menstrual cycle - cervical abnorm Flashcards

Question

# Define Dysfunctional Uterine Bleeding (DMB) usually caused by problem with?

Answer 1

abnormal uterine bleeding unrelated to anatomical lesions of the uterus, pelvic pathology, pregnancy, or systemic disease; usually caused by a problem with the HPO axis Anovulation dx of exclusion!!! - r/o EVERYTHING else

Answer 2

_menopause_ * permanent cessation of menstruation; defined retrospectively * Average age of menopause is 51.4 years old in the USA _premature ovarian insufficiency (POI)/premature ovarian failure (POF_): premature menopause before age 40

Answer 3

* If patient presents with irregular menstrual cycles +/- menopausal symptoms… * \<40 y/o -\> complete evaluation * 45-50 y/o -\> evaluation similar to workup of oligo/amenorrhea, other causes of menstrual dysfunction must be ruled out * \>45 y/o -\> diagnostic testing not recommended

Answer 4

•Decline in the quality and quantity of follicles and oocytes _1 . Granulosa cell_s in follicles _stop making estrogen and inhibin_ 2. Loss of inhibin = loss of the negative feedback loop to hypothalamus and pituitary 3. Therefore _FSH and LH increase_ in production by pituitary 4. Ovary cannot respond to FSH 5. Permanent amenorrhea once all follicles are depleted

Answer 5

**_oral 17-beta estradiol:_** If baseline VTE and stroke risk low * AVOIDED in: * Hypertriglyceridemia * gallbladder disease * known thrombophilias * migraine headaches with aura **_transdermal 17-beta estradiol_**: Lower risk of VTE, stroke, & hypertriglyceridemia **_vaginal estrogen_**:Will only treat vaginal atrophy, not hot flashes, Progestin probably not needed , but maybe with vaginal creams due to higher systemic absorption May be used indefinitely, low risk of adverse effects * vaginal ring (estring) * vaginal tablet (vagifem) * vaginal cream (premarin or estrace) * unopposed estrogen therapy (ET) for women s/p hysterectomy * combined estrogen- progestin therapy (EPT) for women with an intact uterus Unopposed estrogen therapy is a risk for developing endometrial hyperplasia! •Give estrogen and progesterone bc progesterone is protective to the Uterus

Answer 6

Unopposed estrogen therapy is a risk for developing _endometrial hyperplasia!_ * Give estrogen and progesterone bc progesterone is protective to the Uterus * combined estrogen- progestin therapy (EPT) for women with an _intact uterus_

Answer 7

Used for women who are not candidates for MHT due to breast cancer or cardiovascular risk * SSRIs * SNRIs * anti-epileptics, and centrally acting drugs _low-dose paroxetine_ (7.5 mg/day) _1st choice_ because only drug that has received approval by the FDA for the treatment of hot flashes _Gabapentin_ (Neurontin) – especially if hot flashes occur primarily at night

Answer 8

* Breast cancer * Coronary heart disease (CHD) * Venous thromboembolism (VTE) * Cerebrovascular accident (CVA) * Transient ischemic attack (TIA) * Liver disease * Unexplained vaginal bleeding * Endometrial cancer

Answer 9

**in women \< 35 y/o = \>12 months** of regular intercourse / donor insemination without use of contraception i**n women \< 35 y/o = \>6 months** of regular intercourse or donor insemination without use of contraception

Answer 10

**Labs** TSH Prolactin CBC ABO, Rh, & antibody screening **ovarian evaluation** Antral Follicle Count (AFC) Anti-Mullerian Hormone (AMH) Day 3 labs (FSH & estradiol) -\> FSH is HIGH w/ LOW egg reserve, Measure at SAME time Clomiphene Citrate Challenge Test (CCCT) **uterine evaluation** _Hysteroscopy_ – look inside uterus w/ camera – no evaluation of tubes _Hysterosalpingogram (HSG)_ – **first evaluation**, looks at uterus and fallopian tubes (detect tubal lesions) •Uncomfortable and not well tolerated S_onohysterogram/Sonohystogram_ - saline infused into uterus w/ US guidance, can view ovaries as well •More comfortable and well tolerated

Answer 11

**•Based on the underlying pathology** Based on the manipulation of the HPO axis via _Ovulation Induction vs. Controlled Ovarian_ _Stimulation_ in combination with timed intercourse (TI), intrauterine insemination (IUI), or assisted reproductive technologies (ART) •Lifestyle modifications and psychological/emotional support are important Intrauterine Insemination (IUI) - Semen is spun down in the lab, washed, and injected into the uterine cavity via catheter threaded through the cervix In Vitro Fertilization (IVF) Cryopreservation

Answer 12

Irregular menstrual cycles (oligo- or anovulation) Hyperandrogenism Acne Hirsutism Male pattern (scalp) hair loss or thinning Deeping of voice and clitoromegaly rare Elevated serum testosterone Obesity Acanthosis nigricans Mood changes

Answer 13

**Rotterdam criteria** (must have 2/3 of the following) ## Footnote 1. Ovulatory dysfunction (oligo and/or anovulation) 2. Chemical and/or biochemical signs of hyperandrogenism 3. Polycystic “string of pearls” appearance of ovaries on transvaginal ultrasound

Answer 14

•Weight loss via diet and exercise is 1st line intervention

Answer 15

**•In women not pursuing pregnancy** FIRST LINE - (OCPs) SECOND LINE - Metformin * Antiandrogens added after 6 months of OCP use if response suboptimal… 1st line is Spironolactone 50- 100 mg twice/daily * GnRH agonists **•In women pursuing pregnancy** _FIRST LINE - Letrozole_ SECOND LINE - Clomid •although Letrozole is not approved by the FDA for this indication

