Obgyn First Aid – Gynecology

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age range of thelarche
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8-11
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age range of menarche
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10-16
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Follicular phase of menstrual cycles – what days? – what hormone increased? – uterine changes?
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– 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)
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Ovulation – what day of cycle? – which hormones spike?
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– day 14 – LH and FSH spike -> rupture of ovarian follicle -> release of a mature ovum – rupture follicular cells involute and create the corpus luteum
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Luteal phase – what days? – what hormone is increased? – uterine changes?
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– 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
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premature menopauses = < age ___
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40
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hormonal changes in menopause lipid profile in menopause
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– first increased FSH, then increased LH – increased total cholesterol, decreased HDL
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non-HRT Menopause tx (3)
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– SSRI/SNRIs, clonidine, and/or gabapentin
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Primary amenorrhea – definition
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Absence of menses by age 16 with secondary sexual development presentation, or the absence of secondary sexual characteristics by age 14
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Amenorrhea + Absence of secondary sexual characteristics – due to? – etiologies?
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– 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)
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Amenorrhea + presence of secondary sexual characteristics? – etiologies (3)
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estrogen production but other anatomic/genetic problems 1. Mullerian agenesis 2. imperforate hymen 3. complete androgen insensitivity
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Diagnosis of primary amenorrhea
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1. pregnancy gest 2. bone radiograph to determine if bone age is consistent w/pubertal onset 3. ultrasound to evaluate the ovaries
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primary amenorrhea – what to do if bone age is >12 years but there is no sign of puberty?
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obtain LH/FSH levels and consider where the problem is on the HPA axis
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primary amenorrhea – what to do if bone age is <12 years but there is no sign of puberty?
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if pt is of short stature w/normal growth velocity = constitutional growth delay
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primary amenorrhea – what to do if normal breast development and no uterus?
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obtain a karyotype to evaluate for androgen insensitivity (XY)
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primary amenorrhea – what to do if normal breast development and uterus?
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measure prolactin and obtain an MRI to assess the pituitary gland
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tx of hypogonadism
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begin HRT with estrogen alone at the lowest dose ==> 12-18 months later begin cyclic estrogen/progesterone therapy (if uterus is present)
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contraindications to estrogen containing hormonal methods
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pregnancy hx of stroke/DVT breast cancer undiagnosed abnormal vaginal bleeding estrogen dependent cancer benign/malignant liver neoplasm current tobacco use and age >35
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Secondary amenorrhea
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absence of menses for 6 consectutive months in owmen who have passed menarche
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2ndary amenorrhea – dx (3)
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1. pregnancy test 2. if negative ==> measure TSH and prolactin 3. initiate progestin challenge
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Progestin challenge – positive vs. negative work up
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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
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2ndary ammenorhea – what to do if clinical virilization is present?
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– measure testosterone, DHEAS, and 17-hydroxyprogesterone
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tx of premaure ovarian failure (age <40)
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if uterus present, tx with estrogen plus progestin replacement therapy
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morning after pill – 3 options/effectiveness?
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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
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oligomenorrhea
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increased length of time between menses (35-90 days)
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polymenorrhea
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frequent menstruation (<21 day cycle); anovular
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menorrhagia
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increased amount of flow >80 ml of blood loss per cycle or prolonged bleeding (flow >8days)
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metorrhagia
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bleeding between periods
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menometrorrhagia
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excessive and irregular bleeding
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When to perform endometrial biopsy for abnormal uterine bleeding?
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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)
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what is the most common cause of abnormal uterine bleeding and ammenorrhea?
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pregnancy
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tx of heavy bleeding
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high dose estrogen IV –> stops bleeding in an hour if bleeding not controlled within 12-24 hrs –> D&C indicated
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tx ovulatory bleeding
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NSAIDs to decreased blood loss, OCPs, Mirena IUD
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Tx anovulatory bleeding (4)
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– Progestins x10 days – Desmopressin to increase vWF and F VIII – OCPs – Mirena IUD
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what to do if medical management of abnormal uterine bleeding fails?
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1. D&C 2. Hysteroscopy – identify endometrial pollyps, biopsies 3. Hysterectomy or endometrial ablation
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enometriosis – definition -history/PE – diagnosis
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– 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)
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endometriosis – tx (3) – complicaitons
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– 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
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adenomyosis – definition – history/pe (triad) – diagnosis
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– 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
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adenomyosis – tx – complications
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– 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
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tx of congenital adrenal hyperplasia
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– Glucocorticoids (prednisone)
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hormonal imbalances in PCOS
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– increased testosterone – Increased LH>FSH ration (>2:1) – increased estrogen (aromatization)
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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)
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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
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Tx 1. asymptomatic cysts of bartholin’s duct 2. abscess of bartholin’s duct
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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*
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Normal vaginal secrtions 1: midcycle estrogen surge: 2. luteal phase/pregnancy:
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1. clear, elastic, mucoid secretions 2. thick and white secretions, adhere to vaginal wall
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Criteria for BV (4)
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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
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Trichomonas – history – exam – discharge – wet mount – tx
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– 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*
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complications of BV and trichomonas
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chorioamionitis/endometrisis, infection, preterm delivery, miscarriage PID
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Cervicitis – etiologies (infectious vs. noninfectious) – hx/ PE – dx/tx
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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
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PID – hx/PE
