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145 Cards in this Set
- Front
- Back
Recurrent Yeast
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1. Inadeqaute treatment
2. Resistant Organism 3. underlying condition which predispose to recurrence |
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BV
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Flagyl 500 mg TID x 5 days
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Gonrorrhea
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Azithro 2 grams PO
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Chlaymidia
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Azithro 1 gram po
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Hypothyroidism
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TSH > 10 mIU/L and decrease in T4 levels
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Sublinical Hypothyroidism
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slight elevation in TSH and normal FT4
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Treatment of Hypothyroidism
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1.8/mcg/kg/day elderly 1.0 ug/kg/day
check TFTs every 4-6 weeks |
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pH of vaginal candidiasis
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vaginal pH in women with Candida infection is typically normal (4 to 4.5), which distinguishes candidiasis from trichomoniasis or bacterial vaginosis
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What do you see on micro with vaginitis
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Candida species can be seen on a wet mount of the discharge; adding 10 percent potassium hydroxide destroys the cellular elements and facilitates recognition of budding yeast, pseudohyphae, and hyphae
However, microscopy is negative in up to 50 percent of patients with culture confirmed vulvovaginal candidiasis |
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Treatment of Chronic Vaginal Candidiasis
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fluconazole 150 mg every 72 hours for three doses, followed by maintenance fluconazole therapy once per week for six months
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Aromastase inhibitors
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aromatase enzyme cytochrome p450 enzyme converts androgens to estrogens in many tissues
tissue include the brain, bone, breast, skin, adipose and ovary, and endometrium they block these enzymes reversibly Letrozole and Anastrozole |
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Name 2 Aromatase inhibitors
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Letrozole and Anastrozole
used for breast cancer side effects- vasomotor symptoms, vaginal dryness, arthralgia, and decreased BMD In contrast to Tamoxifen and Evista have a reduced incidence of VTE and endometrail carcinoma |
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Differential for breast cyst
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ductal cyst
hemorrhagic or traumatic cyst fibrocystic change fibroadenoma mastits carcinoma |
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Breast Discharge
green or yellow purulent-- yellow or pink serosanguineous- Bloody serosanguineous- cleary/watery |
green or yellow ---- duct ectasia
purulent-- bacterial infection (masitis or abscess) yellow or pink serosanguineous- intraductal papilloma, fibrocystic changes Bloody serosanguineous- intraductal papilloma cleary/watery very worrisome for carcinoma |
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Risk of Cancer
Milky galactorrhhea, green/yellow or purulent- yellow or pink seroaunguineous- bloody serosanguienous clear water |
Risk of Cancer
Milky galactorrhhea, green/yellow or purulent- rare yellow or pink seroaunguineous- 5-10% bloody serosanguienous 5-10% clear water >30-50% |
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In post menopausal woman cystic mass do you excise or aspirate
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excise
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Evaluate a breast mass
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History
How long Discharge skin or nipple changes recent trauma family history of breast, colon, uteirne, first degree relative pre menopause Negative mammogram persistent mass- gets Ultrasound cystic gest aspiration for diagnosis, persistent mass regardless should get elvaulted by general surgeon more aggressive evaluation of solid breast masses - excisional biopsy of a palpable solid mass is advisable careful and bilateral breast exam identification of the site of nipple d/c, usually a solitary duct diagnostic mammogram with contact ulstroudn refferal to breast specialist ductal lavage- to sample the affected duct ductogram to evaluate for an intraductal mass excisional biopsy of any suspicious findings generally performed under fine wire cannulation of the duct and excision around the wire under radiographic guidance |
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a bilateral milky discharge is galactorrhea usuaaly due to
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1. persistent breast activity following pregnancy/breast feeding
2. discontinuation of OCPs 3. Idiopathic causes |
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Idiopathic
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is an adjective used primarily in medicine meaning arising spontaneously or from an obscure or unknown cause.
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Gail Model
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The Gail Model is a scientifically published, nationally accepted standard for evaluating your relative risk of developing breast cancer based on your family history.
*The Gail Model Risk Assessment is not intended for women who have had lobular cancer in-situ (LCIS) or ductal cancer in-situ (DCIS) or who have had a previous breast cancer The Breast Cancer Risk Assessment Tool was designed for use by health professionals. If you are not a health professional, you are encouraged to discuss the results and your personal risk of breast cancer with your doctor. The tool should not be used to calculate breast cancer risk for women who have already had a diagnosis of breast cancer, lobular carcinoma in situ (LCIS), or ductal carcinoma in situ (DCIS). The BCRA risk calculator may be updated periodically as new data or research becomes available. Although the tool has been used with success in clinics for women with strong family histories of breast cancer, more specific methods of estimating risk are appropriate for women known to have breast cancer-producing mutations in the BRCA1 or BRCA2 genes. Other factors may also affect risk and are not accounted for by the tool. These factors include previous radiation therapy to the chest for the treatment of Hodgkin lymphoma or recent migration from a region with low breast cancer rates, such as rural China. The tool's risk calculations assume that a woman is screened for breast cancer as in the general U.S. population. A woman who does not have mammograms will have somewhat lower chances of a diagnosis of breast cancer. |
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SERM
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Raloxifene reduced 9 cancer /1000
has an indication for osteoporosis decrease in vertebral fractures 7/1000 No endometrial cancer Tamoxifen reduced 7 cancers /1000 decrease in nonvertebral fractures 3/1000 increase in VTE 4/1000 increase in endoetrial cancer tamoxifen great risk of cataracts |
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Premenopausal and breast cancer
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For premenopausal women at high risk of breast cancer, we suggest tamoxifen rather than observation These women are not candidates for an AI.
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SERM vs AI for breast cancer prevention
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Whether an AI is a more effective chemoprevention than a SERM is unknown, since they have not been directly compared. However, an AI is a reasonable alternative to tamoxifen or raloxifene for postmenopausal women at an increased risk of breast cancer.
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Post menopausal bleeding
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only a small amount have cancer
atrophic endometrium with inflammation idiopathic bleeding presence of endometrial polyp or sumucuosu /intracavitary myoa bleeding relating to hormone replacement therapy cervicities atrophic vaginities urethritis bleeding from anorectal sources |
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stripe less than _____ mm excludes 99% of endometrial cancer
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< 4mm
could be 5 mm The endometrial lining is thicker than 4 mm The endometrium shows diffuse or focal increased echogenicity (heterogeneity) The endometrium is not adequately visualized The woman has persistent bleeding. Persistent bleeding can be a sign of endometrial cancer even when the endometrial thickness is less than 4 to 5 mm since a thin or indistinct endometrial stripe does not reliably exclude type 2 endometrial cancer [29,30]. Therefore, women with persistent bleeding should be evaluated furthe |
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persistent bleeding would warrant
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hysteroscopy and endocervical sampling
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Physiologic herniation of midgut
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8-12 weeks
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Treatment of Gonorrhea
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ceftriaxone 250 mg intramuscularly and either azithromycin 1 g orally as a single dose or doxycycline 100 mg orally twice daily for 7 days
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Chlamydia screen all women
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less than age 25
treatment doxy 100 mg BID x 7 days azithro 1 gram po Levoquin 500 mg q day x 7 days erythromycin 500 mg QID x 7 days Ofloxacin 300 mg BID x 7 days |
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Primary Herpses
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Valtrex 1000 mg BID x 10 days
Acyclovir 400 mg TID x 10 days supression 1000 mg q day acyclovir 400 mg BID |
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suppressive therarpy HSV
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36 weeks, Acyclovir 400 mg TID, or valtrex 1000 mg BID, increase dose because of increase GFR in pregnancy
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Hypoestrogenic have
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normal to low FSH
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Idopathic Hirsutism vs Virilization
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Testostereone
DHEA |
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Lymphogranuloma venereum (LGV)
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Lymphogranuloma venereum (LGV) is caused by C. trachomatis serovars L1, L2, or L3 (194). The most common clinical manifestation of LGV among heterosexuals is tender inguinal and/or femoral lymphadenopathy that is typically unilateral. A self-limited genital ulcer or papule sometimes occurs at the site of inoculation.
