General gynecology Flashcards
(297 cards)
1
Q
what is labial fusion
A
congenital anomaly
associated with excess androgens
develop abnormal genitalia
treat with estrogen cream
2
Q
what is imperforate hymen and how do you treat it
A
congenital abnormality
junction between the sinovaginal bulb and the UG sinus is not perforated
obstructs flow
manifests as primary amenorrhea at puberty, hematocolpos (blood behind hymen)
tx is surgery
3
Q
what are vaginal septums
A
congenital anomaly
when vagina forms, sinovaginal bulbs and mullerian tubercles must be canalized –> if not, you get a transverse vaginal septum between the lower 2/3 and upper 1/3
leads to primary amenorrhea
treat with surgery
4
Q
how do you treat the congenital anomaly of vulvar hypertrophy
A
you get raised white lesions from irritation–> treat with cortisone cream BID
5
Q
what is a bartholin’s cyst and how do you treat it
A
at 4 or 8 oclock on the labia minora
treat with sitz baths
if infected, do I and D or word catheter
6
Q
what causes fibroids
A
estrogen dependent local proliferation of smooth muscle cells, usually in women of child bearing age and then they regress at menopause
has pseudocapsule of compressed muscle cells
are found in 20-30% of american women at age 30
7
Q
what population is at higher risk for uterine fiberoids
A
african american women
8
Q
signs and symptoms of fibroids
A
menorrhagia (submucous)
metrorrhagia (subserous, intramural)
pressure symptoms (from pressing against bladder)
infertility
50% are asymptomatic
9
Q
what are parasitic fibroids
A
get their blood supply from the omentum
10
Q
what histologic changes can be associated with fibroids
A
hyaline change
cystic change
calcific change
fatty change
red/white infarcts
sarcomatous change (most rare)
11
Q
what are the risks associated with fibroids in pregnancy
A
spontaneous abortion
IUGR
PTL
dystocia
fibroids may grow during pregnancy
12
Q
what are the medical treatment options for fibroids
A
depo provera
lupron (GnRH antagonist)
danazol
13
Q
what are the surgical treatment options for fibroids
A
momectomy (only for fertility purposes)
hysterectomy is indicated if anemic from bleeding, severe pain, size above 12, urinary frequency, growth after menopause
there is a new role for embolization with IR
14
Q
define endometrial hyperplasia
A
abnormal proliferation of gland/stromal elements and overabundance of HISTOLOGICALLY NORMAL epithelium
15
Q
what is the risk of cancer, and how do you treat, endometrial hyperplasia that is:
simple without atypia
A
1% cancer
provera
16
Q
what is the risk of cancer, and how do you treat, endometrial hyperplasia that is:
complex without atypia
A
3% cancer
provera
17
Q
what is the risk of cancer, and how do you treat, endometrial hyperplasia that is:
simple with atypia
A
9% cancer
provera versus hysterectomy
18
Q
what is the risk of cancer, and how do you treat, endometrial hyperplasia that is:
complex with atypia
A
27% cancer
hysterectomy
19
Q
what are risk factors that predispose you to endometrial hyperplasia
A
unopposed estrogen
PCO
granulosa/thecal tumours
20
Q
how do you diagnose endometrial hyperplasia
A
endometrial biopsy
21
Q
define adenomyosis
A
endometrium in myometrium
22
Q
how does adenomyosis usually present
A
30 yo multiparous woman with HEAVY, PAINFUL periods
enlarged uterus that is either boggy/soft or woody/firm with pelvic heaviness
23
Q
how do you treat adenomyosis
A
hysterectomy with analgesia
24
Q
define pelvic endometriosis
A
presence of endometrial glands outside of endometrium
25
what are the theories of why pelvic endometriosis develops
1. sampson's reflux menstruation--> most likely
2. coelomic metaplasia--> irritant to peritoneum
3. family history/genetic
4. immunologic
5. lymphatics and vascular mets
6. iatrogenic dissemination (ie see it on the other side of a C/S scar)
26
why do you do get pain with pelvic endometriosis
induces fibrosis which causes pain
27
signs and symptoms of pelvic endometriosis
pain
infertility
bleeding/ovarian dysfunction
hematochezia/hematuria
dyspareunia
28
where might you find endometrial tissue in a woman with pelvic endometriosis
peritoneum
ovary ("chocolate cysts")
round ligament
fallopian tubes
sigmoid colon
29
how do you diagnose endometriosis
laparoscopy
30
how do you treat pelvic endometriosis
NSAIDS
OCP/provers
