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EOR Exam - Women's Health > Gynecology Part 2 > Flashcards

Gynecology Part 2 Flashcards

1
Q

Define pelvic inflammatory disease (PID).

A

Ascending infection of the female gynecological tract.

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2
Q

What are the S/S of PID?

A

Typically asymptomatic until late disease.
S/S: abnormal vaginal discharge, LQ pain, inter-menstrual or post-coital bleeding, fever, N/V
PE: uterine and adnexal tenderness, cervical motion tenderness (chandelier sign) mucopurulent discharge from cervix, friable cervix

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3
Q

What are the complications associated with PID?

A

Adhesions causing chronic pelvic pain
Infertility s/p tubal occlusion
Ectopic pregnancy s/p salpingitis
Fitz-Hugh-Curtis Syndrome –> inflammation of liver capsule with no involvement of parenchyma, adhesion formation, RUQ pain

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4
Q

What are the risk factors for PID?

A

Age < 25, multiple partners or partners with multiple partners, Hx of STI, inconsistent condom use

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5
Q

List the diagnostic criteria for PID.

A

Sexually active and age = 25 or Hx of STI … AND …
Tenderness on pelvic exam … AND …
No other etiology

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6
Q

How is PID treated?

A

Outpatient: ceftriaxone IM x 1 and doxycycline x 14 days - add metronidazole if bacterial vaginosis present
Inpatient: 24 hours of IV abx (cefotetan/cefoxitin - 2nd gen) then sent home with doxycycline x 14 days

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7
Q

What are the indications for inpatient treatment of PID?

A

Pregnancy, no response to outpatient treatment, presence of severe fever, nausea, or vomiting

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8
Q

What is likely to result from persistent PID?

A

Tubo-ovarian abscess

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9
Q

How is the diagnosis of tubo-ovarian abscess made?

A

S/S of PID, adnexal or posterior cul-de-sac mass on PE, LQ pain, fever, leukocytosis with left shift

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10
Q

How is tubo-ovarian abscess treated?

A

Broad spectrum abx –> same as PID. Some may require surgical drainage.

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11
Q

What are the most common STIs that result in PID?

A

Chlamydia and gonorrhea

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12
Q

What is the image test of choice to evaluate for tubo-ovarian abscess?

A

transvaginal US –> may also use CT to r/o other causes of surgical or acute abdomen

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13
Q

Define endometritis. What is the name for the infection if it invades the myometrium?

A

Infection of the endometrium. Invasion into myometrium = endomyometritis

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14
Q

What are the risk factors for endometritis?

A

Retained placenta, STIs, IUD placement

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15
Q

What are the diagnostic criteria for endometritis?

A

Uterine tenderness on bimanual exam, fever, leukocytosis

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16
Q

What are the symptoms of chronic endometritis?

A

Patients are asymptomatic

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17
Q

What is the treatment for endometritis?

A

Clindamycin, gentamycin, or cephalosporins –> continue until clinical improvement or afebrile.

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18
Q

What is the causative organism of syphilis?

A

Treponema Pallidum

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19
Q

What is the testing done for syphilis and when is it performed?

A

RPR: quick but non-specific, used for screening
Treponema 3 Test - blood test for syphilis abs
Performed as part of standard STI and pre-natal screening

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20
Q

How is a person tested for syphilis if they previously had the disease?

A

Treponema tests will remain positive for life and thus, may show a false positive in someone that has recovered from the disease. A positive treponema test should be followed by a quantitative non-treponema test to confirm diagnosis and guide management.

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21
Q

Describe the stages of syphilis.

A

Primary: painless ulcer (chancre). Highly infectious stage that lasts 3-6 weeks
Secondary: Maculo-papular rash on palms and soles, flat genital wart, and systemic s/s lasting 2-6 weeks
Latent: asymptomatic –> can last 1 - 60 years
Tertiary: cardiovascular, skin, bone, and neuro symptoms that may be permanent.

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22
Q

What is the treatment for syphilis?

A

Early: PCN G Benzathine IM x 1
Late: PCN G Benzathine IM once per week for 3 weeks
Neuro: PCN G IV for 10 - 14 days

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23
Q

How is a patient with a PCN allergy treated for syphilis?

A

PO doxycycline/tetracycline x 14 days

Doxy/tetra contraindicated in pregnancy. Pregnant patient allergic to PCN requires PCN sensitization.

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24
Q

What is tabes dorsalis?

A

Demyelination of the dorsal columns causing loss of proprioception, vibration, fine touch, DTRs, and high step gate –> part of neurosyphilis

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25
Q

Describe the pathophysiology of bacterial vaginosis (BV).

