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Main routes of spread of cervical cancer

Vaginal mucosa
Paracervical lymphatics (also parametrial,obturator, hypogastric, external iliac, and sacral in that order)
Direct extension into parametrium

Dermoid cysts of ovaries, what percent are bilateral


Most common germ cell tumor

Benign cystic teratomas. OCcur primarily during reproductive years, but also in childrena and PM women

Symptoms of benign cystic teratomas

Usually asymptomatic, but can cause severe pain if torsion, or if sebaceous material pills and creates a reactive peritonitis

Treatment of bartholin gland cyst

Complete excision, esp in women >40 yo who present with cystic or solid mass in this area. Incidence of adenocarcinoma of bartholin gland peaks in 60s.

Abscess formation with bartholin cyst

As well as appropriate antibiotics.

STages of cervical cancer

Stage 1 - limited to cervix
Stage 1a - preclinical, microscopic
Stage 1b - Macroscopic
Stage 2 - involves vagina but not lower one third, or infiltrates parametrium but not to pelvic side wall
Stage 2a - Vaginal but not parametrial extension
Stage 2b - Parametrial extension
Stage 3 - Lower 1/3 vagina or extension to pelvic side wall
3a - Vagina but not pelvic side wall
3b - pelvic side wall, assoc with hydronephrosis or a nonfunctioning kidney caused by tumor

Stage 4 - outside the reproductive tract!

Cervical cancer with hydronephrosis, what stage at least?

Stage 3b

Bounds of Stage 1a cervical cancer

Lesions within 3mm of basement membrane, no wider than 7mm, with no lymph or vasc invasion, no confluent tongues

Mets in Stage 1a cervical cancer?

1.2% according to one study.

Stage 1a cervical cancer treatment

Intrafascial hysterectomy.... not sure what that is.

Invasive vulvar carcinoma treatment

Surgical. Radical vulvectomy and bilateral inguinal LAD...

IF inguinal nodes show sign of disease --> bilateral pelvic lymphadenectomy..

Local advanced carcinoma? Consider radiation therapy.

Stage IIIb cervical cancer

Extension to pelvic side wall, can involve the ureters.

Most common cancer in pregnant women

Cervical cancer, mainly because this is a cancer that can affect younger, childbearing women.

Radical hysterectomy indicated for Stage 1b cervical cancer, what is taken and what can be spared

Upper 1/3 of vagina
UTerosacral and uterovesical ligamnets
Pelvic node dissection
Entire parametrium

You can spare both ovaries in a younger patient!!! Cervical cancer mets to the ovaries are pretty rare indeed.

PMB with atypical complex hyperplasia, risk of assoc endometrial carcinoma?

25-30%!!! Thus total abdominal hysterectomy is encouraged.

What if hysterectomy is not an option? Progesterone therapy can be used.

PMB, first step?

In office endometrial biopsy, prior to any medicalor surgical intervention.

Worrisome breast discharge characteristics


Usual cause of unilateral bloody nipple discharge

Intraductal papilloma

Carcinoma must be ruled out!!
OTher causes include duct ectasia and fibrocystic breast disease.

Two most common benign breast disorders

Fibrocystic changes
Fibroadenomas - firm, solid, well-circumscribed, nontender, freely mobile mass.

Avg diameter of fibroadenomas

2.5 cm

Fibrocystic breast changes, who gets them

1/2 to 1/3 of reproductive aged women.

What are fibrocystic breast changes

Exaggerated response of the breast tissue to normal hormones.

Diffuse b/l nodularity is typically encountered.

Cystosarcoma phylloides

Rare fibroepithelial tumors - 1% of breast malignancies.
Rapid growth, most frequent breast SARCOMA, and occur most frequently in fifth decade of life.

Fat necrosis presentation

Firm, tender mass surrounded by ecchymosis. Skin retraction can occur, which makes this hard to distinguish from cancer.

Fibroid degeneration during labor, is this common?

No. But fibroids can outgrow blood supply --> carneous degeneration, leading to preterm labor..

