Women's Health 2 Flashcards
(358 cards)
1
Q
Definition of infertility: inability of a couple to conveive after ______ of unprotected sexual intercourse
A
one year
2
Q
Causes of infertility: Female: \_\_\_\_\_\_ Male: \_\_\_\_\_\_ Combined: \_\_\_\_\_\_ Unexplained: \_\_\_\_\_\_\_
A
Female: 40%
Male: 40%
Combined: 20%
Unexplained: 8-15%
3
Q
MC cause of female infertility
A
anovulation
4
Q
Advanced maternal age \_\_\_\_\_ natural birth rates \_\_\_\_\_ miscarriages \_\_\_\_\_ time to achieve pregnancy \_\_\_\_\_ response to infertility Tx
A
decreases
increases
prolongs
impairs
5
Q
Peak female fertility age
A
27
6
Q
Female fertility declines become most significant at age:
A
35
7
Q
Chance for pregnancy is <10% over age:
A
40
8
Q
Pregnancy rate is ZERO with Tx at age:
A
45
9
Q
Which is worse for fertillity: cigarettes or weed?
A
weed
10
Q
Infertility of a couple for _____ years is associated with decreased fertility
A
3-5 years
11
Q
4 things to consider when evaluating a couple for infertility
A
- duration of infertility
- frequency of sex
- methods of contraception
- previous eval and Tx
12
Q
1 test for evaluating infertility in a female
A
hysterosalpingography
13
Q
7 most important areas to eval on PE for infertility workup
A
- weight/BMI
- skin: acanthosis nigricans is a sign of insulin resistence
- thyroid evaluation
- breast abnormalities
- androgen excess
- abdominal/pelvic exam
- vaginal/cervical abnormalities
14
Q
Infertility Dx Eval: Day 1 of the cycle
A
cycle starts
15
Q
Infertility Dx Eval: Day 3 of the cycle
A
FSH, estradiol are at their lowest level
16
Q
Infertility Dx Eval: Day 6-12 of the cycle
A
saline infusion, HSG, surgery (laproscopy or hysteroscopy)
17
Q
Infertility Dx Eval: Day 13-17
A
US assessment/follicle eval
18
Q
Infertility Dx Eval: Day 21
A
progesterone/luteal phase evaluation
19
Q
What is the average size of an egg that’s about to release a follicle?
A
20mm
20
Q
What does a hysterosalpingogram asses?
A
uterine cavity and tubal patency
21
Q
What days of the cycle is a hysterosalpingogram performed?
A
Days 6-12
22
Q
Describe a hysterosalpingogram
A
a fluroscopic procedure using water or oil soluble contrast dye
23
Q
False negative rate of hysterosalpingograms
A
25%
24
Q
What med should you STOP before performing a HSG procedure?
A
Metformin
25
What is definitive evidence of ovulation??
PREGNANCY
26
When is ovarian reserve testing usually performed?
women >35 you to test ofr fertility potential
27
What day of the cycle is ovarian reserve testing performed?
Day 3
| FSH, estradiol
28
What does ovarian reserve testing provide information about?
ovarian volume
| antral follicle count
29
4 types of ovulatory defects
1. hypothalamic-pituitary dysfunciton
2. polycystic ovarian syndrome
3. premature ovarian failure
4. luteal phase defects
30
Indications for fertility surgey
Performed to normalize pelvic anatomy, especially in the uterine cavity
Tx:
- pelvic endometriosis adhesions
- uterine pathology (fibroids, adhesions, septum)
- ovarian abnormalities
31
Fertility surgery is done less often today due to advent of ____.
ART Technology
32
3 common surgical fertility procedures
laparoscopy
hysteroscopy
laparotomy
33
Male infertility is often due to:
OTHER MEDICAL CONDITIONS
34
10% of infertile males are at increased risk for:
significant medical condition
35
Best results of semen analysis are through what?
certified reliable laboratory
36
Men should abstain from ejaculation for ____ before semen analysis
2-3 days
37
For semen analysis it is recommended that _____ properly performed tests are performed ____ apart for best results
2; 4 weeks
38
Normal sperm concentration
>20 milion/mL
39
Normal total sperm number
>40 million/ejaculate
40
Normal percent motility of sperm
>50%
41
Definition of oligospermia
sperm count <20 million/ml
42
Definition of asthenospermia
Sperm motility <50%
43
Definition of teratospermia
Abnormal morphology (Kruger <5%)
44
Definition of Azoospermia
no sperm found in the ejaculate
45
Definition of aspermia
No semen noted with ejaculation
46
Definition of Necrospermia
No motile viable sperm noted
47
What makes a pregnancy test positive? (4)
- motile sperm with normal concentration
- mature egg ovulated
- open fallopian tube
- endometrium for normal implantation
48
Summary of infertility eval
1. H&P of female
2. semen analysis
3. hysterosalpingogram/US
4. labs
5. prenatal vitamins/folic acid supplementation
6. Tx based on significant findings
49
Tx options for cycle in infertility
- Low tech ART/ovulation induction: Clomid/Letrozole, controlled ovarian hyperstimulation, insemination
- Real time ART: in vitro fertilization
50
Clomid Ind and MOA
Ind: unexplained infertility, PCOS, anovulation
MOA: acts on the hypothalamus and increases FSH to stimulate the ovary
51
S/E of Clomid
- multiple gestations
- increased risk of ectopic pregnancy
- ovarian cysts
- mood swings
- visual disturbances
- vaginal dryness
- thinning of the endometrial lining
52
Insemination is used for:
male factor and unexplained infertility
53
When is insemination done?
