USMLE Gynecology III

  1. Management of Lichen Sclerosis
    • Lichen sclerosus (LS) is one of few conditions for which use of high-potency topical corticosteroids on the genitals is recommended.
    • An ultrapotent topical corticosteroid (eg, clobetasol) ointment is the first-line treatment for relief of itching and other symptoms.
    • Patients should be counseled that it is not known whether corticosteroids can prevent scarring and squamous cell carcinoma (SCC).
    • More than once-daily application increases adverse effects such as skin atrophy, discoloration, and striae.
  2. Lactational Mastitis
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  3. Menorrhagia
    • It is defined as prolonged or heavy menstruation, typically lasting longer than 7 days or exceeding 80 ml. In a young patient that has only recently experienced menarche, heavy menses with an irregular cycle can be attributed to anovulatory cycles.
    • Females in this age group have an immature hypothalamic-pituitary-ovarian axis that may fail to produce gonadotropins (LH and FSH) in the proper quantities and ratios to induce ovulation. Up to 90% of all menstrual cycles in the first year after menarche may be anovulatory.
    • Because the endometrium is responsive to baseline estrogen levels during the female's cycle the endometrium will develop and eventually slough resulting in some cyclic bleeding due to a breakthrough phenomenon.
  4. Physiology of the fertility Window
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  5. Mittelschmerz Syndrome
    • Ovulation typically occurs on days 10-14 counting from the first day of the previous menses.
    • This physiologic event causes discomfort when rupture of the follicle releases the egg.
    • The concomitant release of a small amount of blood during this process irritates the peritoneum. Patients may have a recurrent monthly instance of pain halfway through their menstrual cycle or experience a single more uncomfortable episode. The pain is unilateral and usually lasts less than a day, resolving without intervention.
    • Management consists of ruling out a more acute etiology as indicated by history and physical examination, followed by reassurance.
  6. Ovarian hyperstimulatlon syndrome
    • It is an iatrogenic complication of ovulation-inducing medications.
    • It is characterized by diffuse abdominal pain due to ovarian enlargement by multiple follicles and may be accompanied by ascites and respiratory difficulty.
  7. BRCA mutations and Ovarian Cancer
    • BRCA mutations predispose patients to breast and ovarian cancers.
    • Typically identified in an individual with breast cancer at age less than 50 or ovarian cancer at any age, carrier status confers significant implications for lifetime cancer risk for family members.
    • Specifically, BRCA 1 and BRCA2 mutations carry a 60% and 20% lifetime risk of ovarian cancer, respectively.
    • Premenopausal prophylactic bilateral salpingo-oophorectomy (BSO) has been shown to significantly decrease the incidence of ovarian cancer (as well as breast cancer and overall mortality) in BRCA-positive individuals and is recommended as soon as childbearing is complete.
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  8. Evaluation of a Palpable Ovarian Mass
    • Pelvic ultrasonography is the first-line test for evaluation of a palpable adnexal mass.
    • Pelvic ultrasound (Abdominal+ Transvaginal) will show the uterus (including endometrium), ovaries, and cul-de-sac.
    • The fallopian tubes are not visible on ultrasound unless pathology is present.
    • Ultrasound has a high specificity for detection of malignant sonographic features (eg, thick septations, solid components).
    • It is noninvasive, well tolerated, requires no radiation, is readily available, and is cost effective. However, performance can be limited by patient obesity.
    • Ultrasonography is superior to CT scan for evaluation of the pelvic organs, and CT scan is reserved for detection of metastases from ovarian cancer.
  9. Epithelial Ovarian Carcinoma
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  10. Epithelial ovarian carcinoma
    • It refers to a malignancy involving the ovary, fallopian tube, and peritoneum.
    • Histologically, abnormalities can begin at any of these sites and present with the hallmark large ovarian mass and widespread pelvic and abdominal metastasis regardless of primary origin.
    • Ultrasound is the first-line imaging modality to investigate pelvic pain and/or an adnexal mass.
    • The presence of peritoneal fluid in a postmenopausal woman is pathologic and is the origin of the typical symptoms of bloating, pain, early satiety/anorexia, and abdominal distension seen in ovarian cancer.
