Gynecology APGO uWise

Question 1

Dysmenorrhea + Dyspareunia

What else?

Answer 1

Endometriosis

- nodularity on uterosacral ligament

Question 2

Endometrial glands embedded in wall of uterus

Answer 2

Adenomyosis

Question 3

Oligomenorrhea in an overweight patient?

Answer 3

Polycystic ovarian syndrome

Question 4

Inability to conceive for 1 year +
Dysmenorrhea + dyspareunia
Palpable, tender adnexal mass
Complex ovarian cyst
Simple cyst

Answer 4

Endometriosis = endometrial glands outside the uterine cavity

Question 5

Complex ovarian cyst

Answer 5

Endometrioma

- chocolate cyst

Question 6

Conservative management for endometriosis?

Answer 6

OCP’s

NSAIDs

Question 7

Treatment for severe endometriosis w/ failed conservative medical management (OCP’s)?

Answer 7

Surgery to manage symptoms
- conservative: ablation, excision
- definitive (total hysterectomy/BSO)
So in young pt who desires pregnancy, laser ablation if no adnexal masses and ovaries are not enlarged.

Question 8

Why OCP’s for conservative treatment of endometriosis?

Answer 8

Get - feedback to pituitary-hypothalamic axis

• this stops stimulation of ovary
• this suppresses sex hormone production (E)
• Estrogen normally stimulates endometrial tissue and we want this suppressed

Question 9

Danazol

• indications?
• SE’s?

Answer 9

• synthetic androgen
  
  • used to treat endometriosis
    SE: androgenic side effects Dan the Man
• wt gain + hair + ache + lipid levels

Question 10

GnRH

- indications?

Answer 10

Can only be used short-term

• control pelvic pain in endometriosis pt only if unresponsive to other hormone treatments
• have more side effects that OCP’s when treating endometriosis

Question 11

Test/procedure to confirm endometriosis?

Answer 11

Diagnostic laparoscopy

Biopsies

Question 12

Complex ovarian cyst

- how differentiate?

Answer 12

1. ) Symptoms of endometriosis? (dysmenorrhea + dyspareunia)
2. ) Mid-cycle: think hemorrhagic cyst
3. ) Obese + oligomenorrhea: think PCOS

Question 13

Complex ovarian cyst

• 48yo smoker
• next best step?

Answer 13

Repeat U/S in 2 months
- if mid cycle will resolve on it’s own
OCP’s are contraindicated in 35+ smoker

Question 14

Ovarian mass w/ sudden onset severe pain + nausea

Answer 14

Ovarian torsion

Question 15

Severe RLQ pain + nausea + tachycardia + ovarian mass + free fluid in pelvis + hematocrit 29%…next step?

Answer 15

Surgical exploration

• likely ovarian torsion
• already did U/S
• ovarian torsion requires immediate surgical attention

Question 16

Endometriosis + unable to conceive for 18 months + otherwise negative workup…next step to help fertility?

Answer 16

1.) Clomiphene citrate: stimulate ovulation
2.) Intrauterine insemination is also option
If these fail…in vitro fertilization or adoption

Question 17

Urinary frequency, urgency, nocturia
Mild cystocele + rectocele
Post-void volume = 400cc

Answer 17

Overflow incontinence: failure to empty bladder adequately
1.) Underactive detrusor (DM, MS, neuro)
2.) Obstruction (postop, severe prolapse)
Normal post-void residual = 50-60cc

Question 18

What is mixed urinary incontinence?

Answer 18

Stress incontinence

Urge incontinence

Question 19

Risk factors for pelvic organ prolapse?

Answer 19

Increased age, obesity, CT disorders (Ehlers-Danlos) + chronic constipation + vaginal delivery
Also: family hx of prolapse!

Question 20

Urinary leakage w/ cough, sneeze, lift
Vaginal deliveries infants > 9lbs
Previous hysterectomy + BSO
Post-void volume = normal
Q-tip test = straining angle 60 degrees
Pt failed kegel exercises

Answer 20

Stress incontinence - increased and pressure in absence of detrusor contraction
Most due to urethral hypermobility
Straining Q-tip > 30 degrees from horizon
Very occasionally due to sphincter deficiency of urethra

Question 21

Surgery for stress incontinence?

