PROLOG: Patient Management in the Office Flashcards
1
Q
Smoking in females has been linked to:
A
Accelerated follicular depletion due to harmful effects of tobacco smoke and gametogenesis
Have to undergo more IVF cycles until success is achieved
Increased risk of SAB, ectopic pregnancy, IUGR
Males who smoke have lower semen concentration, motility, and/or morphology. However, even if these parameters are reduced, they are often still in the low normal range.
2
Q
Pituitary gland during pregnancy
A
Enlarges during pregnancy, primarily due to hypertrophy and hyperplasia of the lactotropes in response to elevated serum estrogen levels
Tumor growth leading to significant symptoms complicates ~2% of microadenomas and 21% of untreated macroadenomas > significant expansion may lead to headaches or compression of the optic chiasm and blindness so visual field testing is considered in every trimester for women with macroadenomas
3
Q
First-line treatment for microadenomas and macroadenomas
A
Medical: dopamine agonist (bromocriptine, cabergoline) - decrease [serum prolactin]
Surgery: refractory tumors
4
Q
Symptoms of urethral diverticulum
A
Dyspareunia (10%)
Dysuria (33%)
Recurrent UTI (50%)
Stress incontinence (50%)
5
Q
Most likely cause of patients discontinuing oxybutynin for urge urinary incontinence?
A
** Xerostomia **
Constipation
Blurry vision
Anticholinergics: competitively inhibit ACh at the muscarinic receptors and decrease involuntary detrusor muscle contractions (oxybutynin, tolterodine, fesoterodine)
6
Q
Most common reason discovered during workup for RPL?
Suspected causes of RPL?
A
No apparent reason
7
Q
AMH and evaluation of infertility:
What are AMH levels predictive of?
Where is serum AMH made?
A
AMH levels = predictor of response to exogenous gonadotropins
Lower serum AMH levels ( <1 ng/mL) have been associated with poor responses to ovarian stimulation, poor embryo quality, and poor pregnancy outcomes in IVF
Serum AMH made by the granulosa cells of pre-antral and small antral follicles. [AMH] gonadotropin-independent; can be obtained any day of the menstrual cycle.
8
Q
When to discontinue cervical cancer screening in HIV-negative women with a history of negative cervical cytology screening?
A
At age 65 yo
9
Q
Cushing’s Disease vs Cushing Syndrome
A
Cushing’s Disease: Excess of cortisol in the blood caused by pituitary tumor secreting ACTH > cortisol level will decrease with high dose dexamethasone suppression test
10
Q
Fragile X premutation and premature ovarian insufficiency
A
X-linked disorder caused by triplet expansion repeats in FMR1 gene
Patients diagnosed with hypergonadotropic hypogonadism should be tested for premutation, should receive genetic counseling.
11
Q
Proportion of twin births in the US attributable to IVF
A
17% (approximately 1 in 6 twin pregnancies)
12
Q
What is the longest time GnRH agonist should be used, according to the FDA, for endometriosis?
A
12 months (loss of bone mineral density)
13
Q
Most common cause of infertility
A
Unexplained infertility
14
Q
Primary pathophysiology of infertility in obese patients
A
Insulin resistance > hyperinsulinemia > related to androgen excess and reduced SHBG synthesis > increases androgen production > alters HPA axis and therefore, ovarian physiology > anovulation
15
Q
Key surgical principle for rectovaginal fistula repair
A
Wide margins of adjacent tissue for excision
Complete excision of fistulous tract
Multilayered closure
16
Q
Treatment of vulvar psoriasis
A
Does not result in classic scaly appearance; repeat moisture and heat may make it resemble candidiasis
Treatment: hydrocortisone for mild disease, prolonged topical steroids for moderate disease
17
Q
A
Lichen planus
Involvement of mucosal surfaces (oropharynx and vagina)
Treatment: topical high-dose clobetasol
18
Q
First line treatment for chronic cyclic pelvic pain with regular menses and normal pelvic exam
A
NSAIDs
19
Q
Treatment for postpartum psychosis
Treatment for postpartum depression (severe)
A
Hospitalization + risperidone
Hospitalization + SSRI
20
Q
First-line treatment for PMS
A
SSRI
21
Q
Treatment for female sexual interest and arousal disorder
A
Flibanserin (serotonin receptor agonist/antagonist)
22
Q
PEP for HIV recommendation post-sexual assault
A
23
Q
Emergency contraception following sexual assault
A
- Ulipristal acetate: 30 mg single dose PO, within 5 days from assault
- Levonorgestrol (plan B): 1.5 mg single dose PO
- Copper IUD
- Mifepristone: 600 mg single dose
24
Q
Best pharmacotherapy option for opioid use disorder in pregnancy
A
Buprenorphine (long-acting partial mu-opioid agonist): decreased risk of overdose, less need for dosage adjustment,
25
Incidence of IPV
50%
26
STI prophylaxis following sexual assault
27
Incidence of perinatal depression
14.3% (approximately 1 in 7 women)
28
A 53 yo perimenopausal female with history of cHTN presents with hot flashes. BP 140/90.
