CH5: Gynecologic, Reproductive, and Sexual Disorders Flashcards

Question

How do you conduct progesterone challenge test

Answer 1

medroxyprogesterone acetate (Provera) 10 mg PO QD x 10 days. Bleeding should occur within 7-14 days, which indicates adequate estrogen production and stimulation, as well as no problem with the outflow tract. If no bleeding occurs in 2 weeks, will need further evaluation with FSH/LH tests.

Answer 2

FSH and LH If FSH/LH low ... likely hypothalmic or pituitary cause If FSH/LH high... likely ovarian failure/menopause

Answer 3

hypothalmic or pituitary cause

Answer 4

premature ovarian failure/menopause

Answer 5

anovulation

Answer 6

- perimenopause - pregnancy - HPO axis abnormalities - endocrine disorders (thyroid, adrenal) - chronic illnesses - extreme stress or exercise, particularly those causing weight loss - drug use

Answer 7

pregnancy test, TSH, prolactin, FSH/LH

Answer 8

- medroxyprogesterone acetate (MPA) x10 days of each month | - or combined hormonal contraceptives

Answer 9

combination of heavy menstrual bleeding (>80mL blood loss per month) and prolonged menstrual bleeding (bleeding episodes lasting >8 days)

Answer 10

leiomyoma (fibroid), adenomyosis, endometrial or endocervical polyp, endometrial hyperplasia, endometrial or cervical cancer

Answer 11

von Willebrand disease, ideopathic thrombocytopenia purpura, aplastic anemia, platelet dysfunction, clotting factor deficiencies

Answer 12

liver disease, kidney failure, adrenal hyperplasia, thyroid dysfunction

Answer 13

anticoagulants, anticonvulsants, antipsychotics, digitalis, copper IUD, chronic NSAID or aspirin use, tamoxifen,

