1. Gynecology Board Review February 2009 RAPID FIRE Review of the Review……

2. The Newborn  1 day old infant with enlarged breast tissue on exam  Is this normal? Yes Maternal estrogens has influence 2 days - up to 3 weeks  What other associated findings may be present? Galactorrhea, pink vaginal discharge  Management? Reassurance

3. 4 yo female with pain with urination. Exam—erythematous labia & perineum, no discharge, no foreign objects ….  What are some causes vulvovaginitis? Non-sexually transmitted  Chemical  bubble baths  Poor hygiene, tight clothing  Foreign objects (foul odor)  Pinworms  Infectious Sexually transmitted  Gonorrhea  Chlamydia  Trichomonas  Herpes cim

4. Vaginal Secretions pHWet mountDischarge Physiologic<4.5 Epithelial cells Prepubertal—mixed flora Pubertal--lactobacillus Clear / white BV>5 Clue cellsGray-white + Whiff test Trich>5 Motile flagellaGreen-gray Frothy Strawberry cervix Candida<4.5 PseudohyphaeWhite Cottage cheese

5. What we got here????  Infancy / preschool  Sx Dysuria Bacterial Infxn  Vulvovaginitis  Recurrent UTIs  Resolve spontaneously 1-2 yrs  Treatment???? Estrogen cream

6. 14 yo female, tanner 5 breast, no menses yet with cyclical abdominal pain?????  Dx? Imperforate Hymen  What are common findings? Hydrometrocolpos—retained menstrual fluids Bluish bulging hymen Midline abdominal mass

7. 17 yo female severe intermittent LL abdominal pain x 1 day. Radiates lower leg. Associated nausea and vomiting  Dx? Ovarian Torsion  How do we dx? Doppler Pelvic U/S Laparoscopic exam  Diagnostic + Therapeutic DO NOT DELAY w/CT or MRI

8. PID  Triad? Lower abdominal tenderness+ Adnexal tenderness + Cervical motion tenderness  Treatment? Outpatient  Ceftriaxone 250 mg IM x 1 + Zithromax 1 gram x 1  Alternative: Ceftriaxone + Doxy 100 mg PO x 14 d Inpatient  Cefotetan 2 gram Q12 hr + Doxy 100 mg IV/PO Q12  Pain Persist….GET ULTRASOUND  r/o TOA

9. Female teenager with RUQ pain + N/V. Meds include OCPs. Best initial step to dx?  Possible Dx? Fitz Hugh Curtis  Perihepatitis  LFTs normal  Diagnosis with? Cervical cultures  Gonorrhea or Chlamydia

10. What is shown here??  Urethral Prolapse  More common in…? African American Obese  Treatment?? Estrogen cream BID

11. The STDs BugBuzzwordsTreatment Trich Flagellated organsims Frothy yellow malodorous d/c Strawberry cervix Dyspareunia Metronidazole 2 g x 1 ****Treat partner Gonorrhea Asymptomatic Joint pain (disseminated) RUQ pain Ceftriaxone 125 mg IM x 1 Cefexime, Cipro Chlamydia Treated for if + sx for Gonorrhea Zithromax or Doxy Herpes Painful genital ulcers Multinucleated giant cells Acyclovir x 7 d

12.  What are the reportable STDs? Chlamydia Gonorrhea HIV Syphilis

13. HPV  What types are associated with genital warts? 6, 11  Cervical cancer? 16, 18, 31, 33, 35  What types do the vaccine (Gardisil) protect against? 6, 11, 16, 18  When vaccine given? 3 shots Ages 9 – 26 years 0, 2, 6 mos

14. 14 yo female presents with malodorous vaginal discharge. She reports that she is not sexually active.  What do you suspect? Bacterial vaginosis  What do you expect the wet mount to look like? Ph >4.5, epithelial cells + bacteria = clue cells + Whiff Test  Treatment? Metronidazole 500 mg BID x 7d

15. Pap Smear Indications  Sexually Active? Any age Every year What else??  Urine PCR for Gonorrhea and Chlamydia  Not sexually active? At age 18 Repeat Q3 yrs

16. Oral Contraceptives  Absolute Contraindication Breast Cancer CAD CVA DVT / PE / Thrombotic Dz Hepatic Disease Elevated Lipids Pregnancy  Relative Contraindications HTN Depression Migraines Drugs

17. GO OUT AND CURE HAVE A GREAT AFTERNOON!!!!