GYNO Flashcards
(134 cards)
1
Q
is a symptom not a diagnosis; causes acronym: PALM COEIN
A
Abnormal uterine bleeding
2
Q
PALM COEIN
A
structural: polyp, adenomyosis, leiomyoma, malignancy, hyperplasia then nonstructural coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not otherwise classified
3
Q
Diagnostics for Abnormal uterine bleeding
A
GYN exam to start … followed by labs
Transvaginal ultrasound, pregnancy test, CBC, cervical cancer screening (if due), potential orders: TSH/FTF, hormone tests- prolactin, androgens estrogens, PT/PTT, bleeding disorder labs, endometrial biopsy
45+ should get a endometrial sampling or less than 45 if hx of unopposed estrogen exposure
Heavy bleeding >80mL
4
Q
Tx for for Abnormal uterine bleeding
A
COCs, progesterone only contraceptives, TXA (Lysteda oral or IV if severe) or NSAIDs taken when pt is bleeding, endometrial ablation, Depo-Provera, Mirena
Acute emergent: ER uterine tamponade, IV, estrogen, uterine artery embolism, hysterectomy
5
Q
primary vs secondary amenorrhea
A
Primary (never menstruation) vs secondary (previous menstruation)
6
Q
Female athlete triad
A
amenorrhea, osteoporosis, and disordered eating
7
Q
Dx for amenorrhea
A
hcg, FSH, LH, TSH, prolactin (Acromegaly; if elevated order MRI or CT), progesterone challenge
8
Q
Tx for amenorrhea
A
tx underlying cause if discovered. Maintain optimum weight (by either gaining or losing). Irreversible bone loss can occur after 3 yrs of amenorrhea- calcium and vit
9
Q
mastalgia/ Mastodynia
A
Breast pain
10
Q
Cyclic vs noncyclic breast pain ?
A
Cyclic → usu 3rd or 4th decade; bilateral outer breasts radiating to upper arm and axilla
Noncyclic → unilateral, localized, sharp, burning. Rarely a presentation of CA
11
Q
PE for breast pain. questions to ask?
A
mass (change w/ cycle?), nipple discharge (benign: creamy, gray, or green; abnormal: watery, serous, bloody), skin dimpling.
Skin changes that may signify cancer include erythema, edema, retraction, dimpling, peau d’orange, and nipple excoriation or crustiness.
Hx ?s: hormone therapy, breast surgery, age at menarche and menopause, prenancy and lactation, breast CA screening, family hx
12
Q
dx for noncyclic breast pain
Noncyclic = unilateral, localized, sharp, burning. Rarely a presentation of CA
A
mammogram if postmenopausal; US for young women; CXR if trauma. Hcg
13
Q
Tx for breast pain
A
reassurance that most pain resolved spontaneously, firm supportive bra, low-fat diet, reduced caffeine, NSAIDs, change OCP to lower estrogen and higher progesterone
14
Q
What to do if no resolution of symptoms after 3-7 days of ABX for mastitis
A
consider inflammatory breast cancer- get mammogram/ U/S-but mammogram is not indicated in pregnant/lactating women
`
15
Q
what to rule out with nipple d/c & galactorrhea
A
pituitary adenoma
16
Q
common in premenopausal and pregnant women, bilateral; only with compression; multiple ducts involved. Clear, gray, yellow, white, or dark green
A
Physiologic galactorrhea
17
Q
spontaneous, bloody, serous fluid from breast, unilateral, involving one duct, a/w mass
A
Pathologic galactorrhea
18
Q
Bilateral nipple discharge usually has some physiologic causes, such as_________ . Can draw a prolactin level to assess. *more concern if it’s bloody, green, and if it is spontaneous
A
hyperprolactinemia
19
Q
Labs for nipple d/c & galactorrhea
A
: Prolactin, TSH, CBC, CMP, hcg- consider mammogram to assess for non palpable masses, test nipple discharge for occult blood; Periareolar US
20
Q
What to do If prolactin elevated when assessing galactorrhea
A
MRI of brain
21
Q
Is a rare form of breast cancer. Superficial skin manifestation, usually begins as ductile cancer (1-3% of breast CA cases)
Itchy, usually unilateral, well demarcated, erythematous scaly plaque that’s usually around the nipple and the areola.
