OBGYN Flashcards

1
Q

What are the 3 signs seen on the cervix during pregnancy

? ligament assists w/ holding fallopian tubes and ovaries?

A

Chadwick: early inc vascularity
Goodell: cervical softening due to edema
Hegar: isthmus/uterus softening

Broad ligament- contains arteries, veins and nerves

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2
Q

What part of the broad ligament are the fallopian tubes in?

What are the 4 parts of the fallopain tubes?

A

Mesosalpinx

Infundibulum
Ampulla
Isthmus
Interstitial/intramural

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3
Q

What arteries feed blood to the ovaries

Where do these arteries drain to?

A

Ovarian/Uterine arteries through medulla

L ovary- L renal vein
R ovary- IVC

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4
Q

What are the two parts of the pelvis

What is the term of the head position desired for delivery

A

True: immobile/constraining
False: above linea terminalis; supports pregnant uterus

Occiput anterior- back of baby head facing mother anterior

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5
Q

What are the 3 baby head presentation positions possible for birth

What are the 3 pelvic landmarks

A

Vertex- occiput anterior?
Sinciput
Brow

Interspinous diameter
Transverse inlet
Obstetrical conjugate- needs to be 11cm for delivery

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6
Q

What are the two hip categories favorable for vaginal delivery?

What two categories are not favorable?

A

Gynecoid, Arthropoid

Android, Platypelloid

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7
Q

What mother position may help increase pelvic outlet diameter?

Linea terminalis is AKA and includes ? structures

A

McRoberts maneuver: hyperflexion of legs in dorsal lithotomy, inc by 1.5-2cm

AKA Innominate line, separates false/true pelvis
Pubic crest
Pectineal line
Arcuate line
Sacral ala
Sacral promontory
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8
Q

What makes the bony pelvis

What part contains all of the abdominal organs?

A

Innominate bones
Sacrum

True/lesser pelvis

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9
Q

The false/greater pelvis is bound in what 3 locations

Where are the superficial vascular structures in the abdomen supplied w/ blood from and travel in ? direction

A

Lumbar vertebrae- post
Iliac fossae- laterally
Abdominal wall- ant

Femoral artery
Diagonal towards umbilicus

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10
Q

What vascular structures provide blood to the muscles and fascia of the anterior abdominal wall

What is the name of the c-section incision and what strucutres may be unintentionally hit?

A

External iliac vessels

Maylard
Inferior epigastric artery on lateral side of rectus belly

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11
Q

When entering through a Pfannenstiel incision, what is the risk?

Hypothalamus releases ?

Ant Pit releases ? to take affect on ?

A

Severing Iliohypogastric nerve, loss of sensation over lateral gluteal/hypogastric regions

GnRH

LH/FSH on ovaries

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12
Q

Ovaries release ? two hormones that conduct ? two functions

What is the only female organ not changed during pregnancy?

A

Estrogen: proliferative; helps endometrium grow
Progresterone: secretory; helps w/ glandular processes

Ovary

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13
Q

What are the 3 sources of gonad tissues

A

Mesothelium: lines posterior abdominal wall

Mesenchyme: embryonic CT

Primordial germ cell: earliest undiff sex cells

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14
Q

What is the sequence of differentiation of gonad development into ovaries

When does ovary/testis differentiation begin?

A
Mesothelium
Gonad ridge
Gonad cord
Indifferent gonads
Ovary

Begins: 5w of gestation
Committed: 7w of gestation

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15
Q

? ducts develop into testes
? ducts develop into ovaries

Testes only develop from the ducts if ? is avail, otherwise ovaries develop

A

T: mesonephric/wolffian by 7wks
O: paramesonephric/mullerian by 12wks

TDF

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16
Q

How is the male phenotype made?

What hormone has no role in the gonad differentiation process?

A

Undifferentiated gonad + Y chromosome= TDF

Testes= MIF, T, DHT:
testes development, testosterone, mullerian inhibiting factor, fusion of labial folds, growth of phallus/prostate

Estrogen

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17
Q

What processes occur prior to gonadal differentiation?

Ovary can be histologically identified by ? wk but isn’t truly developed until ? wk

?wk does the cortical cords break down and into ?

A

Germ cells migrate to ridges/cords

10 and 12

16wk into premordial follicles

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18
Q

Primordial germ cells contain ? which derive from ? tissue

While still in a fetus, what replication process are the oogoniums doing?

A

Oogonium
Mesoderm, surface epithelium

Mitosis- diploid 46xx

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19
Q

By 20th wk of development, oogonium are committed and stop/rest at ? step of replication?

8-12wks of gestation, Hcg peaks and stimulates production of ? signaling the start of ?

A

Prophase I

Testosterone
Anti-mullerian hormone

Gonadal differentiation

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20
Q

What male/female organs are present at 9wks of development

11wks?

12wks?

