OB/GYN EOR Exam Cards

Question 1

Non-endocrine tissue in the body that produces estrogen

Answer 1

Fat tissue

Question 2

Role of LH and FSH

Answer 2

Cause secretion of Estrogen, Progesterone and other hormones from ovaries
Stimulate thecal and follicular cells to mature an egg

Question 3

Roles of estrogen

Answer 3

Growth of endometrium
Breast in largement
Induces LH surge
Assists in libido

Question 4

Roles of progesterone

Answer 4

Decreases uterine contractility
Promotes breast development and differentiation
Signals lactation as it falls
Maintaining pregnancy

Question 5

Activins

Answer 5

Stimulate FSH secretion
Involved in WBC production and embryo development

Question 6

Inhibins

Answer 6

Inhibit FSH so we don’t use all out follicles at once

Question 7

Follistatins

Answer 7

Inhibit activins
Regulate gonadotropin secretion

Question 8

Relaxin

Answer 8

Relaxes pubic symphisis and pelvic joints in pregnancy
Inhibits uterine contractions
Mammary and follicular development

Question 9

Positive feedback on the HPO

Answer 9

Estrogen at high levels increases GnRH and LH secretion
Activin promotes gonadotropic cell function

Question 10

Ad===Thelarche

Answer 10

Beginning of breast development
First sign of puberty in females

Question 11

Pubarche

Answer 11

Onset of pubic and axillary hair, after breasts and before menstruation

Question 12

Day one of a period

Answer 12

The first day of bleeding

Question 13

Normal menstrual cycle

Answer 13

28 days on average

Question 14

Follicular phase

Answer 14

Length varies - getting a new follicle ready

Question 15

Hormones of the follicular phase

Answer 15

FSH stimulates a few follicles and then realease inhibin to stop more follicles
One grows and secretes Estrogen
Estrogen causes LH surge, triggering ovulation

Question 16

Typical ovulation day

Answer 16

Day 14

Question 17

Mittelschmerz

Answer 17

Pain upon ovulation

Question 18

Corpus hemorrhagicum

Answer 18

Ruptured follicle fills with blood

Question 19

Luteal phage

Answer 19

consistently 14 days
Corpus luteum forms from corpus hemmorrhagicum

Question 20

Hormones of luteal phase

Answer 20

FSH drops
Corpus luteum produces estrogen which inhibits LH which is stimulating the corpus luteum
CL scars up if no pregnancy

Question 21

Proliferative phase of the uterus

Answer 21

Estrogen forms the stratum functionale about days 5-16 - endometrium growth
Glands are made bu don’t work yet

Question 22

Secretory phase of the uterus

Answer 22

About 14 days
CL is formed
Progesterone from the CL decorates the uterus
Glands become coiled and secrete fluid

Question 23

Menstrual phase

Answer 23

Loss of blood flow results in the death of the stratum functionale

Question 24

Cervical changes during the menstrual cycle

Answer 24

Estrogen makes cervicle mucus thinner and more hospitable to sperm - fern like pattern on slide first half of cycle

Progesterone makes the muscous THICK and impenatrable

Question 25

Cervical ectopy

Answer 25

Caused by opening of cervical opening/unrolling exposing columnar epithelium of the inner cervix Darker area of tissue - looks like an infection

Question 26

Birth control and cervical ectopy

Answer 26

Stays around longer with birth control

Question 27

Falopian tube cilia and hormones

Answer 27

Estrogen - beat faster Progesterone - beat slower

Question 28

Muscle and hormones

Answer 28

Progesterone - reduces spasms, relaxes smooth muscle, antagonizes insulin Estrogen - Improves skeletal muscle contractility

Question 29

Fat skin and Sodium/Water effect of progesterone

Answer 29

Maintains skin Fat gain in pregnancy Excretion of sodium and water

Question 30

Cardiovascular changes of pregnancy

Answer 30

Laterally displaced PMI Supine hypotensive syndrome from uterus compressing IVC Larger heart and HR increase by 15bpm Drop in BP w/ increase in volume May see some murmur, SVT, Left shift, ST depression

Question 31

Pulmonary changes in pregnancy

Answer 31

Congested upper respiratory tract from vasodilation Higher and wider ribcage Less dead space in lungs with increased tidal volume Mild respiratory alkalosis

Question 32

Renal changes during pregnanacy

Answer 32

Transient renal hypertrophy Dilated ureters, hydronephrosis Risk of UTI Increased load on kidneys Increased GFR Some leakage of protein and glucose but not to excess Increased renin

Question 33

GI changes in pregnancy

Answer 33

Increased salivation Gum hypertrophy Increased transit times Slow gallbladder emptying Increased heartburn NO worsening dental health is normal

Question 34

Heme/Onc and Fluid changes in pregnancy

Answer 34

Increased in blood volume by 50% More RBCs Increased WBCs More blood clots Less immune function

Question 35

When is prolactin highest

Answer 35

During pregnancy to help mammary glands develop

Question 36

Thyroid and pregnancy

Answer 36

Increase in production PTH decreases in 1st trimester and increases in 2 and 3

Question 37

Eye changes in pregnancy

Answer 37

Glaucoma gets better, cornea can thicken

Question 38

Skin changes in pregnancy

Answer 38

Increased skin pigmentation Linea nigra - black line down midline of abdomen Melasma - Brown butterfly rash on cheeks Stretch marks -Red to Brown

Question 39

Other skin changes that may be seen in pregnancy

Answer 39

Spider angiomas Palmar erythema Cutis marmorata Varicosities in legs Brittle nails Thickening of hair

Question 40

Metabolic changes in pregnancy

Answer 40

Increased fatigue Increased appetite, weight, thirst

Question 41

Weight increase during pregnancy

Answer 41

Average increase of 25-35 lbs Loose about 20 lbs at delivery and thereafeter

Question 42

Calories per day recommended for pregnancy and lactation

Answer 42

300 per day during pregnancy 500 per day during lactation

Question 43

Protein intake recommendation for pregnancy

Answer 43

1g/kg/day Plus 20 g/d in 2nd half

Question 44

Pregnancy calcium recommendation

Answer 44

1200 mg/d

Question 45

Iron recommendation for pregnancy

Answer 45

60-120 mg/day if defficient

Question 46

Folic acid supplementation in pregnancy

Answer 46

.4 mg/day 1 month before conception and first 3 months 1g/d for insulin dependant diabetics, Valproate, or Carbamazepime 4mg/d if hx of tube defects

Question 47

B6 for pregnancy

Answer 47

Helps with nausea

Question 48

Placenta

Answer 48

Part of the fetus - takes up most of the blood brought to the uterus Eats into the wall Uterus needs to contract to prevent bleeding

Question 49

SUbstances that don't cross the placenta

Answer 49

Only very large Heparin and Insulin

Question 50

Initial evolution of fertilized egg

Answer 50

Zygote, morula, blastocyst

Question 51

Week at which organ development begins

Answer 51

Weeks 5

Question 52

Landmarks at weeks 6-7

Answer 52

Limb buds and heart beat

Question 53

Week 9 landmarks

Answer 53

All essentail organs have begun to form

Question 54

Week 10 landmarks

Answer 54

Fetal heart tones heard on US End of embryonic period - fetal period begins

Question 55

Lanugo development

Answer 55

Weeks 15-18

Question 56

Weeks 19-22 landmarks

Answer 56

Fetus can hear Feel movement of fetus

Question 57

Threshold of survivability

Answer 57

Weeks 23-25 some survive Week 26+ most survive

Question 58

Week 26

Answer 58

Hands and startle reflex

Question 59

Weeks 27-30

Answer 59

Surfactant production begins to occur

Question 60

Mesonephric ducts

Answer 60

Turn into male structures

Question 61

Paramesonephric ducts

Answer 61

Turn into female structures

Question 62

Time of testes descending

Answer 62

About week 28, should be there by week 32

Question 63

Term baby

Answer 63

Born at 37+ weeks

Question 64

Preterm baby

Answer 64

20-37 weeks

Question 65

Abortion baby

Answer 65

ALL pregnancy losses before 20 weeks

Question 66

Living children

Answer 66

Any infant who lives for 30+ days

Question 67

Primipara

Answer 67

Has delivered once AFTER 20 weeks

Question 68

1st trimester

Answer 68

1-14 weeks

Question 69

2nd trimester

Answer 69

15-28

Question 70

3rd trimester

Answer 70

29-42

Question 71

Amount of pregnancies that are unplanned

Answer 71

Up to half

Question 72

Pre-conceptual care

Answer 72

Help modify risk factors before conception to improve pregnancy outcome

Question 73

Presentation of pregnancy

Answer 73

Amenorrhea - May have conception bleeding Chadwick sign - Bluish red uterus, soft Breast enlargement and tenderness Areolar enlargement

Question 74

Fetal movement

Answer 74

May not feel until 20 weeks first time May feel 16-18 weeks after first time

Question 75

Pregnancy diagnosis

Answer 75

Urine hCG detectable 8-9 days after ovulation, can also detect in blood

Question 76

3 hormones similar to hCG

Answer 76

LH, FSH, TSH

Question 77

How rapidly should hCG increase?

Answer 77

Value doubles every 1.4-2 days

Question 78

95% detection level for hCG

Answer 78

12.3 mIU/mL

Question 79

First US evidence of pregnancy

Answer 79

4-5 weeks Gestational sack seen Transvaginal US

Question 80

Yolk sac on US

Answer 80

Seen at 5-6 weeks COnfirms location in the uterus (r/o ectopic) Echogenic ring with anechoic center

Question 81

Fetal Pole/Embryo

Answer 81

Seen after 6 weeks, looks like a hole in the muscle

Question 82

Crown Rump length

Answer 82

Measure from head to butt can be done 6-12 weeks More reliable estimate of age than LMP Most accurate at 12 weeks

Question 83

Naegele's rule

Answer 83

LMP+7 days-3 months

Question 84

Hx for pregnancy

Answer 84

Prior pregnancies Contraceptive use/desires Menses interval Depression Abuse Drug/Alcohol use/Drugs

Question 85

PE for pregnancy

Answer 85

Pap smear over 21 Chlamydia and Gonoirrhea testing Cervical dilation, length, consistency Bony pelvic architecture

Question 86

Uterine sizes over time

Answer 86

6 week - Small orange 8 week - Large orange 12 week - Grapefruit

Question 87

When should a Rho gam shot be given

Answer 87

at 28 weeks to negative mothers with positive babies Also for vaginal bleeding intrapartum Post delivery of neg mothers with positive babies

Question 88

Kleihauer-Betke

Answer 88

Tests for number of fetal RBCs in circulation, in cases of trauma may need to test and give Rho gam

Question 89

Rh IgG attack rate on fetal RBCs

Answer 89

.3 mg will eradicate 15mL Fetal RBCs (eq. to 30 mL fetal blood)

Question 90

Rubella

Answer 90

MCC of fetal growth restriction Infection in first trimester can cause abortion Vaccine needs to be taken 1 month BEFORE getting pregnant

Question 91

Syphillis

Answer 91

T. pallidum Treat with PCN-G - desensitization recommended if allergic

Question 92

Prenatal counseling recommendations

Answer 92

Prenatal vitamin - 400mcg folic acid and Iron May work but should not do intense or hazardous work

Question 93

Pregnancy weight gain

Answer 93

25-35 lbs if okay weight Less if they weigh more

Question 94

Risks associated with obesity while pregnant

Answer 94

Hypertension/Preeclampsia Gestational diabetes Macrosomia and C section

Question 95

Additional diet for pregnancy

Answer 95

Increase by 100-300 calories per day Avoid FISH/SEAFOOD

Question 96

4 risk factors for lead exposure in mothers

Answer 96

Immigrant Remodeling home with lead Live near lead source Contaminated water

Question 97

Air travel and pregnancy

Answer 97

Safe up to 35 weeks Need to ambulate

Question 98

Dental treatment and pregnancy

Answer 98

Okay to get radiographs Recommended to have done

Question 99

Caffeine and pregnancy

Answer 99

5+ cups of coffee per day can increase risk Under 200mg/day is okay

Question 100

Exercise and pregnancy

Answer 100

Do not usually need to limit exercise Encourage mild to moderate exercise - don't ramp it up 10 lb lifting is the general rule Don't scuba dive, etc.

Question 101

Smoking and alcohol and pregnancy

Answer 101

Need to avoid including vaping Binge drinking is especially problematic

Question 102

Breastfeeding recommendations

Answer 102

6 months is preferred 2 years by WHO (also recommedning ofr Africa) 8-12 times daily with 15 minutes per session Helps with weight loss, child obesity, chronic disease, bonding

Question 103

CI to breastfeeding

Answer 103

HIV Drug/Alcohol use Galactosemia Hep C with broken skin Active TB Medications Undergoing breast cancer tx Active herpes lesions on breast

Question 104

Pregnancy visit spacing

Answer 104

Every 4 weeks until 28 Every 2 until 36 Every week until delivery

Question 105

Prenatal surveillance

Answer 105

Fetal HR Height of the fundus

Question 106

Fundus height benchmarks

Answer 106

12 weeks -emerging from bony pelvis 16 weeks - Between pubic symphysis and umbilicus 20 weeks - Fundus at the umbilicus 20-34 - correlates with gest age +/- 2cm

Question 107

Timing of gestational diabetes screening

Answer 107

24-28 weeks 50 g glucose with test right after

Question 108

Lab tests during pregnancy

Answer 108

CBC at 28 weeks Syphillis and HIV 28 weeks for high risk Rh testing 28-29 weeks Group B strep testing 35-37 weeks

Question 109

Vaccines and pregnancy

Answer 109

Hep A and B Flu vaccine Tdap RSV between 32 and 36 weeks COVID

Question 110

Tx for nausea and vomiting in pregnancy

Answer 110

Small meals BRAT diet Ginger B6 Prochlorperazine Metoclopramide Odansetron

Question 111

Hyperemesis gravidarum

Answer 111

Vomiting severe enough to produce weight loss, electrolyte disturbances, ketosis, dehydration, etc.

