Flashcards in OB GYN Deck (157)
Physiologically, what is responsible for dysmenorrhea?
Prostaglandin release from the endometrium
What contraceptive therapies can reduce dysmenorrhea? (3)
- Combined OCPs
- Intravaginal ring
- Progesterone implant
- Mirena IUD
What contraceptive therapies can reduce dysmenorrhea A/W ENDOMETRIOSIS? (4)
- Combined OCPs
- Progesterone implant
- Mirena IUD
- Depot provera
How long before combined OCPs control the (name this symptom) a/w menstrual irregularities?
How effective (%) is the progesterone-only OCP for controlling menstrual irregularities?
Besides OCPs, what are 2 other methods of controlling menstrual irregularities?
- Depot provera
- Mirena IUD
(but they both have initial irregular bleeding)
Can women on OCPs still have PMS sx?
- May benefit from a longer interval
What are some alternatives to surgery for menorrhagia?
- OCPs (reduce blood loss 40-50%)
- Mirena IUD, implanon (a/w initial bleeding, but good outcomes)
Which of the following is the best for treating menorrhagia?
- Endometrial ablation
- Mirena IUD
What are the 2 most cost-effective treatments for menorrhagia?
- Combined OCPs
- Mirena IUD
What is the only therapy proven to improve pre-menstrual dysphoric disorder?
OCPs containing Drospirenone
What therapy can also be helpful in suppressing menstruation, therefore limiting PMS?
Extended-cycle combined OCPs
What types of contraceptive therapies can reduce or eliminate migraines?
Extended cycle contraceptives (OCPs, depot-provera, patch)
- Due to fluctuation in hormones
For women who experience migraines w/ focal neurologic signs, smoke, or are > 35, what contraceptive therapies should they use?
Progesterone only, barrier, or IUD contraception
What contraceptives are effective in reducing hirsutism and acne?
*All combined oral contraceptives
- ^ SHBG, suppress LH-driven hormone production, thereby reducing free androgen levels
Although all combined contraceptives can reduce hirsutism and acne, how can this effect be enhanced?
Combined OCPs containing anti-androgen preparations (drospirenone, cyproterone acetate) were superior in some comparative trials
- Drospirone also reduces PMS sx in combined OC's
What is a possible explanation for why the patch and vaginal ring are less effective in controlling hirsutism and acne?
They bypass the first-pass effect of the liver and may be less effective as a result
How effective are progesterone-only preparations for treating acne?
What contraceptive techniques can be used to treat endometrial cancer?
- Combined OCs (reduce risk 50%, short or long-term)
- Depot provera (similar reduction)
- Mirena IUD (can be used to treat hyperplasia w/o atypia, although regular surveillance is still essential)
What contraceptive form is effective for reducing the risk of ovarian cancer?
Combined OCs (reduce risk 27%)
- Length of use increases risk reduction
What contraceptive form is effective for reducing the risk of colorectal cancer?
Combined OCs (reduce risk 18%)
How do OCPs alter ovarian cysts?
They do not change regression
How can OCPs affect bone mass in premenopausal women?
- Premenopausal: may decrease bone mass (take adequate calcium)
- Postmenopausal: may increase bone mass
Do OCPs reduce fx risk?
No good studies
How do depot provera and implanon affect bone mineral density?
May decrease, but resolves s/p discontinuation
How do OCPs affect leiomyoma size?
- Mirena: no effect
- Asx bacteruria
- Acute pyelonephritis
o Asymptomatic bacteriuria – considerable bacteriuria in a pt w/o symptoms
o Cystitis – infection limited to the lower urinary tract (dysuria, frequency, urgency)
o Acute pyelonephritis – infection of the renal parenchyma usually w/ fever and flank pain
Define UTI "relapse".
Define UTI "reinfection".
Relapse – recurrent UTI w/ same organism after adequate therapy
Reinfection – recurrent UTI by same organism after intervening negative UCx, or recurrent UTI w/ different organism
More than __% of women will get a UTI in their lifetime.
________ (organism) causes most UTIs.
(has virulence factors that help it chill in bladder)
What are some UTI r/f's for school-aged girls?
- New onset sex
- Congenital abnormalities
What are some UTI r/f's for premenopausal women?
- History of UTIs
- Frequent sex
- Diaphragm use
- Frequent spermicide use
- Renal stones
- Urinary retention (MS, paraplegia, etc.)
