REI Flashcards
44yo nulligravid, not interested in pregnancy, no male partner wants to discuss fertility preservation options. Best step in management?
Expectant management (NOT oocyte cryopreservation)
- Clinical pregnancy rate per thawed oocyte = 4.5-12%
- At 4.5%, would need ~22 oocytes to result in one pregnancy
- Live birth rate = 2-12% for women <38yrs
- Therefore, ASRM does not recommend oocyte vitrification in those older than 38
Prolog REI - Q1
52yo s/p hyst+BSO at age 47 taking 0.625mg CEE daily… the complication she is at greatest risk of by continuing is?
Stroke (NOT VTE)
- risk of stroke vs placebo = 1.39
- VTE risk is higher, but not as high as stroke
- transdermal = decreased risk of VTE
-Combo Ez and Pg have decreased risk of colon cancer
Prolog REI - Q3
27yo G1P0 at 29wks with hirsutism, PCOS, and bilateral solid ovarian masses. Testosterone 804 mg/dL, DHEAS 150ng/dL, CA-125 wnl. What are the masses, and how do you manage?
Ovarian luteomas -> benign hyperplasia of large lutein cells by HCG
- usually regress 2-3 weeks postpartum –> EXPECTANTLY MANAGE
- yellow-brown solid tumors
- histology: round-to-polygonal cells with eosinophilic cytoplasm. Stain + for inhibin A, neg of AFP.
- other causes of gestational hyperandrogenism: drugs, sertoli-leydig, krukenberg, placental aromatase deficiency
- Luteoma vs Theca-Lutein cysts: both benign
- Luteoma: 47% bilateral, 79% fetal virilization
- Theca-Lutein: almost always bilateral, do NOT cause fetal virilization
Prolog REI - Q4
21yo nulligravid wants to be an egg donor. Has levonorgestrel IUD, tattoo, hx of chlamydia 6 months ago, breast cancer in maternal grandma and T2DM in father. She is ineligible to donate because…?
Hx of chlamydia in the last 12 months
- eligible if treated with a neg result
- Hep B, C, RPR, HIV are permanent exclusion
Prolog REI - Q6
Primary infertility, male with urinary incontinence, ejaculatory semen volume of 0.5mL. Post ejaculatory UA showed 50 million total motile sperm and normal morphology. Most appropriate treatment for this couple’s infertility?
Retrograde sperm for IUI
- consider retrograde ejaculation for any semen volume <1mL
- total motile sperm count = ejaculatory volume x sperm concentration x motility
Prolog REI - Q9
39yo with menorrhagia, 2cm class 3 fibroid, not desiring pregnancy or surgical treatment. Most effective long-term medical management to control her heavy bleeding is?
Levonorgestrel-releasing IUD
- Incidence of fibroids by age 50 = 80% in African American women and 70% in white women
- Progestin role is unclear but ulipristal (an antiprogestin) has been showed to show decrease in size
- GnRH agonists and antagonists have been shown 30-40% shrinkage in fibroid in first 3 months of use
- IUD delivers 20mcg of hormone daily
Prolog REI - Q2
29yo with secondary amenorrhea and desire for fertility. Fam hx significant for maternal aunt and uncle with tremor/ataxia syndrome. FSH 112 and 92 1 month apart, estradiol <20, TSH, PRL and karyotype wnl. Next best lab test to order?
FMR1 gene premutation screening (Fragile X)
Primary ovarian insufficiency = <40yrs, at least 4 months of amenorrhea, 2 FSH concentrations in menopausal range at least 1 month apart
- most common etiology is idiopathic
Fragile X: x-linked
- FMR1 gene on long arm of X chromosome, Xq27
- CGG repeats; normal = <45, 45-54 intermediate, 55-200 premutation and assoc with POI, >200 full mutation
- 6% of women with POI will have FMR1 premutation
Other causes of POI: polyglandular autoimmune syndrome, FSH receptor mutations, Turner
Prolog REI - Q5
32yo with regular menses and 3yrs primary infertility. HSG with bilateral hydrosalpinx. In addition to antibiotics, next best step is…?
