86. Gyne

Question 1

What parts of the female anatomy can tort?

Answer 1

ovaries and or fallopian tube between utero-ovarian and infundibulopelvic ligaments
once these twise, venous and lymphatic obstruction occurs, leding to edema nad progressing to ischemia and necrosis

Question 2

What are risk factors for ovarian torsion?

Answer 2

mc in reproductive years due to development of corpus luteal cyst
complication of pregnancy 1-2nd trimester
premarche - excess mobility of adnex
postmenarche - enlarged ovary >5cm due to benign neoplasm or cyst (due to ovulation induction, hyperstim syndrome or polycystic ovarian syndeom)
if have a mass - malignant tumor, endometrioma, TOA

Question 3

Describe the classic symptoms of ovarian torsion

Answer 3

severe sharp unilateral lower abdo pain with nausea and emesis
pain lasting several hours to days
intermittent resolution with spont detorsion
rarely peritoneal signs

Question 4

List 6 ddx for ovarian torsion

Answer 4

appendicitis, ruptured ovarian cyst, cystitis or pyelonephritis, nephrolithiasis, pel- vic inflammatory disease, uterine leiomyoma, diverticulitis, bowel obstruction, and ectopic pregnanc

Question 5

What are recommended tests for ovarian torsion

Answer 5

ultimately clinical !!! and then go for laparoscopy
u/s - asymm enlargement, poor doppler flow (absent arterial is highly sp for torsion), may have mass, evidence of hemorrhage or pelvic fluid, whirlpool sign (twisting of pedicle and coiled vessels)

typically crp and wbc high, need beta to help r/o ectopic (along with u/s etc)

Question 6

List 5 ultrasound characteristics associated with adnexal torsion

Answer 6

Enlargement of the ovary Associated ovarian mass Loss of enhancement Edema
Free pelvic fluid
Loss of venous waveforms Loss of arterial waveforms

Question 7

List 5 CT characteristics associated with adnexal torsion

Answer 7

Enlargement of the ovary Associated ovarian mass Thickening of the fallopian tube Free pelvic fluid
Edema of the ovary
Deviation of the uterus to the affected side Associated hemorrhage

Question 8

What is the most type of cyst in women?

Answer 8

follicular/functional

om a follicle that fails to rupture or regress, and is defined as pathologic when the diameter exceeds 3.0 cm. Follicular cysts are typically thin-walled and filled with clear fluid, whereas a cor- pus luteal cyst is often filled with hemorrhagic fluid

Question 9

DDX benign cyst in women - list 4

Answer 9

follicular
corpus luteal (hemorrhagic)
endometrioma)
teratoma/dermoid cyst
fibroma
cysadenoma

Question 10

Rupture of corpus luteal cyst is associated with what?

Answer 10

significant exercise, coitus or trauma

Question 11

What serum antigen is elevated in women with ovarian ca? (*80% of the time)

Answer 11

Ca- 125

Question 12

How to determine what type of cyst? (ie what imaging should you do?)

Answer 12

u/s! abdo and transvag

Question 13

What are ultrasound findings indicative moreso of malignant cyst?

Answer 13

internal septations
solid elements within cystic structures
thickened wall
large ascites/free fluid

Question 14

CT findings suggestive of malignant cyst (though keep in mind u/s preferred!!)

Answer 14

cystic solid masss
necrosis in solid lesion
complex/cystic lesion with thick, irregular walls and presence of ascites, periotneal maets, lymphadenopathy

Question 15

What is the first day of the mentrual cycle? How does E2 and P2 evolve over the cycle?

Answer 15

first day of menses. During the first part of the menstrual cycle, the endometrium thickens under the influence of estrogen, and a dominant follicle develops in the ovary, releasing an ovum at the mid- point of the cycle. After ovulation, the luteal phase begins and is char- acterized by the production of progesterone from the corpus luteum. Progesterone matures the lining of the uterus and, if implantation doenot occur, the corpus luteum dies, accompanied by sharp drops in pro- gesterone and estrogen levels. These changes typically are followed by menstruation. Menstrual bleeding is usually predictable, cyclic, and results from withdrawal of the effects of hormones on the endome- trium, which occurs approximately 14 days after ovulation.

Question 16

List the Classifcation of AUB

Answer 16

PALM—Structural Causes
Polyp (AUB-P) Adenomyosis (AUB-A)
Leiomyoma (AUB-L)
- Submucosal leiomyoma (AUB-LSM)
- Other leiomyoma (AUB-LO)
Malignancy and hyperplasia (AUB-M)

COEIN—Nonstructural Causes
Coagulopathy (AUB-C)
Ovulatory Dysfunction (AUB-O)
Endometrial (AUB-E) Iatrogenic (AUB-I)
Not yet classified (AUB-N)

Question 17

When is postmenopausal women having bleeding considered abnormal?

