Repro Exam Flashcards
when is Rhogam given?
28 weeks
when is the QUAD screen given?
second trimester
when is round ligament pain common?
second trimester
when is G/C tested for?
1st and 3rd trimester
when is GBS tested for?
35+ weeks
what is the first line treatment for N/V in pregnancy?
unisom
when is the GCT given?
24-28 weeks (first trimester if risk factors)
HA, vision changes, and RUQ pain are sx of what?
preeclampsia
how many weeks is considered a term pregnancy?
37
what is the standard for kick counts?
10 kicks/2 hrs
when is a fetal non-stress test performed?
after 28 weeks
what is considered post term (and labor should be induced)?
42 weeks and up
where is the most common place for the sperm and egg to meet?
ampulla
what are the risk factors for an ectopic pregnancy
1) previous ectopic
2) tubal surgery
3) endometriosis
4) hx pelvic infection
5) hx of infertility
6) IUD (if currently inserted)
7) smoking
what are the most common symptoms of an ectopic pregnancy
1) abd pain
2) missed LMP
3) vaginal bleeding
which should be included in the workup if you suspect an ectopic?
1) BHcg
2) CBC
3) type and screen
4) pelvic US
what does a bhcg tell you over a upreg?
quantity
what is the discriminatory zone and what is the lab range?
bhcg level at which an intrauterine gestational sac should be seen
at what value should a gestational sac be seen on US?
> 2000
at what point in a pregnancy should a gestational sac be seen?
4-5 weeks
at what point in a pregnancy should a yolk sac be seen?
5 weeks
at what point in a pregnancy should a fetal pole be seen?
6 weeks
at what point in a pregnancy should fetal heart motion (FHM) be seen?
6 1/2 weeks
how would you expect a bhcg value to change over 2 days?
should at least double
what is a heterotypic pregnancy?
extrauterine and intrauterine pregnancies occur simultaneously
how is a an ectopic dx?
1) adnexal mass c/w ectopic
2) free fluid in pelvis (ruptured ectopic)
3) hemodynamically unstable
4) bhcg > 1500-2000 w/o an intrauterine sac
what should you do if you suspect an ectopic but can’t prove it yet?
1) repeat bhcg in 48 hrs
2) repeat pelvic US
3) give ectopic precautions and bleeding precautions
how is an ectopic pregnancy managed medically?
Methotrexate (MTX)
check bhcg on day 1, 4, 7
how is an ectopic pregnancy managed surgically?
laparoscopic salpingectomy/salpingostomy
how do you know if a medically managed ectopic was a “success”?
15% in bhcg between day 4-7
how long should bhcg be followed after treating an ectopic?
until < 5 (considered negative)
when is surgical management for an ectopic used over medical?
1) evidence of rupture
2) hemodynamically unstable
3) CI to MTX
what must you remember to give a patient with an ectopic?
Rhogam!
what two supplements counteract MTX?
DHA and folic acid
for which surgical procedure to remove an ectopic must bhcg be followed and why?
salpingostomy
b/c need to make sure you removed all of the pregnancy
why must remnants from a surgical excision of an ectopic be sent to pathology?
to confirm chorionic villi
what is GTD?
gestational trophoblastic disease
lesions characterized by abnormal proliferation of placenta trophoblast (complete or partial hydatiform mole or placental site nodule)
what is GTN?
gestational trophoblastic neoplasia
malignant neoplasms arising from abnormal proliferation of placental trophoblast (choriocarcinoma, placental site trophoblastic tumor, epitheliod trophoblastic tumor, invasive mole)
which surgical procedure for an ectopic has more risk of recurrence and threat to fertility?
both the same!
what are the sx of GTD?
1) abnormal vaginal bleeding
2) uterine size > dates
3) hyperemesis gravidarum
4) bhcg > 100,000
5) hyperthyroidism
6) preeclampsia
what gives you morning sickness in pregnancy?
bhcg
how is a molar pregnancy (GTD) dx?
1) bhcg level > 100, 000
2) US
3) pathology = definitive
how does a complete mole look on US?
“snowstorm” appearance form hydropic villi w/o fetal parts
how does a partial mole look on US?
+/- fetal parts
enlarged cystic placenta
which type of mole confers a higher risk of GTN?
complete mole
why must a woman use contraception and be sure not to become pregnant after have a GTD treated?
if get pregnant - can’t tell if the bhcg is positive from the mole or a new pregnancy
how can you tell if GTD has progressed to GTN?
1) bhcg rise 10% over 2 weeks
2) bhcg plateau 10% over 3 weeks
3) bhcg positive at 6 month
what is the tx for low risk GTN?
single agent
MTX or Actinomycin-D
what is the tx for high risk GTN?
multi agent
EMA-CO (etoposide, MTX, actinomycin-D, cyclophosphamide, vincristine)
after a GTD is treated how is bhcg followed?
weekly until < 5
monthly for 6 mon
what is another name for the placenta?
chorion
what is another name for the sac?
amnion
how many days before split result in conjoined twins?
> 12
how many days before split results in monochorionic diamniotic twins?
