Exam 2 Flashcards
(167 cards)
1
Q
physiological consequences of ovarian failure
A
- vasomotor symptoms
- menstraul changes
- Sleep distrubances
- mood changes
- genital atrophy
- cardiovascular disease
- osteoporosis
2
Q
cessation of menses for 6 months
A
menopause
3
Q
average age of menopause
A
- 4
* 2 yrs earlier if a smoker and earlier if undernourished
4
Q
late menopause-age _____
premature ovarian failure- age ____
A
late- age 50
premature- 40
5
Q
amenorrhea, symptoms of estrogen deficiency, gonadotrophin (FSH/LH) in the menopause range
A
premature ovarian failure
*failure does not imply total cessation –> 5-10% have been able to conceive and deliver normal pregnancies because they may intermittently produce estrogen.
6
Q
symptoms:
hot flashes
vaginal dryness
dyspareunia
A
premature ovarian failure
*normal puberty, and regulr menses prior
7
Q
what labs do u check for premature ovarian failure
A
HCG (pregnancy)
prolactin
FSH
E2
additional labs: TSH, DEXA-scan, karyotype, auto-antibodies
*pelvic u/s and biopsy have no proven benefit
8
Q
implications of premature ovarian failure
A
- osteoporosis
- CHD
- hot flashes
- vaginal dryness
9
Q
treatment of premature ovarian failure
A
estrogen therapy/OCPs
*used to prevent complications of low estrogen state
10
Q
what menopause stage?
cycle irregularity –> increased FSH, normal/high estradiol secretion (increased aromatase activity), low luteal progesterone secretion
A
early menopause
11
Q
what menopause stage?
increased cycle variability, FSH and estradiol levels fluctuate
A
late menopause
12
Q
what menopause stage?
no estrogen secretion by ovary; LH continues to be released which causes the ovary to continue to produce and secrete androgens
A
postmenopause
13
Q
what is typically the 1st symptom in perimenopause/menopause
A
hot flashes/power surge
*75% of women affected
14
Q
symptoms: sleep disturbance anovulatory bleeding irregular bleeding UTI, incontinence sexual dysfucntion forgetfulness, irritability joint pain, dry skin, breast pain, migraines
A
perimenopause/menopause
*sometimes heavy bleeding during perimenopause
15
Q
How do you diagnose menopause?
A
- based on symptoms and mesnstrual cycle history
* 6 months of amenorrhea in a woman >45 yrs. w/ no biologic or physiologic cause (labs not routinely indicated: FSH/LH)
16
Q
DDX of menopause
A
DDX: hyperthyroidism, pregnancy, hyperprolactinemia, medications (IUDs, chemo, radiation)
17
Q
Increased FSH, variable cycle lengths, cessation of menstruation
A
menopausal transition
18
Q
describe what causes menopause
A
Declining ovarian response to FSH results in decreased estrogen–> no feedback to cause an LH surge–>therefore no ovulation, no progesterone from corpus luteum, no progesterone drop off and no bleeding
19
Q
why is there GU symptoms for menopause
A
due to less estrogen –> vaginal and urethral atrophy –> stress and urge incontinence from atrophic urethral changes and disrupted urethral seal, vaginal dryness, increased pH leading to increased vaginitis
20
Q
why is there sexual dysfunction with menopause
A
decrease estrogen –> decreased blood flow to vagina and vulva
21
Q
why are there skin/nails symptoms with menopause
A
increased testosterone leads to facial hair, skin is less elastic, nails become thin
22
Q
what is the most common age group of abortions
A
45-50y/o and 14-18 y/o
23
Q
risks associated with HRT
A
- thromboembolism (mostly in women with risk, E+P only)
- increased risk of Breast CA ( E +P only)
- increased risk of CHD (E+P only)
- increased risk of stroke (greater with E)
24
Q
HRT has shown to be beneficial for what?