Answer 16

\*General term for vag infxn, inflam, or chg in norm vag flora Sx: Discharge change, pruritus, odor, discomfort/dyspareunia, dysuria Majority is caused by infectious agents\*: \*\*90%; = Gonorrhea, Chlamydia, Mycoplasma (bacterial = MC)

Answer 17

**vLactobacilli (95%)!!** Ø Other 5% includes… * Streptocococci sp, Staphylococcus epidermis * Diptheroid sp. * \*Gardnerella vaginalis * Peptostreptococci sp, Bacterioides sp. , Anaerobic Lactobacillus * Ureaplasma urealyticum , Mycoplasma hominis **•Non keratinized, squamous epithelium, Estrogenized** •Rich in Glycogen -\> substrate for Lacto, breaks down -\> Lactic acid, fostering acidic envt -\> pH 4.0-4.5, maintaining norm flora **•Norm pH is 4.0-4.5** = important for DX vaginal issues\*

Answer 18

**Shift in vaginal flora from lactobacilli to diverse bacteria** •Increase production of amines by new bacteria **•pH rises-** loss of lactobacilli _• Leads to overgrowth of anaerobes_ •Anaerobes produce and enzyme that breakdowns vaginal peptides into amines producing the malodorous smell of BV Most common cause of abnormal vaginal discharge in women of childbearing age (40-50%) •50% AA

Answer 19

Gardnerella vaginalis Prevotella species Bacteroides species Porphyromonas species Peptostreptococcus Mycoplasma/ Ureaplasma **Resultant rise in pH to \>4.5**

Answer 20

Asymptomatic- 50-75% _Discharge (thin, off-white)_ Odor (fishy)- 50% More noticeable after intercourse During menses

Answer 21

Alone typically does not cause dysuria, dyspareunia, pruritis, or vaginal inflammation _•May be associated with acute cervicitis_ • Presence may suggest mixed vaginitis **•Think co-infectio**n – BV & yest commonly co-infected

Answer 22

**Amsel criteria** 1. _Thin, grayish-white discharge_ 2. _pH \>4.5_ 3. _Positive whiff test (amine)_- drop of KOH on sample of discharge with resultant fishy odor 4. _Clue cells_ on saline wet mount epithelial cell covered in bacteria “crushed glass” appearance = epithelial cells surrounded in bacterial

Answer 23

**Metronidazole** – do not drink alc = N/V Metrogel Clindamycin (avoid if pregnant / breast feeding) _**Alternative**:_ Tinidazole Clindamycin Clindmycin ovules **_Suppressive_**: recurrent BV * Metrogel 0.75% twice weekly for 4-6 months * Oral Metronidazole course, followed by boric acid 600 mg intravaginally for 21 days and suppressive metronidazole gel for 4-6 months

Answer 24

Characterized by inflammation in presence of Candida species (_Candida albicans 80-92%)_ •Present in normal flora of 25% of women _Second most common cause of vaginitis_ * As many as 50% of clinically dx women have another condition * Highest among women during reproductive years * Uncommon in postmenopausal women unless they are taking estrogen therapy and prepubertal girls

Answer 25

**Vulvar pruritis (dominant feature)** Burning, Soreness, Irritation Dysuria Dyspareunia Erythema of external genitalia, vagina and cervix Vulvar excoriation and fissures Scant discharge _Discharge is white, thick, adherent to vaginal walls, clumpy (cottage cheese)_ No or minimal odor Cervix is usually normal

Answer 26

Microscopy of vaginal dc pH is typically normal 4-4.5 \*\*\*\*\*\* • Distinguishes from BV, Trich KOH on discharge - \> Hyphae and budding

Answer 27

_Simple uncomplicated infection_ • Fluconazole (Diflucan) 150 mg 1 dose _Complicated Infections_ * Fluconazole 2-3 sequential doses 72 hours apart * 7-14 days of topical if preferred * Clotrimazole, miconazole, terconazole _Pregnancy_ • Clotrimazole, miconazole intravaginally x 7 days

Answer 28

Genitourinary infection with the protozoan _Trichomonas vaginalis_ The most common non-viral STD worldwide Can be asymptomatic

Answer 29

Mostly asymptomatic * Erythema of vulva and vaginal mucosa * **Classic green-yellow, frothy,** malodorous discharge (10-30%) * Punctate hemorrhages on cervix (s**trawberry cervix)** (2%)

Answer 30

5-nitroimidazole drugs are the only class that provide curative therapy * **Metronidazole** 500 mg BID x 7 days * **Tinidazole** 2 g qd x 2 days or 1 g qd x 5 days Tinidazole better tolerated with less GI side effects but $$$ Topical therapy is ineffective

Answer 31

MOSTLY asymptomatic: ## Footnote * _Mucopurulent or clear urethral discharge_ * Burning sensation * Associated with prostatitis, epididymitis, infertility, balanitis, prostate cancer

Answer 32

normal pH 4.0-4.5 BV - Elevated pH to \>4.7 Candidasis - pH is typically normal 4-4.5 Trich - pH is elevated \>4.5

Answer 33

Nucleic acid amplification tst (NAAT) Point of care (POCT) - AFFIRM VP III, OSOM Trich Rapid Test

Answer 34

Causes cervicitis in women and urethritis in men Extragenital infections- pharynx and rectum

Answer 35

**Women**: mostly asymptomatic _Cervicitis- most common friable cervical mucosa_ If sx do develop - w_ithin 10 days post exposure_ * Pruritis * Mucopurulent discharge _Pain is atypical unless PID-_ abdominal or dyspareunia •10-20% of women with gonorrhea develop PID

