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Flashcards in Gynecology Deck (111):
1

Patient with bilateral nipple discharge presents. What is on top of differential and what do you want to order?

Prolactinoma
PRL and TSH levels

2

What is the most common cause of unilateral, nonbloody nipple discharge?

Intraductal papilloma

3

What is commonly the cause of bloody nipple discharge?

Malignancy

4

Is cytology ever helpful for nipple discharge?

No

5

What is used for a definitive diagnosis of the patient with unilateral nipple discharge?

Surgical duct excision

6

How does fibrocystic disease present and what is tx?

Bilateral, painful breast lump which fluctuates with menstrual cycle. OCPs help

7

39 yo patient presents with firm, discrete, and highly mobile breast nodule. Most likley dx?

Fibroadenoma

8

Any woman with a breast mass should receive what work-up?

Clinical breast exam
US or mammogram (latter if >40)
Fine-needle aspiration biopsy

9

Do fibroadenomas need too be treated?

No, only if they're growing quick

10

What patient population receives US for evaluation of a breast mass and why?

Younger woman with cystic feeling mass. US is helpful bc they often have denser breasts

11

In what situations is a mammogram used to evaluate a breast mass?

>50
Cyst recurring multiple times
Skin erythema and consistency with malignancy
Bloody nipple discharge
Mass doesn't appear completely FNA

12

What is needed to evaluate a breast mass after US or mammogaphy?

FNA or core needle biopsy (core needle is better)

13

What is treatment regimen for ductal carcinoma in situ?

Lumpectomy, tamoxifen x 5yrs, radiation therapy

14

What is treatment regimen for lobular carcinoma in situ?

Tamoxifen x 5yrs; surgery is not necessary

15

What are risks of tamoxifen use? What are contraindications?

Risks: endometrial carcinoma, VTE
Contraindications: previous VTE or high risk for VTE, active smoker

16

What are the USPSTF's recommendations for breast cancer screening?

No longer advised to do clinical breast exams or teach self-exam
>50 get mammogram every 1-2 years; only start before if have particularly high risk

17

Where does invasive ductal carcinoma metastasize?

Bone, liver, and brain; it is often unilateral

18

What type of lymph node biopsy preferred in invasive breast disease?

Sentinel node biopsy

19

When is trastuzumab indicated for mgmt of breast cancer?

When HER2/neu positive

20

How does treatment of HER+ cancer differ between pre- and post-menopausal women?

Premenopausal: Chemo +/- RT + tamoxifen
Posmenopausal: Chemo +/- RT + aromatase inhibitor

21

You feel an asymmetric, nontender uterus in an African-American woman. What is dx?

Leiomyoma

22

What cause of an enlarged uterus is estrogen responsive and thus may grow or change during pregnancy or menopause, respectively?

Leiomyoma

23

What causes symmetric enlargement of the uterus?

Adenomyosis

24

What is adenomyosis and how does it feel?

Endocrine glands of uterus implanted in myometrium causing dysmenorrhea and menorrhagia; not estrogen responsive; feels soft, symmetrical, globular, and tender

25

A patient presents with an enlarged uterus but also constipation and difficulty urinating. If this is a benign growth what may it be?

Leiomyoma

26

Are leiomyomas tender or nontender?

Nontender

27

Your patient with known adenomyosis presents with menorrhagia. What medical therapy may help?

Levonorgestrel IUD may decrease heavy bleeding

28

What is definitive therapy for leiomyomas and adenomyosis?

Hysterectomy

29

What are nondefinitive procedural methods for tx of leiomyomas?

Myomectomy
Embolization of vessels

30

What is the most common gynecologic malignancy?

Endometrial carcinoma

31

When reduced for simplicity, what is the risk factor for endometrial carcinoma?

Unopposed estrogen states

32

Women with anovulation due to PCOS are at high risk for what malignancy? What can be given to help reduce the odds of that malignancy?

