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R2 - Family Medicine > OB/Gyn > Flashcards

OB/Gyn Flashcards

1
Q

Dysfuncitonal Uterine Bleeding

A
  • Presents as abnormal bleeding with a generally unremarkable PE
  • Abnormal uterine bleeding in non-pregnant women
    • different from normal cycle in terms of regularity, flow, duration, and volume
  • normally occurs right after menarche or during perimenopause
  • Causes = PALM-COIEN (polyp, adenomyosis, leiomyoma, malignancy - coag, ovulatory dysFN, endometrial, iatrogenic, not otherwise classified)
  • Menorrhagia = heavy or prolonged bleeding
  • Metrorrhagia = irregular bleeding between menses
  • PE includes speculum, evaluate for bleeding from other sources
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2
Q

Diagnostic studies for DUB

A
  • B-hCG, CBC, iron, PT, PTT, documentation of ovulation, thyroid, serum P, LFTs, PRL, serum FSH
  • Pap, US, hysterosalpingography, hysteroscopy, and/or D&C
  • endometrial bx should be done on all women over 35yo w/ obesity, HTN, or DM and on all postmenopausal pts
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3
Q

management of DUB (AUB)

A
  • depends on severity of bleeding - may include observation, iron therapy, and volume replacement
  • progestin trial - if bleeding stops, anovulatory cylces are confirmed
  • OCPs:
    • older women w/o risk factors
    • OCPs should NOT be used in women over 35 who smoke, have HTN, DM, or hx of vascular dz, breast CA, liver dz, or focal HA
  • D&C can be dx and curative
  • refractory cases may require endometrial ablation or vaginal hysterectomy
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4
Q

dysmenorrhea general characteristics

A
  • PRIMARY: painful menstruation caused by increased prostaglandin and leukotriene levels - painful uterine cramping, N/V/D
    • Onset: usually w/in 2yrs menarche, peak incidence = late teens/early 20s
    • THERE IS NO PATHOLOGIC ABNORMALITY
  • SECONDARY: painful menstruation caused by identifiable condition (usually uterus or pelvis - endometriosis, adenomyosis, fibroids, PID, IUD)
    • usually affects older women (>25yo)
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5
Q

clinical features of dysmenorrhea

A
  • Primary: sxs are central lower abdomen or pelvis radiating to back or thighs, beginning before or at onset of menses, lasting 1-3 days
    • PE, labs, radiologic tests = nl
  • Secondary: similar sxs as above but may also include bloating, heavy menstrual bleeding, and dyspareunia
    • less related to first day of flow
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6
Q

diagnostic studies for dysmenorrhea

A
  • dx of primary dysmenorrhea based on hx, use of menstrual diary, PE
  • specific tests for secondary dysmenorrhea - hysteroscopy, D&C, laparoscopy
    • all allow both dx and tx
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7
Q

management of dysmenorrhea

A
  • Primary:
    • start NSAIDs right before expected menses, continue 2-3 days
    • OCPs, vit B (B1, thiamine; B6, pyridoxine), magnesium, acupuncture, heat, regular exercise
  • Secondary:
    • underlying conditions should be treated
    • sx treatment may be sufficient
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8
Q

general characteristics of menopause

A
  • definition: menopause is the last menses, and perimenopause (usually lasting 3-5 yrs) is the time surrounding menopause.
  • Dx made: 1 yr of no periods after age 40 with no pathologic cause
    • FSH elevated (21-100), estradiol low (<20)
    • progesterone levels nl
  • mean age = 51.5 yrs
  • smoking is associated with early menopause
  • premautre menopause (spontanous premature ovarian failure) is cessation of menses before age 40 years
  • ovaries continue to produce testosterone and androstenedione; estrone is the predominant postmenopausal circulating estrogen
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9
Q

clinical features of menopause

A
  • vasomotor sxs (hot flashes) vary in intensity - usually resolve in 2-3 yrs (3-6 wks with E tx)
  • urogenital atrophy can cause poor vaginal lubrication, dyspareunia, dysuria, urge incontinence, pelvic relaxation, atrophic cystitis, easy bleeding
  • accelerated bone loss may cause osteoporosis
  • E related cardiovascular protection declines
  • changes in sleep cycle
  • skin thins, becomes less elastic, facial hair increases, hair loss increases and nails become brittle
  • confusion, memory loss, lethargy, depression, loss of sex interest
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10
Q

diagnostic studies for menopause

A
  • FSH of greater than 30 is diagnostic of menopause
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11
Q

