Brown Womens health

15-3 Lori, age 38, states that she has not had a pelvic examination in 5 years because she does not like having the digital rectal examination. How do you respond? "Let's schedule an examination now because women no longer need a rectal exam with routine pelvic examinations." "OK, we'll do a pelvic, and I'll just put 'refused' on the chart to cover my liability." "We really need to do one because the rectal examination has been shown to pick up many abnormalities such as rectal polyps." "I'll try to be quick with the rectal examination and get it over with."

"Let's schedule an examination now because women no longer need a rectal exam with routine pelvic examinations." The American College of Obstetricians and Gynecologists (ACOG) recommends that women age 50 and older should be screened for colorectal cancer using one of five recommended screening strategies. If fecal occult blood testing (FOBT) is used, patients should collect two or three samples at home and return them for laboratory analysis. Single samples obtained by digital rectal examination in the OB-GYN's office are not adequate for colorectal cancer screening.

15-101 Mary, age 50, desires hormone replace- ment therapy (HRT) for her hot flashes, which she cannot stand. You have discussed the pros and cons and given her some alternative suggestions. Her mother had a history of osteoporosis. You have decided to initiate therapy for 1 year. She asks you if she also needs to take calcium or vitamin D for prevention of osteoporosis. How do you respond? A. "Research has shown that HRT alone is sufficient to protect against osteoporosis." B. "Yes, calcium intake should be increased to 1,000 mg/day along with 600 mg of vitamin D to decrease bone turnover and increase intestinal absorption." C. "If you decide to take calcium and vitamin D, you can stop the HRT." D. "If you are getting sufficient exercise, you don't need to take calcium and vitamin D."

15-101 Answer B Hormone replacement therapy (HRT) may beused for short-term effectiveness in treating hot flashes in the absence of a personal or family history of breast cancer or a previous problemwith venous thrombosis. It is no longer considered cardioprotective. It is effective in preventing bone loss. Prevention of osteoporosis includes HRT, exercise to help decrease bone turnover, and intake of calcium and vitamin D per day. Women aged 19 to 50 years should take the recommended dietary allowance dose of calcium 1,000 mg/day with vitamin D 600 IU/day. Women aged 51 to 70 years should take calcium 1,200 mg/day with vitamin D 600 IU/day. Women aged 71 and older should take calcium 1,200 mg/day with vitamin D 800 IU/day.

15-102 Which type of breast cancer involves infiltration of the nipple epithelium and has an initial symptom of itching or burning of the nipple? Ductalcancer Paget's disease Mammaryductectasia Fibroadenoma

15-102 Answer B Paget's disease (Paget's carcinoma) is a rare type of breast cancer involving infiltration of the nipple epithelium. It begins with itching or burning of the nipple combined with superficial erosion, crusting, or ulceration. It is usually misdiagnosed as an infection. It has an excellent prognosis if the cancerous changes are confined to the nipple. Mammary duct ectasia, also known as plasma cell mastitis, is a palpable lumpiness found beneath the areola. Duct ectasia involves periductal inflammation, dilation of the ductal system, and an accumulation of fluid and dead cells that block the involved ducts. It is sometimes difficult to differentiate from cancer because it also occurs in perimenopausal or late premenopausal women. Fibroadenomas are overgrowths of periductal stromal connective tissue that compress ducts into well-defined lumps with circumscribed edges and smooth boundaries. They are mobile, firm, nontender lumps and usually occur in women younger than age 25.

15-104 Which type of cyst of the female reproductive system usually results in pain, redness, a perineal mass, and dyspareunia? A. Ovarian cyst B. Bartholin's cyst C. Gardner's cyst D. Nabothian cyst

15-104 Answer B Bartholin's cyst is an obstruction or infection ofthe Bartholin's gland. It results in pain, redness, a perineal mass, and dyspareunia. An ovarian cyst may be functional or inflammatory. A functional ovarian cyst occurs during ovulation and may be asymptomatic and resolve spontaneously, or it can cause pain, menstrual irregularity, or amenorrhea. An inflammatory cyst is an infection of the ovary or uterine tube and results in an elevated white blood cell count, a low-grade fever, pain, and excessive menstrual flow. A Gardner's duct cyst is present in the vagina during fetal development and usually goes away before birth. However, it can be persistent after birth on the sidewalls of the vagina and does not cause any symptoms. A nabothian cyst is a mucus-filled lump on the surface of the cervix and is asymptomatic.

