OBGYN Flashcards
A 32 yo F presents to her PCP complaining of painful periods, pain with sex, and painful bowel movements. She has been trying to have kids since she got married 2 years ago. A pelvic exam reveals a 6 cm tender mass in the rectouterine pouch (RUP) along with nodularity of the uterosacral ligaments.
This is endometriosis (deposition of endometrial tissue outside the uterus). There are many theories as to why this occurs but “retrograde menstruation” is a commonly peddled one. Consider this as your dx with mention of the 3D’s->dyschezia, dysmenorrhea, and dyspareunia. The most common location is the ovary (where it can bleed and cause an endometrioma) followed by the RUP. Definitive dx is with laparoscopy. Tx options include combined/progestin OCPs (nuke HPG axis), continuous GnRH (not pulsatile), and surgery if fertility is desired (or TAHBSO if postmenopausal and reproduction is no longer required).
Endometriosis is the most likely cause of ——— in a ——— woman over the age of ———, without a history of ———
infertility
menstruating
30
pelvic inflammatory disease.
A 37-year-old patient reports hemoptysis during her period.
Endometriosis of the nasopharynx or lung.
In endometriosis, severity of symptoms does not necessarily correlate with ———, but may correlate with the ———
quantity of ectopic endometrial tissue
depth of penetration of the ectopic tissue
Long-term complications of endometriosis:
Prolonged bleeding of ectopic tissue causes ———, may contribute to: (4)
scarring (adhesions).
infertility, small bowel obstruction, pelvic pain, and difficult surgeries.
Congenital anomalies that promote ——— may be found in adolescents with endometriosis.
retrograde menstruation
Chronic pelvic pain may result from endometriosis with associated
adhesive disease
Classic symptoms of endometriosis:
Dysmenorrhea, dyspareunia, and dyschezia
———- has been shown to reduce endometriosis-related dysmenorrhea.
Acupuncture
The pulsatile release of endogenous GnRH ——— FSH secretion. GnRH agonists cause ———- of pituitary receptors and ——— FSH secretion. This creates a ——— state.
stimulates
down regulation
suppress
pseudomenopause
The only way to definitively diagnose adenomyosis is with
microscopic examination of the uterus after hysterectomy.
When an enlarged uterus is found on exam, ultrasound can help differentiate between ——— and ———
adenomyosis and uterine fibroids.
The diagnosis of adenomyosis
is suggested by characteristic
clinical findings; ———-(3) after ——— and ——— have been ruled out)
heavy menses, dysmenorrhea, enlarged uterus
endometriosis
leiomyomas
Adenomyosis is classically described as an ——— uterus on physical exam.
enlarged, globular, “boggy”
Adenomyosis vs Endometriosis: Cyclic-ness of pain
Adenomyosis: Noncyclic pain
Endometriosis: Cyclic pain
Adenomyosis vs Endometriosis: Age and parity of women
Adenomyosis: Typically found in older, multiparous women
Endometriosis: Typically found in young, nulliparous women
Adenomyosis vs Endometriosis: Responsive to hormonal stimulation.
Adenomyosis: Tissue is not as responsive to hormonal stimulation
Endometriosis: Tissue is responsive to hormonal stimulation.
Oligomenorrhea is fewer than ——— menstrual cycles per year or cycle length of ——— days or more
nine
35
Primary amenorrhea:
Absence of menses by age 15 with normal growth and secondary sexual characteristics
or
absence of menses by age 13 with no secondary sexual characteristics
Secondary amenorrhea:
Absence of menses for ≥3 months in a woman who previously had a regular menstrual cycle
or
>6 months in a woman who had irregular menses
A 32-year-old G0P0 patient presents with a 3-year history of infertility. She
experienced menarche at age 13, and has regular menses every 28 days. She reports severe pain 2–3 days before her period, pain during her period, and pain with intercourse. She reports no history of sexually transmitted infections (STIs). Her husband has one child from a previous marriage. On exam, she has uterosacral nodularity and a fixed, retroflexed uterus. How should the suspected diagnosis be confirmed? What findings would be present on a tissue biopsy?
The patient has classic symptoms of endometriosis: dysmenorrhea and dyspareunia. Endometriosis is often associated with infertility. Although history and exam may suggest endometriosis, diagnostic laparoscopy is required to make a definitive diagnosis. The tissue biopsy would show endometrial glands, stroma, and hemosiderin-laden macrophages. The most common sites of involvement are the ovaries and pouch of Douglas.
A 39-year-old G4P4 patient presents with worsening heavy menstrual bleeding (HMB) and dysmenorrhea. On physical exam, the uterus is 14 weeks’ size, globular, boggy, slightly tender, and mobile. What is the next best step in management?
There is no proven medical therapy for adenomyosis, and hysterectomy is the only guaranteed treatment. However, conservative management with hormonal therapy is a reasonable next step. NSAIDs and OCPs can improve dysmenorrhea and regulate the heavy menses.
A 40 yo F complains of increasing pain with menses for the past 11 months. Her periods are extremely heavy. Her last child was delivered 12 years ago with a subsequent tubal ligation. On pelvic exam, her uterus appears enlarged and tender with a globular, soft consistency.
This patient has adenomyosis (the deposition of endometrial glands in the myometrium). In contrast with a leiomyoma that has an asymmetric, firm, and nontender uterine presentation, adenomyosis has a symmetric, soft, and tender uterine presentation. Dx is usually clinical although an MRI may be helpful. It is very HY to know that dx can only be made conclusively by the examination of tissue after surgery. Tx is usually with the levonorgestrel IUD which may curb the menstrual bleeding. Definitive treatment revolves around getting a hysterectomy.
When evaluating a patient with primary amenorrhea, note presence/absence of
breasts and uterus
Primary amenorrhea + elevated serum FSH =
Gonadal dysgenesis. Most common cause of primary amenorrhea ~40–45%.
17α hydroxylase deficiency:
46,XX: Breast ———, uterus ———; 46,XY: Breast ———, uterus ———
46,XX: Breast absent, uterus present 46,XY: Breast absent, uterus absent
Androgen insensitivity:
Patients look female externally. No pubic hair. Remove gonads after puberty to avoid risk of malignancy (gonadoblastoma or dysgerminoma).
An 18-year-old G0 patient presents with primary amenorrhea. Her sister
experienced menarche at age 12. She reports no use of drugs, heavy exercise, or significant weight loss. She is 5′5′′ and 130 lb. Her blood pressure is 110/60. Physical exam demonstrates Tanner stage IV breasts, no axillary or pubic hair, and a blind vaginal pouch. What is the most likely diagnosis?
Answer: Androgen insensitivity. Breasts are present; uterus and axillary/pubic hair is absent in androgen insensitivity.
What is the result of Müllerian agenesis?
Absent uterus
Second most common cause of primary amenorrhea
Müllerian agenesis
Normal breast and pubic hair + no menses + cyclic pelvic pain + bulging blue mass at the introitus =
Hematocolpos from imperforate hymen
Androgen Insensitivity vs Müllerian Agenesis: Karyotype
Androgen Insensitivity: XY
Müllerian Agenesis: XX
Androgen Insensitivity vs Müllerian Agenesis: Breast
Androgen Insensitivity: Present
Müllerian Agenesis: Present
Androgen Insensitivity vs Müllerian Agenesis: Uterus
Androgen Insensitivity: Absent
Müllerian Agenesis: Absent
Androgen Insensitivity vs Müllerian Agenesis: Pubic/axillary hair
Androgen Insensitivity: Absent
Müllerian Agenesis: Normal
Androgen Insensitivity vs Müllerian Agenesis: Testosterone
Androgen Insensitivity: Normal male levels
Müllerian Agenesis: Female levels
Androgen Insensitivity vs Müllerian Agenesis: Further evaluation
Androgen Insensitivity: Need gonadectomy
Müllerian Agenesis: Renal/skeletal abnormalities
The most common cause of secondary amenorrhea is
pregnancy. Always check a pregnancy test in a reproductive-age woman.
A 30-year-old G2P2002 patient, with last menstrual period (LMP) 8 weeks ago, presents with no menses for 2 months. She usually has menses every 28 days lasting for 5 days. She reports no medical or surgical history. She has had two vaginal deliveries at term. She uses combination oral contraceptive pills (OCPs), and has not missed any pills recently. What is the next step in management of this patient?
The most common cause of amenorrhea in a reproductive-age woman is pregnancy, so a urine or serum β-hCG should be checked. Contraception use does not prevent pregnancy 100% of the time.
Adolescent girls with amenorrhea should be screened for
disordered eating patterns
What is Sheehan syndrome?