4-8
how many days before split results in monochorionic monoamniotic twins?
8-12
how many days before split results in dichorionic diamniotic twins?
0-4
how can you tell if twins are fraternal or identical?
genetic testing at birth
what does the T sign on US tell you about twins?
monochorionic
what does the lambda sign on US tell you about twins?
dichorionic
what is the risk with monochorionic twins?
congenital anomalies (heart defects)
what is the risk with monochorionic diamniotic twins?
twin twin transfusion syndrome (TTTS)
twin anemia polycythemia sequence (TAPS)
twin reversed arterial perfusion (TRAP)
what is the risk with monochorionic monoamniotic twins?
cord entanglement/accident
when are DCDA twins delivered?
38 wks
when are MCDA twins delivered?
34-37 wks
when are MCMA delivered?
32-34 wks
at what point is mom of MCMA twins managed inpatient?
@ 24wks
how do you determine mode of delivery for twins?
depends on presentation of twin A
if twins are vertex-vertex, how are they delivered?
vaginally
if twins are vertex/breech or transverse, how are they delivered
vaginally or C section
if twin A is non-vertex how are they delivered?
C section
if twins are MCMA, how are they delivered?
C section
why would you screen for pregestational DM (GCT at 1st prenatal visit)?
1) BMI > 30
2) 1st degree relative with DM
3) hx of GDM in prior pregnancy
4) hx macrosomic infant
5) physical inactivity
6) A1C > 5.7
what guidelines are used in the US for GDM dx?
carpenter/coustan
how many times daily for glucose be checked in GDM?
4-5x
what are the benchmarks to follow for glucose in GDM?
fasting < 95
1 hr postprandial < 140
2hr postprandial < 120
how does the dose of insulin needed trend throughout pregnancy
increases b/c resistance increases as you go along
what risks do glyburide pose if used for GDM?
risk of macrosomia and hypoglycemia
how often are growth scans required in GDM?
q4wks
in addition to a growth scan, what does A2 GDM require for surveillance?
non-stress test (NST) wkly 28-32 weeks
what testing does a GDM mother get post partum?
75g OCTT at 6-12 wks postpartum
what is the definition of chronic HTN in pregnancy?
BP > 140/90
GA < 20wks
what characteristics do GHTN, pre-eclampsia, and eclampsia have in common?
BP > 140/90
x2 > 4hrs apart
GA > 20 wks
what is eclampsia?
condition where high blood pressure results in seizures during pregnancy
how is pre-eclampsia with severe features defined?
BP> 160/110
severe ft. = ptl < 100,000, pulm edema, headache, vision changes, oliguria
what is pre-eclampsia?
multisystem d/o caused by placental and maternal vascular dysfunction
what is treatment for pre-eclampsia?
delivery
how is GHTN differentiated from pre-eclampsia?
proteinuria
what BP meds are recommended in pregnancy?
labetolol, hydralazine, nifedipine, methyldopa
what are the fetal consequences of Rh incompatibility?
anemia, hydrops fetalis, death
when is Rhogam given?
28 wks
within 72 hrs of delivery if Rh positive
setting of any sensitizing event
what is considered preterm labor?
< 37wks
what is the definition of labor?
regular contractions and cervical changes
what are tocolytics?
prevent uterine contraction
what is betamethasone used for?
given to mothers in preterm labor for fetal lung maturity
what is magnesium sulfate used for?
cerebral palsy prevention
what are the stronger tocolytics?
nifedipine, indomethacin
what are CI to tocxolysis (where baby really just needs to come out)?
1) fetal distress
2) placental abruption
3) pre-eclampsia
4) intrauterine fetal demise
5) intrauterine infection
6) lethal fetal anomaly
how is a premature rupture of membranes dx?
sterile speculum exam
what is PROM?
premature rupture of membranes
ROM before onset of labor (contractions)
what is PPROM?
preterm premature rupture of membranes
ROM < 37 wks and before onset for labor
what is prolonged rupture of membranes?
ROM > 18 hrs
what is the “latency period”?
time between ROM and delivery
if a pregnancy is at term and the water breaks, how long is the latency period?
1-2 days
what labs must be checked after ROM?
gonorrhea, chlamydia, UA, urine culture, GBS
at what point in pregnancy must D&E be considered if there is a PROM?
< 24 wks
how is a PROM patient managed inpatient?
1) daily non-stress test
2) serial growth US
3) limit vaginal exams (d/t infection risk)
what type of cells make up the endocervix?
columnar epithelium
what type of cells make up the ectocervix?
nonkeratinizing squamous epithelium
how does the cervix change after menarche?
acidification –> ectocervis undergoes squamous transformation –> metaplastic changes radiate inward from the original squamocolumnar junction to new SCJ —> creates a transformation zone
when is ectropion seen?
