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Questions and Answers List

level questions: Level 1

QuestionAnswer
PALM-COEIN Polyps, Adenomyosis, Leiomyomas, Malignancy, Coagulopathy, Ovulatory dysfunction, Endometrial, Infection/IatrogenicWhat are the causes of Abnormal Uterine Bleeding?
Ovulatory: Regular cycles Causes: Structural & coagulation defects Anovulatory Cause: hormonal or endocrineClassification of AUB?
No periods for 3 mo ( if previous regular), or 6 mo if previously irregular W/U : HCG, TSH, FSH, Prolactin, PaP, STI checkAmenorrhea definition and cause
AUB > 35 y.o or < 35 with RF ( PCOS or obesity, DM, tamoxifen), postmenopausal bleeding.Indication for endometrial Bx:
Chronic amenorrhea with negative w/u to determine if there is unopposed estrogen. Treat with medroxyprogesterone ( Provera) 10 mg/d x 10 day Menstrual blg within a week suggest presence of estrogen.Indication for progesterone challenge
Bleeding > 7 days of 2-3 days longer than usual. Frequent bleeding < 21 d.What is the definition of Menorrhagia?
'Adolescent: Von Willebrand Dz Young adult: an ovulation, pregnancy , infection Adult: Fibroid, PCOS, thyroid Postmenapausal: anticoagulation, malignancyWhat are the most common causes of menorrhagia/ age group?
OCP ( 35 mcg estradiol) bid- qid stops bleeding in 48 hours. continue with OCP (LoOvral) x 3 mo. If OCP contraindicated Rx Provera 10 mg x 14 d + NSAID Consider Mirena IUD Give FeSO4 if anemicHow do you treat menorrhagia as outpt?
CBC, PT, PTT, TSH, HCG, GC/Chlamydia, TSH, Prolactin, Pap Vag exam to check for infection, polyp If suspect Von Willebran, check Factor 8 and VW factor Ag and activity. USWhat is the W/U of menorrhagia
Rotterdam criteria 2/3 Ovulatory dysfunction, Clinical androgen excess, Polycystic ovaries on US ( not required)PCOS Definition
Wt loss and exercise OCP MetforminHow do you treat PCOS?
Obesity, hydadrenitis, keratosis pillars, skin tags, Acanthosis ingrains, hirsutism, alopecia, acne, broad shouldersWhat are some of the findings associated with PCOS?
Abnormal HPO signaling releasing excess LH over FSH. LH triggers production of androgens. High insulin stimulates ovary to produce androgens. Increase androgens inhibit ovarian follicle maturation.What causes PCOS?
PCOS ( most common), 21 hydroxylase deficiency, Tumor ( adrenal or ovary, Ovarian hyperthecosis ( insulin resistance in postmenaupause) Drugs ( Danzol)What are the causes of hirsutism?
Total testosterone ( > 150 is abnormal)- check off OCP If elevated check DHEA-S ( to r/o adrenal tumor > 700 abnl) Check 17 hydroxyprogestrone to r/o 21 hydroxylase deficiency HCG, Prolactin, US, and CT if DHEA is elevated.What is the w/u of hisutism?
Wt loss, OCP ( 30-35 mcg Estradiol if < 40 y.o,) ( 20 mcg Estradiol if > 40) with low androgenic progesterone ( drosperinone) If no response in 6 mo consider Spironolactone 50 mg bid ( androgen receptor antagonist) Finasteride ( 5 alpha reductase inhibitor)Treatment of Hirsutism
Start at 21- 29 every 3 years with cytology alone. 30-65: HPV and cytology q 5 years or cytology alone Q 3 years or HR HPV Q 5 years. Type 16 & 18 go to colposcopy.Who do you screen with Pap?
Repeat cotest in 12 mo or test for HPV 16&18How do you manage + HPV and - Pap
Colposcopy.How to you manage + HPV and ASCUS
Women > 65, or total hysterectomyWhen do you stop screening for cervical cancer?
If pt > 40 need endometrial Bx.How do you manage endometrial cells on Pap?
Screen for 20 years post treatment Initially every year with contest x 2, If neg in 3 years, if neg in 5 years.How often do you screen woman with hx of CIN 2 or greater?
Repeat in 3 years. Low risk of progression 0.28%How do you manage ASCUS with -HPV
Girls: 9- 26 Men 11-26 Three doses: 0, 2, 6 Protects against HPV 6,11,16, 18,HPV vaccine indication
CIN1 = HPV infection CIN 2= High grade lesions : 40% regress CIN 3 = Progress to cervical cancer.Pap Classifications
Ovaria cyst or ectopic pregnancyWhat are the causes of adenexal mass in premenopausal women?
Massis cystic < 10 cm with no septation or papilla. Monitor with serial US Q 4-8 wk. Most regress If persistent > 12 wk or if mass > 10 cm, painful, or postmenopausal referral to surgery Treat with NSAIDS and OCP to prevent future cyst.When can you treat cyst as outpt?
Azithromycin 1 mg single dose or Doxy 100 mg bid x 7 days.What is the treatment of chlamydia?
Sexually active women < 25Who do you screen for STI?
Ceftriaxone 250 mg IM with Azithro 1 gm or Doxy 100 mg bidx7. Oral option os Cefixime ( Suprax) 400 mg po in one since dose Test for cure in 1 wk. If PNC allergic use Azithro 2 gm in single dose.How do you treat Gonorrhea?