24 hours after LH surge or 36-40 hours after hCG trigger
54
What is ART?
= assisted reproductive technology...
| a process of manipulating eggs and sperm outside the body in the laboratory
55
Name 3 types of ART
IVF: in vitro fertilization
GIFT: gamete intrafallopian transfer
ZIFT: zygote intrafallopian transfer
56
Explain IVF
extraction of oocytes, fertilization in the lab, transcervical transfer of embryos into the uterus
57
Explain GIFT
placement of oocytes and sperm into the fallopian tube
58
Explain ZIFT
placement of fertilized oocytes into the fallopian tube
59
What can we do to help infertility in general?
overcome severe male factor with intracytoplasmic sperm injection
60
What can we do to help couples that are worried about genetic disorders or want to select the sex of their baby
Preimplantation genetic diagnosis
61
What can we do to help infertility issues in single women or same sex couples?
donor egg/sperm, surgogacy
62
FISH is used for what type of genetic analysis?
sex selection
| aneuploidy
63
PCR is used for what type of genetic analysis?
single gene defects
64
Definition of dysmenorrhea
painful menstruation that prevents a woman from performing normal activities
65
How many women have dysmenorrhea?
10-15%
66
What are the two categories of dysmenorrhea?
primary & secondary
67
Describe primary dysmenorrhea
- caused by an excess of prostaglandins
| - no clinically identifiable etiology
68
Which type of dysmenorrhea declines with age?
primary dysmenorrhea
69
Sx of primary dysmenorrhea
- suprapubic pain
- "labor-like," colicky, spasmodic, aching, pressure radiating to the back and/or thighs
- recurrent with onset of menses
- lasts hours to 1-3 days
DIFFUSE PELVIC PAIN RIGHT BEFORE OR WITH THE ONSET OF MENSES
70
What do prostaglandins do in the uterus and GI tract?
POTENT smooth muscle stimulants
- uterus: intense contractions
- GI: nausea, vomiting, diarrhea
71
Tx for primary dysmenorrhea
FIRST LINE: NSAIDs: interrupt COX-mediated PGE production
SECOND LINE: OCPs, hormonal contraceptives: eliminate menstruation, inhibits ovulation, and limits endometrial thickness
Laparoscopy if meds fail
72
Describe secondary dysmenorrhea
- Due to a clinically identifiable cause (pelvic pathology or recognized medical condition)
73
What type of dysmenorrhea increases with age?
secondary dysmenorrhea
74
CC in secondary dysmenorrhea is due to a specific etiology. Name three types
1. intramural: within wall of uterus
2. intrauterine: within the uterine cavity
3. extrauterine: outside the uterus
75
An intramural etiology of secondary dysmenorrhea where the endometrium grows into the uterine wall
adenomyosis
76
An intramural etiology of secondary dysmenorrhea where there is a benign overgrowth of the muscle layer
uterine fibroids
77
Name some intrauterine etiologies of secondary dysmenorrhea (5)
```
uterine fibroids
endometrial polyps
intrauterine devices
infection
cervical stenosis/lesions
```
78
Name some extrauterine causes of secondary dysmenorrhea (4)
- endometriosis
- inflammation (PID)
- adhesions
- non-GYN (GI, interstitial cystitis)
79
Tx for secondary endometriosis
specific to etiology
80
Definition of endometriosis
growth of the endometrium outside the uterine cavity...
| endometrial "implants" of ectopic location outside the uterine cavity
81
Classic Sx of endometriosis
```
dysmenorrhea
dyspareunia
infertility
pelvic pain
GI/GU Sx
```
82
Clinical signs of endometriosis
Fixed, retroflexed uterus
| Tender, palpable ovarian mass
83
Does the location and amount of lesions in endometriosis correlate with pain Sx?
