Reproductive Scenarios Flashcards
(35 cards)
Metronidazole 2g PO as single dose of 500mg twice daily for 7 days is the tx regimen for which of the following vaginal infections?
a) chlamydia
b) candidiasis
c) trichomoniasis
d) Staphylococcus
c: The high-dose regimen of metronidazole is for the tx of Trichomoniasis. Trichomoniasis vaginalis causes this common STD. The clinical characteristics include a profuse yellow, frothy, malodorous pruritic d/c. Sometimes a ‘strawberry cervix’. pH is between 4.5 and 6. The tx for chlamydia is azithromycin or doxycycline.
A 25yo nullipara presents for consultation because she suddenly stopped menstruating. On questioning her further it is found out that she recently lost 19lbs after starting long distance running. The MOST appropriate step in her evaluation is measurement of:
a) serum thyroid stimulating hormone concentration (TSH)
b) serum prolactin concentration
c) human chorionic gonadotropin (hCG) concentration
d) serum estradiol-17b concentration
e) serum testosterone concentration
c: Although exercise-induced secondary amenorrhea ay seem apparent in this case, it is imperative that pregnancy is rolled out as a cause of amenorrhea. All amenorrheic women of reproductive age should be assumed to be pregnant until proven otherwise. Therefore, hCG test is indicated as first step in evaluation of this pt. Sudden weight loss and increased physical activity can cause secondary amenorrhea, as can hypothyroidism and hyperprolactinemia. If ordering serum estradiol concentrations, an FSH level should also be ordered. Serum estradiol levels alone are less useful than FSH in deciphering the cause of amenorrhea. Decreased estradiol occurs with either hypothalamic-pituitary axis failure or ovarian failure. Decreased FSH indicates hypothalamic-pituitary axis failure whereas elevated FSH indicates ovarian failure. Ordering serum testosterone levels should only be considered if the pt has symptoms of PCOS or androgen excess.
Which of the following two causes of non traumatic vaginal bleeding are seen MOST frequently in the adolescent and reproductive aged women?
a) pregnancy and coagulopathy
b) thyroid dysfunction and anovulation
c) exogenous hormone use and polyps
d) anovulation and pregnancy
d: Anovulatory bleeding is seen in 10% to 15% of all gynecologic pts and is the most common cause of abnormal vaginal bleeding in adolescents. In perimenarchal adolescents it is causes by an immature hypothalamic-pituitary-ovarian axis. The top five causes of vaginal bleeding in the adolescent are listed by frequency: anovulation, pregnancy, exogenous hormone use, and coagulopathy. The top six causes of vaginal bleeding in the reproductive age woman are pregnancy, anovulation, exogenous hormone use, uterine leiomyomas, cervical and endometrial polyps, and thyroid dysfunction. The top four causes of vaginal bleeding in postmenopausal women are endometrial lesions, exogenous hormone use, atrophic vaginitis, and other tumors
A 25yo nulliparous white woman has a cc of heavy and frequent menstrual bleeding for the past year. She has never been sexually active; is moderately overweight; and has hirsutism and acne. She denies vaginal dryness, mood changes, or hot flashes. She also denies hot or cold intolerance, diarrhea, or heart palpitations. What part of this hx suggests polycystic ovarian syndrome (PCOS)?
a) her age and parity
b) sexual activity
c) weight, skin, and hair changes
d) moods and temperature
c: PCOS is suggested by her being moderately overweight and having hirsutism and acne. As has been claimed in many clinical medicine lectures over the years, 80-90% of the diagnosis can be made from the medical hx. The essential parts of the hx when investigating the causes of dysfunctional uterine bleeding are the age of menarche, menstrual hx, date of the first day of the last normal menstrual period, contraceptive use, signs and symptoms of coagulopathy (nosebleeds, petechiae, and ecchymoses), endocrine symptoms, menopause symptoms, weight changes and stress.
A man and woman in their 20s have been trying to unsuccessfully conceive for the last year. The woman has regular menses and a 28 day cycle. In the initial evaluation, which of the following tests or evaluations should be considered first line?
a) semen analysis
b) postcoital testing
c) hystersalpingogram
d) endometrial bx
a: Generally, infertility is defined as the inability for a couple to conceive after reasonably frequent unprotected sex for 1 year. In approaching the diagnostic work up for infertility, with a thorough physical exam and hx of both partners, the clinician should establish the following points: 1) does the woman ovulate? (if not, why?); 2) does the semen have normal characteristics? 3) is there a female reproductive tract abnormality? Noninvasive tests should be done first line. For the male partner, semen analysis is noninvasive and helpful, though not diagnostic. In the initial evaluation of the female partner, noninvasive procedures, such as measurement of the LH and mid-luteal phase progesterone (to determine ovulatory function) and TVUS (to r/o possibility of fibroids or polycystic ovaries), are first line investigations. Pelvic ultrasound should also be routine because it allows for a more precise evaluation of the position of the uterus within the pelvis and provides more info about its size and irregularities. Hysterosalpingography is an invasive procedure and therefore not first line. Endometrial bx and postcoital testing are no longer recommended because they have poor predictive value.