What medication best to treat both BP and vasomotor symptoms?
Clonidine (alpha 2-agonist)
Most common side effects: dry mouth, insomnia, drowsiness
Watch out for: rebound HTN
29
Female sterilization and relationship to menstrual cycle
Decrease in menstrual blood flow, decrease in menstrual pain, increase in cycle irregularities
30
What DEXA screening result is consistent with osteoporosis?
At what age should DEXA be performed?
A T-score greater than or equal to two 2.5 standard deviations below the mean (T-Score is based on a healthy 30-35 yo)
DEXA should be done at age 65 in a patient without risk factors.
31
In a healthy individual without risk factors, what is the recommendation regarding pneumococcal vaccination?
What are the two kinds of vaccines available?
All adults \>/= 65 yo should continue to receive **one dose of PPSV23.** If the decision is made to administer PCV13, it should be given at least 1 year before PPSV23.
Continue to recommend PCV13 in series with PPSV23 for adults aged 19 and older **with an immunocompromising condition, CSF leak, or cochlear implant.**
1. Pneumococcal polysaccharide vaccine **(PPSV23/Pneumovax)**: composed of partially purified pneumococcal capsular polysaccharides
2. Pneumococcal conjugate vaccine **(PCV13/Prevnar)**: composed of pneumococcal capsular polysaccharides covalently linked (conjugated) to a protein
32
What is the major limitation of conjugated equine estrogen-bazedoxifene use?
There are limited data regarding the long-term effects of bazedoxifene alone and conjugated equine estrogen/bazedoxifene on the breast.
SERMs bind with high affinity to the estrogen receptor and have estrogen agonist and antagonist properties that vary depending on the individual target organ.
33
What is the pregnancy rate when the copper IUD is used for emergency contraception?
0.1% (1 per 1,000)
34
What contraceptive method has the lowest failure rate in the first year of use?
Contraceptive implant (failure rate of 0.05 per 100 women); the 4-cm rod contains etonogestrel, which is slowly released and prevents pregnancy **primarily by suppression of ovulation.** additionally, it may **thicken cervical mucus** and **thin the endometrial lining**
35
When is colonoscopy for screening of CRC recommended?
Age 50
For AA females, at Age 45
36
A 77-yo patient follows up for the results of her DEXA scan. Her T-score is -1.7. What is the next step in management?
**Fraction risk assessment (FRAX) calculator** must first be used to determine the risk of fracture \> used to predict the risk of osteoporotic fracture for a person over the next 10 years
Women who are found to have a 10-year risk of *major osteoporotic fracture \>/= 20%* or a risk of *hip fracture \>/= 3%* using FRAX calculator are candidates for treatment with medical therapy
37
MOA of **denosumab**
Treatment option for **osteoporosis** (antiresorptive treatment)
It is the human monoclonal antibody to the receptor activator of nuclear factor-kB ligand. The receptor activator of nuclear factor-kB ligands to the receptor activator of nf-kB on the surface of osteoclasts \> promotes proliferation and differentiation of these osteoclasts.
The antibody blocks this interaction therein decreasing bone resorption and increasing BMD as a result.
38
A 37 yo G6P2042 patient arrives for her annual screening exam. She has no new complaints or problems. She has an extensive family history of breast, ovarian, renal, prostate, lung, small and large bowel, and skin cancers.
Which of these cancers is associated with **BRCA1** carriers?
The risk of **prostate cancer** in men with BRCA1 mutation has been associated with a 3.75-fold increase, which translates to ~9% risk by age 65.
Men with BRCA2 mutations are at a higher risk of prostate cancer by age 65, with a 5- to 9-fold increased risk, which translates to ~33%.
39
Key Facts to Remember for the BRCA 1/2 Syndromes
Chromosome
Risk of Breast Cancer by Age 70
Associated Breast Cancer Type
Risk of Ovarian Cancer by Age 70
Timing of BSO
Associated malignancies
40
BMI Classification
41
What is the **MOST** common cause of vaginitis in the pediatric population?
Treatment?
**Group A beta-hemolytic** ***Streptococcus*** (GAS is found in 7% to 20% of pediatric girls with vulvovaginitis)
Children may transmit respiratory flora from the nose and oral pharynx to the vulva
Treatment: **Amoxicillin 40 mg/kg TID for 10 days**
42
Who is a candidate for vulvectomy?
43
What is **Elagolix** and when is it used?
