GU CM Flashcards

Question

nephrolithiasis calcium oxalate stones can you see it on a xray? what is it usually associated with? what are 4 associated factors? 3 tx options in general?

Answer 1

MOST COMMON TYPE OF STONE 1. **_RADIOOPAQUE_** 2. usually associated with high calcium levels in the blood and urine 3. contributing factors: excessive bone reabsorption, bone disease, hyperparathyroidism and renal tubular acidosis predispose for these stones TX: treat underlying conditions increased fluid intake thiazide diuretics | (70-80%)

Answer 2

**_caused by low Ph (acidic) urine_** 1. **_radiolucent_** cant be seen on xray 2. caused by high levels of uric acid in the urine or gout 3. RF: obesity/diabetic or both Tx: 1. decrease uring PH below 6 (more alkaline) using _potassium citrate_ 2. allopurinol with decrease purine diet (fish, shellfish, and meats)

Answer 3

**_autosomally recessive inherited abnormalities CYSTINURIA_** "childhood caliculi" 1.**_smooth-edged ground glass appearence_** TX: 1. increase urine volumes to 3 L a day and increase urine pH to greater than 7 2. occasionally chelating agents

Answer 4

1. non-contrast CT (gold standard) used to identify the size, location and type of stone ## Footnote - _low density_ (aka can't see): uric acid, cystine - _high density_: calcium oxalate, struvite - _struvite_: laminar, rugged apperance, full of casts with "stag horn apperance" \*\*\*\*\*do renal US for pregnant people who can't have the CT\*\*\*\* 2. labs 1. urinalysis (stone type/blood) 2. BMP (calcium and creatinine if worried about kidney function) 3. 24 hour urine for the amount excreted 4. thyroid function test

Answer 5

high humidity high temp sedentary high animal protein and high salt FH for calcium stones hyperthyroidism/hypothyroidism

Answer 6

**Most common:** 1. unilateral flank pain 2. sudden onset 3. renal colic 4. hematuria **Less common:** 1. vague abdominal pain 2. acute abdominal/flank pain 3. difficulty urinating 4. penile or testicular pain

Answer 7

acute renal failure urosepsis urinary obstruction concomitant pyelonephritis \>10 cm haven’t passed for 4-6 weeks

Answer 8

**1. NSAIDS and opoids!!** **1.5. increased fluid intake key!** **2. shock wave lithotripsy (small renal caliculi)** **3. precutaneous nephrolithotomy** **4. rigid and flexible ureterscopy +/- stent placement** (tx of choice for maority of middle and distal urethral stones or those who failed shock wave lithrotripsy) **5. diet changes for Ca oxalate stones** (decrease spinach, animal protein, Na intake)

Answer 9

most common abnormality elevated Ca excretion, decreased serum Ca

Answer 10

**size** 5-10 mm less likely to pass on their own \>10 mm won’t pass on their own **location** stones in proximal ureter less likely to pass ureterovesicular junction more likely to pass _Meds to help pass:_ alpha blocker (tramsulosin) CCB (nifedipine)

Answer 11

1. most managed conservatively with pain management Nsaids and Opoids (BETTER USED TOGETHER!!) 2. hydration 3. strain urine **consider hospitalization:** uncontrolled pain/fever can’t tolerate oral intake

Answer 12

⅓ will experience stone recurrence within 5 years ½ experience stone reccurence within 10 years

Answer 13

**uncomplicated UTI** - acute cysitits - acute pyelonephritis **complicated UTI** 1. something that makes the more likely to fail treatment - obstruction - anatomic abnormality urologic dysfunction - MDR uropathogen 2. pregnant 3. elderly 4. children 5. males 6. recurrent

Answer 14

associated with preterm birth, low birth weight, prenatal mortality screen in 1st trimester with UC **_admit them since dangerous with baby_** always check urine culture if asymptomatic because the bacteria in the urine can cause the things under A, if + treat with abx **_if they get 2+ positive tests with greater than 100,000 positive tests they they will be on suppressive abx for the remainder of the pregnancy_**

Answer 15

**postmenopausal women** 1. bladder/uterine prolapse 2. loss of lactobacilli in vaginal flor allos for E. coli to take over 3. diabetes (sugar) **benign prostatic hypertrophy**

Answer 16

white children more common than black children **fever, hematuria, abdominal pain** **DOC: 2nd-3rd line cephalosporin** _7-14 days_ if febrile _5 days_ if immune competent and afebrile

Answer 17

unusual for men 15-50 RF: **uncircumcised, anal intercourse** antibacterial material in prostatic fluid **18-20 cm urethra**

Answer 18

**30:1 ratio women to men** because women have a significantly short urethra route of infection: ascending from the urethra UTI most commonly from _uncomplifcated acute cystitis_ pathogenisis: 1. colonization of vaginal introitus by uropathogens from fecal flora ascend from urethra into bladder **CYSTITIS** 2. uropathogens ascend from bladder to kidney via ureters RARELY CAUSED BY SEEDING OF BACTERIA

Answer 19

female sex frequent sexual intercourse diaphragm/spermicide use delayed post-coital micturition (not urinating after intercourse) hx of UTI

Answer 20

**e.coli most common 75-95%** proteus mirabilis klebsiella pneumoniae enterococcus

Answer 21

cystitis: ## Footnote 1. dysuria or burning while urination 2. increased frequency/urgency 3. suprapubic pain/discomfort 4. hematuria 5. voiding small amounts 6. AFEBRILE pyelonephritis 1. FEBRILE 2. chils 3. flank pain 4. costovertebral tenderness 5. CBC with left shift

Answer 22

**1. UDIP** _+ leukocyte esterase (product of baceteria)_ _+ nitrites (conversion of nitrates to nitrites via bacteria)_ _+WBC_ _+WBC casts (**INDICATES KIDNEY ORIGIN!\*\*\***)_ **2. hematuria** **3. culture greater than 100,000**

Answer 23

**_acute cystitis_** _DOC1: TMP-SMX_ DOC2: CIPRO DOC3 if pregnant/allergic: Nitrofurantoin \*\*\*add _pyridium_\*\*\* **_acute pyelonephritis_** _DOC1: ciprofloxacin_ DOC2: TMP-SMX \*\*\*\*\*NOTE THE DOC FOR FOR THESE TWO ARE DIFFERENT!!!\*\*\*\*\*

Answer 24

CIPROFLOXACIN!! others: fluoroquinolone, amp+gentamycin, ceftriaxone

Answer 25

cathertized associated UTI ## Footnote _if asymptomatic don’t need to treat with abx_ screen urine 48 hours after removing catheter

Answer 26

_3 or more episodes per year confirmed UC_ OR _2 UTIs in last 6 months_ ## Footnote consider self treatment at first sign (urine cup for UC) vaginal estrogen in women since they have a decrease in lactobacillus

Answer 27

**_treat:_** 1. pregnant 2. before urologic procedures 3. after renal transplant **_DONT TREAT_** 1. diabetics 2. elderly 3. patients with spinal cord injury or indwelling urethral catheter

Answer 28

YES! then adjust abx as appropriate! :)

Answer 29

thelarche: breast development in females pubarche: production of pubic/axillary hair menarche: menses

Answer 30

consistent menstrual cycle with a length of 21 days or FEWER!!!

Answer 31

consistent menstrual cycle with a length of 35 days or GREATER

Answer 32

painful menstruation

Answer 33

1. increase bladder compactiy 2. decreased in bladder contractions 3. improve urgency sxs SE: NO PEE, NO SEE, NO SHIT, NO SPiT

Answer 34

contraction of the pelvic floor muscles hold 3-5 seconds 50-100 reps a day

Answer 35

dx of exclusion where abnromal bleeding without pathologic cause has been ruled out in very young or perimenopausal woman ## Footnote usually an issue with the _hypothalmic-pituitary-ovarian hormaone axis_ **MC: shortly after menarche or during perimenopause because of increased _anovulatory_ cycles (90%) since there is _unopposed estrogen_ it leads to _irregular, unpredictable sheeding/bleeding_**"think: when cycle changes" DX: **Always run:** **CBC and platelents** **PREGNANCY TEST** consider: all other testing needed to rule everything else out!!

Answer 36

1. MC: NSAIDS Acute: 1. oral progestins 2. IV estrogen for life threatening bleeding chronic: 1. cycle with low dose COP, patch, or vaginal ring 2. cycle with progestin 3. choice depends on sage, smoking hx, preference 4. endometrial ablation

Answer 37

endometrial cancer

Answer 38

MC gynecological cancer ## Footnote **_most postmenopausal 75%, 50-60 years old_** **_estrogen dependent cancer_** _mc sxs, inappropriate uterine bleeding postmenopausal_ type 1: MC type unopposed estrogens stimulate the endometrium well differentiated starts as hyperplasia curable type 2: endometiral atrophy undifferentiated clear cell and papillary serous histology mor agressive and found at later stage DX: **_1. entometrial bx_** 2. transvaginal US **_\>4mm_** 3. hysterscopy with bx 4. **_dilation and cutterage_** GOLD STANDARD but not more effective, and not therapeutic

Answer 39

1. total hysterectomy 2. radiotherapy and chemo at advanced stages 3. reccurence is txed with high dose progestins OCP have protective effect?

Answer 40

1. obesity-fat makes weak estrogen which are unopposed after menopause and causes cellular change in uterus 2. metabolic syndrome 3. diabetes 4. polycystic ovarian syndrome 5. exogenous unopposed estrogen 6. tamoxifen (breast cancer med)

Answer 41

1. high weight + unoppposed estrogen+low exercise +low isofalvones leads to _unhealthy endometrium_ 2. unhealthy endometrium leads to _endometrial hyperplasia_ (overgrowth of endometrial cells, **premalignant** and presents with heavy periods) \*\*\*intervene here with diet, exercise, weight loss program, hormone therapy 3. if no intervention leads to _endometrial hyperplasia with atypical cells_ \*\*intereven here with hormone therapy and surgery\*\* 4. if not intervention wil leads to _endometrial adenocarcinoma which is CANCER!!!_

Answer 42

1. **endometrial hyperplasia without atypical cells:** diet, exercise, weight loss program, hormone therapy **(progestin pO or mirena so estrogen isn't unopposed and limits endometrial growth)** 2. **endometrial hyperplasia with atypical cells**: hormone therapy and surgery to remove effected areas **3. endometrial adenocarcinoma: HYSTERECTOMY with radiation and chemo for advanced stages**

Answer 43

tissue histologically that r**_esembles endometrium_** found **_outside_** of the uterus, **_MC on ovary and pelvis_****_,_** that **_responds to cycical hormonal changes,_** at **_less than 35 years ol_****_d who is nullparous_** (not given birth to child) mc cause of infertility 25-35% classic triad: 1. cyclic prementrual pain, pelvic area 2. dysmennorhea (including spotting) 3. dyspareunia (with deep thrust) PE: tender nodularity of the _cul de sac_ and uterine ligs DX: 1. US 2. laproscopy Tx: (based on sxs and location, child bearing desire) 1. NSAIDS 2. OCP-relieve sxs 3. progestins- reduce flow, ovulation and cause less bleeding/discmfort 4. danazol 5. GnRH-block release of pituiatry hormoens governing menses 6. surgery-last resort if fertiliy is to be maintained

Answer 44

benign uterus smooth muscle tumor, MC in african americans and those older than 40 ## Footnote small, to large, singe, multiple **_estrogen dependent_** and seen more comonly in those who have endometrial hyperplasia, anovulatory statees, and estrogen producing ovarian tumors SXS: **_bleeding is MC sxs_** **mennorrhagia** PE: **_firm, enlarged, irregular uterine mass_** DX: **_Pelvic US_** D&C laproscopy

