General Gynecology Flashcards
(313 cards)
1
Q
Virchow’s Triad
A
Causes of DVT
- Hypercoagulable state
- Stasis or non-lamilar flow
- Irregular vessel wall (endothelial damage)
2
Q
Risk factors for DVT?
A
- Age >40yo
- Surgery for malignancy
- Prolonged surgery >30 mins
- Obesity
- Delayed post-operative ambulation
- Medical Dz (DM, heart failure, COPD, prior DVT)
- Varicose veins
- Thrombophilias (50% of cases)
3
Q
Mutations as etiology of DVT?
A
- MTHFR (Low risk of thrombosis)
- Leiden V (5% throm risk)
- Prothrombin G20210A (2-5% throm risk)
- Protein C (5-10% throm risk)
- Protein S (5% throm risk)
- Antitrhombin III (30-50% throm risk)
- Lupus anticoagulant (>5% risk)
4
Q
Test for Anti-phospholipid Syndrome
A
(Acquired condition)
- Lupus anticoagulant
- Anti-Cardiolipin Ab
- Anti-b2-glycoprotein I
5
Q
Work/up for DVT?
A
- Doppler u/s
- Test of choice for major (fem/pop) veins
- Sens/spec: 91/99%
- Not sensitive for tibial v or at/below ankle - Venography
- Gold standard
- invasive (use when other tests are equivocal) - Impedance Plethysmography
- highly sensitive but not specific
6
Q
Clinical Features of PE
A
- dyspnea
- chest pain
- tachypnea
- hemoptysis
- tachycardia
7
Q
Work-up for PE
A
- Spiral CT (sens/spec 94% for central PE)
- Arterial blood gas (PaO2 <90 mmHg)
- VQ scan- not very specific or sens
- ECG-nonspecific but recommended as adjunct (tachycardia & R-axis deviation)
8
Q
Treatment of PE
A
Heparin with conversion to Warfarin
9
Q
MOA of Heparin
A
Cofactor for Antithrombin II
Increases inhibition of thrombin and Factor Xa
10
Q
Loading dose of Heparin for DVT vs PE?
A
DVT: 100u/kg (min 5000u)
PE: 150u/kg
11
Q
Maintenance Dose of Heparin for DVT & PE?
A
15-25 u/kg/hr and convert to Warfarin once patient is stable (or sub Q heparin if patient is pregnant)
12
Q
Prevention dose of Heparin?
A
5000 u BID (no effect on PTT)
5000 u every 8 hrs in pts with gyn cancers
13
Q
Complications of Heparin
A
- Osteoporosis
- Alopecia
- Thrombocytopenia (long term tx)
14
Q
Treatment protocol for DVT/PE with Heparin.
A
- 5000u bolus, then 1000-1200 u/hr x5d
- then sub Q 8000-10000 u BID
- establish PTT at 1.5-2.5 times normal
- Initiate Coumadin tx same day or after (not before)
15
Q
Treatment protocol for DVT/PE with Lovenox.
A
- 1 mg/kg (generally 40-60 mg) BID or
- 1.5 mg/kg once daily
- Initiate Coumadin tx same day or after (not before)
- PT/PTT are normal w/ Lovenox
16
Q
HIT- Which meds?
A
Can occur with Heparin or Lovenox
17
Q
Repair of Bladder Injury
A
- Assess location of injury w/ respect to trigone
- Close in 3 layers if possible
a. Non-locking continuous 3-0 vicryl through mucosa & submucosa
b. Interrupted 3-0 vicryl to muscular layer
c. Interrupted 2-0 vicryl to para-vesical fascia layer - Instill sterile milk to assess integrity of closure
- Consider cystoscopy w/ or w/o indigo carmine
- Abx
- Indwelling catheter for 7 days
18
Q
Repair of Ureteral Injury (End-to-End)
A
End-to-end anastamosis
-spatulate ends
-4-6 interrupted sutures of 4-0 chromic through full thickness of cut edge
-performed regardless of location provided no tension
-ureteric stents and bladder catheter in situ for 10 days
If end-to-end cannot be performed w/o tension consider other options
19
Q
Ureteroneocystotomy
A
Implanting ureter into bladder
-typically if breach <5cm from bladder
20
Q
If ureteral injury is >5cm from bladder what procedures can you try?
A
Psoas hitch
Boari flap
Ureteroureterotomy (implanting ureter into contralateral ureter)
21
Q
Repair of Bowel Injury
A
Small bowel laceration parallel to long axis of bowel
(end-to-end closure), avoid narrowing of lumen
-mucosa/muscularis in single layer w/ interrupted vicryl 3-0
-muscularis/serosa w/ 3-0 non-absorbable suture
Small bowel laceration at right angles to long axis of bowel (side to side narrowing)
22
Q
Bowel Prep
A
Option 1 Day -1: Golytely 1.5 L/hr till clear
Day -0:Cefoxitin 2gm iv 30 mins pre-op
Option 2 Day -1 Neomycin 1gm + Erythromycin 1gm at 2, 4, +10pm
23
Q
Cherney
A
Excise rectus muscle off pubis, can damage inferior epigastric vessels- good exposure of lower abdomen
24
Q
Maylard
A
Muscle cutting: must ligate inferior epigastric vessels behind lateral rectus sheath edge. Do not separate sheath off rectus muscle-good exposure of abdomen
25
Contraindication to Pfannenstiel Incision
Obesity
26
Considerations for closure of obese patient
Secure fascial closer (consider PDS or permanent suture)
Do not place prophylactic drain in sub Q tissue
Close subq tissue > 2 cm
27
Causes of Post-op Fever
```
Winds Bowel obstruction/ileus/Pneumonia
Water Bladder
Wound Ifx (ut, vag cuff, abdominal)
Walking DVT
Wonder Drugs Drug Allergies
Wonder Breasts PP nursing patient
```
28
Work-up for post-op fever?
Exam: Pulse, BP, temp
Lungs
Abd Incision
Vag Incision
Extremities (evidence of DVT, thrombophlebitis)
Renal Angle Tenderness
Abdomen
Labs: CBC, Urine c&s, blood cx, CXR, Erect AXR, doppler u/s, u/s of pelvis (looking for hematoma which could be infected).
Consider drug fever
Consider thrombophlebitis (tx w/ heparin, dx and tx in cases of refractory fever of unknown cause)
29
Definition of Fever
>100.4 x 2 (4 hr apart and excluding 1st 14 hrs b/c of cytokine release from tissue) or
> 101.5
30
Timing of Fever w/ respect to likely Dx:
1-3 d- Pneumonia/GI
3-7 d- DVT, Wound Infection, UTI, pneumonia, phlebitis
7+ d- Bladder/ureteric injury
31
Describe the Grades of Pelvic Organ Prolapse
1st Degree-down to ischial spines
2nd Degree- b/w spines & introitus
3rd Degree- Cervix below introitus
4th Degree- Uterus below introitus (procidentia)
32
Treatment of Prolapse
```
Don't forget
Kegel's pelvic floor exercises
Vaginal cones
Topical estrogen if atropic changes
Treat causes of chronic cough, constipation
Pessary
Surgery
```
33
How do you diagnose an enterocele?