Nope
84
2 major problems that endometriosis results in
1. infertility (30-50%
| 2. chronic pelvic pain (70-80%)
85
Sampson's Theory of the etiology of endometriosis
direct implantation of endometrial cells due to retrograde menstruation
86
Halban's Theory of the etiology of endometriosis
vascular and lymphatic dissemination of endometrial cells
87
Meyer's Theory of etiology of endometriosis
metaplasia of "multipotential" cells in peritoneal cavity
88
Endometriosis tends to cluster in ____. Likely a ____, interaction between ____ and _____.
families; complex trait; multiple genes; environment
89
Endometriosis Dx (definitive, gold standard)
PE
Laparoscopy with biopsy is definitive Dx
Hystologic study is gold standard
90
What would a laproscopy show if there is endometriosis?
raised patches of thickened, discolored scarred or "powder burn" appearing implants of tissue
Endometrioma
91
What is endometrioma?
endometriosis involving the ovaries large enough to be considered a tumor, usually filled with old blood appearing chocolate-colored ("chocolate cyst")
92
Classic triad of endometriosis
1. cyclic premenstrual pelvic pain
2. dysmenorrhea
3. dyspareunia
93
What is dyschezia and what disease process is it common in?
painful defecation
| endometriosis
94
What is the most common site for endometriosis?
ovaries
95
T/F: ectopic endometrial tissue responds to cyclic hormonal changes
True
96
Progression of endometriosis (4 steps)
1. clear vesicles
2. red vesicles
3. blue dome cysts (4-10 years)
4. black lesions (7-10 years)
97
Endometriosis medical Tx
Ovulation suppression
1. combined OCPs + NSAIDs for premenstrual pain
2. Progesterone
3. Leuprolide
4. Danazol
98
How does progesterone work in endometriosis Tx?
suppresses GnRH, causes endometrial tissue atrophy, suppresses ovulation
99
How does Leuprolide work in endometriosis Tx?
GnRH analog causes pituitary FSH/LH suppression
100
How does Danazol work in endometriosis Tx?
testosterone (induces pseudomenopause by suppressing FSH and LH mid-cycle surge)
101
Endometriosis surgical Tx (2)
1. If fertility desired: conservative laparoscopy with ablation
2. if fertility not desired: total abdominal hysterectomy with salpingo-oophorectomy
102
Definition of chronic pelvic pain
non-cyclic pain for 6 or more months
103
What does this sound like:
- pain has little relief from conventional Tx
- Pain not proportional to tissue damage
- Vegetative signs of depression
- Limited physical activity
- change in family emotional roles
- Functional disability
Chronic pelvic pain
104
MULTIPLE etiologies of chronic pelvic pain. Name a few.
GYN
GU
Neuro/MSK
Supratentorial
105
Most common cause of chronic pelvic pain
Endometriosis
106
T/F: normal pelvic pain precludes the possibility of finding pelvic pathology
False
107
____ of chronic pelvic pain patients have a history of physical and/or sexual abuse
50%
108
Chronic pelvic pain is commonly associated with ____.
depression
109
On the bimanual exam, the ovaries are expected to be...
- Palpable in _____% of reproductive-aged women
- Non-palpable prior to _____ and following _____.
50%
| menarche; menopause
110
You MUST assess palpable varies as _____% of ovaries are malignant
25%
111
What is the most common GYN cancer?
endometrial
112
What is the second most common GYN cancer?
ovarian cancer
113
What type of GYN cancer has the HIGHEST mortality of all the GYN cancers?
ovarian cancer
114
Ovarian cancer RF (3)
- FAMILY HISTORY
- increased number of ovulatory cycles (infertility, nulliparity, and >50 years old)
- BRCA1/BRCA2
- Caucasian
- Puetz-Jehgers, Turner's syndrome
115
Protective factors against ovarian cancer
- OCPs (decreases # of ovulatory cycles)
- high parity
- TAH
116
Ovarian cancer Sx
ASYMPTOMATIC until advanced disease stages, mets (>70% are stage III-IV at detection)
- abdominal fullness
- back/abd pain
- urinary frequency
- constipation
- irregular menses, menorrhagia, postmenopausal bleeding
117
Ovarian is the ____ leading cause of cancer-related death in the US
5th
118
Genetic ovarian cancer occurs _____ earlier than non-heritable disease
5-10 years
119
Name 3 genes associated with ovarian cancer
BRCA1
BRCA2
Lynch II Syndrome (1st and 2nd degree relatives with breast, colon, endometrial, and ovarian cancer)
120
Ovarian cancer on PE
- palpable abdominal or ovarian mass
- ascites
- omental caking: "gravel under a blanket"
- Sister Mary Joseph's node
- pleural effusion, edema
121
What is Sister Mary Jose[h's node and what cancer is it associated with?
Mets to the umbilical lymph node; ovarian cancer
122
Ovarian cancer Dx
Biopsy
123
What does positive biopsy look like for ovarian cancer?