Answer 45

depends on the age, parity, reproductive plans, general health, size and location 1_. observation-MC_ 2. GnRH agonist-shrink fibroid 6 months only 3. OCP/IUD progestin-inhibit estorgen 4. myomyectomy-high risk of reccurence so done close to when she wants to become pregnant 5. hysterectomy \*definitive\* 6. uterine fibroid embolization (UFE)

Answer 46

`1. **pedunculated**: bubble off uterus with stock 2. **intracavity**: within uterus 3. **intramural**: within the uterine muscle 4. **submucous**: directly under the endometrium, causes uterine bleeding 5. **subserous**: directly under the serous lining, outside of the muscle

Answer 47

1. endometrial cancer 4x 2. spontaneous abortion

Answer 48

one organ protruding into another where it isn't supposed to be RF: **_weakness of pelivic floor muscles_** **_MC cause: childbirth_** SXS **_pelvic fullness, heaviness, and "falling out" sensation or "sitting on a ball"_** **_low back pain esp with prolonged standing that improves after laying down_** urinary frequency urgengy and stress PE: **_bulging mass est with increased intrabdominal pressure ie valsalva_** Tx: 1. **_DO NOTHING IS ASYMPTOMATIC!!!_** 2. pessaries 3. **_keagles_** 4. estrogen (improve atrophy) 5. surgery

Answer 49

uterine herniation into the vagina Types: **anterior wall desent:** protrustion of the urethra into vaginal canal **posterior wall descent:** protrusion of the rectum into the vaginal canal **central prolapse**: protrusion of the uterus into the vaginal canal

Answer 50

posterior bladder herniating into anterior vagina

Answer 51

distal sigmoid colon (rectum) into the posterior distal vagina

Answer 52

1. age MC after menopause, risk increases to 50% post menopause 2. parity-vaginal delivery 3. _obesity_-increased intrabdominal pressure 4. chronic cough 5. chronic constipation

Answer 53

**grade 1:** dsecent into the upper 2/3 of the vagina **grade 2:** cervix approaches the introitus (vaginal canal) **grade 3:** outside introitus (seen outside body) **grade 4:** entire uterus outside of the vagina-complete prolapse

Answer 54

**_IT IS A STI!!!!_** ## Footnote HPV in 99.7% of cases HPV: **_16, 18_**, 31, and 33

Answer 55

3rd most common GYN cancer in US and #2 of ALL CANCERS in women worldwide ## Footnote usually occurs at the **_transformation zone_** (at SJC junction between squamous epithelium and glandular epitelium) squamous cell 69% adenocarcinoma 25%

Answer 56

cervical dysplasia is a precursor for cervical cancer ## Footnote **Cervical intraepithelial neoplasia _CIN_ is the _preinvasive phases of cervical cancer_** (it isn't cancer yet!) **carcinoma in situ _CIS is the first cell change to cancer_** Ages: 20s: common occurance of CIN 25-35: CIS becomes more common in addition to continuation of CIN 40-50: Cervical cancer

Answer 57

CIN1: mild dysplasia CIN2: modterate dysplasia CIN3: severe dysplasia \*\*1/3 of patients will progress to carcinoma\*\* CIS: carcinoma in situ

Answer 58

gardisil vaccine protects: 6, 11, _16, 18_ reccomended ages for bots and girls 11-26 years old

Answer 59

decreased the insicidence and mortality from cervical cancer 75% in the last 50 years in developed countries, 95% according to hoffmans lecture?

Answer 60

SXS: early cervical CA is **_asymptomatic_** irregular or heavy vaginal bleeding **_post coital bleeding and spotting MC sxs_** PE: **_possible lesions that are raised and friable_** DX: colpscopy with bx Tx: if early stage **_\<4 mm and confined to cervix can be cured via:_** 1. radical hysterectomy 2. fertility-sparing surgery 3. radiation and chemo **_if metastic of reccurent, media survival is less than 2 years_**

Answer 61

used to follow up abnormal pap results ## Footnote magnifies cervix cervix stainged with **_acetic acid (vinegar) or iodine_** to identify the areas that need to be bxed tx/management options 1. loop-electrosurgical excision procedure (LEEP) 2. ablation of T-zone with cryrotherapy or laser

Answer 62

1. mild lesions may resolve spontaneously 2. preinvasive neoplasia can be txed with electrocautery, cryocautery, laser surgery, conization, large loop excesion of transitional zone, or LEEP procedure (Green book)

Answer 63

responsible for 70% of cervical cancers **_16_:** higher rates of **_squamous cell cancers_** CIN3 **_18:**_ higher rates of _**adenocarcinomas_**

Answer 64

1. start at age 21 until 65 (don't check if under 21 and sexually active) ## Footnote 2. screen every _3 years_ from _21-29_ 3. _pap + HPV "co-test" every 5 years_ if between _30-65_ \*\*notice you don't screen for the actualy HPV virus if you are under 30

Answer 65

**_premature cervical dilation established in the 2nd trimester_** RFs: 1. previous cervical trauma/procedure 2. uterus defects 3. DES exposure in utero 4. multiple gestations SXS: 1. vaginal bleeding 2. vagininal discharge esp in 2nd trimester 3. _painless dilation and effacement of cervix_ **TX:** **1. bedrest** **2. cerclage (suturing of cervical OS)**

Answer 66

premaligment and malignant lesions commonly associated with HPV **_vaginal intraepithelial neoplasia (VAIN)**_/_**vaginal cancer_** RARE less than 1% of all GYN cancers women over 50 **MC presentation is postmenopausal blleding or bloody discharge** **_vulvar intraepithelial neoplasia (VIN)/vulvar cancer_** 3-5% of all GYN cancers **MC are _squamous cell carcinoma in postmenopausal woment_** younger women with warty lesions assocaited with HPV older women less associated with HPV **_puritis MC precention or asymptomatic_** red/white ulcerative crusty lesions

Answer 67

DX: colopscope Tx: **excision** **laser** **tropical antineoplastic agents** 1. 5-FU 2. imiuimod

Answer 68

**MC vulvar dermatological disorder** benign chronic inflammatory process SXS - pain - dysuria from loss of elasticity **_ACUTE_** **_red/purple_** lesions on **_non-hair-bearing ares_** in the perineum and perianal area in a **_hourglass pattern_** - erythema and edema - white plaques (keratosis) - intense puritis **_Chronic_** skin becomes **thin, white, and shiny** **can lead to loss of genital landmarks** - labia fusion - introital stensosi Tx: STOP SCRATCH ITCH CYCLE -STEROIDS

Answer 69

squamous cell carcinoma

Answer 70

obstruction of the duct of bartholins gland causing retention of secretions and cystic dilation that can cause infection SXS non infected: minimal infected: pain, tenderness, erythema, dyspareunia with fluctulant mass DX: culture/cbc Tx: none if asymptomatic drain with ward catheter or marsupulize excisions if recurrent

Answer 71

two glands located slightly posterior to the left an right of the opening of the vagina function: secrete mucous to lubricate the vaginal opening 1-2 drops when sexually aroused

Answer 72

the absense of a menses **primary: never had menses, younger girls** -absense of menstruation before age 16 **secondary: had menses and stopped _for 3 months if cycles are normal, or 6 months if the cycles are irregular_** **_most common cause is pregnany!!_** others: 1. drug use 2. stress 3. weight gain 4. excessive exercise 5. _Asherman's syndrome_-acquired endometiral scarring 6. _polycystic ovary syndrome_

Answer 73

DX: 1. **_PREGNANCY TEST EVERYTIME!!!_** 2. progesterone challange idirectly determines if the ovary produces estrogen if endometrium is primed with estrogen (functioning ovaries) progestin will produce menses expect withdrawal bleeding within several days of completing progestin course Tx: 1. OC 2. cyclic progesterone for 5-12 days a month for smokers for over 35 year olds

Answer 74

**_painful menstruation_** **_primary_** not due to pelvic pathology due to **_excess of prostaglandins and leukotrienes**_ leading to _**painful uterine contractions, N/V/D_** starts 1-2 years after the onset of menarche in **_teenagers_** **_secondary_** **_due to pelvic pathology_** so a identifiable condition **_25 years and older_** endometriosis, adenomyosis, uterine fibroids, PID, IUD

Answer 75

sxs ## Footnote **primary:** 1. cramping, bloating, and lower abdominal pain that radiates to the back or thighs 2. begins before or during menses for 1-3 days **secondary:** the above PLUS 1. bloating 2. mennorrhagia/dyspareunia tx: primary: **NSAIDS** **heat, exercise, OCP** secondary: tx underlying condition

Answer 76

**cluster of physical, behavioral, mood changes with cyclical occurence during luteal phase of the menstrual cycle** **occurs 1-2 weeks prior to mentstraion and ends 1-2 days after the onset of sxs** a symptom free period during the follicular phase, day 1 of menses must exist **_75%_** of women have some symtpms of this 5% have severe sxs and distress that limit their ability to participate in lfe basically DX: thryoid to rule out thyroid issues CBC to rule out anemia Tx: **1. limit caffine, alcohol, sodium** **2. frequent high-complex carb meals** **3. stress management/exercise** **4. SSRIs 14 days prior to the onset of menses** **5. NSAIDS**

Answer 77

**cessation of menses after 1 year** loss of ovarian activity at approximately 51 SXS: vaso motor sxs from decreased estrogen production **_1. HOT FLASHES_** upper body, face, chest, and neck - interfere with sleep - 75% have them - last 6 months -2 years depends on person **_2. atrophic vaginitis with discharge and itching and loss of elasticity_** -can lead to dyspareunia and sexual dysfunction making a low quality of life, self-esteem, and sexual intimacy **_3. sleep distrubances_** **_4. new onset depression_**

Answer 78

1. systemic hormone therapy most effective estrogen or progesterone with the lowest effective dose and shortest duration but _limited to 5 years or less of use_ ## Footnote 2. SSRIs 2nd 3. SNRIs

Answer 79

**use progesterone and estrogen as hormone therapy for this** must consider if woman has uterus or not BEFORE giving hormone therapy 1. if no uterus: can use esterogen alone this is the most effective tx, however, it **_increases the risk for endometrial cancer so you ONLY use it patients WITHOUT a uterus_** 2. if uterus: must use estrogen AND progesterone **_NO icnreased risk for endometrial cancer so can be used in patients with a uterus_** slightly increases risk for breast cancer so must keep this in mind

Answer 80

typically a clincial dx in labs you would use FSH to dx because this would be high as well as LH while the estrogen levels are still low they are at increased risk for osteoporosis so may want to consider putting them on medicalion to prevent this

Answer 81

BREAST CANCER

Answer 82

endometrial cancer

Answer 83

OSTEOPOROSIS

Answer 84

**_failure to conceive past 1 year of unprotected regular intercourse**_ _**in women less than 35 and after 6 months in women older than 35_** 30% male, 30% female, 25% unknown RF: 1. cigarette smoking 2. radiation 3. chemo 4. autoimmune dxs

Answer 85

**OOCYTE aging** _1. decrease in both the quality and quantity of oocytes_ 2. 1-2 million follciles at birht to 300,000 at the onset of puberty 3. loss acceralates quicky at 30s 35-39 is when you see the biggest population of couples seeking fertility help!!

