GYN Prologue-Walden's deck Flashcards
(177 cards)
1
Q
hysterectomy w/ BSO or without BSO most effective for endometriosis?
A
w/ BSO; if no BSO risk for recurrence of sx up to 61%
2
Q
women who are menopausal less than 40yo (d/t surgical or other reason) have associated ^ risk of
A
50% higher risk of death from CV dz compared w/ women at menopause btwn age 49-50
also more likely to have vasomotor sx, etc
Estrogen therapy IS recommended in these pts
3
Q
should you give pts HRT who got hyst BSO for endometriosis?
A
in general, YES esp if <40. risk of sx recurrence is <1%
4
Q
Meds and their efficacy in treating menopause
A
-Clonidine: alpha 1 agonist, 40% decrease in meno sx
-gabapentin gaba analog, 45-70% decrease in sx
-paroxetine SSRI: 40% decrease in sx
-micronized progesterone: some help but estrogen much better, but obvi should use in combo in pt w/ uterus
5
Q
need progesterone in pts after hyst for menopause sx?
A
technically no BUT in pts w/ endometriosis, theoretical risk of malignant transformation of endometriosis implants w/ estrogen alone (really only theoretical risk RN)
6
Q
how to DX BV? Amsel criteria
A
1) thin gray/white discharge
2) vag pH 4.5 or greater
3) positive whiff test w/ KOH
4) >20% clue cells
7
Q
up to 75% of women w/ what vag discharge are asx?
do you need to treat if asx?
A
BV, and no-no need to tx
unless recurrent infxn and pt have concurrent infxns like HIV, GCCT/HSV
8
Q
tx regimens for BV?
A
1) Secnidazole-2nd gen 5-nitroimidazole. longer 1/2 life than flagyl which means can give less frequently/lower # of days. Given as SINGLE dose of 2g (mixed in liquid or applesauce etc.)
***pearl: this is a good alternative for your pt who is not compliant, won’t take full 7d of flagyl or has AE to oral flagyl/doesn’t like vaginal gels
2) 7d of oral flagyl, 7d of oral clinda
3) tinidazole 2g PO qd x2d
5) 5d of vaginal metrogel
6) 7d of clinda cream or 3d of clinda ‘ovules’ 100mg vaginal
CDC actually breaks this down to preferred vs alternative:
-preferred: #2, #5, #6 (1st prt only the one for 7d of vag clinda)
-everything else is alternative
9
Q
indications for suppression of BV?
A
more than 3 documented episodes of BV within 12 months
and suppression regimen per ACOG PB: may be offered twice weekly suppressive metronidazole gel for 16 weeks after treatment for the acute episode
10
Q
MCC of GYN CA in the US?
A
Endometrial!
MCC world wide is still cervical CA
11
Q
2 ways to describe premalignant endometrial lesions
A
1) WHO schema=4 categories
a. simple hyperplasia: risk malig=<1%
b. complex hyperplasia: risk malg=3%
c. simple hyperplasia w/ atypia=8%
d. complex hyperplasia w/ atypia AKA complex atypical hyperplasia (CAH)
**anything w/ atypia indicates pre malignant and high malignant potential
2) EIN schema
a. benign endometrial hyperplasia
b. endometrial intraepithelial neoplasia
c. endometrial adenocarcinoma
EIN is equivalent to CAH
12
Q
risk of endometrial CA w/ diagnosis of CAH AKA EIN?
A
40% chance of concurrent carcinoma diagnosis at time of hysterectomy (aka on frozen or permanent path)
13
Q
tx rec for premalignant endo lesions?
A
EIN/CAH: if no fert desires: hysterectomy w/ GYN ONC so they can do frozen w/ SLN mapping (ICG); for doing the hyst can be done W/ OR W/OUT BSO
-BSO decision is individualized
benign endo hyperplasia: hormonal therapy (could theoretically also do hyst but not absolutely necessary, this is the one ok for benign GYN to do)
obviously for full blown cancer would do hyst w/ gyn onc
14
Q
hormonal treatment for endometrial hyperplasia?
A
no standardized recommendations/consensus
options include: oral medroxyprogesterone (provera), IM depo, micronized vag progesterone, oral megestrol acetate (megace), levonorgestrol IUD
15
Q
rec frequency of endometrial sampling in pts tx w/ hormonal therapy for endometrial hyperplasia?
A
again no set consensus, however q3-6mo is currently accepted
16
Q
OAB affects x/x ppl in the US?
A
1/6
17
Q
MC presenting symptom of bladder CA?
