question

age range of thelarche

answer

8-11

question

age range of menarche

answer

10-16

question

Follicular phase of menstrual cycles - what days? - what hormone increased? - uterine changes?

answer

- days 1-13 - increased FSH -> growth of follicles -> increased estrogen production - rsults in development of straight glands and thin secretions of uterine lining (proliferative phase)

question

Ovulation - what day of cycle? - which hormones spike?

answer

- day 14 - LH and FSH spike -> rupture of ovarian follicle -> release of a mature ovum - rupture follicular cells involute and create the corpus luteum

question

Luteal phase - what days? - what hormone is increased? - uterine changes?

answer

- 15-28 - corpus luteum produes estrogen and progesterone -> endometrial lining develops into thick endometrial glands with thick secretions (secretory phase) - in the absence of implantation the corpus luteum canot be sustained and endometrial lining sloughs off

question

premature menopauses = < age ___

answer

40

question

hormonal changes in menopause lipid profile in menopause

answer

- first increased FSH, then increased LH - increased total cholesterol, decreased HDL

question

non-HRT Menopause tx (3)

answer

- SSRI/SNRIs, clonidine, and/or gabapentin

question

Primary amenorrhea - definition

answer

Absence of menses by age 16 with secondary sexual development presentation, or the absence of secondary sexual characteristics by age 14

question

Amenorrhea + Absence of secondary sexual characteristics - due to? - etiologies?

answer

- no estrogen production - 1. constitutional growth delay = most common cause 2. primary ovarian insufficiency (turners, hx radiation /chemo) 3. Central hypogonadism (undernourishment, stress, hyperprolactinemia, exercise, CNS tumor, Kallman's syndrome)

question

Amenorrhea + presence of secondary sexual characteristics? - etiologies (3)

answer

estrogen production but other anatomic/genetic problems 1. Mullerian agenesis 2. imperforate hymen 3. complete androgen insensitivity

question

Diagnosis of primary amenorrhea

answer

1. pregnancy gest 2. bone radiograph to determine if bone age is consistent w/pubertal onset 3. ultrasound to evaluate the ovaries

question

primary amenorrhea - what to do if bone age is >12 years but there is no sign of puberty?

answer

obtain LH/FSH levels and consider where the problem is on the HPA axis

question

primary amenorrhea - what to do if bone age is <12 years but there is no sign of puberty?

answer

if pt is of short stature w/normal growth velocity = constitutional growth delay

question

primary amenorrhea - what to do if normal breast development and no uterus?

answer

obtain a karyotype to evaluate for androgen insensitivity (XY)

question

primary amenorrhea - what to do if normal breast development and uterus?

answer

measure prolactin and obtain an MRI to assess the pituitary gland

question

tx of hypogonadism

answer

begin HRT with estrogen alone at the lowest dose ==> 12-18 months later begin cyclic estrogen/progesterone therapy (if uterus is present)

question

contraindications to estrogen containing hormonal methods

answer

pregnancy hx of stroke/DVT breast cancer undiagnosed abnormal vaginal bleeding estrogen dependent cancer benign/malignant liver neoplasm current tobacco use and age >35

question

Secondary amenorrhea

answer

absence of menses for 6 consectutive months in owmen who have passed menarche

question

2ndary amenorrhea - dx (3)

answer

1. pregnancy test 2. if negative ==> measure TSH and prolactin 3. initiate progestin challenge

question

Progestin challenge - positive vs. negative work up

answer

10 days of progestin - positive challenge (withdrawal bleed) ==> test LH ==> if increased indicates anovulation the is likely due to noncyclic gonadotropin secrtion (PCOS), if decreased = idiopathic anovulation - negative challenge (no bleed) = uterine abnormality or estrogen deficiency ==> test FSH ==> if elevated = hypergonadotropic hypogonadism/ovarian failure, if decreased ==> cyclic estrogen/progesterone test ==> withdrawl bleed = hypogonadtropic hypogonadism (due to increased stress, exercise, etc.), no withdrawal bleed = endometrial or anatomic problem

question

2ndary ammenorhea - what to do if clinical virilization is present?

answer

- measure testosterone, DHEAS, and 17-hydroxyprogesterone

question

tx of premaure ovarian failure (age <40)

answer

if uterus present, tx with estrogen plus progestin replacement therapy

question

morning after pill - 3 options/effectiveness?

answer

1. combined estrogen/progestin = 75% effective 2. progestin only 80% effective 3. copper IUD 99% = can be used as EC and continued fo rup to 10 years of contracpetion

question

oligomenorrhea

answer

increased length of time between menses (35-90 days)

question

polymenorrhea

answer

frequent menstruation (<21 day cycle); anovular

question

menorrhagia

answer

increased amount of flow >80 ml of blood loss per cycle or prolonged bleeding (flow >8days)

question

metorrhagia

answer

bleeding between periods

question

menometrorrhagia

answer

excessive and irregular bleeding

question

When to perform endometrial biopsy for abnormal uterine bleeding?