15-105 Jennifer, age 42, presents for her well- woman examination, and you notice "dimpling" on her left breast. Your differential diagnosis includes breast cancer. fibrocystic breast disease. Paget's disease. striae from recent dieting.

15-105 Answer A Dimpling on the breast is known as peau d'orange because it looks like an orange peel and may indicate a breast tumor due to pulling and retraction of the underlying tissue by the tumor. A nodule in fibrocystic breast disease is benign, tender, movable, and may be soft to firm. Mammary Paget's disease is cancer of the mammary ducts. Striae are streaks of light-colored skin that occur after rapid skin stretching.

15-109 Cynthia says that her health-care provider wants to do a colposcopy. She asks you what this is. You tell her that a colposcopy A. visualizes the cervical, vaginal, or vulvar epithelium under magnification to identify abnormal areas that may require a biopsy. B. involves removal of one or more areas of the endometrium by means of a small device without widening the cervix. C. allows visual examination of the uterine cavity with a small scope passed through the cervix. D. allows visualization of the abdominal and pelvic cavity through a small scope passed through a small abdominal incision.

15-109 Answer A A colposcopy visualizes the cervical, vaginal, or vulvar epithelium under magnification to identify abnormal areas that may require a biopsy. It is performed in the office. An endometrial biopsy removes one or more areas of the endometrium by means of a curette or small aspiration device without cervical dilation. A hysteroscopy allows visual examination of the uterine cavity with a small fiber-optic endoscope passed through the cervix. A laparoscopy allows visualization of the abdominal and pelvic cavity through a small fiber- optic endoscope passed through a subumbilical incision.

15-111 A sexually active woman should be aware that genital herpes simplex virus may be transmitted to a partner or newborn even in the absence of lesions because of viral shedding. is suppressed during menstruation, physical or emotional stress, immunosuppression, sexual intercourse, and pregnancy. has recurrences that usually last the same length of time as the initial outbreak. requires the use of condoms only during outbreaks.

15-111 Answer A A sexually active woman should be aware that genital herpes simplex virus may be transmitted to a partner or newborn even in the absenceof lesions because of viral shedding. Genital herpes may be transmitted to a partner at any time; therefore, condoms should always be used. Menstruation, physical or emotional stress, immunosuppression, sexual intercourse, and pregnancy may actually trigger herpes recurrences. Herpes recurrences usually do not last as long as the initial occurrence.

15-114 Which glands are posterior on each side of the vaginal orifice and open onto the sides of the vestibule in the groove between the labia minora and hymen? Bartholin's glands Skene's glands Paraurethralglands Cystocele

15-114 Answer A Bartholin's (greater vestibular) glands are posterior on each side of the vaginal orifice and open onto the sides of the vestibule in the groove between the labia minor and hymen. Skene's (lesser vestibular, paraurethral) glands open onto the vestibule on each side of the urethra. Cystocele is a herniation of posterior bladder into the anterior vagina with a primary symptom of incontinence.

15-115 Sandra, age 63, says that her previous doctor never discussed why he took her off hormone replacement therapy (HRT) 3 years ago. Her last menstrual period was at age 49, and she started HRT that same year. You share with her some of the results of the Women's Health Initiative (WHI). Which statement is true regarding the study? Estrogen plus progestin increased the risk of a cardiac event in apparently healthy women after 10 years of use. Women on HRT are at a higher risk of colorectal cancer. Postmenopausal hormones do not actually prevent fractures of the hip. Estrogen alone is associated with a greater risk of breast cancer than a combination of estrogen plus progestin.

15-115 Answer A The Women's Health Initiative (WHI) found that estrogen plus progestin increased the risk of a cardiac event in apparently healthy women if used more than 10 years post menopause. Usersof postmenopausal hormones are actually at alower risk of colorectal cancer; the mechanisms by which hormone use might reduce risk are unclear. The WHI was the first trial with definitive data supporting the ability of postmenopausal hormones to prevent fractures of the hip, vertebrae, and other sites. Estrogen plus progestin appear to be associated with greater risk of breast cancer than estrogen alone.

