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Fall Y3 > Repro Exam 3 > Flashcards

Repro Exam 3 Flashcards

1
Q

List the criteria for dx of PCOS

A

ovarian dysfunction
clinical evidence of androgen excess
polycytic ovaires
exclusion of other conditons that cause same signs/sx

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2
Q

Discuss the pathophysiology underlying PCOS including insulin, steroidal hormones, FSH/LH, metabolic effects, androgen effects and origin, effects on endometrium

A

hyperandrogenism: dysfunctional gonatropin metabolism and excessive androgen production are believed to be downstream consequences of insulin
resistance, deregulation of hypothalamic-pituitary axis (LH/FSH) and possibly
abnormal melatonin levels that hinder LH/FSH balance

Low or
low-normal SHBG with a serum testosterone within the upper end of normal
range may be associated with excess androgen stimulation in target tissues
because of elevated free testosterone

5-alpha reducatse activity is increased

insulin: prompts the ovary theca cells to enhance the synthesis & release of
androgens and indirectly enhance androgen synthesis through modulation of CHO
levels

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3
Q

Discuss the ways hyperandrogenism presents clinically from most common to least common

A

hirsutism
acne
male pattern balding

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4
Q

What are the mechanisms that underlie CVD in the PCOS patient?

A

Impairment of cardiac structure & function - inc cardiac size & dec ejection
fraction, inc BP
Endothelial dysfunction - likely 2nd to insulin resistance (IR)
Lipid abnormalities - inc Tg’s, LDL, & dec HDL – likely 2nd to IR
Chronic low-grade inflammation
Cardiopulmonary impairment - dec maximal O2 consumption (2 studies
have shown with PCOS pts) – directly related to IR

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5
Q

What are the MOA that underlie the development of endometrial hyperplasia and carcinoma in the PCOS patient?

A

Due to anovulation, presence of DM II (hyperinsulinemia) & obesity,
HTN
inc insulin levels associated with inc risk for cancer due to up-regulation of
estrogen-producing aromatase enzyme systems in endometrial glands &
stroma → additive & deleterious results for a pt with both inc insulin &
anovulatory.
inc fasting plasma insulin causes endometrial hyperplasia to advance to
carcinoma 30% of the time.
Anovulation – prolonged exposure to estrogen in the absence of
progesterone.
Dysregulation of endometrial gene expression in PCOS women
accompanies progesterone resistance in the tissue.
Hyperandrogensism – common finding in endometrial cancer. Androgen
receptor & 5α-reductase are present in endometrium with overexpression
of endometrial androgen receptors.
Hypersecretion of LH (modulator of endometrial growth) – evidenced by
ability of LH to promote growth of human endometrial cancer cells in
vitro. LH receptors also are overexpressed in anovulatory PCOS women
with endometrial hyperplasia and carcinoma

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6
Q

What is the initial lab work for dx? What imaging if necessary to meet 2 of the 3 criteria can be ordered?

A

serum free testerone, total testosterone, FSH/LH,
TVUS

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7
Q

List the goals of medical management for a PCOS patient

A

Restoring/Induction of ovulation
Normalization of endometrium
Amelioration of symptoms hyperandrogenism
Reduce insulin resistance
Management of underlying of metabolic abnormalities, & reduce risk factors for
type 2 diabetes & CVD

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8
Q

Lifestyle is the first line treatment for PCOS pts with dysinsulinemia, list the lifestyle treatments and what outcomes are shown with each when incorporated

A

stress management: Stress of all kinds – causes ↑ in adrenaline & norepinephrine → ↑
in blood glucose, dec insulin secretion, ↑ prod but dec utilization, dec inflammation
sleep hygiene: inc appetite and food intake, inc weight gain, inc IR and glucose intolerance
weight loss: inc insulin sensitivity, dec hirtuism, inc SHBG, dac total & free T to normal or near normal levels
Exercise: dec IR, aids in weight loss, inc permeability of glucose into muscle cells w/o insulin
diet: dec insulin, dec inflammation, increase SCFA’s, regularize cycle,

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9
Q

List the most effective nutraceuticals (including doses) that improve most parameters of PCOS pts

A

Fish oil
Vit E succinate and ebselen
NAC 1.2-1.8 gms/day
Chromium 200-1000 mcg/day
Vit D3 1500-2000 IU/day
probiotics
Myo-inositol and D-chiro-inositol 2000-4000 mg/day and 100-600 mg/day
CoQ10 60 mg TID
L-Carnitine 3 g/day TID

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10
Q

List the botanicals (with doses) you would incorporate with a PCOS pt with glucose-insulin issues and dyslipidemia. List C/I as well

A

berberine 200-500 mg TID CI in pregnancy
Gymnema sylvestre 200-500 mg TID CI in pregnancy
Cinnamon 1/2 1 and 1/2 tsp with meals
Flaxseeds 2-4 tbsp/day
Nettle root
Green tea 500 mg CI pregnancy
Saw palmetto 350 mg/day CI pregnancy
Spearmint 1 cup of tea BID
Vitex agnus-castus 20-40 mg CI pregnancy
cimicifuga racemosa 20 mg BID
Paeonia lactiflora 7.5 g/day CI pregnancy
tribulus terrestris 250 mg TID for 1-2 mon CI pregnancy
Glycyrrhiza glabra CI pregnancy
Sarsaparilla, trigonella, caullaphylum CI pregnancy

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11
Q

Discuss the forms progesterone/progestins available for PCOS pts and how and when you would prescribe them with doses and C/I

A

Progesterone: OMP 100-400 mg qhs 10-14 days
every 1 to 2 months, used for protecting endometrium, regulates menstural cycle, treament of endometiral hyperplasia

Progestins: treatment of endometrial hyperplasia, provera (5-10 mg/d), norethindrone acetate (2.5-10 mg/d) either cyclically or continously

Mirena IUD: treatment of hyperplasia/prevention of carcinoma

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12
Q

When is metformin useful with PCOS and how would you prescribe it with doses as well as C/I

A

restores menstrual cyclicity & ovulation in 30-50% of PCOS pts,
ability to protect endometrium is less well establishes considered second-line
therapy

CI: prgenancy

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13
Q

What are the pharmaceuticals options for the PCOS pt with infertility; give doses and C/I

A

Clomiphene citrate: 150 mg/d
Letrozole
IVF

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14
Q

what are the surgical options for PCOS?

A

Laproscopic ovarian diathermy
transvaginal laproscopic ovaran drilling
ovarian wedge resection/ovarian drilling

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15
Q

What are the 6 sources of pelvic pain?

A

Gastrointestinal
Urological
Gynecological
Psychological
Musculoskeletal
Neurological
Immunological
Vascular

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16
Q

What are the most common causes of pelvic pain from each system

A

GI: IBS, IBD,

Urinary: intersisital cystitis

MSK/Neuro: abdominal wall myofasical pain, pelvic flor myalgia, Abdominal Cutaneous Nerve Entrapment in a surgical scar, Abdominal Epilepsy, Abdominal Migraine, Shingles – herpes zoster

GYN: adhesions, endometriosis, adenomyosis

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17
Q

What are the red flag symptoms in pelvic pain?

A

Unexplained weight loss
Hematochezia
Perimenopausal Irregular Bleeding
Post-Menopausal Vaginal Bleeding
Post Coital Bleeding

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18
Q

What is an important consideration when prescribing anti-inflammatory pain medication for dysmenorrhea?

A

clotting disease
kidney and liver disease

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19
Q

What are the three most common conventional therapies for dysmenorrhea?

A

NSAIDs
Oral contraceptives
Mirena IUD

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20
Q

Describe how estrogen dominance increases pain in endometriosis?

A

↑ estrogen → ↑ BDNF → ↑ hyperalgesia
Defective formation & metabolism of estrogen –
responsible for promotion & dev of endometriosis

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21
Q

Explain how endometriosis is like an auto-immune disease, cancer and endocrine disorder

A

women with endometriosis have
certain immune defects/dysfunction unable to clear up the
tissue when it implants. Concentrations of macrophages,
leptin, tumor necrosis factor-α, and interleukin-6 often are
higher in the abdominal fluid of women with
endometriosis

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22
Q

What are the 3 most common sites for endometriosis to implant?

A

Cul-de-sac
Left broad ligament
left utero-sacral ligament

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23
Q

What are the 8 most common symptoms of endometriosis?

A

dysmenorrhea, non-menstural pelvic pain, deep dypareunia/dyschezia, lateral pelvic pain, bladder pain, frequency, dysuria, irrehular vaginal bleeding. IBS, infertility

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24
Q

How is endometriosis definitively diagnosed?

A

Laparoscopy
Laparotomy

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25
Q

What are the treatment goals in managing endometriosis ?

A

Relieve symptoms (eg, pain or mass)
Prevent complications related to the adnexal mass (eg,
rupture or torsion)
Exclude malignancy
Improve subfertility
Preserve ovarian function
Symptomatic or expanding endometriomas are removed
laparoscopically.
To protect ovarian reserve, asymptomatic and small (≤5 cm)
endometriomas can be left in place.

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26
Q

What are the standard treatments in Endometriosis?

