ObGyn Female Reproduction/Breast Flashcards Preview

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Flashcards in ObGyn Female Reproduction/Breast Deck (171):
1

What's the most common cause of unilateral discharge (serous or bloody)

Intraductal Papilloma

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2

How does Ductal carcinoma in situ present on mammography?

microcalcifications

3

CP of Fat necrosis of Breast - 4

  1. Firm mass
  2. IRREGULAR SHAPED mass
  3. previous trauma

Mammogram: Oil cyst +/- calcifications that appear malignant  but has fat globules and foamy macrophages on bx

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4

CP for Fibroadenoma - 5

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  1. painless mass
  2. firm mass
  3. solitary mass
  4. mobile
  5. ~2 cm

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5

Fibrocystic changes of the breast are common in ____(pre/post) menopausal women

How does this typically present? - 2

PREmenopausal

  1. cyclical bilateral breast pain
  2. diffuse nodularity

This cyclical BL breast pain is exacerbated with caffeine!

6

CP for Inflammatory Breast CA - 7

  1. Peau d'orange appearance (superficial dimpling & pitting)
  2. Diffuse breast erythema
  3. breast edema
  4. breast pain
  5. nipple changes (retraction, flattening)
  6. Axillary LAD
  7. +/- nipple discharge

often confused with infectious process, but difference is IBC has NO FEVER and DOESN'T RESPOND TO ABX

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7

CP for Lobular breast carcinoma - 3

  1. FIXED palpable mass
  2. Irregular borders
  3. +/- Bilateral

8

Paget Disease of the Breast is a form of ____(type of CA) that presents how? - 3

Ductal ADC

  1. crusty eczematous or ulcerating nipple & areola
  2. +/- bloody nipple discharge
  3. +/- nipple retraction

85% of Paget Disease of Breast is 2/2 underlying DCIS of glandular rissue which migrate thru mammary ducts to nipple surface. Dx = Mammogram and biopsy

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9

How do you discern pharyngitis 2/2 Neisseria Gonorrhea from pharyngitis 2/2 infectious mononucleosis? 

N. Gonorrhea = non-exudative pharyngitis, and has PID  lower abd pain

vs.

Mono = exudative pharyngitis and has fatigue

otherwise, presentation is similar

10

Describe Lichen Sclerosus MOD

autoimmune chronic inflammatory condition of anogenital region that affects women of any age that --> vulvar squamous cell carcinoma

THIS DOES NOT AFFECT THE VAGINA!

dx = vulvar punch biopsy

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11

Signs and Symptoms of  Lichen Sclerosus - 5

  1. Pruritus SEVERE
  2. Dyspareunia
  3. White Grayish pale vulva (distinguishes from postmenopausal vaginal atrophitis)
  4. Cigarette paper texture of vulva (thin, crinkled)
  5. loss of vulvar anatomy (introitus, labia minora, clitoral hood)

dx = vulvar punch biopsy

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12

CP for Vulvar yeast - 3

  1. Red patches
  2. Flaky patches
  3. Satellite lesions

13

Etx of Lactational Mastitis?    

What are the s/s?-4    

do not confuse with Inflammatory Breast CA

inadequate milk duct drainage allows Staph Aureus from infant's nasopharynx or mother's nipple skin to multiply in stagnant milk --> 

  1. Breast Erythema in quadrants
  2. Breast Pain in quadrants
  3. LAD
  4. FEVER

Tx = KEEP BREASTFEEDING + Dicloxacillin + Ibuprofen

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14

Risk factors for Endometrial adenocarcinoma -3

  1. EEE - Excess Estrogen Exposure (HRT, neoplasm, [menstruation outside of 12-52], Nulliparity, Anovulation/PCOS)
  2. Tamoxifen
  3. Obesity (excess insulin--> ⬆︎androgen release from ovarian theca --> excess androgen is converted into estrone --> EEE)

Smoking and Progestin OCP ⬇︎Endometrial CA Risk

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15

CP for Endometrial CA?-2

Dx for Endometrial CA?-2

  1. Intermenstrual bleeding (Dx= BIOPSY = goldstandard)
  2. Postmenopausal bleeding (Dx =  Pelvic US for postmenopausal)

Smoking and Progestin OCP ⬇︎Endometrial CA Risk. Progestin actually stimulates endometrial differentation and not uncontrolled proliferation

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16

What are the major risk factors for Breast CA - 8

  1.  1st degree relative with breast CA
  2. Prolonged estrogen exposure (menstruating outside of 12-52 y/o range vs utero DES vs HRT)
  3. Genetics (BRCA 1/2 mutation)
  4. Alcoholic
  5. Obesity
  6. Radiation
  7. Age 40-70 yo
  8. White

Average Menopause onset = 51

17

The BRCA gene mutation puts women at risk for what 2 CA

  1. Breast
  2. Ovarian

Only do BRCA testing on women (or if they have 1st degree relatives) with breast CA < 50 yo or women with ovarian CA at any age

18

Tx for Lichen Sclerosus

Clobetasol ointment  (high potency topical CTS)

dx = vulvar punch biopsy

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19

Explain how women can develop urine leakage thru their vagina and NOT the urethra

bladder injury during pelvic surgery, pelvic radiation or prolonged labor --> Vesicovaginal fistula  --> continuous painless vaginal urine leakeage and possible cystitis (from bladder being exposed to vaginal flora)

Dx = cystourethroscopy

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20

Describe the CP for Bacterial Vaginosis -2

  1. Whitish Gray vaginal discharge
  2. Malodorous discharge

21

Interstitial cystitis is AKA _______. How does it present?-3

Painful Bladder Syndrome

  1. Chronic pelvic pain
  2. Urinary sx (dysuria, urgency, frequency)
  3. Dyspareunia

22

What is the difference between a Urethral diverticulum and a Urethrocele? 