A

Penis Clitoris Minora

Majora Scrotum

External urethra
M: Prepuce, scrotal raphe
F: Clitoris, mons, vaginal orifice

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21
Q

Define Didelphys

Define Bicornuate uterus

Define Bicornuate w/ rudimentary horn

Define Septate

Define Unicornuate

A

Inferior duct fails to fuse, single or double vagina

Duplicated upper uterus body

Slowed growth of one duct, no fusion

Failure of resorption, septum

One duct fails to develop; PT fertile but risk of preterm delivery/loss

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22
Q

Define Ovotesticular DSD

What is an example of this

What can cause this example

A

Chromatin +
Most 46XX w/ ovotestis
M or F w/ ambiguous genital

46XX:
+ ovary, ambiguous externals
Excess androgens= virilization (fusion, hypertrophy, sinus)
+ Wolf and Muller cells

Causes:
Impair Fetal Steroidgenesis- CAH (no 21 hydroxylase)
Mother took androgens
Luteoma: masculinizing tumor

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23
Q

46XY DSD

A

D/o of testicular development= dec production of T/MIS, causes low virilization
Chromatin -

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24
Q

Define Androgen Insensitivity Syndrome

Kallmann Syndrome

A

Genotype: male
Phenotype: female
Female genital Abdominal/inguinal testis
No masculinization, menses

