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MT2 Flashcards

1
Q

Infertility in >35 years

A

No conception after 12 months of intercourse without contraception

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2
Q

Infertility in >35 years

A

No contraception after 6 months of intercourse without contraception

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3
Q

Two types of infertility

A

1’ and 2’

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4
Q

Primary infertility

A

With nulligravida

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5
Q

Define nulligravida

A

No pregnancy

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6
Q

Secondary infertility

A

History of prior pregnancy

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7
Q

Pregnancy rates after infertility diagnosis

A

2%

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8
Q

Female causes of infertility = prevalence of pelvic factors (%)

A

35%

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9
Q

Pelvic factors of infertility (4)

A

Infection
Surgical history
Contraception and pregnancy history
Menstrual cycle abnormalities

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10
Q

Pelvic factors of infertility: infection (5)

A 
PID
STI
Septic abortion
EndoMETRITIS
Pelvic TB
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11
Q

Ovulatory factor of infertility prevalence (%)

A

15

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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
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13
Q

List some anti-estrogens (3)

A

Lupron
Depo-provera
Dana zoo

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14
Q

Pelvic factors of infertility: surgical history (5)

A 
D/c
Ruptured appendicitis
EndoMETRIOSIS
Adenexal surgery
Fibroids
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15
Q

Pelvic factors of infertility: contraception and pregnancy history (4)

A

Prior IUD use
DES exposure in-utero
Ectopic pregnancy
Habitual abortion

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16
Q

Pelvic factors of infertility: menstrual cycle abnormalities (3)

A

2’ amenorrhea
EndoMETRIOSIS
Cyclic abdominal or pelvic pain

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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%)
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18
Q

Male factors of infertility (35%) (4)

A

Varicocele (42%)
Unexplained (22%)
Obstructive azoospermia (14%)
Undescended testis (3%)

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19
Q

Normal FSH levels

A

<10-15 mIU/mL

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20
Q

Normal E2 level

A

<80pg/mL

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21
Q

Mid cycle US to assess what? (2)

A

Follicle growth

Endometrial lining

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22
Q

HSG to assess what? (1)

A

Latency of fallopian tubes

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23
Q

How can you document ovulation? (3)

A
  1. Midluteal phase progresterone level
  2. Basal body temperature
  3. Urinary LH kits
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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

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25
Q

Evaluation of male partner begins with what analysis?

A

Semen

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26
Q

When should semen analysis be performed?

A

After 2-5 days of abstinence

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27
Q

According to WHO criteria, what are the 4 normal factors of semen analysis?

A
  1. Volume 2-5 mL
  2. > 20 million/mL sperm number
  3. Motility >50% or >25% rapid, forward motility
  4. 35% normal morphology
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28
Q

After diagnosis with infertility, to whom do you refer? (6)

A 
Reproductive endocrinologist
Gynecologist
Urologist
Naturopathic physician
Acupuncturist
Psychologist
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29
Q

First step of complementary therapies to aid in infertility

A

Address basic issues of diet and lifestyle

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30
Q

Study of >2000 couples with successful pregnancy factors:

A

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

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31
Q

PCOS and BMI >25 notes

A

Lose weight = become more fertile!

>5% restored menstrual regularity in 89%

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32
Q

High protein vs. high carb diet x 1 month in PCOS patients achieved what effect?

A

Significant BMI improvements, metabolic markers and ovulation/menstrual cycle.

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33
Q

Excess abdominal fat = strongly related to what

A

Reproductive disorders!!!’

- related to insulin resistance, particularly in infertile women with PCOS

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34
Q

Daily exercise and whole foods diet low in processed foods, alcohol and caffeine had what effect?

A

Normalize weight and blood sugar!

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35
Q

CONSUMPTION OF FISH AND INFERTILITY!?!?!? (3 points)

A

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

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36
Q

Celiac disease causes what? Adherence to what may improve fertility?

A

Deficiency in number of nutrients.

Adherence to gluten free diet may improve fertility

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37
Q

News on caffeine and fertility?

A

Pretty much, just don’t.

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38
Q

Each hour of vigorous activity associated with what

A

7% lower risk of ovulation infertility

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39
Q

Regular exercise before IVF may do waht

A

may negatively affect outcomes

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40
Q

Women who exercise >4h / week x 1-9 years (3 factors)

A

40% less likely to have live birth
3x more likely to cancel cycle
2x’s as likely to have implantation failure or SAB

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41
Q

Women who participated in aerobic exercise =

A

30% less likely to have live brith vs. nonexercisers

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42
Q

Past or current stress, especially depression may be the cause of what?