Postpartum pituitary dysfunction due to intrapartum ischemia
In Sheehan syndrome, patients do not produce ——— due to ———
milk
the absence of prolactin
Sheehan syndrome typically presents with —(2)— after delivery in a patient with a history of ———
failure of postpartum lactation and failure to resume menses
severe postpartum hemorrhage
Sheehan syndrome: ——— occurs due to severe ——— resulting in hypotension and often requiring blood transfusion. Treatment includes ———
Pituitary cell infarction
post-partum hemorrhage
replacement of pituitary hormones
Primary ovarian insufficiency:
3 key elements presentation
■ Age <40
■ Amenorrhea
■ Elevated FSH
A 35-year-old G2P2002 patient with LMP 1 year ago presents with hot flashes and vaginal dryness. Her serum FSH is very high. What is the most likely diagnosis?
Primary ovarian insufficiency. Symptoms are similar to those in menopause and diagnosis is confirmed with elevated FSH
Patients who exercise or play sports intensely may develop the “female athlete triad,” characterized by
amenorrhea, disordered eating, and decreased bone mineral density. The primary issue is energy imbalance, whereby more calories are expended than consumed.
——— is the most common cause of hirsutism.
PCOS
A 35-year-old G3P3003 patient presents with absence of menses for 8 months. She reports menarche at age 12 with menses every 40–50 days until recently. She reports a 20-lb weight gain over the last year. She used letrozole to become pregnant with her last two pregnancies. Vitals show height 5′4′′, weight 220 lb, BP 120/80. She has hair on her upper lip and chin, acne, and oily skin on her face. What is the most likely diagnosis? If left untreated, what is this patient at ↑ risk for?
Polycystic ovarian syndrome (PCOS). Diagnosis of PCOS is established with two out of three of the following: a history of oligomenorrhea/amenorrhea, features of hyperandrogenism (acne, hirsutism), and multiple ovarian cysts seen on ultrasound. This patient is at ↑ risk for endometrial hyperplasia or cancer if left untreated.
A 28-year-old G0 patient has been unable to conceive with her husband over 1 year of regular, unprotected intercourse. Her periods are irregular. She has a BMI of 30, displays coarse facial hair, and a dark velvety pigmentation on the back of her neck. What is the likely diagnosis in this patient? What is the most likely reason she is unable to conceive?
Polycystic ovarian syndrome (PCOS) affects approximately 5% of all women, and is a leading cause of infertility. Her exam shows evidence of hyperandrogenism and insulin resistance. She is anovulatory and will likely need an ovulation induction agent to conceive.
Treatment of choice for PCOS:
Combined OCPs as they manage hyperandrogenism, menstrual irregularities, and provide contraception.
Asherman syndrome: Intrauterine adhesions can
obliterate the endometrial cavity and cause amenorrhea.
Asherman syndrome is ——— secondary to ———
intrauterine adhesions
uterine curettage associated with pregnancy (including after SAB, for retained placenta, or PPH) or shortly thereafter with resultant scarring.
The most common symptoms associated with Asherman syndrome include (4)
amenorrhea or light periods, infertility, cyclic pelvic pain, recurrent pregnancy loss.
Progestin challenge test:
Give oral progestin for 10 days. If the endometrium has been primed with estrogen from ovaries or peripheral fat, the withdrawal of progestin after 10 days will cause endometrial sloughing with resultant withdrawal bleed. No withdrawal bleeding indicates absence of ovaries, estrogen deficiency, or outflow obstruction.
Consider Asherman syndrome as the dx if a woman has ——— and the Q stem gives you a history of (2)
amenorrhea
dilation and curettage or super bad PID
(In some cases, these “uterine disturbances” create scar tissue that can cause amenorrhea/infertility)
Asherman syndrome treatment
Hysteroscopic lysis of these adhesions + estrogen typically is a good management step.
Do not forget to order a ——— in a woman presenting with amenorrhea
serum B-HCG
(In addition, consider taking a look at the TSH, prolactin levels (give Cabergoline as tx), androgen levels (testosterone and DHEAS), etc. )
A woman with PCOS will have a ———progesterone withdrawal challenge
+ve
A woman with Asherman’s syndrome/some kind of obstructive lesion in the uterus/cervix will have a ———progesterone withdrawal challenge.
-ve
(This will also be the case with someone having low E2 levels.)
The Tanner stages of development refer to the ———; these are———
sequence of events of breast and pubic hair development.
Stage 1: Prepuberty
Stages 2–4: Development stages
Stage 5: Adult development
The first menstrual bleeding is usually caused by the effects of——— stimulating the ———, rather than by ovulation.
estradiol
endometrial lining
Puberty is believed to begin with ———
disinhibition of the pulsatile GnRH secretion from the hypothalamus
GnRH stimulates the
anterior pituitary gland to secrete follicle-stimulating hormone (FSH) and luteinizing hormone (LH)
At puberty in girls, FSH stimulates ———, and along with LH, stimulates production of ——— (which causes (3))
growth of ovarian follicles
estradiol in the ovaries
breast development, skeletal growth, and stimulation of the endometrium
(Later, FSH and LH lead to ovulation and menstruation)
Thelarche is ———; average age ———; dominant hormone ———
breast budding
10
estradiol
Pubarche is ———; average age ———; dominant hormone ———
axillary and pubic hair growth
11
Adrenal hormones (androgens)
Menarche is ———; average age ———; dominant hormone ———
first menses
12
Estradiol
A female age ——— or older without any breast development should be evaluated for delayed puberty.
13
Menstrual cycle is from he HPO axis and uterus interacting to allow ovulation approximately ——— [average ——— days (+/– ———days)].
once per month
28
7
In menstruation, many follicles are stimulated by ———, but the follicle that ——— will be released
FSH
secretes more estrogen than androgen
In menstruation, the dominant follicle ——— so that its positive feedback causes an ———
releases the most estradiol
LH surge
Menstruation: Withdrawal of ——— causes ———
progesterone
endometrial sloughing
■ Average duration of menses =
■ Normal menstrual cycle length =
5 days
21–35 days
——— released from the ——— cause dysmenorrhea.
Prostaglandins
endometrium
Before ovulation vs after ovulation: ovarian phase
Before ovulation: follicular
After ovulation: luteal
Before ovulation vs after ovulation: uterine phase
Before ovulation: proliferative
After ovulation: secretory
Before ovulation vs after ovulation: dominant hormone
Before ovulation: estrogen
After ovulation: progesterone
Follicular phase: FSH causes (2)
follicle maturation and estrogen secretion
Follicular phase (day 1-14): Estrogen causes
endometrial proliferation
Ovulation (Day 14): The LH surge causes the ———. The ruptured follicle then becomes the ———, which secretes ———.
oocyte to be released from the follicle
corpus luteum
progesterone
Luteal phase (14-28): Corpus luteum secretes ———, which causes (2)
progesterone
Endometrial maturation and↓FSH,↓LH
Ovulation takes place ——— hours after LH surge and ——— hours after LH peak.
24–36
12
The length of the ——— phase is highly variable. The ——— phase is usually about 14 days due to the ———. Individuals who have changes in their cycle length typically experience changes in the ——— phase.
follicular
luteal
length of time the corpus luteum is able to secrete progesterone
follicular
The corpus luteum is maintained after fertilization by ———, which is released by ———.
hCG
embryo
After progestin challenge test, give ——— to Distinguish Between Hypoestrogenism or an Outflow Tract Obstruction (Asherman’s Syndrome or Cervical Stenosis):
If bleeding occurs, amenorrhea is due to ———
If bleeding does not occur, then most likely it is ———
Estrogen and Progestin (Give estrogen to ensure endometrial proliferation, followed by a progestin to induce withdrawal bleeding. )
hypoestrogenism (hypothalamic amenorrhea or premature ovarian failure)
outflow tract obstruction – either Asherman’s syndrome or cervical stenosis.
“bluish bulge” in the vagina associated with ———; treated with ———
an imperforate hymen
“cruciate incision”
23 yo F has had menses before, missed her last 3 periods, urine B-HCG is +ve
she’s pregnant
23 yo F has had menses before, missed her last 3 periods, biopsy reveals lymphoid follicles in the thyroid
Hashimoto’s, high TRH, hyperprolactinemia
23 yo F has had menses before, missed her last 3 periods, has galactorrhea
prolactinoma (tx with bromocriptine, cabergoline)
23 yo F has had menses before, missed her last 3 periods, was diagnosed with schizophrenia 3 mo ago
dopamine antagonists, hyperprolactinemia.
35 yo F has had menses before, BMI of 32, irregular menses for the past 5 years
PCOS
Gestational age:
The time of pregnancy counting from the first day of the last menstrual period (LMP).
First trimester:
Second trimester:
Third trimester:
First trimester: 0–12 weeks.
Second trimester: 13–27 weeks.
Third trimester: 28 weeks–birth.
Embryo:
Fetus:
Embryo: Fertilization–8 weeks.
Fetus: 9 weeks–birth.
Previable:
Periviable:
Preterm:
Term:
Previable: <22 weeks.
Periviable: 22–24 weeks.
Preterm: 20–36 weeks.
Term: 37–42 weeks.
Remember that ——— has the highest correlation with congenital abnormalities.
alcohol use
20 yo F has breasts and a uterus, levels of all hormones are normal
imperforate hymen, or anything weird that blocks the vagina. She is actually menstruating, but the blood is not making its way out. Dx is by PE, tx is with surgery.