90% epithelial
124
What can you use to screen high risk patients for ovarian cancer?
transvaginal US
125
3 components of BRCA Tx
- enhanced screening
- prophylactic risk-reducing surgery (bilateral mastectomy, bilateral salpingo-oophorectomy)
- chemoprevention (Tamoxifen, OCPs)
126
How does ovarian cancer spread?
direct extensino within the peritoneal cavity
| Mets go to: liver, diaphragm, omentum, bowels
127
You should always include a ________ on GYN cancer exam to evaluate for adnexal masses or nodules in the cul-de-sac
rectovaginal exam
128
What is Cancer Antigen 125 (CA-125) used for
NOT for screening the general population because it is non-specific!! (also possible for pt to have cancer without elevated CA-125)
Better utilized as a tumor marker
129
Early stage ovarian cancer Tx
TAH-BSO + selective lymphadenectomy
130
Surgical ovarian cancer Tx
Tumor debulking
131
What is used to monitor ovarian cancer treatment progress?
serum CA-125 levels
132
Chemotherapy for ovarian cancer
Paclitaxel + Cisplatin or Carboplatin
133
Problem with intraperitoneal Cisplatin chemotherapy
high toxicity
134
Prognosis for ovarian cancer
<5% cured
| >80% of patients in remission have recurrence about 2.5 years later
135
2 prevention strategies for ovarian cancer
- OCPs/hormonal contraception
| - prophylactic BSO
136
T/F: current Tx for ovarian cancer do NOT cure it most of the time
True
137
____ occur when follicles fail to rupture and continue to grow
follicular cysts
138
_____ cysts fail to degenerate after ovulation
corpus luteal
139
As a general rule, what should you do with cysts over and under 5 cm?
>5cm: surgery
| <5cm: serial US
140
Solid masses are _____ until proven otherwise
malignant
141
What type of cyst is due to normal ovarian function?
functional cysts
142
_____ are fluid-filled sacs or pocket-like structures that form on or inside the ovary
functional ovarian cysts
143
Do functional ovarian cysts cause pain?
rarely
144
_____ occur when a sac on the ovary does not release an egg and the sac swells up with fluid
follicular cysts
145
In a follicular cysts, the follicle _____.
fails to rupture when mature
146
Sx of follicular cysts
the bigger, the most likely to cause:
- pain in the RLQ
- metrorrhagia (irregular menstrual cycle)
- pain during or after sex
147
What type of cyst occurs when the corpus luteum fails to break down and disappear?
corpus luteal cyst
148
corpus luteal cyst produces ____, which delays menses
progesterone
149
Corpus luteal cyst Sxq
- dull aching LQ pain
| - secondary amenorrhea
150
The "Ring of Fire" Sign on US can be seen in what two conditions?
1. corpus luteal cysts (MC)
| 2. ectopic pregnancy
151
Endometriosis causes what type of cyst?
endometrial cyst
152
How do endometrial cysts form?
tissue from inside the uterus forms the nucleus of the cyst
153
What's the "classic chocolate cyst"?
endometrial cyst
154
Endometrial cyst Tx
surgical excision
155
Endometrial cyst Sx
abd pain
vaginal bleeding
HA
156
Corpus luteal cyst Tx
OCPs for recurrence/persistance
157
What is the main complication we're concerned about with ovarian cysts?
torsion
158
Dx of functional ovarian cysts
pelvic US
159
What do follicular ovarian cysts look like on US?
smooth, thin-walled unilocular
160
What do luteal cysts look like on US?
complex, thick-walled with peripheral vascularity
| order BhCG to r/o pregnancy
161
What type of cyst is a mature cystic teratoma?
dermoid cyst
162
Dermoid cyst Tx
surgical (high potential for torsion)
163
Most ovarian cysts ____ are functional and usually spontaneously resolve, so Tx: (3)
<8cm;
- rest
- NSAIDs
- repeat US after 6 weeks
164
If cyst is >8cm or found postmenopause, Tx:
laparoscopy or laparotomy
165
Endometrial cancer is ____ most common GYN cancer and _____ most common cancer overall in women
1st; 4th
166
Endometrial cancer is most common in what age?
postmenopausal: 50-60 years old
167
Endometrial cancer is ____-dependent
estrogen
168
Endometrial cancer RF
- increased estrogen exposure
- PCOS
- obesity
- nuliparity
- estrogen replacement therapy
- late menopause
- Tamoxifen use (estrogen stimulates endometrial growth)
- HTN
- DM
169
Definition of endometrial proliferation
overabundance of normal endometrium
170
Definition of endometrial hyperplasia
proliferation of both glandular and stromal elements
171
Definition of endometrial atypia
altered histologic architecture
172
Hyperplasia Tx
Normally: hysterectomy or D&C + progesterone
Atypical: TAH
173
Atypical is ____% more likely to
30%
174
Combination OCPs are protective against ____ and ____.
ovarian and endometrial cancer
175
Endometrial cancer Sx
ABNORMAL UTERINE BLEEDING
- postmenopausal bleeding
- menorrhagia
- metrorrhagia
- watery vaginal discharge
176
endometrial cancer Dx
Endometrial biopsy
| US
177
MC type of cancer shown on endometrial biopsy
adenocarcinoma
178
US shows what in endometrial cancer?