management of menopause

A
  • treated on the basis of individual risk factors and sxs
  • lifestyle modifications may help sxs, reg exercise can decrease menopausal sxs
  • women with INTACT uterus should NOT use E alone (increased risk of endometrial CA)
  • combined hormone replacement tx indicated for short-term tx of hot flashes
    • can increase risk of CV dz, breast CA, and cognitive changes
  • contraindications to hormone tx include undiagnosed vaginal bleeding, acute vascular thrombosis, liver dz, hx of endometrial or breast CA
  • Ca and vit D supplementation, bisphosphonates, SERMs, calcitonin all used for osteoporosis
  • topical E can improve urogenital sxs
  • SSRI and SNRIs (caution with use with tamoxifen)
  • soy, black cohosh, and ginseng may also help alleviate sxs
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12
Q

Cervical carcinoma etiology, RF, sxs, dx, tx

A
  • bimodal distribution (35-39; 60-64)
  • RF: HPV exposure, early coitarche, multiple sex partners, immunosuppression, SMOKING, low SE status, lack of reg pap smears
  • sxs: postcoital bleeding, vaginal bleeding and d/c, dyspareunia
  • dx: abnormal cytology, HPV (+), gross lesion
  • tx:
    • stage 1: conservative, simple, or radical hysterectomy
    • stage 2 +: chemo +/- radiation
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13
Q

cervical dysplasia

A
  • MCC: HPV 16 and 18 (18 MC with adenocarcinoma)
  • Most HPV infxns regress in 2 yrs
  • HPV not enough to cause cancer itself - requires cofacts (smoking, hormones, OCP (>5y), dietary, immunosuppression (lupus), HIV)
  • RF: old, AA, low ES, low edu, increased # sex partners, SMOKING, multiparous,, hx of STD
  • Indications for conization (LEEP or cold knife):
    • unsatisfactory colpo
    • +endocerv curettage
    • Pap smear indicating adenocarcinoma in situ
    • bx that cannot rule out invasive CA
    • Discrepancy between pap smear and bx result
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14
Q

cervical cytology results and recommended next steps

A
  1. ASCUS (atypical squamous cells of undetermined significance)
    1. repeat cytology at 6-12 mo
      1. if both negative, return to routine screening
      2. if either +, colposcopy
  2. AGC (atypical glandular cells of undetermined significance)
    1. colposcopy with bx of lesions
  3. LSIL (low-grade intraepithelial lesions)
    1. colposcopy with bx of lesions
  4. HSIL (high-grade intraepithelial lesions)
    1. colposcopy with bx of lesions
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15
Q

Breast cancer RF

A
  • age, sex, first degree relative, BRCA1 or 2
  • associated factors: nulliparity, ealry menarche, late menopause, post men ERT or radiation exposure, advanced maternal age at first term birth
  • ALL invasive lobular and 2/3 ductal carcinomas are HER2 pos (estrogen-receptor)
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16
Q

Breast CA presentation

A
  • single, nontender, firm, immobile mass
  • 45% upper outer quadrant, 25% under nipple and areola
  • signs: early, no palpable masses
    • rare: nipple d/c, retraction, dimpling, breast enlargement, shrinkage, skin thickening or peau d’orange, eczematous changes, breast pain, fixed mass, axillary node enlargement, ulcerations, arm edema, palpable supraclavicular nodes
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17
Q

Breast CA dx, tx

A
  • dx: any solid dominant breast mass on exam evaluated with FNA or excisional bx
    • genetic testing for pts with strong family hx
    • axillary lymph node staging with sentinel lymph node bx
  • tx: tamoxifen: for estrogen receptor pos dz and postmen women
    • adjuvant chemo and hormonal manipulaiton
    • lumpectomy with sentinel node bx preferred for early stage
    • breast cancer associated with higher risk of endometrial cancer and vice-versa
    • axillary lymph node status is the most important prognostic factor for invasive carcinoma in the absence of distant metastasis
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18
Q

chlamydia diagnostics and tx

A
  • Tx: NAAT, wet mount (leukorrhea >10 WBC), culture, enzyme immunoassay, PCR
19
Q

pagets dz of the breast

A
  • uncommon, ductal carcinoma, presents as eczematous lesions of the nipple
  • presentation: eczematoid eruption and ulceration of nipple and areola, pain, itching, burning
    • bloody d/c or nipple retraction
  • signs: scale, crust, itching, palpable mass (50%)
  • dx: full-thickness bx
  • tx: local excision, breast conservation with whole breast radiation (if negative margins)
    • most are high grade and show HER2 overexpression
20
Q

