Gynecology Flashcards
(127 cards)
1
Q
Autosomal recessive disease, adrenal insufficiency and genital ambiguity in early infancy in females
A
Classical CAH
2
Q
- Less severe form of the classical disorder - 20 to 50 percent 21-hydroxylase enzyme activity compared with 0 to 2 percent in classical - No Salt wasting - androgen excess - adolescent females present with hirsutism, oligomenorrheaa, acne
A
Nonclassic CAH
3
Q
Upper body obesity, hypertension, striae, bruising, hyperglycemia: which feature of Cushing syndrome is missing?
A
Proximal myopathy
4
Q
Management of asymptomatic, unilateral cyst measuring less than 10 cm in pre-menopausal woman
A
Observation: repeat exam and ultrasound in 3 months
5
Q
Ovarian cyst features which are concerning
A
septation, mix of cystic and solid components, thickened walls
6
Q
Significance CA 125 in pre-menopausal woman with ovarian cyst
A
Frequently false positive in pre-menopausal women
7
Q
Role of aspiration of fluid from ovarian cyst
A
Not advisable because of inefficacy (re-accumulation), malignant seeding
8
Q
Measured parameter on gynaecological ultrasound and MRI. Appearance and thickness of the endometrium depends on phase of cycle; menopausal status
A
Endometrial stripe
9
Q
Post-menopausal bleeding causes
A
vaginal/endometrial atrophy polyp hyperplasia cervical/endometrial cancer
10
Q
Endometrial stripe is less than 4 mm transvaginal ultrasound. Negative predictive value for endometrial cancer approaches:
A
99%
11
Q
Progesterone challenge test
A
Evaluation of amenorrhea in pre-menopausal women
12
Q
Estrogen status over time can be assessed with a _____ Withdrawal bleeding confirms endogenous estrogen exposure. Absence of bleeding can be due to either hypoestrogenism or an outflow tract disorder.
A
progestin withdrawal test (medroxyprogesterone 10 mg for 10 days)
13
Q
absence of menses for more than three months in girls or women who previously had regular menstrual cycles or six months in girls or women who previously had irregular menses
A
Secondary amenorrhea
14
Q
Initial laboratory testing for women with amenorrhea without hyperandrogenism should include:
A
PRL, FSH, TSH
15
Q
Work up of secondary amenorrhea + hirsuitism, acne
A
Testosterone + (PRL, FSH, TSH)
16
Q
Post-menopausal bleeding + greater than 4 mm stripe on vaginal ultrasound: mx?
A
Endometrial biopsy
17
Q
Dyschezia
A
Ineffective defecation, manifested as straining in the absence of constipatio
18
Q
Weight loss in pregnancy greater than _% due to morning sickness is concerning
A
5
19
Q
Hyperemesis gravidarum: criteria
A
- more than three episodes per day - severe dehydration, ketonuria, electrolyte abns. - weight loss more than 5%
20
Q
Vitamin _ should be prescribed as first-line treatment for nausea and vomiting of pregnancy.
A
Vitamin B6 should be prescribed as first-line treatment for nausea and vomiting of pregnancy.
21
Q
Physicians should consider prescribing doxylamine + vitamin B6 for treatment of nausea and vomiting of pregnancy because the combination reduces symptoms by 70%.
A
doxylamine
22
Q
Which anti-emetic for emesis in pregnancy?
A
- Doyxlamine + B6 - diphenhydramine or meclizine - Can add prochlorperazine, metoclopramide - Requiring hospitalization: ondansetron
23
Q
Etonogestrel implant
A
is a single-rod progestin contraceptive placed subdermally in the inner upper arm for long-acting (three years) reversible contraception
24
Q
Reversible, highly effective contraception
A
- IUD - Etonogestrel implant
25
Why bimanual examination before IUD insertion?
Active cervicitis is contra-indication
26
Most effective Rx for post-menopausal vasomotor symptoms
Estrogen
27
Rx: postpartum depression
SSRI
28
Rx: post-menopausal vasomotor symptoms + contraindication to estrogen
Paroexetine
29
Common vaginoses
Bacterial, candidiasis, Trichomoniasis
30
Thin white gray discharge + odor
Bacterial vaginosis
31
Thick white discharge, dysuria, burning + vaginal erythema
Candidiasis
32
Frothy discharge, + odor, pruritus, dysuria
Trichomonas
33
Amine odor after mixing KOH with discharge
Bacterial vaginosis
34
Cervicitis caused by N gonorrhea and C trachomatis. Typical symptoms
- Usually asymptomatic - Possible mucopurulent discharge +- bleeding from cervix
35
Cervicitis caused by N gonorrhea and C trachomatis.: Dx method?
Urine or Cervical or vaginal swab
36
The diagnostic test of choice for chlamydial infection of the genitourinary tract is
nucleic acid amplification testing (NAAT) of vaginal swabs for women or urine for men.