Answer 36

**_Men_**: Majority of men are asymptomatic _Urethritis_ Incubation period _2-5 days:_ Mucopurulent discharge Dysuria * Epididymitis can develop if not treated * Rare complications include penile lymphangitis, periurtehtral abscess * Urethral strictures

Answer 37

HX & PE **Genital swab-female** **Urine-male (first catch)** _NAAT (quicker than cx- looks for RNA test of choice for diagnosis_ •But does not test for susceptibility- culture

Answer 38

**_Ceftriaxone_** 250 mg IM x 1 plus However also recommended _is to add on **Azithromycin** 1 g x 1_ (Even if you are only treating gonorrhea) _Alternate: for cephalosporin allergy_ * Azithromycin 2 g PO x 1 plus * Gentamycin 240 mg IM x 1 _Pregnant women-same preferred regimen_ •Coinfection with _chlamydia should use azithromycin_ instead of doxy

Answer 39

Screening: Sexually active women 25 and under- annual

Answer 40

Gram-negative Chlamydia trachomatis – gram negative * Efficient disease transmission * Incubation period of symptomatic disease from 5-14 days * Long growth cycle-why treatment with antibiotics with a long half-life or a prolonged course is necessary

Answer 41

**Women: majority asymptomatic, rationale for screening** _•Cervix is the most common affected site_ * Nonspecific sx * Change in vaginal discharge * Mucopurulent endocervical dc * Cervical bleeding * Sexually active, young female with UA pos but cx negative, may or may not present with sx * Misdiagnosed as having cystitis unless specific chlamydia test is sent

Answer 42

**_Men: asymptomatic from 40-90%_** * **_Urethritis_** chlamydia is most common cause of nongonoccal urethritis * Mucoid or watery discharge which is scant * Dysuria * Incubation period is 5-10 days * Chlamydia frequent cause of epididymitis in men under 35

Answer 43

_Aptima Combo 2 Assay_ Xpert CT/NG- 90 minutes •First cleared for extragenital diagnostic testing of gonorrhea and chlamydia of throat and rectum

Answer 44

Azithromycin Doxycycline _Alternate_ Ofloxacin Levofloxacin _Pregnant-_ Azith, no doxy

Answer 45

**Pain is atypical unless PID**- abdominal or dyspareunia •10-20% of women with gonorrhea develop PID

Answer 46

Azithromycin instead of Doxy

Answer 47

**Chlamydia** Gonorrhea * 2nd MC reported communicable DZ, * 2nd most prevalent STI

Answer 48

GON - 1. 3. CHLA - 2 , 4

Answer 49

**Acute infxn of upper genital tract in W** _•Including uterus, ovaries, fallopian tubes, endometrium_ * Initiated by STI, \*_MC GRHEA or CHLA;_ * 15% of W with GRHEA and 30% (10-15%) of W with CHLA -\> will go on to dvp PID * GRHEA PID tends to be more severe * Prev has DEC in U.S, 90,000 outpt visits

Answer 50

Uterus Ovaries Fallopian tubes Endometrium

Answer 51

Neisseria gonorrhoeae Chlamydia trachomatis Mycoplasma genitalium E.coli (postmenopausal)

Answer 52

Typically acute but can be indolent and develop over weeks to months Varying clinical syndromes Mild vague pelvic symptoms to tubo-ovarian abscess Rarely fatal intra-abdominal sepsis **Liver inflammation-perihepatitis (Fitz-Hugh Curtis Syndrome) 10% of women with PID**

Answer 53

**-Lower ABD or pelvic pain (bilat); MC** - Character of pain variable, can be subtle; worsens with sex - Onset of pain during or shortly after menses; abnorm bleeding - Rebound tenderness, pelvic organ tenderness, fever, decreased bowel sounds, inflamm of genital tract (CMT) - Uterine + adnexal tenderness on bimanual - Purulent cervical or vaginal discharge

Answer 54

_\*Does not prompt W to seek car_e; SX not severe enough -\> _\*Sequelae can be devastating:_ -Tubal factor infertility **-Many W presenting with infertility due to tubal adhesions or distal tubal occlusion, which appear PID related, gave no HX of PID!!\***

Answer 55

HX: risk factors (sexual hx) PE: * Pelvic – pelvic organ tenderness (CMT) * Purulent discharge Imaging: CT (uncertain dx or complications), US _Additional Criteria]:_ 1. Temp \>101F (38.3 C) 2. Abnormal discharge 3. WBC on micro 4. Documentation of GC/Ch infxn 5. ELEV CRP

Answer 56

reproductive sequelae

Answer 57

Severe clinical illness – (high fever, N/V, severe ABD pain) Complicated PID with pelvic abscess Possible need for invasive diagnostic testing - (ex-lap) Inability to take PO meds; Lack of response to PO meds Concern for nonadherence Pregnant

Answer 58

**~ Mild to Moderate DZ:** \*Ceftriaxone IM + Doxy Cefoxtin IM + Doxy + Probenecid **~ Inpatient:** \*_Cefoxtin_ IV or Cefotetan IV _+ Doxy_ \*Clinda + Gentamycin

Answer 59

**Treponema pallidum** * Spirochete (delicate corkscrew shaped organism), discovered 1905 * Too small for ID on direct micro, complicates DX \***Transmission** occurs from direct contact with infectious lesion during intercourse * Can initiate infxn wherever inoculation occurs!!! * Can spread via kissing, touching person’s active lesions on lips, oral cav, breasts, or genitals * Crosses placenta; cause fetal infxn

Answer 60

\*Occurs within wks – mths after initial infxn 1°: Chancre = painless lesions @ site of inoculation 2°: Untreated = Dvp constitutional sx, rash, adenopathy, alopecia, hepatitis Early-Latent: ASX infxn acq within prev 12 mths = considered infxnious