  11. Management of Epithelial Ovarian Carcinoma
    • Exploratory laparotomy with cancer resection, staging, and inspection of the entire abdominal cavity is the definitive treatment when there is a high clinical suspicion of EOC, particularly with an acute presentation.
    • During surgery, the ovaries, uterus, omentum, and any visually apparent cancerous lesion will be removed and pelvic and paraaortic lymph nodes will be dissected.
    • Chemotherapy with platinum-based agents is initiated after surgery.
  12. Mature cystic teratoma (dermoid cyst)
    • It is a common benign ovarian cyst occurring in young women.
    • Patients are usually asymptomatic but can experience pelvic pain.
    • Physical examination findings of adnexal fullness or firm ovarian mass prompt evaluation with ultrasound. Pelvic ultrasonography confirms an ovarian cyst, typically with calcifications.
    • Laparoscopic cystectomy is the treatment of choice. Dermoid cysts have a typical intraoperative appearance of thick sebaceous yellow fluid with ectodermal (eg, teeth,hair), mesodermal (eg, muscle), and endodermal (eg, lung) components.
    • Intraperitoneal spillage of cyst contents should be avoided as it can cause chemical peritonitis.
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  13. Abdominal or Pelvic Pain In Women
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  14. Ruptured Ovarian Cyst
    • Symptoms are caused by peritoneal irritation from leaking of cyst contents.
    • Patients typically develop sudden onset of unilateral lower abdominal pain, often after strenuous activity or sexual intercourse.
    • Physical examination shows tenderness of the lower abdomen, and an adnexal mass is sometimes palpable.
    • A complete blood count should be ordered to assess for anemia due to acute blood loss (ovarian bleeding from cyst rupture), and a pregnancy test should be obtained to exclude ectopic pregnancy.
    • Pelvic ultrasound usually shows pelvic free fluid from leaking cyst contents, but an adnexal mass may be absent in the case of complete rupture.
  15. Unruptured Ovarian Cyst
    • An uncomplicated cyst rupture with no fever, hypotension, tachycardia, or signs of hemoperitoneum/infection can be managed conservatively with analgesics on an outpatient basis.
    • Patients who are hemodynamically unstable or have significant hemoperitoneum require surgical intervention.
  16. Dermoid ovarian cyst (mature cystic teratoma)
    • It is a common benign germ cell tumor that occurs in premenopausal women.
    • Cyst contents include sebaceous fluid, hair, and teeth.
    • Adnexal fullness on routine physical examination in an otherwise asymptomatic patient is a common presentation, although some patients may experience pelvic pain or pressure.
    • Ultrasound findings of hyperechoic nodules and calcifications in dermoid cysts are typical and diagnostic.
    • Treatment is with surgical removal of the cyst.
  17. Ovarian torsion
    • It is a gynecologic emergency typically occurring in premenopausal patients, including adolescents.
    • Pelvic pain in a patient with a known ovarian mass should be suspected as ovarian torsion until proven otherwise.
    • Dermoid cysts in particular have a higher likelihood of torsion than other types of ovarian masses.
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  18. Pathophysiology of Torsion
    A mass on the ovary puts weight on the adnexa and makes it vulnerable to twisting around its supporting structures (infundibulopelvic ligament or utero ovarian ligament), which contain the ovarian blood supply.
  19. Clinical Features of Torsion
    • Symptoms arise due to ischemia and eventually necrosis of the ovary. The typical presentation includes unilateral pelvic pain with possible nausea, vomiting, and fever.
    • The pain is usually severe and of acute onset and can become constant or remain intermittent.
    • Diagnosis is with ultrasound demonstrating absent blood flow to the ovary; the presence of an ovarian mass makes torsion more likely.
    • Treatment is with prompt surgical detorsion, cystectomy, and possibly removal of the adnexa if there is necrosis despite restoration of circulation.
  20. Diagnosis and Treatment of Ovarian Torsion
    • Ultrasound differentiates ovarian torsion from other acute gynecologic conditions (eg, ruptured cyst) by the presence of an adnexal mass and lack of Doppler flow.
    • Patients require prompt surgery- laparoscopic cystectomy and detorsion - with goals of restoring normal anatomy and saving the ovary from irreversible necrosis.