LGV is an invasive, systemic infection, and if it is not treated early, LGV proctocolitis can lead to chronic, colorectal fistulas and strictures. Genital and colorectal LGV lesions can also develop secondary bacterial infection or can be coinfected with other sexually and nonsexually transmitted pathogens. Diagnosis is based on clinical suspicion, epidemiologic information, and the exclusion of other etiologies for proctocolitis, inguinal lymphadenopathy, or genital or rectal ulcers. C. trachomatis testing also should be conducted, if available. Genital and lymph node specimens (i.e., lesion swab or bubo aspirate) Doxycycline 100 mg orally twice a day for 21 daysErythromycin base 500 mg orally four times a day for 21 days Chlamydia serology (complement fixation titers >1:64) can support the diagnosis of LGV |
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Granuloma Inguinale (Donovanosis)
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Granuloma inguinale is a genital ulcerative disease caused by the intracellular gram-negative bacterium Klebsiella granulomatis (formerly known as Calymmatobacterium granulomatis). The disease occurs rarely in the United States, although it is endemic in some tropical and developing areas, including India; Papua, New Guinea; the Caribbean; central Australia; and southern Africa
Azithromycin 1 g orally once per week for at least 3 weeks and until all lesions have completely healed OR Ciprofloxacin 750 mg orally twice a day for at least 3 weeks and until all lesions have completely healed OR Erythromycin base 500 mg orally four times a day for at least 3 weeks and until all lesions have completely healed OR Trimethoprim-sulfamethoxazole one double-strength (160 mg/800 mg) tablet orally twice a Doxycycline 100 mg orally twice a day for at least 3 weeks and until all lesions have completely healed Clinically, the disease is commonly characterized as painless, slowly progressive ulcerative lesions on the genitals or perineum without regional lymphadenopathy; subcutaneous granulomas (pseudoboboes) might also occur. The lesions are highly vascular (i.e., beefy red appearance) and bleed easily on contact The causative organism is difficult to culture, and diagnosis requires visualization of dark-staining Donovan bodies on tissue crush preparation or biopsy beefy red inguinal lesions In addition, the painless genital ulcers can be mistaken for syphilis.[3] The ulcers ultimately progress to destruction of internal and external tissue, with extensive leakage of mucus and blood from the highly vascular lesions. The destructive nature of donovanosis also increases the risk of superinfection by other pathogenic microbes. Small, painless nodules appear after about 10–40 days of the contact with the bacteria. Later the nodules burst, creating open, fleshy, oozing lesions. The infection spreads, mutilating the infected tissue. The infection will continue to destroy the tissue until treated. The lesions occur at the region of contact typically found on the shaft of the penis, the labia, or the perineum. Rarely, the vaginal wall or cervix is the site of the lesion. At least one case in India led to partial auto-amputation of the penis. The patient tested positive for HIV-2 and had been infected for six years The diagnosis is based on the patient's sexual history and on physical examination revealing a painless, "beefy-red ulcer" with a characteristic rolled edge of granulation tissue. In contrast to syphilitic ulcers, inguinal lymphadenopathy is generally absent. Tissue biopsy and Wright-Giemsa stain is used to aid in the diagnosis. The presence of Donovan bodies in the tissue sample confirms donovanosis. Donovan bodies are rod-shaped, oval organisms that can be seen in the cytoplasm of mononuclear phagocytes or histiocytes in tissue samples from patients with granuloma inguinale. They appear deep purple when stained with Wright's stain. These intracellular inclusions are the encapsulated gram-negative rods of the causative organisms. They were discovered by Charles Donovan. |
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Bechets Disease
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rare immune-mediated small-vessel systemic vasculitis[2] that often presents with mucous membrane ulceration and ocular problems. Behçet's disease (BD) was named in 1937 after the Turkish dermatologist Hulusi Behçet, who first described the triple-symptom complex of recurrent oral aphthous ulcers, genital ulcers, and uveitis
Visual acuity, or color vision loss with concurrent mucocutaneous lesions and/or systemic Behçet's symptoms should raise suspicion of optic nerve involvement 1 mg/kg/d oral prednisone) |
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PCOS
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Rotterdam[
present if any 2 out of 3 criteria are met 1.oligoovulation and/or an ovulation 2.excess androgen activity 3.polycystic ovaries (by gynecologic ultrasound) 12 or more follicles on an ovary 2-9 mm FSH/ LH ratio in IU 3:1 or 2:1 when measured on day 3 of the cycle DHEAS 17 Hydroxyprogesterone r/o non classical adrenal hyperplasia 24 hour urine cortisol (to rule out cushiness) Testosterone r/o ovarian tumor Lipid Panel 75 gram OGTT Prolactin TSH EStradiol |
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PCOS
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In PCOS, there is a so-called "follicular arrest", i.e., several follicles develop to a size of 5–7 mm, but not further. No single follicle reaches the preovulatory size (16 mm or more). According to the Rotterdam criteria, 12 or more small follicles should be seen in an ovary on ultrasound examination. The follicles may be oriented in the periphery, giving the appearance of a 'string of pearls'
Laparoscopic examination may reveal a thickened, smooth, pearl-white outer surface of the ovary. There are often low levels of sex hormone binding globulin Serum (blood) levels of androgens (male hormones), including androstenedione and testosterone may be elevated. Dehydroepiandrosterone sulfate levels above 700-800 µg/dL are highly suggestive of adrenal dysfunction because DHEA-S is made exclusively by the adrenal glands. The free testosterone level is thought to be the best measure, with ~60% of PCOS patients demonstrating supranormal levels. The Free androgen index (FAI) of the ratio of testosterone to sex hormone-binding globulin (SHBG) is high and is meant to be a predictor of free testosterone, but is a poor parameter for this and is no better than testosterone alone as a marker for PCOS, possibly because FAI is correlated with the degree of obesity Insulin-like growth factor-I – Serum IGF-I concentrations are elevated in virtually all patients with untreated acromegaly and provide excellent discrimination from normal individuals. IGF-1 We suggest measuring serum IGF-I levels in all girls with hyperandrogenism, but particularly in those who undergo acral overgrowth or who have symptoms suggestive of a pituitary tumor. The oral estrogen of OCPs lowers IGF-I levels. Thyroid function tests – Normal serum TSH is ordinarily adequate to rule out thyroid dysfunction. Estrogen raises total serum T4 by elevating thyroxine binding globulin levels, but low-dose OCPs do not generally cause falsely abnormal results for these tests. |
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Labs
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Serum cortisol – A mid-day cortisol concentration of <10 mcg/dL, provides evidence against endogenous Cushing's syndrome, but normal individuals may have levels twice this high in early morning
Early-morning 17-hydroxyprogesterone – An 8 AM 17-hydroxyprogesterone (17-OHP) it wanes rapidly thereafter due to the diurnal variation of adrenal steroid secretion. It is important to obtain the sample during the early follicular phase of the menstrual cycle or while the patient is anovulatory, because 17-OHP rises during the preovulatory and luteal phases of the cycle. Under these conditions, in patients not taking oral contraceptives, a 17-OHP value of >170 to 200 ng/dL ( is suggestive of nonclassical CAH and is also compatible with the rare virilizing tumor. Confirm with ACTH test TSH Prolactin 17-OH Progesterone level- done in early follicular phase at 0800 serum cortisol mid day total and free testosterone are best assessed in the early morning, on days 4 through 10 of the menstrual cycle , need to be off OCPs total testosterone > 60 ng/dl abnomal |
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Androgens and PCOS
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TESTING FOR ANDROGEN EXCESS — The key androgen to measure is serum testosterone. However, there are many pitfalls in testosterone assays at the low levels found in women, and reliable testosterone assays are not available to many physicians. Serum total and free testosterone are best assessed in the early morning, on days 4 through 10 of the menstrual cycle in regularly cycling women; norms are standardized for this part of the menstrual cycle. Oral contraceptive pills interfere with the assessment of androgens. They suppress gonadotropins, elevate sex hormone binding globulin (SHBG), and directly inhibit steroidogenic enzymes such as 3ß-hydroxysteroid dehydrogenase (3ß-HSD). They normalize androgens in polycystic ovary syndrome (PCOS) and also have been reported to normalize androgens in some virilizing tumors. After discontinuing oral contraceptive pills, normal women may transiently have a slightly high total testosterone level but a normal free testosterone level because SHBG turnover is slower than testosterone turnover.
