Repro tx Flashcards
Medical abortion with pills
Mifepristone (Mifeprex) + Misoprostol (Cytotec)
When can Mifepristone (Mifeprex) + Misoprostol (Cytotec) be used for abortion?
up to 9 weeks (63 days) gestation
CI of mifepristone
Ectopic pregnancy Severe anemia (must have hgb >10) Coagulopathy Anticoagulant therapy Chronic adrenal failure Long-term corticosteroid use Current IUD in place Allergy
When should you follow up after medical abortion?
2 wks check with US to confirm complete
Medical abortion with injection
Methotrexate + misoprostol
Methotrexate + misoprostol MOA
inhibits embryonic cell division
When is Methotrexate + misoprostol indicated
if ectopic is suspected otherwise rarely used
Septic abortion
Clindamycin + Gentamycin ± Ampicillin
progestin moa for contraception
inhibit LH release and prevent ovulation
estrogen moa for contraception
inhibit FSH and prevent folliculogenesis
Turner’s Syndrome
Replace estrogen and cyclic progesterone to induce menses
Mullerian Agenesis
Surgical reconstruction of the vagina
Imperforate Hymen
Surgical
Transverse Vaginal Septum
Surgical
Functional Hypothalamic Amenorrhea
Manage nutritional status
OCPs for estrogen replacement
Sheehan Syndrome
Replace pituitary hormones
Premature Ovarian Failure
HRT
Estrogen + progesterone
Weight-bearing exercise
Calcium and Vitamin D supplement
Asherman Syndrome
Hysterscopic lysis of adhesions
Endometriosis
NSAIDS + Continuous Hormonal therapy
PMS and PMDD
SSRI Fluoxetine (Prozac) 20 mg po QD
or
Sertaline (Zoloft) 50-150 mg po QD
OCPs (2nd line)
if mild just lifestyle mod
Ovarian Hyperstimulation Syndrome (OHSS)
Mild/moderate – treat symptomatically/expectant management at home
Severe – hospitalization and aspiration of fluid (may need to repeat several times)
1st line tx for infertility due to ovulatory d/o
Clomid
2nd line is Femara
Endometrial Polyps
Sx polyps should be removed (or if over 50) via hysteroscopy
If asymptomatic- expectantly manage unless > 1.5 cm, multiple, infertile or prolapsed
Adenomyosis
Expectantly manage
NSAIDs PRN pain
LNG IUD. Or OCP to control bleeding (not to treat condition)
Hysterectomy is definitive tx
Leiomyoma
“fibroids”
Hysterecomy is definitive tx
Hormonal therapy (tp stop bleeding)- LNG IUD, implant, OCP, GnRH analogues
Endometrial Hyperplasia
Surveillance
Progestin therapy - to shed lining
Hysterectomy
Endometrial Cancer
Stage I & II- total hysterectomy w/ bilat salpingo- oophorectory (TAH-BSO) ± pelvic radiation
Stage III & IV- pelvic and para-aortic lymphadenectomy, omentectomy if type II
Leiomyosarcoma
poor prognosis
Ovarian Cysts
Most resolve spontaneously w/in 1-2 menstrual cycles
Sx tx- NSAIDs, heat
Hormonal- OCP (simple cysts)
Surgical mgmt- cyst aspiration, laparoscopy (>4-5 cm + sx)
Endometrioma
do NOT resolve spontaneously
Expectantly manage
Removal - laparoscppy if >5 mm
OCP
Lupron in form of depot
Medullary and Germ cell Tumors
Do NOT typically resolve w/ time
Monitor and resect
Ovarian Torsion
De-torsion and ovarian conservation, possibly ovarian cystectomy, possible oopherectomy
Polycystic Ovarian Syndrome (PCOS)
Endometrial protection: OCP, progesterone IUD (mirena, lyletta, kyleena, Skyla), provera x 10-14 d q1-2 months, metformin
Acne: spironoloactone, Tri-cyclic OCP
Hirsuitism: low androgen OCP (desogestrel, drospirinone), spironolactone
Infertility: weight loss, metformin, Clomiphene citrate (Clomid), letrozole, FSH injections, IUI, IVF, ovarian drilling
Insulin resistance and/or hyperandrogenism: weight loss, Metformin
Prostatitis Type I
(Acute Bacterial) <35 risk of STI
treat for N gonorrhoeae and Chlamydia
Ceftriaxone 250 mg IM x 1 or 400 mg po x 1