luprin (GnRH agonist)--> induces pseudomenopause
laser surgery/coagulation of implants
TAH/BSO
31
what is the usual cause of ovarian cysts
usually follicular from failure of follicle rupture--> often disappear within 60 days
3-8 cm
32
what are the types of ovarian cysts
1. corpus luteum cysts--> firm/solid
2. cystic/hemorrhagic--> hemoperitoneum
3. theca lutein--> bilateral, filled with straw fluid, high beta hCG
33
how do you diagnose ovarian cysts
ultrasound
Ca125 in cases where ovarian cancer is suspected
34
what is the differential diagnosis for ovarian cysts
ectopic pregnancy
tuboovarian abscess
torsion
endometriosis
neoplasm
35
treatment for ovarian cysts
if premenopausal--> can observe if size is below 8 cm
if post menopausal (any size) or premenopausal above 8 cm--> needs laparoscopy vs. laparotomy for cystectomy or oophrectomy
36
how do you diagnose chlamydia trachomatis
direct fluorescence antibodies
37
how do you treat chlamydia trachomatis
doxycycline 100 mg BID for 7 days
-or-
azythromycin 1g PO (one dose)
38
how do you diagnose gonorrhea
gram stain and culture
39
what are the risk factors for gonorrhea
low socioeconomic status
urban
nonwhite
early sex
previous gonorrhea infection
40
how do you treat gonorrhea
treat both partners
Cipro 500 mg PO
usually transfers male to female more than female to male
41
what organism causes syphilis
treponema pallidum
42
how do you diagnose syphilis
dark field microscopy
43
how do you treat syphilis
if less than 1 year duration--> pen G 2.4 million U IM
if more than 1 year duration--> pen G 2.4 million U IM x 3 doses
44
how do you treat HSV
first episode--> acyclovir or valcyclovir
45
what is the natural history of HSV
of the genital eruptions, 66% are due to HSV 2 and 33% due to HSV 1
vesicles rupture in 10-22 days leaving a painful ulcer
can use antivirals also as suppressing agents as the virus hangs out in the dorsal root ganglion
46
what types of HPV cause genital warts
6 and 11
47
what types of HPV cause cervical cancer
16, 18, 31
48
what is the treatment for HSV
podofilox
cryotherapy
podophyllin rein
TCA
aldara cream
49
what is a chancroid
caused by haemophilus ducreyi
painful soft ulcer with inguinal LAD
50
how do you treat a chancroid caused by haemophilus ducreyi
ceftriaxone 250 IM once
-or-
azythromycin 1 g once PO
-or-
erythromycin
*treat partner
51
how does lymphogranuloma venerum present
primary--> papules/shallow ulcer
secondary--> painful inflammation of inguinal nodes with fever, headache, malaise, anorexia
tertiary--> rectal stricture, rectovaginal fistula, elephantitis
52
how do you treat lymphogranuloma venerum
doxycycline 100 mg PO BID for 21 days
53
what is molluscum contagiosum
pox virus from close contact
1-5 mm umbilicated lesions anywhere except for the palms or soles of feet
are asymptomatic and resolve on their own
54
what are risk factors for candida
antibiotic use
pregnancy
diabetes
immunocompromised
55
signs and symptoms of candida
burning, itching
vulvitis
cottage cheese discharge
dyspareunia
56
how do you diagnose candida
wet prep with KOH shows BRANCHING HYPHAE
57
what do you see on exam for candida
white plaques with or without satellite lesions
58
how do you treat candida
over the counter creams work well (monistat)
if resistant--> DIFLUCAN 150 mg PO once
59
what organism causes trichomonas
unicellular flagellated protozoan
60
signs and symptoms of trichomonas
itching
increased discharge that is yellow/gray/green and frothy
61
what do you see on exam for trichomonas
strawberry cervix
foamy discharge
62
how do you diagnose trichomonas
"see the buggers zipping all over your wet prep"
63
how do you treat trichomonas
metronidazole 500 mg PO BID for 7 days
use a condom with partner for 2 weeks
*avoid metronidazole in first trimester
64
what organism causes bacterial vaginosis
gardnerella vaginalis
65
signs and symptoms of bacterial vaginosis
odorous discharge
66
how do you diagnose bacterial vaginosis
whiff test by adding KOH
see clue cells on wet prep (spotty squamous cells)
67
how do you treat bacterial vaginosis
metronidazole 500 mg BID for 7 days
68
is bacterial vaginosis and STI
no
69
what are the symptoms of vaginal atrophy
burning on sex
occurs post menopausal
treat with estrogen
70
what organisms cause PID
```
neisseria
chlamydia
mycoplasma
ureaplasma
bacteroides
among others...
