17 GYN Flashcards Preview

STEP 2CK Review > 17 GYN > Flashcards

Flashcards in 17 GYN Deck (56):
1

You see an adnexal mass on U/S
how to think about it in:

-premenstrual
-reproductive age
-postmenopausal

-ovarian CA (germ cell) until proven otherwise
-Simple cyst, vs complex cyst (many possibilities)
-ovarian CA (epithelial) until proven otherwise

2

Types of incontinence (3) main ones
-dx
-tx

1. stress--'sneeze and pee,' no nocturia. multiple births. Give pessary, surgery

2. urge (hypertonic)--urge and nocturia. Antispasmodic--anticholinergic (oxybutynin)

3. overflow (hypotonic)--no urge, yes nocturia. Neurogenic cause (trauma, diabetes, MS). Bethanechol/doxazosin, cath.

3

Structural abnormality causing vaginal bleeding
-DDx
-differences on exam
-how to workup

fibroids--asymmetric enlarged uterus
polyps--normal
adenomyosis--symmetric enlarge uterus

Start with transvag U/S. Best MRI
Possible bx if r/o CA

4

MTX for ectopic, criteria (4)

1. B-HCG <8000
2. <3cm
3. no fetal heart tones
4. no folate supplementation

No rupture.

5

"grape-like" structure in vagina

2 things:
-Vaginal adenoCA from DES use in mom

-molar pregnancy can also have grape-like mass in vagina

6

Cervical CA screening
-immunocompetent, different ages
-immunocompromised

q3y 21-29
q3y or q5 PAP +HPV testing, 30-65
65 stop if no abnormal screens before

start at sex onset

7

MCC pre-menarchal bleeding in young girl

foreign body

do speculum exam under anesthesia

8

vulva: "porcelain-white" lesions, itchy
think what, do what

Think lichen sclerosis
Bx to r/o SCC
steroids

9

spontaneous abortion, completed.
-do what for patient (4)

-U/S to make sure all products gone
-track B-HCG to 0
-give OCPs
-give Rhogam

10

TOA
-how to tx

Give Abx first (Amp-Gent-MTZ)
GNR: Amp-Gent, or Cipro
Anaerobes: MTZ, or Clinda

surgery not always necessary

11

Red vulvar lesion

Pagets.
Bx to confirm, then Local resection

12

abortion types (5)
os
passage of products
U/S

Vag Bleeding
threatened--os closed, no passage, live baby
inevitable--os open (or about to), no passage, dead baby
incomplete--os open, yes passage, retained parts
complete--os closed, yes passage, empty uterus

Missed--os closed, no passage, dead baby still inside

13

Primary amenorrhea
-how to approach, DDx, big picture

Think 2 things: Does pt have functional axis, and does she have the anatomy to bleed from (uterus)?

yes, yes--imperforate hymen, anorexia, stress
yes, no--mullerian agenesis, AIS
no, yes--Turners, Kallmans, Craniopharyngeoma

Physical exam for axis (breast buds, axillary hair)
U/S for anatomy, looking for uterus

14

Choriocarcinoma
-where to find mets

lung, brain

15

Endometriosis
-3 sxs to know

-dyspareunia
-dysmenorrhea
-infertility!

16

post-menopausal female with ascites, but no liver dz.
Think what

epithelial ovarian CA

17

Couple can't have a child
-when is it considered 'infertility'
-describe workup

infertility: >1y trying
blame man first (test for ED, semen)
then woman: bad mucus, anovulation, anatomy, endometriosis

18

Pt with Postmenopausal bleeding. you get endometrial sample. Do what for:

-simple hyperplasia, atypia
-complex atypia, dysplasia, or adenocarcinoma

-conservative, tx with Progesterone

-TAH-BSO. If mets add chemo

19

Choriocarcinoma
-how to dx
-tx (2)

elevated B-HCG, look at U/S
stage with CT
worry about liver/brain mets!

1. suction curretage (not D+C)
2. If mets, 'MAC" MTX, actinomycin, cyclophosphamide

20

Vulvar lesion:
what is use of acetic acid?

Put it on, if lesion turns white, it is HPV condyloma acuminatum.

