Women's health - rosh

Answer: Adenocarcinoma.

. Question: What is the most common type of endometrial carcinoma?

ABegin workup for primary amenorrheaCorrect Answer Avid exercise (B) can be a cause of both primary and secondary amenorrhea, by causing functional hypothalamic amenorrhea, however, this is only diagnosed after ruling out all other causes. Inducing a cycle with medroxyprogesterone (C) is a strategy used for the treatment of secondary amenorrhea. Not initiating a workup (D) is inappropriate, as primary amenorrhea is defined by age 13 if no secondary sexual characteristics have developed.

A 13-year-old girl presents to the office with her mother, who is concerned she has not had a menstrual cycle. She is an avid runner, logging 30 miles per week. On exam, she exhibits no breast development or axillary or genital hair. Her mother was 15 when she started her menstrual cycle. What is your next step? ABegin workup for primary amenorrhea BEncourage her to stop exercising for 3 months CInduce cycle with medroxyprogesterone DNo workup but provide education on the topic

BPrimary amenorrheaCorrect Answer. Primary amenorrhea, seen in approximately 2.6% of the population, is defined as absence of menarche by age 15 in a woman with normal growth and secondary sexual development or age 13 in a woman without normal growth and secondary sexual development. Secondary amenorrhea occurs in women who have previously menstruated and is defined as absence of menses for more than 3 cycles or 6 months. The most common cause of primary amenorrhea is caused by gonadal dysgenesis due to a chromosome abnormality, while other causes include hypothalamic disease, pituitary disease, abnormal hymen (as in the patient above) or vagina development, or uterine agenesis. The patient may have a family history significant for sexual development abnormalities. The most common cause of secondary amenorrhea is pregnancy, followed by abnormalities of the hypothalamic-pituitary-ovary axis, thyroid disease, and ova

A 14-year-old girl presents to clinic with some frustration over never having a menstrual period. She is short in stature and has Tanner stage 2 breast development. As you begin a gynecological exam, you realize you cannot pass a speculum into the vagina. Which of the following is the most likely diagnosis? AAbnormal uterine bleeding BPrimary amenorrhea CSecondary dysmenorrhea DSheehan syndrome

CPredominance of gram negative rods on gram stainCorrect Answer. A predominance of gram-negative rods on gram stain is characteristic of bacterial vaginosis, an overgrowth of vaginal anaerobes. Improvement on oral metronidazole (A) is characteristic of both bacterial vaginosis and trichmoniasis. Patients taking metronidazole should be cautioned about a disulfiram-like reaction if alcohol is consumed during a course of metronidazole. Multiple punctate hemorrhagic cervical lesions (B) describe the classic "strawberry cervix" that is associated with trichmoniasis. A vaginal pH of <4.5 is normal, but a more basic vaginal pH of 5.5 (D) is characteristic of both bacterial vaginosis and trichmoniasis.

A 15-year-old girl presents with vaginal discharge over the past two weeks. She reports recently becoming sexually active but uses condoms consistently during intercourse. Which of the following favors a diagnosis of bacterial vaginosis over trichomoniasis? AImprovement on oral metronidazole BMultiple punctate hemorrhagic cervical lesions CPredominance of gram negative rods on gram stain DVaginal pH of 5.5

CPlacental abruptionCorrect Answer

A 17-year-old girl is examined for a routine visit. She eats a healthy diet. She also stays active by playing volleyball three times a week. Her grades are mostly Bs. She reports she started to be sexually active for the past six months and has delayed periods for two months now. She had her menarche at 12 years old and has regular periods. She also smokes a quarter of a pack of cigarettes per day. Which of the following is an adverse pregnancy outcome due to maternal smoking? AHyperbilirubinemia BLarge for gestational age CPlacental abruption DRespiratory distress syndrome

CIncreased luteinizing hormoneCorrect Answer. The patient has manifestations of hyperandrogenism and menstrual abnormalities that are suspicious for polycystic ovary syndrome (PCOS). PCOS is characterized by the triad of oligo-ovulation or anovulation, clinical or biochemical hyperandrogenism, and ovarian cysts (greater than or equal to 12 follicles) Increased cortisol (A) is due to hypercortisolism that presents with facial plethora, supraclavicular fat pads, buffalo hump, truncal obesity, and purple striae, which the patient does not have. Increased follicle-stimulating hormone (B) is present in ovarian failure, which can be due to Turner syndrome, autoimmune disease, chemotherapy, or premature menopause. Increased thyroid-stimulating hormone (D) is due to hypothyroidism and commonly manifests as fatigue, constipation, weight gain, bradycardia, coarse hair and skin.

A 17-year-old girl is seen in clinic due to complaints of excessive body hair. She denies taking any medication. She has irregular menses and denies sexual activity. On exam, her BMI is 31, with moderate hirsutism on upper lip and chest, moderate acne on her face, Tanner 5 breasts and pubic hair. The rest of her exam findings are normal. Which of the following is an expected laboratory finding? AIncreased cortisol BIncreased follicle-stimulating hormone CIncreased luteinizing hormone DIncreased thyroid-stimulating hormone

BInitiate screening at age 21 with cytology onlyCorrect Answer. HPV testing is not recommended in women under age 30 (A). Younger women are more likely to have transient HPV infections, and testing at a young age leads to unnecessary colposcopies. Cervical cancer screening with cytology only (D) or cotesting with HPV (C) is not recommended in patients under age 21 regardless of sexual activity.

