USMLE Step 2 Lesson 1: Gynecological Cancers: Part I

Gynecology

Gynecology Highlights for the USMLE Step 2 Manuel Penalver, MD

Cancer

Etiolog Symp y

Hist

Mort

Scree n

Cervical

HPV

Postcoital SCC Bleeding Adenocar c

Uremia

PAP

Endometr Estroge Postmen Adenocar Mets ial n op Bleeding Ovarian Ovulatio Abd dist Epithelial Bowel n Ascites Germ cell Obstructi SC Stromal Vulvar HPV Pruritis SCC Melanom a Tubular Unknow Clear & n serous DC Vaginal HPV Bloody DC SCC Mets Adenocar Mets c Mets on c

Cancer

Etiolog Symp y

Hist

Mort

Scree n

Cervical

HPV

Postcoital SCC Bleeding Adenocar

Uremia

PAP

c Endometr Estroge Postmen Adenocar Mets ial n op Bleeding Ovarian Ovulatio Abd dist Epithelial Bowel n Ascites Germ cell Obstructi SC Stromal Vulvar HPV Pruritis SCC Melanom a Tubular Unknow Clear & n serous DC Vaginal HPV Bloody DC SCC Mets Adenocar Mets c Mets on c

Cancer

Etiolog Symp y

Hist

Mort

Scree n

Cervical

HPV

Postcoital SCC Bleeding Adenocar c

Uremia

PAP

Endometr Estroge Postmen Adenocar Mets ial n op Bleeding Ovarian Ovulatio Abd dist Epithelial Bowel n Ascites Germ cell Obstructi SC Stromal Vulvar HPV Pruritis SCC Melanom Mets on c

a Tubular Unknow Clear & n serous DC Vaginal HPV Bloody DC SCC Mets Adenocar Mets c

Cancer

Etiolog Symp y

Hist

Mort

Scree n

Cervical

HPV

Postcoital SCC Bleeding Adenocar c

Uremia

PAP

Endometr Estrog Postmen Adenocar Mets ial en op Bleeding Ovulatio Abd dist Epithelial Bowel Ovarian n Ascites Germ cell Obstructi SC Stromal Vulvar HPV Pruritis SCC Melanom a Tubular Unknow Clear & n serous DC Vaginal HPV Bloody DC SCC Mets Adenocar Mets c Mets on c

USMLE Step 2 Lesson 2: Gynecological Cancers: Part 2

Cancer Etiology Symp Hist Mort Scree n Cervical HPV Postcoital SCC Bleeding Adenocar c Endometr Estrogen Postmen Adenocar Mets ial op Bleeding Ovarian Ovulation Abd dist Epithelial Bowel Ascites Germ cell Obstructi SC Stromal Vulvar HPV Pruritis SCC Melanom a Tubular Unknown Clear & serous DC Vaginal HPV Bloody DC SCC Mets Adenocar Mets c Mets on c Uremia PAP

Cancer

Etiolog Symp y

Hist

Mort

Scree n

Cervical

HPV

Postcoital SCC Bleeding Adenocar c

Uremia

PAP

Endometr Estroge Postmen Adenocar Mets ial n op Bleeding Ovarian Ovulatio Abd dist Epithelial Bowel c

Ascites

Germ cell Obstructi SC Stromal on

Vulvar

HPV

Pruritis

SCC Melanom a

Mets

Tubular

Unknow Clear & n serous DC

Adenocar Mets c

Vaginal

HPV

Bloody DC

SCC

Mets

Cancer

Etiolog Symp y

Hist

Mort

Scree n

Cervical

HPV

Postcoit SCC al Adenocar Bleeding c

Uremia

PAP

Endometr Estroge Postmen Adenocar Mets ial n op Bleeding Ovarian Ovulatio Abd dist Epithelial Bowel n Ascites Germ cell Obstructi SC Stromal Vulvar HPV Pruritis SCC Melanom a Tubular Unknow Clear & n serous DC Vaginal HPV Bloody SCC Mets Adenocar Mets c Mets on c

DC

Cancer

Etiolog Symp y

Hist

Mort

Scree n

Cervical

HPV

Postcoital SCC Bleeding Adenoca rc

Uremia

PAP

Endometr Estroge Postmen Adenoca Mets ial n op Bleeding Ovarian Ovulatio Abd dist Epithelia Bowel n Ascites l Germ cell SC Stromal Vulvar HPV Pruritis SCC Melanom a Tubular Unknow Clear & n serous DC Vaginal HPV Bloody DC SCC Mets Adenoca Mets rc Mets Obstructi on rc

