WomensHealth_Test2
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| Pre-conception care always think... | BMI!!!
Age, Hx, Meds, FH, substance abuse, diet
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| During physical exam for preconception care what should you check for? | Dental Caries
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| During labs for preconception care what should you check for? | Rubella, varicells, HepB, HIV, RPR, CBC, G/C culture
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| Which immunizations can you NOT give if pregnant? | MMR & Varicella
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| How much folic acid pre-pregnancy? | .4-.8mg daily
_4mg if hx of neural tube defects
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| When is 1st visit recommended? | ~6-8 wks gestation
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| Gravida-v Para- w x y z | v=# pregnancies
w=# full term births
x=# pre-term births (<37wks)
y=# abortions (spont, induced, ectopic)
z=# living children
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| How would you calculate estimated date of confinement (EDC=Delivery Date)? | Add 7 days to LMP and subtract last month:
LMP: 2/20/11 then EDD=11/27/12
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| Blue/purple coloration of cervix/vagina | Chadwick's Sign
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| Palpable softening at isthmus | Hegar's Sign
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| What MUST you do on physical exam for 1st prenatal visit? | Pap smear, Chlamydia/Gonorrhea Swab
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| Additional labs for women @risk | TB, HepC, Varicella, Trich Vaginalis, HSV, Hgb A1C
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| What's absolutely necessary to perform at the first prenatal visit | Ultrasound to confirm pregnancy
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| When is the second trimester? | Week 13-end of 26
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| When is the third trimester? | Beginning of week 27
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| How many times should she visit in the first 28 weeks? (1st and 2nd Trimester) | Every four weeks
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| How many times should she visit in wks 28-36 | Every two weeks
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| The first fetal movements (if first pg usually @18-20wks) | Quickening
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| After the first visit, what should you begin monitoring? | BP
Fetal Heart Tones (120-160bpm norm)
Fundal height
Extremities
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| In third trimester what should you do to see the position of the head? | Leopold Maneuvers
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| In third trimester why check the cervical exam? | For: Dilation
Effacement
Station
Presenting Part
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| Station 0 of head | Head is @bony ischial spines & fills the maternal scrotum
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| Negative Stations of head | Number of cm head is above the ischial spines
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| Positive stations of head | Number of cm head is below the ischial spines
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| What should you test for at every visit?? | Urine for protein & sugar
_Test for CBC in early 3rd trimester to assess for anemia
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| When should you screen for gestational diabetes? | At 24-28wks
_>1 abnormal value is sign after 75g 2hr oral glucose tolerance test
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| During initial labs you use this and then test again in the third trimester. If this tests NEGATIVE then should give Immunoglobulin at 28-30wks | Rhogam
_Rh Immune Globulin 300ug
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| When should you test for GrpB strep (swabbing both lower vagina & rectum). | Btwn 35-37wks (right before delivery)
_If +, need intrapartum Abx prophylaxis to decrease incidence of neonatal GBS
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| When can you offer aneuploidy screening? | At <20wks
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| 1st Trimester Combined Test for Aneuploidy (Down's) | Performed 11-13wks w/nuchal translucency w/serum markers
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| 1st Trimester Quad Screen for Aneuploidy (Down's), Neural Tube Defects, Trisomy 18 | Maternal serum screen
_Can perform @15-18wks (as late as 22wks)
_AFP _hCG _uE3 _Inhibin A
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| In the 1st trimester, why do an obstetric ultrasound? | For dating purposes, to ck for bleeding or pain, locate pregnancy location
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| In the 2nd trimester, why do an obstetric ultrasound? | Fetal growth, anatomy survey, placenta location
_@18-20wks
_Level 1:Basic
_Level 2:In Depth
Determine future sex
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| In the 3rd trimester, why do an obstetric ultrasound? | Fetal growth, presentation, bleeding
_Biophys Profile
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| During the 3rd trimester do a biophysical profile to check for what? | Fetal movement, tone, breathing.