A 19-year-old woman who is sexually active presents to your office with questions about cervical cancer screening. She wants to know when she should start getting screened since she's been sexually active for 2 years. Which of the following is the most appropriate next step in management? AInitiate screening at age 21 with cytology and human papillomavirus testing BInitiate screening at age 21 with cytology only CInitiate screening now with cytology and human papillomavirus testing DInitiate screening now with cytology only

BCefoxitin and doxycyclineCorrect Answer. Cefoxitin and doxycycline are an appropriate antibiotic regimen for a patient with a tubo-ovarian abscess (TOA). A TOA usually follows pelvic inflammatory disease (PID) and infection with sexually transmitted infections, particularly N. gonorrhoeae and C. trachomatis. Treatment includes gynecologic consultation, hospital admission, and intravenous antibiotics. Large abscess may require surgical drainage. appropriate inpatient regimens: >>cefotetan + doxy >>cefotoxitin + doxy >>ceftriaxone + doxy + metronidazole

A 21-year-old woman presents with pelvic pain that has been worsening over the last two days. She reports vaginal discharge, nausea, and chills for the last week. Physical exam reveals thin, copious vaginal discharge, cervical motion tenderness, and a mass in the left adnexa. Pregnancy test is negative. A pelvic ultrasound reveals a complex multiloculated left adnexal mass. Which of the following antibiotic regimens represents the most appropriate pharmacotherapy? AAmpicillin/sulbactam and clindamycin BCefoxitin and doxycycline CCeftriaxone and azithromycin DVancomycin

DShe should receive Rh immunoglobulin 50 µg within 72 hours (correct). An anaphylactoid reaction (A) is not associated with the administration of Rh immunoglobulin and a test dose is not required nor recommended at the time of administration. The most common side effect of administration is soreness at the injection site. Rh immunoglobulin 300 μg (B) is the recommended dose once a woman is more than 12 weeks pregnant. Prior to 12 weeks, the recommended dose is only 50 μg although in many hospitals this dose is not available and 300 μg is administered. After 12 weeks, there is a higher volume of fetal blood which can allow a larger quantity of maternal-fetal mixing of blood. Therefore, the higher dose is recommended. Rh immunoglobulin is indicated (C) in this case of what appears to be a complete abortion.

A 22-year-old woman presents with vaginal bleeding with clots that started one hour prior to arrival. She is 10 weeks pregnant based on a previous ultrasound confirming her intrauterine pregnancy. Bedside ultrasound today does not show an intrauterine pregnancy. Her blood type is A negative and the father of the baby's blood type is not currently known. Which of the following is the best strategy for administration of Rh immunoglobulin? AA test dose should be administered first because of the risk of an anaphylactoid reaction BRh immunoglobulin 300 µg is required CRh immunoglobulin is not indicated DShe should receive Rh immunoglobulin 50 µg within 72 hours

DWord catheter placement for 4-6 weeks (correct). A Bartholin abscess occurs with infection of an obstructed Bartholin gland, a pea-sized mucous secreting gland located on each side of the labia minora in the 4 and 8 o'clock positions. Treatment of the abscess is with incision and drainage. After the loculations are broken up, and all contents of the abscess have been expressed, either gauze packing or a Word catheter is placed. Gauze packing is removed after 24 to 48 hours, and patients may require marsupialization at a later date. The Word catheter is a plastic catheter with a balloon on the end that is filled with 2-4 mL of water and expanded within the abscess cavity. It is important that the incision is made only slightly larger than the opening required for catheter placement. The catheter remains in place for 4-6 weeks, and patients are instructed to abstain from vaginal intercourse. This duration is required

A 22-year-old woman with no prior medical history presents with pain and swelling to the vulva. On examination, you notice an area of swelling with induration and central fluctuance at the 8 o'clock position of the vaginal orifice. What is the best next step in management? AAntibiotics and outpatient follow up with gynecology BIncision and drainage in the operating room CTesting for gonorrhea and chlamydia DWord catheter placement for 4-6 weeks

DType and screen (correct) The nitrazine blue test (A) is pH test useful for the diagnosis premature rupture of membranes and is not indicated in late-term vaginal bleeding unless rupture of membranes is suspected. A pelvic exam (B) would be dangerous in a woman with a complete placenta previa as palpation of the placenta may result in hemorrhage. Transvaginal ultrasound (C) is not necessary for confirmation of a placenta previa diagnosed on abdominal ultrasound and should be performed with care in cases of complete placenta previa to avoid the risk of hemorrhage.

A 23-year-old G1P0 woman at 30 weeks gestation presents to the emergency department for vaginal bleeding. She has had no prior prenatal care. She reports that she is soaking through one pad every 8 hours, denies abdominal cramping or a gush of water and endorses good fetal movement. Her vital signs are T 37.2°C, HR 100, BP 105/70, RR 18. Her abdomen is soft, non-tender, and consistent with a 30 week pregnancy. A transabdominal ultrasound shows a viable intrauterine pregnancy and a placenta that completely overlies the cervical os. Which of the following investigations is indicated in this patient? ANitrazine test BPelvic exam CTransvaginal ultrasound DType and screen

CInfundibulopelvic ligamentCorrect Answer. Ovarian torsion occurs when there is a complete or partial rotation of the ovary on the ligaments that support it, The broad ligament (A) helps hold the uterus in position and also carries blood vessels, nerves, and lymphatics to the structures within the mesentery that supply the uterus, fallopian tubes, and ovaries. The cardinal ligaments (B) are fibrous bands that attach the cervix to the lateral pelvic walls. The round ligaments (D) connect the anterior uterus and travel into the pelvis through the inguinal canal to attach to the labia majora. They help keep the uterus in an anteverted position. The uterosacral ligaments (E) attach the posterior cervix to the anterior surface of the sacrum.

