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131 Cards in this Set
- Front
- Back
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Atypical glandular cells < 35 yo w/ no endometrial cancer risk factors
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colposcopy
endocervical curettage HPV DNA testing |
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Atypical glandular cells > 35 yo, positive endometrial cancer factors
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colposcopy
endocervical curettage HPV DNA testing endometrial biopsy |
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Atypical squamous cells of undetermined significance 21 yo or younger (ASC-US)
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Repeat pap smear at 12 months
If Pap smear negaive or ASC-US or LSIL, repeat at 12 months |
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Atypical squamous cells of undetermined significance over 21 years of age
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Immediate colposcopy
HPV DNA testing Repeat Pap smear at 6 months |
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Low grade squamous intraepithelial lesions (LSIL) less than 21 years of age
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Repeat pap smear at 12 months
If Pap smear negaive or ASC-US or LSIL, repeat at 12 months |
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Low grade squamous intraepithelial lesions (LSIL) greater than 21 years of age
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immediate colposcopy
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High grade squamous squamous epithelial lesions (HSIL) or atipical squamous cells suspicious of high-grade dysplasia (ASC-H)
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immediate colposcopy for all age groups
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If colposcopy unsatisfactory
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Perform endocervical curettage and cervical biopsy
Treat based on findings |
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Menopause
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HAVOC
Hot flashes atrophy of the vagina osteoporosis coronary artery disease |
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Menopause treatment
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Hormone replacement therapy
- however, increases the risk of breast and endometrial cancer, and cardiovascular morbidity |
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Vaginal atrophy tx
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long term: estradiol ring
short term: estrogen vaginal cream |
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Contraindications to estrogen containing contraception
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pregnancy
hx of CAD or DVT breast cancer undiagnosed abnormal vaginal bleeding estrogen dependent cancer benign/malignant liver neoplasm current tobacco use age >35 |
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COntraindications to Mirena and Copper T IUDs
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known/suspected pregnancy
unexplained vaginal bleeding current purulent cervicitis active/recurrent PID actinomycosis bicornuate or septate uterus uterine/cervical cancer pap smear w/ squamous intraepithelial lesions or two atypical Pap smeas hx of heart valve replacement or artificial joints |
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Rape/Sexual abuse managemnet
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saline prep for sperm
gonorrhea/chlamydia smear/culture Serological testing: HIV, syphilis, HSV, HBV, and CMV Serum pregnancy test Blood alcohol, urine toxicology |
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Infectious vulvovaginitis
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when in kids, stds, then report to child protective services
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Candida vaginal discharge
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may be associated w/ diabetes; measure glucose and/or check for glucosuria
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Sarcoma botryoides (rhabdomyosarcoma)
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"bunch of grapes" within the vagina
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Precocious puberty workup
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1. radiograph of wrist/hand to determine bone age
- if w/in one year, puberty not started or just begun - if exceeds by 2 years, puberty present at least one year, or rapidly progressing --> then check for: GnRH (leuprolide) stimulation test: - If LH +, then central prcocious puberty - If LH -, then peripheral precocious puberty, then do following: - ultrasound of ovaries and adrenals - estradiol (increased in ovarian cysts/tumors) - Androgens - 17-OH progesterone |
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Causes of central precocious puberty
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constitutional (idiopathic)
hypothalamic lesions (hamartomas, tumors, congenital malformations) Dysgerminomas Hydrocephalus CNS infections CNS trauma/irradiation Pineal tumors Neurofibromatosis Tuberous sclerosis |
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Causes of peripheral precocious puberty
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Congenital Adrenal Hyperplasia
Adrenal tumors McCune Albright Syndrome (polyostic fibrous dysplasia) Gonadal tumors Exogenous estrogen, OCP's) Ovarian cysts |
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treatment of central precocious puberty
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leuprolide
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treatment of peripheral precocious puberty
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ovarian cysts: regresses spontaneously
CAH: glucocorticoids Adrean or ovarian tumors: resection McCune Albright: antiestrogens (tamoxifen) or estrogen synthesis blockers (ketoconazole or testolactone) |
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Diagnosis of Amenorrhea
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1. Pregnancy test, if -,
2. radiograph for bone age - if normal growth velocity, then constitutional growth delay - if bone age > 12, but no puberty, then amenorrhea, next step 3. look at LH/FSH ratio and compare to GnRH and estrogen/progesterone |
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decreased GnRH
decreased LH/FSH decreased estrogen/progesterone |
hypogonadotropic hypogonadism
hypothalamic or pituitary problem |
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increased GnRH
increased FSH/LH decreased estrogen/progesterone |
hypergonatodropic hypogonadism
ovaries fail to produce estrogen |
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increased GnRH
increased FSH/LH hgh estrogen or progesterone |
PCOS or problem w/ estrogen receptors
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normal pubertal hormones
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suggests anatomic problem
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normal breast development and no uterus