Question 112

Tx for back pain in pregnancy

Answer 112

Shoes, maternity belt Tylenol Muscle relaxers

Question 113

Hemorrhoid tx in pregnancy

Answer 113

Topical anesthetics Warm bath Compression socks for varcosities

Question 114

Tx for heartburn in pregnancy

Answer 114

Antacids H2 blockers PPIs

Question 115

Pica in pregnancy

Answer 115

Craving for dirt, ice, starch Assoc. with iron deficiency

Question 116

Tx for sleep issues with pregnancy

Answer 116

Benadryl and naps

Question 117

Leukorrhea

Answer 117

Increased vaginal discharge during pregnancy - generally not pathologic

Question 118

2 MC congenital abnormalities

Answer 118

Heart and Cleft palate

Question 119

Threshold for downs risk

Answer 119

35years

Question 120

Marker for neural tube defects

Answer 120

Alpha feto protein May screen 15-18 weeks Can use a US for it (more common)

Question 121

Down syndrome screening recommendation

Answer 121

Offer to everyone regardless of risk Screening NOT diagnostic NUchal translucency and PAPP-A value

Question 122

Second trimester down screening

Answer 122

hCG AFP Unconjugated estriol

Question 123

Cell free DNA

Answer 123

Check for genetic abnormalities and gender 99% detection rate Blood draw at 9-10 weeks

Question 124

Amniocentesis

Answer 124

15-20 weeks 20 cc of fluid Assess karytype, can be done for comfort Evaluate for fetal lung maturity Chance of fetal loss 1 in 300-500

Question 125

Chorionic villus sampling

Answer 125

10-13 weeks Assess fetal karyotype Transabdominal or transcervical

Question 126

CI to CVS

Answer 126

Vaginal bleeding Higher risk of pregnancy loss - 2% Uterine ante or retro flexion

Question 127

Fetal blood sampling

Answer 127

For fetal anemia Cord blood sampling Perfromed at cord insertion

Question 128

s/s of fetal stress

Answer 128

Low HR Low fetal movement

Question 129

Recommendations for antepartum testing

Answer 129

Every week starting weeks 32-34 (26-28 if high risk)

Question 130

Factors effecting fetal movement

Answer 130

Diminished by increased movement Sleeping Placement of the placenta Should be consistent in its habits

Question 131

Non-stress test

Answer 131

For a baby not moving Measure heartbeat of fetus - should see 2+ accelerations in a 20 minute time span

Question 132

What to do to wake baby up for a nonstress test

Answer 132

Acoustic stimulator up to three times - should have a positive result after

Question 133

Biophysical profile

Answer 133

Score 0 or 2 in five categories Non stress test Breathing Movement Tone Amniotic fluid volume (2x2 pocket)

Question 134

BPP interpretation 8

Answer 134

Normal - deliver if abnormal amniotic fluid index

Question 135

BPP interpretation 6

Answer 135

Deliver if over 36 weeks Repeat within 24 hours Deliver if still 6 or lower, observe if above 6

Question 136

BPP interpretation 4

Answer 136

Probably asphyxia repeat or deliver

Question 137

BPP interpretation 2

Answer 137

DELIVER!!

Question 138

Doppler velocitrimetry

Answer 138

Looks at fetal blood flow Umbilical artery - Shows lack of blood to flow to fetus = growth restriction Middle cerebral artery - Fetal anemia and growth restriction

Question 139

Complete dilation

Answer 139

10cm - max amount

Question 140

Effacement

Answer 140

How thick the cervix is - 0% is 4cm, 100% is no cervix left

Question 141

Braxton Hicks contractions

Answer 141

False contractions - more likely with more pregnancies, dehydration

Question 142

Bishop score favorable for labor

Answer 142

Greater than 8

Question 143

Diagnoses for labor

Answer 143

Water breaking Ferning AFI - Amniotic fluid Nitrazine

Question 144

Vaginal bleeding in labor

Answer 144

A small amount can be okay

Question 145

Tx for group be strep vaginal colonization

Answer 145

PCN Erythromycin or Clinda for allergies

Question 146

IV pain medication for labor

Answer 146

Usually avoided in later stages of labor to avoid fetal respiratory distress Epidural anesthesia preferred

Question 147

Where is an epidural given

Answer 147

L3-L4 intercostal space

Question 148

CI to an epidural

Answer 148

Bleeding disorder or recent heparin use Patient preference Thrombocytopenia

Question 149

Regional anesthesia

Answer 149

One time dose for C section Pudendal block - less common for pregnancy today

Question 150

General anesthesia for deliver

Answer 150

Usually only used in emergencies and C sections Danger of maternal aspiration

Question 151

Bishop score that indicates likely failure of induction and what can be done

Answer 151

Less than 5 Cervical ripening

Question 152

Cervical ripening medication

Answer 152

Prostaglandins - Cervidil or Cytotec Both vaginal, Cytotec is oral as well Can cause tachysystole, fever, vomiting, diarrhea, uterine rupture CI - C-section, Hysterotomy, Myomectomy

Question 153

Induction of labor

Answer 153

Pitocin IV infusion that increases over time Danger of tachysystole and rupture Stop if fetal distress occurs

Question 154

Manual induction of labor

Answer 154

Balloon catheter or laminaria More effective with ptosin Inserted vagnially Amnio hook to break water

Question 155

Augmentation of labor

Answer 155

Strengthen contractions - Use ptocin

Question 156

Operative vaginal delivery

Answer 156

Forceps or vacuum Can cause lacerations (forceps - vaginally) (Vaccuum -Perineal) Use for fetal compromise or if a C section can no longer be done

Question 157

First stage of labor

Answer 157

Onset to complete cervical dilation 1st 6 cms are much slower

Question 158

Second stage of labor

Answer 158

Cervial dilation to fetal expulsion

Question 159

Third stage of labor

Answer 159

Fetal delivery to placental delivery

Question 160

Fourth stage of labor

Answer 160

Placental delivery to one hour postpartum

Question 161

Adequate labor

Answer 161

Over 200 Montevideo unites in 10min as measured by intrauterine catheter Start ptosin if inadequate

Question 162

Fetal variabilities that affect labor

Answer 162

Fetal size and alignment

Question 163

Vertex

Answer 163

Head first delivery

Question 164

Breech

Answer 164

Butt first delivery

Question 165

Shoulder/compound

Answer 165

Something in front of baby arm

Question 166

Funic

Answer 166

Umbilical cord first - C SECTION!!

Question 167

Direction baby should be looking when born

Answer 167

Down to the floor (posteriorly)

Question 168

Determinationof fetal position in Uterus

Answer 168

Mother lies supine Leopolds maneuver: Evaluate fetal lie, weight, position and presentation Difficult with obesity, multiples, excess amniotic fluid US is best bet though

Question 169

C-section indication

Answer 169

More than two fetuses Any non vertex position 5,000+grams 4,500+ grams and diabetic mother

Question 170

Pelvic shapes

Answer 170

Gynecoid - best Antropoid - Narrow front to back Android - Triangular Platypelloid - Narrow side to side

Question 171

Active phase arrest labor

Answer 171

No progression in cervical dilation in 6cm dilated patients despite four hours of adequate contractions or 6 hours of inadequate contraction with augmentation C-section indicated

Question 172

Prolonged second stage labor

Answer 172

More than 3 hours pushing for nulliparous and 2 hours in multiparous Indication for C section

Question 173

IUDC

Answer 173

Catheter to measure strength of contractions

Question 174

Umbilical cord prolapse

Answer 174

Emergency if cord get pinched - needs to be propped up manually Indication for immediate C section while holding baby off the cord

Question 175

Indications of second stage

Answer 175

Pelvic/rectal pressure Mother has active role in pushing out fetus

Question 176

Molding

Answer 176

Fetal head shaping to shape of pelvis as it works its way out

Question 177

Perineal laceration first degree

Answer 177

Injury to perineal skin and vaginal mucosa only

Question 178

Second degree perineal laceration

Answer 178

Injury to perineal body (space between vagina and rectum)

Question 179

Third degree perineal laceration

Answer 179

Injury through external anal sphincter

Question 180

Fourth degree perineal laceration

Answer 180

Injury through rectal mucosa

Question 181

Episotomy

Answer 181

Intentionally making a perineal laceration Usually causes problems - not popular Midline or Mediolateral - more painful to the side

Question 182

Shoulder dystocia

Answer 182

Fetal shoulder impaction on the pubic symphysis Macrosomia, Diabetes, Obesity, Operative deliver are risk factors

Question 183

Dangers to the fetus in shoulder dystocia

Answer 183

Humerus or clavicle fracture, Brachial plexus injury, Death

Question 184

Management of shoulder dystocia

Answer 184

Episiotomy Mcroberts maneuver - sharp flexion of maternal hips Suprapubic pressure Rubin, Wood's corkscrew - rotate baby Symphisiotomy

Question 185

Delivery of the placenta

Answer 185

Done with one hand on the umbilical cord with gentle downward traction

Question 186

Uterine inversion

Answer 186

Uterus is pulled out through the vagina Replace uterus - use NOX or terbutylline to relax so it can go back inside

Question 187

Fourth stage of labor risk and definition

Answer 187

Postpartum hemorrhage - Uterine atony, Lacerations, retained placental fragments Defines as 500+cc's in a vaginal deliver or 1000+cc's in a c-section

Question 188

Tx for uterine atony Four Meds

Answer 188

Pitocin, Methergine, Cytotec, Hemabate

Question 189

Engagement

Answer 189

First movement of delivery Passage of the widest aspect of the fetal presenting part (typically the head) below the plane of the pelvic inlet (level of ischial spines)

Question 190

Descent

Answer 190

Second maneuver of labor Moving down into the bony pelvis

Question 191

Flexion

Answer 191

Head flexes to fit through the birth canal

Question 192

Internal rotation

Answer 192

Head of baby either rotates from transverse to anterior or posterior position

Question 193

Extesnsion

Answer 193

Head extends out as the baby passes into the vaginal

Question 194

External rotation / Restitution

Answer 194

Head rotates back to its original position prior to internal rotation - aligns with fetal torso

Question 195

Expulsion

Answer 195

Rest of baby comes out

Question 196

7 Cardinal movements of labor

Answer 196

Engagement Flexion Descent Internal rotation Extension External rotation/Restitution Expulsion

Question 197

Normal fetal HR

Answer 197

110-160

Question 198

Fetal bradycardia

Answer 198

Under 110 bpm May be due to lupus heart block or maternal hypotension

Question 199

Absent fetal HR variability

Answer 199

Absent - worrisome

Question 200

Minimal fetal HR variability

Answer 200

1-5bmp variation Fetus asleep or inactive

Question 201

Moderate fetal HR variability

Answer 201

5-25bpm variation Considered normal

Question 202

Marek fetal HR variability

Answer 202

25+ bpm variation Worrisome

Question 203

Normal acceleration of fetal HR

Answer 203

15bpm for 15s after 32 weeks 10bpm for 10s before 32 weeks

Question 204

Early decelerations

Answer 204

Begin and end with contractions Result of head compression No intervention required

Question 205

Late decelerations

Answer 205

Begin at peak of contraction and slowly return to baseline after contraction is finished Result of compromised bloodflow during contractions - uteroplacental insufficiency

Question 206

Tx for late decelerations

Answer 206

Position, Oxygen, Stop Pitocin, Check cervix, consider C section or assisted vaginal delivery

Question 207

Variable decelerations

Answer 207

V shaped at any time due to cord compression The deeper and longer, the more concerning Reposition Infuse water into the uterus

Question 208

Sinusoidal fetal HR

Answer 208

Most often fetal anemia - always concerning

Question 209

Category I fetal heart tracing

Answer 209

FHR 110-160 Moderate FHR variability No late or variable decelerations

Question 210

Category II fetal heart tracing

Answer 210

Neither category I or III

Question 211

Category III fetal heart tracing

Answer 211

Absent FHR variability with any of the following Recurrent late decelerations Recurrent variable decelerations Bradycardia Sinusiodal waveform

Question 212

Contraction stress test

Answer 212

Use pitocin to trigger 3 contractions in ten minutes Test for poor fetal HR patterns during contractions Recurrent late decelerations - Positive - Bad Good looking - Negative test Equivocal (maybe one deceleration - Wait and see

Question 213

MC site of ectopic pregnancy

Answer 213

Ampulla of fallopian tube Can also occur in C-section scar (becoming more frequent

Question 214

Risk factors for ectopic pregnancy

Answer 214

Prior STDs PID Endometriosis IUD Assistive reproductive technology

Question 215

Presentation of ectopic pregnancy

Answer 215

Vaginal bleeding Lower abdominal pain Adnexal mass Abdominal pain on rupture Hemodynamic instability

Question 216

beta hCG at which pregnancy should be visible in the uterus

Answer 216

1500-2000mIU/mL Should be increasing at a steady rate if pregnancy is normal

Question 217

US for ectopic pregnancy

Answer 217

No yolk sac seen in uterus with pseudo gestational sack Donut sign - thick walls

Question 218

HCg monitoring if you dont see an intrauterine pregnancy

Answer 218

Check every other day

Question 219

Ectopic pregnancy treatment

Answer 219

Methotrexate - Patient needs to be compliant, no fetal cardiac activity, under 3.5 cm, beta hCG under 5000 Check hCG decrease by day 7 Increased abdominal pain afterwards, N/V/D

Question 220

Surgery for ectopic pregnancy

Answer 220

Salpinostomy - open up and remove - creates higher risk of ectopic pregnancy Salpingectomy - Preferred

Question 221

Complete abortion

Answer 221

Expulsion of all products of conception before 20 weeks - can do analysis of products

Question 222

Incomplete abortion

Answer 222

Not all of the products of conception are expelled Vaginal bleeding and abdominal cramping May see protruding POC through cervical os Curettage, Prostaglandins and removal of tissue for tx

Question 223

Inevitable abortion

Answer 223

No expulsion but vaginal bleeding and dilation of the cervix such that viability is unlikely Treat with prostaglandins - keep pregnancy if fetal heartbeat

Question 224

Missed abortion

Answer 224

Death of embryo or fetus before 20 weeks with complete retention of products of conception US shows nonviable pregnancy Wait to pass or prostaglandins, Curettage, Expectant management

Question 225

Threatened abortion

Answer 225

Any bleeding before 20 weeks Cervical os closed Pelvic rest and close monitoring

Question 226

Complete Molar pregnancy

Answer 226

Excessive growth of placenta Large for dates 2 sets of paternal chromosomes Very high hcg Excessive placental tissue No POC

Question 227

Incomplete molar pregnancy

Answer 227

Two paternal and one half maternal set of chromosomes Small for dates Missed abortion Fetal parts present

Question 228

Diagnostics for Molar pregnancy

Answer 228

Snowstorm appearance on US Thickened multicystic placenta Confirm via pathology Vomiting preeclampsia before 20 weeks

Question 229

Management of molar pregnancy

Answer 229

CXR for cancer CBC Thyroid EKG Suction, dilation and curettage Pitosin to evacuate uterus Rhogam if Rh negative Watch for cancer with serial hCG - should decrease - birth control for some time

Question 230

Questions to ask about Antepartum bleeding

Answer 230

Check where it is coming from (could be UTI or hemorrhoids) Sexual activity - ask

Question 231

Placental abruption

Answer 231

Separation of the placenta either partially or totally from its implantation site Concealed or revealed Usually early in pregnancy - monitor Can cause hypovolemic shock - deliver immediately

Question 232

Revealed placental abruption

Answer 232

Presents with vaginal bleeding

Question 233

Diagnosis of placental abruption

Answer 233

Exclusion diagnosis - pay attention if mother has experienced trauma

Question 234

Couvelaire uterus

Answer 234

Purplr/Blue uterus from blood infiltration

Question 235

Management of placental abruption

Answer 235

Deliver -Vaginal preferred for dead fetus; C-section is quicker with bleed risk

Question 236

Placenta previa Four Risk Factors

Answer 236

Placenta covering cervix Increases with age, parity, c-section, smoking

Question 237

Presentation of placenta previa

Answer 237

Painless vaginal bleeding seen after second trimester

Question 238

Diagnosis of placenta previa

Answer 238

Should be excluded in any bleeding patient who presents after the 2nd trimester Transvaginal US to visualize NO DIGITAL EXAM ONCE CONFIRMED!!!

