Female Reproductive Flashcards

Question 1

Q

Danger Signals

D_______ Breast Mass/Breast Cancer

P_____ Disease of the Breast

In_______ Breast Cancer

(1)-(1) associated Hereditary Breast and Ovarian Cancer

O_____ Cancer

E_____ Pregnancy

Answer

A

Dominant Breast Mass/Breast Cancer

Paget’s Disease of the Breast

Inflammatory Breast Cancer

BRCA1-BRCA2 associated Hereditary Breast and Ovarian Cancer

Ovarian Cancer

Ectopic Pregnancy

Question 2

Q

(1)

Recent or acute onset of a red, swollen, and warm area in the breast of a middle-aged woman (median age 59 years) that is rapidly growing. Symptoms develop quickly. May have breast tenderness or itching. Can mimic mastitis. Often, there is no distinct lump on the affected breast. The skin may be pitted (peau d’orange) or appear bruised. Suspect in women with progressive breast inflammation that does not respond to antibiotics. Most women with this have lymph node metastases, and one-third have distant metastases when diagnosed. More common in African Americans, who are usually diagnosed at a younger age. A rare but very aggressive form of breast cancer (1%–5%).

Answer

A

Inflammatory Breast Cancer (IBC)

Question 3

Q

(1)

Adult to older female with a dominant mass on one breast that feels hard and is irregular in shape. The mass may be attached to the skin/surrounding breast tissue (or is immobile). Among the most common locations are the upper outer quadrants of the breast (the tail of Spence). Skin changes may be seen, such as the “peau d’orange” (localized area of skin that resembles an orange peel), dimpling, and retraction. Mass is painless or may be accompanied by serous or bloody nipple discharge. The nipple may be displaced or become fixed. Order a mammogram and refer the patient to breast surgeon. Be aware that up to 15% of women with breast cancer will have a negative mammogram. An ultrasound can detect the mass. Refer to breast specialist for a diagnostic biopsy. The most common sites for metastatic disease are the bone (e.g., back pain), liver (e.g., jaundice, abdominal pain, anorexia, nausea), lungs (e.g., dyspnea, cough), and brain (e.g., headache).

Answer

A

DOMINANT BREAST MASS/BREAST CANCER

Question 4

Q

(1)

Patients with a personal (or family history) of breast, ovarian, prostate, or pancreatic cancer may benefit from a hereditary cancer risk evaluation (genetic counseling) so that they can find out their risk for these cancers.

Answer

A

BRCA1- AND BRCA2-ASSOCIATED HEREDITARY BREAST AND OVARIAN CANCER

Question 5

Q

BRCA1- AND BRCA2-ASSOCIATED HEREDITARY BREAST AND OVARIAN CANCER

BRCA1 and 2 inherited in a (1) pattern
Up to 6% of (1) cancer and 20% of (1) cancer cases
(1) ethnicity higher risk for BRCA1/2 mutations
Men with BRCA mutations higher risk for (2) cancers

Answer

A

BRCA1 and 2 inherited in a autosomal dominant pattern
Up to 6% of breast cancer and 20% of ovarian cancer cases
Ashkenazi Jew ethnicity higher risk for BRCA1/2 mutations
Men with BRCA mutations higher risk for breast and prostate cancers

Question 6

Q

BRCA1- AND BRCA2-ASSOCIATED HEREDITARY BREAST AND OVARIAN CANCER

Screening for those with family history? How?

Answer

A

Start screening 10 years earlier than age that family member was diagnosed

Screening with annual mammogram, annual breast MRI, and clinical breast exam every 6-12 months

For example, if a sister was age 35 when diagnosed with breast cancer, then screening for breast cancer by MRI can start at the age of 25 years.

Question 7

Q

(1)

Older female reports a history of a red-colored rash that is scaly (resembling eczema) and starts on the nipple and spreads to the areola of one breast. Some women complain of itching, pain, or burning sensation. The skin lesion slowly enlarges and evolves to include crusting, ulceration, and/or bleeding on the nipple. Up to half of women will have a breast mass. Rarely, can be found in men.

Answer

A

PAGET’S DISEASE OF THE BREAST

Question 8

Q

(1)

Reproductive-age sexually active female with pelvic pain that may be diffuse or localized to one side, sometimes accompanied by vaginal bleeding. Pain onset may be abrupt or more gradual. Pain can be dull or sharp (but usually not crampy). If intraperitoneal bleeding, the pain may radiate from the middle to the upper abdomen, and/or it may be referred to the shoulder. May shuffle instead of walking normally to decrease jarring of pelvis. Reports amenorrhea to light menses in the previous 6 to 7 weeks.

Answer

A

ECTOPIC PREGNANCY

Question 9

Q

Ectopic Pregnancy

Risk Factors = current use of (1) device, tubal _______, in vitro _________
Majority occur where?
Diagnostics (2)
Leading cause of _____ for women in first trimester of pregnancy in ED
Refer to ___

Answer

A

Risk factors include prior ectopic pregnancy, current use of an IUD, tubal ligation, and in vitro fertilization (IVF).
Majority (96%) of ectopic pregnancies occur in the fallopian tube.
Definite diagnosis is by serum quantitative chorionic gonadotropin level and transvaginal ultrasonography.
Leading cause of death for women in the first trimester of pregnancy in the United States.
Refer to ED.

Question 10

Q

(1)

Typical patient is a middle-aged or older woman with vague symptoms of abdominal bloating or abdominal discomfort, low-back pain, pelvic pain, dyspareunia, and changes in bowel habits. Other symptoms are unusual lower abdominal or lower back pain and/or unusual tiredness or fatigue. Most patients (75%) are diagnosed when it has already spread, which accounts for the poor overall survival rate. Five-year survival with distant metastases is 25%, but if caught at stage 1 disease, it is >90%.

Answer

A

Ovarian Cancer

Question 11

Q

Ovarian Cancer Screening

(1) lab testing
(1) imaging

Efficacy of both?

Answer

A

CA-125

Transvaginal US

There are currently no laboratory or imaging tests that can detect it at early stages. Annual “CA 125” testing alone lacks sufficient specificity for screening average-risk patients. For women who are at higher risk of ovarian cancer, transvaginal ultrasound was found to perform poorly in detecting early-stage epithelial ovarian cancer.

Question 12

Q

Ovarian Cancer

Look for family history of ____ or more first- or second-degree (cousins, aunts, uncles) relatives with a history of ovarian cancer or a combination of ovarian and breast cancer, especially in women of (1) ethnicity with a first-degree relative (or second-degree relatives on the same side of the family) with breast or ovarian cancer.

Women with high-risk family history should be referred for ______ counseling and testing (e.g., ____ mutations, _____ syndrome). Screening can start ____ years before the earliest age of first diagnosis of ovarian cancer in a family member.

Answer

A

Look for family history of two or more first- or second-degree (cousins, aunts, uncles) relatives with a history of ovarian cancer or a combination of ovarian and breast cancer, especially in women of Ashkenazi Jewish ethnicity with a first-degree relative (or second-degree relatives on the same side of the family) with breast or ovarian cancer. Women with high-risk family history should be referred for genetic counseling and testing (e.g., BRCA 1/2, Lynch syndrome). Screening can start 10 years before the earliest age of first diagnosis of ovarian cancer in a family member.

Question 13

Q

Normal Breasts

Puberty in girls starts with breast ____ (tanner stage ___) and ends at stage V
During puberty what is common symptom and appearance of breasts for both girls and some boys?
What part of the breast do majority of breast cancers occur?

Answer

A

Puberty in girls starts with breast buds (Tanner stage II) and ends at stage V.
Tender, Asymmetrical breasts common during puberty, it is common for both girls and some boys (45%) to have breasts (gynecomastia)
“Tail of Spence” upper outer quadrant of the breasts is where the majority of breast cancer is located

Question 14

Q

Normal Breasts

(1) = benign fluid filled cysts that are round to oval in shape, highest prevalence in women 35-50 yo

(1) = most common type of solid breast tumor, consists of fibrous tissue that can range from a few mm to 2.5 cm in size

Answer

A

Benign fluid filled cysts = fluid filled cysts that are round to oval in shape, highest prevalence in women 35-50 yo

Fibroadenomas = most common type of solid breast tumor, consists of fibrous tissue that can range from a few mm to 2.5 cm in size

Question 15

Q

Fibroadenomas

(1) Imaging test of choice
(1) to confirm diagnosis
(1) higher levels can make them grow, while low levels can make them shrink

Are they associated with breast cancer?

Answer

A

Ultrasound = imaging test of choice

Needle biopsy needed to confirm diagnosis for some

Estrogen - higher levels make them grow, lower levels (menopause) can make them shrink

Not associated with Breast CA except for complex fibroadenomas

Question 16

Q

Breast Cancer

% risk associated for women with BRCA1 or BRCA2 gene mutation for breast CA?

Risk factors for breast cancer in men (3)

Diagnostic test for breast cancer (or any type of solid tumor) is?

Answer

A

Women with BRCA1 or BRCA2 gene mutation (or both) have up to a 72% risk of being diagnosed with breast cancer in their lifetime.

Risk factors for breast cancer in men are cryptorchidism, positive family history, and BRCA 1/2 mutation.

The diagnostic test for breast cancer (or any type of solid tumor) is the tissue biopsy.

Question 17

Q

(1)

Bright-red bumpy tissue with an irregular surface on the cervical surface around the os (Figure 1). It is a benign finding. It is made up of glandular cells (same cells that are inside the cervical os). It is more friable (bleeds easily) compared with the squamous epithelial cells on the surface of the cervix. It can change in size (or shape) and will disappear or regress over time.

Answer

A

Cervical Ectropion

Question 18

Q

Cervical Ectropion

Common finding in (2) women

Answer

A

Women taking birth control pills

Pregnant women (due to high estrogen)

Question 19

Q

Cervical Ectropion

What should you do if someone has this when performing a pap, why?

Answer

A

Important to sample the surface of the transformation zone (TZ) area when performing a Pap test. The TZ is the area where the ectropion transitions to the smooth cervical surface of squamous epithelial cells. Abnormal cells are more likely to develop (due to metaplasia) in the TZ.

Question 20

Q

Normal Cervical and Vaginal Mucus

Varies from scant (“___”), th____ white, r____ white (white and clear mucus) to cl____ stringy mucus.

