REI CREOG REVIEW

Jamie P. Dubaut, MD

Department of OB/GYN – University of Kansas School of Medicine, Wichita

January 13, 2016

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Disclosures

• 170 days until REI fellow

• UWorld

• PROLOG REI 7th edition is copyrighted by ACOG/CREOG

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CREOG stats

• Part A: 166 questions, 2.5 hours1 (150 min) (54 sec/Q)

• Part B: 167 questions, 2.5 hours (150 min) (54 sec/Q)

• 50 sec/question = 10 minutes extra each Part

• 10th %tile = 174 correct

• 50th %tile = 200 correct

• 90th %tile = 226 correct

• Relevance to pacing: don’t run out of time for 10 easy questions that could boost your percentile 20%

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PROLOG REI 7th edition

• 161 questions, ~20 seconds/question

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82. Precocious puberty

• <8 yo menarche +

• thelarche

• or adrenarche

• or both

• Treat central idiopathic precocious puberty w/ GNRH agonist

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20. Premature thelarche

• Premature thelarche – <8 yo, or <6 AA, <7 white

• Ddx: (TSH) hypothyroidism/functional ovarian cysts, (E2) exogenous estrogen vs estrogen-producing tumor, (bone age>2 yrs ahead) precocious puberty

• If you don’t know the answer to a puberty question, guess “bone age”, aka xray of the left hand compared to atlas

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62. Premature adrenarche

• Premature axillary/pubic hair growth before 8 + pubertal DHEA and DHEAS levels W/O menarche

• Ddx: idiopathic (most), congenital adrenal hyperplasia, Cushing disease, virilizing adrenal or ovarian tumor, exogenous androgens

• Higher risk of hyperandrogenism in adulthood (PCOS)

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61. Peripheral precocious puberty

• McCune-Albright syndrome: precocious puberty, café-au-lait spots (skin discoloration), fibrous dysplasia (limp +/- pain).

• PERIPHERAL precocious puberty, WON’T respond to (central-acting) GNRH agonists or antagonists. DOES respond to aromatase inhibitors (decreasing production of estrogen)

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30. Labial adhesions in children

• Symptomatic: estrogen cream for a few weeks

• Asymptomatic: observation, 80% resolve within a year, none persist after puberty

• If E2 cream fails, or urinary retention, go to surgery.

• Don’t traumatize a child with office labial separation

• ? possibility of abuse if prepubertal bacterial vaginosis

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42. Dysmenorrhea

• 60-90% of adolescents

• Higher levels of prostaglandins than asymptomatic individuals, highest in first 48 hours of menses.

• COCs & NSAIDs both decrease prostaglandin production

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92. AUB in adolescent

• Oligoovulation “physiologic” at extremes of reproduction, may be accompanied by heavy bleeding

• Coagulopathy must be considered in adolescent w/ menorrhagia

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84. Acne in adolescent

• COC’s decrease free androgens by increasing SHBG, decreasing ovarian production

• Spironolactone blocks androgen receptor & inhibits 5alpha-reductase. Potentially teratogenic & may cause heavy bleeding. Works well combined w/ COCs.

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76. Mullerian anomalies

• 3D TVUS best first screening tool for mulleriananomalies (especially coronal reconstruction view)

• More information about fundus than HSG

• MRI gold standard, contraindicated w/ Harrington rod

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23. & 27. Mullerian dys/agenesis

• Mullerian agenesis/MRKH syndrome: XX, absent uterus & upper 2/3 vagina, nl 2° sex, nl external genitalia, nl ovaries, 30% renal abnl

• vaginal dilators (E2 as adjunct/lubricant) when desires sexual function>McIndoe neovagina w/ skin graft or Vechetti laparoscopic

• IVF w/ gestational carrier (or uterine transplant) best reproductive option

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33. Turner syndrome

• 50% of Turner syndrome pts are mosaics

• Mosaics more likely to have spontaneous menses, be taller

• 11% menarche if 45,X

• 34% if 45,X/46,XX

• 68% if 45,X/46,XX/47,XXX

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45. & 60. Congenital adrenal hyperplasia

• 21 hydroxylase deficiency, Levels of 17OHP to make diagnosis, Virilizing (9-15 wga) vs salt-wasting• 11beta-hydroxylase less common, +HTN

• Autosomal recessive diseases are ideal for preimplantation genetic diagnosis

• Prenatal dexamethasone must start as soon as pregnancy known, and exposes 7/8 potential fetuses and mother to adverse effects of dexamethasone (poor verbal working memory, worse self-perception of scholastic competence & social anxiety; weight gain, striae &edema, mild HTN, GDM)

• 1/8 that could benefit from dexamethasone, still some have virilization at birth, esp if start after 9 wga

