1
Q
What two benign breast masses are classically described as having cyclical growth and regression?
A
fibrocystic changes and fibroadenomas
2
Q
How should fibroadenomas be managed?
A
- perform a core needle biopsy to make the diagnosis
- repeat ultrasound in 6 months and excise if it has increased in size
3
Q
Describe the presentation and management of intraductal papilloma.
A
- it typically presents with bloody nipple discharge
- it should be imaged with US or mammography if younger or older than 30
- core needle biopsy is used to make the diagnosis and then it should be excised to rule out hidden cancer
4
Q
How are mastitis and breast abscesses treated?
A
- both should receive dicloxacillin or cefalexin for antibiotic coverage; use bactrim or clindamycin if MRSA is suspected
- aspirate or drain any abscesses
5
Q
What is the recommendation for breast cancer screening?
A
- perform mammogram every 1-2 years starting at age 50 for the general population and at age 40 or ten years younger than earliest relative in those with a FH
- stop at age 75
6
Q
Who should have BRCA screening?
A
- FH of ovarian, fallopian tube, primary peritoneal cancer, or male breast cancer
- two family members with breast cancer under age 50
- personal history of two primary breast cancers, breast cancer before age 50, or triple negative breast cancer before age 60
7
Q
Describe the presentation, association, and management of Paget disease of the breast.
A
- it is a migration of neoplastic ductal epithelial cells to the nipple
- presenting as a scaly, vesicular, or ulcerated lesion of the nipple
- usually associated with an underlying adenocarcinoma
- patients should undergo mammogram and wedge or punch biopsy followed by simple mastectomy
8
Q
What is a phyllodes tumor? How does it present?
A
- it is a papillary projection of epithelial-lined stroma
- typically presents as a smooth, mobile, rapidly growing mass
9
Q
What is LCIS and how does it present?
A
it is an atypical proliferation within terminal duct lobules and it is usually an incidental finding
10
Q
What is DCIS and how does it present?
A
it is a proliferation of neoplastic epithelial cells within mammary ducts that presents as suspicious micro calcifications on mammography
11
Q
The classic, hard, immovable, single breast lesion with irregular borers is most likely one of what two cancers?
A
ductal or lobular carcinoma
12
Q
Which breast cancer demonstrates invasion of neoplastic cells into mammary storm and adipose in a single-file pattern?
A
lobular carcinoma
13
Q
How do we define primary and secondary amenorrhea?
A
- primary amenorrhea is the absence of menses by age 13 without secondary sexual characteristics or by age 15 with those characteristics
- secondary amenorrhea is the absence of menses for 3 months in those with regular menses or 6 months in those with irregular menses
14
Q
The first step in evaluating amenorrhea should always be what?
A
B-hCG to rule out pregnancy
15
Q
Describe the workup for secondary amenorrhea.
A
- serum B-hCG to rule out pregnancy
- check TSH with follow up free T4 if abnormal
- check prolactin level and get an MRI head if elevated
- check FSH and look for symptoms of primary ovarian insufficiency if elevated
- check estradiol if FSH is low or normal, if estradiol is low, get a pituitary MRI for hypogonadotropic hypogonadism
- check testosterone or look for clinical hyperandrogegism suggestive of PCOS
- perform a progesterone withdrawal test; bleeding is indicative of anovulation
- if there is no bleeding, perform an estrogen-progesterone challenge test
> no bleeding suggests an outflow tract obstruction and a hysteroscopy or hysterosalpingogram should be performed
> bleeding suggests an estrogen deficiency and a pituitary MRI should be done for hypogonadotropic hypogonadism
16
Q
Describe the presentation, diagnosis, and treatment of premenstrual syndrome and premenstrual dysphoric disorder.
A
- both present with headache, breast tenderness, pelvic pain and bloating, irritability, and lack of energy surrounding menses, but PMDD is more severe and disrupts daily activities
- diagnosis is based on patient journal of symptoms; must be present for two consecutive cycles with one symptom free week in the first part of the cycle
- treat with avoidance of caffeine, alcohol, cigarettes, and chocolate; use SSRIs for severe affective symptoms
17
Q
What is the best diagnostic test for menopause?
A
an increased FSH level in the context of symptoms
18
Q
What are the indications and contraindications for hormone replacement therapy?
A
- indicated for short-term symptomatic relief of menopause and the prevention of osteoporosis, but use should be limited to less than 5 years
- contraindicated for those with a history of PE, DVT, or estrogen-dependent breast or endometrial carcinoma
19
Q
OCPs reduce the risk of which cancers?
A
ovarian and endometrial carcinoma
20
Q
OCPs are contraindicated for which populations?
A
women with a history of migraine with aura or hypertension and smokers over 35
21
Q
What are the adverse effects of depot medroxyprogesterone?
A
weight gain, acne, and vaginal spotting
22
Q
How do copper and progesterone IUDs function?
A
- copper ions impair sperm migration and viability while the IUD impairs implantation
- progesterone thickens cervical mucus which impairs fertilization
23
Q
What should be first-line for routine and emergency contraception?