Refer - skin biopsy needed and mammogram
A
Paget’s Disease of Breast
22
Q
Unilateral, continuous hx with slow progression, moist or dry, irregular but distinct border, nipple always involved and disappears in advanced cases, itching common
A
Paget’s Disease of Breast
23
Q
Usually bilateral, intermittent hx with rapid progression, moist initially, indistinct border, areola involved, nipple may be spared, itching common
A
Eczema of breast
24
Q
Tx Paget’s Disease of Breast
A
Tx: mastectomy, radiation
Managed by surgical oncologist
25
Breast masses/ CA protective factors
childbirth before 30, multiple births, breastfeeding
26
Breast masses/ CA risk factors
HRT (5% increased risk per year of use; returns to baseline w/in yr of stopping), dense breasts,
Fibroadenomas and cysts do NOT increase risk
27
usually firm discrete mass or an area of diffuse firmness of breast tissue with or without skin thickening, cysts are rare in post menopausal women and shoulbe considered breast cancer until proven otherwise (unless on HRT)
breast cancer mass
28
most common; painless, freely movable, rubber feeling or hard; increase in size toward end of cycle
Fibroadenomas
29
Breast masses/ CA screening tools
Gail model, The Breast Cancer Risk Assessment Tool , Tyrer-Cuzick Model
30
Breast masses/ CA diagnostics
BRCA genetic testing if strong family hx, mammogram (USPSTF biennial 50-74), MRI, 3d mammogram (younger women with dense breasts), diagnostic mammography AND ultrasonography initially for palpable mass 25+ usually just ultrasound for <25 average risk f/u bc 15-18 percent false negative
31
Breast masses diagnostics if cyst ?
cyst→ aspiration and cytology, f/uin 4-6wks to determine if cyst reoccured; non cystic mass→ biopsy
32
Non-cancerous, usually affects both breasts. change in estrogen/ androgen ratio
Often seen in overweight boys
RT: aging, malnutrition, hypogonadism, thyroid problem, excess drinking/ cirrhosis, testical or adrenal cancer, chemo, ketoconazole, digoxin, exogenous steroids
Normal in newborn male infants due to moms hormones
Obtain family hx of breast or ovarian cancer, BRCA mutation
Gynecomastia
Usu resolves on own w/in 6 mos
33
Aggressive fast-growing cancer. Unilateral
May look like an infection of the breast
Refer!
Inflammatory Breast Cancer
34
Dx for gynocomastia?
Diag: if needed, US <25; mammogram >25yo or any age you feel a suspicious mass
35
extra nipples
polythelia
36
>6 mo.
Patho: unclear- hyperesthesia/ allodynia and pelvic floor dysfunction
Dd: endometriosis, interstitial cystitis, painful bladder syndrome, depression, IBS, pelvic adhesions, trauma, pelvic inflammatory disease (can be comorbid)
chronic pelvic pain
37
Red flag findings of chronic pelvic pain
postcoital bleeding, postmenopausal bleeding, unexplained weight loss, pelvic mass, hematuria, extreme burning/ pain
38
chronic pelvic pain diagnostics
pelvic ultrasound r/o anatomic abnormalities, laparoscopy (severe pain), CBC, ESR, Urinalysis, chlamydia/ gonorrhea, pregnancy test
39
Tx of chronic pelvic pain
Meds: depot medroxyprogesterone, gabapentin, NSAIDS, gonadotropin releasing hormone agonists (Zoladex) (better for endometriosis)
Antidepressants (TCAS, SNRIs, anticonvulsants (lyrica, gabapentin)
Nonpharm: pelvic floor physical therapy, behavioral therapy cutaneous allodynia
Hysterectomy
40
How to dx and tx vulvar lichen sclerosis
dx with biopsy
| Tx with steroids
41
How to dx and tx vulvar lichen sclerosis
dx with biopsy
| Tx with steroids
42
starts 6-12 months after menarche starts, a/w low anterior pelvic pain around menstrual cycles
Primary dysmenorrhea
43
some years of painless menstruation then painful menstruation - not described as beginning in adolescents and usually underlying pathology
Secondary dysmenorrhea-
44
Red flags of dysmenorrhea
unilateral dysmenorrhea, ectopic pregnancy,
45
treatment of dysmenorrhea
