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SO1E04: HIGH YIELD WOMEN'S/REPRO HEALTH
- paspacjourney
- Sep 2, 2022
- 16 min read
Updated: Sep 4, 2022
Check out our transcript and cited resources for the pod episode on OBGYN High Yields. For even more reviews, be sure to subscribe and follow us on Instagram.
Hello & Welcome to PASPAC Podcast, Your Audio Passport from Physician Assistant Student to Certified - and beyond – with your host, Rebecca Harrell, MPA, PA-C
Today our destination is a high yield review of Women's/Repro Health based on the EOR content blueprint.
So, Sit back, Relax, and lets do the dang thing
Hey everyone, its Becca
As usual we’re going to cover the highest yield concepts on the Women Health’s EOR, going in descending order of the percentages on the EOR Blueprint starting with Menstruation which makes of 15% of the gynecology section.
As we move through this section, whenever I am discussing a condition affecting women or a women in the stem, please keep in mind this will apply to anyone assigned female at birth or with female reproductive organs, which can include transmales, nonbinary, and intersex individuals.
MENSTRUATION
Your patient is a 51 year old G3P3 woman who presents to your office due to new hot flashes, sleep disturbance, and vaginal itching and discomfort. History revels her last period was about 12 months ago. What hormonal changes to you expect her labs to show?
Elevated FSH (>15-25 iu/l)
Decreased estrogen and progesterone
Patients going through menopause typically present older than 45 years old with average patient starting at 51 years old.
Menopause will be described as a patient with history of amenorrhea for 12 months with classic symptoms of hot flashes due to inappropriate vasodilation leading to a drop in core body temperature secondary to declining estrogen acting on the hypothalamus – resulting in inappropriate vasomotor symptoms as seen in hot flashes.
They may also report sleep disturbances and vaginal discomfort due to dryness resulting from decrease in estrogen, which is called Atrophic vaginitis and is the most common cause of post-menopausal bleeding and treated with topical estrogen and lubricants.
Remember, even if suspected bleeding is 2/2 atrophic vaginitis, endometrial biopsy should be done on ALL woman > 45 with abnormal uterine bleeding due to risk of endometrial/uterine cancer which is present in 5-10% patients with postmenopausal vaginal bleeding
Perimenopause starts about 4 years before the last menstrual period and will consist of irregular cycles with fluctuations in hormones
Long term consequences from decrease in estrogen leads to bone loss, weight gain, increased risk of CVD and weight gain.
In women with moderate to severe symptoms, those who have NOT had a hysterectomy can take Menopausal Hormone Therapy with estrogen PLUS progesterone
Progesterone must be included to prevent cancer risk from endometrial hyperplasia from estrogen alone
Estrogen is contraindicated in those with breast cancer history, CAD, prior VTE history, or active liver disease
Your 22 year old G2P2002 female patient comes into the ER due to pelvic pain, dysmenorrhea, and dyspareunia with painful bowel movements all surrounding the cycle. Physical exam is abnomral aside from tenderness on with pelvic examination. Pelvic ultrasound and abdominopelvic CT are both normal. What is your top differential?
Endometriosis
This results from abnormal endometrial tissues growing in extrauterine sites, most commonly in the pelvis with ovaries affected.
Patients primarily affected are typically at reproductive age presenting with the 3Ds – Dyspareunia, Dyschezia, and Dysmenorrhea with little to no abnormalities seen on imaging or during physical exam
Laparoscopy is the definitive diagnostic test for visualizing ectopic endometrium +/- chocolate cysts
Treat pain with NSAIDs, hormone control with OCPs, and gyn referral for discussion of hormonal therapy and/or surgical management
Okay lets get into gynecological infections which make up 12% of your gynecology content on the EOR
GYN INFECTIONS
Your patient is a nulligravid female patient who presents to the office due to cervical discharge which started after having sex with a new partner. Physical exam reveals increased cervical discharge. Whiff test is negative, pH is within normal limits, but microbiological gram stains shows obligate intracellular organisms and gram negative diplococci. What do you prescribe as treatment?
Doxycycline PO for 7 days to cover for Chlamydia and Ceftriaxone 500 mg IM to cover for Gonorrhea.