A
menopause/perimenopause
osteoporosis
25
how do you treat menopause
HRT
| -low dose OCP (sadfe in non-smokes
26
alternative treatment options for menopause
1. vaginal lubricants (replens)
2. SSRIs/SNRIs
3. gabapentin
27
recommendations for HRT in menopausal women
1. short term therapy (2-3 yr but not more than 5 yrs)
2. use lowest dose possible
3. tailor to paitent's needs
4. women wit ha uterus need combination estrogen and progetin therapy
28
HRT for menopause is contraindicated in who?
1. Hx of breast CA/ovarian CA (R)
2. CAD (absolute)
3. Previous venous thromboembolism or stroke (absolute)
4. undiagnosed vaginal bleeding (absolute)
5. pregnancy (absolute)
6. severe liver disease (absolute)
7. acitve gallbaldder disease (R)
8. migraine HA (R)
9. atypical ductal hyperplasia of the breast (R)
10. MUST use a progestin with estrogen in women with a uterus (Estrogen-only if previous hysterectomy)****
29
___% of women have incontinence
| ---% of women in US have prolapse
20-40% of women in mid-life and beyond have some incontinence
16% have prolapse
30
why is prolapse more common in older women?
```
more childbirths
#1 risk factor for UI is childbirth
```
31
cystocele
bladder prolapse
| *most common
32
apex prolapse
vaginal prolapse
33
rectocele
retum prolapse
34
what is a prolapse?
hernia= tissue weakness, and a different organ falls into the bladder
35
"splint"
needing to enter a finger in the vagina in order to fully empty the rectum/stool in a rectocele
36
how do you exam for a prolapse
1. have pt. bare down or valsalva
| 2. do a split sepculum exam (Isolate and look at the front and back wall of the vagina)
37
treatments for prolapse
1. nothing- not life threatening but is uncomfortable
2. pelvic floor physical therapy
(Strengthen levator ani muscles with kegels)
3. Pessary
4. Surgery
38
what is the gold standard treatment for prolaspse
abdominal sacral colpopexy
(The upper vaginal vault is secured to the sacrospinous ligament with sutures, restoring vaginal wall support and correcting prolapse)
39
how do you repair a rectocele
suture based
| pull healthy tissue to create a shelf
40
what is a normal amount to void urine
daytime: no more than once every 2 hrs (8-12x/day)
nighttime: 1-2x
41
nocturia
voiding more than 2x at night
42
complications of nocturia
sleep loss--> depression
43
available assessments for UI
1. history and physical (POP-Q)
2. Voiding diary
3. Post-void residual
4. Urine culture
5. Stress test
6. Q-tip test
7. Uroflow
8. Urodynamics
9. Cystoscopy
44
```
cough
sneeze
laugh
exercise
position change
```
stress UI
45
urgency
frequency
nocturia
dysuria
urge UI
46
hesitancy
interrupted flow
poor stream
incomplete void
overflow UI
47
hypermobile urethra
stress UI
48
detroucer mm. contracts too frequently “I know every bathroom in town”
urgency UI
49
UI caused by neurologic injury or DM
overflow UI
50
sections in a voiding diary
```
3 day diary
intake
output
frequency
activities associated w/ incontinence
insensible loss
```
51
what do you check for on PE when evaluating for UI
1. estrogen status
2. Neuro screening (bulbocavernosus and anal wink reflexes)
3. Anatomical defects resting and straining (POP-Q)
52
what nerves affect UI
