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Chapters 1-4

Layers of the uterus serosa myometrium endometrium
lymphatic drainage of the ovaries pelvic and para-aortic LN's
When to perform a wide-shallow cervical cone bx if Pap smear shows changes that are more severe than the colposcopy-directed bx
When to perform a narrow-deep cervical cone bx if lesion extends from the exocervix into the endocervical canal
What are the long term risks of cervical cone bx? cervical stenosis and cervical insufficiency
When to use a LEEP? Loop Electrocurgical Excision Procedure. Use to dx and tx cervical dysplasia - uses electric current to remove abnl cervical tissue (seals off vessels as it cuts)
What are the long term risks of LEEP? cervical stenosis and cervical insufficiency
What is the f/u after a LEEP? Pap smears q6mo for 2y to ensure that the dysplastic changes don't return
When to use cryo? to destroy dysplastic cervical tissue
What are the long term risks of cervical cryo? cervical stenosis
Subtotal hysterectomy remove uterus leaving cervix
total hysteresctomy most common, removes both uterus and cervix
radical hysterectomy; when is this procedure done? for early stage cervical CA, removes both uterus, cervix, proximal vag, and broad ligaments
When to start breast cancer screening/mammography? 40 if no risk factors. 34 if risk factors such as BrCA in 1st deg relative, fam h/o BRCA gene
Grade I uterine prolapse cervix half-way into vaginal introitus
Grade II uterine prolapse cervix into the introitus
Grade III uterine prolapse cervix outside the introitus
Grade IV uterine prolapse uterus including the vaginal walls outside the introitus
Detrusor muscle has which receptors and what do they do? (3) Beta - relaxes the bladder and prevents micturition; cholinergic - contracts the bladder and aids voiding; alpha - contracts the urethra to prevent micturition
alpha-blockers to enhance micturition a-receptors contract the urethra to stop micturition. Drugs to relax the urethra and let pee out: phenoxybenzamine.
alpha-agonists to tx incontinence a-receptors contract the urethra to stop micturition so you want to enhance that to tx incontinence. Alpha agonists are ephedrine and imipramine.
B-agonists to tx incontinence B receptors relax the bladder --> B-agonists prevent leakage of urine. Flavoxate and progestins
anti-cholinergics to tx incontinence cholinergic receptors contract the bladder and make you pee, so to tx incontinence, you block the cholinergic receptors with oxybutinin and propantheline
cholinergics to enhance micturition cholinergics contract the bladder, so you want to enhance that to enhance micturition --> bethanecol or neostigmine
what is nl residual volume in the bladder? 50mL
How much volume before a person has the urge to void? 400-500mL
incontinence from an infection tumor or foreign body. What will the UA show? sensory irritative incontinence. UA will have WBCs if infection, or RBCs if stone, tumor, or FB
in sensory irritative incontinence, what is the residual vol and detrusor contractions like? nl residual vol, but involuntary detrusor contractions (from the irritation)
most common form of urinary incontinence stress incontinence
What will distinguish urinary stress incontinence from the other types of incontinence? stress incontinence does not occur at night
Q-tip test qtip placed in urethra will rotate >30 degrees if pt has urinary stress incontinence when pt increases intra-abdominal pressure
involuntary loss of urine that happens day or night, large amounts often without warning, lots of urgency. What kind of incontinence and what can be said about residual vol and detrusor contractions? How to tx? Hypertonic/Motor Urge Incontinence. Idiopathic involuntary detrusor contractions with nl residual vol. Tx with oxybutinin (anti cholinergic to relax the detrusor)
Intermittent small amounts of urinary leakage throughout the day, but always feeling a full bladder. What is it? What can be said about residual vol and detrusor contractions? What is the neuro exam? Hypotonic/Overflow caused by denervation or meds. Bladder is overdistended n hypotonic, so doesn't contract to void. Only leak urine when bladder too full. High residual vol with no involuntary detrusor contractions. Decreased pudendal sensation.
