Female Reproductive System and Breast III

Question 1

What is the likely diagnosis in a women age > 30 with a well-circumscribed, soft, mobile breast mass?

Answer 1

Breast cyst (benign)

breast cysts are soft and most common after age 30, versus a fibroadenoma, which is hard and most common before age 30

Question 2

What is the likely diagnosis in a young sexually active woman that presents with multiple papular lesions around the vagina? Some lesions bleed with manipulation.

Answer 2

Condylomata acuminata (genital warts)

due to infection with HPV (strains 6 & 11); in contrast, condyloma lata (secondary syphilis) typically causes flat, velvety lesions

Question 3

What is the likely diagnosis in a young woman that presents with a soft, mobile, well-circumscribed mass at the base of the labia majora?

Answer 3

Bartholin duct cysts

common in women age

Question 4

What is the likely diagnosis in a young woman that presents with chronic pelvic pain, especially with exercise, and a homogenous cystic ovarian mass on ultrasound?

Answer 4

Ovarian endometrioma (secondary to endometriosis)

endometriomas are also associated with infertility, which improves with surgical resection of the endometrioma

Question 5

What is the likely diagnosis in a young, sexually active woman that presents with fever, sore throat, and lower abdominal pain? Physical exam reveals erythematous tonsils without exudates and non-tender cervical lymphadenopathy.

Answer 5

Gonococcal pharyngitis with pelvic inflammatory disease

versus Epstein-Barr virus, which typically causes tender cervical lymphadenopathy and exudative pharyngitis

Question 6

What is the likely diagnosis in an adolescent girl that presents with amenorrhea and cyclic lower abdominal pain with a bulging vaginal mass on physical exam?

Answer 6

Imperforate hymen

the bulging vaginal mass is a hematocolpos

Question 7

What is the likely diagnosis in an adolescent girl with delayed puberty, clitoromegaly, and osteoporosis? Laboratory exam reveals undetectable estrogen and elevated testosterone levels.

Answer 7

Aromatase deficiency

Question 8

What is the likely diagnosis in an afebrile middle-aged woman that presents with unilateral breast warmth, erythema, and swelling refractory to antibiotics?

Answer 8

Inflammatory breast carcinoma

lack of fever and no response to antibiotics help distinguish inflammatory breast cancer from mastitis; other distinguishing features include axillary lymphadenopathy and a peau d’orange appearance

Question 9

What is the most accurate way to determine estimated gestational age?

Answer 9

ultrasound crown-rump measurement in the first trimester

last menstrual period may be used to estimate gestational age if the patient has normal menses and a reliable LMP

Question 10

What is the most common gynecologic malignancy in the U.S?

Answer 10

Endometrial cancer

Question 11

What is the most common side effect of combined oral contraceptives?

Answer 11

Breakthrough bleeding

other side effects include hypertension, increased risk of venous thromboembolism, and increased risk of cervical cancer

Question 12

What is the most common side effect of tamoxifen?

Answer 12

Hot flashes (80%)

due to anti-estrogenic activity in the CNS which causes thermoregulatory dysfunction in the anterior hypothalamus

Question 13

What is the most effective emergency contraceptive?

Answer 13

Copper intrauterine device (IUD)

contraindicated if the patient has acute cervicitis or PID; emergency contraceptive pills are less effective

Question 14

What is the next step in diagnosis for a middle-aged woman that presents with “night sweats”, insomnia, and irregular menses? Pregnancy test is negative.

Answer 14

Measure serum TSH and FSH

these symptoms could be due to menopause or hyperthyroidism, thus both should be evaluated

Question 15

What is the next step in diagnosis for a woman that presents with stress urinary incontinence with an irregularly enlarged uterus on physical exam?

Answer 15

Pelvic ultrasound

SUI due to direct pressure of fibroids on the bladder

Question 16

What is the next step in management for a 14-year-old girl that presents with lack of menses? Breast and pubic hair are tanner stage 3.

Answer 16

Reassurance and re-evaluation

primary amenorrhea is not diagnosed until age > 15 with normal secondary sex characteristics (age > 13 without)

Question 17

What is the next step in management for a 45-year-old woman that presents with insomnia, fatigue, weight gain, ameorrhea, and an enlarged uterus?

Answer 17

measure hCG level

all women of reproductive age (~12 to 49) with amenorrhea and signs of pregnancy should be evaluated with an hCG level

Question 18

What is the next step in management for a hemodynamically stable young woman with RLQ pain and a beta-hCG level of 1000 IU/L? Transvaginal ultrasound reveals no intrauterine or extrauterine pregnancy.