Total testosterone – The automated assays that are used to measure total testosterone in most laboratories are not suitable to accurately measure levels in females. The interpretation of the laboratory results is further complicated by systematic differences between assays and excessively broad normal ranges derived from populations of apparently normal women with unrecognized androgen excess. The normal upper limit for serum total testosterone in women is approximately 60 ng/dL (2.0 nmol/L) with the new generation of liquid chromatography mass spectrometry methods. Free testosterone – An elevation in serum (or plasma) free testosterone is the single most sensitive test to establish the presence of hyperandrogenemia. The serum free testosterone concentration is about 50 percent more sensitive for the detection of hyperandrogenemia than the total testosterone concentration. This is because elevated insulin levels (a frequent concomitant of PCOS) and elevated androgen levels both act to inhibit hepatic production of sex hormone-binding globulin (SHBG), which is the main determinant of the bioactive portion of serum testosterone, the fraction that is free or "bioavailable," the latter including the fraction that is loosely bound to albumin. Despite these advantages, assaying the free testosterone level introduces other potential sources of error because of systematic differences between assays. Direct assays of the free testosterone concentration are inaccurate and should be avoided. The best methods calculate free testosterone as the product of the total testosterone and a function of SHBG: free testosterone = total testosterone x percent free testosterone, where percent free testosterone is most commonly determined by dialysis or calculated from the SHBG concentration. The combination of a high-normal total testosterone and a low-normal SHBG yields a high free testosterone concentration. The most accurate androgen determinations come from specialty laboratories using established, validated assays in well-characterized control women. Dehydroepiandrosterone sulfate (DHEAS) – DHEAS is a marker for adrenal hyperandrogenism. Measurement is not necessary in the initial evaluation of PCOS in most girls. The major utility of measuring DHEAS levels is to rapidly identify an unusual virilizing adrenal disorder, such as cortisone reductase deficiency , or an adrenal tumor. Girls with a virilizing tumor usually present with a rapid onset of virilizing features, and DHEAS levels are often markedly elevated (>700 mcg/dL, 13.6 mmol/L) if the tumor is of adrenal origin. However, a substantial minority of tumors are indolent in onset and mimic PCOS in presentation. Oral contraceptive pills have equivocal effects on the DHEAS level. Recommended tests — If a reliable method for measuring serum free (or bioavailable) testosterone is available to the practitioner and cost is not an issue, this test is the preferred choice for initial testing rather than measurement of total testosterone. If a free testosterone test in a reliable specialty laboratory is not readily available, it is reasonable to begin the evaluation with a total testosterone determination. Most patients with PCOS have serum testosterone concentrations below 150 ng/dL (5.2 nmol/L). A total testosterone >200 ng/dL (6.9 nmol/L) increases the likelihood of a virilizing neoplasm. Patients who have clinical features consistent with PCOS but have an initial normal testosterone should have repeat testing, preferably an early morning serum free testosterone level in a reliable specialty laboratory along with determination of SHBG. It may be helpful to consult with a specialist at this point |
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21 hydroxylase deficiency in adult onset CAH measure
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17 hydroxy progesteorne
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Treatment of PCOS
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1. Exercise and weight loss
2. OCPs- Yaz 20 mcg/3 mg drospirenone) or Orhtochyclen (20 mcg/ .25 mg of norgestimate) 3. Metformin 4. Spironolactone 5. 5 alpha reductase inhibtor- Finasterine teratongenic 6. Cyproterone- postent progestin and antiandrogen 7. Vaniqa (eflornithine hydrochloride cream 13.9%) is a topical drug that inhibits hair growth. It is not a depilatory and must be used indefinitely to prevent regrowth. drosperinone 3 mg = 25 mg of spirnonolactone |
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Least androgenic progesterones
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Norgestimate (eg, Ortho-Cyclen or Tri-Cyclen) and desogestrel (eg, Desogen or Ortho-Cept) appear to be the least androgenic
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ortho cyclen
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0.25 mg norgestimate
35 mcg of EE |
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Yaz
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3 mg of drospirenone and 20 mcg of ethinyl estradiol
24/4 Yasmin 21/7 3 mg DRSP and 0.03 mg ethinyl estradiol |
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Seasonale vs Seasonique
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(levonorgestrel/ethinyl estradiol tablets) of 84/7 0.15 mg of levonorgestrel, 30 mcg of ethinyl estradiol,
Seasonique (levonorgestrel, ethinyl estradiol) (levonorgestrel/ethinyl estradiol tablets and ethinyl estradiol tablets) is an extended-cycle oral contraceptive consisting of 84 light blue-green tablets each containing 0.15 mg of levonorgestrel, a synthetic progestogen and 0.03 mg of ethinyl estradiol, and 7 yellow tablets containing 0.01 mg of ethinyl estradiol. |
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Allesse
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21 /7 0.10 mg of levonorgestrel, 20 mcg of ethinyl estradiol,
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Clomid
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SERM
estrogen agonist and antagonist properites in hypothalamus estrogen levels are perceived as low causing increased GnRH release increased FHS and LH release which stimulates follicle development side effects- hot flashes, mood swings, headaches, if associated with visual disturbances should /dc due to reports of optic neuropathy, pelvic discomfort , decreased cervical mucus, thin endometrium |
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Treatment of Mom with Hyperthyroidism
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frist trimester - PTU
2nd and 3rd trimester- Methimazole aim for slightly hyperthyroidism |
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Osteoporosis
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Increases bone density, weight bearing and exercise