After menses, vaginal discharge is sc____.

During midcycle, a large amount of ____-____ mucus (the mucus ____) is normal, except if the patient is on hormonal contraceptives (which _____ the mucus plug).

Can be mixed with blood and appear as a ___ to dark-br______ color during the menstrual cycle.

Answer

A

Varies from scant (“dry”), thick white, runny white (white and clear mucus) to clear stringy mucus.

After menses, vaginal discharge is scant.

During midcycle, a large amount of runny, clear mucus (the mucus plug) is normal, except if the patient is on hormonal contraceptives (which thicken the mucus plug).

Can be mixed with blood and appear as a red to dark-brownish color during the menstrual cycle.

Question 21

Q

Normal Uterus

(2) parts of uterus
(2) parts of uterus endometrium

(1) (uterine leiomyoma or myoma) can enlarge the uterus. They can be asymptomatic or may cause heavy menstrual bleeding (menorrhagia), pelvic pain or cramping, and bleeding between periods.

Fibroids usually?
Fibroids can cause urgency if presses on?
Fibroid rarely are?

Answer

A

Uterus = uterine corpus and uterine cervix

Uterus endometrium = glandular epithelium and stroma

Fibroids (uterine leiomyoma or myoma) can enlarge the uterus. They can be asymptomatic or may cause heavy menstrual bleeding (menorrhagia), pelvic pain or cramping, and bleeding between periods.

Fibroids usually benign
Fibroids can cause urgency if presses on bladder
Fibroid rarely are malignant and cause uterine cancer (leiomyosarcoma)

Question 22

Q

Normal Ovaries

Hormones produced by ovaries (3)

(1) = condition with multiple cysts on ovaries
* What happens to hormone levels in PCOS? results in S/S of a____, hir_____, ____menorrhea, insulin _____

What happens to the ovaries during menopause? What does it mean if you feel a palpable ovary during menopause? What should you do?

Answer

A

Ovaries produce estrogen, progesterone, and small amount of testosterone (androgens)

Polycystic ovary syndrome (PCOS) = condition with multiple cysts on ovaries

Higher levels of estrogen and androgen levels in PCOS. Results in S/S of acne, hirsutism, oligomenorrhea, insulin resistance

Ovaries atrophy during menopause. Palpable ovary always abnormal. Workup for ovarian cancer using pelvic/intravaginal US and refer to gynecologist

Question 23

Q

Benign Variants

(1) nipples form a V-shaped line on both sides of the chest down the abdomen and are symmetrically distributed

Answer

A

Supernumerary nipples form a V-shaped line on both sides of the chest down the abdomen and are symmetrically distributed

Question 24

Q

Menstrual Cycle

Typically ___-day menstrual cycle

(3) phases, days what to what?

Answer

A

28-day menstrual cycle

Follicular Phase (Days 1-14)

Ovulatory Phase (Day 14) Midcycle

Luteal Phase (Days 14-28)

Question 25

Q

Follicular Phase

Day 1-14

Each month (1) hormone is produced by anterior pituitary
FSH function =
(1) is produced by the developing follicles (“eggs), there is the predominant hormone during the first 2 weeks of menstrual cycle
Estrogen function = (1) known as the _____ phase

Answer

A

Each month FSH hormone is produced by anterior pituitary
FSH function = maturation of follicles in woman’s ovary
Estrogen is produced by the developing follicles (“eggs), there is the predominant hormone during the first 2 weeks of menstrual cycle
Estrogen function = stimulate development and growth of endometrial lining known as the proliferative phase

Question 26

Q

Ovulatory Phase

Midcycle Day 14

(1) secreted by anterior pituitary, which induces ovulation and maturation of _____ follicle on day 14
The follicle migrates to the fimbriae of the (1)
It takes about __ days for the egg to move through the fallopian tube, where conception can take place

Answer

A

Luteinizing hormone (LH) secreted by anterior pituitary, which induces ovulation and maturation of dominant follicle on day 14
The follicle migrates to the fimbriae of the fallopian tube
It takes about 5 days for the egg to move through the fallopian tube, where conception can take place

Question 27

Q

Luteal Phase

Day 14-28

(1) predominant hormone during last 2 weeks of cycle

This hormone is produced by (1) and helps stabilize the endometrial lining

Answer

A

Progesterone = predominant hormone during last 2 weeks of cycle

It is produced by corpus luteum and helps stabilize the endometrial lining

Question 28

Q

Menstruation

What happens to levels of estrogen and progesterone during menstruation?

This then stimulates the _____ → _____ and the cycle starts again

Answer

A

Estrogen and progesterone fall drastically during menstruation

This then stimulates the hypothalamus → anterior pituitary (FSH) and the cycle starts again

Question 29

Q

Fertile Time Period

Time period of highest chance of pregnancy?

What does vaginal mucous look like during this time? This sign is used in the (1) method of birth control to indicate fertile period of cycle
There are now ovulation kits that can detect urinary (1) - false positives in women with (3)

Answer

A

Sexual intercourse 1-2 days before ovulation offers highest chance of pregnancy

Copious amounts of clear mucus that feels thin and elastic in vagina → cervical mucus method of birth control to indicate fertile period of cycle
Ovulation kits detect urinary LH - false positives in women with PCOS, ovarian insufficiency, and menopause

LH in urine appears 12 hours after it is in serum (released by anterior pituitary)

Question 30

Q

Conception

Conception occurs when?

As the fertilized egg travels down the fallopian tube into the uterus it continues to ____ until it becomes a _____
The blastocyst implants into the _____ where it becomes an _____
It can take 3-4 days for the fertilized egg to fully implant in the uterus
The placenta is fully formed by ___-___ weeks
Estrogen and progesterone levels ____, along with (1) which is produced by the placenta
Pregnancy lasts (1) days or (1) weeks

Answer

A

Conception occurs when sperm fertilizes the egg

As the fertilized egg travels down the fallopian tube into the uterus it continues to divide until it becomes a blastocyst
The blastocyst implants into the endometrium where it becomes an embryo
It can take 3-4 days for the fertilized egg to fully implant in the uterus
The placenta is fully formed by 18-20 weeks
Estrogen and progesterone levels increase, along with human chorionic gonadotropin (HCG) which is produced by the placenta
Pregnancy lasts 280 days or 40 weeks

Question 31

Q

Cervical Cytology

(1) Test = _____-based cervical cytology is used to screen for cervical cancer

High false-____ rate 20-45%
The test is called (1), which is read by a computer, is now more popular in US than conventional pap smear kit
What is a sign of inflammation when performing the pap? What should you then rule out?
Some females have slight ____ after a pap test

Answer

A

Pap Test = liquid-based cervical cytology is used to screen for cervical cancer

High false-negative rate 20-45%
The test is called Thinprep, which is read by a computer, is now more popular in US than conventional pap smear kit
If cervix bleeds easily when brush is inserted to obtain the sample, may be a sign of inflammation. Rule out cervicitis
Some females have slight spotting after a pap test

Question 32

Q

Cervical Cytology

Can you perform a pap test or liquid based cytology during the menstrual period?
When is the best time to perform a pap test in relation to period?
2-3 days before pap test, what should you advise the patient to avoid doing?

Answer

A

DO NOT perform pap test or liquid based cytology during menstrual period
Best time to perform Pap test is at least 5 days after period stops
2-3 days before pap, patient should avoid douching, vaginal foams/medicines, tampon use, and vaginal intercourse

Question 33

Q

USPSTF Guidelines for Cervical Cancer Screening

Type of exam, screening interval

< 20 yo =

21-29 yo =

30-65yo =

Answer

A

< 20 yo = DO NOT screen

21-29yo = liquid based cytology or pap test Q3 years

30-65yo = liquid based cytology or pap test Q3 years or cotesting with HPV every 5 years

Question 34

Q

USPSTF Guidelines for Cervical Cancer Screening

>65 yo =

Hysterectomy =

Answer

A

>65 yo = Can stop screening if not high risk*

Hysterectomy = Can stop screening if not high risk*

Question 35

Q

ACOG Guidelines

Those that need more frequent cervical cancer screening include

____ positive women
history of (1)
(1) exposure

Answer

A

HIV positive women
history of cervical cancer
DES exposure

Question 36

Q

Liquid-Based Cervical Cytology Test (ThinPrep)

Insert the broom-shaped plastic brush into the cervical __ and rotate in the ____ direction for ____ turns.
If a ________ zone is present, make sure that it is included. Place the brush in the liquid medium and swish gently.
Remove brush and cover with the plastic cap.
The cervical cytology test is read by a ______, and abnormal results are reviewed by a cytologist and/or pathologist.

Answer

A

Insert the broom-shaped plastic brush into the cervical os and rotate in the same direction for five turns.
If a transformative zone is present, make sure that it is included. Place the brush in the liquid medium and swish gently.
Remove brush and cover with the plastic cap.
The cervical cytology test is read by a computer, and abnormal results are reviewed by a cytologist and/or pathologist.

Question 37

Q

Conventional Pap Smear

Use wooden _____ to scrape cervical surface (_____cervix).
Then insert the brush into the cervical __ (endocervix) and twist gently in a circle.
Smear the ____ slide with ____ samples. ____ the liquid fixative on the glass slide and label.
By sampling the ectocervix first, the chances of bleeding are minimized.

Answer

A

Use wooden spatula to scrape cervical surface (ectocervix).
Then insert the brush into the cervical os (endocervix) and twist gently in a circle.
Smear the glass slide with both samples. Spray the liquid fixative on the glass slide and label.
By sampling the ectocervix first, the chances of bleeding are minimized.

Question 38

Q

(1)

Standardized system that is used for reporting cervical cytology results.

Satisfactory specimen has both?
If a woman is being treated by pelvic radiation or is pregnant, what should you do?
Lubricants or excessive blood can do what?

Answer

A

The Bethesda System

Satisfactory specimen has both squamous epithelial cells and endocervical cells but the absence of endocervical cells is not unusual
If woman is being treated by pelvic radiation or is pregnant, make sure this info is included in the cytology requisition
Lubricants or excessive blood can interfere with results

Question 39

Q

(1)

Term that is used to describe cervical cells that look mildly abnormal but the cause cannot be identified (infection, irritation, or a precancer)

Answer

A

Atypical Squamous Cells of Undetermined Significance (ASCUS)

Question 40

Q

ASCUS Work-Up

If someone has ASCUS what should you do depending on age?