Oral GnRH antagonist that was approved by the FDA in 5/2020 for treatment of HMB 2/2 uterine fibroids
Given with or without hormonal add-back therapy (estradiol and norethindrone acetate) for at least 12 months before reevaluation; preparation available as two co-packaged capsules: one contains elagolix 300 mg + estradiol 1 mg + norethindrone 0.5 mg (AM); other contains elagolix 300 mg alone (PM)
Reserved for cases that did not improve with conventional therapy and myomectomy; associated with 50% reduction of menstrual flow and reduction of leiomyoma size by also 50% in 6 months
44
Management of uterine fibroids (Medical/Surgical)
45
What colposcopic finding with use of acetic acid associated with high-grade hypoplastic lesion of the cervix?
Dull white coloration
If Lugol solution used, a negative stain is noted
46
Underlying pathophysiology of primary dysmenorrhea
**Increased prostaglandins E2 and F2 alpha** at the beginning of menses to facilitate monthly shedding \> increase in prostaglandins leads to uterine contractions \> leads to **temporary ischemia** of the uterine corpus \> leads to stimulation of **type C pain fibers**
47
Treatment options for urgency urinary incontinence
Also botulinum toxin A: primarily acts as a muscle paralytic by inhibiting the presynaptic release of ACh from motor neurons at the NMJ, in this case at the detrusor muscle
48
PCOS is a diagnosis of exclusion via the Rotterdam criteria:
PCOS can be diagnosed in women if they have 2 of the 3 following criteria:
1. Oligo or anovulation
2. Clinical or biochemical hyperandrogenism
3. Polycystic ovaries on U/S characterized by having 12 or more antral follicles between 2 and 9 mm or an ovarian volume greater than 10 mL
49
Pathophysiology of PCOS
Abnormal pulse frequency of GnRH \> increased pulse frequency causes elevations in LH pulse frequency and, to a less extent, an increase in FSH pulse frequency
Increased LH pulse frequency leads to LH binding to ovarian theca cells \> increased steroidogenesis \> increased androgen levels
50
How does insulin resistance (IR) affect PCOS women?
IR causes increased insulin levels \> insulin binds to IGF-1 receptors on ovarian theca cells and increase ovarian steroidogenesis \> increased ovarian androgen production
Increased ovarian androgen production + increased insulin levels combine to **decrease hepatic SHBG levels** \> increases free testosterone level b/c it is not bound to the protein
51
Most definitive way to diagnose adenomyosis
Histology
Endometrial glands and stroma are present within uterine musculature \> ectopic endometrial tissue appears to induce hypertrophy and hyperplasia of the surrounding myometrium, which results in a diffusely enlarged uterus
52
First line treatment for genito-pelvic pain and penetration disorder
Pelvic floor therapy
53
What percentage of women with PCOS have T2DM?
10%
54
Who is most likely to experience **pelvic congestion syndrome (PCS)**?
Premenopausal, multiparous women
55
What is **endometriosis**? And what have endometriotic tissue been found to contain?
Endometrial cells growing outside of the endometrial canal have been found to contain 5 alpha-reductase (indicates that androgens may have the ability to act on endometriotic cells)
56
What % of women experience pelvic pain shortly after a UAE due to fibroid uterus?
\>90%
As the blood within the fibroid clots, ischemia occurs, and women develop intense pelvic cramping (approximately 4-6 hours after the procedure)
57
Semen Analysis
Aspermia
Asthenospermia
Azoospermia
Hypospermia
Oligospermia
Severe Oligospermia
Teratozoospermia
58
Pelvic Organ Prolapse Classification
Stage 0, I, II, III, IV
59
A 31 yo G4P0 was diagnosed with a Mullerian anomaly, but unsure which one. Reports 4 spontaneous pregnancy losses in 1TS. Which Mullerian anomaly is she most likely to have?
**Septate uterus**
(carries greatest risk of miscarriage; likely the result of implantation on or near the septum leading to poor placental blood flow, and is most common)
Miscarriage rate \>50%
60
Presacral neurectomy
Division of superior hypogastric plexus
The hypogastric plexus consists of fine strands of nerves embedded in areolar tissue. The plexus is formed as a continuation of the aortic and inferior mesenteric plexuses and passes over the bifurcation of the aorta. It then continues below the promontory of the sacrum before dividing into the R and L inferior hypogastric nerves
61
Pudendal nerve block
Pudendal nerve provides both sensory and motor innervation to the perineum
As the fetus descends in the late first stage or second stage of labor, distention of the vagina, pelvic floor, and perineum elicit stimuli through the pudendal nerve and anterior primary divisions of the sacral nerves S2 through S4.
62
Prolapse location and associated procedure
63
What is an **ectropion**?
Normal finding in many adolescent females, women on combined OCPs, and pregnant women; it is the migration of endomcervical/columnar tissue fromt he endocervix distaly \> subsequently, red, glandular, columnar epithelium is presents outside the xternal os and is easily seen on speculum exam
64
Which imaging modality is the most sensitive and specific for confirmation of urethral diverticulum?
Pelvic MRI
65
What percentage of women who are successfully fitted with a pessary will have resolution of their prolapse symptoms at 4 months?