answer

1. if endometrium is >4mm in a post-menopausal woman (age >45) 2. if patient is >35 years of age w/risk factors for endometrial hyperplasia (obesity, diabetes)

question

what is the most common cause of abnormal uterine bleeding and ammenorrhea?

answer

pregnancy

question

tx of heavy bleeding

answer

high dose estrogen IV --> stops bleeding in an hour if bleeding not controlled within 12-24 hrs --> D&C indicated

question

tx ovulatory bleeding

answer

NSAIDs to decreased blood loss, OCPs, Mirena IUD

question

Tx anovulatory bleeding (4)

answer

- Progestins x10 days - Desmopressin to increase vWF and F VIII - OCPs - Mirena IUD

question

what to do if medical management of abnormal uterine bleeding fails?

answer

1. D&C 2. Hysteroscopy - identify endometrial pollyps, biopsies 3. Hysterectomy or endometrial ablation

question

enometriosis - definition -history/PE - diagnosis

answer

- functional endometrial glands/stroma outside the uterus - cyclical pelvic and or rectal pain and dyspareunia - dx 1. by direct visualization by laparoscopy/laparotomy 2. classic lesions have blu-black or dark brown "powder burned appearnce" 3. ovaries may have endometriomas (chocolate cysts)

question

endometriosis - tx (3) - complicaitons

answer

- 1. pharm: inhibit obulation (OCPs first line, GnRH analogs, danazols, NSAIDs, progestins) 2. conservative surgical tx 3. definitive surgical tx: total abdominal hysterectomy/bilateral salpingo-oophorectomy - infterility

question

adenomyosis - definition - history/pe (triad) - diagnosis

answer

- endometrial tissue in the mymoetrium of the uterus - classic triad of noncyclical pain, menorrhagia, enlarged uterus - dx w/ US (difficult to distinguish from leiomyoma), MRI, ultimately pathologic diagnosis

question

adenomyosis - tx - complications

answer

- 1. pharm: NSAIDS (first line = symptomatic), + OCPs or progestins 2. conservative surgical tx (endometrial ablatoin/resection) - high tx failure 3. hysterectomy - can rarely progress to endometrial carcinoma

question

tx of congenital adrenal hyperplasia

answer

- Glucocorticoids (prednisone)

question

hormonal imbalances in PCOS

answer

- increased testosterone - Increased LH>FSH ration (>2:1) - increased estrogen (aromatization)

question

PCOS tx 1. in women who are not attempting to conceive 2. women who are attempting to conceive 3. symptom specific (hirsutism, cardiovascular risk factors/lipids)

answer

1. OCPs, progestin, metformin 2. Clomiphene +/- metformin 3. hirsutisim = OCPs first line, anti-androgens (spirnolactone, finasteride), metformin CVS risk factors = diet, weight loss, exercise, statins

question

Tx 1. asymptomatic cysts of bartholin's duct 2. abscess of bartholin's duct

answer

1. no therapy +/- warm soaks 2. aspiration or incision an drainage with Word catheter insertion to prevent reaccumulation; culture for chlamydia *ABX UNNECESSARY UNLESS CELLULITIS IS PRESENT*

question

Normal vaginal secrtions 1: midcycle estrogen surge: 2. luteal phase/pregnancy:

answer

1. clear, elastic, mucoid secretions 2. thick and white secretions, adhere to vaginal wall

question

Criteria for BV (4)

answer

1. abnormal whitish/gray fishy discharge 2. vaginal pH >4.5 3. + amine (whiff) test = fish smell w/KOH 4. clue cells (epithelial cells coated with bacteria) requires 3/4

question

Trichomonas - history - exam - discharge - wet mount - tx

answer

- increased discharge, odor, prritus, dysuria - "strawberry petechia" in upper vagina/cervix - profuse malodorous yellow green frothy dischage - wet mount = motile trichomonads - tx = PO metrnodizole - *tx partners, test for other STDs*

question

complications of BV and trichomonas

answer

chorioamionitis/endometrisis, infection, preterm delivery, miscarriage PID

question

Cervicitis - etiologies (infectious vs. noninfectious) - hx/ PE - dx/tx

answer

inflammation of the uterine cervix - infectious = chlamydia, gonococcus, trichomnas, HSV, HPV, non-infectious = trauma, radiation, malignancy - yellow/green mucopurulent discharge, + cervical motion tenderness, absence of other signs of PID - dx/tx: same as other STDs

question

PID - hx/PE

answer

- lower abdominal pain, fever/chills, menstrual disturbances, purulent cervical discharge - cervical motion tenerness (chandelier sign) and adnexal tenderness also seen

question

PID - dx criteria

answer

Diagnosed by the presence of acute lower abdominal pain or pelvic pain + 1 of the following: 1. uterine tenderness 2. adnexal tenderness 3. cervical motion tenderness

question

what does a WBC >100,000 mean for PID?

