Gynecology Flashcards
1
Q
Labial Adhesions
- Tx
- Asymptomatic patients - ____
- Symptomatic patients - ____
A
Labial Adhesions
- Tx
- Asymptomatic patients - Many need no treatment, and their adhesions resolve during puberty when estrogen levels rise
- Symptomatic patients - Topical estrogen cream BID until adhesion resolves (usually by 6 weeks). If treatment is unsuccessful and patient is symptomatic, manual separation is required after applying topical analgesics.
2
Q
Ovarian cyst
- Tx:
- Physiologic cysts that are asymptomatic less than ___cm can be managed conservatively with observation only or cycled OCPs.
- If the cyst is large and persistent, a laparoscopic cystectomy is needed.
- If a cyst is found that is greater >__cm in diameter, it should be removed bc of to the risk of torsion due to size of the lesion.
A
Ovarian cyst
- Tx:
- Physiologic cysts that are asymptomatic and <6cm can be managed conservatively with observation only or cycled OCPs.
- If the cyst is large and persistent, a laparoscopic cystectomy is needed.
- If a cyst is found that is greater >5cm in diameter, it should be removed bc of to the risk of torsion due to size of the lesion.
3
Q
Abnormal Uterine Bleeding
- Occurs in cycles less than \_\_ days or >\_\_ days apart - Lasts >\_\_ days, or - Results in a large amount of blood loss per episode (>\_\_\_ ml, >\_\_ full pads or tampons/day, and/or causes anemia)
A
Abnormal Uterine Bleeding
- Occurs in cycles <20 days or >45 days apart - Lasts >8 days, or - Results in a large amount of blood loss per episode (>80 ml, >6 full pads or tampons/day, and/or causes anemia)
4
Q
Primary Dysmenorrhea
- Def: Painful uterine cramping that precedes and accompanies menstrual flow in the absence of pelvic disease.
- Tx:
- ______ are considered 1st line tx for primary dysmenorrhea
- If symptoms commonly occur and are predictable during the cycle, it is best to begin treatment 1-2 days before the onset of menses and taken on a scheduled basis for 2-3 days in total.
- If pain is not controlled, a trial of _____ may be indicated.
- ______ are considered 1st line tx for primary dysmenorrhea
A
Primary Dysmenorrhea
- Def: Painful uterine cramping that precedes and accompanies menstrual flow in the absence of pelvic disease.
- Tx:
- NSAIDs are considered 1st line tx for primary dysmenorrhea
- If symptoms commonly occur and are predictable during the cycle, it is best to begin treatment 1-2 days before the onset of menses and taken on a scheduled basis for 2-3 days in total.
- If pain is not controlled with NSAIDs, a trial of OCPs may be indicated.
- NSAIDs are considered 1st line tx for primary dysmenorrhea
5
Q
Premenstrual Syndrome (PMS)
- Dx for PMS:
- At least 1 symptom during the luteal phase (at least 5 days leading up to menses) that occurs in 3 consecutive cycles:
- Physical: Bloating, fatigue, breast tenderness, hot flashes
- Behavior: Mood swings, anxiety, depression, irritability
- At least 1 symptom during the luteal phase (at least 5 days leading up to menses) that occurs in 3 consecutive cycles:
- Tx: ______
A
Premenstrual Syndrome (PMS)
- Dx for PMS:
- At least 1 symptom during the luteal phase (at least 5 days leading up to menses) that occurs in 3 consecutive cycles:
- Physical: Bloating, fatigue, breast tenderness, hot flashes
- Behavior: Mood swings, anxiety, depression, irritability
- At least 1 symptom during the luteal phase (at least 5 days leading up to menses) that occurs in 3 consecutive cycles:
- Tx: For mild PMS, there is no specific tx. Some studies show that exercise helps with some symptoms.
6
Q
Premenstrual Dysphoric Disorder (PMDD)
- PMDD is a severe form of PMS characterized by predominant anger and irritability. Whereas PMS causes unpleasant psychological and physical symptoms, PMDD causes debilitating symptoms that interfere with normal daily functioning.