Partial: point mutation on androgen receptor gene

Kallman: Hypo Hypo; anosmia
Dec FSH LH and E
SECONDARY Hypogonadism

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25
Klinefelter Syndrome Turner Syndrome Why is it life saving to Dx infants w/ DSD early in life
47XXY 1* hypogonadism Dec T, Inc LH/FSH 45XO 1* Hypogonadism Hypergonadtropic hypogonadism Dec E, Inc FSH/LH Avoid Adrenal crisis- Na crisis at day 4-15, death due to HypoNa/HyperK
26
# Define Gametogenesis What type of replication occurs here?
Development of precursors into oocytes or spermatozoa Meiosis I: diploid to haploid
27
How do they replicate and into ? Where is the transition from dip to hap and mitosis to meiosis?
``` Spermatogonia Spermatogonium 1* spermatocyte 2* spermatocyte, Spermatid Sperm ``` 1* to 2*= dip to hap 1* to 2*= mitosis to meiosis I
28
During spermatogenesis, when do sperm cells go from diploid into haploid? One 1* spermatocyte= ? mature, mobile sperm
1* spermatocyte, diploid Meiosis I 2* spermatocyte, haploid 1 primary= 4 mature
29
# Define Non-Disjunction What is the last phase of spermatogenesis? Why is this last phase important and where does it take place?
1* spermatocyte error at first meiotic division Spermiogenesis: spermatid into spermatozoa Golgi body into acrosome in Sertoli cells- enzymatic penetration of zona pallucida Development of mitochondria in middle portion of sperm tail
30
What type of cells line the seminiferous tubules What are the 3 functions of these cells?
Sertoli cells Sperm development Spermatogenesis regulation Passive transport from seminiferous to epididymis
31
Sperm mature during ? phase of development? Where do they mature and how long does it take?
Spermiogenesis Seminiferious tubules x 3mon: 2mon process, 1mon maturation
32
What are the series of hormone events prior to ovulation? LH stimulates ? cells to make ? two products These products are taken up by ? cell and turned into ?
Inc estrogen causes LH surge= ovulation Theca cells: Cholestterol + LH= Androstenedione, Testosterone Granulosa cells: Androstenedione + FSH= Estrone, Estradiol
33
What is the name of the scar tissue the corpus luteum turns into after ovulation? Corpus luteum grows during ? phase under the influence of ? This product stimulates ? cells to produce ?
Corpus albicans 7-10 days later Luteal, LH Granulosa cells, progesterone
34
Changes/variations of a woman's period is due to ? phase of the menstrual cycle What are the two layers of the endometrium which covers ?
Follicular, luteal is regulated more strict/less fluctuant Functionalis, Basalis Myometrium
35
The constriction of the spiral arteries deprive the ? layer is what causes ? What happens during the Proliferative phase What does the Secretory Phase stimulate the release of
Functionalis Period Estrogen, arteries lengthen, endometrial growth maxes, glands are straight/narrow due to glycogen Glycogen/mucus
36
Secretory phase is occurring because ? What hormone is high at ovulation/ferning
Prepping to implant Estrogen Inc amount of alkaline mucus, Dec viscosity/spinnbarkheit
37
``` How many days after Ovulation for each to occur: Fetilization Entrance of Blastocyst Implant Trophoblast and attach Sync hCG rescue ```
1 4 5 6 8 10
38
What are the two phases of fertilization What happens at the end of these two phases
Acrosomal reaction: penetrating zona pellucida Zona reaction: chemical change in solubility, impermeable Fusion of oocyte/spem= completion of Meiosis II; Ootid->zygote
39
What hormones effect zygote/blastocyst transit through fallopian tube? What is the name of the 16 cell structure that precedes a blastocyst entering a uterus
Estrogen + sticking Progesterone - sticking Prostaglandin E + tube relax Prostaglandin F + tube motility Morula
40
What are the two layers of the blastocyst What hormone is produced and what's it's purpose
Embryoblast: forms embryo, amnion, cord Trophoblast/chorion: forms placenta, hCG Chorion: fetus portion of placenta hCG 7-10 days post-fertilization, preserves CL until placenta halts menses Cause of Morning Sickness
41
What are the 3 phases of implantation Define Decidua and its function Why is this structure important
Apposition Adhesion Invasion Maternal side of placenta, establishes embryo implantation Endometrium of pregnancy, separates at birth Essential for maternal blood contact w/ trophoblast
42
What are the 3 parts of the decidua Trophoblast differentiates into the Cyto/Synch blast by day ? After implantation, these further differentiate into ?
Basal Capsul* Parietal Day 8 Extra/Villous Trophobalsts: Extra- anchor chorionic villi to uterus Vill- chorionic gas, nutrient, hormone exchange
43
# Define CV Sampling How many vessels in the umbilical cord? What is the maternal surface of the placenta called and divided into?
Chorionic Villi- chromosomal abnormalities AAV V: oxy, high press R side AA: de-ox, low press L side Basal plate: divides into clefts/lobules (coutyledon) Extends in intervillous space
44
# Define Nitabuch Layer What are the 3 abnormalities of this layer What is the risk factor for these abnormalities
Maintains separation by fibrinoid degeneration of decdiuda basalis Prevents placental invasion into uterus P Accreta: adheres P increta: invades P percreta: perforates Previous uterine surgery/c-section
45
How long after conception does it take for maternal blood flow to enter placenta Placental growth is more rapid than the fetus during the first trimester, they are equal by ? wk and ? at birth
1mon: enters intervillous space from spiral arteries, bathes sync-blasts 17wks 1/6th of fetal weight
46
hCG levels are abnormally low during ? and high during ? This is the hormone responsible for ? two downsides of pregnancy
Low: ectopic, spontaneous abortion High: gestational trophoblastic neoplasia N/V Hyperemesis gravidarum
47
What part of the maternal/fetal blood transfer has higher pressure/values Why does fetal gas exchange have a three fold advantage
Uterine artery Fetal Hbg higher O2 affinity Bohr effect: dec o2 affinity w/ dec pH Fetus has higher Hgb
48