Answer 61

Untreated pts that go on to dvp complications from infxn _Late-Latent_: untreated asyx after 12 mths = have DZ but not considered infective + are ASX _Tertiary_: major complications = \*\*Aortitis, Aortic Valve regurg, Gummatous DZ (granulomatous lesions everywhere)

Answer 62

**Non-Treponemal** Reagin antibodies – NON SPECIFIC Initial screening in ASX: cheap, easy Quantifiable: reported as titers (1:32) AB in serum diluted Can be used to monitor TX; titers DECLINE after TX! **Treponemal:** SPECIFIC for Abs against SPECIFIC treponemal antigens - INCly used as initial screen, not just confirmatory _(but can be used to confirm when nonT tests are reactive)_

Answer 63

**Early SYP]** \*Penicillin G benzathine \*Doxy **[Late SYP]** \*Penicillin G benzathine \*Doxy \*Prednisone –w/ CV SYP **[NeuroSYP]** \*Penicillin G cont.infusion \*Procaine penicillin IM + Probenecid \*Ceftriaxone D \*Doxy

Answer 64

6, 11, 16, 18:

Answer 65

**•When SX are absent = ‘Subclinical Viral Shedding’** * May occur quickly in new sex parts (3.5 mths) * Infreq condom use * 1° infxn incub after exposure: 4 D (2-12 range)

Answer 66

\*Most are ASX - Abnormal PAP or (+) HPV test may be 1st indication - Vulvar/vag warts - Itchy + painful - Most HPV strain that cause cervical cancer do NOT cause warts !!!!

Answer 67

**Routine vacc is recommended for ALL adolescents + young adults:** Young M&W – 26 11-12: (2) shots given 6-12 mths apart \>14: (3) shots given over 6 mths

Answer 68

Three vaccines available -\> 1. **9-valent (Gardasil-9): types 6,11,16,18,31,33,45,52,&58** 2. Quadvalent (Gardasil): 6,11,16,18 3. Bivalent (Cervarix): 16,18

Answer 69

\<21): no screening (21-29): PAP q 3 yrs, no HPV tst (30-65): PAP q 3 yrs & HPV tst q 5 yrs (\>65): no screening (hyster removal of cervix): no screening

Answer 70

**Self-admin** Podofilox gel Aldara + Zyclara (Imiquimod) cream Sinecatechins (Veregen) ointment **Office Based** Trichloroacetic acid (TCA): = remove vag warts Cryoablation: liquid nitrogen Laser ablation

Answer 71

**1°:** infxn in a pt w/o previous Ab’s **Non 1°** 1st episode: acq of gen HSV-1 in a pt with Ab’s to HSV-2 acq of gen HSV-2 in a pt with Ab’s to HSV-1 **Recurren**t: reactive of gen HSV in which HSV type recover from lesion = same type as Ab’s in serum

Answer 72

**1° - \*Painful gen ulcers = Systemic SX:** - Dysuria, fever, HA - Tender inguinal LAD - Infxn can be mild to ASX - SX tend to be more severe in W **Non 1 \*Fewer lesions, Less systemic SX** -AB’s from one HSV offer some protection against the other **Recurrent - \*Less severe than either 1° or Non1°** - Mean duration of lesions = shorter than 1° - Systemic SX infrequent _-Approx 25% of recurrent episodes are ASX_

Answer 73

Choice of test may vary with clin presentation - _Active lesions_ can be ‘unroofed’ for fluid (sent for viral cx & PCR) - Serologic testing

Answer 74

Even though it is one of the MC STI’s, it is **NOT recommended in ASX adolescents & adults**

Answer 75

**1° HSV Infxn**: \*b/c DZ tends to be more severe; all pts should be _started on antivirals w/I 72 hrs of onset of clinical SX (_Usu duration = 7-10 D) Famciclovir 250 mg TID Acyclovir 400 mg TID, or 200 mg 5x daily Valacyclovir 1000 mg BID **Recurrent DZ: Chronic Suppressive Therapy** - Acyclovir 400 mg BID Famciclovir 250 mg BID Valacyclovir 500 mg QD, or 1000 mg QD **Episodic Therapy -\>** Acyclovir Famciclovir Valacyclovir

Answer 76

Fibrocystic Breast Changes

Answer 77

_fibrocystic_ Hormone induced breast changes -cyclic in nature Painful bilateral breasts, Freely moving in regard to adjacent structures “Lumpiness” fluctuates with the menstrual cycle _fibroadenoma_ noncyclic, Painless, Increase size with pregnancy •Round, oval, Hard or rubbery

Answer 78

* _Ultrasound_ = Distinguishes cystic from solid mass * _Fine Needle Aspirate_ = US is done before a fine needle aspirate with cyst. * _Mammogram_ = Further evaluation of clinically suspicious masses & Further evaluation of solid masses * _Core Needle Biopsy (CNB)_ = for solid mass, definitive dx for fibroadenoma

Answer 79

It's a scoring system radiologists use to describe mammogram results. ## Footnote _Simple_ – reassurance _Complicated_: risk of cancer directly related to findings on bx * BI-RADS 2 – benign * BI-RADS 3 – repeat imaging in 6 mo, FNE can be performed instead of 6mo imaging to Confirm lesion is benign. _Complex_: BI-RADS 4/5 * Require ultrasound guided CNB to Dx benign vs malignant. * FNE is NOT sufficient

Answer 80

fibroadenomas

Answer 81

Blockage of duct and reduced drainage _Offending organism: S. aureus, MRSA_ -\> grows in stagnant milk _Antibiotics_: dicloxacillin or cephalexin Get rid of milk

