Step studying 5 Flashcards
What are the epithelial cell ovarian tumors
Serous, mucinous, endoemetriod, and brenner
Risk factors for epithelial cell ovarian tumors
♣ Pathology of epithelial tumors = endothelial trauma aka ovulation
• So risk increases with age and nulli/low parity
♣ Associated with BRCA1, BRCA2, and HNPCC
Presentation and prognosis of epithelial cell ovarian tumors
Are malignant
♣ Usually present as stage IIIb or worse due to asymptomatic
♣ Advanced disease often present with renal failure, small bowel obstruction, or ascites
Tx of epithelial cell ovarian tumors
TAH + BSO + Chemo (Paclitaxel)
What are the ovarian germ cell tumors
Teratoma, Dysgerminoma, Endodermal sinus tumor, Choriocarcinoma
Presentation of germ cell ovarian tumors
- Are non-malignant
- Usually present in teenage girls as an adnexal mass and weight gain
Tx of ovarian germ cell tumors
Unilateral salpingoophorectomy
Tx of choriocarcinoma
- Surgical = TAH, debulking
* Medical = MAC (Methotrexate, Actinomycin D, Cyclophosphamide)
What are the 3 types of vulvar cancer and their presentation
- SCC = black and itchy lesion
- Melanoma = black and itchy lesion
- Paget’s = RED and itchy
Tx of 3 types of vulvar cancer
- SCC = vulvectomy and lymph node dissection
- Melanoma = vuvlectomy and lymph node dissection
- Paget’s = (less aggressive cancer) wide local excision
Tx of simple ovarian cyst
• <3 cm = nothing
• <10 cm = repeat imaging
o If it grows or does not resolve, then remove
• Wrong treatments:
o Aspiration
o OCPs
Tx of complex ovarian cysts
• >10 cm = remove
Tx of endometriosis
NSAIDs, OCPs
Diagnosis of endometrioma
Diagnostic laparascopy with visualization of chocolate cyst
Tx of ectopic pregnancy
Methotrexate only okay very early on in pregnancy (b-hCG <5,000, gestational sac <3cm, no cardiac activity)
Otherwise tx is surgery
- Salpingostomy if no rupture
- Salpingectomy if rupture
Diagnosis of ovarian torsion
US with doppler to see decreased flow
Diagnosis of tuboovarian abscess
It is a subtype of pelvic inflammatory disease
- Will have tenderness at CMT, adnexal, or uterine
- US for diagnosis
Tx of tuboovarian abscess
• Cefoxitin + Doxycycline + Metronidazole
• Clindamycin + Gentamycin
♣ Surgery in worst case scenario
How do you calculate corrected sodium in a patient who is hyponatremic in the setting of hyperglycemia
Observed sodium + 2 for every 100 that glucose is over 100
Tx of endometriosis
NSAID + OCP
- Laparatoscopy if above tx is unsuccessful
Medication tx of agitation in the elderly
Low dose Haloperidol
Adverse effects of oxytocin
- Hyponatremia (oxytocin is produced by posterior pituitary and has similar structure to ADH and can lead to water retention and thus hyponatremia
- Tachysystole
- Hypotension
What do you do when b-hCG is below discriminatory zone and you can’t visualize anything on US
• Can check quant again in 48 hours if it is not yet at discriminatory zone
o Normal IUP should double b-hCG in 48 hours
o Ectopic pregnancy will have a slower rise in b-hCG (will not double)
What are the causes of abnormal uterine bleeding
PALM COEIN
Polyps Adenomyosis Leiomyoma Malignancy Coagulopathy Ovarian dysfunction Endometrium Iatrogenic (IUD) Not yet classified
Tx of fibroids
• OCP/IUD +/- NSAIDs for pain
Surgery options for fibroids
- Leuprolide to shrink prior to surgery
- Myomectomy if want to maintain fertility
- TAH if she doesn’t want kids
Describe pathogenesis of PCOS
o Increases LH = stimulation of theca cells = increased androgen production by theca cells = increased peripheral conversion of androgens into estrone in adipose tissue = decreased FSH (negative feedback) = decreased stimulation of granulosa cells = degeneration of follicles cystic follicles
Diagnosis of PCOS
Diagnostic criteria (1 + 2 or 3): (1) Oligo- or anovulation (2) Hyperandrogenism ♣ Elevated DHEAS ♣ Elevated Testosterone ♣ LH:FSH > 3:1 (3) Polycystic ovaries on US
Describe how Kallman syndrome causes amenorrhea
♣ Defective migration of GnRH-releasing neuron (problem at level of the hypothalamus)
