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Flashcards in gynecology Deck (104):
1

bilateral nipple discharge
- dx?
- tests?

prolactinoma
tests: TSH, prolactin level

2

unilateral non-bloody nipple discharge

intraductal papilloma

3

w/u of nipple discharge

mammogram
surgical duct excision for definitive diagnosis

4

Tx, fibrocystic disease

OCPs
severe pain - danazol

5

steps in dx of any pt with a breast mass

1. clinical breast exam
2. imaging: USG or diagnostic mammo (>40 yo)
3. FNA biopsy

6

Tx. fibroadenoma

no tx. necessary
surgical removal may be done is mass is growing

7

follow-up for a cytic mass that disappears on FNA (clear fluid)

CBE, 6 weeks after
- if mass has recurred, get repeat USG and FNA

8

bloody aspirate from cyst must be...

sent for cytology

9

in what cases do you need to get mammography

cyst recurs > 2x w/in 4-6 weeks
blood fluid on aspirate
mass does not disappear after FNA
bloody nipple discharge
skin edema or erythema present

10

cluster of microcalcifications seen on mammogram - next step?

core biopsy

11

DCIS - next step in management

lumpectomy + RT +/- tamoxifen

12

LCIS - next step

tamoxifen for 5 years
-not necessary to perform surgery

13

risks assoc with tamoxifen

endometrial carcinoma
thromboembolism

14

breast ca. screening guidelines

mammogram every 1-2 years above age 50

15

BRCA1/2 gene testing indications

1. fhx of early onset breast or ovarian ca
2. breast and/or ovarian ca in same pt
3. fhx male breast ca
4. ashkenazi jew

16

when is BCT not indicated?

1. pregnant pt
2. 2+ sites in separate quadrants
3. prior irradiation to breast
4. positive tumor margins
5. tumor > 5 cm

17

HR+ therapy for post-menopausal women with breast ca.

aromatase inhibitors - anastrazole, exemestane, letrozole

18

when can be LHRH analogs or ovarian ablation be used in breast ca?

alternative or additional therapy to tamoxifen in pre-meno women

19

when is chemotx included in management of breast ca.

tumor size > 1 cm
LN positive disease
may be neo-adjuvant

20

enlarged, firm, asymmetric and nontender uterus

leiomyoma

21

symmetric, tender uterus that feels soft. pt c/o dysmenorrhea and menorrhagia - dx?

adenomyosis - endometrial glands and stroma located w/in myometrium; no change in size w/ high or low estrogen states

22

U/S finding in adenomyosis

diffusely enlarged uterus with cystic areas w/in the myometrium

23

definitive diagnosis of both adenomyosis and leiomyomas

histology

24

Management: leiomyomas

1. serial pelvic exams and observation
2. myomectomy
- next deliveries must C/S due to risk of scar rupture
- preserves fertility
3. embolization of vessels
- preserves uterus
4. hysterectomy
- best choice once fertility is completed

25

tx. adenomyosis

IUD placement (levonorgestrol)
definitive therapy: hysterectomy

26

first step in management of any pt with postmenopausal bleeding

endometrial biopsy

27

normal size of endometrial lining stripe in postmeno women on u/s

< 5 mm thick

28

if endometrial ca. if found on biopsy - when do you add on RTH? CTH?

1. RTH - if LN mets, > 50% myometrial invasion, positive surgical margins or poorly diff. tumor
2. CTH - metastasis

29

mngmt of simple ovarian cyst

U/S for initial assessment - if asx, no further tx

30

when do you do laparoscopic removal of ovarian cyst

> 7 cm in size
previous steroid contraception w/o resolution of cyst

31

mngmt: complex (dermoid) cyst

laparoscopic/laparotomy removal (cystectomy or oophorectomy)

32

U/S dx of ovarian torsion

no blood supply seen on doppler

33

tx. ovarian torsion

emergent surgery

34

sudden severe lower abdominal pain in presence of adnexal mass

presumed to be ovarian torsion
- laparascopy should be performed

35

initial workup of ovarian mass

BHCG
USG
laparoscopy if > 7 cm or complex

36

9 yo F presents with right adnexal pain and complex cystic mass on u/s

germ cell tumor of ovary - MC dysgerminoma
order: LDH, B-hcg, AFP

37

67 yo F presents with progressive weight loss, distended abdomen and left adnexal mass

ovarian ca - MC serous, epithelial tumors
order:CA125, CEA

38

58 yo F presents with post-meno bleeding. Endo biopsy shows hyperplasia. U/S shows right ovarian mass

granulosa thecal ovarian tumor
- secrete estrogen and cause endo hyperplasia
order: estrogen level

39

48 yo F complains of facial hair and hoarseness. Adnexal mass found on exam

sertoli-leydig cell tumor - secretes T and causes masculinization syndrome
measure: Testosteron levels