20 yo F supermodel (or hardcore athlete) has breasts and a uterus (what should be true of her hormone levels?)
this is either anorexia nervosa/just working out too much. In the setting of severe physiologic stress, the GnRH axis is turned off. Therefore, GnRH/LH/FSH/Estrogen levels are all low.
20 yo F has breasts and no uterus, testosterone levels are super high
she has no uterus b/c she is 46 XY. this is testicular feminization syndrome (or Androgen Insensitivity Syndrome)- Sertoli cells make MIH so the mullerian duct is nuked (oviducts, uterus, upper third of the vagina). She has breasts b/c the testosterone is aromatized to estrogen in the periphery. Why should she have an orchiectomy after puberty?
20 yo F has breasts and no uterus, karyotype reveals a 46 XX phenotype
Mullerian Agenesis (Mayer Rokitansky Kuster Hauser Syndrome). For whatever reason, the mullerian duct does not develop so there’s no uterus. She has ovaries which produce estrogen (ovaries are not derived from the mullerian ducts) so she has breasts. Whenever you see breasts, estrogens are around. Whenever you see pubic hair, androgens are around.
20 yo F has no breasts, but has a uterus, she can’t smell
Kallmann Syndrome, everything will be low-GnRH down. No breasts b/c the ovaries are making no estrogen. Give pulsatile leuprolide.
20 yo F is 3’ 5” tall, low posterior hairline, widely spaced nipples, BP of 150/120 in the arms and a BP of 65/40 in the legs, has a uterus, no breasts
this is Turner’s syndrome. Turner’s is a kind of hypergonadotropic hypogonadism (streak ovaries) so the FSH levels will be high. Karyotype is 45 XO. Common associations include bicuspid aortic valves, coarctation of the aorta (BP differences b/w the arms and legs), horseshoe kidney, amongst other anomalies. With the ovaries basically non-existent, there is no estrogen (or very little), so there is no breast development.
20 yo F with a uterus, no breasts, and visual field deficits
some kind of brain tumor (like a craniopharyngioma, considering the VF deficits). A compressive lesion of the anterior pituitary may hamper LH/FSH production so the ovaries are not stimulated (so there’s no estrogen = no breasts).
A 31-year-old G2P1001 patient at 17 weeks’ gestation undergoes routine prenatal tests. Her results show that her blood type is A negative, and her antibody screen is positive. She does not report undergoing a blood transfusion in the past or any complications with her last pregnancy. What is the next step in the management of this patient?
The next step is to identify the antibody. There are many types of antibodies, and in a patient that is Rh negative, it should not be assumed that she has Rh antibodies.
The only contraceptive methods that protect against STIs are
the male and female condoms
——— accounts for most condom failures.
Inconsistent condom use
If diaphragm left in for too long (>24 hours), in rare cases, may result in
Staphylococcus aureus infection (which may cause toxic shock syndrome).
Efficacy rates for spermicides are much higher when
combined with other barriers (i.e., condoms, diaphragms).
A 37-year-old G2P2 patient desires a reversible form of contraception. Her history is significant for migraines with visual aura, uncontrolled hypertension (HTN), and family history of breast cancer in her mother. She smokes two packs of cigarettes daily. She requests combination oral contraceptives (COCs). How should this patient be counseled?
The patient is not a candidate for COCs because she has several contra- indications that put her at an increased risk for developing venous thromboembolism and stroke. Contraindications for COC use include age >35 years old and smoking, history of venous thromboembolism, uncontrolled HTN, diabetes with vascular disease, migraines with visual aura, and benign or malignant liver tumors, cirrhosis, and personal history of breast cancer.
——— headaches are not a contraindication for COCs. ——— headaches can increase risk of stroke in patients who take combination hormonal contraception.
Tension
Migraine with visual aura
P450 inducers will decrease the efficacy of ——— contraceptives (e.g., phenytoin, rifampin, griseofulvin, carbamazepine, barbiturates) due to accelerated metabolism of ———.
oral
OCPs
Hormonal patch may be less effective in
obese (≥200 lb) women.
Types of endogenous estrogens:
Reproductive life: ———
Pregnancy: ———
Menopause: ———
Estradiol
Estriol
Estrone
(Estrone (E1): People make this type of estrogen after menopause.
Estradiol (E2): This is the most common type of estrogen that people make.
Estriol (E3): This is the main type of estrogen in a pregnant person’s bloodstream.)
The inactive pills in the COC simulate ———, which results in menses.
hormone withdrawal of the normal menstrual cycle
Always check a β-hCG to rule out pregnancy before prescribing the acne medicine ——— (very teratogenic!).
isotretinoin
What is the treatment for idiopathic hirsutism?
OCPs
Oral contraception mechanism in a nutshell:
■ Estrogen inhibits ———
■ Progestin inhibits ———
FSH (prevents follicular development)
LH (inhibits ovulation)
COC: Estrogen and progesterone combined. Main mechanisms: (4)
■ Prevents ovulation
■ Alters uterine and fallopian tube motility
■ Thickens cervical mucus to prevent
sperm penetration
■ Causes endometrial atrophy
There is no proven link between OCP use and ↑ in
breast cancer
Estrogen can impact ———, so combination pills are not recommended for ———.
——— are recommended until that time.
breast milk supply and production
nursing mothers until milk supply is stable
Progestin-only pills
Side effects of estrogen: (3)
■ Breast tenderness
■ Nausea
■ Headache
Side effects of progestin: (4)
■ Depression
■ Acne
■ Weight gain
■ Irregular bleeding
Why is estrogen a procoagulant?
Estrogen ↑ factors VII and X and ↓ antithrombin III.
A 20-year-old G0 patient desires long-acting reversible contraception. She has a history of epilepsy for which she takes an anticonvulsant. She still has seizures once about every 6 months. She is also wary of anything that goes ‘in her body’. What is the best contraceptive method for her?
Medroxyprogesterone acetate (DMPA) injection can ↑ the seizure threshold and ↓ the number of seizures. It also ↓ the number of sickle cell crises in patients with sickle cell disease. It improves anemia, ↓ dysmenorrhea and ovarian cysts, and improves symptoms of endometriosis.
Most common complaint / reason for stopping Medroxyprogesterone acetate (DMPA) injection:
Weight gain
Non-user-dependent methods like the IUD, subdermal implant, and injections have lower failure rates than ———.
OCPs
IUDs and contraceptive implants, also called long-acting reversible contraceptives (LARC), are the most effective
reversible contraceptive methods
If the IUD strings are not visible on follow-up speculum examination, a cytobrush can be used to ———. If this is not successful, then an ——— should be performed to determine the location of the IUD. If the IUD is not visible in the uterus on ———, then an ——— should be performed to assess for possible ———.
try to pull the strings down and out of the cervical os.
ultrasound
ultrasound
abdominopelvic X-ray
uterine perforation
A 25-year-old G1P1patient, who delivered a full-term infant 6 months previously,
presents for IUD insertion. She reports that she is in a long-term, monogamous relationship. She reports no history of STIs or other medical conditions. She undergoes the insertion of an IUD without any apparent complications. The patient presents 4 days later with abdominal pain, nausea, vomiting, and fever. Speculum exam reveals malodorous discharge and IUD strings at the cervical os. What is the most likely cause for the patient’s symptoms?
Endometritis due to contamination during insertion. Infections that occur near the time of IUD insertion are usually due to ascending infection from vaginal flora. Infections, months to years, after the IUD placement may be due to STIs.
Contraindication for IUD placement: ———, due to ———
Severe distortion of uterine cavity (e.g., bicornuate uterus or large obstructive fibroids)
increased difficulty with insertion, increased risk of IUD expulsion/ embedment/perforation, and decreased efficacy.
The absolute risk of ——— is lower for women using an IUD compared with women not using contraception or using other reversible methods of contraception. However, should a pregnancy occur in a patient using and IUD, the risk of ——— is higher, ranging from 10 to 30%.
ectopic pregnancy
ectopic pregnancy
——— are the most effective method of emergency contraception (both types are more than 99% effective). Another benefit of this method is that they may be ———
IUDs
left in place in order to continue to provide ongoing, highly effective contraception.
The only contraceptive methods that protect against STDs are
abstinence/condoms.
Combined OCPs work by (2)
inhibiting ovulation (E2 -ve feedback)
ncreasing the thickness of cervical mucus (progesterone)
Avoid combined OCPs in individuals with (7)
history of a DVT/PE
Weird genetic diseases like Factor 5 Leiden
history of cancers driven by E2 (like breast)
people with bad HTN
patients with hepatic adenomas
smokers > 35 yo
h/o migraine with aura/atypical migraine involving neuro deficits.
Combined OCPs decrease the risk of
ovarian/endometrial cancer (fewer cycles)
If a lady is being treated for TB and becomes pregnant with regular combined OCP use, think of
revved up metabolism from rifampin mediated CYP450 induction.