OCPs, menarche (before squamous metaplasia)
why is ectropion prone to bleeding?
columnar cells are not meant for friction
what is a nabothian cyst?
forms on the cervix during squamous metaplasia
mucus trapping –> bleb formation
trapping what normally would get secreted
what is the MC benign cervical neoplasm?
cervical polyp
what is a cervical polyp?
hyperplastic endocervical fold of columnar epithelium
which is more likely to bleed - cervical polyp or nabothian cyst?
cervical polyp
why would a cervical polyp be removed?
bothersome to patient (bleeding)
how does cervical insufficiency differ from preterm labor?
preterm labor = painful
cervical insufficiency = painless
what can cervical stenosis lead to?
hematometra (retention of blood in uterus) and infertility
what is the MC STI?
HPV
what is the strongest factor that predisposes someone to HPV?
sexual partners
what percent of HPV cases regress in 2 years?
70-90%
when do paps start?
21
when are paps done from 21-29?
q3yrs
when is pap with HPV cotesting done?
30-65 y/o
when would you need a pap earlier than 21?
if you have HIV
start pap at time dx or once sexually active if congenitally acquired
what is colposcopy?
used to evaluate abnormal pap or persistent HPV infection
what is used during a colposcopy?
acetic acid (makes it white) & Lugol’s sol’n (makes it brown)
what is another name for cervical dysplasia?
cervical intraepithelial neoplasia
what is cervical dysplasia?
HPV-mediated abnormal growth of squamous epithelium
since cervical dysplasia can be potentially malignant, how is it classified?
by risk
- CIN 1 = low risk
- CIN2-3 = high risk
how is CIN characterized into high risk vs low risk?
1) cellular immaturity
2) cellular disorganization
3) nucelar abnormalities
4) increased mitotic activity
in terms of placement on the cervix, how is CIN grade determined?
CIN 1 = lower 1/3 of epithelium
CIN 2 = middle 1/3
CIN 3 = upper 1/3
what is the treatment for CIN2-3?
excision method - LEEP/cold knife cone
ablative method - cryotherapy
what is the downside of ablation?
harder to see if you got everything (nothing goes to path like with LEEP)
what is the most common gyn cancer in women in the world?
cervical
what are the histological types of cancer?
1) squamous cell carcinoma
2) adenocarcinoma
3) mixed cervical carcinoma and neuroendocrine tumors
what is the most common type of cervical cancer?
squamous cell carcinoma
what are the sx of cervical cancer?
1) abnormal bleeding
2) watery d/c
3) postcoital bleeding
4) venous/lymphatic/ureteral compression
why is adenocarcinoma of the cervix sneaky?
just b/c you removed the cancer from place on the cervix doesn’t mean that you don’t have it elsewhere (skip lesion)
what is the tx for stage IA cervical cancer?
radical hysterectomy
what is the tx for stage IB - IIA cervical cancer?
surgery and/or pelvic radiation
what is the tx for stage IIB - IVA cervical cancer?
radiation and chemo
what is the tx for stage IVB cervical cancer?
palliative care
what supplementation might a breast feeding baby need?
vitamin D
what in terms of immunity does a breastfeeding baby get from mom?
IgA
what are maternal benefits of breastfeeding?
1) decr postpartum depression
2) boosts maternal weight loss
3) uterine involution (oxytocin release, uterine contractions, minimizes hemorrhage)
what is colostrum? and when does it occur?
yellow milk containing fat, minerals, IgA
starts at 2nd day postpartum
what is mature milk composed of?
protein, lactose, water, fat
what maintains lactation?
decrease in estrogen and progesterone causes loss of PRL inhibition
how does the role of oxytocin differ from PRL in terms of breastfeeding?
oxytocin is responsible for the myoepithelial contraction within the alveoli
how does PRL affect the ovaries?
suppresses ovulation by inhibiting GnRH, LH, FSH
what are 4 problems with breastfeeding?
1) mastitis
2) suppression
3) mastitis
4) nipple problems
5) infant drug exposure
when is mastitis MC?
2-4 hours postpartum
what is the MC cause of mastitis?
staph aureus from infants pharynx
what medications can suppress lactation?
1) bromocriptine
2) pseudoephedrine
3) estrogen-containing contraceptives
what medication can boost lactation?
domperidone
when are NSAIDs contraindicated?
pregnancy but ok during breastfeeding!
why are NSAIDs CI in pregnancy?
can cause closure of the patent ductus arteriosus
what medications can impact a baby via breastmilk and how?
1) narcotics –> sedation
2) nitrofurantoin –> hemolytic anemia in G6PD deficient babies
what is the MC cause of maternal death?
hemorrhage (ante, intra, or postpartum)
what are the MC causes of 3rd trimester bleeding?
1) placenta previa
2) abruption
3) preterm labor
what is placenta previa?
placenta covering the cervix
doesn’t move up the uterus to where there is more muscle likes it’s supposed to
what is placenta accreta?
abnormal placental attachment to the myometrium
absent Nitabuch’s layer causing defective decidual formation
what is the decidua?
the endometrium during pregnancy
what is an accessory or “succenturiate” lobe?
small lobe of the placenta that often infarcts
what is the risk with a “succenturiate” lobe?
retained portion of the placenta after birth
can result in postpartum bleeding
what is required after a “succenturiate” lobe?
hysterectomy upon delivery of baby
what is abruptio placentae and how does it start?
premature separation of the placenta
initiated by hemorrhage into the decidua basalts which causes a decidua hematoma and decidua separation from the basal plate
what can abruptio placentae lead to and why?
