Women's Health

Question 1

4 Principles of Practice

Answer 1

Safety of our patients
True to our professional pledge (Hippocratic Oath)
Must transform to a value-base system of health care delivery
Must focus on prevention and early mitigation of disease

Question 2

Barker Hypothesis

Answer 2

perturbations / disturbances in the gestational environment may influence the development of adult diseases such as CV disease, obesity, diabetes, and stroke.

Question 3

Appropriate Age and Interval of health screening for women

Answer 3

PAP age 21-29 every 3 years then may do co-testing every five years age 30 to 65.
Annual breast exam at age 40, every 1-3 years before that
Mammogram at age 40 (ACOG) or 50 (USPTF)
Colonoscopy age 50, every 4-5 years
TSH at age 50
Cholesterol/lipids at least every 5 years until 65
BP screening every 2 years at least
Height/Weight BMI every visit
Bone Mineral Density testing age 65+, or younger if risk is present

Question 4

Preconception screening components and timing

Question 5

Elements of the well woman physical

Answer 5

Obstetric History

Menstrual History (age of menarche, intervals, duration, character

Contraceptive History - type and complications

Medical History

Surgical History

Social History

System review and exam (including breast exam)

Question 6

Differentiate the signs of pregnancy (presumptive, probable, positive)

Answer 6

Presumptive - skin and mucous membrane changes. Chadwick sign is the dark discoloration of vulva and vaginal wall. The Chloasma is the pigmentation under the eyes

Probable - Physical changes to uterus. Globular change, softening of uterus

Positive - Fetal heartbeat, fetal movements

Question 7

Hegar Sign

Answer 7

Uterine consitenency is softer and able to palpate the connection between cervix and fundus

Question 8

Fetal Heartbeat Detection

Answer 8

Endovaginal ultrasound - 6-7 weeks (sac identified at 5 weeks)
Doppler - 9-12 weeks
Stethoscope - 16-20 weeks

Question 9

Fetal movement can be felt

Answer 9

7-8 weeks

Question 10

Benign conditions of the vulva

Answer 10

epithelium of the vulva is susceptible to the same skin pathologies seen on other parts of the body. Often the appearance of those processes may be altered by the moisture and warmth of the genital tissue

White lesions , red lesions, or pigmented lesions

Question 11

Licen sclerosus

Answer 11

commonly found in the anogenital area of midlife women. It often presents with intense pruritus, dyspareunia and burning pain, but can also be an asymptomatic finding. Anal involvement can cause constipation. The skin is white, thin, and inelastic, with a crinkled cigarette-paper appearance on gentle stretch. Widespread excoriation is common. It starts with isolated pearly white papules and plaques that coalesce over time and form scars. The result is a “figure of 8” field of scarring from the area encircling the labia, constricting down around the perineal body and ballooning out again around the perineal area into the gluteal cleft. The clitoral hood scars, burying the clitoris. Treat with potent topical steroids.

Question 12

Hidradenitis suppurativa

Answer 12

Painful, recurrent condition of the apocrine glands; results in red papules that have chronic purulent drainage; increased risk with obesity and smoking. Treat with corticosteroid injections in lesions and antibiotics if cellulitis is also present

Question 13

Seborrheic dermatitis

Answer 13

Affects skin folds of genital area; skin has red-glazed shiny appearance; may also find dry, greasy areas of the scalp too. Treat with topical corticosteroids

Question 14

Vulvovaginal atrophy

Answer 14

Occurs in many postmenopausal women; underlying fat of the labia decreased with thinning of the epithelium; appears white and vaginal opening may constrict. Treat with estrogen creams or moisturizers

Question 15

Aphthous ulcers

Answer 15

extremely painful lesions, similar to the “canker sores” found in the mouth. They can be small (<1cm) and eventually heal without scarring, or they can be larger (>2cm diameter and 1cm deep) and cause permanent scarring. Recurrence rates are as high as 35%. Symptomatic care.