Answer 82

Breastfeeding or pumping is important for resolution of infection and relief of discomfort. Reduces duration & Improves outcomes I&D _Empiric therapy against S. aureus_ * Dicloxacillin * Cephalexin * trimethoprim-sulfamethoxazole

Answer 83

Gynecomastia ## Footnote Caused by an increase in the ratio of estrogen to androgen activity

Answer 84

concentric, rubbery-to-firm disk of tissue often mobile located directly beneath the areolar area

Answer 85

_Be careful to differentiate from:_ pseudogynecomastia = (fat) from breast carcinoma = (commonly unilateral, non-tender, fixed masses) **Don’t miss a testicular cancer! \***

Answer 86

**fibroadeonma - 10-30** s_mooth, rubbery_, round, _NONTENDER, PAINLESS_ **fibrocystic & cancer - 30 - 50** _"lumpy"_ rope-like, _tender_, size _fluctuation w/ menses_ / premenstraul pain is worse, cysts are round and mobile **cancer until proven otherwise - \>50** firm, hard, _non-tender, irregular borders, fixed to usrrounding tissue_

Answer 87

Most common non-invasive: Ductal carcinoma in situ Most common invasive: infiltrating ductal

Answer 88

breast cancer ## Footnote 2nd most Dx malignancy behind lung cancer

Answer 89

_Early_ * Immobile, fixed, ill-defined margins * Linear calcifications on mammography **•Painless mass** _Late_ * Mass fixed to skin/chest wall * Skin/nipple retractions * Asymmetrical breast enlargement * Breast edema, erythema, and **pain** * Bloody nipple discharge * Jaundice **•Bone pain** **•Weight loss** **•Peau D’ orange** - Resemblance to the skin of an orange due to lymphedema

Answer 90

_Inflammatory_: Rapidly progressing, tender, firm, and enlarged breast with thickening of the underlying skin * Require full-thickness skin biopsies * Presence of dermal lymphatic invasion = Inflammatory Breast Cancer * It is important to rule out inflammatory breast cancer if a suspected breast infection does not respond to antibiotics _Lymphadenopathy_: * Normal lymph nodes are movable, non-tender \<5 mm * Nodes affected by malignancy, Matted, hard, firm, immovable * Fixed to skin or deeper tissues * \>1cm denote metastases **•Axillary LN involvement and/or Supra/infraclavicular nodes (think metastatic disease)** **•Sentinel nodes are first lymph nodes targeted by tumor invasion** •Sampled 1st in surgery to check for spread

Answer 91

Her 2+ = herceptin ER/PR+, HER - = tamoxifen, aromatase inhibitors

Answer 92

**•ER/PR+, HER2-)** = premenopausal women _side effects:_ DVT, uterine cancer, vasomotor sx •Given for 5-10 yrs then switch to AI dec reccurrence by 40-50%, dec mortality by 25% caution w/ strong CYP2D6 inhibitors

Answer 93

**ER/PR+, HER2-**) - CI in premenopausal women side effects: Less DVT / uterine ca B_UT more bone loss, myalgia and arthralgia_ superior to SERM anatrozole exemestane letrozole

Answer 94

**•HER2+** w/ chemo regimen * Against HER-2 oncogene (+) ‘over-expression’ * Dramatically improved survival

Answer 95

Bone * Liver * Lung * Brain

Answer 96

sentinel LN

Answer 97

_mammo_ - For women at average risk, screening mammograms should be performed annually **beginning at age 40** _US_**-** diagnostic follow-up of an abnormal screening mammogram * can differentiate a solid mass from a cyst * to provide guidance for biopsies and other interventions **•Ultrasound is the first line of imaging in a woman who is pregnant or less than 30 years old with focal breast symptoms or findings**

Answer 98

Ultrasound is the first line of imaging in: a woman who is _pregnant_ _\<30 years ol_d with focal breast symptoms or findings

Answer 99

**Leiomyoma (Fibroids)** Benign tumor arising from smooth muscle cells of the myometrium * Resemble normal tissue * Feel firm and smooth

Answer 100

Locations: **•Intramural Myoma** * Subserosal Myoma * Submucosal Myoma * Cervical Myoma * Pedunculated (Stemmed)

Answer 101

**Enlarged Uterus** **Irregular Uterus** **+/- Tender uterus** _Transvaginal Ultrasound_ Saline Infused Sonography (sonohysterography) Hysteroscopy MRI Hysterosalpingography (HSG)

Answer 102

**Goal: Symptomatic relief** Studies have found menopause causes fibroids to shrink → relief of symptoms _Treatment options:_ Watchful waiting Medical Management * NSAIDS – only for dysmenorrhea * OCPS * Levonorgestrel IUD (Mirena/Skyla) * Gonadotropin releasing hormone (GnRH) * Danazol _Surgery:_ Mainstay of treatment •Indications for treatment: AUB, bulk related symptoms, infertility, recurrent miscarriages

Answer 103

Ectopic endometrial tissue within the _myometrium_ * Ectopic tissue induces hypertrophy and hyperplasia in the myometrium * Diffusely enlarged uterus → “Boggy Uterus” Resemble fibroids

Answer 104

**Definitive diagnosis only via histology s/p hysterectomy** Transvaginal ultrasound and MRI very helpful MRI better but more expensive – _KEY WORDS:_ * “Asymmetric thickening of the myometrium” * “Linear striations” * “Loss of clear endomyometrial border” * “Increased myometrial heterogeneity”

Answer 105

**_Hysterectomy_ – only guaranteed treatment** _Uterine artery embolization_ – some success (not well studied) _OCPs/IUD_ – Can attempt to help decrease bleeding and pain. --\> Not FDA approved for Adenomyosis _Gonadotropin releasing hormone analogs (Lupron) and Aromatase Inhibitors (Anastrozole, Letrozol_e •May decrease dysmenorrhea and menorrhagia symptoms, Temporary