Metronidazole 500 mg bid x 7 days or Metrogel one applicator daily for 5 days Clindamycin 2% cream applicator 7 days, Clinda ovules 100 mg intravaginally x 3 days. Partners need not to be treated.How do you treat BV?
New sex partner, douche, Abx use, IUD, pregnancy.Risk factors for BV
Metronidazole 2 mg single dose or 500 bid x 7 days Treat sex partnerHow do you treat Trich?
Fluconazole ( Diflucan ) 150 mg single dose Miconazole cream 2% itravaginally x 7 days Clotrimazole cream 2 % for 14 days.How do you treat vaginal yeast infection
> 4 infection in a year Fluconazole 150 mg Q 3 d for 2 wks, followed by one a week for 6 mo. RF: Hyperglycemia, Pregnancy, OCP, Immunosuppresion, diaphragm and IUD.How do y ou treta chronic yeast infections?
Ceftriaxone 250 mg IM and Doxy 100 mg bid x 14 days + Metronidazole 500 mg bid x 14 daysPID treatment
IUD does not post threat to PID after 20 days of insertion IUD does not need to be removed if pt improving 72 hours after Abx started.PID and IUD
Pregnant, severely ill, N/V high fever, suspect turbo-ovarian abscess,When do you hospitalize for PID?
Test for cure 3 mo Treat partner if sex active last 6 mo Check HIV and PRPPID Monitoring
Plan B ( levonorgestrel) 2 pills at once Cefriaxone 125 mg IM + Azithromycin 1 gm or Doxy 100 bidx7d Check GC, Chlamydia, wet prep, RPR, HIV-RNA, Hep BsAg and IgM, HCG Recheck HIV and RPR in 6 wk, 3 and 6 mo.What is the Prep for sexual assault?
Receptive anal: .5-3% Vaginal: .1-.2% Oral < .1%What is HIV risk for sexual assault?
Tenofovir-emtricitabine (Truvada) daily for 7-10 days Must be started within 72 hours of assault. Check GFR > 60 OK, Bep b and HCG.What is PEP for sexual assault?
IUD > 99 % Implants ( Implanon and Nexpalnon) Surgical sterilization AbstinenceWhat are the most effective methods of contraception?
OCP, Injectables Depo Provera), Vaginal ring ( Nuvaring), Patch ( Ortho Evra)What are the other effective methods of contraception (1-99%)?
Types: 52 mg ( Mirena) or Liletta: Skyla ( 13.5 mg) last 3 years and smaller. Duration of use : up to 7 years SE: change in bleeding pattern, spotting. 20% are amenorrmheic at one year.Mirena IUD side effects
Duration 10 years. Also used as emergency contraception placed within 5 days of unprotected intercourse. Associated with heavy periods and cramps. Risk of uterine perforation 1/1000Copper IUD SE
Implanon or Nexplanon ( Etonogestrel) Duration 3 years, bu effective up to 4. SE: Change in bleeding pattern. Decrease dysmenorrhea and pelvic pain.Implantable contraception
Intravaginally for 3 wk, then leave out 1 wk or use continuously and change every 4 wk. SE: Higher risk of DVTNuva Ring SE
Ortho Evra: Contains progesterone drospirenone which is associated with a risk of DVT 6x more than other OCP.Patch OCP
Levonogestrel 3x Drospeninone/Desogestrel 6x Patch 7.9X Nuvarink 6.5XDVT risk with OCP
IM Q 3mo : Progesterone only. SE: Irregular bleeding. 50% amenorrhea after 1 year. May lower bone mineral density which reverts to normal with cessation.Depo-Provera
Plan B ( levonorgestrel 0.75 mg ) 2 pill at once. Yuzpe: 2 doses 12 hours apart: Lo/Ovral 4 pill 12 hours apart. 86% effective No pregnancy test needed if used up to 72 hours after unprotected intecourse. No prescription needed if > 18. Decrease risk of pregnancy 85% No teratogenic effects Smoking , hypertrigliceride, and hx of DVT not contraindication.Emergency Contraception
Smokers > 35, Hx of DVT, Hx of Stroke, PVD, migraine with aura, HTN, SLE with antiphospholipid Ab, DM with complication, Breast cancerWhen do you avoid estrogens for contraception?
< 35 mcg EstradiolOCP estrogen: what is the highest dose can use ?
Praroxetine ( FDA approved) Also, ecitalopram, petaline fluoxetine and gabapentin.Post menapausal hot flash treatment?
DEXA: Hip T score ( standard dev. from mean in young healthy women) T score: < -2.5 Osteopenia : T -1--2.5Osteoporosis Definition
Low BMI, postmenopausal, Asia, Hx of fx not associated with trauma, smoking, steroid use > 5 mg/d x > 3mo. , ETOH, anticonvulsant, sedentary Comorbidities: COPD, RA, hypogonadism, hyperparathyroid, , MM, Cushing, Celiac.Risk factors for osteoperosis
All women > 65, or younger with RF, evidence of osteopeniaWho do you screen for osteoporosis?
T score < 2.0 T score < 1.5 with RF All with osteoporotic fxWho do you treat for osteoporosis?
Ca citrate/Vit D 1500/400-800 IU and Vit K. Biophosphanate ( Alendronate or Risendronate) decrease fx 50% Raloxifene SERM ( hot flash and thrombosis) Calcitonin Smoking cessation and ETOH limitWhat is the treatment for osteoporosis?
Renal insufficiency, Vit D deficiency, Hyperparathyroid, Hyperthyroid, Hypogonadism, Chronic liver disease, MM, Inflammatory bowel disease, CeliacWhat are the secondary causes of osteoporosis?