Even if the patient does not have confirmed Gonorrhea with testing, you would still empirically treat someone with suspected Chlamydia for Gonorrhea.
If the patient was pregnant, you would substitute the Doxycycline with Azithromycin 1 gm PO
Chlamydia is the most common STD in the US and while typically asymptomatic in females, the most common manifestation of symptomatic chlamydia is cervicitis.
Don’t forget to treat sexual partners as well and abstain for 1 week following treatment initiation
Differentials for infectious causes of symptoms include Bacterial Vaginosis, Trichomoniasis, and Candidiasis
BV presents with thin grayish-white malodorous discharge which gives off a positive whiff test with basic pH and Clue Cells visualized on wet mount which are rod and cocci studded epithelial cells
As we’ve discussed in prior episodes, most common cause of this is Gardnerella Vaginalis and other anaerobe overgrowth secondary to decreased lactobacilli
Treat with Metronidazole PO and remember to remind patient’s to avoid alcohol while on metro to avoid a disulfiram reaction
Alternatively, can treat with intravaginal Metronidazole or Clindamycin cream
Trich will typically present with vulvovaginal pruritus or discomfort, frothy greenish malodorous vaginal discharge and a strawberry cervix, which is visualization of punctate hemorrhages on cervix during pelvic exam.
pH will be more basic and wet mount will show mobile flagellated trichomonads swimming around and +WBCs
Treatment is also with metronidazole
Candidal Vaginitis is 2/2 overgrowth of candida usually seen in those with immunocompromise, such as poor control of diabetes or recent use of antibiotics. Vaginal symptoms include pruritus and burning and physical exam will reveal thick, white curd-like vaginal discharge adherent to vaginal walls without odor
Wet mount with 10% KOH will reveal spores and branch chain hyphae or pseudohyphae and pH is normal
Treat with PO antifungal like PO Fluconazole, but if pregnant, the preference is intravaginal treatment with Clotrimazole or Miconazole
Your patient with history of chlamydial infection comes into the ER with lower abdominal pain in the setting of mucopurulent vaginal discharge and recent dyspareunia. Physical exam reveals adnexal tenderness and positive chandelier sign. Her urine pregnancy test comes back positive and echo confirms intrauterine development. How should you treat her suspected diagnosis?
First, because she is pregnant, you would want to admit to the hospital in order to deliver IV 2nd gen cephalosporins like IV Cefoxitin or Cefotetan and 1g Azithromycin for her suspected diagnosis of PID
In mild cases of PID, you can treat with Ceft and Doxy +/- Metro outpatient, but anyone with a high fever or signs of systemic toxicity should be considered inpatient.
Differentials of acute abdomen in female patients should include your normal heavy hitters like appendicitis but also remember to consider Tubo-ovarian abscess, ectopic pregnancy, ovarian torsion.
Lets move onto Neoplasms, making up 10% of the EOR
GYN NEOPLASMS
What is the most common cause of Cervical Cancer?
Your 61 year old female patient presents with vague GI symptoms including early satiety, bloating, and abdominopelvic pain with a palpable adnexal mass on exam. History reveals her mother and aunt both had breast cancer and she has always suspected she would also have it because it tends to run in their family. Pelvic ultrasound reveals a mass, increasing your suspicion of her top differentials based on her H&P. What tumor marker do you suspect would be elevated in this patient?
CA-125
This patient likely has Ovarian Cancer which is the 2nd mc gynecological malignancy and the leading cause of gyn cancer death
Her risk factors include positive family history of breast cancer which is likely secondary positive BRCA1 or BRCA2 and is strongly linked with familial ovarian cancer syndrome
The tumor marker CA-125 is elevated in 50-90% of women with early ovarian cancer, but 2/3 women present with advanced disease on diagnosis.
The most common type of primary ovarian cancer is epithelial in origin and typically affects those > 60 years, but the most common in women under 20 years old is germ cell in origin, which typically presents as a malignant dysgerminoma or teratoma
Symptoms presented in the stem, especially early satiety and bloating, should make you think of ovarian cancer. I remember this by imagining the O for ovarian as a bloated belly.
What is the treatment of the most common gynecological malignancy in the US?
