OBGYN Exam Flashcards
What is the most common viral STI in women?
HPV
which subtypes of HPV are most common, but benign
6 & 11
Which HPV subtypes are HIGH RISK
16, 18, 31, 33
16 & 18 associated with cervical cancer
Is biopsy necessary for diagnosis of low risk HPV?
not always, if easily recognized
What do you treat SMALL, low risk HPV lesions with?
topical medications; podophyllin, trichloroacetic acid
Imiquimod
How do you treat LARGE, low risk HPV lesions?
procedurally:
crysurgery
laser ablation
surgical removal
between HPV 16 & 18, which strand is most strongly linked to vaginal cancer and its precursors (VAIN II, III)
16
What solution is used on affected HPV tissue to make it turn white so you can biopsy/remove it?
acetic acid
Do HPV infections clear on their own?
70% clear within 1 year; 91% clear within 2 years
What is “latent HPV infection”
if patient does not have complete clearance of HPV, it may harbor the viral genome in undetectable numbers
which genes does HPV “shut off”
p53 & pRb
p53 controls atherosclerosis
HPV is a non-traditional risk factor for what?
CAD - preventing the HPV infection can also reduce CAD
risk factors for persistent HPV
previous genital infectionsimmunosuppression (HIV) parity > 3 multiple sex partners smoking multiple HPV <18 years old at first intercourse
3rd most common GYN cancer?
cervical cancer
what are the 2 types of cervical cancers; and what is the most common?
squamous cell & adenocarcinoma
SQUAMOUS cell is most common
What are they symptoms of cervical cancer?
asymptomatic!
MAY present with post-coital bleeding, but usually not cancer.
if seen on exam, what will a cervical cancer lesion look like?
friable, bleeding lesion
Patient presents with post-coital bleeding. On exam you observe friable, bleeding cervical lesion. What is your next step in diagnosing?
PAP + biopsy of the lesion
management of cervical cancer in situ (stage 0)
LOOP EXCISION or cervical cone biopsy
Treatment of invasive cervical cancer
hysterectomy
radiation and chemo for stages 3 & 4
At what age do we do cervical cancer screening and what intervals?
21-65 every 3 years JUST PAP SMEAR
30-65 every 5 years if they get the PAP + HPV testing
What type of cells are required for adequate Bethesda test (PAP test)
endocervical cells
How do inflammatory cells affect a PAP smear (Bethesda system)
they may make the pap “unsatisfactory”; some are acceptable while others require REPEAT pap in 6-12 weeks
Patient presents for a pap smear (Bethesda), and you submit cells to the lab; they come back unsatisfactory due to “obscuring inflammation”. What is your plan of action?
Get a repeat pap in 6-12 weeks
Pap smear results return saying “ASCUS”. what does this stand for and what is your plan of action?
atypical squamous cells of Uncertain Significance
Reflex HPV testing or repeat PAP at 12 months
Pap returns with results reading ASC-H. what does this mean?
Atypical squamous cells - possible HIGH grade lesion
How to manage ASC-H lesion?
colposcopy/biopsy/HPV testing
Which PAP results indicate a transient HPV infection that is unlikely to proceed to cancer?
LSIL (Low-grade squamous intraepithelial lesion)
What does the Pap results mean if it reads: HSIL?
High-grade squamous intraepithelial lesion
HPV viral persistence and invasive potential
What are the levels of Pap smear results, from benign to severe?
Negative
ASCUS & ASC-H = atypical squamous cells (monitor)
LSIL = transient HPV but unlikely to proceed to cancer
HSIL = HPV viral persistence and invasive potential
Cancer.
For what lesion grades do we perform Loop excision (LEEP) (heated wire loop used to remove abnormal tissue)
grade 2 or higher
CIN II, III, CIS
what are the two most common techniques for further testing/treatment of abnormal cervical cells
colposcopy w/ biopsy loop excision (LEEP)
What does histology CIN1 mean from biopsy?
