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BCM > Women's Health 2 > Flashcards

Women's Health 2 Flashcards

1
Q

Definition of infertility: inability of a couple to conveive after ______ of unprotected sexual intercourse

A

one year

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2
Q 
Causes of infertility:
Female: \_\_\_\_\_\_
Male: \_\_\_\_\_\_
Combined: \_\_\_\_\_\_
Unexplained: \_\_\_\_\_\_\_
A

Female: 40%
Male: 40%
Combined: 20%
Unexplained: 8-15%

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3
Q

MC cause of female infertility

A

anovulation

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4
Q 
Advanced maternal age 
\_\_\_\_\_ natural birth rates
\_\_\_\_\_ miscarriages
\_\_\_\_\_ time to achieve pregnancy
\_\_\_\_\_ response to infertility Tx
A

decreases
increases
prolongs
impairs

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5
Q

Peak female fertility age

A

27

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6
Q

Female fertility declines become most significant at age:

A

35

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7
Q

Chance for pregnancy is <10% over age:

A

40

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8
Q

Pregnancy rate is ZERO with Tx at age:

A

45

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9
Q

Which is worse for fertillity: cigarettes or weed?

A

weed

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10
Q

Infertility of a couple for _____ years is associated with decreased fertility

A

3-5 years

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11
Q

4 things to consider when evaluating a couple for infertility

A
  1. duration of infertility
  2. frequency of sex
  3. methods of contraception
  4. previous eval and Tx
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12
Q

1 test for evaluating infertility in a female

A

hysterosalpingography

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13
Q

7 most important areas to eval on PE for infertility workup

A
  1. weight/BMI
  2. skin: acanthosis nigricans is a sign of insulin resistence
  3. thyroid evaluation
  4. breast abnormalities
  5. androgen excess
  6. abdominal/pelvic exam
  7. vaginal/cervical abnormalities
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14
Q

Infertility Dx Eval: Day 1 of the cycle

A

cycle starts

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15
Q

Infertility Dx Eval: Day 3 of the cycle

A

FSH, estradiol are at their lowest level

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16
Q

Infertility Dx Eval: Day 6-12 of the cycle

A

saline infusion, HSG, surgery (laproscopy or hysteroscopy)

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17
Q

Infertility Dx Eval: Day 13-17

A

US assessment/follicle eval

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18
Q

Infertility Dx Eval: Day 21

A

progesterone/luteal phase evaluation

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19
Q

What is the average size of an egg that’s about to release a follicle?

A

20mm

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20
Q

What does a hysterosalpingogram asses?

A

uterine cavity and tubal patency

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21
Q

What days of the cycle is a hysterosalpingogram performed?

A

Days 6-12

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22
Q

Describe a hysterosalpingogram

A

a fluroscopic procedure using water or oil soluble contrast dye

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23
Q

False negative rate of hysterosalpingograms

A

25%

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24
Q

What med should you STOP before performing a HSG procedure?

A

Metformin

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25
Q

What is definitive evidence of ovulation??

A

PREGNANCY

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26
Q

When is ovarian reserve testing usually performed?

A

women >35 you to test ofr fertility potential

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27
Q

What day of the cycle is ovarian reserve testing performed?

A

Day 3

FSH, estradiol

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28
Q

What does ovarian reserve testing provide information about?

A

ovarian volume

antral follicle count

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29
Q

4 types of ovulatory defects

A
  1. hypothalamic-pituitary dysfunciton
  2. polycystic ovarian syndrome
  3. premature ovarian failure
  4. luteal phase defects
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30
Q

Indications for fertility surgey

A

Performed to normalize pelvic anatomy, especially in the uterine cavity
Tx:
- pelvic endometriosis adhesions
- uterine pathology (fibroids, adhesions, septum)
- ovarian abnormalities

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31
Q

Fertility surgery is done less often today due to advent of ____.

A

ART Technology

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32
Q

3 common surgical fertility procedures

A

laparoscopy
hysteroscopy
laparotomy

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33
Q

Male infertility is often due to:

A

OTHER MEDICAL CONDITIONS

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34
Q

10% of infertile males are at increased risk for:

A

significant medical condition

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35
Q

Best results of semen analysis are through what?

A

certified reliable laboratory

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36
Q

Men should abstain from ejaculation for ____ before semen analysis

A

2-3 days

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37
Q

For semen analysis it is recommended that _____ properly performed tests are performed ____ apart for best results

A

2; 4 weeks

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38
Q

Normal sperm concentration

A

> 20 milion/mL

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39
Q

Normal total sperm number

A

> 40 million/ejaculate

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40
Q

Normal percent motility of sperm

A

> 50%

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41
Q

Definition of oligospermia

A

sperm count <20 million/ml

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42
Q

Definition of asthenospermia

A

Sperm motility <50%

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43
Q

Definition of teratospermia

A

Abnormal morphology (Kruger <5%)

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44
Q

Definition of Azoospermia

A

no sperm found in the ejaculate

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45
Q

Definition of aspermia

A

No semen noted with ejaculation

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46
Q

Definition of Necrospermia

A

No motile viable sperm noted

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47
Q

What makes a pregnancy test positive? (4)

A
  • motile sperm with normal concentration
  • mature egg ovulated
  • open fallopian tube
  • endometrium for normal implantation
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48
Q

Summary of infertility eval

A
  1. H&P of female
  2. semen analysis
  3. hysterosalpingogram/US
  4. labs
  5. prenatal vitamins/folic acid supplementation
  6. Tx based on significant findings
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49
Q

Tx options for cycle in infertility

A
  • Low tech ART/ovulation induction: Clomid/Letrozole, controlled ovarian hyperstimulation, insemination
  • Real time ART: in vitro fertilization
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50
Q

Clomid Ind and MOA

A

Ind: unexplained infertility, PCOS, anovulation
MOA: acts on the hypothalamus and increases FSH to stimulate the ovary

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51
Q

S/E of Clomid

A
  • multiple gestations
  • increased risk of ectopic pregnancy
  • ovarian cysts
  • mood swings
  • visual disturbances
  • vaginal dryness
  • thinning of the endometrial lining
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52
Q

Insemination is used for:

A

male factor and unexplained infertility

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53
Q

When is insemination done?