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81. CAH (Late onset)

• Test 17-OHP in follicular phase for less false positives

• Confirmation test = 17-OHP after ACTH stim

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48. & 86. & 103. & 128-130. AIS/Swyer

• AIS: Breast development w/o pubic hair development, no uterus. XY karyotype, male testosterone levels, androgen receptors are insensitive. X-linked

• Mullerian dysgenesis +pubic hair, female testosterone levels, XX karyotype

• Swyer syndrome XY gonadal dysgenesis, POF/no puberty, + uterus, female testosterone levels

• ANY gonads with –SRY part of Y chromosome (AIS, Swyer) need removal (after puberty in AIS)

• Swyer syndrome taller than Turner syndrome

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93. Elevated DHEAS

• Almost exclusively made in adrenals

• Normal <300 ug/dL, PCOS 300-700, >700 suspect adrenal tumor

• Abdominal CT vs MRI

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98. & 107. Ovarian androgen-secreting tumor

• Evaluate for ovarian androgen-secreting tumor if atypical hirsutism or virilization, testosterone high, DHEAS wnl

• Premenopausal: Sertoli-Leydig more common

• Postmenopausal: hilus cell tumors more common

• PCOS & CAH not associated w/ virilization: male pattern baldness, voice change, cliteromegaly

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68. & 100. Maternal virilization in hyperreactioluteinalis• Benign conditions of ovary unique to pregnancy,

leading to hirsuitism and virilization

• Luteoma (solid)

• Hyperreactio luteinalis (multiple theca-lutein cysts bilaterally, morphologically similar to OHSS), more likely in multiples or molar preg, but may be seen in normal preg

• Both resolve when HCG levels do, but a solid ovarian mass may have more indication (broader ddx) for earlier assessment

• Fetal virilization does not occur

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112. Hirsutism

• Management 2-pronged: medical therapy to decrease androgen activity (effect may take 6 months), cosmetic therapy to remove terminal hairs.

• COCs increase SHBG and decrease testosterone production

• Avoid sprionolactone w/ renal compromise

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149-151. Ddx for hirsutism

• Cushing syndrome, diagnose w/ 24 hour free urinary cortisol

• Sertoli-Leydig, high testosterone

• Late-onset CAH, high follicular 17OHP

• All can cause hirsutism

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25. & 41. Menstrual cycle physiology

• Withdrawal of P4 (aka administration of cyclic progesterone) mimics involution of corpus luteum

• Ovary: follicular/luteal (luteal phase typical 14 days)

• Endometrium: proliferative/secretory

• Reason to read all answer choices/strategy for guessing: if two answers are the same/both look correct, you may have read the question wrong/neither is likely the right answer

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121. Window of fertilization

• Great majority of pregnancies occur in 3-day window ending on day of ovulation, practically all occur in 6-day window ending day of ovulation

• OPK’s detect urinary LH surge ~24 hours prior to ovulation

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18. & 56. & 80. & 106. Heavy menstrual bleeding• AUB causes=PALM(structural)-COEIN; treatments

surgical, hormonal, nonhormonal.

• Nonhormonal effectiveness: TXA>NSAIDS>placebo

• COC+TXA contraindicated

• TXA also superior to cyclic progestin-only

• LNG-IUD more effective than NSAIDs, TXA, COCs, POPs, as effective endometrial ablation for menorrhagia

• Doesn’t require pt adherence to pills

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4. Endometrial polyp

• Don’t use a sledgehammer to kill a fly. (Operative hysteroscopy>D&C or endometrial ablation for polyp).

• Don’t ablate if fertility desired

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2. Tamoxifen

• Tamoxifen + bleeding = most likely polyps (8-36%), most dangerous endometrial carcinoma (1.3-20%)

• Fetal image=>

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49. DMPA unscheduled VB

• Long-acting, progestin only methods: common side effect unscheduled bleeding 2/2 superficial vascular fragility of thin endometrium (<5 mm stripe)

• Antiprogestin mifepristone may help

• Estrogen temporarily thickens/stabilized, but not long term solution

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7. Migraine and use of oral contraceptives

• Testable: rare presentations of common diseases, common presentations of rare disease. Aura=focal neurological sx: absolute contraindication to COCs.

• Menstrual migraine treatment: periodic scheduled NSAIDs +/- triptans.

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19. Contraception for pt w/ VTE66. Contraception for pt w/ SLE & 2°APS• Don’t give estrogen-containing contraceptives to inherited

or acquired thrombophiliacs.