Endometrial carcinoma due to unopposed estrogen stimulation; progestin

33

All postmenopausal bleeding is ______ until proven otherwise

Endometrial carcinoma

34

In postmenopausal patients how thick should the endometrial stripe be on ultrasound?

35

20 yo female presents with negative B-hCG and ultrasound showing a solitary cystic mass of adnexal region. Dx?

Simple cyst

36

What are indications of removal of a simple ovarian cyst?

If >7cm in diameter OR
Steroid contraception fails to allow it to resolve

37

Sudden onset of severe lower abdominal pain in presence of adnexal mass is .....

Ovarian torsion

Mgmt: laparoscopy and detorsioning should be done if blood supply not affected

38

How are complex ovarian cysts managed?

Laparoscopy/laparotomy

39

What are risk factors for ovarian cancer, in general terms?

Anything which increases number of ovulations and BRCA1 gene

*Thus protective factors are OCPs, breastfeeding, anovulation

40

What population are germ cell tumors most common? What are some markers?

young woman (dysgerminoma is most common)
presents as complex cystic mass with pain
LDH, B-hCG, and AFP

41

What is the most common type of ovarian cancer in postmenopausal women and what are the markers?

Epithelial type ovarian cancer
CA-125, CEA

42

What ovarian mass presents with excessive estrogen release?

Granuloasa-theca (stromal) tumor

43

What ovarian mass presents with excessive testosterone release?

Sertoli-Leydig cell (stromal) tumor

44

In a patient that presents with bilateral ovarian tumors and a history of dyspepsia what should you suspect? What is a tumor marker?

Krukenberg tumor (metastatic gastric cancer to both ovaries)
CEA

45

In premenopausal women what is the surgical mgmt of ovarian tumors?

Salpingo-oophorectomy

46

Which HPV types are associated with benign condyloma acuminata?

HPV 6 and 11

47

What are risk factors for cervical cancer?

Smoking, multiple sexual partners, immunosuppression, early age of intercourse

48

When is screening for cervical cancer started?

21

49

At what age can cervical cancer screening be stopped if the last Pap smear was normal?

65

50

Is Pap smear recommended for women with hysterectomy?

No

51

How frequently is cervical cancer screened for?

Every 3 yrs

If >30 then can get Pap and HPV DNA screen and get tested every 5 yrs

52

If a women has two cervical cancer screens showing ASCUS what is the next step in mgmt?

Colposcopy and biopsy because two in a row is suggestive of cervical inflammation which may be cancer

53

A patient presents for cervical cancer screening and gets ASCUS what is the next step for mgmt if follow-up is certain?

What is follow-up is not certain?

Follow-up certain: repeat Pap in 3-6 months with HPV DNA testing

Follow-up uncertain: colposcopy and biopsy

54

Patient presents with ASCUS and f/u HPV testing shows HPV type 6. What is next step?

What if it was HPV 16 or 18?

Can follow-up with other ASCUS in 3-6 months

If high risk HPV (16 or 18) then colposcopy and biopsy

55

When is endocervical curettage completed in cervical cancer screening?

In nonpregnant patients with abnormal pap smears this must be done to rule out endocervical lesions

56

What is a longterm complication of cervical cone biopsies?

Incompetent cervix or cervical stenosis

57

Your patient with CIN 2 just had ablation. How should you manage long term?

Observe and f/u with Pap, colposcopy, and/or HPV every 4-6 months for 2 years

58

A patient presents with recurrent CIN 2 cervical cancer. What is mgmt?

Hysterectomy

59

How are pregnant women with HGSIL further evaluated?

They still get colposcopy and biopsy

*The only thing not done for pregnant women is endocervical curettage

60

How do you manage a pregnant patient with invasive cervical cancer identified at before or after 24 weeks?

Before 24 weeks: radical hysterectomy and radiation therapy

After 24 weeks: conservative mgmt until 32-33 weeks, then delivery, then mgmt

61

What is further mgmt of microinvasive cervical cancer in pregnant patients?