Progestin only pills MOA involves thickening
cervical mucus
Progestin only pills associated with (2)
weight gain
reversible osteoporosis.
Progestin only pills are good ——— options
postpartum
A progesterone derivative (Megestrol) is given to
stimulate the appetite in cachectic patients
The Cu IUD is an excellent contraceptive that works by causing
an inflammatory reaction that makes the uterus inhospitable for sperm and eggs
Remember the association of ———with a history of tubal ligation.
ectopic pregnancies
The Cu IUD is should be avoided in a woman with (2)
History of heavy menses
Wilson’s disease
A 22 yo G1P1 female visits her obstetrician 1 week after she delivered a boy that weighed 6 Lbs and 4 ounces. The delivery was unremarkable with APGAR scores of 8 and 9 at 1 and 5 minutes respectively. The patient plans to have her next baby when she graduates from graduate school 2 years from now. In addition to routine screening for postpartum depression, what is the next best step in the management of this patient?
a. Discussion of the benefits of breastfeeding as an excellent long term form of birth control.
b. Cervical swabs for N. Gonorrhoeae and C. Trachomatis.
c. Prescription for a combined oral contraceptive pill.
d. Prophylactic sertraline for postpartum depression.
e. Obtaining consent for the administration of depo medroxyprogesterone acetate
during this visit.
The best answer here is E.
Progestin only contraceptives are the ideal option
In the postpartum period, ——— may be ok as birth control for a 6 mo period, however it is not completely reliable.
breastfeeding
In a woman that expresses a desire for birth control postpartum, resist the temptation to prescribe
anything containing estrogen (inhibits breastfeeding)
Progestin only contraceptives MOA involves
thickening cervical mucus
Progestin only contraceptives protect against
endometrial cancer
Progestin only contraceptives avoided in the setting of
breast cancer (or other progesterone receptor positive gynecologic malignancies)
Association of injectable progesterone with (3)
delayed return to fertility after discontinuation (up to a year)
possible weight gain
in some cases, a decrease in bone mineral density
Treat breast mastitis with
dicloxacillin
A 26-year-old patient who is 4-weeks postpartum presents with a 1-day history of fever of 100.9°F (38.3°C) and breast tenderness. She has been breast-feeding without problems and reports no other symptoms. Her left breast has a 4-cm area of induration and erythema at the 3 o’clock position that is tender to palpation. Milk expressed from that breast is white. What is the most likely diagnosis? What is the treatment?
Mastitis. Focal area of breast infection and fever approximately 1 month postpartum is consistent with mastitis. The patient should be started on dicloxacillin.
Breast-Associated Fevers: Mastitis timeframe
Breast-Associated Fevers: Mastitis timeframe
Mastitis (Breast-Associated Fevers): timeframe
Anytime while lactating (usually >3–4 weeks postpartum)
Mastitis (Breast-Associated Fevers): presentation
Focal erythema and induration, streaking on the breast
Mastitis (Breast-Associated Fevers): causative agent
Staph aureas, MRSA, coag negative staph
Mastitis (Breast-Associated Fevers): management
Treat with dicloxacillin for 7–10 days
Mastitis (Breast-Associated Fevers): continue breastfeeding?
Yes
Breastfeeding is associated with a decreased risk of (2)
Breast cancer (Prolactin shuts down GnRH which nukes estrogen production. Estrogen drives many breast cancers.)
Ovarian cancer (Prolactin shuts down GnRH which causes anovulation. With anovulation, the ovarian epithelium does not have to be broken down and repaired each month (which happens with ovulation). This reduces the potential for malignant transformation of ovarian epithelium.)
Breast feeding helps with
weight loss
A woman with (3) should not breastfeed
HIV
active TB
active herpes lesions on the breast
Infants with ——— is a contraindication to breastfeeding.
Galactosemia
A 28-year-old woman, gravida 1, para 1, comes to the office to discuss a recent cervical pap smear. The cytology report says that she has atypical squamous cells of undetermined significance (ASCUS). She has never had an abnormal pap smear result before. Reflex human papillomavirus (HPV) testing is negative. Which of the following is the most appropriate next step in managing this patient?
- Human papillomavirus vaccine
- Repeat pap smear with HPV testing in 1 year
- Repeat pap smear with HPV testing in 3 years
- Colposcopy with biopsies
- Loop electrosurgical excision procedure
Repeat pap smear with HPV testing in 3 years (Note: At which point 28yo pt will be over 30!)
Co-testing, pap smear and human papillomavirus (HPV) testing, is an appropriate follow-up plan for young women with atypical squamous cells of undetermined significance (ASCUS). This should be performed 3 years after the abnormal cytology report.
For the woman described in the question, a pap smear has identified atypical cells of undetermined significance (ASCUS). According to the American Society for Colposcopy and Cervical Pathology (ASCCP) as well as the American College of Obstetricians and Gynecologists (ACOG), the preferred next step is to do reflex human papillomavirus (HPV) testing. If HPV testing is negative, as in this patient, the next step is to repeat a pap smear with reflex HPV testing in 3 years (this is known as “co-testing”). However, if HPV testing is positive, colposcopy is warranted. For women age 30 or great, ASCUS doesn’t even warrant HPV testing - current recommendations are just to do co-testing in 3 years.
An acceptable alternative to reflex HPV testing is to repeat the pap test in one year, but HPV testing is more likely to grant immediate peace of mind, as well as reduce the number of procedures performed.
A 30-year-old woman is brought to the emergency department because of altered mental status. Collateral history shows that the patient has been fatigued over the last 24 hours, and today did not recognize her husband. In addition, she has had a decreased appetite and vomiting over the past 12 hours. She is known to have cervical cancer for which she is awaiting treatment. Current medications include only oxycodone. Vitals signs show her temperature is 37°C (98.6°F), pulse is 85/min, respirations are 26/min, blood pressure is 160/90 mmHg, and oxygen saturation is 94% on room air. Physical examinations shows a drowsy, diaphoretic female, asterixis, and moderate distension inferior to the umbilicus. Initial laboratory results are shown below.
Sodium: 135 mEq/L
Potassium: 4.9 mEq/L
Chloride: 99 mmol/L
Bicarbonate: 12 mEq/L
Blood Urea Nitrogen: 65 mg/dL (high)
Creatinine: 3.5 mg/dL (high)
Glucose: 122 mg/dL
Hemoglobin: 14 g/dL
Which of the following is the most likely cause of this patient’s altered mental status?
- Medication overdose
- Uremic encephalopathy
- Brain metastasis
- Hepatic encephalopathy
- Severe sepsis
Uremic encephalopathy
Complications of malignancy can present in a variety of ways, as shown in this case of cervical cancer. Obstructive uropathy can cause post-renal failure leading to uremia and uremic encephalopathy. The patient has confusion, decreased alertness, vomiting, and asterixis, all which are consistent with an encephalopathic condition.
This patient has confusion, decreased alertness, vomiting, and asterixis, all of which are consistent with an encephalopathic condition. Note that the patient also has acute renal failure, with a BUN of 65 g/dL and a creatinine of 3.5 mg/dL, and an anion gap of 24. The most likely cause of these abnormalities is acute uremic encephalopathy. Uremia will cause an anion gap metabolic acidosis, which may explain why the patient is diaphoretic and tachypneic. One possible etiology of this patient’s renal failure is obstructive uropathy from the underlying cervical cancer compressing the lower urinary outflow tract. The patient’s lower abdominal distension likely represents a distended bladder.
HPV types associated with low-
grade cervical lesions and 90% of anogenital warts
Types 6 and 11
HPV types associated with >50% of high-grade cervical lesions and 70% of cervical cancer
HPV Types 16 and 18
Vaccines against high-risk strains of HPV are currently FDA approved for
females and males between the ages of 9 and 45 years
Risk Factors for Cervical Dysplasia
and Cervical Cancer
■ HPV infection
■ ↑ sexual activity (↑ risk of viral/bacterial infections)
■ Low socioeconomic status (likely due to limited access to health care and screening)
■ Genetic predisposition
■ Cigarette smoking (increases risk for squamous cell cancers but not adenocarcinomas)
■ OCPs (condoms
↓ risk in these women)
■ Immunosuppression
A 21-year-old G2P2 patient desires contraception. She has been sexually active for
4 years, with three lifetime partners. Her menses are irregular. Before prescribing combined OCPs, what tests need to be performed?