A
hematuria
tobacco use is greatest RF, others include radiation, occupational exposures (chemicals handled by hair dressers)
18
Q
w/u of hematuria
A
start with udip/UA, if no evidence of UTI–>imaging if no evidence of kidney stones,
needs further eval–>cystoscopy
19
Q
renal US results w/ various DOS
A
1) CKD: kidneys will look smaller from long term vascular disease
2) acute kidney disease AKI etc: kidneys will be enlarged 2/2 obstruction of ureter by stone/iatrogenic injury malignancy etc
20
Q
indications for various imaging studies of the urinary tract:
A
-rec imaging for upper urinary tract in pts w/ hematuria: CT urography (w/out contrast=good for stones, w/ contrast good for seeing anatomy)
-IV pyelography: looks for patency of ureters (would use this if worried bagged the ureter intraop–think pts w/ abd pain, fever, decreased UOP, elevated Cr)
-lower urinary tract imaging: voiding cystography -used to look for bladder defects, integrity of cystotomy repair (what happens is they use fluroscopy in the bladder while pt is voiding)
21
Q
what is anaphylactic shock?
A
IMMEDIATE hypersensitivity RXN w/in mins/hours after exposure (but >90% happen within first 5-10mins)
sx: pruritus, flushing, hives (thus dx can be delayed if ur pt is intubated bcuz they can’t tell you ab these sx)
thus in the OR: hallmark of anaphylaxis is ‘cardiovascular and respiratory collapse’ also think rash and laryngeal edema
obvi treat these pts w/ epi
22
Q
what is septic shock?
A
secondary to infxn, peripheral VASODILATION–>hypotension, and intravascular HYPOVOLEMIA.
ur pt will have: fever, hypotension, tachycardia, low UOP
tx: pressors if needed, abx, IVF
23
Q
what is Virchow’s triad?
A
this is for VTE
1. venous stasis
2. endothelial injury
3. hypercoaguable state
24
Q
what is OSA?
A
periodic obstruction of upper airway during sleep can cause daytime sleepiness, distractable behavior, desat while sleeping
25
pain regimen for osa pts after surgery
pretty self explanatory, minimize shit that will suppress their respiratory drive, should have 'multimodal'
aka try nerve blocks, IT, TAP, epidural etc w/ toradol and gabapentin before doing narcotics esp PCAs or benzos
26
pt w/ CIN 3 on colpo then undergoes a LEEP. Path shows CIN 3 w/ negative margins and negative ECC. When should she have next pap?
cytology w/ HPV co-testing in 12mo
if the pt had positive margins or positive ECC then preferred f/u would be pap cytology w/ ECC at 6mo OR could also offer repeat excisional procedure vs hyst at 6mo as well
27
presentation of ovarian torsion
N/V, colicky abd pain, fevers, tachycardia
28
US findings of torsion
more likely w/ cysts >5cm
ovary may appear enlarged and edematous
doppler may be absent or may have a whirlpool appearance
29
tx of ovarian torsion
urgent to OR
ovarian detorsion, cystectomy
if high suspicion for malignancy then obvi oophorectomy
30
when doing surg for ovarian torsion what should you do if ovary looks necrotic or ischemic?
if pt is reproductive age or who desire fertility, should leave ovary! the ovary typically reperfuses and regains function even if looks bad
ovarian fixation/oophoropexy not routinely recommended
31
chronic pelvic pain dx
NONCYCLICAL pain for 6mo (may also experience dysmenorrhea but pain persists outside of menses as well) or greater localized to the pelvis, ant abdominal wall at or below umbilicus, lumbosacral area, or buttocks
32
incidence of CPP in women age 18-50 yo?
15-20%
33
associated conditions w/ endometriosis?
IBS dx by the ROME III criteria: recurrent abd pain w/ changes in bowel consistency for atleast 6mo, sx experienced atleast 3 days in 3mo period AND 2 of the following: pain relieved by defectation, onset of pain related to change in frequency of stool, onset of pain related to change in appearance of stool
Bladder Pain Syndrome (aka IC): can be diagnosed on cysto but not first line and not always found this way. should start w/ validated questionnaire such as pelvic pain and urgency/frequency PUF
34
overall life time incidence of fibroids in women?
in other words 'fibroids are found in x percent of women at some point in their lives?'
75%
35
concerning sign of fibroids for CA?
any fibroid that increases in size after menopause
however on US really can't distinguish between a reg fibroid and sarcoma, also wouldn't diagnose it on EMB unless invasive
36
risk of leiomyosarcoma?
risk for sarcoma 0.05 to 0.28%
37
RF for leiomyosarcoma?
women>40 median age of 60, women who use tamoxifen >5yr, hx of pelvic radiation, known hereditary cancer syndrome (lynch, hereditary leiomyomatosis, RCC)
38
MRI for leiomyosarcoma?
some benefit over US is shown, show up as 'infiltrating myometrial mass of heterogenous hypointensity on T1 images w/ ill defined border'
on T2 images: 'central hyperintensity w/ central necrosis
can kind of think of T1 as w/ contrast: fat will show up bright
T2 think of w/out contrast, water/blood/fluid will show up bright
(however both T1 and T2 can technically be used w/ contrast)
39
57yo postmenopausal female has abd bloating, VB, and pelvic pressure. Had TVUS 1yr ago w/ 4cm fibroid. HX of ER/PR positive breast CA, s/p mastectomy. Had Tamoxifen for 8yrs. EMB neg. TVUS shows enlarging fibroid (bigger than 4cm w/ central necrosis). What should you do?