Amniotic Fluid Volume
Results of nonstress testing
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| Recommended weight gain for BMI <18.5 during pregnancy (underweight) | 28-40 lbs
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| Recommended weight gain for BMI 18.5-24.9 during pregnancy (normal weight) | 25-35 lbs
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| Recommended weight gain for BMI 25-29.9 during pregnancy (overweight) | 15-25 lbs
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| Recommended weight gain for BMI >30 during pregnancy (obese) | 11-20 lbs
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| Tests for fetal well-being | Fetal movement/Kick counts
Non-stress Test (NST)
Contraction Stress Test (CST)
Biophysical profile
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| Antiemetics used for N/V during pregnancy | Phenergan, Compazine, Reglan, Zofran, Ginger
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| Uterine activity that results in progressive dilation & effacement of the cervix | Labor
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| Thinning/shortening of cervix length. Normal is >2.5cm | Effacement
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| Diameter of cervical os in centimeters. Complete=10cm dilation & 100% effacement | Dilation
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| Regular intervals, gradually increasing in frequency. Increasing intensity; cervical dilation, back/ab pain, no sedational relief. | True Labor
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| Irregular intervals & duration of contractions, intensity NOT changed, no cervical dilaiton, low ab pain, can relieve w/sedation | False Labor
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| Pooling of amniotic fluid in vagina or direct visualization of fluid leaking through cervix may support this | Membrane Rupture
_Leaks amniotic fluid
_Nitrazine Test: Intact pH-5-6
Ruptured pH6.5-8 *blue
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| Fern test would show what? | Amniotic fluid status (if dry, will have fernlike pattern)
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| Interval btwn labor onset & full cervical dilation & effacement. | First stage of labor
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| Begins with first regular contraction & ends at 3-4cm. Rate of dilation is slow ~.5cm/hr | Latent phase in the first stage of labor
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| Follows the latent phase (of first stage of labor) with rate increasing to ~1cm/hr. Ends with complete dilation | Active phase in the first stage of labor
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| Begins w/complete dilation & ends with infant delivery. Entails the "pushing" phase of birth | Second stage of labor
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| Delivery of infant & ends with delivery of placenta | Third stage of labor
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| Uterine contractions will increase in freq/strength in the POWER PROGRESS of labor. will lead to increased sensitivity of uterine m fibers to oxytocin. What causes initial change? | Prostaglandins E2 & F2alpha
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| During the power phase, what is the adequate labor of uterine contractions | 3-5 contractions in 10min
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| measures frequency and duration of contractions, but not intensity | External tocodynamometry
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| Measures frequency, duration AND intensity of contraction via IUPC (intrauterine pressure catheter) | Internal tocodynamometry
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| Macrosomic Infant | >4500 grams
_Large infants
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| Relation of the fetal presenting part to the right or left side of the maternal pelvis | Position
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| Bounded by the symphysis (top), sacral promontory (posterior), & pectinate lines (lateral) | Inlet part of bony pelvis
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| Midpoint of symphysis (top), midpoint of sacral curve (posterior), & ischial spines (lateral) | Midpelvis part of bony pelvis
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| Inferior border of symphysis (anterior), tip of sacrum (posterior), ischial tuberosities (lateral) | Outlet part of bony pelvis
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| Most common, best suited for childbirth | Gynecoid position
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| Occiput posterior presentation | Anthropoid
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| Most UNFAVORABLE position for delivery | Android
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| Least common type of delivery | Platypelloid
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| Passage of the widest diameter of the presenting part to a level below the plane of the pelvic inle | Engagement
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| #2 Flexion | With the head completely flexed, the fetus presents the smallest diameter of its head
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| #3 Descent | Greatest rate of descent occurs during the latter portions of 1st stage of labor and during 2nd stage of labor
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| #4 Internal Rotation | Rotation of presenting part from its original position (usually transverse) to anteroposterior position as it passes through the pelvis
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| #5 Extension | Occurs once fetus descends to level of introitus; head will extend beneath maternal pubic symphysis & head delivers
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| #6 External Rotation (Restitution) | The head rotates 45 degrees to line up with shoulders which are oblique in maternal pelvis
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| Uterus rises in abdomen, globular configuration, gush of blood and/or lengthening of umbilical cord | Third Stage of Labor
_Placental delivery
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| Baseline Rate of Fetal Heartrate | 120-160
_>180 severe tachy
_<100 severe brady
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| Fluctation in HR with changing amplitude in every beat | Short term variability
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| Wavelike pattern that changes 4-6 cycles/min | Long term variability of HR
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| Acceleration, increases 15bpm above baseline & lasts 15 seconds | Periodic changes in fetal HR
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| Mirrors shape of contraction. Due to head compression. Physiologic. | Early deceleration of HR
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| With respect to timing of contraction, shape & severity. Caused by cord compression | Variable deceleration in HR
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| Caused by fetal HYPOXIA, placental insufficiency, maternal HYPOtension or hypoxia | Late deceleration in HR
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| Short term variability with long term variability present in fetal heartrate | Normal fluctuation
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| Lamaze, relaxation techniques | Psychoprophylaxis
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| Sedatives (Vistaril), Narcotics (Demerol, Stadol, Nubain), Dissociative Drugs (Ketamine) | Systemic Drugs during labor
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| Paracervical block, pudendal block, epidual | Labor Pain Relief
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| Perineal laceration involving only skin & vagina | 1st degree perineal laceration
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| Perineal laceration involving skin, vagina & deeper perineal tissues | 2nd degree perineal laceration
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| Perineal laceration involving external anal sphincter & skin, vagina & depper perianal tissues | 3rd degree perineal laceration
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| Perineal laceration involving rectal mucosa, external anal sphincter,skin, vagina & depper perianal tissues | 4th degree perineal laceration
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| 9-13 points on Bishop score | High likelihood of successful induction of labor
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| 0-4 points on Bishop score | High likelihood of failure with induction of labor
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| Stripping membranes, amniotomy, PGE gel, oxytocin, Cytotec | Induction of labor
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| Complications of oxytocin | 1)Uterine Hyperstimulation: >5 contractions every 10 minutes
2)Fetal distress/intolerance to labor: LATE decelerations of fetal HR
3)Water intoxication: caused by antidiuretic properties of oxytocin
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| Period following delivery of baby & placenta to about 6 weeks postpartum. | Puerperium
_Anatomy resolves: uterus involutes, cervix loses marked vascularity/glandular hypertrophy/hyperplasia, ovarian function(lactating influenced by prolactin. While lactating, no ovulation). Vaginal vault will decrease in size.