A

Loss of lactobacilli –> decreased hydrogen peroxide production –> higher than normal (4.5) pH –> overgrowth of other microbes (mostly Gardnerella)

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26
Q

What S/S are associated with BV?

A

Fishy odor and thin white/gray discharge

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27
Q

Describe the amine whiff test as it relates to BV.

A

A secretion sample is mixed with KOH. If positive for BV, it will produce a fishy, amine-like odor.

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28
Q

Is the causative organism in BV gram negative or gram positive?

A

Typically, the predominant microbe in BV is gram negative.

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29
Q

What abx are most commonly used to treat BV?

A

Metronidazole or clindamycin

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30
Q

What is found on microscopy in BV?

A

Clue cells –> stippled epithelial cells

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31
Q

How should a patient with BV be counseled?

A

Educate on vulvovaginal health –> no douching, no soaps

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32
Q

What are the S/S of a vaginal candidiasis infection?

A

itching/burning, thick white discharge, dyspareunia, beefy red vaginal mucosa

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33
Q

How is vaginal candidiasis treated?

A

Fluconazole PO, 150mg x 1 - may consider 2nd dose at 72 hours for severe disease. May also use 7 day course of -azole vaginal cream.

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34
Q

What chronic medical condition predisposes patients to recurrent vaginal candidiasis?

A

DM –> hyperglycemia enhances candidiasis ability to bind to vaginal epithelium.

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35
Q

What type of pathogen causes trichomonas?

A

A parasitic protozoan.

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36
Q

What are the S/S of trichomonas?

A

Men are often asymptomatic. Females present with itching, burning, post-coital bleeding, dysuria, frothy white/gray discharge.

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37
Q

What is the hallmark sign of trichomonas seen on pelvic exam?

A

Strawberry cervix –> only seen in about 10% of patients but is pathognomonic for trichomonas when present.

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38
Q

What is the treatment for trichomonas?

A

Metronidazole - PO only

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39
Q

How should a patient with trichomonas be counseled?

A

Important to encourage their partner(s) to be treated even though they will likely be asymptomatic.

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40
Q

What is meant by the term “test of cure”.

A

Patients should be retested for trichomonas 2 weeks to 3 months after initial treatment to ensure infection has resolved.

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41
Q

What is a BD affirm test and what is it used to detect?

A

DNA test used to identify BV, candidiasis, and trichomonas.

42
Q

What will be the result of the amine whiff test in a patient that has BV, candidiasis, and trichomonas?

A

BV: positive
Cand: negative
Trich: positive

43
Q

What will the pH of vaginal secretions be in a patient that has BV, candidiasis, and trichomonas?

A

BV: > 4.5
Cand: < 4.5
Trich: > 5.0

44
Q

What will be found on microscopy in a patient that has BV, candidiasis, and trichomonas?

A

BV: clue cells - stippled epithelium
Cand: pseudohypha - cluster of newly dividing cells in an elongated ellipsoid shape
Trich: distinct flagella from parasitic cells

45
Q

Define atrophic vaginitis.

A

Atrophy of vaginal and vulvar tissues s/p hypoestrogenic state (often seen in menopause)

46
Q

What are the S/S of atrophic vaginitis?

A

Dryness, burning, irritation, dyspareunia, urinary urgency, dysuria, recurrent UTIs, fissures, petechiae, labia minora resorption, loss of rugae, prominent meatus, urethral eversion or prolapse.

47
Q

How is atrophic vaginitis treated?

A
  1. vaginal moisturizing agents

2. if #1 fails, low dose vaginal estrogen (ring, cream, insert)

48
Q

What is a contraindication to the use of estrogen in the treatment of atrophic vaginitis?

A

Estrogen-dependent cancers - breast and colorectal

49
Q

What is the most common cancer in females?

A

Breast Cancer

50
Q

What is the clinical relevance of BRCA?

A

BRCA-1 and BRCA-2 are genes for breast cancer. Patients that test positive for a mutation on either BRCA gene have an 55% - 85% increased risk of developing breast cancer.

51
Q

In addition to genetics, list other risk factors for developing breast cancer.

A

Inc age, Breast CA Hx, Hx in 2 close family members, radiation exposure, having no children before age 35, early menarche, late menopause, North American or European ancestry, obesity, urban residence, primary ovarian or endometrial CA

52
Q

What are the screening recommendations for breast cancer?

A

Mammogram every 2 years between ages 50 and 74. BRCA positive or those with family history may be screened earlier, more frequently, and with MRI.