Answer 86

1. ovulatory disease MC 25% ## Footnote PCOS, eating disorders, CUshings, CAH, Turners, thyroid disease 2. endometriosis 15% damage or lining changes prevent ovulation fertiliation and implantation 3. pelvic adhesions 4. tubal blockage 5. uterine fiboirds 6. congenital defects

Answer 87

1. testicular disease 30-40% MC ## Footnote Klinefelders syndrome varicocele Y chromosome deletions STIS 2. disorders of sperm transport 10-20% epididylmal dysfunction vas deferens dysfunction ejaculatory dysfunctions 3. hypothalamic pituitary disease (secondary hypogonadism) 1-2%

Answer 88

1. FSH-ovarian function at day three 2. TSH-thyroid function 3. menstrual hx 4. LH surge prior to ovulation or luteal progesterone 5. prolactin 6. pelvic US 7. hysterosalpingogram (HSG)

Answer 89

1. semen analysis ## Footnote volume and pH asses sperm: _motility, concentration, and morphology_ _leukocyte count_ _immature germ cells_ collect 2-7 days after abstinence, need at LEAST _2 samples collected 1-2 weeks apart_ 2. decrease alcohol, marijuana, tobacco use 3. endocrine levels 4. genetic testing

Answer 90

1. under 35 y/o after 12 months 2. 35-40 y/o after 6 months 3. upon presentation - over 40 - amenorrhea - hx of chemo, radiation, end stage endometriosis - uterine or tubal dx - male with hx of groin, testicular surgery, chem, or radiation

Answer 91

1. smoking cessation 2. decreased caffine, alcohol use 3. appropriate timing of sex around ovulation time using predictor kit 4. **therapeutic interventions** - **clomid** ovulation stimulator - interuterine insemination (IUI) - in vitro fertilization (IVF) 5. male tx hypogonadism from hyperprolactin: bromocriptine to lower prolacting - other hypogonadism: HcG injections - sperm disorders: retrograde ejaculation

Answer 92

1. climpiphene + intrauterine insemination since low cost and low SE ## Footnote 2. gonadotropin injections and interuterine insemination

Answer 93

**uterine thickening that occurs when entometrial tissue invades the myometrium**, and can cause a mass in the uterus called a _adenomyoma_ unknown cause MC: women older than 30 who have had children, increases with age! SXS: **_tender and "boggg" uterus_** **_mennorrhagia_** (heavy menses) **_dysmenorrhea_** PE enlarged uterus uterine mass DX: US endometrial sample MRI Tx: 1. nothing 2. progestin containing IUD (supress bleeding and allows mass to shrink) 3. OC 4. surgery last chance

Answer 94

basically PMS on steroids that **disrupts daily living** must have _5 or more of these symptoms_ and _occur the week before the onset of menses and start to improve within a few days after the onset of menses and not during other times_ 1. marked affective lability (mood swings, sensitivity) 2. marked irritability or anger or increased interpersonal conflicts 3. marked depressed mood, feelings of helplessness, self-depreciating thoughts 4. marked anxiety, tension, feeling of being on edge 5. decreased interest in usual activities 6. subjective sense of difficulty in concentration 7. lethargy, easily fatigued, marked lack of energy 8. marked change in appetite, overeating, or specific food cravings 9. hypersomnia or insomnia

Answer 95

75% of women have it at least once **_candida albicans MC and causes 90% of cases_** also candida glabrata and tropicalis SXS: cheesy white discharge intense itching inflammed vagina and vulva DX: clinical wet prep with KOH Tx: ***_imadazoles_ oral or topical*** recurrent: likely glabrata or tropicalis **_fluconazole for 2 weeks_**

Answer 96

only if they are asymptomatic!

Answer 97

caused by the combination of **_low estrogen_** - prepubertal - post menopausal - after childbirth esp if nursing **_and_** **_thinned vaginal epithelium_** SXS dryness, spotting, seroanginious discharge, dyspareunia Tx: intravaginal estrogen

Answer 98

clear cell adenocarcinoma of the vagina

Answer 99

**vulvar pain in the absence of physical findings** **1. PROVOKED** 20-30 year olds comes after something like childbirth or infecion vestibular erythema tendernress introital pain **2. UNPROVOKED** over age 40-60 larger area of pain cause unknown SXS burning, irritation, hyperalgesia Tx 1. pelvic floor pT 2. lidocaine 3. tea tree 4. topical estrogen 5. tricyclic antidepressant 6. _gabapentin_ 7. vulvar vesticuloectomy 8. chronic pain referral

Answer 100

where the **_inner lining of columnar cells**_ meets the _**exterior sruface of squamous cells_** "eversion of the columnar epithelium onto the ectocervix" however this moves **inward** over time which is why you cant see it transformation zone: 1. where metaplasia and hyerplasia occur 2. neoplastic changes occur here 3. can be visualized in younger people (pic) but not in older peopel ebcause it moves into the cervical canal **_approximately 3cm_** from original location

Answer 101

yellowish translucent pear-like shaped cyst on the ecto cervix

Answer 102

small, pedunculated neoplasms, _red_, _FRIABLE_ that originate from the endocervix and protrude _2-3 cm_ ## Footnote very common esp if older than 20, most are BENIGN DX: remove by grasping with forceps and twisting to send to pathology to r/o malignant changes

Answer 103

**narrowing of the endocervical canal, usually at the OS, with partial to completely occlusion of the OS** causes: 1. congenital 2. hypoestrogenic 3. neoplastic 4. post surgical

Answer 104

1. blood clots DVT/PE 2. pregnancy hx (rule out w/test) 3. clotting disorders (factor V lieden) 4. medications/allergies 5. smoking status 6. weight/BP

Answer 105

COC: BP (no HTN) IUD: pelvic exam, rule out STIs

Answer 106

MOST EFFECTIVE, pregnany rate less than 1% can be used in all women _including adolescence_ bad things: longer bleeding and worse cramps OPTIONS: **1. Nexplanon implant** **2. paraguard COPPER IUD** **3. Levonorgestrel release IUD** **-mirena** **-liletta** **-Skyla** **4.methdroxyprogesterone acetate depo-provera shot**

Answer 107

**Hormone: progestin** **duration: 3 years** **menses: lighter, irregular with unscheduled bleeding** Don't use: in someone who poor tolerance to amennorhea or unscheduled bleeding

Answer 108

**hormone: NONE!!! COPPER ONLY!!** **duration: 10 years** **menses: may get heavier with more cramping and unscheduled bleeding** risks: uterine perforation, expulsion, infection don't use: 1. heavy ir painful menses 2. iron deficiency 3. anemia 4. uterine abnormality 5. copper allergy 6. wilsons disase foreign body rxn and chemical changes may be toxic to sperm and ova

Answer 109

mirena liletta skyla **hormone: progestin** **duration: 3-5 years depending on type** **menses: lighter and irregular with unscheduled bleeding** risks: uterine perforation, expulsion, infection poor choice: lower tolerance to amennorhea or unscheduled bleeding

Answer 110

**pregnancy rate 6% first year of use** **hormone: progestin** **injection: every 12 weeks (3 months)** **menses: lighter and irregular with unscheduled bleeding** risks: weight gain and mood swings poor choice: for quick return of fertility

Answer 111

**pregnancy rate: 9%** **hormone: progestin and estrogen** **pill: many combinations- _28 day, 21 day, extended cycle_** **ortho evra patch-** **Nuvaring-_monthly_** **menses: lightr, regular predictable withdrawal bleeding with cyclic use**

Answer 112

RISKS/Contras: 1. breast cancer 2. estrogen/progestin dependent neoplasms 3. hepatic tumors 4. stroke 5. DM with vascular 6. DVT/PE 7. hypercoagabilities (factor V) 8. migraines with aura 9. HTN uncontrolled 10. rythmn dxs lik afib 11. women older than 35 smoke

Answer 113

1. reduction in dysmennorhea with more regular cycles 2. reduce risk of etopic pregnancy 3. reduce PMS PMDD 4. decrease ovarian cancer 5. reduced endometrial cancer 6. reduction in acne 7. reduced hirsutism

Answer 114

1. increase risk of breast cancer 2. increase vascular thrombolytic event from increased lipids (DVT/PE, AMI/CAD)

Answer 115

1. Essure ## Footnote hyteroscopic steralization-metal coil inserted into the distal portion of each fallopian tube office based procedure under anastesia 2. bilateral tubal ligation laparoscoptic vs mini-lapro samoe day surgery 3. vasectomy non-scapel vasectomy-puncture is made through the scrtom skin overlying the vase defference and widened only enough to externalize the vas deference for transection officed based under local anastesia _need 20 ejaculates to get the left over sperm out_

Answer 116

greater for STIs, not great for pregnacy 18% failure rate

Answer 117

anywhere from 15 mins to 2 hours

Answer 118

**1. inhibits secretion of pituitary gonadotropins via NEGATIVE feedback mechanism which prevent follicular follicle development and ovulation** **2. alters endometirum (thinning) which may effect implantation by producing unfavorable environment for fertilization** **3. thickens cerivcal mucous which inhibits sperm passage/penetration**

Answer 119

1. levonorgestrel OTC (so convient) "plan B" 50-94% efficacy ## Footnote 2. ulipristal Rx "Ella" 98-99% effective \*\*MOST EFFECTIVE oral\*\* 3. paraguard \*MOST EFFECTIVE METHOD\*

Answer 120

nullparity (not having children) increases the risk for breast cancer because it increases the number of menses the woman has thus **increasing the amount of unopposed estrogen she is exposed to** **this stimulation of cell proliferation during every cycle increases the risk for development of breast cancer** **those who have early menarch and late menopause are also at increased risk because it increases the number of menses they have and ultimately exposes them to more estrogen** **_first pregnancy_ appears to have a protective effect** **COOL FACT: THIS IS WHY NUNS HAVE A HIGH RISK FOR BREAST CANCER!!!**

Answer 121

**Pulsatile release:** maintains normal FSH, LH levels in the blood as GnRH is released it binds to gonadotrophs and causes released of **STORED** LH and FSH \*\*allowing a period of rest between pulses allows the gonadotroph to increase stores aka *priiming effect\*\** **continuous release**: results in a **REDUCTION** of the pituitary contens of FSH and LH and their release (since trying to replenish stores) clinical implications **GnRH agonists and antagonists:** down regulate LH and FSH release since it continiously sitmulates receptors and doesn't allow for the gonadotrophs to replemsih stores these can be used in certain cancers to lmit the amount of estrogen/progesterone they are exposed to since this is the ultimate product of this process. \*\*may cause an intial flare in sxs and then down regulate\*\* - breast cancer - endometriosis - prostatic cancer

Answer 122

steroids are made from cholesterol which comes from acetate ## Footnote **progesterones: 21 carbons** **androgens: 19 carbons** **estrogens: 18 carbons** **converstion of one steroid to another can be accomplished by enzymes that are a part of the cells _biosynthetic package_ where _carbons can be taken away but NOT added_** aka a progesterone can become an estrogen but an estrogen can't become a progesterone

Answer 123

most likely acetate with the intermediate as cholesterol, however, direct synethesis also occurs with cholesterol that is produced by the liver or supplied by the diet

Answer 124

FRIST STEP: converstion of **cholesterol to pregnenolone "MOTHER OF ALL STEROIDS"** since all steroids stem rom this and process which occurs in the mitochondria of ther steroid producinc cell this process is **_cataliyzed by mitochondrial cytochrome P450 side chain cleaving also referred to as desmolase 20-22_** **_cholesterol is a negative feedback regulator of HMG CoA reductase_**....so when cholesterol is high this enzyme decreases, when cholesterol is low this enzyme increases \*\*\*THINK ABOUT IT: this is why HMG CoA reductase inhibits work for someone with high cholesterol, it prevents further synthesis!\*\*\*

Answer 125

structually similar to cholesterol since that is what they are derived from so they are highly fat soluble and poorly water soluable....this means you find them bound to plasma proteins in the blood. MC albumin, sex steroid hormone, and cortisol binding globulin **_albumin_**: low affinity for bound steroids, weak bond **_sex hormone binding globulin (SHBG):_** high affinity for androgens (testosterone) and estrogens but low affinity for progestens and cortisol, strong bond

Answer 126

when you ask for a the lab to quantify the serum steroids it is a **combination of BOTH 'free" unbound steroids and bound steroids** (how most are) bioavaliable steroid referrs to both the bound and unbound steroid present

Answer 127

meaures the amoutn of bioavaliable testosterone in a person this can help to explain a pt who presents with hirsuitism or features suggesting androgen excess