S2, 3, 4 keeps your pee pee off the floor
53
Test that evaulate for UI
1. CST (cough stress test)
2. Postvoid residual (PVR)
3. Multichannel Urodynamics (UDS)
* don't do Q-tip test (no predictive outcome)
54
definitely abnormal PVR
>200cc
55
what is the Q-tip test suppose to detect
urethral hypermobility
56
- Uses instruments to measure and display physiologic functions of lower urinary tract
- Pressure catheter in bladder and vagina or rectum
- Pdet calculated
Multichannel Urodynamics (UDS)
57
indications for Multichannel Urodynamics (UDS)
1. Uncertain diagnosis (Findings don’t match complaint)
2. Complex history
3. Previous surgery
4. Patient not satisfied with initial treatment
5. Surgery planned in a complicated patient
6. Comorbid conditions
58
treatments for UI
```
Nonsurgical:
pelvic floor muscle training
bladder training
prompted voiding
lifestyle modifications
anticholinergic drugs
```
```
Surgical:
open retropubic colposuspension (burch procedure)
Sling procedure
Sacral neuromodulation
Botox
```
59
what lifestyle modifications can you do to help with UI
1. restrict fluid intake
2. avoid caffeine and alcohol
3. Minimze evening intake of fluids (quit drink 2 hrs before bed)
4. manage constipation
5. smoking cessation
6. treat pulmonary disease
* other irritants: white wine, vit. C, artificial sweetner
60
Frequent voluntary voiding to keep the bladder volume low
bladder training
61
- Bladder filling begins with an audible signal to let the patient know the bladder pressure is rising; tone varies with increasing pressure; bladder is repeatedly filled while patient focuses on suppressing detrusor contractions
- 1 hour session per week
biofeedback
| *also used for pelvic floor strengthening exercise
62
Mainstay of medical treatment for overactive bladder
anticholinergic drugs
63
how do anticholinergic drugs help UI
prevents spasming of the bladder
| *may cause dry mouth, eyes and consipation
64
Most commonly prescribed anticholinergic drugs
Oxybutinin (Ditropan)
Tolteridine (Detrol or Toviaz)
*typically takes 2-3 tries before finding one that works
65
sacral neuromodulation
“pacemaker” to the bladder to treat UI
(Minimally invasive, Minimal pain, Fluoroscopy, Simple technique)
-reversible
66
how does botox help UI
prevents bladder spasm
| *need repeat shot every 6 months
67
how many kegels should you do
30 each day with 10sec squeezing: 10 sec rest
68
first-line of treatment of USI
kegels
69
1st line of therapy for prolapse
pessaries (supportive donut-like ring that go behind pubic bone)
70
- Collagen, carbon-coated beads, fat
- Periurethral/transurethral Injection around bladder neck and proximal urethra
- “Washer effect”
Periurethral bulking agents
71
proposes that urinary incontinence results from a failure of the pubourethral ligaments in the mid-urethra, therefore treat with
therefore use tension-free vaginal tape
72
placed at the miduretrha to raise the urethra back into place – can be performed vaginally
TFT
| *likely new gold standard
73
refer to urogyn when?
- Symptoms do not respond to initial treatment within 2 to 3 months
- recurrent symptomatic UTI
74
dimpling or pulling of breast tissue occur when what is affected?
