Flashcards in Clin Med Deck (216):
How do you treat dysfunctional uterine bleeding?
NSAIDs!! (or Mirena IUD)
What are risks to developing urinary incontinence? (4)
2. hormonal status
3. birthing trauma
How do you treat urinary incontinence?
anti cholinergics (oxybutinin, tolterodine)
How does vaginal neoplasia present?
can be flat, raised, white, red, black multicentric lesions
How do you treat bartholin's gland cyst?
1. none if asymptomatic
2. drain w/ ward catheter or massupialize
3. excision if recurrent
Patient presents with red/purple lesion on non-hair regions of vulva in HOURGLASS pattern with intense puritis
What are you at risk for with lichen sclerosis?
squamous cell carcinoma
How do you treat lichen sclerosis?
Stop scratch-itch cycle (steroids, topical high-potency then down titrate)
How do you diagnose bacterial vaginitis?
1. Thin, homogenous vaginal d/c
2. FISHY odor (KOH "whiff test")
3. clue cells (>20%)
4. Vaginal pH>4.5
Do you want to get a culture to confirm BV?
How do you treat bacterial vaginitis?
Patient presents with cheesy, white discharge and intense itching with inflamed vagina/vulva.
Candida infectious vaginitis
How do you treat vaginal candidiasis?
1.Imidazoles (clotrimazole, miconazole, nystatin) brief
Do you treat male sex partner of someone with vaginal candida?
Only if he has symptomatic balantis
What are common PMS sxs?
2. breast pain
5. attitude change
How do you diagnose PMDD?
1. 5+ sxs before final week before menses
2. improves after menses
3. absent week after menses
4. needs to disrupt daily fxns
How do you treat PMS/PMDD?
1. limit caffeine, tobacco, etoh, Na
2. frequent, high-complex carb meals
3. stress management, aerobc exercise
4. Chaste Berry, St. John's Wort
What is a ddx for amenorrhea?
1. GnRH defect
2. pituitary defect (prolactin, FSH/LH)
3. Ovarian defect (PCOS, menopause, dysgenesis)
4. Mullerian defects or agenesis (primary)
How do you dx amenorrhea?
Progesterone challenge! (expect withdrawl bleeding) Indirectly determines if ovary is producing estrogen
How do you treat amenorrhea if pregnancy is desired?
Induce ovulation (clomiphene citrate)
How do you treat amenorrhea if pregnancy is not desired?
2. cyclic progesterone (esp. if OCPs contraindicated)
What is prolapsing if you see an anterior wall descent?
What is prolapsing if you see the posterior wall descending?
What is prolapsing in a central prolapse?
What are causes of prolapse?
1. age (esp. after menopause)
2. parity (esp. if over 2 deliveries)
4. chronic cough (increase intra-and pressure
5. chronic constipation
Patient presents with vaginal fullness, pressure and dyspareunia?
How do you prevent getting prolapse?
1. kegel exercises (during PG)
2. consider estrogen therapy after menopause to maintain pelvic tissue tone
What is the most common gynecologic malignancy?
When is endometrial cancer most often seen?
What is the most common type of endometrial CA?
What are clinical features of type 1 endometrial CA?
1. unopposed estrogens
2. well differentiated
3. starts as hyperplasia
4. less aggressive
What are clinical features of type 1 endometrial CA?
1. endometrial atrohpy
3. more aggressive
What are risk factors to developing endometrial CA?
2. metabolic syndrome
5. unopposed estrogen
How do you treat acute vaginal bleeding?
1. oral progestins
2. IV estrogen
How do you treat long-term vaginal bleeding?
1. low-dose OCP
3. Mirena IUD
5. GnRH agonist
Patient presents with metorrhagia, menorrhagia and dysmenorrhea and a mass is felt during bimanual exam
How do you treat leoimyomata?
1. no tx is an option
2. GnRH agonist: to shrink by reducing hormones that stimulate it
3. OCPs: control bleeding
4. Progestin-releasing IUD
5. Myomectomy: preserves fertility, high-risk for fibroid recurrence
7. uterine fibroid embolization
Patient presents with severe pelvic pain, dysmenorrhea, and dyspareunia
How do you confirm dx of endometriosis?
How do you treat endometriosis?