USMLE Step 2 Lesson 3: Gynecological Cancers: Part 3

Cancer Etiolog Symp y Cervical HPV Postcoital SCC Bleeding Adenoca rc Uremia Hist Mort Scree n PAP

Endometr Estroge Postmen Adenoca Mets ial n op Bleeding Ovarian Ovulatio Abd dist Epithelia Bowel n Ascites l Germ cell SC Stromal Vulvar HPV Pruritis SCC Melanom a Tubular Unknow Clear & n serous DC Vaginal HPV Bloody DC SCC Mets Adenoca Mets rc Mets Obstructi on rc

Cancer

Etiolog Symp y

Hist

Mort

Scree n

Cervical

HPV

Postcoital SCC Bleeding Adenocar c

Uremia

PAP

Endometr Estroge Postmen Adenocar Mets ial n op Bleeding Ovarian Ovulatio Abd dist Epithelial Bowel n Ascites Germ cell Obstructi SC Stromal Vulvar HPV Pruritis SCC Melanom a Tubular Unknow Clear & Adenocar Mets Mets on c

serous DC

Vaginal

HPV

Bloody DC

SCC

Mets

Cancer

Etiolog Symp y

Hist

Mort

Scree n

Cervical

HPV

Postcoital SCC Bleeding Adenocar c

Uremia

PAP

Endometr Estroge Postmen Adenocar Mets ial n op Bleeding Ovarian Ovulatio Abd dist Epithelial Bowel n Ascites Germ cell Obstructi SC Stromal Vulvar HPV Pruritis SCC Melanom a Tubular Unknow Clear & n serous DC Vaginal HPV Bloody DC SCC Mets Adenocar Mets c Mets on c

Cervical Cancer Etiology HPV:

70 subtypes May lead to genital warts, which may lead to condyloma acuminata Can cause pre-cancer (dysplasia or carcinoma in situ)

Can cause ectocervical cancer

Colposcopy:
Performed on abnormal Pap smears Magnifies 10-12 times Acetic acid used for better visualization (Cryo, laser, or LEEP (Loop Electro cervical Excision Procedure)

Gestational Trophoblastic Disease Hydatidiform Mole: Suspect hydatidiform mole if:

o o o o Uterus is bigger (as mentioned above) Elevated HCG Vaginal bleeding Hypertension (early in pregnancy <20 weeks).

Treatment:
Pre-cancer o o o o o Cryosurgery Laser surgery LEEP Early: Hysterectomy + Para-aortic lymphadenectomy Late: Chemotherapy (cysplatinum) & radiotherapy

True cancer

Indication for cone biopsy:

Positive ECC Unsatisfactory colposcopy (mosaicism that goes inside) Two-step discrepancy between cytology and histology

Microinvasive cervical cancer: cone only way to diagnose

Colposcopy:
Performed on abnormal Pap smears Magnifies 10-12 times Acetic acid used for better visualization (Cryo, laser, or LEEP (Loop Electro cervical Excision Procedure)

Treatment:
Pre-cancer o o o o o Cryosurgery Laser surgery LEEP Early: Hysterectomy + Para-aortic lymphadenectomy Late: Chemotherapy (cysplatinum) & radiotherapy

True cancer

Indication for cone biopsy:

Positive ECC Unsatisfactory colposcopy (mosaicism that goes inside) Two-step discrepancy between cytology and histology Microinvasive cervical cancer: cone only way to diagnose

Cervical intraepithelial neoplasm (CIN) Classification: CIN I: Mild dysplasia CIN II: Moderate dysplasia CIN III: Severe dysplasia/Carcinoma in situ

Endometrial Cancer
Etiology: o o o Estrogen Post-menopausal bleeding Adenocarcinoma Symptom: Histology:

Endometrial Cancer
Diagnosis: o o Done by endometrial sampling (curettage & histologic exam) Endometrial hyperplasia suggests premalignant lesion

USMLE Step 2 Lesson 4: Gestational Trophoblastic Disease Gestational Trophoblastic Disease Hydatidiform Mole: Suspect hydatidiform mole if:
o o o o Uterus is bigger (as mentioned above) Elevated HCG Vaginal bleeding Hypertension (early in pregnancy <20 weeks).

