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Flashcards in Clin Med Deck (216):
1

How do you treat dysfunctional uterine bleeding?

NSAIDs!! (or Mirena IUD)

2

What are risks to developing urinary incontinence? (4)

1. age
2. hormonal status
3. birthing trauma
4. prolapse

3

How do you treat urinary incontinence?

anti cholinergics (oxybutinin, tolterodine)

4

How does vaginal neoplasia present?

can be flat, raised, white, red, black multicentric lesions

5

How do you treat bartholin's gland cyst?

1. none if asymptomatic
2. drain w/ ward catheter or massupialize
3. excision if recurrent

6

Patient presents with red/purple lesion on non-hair regions of vulva in HOURGLASS pattern with intense puritis

Lichen sclerosis

7

What are you at risk for with lichen sclerosis?

squamous cell carcinoma

8

How do you treat lichen sclerosis?

Stop scratch-itch cycle (steroids, topical high-potency then down titrate)

9

How do you diagnose bacterial vaginitis?

Amsler Criteria:
1. Thin, homogenous vaginal d/c
2. FISHY odor (KOH "whiff test")
3. clue cells (>20%)
4. Vaginal pH>4.5

10

Do you want to get a culture to confirm BV?

NO!

11

How do you treat bacterial vaginitis?

1. metronidazole
2. clundamycin

12

Patient presents with cheesy, white discharge and intense itching with inflamed vagina/vulva.

Candida infectious vaginitis

13

How do you treat vaginal candidiasis?

mild/moderate:
1.Imidazoles (clotrimazole, miconazole, nystatin) brief

14

Do you treat male sex partner of someone with vaginal candida?

Only if he has symptomatic balantis

15

What are common PMS sxs?

1. headache
2. breast pain
3. bloating
4. irritability
5. attitude change

16

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

17

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

18

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)

19

How do you dx amenorrhea?

Progesterone challenge! (expect withdrawl bleeding) Indirectly determines if ovary is producing estrogen

20

How do you treat amenorrhea if pregnancy is desired?

Induce ovulation (clomiphene citrate)

21

How do you treat amenorrhea if pregnancy is not desired?

1. OCPs
2. cyclic progesterone (esp. if OCPs contraindicated)

22

What is prolapsing if you see an anterior wall descent?

bladder

23

What is prolapsing if you see the posterior wall descending?

rectum

24

What is prolapsing in a central prolapse?

uterus

25

What are causes of prolapse?

1. age (esp. after menopause)
2. parity (esp. if over 2 deliveries)
3. obesity
4. chronic cough (increase intra-and pressure
5. chronic constipation

26

Patient presents with vaginal fullness, pressure and dyspareunia?

prolapse

27

How do you prevent getting prolapse?

1. kegel exercises (during PG)
2. consider estrogen therapy after menopause to maintain pelvic tissue tone

28

What is the most common gynecologic malignancy?

endometrial cancer

29

When is endometrial cancer most often seen?

7th decade

30

What is the most common type of endometrial CA?

Type 1

31

What are clinical features of type 1 endometrial CA?

1. unopposed estrogens
2. well differentiated
3. starts as hyperplasia
4. less aggressive

32

What are clinical features of type 1 endometrial CA?

1. endometrial atrohpy
2. undifferentiated
3. more aggressive

33

What are risk factors to developing endometrial CA?

1. obesity
2. metabolic syndrome
3. DM
4. PCOS
5. unopposed estrogen
6. Tamoxifen

34

How do you treat acute vaginal bleeding?

1. oral progestins
2. IV estrogen

35

How do you treat long-term vaginal bleeding?

1. low-dose OCP
2. progestin
3. Mirena IUD
4. Danazol
5. GnRH agonist
6. NSAIDs

36

Patient presents with metorrhagia, menorrhagia and dysmenorrhea and a mass is felt during bimanual exam

Leiomyomata (fibroids)

37

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
6. hysterectomy
7. uterine fibroid embolization

38

Patient presents with severe pelvic pain, dysmenorrhea, and dyspareunia

endometriosis

39

How do you confirm dx of endometriosis?

laparoscopy

40

How do you treat endometriosis?