Answer 106

_Leiomyoma (Fibroids)_ - Benign t**umor arising from smooth muscle cells** of the myometrium ## Footnote •Resemble normal tissue, Feel firm and smooth _Adenomyosis_: **Ectopic endometrial tissue** within the myometrium * Ectopic tissue induces hypertrophy and hyperplasia in the myometrium * Diffusely enlarged uterus → “Boggy Uterus”

Answer 107

**Leiomyoma (Fibroids) :** Most are small and asymptomatic, Heavy or prolonged menstrual bleeding **Adenomyosis**: Diffusely enlarged uterus → “_Boggy Uterus_ * Heavy Menstrual Bleeding – 65% * Dysmenorrhea- 25% * Chronic pelvic pain

Answer 108

Presence of normal endometrial mucosa abnormally implanted in locations other than the uterine cavity Ectopic areas respond to cyclical hormonal fluctuations similar to intrauterine endometrium Including release of prostaglandins leading to inflammatory process and scarring of ectopic areas Estrogen dependent disease – Menopause leads to resolution of symptoms

Answer 109

**•Ovaries (MOST COMMON)** * Uterus (Perimetrium) * Posterior cul-de-sac * Broad ligament/Uterosacral ligament * Rectosigmoid colon * Bladder

Answer 110

**Severity of symptoms do not always correlate to extent of disease** Asymptomatic Dysmenorrhea Heavy or irregular bleeding _Lateral displacement of the cervix_ _Localized tenderness in the posterior culde-sac (Pouch of Douglas)_ _Palpable tender nodule in the posterior cul-de-sac (Endometrioma)_

Answer 111

**_Laparoscopy with biopsy_ – Primary diagnostic modality** •Classic blue black or powder burned appearance _Transvaginal or Endorectal ultrasonagraphy_ _Pelvic Ultrasound_ • first line study to help rule out other pathology and identify findings suggestive of endometriosis _MRI_

Answer 112

_Endometrioma_ – “Chocolate Cyst” •Most common on ovaries

Answer 113

**95% response to medical management – 50% will have return of symptoms after 5 years of medical management** _Hormonal Contraceptive:_ Combined (Estrogen/Progestin) •Progestin only _(GnRH) analogues (Lupron)_ • Restricted to 6 months --\> Risk osteoporosis and lots of menopause type side effects _Danazol (Androgenic Steroid)_ *Surgical Options:* _Hysterectomy_ with or without bilateral oophorectomy – Hysterectomy with BSO considered definitive therapy _Laparoscopic uterine nerve ablation_ – Resection of nerve bundles _Drainage and laparoscopic cystectomy_ L_aparoscopy and surgical endometrial implant ablation_ – Reoperation rate high 50%

Answer 114

Cyst: sac filled with liquid or semiliquid material Occur in women of all ages including neonatal/infancy phases • Most prevalent during infancy, adolescence, and childbearing years _Functional ovarian cysts_ → Most common cystic ovarian lesion – Occur most commonly in women of reproductive age * Follicular * Corpus luteal cyst * Theca lutein cyst * Endometrioma _Simple cyst_: Simple fluid, thin wall. E.g: Follicular, Luteal, serous cystadenoma _Complex cyst:_ debris, blood, varied wall thickness, septations, hemorrhagic

Answer 115

* Follicular * Corpus luteal cyst * Theca lutein cyst * Endometrioma

Answer 116

_Follicular Cysts_ * Balloon does not pop / NO RUPTURE – cyst is formed * Resolve spontaneously 2-3m -\> 70-80% resolve on their own On ultrasound, present as simple unilocular, anechoic cysts with a thin, smooth wall _Corpus Luteal Cyst_ •Occurs after ovulation– it pops but corpus luteum does not dissolve and becomes cyst •Thicker walls “Ring of Fire” Doppler appearance = ring of blood flow

Answer 117

•Hormonal Overstimulation by βhCG – hyperstimulation ovaries and cysts created bilateral Gestational Trophoblastic Disease; Hormonal therapy (E.g. infertility treatment); - seldom in singleton pregnancy Septations do not show enhancement on ultrasound

Answer 118

* Cyst formed with endometrial tissue → “Chocolate Cyst” * Most common during reproductive years Chronic pelvic pain Hormonally responsive

Answer 119

* 10 or more peripheral simple cysts * **Characteristic “string-of-pearls” appearance**

Answer 120

Mature Cystic Teratoma Cystadenoma Cystadenofibroma

Answer 121

Mature Cystic Teratoma •Do not resolve spontaneously **•Associated with ovarian torsion if \>5cm** •10% of all ovarian neoplasms – can turn into cancer

Answer 122

Serous – older women (40-50 yo) * Benign ovarian tumors * 15-25% bilateral _Mucinous_ - less frequent than serous, younger women (20-40 yo) * Can be very large * Filled with mucinous material * 5-10% bilateral

Answer 123

_Cystadenofibroma_: Rare & Benign •Surface epithelial tumor of ovary Common in 15-65 yo * Complex cystic to solid appearing mass * Tx: Oophorectomy (ovary removal)

Answer 124

reproductive age - Mature Cystic Teratoma 40-50 - Cystadenoma (serous) 20-40 - Cystadenoma (Mucinous) 15-65 -Cystadenofibroma

Answer 125

Sudden onset sharp pain

Answer 126

**_Ultrasound_ – First line method of choice** •Helps distinguish complex, simple or solid lesions _CT Pelvis_ - Only for malignancy staging _MRI_ - Done after u/s if needed * Can evaluate for complex masses * Use with caution as may delay care if neoplasm is of concern