Question 239

Point before which previa is unlikely to persist

Answer 239

23 weeks

Question 240

Management for placenta previa

Answer 240

Delivery via C-section as late as possible Deliver sooner if persistently bleeding Goal to keep pt pregnant as long as possible

Question 241

Placenta accrete

Answer 241

Abnormally adhered Accreta - Attached to myometrium Increta - Attached into myometrium Percreta - Goes through myometrium

Question 242

Risk factors for placenta accrete syndromes

Answer 242

C section or placenta previa

Question 243

Presentation of pracenta accrete

Answer 243

Found on US Hard to deliver placenta Recommended early delivery at 34-36 weeks May consider leaving placenta insode or hysterectomy -MC

Question 244

Cervical insufficiency

Answer 244

Painless cervical dilation during the second trimester d/t prior cervical trauma

Question 245

Eval and management of cervical insufficiency

Answer 245

US to confirm Swab for infection Trendelenburg psoition Pelvic rest Cerclage - stitch in the uterus kept in until week 36 Delivery

Question 246

Tx of cervical insufficiency for next pregnancy

Answer 246

US to measure Preventative Cerclage - Rescue (wait) or Elective (don't wait)

Question 247

Cerclage

Answer 247

Stitch in the uterus - what Mary Crawley got

Question 248

Preterm birth - 4 reasons

Answer 248

Delivery of infant before 37 weeks Spontaneous Idiopathic Maternal or fetal indication Twins+

Question 249

Fetal fibronectin and early labor

Answer 249

Sensitive but not specific for preterm labor - can rule it OUT

Question 250

Workup for preterm labor

Answer 250

Tocolysis - Stops contractions for 48 hours max Administer steroids for fetal development Nifedipine Mag Sulfate Prostaglandin inhibitors Beta agonists - Terbutaline

Question 251

Management for preterm labor

Answer 251

Steroid for fetal lung maturation Betamethazone indicated 24-34 weeks Cerclage to help prevent Progesterone NOT helpful unless vaginal

Question 252

Reason for magnesium sulfate in preterm labor

Answer 252

Prevents neonatal intercranial hemorrhage weeks 24-32 for at least 12 hours

Question 253

Preterm premature rupture of membranes

Answer 253

Check for pooling, nitrazine swab, ferning of vaginal mucosa to confirm Risk of cord prolapse - don't send home

Question 254

Managementof preterm premature rupture of membranes

Answer 254

Patient hospitalized for remainder of pregnancy Corticosteroids for fetal lung maturity Tocolysis Ampicillin or Erythromycin can extedn time before delivery

Question 255

Intrauterine growth restriction

Answer 255

Stick with original due date May be due to alcohol, smoking, young patients, TORCH infections

Question 256

Dangers with IUGR

Answer 256

Stillbirth Encephalopathy Palsy Still monitor even if parents are small

Question 257

Diagnosis for IUGR

Answer 257

Less then 10th percentile overall growth OR less than 10th percentile abdominal circumference is indicative US

Question 258

Management of IUGR

Answer 258

Amiotic fluid volume management US for circumference and weight Umbillical artery doppler monitor Serial growth scans Plan for delivery at 38 weeks

Question 259

Fetal death risk factors

Answer 259

Age AA race Smoking diabetes

Question 260

Dx and management of fetal death

Answer 260

Usually incidental - US Plan for delivery Karyotyping, Autopsy

Question 261

Management for future pregnancies after a fetal death

Answer 261

Control modifiable risk factors Offer genetic testing Anatomy scan at 18 weeks growth US at 32 weeks Begin antepartum surveillance 1-2 weeks prior to when stillbirth happened Elective induction or C section at 39 weeks

Question 262

Hypertension in pregnancy

Answer 262

Over 140/90 on two occasions at leat 2 hours apart

Question 263

Chronic hypertension and pregnancy

Answer 263

Present before 20 weeks or persistent 12 weeks after delivery is an underlying chronic HTN ACEIs and Angiotensin receptor agonists are CI

Question 264

Prenatal care for chronic HTN

Answer 264

EKG, Echo (at risk for cardiomyopathy) Baseline labs

Question 265

Medications for HTN in pregnancy

Answer 265

Labetolol or Calcium channel blockers Aspirin reduced preeclampsia risk

Question 266

Management for chronic hypertension in pregnancy

Answer 266

Close observation Deliver early at 37-39 weeks

Question 267

Gestational HTN

Answer 267

After 20 weeks BP becomes 14/90+ Resolves by 12 weeks postpartum Treat and manage like chronic HTN in pregnancy

Question 268

Preeclampsia

Answer 268

Hypertension and proteinuria after 20 weeks gestation 0.3g+ urine protein on dipstick Can also present with: Thrombocytopenia, Renal insufficiency, Liver disease, Pulm edema

Question 269

Risk factors for preeclampsia

Answer 269

Young age First pregnancy Multifetal Obesity Other vascular disorders

Question 270

Dx of preeclampsia

Answer 270

140/90+ BP Proteinuria dipstick of 2+ 300mg or more in a 24 hour urine collection Could also be with thrombocytopenia

Question 271

Eclampsia

Answer 271

Occurence of generalized convulsion and or coma in the setting of preeclampsia with no other neuro condition Before, during, or after labor - hold in hospital after birth

Question 272

Preeclampsia superimposed on chronic HTN

Answer 272

Need to have close monitoring of labs and home blood pressure so that it can be caught

Question 273

HELLP

Answer 273

Hemolysis, Elevated Liver Enzymes, and Low Platelet Count RUQ pain because liver bleeds and distends capsule Risk of hepatic hematoma and rupture Indicates SEVERE preeclampsia

Question 274

Tx for preeclampsia

Answer 274

Delivery Monitor closely if mild HTN therapy if 160/110 or greater Labetolol (IV), Hydralazine (IV), or nifedipine (PO) can be used

Question 275

Magnesium sulfate and preeclampsia

Answer 275

To prevent seizure, NOT BP Continued after delivery until the patient diureses

Question 276

Pregestational diabetes

Answer 276

Check hemoglobin A1c first trimester A1c over 6.5% Higher A1c = More fetal anomalies - significant risk over 12% Fasting glucose over 125, nonfasting over 200

Question 277

Complications of pregestational diabetics

Answer 277

Spontaneous abortion Preterm birth IUGR Cardiac defects Hydramnios Macrosomia

Question 278

Neonatal effects of pregestational diabetes

Answer 278

Baby born with overproduction of insulin - hypoglycemia Hypocalcemia Diabetes and Obesity later in life

Question 279

Preconception care for diabetes

Answer 279

Glucose 70-110 mg/dL A1c 7% or lower Folic acid supplementation

Question 280

First trimester care for DM

Answer 280

Careful glucose monitoring HGA1c under 6 81 mg Aspirin for preeclampsia prevention 24 hour urine

Question 281

Second and third trimester care for diabetic mothers

Answer 281

US at 18-20 weeks Fetal echo at 20-24 Antepartum testing at weeks 32-34 Deliver 36-40 weeks Vaginal or C section delivery

Question 282

Postpartum diabetes management

Answer 282

Insulin may need to be decreased - mom needs more insulin during gestation

Question 283

Gestational diabetes

Answer 283

Commonly recurrence Diabetes after the first 20 weeks Ethnic populations are at higher risk Increased risk of DM later in life

Question 284

Screening for Gestational Diabetes

Answer 284

50g one hour glucose challenge followed by 100g 3 hour test - fasting

Question 285

Limits for 3 hour GTT

Answer 285

Fasting 95 1 hour 180 2 hours 155 3 hours 140

Question 286

Management of rgestational diabetes

Answer 286

Keep fasting BS under 95 and postprandial under 120 Diet modification - 40-20-40 diet Insulin - First line Metformin - also good May consider early induction or not with vaginal delivery depending on size Same risk factors as pregestational diabetes

Question 287

Postpartum management of gestational diabetes

Answer 287

All should receive a 75g 2 hour OGTT at 6-12 weeks postpartum

Question 288

Vanishing twin

Answer 288

Twin vanishes or is lost before the second trimester 10-40% of all twin pregnancy

Question 289

Diagnosis of multifetal gestation

Answer 289

Uterus larger than expected Determine chorionicity in the first trimester with US

Question 290

Dichorionic twins

Answer 290

Two separate placentas with a thick 2mm+ dividing membrane Twin peak sign aka lambda or delta sign

Question 291

Monochorionic twins

Answer 291

Thin under 2mm dividing membrane T sign on US - right angle relationship between membranes

Question 292

Monoamniotic twins

Answer 292

One amniotic sac - the later the split the more the twins share High risk of fetal death - deliver 32-24 weeks, steroids at 24-28 weeks with antepartum testing

Question 293

Complications of multifetal pregnancies

Answer 293

Congenital malformations Spontaneous abortions Low birth weight HTN Size dischordance

Question 294

Twin-Twin Transfusion syndrome

Answer 294

In monochorionic twins One twin gets all the nutrients, one gives all the nutrients May be able to ablate vascular abnormalities causing TTTS May need selective abortions Harms both twins -One anemic, one congested

Question 295

Weight gain expectation for multifetal pregnancies

Answer 295

37-54lbs. weight gain

Question 296

Labor management for DD twins

Answer 296

38 weeks, can be vaginal - first twin should be vertex!!

Question 297

Labor management for MD or MM twins

Answer 297

Usually C section at 34-37 weeks and 32-34 weeks respectively - first twin should be vertex!!

Question 298

Maternal hypothyroidism

Answer 298

Fetus does not produce own thyroid before 12 weeks Check TSH every trimester Cold, Fatigue, Muscle Cramps, Hair loss MC - Hashimotos thyroiditis Treat with levothyroxine

Question 299

Screening for maternal depression

Answer 299

Screen for in patients in initial visit and at every visit if at risk

Question 300

Tx for depression during pregnancy

Answer 300

Counselling SSRI or SNRI are first line If mother is stable on current antidepressant - don't change

Question 301

Zuranlone

Answer 301

For post partum depression with and SSRI or SNRI

Question 302

Substance abuse among pregnant women

Answer 302

7.2% abused pain relievers 12% Drank 25+% Smoked including marijuana

Question 303

Screen for substance abuse in pregnancy

Answer 303

Try to screen all patients if possible - tend to use for those with risk factors

Question 304

Opioid substitution for pregnancy

Answer 304

Methadone, Suboxone, Subutex All associated with neonatal withdrawal Subutex does not cross the placenta as early

Question 305

UTI dx and tx in pregnancy

Answer 305

Always do a urine screen when first presenting as pregnant Can cause preterm birth Macrobid or Keflex and recheck urine a week after

Question 306

Suppressive UTI therapy in pregnancy

Answer 306

Macrobid 100mg PO daily

Question 307

Pyelonephritis in pregnancy

Answer 307

Flank pain Admit w/ IV abx and prophylaxis Assess for kidney stone

Question 308

Definition of infertility

Answer 308

1 year of unprtected intercourse of reasonable frequency in under 35 6 months for those over 35

Question 309

Primary v. Secondary infertility

Answer 309

Primary no prior pregnancies Secondary - prior pregnancy

Question 310

How often is reasonable to have sex for fertility

Answer 310

Once every other day Make sure you're having it during the right time

Question 311

Workup for many pregnancy losses

Answer 311

Do genetic testing to see if there is a problem Look for uterine septum on US

Question 312

Dx for ovulatory dysfunction

Answer 312

Use menstual hx as a predictor Ask about mittleschmirtz TSH, Weight over or under Basal body temperature US to look at ovarian reserve Urine LH sticks

Question 313

Serum progesterone

Answer 313

Check around 21 days for ovulation Relatively cheap

Question 314

Serum FSH

Answer 314

Predictor of ovarian reserve - less inhibin Check on day 3 of cycle Estradiol compensation (elevation) indicates a depleated ovarian reserve

Question 315

Antimullerian hormone testing

Answer 315

Expressed by granulosa cells Possible role in dominant follicle recruitment Under 1ng/mL can indicate depleated ovaries High in PCOS

Question 316

Tx for ovulatory dysfunction

Answer 316

Check hyperprolactinemia Treat any adenoma Levothyroxine for hypothyroid Ovulation induction

Question 317

Clomiphene for ovulation dysfunction

Answer 317

Clomiphene - Estrogen antagonist results in increased FSH given around day 3 of cycle PO

Question 318

Aromatase inhibitors for ovulation induction

Answer 318

Letrozole Inhibits estrogen and increases FSH PO High BMI and PCOS

Question 319

Gonadotropins

Answer 319

Variety of IM formulations Expensive

Question 320

COmplications of ovulation induction

Answer 320

Multifetal gestation Ovarian hyperstimulation syndrome - enlarged ovary with cysts - causing abdominal pain, distention

Question 321

Intrauterine insemination

Answer 321

Sperm washed and concentrated and inserted into the uterus - less expensive than and tried before IVF

Question 322

IVF

Answer 322

Sperm and ova combine seperately and inserted into uterus

Question 323

Tubal and pelvic factors that can lead to infertility

Answer 323

Endometriosis Surgery such as appendectomy Pelvic infection

Question 324

Dx for tubal issues

Answer 324

Hyerosalpingogram on days 5-10 - uses radio-opaque medium in uterus Chromopertubation - Methylene blue for tube patency with laparoscopy Expensive

Question 325

Tx for tubal and pelvic factors

Answer 325

Cannulation to create patency Reconstruction post op Removal if dyfunctional tube causing issues IVF with removal of adhesions

Question 326

Uterine factors that cause infertility

Answer 326

Polyps, Uterine septum, Fibroids Dx with US or Hysteroscopy, endometrial biopsy before IUI or IVF

Question 327

Asherman's syndrome

Answer 327

Intrauterine adhesions that can resemble a fetus on US Form after dilation and curettage