Chlamydia etiology and sxs

A
  • Most common bacterial STD
  • RF: lack of condom use, lower socioeconomic status, living in an urban area, having multiple sex partners
    • most common in F 15-19, then 20-24
    • independent risk factor for cervical cancer
  • Sxs:
    • men: dysuria, purulent urethral discharge, itching, scrotal pain and swelling, fever
    • women: puruelnt urethral discharge, intermenstrual or post-coital bleeding, dysuria
      • mucopurulent discharge from cervical os, friable cervix
21
Q

Gonorrhea etiology and sxs

A
  • transmitted sexually or neonatally
  • 30% coinfected with chlamydia
  • Sxs: asymptomatic in women, symptomatic in men
    • Cervicitis or urethritis (purulent discharge, dysuria, intermenstrual bleeding)
    • Disseminated: fever, arthralgias, tenosynovitis, septic arthritis, endocarditis, meningitis, skin rash (distal extremities)
22
Q

Gonorrhea dx and tx

A
  • dx: NAAT, gram stain (leukocytes, gram neg intracell. diplococci), cultures (men from urethra, women from endocervix)
  • tx: tx empirically because cultures take 1-2d
    • Ceftriaxone x1, add Azithromycin or doxy to cover chlamydia
    • if disseminated, hospitalize and IV or IM ceftriaxone
  • Complications of dz: PID, infertility, epididymitis, prostatitis, salpingitis, tubo-ovarian abscess, Fitz-Hugh-Curtis syndrome
23
Q

lymphogranuloma venereum

A
  • MCC: chlamydia trachomatis - primary infxn of lymphatics and lymph nodes
  • Sx: hx of proctitis with or without anal lesions
    • first stage = painless genital ulcer 3-12d after infxn
    • second stage = unilateral lymphadenitis or lymphangitis with tender inguinal or femoral LAD
    • Enlarged bubos, which are painful
    • Tender lymphadenopathy at the femoral and inguinal lymph nodes, separated by a groove made by poupart ligament (“sign of the groove”)
  • dx: serologic testing for syphilis - RPR/VDRL
  • Tx: drainage of buboes, doxy 100mg BID x 21d
24
Q

chancroid

A
  • etiology: haemophilus ducreyi (G-)
  • sxs: PAINFUL chancre
    • PAINFUL lymphadenopathy - leads to bubo formation
    • dysuria and dyspareunia in Fs
    • multiple painful punched out ulcer with undermined borders
  • dx: serologic testing for syphilis - RPR/VDRL
    • culture and gram stain of fluctuant lymph node or ulcer for H ducreyi
  • Tx: 1 g azithromycin
    • fluctuant inguinal lymph nodes should be incised and drained
25
Q

HPV

A
  • etiology: MC - condylomata acuminatum
    • Low-risk types: 6, 11
      • anogenital warts - most common viral STD in US
    • Causes nearly 100% of cervical cancers - most significant RF for cervical CA
  • sxs and signs: most asymptomatic
    • flesh-colored papillary exophytic lesions on genitalia
  • dx: RPR/VDRL - r/o syphilis
    • HIV, HPV viral typing not recommended daily
    • Shave or punch bx confirms - hyperplastic prickle cells, koilocytotic or vacuolated squamous epithelial cells in clumps on pap (cervical warts)
  • tx: most resolve spontaneously
    • podophyllin or trichloroacetic acid
    • surgery (cryotherapy, excision, electrocautery, intralesional interferon
    • guarasil
  • 6, 11 = warts
  • 16, 18 = cervical CA
  • condoms reduce transmission of warts
26
Q

Herpes simplex virus (herpes labialis), HSV-1

A
  • transmission: kissing, resides in trigeminal ganglion
  • signs and sxs: fever, malaise, vesiculopustular oral lesions in groups
    • herpes labialis (cold sores): most common on lips, painful, heal in 2-6 wks
    • bell palsy
    • herpetic whitlow
  • dx: clinical dx with lesions dewdrop on a rose petal
    • tzanck smear - multinucleated giant cells
    • culture of HSV
    • ELISA
    • PCR
  • tx: acyclovir
  • complications: herpes encephalitis, HSV keratitis
27
Q

Genital herpes, HSV-2

A
  • resides in sacral ganglion
  • prior HSV-1 infxn confers partial immunty to HSV2
  • signs and sxs: severe, prolonged sxs
    • fever, HA, malaise
    • painful vesicles on genitals (itching, dysuria, multiple, bilateral)
    • tender inguinal lymph nodes
  • dx: HSV1 and HSV2 Ab negative
    • PCR, culture if active lesion present
  • tx: acyclovir, sitz baths, topical xylocaine
  • complications: aseptic meningitis, keratitis, blepharitis, keratoconjunctivitis
  • C section recommended for pregnant women with active infxn
28
Q