answer

has a poor positive and negative predictive value

question

PID - tx (outpatient vs. inpatient regimens)

answer

- abx - *should not be delayed while awaiting culture results* - outpatient regimens: 1. Ofloxacin or levoflaxcin x 14 days +/- metronidazole 2. ceftriaxone IM x 1 dose or cefoxitin + probenecid + doxycycline x 14 days +/- metronidazole - inpatient regimens: 1. cefoxitin or cefotetan + doxy x 14 days 2. clinday plus gent x 14 days

question

when to drain tubo-ovarian/pelvic abscess?

answer

1. if the mass persists after abx tx 2. abscess >4-6 cm 3. mass in cul-de-sac in midline and drainable through vagina

question

chandelier sign

answer

severe cervical motion tenderness that makes the patient jump for the chandelier on exam

question

Toxic shock syndrome - hx/PE

answer

- abrupt onset of fever, vomiting, and water diarrhea w/fever >38.9 (102) - diffuse macular erythematous rash - nonpurulent conjunctivitis - desquamation, especially of the palms and soles, generally occurs during recovery within 1-2 weeks of illness

question

Toxic shock syndrome - Dx (blood cultures?) - Tx (3)

answer

- blood cultures are NEGATIVE b/c symptoms result from toxin tx: - rapid rehydration -anti-staphylococcal drugs (nafcillin, oxacillin) - corticosteroids can reduce severity of illness and decrease fever

question

Uterine leiomyoma - benign or malignant? - responsive to what hormones? relationship to menopause? - malignant transformation?

answer

- most common BENIGN neoplasm of the female genital tract - tumors are estrogen and progesterone sensitive = increase in size during pregnancy and decrease after menopause - malignant transformation to leimyosarcoma is rare

question

leiomyoma - hx/PE

answer

- most cases are asymptomatic - symptoms = longer heavier periods, anemia, pelvic pressure and bloating, constipation and rectal pressure, dysmenorrhea, dyspareunia - PE: firm, nontender irregular enlarged ("lumpy bumpy") or cobblestone uterus

question

leiomyoma -tx - medical vs. surgical

answer

1. pharm: NSAIDs, OCPS, medroxyprogeterone or danazol to slow/stop bleeding, GnRH analogs to decrease size of myomas 2. surgery: - women of child bearing years -> abdominal or hysteroscpic myomectomy - women who have ocmpleted child bearing -> total or subtotal hysterectomy - uterine artery embolization (25% need further tx)

question

Type I endometrial cancer - precursor lesion? - epidemiology - etiology - mean age at diagnosis - prognosis

answer

ENDOMETROID = TYPE 1 - derived from atypical endometrial hyperplasia - most common female reproductive cancer (75% of endometroid cancers) - due to unopposed estrogen stimulation - 55 - favorable

question

Type II endometrial cancer - derived from what cell/s? - epidemiology? - etiology - precursor lesion - mean age at diagnosis - prognosis

answer

SEROUS - derived from *serous or clear cell* histology - 25% of endometiral cancer - unrelated to estrogen, p53 gene mutation is present in 90% of cases - none - 67 - poor

question

Endometrical cancer - Tx

answer

1. high dose progestins for child bearing age women 2. TAH/BSO +/- radiation for postmenopausal women 3. TAH/BSO w/adjuvant chemotherapy for advanced stage cancer

question

differential diagnosis for pre-menopausal uterine bleeding

answer

uterine fibroids, enometrial polyps, adenomyosis, endometrial hyperplasia, ovarian cysts, thyroid dysfunction

question

- upper 1/3 of cerix = ___ histology? - lower 2/3 (ectocervix) = ___ histology?

answer

- columnar cells - squamous cells

question

cervical cancer screening guidelines

answer

- beginning at age 21 q3 years w/cytology - for women age 30 to 65 years who want to lengthen the screening interval, screening with a combination of cytology and human papillomavirus (HPV) testing every 5 years.

question

ASC-US -->

answer

atypical squamous cells of undetermined significance (on cervical cytology) 1. HPV DNA testing: if negative -> repeat pap smear at 12 months, if + --> colposcopy OR 2. repeat cytology at 6 and 12 months --> if both pap smears are negative then return to routine screening, if either Pap is positive for ASC-US or higher--> colposcopy

question

ASC-H -->

answer

atypical squamous cells cannot exclude HSIL - all nonpregnant women should have colposcopy

question

LSIL (CIN I) - what to do first? - what if unsatisfacotry/no visible lesion? - if CIN 2, 3 -if no CIN 2,3 - post-menopausal women? - pregnant women?