Bone density 65 If risk factors- caucasion, previous fracture, <127, tobacco, etoh Paak bone mass age 19- bone health during adelsesnce is important 67 yo present s for an annual exam what tests should be ordered for this patient may or may not need a pap mammogram bone density lipid panel, TSH, - Colonoscopy Screening for bone density screen at age 65 if risk factors screen earlier Previous scrapture, smoker, immuno compromised, <127 lbs, family history, alcohol, Tscore- osteoporsis <2.5 Frax score- risk of osteopotoic fracture.20 perecnt, or hip fracture.3% Calculate a frax- go online enter the date online tool. Hysterectomy 5 years for cervical dysplasia Needs a pap and needs it for 20 years For the past 2 years she has had a new sexual partern should she have a pap Having a new pap is not an indication for a pap Workup for hyperthyroidism Bone Density at 65 unless risk factors- Steroid use, osteoporosis, smoking, alcohol, family history, gnrh, aromatase inhibitors,- Frac scoring- 2 reasons To see if earlier screening 10 year any risk of fracture 9.3% or greater (this is what the score in the exam) T score Osteopenia- lifestyle changes, 10 year of hip fracture 3% and 10% year risk of any fracture of 20%- means osteopenia has frac of 20% Alendronate 70 mg once a weight- emty, osteonecrosis of jaw more IV and Chemotherapy Calcitonin Concominant Paratyhroid Hormone Vitain D 24 hr calciu urine- TSH and FT4 Telopeptides • CLINICAL RISK FACTOR ASSESSMENT • Advanced age • Personal history of fracture as an adult • Glucocorticoid therapy • History of fragility fracture in a first-degree relative • Low body weight • Cigarette smoking • Excessive alcohol consumption • Medical diseases • Other risk factors • - Possible risk factors Bone turnover markers (BTMs) Bisphosphonates inhibit the digestion of bone by encouraging osteoclasts to undergo apoptosis, or cell death, thereby slowing bone loss When order bone scans 65 or older or risk factors T score- compares a patient to a 32 year Compares a person to same age, ethnicity Osteopoenia -1.0 Osteoporosis -2.5 Initiate less than -2.5 Calcuate frax score- Bisphosonates Gerds Osteonecrosis of the jaws Path frcture of the jaw Weight bearing exercise Calcium and vitamin d Check TSH every 5 years for thyroid Osteoporosis Dexta scan- if frac score same as 65 fear old Steroids, heparin, family history, Initate treatment age 65- T score 2.5 Ostepenia 1.5 if risk fracture on 10 year risk of fracture fosamax 70 mg weekly- contraindications to fosamax selective estrogen receptor modulator raloxifene- venous thrombolism, hot flashes, dose of raloxifene- jaw fracture mechanism of action next dexta scan in 2 years 800 IU vitain D, 1300 mg calcium vitamin goes up 800 at 71, 600 for everone else 1300 mg teen age because that bone mass, then 1000, when stop medications osteonecrosis therapy- radiation therapy, dental work , if repeat scan stable in 2 years when do you repeat if worse then would get if stable on treatment no new risk factors then contracindications- renal failure,"", inability to sit up drug free holiday after 5-10 years thyroid function, hypoparathyroidis 17 yo 1200 mg peak bone mass- late teans FRAX has been most widely used as an aid in decision making regarding treatment initiation when the patient’s BMD score is in the low bone mass (osteopenia) range Treatment should be considered when there is a 3% risk of hip fracture or a 20% risk of a major osteoporotic fracture (defined as a fracture of the forearm, hip, shoulder, or clinical spine) or both in the next 10 years. It is important to note that FRAX is valid with or without the incorporation of the femoral neck BMD score. Caucasian females and males found that final peak bone mass occurred around 19 years in women Hip femoral neck, lubar spine The fracture risk assessment tool is valid for women older than 40 years, and the National Osteo-porosis Foundation recommends it be used in women who are postmenopausal, are not receiving osteoporosis treatment, have a T-score indicating low bone mass, and have no prior hip or vertebral fracture. Another limitation is the use of categorical variables where the effect is known to be related to the degree of exposure (eg, alcohol intake, corticosteroid use, smoking, and number of prior fractures). The fracture risk assessment tool is not considered valid for women who are taking prescription drugs for osteoporosis First Tier Complete blood count Metabolic profile 24-Hour urinary calcium level 25-Hydroxyvitamin D level Thyroid stimulating hormone le Second Tier Celiac panel Serum protein electrophoresis Bisphosphnonates 1. Alendronate (Fosamax) 2. Risedronate (onthly 3. Ibandronate Boniva (monthly) 4. Zoledronate (REclast) 5 mg every 2 year IV for prention, 5 mg once a year for treament Raloxifene_ SERM Salmon Calcitonin- reduces vertebral fractures, use 5 years post menopause, Calcitonin is a peptide composed of 32 amino acids that binds to osteoclasts and inhibits bone resorption Calcitonins from many species are effective in humans, but salmon calcitonin is the one most widely used. It is highly potent in humans because of its high affinity (40 times that of human calcitonin) for the human calcitonin receptor and its slow rate of clearance The only other calcitonin used clinically is human calcitonin, which is less potent but also less antigenic than salmon calcitonin. Most clinical trials of calcitonin have used salmon calcitonin, but human calcitonin is as effective Really only use for bone pain from osteoporotic |
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Menopausal Symptoms
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Works for Hot Flahses
Estrogen- standard, low, ultra low Combined estrogen/progesterone Progestin- Depoprovera SSRI, SNRI Paxil 7.5 mg q day Clonidine 0.1 mg q day Gabapentin 600-900 mg q day Tibolone 2.5 mg /day Stellate Ganglion block Treatment of Menopausal Vaginal Symptoms 1. Ospemifene 60 mg q day- SERM 2. Vaginal Lubricants 3. Vaginal Moistureizers 4. Vaginal estrogen Stop hormones age 65 Black Cohash may help but can get liver failure Don’t need progesterone with vaginal estrogen |
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SERM approved for vaginal dyspareunia
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Ospemifene 60 mg q day- SERM
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Uteral Sacral Vaginal Vault Suspension
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At vaginal angle gram anterior pelvic fascia
don't go into vagina then posterior grab the endopelvic fascia then get middle part of the uteral sacral ligament go through it twice use 0 ethibond, hold the first not |
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Close the Enterocele
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1. Mcall Culdoplasty- uteral sacral plication- 20 silk or ethibond- grab posterior peritneum and ligament an plicate them together
2.Moschcowitz culdoplasty 3. Halban - vertical closure long acting monofilament sutures anterior rectal wall to posterior wall of vagina |
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Doderlein proceudre
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Doderlein procedure — Another method for vaginal hysterectomy is the Doderlein vaginal hysterectomy . Using this method, an incision is made in the vaginal epithelium at the junction of the bladder and anterior cervix. The pubovesicocervical fascia is dissected from the lower uterine segment and the anterior cul-de-sac is entered. The cervix is pushed posteriorly and the uterine fundus is delivered through the anterior cul-de-sac. The hysterectomy is then begun much in the same manner that one would proceed with an abdominal procedure.
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Contraception and Breast Cancer
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Copper IUD, Condoms, Diaphram
Mirena may have higher rates of reoccurrence |
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Obesity and Contraception
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increasing BMI has increased failure rate with contraception.
Also increased VTE with Obesity progestones would be better- IUD, Depo Provera, Minipill |
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How do IUDs work
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act both pre and post fertilization
inhibition of sperm altered tube motility ovum destruction plus mirena endometrial suppression and altered cervical mucus |
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What is low dose OCP and ultra low OCP
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0.02mg of estrogen (usually ethinyl estradiol) are classed as ‘ultra low dose’ contraceptive pills. 0.02mg of estrogen is sufficient for contraception but the side effects of spotting and breakthrough bleeding are more common with these types of ultra low dose birth control pills than with low dose pills containing 0.030mg or 0.035mg of estrogen.
