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131 Cards in this Set

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Atypical glandular cells < 35 yo w/ no endometrial cancer risk factors
colposcopy
endocervical curettage
HPV DNA testing
Atypical glandular cells > 35 yo, positive endometrial cancer factors
colposcopy
endocervical curettage
HPV DNA testing
endometrial biopsy
Atypical squamous cells of undetermined significance 21 yo or younger (ASC-US)
Repeat pap smear at 12 months

If Pap smear negaive or ASC-US or LSIL, repeat at 12 months
Atypical squamous cells of undetermined significance over 21 years of age
Immediate colposcopy
HPV DNA testing
Repeat Pap smear at 6 months
Low grade squamous intraepithelial lesions (LSIL) less than 21 years of age
Repeat pap smear at 12 months

If Pap smear negaive or ASC-US or LSIL, repeat at 12 months
Low grade squamous intraepithelial lesions (LSIL) greater than 21 years of age
immediate colposcopy
High grade squamous squamous epithelial lesions (HSIL) or atipical squamous cells suspicious of high-grade dysplasia (ASC-H)
immediate colposcopy for all age groups
If colposcopy unsatisfactory
Perform endocervical curettage and cervical biopsy

Treat based on findings
Menopause
HAVOC

Hot flashes
atrophy of the vagina
osteoporosis
coronary artery disease
Menopause treatment
Hormone replacement therapy
- however, increases the risk of breast and endometrial cancer, and cardiovascular morbidity
Vaginal atrophy tx
long term: estradiol ring
short term: estrogen vaginal cream
Contraindications to estrogen containing contraception
pregnancy
hx of CAD or DVT
breast cancer
undiagnosed abnormal vaginal bleeding
estrogen dependent cancer
benign/malignant liver neoplasm
current tobacco use
age >35
COntraindications to Mirena and Copper T IUDs
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
Rape/Sexual abuse managemnet
saline prep for sperm
gonorrhea/chlamydia smear/culture
Serological testing: HIV, syphilis, HSV, HBV, and CMV
Serum pregnancy test
Blood alcohol, urine toxicology
Infectious vulvovaginitis
when in kids, stds, then report to child protective services
Candida vaginal discharge
may be associated w/ diabetes; measure glucose and/or check for glucosuria
Sarcoma botryoides (rhabdomyosarcoma)
"bunch of grapes" within the vagina
Precocious puberty workup
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
Causes of central precocious puberty
constitutional (idiopathic)
hypothalamic lesions (hamartomas, tumors, congenital malformations)
Dysgerminomas
Hydrocephalus
CNS infections
CNS trauma/irradiation
Pineal tumors
Neurofibromatosis
Tuberous sclerosis
Causes of peripheral precocious puberty
Congenital Adrenal Hyperplasia
Adrenal tumors
McCune Albright Syndrome (polyostic fibrous dysplasia)
Gonadal tumors
Exogenous estrogen, OCP's)
Ovarian cysts
treatment of central precocious puberty
leuprolide
treatment of peripheral precocious puberty
ovarian cysts: regresses spontaneously
CAH: glucocorticoids
Adrean or ovarian tumors: resection
McCune Albright: antiestrogens (tamoxifen) or estrogen synthesis blockers (ketoconazole or testolactone)
Diagnosis of Amenorrhea
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
decreased GnRH
decreased LH/FSH
decreased estrogen/progesterone
hypogonadotropic hypogonadism

hypothalamic or pituitary problem
increased GnRH
increased FSH/LH
decreased estrogen/progesterone
hypergonatodropic hypogonadism

ovaries fail to produce estrogen
increased GnRH
increased FSH/LH
hgh estrogen or progesterone
PCOS or problem w/ estrogen receptors
normal pubertal hormones
suggests anatomic problem
normal breast development and no uterus
obtain karyotype to work up androgen insensitivity syndrome
Normal breast development and uterus
measure prolactin and get cranial MRI
Treatment for constitutional growth delay
no treatment needed
hypogonadism tx
hrt w/ estrogen alone at previous dose