Answer 127

Reproductive Age _Simple:_ * \<5 cm observe * 5-7cm f/u annually * \>7 cm either MRI or surgery _Hemorrhagic:_ • \>5cm f/u ultrasound 6-12 weeks

Answer 128

•\>1cm-7cm ultrasound annually +/- CA-125

Answer 129

_Dermoid_ * U/S q6-12 months * Cystectomy _Endometrioma_ * Initial f/u ultrasound 6-12 weeks * U/S annually * Cystectomy

Answer 130

_Analgesia management_ _Hormonal Contraceptio_n - Recurrent Functional Cysts Indications for _ovarian cystectomy or oophorectomy_ * Symptomatic cysts – Persistent 5-10cm cysts (esp. symptomatic) * Ovarian Torsion or Suspected malignancy _Surgery not indicated required for_ * Follicular or Corpus Luteal Cyst * unless very large or hemorrhagic with rupture

Answer 131

Herniation of pelvic organs to or beyond the vaginal walls Anatomic support of pelvic organs via pelvic floor and connective tissues. * _Levator ani muscle complex_ – primary support * Pubococcygeus * Puborectalis * Iliococcygeus

Answer 132

_•Anterior Compartment Prolapse (Cystocele)_ –Hernia of anterior vaginal wall with descent of bladder _•Posterior Compartment Prolapse (Rectocele) -_Hernia of posterior vaginal segment with descent of the rectum. _•Enterocele_ –Hernia of the intestines to or through the vaginal wall.

Answer 133

**Sitting on egg or balloon** **Prolapse does NOT cause pain \*\*\*** _Defecatory Symptoms:_ *Constipation – most common\** * Fecal urgency * Fecal incontinence, e.g. during intercourse * Incomplete emptying _Urinary symptoms_ * Slow urine stream * Sensation of incomplete emptying * Overactive bladder (urgency, frequency, incontinence) * 2-5x increase risk _Sexual_ * Avoidance, shame * +/- dyspareunia

Answer 134

**Simplified Pelvic Organ Quantitation System (POP-Q)** _Stage 0_- No prolapse _Stage I_ –Prolapse 1cm above hymenal plane _Stage II_ – Prolapse descends to introitus _Stage III_ – Prolapse greater than 1cm past hymenal remnant, *but does not cause complete vaginal vault eversion or complete uterine procidentia.* _Stage IV_ – Complete vaginal vault eversion or complete uterine procidentia, * i.e. vagina and/or uterus are maximally prolapsed with entire extent of vaginal mucosa everted

Answer 135

Indicated only for symptomatic (urinary, bowel, or sexual dysfunction) _•Do NOT have to treat if patient is asymptomatic_ or if they are not bothered by their symptoms **Conservative:** _Pessary_ - Silicone devices vary size and shape * 50% discontinue use after 1-2 years * Must be removed and cleaned regular basis P_elvic Floor Muscle Exercise (PFME)_ - Physical Therapy **Surgical**: Anterior vaginal wall prolapse repair - _Anterior colporrhaphy_ (highly recurrent) Posterior vaginal wall prolapse repair - _Posterior colporrhaphy_ _Apical defect_ * Sacral colpopexy * Hysterectomy with Uterosacral or Sacrospinous Ligament Suspension

Answer 136

**Ovarian torsion** – 70% women 20-39yo age, _Mature Cystic Teratoma_ * Adnexa and ovary typically involved * Most cases involve ovarian masses measuring 6-10cm _•Typical symptoms_ –sharp sudden, then waxing/waning pain, n/v _•Goal of emergent surgery_: laparoscopic detorsion for adnexa and ovary salvage → TIME IS OVARY **Hemorrhagic cyst** - Rupture and internal bleeding • Common – _Corpus luteal cyst_ day 20-26 of cycle Persistent pain or pressure

Answer 137

Prolapse does NOT cause pelvic pain \*\*\*\*\* •Main concerns are: * inability to empty bladder (incr. risk for infections) * and defecatory dysfunction

Answer 138

* Low-grade squamous intraepithelial lesion (LSIL) * High-grade squamous intraepithelial lesion (HSIL)

Answer 139

**CIN 1 -\> LSIL** (condyloma/cervical intraepithelial lesion) **•CIN 2** * p16-negative are referred to as LSIL * p16-positive are referred to as HSIL **CIN 3 -\> HSIL**

Answer 140

**Role of human papillomavirus** - HPV infection is necessary for development of cervical neoplasia * HPV alone is not sufficient to cause these disorders **HPV types/persistence** **Cervical “transformation zone” (T-zone)**- of the cervix is the site of carcinogenesis by infection with oncogenic subtypes of HPV **Sexual transmission**

Answer 141

**•Low-risk types** (HPV 6 and 11) **• High-risk types** (HPV 16 and 18) * Squamous cell carcinoma – HPV 16 (59%), 18 (13%) * Adenocarcinoma – HPV 16 (36%), 18 (37%)

Answer 142

The reason HPV infection persists in some women and not in others is **unknown** **•Older age** - 50% high-risk HPV infections persist in women older than 55 years of age 20% rate of persistence in women under age 25 **•Duration of infection** - The longer an HPV infection has been recognized, the longer it will take to clear •**High-risk HPV subtype** - More likely to persist than low oncogenic types

Answer 143

•The area when glandular epithelium replaces squamous epithelium is called transformation zone (T-zone) Cervical neoplasia originates within the T-zone

Answer 144

**Primary prevention** - vaccination •condoms are only partially protective **Secondary prevention** - aimed at cervical cancer rather than CIN itself •CIN -\> appropriate monitoring and treatment

Answer 145

**_•Quadrivalent vaccine (Gardasil)_ targets HPV types 6, 11, 16, and 18. - targets all 4 subtypes** •_9-valent vaccine (Gardasil 9)_ targets HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58. - Targets high risk HPV _Bivalent vaccine (Cervarix)_ targets HPV types 16 and 18.