TAH BSO, d/t risk for sarcoma
-pt is post menopausal w/ enlarging fibroid and is symptomatic. Additionally buzz word of central necrosis and hx of tamoxifen>5yr duration
40
ERAS protocol components
1. SCDs for DVT PPX 2. aggressive management of peri/postop nausea 3. emphasis on early ambulation 4. encourage early postop feeding specifically regular diet within first 24 hrs
for pain-scheduled tylenol/nsaid, consider gabapentin
-dexamethasone has been shown to decrease pain and nausea
-do NOT do a bowel prep (really isn't even rec. for bowel surgery unless doing anterior low resection), bowel prep has been shown to have worse outcomes w/ dehydration, lyte abnormalities, pt stress
41
incidence of mastalgia
aka breast pain, 50% of reproductive age women
42
2 types of mastlagia?
1. cyclical
-almost always benign
-presents in late luteal phase (luteal is d14-28), typ resolves w/ onset of menses
-usually b/l and diffuse
-if pts meet the above criteria do not need imaging manage w/ reassurance and conservative measures (well fitting bra, NSAIDS)
2. non-cyclical: if focal likely d/t structural abnml like muscle strain etc
-should consider imaging for women w/ focal mastalgia and if palpate a mass should always do imaging
43
management of cyclical mastalgia?
1. conservative: good bra/NSAIDS
(avoiding certain foods/taking supplements/avoiding caffeine while low risk measures have not been shown to actually improve/tx mastalgia)
-taking OCPs has not been shown to help, rather OCPs can cause mastlagia (but usually self limiting)
2. Danazol: androgen that suppresses pituitary gonadatropin release (inhibits release of FSH/LH)
-ONLY FD approved tx for mastalgia
-only reserved for severe/refractory mastalgia bcuz of androgenic SE (wt gain, irreg menses, hot flashes, voice deepening, acne, hirsuitism)
3. Tamoxifen SERM: can be used for mastalgia, but shouldn't be used for >6mo d/t risk of hyperplasia and VTE, also bad meno SE
-not FDA approved for this tx
44
pt satisfaction w/ UAE vs hyst/myomectomy?
no difference
45
incidence of endometritis after UAE?
1%
presents w/ fever, pelvic pain, purulent discharge, CMT
occurs days to wks after procedure
TX=broad spec abx
46
postembolization syndrome after UAE
sx: fever, pain, nausea, malaise
caused by infarction, ischemia, necrosis of fibroids
how to distinguish from endometritis? NO purulent discharge
47
incidence of postembolization syndrome after UAE
30-40%
48
timing of postembolization syndrome after UAE
typically POD#1-2, resolves w/in 7d
in contrast sx that develop after this are more concerning for endometritis
49
stage 0 POP
no prolapse, anterior and posterior points are all -3, and C cervix or D posterior fornix is btwn -TVL and -TVL -2cm
50
stage 1 POP
most distal prolapse is more than 1cm above the level of the hymen (less than -1cm)
51
stage 2 POP
the most distal prolapse is between 1cm above and 1cm below the hymen (could be -1, 0, or +1)
52
stage 3 POP
most distal prolapse is more than 1cm below the hymen but no further than 2cm less than TVL
so for ex if TVL is 6cm, then prolapse could be +1 to +4
53
stage 4 POP
complete procidentia most distal prolapse protrudes to atleast TVL minus 2cm
so if tvl 6cm, then atleast +4
54
primary dysmenorrhea
painful periods in absence of underlying condition
-pelvic pain just before or 1st few days of menses
55
1st line tx of primary dysmenorrhea
nsaids
Can consider cOCPs if no improvement w/ nsaids
SSRI not indicated (these are used for PMDD)
56
life time risk of ovarian cancer for BRCA 1 carrier vs BRCA 2 carrier?
39-46% (40) vs 12-20% (15)
57
when should BRCA 1 have BSO vs BRCA 2 carrier?
BRCA 1=age 35 to 40
(1+2 is 3)
BRCA 2 age 40-45
(2+2 i 4)
BSO decreases risk of ovarian cancer in both by 80%
58
how does ovarian cancer arise from fallopian tubes?
starts in tube w/ serous, clear cell, and endometrioid ovarian cancers
-often involves the tp53 mutation and involves distal fimbria
this is why we can do complete salpingectomies now
-having RRS decreases risk of ovarian cancer by 42-65%
-think RRS prevents retrograde flow through the tube and into peritoneal cavity
59
when should nml low risk person get pneumococcal vaccine?
age 65
60
when should nml low risk persom get herpes zoster/shingles vaccine?
age 60
as an FYI, the CDC has resources for travel medicine clinics-so if you have a pt asking for what vaccines they need when they go to africa you can google cdc travel medicine clinics and then it will give you a list of clinics near you!