12-18 months later, begin cyclic estrogen/progesterone
anatomic amenorrhea
surgery
secondary amenorrhea
absence of menses for 6 consecutive months in women who have passed menarche
secondary amenorrhea workup
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
secondary amenorrhea nd hyperglycemia or hypotension
dexamethasone test
- determine if CAH, Cushings, or Addisons
secondary amenorrhea and virilization
mild: PCOS, CAH, Cushings
moderate - severe: ovarian or adrenal tumor
primary dysmenorrhea
menstrual pain associated w/ ovulatory cycles in teh absence of pathological findings
primary dysmenorrhea dx
diagnosis of exclusion, rule out secondary dysmenorrhea
primary dysmenorrhea tx
NSAIDs, topical heat thearpy, combined OCP's, Mirena IUD
secondary dysmenorrhea
orgnic cause: endometriosis, adenomyosis, tumors, fibroids, adhesions, polyps, PID
secondary dysmenorrhea dx
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
Endometriosis
functional endometrial glands/stroma outside uterus

cyclical pain and/or rectal pain and dyspareunia
Endometriosis dx
laparoscopy
blue-black or dark brown appearance
ovaries may have endometriomas (chocolate cysts)
Endometriosis tx
1. inhibit ovulation w/ either OCP's, leuprolide, or danazol
2. conservative surgical treatment
3. definitive: TAH/BSO +/- lysis of adhesions
Adenomyosis
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
Adenomyosis tx
1. NSAIDs fist line
2. OCP's or progestins can be added
3. Endometrial ablation or resection using hysteroscopy
4. definitive: hysterectomy
Endometriosis complication
infertility
Adenomyosis complication
rarely, can progress to endometrial cancer
Menorrhagia
increasing amount of flow or prolonged bleeding; may lead to anemia
Oligomenorrhea
an increase in lenth of time btw menses (35 - 90)
Polymenorrhea
Frequent menstruations (< 21 day cycle); anovular
Metrorrhagi
bleedin between periods
Menometrorrhagia
excessive and irregular bleeding
abnormal uterine bleeding diagnosis
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
Treatment of heavy bleeding
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
Treatment of ovulatory bleeding
1. NSAIDs to decrease blood loss
2. if hemodynamically stable, treat w/ OCP or Mirena IUD to thicken endometrium and control bleeding
Treatment of anovulatory bleeding
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
if medical management fails for abnormal uterine bleeding...
1. D&C
2. Hysteroscopy
3. Hysterectomy or endometrial ablation
Congenital Adrenal Hyperplasia
increased androgens, testosterone, DHEAS, and 17-OH progesterone levels
Tx of CAH
glucocorticoids and mineralocorticoids
Polycystic Ovarian Syndrome
two of three criteria:
1. polycystic ovaries
2. oligo-/anovulation
3. clinical or biochemical evidence of hyperadnrogenism
PCOS dx
1. increased testosterone
2. r/o w/ tsh, prolactin, 17-OH progesterone, cushings w/ 24 hr cortisol
PCOS tx
if not attempting to conceive: combination of OCP's, progestins, metformin

if attempting to conceive: clomiphene +/- metformin
Treatments for male infertility
hormonal deficiency
intrauterine insemination
donor insemination
in vitro fertilization
intracytoplasmic sperm injection
induction of ovulation
clomiphene
gonadotropins
pulsatile GnRH
bacterial vaginosis
grayish-white discharge

Fishy odor

Clue cells

Tx: metronidazole or clindamycin
Trichomonas vaginosis
yellow-green frothy discharge, pruritus dysuria

flagellated organisms

Tx: PO metronidazole or tinidazole
- treat partners and test for other STDs
Candida vaginosis
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
Pelvic Inflammatory Disease
infection of upper genital tract associated w/ gonorrhoeae or chlamydia and anaerobes

cervical motion tenderness
PID workup
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
PID tx
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
Indications for PID surgery
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
Uterine leiomyoma (fibroids)
benign neoplasm of female genital tract; but may cause infertility or menorrhagia, or pain
Uterine Fibroid dx
1. cbc - look for anemia
2. ultrasound - look for uterine myomas; exclude ovarian masses
3. MRI: delineate intramural and submucous myomas
Uterine fibroid tx
1. NSAIDs
2. combined hormonal contraception
3. leuprolide or naferlin (GnRH analogs) to decrease size of myomas, suppress further growth, and decrese surrounding vascularity
Uterine fibroid surgery
childbearin years: myomectomy or hysteroscopy w/ leiomyoma resection

completed childbearing: total or subtotal abdominal or vaginal hysterectomy

Uterine artery embolization
If uterine mass continues to grow after menopause...
malignancy must be ruled out w/ a biopsy
Type I endometrial cancer
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
Type I endometrial cancer tx
high dose progestins for women of childbearing age; TAH/BSO +/- radiation for postmenopausal women
Type II endometrial cancer
Serous