Urethral diverticulum = distinct outpouching of urethra (with a separating border) into ANT vaginal wall --> circumscribed cystic mass

vs

Urethrocele = urethral prolapse into vagina (continuous with the rest of the urethra) secondary to loss of ligamentous support

BOTH OF THESE CAUSE URINARY INCONTINENCE THRU THE UREHTRA

23

How does Vaginal CA (SQC or Clear cell ADC) present?-4

Who usually gets Vaginal SQC? 

Where does Vaginal SQC occur in the vagina?

  1. Malodorous vaginal discharge
  2. Vaginal irregularity aesthetically (mass, plaque, ulcer)
  3. Postmenopausal bleeding
  4. Postcoital bleeding

Vaginal SQC = > 60 yo

Vaginal SQC = POSTERIOR Upper 1/3 of vaginal wall

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24

How does Vaginal CA (SQC or Clear cell ADC) present?-4

Who usually gets Vaginal Clear cell ADC and what's unique about them? 

Where does Vaginal Clear cell ADC occur in the vagina?

  1. Malodorous vaginal discharge
  2. Vaginal irregularity aesthetically (mass, plaque, ulcer)
  3. Postmenopausal bleeding
  4. Postcoital bleeding

Vaginal Clear cell ADC = < 20 yo ; these pts usually have difficulty conceiving and maintaining pregnancy

Vaginal SQC = anterior Upper 1/3 of vaginal wall

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25

What are the risk factors for Vaginal SQC?

same as Cervical CA risk factors

(cervical CA migrates to vagina)

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26

In Ovarian CA, why is the specificity for CA-125 much higher in older women? 

CA-125 can be elevated in younger women who have leiomyomata or endometriosis, so elevated CA-125 is only associated w/ovarian CA in POSTmenopausal women

27

For ovarian CA, what can CA-125 be used for?

Postmenopausal women have ⬆︎risk of ovarian CA

  1. Monitors for recurrence after ovarian CA tx
  2. used in initial w/u of an ovarian mass to determine if it is malignant or benign

DO NOT DO NEEDLE ASPIRATION ON OVARIAN MASS PTS SINCE CA STATUS IS UNKNOWN AND MAY BE IATROGENICALLY SPREAD DURING ASPIRATION

28

Pt comes in with Postmenopausal bleeding

How do you evaluate them?

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29

Why should pts taking estrogen for postmenopausal sx also should be taking progesterone if they have a uterus?

Unopposed estrogen --> uncontrolled endometrial proliferation (CA). Progesterone can regulate proper endometrial differentiation

just remember, estrogen replacement therapy can --> postmenopausal bleeding on its own

30

DDx for Postmenopausal bleeding - 4

  1. Endometrial CA (ADC, hyperplasia)
  2. Cervical CA
  3. Vaginal CA (clear cell ADC, SQC)
  4. Estrogen replacement therapy

31

Pt comes in with with Breast Mass

How do you evaluate them?

DDx = CCAFF

DDx = CCAFF

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32

What is the classic ultrasound description of a cyst

posterior acoustic enhancement (indicates fluid is present) with no echogenic debris or solid components

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33

Pt has just been diagnosed with Simple breast cyst and has tenderness in the area

How do you manage them? - 3

1st: Drain breast cyst for sx relief

2nd: f/u in 6 mo

3rd: convert to f/u annually if no s/s of recurrence

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34

Why is mammography in women < 30 y/o relatively not recommended? - 2

  1. Dense breast tissue in women < 30 yo might impede assessment of breast masses
  2. Breast radiation can --> Breast CA in and of itself

35

In women with breast mass, after using Ultrasound to determine the type of mass...

what are the different types of biopsies and when are they used? - 3

  1. Core = used for solid, acellular stroma masses
  2. Excisional = used for LARGE masses
  3. Fine Needle = used for cystic or very small masses

Again, use US first to determine what type of mass you're dealing with

36

Describe the clinical progression of primary syphilis chancres

single papule that turns into shallow, PAINLESS, nonexudative ulcer with indurated edges, accompanied with BL inguinal LAD

THESE ARE EXTREMELY INFECTIOUS!

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37

What are the features of a ChancROID?-3 ; Is it painful? ;  What organism causes this?

  1. Multiple deep ulcers
  2. Exudative Grayish yellow Base
  3. PAINFUL inguinal coalesced bubo nodes

Organisms clump in long strands like a "school of fish"

PAINFUL

Haemophilus Ducreyi

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38

What are the features of a Genital Herpes?-3 ; Is it painful? 

  1. Multiple small shallow ulcers
  2. Erythematous base
  3. LAD

PAINFUL

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39

What are the features of a Lymphogranuloma Venereum?-3 ; Is it painful? ;  What organism causes this?

  1. Multiple small shallow ulcers (similar to herpes)
  2. Large PAINFUL coalesced inguinal lymph nodes = Buboes
  3. Intracytoplasmic chlamydial inclusion bodies

** Initial lesion is NOT painful but Buboes are **

Chlamydia Trachomatis

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40

 Behcet Syndrome CP

Vasculitis-mediated Recurrent Multiple Ulcers (aphthous and genital)

41

What are the features of Donovanosis granuloma inguinale?-3 ; Is it painful? ;  What organism causes this?

Mostly in India

  1. Extensive ulcers WITH NO LAD
  2. Granulation like base
  3. Deeply staining gram neg intracytoplasmic cyst = Donovan bodies

No, not painful

Klebsiella Granulomatis

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42

What do you do if a pt with clinical s/s of syphilis has a negative RPR? 

Empiric PCN G IM

RPR false negatives are a thing so you should repeat serology in 2 weeks to see if tx reduced titers. Also, Treponemal Pallidum can NOT be cultured so don't do it!