Bilateral salpingectomy
Tubal disease = 25-35% of female factor infertility and more than half result from salpingitis
Prolog REI - Q7
17yo with primary amenorrhea. Tanner IV breasts, Tanner I pubic/axillary hair and blind-ending vagina. Diagnosis?
Androgen-insensitivity syndrome
- X-linked recessive
- mutation in androgen receptor on long arm of X chromosome, Xq
- Testosterone -> dihydrotestosterone by 5 alpha reductase –> formation of penis, scrotum, and prostate
- testosterone converted to estradiol by aromatase
Swyer = phenotypically female but 46, XY with complete gonadal dysgenesis
- inactivating mutation of sex-determining region of Y gene
Klinefelter = 47, XXY
Turner = 45, XO
Prolog REI - Q8
28yo G1P0 with positive UPT, hx hyperprolactinemia. MRI shows pituitary macroadenoma measuring 1.2cm and abutting optic chiasm. Currently tolerating cabergoline and has mildly elevated PRL. Given current pregnancy, the most appropriate management is…?
Switch to bromocriptine
- both dopamine receptor agonists
- cabergoline: more potent, improved patient adherence (2x weekly dosing), and fewer adverse effects
- bromocriptine: not shown to increase congenital malformations
- cabergoline also showed to be safe, but there is much more data on bromocriptine so currently it is the preferred medication in pregnancy
- Remember visual-field testing every trimester
- Monitoring prolactin levels not helpful during pregnancy
- For MICROadenoma or macro but away from optic chiasm, stop DA agonist once pregnancy confirmed. Start bromocriptine if tumor growth evident.
Prolog REI - Q10
33yo G2P2 5 months postpartum with heat intolerance, fatigue, and occasional palpitations. HR 110 bpm. TSH low, mildly elevated free thyroxine. Best next step?
Metoprolol
Postpartum thyroiditis:
- Usually 3-6 months postpartum in patient who was euthyroid before pregnancy
- prevalence 5%, likely to recur in up to 70% of subsequent pregnancies
- major risk factor: positive thyroid antibodies in first trimester +gDM
- classic form: thyrotoxicosis followed by transient hypothyroidism, then return at 12mos
- Differentiate between postpartum thyroiditis and Graves with goiter with bruit and ophthalmopathy
Prolog REI - Q11
38yo with primary infertility. AMH 0.75, day 3 FSH 14. Normal HSG. Partner with oligospermia, 2.2mil, 35% motility, and 1% morphology and varicocele. Best next step?
IVF with intracytoplasmic sperm injection (ICSI)
- NOT varicocelectomy
- Varicoceles in 15% population and 40% in infertile male population
- Most are left sided because of drainage of left spermatic vein into higher resistance left renal vein; right spermatic vein drains into vena cava
- surgical intervention when clinically palpable, established infertility, normal female, and male has 1+ abnormal semen parameters
- In example, multiple abnormal semen parameters + female 38 with diminished ovarian reserve
Prolog REI - Q12
48yo with irregular menses, hot flushes, night sweats. Otherwise healthy. TSH wnl. UPT neg. Next best lab test, if any?
NONE.
- Early menopause transition = persistent difference of 7+ days in length of consecutive cycles, fewer than 60 days of amenorrhea
- median duration of menopausal transition = 4+ years
- median onset = 47yrs
Prolog REI - Q13
27yo G0 with PCOS unsuccessful after 3 cycles of Clomid. Hirsutism, BMI 35, AMH 9.5. Each ovary >20 antral follicles. Semen analysis 2ml volume, 10mil/mL, 10% motility, normal morphology. Best treatment?