Question 328

Cervical factors that cause infertility

Answer 328

Infection Thick mucous d/t high estrogen

Question 329

Dx and tx for cervical factors

Answer 329

Postcoital test - how many sperm got through Bypass with IUI

Question 330

Male hx for infertility

Answer 330

Testosterone use!! Get a semen analysis Mumps, ED, Hx of infection

Question 331

Lag time for sperm to be impacted

Answer 331

Takes 3 months for effects to be felt - look at that in hx

Question 332

Semen analysis

Answer 332

Refrain from ejaculation for 2-3 days Too much sex can reduce sperm count per time f/u analyze for antisperm antibodies f/u low volume with urology

Question 333

Tx for low sperm count

Answer 333

IUI - Under 20 million per mL

Question 334

Azoospermia

Answer 334

Congenital absence of vas deferens d/t cystic fibrosis

Question 335

Asthenospermia

Answer 335

Decreased sperm motility Prolonged abstinence Infection Varicocele IUI to treat

Question 336

Antisperm antibodies

Answer 336

Can be d/t vasectomy, infection, testicular torsion

Question 337

Hormonal evaluation of male infertility

Answer 337

Look for low FSH and or Testosterone Giving testosterone can actually suppress sperm production

Question 338

PMDD

Answer 338

Premenstual dysphoric dysorder

Question 339

Premenopause

Answer 339

Erratic hormones, menses begin to be irregular

Question 340

Postmenopause

Answer 340

No menses for a year

Question 341

Dysmenorrhea

Answer 341

Painful menstrual bleeding

Question 342

Metorrhagia

Answer 342

Menstrual bleeding between periods

Question 343

Menometorrhagia

Answer 343

Irregular, unpredictable bleeding

Question 344

Oligomenorrhea

Answer 344

Periods more than 35 days apart

Question 345

BSO

Answer 345

Bilateral salpingo-oophorectomy

Question 346

TAH

Answer 346

Total abdominal hysterectomy - through abdomen

Question 347

TVH

Answer 347

Total vaginal hysterectomy - comes out through vagina

Question 348

Radical hysterectomy

Answer 348

Takes out uterus and additional tissue including the cervix

Question 349

Term pregnancy

Answer 349

37-42 weeks

Question 350

Preterm

Answer 350

20-36 weeks

Question 351

Abortion

Answer 351

Before 20 weeks

Question 352

Puerperium

Answer 352

Birth to 6 weeks postpartum

Question 353

3 trimesters

Answer 353

1 - 0-14 2 - 15-28 3 - 29-42 Each is 2 Weeks

Question 354

FHT

Answer 354

Fetal Heart Tones

Question 355

Grand multigravida

Answer 355

More than 5 times pregnant

Question 356

GTPAL

Answer 356

Gravida Term Preterm Abortions Lived 30 days

Question 357

Para

Answer 357

Pregnancies carried to term

Question 358

Recommended age for 1st reproductive health visit

Answer 358

Age 13-15 Only screen if STD suspected or symptomatic

Question 359

Age to begin pelvic exams and pap smear

Answer 359

21 years old Frequency of pelvic depends on risk factors with pap every 3-5 years

Question 360

General breast exam screening

Answer 360

Every 1-3 years 20-39, yearly after 40 with mammograms done starting at 40

Question 361

Speculum lubrication for pap smear

Answer 361

Use warm water (officially)

Question 362

Two ways to do pap smear

Answer 362

Use scraper and brush, or use the combo tool

Question 363

General breast exam method

Answer 363

Palpate 4 quadrants and 4 positions Palpate for regional lymphadenopathy Palpate tail of spence

Question 364

Bimanual exam

Answer 364

One hand in vagina and one on lower abdominal wall Test for size shape, mobility, and consistency of organs

Question 365

Skin exam recommendations

Answer 365

Q3 years 20-40 and then yearly 40+ Same as pap smears!!

Question 366

Pap screening recommendations

Answer 366

21-29 every 3 years 30-65 every 3 years or HPV with pap every 5 years Stop screening at 65

Question 367

Reasons to stop pap smears after 65

Answer 367

No hx of dysplasia/cancer 3 negative smears or 2 negative Pap+HPV in a row

Question 368

When do pap smear guidelines NOT apply

Answer 368

Hx of cervical cancer, HIV+, Immunedeficient, DES exposure

Question 369

STD screenings for ALL pregnant women

Answer 369

Hep B, HIV, Syphillis

Question 370

STD screenings in all women under 25

Answer 370

Gonorrhea and Chlamydia

Question 371

STD to screen for in high risk sexual behavior women

Answer 371

Hep C

Question 372

STD screening for all sexually active women

Answer 372

HIV - One time screen Gonorrhea and Chlamydia - Yearly if under 25

Question 373

STD screenings for High risk sexual behavior women

Answer 373

Annual for All: HIV Syphillis Trichomoniasis Hep B and C G/C HSV

Question 374

Breast cancer screening

Answer 374

Depends on agency - start yearly 40-50 years old - definitely by 50 Clinical breast exam optional, Mammogram required

Question 375

When to stop mammograms

Answer 375

When you wouldn't treat cancer if you found it 74 per official guidelines

Question 376

Colon cancer screening recommendations

Answer 376

FOB, FITm CT Colonoscopy 45-75 - recommended against after 75

Question 377

Bone density screening recommendations

Answer 377

65 years old Or any woman who's risk is equal to a 65 year old woman

Question 378

Bethesda system

Answer 378

Pap smear evaluation - grades pap cells for cancer

Question 379

Atypical squamous cells

Answer 379

ASC - Lowest concern abnormal pap smear cells, can see in infection or atrophy Undetermined significance = ASC-US Cannot exclude High Grade = ASC-H

Question 380

Low grade squamous intraepithelial lesion

Answer 380

LGSIL or LSIL Corresponds to CIN-I

Question 381

High grade squamous intraepithelial lesion

Answer 381

HGSIL or HSIL Corresponds to CIN II or CIN III

Question 382

Atypical glandular cells

Answer 382

Do not match normal cervical glandular cells but are also not cancer Associated with adenocarcinoma of endocervix or of endometrium

Question 383

CIN I

Answer 383

Disordered growth of lower 1/3 of epithelial lining - mild

Question 384

CIN II

Answer 384

Disordered growth of lower 2/3 of epithelial lining - moderate

Question 385

CIN III

Answer 385

Disordered growth of over 2/3 of epithelial lining of cervix - considered full thickness

Question 386

CIN

Answer 386

Cervicle Intraepithelial Neoplasia

Question 387

Treatment for CIN stages

Answer 387

Always treat CIN II or III Except for in pregnant women (wait till after birth) or in adolescents with CIN II we can observe

Question 388

Risk factors for cervicle dysplasia

Answer 388

Multiple sexual partners High risk partner HPV hx Other STIs Immune suppressed Contraceptive use long term Multiparous

Question 389

Management for ASC-US

Answer 389

Repeat pap in 6 months and then again in 6 more months Second abnormal smear - refer for colposcopy Test for HPV - colposcopy if positive Colposcopy

Question 390

Colposcopy

Answer 390

Like a cervicle exam - use a magnifying light as well as acetic acid Curette or brush endocervical canal

Question 391

Indications for coloposcopy

Answer 391

Abnormal cervicle cytology CLinically abnormal cervix Unexplained intermenstrual or postcoital bleeding Vulvar or vaginal neoplasia In utero DES exposure

Question 392

CIN I on colposcopy management

Answer 392

Expectant management 2 pap q6 months as with ASC-US Repeat colpscopy if positive or +HPV

Question 393

CIN II-III or cancer on colposcopy management

Answer 393

Surgery

Question 394

Cervix surgery

Answer 394

Take out part of the cervix for cancer

Question 395

3 estrogens in women

Answer 395

Estrone (E1) - Order when worried that thye have little estrogen Estradiol (E2) - What we are usually talking about when talking about estrogen - ordered to monitor menopause, etc. Estriol (E3) - Screen for fetal pathology and assess preterm labor risk

Question 396

Where progesterone is produced

Answer 396

Corpus luteum Placenta Biotin - causes flase elevation Should not be present post menopause

Question 397

Percent of pregnancies that are unintended

Answer 397

50%

Question 398

Percent of pregnancies that were unwanted but women not using birth control

Answer 398

40%

Question 399

Coitus Interruptus

Answer 399

Pull out method Very ineffective - very high failure rates Semen can leak out before orgasm Not recommended

Question 400

Postcoital Douche

Answer 400

Fluch semen out of vagina Not reliable - sperm are fast Not recommended

Question 401

Lactational amenorrhea

Answer 401

Suckling to reduce GnRH to suppress ovulation Pregnancy rate of 7.4% after 12 months - less effective with time Need to be amenorrheic Start other birth control at 3 months postpartum

Question 402

Periodic abstinence

Answer 402

Calendar methods - 11-25% failure rate May be related to birth defects

Question 403

Most effective determinant for ovulation

Answer 403

serum LH - not practical

Question 404

Fertile period for periodic abstinence

Answer 404

2 days before and after ovulation - not very reliable

Question 405

Temperature method of birth control

Answer 405

Check temp in the morning first three days of elevated temperature after drop are the fertile period

Question 406

Failure rate of combined temp/calendar method

Answer 406

5 per 100 couples per year - if consistent, need to be consistent

Question 407

Cervical mucous method

Answer 407

Billings method Check cervical mucus - when its thin, patient is fertile

Question 408

Symptothermal method

Answer 408

Notice ovulation symptoms and be aware - most effect natural method

Question 409

2 types of OCP

Answer 409

Combo or Progestin only pills

Question 410

Combination OCPs

Answer 410

Include estrogen and a progestin -some kind of both

Question 411

3rd or 4th generation progestins

Answer 411

Better to avoid male secondary sex characteristics Worse for risk of clotting - DVT, etc.

Question 412

Monophasic COC

Answer 412

Same hormones daily

Question 413

Multiphasic COC

Answer 413

Different doses during the cycle May give placebo at some points

Question 414

Administration of COC

Answer 414

Ideally start on first day of cycle or just start the day you pick it up and your body will adjust

Question 415

Single missed dose COC

Answer 415

Single high monophasic - makeup on the next day

Question 416

Multiple missed doses for COC

Answer 416

Double dose and use added barrier contraceptive for 7 days

Question 417

Tx for missed COC w/ coitus in past 5 days,

Answer 417

consider emergency contraception

Question 418

MOA of COCs

Answer 418

Suppress LH and FSH Alter cervical mucus Make endometrium less receptive to implantation

Question 419

Drug interactions with COCs

Answer 419

Antibiotics, Anticonvulsants, NSAIDs, SSRIs

Question 420

Benefits of COC

Answer 420

Lower risk of ovarian and endometrial cancer MSK benefits Lower ectopic pregnancy Less menstrual pain

Question 421

Major side effects of COCs

Answer 421

Increased thromboembolic risk MI risk increases Stroke Liver disease Cervical and Breast cancer increase

Question 422

Cautions for COCs

Answer 422

No use in migraine HAs with aura May impair breast milk

Question 423

Four Minor SEs for COCs

Answer 423

Nausea, dizziness, fatigue Weight gain 2-5lbs Abnormal menses Melasma

Question 424

8 Contrindications for COCs

Answer 424

Pregnancy Undiagnosed vaginal bleeding Migraine with Aura Prior history of thromboembolic event Uncontrolled HTM DM, or SLE Smokers over 35 Breast cancer hx Active liver disease

Question 425

Progestin only contraceptives

Answer 425

Does not suppress ovulation Thicken cervical mucous and make endometrium unsuitable Need to be very compliant

Question 426

Disadvantages of POCs

Answer 426

Must take at same time of day daily Higher bleeding and pregnancy rates Cancer is still a risk

Question 427

CI to POCs

Answer 427

Unexplained uterine bleeding Breast cancer Hepatic neoplasms Pregnancy Active severe liver disease

Question 428

Three ,method of emergency contraception

Answer 428

Yuzpee method Levonorgestrel Copper IUD

Question 429

Yuzpee method of contraception

Answer 429

Emergent COC with levonorgestrel 1st dose within 72 hours of intercourse - sooner is better Causes nausea

Question 430

Levonorgesterol alone

Answer 430

Plan B - OTC Single dose of 1500mcg Within 72 hours ideally, stops LH surge - not useful if already ovulated

Question 431

Ulipristal

Answer 431

Ella - OTC Single dose of 30mg Within 72 hours recommended Prevents LH surge - slightly better than plan B

Question 432

Emergent Copper IUD

Answer 432

May inhibit implantation or interfere with sperm function Insert up to 5-7 after OTC Emergency contraception

Question 433

Levonorgestrel IUD for emergency contraception

Answer 433

52 mg for emergency contraception Insert up to 5 days post intercourse

Question 434

Vaginal ring

Answer 434

Combination contraception 3 weeks per month No fitting, can remove for three hours and still work

Question 435

Failure rate of vaginal ring

Answer 435

0.65 per 100 women per year

Question 436

Transdermal patch contraception

Answer 436

New patch weekly for 3 weeks a month, not directly on breast - rotate sites Less than 1% failure with less efficacy in obese patients

Question 437

CI of transdermal patch and detachment

Answer 437

Have to restart if it has been off for 24 hours

Question 438

Depot Medroxyprogesterone Acetate

Answer 438

SepoShot Progesterone Q3 months 3% failure rate for typical (imperfect) use 0.3 - Ideally

Question 439

Benefits of Depot Medro shot

Answer 439

Lower risk of ectopic pregnancy Lower risk of endometrial cancer Lower sickle cell crises May help endometriosis

Question 440

Side effects of Depot Medroxyprogesterone Acetate Shot

Answer 440

Decreased bone density Irregular menses Takes 10 months to return to baseline and get pregnant

Question 441

Levonorgestrel implant

Answer 441

Implanted in arm Contains a progesterone - etonogesterol Almost 100% Up to 3 years - some studies is 5

Question 442

SE of implants (nexplanon)

Answer 442

Minor bruising, swelling, and itching at insertion site Irregular menses Weight gain HA

Question 443

Copper IUD non-emergent

Answer 443

FDA approved for 10 years Uncertain MOA 0.6-0.8 per 100 woman-years

Question 444

Risks/SEs of Copper IUD

Answer 444

Ectopic pregnancy Spontaneous abortion Uterine perforation Menstrual irregularities, cramping, vaginitis

Question 445

Contrindication to copper IUD

Answer 445

Pregnancy Active infection Wilson disease Cancer or unknown bleeding PID

Question 446

Levonorgestrel IUD

Answer 446

Good for people having heavy periods and cramping 8 year lifespan Very low failure Bleeding as a SE, helps with cramping, breast pain 52 mg

Question 447

Low dose levonorgestrel IUD

Answer 447

Kylea - 5 Skylea - 3 Not for cramps or menorrhagia

Question 448

IUD expulsion

Answer 448

Check for strings Happens in up to 5% in first year of use Test for pregnancy if expelled