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| How long hospitalize after birth? | Natural: 1-2days
C-Section: 2-4days
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| Autoab's attack ECM & basement. Affects all levels of skin. 22% genetic. _Trauma: Kobner's phenom (possible) _Contact dermatitis | Lichen Sclerosus
_POST Menopause
_Pruritis
_Dysuria, Dyspareunia(painful sex)
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| Itchy "cellophane paper" waxy/hyperkeratotic WHITE plaques. See purpura, erosion, fissures. (NOT seen where there is keratin, hair or mucous membranes) | Lichen Sclerosus
_Menopausal women
_On vestibule, vagina, rectal mucosa
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| Left untreated this disease which causes cellophane waxy white plaques may cause squamous cell carcinoma. | Lichen Sclerosis
_At risk of old or HYPERkeratotic lesions
_May be HYPOthyroid
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| Labs for dx of Lichen Sclerosus (itchy cellophane paper waxy keratin plaques) | Vulvar Punch Biospy
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| Tx of of Lichen Sclerosus (itchy cellophane paper waxy keratin plaques) | TOPICAL Ultrapotent Steroid OINTMENT
_Temovate!!
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| Cysts form here as result of obstruction caused by trauma or inflammation. Abscess forms from infected cyst or primary gland infection (polymicrobial or STI) | Bartholin Cyst (in labia minora)
_Acute, painful UNILATERAL labial swell
_Painful sex, pain when sitting/walking
_Tender, fluctuating mass that's red/swollen w/cellulitis.
_May see FEVER associated w/infection
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| Tx of Bartholin cyst | Incision/drainage with Word Catheter
_Culture the pus
_Empirically give Keflex or Doxy
_Sitz baths 2-3dd after I&D
_NO SEX till remove catheter
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| Neoplastic cells in squamous epithelium. | Vulvar Intraepithelial Neoplasia (VIN)
_Only VIN 2/3 are true precursors to vulvar cancer
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| Associated with HPV 16 & 18. Usual type. See in young women. Risk: smoking, immunosuppresion, many sex partners | Vulvar Intraepithelial Neoplasia Usual(VINu)
Dx: Vulva Colposcopy (acetic acid, lesions will change color from gray to white or red to black)
_Typically NO sx
_Often associated with cervical intraepithelial neoplasia, therefore MUST perform colposcopy
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| When should you biopsy a VIN (vulvar intraepithelial lesion) | If has pigment
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| Treatment of VINu (vulvar intraepithelial lesion-usual) with medication | All are OFF-LABEL; none really guarantee cure
-5FU (Efudex)
-Interferon (Intron-A)
-Imiquimod (Aldara)
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| Standard of care tx of VINu | Surgical Tx:
CO2 laser vaporization (destroys entire epithelium)
Local wide excision
Vulvectomy
Post-Tx Rate: 30-50%
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| NOT associated with HPV. Differentiated, effects older women >70, involves LOWER 1/3 of epithelium ONLY | VINd (vulvar intraepithelial lesion-differentiated)
_Associated w/sqaumous cell hyperplasia (Lichen's...)
_Prevention: Tx of underlying condition
_Tx: Surgery
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| Post-treatment of VIN | Colposcopy vulvar inspection at 6mos, 12mos and then annually.
