office

Question 1

who should get DEXA scan
who should get early dexa scan

Answer 1

start at 65 plus
can screen earlier than 65 if they have risk factors
-if frax risk is >8.4% , should get early dexa (8.4 is average fracture risk for 65 year old)
-risk factors: personal hx of fracture, first degree relative with fracture, current cig smoker, drugs, frail, inadequate physical activity, estrogen deficiency, alcoholism, RA, gastric bypass

Question 2

MOA of bisphosphonates

Answer 2

inhibit osteoclast activity (bone resorption)

Question 3

contraindications to bisphosphonates

Answer 3

esophageal abnormalities (including reflux) and renal failure
unable to sit up for 30 minutes after taking it
hypocalcemia

Question 4

indications for treatment with bisphosphonates

Answer 4

-T score <-2.5 (osteoporosis) or
-T score <-1 (low bone mass) and frax score >3% for hip fracture or 20% for major fracture
-history of fragility fracture regardless of t score

Question 5

when to repeat dexa

Answer 5

no sooner than q2 years if not on treatment
if on treatment, every 1-3 years until stable. do not need to repeat once DEXA stable or improved, unless risk factors change
take a holiday after 5 years of treatment

Question 6

secondary causes for osteoporosis

Answer 6

if they are not improving on bisphosphonates and DEXA scan getting worse
-parathyroid disease
-thyroid disease
-calcium and vitamin d level

Question 7

what is frax score

Answer 7

fracture risk screening tool for women >40
predicts risk of osteoporotic fracture in the next 10 years

Question 8

when would you use a z score

Answer 8

useful for premenopausal women at risk for secondary causes of osteoporosis. compares to people of same age, sex and race.
z score of <-2 warrants eval for secondary causes

Question 9

what birth control do you usually prescribe?
What is MOA? SE?
what do you do if you have breakthrough bleeding in the middle of the cycle or towards the end of the cycle?

Answer 9

norethindrone acetate (1.5 mg)
ethinyl estradiol (30 mcg) or loestrin 1mg/20 mcg
suppresses ovulation (blocks FSH and LH surge). SE; AUB, mood changes, acne
mid cycle: increase the estrogen
towards the end of the cycle: increase progesterone, progesterone not stabilizing the endometrium enough (could try a triphasic pill)

Question 10

contraindications to OCPs

Answer 10

uncontrolled HTN
migraines with aura
liver disease
pregnancy
undiagnosed vaginal bleeding
smoking past age 35
Breast cancer
Estrogen positive tumor
Known thrombophilia
Thrombosis
CVD/CHD
First 21d op

Question 11

side effects of HRT
Estrogen/Progesterone
Estrogen alone

Answer 11

E/p:
increased breast CA (after 5-7 yrs), cardiac issues (if starting more than 10 years after menopause, not in younger women in the HERS study)
increase VTE
increase risk of CVA (if >70)

decrease colon Ca
decrease all fractures
decrease vasomotor

Estrogen :

decrease coronary heart disease
decrease all fracture
increase in VTE
increase CVA (lower risk)

Question 12

contraindications to HRT

Answer 12

pregnancy
breast cancer
estrogen sensitive tumor
undiagnosed vaginal bleeding
liver disease
history of VT or thrombophilia
coronary heart disease
CVA/TIA

Question 13

gyn risks with smoking

Answer 13

cervical cancer, HPV mediated disease, bacterial vaginosis, decreased ovarian reserve and fertility, increased risk of breast cancer, VTE, osteoporosis, early menopause, bladder cancer
in pregnancy increased risk of IUGR, PPROM, LBW, previa, abruption, ectopic pregnancy, SAB, IUFD

Question 14

how to counsel someone on stopping smoking

Answer 14

the 5As
Ask
Advise
Assess
Assist
Arrange

Question 15

smoking cessation aids if pregnant

Answer 15

wellbutrin
limited data on chantix (varenicline), but seems to be safe
patch/gum- acog is lukewarm, may not actually be cutting down on nicotine

Question 16

galactorrhea and amenorrhea

Answer 16

H&P
evaluation of medications (dopamine antagonists (DA is competitive antagonist to prolactin) like antipsychotics, reglan)
ask for any headaches or visual changes (would see narrowing of peripheral vision- bitemporal hemianopsia), feel for the thyroid
labs (HCG, TSH, fasting prolactin, no nipple stimulation or intercourse or masturbation for at least 24h before)
if prolactin elevated, but less than 100, repeat the test (maybe ate or had orgasm, make sure it is truly an elevation)
if elevated twice- get MRI
headaches or visual changes- get MRI
if prolactin >100- get MRI
Can then refer to neurosurgery or endocrinology

Question 17

galactorrhea treatment (elevated prolactin)

Answer 17

DA agonist
cabergoline or bromocriptine (side effect of orthostatic hypotension and nausea)

Question 18

sti ppx for rape victim

Answer 18

500 mg ceftriaxone IM x1
100 mg doxycycline BID x7d
500 mg metronidazole BID x7d
HepB (+/- Ig) and HPV vaccines
if HIV+, start HAART within 72h. If HIV unknown and <72h, call HIV hotline to estimate risk and benefit of 28d HAART
emergency contraception