Answer 14

``` STRUCTURAL: PALM Polyps Adenomyosis Leiomyoma Malignancy/hyperplasia ``` NON-STRUCTURAL: COEIN Coagulopathy Ovulatory dysfunction (PCOS, thyroid, endocrine) Endometrial (inflammation, infection, vasoconstriction disorder) Iatrogenic (medications, devices) Not yet classified (rare disorders, like arteriovenous malformations)

Answer 15

- pregnancy test - pap test as needed - STI test as needed - CBC - TSH ADDITIONALLY - - FSH/LH (to evaluate estrogen stimulation, rarely indicted) - endometrial evaluation if >40yo (biopsy, TVUS, saline infusion sonohysteroscopy) - coagulation studies as indicated

Answer 16

- NSAIDs | - tranexamic acid

Answer 17

Start at menses onset and continue for 5 days or until cessation of menstruation. Works by increases the ratio of vasoconstrictive prostaglandins to vasodilating prostaglandins

Answer 18

this is an antifibrinolytic agent that blocks the lysis of fibrin clots. Take up to the first 5 days of menses. Works to decrease blood loss in folks who have increased endometrial plasminogen activity. Side effects include nausea, leg cramps. Contraindicated in folks with h/o or at risk for thrombosis/clots

Answer 19

- parenteral estrogen or high-dose oral estrogen gradually tapered, then MPA added last 10 days to initiate a withdrawal bleed (UTD: Premarin 2.5mg BID - 4x daily until bleeding is minimal [no more than 21 days] followed by MPA 10mg x 10 days to have a withdrawal bleed) - high-dose oral progestin therapy, gradually tapered (UTD: norethindrone 5mg QD-BID or MPA 10mg -20mg QD-BID for 5-10 days) According to UpToDate: First-line therapy for hemodynamically stable women is high-dose oral estrogen. We give ****Premarin 2.5 mg four times per day until the bleeding subsides or is minimal.**** For women with moderate bleeding, we change the regimen to twice daily. We do not continue this regimen for more than 21 to 25 days. After the estrogen is discontinued, a progestin should be given; we use oral medroxyprogesterone acetate (10 mg/day) for 10 days. Estrogen therapy alone is more effective than combined estrogen-progestin or progestin-alone therapy Also okay to use the OCPs they are already taking! High doses of oral contraceptives (OCs) (eg, an OC containing 35 mcg ethinyl estradiol taken two to four times daily) will cause bleeding to subside in most women within 48 hours [2,17]. We use a cascading regimen (ie, five pills on day 1, four pills on day 2, three pills on day 3, two pills on day 4, and one pill on day 5). For women with moderate bleeding, we start with three pills daily. An antiemetic medication should be prescribed (eg, promethazine 12.5 to 25 mg per rectum, as needed). Treatment with one pill daily of OCs should continue for at least one week after the bleeding subsides and then should be stopped for three to five days to allow for a withdrawal bleed. Standard dose OCs may then be restarted either to prevent recurrent menorrhagia or for contraception.

Answer 20

- LNG-IUD (FDA approved indication) - combined hormonal contraceptives (cyclic, extended, or continuous regimens) - DMPA

Answer 21

- endometrial ablation - dilation & curettage (D&C - both diagnostic and therapeutic) - hysterectomy

Answer 22

a symptom complex associated with menstrual irregularity due to oligo-ovulation or anovulation and clinical or biochemical signs of hyperanrogenism

Answer 23

No - approximately 25% of normal females will demonstrate ultrasonographic evidence typical of polycystic ovaries

Answer 24

6-7% of reproductive-age females

Answer 25

endometrial cancer, diabetes mellitus, heart disease

Answer 26

- irregular menses (amenorrhea or infrequent bleeding) (>90%) - gradual onset hirsutism in puberty or early 20s (50-70%) - other signs of androgen excess (acne, deep voice, male pattern baldness - 15 to 25%) - infertility - abdominal obesity (50-60%) - acanthosis nigricans, skin tags in neck area

Answer 27

hirsutism, increased muscle mass, frontal balding, clitoral enlargement, deepening voice, decrease in breast size

Answer 28

- pregnancy test - serum prolactin - serum TSH - biochemical hyperandrogenism (serum total testosterone and SHBG OR bioavailable and free testosterone) - serum 17-hydroxyprogesterone (17-OHP) (PER ANNIE: THIS IS NORMAL IN PCOS, ELEVATED IN NCCAH. IN BOOK: >800 ng/dL suggests PCOS; elevated but <800 think congenital adrenal hyperplasia) - endometrial biopsy to r/o hyperplasia - TVUS to assess ovaries - glucose, lipids

Answer 29

at least 2 of the 3 following must be present in an adult female: - oligo-ovulation or anovulation - clinical or biochemical hyperandrogenism - polycystic ovaries

Answer 30

letrozole. If ineffective, refer to reproductive endocrinologist

Answer 31

direct therapy towards preventing endometrial hyperplasia and pregnancy - low dose combined hormonal contraceptives with low-androgenicity progestins (i.e., drospirenone) will inhibit LH secretion and LH-dependent ovarian androgen production, increase SHBG of free testosterone, regulate menstrual cycles, and protect against endometrial cancer - progestin-only contraceptives will provide contraception and prevent against endometrial cancer

Answer 32

focus on preventing endometrial hyperplasia - endometrial biopsies as needed - MPA for 10 days of month to induce a withdrawal bleed, can be used every month or Q2-3 months - may consider metformin use as insulin-sensitizing agent - monitor for development of diabetes, hyperlipidemia, obesity

Answer 33

eflornithine HCl topical cream

Answer 34

the presence of endometrial stroma and glands outside of the uterus

Answer 35

general estimate: 7-10% of premenopausal folks - found in 5-15% of surgeries performed on reproductive age females - found in up to 30% of infertile females during surgery

Answer 36

- 20-30 years of age - caucasian - nulliparous

Answer 37

endometriosis

Answer 38

MOST COMMON - dysmenorrhea - infertility - premenstrual spotting - heavy menstrual bleeding - pelvic pain - dyspareunia LESS OFTEN - low back pain - diarrhea - dysuria - hematuria - difficult or painful defecation - rectal bleeding * symptoms classically occur before or during menses

Answer 39

- fixed, retroverted uterus - bilateral fixed, tender adnexal masses - nodularity or tenderness of uterosacral ligaments and cul de sac - tenderness, thickening, or nodularity of the rectal-vaginal septum - cervical motion tenderness associated with menses - visible lesions on laparoscopy

Answer 40

Direct visualization with laparoscopic procedure is the only means of confirmation. Otherwise, US cannot demonstrate a specific pattern but could possibly be used to differentiate solid vs. cystic lesions and help distinguish an endometrioma from other adnexal abnormalities. CT and MRI can provide only presumptive evidence and are not diagnostic. CA125 levels may correlate with degree of disease or response to treatment, however, they are not diagnostic because of low sensitivity and specificity

Answer 41

There is no universal/sure cure. The goal is to relieve pain, restore fertility (as desired), and prevent progression

Answer 42

- analgesics (NSAIDs are first line) - continuous use of combined oral contraceptive pills produces atrophy of the implants and an acyclic hormone environment - GnRH agonists or danazol may induce regression of endometrial implants (more aggressive, menopausal symptoms likely) - progestins like IM DMPA or SQ 104 DMPA - laser surgery or hysterectomy with BSO

Answer 43

Benign condition where ectopic endometrium is found within the myometrium, or muscle layer. This is sometimes considered a subtype of endometriosis

Answer 44

estimates vary greatly, ranging from 10-90% of hysterectomies. Diagnosis is most common in parous females between 40-50yo

Answer 45

1. increasingly severe dysmenorrhea and heavy bleeding during menses 2. infertility

Answer 46

1. boggy, tender uterus 2. diffuse, globular enlargement - may be 8-10 weeks gestation size 3. may see evidence of anemia

Answer 47

US and/or MRI may rule out other pathologies and an endometrial biopsy is important in cases of AUB, however, can only be definitively diagnosed upon hysterectomy

Answer 48

Symptomatic treatment options include NSAIDs for pain, hormone suppression to alleviate symptoms, hysterectomy is curative

Answer 49

Benign tumor of the pituitary. Most common type of pituitary adenoma secretes prolactin (>50%)

Answer 50

Incidence is unknown. Most pituitary adenomas occur in folks younger than 40yo.

Answer 51

- spontaneous discharge from unilateral or bilateral nipples that is clear or milky - irregular menses or secondary amenorrhea - visual disturbances and/or headaches (if adenoma)

Answer 52

May be no remarkable findings. Possible to have milky nipple discharge or papilledema on fundoscopic exam

Answer 53

- pregnancy test - TSH - serum prolactin - microscopy of nipple secretions - CT or MRI brain to r/o adenoma

Answer 54

prolactin elevated if >20ng/mL, refer to reproductive endocrinologist. If 100-300 ng/mL, this is very suspicious for adenoma.

Answer 55

follow with yearly prolactin level monitoring

Answer 56

Lifestyle = decrease breast stimulation Medication = dopamine agonist BROMOCRIPTINE or CABERGOLINE, because dopamine inhibits prolactin. This provides symptomatic relief, decreases or stops galactorrhea, is the treatment of choice with highest cure rate. Surgery = for failed medical management only, may consider transphenoid neurosurgery with recurrence rate of 10-70%, requires close follow-up Radiation = reserved only for recurrences or refractory cases, may take several years before results seen with declining prolactin levels

Answer 57

Pendunculated growth arising from the mucosal surface of the endocervix

Answer 58

4% of gyn patients; most common of the benign neoplasms of the cervix. Most commonly seen in peri-menopausal, multigravida folks between ages 30-50 years old

Answer 59

Considered benign. Malignant changes are rare.

Answer 60

inflammation, trauma, pregnancy, abnormal local response to a hypoestrogenic state

Answer 61

may be asymptomatic or may have abnormal vaginal bleeding including intermestrual and post-coital

Answer 62

May be single or multiple painless polypod lesions at the cervix that range in size from a few mm up to 2-3 cm. They are usually reddish-purple to cherry red in color, smooth, soft, and bleeds easily. Pelvic exam will otherwise be normal

Answer 63

Cancer, prolapsed myoma (fibroid), retained products of conception

Answer 64

Send removed polyp for histologic evaluation to rule out cancer. A pap test can rule out premalignant cervical lesions or cancer of the cervix.

Answer 65

May be removed which is usually curative. Do not remove during pregnancy. Cervical polyps recur frequently

Answer 66

Aka leiomyoma, leiomyomata, myoma A nodular, discrete tumor varying in size rom microscopic to large, multiple nodular masses which are classified according to location: submucosal, subserosal, intraligamentous, intramural (interstitial), pedunculated. Most common benign pelvic neoplasm

Answer 67

- submucosal: protrude into the uterine cavity - subserosal: bulge through the outer uterine wall - intraligamentous: within the broad ligament - intramural (interstitial): stays within the uterine wall as it grows, most common form - pedunculated: on a thin pedicle or stalk attached to the uterus

Answer 68

intramural (interstitial) - within the uterine wall

Answer 69

The etiology is largely unknown. They may arise from smooth muscle cells of the myometrium.

Answer 70

20% of gyn patients in reproductive years. Although, asymptomatic fibroids may be found in as many as 40-50% of females >40yo. More common in African American than Caucasian females. There is also an increased incidence with family history

Answer 71

Usually asymptomatic. If symptoms, most commonly see heavy or prolonged menstrual bleeding, pelvic pain/pressure, dyspareunia. May cause acute pain if pedunculated/twisted/infarcted. May cause bowel and bladder problems if large and pressing on surrounding structures

Answer 72

heavy, prolonged menstrual bleeding

Answer 73

may not be detectable. Or, may have abdominal enlargement, an enlarged irregularly shaped or displaced uterus, a pedunculated tumor may be seen protruding from the cervix. Tumors are usually painless on palpation. There is a wide variance in size from 3-4mm up to 15lbs

Answer 74

spontaneous abortion, premature labor, anemia, infertility

Answer 75

- pap test to exclude cervical cancer (if visible protrusion) - pregnancy test (if AUB or enlarged uterus) - CBC (if heavy menstrual bleeding or anemia suspected) - fecal occult blood test (if colon or rectal symptoms present) - endometrial biopsy or D&C (for AUB) - US, sonohystogram, CT, or MRI to confirm the diagnosis - hysteroscopy if need to visual inside of uterine cavity

Answer 76

May not require any treatment if asymptomatic. May be useful to have periodic bimanual examination to ensure no growth or abnormal changes. Medical and surgical options may be considered if symptomatic. Medical: aimed at reducing growth and bleeding Surgical: removal of whole or part of fibroid and/or uterus

Answer 77

- progestin agents may decrease fibroid size and bleeding (i.e., MPA) - combined hormonal contraceptives may help with heavy menstrual bleeding but will not decrease fibroid size - LNG-IUDs (i.e., Mirena) may help with heavy bleeding and decrease dysmenorrhea but will not decrease fibroid size and may be contraindicated if fibroids distort the uterine cavity d/t risk for expulsion - GnRH agonists can reduce fibroid size 40-60% however regrowth occurs 50% of the time and these medications cause significant symptoms including menopause. Best fit for short-term use to shrink fibroid size pre-operatively, before attempting pregnancy, or in folks attempting to avoid surgery - remember to treat underlying anemia as needed

Answer 78

abnormal bleeding, rapid growth, desire for definitive diagnosis of the mass if otherwise uncertain, encroachment on organs, symptoms are not well-managed on pharm therapies

Answer 79

- myomectomy: via hysteroscopic resection, this method is fertility-preserving with a 30% recurrence rate - uterine artery embolization: may not preserve fertility, increases risk of IUGR in future pregnancy, up to 40% recurrence rate - hysterectomy: no fertility, no recurrence

Answer 80

functional (s/t hormonal stimulation), dermoid (benign cystic teratoma - the most common ovarian germ cell tumor)

Answer 81

- follicular: occur in the follicular phase of the menstrual cycle when continued hormonal stimulation prevents fluid resorption - corpus luteum: occurs in the luteal phase, when the corpus luteum fails to degenerate

Answer 82

A type of functional ovarian cyst occurring in the follicular phase of the menstrual cycle that persist when continued hormonal stimulation prevents fluid resorption. They are rare before menarche and after menopause. They are the most common adnexal mass in the reproductive years, accounting for 20-50% of all ovarian cysts. They usually will resolve within 2-3 menstrual cycles which may be unnoticeable or rupture may cause pain or ovarian torsion

Answer 83

A type of functional ovarian cyst occurring when the corpus luteum fails to degenerate after 14 days. May hemorrhage into the cystic cavity.

Answer 84

Aka benign cystic teratoma. They are one of the most common neoplasms of the ovary, occur during the reproductive years. Composed of well-differentiated tissue from all three germ layers. Usually measure 5-10cm in diameter and 10-15% are bilateral.

Answer 85

Usually asymptomatic. They may cause acute pain if twist or rupture. If large, may cause sensation of pelvic pressure or fullness. Rarely cause AUB.

