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freq of pap smear start at 21, stop at 70 if 3 conseq nmls,<30 do q2yrs, >30 q2-3yrs or q3yrs if 3 conseq nml pap
management of ASCUS repeat Pap q4-6mos until 2x nml paps, if 2nd ASC-US need colposcopy. Can do HPV DNA
when do colposcopy anything above ASC-US or AGCNOS. Ectocervical bx=bx of any suspicious lesions seen on colpo. Results of bx are compared to Pap results to make sure they are consistent; do w ECC in all non pregnant
management recurrent CIN loop electrosurgical excision (LEEP), or cold-knife conization
when do cone bx if ECC shows abnml cells, if colposcopy shows lesion extending into endocervical canal, if cervical bx shows microinvasive (CIS) or AIS (Adenocarcinoma in situ), if Pap smear showed worse than found on bx from Colpo
once confirmed CIN1 and colpo adequate, management? rept pap 6-12mos and HPV DNA testing in 12mos
tx of CIN2,3 ablation if ECC negative: cryotherapy, laser, electrofulcuration. Can also do LEEP or cold knife (why would you??). Need ablate whole T zone if CIN2,3
if colpo was inadequate and CIN, what do? loop electrosurgical excision (LEEP), or cold-knife conization. Also use for primary tx of CIN1,2,3 and if have recurrent CIN. Excise entire T zone if CIN2,3.
how manage preg women w CIN? Microinvasion pap and colpo q3mo, at 6-8wks PP re-evaluate w Pap and colpo and do definitive tx; microinvasion: need cone bx to ensure no frank invasion
how manage preg women w invasive cervical cancer if <24 wks should get definitive tx w radical hys or radiation; if >24wks wait until 32wks and do c/s and definitive tx
staging cervical cancer I a=<3mm deep, b <=5mm, c=>5; IIa=upper 2/3 vagina parametria not involved, b=parametria involved; III=lower 1/3 vagina, or pelvic wall or hydronephrosis; IV=bladder, rectum, mets
ASCUS-H management do colpo, ECC
AGCUS management colpo, ECC, EMB
LGIS management colpo and ECC, if comes back CIN2 can wait if CIN3 LEEP
tx of PE in preg IV heparin 5-7 days, then 3mos subQ and low dose heparin for remainder of preg and up to 4wk PP
tx cervical cancer Ia1 (3mm)=simple hys, IaII (>3mm <5mm)=modified radical hys w upper 1/3 vagina; Ib/Iia (>5mm, 2/3vag)=radical hys +LN dissection OR radiation; Iib,III,IV=radiation
when is adjuvant radiation and chemo given in cervical cancer met to LN, tumor>4cm, poorly difft'd, + margins
f/u cervical cancer pap q3mo for 2yrs, then q6mo for 3 yrs
tx of recurrent cervical cancer local can undergo radiation, if recd radiation prev might be candidates for pelvic exenteration; Distant mets: chemo (cisplatinum)
paper thin, bluish vulva, most likely dx? How dx? Tx? most likely lichen sclerosis seen in post menopause w itching, dx w bx, tx w clobestrol
what differentiate lichen sclerosis from, how tx the two? squamos hyperplasia which has more white, firm, cartilaginous lesion and tx w steroids (v high dose clobestrol for lichen sclerosis)
risks for vulvar dysplasia, cancer obesity, HTN, HPV16, 18. Can be seen w CIN
describe Paget dz of vulva vulvar cancer that's red
staging vulvar cancer I <=2cm, II= >2cm, III= + unilateral inguinal LN, spread to lower urethra, vagina, or anus; IV a=upper urethra, bladder/rectum, pelvic bone + bilateral inguinal LN; b=any distant mets of pelvic LN
tx of vulvar cancer if <2cm and invasion <1mm can have local excision, if >1mm need LN dissection
3 types of vulvar cancer and features MC scquamos, melanoma (dark, assoc w other cancers, ie GI, GU and breast), and even less common Paget
differentiate bw cystic (aka fibrocystic dz) and fibroadenoma fibrocystic=MC in young, painful, often cyclic w menses, confirm w U/S; fibroadenoma=solid, painless, smooth rubbery
tx for fibrocystic breast reduce caffeine, vit E, OCPs, bromocriptine, tamoxifen
