Block 19 Explanations
• A 31-year-old woman comes to the physician because she has not had a menstrual period for 7
months. She previously had normal cycles. She also states that over the past year she has felt
increasingly weak and tired. She notes that she always feels cold and that her hair has been thinning
over the course of the year. She also complains of constipation, weight gain, and depression. Her
temperature is 36.7 C (98 F), blood pressure is 100/60 mm Hg, pulse is 56/minute, and respirations
are 10/minute. Examination is significant for brittle hair and delayed deep tendon reflexes. Urine
human chorionic gonadotropin (hCG) is negative. Thyroid stimulating hormone (TSH) is 20 µU/mL.
Prolactin is normal. Which of the following is the most likely cause of this patient's amenorrhea?
• Hyperprolactinemia
• Hypothyroidism
• Kallmann syndrome
• Polycystic ovarian syndrome
• Pregna
ncy
Explanati
on:
The correct answer is
B. Secondary amenorrhea is defined as the absence of menses for 6 cycle intervals or 12 months in a
woman who previously had regular cycles. This patient, therefore, has secondary amenorrhea. She
also has a constellation of signs and symptoms that are highly suggestive of hypothyroidism. Patients
with hypothyroidism often complain of some combination of weakness, fatigue, cold intolerance,
constipation, weight gain, depression, or thinning of the hair. Physical examination can reveal
bradycardia and low blood pressure. Laboratory evaluation often shows an elevated TSH as the
pituitary attempts to stimulate the underfunctioning thyroid. However, many patients with
hypothyroidism will be asymptomatic and the thyroid abnormality is found by thyroid function tests.
Hypothyroidism likely leads to amenorrhea through changes in GnRH production. Treatment with
thyroid replacement will often return these patients to regular menses. Hyperprolactinemia (choice A)
is the cause of secondary amenorrhea in approximately 20% of cases. This patient, however, has a
normal prolactin level. Kallmann syndrome (choice C) is a rare cause of primary amenorrhea. This
syndrome is characterized by gonadotropin deficiency, anosmia or hyposmia, cleft lip or palate, and
minimal sexual development. This patient does not have primary amenorrhea. Polycystic ovarian
syndrome (choice D) is often characterized by obesity, hirsutism, infertility, and oligomenorrhea.
Thyroid dysfunction is not part of
,this syndrome. Pregnancy (choice E) is, by far, the most common cause of secondary amenorrhea.
This patient has a negative urine hCG.
• A 75-year-old woman comes to the physician because of irregular vaginal bleeding. She has been
menopausal for the past 25 years, but has noted on-and-off spotting for the past 2 years, which she
finds intolerable. She has a complicated past medical history including hypertension, diabetes, and
severe chronic obstructive pulmonary disease. Examination is unremarkable. An endometrial biopsy
is performed that demonstrates an endometrial polyp with atypical cells that are difficult to grade.
Which of the following is the most appropriate next step in management?
• Hormone replacement therapy
• Oral contraceptive pill
• Hysteroscopy
• Laparoscopy
• Hysterecto
my
Explanation:
The correct answer is
C. This patient is likely having irregular spotting secondary to the polyp. Endometrial polyps are
projections of endometrial tissue that protrude into the endometrial cavity. They can be seen in
women of any age, but are most commonly seen in perimenopausal women. This problem should be
addressed for 2 reasons: 1. The bleeding per vagina is distressing to the patient. 2. There are some
atypical cells from the biopsy that may represent cancer and polyps can contain malignant cells within
them. Therefore, the polyp should be removed. The question then becomes how best to remove it. A
hysteroscopy can be performed under monitored anesthesia care (MAC), an approach that provides
adequate anesthesia without requiring the patient to have general anesthesia. It would be preferable
to avoid general anesthesia in a patient with so many medical conditions. Hysteroscopy would allow
visualization of the entire uterine cavity and removal of the polyp. A curettage should be performed
afterward to fully sample the cavity. Hormone replacement therapy (choice A) would not be the most
appropriate next step. First, the polyp must be removed and histologic evaluation of the polyp and
endometrial tissues performed to rule out malignancy prior to instituting hormone replacement
therapy. The oral contraceptive pill (choice B) would not be appropriate management for a 75-year-
old woman, as the dose of hormones is higher than necessary. Laparoscopy (choice D) would not be
indicated. This patient is having spotting, which is an intrauterine process. Laparoscopy allows
visualization of only the external, serosal uterine surface. Hysterectomy (choice E) would not be the
most appropriate management. Hysterectomy would take care of the patient's spotting and would
provide tissue for pathologic diagnosis. However, in this patient with multiple medical problems, the
same goals can be achieved with the less invasive procedure of hysteroscopy.