Question 16

Epidermal cysts

Answer 16

most common type of genital cyst, peaking in incidence in women in their 40s and 50s and located primarily in the labia majora, labia minora, and inguinal areas. Epidermal cysts develop when the hair follicles become obstructed; the deeper portion of the follicle swells to accommodate the desquamated cells. These cysts are generally dome-shaped, clear white to skin colored lesions rising above the surrounding epithelium. Cosmetic concern.

Question 17

Urethral caruncle v. overt urethral prolapse

Answer 17

caruncle is a solitary red papule at the meatus less than 1cm and dome shaped. A urethral prolapse looks like a swollen red cuff surrounding the meatus and occurs at the extremes of age.

Question 18

Congenital abnormalities of the vulva

Answer 18

The most significant of the vulvar anomalies are those that pose challenges to the assignment of gender at birth. Caution, sensitivity, complete evidence collection, and clear communication with often anxious family members are all required

Question 19

Female pseudohermaphroditism

Answer 19

Female pseudohermaphroditism is caused by in utero masculinization due to androgens from maternal or fetal congenital adrenal hyperplasia, androgen-producing tumors of the mother’s ovary or adrenal glands, or the mother’s use of exogenous androgens. Often the infant will present with ambiguous genitalia.

Question 20

Androgen insensitivity syndrome

Answer 20

Androgen insensitivity syndrome (a form of male pseudohermaphroditism and formerly called testicular feminization) is a genetic deficiency of androgen receptors that results in a 46,XY infant developing female external genitalia and, later in life, secondary sexual characteristics.

Question 21

Iatrogenic anatomical changes of the vulva

Answer 21

may be the result of medical procedures such as episiotomies or cultural dependent such as female genital mutilation.

Question 22

Benign conditions of the vagina

Answer 22

The epithelium of the vagina is also subject to chemical irritants and contact dermatitis and it is also sensitive to estrogen levels.

Question 23

Vaginal ulceration

Answer 23

Most ulceration of the vagina is associated with acute infection due to herpes simplex or cytomegalovirus; vaginal lichen planus may present as ulcers

Question 24

Bartholin cyst

Answer 24

Cystic mass below hymenal ring at 4 or 8 o’clock; must rule out underlying malignancy in older women. Asymptomatic - no treatment, symptomatic - drain with Word catheter

Question 25

Vaginisumus

Answer 25

involuntary contraction of the muscles surrounding the introitus. It may have psychological and/or physical causes, but the contraction makes any vaginal penetration either extremely painful or impossible. Many women with vaginismus report prior sexual abuse, but others may deny any such trauma. It is important that the health care professional understands that vaginismus is an involuntary reaction much like the reflex to shut the eyelid when a foreign object is seen to be approaching. Voluntary control can be learned, but it takes much counseling and patience.

Question 26

Congenital abnormalities of the vagina

Answer 26

Vaginal agenesis represents the most extreme instance of a vaginal anomaly, with total absence of the vagina except for the most distal portion. The more common structural anomalies of the vagina include canalization defects such as imperforate hymen, transverse and longitudinal vaginal septa, partial vaginal development, and double vagina

Question 27

Adenosis of the vaginal wall

Answer 27

Adenosis of the vaginal wall consists of islands of columnar epithelium in the normal squamous epithelium. It is often located in the upper third of the vagina. The incidence of this finding is much higher in women exposed to diethylstilbestrol in utero.

Question 28

Differentiate the types of vulvar and vaginal cancer

Answer 28

Most tumors are squamous cell carcinomas, and they occur mainly in postmenopausal women. A history of chronic vulvar itching is common and may present with a vulvar lump Paget disease of the vulva predominantly affects postmenopausal white women, Itching and tenderness are common and may be long-standing. The affected area is usually well demarcated and eczematoid in appearance Malignant melanoma is a pigmented lesion

Question 29

Clinical features of vulvar and vaginal cancer

Answer 29

Carcinoma in situ of the vagina (vaginal intraepithelial neoplasia [VAIN]) is much less common than its counterparts on the cervix or vulva. Most lesions occur in the upper third of the vagina, and the patients are usually asymptomatic.