What are some UTI r/f's for postmenopausal women?
- Vaginal atrophy
- Urinary retention
- Poor hygiene
- Pelvic organ prolapse
- Type 1 diabetes
- History of UTI
Recall: sx of cystitis? (dx of UTI)
- Suprapubic tenderness
If you see cystitis sx, what must you r/o?
- Urethritis from GC-chlamydia or HSV can be similar
- Pyelonephritis: fever and chills, flank pain, varying degrees of other sx
How could a UTI appear in an older woman?
Older women may be asymptomatic, have sepsis, urinary continence, or any other sx above (frequency, urgency, dysuria, suprapubic tenderness)
Diagnosis of significant bacteriuria is > ________ colonies, but ________ to _________ in a symptomatic woman may be acceptable.
If you see leukocyte esterase or nitrites on a UA, are you done with w/u for UTI dx?
Fast but false negatives happen so you should get a UCx and UA anyways
UTI abx resistance rates > __ to __ % necessitate a change in antibiotic class.
List 5 tx regiments for uncomplicated acute bacterial cystitis, starting w/ the preferred tx.
- bactrim 1 tablet BID 3 days (preferred therapy)
- trimethoprim 100 mg BID 3 days
- cipro 250 mg BID 3 days
- Nitrofurantoin monohydrate 100 mg BID 7 days
- fosfomycin 3 g single dose
Is outpatient treatment ever okay for pyelonephritis?
Okay in stable patients who can take PO meds
Generally, how long is abx tx for cysitis vs. peylonephritis?
3 days (cystitis) vs. 14 days (pyelo)
What are some good antibiotic mgmt strategies for pyelonephritis?
IV or PO:
• Gram positive organism on stain – amoxicillin or ampicillin
• cipro (bactrim if resistance patterns are known and low)
• for septic pts, amp + gent, zosyn, fluoroquinolones, or 3rd gen
cephalosporins alone or in combination
Recurrent UTI occurs to __ to __% of women within 1 year of UTI.
Women have a __ to __% change of frequent UTIs over "many years"
Discuss how you'd treat recurrent UTIs.
- What if they have FREQUENT recurrence?
- What if they have a known post-coital risk?
- *Risk assessment and behavioral change are important
- Nl tx as above ok, w/ test of cure after 1-2 weeks
- For frequent recurrence: once daily tx for 6-12 months w/ reassessment after
- Women w/ known post-coital risk: post-coital prohylaxis w/ single dose of agents above is effective
Which UTI medication is less effective in post-menopausal women?
Fosfomycin (should not be used)
For pts w/recurrent UTIs, after they take their 3-day therapy, they should return if sx don't improve after how long?
In UTI, when is a UCx helpful?
UCx can be helpful in pt’s w/ persistent sx for 48 hrs on treatment or in recurrences
Is imaging useful during UTI tx?
Imaging not cost-effective or useful unless no response to therapy or clinical worsening on tx w/ other tests (UCx) already done
Which antibiotic can cause hemolytic anemia in G6PD deficiency?
Nitrofurantoin (so ask for OSCE)
Which of the following have been shown to be effective in reducing UTI recurrence?
Postcoital voiding, aggressive hydration, douching, yogurt to the vagina, and wiping techniques.
How is cranberry juice useful in the UTI world?
Cranberry juice/tablets are effective in reducing recurrences, but ideal dosing and duration not known
Are methenamine salts useful in preventing UTI recurrences?
Is estrogen tx useful in preventing UTIs in women?
Estrogen therapy may be beneficial in preventing recurrence in postmenopausal women, but more evidence is needed
Is screening and treating asymptomatic bateriuria in nonpregnant women recommended or supported by evidence?
What are some HPI questions to ask w/r/t vaginitis?
- Change in discharge
- Malodor, itching
- Location (vulva, vagina, anus)
- Relation to menstrual cycle
- Sexual history
- Response to prior treatment including self-treatment and douching
If sx of vaginitis, samples should be taken for the following tests during speculum exam:
Amine "whiff" test
Wet mount (saline)
(10%) KOH microscopy
In vaginitis pts, samples for pH should be taken from the _________________.
Mid-vaginal side wall
Dx of candidiasis requires 1/2 of the following:
(1) visualization of blastospores or pseudohyphae
(2) positive culture in a symptomatic woman
What differentiates uncomplicated from complicated vulvovaginal candidiasis?
