OB Cram Flashcards
Cyst size for Premenopause women and management
3cm or less: norm variant
5cm or less: no Tx
5-7cm: repeat TVUS 12 wks, persistant= annual
+7cm: MRI/surg eval
Cyst size for Post-menopause women
1cm or less: norm variant
5cm or less: CA125 level, norm= repeat TVUS 12 wks, perisitant= annual
>7cm: MRI/surg eval
Risk factors for Endometrial CA
Nullparity
Obese
PCOS
Estrogen
White
Infertile
DM/CHTN/Gallbladder dz
Early menarche
Late
Irregular
North american/european
Tamoxifen
COC w/ smoking
Old
What is the primary driver of endometrial cancer risk
Paps stop at ? age
AGC Pap result management
Estrogen exposure length
65
Colpo and endocervical/metrial sampling
No concern for HPV status
Post menopause PT w/ HTN, DM and PCOS w/ vaginal bleeding x 2wks, what is next step?
When is endometrial ablation used for Tx
Hysteroscopy
AUB w/ reproduction complete
Endometriosis Tx concurrent w/ laproscopic exam
When is Uterine Artery Embolization used for Tx
AUB, acute menorrhagia if balloon tamponade fails
Leiomyomatas
Leiomyoma
MC pelvic tumor in women that are Estrogen dependent
Round/rubbery
Present: bleeding, pressure, pain, infertility
Dx: US
Tx: COCs (dec bleeding) UAE Hysterectomy
Adenomyosis
Endomettriosis in myometrium
Present: Heavy bleeding or Dysmenorrhea in parous women 40-50y/o
Dx: TVUS, MRI
Tx: Hysterectomy Progestin IUD Danadol COC GnRH agonist
Polyps
MC Sx: mentrorrhagia
Dx: TVUS, Sonohystography
Tx: if Sx/Large, remove
Endometrial Hyperplasia
From recurrent/chronic annovluation due to unopposed estrogen
MC presentation: AUB in post-menopause female +50
Dx:
Pre-Meno: biopsy, Gold Standard
Post-Meno: TVUS= Dx equivalent, <4mm= low risk
What classification of endometrial hyperplasia has the highest/lowest chance for progressing to Ca?
How are atypia cases Tx
Most: Complex hyperplasia w/ atypia
Less: Simple hyperplasia w/out atypia
Post menopause, no kids: hysterectomy w/ BSO
Pre-meno atypia, wants kids: progestin, EMB q3mon
How are endometrial hyperplasia cases w/out atypia Tx
Pre-meno: progestin or COC w/ q3-6mon EMB
Inc progesterone or refer to hysterectomy
Post-meno: COC/progestin w/ EMB q3-6mon
Endometrial Ca
MC Gyn Ca in US
MC Sx: vaginal bleeding
Sx: Pressure Irregular bleeding Girth Satiety Bloat
Dx: EMB
Post-Meno w/ stripe 5mm or more= biopsy
D&C if biopsy c/i or persistant bleeding w/ normal biopsy
Tx: Hysterectomy w/ BSO and lymph node staging
HT w/ progestin (Tamoxifen)
What Ca condition may require a hysterectomy as prophylaxis
PTs w/ this need to have ? screening procedure started at ? age
Lynch Syndrome
30-35y/o: EMB Q1-2yrs
How is endometrial Ca Tx if fertility is trying to be spared?