Cooper's ligament
75
how often do you perform a breast exam
1-3 yrs for women 20-39
annually if >40
*encourage breast awareness exams
76
how do u describe the location of a breast lump
use a clock-like description (3 oclock, 2cm from nipple)
77
women start having a mammogram yearly at what age
40
* in a pt with 1st degree relative w/ early onset of breast CA, start screening 10 yrs prior to relatives dx
(ex. mom dx at 45, start mammogram at 35)
* *could get false + if done too early
78
mammogram screening vs 3D (digital breast tomosynthesis)
- 3D allows for multiple view (screening has 2 views)
- 3D better for women with dense breast
- 3D has 8% more radiation
79
BI-RADS
breast imaging reportin and data system
| 1 inadequate pic, 2 neg---> 6 known bipsy-proven
80
why are breast u/s useful
differentiating between cystic and solid
81
when are breast MRIs recommended
for women with >20% CA risk
| *not good for screening bc a lot of false positives are picked up (high sensitivity, low specificity)
82
describe a malginant lump
poorly defined
usually less mobile
non-tender
may cause skin dimpling or nipple retraction
may have nipple discharge
may have overlying skin changes (pea d' orange)
83
how do u further assess a palpable lump
1. imaging
| 2. breast biospys (incisional or excisional) vs core-needle biospy or FNA
84
obtains clusters of epithelial cells
- interprets as bengin or mallignant
- higher insufficient sample rate
FNA
85
vacuum-assisted device that removes multiple cores of tissue
core needle
86
triple test
clinical exam
imaging
needle biopsy
*99% accurate when all 2 c/w benign lesion
87
mastodynia or mastalgia
severe breast pain >5 days/month
| *most common in perimenopausal women
88
when is cyclic breast pain worst
right before menses
89
tx of cyclic breast pain
1. NSAIDS or tylenol
-supportive bra
OCPs
limiting caffeine (not proven)
evening primrose oil
warm or cool compresses
90
what do u want to check out with non-cyclic breast pain
bilateral: PRL (prolactin) and BHCG (pregnany test)
| r/o musculoskeletal, cardiac, chest wall, meds, cyst, mass
91
Probable hormonal influence since _______ wax and wane with the menstrual cycle,
fibrocytic changes
* becoming more palpable (and tender) just prior to menses
* not a disease
92
how do u dx breast simple cysts
u/s
| sonolucent, smooth margins
93
how to tx breast simple cysts
- often go away on own or fluctuate w/ menstrual cycle
- can be aspirated if symptomatic
- can excise if recurrent
94
May see septations or intracystic masses
| Wall thickening or irregularity
complex cyst
| *require excision or biopsy
95
Benign, focal abnormality of a breast lobule
fibroadenoma
96
Feel rubbery, firm, well-marginated, very mobile, usually painless
fibroadenoma
97
how to f/u with fibroadenoma
Imaging at minimum with potential biopsy or excision
98
what is the most common cause of breast infection
S. aureus
99
Symptoms: localized swelling, erythema, pain, warmth, chills, fever, flu-like symptoms
Puerperal Breast Infections: mastisis
100
mastisis affects ___% of nursing moms
2-3%
101
how to treat Breast Infections: Puerperal
antibiotics (consider abscess if no improvment after 48 hrs)
| *Continue nursing, apply heat, avoid cracked nipples
102
examples of Breast Infections: Nonpuerperal
cellulitis
| abcess
103
olliculitis, infection of epidermal inclusion cysts
peripheral abcess
104
how do u tx an abcess
antibiotics or incision and drainage (I and D)
105
how do u tx cellulits
antibiotics
| *Uncommon, should prompt imaging if unresolved
106
arise from keratin-plugged milk ducts
subareolar abcess
107
how do u tx subareolar abcess
incision and drainage or duct excision
108
Mastitis Treatment
```
Course of abx for 7 – 10 days
Cephalexin**
Amoxicillin/Clavulante
Azithromycin
Dicloxacillin**
Clindamycin
*F/U w/ documented resolution is imperative
```
109
who expresses nipple discharge
40% of premenopausal women
55% of parous women
74% of women who have lactated in the last 2 yrs
110
Benign Characteristics of nipple discharge
White, green, or yellow
NOT spontaneous (after intercourse or shower)
Bilateral
111
pathologic characteristics of nipple discharge
Unilateral or single duct
Spontaneous
Persistent
Bloody/red, pink, orange, brown, black, or clear
112
causes of nipple discharge
Physiologic (Manual stimulation, traum)
Pathologic (Galactorrhea, prolactinomas, primary hypothyroidism)