37
Three tests for women with recurrent miscarriage
- Antiphosopholipid antibody - Hysterosalpingogram (or sonohysterogram) - Parental karyotype
38
Why is a thrombophilia work up not needed for recurrent miscarriage?
- Associated with fetal death and miscarriage after 20 weeks
39
Inhaled steroid for pregnant women
Budesonide
40
Most appropriate first test for second trimester loss
Pathology and Karyotype fetus,
41
Penicillin allergy; pregnant woman with post-coital UTI. Rx:
Nitrofurantoin (Post-coital cephalexin for pen non-allergic)
42
Is cipro safe in pregnancy?
Best avoided: safety not established
43
Second semester TSH of 5 to 10; Mx
Measure thyroxine level
44
- member of the TGF-beta family - expressed by preantral and early antral follicles - level reflects the size of the primordial follicle pool, and may be the best marker of ovarian function
Anti-müllerian hormone
45
Why is cervical cancer in the absence of heterosexual activity extremely rare?
probably because sperm assist HPV infection of cervical epithelium
46
HPV serotypes 16, 18, 33, 35, and 39 confer are often associated with
high-grade neoplasia and invasive cancer
47
HPV serotypes 6, 11, and 42 are more often associated with
low-risk lesions and condylomata
48
Gardasil: Recommended for women younger than __ years of age, and is most effective in women never exposed to \_\_
26, HPV
49
[Cause of lesions anus](http://en.wikipedia.org/wiki/File:SOA-Condylomata-acuminata-around-anus.jpg)
HPV infection: Condylomata acuminata (verrucous-like lesions; Fig. 64-2)
50
Pap smear screening should be initiated in all women once ___ or at age __ years (whichever is first)
Pap smear screening should be initiated in all women once sexually active or at age 21 years (whichever is first)
51
**Cervical cancer screening**
Screen every _ years in women age 21 to 29 (more frequently in women with \_, immunosuppression, diethylstilbestrol exposure, history of CIN)
Women over the age of _ who have had at least __ negative smears can be screened every 3 years
Women at high risk (see preceding risk factors) require annual Pap smear screening \_\_\_.
In women who have undergone hysterectomy without a cervical remnant, Pap smears are no longer required unless the hysterectomy was performed for \_
Because cervical cancer develops slowly and risk factors decrease with age, it is reasonable to discontinue cervical cancer screening over age 65 in women who have three or more negative cytology test results in a row and no abnormal test results in the past 10 years
Screen every 2 years in women age 21 to 29 (more frequently in women with HIV, immunosuppression, diethylstilbestrol exposure, history of CIN, or other risk factors)
Women over the age of 30 who have had at least three negative smears can be screened every 3 years
Women at high risk (see preceding risk factors) require annual Pap smear screening indefinitely
In women who have undergone hysterectomy without a cervical remnant, Pap smears are no longer required unless the hysterectomy was performed for cervical cancer
▪
Because cervical cancer develops slowly and risk factors decrease with age, it is reasonable to discontinue cervical cancer screening over age 65 in women who have three or more negative cytology test results in a row and no abnormal test results in the past 10 years
52
Used for classification of Pap smear adequacy and results (Table 64-1)
Bethesda System
53
Bethesda system
1. ASCUS
2. AGUS
3. LGSIL
4. HGSIL
5. Invasive Cancer
54
AGUS: Significance
More related to endometrial rather than cervical cancer
55
Mx: AGUS
1. Colposcopy with directed biopsy
2. Endometrial biopsy
3. If all normal, repeat Pap in 3–6 mo
56
Mx: LGSIL, HGSIL
Colposcopy and directed biopsies
57
Three management options in ASCUS
1. Repeat Pap smear in 4–6 months:
1. If 2 repeats normal, yearly screening
2. If ASCUS obtained before two normal repeats, refer for colposcopy
2. Colposcopy:
1. If normal, resume annual Pap screening
2. If abnormal, perform biopsies
3. DNA testing for HPV
1. If positive, refer for colposcopy
2. If negative, repeat Pap smear in 1 year
58
Commonest finding on abnormal Pap smears
ASCUS
59
Majority of women with ASCUS have __ findings on colposcopy
Benign
60
ASCUS, immunosuppressed should always prompt
colposcopy
61
Percentage of ASCUS and AGUS are cancer?
