Gyn Differentials And Steps

Question 0

Bartholin’s duct cyst/abscess – management?

Answer 0

1. If pt over 40, biopsy
2. If one-2 cm, leave untreated
3. I&D with word catheter, or marsupialization

Question 1

Ddx - vulvar lesion?

Answer 1

Non-neoplastic - Crohn’s, erythema multiforme, bulbous pemphigoid, plasma cell vulvitis

Neoplastic - SCC, BCC, melanoma, Paget’s

Question 2

Differential diagnosis for abnormal bleeding without pelvic mass?

Answer 2

Endometrial polyps, endometrial hyperplasia, endometrial cancer, adenomyosis

Question 3

Differential diagnosis for pelvic mass or uterine enlargement?

Answer 3

Uterine - pregnancy, adenomyosis, gliomyosarcoma, fibroids

Ovary – cyst, neoplasm, TOA

Question 4

Indications for surgical intervention for fibroids?

Answer 4

1. Growth – rapid, after menopause, >12 weeks gestation
2. Bleeding - abnormal, secondary amenorrhea, and anemia
3. Urinary frequency or retention
4. Infertility

Question 5

Endometrial hyperplasia - diagnosis?

Answer 5

1. Endometrial biopsy

2. If equivocal D&C, unless under 30

Question 6

Endometrial hyperplasia - tx?

Answer 6

Medical:

1. Progestin for 3 months
2. Repeat biopsy
3. Repeat progestin if needed

Surgical:
1. If without atypia, D&C
2. If atypical complex
 a. hysterectomy 
 B. If want to keep fertility, curettage, long term progestin, ovulation induction

Question 7

Management of a cystic adnexal mass?

Answer 7

1. Postmenopausal with cyst greater than 2 cm – exploratory laparotomy
2. Reproductive age
   a. Less than 6 cm – observe for two months then repeat US
   b. 6-8 cm – observe if unilocular, explore if multilocular or solid on ultrasound
   c. Greater than 8 cm – cystectomy
3. Palpable cyst postmenopausal – oophorectomy

Question 8

Management of endometriosis?

Answer 8

1. Pseudopregnancy - NSAIDs, OCP, Provera (use these patients who are not seeking to conceive)
2. Pseudo-menopause – danazol (androgen derivative), Lupron
3. Conservative surgical therapy – ablation of visible endometriosis
4. Definitive surgical therapy – total hysterectomy, Salpingo-oophorectomy, lysis of adhesions,

Question 9

Patient presents with increasingly heavy menses and pressure on the bladder. Physical exam shows diffusely enlarged uterus which is mildly tender. Diagnosis?

Answer 9

1. Pelvic ultrasound initially
2. MRI to confirm

Hysterectomy

Question 10

Differential for adnexal mass?

Answer 10

Ovarian cyst
Ectopic pregnancy
PID
TOA
Endometriosis
Fibroids
Ovarian neoplasm

Question 11

Management for uterine prolapse?

Answer 11

1. Kegels
2. In postmenopausal women, Estrogen replacement to improve tissue tone
3. Vaginal pressaries
4. Surgical - colporrhaphy (repair fascial defect)

Question 12

Evaluation for incontinence?

Answer 12

1. UA, urine culture
2. Standing stress test
3. Cotton swab test (for hypermobile bladder neck) – indicates stress incontinence
4. Cystometrogram – Distinguishes between genuine stress incontinence and detrusor instability
5. Uroflowmetry – for patients complaining of hesitancy, incomplete bladder emptying

Question 13

Treatment for stress incontinence?

Answer 13

1. Kegel
2. Pessaries
3. Alpha adrenergic agents (pseudoephedrine) to increase sphincter tone
4. Estrogen to increase sphincter tone
5. Surgery to return hypermobile bladder original position

Question 14

Treatment of detrusor instability?

Answer 14

1. Behavior modification (bladder training, Kegel, hypnosis, psychotherapy)
2. Anticholinergics
3. Beta-adrenergic agonists
4. Smooth muscle relaxants
5. Tricyclic antidepressants

Question 15

Diagnosis of total incontinence?

Answer 15

1. Methylene blue dye instilled in the bladder leaks if vesicovaginal fistula
2. Indigo Carmine IV will leak if you ureterovaginal fistula
3. Cystourethroscopy to identify number and location of fistulas

Question 16

Total incontinence – treatment?

Answer 16

1. Surgery – obstetric fistula can be repaired immediately but surgical facilities must wait 3 to 6 months
2. If waiting period, give antibiotics and estrogen

Question 17

Differential for primary amenorrhea?

Answer 17

1. Outflow tract abnormalities – imperforate hymen, transverse vaginal septum, vaginal agenesis, uterine agenesis
2. End organ disorders – ovarian agenesis, ovarian failure, turners
3. Central disorders – Kallmann syndrome, hypothalamic (compression, TB, radiation, sarcoidosis)
4. Pituitary – surgery/radiation , hemosiderosis

Question 18

Causes of primary gonadal failure?

Answer 18

1. Enzyme defects
2. Testicular regression syndrome
3. True hermaphrodite
4. Gonadal dysgenesis – turners, Swyers
5. Ovarian resistance – savages
6. Postinfection (mumps).
7. radiation/chemotherapy