A

24 hours after LH surge or 36-40 hours after hCG trigger

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54
Q

What is ART?

A

= assisted reproductive technology…

a process of manipulating eggs and sperm outside the body in the laboratory

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55
Q

Name 3 types of ART

A

IVF: in vitro fertilization
GIFT: gamete intrafallopian transfer
ZIFT: zygote intrafallopian transfer

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56
Q

Explain IVF

A

extraction of oocytes, fertilization in the lab, transcervical transfer of embryos into the uterus

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57
Q

Explain GIFT

A

placement of oocytes and sperm into the fallopian tube

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58
Q

Explain ZIFT

A

placement of fertilized oocytes into the fallopian tube

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59
Q

What can we do to help infertility in general?

A

overcome severe male factor with intracytoplasmic sperm injection

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60
Q

What can we do to help couples that are worried about genetic disorders or want to select the sex of their baby

A

Preimplantation genetic diagnosis

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61
Q

What can we do to help infertility issues in single women or same sex couples?

A

donor egg/sperm, surgogacy

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62
Q

FISH is used for what type of genetic analysis?

A

sex selection

aneuploidy

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63
Q

PCR is used for what type of genetic analysis?

A

single gene defects

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64
Q

Definition of dysmenorrhea

A

painful menstruation that prevents a woman from performing normal activities

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65
Q

How many women have dysmenorrhea?

A

10-15%

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66
Q

What are the two categories of dysmenorrhea?

A

primary & secondary

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67
Q

Describe primary dysmenorrhea

A
  • caused by an excess of prostaglandins

- no clinically identifiable etiology

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68
Q

Which type of dysmenorrhea declines with age?

A

primary dysmenorrhea

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69
Q

Sx of primary dysmenorrhea

A
  • suprapubic pain
  • “labor-like,” colicky, spasmodic, aching, pressure radiating to the back and/or thighs
  • recurrent with onset of menses
  • lasts hours to 1-3 days

DIFFUSE PELVIC PAIN RIGHT BEFORE OR WITH THE ONSET OF MENSES

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70
Q

What do prostaglandins do in the uterus and GI tract?

A

POTENT smooth muscle stimulants

  • uterus: intense contractions
  • GI: nausea, vomiting, diarrhea
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71
Q

Tx for primary dysmenorrhea

A

FIRST LINE: NSAIDs: interrupt COX-mediated PGE production

SECOND LINE: OCPs, hormonal contraceptives: eliminate menstruation, inhibits ovulation, and limits endometrial thickness

Laparoscopy if meds fail

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72
Q

Describe secondary dysmenorrhea

A
  • Due to a clinically identifiable cause (pelvic pathology or recognized medical condition)
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73
Q

What type of dysmenorrhea increases with age?

A

secondary dysmenorrhea

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74
Q

CC in secondary dysmenorrhea is due to a specific etiology. Name three types

A
  1. intramural: within wall of uterus
  2. intrauterine: within the uterine cavity
  3. extrauterine: outside the uterus
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75
Q

An intramural etiology of secondary dysmenorrhea where the endometrium grows into the uterine wall

A

adenomyosis

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76
Q

An intramural etiology of secondary dysmenorrhea where there is a benign overgrowth of the muscle layer

A

uterine fibroids

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77
Q

Name some intrauterine etiologies of secondary dysmenorrhea (5)

A 
uterine fibroids
endometrial polyps
intrauterine devices
infection
cervical stenosis/lesions
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78
Q

Name some extrauterine causes of secondary dysmenorrhea (4)

A
  • endometriosis
  • inflammation (PID)
  • adhesions
  • non-GYN (GI, interstitial cystitis)
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79
Q

Tx for secondary endometriosis

A

specific to etiology

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80
Q

Definition of endometriosis

A

growth of the endometrium outside the uterine cavity…

endometrial “implants” of ectopic location outside the uterine cavity

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81
Q

Classic Sx of endometriosis

A 
dysmenorrhea
dyspareunia
infertility
pelvic pain
GI/GU Sx
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82
Q

Clinical signs of endometriosis

A

Fixed, retroflexed uterus

Tender, palpable ovarian mass

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83
Q

Does the location and amount of lesions in endometriosis correlate with pain Sx?

A

Nope

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84
Q

2 major problems that endometriosis results in

A
  1. infertility (30-50%

2. chronic pelvic pain (70-80%)

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85
Q

Sampson’s Theory of the etiology of endometriosis

A

direct implantation of endometrial cells due to retrograde menstruation

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86
Q

Halban’s Theory of the etiology of endometriosis

A

vascular and lymphatic dissemination of endometrial cells

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87
Q

Meyer’s Theory of etiology of endometriosis

A

metaplasia of “multipotential” cells in peritoneal cavity

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88
Q

Endometriosis tends to cluster in ____. Likely a ____, interaction between ____ and _____.