A

Many cases of unexplained infertility

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43
Q

Stress hormones have what effect on the reproductive system

A

Inhibitory effects, thus stress needs to be addressed in anyone receiving fertility svcs.

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44
Q

Techniques for stress reduction (8)

A 
Biofeedback
Individual.couple therapy
Progressive muscle relaxation
Acupuncture
Yoga
Tai chi
Qi gong
Meditation
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45
Q

Improvement 2 fold vs. no accupuncture is seen where?

A

IMPROVEMENT OF PREGNANCY RATES!

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46
Q

Pelvic US confirms that what modality can improve pelvic flow and thus improve fertility rates?

A

Acupuncture!!!!

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47
Q

Acupuncture may also be helpful with what 6 other conditions?

A
  1. Improving sperm
  2. Menstrual cycle regulation
  3. Ovulation
  4. Stress
  5. Anxiety
  6. Depression
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48
Q

Effects of acupuncture may be mediated through where?

A

Endogenous opioid peptides in CNS, particularly through beta-endorphin

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49
Q

Prenatal vitamins should include

A

Folic acid and iron

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50
Q

B12 deficiency may be associated with ? Thus causing what (2)

A

Menstrual cycle dysfunction; recurrent miscarriages and infertility

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51
Q

What has been shown to improve uterine blood flow and fertilization rates with prior failed IVF?

A

ARGININE!

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52
Q

ROS = increases risk for what and how? (4)

A

Infertility; negative effect on OOCYTE maturation, fertilization, embryo development and pregnancy

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53
Q

What deadly habit can increase ROS?

A

SMOKING!

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54
Q

Smokers had significantly lower levels of what compared to non=smokers

A

Follicular fluid beta-carotene

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55
Q

Smokers showed a significantly lower __ rate in comparison to non smokers

A

Fertilization

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56
Q

Follicular depletion of AO betacarotene occurs in response to oxidative stress imposed by ??

A

Cigarette smoke!

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57
Q

Overall, low AO has been found in?

A

WOMEN WITH INFERTILITY

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58
Q

Low magnesium/selenium = associated with

A

Infertility

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59
Q

What botanical may help lengthen lateral phase, decrease prolactin and restore ovulation?

A

Vitex = chaste tree

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60
Q

Green tea = related to reduced (3)

A

Food intake
Body weight
Blood levels of testosterone, estradiol, lepton, insulin, insulin-like growth factor I, LH, glucose, cholesterol and TG

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61
Q

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?

A

Green tea

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62
Q

These two botanicals help to stimulate ovulation and improve ovarian function

A

Tribulus and rhodiola

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63
Q

Combination of tribulations and rhodiola =

A

Pregnancy prep by vitanica

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64
Q

Phytoestrogen supplementation for ? = ? (3)

A

luteal phase support resulted in higher values for implantation rate, clinical pregnancy and ongoing pregnancy/delivered rate

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65
Q

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

A

FSH, LH and 17 beta-estradiol;

Endometrial thickness

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66
Q

Topical, oral or vaginal natural progesterone was found to (4)

A
  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
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67
Q

What - IF DEFICIENT - may improve ovarian function?

A

DHEA

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68
Q

Treatments for sperm (5)

A

Vit C, E, glutathione, lycopene and coQ10

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69
Q

AO’s improve what

A

Sperm quality and quantity

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70
Q

How do AO’s improve sperm quality and quantity?

A

Decreasing ROS

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71
Q

In suboptimal sperm, what AO’s are have beneficial effects?

A 
Vit C
Vit E
Glutathione
Lycopene
CoQ10
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72
Q

What can decrease sperm DNA damage and improve motility

A

AO’s

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73
Q

200mg ____ improved fertilization rate of fertile Norma’s per ic males with low fertilization rates after 1 month treatment by reducing lipid peroxidation potential

A

Vitamin E

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74
Q

DNA fragmented sperm treated with (2)

A

VIt C and Vit E

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75
Q

Sperm motility problems treated with

A

L-acetyl carnitine alone or in combo with L-carnitine

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76
Q

Carnations may be of benefit post abx in __ or __

A

Bacterial prostatitis or post NSAID in abacterial prostatitis

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77
Q

Sperm count treatment (2)

A

Folic acid and zinc sulfate

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78
Q

Men with severe oligospermia

A

Phytoestrogens

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79
Q

In males, caffeine, nicotine, marijuana and alcohol have been correlated with

A

Poor sperm quality and quantity

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80
Q

Oligospermia correlated with low intake of

A

Fruit.vegetables

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81
Q

Neoplasm definition

A

Atypical cell growth

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82
Q

What classifications of neoplasms can you have (3)