THESE ARE EXTREMELY INFECTIOUS!

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43

What is the DDx for Stress urinary incontinence - 2

Incontinence with coughing/lifting/sneezing

  1. Urethral Hypermobility (injury to pelvic floor muscles and/or urethral prolapse --> urethral hypermobility or bladder cystococele can --> bladder prolapse and all of this --> vaginal bulge and incontinence)
  2. ⬇︎Urethral tone

Tx = Kegel excercises vs urethral sling

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44

What is the DDx for Urge Incontinence - 4

Sudden urge to urinate all the time

Detrusor hyperactivity 2/2

  1. UTI
  2. Estrogen deficiency (urethral closure --> ⬆︎intrabladder pressure --> urge)
  3. Multiple Sclerosis
  4. DM

45

What is the DDx for Overflow incontinence - 2

 

  1. DM neuropathy
  2. mechanical obstruction

⬇︎Detrusor activity or mechanical outlet obstruction --> Overdistended bladder --> involuntary dribbling and incomplete empyting (⬆︎PVR)

46

Normal Post Void Residual for Women

< 150 cc

47

Normal Post Void Residual for Men

< 50 cc

48

Explain why clinicians no longer should empirically treat both Chlamydia and Gonorrhea if only one is positive

Since the NAAT (Nucleic Acid Amplification Test) is now so specific and sensitive that there is little chance of false negatives, empiric tx of both infections is no longer required if there is only 1 that actually has a positive result

49

DDx for palpable breast mass - 5

CCAFF

  1. CA
  2. Cyst
  3. Abscess
  4. Fibroadenoma
  5. Fat necrosis

50

What are the risk factors for stress urinary incontinence secondary to pelvic floor weakening - 3

  1. Pregnancy/Childbirth
  2. Obesity
  3. Menopause

Diagnosed with Q-tip urethral hypermobility test

51

Tx for Stress Urinary Incontienence - 4

  1. URETHRAL SLING
  2. Kegel exercise physical therapy
  3. Vaginal pessary
  4. Bladder neck Injectable bulking if etx is related to sphincter deficiency

52

What are bodily signs of ovulation - 3

  1. CLEAR cervical mucus discharge (looks like uncooked egg white) - starts thin and then becomes thick after ovulation
  2. ⬆︎temperature
  3. Mittelschmerz mid-cycle (day 14) pelvic pain 

order: LH surge --> 36 hrs will pass --> Ovulation

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53

What is the cervical mucus plug?

yellowish brown thick cervical mucus shed right before labor that prevents asecending infxn during pregnancy

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54

What are the Emergency Contraception options?-4  ; What is the time limit for which you can use each of them?

  1. Copper IUD - useful for up to 5 days post intercourse [impairs implantation and MOST EFFECTIVE]
  2. Ulipristal PO - 5 days [delays ovulation]
  3. Levonorgestrel progestin (Plan B) - 3 days [delays ovulation]
  4. OCP progestin - 3 days [delays ovulation]

these are NOT effective after implantation occurs and fertilization is possible 24 hours after ovulation

55

Ovarian reserve starts to decline in older woman around the age of _____. Which lab should you order to confirm this? 

35 ; FSH would be higher in a ovarian reserve declining woman

56

How does high androgen levels affect fertility for Women? 

high Androgen (such as PCOS) --> ⬇︎GnRH release from feedback inhibition --> ⬇︎FSH --> ⬇︎ovarian maturation --> 2°follicle atresia --> 

  1. Anovulation chronically
  2. Amenorrhea
  3. Polycystic Ovaries

57

Clinical definition of Primary infertility - 3

Failure to conceive after 

  1. ≥ 1 YEAR of unprotected timed sexual intercourse (or 6 months if women is ≥35 yo)
  2. pt ≤ 34 yo
  3. pt is nulliparous

Dx = first order semen analysis then --> hysterosalpingogram then --> +/- Laparoscopy

58

Adenomyosis CP - 3

  1. symmetrically enlarged TENDER uterus  (> 12 weeks in size)
  2. Menorrhagia
  3. Dysmenorrhea eventually --> Chronic Pelvic Pain

etx: glands invade uterine myometrium --> blood deposition inside myometrium during cycle --> dysmenorrhea from irregular contractions and menorrhagia from extra deposited blood

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59

Adenomyosis dx

True dx = pathological exam of tissue after hysterectomy

etx: glands invade uterine myometrium --> blood deposition inside myometrium during cycle --> dysmenorrhea from irregular contractions and menorrhagia from extra deposited blood

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60

What's the most common sign of Endometrial Polyps

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PAINLESS intermenstrual bleeding

61

Most common causes of Intermenstrual bleeding - 5

"I'm seeing some spotting in between my periods"

  1. Endometrial Polyps - Painless and light
  2. Adenomyosis
  3. Endometrial ADC/hyperplasia - Older women
  4. PID - due to cervicitis
  5. Cervical CA

62

Leiomyomata uterine Fibroids CP - 5

  1. Pelvic pressure --> urinary incontinence/incomplete voiding/constipation
  2. irregularly enlarged NONTENDER uterus  
  3. Menorrhagia (especially with submucosal)
  4. Dysmenorrhea (especially with submucosal)
  5. Progressively longer menses due to deformity of the uterus from fibroids

Submucosal and Pedunculated are the worst!