A

families; complex trait; multiple genes; environment

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89
Q

Endometriosis Dx (definitive, gold standard)

A

PE
Laparoscopy with biopsy is definitive Dx
Hystologic study is gold standard

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90
Q

What would a laproscopy show if there is endometriosis?

A

raised patches of thickened, discolored scarred or “powder burn” appearing implants of tissue
Endometrioma

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91
Q

What is endometrioma?

A

endometriosis involving the ovaries large enough to be considered a tumor, usually filled with old blood appearing chocolate-colored (“chocolate cyst”)

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92
Q

Classic triad of endometriosis

A
  1. cyclic premenstrual pelvic pain
  2. dysmenorrhea
  3. dyspareunia
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93
Q

What is dyschezia and what disease process is it common in?

A

painful defecation

endometriosis

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94
Q

What is the most common site for endometriosis?

A

ovaries

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95
Q

T/F: ectopic endometrial tissue responds to cyclic hormonal changes

A

True

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96
Q

Progression of endometriosis (4 steps)

A
  1. clear vesicles
  2. red vesicles
  3. blue dome cysts (4-10 years)
  4. black lesions (7-10 years)
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97
Q

Endometriosis medical Tx

A

Ovulation suppression

  1. combined OCPs + NSAIDs for premenstrual pain
  2. Progesterone
  3. Leuprolide
  4. Danazol
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98
Q

How does progesterone work in endometriosis Tx?

A

suppresses GnRH, causes endometrial tissue atrophy, suppresses ovulation

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99
Q

How does Leuprolide work in endometriosis Tx?

A

GnRH analog causes pituitary FSH/LH suppression

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100
Q

How does Danazol work in endometriosis Tx?

A

testosterone (induces pseudomenopause by suppressing FSH and LH mid-cycle surge)

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101
Q

Endometriosis surgical Tx (2)

A
  1. If fertility desired: conservative laparoscopy with ablation
  2. if fertility not desired: total abdominal hysterectomy with salpingo-oophorectomy
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102
Q

Definition of chronic pelvic pain

A

non-cyclic pain for 6 or more months

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103
Q

What does this sound like:

  • pain has little relief from conventional Tx
  • Pain not proportional to tissue damage
  • Vegetative signs of depression
  • Limited physical activity
  • change in family emotional roles
  • Functional disability
A

Chronic pelvic pain

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104
Q

MULTIPLE etiologies of chronic pelvic pain. Name a few.

A

GYN
GU
Neuro/MSK
Supratentorial

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105
Q

Most common cause of chronic pelvic pain

A

Endometriosis

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106
Q

T/F: normal pelvic pain precludes the possibility of finding pelvic pathology

A

False

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107
Q

____ of chronic pelvic pain patients have a history of physical and/or sexual abuse

A

50%

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108
Q

Chronic pelvic pain is commonly associated with ____.

A

depression

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109
Q

On the bimanual exam, the ovaries are expected to be…

  • Palpable in _____% of reproductive-aged women
  • Non-palpable prior to _____ and following _____.
A

50%

menarche; menopause

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110
Q

You MUST assess palpable varies as _____% of ovaries are malignant

A

25%

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111
Q

What is the most common GYN cancer?

A

endometrial

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112
Q

What is the second most common GYN cancer?

A

ovarian cancer

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113
Q

What type of GYN cancer has the HIGHEST mortality of all the GYN cancers?

A

ovarian cancer

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114
Q

Ovarian cancer RF (3)

A
  • FAMILY HISTORY
  • increased number of ovulatory cycles (infertility, nulliparity, and >50 years old)
  • BRCA1/BRCA2
  • Caucasian
  • Puetz-Jehgers, Turner’s syndrome
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115
Q

Protective factors against ovarian cancer

A
  • OCPs (decreases # of ovulatory cycles)
  • high parity
  • TAH
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116
Q

Ovarian cancer Sx

A

ASYMPTOMATIC until advanced disease stages, mets (>70% are stage III-IV at detection)

  • abdominal fullness
  • back/abd pain
  • urinary frequency
  • constipation
  • irregular menses, menorrhagia, postmenopausal bleeding
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117
Q

Ovarian is the ____ leading cause of cancer-related death in the US

A

5th

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118
Q

Genetic ovarian cancer occurs _____ earlier than non-heritable disease

A

5-10 years

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119
Q

Name 3 genes associated with ovarian cancer

A

BRCA1
BRCA2
Lynch II Syndrome (1st and 2nd degree relatives with breast, colon, endometrial, and ovarian cancer)

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120
Q

Ovarian cancer on PE

A
  • palpable abdominal or ovarian mass
  • ascites
  • omental caking: “gravel under a blanket”
  • Sister Mary Joseph’s node
  • pleural effusion, edema
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121
Q

What is Sister Mary Jose[h’s node and what cancer is it associated with?

A

Mets to the umbilical lymph node; ovarian cancer

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122
Q

Ovarian cancer Dx

A

Biopsy

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123
Q

What does positive biopsy look like for ovarian cancer?

A

90% epithelial

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124
Q

What can you use to screen high risk patients for ovarian cancer?