A pregnancy test, Pap test, and STI screening
Define a Pap test
A Pap test is a cytologic screening test for cervical dysplasia
The methods available for cervical cancer screening are
Pap test (i.e., cytology), HPV testing, and co-testing with both cytology and HPV
The ectocervix is comprised of ——— epithelium, and the endocervix (including cervical canal) is comprised of ——— epithelium.
squamous
glandular (columnar)
Pap test is a screening test that provides ——— information, not ——— information
cytologic
histologic
Pap test screening should begin
not begin until age 21, regardless of sexual activity
USPSTF recommendations on screening for cervical cancer
Screening in women age 21 to 65 years with cytology (Pap smear) every 3 years or, for women ages 30 to 65 years who want to lengthen the screening interval, screening with a combination of cytology and HPV testing every 5 years
Pap smears are not helpful in women after
hysterectomy (for non-cancer disease)
Contrast types of cervical cancer in terms of commonness and location:
Squamous cell cancer (outer cervix) is the most common kind of cervical cancer
Adenocarcinomas can also occur but are typically in the inner cervix that is not necessarily visible with a speculum exam
Most cervical cancers arise in the
transformation zone between the ecto and endocervix
(Specifically, most cervical cancers arise at the squamocolumnar junction)
RFs for cervical cancer:
The biggest RF is a history of exposure to HPV (especially 16 and 18).
Other RFs include:
having multiple sex partners, having a h/o of STDs,
having HIV (immunosuppression),
smoking
You certainly need to know the screening guidelines for cervical cancer.
A woman should be screened every 3 years from 21-29. A similar regimen can be pursued after the age of 30. However, a pap smear + HPV screening can be conducted every 5 years. Screening can be stopped at 65 if multiple pap smears have been normal.
Screening for cervical cancer no longer necessary if:
A patient that undergoes a hysterectomy FOR BENIGN REASONS does not need further screening after the procedure. For NON-BENIGN reasons, a pap smear of the vaginal cuff must be undertaken at routine intervals.
A pap smear revealing ASCUS (atypical squamous cells of undetermined significance) should be followed by ——— if the patient is over 25. If HPV+, ———. If < 25, ———. If +ve, ———.
HPV testing
proceed to a colposcopy
an acceptable option is to repeat the pap in a year (but preferred from osmosis also HPV Testing)
proceed to colposcopy
Option 1 (for the > 25 yo F) is also acceptable.
If a pap smear reveals ASC-H (ASC but cannot exclude HSIL; atypical squamous cells, cannot exclude a high-grade squamous intraepithelial lesion):
proceed to a colposcopy
If a pap smear reveals AGUS (Atypical Glandular Cells of Undetermined Significance), your NBSIM is:
to get a whole bunch of tests:
colposcopy, endocervical curettage, and an an endometrial biopsy
If a pap smear reveals low-grade squamous intraepithelial lesions (LSIL or cervical intraepithelial neoplasia (CIN 1)), it is typically acceptable to ———. In some rare cases with super low risk individuals (aka really young), ———
get a colposcopy with biopsy
the pap may be repeated in a year since these individuals will more than likely clear the infection
High-grade squamous intraepithelial lesions (HSIL or CIN 2 or 3),———l
proceed to a colposcopy always
An unusual answer you may see on the NBME is to perform a Loop Electrosurgical Excision Procedure (LEEP) procedure to excise the lesion
If a pap smear shows LSIL (CIN 1) but a colposcopy with biopsy shows something different (e.g. HSIL with CIN 2⁄3):
repeat the colposcopy and get an endocervical curettage
Consider cervical cancer if a Q stem gives you a patient with cervical cancer RFs in the setting of:
post-coital bleeding
Cervical cancer can metastasize to ——— structures and cause ———
urinary system (like ureters)
hydronephrosis leading to renal failure (When cervical cancer spreads to other areas of the pelvis, it can block one or both ureters, which carry urine from the kidneys to the bladder. This can lead to a condition called hydronephrosis. In hydronephrosis, blocked ureters cause urine to build up in the kidneys.) This is the MCCOD in cervical cancer.
Key complication of LEEP and conization procedures:
cervical insufficiency (painless pregnancy loss)
A 22-year-old woman comes to her primary care physician’s office for a follow up of an abnormal Pap smear result. The patient had a Pap smear completed one month ago, which showed a low-grade squamous intraepithelial lesion, and tested positive for double stranded DNA naked icosahedral DNA virus. History reveals she began having sexual intercourse at age 16 and has had 4 lifetime partners. There is no history of sexually transmitted infections or pregnancies. She uses oral contraceptive pills regularly and condoms “most of the time.” She denies tobacco or illegal drug use. She has not had any vaccinations for the prevention of sexually transmitted infections. Which of the following is the most appropriate next step of management in this patient?
- Loop electrosurgical excision procedure
- Hysterectomy
- Repeat cervical cytology in 12 months
- Repeat Pap smear in 4 months
- Colposcopy
Repeat cervical cytology in 12 months
HPV, double stranded DNA virus, is the most commonly transmitted sexual infection and is a major cause of cervical cancer. Patients ages 21-24 with a low-grade squamous intraepithelial lesion should be treated conservatively and scheduled for a follow up cytologic screening test in 12 months
Cytologic (Pap test) abnormalities are described using the term ———. Histologic (biopsy) abnormalities are described using the term ———.
“squamous intraepithelial lesion” (SIL)
“cervical intraepithelial neoplasia” (CIN)
A 45-year-old G4P4 patient presents for a routine annual exam. Her Pap test returns
with a report of ASCUS. Her Pap tests have always been normal in the past. What is the next best step to evaluate her cancer risk?
High-risk HPV DNA testing. If high-risk HPV DNA testing is “positive,” indicating the presence of a hrHPV strain, then a colposcopy and indicated biopsies should be performed. If the HPV testing is negative, she can be managed as per her age-based protocol.
A 35-year-old woman comes to the office because of irregular bleeding since her last period three weeks ago. She says her bleeding is consistently postcoital. Examination shows no abdominal masses and no peripheral edema. Her urethra is normal, and her fecal occult blood test shows no abnormalities. She is not pregnant. Which of the following is the most likely diagnosis?
-Uterine fibroids
-Urethral caruncle
-Ectopic pregnancy
-Peri-menopausal bleeding
-Cervical neoplasia
Cervical neoplasia may be characterized by postcoital bleeding for about 11% of cases. Postcoital bleeding refers to spotting or bleeding unrelated to menstruation that occurs during or after sexual intercourse. Other causes include cervical polyps, vaginal cancer, or genital infections.
(If the bleeding is consistently postcoital, it suggests cervical pathology, such as cervical polyps, cervicitis, or cervical neoplasia.)
ACOG Screening Guidelines for cervical cancer in individuals aged 21–29
Individuals aged 21–29 should be screened with cervical cytology (Pap test) alone every 3 years
ACOG Screening Guidelines for cervical cancer in individuals aged 30–65
There are now three recommended options for cervical cancer screening
in individuals aged 30–65 years:
■ Cytology alone every 3 years.
■ FDA-approved primary hrHPV testing alone every 5 years.
■ Co-testing with cytology and hrHPV testing every 5 years.
ACOG Screening Guidelines for cervical cancer in high risk individuals
Frequency of Pap test screening should be individualized, and may need to occur earlier/more often in women who have HIV, are immune compromised, were exposed to diethylstilbestrol (DES) in utero, or have been previously treated for CIN2, CIN3, or cancer.
ACOG Screening Guidelines for cervical cancer in women under age 21
Women under age 21 should not be screened, because the incidence of cervical cancer is very low, and they have an effective immune response that will usually clear the HPV infection in 8–24 months.
ACOG Screening Guidelines for cervical cancer in women after age 65
Pap tests may be discontinued after age 65 in healthy women with adequate negative prior screening test (Pap test) results and no history of CIN2 or higher.
ACOG Screening Guidelines for cervical cancer in women after hysterectomy
A Pap test may be discontinued after hysterectomy (with removal of the cervix) for benign disease.
A 15-year-old girl comes to the office for a routine annual physical examination. During the appointment, her mother inquires about the human papillomavirus (HPV) vaccine and is happy for her daughter to get the vaccine today. When her mother steps out of the office, the patient says that she started having sex with her boyfriend about two months ago, and she does not want her mother to know. They have always used condoms and her last menstrual period was eight days ago. Which of the following is the most appropriate next step in management?
-Inform the patient’s mother that she cannot get the vaccine because she is already sexually active
-Do a human papillomavirus test to make sure she has not been infected before she gets the vaccine
-Administer a dose today, a second shot in two months, and a third shot in six months
- Administer the vaccine anyway, but it will not be effective
- Obtain a pregnancy test before administering the vaccine
- Administer a dose today, a second shot in two months, and a third shot in six months
The quadrivalent human papillomavirus (HPV) vaccine protects against HPV 6 and 11, which cause 90% of genital warts, and HPV 16 and 18, which cause 70% of cervical cancer cases. Although it is most efficient prior to the onset of sexual activity, it is still recommended for people who are already sexually active.
The human papillomavirus (HPV) vaccine is a three-dose series that is currently recommended for girls and boys ages 9-26 (but ideally between 11-12 years of age) to prevent infection with HPV. The quadrivalent vaccine protects against HPV 6 and 11, which cause 90% of genital warts, and HPV 16 and 18, which cause 70% of cervical cancer cases. There is also a bivalent vaccine which only covers HPV 16 and 18.