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63

Clinical definition of Primary Amenorhhea

girls with no menses by age 15 but who have normal growth and secondary sex characteristics

64

Why do pts with Androgen Insensitivity Syndrome have NO ovaries/fallopian tubes/uterus/cervix but DO have breast? 

they actually have functioning Testes that secrete AntiMullerian Hormone & Testosterone and this --> regression of Mullerian ducts. Breast comes from the aromatization of testosterone into estrogen

Wolffian ducts also degenerate and fetal urogenital sinus does not differentiate into a penis and scrotum --> default of external female genitalia

65

CP of congenital 5α reductase deficiency

ambiguous genitalia at birth 2/2 undervirilization

these pts can not convert Testosterone --> DHT

66

Difference in CP between Androgen insenstivity syndrome and Mullerian agenesis pts

AIS pts will have NO pubic or axillary hair since they don't respond to testosterone (which is what causes axillary/pubic hair in both sexes!)

but

Mullerian agenesis pts have normal testosterone levels so will have pubic and axillary hair

Both obvi have no mullerian duct organs 

67

What are the major s/s of menopause - 5

menopause wreaks HAVOC

  1. Hot flashes 2/2 vasomotor instability
  2. Atrophy of vagina --> dyspareunia, urinary incontinence, paleness, narrowed introitus
  3. Vaginal Dryness --> Pruritus
  4. Osteoporosis 
  5. Coronary artery disease

note: menopause can be 2/2 natural but also chemotherapy, radiation and oophorectomy

68

What are the common side effects of OCPs - 6

  1. HTN
  2. Breast Tenderness
  3. ⬆︎TriAcylGlycerides
  4. Bloating with Nausea
  5. Breakthrough bleeding = most common (usually with lower estrogen doses)
  6. Venous thromboembolism (Migraine w/aura is a ctd for Combined OCPs)

Wt Gain is NOT a side effect of combined OCPs and OCPS actually ⬇︎risk of Endometrial and Ovarian CA

69

What is 1st line tx for Dysmenorrhea in sexually active pts?   ; What about non-sexually active pts?

Combined OCPs ; NSAIDs

Combined OCPs treat dysmenorrhea by ⬇︎endometrial proliferation via atrophy which --> ⬇︎prostaglandin release --> ⬇︎painful uterine contractions

70

Why is Intrauterine Copper device relatively contraindicated in dysmenorrhea pts

its uterine inflammatory rxn actually --> ⬆︎pain

71

Why is Medroxyprogesterone depot relatively contraindicated in young pts - 2

  1. it causes ⬇︎ of bone mineral density
  2. it ⬆︎body fat and ⬇︎lean muscle mass

in addition to Breast tenderness and bleeding for 1st 6 months

72

Why can pts with PID sometimes present with RUQ pain?

uterine infxn extends from fallopian tubes (salpingitis) --> diffuse abd --> Liver capsule--> RUQ pain exacerbated with deep inspiration = Fitz Hugh Curtis perihepatitis

PID causes salpingitis and cervicitis

73

What's the gold standard method to diagnose Cervical Intraepithelial Neoplasia?  ; What's tx for this?

Colposcopy (even if they're pregnant! - DO IT) ; Cervical Conization (via cold knife conization or loop electrosurgical excision procedure)

conization inevitably --> short cervix and cervical stenosis due to scar tissue

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74

What is Asherman syndrome

INTRAUTERINE ADHESIONS  (could be from infxn or uterine surgery)

this can cause 2° Amenorrhea (normal ovulation and hormone levels but mechanical amenorrhea)

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75

CP for Bartholin gland cyst-4  ; What causes this?

  1. 4 or 8 oclock position - base of labium majora
  2. egg shaped
  3. CYSTIC mass 
  4. Painless

; Duct obstruction

can develop into abscess which presents with flutuancy

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76

Describe Gartner duct cyst  ; Where do they come from?

single or multiple submucosal cyst on the lateral aspects of the upper ANT vagina ; incomplete regression of Wolffian duct

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77

Tx for asx Bartholin duct cyst 

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OBSERVATION if asx since it will spontaneously drain :-)

If symptoms are present --> Incision and Drainage f/b word catheter ⬇︎ recurrence

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78

What would you expect symptom presentation for this to be?  ; What would you expect pelvic US to reveal?

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Mature dermoid cystic teratoma of ovary

mostly asx but sometimes with long standing lower abd/pelvic pain ; hyperechoic ovarian cyst with calcifications(from teeth and bone)

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79

What are the 4 CA associated with Lynch Syndrome

  1. proximal Colorectal
  2. Ovarian
  3. Endometrial
  4. Skin

Germline mutation in mismatch repair protein

80

Mngmt for Epithelial Ovarian Carcinoma (ovarian CA) - 2 steps

1st: XLap to remove pelvic mass,  dissect pelvic and paraAortic lymph nodes, inspect entire abd cavity

2nd: Platinum based Chemotherapy

this comes from ovarian, tubal or peritoneal abnormal proliferation

81

What is Choriocarcinoma?  ; What other organ does it involve? ; When does Choriocarcinoma occur?

aggressive form of gestational trophoblastic neoplasia;metastasizes to LUNGS --> cp/dyspnea/hemoptysis

occurs after ANY TYPE OF PREGNANCY

82

Why is it common for adolescents to have irregular and anovulatory menstruation

immaturity of hypothalamic-pituitary-gonadal axis --> inadequate amounts of GnRH --> low FSH and LH --> lack of ovulation --> lack of Menses

Menses normally occurs when corpus lutem (byproduct after ovulation) produces progesterone and this progesterone drops --> Menses/shedding. No ovulation --> No menses

Tx = Progestin-only or Combined OCPs

this self-resovles 1-4 yrs after menarche

83

BRCA mutation is associated with Breast and Ovarian CA

How can pts reduce their risk of developing Epithelial Ovarian Carcinoma?-5

  1. BL Salpingo-Oophorectomy
  2. OCP (only ⬇︎ovarian CA but actually ⬆︎breast CA risk)
  3. 1st gestation < 30 yo
  4. Breastfeeding
  5. Tubal ligation

Epithelial Ovarian Carcinoma comes from Ovarian, Tubal or Peritoneal abnormal proliferation

84

What is the most common complication of an untreated Mature dermoid cystic teratoma? 