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obtain karyotype to work up androgen insensitivity syndrome
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Normal breast development and uterus
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measure prolactin and get cranial MRI
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Treatment for constitutional growth delay
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no treatment needed
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hypogonadism tx
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hrt w/ estrogen alone at previous dose
12-18 months later, begin cyclic estrogen/progesterone |
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anatomic amenorrhea
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surgery
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secondary amenorrhea
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absence of menses for 6 consecutive months in women who have passed menarche
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secondary amenorrhea workup
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1. pregnancy test
2. if negative beta-hcg: measure TSH and prolactin - if elevated TSH: hypothyroidism - if elevated prolactin (inhibits LH/FSH release), points to thyroid pathology - severely elevated prolactin, prolactin secreting pituitary adenoma 3. If normal beta-HCG: progestin challenge - if + (withdrawal bleeding): anovulation due to noncyclic gonadotropin secretion - PCOS or idiopathic ovulation --> if LH high, PCOS - if no bleed, uterine or estrogen abnormality, so check FSH - elevated FSH: hypergonadotropic gonadism / ovarian failure - decreased FSH: cyclic estrogen/progesterone test. - if withdrawal bleeding, hypogonadotropic hypogonadism - if no withdrawal of bleeding, endometrial or anatomic problem |
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secondary amenorrhea nd hyperglycemia or hypotension
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dexamethasone test
- determine if CAH, Cushings, or Addisons |
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secondary amenorrhea and virilization
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mild: PCOS, CAH, Cushings
moderate - severe: ovarian or adrenal tumor |
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primary dysmenorrhea
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menstrual pain associated w/ ovulatory cycles in teh absence of pathological findings
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primary dysmenorrhea dx
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diagnosis of exclusion, rule out secondary dysmenorrhea
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primary dysmenorrhea tx
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NSAIDs, topical heat thearpy, combined OCP's, Mirena IUD
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secondary dysmenorrhea
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orgnic cause: endometriosis, adenomyosis, tumors, fibroids, adhesions, polyps, PID
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secondary dysmenorrhea dx
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1. beta-hCG to r/o ectopic pregnancy
2. order following: - CBC to r/o infection/neoplasm - UA to r/o UTI - gonococcal/chlamydial swabs to r/o STDs/PID - stool guiac to r/o GI pathology 3. look for pelvic pathology causing pain |
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Endometriosis
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functional endometrial glands/stroma outside uterus
cyclical pain and/or rectal pain and dyspareunia |
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Endometriosis dx
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laparoscopy
blue-black or dark brown appearance ovaries may have endometriomas (chocolate cysts) |
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Endometriosis tx
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1. inhibit ovulation w/ either OCP's, leuprolide, or danazol
2. conservative surgical treatment 3. definitive: TAH/BSO +/- lysis of adhesions |
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Adenomyosis
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Endometrial tissue IN myometrium of utuerus
noncyclical pain, menorrhagia, enlarged uterus dx: ultrasound useful but can't distinguish lyiomyoma and adenomyiosis -- only MRI can but it is costly |
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Adenomyosis tx
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1. NSAIDs fist line
2. OCP's or progestins can be added 3. Endometrial ablation or resection using hysteroscopy 4. definitive: hysterectomy |
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Endometriosis complication
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infertility
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Adenomyosis complication
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rarely, can progress to endometrial cancer
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Menorrhagia
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increasing amount of flow or prolonged bleeding; may lead to anemia
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Oligomenorrhea
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an increase in lenth of time btw menses (35 - 90)
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Polymenorrhea
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Frequent menstruations (< 21 day cycle); anovular
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Metrorrhagi
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bleedin between periods
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Menometrorrhagia
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excessive and irregular bleeding
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abnormal uterine bleeding diagnosis
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1. obtain beta-hcg to r/o ectopic pregnancy
2. order cbc to r/o anemia 3. pap smear to r/o cervical cancer 4. tft to r/o thyroid, pt, ptt, bleeding time to r/o bleeding disorders 5. ultrasound to look at ovaries, uterus and endometrium 6. if endometrium > 4 mm in postmenopausal, do biopsy |
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Treatment of heavy bleeding
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1. high dose IV estrogen stabilizes endometrial lining and stops it in one hr
2. then if not controlled in 12-24 hrs, D&C |
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Treatment of ovulatory bleeding
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1. NSAIDs to decrease blood loss
2. if hemodynamically stable, treat w/ OCP or Mirena IUD to thicken endometrium and control bleeding |
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Treatment of anovulatory bleeding
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convert proliferative endometrium to secretory endometrium
1. progestin to stimulate withdrawal bleeding 2. younger patients w/ bleeding disorder, try desmopressin followed by vwf adn VIII |
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if medical management fails for abnormal uterine bleeding...
