Women's Health EOR Correct 100%

A 23-year-old female presents complaining of vaginal irritation, pruritus and a discharge described as grayish with a "fishy" odor. LNMP was 1 week ago, urine hCG is negative and she denies recent sexual activity. What is most likely to be found on microscopic exam? A clue cells B Gram negative diplococci C motile organisms D spores - ANSWER A This patient has bacterial vaginosis. It is a polymicrobial disease with overgrowth of Gardnerella which is not sexually transmitted. The discharge is malodorous, "fishy", sometimes frothy. On wet mount, epithelial cells appear covered with bacteria obscuring cell borders (clue cells). A 33-year-old G2P1 has just delivered a singleton male infant with no complications. The umbilical cord was doubly clamped and cut by the father. There are no cervical or vaginal lacerations. Within 10 minutes, there is minimal fresh blood in the vagina, the umbilical cord has lengthened and the uterus has become firm. What is the diagnosis? A abruptio placentae B normal placental separation C uterine atony D vasa previa - ANSWER B Spontaneous normal placental separation is impending when the uterus becomes firm, there is a sudden gush of blood from the vagina and the umbilical cord moves down out of the vagina. When is the best time to draw maternal serum alpha fetoprotein? A 10-12 weeks B 15-18 weeks C 20-22 weeks D 24-28 weeks - ANSWER B Maternal serum alpha-fetoprotein should be drawn at 15-18 weeks' gestation; it screens for open neural tube defects. A 23-year-old female who is G1P0 and 16 weeks pregnant presents to the emergency department with painless vaginal bleeding x 2 hours. She denies fever or abdominal pain or cramping. Ultrasound confirms intrauterine gestation. Fetal heart tones (FHTs) are strong at 165 bpm. She had a normal Pap smear 2 years ago. Exam reveals cervical dilation at 2 cm. What is the most appropriate intervention at this time? A cervical cerclage B dilation and curettage C dilation and evacuation D delivery - ANSWER A This patient presents with cervical insufficiency. This is still a viable pregnancy because she has no abdominal cramping and she is now in the 2nd trimester but she is starting to dilate. A cervical cerclage is recommended between 13-16 weeks' gestation. Contraindications to cerclage placement include bleeding of unknown etiology, infection, labor, ruptured membranes and fetal anomalies. A 53-year-old woman presents to her primary care physician for a routine examination. She notes that she began having hot flashes several months prior to presentation along with occasional painful urination. She notes that her periods have become more frequent and irregular, but have become lighter overall. Which of the following is most likely to be true regarding this patient's levels of follicle stimulating hormone (FSH), luteinizing hormone (LH), and androstenedione? A Increased FSH, increased LH, increased androstenedione B Increased FSH, increased LH, no change in androstenedione C Decreased FSH, decreased LH, increased androstenedione D Decreased FSH, no change in LH, no change in androstenedione E No change in FSH, decreased LH, increased androstenedione - ANSWER B This patient's clinical presentation is consistent with menopause, which is characterized by increased FSH and LH, with no change in androstenedione levels. Metronidazole 2 g orally as a single dose or 500 mg twice daily for 7 days is the treatment regimen for which of the following vaginal infections? A chlamydia B candidiasis C trichomoniasis D Staphylococcus - ANSWER C The high-dose regimen of metronidazole is for the treatment of Trichomoniasis. Trichomonas vaginalis causes this common sexually transmitted disease. The clinical characteristics include a profuse yellow, frothy, malodorous, pruritic discharge. Sometimes a strawberry cervix (subepithelial redness) is seen. The pH is between 4.5 and 6. The treatment for chlamydia is azithromycin or doxycycline. Candidiasis would be treated with an imidazole. Staphylococcus infection could be treated by many different antibiotics other than metronidazole. A 25-year-old nullipara presents for consultation because she suddenly stopped menstruating. On questioning her further it is found that she recently lost 19 lb after starting long-distance running. The MOST appropriate step in her evaluation is measurement of A serum thyroid stimulating hormone (TSH) concentration B serum testosterone concentration C serum prolactin concentration D human chorionic gonadotropin (hCG) concentration E serum estradiol-17b concentration - ANSWER D Although exercise-induced secondary amenorrhea may seem apparent in this case, it is imperative that pregnancy is ruled out as a cause of the amenorrhea. All amenorrheic women of reproductive age should be assumed to be pregnant until proven otherwise. Therefore, an hCG test is indicated as a first step in the evaluation of this patient. 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 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 patient has symptoms of PCOS or androgen excess. A 25-year-old nulliparous white woman has a chief complaint 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 swings, or hot flashes. She also denies hot or cold intolerance, diarrhea, or heart palpitations. Which part of this history suggests polycystic ovarian syndrome? A her age and parity B sexual activity C weight, skin, and hair changes D moods and temperature - ANSWER C Polycystic ovarian syndrome (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% to 90% of the diagnosis can be made from the medical history. The essential parts of the history when investigating the causes of dysfunctional uterine bleeding are age of menarche, menstrual history, 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 unsuccessfully to 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 hysterosalpingogram