The vaccine has a very good safety profile, and few side effects beyond tenderness at the injection site have been noted. Although the human papillomavirus (HPV) vaccine is contraindicated in pregnancy, routine pregnancy testing is not recommended prior to vaccination. The patient is using contraceptives and her last menstrual period was a week ago, making pregnancy unlikely. She should be urged to continue using contraceptives for the duration of the series. The vaccine is contraindicated in pregnancy because there have not been enough studies of its safety in this group (pregnancy category B).
However, in women who were inadvertently vaccinated without prior knowledge of their pregnancy status, there has been no increased risk to the fetus, and there is no need to terminate such a pregnancy. The vaccine series can be completed after the pregnancy.
What HPV genotypes are contained in the Gardasil quadrivalent vaccine?
Types 6, 11, 16, and 18
Protects against 70% of cervical cancers and 90% of genital warts
(Note: Only the 9-valent vaccine is available in the United States (GARDASIL-9))
Administration schedule for HPV vaccine (Gardasil)
Administered as three doses: 0.5 mL intramuscularly given at intervals of 0, 2, and 6 months
US Advisory Committee on Immunization Practices (ACIP) recommendations for HPV Vaccines:
- Routine vaccination at age 11–12, but can be given as early as age 9.
- For adolescents and adults aged 13–26 years who have not been previously vaccinated or have not completed the series, catch-up vaccination is recommended.
- For adults 27 years and older, catch-up vaccination is not routinely recommended, and should be made on an individual basis.
Not recommended for pregnant women. Can be given to breast-feeding women
Management of abnormal Pap tests in women ages ——— differs from those age ——— because of the low incidence of cervical cancer in this age group.
21–24
≥25
CIN1 is a ———. It is referred to as ——— in the LAST system.
low-grade lesion with mild atypical changes in the lower one-third of the epithelium
low-grade SIL (LSIL)
CIN2 is a ———. Specimens that are p16-negative are referred to as ——— and those that are p16-positive are referred to as ———
high-grade lesion, with atypical changes confined to the lower two-thirds of the epithelium (difficult to differentiate from CIN3; stratified according to p16 immunostaining to identify precancerous lesions)
LSIL
high-grade SIL (HSIL)
CIN3 is a ———, and is referred to as ——— in the LAST system.
high-grade lesion, where atypical cells encompass >2/3 of the epithelium
HSIL
(CIN2 and CIN3 are often treated the same)
A 45-year-old G4P4 patient presents for a routine annual exam. Her Pap test returns
with a report of ASCUS. Her Pap tests have always been normal in the past. What is the next best step to evaluate her cancer risk?
High-risk HPV DNA testing. If high-risk HPV DNA testing is “positive,” indicating the presence of a hrHPV strain, then a colposcopy and indicated biopsies should be performed. If the HPV testing is negative, she can be managed as per her age-based protocol.
Next step if pap finds atypical squamous cells of undetermined significance (ASCUS):
- Reflex HPV testing if under age 30, concurrent HPV testing if age 30 and above.
- If HPV negative—continue routine screening per protocol.
- If HPV positive—colposcopy if age ≥25, repeat cytology (Pap test) in 1 year if age 21–24.
Next step if pap finds atypical squamous cells, cannot exclude HSIL (ASC-H):
Colposcopy with indicated biopsies
Next step if pap finds LSIL:
Colposcopy with indicated biopsies if age ≥25, repeat cytology (Pap test) in 1 year if age 21–24
Next step if pap finds HSIL:
Colposcopy with endocervical curettage and indicated biopsies
List results of an abnormal Pap test in order of severity:
●Atypical squamous cells of undetermined significance (ASC-US)
●Low-grade squamous intraepithelial lesions (LSIL)
●Atypical squamous cells cannot exclude high-grade squamous intraepithelial lesion (ASC-H)
●High-grade squamous intraepithelial lesions (HSIL)
●Atypical glandular cells (AGC)
Next step if pap finds atypical glandular cells (AGC):
Colposcopy with indicated biopsies, endocervical curettage (ECC), and endometrial biopsy
——— percent of women with abnormal cytologic findings can be adequately evaluated with colposcopy.
Ninety
What must be completely visualized for adequate colposcopic evaluation?
- TZ
- Extent of lesion in its entirety
Define Colposcopy with Cervical Biopsy
A procedure that utilizes staining and a low-magnification microscope, mounted on a stand, for the viewing of the cervix, vagina, and vulva; illuminated, magnified view, which aids in identifying lesions and biopsying suspicious areas to obtain histologic diagnosis.
(1. Speculum inserted; 2. Acetic acid applied: The neoplastic cells appear whiter; 3. Colposcopy; 4. Cervical biopsy: Neoplastic and dysplastic areas are then biopsied under colposcopic guidance; 5. ECC: A curette is used to scrape the cervical canal to obtain endocervical cells for cytologic examination.
If colposcopy-based biopsy results or ECC is positive for CIN2 or CIN3 (HSIL), then
a cone biopsy or a LEEP should be performed as both a diagnostic and therapeutic procedure
A 23-year-old woman, gravida 1, para 1, comes to the office to discuss a recent cervical pap smear from her annual examination. The cytology report says that she has a high-grade squamous intraepithelial lesion (HSIL). She has no complaints and none of her previous cytology reports show any abnormalities. Which of the following tests or treatments is the best next step in managing this patient?
-Return in 6 months for repeat pap smear
-Human papillomavirus vaccine
-Return in 3 months for repeat pap smear
-Colposcopy with biopsies
-Loop electrosurgical excision procedure
Colposcopy with biopsies
Colposcopy and biopsy of any suspected lesions is the best management plan for a woman aged 21-24 years old with a cytological diagnosis of high-grade squamous intraepithelial lesion (HSIL). In women >25 years old, either colposcopy or loop electrosurgical excision procedure (LEEP) would be an appropriate recommendation.
A 25-year-old woman comes to the clinic for a Pap smear. She has been treated for multiple sexually transmitted infections in the past. She is sexually active and does not use contraception. Her temperature is 37.0°C (98.6°F), pulse is 80/min, and respirations are 14/min. Physical examination shows no abnormalities. Pelvic examination is normal without evidence of cervical discharge or motion tenderness. A Pap smear is obtained and shows high-grade squamous intraepithelial lesions. Colposcopy is performed and shows cervical intraepithelial neoplasia (CIN) grade 3. Which of the following is the most appropriate treatment for this patient’s condition?
-Abdominal hysterectomy
-Repeat colposcopy to rule out false positive
-Vaginal hysterectomy
-High dosage of prednisone
-Loop electrical excision procedure
Loop electrical excision procedure
In patients who have cervical intraepithelial neoplasia (CIN) grade 3, a cervical ablative procedure is the next best step in management. This can be accomplished with a loop electrical excision procedure (LEEP).
Excisional or ablative procedures, such as a loop electrical excision procedure (LEEP), laser therapy, cryotherapy, and cervical cone biopsy are appropriate for the management of cervical intraepithelial neoplasia (CIN) grades 2 or 3.
CIN 1 lesions often regress spontaneously without further management and only follow up for repeat smear or colposcopy is required. The rate of spontaneous regression of CIN 2 or 3 is lower, warranting a procedure to remove the abnormal cells. If left untreated, CIN may progress to cervical cancer.
Cone Biopsy and Loop Electrosurgical Excision Procedure (LEEP) are both excisional procedures which involve
excising a cone-shaped portion of the cervix, including the endocervical canal and TZ
(They are intended to be both diagnostic and therapeutic)
A 24-year-old woman, gravida 0, para 0, comes to the office for a routine gynecologic examination. She has no specific complaints. Her first pap smear from three years ago showed normal cervical cytology. Last year, she received 3 doses of the human papillomavirus (HPV) vaccine. She is sexually active with two male partners and says that they use condoms intermittently. She is otherwise in good health and her medical history is noncontributory. Her paternal grandmother was diagnosed with cervical cancer at age 55. Which of the following is the most appropriate option for the patient at this time?
- Do not perform pap smear at this visit; women do not need routine cervical cytology screening if they have received the human papillomavirus vaccine
- Perform pap smear at this visit; women 21-29 years old should receive cervical cytology screening every 3 years
- More information about the patient’s family history of cervical cancer is needed before a decision can be made about cervical cytology screening
- Perform pap smear at this visit; women with multiple sexual partners should receive cervical cytology screening more frequently than the general population
- Do not perform pap smear at this visit; women aged 21-29 years old should receive combined cervical cytology screening and HPV co-testing every 5 years
Perform pap smear at this visit; women 21-29 years old should receive cervical cytology screening every 3 years
Cervical cytology screening (pap smear) for cervical cancer is recommended every 3 years for women aged 21-29, and cervical cytology plus HPV co-testing every 5 years in women aged 30-65 by the American College of Obstetricians and Gynecologists.