```
71
symptoms of PID
```
diffuse lower abdo pain
vaginal discharge
bleeding
dysurina
dyspareunia
CMT
adnexal tenderness
GI discomfort
```
72
how do you diagnose PID
cervical motion tenderness
adnexal tendereness
discharge
fever
elevated WBC
elevated ESR
*mostly based on clinical exam
73
what labs should be ordered if PID suspected
cultures
pelvic U/S if mass is palpated
monitor WBCs
74
how do you treat PID
ceftriaxone 2 g IV q12, doxycycline 100 mg IV or clinda-genta
usually treat for 48 hours IV then if afebrile step down to doxycycline 100 mg PO BID for 14 days
75
what can be a complication of PID
tubo ovarian abscess (TOA)
persistent PID progresses to TOA in 3-16% of cases
presents as adnexal fullness/mass (not walled off like a true abscess)
76
how do you diagnose TOA
U/S
pelvic CT if obese
increased WBC with left shift and increased ESR
77
how do you treat TOA
hospitalize for IV abx--> triple therapy with ampicillin, gentamycin, clinda
if TOA ruptures or doesnt resolve--> surgery
78
what is toxic shock syndrome
vaginal infection not associated with menstruation
can be assoc with delivery, C/S, post partum endometritis, spontaneous abortion or laser treatment
79
what is the causative agent and process behind TSS
STAPH AUREUS produces epidermal TSS T-1 that produces fever, erythematous rash, desquamation of palmar surfaces and hypotension
can also see GI disturbance, malaise, mucous membrane hyperemia, change in mental status
80
what might you see on labs in TSS
increased BUN/Cr
decreased platelets
NEGATIVE BLOOD CX
81
treatment for TSS
ALWAYS HOSPITALIZE
may need ICU and IV fluids and/or pressors
antibiotics do not shorten the length of the acute illness but they do decrease the risk of recurrence
82
what type of muscle is the detrusor muscle and the urethra
smooth muscle
83
what is the innervation of micturition
PSNS--> S2, 3, 4 allows micturition via cholinergic receptors
84
what is the innervation of "holding" urine
SNS--> hypogastric nerves, T10-L2 prevents urination by contracting the bladder neck and internal sphincter via norepinephrine receptors
somatic control of external sphincter via pudendal nerve
85
what is the exam for pelvic relaxation defects caused
POP Q
stage 1--> prolapse upper 2/3 of vagina
stage 2--> to the level of the introitus
stage 3--> outside of the vagina
86
treatment for pelvic relaxation defects
kegels (contraction of levator ani)
estrogen replacement
vaginal pessaries
surgery
87
what causes urge incontinence
detrussor instability
88
symptoms of urge incontience
urgency
often cannot make it to bathroom
89
causes of urge incontinence
foreign body
UTI
stones
cancer
diverticulitis
90
diagnosis of urge incontinence
based on history
can be shown on urodynamic studies (catheter in bladder, rectum and machine to measure the difference...bladder is filled with NS and response to that filling is measured)
91
treatment for urge incontinence
kegel exercises
anticholingerics (ditropan, amytriptaline)
muscle relaxants
beta agonists
estrogen replacement
*surgery not used here, medical therapy more appropriate
92
what do urodynamic tests show in the setting of urge incontinence
involuntary/uninhibited bladder contraction
93
what are the symptoms of stress incontinence
involuntary loss of urine when there is increased abdo pressure mostly from sneezing, coughing, laughing which transmits pressure to the urethra
94
what is the mechanism of stress incontinence
intrinsic sphincter defect
hypermobile bladder neck
pelvic relaxation
95
what are the causes of stress incontinence
trauma
neuro dysfunction
associated with multiparity
96
treatment for stress incontinence
kegels
alpha agonists
estrogen cream
retropubic urethroplexy
trans vaginal tape procedure
97
what is a retropubic urethroplexy
surgery in which the periurethral tissue is joined with cooper's ligament --> BURCH
98
what is a trans vaginal tape procedure
periurethral tissues are raise towards the abdo wall using a mesh sling placed under local anesthesia
99
symptoms of overflow incontinence
dribbling
urgency
stress
100
mechanism of overflow incontinence
underactive detrussor muscle leading to poor or absent bladder contractions
101
causes of overflow incontinence
DM
drugs
fecal impaction
MS
neuro impairment
102
treatment for overflow incontinence
treat underlying cause
Hytrin
bethanechol
intermittent catheterization
dantroleen
103
diagnosis of overflow incontinence
urodynamic studies
post void residual scan (over 100 cc is abnormal)
104
what are the risk factors for urinary fistula
PID
radiation
endometriosis
prior surgery
105
what are the symptoms of urinary fistula
produces continuous urine leakage commonly following pelvic surgery/radiation
106
how do you diagnose urinary fistula
methylene blue dye injection into the bladder --> place tampon in vagina--> if there is a vesicovaginal fistula, tampon will be blue
indigo carmine due given IV with tampon in vagina--> if ureterovaginal fistula, tampon will be blue
107
treatment for urinary fistula
surgery--> must wait 3-6 months to repair post surgical fistulas
108
what happens during puberty
secondary sex characteristics develop
growth spurt
achievement of fertility
109
define adrenarche
6-8 years old
regenerates zona reticularies that produces DHEA-S, DHEA and androsteinone
110
define gonadarche
pulsatile GnRH secretion goes into anterior pituitary to secrete LH, FSH
111
define thelarche
around age 11
breast formation--> tanner stages
112
define pubarche
around 12 years old
pubic hair and axillary hair development
113
when do girls usually have their growth spurt
age 9-13
114
what happens during the growth spurt