Chorionic villi drain nutrients/O2 from maternal blood using ? method Fetal envirionment generally has ? pH level Umbilical cord that wraps around a fetus' neck is called a ?
Bohr effect Acidic Nuchal cord
49
What are the 3 modifications to fetal circulation that maintains R to L shunting
Duct Art: connect aorta and PA, diverts blood to brain/heart, away from lungs FOvale: shunts oxygenated blood from RA to circulation DVenosus: bypasses hepatic circulation; remnant is ligamentum venosum
50
Placenta previa is a risk factor for ? placental abnormality End of video 2, labeling chart What is the MC complaint to GYN?
P acreta Check Abnormal uterine bleeding
51
What Tanner Stage represents the onset of puberty and 2* characteristics? What hormone controls breast development? What hormone controls pubic hair development?
Stage 2, Thelarche Estrogen Androgen
52
During childhood, there's no puberty due to low levels of ? Puberty starts when the feed back inhibition of ? decreases
FSH LH Estradiol Estradiol and GnRH
53
# Define Thelarche and Adrenarche What is the time span between onset of thelarche and onset of menarche
Thel: breast development; first Adren: pubic hair growth 2.5yrs
54
What is the sequential acronym of puberty development stages An earlier onset of puberty linked and due to ? Menarche initiation can not start if female PTs weigh less than ?
TAPup Me Thelarche Adrenarche Pubarche Peak growth velocity Menarche Obesity, leptin as initiator hormone 106lbs/48kg
55
Tanner Breast Staging Tanner Pubic Hair Staging
1: elevation of papilla 2: buds, areola diameter inc 3: enlargement, no separation 4: secondary mound 5: mature breast 2: sparse along labia 3: darker hair over pubes 4: dark/coarse hair 5: dark/coarse hair extends to thighs
56
What are the two types of precocious puberty and how are they Tx
Central, GnRH dependent: high LH/FSH inc estrogen levels Tx w/ GnRH agonist- inhibits LH/FSH Peripheral, GnRH independent: 'precocity'; lack of HPO axis activation= low FSH/LH Tx: ovarian tumor, CAH, exogenous exposure
57
What are the risks if Precocious Puberty goes UnTx Continue Tx until ? age
Early growth plate closure Psych distress 11/yo
58
What tests are done for girls w/ precocious puberty due to estrogen excess What is the criteria for delayed puberty What is the MC cause
Hand x-ray: bone age FSH LH TSH Pelvic sonogram CNS MRI No thelarche by 13 or, No menarche by 16 Constitutional delay
59
What needs to be checked if PT presents w/ delayed puberty How is it Tx
FSH/LH Gonads: 1* hypogonadism; high FSH/LH (hypergonadotropic) Hypothalamus: 2* hypogonadism; low FSH/LH (hypogonadotropic) Monitor, possible gonad steroids
60
What are the 3 HyperHypo causes of Delayed Puberty What are the 3 HypoHypo causes?
Turners, Gonad dysgenesis, Premature Ovarian Failure /AKA Primary Ovarian Insufficiency; cause of delayed puberty CNS Adrenal Psychosocial
61
Disruption of the HPO axis can alter ? 3 functions of the menstrual cycle How much blood loss is considered normal or excessive? When are menstrual cycles the most irregular
Reproduction Ovulation Menstruation 20-60mL +80mL bad 2yrs after menarche 3yrs before menopause
62
Females are born with ? ova, but only ? are present at start of puberty How many ovulation are expected throughout life? ? hormone controls the follicular phase and ? effect does it have on the endometrium
1-2mill; <400K 400 Estrogen; proliferative
63
What is the whole purpose of the luteal phase? "Progesterone withdrawal"= ?
Prep endometrium for implantation Menstrual bleeding
64
What are the 3 forms of estrogen Where are they secreted from The 4 transmitters E+3/P respond to ?
Estradiol Estrone Estriol Theca interna Granulosa cells Gonadotropins
65
What are 3 effects of FSH on ovary Sequence of hormonal events leading to ovulation Female who has an anovulatory menstrual cycle means there is no ? phase
E/P production Inc LH receptors Follicle maturation Inc estrogen, LH surge, ovulation Luteal
66
Why/how do females w/ an anovulatory menstrual cycle still have regular menses? Define criteria for 1* Amenorrhea
Estrogen break through- loses ability to maintain endometrium No menses by 16 w/ normal 2* characteristics No menses by 14y/o and no 2* characteristics No menses by 3yrs of thelarche
67
# Define Criteria for 2* Amenorrhea All causes of 2* amenorrhea can also cause ?
Cessation of menses x 3mon and previously regular Primary amenorrhea
68
PT w/ AIS would have ? type of amenorrha Hypergonadotropic Hypogonadism can be causes by what two d/os?
Primary Turners 46XX and 46XY
69
# Define Hypothatlamic Amenorrhea What can cause this
Low GnRH/FSH secretion Non-ovulatory Stress/exercise Weight loss Celiac Dz
70
# Define Kallman syndrome What is the first and second MC cause of 2* amenorrhea
Congenital GnRH deficiency w/ anosmia 1st: Pregnancy 2nd: anovulatory cycles Functional hypothalamic amenorrhea
71
What effect would hyperprolactinemia have on a PT? After initial exam and labs, what test is done for assessing amenorrhea
Dec GnRH, low LH/FSH Progesterone withdrawal test: give exogenous progesterone + bleeding= estrogen developed endometrium or; PT outflow tract in tact - bleed= unsure if proliferative phase occurred or if estrogen is functional
72
What are the primary tests ordered for amenorrhea evaluation What are the 3 radiological tests ordered
hCG FSH Prolactin Estradiol TSH/fT4 Transvaginal US: PCOS, uterine agenesis, ovarian tumor Hysterosalpingogram- mullerian anomalies/uterine adhesion MRI: mullerian anomalies, hypothalamic pituitary Dz
73
If progesterone challengne test doesn't cause bleeding, what is the next step
E/P challenge + bleed= FSH check FSH >40: ovarian failure FSH>5: stress, CNS tumor, Sheehan (post-partum necrosis/ischemia) -bleed= obstruction/Ashermann
74
Frequent menstrual bleeding is a cycle that is ? days while infrequent cycles is ? days Amenorrhea is a menstrual cycle absent for ? months or more and irregular bleeding is a cycle varying more than ? days
<21 >35 6mon >20 days
75
How many days is classified as prolonged or shortened menstrual bleeding How much blood is considered heavy or light flow
> 8 days <2 days >80cc <5cc