Answer 18

Repeat serum beta-hCG in 2 days

in a viable pregnancy, beta-hCG levels should double every 2 days (ectopic and non-viable pregnancies are associated with a slower rise); once beta-hCG is > 1500 IU/L, a TVUS should be repeated

Question 19

What is the next step in management for a postmenopausal woman with a suspected granulosa cell tumor that presents with vaginal bleeding and a thickened endometrial stripe on ultrasound?

Answer 19

Endometrial biopsy

postmenopausal bleeding and thickened endometrium are concerning for endometrial hyperplasia/cancer; must be evaluated with endometrial biopsy, which is the gold standard test to rule out endometrial malignancy

Question 20

What is the next step in management for a postmenopausal woman with an incidentally discovered ovarian cyst on ultrasound?

Answer 20

Measure CA-125 levels

an elevated CA-125 level in a postmenopausal patient is suspicious for malignancy, even if the ultrasound findings seem benign

Question 21

What is the next step in management for a pregnant patient with high-grade squamous intraepithelial lesion discovered on Pap testing?

Answer 21

Immediate colposcopy +/- biopsy (safe during pregnancy)

cervical excision is needed if invasive cancer is found; if the transformation zone (squamocolumnar junction) is not visualized during colposcopy, an endocervical curettage may be deferred until after pregnancy

Question 22

What is the next step in management for a premenopausal woman with a palpable adnexal mass on physical exam?

Answer 22

Pelvic ultrasound

CA-125 levels are not as useful for initial evaluation of an ovarian mass in premenopausal women (in postmenopausal women, pelvic ultrasound and CA-125 are part of the initial workup)

Question 23

What is the next step in management for a woman that presents with a thin, white plaque suspicious for lichen sclerosus?

Answer 23

Vulvar punch biopsy

necessary to confirm the diagnosis and rule out vulvar squamous cell carcinoma

Question 24

What is the next step in management for a woman with bilateral, milky nipple discharge that is guaiac negative?

Answer 24

Serum prolactin, TSH, and pregnancy test

consider brain MRI in patients with elevated prolactin or signs of pituitary mass

Question 25

What is the next step in management for a young woman that presents with diffuse periumbilical abdominal pain that then localizes to the right lower quadrant? Her LMP was one month ago.

Answer 25

Pregnancy test should be administered to any woman of childbearing age before performing any diagnostic tests (e.g. X-ray, CT scan)

Question 26

What is the next step in management for an afebrile woman that experiences relief of symptoms following aspiration of clear fluid from a simple breast cyst?

Answer 26

Repeat breast examination in 2 - 4 months cystic fluid can reaccumulate; if no signs of recurrence, annual screening can be resumed

Question 27

What is the next step in management for an elderly woman that presents with bloody, malodorous discharge and an irregular vaginal lesion?

Answer 27

Biopsy of the lesion this patient likely has vaginal sqaumous cell carcinoma

Question 28

What is the preferred adjuvant treatment for ER+ breast cancer in postmenopausal women?

Answer 28

Aromatase inhibitors (e.g. anastrozole)

Question 29

What is the preferred adjuvant treatment for ER+ breast cancer in premenopausal women?

Answer 29

Tamoxifen

Question 30

What is the preferred initial imaging modality for suspected gynecological tumors?

Answer 30

Pelvic ultrasound high sensitivity for diagnosing uterine fibroids and ovarian pathology

Question 31

What is the preferred method of contraception for patients with breast cancer?

Answer 31

Copper IUD all hormone-containing contraceptives are contraindicated in patients with breast cancer (both estrogen and progesterone may have a proliferative effect on breast tissue)

Question 32

What is the preferred test to diagnose Haemophilus ducreyi infection (chancroid)?

Answer 32

Bacterial culture

Question 33

What is the preferred test to diagnose HSV infection?

Answer 33

PCR testing more sensitive and specific than viral culture and Tzanck smear

Question 34

What is the recommended contraceptive for a woman with a history of anemia and medication non-compliance?

Answer 34

Levonorgestrel IUD typically causes amenorrhea, which is beneficial in patients with anemia (versus the copper IUD, which can cause heavy menstrual bleeding); less common side effects include mood changes, breast tenderness, and headache

Question 35

What is the recommended follow-up following removal of a breast lesion found to be fat necrosis?