Age 20 years or younger =*
Age 21 to 24 years =*
Age 25 to 29 years =*
Age 30 years or older =*

Answer

A

Age 20 years or younger:* Do not perform Pap if younger than 21 years.
Age 21 to 24 years:* Preferred is repeat Pap test in 12 months (acceptable is reflex HPV test).
Age 25 to 29 years:* Preferred is reflex HPV test. Acceptable is repeat Pap test in 12 months.
Age 30 years or older:* Cotesting for high-risk HPV. If HPV positive, refer for colposcopy.

Question 41

Q

(1)

Term used to indicate presence of cervical cells that definitely look abnormal. A possible precancer is present and requires more testing and possible treatment.

Answer

A

Atypical Squamous Cells and Cannot Exclude a High-Grade Squamous Intraepithelial Lesion

Question 42

Q

Atypical Squamous Cells and Cannot Exclude a High-Grade Squamous Intraepithelial Lesion (ASC-H)

Workup for all ages includes?

Answer

A

Age 21 to 24 years:* Refer for colposcopy.
Age 25 to 29 years:* Refer for colposcopy.
Age 30 years or older:* Refer for colposcopy.

Question 43

Q

Atypical Glandular Cells

Overall what does it mean?

More common in _____ women (ages 40–69 years). Risk of cancer goes up with age.
There are several subcategories. Follow-up test depends on atypical glandular cell (AGC) subcategory.
Follow-up tests include c______, endo_____ sampling, and endo____ sampling.

Answer

A

Associated with premalignancy or malignancy in 30% of cases

More common in older women (ages 40–69 years). Risk of cancer goes up with age.
There are several subcategories. Follow-up test depends on atypical glandular cell (AGC) subcategory.
Follow-up tests include colposcopy, endocervical sampling, and endometrial sampling.

Question 44

Q

(1)

Cervical cells show changes that are mildly abnormal; usually caused by an HPV infection.

Workup

Age 21 to 24 years:*
Age 25 to 29 years:*
Age 30 years or older:*

Answer

A

Low-Grade Squamous Intraepithelial Lesions

Age 21 to 24 years:* Repeat Pap test in 12 months.
Age 25 to 29 years:* Refer for colposcopy.
Age 30 years or older:* Preferred is repeat Pap test in 12 months; acceptable to refer for colposcopy.

Question 45

Q

(1)

Lesions that suggest more serious changes in the cervix than low-grade squamous intraepithelial lesions (LSILs). They are more likely than LSILs to be associated with precancer and cancer.

Workup

Age 21 to 24 years =*
Age 25 years or older =*

Answer

A

High-Grade Squamous Intraepithelial Lesions

Age 21 to 24 years:* Refer for colposcopy.
Age 25 years or older:* Refer for immediate excisional treatment or colposcopy. It can be done by LEEP (loop electrosurgical excision procedure) with cervical conization or surgery of the cervix.

Question 46

Q

HPV DNA Test (Reflex HPV Testing)

HPV types ___ and ___ cause nearly all cases of cervical cancer. Women are exposed to high-risk HPV through (1)

_______ vaccine (males or females) is given at age __ or __ years (or as young as ages 9 through 26 years). If given before age 15 years, a ___-dose series is required. The second dose should be given __ to __ months after the first dose (0, 6–12).

If first dose of Gardasil given at age 15 years or older, a _____-dose schedule is recommended (0, 1–2, 6).

If the vaccine schedule is interrupted, do you have the vaccine series over?

Gardasil is not recommended for those older than ____ years, but some adults aged 27 years or older may benefit from HPV immunization (Centers for Disease Control and Prevention [CDC], 2019).

Answer

A

HPV types 16 and 18 cause nearly all cases of cervical cancer. Women are exposed to high-risk HPV through sexual intercourse.

Gardasil (males or females) is given at age 11 or 12 years (or as young as ages 9 through 26 years). If given before age 15 years, a two-dose series is required. The second dose should be given 6 to 12 months after the first dose (0, 6–12).

If first dose of Gardasil given at age 15 years or older, a three-dose schedule is recommended (0, 1–2, 6).

If the vaccine schedule is interrupted, vaccine doses do not have to be repeated (no maximum interval).

Gardasil is not recommended for those older than 26 years, but some adults aged 27 years or older may benefit from HPV immunization (Centers for Disease Control and Prevention [CDC], 2019).

Question 47

Q

(1)

A specialized “microscope” used to visualize the cervix, obtain cervical biopsies, and gain access to the cervix during cryotherapy or laser ablative therapy. The diagnostic test for cervical cancer is a ______ of the cervix, which is obtained during this procedure.

Answer

A

Colposcopy

A specialized “microscope” used to visualize the cervix, obtain cervical biopsies, and gain access to the cervix during cryotherapy or laser ablative therapy. The diagnostic test for cervical cancer is a biopsy of the cervix, which is obtained during a colposcopy.

Question 48

Q

Colposcopy Procedure

A vaginal ______ is used to expose the cervix.

After the cervix is studied, it is washed with (1), which helps remove mucus and causes the abnormal areas of the cervix to turn a bright-_____color that resembles leuko_____ (____whitening).

Biopsy samples are obtained from the ______ areas on the cervix, cervical ___ (glandular cells), and ______ junction.

After a colposcopy, a small amount of cramping and bloody spotting is _____ (red, brown, black) in the next few days after the procedure. Rx (1) or analgesics can be used for the pain as needed.

Answer

A

A vaginal speculum is used to expose the cervix.

After the cervix is studied, it is washed with acetic acid 3% to 5% (vinegar), which helps remove mucus and causes the abnormal areas of the cervix to turn a bright-white color that resembles leukoplakia (acetowhitening).

Biopsy samples are obtained from the acetowhitened areas on the cervix, cervical os (glandular cells), and squamocolumnar junction.

After a colposcopy, a small amount of cramping and bloody spotting is normal (red, brown, black) in the next few days after the procedure. Nonsteroidal anti-inflammatory drugs (NSAIDs) or analgesics can be used for the pain as needed.

Question 49

Q

(1)-(2)

Treatment for abnormal superficial cervical cells.

Answer

A

Ablative Treatment

Cryotherapy, Laser Therapy

Treatment for abnormal superficial cervical cells.

Question 50

Q

(1)

Device that is used like a scalpel to cut through the cervix (conization) to treat cervical cancer and obtain cervical biopsy specimens. Depending on the result of the biopsy (size, depth, and severity), the cancerous cells can be removed by cryotherapy for mild lesions, laser ablation, or surgical conization of the cervix.

Answer

A

Loop Electrosurgical Excision Procedure

Question 51

Q

(1)

Useful for helping with the diagnosis of fungal infections (hair, nails, skin). Works by causing lysis of squamous cells, which make it easier to see

(2)*

Vaginal specimens do not require this to visualize (1) organism

Answer

A

Potassium Hydroxide Slide (KOH slide)

hyphae and spores

Vaginal specimens do not require KOH to visualize Candida.

Question 52

Q

(1)

A test for bacterial vaginosis (BV).

A positive result occurs when a ____, ___-like odor is released after one or two drops of KOH are added to the slide (or a cotton swab soaked with discharge).

Answer

A

Whiff Test

A positive result occurs when a strong, fish-like odor is released after one or two drops of KOH are added to the slide (or a cotton swab soaked with discharge).

Question 53

Q

(1)

Used as an adjunct for evaluating herpetic infection (oral, genital, skin).

A positive smear will show (1) in squamous epithelial cells. Not commonly used.

Answer

A

Tzanck Smear

A positive smear will show large abnormal nuclei in squamous epithelial cells. Not commonly used.

Question 54

Q

Exam Tips

Recognize menopausal female body changes. If ______ ovary (abnormal), rule out ovarian _____ and order an intravaginal ______.

Palpation of postmenopausal women’s breasts will feel ____ with ____ volume and may be pen____.

Be familiar with physical breast exam findings (h____ -___egular mass that is not ______) and follow-up of breast cancer.

Answer

A

Recognize menopausal female body changes. If palpable ovary (abnormal), rule out ovarian cancer and order an intravaginal ultrasound.

Palpation of postmenopausal women’s breasts will feel softer with less volume and may be pendulous. (hanging loosely)

Be familiar with physical breast exam findings (hard irregular mass that is not mobile) and follow-up of breast cancer.

Question 55

Q

Exam Tips

Pap/cytology and HPV testing are not recommended before age ___ years, even if sexually active, or if the person has an STD or sexually transmitted infection (STI) or has multiple sex partners. Can perform (1) exam to check for pelvic inflammatory disease (PID) and test for chlamydia/gonorrhea.

Do not confuse ______ biopsy with colposcopy, a test used to visualize the cervix and obtain cervical biopsy.

Answer

A

Pap/cytology and HPV testing are not recommended before age 21 years, even if sexually active, or if the person has an STD or sexually transmitted infection (STI) or has multiple sex partners. Can perform bimanual gynecologic exam to check for pelvic inflammatory disease (PID) and test for chlamydia/gonorrhea.

Do not confuse endometrial biopsy with colposcopy, a test used to visualize the cervix and obtain cervical biopsy.

Question 56

Q

Clinical Pearls

Using a small amount of K-Y Jelly to lubricate the tips of the speculum (in patients with ____ vaginitis to reduce pain and vaginal bleeding), does this affect pap results?

In reproductive-aged females who present with acute abdominal or pelvic pain, always perform a (1)

Girls and teenagers have larger _____. Some adult women on (1) pills may develop ectropion.

Cervical cancer 5-year survival rates: _____, 92%; _____ spread, 56%; distant ______, 17%.

Answer

A

Using a small amount of K-Y Jelly to lubricate the tips of the speculum (in patients with atrophic vaginitis to reduce pain and vaginal bleeding) will not affect the Pap test results.

In reproductive-aged females who present with acute abdominal or pelvic pain, always perform a pregnancy test (use good-quality urine human chorionic gonadotropin strips).

Girls and teenagers have larger ectropions. Some adult women on birth control pills may develop ectropion.

Cervical cancer 5-year survival rates: Localized, 92%; regional spread, 56%; distant metastasis, 17%.

Question 57

Q

Infertility

=

There is up to an ___% chance of becoming pregnant within 1 year of unprotected sexual intercourse.