answer

1. all women should first have colposcopy --> - if unsatisfactory or no visible lesion --> endocervical sampling - if CIN 2, 3 --> further management - if no CIN 2,3 --> repeat pap at 6 + 12 months OR HPV testing at 12 months - postmenopausal = reflex HPV DNA, colposcopy, or repeat pap smear at 6 and 12 months - defer colposcopy until 6 weeks post partum

question

AGC --> - all women? - >35?

answer

Atypical glandular cells of undetermined significance - all women should have colposcopy with endocervical sampling, and HPV testing - women >35 or abnomral bleeding should have colposcoy with endocervical AND endometrial sampling

question

HSIL - if CIN 2/3 - if no CIN 2/3 - persistent HSIL - pregnant women

answer

all non pregnant women should have colposcopy w/endocervical sampling and then proceed as follows: 1. CIN 2, 3 : excision/ablation of lesion 2. no CIN 2, 3: excision or observation w/Pap smear and colposcopy q6 months for a year OR immediate LEEP 3. persistent -> excision 4. pregnant women SHOULD have colposcopy without endocervical curretage

question

CIN I - tx - >21? - <21? - when to return to routine screening?

answer

- close observation - > 21 --> pap smear and screening at 6 and 12 months and/or HPV DNA at 12 months - *HPV TESTING IS NOT RECOMMENDED* - after 2 negative pap smears or a negative DNA test, pts can be managed w/routine annual follow up

question

persistent CIN I tx (2)

answer

> 2 years CIN I Ablation: cryotherapy or laser ablation Excision: LEEP, laser and cold knife conization

question

CIN II and III NON-INVASIVE tx

answer

- Ablation - Excision - hysterecotmy is a tx option for recurrent II or III

question

Post-ablative or excision therapy for NON-INVASIVE follow up 1. CIN I, II or III with negative margins 2. CIN I, II or III with positive margins 3. unknown margins

answer

1. pap smear at 12 months and/or HPV testing 2. pap smear at 6 months; consider repeat endocervical curretage 3. pap smear at 6 months and HPV DNA at 12 months

question

Tx of invasive disease 1. microinvasive carcinoma (Ia1) -> 2. Stages IA2, IB1, IIA --> 3. Stages IB2, IIB, III, IV -->

answer

1. cone biopsy and close follow up or simple hysterectomy 2. radical hysterectomy (the uterus, cervix, ovaries, oviducts, lymph nodes, and lymph channels are removed. w/bilateral pelvic node dissection) w/concomitant radiation + chemo or with radiation plus chemo alone 3. radiation therapy plus cisplatin-based chemo

question

cervical cancer screening for women w/hysterectomy

answer

- if done for benign reasons (bleeding, fibroids) and no hx of CIN II/III -> discontinue screening - if hx of CIN II/III --> can discontinue pap smear screening after 3 consecutive negative screening tests (prior or subsequent to hysterectomy) *if supracervical hysterectomy = must continue screening *if hx of invasive disease --> continued screening

question

80% of all cervical cancers are what cell type?

answer

SCC

question

what kind of cell accounts for the remaining 20%?

answer

adenocarcinoma (clear cell)

question

Cervical cancer - STage I = - stage II Stage III STage IV

answer

1. confined to cervix 2. extendds beyond the cervix but not to pelvic side walls or lower third of vagina 3. extends to pelvic sidewalls or lower 1/3 of vagine 4. extension beyond the pelvis, invasion into local structures (bladder, rectum, distant metastases)

question

when to stop screening for women w/ hx of CIN II/III?

answer

should have routine screening for 20 years after diagnosis or at age 65 (whichever comes LAST)

question

timing of pain in primary dysmenorrhea vs. endometrosis

answer

pain of dysmenorrhea occurs wtih ovulatory cycles on the 1st or 2nd day of menstruation pain form endometrosis may begin 1-2 days to weeks before menstruation , and worsens 1-2 days before menstruation and is relieved right after the onset of menstrual flow

question

Vaginal cancer - cell type postmenopausal women vs. younger women ? - found in what portion of the vagina?

answer

= SCC in post-menopausal, younger women have other histological types (Adeno, clear cell) - usually found in upper 1/3 of vagina

question

first step in workup of ovarian cancer?