Small
62
Risk of high grade lesion with follow up histology for LSIL and HGSIL
LSIL: 15-30%
HGSIL: 70-75%
63
ASCUS
Atypical squamous cells of undetermined significance (ASCUS)
64
AGUS
Atypical glandular cells of undetermined significance (AGUS)
65
LGSIL, HGSIL
Low-grade squamous intraepithelial lesion (Risk:15-30%)
High-grade squamous intraepithelial lesion (Risk: 70-75%)
66
The cervical epithelium most often affected by malignant transformation is where the __ cells of the endocervical canal are undergoing transformation into the __ cells of the exocervix (called the “transformation zone”) (Fig. 64-1)
The cervical epithelium most often affected by malignant transformation is where the **columnar** cells of the endocervical canal are transforming into the **squamous** cells of the exocervix (called the “transformation zone”) (Fig. 64-1)
67
If LGSIL is confirmed by colposcopy and histology, treatment can be expectant with quarterly Pap smears because:
Majority revert to normal without treatment
68
Rx: HGSIL
1. conization: if pathology negative for invasive cancer, and the margins free of disease, treatment is considered complete
2. LEEP, CKC, laser conization, or cryosurgery
69
Rx: Invasive cervical cancer
1. Stage I : hysterectomy +- radiation
2. Stages II and III: radiation
3. Stage IV: radical surgery + radiation, or palliative chemotherapy or radiation
70
Hemolysis
Elevated liver enzymes (AST and ALT up to 4000 U/L)
Low platelet count (as low as 6000/mm3)
Other symptoms
Epigastric pain
Nausea, vomiting
Headache
Edema
HELLP Syndrome
71
Antihypertensive therapy not indicated for mild hypertension in pregnancy (generally defined as less than ___ mm Hg),
150/100
72
Rx: hypertension in pregnancy
Methyldopa
73
Anti-hypertensives which are absolutely contraindicated in pregnancy
ACEI and ARBs
74
A reasonable goal is to keep maternal blood pressures in the ___ range
140–160/90–100 mm Hg
75
Preeclampsia: hypertension occurring for the first time after __ weeks’ gestation with proteinuria (\_\_mg/24 hr) and edema
Preeclampsia: hypertension occurring for the first time after **20** weeks’ gestation with proteinuria (\>**300** mg/24 hr) and edema
76
HELLP Syndrome
Variant of preeclampsia : microangiopathic anemia, thrombocytopenia, or hepatocellular necrosis
77
Ddx: HELLP Syndrome
1. HUS
2. TTP
78
Benefit of blood glucose values well controlled in gestational diabetes
Shoulder dystocia and macrosomia rates are decreased
79
Rx: gestational diabetes
Metformin, sulfonylurea, insulin
80
Risks of antithyroid meds in pregnancy
1. Propylthiouracil and methimazolemay be teratogenic
2. Radioiodine is contraindicated
81
\_\_\_ : safest SSRI in pregnancy; avoid \_\_\_, which has been associated with congenital heart defects
Fluoxetine: safest SSRI in pregnancy; avoid paroxetine, which has been associated with congenital heart defects
82
Which category drugs may be given in pregnancy after weighing risks versus benefits; which cannot be given in pregnancy?
C and D
Category X: Studies in humans and animals demonstrate significant fetal risk; contraindicated in pregnancy
Category A: Controlled studies in women fail to demonstrate risk to fetus in first trimester; unlikely to cause fetal harm
▪
Category B: Studies of animal reproduction have not demonstrated risk to fetus, but no controlled studies in pregnant women; or animal studies have shown effect, but no controlled studies in pregnant women
▪
Category C: Animal studies have revealed adverse effects in fetus; no controlled studies in women; should be given only if potential benefit justifies risk
▪
Category D: Evidence for fetal risk, but benefits may be acceptable in pregnant women despite risk
▪
Category X: Studies in humans and animals demonstrate significant fetal risk; contraindicated in pregnancy
83
Rx: acne in pregnancy
Topical clindamycin, erythromycin, or benzoyl peroxide
84
Allergic rhinitis
1. Topicals
2. Antihistamines
3. Pseudoephedrine
85
Cough in pregnancy
Guaifenesin and dextromethorphan
86
GERD in pregnancy
CaCO3, ranitidine
87
Bronchitis in pregnancy
Amoxicillin and azithromycin
88
UTI in pregnancy
Nitrofurantoin
89
Thrombophlebitis in pregnancy
Heparin
90
Antimicrobials contraindicated in pregnancy
Tetracyclines (brittle bones and cartilage and yellow teeth)
Fluoroquinolones (arthropathies
91
Anticonvulsants contraindicated in pregnancy
1. Phenytoin
2. Carbamazepine
3. Valproic acid
92
Why are loop diuretics contraindicated in pregnancy?
Fetal growth restriction and distress
93
Only one live vaccine, the _ , is safe in pregnancy
OPV
94
A 33-year-old patient has questions about the different types of oral contraceptives on the market and the dosing of the pill. In particular, she is worried that if she misses a day, she might become pregnant. Which of the following is correct advice?