Dx hysteroscopy
D&C sample
Hormone Tx
Functional Cyst
> 3cm in woman of reproductive age
Sxs: dull pain, heaviness
Hemorrhagic cyst- inc Sxs
Dx: bimanual exam, US
Cyst + Pain= surg eval
MC epithelial benign neoplasm
What is the largest
? is MC benign ovarian neoplasm
Serous cystadenoma
Mucinous cystadenoma
Benign Cystic teratoma: Germ cell
PT w/ ovarian mass may have ? key Sxs
Weight loss
Ascites
Pleural effusions
Bimanual
US
CA-125- if Post-Meno
Dx w/ biopsy
Complex cyst management
Ovarian Torsion
Pre-Meno: TVS in 12wks, perisistent= MRI/surg eval
Post-Meno: surg eval
Twisted adnexal component: ovary and tube
Highest rate: adnexa 6-10cm
R more common, L protected by sigmoid
Steroid hormones cause maleness
DHEA: adrenal- weak
Androstenedione: adrenal, ovary- weak
T: adrenal, ovary, adipose- potent
DHT: follicle, genital skin- most potent
Hypertrichosis
Hirsutism
Virilization
Genetic variant, not due to androgens
Terminal hair in male patterns, due to androgens
Acne, baldness, hypertrophy, due to androgens
PCOS
Inc androgens and estrogen
Sxs: Hirsutism AUB PCOs Infertile Obese
Dx: hyperandrogen, olio/anovulation
Ovarian Hyperthecosis
Leutenized theca cells
Balding Hypertrophy Deep voice
Inc insulin resistance
Acanth Nigrans
HAIRAN
Hyper Androgen Insulin Resistant Acanth Nigrican
Hyperandrogen
Severe insulin resistance
How is hirsutism scored
How is idiopathic hirsutism Dx
How is it Tx
Ferriman Gallwey system
Normal androgen, menses
Inc 5-AReductase
Mild PCOS ?
Ovulation: COC, Metformin
Hair: COC, Spirinolactone Flutamide Eflornithine
RFs for ovarian Ca
FEP BLOWN PEN
FamHx
Early menarche
Post meno HT
Breast Ca Late meno Old White NA/Ne
PID
Ethnic
Nullparity
RFs for cervical neoplasm
ALE MET SPICE
Age
Low status
Ethnic
Multiple partners
Early coitus
Tobacco/diet
Screening low/poor Parity ImmSupp Cervical HPV Exog hormones
Cervical Stenosis causes
Txs
CIN Tx
Hypoestrogen
Dilator
Vaginal estrogen
Nabothian Cyst
Columnar cells trapped under squamous- secrete mucus
Not Tx unless pain- cautery/excise
HPV 6,11 causes ?
HPV 16,18 causes
If these last longer than ?mon, risk increases
Genital warts
Laryngeal papillomas
Cervical Ca
16- most oncogenic; anogenital, oropharyngeal cancer
6mon into squamous intraepithelial lesion
Pap smear algorithm by ages
<21: no screen
21-29: Pap Q3yrs, reflex if +
30-65: Co-test Q5yrs, Pap Q3yrs
>65: 3 consecutive negatives
Post Hyst w/ CIN2 Dx in past 20yrs: annual vaginal swabs x 20yrs past Dx date
ASCUS
21-24: Pap 12mon
25-29: Reflex HPV
- HPV: Cotest 3 yrs
+ HPV: Colpo
LSIL
21-24: Pap 12mon
25-29: Colpo
-HPV: Pap/CoTest 12mon
+HPV: Colpo
Pregnant: Colpo
ASC-H
21-24: Colpo
25-29: Colpo
-HPV: Colpo
+HPV: Colpo
No CIN2: Colpo/Cyto Q6mon x 2yrs
HSIL
21-24: Colpo
25-29: Exc/colpo
-HPV: Exc/colpo
+HPV: Exc/colpo
No CIN2: Colpo/Cyto Q6mon x 2yrs
AGC
Atypical: Sampling, no pathology= colpo
Other sub-cats: Colpo and Sampling if +35y/o w/ bleeding/anovulation
Unsat Cytology
No/-HPV: Cytology 2-4mon
+HPV: Colpo/Cytology 2-4mon
No EC/TZ
21-29: routing screen
+30: -HPV- routine screen
+30: +HPV- Cytology/genotyping 1yr
PTs >30y/o w/ negative cytology but are HPV +
Cotest 1yr, ASC/HPV += Colpo
ASC/HPV- = Cotest 3yrs
DNA Typing: 16,18= colpo
Neg for 16,18= cotest 1yr
Exophytic cervical cancer arises from ?
Endophytic cervical cancer arises from ?
Ectocervix
Endocervix
What meds may be used for cervical Ca Tx during pregnancy but usually result in loss
How often are they f/u w/
How long ar PTs w/ cervical/vaginal cuff pap f/u w/?
Cisplatin w/ cicristine
Paclitaxel
Q3mon x 2yrs
Q6mon x 5yrs post Tx
Annually
Annually x 20yrs post-Tx
What is NOT a RF for vulvar cancer?