bloody discharge from a benign tumor, think… intraductal papilloma, will have unilateral discharge w/o palpable mass
non tender, rapidly enlarging firm, smooth mass cystosarcoma phylloides, benign, need excision w wide margin to avoid recurrence
4 types of malignant breast tumors infiltrating ductal (MC 80%), infiltrating lobular (more often bilateral and better px), inflammatory, Pagets
describe inflammatory breast cancer course grows rapidly w early met potl, blocks lymph vessels leading to redness, peau d orange
mammography guidelines start at 40yo q1-2yrs, if genetic risk start earlier
when need breast bx **need core needle bx for any nonpalpable suspicious mass on mammo or any palpable mass
risks breast cancer BRCA1,2. prolonged unopposed estrogen, high fat, obesity
w/u breast mass 40-50 first gets mammo + core bx at the very least. If core is -, may do excisional bx
diff when treating breast cancer during preg no chemo in 1st trimester and never any radiation during preg (still would get mammo and bx if suspicious mass)
when use adjuvant therapies in breast cancer pretty much everyone, if receptor are + use hormonal agents, chemo also used.
how is inflamm breast cancer tx differently from others need preop chemo
when lumpectomy v mastectomy (and difft types mastectomy) lumpectomy if <4cm, simple mastectomy if widespread DCIS or LCIS; modified radial mastectomy (where also remove breast and axillary nodes) for larger tumors
what's the diff simple mastectomy v modified radical modified radical also take axillary nodes [radical is when also remove chest wall mscl, don't do that anymore]
what tx if hormone receptor + (ie estrogen, progesterone) tx w tamoxifen (selective estrogen receptor modulator)
which benign breast mass more assoc w menses fibrocystic dz (v fibroadenoma)
who needs preop chemo in breast cancer all inflamm breast cancer, also for LN mets before surgery I think
key prognostic factors breast cancer LN status, tumor size, R status, DNA ploidy (aneuploid worse)
Mirena v Paraguard IUD--how freq change, how effect menstrual cramping and bleeding Mirena 5yrs, can decrs menstrual cramping and bleeding, Paraguard 7yrs can incrs menstrual cramping and bleeding
absolute contraindications IUD unDx uterine bleeding, known/suspected Gyn cancer, acute cervical/uterine/tubal infxn
relative contraindications IUD nulliparity, extopic preg, medical conditions putting at risk for infxn
failure rate combined OCPs and progestin pills 2-3% w ideal use
failure rate barrier methods contraception 20%
failure rate IUD 1%
what specific bug infxn is incrsd w IUD actinomyces Israelii
absolute contraindications OCP? CVS: any thromboembolic event, CAD; Cancer: breast, endomet, melanoma; Liver: abnml LFTs, liver tumor; undiagnosed uterine bleeding, vascular dz like SLE
relative contraindications OCP DM, SC, HTN, hyperlipidemia, migraines, depression, (?+smoking, >35yo)
estrogen effects from OCP fluid retention from decrsd Na excretion, cholelithiasis, incrsd hepatic protein production (incl coag factors), incrs HDL and decrs LDL, incrsd venous and arterial thrombosis
progesterone effects from OCP mood changes and depression from decrsd serotonin, androgenic effects (wgt gain, acne), decrsd HDL and incrsd LDL
how OCPs effect risks for cancers decrsd risk of endometrial and ovarian and colon, incrsd cervical and maybe breast cancer as well as CAD and thromboembolic dz
how does clomiphene work, what day taken on taken on day 5 of cycle for 5 days. Blocks estrogen (similar structure to estrogen), pituitary incrses GnRH rel
describe how human menopausal gonadotropin is administered, SE? given mid cycle, watch for hyperstimulation (enlarged ovary and ascites requiring hospital admission)
what's nml semen 2-5ml, >20million/ml, motility >50%, nml forms >50%, pH 7.2-7.8