nutrition, vitamines, heat packs, NSAIDS, oral contraceptives, Mirena IUD
46
pain with sexual activity
Dyspareunia-
47
Possible factors of Dyspareunia
RF: PID, endometriosis, postpartum, perimenopausal, psychological factors,
CM: lubrication issue, superficial issue like with lichen planus, lichen sclerosis UTI…lots of differentials, Deep pain- usually endometriosis, structural, bladder stones,
48
Most common cause of dyspareunia
endometriosis
49
diagnostics for dyspareunia
pelvic exam then KOH prep, cultures of vaginal discharge, pap, STI, Q tpvd low oxalate diet calcium citrate, ip test, CBC, ESR, HCG
50
Nonpharm Tx for dyspareunia
Provoked vestibulodynia/ vulvar vestibulitis: 1st line is psychological/ behavioral therapies, endometriosis: Vitamin E/C/gluten free diet, other: pelvic floor therapy, capsaicin cream, lubrication
51
pharm Tx for dyspareunia
estrogen cream, if estrogen CI consider ospemifene (selective estrogen receptor modulator or topical aqueous lidocaine, topical steroids for lichen sclerosus, vaginismus - botox, lidocaine injections, PVD- topical amitriptyline cream, topical estrogen 1x/day 4-8 weeks, interferon injections, endometriosis- hormonally OCP/ surgically
52
Vulvar area chronic pain at least 3 months
Vulvodinia
53
Fear reaction to any form of vaginal penetration = spasms
vaginismus
54
Inability to perform, lack of arousal, lack of interest, lack of orgams, pain on penetration (one or all of these)
Def: femal sexual interest/arousal disorder, femal orgasmic disorder, genito-pelvic pain/penetration disorder (req 6 mo duration of symptoms)
female sexual dysfunction
55
screening tools for female sexual dysfunction
sexual satisfaction scale, female sexual function index
56
diagnostic labs for female sexual dysfunction
guided by history/PE, if indicated- testosterone, Sex hormone binding globulin, DHEA, estradiol, calculated free testosterone, LH/FSH, pelvic ultrasound, CBC, CMP, A1C, lipid, renal liver,
Ask what meds they are on... SSRIs?
57
Tx options for female sexual dysfunction
Vaginal moisturizers, topical vaginal low dose estrogen, SERMS, Testosterone (off label), pelvic floor therapy
58
Nonpharm Tx options for female sexual dysfunction
Diet exercise, sleep, cholesterol reduction, tobacco cessation, BP/ glycemic control, psychology
59
PLISSIT model for addressing sexual health with women
Give permission, limited information, specific suggestions, intensive therapy
60
Pretty rare but most commonly seen in women in their 50s
Usually remains undetected until sx appear… more extensive
Sx: pelvic pain, urinary urgency, abdominal pain, bloating
Look into this if pt has sx t > 6 months that aren't going away
Ovarian Cancer
61
RF for Ovarian Cancer
being in your 50s, having the BRCA1 or the BRCA2 gene, personal history of breast cancer, colon cancer, never having had a child.
62
Stages 1-4 of ovarian cancer
Stage 1= CA in 1 or both ovaries
Stage 2= spread to pelvis
Stage 3= spread to abdomen
Stage 4= beyond abdomen
63
hard to diagnose .. transvaginal US; Order CA-125 test (tumor marker); CT pelvis
Expensive test that looks at proteins produced by ovarian cells
Can be elevated from causes other than ovarian cancer (ex. diabetes , lupus)
Dx for ovarian cancer
64
Exam pearls for ovarian cancer
any evaluation of the ovary in post-menopausal women where you find an enlargement in your evaluation should signify that you want to rule out malignancy and usually requires a referral
65
Most common in post menopausal women btw 50-60 years of age
| * post meno-pausal bleeding, fullness or pressure in pelvis
Endometrial Cancer
66
RF of Endometrial Cancer
Older age, never being pregnant, obesity (excess androgen is converted to estrogen), breast cancer tx meds (tamoxifen), hx of colon cancer, estrogen exposure w/o progesterone
Greater risk if family hx of colon cancer
67
How to dx endometrial cancer?
| Stages?