answer

transvaginal ultrasound

question

benign vs. maligant pelvic masses -mobility - consistency -location - cul de sac

answer

1. mobile vs. fixed 2. cystic vs. solid/firm 3. unilateral vs. bilateral 4. smooth vs. nodular

question

Transvaginal ultrasound - adnexal mass benign vs. malignant 1. size 2. consistency 3. septations 4. location 5. other

answer

1. 8 cm 2. cystic vs. solid/cystic/solid 3. unilocular vs. multilocular 4. unilateral vs. bilateral 5. calcifications vs. ascites

question

tumor markers 1. epithelial 2. endodermal sinus 3. embyronal carcinoma 4. choriocarcinoma 5. dysgerminoma 6. granulosa cell

answer

1. CA-125 2. AFP 3. AFP, hCG 4. hCG 5. LDH 6. inhibin

question

tx of ovarian masses 1. pre-menarchal woman 2. pre menopausal women 3. post-menopausal women

answer

1. masses >2cm require close follow up and often surgical removal 2. observation if asymptomtic, mobil unilateral 8-10 cm and those that are complex/unchnaged on repeat pelvic exam/US 3. closlely follow w/US asymptomatic, unilateral simple cysts <5 cm w/normal CA-125, surgically evaluate palpable masses

question

Tx of ovarian cancer (3)

answer

1. surgery - staging --> TAH/BSO w/omentectomy and pelvic and para-aortic lymphadenectomy 2. post-operative chemo (routine except for women with early stage or low grade ovarian cancer) 3. radiation therapy: effective for dysgerminomas

question

Prevention in women with BRCA-1

answer

screened annually with US and CA-125 testing - prophylactic oophorectomy is reccomended by age 35 or w/completion of childbearing

question

Total incontinence - hx of urine loss? - mechanism? - tx?

answer

- uncontrolled lose at all times in all positions - loss of sphincteric efficiency (previous surgery, nerve damage, cancer infiltration), abnormal connection between urinary tract and skin (fistula) - surgery

question

Sress incontinence - hx of urine loss? - mechanism? - tx?

answer

- after increased intra-abdominal pressure - urethral sphincteric insufficiency due to laxity of pelvic floor musculature, common in multiparous women or after pelvic surgery - kegel exercises and pessary, vaginal vault suspension surgery

question

Urge incontinence - hx of urine loss? - mechanism? - tx?

answer

- strong unexpected urge to void that is unrelated to position or activity - detrusor hyperreflexia or sphincter dysfunction due to inflammatory conditions or neurogenic disorders of the bladder - anti-cholinergic medications or TCAs; behavioral training

question

Overflow incontinence - hx of urine loss? - mechanism? - tx?

answer

- chronic urinary retention - chronically distended bladder with increased intravesical pressure that just exceeds the outlet resistance, allowing a small amount of urine to dribble out - placement of urethral catheter in acute settings, tx underlying diseased, timed voiding

question

central precocious puberty - deifnition - tx

answer

EARLY activation of hypothalamic GnRH production tx = leuprolied (first line)

question

peripheral preciocious puberty - definition - tx

answer

results from GnRH independent mechaisms - tx= treat the cause

question

tx CAH

answer

glucocorticoids

question

McCune-albright syndrome - definition - tx

answer

suspected when 2/3 criteria are present: 1. Autonomous endocrine hormone excess, such as in precocious puberty 2. Polyostotic fibrous dysplasia 3. Unilateral café au lait spots anti-estrogens *tamoxifen), or estrogen synthesis blockers (ketoconazole, tetolactone)

question

first step in work up of precocious puberty

answer

determine bone age w/hand and wrist radiographs

question

1. what if bone age is within 1 year of chronological age? 2. what if bone age is >2 years of chornological age?

answer

1. puberty has not started or just begun 2. puberty started >12 months ago or puberty recently started and progressing rapidly

question

second step in work up of precocious puberty

answer

GnRH agonist (leuprolide) stimulation test

question

what if GnRH agonist (leuprolide) test is 1. positive 2. negative

answer

1. central precocious puberty ---> CNS tumor vs. constitutional precocious puberty 2. peripheral precocious puberty --> US of ovaries, gonads, adrenals --> ovarian cyst/adrenal tumor/gonadal tumor vs. exogenous estrogen/CAH

question

precocious puberty - what age?

answer

pubarche and thelarche before 7 years of age in caucasian girls and 6 years of age in african american girls

question

delayed puberty =

answer

absent or incomplete breast development by the age of 12

question

first step in the work up of a breast mass in 30

answer

US (determines solid vs. cystic) >30 --> mammography

question

breast cancer staging

answer

stage 1 = tumor size < 2 cm stage 2 = tumor size 2-5 cm stage 3 = axillary node involvement stage 4 = distant mestastasis

question

if taking emergency contraception, when can you begin OCPs?

answer

can begin taking them immediately

question

contraindications to estrogen/progesterone OCPs? (4)

answer

Contraindications to estrogen include a 1. history of thromboembolic disease 2. women who are lactating 3. women over age 35 who smoke 4. women who develop severe nausea with combined oral contraceptive pills

question

tubal ligation decreases the risk of which cancer?

answer

ovarian cancer (not breast, cervical or endometrial)

question

what decreases the efficacy of the patch in women?

answer

increased BMI

question

when would you prescribe 17-hydroxyprogesterone to a patient?

answer

if she has a history of pre-term birth (prevention of pre-term birth)

question

tx of anti-phospholipid antibody syndrome?