40

64 yo F with history of gastric ulcer and worsening dyspepsia presents with weight loss and abdominal pain. Adnexal mass present

metastatic gastric ca to ovary (Krukenberg tumor)
marker: CEA

41

finding of ASCUS on pap in pt < 24 yo

repeat pap in 12 months
- can repeat again in 12 months if ASCUS, LSIL or negative result
- if 3x result --> get colposcopy

42

ASCUS in pt > 25 yo

get reflex HPV testing
colpo + biopsy only if 16 or 18 present

43

endocervical curettage

all nonpregnant patients undergoing colposcopy for abnormal pap smear should undergo ECC to R/O endocervical lesions

44

when do you perform a cone biopsy

if colposcopy or ECC and pap smear findings are not consistent OR biopsy showed microinvasive carcinoma

45

mngmt of CIN 2 or 3

ablative modalities - cryotherapy, laser
excisional modalities - LEEP, cold knife conization

46

adjuvant (CTX or RTH) for cervical ca. (indications)

tumor > 4 cm
mets to LN
poorly diff
positive margins
local recurrence

47

ASCUS finding in pregnancy - next step?

colposcopy and biopsy
if CiN 2/3 --> repeat colposcopy each trimester and 6-12 weeks postpartum

48

finding of microinvasive cervical ca. in pregnancy

cone biopsy to ensure no frank invasion
deliver vaginally, reevaluate and tx. 2 mos postpartum

49

finding of invasive cervical ca in pregnancy

< 24 weeks: definitive treatment
>24 weeks: conservative until 32-33 weeks, then delivery by C/S with definite treatment

50

initial work-up for pelvic pain

1. pelvic exam
2. cervical culture
3. labs: ESR, WBC, bcx if fever
4. sonogram

51

outpatient mnmgt of acute salpingo-oophoritis

1x IM ceftriaxone + PO doxycycline

52

inpatient mnmgt of acute salpino-oophoritis

IV cefotetan or cefoxitin + doxycycline

53

young woman presents with severe, lower abdominal pain, back pain, rectal pain. She has a fever, NV and tachycardia. On labs: WBCs very elevated. Pus on culdocentesis - Dx?

tuboovarian abscess
- USG shows unilateral pelvic mass
- bcx: anaerobic organisms

54

Tx. tuboovarian abscess

cefoxitin + doxycycline
- if no response w/in 72 hours, may require laparotomy

55

primary dysmenorrhea

recurrent, crampy lower abdominal pain with NVD during menstruation; caused by excessive PGF2 which acts on both uterine and GI smooth mm

56

tx. primary dysmenorrhea

NSAIDs
2nd line: OCPs

57

dysmenorrhea, dyspareunia, dyschezia and infertility in a mid 20s female

endometriosis - endometrial glands outside the uterus

58

MC sites of endometriosis

ovary - adnexal enlargements
cul de sac - painful rectovaginal exam, uterosacral nodularity

59

diagnosis of endometriosis

laparoscopy

60

tx. endometriosis

first line: OCP
2nd line: androgen derivative (danocrine, danazol) or GnRH analogs (leuprolide)

61

MCC of premenarchal bleeding

foreign body

62

what needs to be ruled out in premenarchal bleeding

1. abuse
2. sarcoma botyroides
3. tumor of pituitary or ovary

63

Dx. testing premenarchal bleeding

1. pelvic exam under sedation
2. CT/MRI of pituitary, abdomen and pelvis to look for E-prod tumor
3. if w/u is negative: idiopathic precocious puberty

64

first test to do in eval of irregular bleeding in reproductive aged woman

pregnancy test - Bhcg

65

primary amenorrhea

absence of menstruation at age 14 w/o secondary sexual characteristics or age 16 w/ secondary sexual development

66

amenorrhea: breasts present, uterus present

secondary amenorrhea --> imperforate hymen, vaginal septum, AN, excessive exercise, pregnancy

67

amenorrhea: breasts absent, uterus present

1. FSH level and karyotype
FSH elevated - Turners
FSH low - hypothalamic pituitary failure, normal karyotype

68

amenorrhea: breasts present, uterus absent

1. order Test levels and karyotype
Mullerian agenesis: XX, normal testosterone for female
testicular feminization: XY, normal test for male

69

normal female secondary sexual characteristics, normal estrogen and testosterone levels (ovaries are intact), but have asbence of fallopian tubes, uterus, cervix and upper vagina - dx? tx?

Dx. Mullerian agenesis
Tx. surgical reconstruction of vagina for intercourse, infertility counselling

70

pt presents with primary amenorrhea. On exam she has breasts, but no pubic hair, vagina ends in blind pouch; b/l inguinal masses present. Labs show normal estrogen and testosterone levels. Dx. Tx

Dx. androgen insensitivity
Tx. removal of testes prior to age 20
estrogen replacement

71

mngmt of primary amenorrhea in Turner's syndrome

E and P4 replacement

72

pt presents with primary amenorrhea, no secondary sexual characteristics. FSH levels are low.