what is nl vaginal pH? <4.5
What is a nl result on Nitrazine paper? checks vaginal pH. Nl result is papers turns yellow (pH<4.5), abnl is dark result --> pH > 4.5
most common vaginal complaint in the US bacterial vaginosis
fishy odor on vaginal discharge bacterial vaginosis
Tx of bacterial vaginosis metronidazole or clindamycin since BV is overgrowth of anaerobic bacteria in vagina
Tx of trichomonas vaginitis oral metronidazole for pt and partner
Tx of candical vaginitis oral fluconazole or vaginal cream
can metronidazole be used in pregnancy? yes!
most common vaginal complaint worldwide trichomonas vaginitis
how does a woman get trichomonas sexually from man since trichomonad resides asx in male seminal fluid
frothy green discharge trichomonas vaginitis
curdy and white vaginal discharge candidal vaginitis
grayish white vaginal discharge bacterial vaginosis
risk factors for Candidal Vaginitis DM, abx, pregnancy, obesity, decreased immunity
bacterial vaginosis (discharge, pH, odor, itching, burning, dyspareunia, wet mount) grayish white discharge, pH > 5.0, fishy odor with pos whiff test, no bitching or burning, no dyspareunia, clue cells and no WBCs on wet mount
trichomonas vaginitis (discharge, vag epithelium, pH, itching, burning, dyspareunia, wet mount) frothy green discharge, vag edematous and inflammed, pH > 5.0, positive itching, burning, dyspareunia; actively motile organisms on wet mount + WBCs
Candidal vaginitis (discharge, vag epithelium, pH, itching, burning, dyspareunia, wet mount) white and curdy discharge, vag epith edematous and inflammed, nl pH, positive itching, burning, dyspareunia; pseudohyphae on wet mount + WBCs
pseudohyphae on KOH prep consider yeast infection (candidal vaginitis)
clue cells, rare WBC's bacterial vaginosis
does partner need to be treated in candidal vaginitis? no
watery cervical mucus discharge, no burning or itching nl physiologic discharge, estrogen predominance
strawberry cervix trichomonas vaginitis
vaginal pH in bacterial vaginosis >5.0
tx for too much watery cervical discharge steroid contraception that includes progestins
vulvar itching - what should you do? bx because could be a dystrophy (no malignant predisposition - hyperplasia or lichen sclerosis), a premalignant lesion (squamous dysplasia or CIS) or malignant (squamous cell ass with HPV, melanoma - black lesion, Paget's disease - red lesion.
whiff test bacterial vaginosis
What does vulvar squamous hyperplasia look like? Tx? white area, firm and cartilaginous, keratin/epith proliferation. Tx with flourinated corticosteroid cream
What does vulvar lichen sclerosis look like? Tx? bluish-white papules-->plaques, thin and feels like parchment, epith thinning. Tx with Clobetasol cream.
Tx for vulvar squamous dysplasia surgical excision since it is pre-malignant
Vulvar CIS histologically. Tx? Histologically full thickness, but does not penetrate the basement membrane. Tx with laser vaporization.
What organism causes vulvar CA? HPV --> squamous cell vulvar CA.
What is the most important prognostic factor in Vulvar melanoma? depth of lesion
Black lesion on vulva vs. red lesion black lesion is melanoma and red is paget disease.