3. progestins: reduce menstrual flow, inhibit ovulation (less pain)
4. Danazol: synthetic testosterone (can cause male physical traits)
5. GnRH agonist: block release of pituitary hormones
What is the main cause of cervical CA?
HPV! (99% of cases!)
What is the most common pathology of most cervical CA?
What are risk factors of cervical CA?
same as risks for getting STD (early sex, lots of sex partners, h/o STIs)
Also: smoking and immunosuppression
What are clinical features of cervical CA?
1. irregular or heavy vaginal bleeding
2. postcoital bleeding
How do you dx cervical CA?
Where does cervical CA usually originate?
transformation zone (squamocolumnar junction)
How do you treat early stage cervical CA?
(confined to cervix,
What is the prognosis of someone with metastatic/recurrent cervical CA?
under 2 years
Which HPV strain is associated with HPV 16?
Which HPV strain is associated with HPV 18?
What is the screening schedule for paps?
1. every 3 years 21-29yo, NO HPV screening
2. 30-65, co-test every 5 years
What is the next step with the pap result: normal cytology, HPV positive
option 1: repeat pap in 1 year (if normal, every 3 years; if abnormal, colposcpy)
option 2: HPV genotyping (if 16/18 colposcopy; if not 16/18, repeat pap in 1 year)
What is next step for ASC-US pap results?
atypical squamous cells of undetermined significance
Women over 25: reflex HPV
(if positive: colposcpy; if negative; repeat co-test 3 yrs)
Women 21-24: repeat pap in 1 year
What is next step for LSIL?
Low-grade squamous intraepithelial lesion
What is next step for ASC-H?
atypical squamous cells, cannot exclude high-grade SIL
-colposcopy for all, no matter HPV status
What is next step for HSIL?
High-grade squamous intraepithelial lesions (mod-severe dysplasia; carcinoma in situ)
-Over 25: colposcopy or LEEP
-21-24: UNACCEPTABLE immediate LEEP
What is next step for ACG?
atypical glandular cells
-if over 35: endometrial sampling
What is the risk of CIN I?
most will regress in 1-2 years
What is the risk of CIN II?
5% will progress to cervical CA
What is the risk of CIN III?
12-40% will progress to cervical CA
What is the point of colposcopy?
magnifies cervix; diagnostic procedure to f/u abnormal pap
How do you treat CIN II and CIN III?
- LEEP (loop electro surgical procedure)
-ablation of T-zone w/cryosurgery or laser
-"wait and watch" if 21-24 OR pregnant
Patient presents with PURULENT vaginal discharge, intermenstrual bleeding and postcoital bleeding?
What are the usual causes of acute cervicitis?
Gonorrhea, chlamydia, Candida
What does acute cervicitis put you at risk for?
What causes a strawberry cervix?
Trichomonas acute cervicitis
How do you dx acute cervicitis?
-test for Gonorrhea/chlamydia
-test for BV/trich (wet mount)
-r/o PID via bimanual exam
How do you treat acute cervicitis?
Patient presents with yellowish, translucent raised pearl-like lesions on ecto cervix?
Patient presents with postcoital bleeding, and red friable growth protruding from cervical os?
How do you treat cervical polyp?
remove with forceps and SEND TO PATHOLOGY!
What does FSH do during follicular phase?
What does estrogen due during proliferative phase?
increased estrogen causes increased stratum functionalis
What happens at ovulation (hormone wise)?
FSH/LH surge cause Graafian follicle to rupture
How long is the oocyte viable for?
What does the corpus luteum secrete during luteal phase?
What does progesterone due during luteal phase?
it "quiets" uterine lining, making it conductive to implantation
How do you define infertility?
1. failure of couple to conceive after 12 months of regular intercourse
2. If over 35yo, after 6 months
What are common causes of female infertility?
1. ovulatory d/o (eating d/o, cushings, Turner, thyroid)
3. pelvic adhesions
What are common causes of male infertility?
1. hypothalamic pituitary disease
2. testicular disease (Klinefelters, varicocele, epididymo-orchitis)
3. disorders of sperm transport
How do you get semen analysis?
1. 2-7 hours of abstinence
2. at least 2 samples 1-2 weeks apart
When would you immediately start to eval someone for infertility?
1. over 40yo
3. h/o chemo, radiation
4. advanced endometriosis
5. male partner (mumps, impotence, ED, chemo)
How do you treat infertility?