Question 30

Management of vulvar and vaginal cancer

Answer 30

Interdisciplinary approach, surgical excision with adjuvant radiation and chemo

Question 31

Prognosis of vulvar and vaginal cancer

Answer 31

The overall survival rate for vulvar carcinoma is about 70%. The most important prognostic factor is the status of the groin lymph nodes. Patients with positive nodes have a 5-year survival rate of about 50%, whereas those with negative nodes have a 5-year survival rate of about 90%.

Question 32

Bacterial vaginosis

Answer 32

Overgrowth of lactobacilli. Foul or fishy discharge Thin, gray-white discharge Itching / burning may indicate co-infection Positive Whiff test with 10% KOH Clue cells on wet prep Treat with metrondiazole for 7 days and a metrondiazole or clindamycin cream

Question 33

Vulvovaginal candidiasis

Answer 33

Overgrowth of yeast from hormone imbalance or ABX use Intense vulvar and vaginal itching, burning, fissuring Thick / creamy, non-odorous discharge (cottage cheese) Vulvar erythema causing dysuria Cutaneous penis legions in partner Wet prep shows yeast or hyphae Treat with topical antifungal OTC or if recurring use prescription strength

Question 34

PID

Answer 34

Vaginal infection that ascended, usually 15-30 years age Lower ABD tenderness worse with movement / intercourse Adnexal tenderness and/or mass Cervical motion tenderness Purulent endocervical exudate Fever, N/V, Discharge, AUB less common Elevated WBC, STI testing, rule out pregnancy Treat ceftriaxone IM once with doxycycline / metrondiazole 14 days Treat partner, refer if severe illness or pregnant

Question 35

Trichomoniasis

Answer 35

Protozoan infection Yellow-green frothy discharge with foul odor strawberry cervix Vulvar itching, redness, burning of genitalia Dysuria Wet prep shows organism and urine WBC >10 Vaginal pH >4.5 Treat with metrondiazole (7 days women, one time 2g dose men)

Question 36

Gonorrhea

Answer 36

STI May be asymptomatic, dysuria and discharge more common in men Women may have purulent discharge, lower ABD pain, cervical purulent discharge Test for pregnancy, vaginal culture, oral culture Treatment is Ceftriaxone IM and Azithromycin PO once (or doxycycline for 7 days) - co-treating for chlamydia Avoid sex until 7 days after treatment complete re-test in 3 months, report to health department

Question 37

Chlamydia

Answer 37

May be asymptomatic with dysuria Muccopurulent cervical discharge Spotting after intercourse ABD pain or 'heaviness' Friable cervix with errosions / irritations Urine NAAT and HCG, cervial culture swab Treat with Azithromycin 1g once (or 7 days doxy), consider also giving ceftriaxone IM to co-treat gonorrhea Return for re-test in 3 months, report to health department

Question 38

Syphilis Stages

Answer 38

Primary - single painless firm ulcer (chancre) that heals in 2-6 weeks Secondary - nonpruitic rough reddish-brown macular rash on torso, hands, feet and raised white lesions in mouth or perineum. Swollen lymph nodes, anorexia Latent - Dementia, blindess, deafness, ataxia, numbness, aortic clacification, skin ulcers

Question 39

Syphilis

Answer 39

Primary - Penicillin G IM and Probenecid for 14 days refer to infectious disease and report to health department

Question 40

Herpes

Answer 40

Life-long viral infection Flu-like symptoms with lymphadenopathy, dysuria Vesicular lesions initially followed by ulcerated area on erythematous base or punched out look, pain at lesion site HSV PCR test of lesion Outbreak can be treated within 72 hours with acyclovir Suppressive therapy if 10+ outbreaks a year