Who gets Paget disease of the vulva? post-menopausal white women
Staging of vulvar CA 0: basement membrane intact, 1: <2cm, 2: >2cm, 3: unilateral nodes, 4: mets
Tx of Vulvar CA vulvectomy or LADectomy
When can you do a local excision and NOT LADectomy in vulvar CA? lesion <2cm wide and <1mm deep
Which vulvar CA pts should get LADectomy any lesion >1mm deep
Who can get unilateral LADectomy in vulvar CA? if lesion does not affect midline structures (clitoris, labia minora, peineal body)
cauliflower vulvar lesion, any malignant predisposition? condyloma acuminata, HPV 6&11, no malignant predisposition
Risk factors for cervical cancer early intercourse, multiple sex partners, smoking, immunosuppression
the most common site for cervical dysplasia transformation zone
when to start Pap screening? When to stop? 3 years oafter onset of sex or 21 yo; stop when 70 and after >= 3 consecutive normal PAP smears OR after total hysterectomy if hysterectomy was not done for cervical CA
how often to screen for cervical CA? <30 yo: screen annually if conventional and q2y if liquid; >=30yo q2-3 y if >= 3 consecutive nl PAP smears
5 results for PAP smears 1. neg, 2. atypical squamous cells, 3. LSIL (low grade - CIN1, mild dysplastic changes), 4. HSIL (must bx because CIN 2-3 and shows mod to sev dysplastic changes), 5. Cancer
CIN cervical intraepithelial neoplasia
CIN1 mild cervical dysplasia
CIN2 mod cervical dysplasia
CIN3 severe cervical dysplasia or cancer in situ
what should you consider if pt has vag bleeding after intercourse cervical polyps, cervical CA
How to manage cervical polyps? removal (twisting off and electrocautery to remove the base) and abx even if no signs of infection; send off to pathology
what is the percent chance that a cervical polyp will regrow after you cut it off? uncommon for it to grow back
what is nabothian cyst? How to tx? a cervical pimple - mucus filled cyst. No sx's so tx not necessary, but it won't go away by itself, so you can clear them with cryo or electrocautery
How to stage cervical CA? clinically - NOT by MRI or CT!!
Cervical CA: Stage I, Ia1, Ia2, Ib Limited to Cervix. Ia1. <= 3mm deep (minimally invasive), Ia2. 3mm<x<5mm (microinvasion), Ib. >5mm deep (frank invasion)
Cervical CA: Stage II Adjacent to the cervix (upper vagina, endometrium)
Cervical CA: Stage III Further from the cervix (lower vagina, pelvic side wall)
Cervical CA: Stage IV Bladder, rectum, outside pelvis or distant mets
Tx of Stage Ia1 cervical CA simple hysterectomy (Ia1 is <3mm deep, minimally invasive, limited to cervix)
Tx of Stage Ia2 cervical CA modified radical hysterectomy (Ia2 is 3mm<x<5mm deep, micro-invasive, limited to cervix)
Tx of Stage Ib or IIa Cervical CA if premenopausal (Ib is >5mm deep, frank invasion; IIa involves upper vagina) radical hysterectomy with pelvic and para-aortic LADectomy
Tx of Stage Ib or IIa Cervical CA if postmenopausal (Ib is >5mm deep, frank invasion; IIa involves upper vagina) peritoneal washings or pelvic radiation
Which tx is more efficacious for cervical CA - surgical resection or radiation? both are the same
Tx of Stage IIb, III, or IV Cervical CA Radiation and chemo for all ages
F/u for pts with tx'ed cervical CA (no recurrance or mets) PAP smears q 3mo x2y --> q 6mo x 3y
Tx for pts with cervical CA and local recurrance radiation --> if failed radiation already then pelvic exenteration
Tx for pts with cervical CA and distant mets chemo with cisplatin
How does pregnancy affect the trajectory of a precancerous cervical lesion doesn't affect or accelerate progression to invasive CA
Risk factors for Cervical CA mets and tumor recurrance (4) 1. mets to LN's, 2. tumor >4cm, 3. poorly differentiated lesions, 4. pos margins after resection
Colposcopy and bx in a pregnant person same as non-pregnant, except will not get endocervical curretage
Pregnant pt with cervical intraepithelial neoplasia PAP's q 3mp during pregnancy and colposcopy and PAP 6-8 weeks post-partum; lesions tx post-partum
Pregnant pt with cervical microinvasion (Ia2) cone bx to ensure no frank invasion, conservative management, vag delivery --> tx 8 weeks post partum.
Pregnant pt with invasive cervical CA if <24 weeks --> abortion and radical hysterectomy or radiation. If >24 weeks --> conservative management until 32-33 weeks --> C/S --> hysterectomy or radiation.
When to give HPV vaccine. When is it most effective? 8-26 yo, targetting 11-12, most effective before body exposed to HPV.