A

transvaginal US

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125
Q

3 components of BRCA Tx

A
  • enhanced screening
  • prophylactic risk-reducing surgery (bilateral mastectomy, bilateral salpingo-oophorectomy)
  • chemoprevention (Tamoxifen, OCPs)
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126
Q

How does ovarian cancer spread?

A

direct extensino within the peritoneal cavity

Mets go to: liver, diaphragm, omentum, bowels

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127
Q

You should always include a ________ on GYN cancer exam to evaluate for adnexal masses or nodules in the cul-de-sac

A

rectovaginal exam

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128
Q

What is Cancer Antigen 125 (CA-125) used for

A

NOT for screening the general population because it is non-specific!! (also possible for pt to have cancer without elevated CA-125)
Better utilized as a tumor marker

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129
Q

Early stage ovarian cancer Tx

A

TAH-BSO + selective lymphadenectomy

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130
Q

Surgical ovarian cancer Tx

A

Tumor debulking

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131
Q

What is used to monitor ovarian cancer treatment progress?

A

serum CA-125 levels

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132
Q

Chemotherapy for ovarian cancer

A

Paclitaxel + Cisplatin or Carboplatin

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133
Q

Problem with intraperitoneal Cisplatin chemotherapy

A

high toxicity

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134
Q

Prognosis for ovarian cancer

A

<5% cured

>80% of patients in remission have recurrence about 2.5 years later

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135
Q

2 prevention strategies for ovarian cancer

A
  • OCPs/hormonal contraception

- prophylactic BSO

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136
Q

T/F: current Tx for ovarian cancer do NOT cure it most of the time

A

True

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137
Q

____ occur when follicles fail to rupture and continue to grow

A

follicular cysts

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138
Q

_____ cysts fail to degenerate after ovulation

A

corpus luteal

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139
Q

As a general rule, what should you do with cysts over and under 5 cm?

A

> 5cm: surgery

<5cm: serial US

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140
Q

Solid masses are _____ until proven otherwise

A

malignant

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141
Q

What type of cyst is due to normal ovarian function?

A

functional cysts

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142
Q

_____ are fluid-filled sacs or pocket-like structures that form on or inside the ovary

A

functional ovarian cysts

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143
Q

Do functional ovarian cysts cause pain?

A

rarely

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144
Q

_____ occur when a sac on the ovary does not release an egg and the sac swells up with fluid

A

follicular cysts

145
Q

In a follicular cysts, the follicle _____.

A

fails to rupture when mature

146
Q

Sx of follicular cysts

A

the bigger, the most likely to cause:

  • pain in the RLQ
  • metrorrhagia (irregular menstrual cycle)
  • pain during or after sex
147
Q

What type of cyst occurs when the corpus luteum fails to break down and disappear?

A

corpus luteal cyst

148
Q

corpus luteal cyst produces ____, which delays menses

A

progesterone

149
Q

Corpus luteal cyst Sxq

A
  • dull aching LQ pain

- secondary amenorrhea

150
Q

The “Ring of Fire” Sign on US can be seen in what two conditions?

A
  1. corpus luteal cysts (MC)

2. ectopic pregnancy

151
Q

Endometriosis causes what type of cyst?

A

endometrial cyst

152
Q

How do endometrial cysts form?

A

tissue from inside the uterus forms the nucleus of the cyst

153
Q

What’s the “classic chocolate cyst”?

A

endometrial cyst

154
Q

Endometrial cyst Tx

A

surgical excision

155
Q

Endometrial cyst Sx

A

abd pain
vaginal bleeding
HA

156
Q

Corpus luteal cyst Tx

A

OCPs for recurrence/persistance

157
Q

What is the main complication we’re concerned about with ovarian cysts?

158
Q

Dx of functional ovarian cysts

159
Q

What do follicular ovarian cysts look like on US?

A

smooth, thin-walled unilocular

160
Q

What do luteal cysts look like on US?

A

complex, thick-walled with peripheral vascularity

order BhCG to r/o pregnancy

161
Q

What type of cyst is a mature cystic teratoma?

A

dermoid cyst

162
Q

Dermoid cyst Tx

A

surgical (high potential for torsion)

163
Q

Most ovarian cysts ____ are functional and usually spontaneously resolve, so Tx: (3)

A

<8cm;

  • rest
  • NSAIDs
  • repeat US after 6 weeks
164
Q

If cyst is >8cm or found postmenopause, Tx:

A

laparoscopy or laparotomy

165
Q

Endometrial cancer is ____ most common GYN cancer and _____ most common cancer overall in women

166
Q

Endometrial cancer is most common in what age?

A

postmenopausal: 50-60 years old

167
Q

Endometrial cancer is ____-dependent

168
Q

Endometrial cancer RF

A
  • increased estrogen exposure
  • PCOS
  • obesity
  • nuliparity
  • estrogen replacement therapy
  • late menopause
  • Tamoxifen use (estrogen stimulates endometrial growth)
  • HTN
  • DM
169
Q

Definition of endometrial proliferation

A

overabundance of normal endometrium

170
Q

Definition of endometrial hyperplasia

A

proliferation of both glandular and stromal elements

171
Q

Definition of endometrial atypia

A

altered histologic architecture

172
Q

Hyperplasia Tx

A

Normally: hysterectomy or D&C + progesterone
Atypical: TAH

173
Q

Atypical is ____% more likely to

174
Q

Combination OCPs are protective against ____ and ____.