A

Benign
Low malignant potential
Malignant

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83
Q

Complications of ovarian mass (5)

A 
Torsion
Rupture
Infection
Hemorrhage
Malignant potential (- functional cysts)
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84
Q

Functional cysts (3)

A

Follicular cyst
Corpus luteum cyst
Theca leutein cyst

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85
Q

Neoplasms (1)

A

Desmond

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86
Q

Other ovarian masses (3)

A

Endometrioma
PCOS
Turbo-ovarian abscess

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87
Q

MC functional cyst

A

Follicular

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88
Q

Least common functional cyst

A

Corpus luteum

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89
Q

Rare functional cyst

A

Theca lutein

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90
Q

MC ovarian mass (also benign)

A

Functional cyst

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91
Q

This results from dominant follicle’s failing to rupture (1 of two causes)

A

Follicular cyst

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92
Q

This results from immature follicle’s failing to undergo normal process of atresia (1 of two causes)

A

Follicular cyst

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93
Q

How long do follicular cysts last

A

1-3 months

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94
Q

What are hemorrhagic/chocolate cysts?

A

Blood filling cavity of follicular cyst

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95
Q

What cysts are less common but more clinically important?

A

Corpus luteum cysts

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96
Q

Which cyst may be associated with normal endocrine function or prolonged progesterone secretion?

A

Corpus luteum cyst

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97
Q

This results if the sac doesn’t dissolve, but seals off after egg is released, thus fluid builds up inside

A

Corpus luteum cysts

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98
Q

When do corpus luteum cysts occur?

A

2-4 days post ovulation

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99
Q

How long do corpus luteum cysts last?

A

Resolve within a few weeks but can grow to 4 inches and may bleed or cause torsion

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100
Q

What is the chance of recurrence with corpus luteum cysts?

A

31%

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101
Q

These are almost always bilateral and asymptomatic

A

Theca lutein cysts

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102
Q

What is the cause of the ca lutein cysts?

A

Prolonged or excessive stim of ovaries by endogenous or exogenous gonadotropins

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103
Q

What are some examples of prolonged or excessive stimulation of ovaries by endogenous or exogenous gonadotropins? (5)

A 
Multiple pregnancies (twins)
Fertility drugs
Molar pregnancies
Choriocarcinoma
Diabetics!!
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104
Q

Do theca lutein cysts resolve spontaneously?

A

Yes

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105
Q

How do you Discover functional ovarian cysts?

A

These are asymptomatic so they’re discovered during routine pelvic exam

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106
Q

What would you feel when doing a routine pelvic exam and discover a functional ovarian cyst?

A

Unilateral pressure, fullness or pain in lower abd.

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107
Q

What would the patient report with a functional ovarian cyst? (2)

A

Dull ache in lower back and thighs

Pain during sex

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108
Q

If producing excess hormones in a functional ovarian cyst, what are 3 symptoms?

A

Painful menstrual periods and abnormal bleeding
N/V
Boob tenderness

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109
Q

What are some immediate referral symptoms of functional cyst? (5)

A 
P w/ fever/vomiting
Sudden,severe abd. Pain
Fainting, dizzy, weak
Rapid breathing or herat rate (tachypnea, tachycardia)
SHOCK
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110
Q

Desmond tumor/cyst AKA

A

Teratoma

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111
Q

Characteristics of teratoma? (4)

A

Monstrous growth
Has all 3 germ layers
Has skin, hair, glands, muscle, bone, teeth, eww, cartilage, respiratory/GI epithelium,, thyroid tissue
Benign OR MALIGNANT

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112
Q

Would we remove a teratoma?

A

Yes! Potentially also the ovary or both ovaries. This means they’ll go into menopause. She would also need estrogen and progesterone HRT.

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113
Q

Teratomas are rare?

A

VERY rare, but still a possibility

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114
Q

Teratoma epidemiology (5)

A

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.

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115
Q

Endometrioma diagnostic tool

A

ULTRASOUND

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116
Q

Are endometriomas painful?

A

Can be painless to severely painful

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117
Q

If not resected, endometriomas frequently recur?

A

Yes

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118
Q

“Pelvic pain that is getting worse and worse”

A

Turbo-ovarian abscess

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119
Q

Endometrioma

A

Tissue that normally lines the uterus grows inside the uterus. OMG!!

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120
Q

What is a tubo-ovarian abscess?

A

Infection of tubo/ovarian junction

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121
Q

What is the common cause of turbo-ovarian abscess?

A

Gonorrhea/chlamydia

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122
Q

What are some symptoms of tubo-ovarian abscess? (4)

A

Tubal/ovarian swelling/enlargement
Pelvic pain
Fever
Vaginal discharge

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123
Q

What are two long term sequence of turbo-ovarian abscess?