A 24-year-old patient presents to the emergency department and reports severe right-sided lower abdominal pain that began suddenly about 30 minutes ago and is associated with nausea. She has a temperature of 98.4°F, blood pressure of 152/72 mm Hg, and heart rate of 122 bpm. A serum beta-human chorionic gonadotropin is negative. On physical exam, the patient has moderate abdominal tenderness from palpation to the lower right quadrant, with active bowel sounds. A Doppler pelvic ultrasound reveals a 6 cm ovarian mass with impaired blood flow to the ovary. Which of the following structures does the patient's condition involve pathology in? ABroad ligament BCardinal ligament CInfundibulopelvic ligament DRound ligamentYour Answer EUterosacral ligament

DSelective serotonin reuptake inhibitors (correct). In women whose daily function is altered due to the cyclical, luteal phase symptoms of PMS, selective serotonin reuptake inhibitors (SSRIs) are recommended as first-line therapy. Anticholinergics (A) block central and peripheral nervous system acetylcholine transmission. Their common side effects of confusion, irritability, dysphoria, memory difficulty, and poor concentration would not be recommended in a patient who is already cognitively and vocationally impaired. Surgery, consisting of hysterectomy (B) with bilateral oophorectomy, is reserved for rare refractory cases of severe disabling PMS symptoms. Oral contraceptive pills (C) are recommended as second-line therapy in those women who cannot tolerate the side effects of, do not respond to SSRIs, or also have depressive symptoms or depression accompanying the other symptoms.

A 24-year-old woman presents for an initial evaluation of cyclical symptoms of irritability, painful bloating, and depression. These symptoms occur regularly 4-5 days prior to the beginning of menstruation. During these few days, the patient typically has to miss work due to the "awful pain and mental clouding." Which one of the following treatment options do you recommend as first-line therapy? AAnticholinergics BHysterectomy COral contraceptive pills DSelective serotonin reuptake inhibitors

AAmpicillinCorrect Answer. Once preterm, prelabor rupture of membranes is confirmed, ampicillin, a penicillin antibiotic, is given to decrease infection in the mother and the infant thereby delaying preterm labor. It is recommended that azithromycin 1 gram orally followed by ampicillin 2 grams intravenously every 6 hours for 48 hours, this is then followed by a course of oral amoxicillin for 5 days.

A 25-year-old G1P0 woman at 33 weeks gestation presents to her obstetrician with a complaint of wetness and leakage from her vaginal area. On physical exam, fluid can be seen coming from the cervical canal. The cervix is not dilated. Fern test is positive. Which of the following medications should be given at this time to delay delivery? AAmpicillin BBetamethasone CIndomethacin DProgesterone

DThere is an increased risk for fetal demise (correct). This woman has classic symptoms of intrahepatic cholestasis of pregnancy. It is characterized by pruritus which is often concentrated in the palms of the hands and soles of the feet. Serum bile acids are almost always elevated and there is a significant increase in intrauterine fetal demise. Aminotransferases are often elevated (A) in this disease. The treatment of choice is ursodiol which helps increase hepatic bile flow and decrease bile acid levels. This improves pruritus and also helps lower aminotransferase levels. Cholestyramine (C), which decreases absorption of bile salts in the ileum, is not as effective as ursodiol in decreasing pruritus. Intrahepatic cholestasis of pregnancy will recur (B) in over half of subsequent pregnancies.

A 25-year-old G2P1 woman presents to your office at 32 weeks gestation with a complaint of severe itching, particularly on the palms of her hands and the soles of her feet. Lab results reveal elevated bile acids. Regarding this disease, which of the following statements is most correct? AAminotransferases are low BDisease recurrence is rare in subsequent pregnancies CThe treatment of choice is cholestyramine DThere is an increased risk for fetal demise

EValproate (correct). Valproate is considered teratogenic and is associated with developmental delay and lower intelligence quotient scores when individuals are exposed prenatally as well as neural tube defects. Carbamazepine (A) is considered teratogenic, increasing the risk of congenital disorders such as spina bifida and cleft palate. However the absolute risk is low and can still be used in stable patients with shared decision making. Lamotrigine (B) has not been shown to be teratogenic. In addition, the studies that have been completed regarding lamotrigine and pregnancy show favorable outcomes. Lamotrigine has also been studied more extensively for adverse effects than quetiapine and risperidone. Lithium (C) crosses the placenta and is associated with serious postnatal effects, including lithium toxicity causing low Apgar scores, bradycardia, feeding difficulties, or cardiac dysrhythmias. However again with

A 28-year-old woman with a medical history of bipolar I disorder presents for medication counseling. She is actively trying to conceive and is worried her medication may harm her baby. She has no other significant medical history or current issues. Her vital signs are a BP of 122/73 mm Hg, HR of 67 bpm, SpO2 99% on room air, and T of 98.7°F. A physical exam is completed and is within normal limits. Which of the following medications has been associated with intellectual disability? ACarbamazepine BLamotrigine CLithium DQuetiapine EValproate