, • A 31-year-old woman, gravida 1, para 0, at 36-weeks' gestation with twins comes to the physician
for a prenatal visit. The patient has had no contractions, bleeding from the vagina, or loss of fluid,
and the babies are moving well. An ultrasound that was performed today shows that the presenting
fetus is vertex and the non-presenting fetus is breech. Both fetuses are appropriately grown and
greater than 2000 g. The patient wants to know if she should have a vaginal or cesarean delivery.
Which of the following is the proper counseling for this patient?
• Both vaginal delivery and cesarean delivery are acceptable.
• Cesarean delivery is mandated because the fetuses are > 2000g.
• Cesarean delivery is mandated because the second twin is breech.
• Vaginal delivery is mandated because the fetuses are > 2000g.
• Vaginal delivery is mandated because the first twin is
vertex. Explanation:
The correct answer is
A. Mode of delivery with twin gestations is an area that has generated controversy over time. Patients
with vertex-vertex twins are generally allowed to have a vaginal delivery. Patients with a presenting
twin that is non-vertex are generally advised to have a cesarean delivery. Patients with the presenting
twin vertex and the non-presenting twin non-vertex may decide which mode of delivery they would
prefer. Once the presenting (vertex) twin has delivered, there are essentially 2 options for delivery of
the second (non-vertex) twin. The first option is an external cephalic version, in which the head of the
second twin is guided into the pelvis so that it becomes a vertex presentation. The second option is a
breech extraction of the second twin. Breech extraction may be performed so long as there is an
adequate pelvis, a fetal weight greater than 2,000g, an experienced physician, a flexed fetal head, and
available general anesthesia. To state that cesarean delivery is mandated because the fetuses are >
2000g (choice B) is incorrect. The fact that the fetuses are > 2000g makes a vaginal delivery with a
non- vertex second twin possible. To state that cesarean delivery is mandated because the second
twin is breech (choice C) is incorrect. As explained above, vertex-nonvertex twins may be delivered
vaginally so long as certain criteria are met. To state that vaginal delivery is mandated because the
fetuses are > 2000g (choice D) is incorrect. Vaginal delivery is possible because the fetuses are >
2000g, but the mother may still choose to have a cesarean delivery. To state that vaginal delivery is
mandated because the first twin is vertex (choice E) is incorrect. With the first twin vertex, vaginal
delivery is possible, but with a non-vertex second twin, cesarean delivery would also be entirely
appropriate.
• A 27-year-old woman comes to the physician because of fevers and back pain. She states that a few
days ago she had burning with urination. Over the next few days she developed fevers and chills and
a pain on the right side of her back. She has no medical problems and takes no medications. Her
• A 31-year-old woman comes to the physician because she has not had a menstrual period for 7
months. She previously had normal cycles. She also states that over the past year she has felt
increasingly weak and tired. She notes that she always feels cold and that her hair has been thinning
over the course of the year. She also complains of constipation, weight gain, and depression. Her
temperature is 36.7 C (98 F), blood pressure is 100/60 mm Hg, pulse is 56/minute, and respirations
are 10/minute. Examination is significant for brittle hair and delayed deep tendon reflexes. Urine
human chorionic gonadotropin (hCG) is negative. Thyroid stimulating hormone (TSH) is 20 µU/mL.
Prolactin is normal. Which of the following is the most likely cause of this patient's amenorrhea?
• Hyperprolactinemia
• Hypothyroidism
• Kallmann syndrome
• Polycystic ovarian syndrome
• Pregna
ncy
Explanati
on:
The correct answer is
B. Secondary amenorrhea is defined as the absence of menses for 6 cycle intervals or 12 months in a
woman who previously had regular cycles. This patient, therefore, has secondary amenorrhea. She
also has a constellation of signs and symptoms that are highly suggestive of hypothyroidism. Patients
with hypothyroidism often complain of some combination of weakness, fatigue, cold intolerance,
constipation, weight gain, depression, or thinning of the hair. Physical examination can reveal
bradycardia and low blood pressure. Laboratory evaluation often shows an elevated TSH as the
pituitary attempts to stimulate the underfunctioning thyroid. However, many patients with
hypothyroidism will be asymptomatic and the thyroid abnormality is found by thyroid function tests.
Hypothyroidism likely leads to amenorrhea through changes in GnRH production. Treatment with
thyroid replacement will often return these patients to regular menses. Hyperprolactinemia (choice A)
is the cause of secondary amenorrhea in approximately 20% of cases. This patient, however, has a
normal prolactin level. Kallmann syndrome (choice C) is a rare cause of primary amenorrhea. This
syndrome is characterized by gonadotropin deficiency, anosmia or hyposmia, cleft lip or palate, and
minimal sexual development. This patient does not have primary amenorrhea. Polycystic ovarian
syndrome (choice D) is often characterized by obesity, hirsutism, infertility, and oligomenorrhea.
Thyroid dysfunction is not part of
,this syndrome. Pregnancy (choice E) is, by far, the most common cause of secondary amenorrhea.
This patient has a negative urine hCG.