- Dx for PMDD:
- At least 5 of the following symptoms occur during the majority of menstrual cycles during the past year (over half of the menstrual cycles, must cause severe distress or interference with daily life)
- One or more of the following are required
- 1) Marked affective lability (eg mood swings such as feeling suddenly sad or tearful; increased sensitivity to rejection)
- 2) Marked irritability, anger, or increased interpersonal conflicts
- 3) Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts
- 4) Marked anxiety, tension, and/or feelings of being “keyed up” or “on edge”
- One or more of the following symptoms must additionally be present, to reach a total of 5 symptoms when combined with symptoms from those listed above
- 1) Decreased interest in usual activities (eg work, school, friends, hobbies)
- 2) Subjective difficulty in concentration
- 3) Lethargy, easy fatigability, or marked lack of energy
- 4) Marked change in appetite, overeating, or specific food cravings
- 5) Hypersomnia or insomnia
- 6) A sense of being overwhelmed or out of control
- 7) Physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of bloating, or weight gain
- Tx:
- ______ are 1st line for severe PMS/PMDD.. Symptoms often improve within 24-48 hours.
- If 1st SSRI is ineffective, another or an ________may be tried.
- PMS/PMDD has significant association with _________
A
Premenstrual Dysphoric Disorder (PMDD)
- PMDD is a severe form of PMS characterized by predominant anger and irritability. Whereas PMS causes unpleasant psychological and physical symptoms, PMDD causes debilitating symptoms that interfere with normal daily functioning.
- Dx for PMDD:
- At least 5 of the following symptoms occur during the majority of menstrual cycles during the past year (over half of the menstrual cycles, must cause severe distress or interference with daily life)
- One or more of the following are required
- 1) Marked affective lability (eg mood swings such as feeling suddenly sad or tearful; increased sensitivity to rejection)
- 2) Marked irritability, anger, or increased interpersonal conflicts
- 3) Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts
- 4) Marked anxiety, tension, and/or feelings of being “keyed up” or “on edge”
- One or more of the following symptoms must additionally be present, to reach a total of 5 symptoms when combined with symptoms from those listed above
- 1) Decreased interest in usual activities (eg work, school, friends, hobbies)
- 2) Subjective difficulty in concentration
- 3) Lethargy, easy fatigability, or marked lack of energy
- 4) Marked change in appetite, overeating, or specific food cravings
- 5) Hypersomnia or insomnia
- 6) A sense of being overwhelmed or out of control
- 7) Physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of bloating, or weight gain
- Tx:
- SSRIs are 1st line for severe PMS/PMDD. fluoxetine and sertraline are the 2 FDA approved drugs; or paroxetine and citalopram). Symptoms often improve within 24-48 hours.
- If 1st SSRI is ineffective, another SSRI or an estrogen-progesterone oral contraceptive may be tried.
- PMS/PMDD has significant association with a number of primary psychiatric disorders, primarily MOOD AND ANXIETY DISORDERS
7
Q
Lichen Sclerosus
- Uncommon chronic inflammatory disease of unknown cause that usually affects the anogenital region.
- Pt:
- Begins as small pink or white papules that coalesce to form plaques. Ultimately, the lesions become atrophic and appear as shiny, wrinkled, ivory-colored atrophic patches located in a figure-of-8 or hourglass distribution surrounding the vulva, perineum, and anus.
- Tx: No cure but many cases involute at or before puberty. 1st line tx usually is with ______. Once control is achieved, the topical steroid is withdrawn and maintenance therapy with a ______ is often begun.
A
Lichen Sclerosus
- Uncommon chronic inflammatory disease of unknown cause that usually affects the anogenital region.
- Pt:
- Begins as small pink or white papules that coalesce to form plaques. Ultimately, the lesions become atrophic and appear as shiny, wrinkled, ivory-colored atrophic patches located in a figure-of-8 or hourglass distribution surrounding the vulva, perineum, and anus.
- Tx: No cure but many cases involute at or before puberty. 1st line tx usually is with a medium-to-high potency topical steroid. Many clinicians initiate therapy with an ultrapotent (group 1) agent like clobetasol propionate or betamethasone dipropionate, tapering the frequency or potency as the condition improves. Once control is achieved, the topical steroid is withdrawn and maintenance therapy with a topical calcineurin inhibitor is often begun.