endometrial stripe >4mm
179
Ind for endometrial biopsy
- PMB
- >35 years old with abnormal bleeding
- increased endometrial stripe on TVUS
- Tamoxifen
180
Stage I endometrial cancer Tx
Hysterectomy
181
Stage II, III endometrial cancer Tx
TAH + BSO + lymph node excision
+/- post-op radiation therapy
182
Stage IV endometrial cancer Tx
systemic chemotherapy
183
Most common type of mets in endometrial cancer
lung
184
What is the precursor to endometrial carcinoma?
endometrial gland proliferation
185
Why does endometrial hyperplasia happen?
continuous increased unopposed estrogen (unopposed by progesterone)
186
Examples of what can cause increased unopposed estrogen
- chronic anovulation
- PCOS
- perimenopause
- obesity (conversion of androgen to estrogen in adipose tissue)
187
Most common age to see endometrial hyperplasia
postmenopausal
188
Hyperplasia often occurs within ___ of estrogen-only therapy
3 years
189
Endometrial hyperplasia Sx
BLEEDING
- menorrhagia
- metrorrhagia
- postmenopausal bleeding
190
Endometrial hyperplasia Dx
- transvaginal US
| - endometrial biopsy
191
Definitive Dx f endometrial hyperplasia
endometrial biopsy
192
What would you expect to see on transvaginal US if a patient has endometrial hyperplasia?
endometrial stripe >4mm`
193
Tx for endometrial hyperplasia WITHOUT atypia
Progestin
| repeat endometrial biopsy in 3-6 months
194
MOA of progestin therapy in endometrial hyperplasia
stops estrogen from being unopposed, limits endometrial growth
195
Tx for endometrial hyperplasia WITH atypia
hysterectomy
196
Main type of vulvar cancer
90% squamous
197
Main risk factor for vulvar cancer
HPV (16,18,31)
198
Most common Sx of vulvar cancer
pruritis (70%)
asymptomatic (20%)
199
Vulvar cancer Dx
red/white ulcerative, crusted lesions
biopsy
200
Vulvar cancer Tx
surgical excision
radiation
chemotherapy (5-fluorouracil)
201
Most common type of vaginal cancer
squamous (95%)
| Clear cell if DES exposure in utero
202
Vaginal cancer Sx
Asymptomatic, changes in menstrual period, abnormal vaginal bleeding, vaginal discharge
203
Vaginal cancer Tx
radiation therapy
204
Chronic vulvar pruritis
| Thinning, whitish epithelium, "onion skin"
Lichen sclerosis
205
Tx for lichen sclerosis
high potency topical steroids
206
"an itch that rashes"
irritant dermatitis
progressive burning/itching
hyperplastic, hyperpigmented plaques
Lichen simplex chonicus
207
Lichen Simplex Chronicus Tx
antihistamines
mild-moderate potency steroids
BIOPSY if no change in 3 months
208
A benign vulvar lesion, inflammatory blockage of the sebaceous gland ducts.
Small, smooth nodular masses
sebaceous/inclusion cysts
209
Benign vulvar lesion, pigmented
nevi or malignant melanoma
distinguish with vulvar biopsy
210
Prevention for vaginal cancer
- regular physical exams
- avoid HPV exposure
- don't smoke
- Gardasil
211
What type of cells is the ectocervix made of?
non-keratinizing squamous epithelium
212
What type of cells is the endocervix made of?
simple columnar epithelium
213
What happens to cell type at the external os?
site of transition: squamocolumnar junction
214
What happens to the cervix during puberty?
the original SCJ "rolls out" >>
everted tissue is exposed: irritants, hormonal milieu, vaginal secretions >>
squamous metaplasia >>
transformation zone
215
Describe the HPV virus
non-enveloped double-stranded DNA virus
216
what percent of sexually active women are exposed to HPV?
80%
217
How many distinct genotypes of HPV have been identified?
120
218
What are the MC high risk strands of HPV?
16, 18 (70%)
31, 33
219
What are the MC low risk strands of HPV?
6,11
220
HPV is associated with what 6 cancers?
```
cervical
anal
vaginal
vulvar
penile
oropharynx
```
221
What's special about HPV and cervical cancer?
it was the first NECESSARY cause of a cancer ever identified (99% attributable fraction)
222
What is HPV disease?
external genital warts cause by low risk HPV types
223
Cervical cancer is caused by...
high risk HPV types
224
Describe the epitheliotropic life style of HPV
infects sites of epithelial microtrauma, enters the basal epithelial cells, replicates with the cell , HPV infected cells throughout epithelial layers, HPV particles released when epithelium sheds
225
What has provided a >50% decrease in cervical cancer in developed countries over the last 30 years?