CIN1 = mild dysplastic changes
what does CIN2 & CIN3 mean in histology biopsy?
moderate to severe dysplastic changes
How would you manage ASCUS results via Pap smear?
reflex HPV testing OR repeat pap at 12 months
How to manage PAP results that read “ASC-H, LSIL, HSIL”
colposcopy/biopsy and HPV testing
What is the HPV vaccination Gardasil coverage?
16, 18, 6, 11
Quadrivalent
How is the HPV vaccine administered?
3 injected doses over 6 month period
2 injected doses if given BEFORE age 15
what kind of ovarian cyst forms when ovulation fails to occur and the follicle continues to grow, filling with FLUID
follicular cyst
what type of ovarian cyst forms when corpus luteum fails to involute and continues to increase in size
corpus luteum cyst
true or false corpus luteum cysts are normal if pregnancy does not occur
FALSE: they are ABNORMAL if pregnancy does not occur
do simple ovarian cysts (follicular and corpus luteum) persist chronically?
no - most resolve spontaneously in a few weeks-few months
What are the simple ovarian cysts?
follicular and corpus luteum cysts
simple cysts are often asymptomatic, but SOMETIMES symptoms happen when size reaches ____:
> 8-10 cm; symptoms include pain and pelvic heaviness or fullness
Patient presents with pelvic pain and heaviness, but it progressed to SEVERE pain right after intercourse. What is on the top of your differential?
ruptured simple cyst
Why can simple cysts cause irregular menstrual bleeding?
the walls of the cyst are made of granulosa cells, which can retain ability to secrete ESTROGEN and interfere with normal uterine bleeding cycle
What are the 2 types of ovarian cystadenomas and where do they arise from?
serous and mucinous
-ovarian epithelium (outer covering of ovary)
45 year old woman presents with an ovarian cyst that is benign and common in 30% of all cases; It resulted from proliferation of the epithelium, resembling fallopian tubes and secretes clear yellow fluid, making a cystic component. What is the cyst type?
Serous cystadenoma
clear, yellow fluid = serous
33 year old woman presents with an ovarian cyst that is unilateral and multilocular. It is found to contain mucous rather than serous fluid; the endothelium resembles endocervical cells. What type of cyst is this?
Mucinous cystadenoma
what might the symptoms for ovarian cystadenomas be?
asymptomatic; vague pelvic pain/abdominal fullness, increased abdominal girth
patient presents with abdominal fullness and increased abdominal girth. On exam you find large adnexal mass, and US shows large, cystic mass. What is your differential?
ovarian cystadenoma
What kind of ovarian tumors are more likely to be malignant?
solid ovarian tumors
What are the types of BENIGN solid tumors?
Fibroma or thecoma
Teratoma
This type of tumor is made of connective tissue that arose from cortical stroma, size > 3 cm.
Fibroma
What differentiates fibroma between thecoma
if the connective tissue tumor that arose from cortical stroma is LUTEINIZED or ESTROGENIC, it is THECOMA
This type of solid ovarian cyst consists of differentiated tissue from all 3 germ layers, contains thyroid tissue, CNS tissue, hair, teeth
Teratoma
This type of ovarian cyst presents as a “chocolate cyst” on US
Endometrioma: contains old blood and debris
What is the most commonly used treatment for simple ovarian cysts?
suppression of ovulation - ORAL CONTRACEPTIVES commonly used.
If you monitor a simple ovarian cyst, what should happen with the size of it over time?
Size generally decreases by 6 weeks, and most resolve by 3 months
When would you perform laparoscopy regarding an ovarian cyst?
when urgent - torsion, acute peritonitis, or elective for large cysts and symptomatic endometriomas
What is the most common type of OVARIAN CANCER?
epithelial; arise from ovarian epithelium or from the fimbriae of fallopian tubes
What does ovarian cancer cyst look like on US most commonly?
solid with cystic components - complex, irregular mass. Also increased blood flow on doppler
Describe metastasis for ovarian cancer
typically spreads throughout abdomen; mets seen on liver surface, mesentery, small/large bowel, surface of uterus and bladder.
which cancers metastasize to the ovaries?