Answer 35

Routine follow-up

Question 36

What is the recommended management for a patient with suspected endometriosis refractory to NSAIDs and OCPs?

Answer 36

Laparoscopy allows for direct visualization, biopsy, and removal of endometriotic lesions

Question 37

What is the recommended management for an adolescent that presents with fever and leukocytosis secondary to pelvic inflammatory disease?

Answer 37

Inpatient broad-spectrum antibiotic therapy hospitalization is recommended for those with severe presentation (e.g. fever, leukocytosis) and those with a higher risk of noncompliance (e.g. adolescents)

Question 38

What is the recommended screening for asymptomatic patients at average-risk of ovarian cancer?

Answer 38

No screening recommended

Question 39

What is the recommended treatment for a breastfeeding woman with a suspected breast abscess?

Answer 39

needle aspiration, antibiotics, and continued feeding common antibiotics for mastitis include dicloxacillin and cephalexin; incision and drainage is typically reserved for abscesses that are not responsive to needle aspiration and antibiotics

Question 40

What is the recommended treatment for a breastfeeding woman with acute mastitis?

Answer 40

analgesics, breastfeeding, and antibiotics ## Footnote e.g. dicloxacillin or cephalexin; if high suspicion for MRSA, clindamycin, TMP-SMX, or vancomycin may be needed

Question 41

What is the recommended treatment for a hemodynamically stable patient with a ruptured ovarian cyst?

Answer 41

Supportive (e.g. analgesics) hemodynamically unstable patients require urgent surgical intervention

Question 42

What is the recommended treatment for a patient with a painless genital ulcer and bilateral inguinal lymphadenopathy? Serum RPR is negative.

Answer 42

Empiric penicillin treatment patients with negative initial serologies and strong clinical evidence of primary syphilis should be treated empirically (non-treponemal testing has a high false negative rate in early infection)

Question 43

What is the recommended treatment for a patient with ovarian torsion?

Answer 43

Urgent surgical detorsion and cystectomy

Question 44

What is the recommended treatment for a symptomatic Bartholin duct cyst?

Answer 44

Incision and drainage, followed by Word catheter placement

Question 45

What is the recommended treatment for advanced ovarian cancer?

Answer 45

Exploratory laparotomy followed by chemotherapy (e.g. cisplatin + paclitaxel) the ovaries, uterus, omentum, and any visible cancerous lesion are removed and pelvic/aortic lymph nodes are dissected

Question 46

What is the recommended treatment for an asymptomatic Bartholin duct cyst?

Answer 46

Observation spontaneous drainage and resolution may occur; symptomatic cysts require incision & drainage, followed by placement of a Word catheter

Question 47

What is the recommended treatment for atrophic vaginitis refractory to vaginal moisturizer and lubricant?

Answer 47

Topical vaginal estrogen

Question 48

What is the recommended treatment for bacterial vaginosis (Gardnerella infection)?

Answer 48

metronidazole or clindamycin

Question 49

What is the recommended treatment for Candida vaginitis?

Answer 49

Oral fluconazole

Question 50

What is the recommended treatment for confirmed chlamydia infection?

Answer 50

Azithromycin

Question 51

What is the recommended treatment for confirmed gonorrhea infection?

Answer 51

azithromycin + ceftriaxone

Question 52

What is the recommended treatment for endometrial carcinoma?

Answer 52

Hysterectomy +/- chemo- or radiation therapy endometrial hyperplasia may be managed with progestin therapy or hysterectomy, depending on if the patient desires future children

Question 53

What is the recommended treatment for imperforate hymen?

Answer 53

Incision and drainage

Question 54

What is the recommended treatment for non-pregnant women age \> 25 with grade 3 cervical intraepithelial neoplasia (CIN)?

Answer 54

Cervical conization via cold knife conization or loop electrosurgical excision procedure (LEEP)

Question 55

What is the recommended treatment for symptomatic pelvic organ prolapse refractory to lifestyle modifications?

Answer 55

pessary or surgical management conservate management with pessary placement is appropriate for poor surgical candidates

Question 56

What is the recommended treatment for trichomoniasis (Trichomonas infection)?

Answer 56

metronidazole for both the patient and the sexual partner

Question 57

What is typically the first sign of puberty in girls?

Answer 57

Breast development (thelarche) remembered with the mnemonic "boobs, pubes, grow, flow"

Question 58

What microscopy finding is characteristic of bacterial vaginosis (Gardnerella infection)?