Answer 86

- pregnancy test (r/o ectopic if palpable/pain) - TVUS (evaluates mass for cystic vs. solid, complex vs. simple, bilateral vs. unilateral, r/o ectopic pregnancy) - CA125 may be considered in post-menopausal females though it is NOT diagnostic - MRI may be considered if dermoid cyst is suspected

Answer 87

It is NOT diagnostic and may be considered in post-menopausal patient with ovarian cyst. It is a tumor-associated antigen most commonly used to monitor the clinical status of pts with ovarian cancers. It is not routinely used for evaluation of adnexal masses in PRE menopausal folks because of its low specificity for ovarian cancer, as several other conditions may cause elevated levels. Its specificity and predictive value are consistently higher in postmenopausal folks

Answer 88

If <10cm in diameter and simple features on US, may repeat examination after next menses and/or serial US q4-12 weeks to monitor for resolution. If persists >12 weeks and/or is >10cm or solid/complex features, refer to physician

Answer 89

if <10cm and simple features on US with no concerning symptoms or risk factors for ovarian cancer, and if CA125 <35 U/mL, can perform serial US q4-12 weeks. If persists >12 weeks or if CA125 >35, concerning symptoms or risk factors, or complex/solid features, refer to physician

Answer 90

if it does not resolve on its own, recommend laparoscopic removal

Answer 91

human papillomavirus (HPV)

Answer 92

- tobacco smoking - HPV (most commonly malignant = 16, 18, 31) - early coitus (<18yo) - multiple sex partners - no barrier methods - immunosuppression - long-term oral contraceptive use - infrequent/no pap tests

Answer 93

May be asymptomatic. If symptoms, may have postcoital or irregular painless bleeding, odorous bloody or purulent discharge. Late symptoms could include pelvic or epigastric pain, urinary or rectal symptoms.

Answer 94

The cervix may range from normal to having ulcerated, necrotic, or large bulky lesion filling the vagina. The cervix may be firm or rocklike to soft and spongy. There may be bloody, purulent, or odorous vaginal discharge. Anemia may be present if bleeding heavily.

Answer 95

- pap test is the gold standard for screening - biopsy any gross cervical lesions - If malignancy is suspected but there is no gross lesion visible, suggest colposcopy with biopsy - colposcopic evaluation of the vulva and vagina to rule out other lesions - CT, MRI, cystoscopy, sigmoidoscopy, and barium enema may be used as indicated

Answer 96

anticipatory guidance regarding surgery, radiation, chemotherapy, or combination treatments. Refer to gynecologic oncologist

Answer 97

endometrial cancer -- 90-95% of malignancies of the uterine corpus are endometrial cancer

Answer 98

63yo, only 5% of cases occur <40yo

Answer 99

estrogen, particularly unopposed estrogen (either endogenous or exogenous)

Answer 100

- early menarche or late menopause - unopposed estrogen therapy - oligo-ovulation or anovulation - obesity - estrogen-secreting tumors (granulosa cell tumor) - family history of endometrial or CRC cancer - personal history of CRC cancer, diabetes, or HTN

Answer 101

depo provera, OCPs, multiparity

Answer 102

painless vaginal bleeding is typically the first symptom. May start with serous (watery) odorous discharge, soon replaced by bloody discharge with intermittent spotting to steady, painless bleeding followed by hemorrhage. Lower abdominal pain present in 10% of cases

Answer 103

May be none in early stage. May see blood present in the vaginal vault. Advanced disease may present with a pelvic mass or ascites. Uterus may be enlarged and soft. Anemia may be present with heavy blood loss

Answer 104

- pap test may demonstrate glandular abnormalities - endometrial aspiration biopsy - TVUS to measure endometrial stripe with risk for endometrial cancer rare if <5mm - if work-up is non-conclusive and symptoms persist, fractional D&C is the gold standard for diagnosis - hysteroscopy may be considered for identifying lesions or polyps not otherwise found on biopsy

Answer 105

Anticipatory guidance for likely surgical treatment, usually hysterectomy recommended. Surgical staging will determine adjuvant treatment which may include radiation, chemotherapy, progesterone/steroids, or combination. Refer to gynecologic oncologist

Answer 106

epithelial ovarian carcinoma accounts for 80-85% of cases

Answer 107

ovarian cancer

Answer 108

5%, and increases with the number of first or second-degree relatives

Answer 109

BRCA 1: 39-4% lifetime risk | BRCA 2: 12-20% lifetime risk

Answer 110

- family history - gene mutations (BRCA, Lynch, Peutz-Jeghers) - h/o breast, colon, or endometrial cancer - early menarche or late menopause (increased estrogen exposure) - nulliparity or birth of first child >30yo - inferility - endometriosis - obesity - postmenopausal HRT

Answer 111

oral contraceptives, with protection lasting up to 2 decades after use. breast feeding

Answer 112

Often asymptomatic or with symptoms that are mild, vague, or inconsistent. May include abdominal discomfort, pressure sensation to bladder or rectum, pelvic fullness or bloating, vague GI symptoms. Late signs include increasing abdominal girth, abdominal pain, abnormal vaginal bleeding, nausea, anorexia, and dyspepsia

Answer 113

Fixed, irregular, non-tender adnexal mass, possibly bilateral. Ascites. Pleural effusion and subclavicular lymphadenopathy are late signs

Answer 114

- pelvic US with CT or MRI as needed - CA215 levels at baseline are not diagnostic but helpful for following response to treatment - definitive diagnosis is made with laparotomy (surgery)

Answer 115

ovarian cancer, endometriosis, fibroids, pelvic inflammatory infection, hepatitis, other malignancies

Answer 116

Anticipatory guidance regarding surgery typically total hysterectomy with bilateral salpingoophorectomy and omentectomy which establishes histologic staging and grading of the tumor. Will consider chemotherapy and/or radiation with gyn onc. Consider genetic counseling to determine if family members at increased risk and if pt themselves is at increased risk for breast cancer. Refer to gyn onc and high risk genetics.

Answer 117

vaginal carcinoma - 2% of gyn malignancies

Answer 118

mean = 65yo. Range = 30-90yo

Answer 119

persistent HPV with high-risk subtypes, other genital cancers, DES exposure, prior radiation to the area

Answer 120

vaginal intraepithelial neoplasm (VIN)

Answer 121

Stage 1 = 80% | Stage 4 = 17%

Answer 122

vaginal bleeding, odorous or blood tinged discharge, pruritis, palpable or visible mass or lesion, urinary problems if bladder involvement

Answer 123

early lesions appear raised, granular, may be white. Late lesions are friable, granular, and cauliflower-life, may be palpable, may have superficial or deep ulceration. If the lesion is darkly pigmented, suspect melanoma. The most common site of occurrence is the upper 1/3 of the vagina

Answer 124

- pap test to evaluate for cervical cancer - colposcopy and biopsy of the lesion - staging will involve cystoscopy, proctosigmoidoscopy, IV urography, chest radiography, barium enema with CT/MRI to evaluate for metastases

Answer 125

Anticipatory guidance regarding treatment includes laser therapy for pre-cancerous lesions (VAIN I, II, and III). Local excision may be an option for early lesions (partial vaginectomy). Radiation is otherwise the mainstay of treatment. Refer to gynecologic oncologist

Answer 126

High risk HPV infection (30-50% of cases), multiple sexual partners, cigarette smoking, chronic irritation, vulvar dermatoses

Answer 127

squamous cell carcinoma, melanoma, adenocarcinoma, basal cell carcinoma, sarcoma

Answer 128

mean age = 65yo. Range 30-90 yos.

Answer 129

May be asymptomatic. If symptoms, may notice lesion on the vulvar, pruritis, pain, burning, bleeding, odorous discharge that may be blood-tinged

Answer 130

White, red, or irregularly pigmented vulvar lesions that is ulcerated, flat, or wart-like, may be single or multiple. Hyperkeratotic patches (leukoplakia). Excoriation or erythema. Most common sites of involvement are the labia majora and minora. May also see bartholin gland enlargement or inguinal lymphadenopathy

Answer 131

- Pap test, colposcopy can help rule out other sites of disease - Biopsy and wide excision make the definitive diagnosis - CT or MRI to rule out metastasis

Answer 132

Anticipatory guidance regarding treatment which may include local excision, simple or radical vulvectomy, or topical treatments with immunologic agents or chemotherapy. Recurrence is common. Refer to gynecologic oncologist.

Answer 133

a malignant form of gestational trophoblastic disease or may be primary in the ovary. Gestational trophoblastic disease follows any gestational event (i.e., intrauterine or ectopic pregnancy, abortion, hydatiform mole), whereas nongestational choriocarcinoma is a mixed germ cell tumor of the ovary that may occur in childhood or early adolescence.... would be unusual in 20s or 30s. These cancers are disseminated by the blood to the lungs, vagina, brain, liver, kidneys, and GI tract. However, it is one of the few metastatic cancers that can be curable

Answer 134

Symptoms often masquerade as other diseases as a result of metastases to other organs. Strongly suspect if follows a pregnancy event. May have irregular vaginal bleeding (anywhere from intermittent to hemorrhage, or may occur postpartum with uterine subinvolution), or may see amenorrhea (r/t gonadotropic secretion). Lung metastasis may present as hemoptysis, cough, dyspnea. CNS metastasis may present as headache, dizziness, fainting. GI metastasis may present as rectal bleeding or tarry stools, abdominal pain. GU metastasis may present as hematuria.

Answer 135

May have abdominal mass/ascites, blood in vaginal vault, enlarged soft uterus. May see abnormalities of multiple organs if metastatic, including possible vulvar or vaginal metastatic lesion

Answer 136

- quantitative beta HCG. Will see abnormal beta HCG regression titers following a molar pregnancy. - CT scan of abdomen, pelvis, head. Chest radiograph - lumbar puncture may be necessary for diagnosis

Answer 137

Anticipatory guidance that treatment typically consists of surgery and/or chemotherapy. Non-metastatic disease carries a good prognosis and metastatic disease carries a good to poor prognosis. Refer to gynecologic oncologist

Answer 138

An alteration of the normal flora of the vagina (Lactobacillus species) with dominance of anaerobic bacteria. This is the most common vaginal infection in the US for females ages 15-44yo

Answer 139

Lactobacilli are the hydrogen-peroxide producing strains of bacterial flora natural to the vagina during reproductive years. They maintain an acidic environment. A loss in lactobacilli dominance leads to elevated pH (more basic/alkaline) and subsequent overgrowth of other strains of bacteria. Bacterial concentrations are increased 100 to 1000-fold. There is not one specific offending organism, but there are some most common anaerobic strains including Gardnerella.

Answer 140

The textbook says not an STI, but then later goes on to say it can be transferred between female sex partners. It is more common in folks with new or multiple partners, and risk is increased with shared sex toys or douching. BV may also increase the risk for acquiring an STI such as HIV or HSV2

Answer 141

* **gardnerella vaginalis*** - mycoplasma hominis - bacteroides species - haemophilus - mobiluncus - corynebacterium

Answer 142

most often asymptomatic. Otherwise, may experience pruritis (occasionally), a grayish/yellowish/whitish malodorous discharge, a rancid or fishy-odor during menses and after sex

Answer 143

- adherent, homogenous, whitish-gray vaginal discharge - vulvar and vaginal mucosa should appear normal although discharge may coat the vaginal walls and vulva - presence of foul odor

Answer 144

- wet mount of vaginal secretions - pH testing Amsel Criteria is diagnostic (at least 3 out of 4 criteria is diagnostic) + vaginal pH >4.5 + clue cells on saline wet mount >20% of epithelial cells (epithelial cell borders are obscured as a result of stippling with bacteria) + homogenous discharge that is white and coating the vaginal wall + positive "whiff test" demonstrating fishy amine odor to vaginal discharge before or after addition of 10% potassium hydroxide (KOH)

Answer 145

Amsel Criteria Amsel Criteria is diagnostic (at least 3 out of 4 criteria is diagnostic) + vaginal pH >4.5 + clue cells on saline wet mount >20% of epithelial cells (epithelial cell borders are obscured as a result of stippling with bacteria) + homogenous discharge that is white and coating the vaginal wall + positive "whiff test" demonstrating fishy amine odor to vaginal discharge before or after addition of 10% potassium hydroxide (KOH)

Answer 146

blood, semen, trichomonas

Answer 147

an increase in the normal number of WBCs on wet mount

Answer 148

No, cultures for anaerobes are unnecessary at initial evaluation

Answer 149

Treatment is recommended for all pts with symptoms. ORAL: metronidazole (Flagyl) 500mg PO BID x 7 days TOPICAL: metronidazole gel (Metrogel) 0.75%, use one full applicator (5g) intravaginally at bedtime x5 days; OR clindamycin cream 2%, one full applicator (5g) intravaginally at bedtime x7 days For metronidazole use, counsel pt to avoid alcohol until 24 hours after completion of therapy. Side effects may include metallic taste, nausea, headache, dry mouth, dark-colored urine. Clindamycin cream is oil-based and thus may weaken latex condoms or diaphragms if these are being used for contraception. Lifestyle - avoid douching as may increase risk for recurrence.

Answer 150

metronidazole (Flagyl) 500mg PO BID x7 days

Answer 151

- metronidazole gel (Metrogel) 0.75%, use one full applicator (5g) intravaginally at bedtime x5 days - clindamycin cream 2%, one full applicator (5g) intravaginally at bedtime x7 days

Answer 152

- tinidazole 2g PO QD x2 days - tinidazole 1g PO QD x5 days - clindamycin 300mg PO BID x7 days - clindamycin ovules 100mg intravaginally QHS x3 days

Answer 153

If female partner is symptomatic, yes. If male partner, no as will not change course of condition or prevent its recurrence

Answer 154

A vaginal infection caused by trichomonas, an anaerobic flagellated protozoan parasite

Answer 155

increased pH >4.5

Answer 156

increased pH 5.6-7.5

Answer 157

- multiple sex partners - presence of another STI - lack of condom use - sex work - injectable drug use..............?

Answer 158

premature rupture of membranes, preterm labor

Answer 159

intra-amniotic infection, postpartum infection, endometritis

Answer 160

Most males and females are asymptomatic. If symptoms, may describe copious, malodorous, yellow-green discharge with vulvar irritation, pruritis, occasionally dysuria/urgency/frequency. May have intermenstrual bleeding. Symptoms often occur after menses

Answer 161

- erythema, edema, excoriation of the vulva - red speckles "strawberry spots" on the vagina and cervix (punctate lesions) - homogenous watery yellow-green or grayish frothy discharge - vaginal pH >5.0 - friable cervix

Answer 162

trichomoniasis

Answer 163

- saline wet mount is 60-70% sensitive, demonstrates motile trichomonads and an increased number of WBCs - rapid tests on vaginal secretions (10-45 min for results) have great >82% sensitivity and >97% specificity - culture is the only definitive test - urine microscopy may reveal live trichomonads too - if detected on pap test, 40% positive predictive value

Answer 164