15-36 Which blood tumor marker is highly specific to epithelial ovarian cancer? A. BRCA 2 B. CA 125 C. CA 15-3 D. CA19-9

15-36 Answer B CA 125 is a tumor marker that is highly specific to epithelial ovarian cancer. Increased levels (greater than 35 U/mL) may indicate peritoneal diseases such as endometriosis, although significant elevations are usually found with ovarian cancer. About 11% to 17% of women who inherit a harmful BRCA2 mutation will develop ovarian cancer by age 70, whereas CA 125 is highly specific. CA 15-3 level is elevated in metastatic breast disease and may be elevated in benign breast or ovarian disease. CA 19-9 level is elevated in pancreatic and hepatobiliary cancer.

15-43 When premenstrual syndrome symptoms do not respond to dietary and nonmedical therapies, which of the following drugs might you try? A. Antidepressants B. Antihistamines C. Corticosteroids D. Anticholinergics

15-43 Answer A A. Antidepressants When premenstrual syndrome symptoms do not respond to other treatments, you may prescribeany of the following drugs to aid in alleviatingthe symptoms: antidepressants, such as paroxetine (Paxil), fluoxetine (Prozac), or sertraline (Zoloft)to raise the levels of serotonin; diuretics to help relieve bloating; gonadotropin-releasing hormone agonists to suppress the menstrual cycle; antianxiety agents such as alprazolam (Xanax); and an oral progesterone to help relieve bloating and moodiness.

15-49 Sarah, age 29, complains of premenstrual syndrome (PMS). She states she was told that changing her diet might help in managing someof the symptoms. What change in her diet do you recommend? Decrease her intake of protein. Increase her intake of complex carbohydrates. Increase her intake of salt and salty foods. Decrease her intake of fatty foods.

15-49 Answer B In the client complaining of premenstrual syndrome, advise her to increase her intake of complex carbohydrates. A diet high in complex carbohydrates, such as whole grains and cereals, fruits, and vegetables, helps prevent low blood sugar levels and reduces fatigue, jitteriness, and irritability. It may also raise serotonin levels, thus improving mood. Eating several small meals at frequent intervals rather than three large ones also keeps blood sugar on an even level and reduces the feeling of bloating. Women should also restrict their intake of salt, caffeine, and alcohol during the week before their period.

15-50 Human papillomavirus (HPV) may lead to pelvic inflammatory disease. molluscum contagiosum. cervical dysplasia. genitalherpes.

15-50 Answer C cervical dysplasia. When human papillomavirus (Condylomata acuminata) causes genital warts, it may lead to cervical dysplasia and cervical cancer. Pelvic inflammatory disease is usually secondary to gonorrhea or Chlamydia infection. Molluscum contagiosum is a sexually transmitted disease that causes a benign viral skin infection. Genital herpes is caused by herpes simplex virus.

15-51 Stein-Leventhal syndrome, one of the leading causes of female infertility, is more commonly known as pelvic inflammatory disease. polycystic ovary disease. endometriosis ectopic pregnancy syndrome.

15-51 Answer B polycystic ovary disease. One of the leading causes of female infertility, Stein- Leventhal syndrome is polycystic ovary syndrome (PCOS). It is a condition that afflicts many women during their childbearing years. Symptoms of PCOS, which are related to androgen excess and not associated with estrogen deficiency, include amenorrhea, hirsutism, acne, and obesity.

15-53 Of the following symptoms of premenstrual syndrome, the one most commonly expressed by women is A. fatigue. B. depression. C. breast tenderness. D. swelling of the extremities.

15-53 Answer A A. fatigue. Of the symptoms listed in the question, the most commonly expressed symptom of women with premenstrual syndrome is fatigue (90%). Depression occurs about 80% of the time; breast tenderness about 85%; and swelling of the extremities about 67%. Other common symptoms include irritability (91%) and abdominal bloating (90%).

15-56 A 33-year-old woman complains of dyspareunia in the lower back during orgasm. The nurse practitioner should consider A. endometriosis. B. cystitis. C. vaginitis. D. causes related to pelvic inflammatory disease.

15-56 Answer A endometriosis. When a client complains of dyspareunia in the lower back during orgasm, you should consider a diagnosis of endometriosis. Cystitis and vaginitis should be considered when pain occurs at the vaginal canal and adjacent structures with the penis in midvagina. Pelvic inflammatory disease should be considered if pain occurs in the deep pelvis when there is deep penile penetration with thrusting. Causes of dyspareunia are many and diverse and depend on when and where the pain occurs.