53
Q

What is the most common type of breast cancer? What is the second most common?

A

MC: infiltrating ductal carcinoma

2nd MC: lobular carcinoma

54
Q

What is the TNM system and how is it clinically relevant to breast cancer?

A

3-factor system used to stage cancers after diagnosis.
T = Tumor –> grades the size of the primary tumor
N = Nodes –> grades affect on regional lymph nodes
M = Metastases –> grades if distant metastases have been found

55
Q

What is the most common breast-conserving treatment of breast cancer?

A

Lumpectomy

56
Q

Describe what is removed in a modified radical mastectomy.

A

Removal of breast, fascia of pectoralis minor, and axillary lymph nodes.

57
Q

What factors guide the use of chemotherapy in a breast cancer patient?

A

Age, estrogen and progesterone receptor status, and HER-2 expression.

58
Q

What is HER-2 and how is it clinically relevant to breast cancer?

A

HER-2 is a growth protein on the outside of all breast cells. Some breast cancer cells may express higher levels of HER-2 and are classified as HER-2 positive.

59
Q

Why is it important to test all breast cancer patients for estrogen (ER) and progesterone (PR) receptor expression?

A

Tumor expression of ER and PR is both prognostic indicators and potential targets for therapy. Breast cancers that do not express PR or ER are unlikely to respond to hormone therapy.

60
Q

What is Tamoxifen and how is it used?

A

Tamoxifen is a selective estrogen receptor modulator (SERM) medication. It is given to ER positive breast cancer patients as an estrogen receptor agonist that prevents cancer growth.

61
Q

What characteristics of a breast lump indicate the mass is more likely to be breast cancer? What other S/S on physical exam are more indicative of cancer?

A

Mass: ard, non-tender, and immobile
Other: erythema, thickening, dimpling, peau d’orange

62
Q

What portion of the breast is the most common site of a cancerous tumor?

A

Upper, outer quadrant

63
Q

What are the most common findings on mammogram associated with breast cancer?

A

Presence of a soft-tissue mass or density.
Clustered microcalcifications
Spiculated soft-tissue mass (lump with spikes or points on the surface)

64
Q

What is a stereotatic biopsy?

A

Biopsy guided by mammogram.

65
Q

Differentiate next steps in diagnostic evaluation for a palpable mass from those of an abnormal mammography finding.

A

Mass: fine needle aspiration or core needle biopsy
Mamm: Stereotatic biopsy, ultrasound, or breast MRI

66
Q

Other than tamoxifen, what other class of medications is used in hormone therapy to treat beast cancer?

A

Aromatase inhibitors - letrozole or anastrozole

67
Q

What is the primary AE associated with aromatase inhibitors and what is recommended in the evaluation of this AE?

A

Osteoporosis - A baseline DEXA scan should be obtained on post-menopausal women taking an aromatase inhibitor.

68
Q

Define cervical dysplasia.

A

AKA: cervical intraepithelial neoplsia (CIN). It is a pre-malignant condition affecting the squamous cells of the cervix.

69
Q

What is the most significant risk factor for cervical dysplasia?

A

Human Papilloma Virus (HPV)

70
Q

What is the screening test for cervical dysplasia?

A

Papanicolaou (Pap) smears

71
Q

What are the classifications of abnormal findings on a PAP smear?

A

ASC-US: atypical squamous cells of undetermined significance
ASC-H: atypical squamous - cannot exclude high grade squamous intraepithelial lesion
LSIL: low grade squamous intraepithelaia lesion
AGC: atypical glandular cells of undetermined significance
HSIL: high grade squamous intraepithelaia lesion

72
Q

What is the next step in management of patients with a PAP smear result of ASC-H?

A

Colposcopy - regardless of HPV or pregnancy status

73
Q

What is a colposcopy?

A

Microscopic examination of the cervix that helps to determine the need for a biopsy.

74
Q

Colposcopy results are placed into one of three categories. Name the three categories.

A

Mild: Cervical intraepithelial neoplasia-1 (CIN-1)
Moderate: CIN-2
Severe: CIN-3

75
Q

What is the most common cervical cytologic abnormality found on PAP smear?

A

ASC-US

76
Q

Describe the risk of invasive cervical cancer in women with a PAP smear finding of ASC-US.

A

Low risk if not associated with HPV (1/3 - 2/3)

Women with HPV are at higher risk

77
Q

What are the most common HPV strains associated with cervical cancer?

A

HPV-16 and HPV-18

78
Q

What are the two most important risk factors for a woman to contract HPV? What are other risk factors?