increase GH and somatomedian-C result in peak height velocity, increased estrogen levels, fusion of growth plates
115
when does menarche usually occur
ages 12-13
anovulatory period of up to 1 year
may take 2 years to have regular cycle
delayed in athletes
116
what is a pneumonic to remember the tanner stages in women
boobs pubes pits pads (breast, hair, grow, bleed)
117
what are the tanner stages of the breast
1. prepubertal
2. breast bud
3. breast elevation
4. areolar mound
5. adult contour
118
what are the tanner stages of hair
1. prepubertal
2. presexual hair
3. sexual hair
4. mid-escutcheon
5. female escutcheon
119
what is menopause
cessation of menstruation
120
when does menopause usually occur
ages 50-51
if below 40 years--premature
if below 35 years--premature ovarian failure
121
what are the symptoms of menopause
irregular menses
hot flashes secondary to decreased estrogen
mood changes
depression
lower urinary tract atrophy
genital changes
osteoporosis
122
what lab values indicate menopause
FSH above 40
elevated LH
decreased estrogen resulting in decreased negative feedback
123
how do you diagnose menopause
history and physical
PE shows decreased breast size with vaginal, urethral and cervical atrophy due to decreased estrogen
124
how do you treat the symptoms of menopause
HRT --> primarily estrogen and progesterone if patient has uterus
calcium
vit D
exercise to counter decreased osteoclast activity
estrogen cream to counter vaginal atrophy
125
what are contraindications to HRT
vaginal bleeding
thromboembolic disease
breast ca
uterine ca
126
why do we not recommend unopposed estrogen in women with a uterus
without progesterone, it can result in endometrial hyperplasia and cancer
127
what are the consequences of decreased estrogen
unfavorable lipid profile that can result in stroke or MI
increased bone resorption because estrogen decreases osteoclast activity predisposing to fractures etc
atrophy and skin and muscle tone
128
are there problems taking estrogen alone when u dont have a uterus
no
129
what happens if an otherwise phenotypically normal female has a Y chromosome
Y chromosome makes mullerian inhibitory factor--> no uterus if MIF present
130
what hormone is responsible for breast development
estrogen
131
what is the problem in a women who has a uterus, but no breast development
NO ESTROGEN
if FSH high--> ovarian failure (hypergonadotropic hypogonadism)
- -Turner's is another cause--ovaries undergo rapid atresia
- -can be mosaic
- -can be due to 17 hydroxylase deficiency--> MIF is produced so no female internal organs
- -can be due to pure gonadal dysgenesis
if FSH low--> insufficient GnRH, hypopituitarism, gonadal agenesis, 46 xy with testes not developing because MIF NOT released (external female genitalia but no breasts)
132
what does 17 hydroxyalase deficiency cause
MIF is produced so no female internal organs
133
what is the problem if a woman has breasts but no uterus
estrogen in the presence of MIF
Rokitansky Kuster Hauser--> uterovaginal agenesis with other anomalies (46xx)
Androgen insensitivity--> 46 xy; testicular feminization because no receptors for testosterone--> MIF is secreted therefore no mullerian structures
134
what is the problem if there is no breasts or uterus
xy genotype--> i.e 17 hydroxylase deficiency
135
what are some causes of primary amenorrhea
genetic--> turners, ovarian failure, 17 hydroxylase deficiency, hypopituitarism, rokitansky kuster hauser, androgen insensitivity
anatomic--> imperforate hymen, transvaginal septum, vaginal agenesis, no patent vagina
136
what should you ask about in history for secondary amenorrhea
stresses
weight loss or gain
drugs
exercise
UPT
estradiol level
progesterone challenge
137
what does bleeding with the progesterone challenge indicate? what should you check next?
that there is enough estrogen
check FSH, LH and PRL next
138
if a patient with amenorrhea bleeds with the progesterone challenge and LH is high, what should you think?
PCO
139
if a patient with amenorrhea bleeds with the progesterone challenge and LH is normal what should you think
hypothalamic amenorrhea--> stress, exercise, post pill
140
if a patient with amenorrhea bleeds with the progesterone challenge and prolactin is increased, what should you think
prolactinoma
hypothyroid
pregnancy
141
what does no bleeding on progesterone challenge indicate
no estrogen
check FSH, LH, PRL
142
if a patient with amenorrhea does not bleed with progesterone challenge, and FSH is high, what should you think
ovarian failure or resistant ovarian syndrome
143
if a patient with amenorrhea does not bleed with progesterone challenge, and FSH is low or normal what should you think
check MRI/CT for pituitary tumous, sheehan's syndrome
144
other than hormonal causes, what can cause secondary amenorrhea
ashermans after D and C
cervical stenosis after CKC
145
what is Swyer's syndrome
46 xy
gonado-agenesis
no testes
no MIF
yields female genitalia but no breasts because no estrogen
146
what is Kallmans syndrome
absence of GnRH and anosomia
patients have breasts and uterus
147
what is testicular feminization
46xy
insensitive to testosterone
MIF so no internal female genital structures
has estrogen so has breasts
148
what are the probable causes of PMS
abnormal estrogen/progesterone balance
increased PG production
decreased endogenous endorphins
disturbance in RAAS sysytem
149
how do you diagnose PMS
5 of 12 symptoms, including one of first 4:
1. decreased mood
2. anxiety
3. affective lability
4. decreased interest
5. irritability
6. concentration difficulty
7. decreased energy
8. change in appetite
9. overwhelmed
10. edema
12. weight gain
13. breast tenderness
150
when does PMS occur
second 1/2 of cycle
151