76
What is the MC complaint seen in GYN?
Abnormal uterine bleeding PALM COINE Structure: Polyp Adenomyosis Leiomyoma Malignancy/hyperplasia Non-structural: Coagulopathy Ovulatory dysfunction Iatrogenic Not classified Endometrial
77
What is the magic number of double endometrium thickness? How is acute menorrhagia Tx if the PT is stable? How are they Tx if unstable or don't respond to non-surg Tx in first 24hrs
4mm Combo OCP Medroxypreogesterone acetate Both @ higher dose than for contraception ``` Surgery: D&C Balloon tamponade Uterine artery embolization Hysterectomy ```
78
How is chronic recurrent menorrhagia Tx
Stable: 1: Normalize prostaglandins, not effective if taking NSAID 2: Coordinate sloughing- medroxyprogesterone, combo OCP ``` 3: Endometrial suppression- Progestin only OC Extended cycle OC DMPA Levonorgestrel- most effective ``` 4: Antifibrinolytic therapy- for PTs w/ fibrinolytic activity Tranexamic acid
79
When are PTs surgical candidates for abnormal uterine bleeding? Dysmenorrhea is a ? mediated problem causing
Failed medical therapy Child bearing completed Prostaglandin- inc severity= inc prostaglandin levels Back pain, N/V/D, HA
80
When are prostaglandins highest How is primary dysmenorrhea Tx
First 2 days of menstruation NSAIDs Possible combo w/ OCPs, progestin only (Levo, Depo, Nexplanon)
81
PTs w/ migraine and aura can't get ? type of OCPs What is the MC location for endometrial tissue to be found in PTs w/ endometriosis This is a cause of _ dysmenorrhea
Estrogen containing Pelvic peritoneum Ovaries, Uterosacral ligament 2*
82
What are the Sxs of endometriosis This condition may cause the uterus to take on ? shape
Dysmenorrhea Dyspareunia Dyschezia Chronic pelvic pain Retroverted
83
If endometrial tissue is found in the thorax, where is it MC found How is endometriosis Dx and what imaging is not recommended
R side w/ chest/shoulder pain Laparoscopy, allows simultaneous Tx w/ ablation US- lacks sensitivity
84
How can endometriosis be differentiated from dysmenorrhea How is mild endometriosis Tx
Endometriosis occurs 1-2 days prior to menses NSAIDs Cyclic hormones: Progesterone/OCPs NSAID + OCP failure=referral
85
What androgen analog is used during endometriosis Tx to inhibit LH/FSH What is the GnRH agonist used? How is severe recalcitran Dz cases Tx
Danazol- adverse acne/hair growth Leuprolide- initiates pseudomenopause Total hysterectomy w/ bilateral salpingo-oophorectomy
86
What NSAIDs are used during endometriosis Tx Endometriosis frequently co-exists w/ ? and ?
Ibu/ketoprofen Naproxen/Na Mefenamic acid Adenomyosis and Fibroids
87
S/Sxs of PMS Criteris for Pre-Menstrual Dysmorphic D/o
Fatigue Mood Tender Bloat 5 Sxs w/ significant Psych/Social impairment
88
Mood swings of PMS coincide w/ ? phase Why are there mood swings w/ PMS
Luteal: dec serotonin Impact on CNS: Serotonin Noradrenaline GABA
89
Why is there bloating/weight gain during PMS PMDD Dx requires a Sx free period of 7 days that coincides w/ ?
Progesterone (antimineralcorticoid) + estrogen (+ RAAS)= altered E+ balance First half of cycle x 3 cycles Follicular phase- onset of menses
90
What are the top two PE Sxs of PMS What is the top behavioral health Sx
Fatigue Bloating Labile mood
91
How is PMS/PMDD Tx What anovulatory agent is used second line and why is this step done?
SSRIs: Fluoxetine Sertraline Paroxetine Cramp/HA: NSAID Bloat: Diuretic (HCTZ, spironolactone) Combo OCPs GnRH agonist- Leuprolin Places body in false menopause to relieve Sxs
92
When are Sxs of PMS/PMDD worse What is the definition of menopause
End of cycle during switch of p/e Dx at 12mon after final menses Avg age: 52
93
Menopause transition is AKA ? Define Premature Ovarian Failure What is the acronym for the Sxs of menopause
Perimenopause/Climacteric No menses <40y/o due to high FSH/low E/P FSHIUL Flashes Sad HA Insomnia Urinary sxs Libido
94
The vasomotor Sxs of menopause can start as early as ? before FMP How is estrogen a cardio protector? This protection is gone and equal to male risk factors by age ?
2yrs High HDL, Lower TC 70
95
Hormone therapy can be beneficial to PTs but loses the protection if started ? PTs on hormone therapy need to be evaluated every ? Don't give ? type of estrogen to females w/ uterus due to ? risks
Over 60y/o +10yrs after FMP Q6-12mon Unopposed, endometrial hyperplasia, neoplasia, endometrial cancer
96
What estrogen combo hormone therapy can be given to females w/ uterus ? part of hormone therapy causes females to be at inc risk for DVTs
Estrogen + Beazedoxifine Estrogen
97
What is the SHATTERED Family acronym for
Osteoporosis Risk factors ``` Steroid Hyperthyroid/Ca/parathyroid Alcohol/tobacco Testosterone, low Thin, low BMI Early menopause Renal/liver failure Erosive bone dz Diet low in Ca/DM-1 FamHx ```
98
When do women get DEXA scans When do perimenopausal women get DEXA scans
+65y/o One or more RF for osteoporosis Sustained Fxs Specific RFs Low BMI <18.5 Meds accelerating bone loss
99
What is a normal DEXA criteria? Define T Score Define Z score
Normal: +2.5--1.0 Penia: -1--2.5 Porosis:
100
When is osteoporosis medical therapy started? What meds are used to prevent, treat or both Which ones work faster at vertebrae than hip?
T score < -2.5 Vertebral/hip Fx -1 - 2.5 w/ 1+ RF Prevent: estrogen, Vit D Treat: denosumab, calcitonin/PTH 2nd line Both: SERM, bisphosphonates Prevention
101
MOA of bisphosphonates What are the a/e of using?
Inhibit osteoclast resorption Take on empty stomach and stay upright x 30min due to esophageal erosion Osteonecrosis of jaw Atypica femur Fx Prolonged use is worse Take drug holidays
102
Loss of estrogen increases ? activity Loss of ?" of height needs to have a compression Fx considered Where is most Ca lost from
Osteoclast >1.5" Trabecular bone of spine, femoral neck
103
What initial labs are ordered to work up amenorrhea Why is primary ovarian failure a concern?
hCG FSH/LH TSH Prl Estrogen= leads to severe osteoporosis
104
What microbe causes Erythrasma What does it look like under a woods lamp How is it Tx
Corynebacterium Red Local: clindamycin Wide: erythromycin
105