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OVARIAN ISCHEMIA 2/2 TORSION

mass on the ovary --> ⬆︎risk for torsion around its support ligaments which contain ovarian blood supply

It is not common for Mature dermoid cystic teratoma to rupture

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85

Pt has just been hospitalized for PID

Now that she's hospitalized, what are the inpatient abx options for PID?-3

Inpatient: 

  1. CeFOXitin IV + Doxy PO
  2. Cefotetan IV + Doxy PO
  3. Clindamycin + Gentamicin IV

Remember: PID is actually POLYmicrobial

86

What is the outpatient abx regimen for treating PID

CefTriaxone IM + Doxy PO

make sure these pts can tolerate and comply with PO abx

87

What are the risk factors for Cervical CA? - 5

  1. Smoking (impairs immunity)
  2. STI hx
  3. Sexual activity early on or frequent (HPV 16/18 acquisition)
  4. Immunosuppressed
  5. Vaginal or Vulvar CA hx

88

What are risk factors for Ovarian CA - 3

  1. Endometriosis
  2. BRCA 1/2 mutation - 1st degree relatives
  3. repeated ovulation (from trauma to ovarian surface with each cycle)

89

What are the risk factors for Toxic Shock Syndrome - 3

organisms = Staph A and GASP

  1. Tampons
  2. Surgery (especially nasal/sinus)
  3. Burns/skin lesions

90

CP for Toxic Shock Syndrome - 5

organisms = Staph A and GASP

  1. Generalized macular rash INVOLVING palms & soles
  2. hypOtension
  3. Fever
  4. Vomiting
  5. Diarrhea

91

What are the guidelines for ANNUAL GC/Chlamydia Screening (Women vs Men)

Women

  1. ALL Sexually active women < 25
  2. Sexually active women > 25 IF HIGH RISK

Men: Insufficient evidence :-(

ANNUAL GC/Chlamydia screening done via NAAT - vaginal or cervical swab

92

Guidelines for PAP Smear Cervical CA Screening - 3

  1. [Age 21 - 65  every 3 years (cytology only)]  ≥ 3x consecutively before stopping after 65
  2. [Age 30-65 can alternatively get Co-HPV Testing every 5 years]  ≥ 2x consecutively before stopping after 65
  3. Risk Groups (immunocompro/CIN2, 3 or CA hx) need more frequent screening and voids out #1 and 2 if present

Immune system in under 21 yof clears HPV on its own within 1-2 years, thus < 21 yo don't need testing

93

Condyloma Acuminata is caused by _____ & _____. Describe its appearance - 2  

HPV 6 & 11

Could Either be: 

  1. multiple exophytic (cauliflower-like growth) skin-colored lesion +/- friability    OR
  2. multiple sessile (broad & flat) & smooth papules that's skin-colored +/- friability

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94

Condyloma Lata is caused by ______.  ; How would you describe these lesions?-2

Treponema Pallidum SECONDARY syphillis

  1. FLAT
  2. VELVETY

95

What are the causes of Functional Hypothalamic Amenorrhea?-6   ; Explain how they cause amenorrhea  ; What's the most common long term complication for these pts? 

 

Functional hypOthalamic amenorrhea ; these pts have low FSH and therefore NO postmenopausal sx

  1. Excessive Exercise
  2. Very low calorie diet/starvation
  3. low BMI/Anorexia/Wt loss
  4. Stress
  5. Depression
  6. Chronic illness

; Osteoporosis from lack of estrogen

note: these pts will NOT have normal mentrual cycles

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96

hCG is secreted by _____ and responsible for what? ; When does hCG production begin?

syncytiotrophoblast ; preserves corpus luteum (which secretes progesterone) during early pregnancy until the placenta can take over ; 8 days after fertilization

hCG also stimulates maternal thyroid and promotes male sex differentiation

97

Which hormone prepares the endometrium for implantation of a fertilized egg? 

Progesterone Prepares endometrium via decidualization

98

Which hormone induces prolactin production during pregnancy? 

Estrogen 

99

Which hormone is responsible for myometrium relaxation during pregnancy? 

Progesterone 

100

MOD for PCOS

Hyperinsulinemia and Elevated LH --> ⬆︎ Androgen release from Ovarian Theca which is converted to Estrone--> Elevated Estrone  which feedbacks on the hypothalamus --> ⬇︎GnRH --> ⬇︎FSH imbalance -->  failure of follicle maturation and anovulation --> No progesterone --> Endometrial CA

tx = weight loss and clomiphene citrate

Note: if pt has high levels of sex hormone binding globulin, total testosterone may be low. so clinical dx may be necessary

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101

How should pts with PCOS go about restoring ovulatory cycles 1st? What's another option if that doesn't work? 

1st: WEIGHT LOSS!

2nd: Clomiphene citrate (GnRH agonist)

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102

Why do women who've recently delivered and are breastfeeding have no menstrual cycles? 

Elevated Prolactin (responsible for mammogenesis and galactogenesis) inhibits GnRH release --> anovulation and amenorrhea for ≤ 6 months

after 6 months, even with breastfeeding women will start to ovulate again and even before then, this is not a reliable form of contraception

103

Lichen Sclerosus and Atrophic Vaginitis can present similarly

What is the major distinguishing feature? 

