yes
118
"Pelvic pain that is getting worse and worse"
Turbo-ovarian abscess
119
Endometrioma
Tissue that normally lines the uterus grows inside the uterus. OMG!!
120
What is a tubo-ovarian abscess?
Infection of tubo/ovarian junction
121
What is the common cause of turbo-ovarian abscess?
Gonorrhea/chlamydia
122
What are some symptoms of tubo-ovarian abscess? (4)
Tubal/ovarian swelling/enlargement
Pelvic pain
Fever
Vaginal discharge
123
What are two long term sequence of turbo-ovarian abscess?
Infertility (scarred uterine tubes)
| Chronic pelvic pain (adhesions)
124
Ovarian mass malignancy risk PREMENOPAUSAL
13%
125
Ovarian mass malignancy risk POSTMENOPAUSAL
45%
126
Ovarian mass malignancy risk in women over the age of 40
90%
127
What is the 5th leading cause of cancer deaths?
Ovarian cancer (because by the time there are symptoms, it is usually quite advanced. It's a silent killer!)
128
This accounts for 50% of all GYN cancer deaths
Ovarian cancer
129
Peak age of ovarian cancer?
60-65
130
Ovarian cancer risk factors (10)
```
Family history
Nullparity
Early menarche
Late menopause
Fertility promoting drugs
Geography
Ethnicity
Sedentary lifestyle
High fat diet
Endometriosis
```
131
Ovarian cancer risk factors: family history of what 5 cancers? And what two genes?
Boob, ovarian, colon, prostate, pancreatic;
| BRCA1/2
132
Nullparity = increased risk of ovarian cancer d/t
Uninterrupted ovulation
133
Early menarche as an ovarian cancer risk would mean before _ years of age, late menopause > _ years of age, with a total overal period cycle of over _ years
14
55
10
134
Ovarian cancer risk increases in what two areas, and is lowest where?
Northern america and europe;
| Japan
135
This ethnicity has increased risk of ovarian cancer (higher incidence vs. mortality rate)
Ashkenazi jewish
136
Clinical symptom presentation (7)
Often asymptomatic until late stage
Pressure - associated with large mass size (may be LBP)
Pain - associated w/ rupture, torsion/hemorrhage, cancer, functional cyst (May be LBP)
GI sx's: nausea, epigastric upset, gas/bloating
Menstrual abnormalities - oligomenorrhea or amenorrhea, DUB
Hormonal changes: feminization/masculinization
Cancer sx's: mass, weight loss, night sweats, anemia, ascites
137
What two clinical symptom presentations may present as low back pain in ovarian cancer
Pressure and pain
138
What labs are you going to utilize to diagnose ovarian cancer? (5)
HCG, CBC, renal/LFT, tumor markers -Ca125, CEA
139
What radiographic evaluation are you going to use when diagnosing ovarian cancer?
Pelvic US - complex mass in postmenopausal women is highly suspicious
140
Pelvic exam with rectovaginal will aid in diagnosis of waht cancer
Ovarian
141
What x-rays would you consider in combination of labs, pelvic US and pelvic exam with recto vagina lol for ovarian cancer?
CXR, CT scan (consider d/t hx and evaluation and labs)
142
Does elevated CA-125 mean cancer?
No false positives.
143
elevated CA-125 can also indicate these 5 false positives:
```
Fibroids
Benign ovarian tumors
Adenomyosis
Endometriosis
PID
```
144
USPSTF recommends against routine screening for what cancer
Ovarian
145
Why would USPSTF recommend against routine screening for ovarian cancer?
D/t highly invasive diagnostic testing folllowing a positive. There are a lot of false positives. And there is small effect on overall mortality from early detecting.
Thus potential harms outweigh benefits of screening.
146
Stage 1 ovarian cancer % and 5 year survival
25%, 75-100%
| Limited to ovaries
147
Stage 2 ovarian cancer % and 5 year survival
10%, 45-60%
| Pelvic extension
148
Stage 3 ovarian cancer % and 5 year survival
42%, 15-50%
| ABDOMINAL LYMPH SPREAD
149
Stage 4 ovarian cancer % and 5 year survival
23%, 5%
| MALignant pleural effusion, METS to liver. :(
150
DDX for ovarian cancer (7)
```
Ectopic pregnancy (B-HCG)
Infectious (hydrosalpinx, turbo-ovarian abscess)
Functional cyst
Endometriosis
Neoplasms (benign and malignant)
METS disease
Masses in adjacent tissues or organs
```
151
What is the gold standard for diagnosing ovarian mets?