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HTN and OCPs
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okay if you nor personal family history of CVA low dose combination okay
Older >35, poor HTN smokers, close family CVA combined OCPs should not be used progestin only methods pose no significant risks in patients with HTN |
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OCPs and DM
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hormonal OCPS have o effect on glucose metabolis
older progesterones did antagonize insulin, younger women with well controlled DM and no vascular disease OCPs okay IF > 35 with vascular disease, or poor control OCPs should be avoided watch Latinas and Navajos |
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SLE and OCPs
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combination OCPs is safe in women with mild to moderate lupus disease who do not have
1. Anitphospholipid antibody 2. Vascular disease 3. Nephritis Progestin only and contraceptives are safe in these patients 25% of patients who conceive with lupus choose to terminate their pregnancy |
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Vaccines for 18 yo
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Gardicil
TDAP Hepatitis B and A MMR Meningococcal |
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When can d/c paps
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age 65-70 if no history of abnormal cytology in past 1- years, and if three annual screenings have been negative
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Mammograms start
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biannual age 40
annual age 50 |
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BRCA testing in
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1. Women with a personal history of breast and ovarian cancer
2. Women with ovarian cancer and a first or second degree relative with either ovarian cancer or premenopausal breast cancer 3. Women with ovarian cancer who are ashkenazi jewish 4. women with breast cancer at or before age 40 and are ashkenazi jewish 5. women with breast cancer at or over age 50 and a first or second degree relative with ovarian or male breast cancer 6. Women who have a first degree relative who has been identified as carrying the BRCA 1 or 2 mutation |
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Prepubertal vulvovaginal pruritis differential
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inflammation/infection
trauma or foreign body urologic pathology genital tract neoplasm |
|
Treatment of Labial adhesions
|
2-6 weeks of topical estrogen followed by gentle separation of the thinned adhesions in the office with a topical anesthetic
use of emollient such as petroleum will aid in preventing recurrent adhesions surgical separation should not be required unless there is a history of prior surgical separation |
|
Patient safety in a surgical enviornment
|
The care team review in the presence of the patient
1. the intended procedure 2. the intended procedure site 3. any implants or grafts to be employed 4. documents and pertinent studies are all present mark site prior to anesthesia Time out 1. correct patient/ID 2. correct operative site 3. implants or grafts to be employed |
|
Common errors when writing a prescription
|
legibility of the order
missing components dosage, strength, time improper use of decimals and of trailing zeros use of non standard abbreviations, improper use of PRN orders similar trade names of medications or sound alike names errors in verbal medication order transfer |
|
What do combination OCPs do to cholesterol
|
estrogen component
decreases LDL increases HDL moderated increase in TG progestin component has an opposite and unfavorable effect on lipid profile women with controlled dyslipidemias or cholesterol <160 can be on 35 mcg or lower in these women choice of a lower progestin pill or a less androgenic pill will improve the effect on lipid panel monthly monitor of lipids first few months If LDL >1600 look at other methods women with controlled dyslipidemia but with other risk factors HTN, DM, tobacco use, obesity or family history of early onset CAD look at other methods |
|
5 comments of Metabolic Panel
|
1. Resting BP >130/85
2. Waist circumference >35 inches (thinks smokers OCPs) 3. Elevated Fasting Glc >100 mg/dl 4. HDL <50 mg/dl 5. Elevated TG >150 mg/dl |
|
depo lupron
|
amenorrhea in most patients
improved hematocrit myoma size reduction 50% in 3 months cannot treat for >12 months due to osteoporosis FDA approval only fro preop improve HCT |
|
UAE
|
can decrease the amount of bleeding, and pains
reduciton in mass is not constantly demonstrated because no histology can't rule out malignancy not recommended in menopause |
|
What is a normal CA-125 level
|
normal value is less than 35 U /ml.
|
|
Name types of transfusions reactions
|
Occur in 20% of cases
1. Simple Febrile Reaction- antibody reaction against the donor leukocytes in the product. self limited mange by antipyretics but can be similar to hemolytic reaction-fever, headache, myalgias, tachyardia, dyspena, chest pain 2. Allergic Reaction occur in 1%, of transfusions, urticaria during the transfusions in the absence of other symptoms. Allergy is due to plasma proteins in the product, Antihistamines, and complete the reaction 3. Anaphylactic reaction- bornchospasm, wheezing, or collapse, IM or SC Epi 1:1000 0.3 to 0.5 cc 4. Hemolytic reaction- recipients antibodies induce hemolysis of donor RBCs in the product. Occurs in 1 to 4 per one million transfusions, mortality is high, massive RBC destruction and DIC symptoms fever, headache, myalgias, pain in back and at transfusion site, signs of coagulopathy and cardiopulmonary compromise treament 1. Immediate cessation of transfusion 2. support renal fucntion with IV hydration, mannitol and furosemide 3. Labs- Renal, Liver, Chemistries, coagulation profile 4. DIC managed with FFP, possibly steroids and heparin 5. Donor blood and a blood sample from recipient is sent stat to blood bank for identification of hemolytic reaction and of ABO incompatibility |
|
Differential Diagnosis of a cyst
|
phsyiologic ovarian cyst
benign neoplasm malignant neoplas endometrioma abscess collection fallopian tube peritoneal or congenital remnant cyst (paratubal cyst) |
|
Work up of Cyst
|
pelvic exam and rectal exam
exclude pregnancy Ultrasound characterization |
|
Maligant signs on a cyst
|
septations or complex internal architecture
irregularity of the internal cyst wall or modularity bilateral cyst doppler flow assessment complex internal archicterure solid masses any elevation of tumor markers |
|
Cyst less than _____ cm diameter is not neoplastic 95% of the time
|
5 cm
|
|
Cysts what size do you take out
|
take out > 10 cm
5-10 watch for 6-8 weeks if not resolved generally can take out surgical management is undertaken for any enlargement of a cyst in a menopausal women |
|
In menopausal patients neoplastic masses are benign > ______ of the time
|
over 80% of the time
|
|
Differential diagnosis with adnexal mass and vaginal bleeding
|
early IUP with implantation bleed
threatened SAB, incomplete SAB, completed SAB multiple gestation involving SAB of one twin ectopic molar pregnancy heterotopic Labs HCG quant rH and blood type Pelvic and transvaginal U/S |
|
Ectopics tend to intramural or intraluminal
|
intramural- because they implant in the time
there is always some degree of postoperative scarring and potential for tubal occlusion salpingostomy does carry a risk of future ectopic pregnancy |
|
Methotrexate can use
|
no contraindications
desires future fertility able to follow up HCG is less than 15K adnexal mass is less than 3.5 cm No fetal cardiac activity No blood dyscrasias No liver disease No peptic ulcer No renal insuffiency No chronic pulmonary disease |
|
BMI
|
weight in Kg over Height in M2
|
|
Ectopic change from laparoscopic to laparotomy if
|
active bleeding prevents ID of bleeding site
cornual ectopic pregnancy hemodynamically unstable severe adenxal disease |
|
Cornual Pregnancy
|
conrual or intersitial
1% of ectopics cornual excision is generally successful preop consent possible hysterctomy usually laparotomy salpingostomy hysteroscopic and lparoscopic |
|
normal CA 125
|
0-35 U/ml
In a post-menopausal woman with a palpable adnexal mass and CA-125 level greater than 65 U/mL, the positive predictive value is >95% for ovarian malignanc |
|
Cervical Pregnancy
|
if cervical pregnancy is suspected, bimanual examination is avoided until imaging studies have excluded the diagnosis. If bimanual examination is performed, the endocervical canal should not be explored as this is likely to cause hemorrhage. A prominent finding on bimanual examination of cervical pregnancy is a soft cervix that is disproportionately enlarged compared to the uterus; this has been called "an hour-glass" shaped uterus. By comparison, enlargement of the uterus without significant cervical enlargement is characteristic of intrauterine pregnancy, although the cervix softens and becomes mildly congested.