Total Hysterectomy WITH bilateral salpingo-oophorectomy (THBSO)
Endometrial aka Uterine Cancer is the most common gynecological malignancy in the US with adenocarcinoma as the most common type
You should suspect this diagnosis in any postmenopausal woman with painless abnormal uterine bleeding, especially with positive family history of colon cancer or endometrial cancer (Lynch Syndrome)
Remember other risk factors for endometrial cancer, including estrogen monotherapy
Biopsy should be provided for all postmenopausal patients with AUB, but if they choose to perform TVUS – look to see if there is a thickened endometrial strip > 4 mm
Okay, we’ll get into more cancer high yields in our rapid review at the end but now lets move on with Breast Disorders, making up for 8% of your EOR
BREAST DISORDERS
Your 26 year old G1P1001 female patient is 3 weeks postpartum when she report painful lumps on her breast with overlying erythema, edema, and warmth. Physical reveals firm, shiny skin on her breast with nipple fissures and discharge. Vitals are all within normal limits on exam except a fever of 100.4 F. What should be initiated as treatment?
Dicloxacillin
You need a drug that will provide good coverage for staph strains - especially Staph Aureus, which is the most common organism in mastitis and breast abscess
Breast feeding is the most common cause of mastitis, which is cellulitis of breast tissue typically due to clogged milk ducts, but this can occur in other populations.
Patients should be educated to continue breast feeding to prevent abscess and allow for efficient removal of milk
If the affected site has overlying fluctuance, suspect breast abscess is present and treat with I&D
Your 30 year old female patient arrives to your OBGYN clinic to discuss her intense bilateral breast pain that occurs right before her periods. Physical exam reveals mobile, tender, masses that have a rope-like quality on palpation. What can be done for this patient that is both diagnostic and therapeutic?
Aspiration of the cystic lesions - both diagnostic and therapeutic
The most common condition leading to multiple lesions in the breast is Fibrocystic Breast Disease
Fluid aspirated in this condition is typically described as "straw-colored"
Ultrasound can also be used for diagnosis but is not therapeutic.
Unlike Fibroadenomas, fibrocystic breast disease is not associated with increased risk of breast cancer.
We’ll cover more high yield gynecologic disorders in our rapid review but let’s move onto obstetrics now starting with Prenatal Care and Normal Pregnancy making up 16% of your EOR
PRENATAL CARE AND NORMAL PREGNANCY
Your G1P0 patient at 37 weeks gestation will likely possess which physiological acid-base status?
Respiratory Alkalosis
Remember respiratory alkalosis is secondary to a decrease in Pco2 which is seen in conditions like hyperventilation, but also in pregnancy
I try to remember this as less room to breath in air that changes to CO2 leading to an overall decrease of pco2 and subsequent alkalosis
Other normal physiological changes in pregnancy include increased HR, cardiac output and blood volume which subsequently leads to that ability to auscultate a split S2 heart sound.
Some decreased physiological changes include decreased gut motility, systemic vascular resistance, albumin, H&H, among others
When should a patient undergo screening for Group b Strep during pregnancy?
In third trimester around weeks 35-37
If positive for GBS, Antibiotics should be administered around time of labor to reduce risk of vertical transmission to the neonate.
Antibiotic of choice is Penicillin G
Other testing of particular importance to remember include:
Screening for rubella, syphilis, and other STDs around weeks 10-12 or first prenatal visit
Maternal AFP around 16-18 weeks
Serum Quad or Amniocentesis around 15-22 weeks
Glucose challenge around 24-28 weeks
28 week visit should also include administration of anti-d immunoglobulin (aka RhoGAM) at that time as well or any period of bleeding during pregnancy in a Rh- female with potential Rh+ fetus
Begin checking fetal position ~Week 36-37
Most common cephalic presentation at delivery is Left occiput anterior, which is also the position that leads to the least risk of adverse outcomes
Leopold maneuver should be performed to determine the presentation
Let’s get into pregnancy complications making up 15% of your EOR exam
PREGNANCY COMPLICATIONS
Your 21 year old G2P0010 patient with a BMI of 38 presents for her 24 week visit to perform her initial glucose challenge test. One hour later, she is determined to require a diagnostic glucose tolerance test. What must her glucose level have been at the 1 hour mark to require this?