IVF and delayed frozen embryo transfer (NOT letrozole and IUI)
- Oligoasthenospermia
- Semen analysis shows low concentration, low motility, low volume, and only 2 million total motile sperm
- For IUI to be successful, generally more than 10 million total motile sperm is required
Prolog REI - Q14
32yo G0 with hx of secondary amenorrhea for 1 year. Normal FSH, TSH. Low estradiol. Prolactin 80. MRI shows 5mm pituitary adenoma. Wants pregnancy in next 2-3 months. Next best step in management of amenorrhea?
Cabergoline
Prolactin >250mcg/L most likely associated with macroadenoma (>10mm)
- Hyperprolactinemia causes amenorrhea because prolactin inhibits GnRH from hypothalamus -> low FSH/LH (FSH may be low-to-normal due to long half-life though)
- Suppress PRL with dopamine agonists, replace estrogen with OCPs or estrogen
- Cabergoline = first line rather than bromocriptine (higher efficacy)
- Stop dopamine agonists when pregnancy confirmed (cross placenta)
- Cabergoline linked to cardiac disease
Prolog REI - Q15
68yo with 8yr history of hair growth on face, chest, male-pattern baldness, and deepening voice. Hx PCOS. BMI 27, BP 126/78. Morning testosterone 127, FSH 98, LH 52, DHEAS 35, morning cortisol 8. TVUS showed R ovary 5x4, left 4.8x3.1. Most likely diagnosis?
Ovarian hyperthecosis (NOT sertoli-leydig cell tumor, CAH, or cushing syndrome)
- The menopausal ovary continues to produce testosterone and androstenedione + decrease in sex hormone-binding globulin = relative increase in testosterone but should not cause severe hirsutism/virilization
- Normal hair growth can include some terminal hairs on upper lip/chin but not shoulder/chest/abdomen
- Score >8 on Ferriman-Gallway scale = hirsutism in premeno women
- Think tumor when testosterone >200 (ovarian) and DHEAS >700 (adrenal) in premenopausal. Postmenopausal: testosterone >100
- Most common cause of hirsutism on postmeno = ovarian source
- tx of hyperthecosis in postmeno = BSO
- 3 types of ovarian neoplasms that can cause hyperandrogenism: Sertoli-Leydig, lipoid cell tumor, and hilus cell tumor
Prolog REI - Q16
25yo with BRACA1, wants pregnancy in next 5 years. Contraceptive method that provides greatest protection against subsequent cancer is…?
Estrogen+progesterone OCP
BRCA1 = 65-74% lifetime risk breast cancer, 39-46% ovarian (serous or endometrioid)
OCPs can decrease risk of ovarian cancer by as much as 80% (duration of benefit unknown)
- Small but significant increase in breast cancer risk associated with OCPs, esp in BRCA, but breast cancer easier to surveil than ovarian
- Suppressing ovulation with implant would also likely decrease ovarian cancer risk but hasn’t been studied enough yet
Prolog REI - Q17
34yo w/ husband use donor sperm and achieve pregnancy. Couple asks whether they should disclose this to their child. Current recommendation regarding timing of disclosure is…?
When the child can understand
- Current recommendation that child of adoption or anonymous donor be told before puberty so that the child can absorb the information over time
Prolog REI - Q18
24yo G1P0 at 6wks has vaginal bleeding. TVUS reveals nonviable pregnancy. Repeat US 1 week later the same. She requests medical management. Best single agent is?
Misoprostol
- PGE1 analog
- complete expulsion in 66-99% of patients
- When given 600-800mcg sublingually or vaginally, typically evacuation takes place within 24hrs
- Inadvertent use in a viable pregnancy may lead to facial, skull, and limb defects
Prolog REI - Q19
25yo G0 with infertility. HSG and SA wnl. AMH 0.8. Hx stage III endometriosis and multiple laparoscopies. US showed right sided mass 2x2cm, probable endometrioma. Treatment option most effective to help this patient achieve pregnancy is….?
IVF (NOT operative laparoscopy)
- When endo is moderate or severe and hx of multiple surgeries, IVF is most effective. Also has low AMH. IUI less effective.
- OCPs, GnRH agonsits/antagonists are ineffective for endo-related infertility
- Elagolix: GnRH antagonist -> short term suppression of HPO axis. Can use up to 2 years.