DIC
b/c decidua separation from the basal plate causes further separation and bleeding which leads to DIC
what is uterine rupture and what is a major risk factor for it?
complete separation of all layers of the uterus
prior uterine scar
how is the source (baby or mom) of intrapartum hemorrhage determined?
Apt test
test specimen of the blood that comes out and turns a different color if its mom vs baby
what is the definition of postpartum hemorrhage
intrapartum and postpartum 24 hrs > 1000mL blood loss with delivery and s/sx of hypovolemia
what are causes of postpartum hemorrhage?
1) uterine atony
2) obstetric trauma
3) uterine inversion
4) abnormal placentation
5) coagulation d/o
6) DIC
what is sequelae of postpartum hemorrhage?
Sheehan, mortality, DIC, hypovolemic shock, end-organ failure
what is anaphylactoid syndrome?
amniotic fluid embolism
fetal antigens enter the mother and there is an inflammatory response that causes DIC and decrease of myocardial function
when should pitocin be given during labor?
before the end of stage 3 (before the end of placental delivery)
how is puerperal endometriosis start?
intraamniotic infection ascending from lower GI or GU tract
what are the risk factors for puerperal endometriosis?
prolonged labor and membranous rupture
what is usually the cause of puerperal endometriosis?
polymicrobial
what do you do if a woman goes into preterm labor and you haven’t swabbed her for GBS yet?
give abx (assume positive)
what is the SART?
sexual assault response team
what is a SANE?
sexual assault nurse examiner
what is PERK and when is it good for?
physical evidence recovery kit
good for up to 96hrs after assault
which injuries are only seen within 24hrs of assault and why?
anogenital injuries b/c they heal very quickly
what are the 2 MC places of injury in sexual assault?
fossa navicularis and posterior fourchette
how do you handle a Nuvaring in an assault patient?
take out, swab and put back
why is an HIV test not done in SANE exam?
don’t want to tell them same day they got assaulted that they also have HIV
also it wouldn’t be from assault it have been contracted earlier
what is the MC dx in patients seeking evaluation of breast lumps?
fibrocystic changes
what is the pathological agent in mastitis?
staph aureus
what are the sx of mastitis?
induration, redness, swelling, pain, heat and edema
what is fat necrosis?
firm nodule that can mimic CA
often hx of trauma causing damage to breast fat
what is MC breast disorder?
fibrocystic changes
what is the age range fibrocystic changes are dx?
20-40
what is fibrocystic breast disease associated with?
hyperestrenism
what are the non proliferative patterns of FCC?
1) cyst formation
2) fibrosis
3) adenosis
what are the proliferative patterns of FCC?
1) sclerosing adenosis
2) epithelial hyperplasia
3) atypical hyperplasia
4) small duct papilloma
what are the features of sclerosing adenosis?
1) small lesions
2) mammography calcifications
3) rarely palpable
4) proliferation of acini
what FCC confers a moderately increased risk?
atypical ductal hyperplasia
atypical lobular hyperplasia
what diseases can be associated with gynecomastia?
cirrhosis and functioning testicular tumor
what are the stromal breast tumors?
fibroadenoma
phyllodes tumor
what are the epithelial breast tumors?
large ductal papilloma
carcinoma
what tumor causes bloody nipple d/c?
large duct papilloma
Paget’s disease is a subtype of what?
DCIS
what are the clinical features of invasive carcinoma?
1) fixed firm nodule
2) dimpling of skin
3) retraction of nipple
what are the “special” histological breast carcinomas?
1) mutinous carcinoma
2) medullary carcinoma
3) papillary carcinoma
what are the most common causes of infectious vaginitis?
1) bacterial vaginosis
2) vulvovaginal candidiasis
3) trichomoniasis
what is the vulva?
external female sex organs
what is the normal pH of a menstruating woman?
3.5 - 4.5
generally, what type of bacteria reside in the vagina?
aerobic
what do the lactobacilli do in the vagina?
1) produce lactic acid
2) inhibits growth of bacteria
3) maintains acidic environment
specifically, what 3 types of bacteria are typically present in the vagina?
yeast and pathogenic bacteria in small amounts
lactobacilli
what is the purpose of the lactic acid production in the vagina?
detrimental to the growth of pathogens
what is physiologic discharge?
clear/cloudy odorless, non-adherent to walls
contains lactobacilli
when does physiologic discharge MC occur?
1) ovulation
2) postcoitus
3) postmenses
4) pregnancy
what can be examined on a wet mount?
1) BV (saline)
2) trichomonas (saline)
3) candida (KOH)
where do you take the specimen from for a wet mount?
lateral wall of the vagina
what is the BD Affirm VP III lab study?
used for bacterial vaginosis
DNA probe
what does BD Affirm VP III test for?
Gardnarella vaginalis, Trichomonas vaginalis, Candida
what is the MC vaginal infection in WOCBP?
BV
what is the MC cause of vaginal d/c and odor?