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1. D&C
2. Hysteroscopy 3. Hysterectomy or endometrial ablation |
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Congenital Adrenal Hyperplasia
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increased androgens, testosterone, DHEAS, and 17-OH progesterone levels
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Tx of CAH
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glucocorticoids and mineralocorticoids
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Polycystic Ovarian Syndrome
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two of three criteria:
1. polycystic ovaries 2. oligo-/anovulation 3. clinical or biochemical evidence of hyperadnrogenism |
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PCOS dx
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1. increased testosterone
2. r/o w/ tsh, prolactin, 17-OH progesterone, cushings w/ 24 hr cortisol |
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PCOS tx
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if not attempting to conceive: combination of OCP's, progestins, metformin
if attempting to conceive: clomiphene +/- metformin |
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Treatments for male infertility
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hormonal deficiency
intrauterine insemination donor insemination in vitro fertilization intracytoplasmic sperm injection |
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induction of ovulation
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clomiphene
gonadotropins pulsatile GnRH |
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bacterial vaginosis
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grayish-white discharge
Fishy odor Clue cells Tx: metronidazole or clindamycin |
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Trichomonas vaginosis
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yellow-green frothy discharge, pruritus dysuria
flagellated organisms Tx: PO metronidazole or tinidazole - treat partners and test for other STDs |
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Candida vaginosis
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risk factors: DM, broad spectrum abx, pregnancy, steroids
pruritus,dysuria, burning thick, white, curdy texture w/o odor KOH: hyphae Tx: topical azole or PO fluconazole |
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Pelvic Inflammatory Disease
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infection of upper genital tract associated w/ gonorrhoeae or chlamydia and anaerobes
cervical motion tenderness |
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PID workup
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1. order beta-hCG and ultrasound to r/o pregnancy and evaluate for tubo-ovarian abscess
U/S: - thickening or dilation of fallopian tubes fluid in cul-de sac multicystic ovary tubo-ovarian abscess |
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PID tx
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1. immediate abx
2. outpatient regimens a: ofloxacin or levofloxacin x 14 days +/- metronidazole x 14 days b: ceftriaxone IM x 1 dose or cefoxitin + probenicid + doxycyclin x 14 days +/- metronidazole x 14 days inpatient: cefoxitin or cefotetan + doxycyclin x 14 days - clindamycin + gentamicin x 14 days |
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Indications for PID surgery
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drainage of tubo-ovarian/pelvic abscess:
is mass persists after abx, abscess is > 4-6 cm, mass in cul-de-sac in midline if patient deteriorates: exploratory lab, may need TAH/BSO w/ lysis of adhesions |
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Uterine leiomyoma (fibroids)
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benign neoplasm of female genital tract; but may cause infertility or menorrhagia, or pain
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Uterine Fibroid dx
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1. cbc - look for anemia
2. ultrasound - look for uterine myomas; exclude ovarian masses 3. MRI: delineate intramural and submucous myomas |
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Uterine fibroid tx
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1. NSAIDs
2. combined hormonal contraception 3. leuprolide or naferlin (GnRH analogs) to decrease size of myomas, suppress further growth, and decrese surrounding vascularity |
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Uterine fibroid surgery
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childbearin years: myomectomy or hysteroscopy w/ leiomyoma resection
completed childbearing: total or subtotal abdominal or vaginal hysterectomy Uterine artery embolization |
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If uterine mass continues to grow after menopause...