61
dx of PCOS? Rotterdam criteria need 2/3
hyperandrogenism (hirsuitism), anovulation/oligoamenorrhea, polycystic ovaries
62
sequelae of PCOS?
obesity, metabolic syndrome, endometrial CA, mood DO, insulin probs
63
initial tx of PCOS?
WT LOSS! >5% wt loss improves reproductive and metabolic outcomes
64
metformin for pcos?
obviously improves glucose tolerance, can also increase ovulation rates, but its use alone does not improve fertility and obvi no impact on hirsuit sx
65
what % of pregnancies are ectopic?
2% of all pregnancies are ectopic
66
confirmed dx of failed IUP on US? (4 options)
1. CRL>7MM and no FCA
2. MSD>25mm w/ no embryo (empty)
3. initial scan shows gest sac no yolk sac-->rpt US in 14d without EMBRYO AND FCA
4. initial scan shows gest sac AND yolk sac-->rpt US in 11d without EMBRYO AND FCA
67
when do do hysteroscopy D&C for PMB?
always for EMB w/ insufficient tissue, or in pts with prior normal EMB and persistent or recurrent bleeding
not wrong to start w/ it based on pt factors/clinical suspicion etc.
obviously good for directed sampling
68
PCOS affects what % of reproductive age women?
5-10%
69
do you need a positive culture to treat endometritis?
no; GCCT is neg in approx 50% of casees, thus tx based on clinical diagnosis
70
what % of women with fibroids will be symptomatic?
25%
71
average size reduction of fibroids w/ UAE?
decreases size by 42% by 3mo
72
MC reason pt will DC nexplanon?
irregular bleeding which is estimated that up to 1/2 of pts ask for removal within the first 6mo!
73
SE of nexplanon?
acne, amenorrhea, irregular bleeding, weight gain
74
depo use after _ period of time has risk of significant associated BMD loss? (has FDA black box warning)
after 2yrs!
75
how to treat unscheduled bleeding w/ nexplanon?
no official consensus, obvi we typ use estrogen like OCP pill, prologue also says you can use NSAIDs, mifepristone plus estradiol, mifepristone plus doxy, or doxy alone
BUT the first line 'tx' is reassurance
they say that women's bleeding profile that develops AFTER the 1st 3mo will be predictive of anticipated bleeding for the next 2 years
ex. if your bleeding sucks after 3mo will likely cont to suck but if your spotting improves after 3mo will likely be ok
76
AUB affects _ to _ % of reproductive age women
10-30%
77
36yo woman prev had normal cycles, now w/ hx of 1 abnml cycle with menorrhagia and increased duration of bleeding. She also has fatigue and SOB. She has ecchymosis on legs. TVUS is nml. Hgb 9, plt 81, WBC 3, nml lft/cr. HIV neg. Autoimmune panel is neg. What is best way to confirm her dx/what does she have?
Hematologic cancer, she needs bone marrow biopsy
78
ITP
idiopathic thrombocytopenic purpura ITP
-on peripheral smear would have megakaryocytes=fragmented platelets with nml appearing red cells
79
HUS and TTP are 2 types of _ anemia?
microangiopathic hemolytic anemia
-both cause anemia but not neutropenia
-both will have intravascular red blood cell fragmentation that produces schistocytes on the peripheral blood smear
-HUS: presents in children and has uremia on labs (elevated BUN)
-TTP: fever, mental status change, low plts
-caused by deficiency of ADAMTS 13
-tx with urgent plasamphoresis (only use steroids in severe cases)
80
what clotting factors does the liver produce
I (fibrinogen) II (prothrombin) V, VII, VIII, IX, X, XI, XIII, protein C, protein S, antithrombin
this is why women w/ cirrhosis have AUB
81
when to perform EMB?
for all women>45yo w/ AUB, or postmenopausal, or in women <45 w/ AUB that are obese or long standing hx of unopposed estrogen
should also perform EMB in women <45 if they don't meet above criteria but they have persistent AUB despite medical management
82
systemic bleeding DO that can cause aub
1. abnormalities w/ primary hemostasis
a. thrombocytopenia
i. bone marrow failure
ii. immune: autoimmune thrombocytopenia; drug related; HIV
iii. nonimmune: TTP, HUS, HELLP
b. qualitative plt abnmls
i. VWD
2. abnormalities w/ secondary hemostasis
a. congenital factor deficiencies
b. oral anticoagulants
c. acquired factor VIII inhibitors
3. hyperfibrinolytic stats
a. alpha 2 antiplasmin deficiency
b. plasminogen activator inhibitor 1 deficiency
4. complex coagulopathies
a. DIC
b. liver disease
83
you get stuck w/ a needle during a vaginal lac repair with a pt with known hepatitis C. Your labs come back positive with HCV antibody. Your viral load HCV RNA is negative. What should you do next?
