Structured Cases - clinic Flashcards
When do you perform a CKC over a LEEP?
CKC referral over LEEP in following settings:
-AIS
-post menopausal
-+ ECC
-inadequate colposcopy
-positive LEEP margin
-discrepancy between pap and colpsocpy
-CIN3/CIS
When would you do a LEEP With a top hat?
if you have a young patient with a +ECC and concerns for future fertility
What is the maximum dose of lidocaine with epinephrine?
7 mg/kg
Who should be considered for evaluation for BRCA?
-genetic counseling and BRCA testing
- Personal hx breast cancer & ovarian cancer
- woman with ovarian cancer and first degree relative with O cancer or premenopausal breast cancer
- woman with breast cancer at 50 + first/second degree relative with O cancer or male breast cancer
- A. Jewish + ovarian cancer or breast cancer (dx < 40 yo)
- First degree relative with BRCA 1/2 mutation
When to do early DEXA screening…
What is early DEXA screening?
If risk factors (or family hx) factors for osteoporosis.. scene between 50-55. or earlier if specific medical factor (eating disorder, chronic steroid use, cancer therapy)
If in doubt on who needs an early DEXA, what can you do?
Calculate their FRAX score.
If FRAX >8.4 –> early screen
*this score is the baseline fracture risk fo a 65 yo female
When do you start pharmacotherapy?
1) Osteoporosis (T -2.5)
2) Osteopenia (-1 to -2.5) + elevated FRAX
FRAX high if hip fracture risk 3% or overall major fracture risk is 20%
How do you treat osteoporosis?
1) Lifestyle counseling: weight bearing exercises, avoid ethos.tob, reduce fall risk,
Calcium 1000/1200 (>50) +
Vitamin D 600/ 800 (>70)
2) check for underlying cause…
CBC/CMP/Ca/Mag/Po4
TSH
Vitamin D
24 hour urine
3) Start treatment
bisphosphantes
If severe GERD –> IV Bisphosphonate or RANK-L
Consider Raloxifene if young PMW, high risk for breast cancer and no VMS
How often do you repeat a DEXA test once treatment started?
Every 2 years
If T score stable, don’t need to repeat unless new risk factors developed or on a drug holiday
What do you do if your patients BMD continues to decline despite therapy, and compliance?
Referral to a bone specialist
What are several risk factors for osteoporosis?
personal history of fracture
first degree relative with hip fracture
ETOH consumption (>3 drinks/day)
Inadquate physical activity
frail, weight < 127 lbs
tobacco use
low calcium diet
estrogen deficiency
caucasian race
DM
Eating disroders
Malabsorption
HIV/AIDS
When should a drug holiday be done ?
5 years on bisphosphonate therapy
What are contra-indications to bisphosphantes?
A/E
Renal failure
GERD or PUD
inability to be upright after taking medication for 30 mine
A/E: mylagias, joint pain, GI upset, osteonecrosis of jaw, atypical femur fracture
A woman has an aunt with breast cancer pre-menopausal… She wants birth control. What do you do?
RX it for her
There is no need to restrict the use of any hormonal contraception in a woman with a family hx breast cancer OR women who carry BRCA 1 or 2 mutation (and don’t have breast cancer)…
Consider the OCP actually protecting against ovarian cancer… until they can get their RRBSO
OCP’s and special scenarios
- HTN (140-150/90-99)
- HTN severe
- HTN - meds controlled
- DM - uncomplicated, on insulin
- DM x 20 years (or with microvascular disease)
- Avoid COCP unless no other method appropriate
- AVOID COCP and Avoid DMPA due to increase in lipid profile (increased risk for CV disease)
- If < 35, no tobacco use, may consider a trial of COCP… serial BP monitoring monthly after start
- Ok for COCP
- COCP CIN
-use POP, LNG-IUD, or subnormal implant
Patient with lupus wants C-OCP…
What do you do?
Check for APLS, make sure there isn’t severe thormbocytopenia, ensure they aren’t on immunosuppressive meds…
If APLS–> do not pass go
Progestin only safety
Plug in information into the CDC app for recommendations
What type of birth control pills do you use?
What is the dose?
-Lo-estrin
-Yaz (24 day)
-Sprintec
- Loestin: Norethindrone 1 mg + EE 20 mcg
- Yaz- Drospernone 3 mg + EE 20 mcg
- Sprintec- Norgestimate 0.25 + EE 35 mcg
When should you do STI screening at the time of IUD placement in an adolescent?
wHat do you do if it comes back positive?
If they have not had STI testing, screening them
Treat them and leave IUD In place
Emergency contraception
Unprotected intercourse 4 days ago… What can you use?
Which method is most effective EC?
IF used within 3 days, which is more effective (Plan B or ulipristil?)
Is the LNG-IUD FDA approved?
All EC except Plan B and high dose OCP’s
Most effective: Cu IUD
Ulipristil is more effective
No, DO NOT USE LNG IUD
You have a patient on DMPA for AUB…
What do you need to counsel her about?
1) need adequate calcium/Vitamin D intake, exercise regularly, avoid excess etoh or tobacco,
Effects of DMPA of BMD is similar to that of pregnancy or lactation. Do not need to do a DEXA scan. The BMD effects are fully reversible. DMPA can be used indefinitely
Endometrial ablation counseling
-who is a good candidate?
-success rates?
completed child bearing
reliable contraception
low risk for endometrial hyperplasia/cancer
failed medical therapy (or declined)
willing to accept possible hysterectomy if fails
Success rate: 80% decrease in volume, 30% have ammenorhea
Patient presents with irregular bleeding and unusual hair distribution.
What is your differential?
What is your work up?
What do you do if DHEA > 700?
What about if labs are normal, cycles are normal, and just plane hirsutism?