- metronidazole (Flagyl) 2g PO 1x alternatively, tinidazole 2g PO 1x OR metronidazole (Flagyl) 500mg PO BID x7 days Counsel to avoid alcohol until 24 hours after finish course of metronidazole. All sex partners should be treated. Offer repeat testing in 3 months for detection of reinfection. If treatment failure, use metronidazole or tinidazole 2g PO QD x7 days. Screen for other STIs as indicated.

Answer 165

metronidazole (Flagyl) 2g PO 1x

Answer 166

Yes, metronidazole crosses the placenta but there has been no teratogenicity or mutagenic effects found in infants. Similarly, metronidazole is secreted in breastmilk but there is no evidence of adverse effects in infants exposed to metronidazole in breastmilk. Some clinicians will defer breastfeeding for 12-24 hours after maternal treatment (2g PO 1x metronidazole).

Answer 167

yeast infection. inflammatory vulvovaginal process caused by a yeast organism (dimorphic fungus), candida, which superficially invades the epithelial cells

Answer 168

Second most common vulvovaginal infection (second to BV). 75% of females will have at least one episode in reproductive years, 45% will have a second episode, and 5% will have recurrent or intractable episodes

Answer 169

85-90% is Candida Albicans (C. albicans) | Remaining infections are usually C. galbrata and C. tropicalis, which are more resistant to therapy

Answer 170

- pregnancy - reproductive years - uncontrolled diabetes - immunosuppressive disorders - frequent intercourse - antibiotic use - high dose corticosteroids

Answer 171

- irritation of vulva, pruritis, soreness, external dysuria - discharge may be thick, curdy, thin/watery, or with yeast odor - dyspareunia upon penetration

Answer 172

- erythema of vulva and vagina - discharge adherent to vaginal wall - cervix will appear normal on speculum exam

Answer 173

- wet mount of vaginal secretions with 10% KOH will demonstrate mycelia, spores, and pseudohyphae - vaginal pH is usually normal (<4.5) and amine whiff test negative - may see increased number of WBCs on wet mount - fungal culture is the confirmatory diagnosis - most often used in cases of frequent recurrence or intractable episodes to determine which candida is causative

Answer 174

Frequent recurrence (i.e., 4+ symptomatic episodes in 1 year) or intractable episodes, as may be an atypical causative species

Answer 175

azole antifungals are more effective than nystatin

Answer 176

fluconazole (Diflucan) 150mg PO x1

Answer 177

MANY OPTIONS! All must be placed INTO the vagina (not just vulvar application) to achieve effect. Overview: primary options include clotrimazole or miconazole, 1%- 4%, 5g intravaginally x3-7 days Creams & Ointments - - clotrimazole 1% cream, 5g intravaginally x7-14 days - clotrimazole 2% cream, 5g intravaginally x3 days - miconazole 2% cream, 5g intravaginally x7 days - miconazole 4% cream, 5g intravaginally x3 days - tioconazole 6.5% ointment, 5g intravaginally 1x Suppositories - - miconazole 200mg vaginal suppository, QD x3 days - miconazole 1200mg vaginal suppository, 1x

Answer 178

if 4 or more symptomatic episodes in 1 year with no predisposing factor, culture to identify if non-albicans candida species is present. Consider longer duration of therapy or a maintenance regimen, as well as intravaginal probiotics.

Answer 179

- azole creams and suppositories are oil-based so they can weaken latex condoms or diaphragms - partner treatment is not routinely recommended (unless male partner has balanitis) - encourage use of cotton underwear

Answer 180

Usually requires a longer (7-14 day) course of topical azoles, or a repeat dose of fluconazole 72 hours after the initial dose

Answer 181

May need longer (7-14 day) course of topical azoles

Answer 182

VVC occurs frequently in pregnancy. DO NOT USE ORAL AGENT. Recommend topical azole therapies applied x7 days.

Answer 183

pneumonia, conjunctivits

Answer 184

most common STI in the US. The cause of up to 50% of pelvic infections. >4 million annually

Answer 185

- cervicitis - endometritis - PID - ectopic pregnancy - infertility - acute urethral syndrome (asymptomatic bacteruria) - postpartum infections - premature labor - premature ROM - perinatal morbidity

Answer 186

- sexually active - <25 yo - multiple partners - no barrier method

Answer 187

May be asymptomatic. If symptoms, may experience: - postcoital bleeding - intermenstrual bleeding or spotting - UTI symptoms (dysuria, frequency) - vaginal discharge - abdominal pain

Answer 188

- mucopurulent endocervical discharge - edematous, tender cervix that bleeds easily (CMT) - suprapubic pain or tenderness on palpation

Answer 189

- NAAT (nucleic acid amplification test) is recommended by the CDC - culture is also possible, but expensive Swab should be collected from the vagina (preferred), endocervix, urine (slightly less sensitive), or from any anatomic site of exposure (i.e., rectal, oropharyngeal) Consider additionally screening for gonorrhea, syphilis, HIV, and wet mount for other vaginal infection

Answer 190

CDC 2015: - azithromycin 1g PO 1x (preferred) - alternatively, doxycycline 100mg PO BID x7 days

Answer 191

first line = azithromycin 1g PO 1x or doxycycline 100mg PO BID x7 days second lines = basically, other options include amoxicillin or erythromycin for 7-14 days - amoxicillin 500mg PO TID x7 days - erythromycin base 500mg PO QID x7 days - erythromycin base 250mg PO QID x14 days - erythromycin ethylsuccinate 800mg PO QID x7 days - erythromycin ethylsuccinate 400mg PO QID x14 days

Answer 192

azithromycin 1g PO 1x Doxycycline should not be used in pregnancy because it can cause discoloration of teeth in children. Erythromycin estolate is also contraindicated in pregnancy because of drug-related hepatotoxicity

Answer 193

- All sex partners within past 60 days should be evaluated, tested, and treated - The most recent sex partner should be evaluated, tested, and treated even if that was >60 days ago - Expedited Partner Treatment (EPT) laws vary by state - Avoid intercourse for 7 days after the single-dose azithromycin treatment, or for the full 7 days of the 7-day other regimens - Recommend return for test of reinfection 3 months after treatment completion - Test of cure is not routinely recommended; can recommend in cases of suspected nonadherence or persistent symptoms. Should wait at least 3 weeks after treatment before completing (as earlier than 3 weeks may have a false negative)

Answer 194

- Recommend test of REINFECTION in 3 months - If compliant with therapy and asymptomatic, no test for CURE is necessary. However, if test of cure is requested, should wait 3 weeks before testing (otherwise may get false negative)

Answer 195

condyloma acuminata

Answer 196

90% of anogenital warts are caused by HPV strains 6 and 11 which are very low risk for malignancy

Answer 197

Sexually-transmitted through skin-to-skin contract during periods of viral shedding. HPV is highly contagious, as 25-65% of partners will have HPV

Answer 198

HPV genital warts/condyloma acuminata

Answer 199

pregnancy, diabetes, steroid hormones, folate deficiency, immunosuppressive diseases (ESRD)

Answer 200

- wart-like lesions of the anogenital region, pedunculated conical or cauliflower appearance that are whitish to pinkish gray, granular, rough texture - lesions may be singular or multiple, may cluster - perianal region may bleed easily and be painful, malodorous, and pruritic

Answer 201

- wart-like lesions (conical, cauliflower appearance) may be single or multiple anywhere on anogenital region - may appear granular or cobblestone - color will vary from pink to gray. If darkly pigmented, have high suspicion for malignancy

Answer 202

- diagnosis can usually be made clinically, by appearance - if uncertain, biopsy of lesion. Also consider biopsy if no response to or worsening during treatment, if the patient is immunocompromised, or if the lesions are dark, indurated, bleeding, or ulcerated - consider swab and serologic testing for other STIs

Answer 203

If untreated, it is possible that it may - resolve on own - persist, remain unchanged - increase in size or number

Answer 204

No treatment has been proven to be better than another, as such, treatment choice should depend on patient preference, availability, and provider experience

Answer 205

- may leave untreated if pt prefers - if treatment desired, goal is to eliminate visible disease and improve symptoms - keep the area clean and dry - advise condom use - offer various provider-delivered (cryotherapy, TCA, surgical removal) or patient-applied (imiquimod, podofilox, sinecatechins) treatments

Answer 206

- cryotherapy using liquid nitrogen; repeat Q1-2 weeks for 6 weeks - trichloroacetic acid (TCA) or bichloroacetic acid 80-90% solution Q1 week for 6 weeks If lesions are not resolved at the end of 6 weeks of treatment, may re-evaluate, change treatment plan, or refer to surgery: - surgical removal with a tangential shave excision, curettage, laser, or electosurgery

Answer 207

cryotherapy is performed with liquid nitrogen every 1-2 weeks for 6 weeks. Liquid nitrogen is applied directly to the vulvar or vaginal lesion with a cotton swab or a fine spray. The treatment is applied for 30 to 60 seconds, until an ice ball forms and encompasses the lesion and 1 to 2 mm surrounding area. Repeated weekly application is required until the lesions have resolved. This destroys wart tissue via cell lysis. Although it is an office procedure, cryoablation causes pain during application and variable localized inflammation afterward. Providing local anesthesia for the procedure is especially important when the area undergoing cryotherapy is extensive. Side effects/adverse reactions include skin irritation, edema, blistering, and ulceration. Posttreatment hypopigmentation is also relatively common. This is safe in pregnancy.

Answer 208

Use trichloroacetic or bichloroacetic acid 80 - 90% soluation. Apply a small amount to the wart using a cotton swab and allow it to dry. It will turn white. Can apply sodium bicarbonate or talc to neutralize or remove the unreacted acid. Application of an ointment or gel (such as petroleum or lidocaine jelly) to the normal tissue surrounding the wart can help prevent spreading of acid to unaffected areas. Do not apply too much as can cause chemical burns of the vulva. Do not sit, stand, or dress until dried. Reapply weekly for 4-6 weeks. 70% clearance rate. This is safe in pregnancy. These are caustic acids that destroy the wart tissue via chemical coagulation of tissue proteins.

Answer 209

- imiquimod 3.75% or 5% cream 3x weekly for 16 weeks - podofilox 0.5% gel or solution BID x3 days, withhold x4 days, then repeat weekly PRN up to 4x - sinecatechins 15% ointment applied TID for up to 16 weeks

Answer 210

- imiquimod 3.75% or 5% cream Apply sparingly to affected area at bedtime, 3x per week. Can use for up to 16 weeks. The area should be washed with mild soap and water in the morning, 6 to 10 hours after application. Safety during pregnancy is unknown

Answer 211

- podofilox 0.5% gel or solution Apply sparingly to visible warts BID for 3 consecutive days, then withhold use for 4 consecutive days. Repeat this cycle weekly for up to 4 weeks. Safety during pregnancy is unknown.

Answer 212

- sinecatechins 15% ointment (green tea derivative) Apply to visible warts TID for up to 16 weeks. Medication should NOT be washed off after use. Safety during pregnancy is unknown

Answer 213

- no resolution after 6 weeks of standard therapy - pt is immunosuppressed - lesions are darkly pigmented, indurated, ulcerated, or otherwise suspicious - biopsy for HPV type and refer - cervical condylomas must rule out HSIL before treatment (pap test)

Answer 214

The patient-applied therapies (imiquimod, podofilox, sinecatechins) should be avoided in pregnancy. May consider wart removal with surgical or ablative provider-administered therapies but complete resolution may not be possible until after pregnancy. Counsel patients that HPV types 6 and 11 (which cause genital warts) can cause respiratory papillomatosis in infants and children, though risk is low

Answer 215

chlamydia trachomatis

Answer 216

neisseria gonorrhea (gram-negative, intracellular diplococcus requiring a carbon dioxide environment to survive)

Answer 217

- pelvic inflammatory disease (PID) - infertility - ectopic pregnancy - septic arthritis - bacteremia - infections of bartholin or skenes glands - perihepatitis - proctitis (rectal inflammation) - eye infection in neonates (vertical transmission) - premature ROM - chorioamnionitis - premature neonate

Answer 218

- sexually active <25yo - multiple partners - inconsistent condom use - history of STI - commercial sex work - illicit drug uce

Answer 219

may be asymptomatic. otherwise, may report: - vaginal discharge - postcoital bleeding - dysuria - vulvar pain (think bartholin or skenes gland infection) - pelvic pain (think PID) - proctitis/anal bleeding (think anal infection) - sore throat (think pharyngeal infection) - joint pain (think septic arthritis, bacteremia)

Answer 220

- mucopurulent endocervical discharge - inflamed skenes or bartholin glands - friable cervix - 20% may have signs of endometritis, salpingitis, or pelvic peritonitis from uterine invasion of infection after menses - septic arthritis or signs of infection at other sites

Answer 221

- NAAT (recommended by CDC 2015) - culture on thayer-martin medium (which would also allow for susceptibility testing if treatment failure is suspected) - concurrent testing for chlamydia, serum syphilis and HIV

Answer 222

CDC 2015: - ceftriaxone 250mg IM 1x AND azithromycin 1g PO 1x (co-treatment for chlamydia) CDC 2020: - ceftriaxone 500mg IM 1x - co-treat for chlamydia ONLY if has not been excluded, and do not use azithromycin (growing resistance). Use doxycyline 100mg BID x7 days

Answer 223

the single-dose IM injection of ceftriaxone is safe to use in pregnancy for gonorrhea. for chlamydia, doxycycline is contraindicated in pregnancy so must use azithromycin

Answer 224

- test of cure is not recommended | - test for reinfection is recommended 3 months following

Answer 225

- avoid sexual intercourse until all partners are treated and asymptomatic - all sexual partners within 60 days of onset should be evaluated and treated, or most recent partner even if >60 days

Answer 226

A common, incurable, chronic, recurrent viral disease commonly sexually transmitted through skin-to-skin contact

Answer 227

HSV-1 is commonly found in the mouth, accounts for only 15% of genital infections. HSV-2 causes 85% of genital infections

Answer 228

yes! asymptomatic vial shedding accounts for the majority of transmission

Answer 229

- h/o STI - multiple sex partners - trauma to skin (portal of entry for virus) - immunosuppressed

Answer 230

- oral or genital lesions - herpes encephalitis - herpes meningitis - diffuse infection in immunocompromised individuals - perinatal infection

Answer 231

Most women with infected neonates had no known history of HSV. Infection is transmitted during labor and birth. The risk for transmission to the neonate is highest if pregnant woman gets the primary infection near the time of birth (30-50% risk) vs. if there is a RECURRENT episode near time of birth (<1% risk)

Answer 232

primary infection -- 66% will have systemic symptoms including fever, malaise, or headache which begins within 1 week of exposure, peaks on day 4, and subsides over the next week. This will be followed by localized genital pain, with a prodrome of pruritis and erythema 1-2 days before appearance of lesions. Lesions may then form as small, painful vesicles over the labia, mons pubis, vagina, and peri-anal area (4-10 days). These vesicles then rupture forming shallow, painful, wet ulcerations that last 1-2 weeks which should heal without scarring. 75% will have associated vaginal discharge 90% will have cervical involvement including vesiculation or easy bleeding Tender inguinal lymphadenopathy may be the last symptom to resolve

