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HPV 16 and 18
There are over 100 types of HPV. 30-40 types infect the genital tract. 20 types are oncogenic (high risk). What 2 types cause 70% of cervical cancer and high grade HPV?
Old Gardisil reduced HPV risk by what percent?
New Gardisil reduces the risk of HPV by what percent?
What is ABSOLUTELY necessary to develop cervical cancer?
False (it can cause oropharyngeal cancer, anal cancer, vulvar and vaginal cancer, and penille cancer)
T/F: HPV is absolutely necessary to cause cervical cancer BUT it cannot cause other cancers.
skin to skin contact (including during sex, condoms don't protect against HPV because it doesn't cover all the skin)
How is HPV transmitted?
smoking (other risk factors: STI risk factors, immunosuppression, and young age due to lack of acquired immunity)
What is the only modifiable risk factor for HPV?
T/F : Once you have cleared and HPV infection you are forever protected against that specific type of HPV.
True (almost all sexually active people get it during their lives)
T/F: HPV is very common
double stranded, DNA, integrates
HPV is a _______stranded _______ virus. It ________ into the host genome. It uses the E6 and E7 oncogenes to inhibit tumor suppressor genes.
inhibit p53 function. Inhibit both p53 and retinoblastoma family proteins.
HPV oncogenes. What does E6 do? What does E7 do?
T/F: Vast majority of HPV infections are transient. They are asymptomatic and resolve spontaneously within 2 years.
= Infection by the same HPV type after 2 years. Leads to invasive cervical cancer through a stepwise sequence of progressive neoplasia.
How long does it take from initial infection of HPV to develop invasive cancer?
young women, young women (mean duration of infection is 8 months and most clear it in 2 years)
What population is more likely to have HPV? What population clears HPV the most rapidly?
11-12 years (b/c more likely to be sexually naive and not exposed to HPV in the past so get a greater immune response, but can give it from 9-45 yo)
What is the target age range for gardisil?
less (also circumcision reduces the risk of persistent infections)
The prevalence of HPV in men is as high or higher than in women but it is less/more likely to persist.
Takes a sample of superficial epithelium cells from the cervix. The cells are fixated and evaluated by a cytopathologist using liquid based cytology mostly. Can use this as primary screen for high risk HPV.
What are the PAP guidelines for <21 yo?
Pap q 3 years
What are the PAP guidelines for 21-29 yo?
Cotesting (pap + HPV) q 5 years
What are the PAP guidelines for 30-65 yo?
No screening if no history of abnormal pap in the last 20 years and no Hx of CIN2. (Continue screening if immunocompromised, history of DES exposure b/c was born before 1972.
What are the PAP guidelines for>65 yo?
Squamocolumnar junction (where the columnar epithelium meets the stratified epithelium on the cervix)
What part of the cervix do you want to collect cells from on a pap?
95% of cervical cancer happens right outside of the squamocolumnar junction at the _________.
CIN1, CIN2, CIN3
Cervical cancer: mild dysplasia = ______, moderate dysplasia = ______, Severe dysplasia = ________, then you get carcinoma in situ
vinegar (helps you know where to biopsy)
What can you put on the cervix to make the dysplasia turn white?
= magnification and illumination to aid visual inspection of the cervix, vagina, and anogenital area. Helps the clinician identify and biopsy areas of greatest concern.
What kind of cells do you need to see on the pap pathology report to make sure you got the right spot and it was a good pap?
Never treat (follow up in one year)
1% of women with CIN1 will go on to cervical cancer. What do you do for CIN1?
Sometimes treat (don't treat if they are young women who are not done with child bearing. monitor every 6 mos, if you do treat, treat with excisional or ablative method)
5-12% of women with CIN2 will go on to have cervical cancer. What do you do for CIN2?
Always treat (excision or ablative treatment)
60% of women with CIN3 will go on to have cervical cancer. What do you do for CIN3?
Where can you go for treatment guidelines for cervical dysplasia that is agreed upon by everyone?
Cold-kife cone biopsy (make a conical removal of the cervic and remove the area of dysplasia and the transformation zone, very painful and bleeds like crazy)
Incisional treatment of cervical dysplasia.
LEEP (has radiogrequency current and you can excise the cervix and coagulate while you do it. Local anesthesia, most common CIN treatment)
Most common treatment of cervical dysplasia.
Can't send tissue to pathology
What is the disadvantage of ablative therapies?
What disease does this clinical presentation match with? bleeding often post-coital, inadequate PAP/HPV screening, back pain, anorexia, weight loss.
stage it (cervical cancer spreads locally mostly. Stage it in the office with a bimanual exam. STAGING DEPENDS PRIMARILY ON PELVIC EXAM)
What is the next step after you make the Dx of invasive cervical cancer?
direct extension (cervix -> upper 2/3 of vagina -> lower 1/3 of vagina or pelvic side wall -> adjacent or distant organs)
How does cervical cancer spread?
Radical hysterectomy, brachytherapy (radiation directly to the cerix, done for advanced cancer)
What are the 2 treatments for invasive cervical cancer?
What is the most important prognostic factor for invasive cervical cancer?
7, 6, 11
Gardisil protects against __ types of high-rise HPV including 16/18and alsoo protects against HPV _____ and _______ which reduces the risk of condylomas (genital warts) by 90%.
Endometrial cancer, abnormal bleeding.
This is the most common gyn cancer in the US. 75% are diagnosed at stage 1. Best survival of all the cancers. What is it and what does it normally present with?
IF you have menorrhagia or post menopausal bleeding then you need to look at malignancy. You can use this to look for malignancy or hyperplasia in the office.
Endometrial hyperplasia and/or cancer
You should always suspect this if the menses is heavy, prolonged, or frequent or if there is any postmenopausal bleeding.
Endometrial hyperplasia. Simple glands with no cytological atypic
Simple atypical hyperplasia
Endometrial hyperplasia. Simple glands with cytological atypia
Endometrial hyperplasia. Complex glands with no cytological atypia
Complex atypical hyperplasia (this is the most concerning and is treated like cancer)
Endometrial hyperplasia. Complex glands with cytological atypia
increased age, excess estrogen stimulation (nulliparity, morbidly obese, tamoxifen therapy, PCOS), genetic Lynch syndrome
What are the risk factors for endometrial hyperplasia?
Smoking, OTC, parity, early menopause, lean habitus
What are the protective factors for endometrial hyperplasia?
Progestin therapy (stabilizes the estrogen)
For endometrial hyperplasia that is simple of complex without atypic what is the treatment?