Perform recto-vaginal exam, ask pt to Valsalva. Feel for a bulge of the cul de sac herniation *usually containing bowel) b/w fingers
34
Ypes of enterocele repair
Moskowitz
| McCall
35
Moskowitz
Serial purse string sutures obliterating the cul de sac through an abdominal incision.
No dissection of the peritoneal pouch
36
McCall
Plication of uterosacral ligaments in the midline
Performed vaginally
No dissection of the peritoneal pouch
37
Five compartments of possible prolapse
```
Uterine prolapse
Anterior vaginal wall (Cystocele)
Posterior vaginal wall (Rectocele)
Enterocele
Vaginal outlet (Perineal body)
```
38
3 Main types of Urinary Incontinences
1. SUI
2. Urgency Urinary Incontinence (UUI), aka OAB
3. Mixed
39
W/up of urinary incontinence?
```
Hx
UA
demonstration of SUI w/ + cough test
assessment of urethral mobility
measure PVR
(Review pg 85)
```
40
Non-surgical treatment of SUI & Urge Incontinence
Pelvic floor exercises w/wo physiotherapy
Weight Loss
Dietry/Fluid modification/bladder retraining
Devices (plugs, continence pessaries & weighted cones
41
Non-surgical tx of Urge UI
Beta-3 adrenoreceptor agonist (Mirabegron)
SE: tachycardia, HA, diarrhea
Contraindications: uncontrolled HTN, severe
renal/liver disease
Anti-muscarinic (Oxybutinin/Tolterodine)
Blocks parasympathetic M2/M3 R to (-) involuntary
detrusor ctx
SE: dry eyes, dry mouth, constipation, gastric
retention
Contraindications: narrow angle glaucoma
Onabotulinum toxin A (100u intravesical Q6m)
42
Non-surgical tx of Urge UI
Beta-3 adrenoreceptor agonist (Mirabegron)
SE: tachycardia, HA, diarrhea
Contraindications: uncontrolled HTN, severe
renal/liver disease
Anti-muscarinic (Oxybutinin/Tolterodine)
Blocks parasympathetic M2/M3 R to (-) involuntary
detrusor ctx
SE: dry eyes, dry mouth, constipation, gastric
retention
Contraindications: narrow angle glaucoma
Onabotulinum toxin A (100u intravesical Q6m)
comp to anti-musc, similar dec incont episodes but
more pts w/ complete relief of Urge UI
SE: UTI, urinary retention
Sacral neuromodulation for refractory urge UI
43
Treatment options for urolithiasis?
Antibiotics
Anti-emetics
Analgesics
Renal decompression w/ ureteric stent, per cutanesou nephrostomy, ureteroscopic stone removal, lithotripsy (contraindicated in pregnancy)
44
Complications of Newer Surgical Procedures for Incontinence (Mid-urethral slings, needle or suture suspensions)
1. Surgical site bleeding
2. Urinary retention or persistent SUI
3. Placement of mesh in bladder
4. Erosion of sling material or suture into bladder
5. Space of Retzius hematoma
6. Local anesthetic toxicity (TVT/TOT)
7. Injury to ureter or bowel (uncommon)
45
Mesh graft erosion complication rate?
5-19%
46
Complications of Mesh Graft
1. Chronic pelvic pain
2. Fistula formation
3. Graft infection
4. Delayed graft erosion or exposure
5. Vaginal discharge/odor
47
Management of Mesh erosion?
1. Observe, pelvic rest 6-8 weeks, vaginal estrogen (20-30% effective)
2. Office excision of mesh (40% effective)
3. Excision in OR, dissect overlying epithelium, excise & remove mesh, close epith, cystoscopy r/o bladder erosion (90-95% effective)
48
Timing of repair of RV fistula?
Immediately at time of damage or wait 3-4 m for dec in inflam/infx
49
Preop prep for RV fistula repair?
```
Estrogen cream (if postmenopausal)
Abx
Laxatives
bowel prep
Try to reverse/treat any underlying dz (eg. IBS)
```
50
Bowel prep
Golytely 1 liter/hr till clear effluent (max 4 hr or 4 L) beginning day prior to surgery
51
Considerations for RV fistula repairs?
1. Excise fistulous tract
2. Place as many layers as feasible b/w both cavities, do not overlap suture lines
3. Determine location of fistula
4. If close to introitus do 3rd degree tear repair
5. Otherwise do simple fistulectomy: close in 3 separate layers (rectal submucosa, muscularis, and vaginal mucosa)
6. Suture material : Tension bearing- 2-0 vicryl
Non-tension bearing- 3-0 vicryl
52
How would you determine location or type of fistula?
IVP
| dual tampon test
53
Vesico-Vaginal Fistula management?
1. Foley catheter decompression of bladder for 4-6 w minimum.
2. If no spontaneous resolution (by 12 weeks) do 3 layer closure technique:
-Excise fistulous tract
-Approximate bladder submucosa
-Approximate bladder muscularis
-Vaginal mucosal closure
or
3. Latzko Technique
-partial colpocleisis to treat fistula
-Denudement of vaginal wall around fistual w/o
excising it
-concern for vaginal shortening.
54
Uretero-vaginal fistula dx?
Cystoscopy & IVP to identify fistula site & exclude bladder injury.
55
Management of Uretero-vaginal fistula? Lower
1. Ureteral catheter stenting (30-40% healing at 3-4 w)
2. Failure of spont healing:
- ureteroneocystotomy
- IVP at 3,6, 12 m
56
Management of Uretero-vaginal fistula? Upper
1. Percutaneous nephrostomy for renal decompression
2. Ureteral re-implantation at 12 w post initial operation
3. IVP at 3,6,12 m
57
HCG units
mIU/ml
58
Expected HCG titer rises
1.3-2 times every 48 hrs until approx 6 weeks then rate slows to doubling every 72 hrs.
59
Discriminatory zones for hcg?
1500 mIU/ml for vag probe
| 6000 mIU/ml for abd probe
60
MOC of MTX
Folate antagonist (inhibits DHFR which converts DHF to THF)
61
Absolute Indications for MTX treatment?
```
Hemodynamically stable
Compliant
Desirous of fertility
Non-laparoscopic dx
No contraindications to MTX
```
62
Relative indications (opposite of relative contraindications) for MTX tx.
1. no fetal cardiac motion
2. size <3.5cm
3. hcg <5000
63
Absolute contraindications of MTX tx.
```
Liver DZ
Active pulmonary disease
Peptic ulcer disease
Blood dyscrasia
Sensitivity to MTX
Immunosuppression
```
64
Dosage Regimens & follow-up?
1. Single dose: 50 mg/m2 BSA
2. Multiple dose: 1mg/kg on days 1,3,5 (and 7)-recommended for cornual/cervical pregnancies when managed medically
Bhcg should drop 15% on days 3 and 7 after treatment.