-Pharmacologic (Psychoactive and antihypertensive agents, opiates, marijuana, estrogen-containing meds)
- Idiopathic
113
Gynecomastia
Literally means “female breasts”
| Men may have visible enlargement of breast or palpable change (often feels like a firm, rubbery subareolar mass)
114
cause of Gynecomastia
- Results from excess estrogen or estrogen/testosterone imbalance
- Symptom of physiological change, drug side effect (drugs that increase estrogen level), other disease, tumor, idiopathic
* Prevalence increases with age
115
Pathophysiological causes of gynecomastia
hypogonadism, hyper/hypo-thyroidism, ETOH-induced liver cirrhosis, testicular tumors, adrenal tumors
116
what is the prevalence of breast CA
1: 8
* Women are 6 times more likely to die from heart disease
* risk increases w/ age (median age 61)
* incidence is highest in white women but mortalitiy is higher in AA
117
most common CA in women
breast cancer > colorectal > lung
118
factors that increase ones risk of breast CA
1. female
2. age
3. genes (BRCA1/2)
4. Fhx
5. PMH
6. high breast tissue density
7. high-dose radiation to chest
8. never breastfed, no full term pregnancies, recent OCP use
9. alcohol
10. height
119
estimates a woman's risk of developing invasive breast CA over the next 5 yrs and in their lifetime (up to 90)
uses 7 risk factors
history of LCIS or DCIS
age
age at onset of menstration
age at the time of their first live birth
number of 1st degree relatives wiht breast CA
history of breast biopsy
race/ethnicity
Gail Model
120
When do u consider prophylatic Breast CA therapy for a woman?
5 year risk of > 1.7% according to Gail model
consider chemoprevention with tamoxifen/raloxifene (decreases rate of invasive breast cancer by 50% after 5 years of treatment)
121
>20% lifetime risk: consider annual mammography plus breast MRI, CBE every 6 mo., monthly BSE
tyrer-cuzik model = adds in famililal risk
122
True or False?
```
Most cases of
breast cancer are
a result of
inherited genetic
mutations
```
false
| *Genetic mutations likely account for between 5 and 10% of breast cancers
123
what types of genes are BRCA 1/2
tumor suppressor genes
| *Accounts for 3 – 5 % of breast cancers (10% of ovarian cancers)
124
Chromosome 17
More common
More aggressive tumors grade III, Her2/neu and ER-negative
More risk of ovarian CA (39 – 46%)
BRCA 1
125
Chromosome 13
Responsible for the majority of male breast cancers
Carries increased risk for pancreatic, prostate, and stomach CA, and melanoma
Risk of ovarian CA 12 - 20%
BRCA 2
126
screenig when BRCA +
- CBE twice a year + annual mammography and MRI beginning at age 25 years (or sooner based on earliest age onset in the family)
- "Periodic” CA 125 and transvaginal US starting at 30 yo (or 5 – 10 years before age of first ovarian CA diagnosis)
127
treatment for BRCA +
- Bilateral mastectomy reduces the risk of breast cancer by 90–95%
- BSO by age 40 years (or after childbearing) reduces ovarian cancer risk by 85–90% and breast cancer risk by 40 – 70%
- Tamoxifen reduces breast cancer risk by up to 62% in BRCA2 patients
128
different types of breast CA
Ductal carcinoma
(most common)
Lobular carcinoma
Other types
DCIS
LCIS
*non-invasive CA, well localized
129
Originates in the cells lining the milk ducts
>80% of all breast cancers are this type
invasive ductal carcinoma
130
10-15% of all breast cancers
Originates in the lobes of the breast
invasive lobular carinoma
131
1-5% all breast CA
Cancer cells block lymph vessels of the skin
Quite aggressive, often occurs in younger women and more common in AA women
Peau d’orange, inflamed appearance
inflammatory breast CA
132
Usually non-palpable and detected on mammogram
Often associated with calcifications
20% all mammographically detected cancers
DCIS (ductal carcinoma in situ)
| *Risk of progression to invasive cancer is unknown
133
treatment of DCIS
lumpectomy (+/- radiation) or mastectomy
134
Incidental finding
May require surgical intervention
Most helpful as marker for increased risk (20-30%) for invasive breast ca in either breast
LCIS (Lobular carcinoma in situ)
135
breast CA Prognostic Factors
```
Size: the smaller, the better
Grade: differentiation and rate of proliferation
ER/PR status
Her2/neu oncogene overexpression
Lymph node (LN) involvement
```
136
breast CA treament
1. chemo
2. surgery
3. radiation
4. endocrine therapy
137
tx type?