Cone bx to evaluate fr frank invasion; deliver vaginally and then re-evaluate post-partum

62

Gardasil is given to females of what age range?

8-26 yo

63

What strains does Gardasil protect against?

HPV 6, 11, 16, 18

64

Is Gardasil ok for use in pregnant, lactating, and immunosuppressed patients?

No

65

Patient presents with yellow cervical discharge in the absence of other symptoms. What is the diagnosis and tx?

Cervicitis

Treat for Chlamydia and Gonorrhea with one time dose of IV azithromycin or doxycline and IM ceftriaxone

66

Patient presents with lower pelvic pain after menstruation. ESR and WBC are increased and cervical cultures are positive. What is the dx and what do you want to rule out?

Acute salpingo-oophoritis

Get a sonogram to rule out pelvic abscess

67

Patient comes in complaining of pelvic pain but cervical cultures and ESR are negative. A sonogram demonstrates bilateral cystic pelvic masses. What is the likely dx?

Chronic PID

68

What is the procedural mgmt of chronic PID?

Lysis of adhesions may rid of infertility
Chronic, non-remitting pain may require TAH, BSO

69

Patient presents with lower pelvic pain, back/rectal pain, nausea, vomiting, and appears ill. Dx?

Tubo-ovarian abscess

70

What do blood cultures grow in tubo-ovarian abscess? What is seen on culdocentesis and sonogram?

Anaerobes
Culdocentesis (needle aspiration of fluid from pouch of Douglas): pus
Sonogram: unilateral pelvic mass

71

How is tubo-ovarian abscess managed/treated?

Admit and give IV cefoxitin and doxycycline
If the patient isn't improving over 72 hrs then do ExLap +/- TAH/BSO or can do percutaneous drainage

72

What is primary dysmenorrhea?
What is cause?
What is tx?

Abdominal pain, nausea, and vomiting accompanying menstruation usually 5yrs after onset of menstruation

Caused by excessive prostaglandin F2 release which leads to additional contractions and acts on GI smooth muscle

1st line NSAIDs, 2nd line OCPs

73

What is the most common cause of secondary dysmenorrhea?

Endometriosis

74

How does endometriosis present?

Dysmenorrhea, dyspareunia, dyschezia, and infertility in patients >30

75

What is a chocolate cyst?

Endometriosis in an ovary

76

Uterosacral ligament nodularity and tenderness on rectovaginal exam is indicative of .....

Endometriosis

77

How is endometriosis definitively diagnosed?

Laparoscopy

78

What else can cause elevations of CA-125 besides ovarian cancer?

Endometriosis
Cirrhosis
Peritonitis
Pancreatitis

79

What are first and second line treatment options for endometriosis? Why do they work?

1st line: progestins or OCP; progestin inhibits endometrial tissue growth

2nd line: testosterone (danazol) or GnRH analogs (leuprolide)

Can also do lysis of adhesions or TAH/BSO for severe disease

80

What is the most common cause of premenarchal vaginal bleeding? What must you rule out?

Presence of foreign body

Rule out: sarcoma botryoides, tumor of ovary/pituitary, sexual abuse. Do a pelvic exam under sedation and get CT/MR imaging to rule out the other issues

81

What is Mullerian agenesis and what is mgmt?

Absence of Mullerian duct derivatives (fallopian tubes, uterus, upper vagina, cervix). Ovaries present and E and T levels are normal

Vaginal reconstruction

82

Patient presents with scant axillary and pubic hair development and complains of ever having a period yet. US reveals testes. Dx and mgmt?

Androgen insensitivity syndrome

Removal of testes before age 20 bc of heightened risk of cancer and estrogen replacement

83

What is Kallmann syndrome?

Anosmia and hypothalamic-pituitary failure leading to primary amenorrhea

84

Patient presents with primary amenorrhea and uterus is present on US but you find low FSH. Dx? Mgmt?

