Gynecology - GU disorders + STIs

Question 1

PID will often present after

Answer 1

a period - blood is a good culture medium

Question 2

always do cervical motion tenderness as a

Answer 2

1 handed exam! DO NOT put nondominant hand on abdomen when doing it!

Question 3

Herpes crossing midline - is this primary or secondary infection?

Answer 3

Primary

Herpes DOES not cross midline in recurrences - if it does, suggests primary infection

Question 4

Labial fusion

Answer 4

Assoc w/ excess androgens
- usually result of exogenous androgen exposure

Most common enzyme deficiency = 21 hydroxylase deficiency —> CAH

Tx = reconstructive surgery

Question 5

Tx 21 hydroxylase d/o

Answer 5

Exogenous cortisol

Will feedback to decrease ACTH to decrease adrenal gland hormone secretion

Question 6

Imperforate hymen

Answer 6

Central portion epithelial cells of hymenal membrane fail to degenerate and form hymenal ring

Usually dx at puberty in adolescents who p/w primary amenorrhea and cyclic pelvic pain.

Tx
- surgery to excise the extra tissue, evacuate any obstructed material, and create a normal sized vaginal opening

Question 7

Transverse vaginal septum

Answer 7

Usually at lower 2/3 of vagina

Failure of mullerian tubercle to be cannalized

P/w primary amenorrhea and cyclical pain

Normal external genitalia
Vagina ends in blind pouch 2/2 septum

Tx = surgery

Question 8

Vaginal atresia

Answer 8

• lower vagina fails to develop and is replaced by fibrous tissue.
• ovaries, uterus, cervix, and upper vagina are all normal.
• usually happens when urogenital sinus fails to contribute
  the lower portion of the vagina
• presents during adolescence with primary amenorrhea and cyclic pelvic pain.

PE

• absence of introitus
• presence of vaginal dimple

MRI/US can show large hematocolpos
Confirm nl upper repro tract

Tx

• surgery
• incise fibrous tissue and dissect until nl upper vagina ID’d
• the normal upper vaginal mucosa is then brought down to the introitus and sutured to the hymenal ring

Question 9

Vaginal agenesis

Answer 9

aka Mayer-Rokitansky-Kuster-Hauser syndrome

Congenital absence of vagina
+
absence/hypoplasia of all or part of the cervix, uterus, and fallopian tubes

Features:

• nl external genitalia
• nl secondary sexual characteristics (breast development, axillary, and pubic hair),
• bl ovarian function.
• phenotypically and genotypically female

Usually present in adolescence with primary amenorrhea.

Tx:

• nonsurgical - create vagina using serial vaginal dilators pessed into perineal body (4mo - several yrs)
• surgery to create neovagina

Fertility

• after surgery, sex is ok
• pt can’t carry preggers - can harvest eggs for gestational surrogate though

Question 10

Lichen sclerosis of vulva

Answer 10

Inflammatory dermatosis

Symmetric white, thinned skin on labia, perineum adn perianal region
- shrinkage and agglutination of labia minora

Usually in postmenopausal women

3-4% Inc risk vulvar cancer

Sx:

• pruritus
• dyspareunia
• usually no sx

Dx:
- always get bx to r/o vulvar SCC

Tx:
- high potency topical steroids (clobetasol or halobetasol)

Question 11

Lichen planus of vulva

Answer 11

Multiple shiny, flat, red-purple papules usually on inner aspects of labia minora
- often erosive

Assoc w/ vaginal adhesions and erosive vaginitis

Usually in 50s-60s

Same as lichen sclerosis 3-4% inc risk of cancer

Sx:
- puruitus with mild inflammation –> severe erosions

Tx:
- high potency topical steroids (clobetasol or halobetasol)

Question 12

Lichen simplex chronicus of vulva

Answer 12

thickened skin w/ accentuated skin markings and exocriations 2/2 chronic itching and scratching

Itching 2/2 many conditions (atopic dermatits, psoriasis, etc)

Tx:
- medium to high potency topical steroid

Question 13

When do you bx benign lesions of vulva presenting with vulvar itching, irritation, burning?