1. Given her age, the mini-pill would be a good option for her because it contains only estrogen
2. Combination pills are more effective than the mini-pill because they contain both estrogen to inhibit ovulation and progestin to affect cervical mucus
3. Monophasic pills usually contain constant doses of progestin but escalating doses of estrogen
4. If she misses only one pill in the cycle, she does not need to worry about taking it when she realizes it
5. The mini-pill is significantly more effective than combination pills but is used less often because of side effects
2
Combination pills are more effective than the mini-pill because they contain both estrogen and progestin. The mini-pill, which contains progestin only, is probably somewhat less effective but is a good choice in older women with cardiac risk factors or in lactating women (not this patient). Monophasic pills contain constant doses of both estrogen and progestin. Finally, if a woman misses even one pill, she should take it immediately upon realizing this.
95
An 18-year-old woman presents for a routine Papanicolaou (Pap) smear because she has been sexually active for a year. She has had one sexual partner. Her pelvic examination is unremarkable. You obtain a liquid-based Pap smear. The result returns as “atypical squamous cells of unknown significance" (ASCUS). What is your advice?
1. Treat with metronidazole and repeat the Pap smear in 2 months
2. Recommend colposcopy
3. Request human papillomavirus (HPV) testing on the sample; if positive, repeat the Pap smear in 3 to 6 months
4. Request HPV testing on the sample; if positive, refer to colposcopy
5. Request HPV testing on the sample; if negative, repeat the Pap smear in 1 to 2 months
4
ASCUS is a very common finding on routine Pap smears. There was no evidence of infection or inflammation on examination, so treatment with metronidazole is unnecessary. Referring directly to colposcopy will result in overuse of this procedure. Because a liquid-based cytology was obtained, HPV testing can be performed, and the information about HPV status will greatly aid in managing the patient. If positive, the patient should be referred for colposcopy rather than repeating the Pap smear in 3 to 6 months. If negative, the Pap smear can be repeated in 1 year, not 1 to 2 months.
96
A 29-year-old woman with mild persistent asthma is 10 weeks pregnant. She calls the office urgently with increasing shortness of breath. You bring her in for urgent evaluation. Her dyspnea began 3 days ago with exposure to a neighbor’s cat. She denies chest pain, fever, or cough, and feels her current symptoms are typical of an asthma flare. She has been using her albuterol inhaler with increasing frequency but no clear benefit. Her past medical history is unremarkable. In addition to the albuterol, she also uses inhaled fluticasone 44 μg twice daily. On exam, she has audible wheezes diffusely but no other findings. Her oxygen saturation in the office is 94% on room air. What is the most appropriate intervention?
1. Discontinue inhaled fluticasone, as use during the first trimester can lead to fetal growth retardation, and add albuterol nebulizer treatments
2. Prescribe a short course of oral prednisone with a taper
3. Increase inhaled fluticasone to 110 μg twice daily
4. Send her to the emergency department immediately for intravenous methylprednisolone, as oral prednisone is contraindicated in pregnancy
5. Add salmeterol 1 inhalation twice daily to avoid increasing short-acting β-agonist therapy with its detrimental effects on the fetus
2. Prescribe a short course of oral prednisone with a taper
The patient presents with an acute asthma exacerbation and stable oxygenation. She requires aggressive therapy, however, to avoid deterioration with subsequent decreased oxygenation to the fetus.
In general, all asthma medications are reasonable to use in pregnancy, as the risk to the fetus from hypoxemia far outweighs the risk of any asthma medications. Given that she already is taking inhaled corticosteroids (fluticasone) and using an inhaled β-agonist frequently, she requires more aggressive therapy with a prednisone taper. Intravenous methylprednisolone offers no advantage over oral prednisone with regard to safety in pregnancy. Inhaled fluticasone does not require discontinuation, as it is not known to be associated with fetal growth retardation. Conversely, increasing the dose of inhaled fluticasone is not adequate or appropriate to treat an acute asthma exacerbation. Finally, a long-acting β-agonist, such as salmeterol, is not safer for the fetus than short-acting β-agonist therapy and is also not indicated for acute asthma flares.
97
A 23-year-old woman, pregnant for the first time, is admitted at 32 weeks’ gestation after an office visit where her blood pressure is 170/110 mm Hg. She has had epigastric pain and vomiting since last night. Examination reveals significant edema. On admission, her platelet count is 45,000/mm3 and her aspartate aminotransferase (AST) is 2300 U/L. Which of the following would you not expect?
1. Hematocrit of 24%
2. Urine protein of 4+ (3 g/24 hr)
3. No increase in risk of seizure
4. Peripheral blood smear consistent with thrombotic thrombocytopenic purpura (TTP)
5. Possible recurrence with subsequent pregnancies
3, No increase in risk of seizure
This patient has severe preeclampsia and probable associated HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome. It would not be surprising to find a low hematocrit secondary to hemolysis. The peripheral blood smear in HELLP is nondiagnostic and is also consistent with TTP or hemolytic uremic syndrome. The elevated urine protein is expected with preeclampsia. Severe preeclampsia puts this patient at high risk of seizure, and intravenous magnesium sulfate should be started. She is also at risk of recurrence of the preeclampsia with subsequent pregnancies.