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malignancy must be ruled out w/ a biopsy
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Type I endometrial cancer
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Endometroid
3/4 of endometrial cancers d/t unopposed estrogen stimulation (e.g., tamoxifen, exogenous estrogen-only therapy) precursor is hyperplasia or atypical hyerplasia favorable outcome |
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Type I endometrial cancer tx
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high dose progestins for women of childbearing age; TAH/BSO +/- radiation for postmenopausal women
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Type II endometrial cancer
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Serous
1/4 or endometrial cancers Unrelated to estrogen; p53 mutation in 90% cases No precursor lesion Poor prognosis |
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Type II endometrial cancer tx
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TAH/BSO w/ adjuvant chemotherapy for advanced stage cancer
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HPV screening
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starting at age 21 or no more than three years after becoming sexually active, women should have a pap smear w/ conventional cervical cytology annually
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CIN I tx
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close observation
if > 21 yaers old: pap smear screening at 6 and 12 mo and/or HPV testing at 12 mo indicated If < 21, HPV testing not recommended After two negative pap smears or a negative DNA test, patients can be managed routinely Persistent CIN I can be treated w/ ablative or excisional therapy (LEEP) |
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CIN II and III tx
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treat w/ ablative (cryotherapy or laser ablation) or excisional therapy (LEEP; laser and cold-knife conization)
hysterectomy a treatment option |
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post-ablative or excisional therapy follow up for CIN II and III
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CIN I, II, or III w/ negative margins: pap smear at 12 mo and/or HPV testing
CIN II or III w/ positive margins: pap smear at 6 mo CIN III or III w/ unknown margins, pap smear at 6 mo and HPV DNA testing at 12 mo |
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Invasive CIN tx
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Miroinvasive carcinoma (IA1): cone biopsy and close f/u or simple hysterectomy
IA2, IB1, and IIA: radical hysterectomy and concomitant radiation and chemotherapy or w/ radiation + chemotherapy alone IB2, IIB, III, IV: radiation therapy + cisplatin based chemothrapy |
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Vulvar cancer
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like cervical cancer, risks icnlude HPV 16, 18, 31
lesions early appear white, pigmented, raised, thickened, nodular, or uclerative lesions late appear large, cauliflower-like, or hard ulcerated area in the vulva |
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Vulvar cancer dx
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1. vulvar punch biopsy
2. VIN I and II: associated w/ mild and moderate dysplasia 3. VIN III: carcinoma in situ |
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Vulvar Cancer Treatment
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precancerous: reduce predisposing factors
high grade: topical chemotherapy, laser ablation, wide local excision, skinning Invasive: radical vulvectomy and regional lympadenectomy or wide local excision |
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Vaginal cancer
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abnormal vaginal bleeding, abnormal discharge, postcoital bleeding
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Vginal discharge dx
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cytology
colposcopy biopsy |
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Vaginal discharge tx
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1. local excision of involved areas when they are few and small
2. extensive involvement of vaginal mucosa may require partial or complete vaginectomy 3. invasive disease requires radiation therapy or radical surgery |
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Lynch II syndrome
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hereditary nonpolyposis colorectal cancer; associated w/ increased risk of colon, ovarian, endometrial, and breast cancer
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Ovarian cancer Dx
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increased CA-125
- may be benign disease in premenopausal women - higher likelihood of malignancy in postmenopausal women Screen high-risk women w/ ultrasound |
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Treatment of ovarian masses
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Premenarchal women: masses > 2 cm require exploratory laparotomy
Premenopausal women: observe for 3-6 weeks for asymptomatic mobile unilateral cystic masses < 8-10 cm. most resolve spontaneously if > 8-10 cm, surgical evaluation Postmenopausal women: if asymptomatic and under 5 cm w/ normal CA-125, follow closely w/ ultrasound Palpable masses warrant surgical evaluation by exploratory laparotomy |
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Treatment of ovarian cancer
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surgery staging followed by TAH/BSO w/ omentectomy and pelvic and para-aortic lympadenectomy
postoperative chemotherapy for early-stage or low-grade ovarian cancer |
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Frequency of female genital tract cancers
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endometrail > ovarian > cervical
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Deaths in female genital cancers
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ovarian > endometrial > cervical
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Ovarian cancer prevention
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oral contraceptives decrease risk
women w/ BRCA1 gene mutation should be screened annually w/ ultrasound and CA-125 testing - prophylactic oophorectomy is recommended by age 25, or when childbearin is completed |
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Pelvic organ prolapse
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sensation of bulge or protrusion in vagina
Tx: high fiber diet, weight reduction, pessaries to reduce prolapse most common surgical procedure is vaginal or abominal hysterectomy w/ vaginal vault suspension |
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Fibrocystic change