repeat HCV viral load in 3wks
the risk of contracting HCV after needle stick (percutaneous exposure) is only 1.8% so you got unlucky :/
AND PEP postexposure PPX is not recommended as it is not effective for HCV
so actually immediately after exposure it would be impossible to have a viral load or test pos for HCV, so by having HCV ab pos means you had a prior infxn and cleared it; 3wks is the earliest you would expect to see a viral load which is why repeat testing is recommended, if you had a viral load @3wks, then this is when you would start antiviral therapy=elbasivir-grazoprevir for 12wks
if your antibody HCV test was initially negative, then they would recommend repeat antibody testing at 6mo
84
approximately _ to _ % of ppl infected w/ HCV will clear the virus and do not become chronically infected?
15-25%
85
in postop pt with hypovolemia taking beta blockers it can mask what?
tachycardia. if you have a pt taking metoprolol, we continue this periop most of time bcuz cardioprotective, but bcuz of this you may not get the responsive tachycardia
86
pt postop from TAH with EBL of 500 who has CHF and HTN has UOP of 12ml/hr on POD1. Hgb 12-->11. Should you reassess in 8hr, collect feNA, or do a lasix challenge
collect a fena pt still could be volume down
FENA<1 pre-renal
FENA>1 intra or post renal
prerenal dehydration hypovolemia
intra-renal ATN or pathology related to kidney itself
post-renal obstruction of ureter or bladder or kink in foley etc
87
64yo female has hx of ER positive breast CA s/p lumpectomy and radiation currently on anastrazole. She drinks and smokes. DEXA shows -2.6. In addition to stop smoking and drinking what should you give her?
zolendronic acid
88
osteoporosis affect what fraction of women greater than 50yo worldwide?
1/3
89
RF for osteporosis
prior fx, tobacco use, 3 or more alc drinks per day, prolonged corticosteroid use, RA, >65yo, bmi <20, white or asian, hypogonadism, sedentary, low calcium/vit D
90
T score for osteopenia?
between -1 to -2.5
91
when should you tx for osteoporosis
-any postmenopausal women w/ hx of hip/vertebral fx
-with DEXA less than -2.5 (more negative)
-10 year probability of hip fx is >3%
-or risk of any fx is >20%
92
how to calculate risk for fracture?
FRAX tool fracture risk assessment tool
calculates a pt's 10 yr probability of a MAJOR osteoporotic fx and HIP fx
if >20% for major or >3% for hip, then tx
93
does anastrazole ^ risk of osteoporosis
yes; it is aromatase inhib meaning it prevents androgens from turning into estrogen (why it is good for ER pos breast CA)
-but does ^ risk of bone loss
94
first line tx for osteoporosis?
bisphosphonates
-inhibit osteoclasts and prevent bone reabsorption
SE include GI upset and osteonecrosis of the jaw
95
zoledronic acid is a bisphosphonate should consider when?
if ur pt has gerd or GI DO or bariatric surgery hx use this bcuz its IV so no GI sx; it is more expensive though
96
calcitonin
produced by thyroid
binds to osteoclasts-->inhibits bone resorption
not first line for osteoporosis
97
SERM vs aromatase inhibitor?
SERMs (Selective Estrogen Receptor Modulators) and Aromatase Inhibitors (AIs) are both hormone therapies used in breast cancer treatment
SERMs block the effects of estrogen on breast tissue by binding to estrogen receptors
(tamoxifene, raloxifene, bazadoxifene)
while AIs block the production of estrogen in the body
(anastrazole, letrozole)
SERMs can increase the risk of endometrial cancer and blood clots, while AIs can increase the risk of osteoporosis and fractures,
98
indication for estrogen and bazedoxifene combo
for menopausal sx! a positive SE of this combo is that it can help tx/prevent osteoporosis but it is not approved for this
-can use in women w/ a uterus bcuz the SERM is anti-estrogen in breast and uterus, also good for breat CA
99
raloxifene
SERM; anti estrogen on breast and uterus, pro-estrogen on bone
-but really high risk for VTE 2-3 fold over placebo and shouldn't be used in women who smoke
100
teriparatide
recombinant PTH
-used for severe osteo (t score less than -3.5 OR less than -2.5 w/ a concurrent fragility fx)
-daily subQ injection can be given up to 2 yrs
-v $$$
101
mode of hysterectomy with highest risk of vaginal cuff dehiscence?
laparoscopic (0.64 to 1.3%)
abd 0.2-0.3%
vaginal 0.11-0.13%
vaginal closure after lap hyst (0.21-0.46%)
apparently robotic assisted up to 6% but smaller studies looking at this
102
risk factors for cuff dehiscence?