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– lower abdominal pain, fever/chills, menstrual disturbances, purulent cervical discharge – cervical motion tenerness (chandelier sign) and adnexal tenderness also seen
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PID – dx criteria
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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
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what does a WBC >100,000 mean for PID?
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has a poor positive and negative predictive value
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PID – tx (outpatient vs. inpatient regimens)
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– 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
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when to drain tubo-ovarian/pelvic abscess?
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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
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chandelier sign
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severe cervical motion tenderness that makes the patient jump for the chandelier on exam
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Toxic shock syndrome – hx/PE
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– 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
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Toxic shock syndrome – Dx (blood cultures?) – Tx (3)
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– 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
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Uterine leiomyoma – benign or malignant? – responsive to what hormones? relationship to menopause? – malignant transformation?
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– 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
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leiomyoma – hx/PE
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– 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
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leiomyoma -tx – medical vs. surgical
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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)
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Type I endometrial cancer – precursor lesion? – epidemiology – etiology – mean age at diagnosis – prognosis
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ENDOMETROID = TYPE 1 – derived from atypical endometrial hyperplasia – most common female reproductive cancer (75% of endometroid cancers) – due to unopposed estrogen stimulation – 55 – favorable
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Type II endometrial cancer – derived from what cell/s? – epidemiology? – etiology – precursor lesion – mean age at diagnosis – prognosis
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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
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Endometrical cancer – Tx
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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
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differential diagnosis for pre-menopausal uterine bleeding
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uterine fibroids, enometrial polyps, adenomyosis, endometrial hyperplasia, ovarian cysts, thyroid dysfunction
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– upper 1/3 of cerix = ___ histology? – lower 2/3 (ectocervix) = ___ histology?
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– columnar cells – squamous cells
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cervical cancer screening guidelines
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– 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.
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ASC-US –>
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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
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ASC-H –>
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atypical squamous cells cannot exclude HSIL – all nonpregnant women should have colposcopy
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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?
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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
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AGC –> – all women? – >35?
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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
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HSIL – if CIN 2/3 – if no CIN 2/3 – persistent HSIL – pregnant women
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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
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CIN I – tx – >21? – <21? – when to return to routine screening?
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– 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
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persistent CIN I tx (2)
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> 2 years CIN I Ablation: cryotherapy or laser ablation Excision: LEEP, laser and cold knife conization
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CIN II and III NON-INVASIVE tx
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– Ablation – Excision – hysterecotmy is a tx option for recurrent II or III
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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
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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
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Tx of invasive disease 1. microinvasive carcinoma (Ia1) -> 2. Stages IA2, IB1, IIA –> 3. Stages IB2, IIB, III, IV –>
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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
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cervical cancer screening for women w/hysterectomy
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– 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
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80% of all cervical cancers are what cell type?
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SCC
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what kind of cell accounts for the remaining 20%?
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adenocarcinoma (clear cell)
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Cervical cancer – STage I = – stage II Stage III STage IV
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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)
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when to stop screening for women w/ hx of CIN II/III?
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should have routine screening for 20 years after diagnosis or at age 65 (whichever comes LAST)
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timing of pain in primary dysmenorrhea vs. endometrosis
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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
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Vaginal cancer – cell type postmenopausal women vs. younger women ? – found in what portion of the vagina?
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= SCC in post-menopausal, younger women have other histological types (Adeno, clear cell) – usually found in upper 1/3 of vagina
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first step in workup of ovarian cancer?
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transvaginal ultrasound
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benign vs. maligant pelvic masses -mobility – consistency -location – cul de sac
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1. mobile vs. fixed 2. cystic vs. solid/firm 3. unilateral vs. bilateral 4. smooth vs. nodular
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Transvaginal ultrasound – adnexal mass benign vs. malignant 1. size 2. consistency 3. septations 4. location 5. other
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1. 8 cm 2. cystic vs. solid/cystic/solid 3. unilocular vs. multilocular 4. unilateral vs. bilateral 5. calcifications vs. ascites
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tumor markers 1. epithelial 2. endodermal sinus 3. embyronal carcinoma 4. choriocarcinoma 5. dysgerminoma 6. granulosa cell
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1. CA-125 2. AFP 3. AFP, hCG 4. hCG 5. LDH 6. inhibin
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tx of ovarian masses 1. pre-menarchal woman 2. pre menopausal women 3. post-menopausal women
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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
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Tx of ovarian cancer (3)
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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
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Prevention in women with BRCA-1
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screened annually with US and CA-125 testing – prophylactic oophorectomy is reccomended by age 35 or w/completion of childbearing
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Total incontinence – hx of urine loss? – mechanism? – tx?
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– 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
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Sress incontinence – hx of urine loss? – mechanism? – tx?
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– 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
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Urge incontinence – hx of urine loss? – mechanism? – tx?
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– 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
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Overflow incontinence – hx of urine loss? – mechanism? – tx?
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– 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
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central precocious puberty – deifnition – tx
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EARLY activation of hypothalamic GnRH production tx = leuprolied (first line)
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peripheral preciocious puberty – definition – tx
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results from GnRH independent mechaisms – tx= treat the cause
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tx CAH
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glucocorticoids