A

Combined estrogen and progestin contraceptives
Progestins
GnRH analogs
GnRH antagonists
androgen agents
Aromatase inhibitors
NSAIDS
Excison
Ablation
Hysterectomy

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27
Q

List the 4 ways that progestins treat endometriosis ?

A

inhibits matrix metalloproteinases, growth factors, inflammatory reactions, and peripheral esterogen

Anti-angiogenic, immunomodulatory &
anti-inflammatory effect
Inhibit implantation & growth of refluxed menstrual
endometrium

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28
Q

List the classes of endocrine disruptors that contribute to endometriosis.

A

Persistent organic pollutants
Plastics
Pesticides
Fungicides
pharmaceutical agents
heavy metals
phytoestrogens

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29
Q

What are the 3 symptoms related to adenomyosis?

A

dysmeorrhea
menorrhagia
large clots

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30
Q

What is the classic presentation for pelvic congestion syndrome?

A

Multiparous woman with chronic, dull pelvic pain, typically
with postcoital ache that may last for days
Better lying down, worse standing and pregnancy
fullness in legs, bladder irritability
due to perivesical varicosities.

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31
Q

what is the definition of chronic pelvic pain?
a. non-cyclic pain > 6 mon, localized to the pelvis
b. cyclic pain > 6 month localized to the pelvis
c. non-cyclic pain >3 mon localized to the pelvis
d. cyclic pain > 3 mon localized to the pelvis

A

non-cyclic pain > 6 mon, localized to the pelvis

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32
Q

what are risk factors for developing pelvic pain?

A

Drug or alcohol abuse
Miscarriage
Heavy menstrual flow
PID
Previous C-section/pregnancy
Pelvic pathology
Physical/sexual abuse
Psychological co-morbidity
Age (reproductive age)
Hx of surgery (abdominal-pelvic surgery)
Cervical surgery for dysplasia
Hysterectomy

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33
Q

What PE do you preform for someone with pelvic pain?

A

abdominal
pelvic
rectal

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34
Q

what labs do you run for someone with pelvic pain?

A

CBC, CRP, ESR, UA, urine culture, PCR urine testing, HCG, serum hormones, stool dysbiosis, heavy metals, SNP testing, environmental toxin exposure

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35
Q

what labs are helpful for endometriosis?
a. Antiendometrial antibody
b. CA 125
c. CA 19-9
d. TNFα in peritoneal fluid
e. all

A

all

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35
Q

what labs are helpful for endometriosis?
a. Antiendometrial antibody
b. CA 125
c. CA 19-9
d. TNFα in peritoneal fluid
e. all

A

all

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36
Q

what is sonohysterogram good at dx?
a. polyps
b. recto-vaginal endometriosis
c. adenomyosis
d. all

A

all

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37
Q

What is CT best at ruleing out?
a. polyps
b. appendicits
c. adenomyosis
d. endometriosis

A

appendicits

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38
Q

what is pelvic US able to detect?
a. stage 3-4 endometriosis
b. retroperitoneal and uterosacral lesions
c. ovarian endometriomas
d. all

A

all

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39
Q

what is the definiton of dymenorrhea?

A

difficult menstrual flow or painful menses in women
with normal pelvic anatomy

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40
Q

Which of the following is not a symptom of dysmenorrhea?
a. intermittent spasms of cramping pelvic pain beginning shortly
before or at onset of menses, lasting 1-3 days
b. N/V/D
c. fatigue
d. pain w/ sex

A

pain w/ sex

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41
Q

what are the risk factors associated with dysmenorrhea?

A

Young age less than 30 yo
Nulliparity
Heavy menstrual flow
Premenstrual symptoms
Irregular menses
Clinically suspected PID
Sexual abuse
Menarche before age 12 yo Low BMI
Sterilization
Long menstrual periods
Positive family history
Obesity & EtOH consumption
Smoking
Depression
Attempts to lose wt.
Anxiety
Disruption of social network

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42
Q

What are the diagnostic strategy for endometriosis?

A

Findings of retroverted uterus, decreased uterine mobility, CMT,
and tender utero-sacral nodularity are suggestive of endometriosis
when present
Empiric diagnosis and tx of endometriosis is reasonable based on
clinical presentation and suspicion
Patients with persistent sxs after empiric tx should be referred for
laparoscopy

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43
Q

What are natural tx for endometriosis?

A

exercise
hydrotherapy
physical medicine
counseling
treat dysbiosis
diet

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44
Q

what are the nutritonal supp for endometriosis?

A

melatonin
probiotics
EFA
vit C
beta carotene
Vit E
B vit
selenium
magnesium
lipotropic agents
digestive enzymes
pycnogenois
tumeric
boswellia
bromelain
NAC

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45
Q

what is the definition of adenomyosis?

A

homogeneous thickening of the inner layers of the
myometrial layers underlying the endometrium – termed the junctional
zone (JZ). This maybe due to benign endometrial invasions into the
myometrium.

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46
Q

what is the cause of adenomyosis?

A

VEGF, hypoxia-inducible factor-1a expression & microvessel
density are ↑ particularly in epithelial cells compared with normal
controls

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47
Q

What is the tool to diagnose adenomyosis
a. TVUS
b. clinical
c. MRI
d. a and c

A

a and c

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48
Q

what is the link between adenomyosis and fertility?

A

Excessive JZ contractions and sperm transport have been shown to reduce implantation

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49
Q

What are the conventional treatments for adenomyosis?
a. uterine embolization
b. angiogenesis inhibitors
c. Mirena IUD
d. gonadotropin-releasing hormone analogues
e. all of the above

A

all

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50
Q

what are the natural treatments for adenomyosis?

A

hydrotherapy
vinager packs
castor oil
holitic pelvic care/PT/myofascial release
counseling
undas

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51
Q

what is the definiton of pelvic congestion syndrome?

A

chronic pelvic pain with ovarian vein varicosities,

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52
Q

what is the etiology of pelvic congestion syndrome?
a. Congenital absence of valves within ovarian veins
b. Acquired valvular incompetence
c. Multiparity
d. Ovarian vein compression
e, all

A

all

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53
Q

what is the sx presentation for pelvic congestion syndrome?
a. chronic dull pelvic pain with postcoital ache
b. better lying down
c. fullness in legs and bladder irritability
d. all of the above

A

all

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54
Q

how is pelvic congestion syndrome diagnosed?
a. TVUS
b. MRI venography
c. venography
d. all of the above

A

all of the above

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55
Q

what is the criteria for identifying Pelvic Congestion Syndrome on US?

A

Dilation of pelvic veins > 6 mm, reversal of flow within
ovarian veins & dilated veins in myometrium

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56
Q

what are the treatments for pelvic congestion syndrome?
a. progestones
b. implanon
c. hysterectomy and oophorectomy
d. ovarian vein ligation
e. embolization
f. all of the above

A

all

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57
Q

What is the etioogy of PMS/PMDD?
a. changes with GABA
b. neurotransmitter imbalances
c. serotoninergic dysregulation
d. fluctuating sex steriod levels
e.

A

changes with GABA, neurotransmitter imbalances, serotoninergic dysregulation, fluctuating sex steriod levels, bloating, genetics, deficiencies in prostaglandins, mag and ca levels

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58
Q

What are the RF for PMS/PMDD?

A

ovulatory cycles, age, stress, genetics, obesity, smoking, depression, anxiety

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59
Q

what is the pattern of symptoms in PMS/PMDD?

A

Cyclic recurrence of symptoms during luteal phase of menstrual cycle
Beginning 2 weeks or so before the onset of menses and results in difficulties in daily functioning and last for an average of 6 days a month
Symptoms diminish rapidly with the onset of menses

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60
Q

what is the most common affecive or behavioral sx of PMS?
a. mood swing
b. depression
c. anxiety
d. irritability

A

mood swing

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61
Q

what are the most common physical manifestation?
a. breast tenderness
b. abdominal bloating
c. fatigue
d. b and c

A

b and c

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62
Q

which of the following is TRUE regarding PMS and PMDD?
a. they are the same thing
b. PMS is more severe than PMDD
c. PMDD is more severe than PMS

A

PMDD is more severe than PMS

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63
Q

what is the only proven RF of PMS/PMDD?
a. ovulatory cyles
b. age
c. stress
d. genetics

A

ovulatory cyles

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64
Q

what are the psychological sx associated with PMS and PMDD?

A

Tension
Mood swings
Lack of concentration
Confusion
Forgetfulness
Restlessness
Loneliness
Sleep disturbance
Increased appetite
Decreased self-esteem
Decreased coordination, accident prone
Irritability
Anger
Depressed mood
Crying and tearfulness
Anxiety

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65
Q

What are the behavioral sx associated with PMS/PMDD?

A

Change in sexual interest
Food cravings, overeating
Increased social isolation
Increased verbal abuse and criticism of others

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66
Q

what are the physical sx associated with PMS/PMDD?

A

Fatigue, Headaches, Breast tenderness and swelling, Back pain, Abdominal pain and bloating, Weight gain, Swelling of extremities, Water retention, Nausea, Muscle and joint pain, Dizziness, Constipation, Hot flashes, Acne, Palpitations, Rhinitis

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67
Q

What must be included to diagnosis PMS/PMDD?