Pelvic Inflammatory disease etiology and sxs

A
  • etiology: infxn ascends from cervix to involve endometrium and/or fallopian tubes
    • MCC = gonorrhea, chlamydia, genital mycoplasmas
    • RF: endocervical infxn, BV, hx of PID, vaginal douching, IUD insertion, D&C or C-section
  • signs and sxs:
    • mucopurulent malodorous vaginal discharge
    • abd pain
    • abnl vaginal bleeding
    • bilateral lower abdominal and pelvic pain
    • N/V
    • urethritis, proctitis
    • Fever
    • yellow endocervical discharge, easily induced bleeding
    • uterine or adnexal tenderness and swelling, CMT
    • rebound/guarding
29
Q

Pelvic inflammatory disease dx and tx

A
  • Dx: ESR elevated, leukocytosis, B-hCG, NAATs, gram stain
    • US: enlarged fallopian tubes with fluid in cul-de-sac
    • laparoscopy - last line, rule out appy, ectopic, tumor
    • endometrial bx
  • outpt: ceftriaxone IM and doxy PO x14d
    • +/- flagyl BID x 14d
  • inpt: hosp if: dx uncertain, pregnant, abscess suspected, severely ill or N/V preclude outpt management, HIV pos
    • Doxy + IV cefotetan or cefoxitin x 48h, then PO doxy BID x14d
    • clindamycin + gentamicin qh x48h, then PO doxy BID x14d
30
Q

trichomoniasis

A
  • signs, sxs: increased d/c and odor, dysuria, frequency, dyspareunia, itching, irritation
    • thin yellow-green to gray, adherent frothy discharge in vagina
    • malodorous, musty (amine)
    • hyperemic mucosa, friable cervix, strawberry cervix (petechiae)
  • dx: wet mount, ph 5-6.5 (basic)
  • tx: 2 g metronidazole PO x1, no ETOH 48h, TREAT PARTNER
31
Q

bacterial vaginosis

A
  • MCC vaginitis
  • RF: new partner, smoking, IUD, douching, pregnancy
  • signs, sxs: mostly asx
    • increased vag d/c
    • dysuria, frequency, dyspareunia
    • noticeable fishy discharge after menses or intercourse, no itching
    • thin ivory/gray d/c
  • dx: amsel criteria (3 of 4)
    • thin, gray, homogenous d/c
    • positive whiff
    • clue cells
    • elevated pH >4.5 (basic)
  • tx: metronidazole BID x7d
    • Or vaginal metronidazole
32
Q

atrophic vaginitis

A
  • postmenopausal women, thinning of vag epithelium
  • signs, sxs: dyspareunia, thin vag d/c, vag pruritis, burning, soreness
    • atrophic vulvar changes (smooth, shiny, pale, dry, thin), scattered vag petechia, thin clear or brown d/c (leukorrhea)
    • UTI, urge incontinence may be associated
  • Dx: clinical dx
    • vaginal cytology (greater % of parabasal cells)
    • vaginal pH: 5-7
  • tx: H2O soluble lubes, topical vaginal estrogens, oral estrogens
33
Q

candidiasis

A
  • 2nd MCC vaginitis
  • RF: high dose OCP, diaphragm use, DM, abx, pregnant, immune suppression, tight clothes
  • signs, sxs: vulvar or vag itching, burning, external dysuria, dyspareunia, odorless thick cottage cheese curd-like d/c
    • erythema of vulva, excoriations from scratching
  • dx: wet mount - budding yeast
    • gram stain - pseudohyphae
    • vaginal culture (+) for yeast
    • pH <4.7 (acidic)
  • tx: fluconazole 150 PO once
    • tx uncircumcised partners
    • short-course topical azole
    • recurrent: weekly topical /PO
    • resistant: boric acid TID x7d
34
Q

primary, secondary, latent, and tertiary syphilis

A
  • TREPONEMA PALLIDUM
  • Primary:
    • chancre - painless, clean base, 3-4wk after exposure, heals in 14wk w/o light tx, HIGHLY INFXS
    • inguinal lymphadenopathy
  • Secondary:
    • flu-like (HA, fever, sore throat, malaise)
    • 4-8 wks after chancre heals, maculopapular rash
    • aseptic meningitis
    • 1/3 develop latent syphilis
  • Latent:
      • serological test in absence of clinical sxs
    • 2/3 remain asymptomatic
    • “early latent” = if serology + for <1 y, may relapse to secondary
    • “late latent” = if serology + for >1y, patients are contagious
  • Tertiary:
    • years after primary infxn
    • neurosyphilis, CV syphilis, gummas
      • neurosyph: dementia, personality changes, tabes dorsalis (post column degen, loss of corrdination of mvmt)
    • rare d/t tx with PCN
35
Q