- Laparoscopic ovarian cystectomy may be recommended with endometriomas >3cm in diameter
Prolog REI - Q20
27yo with PCOS, infertility, BMI 50, hx roux-en-y. Plans to wait 18months after surgery before pregnancy as recommended. Bicornuate uterus. Best contraception for her?
Etonogestrel/Ethinyl estradiol vaginal ring
- Not OCPs due to gastric bypass, not Depo due to weight gain, not IUD due to bicornuate uterus
- Increased adipose -> increased aromatase -> increased estrogen -> HPO axis suppressed -> decreased FSH and LH -> ovulatory dysfunction
- Insulin stimulates testosterone production through ovarian insulin-like growth factor 1 receptor -> ovulatory dysfunction
Prolog REI - Q21
28yo at 33wks presents with increasing facial, chest, and abdominal hair growth + voice deepening and male-pattern baldness. Testosterone 1032. US shows bilaterally enlarged ovaries, left 11x9x7 with multiple cysts with spoke-wheel appearance. Right ovary 10x8x6 with cysts. Most likely diagnosis?
Hyperreactio luteinalis aka theca lutein cyst (other options: hilar cell tumor, luteoma of pregnancy, sertoli-leydig tumor)
- most common cause of hyperandrogenism in pregnancy
- bilateral
- most asymptomatic, 20-30% can cause hirsutism/virilization
- luteinization and hypertrophy of ovarian thecal cells stimulated by hcg
Pregnancy luteoma: may be bilateral or unilateral, benign
- hypertrophy of ovarian stromal cells from hcg
- solid, cystic, or complex ovarian masses, multinodular, brown-yellow in color
Prolog REI - Q22
30yo G3P3 s/p precip delivery 6 weeks ago c/b PPH and transfusions now having fatigue, abdominal cramps, amenorrhea, and failure to lactate. Uterus 6wk size. The sign or symptom that is the best predictor of continued amenorrhea is…?
Failure to lactate
Sheehan syndrome:
- pituitary increases 120-136% by end of 3rd trimester
- can be life-threatening
- can cause hypotension, shock, hypoglycemia, hyponatremia, diabetes insipidus, adrenal insufficiency
Prolog REI - Q23
36yo G1P1 presents for contraceptive counseling. T2DM well-controlled on Metformin. BMI 29. No other medical conditions. Most appropriate contraceptive?
LARC (NOT OCPs, patch, or progestin-only pill)
- Combined OCPs or Depo may increase fasting blood glucose levels in women with diabetes and may exacerbate risk of VTE (patch more than OCPs)
- Progestin-only pills are safe but may have adverse effect on glucose and need daily adherence
Prolog REI - Q24
26yo G0 with episode of PID 6 months ago now concerned about a potential ectopic pregnancy. In this patient, the most likely pathology associated with a future ectopic pregnancy is….?
Fallopian tube serosal adhesions (other options being pelvic adhesions, TOA, loss of ciliated cells in fallopian tube)
PID:
- 85% caused by chlamydia, gonorrhea, or BV
- 15% from enteric or respiratory organisms colonized the lower genital tract
- Ectopic pregnancy rates after PID range from 0.6% to 9%
- After 1 infection, 12.8% will have tubal occlusion.
After 2, 35.5%.
3+ infections, 75% will have occluded fallopian tubes.
Prolog REI - Q25
18yo with known diagnosis of mullerian agenesis going to college and wants functional vagina. Normal external genitalia and vaginal dimple. The preferred approach to creation of a neovagina for this patient is…?
Dilation vaginoplasty
- safer, patient controlled, and more cost effective than surgery
- 90-96% achieve anatomic and functional success
- 10-20 min 2-3x/day with successfully increasing length and diameter of dilator size
- may take 5-12 months for functional vagina (6cm in length or capacity to have successful sexual activity)
Other procedures:
- intestinal vaginoplasty
- McIndoe procedure
- Davydov procedure (peritoneal vaginoplasty)
- Vecchietti procedure
Mayer-Rokitanski-Kuster-Hauser syndrome: ~1/5000
- 46XX, normal ovaries
- Renal and skeletal anomalies as well
Prolog REI - Q26
The physiologic event that induces completion of the first meiotic division of the oocyte is the…?