what are some ways to mitigate the effects of PMS
avoid caffeine, alcohol, tobacco
low sodium diet
weight reduction
stress management
drugs--> NSAIDS, OCPs, lasix, calcium, vitamin E, SSRI
152
what is dysmenorrhea
pain and cramping during menstruation that interferes with acts of daily living
153
what is primary dysmenorrhea
presents at age below 20 years because of increased PG occurring with ovulatory cycles
154
what is secondary dysmenorrhea
```
endometriosis
adenomyosis
fibroids
cervical stenosis
adhesions
```
155
what is menorrhagia
heavy prolonged menstrual bleeding
over 80 mL per cycle (average is 35 mL)
more than 24 pads per day
156
what can cause abnormal uterine bleeding
```
fibroids
adenomyosis
endometrial hyperplasia
endometrial polyps
cancer
pregnancy complications
```
157
how should you manage AUB in a pubertal girl
give Fergon, NSAIDS and premarin until bleeding stops
check vWF
158
how do you manage AUB in a 16-40 year old woman
think endometriosis, adenomyosis, fibroids
EMB, OCPs
159
how do you manage AUB in over 40 year old woman
endometrial cancer
treat with EMB, depo provera, D and C, TAH
160
define metrorrhagia
intermenstrual bleeding
think endometrial polyps, endometrial/cervical cancer, pregnancy complication
161
define polymenorrhea
cycles are less than 21 days between periods
anovulation
162
define oligomenorrhea
cycles more than 35 days apart
due to disruption of gonadal pituitary axis or pregnancy
163
what are the causes of ovulatory bleeding
early--> estrogen is not increasing fast enough
mid--> estrogen drop off at ovulation
later--> progesterone deficiency
treat with NSAIDs which can decrease blood loss by 20-50%
164
how do you diagnose hirsutism/virilism
assess body hair systematically--> hair type is villus hairs which cover the entire body or terminal hairs become thick
free testosterone--> the OVARY produces the most testosterone
DHEAS--> ADRENAL produces the most DHEAS, screens for adrenal tumours
17 hydroxy progesterone--> CAH
165
define symptoms of hirsutism
increase in terminal hairs especially on face, chest, back
diamond shaped escutcheon in male
increased 5 alpha reductate
166
define symptoms of virilism
male features
deepening of voice
balding
increasing muscle mass
clitoromegaly
breast atrophy
male body habitus
167
possible causes of virilism/hirsutism
adrenal tumours
ovarian tumour
PCOS
cushings--> increases ACTH, cortisol
CAH--> 21 and 11 hydroxylase deficiency
168
what is PCOS
can include numerous ovarian cysts but is more than that--> includes:
insulin resistance (diagnosed by fasting glucose/insulin ratio less than 4.5)
hirsutism (from hyperandrogenemia)
anovulation (irregular heavy periods)
FSH: LH ratio above 2.5:1
169
how do you treat PCOS
metformin for insulin resistance
clomid for anovulation (if desires fertility)
170
define infertility
inability to achieve pregnancy after 12 months of unprotected intercourse
171
what are the causes of infertility
idiopathic--> 10%
male and female--> 10%
female causes--> 40%
male causes--> 40%
172
what are the categories of female causes of infertility
1. ovulatory
2. tubal
3. peritoneal
4. uterine
5. luteal phase defect
173
what are some of the ovulatory causes of infertility
anovulation
endocrine
PCOS
premature ovarian failure
174
how do you manage ovulatory causes of infertility
ovulation induction--> 70% success
CLOMID--> antiestrogen that results in increased FSH, more mature follicles and ovulation (side effects hot flashes, emotional lability, depression, multiple gestation)
PERGONAL--> purified FSH/LH HMG IM injection in follicular phase (85-90% effective)
IVF, GIFT, ZIFT--> ovulation induction, harvest oocytes, add sperm, fertilize, place in uterus
175
what are some tubal causes of infertility
adhesions
endometriosis
PID
salpingitis
176
how do you manage tubal causes of infertility
tubal reconstruction
177
what are some peritoneal causes of infertility
endometriosis
adhesions
PID
178
what are some uterine causes of infertility
asherman's
fibroids
179
how do you treat uterine causes of infertility
myomectomy for fibroids
180
how do you treat luteal phase defects
progesterone during and after conception
181
what are some male causes of infertility
cryptocordism
varicocele
epidydimitis
prostatitis
182
how do you manage male causes of infertility
intrauterine insemination
183
what are some meds that can decrease male fertility
cimetidine
colchicines
sulfalazine
allopurinol
erythromycin
steroids
tetracycline
184
what is the work up for infertility
sperm count--> FIRST
TSH, prolactin
HSG--> assess tubal patency and diagnose intrauterine defects
post coital test--> quality of mucus and sperm, done on day 12-14
BBT-temperature curve--> spike predictive of ovulation
progesterone day 21 level to assess ovulation
diagnostic scope to look for endometriosis
185
what is lichen sclerosis
thin skin, hyalinized collaged in the vulva
white plaques
186
how do you treat vaginal lichen sclerosis
clobetasol (high potency steroid)
187
what is extramammary paget's disease
intraepithelial neoplasia of the vulvar skin
find it in women over 60 with vulvar purities
presents as pale atypical cells with mitotic figures
20% have adenoca underneath
188
what are the symptoms of extramammary paget's disease
pruritus unrelieved by anti-fungals
189
how do you diagnose extramammary paget's disease
biopsy
190
how do you treat extramammary paget's disease
wide local excision, colposcopy
191
why do we care about extramammary paget's disease
20% have adenocarcinoma underneath
associated with other cancers--> GI, breast, cervical and with chronic inflammatory changes
scare yields red velvet and white plaques on labia
infranodal spread likely to be fatal
192