15-57 Marsha, age 42, is having chronic abnor- mal uterine bleeding (AUB-C) and cannot take oral contraceptives due to a history of a deep vein thrombosis (DVT). Management includes which medication? Medroxyprogesterone Ethinyl estradiol Conjugated estrogen Piroxicam

15-57 Answer A Medroxyprogesterone Management of abnormal uterine menstrual bleeding (AUB) is directed toward controlling bleeding and preventing a recurrence. For women who cannot take oral contraceptives (OCs), medroxyprogesterone is offered. For teenagers, management includes observation for those with mild cases and no anemia, medroxyprogesterone for clients not sexually active, or OCs for those who are sexually active. For women of reproductive age, treatment is based on the woman's desire for fertility or contraception. OCs containing ethinyl estradiol (EE) are used in acute bleeding episodes. For women with severe acute bleeding but who remain hemodynamically stable, conjugated estrogen is used until bleeding stops. Piroxicam is used for dysmenorrhea.

15-59 Which of the following lifestyle factors is associated with an increased risk for breast cancer? Being underweight Having one to two drinks of alcohol per day Smoking Eating a low-fat diet

15-59 Answer C Smoking Smoking is one of the lifestyle factors associated with an increased risk for breast cancer. Others include a high-fat diet, two or more drinks of alcohol per day, obesity, a high socioeconomic status, and breast trauma.

15-64 A 21-year-old woman comes to your office and reports a history of genital warts. In reference to the HPV vaccination (Gardasil or Cervarix), she should be educated that she is not in the correct age group and is not a candidate for the vaccination. she should receive the HPV vaccination. she already has been exposed to HPV; therefore, she is not a candidate for the vaccine. there is a vaccine coming out shortly specifically for those who have been exposed. She should wait.

15-64 Answer B The human papillomavirus is the most common sexually transmitted infection (STI). There are more than 40 HPV types that can infect the genital areas, mouth, and throat of males and females. According to the Centers for Disease Control and Prevention (CDC), females should get the vaccine before they become sexually active and prior to becoming exposed to HPV. Females who are sexually active may also benefit from the vaccine, but they may get less benefit from it. Women who have an existing history of genital warts have generally been exposed to HPV types 6 and 11, which are not oncogenic. However, few sexually active young women are infected with all HPV types prevented by the vaccines, so most young women could still get protection by getting vaccinated. While this question just asked about a young woman, the CDC recommends that the HPV vaccine be given to both boys and girls at age 11 or 12 so that they are protected before ever being exposed to the virus.

15-89 Which of the following ovarian tumors or cysts has the potential for malignancy? A. Follicle cysts B. Brenner's tumor C. Fibroma D. Secondary ovarian tumors

15-89 Answer D Secondary ovarian tumors account for about 10% of the fatal malignant diseases in women. They are usually the result of bowel or breast metastases to the ovary, and all of the tumors are malignant. Follicle cysts are frequent in the menstrual years, never occur in the postmenopausal years, and do not have a potential for malignancy. Follicle cysts often disappear after a 2-month regimen of oral contraceptives. Fibromas account for less than 5% of the ovarian tumors and very rarely have the potential for malignancy. Brenner's tumor accounts for about 1% of ovarian tumors, occurs more than 50% of the time in postmenopausal women, and very rarely has the potential for malignancy.

15-65 Mrs. Williams would like to schedule an appointment to bring her 18-year-old daughter in to see you for her first gynecological exam and Pap smear. The most appropriate reply would be which of the following? "I would be happy to see your daughter and complete her gynecological exam and Pap smear." "Your daughter does not need a gynecological exam and Pap at this time." "Your daughter only needs a gynecological exam and Pap smear when she becomes sexually active." "I would be happy to see your daughter and complete her gynecological exam; however, she does not need a Pap smear until the age of 21."

15-65 Answer D In the past, the American Cancer Society,the American College of Obstetricians and Gynecologists (ACOG), and the American Society of Colposcopy and Cervical Pathology (ASCCP) recommended the initiation of cervical cytology screening in an adolescent based on time since onset of vaginal intercourse. However, therewas much confusion and nonadherence to the guidelines. Many adolescents were being screened inappropriately. A study by Barnholtz-Sloan and colleagues shows that screening in adolescents does not appear to change the rate of cervical cancerin these groups, and the ACOG and ASCCP now recommend that cervical cytology screening begin at age 21 regardless of the age of onset of sexual activity. The few rare cases of cervical cancer in this population do not appear to have been preventable by screening.