Answer 128

the majority of steroids are bound with proteins in the blood. many are bound with albumin, but many are **bound with sex hormone binding globulin (SHBG)** when bound with SHBG **the steroid becomes _inactivated_**. In men, more percent of testosterone is bound to ALBUMIN and therefore dissociates quickly, where in women is bound to SHBG and therefore is inactivated! This explains the higher **_andronization_** of males than females because the testosterone is more bioavaliable

Answer 129

not usually.....the carrier proteins like abumin and sex hormon binding globulin are always in excess of steroids, so if there are massive increases they can accound for this and it will have little effect on the body the problem arises when there isn't enough binding proteins like ablumin or SHBG where the slight changes in hormones show their effects more readily and is seen in conditions like **liver diseases**

Answer 130

_very low_ (much lower than cholesterol) with binding proteins like albumin and sex hormone binding globulins ## Footnote want to keep these low because they are like cholesterol and are lipid soluble, this means that they _can readily enter the cell_ if these were present in high concentrations in the plamsa, they could readily enter the cell and disrupt the membrane integrity! this is why _even small levels of plasma steroids are present in the bound protein form_

Answer 131

found intracellular in both the nucleus and the cytoplasm often bound to _heat shock proteins_, that when stimulated by a steroid disocciate and bind to non steroid ligands like Thyroid hormones or vitamins once stimulated: they undergo _conformational change_ that allows them to recognize _hormone-resonse elements (HREs)_ in the DNA which then allows for protein transcription/production

Answer 132

most sex steroid hormones **_(progesterone, estrogen, and testosterone)**_ are made in the _**gonads**_ with the exception of a _**pregnant female_** however it has been made clear the **_target organs have the ability to**_ _**participate in INTERCONVERSION of one steroid to another_** thus they can take a ciculating hormone and transform it enzymatically into another steroid to use LOCALLY **via its biosynthetic package of enzymes** EX: 5alpha-reductase converts testosterone to 5alpha-dihydrotestosterone "DHT" which is stronger!

Answer 133

**5alpha reducatse** converts **testosterone** to **DHT** which is a stronger vesion of testosterone _5-8 % of total testosterone is converted to this_ **5alpha-reductase inhibitors, AKA FINASTRIDE, PREVENT the conversion of testosterone to DHT which can _support the development of benign prostatic hypertrophy_** so reducing this enzyme in men helps to shrink enlarged prostates, can also help with baldness since DHT also contributes to this

Answer 134

**HYPOTHALAMUS: RELEASES GnRH** TRAVELS VIA HYPOPHYSEAL PORTAL VEINS TO **ANTERIOR PITUITARY RELEASE FSH AND LH** TRAVELS VIA BLOOD TO **THECAL/GRANULOSA CELLS** **RELEASE ESTROGEN, PROGESTERONE, TESTOSTERONE** keep in mind GnRH and FSH/LH released in CHICORDIAL PULSES!!

Answer 135

**neurohormone** encoded on chromosome 8 on single gene serum levels: difficult to obtain since its release is confined to the hypophyseal portal blood supply and it has a short halflife 2-4 mins

Answer 136

"gonadotrophins" since they effect gonad steroid synthesis in BOTH sexes ## Footnote both contain alpha (identical) and beta subunits (different) gylcosylated with sugar **FSH is cleared more slowly since it has more carbohydrates and this explains why when looking at infertility you check this because it provides more of a picture while LH is cleared fast and only provides a snapshot**

Answer 137

effect FSH release from anterior pituitary ## Footnote inhibins: allows only one follicle to be selected as graafian activin: allows for developement

Answer 138

GnRH is considered the most important final common mediator of ovulation ## Footnote because the hypothalmus is the first step in the hypothalamo-pituitary-gonadal axis process to **release GnRH** OVULATION is needed for PREGNANCY so must have these pieces working if you want to get pregnant!! CNS can lead to infetility issues

Answer 139

**_OVARY_** from **_first day of menses to ovulation_** ~10-16 days Key points: 1. new _antra follicles_ are recruited to proliferate 2. one of these will be selected as the _graafian follicle_

Answer 140

**_UTERUS_** from the **_first day of menses to ovulation_** 1. the uterus is under the influence of increase **estrogen** and the **stratum functionalis** of the endometrium proliferates from **1-2 mm to 8-10 mm** in thickness 2. increase in estrogen **promotes the formation of progesterone receptors in the uterus so it can respond to progesterone in the post ovulatory phase of the cycle**

Answer 141

the **Graafian follicle** during the follicular phases **ruptures in response to _midcycle FSH/LH surge_ causing the occyte to be expelled from the follicle into the fallopiian tube** viable for ~24 hours where if sperm enter the oocyte can be fertilized at the ampullary-isthmus junction

Answer 142

**OVARY after ovulation** until **onset of next menses** (assuming pregnancy doesn't occur 1. corpus luteum (formerly graafian follicle) is functional unit of the luteal phase and **_produces increased levels of progesterone_** 2. occurs 13-15 post ovulation

Answer 143

**UTERUS after ovulation until next menses** 1. high levels of **prosterone secreted from corpus luteum** have a "_quieting_' effect on the unterine endometrium and facilitate - secretions from the uterine endometrial glands to make condusive for implantation of a **blastocyst** - if no implantation: the **corpus luteum dies and the endometrial tissue looses its blood supply since loss of progesterone production and causes necrosis of linging and sloughing!! MENSES** and the begining of a new cycle

Answer 144

1. oogonia undergo _MITOSIS for 3-4 months_ 2. _Enter meiosis I_ and are called _OOCYTES_ 3. they become **_arrested in PROPHASE of the first meiotic division_** 4. start to be surrounded with **_PRE-granulosa cells_** and is termed primordial follicle

Answer 145

1. pulsatile LH and FSH released at **puberty**"awaken" the **primordial follicles** 2. primoridial follicles become **primary follicles with zona pellucida** that serves as attachment for the granulosa cells 3. primary follicles become **secondary occytes or "pre-antral follicles"** where the _granulosa cells increase in size and the thecal layer forms_ \*\*\*up until this point the the development has occured INDEPENDENT OF GONADOTROPINS\*\*\* 4. LH and FSH increase in response to decreasing estrogen and progesterone from the previous cycle stimulating the pre-antral follicle to tern into a **tertiary follicle** 5. one of these is _selected as the **graafian follicle**_

Answer 146

Increasing **FSH and LH** cause **an increase of estradiol 17B** which initially has a _NEGATIVE FEEDBACK_ of FSH and LH causing the storage of FSH and LH via decreased GnRH release as the **follicle develops** from early follicular phase to late follicular phase, the **LH receptors** that were originally present on only the thecal cells **become present on the granulosa cells where the FSH receptors are.** during this time the number of _granulosa cells size and number are increasing_ and _thecal membrane formation_ the **increase in LH binding** to these receptors (as stated above) causes the production of _andosteridione,_ which is **convered to estrogen via aromatase enzyme** this process increases the NET ESTROGEN to an extent that it causes **_POSTIVIE FEEDBACK_** on **GnRH in the hypothalamus and rlease of FHS and LH** and a **_LH SURGE_** that is a PARADOX (FSH doesn't surge because of the increase of **inhibin A levels rise as estogen rise)** **LUTEAL surge** causes the **estrusion of the oocyte from the follicle and completion of meiosis I.** OVULATION!

Answer 147

low levels of estradiol 17 B feedback NEGATIVELY on FSH and LH release at both the level of both the pituitary and the hypothalamus in the early follicular phase and in the luteal phase HOWEVER, in the late follicular phase very high plasma levels of estradiol 17 B promote a POSITIVE feedback on both the pituitary and hypothalamus which is necessary to facilitate the midcycle surge of FSH/LH just prior to ovulation

Answer 148

if you use low levels of estrogen “low estrogen pill” it is inhibitory on FSH and LH and so you never get the LH surge which prompts ovulation! this means the ooccyte is never released into the fallopian tube also prevents the lining of the endometrium from proliferating since this also suppresses progesterone

Answer 149

the low levels inhibit FSH and LH release with halts the whole process give pt **_clophene citrate**_ that is a _**estrogen antagonist**_ that increases these levels by _**knocking out the low estrogen levels_** this plays of the feeback mechanisms

Answer 150

early to mid follicularp phase: ## Footnote **1. LH receptors are only found on the thecal cells** (outer layer) of the dominant follicle 2. FSH only found on granulosa cells mid to late follilcular phase: 1. **_LH receptos begin to appear along with FSH receptors on the granulosa cells of the selected follicle_** \*\*\*\*\*\*MAKES IT MORE RESPONSICE TO THE LH SURGE WHICH STIMULATES OVULATION AND THE DEVELOPMENT OF THE CORPUS LUTEUM POST OVULATION\*\*\*\*

Answer 151

the increase from the **LH surge "lutinizes" (give the ability to make progesterone** to the corpus luteum **through stimulation of the LH receptors on the thecal and granulosa cells** causes **_massive**_ _**progesterone release and some estrogen_** which **prepares the endometrium for implantation by** **quieting it and**: - increasing blood flow - increasing nuitrient secretions - decreasing contractions of uterus massive release of progesterone and some estrogen **inhibits the FSH and LH release via GnRH inhibition** via _NEGATIVE FEEDBACK_ if no pregnancy the CL begins to die *(Cl needs FSH to LH to live and you have suppressed it so much through negative feedback there isn't enough to support it)* and the plasma estrogen and progesterone decrease, causes _NECROSIS OF ENDOMETRIAL LINING AND NECROSIS_ **starting the cycle over with the increase if estrogen and progsterone in follicular phase**

Answer 152

the **blastocyst implants on the endometrial wall** and forms _placental membranes_ that secrete **_human choronic gonadotropin_** HCG has a **very similar structure to LH** so it can therefore **_rescue the corpus luteum by binding with LH receptors_** this means the **PROGESTERONE PRODUCTION CONTINUES UNTIL WEEK 9-10 WHERE THE STEROID SYNTHESIS SWTICHES OVER TO THE PLACENTA** aka luteal-placental transition period

Answer 153

**inadequate secretory transformation of the endometrium** **resulting from deficient progesterone production-\>_contributes to both infertility and recurrent pregnancy loss_** Causes: 1. abnormal follicular development from inadequate FSH and LH - causes inadequate growth of granulosa cells - causes lower estrogen levels - lower estrogen levels promote **suboptimal LH surge at ovulation resulting in deficient progesterone in the luteal phase**

Answer 154

increased risk of developing breast or uterine cancer since they stimulate proliferation of cells in both these tissue types

Answer 155

MC cause of infertility in women!! ## Footnote often in adolescents **_endrocine syndrome with triad of_** (must have 2/3) **1. oligo (infrequent) or ammenorhea (chronic anovulation)** **2. hyerandrodenism (obesity/hirsuitism)** **3. evidecent of polycystic ovaries** (not everyone) thought to be caused or involved with **_increased insulin resistance**_ (increases the androgens) and _**unopposed estrogen which increases risk for endometrial cancer since the person isn't ovulating and there is no progesterone production_**h

Answer 156

caused by an abnormal hypothalamus-pituitary ovarian axis **1. increased LH realeased compared to FSH** **2. increase androstenedione and testosterone by the thecal cells of the ovary** **3. androstienedione is converted to estrogen in the tissues, and is a weak estrogen** **4. this STIMULATES LH release and inhibits FSH release** **5. the low levels of FSH prevent the follciles from fully developing and ovulation doesn't occur** **6. the androstienedione that accumulates from the LH binding to the thecal cells continues to increase the androgen present cause HIRSUITISM and ACNE** **7.this is a viscious cycle that cause anovulation and also the cystic formation of the ovaries** **\*\*\*INSULIN PLAYS ROLE BECAUSE IT IS THOUGHT TO CONTRIBUTE TO HIGH ANDROGEN LEVELS AND MAKE THE SITUATION WORSE!!!\*\*\*\*** this explains why they are at risk for unopposed estrogens because since there is no ovulation (or corpus luteum development) there is no increase in progesterone which leaves the estrogen unopposed and increased risk for endometrial cancer!