98
A 27-year-old women who has had diabetes since age 8 years and chronic hypertension since age 22 years, and who has had no previous pregnancies, comes to you for prepregnancy consultation. Her current medications include ramipril and glipizide. Which of the following advice would be incorrect to give your patient?
1. Continue the ramipril through the pregnancy to protect renal function from diabetes
2. Tight glycemic control should be in place before conception
3. Optimal blood sugars before and during pregnancy are 60 to 80 mg/dL fasting and 60 to 120 mg/dL 2 hours postprandial
4. Sulfonylureas and metformin are often used to treat diabetes in pregnancy, but sometimes insulin is required to maintain tight control
5. Her diabetes, if not controlled, could lead to fetal macrosomia
Continue the ramipril through the pregnancy to protect renal function from diabetes
Angiotensin-converting enzyme inhibitors (e.g., ramipril) are contraindicated in pregnancy; it should be discontinued before attempting conception. Uncontrolled diabetes can lead to fetal macrosomia or growth retardation, as well as other fetal abnormalities, including death. Tight control to prevent such complications is crucial, and the goals outlined in Answer C are appropriate. Insulin is the preferred drug for diabetes in pregnancy.
99
A 19-year-old college student presents to your office for a routine health checkup. She has no significant medical history. She lives in a dormitory room with several friends and drinks alcohol on the weekends. She is sexually active with her boyfriend and uses condoms for birth control. Her physical examination, including pelvic exam, is normal. The Papanicolaou (Pap) smear results return in 1 week as “low-grade squamous intraepithelial lesion" (LGSIL). Which of the following is true regarding her condition?
1. She will most likely require a surgical procedure, such as a laser conization, but cure is likely
2. HPV testing will be helpful in decision-making regarding colposcopy referral
3. If a repeat Pap smear in 6 months shows “high-grade squamous intraepithelial lesion" (HGSIL), she will need colposcopy
4. Her risk for cervical cancer is low; repeat Pap testing in 12 months is appropriate
5. The finding of LGSIL has a high likelihood of regressing to normal
The finding of LGSIL has a high likelihood of regressing to normal
This patient’s Pap smear result, LGSIL, confers a 15% to 30% risk of having an HGSIL on colposcopy. In the majority of instances, LGSIL actually regresses to normal and has a benign prognosis. The need for eventual laser conization is unlikely. Nevertheless, the result does require further evaluation with colposcopy. Simply repeating the Pap smear in 6 to 12 months or using HPV testing to help triage the need for colposcopy (as with atypical squamous cells of unknown significance [ASCUS]) would not be aggressive enough or appropriate in this situation. You will also want to offer her the HPV vaccine if she hasn’t had it already.
100
A 38-year-old woman is currently on an oral contraceptive for birth control. She is married and monogamous with her husband. Her sons are 10 and 7 years old, and she is not interested in having any more children. Lately, she has become concerned about how the oral contraceptive makes her feel and is worried that it might cause breast or ovarian cancer. Her family history is notable for an older sister who died of ovarian cancer at age 50. The patient does not drink or smoke. Her physical examination is unremarkable. What do you tell her about her contraceptive options?
1. The oral contraceptive agent will not increase her risk of ovarian cancer; in fact, it may be protective
2. She should discontinue the oral contraceptive as it is contraindicated in women over the age of 35 years
3. Injectable long-acting progesterone may be a better option as it will help protect against bone mineral density loss
4. An intrauterine device (IUD) would not be a good option given the increased risk of ectopic pregnancy at her age
5. Administering the contraceptive as a patch rather than a pill will avoid the increased risk of breast cancer
1. The oral contraceptive agent will not increase her risk of ovarian cancer; in fact, it may be protective
This woman has many options for contraception. Certainly, continuing her current oral contraceptive would be acceptable—as long as her anxiety with it is alleviated. Oral combination contraceptives are relatively contraindicated only in women over 35 years who smoke. They are not associated with ovarian cancer and, in fact, may be protective. The association of oral contraceptive with breast cancer is less clear, but probably not significant. Using a patch rather than a pill will do nothing to attenuate this risk. Long-acting (depot) progesterone has been linked to reversible bone mineral density loss and thus may not be the best first-line choice for this older woman. Finally, an IUD is a very reasonable option for her and is not associated with an increased risk of ectopic pregnancy in any age group.
101
A 20-year-old young woman presents to your office for an urgent appointment. She is distraught as she recently discovered her boyfriend, with whom she is sexually active, has genital warts. She is worried that she may contract these and that she might develop cervical cancer. She has been in a monogamous relationship with her boyfriend for about 9 months. She is otherwise healthy. What do you recommend for cervical cancer screening?