Answer 233

May experience the same symptoms as primary infection but should be more mild and shorter in duration. Usually no constitutional symptoms. ``` May expect: - prodrome lasts 1-2 days - vesicles 3-5 days - drying out 2-3 days (6-9 days total) ```

Answer 234

- small, vesicular genital lesions and ulcerations at varying stages of progression - exquisite pain at site of lesion - inguinal lymphadenopathy

Answer 235

- culture collected from the base of the vesicle or ulcer (may have low sensitivity, depending on the stage of the lesion i.e., if closed) - PCR assay is the most sensitive test (rarely used) - type-specific serologic tests (blood test) can identify HSV 1 or 2 antibodies with varying degrees of sensitivity and specificity

Answer 236

HSV1: - blood tests have LOW sensitivity HSV 2: - blood tests have HIGH sensitivity (91-100%) - blood tests have HIGH specificity IF collected 6-12 weeks after initial infection (92-98%) Serologic is MOST useful for identifying HSV2 antibodies, because up to 97% of US females have antibodies to HSV1

Answer 237

there is no definitive cure; virus sticks around forever. Systemic antiviral drugs can suppress symptoms but they do no eradicate the latent virus or affect risk of recurrence, frequency of recurrence, or severity of symptoms once the drug is stopped. Suppressive therapy may be used to reduce viral shedding and rate of transmission to sexual partners, as well as to reduce frequency of recurrence

Answer 238

**valacyclovir (Valtrex) 1g PO BID x7-10 days** - acyclovir 400mg PO TID x7-10 days - acyclovir 200mg PO 5x daily for 7-10days - famiciclovir 250mg PO TID for 7-10 days

Answer 239

initiate treatment during prodrome or within 1 day of lesion onset for most effectiveness ** valacyclovir (Valtrex) 500mg PO BID x3 days ** - valacyclovir (Valtrex) 1g PO QD x5 days - acyclovir 400mg PO TID x5 days - acyclovir 800mg PO BID x5 days - famiciclovir 125mg PO BID x5 days - famiciclovir 1000mg PO BID x1 day - famiciclovir 500mg PO 1x, followed by 250mg PO BID for 2 days

Answer 240

** valacyclovir (Valtrex) 500mg PO QD ** - valacyclovir (Valtrex) 1g PO QD - acyclovir 400mg PO BID - famiciclovir 250mg PO BID

Answer 241

Uninfected pregnant person is at most risk of neonatal vertical transmission at birth if acquires near time of birth. If partner has known HSV, use condoms with all sexual contact when asymptomatic. Consider abstaining when partner has prodrome or active genital lesions, as well as near estimated time of birth. Consider treating partner with suppressive therapy to lower risk of transmission

Answer 242

- acyclovir can be safely used in all stages of pregnancy and lactation - valiciclovir and famicyclovir have limited data but are generally considered low risk - consider using suppressive therapy for pregnant folks with recurrent genital infections starting at 36 weeks gestation - there is no data to support the use of antiviral suppressive therapy for pregnant folks who have been found to be sero-positive for HSV but have never had a clinical outbreak - a c-section should be offered if the pregnant person has an active lesion or prodromal symptoms at the time of labor

Answer 243

- cool topical compresses PRN to reduce swelling and inflammation (i.e., put creams in fridge) - OTC topical burow's solution (5% aluminum subacetate) - topical anesthetics (4% lidocaine cream)

Answer 244

a mildly contagious viral epithelium proliferation of the skin. Caused by virus called molloscum contagiosum, un unassigned pox virus containing double-stranded DNA Transmitted skin-to-skin, fomite, and auto-inoculation Most common in children and young adults

Answer 245

- flesh-colored or white or pink, waxy, smooth, firm, spherical papules - skin lesions contain umbilicated apex with central plug - usually <20 lesions - lesions range in size from pinhead to 2-5mm in diameter - presents on trunk and lower extremities in children; on lower abdomen, inner thigh, pubic area, and genitalia on adults - usually asymptomatic or otherwise may have pain, pruritis, and inflammation

Answer 246

- multiple lesions, usually <20 - lesions are characteristically light-colored with umbilicated center - lesions are found on face, neck, trunk, lower extremities, abdomen, inner thigh, and/or genital area

Answer 247

- typically a clinical diagnosis, biopsy is not usually indicated but may be considered which would demonstrate cytoplasmic inclusions, molloscum bodies - consider testing for other STIs in young adults who are sexually active

Answer 248

- will usually resolve spontaneously without scarring - may offer superficial incision to express contents with comedo extractor - may offer curettage with cautery - for multiple lesions, cryotherapy may be offered with liquid nitrogen or silver nitrate - the above treatments may cause scarring

Answer 249

treponema pallidum bacteria

Answer 250

average 21 days, but may range from 10-90 days

Answer 251

the organism enters skin through microscopic breaks in the skin during sexual contact

Answer 252

1. primary - may be asymptomatic, or painless chancre 2. secondary - systemic symptoms, often mucocutaneous lesions 3. latent - asymptomatic but may be detected by serum testing 4. tertiary - widespread symptoms, nodular lesions, cardiac symptoms, neurosyphilis, serious complications. Not infectious at this point

Answer 253

may be asymptomatic or, may note a painless, ulcerated lesion with raised border and indurated base, rolled edges called a chancre. This may appear anywhere that the point of entry was -- genitals, mouth, anus. Will spontaneously disappear on own in 3-6 weeks May additionally have painless lymphadenopathy

Answer 254

Following resolution of the primary chancre, symptoms become systemic - may begin 4-6 weeks after appearance of the primary lesion, and tends to resolve in 1 week to 2 months. May have a localized or diffuse mucocutaneous rash to palms and soles, may have mucous patches and condylomata lata. May have generalized lymphadenopathy along with flu-like symptoms including low-grade fever, headache, sore throat, malaise, and arthralgias. - highly contagious

Answer 255

Latent stage begins after spontaneous resolution of secondary stage. In this stage, there are no clinical manifestations but infection can be detected by serologic testing. Early latent = within 1 year Late latent = after 1 year May remain latent or may progress to tertiary stage

Answer 256

- characterized by gummas (nodular lesions) involving the skin, mucous membranes, skeletal system, and viscera - Cardiac symptoms, aortitis, aneurysm, or aortic regurgitation - Neurosyphilis may present without symptoms or with nerve dysfunction, acute or chronic meningitis, stroke, tabes dorsalis, meningovascular syphilis, general paralysis, insanity, iritis, chorioretinitis, and leukoplakia - This stage is not infectious

Answer 257

- chancre on the vulva, vagina, cervix, penis, or at any site of organism entry marks primary stage - secondary stage may see generalized maculopapular rash, mucocutaneous lesions, and adenopathy - condyloma lata appear as wart-like lesions on vulva, penis, perianal region, and upper thighs - gummas are characteristic of tertiary stage - appear as nodules that enlarge, ulcerate,and become necrotic

Answer 258

- nontreponemal tests are often the first step -- specifically, the VDRL (venereal disease research laboratory) and/or RPR (rapid plasma reagin)... these are 80-90% accurate in making a diagnosis but are nonspecific - a positive RPR or VDRL test must be followed by a confirmatory treponemal test... these include FTA-ABS (fluorescent treponemal antibody absorption), or a TP-PA (T. pallidum particle agglutination) which are more specific - the treponemal tests (FTA-ABS; TP-PA) tend to remain positive for lifetime, regardless of if treated for syphilis - the non-treponemal tests (VDRL, RPR) titers usually correlate with disease activity, and results should be reported quantitatively

Answer 259

VDRL (venereal disease research lab) | RPR (rapid plasma reagin)

Answer 260

FTA-ABS (fluorescent treponemal antibody absorption) | TP-PA (T. pallidum particle agglutination)

Answer 261

- nontreponemal tests (VDRL, RPR) - treponemal confirmatory test (FTA-ABS, TP-PA) - testing for other STIs including HIV - lumbar puncture makes the diagnosis of neurosyphilis in late latent or tertiary stages

Answer 262

- pregnant people - positive treponemal test - people previously positive/treated who later have a 4-fold rise in quantitative nontreponemal tests - people with uncertain diagnosis with syphilis unable to be excluded - anyone exposed within 90 days preceding the diagnosis of syphilis (any stage) in a sexual partner.... treat this patient presumptively even if sero-negative - anyone who was exposed more than 90 days preceding the diagnosis of syphilis (any stage) in a sexual partner.... treat presumptively if test results are not immediately available and the opportunity for follow-up is uncertain

Answer 263

- serologic testing for syphilis today - treat presumptively d/t unsure follow-up! benzathine penicillin G 2.4 million IM single dose - other STI testing per patient request

Answer 264

* * benzathine penicillin G 2.4 million units IM x1 ** - doxycycline 100mg PO BID x 14 days - tetracycline 500mg PO QID x 14 days

Answer 265

early latent - benzathine penicillin G 50,000 units/kg IM (up to the adult dose maximum of 2.4 million in a single dose) late latent or unknown duration - benzathine penicillin G 50,000 units/kg IM (up to the adult dose maximum of 2.4 million in a single dose) given as three doses at 1-week intervals (total 150,000 units/kg across all 3 doses, up to the adult max cumulative of 7.2 million units)

Answer 266

benzathine penicillin G 7.2 million units total, administered as three separate doses of 2.4 million units IM each at 1-week intervals

Answer 267

same penicillin regimen as not pregnancy (benzathine penicillin G) - pregnant patients who do not have a 4-fold drop in titers after 3-month period need repeat treatment

Answer 268

- may have a higher incidence of neuro involvement and higher rate of treatment failure --> close follow-up is important - serologic test results may be atypical - when the clinical picture is positive but the serologic test is negative, can use biopsy, dark-field, and direct-flourescent antibody staining to confirm

Answer 269

- perform quantitative non-treponemal serologic tests (VDRL, RPR) at 6, 12, and 24 months - expect titers to decline at least 4-fold within 12-24 months follow-up - 4-fold increase in titers at any time indicates inadequate treatment or a new infection (or in pregnancy, a less than 4-fold drop in titers after 3 months needs repeat treatment) - expect treponemal tests (FTA-ABS, TP-PA) to remain positive for most individuals throughout life, regardless of treatment or disease activity - report all cases to proper agency for follow-up of sexual contacts

Answer 270

an acute, contagious, ulcerative bacterial infection caused by haemophilus ducreyi that is sexually transmitted. haemophilus ducreyi is a short, non-motile gram-negative rod and anaerobe that grows in chains known as a school-of-fish pattern Occurs only in a few areas of the US in discrete outbreaks - may be associated with drug use, commercial sex, or acquisition outside of US (most commonly seen in tropical and subtropical climates in regions of Africa and the Caribbean)

Answer 271

may be asymptomatic. if symptoms, - papules or painful ulcerations on the labia, anogenital skin, vagina, and or cervix - may have foul odor - 30-60% of cases will develop bilateral, tender, suppurant inguinal lymphadenopathy (bubo) after 1 week - lesions will resolve in 1-2 weeks if treated; 1-3 months if untreated

Answer 272

- definitive test is culture to identify H. ducreyi, cultere collected from the lesion or bubo. However, may be difficult to isolate on culture and requires a specific medium, sensitivity is <80% - gram stain may reveal gram-negative rods or chains on microscopy - clinical signs are characteristic: + genital ulcers with typical characteristics + regional lymphadenopathy + negative HSV test + suppurant inguinal adenopathy - test for other STIs including HIV, syphilis as indicated

Answer 273

- deep ulcerations with irregular, scalloped borders - bilateral tender suppurant inguinal lymphadenopathy - lesions may be found on the labia, vagina, anogenital skin, or cervix - may have foul odor

Answer 274

Treatment is curative, but may leave scarring in severe cases. CDC (2015) recommends the following options: - azithromycin 1g PO 1x - ceftriaxone 250mg IM x1 - ciprofloxacin 500mg PO BID x3 days - erythromycin base 500mg PO BID x7 days

Answer 275

- yes, re-examine in 3-7 days and re-evaluate plan if ulcerations have not improved

Answer 276

All sex partners within 10 days before the onset of chancroid symptoms should be evaluated and treated

Answer 277

An ulcerative, bacterial STI that causes genital ulceration and inguinal lymphadenopathy that is caused by Chlamydia Trachomatis (subtypes L1, L2, and L3). Very infrequent in the US, endemic in tropical regions, more commonly in males 5:1 ratio males to females

Answer 278

may be asymptomatic. if symptoms, - painless ulcerations that heal within a few days (50%) - tender lymphadenopathy usually occurs 1-4 after ulcer and may be associated with fever, malaise, headache, and myalgias - may have painful bowel movements with blood or pus from the rectum

Answer 279

- painless genital ulceration at the site of inoculation which disappears in a few days - tender inguinal and/or femoral lymphadenopathy, most commonly unilateral - rectal exposure may result in proctocolitis or inflammatory involvement of perirectal or perianal lymphatic tissues, leading to fistulas and strictures

Answer 280

- aspirate from fluctuant lymph node with culture or NAAT will show chlamydia in 50% of cases - serologic testing will demonstrate a titer of more than 1:64 in active disease - CBC demonstrating mild leukocytosis or monocytosis - elevated ESR - screen for other STIs including HIV as indicated

Answer 281

CDC (2015) - doxycycline 100mg PO BID x21 days OR... erythromycin base 500mg PO QID x21 days

Answer 282

should be avoided in the second and third trimesters of pregnancy due to risk of discoloration to fetal teeth and bones doxycycline is compatible with breastfeeding

Answer 283

safe in pregnancy and breastfeeding

Answer 284

yes, follow clinically until all signs and symptoms have resolved

Answer 285

all sex partners within the last 60 days before onset of symptoms should be examined and treated with a chlamydia regimen (azithromycin 1g PO 1x or doxycycline 100mg PO BID x7 days)

Answer 286

A spectrum of inflammatory disorders of the upper female genital tract including any combination of salpingitis, endometritis, tubo-ovarian abscess, and pelvic peritonitis

Answer 287

* * chlamydia trachomatis * * neisseria gonorrhea - polymicrobial infection (may include escheria coli, gardnerella vaginalis, haemophilus influenzae, mycoplasma hominis

Answer 288

infertility, ectopic pregnancy, chronic pelvic pain

Answer 289

- sexually active <20yo - multiple sex partners - h/o PID - chlamydia, gonorrhea, or BV infection - vaginal douching

Answer 290

may be acute or mild - abdominal pain - vaginal discharge - fever - dysuria - dyspareunia - nausea/vomiting - vaginal spotting or bleeding (30%)

Answer 291