Answer 58

Clue cells (epithelial cells coated with bacteria)

Question 59

What microscopy finding is characteristic of Candida vaginitis?

Answer 59

pseudohyphae and/or budding yeast

Question 60

What microscopy finding is characteristic of trichomoniasis (Trichomonas infection)?

Answer 60

Motile protozoa

Question 61

What ovarian tumor is associated with estrogen secretion?

Answer 61

Granulosa cell tumor

Question 62

What pelvic surgery complication is characterized by continuous involuntary loss of urine through the vagina in the absence of other urinary symptoms?

Answer 62

Vesicovaginal fistula may present within a month after surgery; dye tests and/or cystourethroscopy can help identify small fistulas not seen on visual inspection

Question 63

What pharmacologic agent may be used in the treatment of overflow incontinence?

Answer 63

Cholinergic agonists (e.g. bethanecol)

Question 64

What pharmacologic agent may be used in the treatment of urgency incontinence?

Answer 64

Anti-muscarinic agents (e.g. oxybutynin) first-line treatment should consist of lifestyle modifications and/or bladder training; a newer agent, mirabegron (beta3-adrenergic agonist) may be offered to patients who cannot take antimuscarinic drugs

Question 65

What race/ethnicity is associated with the highest risk of breast cancer?

Answer 65

White race

Question 66

What serum marker is characteristically elevated in choriocarcinoma?

Answer 66

beta-hCG

Question 67

What serum tumor marker is useful for monitoring treatment response and recurrence of ovarian neoplasms?

Answer 67

CA-125 may also be used as part of the initial workup for postmenopausal women with suspected ovarian cancer

Question 68

What ultrasound finding is typical for an ovarian endometrioma?

Answer 68

Homogenous cystic mass

Question 69

Which cause(s) of vaginitis are associated with a normal pH (3.4 - 4.5)?

Answer 69

candida vaginitis

Question 70

Which cause(s) of vaginitis are associated with an elevated pH (\> 4.5)?

Answer 70

bacterial vaginosis and trichomoniasis

Question 71

Which genital infection is characterized by a single painless ulcer (chancre) often with non-tender bilateral lymphadenopathy?

Answer 71

Treponema pallidum (primary syphilis)

Question 72

Which genital infection is characterized by extensive, painless ulcers without lymphadenopathy?

Answer 72

Klebsiella granulomatis (granuloma inguinale) primarily seen in India, Guyana, and New Guinea (rare in the U.S)

Question 73

Which genital infection is characterized by small, painless ulcers that can progress to painful, fluctuant adenitis (buboes)?

Answer 73

Chlamydia trachomatis L1-L3 (lymphogranuloma venereum)

Question 74

Which genital infection is characterized by tender, large ulcers with a grayish exudate and severe lymphadenopathy?

Answer 74

Haemophilus ducreyi (chancroid)

Question 75

Which genital infection is characterized by tender, small ulcers with an erythematous base and mild lymphadenopathy?

Answer 75

Herpes simplex virus

Question 76

Which selective estrogen receptor modulator (SERM) is preferred for treatment of postmenopausal osteoporosis?

Answer 76

Raloxifene antagonist of estrogen in both breast and endometrium therefore no associated cancer risk

Question 77

[...] consumption is a dose-dependent risk factor for breast cancer.

Answer 77

**Alcohol** consumption is a dose-dependent risk factor for breast cancer.

Question 78

[...] is transient mid-cycle ovulatory pain that may mimic appendicitis.

Answer 78

**Mittelschmerz** is transient mid-cycle ovulatory pain that may mimic appendicitis. e.g. on day 10-14 (corresponding with the time of ovulation)

Question 79

Polycystic ovarian syndrome often presents in young, obese women with [...] and symptoms of [...] excess.

Answer 79

Polycystic ovarian syndrome often presents in young, obese women with **oligo- or amenorrhea** and symptoms of **androgen** excess. laboratory findings include normal/elevated testosterone and estrogen levels with an imbalance of LH/FSH (often \> 2:1 ratio of LH:FSH)

Question 80

[...] often presents in young, obese women with oligo- or amenorrhea and symptoms of androgen excess.

Answer 80

**Polycystic ovarian syndrome** often presents in young, obese women with oligo- or amenorrhea and symptoms of androgen excess. laboratory findings include normal/elevated testosterone and estrogen levels with an imbalance of LH/FSH (often \> 2:1 ratio of LH:FSH)