May also be assoc with fetal malpresentation caused by distortion of endometrial cavity. *May also contribute to postpartum hemorrhage.

How to characterize uterine leiomyosarcomas

>5 mits/10hpf on microscopic exam. Ooccurs de novo.

PMB with rapidly enlarging uterus

Uterine leiomyosarcoma - rare though!!

Treatment of BV

Metro 500mg BID x 7 days. Anaerobic bact overgrowth

Treatment of Trich

Metronidazole 2g one time dose

Treatment for chlamydia

Azithromycin 1 g
Doxy 100mg BID x 7 days

Fever, lower abdominal pain, leukocytosis

OVarian torsion!
Acute salpingitis

Ruptured ovarian cysts

ACute abdominal pain without fever

Usually occurs around ovulation.

TOA management

Admission, IV antibiotics
no improvement?
Drainage via laparotomy, laparoscopy, or CT percutaneous drainage.

Antibiotics for PID, inpatient

Cefoxitin 2g IV q6h or Cefotetan 2g IV q12h + Doxy 100mg BID


Clinda 900mg q8h + Gent IV or IM

Antibiotics for PID outpatient

Cefoxitin 2g IM + Probenecid 1g in a single dose
Ceftriaxone 250mg IM + Doxy 100mg BID x14 days.
Ofloxacin + (Clinda OR Metro)

Vulvodynia, what is this

1. SEvere pain on vestibular touch or attempted vag entry
2. Tenderness to pressure localized withinthe vulvar vestibule
3. Visible findings, vulvar erythema of varying degrees

Treatment of vulvodynia

Avoid tight clothing,tampons, hot tubs, soaps --> avoid vulvar irritants!!!

1. Topicals: Lidocaine, estrogen, steroids
2. TCAs and intralesional interferon

Surgical resection

Vulvodynia vs contact derm

Vulvodynia pain during penetration
Contact derm pain all the time...

Lichen sclerosus

Thin, diffuse, whitish epithelial areas on the labia majora/minora, clitoris, and perineum. Severe cases may be difficult to identify normal anatomic landmarks.

Most common symptom --> chronic vulvar pruritus.

VIN symptoms

Vulvar pruritus
Chornic irritation
Raised lesions (most commonly along the posterior vulva and in the perinealbody and have a whitish cast and rough texture)

Indications for a cone biopsy

1. Unsatisfactory colpo exam (entire transformation zone cannot be seen)
2. Colpo directed cervical biopsy that indicates possibility of invasive disease
3. Neoplasm in nedocervix
4. Cells on cervical biopsy do not adequately explan cells seen on cytologic exam

PAP - HGSIL, but normal or equivocal colposcopy.

10% of colpo results will belike this. Conization of the cervix is thus required to rule out lesions higher in the endocervical canal.

Glandular paps, what percentof paps

0.5% of paps

Glandular pap results, assoc with what

Squamous lesions
Adenocarcinoma in situ
Invasive adenocarcinoma

AGUS on pap

Immediate colpo
Endocervical curettage
PM patient? Endometrial sampling

What is a Frei test

Used to identify lymphogranuloma inguinale. Antigen made from tserille pus produce a reaction in patients with lymphogranuloma inguinale when injected intradermally.

No longer used because gross, and also low .

How long between HIV exposure and seroconversion

2-8 months, probably retest at least 4-12 weeks or so.

What is Lymphogranuloma venereum

C. trachmatis, most commonly found in the tropics.

Begins as painless ulcer or vaginal vestibule... then develops painful adenopathy in the inguinal and perirectal areas.

Diff diagnosis for single genital ulcer

Lymphogranuloma venereum
Granuloma ingunale

Granuloma inguinale?

C. granulomatis --> donovan bdies.

Treatment of Lymphogranuloma venereum or Granuloma inguinale


How to treat chancroid


Environmental factor that increases risk of cervical dysplasia

Tobacco smoke.

Ovarian enlargement in young woman, what is this, how should it be managed?