ULTRASOUND
152
Physical exam of patient with ovarian mass (5)
```
Lymph node survey
Breast exam (ovary = common site for mets)
Abdominal exam
Bimanual exam
Rectovaginal exam
```
153
What are you looking for in a Bimanual exam of a patient with ovarian mass? (4)
Estimate size
Location
Consistency and
Mobility
154
What are you looking to assess in a rectovaginal exam in an individual with ovarian mass?(5)
Posterior uterine surface, uterosacral ligaments, parametric (Ct around uterus), posterior cul de sac and rectum
155
What are some characteristics of most likely benign ovarian masses on an ultrasound? (5)
```
Cystic
Smooth
Unilocular
Unilateral
Small (<5cm)
```
156
Consider laparoscopy when ovarian mass is ... (4)
>7-10cm
Continues to grow
Looks suspicious on ultrasound
With suspicious history, presentation and PE
157
How would one prevent ovarian cancer?
```
Nutrition and lifestyle
Exercise, weight loss
Breast feeding
Hormonal contraception
BI tubal ligation
Prophylactic BI oophorectomy
```
158
nutrition and lifestyle: what are some points of interest to reduce ovarian cancer risk? (5)
```
Eliminate animal fats, saturated fats
Eliminate alcohol (Esp. Wine)
Quit smoking
High fruits.vegetables especially when young
Decrease cholesterol
```
159
What are some essential nutrients to consume to decrease risk of ovarian cancer? (5)
```
Beta carotene
Vitamin C/E
Isoflavones
Folic acid
Selenium
```
160
Common ovarian masses in newborn
Small functional cysts 1-2cm that regress in months
161
Common ovarian masses in premenarchal girls
Teratomas/Desmond's
162
Common ovarian masses in reproductive age (6)
Functional cysts, endometriomas, tubo-ovarian abscesses, PCOS, ectopic pg, teratoma
163
Common ovarian masses in postmenopausal
MUST R/O cancer!
| Increased risk of malignancy (1' ovarian carcinoma and METS from uterus, breast or GI)
164
MAJORITIY OF CERVICAL CANCERS IN THE US OCCUR IN WOMEN WHO: (3)
Have never been screened
Have not been screened within past 5 years
Have not received appropriate follow up after abnormal pap smear
165
Squamous cells cover outside of? (2)
Cervix and vagina
166
Columnar cells cover what structure"?
Canal of cervix
167
Junction between two cell types is the
Transitional zone (SCJ)
168
What occurs in the SCJ?
Abnormal grow/dysplasia develops = 95% of all CIN.
169
Outside of cervix and vagina are covered in what type of cells
Squamous
170
Canal of cervix is lined by what kind of cells
Columnar
171
What is cerivcal dysplasia?
Disordered growth
| - atypical or dysplastic growth
172
Amount of disorganization in cervical dysplasia is graded into mild moderate or severe. Number them.
Mild : CIN I (cervical intraepithelia neoplasia)
Moderate: CIN II
Severe: CIN III or carcinoma in situ
173
Dysplasia and carcinoma-in-situ =
All of the abnormalities are confined to the surface of the cervix
174
Invasive cancer
Cells are disordered throughout entire thickness of the lining and they invade the tissue underlying the surface
175
USPSTF found this about annual pap screens
Every 2-3 years after 3 consecutive normal annual paps = same outcome
This is old screening
176
2 types of pap tests
```
Conventional
Liquid based (thinprep, sure path)
```
177
Conventional pap test sensitivity and specificity
Sensitivity: 50-90%
| Specificity >90%
178
Liquid based pap test sensitivity and specificity and what can it detect
Sensitivity 70-90%
Specificity >90%
Used to detect HPV, GC, CT
179
2500-3000 cervical cancer cases in US/year are in women with what
Normal pap tests
180
Bethesda classification of paps
```
Normal
Atypia
ASCUS
CIN I
CIN II
CIN III
CIS
Cervical cancer
```
181
Atypia bethesda classification of paps
(NAtAsCIN3CisCc)
| Variation of normal, such as irritation or inflammation
182
Ascus bethesda classification of paps
(NAtAsCIN3CisCc)
ASCUS: abnormal squamous cells of undetermined significance
Benign changes that should be monitored
183
CIN I bethesda classification of paps
(NAtAsCIN3CisCc)
MILD dysplasia
AKA LGSIL: low grade squamous intraepithelial lesion
184
What grade of cervical intraepithelial neoplasia is LGSIL?
