OB/Gyn

Question 1

Dysfuncitonal Uterine Bleeding

Answer 1

• 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

Question 2

Diagnostic studies for DUB

Answer 2

• 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

Question 3

management of DUB (AUB)

Answer 3

• 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

Question 4

dysmenorrhea general characteristics

Answer 4

• 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)

Question 5

clinical features of dysmenorrhea

Answer 5

• 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

Question 6

diagnostic studies for dysmenorrhea

Answer 6

• 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

Question 7

management of dysmenorrhea

Answer 7

• 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

Question 8

general characteristics of menopause

Answer 8

• 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

Question 9

clinical features of menopause

Answer 9

• 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

Question 10

diagnostic studies for menopause

Answer 10

• FSH of greater than 30 is diagnostic of menopause

Question 11

management of menopause

Answer 11

• 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

Question 12

Cervical carcinoma etiology, RF, sxs, dx, tx

Answer 12

• 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

Question 13

cervical dysplasia

Answer 13

• 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

Question 14

cervical cytology results and recommended next steps

Answer 14

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

Question 15

Breast cancer RF

Answer 15

• 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)

Question 16

Breast CA presentation

Answer 16

• 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

Question 17

Breast CA dx, tx

Answer 17

• 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

Question 18

chlamydia diagnostics and tx

Answer 18

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

Question 19

pagets dz of the breast

Answer 19

• 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

Question 20

Chlamydia etiology and sxs

Answer 20

• 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

Question 21

Gonorrhea etiology and sxs

Answer 21

• 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)

Question 22

Gonorrhea dx and tx

Answer 22

• 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

Question 23

lymphogranuloma venereum

Answer 23

• 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

Question 24

chancroid

Answer 24

• 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

Question 25

HPV

Answer 25

• 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

Question 26

Herpes simplex virus (herpes labialis), HSV-1

Answer 26

• 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

Question 27

Genital herpes, HSV-2

Answer 27

• 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

Question 28

Pelvic Inflammatory disease etiology and sxs

Answer 28

• 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

Question 29

Pelvic inflammatory disease dx and tx

Answer 29

• 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

Question 30

trichomoniasis

Answer 30

• 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

Question 31

bacterial vaginosis

Answer 31

• 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

Question 32

atrophic vaginitis

Answer 32

• 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

Question 33

candidiasis

Answer 33

• 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

Question 34

primary, secondary, latent, and tertiary syphilis

Answer 34

• 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

Question 35

Syphilis dx and tx

Answer 35

• 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

Question 36

breast abscess

Answer 36

• 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

Question 37

breast fibroadenoma

Answer 37

• 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

Question 38

fibrocystic breast dz

Answer 38

• 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

Question 39

mastitis

Answer 39

• 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

Question 40

cystocele etiology, RF, and sxs

Answer 40

• 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

Question 41

cystocele dx and tx

Answer 41

• 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

Question 42

rectocele etiology, RF, sxs

Answer 42

• 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

Question 43

rectocele dx, tx

Answer 43

• 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