A

Restriction of symptoms to the luteal phase of the menstrual cycle
Affective and somatic symptoms
Impairment in function
Exclusion of other diagnoses that may better explain the symptoms

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68
Q

what is ACOG diagnostic criteria for PMS?

A

Patient reports at least one symptom associated with “economic or social dysfunction” that occurs during the five days before the onset of menses and is present in at least three consecutive menstrual cycles. Symptoms may be affective or physical symptoms

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69
Q

What is the DSM-V criteria for PMDD?

A

Patient report at least five or more symptoms, with at least one of four specific symptoms must be present:
* Depressed mood, sudden sadness, mood swings, ↑ sensitivity to
* rejection*
* Irritability, anger*
* Anxiety, tension, feeling on edge*
* Sense of hopelessness, self-critical thoughts*

One or more of the following symptoms must be present to reach a total of five symptoms overall:
* Decreased concentration
* Decreased interest in usual activities
* Lethargy, lack of energy, easy fatigability
* Change in appetite, food cravings, overeating
* Feeling overwhelmed or out of control
* Breast tenderness or swelling, bloating weight gain, or joint/muscles aches
* Sleeping too much or not sleeping enough

Symptoms must have been present in most menstrual cycles that occurred the previous year, and the symptoms must be associated with significant distress or interference with usual activities (eg, work, school, social life).
These criteria also specify that PMDD may be superimposed on other psychiatric disorders, provided it is not merely an exacerbation of those disorders.

Additional Criteria
Necessary for both PMS & PMDD
Symptoms occur 5 days before menses, remit 4 days of menses onset, and do not reoccur until at least cycle day 13
Symptoms present in the absence of any pharmacologic therapy, hormone ingestion, or drug or alcohol use
Symptoms occur reproducibly during two cycles of prospective recording
Symptoms cause identifiable dysfunction in social or economic
performance/school
May be superimposed on other psychiatric or medical d/o’s, provided it is not merely an exacerbation of that disorder.

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70
Q

what are the lifestyle treatments of PMS/PMDD?

A

stress management, sleep hydiene, exercise, mind/body techinques, diet (reducing or eliminating alcohol,
caffeine, refined sugars, salt, dairy products and animal fats), accupunture,

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71
Q

what are the nutritonal supplements used to treat PMS/PMDD?

A

Lecithin phosphatidylserine & phosphatidic acid complex (decrease cortisol), cal, mag (essential cofactor for estrogen metabolism and neurotransmitter synthesis, as well as cause depletion of brain dopamine, which may alter mood), B6 (cofactor for estrogen metabolism and neurotransmitter synthesis), Vit E (for mastalgia), EFA (reduce emotional sx), Vit D (effect
calcium levels, cyclic sex steroid hormone fluctuations,
and/or neurotransmitter function), zinc (helps with fatty acid metabolism), DIM, flaxseed (estrogen balance), 5-HTP (inc serotonin), Lipotropics, Liver Detox

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72
Q

what botanicals are used to treat PMS/PMDD?

A

vitex, ginkgo, st john’s wort, cimicifuga racemosa,

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73
Q

What pharmaceuticals are used to treat PMS/PMDD?

A

SSRI’s
OCP
OTC
estradiol implants/pacthes
progestins
GnRH agonists
diuretics
androgens
benzodiazepines
progesterone

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74
Q

compare follicular cysts and corpus luteum cysts
a. follicular cysts are when follicle fails to rupture with ovulation where corpus luteum is when fails to regress normally after ovulation
b. corpus luteal cysts smooth, thin-walled, and unilocular and follicular cysts complex or simple, thick-walled, or contain internal debris
c. corpus leuteum cyst are larger than 2.5 cm in diameter and follicular cysts grows to 3cm
d. corpus leuteum cyst excess estradiol production and follicullar cyst are hemorrhagic

A

follicular cysts are when follicle fails to rupture with ovulation where corpus luteum is when fails to regress normally after ovulation

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75
Q

which cyst occur in pregnancy?
a. theca lutein cyst
b. corpus luteum cyst
c. follicular cyst
d. a and b

A

a and b

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76
Q

what is the pain from rupture described as?
a. sudden, sharp, unilateral
b. often preceded by intercourse/exercise
c. N/V, fever
d. all of the above

A

all of the above

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77
Q

what are the sequelae for cyst?
a. rupture and possible peritonitis
b. adnexal torsion
c. cancer
d. all of the above

A

all of the above

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78
Q

which of the following of adnexal torsion?
a. associated with <4 cm cysts
b. preceded by exercise or intercourse
c. sudden, sharp, unilateral, right sided
d. all of the above

A

all of the above

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79
Q

what is the sx associated with adexnal mass/cyst?

A

asx, lower abdominal pain, N/V, constipation/bloating, diffcult or frequent urination, dysmenorrhea, dyspareunia, fever, abnormal uterine bleeding

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80
Q

what is the RF for ovarian cancer?

A

strong FHX, advancing age, Caucasian, infertility, nulliparity, Hx of breast cancer, PCOS, endometriosis, cigarette smoking & BRCA gene mutations

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81
Q

what are the sxs of ovarian cancer associated with advanced disease?

A

Dyspepsia, early satiety
Sensation of bloating/increased abdominal size
Pelvic/abdominal pain
Constipation
Ascites
Urinary urgency/frequency

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82
Q

what is the labs for dx cyst/adnexal mass?

A

CBC, pregnancy test, UA, genital culture, LDH, β-hCG, & α-fetoprotein, CEA, and serum CA-125

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83
Q

what imaging is used for dx of adnexal masses/cysts?
a. pelvic US
b. CT scan
c. MRI
d. all

A

all

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84
Q

what is the managment for premenopasual women with adnexal mass?

A

Observe – if asxs & cystic mass is < 8 cm, simple in US appearance - follow with TVUS in 1-3 months - 70% will resolve spontaneously
Gray area clinically – cystic masses 7-8 cm that are asxs

Proceed with surgical removal
* Persistence of mass, does not respond to treatment, is symptomatic
* Change in US characteristics – more complex appearance, solid enlargement, or evidence of ascites (suggestive of malignancy)
* Mass > 8 cm, solid appearance on US, bilaterally, presence of
* ascites (UpToDate 2012 indicates > 10 cm size of cyst or mass)

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85
Q

what is the management of Postmenopausal woman with adnexal mass?

A

Asymptomatic 3-5 cm unilocular cyst with normal CA-125 - 0% risk of malignancy (international multicenter study) – follow at 3, 6, 9, & 12 mos US, then annually thereafter.
Complex mass < 5 cm & normal CA-125 – repeat TVUS & CA125 in 4 wks.
Symptomatic pts with suspicious mass & ↑ CA-125 → surgical
referral.

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86
Q

what is the indication for laproscopy?
a. <8 cm and benign
b. >8 cm or suspicious for cancer

A

<8 cm and benign

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87
Q

what are botanicals/supp to treat adnexal mass?

A

green tea, Vitex, Turska’s Revised Formula, ground flaxseed, symplex F, Lipotropic complex or SLF

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88
Q

what conventinal tx for adnexal mass?
a. OC
b. pain med
c. surgery
d. all of the above

A

all of the above

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89
Q

what are the RF associated with myoma?

A

age (40), FH, African-american, diet (meat), exercise, PCOS, OC, endogenous hormonal tx, weight, smoking, tissue injury, infertility, menopasual HT

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90
Q

what is the link between estrogen and myoma growth?

A

Low levels of enzymes that convert estradiol to estrone in myomas may ↑ estradiol in the tissue → up-regulation of E & P receptors → ↑ responsiveness to E → myoma growth

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91
Q

what are the sx associated with myomas?

A

abnormal uterine bleeding, pain, urinary
frequency, nocturia, & urgency, infertility, constipation

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92
Q

what is the imaging used to diagnose myomas?

A

TVUS, HSG, SIS, MRI, hysteroscopy

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93
Q

which of the following is not an advatage to hysteroscopy?
a. direct visulaization
b. simultaneous theraputic intervention
c. out-patient setting and minimal complications
d. inability to detect intramyometiral extension

A

inability to detect intramyometiral extension

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94
Q

which of these is NOT an effect of myomas on fertilization?
a. Anatomic distortion of cx
b. Altered uterine contractility
c. Deformity of endometrium
d. Distortion of shape of endometrium

A

Distortion of shape of endometrium

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95
Q

Which of the following is NOT an effect of myomas on implantaion
a. Altered endometrial development
b. Prevention of efflux of d/c or bld
c. Distortion of shape of endometrium
d. Obstruction of tubal ostia

A

Obstruction of tubal ostia

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96
Q

what is involved in the managment of myomas for those that are asymptomatic?
a. observation and follow-up at 6 mon
b. medication
c. embolization
d. surgery

A

observation and follow-up at 6 mon

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97
Q

Which of the following is NOT a factor influencing treatment options for myomas?
a. Severity of symptomatology
b. Desire for future fertility
c. Comorbid conditions
d. ethinicty

A

ethinicty

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98
Q

What are the medications used to treat myomas?