A

Infertility (scarred uterine tubes)

Chronic pelvic pain (adhesions)

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124
Q

Ovarian mass malignancy risk PREMENOPAUSAL

A

13%

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125
Q

Ovarian mass malignancy risk POSTMENOPAUSAL

A

45%

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126
Q

Ovarian mass malignancy risk in women over the age of 40

127
Q

What is the 5th leading cause of cancer deaths?

A

Ovarian cancer (because by the time there are symptoms, it is usually quite advanced. It’s a silent killer!)

128
Q

This accounts for 50% of all GYN cancer deaths

A

Ovarian cancer

129
Q

Peak age of ovarian cancer?

130
Q

Ovarian cancer risk factors (10)

A 
Family history
Nullparity
Early menarche
Late menopause
Fertility promoting drugs
Geography
Ethnicity
Sedentary lifestyle
High fat diet
Endometriosis
131
Q

Ovarian cancer risk factors: family history of what 5 cancers? And what two genes?

A

Boob, ovarian, colon, prostate, pancreatic;

BRCA1/2

132
Q

Nullparity = increased risk of ovarian cancer d/t

A

Uninterrupted ovulation

133
Q

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

134
Q

Ovarian cancer risk increases in what two areas, and is lowest where?

A

Northern america and europe;

Japan

135
Q

This ethnicity has increased risk of ovarian cancer (higher incidence vs. mortality rate)

A

Ashkenazi jewish

136
Q

Clinical symptom presentation (7)

A

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
Q

What two clinical symptom presentations may present as low back pain in ovarian cancer

A

Pressure and pain

138
Q

What labs are you going to utilize to diagnose ovarian cancer? (5)

A

HCG, CBC, renal/LFT, tumor markers -Ca125, CEA

139
Q

What radiographic evaluation are you going to use when diagnosing ovarian cancer?

A

Pelvic US - complex mass in postmenopausal women is highly suspicious

140
Q

Pelvic exam with rectovaginal will aid in diagnosis of waht cancer

141
Q

What x-rays would you consider in combination of labs, pelvic US and pelvic exam with recto vagina lol for ovarian cancer?

A

CXR, CT scan (consider d/t hx and evaluation and labs)

142
Q

Does elevated CA-125 mean cancer?

A

No false positives.

143
Q

elevated CA-125 can also indicate these 5 false positives:

A 
Fibroids
Benign ovarian tumors
Adenomyosis
Endometriosis
PID
144
Q

USPSTF recommends against routine screening for what cancer

145
Q

Why would USPSTF recommend against routine screening for ovarian cancer?

A

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
Q

Stage 1 ovarian cancer % and 5 year survival

A

25%, 75-100%

Limited to ovaries

147
Q

Stage 2 ovarian cancer % and 5 year survival

A

10%, 45-60%

Pelvic extension

148
Q

Stage 3 ovarian cancer % and 5 year survival

A

42%, 15-50%

ABDOMINAL LYMPH SPREAD

149
Q

Stage 4 ovarian cancer % and 5 year survival

A

23%, 5%

MALignant pleural effusion, METS to liver. :(

150
Q

DDX for ovarian cancer (7)

A 
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
Q

What is the gold standard for diagnosing ovarian mets?

A

ULTRASOUND

152
Q

Physical exam of patient with ovarian mass (5)

A 
Lymph node survey
Breast exam (ovary = common site for mets)
Abdominal exam
Bimanual exam 
Rectovaginal exam
153
Q

What are you looking for in a Bimanual exam of a patient with ovarian mass? (4)

A

Estimate size
Location
Consistency and
Mobility

154
Q

What are you looking to assess in a rectovaginal exam in an individual with ovarian mass?(5)

A

Posterior uterine surface, uterosacral ligaments, parametric (Ct around uterus), posterior cul de sac and rectum

155
Q

What are some characteristics of most likely benign ovarian masses on an ultrasound? (5)

A 
Cystic
Smooth
Unilocular
Unilateral
Small (<5cm)
156
Q

Consider laparoscopy when ovarian mass is … (4)

A

> 7-10cm
Continues to grow
Looks suspicious on ultrasound
With suspicious history, presentation and PE

157
Q

How would one prevent ovarian cancer?