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| Most common symptom of vulvar cancer | Pruritis
_Usually asymptomatic, therefore INSPECT THE VULVA
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| Varies in appearance from large, exophytic, cauliflowerlike lesion to small ulcerative lesion with lesion to small ulcerative lesion with surrounding hyperkeratosis | Squamous cell carcinoma in vulva
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| Raised lesion w/ULCERATED center & rolled borders | Basal Cell carcinoma in vulva
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| Seen @labia minora & clitoris. Raised DARK pigment lesion | Malignant Melanoma on vulvar cancer
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| Tx of vulvar cancer | Surgical removal with inguinal node dissection (radiate if lymph involved)
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| HPV must be present in order to develop this neoplasm. May have NO history of cervical cancer/neoplasms. | Vaginal Intraepithelial Neoplasia (VaIN)
_In UPPER 1/3 of vagina
_Usually preceded by sqaumous carcinoma of vulva or cervix
_At risk if have hx of CIN III
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| Benign Viral proliferation of VaIN | VaIN 1 (Vaginal Intraepithelial Neoplasm-1)
_Observation with cytology/HPV/Colposcopy every 6months
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| Intermediate risk of proliferation of VaIN | VaIN 2 (Vaginal Intraepithelial Neoplasm-2)
_Surgery +/- chemo
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| True precursor to vaginal cancer | VaIN 3 (Vaginal Intraepithelial Neoplasm-3)
_Surgery +/- chemo
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| Detection of VaIN (Vaginal Intraepithelial Neoplasm) | Pap Smear (cytology)
Colposcopy
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| When would you perform a vaginectomy when dealing with VaIN (Vaginal Intraepithelial Neoplasm) | Suspect invasion, >40, cytology & colposcopy differ & if extended sampling is needed.
_Will remove UPPER 1/3 of vagina (90%success)
-SE: shorter vagina, blood loss, skin graft, poor sexual functioning
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| Used to destroy dysplastic cells to 1.5mm depth but unable to assess lesions extending into vault or lesions within surgical scar from TAH & operator dependent | Laser Vaporization
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| Topical chemo used for VaIN tx _ONLY use if other tx NOT available! | 5FU (50-85% success). Causes vaginal epithelium to slough.
_ONLY used if other tx options NOT feasible!
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| Most common reason for vaginal cancer | Metastasis from endometrium, ovary or cervix
_ONLY when PRIMARY site is from vagina can you call it vaginal cancer
_<20% dx under 50
_Squamous Cells MOST common
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| Most common cell type in vaginal cancer | Squamous cell
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| Milky discharge, vaginal odor & post-sex bleeding are signs of this | Vaginal cancer
_Since so rare, no standard tx
_Combo: vaginectomy & radiation
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| MOST common type of ovarian cyst. NON-malignant. Will regress after 1-2 menstrual cycles. | Follicular Cyst
_Mature follicle won't rupture OR
_Non-dom follicles will not die in presence of Graafian
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| NON-resorption of blood from the cavity of the corpus luteum (>3cm) called this. Will resolve after 1-2 menstrual cycles | Corpus Luteum Cyst
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| This cyst, seen with INC chorionic gonadotropin levels is typically seen bilaterally. Fluid is clear, straw-colored. _Hydatidiform Mole _Choriocarcinoma _Clomid Therapy for infertility | Theca Lutein Cyst
_Will regress if tx underlying disorder
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| Half of all benign neoplasms are this. Come from germ cells & found along migration pathway of germ cells-->glands. | Mature Teratoma
_Will see well-differentiated tissue from any of 3 germ layers (ectoderm, mesoderm, endoderm)
_Cyst lined with keratined squamous epithelium w/abundant sebaceious & apocrine glands
_USUALLY ectodermal origin: hair, teeth
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| This cyst doesn't typically have sx unless secondary to torsion or rupture. Have urinary frequency/urgency. See back pain. Will feel a pelvic mass on bimanual exam. | Mature Teratoma
_Will see well-differentiated tissue from any of 3 germ layers (ectoderm, mesoderm, endoderm)
_Cyst lined with keratined squamous epithelium w/abundant sebaceious & apocrine glands
_USUALLY ectodermal origin: hair, teeth
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| Dx of Mature Teratoma _Will see well-differentiated tissue from any of 3 germ layers (ectoderm, mesoderm, endoderm) _Cyst lined with keratined squamous epithelium w/abundant sebaceious & apocrine glands _USUALLY ectodermal origin: hair, teeth | Transvaginal ultrasound (unilateral, COMPLEX cyst)
CEA, CA-125, AFP, bHCG (all should be within normal)
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| Tx of Mature Teratoma _Will see well-differentiated tissue from any of 3 germ layers (ectoderm, mesoderm, endoderm) _Cyst lined with keratined squamous epithelium w/abundant sebaceious & apocrine glands _USUALLY ectodermal origin: hair, teeth | Lapartomy/Laparoscopy
Ovarian cystectomy/oophorectomy
_10% chance of recurrence
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| Highest incidence among women 65-74 | Ovarian Cancer
_2nd most common gyno cancer
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| Incessant Ovulation Theory of Ovarian cancer | Repeated ovarian epithelial trauma by follicle rupture & subsequent epithelial repair causes genetic change within surface epithelium
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| Gonadotropin Theory of Ovarian cancer | Persistent stimulation of ovaries by gonadotropin coupled w/local effects of endogenous hormones. INC surface epithelial proliferation & subsequent mitotic activity.