1. smoking cessation
2. women decrease caffeine and alcohol
How do you define menopause?
1 year after LMP
What is the median age of menopause onset?
What is happening, hormonally, during menopausal transition?
1. decreased estradiol and progesterone
2. increased FSH
What happens during vaginal atrophy?
1. loss of superficial GU cells (thinning of tissue)
2. loss of vaginal rugae and elasticity
3. loss of subcutaneous fat in labia majora
4. vaginal pH more ALKALINE (alter vaginal flora, more risk infection)
5. vaginal secretions decrease
What are problems with unopposed estrogen treatment (in women with a uterus)
Increased endometrial CA risk
Why does adding progestin help reduce risk of endometrial CA?
helps shed uterine wall and reduce endometrial hyperplasia
What are other risks of estrogen therapy?
breast CA, CAD, CVA/DVT
What does HRT REDUCE the risk for?
fractures, colon CA
What are alternative treatments of vasomotor sxs other than HRT?
1. SSRIs (paroxetine)
2. SNRI (venlafaxine)
5. progestin-only (breast CA risk still)
LIFE STYLE CHANGES! (exercise, cotton bedding, fans)
How do you treat vaginal atrophy?
1. vaginal estrogen
2. non-hormonal options (ospemifne, vaginal lube)
What is mastalgia?
What are common sxs of cyclic breast pain?
3. severe upper outer quadrant
4. usually 1 week before menses (due to proliferation of normal glandular tissue)
What are common sxs of non-cyclic breast pain?
1. women 40-50yo
2. sharp/burning pain
3. often unilateral, NOT associated with menses
4. multiple etiologies (pendulous breasts)
How do you dx breast pain?
1. breast exam
2. US (add mammo if over 30)
How do you treat breast pain?
1. usually self-limited
2. support garments
4. mild analgesics (acetaminiphen, advil)
5. evening primrose oil
What is the only FDA-approved treatment for breast pain?
52 yo women presenting with abdominal distention, abdominal bloating, and urinary frequency and ascites
What are risk factors for ovarian CA?
1. genetic predisposition (BRCA1/2)
2. over 65
3. early menarche, late menopause
4. FRENCH CANADIENS
5. infertility, never been PG
What are protective factors against ovarian CA?
2. more than 1 full-term PG before 35yo
4. tubal ligation
5. avoid TALC
What is the most lethal form of ovarian CA?
What are the other 2 forms of ovarian CA?
1. germ cell (adenexal mass and germ cells, younger girls)
2. stromal cell
How do you diagnose ovarian CA?
How do you treat ovarian CA?
2. chemo (radiation does not work well)
How do you clinically diagnose PCOS?
1. oligo or amenorrhea
2. hyperandrogenism (obesity, hirsutism)
3. evidence on US
What are complications of PCOS?
1. infertility (most common cause in women)
2. insulin resistance (higher risk for DM)
3. unopposed estrogen
What are the hormonal interactions in PCOS?
1. Insufficient FSH to stimulate granulosa cells
2. LH continues to get released and stimulates theca cells to make androgens-- acne, hirsutism
How do you treat PCOS?
1. treat unopposed estrogen and insulin resistance
2. OCPs treat estrogen and hirsutism
4. Clomiphene citrate for infertility (ovulation induction)
---higher risk for multiple gestations
What is the most common type of ovarian cyst?
What causes follicular cysts?
result from failure to ovulate
What type of ovarian cyst occurs after ovulation?
corpus luteum cyst
When due theca-lutein cysts occur?
during pregnancy (molar gestation)
What is a theca-lutein ovarian cyst?
How do you treat ovarian cysts?
1. If fluid-filled: monitor with US
2. If NOT fluid-filled: REMOVE IT!
3. if over 6cm: REMOVE! risk of torsion
4. prevention with OCPs
5. treat pain with NSAIDs
What type of cell does LH stimulate?
What do theca cells produce?
What does inhibin do?
released via FSH and negative feedback on FSH
What stimulates granulosa cells?
What do granulosa cells do?
1. oocyte development
A patient presents with rash, fever/malaise, headache and alopecia (with a moth eaten appearance)
What is the treatment for secondary syphilis?
Pen G IM once (or doxy PO x14days)
What else can HPV cause other than cervical CA?
What is the treatment for HPV?