Answer 13

Ulceration
Unifocal lesions
Uncertain suspicion of lichen sclerosis
Lesions or sx persisting after tx

Use colposcope!

Question 14

1 tumor found on vulva

Answer 14

Epidermal inclusion cysts

- 2/2 blocked pilosebaceous duct or blocked hair follicle

Question 15

Fox fordyce disease

Answer 15

Chronic pruritic papular eruption that localizes to areas where apocrine glands are found

Question 16

Hidradenitis suppurativa

Answer 16

Skin dz most commonly affecting areas of apocrine sweat glands or sebaceous glands

Infected areas –> form multiple abscesses –> need I&D

Question 17

Where are skene’s glands?

Answer 17

next to urethra meatus

Question 18

Suspected bartholin’s dcut cyst - what do you do?

Answer 18

If > 40 yo, need to do bx to rule out rare Bartholin’s gland carcinoma

Usually self resolving

If cyst is large, can lead to abscesses and need I&D or word catheter placement

Marsupialization for recurrent duct cysts/abscesses

Warm sitz baths recommended

Question 19

Gartner’s duct cysts

Answer 19

remnants of mesonephric ducts of wolfiann system

usually in upper part of vagina

Question 20

DES exposure in utero…resulting risks?

Answer 20

Cervical lesions (cervical hoods, cervical collars, cervical hypoplasia, etc)

Cervical insufficiency in preggers

Clear cell adenocarcionma of cervix

Question 21

Most cervical cysts are

Answer 21

Dilated retention cysts called nabothian cysts

Caused by intermittent blockage of endocervical gland

Usually no sx

Question 22

Origins of reproductive structures

Answer 22

All arise from mullerian system except ovaries (from genital ridge) and lower 1/3 of vagina (from urogenital diaphragm)

Question 23

Many uterine abnormalities can be associated with

Answer 23

Inguinal hernias

Urinary tract anomalies

Question 24

Uterine septae vs bicorunate uterus in preggers

Answer 24

Uterine septae
- usually suffer from recurrent 1st trimester loss as septae is not vascularized so placenta can’t implant

Bicornuate uterus
- second trimester pregnancy loss, malpresentation, preterm labor and delivery

Question 25

Uterine leiomyoma

Answer 25

Benign proliferations of smooth muscle cells of myometrium Usually happen in women of childbearing age Regress during menopause Hormonally response to estrogen and progesterone

Question 26

Classification of leiomyomas Characteristics

Answer 26

Submucosal (beneath endometrium) - usually assoc w/ heavy or prolonged bleeding Intramural (in muscular wall of uterus) - most common Subserosal (beneath uterine serosa)

Question 27

Fibroids vs adenomyosis

Answer 27

Fibroids have pseudocapsule - compressed areolar tissue + smooth muscle cells - little blood vessels - as fibroids enlarge, can outgrow blood supply, infarct, and degenerate, causing pain Adenomyosis tends to be more diffusely organized in myometrium MRI to distinguish between the two!

Question 28

Ways to dx fibroids?

Answer 28

Pelvic US Can also use HSG, saline infusion sonogram, and hysteroscopy for location and size of uterine fibroids - good for submucosal ones

Question 29

Medical therapies for Uterine Leiomyomas

Answer 29

GO PAN AM ``` GnRH agonists (leuprolide, nafarelin) OCPs ``` Progestins (mirena IUD, medroxyprogesterone) Antifibrinolytics (tranexamic acid) NSAIDs ``` Androgenic steroids (danazol) Mifepristone ```