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| Reduce risk for ovarian cancer | Multiparity
Breastfeeding
Long-Term OCC use
Bilateral Tubal Ligation
Low Fat Diet
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| Serous epithelial neoplasm in OVARIAN cancer | From fallopian tube
_MOST common type!!!
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| Mucinous epithelial neoplasm in OVARIAN cancer | From cervix
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| Clear cell epithelial neoplasm in OVARIAN cancer | From mesonephros
_<1%
_Rarely reach size of serious/mucinous neoplasms
_Bio AGGRESSIVE
_HYPERCalcemia & HYPERpyrexia
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| Neoplasm from germ cells, 20-30yo, grow rapidly, favor lymphatics & contain mix of tumor types. Typically unilateral. | Germ Cell Neoplasms in Ovarian Cancer
_Produce helpful tumor markers
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| Dysgerminoma, endodermal sinus tumor, immature teratoma, embryonal carcinoma & choriocarcinoma | Subtypes of Germ Cell Neoplasms in Ovarian Cancer
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| MOST common type of germ cell neoplasm | Dygerminoma
_Unilateral
_<30
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| Bilateral germ cell tumor with MOST RAPID growth. Makes AFP | Endodermal Sinus Tumor
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| 2nd most common type of germ cell neoplasm seen typically under 20. Makes AFP | Immature Teratoma
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| Uncommon germ cell tumor with rapid growth & EXTENSIVE SPREAD. Makes AFP AND HCG | Embryonal Carcinoma
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| Germ cell neoplasm seen with precocious puberty, uterine bleeding or amenorrhea. VERY RARE. 20's | Choriocarcinoma
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| MOST common type of sex-cord stromal tumor. Causes HYPERestrogenism (precocious puberty, post menopause bleeding). In 50s. | Granulosa Cell
_Sex-Cord Stromal Tumors
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| Rare sex-cord stromal tumor that causes HYPERandrogenism. See in 30-40. | Sertoli-Stromal cell
_Sex-Cord Stromal Tumor
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| No sx until advanced, Nausea, dyspepsia, changed bowel habits, ab distension, pelvic pressure, abnormal vaginal bleeding, wt loss | Ovarian Cancer
_Ascites, Inguinal Lymphadenopathy, Pelvic mass
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| When would you order CA-125? | Suspect EPITHELIAL ovarian cancer
>65U/mL
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| When would you order hCG, AFP, LDH | Suspect GERM cell tumor
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| Only 2 germ cell tumors to for sure show hCG | Choriocarcinoma
Embryonal Carcinoma
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| Only 2 germ cell tumors to definitely NOT show AFP | Choriocarcinoma
Dysgerminoma
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| Tx of Ovarian Cancer | Consult gyno oncologist
Surgical Staging
Chemo
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| Uncontrolled androgens/metab will INC testosterone, androsterendione, DHEA-S. Will see INSULIN-RESISTANCE & HYPERinsulinemia because insulin changes FSH/LH effects on ovarian function. Will DEC synthesis of SHBG & IGF1. Will see DEC Adiponectin. | Polycystic Ovarian Syndrome
_Ovarian Androgen EXCESS
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| Under INC levels of insulin androstenedione what happens to androgens? | Androgens converted to testosterone instead of estrogen.
This will INC SHGB but because of already high insulin levels, production will be decreased, causing INC in free testosterone.