Syphilis dx and tx

A
  • Dark field microscopy (GOLD STANDARD)
  • Serologic tests (MC)
    • Non-treponemal tests: RPR, VDRL
    • Treponemal tests: FTA-ABS, MHA-TP
      • if FTA-ABS +, check for CSF-FTA-ABS
  • test all pts for HIV
  • Tx: PCN G (one dse IM)
    • doxy and tetra x2wks if PCN allergy
    • latent or tertiary: PCN x3 doses IM (1 wk apart)
    • neurosyph: IV PCN x 10-14d
      • repeat nontreponemal tests q3 mos
    • Jarisch-Herxheimer rxn can occur w/ sudden massive destruction of spirochetes - prevent by administering antipyretics during first 24h of tx
  • Report to public health agency
36
Q

breast abscess

A
  • occurs especially during nursing (MC s. aureus)
  • presentation: redness, tenderness, induration
  • dx: incision and bx if severe or indurated - r/o inflammatory carcinoma
  • tx: bactrim, clinda, doxy
37
Q

breast fibroadenoma

A
  • more common in AA and young (15-35)
  • presentation: round, firm (soft, rubbery), painless, freely movable, discrete, mobile
    • hormonal relationship: cyclical size
  • signs: nontender, unilateral, mobile density, smooth firm mass
  • dx: if <30 - US +/- FNA
    • if >30 - mammogram
    • Excisional bx (if <25), if BRCA + mom
  • tx: decrease caffeine
38
Q

fibrocystic breast dz

A
  • MC benign breast condition (MC 30-50yo)
  • Presentation: asx or painful, bilateral, size fluctuation during menstrual cycle
    • MULTIPLE LESIONS distinguishes fibrocystic changes from carcinoma
    • breast pain, dipple discharge, lumpy and bumpy prior to menses
  • signs: tender, bilateral, mobile density, thick gray-green nipple d/c, worse with caffeine intake
  • dx: US +/- bx, FNA (diagnostic and tx)
  • tx: support bra, decrease caffeine, danazol
  • increased risk breast CA when atypia is present
39
Q

mastitis

A
  • MC in postpartum (2-4th week, S. aureus)
  • Presentation: lactating women, FEVER, chills, flu-like, acute, responds to abx
  • signs: decreased milk, redness, tenderness, firm mass, breast pain, unlilateral, heat
  • dx: culture of purulent material or milk (not routine)
  • tx: dicloxacillin (PCN allergy - erythromycin)
    • cold compress, NSAIDs and tylenol, continue to breast feed and express milk
40
Q

cystocele etiology, RF, and sxs

A
  • anterior vaginal prolapse of the posterior bladder wall into the vagina, emerging from the introitus
  • pelvic floor injury during childbirth
  • RF: genetics, prior prolapse surgery, connective tissue dz, pregnancy, vaginal delivery, parity, advanced age, obesity, menopause, DM, race
  • sxs: vaginal bulge or fullness, pressure, heaviness, worse with valsalva
    • concurrent urinary incontinence
    • incomplete emptying (retention, straining to void (obstruction)
  • examine in lithotomy position and standing
  • pt must push up bladder in order to void
41
Q

cystocele dx and tx

A
  • Dx: POP-Q (pelvic organ prolapse quantification), US or MRI, Q-tip test, voiding cystourethrogram, cystometrogram
  • tx: pessary, anterior vaginal colporrhaphy, tension-free vaginal tape procedure
  • prophylaxis: kegel exercises (strengthen levator ani and perianal mm.), estrogen tx after menopause
42
Q

rectocele etiology, RF, sxs

A
  • etiology: prolapse of posterior vaginal wall and rectum
  • RF: pelvic floor injury during childbirth
  • sxs: prolonged, excessive use of laxatives or frequent enemas (constipation)
    • introital bulging, concurrent fecal incontinence, constipation, low back pain, dyspareunia
    • left decubitus position for detection
  • complications: hemorrhoids
43
Q

rectocele dx, tx

A
  • dx: POP-Q (pelvic organ prolapse quantification), anal manometry, transanal US, MRI, colonoscopy, defocography, EMG
  • tx: nonsurgical (use of meds: laxatives, EST), posterior colporrhaphy (repair of posterior fascial defects), colpocleisis (closure) or colpectomy (removal) of the vagina if not sexually active

R2 - Family Medicine (14 decks)

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