8
Q
Estrogen-containing methods (OCPs, patch, ring)
- Main risk is the risk of a venous thromboembolism
- Absolute contraindications
- Prior hx of venous thromboembolism
- Uncontrolled HTN with SBP > 160 or DBP >100
- Hx of migraines _______
- Current breast cancer
- Smoking for women >____ years old
- SLE with antiphospholipid antibody
- Hepatocellular disease: Severe cirrhosis, malignant liver tumor, hepatocellular adenoma
- Thrombogenic mutations
- Current or past hx of cerebrovascular event
- Ischemic heart disease
- Complicated valvular heart disease
- Complicated solid organ transplant
- Major surgery with prolonged immobilization
- Postpartum <21 days
- Breastfeeding <12 days postpartum
- Absolute contraindications
A
Estrogen-containing methods (OCPs, patch, ring)
- Main risk is the risk of a venous thromboembolism
- Absolute contraindications
- Prior hx of venous thromboembolism
- Uncontrolled HTN with SBP > 160 or DBP >100
- Hx of migraines with aura
- Current breast cancer
- Smoking for women >35 years old
- SLE with antiphospholipid antibody
- Hepatocellular disease: Severe cirrhosis, malignant liver tumor, hepatocellular adenoma
- Thrombogenic mutations
- Current or past hx of cerebrovascular event
- Ischemic heart disease
- Complicated valvular heart disease
- Complicated solid organ transplant
- Major surgery with prolonged immobilization
- Postpartum <21 days
- Breastfeeding <12 days postpartum
- Absolute contraindications
9
Q
Emergency contraception
- Copper IUD
- If inserted within 5 days, it is very effective choice. Effectiveness is not reduced if overweight or obese
- ELLA (ullipristal)
- Only by prescription - Exclude _____ before prescribing
- __ efficacy over time
- Plan B / Levonorgesterol / After Pill
- Swallow as soon as possible within ____ days.
- Less effective with ____
- Labs?___
A
Emergency contraception
- Copper IUD
- If inserted within 5 days, it is very effective choice. Effectiveness is not reduced if overweight or obese
- ELLA (ullipristal)
- Only by prescription - Exclude pregnancy before prescribing
- Does not decrease in efficacy over time, is as effective on 5th postcoital day as it is on the 1st postcoital day. Swallow within 5 days
- More effective than levonorgestrel overall, esp for women >154lbs
- Plan B / Levonorgesterol / After Pill
- Swallow as soon as possible within 3 days. Works up to 5 days (120 hours) after unprotected sex but efficacy decreases per day. Most beneficial if taken as soon as possible.
- Less effective with high BMI >25
- No lab tests required
- Will not interrupt implanted pregnancy
- Is not teratogenic
10
Q
OCPs and other drugs
- _______ is the only antimicrobial proven to decrease serum concentrations of estrogen & progestin components of combination OCPs
- Many _______ reduce both estrogen & progestin levels
- Several antiepileptic medications decrease the efficacy of hormonal contraceptives
- ____
- _____
- _____
- ____
- ____
- _____
- Sex steroids are not affected by other AEDs, like ____, _____, _____, and ______ (though OCPs do lower _____ levels and increase breakthrough seizures)
- Other drugs that reduce efficacy of OCPs:_____, ____ taken within 3 hours of OCP ingestion, most _____
A
OCPs and other drugs
- Rifampin is the only antimicrobial proven to decrease serum concentrations of estrogen & progestin components of combination OCPs
- Many antiretrovirals reduce both estrogen & progestin levels
- Several antiepileptic medications decrease the efficacy of hormonal contraceptives
- Phenytoin
- Carbamazepine
- Barbiturates
- Primidone
- Topiramate
- Oxcarbazepine
- Sex steroids are not affected by other AEDs, like Keppra, Valproid acid, Gabapentin, and Lamotrigine (though OCPs do lower lamotrigine levels and increase breakthrough seizures)
- Other drugs that reduce efficacy of OCPs: St. John’s Wort, Antacids taken within 3 hours of OCP ingestion, most antiretrovirals
11
Q
OCPs alter results of laboratory testing
- Estrogen component raises serum concentrations of binding proteins:
- Thyroxine-binding globulin (TBG)
- Cortisol-binding globulin (CBG)
- Sex hormone-binding globulin (SHBG)
- Therefore:
- Increase in TOTAL serum concentrations of
- ____ and _____
- _____
- _____
- _____
- Serum concentrations of FREE T4, T3, cortisol, estradiol, and testosterone remain unchanged
- Increase in TOTAL serum concentrations of
A
OCPs alter results of laboratory testing
- Estrogen component raises serum concentrations of binding proteins:
- Thyroxine-binding globulin (TBG)
- Cortisol-binding globulin (CBG)
- Sex hormone-binding globulin (SHBG)
- Therefore:
- Increase in TOTAL serum concentrations of
- Thyroxine (T4) and triiodothyronine (T3)
- Cortisol
- Estradiol
- Testosterone
- Serum concentrations of FREE T4, T3, cortisol, estradiol, and testosterone remain unchanged
- Increase in TOTAL serum concentrations of
12
Q
Bacterial Vaginosis (most common)- NOT STD
- Path: When levels of _____ are decreased, the pH of the vaginal environment is increased, which allows for the overgrowth of _____ bacteria, such as _____ (most common) and other anaerobic species (Mycoplasma hominis)
- Dx:
- Amsel criteria, 3 of the following 4 criteria.
