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Flashcards in General Gynecology Deck (313)
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1

Virchow's Triad

Causes of DVT
1. Hypercoagulable state
2. Stasis or non-lamilar flow
3. Irregular vessel wall (endothelial damage)

2

Risk factors for DVT?

1. Age >40yo
2. Surgery for malignancy
3. Prolonged surgery >30 mins
4. Obesity
5. Delayed post-operative ambulation
6. Medical Dz (DM, heart failure, COPD, prior DVT)
7. Varicose veins
8. Thrombophilias (50% of cases)

3

Mutations as etiology of DVT?

1. MTHFR (Low risk of thrombosis)
2. Leiden V (5% throm risk)
3. Prothrombin G20210A (2-5% throm risk)
4. Protein C (5-10% throm risk)
5. Protein S (5% throm risk)
6. Antitrhombin III (30-50% throm risk)
7. Lupus anticoagulant (>5% risk)

4

Test for Anti-phospholipid Syndrome

(Acquired condition)
1. Lupus anticoagulant
2. Anti-Cardiolipin Ab
3. Anti-b2-glycoprotein I

5

Work/up for DVT?

1. Doppler u/s
- Test of choice for major (fem/pop) veins
- Sens/spec: 91/99%
- Not sensitive for tibial v or at/below ankle
2. Venography
- Gold standard
- invasive (use when other tests are equivocal)
3. Impedance Plethysmography
- highly sensitive but not specific

6

Clinical Features of PE

1. dyspnea
2. chest pain
3. tachypnea
4. hemoptysis
5. tachycardia

7

Work-up for PE

1. Spiral CT (sens/spec 94% for central PE)
2. Arterial blood gas (PaO2 <90 mmHg)
3. VQ scan- not very specific or sens
4. ECG-nonspecific but recommended as adjunct (tachycardia & R-axis deviation)

8

Treatment of PE

Heparin with conversion to Warfarin

9

MOA of Heparin

Cofactor for Antithrombin II
Increases inhibition of thrombin and Factor Xa

10

Loading dose of Heparin for DVT vs PE?

DVT: 100u/kg (min 5000u)
PE: 150u/kg

11

Maintenance Dose of Heparin for DVT & PE?

15-25 u/kg/hr and convert to Warfarin once patient is stable (or sub Q heparin if patient is pregnant)

12

Prevention dose of Heparin?

5000 u BID (no effect on PTT)
5000 u every 8 hrs in pts with gyn cancers

13

Complications of Heparin

1. Osteoporosis
2. Alopecia
3. Thrombocytopenia (long term tx)

14

Treatment protocol for DVT/PE with Heparin.

1. 5000u bolus, then 1000-1200 u/hr x5d
2. then sub Q 8000-10000 u BID
3. establish PTT at 1.5-2.5 times normal
4. Initiate Coumadin tx same day or after (not before)

15

Treatment protocol for DVT/PE with Lovenox.

1. 1 mg/kg (generally 40-60 mg) BID or
2. 1.5 mg/kg once daily
3. Initiate Coumadin tx same day or after (not before)
4. PT/PTT are normal w/ Lovenox

16

HIT- Which meds?

Can occur with Heparin or Lovenox

17

Repair of Bladder Injury

1. Assess location of injury w/ respect to trigone
2. 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
3. Instill sterile milk to assess integrity of closure
4. Consider cystoscopy w/ or w/o indigo carmine
5. Abx
6. Indwelling catheter for 7 days

18

Repair of Ureteral Injury (End-to-End)

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

Ureteroneocystotomy

Implanting ureter into bladder
-typically if breach <5cm from bladder

20

If ureteral injury is >5cm from bladder what procedures can you try?

Psoas hitch
Boari flap
Ureteroureterotomy (implanting ureter into contralateral ureter)

21

Repair of Bowel Injury

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

Bowel Prep

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

Cherney

Excise rectus muscle off pubis, can damage inferior epigastric vessels- good exposure of lower abdomen

24

Maylard

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