1. patient application: podofilox or imiquimod
2. provider application: cryotherapy, surgery
Male presents with runny white penile discharge and dysuria
How do you dx chlamydia?
How do you treat chlamydia?
Azithromycin 1g PO x1 (or doxycycline x7 days)
When do you f/u chlamydia?
NO f/u needed unless:
2. compliance questions
What is a hallmark of gonorrhea?
Male presents with thick white/yellow penile discharge and dysuria
How do you treat gonorrhea?
Ceftriaxone IM single dose PLUS azithromycin PO single dose
When do you f/u gonorrhea?
3 months after treatment
Who should get tested for BRCA?
1,. Eastern European
2. African American female dx before 35
3. family members of male with breast CA
4. woman with breast CA in both breasts
5. multiple family members with breast CA
6. blood relative with breast CA before 50
When should mammos be started if there is a family history?
Why is there controversy of when to start mammos?
1. unnecesary work up
2. increased radiation exposure
What is the gold standard for eval of a mass to determine if it is solid or cystic?
What is the most common non-invasive breast CA?
Ductal carcinoma in situ
What is the most common type of breast CA?
Invasive ductal carcinoma (IDC)
What is the f/u for someone in breast CA remission?
1. exam q3-6 months first 3 years
2. every 6-12 months 4-5 years
3. annually post-5 years
4. yearly mammo
5. yearly pelvic (some tx increase uterine CA)
What is the 2nd most common type of breast CA?
How do you dx inflammatory breast CA?
skin punch biopsy
Where are common sites of breast CA metastasis?
1. lymph nodes
2. muscles, fatty tissue, SKIN
4. bone marrow
Woman presents with localized, painful inflammation of breast associated with fever and malaise?
What is the usual culprit of lactational mastitis?
What happens if you leave lactational mastitis untreated?
How do you treat lactational mastitis?
2. Clindamycin (MRSA)
What is the breast "triple test" that will make you never miss breast CA dx?
2. mammo w/US
3. needle biopsy (fine needle aspiration, core needle biopsy)
22 yo presents with solid, firm and mobile mass that is "rolled to an edge"
How do you dx fibroadenoma?
core needle biopsy
Patient presents with a solitary, fluid-filled mass that is influenced by hormonal fluctuation?
How so you treat breast cyst?
1. fine needle biopsy
2. following aspiration-- 2-4 month f/u to document stability
What are features of pathologic nipple discharge?
1. spontaneous (not just with compression)
3. confined to one duct
5. clear, yellow, white, dark
6. associated w/mass
7. over 40yo
What are features of benign nipple discharge?
1. discharge only w/compression
3. multiple ducts
4. fluid may be clear, yellow, white, dark green
What is the first stage of labor?
onset of true labor to full dilation (6-20 hour for first time; 2-14 hours 2+ times)
What is the second stage of labor?
full dilation to delivery (30min- 3hr; 5-60min)
What is the third stage of labor?
separation and expulsion of placenta (0-30 min)
How often should you monitor FHR?
1. every 30 min in active labor
2. every 5-15min in 2nd stage
What are signs of labor?
1. lightening (easier breathing); 2 weeks before
2. false labor (days)
3. premature rupture of fetal membranes (w/i 24 hrs)
4. bloody show (24-48 hrs)
5. GI upset
What are indications for a C-section?
1. repeat C-section
3. failure to progress
5. fetal distress
Patient presents with retraction ring across uterus between symphsis and umbilicus
What are risks of uterine rupture?
1. high parity
2. previous C-section
3. overstimulation with oxytocin
What classifies as postpartum hemorrhage?
blood loss over 500cc with vaginal birth and over 1000cc with c-section
What are the 3 ps of complicated labor?
1. power (uterine contractions, maternal effort)
2. passenger (baby)
3. passageway (bone of pelvis)
What are risk factors for complicated delivery?
1. occiput posterior position
5. short stature
What is the major risk of premature rupture of membrane?
INFECTION (choriomionitis, endometriosis)
What do you want to avoid with premature membrane rupture?
AVOID digital exam
How do you treat PROM? PPROM?
PROM (after 37 weeks): induce labor
PPROM (before 37 weeks): hospitalized w/bed rest
What is the most common cause of third trimester bleeding?
What are risk factors for placenta abruption?