when is intrauterine insem used? ICSI? intrauterine insem is for mild semen abnlties, ICSI+IVF for severe
phases of infertility w/u Phase I: semen analysis (1st) and document ovulation; 2: hysteosalpingogram after menses to make sure tubes patent; 3: IVF
how measure ovarian reserve FSH on day 3 of cycle (if >12 then impending ovarian failure)
how is precocious puberty defined 2ry sex characteristics <8girls, <9boys
order of puberty thelarche (breast), adrenarche (pubic/axillary hair), then hgt wgt and then menarche
what's the diff bw true and pseudo precocious puberty true or central=gonadotropin, just the hypothal-pituit-ovarian axis is activated early; pseudo or peripheral=estrogen comes from ovaries but not from gonadotropins
ex of pseudo precocious puberty McCune Albright, granulosa cell tumor of ovary
what's the diff premature ovarian failure and premature menopause premature ovarian failure <30 (usu autoimmune), premature menopause 30-40
how does FSH level help in determining hormone trbls in amenorrhea if FSH low it’s a hypothal problem, if high its ovarian (ie premature ovarian failure)
adnexal mass and hyperthyroid symptoms--think? struma ovarii (dermoid cyst w >50% thyroid component)
dark urine, had just had UTI think G6PD and likely was treated w a sulfa, ie nitrofurantoin
which UTI Abx can't be used in preg bactrim and fluoroquinolones, also doxycycline (any tetracyclines)--so often use nitrofurantoin
when steroids given for pts going into labor? What does it help w at difft GA? steroids if 24-34 (24-28wks decrs risk IVH, 28-34 decrs RDS and help lung maturation)
what need to check while preg pt on Mg UOP (since excreted by kidney), pul edema/respir depression, loss of DTR
which ovarian tumors secrete estrogen? Androgen? estrogen=granulosa cell; androgen=Sertoli-Leydig
how differentiate mullerian agenesis and androgen insensitivity both have absnet uterus and blind vagina and nml breast, but mullerian agenesis often has renal abnmlties should have nml testosterone and nml pubic hair (androgen insensitiv has decrsd)
how is LH surge stimulated At low estrogen inhibits LH release, but as incrsd and sustained 50hr positive feedback leading to LH surge
2 types of precocious puberty, MC Gonadotropin dependent/true/central (MC), Gonadotropin inde/pseudo/peripheral
risk factors osteoporosis, MC fam hx (MC), fair-skinned, white, low BMI, caffeine, smoking, EtOH, high protein, low calcium and vit D
desribe raloxifene's action SERM, estrogen agonist in bone, but antagonist in breast and endometrium; used in osteoporosis
contraindications hormone replacement therapy undiagnosed vaginal bldg, endometrial or breast cancer, active thrombosis; if still have uterus must give w progesterone
how amenorrhea defined ( mos)
how dx PMS symptom diary 3 cycles showing symptoms absent during preovulatory, present in 2 ovulatory wks, interfere w nml fxn, resolve w onset of menses
what o'clock Bartholin's cyst 5 and 7
what o'clock Skene's gland 10 and 2
tx for PMS SSRI, other Rx (B6, diuretics) have been suggested but only Fluoxetine, Xanax, and GnRH showed they worked over placebo
what markers need order for hirsutism w/u and what show DHEAS (marker adrenal tumor), 17OHP (late onset CAH), Testosterone (mildly elevated in PCOS, markedly elevated in androgen ovarian tumor)
how does OCP help PCOS hirsutism suppressing LH stimulation of theca cells; incrs SHBG decrsing free testosterone
key lab values unique to PCOS LH/FSH>3. SBHG is decrsd
define 1ry amenorrhea 14yo w/o 2ry sex of 16 w/ 2ry sex
how w/u 1ry amenorrhea see if breasts present, uterus present, karyotype and testosterone
1ry amenorrhea: breasts present, uterus present, what's the difftl breasts means estrogen is there, difftl includes anatomic (imperforate hymen, vaginal septum), hormone (anorexia, excessive exercise) and preg before menses.