A

Oral & Injectable Contraceptives, Levonorgestrel Intrauterine Systems (LNG-IUS; Mirena IUD), NSAIDS, Gonadotropin-releasing hormone agonist analogues, Antiprogesterones, SERMs, androgens, aromatase inhibitors, somatostatin analogues, Cabergoline

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99
Q

Which of the following best explains the benefit of using Oral & Injectable Contraceptives?
a. dec menorrhagia
b. ↓ myoma volume
c. reduction in myoma size, uterine size & development of
amenorrhea
d. ↓ myoma growth

A

dec menorrhagia

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100
Q

Which of the following best explains the benefit of using Levonorgestrel Intrauterine Systems?
a. dec menorrhagia
b. ↓ myoma volume, menorrhagia, blood loss
c. reduction in myoma size, uterine size & development of
amenorrhea
d. ↓ myoma growth

A

↓ myoma volume, menorrhagia, blood loss

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101
Q

Which of the following best explains the benefit of using Gonadotropin-releasing hormone agonist analogues?
a. dec menorrhagia
b. ↓ myoma volume, menorrhagia, blood loss
c. reduction in myoma size, uterine size & development of
amenorrhea
d. ↓ myoma growth

A

reduction in myoma size, uterine size & development of
amenorrhea

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102
Q

Which of the following best explains the benefit of using Antiprogesterones?
a. dec menorrhagia
b. ↓ myoma volume, menorrhagia, blood loss
c. reduction in myoma size, uterine size & development of
amenorrhea
d. ↓ myoma growth, size, induction of amenorrhea

A

↓ myoma growth, size, induction of amenorrhea

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103
Q

which of the following is not a complication with Gonadotropin-releasing hormone agonist analogues?
a. menopausal like sx
b. bone loss
c. fibroid degeneration
d. all of these are complications

A

all of these are complications

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104
Q

Which of the following best explains the benefit of using SERMs?
a. dec menorrhagia
b. ↓ myoma volume, menorrhagia, blood loss
c. reduction in myoma size, uterine size & development of
amenorrhea
d. inhibits collagen synthesis in myoma cells

A

inhibits collagen synthesis in myoma cells

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105
Q

Which of the following best explains the benefit of using androgens?
a. dec menorrhagia
b. ↓ myoma volume, menorrhagia, blood loss
c. ↓ fibroid size & related sxs
d. inhibits collagen synthesis in myoma cells

A

↓ fibroid size & related sxs

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106
Q

What

A
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107
Q

what are natural tx for myomas?

A

green tea, vit D, ground flaxseed, probitocs, enzymes, fasting, calcium d-glucurate, DIM, castor oil, sitz bath,

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108
Q

what are the surgical options for tx of myoma?

A

Hysteroscopic myomectomy, Endometrial ablation, Abdominal hysterectomy, vaginal hysterectomy, supracervical
hysterectomy, Myomectomy, hysteroscopic resection, laparoscopic myomectomy, Laproscopic myolysis, laproscopic bipolar uterine artery coagulation, embolotherapy, MRI guided focused US surgery

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109
Q

What of the following is an effective contraceptive method?
a. condoms
b. spermicides
c. vaginal ring
d. contraceptive implant

A

vaginal ring

110
Q

Which is the most effective contraception?
a. IUD
b. oral contraceptives
c. injectable contraceptives
d. diaphrgam

A

IUD

111
Q

Which is the least effective?
a. cervical caps
b. transdermal
c. IUD
d. sterilazation

A

cervical caps

112
Q

which of the following is NOT an example of a LEAST effective form of contraception?
a. diaphragm
b. cevrical caps
c. condoms
d. spermicides
e. withdrawal
f. period of abstience
g. vaginal ring

A

vaginal ring

113
Q

which of the following is NOT an example of an effective form of contraception?
a. condoms
b. injectable
c. oral
d. transdermal
e. vaginal ring

A

condoms

114
Q

which of the following is NOT an example of a MOST effective form of contraception?
a. IUD
b. implant
c. sterliazation
d. withdrawal

A

withdrawal

115
Q

Which contraceptive method has the highest percentage of unintended pregnancies and why?
a. condoms
b. cervical cap
c. oral contraceptive
d. transdermal system

A

oral contraceptives

116
Q

What is LARC?
a. Long-Acting Reversible Contraception
b. Long-Acting Reusable Contraception

A

Long-Acting Reversible Contraception

117
Q

Which contraceptives fall under LARC?
a. intrauterine contraception
b. OCPs
c. contraceptive implants
d. a and c

A

intrauterine contraception, contraceptive
implants

118
Q

At an office visit for contraception what is necessary for you as a provider to convey to your patient to ensure successful use of the method that is chosen?
a. proper use
b. risks and side effects
c. if backup method is required for emergencies or since initiating it
d. all

A

a. proper use
b. risks and side effects
c. if backup method is required for emergencies or since initiating it

119
Q

What are the characteristics of the contraceptive methods with the highest typical failure rate?
a. require daily use
b. require use right before sex
c. require no work
d. a and b

A

a and b

120
Q

What is important to include in the shared decision making process of the interviewing time regarding contraception?
a. explain the different methods and the proper use of each
b. help identify what the patient is looking for in regards to contraceptive
c. have the patient diecide and start method following CDC guidlines
d. all

A

all

121
Q

What are some important aspects for the promotion of health equity especially in the context of contraception?
a. shared decison making
b. asking the patient about what they want
c. remebering that there is historical trauma related to contracetpion and BIPOC populations
d. all

A

all

122
Q

What history is important to attain in the interview for contraception?
a. PMH (medical, surgical, ob, GYN, STI, problems with contraceptives in the past)
b. partner status, frequency of intercourse
c. FMH (vascular, cancer)
d. all

A

all

123
Q

What physical exam is required in order to provide hormonal contraception? (Choose two)
a. BP
b. gyn exam
c. pap, culture
d. BMI

A

BP and BMI

124
Q

What are the advantages of Fertility Awareness Based Methods?
a. to avoid and detect pregnancy
b. to detect imparied fertility
c. to detect a need for medical attention
d. offers protection against STI

A

ofers protection against STI

125
Q

What are the disadvantages of Fertility Awareness Based Methods?
a. offers no protection against STIs
b. hard to use if you don’t have regular cycles
c. higher risk of getting pregant
d. can’t detect impaired fertility

A

can’t detect impaired fertility

126
Q

When would Fertility Awareness Based Methods not be indicated?
a. irregular cycles
b. inability to interpert fertility signs correctly
c. peristent reproductive tract infx
d. all of the above

A

all

127
Q

What dose Fertility Awareness Based Methods consist of?
a. knowing what day they are most fertile
b. counting days and recodring length of last several cycles and calculate fertile days
c. observation of fertile signs such as vaginal discharge, basal body temp, and LH surge
d. all of these could be the patients method

A

all of these could be the patients method

128
Q

What is the goal of Fertility Awareness Based Methods?
a. using body indicators to determine the fertile time to avoid sex during those times
b. using body indicators to determine the fertile time to get pregnant
c. using body indicators to determine the fertile time to track cycle
d. none of the above

A

using body indicators to determine the fertile time to avoid sex during those times

129
Q

What factors make Fertility Awareness Based Methods more challenging?
a. Recent childbirth
b. Current breast feeding
c. Recent menarche
d. Recent D/C of hormonal contraceptive method
e. Approaching menopause
f. all of the above

A

all of the above

130
Q

Which of the following is non-contraceptive benefit of condoms?
a. protection from HIV
b. reduces risk of PID
c. protection of female fertility
d. all of the above

A

all of the above

131
Q

What is the MOA of condoms?
a. capture seminal fluid and sperm within device
b. kill sperm and seminal fluid
c. prevent fertilization
d. barrier to seminal fluid and sperm

A

capture seminal fluid and sperm within device

132
Q

What are considerations for proper use of condoms?
a. Avoid use with oil-based lubricants and petroleum jelly only use water-based lubricants with latex
b. Cannot be stored at high temperatures
c. Need to be handled gently to avoid damage and applied properly, leaving a reservoir at the tip of the penis
d. Must be used correctly, consistently, and must withdraw the penis immediately after intercourse
e. all of the above

A

all of the above

133
Q

Which contraception has a lower typical use rate for pregnancy than condoms?
a. IUD
b. spermacides
c. withdrawal
d. diaphragm

A

IUD

134
Q

What is the typical use likelhood of pregnancy for condoms?
a. 13
b. 7
c. 0.2
d. 0.7

A

13

135
Q

what is the MOA of diaphragm?
a. barrier to the ascent of sperm from the vagina into the uterine cavity and sperm death
b. capture seminal fluid and sperm within the device

A
136
Q

what is the MOA of diaphragm and cervical caps ?
a. barrier to the ascent of sperm from the vagina into the uterine cavity and sperm death
b. capture seminal fluid and sperm within the device
c. killing sperm
d. binds to sperm and blocks motility

A

barrier to the ascent of sperm from the vagina into the uterine cavity and sperm death