A
- routine: IUD of any kind
- emergency: copper IUD
24
Q
What are four emergency contraception options and how do they work?
A
- copper IUD: inhibits sperm function
- ulipristal: inhibits ovulation
- mifepristone: inhibits ovulation
- levonorgestrel: inhibits ovulation
25
Describe the different presentations for lichen sclerosis, lichen plants, and squamous cell hyperplasia.
- lichen sclerosis presents as thin, white skin extending from the labia to the perianal region, often with atrophy of the labia minora
- lichen planus presents as violet, flat papules
- squamous hyperplasia presents as raised white lesions in patients with chronic irritation and pruritis
26
Which of the following has an increased risk for cancer: lichen sclerosis, lichen plants, and squamous cell hyperplasia.
lichen sclerosis in post-menopausal women
27
Describe lichen sclerosis and how it should be treated.
- presents as thin, white skin extending from the labia to the perianal region, often with atrophy of the labia minora
- increases risk for cancer in post-menopausal women
- treat with topical corticosteroids
28
Describe lichen planus and how it should be treated.
- presents as violet papules
| - should be treated with corticosteroids
29
Describe squamous hyperplasia and how it should be treated.
- presents as raised, hyperkeratotic, white lesions in patients with a history of chronic pruritis or vulvitis
- treat with sitz baths and lubricants to relieve the pruritis
30
Describe the presentation and treatment of bartholin gland cysts.
- they present as a painful, tender mass at the 4 and 8 positions of the vaginal introits
- treatment is with drainage and culture of the fluid for STDs
31
Describe the presentation, diagnosis, and treatment of bacterial vaginosis.
- presents with a gray/white discharge that has a fishy odor
- pH is greater than 4.5 and clue cells are found on wet prep
- treat with metronidazole or clindamycin
32
Describe the presentation, diagnosis, and treatment of vaginal candidiasis.
- presents with a thick, white, clumpy vaginal discharge and vulvar irritation
- wet prep finds pseudohyphae and buds
- treat with intravaginal imidazoles or oral fluconazole
33
Describe the presentation, diagnosis, and treatment of trichomonas.
- presents with a frothy, green discharge and vulvar irritation
- pH is greater than 4.5 and wet prep shows motile flagellates
- treat patient and sexual partners with metronidazole
34
What is the appropriate workup of a breast lesion?
- perform an US if less than 30 or a mammogram if over 30
- for simple cysts, perform a therapeutic aspiration or observe
- for a complex cyst with internal echoes, perform an FNA
- for a suspicious, solid, or indeterminate masses, perform a core-needle biopsy or excisional biopsy
35
Describe the presentation, diagnosis, and treatment for paget disease of the vulva.
- it is an intraepithelial neoplasia that presents with vulvar soreness, pruritus, and a red lesion with superficial white coating
- biopsy is required for diagnosis
- treatment is with vulvectomy
36
Describe the presentation, diagnosis, and treatment fro squamous cell carcinoma of the vulva.
- presents with pruritus, bloody vaginal discharge, and a labial lesion
- biopsy is required for diagnosis
- treatment is with vulvectomy
37
How is cervicitis treated?
- empiric treatment is with azithromycin and ceftriaxone
- for confirmed chlamydia, use only azithromycin
- for confirmed gonorrhea, use azithromycin and ceftriaxone
38
How is pelvic inflammatory disease treated?
- ceftriaxone and doxycycline as an outpatient
- cefoxitin or cefotetan plus doxycycline for inpatient
- gentamicin and clindamycin for inpatients allergic to penicillin
39
Describe the etiology, presentation, and management of tube-ovarian abscesses.
- usually polymicrobial
- they present with cervical motion tenderness, lower abdominal pain, fevers, and chills; rupture may lead to hemodynamic compromise and peritoneal signs
- the best imaging modality is transvaginal ultrasound; CT is only used if bowel pathology must also be excluded
- treat with IV cefoxitin and doxycycline; drain if patients don't improve after 48-72 hours or if they have an abscess larger than 9cm
40
Which HPV types are associated with cancer and which are associated with condyloma acuminata?
- cancer: 16 and 18
| - warts: 6 and 11
41
How should abnormal HPV co-testing with a normal pap be managed?
do HPV DNA typing for 16 and 18 now or repeat co-testing in 1 year
42
How should atypical glandular or endometrial cells found with pap be managed?
- for glandular cells: perform colposcopy with endometrial sampling
- for endometrial cells: perform endocervical and endometrial sampling
43
How should each of the following be managed in 21-25 year olds:
- routine pap screening
- ASCUS
- LSIL
- HSIL
- routine pap screening: every three years
- ASCUS: repeat cytology in 1 year
- LSIL: repeat cytology in 1 year
- HSIL: colposcopy with endocervical curettage
44
How should each of the following be managed in 25-30 year olds:
- routine pap screening
- ASCUS
- LSIL
- HSIL
- routine pap screening: every three years
- ASCUS: order HPV testing, if positive perform colposcopy and endocervical curettage; if negative, repeat pap in 3 years
- LSIL: colposcopy and endocervical curettage
- HSIL: colposcopy and endocervical curettage
45
How should each of the following be managed in 30-65 year olds:
- routine pap screening
- ASCUS
- LSIL
- HSIL
- routine pap screening: every 5 years with co-testing
- ASCUS: order HPV testing, if positive perform colposcopy and endocervical curettage; if negative, repeat pap in 3 years
- LSIL: order HPV testing, if positive perform colposcopy and endocervical curettage; if negative, repeat pap in 1 years
- HSIL: colposcopy and endocervical curettage
46
When is an endometrial biopsy indicated for abnormal uterine bleeding?
