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Gyn Tx
Gynecology
| Question | Answer |
|---|---|
| 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:
Abarnard
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