75-80%
66
What is the fertility rate for unilateral cryptorchidism? bilateral cryptorchidism?
80%, 50%
67
Absolute contraindications to UAE
* Current pregnancy
* PID
* Uterine malignancy
* Asymptomatic fibroids
68
What muscles are chiefly responsible for pelvic floor muscle spasms?
Puborectalis
Iliococcygeus
Pubococcygeus
69
Function of the **bulbospongiosis** muscle?
Clitoral erection and contraction during orgasm
70
**Precocious puberty** is defined as?
Early breast or pubic hair development or both before age 8 years
71
Highest PPV in detecting pelvic congestion syndrome?
Treatment for **pelvic congestion syndrome**
TVUS
72
**Stress urinary incontinence** \> most common complication after placement of **midurethral sling**? **retropubic sling**?
**Urinary urgency**
Most patients' symptoms resolve with conservative treatment with anticholinergics or no treatment at all
**Urinary retention**
73
Initial resuscitation for septic abortion
* Establish IV access for IV fluids and blood products
* Obtain blood cultures
* Initiate broad spectrum abx
* IV until patient afebrile for 48 hours then oral abx for 10-14 days
* Evacuate uterus of any contents
74
Diagnostic modality for endometriosis vs endometrioma
Although diagnostic laparoscopy gold standard for diagnosing endometriosis, **pelvis U/S** sufficient to make diagnosis of endometrioma
75
Diagnostic criteria for metabolic syndrome
76
How should hydrosalpinges be managed re: fertility?
Most commonly a result of PID from gonorrhea or chlamydia
They should be removed to increase
77
What is the prevalence of infertility in women between the ages of 35 to 39 yo?
22%
78
First-line treatment for ovulation induction in women with PCOS
Clomiphene citrate
Approximately 75% should ovulate, and pregnancy rates are 50% after 3 or 4 cycles in the infertile *anovulatory woman*
79
Management of **hidradenitis suppurativa** (early disease vs chronic disease)
Early disease: antibiotics (e.g., clindamycin)
Chronic disease: wide operative excision
80
Three of the major muscles involved with vaginismus
1. Bulbocavernosus
2. **Puborectalis**
3. Levator ani group **(pubococcygeus\*\*, iliococcygeus)**
81
What is abdominal leak-point pressure?
The intravesical pressure at which urine leakage occurs because of increased abdominal pressure in the absence of a detrusor contraction
82
First-line treatment in patients with vulvodynia
**Amitriptyline 5-25 mg tablet nightly** and increased by 10-25 mg each week \> max dose: 150 mg daily
83
What is the easiest and most objective way to assess whether ovulation has occurred?
Serum progesterone 1 week before anticipated next menses
Levels greater than 3 ng/mL signify ovulation when checked approximately 1 week prior to the next anticipated menstrual cycle
84
Most common symptoms of adenomyosis
Heavy and painful menstrual cycles
(Should not have dyspareunia, irregular menses)
85
Hidradenitis suppurativa, Hurley Stages
86
What are the Lynch syndrome-related genes?
MLH1, MSH2, MSH6, PMS2, EPCAM
87
What is **Lynch Syndrome**?
Types of testing (3)
Hereditary non-polyposis colorectal cancer (HNPCC): Highly penetrant AD hereditary cancer syndrome that accounts for approximately 2% of uterine cancer cases.
Types of testing:
1. **IHC**: used to test tumors for the expression of the 4 mismatch repair genes (MLH1, MLH2, MSH6, and PMS2) by testing for the presence of their protein products. If all 4 protein products present, it r/o Lynch syndrome in nearly all cases.
2. **Microsatellite instability testing**: used to determine if there has been an insertion or deletion of nucleotides to informative microsatellites. If no microsatellite instability is present, Lynch syndrome is essentially ruled out.
3. ***MLH1* promoter methylation testing:** must be performed when IHC testing reveals an absence of the *MLH1* protein or when microsatellite instability is present.
1. *MLH1* protein is absent and there is methylation of the *MLH1* promoter --\> Lynch syndrome is excluded.
2. *MLH1* protein is absent and there is no methylation of the *MLH1* promoter --\> patient requires germline DNA testing for Lynch syndrome
88
Latent syphilis
No clinical signs or symptoms of syphilis but has serologic evidence of infection
89
Classic lesion of **primary syphilis**
**Chancre**, which is usually (but not always) painless
Usually appears approximately 21 days after infection, but it can occur anytime between 3 and 90 days \> ulcer has nonexudative base and is associated with mild to moderate regional lymphadenopathy that is often bilateral
90
Correct sequence of the layers of the bladder after the lumen
1. Transitional epithelium
2. Lamina propria
3. Submucosa
4. Detrusor muscle
5. Adventitia
91
When is the **BEST** time in the menstrual cycle to perform a hysteroscopy?