In the United States, approximately 50% of pregnancies are un______. Women seeking to prevent pregnancy can choose from several options with varying degrees of reported effectiveness

Answer

A

Infertility is defined as having unprotected sex for 1 year with failure to achieve pregnancy.

There is up to an 85% chance of becoming pregnant within 1 year of unprotected sexual intercourse.

In the United States, approximately 50% of pregnancies are unplanned. Women seeking to prevent pregnancy can choose from several options with varying degrees of reported effectiveness

Question 58

Q

Contraception

Most Effective Options (3)

Less Effective Options (5)

Least Effective Options (5)

Answer

A

Most Effective Options = Implant, IUD, Sterilization

Less Effective Options = Injectable, Pills, Patch, Ring, Diaphragm

Least Effective Options = Condoms, Withdrawal, Sponge, Fertility Awareness monthy tracker, Spermicide

Question 59

Q

Contraception Patient Education

Vasectomy or Hysteroscopic sterilization =

Injectable = get repeat injections on ____

Pills = take a pill each ____

Patch, Ring = Keep in ____, ch____ on time

Diaphragm = use correctly every time you have _____

Condoms, Sponge, Withdrawal, Spermicides = use correctly everytime you have ____

Fertility awareness based methods = ab____ or use ____ on ____ days. Newest methods (standard days method and two day method) may be the easiest to use and consequently more effective, what are these methods?

Answer

A

Vasectomy or Hysteroscopic sterilization = use another method for first 3 months

Injectable = get repeat injections on time

Pills = take a pill each day

Patch, Ring = Keep in place, change on time

Diaphragm = use correctly every time you have sex

Condoms, Sponge, Withdrawal, Spermicides = use correctly everytime you have sex

Fertility awareness based methods = abstain or use condoms on fertile days. Newest methods (standard days method and two day method) may be the easiest to use and consequently more effective, what are these methods?

The Standard Days Method (SDM) is a fertility awareness-based family planning method that identifies a 12-day fertile window during which women with regular menstrual cycles (26–32 days long) should abstain from sex or use a barrier method to prevent pregnancy*
The TwoDay method is* a variation of the cervical mucous method.

Question 60

Q

Minors and Contraception

According to the Guttmacher Institute (2020), there are ___ states and the District of Columbia that explicitly allow all individuals to consent to contraceptive services.

Some states require a specified age (e.g., age ___or older) to consent to such care.

Approximately 24 states permit minors to consent to contraceptive services in certain circ_______.

M______ minors or em______ minors do not need parental consent.

Answer

A

According to the Guttmacher Institute (2020), there are 23 states and the District of Columbia that explicitly allow all individuals to consent to contraceptive services.

Some states require a specified age (e.g., age 14 or older) to consent to such care.

Approximately 24 states permit minors to consent to contraceptive services in certain circumstances.

Married minors or emancipated minors do not need parental consent.

A list of state requirements in regard to minors obtaining contraceptive services with/without parental consent is available at https://www.guttmacher.org/state-policy/explore/ minors-access-contraceptive-services.

Question 61

Q

Rule Out Pregnancy

According to the CDC (2016), a healthcare provider can be reasonably certain that a woman is not pregnant if she has no symptoms or signs of pregnancy and meets the following criteria:

When after start of normal menses? (or after an induced or spontaneous abortion)
Has had no (1) since the start of last normal menses
Has been correctly and consistently using a reliable method of _______
Is within ___ days postpartum
Exclusively _______ or for the vast majority of time (>85%) and is_____hoeic and
Check if pregnant with urine pregnancy test before starting?

Answer

A

At least 7 days or less after start of normal menses (or after an induced or spontaneous abortion)
Has had no sexual intercourse since the start of last normal menses
Has been correctly and consistently using a reliable method of contraception
Is within 4 days postpartum
Exclusively breastfeeding or for the vast majority of the time breastfeeds (>85%) and is amenorrhoeic and <6 months postpartum
Check if pregnant with urine pregnancy test before starting hormonal and IUD contraception

Question 62

Q

Combined Hormonal Contraception

(1) + (1)

Works in a synergistic manner by stopping ovulation (inhibits ___ surge) and thickening (1)

There are several types of (3)

Answer

A

Estrogen and Progesterone

Works in a synergistic manner by stopping ovulation (inhibits LH surge) and thickening mucus plug

There are several types of oral contraceptives, transdermal patch, and vaginal ring

Question 63

Q

Combined Oral Contraceptives

9% Typical Use Failure Rate

Monophasic Pill =

Biphasic Pill =

Triphasic Pill =

Ethinyl Estradiol and Drospirenone =

Extended Cycle Oral Contraceptive =

Answer

A

Monophasic Pill = Loestrin FE 1/ 20

Biphasic Pill = Ortho-Novum 10/11, Mircette, Jenest

Triphasic Pill = Ortho Tri-Cyclen, Cyclessa, Tri-Norinyl, Tri-Levlen, and Triphasil

Ethinyl Estradiol and Drospirenone = Yaz/Yasmin

Extended Cycle Oral Contraceptive = Seasonale

Question 64

Q

(1)

21 consecutive days of estrogen/progesterone (same dose daily). For the last 7 days of the cycle, the placebo pills contain iron supplementation (7 days of iron pills).

Answer

A

Loestrin FE 1/20

(Monophasic Pill)

Answer 65

A

Ortho Novum 10/11, Mirette, Jenest

Biphasic Pills

Answer 66

A

Ortho Tri-Cyclen, Cyclessa, Tri-Norinyl, Tri-Levlen, Triphasil

Contains 21 days of active pills and 7 days of placebo pills. The dose of hormones varies weekly for 3 weeks (“triphasic”). Progestin used is norgestimate. Indicated for acne.

Answer 67

A

Yaz 28, Yasmin

Uses drospirenone (a spironolactone analog) as the progestin component
Results in lighter menses and lower rates of unscheduled bleeding
Consider for women with acne, PCOS, hirsutism, or premenstrual dysphoric disorder disorder (PMDD)
Higher risk of DVT and hyperkalemia

Answer 68

A

Labs: Check the potassium level if patient is on an angiotensin-converting enzyme inhibitor (ACEI), angiotensin receptor blocker (ARB), or potassium-sparing diuretic or has kidney disease.

Answer 69

A

Seasonale

Extended-Cycle Oral Contraceptive Pills

84 days hormones (3 months) of estrogen/progesterone with 7 days placebo pills

This method typically results in four periods per year, although breakthrough bleeding is not uncommon during the first few months.

Literally 1 period per season

Answer 70

A

Cervical Ring

Ortho Evra Transdermal Contraceptive Patch

Both have 7% Typical Use Failure Rate

Answer 71

A

NuvaRing

Plastic cervical ring that contains EE = Etonogestrel and Ethinyl Estradiol

It is left inside the vagina for 3 weeks (21 days), then removed for 1 week (when woman has her period).

Educate patient on how to apply = Fold in half and insert into vagina

The ring should fit snugly around cervix.

Do not use NuvaRing if cigarette smoker aged > 35 years

Answer 72

A

Wear a new patch 1 week at a time for 3 weeks in a row. During the fourth week, do not wear a patch.

Higher risk of VTE bc releases higher levels of estrogen compared with oral contraceptives

Absolute and relative contraindications for combined estrogen-progesterone method of contraception are the same as oral contraceptives

Patch can be worn on back, chest (except breast), upper back, arm, abdomen

Answer 73

A

My Migraines with focal neurological aura

C CAD or CVA

U Undiagnosed genital bleeding

P Pregnant or suspect pregnancy

L Liver tumor or active liver disease

E Estrogen-dependent tumor

T Thrombus or emboli

S Smoker aged 35 or older

Answer 74

A

Migraine headaches
- Migraines and >35 years
- Migraines with focal neurological findings are an absolute contraindication because of increased risk of stroke
Smoker <35 years
Fracture or cast on lower extremities
Adequately controlled hypertension

Answer 75

A

Any condition (past or present) that increases the risk of blood clotting

History of thrombophlebitis or thromboembolic disorders (e.g., DVT)
Genetic coagulation defects, such as factor V Leiden disease
Major surgery with prolonged immobilization

Smoker older than the age of 35, >15 cigarettes per day

Also considered a relative contraindication because women <35 years who smoke can take the pill (if no other contraindications exist)

Answer 76

A

Any condition that increases the risk of strokes

Migraine with aura or focal neurological symptoms or migraine without aura at age 35 years or older
History of cerebrovascular accidents (CVAs) and transient ischemic attacks (TIAs)
Hypertension (if systolic blood pressure [SBP] >160 mmHg or diastolic BP [DBP] >100 mmHg)

Inflammation and/or acute infections of the liver with elevated liver function tests (LFTs)

In acute infection or inflammation of the liver (e.g., mononucleosis) with elevated LFTs, estrogen is contraindicated
When LFTs are back to normal, can go back on birth control pills
Hepatocellular adenomas or malignant (hepatoma)
Cholestatic jaundice of pregnancy

Answer 77

A

Known or suspected cardiovascular disease

Moderately to severely impaired cardiac function
Complicated valvular heart disease (risk atrial fibrillation, history of subacute bacterial endocarditis)
Coronary artery disease (CAD)
Diabetes with vascular component
Systemic lupus erythematosus
Hypertension if SBP is ≥160 or DBP 100 mmHg
Two or more risk factors for arterial cardiovascular disease (such as older age, smoking, diabetes, hypertension)

Answer 78

A

Some reproductive system conditions or cancers

Known or suspected pregnancy
Undiagnosed genital bleeding or breast mass
Breast, endometrial, or ovarian cancer (or any estrogen-dependent cancer) <21 days postpartum

Contraindications for drospirenone (Yaz, Yasmin, Slynd): Hyperkalemia, kidney disease or kidney failure, adrenal insufficiency

Answer 79

A

Ovarian cancer and endometrial cancers (decreased by 40%–50%)

Decreased incidence of:

Dysmenorrhea and cramps (decrease in prostaglandins)
Decreased pelvic pain for patients with endometriosis
Acne and hirsutism (lower levels of androgenic hormones)
Ovarian cysts (due to suppression of ovulation)
Heavy and/or irregular periods (due to suppression of ovaries)

Answer 80

A

Perform thorough health history to find out if patient has a contraindication. Rule out pregnancy. Check BP (rule out hypertension).