1. NSAIDs
2. OCPs
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
6. surgery

41

What is the main cause of cervical CA?

HPV! (99% of cases!)

42

What is the most common pathology of most cervical CA?

squamous cell

43

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

44

What are clinical features of cervical CA?

1. irregular or heavy vaginal bleeding
2. postcoital bleeding

45

How do you dx cervical CA?

cervical biopsy

46

Where does cervical CA usually originate?

transformation zone (squamocolumnar junction)

47

How do you treat early stage cervical CA?

(confined to cervix,

48

What is the prognosis of someone with metastatic/recurrent cervical CA?

under 2 years

49

Which HPV strain is associated with HPV 16?

squamous cancer

50

Which HPV strain is associated with HPV 18?

adeocarcinoma

51

What is the screening schedule for paps?

1. every 3 years 21-29yo, NO HPV screening
2. 30-65, co-test every 5 years

52

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)

53

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

54

What is next step for LSIL?

Low-grade squamous intraepithelial lesion
-colposcpy?

55

What is next step for ASC-H?

atypical squamous cells, cannot exclude high-grade SIL
-colposcopy for all, no matter HPV status

56

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

57

What is next step for ACG?

atypical glandular cells
-colposcopy
-if over 35: endometrial sampling

58

What is the risk of CIN I?

most will regress in 1-2 years

59

What is the risk of CIN II?

5% will progress to cervical CA

60

What is the risk of CIN III?

12-40% will progress to cervical CA

61

What is the point of colposcopy?

magnifies cervix; diagnostic procedure to f/u abnormal pap

62

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

63

Patient presents with PURULENT vaginal discharge, intermenstrual bleeding and postcoital bleeding?

acute cervicitis

64

What are the usual causes of acute cervicitis?

Gonorrhea, chlamydia, Candida

65

What does acute cervicitis put you at risk for?

PID

66

What causes a strawberry cervix?

Trichomonas acute cervicitis

67

How do you dx acute cervicitis?

-test for Gonorrhea/chlamydia
-test for BV/trich (wet mount)
-r/o PID via bimanual exam

68

How do you treat acute cervicitis?

empiric abx

69

Patient presents with yellowish, translucent raised pearl-like lesions on ecto cervix?

Nabothian cysts

70

Patient presents with postcoital bleeding, and red friable growth protruding from cervical os?

cervical polyp

71

How do you treat cervical polyp?

remove with forceps and SEND TO PATHOLOGY!

72

What does FSH do during follicular phase?

recruits follicles

73

What does estrogen due during proliferative phase?

increased estrogen causes increased stratum functionalis

74

What happens at ovulation (hormone wise)?

FSH/LH surge cause Graafian follicle to rupture

75

How long is the oocyte viable for?

24 hours

76

What does the corpus luteum secrete during luteal phase?

progesterone

77

What does progesterone due during luteal phase?

it "quiets" uterine lining, making it conductive to implantation

78

How do you define infertility?

1. failure of couple to conceive after 12 months of regular intercourse
2. If over 35yo, after 6 months

79

What are common causes of female infertility?

1. ovulatory d/o (eating d/o, cushings, Turner, thyroid)
2. endometriosis
3. pelvic adhesions
4. HYPERprolactinemia

80

What are common causes of male infertility?

1. hypothalamic pituitary disease
2. testicular disease (Klinefelters, varicocele, epididymo-orchitis)
3. disorders of sperm transport

81

How do you get semen analysis?

1. 2-7 hours of abstinence
2. at least 2 samples 1-2 weeks apart

82

When would you immediately start to eval someone for infertility?

1. over 40yo
2. oligo/amenorrhea
3. h/o chemo, radiation
4. advanced endometriosis
5. male partner (mumps, impotence, ED, chemo)

83

How do you treat infertility?

1. smoking cessation
2. women decrease caffeine and alcohol

84

How do you define menopause?

1 year after LMP

85

What is the median age of menopause onset?

51yo

86

What is happening, hormonally, during menopausal transition?