Question 41

Genital Warts

Answer 41

Viral lesion caused by HPV Highly contagious 'cauliflower' appearance or flat, domed, or rough papules Wars can be found on vulva, vaginal opening, anal opening, foreskin, scrotum May be painful, itchy Treat with topical ointments, ensure pt is not pregnant Cryotherapy or acids can be used

Question 42

HPV Vaccine

Answer 42

9-14 years old, two doses 6 months apart 15-26 years old, three doses (0, 1-2 months, 6 months) If doses are less than 5 months between first and final, need a booster

Question 43

Breast Cancer screening recommendations in asymptomatic women

Answer 43

ACS - annual at age 40 USPSTF - Every other year at age 50, younger if family history Annual physician breast exam Ultrasound / MRI may be useful for dense breast tissue Definitive diagnosis is made by open biopsy, needle aspiration cytology, or core biopsy. Open biopsy is the gold standard.

Question 44

Common benign breast disorders

Answer 44

Hyperplasia, Fibroadenoma, Intraductal Papilioma, Galactocele

Question 45

Breast Hyperplasia

Answer 45

Hyperplasia is an overgrowth of the cells that line the lobules (milk-producing glands) or ducts (small tubes) inside the breast. May be seen on mammogram or felt, diagnosed by biopsy. Most common benign breast disorder.

Question 46

Fibroadenoma

Answer 46

Most common benign tumor. Sharply circumscribed, freely moveable, more common before age 30. Pregnancy may stimulate their growth

Question 47

Intraductal Papilioma

Answer 47

Rarely palpable, often found due to serous, bloody, or turbid nipple discharge. More common just before menopause. Mammographic and cytologic examination of the fluid is helpful in investigating nipple discharge. Excisional biopsy of the lesion and involved duct is the treatment of choice.

Question 48

Galactocele

Answer 48

Cystic dilation of a duct filled with thick, inspissated, milky fluid. Presents shortly before or after lactation and implies obstruction. May cause secondary infection and mastitis. Needle aspiration is usually curative.

Question 49

Breast Cancer Etiology

Answer 49

Most common malignancy in women, second leading cause of cancer death in women. 1 in 8 chance of developing. 230K cases per year, 40K deaths.

Question 50

Breast Cancer Risk Factors

Answer 50

Age 50+ Family history Early menarche (before 12) Late menopause Any breast biopsy Atypical breast hyperplasia Hormone replacement therapy Breast cancer is 5x higher than in Asia 5-10% result from BRCA1/2 gene

Question 51

Types of Tumors in Breast Cancer

Answer 51

80% are nonspecific infiltrating ductal carcinomas Less common types include infiltrating lobular, medullary, mucinous, tubular, and papillary tumors Inflammatory breast cancer is very rare, usually only in younger women and has warmth, redness, induration of breast tissue

Question 52

Paget Disease of the Breast

Answer 52

Paget disease of the breast occurs in about 3% of patients with breast cancer. It represents a specific subtype of intraductal carcinoma that arises in the main excretory ducts of the breasts and extends to involve the skin of the nipple and areola, producing an eczematoid appearance. The underlying carcinoma, although invariably present, can be palpated clinically in only about two-thirds of patients.

Question 53

Breast Cancer Spread

Answer 53

Local infiltration Lymph spread to axillary nodes then internal mammary nodes, then supraclavicular nodes after axillary Spread into secondary areas such as lungs, liver, bone, ovaries later

Question 54

Staging in Breast Cancer

Answer 54

Staging of Primary Tumor (T) and Regional Lymph Nodes (N) 0 - no sign T1 - Tumor 2 cm or less T2 - Tumor 5 cm or less T3 - Tumor greater than 5 cm T4 - Any size tumor that extends to chest wall or skin N1 - Ipsilateral node axillary moveable N2 - Axillary non-moveable or mammary nodes spread N3 - Supraclavicular/Infraclavicular