BV
why is BV bad in pregnancy?
increased risk of preterm labor
what causes BV?
incr in pH causes overgrowth of bacteria
what is the pathogen MC identified in BV?
Gardnerella vaginalis
are most women sx with BV?
only 50%
which patients are at increased risk of getting BV?
STI patients and WSW
is BV an STI?
no it is sexually associated
how does douching affect the vagina?
makes it more alkalinic
what are the risk factors for getting BV?
1) recent abx use
2) douching
3) unprotected sex
what are the sx of BV?
1) increased d/c white, grey in appearance
2) fishy odor
3) odor worse with sex
what are the signs of BV?
1) thin, white vaginal d/c
2) KOH whiff test
3) clue cells on wet mount
4) few lactobacilli on wet mount
5) ph> 4.5
what is seen on a saline wet pre in BV?
Clue Cells - fuzziness with stippled borders
predominance of anaerobic organisms
why is there not a lot of WBCs on a saline wet prep in BV?
not inflammatory
what is the Amsel criteria?
dx for BV need 3/4 1) homogenous, thin, grayish-white d/c 2) pH > 4.5 3) positive whiff test 4) clue cells on wet mount
what is the recommended tx for BV in pregnancy?
oral metronidazole
what is considered recurrent BV and what does it require that normal BV does not necessarily?
> 3 episodes/yr
1) consistent condom use
2) longer treatment period
when is vulvovaginal candidiasis MC?
in WOCBP
what is vulvovaginal candidiasis?
yeast infection
if you see hyphae on slides but patient is asx do you need to treat? why?
no
b/c candidiasis is part of the normal vaginal flora
what bacteria is the MC cause of vulvovaginal candidiasis?
Candida albicans
what is the less common cause of vulvovaginal candidiasis that usually doesn’t cause sx?
Candida glabrata
what are the sx of vulvovaginal candidiasis?
1) vulvar pruritis
2) vulvovaginal burning and irritation
3) cottage cheese d/c
4) dysuria
5) dyspareunia
what are the signs of vulvovaginal candidiasis?
1) erythema of vulva and vaginal mucosa
2) vulvar edema
3) thick white d/c adherent to vaginal walls
4) pseudohyphae (tree-branch looking) on wet mount
how is the pH affected in vulvovaginal candidiasis?
it isn’t
what is the dx test for vulvovaginal candidiasis?
KOH prep
what type of treatment is best for more severe very itchy vulvovaginal candidiasis? why?
vaginal imidazole (topical) b/c will take care of sx quicker than oral
what is the oral medication for vulvovaginal candidiasis?
fluconazole
what are the types of topical vulvovaginal candidiasis tx?
vaginal imidazole, miconazole, clotrimazone, terconazole
what is recurrent vulvovaginal candidiasis?
> 4 episode/yr
when and how do you tx vulvovaginal candidiasis in pregnancy?
only tx if sx
topical (clotimazole or miconazole)
no PO meds!
what is the tx for candida glabrata? why?
boric acid intravaginally
b/c azoles won’t work for this type
what is the MC non-viral STI?
trichomoniasis
what are the sx of trichomoniasis?
1) yellow green vaginal d/c
2) vulvovaginal irritation
3) dyspareunia
4) dysuria
5) male partner asx
what are the signs of trichomoniasis?
1) motile flagellated organisms on wet mount
2) copious frothy cervical-vaginal d/c
3) strawberry cervix
4) presence of other STIs
what does a strawberry cervix look like?
punctate macular hemorrhages
how is trichomoniasis dx?
saline wet mount - motile trichomonads
pear shaped
what typically is present with trichomoniasis?
BV
why can trichomoniasis not be dx on pap?
can easily get a false positive
what is different about trichomoniasis compared to other STIs?
doesn’t progress to PID like other STIs
what must patients not do during tx for trichomoniasis?
EtOH and abstinence
what does trichomoniasis require that BV does not in terms of tx?
need to tx partner
why is trichomoniasis bad with pregnancy?
preterm labor and low birth weight
what are the bartholin glands for?
moisture and lubrication during sex
how should the bartholin glands feel on exam?
non-palpable
what is a bartholin gland cyst?
cyst that develops when main duct draining the gland is occluded
what is the MC vulvovaginal tumor?
bartholin gland cyst
what are the s/sx of a bartholin gland cyst?
painless vulvar mass detected on pelvic exam
may be uncomfortable if very large
what does the drainage of a bartholin gland cyst look like?
clear, white fluid
what are the s/sx of a bartholin gland abscess?
1) tender, erythematous, severe pain with mucopurulent drainage
2) warm, tender, fluctuant mass
what should also be tested for with a bartholin gland abscess?
G/C
what is a Word catheter?
balloon tipped device inserted after I&D
inflatable tip left in place for 4-6 wks
how does the Word catheter tx a bartholin gland cyst?
promotes formation of epitheialized duct
what is marsupialization?
surgical procedure that forms a new ductal orifice
in which age group is vulvar cancer MC?
postmenopausal women
what are the risk factors for vulvar cancer?