Differential for hirsutism includes familial, PCOS, CAH, androgen secreting tumor, drugs, hypothyroidism, high PRL, Cushings disease
*important to ID if virilization vs. basic hirsutism
Work up: total testosterone, DHEAS, 17-OHP
Concerns for an adrenal tumor, get CT of adrenal gland + REI consult
Suspect familial. Multi-modal therapy (exercise, C-OCP, spironolactone)
What labs do you get if you suspect PCOS (hirustims and irregular cycles)?
TSH, prolactin, 17-OHP,
testosterone (androgen or ovarian secreting tumor), DHEAS, HCG
If HTN and Striae… consider 24 hour urinary free cortisol to look for Cushing’s (as can present as PCOS) but usually with HTN And striae
Testosterone in PCOS likely < 150
Testosterone > 200… look for other source
Diagnostic Criteria for Metabolic Syndrome (3)
1) EBP 130/85
2) waist > 35 inches
3) TG > 150
4) HDL < 50
5) Glucose> 100
Secondary amenorrea work up
Primary Amenorrhea
Defined
no secondary sexual characteristic and no menses by 13
+ secondary sexual characteristic but no menses by 15
by age 15 you should have boob and have started your periods
Primary amenorrhea initial steps
1) Breast +/- (ovaries working)
2) Uterus present?
-Breasts?
-Breasts absent?
3) FSH level
1) Breast present –> evaluate at 2 amenorrhea
2) Breast absent –> estrogen absent
-gonadal failure (XO) + others
or higher up signal failure…
-CNS failure
-CNS lesion, Kallmans (inadequate GNRH), gonadotropin deficiency
3) Uterus absent + breasts –>
uterovaginal agenesis (normal pubes)
OR
short or absent vagina… AIS (XY), sparse pubes
remove gonads at puberty
4) Absent uterus and absent breast? Rare
XY, receptor problem with testosterone…
Describe how you evaluate someone with primary amenorrhea?
1) H&P focused on pubertal development
2)Evauluate anatomy (US or MRI)
3)Abnormal anatomy- blind vaginal pouch, get Karyotype and Testosterone (MRK or AIS)
If normal tract, check hormones: HCG, FSH, TSH, Prolactin
If high FSH: karyotype (r-o turners), FMR1 premutation and adrenal antibodies (POI)
If low to normal FSH: central hypothalamic or pituitary process, consider MRI for eval
16 yo with primary amenorrhea.
-negative progestin challenge..
what next?
1) estrogen challenge to see if she can build up estrogen. IF negative, then anatomic abnormality suspected
-referral to peds endocrine
47 yo has AUB and her bx results show disordered proliferative endometrium, what do you tell her?
This suggests her most recently cycle was anovulatory with loss of cycle endometrial synchronicity. Cycles may return to normal.
If persistent, consider menstrual regulation
47 yo has AUB and her bx results show chronic endometritis, what do you tell her?
Non specific inflammatory response (plasma and lymphocytes). 1/3 of the cases are idiopathic, no identifiable cause, but can also be due to infection…
Treatment: Doxycycline 100 BID X 14 days, Azithromycin if allergic
How does spironolactone work to decrease hirsutism?
1) decreases androgen production and competes with androgen at the hair cell receptor sites
Antiandrogen can cause feminization in male fetus!!
Letrozole and ovulation induction…
Is it FDA approved?
No, not FDA approved
Incontinence/Prolapse p 291
Urge/ OAB
Breast page 299 - 311
HRT speal
Dosing
When is it initiated?
What should you do before starting HRT?
-Hormone replacement therapy is indicated for mod-severe VMS treatment.
-The reduction rate is the same for standard dose HRT and low dose, thus I use the lowest dose possible and there are less side effects (retention, HA, brest tenderness, bleeding)
It can be safely started in women who are < 60 and who are within 10 years of menopause and no CIN.
If HRT started close to menopause, may be cardio protective…
Calculate breast cancer risk (Breast cancer risk assessment tool) and CVD risk (ASCVD calculator)
What are CIN to HRT?
History DVT and/or thrombophilia
CHD
CVA/TIA
Pregnancy
Breast Cancer or estrogen sensitive tumor
Severe liver disease
Can you give HRT in someone with HTN, smoker, or migraines with aura?
Yes… but you should use transdermal formulation
Vivelle Dot
0.0375 mg
twice weekly
+Norethindorne 0.5 mg if uterus
Do all types of HRT increase VTE risk?
Sort of.. transdermal has little or no increased VTE risk..
Others do.
Types of HRT
Oral MPA
Oral micronized progesterone
Oral estrogen
Transdermal
What are benefits of HRT (besides reduction of VMS?)
Reduction of osteoporosis/slows bone loss, improved quality of sleep and well being, urinary incontinence improved, improved dyspareunia
What is low dose estrogen?
Oral CEE 0.3-0.45
Oral estradiol 0.50 mg
Estradiol Patch 0.025 - 0.0375
Nonhormonal forms of treatment for VMS… which are FDA approved?
Treatment:
Paxil - only FDA approved
Gabapentin
Clonidine
Progestin - only for endometrial protection
Veozah
Topical estrogen
Most absorbent
Least absorbent
CIN are not the same as HRT- specifically breast cancer
Most: premarin cream
least: string
Still CIN in hx VTE, stroke, CAD…
If breast cancer, may be an option if NOT on aromatase inhibitor, but check with oncologist
What else can be used to vulvovaginal atrophy?
Ospemifene (SERM)
WHI vs. HERS study… what did they find?
WHI (avg age 60) showed increased CVD risk
HERS study (younger, fresh menopausal women): opposite, no increase in CVD risk..
If patient is on Tamoxifen and HRT… do not start them on what drugs?
SSRIs–> avoid Paxil and Fluoxetine