137
Q

Do diaphragms and cervical cap need to be fitted by a health care provider?
a. true
b. false

A

true

138
Q

What are the potenital contraindications to the diaphragm?
a. Pelvic relaxation with uterine prolapse
b. Cystocele and/or rectocele
c. Sharply anteverted or retroverted uterus
d. Shortened vagina
e. Poor muscular tone
f. Prior vaginal injury or toxic shock syndrome
g. all of the above

A

all of the above

139
Q

what are the risks with using diaphrgam?
a. cystitis
b. toxic shock syndrome
c. pregnancy
d. all

A

all of the above

140
Q

what are the sizes possible with a cervical cap?
a. 22 mm
b. 26 mm
c. 30 mm
d. all of the above

A

all of the above

141
Q

what are the contraindication to cervical caps?
a. history of toxic shock syndrome
b. allergy to spermicide
c. pt inability to insert and determine correct postions
d. all of the above

A

all of the above

142
Q

How long can cervical caps and diaphragms be left in and how long do they need to remain in after sex ?
a. 3; 3
b. 48; 24
c. 6; 6
d. 24; 24

A

6; 6

143
Q

what is the typical use faliure rates for cervical caps?
a. 10-15
b. 13-16
c. 23-32
d. b and c

A

b and c

144
Q

What is the benefit of cervical caps?
a. prevents toxic shock syndrome
b. reduces risk of some STIs
c. less UTIs
d. more comfrotable

A

reduces risk of some STIs

145
Q

which of the following is not a risk/disadvantages of cervical cap?
a. vaginal irritation
b. toxic shock syndrome
c. can use during menstruation
d. increase in vaginal discharge

A

can use during menstruation

146
Q

How do you clean diaphrgams and cervical caps?
a. scrub caps
b. rinse with water
c. immerse in cidex plus for 20 min or soak in clorox/water for 30 min
d. all of the above

A

all of the above

147
Q

What are the relative contraindications for the sponges?
a. allergy to ingridents in the sponage
b. pelvic prolpase
c. shortened vagina
d. all of the above

A

all of the above

148
Q

what are the complications associated with the sponage?
a. vaginal irritation or dryness
b. STIs
c. TSS
d. a and c

A

a and c

149
Q

How is the sponage used?
a. moistened with at least 2 tablepsoons of water and squeezed
b. insert the sponge, the patient folds the sides inward toward the dimple (ie, away from the string) and then inserts the device as far back into her vagina as she can reach.
c. pt checks to make sure its in postion
d. all of the above

A

all of the above

150
Q

what is the MOA spermicide?
a. penetrates sperm cell membranes to produce death or loss of motility
b. barrier to the ascent of sperm from the vagina into the uterine cavity and sperm death
c. capture seminal fluid and sperm within the device
d. interfere with normal development or fertilization of ova

A

penetrates sperm cell membranes to produce death or loss of motility

151
Q

what are the contraindications with use of spermacide?
a. HIV pts or those at risk
b. hypersentivity to is
c. Increases UTI
d. all of the above

A

all of the above

152
Q

What is the MOA for phexxi?
a. penetrates sperm cell membranes to produce death or loss of motility
b. barrier to the ascent of sperm from the vagina into the uterine cavity and sperm death
c. capture seminal fluid and sperm within the device
d. maintains an acidic enviroment which immoblizes sperm

A

maintains an acidic enviroment which immoblizes sperm

153
Q

Phexxi need to be applied before every sexual act.
True or False

A

T

154
Q

what are the side effects of phexxi?
a. vulvovaginal burning/itching
b UTIs
c. vaginal yeast infection & BV
d. all of the above

A

all of the above

155
Q

What is the MOA of Nonhormonal Vaginal Contraceptive Ring?
a. ferrous gluconate binds to sperm, blocking sperm motility
b. barrier to the ascent of sperm from the vagina into the uterine cavity and sperm death
c. capture seminal fluid and sperm within the device
d. maintains an acidic enviroment which immoblizes sperm

A

ferrous gluconate binds to sperm, blocking sperm motility

156
Q

what is the time frame that the nonhormonal vaginal contraceptive ring can be in?
a. 7 years
b. before sex and can stay in for 6 h
c. Insert at end of menses & remove at beginning of next menses or after 29 days
d. before sex and can stay in fro 10 h

A

Insert at end of menses & remove at beginning of next menses or after 29 days

157
Q

What IUD’s are available today for contraception
a. Copper
b. Mirena
c. liletta
d. kyleena
e. skyla
f. all of the above

A

all of the above

158
Q
A

Distorted uterine cavity
Pregnancy
Known pelvic tuberculosis
Current breast cancer (for the levonorgestrel-releasing IUD)
Immediate post-septic abortion
Puerperal sepsis
Unexplained vaginal bleeding
Patients with cervical ca awaiting tx, or endometrial ca
Current malignant gestational trophoblastic disease
Hepatocellular adenoma or hepatoma (for the levonorgestrelreleasing IUD)70
Wilsons disease or copper allergy (copper IUC)70
Current purulent cervicitis infxn with CT or GC, or current PID –(IUD’s can be inserted 3 months or longer after resolution of infection)

159
Q

what are the benefits of IUDs?

A

Highly effective pregnancy prevention
Does not require regular adherence from user to maintain high effectiveness
Long acting
Rapidly reversible
Few medical C/I for most women, including teens & nulliparous women.
Few SEs
Private and does not interfere with the spontaneity of sex.
Avoidance of exogenous estrogen (both IUD types) & hormones (copper IUD only).
Reduced cost with long-term use
Reduced risk of cervical, endometrial, & ovarian cancers

160
Q

Which of the following is not a pre-insertion recomendation for IUD insertions?
a. ibuprofen 1 h before or 1M mag phos
b. crampbark extra or tincture 1/2 h to 1 h before
c. paracervical block
d. have sex right before the appointment

A

have sex right before the appointment

161
Q

What tests do you run before inserting the IUD in high risk patients?
a. STI
b. pregnancy
c. CBC
d. a and b

A

a and b

162
Q

Which of the following is not the guidelines around how long copper IUDs last?
a. 10 year pt < 25
b. 12 yrs pt 25-34
c. until menopause if >35
d. all are true

A

all

163
Q

what is the MOA of the copper IUD?
a.Increases leukocyte infiltration, leading to phagocytosis
of sperm
b. impairs sperm migration, viability, and acrosomal reaction
c. interfere with normal development or fertilization of ova
d. all of the above

A

all

164
Q

Who is the best fit for the copper IUD?
a. those who want to avoid exogenous hormones
b. those want to maintain their cycle
c. desire for longer term contraception
d. need emergency contraception
e. all of the above

A

all

165
Q

Which of the following is not a symptoms that a pt should watch out for after getting a copper IUD?
a. having a normal menstrual period
b. experience abnormal discharge or bleeding
c. pelvic pain or fever
d. exposure to STI’s, or cannot feel the string

A

having a normal menstrual period

166
Q

what are the non-contraceptive benefits of copper IUD?
a. reduction of endometrial cancer
b. reduction in cervical cancer
c. reduction in ovarian cancer
d. all

A

all

167
Q

What are the risk/SE of copper IUD?
a. ectopic pregnancies or spontaneous abortion
b. uterine perforation
c. expulsion
d. PID
e. all

A

all

168
Q

what is included in the mangement of IUD strings?
a. pregnancy test
b. bimanual
c. US
d. all

A

all

169
Q

what are the 4 Levonorgestrel-Releasing System?
a. Mirena, Liletta, Kylenna, Skyla
b. Miderna, Liletta, Kylenna, Skyla
c. Mirena, Liletta, Copper, Skyla
d. Mirena, Lilly, Kyla, Skyla

A

Mirena, Liletta, Kylenna, Skyla

170
Q

How long can the mirena be left in as a contraception?
a. 8 yr
b. 6 yr
c. 5 yr
d. 3 yr

A

8

171
Q

How long can the liletta be left in as a contraception?
a. 8 yr
b. 6 yr
c. 5 yr
d. 3 yr

A

6

172
Q

How long can the Kyleena be left in as a contraception?
a. 8 yr
b. 6 yr
c. 5 yr
d. 3 yr

A

5

173
Q

How long can the Skyla be left in as a contraception?
a. 8 yr
b. 6 yr
c. 5 yr
d. 3 yr

A

3

174
Q

When can insertion of IUD occur?
a. first seven days of menses
b. immediately after first trimester abortion
c. It can be inserted at any time as long as pregnancy is ruled out
d. all of the above

A

all of the above

175
Q

Which of the following is not the MOA of Levonorgestrel-Releasing System?
a. thickened cervical mucus to impede sperm from ascending into uterine cavity
b. alters uterotubal fluid to inhibit sperm migration
c. changes in endometrium via decidualization and glandular atrophy impairs implantation and binding of the sperm and egg
d. Increases leukocyte infiltration, leading to phagocytosis of sperm

A

Increases leukocyte infiltration, leading to phagocytosis of sperm

176
Q

Who is the best fit for LNG-IUD?
a. treatment of endometriosis-related pain
b. those who wish to have reduced menstural bleeding
c. those with anemia due to menstural bleeding
d. all of the above