D endometrial biopsy - ANSWER A Generally, infertility is defined as the inability for a couple to conceive after reasonably frequent unprotected intercourse for 1 year. In approaching the diagnostic work-up for infertility, with a thorough physical examination and history of both partners, the clinician should establish the following points: (1) does the woman ovulate? (if not, why not); (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 the measurement of LH and mid-luteal phase progesterone (to determine ovulatory function) and TVUS (to rule out the possibility of fibroids or polycystic ovaries), are first-line investigations. Pelvic ultrasound should also be part of the routine gynecologic evaluation because it allows a more precise evaluation of the position of the uterus within the pelvis and provides more information about its size and irregularities. Hysterosalpingography is an invasive procedure and therefore not first line in the evaluation. Endometrial biopsy and postcoital testing are no longer recommended for the routine infertility evaluation because they have poor predictive value. A 39-year-old woman, G3, P3, complains of severe, progressive secondary dysmenorrhea and menorrhagia. Pelvic examination demonstrates a tender, diffusely enlarged uterus with no adnexal tenderness. Endometrial biopsy findings are normal. Which diagnostic examination is needed next? A magnetic resonance imaging (MRI) B transvaginal and abdominal ultrasound C hysterosalpingography D laparoscopy E computed tomography (CT) scan of the pelvis - ANSWER B It is important to evaluate why this patient 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 the presence of an intrauterine device. For this patient, it would be important also to rule out leiomyomas, endometrial polyps, and tumors. Given the most common causes, endometriosis and adenomyosis, noninvasive studies with transvaginal and abdominal ultrasound would be a reasonable (and economical) first choice. The imaging diagnosis of adenomyosis is usually made by using TVUS or, more expensively, by MRI. Abdominal ultrasound alone can be highly sensitive for detecting masses, but often lacks specificity for the diagnosis of adenomyosis or endometriosis. Hysterosalpingography is more invasive and is used to exclude endometrial polyps, leiomyomas, and congenital abnormalities of the uterus. The inability to resolve subtle differences in soft tissue attenuation limits the usefulness of computed tomography (CT). Laparoscopy is often needed as a last resort to make the diagnosis of endometriosis where surgical correction can occur simultaneously. Which of the following elements of a patient's history is the greatest risk factor for endometrial cancer? A age greater than 70 years B postmenopausal bleeding C obesity D combination progestin and estrogen hormone therapy - ANSWER B More than 90% of patients with endometrial cancer present with postmenopausal bleeding, thus making it the hallmark history component. In the United States, endometrial cancer is the most common gynecologic cancer. There are approximately 39,000 cases of endometrial cancer diagnosed each year and about 7,400 patients die from the disease. Of all endometrial cancer cases, 75% are type I and 25% are type II. There are several risk factors for developing type I 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 50 lb above their ideal body weight, are at risk for endometrial hyperplasia and endometrial cancer. Type II endometrial cancers tend to occur in older, thinner women without exogenous estrogen exposure. A 36-year-old G2, P2 comes to your office complaining of heavy menstrual bleeding for the past year. The patient 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 examination and laboratory work-up are normal (negative β-hCG, luteinizing hormone (LH), follicle stimulating hormone (FSH), prolactin, clotting times, liver function, and renal function tests), except for the complete blood cell count (CBC) and further labs indicating she has iron deficiency anemia. The patient's weight is 298 lb. In addition to iron supplementation, which of the following is the BEST INITIAL therapy for this patient? A hysterectomy B oral contraceptives C dilation & curettage D long-term conjugated estrogen therapy E daily dosing of aspirin - ANSWER B Oral contraceptives are the best treatment for this patient. Treatment for premenopausal abnormal uterine bleeding is varied. Once infection, fibroid tumors, pregnancy, neoplasm, and iatrogenic causes (eg, medication related) are ruled out, a woman may be treated hormonally to control bleeding. In this patient, 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 patients with irregular cycles, secondary to chronic anovulation, or oligo-ovulation, combined oral contraceptive (COC) pills help to prevent the risks associated with prolonged unopposed estrogen stimulation of the endometrium. Treatment with cyclic progestins for days 16 through 25 following the first day of the most recent menstrual flow is preferred when OCP use is contraindicated, such as in smokers older than age 35 and women at risk for thromboembolism. A 25-year-old patient is complaining of depression and anxiety just prior to her menses. The symptoms have been going on for more than 1 year, 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 examination and general laboratory profile showed no abnormalities. Which of the following is the MOST effective treatment choice for this disorder? A alprazolam B spironolactone C progestin-only oral contraceptive D fluoxetine E ibuprofen - ANSWER D Although approximately 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 (premenstrual syndrome or premenstrual tension), a small percentage have symptoms so severe that they meet the DMS-V diagnosis of premenstrual dysphoric disorder (PMDD). For the treatment of mild to moderate symptoms, lifestyle