Hysteectomy (not a radical hysterectomy. You want to take the uterus and the cervix out)
What is the definitive treatment for endometrial hyperplasia for complex with atypic?
What does prognosis of endometrial hyperplasia depend on?
Hysterectomy, possible node sampling, chemo, and radiation
What are the treatments for endometrial cancer if it is a very advanced disease?
No (early detection already has a good prognosis) you can screen women with Lynch syndrome with biopsy annually.
Should we screen for endometrial cancer?
Tumor that arises from the myometrium. These are rare. There a bunch of different kinds and the prognoses vary.
A type of uterine sarcoma that looks and behaves like a fibroid bu doesn't follow the rules (ie. post menopausal enlarging fibroidEndometrial cancer.
What am I? Presentation: abnormal bleeding. Risk factors: obesity, genetics, prior pelvic radiation. Prognosis: very poor
biopsy or DNC
What does post menopausal bleeding of any type need?
epithelium, storm, germ cell
What are 3 tissues of an ovary that cancer can arise from?
epithelial ovarian cancer
Ovarian cancer is almost always what kind of cancer?
This is the most deadly gynecologic malignancy. It is aggressive, high mortality, and presents late.
Infertilitiy, nulliparity, early menarche or late menopause, BRCA or LYnch genetic, High fat diet
What are some risk factors of ovarian cancer?
Tubal ligation (stick lesions), pregnancy, OCP
What are the protective factors from ovarian cancer?
abdominal pain, early satiety, bloating
Often there are no symptoms with ovarian cancer until stage 3-4 when women present in a triad consisting of what?
fluid wave, pelvic mass, DVT
If you are concerned for ovarian cancer you do a Hx and PE. What could you see on PE?
US (Ct if sometimes) to suggest or reassure that is is/isn't ovarian cancer. You can get tumor markers to suggest or reassure. The diagnostic is to take out the ovary
There is no way to biopsy an ovary. So what do you do?
string of pearls
On US for PCOS ovary what do you see?
Dominant follicle measuring up to 3 cm
On US with a normal ovary what can you see?
On US you can see nodules in the ovary. If you see a cyst that has solid features that is kind of fluid then what is it?
septations (honeycomb appearance)
What will you see on CT or MRI that points to ovarian cancer?
True or False: Ovarian cyts are very common.
Even if it is big (but <10 cm) then it has a 0% chance risk of cancer. (Don't operate if they are asymptomatic. These do not require additional surveillance or intervention)
What is the rule of thumb for simple cysts in pre-menopausal women?
What is the rule for cysts >5 cm in women over 40, complex cysts with solid components, and bilateral cysts?
If someone has a persistent concerning ovarian cyst, or those with ascites present, or if a CA-125 is elevated (in post-menopausal women) what do you do?
Offer if there is known ovarian cyst/cancer. Otherwise it is not recommended by any professional society (most recommend against it) because it has tons of false positives.
What do you do if someone comes in and wants the CA-125 ovarian cancer screening test?
True or False: There is a screening test for ovarian cancer
Clockwise to the l over first so you get dissemination quickly (direct extension to the pelvic and abdominal viscera, lymphatic dissemination as well)
How does ovarian cancer spread?
Web of ovarian cancer cells that create a hard thick nodular momentum is called what?
Surgery (optimal cytoreducion. Take out everything the cancer touched) and chemotherapy
What is the treatment for ovarian cancer?
age and stage (younger than 50 yo have a better outcome)
Prognosis/survival of ovarian cancer depends on what?
Germ cell tumor, young women (peak 20 years)
I am the most common tumor of the ovary. I am almost always benign and most of me are dermoids. What am I and what population am I the most common in?
Although most germ cell tumors are benign some are malignant. How can you tell they are malignant?
Germ Cell Tumor Markers: If a woman is in her teens, 20s, or 30s and no family history then you send these tumor markers. What marker is used for choriocarcinoma?
Germ Cell Tumor Markers: If a woman is in her teens, 20s, or 30s and no family history then you send these tumor markers. What marker is used for yolk sac tumors?
Germ Cell Tumor Markers: If a woman is in her teens, 20s, or 30s and no family history then you send these tumor markers. What marker is used for dysgerminoomas?
Germ Cell Tumor Markers: If a woman is in her teens, 20s, or 30s and no family history then you send these tumor markers. What marker is used for dysgerminomas. immature teratomas, yolk same tumors, mixed tumors?
HCG, AFP, LDH, CA-125
What are the tumor markers you can send for germ cell tumors?
Ovarian torsion, go to OR or you will lose the ovary ("no flow gotta go".)
Twisting of the ovary due to a tumor on the ovary. Results in a loss of blood flow. What is it? What do you need to do?
mature teratoma (dermatoid)
What is the most common culprit for causing ovarian torsion?
sex cord-stromal tumor (granolas cell in women and Sertoli-Leydig in men)
Tumor that arises from gonadal stroma. It is confined to one ovary usually/ has a good prognosis. What am I?
True (b/c the granolas tumor pumps out estrogen)
True or False: Granulosa tumors can cause endometrial cancer.
Hypothalamus, pituitary, ovaries, uterine
What is the HPOU axis?
Hypothalamus secretes GnRH in a _____ that is imperative for the stimulation of the HPO axis.
GnRH stimulates the release of what two hormones from the anterior pituitary?
____ stimulates follicles in the ovary
_____ triggers ovulation.
granulosum, FSH, LH, corpus albicans
Ovary physiology: There a millions of primary ovum (oocytes) surrounded by a single mantle of ___ cells. At puberty ___ creates the development of the follicle. One will get selected. The dominant follicle will ovulate due to a _____ surge. Oocyte gets released. Get a corpus lute that atrophies into a ________ if not fertilized.
Progesterone (derived from cholesterol)
The corpus luteum secretes what hormone?
Follicular phase, FSH
What is the first half of the menstrual period before ovulation called? What hormone will be dominant?
Luteal phase, progesterone
What is the second half of the menstrual cycle called? What hormone is it dominated by?
Proliferative phase, estrogen
What is the first half of the uterine cycle? It is where the uterine ling thickens due to increasing ______.
What is the second half of the uterine cycle called? The cyst like spaces in the endometrium become more productive and produce jelly like material. Get spiral arterioles. Uterine lining is ready for fertilization. IF the pregnancy doesn't occur then the endometrium sheds and women will have their menses.
21-35, 4-6, 30
Normal uterine bleeding. Cycles occur every ___________ with 1-2 day variance between months. Lasts ______ days. And lose ______ amount of blood (with 20-80 cc normal. Use pad/tampon count as judgment).