65
Side effects of MTX?
1. Stomatitis
2. Leukopenia
3. Thrombocytopenia
4. Elevated liver enzymes
66
Risk factors for request of tubal ligation
1. Age=30
2. Parity=2
3. Recent decision to have tubal ligation (short time to 4. decide <6 m)
4. Unstable marriage or unmarried
5. Children not healthy
6. Post-partum tubal
7. Post-partum (neonate w/ poor apgar, premature/IUGR/diseased)
67
CREST study Failure rates at 5 years/1000 pregnancies
```
Non PPTL- 13
PPTL-6
Copper IUD-5
Progesterone IUD-5
Bipolar Cautery-15
Bands-10
Clips-30
```
Rates of ectopic higher w/ younger women
<30 27
>30 7.5
68
Risks if patient gets pregnant w/ IUD in situ
3x increased risk of SAB
| Increased risk of septic abortion and PTL
69
Disadvantages of Robotic Surgery
1. Longer operative times
2. More surgical incisions
3. Potential tendency to attempt laparoscopic procedures beyond one's general skill level
4. Extensive learning curve
5. Increased medical cost of surgical procedures
6. Lack of RCT to show superiority of robotic approach
7. Possible inc risk of vaginal cuff dehiscence
70
Advantages of Robotic Surgery
1. 3-D vision
2. Use of articulated instruments -more accuracy
3. Safer application of thermal energy devices
4. Improved fine motor control
5. Potential for dec in operative time and operative blood loss
6. Permit MIS approach in more complex cases when experienced surgical assist is not available.
71
```
Is Abx coverage necessary and what type for:
Hysterectomy
Laparoscopy
Laparotomy
HSG
Hysteroscopy
Induced AB & D&C
```
Hysterectomy- Cefazolin 1-2 g IV
Laparoscopy- No
Laparotomy- No
HSG- only w/ h/o pelvic infx- Doxy 100mg bid x 5d
Hysteroscopy- No
Induced AB & D&C- Doxy 100mg pre, 200mg post-procedure
72
PCN Allergy Classes and substitutions.
1. Immediate-Anaphylaxis (IGE mediated)-may not substitute w/ cephalosporin (Flagyl, Doxy, Clinda)
2. Delayed hypersensitivity-urticarial (cell mediated)- Cephalosporin acceptable
73
Difference between Ileus and Obstruction
Ileus- Pain- Distention
Post op timing 48-72 hrs
Bowel Sounds- Nil
AXR- Peripheral gas (in colon), Air in rectum
Treatment- NG tube, NPO, IV support, +
cholinergics support
SBO-Pain- Crampy
Post op timing 5-7 days
Bowel Sounds- High pitched
AXR- Central gas (in sml intest) + air fluid levels,
no air in rectum
Treatment- NG tube, NPO, IV support, +
surgery
74
Basic steps in performing an appendectomy?
1. Dissect meso-appendix & ligate appendix vessels
2. Clamp & cut base of appendix
3. Place purse string suture around base
4. Invert (embed) stump prior to closing purse string
75
Potential benefits of appendectomy?
1. Potential to prevent a future emergency appendectomy
2. Potential to exclude a future diagnosis of appendicitis in patients with chronic pelvic or bowel conditions
3. When chemo/rad tx anticipated
76
Opinion on best time to gain most benefit of incidental appendectomy
Greatest potential <35 yo
Possible benefit at 35-50
Not recommended >50 yo
77
McBurney's Point
Line from navel to ASIS, point is 2/3 down the line, point of max tenderness w/ appendicitis
78
Homan's Sign
Tenderness in popliteal area when foot is actively dorsi-flexed suggesting possible thrombosis, only correct 50% of the times.
79
Alternative tx to hysterectomy:
```
OCP's
NSAIDS
GnRH Agonist (pre-op)
Progesterone Modulators (eg. Mefipristone)
Aromatase Inhibitors
```
80
Repeat surgery for recurrence rate for:
1. Single tumor
2. Multiple tumors
1. Single tumors 10%
| 2. Multiple tumors 25%
81
Surgical tx options for fibroids
```
Myomectomy
Open
Laparoscopic Myomectomy
Hysteroscopic Myomectomy
Uterine Artery Embolization
Endometrial Ablation
MRI-Guided US surgery (uses US energy to denature protein w/in myoma bulk-> necrosis
```
82
Preoperative adjuvant tx for fibroids
GnRH agonist therapy
| GNRH antagonist tx
83
Complications of UAE (5-8%)
1. Symptomatic degeneration/pain in target lesion
2. Myometrial infarction/necrosis
3. Myometritis (bacterial seeding from procedure)
4. Bacteremia from arteriotomy
5. Uterine perforation/intraperitoneal injury
6. Uterine artery perforation/hemorrhage
7. Loss of ovarian function in 5-14% of cases
84
Contraindications to UAE for fibroids
1. Women desiring future fertility
| 2. Postmenopausal women
85
Management of Gonorrhea
Ceftriaxone (Rocephin) 250 mg IM + Azithromycin 1gm
Treat partner w/ cefixime 400mg PO + Azithro 1gm PO
No need for TOC even if pregnant,
Reinfection- retest in 3 months
86
Subtypes of Gestational Trophoblastic Disease
1. Hydatiform mole (complete and partial)
2. Invasive mole (GTN)
3. Choriocarcinoma (GTN)
4. Placental site trophoblastic tumor (PSTT) (GTN)
5. Epitheliod Trophoblastic tumor (ETT-subset of PSTT)
87
Differences between partial and complete mole?
```
Partial Mole:
Karyotype: 69XXX or 69 XXY
Fetus: Present
Uterine size: SGA
Theca Lutein cysts: Rare
```
```
Complete Mole:
Karyotype: 46 XX or 46 XY
Fetus: Absent
Uterine size: LGA
Theca Lutein cysts: Common
```
88
Potential problems associated with Moles?
1. Anemia
2. Infx
3. hyperthyroidism
4. coagulopathy
89
Treatment of choice for molar pregnancy, follow-up?
Suction Curettage
| Early US for future pregnancies (up to 10 fold increased risk for another mole)
90
Gestational Trophoblastic Neoplasia
Invasive mole
Choriocarcinoma
Placental site trophoblastic tumor
91
Most common causes of cancer death in US women
```
Lung
Breast
Colon
Leukemia/Lymphoma
Ovary
```
92
Most common cause of cancer death in the world?
Lung
93
Most common cause of GYN cancer death in the world?
Breast
94
Most common cause of GYN pevlic cancer in the world?
cervix
95
Most common cause of GYN cancer in the USA?
uterine
96
Most common cause of GYN cancer death in the USA?
ovary
97
Most common cause of GYN pelvic tumor?
fibroids
98
Histopathology of Hydatiform mole.