According to the CDC (2016), a physical examination, Pap smear, gynecologic exam, STD/STI testing, and/or laboratory blood testing is not required for initiating contraception in most healthy patients.

Exception is pelvic exam before insertion of IUD (to rule out an abnormal uterus or cervicitis) and when fitting a patient for a diaphragm.

Oral contraceptives can be started anytime in the menstrual cycle (rule out pregnancy first)

Answer 81

A

All patients should be instructed to use “backup” (condoms) in the first week (7 days) during the first pill pack.

Quick start: Start taking the pill on the day prescribed (give samples or prescription). Rule out pregnancy first.
Day one start: Take the first pill during the first day of the menstrual period. Provides the best protection.
Sunday start: Take first pill on the first Sunday after the menstrual period starts. Will avoid having a period on a weekend. Higher chance of ovulation happening.

Follow-up visit needed within 2 to 3 months to check BP or any side effects and answer patient’s questions. Can prescribe up to 12 to 13 months of refills for oral contraceptives.

Answer 82

A

Unscheduled Bleeding (Spotting)

Term used for menstrual bleeding that occurs outside of usual cycle.

Educate patient that she may have spotting/light bleeding during the first few weeks after starting birth control pills, transdermal patch, or vaginal ring. For most, it will decrease to 10% or less by the third month.

Discourage patient from switching to another pill brand during the first 3 months because of spotting. Advise patient that most cases resolve spontaneously within a few weeks.

Answer 83

A

Patients on oral contraceptives with lower estrogen dose (20 mcg EE) have higher rates of unscheduled bleeding, compared with those on OCs with higher dose of 30 to 35 mcg of EE.

If patient still has bleeding after a few weeks, an option is to switch to an OC with 30 mcg of EE (Lo/Ovral, Desogen, Loestrin 2, Nordette).

Check if patient is taking pills daily. It takes approximately 3 months for the body to adjust to hormones.

Early symptoms can include nausea and breast tenderness a few days after starting hormones. Symptoms usually resolve in 1 month.

Answer 84

A

Missed 1 Day

Take two pills now and continue with same pill pack (“doubling up”). Continue taking remaining pills at the usual time.

Missed 2 Consecutive Days (or >48 Hours Since Last Pill Should Have Been Taken)

Take the most recent missed pill as soon as possible (even if it means taking two pills the same day). Discard any leftover missed pills. Continue taking remaining pills at the usual time.

Use backup contraception (e.g., condoms) or avoid sex until hormonal pills have been taken for 7 consecutive days.

Answer 85

A

Omit hormone-free pills (or placebo pills) by finishing the hormonal pills in the current pack and starting a new pill pack the next day.

Use backup contraception until hormonal pills have been taken for 7 consecutive days. Consider emergency contraception if unprotected sexual intercourse occurred in the previous 5 days.

Answer 86

A

Anticonvulsants:* Phenobarbital, phenytoin
Antifungals (strong CYP3A4 inhibitors):* Griseofulvin (Fulvicin), itraconazole (Sporanox), ketoconazole (Nizoral)
HIV/hepatitis C virus (HCV) protease inhibitors:* Indinavir, boceprevir
Certain antibiotics:* Ampicillin, tetracyclines, rifampin, clarithromycin
St. John’s wort:* May cause breakthrough bleeding

Answer 87

A

Thromboembolic events can happen in any organ of the body. These signs indicate a possible thromboembolic event. Advise patient to report these or call 911 if symptoms of ACHES:

A Abdominal pain

C Chest pain

H Headaches

E Eye problems; change in vision

S Severe leg pain

Answer 88

A

Typical use failure rate is 9%.

Traditional oral contraceptive pills have 21 days of “active” pills and 7 days of placebo pills. The last 7 days are the “hormone-free” days. The menstrual period usually starts within 2 to 3 days after the last active pill was taken (from very low levels of estrogen/progesterone).

Some brands of birth control pills (e.g., Loestrin FE) contain iron in the pills taken during the last 7 days of the pill cycle (instead of a placebo pill). The last 7 days (hormone-free) of the pill cycle are there to reinforce the habit of daily pill taking.

Answer 89

A

For the first pill cycle, advise patient to use “backup” (an alternative form of birth control) for 7 consecutive days. The extended-cycle OCs are another option to consider.

All the combined oral contraceptives (COCs), the patch, and the NuvaRing contain both estrogen (e.g., EE) and progesterone (e.g., levonorgestrel, norethindrone, desogestrel).

Answer 90

A

The contraceptive patch (e.g., Ortho Evra) results in higher levels of estrogen exposure compared with COCs (higher risk of blood clots, DVT).

The estrogen in COCs can elevate BP. Patients’ BP should be checked within 4 to 8 weeks.

Breastfeeding women can use the progestin-only pill (POP; “minipill”; e.g., Micronor, Nor-QD) or other progestin-only contraceptives. Barrier methods such as condoms can also be used.

Answer 91

A

Depo-Provera (4% Typical Use Failure Rate)

Etonogestrel Contraceptive Implant (0.1% Typical Use Failure Rate)

Progestin-Only Pills (7% Typical Use Failure Rate)

Emergency Contraception (“Morning-After Pill”)

Answer 92

A

Also known as depot medroxyprogesterone acetate (DMPA).

Each dose by injection lasts 3 months. Highly effective.

Check for pregnancy before starting dose. Start within first 5 days of cycle (days 1–5) because females are less likely to ovulate at these times.

Women on Depo-Provera for at least 1 year (or longer) have amenorrhea because of severe uterine atrophy from lack of estrogen

Answer 93

A

Do not recommend to women who want to become pregnant in 12 months. Causes delayed return of fertility. It takes up to 1 year for most women to start ovulating.

Black box warning: Avoid long-term use (more than 2 years). Increases risk of osteopenia or osteoporosis that may not be fully reversible. Using Depo-Provera for more than 2 years is discouraged.

Answer 94

A

Avoid using Depo-Provera in this population, because it will further increase their risk of osteopenia/osteoporosis. Consider testing for osteopenia/osteoporosis (dual-energy x-ray absorptiometry [DEXA] scan).

Recommend calcium with vitamin D and weight-bearing exercises for patients who are on this medicine.

Answer 95

A

The contraceptive implant contains a long-acting form of progestin (etonogestrel). Initially, unscheduled bleeding is common, but when the endometrial lining atrophies, amenorrhea results. Ovulation may not occur for a few weeks to 12 months after removal.

Answer 96

A

Thin plastic rods are inserted on the inner aspect of the upper arm subdermally (nondominant arm). If keloid or heavy scarring occurs, may have problem with removal. Special procedures, including surgery in a hospital, may be needed to remove the implant.

Norplant II (two rods) is effective up to 5 years. Nexplanon (one rod) is effective for up to 3 years.

One out of ten women stop using the implant because of unfavorable changes in menstrual bleeding.

Answer 97

A

Safe for breastfeeding women, and most effective if woman is exclusively breastfeeding. Also known as the “minipill.”

Obese women can take POPs.

It is very important to take the pill at the same time each day. If dose is late (≥3 hours) or a day is missed, the woman should use condoms (backup contraception) or abstain from sexual intercourse for 2 days. There is no placebo week with POPs.

Answer 98

A

Vomiting or severe diarrhea that occurs within 3 hours after taking a dose:* Take another pill as soon as possible. Continue taking pills daily at the same time each day. Use backup contraception. Consider use of emergency contraception if unprotected sex.
Micronor (Norethindrone 0.35 mg):* Take one pill daily at about the same time each day (each pack contains 28 pills). Start taking pill on day 1 of menstrual cycle.

POPs are slightly less effective than oral contraceptive pills. An alternative for women who cannot take estrogen, such as breastfeeding mothers, older smokers, and diabetics with microvascular disease.

Answer 99

A

Works best if taken within 72 hours after unprotected sexual intercourse or if 2 consecutive days of birth control pills are skipped.

Women and men of all ages can get emergency contraceptive pills (except ulipristal acetate) without a prescription in the United States.

89% effective

Advise patient that if she does not have a normal period in next 3 weeks, she should return for follow-up to rule out pregnancy.

Answer 100

A

Ulipristal acetate (Ella):* Take one pill within 5 days (120 hours) of unprotected sex. Needs prescription.
Levonorgestrel:* Plan B One-Step My Way, After Pill, or Next Choice One Dose
A few birth control pills that contain levonorgestrel (e.g., Triphasil) may be used as morning-after pills but are more likely to cause nausea (because of the estrogen).
Take first dose as soon as possible (up to 72 hours after).
Take second dose in 12 hours.
If patient vomits tablet within 1 hour (or less), may need to repeat dose; OTC antiemetics (antihistamine drug class) are dimenhydrinate (Dramamine) and meclizine (Dramamine Less Drowsy).

Answer 101

A

Intrauterine Device (LNG 0.1%–0.4%/Copper 0.8% Typical Use Failure Rate)

Barrier Methods (condoms)

Diaphragm With Contraceptive Gel and Cervical Cap (17% Typical Use Failure Rate)

Sponge (Nulliparous 14%/Multiparous 27% Typical Use Failure Rate)

Answer 102

A

The IUD is the second most commonly used method of contraception in the world (female sterilization is the first).

Paragard is copper bearing (effective up to 10 years)
* Copper IUD can cause heavy menstrual bleeding and cramping the first few months of use.
Mirena contains the hormone levonorgestrel (LNG), which decreases vaginal bleeding.
* Mirena IUD is effective for up to 5 years and is slightly more effective than copper-bearing IUDs (Cu-IUDs).

IUD can be removed if patient desires pregnancy. Not for women who plan on having a baby within 1 to 2 years. Must be inserted by trained health provider. Rule out pregnancy.

Answer 103

A

Active PID or history of PID within the past year

Suspected or confirmed pregnancy or has STD

Uterine or cervical abnormality (e.g., bicornuate uterus)

Undiagnosed vaginal bleeding or uterine/cervical cancer

History of ectopic pregnancy

Answer 104

A

Increased Risk

Endometrial and pelvic infections (first few months after insertion only)

Perforation of the uterus

Heavy or prolonged menstrual periods (Cu-IUDs)

Education

Mirena IUD: Approximately 20% of patients will have amenorrhea in 1 year. Some have lighter periods.

