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Step 3 COPY > gynecology > Flashcards

gynecology Flashcards

1
Q

bilateral nipple discharge

  • dx?
  • tests?
A

prolactinoma

tests: TSH, prolactin level

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2
Q

unilateral non-bloody nipple discharge

A

intraductal papilloma

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3
Q

w/u of nipple discharge

A

mammogram

surgical duct excision for definitive diagnosis

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4
Q

Tx, fibrocystic disease

A

OCPs

severe pain - danazol

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5
Q

steps in dx of any pt with a breast mass

A
  1. clinical breast exam
  2. imaging: USG or diagnostic mammo (>40 yo)
  3. FNA biopsy
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6
Q

Tx. fibroadenoma

A

no tx. necessary

surgical removal may be done is mass is growing

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7
Q

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

A

CBE, 6 weeks after

- if mass has recurred, get repeat USG and FNA

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8
Q

bloody aspirate from cyst must be…

A

sent for cytology

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9
Q

in what cases do you need to get mammography

A 
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
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10
Q

cluster of microcalcifications seen on mammogram - next step?

A

core biopsy

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11
Q

DCIS - next step in management

A

lumpectomy + RT +/- tamoxifen

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12
Q

LCIS - next step

A

tamoxifen for 5 years

-not necessary to perform surgery

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13
Q

risks assoc with tamoxifen

A

endometrial carcinoma

thromboembolism

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14
Q

breast ca. screening guidelines

A

mammogram every 1-2 years above age 50

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15
Q

BRCA1/2 gene testing indications

A
  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
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16
Q

when is BCT not indicated?

A
  1. pregnant pt
  2. 2+ sites in separate quadrants
  3. prior irradiation to breast
  4. positive tumor margins
  5. tumor > 5 cm
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17
Q

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

A

aromatase inhibitors - anastrazole, exemestane, letrozole

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18
Q

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

A

alternative or additional therapy to tamoxifen in pre-meno women

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19
Q

when is chemotx included in management of breast ca.

A

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

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20
Q

enlarged, firm, asymmetric and nontender uterus

A

leiomyoma

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21
Q

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

A

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

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22
Q

U/S finding in adenomyosis

A

diffusely enlarged uterus with cystic areas w/in the myometrium

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23
Q

definitive diagnosis of both adenomyosis and leiomyomas

A

histology

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24
Q

Management: leiomyomas

A
  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
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25
Q

tx. adenomyosis

A 
IUD placement (levonorgestrol)
definitive therapy: hysterectomy
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26
Q

first step in management of any pt with postmenopausal bleeding

A

endometrial biopsy

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27
Q

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

A

< 5 mm thick

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28
Q

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

A
  1. RTH - if LN mets, > 50% myometrial invasion, positive surgical margins or poorly diff. tumor
  2. CTH - metastasis
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29
Q

mngmt of simple ovarian cyst

A

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

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30
Q

when do you do laparoscopic removal of ovarian cyst

A

> 7 cm in size

previous steroid contraception w/o resolution of cyst

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31
Q

mngmt: complex (dermoid) cyst

A

laparoscopic/laparotomy removal (cystectomy or oophorectomy)

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32
Q

U/S dx of ovarian torsion

A

no blood supply seen on doppler

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33
Q

tx. ovarian torsion

A

emergent surgery

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34
Q

sudden severe lower abdominal pain in presence of adnexal mass

A

presumed to be ovarian torsion

- laparascopy should be performed

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35
Q

initial workup of ovarian mass

A

BHCG
USG
laparoscopy if > 7 cm or complex

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36
Q

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

A

germ cell tumor of ovary - MC dysgerminoma

order: LDH, B-hcg, AFP

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37
Q

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

A

ovarian ca - MC serous, epithelial tumors

order:CA125, CEA

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38
Q

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

A

granulosa thecal ovarian tumor

  • secrete estrogen and cause endo hyperplasia
    order: estrogen level
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39
Q

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

A

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

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40
Q

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

A

metastatic gastric ca to ovary (Krukenberg tumor)

marker: CEA

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41
Q

finding of ASCUS on pap in pt < 24 yo

A

repeat pap in 12 months

  • can repeat again in 12 months if ASCUS, LSIL or negative result
  • if 3x result –> get colposcopy
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42
Q

ASCUS in pt > 25 yo

A

get reflex HPV testing

colpo + biopsy only if 16 or 18 present

43
Q

endocervical curettage

A

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

44
Q

when do you perform a cone biopsy

A

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

45
Q

mngmt of CIN 2 or 3

A

ablative modalities - cryotherapy, laser

excisional modalities - LEEP, cold knife conization

46
Q

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

A 
tumor > 4 cm
mets to LN
poorly diff
positive margins
local recurrence
47
Q

ASCUS finding in pregnancy - next step?

A

colposcopy and biopsy

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

48
Q

finding of microinvasive cervical ca. in pregnancy

A

cone biopsy to ensure no frank invasion

deliver vaginally, reevaluate and tx. 2 mos postpartum

49
Q

finding of invasive cervical ca in pregnancy

A

< 24 weeks: definitive treatment

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

50
Q

initial work-up for pelvic pain

A
  1. pelvic exam
  2. cervical culture
  3. labs: ESR, WBC, bcx if fever
  4. sonogram
51
Q

outpatient mnmgt of acute salpingo-oophoritis

A

1x IM ceftriaxone + PO doxycycline

52
Q

inpatient mnmgt of acute salpino-oophoritis

A

IV cefotetan or cefoxitin + doxycycline

53
Q

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?