Midcycle luteinizing hormone (LH) surge
In peak reproductive years, the available follicle pool is at least 12 (capable of responding to FSH and growth).
- Dominant follicle increases its FSH receptors
- FSH stimulate aromatase activity and estradiol secretion. LH receptors acquired.
Series of events within the follicle and surrounding theca cells to prepare for ovulation:
1. First meiotic division and creation of metaphase II oocyte
2. Oocyte extruded 24-36hrs after onset of LH surge
3. Upon fertilization, second meiotic division is completed
Prolog REI - Q27
18 month girl referred for possible abnormality of the external genitalia. Wets diapers without difficulty and is otherwise healthy without urinary tract problems. External genitalia in picture show labial adhesions. Best next step to manage her condition is?
Observation (NOT topical estrogen cream)
Labial adhesions/agglutination peak incidence 3 months - 3 years
- isolated condition without other abnormalities
- low estrogen + inflammation
- generally resolve without treatment
- for symptomatic children, can use topical estrogen 1-2x/day for 2-6 weeks
- can use topical betamethasone BID x 4-6 weeks when estrogen fails
Prolog REI - Q28
32yo G3P3 in for annual. Uses Depo for past 3 years. 20 pack year smoking history, BMI 17. She is at increased risk of developing….?
Bone loss
Use 2 years or more associated with an increased fracture risk
Prolog REI - Q29
29yo G2P2 in for annual 18 months after uncomplicated delivery. Reports sex “not what it used to be”. Receptive to partner but rarely thinks about it herself. Does respond to foreplay. Achieves orgasm without pain. No depression. With respect to her sexual function, the most appropriate step in her management is….?
Reassurance
- Normal to have change in sexual response throughout various stages of life
Female sexual interest/arousal disorder DSM-5: 3 of the following for at least 6 months
- Absent or reduced interest
- Absent/reduced thoughts
- No or reduced initiation, unreceptive to partner
- Absent/reduced sexual excitement/pleasure
- Absent/reduced arousal in response to internal/external cues
- Absent/reduced genital/nongenital sensation during activity
Treatment:
- Reassurance
- Sex therapy
- Medications:
– Flibanserin: 5-hydroxytryptamine 1A agonist and 2A antagonist that decreases serotonin levels and increases dopamine/norepi levels
– short duration of testosterone therapy (insufficient data to support this)
Prolog REI - Q30
25yo G1 presents for first prenatal visit at 10wks gestation. Smokes 1 pack per day and would like to quit. Most effective intervention to help her is…?
Behavior modification counseling
Buproprion is effective and not teratogenic, but has increased risk of suicide
Prolog REI - Q31
28yo infertile couple presents to discuss IVF with ICSI. As a part of your counseling, you discuss that preterm delivery occurs in singleton pregnancies 9.7% of the time following IVF with ICSI compared with 7.9% after spontaneously fertilized pregnancies. The statistical term that best describes this reported increase in preterm delivery is….?
Absolute risk (NOT relative)
- probability that a condition will occur in a subject or population at risk of developing the condition. Often expressed as proportion.
Relative risk = ratio that compares absolute risk of a condition occurring in one group with the absolute risk of that condition occurring in another group
- in cohort studies
- 1 means that the risk is the same for study and control group. <1 = protective effect, >1 = adverse effect
- in example, 0.097/0.079 = 1.23 => 23% increase in the risk of preterm delivery following IVF with ICSI
*Review 2x2 table, sensitivity, specificity, false-positive rate, false-neg rate, prevalence, PPV, NPV, liklihood ratio, etc
Prolog REI - Q32
26yo G0 presents for initial infertility evaluation. Cycles 40-50 days since stopping OCPs 12 months ago, previously Q28 days. Reports fatigue, dry skin, and cold sensitivity. Delayed ankle reflexes on exam. Best next step in her evaluation is…?