Multiple islands with pale core & dark thin rim (normal villi Plus tissue proliferation of surrounding rim)
99
In which tumors would you find Schiller Duvall Bodies
Embryonal Carcinoma
100
Coffee Bean Nuclei
Granulosa Cell Tumor, Brenner Tumor
101
Call Exner Bodies
Granulosa Cell Tumor "Call Girl"
102
Psammoma Bodies
LMP tumors
| Serous Tumors "body builders are serious)
103
LMP tumor
cellular proliferation w/ nuclear atypia
104
Describe pain
```
Precipitating
Quality
Radiation
Severity
Timing
```
105
Most common Diff Dx for chronic pelvic pain
Endometriosis
Adhesions
IBS
IC
106
Classic triad of Interstitial Cystitis?
Urgency
Frequency
Pain
(in absence of objective evidence of another disease)
107
Dx of Interstitial Cystitis?
1. Clinically based on Hx, PE and r/o other etioloties
2. Potassium sensitivity test no longer done (painful & poor predictive value)
3. Interstitial Cystitis Symptom Index-valid questionnaire
4. Cystoscopy w/ hydrodistension-glomerulations (petechiae) or Hunner ulcer w/ bladder distention 80-100cm water pressure under anesthesia & decreased bladder capacity (<350ml) w/o anesthesia (not required)
108
Tx of Interstitial Cystitis?
1. Dietary modifications
2. Pentosan polysulfate (Elmiron)
3. Intravesical instillations w/ various combinations of agents (DMSO, heparin, steroids, lidocaine, Marcaine, TCA, antihistamines)
109
Treatment of Vulvodynia?
1. Vulvar care, local anesthetics, estrogen cream, topical TCA, trigger point injection (steroid & bupivicaine)
2. Oral TCA's or anticonvulsants
3. Biofeedback, pelvic PT
4. Vestibulectomy for refractory cases
110
Theories for etiology of endometriosis
1. Retrograde menstruation
2. Hematological spread
3. Lymphatic spread
4. Coelomic metaplasia-can be seen in premenarchal girls
111
Options for conservative treatment of endometriosis
1. OCP
2. Depo Medrosyprogesterone Acetate (Provera)
3. Depo Leuprolide Acetate (Lupron)
4. Danazol (17alpha-ethinyl testosterone)
112
SE of Depo Lupron
menopausal sx
osteoporosis if long term
Not 1st line tx in pts <16 yo
113
SE of Danazol
Androgenization in higher doses
114
If fertility is desired and disease is advanced which type of tx would be better for endometriosis?
Surgical
115
First annual gyn exam?
13-15 yo, focus on education and hx. No pelvic exam indicated until 21 yo.
116
Annual exam counseling
Exercise
Diet (dec Caffeine, cholesterol, calories)
(inc Calcium 700-1300mg/day, vitamins, high fiber,
folate) (>65 yo 1300 mg /d Ca++, >17 yo 1200mg/d)
STD, contraception, HRT, driving habits/seat belt use, smoking/ETOH/drugs
117
ETOH screen
Tolerance:(how many drinks does it take to get a high)
Annoyed:(has anyone annoyed you by questioning your drinking)
Cut down:(Has anyone told you to cut down on your drinking)
Eye opener:(Do you ever have a drink shortly after waking up)
preferable to CAGE which does not address tolerance
118
The 5 A's of smoking cessation
Ask (about presence & degree of smoking)
Advise (to stop)
Assess (willingness to stop smoking)
Assist (w/ counseling, support grps, materials)
Arrange (follow-up)
119
Health effects of smoking in women
```
lung ca
bladder
renal ca
gynecologic ca
CHD
VTE
osteoporosis
COPD
```
120
Health effects of smoking in pregnancy
```
IUGR
PPROM
LBW
previa
abruption
decreased maternal thyroid function
ectopic pregnancy
increased perinatal mortality
increased spAB and recurrent AB
(Asthma, reactive airway dz, SIDS)
```
121
Recommended amount of Vit D
600 IU/day for ages 1-70 and pregnancy; 800 IU if >70 yo
122
Pap smear Screening Recommendations
- Begin age 21, every 3 years
- Age 30-65- Pap w/ HPV testing every 5 yrs or pap alone every 3 years
- In 2016: women 25 and up consider primary HPV screening as alternative to cytology based screening but cytology or co-testing still preferred
123
When should you stop pap smear screening?
1. 65 and over
2. Total hysterectomy for benign indications
3. H/o hyster for CIN 2/3 or w/ h/o CIN2/3- continue pap smear alone every 3 years until 20 yrs after initial post treatment surveillance
124
Difference in sen/spec b/w conventional pap and thin prep
No apprciable difference in sen/spec for detection of CIN in Meta-anaylsis.
Advantages of thin prep-easier collection, improved sample adequacy, ability to do additional testing
125
NPV of combined HPV + cytology for CINII & III
99%
126
Sensitivity of Pap smear
50%
127
Difference b/w LSIL & CIN2
LSIL-consistent w/ CIN1, not considered a precursor to cancer except in older women over extended time
CIN2-can be precursor to CIN3, therefore grouped w/ CIN3 as precursor to cancer, threshold for treatment if >24 yo
128
Indication for ECC?
1. if colposcopy is unsatisfactory
2. If contemplating ablative tx (results in 10% inc in dx of CIN2,3+)
3. if pap shows ASC-H, HSIL, AGC or AIS
contraindicated in pregnancy
129
On average how long does it take for CIN 3 to progress to invasive cancer.
3-7 years
130
Regression rate of CIN1? CIN2?
CIN1-60%, CIN2-40%
131
Why should all cytology results be assessed?
Sensitivity can be low (30% w/ conventional methods)
| Reproducibility of results not good (only 40-70%)
132
F/up for ASC-US cytology & neg HPV?
cotesting in 3 years
133
F/up for women 30 and, cytology neg, HPV +?
1. Repeat cotest 12 mos, if pap ASCUS or higher or HPV +, colpo, if both normal cotest in 3 years
2. Immediate HPV 16, 18, if pos-> colpo, if HPV neg cotest 12 m
134
Pap-ASCUS >25 yo
```
1. Traige testing w/ HPV preferred
high risk HPV +--> colpo
Negative-->routine age based testing
2. If no HPV testing done: repeat pap in 12 m
If ASC-> colpo
```
135
ASCUS Pap 21-25 yo
Pap Q 12 m
HPV and colpo NOT done routinely, only if Pap =HSIL or >, at subsequent paps even ASC gets a colpo
HPV is common due to repeat infections (not persistent infx which is a cancer risk)
136
Pap-ASC-H, 25 & >
consider similar to HSIL, risk of CIN2,3 is 50%
| COLPOSCOPY, NO HPV TESTING
137
LSIL <25 yo
repeat pap in 12 m,
- -> < HSIL repeat in 12 m
- -> If ASC or > colpo
138
When should you start colon ca screening?
1. Start at age 50 or 45 if African American
| 2. Start 10 yrs before age family member was dx w/ cancer if family hx.
139
F/up after first colonoscopy?