15-70 First-line treatment for polycystic ovary syndrome (PCOS) is A. abilateral oophorectomy. B. oral testosterone therapy. C. a combination of diet modification, weight loss, and stress management. D. a laparoscopy with a bilateral wedge resection.

15-70 Answer C First-line treatment for polycystic ovary syndrome (PCOS) is a combination of diet modification, weight loss, and stress management because obesity and stress alone can contribute to androgen excess. Oral estrogens are considered the first-line treatment for hyperandrogenism, with combination (estrogen and progesterone) oral contraceptives being the medication of choice. Treatment of uncomplicated amenorrhea in PCOS requires, at a minimum, monthly or bimonthly administration of medroxyprogesterone acetate (Depo-Provera). A laparotomy with a bilateral wedge resectionis a treatment for anovulation. Because of the possibility of adhesions and ovarian atrophy, surgical interventions are used only in women who have tried and failed clomiphene citrate ovulation induction and when all other noninvasive options have been considered.

15-77 The best method to diagnose uterine polyps is a hysteroscopy. dilation and curettage. colposcopy. laparoscopy.

15-77 Answer A The best method to diagnose uterine polyps is a hysteroscopy. A hysteroscopy is visualization of the endometrium through a scope to assess for some types of uterine fibroids, polyps, or structural abnormalities. Tissue sampling and removal of the polyps can be done through the hysteroscope. A dilation and curettage consists of scraping the walls of the uterus. A colposcopy is used to examine the vulva, vagina, and cervix. A laparoscopy examines the peritoneal cavity.

15-81 Which of the following is an indication for a colposcopy in a 35-year-old woman? A Pap smear showing dysplasia with high-risk HPV Recurrent chlamydia HIVinfection Historyofleiomyomas

15-81 Answer A Indications for a colposcopy include a Papsmear showing dysplasia or cancer; history of diethylstilbestrol (DES) exposure; persistent unexplained atypia of a Pap with evidence of high risk human papillomavirus; suspicious visible lesion of the cervix, vagina, or vulva; and as a follow-up for previously treated clients. It is also highly recommended for clients with visible condylomata, unexplained vaginal discharge, or a sexual partner with condylomata.

15-83 Mrs. Green, age 43, called the office to make an appointment for her annual Pap smear. Which of the following instructions does she need to be given prior to her appointment? A. "Insert nothing in the vagina for 24 hours before the examination." B. "Douching enhances visualization of the cervix and should be done before the appointment." C. "An infection or menstrual period is no reason to cancel the appointment." D. "The procedure is completely painless."

15-83 Answer A Nothing should be inserted in the vagina for 24 hours before performing a Pap smear. Douching should be discouraged in all women because it changes the normal flora, increasing the likelihood of an infection. An acute infection or heavy menses precludes Pap testing because it alters the ability of the practitioner to obtain an adequate sample. Some women find the Pap test physically or emotionally very uncomfortable; therefore, reassurance about its necessity should be provided.

15-85 Characteristics of polycystic ovary syn- drome (PCOS) include hirsutism, thinness, and hypoinsulinemia. menopausal onset, vitiligo, and hyperinsulinemia. alopecia, thinness, and abdominal cramping. pre menarchal onset, obesity, and hyperinsulinemia.

15-85 Answer D Characteristics of polycystic ovary syndrome (PCOS) include premenarchal onset, obesity, hyperinsulinemia, hyperandrogenism (hirsutism, seborrhea, acne, and alopecia), menstrual disturbances, and infertility. Visible signs of the syndrome are obesity, acne, and hirsutism. Clients with PCOS typically present with complaints of amenorrhea or irregular menstrual cycles, but some have the initial complaint of infertility. About 10% to 20% of clients with PCOS are symptomatic. PCOS should be considered in all clients presenting with amenorrhea, infertility, or hirsutism.

15-88 The most likely cause of amenorrhea is A. an anatomical deviation. B. a genetic factor. C. an endocrine abnormality. D. pregnancy.