Normal vaginal pH is ? Why is this level needed? What are two causes of non-inflammatory vaginitis
4.5 Lactobaccili- creates lactic acid and hydrogen peroxide as defenses BV- gardnerella Candidiasis
106
What is the MC cause of vaginal d/c What is the criteria used for Dx
BV- grey/milky d/c w/ fishy odor Amsel's Criteris: pH >4.5 D/c Odor Clue
107
How is vaginal pH tested How is BV Tx
Nitrazine paper turns blue Metronidazole Clindamycin cream Alt: Secnidazole, Tinidazole, Clindamycin ovules
108
How are recurrent BV infections Tx
No prior extended Tx: Vaginal Metrogel, Clindamycin PO Metronidazole Tinidazole ``` Prior Hx of Tx: Same as above x 2wks then, Suppression therapy w/ Metronidazole gel x 1wk Metronidazole PO x 2wks Tinidazole x 6mon ```
109
What are the adverse outcomes of unTx BV in pregnancy What is the 2nd MC cause of vaginitis
PROM Pre-term delivery Intra-amniotic infection Post-partum endometritis Candidiasis albicans or Glabrata- resistant to -azoles
110
What are the RFs for a candidiasis infection How is it Tx
``` ImmSupp DM Environmental Estrogen ABX use ``` Clotrimazole x 7 days** PO Metronidazole x 1 dose
111
Chronic recurrent candidiasis infections are a ? issue What can cause these repeats?
Host issue w/ 4 repeats/year Dec mannose binding lecting Inc of IL-4
112
What is used for recurrent VVC Tx What is used for suppression therapy?
PO Fluconazole: day 1 4 and 7 After completing Tx regime: PO Fluconazole x 6mon
113
What meds are used for non-albican species of VVC What med can be used for external irritaiton/inflammation
Boric acid x 2wks Fluconazole Q72hrs Mild potency steroid
114
What is the 3rd MC cause of vaginal d/c How is it Dx
Trichomoniasis- frothy green/yellow d/c w/ musty odor ``` Frothy d/c Strawberry cervix pH >4.5 Trichomonads on wet prep (mobile w/ flagella) NAAT* gold standard ```
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How is Trichomoniasis Tx How are PTs w/ BV and Trichomonas infections Tx
Metronidazole 2g PO or, 500mg BID x 2wks if compliant PT Tinidazole 2g x once Tx BV Test of Cure at 1mon and 6on
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What are the causes of vulvar pruritis w/ white lesions What are the causes of pruritis w/ red lesions
Dystrophies: Lichen sclerosus Squamous hyperplasia ``` Dermatoses: Contact/Atopic dermatitis Psoriasis Vestibulitis Lichen planus ```
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# Define Squamous Hyperplasia Define Lichen Sclerosus
Vulvar pruritis that used to be called leukoplakia Lichen simplex chronicus Inflammation of dermis in post-menopause w/ wax/wane itching/late burning Skin appears paper/crinkled
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Lichen Sclerosus has an increased risk for PTs to develop ? How is it Tx
Squamous Ca of vulva Topical CCS- Clobetasol Retinoids if unremitting Phototherapy and 5-aminolevulinic acid if severe
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# Define Lichen Simplex Chronicus How is it Tx
Non neoplastic alteration of vulvar skin due to chronic irritation from itch/scratch cycle MC at L Majora ``` Lube: petroleum jelly, veg oil Sitz bath PO antihistamine Wear cotton gloves at night Topical steroid ``` Unresolved in 1-3wks= biopsy
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Atopic Dermatitis How is it Tx
Hx of allergy/eczema w/ atypical location Scaly patches w/ fissuring Topical steroids ImmunModulators- Tacrolimus
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Where is Psoriasis uncommonly seen in females? Define Koebnerization How is it Tx
Mons pubis Labia Trauma on vulva as inticing factor Emollient/Steroids Dovonex after
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What meds can cause Lichen Planus How does it appear
NSAIDs BB Methyldopa PCN Quinine Cutaneous and mucosal surfaces w/ red erosion/white border D/c Pruritis Burning Post-intercourse bleeding
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What are the 3 variants of Lichen Planus What does it look like How is it Tx
Erosion Papulosquamous Hypertrophic Purple erosive pruritic polygon papules/plaques- can affect gingiva Clobetasol Vaginal hydrocortisone Suppository
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How does Intertrigo present How is it Tx
Crease friction from bacterial/fungal infection Burning/itching Hyperpigmentation Corn starch Mild steroid: inflammation Antifungal: Nystatin/Cotrimazole
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What is the MC cause of vaginal irritation after menopause? How does it present How is it Tx
Atrophic vaginitis Clear/yellow/blood tinged d/c w/ dysparunia Loss of rugae/pale mucosa Topical estrogen
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Bartholin cyst is a concern for CA in women over ? y/o If the cyst is located ?, the PT presents w/ no pain How are these Tx
40 Cyst in duct ASx= none, unless >40 Don't do I&D Word catheter Marsupialization after 2 failures
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What usually follows a bartholin cyst Women w/ this follow on presentation need ? screening
Abscess- polymicrobial w/ correlation to G/C infection STD panel: G/C
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When are ABX used for Barthlin abscess Tx What ABX are used
``` Recurrent/High risk PT: Pregnant Cellulitis Systemic infection ImmSupp ``` TMP/SMX Amox/Clav
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What microbe causes Toxic Shock Syndrome When does it start and how does it present How/why do PTs die of this
Staph A 2days after surgery/onset of menses Macular rash w/out pain/itch ARDS, DIC or HOTN leading to myocardial failure
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What are the major criteria for Dx Toxic Shock What are the minor criteria
``` HOTN OHOTN syncope BP <90 Macular erythroderma Temp >38.8*C Skin desquamation 1-2wks later ``` ``` 3 needed: Diarrhea/Vomit Membrane erythema Elevated Cr Inc platelet count/bilirubin AMS ```
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What increases the chances of vulvar Ca? These are usually caught and Dx in ? stage
Age, HIV 1 or 2