A

ovarian and endometrial cancer

175
Q

Endometrial cancer Sx

A

ABNORMAL UTERINE BLEEDING

  • postmenopausal bleeding
  • menorrhagia
  • metrorrhagia
  • watery vaginal discharge
176
Q

endometrial cancer Dx

A

Endometrial biopsy

US

177
Q

MC type of cancer shown on endometrial biopsy

A

adenocarcinoma

178
Q

US shows what in endometrial cancer?

A

endometrial stripe >4mm

179
Q

Ind for endometrial biopsy

A
  • PMB
  • > 35 years old with abnormal bleeding
  • increased endometrial stripe on TVUS
  • Tamoxifen
180
Q

Stage I endometrial cancer Tx

A

Hysterectomy

181
Q

Stage II, III endometrial cancer Tx

A

TAH + BSO + lymph node excision

+/- post-op radiation therapy

182
Q

Stage IV endometrial cancer Tx

A

systemic chemotherapy

183
Q

Most common type of mets in endometrial cancer

184
Q

What is the precursor to endometrial carcinoma?

A

endometrial gland proliferation

185
Q

Why does endometrial hyperplasia happen?

A

continuous increased unopposed estrogen (unopposed by progesterone)

186
Q

Examples of what can cause increased unopposed estrogen

A
  • chronic anovulation
  • PCOS
  • perimenopause
  • obesity (conversion of androgen to estrogen in adipose tissue)
187
Q

Most common age to see endometrial hyperplasia

A

postmenopausal

188
Q

Hyperplasia often occurs within ___ of estrogen-only therapy

189
Q

Endometrial hyperplasia Sx

A

BLEEDING

  • menorrhagia
  • metrorrhagia
  • postmenopausal bleeding
190
Q

Endometrial hyperplasia Dx

A
  • transvaginal US

- endometrial biopsy

191
Q

Definitive Dx f endometrial hyperplasia

A

endometrial biopsy

192
Q

What would you expect to see on transvaginal US if a patient has endometrial hyperplasia?

A

endometrial stripe >4mm`

193
Q

Tx for endometrial hyperplasia WITHOUT atypia

A

Progestin

repeat endometrial biopsy in 3-6 months

194
Q

MOA of progestin therapy in endometrial hyperplasia

A

stops estrogen from being unopposed, limits endometrial growth

195
Q

Tx for endometrial hyperplasia WITH atypia

A

hysterectomy

196
Q

Main type of vulvar cancer

A

90% squamous

197
Q

Main risk factor for vulvar cancer

A

HPV (16,18,31)

198
Q

Most common Sx of vulvar cancer

A

pruritis (70%)

asymptomatic (20%)

199
Q

Vulvar cancer Dx

A

red/white ulcerative, crusted lesions

biopsy

200
Q

Vulvar cancer Tx

A

surgical excision
radiation
chemotherapy (5-fluorouracil)

201
Q

Most common type of vaginal cancer

A

squamous (95%)

Clear cell if DES exposure in utero

202
Q

Vaginal cancer Sx

A

Asymptomatic, changes in menstrual period, abnormal vaginal bleeding, vaginal discharge

203
Q

Vaginal cancer Tx

A

radiation therapy

204
Q

Chronic vulvar pruritis

Thinning, whitish epithelium, “onion skin”

A

Lichen sclerosis

205
Q

Tx for lichen sclerosis

A

high potency topical steroids

206
Q

“an itch that rashes”
irritant dermatitis
progressive burning/itching
hyperplastic, hyperpigmented plaques

A

Lichen simplex chonicus

207
Q

Lichen Simplex Chronicus Tx

A

antihistamines
mild-moderate potency steroids
BIOPSY if no change in 3 months

208
Q

A benign vulvar lesion, inflammatory blockage of the sebaceous gland ducts.
Small, smooth nodular masses

A

sebaceous/inclusion cysts

209
Q

Benign vulvar lesion, pigmented

A

nevi or malignant melanoma

distinguish with vulvar biopsy

210
Q

Prevention for vaginal cancer

A
  • regular physical exams
  • avoid HPV exposure
  • don’t smoke
  • Gardasil
211
Q

What type of cells is the ectocervix made of?

A

non-keratinizing squamous epithelium

212
Q

What type of cells is the endocervix made of?

A

simple columnar epithelium

213
Q

What happens to cell type at the external os?

A

site of transition: squamocolumnar junction

214
Q

What happens to the cervix during puberty?

A

the original SCJ “rolls out”&raquo_space;
everted tissue is exposed: irritants, hormonal milieu, vaginal secretions&raquo_space;
squamous metaplasia&raquo_space;
transformation zone

215
Q

Describe the HPV virus

A

non-enveloped double-stranded DNA virus

216
Q

what percent of sexually active women are exposed to HPV?

217
Q

How many distinct genotypes of HPV have been identified?

218
Q

What are the MC high risk strands of HPV?

A

16, 18 (70%)

31, 33

219
Q

What are the MC low risk strands of HPV?

220
Q

HPV is associated with what 6 cancers?

A 
cervical 
anal
vaginal
vulvar
penile
oropharynx
221
Q

What’s special about HPV and cervical cancer?

A

it was the first NECESSARY cause of a cancer ever identified (99% attributable fraction)

222
Q

What is HPV disease?

A

external genital warts cause by low risk HPV types

223
Q

Cervical cancer is caused by…

A

high risk HPV types

224
Q

Describe the epitheliotropic life style of HPV

A

infects sites of epithelial microtrauma, enters the basal epithelial cells, replicates with the cell , HPV infected cells throughout epithelial layers, HPV particles released when epithelium sheds

225
Q

What has provided a >50% decrease in cervical cancer in developed countries over the last 30 years?

