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ABOG > Structured Cases - clinic > Flashcards

Structured Cases - clinic Flashcards

1
Q

When do you perform a CKC over a LEEP?

A

CKC referral over LEEP in following settings:
-AIS
-post menopausal
-+ ECC
-inadequate colposcopy
-positive LEEP margin
-discrepancy between pap and colpsocpy
-CIN3/CIS

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2
Q

When would you do a LEEP With a top hat?

A

if you have a young patient with a +ECC and concerns for future fertility

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3
Q

What is the maximum dose of lidocaine with epinephrine?

A

7 mg/kg

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4
Q

Who should be considered for evaluation for BRCA?
-genetic counseling and BRCA testing

A
  1. Personal hx breast cancer & ovarian cancer
  2. woman with ovarian cancer and first degree relative with O cancer or premenopausal breast cancer
  3. woman with breast cancer at 50 + first/second degree relative with O cancer or male breast cancer
  4. A. Jewish + ovarian cancer or breast cancer (dx < 40 yo)
  5. First degree relative with BRCA 1/2 mutation
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5
Q

When to do early DEXA screening…
What is early DEXA screening?

A

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)

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6
Q

If in doubt on who needs an early DEXA, what can you do?

A

Calculate their FRAX score.
If FRAX >8.4 –> early screen

*this score is the baseline fracture risk fo a 65 yo female

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7
Q

When do you start pharmacotherapy?

A

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%

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8
Q

How do you treat osteoporosis?

A

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

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9
Q

How often do you repeat a DEXA test once treatment started?

A

Every 2 years
If T score stable, don’t need to repeat unless new risk factors developed or on a drug holiday

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10
Q

What do you do if your patients BMD continues to decline despite therapy, and compliance?

A

Referral to a bone specialist

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11
Q

What are several risk factors for osteoporosis?

A

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

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12
Q

When should a drug holiday be done ?

A

5 years on bisphosphonate therapy

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13
Q

What are contra-indications to bisphosphantes?

A/E

A

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

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14
Q

A woman has an aunt with breast cancer pre-menopausal… She wants birth control. What do you do?

A

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

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15
Q

OCP’s and special scenarios

  1. HTN (140-150/90-99)
  2. HTN severe
  3. HTN - meds controlled
  4. DM - uncomplicated, on insulin
  5. DM x 20 years (or with microvascular disease)
A
  1. Avoid COCP unless no other method appropriate
  2. AVOID COCP and Avoid DMPA due to increase in lipid profile (increased risk for CV disease)
  3. If < 35, no tobacco use, may consider a trial of COCP… serial BP monitoring monthly after start
  4. Ok for COCP
  5. COCP CIN
    -use POP, LNG-IUD, or subnormal implant
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16
Q

Patient with lupus wants C-OCP…
What do you do?

A

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

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17
Q

What type of birth control pills do you use?
What is the dose?

-Lo-estrin
-Yaz (24 day)
-Sprintec

A
  1. Loestin: Norethindrone 1 mg + EE 20 mcg
  2. Yaz- Drospernone 3 mg + EE 20 mcg
  3. Sprintec- Norgestimate 0.25 + EE 35 mcg
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18
Q

When should you do STI screening at the time of IUD placement in an adolescent?

wHat do you do if it comes back positive?

A

If they have not had STI testing, screening them

Treat them and leave IUD In place

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19
Q

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?

A

All EC except Plan B and high dose OCP’s

Most effective: Cu IUD

Ulipristil is more effective

No, DO NOT USE LNG IUD

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20
Q

You have a patient on DMPA for AUB…
What do you need to counsel her about?

A

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

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21
Q

Endometrial ablation counseling
-who is a good candidate?
-success rates?

A

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

22
Q

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?

A

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)

23
Q

What labs do you get if you suspect PCOS (hirustims and irregular cycles)?

A

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

24
Q

Diagnostic Criteria for Metabolic Syndrome (3)

A

1) EBP 130/85
2) waist > 35 inches
3) TG > 150
4) HDL < 50
5) Glucose> 100

25
Q

Secondary amenorrea work up

A
26
Q

Primary Amenorrhea
Defined

A

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

27
Q

Primary amenorrhea initial steps
1) Breast +/- (ovaries working)
2) Uterus present?
-Breasts?
-Breasts absent?
3) FSH level

A

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…

28
Q

Describe how you evaluate someone with primary amenorrhea?

A

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

29
Q

16 yo with primary amenorrhea.
-negative progestin challenge..
what next?

A

1) estrogen challenge to see if she can build up estrogen. IF negative, then anatomic abnormality suspected
-referral to peds endocrine

30
Q

47 yo has AUB and her bx results show disordered proliferative endometrium, what do you tell her?

A

This suggests her most recently cycle was anovulatory with loss of cycle endometrial synchronicity. Cycles may return to normal.

If persistent, consider menstrual regulation

31
Q

47 yo has AUB and her bx results show chronic endometritis, what do you tell her?

A

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

32
Q

How does spironolactone work to decrease hirsutism?

A

1) decreases androgen production and competes with androgen at the hair cell receptor sites

Antiandrogen can cause feminization in male fetus!!

33
Q

Letrozole and ovulation induction…
Is it FDA approved?

A

No, not FDA approved

34
Q

Incontinence/Prolapse p 291
Urge/ OAB

A
35
Q

Breast page 299 - 311

A
36
Q

HRT speal

Dosing

When is it initiated?

What should you do before starting HRT?

A

-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)

37
Q

What are CIN to HRT?

A

History DVT and/or thrombophilia
CHD
CVA/TIA
Pregnancy
Breast Cancer or estrogen sensitive tumor
Severe liver disease

38
Q

Can you give HRT in someone with HTN, smoker, or migraines with aura?

A

Yes… but you should use transdermal formulation

39
Q

Vivelle Dot

A

0.0375 mg
twice weekly

+Norethindorne 0.5 mg if uterus

40
Q

Do all types of HRT increase VTE risk?

A

Sort of.. transdermal has little or no increased VTE risk..

Others do.

Types of HRT
Oral MPA
Oral micronized progesterone
Oral estrogen
Transdermal

41
Q

What are benefits of HRT (besides reduction of VMS?)

A

Reduction of osteoporosis/slows bone loss, improved quality of sleep and well being, urinary incontinence improved, improved dyspareunia

42
Q

What is low dose estrogen?

A

Oral CEE 0.3-0.45
Oral estradiol 0.50 mg
Estradiol Patch 0.025 - 0.0375

43
Q

Nonhormonal forms of treatment for VMS… which are FDA approved?

A

Treatment:
Paxil - only FDA approved
Gabapentin
Clonidine
Progestin - only for endometrial protection
Veozah

44
Q

Topical estrogen
Most absorbent
Least absorbent

CIN are not the same as HRT- specifically breast cancer

A

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

45
Q

What else can be used to vulvovaginal atrophy?

A

Ospemifene (SERM)

46
Q

WHI vs. HERS study… what did they find?

A

WHI (avg age 60) showed increased CVD risk
HERS study (younger, fresh menopausal women): opposite, no increase in CVD risk..

47
Q

If patient is on Tamoxifen and HRT… do not start them on what drugs?

A

SSRIs–> avoid Paxil and Fluoxetine

48
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49
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50
Q
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ABOG (16 decks)

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