Over 130-140
If this initial challenge screening is positive, patient requires a 3 hour 100g glucose tolerance test within that week to confirm diagnosis
Diagnosis can be made if the glucose at that time is > 95 fasting all the way to > 140 after 3 hours
In patients with GDM, diabetic diet should be initiated with close monitoring of glucose
Treatment of choice if blood sugar remains uncontrolled is with insulin
Reassure patients that 50% of GDM is reversable immediately following delivery
Your G3P2001 female patient at 22 weeks gestation presents with BP 140/98. Her urinalysis is negative for proteins. What is her diagnosis at this time?
Gestational Hypertension
Defined as new onset HTN >20 weeks gestation (<20 weeks = chronic HTN)
Not considered preeclampsia without presence of proteinuria or features of preeclampsia, though half will develop preeclampsia later.
Reduce risk by initiating low dose ASA beginning at 16-28 weeks
First line medications for HTN in pregnancy is Methyldopa and Labetalol. Second line treatments include Nifedipine and Hydralazine.
"Hypertensive Moms Love Nifedipine"
Preeclampsia should be diagnosed in those over 20 weeks gestation with BP > 140/90 WITH proteinuria (which is 300+ mg over 24 hours or 2+ on UA).
You can still diagnose this without proteinuria if patient develops pulmonary edema, hypertensive CNS symptoms (ex. HA), or HEELP along with new onset HTN (HELLP = Hemolysis, Elevated LFTs, and Low Platelets)
The diagnosis of eclampsia is made if the patient is having seizures 2/2 HTN
Seizure prophylaxis with Magnesium Sulfate should be initiated in those with Pre-E and HTN should be controlled with IV Antihypertensives
Only definitive tx of pre-E or Pre-E with severe features is DELIVERY
Your G2P0101 at 25 weeks gestation presents with vaginal bleeding and pelvic pain. Her prenatal history includes difficult control of gestational hypertension and UDS is positive for cocaine. Her uterine fundus is tender to palpation and the fetal monitor shows distress. What is your suspected diagnosis for this patient and how to you treat?
Placental Abruption which is a separation of the placenta from the uterine wall prior to delivery and is considered an obstetric emergency
If mom or fetus are unstable, immediate C-Section should be performed regardless of EGA
Placental abruption should be considered in patients presenting with painful 3rd trimester bleeding, especially in the setting of maternal HTN or cocaine use.
Differentiate with Placenta Previa which is when the placenta overlaps or implants on the cervix, leading to painless third trimester bright red bleeding.
Remember to never perform digital cervical exams on patients with bleeding in 3rd trimester due to risk of hemorrhage
Another differential should include Vasa Previa, which is when the umbilical cord inserts into the membranes of the lower uterine segment, which will present in front of the fetal head leading to hemorrhage at the time of ROM or visualization of the pulsating cords on cervical inspection
Your G1P0 patient with blood type A- presents with vaginal bleeding at 14 weeks gestation. The blood type of the fetuses father is unknown. What could occur if Rhogam is not administered?
Patient may develop antibodies to the D antigen of the fetus if the fetus happens to be Rh + in the setting of an Rh - mother
This will not affect the current pregnancy, but subsequent pregnancies are at risk for fetal hydrops leading to fetal death
RhoGAM should be administered to Rh- patients anytime bleeding presents during pregnancy, again at 28 weeks gestation, and within 72 hours of delivery if fetus is Rh+ or if maternal or fetal blood type is unknown and father is Rh+ or fetus and father’s blood type is unknown
Your G1P0 patient develops new onset hypertension at 18 weeks pregnant with excessive vomiting, abdominal pain, and vaginal bleeding. She states she thinks she could be miscarrying because some of the bleeding looked like a bunch of grapes. Ultrasound reveals a snow-storm appearance with a uterus that is larger than expected size for her weeks gestation. What do you suspect the results of her Beta-hCG to show?