226
Q

what does the Pap smear do?

A

samples cervical cells from the transformation zone with spatula or cytrobrush or broom stick

227
Q

What happens in a conventional Pap smear?

A

direct application of cells to a slide

228
Q

What happens in a liquid-based Pap smear?

A

incorporation of molecular HPV testing, electronic imaging

90% of Pap testing in US

229
Q

USPSTF cervical screening guideline for patients <21 years old

A

no screening, regardless of sexual history

230
Q

USPSTF cervical screening guideline for patients 21-65 years old

A

screen with cytology every 3 years

231
Q

USPSTF cervical screening guideline for patients 30-65 years old

A

start cotesting: combination cytology with HPV testing every 5 years

232
Q

USPSTF cervical screening guideline for patients >65 years old

A

no screening

if history of adequate prior screening and not otherwise high risk for cervical CA

233
Q

Should you screen for cervical cancer when a total hysterectomy is performed for benign disease

234
Q

What should you evaluate for to determine Pap smear results’ specimen adequacy

A

presence of transformation zone cells

235
Q

If transformation zone is not present on Pap smear and HPV is unknown, what do you do?

A

repeat pap in 2-4 months

236
Q

If transformation zone is not present on Pap smear and HPV is negative (>30yo), what do you do?

A

repeat pap in 2-4 months

237
Q

If transformation zone is not present on Pap smear and HPV is positive (>30yo), what do you do?

A

repeat pap in 2-4 months OR colposcopy

if repeat pap is unsatisfactory&raquo_space; colposcopy

238
Q

CIN I is what type of lesion?

A

LOW grade squamous intraepithelial lesion (LSIL)

239
Q

CIN II, III are what type of lesion?

A

HIGH grade squamous intraepithelial lesion

240
Q

Mild dysplasia, contained to basal 1/3 of epithelium

241
Q

MODERATE dysplasia, including 2/3 thickness of basal epithelium

242
Q

SEVERE dysplasia, >2/3 thickness of basal epithelium (includes carcinoma in situ)

243
Q

Full thickness invasion of basal epithelium

A

carcinoma in situ

244
Q

Two types of atypical squamous cells found on cytology

A
  1. ASC-US: Atypical Squamous Cells of Undetermined Significance
  2. ASC-H: Atypical Squamous Cells cant exclude HSIL
245
Q

Describe the Reflex HPV test

A
  • liquid-based cytology
  • tests for 13 high-risk HPV types most commonly associated with high-grade dysplasia and CA
  • increases sensitivity for detection of high-grade lesions and cancers compared to cytology alone
  • 99-100% NPV of combined cytology and HPV DNA testing for high-grade lesions
246
Q

Describe colposcopy

A
  • magnified view of the cervix
  • place dilute acetic acid on areas that correlate with high nuclear density
  • must examine transformation zone
  • biopsy lesions which appear acetowhite or of abnormal vascularity
247
Q

Tx for pre-invasive disease

A

ablative techniques:

  • cryotherapy
  • laser ablation
  • electrocautery

excisional techniques

  • cold knife cone
  • loop electrosurgical excisional procedure (LEEP)
248
Q

CIN I Tx

A
  • observation: 75% resolve by immune system within 1 year

- excision: LEEP, cold knife cervical conization

249
Q

CIN II, III, carcinoma in situ Tx

A

excision or ablation is mainstay of Tx

250
Q

Cervical cancer is the ____ MC GYN cancer

251
Q

Cervical cancer is the _____ MC cancer in women world wide and the most common GYN cancer in developing countries

252
Q

Highest incidence of HPV is at ages….

Average age of Dx is….

253
Q

Median age at death from cervical cancer is….

254
Q

Name 6 risk factors for cervical cancer

A 
HPV
early onset sexual activity
multiple/high-risk sexual partners
smoking
Hx of STDs
High parity
Immunosuppression
Low socioeconomic status
DES exposure (Diethystilbestrol was a synthetic estrogen used in OCPs)
255
Q

Two hystological types of cervical cancer are ___ and ____. Which is MC?

A
  1. Squamous (90%)

2. Adenocarcinoma (10%)

256
Q

Which type of cervical CA is associated with DES?

A

clear cell carcinoma

257
Q

It takes on average _____ for carcinoma to penetrate the basement membrane

A

2-10 years

258
Q

Cervical CA Sx

A
  • POST COITAL BLEEDING is MC
  • Metrorrhagia
  • Pelvic pain
  • Watery vaginal discharge
259
Q

Cervical cancer Dx

A

colposcopic directed biopsy

260
Q

How do you screen for cervical CA?

A

Pap smear with cytology

261
Q

In the face of cancer, Pap smear has a ____% false negative rate. Therefore, what should we do in the case of a visible lesion??

A

50%;

Biopsy any visible lesion!!

262
Q

How do you stage cervical cancer?

A

Cervical and vaginal cancers are the ONLY cancers that are staged CLINICALLY

263
Q

What tool is used to stage cervical cancer?