• A 75-year-old woman comes to the physician because of irregular vaginal bleeding. She has been
menopausal for the past 25 years, but has noted on-and-off spotting for the past 2 years, which she
finds intolerable. She has a complicated past medical history including hypertension, diabetes, and
severe chronic obstructive pulmonary disease. Examination is unremarkable. An endometrial biopsy
is performed that demonstrates an endometrial polyp with atypical cells that are difficult to grade.
Which of the following is the most appropriate next step in management?
• Hormone replacement therapy
• Oral contraceptive pill
• Hysteroscopy
• Laparoscopy
• Hysterecto
my
Explanation:
The correct answer is
C. This patient is likely having irregular spotting secondary to the polyp. Endometrial polyps are
projections of endometrial tissue that protrude into the endometrial cavity. They can be seen in
women of any age, but are most commonly seen in perimenopausal women. This problem should be
addressed for 2 reasons: 1. The bleeding per vagina is distressing to the patient. 2. There are some
atypical cells from the biopsy that may represent cancer and polyps can contain malignant cells within
them. Therefore, the polyp should be removed. The question then becomes how best to remove it. A
hysteroscopy can be performed under monitored anesthesia care (MAC), an approach that provides
adequate anesthesia without requiring the patient to have general anesthesia. It would be preferable
to avoid general anesthesia in a patient with so many medical conditions. Hysteroscopy would allow
visualization of the entire uterine cavity and removal of the polyp. A curettage should be performed
afterward to fully sample the cavity. Hormone replacement therapy (choice A) would not be the most
appropriate next step. First, the polyp must be removed and histologic evaluation of the polyp and
endometrial tissues performed to rule out malignancy prior to instituting hormone replacement
therapy. The oral contraceptive pill (choice B) would not be appropriate management for a 75-year-
old woman, as the dose of hormones is higher than necessary. Laparoscopy (choice D) would not be
indicated. This patient is having spotting, which is an intrauterine process. Laparoscopy allows
visualization of only the external, serosal uterine surface. Hysterectomy (choice E) would not be the
most appropriate management. Hysterectomy would take care of the patient's spotting and would
provide tissue for pathologic diagnosis. However, in this patient with multiple medical problems, the
same goals can be achieved with the less invasive procedure of hysteroscopy.
, • A 31-year-old woman, gravida 1, para 0, at 36-weeks' gestation with twins comes to the physician
for a prenatal visit. The patient has had no contractions, bleeding from the vagina, or loss of fluid,
and the babies are moving well. An ultrasound that was performed today shows that the presenting
fetus is vertex and the non-presenting fetus is breech. Both fetuses are appropriately grown and
greater than 2000 g. The patient wants to know if she should have a vaginal or cesarean delivery.
Which of the following is the proper counseling for this patient?
• Both vaginal delivery and cesarean delivery are acceptable.
• Cesarean delivery is mandated because the fetuses are > 2000g.
• Cesarean delivery is mandated because the second twin is breech.
• Vaginal delivery is mandated because the fetuses are > 2000g.
• Vaginal delivery is mandated because the first twin is
vertex. Explanation:
The correct answer is
A. Mode of delivery with twin gestations is an area that has generated controversy over time. Patients
with vertex-vertex twins are generally allowed to have a vaginal delivery. Patients with a presenting
twin that is non-vertex are generally advised to have a cesarean delivery. Patients with the presenting
twin vertex and the non-presenting twin non-vertex may decide which mode of delivery they would
prefer. Once the presenting (vertex) twin has delivered, there are essentially 2 options for delivery of
the second (non-vertex) twin. The first option is an external cephalic version, in which the head of the
second twin is guided into the pelvis so that it becomes a vertex presentation. The second option is a
breech extraction of the second twin. Breech extraction may be performed so long as there is an
adequate pelvis, a fetal weight greater than 2,000g, an experienced physician, a flexed fetal head, and
available general anesthesia. To state that cesarean delivery is mandated because the fetuses are >
2000g (choice B) is incorrect. The fact that the fetuses are > 2000g makes a vaginal delivery with a
non- vertex second twin possible. To state that cesarean delivery is mandated because the second
twin is breech (choice C) is incorrect. As explained above, vertex-nonvertex twins may be delivered
vaginally so long as certain criteria are met. To state that vaginal delivery is mandated because the
fetuses are > 2000g (choice D) is incorrect. Vaginal delivery is possible because the fetuses are >
2000g, but the mother may still choose to have a cesarean delivery. To state that vaginal delivery is
mandated because the first twin is vertex (choice E) is incorrect. With the first twin vertex, vaginal
delivery is possible, but with a non-vertex second twin, cesarean delivery would also be entirely
appropriate.
• A 27-year-old woman comes to the physician because of fevers and back pain. She states that a few
days ago she had burning with urination. Over the next few days she developed fevers and chills and
a pain on the right side of her back. She has no medical problems and takes no medications. Her