answer

Aspirin + Heparin (combo = 75% more effecitve than Aspirin alone)

question

which has more blood loss - medical or surgical abortion?

answer

medical

question

what medications and what procedures are used during induction of labor for second trimester abortion?

answer

prostaglandins, oxytocin, amniotomy

question

is weight gain a side effect of OCPs?

answer

NO!!!

question

does medroxyprogesterone cause weight gain?

answer

YES

question

does prophylactic c-section prevent shoulder dystocia?

answer

no

question

which type of incontinence is a/w an increased post-void residual volume?

answer

overflow incontinence = underactive detrusor muscle (neurologic disorders, diabetes or multiple sclerosis) or obstruction (postoperative or severe prolapse)

question

best surgical option for stress incontinence?

answer

The majority of GSI is due to urethral hypermobility (straining Q-tip angle >30 degrees from horizon). Some (<10%) of GSI is due to intrinsic sphincteric deficiency (ISD) of the urethra. Patients can have both hypermobility and ISD. *Retropubic urethropexy* such as tension-free vaginal tape and other sling procedures have the best five-year success rates for patients with GSI due to hypermobility.

question

which type of cyst is a/w high levels of b-hcg ?

answer

theca lutein cyst

question

what color is the fluid of theca lutein cysts?

answer

straw colored, bilateral

question

endometriomas - what is the other name for them? where do they arise from?

answer

- chocolate cysts - arise from ectopic endometrial tissue within the ovary

question

more than 75% of ovarian masses in women of reproductive age are _____ cysts

answer

functional cysts

question

what type of cyst would cause acute abdominal pain?

answer

hemorrhagic corpus luteum cyst or ruptured follicular cyst

question

classic presentation of torsed adnexa?

answer

waxing and waning pain nausea vomiting

question

primary tool for work up of ovarian cyst?

answer

pelvic ultrasound

question

management of adnexal mass in a premenarchal or post-menopausal woman?

answer

suggestive of an ovarian neoplasm rather than a funciton cyst and *surgical exploration* is warranted

question

when is investigation with MRI or surgery warranted in reproductive aged women with ovarian cysts?

answer

1. >7 cm 2. persist 3. solid or complex on US = probably not a functional cyst

question

tx of reproductive age women w/cysts <7 cm?

answer

observation w/a follow up US - most follicular cysts resolved spontaneously within 60-90 days - during this observation period patients are started on OCPs => surpress ovulation in order to prevent the formation of future cysts

question

nerves at risk of injury in hysterectomy?

answer

ilioinguinal and iliohypogastric these two nerves exit the spinal column at the 12th vertebral body and pass laterally through the psoas muscle before piercing the transversus abdominus muscle to the anterior abdominal wall. Once at the anterior superior iliac spine, the iliohypogastric nerve courses medially between the internal and external oblique muscles, becoming cutaneous 1 cm superior to the superficial inguinal ring.

question

iliohypogastric nerve ==>

answer

The iliohypogastric nerve provides cutaneous sensation to the groin and the skin overlying the pubis.

question

ilioinguinal nerve ==>

answer

the ilioinguinal nerve follows a similar, although slightly lower, course as the iliohypogastric nerve where it provides cutaneous sensation to the groin, symphysis, labium and upper inner thigh.

question

what environmental factor can increase breast pain a/w fibrocystic change?

answer

caffeine intake worsens pain

question

most important intervention for prevention HIV transmission to newborn?

answer

administration of combined anti-retroviral therapy to the mother throughout preganancy = *3 drug HAART*

question

when is c-section shown to be beneficial in HIV positive mothers?

answer

if viral load at delivery is >1000 copies --> can reduce transmission by 50% zidovuzine + c/s reduces the risk of transmission more than either intervention alone, however combination antiviral therapy is more effective than any of these strategies

question

what drug do HIV exposed infants receive after birth and for how long?

answer

Zidovudine for >6 weeks

question

endometrial biopsy is indicated for abnormal uterine bleeding in: (4)

answer

1. women >45 and all post-menopausal women 2. women age <45 with persistent symptoms or risk factors for endometrial cancer 3. unopposed estrogen exposure (obesity, PCOS) 4. prolonged amnorrhea with anovulation

question

nerves at risk of injury in hysterectomy?

answer

ilioinguinal and iliohypogastric

question

normal order of puberty?

answer

1. thelarche (breast) 2. adrenarche (hair) 3. growth spurt 4. menarche

question

what condition is danazol often used to treat? what is the MOA?

answer

Danazol exhibits hypoestrogenic, hyperandrogenic effects that cause atrophy of the endometrium, which can alleviate the symptoms of endometriosis. Danazol prevents ovulation by suppressing the increase of luteinizing hormone during the middle of the menstrual cycle. Danazol inhibits ovarian steroidogenesis resulting in decreased secretion of estradiol and may increase androgens. Danazol displaces testosterone from sex hormone-binding globulin (SHBG), displacing it and increasing serum testosterone levels. Danazol also directly stimulates androgen and progesterone receptors.