Higher than expected for dates (differentiate this with lower than expected seen in Ectopic pregnancy)
Hydatidiform Moles are considered a gestational trophoblastic disease which originates in the placenta and has potential to metastasize
They can be either complete, without any fetal tissue, or incomplete with some fetal tissue but either way are nonviable
Suspect in patients with new onset HTN < 20 weeks, hyperemesis gravidarum, and “bag of grapes” appearance of vaginal bleeding
CXR should be performed at diagnosis due to risk of metastasis to lungs, but can also mets to liver and brain
Dilation and curettage is recommended as treatment followed by serial hCG levels to confirm resolution
In those who have complete childbearing, hysterectomy is a reasonable alternative
Your G1P0 patient at 35 weeks gestation presents to her OB for evaluation of pregnancy. On pelvic examination pooling of fluid is visualized in the vagina and nitrazine paper turns blue. Your suspicion is confirmed by ferning visualized on microscopic evaluation of the fluid. What should be done?
Because she is between 34-36 weeks, she should receive GBS prophylaxis with antibiotics to reduce risk of chorioamnionitis and corticosteroids should be administered with delivery by 37 weeks
In patients presenting with preterm/premature rupture of membranes between 23-31 weeks, magnesium sulfate should be administered as well to provide neuroprotection to the fetus.
Okay, that was a good amount of pregnancy complications let’s move onto labor and delivery complications which makes up 8% of the EOR
LABOR & DELIVERY COMPLICATIONS
Your G1P0 female patient at 41 weeks gestation presents to the L&D unit due to consistent and progressive contractions. Her pregnancy has been complicated by Gestational Diabetes and the fetus is large for gestational age. As the patient is pushing, the fetal head finally emerges, but then retracts back into the perineum. What should be done?
Advise mother not to push and initiate the McRoberts Maneuver for treatment of the likely shoulder dystocia given the presence of turtle sign (retraction of fetal head) in the setting of risk factors.
Shoulder dystocia usually results from the anterior shoulder getting impacted behind the pubic symphysis
McRoberts Maneuver consists of hyperflexing the hips and legs of the mom while applying suprapubic pressure
Last resort is the Zavenelli Method which is the reinsertion of fetal head followed by a c-section
Most common fetal complication of shoulder dystocia is transient brachial plexus palsy (ex. Erbs) and most common maternal complication includes hemorrhage and fourth-degree lacs
We’ll cover a couple other high yield labor and delivery complications in our rapid review, but for now lets transition into postpartum care which accounts for 6% of the EOR
POSTPARTUM CARE
Your patient loses 1500 ccs of blood after a lengthy labor and delivery. What do you suspect is the cause of her postpartum hemorrhage?
Uterine Atony
This is the mcc postpartum hemorrhage which is defined by cumulative blood loss of > 1000 mL or signs and symptoms of hypovolemia within 24 hours delivery
Uterine atony should be suspected if the uterus is enlarged and boggy after delivery
Treatment involves vigorous uterine massage along with Pitocin administration or fluid resuscitation if severe blood loss or signs of hypovolemia
Retained placenta is a rare cause of postpartum hemorrhage but can lead to infection which is another reason why the placenta is thoroughly examined after delivery to ensure passed intact
About 2 days following a C-Section, your patient develops fever and pelvic pain. Pelvic exam reveals foul smelling lochia and her labs reveal leukocytosis. What do you suspect is er diagnosis?
Endometritis
This it the most common postpartum infection and results from an acute bacterial infection in the uterine endometrium after delivery.
If infection occurs prior to delivery, it is usually secondary to chorioamnionitis, so ensure to differentiate if the fever and other signs of infection begin before or after delivery in the stem.
Biggest risk for endometritis is history of C-section but other risks include PROM > 24 hours, active labor > 12 hours, high number of pelvic exams, or even PID.
Treat with broad spectrum IV antibiotics and admit, if not already hospitalized
RAPID REVIEW
1. What should be suspected in a patient with recurring painful genital and oral vesicles of various sizes with surround red rim in the setting of relapsing uveitis and a positive pathergy test?