1. After three annual Papanicolaou (Pap) smears that are normal, she can increase the screening interval to Pap smears every 3 years
2. The human papillomavirus (HPV) strains that cause cervical cancer do not cause genital warts; therefore, she can defer screening for another year
3. She should undergo a Pap smear with HPV testing
4. A finding of squamous metaplasia on Pap smear should prompt HPV testing
5. She does not require cervical cancer screening as she has not reached 21 years of age
NEXT QUESTION
She should undergo a Pap smear with HPV testing
This patient should undergo cervical cancer screening now as she is sexually active and has probable exposure to HPV. Guidelines suggest screening at age 21 or upon initiation of sexual activity, whichever is first. HPV testing in women less than 30 years of age is more controversial, given that many women will spontaneously clear the infection with no sequelae. This patient, however, has a known exposure, and HPV testing (with serotyping of low- vs. high-risk serotypes) will add in prognosticating her future risk of cervical cancer. It is true that the HPV strains that cause genital warts are usually low-risk strains, but that alone would not be sufficient to defer screening in this patient. Most guidelines do not recommend lengthening the screening interval to 3 years until a woman reaches 30 years of age, regardless of HPV status. A finding of squamous metaplasia is normal and does not require further testing of any kind. Even though she is already sexually active, you will want to consider offering the HPV vaccine, if she hasn’t had it already.
102
A 50-year-old woman presents to your office with moderate hot flashes that began about 6 months ago. They are worsening in severity and wake her up many times throughout the night. She is becoming increasingly sleep-deprived and describes inability to concentrate at work. Her last menses was 10 months ago. She is on a small dose of a thiazide diuretic for mild hypertension but is otherwise healthy. Which of the following is true about the treatment of her hot flashes?
1. α-Adrenergic agents are the best-tolerated option and would be a good choice for her
2. Venlafaxine is the most effective alternative to estrogen
3. Coping mechanisms alone may not be enough for her; estrogen is reasonable to try
4. Gabapentin provides the quickest onset and the fewest side effects; it should be prescribed for her
5. Estrogen will work for her, but its use should be limited to under a year
3. Coping mechanisms alone may not be enough for her; estrogen is reasonable to try
This woman has moderate hot flashes associated with menopause that are now affecting her quality of life and ability to work. She deserves treatment. There is no “right” or “wrong” choice for therapy, although estrogen has the quickest onset and best efficacy. It is very reasonable to try it in this patient, given her moderate to severe symptoms. Coping mechanisms (such as wearing lightweight layers and keeping a fan on) may not be adequate. Estrogen use should be limited to 5 years, not 1 year. The other prescription alternatives are reasonable, but reduce hot flash frequency and severity by roughly 50%. It is not true that α-adrenergic agents are the best tolerated (they are the least well tolerated). Likewise, venlafaxine is not necessarily the most effective and gabapentin does not have the quickest onset or fewest side effects. Head-to-head trials for most estrogen alternatives are lacking.
103
As a practicing internist, you see many pregnant women as patients. While they often call their obstetrician for advice regarding their pregnancy, you still receive many phone calls about common problems, such as allergic rhinitis, urinary tract infections, and reflux disease. Which of the following is not appropriate advice for a pregnant woman?
1. For a urinary tract infection, nitrofurantoin is a good choice
2. For allergic rhinitis, diphenhydramine is worth trying
3. For gastroesophageal reflux, omeprazole is recommended
4. For a severe headache, acetaminophen is an acceptable option
5. For acne, topical clindamycin is a reasonable strategy
PPIs are Category C and should be avoided if possible. New evidence has questioned whether they have risks in the second and third trimester, but generally H2 blockers (Category B) are preferred for GERD.
104
Which of the following is true regarding cervical cancer screening with a Papanicolaou (Pap) smear?
1. A finding of atypical squamous cells of undetermined significance (ASCUS) on Pap smear with a negative DNA test for human papillomavirus (HPV) can be followed with a repeat Pap smear in 1 year
2. A finding of atypical glandular cells of undetermined significance (AGUS) is less serious that ASCUS and can be followed with a repeat Pap smear in 4 to 6 months
3. Cervical cancer screening with a Pap smear is recommended beginning at age 21 years, regardless of sexual activity
4. Trichomonas found on a routine Pap smear should be confirmed with a normal saline prep before initiating treatment
5. If a Pap smear shows ASCUS, but colposcopy reveals cervical intraepithelial neoplasia grade II, there was probably a sampling error and a repeat colposcopy should be performed
A finding of atypical squamous cells of undetermined significance (ASCUS) on Pap smear with a negative DNA test for human papillomavirus (HPV) can be followed with a repeat Pap smear in 1 year
HPV testing can be useful in triaging patients with a finding of ASCUS on Pap smear. If negative, repeating the Pap smear at 1 year is an appropriate course of management. If positive, the patient should be referred for colposcopy. AGUS is often related to more serious disease than ASCUS (usually endometrial rather than cervical cancer) and should be followed more aggressively. Colposcopy and biopsy are more appropriate than repeat Pap testing. Recommendations are to begin cervical cancer screening at age 21 years or when sexually active, whichever comes first. Any infection, such as Trichomonas, found on a routine Pap smear, should be treated. A normal saline prep is not necessary for confirmation. Finally, if there is a discrepancy between a Pap smear reading and a histologic finding by colposcopy, treatment should be initiated if the histologic diagnosis is more serious (as in this case). The patient should have definitive therapy with cold knife or laser conization or a loop electrosurgical excision procedure (LEEP). If the histologic diagnosis is less severe, a sampling error may have occurred and a larger biopsy should be taken.