• Annual VTE 4 in 10,000 nonhormone users, 1 in 1,000 over 40

• Obesity & smoking 2-3 fold risk

• COCs 7 in 10,000

• FVL 3-fold, FVL+COCs 15-fold

• COC’s contraindicated in primary or secondary antiphospholipid syndrome, or SLE w/ antiphospholipidantibodies. OK to give COCs if SLE non-obese.

• Theoretical concern for IUD-infection in autoimmune dz, but studies show ok in SLE.

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44. & 67. Contraception for pt w/ DMI

• COC’s at current estrogen doses are safe for women w/ well-controlled diabetes (certainly safer than pregnancy). LARC or depo-provera would be even better.

• Less than 50% of pts w/ DM plan their pregnancies.

• W/o counseling, 11% of DMI chose tubal ligation over 7% w/o chronic condition (36-44 yo), & 5.8% of DMI used LARC.

• Well-controlled DMI is not a contraindication to pregnancy, make sure patients know about LARCs.

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17. Obesity & contraceptive choices

• At least 4 CREOG answers will be LARC or IUD.

• Obese women s/p abortion less likely to choose injectable progestin.

• Non-estrogen containing methods less risk of VTE, HTN; obesity risk factor for VTE, HTN.

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55. Contraception for smoker >35

• Thromboembolic events: (1) venous (VTE, PE) (2) arterial (MI, stroke)

• COCs increase clotting factors, nicotine increases platelet aggregation.

• Smokers over 35 at risk for (1) and especially (2)

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102. IUD complications w/ infection

• 10% risk of PID if +chlamydia or gonorrhea at IUD insertion

• Ok to screen low-risk women at time of insertion

• Antibiotic prophylaxis doesn’t reduce infection

• Aseptic technique is enough, use betadine

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146-148. MOA of contraception

• Circulating LNG level

• Lowest in LNG-IUD (100-200 pg/mL)

• Midrange in COC w/ LNG (2,000-3,000 pg/mL)

• Highest in single dose LNG emergency contraceptive (10,000-15,000 pg/mL)

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65. Morning-after contraception

• Ella = single-dose ulipristal

• Plan B one step = single-dose levonorgestrel

• Levonorgestrelmore effective & less nausea than high-dose COC

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26. Pregnancy termination

• Mifepristone=FDA-approved antiprogestin for 1st trimester abortion, shown to increase odds of medically completed 2nd trimester abortion, 79.8% vs 36.9% w/ misoprostol alone.• (A) (B) (C) and (E) are progestins, (D) binds progestin

receptor 5x as strongly but doesn’t activate it: it is an antiprogestin.

• If you happen to know the mechanism of action of each drug, or know that one of them is not like the other, strongly consider guessing the anomaly, especially if you don’t know correct answer

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116. Multifetal pregnancy reduction

• 75-100% of triplets deliver preterm, avg 32 wga

• Goal of HOPR is increase odds of at least 1 live birth; does reduce other pregnancy complications from high-order baseline

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9. Patient w/ gastric bypass

• Wait 12-18 mo s/p bariatric surgery to conceive.

• Abd pain, N/V in preg s/p bariatric =>consult bariatric surgeon early: (GI obstruction, GI bleed, hernia, leak).

• Consider pre/intra-pregnancy nutrition consult/deficiency eval.

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51. & 125. Obesity & pregnancy• Obesity associated w/

increase in…

• Oligoovulation (even w/o PCOS)

• Miscarriage

• Congenital malformations

• Stillbirth

• GHTN/preeclampsia

• GDM

• VTE

• C/S

• PPH

• Anesthesia complications

• Maternal mortality

Preconception nutrition assessment & consultation 1st

line for infertility-oligoovulation: ovulation may return w/ weight loss

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155-158. Obesity & pregnancy best treatments

• Hirsutism, anovulation, glucose intolerance, and morbid obesity

• Bariatric surgery

• Recurrent pregnancy loss, galactorrhea, and a shortened luteal phase

• Dopamine agonist

• Infertility, oligoovulation, normal FSH/TSH/prolactin

• Clomiphene citrate

• Anemia, AUB, several 1-cm submucosal leiomyomas

• Myomectomy

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52. Bulimia & binge-eating disorder

• Bulimia = binge-eating + inappropriate compensatory behavior

• Nutritional rehab good but not enough by itself

• For both, cognitive behavioral therapy has highest remission rates

• If CBT alone not enough, high dose SSRI can help

• Don’t give buproprion, risk of seizure if purging

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54. Anorexia and nutrition• Screen for anorexia “SCOFF”

• Anorexia often leads to hypothalamic amenorrhea.

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15. Reproductive fxn, nutrition, proteins

• Leptin=satiety, low if starving, leads to decrease GNRH & gonadotropins

• Ghrelin=hunger hormone, high in anorexia.