CMagnesium sulfateCorrect Answer. A pregnant or recently postpartum patient with new-onset seizure should be considered to have eclampsia. Eclampsia refers to seizures that develop as a complication of severe preeclampsia. Most cases of eclampsia occur in the third trimester, with approximately 80% occurring during delivery or within the first 48 hours after delivery, though seizures may occur as late as several weeks postpartum. Magnesium sulfate is the drug of choice for prevention of eclamptic seizures. A loading dose of 4-6 g of magnesium sulfate should be administered over 15-20 minutes, followed by a maintenance infusion of 1-2 g per hour. Most eclamptic seizures terminate with magnesium. Labetalol (A) may be used to control severe hypertension in a patient with preeclampsia or eclampsia but does not treat seizures. Lorazepam (B) and phenobarbital (D) are second- and third-line choices, respectively, if eclamp

A 29-year-old woman who is 1 week postpartum following a pregnancy complicated by preeclampsia with the delivery of a full-term infant is brought in by emergency medical services with an ongoing generalized tonic-clonic seizure. Which of the following medications should be administered first? ALabetalol BLorazepam CMagnesium sulfate DPhenobarbital

CLaparoscopyCorrect Answer Bloodwork (A) may help in the workup of infertility and possible anemia but plays no role in the diagnosis of endometriosis. Colposcopy (B) is a procedure used to help diagnose abnormalities of the cervix and vagina and plays no role in the evaluation of endometriosis. Although pelvic ultrasound (D) may be used in the workup of a patient with pelvic pain and can help assess the structure of the uterus, ovary, and endometrial lining, it is not used to make the actual diagnosis of endometriosis

A 30-year-old woman presents to the office with dysmenorrhea, pelvic pain, and infertility for the last 5 years. What is the most appropriate next step to confirm a diagnosis of endometriosis? ABloodwork BColposcopy CLaparoscopy DPelvic ultrasound

ESwitch to nifedipine ER (correct). Comments on these medications in the table on Rosh stated: -for labetolol: avoid in bradycardia -for Nifedipine ER: avoid in tachycardia Continuing the current treatment (A) is not appropriate as ACE inhibitors, such as lisinopril, are not safe in pregnancy. These medications are teratogenic in the first trimester, and thus it is important to discontinue use if the patient has plans of becoming pregnant within the next few months. Amlodipine (B) and chlorthalidone (C) are not considered safe during pregnancy. Switching to labetalol (D) is not the most appropriate treatment for this patient, given that her heart rate is 65 bpm during the visit. Labetalol is a beta-blocker that would further reduce the patient's heart rate. In addition, beta-blockers should be avoided in patients with asthma.

A 31-year-old woman with a history of hypertension and asthma presents to her OB/GYN's office. The patient is planning a pregnancy within the next few months. She takes lisinopril daily and albuterol as needed and is not on any other medications. Her vital signs are a HR of 65 bpm, RR of 17/min, SpO2 of 99% on room air, BP of 118/80 mm Hg, T of 97.3°F, and BMI of 28.6 kg/m2. Her most recent laboratory findings consist of the following values: A1C of 5.9%, potassium of 3.8 mmol/L, and creatinine at 0.8 mg/dL. Which of the following is the most appropriate management for this patient's hypertension? AContinue current treatment BSwitch to amlodipine CSwitch to chlorthalidone DSwitch to labetalol ESwitch to nifedipine ER

AActive hepatic diseaseCorrect Answer. Postpartum hemorrhage is an obstetrical emergency and is the most common cause of maternal death globally. Postpartum hemorrhage is defined as a cumulative blood loss of greater than 1000 mL or bleeding that causes signs or symptoms of hypovolemia within 24 hours despite the delivery route. Management of postpartum hemorrhage should begin with identification of the cause of hemorrhage. First line treatment of uterine atony is manual uterine massage and uterotonic agents. Oxytocin is typically the first agent used, with carboprost and methylergonovine typically used in cases of continued bleeding after oxytocin use. Carboprost, a prostaglandin analog that stimulates uterine contractility, it has an absolute contraindication for patients with active hepatic and renal disease. Hypertension (C) and coronary artery disease (B) are contraindications to the use of methylergonovine, an

A 32-year-old G4P3 woman with a history significant for polyhydramnios is brought to the emergency department 15 minutes after a home birth. She reports persistent vaginal bleeding with thick clots. She is anxious and diaphoretic. Her physical exam is notable for a large, boggy uterus. She receives oxytocin intramuscularly as intravenous access is started. Repeat examination reveals a persistently boggy uterus with significant active vaginal bleeding. Which of the following is an absolute contraindication to the use of carboprost in the management of this patient? AActive hepatic disease BCoronary artery disease CHypertension DSeizures

DRepeat Pap smear and human papillomavirus testing in one year (correct). If the Pap smear test is negative and HPV test is positive, providers may either repeat Pap smear and HPV co-testing in one year or order HPV DNA typing to detect HPV subtypes 16 or 18. All patients should be counseled on safe sex practices (A) regardless of lab results. Patients with significantly abnormal cytology require further evaluation with repeat cytology and HPV testing or colposcopy (B). Negative cytology would not require immediate referral for colposcopy. For women aged 30 years and older, the recommendation for a Pap smear with negative cytology and negative HPV is repeat co-testing in five years (C).