Educate patients to periodically check for missing or shortened string, especially after each menstrual period. If the patient or clinician does not feel the string, order a pelvic ultrasound.

Answer 105

A

Male condoms more effective than female (18% vs. 21% failure rate)

Do not use with any oil-based or silicone oil based lubricants , creams, and so forth

Answer 106

A

Not as effective as hormonal forms of contraception. The cervical cap is less effective than a diaphragm. After vaginal birth, the failure rate of the cervical cap increases to 29%.

The diaphragm must be used with spermicidal gel with every act of intercourse. Apply the spermicidal foam/gel inside the vagina without removing the diaphragm.

After intercourse, leave diaphragm inside vagina for at least 6 to 8 hours (can remain inside vagina up to 24 hours). The cervical cap can be left in the vagina up to 2 days.

The cervical cap (Prentif cap) can be worn up to 48 hours. Compared with the diaphragm, the Prentif cap may cause abnormal cervical cellular change (abnormal Pap).

Answer 107

A

Spermicidal gel (nonoxynol-9, or N-9) increases risk of infection with STD, including HIV. It is thought to cause irritation of the cervical surface (breakdown of the skin barrier) after multiple uses.

Both diaphragm and cervical cap require a prescription and must be fitted.

Avoid lubricants that contain silicone oil; they can cause deterioration of the silicone diaphragm or cap.

After each pregnancy by vaginal birth or weight gain (or loss) of 20%, they need to be refitted. The cervical cap and diaphragm cannot be used during menstruation.

Answer 108

A

Vaginal and cervical irritation (N-9) increases risk of HIV, UTIs, and toxic shock syndrome (rare).

Answer 109

A

OTC. Made out of soft foam that contains spermicide. It is inserted inside the vagina so that it covers the cervix.

It can be inserted up to 24 hours before sex, and it should be left in place at least 6 hours after sexual intercourse. The sponge should not be worn for more than 30 total hours.

Spermicide use (nonoxynol-9) increases risk of HIV infection (see section on diaphragm for rationale).

Answer 110

A

Vaginal and cervical irritation (nonoxynol-9) increases risk of HIV infection.

TSS is rare.

Answer 111

A

Low-dose birth control pills contain 20 mcg to 35 mcg of EE.

Desogen, Ortho-TriCyclen, and Yaz/Yasmin are all indicated for treatment of acne.

Know what to do if 2 consecutive days of the pill are missed. = take most recently missed pill (even if taking two pills on same day), discard any leftover missed pills - and continue taking remaining pills at the usual time

Avoid using Depo-Provera in anorexic and/or bulimic patients (very high risk of osteoporosis). - is progesterone only

Women taking Seasonale (84 days hormones/7 days placebo pill) will have only four periods per year.

Answer 112

A

Mefenamic acid (Ponstel) is an NSAID that is very effective for menstrual pain.

Know how to use Plan B (emergency contraception) = can take within 72 hours or if skilled 2 consecutive days of birth controll pills, does not need prescription, take as soon as possible and second dose 12 hours later, use antiemetic if pill causes nausea, follow up to RO pregnancy if no period in next 3 weeks

Cu-IUD lasts 10 to 12 years. Mirena (progesterone IUD) lasts 5 years.

Some questions will ask for the best birth control method for a case scenario. Remember the contraindications or adverse effects of each method (e.g., Depo-Provera).

Answer 113

A

Yaz or Yasmin contain estrogen and drospirenone. Has a higher risk of blood clots, stroke, heart attacks, and hyperkalemia.

Do not recommend Depo-Provera or IUD for women who want to become pregnant in 12 to 18 months because it may cause delayed return of fertility. It can take up to 1 year for some women to start ovulating.

Cu-IUD probably has the broadest indication for use as a contraceptive for women with medical conditions (e.g., diabetics, smoker for more than 35 years, on anticonvulsant or antiretroviral therapy, ovarian cancer, ischemic heart disease, liver tumors).

Answer 114

A

Primary dysmenorrhea refers to the recurrent crampy pain in the pelvic area caused by menstruation that is not caused by disease.

Secondary dysmenorrhea refers to the same type of pain caused by a disease such as endometriosis.

Endometriosis is associated with heavy menstrual periods (menorrhagia) with severe cramping. The treatment options are NSAIDs, acetaminophen (paracetamol), and/or hormonal methods. All NSAIDs are probably effective

Answer 115

A

Mefenamic acid (Ponstel): 250 mg every 6 hours for pain as needed

Naproxen sodium (Aleve):* 275 mg every 6 to 8 hours as needed
Ibuprofen (Advil):* 400 mg to 600 mg every 4 to 6 hours as needed
Ketoprofen (Orudis):* 25 mg to 50 mg every 6 to 8 hours as needed
Acetaminophen (Tylenol):* One to two tablets every 4 to 6 hours as needed (if NSAIDs contraindicated)

Answer 116

A

If poor to no relief, consider extended-cycle OCs such as Yaz (24/4) or extended-cycle OCs (Seasonale).

Progestin-only methods may also be effective.

Refer to gynecologist to rule out endometriosis if severe menstrual cramp pain with heavy menses (can cause iron-deficiency anemia).

Answer 117

A

Absence of menses, which can be transient, intermittent, or permanent.

Primary amenorrhea is the absence of menarche by age 15 years (or older).

Secondary amenorrhea is the absence of menses for more than 3 months in girls/women who previously had regular menstrual cycles, or if irregular cycles, it is missing menses for 6 months.

The most common cause of secondary amenorrhea is pregnancy.

Answer 118

A

Very common condition found in reproductive-aged women between the ages of 30 and 50 years.

Previously called fibrocystic breast disease.

These are nonmalignant breast lesions, which are either nonproliferative (benign) or proliferative (fibroadenomas, fibrosis, papillomas, mild-to-moderate hyperplasia, others).

Women with proliferative lesions have a slightly increased risk of breast cancer.

Many have cyclic monthly breast changes that occur in the premenstrual period, such as breast engorgement and breast pain (mastodynia), which improve after menses starts.

Answer 119

A

Woman aged 30 to 50 years complains of the cyclic onset of bilateral breast tenderness and breast lumps that start from a few days (up to 2 weeks) before her period for many years.

Once menstruation starts, the tenderness disappears, and the size of breast lumps decreases.

May report that the lesion or mass has grown in size. During breast examination, the breast may feel lumpy, nodular, or cystic.

If mass present, it is mobile with discrete edge, not attached to the skin, and feels rubbery to firm texture (not hard). Nipples and/or breast may feel tender.

Answer 120

A

Objective Findings

Multiple mobile and rubbery to firm (not hard) masses on one or both breasts.

Treatment Plan

Stop caffeine intake. Take vitamin E and evening primrose capsules daily.

Wear bras with good support.

Referral needed if dominant mass, skin changes, fixed mass.

Answer 121

A

Breast cancer is the most common type of cancer in women, and it is also the second most common cause of death among women in the United States (leading cause of death is heart disease).

Most cases of breast cancer in the United States are diagnosed by an abnormal mammogram, but up to 15% of women have a breast mass that is not detected on a mammogram (mammographically occult disease).

The gold standard diagnostic is biopsy of the breast/axillary mass.

Answer 122

A

Older age (50 years or older)
Genetic mutations (BRCA 1/2)
Early menarche (before age 12), late menopause (after age 55)
Dense breast
Personal or Family history of breast cancer
Radiation therapy to the chest/breast before age 30 (treated for Hodgkin’s lymphoma)
Mother took diethylstilbestrol (DES; 1940–1971)

Answer 123

A

Not being physically active
Obese after menopause
Hormones (estrogen and progesterone) taken during menopause for >5 years
Pregnancy at age 30 or older
Not breastfeeding
Nulliparity
Moderate-to-high alcohol intake.

Answer 124

A

Breast cancer types:* Ductal carcinoma in situ (DCIS), infiltrating lobar carcinoma (CA), infiltrating ductal CA, mixed lobar and ductal CA, PDB, inflammatory breast CA, phyllodes tumor, breast sarcoma (rare).
Breast cancer receptors:* Estrogen receptor (ER), progesterone receptor (PR), HER2 (human epidermal growth factor receptor). Most breast cancers (80%) are hormone-receptor positive (ER and/or PR).

Answer 125

A

Biennial screening mammography for women aged 50 to 74 years.

There is insufficient evidence for digital breast tomosynthesis (DBT) as the screening method for breast cancer.

Answer 126

A

Patient (or clinician) detects a dominant breast mass that is painless.

Mass feels hard, has irregular edges, and is not mobile. May have axillary adenopathy, skin changes (dimpling or peau de orange, thickening), or erythema (IBC).

May have nipple discharge (bloody) or erosion. Scaling on the nipple and/or areola is a sign of PDB.

Symptoms of metastases include bone (back pain, leg pain), liver (nausea, jaundice, anorexia, pain), lungs (shortness of breath, cough), and/or brain (headache).

Answer 127

A

Mammogram:* Grouped microcalcifications, spiculated high-density mass.
Breast ultrasound/sonogram:* Distinguish if mass is cystic or solid/malignant (e.g., calcifications).
MRI of the breast (with gondolium):* Used to screen women at high risk of breast cancer. Most invasive breast cancers are enhanced on gondolium-contrast MRI.

Answer 128

A

Age 30 years or older with dominant breast mass:* Order diagnostic mammogram and breast ultrasound (to determine if cystic or solid). If abnormal mammogram, refer to breast specialist.
Age 30 years or younger:* Order breast ultrasound with/without diagnostic mammogram/breast biopsy. If low clinical suspicion, may observe for one or two menstrual cycles.

Answer 129

A

Skin changes (peau de orange, dimpling):* Order diagnostic mammogram with biopsy of underlying mass.
If family history of breast and/or ovarian cancer* (first-degree includes parents/siblings and second-degree relatives are aunts/uncles/cousins): Refer to geneticist. Ashkenazi Jews are at higher risk of BRCA 1/2 mutations.

Answer 130

A

Physical exam:* Breast examination search for masses, axillary, supraclavicular, and cervical adenopathy.
Secondary prevention:* Aspirin use at least once per week (associated with up to 50% reduction in death from breast cancer); tamoxifen for certain patients at higher risk at age 35 years or older.