A 
Nutrition and lifestyle
Exercise, weight loss
Breast feeding
Hormonal contraception
BI tubal ligation
Prophylactic BI oophorectomy
158
Q

nutrition and lifestyle: what are some points of interest to reduce ovarian cancer risk? (5)

A 
Eliminate animal fats, saturated fats
Eliminate alcohol (Esp. Wine)
Quit smoking
High fruits.vegetables especially when young
Decrease cholesterol
159
Q

What are some essential nutrients to consume to decrease risk of ovarian cancer? (5)

A 
Beta carotene
Vitamin C/E
Isoflavones
Folic acid
Selenium
160
Q

Common ovarian masses in newborn

A

Small functional cysts 1-2cm that regress in months

161
Q

Common ovarian masses in premenarchal girls

A

Teratomas/Desmond’s

162
Q

Common ovarian masses in reproductive age (6)

A

Functional cysts, endometriomas, tubo-ovarian abscesses, PCOS, ectopic pg, teratoma

163
Q

Common ovarian masses in postmenopausal

A

MUST R/O cancer!

Increased risk of malignancy (1’ ovarian carcinoma and METS from uterus, breast or GI)

164
Q

MAJORITIY OF CERVICAL CANCERS IN THE US OCCUR IN WOMEN WHO: (3)

A

Have never been screened
Have not been screened within past 5 years
Have not received appropriate follow up after abnormal pap smear

165
Q

Squamous cells cover outside of? (2)

A

Cervix and vagina

166
Q

Columnar cells cover what structure”?

A

Canal of cervix

167
Q

Junction between two cell types is the

A

Transitional zone (SCJ)

168
Q

What occurs in the SCJ?

A

Abnormal grow/dysplasia develops = 95% of all CIN.

169
Q

Outside of cervix and vagina are covered in what type of cells

170
Q

Canal of cervix is lined by what kind of cells

171
Q

What is cerivcal dysplasia?

A

Disordered growth

- atypical or dysplastic growth

172
Q

Amount of disorganization in cervical dysplasia is graded into mild moderate or severe. Number them.

A

Mild : CIN I (cervical intraepithelia neoplasia)
Moderate: CIN II
Severe: CIN III or carcinoma in situ

173
Q

Dysplasia and carcinoma-in-situ =

A

All of the abnormalities are confined to the surface of the cervix

174
Q

Invasive cancer

A

Cells are disordered throughout entire thickness of the lining and they invade the tissue underlying the surface

175
Q

USPSTF found this about annual pap screens

A

Every 2-3 years after 3 consecutive normal annual paps = same outcome

This is old screening

176
Q

2 types of pap tests

A 
Conventional
Liquid based (thinprep, sure path)
177
Q

Conventional pap test sensitivity and specificity

A

Sensitivity: 50-90%

Specificity >90%

178
Q

Liquid based pap test sensitivity and specificity and what can it detect

A

Sensitivity 70-90%
Specificity >90%
Used to detect HPV, GC, CT

179
Q

2500-3000 cervical cancer cases in US/year are in women with what

A

Normal pap tests

180
Q

Bethesda classification of paps

A 
Normal
Atypia
ASCUS
CIN I
CIN II
CIN III
CIS
Cervical cancer
181
Q

Atypia bethesda classification of paps

A

(NAtAsCIN3CisCc)

Variation of normal, such as irritation or inflammation

182
Q

Ascus bethesda classification of paps

A

(NAtAsCIN3CisCc)
ASCUS: abnormal squamous cells of undetermined significance

Benign changes that should be monitored

183
Q

CIN I bethesda classification of paps

A

(NAtAsCIN3CisCc)
MILD dysplasia
AKA LGSIL: low grade squamous intraepithelial lesion

184
Q

What grade of cervical intraepithelial neoplasia is LGSIL?

185
Q

What two grades of cervical intraepithelial neoplasia are high grade? HGSIL

A

CIN II, CIN III

186
Q

What does CIN stand for?

A

Cervical intraepithelial neoplasia

187
Q

CIN II bethesda classification of paps

A

(NAtAsCIN3CisCc)
MODERATE dysplasia
Aka HGSIL

188
Q

CIN III Bethesda classification of paps

A

(NAtAsCIN3CisCc)
SEVERE DYSPLASIA
Aka HGSIL

189
Q

CIS bethesda classification of paps

A

(NAtAsCIN3CisCc)
Carcinoma in situ
PRECANCER
(Remember carcinoma in situ = localized one area/layer of dysplasia. Not whole area of dysfunction like cancer)

190
Q

HOW is cervical dysplasia and HPV detected?