TSH (Hypothyroidism)
Hashimoto’s aka chronic lymphocytic thyroiditis
- 5-10x more common in women than men
- TPO antibodies, high TSH, low T4
Prolog REI - Q33
IVF with ICSI has an increased risk of what?
Imprinting disorders
- Specifically mentioned Beckwith-Wiedemann and Silver-Russell.
Not with Angelman or Prader-Willi though.
- Also associated with increased incidence of monozygotic twins (NOT dizygotic though) and lower male-to-female sex ratio
Prolog REI - Q34
Newborn with ambiguous genitalia. Karyotype 46, XX. Best next lab test is?
17-hydroxyprogesterone (17-OHP)
CAH: most often 21-hydroxylase def
- Check karyotype, testosterone, FSH, LH, 17-OHP, AMH, electrolytes, consider imaging
Ambiguous genitalia in female with CAH can be caused by:
- 21 hydroxylase def, 11 beta-hydroxylase, or 3 beta hydroxysteroid dehydrogenase def
21-hydroxylase: CYP21A2 mutation, autosomal recessive
- 75% are salt wasting, 25% simple virilization
- hard to detect in males because they won’t have ambiguous genitalia but can have adrenal crisis
** Review cholesterol pathway
Prolog REI - Q35
35yo G2P2 is desiring pregnancy with new partner. She had intrauterine microinserts placed hysteroscopically 5 years ago. Best option for her to achieve pregnancy is…?
IVF (NOT removal of inserts aka Essure)
Prolog REI - Q36
32yo G4P0 with recurrent pregnancy loss. HSG and SIS show septate uterus. Best next step in management?
Operative hysteroscopy
Uterine septum = distance of >1.5cm from a line drawn between the two tubal ostia with the angle of the indentation of <90 degrees
Normal/arcuate = depth <1cm, angle >90 degrees
Bicornuate = depth >1cm
Prolog REI - Q37
55yo G3P3 healthy women is interested in HRT for her menopause symptoms. In the past she was on 17B-estradiol, topical progesterone (cream and spray), and triestrogen. Of these, the one with the proven efficacy, safety, and FDA approval is…?
17B-estradiol
Biestrogen, triestrogen not FDA regulated
- Evidence lacking for bioidentical hormones over conventional HRT
- Variable bioavailability and bioactivity means underdosages and overdosage are possible
- conventional HRT preferred
Prolog REI - Q38
16yo with secondary amenorrhea, feels “fat”. BMI 16.5. No bleed after provera withdrawl. What will her LH, FSH, and morning cortisol levels look like (high, low, normal)?
Low LH and FSH, high cortisol
- Hypogonadotropic hypogonadism
Hypothalamic-pituitary-adrenal axis in anorexia will show elevated cortisol, often with decreased suppression after dexamethasone
DSM-5 anorexia: 1. Restriction of energy intake 2. Intense fear of gain 3. Denial of seriousness
Elevated LH, FSH, and low cortisol = hypergonadotropic hypogonadism and possible hypoadrenalism. Primary ovarian insufficiency due to polyglandular autoimmune failure syndrome.
Low LH, low-normal FSH, and low cortisol = hypogonadotropic and possibly hypoadrenalism. Evaluate pituitary. ACTH stim test.
Elevated LH, FSH, and normal cortisol = primary ovarian insufficiency
Prolog REI - Q39
4yo girl with signs of puberty Tanner III breast, Tanner I pubic hair. Development rapid in past 4 months. LH elevated for age, estradiol elevated to puberty level. Most important reason to initiate treatment is to…?
Attain appropriate adult height
- risk of accelerated bone growth and epiphyseal closure
Precocious puberty:
- central = GnRH dependent. 90% idiopathic.
