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AUB, adnexal mass, ectopic, molar, (105 cards)

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1
Q

Contraindications to UAE

A

Hypersensitivity to contrast agent used in angiography
Malignancy
Coagulation disorders which cannot be corrected
Pregnancy
Infections or inflammation of the reproductive or urinary tract
History of pelvic irradiation
Hyperthyroidism
Renal failure
Women who are not ready to accept the approximately 3-20% risk of failure and subsequent absolute need for hysterectomy due to intractable pelvic pain or infection after UAE

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2
Q

How to dose NSAIDS for AUB ?

A
  • ibuproben 600mg daily

- naproxen 500mg at start of period, then 250-500mg BID for 4-5 days.

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3
Q

How to dose TXA for AUB?

A

1.3g TID up to 5 days

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4
Q

Vulvodynia treatment

A
  • eliminate triggers
  • topical anesthetic ointment
  • amitriptyline
  • pudendal nerve block
  • topical steroids
  • gabapentin
  • botox
  • PFPT
  • consider bx because 60% of dermatoses
  • refractory localized vulvodynia-can offer vestibulectomy.

try each one for 3-6 months

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5
Q

Lichen sclerosis histology

A

thinned epithelium, blunting of the rete ridges, chronic inflammatory infiltrate in the dermis

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6
Q

For which STDs does ACOG recommend expedited partner therapy?

A

Gonorrhea and Chlamydia

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7
Q

Painful ulcers DDx

A

Herpes

Chanchroid

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8
Q

Painless ulcers DDx

A

Lymphogranuloma venerium,
Syphillis,
granduloma inguanale
aka Donovanosis

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9
Q

Herpes

Exposure to onset
Symptoms

A
  • 4-6 days

- can have fevers, myalgias that last 3-4 days

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10
Q

Herpes
Describe the clinical course of the first outbreak

how long is viral shedding possible?

How long until antibodies appear?

A

worsening symptoms for 6-7 days then gradual improvement into week 2.

viral shedding until lesions are crusted over

12 weeks until antibodies

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11
Q

Recurrent Herpes
Describe the clinical course

How long is viral shedding possible?

A

prodrome 1-2 days before lesions, then lesions for 4-5 days until the lesions crust over

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12
Q

Herpes

How to test for it?

A

viral culture swab of unroofed lesion

OR

PCR for CNS
cytology is no longer recommended

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13
Q

Herpes

first time treatment?
recurrent treatment?
suppression treatment?

alt options, MOA, SE

A

Warm soaks, sitz baths, lidocaine jelly

First

  • acyclovir 400mg TID x 7-10 days
  • valacyclovir 1g BID x 7-10 days

Recurrent
acyclovir 800mg BID x 5 days
Valacyclovir 1g daily x 5 days

suppression
acyclovir 400mg BID
valacyclovir 1g daily

inhibits viral DNA polymerase by inserting into viral dNA and acting as a chain terminator, n/v/d, headache, rash, itching

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14
Q

Herpes in pregnancy

Risks to fetus if primary outbreak is in the first trimester?
When to start suppression?
criteria for c-section?
Chance of transmission?

A

chorioretinitis, microcephaly, skin lesions

36 weeks

active lesions, prodromal symptoms, or outbreak in the 3rd trimester.

  • 40-80% transmission if primary outbreak at delivery
  • 3% transmission if recurrent lesion at delivery
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15
Q

Chanchroid

organism?
presentation?
how to diagnose?
How to treat?

A

Haemophillus ducreyi

superficial ragged edge ulcer, red halo, necrotic exudate

clinical dx-VERY painful ulcer and lymphadenopathy
can do PCR

azithro 1g PO once
CTX 250mg IM once

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16
Q

What is a bubo?

When does it present?

A

painful lymphadenophathy seen in chanchroid and LGV

7-10 days after initial chancroid lesion or by itself with LGV

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17
Q

Lymphogranuloma venereum

organism?
presentation?
how to diagnose?
How to treat?

A

Chlamydia trachomatis

painless ulcer w or w/o bubo, cervicitis, urethritis, groove sign

clinical vs. swab of ulcer or aspirate the bubo and send for chlamydia NAAT

Doxy 100 BID x 21 days
azithromycin 1g weekly x 3 weeks

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18
Q

Granuloma Inguinale aka donovanosis

organism?
presentation?
how to diagnose?
How to treat?