-infxn of cuff or hematoma
-impaired wound healing: DM, smoking, autoimmune, cancer
-increased intra-abdominal pressure: obesity, valsalva, chronic cough, trauma-intercourse
-post menopausal
103
why does laparoscopic hyst have highest rate of dehiscense?
proposed that the energy modality increases tissue damage (creating colpotomy on coag w/ monopolar)
or poor technique
or in robotic cases where it is so zoomed in either stitches too far apart or bites too close to wound edge
104
vaginal pH in women with genitourinary syndrome of menopause?
elevated at pH of 5-7
105
cytology of GSM genitourinary syndrome of menopause
increase in parabasal cells and decrease in superficial cells
106
sx of GSM
atrophic vagina w/ PALE and SHINY epithelium
may have dyspareunia, pruritus, discharge, pelvic pain, urinary frequency urgency incontinence
107
tx for GSM?
first line is vaginal estrogen
-can also use vaginal moisturizers like replens
-or SERMs (ospemifene) but remember this has high risk of VTE
-vaginal dehydroepiandrosterone (converts from testosterone to estradiol locally but not systemically)
-prasterone: daily vaginal insert
-vaginal laser therapy (like mona lisa): good in pt want to avoid hormone, some suggestion of improvement of sx based on studies
108
lichen planus
inflammatory disorder of skin and mucosa, can involve vulvovaginal
-sx burning, pruritus, discharge, painful sex
-erosive is most comm form, sharply demarcated erosive changes w/ WHITE LACY appearing striae dx confirmed via bx
-wickham's striae are pathopneumonic
may also affect the mouth and vagina
-on histopathology: lichenoid rxn w/ dermoepidermal junction w/ lymphocytic infiltrate irregular epidermal hyperplasia
109
lichen sclerosis
skin thin, white, crinkled (tissue paper), loss of architecture. confirm w/ bx
Population: prepubescent girls & PM women
SX: pruritus, dyspareunia
on histopathology: lichenoid inflammatory pattern, hyperkeratosis, thinning w/ loss of RETE ridges
110
tx for lichen planus
topical steroid
111
tx for lichen sclerosis?
topical steroid
112
lichen simplex chronicus
population: mid to late adults
-chronic itch scratch cycle!
Appears: erythema, scaling, lichenified plaques, excoriations from scratching
Bx for dx
Histopathology: irregular acanthosis, hyperkeratosis, parakeratosis, superficial perivascular infiltrate
113
tx of lichen simplex chronicus
remove offending agent! topical steroid, consider systemic steroid to avoid itch scratch cycle if exacerbated by topical cream
114
vulvo/vaginal psoriasis
Population: peak during 30s and 50-70s
-chronic pruritus
Appear: WELL DEMARCATED pink plaques, Kobner phenomenon, often look diff than the plaques on other body parts 2/2 moisture
Bx for dx
Histopathology: regular acanthosis, parakeratosis, psoriasiform hyperplasia
115
tx for vulvar psoriasis
low to mid potency topical steroid
116
you're doing a lap hyst on a 34yo, you inadvertently touch monopolar scissors to the bowel during coagulation. There is a 1.5cm area of white blanching bowel without evidence of bowel spillage. What should you do?
segmental bowel resection with reanastamosis
prologue says if just serosal thermal injury you can do a pursestring closure but basically you can never tell w/ thermal how deep it is which is why resection is best answer
the resection should have a margin of 4-5cm on all sides surrounding the blanched area to prevent perforation from tissue necrosis
117
incidence of bowel injury in gyn surgery is low but x percent is not recognized until the postop period
overall incidence of 1 in 769 ~0.13%
41% aren't recognized until post-op
29% are d/t electrosurgical modalities which is why so much isn't found until postop
118
when is resection w/ colostomy appropriate vs resection w/ reanastamosis?
in regard to gyn surgery w/ thermal injury
this is indicated if: 2 more more bowel injuries, needing to transfuse, or sig contamination from bowel leakage
119
when can you sew the bowel for a bowel injury?
-for non-thermal injuries such as injury with trocar that involves less than 50% of the bowel circumference
-close in 2 layers and suture line should be PERPENDICULAR to long axis of bowel to prevent stricture
-should also give add. dose of abx to cover anaerobes like flagyl
-inner layer absorbable braided like vicryl, outer layer often 3-0 silk
120
can you ever not repair a bowel injury?
yes if done w/ veress needle for example and it is small and only serosa is impacted (muscle and mucosa intact)
BUT you should still suction and irrigate and give abx
121
bowel injury from non-thermal source when do you need to do a resection?
if involves >50% of bowel circumference
122
overall features of ovarian mass on US that are concerning for cancer
>10cm, papillary projections, solid components, irregularity, ascites, increased doppler flow
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interval for repeat US with benign appearing adnexal mass
3-6mo
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old lady comes in altered, found to have cr of 3.0 and obstructive uropathy 2/2 procidentia what should you do?
place a pessary
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12yo has 3wk hx of worsening abd pain. Started periods few mo ago. Not sexually active. Abd US shows 15cm right ovarian mass w/ solid components, edema, and free fluid. HCG 109, LDH 850, CA 125 30, AFP 8. Dx?
dysgerminoma=^^LDH
dysgerminoma is the most common malignant ovarian germ cell tumor
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AFP is elevated w/ what tumor?
immature teratoma
will have immature cells from all 3 germ cell layers
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how long prior to surgery should pts w/ diabetes hold oral DM meds?