- peripheral = GnRH independent
- girls <8yrs. Evaluate if white girls <7 and African-American <6yrs.
- treat with GnRH agonist to down-regulate
Prolog REI - Q40
41yo G3P3 underwent laparoscopic tubal ligation 8 years ago, not considering tubal reversal. Regular menses, healthy, normal semen analysis. The factor in their history that will affect most directly the likelihood of successful pregnancy after tubal reversal is…?
The woman’s age
- <40yrs with normal ovarian function and male partner have pregnancy rate 70-90% at 2 years
- if undergoing tubal anastomosis, ideally length should be greater than 5cm
Prolog REI - Q41
45yo with regular menses presents for annual exam. Right-sided fullness noted on exam. US showed right simple appearing cyst, 3x3cm. No ascites. Contralateral ovary and uterus wnl. Next best step?
No further evaluation
Simple cysts up to 10cm are considered benign. Risk of malignancy with a unilocular cyst regardless of age is 0-1%.
Risk of ovarian cancer by age 70
BRCA1 = 69%
BRCA2 = 41-45%
Lynch = 5-10%
Prolog REI - Q42
32yo G1P1 present for secondary infertility. Normal cycles with intermenstrual spotting. HSG and TVUS show polyp. Before initiating clomid, most appropriate next management option is…?
Hysteroscopic polypectomy
PALM-COEIN
- Prevalence of polyps in AUB = 13-50%
- Most benign, 1-3% prevalence of premalignant atypical endometrial hyperplasia in a polyp and 0.5-3% risk cancer
- RF: obesity, unopposed estrogen, tamoxifen, late menopause
- interfere with embryo receptivity and implantation
EMB if >45yrs or <45 with risk factors, failed medical management, or persistent AUB
Prolog REI - Q43
45yo presents for annual exam. Regular menses. Gail Risk Assessment Model breast cancer 5-year risk score is 4%. You recommend chemoprophylaxis with tamoxifen. You counsel her that her breast cancer risk reduction after 5 years of chemoprophylaxis is…?
50%
Average woman’s risk of breast cancer = 12.5% (1 in 8)
Gail Risk Assessment Model :
- uses genetics Plus age at menarche, age at first birth, Fam history, race/ethnicity, and prior breast biopsies to provide 5-year and lifetime predictions.
- Premenopausal women with risk >1.7% are candidates for chemoprophylaxis (tamoxifen 20mg daily for 5 years)
Adverse effects of tamoxifen:
-2.5 fold incr risk of endometrial ca
-more extreme hot flushes
-increased vaginal discharge.
First study showed reduction by 50%
STAR trial compared raloxifene and tamoxifen. Identical efficacy.
Raloxifene is the best for postmenopausal women due to less endometrial cancer risk, but can cause ovarian stimulation in premenopausal women.
Prolog REI - Q44
53yo and 54yo partner are requesting egg donation for pregnancy. Both healthy. You explain your clinic’s policy is not to transfer embryos into women older than 50 due to risks of pregnancy. The ethical principle that supports consideration of the patient’s request is…?
Autonomy
Beneficence = do good and benefit the patient
Justice = be fair
Nonmaleficence = do no harm
Prolog REI - Q45
32yo with amenorrhea and galactorrhea, now with headaches for 2 months. Negative progesterone withdrawl. Morning fasting prolactin is 32 ng/mL, TSH wnl, HCG neg. On dilution of the blood sample, the repeat prolactin was 1,250 ng/mL. The best imaging to order is…?
Brain MRI
“High-dose hook effect” - circulating prolactin concentrations are so elevated that they saturate all binding sites of the assay antibodies and give falsely low results.
Prolactin:
- Anterior pituitary. Inhibited by dopamine (check for dopamine blockers such as risperidone and metoclopramide)
- circulating level is directly proportional to size of the tumor. Micro <10mm, macro >10 mm
- normal fasting prolactin = 2-25 ng/mL
- causes of prolactinoma/ hyperprolactinemia: MEN type 1, pregnancy, lactation, primary hypothyroidism, cirrhosis, kidney failure, anterior chest wall lesions
- MRI preferred imaging
Prolog REI - Q46
23yo with hx of stage II endometriosis and chronic pelvic pain. Tenderness on pelvic floor muscles on exam. Desires pregnancy ASAP. Treatment strategy most appropriate to address her pain is…?