Answer 157

DX: 1. increased testosterone levels 2. **_US_** TX: 1. **OCP** **first COC if contra then POP** treats hirsuitism and unopposed estrogen 2. **metformin for insulin resistance** 3. **clompihene citrate** for infertility-ovulation inducer

Answer 158

**cystic enlargement of ovarian structures** DX: **_US_** Tx: 1. fluid filled **_monitor with periodic US_** because most resolve on their own and ovary still functional 2. if not fluid filled remove with **_laproscopic MC, remove is greater than 6 cm because increase risk of torsion_** **_3.NSAIDS_** prevention: OCPS

Answer 159

**mc cyst type** **"strawberry filled"** usually not sxs resolve spontaneous result from failure of ovulation so it doens't produce a functional egg

Answer 160

occurs **_after ovulation_** ## Footnote **thin walled and unilocular** **_developes withing the corpeus luteum_**

Answer 161

**_3cm_** at risk for multiple gestations _coinsides with molar gestation_ molar gestation: there's not true DNA developing but enough it develops like a fetus but it will never be viable and has **_teratomas_** and can develop outside of the uterus

Answer 162

"chocolate cyst" ## Footnote piece of endometriosis goes to the ovary and called this because of the accululation of blood and is messier if itruptures

Answer 163

Ovarian cancer! "silent killer" by the time we dx it it is already really progressed and metastisizes!

Answer 164

REMOVE IT!! ASAP!!!

Answer 165

no because it does not appeare to reduce mortality

Answer 166

CA-125 BRCA1 and 2

Answer 167

_epithelial carcinomas_ 85-90% of all ovarian cancers

Answer 168

**1. _epithelial_** ## Footnote **MC TYPE** **most are benign** - epithelial carcinomas 85-90% of all ovarian cancers - clear cell-rarely benign - transitional **_2.**_ _**germ cell_** occurs in cells that produce eggs young women teenage-20s 5-10% _teratomes or dermoid cysts are in 40-50% and can contian hair and teeth_ _3. stomal carcinoma_ in connective tissues of the ovaries that produce estrogen and progesterone rare low grade _produce hormones_

Answer 169

OCP more than 1 full term pregnancy before age 35 breast feeding tubal ligation

Answer 170

83% of women...so pay attention!

Answer 171

it is dx in late prognosis! so it kills a lot of people "silent killer"

Answer 172

increase lifetime risk by 25-50% ## Footnote \*\*\*consider **_prophylactic billateral salpino-oophorectomy (BSO) by age 35 or as SOON as childbearing is complete for familial ovariance cancer syndrome!!!!!\*\*\*\*_**

Answer 173

1. BRCA1 BRCA2 2. 65-75 years 3. early menarch, late menopause 4. _french canadians_ 5. never being pregnant 6. obesity

Answer 174

**usually asymptomatic until late disease** **_late stage sxs usually when person presents_** **1. abdominal pain/bloating** **2. early satiety (feeling full)** **3. urinary urgency/frequency** palpable ovary needs evaluation!!! dx: 1. transvaginal US 2. laparoscopic evaluation

Answer 175

1. surgery-removal of tumor (may be total hysterectomy) ## Footnote 2. oophorectomy 3. chemotherapy 4. sometimes radiation

Answer 176

45% 5 year survival rate ## Footnote highly dependent on stage of dx \*\*EARLY DETECTION IS KEY: survival increases to 75% if detected before leaving ovary!!\*\*

Answer 177

low=genital warts ## Footnote hight=cervical cancer/genital cancers

Answer 178

_women over 25_: do HPV testing, if + go to colposcopy if - repeat cotesting in 3 years _21-24 year olds_ repeat in 1 year

Answer 179

_over 25_ perform HPV cotest if positive do colposcopy, if negative restest in 1 year _age 21-24_ repeat pape in 1 year, if above LSIL then colposcopy, if not continue guidelines

Answer 180

high risk of carcinoma colposcopy for _ALL_ no matter HPV status

Answer 181

correlates with CIN II or III at least ## Footnote _25 and over_ colposcopy OR immediate loop electrosurgical excision LEEP _12-24 year olds_ colposcopy ONLY

Answer 182

colposcopy PLUS endometrial sampling if over 35 or at high risk for endometrial cancer

Answer 183

**MOST COMMON BREAST COMPLAINT IN PRIMARY CARE** premenopausal more common than post menopausal since _often cyclic, and increases in women taking OCP or hormonr replacement_ Non-cyclic women 40-50 sharp burning pain unrelated to mestruation _brest exam AND US **ADD MAMMO if over 30**_ cyclic heaviness soreness billaterall, MC in _upper outer quadrant_ _associated with hormone chages, usually 1 week prior to menstration_ (because the breast tissue proliferates _breast exam, US, add mammo if over 30_

Answer 184

1. usually self limited 2. support garments 3. compresses 4. analgesics 5. evening primrose 6. danazol _only Rx for mastalgia but lots of SE_

Answer 185

usually benign 1. normal milk production a. normal secretory milk b. occurs 6 months after cessation of breast feeding 2. galactorrhea a. caused by _hyperprolactinemia, causing bilateral milky nipple discharge_ 3. pathologic (suspicious) a. secretion of other fluids other than milk **b. most common cause is papilloma (papilloma tumor growing from the lining of the breast**

Answer 186

1. spontaneous 2. unilateral 3. bloddy, clear, yellow, white, dark green (LOTS OF COLORS) 4. associated with mass _5. women over 40_

Answer 187

1. _discharge with compression only_ 2. often bilateral 3. clear, yellow, dark green

Answer 188

exclude cancer!!!!!!!!! ## Footnote this is 2nd most common breast complain in primary care, 90% are benign but still need to rule out cancer!!!

Answer 189

1. breast exam 2. mammorgram (often with US) 3. needle BX **A. fine need aspiration (FNA)** **B. core needle Bx (CNB)**

Answer 190

bx via... 1. fine needle aspiration 2. core needle bx 3. open bx

Answer 191

breast cancer!

Answer 192

1. lymph node 2. muscle, fatty tissue, skin 3. bone 4. bone marrow 5. liver 6. lungs 7. brain

Answer 193

1. lumps 2. bumps 3. skin changes 4. dimpling 5. red, hot 6. pain/no pain 7. regional node enlargement

Answer 194

benign conditions predominate

Answer 195

malignant lesions ## Footnote in postmenopausal women, any dominant mass or assymetry should be presumed cancerous until proven otherwise

Answer 196

US!!! sometimes simplest is to aspirate the mass

Answer 197

a definitive dx...bx it!!!

Answer 198

Biopsy!!! superior to even the most advanced imaging

Answer 199

assume nothing! aspirate or refer to surgeon

Answer 200

cells collect around the nipple causing eczematous appearance Rare-5% 97% also have **_ductal carcinoma in situ OR invasiver cancer elsewhere in the breast_** sxs: **_ITCHING_** **_TINGLING_** **_BURNING_** **_scaling and thickening of the skin_** **_yellow or bloody discharge from the nipple_**

Answer 201

_MOST COMMON TYPE OF NON-INSIVE BREAST CANCER_ _1 in 5, 25% of all BC is this_ non-lifethreatening, typically without signs and symptoms **increases risk of developing invasive BC** **80% found on mammorgram** tx: 1. lumpectomy alone 25-30% recurrence 2. lumpectomy and radiation 15% recurreny

Answer 202

collection of abnormal cells, not true cancer ## Footnote **_increases risk of invasive cancer later in life_** dxed before menopause, usually dxed becuase bx performed for some other reason **hormonal receptor positive**

Answer 203

most common invasive breast cancer!!! 70-80% of BC SXS: **_1. swelling of all or part of the breast_** **_2. skin irritation or dippling_** **_3. breast pain_** **_4. nipple pain/nipple turing inwards_** **_5. nipple discharge other than milk_** **_6. enlarged lymph nodes in the axilla_** TX: 1. lumpectomy less than 2 cm 2. mastectomy (partial, total, radical) 3. sentinel lymph node bx 4. axillary lymph node bx 5. post surgical radiation

Answer 204

1. provider visit with exam every 3-6 months for first 3 years 2. every 6-12 months for 4-5 years 3. every year post 5 years 4. yearly mammogram

Answer 205

**1. chemotherapy** **2. hormonal therapy** **3. estrogen receptor down regulatiors-tamoxifen** **4. oviaran shut down or removal** **5. HER2 therapies-block HER2 that allows for rapid cancer growth**

Answer 206

**2ND MOST COMMON TYPE 10% OF CA** **BEGINS IN THE MILK PRODUCING LOBULES** occurs later in life around 60s

Answer 207

rare, average age in 55s **_looks like eczema on the breast (not confined to nipple), breast enlarged_** DX: 1. **_skin punch bx_** Staging: **_1. CXR_** **_2. CT of chest/abdomen_** **3. bone scan** **4.LFT** TX: _1. chemotherapy prior to surgery_ _2. targeted therapy: if HER2 receptor postivie **also treat prior to surgery HECEPTIN**_

Answer 208

if cancer response to first dose chemo before surgery: _modified radical mastectomy_ ## Footnote if no response to first dose chemo before surgery: _another round chemo + radiation and likely radiation AFTER surgery_

Answer 209

1. female 2. greater to 55 3. no children, no breastfeeding 4. exogenous exposure to estroen 5. family hx postive for BC 1st degree relative 6. BRCA1 and 2 7. obesity

Answer 210

60% increase in risk of BC 1. develope breast cancer earlier 2. have bilaterally breast more often

Answer 211

1. yearly breast exam by provider 2. US 3. _aspiration/bx=gold standard_ 4. mammogram-controversial time frame

Answer 212

very controversial ## Footnote 2 main: - start at 40, Q 1 or 2 years - start at 50, Q1 or 2 years

Answer 213

1. size 2. spread to lymph node 3. metastasis

Answer 214

1. eastern european 2. AA before dx before 35 3. in all family of man dx 4. women with BC in both breasts 5. multiple family with breast or ovarian cancer 6. blood relative before 50

Answer 215

solid round, firm, notender, mobile mass "rolled to and edge" **TYPICALLY IN YOUNG woman 15-35** **likely from hormones** **DX:** _core needle bx_ TX: _excision_

Answer 216

diffuse/ill-defined, **_TENDER_** fluid filled mass MC in premenopausal, cyclic breast pain **OFTEN ASSOCITED WITH HORMONAL CHANGES**, AND CAN CHANGE IN SIZE WITH MENSTRUATION presenting complaint: **_pain/palpable mass_** DX: 1. _US_ _2. fine need aspiration for confirmation_ **3. _CBE or US in 2-4 months following aspiration to document stability_**

Answer 217

billateral, milky nipple discharged caused by hyperprolactinemia

Answer 218

**benign proliferation of glandular tissue in male breast** neonatal, pubertal, older males due to **_increased estrogen and decreased androgen_** PE: _palpable mass over .5 cm (usually under the nipple)_ _NONTENDER_, _FIXED_ TX: usually self limited

Answer 219

1. drugs 2. cirrhosis 3. hypogonadism 4. tumors 5. CKD

Answer 220

**inflammation and pain of the breast, most frequently occuring _during breastfeed from infection with staph aureus or strep_** **_MC: staph!!!_** if left untreated can become an abcess!! PE: 1. hard, red 2. inflammed tender area of breast \*\*\*since infection blocks off the duct and it becomes backed up, and at increased risk from breastfeeding since there are more cracks from suckling\*\*\* tx: **_DICLOXACILLIN or CLINDAMYCIN (MRSA)_**