Question 30

Indications for surgical intervention for uterine leiomyomas

Answer 30

Abnl uterine bleeding -----> anemia Severe pelvic pain or secondary amenorrhea Uterine size > 12 wk obscuring eval of adnexa Urinary freq, retention, hydronephrosis Growth after menopause Recurrent miscarriage or infertility Rapid increase in size Tx: - uterine artery embolization (not for those wanting more fertility and large and pedunculated fibroids) - MRI-guided high intensity ultrasound (premenopausal, done with kids) - myomectomy (want fertility) - hysterectomy

Question 31

Endometrial polyps

Answer 31

Benign overgrowths of endometrial glands and stroma over vascular core Usually in 40s-50s Tamoxifen women at risk Present w/ abnl vaginal bleeding Eval w/ US, sonohysterogram, hysteroscopy Tx - can be malignant or premalignant so remove in all postmenopausal; premenopausal remove too

Question 32

Endometrial hyperplasia

Answer 32

Source of abnl uterine bleeding Abnl prolif of both glandular adn stromal elements of endometrium Can happen when endometrium exposed to continuous estrogen w/o progesterone Risk endometrial carcionma Dx: - bx in office - D&C

Question 33

Risks for endometrial hyperplasia

Answer 33

Unexposed estrogen exposure ``` Obesity Nulliparity Late menopause exogenous estrogen w/o progesterone Tamoxifen use HTN DM Lynch II syndrome ```

Question 34

Tx endometrial hyperplasia

Answer 34

Simple + complex atypia - progestin therapy (depoprovera or provera) - repeat EMB for regression Atypical hyperplasia - D&C eval - hysterectomy if no kids in future - if want kids, progestin management, repeat EMB at 3 months -----> if persistence after 9 months, hysterectomy recs

Question 35

Functional cysts of the ovaries

Answer 35

Follicular (most common) | Corpus luteum

Question 36

Follicular cysts of ovary

Answer 36

Most common Happen after failure of follicle to rupture during follicular maturation phase of menstrual cycle Usually resolve spontaneously in 2-3 months Simple cysts < 2.5cm are physiologi

Question 37

Corpus luteum cysts of ovary

Answer 37

Occur during luteal phase Happen when corpus luteum fails to regress after 14d and becomes enlarged or hemorrhagic Can rupture!

Question 38

Theca lutein cysts of ovary

Answer 38

Large bilateral cysts filled w/ clear straw colored fluid 2/2 stim from abnormally high bhCG (eg molar preggers, choriocarcionma, ovulating induction)

Question 39

Endometriomas

Answer 39

Ectopic endometrial tissue within ovary Aka "chocolate cysts"

Question 40

Endometriosis

Answer 40

Endometrial tissue outside of the uterus Sx: cyclic pelvic pain beginning 1 or 2 weeks before menses, peaking 1 to 2 days before the onset of menses, and subsiding at the onset of menses or shortly thereafter. #1 dx in eval of infertility in couples

Question 41

Dysmenorrhea starting in 3rd decade, worsen with age...what do you worry about? Previously pain free cycles

Answer 41

Endometriosis

Question 42

Only way to definitively dx endometriosis

Answer 42

Laparoscopy or laparotomy...surgery!

Question 43

Tx endometriosis

Answer 43

No role for med therapy in those planning to conceive NSAIDs Suppress ovulation and menstruation: Combo contraceptives Progestins (suppress menstruation) Suppress LH and FSH --> no estrogen: Danazol GnRH agonist Aromatase inhibitors off label

Question 44

Adenomyoma

Answer 44

A well-circumscribed collection of endometrial tissue within the uterine wall. They may also contain smooth muscle cells and are not encapsulated (no pseudocapsule like fibroid)

Question 45

Adenomyosis

Answer 45

An extension of endometrial tissue into the uterine myometrium leading to abnormal bleeding and pain. The uterus becomes soft, globular due to hypertrophy and hyperplasia of the myometrium adjacent to the ectopic endometrial tissue usually most extensive in the fundus and posterior uterine wall. MRI to dx

Question 46

Tx adenomyosis

Answer 46

Extends from the basalis layer of the endometrium, it does not undergo the proliferative and secretory changes traditionally seen in normally located endometrium or in endometriosis. adenomyosis is less responsive to treatment with OCPs or other hormonal treatments. Progestin-containing IUD and hysterectomy are the most effective means of treatment.