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| Infertility, anovulation, obesity, acne, hirsutism, male-pattern baldness, acanthosis nigricans, metabolic syndrome, sleep apnea | Polycystic Ovarian Syndrome
_Ovarian Androgen EXCESS
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| What must you rule out before you dx female with Polycystic Ovarian Syndrome _Ovarian Androgen EXCESS | HYPERprolactinemia
CAH
Cushings
--After rule out, THEN must have 2 of 3: oligomenorrhea, HYPERandrogenism, polycystic ovaries
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| What would you expect to find on ultrasound of Polycystic Ovarian Syndrome _Ovarian Androgen EXCESS | >12 follicles in each ovary (2-9mm)
String of Pearls appearance
Ovaries >10ml
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| What lab would be a good indicator of Polycystic Ovarian Syndrome _Ovarian Androgen EXCESS | LH: FSH will =3:1
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| Tx for Polycystic Ovarian Syndrome _Ovarian Androgen EXCESS | Weight Loss (INC SHGB, dec testosterone)
Metformin (only if have HYPERinsulin)
Combined Oral Contraceptives
Fertility consult
Provera (protects endometrium)
Lifestyle modification
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| Risks associated with Polycystic Ovarian Syndrome _Ovarian Androgen EXCESS | Endometrial Hyperplasia/Carcinoma
Type2 DM
HTN
High Cholest
Cardio Dz
Stroke
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| Bartholin glands are located where? | At 4 and 8 o'clock position of labia minora
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| Most common cause of vaginal cancer | Metastasis
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| Stratified squamous epithelium in cervix | Exocervix
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| squamo-columnar junction & metaplastic squamous epithelium in cervix | Transformation zone of cervix
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| Single layer mucin-producing columnar cells in cervix | Endocervical canal
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| HPV will infect which level first before remaining latent, then activated by immune deficiency | Basal Layer
_mature basal cells containing HPV will migrate from basement membrane to surface
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| High risk type of HPV | HPV 16 & 18
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| Low risk type of HPV | HPV 6 & 11
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|
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| Will long-term COCs put you at risk for HPV? | Yes, COCs are a risk factor for HPV infection
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|
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| When should you begin screening for HPV | Begin at 21
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| When should you begin performing PAPs? | NEVER before 21
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|
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| When should you stop screening for cervical cancer? | Between 65-70 if last 3 consecutive PAPs were normal & no abnormal PAP in the last 10 yrs and no HSIL in last 20yrs
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|
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| When should you stop screening for cervical cancer after hysterectomy? | If hysterectomy was for BENIGN reasons, can stop screening
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|
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| How often should you screen for cervical cancer? | Every 2 yrs
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|
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| When should you do Cytology + HPV DNA? | In Women >30
_If DNA is neg, repeat every 3yrs until 45
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|
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| BEST screening test for cervical cancer | HPV DNA
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|
||||
| Receive results with negative HPV DNA. What does this say about the cytology? | NORMAL cytology
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|
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| Receive results with positive HPV DNA. What should you do? | Refer for colposcopy
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|
||||
| Causes of atypical cells of undetermined significance, NOT HPV: | Chlamydia Trach
HSV
Vulvovaginal Atrophy
🗑
|
||||
| See low-grade squamous intraepithelial lesion(HYPERchromatic w/INC cytoplasm) What should you assume? | That there's HPV DNA
_Refer for Colposcopy!!
🗑
|
||||
| Large cell with INC cytoplasm. Hyperchromatic nuclei | Low-grade squamous intraepithelial lesion
🗑
|
||||
| Large cell with DEC cytoplasm. Hyperchromatic nuclei | High-grade squamous intraepithelial lesion
_Assume +HPV and refer for colposcopy
🗑
|
||||
| What should you do for cytology that may suggest intraepithelial lesions in adolescents? | Repeat cytology in 12 months. Remember do NOT give PAP till 21!!
_2 positive results, refer for colposcopy
🗑
|
||||
| Why should you differentiate between transient & persistent HPV infection (+HPV but NEG cytology). Repeat in 12 mos. | Persistently +HPV puts at risk for devo of cervical intraepithelial neoplasia
🗑
|
||||
| Woman with endometrial cells on PAP & menopausal. Next step? | Transvaginal US +/- endometrial biopsy
🗑
|
||||
| What does it mean to see endometrial cells on PAP? | Functioning endometrium
Benign endometrium w/stromal breakdown
Hormone alteration & endometrial cancer
🗑
|
||||
| Cervical lesion in LOWER 1/3 of epithelial lining | CIN 1 (Cervical Intraepithelial Neoplasm)
_Typically regress in 1yr
🗑
|
||||
| Cervical lesion in LOWER 2/3 of epithelial lining | CIN 2 (Cervical Intraepithelial Neoplasm)
_half regress, a quarter progress
🗑
|
||||
| Cervical lesion with >2/3 of epithelial lining | CIN 3 (Cervical Intraepithelial Neoplasm)
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|
||||
| Biopsy confirmed CIN1 (lower 1/3 epithelium) | EXPECTANT management
_Repeat cytology/HPV test in 12 months
_If still abnormal, refer for colposcopy
_Lasts >1 yr, can excise
🗑
|
||||
| Biopsy confirmed CIN2/3 (involves lower 2/3 epithelium) | Tx!!