Many tx: imiquimod, cryo, etc

21

Simple vs complex ovarian cyst
-what is difference
-tx
-what if already on OCPs

Simple: smooth, fluid filled, <7 cm.
Complex: loculated, >7cm, already on OCPs, not resolved in 2 months

Simple: rU/S in 3-4 mo, Should resolve.
OCPs don't really help, as previous thought

Complex: CT
If simple cyst found and pt already on OCPs, go straight to CT. Higher risk for malig. This is not simple cyst anymore, it is complex.

22

Rectocele
-what does this cause

rectum falls foward into vaginal space
-constipation. Pt can push finger into vagina to press on rectum to push stool. (Transvag digital compression)

23

menopause
perimenopause
menopausal transition

definitions

average age menopause
when too early

3 common sxs

What labs

1. 1 year+ after last menses occured
2. time period from onset of menstrual iregularity to start of menopause
3. same as perimenopause

average: 51. too early:40

hot flashes, vaginal dryness, mood swings

High FSH is dx, somewhat high LH

24

menopausal woman with hot flashes
-possible to tx? what to avoid

can use Venlafaxine (SNRI)
-avoid hormone replacement therapy (endometrail CA)

25

CAH
congenital adrenal hyperplasia
-what test
-which type MCC, how present

screening test: 17 OH Progesterone

21 OH-lase def. neonate with hypoNa, hyperK, hypotension. Both aldo and cortisol shunted.

26

Secondary amenorrhea,
-how to do full workup after first step of r/o 4 initial causes

Test the HPO axis, going backwards.

1. Progestin challenge (can endometrium bleed?)
If bleed, then anovulation

2. E+P challenge
If bleed, normal uterus.
If no bleed, then endometrial dysfxn (eg Ashermans)

3. LH, FSH
If high, then ovarian dysfxn--menopause or Savage (check for follicles on U/S)
If low, then central issue--pit problem, MRI

27

Fibroids
-tx options (3)

1. If mom wants to get pregnant, do surgery (myomectomy)
2. TAH if mom does not want to get pregnant
3. Leuprolide to shrink if too big for surgery

28

Pap smear comes back:
-ASCUS
-Abnormal

-do what

ASCUS: get HPV test or rPAP in 3 mo if age21-24. If either abnormal, do colpo

Abnormal: do colpo

29

Post partum hemorrhage
-management
-what blood vessels to ligate, what order?

1. massage
2. meds--oxytocin, transfuse
3. surgery (ex-lap)
-uterine a 1st to ligate
-then, internal iliacs
-then, TAH!

30

Missed abortion
-how to remove dead baby/products?

<24 weeks: D+C/suction
>24 weeks: induce

31

Female sexual development order, what ages?

"boobs, pubes, grow, flow" 8,9,10,11
8--breast
9--axillary hair
10--growth spurt
11--menarche

32

DUB dysfunctional uterine bleeding
-tx in emergency
-tx

Anovulation.
Even without firm dx, if life threatening bleeding, use IV estrogen.

OCPs and NSAIDs (paradoxical. NSAIDs block prostglandins)
-endometrial ablation possible too

33

-Risk of ectopic:

-normal risk
-hx of ectopic
-hx of ectopic, with salpingostomy
-hx of ectopic, with salingectomy

1%

all others 15%

34

female with LMP 4 weeks ago. Has had N/V for past 3 weeks and can't keep anything down. UPreg+, TSH normal, orthostatics+

Think what

Hyperemesis gravidarum
-Do U/S, look for possible mole (snowstorm)

35

chlamydia tx:
if can't do doxy, use what

azithro

36

Vulvar cancers and their tx
(3)

what is lichen sclerosis

1. SCC (MCC)
2. Melanoma
both get vulvectomy and LN dissection

3. Paget's --"red lesion," local resection

Lichen sclerosis is premalignant SCC, very itchy. Also dx by bx, use steroids

37

Cystocele
-what does this cause
-dx
-how to tx

bladder falls into vaginal space
Stress incontinence

Q-tip sign or anterior prolapse

Kegels and Pessary to strengthen pelvic floor, eventual surgery

38

Cervical CA screening finds CA
-what txs
-what if pregnant

If only ectocervical, not endo, can do local destruction only: LEEP, Cryo, laser

If both ecto and endo, do both local destruction and Cone Bx

If pregnant, no cone bx (wait til after pregnancy). can still do LEEP, cryo

39

PCOS
-tx (4 meds)