Abnormal uterine bleeding (AUB)
= excessive flow or duration
Abnormal uterine bleeding (AUB)
= irregular intervals
Abnormal uterine bleeding (AUB)
= intervals > 35 days
Abnormal uterine bleeding (AUB)
= intervals <24 days
Abnormal uterine bleeding (AUB)
= no menses by 16 years
Abnormal uterine bleeding (AUB)
= No menses for 3 cycles or 6 mos.
Palm = structural
Coein = other
Not yet classified
What are all the etiologies of AUB supported by ACOG?
Hypothalamic hypogonadism, osteoporosis
I am caused by altered GnRH section. This can be because of anorexia or disordered eating, excessive exercise, stress, or idiopathic. I am one of the most common causes of amenorrhea or iligomenorrhea especially in athletes. What am I? What are women who have me most at risk for?
FSH (low), estradiol (low), clinical picture of amenorrhea. US will show thin uterine lining (uterine streak)
How do you diagnose hypothalamic hypogonadism?
Hypothalamic hypogonadism has a thin uterine ling. PCOs has a thick uteirne lining with lots of cysts
How do you differentiate hypothalamic hypogonadism from PCOS on US?
Estrogen (ie. OTC) and treat underlying cause if possible
How do you treat hypothalamic hypogonadism?
light, heavy. TSH (once you get it under control the ovulation comes back to normal)
Hyper and hypothyroid can cause AUB. TSH comes from anterior pituitary and interrupts the negative feedback of the entire HPO. This can cause chronic anovulation.
Usually Hyperthyroid causes _____ periods and hypothyroid causes ______ periods.
What is the Tx?
Prolatinoma, Tx depends on how big it is (usually treat medically with dopamine agonists, stop meds that inhibit dopamine, or surgery if it is big)
Most common pituitary tumor. It secretes prolactin which suppresses the GnRH secretion. Causes ammenorhea or oligomenorrhea. What is the treatment?
Which is NOT an associated sign or symptom of prolactinoma: galactorrhea, fatigue, headache, ammenorrhea/oligiomenorrhea?
Benign tumor that is sitting in the median eminence causing GnRH to not reach the the pituitary.
Post partum hemorrhage that causes an infarct of the entire anterior pituitary. Causes a deficit in prolactin so can't breast feed. Long term causes bone mineral density changes and amenorrhea. Blocks GnRH from stimulating completing the HPO axis.
PCOS, androgen production
One of the most common reasons for gyn visits. Has centrally located cysts and ovulation does not occur. What am I and what is the primary problem?
PCOS due to excess androgen production
Anovulation, infertility. irregular masses, increased risk of endometrial cancer, hirsutism, and acne are all problems of what condition?
2. Ovulatory dysfunction (oligo-, menorrhagia, or amenorrhea)
3. Polycystic ovaries on US
Must have 2/3 to make Dx
What are the diagnostic criteria for PCOS?
Yes (oligomenorrhea and hyperandrogegism)
K.C. is a 30yo G0 presenting with infertility. She gets periods every 3-4 months. On exam, her BMI is 48, she has acne and coarse hair growth along her chin and abdomen. Does she meet criteria for PCOS?
Androgens have negative feedback at HP. Get decreased FSH so no dominant follicle forms. No LH surge so no ovulation
In PCOS you can get arrested follicle development. This means you have lots of follicles but not a dominant one. Why? This causes the ovaries to tend to be bigger.
We don't know but it may be due to insulin resistance.
hat causes PCOS?
androgens, acanthosis nigricans, DMII
Hyperinsulinemia increases ________. In women with PCOS you tend to see this on PE and may have a Hx of _____, if not you need to screen annually.
Weight loss of 5%, hormonal birth control. metformin. IF they want to get pregnant then you can do ovulation induction. If they don't want to get pregnant then can use androgen receptor blockers (spironolactone, flutamide)
What is the treatment for PCOS?
K.C. is a 30yo G0 presenting with infertility. She gets periods every 3-4 months. On exam, her BMI is 48, she has acne and coarse hair growth.You make the diagnosis of PCOS. Which is the best initial treatment approach?
Premature ovarian insufficiency (POI), DX with FSH levels (will be elevated)
I am aka premature menopause (ie. 30s). Causes elevated gonadotropinsand hypoactive ovaries. Will have thin endometrial lining and smaller ovaries with less cysts. What am I? How do you Dx?
Genetic (ie. deletions or mutations X chromosome or absent X chromosome -Turners), Cancer treatment. autoimmune, idiopathic
What are the causes of POI (4)?
Give estrogen to prevent bone mineral density loss and symptomatic relief. Send to reproductive endocrinologist because the longer you wait the lower the yield to stimulate the ovaries.
What is the treatment for POI?
RJ is a 14yo patient presenting with delayed puberty. She is 4 ft 10 in tall, and has not undergone thelarche or pubarche. You think you know the diagnosis.You order an FSH.
You expect that it will be __________.
I am common and often asymptomatic though I may cause AUB. I am not considered premalignant. I can be found incidentally and tend to be on a narrow stalk.
Normally you would not remove an endometrial polyp. When is it recommended?
Echodense, globular, will float around and move in saline
What does an endometrial polyp look like on US?
Once you Dx an endometrial polyp then what can you do to remove it?
I typically cause menorragia and dysmenorrhea. I have a thickened myometrium because of the scattered endometrium glands stuck in the myometrium. My pain can typicallyy be relieved by ibuprofen or tylenol. I am endometrium fond the myometrium (in the uterine wall only). Uterus can be enlarged over time and soft and boggy but symmetrical.
I am endometrium outside of the uterus and unlikely to cause AUB. I am found most commonly in the pelvis due to retrograde menstruation. Can have a fixed uterus/frozen uterus on bimanual exam. Can cause tubal scaring, tubal occlusion, and infertility.I can cause dysmenorrhea.
Clinical Dx based on Hx (US can be used as well)
How do you Dx adenomyosis?
Aka fibroids. Can cause menorrhagia or pain and pressure. Are homogenous and hard. Causes a big uterus that is hard and nodular on bimanual exam.
Leiomyoma beneath the endometrium. Bulges inward .Presents as heavier bleeding.
Leiomyoma within the myometrium. Most common type.Can be asymptomatic depending on the size.
Leiomyoma beneath the serosa. Bulges out causing pain and pressure.
True (if they aren;t causing harm then leave them there)
T/F: Leiomyomas are benign and asymptomatic.
grow, stop growing
During pregnancy a fibroma will _____ because of estrogen and high blood supply. Then during menopause the fibroid should ______.
birth control, hysteroscopic resection
Tx of submucosal fibroid.