In the **early proliferative phase** (when the endometrial lining is the thinnest)
Allows for better visualization of anatomical abnormalities such as polyps; thin lining also allows for easier removal of masses noted
92
What is the failure rate of the **copper IUD** within its first year of **typical use? perfect use?**
Typical use: **0.8%**; Perfect use: **0.6%**
93
COCs and SLE
Women with SLE are at increased risk for **ischemic heart disease, stroke, and VTE.**
UNACCEPTABLE HEALTH RISK IF COCs USED
94
Gold standard of diagnosis for postpartum endometritis?
EMB (plasma cells)
95
Recommended Screening for PCOS
* Weight
* BP
* 2-hour GTT
* Fasting lipid and lipoprotein levels
96
What is the lifetime risk of developing ovarian cancer in a woman with a BRCA2 mutation?
10%-27%
97
Current therapies for **primary genital herpes**
* Acyclovir 200 mg five times daily for 7-10 days
* Acyclovir 400 mg three times daily for 7-10 days
* Famciclovir 250 mg three times daily for 7-10 days
* Valacyclovir 1 g twice daily for 7-10 days
98
EMB samples approximately how much of the endometrium?
5-15%
99
Fluid overload at time of hysteroscopy can lead to:
**Hypo-osmolality** and **hyponatremia** \>\> severe levels may cause brain swelling and neurological damage
Incidence \<1%
100
ADA Criteria for Diagnosing DM
* Random plasma glucose PLUS symptoms: **200 mg/dL or higher**
* Fasting plasma glucose: **126 mg/dL or higher**
* 2 h plasma glucose: **200 mg/dL or higher**
* HbA1c: **6.5% or higher**
101
During what point of the menstrual cycle does PMS occur?
**Luteal phase**
\* If PMS symptoms are severe enough to interfere with work, school, social activities or relationships with others, the diagnosis becomes PMDD \*
102
During hysteroscopy, which media is easy to use and is **BEST** at decreasing the risk of electrolyte and osmolar imbalances, as well as decreasing the risk of anaphylactic reaction?
Lactated Ringer (isotonic)
103
Paget disease or inflammatory breast cancer
Next step in management?
Cancer of the nipple and areola
Associated with an invasive breast carcinoma or ductal carcinoma in situ (DCIS) in 85% of cases
Management: **Mammogram and full-thickness skin biopsy**
104
How to clinically diagnose **PID**?
* Cervical motion tenderness
* Fever \> 101 F
* Abnormal cervical or vaginal mucopurulent discharge
* Abnormal WBC count
* *Recent diagnosis of gonorrhea or chlamydia*
105
Treatment of PID
Outpatient treatment:
1. Ceftriaxone 250 mg IM x 1
2. Doxycycline 100 mg BID for 14 days
106
Indication for inpatient treatment: PID
Treatment
Indication for inpatient treatment:
* Pregnancy
* Lack of response to oral abx
* Persistent N/V
* Severe clinical illness
* TOA
* Inability to adhere to therapy
* Possible need for surgical intervention
Treatment: **Cefoxitin 2g IV every 6 h IV** + **doxycyline 100 mg BID** (oral and IV have same bioavailability) until clinical improvement noted for at least 24 h followed by transition to oral therapy with **doxycyline for a 14-day abx course** (+/- **metronidazole 500 mg BID x 14 days** if pelvic abscess or trichomonas present)
107
At what age should you consider biopsying new Bartholin cysts that appear in women?
40 years (to r/o risk of cancer)
108
In women over age 30 with palpable breast mass, diagnostic mammogram is first step.
If BIRADS 1-3, next step?
If BIRADS 4-5, next step?
* 1-3: U/S
* 4-5: tissue biopsy
109
What % of mothers start smoking again within 6 months of delivery?
50-60%
110
31 yo G1P0 at 12w with exertional chest pain for the last 3 months \> diagnosed with **pulmonary arterial HTN**. To start on what medication?
**Epoprostenol** (pulmonary vasodilator)
111
Per ACOG recommendations, women at average risk of breast cancer should be offered screening mammography starting at what age?
40 years until at least 75 years
112
Cancers associated with BRCA mutation
113
**Atypical ductal hyperplasia**: next step in management
**Excisional biopsy** because 10-20% have underlying ductal carcinoma in situ (DCIS) or invasive carcinoma
114
What is the maximum dose of local lidocaine with and without epinephrine that can be used for a procedure?
115
Recommended Syphilis Treatment Guidelines for Non-pregnant Patients
116
Most common side effects of Paragard
Heavier and longer periods and spotting between periods
For most women, these side effects diminish after the first 2 to 30 months
117
Strategies approved to reduce the risk of ovarian cancer (4)
118
Ulcerative Colitis vs. Crohn's Disease
119
Infertility Categories
120
IUD Birth Control Types and Side Effects
121
27 yo G2P1 is 6 weeks pregnant. She experienced severe postpartum depression in her prior pregnancy. She is experiencing symptoms of depression now. You consider SSRI.