PLUS Azithromycin 1000 mg po x 1
Prostatitis Type I
(Acute Bacterial) >35 low STI risk
treat for gram - rods
Ciprofloxacin 500 mg po BID x 4 wks OR
Levofloxacin 500-750 mg po or IV x 4 wks OR
TMP-SMX po BID x 4 wks
Prostatitis Type I
(Acute Bacterial) Severe infection
inpatient, IV ampicillin and gentamicin OR levofloxacin then switch to po abx if afebrile and can pass urine, treat for 6-8 wks
Prostatitis Type II
Chronic bacterial
Ciprofloxacin 500 po BID x 6 wks OR
TMP-SMX 80/400 po BID x 6 wks
Repeated prostatic massage and cx after Abx completed
May require a-blocker therapy for urine retention
Recurrence is common
Prostatitis Type III
Chronic abacterial prostatitis
Refer to urology
Empiric therapy ineffective
Prostatitis Type IV
Asymptomatic inflammatory
No tx necessary
Benign Prostatic Hyperplasia
Mild- reassure and f/u
Mod- drug therapy + lifestyle mod, DEc fluids if polyuria
Severe- refer
Meds for moderate BPH
α-blockers-prazosin
PDE5 Inhibitors- tadalafil
5α reductase inhibitors- finesteride, dutasteride
Prostate Cancer low risk tx
active surveillance
Prostate Cancer Localized, intermediate risk
radical prostatectomy (not necessarily curative and may cause urinary and erectile dysfn), radiation therapy (only used post radical prostatectomy), cryosurgery (less common, fewer adverse events, minimally invasive)
Prostate Cancer Metastatic tx
Androgen deprivation therapy- orchiectomy and/or luteinizing hormone releasing hormone analog *1st line
Bone targeting agents- bisohosphonates (prevent bone pain and prevent fx)
Chemo- docetaxel (if fail ADT)
Vaccines (expensive)
Testicular Torsion
Do not delay time to surgery (90% salvage at 6 hr)
Manual detorsion is a temporary fix but surgery required to prevent
recurrence
Epididymitis
Abx directed at likely pathogen
Ceftriaxone + Azythro or Fluoroquinolone
Orchitis
Symptomatic treatment
Bed rest
Hot or cold packs
Scrotal elevation
Varicocele
Can try surgical repair if infertile but poor
success rate of pregnancy
Hydrocele
Usually resolve on their own in < 1 year
Otherwise may need surgery and drainage
Spermatocele
No tx unless painful → surgically excise
SE of surgery is infertility and chronic pain
Testicular Cancer
Unilateral orchiectomy w/ pathological evaluation
Post-op: CT of chest, abd, and pelvis to look for metastases
Phimosis
May require circumcision
Paraphimosis
Immediate manual reduction
Permanent therapy/prevention requires
circumcision or dorsal slit
Priapism
Drainage and irrigation with sympathomimetic (phenylephrine)
Erectile Dysfunction
Treat underlying condition, lifestule moditications, counseling
PDE5 Inhibitors- Sildenafil, tadalafil, vardenafil *1st line
Local Alprostadil injection, mechanical or prosthetic devices, herbal remedies
Nabothian Cyst
No tx necessary
Ectropian
No tx necessary
Cervical Dysplasia
Cervical Intraepithelial Neoplasia
Treat if high grade (exceptions if pregnant)
Ablation (cryogenic) or excision (LEEP/cold knife core)
Cervical Cancer
Stage IA – radical hysterectomy
Stage IB-IIA – surgery and/or pelvic radiation
Stage IIB-IVA – Radiation and chemotherapy
Stage IVB – Palliative care
Gold standard for BPH tx
transurethral resection of the prostate
Prenatal vitamin for preg women should contain:
Folic acid 400 mcg
DHA
Iron
Absolute CI to methotrexate
Hemodynamically unstable or clinical evidence of ruptured ectopic
Liver disease or alcoholism
Blood dyscrasias
Renal dysfunction
Immunodeficiency
Active pulmonary disease
PUD
Breastfeeding
Relative CI to methotrexate
Bhcg > 5000
Gestational sac > 35mm
+ Fetal heart tones
Patient unwilling/unable to comply with follow up
Patient unwilling to accept blood transfusion