Myomectomy (if they still want kids), hysterectomy using a GnRH agonist - leupprolide before surgery to shrink it, Uterine fibroid embolization
Tx of large intramural or subserosal fibroids
What is the recommended way to do a hysterectomy according to ACOG?
What is (arguably) the most important diagnosis to consider when evaluating AUB?
1. Turner Syndrome/gonadal dysgenesis
2. Polycystic ovarian syndrome (PCOS)
EXAM: Which structure runs under the uterine artery at the level of the internal cervical os?
EXAM: If the endocervical glands are occluded b squamous metaplasia, they form _______ cysts.
EXAM: In the superficial compartment of the anterior triangle of the perineum, you will find all of the following except:
clitoris and its crura, bulbocavernous muscle, barhtolin's gland, superficial transverse perineal muscle, round ligament
EXAM: All of the following are ligaments directly attached to the uterine corpus (body of the uterus) except:
round ligament, uterosacral ligament, sacrospinous ligament, cardinal ligament
EXAM: The ovarian artery branches from the _____.
EXAM: The type of uterine fibroid that often leads to menorrhagia is ______.
EXAM: Choose the organ whose embryological origin that is NOT mullerian:
Reproductive Tract Anatomy. I am adipose tissue that has hair. I am homologous to the male scrotum. I am part of the external genitalia.
Reproductive Tract Anatomy. I have thin folds and do not have hair. I am homologous to the penile urethra. I am part of the external genitalia.
Reproductive Tract Anatomy. I am the lowest portion of the embryologic urogenital sinus. I extend from the clitoris to the posterior fourchette.
Reproductive Tract Anatomy. I am located at 4 and 8 o'clock of the vanilla orifice. I am a gland that is the size of a pea and can be painful if infected.
Bartholin Cyst or Abscess, I&D (no Abx), sit bath, catheter for 2-3 weeks, and avoid intercourse
Patient presents with tender lump on side of the vaginal opening. They have difficulty walking/sitting. They report pain with intercourse. What is it? What is the Tx?
Marsupilization, or excision if they are postmenopausal
What is the treatment for recurrent bartholin abscesses?
squamous cell carcinoma, biopsy it
What is the most common malignancy of the vulva? What do you need to do with it?
What is the 2nd most common vulvular cancer?
T/F: Cancer of the vulva and vagina are devastating b/c they have high morbidity and mortality if they are not caught early on.
Reproductive Tract Anatomy. I am located near the superior extremity of the vulva. I am homologous to the male penis. I have a glans, a body, and 2 crura and a delicate network of free nerve endings
Reproductive Tract Anatomy. I am a conduit between the bladder and the external world. I am 3-5 cm in women which is why women get UTIs more often then men. I have sooth and skeletal muscle sphincters.
Reproductive Tract Anatomy. I can get infected. i can cause pain or be incidental. If large I can obstruct the urethral meatus.
Caruncle, vaginal estrogen cream by prescription.
Urethral prolapse. Affects women in hypoestrogenic state (adolescent or elderly). What am I? what is the Tx?
T/F: You can determine virginity by hymenal evaluation.
hymenal anomalies (ie. imperforate hymen), excision then apply estrogen cream
A patient presents and hasn't ever had her period but has severe abdominal or pelvic pain that is cyclic. What could be an etiology? What is the Tx?
What is a good landmark for the anterior triangle of the perineum?
sphincter muscle of the urethra, superior fascia, deep transverse perineal muscle
What are the layers of the anterior triangle of the perineum?
What is most of the support of the perineum provided by?
What is the innervation of the pelvic diaphragm?
Where is most of the obstetric damage done?
What is formed predominantly by the bulbocavernosus muscle, superficial transverse perineal muscles, and external anal sphincter.
When you ask someone to squeeze their anus you don't see puckering all around the tissue. May or may not have fecal incontinence.
uerine artery branches, iliac
What is the blood supply of the upper 1/3 of the vagina? What about the lymphatic drainage?
Inferior vesicle arteries, internal iliac
What is the blood supply for the middle 1/3 of the vagina? What about the lymphatic drainage?
Middle rectal and internal pudendal arteries, inguinal
What is the blood supply for the bottom 1/3 of the vagina? What about the lymphatic drainage?
ureter goes under the uterine vessels
What does water under the bride mean?
If the endocervical glands are occluded by squamous metaplasia they form _____ cysts that are benign.
What kind of cells make up the endocervical epithelium?
2 uteri that are fused at the base. Key thing is that they have 2 cervices so need to do 2 pap smears. Can have a double or single vagina.
Fork in the road. 2 horse of the uterus. Can have two properly developed horns or one with an underdeveloped horn.
Get MRI of upper renal tract (may not have a kidney)
In patients with Malarian anomalies what do you ALWAYS need to examine?
______ arteries originate from the radial branches of the arcuate arteries, which in turn arise from uterine arteries. They also penetrate the endometrium.
basal arteries (straight and extend only into the basal layer of the endometrium)
2 kinds of arteries supply the endometrial tissue, spiral and _____.
Reproductive Tract Anatomy. 2 wing structures extending from the lateral margins of the uterus to the pelvic walls.
Cardinal ligament, uterine vessels and lower portion of the ureter
Reproductive Tract Anatomy. Base of the broad ligament is thick and continuous with the connective tissue of the pelvic floor. What is it? What lies here?
What forms the lateral boundaries of the retrouterince cul-de-sac (Pouch of douglas)
Reproductive Tract Anatomy. Extends outward and downward to the inguinal canal through which it passes to insert into the upper portion of the labia major (ligament pain of pregnancy)
Reproductive Tract Anatomy. Blood supply for lower portion of the cervix and upper vagina.
Uterine and ovarian artery
What are the 2 principle blood supplies of the uterus?
2 cm lateral to the cervix, there uterine artery crosses under/over the ureter.
huge risk for hemorrhage because it comes off of the aorta
In the pre sacral space you have to be mindful of the vessels because it is easy to injure the middle sacral artery. Why?
True (over 50% of nursing home residents are incontinent of urine).
T/F: Prevalence of urinary incontinence increases with age.
False (it is a symptom of an underlying disease state. Most cases are multifactorial)
T/F: Urinary incontinence is a disease state.
Improve quality of life
Why do we treat urinary incontinence?
What part of the micturition cycle? Bladder is filling. Bladder is expanding and the urethra is tightening.
Bladder filling, first sensation to void, normal desire to void, void,
What is the normal micturition cycle?