These 2 first line:
OCPs--reset axis, induce regular cycles
metformin--this improves PCOS in addition to the DM. mech unknown why

spironolactone--androgen i
clomiphene--induce ovulation

40

Vaginal infections and their tx (3)

Candida--topical fluconazole (suppository), then systemic
BV--topical MTZ, then systemic
Trich--oral MTZ both partners

41

Ovarian CA tumor markers

Dysgerminoma
Endodermal sinus (yolk sac)
CC
teratoma

epithelial CAs

LDH
AFP
B-HCG
none

CA-125

42

Young female with hx of Hodgkin's presents with urinary incontinence.
Think what
how to dx

Crohn's fistula? from radiation treatment
Inject dye into bladder to see where it ends up

43

Precocious puberty in female
-when to suspect, what is danger?
-how to workup?

You see breast buds or axillary hair <8y
Danger: misses growth spurt if early menarche

1. wrist XR: + if >2y above age
2. Leuprolide stim test.

If LH/FSH increase, then central cause. MRI for pit tumor. If no tumor, then "constitutional"and give continuous leuprolide

If LH/FSH no change, look outside HPO axis for estrogen production. (ovaries, adrenal, etc)

44

When to work up primary amenorrhea?

if girl doesn't:
-develop 2nd sex by age 13 (axillary hair, breast buds)
-menarche by 15

45

Asherman's syndrome
Savage syndrome

Asherman's--scarring from sloughed off endometrium
Savage--resistant ovary syndrome

46

PCOS
-dx

no real criteria:
LH/FSH>3
DM
high Testosterone and DHEA

47

Post-coital bleeding
-think what

cervical CA

in post-menopausal, probably vaginal atrophy

48

which type of ovarian CA category worst?
-how present? what 3 sxs to know? (3)
-who at risk, what to do for them

epithelial ovarian CA
-peritoneal seeding. can present with renal fail, SBO, ascites. usu present late stage.

BRCA1/2 at risk. Screen with CA-125 and transvag U/S q6mo. Do ppx TAH-BSO at 35. PPx mastectomy at any age.

HNPCC also at risk.

49

Young female, sex worker, presenting with abd pain x12h. High fever, N/V, SIRS+. Exam has CMT+, left adnexal tenderness, no mass.

-do what

Acute PID. Inpatient because toxic. Ceftriaxone/cefotetan and doxy. Outpt if not SIRS/toxic

Why not TOA? in real life would do U/S to r/o. If TOA or chronic PID, use amp-gent-mtz

50

adenomyosis
how is it described

enlarged, smooth, symmetrical uterus

think endometriosis of myometrium

51

Toxic shock syndrome
-what 2 signs to remember about it

In addition to high fever, N/V/Diarrhea:

-erythematous macular rash
-desquamation of palms/soles

52

Secondary amenorrhea
-What 4 causes to r/o on initial workup?

Just like prolactinoma workup

1. pregnancy? UPreg
2. Prolactin
3. hypothyroidism (high TRH increases prolactin)
4. DA blockers

UPreg, prolactin level, TSH

53

During TAH, what can get mistaken for ureters and get cut?

uterosacral ligaments

54

Menopause
-before what age pathologic
-what labs

<40 is not normal
high LH, FSH. absent follicles on U/S

55

Uterus: 3 ligaments to know
-their clinical correlations

1. suspensory lig. Ovarian torsion--these get torsed, with the ovarian a and v contained in them
2. uterosacral lig. Mistaken for ureters
3. Cardinal lig. ('Pelvic Floor'). Get loose with pregnancy and birth. Can cause: uterine, bladder, and rectal prolapse.

56

Endometriosis
-how to dx, what steps

1st, turn off LH/FSH axis with continuous Leuprolide. See if sxs go away

2. then, dx scope laparscopy for confirm, with laser ablation