1. Every 10 years if normal.
2. colonic polyp, benign 3-5 years
3. Polyp w/ atypia, every 3 years
140
F/up if family h/o colon cancer
One 1st degree relative, Q 5 years
| 2 or more 1st degree relatives, Q 3 years
141
Breast Cancer Screening
Beginning at 40
142
Lung Cancer
Low dose chest CT annually
Adults 55-80 w/ smoking hx (30 pk year hx & current smoker or quit <15 yrs ago, stop screening once pt >15 yrs quit smoking)
143
Glucose/FBS:
annually if high risk, every 3 years beginning at age 45
144
Lipid profile
5 yearly beginning age 45
145
TSH
5 yearly beginning at age 50
146
DEXA
beginning at age 65 or sooner w/ risk factors, repeat no sooner than 2 years
147
UA
yearly after age 65
148
HIV
consider testing annually for ages 13-64 if high risk (>1%), otherwise routinely x1, use clinical judgement
149
Incidence of BRCA I & II
1:300-800
150
Inheritance patter for BRCA
Autosomal dominant inheritance w/ high penetration
151
What % of all ovarian cancers are associated w/ BRCA?
10%
152
What % of all breast cancers are associated w/ BRCA?
5%
153
Risk of breast and ov ca w/ BRCA I?
Breast Ca risk- 65-74% (65-75%)
| Ovarian Ca risk- 39-46% (40-45%)
154
Risk of breast and ov ca w/ BRCA II?
Breast Ca risk- 65-74% (65-75%)
| Ov Ca risk- 12-20% (10-20%)
155
What other ca are associated w/ BRCA gene mutations?
1. prostate
2. pancreatic
3. gastric ca
4. melanoma
156
Lynch II and risk of ovarian cancer
15 fold risk of ovarian cancer
157
What types of ovaria cancers are associate w/ hereditary cancers?
High Grade Serous or endometroid
158
Relationship of hereditary breast cancers to timing of cancers
10 years earlier than sporadic cancers
159
Risk of male breast ca w/ BRCA?
6%
160
Chemoprophylaxis options for BRCA
OCP's to decrease ovarian cancer
| Tamoxifen for BRCA 2
161
Risk Reducing Surgeries for BRCA carriers?
BSO by age 40 or when childbearing complete
Prophylactic mastectomy
80-90% reduction in cancer
162
Tetenus Vaccine
Substitute 1 time dose of Tdap
Then Td every 10 years
Tdap during EACH pregnancy b/w 27-36 weeks EGA
163
MMR
One time dose unless high risk
Give 2
High Risk: healthcare workers
beginning college students
International travelers
Rubella negative PP patients
164
Hepatitis A
International travelers
| illicit drug users
165
Hepatitis B
Pts aged 13-18
Healthcare workers
Those dealing w/ or receiving blood products
IV drug users
More than 1 sexual partner/recent or current STD
Hepatitis B household contacts
166
Influenza
Annually after age 6
167
Pneumoccal Schedule
Once only after 65 (unless w/ chronic medical conditions)
Immuno-compromised
Slenectomy
Chronic medical illness
168
Meningococcal Schedule
by age 15 or prior to high school/military service-90% effective
169
Varicella Schedule
All adults w/o evidence of immunity
| NOT IN PREGNANCY
170
Zoster Schedule
Single dose 60 and over
171
HPV Schedule
```
9-26 yo
3 shots (0,2, 6m)
```
172
Contraindications to HPV vaccine?
Pregnancy
Guil Bar
Severe yeast allergy
173
Nine Valent HPV covers which strains
6, 11, 16, 18 (& 31, 33, 45, 52, 58)
174
When should statins be prescribed?
1. Clinical ASCVD
2. LDL >190
3. DM age 40-75 w/ LDL 70-189 mg/dl & w/o clinical ASCVD
4. LDL 70-189 mg/dL &10 yr ASCVD risk >7.5% based on Framingham Risk Score (FRS)
175
Elements of Framingham Risk Score
1. Age
2. Gender
3. total cholesterol
4. HDL
5. Smoking status
6. systolic BP
176
Target cholesterol and LDL?
Total cholesterol <200
| LDL <130
177
Example and MOA of Bile Acid Resins?
Colestid
| MOA: Increase cholesterol breakdown + excretion
178
Example and MOA of Niacin?
```
Nicotinic acid (Vit B3)
MOA: Lowers TG, tot chol + LDL, raises HDL
```
179
Example and MOA of Fibrates?
Lopid
MOA: Lowers TG & raises HDL
DO NOT USE W/ STATINS, INC RISK OF MYOLYSIS
180
Example and MOA of Statins?
Lipitor, Crestor, Zocor, Prevachol
| MOA: Lowers TG, tot chol, LDL (20-60%), raises HDL
181
Risk factors for CAD?
1. Fam h/o premature CHD
2. HTN
3. DM
4. Female >55 yo w/o HRT
5. Current cigarette smoking
6. Low HDL (<35)
182
CAD in women, how are sx different than in men?
1. Sx more typically atypical
| 2. Stress testing
183
When should DEXA screening begin?
Age >65 or w/ 1 or more risk factors or FRAX >9.3%
184
How often should DEXA be repeated?
No sooner than Q2 yrs unless new risk factors-no tx
| On tx: Q2 yrs until stable, do not repeat once stable or improved
185
Difference between the T-score and the Z-score
T-score: standard deviations from mean peak bone density of a normal young adult.
Z-score: Standard deviations from mean peak bone density of the same age, sex and race
186
Interpretation of T-Scores?
Noramal >/= -1 SD below young adult peak bone mass
Low Bone Mass -1 ot -2 1/2 (formerly Osteopenia)
Osteoporosis = -2 1/2 SD below young adult peak BM
187
Risk Factors for Osteoporosis?
1. Personal h/o major frx
2. 1st degree relative w/ frx
3. Caucasian race
4. Current cigarette smoker
5. Low Ca++ intake
6. Drugs: Anticonvulsants, steroids, chronic heparin,
TPN, long acting progesterone, lithium
7. Frail
8. Inadequate physical activity
9. Estrogen deficiency
10. Alcoholism
11. RA
188
Normal bone loss?
pre-menopausal- 0.5%/yr
| post-menopausal- 5%/yr
189
W/up of osteoporosis
1. Ca++, Vitamin D
2. Chemistry profile
3. 24 hr urine ca++
4. PTH
5. TSH (if on thyroid replacement tx)
190
Utility of FRAX
Fracture risk screening tool (women >40 yo)
Predicts risk for osteoporotic frx in next 10 yrs
Use in decision to tx for low bone mass or to do DEXA on pt <65 yo (if FRAX >9.3%)
191
Indications for treatment based on T-score?
1. T-score of -2.5 w/o risk factors
| 2. T-score of -1.0 or below and FRAX score >/=3 for hip fx or >/=20 for major fx
192
Prevention of Osteoporosis
weight bearing exercise
sunlight
Ca++ supplementation
Vit D supplementation
193
Recommendations for Ca supplementation
Ages 9-18- 1300 mg/d
19-50 yo- 1000 mg/d
Over 50 yo- 1200 mg/d
194
How much Ca++ does average diet contain?
| How much Ca++ does glass of milk have?