A 32-year-old woman presents to your office for a physical exam including a Papanicolaou test (Pap smear). Lab results reveal negative cytology and positive human papillomavirus (HPV). Which of the following is the most appropriate next step in management? ACounsel patient on safe sex practices BOrder colposcopy CRepeat Pap smear and human papillomavirus testing in five years DRepeat Pap smear and human papillomavirus testing in one year

BCervical cerclageCorrect Answer. A cervical cerclage (stitch), performed at 12-14 weeks, is indicated for this woman who is likely suffering from cervical insufficiency secondary to iatrogenic causes. Cervical insufficiency describes a presumed physical weakness of cervical tissue that causes or contributes to the early delivery of an otherwise healthy pregnancy, usually in the second trimester. There is insufficient evidence to recommend bed rest (A) or the use of indomethacin (C) for women with cervical insufficiency. Pessaries (D) have been shown in recent studies to be ineffective at reducing preterm birth in women with cervical insufficiency

A 33-year-old woman presents to the clinic for obstetric care. She reports a history of two consecutive, painless second-trimester miscarriages. Her past medical history is remarkable for previous conization for cervical intraepithelial neoplasia. She is currently twelve weeks pregnant. Which of the following is the most appropriate next step in management in this patient? ABed rest BCervical cerclage CIndomethacin DPessary

AColposcopy with endometrial biopsyCorrect Answer. Colposcopy with endometrial biopsy is the best next step in evaluating patients ≥ 35 years of age with atypical glandular cells found on cervical cytology. If found, atypical glandular cells are associated with premalignant or malignant disease in about 30% of cases. >>Patients under age 35 would be evaluated with colposcopy, but endocervical sampling would only be performed if the patient has risk factors or symptoms are present.

A 40-year-old G3P3A0 woman presents to the OB/GYN office for cervical cytology screening results. The results of her previous cervical cytology have been unremarkable. She has a history of diabetes mellitus type 2 and takes metformin 850 mg twice per day. Her vital signs are a BP of 131/81 mm Hg, HR of 81 bpm, RR of 16/min, SpO2 of 98% on room air, and a T of 98.7°F. Upon physical exam, normally developed genitalia are seen with no external lesions or eruptions. The vagina and cervix show no lesions, inflammation, or discharge. Her cervical cytology results show atypical glandular cells. What is the best next step in management? AColposcopy with endometrial biopsy BEndometrial and endocervical sampling without colposcopy CHuman papillomavirus testing DLoop electrosurgical excision procedure EReturn to routine Papanicolaou screening

BEndometrial ablationCorrect Answer Colposcopy (A) is a gynecologic procedure in which the cervix, vagina, and vulva are directly visualized under illumination and magnification. Hysteroscopy (D) is the current gold standard for evaluating uterine pathology. Both of these diagnostic tests would neither treat nor prevent further menstrual bleeding. Hysterectomy (C) may be a last resort, but endometrial ablation is usually attempted first, as hysterectomy has a high risk of perioperative complications and prolonged recovery.

A 41-year-old woman suffers from heavy and irregular menses, which at times leads to fatigue, lightheadedness, and dyspnea. She has had three hospitalizations in the past year for such episodes. Her gynecologic evaluation has not revealed any pathological cause. The heavy menses continue despite hormonal therapy. Which of the following treatment options should be considered next? AColposcopy BEndometrial ablation CHysterectomy DHysteroscopy

CEndometrial hyperplasiaCorrect Answer Adenomyosis (A), a condition in which endometrial glands invade the musculature of the uterus, produces a diffusely large and tender uterus on examination, along with a high likelihood of chronic pelvic pain. Cervical polyps (B) are unlikely, as postcoital bleeding is the typical defining feature. Uterine leiomyomas (D) are the most common pelvic tumor in women but are unlikely in this patient, as her uterus is described within normal limits and her menstrual cycle is not abnormally painful.

A 46-year-old G2P2 woman presents to her gynecologist's office with a 6-month history of irregular, heavy menses. She states her cramps are no worse than usual and she does not have dyspareunia or postcoital bleeding. On physical exam, she has a body mass index of 32 kg/m2. A bimanual examination reveals a normal-appearing cervix and a smooth, regularly-shaped uterus that is not enlarged. Which of the following is the most likely diagnosis? AAdenomyosis BCervical polyps CEndometrial hyperplasia DUterine leiomyoma

CHuman papillomavirus testingCorrect Answer. The best next step in evaluation when a cervical cytology result returns positive for atypical squamous cells of undetermined significance is reflex human papillomavirus (HPV) testing. HPV is the most common sexually transmitted agent in the United States. HPV types 16 and 18 are most commonly associated with the development of cervical cancer, which is screened for by obtaining cervical cytology (Papanicolaou smear) and HPV testing. The appearance of normal anatomy on pelvic exam does not rule out precancerous or cancerous risk. In this patient's case, the best next step would be HPV testing to determine appropriate management. Another acceptable option is a repeat cervical cytology in 1 year, but HPV testing is preferred.