Question 47

Tx UTI

Answer 47

Initial: - TMP/SMX - nitrofurantoin - fluoroquinolone

Question 48

#1 cause vulvitiss

Answer 48

candidiasis

Question 49

Syphilis - dx - tx

Answer 49

Dx - dark field microscopy - rpr/mha-tp - fta-abs Tx - PCN

Question 50

Herpes - dx - tx

Answer 50

Dx - viral cx - Tzanck smear but not sensitive or specific Tx - acyclovir

Question 51

Chancroid (H. ducreyi) - dx - tx

Answer 51

Dx - gm stain with "school of fish" appearance Tx - Ceftriaxone - azithromycin OR cipro, erythromycin

Question 52

Lymphgranuloma venereum (C. trachomatis) - dx - tx

Answer 52

Dx - complement fixation Tx - Doxycycline or - erythromycin

Question 53

Lesions of syphilis

Answer 53

Primary - painless - red, round firm ulcer with raised edges = chancre - 3 weeks after inoculation - reginal adenopathy Secondary - disseminated - 1-3 mo after primary - flu like sx and myalgias - maculopapular rash on palms and soles

Question 54

How long do VDRL or RPR tests remain + after tx syphilis

Answer 54

6-12 months Will have progressively decreasing antibody titers Repeat these test 1 and 3 months after appearance of ulcer in compliant patient Always confirm a positive with FTA_ABS test adn T. pallidum particle agglutination assay (TTPA)

Question 55

Jarisch Herxheimer reaction

Answer 55

Acute febrile reaction freq accompanied by fever, chills, HA, myalgia, malaise, pharyngitis, rash Happens after any tx for syphilis Transient 2/2 marked systemic release of cytokines

Question 56

Course of primary infection HSV

Answer 56

Flu like sx Vulvar burning and pruritis precede... Multiple vesicles persisting for 24-36 hrs Painful genital ulcers lasting 10-22 days

Question 57

Tx HPV condyloma acuminata/genital warts

Answer 57

Local excision CO2 laser Cryotherapy Topical Trichloroacetic acid Topical podophyllin 5-FU cream Uncomplicated: - imiquimod - podofilox

Question 58

Where does molluscum occur?

Answer 58

anywhere on skin except palms of hands and soles of feet Usually self resolving but can remove w/ local excision, cryotherapy, or TCA

Question 59

Scabies vs pubic lice

Answer 59

Pubic lice usually confined to pubic hair but scabies can spread throughout body!