600-900mg
| tall glass of milk: 500 mg of Ca++
195
Recommendations for Vit D supplementation?
Ages 1-70: 600 IU daily
| >70 yo: 800 IU daily
196
Treatment of Osteoperosis?
Bisphosphonates-1st line
HRT
SERM's
Calcitonin
197
Bisphosphonates MOA? Eg?
Inhibits bone resorption by osteoclasts
| Fosomax 70mg / week
198
Contraindications to Bisphosphonates
```
esophageal abnormalities (incl reflux)
renal failure
```
199
How do you instruct to take Bisphosphonates?
Take on empty stomach
| Remain upright for 30 mins
200
Benefits of HRT for osteoporosis?
5 fewer fx/10,000 women
| 33% hip fx reduction
201
MOA and Benefits of SERM's for osteoporosis?
MOA: Pro-estrogenic on bone, anti-estrogenic on endometrium
| Reduces vertebral fx rate by 50%
202
Calcitonin dosage?
200 IU/day nasal spray
sub Q injection
effective on vertebral fx but expensive, no hip data
203
Risk Reduction for Bone Fx?
No free rugs
Slip on shoes (avoid laces and bending down, shifting center of gravity)
Store objects at eye level (avoids bending)
Optimize vision & lighting
204
Definition of Obesity? Classes?
BMI >30
Class I: 30-35
Class II: 35-39
Class III: >40
205
US obesity rate/state?
>20%
206
What % of of women in US are obese?
35%
207
Management of obesity?
- see pt 1x/month
- behavioral support including support grps
- Medical tx if BMI >30 (>27 w/ med risks)
- Surgical tx if BMI >40 (>35 w/ med risks)
- Exercise min of 30 min brisk walk every other day
- Daily diet: folic acid, calcium, protein (50g), energy 2200 kcal
208
Incidence of rape
1:5 women
209
Rape exam? When and how should it be done?
```
Within 48-72 hrs optimal
Hx
PE
Tests: scalp hair, saliva, comb pubic hair
Cervical Cx
Blood work: HCG, STS, HIV, Hepatitis
Wet smear (trich)
Stains on clothes
Vaginal/Rectal swabs
Fingernail scrapings
Photography when available
Maintain chain of custody of evidence
Emergency contraception
F/up in 6 weeks (std, psych, preg)
```
210
Prophylaxis for rape?
```
250mg ceftriaxone IM
1gm azithromycin
2gm metronidazole
HAART w/in 72 hrs if known HIV pos
If HIV unknown and <72 hrs call HIV hotline
```
211
Abx coverage of GC/Cl
Ceftriaxone 250 mg IM PLUS Azithromycin 1gm
212
Abx for Endometritis/PID Outpatient
Ceftriaxone (Rocephin) 250mg IM PLUS
| Doxycycline 100mg BID x 14 d w/ or w/o metronidazole 500mg BID x14d
213
Abx for PID/Endometritis Inpatient
Cefoxitin (Mefoxin) 2g IV Q6 hr OR
Cefotetan 1g IV Q12 hr
PLUS
Clindamycin 900mg IV Q8 hr
Gentamycin 2 mg/kg load, then 1.5 mg/kg maintenance IV or IM
PLUS
Doxycycline 100mg BID x 14 days
214
Regimens for BV?
```
Clindamycin cream 5gm x 7 d PV
OR
Flagyl 5gm QD PV x 5 d
OR
Flagyl 500mg PO BID x7 days
```
215
Abx Regimen for UTI? Cystitis
```
Trimethoprim 100mg BID x 3 days OR
Trimethoprim + Sulfamethoxazole 100/800mg BID x3 d
(PREFERRED) OR
Nitrofurantoin 100mg BID x 7 d
Give Quinolones if resistant
```
216
Abx Regimens for Pyelonephritis?
Bactrim 100/800 mg IV Q12 OR
Ceftriaxone 2gm IV Q24 hrs, change to PO meds for total of 14 d total
Outpatient: ciprofloxacin 500mg po BID x 7 d
217
Abx Regimens for Primary Syphilis
Benzothaine PCN 2.4 mil u IM x1
218
Abx Regimens for Unknown Syphilis (secondary)?
Benzothaine PCN 2.4 mil u IM Q week x 3 if prior negative status not confirmed
219
Dx of PID
Lower abd/pelvic pain in sexually active female, r/o other causes and ONE other of the MAJOR criteria:
1. Adnexal tenderness
2. Uterine tenderness
3. Cervical motion tenderness
MINOR criteria:
1. fever >38.0
2. Mucopurulent vaginal discharge
3. + Gc/Cl
4. Gramp + diplococci on gram stain
5. WBC >10
220
Criteria for In-patient tx for PID
Cannot exclude surgical emergencies (eg. appendicitis)
pregnant
no response clinically to orals
unable to follow or tolerate outpatient oral regimen
severe illness, nausea, vomiting or high fever
TOA
221
Long term sequela of PID?
Chronic pelvic pain
Infertility
Inc risk of ectopic pregnancy
222
Incubation period of syphilis?
9-90 days
223
Primary lesion of syphilis?
Primary canchre (cold painless ulcer w/ clear margins & punched out crater-like appearance)
224
Secondary lesion of syphilis? What does it look like? When does it appear?
```
6 w to 6 m after primary chancre
condylomata lata
maculopapular rash (torso, palms, soles)
```
225
Tertiary Syphilis
Gumma
Cardiac lesions
Tabes Dorsalis
Argyll-Robinson pupil
226
Serology of Syphilis
Non-specific testing: VDRL, RPR-screening tests (can have false pos), usually returns to negative but may remain weakly pos for life
Specific testing:FTA-Abs, TPI- Confirmatory, typically remains positive
227
How long does sero-conversion take?
4-6 weeks
228
Causes of false positive RPR
```
Auto-immune disease (classically SLE)
Smallpox vaccination
malaria
Mycoplasma pneumonia
Debilitation (aging)
Pregnancy
```
229
Result of toxin release from dying spirochetes of syphilis?
Jarisch-Herxheimer Rxn
| Acute febrile illness, can cause PTL
230
Tx of syphilis if PCN allergic?
Erythromycin
If pregnant: desensitize since Tetracyclines contraindicated (causes yellow teeth) and Erythromycin does not adequately treat fetus
231
Differences b/w syphilis and chancroid?
```
Syphilis:
Single
Painless
Clear Margins (crater-like)
Rubbery painless nodes
Treponema Pallidum
Cold
```
```
Chancroid:
Multiple
Painful
Vague Margin
Painful nodes
Hemophilus Ducreyi
Hot
```
232
Differential Dx of vulvar ulcer?