Dx: endometrial biopsy
Stage 1= only uterus
Stage 2= uterus and cervix
Stage 3= spread beyond uterus but hasn't reached rectum or bladder
Stage 4= also affects bladder and rectum and other parts of body
68
Tx of endometrial cancer
Tx depends on stage of tumor/ cancer
Surgery, hysterectomy, chemo
Good survival rate if not invaded muscles
69
2nd most common malignancy of female GYN tract.. Decreasing due to HPV vaccine.
cervical cancer
70
Most common types of HPV that cause cervical cancer
HPV 16 and 18
71
post coital spotting, bleeding around cervix, menorrhagia; thin, watery, foul discharge
s/s of cervical cancer
72
RF of cervical cancer
exposure to HPV (sexual activity) , increased risk with those sexually active earlier and who have had many partners, HIV, immunocompromised, low SES, women whos moms took DES, smoking
73
protects against 9 types of HPV (including 16, 18, and two more types that cause warts). 3-injection series over 6 mos. Females and males can receive at 9 yrs old; routine pap
gardasil
74
CC= Mass on external vaginal area - very rare CA
| Need biopsies … Refer out
vulvar and vaginal cancers
75
rare and aggressive cancer no burning, itching, or pain
Vulvar melanoma
76
asymptomatic, vaginal bleeding not a/w discomfort
CM vaginal CA:
77
lump, mass, itching, bleeding
CM vulvar CA
78
What to do if suspect vulvar or vaginal cancer?
CM vaginal CA: asymptomatic, vaginal bleeding not a/w discomfort
Refer to gyn for biopsy (vulvar) and colposcopy (vaginal)
Diag vaginal CA: PET and CT
79
Usually leave them alone if not causing a problem (large, pain, difficulty getting pregnancy, abnormal bleeding)
uterine fibroids
80
Cyst in Introitus… may be asymptomatic unless it's infected
may see a larger lump on one side, very tender to touch. Often can just be treated with antibiotics.If not better may need I&D
If enlarged gland found in post-menopausal women presume it is carcinoma
bartholian cyst
81
how is endometriosis tx
BC and NSAIDS *
82
defined as inability to conceive after 1 year of regular timed, unprotected intercourse or donor insemination <35 and 6 months >35, immediate referral for 40+
infertility
83
Rf of infertility
obesity, cigarette smoking, underweight, shift work, occupational exposure, PCOS, varicocele (bag of worms)
84
Dx for male infertility
semen analysis x 2 (2-7 days of abstinence prior to sample) if + oligospermia= 8-10AM FSH, LH, testosterone; if testosterone low obtain prolactin then refer,
85
Dx for female infertility
pap, HPV, chlamydia, gonorrhea, imaging- hysterosalpingogram, older than 35 3 day FSH level an estradiol level, ovulation- basal body temperature charting, urinary LH home kit- LH surge 1-2 days precedes ovulation
86
General treatment scope for PCP related to infertility
improve nutritional status, normalize weight, eliminate cigarette, caffeine, illicit drugs NSAIDs, ETOH, toxins, fertile window- 5 days before-ovulation, intercourse 2x per week, avoid lubricants that may be spermicidal (recc raw egg white/ vegetable oil)
87
How to tx in preg pts?
Chlamydia
*Gonorrhea
+HIV, hepatitis B, syphilis
Chlamydia- azithromycin 1gram orally as single dose
*Gonorrhea (uncomplicated)- ceftriaxone 500mg IM as single dose for persons weighing <150kg
Refer for +HIV, hepatitis B, syphilis
88
Maternal genitourinary and gastrointestinal colonization is the primary risk for the leading cause of neonatal early onset disease (EOD)- eg sepsis, PNA, or meningitis.
GBS - Group Beta Strep
89
Who is high risk for Group Beta Strep
High risk = History of previous GBS-infected newborn, Gestational age of less than 37 weeks at time of delivery, Prolonged rupture of membranes, Very low birth weight
90
Diagnostics for GBS
Genito rectal swab
Screening recommended at 36 0/7-37 6/7 weeks gestation
Findings may include:
Positive genito rectal culture for GBS
Do not screen those with positive GBS bacteriuria as they will require prophylactic treatment regardless.
