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2 cm subserosal fibroid in a pregnant woman at 17 GA, further eval?
No further eval. Although fibroids may demonstrate red or carneous degeneration with rapid growth, this is uncommon for smaller fibroids. Uncommonly, fibroids can be located below the fetus --> C-section. If the fibroid were causing symptoms such as pain or is in a concerning position, it would be good to follow its growt
Single highest risk for bad outcomes with breast carcinoma
Axillary node mets --> led to use of postsurgical adjuvant therapy in these patients.
Clear cell carcinoma of the endometrium....
Tumor origins thoought to be mesonephric duct remnants.
Clear cell carcinoma stains with what
Periodic acid-Schiff staining-positive for glycogen.
Typically appear in older women and are very aggressive.
Mixed Mullerian endometrial cancer has what
Combination of heterologous elemetns, with tissues of different sources, e.g. cartilage.
Sertoli-Leydig cell tumors make up how many ovarian tumors
Histologically they resemble fetal testes, must be differentiated from adrenal tumors which can also produce androgens.
Excessive estrogen production due to theca cell tumors or granulosas may manifest how
Endometrial cancer - 15% of patients!!
Tumors are quite friable, so may present with sx caused by tumor rupture and intraperitoneal bleeding.
Gonadoblastomas contain what
Frequently contain calcifications, are present in women with ambiguous genitalia usually.
Sarcoma botryroides, what is this
Tumor seen in children, malignancy asoc with Mullerian structures such as the vagina and the uterus, including cervix.
Histo appearance of lichen sclerosus
Loss of rete pegs within the dermis, chronic inflammatory infiltrate below the dermis, etc. etc.
Why is lichen sclerosus important
People do have more cancers, but it isn't a precancer. Rather, it must be differentiated from vulvar squamous cancer.
First line therapy for lichen sclerosus
Ultrapotent steroids: clobetasol, halobetasol, diflorasone.
Topical estrogens only if labial adhesions are present.
US findings indicative of exlap in a PM patient with ovarian mass
Internal ovarian papillary vegetations
Size >10 cm
Presence of ascites
Possible ovarian torsion
Solid ovarian lesions
Younger woman with ovarian mass, how to follow?
Follow past one menstrual cycle to determine if it is a follicular cyst, since a follicular cyst should regress after onset of the next menstrual period... IF regression does not occur, then surgery is appropriate.
Large enterocele prolapse, first step in mgmt
Pessary fitting, least invasive...
Sacrospinous ligametn suspension would also be appropriate, but faurther downt he line.
Defects of what fascia are fixed in the repair of central and lateral cystoceles
Pubocervical fascia --> reattaching it to a sidewall
Vaginal vault prolapse, how to fix
Supporting vaginal cuff to uterosacral ligaments, sacrospinous ligament or sacrocolpopexy.
Best 5 year success rates for patients with GSI due to hypermobility
Much more than: needle suspensions and anterior repairs
Why is advancing maternal age associated with increased in dizygotic twins
Increasing FSH, harder to folliculate follicles --> release of multiple eggs.
What is superfecundation
Fertilization of two or more ova from the same cycle by sperm from separate acts of sexual intercourse.
What has been shown to reduce risk of preterm delivering in multiple gestation
Adequate weight gain in first 20-24 weeks of pregnancy... at least 24 lbs by 24 weeks.
Ultrasound markers of dizygotic twins
Dividingmembrane thickness >2mm
Twin peak --> lambda sign
Different fetal genders
Two separate placentas.
Tests of ovulation
Symptoms --> painm ,ovulatory mucus (spinnbarkeit),
Ovulation predictor kits --> LH surge
Serum progesterone in the luteal phase --> one of the best >10
Normal semen values
Volume 1.5-5.5 ml
Count >20 mil/ml
Morphology >14% normal forms
So-called "strict criteria" for sperm morphology - Thaddeus kruger. WHO >30%.
Top causes of female infertility
Tubal disease - top
Ovulatory problems - top
Conditions that warrant earlier medical intervrention, history of
Ruptured ovarian cyst or pelvic surgery
Male reproductive organ disease or surgery
AMA or prolonged history of infertility
Level III care for infertility
Duration > 36 months
Female partener >35 yo
ART is under consideration
Mgmt of complicated anovulation, endometriosis, etc.
WHO classification of anovulation
I --> hypothalamic failure
II --> abnormal hormones, with normal FSH --> PCOS
III --> ovarian failure (high FSH) --> premature ovarian failure or ovarian destruction
Causes of hypothalamic failure for anovulation
Pituitary hypothalamus tumors
FSH for ovarian reserve
Cycle day 3 FSH with E2:
Estradiol level can suppress FSH
Clomiphene citrate challange test
CD3 FSH/E2 with repeat of FSH at CD 10 after Clomiphene
Normal - 43%^
Abnormal - 9%. Test of ovarian reserve.
Antiestrogen, competes with estrogen at hypothalamus and tricks body into thinking that the estrogen is low. Requires nromal hypothalamus and ovaries.
Side effects of clomid
Hot flashes (anti estrogen)
Side effects of gonadotropin shots
May lead to ovarian hyperstimulation syndrome (OHSS) --> can be very sick, or high order multple pregnancies.
Stronger than clomid.
PE of adenomyosis
Enlarged, soft, boggy uterus with no masses palpable. History of progressively worsening severe menstrual pain.
Adenomyosis relieve for women who do not desire hysterectomy
Insertion of a levonorgestrel-containing intrauterine device.
Endometrial biopsy recommendations for women with weird bleeding
Even with solid diagnosis of fibroids, e.g., every woman over age 40 with irregular bleeding needs an endometrial biopsy to rule out carcinoma
Acute uncomplicated cystitis causes
E coli - 80-85% of causes
Citrobacter and enterococc occas
PID + high fever
Inpatient management. Needs aggressive therapy in effort to prevent scarring of her fallopian tubes and possible future infertility.
Also consider for N/V, nulliparous patients, etc.
Outpatient for PID
Ceftriaxone, Cefoxitin, or other third generation cephalosporin (such as ceftizoxime or cefotoxime) + Doxy with or without metronidazole
Initial HSV infection
Viral like symptoms preceding the appearance of vesicular genital lesions. W/ primary infection,dysuria --> retention, may require catehter drainage.
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