Answer 131

A

Polycystic Ovary Syndrome

Answer 132

A

These females are at higher risk for type 2 diabetes, dyslipidemia, metabolic syndrome, endometrial hyperplasia, obesity, nonalcoholic fatty liver disease, depression, and obstructive sleep apnea.

Answer 133

A

Obese teen or young adult complains of excessive facial and body hair (hirsutism 70%), bad acne, and amenorrhea or infrequent periods (oligomenorrhea). Dark thick hair (terminal hair) is seen on the face, cheek, and beard areas. May have male-pattern baldness when older.

Answer 134

A

Transvaginal ultrasound: Enlarged ovaries seen with multiple small follicles (“ring of pearls” appearance)

Serum testosterone, dehydroepiandrosterone (DHEA), and androstenedione are elevated. FSH levels are normal or low.

Fasting blood glucose and 2-hour oral glucose tolerance test (OGTT) are abnormal.

Answer 135

A

First line treatment* = Oral contraceptives (to suppress ovaries)
Second line treatment* = Medroxyprogesterone (Provera) to induce menses

Spironolactone for hirsutism

Metformin to induce ovulation

Weight Loss to reduce androgen and insulin levels

medroxyprogesterone tablets (Provera) 5 to 10 mg daily for 10 to 14 days (repeat every 1–2 months to induce menses).

Answer 136

A

Coronary heart disease (CHD)

Type 2 diabetes mellitus and metabolic syndrome

Cancer of the breast and endometrium

Central obesity

Infertility

Nonalcoholic fatty liver disease

Answer 137

A

Screen women aged > 65 years for osteoporosis

Answer 138

A

Osteopenia and osteoporosis are caused by a gradual loss of bone density secondary to estrogen deficiency and other metabolic disorders.

Most common in older women (White or Asian descent) who are thin with small body frames, especially if positive family history.

Treat postmenopausal women (or men aged 50 years or older) who have osteoporosis (T-score −2.5 or less) or history of hip or vertebral fracture.

Answer 139

A

Patients on chronic steroids (e.g., severe asthma, autoimmune disorders) are at high risk for glucocorticoid-induced osteoporosis; rule out osteoporosis in older women (or men) on chronic steroids, especially if accompanied by other risk factors (lower testosterone, small frame, thin, White, or Asian).
Patients who have anorexia nervosa and bulimia
Long-term use of proton-pump inhibitors (PPIs), such as omeprazole (Prilosec)

Answer 140

A

Gastric bypass, celiac disease, hyperthyroidism, ankylosing spondylitis, rheumatoid arthritis (RA), and others
The “female athlete triad” is a combination of low weight with history of amenorrhea or menstrual dysfunction and low bone density; at higher risk for osteoporosis

Answer 141

A

Low calcium intake (low intake of dairy), vitamin D deficiency, inadequate physical activity

Alcohol consumption (three or more drinks per day), high caffeine intake

Smoking (active or passive)

Answer 142

A

DEXA of hip and spine

Osteopenia T-score = -1.5-2.4

Osteoporosis T-Score = -2.5 or lower standard deviations (SD) at lumbar spine, femoral neck, or total hip region

Pharm therapy if osteoporosis or postmenopausal with hx of fragility fracture/hip fracture/recent fracture

Repeat DEXA in 2 years after treatment

Answer 143

A

Weight-bearing exercises 30 minutes three times per week

Weight-bearing exercises are walking, jogging, aerobic dance classes, most sports, yoga, tai chi.
Swimming and biking are not considered a weight-bearing exercise (but good for severe arthritis).
Isometric exercises are not considered a weight-bearing type of exercise.

Answer 144

A

Calcium with vitamin D 1,200 mg/day with vitamin D 800 IU daily

Smoking cessation if a smoker (smoking cigarettes accelerates bone loss)

FRAX (Fracture Risk Assessment Tool) will give the 10-year probability of hip fracture and major osteoporotic fracture (spine/forearm/shoulder). Website is https://www.sheffield.ac.uk/FRAX/.

Answer 145

A

First line = Bisphosphonates

Selective Estrogen Receptor Modulator Class (Raloxifene, Tamoxifen)*
Parathyroid Hormone Analog*
Other: Miacalcin and Calcitriol*

Answer 146

A

First-line drugs for treating postmenopausal osteoporosis, glucocorticoid-induced osteoporosis (women and men), and osteoporosis in men

Potent esophageal irritant (advise patients to report sore throat, dysphagia, midsternal pain); may cause esophagitis, esophageal perforation, gastric ulcers, reactivation/bleeding peptic ulcer disease (PUD)

Increases BMD and decreases bone resorption

Answer 147

A

Fosamax (alendronate) PO (by mouth) daily or weekly

Actonel (risedronate) PO daily, weekly, or monthly

Take immediately upon awakening in morning with full glass (6–8 ounces) of plain water (do not use mineral water).
Take tablets sitting or standing and wait at least 30 minutes before lying down.
Do not crush, split, or chew tablets; swallow the tablets whole.
Never take these drugs with other medications, juice, coffee, antacids, vitamins.
Will cause severe esophagitis or esophageal perforation if lodged in the esophagus.

Answer 148

A

Consider prophylaxis for high-risk postmenopausal women with osteopenia.

Repeat DEXA after 2 years of therapy.

Contraindications: Inability to sit upright, esophageal motility disorders, history of PUD or history of gastrointestinal [GI] bleeding, chronic kidney disease, certain types of bariatric surgery (e.g., Roux-en-Y gastric bypass)

Osteonecrosis of the jaw (mandible or maxilla) more likely if on intravenous or intramuscular bisphosphonates; patient complains of jaw heaviness, pain, swelling, and loose teeth.

Answer 149

A

Raloxifene (Evista) is category X drug.

Does not stimulate endometrium or breast tissue, since it blocks ERs.

Approved for use in postmenopausal women with osteoporosis who are at higher risk for breast cancer

Do not use to treat menopausal symptoms (aggravates hot flashes).

Black box warning: Increases risk of DVT, pulmonary embolism, and endometrial/uterine cancers; increased risk of death from stroke (postmenopausal women with history of heart disease)

Answer 150

A

These drugs reduce risk of breast cancer (if taken long term up to 5 years).

Selective estrogen receptor modulators (SERMs) are an option for patients who cannot tolerate or have contraindications to bisphosphonates.

Used as adjunct treatment for estrogen-receptor-positive breast cancers

Answer 151

A

Tamoxifen (Nolvadex) is a category X drug.

Used for treatment of breast cancer that is hormone-receptor positive and for prophylaxis in women at high risk for breast cancer; can be taken up to 5 years.

Increased risk of DVT, endometrial cancer, strokes, and pulmonary emboli

Common side effects (SERMs): Causes hot flashes, white or brownish vaginal discharge, weight gain or loss

Answer 152

A

Teriparatide (Forteo) injection is recombinant human parathyroid hormone (PHT) for treatment of osteoporosis; it comes as a prefilled injector.

Warning: It increased the incidence of osteosarcoma in rats.

Answer 153

A

Miacalcin:* Calcitonin salmon, derived from salmon; weak antifracture efficacy compared with bisphosphonates and PTH.
Calcitriol:* Vitamin D analog; must be on a low-calcium diet; monitor patient for hypercalcemia, hypercalciuria, and renal insufficiency; may be effective in preventing glucocorticoid and posttransplant-related bone loss.

Answer 154

A

Average age of menopause for women in the United States is 51 years.

The Women’s Health Initiative (WHI) showed that combined estrogen–progestin replacement therapy (ERT) increased the risk of stroke, heart disease, VTE, breast cancer, and pulmonary embolism.

Answer 155

A

The USPSTF does not recommend for use of combined estrogen–progestin or unopposed estrogen for prevention of chronic conditions (heart disease, osteoporosis).

But the advice does not apply to women who want hormone therapy for relief of menopausal symptoms.

Experts recommend duration of therapy of <5 years because of increased risk of breast cancer.

Many experts consider it safe for healthy women within 10 years of menopause (younger than 60 years) with no contraindications for estrogen.

Women who have a uterus need both estrogen and progesterone (decreases risk of endometrial cancer); use unopposed estrogen for women with hysterectomy.

Answer 156

A

Estrogen can alleviate dyspareunia and vaginal/urethral atrophy.

Estrogen increases the risk of developing or exacerbating systemic lupus erythematosus (birth control pills are contraindicated in women with lupus).

Answer 157

A

Ovarian cancer is the fifth most common cancer in women in the United States. It is seldom diagnosed during the early stages of the disease.

Most often, an older woman complains of vague symptoms, such as abdominal bloating and discomfort, low-back pain, pelvic pain, urinary frequency, and constipation (frequently blamed on benign conditions) for certain women with BRCA1 and BRCA2 mutations.

By the time the cancer is diagnosed, it has almost always metastasized. Symptoms in patients with metastatic disease depend on area affected and may include bone pain, abdominal pain, headache, blurred vision, and others.

Answer 158

A

USPSTF does not recommend routine screening for ovarian cancer in the general population (Grade D)

High-risk women with suspected BRCA 1/2 mutations should be referred for genetic counseling and testing.

If ovarian cancer screening is done, a transvaginal ultrasound with serum cancer antigen (CA-125) is ordered.

The screening starts at age 30 years (or 5–10 years before earliest age of first diagnosis of ovarian cancer in a family member).

Answer 159

A

Some experts recommend risk-reducing Bilateral Salpingo-Oophorectomy (BSO) between ages 35 and 40 years (after childbearing is complete) for certain women with BRCA1 and BRCA2 mutations. This procedure has a significant effect in reducing ovarian cancer risk in this population

Answer 160

A

Bacterial Vaginosis

Candidal Vaginitis

Trichomonal Vaginitis(Trichomoniasis)

Atrophic Vaginitis

Answer 161

A

“Fish-like” vaginal odor; profuse milk-like discharge that coats the vaginal vault

Not itchy/vulva not red; overgrowth of anaerobes

Answer 162

A

Clue cells

NOWBCs

Whiff test = positive

pH > 4.5

Answer 163

A

Cheesy or curd-like white discharge

Vulvovagina red/irritated

Labs = Pseudohyphae*, spores, numerous WBCs

Answer 164

A

“Strawberry cervix”

Bubbly discharge

Vulvovagina red/irritated

Labs = Mobile protozoa with flagella, numerous WBCS

Answer 165

A

Scant to no discharge

Fewer rugae, vaginal color pale; dyspareunia (painful intercourse); may bleed slightly during speculum examination (if not on hormones)

Pap test =* Atrophic changes
FSH and LH levels =* Elevated
low estrogen causes high FSH and LH postmenopause*

Answer 166

A

Caused by an overgrowth of anaerobic bacteria in the vagina.

