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31

Clear cell adenocarcinoma

Buzzword for DES exposure

DES exposure in utero increased risk for ovarian clear cell carcinoma

32

Name 4 medication options to tx endometriosis

Want to cause deciduation of the endometrial lining

1. OCPs = gold standard
2. Progesterone- minipills, depot, IUP
3. GnRH agonists (basically induce menopause so use transiently)
4. Danazol- synthetic androgen to suppress FSH/LH release

33

Describe how endometriosis causes

(a) Pain
(b) Infertility

(a) Ectopic endometrial stroma/glands cause inflammation that build into adhesions and scarring

(b) Adhesions and occlusions => infertility

34

Checking progesterone on what day of the menstrual cycle would help confirm ovluation

Day 21

35

Name 2 etiologies of GnRH independent precocious puberty

GnRH independent precocious puberty = puberty not due to early activation of HPA axis, instead due to some form of peripheral estrogen production

1. McCune Albright syndrome = ovaries producing estrogen w/o stimulation
2. Granulosa cell tumor

36

Buzzword: uterosacral nodularity

Endometriosis

37

Physical exam findings of ectopic pregnancy

-Abdominal or adnexal tenderness
if ruptured- acute abdomen w/ rebound/guarding
-uterus small for gestational size (aka normal sized)

38

Etiology of GnRH dependent precocious puberty

GnRH dependent precocious puberty = early activation of the HPA axis
-most often idiopathic

39

Clinical presentation of ectopic pregnancy

Main features = vaginal bleeding + abdominal pain

40

Outpatient tx for PID

Ceftriaxone IM x1
+ Doxy PO BID x14 days

then RTC in 3 days for f/u
-need broad spectrum b/c of polymicrobial nature of PID infections 2/2 ascending vaginal infxn

41

What blood test is essential in every pt w/ any type of abortion

Type and screen!
Prevent autoimmunization if Rh- mother

42

First steps of management for woman of reproductive age who p/w vaginal bleeding

-beta-hCG
-if pregnant => vaginal ultrasound to determine location of pregnancy (ectopic of IUP)
-pelvic exam etc

43

56 yo nulligravid post-menopausal F p/w intermittent vaginal bleeding

Next step in workup

Transvaginal ultrasound to look at endometrial stripe- if under 4-5mm that's thin and believe bleeding is 2/2 atrophy

If endometrial stripe isn't thin => do endometrial biopsy

44

Contraindications to medical MTX tx for first semester abortion

-fetal cardiac activity (usually fetal heart beat seen around 6 weeks)
-beta-hCG over 5,000
-impaired renal fxn (MTX is renally cleared)
-elevated LFTs (MTX is directly hepatotoxic)
-HD unstable (b/c they're ruptured => need surgery)

45

Surgical tx options for ectopic pregnancy

Salpingectomy vs. salpingostomy

Salpingectomy = removal of fallopian tube
Salpingostomy = surgical unblocking of fallopian tube (remove pregnancy w/o removing the tube)- preserves fertility

46

What is Ashermna syndrome?

Intrauterine adhesions + symptoms (infertility, amenorrhea)
-syndrome 2/2 scar tissue development in the uterine cavity

Infertility if scarring prevents normal implantation
Amenorrhea/AUB when scarring prevents normal endometrial growth/shed

47

3 theories of the mechanism of endometriosis

1. Retrograde menstrual flow (most likely)
2. Vascular/lymphatic dissemination
3. Coelomic metaplasia (from pleuripotent/undifferentiated cells in the peritoneum)

48

Name some RF for endometrial hyperplasia/carcinoma

-unopposed estrogen exposure: nulliparity, early menarche, late menopause
-age
-obesity: adipose tissue contains aromatase => increased peripheral conversion of androgens to estrogens
-Tamoxifen
-granulosa cell tumor of the ovary (secretes estrogen)

49

Overview of tx for ovarian cancer

Surgery, then chemotherapy: surgical b/c almost always diagnosed so late (stage III) so already have peritoneal disease
-often intraperitoneal chemo

50

Which method of ovarian stimulation is more likely to result in multiple gestations

Clomiphene citrate (SERM); 10% risk

GnRH: 25% risk of multiple gestations

51

16 yo G1P1 p/w severe lower abdominal pain, F/C/N/V, rebound tenderness
-purulent vaginal d/c
-b/l adnexal fullness
-+ GC, -RPR, WBC 17.6 w/ left shift

Dx

PID
Major criteria = abdominal/adnexal pain
+
Minor criteria = white count, fever

52

Explain how giving GnRH can suppress ovulation

FSH/LH respond to pulsatile GnRH, not continuous => if you give continuous GnRH it'll suppress FSH/LH release

53

Mechanism of tx in endometriosis

Want to cause deciduation of the endometrial lining => use OCPs, progesterone, GnRH agonist (but only transiently b/c induces menopause)

54

Describe the staging of cervical cancer

Need to have a way to stage it worldwide (aka also in undeveloped countries) => cervical cancer is staged clinically
-staged w/ palpation: feel for parametrial involvement, CXR for pulm involvement

-in developed countries use CT/MRI to further characterize, but overall its clinical (physical exam) staging

55

Name 3 etiologies of hypergonadotropic hypogonadism

Hypergonadotropic hypogonadism = elevated FSH but no response => delayed pubrety
1. Turners (XO)
2. Mullerian agenesis
3. Imperforate hyman

56

Hormone replacement therapy

(a) 4 disadvantages (increased risk of...)
(b) Decreases risk of 2 things

HRT (referring to both estrogen and progesterone)

(a) Increased risk of
1. breast cancer (only w/ both E/P)
2. stroke
3. VTE
4. coronary artery disease (only w/ both E/P, not E alone)

(b) Decreased risk of
1. colon cancer
2. fractures

57

Rate of progression of the dif types of endometrial hyperplasias to cancer

quarter, dime, nickel, penny

25% complex w/ atypia => cancer
10% simple w/ atypia => cancer
5% complex w/o atypia => cancer
1% simple w/o atypia => cancer

58

Differentiate the two classifications of precocious puberty

GnRH dependent (high LH)

vs.

GnRH independent (LH doesn't increase w/ GnRH administration)

59

Mechanism of visualization in colposcopy

Acetic acid- use dilute acetic acid to make atypical cells turn white

60

How to equate the cytology and histology findings in cervical cancer

1/3 of the epithelium involved: LSIL, CIN I

2/3 of the epithelium involved: HSIL, CIN II and III