edically using multidose methotrexate (MTX) therapy with intraamniotic and/or intrafetal injection of local potassium chloride (KCL) (eg, intracardiac injection of about 5 mEq potassium chloride) when fetal cardiac activity is present Dilation and evacuation is a conservative surgical option. The main complication is a high incidence of severe hemorrhage, which can be reduced by preoperative measures such as transvaginal ligation of the cervical branches of the uterine arteries, Shirodkar cerclage, angiographic uterine artery embolization, or intracervical vasopressin injection. The latter is given by injecting 20 to 30 mL of vasopressin (0.5 U/mL) solution with a 1.5-inch 21 gauge needle circumferentially deep into the dense cervical stroma. Transvaginal ligation of the cervicovaginal branches of the uterine artery can be performed, as well. This is done by deviating the cervix to one side and placing a suture at 3 and 9 o'clock on the lateral side of the cervix. The suture is placed high just below the lateral vaginal fornix, similar to sutures placed for hemostasis during cold knife conization. We use 2-0 polyglactin (Vicryl) [3,9]. However, our preference is preoperative angiographic uterine artery embolization If postoperative implantation site bleeding occurs, it can often be controlled by placing a size 26 Foley catheter with a 30 mL balloon into the dilated cervix, with the tip extending into the uterine cavity. Sterile water (as much as 95 mL) is used to inflate the balloon and tamponade the bleeding vessels for 24 to 48 hours. A purse string suture can be placed around the external cervical os and tied after inflation of the balloon to prevent expulsion. After 24 to 48 hours, the balloon is gradually deflated over a period of hours to days and removed, but may be reinflated at any time if bleeding picks up or recurs. The catheter also allows constant uterine drainage. Gelfoam provides temporary obstruction (two to six weeks) of the feeding blood vessels [6,19] and allows for development of collateral blood flow [32]. Because collateral flow begins to develop within hours of the procedure, surgical evacuation should be performed soon after embolization to achieve the full benefit of the procedure. The optimal interval between uterine artery embolization and surgical evacuation has not been established, intervals of several hours to 24 hours have been described |
|
Novasure
|
Novasure at leat 4 cm length and 2.5 cm wide
perform in early follicular phase up to 12 cm 7.5-8 mm dilate up to bipolar radiofrequency by measuring the distance uterine perforation bleeding hematometra- Intrauterine scarring is an expected result of endometrial ablation. When areas of endometrium are adherent and there is endometrial bleeding behind the occlusion, hematometra will occur cervical stenosis uterine cavity occlusion Postablation tubal sterilization syndrome Pelvic infection between the internal and external cervical os. In most of the patients, cervical dilation is associated with a resistance during the passage of the distal tip of the Hegar dilator through the internal cervical os. As soon as this resistance is felt, advancement of the dilator should be stopped and a finger should be placed at the point of contact between the external cervical os and Hegar dilator. Hegar dilator is then withdrawn and the length from its tip to the noted location on the shaft of the dilator is measured. The cavity length |
|
Postablation tubal sterilization syndrome
|
Some women who have undergone tubal ligation prior to endometrial ablation experience cyclic or intermittent pelvic pain. The proposed etiologies of this are: (1) bleeding from active endometrium that is trapped in the uterine cornua and/or (2) uterine contracture and intrauterine scarring. The incidence of this complication is as high as 10 percent in some reports [84]. Prevention, diagnosis, and management of these symptoms are the same as for other presentations of hematometra. In addition, some surgeons assess women with these symptoms laparoscopically and excise the tubal stumps to prevent the distension of the proximal tubal segments during menses.
The diagnosis of PATTS is initially suspected clinically in patients with cyclic cramping with or without menses with a history of endometrial ablation and tubal sterilization. Ultrasound has not been reliably sensitive at diagnosing PATSS. The confirmatory diagnosis is made surgically |
|
Reasons for Endometrial Ablation
|
The basic preoperative criteria for any patient opting for endometrial ablation are, at a minimum, the following:
Abnormal uterine bleeding of benign etiology (as evidenced by preoperative endometrial sampling and histologically benign findings) No desire for future fertility Desire to retain the uterus or to avoid hysterectom |
|
Absolute contraindications for endometrial ablation
|
include the following:
Pregnancy or a desire for future pregnancy Active urogenital or pelvic infection (eg, cystitis, vaginitis, cervicitis, endometritis, salpingitis, pelvic inflammatory disease [PID], or tubo-ovarian abscess [TOA]) Suspected or documented premalignant or malignant conditions of the endometrium or uterus Additional contraindications may include the following: Recent uterine infection A cavity that exceeds the device’s functional length and uterine diameter Hydrosalpinx History of classical cesarean section History of a transmural myomectomy Uterine anomalies |
|
What percentage go onto have a hysterectomy after uterine ablation
|
20-30%
|
|
Thermalchoice
|
37% amennorrhea
81% normal menses 4-12 cm cavity 35 cc of fluid in balloon |
|
Novasure amennoreha and
|
36% amennoreha
76% normal menses |
|
Anesthesia
|
I use a dilute solution of 0.5% lidocaine with 1/200,000 epinephrine. This allows a larger volume of anesthetic to be used in a given dose. Epinephrine also prolongs the anesthetic effect, reduces the amount of systemic absorption, and facilitates transfer of the anesthetic agent into the nerve fiber by increasing local pH. Epinephrine’s effect is predictable, with a transient (40- to 60-second) period of palpitation that quickly disappears. For those patients for whom epinephrine is considered too risky, I’d suggest an alternative anesthesia or anesthetic environment.
I administer the agent via a 22-gauge spinal needle. I place the needle on the anterior exocervical epithelium and ask the patient to cough. This pushes the cervix against the needle, allowing it to penetrate to the point that the bevel is just below the epithelial surface. I inject 1 to 3 mL of the agent at about the 12 and 6 o’clock positions. I grasp the posterior cervix with a single-toothed tenaculum and retract it anteriorly, a technique that aids in identifying the attachment of the uterosacral ligaments. Repeating the cough technique, I inject a small amount of anesthetic agent into the vaginal epithelium at the junction with the cervix; then I advance the needle to a depth of 4 to 5 mm, aiming to position the tip on the medial aspect of the ligament but not so deep that it is in the peritoneal cavity. Taking care to aspirate before injecting, I place approximately 5 to 8 mL of anesthetic solution in each side. I remove the tenaculum from the posterior cervix and reattach it at about the 12 o’clock position. Exerting a slight amount of traction, I inject about 4 to 6 mL of the lidocaine-epinephrine solution in each side of the cervix at about the 4 to 5 o’clock position on the patient’s left side, and 7 to 8 o’clock on the right, to a depth of 3 to 5 cm, aiming to deposit the bulk of the solution in the region of the lower uterine segment and upper cervix. Care must be taken to aspirate to minimize the risk of inadvertent systemic administration. After the anesthetic is injected, I push a conical-tipped syringe filled with 2% lidocaine gel against the exocervix and inject approximately 5 to 10 mL of the gel into the endometrial cavity. I remove the syringe and place 2 to 3 cotton-tipped applicators soaked in 4% liposomal lidocaine cream in the cervical canal, from the internal to the level of the external os. I then let the patient rest for 10 to 20 minutes before starting the procedure. |
|
Slings
|
bleeding- from vginal artery and inferior vesicle artery, both supplying the area of the vesicle neck and the urethra.