1. decreased estradiol and progesterone
2. increased FSH

87

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

88

What are problems with unopposed estrogen treatment (in women with a uterus)

Increased endometrial CA risk

89

Why does adding progestin help reduce risk of endometrial CA?

helps shed uterine wall and reduce endometrial hyperplasia

90

What are other risks of estrogen therapy?

breast CA, CAD, CVA/DVT

91

What does HRT REDUCE the risk for?

fractures, colon CA

92

What are alternative treatments of vasomotor sxs other than HRT?

1. SSRIs (paroxetine)
2. SNRI (venlafaxine)
3. clonidine
4. gapapentin
5. progestin-only (breast CA risk still)
LIFE STYLE CHANGES! (exercise, cotton bedding, fans)

93

How do you treat vaginal atrophy?

1. vaginal estrogen
2. non-hormonal options (ospemifne, vaginal lube)

94

What is mastalgia?

breast pain

95

What are common sxs of cyclic breast pain?

1. heaviness/soreness
2. bilateral
3. severe upper outer quadrant
4. usually 1 week before menses (due to proliferation of normal glandular tissue)

96

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)

97

How do you dx breast pain?

1. breast exam
2. US (add mammo if over 30)

98

How do you treat breast pain?

1. usually self-limited
2. support garments
3. compresses
4. mild analgesics (acetaminiphen, advil)
5. evening primrose oil

99

What is the only FDA-approved treatment for breast pain?

Danazole

100

52 yo women presenting with abdominal distention, abdominal bloating, and urinary frequency and ascites

Ovarian CA

101

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
6. overweight

102

What are protective factors against ovarian CA?

1. OCPs
2. more than 1 full-term PG before 35yo
3. breast-feeding
4. tubal ligation
5. avoid TALC

103

What is the most lethal form of ovarian CA?

epithelial cell

104

What are the other 2 forms of ovarian CA?

1. germ cell (adenexal mass and germ cells, younger girls)
2. stromal cell

105

How do you diagnose ovarian CA?

transvaginal US

106

How do you treat ovarian CA?

1. surgery
2. chemo (radiation does not work well)

107

How do you clinically diagnose PCOS?

1. oligo or amenorrhea
2. hyperandrogenism (obesity, hirsutism)
3. evidence on US

108

What are complications of PCOS?

1. infertility (most common cause in women)
2. insulin resistance (higher risk for DM)
3. unopposed estrogen

109

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

110

How do you treat PCOS?

1. treat unopposed estrogen and insulin resistance
2. OCPs treat estrogen and hirsutism
3. Metformin
4. Clomiphene citrate for infertility (ovulation induction)
---higher risk for multiple gestations

111

What is the most common type of ovarian cyst?

follicular cyst

112

What causes follicular cysts?

result from failure to ovulate

113

What type of ovarian cyst occurs after ovulation?

corpus luteum cyst

114

When due theca-lutein cysts occur?

during pregnancy (molar gestation)

115

What is a theca-lutein ovarian cyst?

Teratoma

116

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

117

What type of cell does LH stimulate?

thecal cells

118

What do theca cells produce?

androgens

119

What does inhibin do?

released via FSH and negative feedback on FSH

120

What stimulates granulosa cells?

FSH

121

What do granulosa cells do?

1. oocyte development
2. inhibin
3. estrogen

122

A patient presents with rash, fever/malaise, headache and alopecia (with a moth eaten appearance)

secondary syphilis

123

What is the treatment for secondary syphilis?

Pen G IM once (or doxy PO x14days)

124

What else can HPV cause other than cervical CA?

genital warts

125

What is the treatment for HPV?

1. patient application: podofilox or imiquimod
2. provider application: cryotherapy, surgery

126

Male presents with runny white penile discharge and dysuria

chlamydia trachomatis

127

How do you dx chlamydia?

NAAT

128

How do you treat chlamydia?

Azithromycin 1g PO x1 (or doxycycline x7 days)

129

When do you f/u chlamydia?

NO f/u needed unless:
1. pregnant
2. compliance questions
3. reinfection

130

What is a hallmark of gonorrhea?

antibiotic resistance

131

Male presents with thick white/yellow penile discharge and dysuria

gonorrhea

132

How do you treat gonorrhea?