Pap smear
226
what does the Pap smear do?
samples cervical cells from the transformation zone with spatula or cytrobrush or broom stick
227
What happens in a conventional Pap smear?
direct application of cells to a slide
228
What happens in a liquid-based Pap smear?
incorporation of molecular HPV testing, electronic imaging
| 90% of Pap testing in US
229
USPSTF cervical screening guideline for patients <21 years old
no screening, regardless of sexual history
230
USPSTF cervical screening guideline for patients 21-65 years old
screen with cytology every 3 years
231
USPSTF cervical screening guideline for patients 30-65 years old
start cotesting: combination cytology with HPV testing every 5 years
232
USPSTF cervical screening guideline for patients >65 years old
no screening
| if history of adequate prior screening and not otherwise high risk for cervical CA
233
Should you screen for cervical cancer when a total hysterectomy is performed for benign disease
No
234
What should you evaluate for to determine Pap smear results' specimen adequacy
presence of transformation zone cells
235
If transformation zone is not present on Pap smear and HPV is unknown, what do you do?
repeat pap in 2-4 months
236
If transformation zone is not present on Pap smear and HPV is negative (>30yo), what do you do?
repeat pap in 2-4 months
237
If transformation zone is not present on Pap smear and HPV is positive (>30yo), what do you do?
repeat pap in 2-4 months OR colposcopy
if repeat pap is unsatisfactory >> colposcopy
238
CIN I is what type of lesion?
LOW grade squamous intraepithelial lesion (LSIL)
239
CIN II, III are what type of lesion?
HIGH grade squamous intraepithelial lesion
240
Mild dysplasia, contained to basal 1/3 of epithelium
CIN I
241
MODERATE dysplasia, including 2/3 thickness of basal epithelium
CIN II
242
SEVERE dysplasia, >2/3 thickness of basal epithelium (includes carcinoma in situ)
CIN III
243
Full thickness invasion of basal epithelium
carcinoma in situ
244
Two types of atypical squamous cells found on cytology
1. ASC-US: Atypical Squamous Cells of Undetermined Significance
2. ASC-H: Atypical Squamous Cells cant exclude HSIL
245
Describe the Reflex HPV test
- liquid-based cytology
- tests for 13 high-risk HPV types most commonly associated with high-grade dysplasia and CA
- increases sensitivity for detection of high-grade lesions and cancers compared to cytology alone
- 99-100% NPV of combined cytology and HPV DNA testing for high-grade lesions
246
Describe colposcopy
- magnified view of the cervix
- place dilute acetic acid on areas that correlate with high nuclear density
- must examine transformation zone
- biopsy lesions which appear acetowhite or of abnormal vascularity
247
Tx for pre-invasive disease
ablative techniques:
- cryotherapy
- laser ablation
- electrocautery
excisional techniques
- cold knife cone
- loop electrosurgical excisional procedure (LEEP)
248
CIN I Tx
- observation: 75% resolve by immune system within 1 year
| - excision: LEEP, cold knife cervical conization
249
CIN II, III, carcinoma in situ Tx
excision or ablation is mainstay of Tx
250
Cervical cancer is the ____ MC GYN cancer
3rd
251
Cervical cancer is the _____ MC cancer in women world wide and the most common GYN cancer in developing countries
2nd
252
Highest incidence of HPV is at ages....
| Average age of Dx is....
35-54;
| 45
253
Median age at death from cervical cancer is....
57 yo
254
Name 6 risk factors for cervical cancer
```
HPV
early onset sexual activity
multiple/high-risk sexual partners
smoking
Hx of STDs
High parity
Immunosuppression
Low socioeconomic status
DES exposure (Diethystilbestrol was a synthetic estrogen used in OCPs)
```
255
Two hystological types of cervical cancer are ___ and ____. Which is MC?
1. Squamous (90%)
| 2. Adenocarcinoma (10%)
256
Which type of cervical CA is associated with DES?
clear cell carcinoma
257
It takes on average _____ for carcinoma to penetrate the basement membrane
2-10 years
258
Cervical CA Sx
- POST COITAL BLEEDING is MC
- Metrorrhagia
- Pelvic pain
- Watery vaginal discharge
259
Cervical cancer Dx
colposcopic directed biopsy
260
How do you screen for cervical CA?
Pap smear with cytology
261
In the face of cancer, Pap smear has a ____% false negative rate. Therefore, what should we do in the case of a visible lesion??
50%;
| Biopsy any visible lesion!!
262
How do you stage cervical cancer?