and dietary changes may be effective. Therefore, a trial of regular aerobic exercise, decrease in caffeine and alcohol intake, 1,200 mg of dietary calcium with 800 IU of Vitamin D per day, and eating complex carbohydrates as opposed to simple sugars could be initiated. For patients whose symptoms affect jobs and relationships, it is warranted to prescribe serotonin reuptake inhibitor such as fluoxetine. Fluoxetine 20 mg can be taken daily or only premenstrually. A 25-year-old nulliparous woman complains of dysmenorrhea that has become progressively worse over the past 2 years. Her pain is described as a constant, aching pain. It begins 2 to 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 diagnosis of endometriosis. Which of the following is the BEST way to confirm the diagnosis definitively? A MRI B pelvic ultrasound C trial of prostaglandin synthetase D laparoscopy E pelvic examination - ANSWER D Diagnostic laparoscopy is the only definitive way to diagnose endometriosis. Ultrasound and MRI may be helpful in the diagnostic work-up, but laparoscopy is the most certain method of diagnosing endometriosis. A 47-year-old G3, P1 woman comes into the office complaining of heavy, painful, and irregular menstrual bleeding that has been going on for the past 6 months to a year. She has not been sexually active for the past year. On physical examination, her uterus is estimated to be the size of a uterus at 12 weeks' gestation. Pelvic ultrasound confirms the presence of a leiomyoma. Her hematocrit is 29%, mean corpuscular volume (MCV) is 68 fL, and serum ferritin is 10 g/L. What should be the first-line therapy? A myomectomy of leiomyoma B hysterectomy C ablation therapy D oral contraceptive therapy in standard doses E depot methodroxyprogesterone acetate - ANSWER E This patient has a leiomyoma of the uterus (or fibroid tumors), which is the most common benign neoplasm, but she is also significantly anemic. The labs suggest iron deficiency anemia. It is important to control her bleeding and treat her anemia prior to surgery. The heavy bleeding that typically accompanies fibroid tumors can be minimized by using intermittent progestin supplementation (depot methodroxyprogesterone acetate 150 mg IM every 28 days) and/or prostaglandin synthetase inhibitors. In general, the size of the mass can be decreased and the bleeding can be lessened, but the only curative treatment is a myomectomy or hysterectomy. A woman has undergone a suction curettage for a hydatidiform mole and was diagnosed with benign gestational trophoblastic neoplasia (GTN). Following this INITIAL treatment, which choice of monitoring should be done for patients in order to prevent the development of choriocarcinoma? A monitor serum radioimmunoassay β-hCG once per week until three to four normal values are obtained, and then monthly for a year B follow-up every 2 weeks with a urine pregnancy test C administer prophylactic chemotherapy D monitor serum hCG levels after 6 months and again at 1 year E monitor serum hCG levels monthly accompanied by chest X-ray to rule out metastases - ANSWER A Gestational trophoblastic neoplasia (GTN) consists of benign GTN, most often a hydatidiform mole and malignant GTN, which includes nonmetastatic and metastatic GTN. Approximately, 15% to 20% of women who have a complete hydatidiform mole and 2% to 4% of partial moles, will go on to develop some form of malignant GTN. Complete and partial molar pregnancies differ clinically, genetically, and histologically. Because of the risk for progression to malignancy, these patients must be monitored. After molar evacuation, serum radioimmunoassay β-hCG levels should be monitored weekly until they have become undetectable. Historically, monitoring has continued monthly after the undetectable levels for at least 6 additional months. However, studies have shown that it is safe to cease monitoring after a single blood sample demonstrates undetectable levels of β-hCG. Urine pregnancy tests are inadequate, and a sensitive radioimmunoassay is mandatory. Prophylactic chemotherapy is controversial because of significant drug toxicity and possible lack of efficacy; it is usually reserved for highest risk cases or for patients who are unable to return for regular follow-up. Routine chest X-ray at every visit is not warranted unless hCG values A 20-year-old nulliparous woman presents to the emergency department (ED) complaining of pelvic pain and fever and chills. Her symptoms have been going on for 3 days. She has had no new sexual partners, but does not routinely use condoms with her current partner because they "have been dating for 1 year." Clinically, her cervix is erythematous, friable, and there is a mucopurulent discharge. The cervical motion tenderness is significant. Her pregnancy 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 influenzae D Escherichia coli E Gardnerella vaginalis - ANSWER B The patient's diagnosis is PID. For her age group, the most likely pathogens are the sexually transmitted ones, C. trachomatis and N. gonorrhoeae. Of these two sexually transmitted diseases (STDs), C. trachomatis is more prevalent. Because the causes are often polymicrobial, treatment should be broad-based and for a long duration. As long as the patient is medically stable and can tolerate oral medication, she can be treated as an outpatient. One recommended outpatient treatment is Ofloxacin 400 mg once daily for 14 days; with or without metronidazole 500 mg twice daily for 14 days. A 20-year-old nulligravida comes to your office complaining of pelvic pain and irregular menstrual bleeding. She denies sexual activity, and her β-hCG urine test is negative. She has never been on oral contraceptives. On pelvic examination, you find unilateral tenderness on the left side, and a palpable cystic mass approximately 4 to 5 cm in size. The MOST likely diagnosis is A ectopic pregnancy