Answer 17

12mo of no bleeding then bleed
or unpreditable bleeding during hormone therapy

Question 18

What conditions are associated with endometrial ca?

Answer 18

db
metabolic syndrome and obesity
anovulatory cycles
nulliparity
age >55y

Question 19

Cervical dysplasia/genital tract pathology can have what kind of bleeding?

Answer 19

irreg/postcoital

Question 20

What are pathologic causes of disrupton of the HPA axis causing AUB - list 2

Answer 20

anorexia ner- vosa, hyperprolactinemia, and primary pituitary disease.

Question 21

Recommended lab test/work up for AUB

Answer 21

depends on cause but mostly:
- bhg
-bimanual exam and pelvic
- hbg
-coagulopathy studies (vWF deficiency can present as this)
-STBBI
- TSH
-u/s

Question 22

n postmenopausal patients with AUB, an endome- trium measuring less than _ -_ mm of thickness on TVUS reliably excludes endometrial cancer.

Answer 22

4-5

Question 23

Management of AUB in the ED - general

Answer 23

1. ABC
   - uncontrolled - IVF, blood products, surgical consult (considered, including urgent dilation and curettage, uterine artery embolization, endometrial ablation, or hysterectomy.)
   - TXA
   IU tamponade with 26 french foley with 30ml of saline

Less urgent:
- IUD
- TXA

Question 24

What is the morning after pill?

Answer 24

ulipristal acetate (a progesterone receptor modulator), levonorgestrel (a pro- gestin), and combined oral contraceptives consisting of progestin and estrogen taken together and often referred to as the Yuzpe regimen. In addition to oral options, the copper IUD is extremely effective as emergency contraception and works through inhibition of sperm function, inhibition of fertilized egg transport, and likely inhibition of implantation

Question 25

How to prescribethe morning after pill beyond 72h

Answer 25

single tablet of 30 mg of ulipristal acetate, is available only with a prescription but has demonstrated effectiveness for up to 120 hours from intercourse, making it a preferred choice over levonorgestrel beyond the 72-hour windo

Question 26

How to prescribe the morning after pill for w/o prescription within 72h

Answer 26

single dose of 1.5 mg or two doses of 0.75 mg levonorgestrel spaced 12 hours apart. The one-time dose of 1.5 mg is simpler to use and is at least as effective as the two-dose regimen and is therefore recommended.30 It is labeled for use for up to 72 hours following intercourse.

Question 27

What are adverse effects of the morning after pill?

Answer 27

nausea headache irreg menstraul bleeding 1 wk - 1 mo

Question 28

Copper IUD risk as "morning after pill"

Answer 28

1/1000 risk uterine perforation assoc with uterine cramping

Question 29

What is the main difference between levonorgesterel and ulipristal on how they stop pregnancy?

Answer 29

delay/inhibit ovulation vs prevents fertilization

Question 30

How should patients be councelled with giving the morning after pill and ongoing pregnancy contraception planning?

Answer 30

It is still possible for a patient who uses emer- gency contraception to get pregnant in the same menstrual cycle, so patients should be advised to use an alternative form of contraception and to undergo a pregnancy test if menstruation is delayed for more than 3 weeks. Patients who receive emergency contraception should be counseled regarding birth control and have a follow-up pregnancy test should they miss their next period.

Question 31

Which of the following statements regarding ovarian torsion is true? a. Abdominal tenderness is predictable b. Complete arterial obstruction is common c. Computed tomography (CT) has a higher sensitivity than ultra- sound d. Most cases are associated with an ovarian mass e. There is a left-sided predominance

Answer 31

d

Question 32

Which of the following patterns of menses should be considered abnormal? a. A 23-day menstrual cycle b. A 40-day menstrual cycle c. Bleeding 6 months after menopause d. Seven days of menstrual flow e. Three days of menstrual flow

Answer 32

b

Question 33

A 33-year-old gravida 3 para 3 woman presents with 7 days of heavy, painless vaginal bleeding. Her only other complaint is diz- ziness. Urine pregnancy test is negative. Vital signs are blood pressure, 85/40 mm Hg, and heart rate, 130 beats/min. The pelvic examination reveals copious vaginal bleeding through a partially open cervical os. The hemoglobin level is 6.8 g/dL. Which of the following interventions is most appropriate? a. 20 μg of ethinyl estradiol daily until the bleeding subsides b. 35 μg ethinyl estradiol bid until the bleeding subsides c. Blood transfusion and urgent gynecologic consultation for dila- tion and curettage d. Premarin, 25 mg intravenously every 6 hours e. Saline hydration followed by a 2-day recheck

Answer 33

c

Question 34

To be most effective, the emergency contraceptive ulipristal should be given as soon as possible but is approved to be given within how many hours of intercourse? a. 12 b. 24 c. 48 d. 72 e. 120

Answer 34

e