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Vulvar Ca is usually ? type What is the 2nd MC type
Squamous on Hart line Malignant melanoma, poor prognosis
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What are the risk factors of vulvar Ca in women <55y/o What risk factors affect >55y/o Women have a 35x inc risk of Ca if they have ? 2 RFs
HPV, smoking Same risk as cervical Ca 15% have HPV Long standing lichen sclerosis Smoker + HPV
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How does Vulvar Ca usually present What procedure is done for exam? Since primary vaginal carcinomas are rare, found cases are usually ? Ca
Pruritis w/ lesion Vulvoscopy- coposcopic exam of vulva w/ biopsy Metastatic to vagina
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What are the types of vaginal Ca
Squamous- HPV, bleeding Adenocarcinoma- metastatic, DES exposure Mesenchymal
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What is the MC type of vaginal malignancy in kids under 5y/o What may be the most rare form?
Rhabdomyosarcoma (mesenchuymal tumor) Leiomyosarcoma
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What is the MC Complaint of PTs w/ vaginal Ca What is the MC region? What if the Ca is on the anterior wall What if it's on the posterior wall?
Vaginal bleeding Upper third of wall Dysuria Urgency Hematuria Constipation
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What are the four types of benign cervical dzx
Polyp Cervicitis Nabothian cyst Stenosis
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S/Sxs of Cervical stenosis How is it Tx
Contracting scar issue on endocervical canal blocks os= Dysmenorrhea Infertility Amenorrhea Dilators Vaginal estrogen x 4wks if Post-monopause
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Cervical os needs to be at least _mm for blood to exit Define Nabothian cyst
5mm Columnar cell trapped under squamous during metaplasia, continue secreting mucus Rarely Sx= no Tx If Sx= cautery/excision
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How does cervicitis present What can cause it What part of the cervix creates mucus
Bleeding cervical epithelium G/C HSV Trichomonas BV Endocervix from glandular columnar cells
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SCJ can regress into endocervix during what 3 low estrogen times? Immature metaplastic cells in the T-zone are vulnerable to the oncogenic effects of ? What other 2 RFs increase these chances
Menopause Lactation Progestin only OCPs HPV Early intercourse and 1st pregnancy
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What is the primary method of detecting pre-cancers Cervical Ca is not considered to be sensitive to ?
Colposcopy Estrogen
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What are the risk factors for cervical neoplasms
Age, inc Low status Ethnicity Male w/ multiple partners Early coitus Tobacco/diet ``` Parity ImmSupp Exogenous hormones Cervical HPV Screenings poor ```
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HPV vaccine is ? prevention while Pap screenings are ? What lab/pap finding is a "surrogate" for cervical Ca
Vaccine- primary Pap- secondary CIN 3: squamous epithelial lesion
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What are the different grades of CIN
1: mild; abnormal cells in lower 1/3, HPV, most regress 2: moderate; abnormal cells to middle 1/3 3: severe; abnormal cells to upper 1/3 Carcinoma in situ- full thickness involvement
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HPV is the MC STI in the US, what type is the most oncogneic worldwide What are the low risk strands of HPV Where does the infection reside in the body
16: ano/oropharyngeal cancers 6 and 11- genital warts, laryngeal papillomas Basal cells
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Since HPV can spontaneously resolve, what is it's key factor to develop in Ca? PTs w/ HPV 16/18 w/ lesions lasting longer than 6mon develop ?
Persistence Squamous Intraepithelial lesion
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# Define Pap Co-Testing Define Reflex Testing
Pap Cyto sample tested for HPV in PTs +30y/ <30y/o w/ abnormal cells on Pap trigger additional tests
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``` What Pap screenings are needed for the following ages: <21 21-29 30-65 >65 Post-Hysterectomy ```
<21: no screening 21-29: Q3yrs w/ Reflex testing 30-65: Co-test Q5yrs, only Pap=Q3yrs >65= 3 consecutive neg Paps Post-Hys, no CIN2 past 20yrs: + cervix= continue screening - cervix= no screening CNI2+ Dx in 20yrs= vaginal swabs x 20yrs past Dx
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Co-test/Reflex test only give you ? data HPV HR DNA test gives you ?
Presence of HPV Sub type of HPV
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HPV results are given using ? criteria What info is given
Bethesda ``` Specimen type Adequacy Interpretation Description ancillary testing Notes/recommendations ```
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What are the 5 categories of resutls that can come back on a pap smear
ASCUS- atypical squamous cells undetermined significance LSIL- low grade squamous intraepithelial lesion ASC-H- atypical squamous cells, can't exclude HSIL HSIL- high grade squamous intraepithelail lesion AGC- atypical glandular cells
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+HPV PTs are managed the same as ? How are they managed
LSIL Colsposcopy
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What is the next step for: >30y/o LSIL, -HPV LSIL but no HPV test LSIL w/ +HPV PT w/ ASC-H PT w/ HSIL
Repeat Co-test in 1yr Colposcopy Colposcopy Colpo regardless of HPV Loop or Colpo
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Pap is a ? tool, Colpo is a ? tool Colpo offers what 3 tools What has to be done prior to procedure
Screen, Dx Biopsy Sampling Visualization Qualitative pregnancy test
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If Colpo is unsat due to T-zone can't be seen, whats then ext step Cervical Ca is #_ of malignancy in females