1ry amenorrhea: breasts absent, uterus present, what's the difftl and how w/u Turner, Hypothal-pit dysfxn, use FSH and karyotype (Turner has 45X and high FSH w streak gonads, hypothal problem has nml karyo and low FSH--need to check brain imaging)
1ry amenorrhea: breasts absent, uterus absent, what's the difftl and how w/u testosterone and karyotype, Mullerian agenesis (46XX, nml 2ry sex and hair, testosterone nml female), Androgen insensitivity (46XY, no pubic/axillary hair, high testosterone (nml for male)--need testis removed)
w/u 2ry amenorrhea always check preg first, then TSH, Prolactin; if those nml progesterone challenge (+ indicates anovulation), if - do estrogen challenge, if + check FSH level.
Estrogen challenge was + (wdrawal bldg) and FSH high, what mean? ovarian failure, if <25yo could be Y chromo mosaicism (order karyo)
Estrogen challenge was + (wdrawal bldg) and FSH low, what mean? hypothal problem, need brain imaging
Estrogen challenge was - (no wdrawal bldg), what mean? outflow obstruct or Asherman (scarring, ie D&C, will need lysis of adhesions)
describe estrogen challenge test; what do results mean 21d of estrogen followed by 7d of progesterone. Any wdrawal bleeding indicates inadequate estrogen
describe ovaries in PCOS peripheral cysts (20-100/ovary). Incrsd androgens prevent nml follicular develop inducing premature follicle atresia. Follicles in various stages of develop and atresia along w stromal hyperplasia and thickened capsule cause bilateral ovarian enlargement
how infertility in PCOS treated Metformin can decrs insulin resistance, decrs testosterone and incrs likelihood of ovulation, can be used w clomiphene. Ovulation also can be w human menopausal gonadotropin (HMG, Pergonal).
how make dx of dysfxnl uterine bleeding, MC cause? r/o anatomic causes/identifiable causes, usu due to hormonal defic or excess
how test for anovulation progestin (MPA=medroxyprogesterone acetate) for 10d. If anovulatory bleeding should stop within 48hrs, remain stopped for the whole 10d and start as soon as trial ends
how OCPs help w PMS endometrial atrophy leads to less prostaglandins
parameters define variable decel <30sec to nadir, change in 15bpm and lasts at least 15sec but less than 2 min
what causes variable decels? Early decels? Late decels? variable=cord compression, early=head compression (think head come out early), late=uteroplacental insuffic
what are three parts of a CVE? (xx/xx/xx) dilation/effacement/station
describe variable decel? Difft degrees abrupt decrs in FHR (<30sec) >15bpm and >15sec, <2min, variable wrt cxns=compress umbilical/vagal stim. Severe: >60bpm or last >60sec. Mild (15-40bpm)-mod (40-60bpm) have no impact on fetal outcome, severe are nonreassuring and can be assoc w acidosis
describe early decel? Late? symmetric, gradual (30sec of more) decrs assoc w cxn, nadir is same as peak of cxn (mirror cxn) from head compression; same shape, gradual but not timed w cxn, assoc w utero-placental insuffic. All are nonreassuring
when deliver mild preE? Severe? if stable 36wks, 34 wks
chemo agents for germ cell ovarian tumor in child? Ovarian cancer? If cervical cancer met germ cell=vinblastine, bleomycin, cisplatin; ovarian=carboplatin, Taxol; cervical=cisplatinum
Created by: ehstephns
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