A

all of the above

177
Q

Which of the following is not a risk of LNG-IUD regarding breast cancer?
a. increased risk of reccurance if continuing to use
b. increasded risk of metastaic disease
c. increased risk of developing ductal cell or lobular breast cancer
d. increased risk of developing breast cancer from the LNG-IUD

A

increased risk of developing breast cancer from the LNG-IUD

178
Q

Which of the following is NOT a side effects of LNG-IUD?
a. PID
b. ectopic pregnancy
c. ovarian cyst
d. expulsion

A

PID

179
Q

what are the non-contraceptive benefits of mirena?
a. decreased menstural flow for those with heavy menstural bleed or iron deficency
b. improvement of dysmenorrhea
c. decreases risk for endometrial, ovarian, and cervical cancer
d. all of the above

A

all

180
Q

What is the MOA of testosterone contraceptives?
a. dec hormones of the brain that signal testes to produce sperm
b. increase hormones of the brain that signal testes to produce sperm
c. locally act on sperm to shut down production of sperm
d. locally act on sperm to kill sperm

A

dec hormones of the brain that signal testes to produce sperm

181
Q

when do pt begin the OCP?
a. whenever
b. 1st day of menstural cycle
c. sunday following 1st day of their menstural cycle
d. b and c

A

b and c

182
Q

How long do you need a back up methods when starting OCPs 5 days from start of menstural period?
a. 1 week
b. 2 days
c. 5 days
d. 2 weeks

A

1 week

183
Q

What is the number of OCPs can you miss before needing a back up contraception?
a. 1
b. 2 in a row
c. 1 a month
d. 5 a month but none in a row

A

2 in a row

184
Q

What are the non-contraceptive health benefits of OCPs?
a. reduced risk of ovarian cancer and endometrial cancer
b. reduction in menstural blood loss
c. reduction in ectopic prgenacy
d. reduction in PID
e. benign breast disease
f. improved acne
g. all of the above

A

all

185
Q

what is the mecahnism of OCps reducing ovarian cancer?
a. supression of ovulation, decreased frequency of injury to ovarian capsue and suppression of gonadotropins
b. reduction in mitotic activity of endometrial cells d/t
progestin effect
c. likely due to stabilization effect of estrogen and progestin on the endometrium
d. increases SHBG

A

supression of ovulation, decreased frequency of injury to ovarian capsue and suppression of gonadotropins

186
Q

What is the MOA behind endometiral cancer reduction from OCPs?
a. suppression of ovulation
b. reduction in mitotic activity of endometrial cells d/t
progestin effect
c. from suppression of ovulation, decreased frequency of
injury to ovarian capsule and suppression of gonadotropins
d. progestin induced changes in cervical mucous making it
thick and viscou

A

reduction in mitotic activity of endometrial cells d/t progestin effect

187
Q

what is the MOA behind OCPs reducing ectopic pregnancy?
a. reduction in mitotic activity of endometrial cells d/t
progestin effect
b. suppression of ovulation
c. progestin induced changes in cervical mucous making it
thick and viscous
d. stabilization effect of estrogen and progestin
on the endometrium

A

suppression of ovulation

188
Q

what is the MOA behind OCPS reducing PID?
a. stabilization effect of estrogen and progestin
on the endometrium
b. progestin induced changes in cervical mucous making it thick and viscous so bacteria can not enter, reduced menstrual flow, and possible changes in uterine contractility so organisms cannot ascend
c. suppression of ovulation
d. increases SHBG

A

progestin induced changes in cervical mucous making it thick and viscous so bacteria can not enter, reduced menstrual flow, and possible changes in uterine contractility so organisms cannot ascend

189
Q

What is the MOA behind OCPs reducing menstural disorders?
a. progestin induced changes in cervical mucous making it thick and viscous so bacteria can not enter, reduced menstrual flow, and possible changes in uterine contractility so organisms cannot ascend
b. increases SHBG
c. suppression of ovulation which inhibits breast cell
proliferation
d. stabilization effect of estrogen and progestin
on the endometrium

A

stabilization effect of estrogen and progestin
on the endometrium

190
Q

What is the MOA behind OCPS reducing benign breast disease?
a. stabilization effect of estrogen and progestin on the endometrium
b. suppression of ovulation which inhibits breast cell proliferation
c. increases SHBG that binds and decreases available
testosterone
d. reduction in mitotic activity of endometrial cells d/t
progestin effect

A

suppression of ovulation which inhibits breast cell proliferation

191
Q

what is the MOA behind OCPs reducing acne?
a. increases SHBG that binds and decreases available testosterone. May suppress 5-alpha reductase. Suppression of gonadotropins results in decreased testosterone
b. suppression of ovulation
c. stabilization effect of estrogen and progestin on the endometrium
d. reduction in mitotic activity of endometrial cells d/t progestin effect

A

increases SHBG that binds and decreases available testosterone. May suppress 5-alpha reductase. Suppression of gonadotropins results in decreased testosterone

192
Q

What are the SE/risks associated with OCPs?
a. cardiovascular events (atherosclerosis, MI, stroke, peripheral arterial disease)
b. venous thromboembolism
c. breast cancer and cervical cancer
d. all of the above

A

all

193
Q

Which of the following is NOT a minor side effect of OCPs?
a. SLE
b. AUB
c. breast tenderness
d. weight loss

A

weight loss

194
Q

a. hx of CVD or high risk of DVT, PE, stroke, coronary/ichemic heart disease, valvular disease, clotting disorder
b. DM, liver disease, SLE, surgery w/ immbolization
c. breast cancer, Lactation or less than 6 wks postpartum, pregancy
d. mirganies with aura
e. smoking and >35
f. all

A

all of the above

195
Q

What drugs are interfere with OCPs?
a. Antibiotics
b. Anti-fungals (fluconazole - diflucan)
c. Anti-convulsants
d. Cholesterol lowering agent (cholfibrate)
e. Sedatives and hypnotics
f. all of the above

A

all

196
Q

Why is hypericum not indicated fro those on OCPS?
a. interfere with efficacy induces cytochrome P450, which may increase COC metabolism and reduce therapeutic efficacy
b. makes pts more depressed
c. it is indicated
d. increseas estrogen

A

interfere with efficacy induces cytochrome P450, which may increase COC metabolism and reduce therapeutic efficacy

197
Q

Why is DIM not indicated for those that take OCPS?
a. interfere with efficacy induces cytochrome P450, which may increase COC metabolism and reduce therapeutic efficacy
b. increase breakdown of estrogen in liver
c. increases estrogen levels
d. they are indicated

A

increase breakdown of estrogen in liver

198
Q

Licorice, garlic, milk thistle, saw palmetto, Vit C, caffeinated green tea, and grapefruit are limited in those who take OCPS becuase they increase estrogen levels
True or False

A

True

199
Q

What is Natazia used for?
a. contraception
b. heavy menstural bleeding
c. endometriosis and PCOS
d. all of the above

A

all of the above

200
Q

what kind OCP is Natazia?
a. quadriphasic Estrogen/Progestin
b. monophasic Estrogen/Progestin
c. biphasic Estrogen/Progestin
d. triphasic Estrogen/Progestin

A

quadriphasic Estrogen/Progestin

201
Q

What dose Drospirenone-containing pills increase risk for?
a. PID
b. VTE and ATE
c. cervical cancer
d. PCOS

A

VTE and ATE

202
Q

What are the relative CI for OCPs?

A

Postpartum less than 21 days
Lactation 3wks
pts with other risk factors for VTE 4-6 wk Undiagnosed/abnormal uterine bleeding
Malabsorptive bariatric surgery
HTN/uncontrolled
Past hx. breast CA with no evidence of recurrence for 5 yrs
Gallbladder disease
drug use that may affect liver enzymes
Migraine w/o aura
Age ≥ 35 yo and smoking < 15 cigarettes/day
Superficial venous thrombosis (acute or hx)
IBD with risk factors for VTE

203
Q

what dose Yasmin impve?
a. PMDD
b. PMS
c. PID
d. a and b

A

a and b

204
Q

What dose Yazmin contain?
a. 30 mcg ethinyl estradiol and 3 mg progestin drospirenone
b. 40 mcg ethinyl estradiol and 3 mg progestin drospirenone
c. 3 mcg ethinyl estradiol and 6 mg progestin drospirenone
d. 50 mcg ethinyl estradiol and 60 mg progestin drospirenone

A

30 mcg ethinyl estradiol and 3 mg progestin drospirenone

205
Q

What are the specific CI for Yasmin and Yaz?
a. chronic renal disease
b. PMS
c. chronic NSAID use
d. a and c

A

a and c

206
Q

What are examples on shorter pill-free intervals?
a. Yaz
b. Loestrin 24
c. Alesse
d. a and b

A

a and b

207
Q

What are continuous OCPs used for?
a. PMDD
b. PID
c. endometriosis
d. PCOS
e. dysmenorrhea
f. endometrial hyperplasia, thrombosis, breast cancer, & future fertility
g. all of the above