Return to office and recheck... because it is most likely a functional ovarian cyst.

If cyst is persistent --> CT scanning or pelvic U/s.

Functional ovarian cysts, how do they form?

Physiologically, during the normal functioning of the ovaries... Follicular cysts are usually asymptomatic, unilateral, thin walled ,filled with a watery straw colore fluid.

Corpus luteum cysts?

Less common than follicular cysts, usually unilateral but often appear complex as they may be hemorrhagic. May also be symptomatic, with dull pain on the side of the affected ovary.

Three types of functional ovarian cysts?

Follicular cysts - straw colored fluid, thin walled

Corpus luteum cysts - may look complex or be hemorrhagic

Theca lutein cyst - least comon of three types, almost always b/l and assoc with pregnancy.

CA-125 good for what

Evaluating PMW w/ pelvic mass
Assessing treatment response

PRoduced in ~80% of ovarian epithelial carcinomas.

Large, bleeding condyloma acuminata


Cystitis - diagnosed when?

Clean catch urine sample - concentration of at least 100,000 bact / mL of urine.

Conservative treatment for urge incontinence has failed, what now

Medical therapy:
- Oxybutynin
- Metaproterenol
- Valium
- TCAs
- Dopamine agonists - Parlodel

Le Fort procedure

Surgical treatment for prolapse

Rates of vaginal vault prolapse in hysterectomy patients

Up to 18% of patients who have undergone hysterectomy.

Degrees of uterine prolapse

First degree - descent limited to upper two thirds of vagina
Second degree - just inside introitus
Third degree - out of introitus
Procidentia - completely out

Vaginal fistulas occur after what

75% after abdominal hysterectomies
25% vaginal operations

Midurethral sling typse

Transobturator tape
Transvaginal tape

What is Kelly plication

Older procedure used to suspend the urethra in stress incontinence. Has lower cure rate for stres incontinence than the burch procedure

Burch procedure

Suspends bladder neck to Cooper ligament of the pubic bone using an abdominal approach.

Sacral colpopexy

Used to repair prolapse of vagina by suspending the vaginal vault from the sacrum

Le fort procedure in whom

Vaginal vault prolapse
Pelvic relaxation
Poor surgical candidates
Not sexually active

Ditropan aka


Diabetes and incontinence

Causes overflow incontinence

Suspected ureteral injury test of choice

Renal ultrasound, noninvasive

IV pyelogram replaced by CT contrast... but contrast is CI in elevatedCI.

Urethral divercticula symptoms

URinary freq
OFten palpable as mass on anterior vaginal wall underneath the urethra.

RAce figures with uterine prolapse

Much lower incidence in black and Asian patients than in whites.

Marshall Marchetti Krantz procedure

Involves attachment of the periurethral tissue to the symphysis pubis for GSUI. Long term cure rate around 80%. 1-2% will get ostetitis pubis, which is an aseptic inflammation. Course is usually chronic.

Troublesome urinary leakage in a PM woman, first step in eval

Urinalysis and culture

Most common cause of fecal incontinence

Obstetric trauma with inadequate repair. Generally the patient is continent of formed stool but not of flatus.

Top causes of fecal incontinence

Obstetric trauma
CNS disease
Rectal prolapse
Diabetes - 20%
Chronic diarrhea

Conservative measures for fecal incontinence

Bulk forming agents
Stop caffeine
Biofeedback and electrical stim of rectal sphincter

Surgery if all else fails...

Risk of colpocleisis

Incontinence, care to be taken around the bladder area.

Most common types of urinary incontinence


Most common cause of incontinence in elderly women


UTerine prolapse repair, risk of what incontinence?

Stress urinary incontinence

Absolute CI to HRT

EStrogen-dependent tumors - breast or uterus
Active thromboembolic disease
Undiagnosed genital tract bleeding
*Active severe liver disease
Malignant melanoma*

Order of puberty

Growth spurt

On average 4.5 years to complete, with a range of 1.5 to 6 years.