question

management of endometrial polyps

answer

Management of an endometrial polyp includes the following: observation, medical management with progestin, curettage, surgical removal (polypectomy) via hysteroscopy, and hysterectomy. Observation is not recommended if the polyp is > 1.5 cm. In women with infertility polypectomy is the treatment of choice.

question

how does hypothyroidism cause hyperprolactinemia?

answer

increased levels of thyroid-releasing hormone increase secretion of prolactin as well as thyroid-stimulating hormone (TSH)

question

what is the clomid challenge test? when is it used and what do the results mean?

answer

A clomiphene challenge test, which consists of giving clomiphene citrate days five to nine of the menstrual cycle and checking FSH levels on day three and day 10, will help determine ovarian reserve A healthy ovary will only require a small level of follicle stimulating hormone (FSH) to produce an egg; whereas, if the ovary is not functioning as well, it will require substantially higher levels of FSH to produce an egg. High levels of FSH are usually a negative indicator of fertility; however, a normal FSH doesn't guarantee egg quality. In essence, an elevated FSH is a poor indicator while a normal FSH is neutral.

question

during what phase of the cycle does PMS occur?

answer

luteal phase

question

how to confirm presence of choricarinoma lung metastases? which procedure should not be done for confirmation?

answer

b-hcg do not do biopsy because lesion is very vascular *Tissue diagnosis is the standard in establishing a diagnosis of almost all malignancies, with the exception of choriocarcinoma*

question

characteristics of cervical mucous in the OVULATORY phase of the menstrual cycle? (3)

answer

- profuse, clear, thin (as opposed to the mucus of post and pre-ovulatory phase which is scant, opaque, and thick) - will stretch to approximately 6 cm - exhibit ferning on slide smear

question

which side is more common in ovarian torsion? why?

answer

right sided torsion is more common due to the longer length of the R utero-ovarian ligament and b/c the L rectosigmoid colon occupies the space around the L ovary

question

what is the levonorgestrel pill used for? what is its MOA?

answer

plan B = emergency contraception progestin pill = delays ovulation, 85% effective

question

name 3 other forms of emergency contraception and their MOA/% effectiveness

answer

1. copper IUD - inflammatory reaction that is toxic to sperm/ova and impairs implantation - 99% effective 2. Ulipristal pill - anti-progestin = delays ovulation >85% 3. OCPs - progestion = delays ovulation, 75% effective

question

do adolescents need consent for EC?

answer

No = in most states contraception is kept confidential

question

what does no withdrawl bleeding following progestin challenge in ammenorheic patient indicate?

answer

problem with HPA - not enough estrogen = no significant bleeding because do not get build up of endometrium

question

Pagets disease of the vulva

answer

- reprsents carcinoma in situ with *no underlying carcinoma* - erythematous, pruritic, ulcerated vulvar skin

question

Indications for cervical conization include:

answer

1) unsatisfactory colposcopy, including inability to visualize the entire transformation zone 2) positive endocervical curettage 3) Pap smear indicating adenocarcinoma in situ 4) cervical biopsies that cannot rule out invasive cancer 5) a substantial discrepancy between Pap smear and biopsy results - ex: discrepancy between the HSIL Pap smear result and the normal reading on the biopsies and the ECC, the patient requires a cervical conization such as LEEP or cold knife cone.

question

uterine cancer screening for patients on tamoxifen?

answer

annual exams - do NOT do annual US because tamoxifen causes changes to the endometrium, including thickening.

question

interstitial cystitis

answer

"painful bladder syndrome" symptoms of suprapubic pelvic and/or genital area pain, dyspareunia, urinary urgency and frequency, and nocturia + *no bacteria isolated*

question

urethritis =

answer

infection of the urethra commonly caused by *c. trachomatis* (+ gonococcus) suspect in women with typical UTI symptoms yet sterile culture and no response to standard abx ==> cultures of urethra for gonoccous and chlaymydia + empiric tx for chlamydia with doxycycline

question

urethral syndrome =

answer

urgency and dyuria cuased by urethral inflammation of unknown etiology,urine culture are negative

question

timing in pregnancy allowed for abortion: 1. manual vacuum aspiration 2. suction curretage (D&C)

answer

1. up to 10 week (early preganancies) 2. 7-13 weeks

question

what is the safest of all surgical termination methods in the first trimester?

answer

suctional curretage

question

MOA of mifepristone

answer

synthetic progesterone receptor ANTAGONIST ==> blocks stimulatory effects of progesterone on endometrial growth

question

until how many weeks can medical abortion w/mifepristone + misoprostol be performed?

answer

9 weeks

question

until how many weeks can MTX be used for medical abortion?