Risk factors include sexual activity, new or multiple sex partners, and douching.

Not an STD; therefore, sexual partner does not need treatment.

Treatment is especially important for pregnant women. Pregnant women with BV are at higher risk for premature labor or low birth-weight babies.

Answer 167

A

Sexually active female complains of an unpleasant and fish-like vaginal odor that is worse after intercourse (if no condom is used). Vaginal discharge is copious and has milk-like consistency. Speculum examination reveals off-white to light-gray discharge coating the vaginal walls. There is no vulvar or vaginal redness or irritation (vaginal anaerobic bacteria do not cause inflammation).

Answer 168

A

Findings:* Clue cells and very few white blood cells (WBCs). May see Mobiluncus bacteria (82%), a gram-negative anaerobic rod-shaped bacteria.
Clue cells:* Made up of squamous epithelial cells with a large amount of bacteria coating the surface that obliterates the edges of the squamous epithelial cells

Answer 169

A

Whiff Test

Apply one drop of KOH to a cotton swab that is soaked with vaginal discharge.

Positive: A strong “fishy” odor is released.

Vaginal pH

Alkaline vaginal pH >4.5. Normal vaginal pH is between 4.0 and 4.5 (acidic).

Answer 170

A

Metronidazole (Flagyl)* BID x 7 days

Alternative: Metronidazole vaginal gel one applicator at bedtime for 5 days.

Watch for disulfiram (Antabuse) effect if combined with alcohol (e.g., severe nausea, headache).

Prescribe clindamycin (Cleocin) cream at HS × 7 days (oil based).

Oil-based creams can weaken condoms.

Sex partners: Treatment is not recommended by the CDC, because BV is not an STD.

Abstain from sexual intercourse or use condoms until treatment is done (increases cure rate by 50%).

Answer 171

A

Overgrowth of Candida albicans yeast in the vulva/vagina. Considered normal vaginal flora but can also be pathogenic. Diabetics, as well as those who are HIV positive, on antibiotics (e.g., amoxicillin), or have any type of immunosuppression, are at higher risk. (The male penis can also be infected [balanitis].) Asymptomatic women and sexual partners do not need treatment.

Answer 172

A

Adult female presents with complaints of white cheese-like (“curd-like”) vaginal discharge accompanied by severe vulvovaginal pruritus, swelling, and redness (inflammatory reaction). May complain of external pruritus of the vulva and vagina.

Answer 173

A

Wet smear microscopy

Swipe cotton swab with vaginal discharge in the middle of a glass slide.
Add a few drops of normal saline (to the discharge).
Cover the sample with a cover slip and examine it under the microscope (set it at high power).

Findings: Pseudohyphae* and spores* with a large number of WBCs

Answer 174

A

Antifungal - AZOLES

OTC:* Miconazole (Monistat), clotrimazole (Gyne-Lotrimin) × 7 days (OTC)
Prescription:* Fluconazole (Diflucan) 150 mg tablet × 1 dose, terconazole (Terazol-3) vaginal cream/suppository.
Severe symptoms or immunocompromised: Fluconazole (Diflucan) 150 mg in two sequential doses given 3 days apart. Do not use oral fluconazole in pregnancy, since it is teratogenic.
Lactobacillus (oral or vaginal) does not prevent postantibiotic vulvovaginitis.

Answer 175

A

Trichomonas vaginalis is a unicellular protozoan parasite with flagella that infects genitourinary tissue (both males and females). Infection causes inflammation (pruritus, burning, and irritation) of vagina/urethra. The most common sites are the urethra (dysuria) and vagina. It can also infect the paraurethral glands, Bartholin glands, cervix, bladder, and prostate.

Answer 176

A

Adult female complains of very pruritic, reddened vulvovaginal area. May complain of dysuria. Copious grayish-green and bubbly vaginal discharge. Male partners may have dysuria and frequency (urethritis) or may be asymptomatic.

Answer 177

A

“Strawberry cervix” from small points of bleeding on cervical surface (punctate hemorrhages)

Swollen and reddened vulvar and vaginal area; vaginal pH >5.0

Dysuria (burning) with urination, copious foamy purulent vaginal discharge

Answer 178

A

Microscopy (use low power): Mobile unicellular organisms with flagella (flagellates) and a large amount of WBCs. Trichomonads will remain motile for only 10 to 20 minutes after collection.

Nucleic acid amplification test (NAAT) for T. vaginalis (vaginal samples better than first-voided urine)

Answer 179

A

Metronidazole (Flagyl) 2 g PO × 1 dose or 500 mg BID × 7 days

Tinidazole 2 g PO × 1 dose

Treat sexual partner because trichomoniasis is considered an STI; avoid sex until both partners complete treatment.

Answer 180

A

Chronic lack of estrogen in estrogen-dependent tissue of the urogenital tract; results in atrophic changes in the vulva and vagina of menopausal women.

Estrogen is the most effective treatment for moderate-to-severe vaginal atrophy. Low-dosed topical estrogen therapy is preferred because of low systemic absorption.

Answer 181

A

Menopausal female complains of vaginal dryness, itching, and pain with sexual intercourse (dyspareunia). Some may have vulvar or vaginal bleeding (fissures) after intercourse. Complains of a great deal of discomfort with speculum examinations (e.g., Pap tests). Pap test result is “abnormal” secondary to atrophic changes. Worsens over time as she gets older. More than half of women do not report symptoms.

Answer 182

A

Atrophic labia with decreased rugae; vulva or vagina may have fissures.

Dry, pale pink color to vagina

Answer 183

A

Nonhormonal vaginal moisturizers and lubricants.

Vaginal moisturizers (e.g., Replens) are intended for use 2 to 3 days per week routinely.

Lubricants can be water based (e.g., K-Y Jelly), silicone based, or oil based (can break down latex condoms).

Answer 184

A

Topical estrogen

It comes in several forms (cream, tablet, capsule, or vaginal ring). Progesterone supplementation is required (if intact uterus) if using long term to decrease risk of endometrial hyperplasia.

Tablet or capsule vaginal estradiol inserts:* 4 mcg (Imvexxy), 10 mcg (Vagifem, Yuvafem, Imvexxy). Insert into vagina daily for 2 weeks, then use weekly thereafter.
Ring form of estradiol:* Estring designed to release 7.5 mcg of estradiol in the vagina daily. Effective for 90 days only, then replace with new ring.

Answer 185

A

If Pap shows atrophic smear, it needs to be repeated in 3 months because atrophic smears are difficult to analyze and can be misinterpreted.

Estrogen can change vaginal cytology back to premenopausal state.

Can be used for 2 to 3 months only, then repeat Pap, or it can be used for longer periods for consistent relief of moderate-to-severe vaginal symptoms.

Answer 186

A

Lichen Sclerosus

Previously known as lichen sclerosus et atrophicus

Answer 187

A

Early skin lesion appears as flat-topped and slightly scaly hypopigmented, white, or mildly red polygonal papules that may coalesce to form larger plaques with peripheral erythema. Over time, when inflammation lessens, the lesion resembles cigarette paper (wrinkled appearance; Figure 1).

Answer 188

A

Endometriosis is an often painful disorder in which tissue similar to the tissue that normally lines the inside of your uterus — the endometrium — grows outside your uterus. Endometriosis most commonly involves your ovaries, fallopian tubes and the tissue lining your pelvis

One theory is that it is due to retrograde menstruation where endometrial cells leave the uterus and start growing on the ovaries, pelvis, uterine ligaments, bowel, bladder, or thorax.

The lesions are stimulated by estrogen (just like the endometrium where the cells originated).

Can result in infertility (25%–35% infertile women have it).

Answer 189

A

Reproductive-aged woman between 25 and 35 years of age with history of moderate-to-severe pelvic pain during menses, heavy cramping, and dyspareunia. The dysmenorrhea may start approximately 1 to 2 days before menses, during menses, or a few days after menses. Ectopic endometrial tissue (endometriomas) can grow on the pelvis, ovary, peritoneum, bladder, bowel, abdominal wall, or thorax.

Answer 190

A

Physical exam findings that suggest endometriosis include nodules in the posterior fornix, adnexal masses, and pain with manipulation of the pelvic organs. Pelvic exam may be normal. Large lesions may show up in pelvic/intravaginal ultrasound. Refer to gynecologist.

Answer 191

A

Estrogen/progesterone contraceptives* (birth control pills, patch, or vaginal ring) or progestin-only therapy* will suppress the ovary and prevent ovulation and hormonal levels.

NSAIDs for dysmenorrhea pain.

Gonadotropin-releasing hormone (GnRH) analogues (e.g., leuprolide/Lupron Depot) and aromatase inhibitors for severe cases (anastrozole/Arimidex).

Answer 192

A

Postmenopausal women’s breasts will feel softer to palpation with less volume.

Know female body changes in menopause. If palpable ovary (abnormal), order an intravaginal ultrasound.

Know physical exam findings (hard irregular mass that is not mobile) and follow-up for breast cancer.

Mefenamic acid (Ponstel) is an NSAID that is very effective for menstrual pain.

Know how to take bisphosphonates (e.g., Fosamax, Actonel) and their contraindications = can cause esophagitis (if gets lodged) so take sitting up/standing, take asap in morning with full glass of water, swallow whole do not crush/chew, do not take with any other drugs

Answer 193

A

Know the bone density score for osteoporosis (T-score of >−2.5 SD) and for osteopenia (T-score of −1.5 to −2.4 SD).

There will be questions on all the types of vaginitis (BV, trichomonal, candidal, atrophic vaginitis). The questions range from diagnosis, workup, and lab tests to treatment.

Become familiar with BV. “Clue cells” are squamous epithelial cells that have blurred edges due to the large number of bacteria on the cell’s surface.

Answer 194

A

Should be screened for underlying glucose metabolism disorders and diabetes.

Brainscape's Knowledge GenomeTM

Female Reproductive Flashcards

Brainscape's Knowledge Genome^TM