A

tuboovarian abscess

  • USG shows unilateral pelvic mass
  • bcx: anaerobic organisms
54
Q

Tx. tuboovarian abscess

A

cefoxitin + doxycycline

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

55
Q

primary dysmenorrhea

A

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

56
Q

tx. primary dysmenorrhea

A

NSAIDs

2nd line: OCPs

57
Q

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

A

endometriosis - endometrial glands outside the uterus

58
Q

MC sites of endometriosis

A

ovary - adnexal enlargements

cul de sac - painful rectovaginal exam, uterosacral nodularity

59
Q

diagnosis of endometriosis

A

laparoscopy

60
Q

tx. endometriosis

A

first line: OCP

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

61
Q

MCC of premenarchal bleeding

A

foreign body

62
Q

what needs to be ruled out in premenarchal bleeding

A
  1. abuse
  2. sarcoma botyroides
  3. tumor of pituitary or ovary
63
Q

Dx. testing premenarchal bleeding

A
  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
Q

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

A

pregnancy test - Bhcg

65
Q

primary amenorrhea

A

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

66
Q

amenorrhea: breasts present, uterus present

A

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

67
Q

amenorrhea: breasts absent, uterus present

A
  1. FSH level and karyotype
    FSH elevated - Turners
    FSH low - hypothalamic pituitary failure, normal karyotype
68
Q

amenorrhea: breasts present, uterus absent

A
  1. order Test levels and karyotype
    Mullerian agenesis: XX, normal testosterone for female
    testicular feminization: XY, normal test for male
69
Q

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?

A

Dx. Mullerian agenesis

Tx. surgical reconstruction of vagina for intercourse, infertility counselling

70
Q

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

A

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

71
Q

mngmt of primary amenorrhea in Turner’s syndrome

A

E and P4 replacement

72
Q

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

A

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

73
Q

tests to order in w/u of secondary amenorrhea

A
  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
Q

progesterone challenge test

A
  1. any withdrawal bleeding = anovulation
    tx. cyclic progesterone
  2. no withdrawal bleeding = estrogen inadequate or outflow obstruction –> order EPCT
75
Q

estrogen-progesterone challenge test (EPCT)

A
  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
Q

tx. of choice for PMDD

A

SSRIs - fluoxetine

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

77
Q

which vitamin may improve symptoms of PMDD

A

vit B6 - pyridoxine

78
Q

Tx. PCOS

A

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

79
Q

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

A

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

80
Q

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

A

CAH

  • elevated serum 17 OH P4
  • positive fhx
81
Q

tx. CAH

A

corticosteroid replacement

82
Q

Tx. idiopathic hirsutism

A

spironolactone

83
Q

Eflornithine (vaniqa)

A

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

84
Q

confirmatory test for CAH

A

ACTH stimulation test

85
Q

prevention of osteoporosis in menopausal women

A

weight bearing exercise

1200 mg Ca and 400-800 IU vit D

86
Q

Dx. menopause

A 
12 mos of amenorrhea
elevated FSH (>50) and LH (not as valuable)
87
Q

menopause < 30 yo

A

POF

- could be secondary to autoimmune disease or Y chromosome mosaicism

88
Q

MC site of osteoporosis

A

vertebral bodies –> crush fractures, kyphosis and decreased height

89
Q

Dx. osteoporosis

A

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

90
Q

First line therapy: osteoporosis

A

bisphosphonates

SERMS

91
Q

second line therapy for osteoporosis

A

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

92
Q

benefits of HRT

A

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

93
Q

risks of HRT

A

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

94
Q

effect of HRT on CV disease

A

not effective for either primary or secondary prevention

95
Q

C/I to IUD placement

A 
pregnancy
pelvic malignancy
salpingitis
active infection - vaginal cx prior to placement
abnormal uterine size/shape
immune suppression
96
Q

steps in w/u of infertility

A
  1. semen analysis
  2. if semen analysis normal –> w/u for anovulation
  3. if above WNL –> fallopian tube abnormalities
97
Q

next step - abnormal semen analysis

A

repeat in 4-6 weeks to confirm findings

98
Q

normal semen analysis values

A 
volume > 2 ml
ph 7.2-7.8
sperm density > 20 million/ml
sperm motility > 50%
sperm morphology > 50 % normal
99
Q

findings consistent with anovulation

A

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

100
Q

ovulation induction

A

clomiphene citrate

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

101
Q

work-up for tube abnormalities

A
  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
Q

RF: gestation trophoblastic disease

A

Taiwan/Phillipines
maternal extremes in age
folate deficiency

103
Q

CF: gestational trophoblastic disease

A 
bleeding from vagina < 16 weeks gestation
passage of vesicles from vagina
HTN
hyperthyroidism
hyperemesis
no fetal heart tones
bilateral theca-lutein ovarian cysts
104
Q

management: gestational trophoblastic disease

A

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

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