    • Salpingo-oophorectomy with torsion is reserved for obvious adnexal necrosis or suspected ovarian malignancy.
    • Untreated torsion may lead to chronic pelvic pain, infertility, hemorrhage, or peritonitis and sepsis.
  21. Cervical mucus secretion during ovulation
    • Mucus secretion close to ovulation (late follicular phase) increases in quantity and can be perceived by patients as vaginal discharge.
    • It corresponds with LH Surge.
    • This mucus is clear, elastic, thin in consistency, and described similar in appearance to an uncooked egg white.
    • It is thought to facilitate sperm transport into the uterus for conception.
    • After ovulation occurs, the mucus becomes thick and less hospitable to sperm.
  22. Discharges and Infections
    • Bacterial vaginosis: thin white discharge with an odor.
    • Candidiasis: thick white to yellow discharge and mucosal erythema.
    • Chlamydia cervicitis: mucopurulent cervical discharge and a friable cervix.
    • Trichomoniasis: yellow-green malodorous discharge.
  23. Colposcopy
    • It evaluates the cervix and vagina under magnification after application of acetic acid to contrast and identify abnormal (eg. aceto-white changes) from normal cells; abnormal vessels (a sign of high-grade lesions) also become more visible.
    • Cervical neoplasia typically occurs at the transformation zone or squamocolumnar junction.
    • If these areas are not visualized during colposcopy (eg, an "inadequate" colposcopy), an endocervical curettage is performed to evaluate the endocervical canal.
    • Endocervical curettage is an invasive procedure and is deferred during pregnancy due to risk of miscarriage and preterm delivery.
    • Cervical biopsy is performed even in pregnancy if a lesion has high-grade features (eg, abnormal vessels).
  24. Screening Cervical Cancer
    • Screening for cervical cancer with Pap tests is performed to detect lesions (eg, low-grade squamous intraepithelial lesions) in earlier, more treatable stages.
    • Pap tests without HPV co-testing are repeated every 3 years beginning at age 21.
    • At age 30, Pap tests with HPV co-testing may be done and repeated every 5 years if negative. HPV testing triages abnormal Pap test results and is not used as a standalone screening test. Regardless of screening interval, Pap testing ends at age 65.
  25. When to stop PAP Smear?
    • Normal Pap tests exclude persistent HPV infection, and patients with adequate screening by age 65 are at low risk of developing cervical cancer. In such patients, Pap tests may be stopped.
    • If a patient has a history of cervical intraepithelial neoplasia 2 or higher on histology, screening continues for another 20 years after detection, past age 65 if indicated.
    • Terminating Pap tests at age 65 may not be appropriate for women with risk factors for cervical cancer (eg, immunosuppression, high-risk sexual activity, tobacco use, diethylstilbestrol exposure).
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  26. Indications of Endometrial Biopsy
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  27. Atypical glandular cells (AGC)
    • AGC on Pap testing may be due to either cervical or endometrial adenocarcinoma. AGC in women age more than 35 or women age less than 35 with risk factors (eg, obesity, anovulation) requires evaluation for endometrial cancer in addition to cervical pathology.
    • Therefore, AGC on Pap testing is investigated with colposcopy, endocervical curettage, and endometrial biopsy to evaluate the ectocervix, endocervix, and endometrium.
  28. Indications for hospitalization for pelvic inflammatory disease
    • • Pregnancy
    • • Failed outpatient treatment
    • • Inability to tolerate oral medications
    • • Noncompliant with therapy
    • • Severe presentation (eg, high fever, vomiting)
    • • Complications (eg, tube-ovarian abscess, perihepatitis)
  29. Treatment of PID
    • PID is treated with empiric broad-spectrum antibiotic therapy. Patients requires hospitalization and parenteral antibiotics if they have nausea, vomiting, dehydration (eg, dry mucous membranes), and severe presentation (eg, high fever, leukocytosis).
    • In addition, hospitalization is recommended for adolescents due to the risk of noncompliance with outpatient therapy.
    • Regimens for hospitalized patients include intravenous (IV) cefoxitin or cefotetan plus oral doxycycline, or parenteral (IV) clindamycin plus gentamicin.