Hypothalamic pituitary failure due to stress, excessive exercise or anorexia nervosa

73

tests to order in w/u of secondary amenorrhea

1. B-hcg
2. TSH level - hypothyroidism
3. PRL level - if high: look for meds, CT/MRI head
4. progesterone challenge test
5. estrogen-P4 challenge test

74

progesterone challenge test

1. any withdrawal bleeding = anovulation
tx. cyclic progesterone
2. no withdrawal bleeding = estrogen inadequate or outflow obstruction --> order EPCT

75

estrogen-progesterone challenge test (EPCT)

1. withdrawal bleeding = inadequate estrogen
- get FSH level
increased FSH - ovarian failure
decreased FSH - hypothalamic-pituitary insuff

2. no withdrawal bleeding = outflow obstruction or endometrial scarring
- order hysterosalpingogram

76

tx. of choice for PMDD

SSRIs - fluoxetine
- if no effect, trial 2nd SSRI, if that fails = OCP

77

which vitamin may improve symptoms of PMDD

vit B6 - pyridoxine

78

Tx. PCOS

OCP
spironolactone - for hirsutism
clomiphene citrate - for infertility
metformin- for insulin resistance

79

rapid onset hirsutism and virilization w/o a family history - dx? next step?

consider ovarian or adrenal tumor
1. USG or CT
Tx. surgical removal of tumor

80

gradual onset hirsutism w/o virilization in 2nd-3rd decade assoc. with menstrual irregularities and anovulation. May present as precocious puberty with short stature.

CAH
- elevated serum 17 OH P4
- positive fhx

81

tx. CAH

corticosteroid replacement

82

Tx. idiopathic hirsutism

spironolactone

83

Eflornithine (vaniqa)

first line topical drug for tx. of unwanted facial and chin hair

84

confirmatory test for CAH

ACTH stimulation test

85

prevention of osteoporosis in menopausal women

weight bearing exercise
1200 mg Ca and 400-800 IU vit D

86

Dx. menopause

12 mos of amenorrhea
elevated FSH (>50) and LH (not as valuable)

87

menopause < 30 yo

POF
- could be secondary to autoimmune disease or Y chromosome mosaicism

88

MC site of osteoporosis

vertebral bodies --> crush fractures, kyphosis and decreased height

89

Dx. osteoporosis

DEXA bone scan
- T score > -2.5
(-1 to -2.5 = osteopenia)

90

First line therapy: osteoporosis

bisphosphonates
SERMS

91

second line therapy for osteoporosis

calcitonin
denosumab - RANKL inhibitor (inhibits osteoclast fxn)
teriparatide - PTH analog used if bisphosphonates fail

92

benefits of HRT

decreased rate of osteoporotic fractures
decreased rate of CRC
decreased serum lipid levels

93

risks of HRT

thromboembolic events
increased risk of dementia
increased risk of MI in combo therapy
increased risk of breast ca with combo therapy > 4yrs

94

effect of HRT on CV disease

not effective for either primary or secondary prevention

95

C/I to IUD placement

pregnancy
pelvic malignancy
salpingitis
active infection - vaginal cx prior to placement
abnormal uterine size/shape
immune suppression

96

steps in w/u of infertility

1. semen analysis
2. if semen analysis normal --> w/u for anovulation
3. if above WNL --> fallopian tube abnormalities

97

next step - abnormal semen analysis

repeat in 4-6 weeks to confirm findings

98

normal semen analysis values

volume > 2 ml
ph 7.2-7.8
sperm density > 20 million/ml
sperm motility > 50%
sperm morphology > 50 % normal

99

findings consistent with anovulation

basal body temp - no midcycle temp elevation
P4 low
endometrial histology: proliferative

100

ovulation induction

clomiphene citrate
s/e: ovarian hyperstimulation (monitor ovarian size during induction)

101

work-up for tube abnormalities

1. Chlamydia IgG - neg ab test r/o tubal adhesions due to infection
2. HSG - if normal, no further w/u
3. laparoscopy - with abnormal HSG to visualize tube and perform tuboplasty

102

RF: gestation trophoblastic disease

Taiwan/Phillipines
maternal extremes in age
folate deficiency

103

CF: gestational trophoblastic disease

bleeding from vagina < 16 weeks gestation
passage of vesicles from vagina
HTN
hyperthyroidism
hyperemesis
no fetal heart tones
bilateral theca-lutein ovarian cysts

104

management: gestational trophoblastic disease

initial eval: B-hcg, TFT, usg
CXR - r/o lung mets
suction D&C
for 6-12 mos - pt on OCP and gets weekly HCG level