Cervical and vaginal cancers are the ONLY cancers that are staged CLINICALLY
263
What tool is used to stage cervical cancer?
imaging (CT, MRI, PET, US)
264
Stage 0 cervical cancer
carcinoma in situ
265
Stage I cervical cancer
microinvasion: lesion confined to cervix
266
Stage II cervical cancer
beyond the cervix, but not to the pelvic sidewall or lower third of vagina
267
Stage III cervical cancer
extends to the pelvic sidewall or lower third of the vagina, or there is hydronephrosis or a non-functioning kidney
268
Stage IV cervical cancer
extends beyond the true pelvis, or has biopsy-proven involvement of rectal or bladder mucosa, distant mets
269
Stage 0 cervical cancer Tx
excision, ablation, or TAH-BSO
270
Stage I cervical cancer Tx
Surgery: conization, TAH-BSO, XRT
271
Stage II-III cervical cancer Tx
Radiation (XRT) + chemotherapy (cisplatin or 5-fluorouracil)
272
Stage IV cervical cancer Tx
palliative radiation therapy, chemotherapy (surgery not likely to be curative)
273
Gardasil protects against what strains of HPV
16, 18, 6, 11
274
Gardasil 9 protects against what strains of HPV
16,18,31,33,45,52,58,6,11
275
Cervarix protects against what strains of HPV
16,18
276
Current recommendations for HPV vaccine
given at age 11 up to 26 years old originally, now available up to age 45
277
Cervical cancer rates won't decrease secondary to vaccination until what year?
2040
278
Current vaccines protect against what percent of cervical cancers?
70-90%
279
DO NOT MISS _____.
unusual vaginal bleeding
280
T/F: pelvic exam = pap smear
FALSE
281
Cervical dysplasia and cervical cancer is preventable with what two things?
screening
| vaccination
282
T/F: vaccinate boys and girls
True
283
Remind patients they still need annual _____.
well-woman exams!!!
284
How many people will be infected with at least one type of HPV at some point?
Almost ALL
285
T/F: intercourse is not necessary for infection with HPV
True
286
____% new cervical HPV infections clear or become detectable within 2 years
90%
287
What is the most common HPV-associated cancer among women?
Cervical cancer
288
Half of cervical cancers occur in women how old?
>50 years
289
What is the most common HPV-associated cancer regardless of gender?
Oropharyngeal SCC
290
By what year will the highest number of HPV related cancer deaths be oropharyngeal?
2020
291
2 dose schedule for HPV vaccine
Before 15th birthday, early as age 9
First and second dose administered <5 months apart. If not, a third dose is required
292
Normal pregnancy lasts how many weeks?
about 40
293
How are the three trimesters divided?
First: 0-13 weeks
Second: 14-27 weeks
Third: 28-40 weeks
294
How to calculate the due date using Naegele's Rule
Due Date= LMP + one year - 3 months + 7 days
295
In what trimester do you test for infectious diseases?
28-40 weeks
296
How does Rh incompatibility affect susequent pregnancies?
Maternal Rh antibody crosses the placenta into the fetal circulation and hemolyzes fetal RBCs
297
Placental location accounts for what percent of bleeding during pregnancy?
5%
298
What is a low-lying placenta?
The placenta is directly adjacent to the internal cervical os
299
What is placenta previa?
the placenta covers all or portion of the internal cervical os
300
Difference between complete or partial placenta previa
Complete: entire cervical os is covered by placenta
Partial: margin of placenta extends across part of the cervical os
301
What is the etiology of placenta previa?
not well understood
May "migrate" as the placenta grows
302
What is indicated in placenta previa?
Cesarian delivery
303
First bleeding with placenta previa happens at how many weeks? Why?
~29-30 weeks
| partial separation of the placenta from lower uterine segment and cervix in response to mild contractions
304
What is placenta previa (accreta)?
Abnormal growth of placental mass into the substance of the uterus
305
What is indicated in placenta (previa) accreta?
CD + TAH
If you try to pull off the accreta, the mom will continue to bleed. Must do TAH.
306
What is placental abruption?
premature separation of normally implanted placenta from the uterine wall
307
What is the problem with placental abruption?
it interferes with oxygenation of the fetus (hemorrhage, clot, infarct)
308
RF for placental abruption
maternal HTN
polyhydramnios/oligohydramnios
multiple gestations
cocaine use
309
A woman presents with third trimester BRB bleeding that is painless. The uterus is soft and non tender. What is the most likely Dx?
Placenta previa
310
How do you Dx a Placenta previa?
Pelvic US
311
Placenta previa Tx
- Hospitalization, bed rest
- Stabilize fetus: Tocolytics (Mg sulfate), Amniocentesis
- Delivery when stable with CD
312
Two most common causes of 3rd trimester bleeding
Placental abruption and placenta previa
313
Is there fetal distress in placenta previa?
No.
| Normal fetal HR
314
A woman presents in her third trimester with dark red vaginal bleeding that is painful. She has a rigid uterus on exam. What is the most likely Dx?
placental abruption
315
Is there fetal distress in placental abruption?
Yes.
fetal bradycardia.