CIN II
185
What two grades of cervical intraepithelial neoplasia are high grade? HGSIL
CIN II, CIN III
186
What does CIN stand for?
Cervical intraepithelial neoplasia
187
CIN II bethesda classification of paps
(NAtAsCIN3CisCc)
MODERATE dysplasia
Aka HGSIL
188
CIN III Bethesda classification of paps
(NAtAsCIN3CisCc)
SEVERE DYSPLASIA
Aka HGSIL
189
CIS bethesda classification of paps
(NAtAsCIN3CisCc)
Carcinoma in situ
PRECANCER
(Remember carcinoma in situ = localized one area/layer of dysplasia. Not whole area of dysfunction like cancer)
190
HOW is cervical dysplasia and HPV detected?
Normal pap results and negative HR-HPV => high negative predictive value
191
Risk factors for cervical dysplasia and cancer (10)
```
Lack of screening
Early sexual activity
High lifetime number of sexual partners (>3)
Smokers (2x!!)
HPV (10x!!)
OC use >5 years
Multiparity
History of STI's
DES exposure in uterine
Steroid use
```
192
Decreased risk of cervical dysplasia and cancer
Barrier contraception use = decreased HPV transition and speeds regression of both penile and cervical lesions
Quit smoking
STOP OCP
193
T/f: cervical cancer in women under 19 years of age is rare
True. Because it takes ~3 years for a persistent HR-HPV to cause mutations
194
T/F HPV is not contagious during intercourse
FALSE
195
T/F condom use is completely protective against HPV
FALSE. The virus can spread through skin to skin contact
196
HPV is found in
>70% of sexually active adults
197
Only 1% of HPV carriers develop what
Venereal warts
198
In teens and early 20's, 70%. Of HR-HPV and 90% LR HPV types regress after 3 years?
Yes
199
HR-HPV = ? And more likely to result in HSIL that lead to what
high risk HPV strains are more likely to result in high grade lesions (HSIL) that lead to cervical cancer
200
LR-HPV strains
Cervical changes less likely to be precancerous
201
LR-HPV may cause
Venereal warts
202
Bad news... rates of progression of carcinoma in situ to invasive cancer range from...
22-60% when followed more than 10 years
203
Are there early signs or symptoms for HPV? Maybe (2)
No!
Cervical discharge
Abnormal uterine bleeding
204
Good news: (5)
HPV Vaccine
Usually slow growing
Paps for early detection
70-90% infections are transient and resolve without intervention
If detected early = treatment is minimally invasive
205
If partner presents with abnormal pap, what then? What diagnostic test?
COLPOSCOPY!
206
What the flip is colposcopy??
Direct magnification and viewing of cervix, vulva, vagina or perinatal tissue plus biopsy of tissue
207
Colposcopy is direct magnification and viewing and biopsy of what 4 tissues
Cervix
Vulva
Vagina
Perinatal tissue
208
What indicators would make one order a colposcopy? (7)
Persistent ASCUS, LGSIL, 2 consecutive abnormal paps
ASCUS/LGSIL in patient unlikely to f/u
Persistent cervical inflammation on pap smear
ASCUS atypical glandular cells on pap
Persistent cervical bleeding
Hx DES exposure (DES daughter)
HIV + PATIENT
209
What does it mean when i have been diagnosed with ASCUS, ATYPIA OR CIN 1? (3)
Goes awa without treatment.