A

imaging (CT, MRI, PET, US)

264
Q

Stage 0 cervical cancer

A

carcinoma in situ

265
Q

Stage I cervical cancer

A

microinvasion: lesion confined to cervix

266
Q

Stage II cervical cancer

A

beyond the cervix, but not to the pelvic sidewall or lower third of vagina

267
Q

Stage III cervical cancer

A

extends to the pelvic sidewall or lower third of the vagina, or there is hydronephrosis or a non-functioning kidney

268
Q

Stage IV cervical cancer

A

extends beyond the true pelvis, or has biopsy-proven involvement of rectal or bladder mucosa, distant mets

269
Q

Stage 0 cervical cancer Tx

A

excision, ablation, or TAH-BSO

270
Q

Stage I cervical cancer Tx

A

Surgery: conization, TAH-BSO, XRT

271
Q

Stage II-III cervical cancer Tx

A

Radiation (XRT) + chemotherapy (cisplatin or 5-fluorouracil)

272
Q

Stage IV cervical cancer Tx

A

palliative radiation therapy, chemotherapy (surgery not likely to be curative)

273
Q

Gardasil protects against what strains of HPV

A

16, 18, 6, 11

274
Q

Gardasil 9 protects against what strains of HPV

A

16,18,31,33,45,52,58,6,11

275
Q

Cervarix protects against what strains of HPV

276
Q

Current recommendations for HPV vaccine

A

given at age 11 up to 26 years old originally, now available up to age 45

277
Q

Cervical cancer rates won’t decrease secondary to vaccination until what year?

278
Q

Current vaccines protect against what percent of cervical cancers?

279
Q

DO NOT MISS _____.

A

unusual vaginal bleeding

280
Q

T/F: pelvic exam = pap smear

281
Q

Cervical dysplasia and cervical cancer is preventable with what two things?

A

screening

vaccination

282
Q

T/F: vaccinate boys and girls

283
Q

Remind patients they still need annual _____.

A

well-woman exams!!!

284
Q

How many people will be infected with at least one type of HPV at some point?

A

Almost ALL

285
Q

T/F: intercourse is not necessary for infection with HPV

286
Q

____% new cervical HPV infections clear or become detectable within 2 years

287
Q

What is the most common HPV-associated cancer among women?

A

Cervical cancer

288
Q

Half of cervical cancers occur in women how old?

A

> 50 years

289
Q

What is the most common HPV-associated cancer regardless of gender?

A

Oropharyngeal SCC

290
Q

By what year will the highest number of HPV related cancer deaths be oropharyngeal?

291
Q

2 dose schedule for HPV vaccine

A

Before 15th birthday, early as age 9

First and second dose administered <5 months apart. If not, a third dose is required

292
Q

Normal pregnancy lasts how many weeks?

293
Q

How are the three trimesters divided?

A

First: 0-13 weeks
Second: 14-27 weeks
Third: 28-40 weeks

294
Q

How to calculate the due date using Naegele’s Rule

A

Due Date= LMP + one year - 3 months + 7 days

295
Q

In what trimester do you test for infectious diseases?

A

28-40 weeks

296
Q

How does Rh incompatibility affect susequent pregnancies?

A

Maternal Rh antibody crosses the placenta into the fetal circulation and hemolyzes fetal RBCs

297
Q

Placental location accounts for what percent of bleeding during pregnancy?

298
Q

What is a low-lying placenta?

A

The placenta is directly adjacent to the internal cervical os

299
Q

What is placenta previa?

A

the placenta covers all or portion of the internal cervical os

300
Q

Difference between complete or partial placenta previa

A

Complete: entire cervical os is covered by placenta
Partial: margin of placenta extends across part of the cervical os

301
Q

What is the etiology of placenta previa?

A

not well understood

May “migrate” as the placenta grows

302
Q

What is indicated in placenta previa?

A

Cesarian delivery

303
Q

First bleeding with placenta previa happens at how many weeks? Why?

A

~29-30 weeks

partial separation of the placenta from lower uterine segment and cervix in response to mild contractions

304
Q

What is placenta previa (accreta)?

A

Abnormal growth of placental mass into the substance of the uterus

305
Q

What is indicated in placenta (previa) accreta?

A

CD + TAH

If you try to pull off the accreta, the mom will continue to bleed. Must do TAH.

306
Q

What is placental abruption?

A

premature separation of normally implanted placenta from the uterine wall

307
Q

What is the problem with placental abruption?

A

it interferes with oxygenation of the fetus (hemorrhage, clot, infarct)

308
Q

RF for placental abruption

A

maternal HTN
polyhydramnios/oligohydramnios
multiple gestations
cocaine use

309
Q

A woman presents with third trimester BRB bleeding that is painless. The uterus is soft and non tender. What is the most likely Dx?

A

Placenta previa

310
Q

How do you Dx a Placenta previa?

311
Q

Placenta previa Tx

A
  • Hospitalization, bed rest
  • Stabilize fetus: Tocolytics (Mg sulfate), Amniocentesis
  • Delivery when stable with CD
312
Q

Two most common causes of 3rd trimester bleeding

A

Placental abruption and placenta previa

313
Q

Is there fetal distress in placenta previa?

A

No.

Normal fetal HR

314
Q

A woman presents in her third trimester with dark red vaginal bleeding that is painful. She has a rigid uterus on exam. What is the most likely Dx?

A

placental abruption

315
Q

Is there fetal distress in placental abruption?