USMLE Step 2 Lesson 5: Abnormal Vaginal Bleeding: Part 1 Abnormal Vaginal Bleeding
Postmenopausal Reproductive Age Premenarchal

Premenarchal Bleeding
Foreign body Trauma Sarcoma botryoides Precocious puberty

Reproductive Age Abnormal Bleeding

Pregnancy Anatomy DUB

USMLE Step 2 Lesson 6: Abnormal Vaginal Bleeding: Part 2 Reproductive Age Abnormal Bleeding
Pregnancy Anatomy DUB

USMLE Step 2 Lesson 7: Adnexal Masses Adnexal Masses

Postmenopausal Reproductive Age Premenarchal

Clinical Case # 1 65-year-old woman presents with enlarged ovary (6-7 cm)
First: Confirm presence of mass with ultrasound

Second: Surgical excision r/o carcinoma

Clinical Case # 2 10-year-old girl presents with adnexal mass

First: Confirm presence of mass with ultrasound Completely abnormal - consider neoplasm

Summary
Reproductive age adnexal masses - leave it alone Premenarchal or postmenopausal adnexal masses - consider neoplasms

Clinical Case # 3 33-year-old woman presents with adnexal mass (6-7 cm) Confirm presence of mass with ultrasound
- Simple - physiologic cyst - f/u 2 months - Complex - dermoid cyst - surgical excision

Clinical Case # 4 An otherwise healthy 33-year-old woman suddenly develops severe lower abdominal pain. An adnexal mass is found on examination
Characteristic - Ovarian torsion Treatment - Untwist ovary

Clinical Case # 5 33-year-old woman presents with adnexal mass. Her last menstrual period was 6 weeks ago. She also notes lower abdominal pain and vaginal spotting

Characteristic - Ectopic pregnancy

Ectopic Pregnancy EP triad:

1: Amenorrhea 2: Lower abdominal pain 3: Vaginal spotting

Clinical Case # 6 33-year-old woman presents with adnexal mass, dysmenorrhea, dyspareunia, and infertility
Characteristic - Endometriosis

Endometriosis
Adnexal mass in reproductive age group Endometrium in ovary / cul de sac Triad 1-Dysmenorrhea 2-Dyspareunia 3-Infertility Diagnosis by laparoscopy

Endometriosis Treatment:
o o o o GnRH analogue such as leuprolide (Lupron) Birth control pills Provera Danazol (Danocrine)

Unsuccessful medical treatment - surgery

Clinical Case # 7 33-year-old woman presents with adnexal mass, lower abdominal pain, fever, and leukocytosis
Characteristic - Tubo-ovarian abscess

Acute PID
History: Lower abdominal pain & fever 7-10 days after menses, no adnexal mass PE: Cervicitis and salpingitis Organisms: Gonococcus and Chlamydiae Tx: Cephalosporin then oral tetracycline

Chronic PID
History: acute symptoms + adnexal mass Organisms: aerobes & anaerobes-vaginal flora Tx: Ampicillin, gentamicin, metronidazol, clindamycin - 72 hr

Reproductive Age
Physiologic cyst Dermoid cyst Ovarian torsion Ectopic pregnancy Endometrioma Tubo-ovarian abscess Ovarian cancer

USMLE Step 2 Lesson 8: Vaginitis

Vaginitis

Spec Exam

Microsco pic Hyphae

pH

Treatment

Candida

Sticky

Antifungal (norma l)

Haemophi Whiff test Clue cells lus Trichomon as Frothy Flagellate d Organisms (Flagyl)

Metronidazo (Flagyl) le Metronidazo le

Vaginitis Spec Exam Candida Sticky

Microsco pic Hyphae

pH

Treatment

Antifungal (norma l)

Haemophil us Trichomon as

Whiff test Frothy

Clue cells

Metronidazo (Flagyl) le

Flagellate d Organisms (Flagyl)

Metronidazo le

Vaginitis

Spec Exam

Microsco pic Hyphae

pH

Treatment

Candida

Sticky

Antifungal (norma l)

Haemophil Whiff test Clue cells us Trichomon as Frothy Flagellat ed Organism (Flagyl)

Metronidazo (Flagyl) le Metronidazo le

Vaginitis

Spec Exam

Microsco pic Hyphae

pH

Treatment

Candida

Sticky

Antifungal (normal)

Haemophil Whiff test Clue cells us Trichomon as Frothy Flagellate d Organisms (Flagyl ) (Flagyl)

Metronidazo le Metronidazo le

Vaginitis

Spec Exam

Microsco pic Hyphae

pH

Treatment

Candida

Sticky

Antifungal (norma l)

Haemophil Whiff test Clue cells us Trichomon as Frothy Flagellate d Organisms (Flagyl) (Flagyl)

Metronidaz ole Metronidaz ole