Answer 221

can be a complication of mastitis and required incision, drainage, and abx

Answer 222

19 million

Answer 223

1. infertility 2. ectopic pregnancy 3. low fetal birth weight 4. chronic pelvic pain 5. cervical and angogenital cancer 6. HIV transmission

Answer 224

youth 50% are in those 15-25 year olds

Answer 225

tx as if they have both

Answer 226

2-5x greater risk!! ## Footnote STIs attract CD4 cells to the genital area, so when infected with HIV they are already there. some STIs cause ulcers and therefore also create a portal of entry by treating the STI you _reduce risk 40%_

Answer 227

neisseria gonorrhoae ## Footnote **_effects cervix, urethra, rectum, pharynx_** "Mucous membrane dxs" of men, women, babies **_antibiotic restisance is hallmark_** men **_1. urethral discharge (thick, milky white, yellowish, or greenish)_** **_2. swollen or tender testicles (epididymitis)_** women **_endocervical or urethra_** 1. **majory asymptomatic** **2. vaginal discharge, dysuria, labial pain/swelling** **3. pain during sex** \*\*\*\*DISSEMINATED GONOCOCCAL INFECTION\*\*\* SXS 1. arthritis-tenosynovitis 2. cutaneous and along tendon sheeths

Answer 228

mother can trasmit during child birth caues: sepsis opthalmia neonatorum

Answer 229

1. \<25 years 2. previous C/other STDS 3. commercial sex work 4. mew or multiple partners 5. inconsistent condom use 6. drug us

Answer 230

NAAT \*make sure to monitor abx susceptibility\* collection method WOMEN: vaginal swab MEN: dirty urine sample

Answer 231

DOC1: ceftriaxone 250 mg IM single dose + (azithromycin OR Doxy) DOC2: only if ceftraixone not avaliable cefixime + (azithromycin or doxy)

Answer 232

**1. bartholins cysts** **2. pelvic inflammatory disease** **3. disseminated gonnocooccal infection**

Answer 233

restest woman/men in 3 months after tx

Answer 234

chlamydia trachomatis ## Footnote **_cervicitis, urethris, proctitis, PID_** men, women, children women _usually asymptomatic_ _mucopurlulent cervicitis, red and hot_ abnormal vaginal discharge pain during sex men _usually asymptomatic_ discharge from the penis, may be _running, whiteish, thin_ burning on urination swollen testicles, epididymitis

Answer 235

DX: NAAT urine test: men vaginal swab: women TX: DOC1: azithromycin 1 g once DOC2: doxy 100 mg BID x 7 days

Answer 236

ONLY IN PREGNANCY ## Footnote \*\*wait 3-4 weeks to restest so the DNA from the dead bacteria doesn't produce a a false positivie\*\*

Answer 237

txing sex partners without a visit...rules still being written in maine. ## Footnote \*\*can legally write prescription for partner if they aren't youre pt so tx increases\*\*

Answer 238

**prodromal phases:** 24 hours before outbreak, get burning and tingling "painful grouped vesicles on erythmatous base!" HSV1: oral lesions **85%** population infected; transmitted via saliva, **outbreak triggered by random things** HSV2: genital herpes (more common and detrimental in women! more likely to have complications like ulcers and necrotic tissue), **25%** population infected DX: 1. clinical for the most part _2. tzank smear, geimsa stain shows **GIANT MULTINUCLEATED CELLS**_, can also check for antibodies for this via PCR TX: supportive therapy suppressive therapy **Acyclovir, valacyclovir, famcyclovir**

Answer 239

HSV-1-trigeminal nerve predilection, eruptions 2x a year common in 6 months-5 years CHILDREN abrupt onset **fever, anorexia, red mucosa** **vesicles appear on gums, lip, tongue** **_vesicles colase to form ulcers or plaques_**

Answer 240

more common in HSV1 than HSV2 primarily in ADULTS **fever, malaise, headache, sore throat** _vesicles on posterior pharynx and tonsils that RUPTURE to form ulcers_ (may have grayish exudate)

Answer 241

**1. herpetic withlow** (vesicles on the fingers) **2. herpes gladiatorum** (disseminated cutaneous infections common ing wrestlers) **3. keratoconjunctivitis** (dendritic corneal ulcers) **4. HSV or CNS ENCEPHALOPATHY!!** YIKES!! causes change in mental status and headache **5. infection during pregnancy** can infect the child

Answer 242

herpes lesion on the FINGERS

Answer 243

causes **genital lesions** 25% of the population infected with this **asymptomatic shedding and painful eruptions can occur** _sacral root ganglion predilection_ _VESICLES_ rupture to form _ULCERS_ reactivation in 90% occur in the first 12 months!! 30% have 6 episodes in their lifetime!!

Answer 244

dorsal root ganglion ## Footnote this is why it reactivates

Answer 245

**_purluent vaginal discharge_** **_usually infectious_** **_risk of PID if not treated_** **_sometimes post-coital bleeding_** comon pathogens; 1. gonorrhea 2. chlamydia 3. candida 4. bacterial vaginosis 5. trichomonis "strawberry cervix"

Answer 246

**leukorrhea main sxs** **noninfectious** dyspareunia dysmennoreah low back pain urinary sxs Tx: 1. cryrosurgery 2. laser 3. electrocautery

Answer 247

treponema pallidum ## Footnote spirochete bacterium transmission: vaginal, anal, oral through contact with _syphilis chancre, and requires contact with open lesions to spread_ More common in MSM and AA 30% occurs during the early or secondary phases early primary secondary early latent late latent tertiary neurosyphilis

Answer 248

1. chancre at site of innoculation thats _NOT PAINFUL_ 2. heals spontaneously 3. quickly becomes systemic 4. spreads to local lymph nodes 5. dividing time of 30 hours

Answer 249

weeks to months after initial infection (25% of untreated) SXS: **_1. RASH MOST COMMON (can be on palps, and soles!!!!)_** 2. fever/malaise 3. annorexia 4. diffuse LAD Additional findings: **_1. condyloma lata_** -war like lessions in the genital area **_2. patchy alopecia_** -_"moth eaten appearance_

Answer 250

totally asymptomatic past 1 year, marks this time ## Footnote **_1. slower metbolism of bacteria and prolonged dividing time_** 2. **_thought to be non infectious_** 3. requires longer tx

Answer 251

infection demonstrateble by serologic testing with Treponema pallidum ## Footnote NO SIGNS OR SYMPTOMS _1 year or less_ _potentially infectious_

Answer 252

1. gummas!! (nodular tumor like growths) 2. cardiovascular - aortitis MC - aortic aneurysm - aortic regurg **_1-30 years after initial exposure_** **_may never have had clinicallly apparent primary or secondary_**

Answer 253

general paresis of the insane **_1. personality change_** **_2. hyperactive reflex_** **_3. argll-robertson pupils_** **_4. sensory deficits_** **_5. tabes dorsalis_** shuffling gate **_6. opthalmic involvement_** - uveitis - neuroretinits - optic neurtis **_7.auditory sxs_** **_8. cranial nerve palsies_** **_9. meningitis sxs_**

Answer 254

transmission to stillborn 90% result in stillborne **HUTCHINGSON TEETH**

Answer 255

1. nontreponemal test ## Footnote **_screening for reactivity to cardiolipin-cholesterole-lecithin_** **_RAPID PLASMA REAGIN with titer_** 2. treponemal test **_CONFIRMATORY_** detects antibodies against treponemal cellular components, QUALITATIVE 3. multiplex PCR \*\*neurosyphilis must do CSF analysis\*\*

Answer 256

**_squamous cell origin_** "something doesn't look right" TX: surgical

Answer 257

DOC1: penicillin G benzathine 2.4 million units IM DOC2: doxycycline

Answer 258

DOC1: 3 shots of 2.4 million penicillin G beenzathin IM over 3 weeks ## Footnote DOC2: doxy PO for 4 weeks

Answer 259

Penicillin G 2.4 million units IM weekly for 3 weeks

Answer 260

penicillin G 3-4 million units IV Q4 OR 24 million units IV over 10-14 days

Answer 261

1. if patient in early stages ## Footnote **A. partner exsposure within 90 days TREAT PRESUMPTIVELY** **B. partner exposure over 90 days TREAT PRESUMPTIVELY if no test avaliable or partner followup unlikely, otherwise ok to tx by evaluation** 2. if patient in late stages **evaluate partner clinically** 3. if pt stage unknown approach same as early

Answer 262

jarish herxherime rxn ## Footnote occurs within 24 hours fever, HA, myalgia can cause early labor or fetal distress

Answer 263

NEED TO TEST ALL PATIENTS WITH SYPHILIS FOR HIV!!!!!! ## Footnote MUST ALSO RETEST IN 3 MONTHS in high prevalence areas!!!!

Answer 264

controversy if it is an STD or not because it is an overgrowth of the patients own flora, however it rarely occurs in women who aren't sexually active **sxs:** **1. malordorous white/grey discharge** **2. pH greater than 4.5** **3. absence of dyspareunia** **DX:** **_CLUE CELLS-cells covered in coccibacilli_** \*\*don't do culture of this, just a wet moutn because it ths the womans own flora so the lab will just show that TX: **METRONIDAZOLE 500 mg BID x 7 days!!**

Answer 265

1. increased risk of preterm birth/rupture of membranes 2. amniotic fluid infection 3. postpartum endometriosis 4. PID 5. postsurgical infection 6. cervical intraepithelial neoplasia 7. mucopuruloent cervicitis 8. acquisition of HIV infection

Answer 266

"acorn infection that is like vaginal yeast in women" infection of the head of the penis usually _fungal_ often seen in _uncircumsized men_ TX: 1. OTC antifungals like monistat or oral fluconazole

Answer 267

**flagellated protozoan** **SXS:** **1. pruritis** **2. malordorous, froththy, yellowgreen discharge** **3. could have erythema around vagina** **4. dyspareunia** **5. post coital bleeding** dx: _1. wet mount show motile flagellates_ 1. amine test positive 2. pH 5-6 Tx: **METRONIDAZOLE in single 2 gram dose**

Answer 268

treat them!

Answer 269

**_water on the testicle from congenital remnants of the tunica vaginalis_** a soft, nontender fullness of the hemiscrotum that transillumates **_dx:_** **_1. us_** **_2. transillumination_** **_tx:_** **_1. usually reassurance_** **_2. hydrocoelectomy_**

Answer 270

parasympathetic: engorgement of the copora cavernosa ## Footnote sympathetic control: contraction of SM and ejaculation

Answer 271

urethral meatus is no present at the tip of the glans a midline defect male may need to sit for urination and may cause issues with ejaculation optioins: 1. subcoronal (beneath glans 2. midshaft 3. penoscrotal Tx: sometimes requires correction

Answer 272

**rigid scarring of the penis resulting in a crooked, painful erection** unknow etiology TX: 1. injection verapamil 2. radiotherapy 3. surgery 4. shock wave therapy

Answer 273

pain without infection....tx with NSAIDS

Answer 274

beta-3 adrenergic MIrabegron that relaxes the SM

Answer 275

tadalafil (cialis)

Answer 276

begin at age 50 if life expectancy is 10+ years

Answer 277

testicular cancer is very curable where prostate cancer isn't

Answer 278

younger less than 35: MC chlamyida ## Footnote older than 35: MC gram neg bacilli, E.coli **_sudden onset of unilateral top of the testicle pain and swelling often caused by secondary infection from reflux of urine_** \*\*\*Prehn sign positive: relief of sxs with elevation of the scrotum\*\*\* DX: US UA TX: 1**. E. coli: ciprofloxacin** 2. **chlamydia/gonnoreah: azithromycin + ceftriaxone**