A 50-year-old G2P2A0 woman presents to the OB/GYN office for follow-up regarding her cervical cytology result. Her history is significant for hypertension, and she takes lisinopril 10 mg daily. She has been coming in for her routine Papanicolaou smear every 3 years with no abnormal results in the past. On her most recent cervical cytology, atypical squamous cells of unknown significance were found. Vital signs are a BP of 127/78 mm Hg, HR of 86 bpm, RR of 16/min, SpO2 of 98% on room air, and a T of 98.7°F. On pelvic exam, normally developed genitalia are noted with no external lesions or eruptions. The vagina and cervix show no lesions, inflammation, discharge, or tenderness. What is the best next step in evaluation of the patient's cytology results? AColposcopy BEndocervical curettage CHuman papillomavirus testing DRepeat cervical cytology in 2 years ERepeat cervical cytology today

DOral paroxetineCorrect Answer. Treatment of symptoms typically involves hormone replacement therapy (HRT). However, some patients, such as this one, are not candidates for HRT, which is contraindicated in patients with a history of breast cancer, congestive heart disease, or venous thromboembolism. Options for treatment for those patients include paroxetine, a selective serotonin reuptake inhibitor (SSRI), serotonin and norepinephrine reuptake inhibitors (SNRIs), antiepileptic medications (e.g., gabapentin or pregabalin), and clonidine, which is an antihypertensive medication Oral clonidine (B) can be given as a possible treatment for this patient's hot flashes, but it is not considered first line. Clonidine is not used often due to its side effects of dry mouth, dizziness, constipation, and sedation. But if clonidine is used, the transdermal preparation is typically preferred over the oral dose due to stability of

A 52-year-old woman with a history of unprovoked deep vein thrombosis at the age of 45 and treated with anticoagulation presents to her gynecologist with concerns for frequent hot flashes. She states her hot flashes mostly occur at night. The patient reports her last period was 2 years ago before having a hysterectomy for uterine fibroids. Her vital signs are a HR of 81 bpm, RR of 18/min, SpO2 of 99% on room air, BP of 126/82 mm Hg, T of 98.8°F, and BMI of 31.6 kg/m2. Her physical exam is normal. What is the best next step in management for this patient's presentation? AIntravaginal estrogen BOral clonidine COral estrogen and progestin therapy DOral paroxetine EWeight loss and vitamin E supplementation

DTransvaginal ultrasound (correct). Transvaginal ultrasound is the preferred initial diagnostic test of choice to evaluate painless vaginal bleeding in a postmenopausal patient in order to rule out endometrial (uterine) carcinoma. Transvaginal ultrasonography is used to measure the endometrial thickness, which should be less than 5 mm in a healthy patient. An endometrial thickness less than 3-4 mm excludes most endometrial pathology in women with postmenopausal vaginal bleeding. A transvaginal ultrasound can identify other causes of vaginal bleeding such as polyps and fibroids. An alternative to transvaginal ultrasound would be an endometrial biopsy which has a high sensitivity, low cost and low risk of complications. If either test is inconclusive, further testing is warranted. Colposcopy (A) is not indicated given the patient's normal Papanicolaou smear. Hysteroscopy (B) should be performed in the operating room i

A 58-year old postmenopausal woman presents with painless vaginal bleeding. Her last menses occurred 5 years ago. She reports that her Papanicolaou smears have always been normal; the last one was obtained a year ago. Which of the following is the next step in management? AColposcopy with endocervical curettage BHysteroscopy CRepeat Papanicolaou smear DTransvaginal ultrasound

CInitiate screening mammography at age 50Correct Answer. The United States Preventive Services Task Force recommends screening mammography for women every two years from ages 50-74 years. Screening mammography for women may start at age 40 (B) in individualized cases based on risk factors. Magnetic resonance imaging (A) is not recommended as a diagnostic tool in breast cancer screening since there is not enough evidence to support its use. Ultrasound (D) is not used as a screening tool in breast cancer screening. Women who have suspicious lesions on mammography are generally sent for ultrasound to better visualize the lesions and determine next steps.

A previously healthy 35-year-old woman presents to your clinic with questions about breast cancer screening. She has no family history of breast cancer and wants to know when she should start screening. Per the United States Preventive Services Task Force, which of the following is the most appropriate next step in management? AInitiate screening magnetic resonance imaging at age 40 BInitiate screening mammography at age 40 CInitiate screening mammography at age 50 DInitiate screening ultrasound at age 50

Patients positive for HPV 16 or 18 should receive colposcopy. Patients with other high-risk HPV types may have repeat HPV-based testing in one year. If the HPV test is again positive, colposcopy should be performed.

A pt tests positive HPV and the provider orders HPV DNA typing to detect subtype. What is the best next step if positive for HPV 16 or 18? What about for other high risk HPV types?