Delayed thelarche

Not by age 13

Delayed adrenarche

Not by age 14

Menarche, delayed when

Not by age 16, or 17

What is considered precocious puberty

Pubertal changes before age 8 in girls, and 9 in boys.

Most common causes of precocious puberty


True sexual precocity

Normal gonadotropin levels (should be low)
Normal ovulatory pattern.

Represents premature activation of a normally operating hypothalamic-pituitary axis.

Usually idiopathic, can also be caused by cerebral causes such as tumors or history of encephalitis or meningitis, or hypothyroidism, POFD, NF, and others.

What is precocious pseudopuberty

Endocrine glands under neoplastic influence produce elevated aboust of estrogens creating either:
- Isosexual precocious pseudopuberty
- Heterosexual (androgens) precocious pseudopuberty --> virilizing signs

Most common cause of isosexual precocious puberty

Ovarian tumors. Some including dysgerminonomas and choriocarcinomas can produce so much gonadotropin that pregnancy tests are positive.

What is incomplete sexual precocity

Usually idiopathic, characterized by only partial sexual maturity such as premature thelarche or premature adrenarche. Gonadotropins are frequently normal.

Gonadotropin-producing tumors

Presacral tumors

Ovarian tumors leads to what sort of precocious puberty

Isosexual precocious pseudopuberty.

Specificially dysgermoniomas or choriocarcinomas...

HRT and Alzheimer

Perhaps HRT decreases risk...

HRT and uterine cancer

Does not increase risk of uterine cancer. Perhaps doe sincreas erisk of breast cancer, heart attakc, stroke, and VTE.

Estrogen use and lipid profile

Decreases total cholesterol and LDL
Increases HDL and triglycerides

Estrogen use and TGs

Increases TGs

Hot flushes and timing of menopause

First menopausal symptoms, can occur years before the cessation of menstruation.

How long does a hot flush last

3 minutes total. Sudden sensation of heat over the chest and face that lasts b/w 1-2 minutes, then followed by a sensation of cooling or a cold sweat.

How long before estrogen therapy reduces hot flushes

Resolution within 3-6 weeks

Natural history of hot flushes

Within 2-3 years after cessation of menstuation.

Chronic anovulation underlying medical problems

Thyroid problems

Heavy and acute bleeding in the context of an atrophic endometrium

25mg of conjugated estrogen q4h until bleeding subsides. Estrogen will helpp because it rebuilds the endometrium stimulating clotting at the capillary level.

Heavy and acute bleeding with a thickened endometrium

Hysteroscopy and D&C. D&C may be helpful in older women to r/o endometrial cancer.

SSRI dosing in PMDD or PMS

Can perhaps limit to the luteal phase

Positive orthostatics

Fall in BP by 20
Rise in HR by 20
Increase in weakness, dizziness, nausea or other symptoms.

First step in inducing ovulation in PCOS

Metofrmin. Insulin is thought ot act on the ovary to stimulate androgen secretion.... Additionally, hyperinsulinemia decreases SHBG

Appropriate lab tests in early menstruation dysfunctional uterine bleeding attributed to anovulation

Bleeding time - 20% of adolescents with DUB have coag defect
Blood ytle and screen

Hirsutism and irregular menses, labs worth getting


Sertoli Leydig cell tumors

aka Androblastomas. 20-40 yo, tend to be unilateral, reaching a size fof 7-10 cm.

Very high levels of testosterone >200, rapidly developing virilizing characteristics such as temporal balding, clitoral hypertrophy, voice deepening, breast atrophy, terminal hair b/w breasts and on the back.

Idiopathic hirsutism, causes

Greater activity of 5alpha-reductase than do unaffected women. Just more hair, nothing else really.

Day in which to draw progesterone levels to confirm ovulation

7 days post ovulation around Day 21.

A Biopsy for a luteal phase defect should be done when

12 days after thermogenic shift, or 2-3 days before expected onset of menses, about day 26 of a 28 day cycle.