What meds are used for preterm labor and when should they be stopped
Betamethasone – for fetal lung maturity (FLM) – STOP @ 37 wks
Magnesium sulfate – for cerebral palsy prevention – STOP @ 32 wks
GBS prophylaxis – Penicillin (not indicated if GBS negative)
Ectopic Pregnancy
Methotrexate (MTX) 50 mg IM on day 1
Check βhCG on day 1, 4 and 7 (should ↓ 15% btwn day 4 and 7)
Rhogam if RH ⊖
Follow until βhCG is <5
Laparoscopic Salpingectomy/Salpingostomy if evidence of ruptire, hemodynamically unstable or CI to MTX
Gestational Trophoblastic Disease (GTD)
Rhogam if RH ⊖
D&C
Serial βhCG weekly until <5 then monthly x 6 mo
Contraception bc do not want to get pregnant while monitoring for 6 mo
GTN
Single agent for low risk (WHO <6): MTX (Methotrexate) or Actinomycin-D
Multi-agent for High risk (WHO >6): EMA-CO (Etoposide, Methotrexate, Actinomycin-D, Cyclophosphamide,
Vincristine)
Gestational diabetes
Diet
Exercise
Blood sugar monitoring
4-5 times per day
Meds if cannot control w/ diet: insulin, metformin, glyburide (↑ risk of macrosomia and hypoglycemia)
6-12 wk Postpartum OGTT
Gestational HTN
Wkly NST and labs
BP meds: Labetalol, Hydralazine, Nifedipine, (Methyldopa)
Delivery at 37-39 wks
Pre-eclampsia w/o severe features
Weekly NST Twice weekly labs
Delivery at 37 wks
Pre-eclampsia w/ severe features
Magnesium sulfate to ↓ seizure risk
BP meds: Labetalol, Hydralazine, Nifedipine, (Methyldopa)
Inpatient
Delivert at 34 wks
Eclampsia
Magnesium sulfate
Lorazepam
Immediate delivery
preterm labor <24 wk
Counsel on comfort measures vs NICU intervention
preterm labor 24-32 wk
Betamethsone (BMZ) 12 gm IM q24hrs x2 doses (for fetal lung maturity) + magnesium sulfate (forr cerebral plasy prevention) + tocolysis (to prevent contractions)
preterm labor 32-34 wk
Betamethsone (BMZ) 12 gm IM q24hrs x2 doses ± tocolysis, GBS pphx
preterm labor 34-37 wk
Betamethsone (BMZ) 12 gm IM q24hrs x2 doses + GBS pphx
PROM 24-32 wk
Betamethasone (BMZ) 12 gm IM q24hrs x2 doses + magnesium sulfate + tocolysis, + abx (amoxicillin and erythromycin x 5 days), deliver at 34 wk
PROM 32-34 wk
BMZ + tocolysis + abx, deliver at 34 wk
PROM 34-37 wk
BMZ + GBS pphx and deliver
PROM > 37 wk
deliver
What should you administer if contractions are weak?
oxytocin
Stimulate cervical ripening
Prostaglandin E2 or E1 (mc)
Transcervical foley catheter
Hygroscopic dilators (Laminaria)
Sexual assault abx pphx
Chlamydia/Gonorrhea/Trichomonas
Ceftriaxone 250mg IM
Azithromycin 1g PO
Metronidazole 2g PO
Preg pphx post sexual assualt
Plan B (72 hours)
Ulipristal (120 hours)
Paragard (120 hours)
Bacterial Vaginosis (BV)
First line: Metrogel Vag (0.75%) insert one aplicator (5g) imtravaginally QHS x 5 days
Metronidazole 500 mg P.O. BId x 7 days (metallic taste, can’t drink alcohol) recommended for pregnant pts
Clindamycin cream (2%) insert one applicator (5 g) intravaginally QHS x 7 days (or ovules x 3 days)
2nd line
Clindamycin 300 mg P.O. BID x 7 days
Uncomplicated Vulvovaginal Candidiasis
Yeast infection
If asymptomatic don’t have to treat
Uncomplicated tx
Diflucan (fluconazole) 150 mg po x 1
Topical Miconazole (monistat), clottimazole (gynelotrimin, tercnoazole (terazol) insert 1 applicator 5g intravaginally at bedtime x 1-3 days
Complicated Vulvovaginal Candidiasis
Yeast infection
Complicated tx (immunocompromised, pregnant, poorly controlled DM)
Diflucan 150 mg po x 2-3 doses 72 hrs apart or
vaginalis imidazole x 7-14 days
Pregnant- clotimazole or micnkazole x 7 days only (NO diflucan)
If Glabrata use boric acid 600 mg intravaginally x 14 days
Trichomoniasis
Partner must be treated and screen for other STIs
First line