- Sporadic or infrequent episodes
- Mild-mod sx or findings
- Suspected Candida albicans infxn
- Nonpregnant woman w/o medical complications
- Recurrent episodes (4+ / yr)
- Severe sx or findings
- Suspected or proved non-albicans Candida infxn
- Women w/ DM, severe medical illness, immunosuppression, other vulvovaginal conditions
What are 2 routes that uncomplicated vaginal candidiasis can be treated?
Topically or orally
Can vaginal candidiasis in pregnancy be treated with topical, oral, both, or neither abx?
(oral dose may be a/w birth defects)
Describe the tx regimen for uncomplicated candidiasis? How does it differ for complicated candidiasis?
Oral fluconazole 150 mg then 150 mg (+ another dose 3 days later for complicated candidiasis)
How long should RECURRENT vulvovaginal candidiasis be treated for? (give interval and med name)
Weekly fluconazole for 6 months
How is bacterial vaginosis dx'd?
Wet mount, culture, or POC rapid antigen test
Describe the 2 medication regimen options for trichomoniasis.
Describe the 2 medication regimen options for BV.
1) Metronidazole 2,000 x 1, 500 BID x 7
2) Tinidazole 2,000 x 1
In bacterial vaginosis, does partner need to be treated?
What should be avoided with metronidazole?
- For how long w/metro?
- For how long w/ tinidazole?
- No alcohol for 24 hrs after metro
- No alcohol for 72 hrs after tinidazole
Name some organisms that can overgrown in BV.
- Gardernerella vaginalis
- Mycoplasma hominis
- Peptostreptococcus sp.
- Fusobacterium sp.
- Provatella sp.
- Atopobium vaginae
- Other anaerobes (due to lack of KOH-producing lactobacilli)
What are some adverse sequelae to BV infxn in pregnancy?
- Pre-term labor
- Low birth weight
Does tx of BV during pregnancy prevent adverse outcomes?
How does pH change w/atrophic vaginitis?
What cells might you see on microscopy?
Elevated pH w/ parabasal or intermediate cells on microscopy
- Tx: E cream
In rare desquamative inflammatory vaginitis, what would you see on microscopy?
How is it treated?
- Lots of PMNs w/ parabasal cells
- Clindamycin cream for 14 days can help, but relapse is common
Here are some things to tell pts w/r/t vaginitis:
- Trich is an STD, but can carry for long periods of time, so doesn’t mean current
partner gave it to you
- BV and candida are not STD’s
- Douching is not a tx for and may exacerbate vaginitis
- Tampon use is not a/w vaginitis
Where are 97% of ectopics located?
What are some causes of ectopic pregnancy?
- Tubal surgery
- Previous ectopic pregnancy
- Exposure to DES in-utero
Other r/f's: infertility, use of reproductive tech, previous pelvic/abd surgery, smoking
What proportion of those with ectopic pregnancy have no r/f's?
Every reproductive aged woman w/ either of these 2 sx should be screened for pregnancy:
- Abd pain
- Vag bleed
When suspecting ectopic, what are 3 possible outcomes of transvaginal US?
- Intrauterine gestation
- Extrauterine gestation
During ectopic dx, if US is non-diagnostic, which is better for determining whether an intrauterine gestation should be visible, known gestational age or hCG?
known gestational age
At what hCG level (range) should an intrauterine gestation be able to be seen on US?
If someone is using IVF, need to rule out _______________________ even if you see an intrauterine gestation.
Serum PROGESTERONE < __ ng/mL signifies an abnormal pregnancy; > __ ng/mL is nl; __-__ is equivocal.
If hCG fails to increase by __% in 48 hrs, the pregnancy is abnormal.
What is the mechanism of methotrexate?
Inhibits dihydrofolate reductase, prevents synthesis of purines, serine and methionine.
Overall success in treating ectopic is __to__%
71-92% (don't memorize)
If hCG > ______ mIU/mL, MULTIPLE doses of methotrexate may be needed to treat ectopic pregnancy.
(or if gestational sac >3.5cm)
When is methotrexate contraindicated?