1) HPV 16, 18, 31
2) vulvar intraepithelial neoplasia (VIN)
3) lichen sclerosus - derm condition characterized by thin white patches of vulva with itching
4) hx cervical cancer
5) HIV infection
what is the MC vulvar cancer?
squamous cell carcinoma
what are the sx of vulvar cancer?
1) vulvar lesion
2) pruritus
3) +/- vulvar bleeding
4) +/- vulvar pain
what does a vulvar cancer lesion look like?
1) unifocal plaque
2) ulcer
3) mass on labia, clitoris, perineum
what is the MC etiology of vaginal cancer?
secondary to another primary metastatic tumor (cervix MC)
what is the etiology of clear cell adenocarcinoma of the vagina?
DES exposure in utero
what is the MC site of vaginal cancer?
upper 1/3
what is the MC form of vaginal cancer?
squamous cell carcinoma
what are the sx of vaginal cancer?
painless vaginal and/or postcoital bleeding
how can trichomonas be transmitted non-venereally (super rare)?
toilet seat
swimming pools
hot tubs
where is milk produced?
lobules
what is the difference between what makes up young breasts vs old breasts?
young - mainly glandular tissue
older - mainly fat tissue
where is the majority of breast cancers?
upper outer quadrant (axillary tail)
when should the breast exam be performed in the cycle?
one week post menses
what is mastalgia?
breast pain
when does cyclic mastalgia occur during the cycle?
during the luteal phase
what is extramammary breast pain?
pain referred from an outside source to the breast
what are causes of cyclic mastalgia?
1) hormonal changes w/menses
2) OCPs
3) fibrocystic breast disease
what are causes of noncyclic mastalgia?
1) pendulous breasts
2) mastitis
3) inflammatory breast cancer
4) poorly fitting bra
5) pregnancy
6) ductal ectasia
7) chest wall causes
what is ductal ectasia?
blocked lactiferous duct
how is mastalgia dx?
1) clinical breast exam
2) examine lymph nodes
3) US
4) mammogram
what are the sx of mastitis?
breast pain, swelling, warmth, redness
what is the MC pathogen that causes mastitis?
staph aureus
when do you tx mastitis?
sx > 12-24 hrs
what are the characteristics of benign nipple d/c?
1) bilateral
2) multi ductal
3) milky
what are the characteristics of pathological nipple d/c?
1) spontaneous
2) unilateral
3) uniductal
4) bloody, yellow or clear
5) stains clothes
6) persistent
where should you press to try to express d/c?
apply pressure around the areola
what labs should be tested to investigate nipple d/c?
1) TSH
2) PRL
3) B-hcg
what is an FNA used for?
lymph node or breast cyst
in what instances is an FNA used (in terms of cancer likelihood)?
low suspicion for cancer
what is the downside of an FNA?
high false negatives and non-diagnostic samples
what is a core needle bx used for?
larger tissue specimen
what is a punch bx used for?
to distinguish between benign and malignant skin changes (Paget’s)
what is the image of choice in women < 30 y/o with focal breast sx?
US
what is a breast MRI used for?
1) screening for high risk women
2) evaluate suspicious findings
3) assess silicone implant integrity
what is the BIRADS score?
suspicion of malignancy
which BIRADS scores should be f/u with bx?
4 & 5
in a < 30 y/o patient, how should an indeterminate exam be followed up?
breast ultrasound
in a > 30 y/o patient, how should an indeterminate exam be followed up?
diagnostic mammogram +/- direct US
how should a patient presenting with a breast mass which isn’t detectable on PE be followed up?
repeat the exam in 2-3 months
what is the “triple assessment”?
1) CBE
2) imaging
3) pathology
what is the difference between a simple cyst and a complex cyst?
simple - fluid filled and benign
complex - fluid + solid components w/small risk for malignancy
are cysts painful or painless?
can be either
how is a breast cyst managed?
US or mammogram
when is a mammogram used for a breast cyst?
> 30 y/o or complex cyst
what is the most common benign breast disease?
fibrocystic breast disease
what are the sx of fibrocystic breast disease?
1) bilateral cyclic pain
2) breast swelling
3) palpable masses
4) lumpy heavy breasts
which patients is fibrocystic breast disease MC in?
20-40 y/o
how is fibrocystic breast disease dx?
US
FNA
mammogram > 30 y/o
what is a fibroadenoma?
benign solid tumors containing glandular & fibrous tissues
when is a fibroadenoma MC?
WOCBP
when do fibroadenomas change?
during pregnancy or estrogen therapy
what is the most common breast cancer?
ductal carcinoma
what are the non-invasive malignant tumors of the breast?
DCIS
LCIS
what are the invasive malignant tumors of the breast?
ductal carcinoma
lobular carcinoma
what are the BRCA genes?
tumor suppressor genes
which population is very likely to have the BRCA mutation?
Ashkenazi Jews
aside from the mass itself, what are the other sx of breast cancer?
unilateral nipple discharge, dimpling, skin thickening, breast pain, eczematous changes
what is the underlying problem with paget’s disease?
ductal carcinoma
which disease presents with the peas d’orange appearance?
inflammatory breast disease
what are the sx of inflammatory breast disease?
erythema
edema
peau d’ orange
how does chemo help post surgery?
prevents recurrence
when is hormonal therapy given in breast cancer?
after surgery, chemo, radiation
when the ACS guidelines suggest offering mammogram to women?