The most common adverse effect to the fetus or neonate from the use of an SSRI?
Neonatal withdrawal syndrome
122
Patients with a positive PPD test and no evidence of active disease by symptoms or CXR are classified as having latent TB.
Treatment?
Isoniazid for 9 months with pyridoxine (B6) supplementation to decrease risk of INH-associated neurotoxicity
Patient who are pregnant need to have baseline LFT testing: The baseline rate o**f 0.1–1% isoniazid-associated** **hepatotoxicity is increased in pregnancy**
Safe to breastfeed
123
Pyelonephritis in pregnancy: Clinical findings
Acute pyelonephritis is a manifestation of **infection of the upper urinary tract and kidneys.**
The typical symptoms of acute pyelonephritis in the pregnant woman are the same as in nonpregnant women and include
**fever (\>38°C or 100.4°F),**
**flank pain,**
**nausea, vomiting,**
**and/or costovertebral angle tenderness.**
Symptoms of cystitis (eg, dysuria) are not always present. Pyuria is a typical finding.
124
Acute pyelonephritis inpatient therapy
**IV cefazolin, 1 g q8h** until patient is afebrile and symptom-free for 24-48 hours and while awaiting cultures
Maintain on **nitrofurantoin (macrobid)** until 4-6 weeks postpartum
125
27 yo G1P0 at 9 weeks. **Heterozygous for prothrombin G20210A** polymorphism. Appropriate management to address her potential risk of venous thrombosis?
Prothrombin gene mutation G20210A is associated with increased production of prothrombin, leading to thrombophilic tendency
In the absence of a prior VTE, the patient's risk is less than 0.5% in pregnancy, similar to women without a known thrombophilia
**Surveillance without anticoagulation**
126
What are the high-risk thrombophilis disorders and their risks of VTE in pregnancy?
* homozygous Leiden V mutation: 1.5%
* homozygous G20210A mutation: 3%
* double heterozygote prothrombin G20210A mutation and Leiden V mutation: 4.7%
* ATIII deficiency: 3-7%
127
What is **premature ovarian failure?**
development of hypergonadotropic hypogonadism before the age of 40 years
128
Up to 6% of young women diagnosed with premature ovarian failure will have the ____ gene premutation.
FMR1
Fragile X syndrome is the most common inherited form of mental retardation, affects approximately 1 in 8,000 females
XLR disorder caused by expansion in CGG DNA trinucleotide repeat that leads to impaired transcription of the FMR1 gene
129
How does otitis media occur in adults?
Results from URI that causes congestion of the nasopharynx and eustachian tube \> obstruction at the narrow part of the ET causes fluid accumulation \> infection (H. flu, S. pneumono)
Tx: Amoxicillin
130
Infants of GDM mothers have an increased risk of?
* Birth weight \> 4000 g
* Hyperbilirubinemia
* Operative delivery
* Shoulder dystocia
* Birth trauma
131
Study to analyze rare outcomes with long-latency periods for the development of the outcome
132
Contraceptive choice for adolescent with migraines and BMI 40
Levonorgestrel IUD
Alternatives: depo medroxyprogesterone acetate and implants (however may add additional weight)
133
Treatment of C. diff infection in adults
134
What is Graves Disease?
Autoimmune condition where IgG antibodies activate thyrotropin receptor --\> increased production of T4 and T3
135
Algorithm for the use of antithyroid drugs with Graves' Disease
136
Flow chart for fetal and placental evaluation of stillbirth
137
Maternal Evaluation at time of demise (Stillbirth)
138
How does Parvovirus B9 lead to fetal death?
Parvovirus B19 is a small single-stranded DNA virus that replicates in rapidly proliferating cells, such as erythroblast precursors.
It leads to arrest of maturation of **fetal red blood cells, hemolysis**, and **transient aplastic crises** that potentially lead to fetal anemia, hydrops, and fetal death.
139
For a viable IUP, when should the gestational sac be visualized?
Between 5.5-6 weeks
140
What is the primary diagnostic imaging step to evaluate complaints of **anal incontinence?**
**Endoanal ultrasonography**
Can identify scarring, loss of muscle tissue, or other local pathology. The findings on endoanal U/S can guide surgical management. The internal anal sphincter appears as the hypoechoic inner circle. The external anal sphincter appears as a circumferential hyperechoic structure in the anal canal. Defects are demonstrated by “graying” or incomplete rings presenting scarring
141
How do combined oral contraceptives treat primary dysmenorrhea?
Combination OCs **decrease uterine prostaglandin production** and relieve dysmenorrhea in 70–90% of patients.
The reduction in prostaglandin from OCs is likely due to the **reduction in endometrial thickness from the progestin component**, because endometrial thickness is directly correlated with prostaglandin release.