Question 19

testing for rape victim

Answer 19

Thorough history and PE
ASK THE PATIENT PERMISSION TO EXAMINE HER
collect her clothing
scalp hair
saliva
pubic hair
fingernail scrapings
vaginal and rectal swabs
NAATs for gc/ct, trichomonas
blood work: HCG, syphilis, HIV, hepB and HepC, stain on clothes
Repeat testing 6 weeks later and at 3 or 6 months

Question 20

desirable cholesterol, LD, HDL, and TG values

Answer 20

cholesterol: <200
LDL: <100
HDL: >60
TG: <150

Question 21

when to start statin

Answer 21

statins reduce RR of CVD by 30%
start if LDL >190
start if 10 year CVD risk calculator >10%, consider if 5-10%
atorvastatin 10 mg qd

Question 22

tamoxifen vs raloxifene

Answer 22

tamoxifen: treatment for breast cancer, endometrial thickening, polyps, increased risk of endometrial CA (2.5 fold), vaginal estrogenization
Raloxifene: treatment for osteoporosis, no effect on endometrium or vagina
Both are SERMs =, both with increased thromboembolism, both reduce breast CA , both increase bone mineral density, increase vasomotor sx

Question 23

Non estrogen alternatives for vasomotor sx

Answer 23

1) SSRIs and SNRIs (paroxetine, fluoxetine, venlafaxine) Avoid paroxetine and fluoxetine if pt also on tamoxifen
2)gabapentin
3) clonidine. Small benefit. Not FDA approved, rarely used ‘
4) progestins- inc risk for breast CA, use for endometrial protection only, not rec
5) Vitamin E (minimal effect)
6) black ohosh, isoflavone, evening primrose, yoga, acupuncture- same as placebo
Dress in layers
Keep living area cool
Avoid hot spicy foods alcohol caffeine
Exercise
Increase water
Reduce stress

Question 24

screening tests during annual visit

Answer 24

GC/CT if 13 to 24 if sexually active, >25 if high risk
Glucose/FBS: annually if high risk, otherwise every 3 years beginning at 45
Lipid profile: every 5 years beginning at 21 yo
DEXA: at 65, sooner w/ risk factors
HIV/HepC: once in lifetime. Con screening HIV anually if high risk
breast exam not indicated if <20, pelvic exam not indicated if <21 UNLESS sig medical history

Question 25

vitamin D recommended amounts

Answer 25

600IU daily if 1-70
800 IU daily if >70

Question 26

Calcium recommendations

Answer 26

19-50: 1000 mg/day
>50: 1200 mg/day

Question 27

other treatments for osteoporosis other than bisphosphonates

Answer 27

-HRT (if all other options fail)
-Raloxifene (reduces vertebral fracture rate by 50%, pro estrogen on bone, anti estrogen in endometrium)
-Calcitonin (200 IU/day nasal spray or subq injection) rarely used, black box warning for malignancy
-Monoclonal body (Rank Ligand Inhibitor

BONE BUILDING THERAPIES
-parathyroid hormone
sclerostin inhibitor (monoclonal antibody)
*treatment for very high fracture risk , T score < -3 or <-2.5 with fractures

Question 28

when to stop pap testing

Answer 28

65+ with no abnormal pap smear (3 consecutive cytologies or 2 consecutive co testing in the past 10 years) , no hx of CIN 2/3 or AIS, or if you have had hysterectomy for benign reasons

Question 29

when should you stop pap testing if you have a hx of CIN2/3

Answer 29

pap smear alone every 3 years until 25 years after post treatment surveillance

Question 30

pap testing in HIV patient

Answer 30

start within 1 year of insertional intercourse, no later than 21 yo
annual cytology x3, then if all normal every 3 years
if > 30 years, cytology alone or co testing every 3 years
continue lifelong screening

Question 31

<25 yo, CIN 2

Answer 31

repeat colpo and pap every 6 months
treatment if persistent at 2 years

Question 32

what do you do if you have positive margins after a LEEP for CIN 2/3

Answer 32

repeat co testing at 6 months regardless of margin status. if positive do colpo and ECC
colpo and ECC at 6 months right off the bat is also acceptable

Question 33

<25, persistent ASCUS

Answer 33

do colpo if persistent after 2 years

Question 34

<25 and HSIL

Answer 34

colposcopy
same with ASCUS-H

Question 35

treatment for VIN, usual type

Answer 35

-wide local excision (preferred, 1 cm margin)

-Ablative therapy (multifocal lesions, involve clitoris, urethra, anus, or introitus to preserve anatomy). Do colpo and take biopsies before to rule out invasive disease since no tissue specimen

-Topical therapy (imiquimod)

Vulvectomy (for persistent recurrence of VIN)

Question 36

surveillance for VIN

Answer 36

monitor vulva every 6 months for 5 years, then annually

Question 37

How do you biopsy vulvar lesion
what do you do if there are positive margins

Answer 37

colposcopy with acetic acid to identify lesions. Biopsy margin of the lesion.
If positive margins- repeat excision. If microscopic, close observation and colpo with biopsy of suspicious lesions. Recurrence is common (1/3 of patients). If pos margins, 50% chance of recurrence

Question 38

Nutritional deficiencies with bariatric surgery patients

Answer 38

Iron folate vitamin B 12 calcium vitamin D
Also decrease in vitamin K