What muscles offer strength, connections, and coordination for micturition?
alpha-adernergic receptors, striated muscle of the urethral wall, mucosal coaptation, vascular congestion, smooth muscle, and elasticity all are intrinsic factors that make sure you don't do what?
T/F:: Patient should be screened for urinary incontinence.
A type of other incontinence. Intact micturition cycle but when they get the urge to go it takes too long to walk to the bathroom.
Urge urinary incontinence is presumed to occur secondary to uninhibited ________ contractions.
muscarinic, beta (just be careful because you can have side effects because those receptors are on other end organs as well)
What kind of receptors play an important role in bladder function?
stress, urge, mixed
What are the 3 main kinds of urinary incontinence?
Incontinence due to an underachieve detrusor or outlet flow obstruction. These patients never completely empty their bladder so they just keep filling it. MS can be a cause of this.
Complex type of UI. Can connect any part of the urinary tract with vagina. Usually iatrogenic.
Complex type of UI with a classic triad of: dysuria, dribbling, and dyspareunia
Dysuria, dribbling, dyspareunia
What is the classic triad for a urethral diverticula?
Insensible urine loss
Leakage without trigger or sensation
IU due to secondary gain.
Take adequate history to determine type of incontinence, UA and culture if indicated (to rule out UTI), bladder diary
Primary care providers can do the initial evaluation and management of urinary incontinence. What are 3 things that PCPs should do for UI?
Abrupts onset of urinary incontinence in the absence of acute UTI warrants what?
cough stress test, look for pelvic organ prolapse or vulvar atrophy, neurologic exam
What should you do on PE for UI? (4)
Light touch and pinprick (thigh, foot)
Neuro exam for the sacral segments 2,3,4
Bulbocavernosus reflex, anal reflex
Neuroexam for the sacral reflex
Extend/flex hip, knee, ankle, invert and evert foot
Neuro exam motor
Levator ani muscle and external anal sphincter
Neuro exam strength and tone
UTI, work it up
What is the number one reason for hematuria in young women? What do you do if it isn't the most common reason?
How long should someone keep a voiding diary?
400-600 ccs, 300 ccs
What is the average capacity of the female bladder? What is the capacity that you will feel urinary urge?
What test can be done in a urology specialty clinic that can show urge incontinence?
Complex urodynamic studies
What can be used in urology specialty clinics to extrapolate abdominal pressures. These are useful to get data for when they go to the OR.
What is the gold standard treatment for stress urinary incontinence?
I am a treatment for stress urinary incontinence. I am placed in the vagina and support the bladder neck. I have a knob that tucks up so if someone coughs or sneezes it prevents leaking.
Stress urinary incontinence
UI that has increased leak of urine during valsalva (cough or sneeze)
Retropubic midurethral sling
Treatment for stress urinary incontinece. I am a mesh that goes under the urethra. The body sees it as a foreign body and causes scar tissue which form a backboard for when you cough or sneeze. I can cause entry into the bladder as a side effect.
Transobturator midurethral sling
Treatment for stress urinary incontinece. I am a mesh that goes under the urethra. The body sees it as a foreign body and causes scar tissue which form a backboard for when you cough or sneeze. I can cause nerve injury or intense bleeding as a side effect.
8 (about every 2-3 hours)
What is the average number of voids in 24 hours?
patient education and behavior management (make sure they aren't taking in too much fluid, caffeine and alcohol make it worse and are irritating to the bladder, put patient on bladder plan, smoking makes it worse)
What is first line treatment for overactive bladder?
Beta agonist (Mirabegron) and antimuscarinics
What are 2 types of medications for overactive bladder in order of what is used most to least?
Mirabegron (Beta agonist)
I am a medication for overactive bladder that activates the B-3 receptor in the detrusor causing the detrusor to relax and increase bladder capacity. I am used more than muscarinic because I don't cause sedation in the elderly.
uncontrolled HTN, ESRD, Liver disease
What is the contraindications for Mirabegron for overactive bladder? (3)
Narrow angle glaucoma, gastroperesis, urinary retention
What are the contraindications for anti-muscarinic for the treatment of overactive bladder?
I am a drug to treat overactive bladder. I act on bladder M2/M3 receptors to inhibit involuntary detrusor contractions. I cause dry mouth, dry eyes, constipation, urinary retention, GERD, blurry vision, and cognitive side effects.
Should you use an extended release drug to treat overactive bladder?
Posterior Tibial Nerve stimulation, weekly for 12 weeks
I am an invasive therapy to treat overactive bladder. I am the equivalent of acupuncture needle to stimulate the posterior tibial nerve. 50% of patients see improvement of symptoms for overative bladder with me. I work because the posterior tibial nerve feeds into the sacral plexus and the sacral plexus innervates the bladder. What am I? How long do you have to use me as a treatment?
Intravesical botox, urinary retention (will get better after cauterization for a few weeks)
I am a favorite treatment for overactive bladder. I kill the contraction of the detrusor muscle. I require repeat injections and have a higher incidence of infection. What am I and what is a major consequence?
Interstim, in patients that need routine MRIs (ie. MS patients)
I am a treatment for overactive bladder. I am the same concept as a pacemaker but for the bladder. Patients are prone under c-arm. I am done under fluoroscopy. Needle goes directly into S3 nerve root and stimulate. If the sxs for overactive bladder get better then you will leave the electrode in place and attach a pace maker to the upper gluteal portion. I am super expensive and patients sometimes don't know how to work me and turn me off by accident. What am I? When am I contraindicated?
Adherence to what is important for efficacy of treatment for overactive bladder and stress urinary incontinence?
Pregnancy and birth (weight issues, large babies, obstructed labors pushing for 4-6+ hours), age
What 3 things affect pelvic support?
False (but a vaginal birth has a 7-fold increase risk until 65 yo when the risk evens out)
T/F: A c-section is preventative of pelvic floor disorders.
advancing age, lack of estrogen
Another factor affecting the pelvic support ligaments is _____. The ligaments deteriorate and become weaker due to ______.
Complete uterovaginal prolapse is aka ______
T/F: Uterine prolapse doesn't happen overnight.
No. (30% will need re-operation for recurrence)
Do we have anything that is a 100% cure all for pelvic organ prolapse?
Obsetetric, genetic, connective tissue disorders, functional, age, menopause, loss of estrogen
What are some risk factors for pelvic organ prolapse? (7)
Isolate each compartment (can ask to bear down to see if anything prolapses out)
On PE with speculum exam you need to try to do what for pelvic organ prolapse?
I can be used to treat pelvic organ prolapse for patients that are ok with an invasive procedure but don't want surgery.