if perf the bladder the tape is withdrawn and the procedure terminated |
|
Larsen
|
Sacrospinous Ligament Suspension of the Vagina
O nylon midurethral retropubic sling |
|
Vesicovaginal Fistula
|
bladder mucosa is identified and closed with interrupted 4-0 synthetic absorbable suture. An attempt should be made to keep the suture in the submucosal layer
A second layer, the bladder muscle, is closed with interrupted 2-0 synthetic absorbable suture. vicryl seek an external blood supply for the fistula site. This can be the bulbocavernosus muscle from beneath the labia majora, or in cases where a large fistula exists or where the fistula is high in the vaginal canal, the gracilis muscle from the leg or the rectus abdominis muscle can be brought in to cover the fistula site. or gracilis muscle from leg It is sutured to the perivesical tissue with interrupted 3-0 synthetic absorbable sutures vaginal mucosa must be mobilized for closure without tension. Generally, the wound is closed with interrupted 0 synthetic absorbable suture. 4-2-0 and then 3 |
|
Bowel prep
|
Mefoxin
clear liquids 48 hrs before mag citrate or golytley |
|
Rectovaginal fistula
|
interrupted sutures 30 vicryl
low anterior resection interrupted sutures without tension 2 layers omental pedicle sewed in |
|
Urinary retention after a sling
|
normal scar contraction can cause over tightening
diagnose by urethroscopy redirection of the sling site and division of side adjacent to the urethra |
|
Cystotomy
|
Bladder Mucosa in 2 laters
bladder submucosa muscularis layer foley left in for 5 days or 24 hrs |
|
Ureteroneocystotomy
|
implant as lose to the bladder base
2 sutures 40 vicryl plased on each side of the end of the ureter then placed through the submucosa and muscularis of the bladder reinforce with suture reapproxiation of the bladder muscularis over the lowr ureter Ureterual stent left in for 10-14 days IVP perform at the time and again in 8-12 weeks |
|
Veres needle
|
he angle of Veress needle insertion should vary accordingly from 45 degrees in non-obese women to 90 degrees in very obese women
aspirate pressure below 10 hanging drop test |
|
Palmers point
|
left side, a 2-mm transverse skin incision was made 3 cm below the left costal margin on the midclavicular line.
2 FB below costal margin OG tube must me inserted to deflate the stomach verress needle perpendicular be perpendicular at this point don't put trendelenbur until trochars are in |
|
4 days post op what is differential diagnosis
|
incomplete closure of vaginal apex with peritoneal fluid drainage
physliologic leukorrhea vesico vaginal fistula uretero vaginal fistula (uroma) rectovaginal fistula |
|
Dual Tampon test
|
tampon in vagina- bladder is filled with methylene blue
dye on the tampon indicates vesico vaginal fistula if no dye on the tampon the bladder is drained and a second tampon is placed and IV indigo carmine is administered- if blue then uretero-vaginal fistula |
|
Management of vesico vaginal fistula-
|
foley placed in bladder for 4-6 weeks
small fistula may heal if continues to drain fix at 12 weeks repair of fistula excise the fistula tract with fresh tissue margins bladder submucosa with 30 Vicryl bladder muscularis with 20 or 30 suture closure of vaginal mucosa with similar suture |
|
Signs of fistula
|
passage of flatus from the vagina
chronic vaginal drainage at weeks to months following operation passage of stool per vaginum persistent pain or irritation in the introital or low posterior vaginal area after delivery |
|
Diagnosis of rectal vaginal fistula
|
assessment of integrity of anal sphincter by exam and ultrasound
salin in the vaginal vault, air is then insufflated into the rectum and the appearance of bubbles in the vaginal vault identifies the fistula site |
|
Closure fo rectal vaginal fistula
|
all inflammation must be allowed to subside
sometimes requiring 12 weeks delay in repair tissue cleanliness with sits baths complete excision of the tract with 2 cm margin |
|
Gyrus Halo spread
watts |
2-3 mm
35 watts |
|
Post op Ileus
|
anorexa, nausea,
abdominal distension decrease in bowel activity 24-72 hours after surgery Abd xray- gas distension of bowel loops management- NPO, IV fluids, amabulations |
|
SBO
|
recurrent emesis often bilious
xray- air fluid levels in the bowel, stair step pattern NG tube decompression passage of cantor tube for mechanical relief of obstruction |
|
Hysteroscopy
|
NS (only true isoolmoar irritant) no hyponatremia, but intravascular fluid overload and third spacing
|
|
Fluid overload with hysteroscopy
|
instillation into a vein
uterine perforation trans fallopian drainage of fluid |
|
Fluids used with hysteroscopy
|
sorbitol 2-3%
glycine solution (no longer used because of hyper ammonia |
|
Complications of Hysteroscopy
|
uterine perforation
bleeding from intracavatary operative site thermal injury to extra uterine structures with or without uterine perforation air embolism intrasvascular fluid overload hyseroscopic irrigant solution |
|
Hysteroscopy complication
|
assess vital sign , pulse ox
listen to lungs Hgb and BMP lasix 20-40 mg IV foley cath conisder chest xray or EKG |
|
Hystersocpy
|
assess fluid/ balance deficit every 3-5 minutes
limit operating time to 45 minutes at fluid deficit of 1000 cc stop and assess Na and Hgb Give Lasix 20 mg IV at 1000 cc Na levels below 120 mg/dl carry high risk of hyponatremic seizure and are managed with 3% NaCL slowly only at 20-25% of volume estimated water deficit to maxim of 150 cc |
|
Don't use nova sure with
|
very small uterine cavities
menopausal women due to atrophic and thinner walled nature of the uterus Uteri with a known or suspected congenital anomaly irregular uterine cavity- submucous or intracavitary myoma large uterine cavities any situation where the integrity of the endometrial cavity is in doubt if shuts down, may need to do hysteroscopic assessment of the endometrial cavity |
|
Differential diagnosis fo fever and abdominal pain
|
PID
TOA Septic Abortion ectopic pregnancy appy pyelonephritis perforation of viscus older chole pancreatitis pneumonia with diaphragmatic inflammation small bowel obstruction |
|
Inpateint treatment of PID
|
pregnancy
acute peritoneal signs other surgical emergency failure of outpatient management no response to oral therapy patient inability to comply |
|
work up menorrhagia
|
thyroid
bleeding disorder anovulation adneomyosis endometrial hyperplasia cervical lesion malignancy |
|
Management of Fibroids alternative to hysterecotomy
|
NSAIDs
OCPs GnRH agonists Aromatase inhibitor Antiprogestins- Mifepristone Uterine artery embolization MRI guided ultrasound Myomectomy- abdominal, lapaoscpic, hysteroscopic |
|
Fever abdominal pain
|
acute abdomen goes to surgery
triple antibiotics copious irrigation, deibriedment placement of drains closure of fascia with delayed absorbable suture like polydioxanone retains strength for 12 weeks close only the fascia dont close the subcutaneous space |
|
Aromastase inhibitors
|
block both ovarian and peripheral estrogen production
can be used to manage fibroids vasomotor symptoms, vaginal dryness, decrease in bone mineral density, and increase in fracture risk adverse affect on cholesterol /lipid profile |
|
Complications of UAE
|
fever from degeneration of myoma
infarction of myoma bacterial seeding into the myoma bed or vessel with myometritis uterine perforation by the catheter, inraperitoneal bleeding, peritonitis, or injury to a viscus bacteremia from the arterial puncture site bleeding or hematoma at the arteriotomy site myometrial necrosis perforation of the uterine artery by catheter with intaperitonneal bleeding , peritonitis, injury to a viscus bleeding or hematoma at the arteriotomy site myometrial necrosis perforation of the uterine artery by catheter with intraperitoneal bleeding or broad ligament or retroperitoneal perforation of uterus with potential for bowel injury |
|
3 ways to place a drain by interventional radiology
|
1. percutaneous through the lower back
2. transgluteal 3. transrectal |
|
Size greater than dates
|
incorrect gestation dating
multi fetal pregnancy uterine fibroids larged adnexal mass molar preganncy |
|
Gestational Trophoblastic Disease
|
