GYN

Question 1

56 F with hx of total hysterectomy. Pap recommendation?

Answer 1

**Paps not needed. **

(Unless history of invasive cervical cancer or DES exposure)

Question 2

25 year-old woman with vaginal discharge.

Which STDs come are likely, Tx?

Answer 2

BV (+whiff with KOH, clue cells, alkaline)–> flagyl

Trichomonas (motile, fagella) –> flagyl

Gonorrhea (PCR DNA) –> CTX

Chlamydia (PCR/DNA) –> Doxy or CTX

Question 3

25 year-old female with vaginal discharge that is purulent with cervical motion tenderness. Dx? Tx?

Answer 3

Gonnorrhea or Chlamydia (look the same in females) –> Treat both: ceftrixone 125mg IM x 1 and** azithromycin 1g PO x 1**

Question 4

25 year-old female with vaginal discharge that is profusely watery, frothy, greenish with strawberry cervix. Dx? Tx?

Answer 4

Trichomonas vaginitis –> Metronidazole

Question 5

Urinary incontinence with sudden loss of urine. Dx? Tx?

Answer 5

Urge incontince (spastic bladder)

–> anticholinergics like oxybutinin (Ditropan) or TCAs in case of glaucoma

Question 6

Urinary incontinence with small losses of urine day and night. Dx? Tx?

Answer 6

Overflow incontinence (neurogenic bladder: DM, MS, neuro dz)

–> Cholenergic agonist like bethanochol (Urecholine) or neostigmine and self-cath

Question 7

What are the risk factors for endometrial cancer?

Answer 7

History of anovulatory cycles

Obesity

Nulliparity

Tamoxifen use

DM

Question 8

Tx for anovulatory bleeding?

Answer 8

Combined OCP

Cyclic progestin (medroxyprogestin acetate 10mg PO x 10-12 days each month

Question 9

What are the causes of abnormal uterine bleeding in non-pregnant women of reproductive age?

Answer 9

PALM-COEIN

_PALM: Structural Causes _

• *P**olyp (AUB-P)
• *A**denomyosis (AUB-A)
• *L**eiomyoma (AUB-L)
• *M**alignancy and hyperplasia (AUB-M)

COEIN: Nonstructural Causes

• • C**oagulopathy (AUB-C)
• • O**vulatory (AUB-O) – Abnormal prostaglandin synthesis and receptor upregulation, Increased fibrinolysis and tpa activity
• • E**ndometrial (AUB-E)
• • I**atrogenic (AUB-I)
• • N**ot yet classified (AUB-N)

…PCOS

Question 10

What is the workup for abnormal uterine bleeding (AUB) in a female < age 45?

Answer 10

First: bHCG, CBC (anemia, thrombocytopenia), INR, TSH, Chlamydia, if needed pap.

Then:** Transvaginal US** –> Hysteroscopy

Then: if still persistent AUB, Endometrial biopsy

For over age 45, straight to Endometrial bipsy

Question 11

Who needs an endometrial biopsy?

Answer 11

Women over age 45 with abnormal uterine bleeding (AUB).

Women under age 45 with hx of unopposed estrogen (PCOS, obesity) or those with persistent AUB/failed medical management.

Question 12

What does the result of a endometrial biopsy showing “proliferative” mean?

Answer 12

Normal in the follicular phase
When associated with abnormal bleeding,
confirms anovulation and the effect of
unopposed estrogen

Question 13

What does the result of a endometrial biopsy showing “secretory” mean?

Answer 13

Confirms that ovulation has occurred

Question 14

What does the result of a endometrial biopsy showing “hyperplasia” mean?

Answer 14

advanced effect of

unopposed estrogen atypia = premalignant

Question 15

What does the result of a endometrial biopsy showing “atrophic” mean?

Answer 15

• *Menopause** or effect of
• *OCPs** / Depo-Provera / continuous ERT

Question 16

When should you treat abnormal uterine bleeding?

Answer 16

If under age 45 without risk factors – ok to trial combined OCP for 7 days (bleeding that stops within 12-24hrs confirms DUB), then start regular OCP for the next 3-6 months OR just cyclic progesterone x 3 months.

If over age 45 or with risk factors – complete diagnostic eval first

Give conjugated estrogen IV in emergent cases!

Question 17

What causes the endometrium to become too thick?

Answer 17

Too much estrogen (Obese patients, PCOS, on unopposed estrogen)

–> Give progestin or OCPs

Question 18

What causes the endometrium to become too thin?

Answer 18

Not enough estrogen –> bleeding (Progestin only contraception or progestin OCP ratio is too high, marathon runners)

–> Add estrogen (change from minipill/progestin only to combination)

Question 19

Treatment options for abnormal uterine bleeding?

Answer 19

NSAIDS (↓ prostacyclin)

OCPs

Tranexamic acid (Lysteda)

Danazol

Levonorgestrel (Mirena)

Endometrial ablation

Hysterectomy

Question 20

What are the common causes of secondary amenorrhea? Workup?

Answer 20

**Pregancy **

→ bHCG

Thyroid disease: Hyper/Hypothyroidism

→ TSH

Estrogen deficiency: Menopause

→ Progestin challenge (medroxyprogesterone 5-10mg acetate x 10 days). Withdrawal bleeding in 2-7 days after completion = unopposed estrogen = risk for endometrial CA –> give progestin or OCPS. No withdrawal bleeding –> Estrogen/Progesterone challenge –> Still no withdrawal bleeding = outflow obstruction (Ashermans or mullerian agenesis). Otherwise check FSH/LH

Androgen excess: PCOS

Pituitary tumor: Prolactinoma

Question 21

What is primary amenorrhea?

Answer 21

No menarche by age 16 (or no menarche + no sex characteristics by age 14)

Question 22

What is secondary amenorrhea?

Answer 22

**No menstruation x 3 months in women with previously normal mentrual cycles **

or

No mentruation x 9 months in women with previously oligomenorrhea.

Question 23

What is the workup for primary amenorrhea?

Answer 23

Question 24

What herbal medicine is often used for the treatment of hot flashes? What is it’s concerning side effect?

Answer 24

Black Cohosh

Elevated LFTs

Question 25

Drugs commonly associated with AIN?

Answer 25

Question 26

Risk factors for endometrial cancer?

Answer 26

Hyperestrogenic states: **Polycystic ovary syndrome** (Chronic anovulation and consequent hyperstimulation of the endometrium) **Nulliparity** **Early menarche** (Combination oral contraceptive use seems to decrease the risk for endometrial cancer)

Question 27

Puberty should occur when in females?

Answer 27

**Any secondary sex characteristics by age 13** **Menarche by age 16** (or to have menarche 5 or more years after the onset of pubertal development.)