Question 55

Clinical features of breast cancer

Answer 55

Carcinoma of the breast is usually painless and may be freely mobile. A serous or bloody nipple discharge may be present. With progressive growth, the tumor may become fixed to the deep fascia. Extension to the skin may cause retraction and dimpling, whereas ductal involvement may cause nipple retraction. Blockage of skin lymphatics may cause lymphedema and thickening of the skin, a change referred to as peau d'orange

Question 56

Treatment / prognosis of breast cancer

Answer 56

Multidisciplinary approach Local excision / breast sparing is more common with adjuvant radiation therapy / chemotherapy as adjuvant reduces relapse risk by 1/3 and death by 30% Routine axillary lymph node dissection has progressively been replaced by lymphatic mapping and sentinel lymph node biopsy Status of lymph nodes is the most important prognosis factor.

Question 57

Etiology and epidemiology of cervical cancer

Answer 57

studies have identified persistent infection with a high-risk human papillomavirus (HPV) as the cause of virtually all cervical cancers.

Question 58

Risk factors for cervical cancer

Answer 58

Young at first coitus (<17) Multiple partners Young age at first pregnancy High parity Low socioeconomic Smoking

Question 59

Atrophic vaginitis

Answer 59

Atrophic vaginitis is inflammation of the vagina as a result of tissue thinning due to not enough estrogen. Symptoms may include pain with sex, vaginal itchiness or dryness, and an urge to urinate or burning with urination. It generally does not resolve without ongoing treatment. Complications may include urinary tract infections. The lack of estrogen typically occurs following menopause.

Question 60

Inflammatory vaginitis

Answer 60

vaginitis is an inflammation of the vagina that can result in discharge, itching and pain. The cause is usually a change in the balance of vaginal bacteria or an infection. Reduced estrogen levels after menopause and some skin disorders also can cause vaginitis. Bacterial, yeast, Trich are most common causes.

Question 61

Endocervicitis

Answer 61

Cervicitis is an inflammation of the cervix, the lower, narrow end of the uterus that opens into the vagina. Possible symptoms of cervicitis include bleeding between menstrual periods, pain with intercourse or during a pelvic exam, and abnormal vaginal discharge. However, it's also possible to have cervicitis and not experience any signs or symptoms. Often, cervicitis results from a sexually transmitted infection

Question 62

Tubo-ovarian Cyst

Answer 62

A tubo-ovarian abscess is a pocket of pus that forms because of an infection in a fallopian tube and ovary. A tubo-ovarian abscess is most often caused by pelvic inflammatory disease (PID)

Question 63

Acute and recurrent cystitis

Answer 63

Recurrent = more than 2 in six months or more than 3 in one year. Requires prophylaxis treatment.

Question 64

Urethritis

Answer 64

Both bacteria and viruses may cause urethritis. Some of the bacteria that cause this condition include E coli, chlamydia, and gonorrhea. These bacteria also cause urinary tract infections and some sexually transmitted diseases. Viral causes are herpes simplex virus and cytomegalovirus.

Question 65

Acute Pyelonephritis

Answer 65

Inflammation of the kidney. Usually organism ascends from urethra to cause the infection. Chills, fever, N/V, CVA tenderness, foul urine, dysuria.

Question 66

Chorioamnionitis

Answer 66

Chorioamnionitis is an infection of the placenta and the amniotic fluid. It happens more often when the amniotic sac is broken for a long time before birth. The major symptom is fever. Other symptoms include a fast heart rate, sore or painful uterus, and amniotic fluid that smells bad.

Question 67

Postpartum endometritis

Answer 67

Postpartum endometritis refers to infection of the decidua (ie, pregnancy endometrium). It is a common cause of postpartum fever and uterine tenderness. Fever, chills, malaise are common.

Question 68

Postabortal infection

Answer 68

postabortal infection as a pelvic infection that occurs within 4 to 6 weeks following an abortion procedure

Question 69

HIV

Question 70

HEP B and C

Question 71

Perinatal infections