A 39yo woman, G3P3, complains of sever, progressive secondary dysmenorrhea and menorrhagia. Pelvic exam demonstrates a tender, diffusely enlarged uterus with no adnexal tenderness. Endometrial bx findings are normal. Which diagnostic test is needed next?
a) MRI
b) transvaginal and abdominal ultrasound
c) hysterosalpingography
d) laparoscopy
e) CT scan of pelvis
b: It is important to evaluate why this pt has an enlarged and tender uterus; therefore the next step in evaluation would be ultrasound. Common causes of secondary dysmenorrhea in this age group are endometriosis, adenomyosis, and presence of an IUD. For this pt, it would be important to r/o leiomyomas, endometrial polyps, and tumors. Given the most common causes, endometriosis and adenomyosis, noninvasive studies with transvaginal and abdominal ultrasound would be first choice. Imaging diagnosis of adenomyosis is usually made by TVUS or MRI. Abdominal ultrasound alone can be highly sensitive for detecting masses, but often lacks specificity for the dx of adenomyosis or endometriosis. Hysterosalpinography is more invasive and is used to exclude endometrial polyps, leiomyomas, and congenital abnormalities of the uterus. Laparoscopy is often used as a last resort to make dx of endometriosis.
Which of the following elements of a pts hx is the greatest risk factor for endometrial cancer?
a) age >70
b) postmenopausal bleeding
c) obesity
d) combination of progesterone and estrogen HT
b: More then 90% of pts with endometrial cancer present with postmenopausal bleeding, thus making it the hallmark hx component. In the US, endometrial cancer is the most common gynecologic cancer. There are several risk factors for developing type 1 endometrial cancer, but in general excessive estrogen is the cause. Therefore, women who are taking postmenopausal unopposed estrogen replacement or tamoxifen and women who are 50lbs above their ideal body weight, are at increased risk for endometrial hyperplasia and endometrial cancer. Type 2 endometrial cancers tend to occur in older, thinner women without exogenous estrogen exposure.
A 36yo G2P2 comes to your office complaining of heavy menstrual bleeding for the past year. She is bleeding through a super tampon and a heavy pad every hour of the first three days of her cycle. Her cycle lasts 5 days and the cycle length has decreased to having a period every 20 days. She complains of fatigue. Her physical exam and laboratory work up are normal (neg b-hCG, LH, FSH, prolactin, clotting times, liver function, and renal function tests), except for her CBC and further labs indicating she has iron deficiency anemia. The pts weight is 289lbs. In addition to iron supplementation, which of the following is the BEST INITIAL therapy for this pt?
a) hysterectomy
b) oral contraceptives
c) D&C
d) long term conjugated estrogen therapy
e) daily dosing of aspirin
b: Oral contraceptives are the best tx for this pt. Tx for premenopausal abnormal uterine bleeding is varied. Once infection, fibroid tumors, PG, neoplasm, and iatrogenic causes (eg, med related) are ruled out, a woman may be treated hormonally to control bleeding. IN this pt, the most likely cause of the bleeding is anovulatory cycles caused by estrogen excess due to her obesity. In addition, the iron deficiency anemia also can cause menometrorrhagia. In pts with irregular cycles, secondary to chronic anovulation, or oligo-ovulation, COC pills help to prevent the risks associated with prolonged unopposed estrogen stimulation of the endometrium. Tx with cyclic progestins for days 16-25 following the first day of the most recent menstrual flow is preferred when OCP use is c/i, such as smokers older than 35 and women at risk for thromboembolism.