``` complaint of pelvic pain AND the presence of ONE or more of the following three findings on physical exam + cervical motion tenderness + uterine tenderness + adnexal tenderness ```

Answer 292

Minimum criteria includes PELVIC PAIN and 1 or more of the following + CMT + uterine tenderness + adnexal tenderness Additional findings that support this diagnosis include + fever (>101F or 38.4C) + mucopurulent cervical or vaginal discharge + abundant WBCs on wet mount microscopy of vaginal secretions + elevated ESR and CRP on labs + NAAT demonstrating diagnosis of N. gonorrhea or C. trachomatis Definitive diagnosis includes ... + endometrial biopsy demonstrating histologic evidence of endometritis, + sonography or other radiographic tests revealing a tubo-ovarian abscess, + and/or laparoscopic examination demonstrating abnormalities consistent with PID

Answer 293

- cervical motion tenderness - uterine tenderness - adnexal tenderness

Answer 294

hospitalization for at least 24 hours to initiate parenteral antibiotic therapy (will include cefotetan AND doxycycline, cefoxitin AND doxycycline, OR clindamycin AND gentamicin)

Answer 295

- ceftriaxone 250mg IM 1x PLUS doxycycline 100mg PO BID x14 days WITH OR WITHOUT metronidazole 500mg PO BID x14 days - cefoxitin 2g IM 1x PLUS probenecid 1g PO administered concurrently in a single dose PLUS doxycycline 100mg PO BID x14 days WITH OR WITHOUT metronidazole 500mg PO BID x14 days

Answer 296

- pregnant - pelvic abscess is suspected - surgical emergency could not be ruled out (ectopic pregnancy, appendicitis) - severe illness including high fever, nausea, vomiting - failure to improve on initial outpatient therapy

Answer 297

follow-up for re-examination within 72 HOURS (3 DAYS) - if not significantly improved, review diagnosis and treatment - consider hospitalization - significant improvement would entail: abatement of fever, reduction in direct or rebound abdominal tenderness, reduction in adnexal or uterine or cervical motion tenderness

Answer 298

All sex partners within the last 60 days before onset of PID symptoms should be evaluated and treated for presumed gonorrhea and chlamydia

Answer 299

hospitalization! pregnant folks with PID are at high risk for maternal morbidity and preterm delivery, need hospitalization for parenteral antibiotics

Answer 300

lichen sclerosus, lichen planus, lichen simplex chronicus

Answer 301

Non-neoplastic disorders of the vulvar epithelium that produce a number of visible changes as well as pain or pruritis that may be severe

Answer 302

Chronic, progressive inflammatory skin condition that primarily affects the perineal and perianal regions. Most common in postmenopausal women. Multifactorial etiology including genetic, familial disposition, and autoimmune components

Answer 303

An inflammatory skin condition manifested in the vulva, vagina, and other mucous membranes of the bone. Typically seen in peri- and post-menopausal women. Will flare and remit spontaneously. Flares last from several weeks to years. Thought to be autoimmune in nature

Answer 304

Thickening of the skin in response to chronic rubbing or scratching, may be thought of as an atopic reaction. Sometimes is a reaction to chronic inflammation from an underlying skin condition

Answer 305

vitiligo, thyroid disorder, alopecia areata, ulcerative colitis

Answer 306

- biopsy confirms diagnosis - saline and KOH wet mount to rule out vaginitis (BV, trich, yeast) - STI testing as indicated

Answer 307

- maculopapular lesions or plaques - loss of pigmentation - markedly thin, white epidermis - symmetry of distribution extends around the anal region (figure eight) - loss of vulvar architecture with obliteration of the clitoris - introital stenosis

Answer 308

- sharply demarcated, shiny, erythematous papules and patches - gray-white lace strands of hyperkeratosis overlay the patches - vagina erythema, erosions, and adhesions - loss of vulvovaginal architecture - may involve other mucosal surfaces of the body

Answer 309

All 3: - pruritis - dyspareunia - dysuria Planus: - burning, raw sensation with possible discharge and bleeding Simplex chronicus: - chronic itch-scratch cycle

Answer 310

- thickened, leathery plaques on the labia majora - excoriations and erosions from scratching - may involve other body areas too such as the nape of neck, forearm, ankle, antecubital and popliteal fossae, scalp

Answer 311

- remove all contact irritants - skin emollients such as vegetable-based oils - skin protectants such as zinc oxide (calamine lotion) and vitamin A and D ointments - baking soda soak or burow's solution (domeboro) - high potency topical steroids with an ointment base (ointment better for vulva than cream) tapered as symptoms improve and/or may continue on for maintenance - oral or injected corticosteroids may be needed with lichen planus - vaginal dilators may be needed to maintain vaginal patency for lichen sclerosus or planus - referral to dermatologist for severe symptoms, unsure diagnosis, or no improvement with treatment - yearly vulvar exam with biopsies as indicated for lichen sclerosus which carries increased risk of vulvar cancer

Answer 312

vulvar cancer (vulvar squamous cell carcinoma) - 4-5% important to do yearly vulvar exam with biopsies as needed

Answer 313

A chronic vulvar discomfort, often described as a burning pain, occurring in the absence of relevant physical findings or a specific clinically-identifiable neurologic disorder. May be generalized pain (mons pubis, labia majora, labia minora, perineum) or localized to the vestibule and clitoris (vestibulodynia)

Answer 314

not very well understood and thought to be multifactorial - altered immune inflammatory process - chronic inflammation - neurologic dysfunction (heightened sensitivity or nerve fiber proliferation) - commonly associated with IBS, interstitial cystitis (painful bladder syndrome) and fibromyalgia

Answer 315

- severe burning, stinging, irritation or raw sensation generalized to the vulva - burning, stinging, tearing, throbbing, razor-blades or cut-glass sensation to the vestibule - entry dyspareunia - dysuria

Answer 316

no visible dermatoses, inflammation, or identifiable cause

Answer 317

- cotton swab test -- apply light touch to the inner thighs, labia majora, vestible, clitoris/hood, and perineum with a cotton swab to localize areas of altered sensation - test for vaginitis or UTI - colposcopy and/or biopsy may be helpful to rule out a dermatosis

Answer 318

limited data exists to support any one therapy. provide anticipatory guidance to expect long-term therapy and may not achieve complete resolution of symptoms - topical ointments for pain relief such as a lidocaine, capsaicin, gabapentin, nitroglycerine, or amitriptyline with baclofen (muscle relaxer) - oral neuropathic pain medications, such as amitriptyline, desipramine (TCAs) or gabapentin - local injections with steroids, interferon, or botox - physical therapy with a pelvic floor PT specialist - laser surgery or excision as last resort - counseling or psychological support for chronic pain

Answer 319

ductal obstruction due to infection or just thickened mucus which leads to cyst formation

Answer 320

- usually nontender - if tender, think abscess - may cause discomfort during sexual intercourse or with walking or sitting

Answer 321

- medially protruding cystic structure at the inferior aspect of the labia (4 and 8 o'clock positions) - most are 1-3cm in size - usually unilateral - nontender, if tender think abscess

Answer 322

- epidermal inclusion cyst - vulvar lipoma - vulvar hematoma - cancer of the bartholin's gland (very rare)

Answer 323

- usually none are needed, as diagnosis is based off of clinical examination - culture may be taken of abscess, and if positive is usually polymicrobial - NAAT for chlamydia or gonorrhea as indicated - biopsy can be considered of the bartholin's gland if >40yo rule out carcinoma

Answer 324

Treatment depends on symptoms, size of the cyst, and whether recurrent or infected (abscessed). Options include: - needle aspiration - incision and drainage with or without placement of a Word catheter - Duct marsupialization or gland excision - broad-spectrum antibiotics tailored to culture results if cellulitis is present

Answer 325

Word catheter allows for formation of an epithelialized tract and thus continued drainage of the gland, reducing the rate of recurrences Placement: make a small incision proximal to the hymenal ring. Insert and inflate the catheter. Tuck the end of the catheter into the vagina. Leave in place for 4-6 weeks until a fistulous tract forms. Complications may include pain during and after placement, or difficulty maintaining the catheter in place.

Answer 326

adequate = presence of endocervical/transformation zone component inadequate = specimen may be obscured by blood or inflammation, inadequate number of squamous cells, air-dried slide, or not-processed because it was unlabeled

Answer 327

negative for intraepithelial lesion | negative for intraepithelial lesion or malignancy

Answer 328

atypical squamous cells of undetermined significance squamous cells on specimen do not appear completely abnormal but they are not able to determine the cause of the abnormal cells

Answer 329

Atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion

Answer 330

Low-grade squamous intraepithelial lesion this encompasses transient HPV infection, mild dysplasia, and/or cervical intraepithelial neoplasia 1 (CIN 1)

Answer 331

High-grade squamous intraepithelial lesion this encompasses persistent HPV infection, moderate dysplasia (CIN 2), and/or severe dysplasia or carcinoma in situ (CIN 3) and will include identification of features consistent with invasion

Answer 332

neoplastic disease (cancer)

Answer 333

If HPV is unknown (any age) or HPV is negative (age 30 or older)..... repeat pap test in 2-4 months If HPV is positive (age 30 or older)... repeat pap test in 2-4 months OR do a colposcopy

Answer 334

colposcopy

Answer 335

These results are highly predictive (though not 100%)... recommend treating

Answer 336

Most of the time this is asymptomatic colonization which would require no treatment If symptoms, may treat

Answer 337

This is very insensitive and non-specific as an indicator for BV, no not use for diagnosis

Answer 338

Evaluate for signs or symptoms of infection if IUD is present and, if symptoms of infection, remove the IUD and treat with antibiotics Otherwise, no treatment is required and IUD removal is not needed

Answer 339

This has high predictive value. Counsel patient on diagnosis and consider a type-specific serology to confirm prior infection and whether it is HSV1 or 2

Answer 340

This is not significant in asymptomatic folks who are not immunocompromised or pregnant

Answer 341

Examine the patient and preform microscopy or other evaluation for vaginitis and STIs as indicated, treat any identifiable cause

Answer 342

Normal, no treatment

Answer 343

Evaluate with endometrial biopsy

Answer 344

Recommend evaluation with endometrial biopsy

Answer 345

PREFERRED: repeat pap test again in 1 year If the repeat test in 1 year is NILM, ASCUS, or LSIL --> repeat again in 1 year. If the repeat test in year 2 is greater than ASCUS, recommend colposcopy. When the test has been negative 2x, resume pap test screening every 3 years. If repeat test in 1 year was ASC-H, atypical glandular cells, or HSIL --> do a colposcopy ACCEPTABLE: reflex HPV test. If HPV negative, repeat pap test in 3 years If HPV positive, repeat pap test again in 1 year

Answer 346

Exact same as for ASCUS pap in 21-24yo, except that to do reflex HPV testing is not a recommended/acceptable alternative strategy. Thus, repeat pap test again in 1 year. If the repeat test in 1 year is NILM, ASCUS, or LSIL --> repeat again in 1 year. If the repeat test in year 2 is greater than ASCUS, recommend colposcopy. When the test has been negative 2x, resume pap test screening every 3 years. If repeat test in 1 year was ASC-H, atypical glandular cells, or HSIL --> do a colposcopy

Answer 347

colposcopy

Answer 348

colposcopy

Answer 349

PREFERRED: reflex HPV test. If HPV negative, repeat pap test in 3 years. If HPV positive, recommend colposcopy ACCEPTABLE: repeat the pap test in 1 year. If negative at 1 year fup, repeat pap in 3 years. If ASCUS or greater at 1 year fup, recommend colposcopy

Answer 350

colposcopy

Answer 351

colposcopy

Answer 352

immediate excisional treatment or colposcopy

Answer 353

pap test cytology only Q3 years

Answer 354

pap test cytology only Q3 years

Answer 355

co-testing (cytology + HPV) Q5 years | acceptable alternative is pap test cytology alone Q3

Answer 356

ACCEPTABLE: repeat co-testing in 12 months. At 1 year fup, if NILM/HPV negative, repeat co-testing in 3 years. If was ASCUS or greater pap and HPV positive, recommend colposcopy ALSO ACCEPTALBE: complete HPV typing If HPV 16 or 18 is positive, recommend colposcopy If HPV 16 and 18 is negative, repeat co-testing again 1 in year.