Including sulfonylureas (glipizide, glyburide)-stimulate rlse of insulin from panc, meglitinides (repaglinide, nateglinide, and mitiglinide)-also stimulate rlse of insulin from panc
hold the day of surgery, bcuz can cause hypoglycemia
these can also ^risk of periop MI
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metformin risk periop?
lactic acidosis; says 'hold temporarily before surgery' doesn't give time frame
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How is UAE performed
by IR; use fluroscopy enter through femoral artery and then inject embolic material into uterine
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absolute contraindications to UAE
ASYMPTOMATIC fibroids, pregnancy, active infection, uterine malignancy
still 'investigational' for women who desire future fertility
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what is risk of submucosal fibroids or pedunculated fibroids w/ UAE
the stalk can necrosis and thus the fibroid is free floating in uterus, it can be explused through cervix-->bleeding, pain, infxn
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can UAE treat adenomyosis?
YES; it is not first line but has been shown to help treat adeno
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def of RPL
3 or more first trimester losses
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w/u for RPL
assessment of uterine cavity (US, SIS etc), testing for APAS, thyroid, prolactin, parental karyotype
in 50-75% of cases, no cause for RPL is found
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in women w/ documented RPL and a negative w/u what is something you can do to potentially treat?
progesterone supplementation in 1st tri
in the luteal phase, progesterone is important for implantation and early pregnancy development, thys a short luteal phase or defects in ovarian progesterone production can lead to RPL
dosing no established; typ vag prog or IM prog
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inheritance of lynch syndrome
AD
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lynch increased risk of what cancers?
endometrial, colon, ovarian
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what genes affected w/ lynch
germline mutation in mismatch repair genes= MLH1, MSH2, MSH6, PMS2
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best initial testing for lynch syndrome? this is for pts who already have CA dx and you're wanting to see if its genetic
testing of the actual tumor w/ immunohistochemical staining
-next best test is micosatellite instability testing, then direct germline testing of DNA
BUT if you have pt w/ ^ risk based on family hx etc then you can do direct germline testing of dna bcuz tumor testing is not option aka they dont have cancer yet
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your pt has cervicitis, you haven't done any testing yet but want to do empiric tx?x
ceftriaxone 500mg IM x1 dose if <150kg, if >150kg then 1g IM x1 dose
-if you haven't ruled out chlamydia then doxy 100mg bid x7d
-but if you have r/o chlamydia then only tx w/ rosephin
if they have cephalosporin allg:
-Gentamicin 240 mg IM in a single dose PLUS Azithromycin 2 g orally in a single dose
If ceftriaxone administration is not available or not feasible:
-Cefixime 800 mg* orally in a single dose
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your non preg pt tested pos for chlamydia should you re-screen her?
yes at 3mo regardless of partner tx, and you should rec they refrain from intercourse for 7d following tx
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pelvic floor PT, muscle training, biofeedback, dietary changes, timed voiding is first line treatment for what?
OAB, urge incontinence
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Mirabegron MOA
beta 3 agonist acts on detrusor and relaxes it which increases bladder capacity aka treats OAB
-should not use in POORLY controlled HTNive pts bcuz can make sx worse, but if tx hTN that is ok
gemtessa vibegron is also beta 3 agonist that doesn't have SE of HTN
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oxybutynin
old antimuscarinic for OAB, act on acetylcholine receptors and block them from causing bladder contraction
AE: dry mouth, constipation, HA
newer antimuscarinics=solifenacin, trospium=little bit better tolerated but still bad SE
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botox for OAB
inhibits release of acetylcholine, inject during cysto
27% report resolution of incontinence at 6mo
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HRT can be offered to women who meet what criteria?
are within 10yr of menopause who suffer moderate to severe vasomotor sx, are considered low risk of cardiac dz and breast cancer
-should not be started after age 60, but if already on HRT it is R/B discussion of continuing past 60yo
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how long should you give HRT
'the lowest dosage for the shortest period of time'
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does HRT increase or decrease risk of cardiovascular disease
BOTH; in women younger than 60 taking HRT it can be cardioprotective
in women older than 60 can have adverse effects
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HRT benefit regardless of age
obvi reduction in sx, but also statistically sig decrease in bone fx and osteoporosis
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higher risk of breast CA in women on HRT
yes but is age dependent as get older increased risk in combo HRT most likely related to increased absolute risk that increases w/ age
poss benefit fo HRT in decreased colon cancer for pts in younger populations but not older
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#1 route of hysterectomy
vaginal; should always offer vaginal first if no contraindications like extra uterine disease, endo, adhesions, big uterus
for obvious reasons-no abd incisions, faster recovery, less complications, shorter hospital stay
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perioperative risk assessment should be done within 6wks of surgery, this should include...