Endometrial
cervical
breast
GI (colon, stomach)
What factor DECREASES risk of ovarian cancer?
pregnancies and oral contraceptive use
ovarian cancer treatment
surgery for staging and removing all visible cancer (“debulking”)
also CHEMO following surgery
is screening recommended for women with average risk of ovarian cancer?
NO! harms of test outweigh the benefits of screening
How long does “normal” menstrual bleeding last?
about 5 days, every 28 days
what is a “normal” amount of blood loss during menstrual bleeding?
40 ml per cycle
How much blood loss defines menorrhagia?
blood loss over 80 ml per cycle
more than 1 pad per hour
double up tampons
needing to get up at night to change the pad
clots larger than a quarter
what is the term for bleeding between periods?
Metrorrhagia
“metro” = time
polymenorrhea is defined as bleeding more often than ____ days
21
oligomenorrhea is bleeding less often than ____ days
35
what are the 3 main groups of factors that contribute to abnormal uterine bleeding?
Anatomic issues
Coagulopathies
Endocrine disorders
What disorder is characterized by excessive growth of endometrium resulting from unopposed estrogen?
endometrial hyperplasia
what are some causes of endometrial hyperplasia?
Anovulatory cycles in perimenopause
PCOS
obesity
Patient presents with abnormal bleeding; she is perimenopausal and gland type on biopsy reveals complex glands without atypia. What is your first line of treatment
hormonal therapy with monophasic high progestin
re-sample endometrium after 3-6 months
what are the 4 types of glandular descriptions of endometrial hyperplasia?
simple
complex
simple with atypia
complex with atypia
What is the highest risk of gland type that will progress to endometrial cancer?
complex with atypia - 30% likely
you treat a woman with endometrial hyperplasia; she has been on cyclic progestin for 6 months and has returned with NO BLEEDING. What is your next step regarding the progestin?
if normal, with no bleeding, OK TO STOP TREATMENT
A woman who has completed hormonal therapy with no improvement in bleeding, what is your next step?
Endometrial ablation if hormonal therapy fails
hysterectomy if atypical cells present
What are the 3 types of endometrial cancers?
adenocarcinoma (MOST COMMON)
Adenosquamous
Clear cell
What does exam typically show in a woman with endometrial cancer?
usually is UNREMARKABLE/normal
35 year old patient endorses palpable cysts throughout her breasts on exam; she notes that her period is coming up in the next few days. What do you tell her?
Tell patient to return immediately after her period; if they completely resolve, they are fibrocystic breasts. If not, WORK UP
Which imaging is best for demonstrating cystic fluid, such as in breast tissue?
Ultrasound
At what age do we perform mammograms?
30+
what is galactorrhea?
milky nipple discharge in absence of pregnancy or normal lactation
On breast exam, you palpate a round, rubbery, nontender mass about 1 cm in diameter. You believe this to be _____
fibroadenoma
if a patient has a fibroadenoma, what is your plan of action?
REMOVAL IS NOT NECESSARY
what does green or brown discharge from MULTIPLE breast ducts indicative for?
cyst fluid related to fibrocystic breasts
serous discharge from SINGLE duct that is green/brown is usually due to what?
something wrong with that duct;
extasia
intraductal papilloma
intraductal cancer
excise the involved duct
what is the most common type of breast cancer?
Ductal carcinoma: carcinoma in situ (DCIS) and infiltrating ductal carcinoma
-infiltrating ductal carcinoma (DUCTAL) is most common!
This type of breast cancer is located in the lobules
lobular; in situ and infiltrating
Patient presents with itchy nipple, unilaterally. She thinks its from the wool sweater she just bought, but you always have to keep WHAT “can’t miss” on your differential?
Paget carcinoma: itchy dermatitis of the nipple w/ ulceration, usually associated with ductal carcinoma
What is the most malignant form of breast cancer, that is often confused with breast abscess?
inflammatory carcinoma
rapidly growing, painful.
Patient presents with a unilateral warm, painful, erythematous breast. What are you concerned about?
inflammatory carcinoma!