When is the hysterosalpingogram done

Mid follicular phase, around day 8. Should not be done when the patient is menstruating or after ovulation has occurred.

When would gonadotropin levels be checked

CD 3

Physical actionst that can cause hyperprolactinemia

Intesive suckling

What is in part reponsible for determining adult eight

Ovarian estrogen production late in puberty

Pituitary response to GnRH stimulation test in normal puberty

Identical to normal

Sexual precocity independent of gonadotropin functioning

Iatrogenic (ingestion of estrogens)
Premature thelarche
Ovarian tumors

Normal sperm analysis

20 mil /ml
>60% with normal shape
Volume 2-6ml
>50% progressive forward motility

Normal pubertal progression

Growth spurt

Examples of conversion of celomic epithelium into endometrium

Endometriosis in men, and in women without mullerian structures

Mullerian agenesis aka

Mayer-RokitanskyKuster-Hauser sydnrome... amenorrhea with the absente of a vagina.

Normal development in Mullerian agenesis

Normal development of breasts, sexual hair, ovaries, tubes, external genitalia. Associated skeletal and urinary tract abnormalities.

Treatment for Mullerian agenesi

McIndoe procedure, creation of an artifical vagina with split thickness skin grafts.

Testicular feminization presentation

10% of all cases of primary amenorrhea.
Absent uterus, blind vaginal canal. Sexual hair is decreased (sign of androgens).

Causes of primary amenorreha

Gonadal dysgenesis
Mullerian agenesis
Testicular feminization

Abnormal luteal phase

Ovulation with poor progestational effect in the second half of the cycle.

This is evaluted at the endometrium, with a biopsy around day 22-26. Midluteal progesterone levels <10 are suggestive but not diagnostic.

Pregnanediol is a metabolic product of progesteroene, and this may be helpful.

Most common reason for amenorrhea in women of reproductive age

Chronic endometritis or scarring of endometrium
Ovarian failure
Emotional stress, extreme weight loss, and adrenal cortical insufficiency


Directly suppress estrogen production
Increas SHBG

Clinical improvement may take up to 6 months to manifest.

Risk of GnRH agonists

Significant bone demineralization after only 6 months of therapy.

Topical cream for hirsutism

Eflornithine hydrochloride --> antimetabolite topical cream

Conservative measures for treating dysmenorrhea

Heating pads
Mild analgesics
SEdatives or antispasmodics
Outdoor exercise

Biochemical makeup of primary dysmenorrhea

Higher than normal concentration of prostaglandins in the endometrium and menstrual fluid.

Thus, prostaglandin synthase inhibitors: INdomethacin, naproxen, ibuprofen, and mefenamic acid (Ponstel).

Also OCPs --> minimize endometrial prostaglandin production during concurrent administration of estrogen and progestin.

REserve narcotics for those that fail other therapies.

Anorexia nervosa hormone concentraitosn

PRL, TSH, and thyroxine are normal
FSH and LHa re low
Cortisol elevated

What decreases PIF

DRugs (phenothiazines)
Hypothalamic lesions
STalk compression

Adipose estrogen

EStrone, from peripheral conversion of androstenedione to estrone in adipose tissue.

Incidence of varicoceles, general population vs infertile

15% general pop
40% infertility

Semen analysis in varicocele

Decrease in number with decrease in motility and increased abnormal forms.

Normal males but with uterus and fallopian tubes

Failure of MIF. Karyotybe is 46,XY, testes are present, and testosterone production is normal.

Danazol, what is this

Progestatinal compound derived from testsoterone used to treat endometriosis.

Induces pseudomenopause, but does not alter basal Gn levels. Appears to act as an antiestrogen and causes endometrial atrophy.

Danazol post pregnancy

Endometrium is atrophied. Although cyclic menses return almost immediately, it is felt that endometrium is too atrophied to avoid SAB. Thus, three or so cycles should pass before they try.

BEst diagnostic study for Asherman

Hysterosalpingogram with fluoroscopy.

Medical treatment of endometriosis

Continuous progestins
GnRH analogs

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