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Lecture notes
ENDOMETRIAL POLYP
A. Pelvic ultrasound
B. Abdominal x-ray
C. CT scan
D. MRI
E. Culdocentesis
OVARIAN TORSION
TORSION
A. Expectant management
B. Pap smear in 3-6 month
C. Colposcopy in 4-6 week
D. Cone biopsy
E. Radical hysterectomy
CERVICAL CANCER
SQUAMOUS CELL
CARCINOMA OF
CERVIX
5.
6.
Ovarian torsion is a surgical emergency. Ovarian torsion occurs when the ovary completely
twists and thus, occludes its blood supply. Patients often present with intermittent pain as
the ovary twists and untwists and then constant, severe pain when the torsion becomes
complete and the ovary becomes ischemic. Time is of the essence and can mean the
difference between saving, versus losing, an ovary. This is important for any patient, but is
particularly important for a young female of childbearing age, especially one who is
nulligravid. The reason that time is so essential is that the longer the ovary stays torsed,
the more likely it is to become necrotic. Most surgeons would perform laparoscopy on this
patient if they felt it was safe to do so. The pelvis can be fully evaluated through the
laparoscope and torsion can often be untwisted using laparoscopic instruments. However,
with large cysts, some surgeons prefer to perform a laparotomy.
Expectant management (choice A) would not be appropriate for this patient. When ovarian
torsion is considered to be likely in a patient, that patient must have surgery. To expectantly
manage these patients is to risk further damage to, and possible loss of, the ovary.
A
follow-up ultrasound in 6 weeks (choice B) is appropriate management for some ovarian
cysts. For example, if this patient were asymptomatic and the cyst did not have features
suspicious for malignancy, one could follow-up with an ultrasound in 6 weeks, as long as the
patient was given strict instructions and precautions regarding the risk of torsion. However,
this patient has severe pain and may be infarcting her ovary and therefore needs surgery.
correct answer is D.
Raloxifene is a medication that belongs to the class of
drugs called selective estrogen receptor modulators (SERMs).
These drugs, of which the most widely known are raloxifene and
tamoxifen, have pro-estrogenic effects in some tissues and antiestrogenic effects in other tissues. Raloxifene has been
approved for the prevention of osteoporosis. This patient, with
her strong family history of osteoporosis, is a good candidate for
prevention. Raloxifene acts as an estrogen agonist in the bone,
it appears to have no effect on hot flashes or to actually cause
hot flashes. Therefore, this perimenopausal patient is most likely
to develop hot flashes while on raloxifene.
A
Papanicolaou smear should ideally be a sampling of the transformation zone.
An adequate sample should show endocervical cells. When endocervical cells
are not present, there is some question as to whether the transformation
zone was fully sampled. If a woman has no risk factors for cervical dysplasia,
has had three normal annual Pap smears in a row, and has a current Pap that
shows no abnormality other than the absence of endocervical cells, then the
Pap smear can be repeated in 1 year. This patient, however, has significant
risk factors for cervical dysplasia, including early initiation of sexual activity,
multiple partners, and unprotected intercourse. Therefore, this patient needs
the endocervical portion of the Pap test to be repeated as soon as possible.
To repeat the Pap smear in 1 year (choice A) would be incorrect management.
As noted above, repeating the Pap smear in 1 year is correct only in patients
who have no risk factors for cervical dysplasia, three normal annual Pap
smears, and a present Pap that is normal except for the lack of endocervical
cells.
Primary amenorrhea is
defined as the lack of spontaneous uterine bleeding by the age of 16.
Secondary amenorrhea is defined as the absence of a menstrual period for 6
months or more in a woman who previously had normal periods or the
absence of menses for 12 months or more in women with previously irregular
menstrual periods. This patient, given that she previously had normal
menstrual periods, has secondary amenorrhea. The most common cause of
missed menses in previously cycling women is pregnancy. Therefore, it is
absolutely essential that a pregnancy test be performed on any woman with
this complaint. Hyperprolactinemia is the cause of amenorrhea in 10 to 20%
of cases, so it is also important that a prolactin level be checked. And,
because thyroid dysfunction can also cause a loss of menses, a TSH should
also be checked. This patient, however, is not pregnant and has normal TSH
and prolactin levels. At this point, some physicians would perform a
progesterone withdrawal test. This consists of giving a woman an
intramuscular injection of progesterone or oral progesterone for 5 to 10 days
and then checking to see if the patient has withdrawal menstrual bleeding. If
withdrawal bleeding occurs within 7 days, then patients are assumed to have
adequate levels of endogenous estrogen production.
Asherman syndrome
(choice A) describes the condition in which menstrual periods do not occur
because the uterine cavity has become obliterated with adhesions. These
adhesions result from trauma to the basal level of the endometrium, most
often occurring at the time of dilation and curettage. Patients with this
syndrome would not be expected to have menses in response to
progesterone.
Endometrial carcinoma
(choice C) typically presents with heavy, irregular bleeding or as
postmenopausal bleeding.
T he Correct answer is E.
The answer is B
Thank you