Answer 21

Retropubic urethropexy: tension free vaginal tape or sling procedure best 5-year rates.

Question 22

Intrinsic sphincter deficiency; best first treatment?

Answer 22

Urethral bulking procedure

• constant leaking of urine
• previous cystocele repairs

Question 23

Treat stress incontinence?

Answer 23

Urethral bulking procedure/injection
- reduces diameter of urethra, creating resistance to leakage
Sling procedure: voiding difficulties are significant
Pseudoephedrine: improve urethral tone
Kegel: strengthen pelvic floor m. and decrease urethral hyper mobility

Question 24

Uninhibited detrusor contractions upon bladder filling. Treatment?

Answer 24

Oxybutynin:

• ACh transmits parasympathetic signal for bladder emptying via muscarinic receptors
• Anticholinergics = mainstay of medical management

Question 25

Treat pelvic protrusion: Symptoms of vaginal pressure + heaviness (large pelvic prolapse)

Answer 25

1. ) Pessary: ring to support = initial treatment 2. ) Pubocervical fascia plicated in midline and laterally to acrus tendineus fascia (white line) to fix: - - - - white line = fix cystocele

Question 26

Urgency, nocturia + large urine loss for several seconds. Post-residual volume - 50cc Urine loss standing or sitting, not activity related

Answer 26

Urge incontinence: - overactive detrusor muscle - get uninhibited contractions - increase in bladder pressure over urethral pressure = leakage

Question 27

Associated defects related to urge incontinence?

Answer 27

Structura/ mechanical defects of: - cystocele - urethrocele

Question 28

Asymptomatic pelvic prolapse

Answer 28

NO intervention necessary | Observation

Question 29

``` 90yo w/ apex/ant/post vaginal prolapse Cardiac + DM Hydronephrosis due to prolapse Can't urinate w/o reduction of prolapse Best next step? ```

Answer 29

Colpocleisis - removal of ant/post vaginal wall - small vaginal canal will exist For women who are no longer sexually active

Question 30

Two ways to treat Gon/Chla IV?

Answer 30

1. ) Cefotetan/xitin + Doxycycline | 2. ) Clindamycin + Gentamicin

Question 31

Outpatient treatment of Gon/Chla?

Answer 31

Ceftriaxone (3rd gen) + Doxycycline +/- Metronidazole

Question 32

What does metronidazole cover?

Answer 32

Anaerobic + protozoal infections - treat C. diff assoc diarrhea - great against H. pylori & Gardnerella v.

Question 33

Acute cystitis in healthy, non-pregnancy women cause?

Answer 33

E. coli in 85% of cases | Also: Staph saprophyticus, Klebsiella, Enterococcus, Proteus.

Question 34

Young F cramping + low pelvic pain | Urinating much more frequently

Answer 34

UTI: do urine analysis

Question 35

What does Clindamycin cover?

Answer 35

Treats anaerobes + streptococcal + staphylococcal infections. Causes C. diff.

Question 36

Doxycycline covers?

Answer 36

Chronic bronchitis | Weird bacteria: H. flu, Moraxella, Legionella, Mycoplasma, Chlamydia

Question 37

How reduce risk of ovarian cancer in young female?

Answer 37

OCP's - five years continuous use reduces risk by 1/2 - but total risk is 1% per female if no family hx

Question 38

How screen pt for ovarian cancer?

Answer 38

BRCA1 & 2 mutations typically seen in hereditary ovarian cancers. So if mom has breast cancer, test mom for BRCA1/2. BRCA covers breast & ovarian cancers.

Question 39

Unilocular simple cyst without evidence of blood, soft tissue elements or excrescences +/- symptoms Fluctuates w/ cycle

Answer 39

Functional ovarian cyst - Serous cyst adenoma's are typically much larger than functional ovarian cysts - Mucinous cystadenoma are multilocular and quite large