Answer 279

**ACUTE:** ## Footnote often in _young_, with _sudden onset_ often **_e.coli, klebsiella (poop bugs)_** **CHRONIC:** prostate normal on exam can be from reccurent infection or inflammation SXS: 1. **FEVER CHILLS** **2. PROSTATE TENDERNESS** **3. DYSURIA (SINCE INFECTION!)** **4. URINARY FREQUENCY** **5. LOW BACK PAIN!** DX: 1. consider prostate massage if first culture negative 2. clinical and UA Tx: 1. ciprofloxacin 2. alpha blockers

Answer 280

testes is anormally twisted in the spermatic cord thus comprimising arterial blood flow and venous drainage which leads to **testicular ischemia** most common in _prepubertal and post pubertal 12-18 year old males_, esp with those who had _crytorchidism_ or late decent of the testes UROLOCIAL EMERGENCY!! SXS: 1. **_negative prehns sign-no relief with elevation of the scrotiom_** **_2. unilateral, swollen, retracted testicle_** **_3. absent cremaster reflex_**

Answer 281

DX: 1. clinically 2. doppler US shows decreased blood flow TX: 1. NSAIDS 2. surgical detorsion and orchiopexy (make teste descended) \*\*\*GOAL: GET THIS ALL DONE WITHIN 6 hours!!!\*\*\*

Answer 282

**phimosis: can't readily retract the foreskin to the corona or the glans "turtle stuck inside"** **paraphomosis: tight forskin around the base of the glans so "turtle head can't go back in"** common in uncircumsized men TX: circumcision!! TOC

Answer 283

increased incidence in nearly ALL MEN!! 80 and up 90% incidence!!! begins around the **_urethra in response to increase dihydrotestosterone production and estrogen causing_** **_urinary obstruction leading to SXS_** SXS: **1. decrease in stream quality** **_a. hesitancy_** **_b. dribbling_** **_c. takes longer to pee, don't pee as far_** **2. incomplete emptying/frequency** **3. retention** **4. nocturia**

Answer 284

international prostate symptom score (IPSS) American system (AUA)

Answer 285

1. watchful waiting 2. medications 3. surgery \*\*depends on severtiy of sxs!!\*\*\*

Answer 286

1. alpha 1 adrenergic blockers "flow" ## Footnote **"TAMULOSIN"** **relax bladder to improve sxs** \*\*\*watch for decreased libido, dizziness, floppy iris syndrome\*\*\* 2. 5 alpha reductase inhibitors "shrink" **"FINASTERIDE"** inhibit enzyme that convert testosterone to 5 alpha dihydrotestosterone (DHT) which decreases testosterone stimulation of the gland 3. combination-increase flow and shrink 1. dutasteride/tamulosin 2. tadalafil

Answer 287

phytotherapy with saw paletto (palm tree extract)

Answer 288

1. transurethral resection of prostate (TURP) 2. transurethral microwave therapy (TUMT) 3. transurethral needle ablation (TUNA) 4. transurethral US guided laser induced prostaectomy (TULIP)

Answer 289

no! only if pt is symptomatic

Answer 290

dilation or vericose spermatic veins usually on the _left_ with _bag of worms feeling_ ## Footnote sxs: 1. non tender mass without transillumination 2. **_increases in size with valsalva_** **_3. decreases in size with scotal elevation_** DX: 1. doppler US TX: surgical repair via vein ligation only if paiful or preventing fertility

Answer 291

**typically in younger men 20-40 years old** 1. seminoma tumors a. less aggressive b. radiosensitive (get radiation tx) c. normal levels \*\*\*\*\*\*seminoma are Simple and Sensitive\*\*\*\*\* 2 non-seminomatous tumors a. screte AFP but not HCG (green book says both sxs: _painless testicular nodule_, solid mass, or enlargement "_heavy testicle_"

Answer 292

cryptochidism (undescended testicle)

Answer 293

dx: ## Footnote **1. US** **2. Self exam/physical exam** **3. tumor markers** **_beta human gonadotrophic hormone_** (beta HCG) **_alpha feto protein (AFP)_** tx: 1. orchioplexy-CUT IT OUT 2. chemotherapy etoposide +cisplatin+/-bleomycin 3. fix cryptochidism before puberty

Answer 294

you must get a chest xray because testicular cancer metastasizes here!

Answer 295

occurs in the secretory gland below the bladder that contributes to seminal fluid **_common, slow growing cancer that leads to urinary obstruction_**"you die with it not from it!! Prostate usually 20 ml (chesetnut or walnut) prostate cancer: 40 ml enlarged golf ball Need to make sure to screeen since hereditary!!!!

Answer 296

gleason scoring ## Footnote 1= well differentiated (favorable) 5=poorly differentiated (unfavorable) THEN add the two bx together for a score between 2-10, 10 is the worst oucome

Answer 297

sxs: _usually asymptomatic_ untill metastsizes to _bone_ causing _bone_ pain might cause urinary sxs if gotten into uretha and cause dx 1. DRE: hard irregularity/nodule, usually posterior 2. transrectal bx or US guided bx 3. if positive _get erdionucleotide bone scane to look for metastasis_

Answer 298

1. _bone_ 2. blood 3. lymph 4. local

Answer 299

controversial 1. DRE 2. PSA 3. prostate cancer antigen 3

Answer 300

african americans general lifetime risk: 16%

Answer 301

1. surgery-radical prostatectomy or robotically ## Footnote a. can cure b. high incidence of impotence and incontinence 2. radiation with external beam or implantable seeds a. not curative b. palliation of bone mets c. less impotence and incontinence than surgery 3. hormone-androgen deprevation a. suppressive, not curative 4. chemo? not effective as much

Answer 302

1. remove testosterone production via orchiectomy (remove teste) ## Footnote 2. inhibit ACTH and estrogen (leuprolide) 3. inhibit testicular synthesis of testosterone (aminoglutethimide) 4. inhibit binding of androgen (flutamide)

Answer 303

serine protease that is involved in liquefaction ## Footnote **pros:** **elevated in 65% of cases** **Cons:** **35% false negative rate** **non specific since also raised in prostate enlargement and prostatis** leads to more dx but doesn't decrease mortality so controversial...why look for a problem?

Answer 304

20% of cases ## Footnote common cause and occurs because the _mood must br right_, commonly effected by _depression and anxiety_ Problems seen: **1. can't initiate** **2. can't fill (encgorge) usually arterial proble** **-diabetes** **-HTN** **-ASHD** **3. can't store veno occlusive** **dysfunction**

Answer 305

80% of cases ## Footnote causes: **1. hormonal** **-loss of testosterone in testicular failure** **-pituitary tumor producing prolactin** **-pituitary failue** **2. drugs** **-antihypertensives** **-psychological** **3. vascular disease** **4. peyronies disease**

Answer 306

psychological in origin ## Footnote SSRis like fluoxetine might help

Answer 307

persistent painful erection ## Footnote emergent urology consult

Answer 308

_primary_ low testosterone, high LH or FSH (north works, south doesn't _secondary_ low testosterone, low to normal LH/FSH, so therefor north not working well too

Answer 309

1. AM total testosterone level 2. if low, repeat morning testosterone x2 Interpreation: A. if low testosterone, with LH and FSH not elevated then it is **secondary hypogonadism** B. if low testosterone, with increased LH and FSH than **primary hypogonadism**

Answer 310

**1. testosterone level** **2. prolactin levels** \*\*if this is high, it causes low levels of testosterone\*\* **3. LH** **4. US** **5. nocturnal penile tumescence testing "tape testing"**

Answer 311

get MRI because it likely has CNS origin, possibly tumor

Answer 312

1. replace testosterone if low 2. phosphodiesterase 5 inhibitor - relaxes SM allowing for filling - can cause headaches and flushing and when combined with nitrates can cause massive dip in BP - effected by high fat meanls SILDENAFIL/TADALAFIL 3. prostaglandin E1 - alprostadil - intra-penile injection or intraurethral 4. vaccum device 5. surgery-penile prosthesis

Answer 313

1. testicular failure 2. problems from hypothalamic/pituary axis \*\*give depo-testosterone _IM_ 1-2x a month!!\*\*

Answer 314

**one or more undescended testes that don't move into the scrotal sac, which remain in the _abdomen or stuck in the inguinal canal_** \*\*those born prematurely or are small for gestational age have he highest risk of effect\*\* **consequences:** **1. infertility** **2. testicular torsion** **3. maligancy** PE: 1. absence of palpable testicle, or palpable within the inguinal canal TX: 1. **_SURGERY! by age 1 to prevent risk of infertility_**

Answer 315

increases risk of malignancy in undescending testis is 4-10 times greater than gerneral population

Answer 316

encompasses everything having to do with birth birthing, prelude to labor, prep for labor, actualy labor process, initial recovery from childbirth

Answer 317

1. progesterone withdrawal 2. fetal lung maturity 3. fetal adrenal glands 4. oxytocin release

Answer 318

estrogen progesterone oxytocin HCG prostaglandins LH relaxin corticotropin-releasing hormone parathyroid hormone related protein

Answer 319

1. cervical dilation 0-10 cm 2. longest stage 3. 7-14 hours 4. early/late, active transition 5. normal first stages eval a. monitoring mother b. monitoring fetus c. body care of woman d. supportive care for family e. screening for complications

Answer 320

1. 10 cm to birth of baby 2. 1-3 hours avg 3. this is when your _push_ 4. fetal and maternal adverse outcomes occur during the second pahse of birth!!

Answer 321

_nulliparious woman_ 1.1-2.9 hours, 3.6 hours with epidural _multiparous woman_ .39-1 hour, 2 hour with epidural \*\*\*hence women who are multiparous take less time to have a child\*\*\*

Answer 322

1. birth and delivery of placenta 2. 10-15 minutes on avg, up to 30 3. uterine contractions 4. uterine fundus at level of umbilicus 5. "folding of placenta at implantation site 6. formation of hematoma between placenta and decidua

Answer 323

the bishop score tells you how likely it is for succesful induction or compense spontaneously ## Footnote score of 8+ is relatibly predictive of succesful induction

Answer 324

**_phase 1:_****_myometrium quiescence (rest)_** occurs for 95% of the pregnancy **_phase 2: uterine awakening_** contractions and cervical softening via collagen fibers **_phase 3: active labor_** **_phase 4: maternal recovery_** a. uterine involution b. cerical repair c. breast feeding d. restoration of fertility

Answer 325

1. compression of nerve ganglia in cervix 2. stretching of the cervix 3. hypoxia of contracted myometrium 4. stretching of the perioneum overlying the fundus 5. uterine actitive - actively contracting upper segement becomes thicker and firm and doesn't relax so it continually pushes baby out - lower uterine segment and cervix become softer distended and mroe passive as labor occurs

Answer 326

increase in vaginal discharge that is blood tinged

Answer 327

1. cervical dilation 2. effacement (shortening and thinning)

Answer 328

1. lightening 2 weeks before-breathe easier 2. cervical changes yielding ripeness 3. false labor (can go on for days) 4. permature rupture of membranes 80% of women will begin labor within 24 hours 5. bloody show 24-48 hours before onset of labor 6. gastrointestinal upset ie vomiting diarreah

Answer 329

6 cm appeares to be the landmark for the start of the active phase

Answer 330

1. sterile vaginal exam ## Footnote **EFFACEMENT** **DILATION** **STATION** distance between fetal presenting part and ischial spine 2. leopolds maneuvers 3. US use this to determine lie, presentation, position and variety

Answer 331

transverse, longitudal

Answer 332

cephalic (head down) breech (butt down) shoulder

Answer 333

occiput/vertex (want) siniput/military brow face

Answer 334

34 weeks because before them babies move around a lot so not as worried about it

Answer 335

frank breech

Answer 336

1. passanger (size/position) 2. pelvis or passage 3. power (uterine contraction) maternal dehydration maternal exhaustion uterine insuffieciency

Answer 337

1. stadol 2. nubain 3. demerol 4. fentanyl 5. nitrous oxide 6. epidural 7. morphine: long labor lasting longer than 2 days

Answer 338

_L4 to toes_ 1. reduced mobility 2. longer labor 3. must weigh with risks **_-epidural fever_** **_-maternal hypotension_** **_-fetal distress_**

Answer 339

1. decent, flexion, and engagement (all together) 2. internal rotation 3. extension of the head 4. external rotation of fetal head 5. expulsion

Answer 340

15-20 mins, sometimes 30 Normal blood loss: less 500 **post partum hemm: over 500** **four traditional signs:** **1. lengthening of umbilical cord** **2. uterus changes to more globular shape and becomes firm** **3. uterus rises in abdomen-placenta descends** **4. GUSH OF BLOOD OCCURS**

Answer 341

postpartum hemmorage 18%

Answer 342

**1. auscultation: fetoscope or dopple** **2. external fetal heart monitor-continuous or intermittent** **3. internal fetal heart rate monitor-fetal scalp electrode**

Answer 343

ferning method

Answer 344

every 30 minutes in active labor ## Footnote every 5-15 minutes in second stage

Answer 345

NO! not according to the US task for! they say it increases the risk of c-section and unnessary use of forcepts and suction on children! increasing risk!