(due to interference with O2 exchange)
316
Placental abruption Dx
Pelvic US
317
Placental abruption Tx
- Hospitaliztion
| - Immediate delivery, CD
318
A painless vaginal bleed during pregnancy WITH fetal distress (bradycardia) is most likely Dx:
Vasa Previa
319
Definition of tansitional (gestational) HTN
HTN, no proteinuria, AFTER 20 weeks gestation
Relieves 12 weeks post partum
320
Definition of chronic (preexisting) HTN
HTN BEFORE 20 weeks gestation or before pregnancy
Persists >6 weeks post partum
321
Definition of preeclampsia
HTN + proteinuria
+/- edema
AFTER 20 weeks gestation
322
Definition of eclampsia
Seizures or coma in patients who meet preeclampsia criteria
LIFE THREATENING for mother and fetus
323
BP requirement for preeclampsia-eclampsia
>140/90
OR
increased by 30/15
AFTER 20th week gestation
324
Hypertensive emergencies: HELLP syndrome
```
Hemolysis,
Elevated
Liver enzymes,
Low
Platelet count
```
(severest forme of preeclampsia without having eclampsia yet)
325
Vague initial Sx of HELLP syndrome
N/V, non-specific viral-like syndrome, RUQ pain from liver dysfunction
326
HELLP syndrome Tx
CV stabilization
Correction of coagulation d/o
Immediate deliver via CD
327
Gestational HTN Sx
asymptomatic
328
Eclampsia Sx
Abrupt, clonic-tonic seizures
1-2 mins
>> postictal state
329
Mild preeclampsia Tx
Delivery if >37 weeks
| Conservatie + steroids to mature lungs if <34 weeks
330
Severe preeclampsia Tx
- PROMPT delivery is only cure
- Hospitalization + Mg sulfate (to prevent seizures)
- BP meds in acute severe HTN (Hydralazine, Labetalol)
331
Eclampsia Tx
- ABCDs first!
- Mg sulfate for seizures
- Delivery!! once pt is stabilized
- BP meds (hydralazine, labetalol)
332
Preexisting HTN Tx
Mild (140-150/90-100): monitor
Moderate/severe (>150/100): Methyldopa is Tx of choice!!
Labetalol
AVOID ACEI and diuretics!!!
333
4 things you check at 20 and 35 weeks with US
1. Fetal anatomy/growth
2. Estimated fetal weight
3. Amniotic Fluid Index
4. Placental location/abnormalities
334
4 ways to measure fetal anatomy/growth
- Head circumfernce
- Biparietal diameter
- Abdominal circumference
- Femur length
335
Definition of intrauterine growth restriction (IUGR)
Fetal weight <10th percentile for GA
336
Things that cause ASYMMETRIC IUGR
HTN
| severe nutritional deficiencies
337
Things that cause SYMMETRIC IUGR
congenital anomalies
| early intrauterine infection
338
Definition of asymmetric IUGR
unequal decrease in the size of structures
| fetal access to nutrients is compromised
339
Definition of symmetric IUGR
anatomy equally diminished in size
relative sparing of fetal brain and heart
alteration of fetal cell number
340
Definition of macrosomia
Fetal weight in >90th percentile for a given ae
341
Risks of macrosomia
- Maternal obesity
- maternal diabetes, GDM
- excessive maternal weight gain during pregnancy
342
When is macrocomia suspected?
when fundal height is >4cm
| confirmed by US
343
Issues with macrosomia
Problematic SVD:
- prolonged 2nd stage of labor
- fetopelvic disproportion (FPD)
- shoulder dystocia
- immediate neonatal injury
Low threshold for C/S
344
Why does preterm labor (PTL) occur?
there is a rise in fetal fibronectin (FFN), an extracellular glycoprotein found in cerviacl mucus early in pregnancy and near term
345
When would you do a FFN swab?
at 24+ weeks WITH Sx of PTL only
346
What percent of PTLs resolve spontaneously?
50%
347
What do you have to rule out if you think someone is entering PTL?
Uterine "irritability"
- UTI
- BV
- dehydration
- multigravida
348
2 goals in the management of PTL
1. detect and treat associated d/o
| 2. recognize and "treat" PTL
349
two meds for treating PTL
tocolytics
| steroids
350
What are tocolytics for?
delaying labor when there is cervical dilation in PTL
351
RF for premature rupture of membranes
```
prolapsed umbilical cord
smoking (doubles risk)
prior PROM or PTL
short cervical length
multiple gestations
polyhydramnios/oligohydramnios
```
352
fluid passing through the vagina is ______ until proven otherwise!!!
amniotic fluid
353
What two tests can be used to Dx PROM?
Nitrazine test
| Fern test
354
How does the Nitrazine test work?
checks pH
355
How dose the fern test work ?
microscopy... amniotic fluid is placed on a slide and dies in room air. If it looks like a fern, it's positive
356
What are the three causative agents of chorioamnionitis?
gonorrhea
chlamydia
GBS
357
Chorioamnionitis signs and symptoms
fever
uterine tenderness
tachycardia
copious vaginal discharge
358
Chorioamnionitis Tx
Abx and immediate delivery