A

Normal pap results and negative HR-HPV => high negative predictive value

191
Q

Risk factors for cervical dysplasia and cancer (10)

A 
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
Q

Decreased risk of cervical dysplasia and cancer

A

Barrier contraception use = decreased HPV transition and speeds regression of both penile and cervical lesions
Quit smoking
STOP OCP

193
Q

T/f: cervical cancer in women under 19 years of age is rare

A

True. Because it takes ~3 years for a persistent HR-HPV to cause mutations

194
Q

T/F HPV is not contagious during intercourse

195
Q

T/F condom use is completely protective against HPV

A

FALSE. The virus can spread through skin to skin contact

196
Q

HPV is found in

A

> 70% of sexually active adults

197
Q

Only 1% of HPV carriers develop what

A

Venereal warts

198
Q

In teens and early 20’s, 70%. Of HR-HPV and 90% LR HPV types regress after 3 years?

199
Q

HR-HPV = ? And more likely to result in HSIL that lead to what

A

high risk HPV strains are more likely to result in high grade lesions (HSIL) that lead to cervical cancer

200
Q

LR-HPV strains

A

Cervical changes less likely to be precancerous

201
Q

LR-HPV may cause

A

Venereal warts

202
Q

Bad news… rates of progression of carcinoma in situ to invasive cancer range from…

A

22-60% when followed more than 10 years

203
Q

Are there early signs or symptoms for HPV? Maybe (2)

A

No!
Cervical discharge
Abnormal uterine bleeding

204
Q

Good news: (5)

A

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
Q

If partner presents with abnormal pap, what then? What diagnostic test?

A

COLPOSCOPY!

206
Q

What the flip is colposcopy??

A

Direct magnification and viewing of cervix, vulva, vagina or perinatal tissue plus biopsy of tissue

207
Q

Colposcopy is direct magnification and viewing and biopsy of what 4 tissues

A

Cervix
Vulva
Vagina
Perinatal tissue

208
Q

What indicators would make one order a colposcopy? (7)

A

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
Q

What does it mean when i have been diagnosed with ASCUS, ATYPIA OR CIN 1? (3)

A

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
Q

What does it mean when i have been diagnosed with CIN II? (3)

A

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
Q

What does it mean when i have been diagnosed with CIN III, CIS or cancer? (6)

A

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
Q

What is cryotherapy?

A

Probe is placed against cervix, damages cells by freezing them. They then shed over next month in heavy watery discharge

213
Q

Is depth hard to control in cryotherapy?

214
Q

Cryotherapy has high failure rate for what?

A

Treating large areas of dysplasia and areas that extend into the cervical canal a

215
Q

How does a LEEP work? (4)

A

Fine wire loop with electrical energy flowing through it.
Tissue removed => sent to lab.
Under local anesthesia
Causes little discomfort

216
Q

LEEP is good for both treatment and diagnosis?

217
Q

What is conization?

A

Removes con-shaped piece of cervix.

218
Q

Confiscation is good for both treatment and diagnosis?

A

Mainly diagnosis, but might have removed all of undamaged tissue as well

219
Q

Conization has high success rate but may interfere with what

A

Future child bearing.

Decreases integrity of the cervix.

220
Q

Alternative/supportive treatments to cervical dysplasia (4)

A

Lifestyle
Nutrition
Vaginall suppositories
Supplements

221
Q

What are some lifestyle changes for cervical dysplasia? (3)

A

Quit smoking, diet, exercise

222
Q

What is a good diet to aid in cervical dysplasia (2)

A

Diet rich in fruits, vegetables, whole grains and legumes.

One that is high in vitamin C, beta carotene and folic acid

223
Q

Low amounts of vitamin C, beta carotene and folic acid have been associated with higher incidence of what?

A

CIN and HPV

224
Q

What vaginal suppositories have been beneficial for cervical dysplasia treatment? (3)

A

Green tea
Vitamin A and herbal compound
Riboflavin (B2) may cause regression of CIN

225
Q

What supplements for cervical dysplasia? (5)

A 
AO reduce risk of CIN and cancer
Folic acid and beta carotenes
Pyridoxine (b6)
Selenium
zinc
226
Q

What is DES?

A

Diesthylstilbestrol

Synthetic non-steroidal estrogen

227
Q

What was the use of DES in 1938-1971

A

Prevent miscarriage and other pregnancy complications

228
Q

What does DES cause?

A

Early onset cancers in daughters!

229
Q

Daughters exposed to DES in uterine have higher rates of (5)

A 
Structural/reproductive tract anomalies
Vaginal/cervical dysplasia and adenocarcinoma
Infertility
Poor pregnancy outcomes
Autoimmune disorders
230
Q

Males exposed to DES in uterine have higher rates of (2)

A

Structural reproductive tract anomalies

Infertility

231
Q

Suggested screening intervals for DES daughters (4)

A

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
Q

Lymph flow

A

Breast -> Axilla -> supraclavicular

233
Q

Ancillary regions of lymph flow (4)

A

Pectoral
Central
Lateral
Subscapular

234
Q

Lymph flow from breast (4 regions)

A

Supraclavicular nodes
Cervical nodes
Opposite boob
Abdominal lymphatic

235
Q

What else are you looking for when palpating supraclavicular nodes?