Indications for cone biopsy/leep:
■ Inadequate view of TZ on colposcopy
■ Positive ECC
■ Treatment for CIN2–CIN3 (HSIL)
■ Treatment for adenocarcinoma in situ
■ When cancer cannot be excluded after colposcopy, biopsy, and ECC
Evaluation of ——— may be challenging with LEEP, because of thermal artifact.
biopsy margins
A 25-year-old G1P0 patient at 38 weeks’ gestation presents to triage reporting contractions that have been increasing in strength and frequency over a 12-hour period. She does not have vaginal bleeding, leakage of fluid, or preeclampsia symptoms. She reports good fetal movement. Fetal heart rate (FHR) is reassuring. She is contracting every 2 minutes on the monitor. The cervical exam is 6 cm dilated, 50% effaced, 0 station, cephalic. What stage of labor is she in? If her labor progresses as expected, what should her cervical dilation be at the next vaginal exam (VE) in 2 hours?
She is in the active phase of the first stage of labor. Since she is a primigravida, her cervix should dilate at a minimum of 1.2 cm/hr. So, in 2 hours, she should be 8.4 cm (or 8–9 cm) dilated.
Prelabor rupture denotes:
spontaneous rupture of fetal membranes before the onset of labor
(Ie, ROM: Rupture of membranes vs PROM: Prelabor rupture of membranes (ROM before the onset of labor))
(Premature ROM can occur at term (PROM) or preterm (PPROM: <37 weeks))
Most common diagnosis associated with preterm delivery
PPROM
Prolonged rupture of membranes refers to
a rupture of membranes lasting longer than 18 hours (i.e. between time of rupture and time of delivery)
Duration of labor is typically shorter in
the multiparous patient than in nulliparous patients
Labor is defined as
regular contractions that result in cervical change
(A patient can have contractions that do not cause cervical change as well as cervical change without contractions—neither of these are “labor”)
Number of stages of labor
There are three stages of labor and two phases of stage 1
Describe first stage of labor:
Begins with onset of uterine contractions of sufficient frequency, intensity, and duration to result in effacement and dilation of the cervix, and ends when the cervix is completely dilated to 10 cm.
Consists of two phases:
1. Latent phase: Begins with the onset of labor and ends at approximately 4–6 cm cervical dilation.
2.Active phase: Rapid dilation. Ends at 10cm.
Describe the second stage of labor
the stage of fetal expulsion:
It begins when the cervix is fully dilated and ends with the delivery of the fetus
Describe the third stage of labor:
The main event is placental separation: It begins immediately after the delivery of the fetus and ends with the delivery of the fetal and placental membranes
(Duration: Usually <10 minutes; considered prolonged if >30 minutes)
The three signs of placental separation are:
- Gush of blood from vagina
- Umbilical cord lengthening
- Fundus of the uterus rises up and becomes firm
Know these! They are commonly asked at delivery.
Remember the three “Ps” that affect the duration of the active phase of labor:
■ Power (strength and frequency of contractions)
■ Passenger (size of the baby)
■ Pelvis (size and shape of mother’s pelvis)
If progress during the active phase is slower than expected, evaluation for adequacy of ———should be done.
uterine contractions, fetal malposition, or cephalopelvic disproportion (CPD)
Abnormalities of the second stage may be either:
protraction or arrest of descent (the fetal head descends <1 cm/hr in a nullipara and <2 cm/hr in a multipara)
In third stage of labor, if 30 minutes have passed without placental expulsion, ——— may be required
manual removal of the placenta
What are the three signs of placental separation?
- Gush of blood
- Umbilical cord lengthening
- Fundus of uterus rises and firms
Contrast true vs false labor in terms of:
Regularity of intervals
Intensity
Location of discomfort
Impact on cervix
Effect of medications
Bloody show is
small amount of blood mixed with cervical mucus that is present with cervical dilation and effacement
(should be distinguished from vaginal bleeding)
Diagnosis of ROM: The patient’s history alone is correct in ——- of patients. ——— can be mistaken for ROM.
90%
Urinary leakage or excess vaginal discharge
Spontaneous rupture of membranes (SROM) most often occurs during the course of
active labor
A 25-year-old G1P0 patient at 39 weeks’ gestation presents to labor and delivery
reporting a gush of fluid from the vagina followed by constant leakage for 2 hours. The fluid is clear and without odor. What tests can help determine whether the patient has ruptured the membranes?
Sterile speculum exam, testing for pooling, ferning, and nitrazine. If these are positive, the membranes are likely ruptured and the fluid noted on the exam is likely amniotic fluid
Findings on sterile speculum exam indicative of ROM:
- Pooling: fluid collection in the posterior fornix or in the posterior blade of the speculum
- Valsalva: If pooling is not present, ask the patient to bear down and perform a Valsalva maneuver. Note if fluid is seen to come through the cervical os = Positive valsalva. Coughing can work here too.
- Ferning: Place a thin layer of the vaginal secretions or pooled fluid on a slide. View the dried amniotic fluid under a microscope for a characteristic ferning pattern made by the crystallized sodium chloride in the amniotic fluid (positive ferning). Confirms ROM in 85–98% of cases (see pic for true vs false fern and results when cervical mucous dries in the absence of amniotic fluid).
- Nitrazine: Place vaginal fluid on nitrazine paper to assess pH. If
nitrazine paper turns blue, this indicates basic pH (positive nitrazine). Amniotic fluid has basic pH as compared to vaginal secretions that have acidic pH. Confirms ROM in 90–98% of cases.
What can cause a false-positive nitrazine test?
■ Vaginal infections with Trichomonas vaginalis or bacterial vaginosis
■ Blood
■ Semen
Define vernix:
The fatty substance consisting
of desquamated epithelial cells and sebaceous matter that normally covers the skin of the term fetus. More common in early term infants.
Define meconium
A dark green fecal material that collects in the fetal intestines and is discharged at or near the time of birth
Meconium staining is more common in
term and postterm pregnancies than in preterm pregnancies
Meconium aspiration syndrome (MAS): Define
Fetal stress, like hypoxia, leads to meconium in the amniotic fluid. With further fetal gasping, the meconium is inhaled into the fetal lungs, causing lung damage.
Meconium aspiration syndrome (MAS): Presentation
At birth, the infant will present with respiratory distress and can develop pulmonary hypertension.
Meconium aspiration syndrome (MAS): Tx
Intubation does not provide adequate oxygenation due to the lung injury and pulmonary hypertension. Infants with MAS may require extracorporeal membranous oxygenation (ECMO) which bypasses the lungs in order to provide oxygen to the baby
Cervix dilation describes ———and is determined by ———
Describes the size of the opening of the cervix at the internal os
(Ranges: From zero to 10 cm dilated)
Determination of dilation: index and/or the middle fingers are inserted in the cervical opening and are separated as far as the cervix will allow. The distance (cervical dilation) between the two fingers is estimated.
Cervical Effacement describes ———and is determined by ———
Describes the length of the cervix. With labor, the cervix thins out and softens, and the length is reduced (When the cervix shortens by 50% (to around 2 cm), it is said to be 50% effaced. When the cervix becomes as thin as the adjacent lower uterine segment, it is 100% effaced (think paper-thin)(
Determination of effacement: Palpate with finger and estimate the length from the internal to external os
Identify each labeled structure
A 33-year-old woman comes to the primary care clinic for an annual well-visit examination. She expresses a desire to become pregnant within the next year and inquires about steps she should take to ensure a healthy pregnancy. She has a past medical history of hypertension that is well-controlled with lisinopril. She has never been pregnant or has had prior issues with infertility. Temperature is 37 ºC (98.6 °F), heart rate is 66/min, blood pressure is 115/75 mmHg, and respiratory rate is 14/min. Physical examination is within normal limits. Which of the following is the most appropriate next step in management?
-Discontinue lisinopril and start nifedipine
-Discontinue lisinopril only after a positive pregnancy test
-Continue lisinopril as it is effectively controlling her blood pressure
-Increase lisinopril dosage to prevent hypertension-related complications in pregnancy
-Continue lisinopril and add oral folic acid supplementation
Discontinue lisinopril and start nifedipine
A key component of preconception counseling is to identify use of medications that are teratogenic. Renin-angiotensin system blocking agents are contraindicated in pregnancy and should be discontinued before conception. Patients should be switched to a pregnancy-safe antihypertensive like nifedipine, methyldopa, or labetalol.
This patient who is planning on becoming pregnant within the next year should be switched from her current ACE inhibitor to a pregnancy-safe antihypertensive like nifedipine. Agents that block the Renin-angiotensin system, such as ACE inhibitors and angiotensin receptor blockers (ARBs) are contraindicated in pregnancy and should be discontinued before conception.
ACE inhibitors and ARBs are contraindicated in pregnancy. These medications have been associated with
neonatal kidney failure and death
Antihypertensives that are safe to use in the perinatal period include
nifedipine, methyldopa, and labetalol
Patients with long-standing or uncontrolled hypertension who become pregnant should have ———. They should be counseled that they are at an increased risk of developing ——— in pregnancy, and they should be started on ——— to reduce their risk of preeclampsia.
vision screening, urine protein evaluation, and an electrocardiogram
preeclampsia and intrauterine growth restriction
low-dose aspirin after 12 weeks of gestation
Describe station
Describes the degree of descent of the presenting part in relation to ischial spines, which are designated at 0 station.