1/4 or endometrial cancers
Unrelated to estrogen; p53 mutation in 90% cases

No precursor lesion

Poor prognosis
Type II endometrial cancer tx
TAH/BSO w/ adjuvant chemotherapy for advanced stage cancer
HPV screening
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
CIN I tx
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)
CIN II and III tx
treat w/ ablative (cryotherapy or laser ablation) or excisional therapy (LEEP; laser and cold-knife conization)

hysterectomy a treatment option
post-ablative or excisional therapy follow up for CIN II and III
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
Invasive CIN tx
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
Vulvar cancer
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
Vulvar cancer dx
1. vulvar punch biopsy
2. VIN I and II: associated w/ mild and moderate dysplasia
3. VIN III: carcinoma in situ
Vulvar Cancer Treatment
precancerous: reduce predisposing factors

high grade: topical chemotherapy, laser ablation, wide local excision, skinning

Invasive: radical vulvectomy and regional lympadenectomy or wide local excision
Vaginal cancer
abnormal vaginal bleeding, abnormal discharge, postcoital bleeding
Vginal discharge dx
cytology
colposcopy
biopsy
Vaginal discharge tx
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
Lynch II syndrome
hereditary nonpolyposis colorectal cancer; associated w/ increased risk of colon, ovarian, endometrial, and breast cancer
Ovarian cancer Dx
increased CA-125
- may be benign disease in premenopausal women
- higher likelihood of malignancy in postmenopausal women

Screen high-risk women w/ ultrasound
Treatment of ovarian masses
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
Treatment of ovarian cancer
surgery staging followed by TAH/BSO w/ omentectomy and pelvic and para-aortic lympadenectomy

postoperative chemotherapy for early-stage or low-grade ovarian cancer
Frequency of female genital tract cancers
endometrail > ovarian > cervical
Deaths in female genital cancers
ovarian > endometrial > cervical
Ovarian cancer prevention
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
Pelvic organ prolapse
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
Fibrocystic change
most common benign breast condition

cyclic bilateral mastalgia and swelling, most prominent just before menstruation

irregular, bumpy consistency to breast tissue
Fibrocystic change tx
dietary modifications (caffeine restriction)

danazol for severe pain, but rarely used
consider OCPs, which decrease hormonal fluctuations
Most common cause of bloody nipple discharge
Intraductal papilloma
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
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
Fibroadenoma
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
Fibroadenoma dx
breast ultrasound - differentiates cystic from solid masses

needle biopsy or FNA

Excision w/ pathologic exam if diagnosis uncertain
Fibroadenoma Tx
excision is curative, but recurrence is uncommon
location of breast cancers
60% in upper outer quadrant
risk factors for breast cancers
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)
Early findings in breast cncer
single, nontender, firm mass w/ ill-defined margins or mammographic abnormaliites w/ no palpable mass
later findings in breast cancer
skin or nipple retraction, axillary lymphadenopathy, breast enlargement,redness, edema, pain, fixation of mass to skin or chest wall
breast cancer late findings
ulceration, supraclavicular lmphadenopathy
paget's disease of nipple
prolonged unilateral scaling erosion of nipple w/ or w/o discharge
metastatic disease of breast
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)
breast cancer diagnosis in postmenopausal women
1. mammography - microcalcifications and irregular borders

mammography detects lesions two years before they become clinically palpable
breast cancer diagnosis in premenopausal women
< 30: ultrasound - diffx solid and cystic mass
Tumor markers for recurrent breast cancer
CEA
CA 15-3
CA 27-29
Breast Cancer Treatment hormone receptor +
tamoxifen
Breast Cancer Treatment estrogen receptor negative
chemotherapy
Breast Cancer Treatment
HER2/neu expression
Trastuzumab
Breast Cancer Treatment Surgical options
1. partial mastectomy plus axillary dissection

followed by radiation therapy

2. modified radical mastectomy (total mastectomy plus axillary dissection)
Contraindications to breast conserving therapy
large tumor size
subareolar location
multifocal tumors
fixation
to chest wall
involvement of nipple or overlying skin
Stage IV Breast Cancer treatment
radiaotherapy, and hormonal therapy

mastectomy only for local symptom control
Most reliable indicator for breast cancer prognosis
TNM I-IV staging
Breast Cancer Stage I
< 2 cm
Breast Cancer Stage II
2-5 cm
Breast Cancer Stage III
Axillary node involvement
Breast Cancer Stage IV
Distant metastasis
ER and PR positive breast cancer prognosis
good
Complications in preast cancer
pleural effusion in 50% metastatic breast cancer

edema of the arm