F/u with pap tests every 4 months in 1st year, 6 months in 2nd year
CIN II treatments for persistent lesions
210
What does it mean when i have been diagnosed with CIN II? (3)
Most don't go away, treatment is recommended.
Cryotherapy
Loop excision (LEEP)
Pap tests every 4 months in 1st year, every 6 months in 2nd
211
What does it mean when i have been diagnosed with CIN III, CIS or cancer? (6)
Treatment or follow up provided by GYN oncologist
Surgical treatment recommended
LEEP
Confiscation or laser beam treatment
Hysterectomy (advanced stages)
Paps every 4 months in 1st year, 6 months in 2nd
212
What is cryotherapy?
Probe is placed against cervix, damages cells by freezing them. They then shed over next month in heavy watery discharge
213
Is depth hard to control in cryotherapy?
Yes
214
Cryotherapy has high failure rate for what?
Treating large areas of dysplasia and areas that extend into the cervical canal a
215
How does a LEEP work? (4)
Fine wire loop with electrical energy flowing through it.
Tissue removed => sent to lab.
Under local anesthesia
Causes little discomfort
216
LEEP is good for both treatment and diagnosis?
Yes
217
What is conization?
Removes con-shaped piece of cervix.
218
Confiscation is good for both treatment and diagnosis?
Mainly diagnosis, but might have removed all of undamaged tissue as well
219
Conization has high success rate but may interfere with what
Future child bearing.
| Decreases integrity of the cervix.
220
Alternative/supportive treatments to cervical dysplasia (4)
Lifestyle
Nutrition
Vaginall suppositories
Supplements
221
What are some lifestyle changes for cervical dysplasia? (3)
Quit smoking, diet, exercise
222
What is a good diet to aid in cervical dysplasia (2)
Diet rich in fruits, vegetables, whole grains and legumes.
| One that is high in vitamin C, beta carotene and folic acid
223
Low amounts of vitamin C, beta carotene and folic acid have been associated with higher incidence of what?
CIN and HPV
224
What vaginal suppositories have been beneficial for cervical dysplasia treatment? (3)
Green tea
Vitamin A and herbal compound
Riboflavin (B2) may cause regression of CIN
225
What supplements for cervical dysplasia? (5)
```
AO reduce risk of CIN and cancer
Folic acid and beta carotenes
Pyridoxine (b6)
Selenium
zinc
```
226
What is DES?
Diesthylstilbestrol
| Synthetic non-steroidal estrogen
227
What was the use of DES in 1938-1971
Prevent miscarriage and other pregnancy complications
228
What does DES cause?
Early onset cancers in daughters!
229
Daughters exposed to DES in uterine have higher rates of (5)
```
Structural/reproductive tract anomalies
Vaginal/cervical dysplasia and adenocarcinoma
Infertility
Poor pregnancy outcomes
Autoimmune disorders
```
230
Males exposed to DES in uterine have higher rates of (2)
Structural reproductive tract anomalies
| Infertility
231
Suggested screening intervals for DES daughters (4)
First pap of onset of menses or intercourse
Baseline colposcopy after onset of intercourse
Vaginal and cervical paps every 6-12 months until 30 years old
After that, yearly cervical and vaginal paps
232
Lymph flow
Breast -> Axilla -> supraclavicular
233
Ancillary regions of lymph flow (4)
Pectoral
Central
Lateral
Subscapular
234
Lymph flow from breast (4 regions)
Supraclavicular nodes
Cervical nodes
Opposite boob
Abdominal lymphatic
235
What else are you looking for when palpating supraclavicular nodes?
Virchows' to ddx pancoast tumor
236
Where is most common site for fibrous cystic changes (benign) and/or malignant disease?
UOQ (upper outer quadrant)
| Note underwire compression thus may have some texture here
237
What is the infframammary line?
Lower arc of the breast
| Also a common fibrous area (Bras can add to thickening)
238
Areas of fibrous tissue are less worrisome if (3)
Symmetrical, painful, freely mobile
239
Clinical breast exam (CBE) is optimal when?