40-44 y/o
when is annual mammogram screening recommended?
45-55
when is biennial mammogram screening recommended?
> 50
how can Turner’s syndrome patients have a child?
use an egg donor
can bear a child b/c they have a uterus but not capable of conceiving on own
why would you get shoulder pain with ectopic pregnancy?
irritation of the diaphragm
referred pain via the phrenic nerve
where do ovarian cysts develop?
ovary or fallopian tube
what can be the sx of an ovarian cyst?
1) pelvic pain
2) pelvic fullness
3) dyspareunia
4) bloating
5) torsion
what are the signs of an ovarian cyst?
adnexal fullness and CMT
what is contained in the cortex of the ovary?
follicles/eggs
where do the most common ovarian cysts arise?
follicle
what are the most common types of ovarian cysts?
simple cysts
corpus luteal cysts
endometrioma
what is a simple cyst?
serous water fluid filled composed of granulosa cells thin walled always benign can become 5-7 cm
what is a complex cyst?
can be filled w/blood or mucous solid component internal debris thick walled septations papilla have a lower threshold of suspicion
which cysts are related to ovulation?
simple cysts and corpus luteal cysts
which cysts can produce estrogen?
simple cyst
which cysts can produce progesterone?
corpus luteal cyst
what does a corpus luteal cyst tell you about a woman’s cycle?
either she is ovulating or she is pregnant but you can’t see it yet
what is a “chocolate cyst”?
ectopic growth of endometrial tissue
what must you do for a chocolate cyst? why?
wait and watch
remove laparoscopically
OCP
these usually do not resolve on their own
what is CA-125?
blood test used to indicate malignancy
used to monitor response to therapy
what is theca lutein cyst?
luteinized follicular cyst
how do theca luteal cysts form?
hyperstimulation from hcg
how are theca lutein cysts resolved?
source of hcg removed
which cysts do not resolve on their own and should be followed?
medullary and germ cell tumors
what is a mature cystic teratoma (dermoid cyst)?
germ cell tumor containing ectoderm, mesoderm, and endoderm
what is a cyst adenoma?
serous and mucinous
when are ovarian cysts suspicious for malignancy?
1) hyperechoic
2) nodular
3) papillary projection
4) presence of ascites
5) blood flow in solid component
6) peritoneal mass
what does a CA-125 value not tell you?
how severe the disease is
what is the MC gyn malignancy?
endometrial
what is the most common cause of gyn CA deaths?
ovarian cancer
what are the s/sx of ovarian cancer?
1) pelvic mas
2) pelvic pain
3) abdominal fullness
4) back pain
5) constipation
6) diarrhea
7) early satiety
what is the MC ovarian cancer?
epithelial cell
when are germ cell tumors MC?
in pediatrics
what are sx of a granulosa theca tumor?
precocious puberty
irregular heavy bleeding
postmenopausal bleeding
what are the sx of sertoli-leydig tumors?
can be masculinizing in adolescence
what is the problem with large cysts?
can cause ovarian torsion
what are the sx of ovarian torsion?
1) severe pain
2) N/V
3) low grade fever
what are the risk factors for ovarian torsion?
1) pregnancy
2) ovarian cysts
3) neoplasms
what is the MC cause of infertility?
PCOS
what is the other name for PCOS?
Stein-Leventhal syndrome
what are the s/sx of PCOS?
1) oligomenorrhea
2) amenorrhea
3) obesity
4) infertility
5) hyperandrogenism
6) insulin resistance
why is PCOS a misnomer?
they don’t have any cysts
they have an incr number of antral follicles
what is used to dx PCOS?
Rotterdam criteria
what is the Rotterdam criteria and how many are needed for PCOS dx?
1) oligo or anovulation
2) clinical signs of hyperandogenism
3) polycystic ovaries (string of pearls)
when does the ovarian reserve decrease the most?
after 35 y/o
how is infertility defined?
inability to conceive after 1 yr
if a woman is <35 and has regular periods, at what point should she be referred to a fertility clinic?
no pregnancy after 1 yr
if a woman is 35-39 and has regular periods, at what point should she be referred to a fertility clinic?
no pregnancy after 6 months
if a woman is 40+ and has regular periods, at what point should she be referred to a fertility clinic?
no pregnancy after 3 months
what is an SIS?
saline infusion sonohysterography
what is SIS used for?
infusion of saline into the uterus allows better visualization of the uterus
on day 3 of menses what would elevated estrogen and FSH point toward?
decreased ovarian reserve
what is a hysterosalpingogram?
insertion of contrast dye into the uterus and fallopian tubes and an X-ray to check contour and tube patency
what are causes of male infertility?
1) varicocele
2) infection
3) ejaculation issues
4) cryptorchidism
5) hormone imbalances
6) chromosomal abnormalities
what is the best timing for sex when trying to conceive?