142
Suggested approach to management of subclinical hypothyroidism
143
How do combined OCPs work to improve hirscutism?
* Suppression of luteinizing hormone
* Decrease ovarian androgen production
* Stimulate synthesis of SHBG
144
Workup for appendicitis in pregnant patient
1. TVUS \> only 50% sensitivity, 96-100% specificity
2. MRI \> CT to reduce fetal exposure to radiation although levels not associated with known cancer/non-cancer fetal issue
Incidence of fetal loss higher with laparoscopic approach
Incidence of preterm delivery higher with open approach
---\> Overall: **open appendectomy preferred**
145
What has aromatase inhibitor therapy been associated with in postmenopausal patients?
Bone mineral density loss
146
A 30-year-old woman presents to your office for infertility. Her gynecologic history is significant for **stage III endometriosis** and **secondary dysmenorrhea**. On transvaginal sonography, there is an **asymmetric thickening of the myometrium with presence of myometrial cysts**. Which of the following is the best next step for treatment of infertility in women with this condition?
IVF 2/2 adenomyosis
147
When does **adenomyosis** occur?
How to diagnose?
What is the main obstetrical concern for adenomyosis surgery in women who conceive after surgery?
Adenomyosis occurs when endometrial glands and stroma are present in the myometrial layer of the uterus.
Histologic exam (definitive)
Uterine rupture
148
Diagnosis of **bacterial vaginosis**
Treatment of choice for symptomatic nonpregnant
women
When women present with such symptoms, a wet mount using 5% potassium chloride should be performed.
For a clinical diagnosis of bacterial vaginosis,
3 out of the following 4 Amsel’s criteria must be met:
1. Abnormal gray discharge
2. Vaginal pH greater than 4.5
3. A positive amine test (“whiff test”)
4. More than 20% of the epithelial cells are clue cells
Treatment: Oral metronidazole for 7 days
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What is **Mondor Disease**?
Treatment consists of **NSAIDS** and **warm compresses** without the need for anticoagulation
150
Approximately what percentage of women with breast cancer present with noncyclic mastalgia as the primary symptom?
5%
151
FIGO Staging of Fibroids
152
What is the electrolyte abnormality that is most frequently encountered in cases of fluid overload at time of hysteroscopic myomectomy?
Hyponatremia
153
A 25-year-old sexually active woman presents with new onset lower abdominal pain and vaginal discharge. Pelvic exam is notable for cervical motion tenderness. Urine HCG is negative.
What is the most appropriate antibiotic regimen to treat this condition?
Ceftriaxone 500 mg IM x 1
Doxycycline 100 mg PO BID x 14 days
Metronidazole 500 mg PO BID x 14 days
Have low threshold for treating presumptive PID because of long term reproductive sequelae in reproductive aged women
Additional supporting criteria for the diagnosis include: fever, mucopurulent cervical discharge or cervical friability, abundant white blood cells on saline microscopy of vaginal fluid, elevated ESR, elevated CRP, and laboratory documentation of cervical infection with Neisseria gonorrhoeae or Chlamydia trachomatis.
154
What is Fitz-Hugh-Curtis syndrome?
A rare complication of pelvic inflammatory disease causing inflammation of the liver capsule and subsequent adhesions between the liver capsule and anterior abdominal wall.
Perihepatitis + PID
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Mittelschmerz
When do ovarian follicular cysts typically rupture?
After physical activity or sexual intercourse.
156
Which subtype of HPV is mostly involved in high-grade squamous intraepithelial lesions?
16
157
Prolactinoma symptoms
158
A 59-year-old woman presents to your office for health care maintenance. Her medical history is uncomplicated. Her gynecologic history is significant for recently diagnosed **lichen sclerosus.**
Which type of vulvar intraepithelial neoplasia is associated with her condition?
**Differentiated vulvar intraepithelial neoplasia**
The new classification for vulvar lesions comprises three groups: LSIL, HSIL, and VIN differentiated type. Of the three, LSIL is not premalignant while the other two are at risk of malignant transformation.
Differentiated vulvar intraepithelial neoplasia is a condition seen in menopausal women on a background of lichen sclerosus. Differentiated VIN is not associated with high- or intermediate-risk human papillomavirus but women with this condition are predisposed to invasive **squamous cell carcinoma.**
159
Which hormone is responsible for the development of external genitalia in males?
dihydrotestosterone
160
What is the source of anti-Müllerian hormone in males?
Sertoli cells
161
A 28-year-old G3P0030 woman presents to the office after her latest miscarriage. She strongly desires pregnancy and is concerned about why none of her pregnancies have lasted past 8 weeks. You initiate a laboratory evaluation that returns positive for a substance that interferes with the assembly of the prothrombin complex. Which of the following represents that test?
Lupus anticoagulant
162
A 28-year-old woman presents to the emergency room complaining of a **severely painful vaginal lesion**. She is sexually active and reports being in a monogamous relationship. Physical exam reveals findings as illustrated above and the absence of associated adenopathy. Which of the following is the most likely diagnosis?