I can be used to treat pelvic organ prolapse. To do me you open up the epithelium and take all the sagging tissue and suture it up. You should not use mesh with me. My complications include injury to surrounding organs, incontinence, voiding dysfunction, bleeding, and recurrence.
I can be used to treat pelvic organ prolapse. To do me you open up the epithelium and take all the sagging tissue and suture it up. You should not use mesh with me. My complications include bleeding, constipation/defecatory dysfunction, pain/dyspareunia, rectovaginal fistula, and recurrence
Sacrospinous ligament suspension
I am a treatment for uterine prolapse. To do me you take the prolapsed tissue and attach it to the sacrospinous ligament affixing it.
What is the gold standard treatment for pelvic organ prolapse?
I am a treatment for pelvic organ prolapse. Use a probe to push everything back in and then form the abdomen you take a piece of mesh and attach it anterioryl, posteriorly, and then take the tail end of the mesh and attach it to the sacrum. I am the gold standard treatment.
Lefort Colpocleisis, no one under 70 yo
I am the best liked treatment for pelvic organ prolapse for elderly patients. I am used in patients with stage 3-4 uterovaginal prolapse and are NOT sexually active. You CANNOT have vaginal penetration after this future. Take all the epithelium off and then evaginate everything using the patient's own tissues and then close up the vagina. Recreate base of vagina and perineum. Vaginal length is 3-4 cm and the opening is 1 cm. What am I? What age is the cut off for this procedure?
Injury to surrounding organs, bleeding, ureteral compromise, nerve injury, recurrence, dyspareunia
What are the 6 complications of apical suspensions to treat pelvic organ prolapse?
What percent of pregnancies in the US are intended? (FYI this stat has been stagnant for decades)
Ability to prevent pregnancy under ideal circumstances. Like a lab study, do it perfectly
Ability of method to prevent pregnancy under common circumstances. Real world use
condoms, correct use consistent use, availability
Barrier method important for STI prevention. 98-99% effective in perfect use but only 80-85% effective in typical use. What am I and what are my 3 goals of use?
Diaphragm (CAYA cup), doesn't protect against STIs
Barrier method. Low cost and essentially no side effects. One size fits all. Can be prescribed. Cups the cervix and provides barrier in the upper vagina. Efficacy is 80-90%. Remove >6 hours but <24 hours after sex. What am I and what is a caveat to my use?
Periodic abstinence, abstinence necessary for 17 days per cycle
I am the most user intensive method for contraception. What am I? How long do people have to do me?
How long can sperm live in the gyn tract?
How long can an oocyte live after ovulation?
estrogen (ethinyl diol)
I am a type of hormonal birth control. I come in doses of 10-50 mcg. I can cause moodiness, breast tenderness, and blood clots. I primarily suppress FSH so you don't make a dominant follicle. What am I?
I am a type of hormonal birth control that is derived from testosterone. My side effects include unwanted hair growth (hirsutism) and acne. Newer versions of me have fewer androgenic effects. I primarily suppress LH so you don't ovulate. What am I?
I am a hormonal birth control that suppresses the LH surge so you are unlikely to ovulate. I also thicken the cervical mucus, thin the endometrium, and decrease tubal peristalsis. I should be used if a patient has HTN. A downside of mine is that I have a higher rate of ectopic pregnancies because of decreased tubal peristalsis.
negative feedback at the hypothalamus and anterior pituitary (because it is constant hormone rather than a cycle)
What is the mechanism of action (generally) of hormonal birth control?
thicken cervical mucus, thins endometrium, and decreases tubal peristalsis.
What 3 things does progesterone do in addition to suppressing LH?
Estrogen, Progesterone, patch, ring, pill
Combined methods of hormonal birth control combine what hormones? What are the 3 types of combined hormonal contraception?
Can a woman who has a contraindication to estrogen receive the patch or the ring for contraception?
If you re prescribing dual combined methods of hormonal contraceptions to a patient and she doesn't want a period what do you write n the prescription so she gets enough doses?
double up next day, double up and use a condom for the next week
Oral contraception of hormonal combined methods have 4-7 days of placebo. They also vary in estrogen dose and type of progestin. If you prescribe these to patients and they miss a day what do you recommend? What if they miss two days?
I am a type of hormonal combined birth control that you wear weekly for 3 weeks. Then on the 4th week you go patch free. I have an increased risk of DVT. What am I? Where can you not wear me?
I am a type of hormonal combined birth control that you insertt vaginally and leave in for 3 weeks then have 1 week off. I can also be used continuously.
Depo Provera, every 3 months
I am a progesterone only injectable contraception. I am very effective (over 99%). However I do cause weight gain and have a BLACK BOX warning for decreasing bone mineral density. I am effective for 3 months but can have affects for up to a year after discontinuing me. I also cause irregular bleeding that can be annoying. What am I? How often do you have to get me?
Nexplanon, FDA says 3 years but can lasts 5 years (EBM approach)
I am an implantable contraception. I go in the arm. I am THE MOST EFFECTIVE METHOD OD BIRTH CONTROL.I am reversible. What am I? How long can I be used?
What are the 2 types of IUDs?
I am what is embedded in the stem of hormonal IUDs. I am approved by the FDA for 5 years but EBM says I can be used for 7 years.
I am a type of IUD that releases free copper which prompts an inflammatory response creating a highly spermicidal intrauterine environment. I work for 10 years but can be used for 12. However, I also cause more painful and heavier periods.
I am a progesterone IUD that causes thickening of the cervical mucus, partially inhibits ovulation, and thins the endometrium.
LARC (including IUD and implants) are ___ times more effective than OCPs, patch, or ring.
What category of contraceptive methods are the most effective?
Where can you find a table for the safety of hormonal birth control methods?
Thromboembolic disorders, known or suspected breast cancer, smokers over 35 yo, uncontrolled HTN, Migraine with aura, SLE with antiphospholipid antibodies
YOU HAVE TO HAVE THESE MEMORIZED. What are the 6 absolute contraindications to EE use (estrogen: COC, patch or ring)?
T/F: Sterilization is considered permanent
What method of female sterilization has the lowest failure rate?
For female sterilization what are you ligating?
I can be used for female sterilization and am used in 80% of cases. I am used to reduce the risk of ovarian cancer.
Plan B, within 3 day
I m a type of emergency contraception. I am a progesterone hormone that uses high dose oral progesterone. I block the LG surge and prevents ovulation. I don't work if you have aired y ovulated though. I reduce the risk of pregnancy by 75% I am found behind the counter. What am I? When do you have to use me by?