5 days post menses d/t decreased hormonal influence
240
In CBE waht are you inspecting? (8)
```
Size
Symmetry
Contour
Skin color
Thickening
Prominent poor
Nipple size/shape (flat, fixed, retracted, thickened)
Rashes/ulceration
```
241
In CBE, palpation is systematic and thorough. Between what ribs do the breast lie?
Ribs 2-6, between eternal edge and midaxillary line
242
What must you include in your palpation in CBE?
Tail *UOQ->axilla
| This includes ancillary, supra/infraclavicular and cervical nodes
243
What should you document in CBE of a breast mass? (8)
```
Location
Size
Consistency
Mobility
Tenderness
Nipple d/c
Skin changes
Lymphadenopathy
```
244
Can CBE be used in lieu of mammography?
Heck no!
245
What are some breast disease/conditions? (7)
```
Mastalgia
Fibroadenomas
Cysts
Fibrocystic breast changes
Mastitis
Introduction papilloma
Nipple discharge
```
246
MC breast symptoms for which a woman consults her doc: (3)
Breast pain
Nipple d/c
Palpable mass
247
Extent of the evaluation for boob stuff depends on (3)
Nature of clinical problem
Age
Risk status
248
Mastalgia defintion
Breast pain/tenderness
249
Mastalgia is MC in
Premenopausal women
250
Is mastalgia a symptom of canceR?
No
| Cancer presents with discomfort 5% of the time
251
Causes of mastalgia (6)
```
Hormonal
PMS
Trauma
Acute infection
M/S
Cancer
```
252
PE>35 with mastalgia, consider?
Mammogram
253
Mastalgia: <35 with normal exam, consider mammogram?
No!
254
60-80% spontaneous remission with what boob condition?
Mastalgia
255
Symptoms may be improved or exacerbated with hormonal treatment for which condition of da boob?
Mastalgia
256
Fibroadenoma affects how many women
10% of women
257
Fibroadenoma = benign or malignant?
Benign!
258
What is fibroadenoma composed of?
Fibrous stroma
259
Fibroadenomas respond to what
Estrogen/progesterone.
| Size may fluctuate with cycle
260
What are the characteristics of a fibroadenoma? (6)
Rubbery, firm, smooth, round, mobile, painless.
261
What would a mammography show of a fibroadenoma?
Solid, well-circumscribed, may be multilobulated/calcified (popcorn appearance!)
262
Up to 20% of women will have multiple lesions in hat boob condition?
Fibroadenoma
263
Age range of fibroadenoma
15-50, not common in menopause
264
Management of fibroadenoma?(5)
```
CBE
Mammogram
US
Needle Bx
Self limiting
```
265
Treatment for fibroadenemoa? (2)
Surgical excision
| Watch And wait
266
Characteristics of simple cyst (3)
Fluid filled lesion
Soft, firm, mobile, well circumscribed, unilateral or bilateral, tender
Cyclical fluctuations
267
Age for simple cysts
15-50 like fibroadenoma ya?
| Not common in menopause
268
In PE, how differentiate simple cyst from solid mass?
Can't. Sucker
269
How do you diagnosis simple cyst? (4)
Mammogram, US, fine needle aspiration, maybe surgical biopsy
270
When would you consider surgical biopsy with simple cyst? (4)
If blood aspirate,
palpable mass doesn't resolve with aspiration,
multiple recurrence in short period,
no fluid aspirated
271
What two diagnostic procedures would you utilize after treatment of a simple cyst?
CBE, mammogram
272
RECURRENT Large cysts shown to slightly increase waht
Cancer risk in some studies but not in others
273
Definition of fibrocystic breast changes (5)
Common, non-cancerous changes in boob tissue
Normal variant in 60% of women
Accompanied by swelling, pain, tenderness
Increased E, decreased P
Often resolves with menopause
274
Symptoms of fibrocystic breast changes (10)
```
Cyclical pain or constant
Variable size
High mobility
Multiple nodules
Premenstrual aggravation
Diffuse swelling
Tenderness
Heaviness
Itchy nips
Usually UOQ
```
275
Methylxanthines found in
Coffee, tea, cola, chocolate and caffeinated meds
276
Prevention of fibrocystic breast changes (5)
```
Avoid caffeine and other methylxanthines
Avoid exogenous estrogens
Low animal fat diet
Increased dietary fiber
Symptoms may be improved or exacerbated with hormonal treatment (OCP, HRT)
```
277
How does low animal fat diet affect FBC?