163
A 17-year-old woman presents to your office because she has never had a menstrual period. She confirms the presence of cyclic changes in her mood and engorgement of her breasts. Physical exam reveals normal secondary sexual characteristics. Laboratory evaluation demonstrates ovarian reserve markers appropriate for age. She is found to have a uterine anomaly. Which one?
Treatment?
Mayer-Rokitansky-Küster-Hauser syndrome (congenital vaginal agenesis)
Treatment? Vaginal dilators constitute the first-line therapy for the creation of a neovagina, with surgical intervention reserved for select cases.
164
A 23-year-old woman is undergoing a colposcopic examination of the cervix because of a high-grade squamous intraepithelial lesion found on cytology. HPV DNA testing was positive for HPV 16. Which was most likely seen on cytologic examination?
Coarse chromatin
165
Which tumor suppressor proteins are inactivated by high-risk human papillomavirus?
P53 and retinoblastoma protein.
166
A newborn is noted to have ambiguous genitalia following delivery. In the nursery, the neonate develops life-threatening hypotension. Blood work reveals an **elevated 17-hydroxyprogesterone**. What is the most common cause of this condition?
21 alpha-hydroxylase deficiency
167
What anal structures are injured during a fourth-degree laceration?
External anal sphincter, internal anal sphincter, and anal epithelium.
168
Above what age should women have an endometrial biopsy performed as a first-line test to evaluate for AUB?
45 or older.
169
In the presence of Müllerian anomalies, which other organ system should be screened for associated anomalies?
Renal and urinary system.
170
Which cystic breast mass is associated with a "blue breast" if the fluid in the cyst is dark?
Mammary duct ectasia.
171
What histologic characteristic is responsible for acetowhite changes seen on colposcopy?
**Larger nuclear:cytoplasm ratio of dysplastic cells** **reflect white** after the cell is dehydrated by application of acetic acid.
172
What nonhormonal medication is approved by the Food and Drug Administration for treating moderate to severe dyspareunia in postmenopausal women?
Ospemifene.
173
Pathophysiology of menstrual migraines
Abortive and prophylactic treatments for migraines
Decline in estrogen
Abortive rx: triptans, DHE, antiemetics, NSAIDs
Prophylaxis: Beta-blockers, CCBs, TCAs
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What organ should be evaluated by ultrasound in a patient with vaginal agenesis?
Kidney
175
When is a test of cure needed for pregnant women treated with gonorrhea or chlamydia?
At 7–14 days after treatment. Uncomplicated, nonpharyngeal, nonpregnant patients do not need a test of cure unless reinfection is suspected, but they need a test of reinfection at 3 months from treatment.
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What causes mucocolpos in neonates with an imperforate hymen?
Increased vaginal secretions due to maternal estradiol.
177
Recurrent UTI definition
two or more uncomplicated UTIs in six months
or
three or more uncomplicated UTIs in 12 months
178
When is treatment of asymptomatic bacteriuria recommended?
Women who are pregnant, who are undergoing a urologic procedure in which mucosal bleeding is anticipated, and who have catheter-acquired bacteriuria persisting 48 hours after catheter removal.
179
What causes a bulging imperforate hymen to be noted at birth?
Mucocolpos resulting from vaginal infant secretions that are stimulated by maternal estradiol.
180
Medications for treatment of osteoporosis
181
What oral medication is most effective at increasing high-density lipoprotein serum levels?
Niacin.
182
Two different mechanisms for stress urinary incontinence
1. Urethral hypermobility: insufficient support to the pelvic floor and the tissue near the urethra and bladder neck.
2. Intrinsic sphincter deficiency: loss of urethral mucosal and muscle tone that normally keeps the urethra closed.
183
What is a contraindication to oxybutynin?
Narrow-angle glaucoma
184
What are the main coagulation factors that are increased with estrogen use?
Factor VII, factor X, and fibrinogen.
185
Which tests should be ordered for a patient with primary amenorrhea and delayed puberty?
Serum follicle-stimulating hormone (FSH) level and karyotype.
186
Recommended doses of antiviral medication for herpes (first vs recurrent) in pregnancy
187
Suppressive HSV therapy
188
What are the first-line pessaries for women who have pelvic organ prolapse?
Ring and Gellhorn
189
When can ovulation resume post abortion?
As early as 10 days after an abortion, which puts women who have an abortion at risk of rapid, repeat unintended pregnancy.
190
Which antidepressant also aids in smoking cessation?
Bupropion
191
What is the characteristic histologic feature for granulosa cell tumors?
Call-Exner bodies
192
Your patient was diagnosed with hypoactive sexual desire disorder and was prescribed flibanserin. What is a contraindication for its use?
Cytochrome P450 Inhibitors (e.g. alcohol)