- Liver disease
- Kidney disease
- Bone marrow issues
- GI issues
(toxic to liver, cleared by kidney, effects rapidly dividing cells)
What are some dosing strategies for methotrexate? (not actual doses, but amounts of doses per tx)
Can use single dose, two dose, or fixed multi-dose (two dose is successful and well-
If surgery for ectopic fails, can you use methotrexate?
Yes, single dose (monitor serial hCG's)
After using methotrexate for ectopic pregnancy, how do you expect the serial hCG's to change?
May increase at first, then decrease (*by at least 15% from day 4 to day 7)
- If it doesn't, repeat dose or consider surgery
Discuss the side effects of methotrexate. (what 2 meds should be avoided?)
o Dose and duration dependent
o N/V, and stomatitis are most common (don’t use NSAIDs or alcohol)
o Abdominal pain 2-3 days post-tx
After ectopic tx, what's an additional risk that you should warn pts about?
What is contraindicated s/p methotrexate tx?
Don’t use folate supplements, no NSAIDs, no alcohol, no sex or vigorous activities, avoid sunlight exposure
Does methotrexate use affect future offspring/pregnancies?
Who can get expectant mgmt for ectopic pregnancies?
Only stable pts who accept risk of rupture and hemorrhage
In pts w/ectopic pregnancy, pts w/ hCG below _____ have higher rates of spontaneous resolution.
Are the main determinants of bone mass genetic or environmental?
Rank the following races in terms of fx rates:
mexican-americans, AAs, whites
whites > mexican-americans > AAs
Chinese Americans have (lower/higher) bone-mineral density than whites and (lower/higher) fx rates.
(but in geneal, fx rates correlate w/BMD)
Peak bone mass achieved by age __ in females.
What is the preferred method for diagnosing osteoporosis?
Dual-energy X-ray absorptiometry (DXA) scan of the lumbar spine and hip
What is T-score and what is the threshold for dx of osteoporosis?
BMD of pt is compared to cohort of young, healthy females; T-score of less than -2.5
establishes the diagnosis
When is the fx risk assessment (FRAX) tool useful? (2)
Women over 40 w/ DXA scores between
-1 and -2.5
(may be helpful to decide when to initiate tx)
List 6 meds used for osteoporosis.
- Hormone therapy
Prevent resorption of bone by inhibiting osteoclast function
Bisphosphonates: adverse effects?
Muscle aches and pains, GI upset, esophageal ulcers
Review some other notable facts about bisphosphonates.
- Discontinuation can continue effects for years depending on the drug
- Zalendronate can’t be used in kidney dysfunction
What are 2 major conditions that raloxifene is used for?
Prevents osteoporosis (vertebral fracture) and invasive breast cancer
Raloxifene: adverse effects?
VTE, leg cramps, stroke
Women close to menopause may experience hot flashes
Is Raloxifene better for older or younger postmenopausal women?
Risk-benefit profile makes this drug better for younger post-menopausal pts
What is the MoA of denosumab and how is it administered?
- Anti-RANK-L antibody
- Administered sub-q every 6 months
What are some adverse effects of calcitonin?
Is calcitonin more effective in older or younger postmenopausal women?
Not effective in women w/ early menopause; must be 5 years out to be treated
Review these facts about PTH (teriparatide)
- What a nice benefit/upside of this drug?
- Improves bone microarchitecture, geometry
- Effects disappear after discontinuation
- 1 subQ injection every 6 months (nice benefit)
- Tx duration limited to 2 years (osteosarcoma in rats)
Alcohol > __ units per day leads to dose dependent increase in fracture risk
How much Ca2+ should someone w/osteoporosis consume per day?
1,000 mg – 1,300 mg / day
How much vit D should someone w/osteoporosis consume per day?
Vit D intake should be 600-800 IU / day
o Upper limit is 4,000 IU / day
In treating osteoporosis, calcium supplementation may increase risk for ___________ and _____________.
CVD and renal stones
Does soy increase bone mineral density?
Not proven to
How old should a woman be before starting screening DXA scans?
What are some things that a pt w/osteoporosis should be counseled on?
- Weight-bearing exercise (reduce risk of falls and fractures)
- take appropriate amounts of Vit D and calcium
- stop smoking and avoid 2nd hand smoke
- reduce alcohol intake
- Adopt fall-prevention strategies
How long can bisphosphonates be used for?
How long can combined HRT be used to prevent osteoporosis?