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108. Functional hypothalamic amenorrhea & osteoporosis• Important to restore normal energy balance, but

meanwhile estrogen in COCs can stabilize bone loss

• Avoid bisphosphonates in women w/ reproductive potential

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117. Hypothalamic amenorrhea

• Diagnosis of exclusion (after hypothyroidism, prolactinemia ruled out)

• FSH, LH, E2 low

• CC/LTZ do not work without functional HPO axis

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64. & 99. Ectopic pregnancy

• Discriminatory zone (hCG at which you should see a normal viable IUP)=1500-2500 mIU/L

• Most conservative threshold for rise in 48 hours: 35% (used to be 53%)

• Methotrexate = antimetabolite impairs DNA replication through inhibiting dihydrofolate reductase• Must be hemodynamically stable w/o acute abdomen, able to f/u

• Relative contraindications: >3.5 cm, cardiac motion, high hCG (6-15K)

• Absolute contraindications: breastfeeding, immunodeficiency, liver disease, blood dyscrasia, active pulm dz, PUD, renal dysfunction

• If quants are falling & she’s stone-cold stable, consider observation. Many of MTX “successes” would have resolved anyway

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96. Chronic pelvic pain

• LNG-IUD 78% relative reduction in dysmenorrhea Stage I-IV endometriosis

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14. & 37. Endometriosis & infertility

• Laparoscopic cystectomy recommended for endometriomas >4cm, for fertility & pain; risk of ovarian reserve reduction.

• ASRM staging system most widely used

• Stage I-II, laparoscopic ablation=> small but sig improvement in LBR

• Stage III-IV, may be better served by IVF 1st line

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36. Leiomyoma in infertility

• (another) IUD answer

• GnRH agonist=short term solution for fibroids

• Levonorgestrel IUD with at least one Type 2 submucosal fibroid 5cm or less: 90% reduction in blood loss, low expulsion rate.

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63. Uterine fibroid embolization

• Uterine arteries injected with polyvinyl alcohol particles/microspheres through transcutaneous femoral artery approach

• Postembolization syndrome: pelvic pain, cramping, n/v, fever, fatigue, myalgias, malaise, leukocytosis• Worst 48 hours, better over next week

• Hospitalized overnight for fever/pain/vomiting control

• Adhesions occur in 59%

• Chronic malodorous discharge 4-7%

• Vaginal passage of myoma 10%

• Infection possible

• Hemorrhage less likely

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73. & 109. PCOS & AUB

• “PCOS is always cycle day 3”= stagnant follicular phase, so disordered proliferative endometrium most likely.

• Endometrial cancer 2.7-fold more likely if PCOS

• Secretory endometrium requires prior ovulation

• Scant endometrium could be seen in menopause or hypothalamic amenorrhea

• Hormonal levels: LH persistently elevated (may have false positive OPKs), estradiol not low but not as high as peri-ovulatory levels

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59. Ovulation induction w/ PCOS

• First line: clomiphene citrate 50 mg/d x5 days, up to 150 mg/d if no ovulation on lower doses

• Metformin alone NS

• Letrozole may have better LBR in obese PCOS, not FDA approved for noncancer use, more expensive

• Gonadotropins: risk of high order multiple pregnancy, stimulate multiple follicles

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11O. Cushing syndrome

• Overexposure to cortisol

• 24 hour free urinary cortisol, overnight dexamethasone suppression test, and midnight serum or salivary cortisol equivalent in accuracy.

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78. & 91. Insulin resistance

• 2 hour GTT screens for impaired glucose tolerance and DMII, recommended for PCOS

• Insulin resistance is measured by hyperinsulinemiceuglycemic clamp

• Acanthosis nigrans

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104. Metabolic syndrome

• Includes

• Obesity, DMII, HTN, dyslipidemia

• Various classification systems, see table in PROLOG

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95. Testing for ovarian reserve

• AMH earliest indication for decreased ovarian reserve

• Does not predict whether or not pregnancy will occur

• Normal >1.5 ng/mL

• PCOS often >3.5 ng/mL

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90. OI treatment options

• Kallman syndrome does not have intact HPO axis.

• CC and aromatase inhibitors (letrozole) require intact HPO axis to induce ovulation/superovulate

• Both LH & FSH present in HMG, better for Kallmansyndrome than rFSH only

• Pulsatile GnRH pumps could work, but GnRH agonists and antagonists both ovulation

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16. Unexplained infertility

• W/o ovarian, male, uterus/tubal cause for infertility (12 mo) = unexplained (25% of infertility evals)

• Normal fecundity 20-25%/month

• After 1 year with unexplained: 2-4%/month

• CC alone, IUI alone, NS

• CC+IUI: 10%/month

• IVF <35 for unexplained: 43%/cycle

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