what is vulvar intraepithelial neoplasia
"VIN--> I, II or III"
dysplasia of the vulva
atypical, thickened skin
degree is proportioned to the number of mitotic figures
can see squamous pearls
193
in what population is VIN most common
post menopausal ages 50-60
194
what virus is correlated with VIN most of the time
HPV 80-90% of the time
195
what are the symptoms of VIN
diffused focal raised or flat white, red, brown or black lesions
vulvodynia
pruritus
196
treatment of VIN
excision with scalpel or laser
f/u colposcopy every 3 months until disease free then every 6 mo
197
what % of gyne malignancies are vulvar
5%
198
what other diseases are associated with vulvar cancer
DM
HTN
obesity
vulvar dystrophies
199
symptoms of vulvar ca
vulvodynia
pruritus
mass --> cauliflower look, hard, indurated
erythema
200
how do you diagnose vulvar ca
biopsy--> see EPIDERMOID in 90% of cases
melanoma 5-10%
basal 2-3%
201
how do you stage vulvar ca
I--> less than 2 cm, no nodes, no mets (Ia is less than 1mm)
II--> over 2 cm, no nodes, no mets but can progress to perineum, urethra and anus
III--> unilateral nodes of any size
IV--> bilateral nodes, mets
202
how do you treat vulvar ca
based on stage
ranges from wide local excision to vulvectomy to radical vulvectomy/lymph node dissection
203
what population is at highest risk of vaginal ca
women in their 50s
204
what % of paps may be false negative
40-50%
| lower in BC because centralized
205
what do "benign cellular changes" mean on an abnormal pap
think infection--wet prep and cultures are next step
206
what does "koilocytosis" mean on an abnormal pap
pathologic description associated with HPV
207
what does "ASCUS" mean on an abnormal pap
atypical squamous cell hyperplasia of undetermine significance
5% hide underlying severe lesions
repeat pap in 3 months, colposcopy is 2 come back as ASCUS
consider HPV typing
208
what does "LGSIL" mean on an abnormal pap
low grade squamous intraepithelial lesion
treat with colposcopy
209
what does "HGSIL" mean on an abnormal pap
high grade squamous intraepithelial lesion
treat with colposcopy
210
what is a colposcopy
magnifies region of the cervix after stained with acetic acid
areas of dysplasia stain WHITE (aceto white focal lesion) and are biopsied
an endocervical curretage is also done
211
how do you treat cervical dysplasia
based on biopsy and ECC result
212
how do you treat mild cervical dysplasia
observation and cryotherapy
213
how do you treat moderate cervical dysplasia
cryotherapy or LEEP
214
how do you treat severe cervical dysplasia
LEEP or cold knife conization (CKC)
215
list the 4 indications for CKC
microinvasion on biopsy
ECC with dysplasia
pap colpo discrepancy--> if pap smear does not correlate with the biopsy results i.e HGSIL with normal biopsy, you may have missed something and need to do CKC
inadequate colpo--> means there is a lesion extending into the os or that you could not visualize the whole lesion on colpo and may be something more extensive
216
what is ECC
endocervical curretage
217
where does most cervical cancer occur
transformation zone
218
what is a koilocyte
has a viral particle
assoc with HPV
219
which HPV types are oncogenic
```
33
35
52
16
18
```
220
which HPV types cause warts
6
| 11
221
what are the symptoms of cervical cancer
vaginal bleeding
discharge
pelvic pain
growth on cervix
may palpate or see mass on exam
222
what is the classic presentation of cervical ca
post coital bleeding
pelvic pain/pressure
abnormal vaginal bleeding
rectal or bladder sx
223
what are the types of cervical cancer
squamous large cell
keratinizing
non keratinizing
small cell (worst prog)
adenocarcinoma
mixed carcinoma
glassy cell--> pregnancy women, usually fatal
224
risk factors for cervical ca
tobacco
multiple sexual partners
age of onset of sex
number of STDs
HIV (cervical ca is an AIDS defining disease)
225
how do you stage cervical ca
based on microinvasion so MUST DO A CONE BIOPSY
0--> carcinoma in situ
I--> contained to cervix
II--> carcinoma beyond cervic, no sidewall
III--> pelvic sidewall, hydronephrosis
IV--> extends beyond pelvis
226
treatment of stage Ia cervical ca
cone biopsy, hysterectomy 100% cure
227
treatment of stage Ib/IIa cervical ca
radiation, radical hysterectomy (cervix, uterus, parametrium, LN)
228
treatment for stages IIb/III/IV cervical ca
extensive radiation and chemo
229
risk factors for ovarian tumours
family history
uniterrupted ovulation
nulliparous
low fertility
delayed childbearing
late onset menopause (OCPs have protective effects)
230
symptoms of ovarian tumours
asymptomatic until advanced stages
urinary frequency, dysuria, pelvis pressure, ascites
231
what are the types of ovarian tumours
1. non neoplastic
2. epithelial (80%)
3. germ cell
4. stromal
5. other
232
how do you treat non neoplastic ovarian tumours
only operate if post menopausal or if greater than 8 cm
233
what are the types of non neoplastic ovarian tumours
follicle cyst
corpus luteum hematoma
PCOS
theca lutein cysts
endometrioma
para ovarian cysts (mullerian)
234
what is the most common type of ovarian tumour
epithelial
235
what are the types of epithelial ovarian tumours
1. serous cystadenoma--> papillary, cystic, malignant, bilateral--> PSAMMOMMA BODIES
2. endometroid--> solid
3. mucinous--> cystic
4. clear cell--> associated with HOBNAIL CELLS on path, association with DES
5. Brunner--> look like transitional epithelium
6. SUET--> solid, undifferentiated
236
what are the types of germ cell ovarian tumours
1. dysgerminoma--> younger people, solid, radiosensitive, lymphocytic infiltrate
2. teratoma--> ectoderm, endoderm, mesoderm; rotikansky's protuberance
3. primary chriocarcinoma of the ovary