91
Tx for GBS
Intrapartum IV antibiotic recommendations: (abx in labor or after ROM)
Penicillin (PCN) G OR Ampicillin
PCN allergy alternatives include:
Cefazolin
Recommend use of Clindamycin in those with known IgE mediated events after receiving PCN and cephalosporins
Prophylaxis treatment is not necessary for those without signs of labor, with intact membranes and planned mode of delivery is cesarean section.
92
Dx for UTI in pregnant woman
When to screen?
Screening for all pregnant women by urine culture once early in pregnancy* (12-16 wks gestation)
UA with reflex culture
Findings may include:
Pyuria
Culture positive for 10^3 or 10^5 colony-forming units/mL (CFU)
Reported symptoms of urgency, frequency and dysuria
93
Common tx for UTI in pregnant woman
Amoxicillin 500mg Q8h x3-7 days
Amoxicillin-clavulanate 500mg Q12hr x3-7 days
Cephalexin 500mg Q8h x3-7 days
94
UTI med tx to avoid in pregnany
Avoid nitrofurantoin and sulfonamides at end of 3rd and during 1st trimester
Avoid trimethoprim in first trimester
95
what to do after tx UTI in pregnant woman
May also provide prescription for yeast tx to be taken at completion of ABX if needed; test of cure after tx and repeat urine cx q6-12 weeks for remainder of pregnancy.
96
Rare disorder consistent with severe, intractable nausea and vomiting (>3 episodes per day), dehydration, large ketonuria and >/= 5% body weight loss.
Possible DDx Gastroesophageal reflux disease (GERD)
Hyperemesis Gravidarum (HG)
97
Dx for Hyperemesis Gravidarum (HG)
None typically recommended in those without dehydration
May consider CMP, CBC, TSH, quantitative human chorionic gonadotropin (hCG), amylase and urinalysis
Findings may include:
Elevated liver enzymes, bilirubin and amylase
Decreased TSH
Elevated specific gravity and/or ketonuria
98
Tx for Hyperemesis Gravidarum (HG)
start with lifestyle modifications
Nonpharmacologic: change prenatal vitamin to folic acid only (Level A); ginger capsules 250mg QID (Level B), consider P6 acupressure wrist bands.
Pharmacologic: Vitamin B6 (pyridoxine) 10-25mg PO (alone or in combination with Doxylamine 12.5mg) 3-4 times a day. (Level A)
99
Low levels of iron, hemoglobin and microcytic hypochromic rbc = Hb, 11 g/dl
Recognize symptoms of fatigue, weakness, rapid heart rate, difficulty concentrating, shortness of breath, pale skin, chest pain, lightheadedness, cold hands and fe
IDA
100
CDC cutoffs for IDA In pregnancy
Hb 11 g/dl in 1st trimester
Hb < 10.5 g/dl in 2nd trimester
Hb 11 g/dl in 3rd trimester
'
Normal for women = Female: 12.1 to 15.1 g/d
101
Labs for IDA in pregnancy
CBC w/ or w/out diff, Serum ferritin (low), serum iron (low), TIBC (elevated), transferrin sat (low)
102
Tx for IDA in pregnancy
treat underlying cause 1st
Iron and vitc rich foods
Oral iron supplementation 60-200 mg/ day elemental ion
Consider Ferrous sulfate 325 mg (65 elemental) TID btw meals if tolerable
Consider Vit C (250-500 mg BID with iron) to max absorption
Continue therapy 3-6 months after deficiency corrected to replenish stores
Educate pregnant women who are vegetarian/ Vegan
103
Tx asthma in pregnancy
SABA of choice: Albuterol
ICS of choice: budesonide; however continue same ICS as before preg. If possible
Salmeterol preferred over leukotriene RA or theophylline
If mom’s asthma is poorly controlled, fetus needs close monitoring (serial US with antenatal fetal testing at 32wks)
104
Tx of constipation during pregnancy
Tx: water, fiber, psyllium, methylcellulose (Citrucel,) , Colace.