- Homogenous, thin, gray-white discharge that smoothly coats the vaginal walls
- > ___% ____ cells on microscopy.
- Vaginal pH >____
- Release of ______ odor with the addition of 10% KOH to a drop of vaginal discharge (positive ____ test)
- Gold standard is Nugent scoring system of the gram stain, which assesses for the relative concentration of large gram-positive rods, small gram-variable rods and cocci (G vaginalis, Prevotella), and curved gram-variable rods (Mobiluncus)
- Amsel criteria, 3 of the following 4 criteria.
- Tx:
- _____ 500mg oral BID for 7 days, or
- Remember that ____ should be avoided while taking metronidazole
- Beware of ____ reaction
- _____ gel 0.75% 1 full applicator (5g) intravaginally daily for 5 days, or
- _____ cream 2% 1 full applicator (5g) intravaginally at bedtime for 7 days
- _____ 500mg oral BID for 7 days, or
- Tx is recommended for all pregnant women with symptoms bc BV can cause adverse pregnancy outcomes (ie PROM, chorioamnionitis, preterm labor, preterm birth, postcesarean wound infection).
- _____ 500mg PO BID for 7 days
- Or _____ 250mg PO TID for 7 days
- Or ____ 300mg PO BID for 7 days
A
Bacterial Vaginosis (most common)- NOT STD
- Path: When levels of lactobacilli are decreased, the pH of the vaginal environment is increased, which allows for the overgrowth of anaerobic bacteria, such as Gardnerella vaginalis (most common) and other anaerobic species (Mycoplasma hominis)
- Dx:
- Amsel criteria, 3 of the following 4 criteria.
- Homogenous, thin, gray-white discharge that smoothly coats the vaginal walls
- > 20% clue cells on microscopy.
- Vaginal pH >4.5
- Release of fishy amine odor with the addition of 10% KOH to a drop of vaginal discharge (positive whiff test)
- Gold standard is Nugent scoring system of the gram stain, which assesses for the relative concentration of large gram-positive rods, small gram-variable rods and cocci (G vaginalis, Prevotella), and curved gram-variable rods (Mobiluncus)
- Amsel criteria, 3 of the following 4 criteria.
- Tx:
- Metronidazole 500mg oral BID for 7 days, or
- Remember that alcohol should be avoided while taking metronidazole
- Beware of disulfiram-like reaction (known adverse effect following ingestion of alcohol during tx with metronidazole
- Metronidazole gel 0.75% 1 full applicator (5g) intravaginally daily for 5 days, or
- Clindamycin cream 2% 1 full applicator (5g) intravaginally at bedtime for 7 days
- Metronidazole 500mg oral BID for 7 days, or
- Tx is recommended for all pregnant women with symptoms bc BV can cause adverse pregnancy outcomes (ie PROM, chorioamnionitis, preterm labor, preterm birth, postcesarean wound infection).
- Metronidazole 500mg PO BID for 7 days
- Or Metronidazole 250mg PO TID for 7 days
- Or Clindamycin 300mg PO BID for 7 days
13
Q
Candida
- Pt: Whitish curd-like discharge adherent to vaginal wall.