```
HSV
Syphilis
Chancroid
LGV
Granuloma Inguinale
Bechet's
Vulvar Carcinoma
```
233
If unsure of cause of vulvar ulcer what is best choice of medication for treatment until dx made?
```
Erythromycin (assuming not pregnant) will cover
Syphilis
Chancroid
Granuloma Inguinale
Lympho Granuloma Venarium
```
234
Important to remember what key follow-up for any single positive STI result?
Full STD panel work-up!!!!
235
Which form of erythromycin is safe in pregnancy? Which is not?
Erythromycin succinate is acceptable in pregnancy
| Erythromycin estolate IS NOT ACCEPTABLE in pregnancy.
236
Bartholin's Gland Management?
Excise gland in pts >40 y/o to r/o adenocarcinoma or in pts w/ recurrent cysts or infections.
237
Bartholin's Abscess Management?
I&D then Word catheter, 4-6 weeks, preferable
| Culture abscess to r/o MRSA.
238
Normal pH of vagina?
<4.7
239
Dx of vaginitis?
hx & sx
pH
10% KOH (yeast)
normal saline wet prep slide
240
Tx of recurrent yeast infx?
>/= 4 attacks/yr
Diflucan 150mg days 1,3,5 and weekly x 6 mos
OR
Boric Acid 600mg BID x 2 weeks.
241
Dx of BV?
pH >4.5
+amine test
>20% of clue cells
242
Complications of BV in pregnancy? Post hyster?
PTL and PPROM, vag cuff cellulitis/PID
243
Dx of Trich?
Increase pH
244
Complications of Trichomonas?
PTL
| PPROM
245
Dx of Tuberculosis?
1. PPD intradermally (Wait 48 hrs to interpret, Positive induration >10mm)
2. IGRA blood test for latent TB, detects immune response to TB bacteria, requires only one visit, not effected by prior BCG vaccine
3. CXR: Apical cavitation, hilar lyphadenopathy
246
Treatment of TB?
6-9 months of
1. Isoniazid 5mg/kg/day
2. Rifampin (interferes w/ OCP) 10mg/kg/day
3. Ethambutol (if Isoniazid resistence) 15mg/kg/day
4. Pyrazinamide 20mg/kg/day
5. Supplement w/ Vit B 12 as above treatment reduces B12 levels
247
Basic principles of Ethics:
1. Autonomy: pt has right of choice
2. Beneficence: promote health and welfare
3. Nonmalificence: do no harm
4. Justice: Equal service to everyone
248
Most common cause of ambiguous genitalia?
Congenital Adrenal Hyperplasia (CAH)
249
Which enzyme deficiency accounts for 90% of CAH?
21 Hydroxylase deficiency (obstructs cortisol production & thus there is no negative feedback to switch off ACTH) leading to more androgen production, salt wasting b/c of inadequate aldosterone production.
250
Order of adolescent development?
Growth Spurt (GR)
Breast (Therlarche)
Pubarche
Andrenarche (Independent of HP maturation)
Menarche (Tanner IV or 2-3 yrs after Thelarche)
GRaB PAM
251
Time for development of normal Cycle?
6 years
252
When would you evaluate amenorrhea in teen?
1. No 2/ sexual development by 13
2. Age 14 w/ hirsutism
3. Age 15 regardless of development or 4 years after onset of puberty
4. >90 days without menses in menstruating adolescent
253
Definition of Precocious Puberty
2.5 standard deviations earlier than mean age
7 yo in white American girls
6 yo in black American girls
254
Life cycle of hair follicle?
Anagen-active phase of hair growth
Catagen-involution of epithelial cells surrounding dermal papilla
Telogen-resting phase
ACT
Hair falls out w/ initiation of anagen
255
Differential Dx of Hirsutism
```
PCO
CAH
Ovarian or Adrenal Tumor
Familial
Drugs (androgens, danazol)
```
256
Lab w/up of hirsutism
1. Total T (r/o abnormal ovarian/adrenal fx)
2. DHEAS (r/o abn adrenal fx,most adrenal tumors excrete excess testosterone)
3. 17 OH progesterone (r/o CAH)
257
Treatment of Hirsutism?
1. OCP
2. Spironolactone
3. Finasteride
4. Flutamide
5. Vaniqua
6. Cosmetic removal
258
MOA of Spironolactone?
blocks androgen R & inhibits 5-a-Reductase
259
MOA of Finasteride?
5-a-reductase inhibitor (inhibits testosterone ->DHT)
260
MOA of Flutamide?
Blocks ornithine decarboxylase
261
MOA or Vaniqua?
Blocks ornithine decarboxylase
262
MOA of OCPs for Hirsutism?
dec androgen production & inc SHBG levels--> inc binding and less free androgen
263
Causes of secondary amenorrhea
1. Pregnancy
2. Hypo/hyperthyroidism
3. Hyperprolactinemia
4. PCOS
5. CAH
6. Stress/exercise
7. Weight loss/anorexia
8. Medications (eg. psychotropics)
9. Premature ovarian failure (consider autoimmune)
10. Androgen secreting tumors
11. ACTH/GH secreting tumors
12. Other hypothalamic lesions (craniopharyngiomas/sarcoid/TB)
13. Ashermans Syndrome
14. Androgen secreting tumors
264
Primary Ovarian Insufficiency
Definition
Causes
Cessation of menses by age 40
Causes: Chromosomal
Chemotherapy/Radiation
Endocrinopathies: hypoparathyroidism,
hypoadrenalism
Autoimmune
Prior pelvic surgery--> damage to ovaries
265
W/up for amenorrhea or h/o regular menses w/ 3 or more m of menstrual irregularities
FSH, LH, E2 (2 random tests at least 1 m apart)
Pregnancy test
PRL, TSH
If dx confirmed:
Karyotype
FMR-permutation
Andrenal Ab (if + get yearly corticotrophin stim test)
Pelvic US
TSH & TPO ab Q 1-2 yrs (20% develop Hashimotos)
266
Tx of Primary Ovarian Insucfficiency
.1mg/d Transdemral Estradiol plus cyclic progesterone x 10-14 d
267
Causes of Abnormal Uterine Bleeding
```
Structural: (AUB-PALM)
Polyp
Adenomyosis
Leiomyoma
Malignancy & Hyperplasia
```
```
Non-structural: (AUB-COEIN)
Coagulopathy
Ovulatory Dysfunction
Endometrial
Iatrogenic
Not yet classified
```
268
Differential Dx for AUB age 13-18?
```
Anovulation -immature HPO axis
Hypothalamic dysfxn (stress, excess exercise)
Coagulopathis
Hormonal contraceptives
Infx
Pregnancy
Tumor
```
269
Differential Dx for AUB age 19-39?
```
Pregnancy
Anovulation (PCOS)
Anatomic lesions (fibroids/polyps)
Hormonal contraception
Hyperplasia/malignancy
```
270
Differential Dx for AUB age >40?
Anovulation (declining ov fx)
Fibroids
Hyperplasia/Malignancy
Atrophy
271
Dx evaluation for AUG?