A

-klebsiella granulomatis
SLOW growing painless ulcer, beefy red, very vascular
-subQ granulomas, NO lymphadenopathy
-clinical of tissue smears

-azithromycin 1g weekly for at least 3 weeks and until lesions are healed

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19
Q

Syphilis

organism?
when to screen?

A

treponema pallidum

  • all pregnant women in 1st and 3rd trimester
  • MSM
  • HIV, taking PrEP, partner with syphilis
  • incarcerated, prostitution, males under 29 years
  • high local prevalence
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20
Q

Syphilis

How to diagnose?
next step after dx?

A

Screen with nontreponemal test: RPR (rapid plasma reagin) or VDRL (venereal dz research lab)
^use this to direct treatment as treponemal tests are positive for life

Confirm with treponemal test: flourescent treponemal antibody absorption or t. pallidum particle agglutination

report to health department

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21
Q

Causes of false positive RPR or VDRL

A

older age, pregnancy, cardiovascular disease, malaria, leprosy, recent immunizations

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22
Q

primary syphilis

incubation period
symptoms
how long until they resolve

A

painless chancre and lymphadenopathy 10-90 days from exposure

3-6 wks regardless of treatment

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23
Q

Secondary syphilis

onset timing
symptoms
how long until symptoms resolve

A

4-8 weeks after chancre

maculopapular rash/lymphanopathy, malaise, fever, condyloma lata

resolve after 2-6 wks regardless of treatment

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24
Q

Early Latent Syphilis

how to diagnose?

treatment

A
  1. +serology
  2. no past dx of syphilis
  3. no evidence of primary, secondary, or late
  4. suspect infection was in the last 12 months