4. yolk sac tumour/endodermal sinus
5. mixed germ cell
237
what are the medical complications of ovarian teratomas
struma ovarii
autoimmune hemolytic anemia
carcinoid syndrome
238
what are the surgical complications of ovarian teratomas
torsion
acute abdo
239
what tests will be positive in primary choriocarcinoma of the ovary
false positive UPT
increased beta hCG
240
what tests will be positive in yolk sac/endodermal sinus ovarian tumours
AFP/LDH
schuller duval bodies
241
what tests will be positive in mixed germ cell ovarian tumours
HCG
AFP
LDH
Ca 125
242
what population is associated with stromal ovarian tumours
50-80 years old
243
what is the defining feature of a stromal ovarian tumours
hormone production
244
what are the types of stromal ovarian tumours and what are their symptoms
1. fibroma--> Meig's syndrome (ovarian tumour, right hydrothorax, ascites)
2. granulosa theca--> feminizing, late recurrence, Call Exner bodies, produce large amounts of estrogen
3. sertoli leidig--> masculinizing, secrete testosterone, crystaloids of reinke secrete androgens
4. gynadroblastoma--> components of male and female
245
how do you stage ovarian cancer
I--> growth to one or both ovaries
II--> extension to pelvic structures
III--> peritoneum
IV--> distant mets
246
what chemo is used in ovarian ca
cisplatin and taxol
247
what blood test is elevated in most ovarian cancers
Ca125--> follow
248
what are the characteristics of cancer of the fallopian tubes
adenoca from mucosa
disease progresses like ovarian ca
peritoneal spread
ascites
bilateral in 10-20% results from mets often
primary is very rare
asymptomatic but may have vague lower abdo pain and discharge
249
treatment for fallopian tube ca
TAH/BSO
cisplatin
cyclophosphamide XRT
250
define complete trophoblastic molar pregnancy
less than 20 years or above 40 years
80% of molar pregnancies are complete
worse because can transform into malignant (20%)
no baby parts
251
define incomplete trophoblastic molar pregnancy
triploid (usually XXY)
may have baby parts
252
symptoms of trophoblastic molar pregnancy
early abnormal bleeding
large for dates
bilateral enlarged ovaries
increased in asians
early toxemia
threatened abortion
hyperemesis, hyperthyroid, HTN
253
risk factors for molar pregnancy
maternal age
history of hyaditiform mole
recurrent SAB
low SES
poor nutrition
254
treatment of molar pregnancy
D and C
consider hysterectomy
255
follow up for molar pregnnacy
monitor HCG for one year
contraception for one year (dont want to confuse rising HCG titers of new pregnancy with those from molar pregnancy)
pelvic exams every 2 weeks until uterus clear
chemo is HCG is icnreased at 6 mo, has lung or other mets or recurrence
256
what is a choriocarcinoma
malignancies associated with pregnancy
majority follow trophoblastic moles, but can also follow normal pregnancy
1/20 000 pregnancies
257
risk factors for choriocarcinoma
same as molar pregnancy
type A women with type O men
258
symptoms of choriocarcinoma
abnormal bleeding after any pregnancy
259
treatment for choriocarcinoma
chemo--> methotrexate, cyclophosphamide/vincristine, etoposide/actinomycin D/MTX
D and C
260
list the types of contraception
rhythm
coitus interruptus
lactational amenorrhea
barrier
IUD
norplant
depoprovera
vasectomy
tubal sterilization
OCP
261
what is the rhythm method of contraception
fertility awareness/abstinences
55-80% effective
ovulation assessment--> BBT
menstrual cycle tracking
cervical mucus exam
262
what is the coitus interruptus method of contraception
withdrawal before ejaculation
15-25% failure
263
what is the lactational amenorrhea method of contraception
nursing delays ovulation by hypothalamic suppression
maximum of 6 months
50% ovulate by 6-12 months
15-55% get pregnant while nursing if no other method
264
what are the barrier methods of contraception
male and female condom
diaphragm
cervical cap or sponge
spermacide
265
how does the copper IUD work
spermicidal response/inhibition of implantation
used when OCP contraindicated and patient is a low STD risk
contraindicated in pregnancy, abnormal vag bleeding, infection
relative contraindication--> nullip, prior ectopic, history of STD, moderate or severe dysmenorrhea
266
failure rate of copper IUD
less than 2%
267
what is depoprovera
medoxyprogesterone acetate
IM slow release over 3 mo
0.3% failure rate
side effects--> irregular menstrual bleeding, depression, weight gain
more than 70% get irregular menses and may eventually have amenorrhea
268
how does vasectomy work for contraception
ligate the vas deferens
less than 1% failure rate
must use condom for 4-6 weeks until azospermia confirmed on semen analysis
70% reanastomose resulting in pregnancy 18-60% of the time
50% make anti-sperm antibodies
269
what is the most used method of birth control
tubal sterilization
270
what is the failure rate of tubal ligation
4%
271
are there side effects of tubal sterilization
no
272
what is the risk of ectopics and risk of death with tubal sterilization
1/1500 ectopic
4/100 000 death
273
what is the mechanism of OCPs
pulsatile release of FSH an LH suppresses ovulation
change in cervical mucus
change in endometrium
274
what are the types of OCP
monophasic--> fixed dose of estrogen and progesterone
multiphasic--> varies progesterone dose each week and lower overall hormones
progesterone--> progestin only, not as effective as combo
275
what are the complications of the OCP
thromboembolism (do not give in women with family history of DVT or PE, with PE themselves, CVA, MI, HTN
276
what are some meds that decrease the efficacy of OCPs
PCN
tetracycline
rifampin
ibuprofen
dilantin
barbituates
sulfonamide
277
OCPs cause decreased efficacy of which meds?