- _____ pH
- Dx: Microscopic examination of vaginal discharge wet-mount with saline or 10% KOH or by gram stain, which reveals _______
- Therapies:
- Intravaginal cream (____) BID for 7 days, anti-fungals. OTC topical. If fails, use prescription
- ______ 150mg PO one time
- Treat infected women’s male sexual partner only if there is evidence of balanitis
- Consider ____ in the setting of recurrent vaginal candidiasis, esp when other RFs are present.
A
Candida
- Pt: Whitish curd-like discharge adherent to vaginal wall.
- Normal pH (3.8-4.5)
- Dx: Microscopic examination of vaginal discharge wet-mount with saline or 10% KOH or by gram stain, which reveals pseudohyphae or budding yeast
- Therapies:
- Intravaginal cream (Clotrimazole, butoconazole, miconazole, nystatin, terconazole) BID for 7 days, anti-fungals. OTC topical. If fails, use fluconazole prescription
- Fluconazole 150mg PO one time
- Treat infected women’s male sexual partner only if there is evidence of balanitis
- Consider diabetes in the setting of recurrent vaginal candidiasis, esp when other RFs are present.
14
Q
Trichomonas - IS an STI
- Pt:
- Most people are unaware that they are affected and are asymptomatic: Most infected males are asymptomatic
- _______ discharge with dysuria. _____ cervix
- pH >_____
- Diagnosis:
- Clinical, but may be confirmed by visualization of _______ on wet mount slide (easiest test, in sensitive) or NAAT (most sensitive test).
- Culture is considered the gold standard for diagnosis of trichomoniasis because its specificity approaches 100%.
- Tx:
- PO _________ for both partners (cure and prevention of transmissions and reinfections). Patients undergoing treatment should abstain from alcohol until 24 hours after completion of therapy for metronidazole. To prevent re-infection of trichomoniasis, patients should abstain from sex until they and their partners have completed tx and are symptom-free
- Treat pregnant women
A
Trichomonas - IS an STI
- Pt:
- Most people are unaware that they are affected and are asymptomatic: Most infected males are asymptomatic
- Yellow-green frothy malodorous discharge with dysuria. Strawberry cervix (cervicitis; cervical hemorrhages)
- pH >4.5
- Diagnosis:
- Clinical, but may be confirmed by visualization of motile organisms (motile flagella) on wet mount slide (easiest test, in sensitive) or NAAT (most sensitive test).
- Culture is considered the gold standard for diagnosis of trichomoniasis because its specificity approaches 100%.
- Tx:
- PO metronidazole for both partners (cure and prevention of transmissions and reinfections). Patients undergoing treatment should abstain from alcohol until 24 hours after completion of therapy for metronidazole. To prevent re-infection of trichomoniasis, patients should abstain from sex until they and their partners have completed tx and are symptom-free
- 3 options:
- One dose of 2g oral metronidazole, OR
- One dose dose of 2g oral tinidazole, OR
- 500mg oral metronidazole BID for 7 days
- Treat pregnant women with 2g metronidazole in 1 dose at any stage of pregnancy
15
Q
Fibrocystic changes (aka benign proliferative breast disease)
- Pt:
- Most common symptom is bilateral fullness with pain and tenderness in _____ of the breast.
Related to menses??____
- Management:
- Changes are usually self-limited and last 1-2 cycles
- _______
Although unproven, limiting ____ intake provides relief for some pts.
A
Fibrocystic changes (aka benign proliferative breast disease)
- Pt:
- Most common symptom is bilateral fullness with pain and tenderness in upper-outer quadrants of the breast. Pain typically begins just prior to menses, peaks at time of menstruation, and resolves soon after onset of menses.
- Management:
- Changes are usually self-limited and last 1-2 cycles
- Analgesics (NSAIDs such as ibuprofen). Symptoms typically improve with oral contraceptives (low dose 20mcg ethinyl estradiol), which can help with the hormonal imbalance.
- Supporting bras, NSAIDs, OCPs, reduce the frequency and duration of pain in 70-90% of females. Although unproven, limiting caffeine intake provides relief for some pts.