1-2 days prior to ovulation and 1 day after
what do ovulation predictor kits (OPK) do?
detect LH surge (which precedes ovulation)
when does body temperature increase in the cycle?
after ovulation
how long can sperm survive in repro tract?
2-3 days
how long is the window for eggs to be fertilized?
24 hrs
what is clomid used for? and what type of drug is it?
first line for ovulatory d/o
SERM
what is femara used for? and what type of drug is it?
suppresses estrogen production
AI
what is ART?
assisted reproductive technology
what is OHSS?
ovarian hyperstimulation syndrome
what can be a complication of OHSS?
3rd spacing - bloating, abdominal fullness, n/v/d, weight gain, decreased urine output, excessive thirst, pleural effusion, SOB, chest pain, electrolyte imbalance
what is polymenorrhea?
incr in frequency of bleeding
what is menorrhagia?
incr in the amount of bleeding
what is oligomenorrhea?
decrease in the frequency of bleeding
what is metromenorrhagia?
irregular intervals of bleeding
what is menometrorrhagia?
irregular intervals of bleeding with excessive amounts of bleeding
what are the structural causes of AUB?
PALM polyp adenomyosis leiomyoma malignancy & hyperplasia
what are the non-structural causes of AUB?
COEIN coagulopathy ovulatory dysfunction endometrial iatrogenic not yet classified
what is a concerning menses account?
soaking two or more pads/hour for >2 hours
which imaging studies can also be used as a treatment?
1) hysterosalpingogram
2) laparoscopy
3) hysteroscopy
in postmenopausal women, what should be the thickness of the uterus?
thin (or else concerning)
which procedure is done in the office setting - endometrial bx or hysteroscopy?
endometrial bx
what is the age you MC see endometrial polyps?
> 50
what are the sx of endometrial polyps?
1) intermenstrual bleeding
2) post-coital bleeding
3) post-menopausal bleeding
how are endometrial polyps dx?
US or hysteroscopy
when should an endometrial polyp be removed?
menopausal or causing sx
what is adenomyosis?
barrier between endometrium and myometrium breaks allowing endometrial cells to invade the myometrium
what is the age you MC see adenomyosis?
30-50
how does adenomyosis differ from endometriosis?
the ectopic endometrial tissue does not respond to hormones
what are the sx of adenomyosis?
1) heavy menstrual bleeding
2) noncyclic pelvic pain
3) progressive dysmenorrhea
how does the uterus feel on PE in adenomyosis?
boggy and globular with symmetrical uterine enlargement
what is leiomyosis?
benign proliferation of smooth muscle cells of the myometrium
what is the MC benign uterine tumor?
leiomyoma
what is esp bad about pedunculated and subserosal fibroids?
can sit on other organs and cause sx
which leiomyoma is assoc with infertility?
submucosal fibroid
what are the s/sx of a leiomyoma?
HMB pelvic pain or pressure infertility compressive sx enlarged, firm, nontender uterus
how is hyperplasia of the endometrium dx?
endometrial bx
what is the cardinal sx of malignancy?
AUB
what does the pap show which is concerning for malignancy?
atypical glandular cells
what are the type I endometrial malignancies called?
endometroid
what are the type II tumors called?
serous and clear cell
what is leiomyosarcoma?
fibroid that has progressed to cancer
rapidly growing mass with vaginal bleeding and pain
what is the prognosis for leiomyosarcoma?
poor
what is anovulatory AUB?
excess estrogen in absence of progesterone
incomplete sloughing of the endometrium
what is ovulatory AUB?
prolonged progesterone secretion
causes irregular shedding of the endometrium
what is the triad that can be found in a later stage chlamydia infection?
urethritis, uveitis, arthritis
what is the MC form of chronic prostatitis - bacterial or abacterial?
abacterial
what is the major hormone contributing to BPH?
DHT
what is the gold standard for treating BPH
TURP
what is the MC malignancy in men in the US?
prostate carcinoma
where does prostate cancer normally arise?
peripheral zone of the posterior prostate
on histology, what does prostate cancer look like?
one layer of basal cells and cherry nucleolus
what is the Gleason grading used for and what is it based on?
staging of prostate cancer
based on architectural parameters
what on a bone scan would be pathognomonic for prostate cancer?
osteoclastic bony mets
which cells support spermatogenesis?
sertoli cells
when does cryptorchidism need to be treated by in order to prevent atrophy?
2 y/o
what is not performed before a surgery on a testicular mass?
bx
what is the age range MC for testicular cancer?
25-45
what are the type of testicular germ cell tumors?
seminoma and non-seminoma
what is the most common germ cell tumor of the testicles
classic seminoma
what does a seminoma look like on gross exam?
solid tan bulky mass
what is a highly malignant testicular tumor and why?
choriocarcinoma
b/c it mets very early
what is ITGCN?
Intratubular germ cell neoplasia - precursor lesion for invasive testicular germ cell tumors (TGCTs) of adolescents and young adults
what is the hormone producing tumor in the testicles?
stromal tumor and leydig cell tumor
are stromal tumors and leydig cell tumors usually malignant or benign?
benign
what is the MC testicular neoplasm in men > 60?
aggressive non-Hodgkin