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most common benign breast condition
cyclic bilateral mastalgia and swelling, most prominent just before menstruation irregular, bumpy consistency to breast tissue |
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Fibrocystic change tx
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dietary modifications (caffeine restriction)
danazol for severe pain, but rarely used consider OCPs, which decrease hormonal fluctuations |
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Most common cause of bloody nipple discharge
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Intraductal papilloma
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Breast mass
under 35 yo no family history movable fluctuant, change w/ cycle |
1 fine needle aspiration
2. if solid, cytology - if malignant treat - if benign/inconclusive, repeat FNA or open surgical biopsy 3. if cyst, - if clear fluid and mass disappears, f/u monthly x3 - if residual mass or thickening, excisional biopsy - bloody fluid, excisional biopsy |
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Breast mass
over 35 yo family history firm, rigid skin changes |
mamography, followed by core or excisional biopsy
- if DCIS/cancer, treat as indicated - if negative, reassure and routine followup |
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Fibroadenoma
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most common breast lesion < 30 yo
round ovoid, rubbery, discrete, relatively mobile, nontender mass 1-3 cm diameter do not change during menstrual cycle, and does not occur after menopause unless patient on HRT |
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Fibroadenoma dx
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breast ultrasound - differentiates cystic from solid masses
needle biopsy or FNA Excision w/ pathologic exam if diagnosis uncertain |
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Fibroadenoma Tx
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excision is curative, but recurrence is uncommon
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location of breast cancers
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60% in upper outer quadrant
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risk factors for breast cancers
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female
older personal hx w/ breast cancer breast cancer in first degree relative BRCA1 and BRCA2 mutations high fat low fiber diet hx of fibrocystic change w/ cellular atypia increased exopsure to estrogen (nulliparity, early meanarche, late menopause, first full term pregnancy after 35) |
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Early findings in breast cncer
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single, nontender, firm mass w/ ill-defined margins or mammographic abnormaliites w/ no palpable mass
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later findings in breast cancer
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skin or nipple retraction, axillary lymphadenopathy, breast enlargement,redness, edema, pain, fixation of mass to skin or chest wall
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breast cancer late findings
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ulceration, supraclavicular lmphadenopathy
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paget's disease of nipple
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prolonged unilateral scaling erosion of nipple w/ or w/o discharge
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metastatic disease of breast
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back or bone pain, jaundice, weight loss
firm or hard axillary node > 1 cm axillary nodes matted or fixed to skin (stage III); ipsilateral supraclavicular or infraclavicular nodes (stage IV) |
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breast cancer diagnosis in postmenopausal women
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1. mammography - microcalcifications and irregular borders
mammography detects lesions two years before they become clinically palpable |
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breast cancer diagnosis in premenopausal women
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< 30: ultrasound - diffx solid and cystic mass
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Tumor markers for recurrent breast cancer
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CEA
CA 15-3 CA 27-29 |
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Breast Cancer Treatment hormone receptor +
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tamoxifen
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Breast Cancer Treatment estrogen receptor negative
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chemotherapy
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Breast Cancer Treatment
HER2/neu expression |
Trastuzumab
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Breast Cancer Treatment Surgical options
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1. partial mastectomy plus axillary dissection
followed by radiation therapy 2. modified radical mastectomy (total mastectomy plus axillary dissection) |
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Contraindications to breast conserving therapy
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large tumor size
subareolar location multifocal tumors fixation to chest wall involvement of nipple or overlying skin |
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Stage IV Breast Cancer treatment
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radiaotherapy, and hormonal therapy
mastectomy only for local symptom control |
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Most reliable indicator for breast cancer prognosis
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TNM I-IV staging
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Breast Cancer Stage I
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< 2 cm
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Breast Cancer Stage II
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2-5 cm
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Breast Cancer Stage III
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Axillary node involvement
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Breast Cancer Stage IV
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Distant metastasis
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ER and PR positive breast cancer prognosis
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good
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Complications in preast cancer
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pleural effusion in 50% metastatic breast cancer
edema of the arm |