LEEP- loop electrosurgical excision procedure CKC- cold knife cone #4, usually from HPV
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How often are Cervical Ca Pts f/u How often are cervical/vaginal cuff paps performed
Q3mon x 2yrs Q6mon until 5yrs Post-Tx Annually Annually x 20yrs post-Tx
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What are the estrogen dependent abnormalities of the uterus? What are fibroids AKA
Adenomyosis Leiomyomata Endometrial hyperplasia Leiomyomata- MC pelvic tumor of women
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What is a common presenting Sxs of fibroids What is the preferred Dx These commonly lead to ? Tx
Bleeding US Hysterectomy
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What is used to reduce/slow bleeding from leiomyomas Define Adenomyosis What is the first image ordered?
Contraceptives IUD Endometriosis w/in myometrium, usually ASx US
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What is the gold standard Tx for Adenomyosis What meds may be tried prior to Tx
Hysterectomy GnRH agonist Danazol IUD COC
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What is the MC Sx of Polyps How are they viewed?
Metrorrhagia US, sonohysterography
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How does endometrial hyperplasia present Who is is MC seen in How is it Dx
Abnormal uterine bleeding Post-menopause women Biopsy- gold standard
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How is endometrial hyperplasia classified for malignancy potential Trans-Vag US is the first Dx step for endometrial hyperplasia only in ? PTs
``` Greatest= complex hyperplasia w/ atypia Least= simple hyperplasia w/out atypia ``` Post-menopause, 4mm or less= low risk
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How are PTs w/ endometrial hyperplasia w/ atypia but want to retain fertility managed? How are PTs w/ endometrial hyperplasia w/out atypia managed
Progestin w/ endometrial biopsy q3mon Then hysterectomy and salpingectomy Pre-Meno:Low progestin x 6mon or COC w/ endometrial biopsy Post-Meno: SAME
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What is the MC Gyn in Ca What are the MC presentations
Endometrial Ca Vaginal bleeding Pelvic pressure Early satiety
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How is endometrial Ca Tx Define Lynch Syndrome
Hysterectomy w/ bilateral salpingoophrectomy and lymph node staging Multiple Ca, usually sentinel Tx w/ prophylactic hysterectomy
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How is endometrial Ca Dx What would be seen on TVUS
Endometrial Biopsy Post-Meno: 4mm or small, ok 5 or more, biopsy
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What tumor marker may be seen in endometrial cancer This responds to ? hormone
CA125, monitor tool May help w/ ovarian masses in Post-Meno PTs Progestin- Tamoxifen
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What are the two types of functional ovarian masses Define endometrioma
Follicular cyst- follicle doesn't rupture, >3mm Lutein cyst- corpus luteum doesn't regress Metaplastic ovarian mass from endometriosis
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How doe functional cysts present How are they dx and Tx
Pain Dull sensation Heavy Bimanual exam, US Tx w/ surgery
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What are sizes of simple cysts and f/u
``` Pre-Men: 3 or less: norm variant 5 or less: no Tx >5 <7: repeat TVUS 12wks, persists= annual TVUS >7: MRI/surg eval ``` Post-Meno: 1 or less: norm variant 5 or less: Norm CA125= repeat US 12wks, persists= annual TVUS 7 or more: MRI, surg eval
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What steroid hormones cause male-ness
DHEA- adrenal gland; weak Androstenedione- adrenal gland and ovary, weak T- adrenal gland, ovary and adipose, potent DHT- follicles and genital skin, most potent
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# Define Hypertrichosis Dfeine Hirsutism Dfein Virilizaiton
Non-sexual hair not due to androgens Terminal thick male pattern hair on female, due to androgens Acne Male baldness Deep voice Due to androgens
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PCOS Dx req's ? 2 things What are the 5 MC presentations
High androgen/estrogen Hyperandrogenism Oligo/anovulation ``` Hirsutism Abnormal bleeding PC ovary Infertility Obesity ```
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What is NOT a required finding for Dx of PCOS Define Ovarian Hyperthecosis How do they present
Poly cystics ovaries Sever PCOS- nest of lutenized theca cells in ovarian stroma Balding Hypertrophy Deep voice Acanthosis nigrans
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HAIRAN Syndrome
Hyper Androgenic Insulin Resistant Acanthosis Nigricans PCOS variant w/ severe insulin resistance
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What causes idipathic hirsutism How is PCOS Tx
Variant Inc 5-alpha reductase activity Mild form of PCOS COCs: progestin only or Clomiphene if pregnancy desired Metformin
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How is the hirsutism of PCOS Tx
``` Androgen blockers: Spirinolactone, Flutamide 5-alpha reductase: Finasteride Eflornithine- slows growth ```
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What causes the most deaths than any other Gyn malignancy Why is this so deadly
Ovarian cancer No screenings
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What is the primary mechanism of ovarian cancer What are some protective steps that can be done
Uninterrupted ovulation Breast feeding OCPs Ligation/hysterectomy Diet high fiber, low fat
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What factors can falsely elevate CA125 What PE finding + a pelvic mass is indicative of ovarian cancer What pulm finding is concern
Premenopause w/ endometriosis, fibroids Ascites Pleural effusion
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What lab findings will be seen in PTs w/ ovarian Ca How is ovarian cancer staged What does BRCA mutation do to prognosis
Thrombocytosis HypoNa Surgery Improves, better response to chemo