A

all

208
Q

What are examples of continuous OCPS?
a. Yaz 20mcg of EE and 3mg of drospirenone
b. Seasonale 30 mcg EE & levonorgestrel 150 mcg
c. Lybrel 20 mcg EE & levonorgestrel 90 mcg
d. b and c

A

b and c

209
Q

What are shorter pill-free OCPs used for?
a. PCOS
b. PMS
c. PMDD
d. endometriosis

A

PCOS

210
Q

Which older patients can take OCPS safely?
a. those with increased risk of VTE or CVD
b. those that smoke
c. those that have DM or large body habitus
d. healthy with non of the above

A

healthy

211
Q

what OCP is recommended for older pt?
a. Loestrin FE
b. Yaz
c. Mircette
d. Mononessa

A

Loestrin FE

212
Q

What is WHO top-tier method for contraception for older folx?
a. IUD
b. implants
c. sterilization
d. all of the above

A

all of the above

213
Q

Which of the following statemens is False about stopping contraception?
a. Nonhormonal method - < 50 yr stop after 2 yr amenorrhea, ≥ 50 yr stop after 1 yr amenorrhea
b. Progestin-only method -<50 or ≥ 50 yr can be continued to 55 yr or switched to nonhormonal method & stop after 1 yr amenorrhea
c. Estrogen-containing method - <50 or ≥ 50 yr – can be continued to age 55 yr if no CV risk factors, or switch to nonhormonal method & stop after 1 yr amenorrhea.
d. all of the above are true

A

all of the above

214
Q

How is Xulane and Twirla applied?
a. Apply a new patch every 7 days for 3 wks followed by a patch-free wk
b. same patch for 3 weeks followed by a patch-free week
c. apply a new patch every 14 days for 4 weeks
d. apply a new patch every day

A

Apply a new patch every 7 days for 3 wks followed by a patch-free wk

215
Q

Xulane and Twirla patches works for women of all sizes
True or False

A

False (>90 kg X and BMI >25 for T)

216
Q

what are the the CI for Twirla?
a. >30 BMI
b. RF for VTE
c. PCOS
d. a and b

A

a and b

217
Q

What are the SE of Twirla patch?
a. VTE
b. arterial thrombosis
c. breast tenderness and dysmenorrhea
d. all of the above

A

all

218
Q

How long is vaginal ring worn and when?
a. 3 weeks and druing all ADLS
b. 5 years and during all ADLs
c. 4 weeks and druing exercise
d. 3 weeks and only during sex

A

3 weeks and druing all ADLS

219
Q

Dose the vaginal ring need to be inserted by a heathcare professsional?
a. yes
b. no

A

no

220
Q

When do Pt insert the vaginal ring and how long do you need aback up method ?
a. prior or in 1st 5 days of menses, use back-up method for 7 days after initiation
b. after menses and need back up method for 1 day
c. prior or in 1st 5 days of menses, use back-up method for 1 days after initiation with d/c of hormonal contraceptive method
d. a and c

A

a and c

221
Q

What are SE for vaginal ring?
a. VTE and arterial thrombosis
b. wt gain, nausea, h/a, sinusitis & URI
c. vagnitis
d. all of the above

A

all of the above

222
Q

What are CI for progestin only contraceptives?
a. Past or current breast cancer
b. Cirrhosis
c. Use of anticonvulsants
d. Bone loss
e. all of the above

A

all of the above

223
Q

What is the MOA of Depo-Medroxyprogesterone acetate?
a. suppression of ovulation → dec gonadotropins surge, thickening cx mucus, thins endometrium
b. changes in cervical mucus & tubal motility
c. Suppresses ovulation by diminishing GnRH hormone and eliminating luteinizing hormone release mid-cycle
d. Suppression of ovarian folliculogenesis via suppression of FSH

A
224
Q

Combined Oral Contraceptives MOA is
a. Suppresses ovulation by diminishing GnRH hormone and eliminating luteinizing hormone release mid-cycle
b. Suppression of ovarian folliculogenesis via suppression of FSH
c. Progestin component effects the endometrium, rendering it less suitable for implantation
d. Changes consistency of cervical mucous (thickening)
which decreases ability of sperm to penetrate due to
progestin component
e. all of the above

A

all of the above

225
Q

What are the non-contraceptive benfits of Depo-Medroxyprogesterone acetate?
a. red ectopic preg
b. dec endometiral cancer
c. dec cickle cell crisis
d. all of the above

A

all

226
Q

What are the AE for Depo-Medroxyprogesterone acetate?
a. dec bone mineral density
b. menstural pattern alterations and weight gain
c. mood changes and depression
d. all of the above

A

all of the above

227
Q

What are the SE and non-contraceptive benefits of the mini-pill?

A

irregular spotting and occastional amenorrhea
dec endomertial cancer

228
Q

What are the progestin-only contraceptives?
a. Depo-Medroxyprogesterone acetate
b. Mini-pill
c. Implants
d. Progesterone Vaginal Ring
e. all of the above

A

all

229
Q

Where is the implant/Nexplanon placed?
a. arm
b. uterus
c. thigh
d. calf

A

arm

230
Q

What is the MOA of the Nexplanon implant?
a. changes in cervical mucus & tubal motility are unfavorable to sperm migration, inhibiting fertilization. At high doses, progestins also inhibit gonadotropin secretion, thereby inhibiting follicular maturation and ovulation
b. suppression of ovulation → dec gonadotropins surge, thickening cx mucus, thins endometrium
c. Suppresses ovulation by diminishing GnRH hormone and eliminating luteinizing hormone release mid-cycle
d. suppression of ovulation, decreased frequency of
injury to ovarian capsule and suppression of gonadotropins

A

changes in cervical mucus & tubal motility are unfavorable to sperm migration, inhibiting fertilization. At high doses, progestins also inhibit gonadotropin secretion, thereby inhibiting follicular maturation and ovulation

231
Q

What are the SE/AE of Necplanon Implant?
a. Irregular bleeding
b. H/a, breast tenderness
c. wt gain, abdominal pain, acne
d. all of the above

A

all of the above

232
Q

What are CI for Nexplanon implant?
a. known or suspected pregancy
b. hepatic tumor or active liver dz
c. Undiagnosed abnormal genital bleeding
d. Known or suspected breast cancer or history of breast cancer
e. Hypersensitivity to any components of the implant
f. all

A

all

233
Q

What are CI for Nexplanon implant?
a. known or suspected pregancy
b. hepatic tumor or active liver dz
c. Undiagnosed abnormal genital bleeding
d. Known or suspected breast cancer or history of breast cancer
e. Hypersensitivity to any components of the implant
f. all

A

all

234
Q

When is Levonorgestrel or estrogen/levonorgestrel combination most effective?
a.72 h after unprotected sex
b. 5 days after unprotected sex
c. 120 h after unprotected sex
d. a and c

A

a and c

235
Q

When is Copper IUD and LNG 52 mg IUD most effective?
a. 72 hour after unproetected sex
b. 507 days after unproteced sex
c. 5-7 days after unprotected sex
d. 120 h after unprotected sex

A

5-7 days

236
Q

Can emergency contraceptives interrupt an existing preganacy?
a. yes
b. no

A

no

237
Q

Which emergency contraception is most effective for preventing pregnancy?
a. IUD
b. Yuzpe method
c. Levonorgestrel
d. ulipristal

A

IUD

238
Q

Which of the following is NOT an advantages of male vasectomy?
a. Safer than female sterilization
b. More easily performed
c. More expensive than female sterilization
d. Does not require gen’l anesthesia

A

More expensive than female sterilization

239
Q

What are the disadvantages of male vasectomy?
a. No protection against STI’s
b. Procedure permanent
c. sperm abnormalities postvasectomy and inc risk for CVD and protsate cancer
d. all of the above

A

all

240
Q

What are RF for STIs?