Both have thin & pale tissue

Lichen Sclerosus does NOT affect the vagina

Atrophic Vaginitis affects both and can be a result of menopause (2/2 natural, chemotherapy, radiation, surgical or lack of estrogen replacement therapy)

104

Describe the appearance of Lichen Planus

Glazed erythematous lesions on vulva with ulcerated areas

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105

Who should be the only demographics to receive BRCA/HER2 testing - 3

  1. Women with Breast CA < 50 yo
  2. Women with Ovarian CA at any age
  3. Women with first degree relatives with #1 or #2

106

CP of ovarian CA - 3

  1. early satiety (from ascities)
  2. abd/pelvic pressure (from ascities) 
  3. GI sx (constipation/diarrhea/bloating/anorexia) - (from ascities)

107

What is the most common pelvic tumor in women?

Leiomyomata uterine fibroids

Submucosal and Pedunculated are the worst!

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108

[T or F] Posterior Cul-De-Sac fluid accumulation in a pregnant woman is an abnormal finding

FALSE 

(this is a normal finding for preggos along with corpus luteum ovarian cyst UNLESS IT'S IN THE SETTING OF ECTOPIC. THEN IT MEANS HEMOPERITONEUM FROM RUPTURE OR OVARIAN CYST RUPTURE)

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109

DDx for Free fluid in the pelvis of a woman - 3

  1. Normal pregnancy change
  2. Ruptured Ectopic --> hemoperitoneum
  3. Ruptured Ovarian cyst

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110

[T or F] Combined OCPs ⬆︎ risk for Endometrial CA  ; Explain

FALSE ; Combined OCPs ⬇︎risk for Endometrial CA because the progestin differentiates endometrial cells

111

[T or F] Combined OCPs ⬇︎ risk for Ovarian CA  ; Explain

TRUE ; Combined OCPs ⬇︎risk for Ovarian CA because it suppresses chronic ovulation which causes chronic damage to surface

112

Dx for Menopause - 3

  1. Amenorrhea for ≥ 1 year
  2. Elevated FSH
  3. HAVOC menopausal sx

Also be sure to measure TSH as menopause sx overlap with hyperthyroid sx

113

Clinical criteria for diagnosing PMS (PreMenstrualSyndrome) relies on PMS sx

What is the Clinical Criteria for PMS?  ; Name some of the PMS sx

PMS sx begin 1 week before menses (luteal phase) and resolves during week after menses (follicular phase) for ≥ 2 menstrual cycles

Sx: 

-Bloating

-Fatigue

-HA

-Hot Flashes

-Breast Tenderness

-Irritability/Mood Swings

-⬇︎Concentration

114

Clinical criteria for diagnosing PMS (PreMenstrualSyndrome) relies on PMS sx

What is the mngmt for PMS? - 5

PMS sx begin 1 week before menses (luteal phase) and resolves during week after menses (follicular phase)

1st: Sx Diary reveal PMS sx timing occured over ≥ 2 menstrual cycles

2nd: Order TSH to r/o hypOthyroidism as cause

3rd: Exercise w/NSAIDs

4th: SSRI 

5th: Combined OCP if SSRI don't work and there's no ctd

115

Why are Combined OCPs contraindicated in pts with [Migraine with aura] hx

There is a rare but serious RISK OF STROKE with use of combined OCs in women with migraine/HA hx, especially if they smoke or are > 35 yo

116

What's the first steps in w/u for Bilateral breast discharge with no lumps, LAD or nipple changes?-4  ; Why? 

 Hyperprolactinemia is most common cause of galactorrea 

  1. PROLACTIN levels - Prolactinoma could --> Hyperprolactinemia
  2. TSH levels - hypOthyroidism could --> ⬆︎TRH & TSH --> Hyperprolactinemia since TRH stimuales prolactin release
  3. PREGNANCY test - Pregnancy could --> Hyperprolactinemia since TSH shares same α-subunit as bHCG
  4. MED REVIEW - D2 blockers/Antidepressants/Opioids all --> Hyperprolactinemia

117

When should the HPV 3 dose vaccine be given to females? 

Between 11-26 yo regardless of anything

*they receive 3 doses spread out*

**this INCLUDES women with genital warts, positive HPV and abnormal cytology hx!!!!**

118

When should the HPV 3 dose vaccine be given to males? 

Between 9-21 (or 26 if HIV+ and/or gay) yo

*they receive 3 doses spread out*

119

In a +bHCG pt who comes in with RLQ pain, vaginal bleeding and a negative Transvaginal US 

why would we wait and repeat the bHCG & transvaginal US in 2 days if at the time it was already 1000

Intrauterine pregnancy is not detectable via transvaginal US until 1500-2000 bHCG. There should be SOMETHING on transvaginal US at that time (whether normal pregnancy or ectopic)

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120

βhCG levels have to be ____ for pregnancy to be detected via transvaginal US, and usually _____ when transabdominal US can finally detect it

What are βhCG levels during: 

A: Ectopic Preg/Miscarriage

B: Molar Pregnancy

βhCG levels have to be 1500-2000 for conclusive pregnancy detection via transvaginal US and usually >5000 for transABDominal US to finally detect it

A: Ectopic Preg/Miscarriage = low βhCG

B: Molar Pregnancy = > 100,000 βhCG!!!

βhCG should double every 2 days in normal pregnancy for first 7 weeks

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121

How does Obesity commonly cause amenorrhea? 

Obesity --> anovulation without affecting LH/FSH levels which--> Amenorrhea

122

What age do women have to be in order to be diagnosed with Premature primary ovarian insufficiency?