Answer 357

Repeat co-testing in 3 years

Answer 358

colposcopy

Answer 359

colposcopy

Answer 360

PREFERRED: repeat co-testing in 1 year. If at 1 year fup pap NILM and HPV negative, repeat co-testing in 3 years. If pap ASCUS or greater or HPV positive, recommend colposcopy ACCEPTABLE: recommend colposcopy

Answer 361

colposcopy

Answer 362

colposcopy

Answer 363

immediate excisional treatment or colposcopy

Answer 364

DES was a synthetic nonsteroidal estrogen approved by the FDA for use to prevent miscarriage and premature labor from 1940 to 1971 It was found to increase the risk for reproductive abnormalities, infertility, and clear cell adenocarcinoma of the cervix and vagina

Answer 365

1940-1971 in 2021, that would be folks ages 50 to 81yo

Answer 366

originally lined with columnar epithelium replaced by squamous epithelium DES exposure will have columnar epithelium columnar epithelium of the vagina is especially susceptible to HPV

Answer 367

25% - vaginal septum - cervical collar - uterine constriction band

Answer 368

1/1000 risk | highest risk for DES-exposed females in their early 20s

Answer 369

HPV and cervical cancer, clear cell carcinoma of vagina, structural changes of cervix and vagina (i.e., vaginal septum, cervical collar), increased incidence of preterm delivery, spontaneous abortion, and ectopic pregnancy

Answer 370

- vaginal adenosis (most common) which refers to glandular epithelium extending from the endocervix into the vagina with a red, granular appearance - nodularity of the cervix or vagina - visible cervical abnormalities such as ridges, cockscomb, collar, hood, pseudopolyps, or hypoplasia - transverse or longitudinal vaginal septum - uterine abnormalities including T-shaped, bicornate or didelphis uterus, or septate uterus

Answer 371

- pap test of cervix AND all four walls of the vagina to rule out cancer. This should be done annually - colposcopy and biopsy of suspicious areas - hysterosalpingogram or US to evaluate for structural anomalies - refer to specialist if abnormality suspected or identified

Answer 372

- noncyclic pelvic pain that lasts longer than 6 months - localized to the pelvic/lower abdominal/lumbrosacral regions - of sufficient severity to cause functional disability and/or leads the individual to seek medical care

Answer 373

- endometriosis - post-PID chronic pelvic pain - adhesions - pelvic congestion syndrome (pelvic varicosity pain syndrome) - ovarian mass - uterine fibroids - adenomyosis - vulvodynia - gyn malignancies (particularly late stage)

Answer 374

- interstitial cystitis (painful bladder syndrome) - myofascial pain syndromes - IBS - GI or urologic malignancies

Answer 375

- paroxysms of sharp, stabbing, sometimes crampy, or dull continuous pain, usually severe - dysmenorrhea, dyspareunia, dysuria, vulvar or vaginal pain - pain may or may not be reproducible during abdominal and pelvic examination - feeling of pelvic pressure or heaviness

Answer 376

Unless related to an underlying specific gyn, urologic, MSK, neurologic, or GI disorder --> may be completely normal. Pain mapping may be useful in locating painful areas more specifically

Answer 377

- pelvic US or hysteroscopy - lab studies are often of little value. may consider: + pregnancy test + CBC + ESR + urinalysis + vaginal infection tests/STI screening + fecal occult blood test If GI/GU symptoms present, consider barium enema, upper GI series, IV pyelogram If MSK symptoms present, consider lumbrosacral radiographic images or orthopedic consult Ultimate diagnosis commonly made by laparoscopy

Answer 378

acupuncture, biofeedback, TENS unit (transcutaneous electrical nerve stimulation)

Answer 379

herniation of the bladder into the vaginal lumen (anterior vaginal wall bulge)

Answer 380

herniation of the urethra into the vagina

Answer 381

Bulging or herniation of the anterior rectal wall into the opening of the vagina (posterior vaginal wall bulge)

Answer 382

herniation of a portion of the small intestine into the upper vagina or into the rectovaginal space

Answer 383

descent of the uterus and cervix into the vagina and towards the introitus

Answer 384

Weakness in the pelvic support structures, including the pelvic diaphragm, ligaments, and fascia Commonly related to neuromuscular injury during vaginal childbirth which results in denervation of the muscular floor Increasing incidence with advancing age May also be caused by conditions that chronically increase intraabdominal pressure, including obesity, constipation, chronic cough, nerve function alterations from diabetes, pelvic surgery, neurologic disorders, or hypoestrogenism

Answer 385

May be asymptomatic and discovered during routine exam. If symptoms, may experience: - pelvic, vaginal, or low back pain and pressure - bulging sensation in the vagina, may make walking uncomfortable - urinary incontinence or incomplete bladder emptying - fecal incontinence or difficulty evacuating feces - dyspareunia - exposed vaginal tissue may become dry and/or ulcerated with purulent discharge

Answer 386

- bulging of the anterior or posterior vaginal walls - various degrees of descent of the cervix into the vagina indicating uterine prolapse - valsalva maneuver may be useful in determining full extent of prolapse - poor muscle strength in the pubococcygeal muscles - complete prolapse of the uterue (prodentia), ulceration, purulent discharge, or bleeding

Answer 387

none - clinical diagnosis if suspect tumor may require appropriate imaging

Answer 388

- pelvic floor muscle strengthening exercises (Kegels) - pelvic floor PT with specialist which may include biofeedback and other modalities - local estrogen therapy for postmenopausal folks - pessary -- requires visit for fitting and instructions on care - surgical repair for severe prolapse

Answer 389

TTS is a rare, potentially fatal, febrile condition affecting multiple systems. It is associated with toxins produced by certain strains of staphylococcus aureus. Approx. 10% of the population lacks sufficient antitoxin antibodies to S. aureus Occurs most commonly in caucasian women younger than 30yo using highly absorbent tampons during menstruation. It is rarely caused by other items in the vagina such as a diaphragm, sponge, or cervical cap. 55% of the time caused by non-menstruation associated factors such as puerperal sepsis, post-cesarean endometritis, mastitis, PID, wound infection, or insects

Answer 390

1-2 per 100,000

Answer 391

- sudden onset fever of 102F or greater - diffuse macular sunburn-like rash over the face, trunk, and extremities that desquamates 1-2 weeks after onset - hyperemia of the conjunctiva, oropharynx, tongue, or vagina - GI symptoms including n/v, diarrhea, abdominal tenderness, and dysphagia - GU symptoms including vaginal discharge and adnexal tenderness - flu-like symptoms including headache, sore throat, myalgia, rigors, photophobia, and arthralgia - cardiopulmonary symptoms - including signs of pulmonary edema, disseminated intravascular coagulation (DIC), endocarditis, acute respiratory distress syndrome (ARDS), orthostatic hypotension - organ failure including renal or hepatic failure - altered sensorium

Answer 392

- cultures to determine the source of infection (i.e., throat, vagina, cervix, blood) - serologic tests to rule out rocky mountain spotted fever, syphilis, and rubeola - urinalysis - evaluation for the presence of multi-organ involvement such as CBC with diff, CMP, clotting profile, ABGs - diagnostic criteria includes involvement of three or more organ systems

Answer 393

refer immediately to the hospital for ICU

Answer 394

- avoid tampons or leave in place no longer than 4 hours - alternate tampons with pads - educate about s/s of TTS if using cervical cap, diaphragm, sponge, or tampons - avoid all of the above if they have a history of TTS

Answer 395

TCA (or BCA) application are the only treatments known to be safe during pregnancy

Answer 396

- experiencing the disorder at least 75% of the time for 6 months - causing significant distress

Answer 397

- sexual interest/arousal disorder - orgasmic disorder - genito-pelvic pain/penetration disorder

Answer 398

complete lack of or significant reduction in sexual interest or sexual arousal

Answer 399

marked delay in, marked infrequency of, or absence of orgasm or reduction in intensity in all or almost all occasions of sexual activity

Answer 400

persistent or recurrent difficulties in relation to vaginal penetration

Answer 401

recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina

Answer 402

- hypoactive sexual desire disorder (HSDD) - delayed ejaculation - premature ejaculation - erectile dysfunction

Answer 403

unable to ejaculate during sexual activity, specifically after 25-30 minutes of continuous sexual stimulation

Answer 404

early ejaculation during vaginal intercourse, individual feels unable to control orgasm; climaxes in less than 1 minute after vaginal penetration. no duration has been established for oral or manual stimulation

Answer 405

- 43% at least 1 problem with sexual desire, arousal, or orgasm - 22% reported this caused significant distress

Answer 406

- Permission (validate concerns, express that problems are real and prevalent) - Limited Information (provide basic education about sexual response cycle, components of desire, identify cause of the problem) - Specific Suggestion (lubricants, erotica, enhancing clitoral stimulation, positioning for comfort) - Intensive Therapy (refer to sex therapist for CBT focused on sexual concerns and solutions)

Answer 407

PRE-MENOPAUSAL - flibanserin (Addyi; 2015) for interest/arousal disorders in PRE-menopausal females. PO QHS - bremelanotide (Vyleesi; 2019) - for interest/arousal disorders in PRE-menopausal females. SQ injection 45 min before sexual activity - sildenafil (Viagra) is not FDA approved for use in females POST-MENOPAUSAL - vaginal estrogens for POST-menopausal vaginal atrophy. variety of administration options - prasterone (Intrarosa; 2016) for dyspareunia. intravaginal insert QHS

Answer 408

dehydroepiandrosterone (DHEA, a precursor hormone) preparation that is converted into active androgens and estrogens

Answer 409

<35yo - Inability to conceive after 1 year of unprotected vaginal-penile coitus If >35yo, after 6 months Or, inability to carry a pregnancy to live birth at any age

Answer 410

female factor - 25-50% male factor - 25-50% combined - 30% unexplained - 10-25%

Answer 411

- anovulation - luteal-phase insufficiency - poor ovarian reserve - inadequate cervical mucus - uterine anomalies - adhesions from surgery or peritonitis - tubal occlusion - endometriosis

Answer 412

- erectile dysfunction causes leading to low sperm production.... - low testosterone (hypogonadism) - varicocele - toxin exposures (radiation, chemicals, drugs) - chronic overheating of testicles - mumps orchitis (testicular inflammation) other causes..... (s/t obstruction) - adhesions in the vas deferens (from epididymitis, genital tract surgery) - hypospadias - phimosis - retrograde ejaculation

Answer 413

congenital defect in which the urethral meatus is located on the ventral surface of the glans, penile shaft, or perineal area

Answer 414

tight foreskin that cannot be retracted, may be congenital or the result of recurrent infections of the glans penis and prepuce

Answer 415

- menstrual history - h/o abnormal pap tests and/or their treatment (i.e., LEEP) - prior pregnancies - duration of trying to conceive - previous fertility treatments and work-ups - frequency and timing of intercourse - sexual dysfunction or dyspareunia - history of STIs or other FU infections - history of pelvic or abdominal surgeries - symptoms of or known diagnosis of endocrine disorder - prior cancer diagnosis and/or chemotherapy/rads - current medications (rx and OTC) - substance use (marijuana, alcohol, illicit drugs) - environmental and occupational exposures - family history of birth defects or infertility

Answer 416

- pelvic US to describe uterine anomalies, ovarian volume, and ovarian cysts - hysterosalpingogram to describe tubal patency - BBT and home predictor kits to detect ovulation - AMH level (serum) + antral follicle count (US) to describe ovarian reserve - serum FSH, LH, estradiol (E2), and progesterone - serum TSH - STI screening - semen analysis

Answer 417

semen volume, sperm number, sperm concentration, motility, vitality, morphology, and pH

Answer 418

ovulation induction with clomiphene citrate (Clomid; SERM) or letrozole (AI)

Answer 419

vaginal or IM progesterone

Answer 420

intrauterine insemination

Answer 421

all the techniques used to achieve pregnancy that involve direct retrieval of the oocytes from the ovary (IVF, GIFT, ZIFT, ICSI)

Answer 422

in vitro fertilization - oocytes are extracted from the ovary, fertilized with sperm in the laboratory, and then transferred through the cervix back into the uterus success rate 15-20% most common ART procedure

Answer 423

gamete intrafallopian transfer - placement of oocytes and sperm into the fallopian tube 25% success rate

Answer 424

zygote intrafallopian transfer (ZIFT) - placement of fertilized oocytes into the fallopian tube 18-20% success rate

Answer 425

intracytoplasmic sperm injection This ART therapy is used when the male has a low sperm count and is combined with IVF or ZIFT -- the oocyte is directly injected with one sperm