BHypofibrinogenemiaCorrect Answer (correct). Abruptio placentae is a condition of premature separation of the placenta from the uterus. This patient exemplifies the presentation of placental abruption. Abnormal placenta-uterus separation may lead to significant fetal and maternal stress. One of the most common maternal complications is a consumptive coagulopathy. Placental separation results in intravascular and retroplacental coagulation. This excessive coagulation depletes platelets, fibrinogen, and other clotting factors, leading to thrombocytopenia and hypofibrinogenemia, as well as an increase in the international normalized ratio and the activated partial thromboplastin time. If placental abruption is a suspected cause of third-trimester bleeding, laboratory evaluation of the above values should be obtained early in the management plan. If abnormalities are found, component therapy should be initiated via trans

A woman in her third trimester of pregnancy is involved in a motor vehicle collision. She presents to the ED with new-onset vaginal bleeding and pelvic pain. Which of the following laboratory abnormalities is consistent with the most likely diagnosis? ADecreased prothrombin time BHypofibrinogenemia CProteinuria DThrombocytosis

BMicroscopic examination of dischargeCorrect Answer. Infective vaginitis is very likely, given the above clinical description. In the initial evaluation of these symptoms, it is important to determine the causative agent. A potassium hydroxide whiff test can be performed to detect the amine-like fishy odor of bacterial vaginosis or Trichomonas vaginitis. However, direct microscopic examination of the discharge suspended in saline (termed wet preparation) will reliably establish the diagnosis and subsequently direct proper therapy. Bacterial culture (A) has limited utility since the vagina is normally colonized with several different bacteria. Ultrasound (C) will not determine which infectious agent is present. Basic laboratory tests (D) will also not reveal the causative agent. Plus, they would more than likely be normal in this stable patient.

A young woman presents with a concern about stained underwear. She reports that, for the last 3 days, she has noticed a malodorous greenish discharge. You take a thorough history and perform a pelvic examination. Which of the following is the best next step in evaluating this concern? ABacterial culture BMicroscopic examination of discharge CPelvic ultrasonography DSerum complete blood count and chemistries

AAutoimmune diseaseCorrect Answer. According to the USPSTF, having an autoimmune disorder puts a patient at high risk for developing preeclampsia. Other risk factors include multifetal pregnancy, chronic hypertension, type 1 or type 2 diabetes and renal disease. Women with a previous pregnancy with preeclampsia are also at high risk,

According to the United States Preventive Services Task Force (USPSTF), which of the following is considered to put a pregnant woman at high risk for developing preeclampsia? AAutoimmune disease BHistory of cesarean section CHyperlipidemia DYoung maternal age

BCopper-containing intrauterine deviceCorrect Answer Levonorgestrel-only pill (C) is an emergency contraceptive for use up to 72 hours after unprotected intercourse. While this is a feasible option for this patient, it is not the best option for her. She has had a prior abortion, practices unprotected intercourse, and does not desire pregnancy for years to come. In her situation, an IUD is the best emergency contraceptive option and has been shown to be the most effective for preventing pregnancy. Mifepristone and misoprostol (D) are medications used for first-trimester pregnancy termination, not for the prevention of pregnancy. They work in combination by separating the placenta through antagonizing progesterone and causing cervical softening.

An 18-year-old G1P0A1 woman presents to the OB/GYN office with concern for an unplanned pregnancy. The patient reports having unprotected intercourse with her partner last night. She states she is not planning on becoming pregnant until she is in her late 20s. Vital signs are a BP of 123/78 mm Hg, HR of 86 bpm, RR of 16/min, SpO2 of 98% on room air, and a T of 98.7°F. A human urine chorionic gonadotropin result is negative. On physical exam, normally developed genitalia are noted with no external lesions or eruptions. The vagina and cervix show no lesions, inflammation, discharge, or tenderness. What of the following is first line for management? ACombined oral contraceptives BCopper-containing intrauterine device CLevonorgestrel-only pill DMifepristone and misoprostol ENonoxynol-9 spermicide

Answer: Sexual activity

Question: What is the most common risk factor for bacterial vaginosis?

Answer: Enoxaparin. It should be discontinued 48 hours prior to delivery. brand name Lovenox (LMWH)

Question: A woman who has been hospitalized for premature rupture of membranes should be given what medication prophylactically to prevent deep vein thrombosis?

Answer: 40.

Question: At what age should patients be referred to a gynecologist to rule out Bartholin gland cancer?

Answer: At least 3-6 months prior to conception.

Question: How long before conception should the patient change medication from valproate to lamotrigine?

Answer: 90% of the time.

Question: How often do placenta previas detected in the first trimester resolve before the second trimester?

Answer: No.

Question: Is prophylactic antibiotics indicated for cervical cerclage placement?

Answer: False.

Question: True or false: atypical glandular cells are a more common finding on cervical cytology than atypical squamous cells.

Answer: False.

Question: True or false: patients who have been vaccinated against human papillomavirus do not need cervical cancer screening.

Answer: Fetal scalp stimulation or fetal scalp pH measurement.

Question: What additional studies are recommended in patients with nonreassuring patterns on fetal heart tracings?

Answer: Pregnancy. The uterus expands and moves out of the pelvis and causes stretching of the round ligament, which elicits pain.

Question: What condition is round ligament pain commonly associated with?

Answer: Clindamycin and gentamicin

Question: What is an acceptable alternative regimen to treat PID in those with a severe allergic reaction to penicillin?

Answer: Gonadotropin-releasing hormone agonists.

Question: What is considered third-line treatment of continued severe premenstrual symptoms in women who do not tolerate or respond to selective serotonin reuptake inhibitors or oral contraceptives?

Answer: Propylthiouracil

Question: What is the appropriate treatment for a patient with hyperthyroidism in the first trimester of pregnancy?.

Answer: Approximate increase of 10 to 15 bpm in pregnancy.

Question: What is the average difference in resting heart rate in a pregnant woman versus a nonpregnant woman?

Answer: Decreased milk volume production

Question: What is the effect of cigarette smoking on breastfeeding?