Reduces severity of PMS breast tenderness and swelling
278
What are two foods to consume to rid of exogenous estrogens?
Legumes and flax seeds
279
Vitamin E's affect on FBC
Relieves pMS symptoms including FBCs, normalize circulating hormones in PMS and FBD
280
Evening primrose oil (EPO) increases what
PGE 1&3
281
What are PG1&3?
Anti-spasmodic and anti-inflammatory
282
Mastitis definition
Infection seen during lactation or when skin disruption
UNILATERAL
Associated with lactating mother, improper latching. May allow staph aureus. REFER FOR ANTIBIOTICS
283
Mastitis presentation (8)
```
Fever
Localized erythema
Pain
Induration
N/V
Malaise
Fever
Chills
```
284
Etiology of mastitis (3)
Staph aureus
S. Epidermis
Strep
285
Risk factors for mastitis (3)
Breast feeding
Trauma
Breast augmentation
286
Mastitis is MC when
First 2-4 weeks postpartum
287
Nipple retraction?
Chronic mastitis!
288
Gala to celebrate (blocked duct) is what
Obstruction of breast doc usually after lactation
289
Symptoms of galactocele
Tender and enlarged
290
Treatment of galactocele
Excise and drain, yo
291
Nipple discharge
Can be d/t benign causes but needs to be further assessed
292
What is the work up for nipple discharge(9)
```
Nature of d/c (serous, bloody, other)
With mass?
Uni/BI?
Single or multiple duct
Spontaneous or must be expressed
Relation to menses
Pre/postmenopausal
Patient using OCPs/HRT
Prolactinoma
```
293
How would you rule out a prolactinoma with nipple discharge?
Prolactin level and if elevated refer for brain imaging (this is like that grey's episode!)
294
What symptoms of nipple discharge work up are concerning for boob canceR? (7)
```
Bloody discharge
Mass
Unilateral
Single duct
Spontaneous
Postmenopausal
Patient using HRT
```
295
Physiologic/benign discharge characteristics (4)
BI
Nonsponteanous (needs stimulation like contact or pressure)
Multiple ducts
Serous d/c can be caused by hormones. Eww
296
Pathological discharge MC cause=
INTRADUCTAL PAPILLOMA!!!!
297
Pathological discharge characteristics (4)
UNI
Spontaneous (intermittent, localized to one duct)
D/c = bloody, serous, serosanginuous or greenish grey)
D/c secondary to breast carcinoma mAY BE ANY COLOR
298
Discharge 2' to boob carcinoma may be what color?
ANY COLOR, IT DON'T DISCRIMINATE!
299
Etiliogies of pathological d/c? (2)
```
INTRADUCTAL PAPILLOMA (BENIGN)
Breast cancer
```
300
Galactorrhea
Inappropriate location in nonpuerperal woman
301
Nonpeurperal ?
During or after pregnancy
302
Galactorrhea characteristics
UNI/BI milky d/c
| Check for high prolactin levels (order CT to r/o pituitary tumor)
303
What is introduction papilloma?
Papillary growth inside lactiferous duct
304
Introduction papilloma is bloody?
Or serous! Both!
305
How would you treat introduction papilloma?
Surgical excision b/c they tend to grow
306
Cause of subareolar abscess
Staph aureus or anaerobic organisms
307
Who gets subareolar abscess?
Women with inverted nipples
308
Increased risk of subareolar abscess after what
Nipple piercing haha
309
Treatment for subareolar abscess?
Antibiotics, drainage, duct excision
310
Subareolar abscess vs introduction papilloma... location. Inside/outside duct?
Subareolar abscess = outside duct
| Introduction papilloma = inside duct
311
MC cancer in women
Breast cancer
312
Second leading cause of cancer deaths in women
Breast cancer.
| 1/3 of women diagnosed with breast cancer will die from it
313
Leading cause of death in women aged 40-55 years old
Breast cancer
314
Screening for breast cancer
Every 1-2 years with or without clinical breast exam starting at age 40