Answer 426

congenital anomalies involving the uterus, fallopian tubes, and upper vagina resulting from the absence of anti-mullerian hormone (AMH)

Answer 427

a mullerian abnormality

Answer 428

- agenesis of the vagina, uterus, or tubes - hypoplasia of the vagina, bicornate uterus, or a partial uterine cavity - atresia with imperforate hymen or cervical atresia (incomplete canalization) - one-third will also have urinary tract abnormalities including ectopic kidney, renal agenesis, horseshoe-shaped kidney, abnormal collecting ducts - as the ovaries may be developed, may see expected secondary sex characteristics

Answer 429

- structural abnormalities may be detected by US, MRI, hysterosalpingogram, or laparoscopy - chromosomal abnormalities are ruled out with karyotyping (will demonstrate 46XX)

Answer 430

referral to reproductive endocrinologist and/or surgeon for consult

Answer 431

a genetically transmitted androgen receptor deficit. the individual is a genotypic male (46XY) but phenotypic (development) female OR has both male and female secondary sex characteristics. the individual will have testes that may be partially-descended or intra-abdominal. however, will also have vagina with labia but no uterus or ovaries

Answer 432

genetic; transmitted by a maternal X-linked recessive gene causing a defect in androgen receptors. 25% risk of having an affected child, 25% risk of having a carrier child

Answer 433

androgen insensitivity syndrome (46XY)

Answer 434

5% risk of malignant transformation of the gonads

Answer 435

- uterus and ovaries are absent - blind pouch vagina present - labia may be underdeveloped, absent, or have scant pubic hair - normal breast development however with small nipples and pale areola - inguinal hernias (50%) or labial masses due to partially-descended testes which may be intra-abdominal - scant body hair - growth and development are normal, however, overall height is usually greater than average female - may have horseshoe kidneys

Answer 436

- karyotyping will reveal 46XY in phenotypically female patient - testosterone elevated, usually >3ng/mL and LH normal to slightly elevated

Answer 437

Referral to endocrinologist or specialist. Anticipatory guidance - Once full developed is attained (after puberty), gonads should be removed at about age 16-18yo to prevent malignant transformation. Hormone therapy replacement after the gonads are removed to desired sexual/gender identity. Evaluate other family members and provide sensitive, individualized counseling.

Answer 438

gonadal dysgenesis - 45X an abnormality in or absence of one of the X chromosomes in a phenotypically female patient 60% have total loss of an X chromosome, 40% are mosaics or have structural abberrations in the X or Y chromosome

Answer 439

Turner's syndrome - 45X

Answer 440

1 in 2,500-5,000 live-born females

Answer 441

- short stature - webbed neck - shield chest with widely spaced nipples - increased carrying angle of the elbow - arched palate - low neck hairline - short fourth meta-carpal bones - disproportionately short legs - swollen hands and feet - lack of breast development - scant pubic hair - amenorrhea - lack of sexual development - may have comorbid autoimmune disorders including hashimoto's thyroiditis (hypothyroidism with goiter formation), addison's disease (adrenal insufficiency), alopecia, and vitiligo - hearing loss - normal intelligence or may have difficulty with mathematical ability, visual-motor coordination, or spatial-temporal processing

Answer 442

- genetic karyotyping reveals 45X - US or MRI - renal US and cardiology consult

Answer 443

referral to endocrinologist and/or multiple specialists as needed to manage multisystem involvement. Anticipatory guidance regarding likely estrogen and progesterone replacement therapies, human growth hormone, and genetic counseling.

Answer 444

"nondisease" aka physiologic breast changes that include nonproliferative microcysts, macrocysts, and fibrosis as well as proliferative changes such as hyperplasia and adenosis hyperplasia with atypia is associated with a moderate risk for breast cancer

Answer 445

- cystic changes - fibrous changes - hyperplastic - adneosis

Answer 446

refers to dilations of the ducts. May regress with menses, may persist, or may disappear and reappear

Answer 447

a mass develops following an inflammatory response to ductal irritation

Answer 448

a layering of cells, has malignant potential if atypical

Answer 449

these are related to changes in the acini in the distal mammary lobules - the ducts become surrounded by a firm, hard, plaquelike material

Answer 450

poorly understood. thought to occur in response to endogenous hormone stimulation, primarily estrogen

Answer 451

fibrocystic breast changes

Answer 452

detectable on radiograph imaging in 90% of females ages 40 and older

Answer 453

- breast pain and nodularity which is usually bilateral - frequently occurs or increases 1-2 weeks before menses - may have clear or white nipple discharge

Answer 454

- multiple, usually cystic masses that are well-defined, mobile, and often tender - absence of overlying breast skin changes - may have clear or white nipple discharge - most common sites include the upper outer quadrant and axillary tail

Answer 455

usually none are needed. - May order mammography to identify and characterize masses if age 40 or older. - May use US to determine whether a mass is cystic. - Fine-needle aspiration (FNA) if there is a dominant mass with cytologic evaluation. - Biopsy or excision id there is a dominant mass and/or other concerning findings are present (i.e., bloody fluid on aspirate)

Answer 456

- blood fluid on aspiration - failure of a mass to disappear after aspiration - recurrence of a cyst after two aspirations - solid mass that is not diagnosed as a fibroma - bloody nipple discharge - nipple ulceration - skin edema or erythema

Answer 457

treatment is not necessary unless symptomatic/desired by patient. provide reassurance. - aspiration of palpable cysts may be curative - supportive bra - NSAIDs, topical or oral - reduce irritants (methylxanthines - caffeine, tea, cola, chocolate) - hormonal contraception may increase or decrease mastalgia - medications including danazol, tamoxifen, and bromocriptine have all been used to treat severe mastalgia however all have major side effects that limit their utility and mastalgia typically returns once they are discontinued

Answer 458

a benign breast mass derived from the fibrous and glandular tissue of the breast

Answer 459

poorly understood. Thought to develop soon after menarche and appears to be hormone-related (as such, may increase in size during pregnancy and regress after menopause)

Answer 460

fibroadenoma

Answer 461

- painless, single, round, rubbery mass - no nipple discharge - does not change with the menstrual cycle

Answer 462

- firm, well-delineated, free-moveable, smooth, rubbery, round typically 2-4cm marble-sized mass that is non-tender, and usually unilateral - may grow up to 15cm - no nipple discharge or skin changes

Answer 463

- attempt FNA to determine whether cystic or solid - excisional biopsy - US and/or mammography will help distingish singular from multiple nonpalpable masses and US is best choice for younger females

Answer 464

If diagnosis is confirmed and the patient is <25yo, reassurance and observation. May be removed to alleviate patient anxiety or if the diagnosis is uncertan. Follow-up with an annual breast exam by a clinician with screening mammograms per national guideline schedules

Answer 465

fibrocystic breast changes

Answer 466

a benign lesion of the lactiferous ducts from proliferation and overgrowth of the epithelial tissue lining the subareolar collection duct It is the most common cause of pathologic nipple discharge

Answer 467

intraductal papilloma

Answer 468

35-50yo, perimenopausal

Answer 469

- bloody, serous, or turbid discharge (not milk) which may occur spontaneously - a mass is not usually palpable - feeling of fullness or pain beneath the areola is possible

Answer 470

- expression of serosanguinous nipple discharge from a single duct when pressure is applied - poorly delineated, soft mass may be palpated - usually singular not multiple - no associated breast skin changes

Answer 471

- mammography and/or US depending on age - excisional biopsy of the duct allows for definitive evaluation - cytology of the expressed fluid (although false-negative rates up to 20% for cancer) - radiologic ductogram use is controversial due to low sensitivity

Answer 472

referral for surgical excision, which is curative

Answer 473

periareolar inflammation with a mass or abscess in a patient who is not lactating. commonly related to staphylococcous areus Most common in the reproductive age group May be associated with breast cysts and cyst rupture

Answer 474

nipple piercing, smoking

Answer 475

- reddened, painful nipple or breast - may or may not have a mass - may or may not have spontaneous purulent nipple discharge

Answer 476

- subareolar warmth, tenderness, or erythema - fluctuant or indurated mass - dimpling or nipple retraction - purulent nipple discharge - mammary duct fistula may be present at the areolar margin

Answer 477

- breast US to assess for abscess and/or fistula | - biopsy if there is a mass present or if inflammation persists after treatment

Answer 478

- oral antibiotic x10 days with an agent that will cover gram-positive organisms (amoxicillin-clavulanate [Augmentin], dicloxacillin, cephalexin) - if poor response to initial antibiotic, culture for MRSA and if positive, treat with doxycycline or TMP-SMX - if abscess, aspiration and/or incision and drainage - remove foreign objects i.e., nipple piercing - recommend warm packs and NSAIDs for pain relief - advise smoking cessation

Answer 479

dilation of the mammary ducts with surrounding inflammation and fibrosis. There is a widening of the ducts with thickening of the duct walls - the ducts fill with desquamated ductal epithelium and secretory proteinaceous contents. The skin bacteria collecting in the duct may then cause inflammation and pain. It is most common in females >50yo and those who smoke.

Answer 480

- green, brown, or black nipple discharge that is often bilateral and spontaneous - may have burning, itching, or sensation of pulling in the nipple area

Answer 481

- multicolor, sticky, bilateral, multiductal nipple discharge - may have a palpable mass behind the nipple - no overlying breast skin changes

Answer 482

- mammography and/or US | - biopsy if a mass is present

Answer 483

- antibiotics - NSAIDs - smoking cessation

Answer 484

lung cancer

Answer 485

breast cancer

Answer 486

breast cancer

Answer 487

1 in 8 (12%)

Answer 488

BRCA 1 and 2

Answer 489

1 in 300-500 in the general population | 1 in 40 Ashkenazi Jewish ancestry

Answer 490

BRCA 1 - 57% risk on average, up to 85% BRCA 2 - 47% risk on overage MALES - 6% lifetime risk

Answer 491

parents, siblings, children

Answer 492

grandparents, grandchildren, aunts, uncles, nephews, nieces

Answer 493

First or Second Degree relatives with: - known mutation carrier - breast cancer dx at <50yo - any male breast cancer - any ovarian, fallopian tube cancers - any peritoneal, pancreatic, or metastatic prostate cancer - multiple primary cancers on the same side of the family

Answer 494

- personal history of breast cancer dx <50yo - triple negative breast cancer dx <60yo - breast cancer at any age if Ashkenazi Jewish - ovarian or fallopian tube cancer - pancreatic or primary peritoneal cancer - multiple primary cancers

Answer 495

- Li-Fraumeni - Cowden - Peutz-Jeghers

Answer 496

- increasing age - family history of breast cancer in one or more first degree relative, especially at early age or in male - inherited gene mutations - other hereditary cancer syndromes - personal history of breast, endometrial, or colon cancer - biopsy-confirmed atypical hyperplasia - high-dose radiation to the chest - high bone density post-menopausal - menarche before age 12yo - menopause after age 55yo - nulliparity - first pregnancy after 30yo - hormone therapy and OCPs (conflicting data) - obesity (postmenopausal) - heavy alcohol use - dense breasts

Answer 497

a measure used to describe the proportion of fibroglandular tissue to fatty tissue seen on mammogram The greater the amount of fibroglandular tissue, the greater the density

Answer 498

breast cancer

Answer 499

- modest increased risk of breast cancer | - reduced sensitivity of mammography

Answer 500

upper-outer quadrant

Answer 501

- breast mass, commonly in upper-outer quadrant - spontaneous clear, serous, or bloody nipple discharge - may have retraction, dimpling, skin edema, erythema, or irritation

Answer 502

- mass that is fixed, poorly-defined, irregular, and usually non-tender - may have nipple discharge or retraction - may have breast skin changes including dimpling, edema, or color changes - may have enlarged lymph nodes in the axillary, supraclavicular, or infraclavicular chains

Answer 503

- mammogram (detects 30-50% of cancers) - US (to distinguish solid from cystic mass) - histology for definitive diagnosis -- open excisional biopsy, FNA, or stereotactic core-needly biopsy - MRI may be useful - CT of liver, lungs, and bone to r/o metastasis - estrogen-receptor status is determined by assay - sentinel node biopsy - negative mammogram and negative aspiration cytology does not exclude malignancy - make sure you have concordance between all findings/results

CH5: Gynecologic, Reproductive, and Sexual Disorders Flashcards

(550 cards)