- in any postmenopausal woman
- in any woman over 45
- in any woman under 45 with risk factors
- in any woman with atypical glandular cells on Pap
47
Why does anovulation lead to abnormal uterine bleeding?
- the ovary produces estrogen but no corpus luteum forms so there is no progesterone and no progesterone withdrawal, which would normally induce menses
- instead, bleeding occurs only when the endometrial lining outgrows the blood supply and destabilizes
48
What is the treatment for anovulation?
must start a LARG or OCP to oppose estrogen or induce menses in order to prevent endometrial cancer
49
What does the differential diagnosis for abnormal uterine bleeding include?
PALM-COEIN
- polyp
- adenomyosis
- leiomyoma
- malignancy/hyperplasia
- coagulopathy
- ovarian dysfunction
- endometrial
- iatrogenic/infection
- not yet classified
50
How is an endometrial polyp diagnosed?
- it can be visualized with transvaginal ultrasound of hysteroscopy
- polypectomy must be performed to confirm the diagnosis
51
If a patient presents with secondary dysmenorrhea, what exam findings would be consistent with:
- endometriosis
- adenomyosis
- leiomyomata
- adhesions
- endometriosis: painful nodules in the posterior cul-de-sac and restricted uterine motion
- adenomyosis: an enlarged, boggy-feeling uterus
- leiomyomata: a rubbery, solid, consistency to an irregularly contoured uterus
- adhesions: restricted uterine motion
52
Describe the presentation, diagnosis, and treatment for adenomyosis.
- presents with dysmenorrhea and menorrhagia; on exam the uterus is large, globular, and boggy
- MRI is the most accurate test although it is a clinical diagnosis
- hysterectomy is the only definitive treatment
53
Describe the presentation, diagnosis, and treatment of leiomyoma.
- presents with heavy, irregular menstrual bleeding, pelvic pain, and pelvic pressure; exam reveals an enlarged, mobile, irregular, and non-tender uterus
- the diagnosis is made by transvaginal ultrasound, but this may not visualize submucosal myomas, which may require saline infusion sonography or hysteroscopy
- treat with hormonal contraceptives, myomectomy, or hysterectomy
54
Describe the presentation, diagnosis, and treatment of endometriosis.
- presents with progressive, cyclic dysmenorrhea, dyspareunia with deep penetration, and abnormal bleeding
- diagnosis can only be confirmed with direct visualization and biopsy via laparoscopy
- medical management involves NSAIDs, hormonal contraceptives, the androgen derivative danazol, GnRH agonists like leuprolide, and aromatase inhibitors
- surgical treatment can be used for patients with severe symptoms or who are finished with child bearing
55
Describe the diagnosis and management for PCOS.
- the diagnosis is made when 2 of the following are present: irregular menses or amenorrhea, evidence of hyperandrogegism, and polycystic ovaries seen on ultrasound
- the diagnosis is also supported by an LH:FSH of more than 3:1
- treatment starts with weight loss; use OCPs for patients not wishing to conceive; use clomiphene and metformin for those who wish to
56
Why is obesity a risk factor for endometrial hyperplasia and carcinoma?
the most common cause of these conditions is unopposed estrogen and adipose tissue has aromatase, which converts androgens to estrogens
57
What is the histologic difference between endometrial hyperplasia with and without atypia?
- without atypia is simply a proliferative endometrium with dilated and contoured glands
- with atypia is characterized by an increased gland to storm ratio and the presence of atypical cells
58
What are the risk factors for endometrial carcinoma?
- obesity and history of PCOS
- tamoxifen therapy
- early menarche and late menopause
- Lynch syndrome
59
How are endometrial hyperplasia with and without atypia managed?
- without atypia has a lower risk for malignant conversion, so surveillance, progestin therapy, and hysterectomy are all options
- with atypia, the risk is high so hysterectomy is the treatment of choice
STEP2
flashcards
Decks in class (27)
# Cards
-
UWorld Review 1161
-
UWorld Review 2162
-
UWorld Review 344
-
GI86
-
Endocrinology68
-
Cardiology87
-
Pulmonology53
-
Infectious Disease67
-
Allergy/Immunology11
-
Rheumatology60
-
Hematology30
-
Oncology31
-
Neurology61
-
Nephrology75
-
Preventative31
-
Dermatology28
-
Surgery90
-
Sports Medicine14
-
ENT17
-
Pediatrics134
-
OB119
-
GYN59
-
Radiology19
-
Ophthalmology12
-
Psychology63
-
Emergency Med60
-
Social Sciences42