A

Virchows’ to ddx pancoast tumor

236
Q

Where is most common site for fibrous cystic changes (benign) and/or malignant disease?

A

UOQ (upper outer quadrant)

Note underwire compression thus may have some texture here

237
Q

What is the infframammary line?

A

Lower arc of the breast

Also a common fibrous area (Bras can add to thickening)

238
Q

Areas of fibrous tissue are less worrisome if (3)

A

Symmetrical, painful, freely mobile

239
Q

Clinical breast exam (CBE) is optimal when?

A

5 days post menses d/t decreased hormonal influence

240
Q

In CBE waht are you inspecting? (8)

A 
Size
Symmetry
Contour
Skin color
Thickening
Prominent poor
Nipple size/shape (flat, fixed, retracted, thickened)
Rashes/ulceration
241
Q

In CBE, palpation is systematic and thorough. Between what ribs do the breast lie?

A

Ribs 2-6, between eternal edge and midaxillary line

242
Q

What must you include in your palpation in CBE?

A

Tail *UOQ->axilla

This includes ancillary, supra/infraclavicular and cervical nodes

243
Q

What should you document in CBE of a breast mass? (8)

A 
Location
Size
Consistency
Mobility
Tenderness
Nipple d/c
Skin changes
Lymphadenopathy
244
Q

Can CBE be used in lieu of mammography?

245
Q

What are some breast disease/conditions? (7)

A 
Mastalgia
Fibroadenomas
Cysts
Fibrocystic breast changes
Mastitis
Introduction papilloma
Nipple discharge
246
Q

MC breast symptoms for which a woman consults her doc: (3)

A

Breast pain
Nipple d/c
Palpable mass

247
Q

Extent of the evaluation for boob stuff depends on (3)

A

Nature of clinical problem
Age
Risk status

248
Q

Mastalgia defintion

A

Breast pain/tenderness

249
Q

Mastalgia is MC in

A

Premenopausal women

250
Q

Is mastalgia a symptom of canceR?

A

No

Cancer presents with discomfort 5% of the time

251
Q

Causes of mastalgia (6)

A 
Hormonal
PMS
Trauma
Acute infection
M/S
Cancer
252
Q

PE>35 with mastalgia, consider?

253
Q

Mastalgia: <35 with normal exam, consider mammogram?

254
Q

60-80% spontaneous remission with what boob condition?

255
Q

Symptoms may be improved or exacerbated with hormonal treatment for which condition of da boob?

256
Q

Fibroadenoma affects how many women

A

10% of women

257
Q

Fibroadenoma = benign or malignant?

258
Q

What is fibroadenoma composed of?

A

Fibrous stroma

259
Q

Fibroadenomas respond to what

A

Estrogen/progesterone.

Size may fluctuate with cycle

260
Q

What are the characteristics of a fibroadenoma? (6)

A

Rubbery, firm, smooth, round, mobile, painless.

261
Q

What would a mammography show of a fibroadenoma?

A

Solid, well-circumscribed, may be multilobulated/calcified (popcorn appearance!)

262
Q

Up to 20% of women will have multiple lesions in hat boob condition?

A

Fibroadenoma

263
Q

Age range of fibroadenoma

A

15-50, not common in menopause

264
Q

Management of fibroadenoma?(5)

A 
CBE
Mammogram
US
Needle Bx
Self limiting
265
Q

Treatment for fibroadenemoa? (2)

A

Surgical excision

Watch And wait

266
Q

Characteristics of simple cyst (3)

A

Fluid filled lesion
Soft, firm, mobile, well circumscribed, unilateral or bilateral, tender
Cyclical fluctuations

267
Q

Age for simple cysts

A

15-50 like fibroadenoma ya?

Not common in menopause

268
Q

In PE, how differentiate simple cyst from solid mass?

A

Can’t. Sucker

269
Q

How do you diagnosis simple cyst? (4)

A

Mammogram, US, fine needle aspiration, maybe surgical biopsy

270
Q

When would you consider surgical biopsy with simple cyst? (4)

A

If blood aspirate,
palpable mass doesn’t resolve with aspiration,
multiple recurrence in short period,
no fluid aspirated

271
Q

What two diagnostic procedures would you utilize after treatment of a simple cyst?