must treat because of transplacental transmission

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25
Late Latent Syphilis how to diagnose?
1. +serology 2. no past dx of syphilis 3. no evidence of primary, secondary, or late 4. suspect infection was over a year ago
26
Tertiary syphilis symptoms
gumma, cardiovascular, neurosyphilis, benign late syphilis
27
symptoms of neurosyphilis
meningitis pain paresthesia loss of DTR ataxia tabes dorsalis (demylenation of the dorsal nerve roots of the spinal cord-lightening pain down the leg) Argyll Roberston pupil (accomodate to distance, but dont react to light)
28
Syphilis treatment primary, secondary, early latent, late latent without neuro sx
primary, secondary, early latent: PCN G 2.4 mil units IM once OR Doxycycline 100mg BID x 14 days Late latent without neuro sx or latent of unknown duration -PCN G 2.4 mil units IM weekly x 3 OR doxy 100 mg BID x 28 days
29
Neurosyphillis dx and rx
test CSF first aqueous crystalline PCN G 3-4 mill units IV q4hr for 10-14 days OR procaine PCN 2.4 mil units IM daily x 10-14 days PLUS probenicid 500mg 4x daily 10-14 days
30
you start treating syphilis and the patient breaks out in a rash and fever in the first 2-8 hrs. Whats the management?
jarisch-herxheimer reaction from killing the spirochete, treat with tylenol occurs 95% of the time in primary and secondary symphilis
31
Syphilis | How to follow patients after initiating treatment?
Check titers at 6 and 12 months Primary and secondary syphilis: expect to see a 4 fold drop (1:16--> 1:4) at 6 months 8-fold drop at 12 months Early latent syphilis: check titers at 6, 12, 24 months 4-fold drop 12 months
32
You treat syphilis appropriately, but titers are not decreasing. next steps
check HIV, re-treat, CSF exam
33
your patient informs you that a previous partner was dx with syphilis within the last 90 days. What do you tell her?
treat her since her exposure was within the last 90 days. If greater than 90 days, but we don't have serology on her, then treat her.
34
Pubic lice organism diagnosis treatment
pediculosis pubis permethrin 1% cream OR malathion 0.5% lotion OR ivermectin 250mcg/kg,PO, repeat in 7-14 days
35
Warts organism diagnosis treatment
HPV 6 and 11 most commonly clinically, can have maternal transmission up to 3 years Pt applied: imiquimod 3.75% of 5% OR podofilox 0.5% Doctor applied: Trichloracetic acid in the office OR cryotherapy or excision. Tca is 1x for 4-6 weeks or until they go away
36
Chlamydia presentation diagnosis treatment
asymptomatic, mucopurulent cervicitis, PID, endometritis NAAT swab of cervix or urine screen all sexually active women under 25 or older with risk factors doxy 100mg BID x 7 days or azithro 1g once TOC in 3 months and at next well woman
37
Chlamydia in pregnancy fetal risks treatment
chlamydia PNA, conjunctivitis azithro 1g PO x 1 or amox 500mg TID x 7 d TOC in 3-4 weeks
38
Gonorrhea presentation diagnosis treatment
mucopurulent discharge, dysuria, AUB, bartolin's/skene's abscesses, conjuctivitis NAAT of cervical swab, urine, or self-swab CTX 500mg IM once (1g IM if >150kg) OR gentamicin 240mg IM +azithromycin 2g PO ONLY add chlamydia treatment if you have not ruled out chlamydia dx. TOC in 2wks only if pharyngeal infection.
39
you treat for gonorrhea, but TOC is still positive. Next step?
send culture and get sensitivities.
40
Name the reportable STIs.
syphilis, gonorrhea, CMT, chanroid, and HIV,
41
trichomonas presentation diagnosis treatment
can be asymptomatic for YEARS strawberry cervix, yellow/green/frothy discharge NAAT testing metronidazole 500mg BID x 7 days OR tinidazole 2g PO once no ex for 7 days TOC in 3 months
42
Trich TOC still positive. Next steps
assess for reinfection treat with tinadazole 2g PO daily and tinadazole 500mg BID per vagina for 14 days if still positive, talk to CDC and ID
43
PID diagnosis treatment outpatient
lower pelvic pain PLUS uterine tenderness or adnexa tenderness or cervical motion tenderness CTX 500mg IM AND Doxy 100mg BID x 14 days Metronidazole 500mg PO BID x 14 days OR replace CTX with cefoxitin 2g IM wi/probenecid 1g PO x 1 f/u in 2-3 days, then 1 month
44
PID inpatient treatment
CTX 1g IV q24hrs AND doxy 100mg PO or IV BID AND metronidazole 500mg PO or IV BID OR clindamycin 900mg IV q 8hrs gent 2mg/kg loading dose followed by 1.5mg/kg q8hrs
45
PID when to operate
no improvement after 3-4 days of IV abx ruptured abscess acute abdomen sepsis consider IR for drainage
46
HIV | health maintenance
CD4 q 3-6 months viral load q 3-6 months and 1 month after changing meds check all of the following PPD, syphilis, toxo IgG, CMV igG, ``` vaccine pneumococcal flu Hep B H. influenzae B Hep C ```
47
HIV clinical course
window course 4-8 wks asymptomatic Seroconversion -flu-like symptoms, rash, -abs development - clinical latency-asymptomatic
48
HIV when to section | when is vaginal delivery okay?