< 40 yo

these pts usually have autoimmune conditions and/or Turner's and present with oligomenorrhea--> amenorrhea and infertility

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123

Selective Estrogen Receptor Modulators (SERMs) are used for _______(indications)-3  ; What are the main side effects of SERMs? - 3

  1. ⬇︎Breast CA risk
  2. adjuvant tx for Breast CA (Tamoxifen)
  3. Postmenopausal Osteoporosis (Raloxifene)

 

SIDE EFFECTS

A: Hot Flashes

B: Venous Thromboembolism (all estrogen agonist ⬆︎resistance to protein C) 

C: Endometrial Hyperplasia/ADC

note: SERMs not only modulate estrogen receptors but they actually block estrogen binding competitively

124

How do you rationalize a pt with a large ovarian mass and a thickened endometrium stripe on US

Granulosa cell ovarian tumors (occurs in postmenopausal and prepubertal girls) secrete estrogen and unopposed estrogen --> Endometrial hyperplasia/ADC

Get an Endometrial biopsy to r/o ADC next!

125

What would you expect the following hormones to be in Hypothalamic hypogonadism (functional hypothalamic amenorrhea)

GnRH

FSH

Estrogen

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126

What would you expect the following hormones to be in Premature primary ovarian insufficiency

GnRH

FSH

Estrogen

these pts usually also have autoimmune conditions (i.e. hypothyroidism) or Turner

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127

What would you expect the following hormones to be in PCOS (polycystic ovarian syndrome)

GnRH

FSH

Estrogen

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128

What would you expect the following hormones to be in Exogenous estrogen use

GnRH

FSH

Estrogen

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129

How does estrogen deficiency cause stress AND URGE incontinence? 

⬇︎estrogen --> Vulvovaginal and URETHRAL ATROPHY -->

Urethral closure --> ⬆︎bladder pressure --> URGE incontinence

and

⬇︎urethral compliance -->STRESS incontinence and UTI

+

Bladder trigone, urethra and pelvic floor muscles are maintained by estrogen

UTI can also cause urge incontinence so be sure to rule this out

130

What are the main causes of Premature primary Ovarian Insufficiency? - 4

  1. natural Menopause
  2. Chemotherapy - targets rapidly dividing granulosa/theca cells
  3. Radiation - targets rapidly dividing granulosa/theca cells
  4. oophorectomy

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131

List the numerous contraindications to Combined OCPs - 11

  1. Migraine with aura
  2. Smokes ≥15 cig/day and ≥35 yo
  3. HTN ≥160/100
  4. Heart disease
  5. DM with end organ damage
  6. Breast CA (estrogen AND progesterone may have proliferative effects on breast tissue)
  7. Liver Cirrhosis/CA
  8. Thromboembolism hx
  9. Prolonged immobilization
  10. Antiphospholipid syndrome hx
  11. ≤3 wks postpartum

132

What is Penetration genitopelvic disorder  ; tx?-2

pain with any vaginal penetration (penis, tampon, gyne exams) 

tx = Vaginal Dilators, Kegel exercises

this is AKA Vaginismus

133

In pts with Pudendal neuralgia, where do they have superficial pain? - 3

  1. Vulva
  2. Perineum
  3. Rectum

these are the pudendal n distribution areas

134

What are the causes of Hydrosalpinx (fluid accumulation in fallopian tubes) - 2

  1. Adhesions (PID, surgery)
  2. Tubal ligation

135

Epithelial Ovarian Carcinoma is caused by abnormal proliferation of ______-3

What are US features of a malignant mass? - 3

Ovarian, Tubal or Peritoneal

  1. Solid
  2. Septated
  3. Ascities --> bloating, early satiety and abd distension

this is different than Mature Dermoid Cystic Teratoma which is benign & derived of ectodermal cells!

136

What is the 1st line tx for Postmenopausal hot flashes?  ; What can you use if that doesn't work? 

WEIGHT LOSS ; Combined OCPs

HEY! HRT IS NO LONGER RECOMMENDED FOR CAD, DEMENTIA OR OSTEOPOROSIS PX!!!!!!!

137

How does the Levonorgestrel progestin IUD work as a contraceptive? - 3

 

  1. thickens cervical mucus
  2. thins the endometrium when present outside of pregnancy which --> implantation impairment AND ⬇︎menstrual bleeding
  3. prevents withdrawal bleeding altogether --> amenorrhea

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138

What is the main side effect of Copper IUD

Menorrhagia

139

What is the main side effect of Medroxyprogesterone injections

Weight Gain

140

What are the main side effects of Levonorgestrel progestin IUD - 2

  1. Breast tenderness
  2. HA

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141

Pelvic US reveals Hyperechoic ovarian cyst with calcifications

Dx? 

Mature dermoid cystic teratoma

 

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142

Pelvic US reveals Homogenous cystic ovarian mass

Dx? 

Endometriosis of ovary (endometrioma)

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143

 Tx for lactational mastitis?-3

Tx = KEEP BREASTFEEDING + Dicloxacillin + Ibuprofen

drain via needle aspiration if abscess is present

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144

Ovarian hyperThecosis is usually diagnosed in ____[pre/post] menopausal women

What is it? 

POSTmenopausal; ⬆︎Theca cell activity --> ⬆︎androgen and ⬆︎insulin resistance --> virilization, hyperglycemia, acanthosis nigricans

this does NOT affect LH and FSH and ovaries are enlarged but not cystic

145

DDx for Menorrhagia (abnormal uterine bleeding) - 10

Pregnancy, Structural, NonStructural, Meds

  1. Pregnancy
  2. Leiomyomata fibroids
  3. Adenomyosis
  4. Endometrial Polyps
  5. Endometrial hyperplasia/ADC (get bx if risk factors present)
  6. Cervical CA
  7. Vaginal CA
  8. Coagulopathy
  9. Ovulatory dsfxn
  10. Copper IUD

146

What does Fat necrosis of breast show on mammography

oil cyst +/- calcifications that may appear to be malignant

ruled out from malignancy based on bx revealing fat globules and foamy macrophages

 

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147

What does Fat necrosis of breast show on core biopsy - 2

fat globules and foamy macrophages

 