folates
anticoagulants
insulin
methyldopa
phenothiazine
278
what are some benefits of the OCP
decrease ovarian/endometrial cancer (by 50%!!!)
decreases ectopics, anemia, PID, cysts, benign breast disease and osteoporosis
279
what % of pregnancies end in therapeutic abortion
25%
280
define the two phases of the menstrual cycle
follicular and luteal phases
proliferative and secretory phases
281
what happens during the follicular phase of the menstrual cycle
release of FSH from pituitary gland results in development of primary ovarian follicle
ovarian follicle produces estrogen --> causes uterine lining to proliferate
at day 14, LH spike in response to this estrogen spike stimulates ovulation and release of ovum from follicle
282
what happens during the luteal phase of the menstrual cycle
begins after ovulation
remnants of the follicle left behind in the ovary develop into the corpus luteum --> secretes progesterone which maintains endometrial lining in prep for implantation if ovum is fertilized
if no fertilizations, corpus luteum degenerates and progesterone levels fall
without progesterone, endometrial lining is sloughed off--> menstruation
283
what effect does the progesterone produced by the corpus luteum have on the endomterial lining
becomes thicker, more glandular and secretory
if fertilization occurs, trophoblast produces hCG which acts to maintain the corpus luteum so it can continue to produce progesterone and estrogen until 8-10 weeks GA when placenta takes over
284
examples of outflow tract abnormalities causing primary amenorrhea
imperforate hymen
transverse vaginal septum
vaginal atresia
vaginal agenesis
testicular feminization
uterine agenesis with vaginal dysgenesis
MRKH syndrome
285
examples of end organ disorders causing primary amenorrhea
ovarian agenesis
gonadal dysgenesis 46XX
Swyer Syndrome/gonadal agenesis 46 XY
ovarian failure
enzymatic defects leading to decreased steroid hormones
Savage Syndrome--ovary fails to respond to FSH and LH
Turner's (due to rapid atresia)
286
what is Savage syndrome
ovary fails to respond to FSH and LH causing primary amenorrhea
receptor defect
287
what is Swyer syndtome
gonadal agenesis with 46 XY karyotype--> testes never develop therefore no MIF therefore have both internal and external female genitalia BUT no estrogen so no breasts
cause of primary amenorrhea
288
central disorders causing primary amenorrhea
hypothalamic
local tumour compression
trauma
TB
sarcoidosis
irradation
Kallman syndtome (congenital absence of GnRH)
pituitary problems
damage from surgery or radiation therapy
hemosiderosis deposition of iron in the pituitary
289
where is GnRH produced
hypothalamus
290
in the presenting complaint of primary amenorrhea, what should you think of if the patient also has:
absent breasts
absent uterus
gonadal agenesis in 46 XY
291
in the presenting complaint of primary amenorrhea, what should you think of if the patient also has:
absent breasts with present uterus
gonadal failure or agenesis in 46XX
292
in the presenting complaint of primary amenorrhea, what should you think of if the patient also has:
breasts present but uterus absent
enzyme deficiencies in testosterone synthesis
testicular feminization
Mullerian agenesis or MRKH
293
in the presenting complaint of primary amenorrhea, what should you think of if the patient also has:
in the presenting complaint of primary amenorrhea, what should you think of if the patient also has:
breasts present and uterus present
disruption of hypothalamic-pituitary axis
hypothalamic, pituitary or ovarian pathogenesis similar to that of secondary amenorrhea
congenital abnormality of the genital tract
294
how should you approach diagnosis/testing of a patient with primary amenorrhea
is there a uterus?
if no--> do karyotype
if yes-->
is there a patent vagina?
if no--> imperforate hymen, transverse vaginal septum or vaginal agenesis--surgery
if yes-->
are there breasts?
if no--> consider as if the progesterone challenge was negative
if yes--> progesterone challenge
295
how do you approach the results to a progesterone test for secondary amenorrhea (and some primary amenorrhea)
1. test is NEGATIVE-->
rule out Asherman's syndrome and cervical stenosis
then do FSH
FSH above 40 mIU/mL--> ovarian failure
FSH below 40 mIU/mL--> severe hypothalamic dysfunction
2. test is POSITIVE-->
are they hirsute?--> if so, consider PCOS, r/o ovarian or adrenal tumour
not hirsute--> mild hypothalamic dysfunction
296
what is Asherman's syndrome
cause of secondary amenorrhea
presence of intrauterine synechiae or adhesions, usually secondary to surgery to infection
297
what are some things that cause hypogonadotropic hypogonadism (secondary amenorrhea)
```
1. hypothalamic dysfunction:
kallmann
hypothalamus tumours
constitutional delay
severe hypothalamic dysfunction
anorexia nervosa
severe weight loss
severe stress
exercise
```
```
2. pituitary disorder:
sheehan syndrome
panhypopituitarism
isolated gonadotropin deficiency
hemosiderosis (ie from thalassemia major)
```