Pelvic physical therapy
Chronic pelvic pain: noncyclic for 6 months. Central pain sensitization.
Prolog REI - Q47
32yo with 3yr history of infertility. No hx of infection, regular menses. Normal semen analysis. HSG picture given (arcuate cavity with salpingitis isthmic nodosa). Best next step in treatment of infertility?
IVF
Proximal fallopian tube occlusion is classified into 3 types: nodular (salpingitis isthmic nodosa, endo), non-nodular (true fibrotic occlusion), and “pseudo” occlusion (debris, polyps, hypoplastic tubes).
Etiology of SIN unknown, possibly from inflammation. More commonly on right than left side, less common bilaterally. Asymptomatic, often picked up on HSG. IVF best treatment.
Prolog REI - Q48
28yo obese women with hx of complex atypical endometrial hyperplasia on progesterone therapy presents for followup. She has missed appointments and becomes belligerent with your staff when asked about past-due payments. Does not have consistent means of transportation. In addition to performing a biopsy, the best next step is referral to…?
Social services
Prolog REI - Q49
50yo woman presenting with hot flushes several times per day, causing embarrassment and disrupting sleep. Otherwise healthy. Best next step in management?
Estrogen and progesterone
Vasomotor symptoms: disturbance in temperature-regulating mechanism in hypothalamus
HRT: benefits outweigh risks in healthy menopausal women who initiate HRT within 10 years of menopause or before age 60
- Risks: breast cancer and VTE primarily
- transdermal route has less VTE risk
Non-hormonal: Paroxetine
Prolog REI - Q50
23yo has persistent facial hair growth, acne, and irregular menses since puberty. Tired of shaving daily. BMI 35, facial acne, dark course hair on chin, lip, abdomen, and thighs. No virilization. Normal TSH and PRL. Best lab test to confirm an adrenal cause of her condition is…?
17-hydroxyprogesterone (17-OHP) - NOT DHEA-s
Nonclassic congenital adrenal hyperplasia (CAH): autosomal recessive mutation in CYP21A2 gene on chromosome 6 that results in 50-80% reduction in 21-hydroxylase activity
- symptoms overlap with PCOS -> distinguish difference with 17-OHP
- Level >200 and <800 ng/dL => further test with cosyntropin (ACTH) stim test
- >800 confirms diagnosis of CAH
Both PCOS and CAH can have mildly elevated levels of androstenedione
DHEAS comes from the adrenal gland, but a tumor would present with rapid hyperandrogenism and virilization (not since puberty in example)
Prolog REI - Q51
16yo sexually active girl is referred by dermatology who would like to start her on isotretinoin for acne. In addition to condoms for contraception, the hormonal contraceptive that is most likely to improve her acne is…?
Combined OCPs
Acne first line: benzoyl peroxide or topical retinoid.
Next: topical clindamycin and dapsone.
Next: PO tetracyclines or OCPs.
Next: Isotretinoin.
OCPs decrease androgen production and increase sex hormone-binding globulin production
Prolog REI - Q52
25yo reports amenorrhea, excessive facial and abdominal hair growth, and frontal scalp balding for the last 6 months. Enlarged clitoris on exam. TVUS shows 3cm right ovarian solid mass. CT confirms and reveals normal adrenal glands. The hormone that is likely to be elevated is…?
Testosterone
Sertoli-Leydig cell tumor:
- sex cord stromal tumor
- typical diagnosis around age 25
- mainly unilateral
- 15-20% are malignant
- often solid
- tx = surgery
androgen-producing organs = ovaries and adrenals
DHEAS >700 => adrenal source
Testosterone >200 => ovarian source
Prolog REI - Q53