105
A 25-year-old woman is 12 weeks pregnant with her second child. She presents to the emergency department with an acute onset of shortness of breath and wheezing. She has a history of mild, intermittent asthma for which she uses an albuterol metered-dose inhaler on an as-needed basis. On examination, her blood pressure is 130/85 mm Hg and her heart rate is 110 beats/min. She is tachypneic and has diffuse, polyphonic wheezes throughout her lung fields. Her oxygen saturation is 94% on room air. What is appropriate management?
1. Administer O2 by nasal cannula, prednisone, and β-agonist nebulizer treatments
2. Administer O2 by nasal cannula and theophylline, as it is Food and Drug Administration Pregnancy Risk Category B
3. Administer O2 by nasal cannula and β-agonist nebulizer treatments; avoid prednisone because of pregnancy and risk to the fetus
4. Administer O2 by nasal cannula and intravenous magnesium sulfate, as it is safe in pregnancy
5. Administer O2 by nasal cannula and prednisone; avoid β-agonist nebulizer treatments because she is in the first trimester
Administer O2 by nasal cannula, prednisone, and β-agonist nebulizer treatments
The risk to the fetus of hypoxemia from the asthma far outweighs any risk of treatment. She should be given oxygen by nasal cannula and treated aggressively, no matter what her trimester. Prednisone and β-agonist nebulizer treatments are both appropriate therapies. Theophylline is Pregnancy Risk Category C and should be avoided unless absolutely required. Magnesium sulfate has not been proven to be efficacious in asthma and alone would not be enough to treat the flare.
106
Which of the following women would not be a good candidate for the use of combination oral contraceptive pills?
1. A 40-year-old woman with no smoking history
2. A 30-year-old woman with a strong family history of ovarian cancer
3. A 29-year-old woman with mild hypertension that is well controlled with a thiazide diuretic
4. A 32-year-old woman with a history of autoimmune hepatitis that is under reasonable control
5. A 34-year-old woman with heavy menses secondary to uterine fibroids
Women with a history of liver disease should be advised not to use them (Answer D). Other contraindications include a history of thromboembolic disease, a history of breast or endometrial cancer, and smokers over age 35 years. In Answer A, the woman does not smoke and would still be a candidate. For Answer B, oral contraceptives may actually decrease the risk of ovarian cancer. In Answer C, the hypertension is well controlled. Only uncontrolled hypertension is a contraindication. Finally, use of an oral contraceptive may actually decrease menstrual bleeding in a woman with uterine fibroids.
107
A 19-year-old woman comes to your office for counseling regarding birth control. She has been using condoms, but does not like “depending on someone else for protection.” She also has “horrible” migraines that only occur premenstrually (once a month) but force her to stay in bed for a day. She is interested in trying a combination oral contraceptive. She is healthy with no chronic medical conditions. When initiating oral contraceptives, which of the following statements would be appropriate advice for the patient?
1. Explain that, if she misses a couple days of her oral contraceptive, she should take one immediately, and then one twice a day until all the missed tablets have been taken. If she does so, she will not need an additional form of contraception for that cycle
2. Inform her that the mini-pill may be a good option for her; because it contains estrogen only, it tends to have fewer side effects
3. She should start the oral contraceptive midcycle, roughly 14 days before her expected menstruation
4. Oral contraceptives are not necessarily contraindicated for premenstrual migraines; in fact, she may opt to have a withdrawal bleed only every 3 months on the pill to decrease the frequency of her migraines
5. Symptoms of premenstrual syndrome (nausea, irritability, headache, bloating) usually worsen after starting an oral contraceptive
Oral contraceptives are a reasonable choice for this healthy, young woman with no contraindications. While oral contraceptives may worsen migraines in general, they may actually alleviate premenstrual headaches and migraines. An added bonus is the ability to take the inert pills only every 3 months (perfectly safe to do), thus decreasing the frequency of premenstrual migraines. If she misses more than one dose, she should take the missed tablets as directed in Answer A, but she should also use an additional form of contraception that cycle. The mini-pill contains progestin only (not estrogen) and is associated with a higher incidence of breakthrough bleeding. It is used predominantly in breast-feeding women or women who cannot tolerate estrogen. Oral contraceptives should be started on the first day of menses, not midcycle. Finally, symptoms associated with premenstrual syndrome tend to improve on oral contraceptives, not worsen.