  30. Outpatient management of PID
    • Doxycycline is used in both inpatient and outpatient management of PID along with ceftriaxone due to its anaerobic coverage.
    • Clindamycin also provides anaerobic coverage and is part of an alternate inpatient regimen for IV treatment of PID.
    • Metronidazole is added when PID is complicated by tubo-ovarian abscess due to required additional anaerobic coverage.
  31. Chlamydia and Gonorrhea in Women
    • Long-term sequelae of chlamydia and gonococcal infections include infertility and ectopic pregnancy due to adnexal scarring.
    • Therefore, all sexually active women age less than 25 are advised to undergo C. trachomatis and N. gonorrhoeae screening annually in addition to routine Pap testing.
    • The nucleic acid amplification test (NAAT) is the gold standard for screening and diagnosis due to its high sensitivity and specificity.
    • For women, NAAT can be obtained by either a vaginal or a cervical swab.
    • A cervical swab may be collected in women undergoing pelvic examination, whereas patient-collected vaginal swabs are a less invasive alternative for younger patients.
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  32. Pelvic Inflammatory Disease
    • PID typically presents with fever, lower abdominal tenderness, mucopurulent cervical discharge, and cervical motion and uterine tenderness.
    • Infection can extend from the upper genital tract to spread throughout the abdomen and cause liver capsule inflammation (eg, perihepatitis or Fitz-Hugh- Curtis disease), resulting in vomiting and slightly elevated transaminase levels.
    • Patients with hepatic involvement present with symptoms of acute PID (fever, lower abdominal pain) as well as pleuritic right upper quadrant pain .
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  33. Neisseria gonorrhoeae
    • It is a common sexually transmitted infection that can cause cervicitis (eg. mucopurulent discharge, irregular bleeding) and lead to PID (eg, fever, lower abdominal pain).
    • Gonococcal pharyngitis occurs due to inoculation of the pharynx during orogenital contact.
    • Although pharyngeal involvement is typically asymptomatic, It may present with pharyngeal edema and nontender cervical lymphadenopathy.
    • Diagnosis is confirmed by nucleic acid amplification testing for gonorrhea.
    • Treatment is with ceftriaxone plus doxycycline.
  34. Recommendation for Chlamydia and Gonorrhoea Screening
    Annual screening for chlamydia and gonorrhea is recommended in all sexually active women age less than 25 and women age more than 25 with risk factors (eg, multiple sexual partners, inconsistent condom use).
  35. Screening Test for Chlamydia and Gonorrhea
    • The nucleic acid amplification test (NAAT) is the gold standard screening and diagnostic test for C trachomatis and N gonorrhoeae due to its high sensitivity (96%) and specificity (99% ).
    • A positive chlamydia NAAT requires treatment of the patient and sexual partners with azlthromycln or doxycycline.
    • Treatment of both infections is no longer required if there is a single positive result.
  36. Polycystic Ovarian Syndrome
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  37. Polycystic ovary syndrome (PCOS)
    • It is a common condition diagnosed in adolescents due to signs of hyperandrogenism and irregular menses.
    • Clinical evidence of hyperandrogenism includes severe nodulocystic acne, male pattern baldness. and hirsutism.
    • Patients usually have elevated serum levels of total testosterone, however these laboratory values may be normal in some due to decreased levels of sex hormone binding globulin, with elevated free testosterone levels instead. Therefore, the diagnosis requires either clinical or biochemical evidence of hyperandrogenism.
  38. Mechanism of Endometrial Carcinoma in PCOS
    • Women with PCOS typically have decreased progesterone secretion due to chronic anovulatory cycles. Therefore, these patients usually have a constant and unbalanced proliferation of the endometrium by estrogens. This unopposed estrogen stimulation places patients at increased risk for endometrial hyperplasia and cancer.
    • Treatment with cyclic progesterone, estrogen/progestin oral contraceptives, or progesterone-releasing intrauterine devices protects the endometrium from hyperplasia and reduces cancer risk.
  39. Effect of Anovulatory Cycles On Endometrium
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Author
Ashik863
ID
335243
Card Set
USMLE Gynecology III
Description
lichen
Updated