Question 449

Spermicides

Answer 449

Most based on Nonoxynol-9 Phexxi - More natural Most OTC Placed in vagina and last around an hour High pregnancy due to non-compliance

Question 450

Contraceptive sponge

Answer 450

Nonoxyl-9 impregnated disk Inserted up to 24 hours before and keep in 6hrs post coitus Less effective than condom

Question 451

Lamb skin condoms

Answer 451

Don't protect against STD's - latex DO

Question 452

Female condom

Answer 452

May prevent STDs, not as effective as a male condom

Question 453

DIaphragm and Spermicide

Answer 453

Rubber dome over cervix Must use the spermicide 6 hours before and 24 hour max placement 6 per 100 with perfect use 15-20 per 100 with typical use

Question 454

Cervical cap

Answer 454

Smaller than a diaphrage -can stay in up to 48 hours Just on cervix May be hard to place

Question 455

Regret frequency for sterilization contraception

Answer 455

20% for women under 30 6% for women over 30

Question 456

Legal limitations to sterilization

Answer 456

Federal won't pay for under 21 - some states may None for incompetent patients

Question 457

4 types of female tubal sterilization

Answer 457

Electrocoagulation Mechanical occlusion Ligation with suture material Salpingectomy

Question 458

Concerns with tubal sterilization

Answer 458

Tubal pregnancy Chronic pelvic pain - tubal ligation syndrome Irregular menses Decreased ovarian cancer when removed

Question 459

Tubal occlusions

Answer 459

No longer done, used a hysteroscopic precedure

Question 460

Chemical tubal occlusion

Answer 460

Usually not done in US, never approved - seen in immigrants

Question 461

Vasectomy

Answer 461

30x less failure, 20x less post-op complications Need 1-2 consecutive sperm counts of zero to confirm it is working Easier reversal

Question 462

Suction curettage

Answer 462

Elective abortion performed 12 weeks for earlier 90% of US abortions Cervical dilation and suction catheter insertion

Question 463

Surgical curettage

Answer 463

Scrape out fetal parts - more bleeding less common than suction

Question 464

Phamraceutical abortion

Answer 464

(Mifepristone OR methotrexate) and/or Misoprostol Used in first trimester SE of cramping/bleeding CI in active liver/renal disease, anemia, bleed risk, IBF -may not expel everything

Question 465

Intraamniotic instillation

Answer 465

Hypertonic solution put into uterus to kill the fetus - lots of side effects

Question 466

Vaginal prostaglandins

Answer 466

For elective abortions - suppository containing misoprostal etc. to trigger preterm delivery Can cause GI side effects, live abortion

Question 467

MOA of misoprostol

Answer 467

Causes uterine contractions and cervicle ripening Used for abortions and induction

Question 468

Dilation and evacuation

Answer 468

Most common elective abortion for 2nd trimester Cervical ripening agents used and forceps to break up tissue Infection and blood loss - does not feel like a delivery

Question 469

Post abortion follow up

Answer 469

Rho-Gam Avoid anything intravaginal for 2 weeks Birth control 2+ elective abortions lead to higher risk of miscarriage

Question 470

Climacteric

Answer 470

Phase of aging from reproductive to non-reproductive age, before actual menopause occurs

Question 471

Average langth of per menopausal transition

Answer 471

1-3 years Part of climacteric period

Question 472

Average age of final menstrual cycle

Answer 472

51

Question 473

Premature menopause

Answer 473

Menopause at 40 or younger

Question 474

Perimenopausal

Answer 474

Going through menopause but still having periods

Question 475

Change in follicles over time

Answer 475

Ones most responsive to FSH are ovulated first

Question 476

Estradiol of menopause

Answer 476

May see bursts of estradiol because follicles are not responding as well

Question 477

Predisposing factors for menopause

Answer 477

Smoking advances by 2 years Reproductive tract disease GU infections Chemo or radiation Surgical impairment to ovarian blood supply

Question 478

Artificial menopause

Answer 478

We do something that destroys the ovaries or take them out May be due to endometriosis, cancer

Question 479

Postmenopausal androgens

Answer 479

Decreased production, but still have androgenic symptoms because ovaries make some testosterone and binding protein is not produced

Question 480

Gonadotropins in menopause

Answer 480

Increase because no estrogen - can be used for diagnosis

Question 481

Common classic menopause symptoms

Answer 481

Irregular bleeding Irritability and mood swings Vaginal dryness Decreased libido Hot flashes Hair loss Hirsutism Weight gain

Question 482

Physical changes of menopause

Answer 482

Atrophy of cervix, uterus, tubes Flattening of vaginal rugae

Question 483

Urinary and mammary changes of menopause

Answer 483

Urgency, frequency, dysuria Urethral prolapse Regression and flattening of mammary glands

Question 484

Atrophic vaginitis

Answer 484

Epithelium becomes thinner and rugae flatten out Painful intercourse and friability Smooth pale and shiny late Diffuse patchy and red early Increased pH

Question 485

Diagnosis of atrophic vaginitis

Answer 485

Clinical dx - may see atrophic cells in cytology

Question 486

Initial tx for atrophic vaginitis

Answer 486

Conservative first Vaginal moisturizers AND lubricants - not the same thing Moisturizers daily - not just for sex

Question 487

Treatment for moderate/severe atrophic vaginitis

Answer 487

Vaginal estrogen, restores pH and microflora Fewer UTIs and overactive bladder symptoms Can go systemic DOn't need a vaginal estrogen if systemic

Question 488

Ospemifene

Answer 488

For atrophic vaginitis Only targets vaginal estrogen receptors, MC MC SE is hot flashes

Question 489

Prasterone

Answer 489

Vaginal DHEA that turns into estrogen for estrogen sensitive individuals

Question 490

Presentation of hot flashes

Answer 490

Elevated HR - normal rhythm and BP Night sweats, Insomnia Cutaneous dilation - flushing

Question 491

Risk factors for hot flashes

Answer 491

Obesity, Lower physical activity, Smoking, African american race

Question 492

Normal hot flash length

Answer 492

seconds to 10 minutes

Question 493

Tx for hot flashes

Answer 493

Estrogen = mainstay, give progestin if they cannot take it alone

Question 494

Reasons to take eastrogen with progestin

Answer 494

Intact uterus due to endometrial cancer risk

Question 495

First line for patients who don't want hormones for hot flashes

Answer 495

SNRI/SSRI Citalopram or Venlafaxine, Paroxetine but it reacts with tamoxifen Gapapentin, Clonidine can also be used

Question 496

Protections of estrogen alone

Answer 496

CHD Fractures Diabetes Not used to treat these conditions

Question 497

Risks of MHT (Hormone therapy

Answer 497

Estrogen causes endometrial cancer - add progestin to prevent Increased risk of breast cancer with combo therapy - d/t progesterone!!

Question 498

Non-cancer risks of MHT

Answer 498

Thromboembolic diesease Gallbradder disease

Question 499

MHT contraindication

Answer 499

Hx of breast cancer Unknown bleeding Endometrial cancer Thromboembolic disease Liver dysfunction Pregnancy

Question 500

1st line MHT for vasomotor symptoms of menopause

Answer 500

Patch before pill - less risk of blood clots but insurance doesn't like to pay so oral is often used

Question 501

Starting MHT

Answer 501

Increase at one month intervals if still symptomatic Recommended not to use for more than 5 years - taper

Question 502

Progesterone only therapy for menopause

Answer 502

Can be oral or IM if we don't want estrogen

Question 503

Tissue selective estrogen complex

Answer 503

SERM and estrogen Reduces some of the risk of using a progesterine

Question 504

Oral estrogen and levonorgestrel IUD

Answer 504

May or may not help reduce risk of breast cancer - dubious

Question 505

Alternative hot flash pharm and GU symptoms

Answer 505

Doesn't really help except oxybutynin

Question 506

CAM for menopause

Answer 506

Isoflavone/Phytoestrogens - soy, lentils, etc. Black Cohosh Vitamin E Weight loss CBT Supplements can still have problematic effects

Question 507

Preparations for atrophic vaginitis

Answer 507

Ring, cream or tablet - every night for two weeks then two times per week May use testosterone if estrogen is contraindicated

Question 508

Lobes per breast

Answer 508

12-20 lobes

Question 509

Apex of breast

Answer 509

Contains major excretory duct

Question 510

Base of breast

Answer 510

Near ribs

Question 511

Montgomery glands

Answer 511

Sebacecous glands of the areola - help the breast stay healthy while breastfeeding

Question 512

Percent of the breast that is adipose tissue

Answer 512

80-85% adipose tissue

Question 513

Coopers ligaments

Answer 513

Hold the breast to the chest wall - deeper

Question 514

Beginning age for breast deveopment

Answer 514

Ages 10-13

Question 515

Breast changes during menstrual cycles

Answer 515

Premenstrual - Epithelial cells proliferate - increased size by a little Post menstrual - Epithelial cells die off, decreased turgor with some tenderness

Question 516

When does the breast reach full development

Answer 516

End of a full term pregnancy only

Question 517

Pregnancy changes of breast

Answer 517

Darkened areola - bulls eye for infant Increased lubrication and milk ducts Fatty tissue almost completely replaced by glands and ducts

Question 518

Trigger and regulator of breast milk production

Answer 518

Progesterone drop triggers and prolactin maintains

Question 519

Menopausal breast changes

Answer 519

Atrophy and loss of functional breast tissue

Question 520

Fluids from breast commonality

Answer 520

40% of premenopausal women 55% of parous women 75% who have lactated in the past 3 years

Question 521

Physiologic breast discharge

Answer 521

Expressed when pressure is applied and from multiple ducts/ both breasts

Question 522

Causes of physiologic breast discharge

Answer 522

Normal lactation Galactorrhea Benign phys discharge Can be an intraductal papilloma

Question 523

Classical presentation of galactorrhea

Answer 523

Bilateral multiductal milky discharge, otherwise normal PE - may want to test for pregnancy

Question 524

Classic pathologic discharge

Answer 524

Unilateral spontaneous bloody for serous discharge from a single duct Bloody is more suggestive of cancer but also more likely due to benign papilloma

Question 525

Cytology of breast discharge

Answer 525

Very los sensitivity - usually skip to imaging

Question 526

Ductography

Answer 526

May show a filling defect in cancer - flush contrast into ducts

Question 527

Ductoscopy

Answer 527

Use tiny endoscope for viewing

Question 528

Definitive diagnostic for pathologic discharge

Answer 528

Microductectomy - excise ducts below areola and send to pathology

Question 529

Gynecomastia

Answer 529

Glandular breast tissue in a biologic male Normal in 60% of pubertal boys - usually resolves in a year Anabolic steroids

Question 530

Psudogynecomastia

Answer 530

Fat tissue that looks like gynecomastia - should not seem a firm tender area beneath the areola - firm Glandular tissue not enlarged

Question 531

Dx for gynecomastia

Answer 531

Elevated PRL or hCG Can also chack testosterone, estradiol Thyroid

Question 532

Tx for gynecomastia

Answer 532

If painful and persistent for 9-12 months SERM - raloxifine or tamoxifen Anastrozole - not recommended long term in teens

Question 533

When would we give testosterone to a male

Answer 533

Only for true hypogonadism

Question 534

MCC of mastitis

Answer 534

Staph areus

Question 535

Risk factors for mastitis

Answer 535

Seen in lactation and nursing in primiparous patients, rare before fifth day postpartum

Question 536

Presentation of mastitis

Answer 536

Painful, erythematous lobule in the outer quadrant of the breast 2nd or 3rd week after birth Systemic signs of infection - high fever not due to simple breast engorgement Antibody coated bacteria in breast milk

Question 537

Presentation of breast abcess

Answer 537

Pitting edema and fluctuation

Question 538

Tx for mastitis

Answer 538

Keep draining breast - feed or pump Local heat, warm compress Well fitted bra Instruct on techniques Acetominophen/ibuprofen

Question 539

Antibiotics for mastitis

Answer 539

Dicloxacillin of Keflex Clinda or Bactrim (not for under 1 month old infants)

Question 540

Abx for severe mastitis

Answer 540

Van and Ceftriaxone OR Zosyn

Question 541

Tx for breast abcess

Answer 541

I&D with abx tx - oral abx usually not sufficient without draining

Question 542

Non nursing breast abcess - peripheral

Answer 542

On side is often because of folliculitis or infected cyst I&D and mastitis abx

Question 543

Subareolar breast abcess

Answer 543

Due to keratin plugged milk ducts behind nipple Simple I&D not enough Requires duct excision with biopsy to rule out cancer

Question 544

Breast fat necrosis presentation

Answer 544

Presents with nipple and skin retraction May have signs or hx of trauma Indistinguishible from breast cancer clinically Biopsy if persistent

Question 545

Fibrocystic breast changes

Answer 545

MCC of cyclic breast pain or mastalgia in women 30-50 Epithelial cells become cystic May be increased in drinkers and estrogen users Worsened by caffeine

Question 546

Age of fibrocystic breast changes

Answer 546

30-50 - correlated with reproductive age, goes away with menopause

Question 547

Presentation of fibrocystic breast changes

Answer 547

Pain or tenderness with lump Present or worse during the premenstrual phase (later half of cycle) Multiple lesions that change in size

Question 548

Discharge of fibrocystic breast changes

Answer 548

Green or brown

Question 549

Dx for fibrocystic breast changes

Answer 549

Mammogram for over 30 US and aspiration -US can be better than an ultrasound to see if lesions are cystic Be on the lookout for odd one out

Question 550

Tx for fibrocystic breast changes

Answer 550

Avoid trauma, well fitting bra Avoid caffeine Low fat diet may help

Question 551

Tx for severe fibrocystic breast changes

Answer 551

Danazol and Tamoxifen Surgery for most refractory cases

Question 552

Prognosis for fibrocystic breast changes

Answer 552

Will subside with menopause Usually not associated with breast cancer

Question 553

Fibroadenoma

Answer 553

Enlarged lobule in young women - early and mid 30s Larger with hormones and usually solitary

Question 554

Presentation of fibroadenoma

Answer 554

Round, smooth, and nontender mass, discrete Can dx clinically but usually get image to be sure

Question 555

Fibroadenoma on imaging and def dx

Answer 555

Well defined solid mass with benign features Def. dx is core biopsy or mass excision

Question 556

Phyllodes tumor

Answer 556

Can become malignant - similar to a fibroadenoma

Question 557

Tx for fibroadenoma or phyllodes tumor

Answer 557

Unclear or rapid growth -surgical excision with wide margins Can monitor/follow-up fibroadenoma if asymptomatic with biopsy or US breast exam

Question 558

Inheritance pattern of BRCA1 and 2

Answer 558

Autosomal dominant Also causes risk in MEN!!