Combined for 5 years (then ^ risk breast cancer)
Estrogen only for longer
List DXA screening interval for T score:
> -1.5 (towards 0)
-1.5 to -2.0
-2.0 to -2.5
! 15 yrs for T-score > -1.5
! 5 yrs for T-score < -1.5 and > -2.0
! 1 yr for T-score < -2.0 and > -2.5
1 in __ women aged 12+ have HSV-2 antibodies.
Are most genital herpes recurrences due to HSV-1 or HSV-2?
Is HSV-1 or 2 a/w genital herpes?
True or false:
Shedding of HSV can occur w/o symptoms and can still spread disease.
What tests can be used to make the dx of HSV?
- Viral culture
- Antigen testing (doesn’t differentiate 1 vs 2)
- AB testing (takes 2-12 wks to make AB's)
How long after infxn until you can see AB's vs. HSV?
22 days (can do ELISA)
True or false:
Can give prophylaxis after high risk HSV exposure.
Describe med tx's for HSV and what affects that can have.
Medications (acyclovir 400 TID then 400 BID, valacyclovir 1,000 BID then 1,000 daily, famcyclovir 250 TID then 250 BID) decrease shedding, symptoms, and lesions, but don’t affect long-term outcomes.
- Tx can be suppressive or episodic
How do you decide whether to do suppressive or episodic tx for HSV flairs?
Episodic works best for people w/ fewer episodes who take the meds when they feel an outbreak coming
Are herpes flairs more severe or milder than the initial outbreak?
In terms of pregnancy, is HSV transmission to fetus a risk? When?
Risk of transmission to a baby is low as long as infection is acquired before or during the
1st half of pregnancy
- Acquiring the virus late in pregnancy carries a 50% risk of transmission
Should ppl with HSV be counseled to tell their partner?
(vaccine in development)
If suspicious of ectopic pregnancy, what test should you order?
What if this test is inconclusive?
- Transvaginal US
- hCG (would see < 53% increase over 48 hrs)
(Progesterone may be helpful, as is abnl if less than 5, but in most ectopics it's 10-20, so not that useful)
Failure to detect a gestational sac by this many days (if EDC is known) is a sign of abnormal pregnancy?
What is the dose of MTX usually given?
50 mg/m^2 IM (give day 1, sometimes day 4 also, and check for 15% decrease hCG b/w days 4-7.
Which has better outcomes for the following in tx of ectopic pregnancy: MTX or salpingostomy:
- Tubal preservation
- Tubal patency
- Repeat ectopic pregnancy
- Future pregnancies
They are equal
Is topical antiviral therapy helpful for HSV genital infxns?
No, just PO
About what % of bone is lost in women w/in 3 years after menopause?
Can osteoporosis be dx'd in a women in the absence of imaging?
Yes, clinically in women w/ hx of low-trauma fx in at-risk woman.
What labs should you order to find the cause of osteoporosis?
24 hr urinary calcium
25-hydroxy vit D level
More than __ drinks of ETOH / day is a/w a dose-dependent increased fx risk in women.
If awoman is < 65 but is post-menopausal already or has high fx risk (skinny, alcoholic, smoker, RA...), what is the first thing to do?
- If fx risk > 9.3%, refer for DXA
If someone has T score < -2.5 on DXA, do you need to do FRAX?
No, just treat
How do you generally treat osteoporosis medically?
- What if they're younger and have breast cancer fam hx?
First line: bisphosphonates
- If younger, consider starting w/ raloxifene and transitioning to bisphosphonates later
Name 3 not uncommon 2ndary causes of bone loss.
- Vit D insufficiency
- Idiopathic hypercalciuria
- Celiacl dz
Women who have a T score -1 to -2.5 (low bone mass) and a FRAX > __% for risk of hip fx or > __% for risk of major osteoporotic fx should be treated with medications.
First step in treating pyelo?
- Then UCx, Susceptibility testing. While waiting: empiric abx
Does the initial tx of symptomatic lower UTI w/ pyruria or bacteruria or both require UCx?
How is BV dx'd clinically?
3/4 Amsel's criteria:
- Abnl gray d/c
- pH > 4.5
- Positive amine (whiff) test
- >20% epithelial cells being clue cells
How can trichomoniasis be dx'd?
- Saline microscopy (motile trichomonads)
- *Trich cx (better)
- OSOM Trich Rapid test (POC)