Medical Hx (si/sx of coagulopathy)
PE
Labs: hcg, PRL, TSH, CBC, PT/PTT (if indicated), cvx cx, endo bx
Imaging:U/S, SHG, Hysteroscopy, MRI
272
When is endo bx indicated?
Women >45 yo
Women <45 yo w/ AUB & unopposed E
Failed medical management
Persistent AUB
273
Treatment for AUB?
Consider NSAIDs, OCPs, transxemic acid, Levonorgestrel IUD
If anovulatory: OCPs, MPA, IUD
Acute/severe bleeding: Estrogen (Premarin 25 mg IV, repeat Q4 hrs up to 6 hrs), OCP taper, progestins, Curettage if unable to treat medically
Surgical Management for chronic bleeding- endometrial ablation (if not chronic anovulation), UAE (fibroids), hysterectomy
274
Dx of PMDD?
Non-focal, >7-10 d
| Sx don't consistently resolve upon onset of menses
275
Dx of PMS?
Sx Focal 3-5 days prior to menses
| Sx resolve at onset of menses
276
Tx of PMS/PMDD?
Vit B6
Ca/Mg
Exercise
Stress Reduction
Dec: caffeine, ETOH, salt, fat
Meds: SSRI for mood swings
Danazol, GnRH agonist to suppress Ovulation
277
What affects Prolactin levels and how?
Prolactin:
Inhibited by Dopamine, PIF (Prolactin Inhibitory Factor)
Stimulated by: TRH, Nipple Stim
278
W/up for Galactorrhea?
Medication hx (antipsychotics, emtoclopramide, SSRI's, oral E)
Breast Exam
Look at D/c under microscope-fat droplets
Cytological smear (for malignancy if concerned)
Prolactin level, TSH
Visual field test
MRI of pituitary foss
279
Considerations for Prolactin blood testing?
early AM
prior to breakfast
prior to exercise
no intercourse or nipple stim
280
Treatment of Galactorrhea
1. Dopamine agonists: Carbergoline (long act), bromocriptine (Carbergoline preferred)
2. Parlodel (bromocryptine)
281
Advantages vs Disadvantages of Dopamine agonists?
Advantages: Long acting dopamine agonist, side effects less severe than parlodel, twice weekly dosage
Disadvantages: Cost
282
Side Effects of Parlodel?
Postural hypotension
Nausea
Headache
If severe SE do dosage 2.5mg BID vaginally instead of PO
283
Units for Progesterone
ng/Ml
284
Units for Androgens
ng/ml
285
Prolactin
ng/ml
286
Estrogens
pg/ml
287
FSH/LH, HCG
mIU/ml
288
TSH
micU/ml
289
Normal DHEAS
96-512
290
Normal total T
2-45
291
Prolactin
<26
292
TSH
0.3-5
293
When do you start work-up for infertility?
1. Anytime if anovulatory/male h/o infertility
2. Age <35 after 12 m of trying
3. Age >35 after 6 m of trying
294
Discussion of history for infertility?
Pattern of menses
Confirm adequate intercourse
PMH
Family Hx
295
W/up testing for infertility
```
Tests: Mid-luteal progesterone
Ovulatory kits/Urinary LH kit
Tubal status: HSG/Laparoscopy w/ chromopertubation
Semen Analysis
Ovarian Reserve- If >35 w/ no conception in 6 m
-Day 2-3 FSH/E2 (high FSH, low E2 abnl)
-AMH
-Antral Follicle count D2-5
-Clomid Challenge Test D10 FSH
```
296
Risk Factors for Decreased Ovarian Reserve
```
Age> 35
FHx early menopause
genetic condition (ie 45 XO mosaic)
FMR-1 Permutation
previous ov surgery (ie endometrioma)
oophorectomy
h/o chemo or XRT
smoking
```
297
Onset of LH surge to ovulation
36 hrs
298
LH peak to ovulation
12 hrs
299
```
Clomiphene:
MOA
Dose
Cost
Multiple reganancy rate
Hyper stim rate
```
```
MOA of clomid- Anti-Estrogen
Dose- 50mg day 5-9
Cost- cheaper than gonadotrophins
Multiple pregnancy rate- 7%
Hyper stim rate- low
```
300
```
Gonadotropin:
MOA
Dose
Cost
Multiple reganancy rate
Hyper stim rate- Lower than gonadotropin
```
```
MOA- FSH + LH
Dose- 1-2 amps IM day 7-14
Cost-More expensive than clomid
Multiple pregnancy rate- 21%
Hyper stim rate- higher than clomid
```
301
How soon before a surgery should OCP's be discontinued?
1 month
302
SLE and OCP's
Ok if mild & w/o antiphospholipid antibodies
| If vascular dz present consider IUD
303
Absolute contraindications for OCPs
```
Breast cancer
Any estrogen sensitive tumor
Pregnancy
Unexplained vaginal bleeding
Thrombosis
Smoker over 35 yo
Liver disease
CHD/CVA
```
304
Extended cycle oral contraceptives
MOA
Content
Eg
84 d of active pill followed by 7 d placebo
Contains levonorgestrel 0.15 mg & ethinyl estradiol 0.03mg
Eg. Seasonale
305
Emergency Contraceptive Options
1. Combined E/P pill- 100 micrograms Estrogen & 0.5 mg Levonorgestrel x 2 doses 12 hr apart
2. Progestin only 1.5 levonorgestrel (Plan B)- more effective and less SE than OCP w/in 72 hrs
3. Copper IUD inserted w/in 5 d of unproteceted inercourse (99% effective)
4. RU-486
306
Depression in pregnancy
- how often should you screen
- incidence
- name of postpartum depression screen
- Treatment
- At least once during pregnancy w/ standardized tool
- 1:7
- Edinburgh Postnatal Depression Screen
- Fluoxitene (low dose used for PMDD), Zoloft ( Sertraline)
307
HRT (Estrogen)- Contraindications
1. Pregnancy
2. Breast CA
3. Estrogen Sensitive tumor
4. Undiagnosed vag bleeding
5. Severe Liver Disease
6. H/o DVT
308
Risks of HRT (Estrogen)
VTE
| Breast CA
309
Benefits of HRT
```
Alleviation of Hot flashes
Possible improvement of memory
Feeling of general well being
Slight improvement in urinary incontinence
Less dyspareunia (local effect)
NOT cardio protective
```
310
WHI findings on Estrogen Replacement Tx
Incr Risk of DVT, strokes
Dec Risk of CHD *not statistically sig
Dec risk of Inv Breast Dz (not statistically sig)??
Dec risk of Fracture rates
311
WHI findings of Combination HRT
Inc risk of stroke
DVT
Breast ca
CHD
312
When is HRT therapy indicated?
Menopausal vasomotor sx
vaginal dryness
prevent early osteoporosis bone loss
SHOULD NOT BE USED FOR PREVENTION OF HEART DZ OR STROKE
313
Formulations of localized estrogen
Premarin, Estring, Vegifem