Terminology (two systems):
1. The ischial spine is zero station, and the areas above and below are divided into thirds. Above the ischial spines are stations –3, –2, and –1, with –3 being the furthest above the ischial spines and –1 being closest. Positive stations describe fetal descent below the ischial spines. +3 statian is at the level of the introitus, and +1 is just past the ischial spines.
- Very similar except that the areas above and below the ischial spines are divided by centimeters, up to 5 cm above and 5 cm below. Above are five stations or centimeters: –5, –4, –3, –2, and –1, with –5 being the 5 cm above the ischial spines and –1 being 1 cm above. Positive stations describe fetal descent below the ischial spines. +5 station is at the level of the introitus, and +1 is 1 cm past the ischial spines.
■ If the fetus is vertex, the station should be determined by the location of the biparietal diameter (BPD), not the tip-top of the head, which may simply be caput and not the head at all. So, when the BPD is at the level of the ischial spines, the station is 0.
Define consistency of cervix changes
Changes progressively from firm to medium to soft, in preparation for dilation and labor. For some context: Firm consistency is described like the forehead, medium like the tip of the nose, and soft like the check.
Describe changes position of cervix
Describes the location of cervix with respect to the fetal presenting part.
■ Posterior: Difficult to palpate because it is behind the presenting part, and usually high in the pelvis.
■ Midposition.
■ Anterior: Easy to palpate, low in pelvis, pointing forward.
During labor, the cervical position progresses from posterior to anterior.
Vaginal prostaglandins are inserted for
ripening (softening) of cervix
IV pitocin is used to
↑ strength and frequency of contractions
(Pitocin is a synthetic oxytocin. It is used to start or enhance labor.)
Bishop scoring system used for
helps to determine the status of the cervix—favorable or unfavorable—for successful vaginal delivery (If induction of labor is indicated, the status of the cervix must be evaluated to help determine the method of labor induction; A score of ≥6 indicates that the probability of vaginal delivery with induction of labor is similar to that of spontaneous labor)
A 32-year-old woman is evaluated for preconception counseling. She received two doses of the human papillomavirus (HPV) vaccine before 15 years of age; the tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine 3 years ago; and the influenza and COVID-19 vaccines during the last influenza season. She has no medical problems and takes no medication. Vital signs are within normal limits and a comprehensive physical examination is within normal limits. Laboratory studies reveal a negative rubella antibody titer and a positive varicella antibody titer. Pregnancy test is negative. Which of the following is the most appropriate next step in management?
-Assure her that no additional vaccines are needed before pregnancy
-Advise her to wait until after pregnancy to receive the rubella vaccine
-Recommend receiving the rubella vaccine immediately after conception
-Administer the rubella vaccine at least one month before she attempts to conceive
-Administer the varicella vaccine now
Administer the rubella vaccine at least one month before she attempts to conceive
Live vaccines (e.g., varicella, MMR) are contraindicated during pregnancy. Women who are planning to become pregnant who do not have immunity to rubella or varicella should receive the respective vaccine before conceiving and should wait at least 4 weeks following vaccination before attempting to conceive.
This patient who presents for preconception counseling lacks immunity to rubella. Therefore, she should receive the measles, mumps and rubella (MMR) vaccine at least 4 weeks prior to conception.
The rubella vaccine is critical in preconception care, because intrauterine rubella infection can lead to severe birth defects (e.g., hearing loss, cataracts, cardiac abnormalities, bone lesions, growth restriction, and neurologic abnormalities, including intellectual disability) and miscarriage. The rubella vaccine is a live vaccine, and should therefore be administered at least one month before conception to avoid any risk to the fetus and ensure immunity is established before pregnancy.
Vaccination against varicella is similar to rubella. The varicella vaccine is a live attenuated vaccine used for primary prevention of chickenpox and the vaccine is not recommended during pregnancy. Ensuring immunity before pregnancy is crucial to avoid significant maternal and fetal complications associated with varicella infection.
The ——— portion of the fallopian tube is the most common site of an ectopic pregnancy.
ampullary
Define a tubal ring:
echogenic, ringlike structure found outside of the uterus, on ultrasonography, that represents an early ectopic pregnancy
Define a pseudosac:
A collection of fluid within the endometrial cavity created by bleeding from the decidualized endometrium and is often associated with an ectopic pregnancy
Fitz–Hugh–Curtis syndrome (perihepatic inflammation)?
Ten percent of patients with acute PID will develop perihepatic inflammation, known as Fitz–Hugh–Curtis syndrome. “Violin string” adhesions can be seen at the liver capsule on laparoscopy with this syndrome. Often seen months to years later during laparoscopy for other indications.
In what media does Neisseria gonorrhea grow?
Thayer-Martin in CO2-enriched environment
Endometrial evaluation for PMB:
with either transvaginal ultrasound or endometrial biopsy. Endometrial biopsy can supply a histologic diagnosis, but it is an invasive and uncomfortable procedure. Therefore, PMB can also be evaluated initially with transvaginal ultrasound. Patients with an endometrial thickness ≤4 mm on ultrasound have a low likelihood of endometrial cancer and require no additional evaluation. In contrast, patients with an endometrial thickness >4 mm require an endometrial biopsy to assess for endometrial hyperplasia or cancer.
Components biophysical profile
Interstitial cystitis: epidemiology
Interstitial cystitis: diagnosis
Interstitial cystitis: presentation
Interstitial cystitis: treatment
RFs for endometrial cancer
Define labial adhesions
Thin, fused labia minora (Labial adhesions can be partial (involving a portion of the labia) or complete)
Candida vulvovaginitis presents with a
Beefy-red rash on the vulva as well as vaginal pruritis and discharge
Lichen sclerosus is characterized by
hypopigmented labial lesions
Urethral prolapse presents in ______ with _______
prepubertal girls
inflamed, friable tissue in a donut shape at the urethral meatus
Evaluation for female factor infertility often includes hysterosalpingography (HSG) to
identify genital tract anomalies and fallopian tube patency
What are bicornuate or separate uterus, and how are they addressed?
2 unfused uterine horns, types of congenital uterine anomalies
Some congenital uterine anomalies, such as a septate uterus, can be surgically corrected to recreate a single, larger uterine cavity
Women age _____ with abnormal uterine bleeding and classic menopausal symptoms (eg, ____) are likely in menopause and require no additional testing. In contrast, women age _____ with these symptoms require measurement of ______.
≥45
night sweats, insomnia, difficulty concentrating
<45
FSH, TSH, and prolactin (eg, FSH (to assess for hypothalamic amenorrhea), TSH (to assess for thyroid disorder), and prolactin (to assess for hyperprolactinemia).
Pathogenesis of 5 alpha reductive deficiency
Presentation of 5 alpha reductase deficiency
Vulvovaginal candidiasis can present with
Vulvovaginal pruritus and erythema, with a thick, white vaginal discharge; some patients (eg, immunosuppressed) can have accompanying oropharyngeal candidiasis (white oral plaques)
Lichen sclerosus can present with
Vulvar pruritus and white vulvar plaques with associated erosions (typically have no vaginal involvement)
Histopathology of granulosa cell tumor
Call-exner bodies (cells in a rosette pattern)
A presumptive diagnosis of GDM can be made with a very elevated 50-g 1-hour GTT (eg, ≥ ——— mg/dL) or confirmed with a 100-g 3-hour GTT
200
Multiple sclerosis, an autoimmune inflammatory demyelinating disease of the CNS that typically presents in ———. ——— often precedes the development of focal neurologic findings. There is an increased risk of both the initial presentation and subsequent relapses in the ———
An ——— should be obtained, and would show:
young adults, especially women of child-bearing age
Extreme fatigue unrelated to activity levels
early postpartum period.
(Although pregnancy is protective for multiple sclerosis)
MRI of the brain and spinal cord
Typically, multiple, scattered, ovoid lesions are seen in the periventricular regions and the spinal cord. Imaging findings can often confirm dissemination in space (multiple CNS locations) and time (age of lesions), which are required to confirm a diagnosis of MS
Androgen insensitivity syndrome presents with
phenotypically female
primary amenorrhea due to an absent uterus
no pubic or axillary hair due to a defective androgen receptor
(complete defect in androgen receptor function)
Presentation of 5-alpha reductase deficiency have
female external genitalia and male internal genitalia (ie, undescended testes) until puberty, at which time they undergo virilization (eg, muscle l growth, voice deepening) due to increased levels of testosterone
(impaired conversion of testosterone to dihydrotestosterone)
Types of twins and associated signs on US
Dichorionic, diamniotic - lambda sign (thick intertwin membrane)
Monochorionic, diamniotic - t or delta sign (thinner intertwin membrane)