108
A 31-year-old woman calls your office in October. She is pregnant at 35 weeks’ gestation and is wondering if she should get the advertised “shingles” vaccine (Zostavax). What vaccine should you offer her?
1. Zoster vaccine
2. Intranasal influenza vaccine (FluMist)
3. Influenza injection vaccine
4. Measles, mumps, and rubella (MMR) vaccine
5. Pneumococcal vaccine
3. Influenza injection vaccine
Zoster, like varicella vaccine, is a live, attenuated virus, and as such it is contraindicated in pregnancy. MMR also falls into this category. It is important during preconception counseling to offer varicella and MMR vaccination to women found to be nonimmune, and conception should be postponed at by at least 4 weeks at a minimum. Injectable influenza vaccination is recommended to all pregnant women, regardless of trimester, and especially to those who will deliver during flu season. Nasal influenza vaccine is a live, attenuated virus and therefore contraindicated. Pneumococcal vaccination is not routinely indicated in the healthy, young adult population.
109
A 28-year-old female patient calls the morning following unprotected intercourse with her partner of 3 years. She forgot to take her oral contraceptive pill for the past 2 weeks and is concerned that she may become pregnant. She asks if she should take all of the missed pills immediately to prevent a pregnancy. What advice do you offer?
1. Take 1 pill now and 1 pill twice daily until all 14 are taken
2. Check a urine pregnancy test in 2 weeks and call again if it is positive
3. Provide medroxyprogesterone 150-mg injection in the office in 1 week
4. Offer levonorgestrel 0.75 mg now and a second dose in 12 hours
5. Reassure her that conception is unlikely after 2 weeks of missed pills
Offer levonorgestrel 0.75 mg now and a second dose in 12 hours
She may benefit from emergency contraception: levonorgestrel in two doses of 0.75 mg or one dose of 1.5 mg. It is at least 75% effective at preventing pregnancy. If one pill is missed, a woman should be advised to take it as soon as it is remembered, but if more than 2 pills are forgotten, alternative contraception should be used as she is at high risk for unplanned pregnancy. Combined oral contraceptives are 98% effective at preventing pregnancy with perfect use. This efficacy drops when pills are missed, and the very low-dose (20-μg estrogen) pills are even more prone to failure when not taken exactly as prescribed as compared to standard-dose pills. Medroxyprogesterone injection is a form of contraception but not indicated as emergency contraception. In this patient, you would also want to identify a more reliable form of birth control for her in the future (e.g., IUD if not planning a pregnancy in the next year).
110
Use of hysterosalpingography
SOL in the endometrial cavity (polyps, fibroids)
111
Tests that can measure ovarian reserve
FSH on day 3 of cycle
Anti-Mullerian hormone
112
Primary ovarian insufficiency
- Less than 40 years old
- amenorrhea for 4 months or more,
- two serum FSH levels (obtained at least 1 month apart) in the menopausal range
113
In 90% of the cases of primary ovarian insufficiency, the cause
remains a mystery.
114
Flibanserin
Only FDA drug used for female sexual dysfunction
115
Most cases of mastitis are caused by
Staph aureus
116
Menopause.Mx
Vasomotor symptoms in patient with contraindication to estrogens
Paroexetine
117
Small cysts along the outer edge of the cervix
Nabothian cyst
## Footnote
- discrete cystic structures that form when a cleft of columnar epithelium becomes covered with squamous cells and the columnar cells continue to secrete mucoid material.
- microscopic to several centimeters
- may occur following minor trauma or childbirth.
The **only indication for treatment is relief from pain** or a bothersome feeling of fullness in the vagina. Ablation of the cyst using **electrocautery** is the usual approach; however, if the diagnosis is uncertain, excision to evaluate histopathology is advised.
118
mass of the ovary, fallopian tube, or surrounding connective tissue
Adnexal mass
119
Intractable pain from metastatic cancer: Mx
PCA
120
Pregnancy: why no fluroquinolones or Bactrim?
quinolones: fetal arthropathy, Bactrim: early -\> malformation, late -\> kernicterus
121
Ashkenazi Jewish woman: pre-conception screening
Tay-Sachs, Canavan,CF, Familial dysautonomia
Varying recs
122
highly effective reversible contraception
IUD or etonogestrel
123
HRT: status post hysterectomy: why estrogen-only Rx?
Progestin necessary only for women with a uterus
The idea is that the patient does not need the risks which progestin incurs.
124
Recurrent first trimester miscarriage: Testing
Anti-phospholipid, parental karyotype + hysterosalpingogram
125
Pregnant: Penicillin + cephalosporin allergy: Pyelonephritis: Rx
Aztreonam
126
Cervical lesion: visible: Mx
Biopsy
Not LEEP or conization
127
Pregnancy: Late: suspected appendicitis: Imaging?
MRI
Not CT, not US (less sensitive). If no MRI, low dose CT is OK.