15-88 Answer D Although pregnancy seems like an obvious choice as the most likely cause of amenorrhea, itis sometimes overlooked, especially if the client denies the possibility of pregnancy and is seeking a pathological reason for the amenorrhea. The most likely physiological causes of amenorrhea that should be considered are pregnancy, lactation, and menopause, if appropriate. Among women who are in the childbearing years, amenorrhea unrelated to pregnancy may signal stress or a life- threatening disease. These conditions may include anatomical deviations, genetic factors, endocrine abnormalities or imbalances, defective enzyme systems, autoimmune diseases, tumors, eating disorders, excessive exercise, and medications.With amenorrhea, a pregnancy test should always be done first to rule out pregnancy or its related complications, such as ectopic pregnancies, complete or incomplete abortions, and trophoblastic neoplasms. The most accurate test for pregnancy is the serum beta human chorionic gonadotropin test.

15-91 There are many causes of amenorrhea. In ballet dancers or marathon runners, which anatomical structure is the probable cause? A. Outflow tract B. Ovary C. Anterior pituitary D. Hypothalamus

15-91 Answer D In exercise-induced amenorrhea, such as occurs in dancers and marathon runners, the location of the problem is the hypothalamus. The outflow tract is the location of the problem with developmental absence of the vagina or uterus, obstruction of the outflow tract, scarred uterine lining, and cervical obstruction. The ovary is the location of the problem in primary amenorrhea if the etiology is a congenital chromosomal abnormality, such as Turner's syndrome. The anterior pituitary is the location of the problem with amenorrhea resulting from prolactin-secreting tumors or nonfunctioning adenomas.

15-92 Laura, age 65, presents to the office com- plaining of vaginal bleeding for 12 days. She reports that she has not had a menses since the age of 52 and that this bleeding looks much like her menses used to look like. Part of the initial work up for postmenopausal bleeding (PMB) should include a pregnancy test. a diagnostic pelvic laparoscopy. an endometrial biopsy. a colonoscopy.

15-92 Answer C an endometrial biopsy. Postmenopausal uterine bleeding is defined as uterine bleeding after permanent cessation of menstruation resulting from loss of ovarian follicular activity. In order to exclude or diagnose endometrial cancer, a woman with postmenopausal bleeding needs to be initially evaluated by obtaining a sampling of the uterine lining by endometrial biopsy. A pregnancy test is not appropriate, for women who are postmenopausal are no longer fertile. A diagnostic pelvic laparoscopy does not evaluate the internal cavity of the uterus. It examines the external surface of the uterus and surrounding organs. A colonoscopy evaluates the inside of the colon, not the uterine cavity.

15-94 The majority of breast carcinomas are found in which anatomical site in the breast? Around the areola In the upper outer quadrant In the lower half of the breast Toward the sternum

15-94 Answer B In the upper outer quadrant Of all breast carcinomas, 60% are found in the upper outer quadrant of the breast, 5% around the areola and nipple, 15% in the upper inner quadrant (toward the sternum), 15% in the lower outer quadrant, and 5% in the lower inner quadrant.

15-95 Ms. Russo, age 59, is a postmenopausal woman who comes to your office complaining of vaginal dryness. She has been sexually active with a new partner and says that penetration is very pain- ful. She has tried over-the-counter lubricants but has not found one that works. Her history is signif- icant for hypertension only. After examination and wet prep, you diagnose her with atrophic vaginitis. The treatment for this condition includes A. terconizolecream. B. metronidiazole gel. C. vaginalestrogencream. D. hydrocortizoneointment.

15-95 Answer C Atrophic vaginitis or vaginal dryness, usually results from the hypoestrogenic environment of the vagina. This is very common in premenopausal and postmenopausal women in the absenceof a secondary vaginal infection. Symptomsmay include vaginal dryness, burning, itching, abnormal vaginal discharge, and dyspareunia. Hypoestrogenic states such as lactation and use of depot medroxyprogesterone can also cause atrophic vaginitis. This condition is best treated with topical estrogen. Terconizole cream is used to treat vaginal yeast infections, metronidazole is for the treatment of bacterial vaginosis, and hydrocortisone cream is used to treat inflammation and itching on external organs.