A

CBE, mammogram

272
Q

RECURRENT Large cysts shown to slightly increase waht

A

Cancer risk in some studies but not in others

273
Q

Definition of fibrocystic breast changes (5)

A

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
Q

Symptoms of fibrocystic breast changes (10)

A 
Cyclical pain or constant
Variable size
High mobility
Multiple nodules
Premenstrual aggravation
Diffuse swelling
Tenderness
Heaviness
Itchy nips
Usually UOQ
275
Q

Methylxanthines found in

A

Coffee, tea, cola, chocolate and caffeinated meds

276
Q

Prevention of fibrocystic breast changes (5)

A 
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
Q

How does low animal fat diet affect FBC?

A

Reduces severity of PMS breast tenderness and swelling

278
Q

What are two foods to consume to rid of exogenous estrogens?

A

Legumes and flax seeds

279
Q

Vitamin E’s affect on FBC

A

Relieves pMS symptoms including FBCs, normalize circulating hormones in PMS and FBD

280
Q

Evening primrose oil (EPO) increases what

281
Q

What are PG1&3?

A

Anti-spasmodic and anti-inflammatory

282
Q

Mastitis definition

A

Infection seen during lactation or when skin disruption
UNILATERAL
Associated with lactating mother, improper latching. May allow staph aureus. REFER FOR ANTIBIOTICS

283
Q

Mastitis presentation (8)

A 
Fever
Localized erythema
Pain
Induration
N/V
Malaise
Fever
Chills
284
Q

Etiology of mastitis (3)

A

Staph aureus
S. Epidermis
Strep

285
Q

Risk factors for mastitis (3)

A

Breast feeding
Trauma
Breast augmentation

286
Q

Mastitis is MC when

A

First 2-4 weeks postpartum

287
Q

Nipple retraction?

A

Chronic mastitis!

288
Q

Gala to celebrate (blocked duct) is what

A

Obstruction of breast doc usually after lactation

289
Q

Symptoms of galactocele

A

Tender and enlarged

290
Q

Treatment of galactocele

A

Excise and drain, yo

291
Q

Nipple discharge

A

Can be d/t benign causes but needs to be further assessed

292
Q

What is the work up for nipple discharge(9)

A 
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
Q

How would you rule out a prolactinoma with nipple discharge?

A

Prolactin level and if elevated refer for brain imaging (this is like that grey’s episode!)

294
Q

What symptoms of nipple discharge work up are concerning for boob canceR? (7)

A 
Bloody discharge
Mass
Unilateral
Single duct
Spontaneous
Postmenopausal
Patient using HRT
295
Q

Physiologic/benign discharge characteristics (4)

A

BI
Nonsponteanous (needs stimulation like contact or pressure)
Multiple ducts
Serous d/c can be caused by hormones. Eww

296
Q

Pathological discharge MC cause=

A

INTRADUCTAL PAPILLOMA!!!!

297
Q

Pathological discharge characteristics (4)

A

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
Q

Discharge 2’ to boob carcinoma may be what color?

A

ANY COLOR, IT DON’T DISCRIMINATE!

299
Q

Etiliogies of pathological d/c? (2)

A 
INTRADUCTAL PAPILLOMA (BENIGN)
Breast cancer
300
Q

Galactorrhea

A

Inappropriate location in nonpuerperal woman

301
Q

Nonpeurperal ?

A

During or after pregnancy

302
Q

Galactorrhea characteristics

A

UNI/BI milky d/c

Check for high prolactin levels (order CT to r/o pituitary tumor)

303
Q

What is introduction papilloma?

A

Papillary growth inside lactiferous duct

304
Q

Introduction papilloma is bloody?

A

Or serous! Both!

305
Q

How would you treat introduction papilloma?

A

Surgical excision b/c they tend to grow

306
Q

Cause of subareolar abscess

A

Staph aureus or anaerobic organisms

307
Q

Who gets subareolar abscess?

A

Women with inverted nipples

308
Q

Increased risk of subareolar abscess after what

A

Nipple piercing haha

309
Q

Treatment for subareolar abscess?

A

Antibiotics, drainage, duct excision

310
Q

Subareolar abscess vs introduction papilloma… location. Inside/outside duct?

A

Subareolar abscess = outside duct

Introduction papilloma = inside duct

311
Q

MC cancer in women

A

Breast cancer

312
Q

Second leading cause of cancer deaths in women

A

Breast cancer.

1/3 of women diagnosed with breast cancer will die from it

313
Q

Leading cause of death in women aged 40-55 years old

A

Breast cancer

314
Q

Screening for breast cancer

A

Every 1-2 years with or without clinical breast exam starting at age 40

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