answer

7 weeks

question

how to confirm effective of medical abortion afterwards?

answer

must follow up in 2 weeks for US and b-hcg (requires 2 visits = downside compared to surgical)

question

2 options for 2nd trimester abortions? which is the safest?

answer

1. Dilation and evacuation (D&E) = most common and safest method of termination 2. Induction of labor

question

major advantage of induction of labor vs D&E for second trimester abortion

answer

deliver an intact fetus = more comprehensive postmortem evaluation

question

how do OCPs work?

answer

induce pseudopregancy state = prevent release of FSH and LH ==> supresses ovulation and prevents preganncy form occuring

question

disadvantages of depo-provera? (3)

answer

1. irregular menstrual bleeding 2. reversible decrease in bone mineralization 3. significant delay in the return of regular ovulation (6-18 months)

question

disadvantage of nexplanon? (1)

answer

irregular and unpredictable light bleeding

question

progesterone only forms of BC (4)

answer

1. progesteron only mini pill 2. depo provera (injectable) 3. nexplanon 4. mirena IUD

question

3 forms of emergency contraception

answer

1. ECP = levonorgestrel 2. coppper IUD 3. ella (ulipristal aceta = selective progesterone receptor modulator)

question

benign cystic teratoms vs. immature teratoma vs. malignant teratoma - tissue type? - tx?

answer

- 1. benign = ectodermal derivatives (skin, hair follicles, sevaceous/sweat glands) 2. immature = all 3 germ layers + immature embryonal structures 3. malignant = immature neural elements (amount of neural tissue determines grade) - tx of benign cystic teratoma = cystectomy tx of malignant teratoms = unilateral salpingoopherectomy with wide sampling of peritoneal implants ==> combo chemo if grade 2/3

question

which type of ovarian tumor is known to grow to be very large?

answer

mucinous tumors (epithelial) ==> can rutpure intra-abdominally and cause pseuudomyoma peritonei ==> repeated bouts of bowel obstruction

question

presentation of fascial disruption at surgical wound site? tx? what condition predisposes to it?

answer

profuse drainage from the incision 5-14 days after surgery requires repair ASAP w/initiation of broad spectrum abx (surgical emergency) diabetes = a/w increased risk for fascial separation b/c it more difficult for wounds to heal

question

tx of wound evisceration

answer

evisceration = protrusion of bowel or omentum through the incision (complete separation of all layers of the wound) tx = sterile sponge wet with saline should be placed over the bowel ==> surgery and abx

question

superficial wound infection - tx?

answer

- open the wound and drain the purulence + broad spectrum abx + wet-to-dry dressing changes - --> wound can heal by secondary intention

question

endometrial tissue that floats with a "frond pattern" is almost always diagnostic for ____

answer

intrauterine pregnancy - helps rule out ruptured ectopic pregnacy (ectopic pregnancy co-existing with an intrauterine preganncy is exceeding rare)

question

when a woman presents w/signs of hemoperitoneum and ectopic is ruled out (endometrial tissue with frond pattern), what is next most likely diagnosis?

answer

rupture of hemorrhagic corpus luteum cyst - corpus luteum cysts can have intrafollicular bleeding bc of thin walled capillaries that invade the granulosa cells from the theca interna ==> when hemorrhage is excessive, the cyst can enlarge and there is an increased risk of rupture

question

when in pregnancy does corpus luteum stop producing progesterone?

answer

10 weeks

question

1. how to confirm dx of corpus luteum cyst? 2. tx?

answer

1. laparoscopy 2. secure hemostasis, once bleeding stops no further tx is required, but if bleeding conintues a cystectomy should be performed ==> if corpurs lutuem is surgically removed prior to 10-12 weeks must supplement progesterone

question

most common cause of hemoperitoneum in early pregnancy?

answer

ectopic pregnancy

question

first sign of hypovolemia?

answer

oliguria = decreased urine output

question

most common method of diagnosing intrauterine adhesions? how is diagnosed confirmed

answer

hysterosalpingogram confirmed w/hysteroscopy

question

tx for IUA?

answer

operative hysteroscopy (resection of adhesions) post-operative management = insertion of IUD or pediatric foley catheter to prevent the recently lysed adhesions from re-forming + estrogents/progesterone

question

is cervical stenosis or IUA a/w cramping pain every month?

answer

cervical stenosis - due to retrograde menses

question

chancroid

answer

- caused by haemophilus ducreyi - lesions with ragged edges, necrotis base - adenopathy

question

lymphogranuloma venereum

answer

- infeciton of lymphatics caused by C. trachomatis (L1-L3) - PAINLESS primary genital ulcers that heal spontaneously ==> - tendery lymphadenopathy ==> bubos that rupture ==> sinus tracts - rectal stricutres

Obgyn First Aid – Gynecology – Flashcards

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