A

MC: Unprotected sex and sex with multiple partners
Other: smoking, young age, immunosuppression

79
Q

What is the most common site of pathologic cellular changes in the cervix?

A

Transformation zone: where squamous epithelium of the ectocervix transitions to glandular epithelium of the endocervix.

80
Q

What are the next steps in the management of a women with a PAP smear finding of ASC-US?

A

HPV testing –> HPV positive = colposcopy. HPV negative = routine follow up screening

81
Q

In what time period is most cervical dysplasia discovered?

A

In women in their early 20s - soon after their first intercourse

82
Q

What are the presenting S/S of a women with cervical dysplasia?

A

Asymptomatic - vast majority of cervical dysplasia is found on routine screening.

83
Q

T/F: A woman can develop cervical cancer without being exposed to HPV.

A

False: Cervical dysplasia requires exposure to HPV

84
Q

Compare and contrast Cervarix and Gardasil.

A

Both are HPV vaccines
Cervarix: immunizes against only HPV 16 and 18
Gardasil: immunizes against 9 HPV variants

85
Q

T/F: Vaccinations for HPV are not used in men.

A

False: HPV can cause oropharyngeal, anal, and penile cancer in addition to vulvar/vaginal and cervical.

86
Q

How common is HPV in the population?

A

Most sexually active people contract HPV at some point in their loves, but then clear it within 2 years without ever developing symptoms.

87
Q

Describe the P53 gene’s role in cancer. What is the specific properties of HPV that affect P53?

A

P53 is a tumor suppressive protein present in all cells. Patients that develop tumors have impaired function of P53. HPV has 2 mRNA transcripts that affect P53. E6 inhibits P53. E7 inhibits P53 and other proteins that help development of cancer.

88
Q

Define persistent HPV infection and state how it is clinically relevant.

A

Persistent HPV is HPV infection that lasts longer than 2 years. Can lead to cervical CA through progressive neoplasia.

89
Q

How long does it take for HPV infection to cause invasive cervical cancer?

A

10 - 25 years

90
Q

Describe the management of a young woman with HPV compare to that of an older woman.

A

HPV treatment tends to have an adverse affect on fertility and young women tend to be more likely to quickly clear HPV. For these reasons, management in younger women is generally less aggressive.

91
Q

Describe the recommended screening guidelines for cervical cancer.

A

< 21 yoa = no screening
Age 21-29 = PAP every 3 years
Age 30-65 = PAP and HPV cotesting every 5 years or PAP every 3 years
Age > 65 = no screening unless Hx of CIN-2 or greater in past 20 years.

92
Q

Do women need to get a PAP smear if they have had a hysterectomy?

A

No

93
Q

Describe the process of colposcopy and state what visual finding is most associated with cancer.

A

Cervix, vagina, and anogenital area are visualized under magnification and illumination. A solution (often acetic acid) is used to highlight areas of concern. An area that is red/yellow and peeling/rolling is most associated with cancer.

94
Q

Describe management of patients based on their CIN category from PAP results.

A

CIN-1: Repeat PAP in 1 year. If negative after 1 year, resume age based screening. May also test for HPV - if negative resume age related screening.
CIN-2: PAP every 6 months and consider colposcopy based on the patient’s desire/ability to bear children. (google search says colposcopy has no effect on fertility via multiple sources???)
CIN-3: Tissue removal by excision or ablation

95
Q

What is the clinical difference between CIN-3 treatment with excision and with ablation?

A

Excision allows for tissue analysis after procedure. Ablation prevents post-procedure tissue analysis.

96
Q

What is a LEEP procedure and what are its benefits?

A

Loop Electrical Excision Procedure - done in an office setting with local anesthesia and produces very little blood loss.

97
Q

What are the S/S of invasive cervical cancer?

A

Post-coital bleeding, back pain, weight loss

98
Q

Name and describe the most important prognostic factor in invasive cervical cancer.

A

Staging is most important - 4 stages.

1: confined to cervix
2: cervix and upper 2/3 of vagina
3: involves lower 1/3 of vagina or pelvic side wall
4: involves adjacent distant organs

99
Q

What is the treatment of invasive cervical cancer?

A

Radical hysterectomy at early stage.

Chemo/radiation at late stage

100
Q

What is molloscum contagiosum?

A

Small, smooth, round, pearly lumps with a central core caused by pox virus through skin to skin contact. Common in kids or as an STI in adults.

101
Q

What is the treatment for molloscum contagiosum?

A

Often resolve with no treatment. Resolution can be sped up by local excision or treatment with topical trichloroacetic acid.

EOR Exam - Women's Health (7 decks)

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