Avoid mineral oil, castor oil, saline, and PEG
d/t progesterone effect on bowel motility (decreased)
105
Early pregnancy Bleeding diagnostics
Transvaginal ultrasound
| Labs: HCGs, CBC, Coags,
106
monitor closely… could move back into right position spontaneously. 95% resolve prior to birth, don't do digital exam, refer to OB
placenta previa
107
3rd-trimester non-obstetric bleeding causes
```
Cervicitis
Vaginitis
Trauma
Polyps
Malignancy
```
108
3rd-trimester obstetric bleeding causes -
Lots of blood- placenta previa, abruptio placentae, vasa previa, uterine rupture
not as much blood- bloody show, intercourse
109
3rd-trimester non-vaginal bleeding causes
hemorrhoids, hemautira
110
early vs late postpartum hemorrhage
Early= > 500 ml in first 24 hours (blood loss underestimated)
Late= > 500 cc after first 24 hours
111
Major causes of postpartum hemorrhage
retained placental fragments, infection, hematomas, sub involution
112
How to manage postpartum hemorrhage
D&C , Antibiotics
113
Fertilized ovum implants anywhere outside the uterus
| RF: PID, chlamydia, OCP,
ectopic pregnancy
114
Ectopic pregnancy triad
pelvic pain, amenorrhea, irregular bleeding
115
unruptured- abdominal pain with or without vaginal spotting/bleed, dizziness, shoulder pain (more common in ruptured), amenorrhea for 1-2 months, nausea, fatigue, breast heaviness, unilateral pelvic/abd pain, speculum: bluish coalition of cervix, budging culdesac, highly indicative findings: adnexal mass, involuntary guarding peritoneal signs
CM of Ectopic pregnancy
116
Diagnostics for ectopic pregnancy
HCG, CBC, transvaginal U/S
| Low rising HCG
117
What to do if you suspect ectopic pregnancy
send to ER
118
How is ectopic pregnancy treated
ER : methotrexate with or without leucovorin or mifepristone, surgical laparoscopy or laparotomy: only treatment option for ruptured; rh negative blood type women should receive RhoGAM
119
What to educate after women received methotrexate for ectopic pregnancy
after methotrexate- women should refrain from Sexual activity, ETOH, folic acid vitamins until after resolution of ectopic pregnancy (3 months)
120
Frequent feeding/pumping, augmentin, dicloxacillin, or cephalosporin for staph or strep. Flu-like sx. Can progress to abscess
mastitis
121
Screening tools for perinatal mood disorders
Beck, Edinburgh, PHQ-9, PPD Screening Scale
122
Dx for perinatal mood disorders
assess for thyroid abnormalities and SI
123
Tx of perinatal mood disorders
CBT, pharm
Low dose SSRI 5-7 days and refer
SSRIs, vit d, DHA, CBT, massage, acupuncture, yoga
124
first 2-3 mos through first year. Affects entire family (child/partner)
Assess: guilt, fatigue, sleep disturbance, loss of interest/concentration, appetite change, agitation, SI
PPD
125
occurs around 2-4 weeks pp delusions, hallucinations, hopelessness → emergency
PP Psychosis
126
What qualifies as preterm labor
labor before 37 weeks gestation
RF: SES, genetic conditions, periodontal disease, multiple gestation, substance use, maternal infections, preeclampsia
Injectable steroids at 24-34 wks gestation to mature fetal lungs
127
new onset HTN with proteinuria
S/S: dizziness, headache, seeing spots, RUQ discomfort, swelling of face and hands.
Refer
preeclampsia
128
Mild vs Severe Preeclampsia
Mild : 140/90, Protein 1+
| Severe : > 140/90, and 3+ urine, may have elevated LFTS
129
Short term vs long term tx of preeclampsia
Short term: Nifedipine, IV Labatelol, Hydralazine
Long term: labetaloal, methyldopa
Baby aspirin, calcium
Delivery at 37 wks
130
Diagnostics for preeclampsia
Twice weekly BP and once weekly CBC, liver enzyme, and creat
131
High BP causes seizures
Mag sulfate for seizure prevention
If less than 34 wks gestation need antenatal corticosteroids
Requires emergent delivery
Eclampsia
132
HELLP Syndrome
```
develops in preeclampsia
H= hemolysis
E= elevated
L= liver enzymes
L= low
P= platelets
```
133
Goal BPs during pregnancy
Gestational Hypertension
Primary care can manage GH just needs to be monitored carefully
Want BP 120-160/80-105
Low dose Aspirin
134
FDA guidelines Unplanned pregnancy
FDA guidelines: medication abortion is avialable up to 10 weeks with mifepristone and misoprostole
Adoption