Question 60

Tx pubic lice

Answer 60

permethrin

Question 61

Tx scabies

Answer 61

permethrin or ivermectin

Question 62

Risk factors for Bacterial vaginosis

Answer 62

``` Mult sex partners Cigarettes Douching Lack of vaginal lactobacilli Fem sex partners ```

Question 63

Dx bacterial vaginosis

Answer 63

3 of findings needed: 1) thin, white homogeneous discharge coating vaginal walls 2) fishy odor when + 10% KOH 3) pH > 4.5 4) Clue cells (vaginal epithelial cells covered with bacteria) on microscopy

Question 64

Tx bacterial vaginsosi

Answer 64

Metronidazole oral or Clindamycin oral Can use topical but not as effective

Question 65

Dx candidiasis

Answer 65

Microscopy exam of KOH prep of vaginal discharge | - hyphae & spores seen better

Question 66

Tx candidiasis

Answer 66

Topical: - miconazole - terconazole Oral - fluconazole

Question 67

Dx T. vaginalis

Answer 67

Profuse d/c with unpleasant odor (any color) +/- frothy Vaginal pH 6-7 Vulvar erythema Strawberry cervix Sx usually worse after menses b/c transient increase in vaginal pH at that time

Question 68

Tx T. vaginalis

Answer 68

Metronidazole oral Tinidazole oral Tx both partners!!!!!!!!

Question 69

Most common causes of cervicitis

Answer 69

N. gonorrhea C. trachomatis

Question 70

Dx and Tx gonorrhea

Answer 70

Dx - nucleic acid amplification tests Tx - ceftriaxone (IM or oral) - azithromycin or doxy for concaminant C. trachomatis infection

Question 71

Tx chlamydia

Answer 71

Usually asymptomatic! Azithromycin (oral) Doxycycline (oral)

Question 72

Screening for chlamydia?

Answer 72

Annual for sexually active women <=25yo, older women with risk factors, and all preggers Common sites for infection = endocervix, urethra, rectum

Question 73

When do you use abx as ppx to prevent endometritis?

Answer 73

C section Surgical terminations of pregnancy Hysterosalpingography & Sonohysterography if woman has hx pelvic infxn or tubes dilated NOT RECOMMENDED IN: - hysteroscopy - endometrial ablation - endometrial bx - IUD placement

Question 74

Tx endometritis or endomyometritis

Answer 74

Unrelated to pregnancy - same as PID --> broad spectrum cephalosporin (cefoxitin or cefotetan) + doxycycline IV Postpartum endomyometritis: - clinda + gentamicin IV Continue until clinical improvement + afebrile for 24-48 hrs

Question 75

Definitive dx of PID

Answer 75

Laparoscopy Endometrial bx Pelvic imaging with PID findings

Question 76

Fitzhugh Curtis syndrome

Answer 76

Perihepatitis from ascending infection resulting in RUQ pain and tenderness LFT elevation

Question 77

Tx PID

Answer 77

Inpatient Broad spectrum cephalosporin (cefoxitin or cefotetan) IV or IV clinda + gentamycin if cephalosporin allergic + Doxycycline IV Continue until clinical improvement for 24 hrs Continue doxy oral for total 14 day course If need to be outpatient... IM ceftriaxone x1 + probenecid oral + oral doxy x14 days

Question 78

Tuboovarian abscess

Answer 78

Usually 2/2 persistent PID Usually not walled off though so more responsive to abx Same tx as PID but may need to drain abscess

Question 79

Imaging to dx tuboovarian abscess vs tuboovarian complex

Answer 79

US May need CT if obese

Question 80

Toxic shock syndrome

Answer 80

Staph aureus producing TSST-1 ``` High fever HYPOtn Diffuse erythematous macular rash desquamation of palms adn soles GI disturbances Renal disturbance Thrombocytopenia ``` Blood cx often negative

Question 81

Tx TSS

Answer 81

IV hydration Abx only decreases risk of recurrence, not shorten length of infection Clinda + vanco

Question 82

Preexposure ppx of HIV

Answer 82

Tenofovir disiproxil fumarate + Emtricitabine

Question 83

Nucleoside analogs for HIV tx

Answer 83

``` Zidovudine Lamivudine Abacavir Didanosine Stavudine ```

Question 84

Protease inhibitors for HIV tx

Answer 84

``` Lopinavir Atazanavir Indinavir Saquinavir Ritonavir ```

Question 85

Lowering vertical transmission rate of HIV

Answer 85

Ziovudine in 2nd trimester ---> reduce viral load by 3rd trimester C/s NO breastfeeding

Question 86

Sx interstitial cystitis

Answer 86

Pelvic pain - usually relieved by voiding Dyspareniua Urinary freq, urgency CYstoscopy - submucosal petechiae or ulcerations

Question 87

Pelvic congestion syndrome

Answer 87

is a cause of chronic pelvic pain occurring in the setting of pelvic varicosities. The cause of pelvic vein congestion is unknown. Hormonal factors contribute to vasodilatation when pelvic veins are exposed to high concentration of estradiol, which inhibits reflex vasoconstriction of vessels, induces uterine enlargement with selective dilatation of ovarian and uterine veins. Pain worse premenstrually and during pregnancy, and is aggravated by standing, fatigue and coitus. The pain is often described as a pelvic “fullness” or “heaviness,” which may extend to the vulvar area and legs. Associated symptoms include vaginal discharge, backache and urinary frequency. Menstrual cycle defects and dysmenorrhea are common. No signs of pelvic floor relaxation were noted on exam.

Question 88

Nerves at risk for nerve entrapment syndrome 2/2 surgery from low transverse incision include

Answer 88