a. Behcet Syndrome – which is a rare autoimmune disorder leading to an idiopathic vasculitis
2. Which HPV subtypes lead to increased risk of VULVAR cancer?
a. HPV 16, 18, and 33
b. Most common type of vulvar cancer is squamous cell carcinoma
3. What should be done for a pregnant patient in labor with genital herpetic vesicles visualized?
a. C-Section
4. What on peripheral smear may be seen to support a diagnosis of HELLP syndrome?
a. Burr cells/ schistocytes indicating hemolysis
b. May also notice pale RBCs 2/2 low hgb and few platelets
5. What is the most common solid pelvic tumor in women?
a. Leiomyoma (Uterine Fibroids)
b. Benign tumor of the uterine muscle
6. What week of gestation should the uterine fundus be palpable at the level of the umbilicus?
a. 20 weeks
b. Starting here, fundal height in cm should match ega until ~32 weeks
c. Postpartum should return to this height in ~ 24 hours of delivery
7. What is the most common cause of spontaneous abortion?
a. Chromosomal abnormalities 60% with uterine malformation as close 2nd
8. What should you advise your patient on regarding prognosis of uterine fibroids?
a. Reassurance that they decrease in size during/after menopause
b. Remember fibroids are the MCC menorrhagia
9. Which complication of PID results in “violin string adhesions”
a. Fitz Hugh Curtis Syndrome aka Perihepatitis
10. What treatment is recommended as endocrine therapy for those with ER+/PR+ breast cancer?
a. Tamoxifen
b. Those with HER2+ can take Trastuzumab, which is a systemic monoclonal antibody
11. Which HPV subtype is considered the most dangerous?
a. HPV 16
12. What is the most common location of an ectopic pregnancy?
a. Ampulla portion of the fallopian tube accounts for the location of 70% of ectopic pregnancies, most commonly presenting around 6-8 weeks gestation
13. What is the first definitive sign of an intrauterine pregnancy?
a. Yolk Sac visualized on sonography
b. Should be seen ~ week 5-6 with a beta-hcg over 2000
14. What is the most common breast mass in adolescents and young adults?
a. Fibroadenoma
b. Small risk of malignancy so monitor these for changes or aspirate with FNA
15. What is the first line treatment of abnormal uterine bleeding?
a. Combination OCPs (estrogen + progesterone)
b. May need to include iron supplements if bleeding has led to anemia
16. What is the most common location of endometriosis?
a. Ovaries
17. What should be suspected in a patient with bitemporal hemianopsia, amenorrhea, and galactorrhea?
a. Hyperprolactinemia secondary to a pituitary adenoma
b. Most common functionary pituitary tumor is a prolactinoma
18. What is the most common cause of post-menopausal bleeding?
a. Atrophic Vaginitis
b. Don’t forget to rule out endometrial cancer with biopsy
19. What is Chandelier Sign?
a. Cervical Motion Tenderness
b. Suspect PID
20. What is the gold standard for treating ectopic pregnancy?
a. Salpingectomy or Salpingostomy is gold standard
b. If caught early enough and small, can consider Methotrexate which is inhibits folic acid metabolism and thus halts the growth of rapidly dividing cells leading to medical miscarriage
21. What is the most common ovarian mass?
a. Follicular Cyst
b. Don’t confuse this with the most common ovarian mass in PREGNANCY which is corpus luteal cyst
22. What is the Rotterdam Criteria used for?
a. Diagnosis of PCOS
b. 2/3 Present – Oligo/anovulation, signs of hyperandrogenism, and/or US (+) polycystic ovaries
23. What should you suspect in a nonpregnant patient of reproductive age with history of PID and new onset of chills and unilateral adnexal tenderness and palpable mass felt on exam?
a. Tubo-Ovarian Abscess
b. May or may not present with fever
c. Treat in the hospital with IV Cefoxitin and Doxy +/- surgical drainage if large
24. What findings on fetal heart rate monitoring suggest uteroplacental insufficiency?
a. Late decelerations, - requires emergent c-section / intervention of recurrent and absent variability
25. What is the most common type of Breast Cancer in both men and women?
a. Invasive ductal carcinoma
b. Typically presents in the upper outer quadrant
26. What is the most common cause of ovulatory infertility
a. PCOS
b. MCC by insulin resistance and will lead to hyperandrogenism (ex. hirsutism/acne) and ovulatory dysfunction.
27. What is the antidote to magnesium toxicity?
a. Calcium gluconate
28. What is the most common breech presentation?
a. Frank – both hips are flexed and both knees are extended (aka feet at head with fetal rump as presenting anatomy)
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