Answer: Breast and pelvic examination, pregnancy test, pelvic ultrasound, and serum follicle-stimulating hormone

Question: What is the initial workup of a patient with primary amenorrhea?

Answer: Atypical squamous cells of undetermined significance.

Question: What is the most common abnormal finding on cervical cytology?

Answer: Atrophy of the vaginal mucosa or endometrium.

Question: What is the most common cause of abnormal uterine bleeding in a postmenopausal woman?

Answer: A pessary, usually of the ring, Smith-Hodge, donut, cube, or inflatable variety.

Question: What medical treatment can be tried in stage I and II uterine prolapse prior to any surgical treatment?

Answer: Packed red blood cells, to treat the volume-depleting and oxygen-carrying insult which stems from abruption.

Question: What other blood product is commonly transfused in a woman with abruptio placentae?

Answer: Copper-containing intrauterine device.

Question: Which emergency contraceptive method's efficacy is not impacted by body weight?

Answer: Endometrial hyperplasia.

What is the most common cause of abnormal uterine bleeding in a woman with obesity who is premenopausal?

Answer: Emergency hysterectomy.

What is the treatment of choice in postpartum hemorrhage due to a morbidly adherent placenta?

BAt the xiphoid processCorrect Answer. At six to eight weeks, the gravid uterus is approximately the size of an orange. At 12 weeks, the top of the fundus is just above the pubic bone; at 20 weeks, at the level of the umbilicus; and at 36 weeks, at the level of the xiphoid process. Subsequently, the fetus descends into the pelvis, and the fundal height may decrease. The fundus is at the umbilicus (A) at 20 weeks; between the pubic symphysis and umbilicus (C) at 16 weeks; and between the umbilicus and xiphoid process (D) at 28 weeks.

Where is the uterine fundus palpable at 36 weeks gestation? AAt the umbilicus BAt the xiphoid process CBetween the pubic symphysis and umbilicus DBetween the umbilicus and xiphoid process

BLate decelerationsCorrect Answer. Early decelerations (A) are caused by fetal head compression during uterine contraction, resulting in vagal stimulation and slowing of the heart rate. Although these decelerations are not associated with fetal distress and thus are reassuring Variable decelerations (D) are shown by an acute fall in the fetal heart rate with a rapid downslope and a variable recovery phase. Variable decelerations are caused by compression of the umbilical cord and are generally associated with a favorable outcome. The true sinusoidal (C) pattern is a rare, but ominous sign and is associated with high rates of fetal morbidity and mortality. It is a regular, smooth, undulating form typical of a sine wave and indicates severe fetal anemia, as occurs in cases of Rh disease or severe hypoxia.

Which of the following fetal heart tracings patterns is indicative of uteroplacental insufficiency? AEarly decelerations BLate decelerations CSinusoidal DVariable decelerations

DVaginal hysterectomy (correct). Vaginal hysterectomy is associated with better outcomes and fewer complications than laparoscopic or abdominal hysterectomy. Operative management of an enterocele with anterior colporrhaphy (B), or a rectocele with posterior colporrhaphy (C) is often performed at the time of the operation for uterine prolapse after the patient has undergone a hysterectomy, but is not the surgical treatment for uterine prolapse.

Which of the following is the most appropriate treatment for stage IV uterine prolapse in a 50-year-old woman with no medical problems and no previous surgical history? AAbdominal hysterectomy BAnterior colporrhaphy CPosterior colporrhaphy DVaginal hysterectomy

BDecrease in concentration of Lactobacillus sp.Correct Answer. reduction in concentration of the dominant lactobacilli. These lactobacilli produce hydrogen peroxide that is important in preventing overgrowth of anaerobes that are normally present in the vaginal flora. Common anaerobes include Gardnerella vaginalis, Ureaplasma sp., and Mycoplasma sp. Increase in concentration of Gardnerella vaginalis (C) can lead to bacterial vaginosis after the decrease in lactobacilli occurs as was described above.

You are in the clinic with a medical student who saw a 17-year-old girl for vaginal discharge. The medical student informs you that the patient reports yellow discharge that is accompanied by pruritus. The patient has been sexually active for the past six months with one partner. The patient also has an intrauterine device placed six months ago. On examination, there is white vaginal discharge with strong odor. The vaginal pH is 5 with clue cells on wet mount. You diagnose bacterial vaginosis. The medical student asks you what causes it. Which of the following statements would best describe the pathogenesis of bacterial vaginosis? AAcquisition of Trichomonas vaginalis BDecrease in concentration of Lactobacillus sp. CIncrease in concentration of Gardnerella vaginalis DOvergrowth of Candida albicans

-prior intraabdominal surgery for an inflammatory process such as endometriosis or pelvic inflammatory disease -->in such cases, an abdominal laparoscopically assisted vaginal or laparoscopic total hysterectomy may be performed.

f/u question regarding previous question: Which of the following is the most appropriate treatment for stage IV uterine prolapse in a 50-year-old woman with no medical problems and no previous surgical history? -- correct answer being vaginal hysterectomy as it is associated w/ better outcomes and fewer complications However, in the notes section of Rosh it states: A vaginal hysterectomy is not advisable in certain circumstances, what circumstances are they referring to?

stage 1: uterus is in the upper half of vagina stage 2: uterus has descended nearly into the opening of the vagina stage 3: uterus has protruded out of the vagina stage 4: uterus is completely out of the vagina

stage 1-4 uterine prolapse definitions are what?