Answer 346

life threatening for the fetus where placenta seperates from the uterus prior to delivery and blood pools behind the placenta ## Footnote MC cause of late pregnancy bleeding SXS: vagina bleeding abdominal pain DX: 1.. US TX: **if less than 36 weeks w/o distress**: monitor in hospital **if fetal or maternal distress:** deliver!! c-section!

Answer 347

1. previous placental abruption 2. HTN 3. abdominal trauma 4. substance abuse 5. premature rupture of membranes 6. blood clotting disorders 7. multiple pregnancy 8. maternal age-especially after 40

Answer 348

**birth of the fetus through an insision in the abdominal and uterine wall** **1/3 of total births** **Causes:** 1. repeat cesarean 2. fetal intolerance to labor 3. fetal position 4. maternal emergency 5. CPD

Answer 349

abnormal labor when the cervix fails to dilate progressively over time and the fetus fails to descend causes **1. pelvis:** passage through pelvis impaired **2. powers**: inadequate contractions to dilate cervix and expel baby -active upper portion with passive lower segement **3. passenger**: cephalopelivc disproportion, malpresentations and malpositions TX: **1. oxytoxin/pitocin to induce contraction** **2. amiotomy** **3. cessarian section** - indicated in _active_ stage measured for at least 4 hours without progress - point of maternal exhaustion **4. forcepts or vaccume options**

Answer 350

**pregnancy that implants outside of the uterus 95% occur in the fallopian tube** **ALWAYS NON VIABLE** **needs immediate attention because is _life threatening_** SXS light bleeding nausea and vomiting dizziness abdominal plain DX: **_slow raising HCG (less than doubling every 48 hrs)_** **_US_** TX: 1. methotrexate 2. laproscopic surgery

Answer 351

1. recent IUD 2. hx PID 3. interfility txs 4. hx of previous ectopic

Answer 352

when the mother is **Rh negative and the baby is Rh positive** the mothers immune system can attach the baby, typically an issue in second pregnancy when IgG passes through the placenta and enters the + baby causeing in second child **_hemoyltic anemia and fetal hydrops (death)_** attack rhesus D antigen on baby RBC DX: **_1. KLEIHAUER-BETKE TEST_**-measures occurence and degree of fetomaternal hemmorage **_2. COOMBS test_**-test for antibodies TX: **_rhogam to destroy anti-fetal-rhesus D antibodies at 28-29 weeks_**

Answer 353

1. anemia 2. hemolytic disease 3. fetal hydrops 4. still birth

Answer 354

premature rupture of membrane PROM: rupture of the amniotic membrane before the onset of labor at or _beyond 37 week gestation_ **if less than 37 weeks called _preterm premature rupture of membranes PPROM_** 90% of women with PROM will begin labor within _48 hours_ RISK with these: **_INFECTION_ aka endometritis and chorioamnionitis** DX: 1. sterile speculum examination 2. fern testing Tx: 1. deliver the baby if over 34 weeks!! prevents infection

Answer 355

postpartum hemorrhage 6%

Answer 356

blood loss requiring transfusion between admission and the postpartum period estimated loss: vaginal: over 500 c-section: over 1000 TX: 1. compression 2. blood 3. **_oxytocin first line tx!!_**

Answer 357

placental issues baby over 4500 gm grand multiparity prolonged labor medications obesity induction precipitous birth first baby instrumental delivery general anesthesia

Answer 358

**abnormal thinning of the lower uterine segment** EMERGENCY SITUATION with fetal mortality 50-75% RISKS: 1. high parity 2. previous c-section or subsequent long labor 3. over stimulation with oxytocin warning sign: retraction ring across the uterus between symphisis and umbilicus \*differentiation of uterine activity during active labor\*

Answer 359

when placenta completely/partially covers the OS ## Footnote DON'T DO VAGINAL EXAMS BECAUSE CAN CAUSE BLEEDING, _significant risk of hemmorage_ SXS: 1. _painless bleeding of the vagina hallmark_ DX: US TX: 1. watchful waiting 2. **_cesaran section_**

Answer 360

**twins: 1 in 100** **triplets: 1 in 1000** \*\*increased frequency from advanced reproductive technologies\*\* **vertex/vertex allows for vaginal birth** most common complications: 1. preterm birth 2. spontaneous abortion complications with twins: 1. intrauterine growth restriction 2. cord acidents 3. death of one twin 4. placental previa/ abruptio

Answer 361

\*\*disease of placental vasculature\*\* ## Footnote **preeclampsia requirements:** **1. over 140/90 on 2 occasions 4 hours apart of over 160/110 _AFTER_ 20 weeks gestation in previous normotensive woman PLUS** **2. proteinuria over 0.3 gm in 24 hr urine** don't routinely tx unless BP unless: SBP over 150 DBP over 100 SXS 1. severe headache 2. chest discomfort 3. SOB 4. confusion DX: **_24 hour urine!!!_** tx: labetalol or hydralazine

Answer 362

preeclampsia with 1. H-hemoysis 2. E-elevated L-iver enzymes 3. Low platelets this is a complication

Answer 363

severe preeclampia _with the addition of seizures after 20 weeks gestation_ ## Footnote _leading cause of maternal and infant illness and death_ TX: **_1. magnesium sulfate_** tx for seizures neuroprotection for fetus can prolong pregancy up to 48 hours **_2. PREFERRED TX IS DELIVERY!!!_**

Answer 364

**SBP: over 140** **DBP: over 90** \*\*occurs prior to pregnancy\*\* and is **_present BEFORE 20 weeks gestation or persists longer than 12 weeks postpartum_** if less than 150/100 WATCH dx: get baseline 1. 24 hr urine 2. UR 3. LEFT 4. thyroid 5. EKG tx: 1. methyldopa 2. labetalol

Answer 365

1. preterm birth 2. c-section 3. superimposed preeclampsia 4. low birth weight 5. perinatal death

Answer 366

2/3 have preterm delivery ## Footnote usually at 36-37 weeks instead of 38-40 weeks

Answer 367

when a woman with chronic HTN develops **_proteinuria_** after 20 weeks gestation **_elevated liver enzymes_** **_low platelets_** 25% of women with chronic HTN will get preeclampsia

Answer 368

HTN DETECTED _after 20 weeks gestation **without** proteinuria_ ## Footnote **PE** **increased BP** **no proteinuria** **TX:** **labetalol** **methlydopa**

Answer 369

spectrum of diseases that arise fom the **_placenta_** and include: 1. hydatidiform moles (molar pregnancy)-MC and benign 2. trophoblastic tumors 3. choriocarcinomas two types of molar preg: 1. partial mole **_a. egg is fertilized by 1-2 sperm which redulicates itself_** **_b. fetus developes but is NONVIABLE and the placent develops into mass of cysts_** 2. complete mole-MC!!! grape like vessicles or snowstorm pattern **_a. 1-2 sperm combine with egg that has no DNA_** **_b. 20% can develope into malignant tumor (choriocarcinoma)_**

Answer 370

SXS: 1. abnormal vaginal bleeding 2. larger uterine sizes 3. hyperemesis gravidum (excessive vomiting) 4. preeclampsia DX: **_US_** **_HCG, persistently elevated_** TX: 1. CHEMOTHERAPY 2. SURGERY

Answer 371

**glucose intolderance that begins or is recognized in pregnancy** gestational diabetes MC in pregnancy (opposed to pregestational Diabetes)-90% gestational! target range: 90 fasting, 120 post prandial DX: 1. glucose on all pregnany women during first prenatal visit **_2. repeat screening at_** _24-28 weeks_

Answer 372

1. levels of **diabetogenic placental steroid and peptic hormones rise linearly through 2nd and 3rd trimester** 2. lead to increase of glucose levels in blood **3. progressive increase in tissue resistance to maternal insulin,** body dose this intentionally because if the mothers tissues are resistant to insulin, she won't take up the glucose and it will pass through the placenta to nourish the baby, mechanism to make sure the fetus gets nuitrients **3. resistance leads to increase of insulin levels** which doesn't help because the tissues are resistant **4. insulin contributes to post prandial hyperglycemia** since it isn't functioning and can't take up the sugar!! **5. when post prandial maternal glucose levels rise excessively it causes _fetal hyperglycemia**_ (since it has all passed through placent to fetus) _**and fetal hyperinsulinemia_** (since increases production to deal with massive glucose infux) **6.hyper insulinemia promotes storage excess** (since the amount avalible from mom is almost never ending compared to volume of blood avaliable in baby) **7.** increased nuitrients lead to macrosomia in baby (_enlargement and delayed pulmonary maturation_)

Answer 373

1.screen **24-28 weeks** via two step dx approach of **_1 hour screen 135-140_ _AND_ 2 abnormal values on _3 hour oral glucose tolerance test_ that includes 1 of 2 fasting value** ## Footnote 2. same screening at **_6 weeks postpartum!!_** \*\*if after being administred the glucose, if elevated, then you know she has DM because she is insulin resistant and it couldnt be taken up in the tissues\*\*

Answer 374

need to screen earlier because they are like to devlope disease sooner

Answer 375

_1. glyburide or insulin_ in uncontrolled diabetes with diet modification/exercise 2. ADA diet

Answer 376

39 weeks, might need induction ## Footnote offer c-section if weight over 4500

Answer 377

T2DM in 5-10 years so screen annually 10-50% risk

Answer 378

20% aka 1:5 important to let mothers know this is common!

Answer 379

first detected 11 days after conception ## Footnote 48 hour doubling time!

Answer 380

1. thyroid function-test ## Footnote 2. maternal infection a. HERPES-always inspect before labor b. **_group B_** **_culuture at 36 weeks since transient on skin and can cause major problems, if pos tx with Peniciilin G_** 3. obesity 4. asthma control can change during pregnancy by 1/3s so just be concious 5. UTI

Answer 381

risk of infectioun ## Footnote tx: ampicillin and gentamycin _if fever add clindamycin_

Answer 382

polymicrobial infection of the **upper reproductive tract** (**uterus, fallopian tubes, and ovaries) that can be either from _sexually transmitted_ or _exogenous_ bacterial** **\*\*the bacteria ascent!\*\*** **RF:** **_1. younger than 25_** **_2. nonbarrier contrception_** **_3. hx of new or symptomatic sex partners_** **_4. previous PID_** **_5. STI_** SXS **_1. lower abdominal/back pain_** **_2. fever_** **_3. esquisitly tender cervix on bimanual exam_** **_chandelier sign!_** **_4. purluent discharge_** DX: 1. test for gonnorhea/chlamydia (since most common) 2. transvaginal US 3. diagnostic laproscopy may be needed TX: ABX!!!!

Answer 383

1. gonnoreah 2. chlamydia 3. staph 4. strep

Answer 384

inflammation of the wall of the uterus

GU CM Flashcards

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