4. low folic acid
7. high parity
What is placenta abruption?
premature separation of placenta after 20th week gestation, before birth
Pregnant lady presents with painless vaginal bleeding?
What is placenta previa?
occurs with placenta partially or completely covers cervical os
What is contraindicated with placenta previa?
Pregnant lady with abnormal vaginal bleeding and a big uterus has US that shows grapelike vesicles and snowstorm pattern
gestational trophoblastic disease
Patient presents with lower bilateral back pain and has chandelier sign on pelvic exam. With purulent discharge and inflammation of Bartholin gland
Pelvic Inflammatory Disease (PID)
What are major complications of PID?
2. ectopic pregnancy
How do you diagnose PID?
1. GC/chlamydia probe
2. transverse vaginal US
How do you treat PID?
1. Mild-- abx, antipyretics, bed rest
REMOVE IUD if present
2. severe-- hospitalization
What are complications of gestational DM?
2. big baby
3. should dystocia
4. premature birth
5. fetal demise
6. delayed fetal lung maturity
How do you diagnose gestational dm?
1. random glucose at first prenatal visit
2. 1hr glucose challenge
3. If over 130-- 3 hr test performed
How do you treat gestational DM?
1. diet and exercise
2. daily glucose log
What is the classic triad of preeclampsia?
1. htn (starting after 20 weeks gestation)
What is severe preeclampsia?
E : elevated
L: liver enzymes
What are risks for getting preeclampsia?
2. age (under 20, over 35)
3. multiple gestation
What are maternal complications of preeclampsia?
1. abruptio placenta
2. renal failure
3. cerebral hemorrhage
4. pulm edema
What are fetal complications of preeclampsia?
2. low birth weight
4. perinatal death
What are clinical features of preeclampsia?
1. edema of face/hands
2. sudden weight gain
3. visual disturbances
4. RUQ pain
5. decreased urine output
How do you diagnose preeclampsia?
1. 2 readings at least 4 hours apart 14-/90 (or one of 160/110)
2. proteinuria 0.3g in 24 hr
How do you treat preeclampsia?
When do you give rhogam?
1. at 28 weeks for Rh negative women
2. w/i 72 hours of delivering Rh+ infant
What are risks of developing ectopic pregnancy?
1. recent IUD
2. h/o PID
3. infertility treatments
4. h/o ectopic pregnancy
Patient presents with unilateral adnexal pain, spotting and tendernss on pelvic exam
how do you diagnose ectopic pregnancy?
1. SLOW-RISING HCG!!
2. transvaginal US
How do you treat ectopic pregnancy?
1. methotrexate and folic acid
2. surgical removal
3. FOLOOW UP HCG and pelvic exam
What is the most common malignancy of young men (20-40 yo)
What type of cells are testicular CA?
germ cell tumors
What are risk factors of developing testicular CA?
3. frequent UTIs
4. lots of sec partners
What type of testicular CA is radiosensitive?
What type of testicular CA is more aggressive?
What testicular CA tumor secretes AFP but not beta hcg?
Patient presents with painless, solid testicular swelling?
How do you dx testicular CA?
1. scrotal US
2. CXR (for staging)
3. hcg (can cause gynecomastia)
4. tumor markers (beta hcg, AFP)
How do you treat testicular CA?
1. orchiopexy (cut out testes)
What type of cells make up prostate CA?
How do you grade prostate CA?
1: well differentiated
2: poorly differentiated
(add 2 prostate biopsies together and get score 2-10)
How do you diagnose prostate CA?
2. BIOPSY!! (radionuclide bone screen for metastatic disease)
What is the gold standard of treatment for prostate CA?
removal of gland!!
What are cons to PSA screening?
1. unnessary testing (will likely die from something else)
2. risk of biopsy
3. risk of treatment
4. NOT SPECIFIC (PSA elevates in BPH, prostatitis)
Patient presents with high fever, chills, low back pain, perineal pain and irritable bladder sxs?
What are common causes of acute prostatitis?
1. E. coli
What is the cause of primary hypogonadism?
What is the cause of secondary hypogondasim?
axis problems (hypothalamic, pituitary)
A patinet has low testosterone/sperm count and HIGH LH/FHS
What lab findings would you expect in someone with secondary hypogonadism?
1. low testosterone
2. normal/low FSH/LH