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Gyn Tx


Higher estrone:estradiol ratio with: Oral estrogen; Higher doses than systemic therapies
More physiologic estradiol:estrone ratio with: systemic (parenterally) estrogen; lower doses than PO estrogens
Most appropriate for urogenital symptoms vaginal estrogen
All approved for vasomotor symptoms Transdermal estradiol gels (all are QD dosing)
In women with a uterus who receive estrogen, a progestin must be given: for ≥ 10 days per cycle to prevent endometrial hyperplasia
In woman without a uterus who receive estrogen, give: estrogen only (don’t need progestin)
Most effective tx for hot flashes Hormone therapy (no effect of progestins on sx)
Most effective tx for sx of urogenital atrophy (vaginal dryness and sexual discomfort): Hormone therapy; may worsen urinary incontinence
Estrogen tx: osteoporosis benefit seen: primarily within >5 yrs of therapy; max protection requires ≥ 10 yrs tx
Reevaluate HRT every: 3-6 months for possible taper or discontinuation
Alt tx for hot flashes Venlafaxine, paxil, Prozac, clonidine, gabapentin
In postmenopausal women, testosterone can improve: Libido, sense of well-being, energy
Women should be on the lowest HRT dose that controls sxs & re-evaluated every __ for possible taper or d/c 3-6 months
HRT indications Tx mod-severe vasomotor sxs assoc w/menopause, mod-severe sxs of vulvar / vaginal atrophy assoc w/menopause, prevent postmenopausal osteoporosis
Benefits of HRT Alleviation of vasomotor symptoms, relief of vaginal dryness/atrophy, raised HDL/lowered LDL, alleviation of mood swings and fatigue, reduced risk of fractures, reduced risk of colon cancer, reduced risk of diabetes
Alt options to HRT to tx menopausal sxs herbal/complementary, bio-identical estrogens, antidepressants, neuroendocrine agents, lifestyle and behavioral modifications
Most studied herb for menopausal sxs: somewhat effective for tx of hot flashes Black Cohosh (Remifemin)
Gabapentin has shown some effect on __ Hot flashes
__ has the highest percent of elemental calcium Calcium carbonate
Nonsteroidal compounds with estrogenic activity derived from plants (phytoestrogens)= soy isoflavones
Tx of cervical abnormalities Cyrotherapy of Cervix; LEEP; Laser; Cervical Conization
Endometrial hyperplasia w/o atypia: tx Provera; Micronized Progesterone; if HRT is resumed, resume at higher dose progestin for longer time, repeat bx 3-6 mos
endometrial ca tx TAH w/BSO
Adenomyosis tx D&C, GnRH agonist, mifeprostone, or TAH (definitive)
ovarian cyst tx small (<8 cm): monitor x1-2 cycles; large: lap exploration
CIN tx electocautery, laser tx, conization, or LEEP; poss TAH for severe dz
vulvar/vaginal ca tx excision; topical 5-FU; laser tx
hydatidiform mole tx benign: chemo; high-risk: chemo +/- adj xrt & surg (curettage or hysterectomy)
Painful bladder syndrome tx Dietary restrictions (Low oxalate diet)
endometritis tx 1stline: clinda + gent; if refractory by 24-48 hr, add amp; Flagyl if sepsis
PCOS Tx options OCP. Metformin. Anti-androgen ( if NOT PG): spironolactone (for hirsutism), finasteride or flutamide. Clomiphene for infertility. Dexamethasone for high DHEA.
Contraceptive methods: most vs least effective Most: IUD, implants, sterilization; Least: diaphragms, condoms, withdrawal/rhythm
OCP CIs PG. AUB. Hx of VTE/CVA/CAD. Estrogen-dependent tumor. Liver dz. Smoker if >35 yo
OCPs MOA inhibition of midcycle LH/FSH surge: inhibits ovulation, thickens cervical mucus, alters endometrium
Gonorrhea tx CTX 250mg IM or Cefixime 400mg PO. Also give Azithro 1gm PO to empirically tx likely co-infection with CT
Chlamydia tx Azithro 1gm PO x1, or doxy 100mg PO BID x7d. Tx partners from within last 60 days. Avoid sex for 7 days after tx.
LGV tx Doxy 100mg PO BID x21 days
HSV tx Ast episode: acyclovir 40mg PO x7-10d (or 200mg 5x/day), vs famciclovir or valaciclovir. Suppression tx for >6 outbreaks/yr
syphilis tx TOC Benzathine PCN 2.4M U IM x1 (latent >1 yr & tertiary: Q week x3 wk. Neurosyphilis: aq PCN q4h x14d
chancroid tx azithromycin 1gm x1 (or CTX 250mg IM x1, or erythro 500 PO TID x7d, or cipro 500 BID x3d)
HPV tx Podophyllin 10-25% topical. Trichloroacetic acid 80-90% Q week. Podofilox gel BID. Imiquimod TIW. Cryotherapy for internal lesion.
fibroid mgmt Asx: bimanual exam Q6 months. Sx: progestin for AUB. Pre-op GnRH agonist -> temporary menopause (fibroid shrinks in absence of estrogen). Mirena.
Endometriosis mgmt Prevention of ovulation. OCP. Danazol x4-6 months. GnRH analogs x6 months. Progestins. Lap ablation of lesions vs BSO
PMS mgmt Tx sxs. Breast pain: danazol, bromocriptine. Bloating: spironolactone, CaCO3. Mood: SSRI, monophasic OCP. Exercise, diet
OCP: use with caution if pt has: DM, HTN, HLD, hx of biliary dz
OCP approved for OMDD Combo pill with progestin drosperinone (diuretic for water retention). CI in renal/liver/adrenal dz
Plan B OCP 2 tabs of 0.75mg levonogestrel (taken together vs 12h apart), within 72h of intercourse
Depo-Provera = injectable progesterone, Q3 months (AE: wt gain, irregular menses)
Implanon = single rod implant that releases 68 micrograms etonorgestrel daily
Ortho Evra = transdermal patch: 150 micrograms norelgestromin & 20 micrograms ethinyl estradiol daily. 3 weeks on & 1 week off
Nuva Ring = 120 micrograms etonogestrel & 15 micrograms ethinyl estradiol daily. 3 weeks in, 1 week off (withdrawal bleeding)
Essure = transcervical (chemical or coils) used to scar proximal portion of fallopian tubes or cornua.
IUD types ParaGard (copper) for 12 years. Mirena (releases levonorgestrel) for 5 years.
most effective reversible means of contraception OCP: (ethinyl estradiol or mestranol) + (norethindrone or levonorgestrel or norgestimate)
minipill OCPs progesterone only; 1/2 as effective as combo pills; best for lactating F or >40 yo
depot contraception usually medroxyprogesterone, 150mg q90 days; 0.3% fail rate in 1st year
infertility tx clomiphene; artificial insemination;assisted repro (IVF)
Created by: Adam Barnard Adam Barnard