Question 559

Risk factors for breast cancer

Answer 559

Nulliparity First full term pregnancy after age 30 Early menarche or late menopause (reverse decreases risk) Combo HRT Hx of uterine or breast cancer

Question 560

Usual presentation of breast cancer

Answer 560

Painless breast mass Hard, fixed, irregular margins, nonmobile May see metastatic symptoms first May also see pain, discharge, erosion, retraction

Question 561

MC site of breast cancer

Answer 561

Upper outer quadrant

Question 562

4 positions for breast exam

Answer 562

Arms over head Laying on back with arms up Arms on hips Leaning forward

Question 563

Concerning PE findings for breast cancer

Answer 563

New unilateral side change in size, contour Unilateral retraction of nipple Edema or erythema Firm, non mobile, matted lymph nodes

Question 564

Main lymph nodes for breast drainage

Answer 564

85% goes to axillary but palpate everything

Question 565

Paget's disease of the breast

Answer 565

Eczematoid eruption and ulceration - arises from nipple areola Pain itching, burning discharge and superficial erosion or ulceration Biopsy Excision/Mastectomy to treat

Question 566

Inflammatory carcinoma

Answer 566

Diffuse, brawny edema with erysipeloid border Orange peel skin may be seen No mass Aggressive but rare - rule out in refractory or unexplained mastitis

Question 567

BIRAD 1 and 2 on mammogram

Answer 567

Okay, anything higher is concerning

Question 568

Definitive diagnosis for breast cancer

Answer 568

Biopsy Fine needle - less invasive but less sensitive Core needle - MOre invasive better Can also excise

Question 569

Hormone receptor sites for cancer

Answer 569

Can have estrogen, progesterone, and HER2 receptors - change how the cance will metastasize Triple neg goes to lungs/liver

Question 570

Indication for hormonal therapy

Answer 570

Positive for ER/PR/HER2 hormone receptors

Question 571

Tamoxifen

Answer 571

Historically drug of choice for hormonal breast cancer - can cause clotting and endometrial cancer

Question 572

Newer treatment for hormonal breast cancer

Answer 572

Anastrozole - aromatase inhibitor, more effective than tamoxifen

Question 573

Therapy for non hormonal (triple neg) breast cancer

Answer 573

Consider an adjuvant -pembrolizumab (keytruda)

Question 574

Selective estrogen receptor modulators

Answer 574

Bind to estrogen receptors and block estrogen SERMs -selective for tissues, tamoxifen is specific to breast tissue Roloxifene blocks in breast and uterus

Question 575

SEs of SERMs

Answer 575

Hot flashes, thin hair, thrombosis Can stimulate OR inhibit estrogen

Question 576

Aromatase inhibitors

Answer 576

Anastrozole, exemastane, letrozole Inhibit aromatase which produces estrogen Menopausal symptoms - hot flash, brain fog, thinning hair Newer for breast cancer

Question 577

Fulvestrant

Answer 577

Little brother elacestrant Destroys estrogen receptors Used for metastatic breast cancer No blood clots or cancer Need receptors to work

Question 578

Breast cancer follow ups

Answer 578

Q4 months for 2 years then Q6 for 3 years for PE Mammogram in 6 months then yearly

Question 579

Median time of breast cancer recurrence

Answer 579

At 4 months

Question 580

Percent of those trafficked who are female and minors

Answer 580

55-70% female About half minors

Question 581

Warning signs of human trafficking

Answer 581

Social withdrawal Physical abuse Neglect Practiced hx Living in unsuitable conditions

Question 582

What to do if you suspect human trafficking

Answer 582

Send tip to national hotline Give resources to patient DOCUMENT

Question 583

Percent of domestic violence victims who are female

Answer 583

85%

Question 584

Women killed by male partner or ex 2001-2012

Answer 584

11,766, more than died in the iraq war in the same period

Question 585

DV

Answer 585

Domestic violence Controlling with disregard for wellbeing

Question 586

Risk factors for DV/IPV

Answer 586

Race - AA Pregnancy is a huge risk factor - DV is the leading cause of death in pregnant women Younger age (16-24) Childhood exposure to violence

Question 587

Presentation of domestic violence

Answer 587

Often vague Chronic pelvic pain Sexual dysfunction Recurrent vaginitis Anxiety and tearfulness during breast and pelvic exam

Question 588

Body complaints of DV

Answer 588

HA Fatigue Sleep disturbance Seems like a somatoform disorder

Question 589

Percent of pregnancies with violence

Answer 589

4-9%

Question 590

Cycle of abuse

Answer 590

Tension building Incident Reconciliation Calm "Honeymoon" phase

Question 591

Screening for domestic violens

Answer 591

Screen everybody at all checkups, especially in pregnancy screen at least once per trimester and postpartum

Question 592

Bestway to screen for domestic violence

Answer 592

Do it in person Say something universal first: Because so many people are abused.....I want to ask Ask about specific behaviors - not general like "rape" or "abuse"

Question 593

Mandatory report events in WV for abuse

Answer 593

Gunshot, Stab, Burn

Question 594

After dx tx for DV

Answer 594

Acknowledge trauma Document with photographs - flag to withold Assess safety and lethality, substance abuse Create safety plan

Question 595

What to do if patient does not want to leave abusive situation

Answer 595

Don't place blame Document Support patient Follow up with patient

Question 596

Majority of teenage rapes

Answer 596

Acquaintance rape - by someone they know

Question 597

Presentation of sexual assault

Answer 597

May say they were mugged, May be asking AIDS or STD screening 60-70% have no obvious physical injury May have bleeding and vaginal irritation, few have major injuries

Question 598

Rape trauma syndrome

Answer 598

Detached shock like state Acute phase - hours to days, tired, HA, startled abates after about two weeks Delayed phase - Months to years, chronic anxiety, mistrust, depression, sexual dysfunction

Question 599

PE for sexual assault

Answer 599

Have a trained person do a sexual assault assessment kit Sexual assault nurse examiner - take care not to tamper with evidence

Question 600

Hx for sexual assault

Answer 600

Describe what happened Any consensual sex What happened between Any infections State "Use of Force"

Question 601

Tx for sexual assault

Answer 601

Emergency contraception after pregnancy test - IUD Ceftriaxone and potentially metronidazole or Doxycycline Hep B and HIV prophylaxis HPV vaccine

Question 602

Psych tx for sexual assault

Answer 602

Refer to counseling even if they appear calm, admit if unstable

Question 603

Follow up for sexual assault

Answer 603

2 weeks - for psych and other issues

Question 604

3 things we need for intact menses

Answer 604

Intact HPO axis Endometrial response to stimulation Way for blood to exit

Question 605

Primary amenorrhea

Answer 605

Have never had a period Often due to a genetic abnormality

Question 606

Secondary amenorrhea

Answer 606

Misses 3 cycles or 6 consecutive months MCC is pregnancy

Question 607

2nd MCC od secondary amenorrhea

Answer 607

PCOS

Question 608

Sheehan's syndrome

Answer 608

Blood loss during birth leads to pituitary necrosis

Question 609

Mullerian dysgenesis

Answer 609

No internal female sex hormones except for ovaries

Question 610

Asherman's syndrome

Answer 610

Uterine fibroids cause unable evacuation of blood

Question 611

Anatomical blockages causing amenorrhea - 2

Answer 611

Transverse septum Imperforate hymen

Question 612

Dx for asherman's syndrome

Answer 612

Hyerosalpingogram

Question 613

Progesterone challenge test

Answer 613

Give progesterin - if they bleed afterwards they are anovulatory

Question 614

Estrogen and Progesterone challenge test

Answer 614

No bleed afterwards means blockage Bleading afterwards = hypogonadism

Question 615

Secondary dysmenorrhea

Answer 615

Casued by something demonstrable

Question 616

Membranous dysmenorrhea

Answer 616

Due to passage of a cast of the uterus through the cervix

Question 617

Primary dysmenorrhea

Answer 617

No known cause - MC type of dysmenorrhea

Question 618

First line tx for dysmenorrhea

Answer 618

NSAID - 400-800 with no more than 1200mg per day May take prophylactically Acetaminophen less effective Continuous heat helps - need a break

Question 619

Erythema ab igne

Answer 619

Rash associated with chronic heat pad use

Question 620

2nd line tx for dysmenorrhea

Answer 620

Hormonal contraceptives Lyletta, Morena - Progesterone IUD

Question 621

Percent of women with PMS or PMDD

Answer 621

75% Highest in 20s to 30s

Question 622

Tx for mild to moderate PMS/PMDD

Answer 622

Dietary changes - caffeine, alcohol, sodium Exercise - aerobic Chasteberry, Calcium carbonate - OTC NSAID for pain Spironolactone for bloating Bromocryptine for breast pain

Question 623

Tx for severe PMS/PMDD

Answer 623

SSRI - 1st line with 50% helped, can be used periodically 2nd line - Hormonal therapy May consider alprazolam GnRH agonist - put pt in menopause

Question 624

Transvaginal US taking

Answer 624

Need an empty bladder - see pelvic organs

Question 625

Transabdominal US taking

Answer 625

Full bladder, less visualization of pelvic organs

Question 626

Sonohysterography

Answer 626

Saline injected into intrauterine cavity - increased sensitivity

Question 627

Gold standard for uterine pathology evaluation

Answer 627

Hysteroscopy - camera in the uterus

Question 628

Tx for Dysfunctional Uterine Bleeding

Answer 628

r/o pregnancy or cancer - oral contraceptives, observation if asymptomatic and no cancer Levonorgestrel IUD, D&C for short term ablation

Question 629

Postmenopausal DUB

Answer 629

MCC - exogenous hormones Always investigate May actually be bleeding from vagina

Question 630

Workup to r/o tumors of reproductive tract in DUB

Answer 630

Endometrial sampling

Question 631

Endometrial ablation

Answer 631

Need to take birth control, not want to be fertile Reduces flow in 70-80%

Question 632

Pretreatment for endometrial ablation

Answer 632

Abx NOT needed GnRH agonist or D&C to thin out endometrium

Question 633

CI to endometrial ablation

Answer 633

Pregnancy, Desire to have children, Endometrial hyperplasia, Postmenopause, IUD in place

Question 634

Vaporization endometrial ablation

Answer 634

Nd-Yag laser Early method Scar endometrium

Question 635

Roller ball

Answer 635

Similar to vaporization Old method

Question 636

Endometrial resection

Answer 636

Old method - caused a lot of perforation

Question 637

Hysteroscopic thermal endometrial ablation

Answer 637

2nd generation Heated saline put in uterus Good for anatomic abnormalities Higher burn risk

Question 638

Radiofrequency thermal ablation endometrial ablation

Answer 638

2nd gen No D&C or progesterin needed Uses a heasted mesh

Question 639

Thermal + RF Endometrial ablation

Answer 639

Brand - Minerva Silicone contours to shape of cavity Balloon filled with RF heated Argon gas Endometrial prep not needed Higher success rates 2nd gen

Question 640

Water vapor termal endmetrial ablation

Answer 640

Seal with baloons and fill with water 2nd gen Safer

Question 641

Cryoablation endometrial ablation

Answer 641

Less pain but less effective 2nd gen

Question 642

Theraml balloon endometrial ablation

Answer 642

Use balloon to conform to contours of uterus No longer done in US - too much burning

Question 643

Sites of endometriosis

Answer 643

Other sites in the abdomen Or distant site outside of the abdomen - can be anywhere

Question 644

Risk factors for endometriosis

Answer 644

Fam hx Early menarchy Nulliparity LOng flow Heavy periods Shorter cycles IE. anything that increases menstrual bleeding

Question 645

Presentation of endometriosis

Answer 645

Dysmenorrhea Pelvic pain Dyspareunia Infertility May worsen with period Severity does not corespond to amount of ectopic tissue

Question 646

PE for endometriosis

Answer 646

Tender nodules in posterior vaginal fornyx Pain with uterine motion Tender adnexal masses may be felt May have no findings

Question 647

Dx for endometriosis

Answer 647

Imaging is usually not helpful Laparoscopy to diagnose definitively

Question 648

Lesions of endometriosis

Answer 648

Powder burns Chocolate cysts Red/Purple raspberry spots

Question 649

Tx for mild/moderate endometriosis

Answer 649

NSAID Progesterone contraceptives

Question 650

Tx for moderate to severe endometriosis

Answer 650

Hormonal - GnRH agonists or antagonists - ie. danazole, letrozole Gabapentin TCAs Surgery

Question 651

Reason to use surgery for endometriosis

Answer 651

Do it when they are wanting to have children b/c they can come back

Question 652

Danazol

Answer 652

Testosterone derivative that acts like progestin Inhibits gonadotropic release SE - Oily skin, acne, deep voice

Question 653

Anastrozole/Letrozole

Answer 653

Aromatase inhibitors Can be used as an adjuvant to Danazol

Question 654

GnRH agonists

Answer 654

Leuprolide, Goserelin, Nafarelin For endometriosis Use for max 6 months Menopause like symptoms

Question 655

GnRH antagonists

Answer 655

Elagolix (Orlissa) Most studied Max 6 months at high or 24 months at low dose Menopause like symptoms

Question 656

Pelvic inflammatory disease presentation

Answer 656

Lower abdominal pain - insidious or acute usually for 2 ish weeks Oral temp > 101F Bilateral lower quadrant tenderness Skene or Bartholin glands around introitus

Question 657

Fitz-Hugh-Curtis syndrome

Answer 657

Liver inflammation with PID

Question 658

Classic sign of pelvic inflammatory disease

Answer 658

Cervical motion tenderness (chandelier sign

Question 659

Dx for PID

Answer 659

Pregnancy test to r/o WBCs in vaginal fluid ESR/CRP may be elevated

Question 660

Imaging for PID

Answer 660

May see thickening, tubo-ovarian complex, may be normal

Question 661

Tx for pelvic inflammatory disease

Answer 661

Outpatient abx if they are not too sick and compliant, IV for inpatient 3 Drugs at same time: Rocephin shot Doxy Metronidazole 14 day course overall

Question 662

Presentation of tubo-ovarian abcess

Answer 662

Tenderness and guarding Mass in abdomen Multi-loculated lesion on US

Question 663

Tx for unruptured tubo-ovarian abcess

Answer 663

Same abx as PID (Metro, Doxy, Rocephin) but for 4-6 weeks

Question 664

Tx for ruptured tubo-ovarian abcess

Answer 664

Life threatening emergency TAH (total abdominal Hysterectomy) and BSO (bilateral salpingo-oophorectomy) with aggressive fluid resuscitation

Question 665

Cystocele

Answer 665

Prolapse of the bladder d/t anterior vaginal wall weakness. Visualized through the vagina and better seen when bearing down

Question 666

Rectocele

Answer 666

Rectal prolapse d/t posterior vaginal weakness Seen in bearing down

Question 667

Uterine prolapse

Answer 667

Uterus slides down towards the introitus

Question 668

Pelvic organ prolapse stages 0-4 Halfway system

Answer 668

0 - Normal 1 - Halfway to hymen 2 - To hymen 3 - Halfway past hymen 4 - Maximal descent

Question 669

Presentation of pelvic organ prolapse

Answer 669

Feeling of heaviness in vagina, urinary symptoms with cystocele Talk about putting fingers in vagina to brace it when urinating/defecating

Question 670

Dx for pelvic organ prolapse

Answer 670

Pelvic exam with bearing down Imaging only if worried about secondary problem

Question 671

Tx for pelvic organ prolapse

Answer 671

Pessary - reexamine in 1-2 weeks for first one, then every 2-3 months after that Kegal exercises

Question 672

Surgical tx for POP

Answer 672

May use mesh or other surgery - mesh can cause irritation

Question 673

Adenomyosis

Answer 673

Endometrial tissue implants in the myometrium Focal or diffuse

Question 674

Risk factors for adenomyosis

Answer 674

Parity and age

Question 675

Presentation of adenomyosis

Answer 675

More areas of invasion = more s/s Menorrhagia, dysmenorrhea Global uterine ENLARGEMENT with uterine softening

Question 676

Imaging for adenomyosis

Answer 676

TVUS Focal thickening of myometrium on US Heterogenous texture on US

Question 677

Tx for adenomyosis

Answer 677

NSAIDs for pain Combo oral contraceptives Endometrial ablation/resection may help somewhat

Question 678

Definitive tx for adenomyosis

Answer 678

Hysterectomy Symptoms also get better after menopause - ride out

Question 679

Leiomyoma

Answer 679

Benign neoplasm of the female genital tract - uterine fibroids

Question 680

Submucous leiomyoma

Answer 680

Directly beneath endometrial lining - on the inside!!