15-96 Maria, age 21, presents to your office today for a well-woman visit. She has never had a Pap smear before. She is sexually active with one part- ner and uses the vaginal contraceptive ring for birth control. She admits that her partner uses condoms only occasionally. She has received only two of the HPV vaccine (Gardasil) injections. Regarding a Pap smear at this visit, she will need a Pap smear only today. she should not have a Pap smear until she gets her third Gardasil injection. she does not need a Pap smear at this visit. She needs only HPV testing today. she will need a Pap smear with HPV cotesting today.

15-96 Answer A The initial Pap smear should be done at age 21. The Pap smear without HPV testing is indicated as HPV cotesting begins at age 30.

15-99 Jackie, age 29, presents with no menstrual bleeding for 4 months. Her usual menstrual cycle is every 21 days and generally lasts for 7 days. She has never missed a period before, and her pregnancy test in the office is negative. This disturbance in her cycle is termed as A. irregular menstrual bleeding (IrregMB). B. absent menstrual bleeding (amenorrhea). C. false pregnancy (pseudocyesis). D. early menopause.

15-99 Answer B No menses in a 90-day period is termed absent menstrual bleeding or amenorrhea. Irregular menstrual bleeding (IrregMB) is bleeding of more than 20 days in individual cycle lengths over a period of 1 year. Heavy menstrual bleeding (HMB) is excessive menstrual blood loss that interferes with a woman's physical, emotional, social, and material quality of life and can occur alone or in combination with other symptoms. Light menstrual bleeding is menstrual flow that is not as heavy as the woman's normal menstrual flow.

15-25 Unilateral galactorrhea may be present with A. an intra ductal papilloma. B. a woman who is lactating. C. a ruptured breast implant. D. pregnancy.

A. an intra ductal papilloma. 15-25 Answer A Galactorrhea (lactation not associated with pregnancy or nursing) is sometimes associated with a pituitary tumor. However, when the dischargeis unilateral, from one or two ducts, a differential diagnosis of fibrocystic breast disease, intraductal papilloma, or carcinoma must be considered.

15-17 In a premenopausal woman, the biggest heart attack risk factor is A. cigarette smoking. B. family history. C. a sedentary lifestyle. D. obesity.

A. cigarette smoking. 15-17 Answer A In a premenopausal woman, the biggest heart attack risk factor is cigarette smoking. If a woman is premenopausal, her own estrogen is most likely to protect her from heart disease, but there are still risk factors associated with heart disease.The more risk factors that apply, the greater the danger. Smoking is the biggest risk factor. Others include a family history of premature heart disease (paternal side before age 55, maternal side before age 65), being older than age 54, going through premature menopause, sedentary lifestyle, and a history of diabetes or high blood pressure.

15-7 A treatment used to improve the chance of pregnancy in an infertile woman who has minimal or mild endometriosis is A. laparoscopic resection or ablation of the lesions. B. dilation and curettage. C.the use of gonadotropin-releasing hormone analogues. D.the use of birth control pills for 3 months and then abruptly stopping.

A. laparoscopic resection or ablation of the lesions. 15-7 Answer A A treatment used to improve the chance of pregnancy in an infertile woman who has minimal or mild endometriosis is laparoscopic resectionor ablation of the lesions. Although dilation and curettage removes tissue, it may not be the specific endometrial tissue involved. Gonadotropin- releasing hormone analogues suppress endometriosis by creating a pseudomenopause, which is not desired in a woman who wants to become pregnant.

15-13 Leiomyomas are found A. within the uterine wall. B. on the vaginal wall. C. within the cervix. D. onthefallopiantube.

A. within the uterine wall. 15-13 Answer A Leiomyomas are commonly called uterine fibroids; they are the most common benign tumor ofthe uterus. Most are small and asymptomatic. Leiomyomas are classified by location within the uterine wall and can be subserous, submucous, and/or intramural. Rarely, a leiomyoma can be intraligamentous, cervical, or parasitic (deriving its blood supply from an organ to which it becomes attached). Most uterine fibroids are surrounded by compressed (otherwise normal) myometrium. When leiomyomas outgrow their blood supply, they can become necrotic and ulcerate.