| Multiple regimens, often after surgery but may be pre-operative if large tumor, IV and oral agents
chemo
* tx 3-6 months
* Combination therapy best, anthracycline-containing regimens are usually best
138
tx type:
Lumpectomy (can be assisted by needle localization if non-palpable), mastectomy, sentinel lymph node biopsy, axillary dissection
surgery
139
____% dominant breast lesions are malignant
20%
140
a true hernia at the top of the vagina allowing the small bowel to herniate though
enterocele
141
```
what POP-Q stage?
no prolapse( (the the cervix is at least as high as the vaginal length)
```
stage 0
142
what POP-Q stage?
| leading edge is more than 1 cm beyond the hymen, but less than or equal to the total vaginal length
stage 3
143
what POP-Q stage?
| complete eversion
stage 4
144
what POP-Q stage?
| Leading part of prolapse is more than 1 cm above the hymen
stage 1
145
what POP-Q stage?
| leading edge is less than or equal to 1 cm above or below the hymen
stage 2
146
Procidentia
when the cervix descends beyond the vulva
147
a clear or milky breast discharge is usually bilateral and associated w/ stimulation or elevated prolactin levels
galactorrhea
148
bilateral salpingo-oophorectomy
removal of fallopian tubes and ovaries
149
intraductal growths composed of abundant stroma and lined by both luminal and myoepithelial cells
papillomas
150
Polythelia
extra nipples
151
Polymastia
extra breasts
152
an increase in the number of glands with associated lobular growth
adenosis
153
more than 2 cell layers on basement membrane
Epithelial Hyperplasia
154
increased fibrosis within the expanded lobule with distortion and compression of the epithelium
Sclerosing Adenosis
155
- a nidus of tubules entrapped in a densely hyalinized stroma surrounded by radiating arms of epithelium
- mimic an invasive carinoma
Radial Scar-
156
- intraductal growths composed of abundant stroma and lined by both luminal and myoepithelial cells
Papillomas
157
obliteration of the lumina of the glandular acini by a uniform population of small, atypical cells
*relaed to atypical lobular hyperplasia
LCIS
| *tx w/ excisional biopsy
158
the ducts are filled with atypical epithelial cells
DCIS
| *evaluate with core needle biopsy followed by surgical biopsy or excision
159
5-15% of all breast CA
| often multifocal and bilateral
invasive lobular carcinoma
160
70-80% of all breast CA
| most likely to spread to lymph nodes
invasive ductal carcinoma
161
stage breast CA based on what system
TNM
| tumor size, involvment of lymph nodes, and distant metastasis
162
used in the treatment of all stages of breast CA, regardless of lymph node status
-Includes chemotherapeutic drugs that kill CA cells and hormonal therapies such as tamoxifen that act as estrogen antagonists
adjuvant (systemic) medical therapy
163
prevent the production of estrogen in postmenopausal women
used to extend survival in women with metastatic CA, as a primary adjuvant therapy, an din conjunction with tamoxifen to prevent CA recurrence
aromaste inhibitors (AIs)
164
-acts on membrane-bound protein produced by Her2/neu
| 0if a pt's CA is found to overexpress Her2/neu protein,_____ can be given as adjuvant therapy
trastuzumab
165
f/u after breast CA treatment
- OB/gyn screens for the first 2 years (f/u every 3-6 months and then annually after that)
- annual mammography and PE continue indefinitely after that
166
what percentage of breast CA are due a BRCA + gene?
3-5%
167
what percentage of ovarian CA are due to BRCA + genes?
10%