A

New sex partner in past 60 days
Multiple sex partners or sex partner with multiple concurrent sex partners
Sex with sex partners recently treated for an STI111
No or inconsistent condom use when not in a mutually monogamous sexual partnership
Trading sex for money or drugs
Sexual contact (oral, anal, penile, or vaginal) with sex workers
Meeting anonymous partners on the internet
Young age (15 to 24 years old)
Men who have sex with men (MSM)
History of a prior STI
HIV-positive status
Pregnant women
Admission to correctional facility or juvenile detention center
Illicit drug use

241
Q

What STIs do women age < 25 need to be screened for?
a. chlamydia & gonorrhea annually
b. HIv at least once
c. Screen for syphilis, trichomoniasis, HBV, and HCV if at increased risk
d. all of the above

A

all of the above

242
Q

What STIs do women >25 yo need to be screened for?
a. HIV at least once
b. gonorrhea, chlamydia, syphilis, trichomoniasis, HBV, and HCV if at increased risk
c. gonorrhea and chlamydia annually
d. a and b

A

a and b

243
Q

What STIs are women who are pregnant screened for?
a. genital chlamydia, syphilis, HIV, HBV, HCV (only if high risk), and gonorrhea at first trimester
b. repeat screening for genital chlamydia, syphilis, HIV, HBV, and gonorrhea if high risk third trimester
c. HIV + women screened for trichomoniasis at first trimester
d. all of the above

A

all

244
Q

What STIs are women who are pregnant screened for?
a. genital chlamydia, syphilis, HIV, HBV, HCV (only if high risk), and gonorrhea at first trimester
b. repeat screening for genital chlamydia, syphilis, HIV, HBV, and gonorrhea if high risk third trimester
c. HIV + women screened for trichomoniasis at first trimester
d. all of the above

A

all

245
Q

What STIs do women who are HIV + need?
a. chlamydia, gonorrhea, trichomoniasis, and syphilis annually
b. HCV at least once
c. HBV and HAV at first vist
d. all

A

all

246
Q

What STIs do HIV - men who have sex with women need to get tested for?
a. HIV at least once
b. screen for gonorrhea, chlamydia, syphilis, HBV, and HCV if at increased risk
c. HAV annually
d. a and b

A

a and b

247
Q

What STIs do HIV - MSM need to be tested for?
a. genital chlamydia, rectal chlamydia, genital gonorrhea, rectal gonorrhea, pharyngeal gonorrhea, syphilis, HIV, HCV at least annually
b. HAV and HBV at first vist
c. More frequent screening (every 3 months) for chlamydia, gonorrhea, syphilis, and HCV is recommended in those with risk factor
d. all of the above

A

all of the above

248
Q

What STIs do HIV + MSM need to get tesed?
a. genital chlamydia, rectal chlamydia, genital gonorrhea, rectal gonorrhea, pharyngeal gonorrhea, syphilis, and HCV at least annually
b. HAV and HBV at first vists
c. More frequent screening (every 3 months) for chlamydia, gonorrhea, syphilis, and HCV is recommended in those with risk factor
d. all of the above

A

all of the above

249
Q

What STIs do HIV + MSW need to be tested for?
a. genital chlamydia, genital gonorrhea, and syphilis annually
b. HBV and HCV at first visit
c. all of the above

A

all of the above

250
Q

What are the indications for hepatitis C virus?

A

Clinical suspicion: Clinical or biochemical evidence of chronic liver disease (eg, persistently elevated alanine aminotransferase), Porphyria cutanea tarda, Mixed cryoglobulinemia, Lichen planus, Necrolytic acral erythema, Unexplained arthritis or false positive rheumatoid factor, Sjögren’s syndrome/sicca symptoms, Membranoproliferative glomerulonephritis, Idiopathic thrombocytopenic purpura
**History of illicit injection or interanasla drug use **
Receipt of potentially contaminated blood products
Belonging to a higher prevalence group (boomers, HIV, chronic hemodiaylsis, incarceration)
**Other potetial exposure to HCV **

251
Q

What is the management of positive STI tests?
a. health department notification
b. partner notification
c. rescreening and retesting
d. all of the above

A

all of the above

252
Q

How can you prevent HIV infection?
a. PEP
b. PrEP
c. condoms
d. all of the above

A

all of the above

253
Q

What are sign/sx of HIV?
a. candida vaginits recurrent at least 4 episodes per year
b. abnormal cervical cytology
c. PID and genital ulcer disease
d. menstrual abnormalities
e. all of the above

A

all

254
Q

What is the pathogenesis of gonorrhea?

A
  1. adhernce to columnar or pseudostratified epithelium, mucus membranes lined by columnar, cuboidal, or noncornified epithelial cells
  2. organism is transported into epithelial cells,
    then submucosal tissues
  3. Release of endotoxins from GC after attachment damages the ciliated & nonciliated cells of fallopian tube epithelium
255
Q

What are the RF for gonorrhea?

A

Minority ethnicity & young age
New sex partner
Multiple sexual partners
Low socioeconomic status
Substance abuse
Early onset of sexual activity
Unmarried marital status
Past hx of GC infection
Prostitution

256
Q

When do genital symptoms of gonorrhea develop in women?
a. 12 day after exposure
b. 20 after exposure
c. 10 days after exposure
d. w/in 10 days after exposure

A

w/in 10 days after exposure

257
Q

What is the** typical** manifestation of gonorrhea?
a. vaginal mucopurulent d/c, dysuria, and pruritus
b. intermenstrual bleeding & HMB/prolonged menstrual bleeding
c. pelvic pain, abdominal pain
d. deep dypareunia

A

vaginal mucopurulent d/c, dysuria, and pruritus

258
Q

How dose gonorrhea present in the cervix?
a. normal or inflammed with mucopurulent d/c
b. ectopy can be edematous, erythematous, and friable
c. most common site
d. all of the above

A

all of the above

259
Q

How dose gonorrhea present in urethra?
a. dysuria
b. urgency
c. frequency
d. all of the above

A

all

260
Q

What non-genital tract manifestations of gonorrhea?
a. pharyngitis
b. conjunctivitis
c. all of the above

A

all

261
Q

What are other genital tract manifestations of gonorrhea?
a. bartholinitis
b. PID
c. proctitis
d. all of the above

A

all

262
Q

What are complications of gonorrhea?
a. PID and bartholin gland abscess
b. Complications of pregnancy (chorioamnionitis, PROM, preterm birth, low birth weight or small for gestational age infants, SAB)
c. perihepatitis and disseminated GC
d. all of the above

A

all of the above

263
Q

What is Disseminated Gonococcal Infection?

A

Bacteremia stage – (50% of pts will have + blood cultures) chills, fever, typical skin lesions (small vesicles) → pustules → hemorrhagic base, → center becomes necrotic, occur on volar surface of upper extremities, hands & digits (occur 50%-75% of 13 cases) & asxs joint involvement – most often affecting knee, elbow, wrist, ankle & metacarpal asymmetrically & migratory. Tenosynovitis occurs in 2/3 of pts – hands, wrists & ankles.

Late stage – frank arthritis with permanent joint damage, endocarditis, meningitis, pericarditis, osteomyelitis, & perihepatitis.

264
Q

How do you diagnosis gonorrhea?
a. NAAT (nucleic acid amplification) either as a swab or urine collection
b. Serological testing
c. viral PCR

A

NAAT (nucleic acid amplification) either as a swab or urine collection

265
Q

What is the treatment for gonorrhea?

A

a. Ceftriaxone (high-dose) 500 mg IM if < 330 lbs and 1 g if > 330 lbs
b. Doxycycline 100 mg bid x 7 days –orally
c. Azithromycin 1 gm po
d. Cefixime-800mg po

266
Q

Which of the following is true regarding care after testing postive for gonorrhea?
a. Avoid sexual activity until 7 days following tx initiation and patients should only resume having sex after sxs have resolved & sex partners have been treated
b. testing for HIV
c. tested fro pregnancy
d. all of the above

A

all of the above

267
Q

What are the naturopathic treatment for gonorrhea?

A

modified fast
EHB, Optibiotic, Biovegetarian
alternating sitz baths
warming socks
castor oil pack
probiotics
vaginal lactobacillus
homeopathy
undas

268
Q

What is the pathogenesis of chlamydia?

A

an obligatory intracellular bacterium – depends on host cell for nutrients & energy and exists in 2 forms:
Elementary body – infectious particle capable of entering the cell
Reticulate body – multiplies by binary fission within the host cell
Reticulate body then forms new elementary bodies – 48-72 hr the cell bursts with release of elementary bodies

269
Q

what are the RFs for chlamydia?

A

Young age - < 25 yo85 Especially < than 20 yo
Hx CT infection is a highly predictive factor for newly detected infection, probably because it identifies persons at high risk for reinfection from a previously untreated sex partner or from a new partner involved in the same sexual network as the original source partner
New partner or more than one sexual partner in past 3 mos.
Hx of a different STI including HIV, is assoc with higher risk of CT
Low socioeconomic status
Nonwhite race93
Douching
Use of nonbarrier methods of contraception or inconsistent condom use

270
Q

What are the symptoms associated with chlamydia?
a. asymptomatic
b. mucopurlent discharge

A
271
Q

Which of the following describes level 1 of pelvic support?
a. terosacral/cardinal ligament complex
b. paravaginal attachments along the length of the vagina to the superior fascia of the levator ani & the arcus tendinous fascia pelvis
c. erineal body, perineal membrane, & superficial & deep perineal muscles which support one third of the vagina
d. result in urethral hypermobility, posteriorly, a distal rectocele or perineal decent

A

terosacral/cardinal ligament complex

272
Q

What is level 2 of pelvic support?
a. terosacral/cardinal ligament complex contributes to prolapse of the uterus and/or vaginal apex
b. paravaginal attachments along the length of the vagina to the superior fascia of the levator ani & the arcus tendinous fascia pelvis contributes to anterior vaginal wall prolapse (cystocele)
c. erineal body, perineal membrane, & superficial & deep perineal muscles which support one third of the vagina
d. result in urethral hypermobility, posteriorly, a distal rectocele or perineal decent

A

paravaginal attachments along the length of the vagina to the superior fascia of the levator ani & the arcus tendinous fascia pelvis contributes to anterior vaginal wall prolapse (cystocele)

Fall Y3 (10 decks)

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