Question 681

Subserous leiomyoma

Answer 681

Directly beneath serosal lining - on the outside!!

Question 682

Intramural leiomyoma

Answer 682

Completely within the myometrium

Question 683

Presentation of leiomyomas

Answer 683

Most are asymptomatic MC symptoms are - Abnormal bleeding, pelvic pressure/pain May torse - causing pain May compress nearby organs

Question 684

PE for leiomyomas

Answer 684

Enlarged uterus with irregular contour

Question 685

Dx for leiomyomas

Answer 685

Iron deficiency on labs US can detect MRI for more detail Hysterography/Scopy can also help

Question 686

Tx for asymptomatic leiomyomas

Answer 686

Can monitor with a yearly US - not a big threat to health

Question 687

Tx for sympomatic leiomyomas

Answer 687

NSAIDs or hormonal therapy depending on sx Regress spontaneously during menopause - menopausal hormone therapy may bring it back

Question 688

Surgical tx for leiomyomas

Answer 688

Total hysterectomy Myomectomy - just remove fibroid Embolization - Clot it up - good results

Question 689

Peak onset for endometrial cancer

Answer 689

70s - many cases can occur younger Obestity increases risk

Question 690

Precursor to endometrial cancer

Answer 690

Endometrial hyperplasia Excess estrogen!!

Question 691

MCC of endogenous over production of estrogen

Answer 691

Obesity - From the fat!

Question 692

Other risk factors for endometrial cancer

Answer 692

PCOS Exogenous unapposed estrogen therapy (w/o progestin and no hysterectomy) More peiords (ie. early menarche, less pregnancies)

Question 693

Risk reduction for endometrial cancer

Answer 693

Progestin or combination contraceptives

Question 694

MC symptoms of endometrial hyperplasia

Answer 694

Abnormal uterine bleeding Simple or complex atypia (complex more likely to become cancer but progesterone cures both)

Question 695

Endometrial hyperplasia with atypia

Answer 695

More concerning that simple/complex Progesterone will not cure

Question 696

Type I endometrial cancer

Answer 696

Not as aggressive YOunger patients Better prognosis

Question 697

Type II endometrial cancer

Answer 697

Less common Poorer prognosis Independant of estrogen

Question 698

Classic endometrial cancer patient

Answer 698

Obese Nulliparous Infertile HTN DM White

Question 699

MC type of endometrial cancer

Answer 699

Adenocarcinoma

Question 700

Presentation of endometrial cancer

Answer 700

Abnormal bleeding in 80% of patients - postmenopausal bleeding may be an indicator Vaginal discharge Cervical os stenosis

Question 701

Tx for endometrial cancer WITHOUT atypia

Answer 701

Progesterone

Question 702

PE for endometrial cancer

Answer 702

May feel inguinal lymph nodes Normal in early stages

Question 703

Imaging for endometrial cancer

Answer 703

US with endometrial thickness over 4 mm is high suspicion for cancer DDx - Biopsy

Question 704

Other tests that may pick up endometrial cancer

Answer 704

D&C - even better than biopsy Sometimes picked up on pap smear

Question 705

Tx for endometrial cancer

Answer 705

Surgery is mainstay - total hysterectomy with BSO - curative in low risk

Question 706

Adjuvant pharm for endometrial cancer

Answer 706

Radiation, Progesterone, Chemo - Doxyrubicin and Cisplatin

Question 707

Tx for excess bleeding in endometrial cancer

Answer 707

NO IV estrogen like we would with other bleeding Tamponade and Packing

Question 708

Functional ovarian cysts

Answer 708

Due to cyclic ovarian changes - do not always cause symptoms Can rupture causing peritonitis Impinge organs

Question 709

Dx for ovarian cyst

Answer 709

Pelvic US is MC way to dx

Question 710

Follicular cyst

Answer 710

MC type of ovarian cyst Follicle doesn't rupture appropriately Usually asymptomatic May cause irregular menstual bleeding

Question 711

Management of follicular cyst

Answer 711

Usually resolve in 2 months OCP can keep cysts from forming May aspirate or surgically remove - usually not necessary

Question 712

Corpus luteum cyst

Answer 712

Corpus luteum did not regress Progesterone abnormalities may lead to late period Torsion, pain, can look like ectopic pregnancy

Question 713

Tx for corpus luteum cyst

Answer 713

Manage symptomatically OCP questionable Surgery if problematic Ring of fire on US

Question 714

Theca Lutein cyst

Answer 714

Caused by elevated hCG Often bilateral and multiple Resolve once hCG goes down May aspirate in pregnancy

Question 715

Endometriomas

Answer 715

Implant of endometrial tissue on the ovary Endometriosis symptoms - chocolate cysts

Question 716

Dermoid cyst

Answer 716

Filled with improper tissue - fat, teeth, etc. Not cancer May rupture

Question 717

Cystadenomas

Answer 717

Cysts that get massive - pain and discomfort Pop, drain, remove

Question 718

PCOS

Answer 718

Stein Leventhal syndrome Enlarged ovaries with multiple cysts Anovulaotry, amennorheic Obese, overweight patients

Question 719

Diagnosis of PCOS

Answer 719

Pt. with variable periods, obesity, hirsutism, oligomenorrhea Polycystic ovaries on US - Oyster ovaries

Question 720

Presentation of PCOS

Answer 720

Menstural abnormalities, early pregnancy loss, Pelvic pain/pressure, T2DM Young endometrial cancer dx Acanthosis nigricans

Question 721

Hormones in PCOS

Answer 721

Mild elevation of androgens Lower sex hormone binding globulin Increased LH:FSH ratio

Question 722

US of PCOS

Answer 722

Ovary with many cysts in it - look like dark pockets

Question 723

Tx for PCOS - conservative

Answer 723

Observe symptoms - should be having at least 8 periods a year Lifestyle changes -loose weight, well balanced diet

Question 724

PCOS moderate therapy

Answer 724

Pregnancy test COC - if not trying to conceive or ring patch if eligible, helps with hyperandrogenism Progesterone alone - second line

Question 725

PCOS insulin sensitization

Answer 725

Metformin is MC drug - safe in pregnancy May also use GLP-1 agonist

Question 726

Tx for PCOS hirsutism

Answer 726

Takes 6-12 months to work COC or GnRH agonist Laser removal, etc. Spironolactone - androgen antagonist 5 alpha reductase inhibitors - finasterid/dutasteride

Question 727

Vaniqua

Answer 727

Expensive hair removal medicine

Question 728

Novel PCOS therapies

Answer 728

Myo-inositol NK34 antagonist

Question 729

PCOS tx for patients who want to get pregnant

Answer 729

Weight loss and lifestyle Letrozole on days 3-7 of period Not safe once pregnant (Clomid used to be first line - SERM - blocks estrogen in hypothalamus)

Question 730

MOA of letrozoleand 4 SEs

Answer 730

Inhibits aromatoase SE - hot flashes, dizziness, fatigue, pain

Question 731

Clomid for PCOS

Answer 731

causes ovarian enlargement, hot flashes, bloating Not great

Question 732

FLuid retention of PCOS tx

Answer 732

Can be extreme - present with hypovolemia and swelling MC with Clomid, FSH LC with Letrozole

Question 733

Surgery for PCOS

Answer 733

Ovarian drilling - laparoscopic laser biopsies jump start the ovaries

Question 734

Ovarian torsion

Answer 734

Emergent condition like testicular torsion Often due to enlarged ovaries May occur in early pregnancy

Question 735

Presentation of ovarian torsion

Answer 735

Sudden onset severe, one sided unilateral abd pain Painful adnexal mass May radiate to thigh, flank, or groin Women may be used to abdominal pain!!

Question 736

Dx for ovarian torsion

Answer 736

Sonography - dx of choice Bull's eye, whirlpool, snailshell pattern Doppler flow disruption Do pregnancy test Transvaginal US may be better

Question 737

Tx for ovarian torsion

Answer 737

Laparoscopic detorion ( can do laparotomy) Remove cyst causing problem Remove if 12+ hours - obvious necrosis

Question 738

MC source of ovarian cancer

Answer 738

Epithelial ovarian cells

Question 739

Ovarian cancer

Answer 739

CA-125 marker - from serous cystadenomas Typical in menopausal patients

Question 740

Other types of ovarian cancer

Answer 740

Germ cell tumor - younger patients Sex cord stromal tumors

Question 741

Risk factors for ovarian cancer

Answer 741

Anything that increases cell turnover Talcum powder

Question 742

Presentation of ovarian cancer

Answer 742

Vague early symptoms Early satiety Fatigue, back pain Late - abdominal pain, ascites, solid irregular adnexal mass

Question 743

Sister Mary Joseph nodule

Answer 743

Belly button nodule due to ovarian cancer

Question 744

CA-125 marker for ovarian cancer

Answer 744

Elevated in 50% of ovarian cancer Associated with many other things - fibroids, endometriosis More specific for postmenopausal women

Question 745

Dx for ovarian cancer

Answer 745

Various markers Pelvic US w/ solids, separation, ascites CT/MRI for more exact Bx for definitive

Question 746

Tx for ovarian cancer

Answer 746

Remove omentum, ovaries, uterus Watch CA-125 to see if cancer resolved

Question 747

Tx for germ cell ovarian cancer

Answer 747

Often try to save the uterus - not as aggressive

Question 748

MC GYN malignancy

Answer 748

Uterine cancer Ovarian - 2nd

Question 749

Sexual response stages - 4

Answer 749

Desire Arousal Orgasm Resolution

Question 750

Hormones that increase libido

Answer 750

Estrogen Testosterone - uspraphysiologic Dopamine Norepinephrine Oxytocin Melanocortins

Question 751

Hormones that inhibit libido

Answer 751

Serotonin - at high levels Prolactin Opioids Endocannabinoids

Question 752

Average female puberty onset

Answer 752

8-13 years old

Question 753

MC sexual dysfunction in women

Answer 753

Low sexual desire - 39% of disorders

Question 754

Female arousal/interest disorder

Answer 754

Low desire or abnormal arousal - must occur 75%+ of the time, lasts for 6+ months Causes distress

Question 755

6 criteria for female interest arousal disorder

Answer 755

Must report 3: Absent interest in sex Reduced fantisizing Reduced initiation Reduced interest/arousal to stimuli Reduced excitment/pleasure Reduced sensation

Question 756

Genitopelvic pain/Penetration disorder

Answer 756

Pain majority of time with sex TIghtening of muscles Avoid vaginal sex Common hx of trauma or abuse

Question 757

Female orgasmic disorder

Answer 757

Don't feel like they finish the way they want to May be due to neuropathy, partner issues, etc.

Question 758

Medications related to sexual disorders

Answer 758

SSRI! TCA Benzos Lithium Anticholinergic HTN meds - BB SERM/Aromatise inhibitors

Question 759

Estrogen for sexual disorders

Answer 759

Increases libido, vaginal lubrication, blood flow to genitalia CI - Blood clots, endometrial cancer Recommended if more than just libido

Question 760

Androgens for sexual disorders

Answer 760

Generally not recommended - may be used in menopause Cause hirsutism, acne, liver disease Last line

Question 761

Dosing testosterone for women

Answer 761

Much lower dose than used for men

Question 762

Serotonin/Dopamine for sexual disorders

Answer 762

Flibanserin - post menopause serotonin agonist/modulator helps with SE of SSRI CI with alcohol, hypotension

Question 763

Bupropion for sexual dysfunction

Answer 763

Helps with norepi and dopamine Helps with arousal response, etc. CI in seizures, anorexia, MAOI use

Question 764

PDE-5 inhibitors in womens sexual dysfunction

Answer 764

Slidenafil Most helpful with physiologic problems - ie. vascular, neuro CI with nitrates

Question 765

Bremelanotide

Answer 765

Agonist of melanocortin receptors for sexual dysfunction New drug -PRN injection stop if no benefit in 6 weeks CI in liver disease, pregnancy

Question 766

Other tx for female orgasmic disorder

Answer 766

Sexual devices Directed masturbation - usually best for partner not to participate at first No scientific evidence for genital cosmetic precedures

Question 767

Tx for sexual pain disorders

Answer 767

Lubricants and estrogen for vaginal atrophy PT for pelvic floor if estrogen fails

Question 768

Tx for vaginismus

Answer 768

PT, Counseling, Gabapentin/Botox

Question 769

Tx for vulvodynia

Answer 769

Lidocaine, TCA, Remove irritants, PT

Question 770

MC symptom of cevicitis

Answer 770

Discharge -many are asymptomatic

Question 771

Cervicitis v. Vaginitis

Answer 771

Discharge see from cervcle os in cervicitis

Question 772

Strawberry cervix

Answer 772

Indicates trichomoniasis

Question 773

Presentation of chronic cervicitis

Answer 773

Often asymptomatic Discharge - less than acute Vaginal bleeding Cervical tenderness Proximal vagina may look okay Urethritis, pelvic pain

Question 774

Microscopic analysis for cervisitis

Answer 774

Gram stain, Wet mounts - clue cells KOH prep PCR

Question 775

Pap smear/ Colposcopy for cervicitis

Answer 775

Double hairpin capillaries for trichomonas Excess leukocytes Cell enlargement - HPV Multinucleated cells with ground glass cytoplasm - HSV

Question 776

Biopsy where cell properties have changed

Answer 776

Indicative of a virus!!