What microbe causes Erythrasma and how does it appear under a Woods lamp
How is it Tx
Breast Ca
Corynebacterium- red
Wide: Erythromycin
Local: Clindamycin
? etiology of vaginitis may be mobile when viewed
What is the predominant microbe and what defenses does it make?
What are the two non-inflammatory causes of vaginitis
Trichomonas
Lactobacilli- hydrogen peroxide, lactic acid
BV, Candidiasis
What is the MC cause of vaginal d/c
This MC cause is due to ?
BV
Over growth of anaerobes: Gardnerella Ureaplasma Mobiluncus Mycoplasma Prevotella
Name of criteria for Dx BV
One of these criteria is tested with a paper named ?
Med Txs
Amsel- pDOC
Nitrazine paper- blue
Metronidazole 500mg PO BID x 7 days
Clindamycin 5g intravaginally x 7 days
How is recurrent BV Tx
1st recurrence, no Tx: Vaginal Metrogel or, PO Metronidazole PO Tinidazole Vaginal clindamycin - ALL x 2wks
Recurrent Recurrent:
Treat acute infection
Suppress w/ Metronidazole gel or Tinidazole
UnTx BV + Pregnancy can lead to ? 4 adverse events
What is the strain of fungus resistant to -azoles
Premature rupture of membrane
Preterm delivery
Amniotic infection
Post-partum endometritis
C Glabrata
Difference of pH between BV and Candidiasis infection
RFs for candidiasis infection
What PT population is more likely to acquire non-albicans fungal ifections
BV= pH >4.5
C: pH <4.5, more acidic
ID ADOPT
ImmSupp Diaphragm ABX DM OCPs Pregnant Tight
Women w DM2
What are the two preferred med for treating candidiasis infections
Chronic candidiasis is linked to PTs w/ ? 2 things
How is recurrent VVC Tx
Clotrimazole
Metronidazole
Mannose binding lectin
Inc IL-4
PO Fluconazole
Suppressive Therapy:
PO Fluconazole 100-200mg wkly x 6mon
How are fungal infections of non-albican species Tx
Trichomoniasis
Boric acid 600mg
PO Fluconazole 200mg
Musty/Frothy green/yellow d/c
Strawberry cervix
pH >4.5
NAAT- gold standard
Trichomoniasis Tx
How are BV/Trichomnoas co-infections Tx
Metronidazole 2g PO x once
Metronidzaole 500mg BID x 2wks
Tinidazole
Tx the BV
Lichen Sclerosis
Post Menopause woman- inflamed dermis w/ paper appearance
Dx Biopsy
Tx: Topics CCS- Clobetasol
Severe- retinoids
Phototherapy/5-aminolevulonic acid
Lichen Simplex Chornicus
Itch Scratch Cycle, no wax/wane
Tx: lubricant, PO antihistamine
Unresolved 1-3wks= biopsy
Atopic Dermatitis
Allergy/eczema Hx
Tx w/ Steroids/Immodulators (Tacrolimus)
Psoriasis
Silver scales that are red in folds
Autoimmune T Cell reaction
Uncommon on Mons Pubis/labia
Koebnerization- vulva Trauma
Tx: emollient, steroid
Maintenance: Dovonex
Lichen Planus
Male and female involvement
Autoimmune d/o of T-cells
Drug induced: BB NSAID Mehtyldopa PCN Quinine
Gingival involvement
Erosive- MC
5PS- polygon
Tx: Clobetasol, vaginal hydrocotrisone
Intertrigo
Friction between skin folds causing burn, itch, hyperpigmentation
Tx: corn starch
Nystatin, Clotrimazole
What is the MC cause of vaginal irritation post-menopause
Atrophic vaginitis
Tx: estrogen
Barthlin Cyst
Occur in duct= no pain
CA concern if >40y/o
ASx= no Tx unless >40
DONT DO I&D
Tx: word catheter, marsupilizaiton- after two failed catheters
Barthalin Abscess
Microbial or G/C
Tx: ABX if recurrent or high risk: Pregnant Cellulitis Systemic ImmSUpp
TMP/SMX
Amox/Clav
2nd Gen ceph
TSS
Vulvar Ca more common in ?
Exotoxin from Staph A 2 after surgery/menses onset
Older
HIV infected
Most Vulvar Cas are ?