Ella, within 5 days
I am a type of emergency contraception. I m an anti-progesterone. I am more effective than plan B (98% effective) but can't be used to induce an abortion. You will need a prescription to use me. What am I? How long do you have to take me?
1 in _ women will have an induced abortion in her lifetime.
False (it did decrease mortality from abortion though. Legalization dramatically increased safety)
T/F: Legalization of abortion dramatically increased the number of abortions done each year.
does she have capacity to make this decision, is she being coerced, does she have the appropriate information to make a decision (ie. gestational age and review of all of the available options)
When you counsel someone on abortion what 3 things must you always determine?
What is used to determine where and how an abortion occurs?
I am an anti-progesterone that causes abortion by initiating the breakdown of the endometrium and shedding the pregnancy from the uterine lining. You will not bleed or cramp in response to me.
2 days after taking mifepristone you can take me. I am a prostaglandin E1 analog approved for treatment of gastric ulcers but I also cause cervical softening and uterine contractions. I cause the expulsion of a pregnancy.
Mifepristone taken in your office followed by misoprostol taken at home 24-48 hours later (they have to take the mifepristone in your office according to the FDA).
What is the regimen for medically/pharmacologically induced abortion?
Patients should come back in a week after a pharmacologically induced abortion to make sure the gestational sac has passed. You can also do an HcG level to look for a _____% drop.
manual vacuum aspiration (done in office or ER), electric vacuum aspiration (done in OR)
What are the 1st trimester options for surgical abortion? For both of these options you need anesthesia, antisepsis, cervical dilation, and suction to evacuate the uterine contents.
After 12 weeks of gestation, if you need a surgical abortion where does that typically happen?
cervical dilation (Use Laminera in the cervix. Then they go home with them in place. Come back the next day and cervix is dilated 2-3x)
After 14 weeks gestation, if a woman undergoes surgical abortion they need what?
Dilation and evacuation, induction of labor
What are the 2nd trimester options for surgical abortion?
Complications of abortion are _____ and are related to gestational age and type of anesthesia. Complications do not increase the risk of subsequent infertility or issues with child bearing not do they increase the risk of breast cancer or depression.
1 in ______ women and 1 in ____ men will be victims of sexual assault. 80% are under the age of 30. 75% know their assailant. African American and Native American are at higher risk.
Are the following risk factors for becoming the victim or the perpetrator of sexual assault:
Alcohol/drug use, impulsive/anti-social tendencies, personal history of abuse, hostility towards women, poverty, general tolerance for violence in the community, and societal norms approving male sexual dominance.
What do the following warning signs suggest: partner overly attentive/critical, psychologic changes, anxiety, and sleep disturbance, bruise on arm, multiparous, sexually active patient with difficulty tolerating pelvic exams.
Hurt, Insult, Threaten, Scream
The mnemonic "HITS" can be used to screen for domestic violence. What does HITS stand for?
Who should be screened for intimate partner violence?
Bacterial Vaginosis, gardnerella
I am an over colonization of the normal vaginal flora. I am caused by a lack of hydrogen peroxide causing a basic pH in the vagina. What am I? What causes me the most?
Bacterial vaginosis, BD affirm test, metronidazole or clindamycine (PO or PV for for up to 6 months. Also don't drink alcohol on metronidazole)
MY sxs include clear, thin discharge that is watery or mucusy, with a fishy odor. What am I? How do you diagnose it? What is the treatment?
Milky vaginal discharge, vaginal pH > 4.5, amine "whiff" test, "clue cells"
For bacterial vaginosis you can use the Ancell's criteria. To be positive you need 3/4 criteria. What are the criteria?
Vaginitis from candiadiasis, Dx with KOH wet mount and BD affirm. treat with flucanazole 150 mg po x 1 (if extensive repeat dose in 72 hours, if skin is involved the apply a clotrimazole for the skin)
My symptoms include itching, burning, dyspareunia, thick white dischage that looks like cottage cheese. What am I? How can you diagnose me? What is the treatment?
Vaginitis from trichomoniasis
I am a sexually transmitted infection. Women may experience itching, burning, post-coital bleeding, dysuria, frothy, white, or grey discharge or a strawberry cervix. What am I? What causes me the most?
Vaginitis from trichomoniasis, Dx with KOH wet mount (look for the trichomonas only 50% effective), or with BD affirm, T with metronidazole orally then repeat STI test in 2 weeks -3 months
Woman presents with a strawberry cervix. What is the Dx, how do you Dx, and what is the Tx.
What is challenging about chlamydia and gonorrhea?
Chlamydia or gonorrhea
Symptoms can include mucopurulent dischage, post coital bleeding, friable cervix, and urinary symptoms. I often am asymptomatic. You would use a NAAT (nucleic acid amplicfication test) to diagnose me. What am I?
all sexually active women < 26 year old (and anyone at increased risk)
The CDC recommends screening for Chlamydia and Gonorrhea in what population?
Azithromycine 1 g PO x 1 (or doxycycline 100 mg po x 7d)
What is the treatment for chlamydia?
Expedited partner treatment, no
What program allows you to write a prescription for the partner of someone diagnosed with chlamydia? Can you use it for gonorrhea?
Gonorrhea, Ceftriaxone 150 mg IM x 1 AND azithromycin 1 g PO x 1
I can cause cervicitis or urethritis, pharyngitis, or an anorectal infection. I have symptoms similar to chalmydia. What am I and what is the treatment?
Pelvic inflammatory disease
Gonorrhea and chlamydia are the most common agents of me. I am an ascending infection that can impact infertility and have increased risk for ectopic pregnancy I also can cause adhesions, chronic pelvic pain, dyspareunia, ad tubal damage.
Pelvic inflammatory disease
Acute salpingitis is known as _____
PAin + 1 of the following: uterine tenderness, adnexal tenderness, cervical motion tenderness
What is the classic triad for PID?
What am I the presentation for: Pain uterine and/or adnexal tenderness, cervical motion tenderness, mucopurulent discharge from the cervix, friablility of the cervix, and fever in 1/3 of patients)
Fitz Hugh Curtis (scarring in the RUQ, violin string appearance) between liver and perineum
What is pathopneumonic for prior PID? Where is it found?
Afe 25 and younger, multiple sexual partners, partners with multiple sexual partners, history of previous STD, inconsistent condom use.
What are some risk factors for PID?
sexually active and 25 or younger OR history of STI or multiple sex partners AND tenderness on pelvic exam AND no other etiology can be found
We should be over diagnosing PID instead of under diagnosing it because of all of the bad sequelae. What are the CDC guidelines to diagnose PID?