Question 777

Cervicitis prevention and screening

Answer 777

Barrier contraception Routine screening in 19-25 Remove cervix with hysterectomy

Question 778

Incompetent cervix

Answer 778

Cervix shortens before 28 weeks gestation Painless

Question 779

Risk factors for cervicle insufficiency

Answer 779

Cervical conization or Hx of previous episode

Question 780

Presentation of cervical insufficiency

Answer 780

2+ cm dilation with minimal contractions 2nd trimester

Question 781

Screening for cervical insufficiency

Answer 781

US at 14-16 weeks Look for funneling and shortening abnormalities No way to predict

Question 782

4 cervical insufficiency abnormalities

Answer 782

TYVU - Trust Your Vaginal Ultrosound Shape of cervix -increasing risk and progression from T to U

Question 783

Tx for cervcal insufficiency

Answer 783

Circlage

Question 784

3 things to look for before circlage -Contraindications

Answer 784

Make sure fetus is still viable 1st Rupture of membranes Look for infection - treat first

Question 785

Pharm tx for cervical insufficiancy

Answer 785

Adjunct to circlage - progesterone

Question 786

Nabothian cysts

Answer 786

Blocked glands on the cervix Smooth rounded, whitish area that does not hurt Benign!!

Question 787

CIN I-III

Answer 787

I - 1/3 II - 2/3 III - In theory entire cervix

Question 788

When do we NOT treat CIN I and II

Answer 788

Pregnant women - wait for delivery Adolescents - observe at first

Question 789

Main risk factor for cervicle dysplasia

Answer 789

HPV!!!

Question 790

Pap smear screening

Answer 790

Start at 21 3 years Every 3 years or PAP+HPV every 5 years 30-65

Question 791

Pap screening after 65

Answer 791

Stop screening if: No hx of mod-severe dysplasia/cancer 3 negative Pap or 2 neg PAP+HPV

Question 792

ASC-US cells on pap smear

Answer 792

Undetermined significance

Question 793

ASC-H cells on pap smear

Answer 793

Cannot exclude a high grade lesion

Question 794

LGSIL/LSIL on pap smear

Answer 794

Corresponds to CIN I

Question 795

HGSIL or HSIL on pap smear

Answer 795

Corresponds to CIN II or III

Question 796

Atypical glandular cells

Answer 796

Rare - cells from endocervix - MAY indicate cancer, may not

Question 797

Management for ASC-US

Answer 797

2 pap smears over 6 months - send for colposcopy if abnormal Might try vaginal estrogen

Question 798

Management for anything that is NOT ASC-US

Answer 798

Send for colposcopy

Question 799

Colposcopy

Answer 799

Low power magnification of cervix - uses camera Add acetic acid to light up abnormal areas Bx abnormal areas

Question 800

Indications for colposcopy - 5

Answer 800

Abnormal pap smear Clinically abnormal cervix Unexplained bleeding Vulvar/Vaginal neoplasia Hx of in utero DES exposure

Question 801

Tx for CIN II-III after biopsy

Answer 801

Surgery with evaluation afterwards

Question 802

Management of cervical dysplasia - cryotherapy

Answer 802

Probe to blanch tissue in cervical os - 7mm margin Makes it hard to visualize for later colposcopy

Question 803

Carbon dioxide laser for cervical dysplasia

Answer 803

More often in operating room Very precise More depth of excision Can biopsy

Question 804

Loop electrosurgical excision procedure

Answer 804

LEEP - Small wire loop to remove with electrical generator Can biopsy Best procedure For cervical dysplasia

Question 805

Cold knife

Answer 805

Cervical displasia For large areas No risk to being able to biopsy

Question 806

Prognosis for cervical dysplasia

Answer 806

80-90% success rates for any method

Question 807

Risk factors for cervical dysplasia recurrence -4

Answer 807

Large lesions Gland involvement Positive margins Positive endocervical curretage

Question 808

MC type of cervical cancer

Answer 808

Squamous cell carcinoma

Question 809

Presentation of cervical cancer

Answer 809

MC symptom = Abnormal vaginal bleeding Bloody leukorrhea, spotting, postcoital

Question 810

Late signs of cervical cancer

Answer 810

Fistula to recum or bladder leading to incompetence Radiating pain Weight loss, fever

Question 811

Signs of cervicle cancer

Answer 811

Cervix appears abnormal Ulceration

Question 812

Endophytic cervix

Answer 812

Barrell shape, enlarged - cancer

Question 813

Exophytic cervix

Answer 813

Friable, bleeding, cauliflower lesions

Question 814

Dx for cervical cancer

Answer 814

Cancer may be present despite negative cytology - if the cervix look suspicious, still suspect

Question 815

Tx for cercal cancer

Answer 815

Radical hysterectomy with lymphadenectomy Chemo is mostly palliative

Question 816

Normal vaginal flora

Answer 816

Aerobes, anaerobes, yeast Lactobacilli that make it acidic

Question 817

Normal vaginal pH before and after menopause

Answer 817

Before - 4-4.5 After - 6.5-7

Question 818

Things that can alter vaginal flora

Answer 818

Low estrogen - decrease Menses - Increase Abx Pregnnacy, Hysterectomy Foreign substances DM/Poor diet - worse

Question 819

Candidal vulvovaginitis presentation

Answer 819

Often in DM Pruritis THick white cottage cheese discharge Minimal odor

Question 820

Dx for vulvovaginal candidiasis

Answer 820

Normal pH Branching filaments and psudohyphae on wet prep/KOH

Question 821

Pharm tx for vulvovaginal candidiasis

Answer 821

Azole - 1st line ie. fluconazole May extend therapy for recurrent cases

Question 822

Alternative vulvovaginal candidiasis tx

Answer 822

Boric acid Gentian violet

Question 823

Vaginal antifungal administration

Answer 823

Administer at night

Question 824

MOA of azoles

Answer 824

Inhibit enzyme for cell membrane synthesis

Question 825

MOA of nystatin

Answer 825

Increase permeability of cell walls

Question 826

Ibrexafungerp MOA

Answer 826

Inhibits glucan synthesis - cell wall production DO NOT TAKE with an azole

Question 827

MOA of boric acid

Answer 827

Interferes with metabolism CI in pregnancy

Question 828

Gentian Violet MOA

Answer 828

May inhibit protein synthesis Not many drug interactions

Question 829

Presentation of bacterial vaginosis

Answer 829

Milky, homogenous, malodorous discharge No inflammation Malodorous esp. after intercourse - fishy

Question 830

Dx of bacterial vaginosis

Answer 830

Vaginal pH 5.5-7 Clue cells - covered in bacteria Fishy odor on KOH prep - wiff test

Question 831

Tx for Bacterial vaginosis

Answer 831

Metronidazole or Clinda Can also use an expensive -azole

Question 832

MOA of metronidazole

Answer 832

Bind to and deactivate enzymes Dizziness, HA, Fatigue Disulfiram reaction

Question 833

Clindamycin MOA

Answer 833

Binds to ribosomes C diff - and not with imodium

Question 834

Vaginal douche

Answer 834

Washing out of vagina - only for bacterial vaginosis - NOT for regular cleaning

Question 835

Presentation of trichomonal vaginitis

Answer 835

Frothy, copious green, foul smelling vaginal discharge Strawberry cervix

Question 836

Dx for trichamoniasis

Answer 836

pH 5-5.5 Motile wet prep - look at right away before they die Culture = Best test

Question 837

Tx for trichomonal vaginitis

Answer 837

Metronidazole or other ~idizole's Cross reactivity to alcohol Liver disease

Question 838

Presentation of gonorrhea

Answer 838

80-85% asymptomatic Copious mucopurulent discharge

Question 839

Dx for gonorrhea

Answer 839

Nucleic acid probe Or culture of discharge

Question 840

Tx for gonorrhea

Answer 840

One shot IM rocephin Treat partners

Question 841

CHlamydia presentation

Answer 841

Cervicitis, dysuria, bleeding May progress to PID or lymphogranuloma venereum CERVIX MAY LOOK NORMAL

Question 842

Dx for chlamydia

Answer 842

Culture Immunoassay Pap smear

Question 843

Tx for chlamydia

Answer 843

Doxycycline ALT: Zmax

Question 844

Noninfectious vaginitis

Answer 844

Irritants, Allergens (latex), Atrophic, Excess sexual behavior

Question 845

Presentation of noninfectious vaginitis

Answer 845

Itching with no bacteria detectable - get a good hx

Question 846

Tx for noninfectious vaginitis

Answer 846

Lubricants SERM Sitz bath Steroid if very painful/inflamed

Question 847

Alternitive tx for vaginitis

Answer 847

White vinegar - better option Herbals Iodine Tea tree oil May kill of good bacteria!

Question 848

Presentation of genital herpes

Answer 848

Vescicles that become painful erosions or ulcers My have a buringing prodrome with inguinal lymphadenopathy

Question 849

Dx for genital herpes

Answer 849

Most often clinical Tzank smear

Question 850

Initial tx for herpes outbreak

Answer 850

7-10 days valacyclovir, Famcyclovir, Acyclovir 1-5 days for recurrent Same drugs for prophylaxis

Question 851

Condyloma acuminatum MC strains

Answer 851

MC HPV 6-11

Question 852

Presentation of condyloma

Answer 852

Culiflower growths - can be anywhere May also be flat with rough surface

Question 853

Before tx analysis for condyloma

Answer 853

PAP smear and biopsy

Question 854

Tx for condyloma

Answer 854

Cryotherapy Podofilox, Imiquimod, Interferon

Question 855

Molluscum contagiousum cause

Answer 855

Pox virus

Question 856

Presentation of molluscum contagiosum

Answer 856

Up to 1cm sized umbilicated papules Inclusion bodies in cell cytoplasm

Question 857

Tx for molluscum contagiosum

Answer 857

Dessication, Freezing, Imiquimod May observe - can cause scarring when removed

Question 858

Presentation of syphillis - 3 stages

Answer 858

1 - Painless sore 2 - Palm and sole rash 3 - Involves heart, brain, etc.

Question 859

Tx for Syphillis

Answer 859

PCN 1st line ALT: Doxy

Question 860

Bartholin gland disease

Answer 860

Glands near vaginal orifices get infected or plugged Red flag post menopause

Question 861

Presentation of bartholin gland disease

Answer 861

Tenderness - have to duck waddle Fluctuant tender mass Systemic signs of infection

Question 862

Tx for bartholin gland disease

Answer 862

Draining won't help Catheter inflation Marsupialization - create a pouch Check for cancer post menopause

Question 863

Abx for Bartholin gland disease

Answer 863

Usually not needed - may still use for prophylaxis

Question 864

Lichen sclerosis

Answer 864

MC non-neoplastic epithelial vulvar disorder Usually women over 60

Question 865

Presentation of lichen sclerosis

Answer 865

Pruritis is MC sx May see pain, white lesions, dyspareunia

Question 866

Progression of lichen sclerosis

Answer 866

Erythema w/ no response to yeast tx White plaques develop Scratching worsens and inflammation does

Question 867

Chronic presentation of lichen sclerosis

Answer 867

Ciggarette paper Phimosis of clitoral hood Labial fusion General loss of structure

Question 868

Complication of lichen sclerosis

Answer 868

SCC - send for biopsy

Question 869

Tx for lichen sclerosis

Answer 869

Potent steroid - Clobetasol with a taper BID to QD eventually PRN for life

Question 870

Adjuncts for lichen sclerosis

Answer 870

Antihistamine, Tacrolimus, Methotrexate

Question 871

Lichen Simplex Chronicus

Answer 871

Due to a specific trigger or chrinic irritation No loss of structure like in Lichen Sclerosis Lots of itching

Question 872

Dx of LSC

Answer 872

Biopsy of lesion

Question 873

Tx for LSC

Answer 873

Hygeine and Sitz bath Medium potency steroid - fluocinolone, triamcinolone)

Question 874

Lichen planus

Answer 874

Flat white plaques on vagina Papules on skin Send to GYN for biopsy Steroids

Question 875

Dark non cancer vulvar lesions

Answer 875

Melanosis lentigo, etc.

Question 876

Vulvar varicosities

Answer 876

Common in pregnancy, concerning in elderly or non-pregnant Sclerosing agent to tx

Question 877

Preinvasive vulvar disease

Answer 877

Strong association with HPV White hyperkeratotic papules with pruritis Dx through biopsy

Question 878

Tx for preinvasive vulvar disease

Answer 878

More aggressive for higher grade Excision, ablations, laser

Question 879

Paget's disease - vulvar

Answer 879

Itching, soreness Red velvet cake presentation with white plaques Can cause structural breakdown

Question 880

Tx for paget's disease

Answer 880

WIDE local excision - need to recheck Stop as soon as possible Very poor prognosis if mets to lymph nodes

Question 881

Vulvectomy

Answer 881

Partial or radical Removes area of skin +/- lymph nodes Not great - last resort for cancer

Question 882

Vulvar cancer

Answer 882

90% SCC Older patients with chronic inflammation or HPV

Question 883

Presentation of vulvar cancer

Answer 883

Itching or macerous skin lesion May just be a "weird spot" w/ no sx

Question 884

Tx for vulvar cancer

Answer 884

Remove tumor - excise Rad vulvectomy - may radiate to reduce Pelvic exenteration if widespread

Question 885

Pelvic exenteration

Answer 885

Removal of everything in the pelvis - diversion of GI and GU tracts

Question 886

Vaginal Intraepithelial Neoplasia

Answer 886

Vagina rather than vulva Colposcopy andbx to dx Condylomatous lesions or flat and granular

Question 887

Tx for Preinvasive vaginal disease

Answer 887

Resection, 5FU not as effective Difficult to get everything out

Question 888

True vaginal cancer

Answer 888

Not spread from the cervix HPV, Smoking are RF

Question 889

Vaginal SCC

Answer 889

Exophytic or ulcerative lesions in the upper 1/3 of vagina

Question 890

Vaginal adenocarcinomas

Answer 890

MC vaginal primary tumor in young patient

Question 891

Vaginal sarcoma

Answer 891

Highly aggressive with grape like masses Older pts -upper vaginal wall

Question 892

Vaginal melanoma

Answer 892

Usually towards the distal vagina

Question 893

Tx for vaginal cancer

Answer 893

Exenteration, Radiation Poor prognosis