PROLOG: Patient Management in the Office Flashcards
Smoking in females has been linked to:
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.
Pituitary gland during pregnancy
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
First-line treatment for microadenomas and macroadenomas
Medical: dopamine agonist (bromocriptine, cabergoline) - decrease [serum prolactin]
Surgery: refractory tumors
Symptoms of urethral diverticulum
Dyspareunia (10%)
Dysuria (33%)
Recurrent UTI (50%)
Stress incontinence (50%)
Most likely cause of patients discontinuing oxybutynin for urge urinary incontinence?
** Xerostomia **
Constipation
Blurry vision
Anticholinergics: competitively inhibit ACh at the muscarinic receptors and decrease involuntary detrusor muscle contractions (oxybutynin, tolterodine, fesoterodine)
Most common reason discovered during workup for RPL?
Suspected causes of RPL?
No apparent reason
AMH and evaluation of infertility:
What are AMH levels predictive of?
Where is serum AMH made?
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.
When to discontinue cervical cancer screening in HIV-negative women with a history of negative cervical cytology screening?
At age 65 yo
Cushing’s Disease vs Cushing Syndrome
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
Fragile X premutation and premature ovarian insufficiency
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.
Proportion of twin births in the US attributable to IVF
17% (approximately 1 in 6 twin pregnancies)
What is the longest time GnRH agonist should be used, according to the FDA, for endometriosis?
12 months (loss of bone mineral density)
Most common cause of infertility
Unexplained infertility
Primary pathophysiology of infertility in obese patients
Insulin resistance > hyperinsulinemia > related to androgen excess and reduced SHBG synthesis > increases androgen production > alters HPA axis and therefore, ovarian physiology > anovulation
Key surgical principle for rectovaginal fistula repair
Wide margins of adjacent tissue for excision
Complete excision of fistulous tract
Multilayered closure
Treatment of vulvar psoriasis
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
Lichen planus
Involvement of mucosal surfaces (oropharynx and vagina)
Treatment: topical high-dose clobetasol
First line treatment for chronic cyclic pelvic pain with regular menses and normal pelvic exam
NSAIDs
Treatment for postpartum psychosis
Treatment for postpartum depression (severe)
Hospitalization + risperidone
Hospitalization + SSRI
First-line treatment for PMS
SSRI
Treatment for female sexual interest and arousal disorder
Flibanserin (serotonin receptor agonist/antagonist)
PEP for HIV recommendation post-sexual assault
Emergency contraception following sexual assault
- 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
Best pharmacotherapy option for opioid use disorder in pregnancy
Buprenorphine (long-acting partial mu-opioid agonist): decreased risk of overdose, less need for dosage adjustment,
Incidence of IPV
50%
STI prophylaxis following sexual assault
Incidence of perinatal depression
14.3% (approximately 1 in 7 women)
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
Female sterilization and relationship to menstrual cycle
Decrease in menstrual blood flow, decrease in menstrual pain, increase in cycle irregularities
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.
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.
- Pneumococcal polysaccharide vaccine (PPSV23/Pneumovax): composed of partially purified pneumococcal capsular polysaccharides
- Pneumococcal conjugate vaccine (PCV13/Prevnar): composed of pneumococcal capsular polysaccharides covalently linked (conjugated) to a protein
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.
What is the pregnancy rate when the copper IUD is used for emergency contraception?
0.1% (1 per 1,000)
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
When is colonoscopy for screening of CRC recommended?
Age 50
For AA females, at Age 45
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
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.
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%.
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
BMI Classification
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
Who is a candidate for vulvectomy?
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
Management of uterine fibroids (Medical/Surgical)
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
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
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
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:
- Oligo or anovulation
- Clinical or biochemical hyperandrogenism
- 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
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
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
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
First line treatment for genito-pelvic pain and penetration disorder
Pelvic floor therapy
What percentage of women with PCOS have T2DM?
10%
Who is most likely to experience pelvic congestion syndrome (PCS)?
Premenopausal, multiparous women
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)
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)
Semen Analysis
Aspermia
Asthenospermia
Azoospermia
Hypospermia
Oligospermia
Severe Oligospermia
Teratozoospermia
Pelvic Organ Prolapse Classification
Stage 0, I, II, III, IV
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%
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
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.
Prolapse location and associated procedure
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
Which imaging modality is the most sensitive and specific for confirmation of urethral diverticulum?
Pelvic MRI
What percentage of women who are successfully fitted with a pessary will have resolution of their prolapse symptoms at 4 months?
75-80%
What is the fertility rate for unilateral cryptorchidism? bilateral cryptorchidism?
80%, 50%
Absolute contraindications to UAE
- Current pregnancy
- PID
- Uterine malignancy
- Asymptomatic fibroids
What muscles are chiefly responsible for pelvic floor muscle spasms?
Puborectalis
Iliococcygeus
Pubococcygeus
Function of the bulbospongiosis muscle?
Clitoral erection and contraction during orgasm
Precocious puberty is defined as?
Early breast or pubic hair development or both before age 8 years
Highest PPV in detecting pelvic congestion syndrome?
Treatment for pelvic congestion syndrome
TVUS
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
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
Diagnostic modality for endometriosis vs endometrioma
Although diagnostic laparoscopy gold standard for diagnosing endometriosis, pelvis U/S sufficient to make diagnosis of endometrioma
Diagnostic criteria for metabolic syndrome
How should hydrosalpinges be managed re: fertility?
Most commonly a result of PID from gonorrhea or chlamydia
They should be removed to increase
What is the prevalence of infertility in women between the ages of 35 to 39 yo?
22%
Hidradenitis suppurativa, Hurley Stages
Cancers associated with BRCA mutation
Atypical ductal hyperplasia: next step in management
Excisional biopsy because 10-20% have underlying ductal carcinoma in situ (DCIS) or invasive carcinoma
What is the maximum dose of local lidocaine with and without epinephrine that can be used for a procedure?
Recommended Syphilis Treatment Guidelines for Non-pregnant Patients
Strategies approved to reduce the risk of ovarian cancer (4)
Ulcerative Colitis vs. Crohn’s Disease
Infertility Categories
IUD Birth Control Types and Side Effects
Treatment of C. diff infection in adults
Algorithm for the use of antithyroid drugs with Graves’ Disease
Flow chart for fetal and placental evaluation of stillbirth
Maternal Evaluation at time of demise (Stillbirth)
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
Suggested approach to management of subclinical hypothyroidism
What is Mondor Disease?
Treatment consists of NSAIDS and warm compresses without the need for anticoagulation
FIGO Staging of Fibroids
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.
Mittelschmerz
When do ovarian follicular cysts typically rupture?
After physical activity or sexual intercourse.
Prolactinoma symptoms
Which hormone is responsible for the development of external genitalia in males?
dihydrotestosterone
What is the source of anti-Müllerian hormone in males?
Sertoli cells
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?
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
Medications for treatment of osteoporosis
Recommended doses of antiviral medication for herpes (first vs recurrent) in pregnancy
Suppressive HSV therapy