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McCune-albright syndrome – definition – tx
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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)
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first step in work up of precocious puberty
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determine bone age w/hand and wrist radiographs
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1. what if bone age is within 1 year of chronological age? 2. what if bone age is >2 years of chornological age?
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1. puberty has not started or just begun 2. puberty started >12 months ago or puberty recently started and progressing rapidly
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second step in work up of precocious puberty
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GnRH agonist (leuprolide) stimulation test
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what if GnRH agonist (leuprolide) test is 1. positive 2. negative
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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
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precocious puberty – what age?
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pubarche and thelarche before 7 years of age in caucasian girls and 6 years of age in african american girls
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delayed puberty =
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absent or incomplete breast development by the age of 12
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first step in the work up of a breast mass in 30
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US (determines solid vs. cystic) >30 –> mammography
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breast cancer staging
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stage 1 = tumor size < 2 cm stage 2 = tumor size 2-5 cm stage 3 = axillary node involvement stage 4 = distant mestastasis
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if taking emergency contraception, when can you begin OCPs?
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can begin taking them immediately
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contraindications to estrogen/progesterone OCPs? (4)
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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
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tubal ligation decreases the risk of which cancer?
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ovarian cancer (not breast, cervical or endometrial)
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what decreases the efficacy of the patch in women?
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increased BMI
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when would you prescribe 17-hydroxyprogesterone to a patient?
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if she has a history of pre-term birth (prevention of pre-term birth)
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tx of anti-phospholipid antibody syndrome?
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Aspirin + Heparin (combo = 75% more effecitve than Aspirin alone)
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which has more blood loss – medical or surgical abortion?
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medical
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what medications and what procedures are used during induction of labor for second trimester abortion?
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prostaglandins, oxytocin, amniotomy
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is weight gain a side effect of OCPs?
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NO!!!
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does medroxyprogesterone cause weight gain?
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YES
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does prophylactic c-section prevent shoulder dystocia?
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no
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which type of incontinence is a/w an increased post-void residual volume?
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overflow incontinence = underactive detrusor muscle (neurologic disorders, diabetes or multiple sclerosis) or obstruction (postoperative or severe prolapse)
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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.
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which type of cyst is a/w high levels of b-hcg ?
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theca lutein cyst
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what color is the fluid of theca lutein cysts?
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straw colored, bilateral
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endometriomas – what is the other name for them? where do they arise from?
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– chocolate cysts – arise from ectopic endometrial tissue within the ovary
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more than 75% of ovarian masses in women of reproductive age are _____ cysts
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functional cysts
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what type of cyst would cause acute abdominal pain?
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hemorrhagic corpus luteum cyst or ruptured follicular cyst
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classic presentation of torsed adnexa?
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waxing and waning pain nausea vomiting
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primary tool for work up of ovarian cyst?
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pelvic ultrasound
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management of adnexal mass in a premenarchal or post-menopausal woman?
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suggestive of an ovarian neoplasm rather than a funciton cyst and *surgical exploration* is warranted
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when is investigation with MRI or surgery warranted in reproductive aged women with ovarian cysts?
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1. >7 cm 2. persist 3. solid or complex on US = probably not a functional cyst
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tx of reproductive age women w/cysts <7 cm?
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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
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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.
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iliohypogastric nerve ==>
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The iliohypogastric nerve provides cutaneous sensation to the groin and the skin overlying the pubis.
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ilioinguinal nerve ==>
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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.
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what environmental factor can increase breast pain a/w fibrocystic change?
answer

caffeine intake worsens pain
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most important intervention for prevention HIV transmission to newborn?
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administration of combined anti-retroviral therapy to the mother throughout preganancy = *3 drug HAART*
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when is c-section shown to be beneficial in HIV positive mothers?
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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
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what drug do HIV exposed infants receive after birth and for how long?
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Zidovudine for >6 weeks
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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
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nerves at risk of injury in hysterectomy?
answer

ilioinguinal and iliohypogastric
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normal order of puberty?
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1. thelarche (breast) 2. adrenarche (hair) 3. growth spurt 4. menarche
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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.
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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.
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how does hypothyroidism cause hyperprolactinemia?
answer

increased levels of thyroid-releasing hormone increase secretion of prolactin as well as thyroid-stimulating hormone (TSH)
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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.
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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
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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
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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?
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problem with HPA – not enough estrogen = no significant bleeding because do not get build up of endometrium
question

Pagets disease of the vulva
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– 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.
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uterine cancer screening for patients on tamoxifen?
answer

annual exams – do NOT do annual US because tamoxifen causes changes to the endometrium, including thickening.
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interstitial cystitis
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“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
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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
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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
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until how many weeks can medical abortion w/mifepristone + misoprostol be performed?
answer

9 weeks
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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
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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

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