Ceftriaxone 250 mg IM x 1 AND doxycycline 100 mg PO BID x 2 weeks (add metronidazole if they have BV as well. ALWAYS call every outpatient PID within 48 hours to make sure they are getting better.)
What is the outpatient treatment for PID?
other surgical emergency can't be ruled out, pregnant, doesn't respond to oral antibiotics, or is really sick (i.e. severe nausea, vomiting, high fever, tubo-ovarian abscess etc.)
Usually PID is treated outpatient unless what 4 things?
Cefotetan IV AND doxyclince oral or IV until clinical improvement then go home for the remainder of the 14 days of doxy
What is the inpatient treatment of PID?
I am one of the most prevalent STIs. I am caused by HSV-1 or HSV-2. Asymptomatic shedding of me is common and people often don't even know they have me.
Clinical diagnosis (can do viral culture or serum HSV antibodies if they really want it)
How do you diagnose herpes?
No (everyone pretty much has it)
Should we screen for Herpes?
Primary initial infection, Antivirals and topical lidocaine (bladder cauterization if retent
What kind of herpes infection am I? No prior HSV antibody. Usually asymptomatic. If I have symptoms it includes shalow painful lesions that turn into ulcers. I resolve spontaneously in 2-6 weeks. I can reactivate due to stress, hormones, or trauma.What am I and what is the treatment?
Initial non-primary infection, antivirals
What kind of herpes infection am I? Prior antibody to one type of HSV but new infection with the other type. I am clinically indistinguishable from recurrent. What am I and what is my treatment?
Recurrent infection, antivirals (either episodic or suppressive if 4+ episodes a year)
What kind of herpes infection am I? Prior antibody to one HSV, recurrent sxs to reactivation of that HSV. SOS include mild pain or tingling but it only lasts 3-7 days. I am triggered by stress, trauma, and menses.What am I and what is my treatment?
Subclinical infection, Valtrex from 36 weeks of pregnancy to delivery
What kind of herpes infection am I? Asymptomatic shedding of HSV virus. No sxs. What is the infection. What should you do if someone has me and is pregnant?
Syphilis, Penicillin G
The incidence of me has been rising and I am part of the STI screening panel and part of the routine prenatal lab work. I am the great imitator.You diagnose me using a VDRL or RPR. What am I and what is the treatment?
What phase of syphilis am I? Painless ulcer with raised edges. Almost always single but highly infectious. I last about 3-6 weeks.
What phase of syphilis am I? Maclopapular rash on palms. Condyloma latum (raised to flat lesions in the perianal region). Flu like symptoms. 6 months after primary infection and lasts 2-6 weeks. I am the great imitator phase.
What phase of syphilis am I? I have no sxs. I have an onset of 1-60 years after secondary.
What phase of syphilis am I? Gumbos. Aortic aneurysm, aortic insufficiency. I can lead to neurosyphilis. I am permanent until treated (but still may stay permanent after that)
I am a sign of neurosyphilis. I am demyelination of the dorsal columns so you get loss of proprioception, vibration, and fine touch. I cause a high stepping, and foot slapping gait.
Argyll Robertson Pupil
I am a sign of neurosyphilis. I accommodate but don't react (think of it like a prostitute). .
I am rare. I am herpes like ulcer at first then grooved inguinal mass. I am caused by Chlamydia L1,2,3. I make the groin all groovy and make you feel crappy with flu like symptoms. To diagnose me you can do a NAT that is sent to the CDC or DPH. What am I and what is my treatment?
I am rare. I am tender papules at first then serpinginious friable ulcers. I am caused by Homophiles decree. You rule out others and use a Gram stain to Dx me. What am I and what is my treatment?
Granuloma inguinale, azithromycin
I am rare. I am a painless papule first then painless, beefy, ulcerative mass. I am caused by calymmatobacertirum granulomatis. I look like vulvar cancer so you will biopsy me and culture me for Dx. What am I and what is my treatment?
Condylmoa acuuminata, clinical diagnosis (if not sure then biopsy), Tx is TCA (trichloroacetic acid) application (but can also that using alder cream, laser ablation, and cryotherapy)
I am genial warts usually caused by HPV 6 and 11. I tend to be transient. What am I, how do you diagnose me, and what is my treatment?
Molluscum contagiosum, clinical Dx, Tx is TCA application (can also just allow it to regress on its own, curettage, cryo, or laser)
I am an STI but if you see me in kids it does not mean they are being abused. I am transient and moderately infectious DNA pox virus. I am a papular, centrally umbilicate lesion. What am I? How do you Dx? What is the Tx?
I am transmitted sexually, casually, and through fomites. I am highly contagious and affect all SES. I cause extreme itching and you might see red papule or burrow tracks in the genitalia and the hands. What am I?
scabies, clinical Dx (can do skin scare;wings to look for feces and eggs), Tx is permethrin cream (Nix) on entire body
Patient presents with intense itching that is worse at night. You see papular rashes with linear burrows on exam. What is the Dx, how do you get the Dx, and what is the Tx?
I am caused by sexual contact or fomites and am highly contagious. I have a crab like appearance and like to stay in the pubic region. I am called pediculosis pubis known more commonly as _____. I need pubic hair to hold on to.
Pubic lice, Permethrin cream (Nix)
Patient presets with intense itching, low grade fever, and malaise if severe. You do a gross inspection of the genital area and see nits. What is the Dx and the Tx.
At what age should women start seeing a gynecologist?
40, or 10 years before onset for FHx
At what age should you being mammograms
At what age should you start getting a colonoscopy?
What is the 2nd most common malignancy in women?
Smoking, Obesity, Excessive alcohol
What are 3 modifiable risk factors for breast cancer?
Nulliparity, longer interval between menarche and first deliver, older age at menopause, younger age at menarche, and dense breasts are all risk factors for breast cancer. What are some protective factors?
Breast exams should occur how often for women ages 25-39?
How often should breast exams occur for women aged 40 and older?
Chronic pelvic pain is defined as pain lasting ______ months.
acute pelvic pain
Ectopic pregnancies, PID, ovarian cysts, and dysmenorrhea are all etiologies of what?
I am commonly found in women who ovulate regularly. I have pain that lasts 1-2 days and is relieved with NSAIDs and OCs.
I begin with n6-12 months of menarche. I am due to increase of prostaglandin production at menstruation. I cause the uterus to contract so you get more cramping. I don't not change with parity.
Longitudinal vaginal septum
I occur from incomplete fusion laterally of the mullein ducts. Often associated with uterine didelphys.
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