Partial mole GTN seen in 3-8 % of cases
Complete Mole 8-20% of cases Labs- CMP, CBC, HCG Chest XRAY or CT, CT- Abd and Pelvis MRI or CT with contrast of brain be sure to exclude possiblitlity of New intrauterine pregnancy with ultrasound treatment based on if non metastatic GTN confined to uterus, Metastatic with good prognosis, Metastatic with poor prognosis |
|
Gestational Trophoblastic Disease
what are poor prognostics |
metastatic with poor prognosis
pretherapy HCG > 40, K long duration >4 months from antecedent pregnancy antecedent pregnancy was a term pregnancy brain or live mets prior chemo |
|
treatment of Nonmetastatic GTN
|
Hysterectomy if child bearing completed (requires less chemo)
Methotrexate IM weekly (dose vary) until at least 2 negative weekly HCG titers |
|
Low Risk Metastatic GTN
|
Hysterectomy is again optional to decrease duration of chemo
single agent again treatment with MTX (IM weekly) until at least 2 negative weekly HCG titers |
|
High risk Metastatic GTN
|
EMA/CO Etoposide/MTX & Folate/Dactinomycin
cyclophosphamide/vincristine surgical excision or embolization of liver or brain mets when necessary biopsy of lesions suspicious for GTN vaginal mets is not necessary |
|
How does Methotrexate work
|
acts by blocking the dihydrofolate redeuctase enzyme and blocking purine synthesis for DNA. Is S phase dependent
|
|
Contraindications to Methotrexate
|
Renal insufficiency - MTX undergoes renal cleared
previous reaction to methotrexate preexisting immune or marrow suppression acitve peptic ulcer disease COPD possibility of an intrauterine pregnancy |
|
Preop diabetic
|
hold routine insulin
intraoperative sliding scale or by baseline infusion at 1 unit/hr Ideal management fasting glc < 120 |
|
Pulmonary Function Tests which are concerning
FEV-1 FVC PO2 |
FEV-1- (forced expiratory volume in 1 second) < 1 liter
FVC forced vital capacity <70% of predicted PO2 < 60 mmg hg should preclude general anesthesia |
|
Doing Leep
|
inject at 4 and 8 of the cervical vaginal junction corresponding to uteral sacral nerves as they travel in the uteral sacral ligaments
|
|
Local C/S under anesthesia
|
Infiltration anaesthesia for Caesarean Section
Michael Cooper Indications: Local anaesthetic infiltration for caesarean section (CS) is a rarely used technique. It has application in the rare situation where both general and regional anaesthesia is contraindicated and in countries with limited health resources. There are few contemporary reports of this technique (1, 2) and most descriptions come from countries (3, 4) where: 1. anaesthetic expertise is lacking, or limited, 2. anaesthetic equipment or gas supplies are unavailable, or 3. a single individual is required to both operate and anaesthetise. Local anaesthetic infiltration has also been used in rare situations such as: 1. Myotonic dystrophy where it has been used in conjunction with spinal anaesthesia for CS with bupivacaine applied directly to the myometrium to relieve incoordinate cycles of uterine spasm / atony (5) 2. Familial dysautonomia (Riley-Day syndrome) (1) Advantages of local anaesthetic infiltration: 1. Allows for immediate commencement of surgery in emergency situations. 2. Useable when central neural blockade (CNB) is technically difficult, eg. kyphoscoliosis (2) , unpredictable in result or contraindicated. 3. Retains the patient's protective airway reflexes. 4. Avoids the sudden haemodynamic changes that may occur with CNB. Technique: A long (18 cm) spinal needle minimises the number of individual injections required. Skin: The skin of the anterior abdominal wall is supplied by the anterior and lateral cutaneous branches of the lower six intercostal nerves and the iliohypogastric and ilioinguinal nerves. For a transverse suprapubic (Pfannensteil) incision simple subcutaneous infiltration is adequate. Fat: The fat layer is relatively devoid of innervation and a large amount of local anaesthetic may be wasted by infiltrating this layer, which is relevant to the often large total dose used. Fascia: Direct infiltration can be used; other authors have recommended bilateral rectus sheath blocks (6, 7). Retropubic space: This can be a difficult area to anaesthetise and may require additional infiltration retropubically and into the pyramidales muscles. Parietal peritoneum: Many authors report this to be a difficult area to anaesthetise and several techniques have been described. 1. The injection of several mls of solution through the fascia (before its division) helps to separate the layers and to anaesthetise the parietal peritoneum. 2. Once the peritoneum is opened, the instillation of 10-15ml of local anaesthetic into the peritoneal cavity. 3. Once the peritoneum is opened, radiate intraperitoneal injections. Visceral peritoneum / uterus: These do not need infiltration, but doing so separates the visceral layer of the peritoneum from the lower uterine segment. Some authors (7, 8) have described field block anaesthetic techniques for vertical classical skin incisions which involve multiple injections and increased discomfort for the patient. They may take longer and require greater skill and use a greater volume of local anaesthetic than simple direct infiltration. These papers, which described the authors personal experiences in the 1950s and 60s cite local anaesthesia as giving better neonatal outcomes than general anaesthesia for CS. Macintosh (9) warns of the risk of rectus sheath block in a patient with abdominal distension (from whatever cause). As the anterior and posterior layers of the sheath are almost in apposition, the needle may pass through both structures giving the false impression that only the anterior layer has been penetrated. Drugs, vasoconstrictor and volume: Many different agents have been used depending on the availability of the drug and the familiarity of the operator with the agent. Bearing in mind the maximum recommended doses of local anaesthetic agents (Table 36.3), the volume required may be as high as 100ml. Not all of this may be required initially, and further infiltration may be necessary after delivery to close the superficial layers. Obviously, local anaesthetic toxicity (Chapter 89) to mother and fetus is a significant risk. This should influence the choice of agent in terms of : 1. The concentration which is required for effective infiltration anaesthesia. 2. The decision to add a vasoconstrictor in order to increase the amount of drug that can be used with safety. 3. The toxicity and metabolism profile of the local anaesthetic. 4. The fetal / maternal ratio of the local anaesthetic. Substantial uptake of lignocaine in the fetal liver can occur (10). Ester local anaesthetics such as 2-chloroprocaine have a half-life in neonatal blood of 43 secs (11). Fetal acidosis favours drug ionisation, retention of local anaesthetic within the fetus and increased risk of fetal toxicity. Choice of agent: Lignocaine 0.5% or chloroprocaine 1% with 1:200,000 adrenaline is adequate for infiltration anaesthesia and both agents are rapid in onset. The addition of adrenaline allows for the use of a greater overall dose. Longer acting agents such as bupivacaine have a slower onset time and a lower free drug concentration in the fetal blood (12). The addition of hyaluronidase has been described (8) but may increase absorption. Surgical technique: Gentle tissue handling is required and retractors are generally not well tolerated. If adequate retropubic anaesthesia has been obtained, a Doyen retractor can be used. Adequate exposure of the uterus can be obtained by using corner stitches to rotate the uterus (4). Manoeuvres that can cause significant pain are: 1. Disengagement of the fetal head from the pelvis. 2. Peritoneal traction (may also cause vagal effects). 3. Externalisation of the uterus. Blood loss is not increased using this technique (4). In their series of 141 caesarean sections, Ranney and Stannage (7) reported 61 patients having a second, 14 a third and 2 a fourth operation. Only three patients wanted to have general anaesthesia for their repeat procedure. |
|
Lidocaine dose
|
7 mg/kg with epi of 1% lidocaine
4.5 mg/kg without epi of 1% lidocaine 10 mg/ml use 0.5 % 60 cc without epi 100 cc with epi |