Hypothalamic-pituitary failure
Mgmt: estrogen and progesterone replacement

85

What are part of the steps of working up secondary amenorrhea?

B-hCG
TSH
Medications
Progesterone or estrogen-progesterone challenge test

86

Premenstrual dysphoric disorder is treated with ....

SSRI, vitamin B6 (pyridoxine)

87

What happens to LH/FSH ratio in PCOS?

Increases (usually to 3:1)

88

Why are patients with PCOS at heightened risk of endometrial cancer?

Anovulation leads to failure of corpus luteum to form and thus no progesterone release. Unopposed estrogen can then increase risk of cancer

89

Patients with PCOS are managed with what medical therapies? (Hint: 4)

OCPs help irregular bleeding and hirsutism
Clomiphene citrate helps in those wanting pregnancy
Spironolactone has anti-androgenic effects
Metformin for insulin resistance

90

A patient presents with rapid onset virilization and hirsuitism. What two tumors are on your differential and how can you differentiate them via labs?

Adrenal tumor: elevated DHEAS

Ovarian tumor: elevated testosterone

91

What is elevated in congenital adrenal hyperplasia? What is another name for the disorder?
What is tx?

Also called 21-hydroxylase deficiency
17-hydroxyprogesterne is elevated
Treat with corticosteroid replacement

92

What is the most common cause of hirsuitism and what is dx?

Idiopathic hirsuitism
Spironolacone and eflornithine (Vaniqa; topical drug for treatment of unwanted facial and chin hair)

93

What test confirms the diagnosis of CAH/21-hydrooxylase deficiency?

ACTH stimulation test

94

Menopause before 30 years of age =

Premature ovarian failure

95

What are T score cutoffs for osteopenia and osteoporosis on DEXA?

Osteopenia is T score -1.5 to 2.5

Osteoporosis is T score > -2.5

96

How do biphosphonates work?

Inhibit osteoclastic bone formation

97

SERMs are helpful in posmenopause by reducing what symptoms?

They reduce osteoporosis and cardiovascular disease

98

Tamoxifen has agonist effects where? antagonist where?

Agonist at bone and endometrium
Antagonist at breast

99

Raloxifene is a SERM with what agonist and antagonist effects?

Agonist at bone
Antagonist at endometrium

100

What is denosumab?

RANKL inhibitor which inhibits osteoclast function

101

When biphosphonates fail what is used for osteoporosis?

Teriparatide (PTH analog)

102

When providing HRT to a postmenopausal woman with a uterus what else must you administer and why?

Progestins because of the endometrial growth qualities of estrogen

103

What are some absolute contraindications for OCPs?

Smoking, uncontrolled HTN, migraines with aura, VTE, hormonal responsive cancer, pregnancy, acute liver disease, thrombophilia

104

OCPs reduce the risk of what cancers?

Ovarian and endometrial

105

What are the steps for evaluating infertility in a couple?

1) Semen analysis
2) Anovulation work-up
3) Fallopian tube abnormality work-up

106

What are risk factors for gestation trophoblstic disease?

Age extremes, folate deficiency, Taiwanese/Philipines

107

Bleeding before 16 weeks gestation, hyperemesis gravidarum, and passage of vesicles should raise suspicion of what?

Gestational Trophoblastic Disease

108

Where can GTN spread?

Distant mets to lungs

109

What is more likely to form malignancy, complete or incomplete hydatiform mole?

What are the karyotype of each?

Complete more likely to form malignancy

Complete is a dizygote
Incomplete is triploid

110

Sonogram showing homogenous intrauterine echoes without a gestational sac or intrauterine parts should raise suspicion for ....

Gestational trophoblastic disease ("snowstorm" appearance)

111

What is mgmt of GTN?

CXR to rule out malignancy
Quantiative B-hCG levels
Suction D&C
Place on effective OCPs to be able to ensure if rising B-hCG levels in the future are recurrence rather than pregnancy