_Cryotherapy or LEEP
_REMOVE transformation zone (this only removes the cells, NOT the HPV virus!)
🗑
|
||||
| Destroys tissue @transformation zone in cervical neoplasm by NO2. | Ablative Therapy
_Disadvantage: Cannot do histo on tissues
_NO invasion, PG, HIV
🗑
|
||||
| After effects of Ablative Therapy | Vasomotor response during procedure
Cramp
Profuse, bad smelling WATER discharge
Infection/Bleeding (<5%)
Cervical Stenosis (<5%)
🗑
|
||||
| What determines success rate in ablative therapy? | SIZE of lesion (not the grade).
Lesions at 3 and 9 oclock have INC blood supply therefore may RESIST the cooling temp.
🗑
|
||||
| High electrical current density-->rapid heating of tissue for cervical dysplasia. Tissue IS ABLE TO SEND to Histo. | Loop Electrosurgical Excision Procedure
_Has replaced Laser surgery!
🗑
|
||||
| Precursor to cervical cancer. Has endocervical gland involvement which is lined w/atypical columnar epithelial cells. | Adenocarcinoma in situ
_Hard to manage since may be in canal & may have skip lesions
🗑
|
||||
| Why might you have delayed dx of Adenocarcinoma in situ | Cytology better at seeing SQUAMOUS than Glandular disease (which is adenocarcinoma)
_MUST perform Endocervical Curettage during colposcopy
🗑
|
||||
| A large area of tissue around cervix is excised for exam | Cold Knife Colonization
🗑
|
||||
| Gardasil protects against which type of HPV | 6, 11, 16, 18 (Quadrivent)
🗑
|
||||
| Cevarix protects against which type of HPV | 16 & 18 (Bivalent)
🗑
|
||||
| This type of cervical cancer is DECREASING. Is microinvasive/invasive | Cervical Squamous Cell Cancer
🗑
|
||||
| This type of cervical cancer is INCREASING | Cervical Adenocarcinoma
_Endocervical, Endometroid, Clear Cell, Adenoid Cystic
🗑
|
||||
| HPV 16 typically causes this type of cervical cancer | Squamous cell (50-60% of the time)
=16SS
🗑
|
||||
| HPV 18 typically causes this type of cervical cancer | Adenocarcinoma (40-60% of time)...ON the rise
_=18A
🗑
|
||||
| Columnar cells with ELONGATED nuclei that are large, hyperchromatic. See MITOSIS & APOPTOTIC bodies | Cervical Cancer
🗑
|
||||
| Typically no sx but may see vaginal bleeding (MOST common), after sex bleed, pelvic pain that unilaterally radiates (sign of advanced dz), and vaginal discharge | Cervical Cancer
🗑
|
||||
| If patient with cervical cancer has pelvic pain that's unilateral with radiation to hip thigh, thoughts? | Late Stage Cervical Cancer
🗑
|
||||
| Arise from smooth m cells in uterine walls. Made of collagen, smooth m, elastin surrounded by pseudocapsule. MORE common in black women (age 50) | Uterine Fibroids
🗑
|
||||
| Does estrogen cause myomas (uterine fibroids)? | Estrogen does NOT cause myomas, but does encourage their growth. Have higher amt of receptors and estrogen may cause INC ECM growth.
🗑
|
||||
| Lies just beneath endometrium | Submucosal uterine fibroids
🗑
|
||||
| Lies just at serosal surface of uterus | Subserosal uterine fibroids
🗑
|
||||
| Lies within the uterine wall | Intramural uterine fibroids
🗑
|
||||
| 50 y/o black woman with abnormal uterine bleeding, pain w/contraction, pelvic pressure, infertile & spontaneous abortions | uterine fibroids
🗑
|
||||
| Saline-Infused sonohystgram & hysteroscopy can help show this | uterine fibroids
🗑
|
||||
| GnRH agonist that decrease fibroid size. Improves anemia before surgery, allows minimal invasive. Do NOT use >6mos!! | Depot Lupron
🗑
|
||||
| For patients w/prolonged, heavy menses with NO submucosal fibroids | Steroidal therapy
OR
Lysteda (oral antifibrinolytic): use ONLY during menstrual cycle
🗑
|
||||
| Preserves fertility/uterus and can be performed on ALL types of uterine fibroids. | Myomectomy
🗑
|
||||
| When can you perform an abdominal or minilaparotomic myomectomy? | Contraindic for laproscopy (cardiopulm dz or fibroids too big)
Prior pelvic/ab radation
severe hip dz
DEC BMM, renal, liver fcn
🗑
|
||||
| Preserves fertility/uterus. ONLY performed on SUBMUCOSAL fibroids | Hysteroscopy
_Use heated loop to resect
_May cause fluid overload & HYPOnatremia
🗑
|
||||
| Minimally invasive for fibroids but no future kids! MUST continue a contraceptive too. Only use if NO distorsion (remove fibroids first) | Endometrial Ablation
_Destroys endometrium
🗑
|
||||
| Preserves uterus but NOT fertility to tx fibroids. Embolize uterine a to cut off blood supply to fibroid | Uterine a Embolization
_NO future kids!!