- viral load >1000 copies/mL or unknown viral load, section at 38 weeks - viral load <1000 on meds you can go 39wks
49
Flibanserin Use MOA SE Contraindications
Female sexual interest/arousal disorder. serotonin receptor agonist and antagonist 100mg PO Qhs weight loss, somnolence, dizziness, nausea ``` contraindications post-menopausal women EtOH within 2 hours of med liver disease CYP3A4 inhibitors-erythromycin, diltiazem, verapamil, grapefruit ```
50
Bremalanotide Use MOA SE Contraindications
Female sexual interest/arousal disorder SubQ prn 45 mins before sex, 1 dose per 24hrs nausea/flushing/site reaction, slows gastric emptying contraindication: HTN, post-menopausal women
51
treatment for post menopausal women with female sexual/arousal disorder.
short term trnsdermal testosterone can be considered per ACOG, not FDA approved 300mcg T patch, assess at 6 weeks, discontinue by 6 months if no help.
52
Menopausal-related sexual dysfunction medication options
- ospemefine | - Prasterone
53
Side effects of HRT
``` AUB breast tenderness nausea bloating hair loss fluid retention in arms and legs dizziness ```
54
Absolute Contraindications to HRT
Active or recent clots undiagnosed AUB breast cancer estrogen dependent neoplasm
55
Relative contraindications to HRT
``` previous clot liver dz gallbladder dz endometriosis migraine with aura smoking severe hypertriglyceridemia ```
56
When to start HRT
age under 60 within 10 years of the stat of menopause
57
How to prescribe HRT?
Many different ways, pick one estradiol 1mg PO daily OR 0. 05 transdermal ethinyl estradiol daily, replace patch weekly OR 0. 625mg conjugated equine estrogen PO if she has a uterus, add progestin PO: estradiol/drosperinone 1mg/0.5mg daily Transdermal: estradiol 0.45mg/0.015mg oer day, replace patch weekly or ADD: LNG-IUD (6 yrs) or prometrium 100mg PO daily
58
WHI What age group? What risk factors did patients have? Which hormone dosing? what was it assessing?
- 50-79 years, menopausal x 10 years - BMI 28.5, 40% smokers, 40% HTN - conj equine estrogen 0.625mg and medroxyprogesterone 2.5mg - assessed for heart dz, bone frax, breast and colon cancer - All HRT increases risk of clots/stroke and decrease risk of fracture - E+P group: increased MI risk and breast cancer, decreased risk of colon cancer - E only: insignificant decreases risk of breast cancer, no impact on MI and colon cancer
59
Do not give SSRI in combination of which chemoprevative drug
tamoxifen give venlafaxine- SNRI is safer paroxetine is a CYP P450 inhibitor
60
At what frax score do you move to a DEXA?
9.3% risk of major fracture fracture risk assessment tool dual energy xray absorptometry
61
At what, FRAX score do you start treatment
3% hip | 20% overall
62
Treatment options for vaginal atrophy
- lubricants, conservative - vaginal estrogen - Ospemefine - Prasterone
63
What is ospemefine? MOA contraindications do you need progestin?
Pill for FDA-approved moderate-severe dyspareunia in postmenopausal women Estrogen agonist/antagonist CI: same as HRT Progestin not need if under 1 year
64
What is prasterone? MOA contraindications
vaginal insert for
65
What is prasterone? MOA contraindications
vaginal insert for mod-sev dysparuenia in post menopausal women steroid-dehydroepiandrosterone 6.5mg qhs same CI as HRT
66
You have diagnosed osteoporosis. Next step?
consider other causes of osteoporosis order CBC, CMP, TSH, 24 hr urinary calcium level, 25-hydroxyvitamin D level consider celiac panel, serum protein electrophoresis
67
Which patients should not calculate a FRAX for?
<40 already on meds already osteoporotic prior hip or vertebral fractures
68
who gets a FRAX?
low bone density or osteopenia on DEXA-->if FRAX is 3% hip or 20% major--> start med Patient is worried, but does not meet DEXA criteria
69
Who gets DEXA?
``` 65+ history of fragility frax <127lbs smoker EtOH Rheumatoid Arthritis parent with history of hip fracture ```
70
Bisphosphonates MOA CI alterntives
inhibit osteoclast activity CI: for orals, cannot sit up for 30 minutes after. esophagitis, renal impairment, hypocalcemia, hx of rous en Y gastric bypass, alternatives: denosumab, raloxifene, tamoxifen (not FDA approved), HRT, nasal salmon calcitonin, recombinant human parathyroid hormone - ab to RANK-L, 60mg SC q6 months
71
MOA and CI for the following alternative osteoporosis treatments denosumab raloxifene nasal salmon calcitonin recombinant human parathyroid hormone
Denosumab: -ab to RANK-L, 60mg SC q6 months, may be need lifelong due to relapse Raloxifene-SERM, inhibit bone resorption, SE-VTE/vasomotor, good for ppl who need breast cancer ppx Nasal salmon calcitonin-inhibits osteoclasts, must be at least 5 years out rPTH-activates bone formation, can only use for 2 years, only for severe dz
72
What do you include in a comprehensive well women visit?