A 26 you pt is complaint of depression and anxiety just prior to menses. The symptoms have ben going on for more than 1yr, but are now starting to interfere with her relationships and her productivity at work. One week prior to menses each month she experiences a depressed mood, a feeling of being on edge, increased irritability, difficulty sleeping, a feeling of being overwhelmed and is easily fatigued. She charted her symptoms daily in a log and returned to the office two cycles later. The log is consistent with the history. Her physical exam and general lab profile showed no abnormalities. Which of the following is the MSOT effective tx of choice for this disorder?
a) alprazolam
b) spironolactone
c) progesterone-only oral contraceptive
d) fluoxetine
e) ibuprofen
d: Approx 40% of menstruating women experience one or more of the cluster of physical, emotional, or behavioral symptoms associated with the luteal phase of the menstrual cycle (PMS), a small percentage have symptoms so severe that they meet the DMS-IV dx of premenstrual dysphoric disorder (PDD). For the tx of mild to moderate symptoms, lifestyle and dietary changes may be effective. Therefore, a trail of regular aerobic exercise, decrease in caffeine and alcohol intake, 1200mg of dietary calcium with 800IU of VitD per day, and eating complex carbs as opposed to simple sugars could be initiated. For pts whose symptoms affect jobs and relationships, it is warranted to prescribe SSRIs like fluoxetine.
A 32yo pt complaining of dysmenorrhea, deep dyspareunia, low back pain, and pelvic pain present to your office for evaluation. She denies menorrhagia and dysuria. She has a regular 28 day cycle. This history BEST fits with which of the following conditions?
a) adenomyosis
b) ovarian cancer
c) endometriosis
d) interstitial cystitis
c: the combo of dysmenorrhea, deep dyspareunia, low back pain, and chronic pelvic pain are most suggestive of endometriosis.The other conditions could all present with a pelvic pain component, but would have a different combo of other symptoms. Adenomysosis is commonly associated with menorrhagia and dysmenorrhea. Ovarian cancer would present with nonspecific findings such as ascites, abdominal discomfort, vague GI symptoms, pelvic or abdominal mass, and pain. Interstitial cystitis typically presents with urinary frequency and urgency, as well as suprapubic, perineal, vulvar, or vaginal pain before, during, or after urination.
A 25yo nulliparous woman complains of dysmenorrhea that has become progressively worse over the past two years. Her pain is described as constant, aching pain. It begins 2-7 days prior to onset of bleeding and does not subside until the menstrual flow decreases. In addition, she complains of pain with intercourse. She has never been pregnant and uses condoms and foam for contraception. You make the presumptive dx of endometriosis. Which of the following is the BEST way to confirm the dx?
a) MRI
b) pelvic ultrasound
c) trial of prostaglandin synthetase
d) laparoscopy
e) pelvic examination
d: Diagnostic laparoscopy is the only definite way to dx endometriosis. Ultrasound and MRI may be helpful in the diagnostic workup, but laparoscopy is the most certain method or diagnosing endometriosis
A 20yo nulliparous woman presents to the ED complaining of pelvic pain and fever and chills. Her symptoms have been ongoing for 3 days. She has no new sexual partners, but does not routinely use condoms with her current partner. Clinically, her cervix is erythematous, friable, and there is a mucopurulent discharge. The cervical motion tenderness is significant. Her PG test is negative and there are no adnexal masses. What is the MOST likely pathogen causing her symptoms?
a) Neisseria gonorrhoeae
b) Chlamydia trachomatis
c) Haemophilus influenza
d) E. coli
e) Gardnerella vaginalis
b: The pts dx is PID. for her age group, the most likely pathogens are sexually transmitted ones, C. trachomatis and N. gonorrhoeae. Of these 2 STD’s, C. trachomatis is more prevalent. Because the causes are often polymicrobial, tx should be broad based and for a long duration. As long as the pt is medically stable and can tolerate oral meds, she can be tx as an outpatient.
A 20yo nulligravida comes to your office complaining of pelvic pain and irregular menstrual bleeding. She denies sexual activity, and her b-hGC urine test is negative. She has never been on OCPs. On pelvic exam, you find unilateral tenderness on left side, and a palpable cystic mass approx 4-5cm in size. The MOST likely dx is:
a) ectopic pregnancy
b) functional ovarian cyst
c) choriocarcinoma
d) sarcoma
e) molar pregnancy
b: A functional ovarian cyst is a much more likely dx than any of the others listed. A follicular cyst develops when an ovarian follicle fails to rupture. The granulosa cells lining the cyst continue to enlarge and fluid continues to accumulate. Symptoms associated with a functional ovarian cyst include mild to moderate unilateral pain and alterations in the menstrual cycle. On occasion, rupture of the follicular cyst causes acute pelvic pain and may need laparoscopic surgery for complete evaluation. In most cases, pain control for 4-5 days is what is indicated as well as the consideration for contraception to suppress future ovarian cyst formation
A 25yo G1P1 presents with 2 days of r. sided pelvic pain and a hx of menstrual irregularities for 2 months. She denies fever, chills, or nausea. She has a negative PG test. Her pelvic exam reveals a 5cm mobile adnexal mass. Which element of the hx or physical exam is MOST specific for the dx of ovarian cysts and not for the dx of appendicitis, viral gastroenteritis, endometrial cysts, carcinoma, or tuba-ovarian abscess?