physical exam, medical history including hx of bleeding DO, prior anesthesia complications, and functional status aka METs
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high risk surgeries
aortic surgery
major peripheral arterial surgery
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intermediate risk surgery
intrathoracic, intraabdominal including laparoscopy/thoracoscopy
carotid surgery
prostate, orthopedic, head and neck
pts in this group w/ 1 or more cardiac risk factor should get preop ekg so like getting hyst and have diabetes/HTN
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low risk surgery
superficial procedures, endoscopy, breast, cataract
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when would preop PFTs be needed
newly or poorly controlled pulmonary disease
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when should you start doing paps on your pt with HIV?
within 1 year of initiation of sex or if already sexually active within one year of HIV diagnosis (even if less than 21)
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pap intervals for HIV pts
if less than 30 years old, should have cytology alone starting w/in 1 yr, then continue repeat pap q1 yr for 3yrs assuming paps normal
-after that can space out paps to q3yrs
after 30yo then they can do cytology alone or co-testing but either way will still need paps done q3yr even w/ co-testing
continue paps past age 65 as well
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risk of adhesions with prior laparoscopy, prior pfannenstiel, prior ML vertical
1.6%; 19.8%; 51.7%
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for palmer's point entry and really for any entry pt should be laying..
flat, then once you've confirmed entry and can look at other ports w/ camera then you can enter in t-burg
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for palmer's what else do you need to make sure anesthesia places for you
an OG to suction or NGT to protect the stomach
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contraindications to palmers entry
1. splenomegaly 2. previous gastric surgery 3. portal hypertension
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tests to help ensure you're in w/ closed laparoscopic technique w/ veress
double click-hear two pops, aspiration test, inject saline, saline drop test
-or an opening pressure of less than 10mm Hg
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layers of the bladder from inner most to outer most
transitional epithelium, lamina propria, submucosa, detrusor muscle, adventitia
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dx of metabolic syndrome?
BP>130/85, fasting BG>100, HDL <50, TG>150, waist circumference>88cm
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for women w/ malpositioned IUD and the stem of the IUD is below the internal os (aka is w/in the cervical canal) what should you do?
always remove it, doesn't matter if they're symptomatic or not, it is a partial expulsion and will not work effectively and should be removed
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if IUD is low in uterine segment but the stem is above the internal os what should you do?
if they're asymptomatic you don't have to remove it, it can still be functional, but if they're having sx you should remove it
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most effective emergency contraceptive?
copper IUD, can be inserted up to 5d after unprotected intercourse, unintended preg rate=0.1%
-MOA: prevents fertilization by affecting sperm viability and function
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ulipristal (Ella)
effective for 5d after unprotected sex; preg rate=0.9 to 2.1%.
MOA=can work before or even during the LH surge, but only before LH peaks, which prevents ovulation by delaying follicular rupture
(doesn't work after ovulation)
-most effective oral contraceptive
-lots of ppl don't use though because requires a prescription
also known as progesterone antagonist or selective progesterone receptor modulator
contains 1 tablet of 30mg of ulipristal acetate
ALL oral contraceptives can be used more than once in a single menstrual cycle
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levonorgestrel pill
most commonly used emergency contraceptive bcuz OTC, must be taken BEFORE THE LH SURGE STARTS
-MOA=delays follicular development
-preg rate=0.6 to 3.1%
-labeled use=3d after unprotected sex
-efficacy decreases w/ ^^BMI
-aka plan B
-1.5mg of levonorgestrel
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can also used cOCP for emergency contraception
up to 5d
lots of SE
preg rate=2 to 3.5%
-take 120mcg of estradiol and 0.5 to 1.2 of progestin followed by a second dose 12hr later
-so for vestura for ex which has 20mcg of estrogen would take 6 pills then another 6 pills 12hr later
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what muscle is punctured during TOT sling?
obturator internus; thus if your pt has neuropathy diffulty abducting thigh this is likely the pudendal nerve impacted which innervates the obturator internus
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score of what or higher on PHQ9 indicates major depressive DO?
10 or higher
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ur patient has atypical glandular cells AGC on pap, what should you do next?
colpo w/ ECC regardless of age of pt
-if pt>35yo or have sig RF for endometrial cancer then you should also perform EMB
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ur patient has AGC and endometrial cells on pap next step?
endometrial and endocervical sampling, if no endometrial pathology then do colpo
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rate of pelvic abscess after gyn surgery
less than 1%
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