• No GnRH to stimulate FSH or LH
What will you seen in Kallman syndrome in terms of:
- Internal sex organs
- External sex organs
- Secondary sex characteristics
♣ Will have uterus and fallopian tubes but no secondary sex characteristics
Tx of Kallmans
♣ Tx: give estrogen and progesterone
Describe how craniopharyngeoma causes amenorrhea
♣ Problem is at the level of the anterior pituitary
• No FSH or LH being produced
What will you seen in Craniopharyngioma in terms of:
- Internal sex organs
- External sex organs
- Secondary sex characteristics
♣ Will have uterus and fallopian tubes but no secondary sex characteristics
Tx of craniopharyngeoma
♣ Tx: give estrogen and progesterone + resection
Describe how Mullerian agenesis causes amenorrhea
♣ Recall that Mullerian ducts create the upper 3rd of vagina, uterus, and tubes
What will you seen in Mullerian agenesis in terms of:
- Internal sex organs
- External sex organs
- Secondary sex characteristics
♣ Normal female (XX)
• No uterus
• Normal female external genitalia
• Female secondary sex characteristics
• Patient will still have ovaries which can produce estrogen and progesterone, and will develop secondary sex characteristics
Tx of mullerian agenesis
• Elevate the vagina and she can live a normal life but infertile
How does Androgen insensitivity syndrome cause amenorrhea
♣ Patient has all male sex characteristics including testes, but testosterone produced by testes is not recognized by the body
What will you seen in Androgen insensitivity syndrome in terms of:
- Internal sex organs
- External sex organs
- Secondary sex characteristics
♣ Karyotypically male (XY)
• Internal sex organs are male (+testes)
• External sex organs are female (+vulva, vagina, clitoris)
• Female secondary sex characteristics
Conversion of testosterone to estrogen allows for secondary female characteristics to still develop
Management of androgen insensitivity syndrome
• Elevate vagina
• Need to perform orchiectomy because undescended testes are at increased risk of testicular cancer
o Wait til after puberty so that testosterone can be produced and turn into estrogen for secondary sex characteristics
What will you seen in Turner syndrome in terms of:
- Internal sex organs
- External sex organs
- Secondary sex characteristics
♣ Will have elevated LH and FSH in attempt to stimulate nonexistent ovaries
♣ Since there are no ovaries to create estrogen and progesterone, there will be no secondary female sex characteristics
Describe how hypothyroidism causes amenorrhea
♣ Low T3/T4 increases TRH (produced by hypothalamus) = increased TRH stimulates the anterior pituitary to produce prolactin = high prolactin inhibits GnRH = low GnRH causes low FSH and LH
First tests that should be ordered for secondary amenorrhea
UPT, TSH, Prolactin
If initial tests for secondary amenorrhea are normal, what is next step
Start from endometrium and work your way up
–> Progesterone challenge
Describe results of progesterone challenge
♣ If she bleeds in response progesterone, problem is anovulation
• Most likely due to PCOS
♣ If she does not bleed, try estrogen + progesterone
Describe results of estrogen + progesterone
♣ If she still does not bleed, problem is endometrial
• Asherman’s, ablation
♣ If she bleeds, then the problem is due to signaling
Next test after P + E if she bled, and interpret results
FSH/LH
♣ High FSH/LH means problem is with ovary
♣ Low/normal FSH/LH means problem is with pituitary or hypothalamus
Next step if she had high FSH/LH
Problem of ovary • US to see if follicles are present o +Follicles ♣ Dx = Resistant ovarian syndrome (aka Savage syndrome) ♣ Tx = hormone replacement o –Follicle ♣ <40 y/o = premature ovarian failure ♣ >40 y/o = menopause
Next step if she had low FSH/LH
o MRI to evaluate anterior pituitary
♣ +MRI = anterior pituitary problem
♣ -MRI = hypothalamic problem
What lab value might you see in menopaus
Increased FSH - Body pump out more FSH in response to decreased estrogen
Tx of hot flashes
SSRI - Venlafaxine