``` iliohypogastric nerve (T-12, L-1) - cutaneous sensation to the groin and the skin overlying the pubis ``` ilioinguinal (T-12, L-1) nerve. - cutaneous sensation to the groin, symphysis, labium and upper inner thigh. These nerves may become susceptible to injury when a low transverse incision is extended beyond the lateral border of the rectus abdominus muscle, into the internal oblique muscle. Damage to the obturator nerve, which can occur during lymph node dissection would result in the inability of the patient to adduct the thigh.

Question 89

Best time to obtain prolactin level

Answer 89

Stimulation of the breast during the physical examination may give rise to an elevated prolactin level. Accurate prolactin levels are best obtained with patients fasting.

Question 90

Any solid dominant breast mass on exam should be evaluated

Answer 90

cytologically, with a fine needle aspiration (FNA), or histologically, with an excisional biopsy

Question 91

Blood discharge breast mass...what do you do?

Answer 91

excisional biopsy be performed to rule out breast cancer, even if aspriation (bloody) drains the mass If clear discharge is obtained on aspiration and the mass resolves, reexamination in two months is appropriate to check that the cyst has not recurred.

Question 92

Definitive surgery for endometriosis

Answer 92

Hysterectomy + BSO Need BSO or continued pain will happen and re-op needed!

Question 93

best way to begin a workup for an incidental finding of an adnexal mass

Answer 93

transvaginal ultrasound

Question 94

BV vs T. vaginalis vs. candida

Answer 94

Trich - inflammation - pruritus - white SMELLY discharge BV - no inflammation Candida - thick discharge, white

Question 95

Tx vaginismus

Answer 95

relaxation Kegels Insertion of dilators, fingers, etc to desensitize

Question 96

Atrophic vaginitis

Answer 96

usually in post-menopausal fem 2/2 decreased estrogen levels Tx: - moisturizers and lubricants - low dose vaginal estrogen therapy

Question 97

Young woman p/w breast lump, no obvious signs of malignancy, what do you do next?

Answer 97

Ask to return after menstrual period for reexam - may have shrunk mass Benign likely if mass shrunk If not, can do US, FNA, and/or excisional bx

Question 98

Abdominal pain in young female in middle of her cycle w/ benign hx and clinical exam most likely...

Answer 98

Mittelschmerz (midcycle pain) ``` Pain lateralizes (unilateral) to ovary that produced mature ovum Sudden onset not too severe pain Nonradiating No N/V/F/C ``` vs PID which is bilateral vs ovarian torison which is sudden onset, radiates to groin or back, + N/V, +/- adnexal mass

Question 99

Copious vaginal d/c White or yellow NOT malodorous No other sx or findings on vaginal exam

Answer 99

PHysiologic leukorrhea No tx necessary, reassure

Question 100

What side torsion of ovary more common

Answer 100

Right 2/2 longer length of R utero-ovarian ligament L rectosigmoid colon occupies space around L ovary Vaginal bleeding is uncommon!!!!

Question 101

Physiologic galactorrhea

Answer 101

Usually b/l Most commonly milky; can be yellow, brown, gray, green Hyperprolactinemia is most commono cause Eval with Prolactin, TSH, possible brain MRI

Question 102

#1 cause mucopurulent cervicitis

Answer 102

Chlamydia