Ceftriaxone IM single dose PLUS azithromycin PO single dose

133

When do you f/u gonorrhea?

3 months after treatment

134

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

135

When should mammos be started if there is a family history?

40yo

136

Why is there controversy of when to start mammos?

1. unnecesary work up
2. increased radiation exposure

137

What is the gold standard for eval of a mass to determine if it is solid or cystic?

aspiration/biopsy

138

What is the most common non-invasive breast CA?

Ductal carcinoma in situ

139

What is the most common type of breast CA?

Invasive ductal carcinoma (IDC)

140

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)

141

What is the 2nd most common type of breast CA?

invasive lobular

142

How do you dx inflammatory breast CA?

skin punch biopsy

143

Where are common sites of breast CA metastasis?

1. lymph nodes
2. muscles, fatty tissue, SKIN
3. bones
4. bone marrow
5. liver
7. lungs
8. brain

144

Woman presents with localized, painful inflammation of breast associated with fever and malaise?

lactational mastitis

145

What is the usual culprit of lactational mastitis?

staph aureus

146

What happens if you leave lactational mastitis untreated?

local abscess

147

How do you treat lactational mastitis?

1. Dicloxacillin
2. Clindamycin (MRSA)

148

What is the breast "triple test" that will make you never miss breast CA dx?

1. PE
2. mammo w/US
3. needle biopsy (fine needle aspiration, core needle biopsy)

149

22 yo presents with solid, firm and mobile mass that is "rolled to an edge"

fibroadenoma

150

How do you dx fibroadenoma?

core needle biopsy

151

Patient presents with a solitary, fluid-filled mass that is influenced by hormonal fluctuation?

breast cyst

152

How so you treat breast cyst?

1. fine needle biopsy
2. following aspiration-- 2-4 month f/u to document stability

153

What are features of pathologic nipple discharge?

1. spontaneous (not just with compression)
2. unilateral
3. confined to one duct
4. bloody
5. clear, yellow, white, dark
6. associated w/mass
7. over 40yo

154

What are features of benign nipple discharge?

1. discharge only w/compression
2. bilateral
3. multiple ducts
4. fluid may be clear, yellow, white, dark green

155

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)

156

What is the second stage of labor?

full dilation to delivery (30min- 3hr; 5-60min)

157

What is the third stage of labor?

separation and expulsion of placenta (0-30 min)

158

How often should you monitor FHR?

1. every 30 min in active labor
2. every 5-15min in 2nd stage

159

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

160

What are indications for a C-section?

1. repeat C-section
2. dystocia
3. failure to progress
4. breeched
5. fetal distress

161

Patient presents with retraction ring across uterus between symphsis and umbilicus

Uterine rupture

162

What are risks of uterine rupture?

1. high parity
2. previous C-section
3. overstimulation with oxytocin

163

What classifies as postpartum hemorrhage?

blood loss over 500cc with vaginal birth and over 1000cc with c-section

164

What are the 3 ps of complicated labor?

1. power (uterine contractions, maternal effort)
2. passenger (baby)
3. passageway (bone of pelvis)

165

What are risk factors for complicated delivery?

1. occiput posterior position
2. nullparity
3. postterm
4. epidrual
5. short stature

166

What is the major risk of premature rupture of membrane?

INFECTION (choriomionitis, endometriosis)

167

What do you want to avoid with premature membrane rupture?

AVOID digital exam

168

How do you treat PROM? PPROM?

PROM (after 37 weeks): induce labor
PPROM (before 37 weeks): hospitalized w/bed rest

169

What is the most common cause of third trimester bleeding?

placenta abruption

170

What are risk factors for placenta abruption?

1. trauma
2. smoking
3. htn
4. low folic acid
5. cocaine
6. alcohol
7. high parity

171

What is placenta abruption?

premature separation of placenta after 20th week gestation, before birth

172

Pregnant lady presents with painless vaginal bleeding?

placenta previa

173

What is placenta previa?

occurs with placenta partially or completely covers cervical os

174

What is contraindicated with placenta previa?

digital exam

175

Pregnant lady with abnormal vaginal bleeding and a big uterus has US that shows grapelike vesicles and snowstorm pattern

gestational trophoblastic disease

176

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)

177

What are major complications of PID?