Metronidazole 2 g po x 1
Metronidazole 500 mg po BOD x 7 days ( no alohol for 1 wk)
2nd line- Tindazole 2 g po x 1
Trichomoniasis for pregnant pt
Pregnancy associated with preterm delivery and LBW
Tx = Metronidazole 2g po x 1
Bartholin Gland Cyst
no tx if asymptomatic but consider bx to r/o malignancy
Batrholin Gland abscess
I&D with word catheter (bring back in 4-6 wks), +/- broad spectrum Abx (Bactrim DS 1 tab po BId x 7 days)
Vulvar Cancer
Surgery - wide iincision to preserve vulva & inguinal lymph node dissection
Radical vulvectomy & reginal lymphadenectomy (try to avoid)
Radiation, chemo
Tx based on stage
Vaginal Cancer
Surgical excision (hysterectomy + upper vaginectomy)
Radiation therapy
Mastalgia
If cyclic just reassurance, sports bra or more supportive bra, weight reduction, pain mgmt, test underlying conditions
Mastitis
Abx if sx > 12-24 hr
Dicloxacillin 500 mg po QID x 10-14 d
if no improvement r/o breast abscess w/ US
Nipple Discharge
Physiologic- no breast stimulation and ST f/u in 2-3 mo, endo referral (pituitary Adenoma)
Refer to breast specialist if malig discharge, abnormal findings
Fibrocystic Breast Disease
Low fat diet, avoid caffeine, coffee soar, chocolate, ETOH (to help with pain)
Manage contraception, hormone replacement therapy, supportive bra, medication as needed
Fibroadenoma
ST f/u w/ repeat sono/breast exam
Expectantly manage
Surgical excision
Chlamydia
Azithromycin 1g single dose
Doxycycline 10p mg BID x 7 days (not in pregnancy because teeth defects in children)
LGV treat for at least 3 wks
Gonorrhea
Ceftriaxone 250 mg IM single dose with 1 g Azithromycin po to prevent resistance
PID
Outpatient
Ceftriaxone 250 mg IM once plus doxcycline 100 mg po BID x 14 days w/ or w/ metronidazole 500 mg bid x 14 days
Inpatient
Cefotetan 2 g IV 1 12 h plus doxycycline 100 mg po BID x 14 d
Chancroid
Azithromycin 1 go po once
Ceftriaxone 250 mg IM once
Ciprofloxacin 500 mg po BID x 3 days
Erythromycin 500 mg TID x 7 days (but avoid because of nausea)
Granuloma Inguinale (Donovanosis)
Azithromycin 1 g weekly or 500 mg QD x 3 wks or until cleared
Syphilis
Early disease (less than one year) penicillin G benzathine (Bicillin‐LA) 2.4 MU, IM, otherwise 3 injections
Can use doxy or deftriaxone
Neurosyphilis IV penicillin ONLY OPTION
Pubic Lice
Permetherin (Nix OTC or Rx Elimite
Malathion
Lindane-
Decontaminate environment and treat partners
Scabies
Permetherin 5% cream
Lindane 1% lotion/cream (↑ resistance, cheaper)
Ivermectin 200mcg/kg PO single dose
Menopausal sx (hot flashes) and osteoporosis
estrogen alone (only if no uterus)
combo progesterone and estrogen (if uterus)
transdermal estrogen (patch, spray, gel)
CI to tx for Menopausal sx (hot flashes) and osteoporosis
hx of breast ca, thromboembolism. undiagnosed vag bleeding, use longer than 3-5 yr for HRT or 7 yr for ERT
hot flashes, osteoporosis, vulvovaginal atrophy
SERM
Raloxifene- good for osteoporosis
Ospemifene- helps with vag atrophy and dysparenunia
CI if thromboembolism hx
Hot flashes due to menopause
SSRI and SNRI to dec vasomotor sx freq
Brisdale is only FDA approved
CI if suicidal ideation or on tamoxifen
postmenopausal osteoporosis
calcium, vit D, weight bearing exercises, fall risk prevention, biphosphonates (prevent fx)
sexual arousal d/o
androgen (not FDA approved)
SE: facial hair, acne, voice changes
vulvovaginal atrophy
local estrogen therap- vag ring, cream tablet
non-estrogen med-osphena (acts like estrogen)
vag lubricants/moistuirzers
uterine prolapse
kegels, pessary use or surgery
rectocele
pessaries + estrogen, or surgery
cystocele
mild-no tx, kegels, pessary, estrogen to help pelvic floor muscles or surgery