Answer 146

**Children and adults aged 9‐26 yo** * routinely recommended at age 11 or 12 y; * vaccination can be given starting at age 9 yo. **Adults aged \>26 yo** * Catch‐up HPV vaccination is not recommended for all adults **Special populations** _pregnant_ - delayed until after pregnancy. _breastfeeding or lactating_ - can receive HPV vaccine.

Answer 147

**Cervical cancer screening co-testing** Testing with both cervical cytology (Pap test) and high-risk HPV infection **Reflex HPV testing aka HPV triage** The collection of a specimen for HPV testing when the cytology sample is collected, but performing the HPV test _only if the cytology results are ASC-US_

Answer 148

**ASC-US** - Atypical squamous cells of undetermined significance ## Footnote More marked than simple reactive changes but do not show LSIL abnormalities Reflex HPV testing aka HPV triage **ASC-H** - Atypical squamous cells: cannot exclude high-grade squamous intraepithelial lesion Cells that likely consist of a mixture of true high-grade SIL and other findings that mimic such lesions require further HPV testing - _Cervical cancer screening co-testing_

Answer 149

* **The mainstays of treatment of HSIL are _excision_ and _ablation_ of the transformation zone of the cervix** * _Hysterectomy_ is an option for women who are * incompletely treated with excision or ablation * who have recurrent CIN

Answer 150

**Excisional treatments** are referred to as _cone biopsies_ or cervical conization •_LEEP_, Loop electrosurgical excision procedure, also called large loop excision of the transformation zone (LLETZ) _•Laser conization_ is another technique **Ablative treatments** use an energy source (eg, _cryotherapy_, laser) to destroy the transformation zone

Answer 151

_Expedited treatment_ - treatment with excision (usually in the form of loop electrosurgical excisional procedure [LEEP]) without having first doing a colposcopy •**SKIP CULPOSCOPY!!!\*\*\* if immediate CIN3+ risk _\>_4%**

Answer 152

* Irregular or heavy vaginal bleeding * Post-coital bleeding - most specific presentation of cervical cancer, may also result from cervicitis

Answer 153

1. Oncogenic HPV infection at the cervical transformation zone 2. Persistence of the HPV infection 3. Progression from persistent viral infection to pre-cancer 4. Development of carcinoma and invasion

Answer 154

**microinvasive disease (stage IA1) with no evidence of intermediate- or high-risk features** - conization or extrafascial hysterectomy – preferred **stage IA2 and IB1** - modified radical hysterectomy **IB2 stage** - radical hysterectomy **early-stage cervical cancer with intermediate-risk features** - adjuvant chemoradiation rather than RT alone **early-stage cervical cancer with high-risk features** - adjuvant chemoradiation rather than RT alone

Answer 155

epithelial ## Footnote •Ovarian cancer is the second most common gynecologic malignancy and the most common cause of gynecologic cancer death

Answer 156

_Genetic predisposition_ * The Lynch syndrome * BRCA gene mutations _Age_ - The incidence of ovarian cancer increases with age

Answer 157

Previous pregnancy Use of OCPs Breastfeeding ALL result in less ovulation = less chance to damage ovary

Answer 158

Infertility Endometriosis PCOS Cigarette smoking ALL result in INCREASED ovulation = more likely to damage ovaries

Answer 159

_Acute presentations_ Pleural effusion Bowl obstruction _Subacute presentations_ Adnexal mass – palpate mass in abdominal region Pelvic or abdominal pain Bloating GI symptoms

Answer 160

_Presence of early symptoms_ Advanced epithelial ovarian cancer typically presents with abdominal distention Nausea Anorexia or early satiety due to the presence of ascites and bowel metastases **Most women with epithelial ovarian cancer have pelvic or abdominal symptoms prior to their diagnosis** _Role of early detection_: The goal of early detection is to reduce epithelial ovarian cancer mortality

Answer 161

Tumor markers - CA 125 ( most common biomarker used to detect ovarian cancer) Pelvic ultrasonography Pelvic exam _1. initial evaluation_ * If there is no indication for diagnostic surgery -\> an evaluation for other etiologies * If an adnexal mass is found and based upon the initial evaluation, there is a suspicion of EOC -\> surgical evaluation _2. Surgical evaluation_

Answer 162

**•Histopathologic examination of excised tissue – GOLD STANDARD** •Evaluate pelvic mass _•Serum CA 125 is for the evaluation of adnexal masses_ * OVA1 and Overa (aka OVA2) are serum biomarkers for evaluation of malignancy * includes CA 125, HE4, and three additional markers

Answer 163

Refer if ANY are present: **premonopausal** elevated CA 125 level ascites evidence of abdominal or distant metastases **postmenopausal** all above + nodular or fixed pelvic mass

Answer 164

**The novel immunotherapeutic vaccine DSP-7888** (ombipepimut-S or adegramotide/nelatimotide), in combination with pembrolizumab (Keytruda) * The anti-cancer vaccine t_argets the Wilms Tumor 1 (WT1) protein_ * DSP-7888 _induces WT1-specific cytotoxic T lymphocytes and helper T cells to attack WT1-expressive cancer cells_

Answer 165

No North-American expert groups recommend routine screening for ovarian cancer. The US Preventive Services Task Force (USPSTF) recommends **against screening for ovarian cancer, except for the known carriers of genetic mutations that increase ovarian cancer ris**k.

menstrual cycle - cervical abnorm Flashcards

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