A

Yes.
fetal bradycardia.
(due to interference with O2 exchange)

316
Q

Placental abruption Dx

317
Q

Placental abruption Tx

A
  • Hospitaliztion

- Immediate delivery, CD

318
Q

A painless vaginal bleed during pregnancy WITH fetal distress (bradycardia) is most likely Dx:

A

Vasa Previa

319
Q

Definition of tansitional (gestational) HTN

A

HTN, no proteinuria, AFTER 20 weeks gestation

Relieves 12 weeks post partum

320
Q

Definition of chronic (preexisting) HTN

A

HTN BEFORE 20 weeks gestation or before pregnancy

Persists >6 weeks post partum

321
Q

Definition of preeclampsia

A

HTN + proteinuria
+/- edema
AFTER 20 weeks gestation

322
Q

Definition of eclampsia

A

Seizures or coma in patients who meet preeclampsia criteria

LIFE THREATENING for mother and fetus

323
Q

BP requirement for preeclampsia-eclampsia

A

> 140/90
OR
increased by 30/15

AFTER 20th week gestation

324
Q

Hypertensive emergencies: HELLP syndrome

A 
Hemolysis,
Elevated
Liver enzymes,
Low
Platelet count

(severest forme of preeclampsia without having eclampsia yet)

325
Q

Vague initial Sx of HELLP syndrome

A

N/V, non-specific viral-like syndrome, RUQ pain from liver dysfunction

326
Q

HELLP syndrome Tx

A

CV stabilization
Correction of coagulation d/o
Immediate deliver via CD

327
Q

Gestational HTN Sx

A

asymptomatic

328
Q

Eclampsia Sx

A

Abrupt, clonic-tonic seizures
1-2 mins
» postictal state

329
Q

Mild preeclampsia Tx

A

Delivery if >37 weeks

Conservatie + steroids to mature lungs if <34 weeks

330
Q

Severe preeclampsia Tx

A
  • PROMPT delivery is only cure
  • Hospitalization + Mg sulfate (to prevent seizures)
  • BP meds in acute severe HTN (Hydralazine, Labetalol)
331
Q

Eclampsia Tx

A
  • ABCDs first!
  • Mg sulfate for seizures
  • Delivery!! once pt is stabilized
  • BP meds (hydralazine, labetalol)
332
Q

Preexisting HTN Tx

A

Mild (140-150/90-100): monitor

Moderate/severe (>150/100): Methyldopa is Tx of choice!!
Labetalol

AVOID ACEI and diuretics!!!

333
Q

4 things you check at 20 and 35 weeks with US

A
  1. Fetal anatomy/growth
  2. Estimated fetal weight
  3. Amniotic Fluid Index
  4. Placental location/abnormalities
334
Q

4 ways to measure fetal anatomy/growth

A
  • Head circumfernce
  • Biparietal diameter
  • Abdominal circumference
  • Femur length
335
Q

Definition of intrauterine growth restriction (IUGR)

A

Fetal weight <10th percentile for GA

336
Q

Things that cause ASYMMETRIC IUGR

A

HTN

severe nutritional deficiencies

337
Q

Things that cause SYMMETRIC IUGR

A

congenital anomalies

early intrauterine infection

338
Q

Definition of asymmetric IUGR

A

unequal decrease in the size of structures

fetal access to nutrients is compromised

339
Q

Definition of symmetric IUGR

A

anatomy equally diminished in size
relative sparing of fetal brain and heart
alteration of fetal cell number

340
Q

Definition of macrosomia

A

Fetal weight in >90th percentile for a given ae

341
Q

Risks of macrosomia

A
  • Maternal obesity
  • maternal diabetes, GDM
  • excessive maternal weight gain during pregnancy
342
Q

When is macrocomia suspected?

A

when fundal height is >4cm

confirmed by US

343
Q

Issues with macrosomia

A

Problematic SVD:

  • prolonged 2nd stage of labor
  • fetopelvic disproportion (FPD)
  • shoulder dystocia
  • immediate neonatal injury

Low threshold for C/S

344
Q

Why does preterm labor (PTL) occur?

A

there is a rise in fetal fibronectin (FFN), an extracellular glycoprotein found in cerviacl mucus early in pregnancy and near term

345
Q

When would you do a FFN swab?

A

at 24+ weeks WITH Sx of PTL only

346
Q

What percent of PTLs resolve spontaneously?

347
Q

What do you have to rule out if you think someone is entering PTL?

A

Uterine “irritability”

  • UTI
  • BV
  • dehydration
  • multigravida
348
Q

2 goals in the management of PTL

A
  1. detect and treat associated d/o

2. recognize and “treat” PTL

349
Q

two meds for treating PTL

A

tocolytics

steroids

350
Q

What are tocolytics for?

A

delaying labor when there is cervical dilation in PTL

351
Q

RF for premature rupture of membranes

A 
prolapsed umbilical cord
smoking (doubles risk)
prior PROM or PTL
short cervical length
multiple gestations
polyhydramnios/oligohydramnios
352
Q

fluid passing through the vagina is ______ until proven otherwise!!!

A

amniotic fluid

353
Q

What two tests can be used to Dx PROM?

A

Nitrazine test

Fern test

354
Q

How does the Nitrazine test work?

355
Q

How dose the fern test work ?

A

microscopy… amniotic fluid is placed on a slide and dies in room air. If it looks like a fern, it’s positive

356
Q

What are the three causative agents of chorioamnionitis?

A

gonorrhea
chlamydia
GBS

357
Q

Chorioamnionitis signs and symptoms

A

fever
uterine tenderness
tachycardia
copious vaginal discharge

358
Q

Chorioamnionitis Tx

A

Abx and immediate delivery

BCM (8 decks)

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