``` Any specific patient concerns update med/surgical hx, GYN, family hx medications tobacco, etoh, substance abuse personal safety immunizations cancer/health screening ```
73
What does BiRADs stand for? | what is the probability of malignancy with each score?
Breast Imaging-Reporting Data system ``` 0-need more evaluation 1-0% 2-0% 3- <2% 4- 20% 5- 90% 6-100% ```
74
Who gets breast MRI?
>20% lifetime risk of breast cancer BRCA1 or BRCA2 first degree relative with BRCA and pt has not been tested chest radiation therapy between 10-30 yo Li-fraumeni Cowden Bannayan-Riley-Ruvalcaba
75
Who to refer for bariatric surgery?
BMI >40 | BMI >35 with medical co-morbidities
76
who gets breast cancer chemo prevention? When to use tamoxifen vs raloxifene?
Gail model 5 yr risk >/= 1.7% or lifetime risk of >/= 20% anybody can get tamoxifen, but only postmenopausals can get raloxafene REMEMBER -raloxafene is good for osteoporosis.
77
Lipid screening by age
9-11- once 18-21 once 40-75- every 5 yrs. consider starting a low-moderate dose statin based on elevated risk
78
Went to stop pap?
65 with negative paps for the last 10 years
79
When to start pap in the following populations? DES HIV Cancer/immunocompromised
- DES, annual cytology starting at age 21 - HIV-within one year of being sexually active, start with cytology alone and if normal for 3 years, then you can mov to standard testing. cancer/immuno...treat like HIV
80
HNPCC | when to do risk reducing surgery and what are you doing?
hyst BSO at 35-40 after childbearing
81
alternative to colonscopy
flex sig q 5 years stool guiac-2 samples from 3 consecutive BMs
82
When to give pneumococcal vaccine
65+ pneumococcal conjugate vaccine (PVC13) pneumococcal polysaccharide vaccine (23) give PVC13 then PPSV23 6-12 months later, ok in pregnancy
83
When to give zoster vax?
2 doses 2-6 months apart in every 50+ regardless of natural immunity.
84
How long is liletta FDA approved for?
6 yr
85
OCPs ``` Patient wants control of acne. which progesterone class do you give? ```
third gen because it has fewer androgen side effects ex desogestrel, norgestimate
86
OCPs ``` Patient has PMS. which progesterone class do you give? ```
4th gen | Drosperonone bc FDA for PMS
87
OCPs Patient missed one pill. recs?
Take the missed pill now, take the next pill at the usual time and use condoms for 7 days
88
OCPs Patient missed two pills. recs?
Take two pills now. take another two pills tomorrow at the usual time, continue with the pack and use condoms for 7 days.
89
OCPs Patient missed three pills. recs?
toss the pack and start a new pack, use condoms for 7 days.
90
Contraception failure rates ``` Etonogestrel implant Hormonal IUD Copper IUD vasectomy Combination OCP Tubal ligation Male Condom ```
``` Etonogestrol implant 0.05% Copper IUD 0.08% Hormonal IUD 0.2% Vasectomy 0.15% Combination OCP 9% Tubal ligation 18-37/1000 Male condom 18% ```
91
relative CI to MTX for ectopic
4+cm heartbeat present hcg 5000+ jehovahs witness or anemic
92
Diagnostic features of failed IUP
CRL 7mm without HB GS 25mm + without HB no embryo with HB 2 wks after GS with no yolk sac no embryo with HB 11 days after GS WITH yolk sac
93
Absolute contraindications to endometrial ablation
pregnancy, known or suspected endometrial hyperplasia or cancer, desire for future fertility, active pelvic infection, IUD currently in situ, and being post-menopausal
94
histology of squamous cell hyperplasia of the vulva gross appearance age treatment
thickened epithelium, no inflammatory infiltrate grossly-leathery appearance age 30-60 triamcinolone and antihistamines
95
Top three causes of death by age 1-19
accidents cancer suicide
96
Top three causes of death by age 20-44
accidents cancer heart dz
97
Top three causes of death by age 45-64
cancer heart dz accidents
98
Top three causes of death by age 65-85
cancer heart dz chronic lung disease
99
painless bleeding, 6 year old, chronic constipation and asthma, presents with a mass at the introitus most likely dx
urethral prolapse rx underlying cause, sitz baths, estrogen cream BID for 1-4 weeks
100
IBS Rome criteria
recurrent abdominal pain - onset 6 months ago - 1 day/wk for 3 months - associated with 2 or more of the following: - relation to defecation - associated with change in stool frequency - associated with change in stool appearance
101
describe the bristol stool form scale
1 to 7 1 hard 4 is normal 7 watery
102
IBS subtypes
Diarhea conspit mixed untyped
103
IBS work up
CBC chem for volume depletion WBC, stool cx, ova and parasite, c. diff rule out colon cancer symtpoms
104
IBS D meds
antimotility loperamide, diphenoxylate anticholinergics belladonna, dicyclomine, hycosamine for bloating and gas HIGH fiber diet (25-35 grams/day)
105
IBS C meds
lubiprostone, linaclotide HIGH fiber diet (25-35 grams/day)

OBGYN Oral Boards (6 decks)

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