a) right sided pelvic pain
b) denial of fever, chills, or nausea
c) menstrual irregularities
d) adnexal mass
c: Menstrual irregularities are most specific for the functional ovarian cysts. Right sided pain could be associated with many items on the differential for abdominal pain. The presence of fever and chills would be more likely seen in appendicitis infections. The negative pregnancy test makes ectopic pregnancy much less likely. The adnexal mass could be a tube-ovarian abscess or an ovarian cyst.
A very firm ovarian mass estimated at 8cm is found in a 33yo woman at her annual examination. Which of the following interventions should be considered first?
a) combo chemo
b) radiation therapy
c) surgical consult
d) exploratory laparoscopy
c: The size and firmness of the ovarian mass suggest endometrial carcinoma, a tumor in which the potential for malignancy is 100%
In women with a BRCA1 gene mutation, which of the following types of cancer are they most at increased risk for developing.?
a) cervical cancer
b) ovarian cancer
c) endometrial cancer
d) vaginal cancer
b: BRCA1 & BRCA2 gene mutations are known genetic markers for BREAST AND OVARIAN CANCERS. There is a syndrome of inherited breast-ovarian cancer. Of all breast cancer cases in the US, 5-7% have the syndrome. About 45% of the syndrome cases carry the BRCA1 gene and 35% carry the BRCA2 mutation
A Pap smear is performed on a 40yo pt who has not had a Pap smear since the birth of her last baby (15 years ago). Today’s Pap smear results indicated squamous cell carcinoma. The reason she sought medical care was for postcoital bleeding. At the time of the Pap smear, there was a friable lesion present. At this point, the most appropriate step in this pts management is:
a) repeat Pap smear in 4-6 months
b) bx visualized lesion and refer pt for gynecological consult
c) colposcopy with endocervical curettage and directed bx
d) loop electrosurgical excision procedure (LEEP) or cervical conizaiton
e) radical hysterectomy and radiation therapy
b: There is no generalized clinical picture of cervical carcinoma, but there are two symptoms often associated with it. They are postcoital bleeding and abnormal uterine bleeding. The average age at dx is 50. Lesions on the cervix that should be considered for immediate bx include new exophytic, friable, or bleeding lesions. In this pt, the lesion should have been biopsied at initial examination and this would have helped to make the dx. When lesions are visualized and the bx confirms carcinoma, no colposcopic assessment is needed. This pt should definitely not wait 4-6 months for a repeat Pap smear. The gynecologic oncologist should stage the cancer and decide on appropriate therapy.
On physical exam of a 24yo nulligravida, an erythematous cervix with a yellow d/c is visualized. The pt has had one new partner in the past 60 days. She uses OCPs for birth control and rarely uses condoms. She has not noticed any pruritis, discharge, or vaginal pain. The wet prep reveals no hyphae or clue cells. Which of the following etiologic organisms BEST fits the clinical information given?
a) S. aureus
b) Chlamydia trachomatis
c) Gardnerella vaginalis
d) Candida albicans
e) HPV
b: Chlamydia should be suspected when there is eversion of the cervix and a mucopurulent cervicitis. Because of this pts use of hormonal birth control, her cervix would likely appear to have erosion, but she has a mucopurulent cervicitis. Bacterial vaginosis typically presents with a white d/c, amine (or “fishy”) odor, and possible itching. Candidiasis often presents with a hx of pruritis and a thick white d/c. On wet prep, bacterial vaginosis is dx by presence of clue cells and a positive KOH “whiff test” and vaginal candidiasis is dx by presence of yeast hyphae.
Cervical cysts are noted while performing a Pap smear. The MOST likely dx is:
a) Bartholin cyst
b) Nabothian cyst
c) cervicitis
d) HPV
e) cervical carcinoma
b: Nabothian follicles, or epithelial inclusion cysts, present characteristic appearance: they contain a dense, yellow, mucoid material. They warrant no further tx. A Bartholin duct cyst is the MC cystic growth in the vulva. When infected, it would be visualized as a fluctuant swelling of the inferior portion of the labia minora, presenting with periodic pain and dyspareunia. Cervicitis will present with a mucopurulent drainage from the cervical os; occasionally, with columnar evasion in chronic cases. Cervical polyps are benign, pedunculated growths of various sizes that extend from the ectocervix or endocervical canal.