T/F: if pt gets HPV vaccine, they don't have to get regular PAP screenings FALSE because vaccine only covers a few types of HPV. Should still get regular screenings.
Who should NOT get the HPV vaccine? pregnant, lactating, immunosuppressed
what uterine anomaly(lies) are associated with urinary tract anomalies as well? mullerian hypoplasia/agenesis (vagina, cervix, fallopian tubes, uterus), both mullerian ducts involved
girl with significant monthly pain during adolescence coinciding with her menses consider unicornuate uterus with a rudimentary horn that has no outlet for menses
stages of uterine development 1) mullerian ducts form, 2) fuse, 3) dissolve
unicornuate uterus is problem in which stage of uterine development? stage 1 because 1 mullerian duct fails to form
didelphys uterus is problem in which stage of uterine development? failure to fuse, stage 2 (this is when you have two separate uteri)
bicornuate uterus is problem in which stage of uterine development? stage 2 because you have failure of fusion at the top (can see two horns from the outside)
septate uterus is problem in which stage of uterine development? Stage 3 because you have a failure of degeneration of wall between the two horns, but from the outside, you only see one uterus
what is a leiomyoma? B9 tumor of smooth muscle in the myometrium
what is the most benign uterine tumor? leiomyoma
what is the pregnancy problem that affects a pt with a didelphys uterus? preterm delivery
what is the pregnancy problem that affects a pt with a bicornuate uterus? preterm delivery and malpresentation
what is the pregnancy problem that affects a pt with a septate uterus? preterm delivery and malpresentation
what is the most common congenital uterine anomaly? bicornuate uterus (45%)
Who is most likely to have a leiomyoma? black woman
What is the most common location for a leiomyoma? in the wall of the uterus
what is the most common sx of a submucosal myoma? abnl, unpredictable vaginal bleeding --> can sometimes result in anemia
menorrhagia heavy menses
metrorrhagia irregular bleeding
menometrorrhagia heavy bleeding in between menses
during what periods would a leiomyoma grow faster? Slower? faster during high estrogen states such as pregnancy (can outgrow its blood supply and degenerate causing extreme pain for pregnant pt); slower when low estrogen like in menopause
pregnant uterus that reaches umbilicus is how many weeks? Pubic symphisis? 20 weeks, 12 weeks
How to tx leiomyoma? What if want to preserve fertility? What if not having any more children? mostly obs n serial pelvic exams; if want to resect, shld shrink presurgically w GnRH analog for 3-6 mo (dec size by 70%, regrow when stop med); if want to preserve fertility - myomectomy; if preserve uterus - embolize; if fertility done - hysterectomy.
what is adenomyosis? endometrial tissue IN the myometrium that is surrounded by a pseudocapsule
What is the Ddx for an enlarged non-pregnant uterus leiomyoma/fibroid (asymmetric, firm, nontender) vs. adenomyosis (symmetric, soft, tender)
diffusely enlarged uterus with cystic areas in the myometrial wall consider adenomyosis
Tx for adenomyosis Levonorgestrel intrauterine system (Mirena) --> decreases heavy bleeding. Definitive tx is hysterectomy
Ddx for post-menopausal bleeding 1. atrophy (vaginal vs endometrial), 2. endometrial CA, 3. HRT
def of menopause 3 continuous months of cessation of menses and elevated gonadotropins
most common gyn malignancy endometrial CA
risk factors for endometrial CA obesity HTN DM. Also nulliparity, late menopause, chronic anovulation (like PCO)
lining stripe in post-menopausal woman should be how thick? <5mm
Staging for endometrial CA done how? What are the stages Surgical staging: I - limited to the uterus, II - cervix, III - adjacent to uterus (serosa, adnexa, vag, LN's), IV - bladder, rectum, distant mets
Tx for endometrial CA by stage all stages should get TAH and BSO. II gets radiation in addition. II and IV get radiation and chemo as well.
Tx for hypotonic bladder Tx with cholinergics to increase detrusor contractions or a-blockers to relax urethra, or self-catheterizations.
Created by: christinapham



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