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148

When is MRI of the breast indicated? - 5

  1. BRCA carrier
  2. 1st degree reliative is BRCA carrier
  3. eval of disease extent
  4. eval of chemotherapy response
  5. chest radiation exposure between 10-30 yo

149

In a woman with normal menstrual cycles, what is usually the cause of infertility if she is > 35 yo?

diminished Ovarian reserve

oocytes are of  number and quality

150

What is an ovarian Fibrothecoma

sex cord-stromal tumor that secretes both but Estrogen > testosterone

151

Vulvar inclusion cyst usually result because of ______ whereas Vulvar epidermal cyst result from ________

local trauma  ; obstruction of sebaceous gland duct

152

What are 4 major s/s of Pregnancy

FAWN

  1. Fatigue +/- insomnia
  2. Amenorrhea
  3. Weight gain
  4. NV

these sx can overlap with Perimenopausal sx so be careful not to quickly dismiss an older pt who's actually pregnant!

153

Tx for Condyloma Acuminata - 5

HPV 6 & 11

  1. Trichloroacetic acid
  2. Cryotherapy c liquid nitrogen or cryoprobe
  3. Podophyllin resin
  4. Podofilox 0.5% gel - pt application
  5. Imiquimod 5% cream - pt application

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154

[T Or F] It is absolutely Ok to perform a Colposcopy in a pregnant woman whose pap recently resulted abnormal

TRUE (Colposcopy is indicated when pap is abnormal even if pt is pregnant! - DO IT) ; So is Cervical bx if a lesion has high-grade features

Endocervical curettage is contraindicated

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155

[T or F] It is ok to perform a Cervical biopsy on a pregnant woman whose pap recently resulted abnormal

TRUE - after Colposcopy, if lesion has high-grade features

Endocervical curettage is contraindicated

156

Atypical Glandular Cells on a Pap may be due to either ____ OR _____ CA

What should you do to work this up? - 3

cervical ; Endometrial (glands migrated to cervical area)

  1. Colposcopy
  2. Endocervical curettage
  3. Endometrial biopsy

With AGC on Pap you need to evaluate Ectocervix, Endocervix and Endometrium

157

What is Mittelschmerz? 

Mittelschmerz = "Middle of the cycle" uL pelvic pain that occurs when blood released from rupture of follicle during ovulation irritates peritoneum  

order: LH surge --> 36 hrs will pass --> Ovulation

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158

What is Ovarian hyperstimulation syndrome

Ovulation inducing medications -->  excessive follicle development -->  ovarian enlargement, ascities, SOB and abd pain

159

How do you manage an active HSV lesion in Pregnant Women who are in labor?  ; How do you manage HSV in Pregnant Women remote to labor? 

c/s ; Valacyclovir px at 36WG

160

Secondary Amenorrhea occurs when women stop having menses for ≥6 months

What is the full workup for Secondary Amenorrhea? 

Evaluate FLAT PiG for 2° Amenorrhea

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161

In a pt with hypothyroidism, why do you need to _____[decrease/increase] her levothyroxine T4 when she becomes pregnant? 

INCREASE (with monitoring of T4)

Estrogen from pregnancy usually ⬆︎Thyroid binding globulin AND bHCG stimulates thyroid which both --> ⬆︎total thyroid hormone in mom for the baby. BUT hypOthyroid pts can't produce adequate thyroid hormone and this can --> congenital hypOthyroidism. So give them more Levothyroxine T4 when pregnant

Levothyroxine = T4 / Liothyronine = T3

162

What are the 1st line abx for treating UTI/cystitis - 3

CAN the UTI, CAN it

  1. Ciprofloxacin
  2. Amoxicillin-clavulanate
  3. Nitrofurantoin

but also can use Fosfomycin and CefTriaxone

163

A friable cervix is one that easily _____ when touched. This is usually a sign of cervicitis secondary to _____

bleeds "crumbles" ; N. Gonorrhea

164

bHCG shares an ___subunit with which other 3 hormones? 

ALPHA; 

  1. FSH
  2. LH
  3. TSH--> Prenant woman naturally have more T3 and T4 (also because Estrogen ⬆︎thyroid binding globulin which ⬆︎total thyroid levels) - these pts are still clinically euthyroid

165

How do you confirm a pt has urinary retention

urinary catheterization ≥150 cc

Bladder can hold up to 400 cc

166

Indications for Pessary - 2

  1. Pelvic organ prolapse
  2. Stress urinary incontinence

167

What are risk factors for Osteoporosis? - 9

Bone Mineral Density (T-score) ≥ -2.5 SD BELOW the mean

  1. PERSONAL OR FAMILY HX OF OSTEOPOROTIC FX
  2. ⬇︎Estrogen (postmenopause)
  3. LOW BMI (malnutrition/malabsorption)
  4. Sedentary lifestyle
  5. Poor Ca+ intake (body needs 1000mg/day premenopausal and 1200mg post)
  6. Smoking
  7. EtOH abuse
  8. White race
  9. CTS

168

Pt's Pap Smear reveals Atypical Squamous Cells of Undetermined Significance

Mngmt? - 3

1st: HPV typing, and if high risk (16 or 18) ---> 

2nd: Colposcopy and if abnml --> 

3rd: Cervical biopsy

169

What are the major risk factors for PreMenstrual Syndrome? - 5 

  1. FAMILY HX OF PMS
  2. Vitamin B6 Pyrodixine deficiency
  3. Ca+ deficiency
  4. Mg deficiency
  5. Age > 30

170

Dx for Functional Hypothalamic Amenorrhea?

 

⬇︎FSH

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171

Which substance actually exacerbates the cyclical bilateral pain associated with Fibrocystic changes of breast? 

Caffeine