A 25yo G1P1 presents to the clinic for her annual exam. She has no hx of abnormal Pap smears, but the results from today’s test show LSIL. Which of the following is the best option for what should be done next?
a) recheck Pap in 1 year
b) repeat Pap smear in 4-6 months, using traditional method
c) repeat Pap smear in 4-6 months, using liquid-based cytology
d) HPV testing
e) colposcopy
e: Based on the guidelines for testing; http://www.acog.org/Patients/FAQs/Abnormal-Cervical-Cancer-Screening-Test-Results (great chart!)
A 58yo woman who is postmenopausal since 8 yrs complains of urinary urgency, frequency, and occasional incontinence. On pelvic exam, her vaginal mucosa appears shiny, pale pink, with white patches, and bleeds slightly to touch. Her UA and Urine culture are negative. Which of the following is the BEST tx?
a) abx by mouth
b) testosterone cream to be applied to affected areas
c) vaginal suppositories containing sulfa abx
d) estrogen-containing vaginal cream or vaginal ring
e) surgical procedure
d: The pts symptoms describe postmenopausal atrophic changes affecting the vagina, bladder, and urethra. In women with more severe changes, vaginal irritation, dyspareunia, and fragility may become problems. Atrophy is dx by present of thin, clear, or bloody d/c; a vaginal pH of 5-7; loss of vaginal rug; and the finding of paranasal epithelial cells on microscopic exam of a wet mount. These symptoms are all d/t estrogen depletion. Tx with topical estrogen preparations appear equally effective.
A 48yo woman comes in for her annual physical exam and biannual screening mammogram. Her family hx is negative for breast ca. Her breast physical exam reveals no palpable masses; however, a screening and diagnostic mammogram demonstrates several course calcifications that are suspicious for breast ca. Which of the following statements is MOST accurate?
a) fine needle aspiration (FNA) would be the best diagnostic method for this finding.
b) because there is no palpable mass on physical exam, the pt may be observed with additional mammography in 3 months
c) an image-guided, local excisional bx provides the most definitive dx
d) a reasonable option for this pt is a core tissue bx done with stereotaxis
e) ultrasound imaging is the diagnostic method of choice for ductal carcinoma in situ (DCIS)
c: For mammography abnormalities that are non palpable and that require bx, imaging guided tissue sampling is necessary. Tissue for dx can be obtained by open surgical bx with needle localization. Although it has less morbidity, core needle bx (CNB) for small foci of highly suspicious micro calcifications with no associated mass is less beneficial because sampling errors are more common and local excision provides definitive tx. With non palpable lesions, CNB or excisional bx is preferred over FNA, because the sample provides adequate tissue for histologic dx and is more accurate. Ultrasonography is helpful if the radiologist thinks that the lesion has the appearance of a cyst, but DCIS cannot be dx until tissue samples and pathology are done.
For the tx of pelvic organ prolapse in a 32yo postpartum and breastfeeding woman, what would be the MOST appropriate first line therapy?
a) systemic estrogen therapy
b) anticholinergics
c) Kegal exercises
d) surgery
e) pessary
c: The pt may benefit from all of the options to some degree, but the most conservative approach would be to start with Kegal exercises. By strengthening the pelvic floor muscles, this problem may become much less bothersome and once natural estrogen levels are restored after the cessation of breastfeeding, the problem may completely be resolved. Systemic estrogens are c/i in breastfeeding because they decrease breast milk production. A pessary may be considered after failure of Kegal exercises. Pessaries could be especially helpful if the pts symptoms significantly interfere with her lifestyle. Surgery would be reserved for a pt whose symptoms do not improve with conservative therapy or who have significant prolapse.
Which of the following is the MOST common symptom of a cystocele?
a) difficulty defecating
b) straining to urinate
c) low back pain
d) dribbling urine when coughing
d: The most common symptoms of a general pelvic relaxation in general is a feeling of pressure or as if something is protruding from the vagina. With a rectocele, pts may have difficulty defecating. Straining to urinate may be a symptoms of a cystocele, but the most common symptom of a cystocele is stress incontinence, which is often described by pts dribbling when they cough, sneeze, or jump. Pelvic relaxation may be improved with Kegal exercises, although once the exercises are discontinued the symptoms often return. Pessaries can also be used to prevent stress incontinence. Ultimately, a surgical referral may be needed to correct the problem