_No numerous/large fibroids!
🗑
|
||||
| Presence of endometrial glands & stroma outside endometrial cavity & uterine muscles. Usually in pelvis. | Endometriosis
_Premenstrual pelvic pain, infertility, painful periods/sex, INC CA-125
🗑
|
||||
| MOST common dx for hospitalizing women 15-44 | Endometriosis
_INC risk of ovarian cancer
_Premenstrual pelvic pain, infertility, painful periods/sex, INC CA-125
🗑
|
||||
| Retrograde menstruation, deficient cellular immunity (INC risk of AI disorders) & hereditary play risk in this dx | Endometriosis
_Premenstrual pelvic pain, infertility, painful periods/sex, INC CA-125
🗑
|
||||
| Premenstrual pelvic pain, infertility, painful periods/sex, INC CA-125 | Endometriosis
🗑
|
||||
| Why is their premenstrual pelvic pain in endometriosis? | Lesion grows w/estrogen & progesterone but their expansion is stopped by surrounding fibrosis-->pressure & inflammation leading to pain which will subside after menses.
🗑
|
||||
| Tender at posterior cul-de-sac. Fixed or retroverted uterus. Adnexal masses or tenderness | Endometriosis
_Premenstrual pelvic pain, infertility, painful period/sex, INC CA-125
🗑
|
||||
| Dx of endometriosis | Laparscopy:
Red petichial lesions on peritoneal surface. Surrounding peritoneum is thick & scarred. Ovaries show lesions or chocolate cysts. See adhesions.
🗑
|
||||
| Red petichial lesions on peritoneal surface. Surrounding peritoneum is thick & scarred. Ovaries show lesions or chocolate cysts. See adhesions. | Endometriosis
_Chocolate Cysts & red petichia on peritoneum
🗑
|
||||
| Tx of mild endometriosis | NSAIDS
🗑
|
||||
| Tx of mod-severe endometriosis | Goal: STOP endometrial tissue stimulation
-OCPs
-Progestins
-Deopot Lupron
_Laparscopy w/fulguration
_hysterectomy w/bilat salping-oophorectomy
🗑
|
||||
| MOST common pelvic genital cancer | Endometrial Cancer
_Early menarche, late menopause, OBESITY!!!
🗑
|
||||
| Huge cause for endometrial cancer | OBESITY!!
🗑
|
||||
| Cause of endometrial cancer | INC estrogen levels which stimulates proliferation of endometrium. Unopposed will cause endometrial hyperplasia & atypia.
🗑
|
||||
| Cancer which arises due to UNOPPOSED endog/exog estrogen. Has FAVORABLE prognosis bc well-differentiated tumor | Type 1 Endometrial Cancer
🗑
|
||||
| Arises independently of estrogen & seen with endometrial atrophy. Poorly differentiated therefore poor prognosis. | Type 2 Endometrial Cancer
🗑
|
||||
| MOST common type of endometrial cancer | Adenocarcinoma
🗑
|
||||
| Endometrial cancer NOT associated with HYPERestrogen state. Poor prognosis | Serous Carcinoma
or
Clear Cell (High grade, aggressive with deep invasion)
🗑
|
||||
| Most common stage of endometrial cancer found | Stage 1 Endometrial Cancer
🗑
|
||||
| Abnormal vaginal bleeding, ab cramping, back pain, weight loss, painful sex. Screen if have hereditary nonpolyposis colon cancer syndrome (HNPCC) | Endometrial Cancer
🗑
|
||||
| Pap smear with endometrial cells may show this | endometrial cancer
🗑
|
||||
| May cause endometrial cancer | Tamoxifen
🗑
|
||||
| Tx of endometrial cancer | Hysterectomy with bilateral salpingoophorectomy w/pelvic & periaortic lymphadenectomy
Radiation (if surgery contraindications)
Chemo (RARE, only if advanced dz)
🗑
|
||||
| 32 yo female presents for her WWE visit and you see she had (-) cytology but (+) HPV DNA on last years Pap. This year cytology remains negative but HPV DNA is still (+). What do you recommend? | Refer for Colposcopy with 2 positive HPV tests
🗑
|
||||
| When should you offer a colposcopy? | With 2 consecutive year HPV + results.
🗑
|
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