Women <55y/o vulvar Ca RFs
Women >55y/o vulvar Ca RFs
Squamous on vestibule
Malignant melanoma- poor prognosis
HPV, smoking
Same RFs as cervical Ca
Non-smoker
No STD Hx
Long lasting Lichen Sclerosis
35 x bigger risk of vulvar Ca risk if ? combo
How is this Ca Tx
Smoker and +HPV
Wide local incision- microinvasive Stage 1A
Vulvar resection if lymph/adenopathy is present
Chemo
MC complaint of vaginal Ca
MC region involved
If its on anterior wall, ? Sxs
Bleeding
Upper 1/3 of wall
Dysuria Urgency Hematuria
During childhood, what 3 hormones are low
What hormone is suppressing the HPO axis from 4-10y/o
FSH LH Estradiol
Estradiol, suppresses GnRH
Sequence of puberty changes
What variant can occur but is a normal variant
TAPuP Me
Thelarche Adrenarche Pubarche Peak growth MenarchePubarche being first
What is the onset of puberty
Define Central Precocious Puberty
Define Peripheral Precocious Puberty
Pulsatile GnRH causes AntPit to release FSH/LH
Dependent, Isosexual
High FSH LH Est
Independent, Iso or Heterosexual
Low FSH LH, High Est
Peripheral precocious can lead to ?
What labs are ordered
Tumors
CAH
Cushing
Exogenous androgens
Hand x-ray
FSH LH TSH
Pelvic sonograph
CNS MRI
Criteria for delayed puberty
What D/os fall under 1* hypogonadism
No thelarche by 13
No menses by 16
Turners
Kleinfelter
POI
How much blood is usually lost during a period?
When are cycles most irregular
20-60mL
2yrs after menarche
3yrs before menopause
3 functions of menstrual cycle
What phase of the menstrual cycle is variable
Reproduction
Ovulation
Menses
Follicular
Acronym for phases and hormones
3 effects of FSH on ovary
PSL- prog sec luteal
Ester Pro Life
Recruit follicle
E/P production
Inc LH receptors
What phases are present and absent in anovulatory menstrual cycle
MC cause of 2* amenorrhea
+ proliferative
- luteal
Pregnancy
2nd: anovulatory
Criteria for 1* amenorrhea
Define 2* amenorrhea
No menses by 16
No menses by 14, absent 2* characteristics
No menses w/in 3 yrs of thelarche
No menses x 3mon who were having menses
1* amenorrhea includes ?
What are the first 3 steps for investigating amenorrhea
Turner
46XX
47XY
Estrogen? US FSH levels: Inc= gonad failure Dec= function/structure issue
Define Functional Amenorrhea
What can cause this
Abnormal GnRh
Low FSH
Female athlete triad
What causes Functional Hypothalamic Amenorrhea
What are the primary tests ordered for amenorrhea
What images are ordreed
10% weight loss
Malnourished
Leptin deficient
Stress
hCG FSH Prolactin Estradiol TSH
US Saline sonography
MRI
Frequency of bleeding
Regularity
Duration
Flow
Frequent: <21 days
Infrequent: 35 days
Amenorreha; absent 6mon
Irregular: >20 day variation
Prolonged; >8 days
Short: <2 days
Heavy: >80cc
Light: <5cc
PALM COINE acronym for AUB
Polyp
Adenomyosis
Leiomyoma
Malignancy/hyperplasia
Coagulopathy Ovulatory d/f Endometrial Iatrogenic Not classified
AUB Acute
Stable: COC: medroxyprogesterone Unstable: D&C Balloon tamponade UAE Hysterectomy
AUB Chronic Tx
NSAIDs
One reset:
Medroxy
COCs
Suppression: Progestin COC Depo Levonorgestrel**
Antifibrinolytic:
Tranexamic acid
Prostaglandins play part of ? dysmenorrhea
Tx
Primary
NSAIDs
COCs
Progestin OCPs
Dexa scan
Score ranges
+65y/o
1 RF for osteoporosis
Sustained Fxs
ALL perimenopausal women
Normal: 2.5 - -1
Penia: -1 - -2.5
Porosis:
Z score
T score
Results to same age
<2.0= Dx eval for 2* cause of porosis
Results to healthy PT 20-35
When is therapy started for osteoporosis
T -2.5 or less
Vertebral/hip Fx
-1 - -2.5 w/ RFs