1. infertility
2. ectopic pregnancy

178

How do you diagnose PID?

1. GC/chlamydia probe
2. transverse vaginal US

179

How do you treat PID?

1. Mild-- abx, antipyretics, bed rest
REMOVE IUD if present
2. severe-- hospitalization

180

What are complications of gestational DM?

1. preeclampsia
2. big baby
3. should dystocia
4. premature birth
5. fetal demise
6. delayed fetal lung maturity

181

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

182

How do you treat gestational DM?

1. diet and exercise
2. daily glucose log

183

What is the classic triad of preeclampsia?

1. htn (starting after 20 weeks gestation)
2. edema
3. proteinuria

184

What is severe preeclampsia?

H: hemolysis
E : elevated
L: liver enzymes
L: low
P: platelets

185

What are risks for getting preeclampsia?

1. nulliparity
2. age (under 20, over 35)
3. multiple gestation
4. DM
5. htn
6. CKD

186

What are maternal complications of preeclampsia?

1. abruptio placenta
2. renal failure
3. cerebral hemorrhage
4. pulm edema
5. DIC

187

What are fetal complications of preeclampsia?

1. hypoxia
2. low birth weight
3. preterm
4. perinatal death

188

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

189

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

190

How do you treat preeclampsia?

labetalol
magnesium sulfate

191

When do you give rhogam?

1. at 28 weeks for Rh negative women
2. w/i 72 hours of delivering Rh+ infant

192

What are risks of developing ectopic pregnancy?

1. recent IUD
2. h/o PID
3. infertility treatments
4. h/o ectopic pregnancy

193

Patient presents with unilateral adnexal pain, spotting and tendernss on pelvic exam

ectopic pregnancy

194

how do you diagnose ectopic pregnancy?

1. SLOW-RISING HCG!!
2. transvaginal US

195

How do you treat ectopic pregnancy?

1. methotrexate and folic acid
2. surgical removal
3. FOLOOW UP HCG and pelvic exam

196

What is the most common malignancy of young men (20-40 yo)

testicular CA

197

What type of cells are testicular CA?

germ cell tumors

198

What are risk factors of developing testicular CA?

1. cryptochidism
2. uncircumcised
3. frequent UTIs
4. lots of sec partners

199

What type of testicular CA is radiosensitive?

seminoma tumors

200

What type of testicular CA is more aggressive?

Non-seminoma tumors

201

What testicular CA tumor secretes AFP but not beta hcg?

Non-seminoatous tumor

202

Patient presents with painless, solid testicular swelling?

testicular CA

203

How do you dx testicular CA?

1. scrotal US
2. CXR (for staging)
3. hcg (can cause gynecomastia)
4. tumor markers (beta hcg, AFP)

204

How do you treat testicular CA?

1. orchiopexy (cut out testes)
2. chemo
3. carboplatin

205

What type of cells make up prostate CA?

adenomatous cells

206

How do you grade prostate CA?

Gleasons Grading:
1: well differentiated
2: poorly differentiated
(add 2 prostate biopsies together and get score 2-10)

207

How do you diagnose prostate CA?

1. DRE
2. BIOPSY!! (radionuclide bone screen for metastatic disease)

208

What is the gold standard of treatment for prostate CA?

removal of gland!!

209

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)

210

Patient presents with high fever, chills, low back pain, perineal pain and irritable bladder sxs?

prostatitis

211

What are common causes of acute prostatitis?

1. E. coli
2. trauma

212

What is the cause of primary hypogonadism?

testicle failure

213

What is the cause of secondary hypogondasim?

axis problems (hypothalamic, pituitary)

214

A patinet has low testosterone/sperm count and HIGH LH/FHS

primary hypogonadism

215

What lab findings would you expect in someone with secondary hypogonadism?

1. low testosterone
2. normal/low FSH/LH

216

How often do you want to recheck testosterone levels?

every 2-3 months