15-28 When a woman has extreme spasticity, which position should she assume for a Pap smear? A. OB"stirrups"position B. Knee-chest position while prone C.V-shaped position without stirrups D.Side-lying position

B. Knee-chest position while prone 15-28 Answer B The woman who has extreme spasticity should assume a knee-chest position while prone for a Pap smear. Assistance may be required to keepthe legs away from the perineal area. The OB stirrups position allows a woman who has difficulty using foot stirrups to assume the standard pelvic examination position. The client may need assistance in putting her legs into the stirrups up to the knees, which can be padded for comfort. The V-shaped position may be used without stirrups or with one foot in a stirrup. One or two assistants may be required to help the woman maintain this position by supporting each straightened leg at the knee and ankle. The client's comfort may be increased by elevating her legs slightly or by usinga pillow under the small of her back or coccyx. The speculum must be inserted with the handle up.The side-lying position does not require stirrupsand is most appropriate for the client who feels most comfortable and balanced lying on her side. This position is also good for the extremely obese woman. An assistant may help elevate one leg if the client cannot spread her legs. The speculum can be inserted with the handle pointing either toward the woman's back or front, but the clinician should be sure to angle the speculum toward the small of the client's back and not straight up toward her head.

15-35 Mrs. Henderson, age 54, asks why she needs progesterone in addition to her estrogen for hormone replacement. Women who have an intact uterus need to add progesterone to their prescribed estrogen because progestin A. assists in relieving the typical hot flashes of menopause. B. reduces the incidence of endometrial hyperplasia and cancer. C. decreases the risk of osteoporosis. D. controls moods wings.

B. reduces the incidence of endometrial hyperplasia and cancer. 15-35 Answer B A woman with an intact uterus needs to add progestin to her estrogen replacement therapy— estrogen plus progestin therapy (EPT)—because it reduces the incidence of endometrial hyperplasia and cancer, both of which are associated with long- term estrogen use. Decreased estrogen levels account for hot flashes as well as mood swings and are related to osteoporosis.

15-42 The average age of menopause in the United States is A. 45 years. B. 48 years. C. 51years. D. 53years.

C. 51 years. 15-42 Answer C The average age of menopause in the United States is 51 years. Menopause is defined by the World Health Organization as the permanent cessation of menstruation resulting from loss of ovarian follicular activity and 12 months of amenorrhea at the time of midlife.

15-5 Which of the following signs and/or symp- toms of a genital herpes infection usually occur(s) first? A. Painfulorpruriticvesicles B. Dysuria C. Prodromal tingling or pruritus of the genital region D. White, curdlike plaques on a red base in the vagina

C. Prodromal tingling or pruritus of the genital region 15-5 Answer C Signs and symptoms of a genital herpes infection include tender inguinal lymph nodes, as well as painful or pruritic vesicles, dysuria, prodromal tingling or pruritus of the genital region (which usually occurs first), and cervical ulcerations. White, curdlike plaques on a red base in the vagina are seen with monilial vaginitis.

15-9 Susan, age 35, has been diagnosed with fibrocystic breast disease. Which of the following may exacerbate the condition? A daily dose of aspirin Spicy foods Chocolate Wearing tight bras

Chocolate 15-9 Answer C There are many interventions that will alleviate the pain of fibrocystic breast disease as well as help decrease the proliferation of breast tissue. Caffeine, chocolate, tea, colas, and drugs containing caffeine should be reduced to help alleviate breast tenderness and reduce nodularity. Vitamin E has been shown to decrease the pain and tenderness associated with fibrocystic change, as well as the proliferation of breast tissue. Daily aspirin therapy and spicy foods have not been associated with fibrocystic breast disease. Wearing a tight-fitting bra does not exacerbate the condition but may increase tenderness.

15-16 Judy, age 30, has severe pain monthly due to her fibrocystic breast disease. Which medication do you suggest she try? Micronizedestradiol(Estrace) Danazol (Danocrine) Paroxetine(Paxil) Venlafaxine(Effexor)

Danazol (Danocrine) 15-16 Answer B For clients with severe pain with their fibrocystic breast disease, danazol (Danocrine) 100 to 200 mg PO twice per day has been found helpful. Danazol is an androgen derivative that suppresses pituitary gonadotropins. With its androgenic effects, such as acne, edema, and hirsutism, most women find that the treatment is worse than the condition and prefer to try milder forms of pain relief. A daily dose of 400 IU of vitamin E may also help. Paroxetine (Paxil) and venlafaxine (Effexor) are both selective serotonin reuptake inhibitors (SSRIs) that have been shown in some studies to relieve hot flashes as well as hormone therapy can.

15-1 Which form of estrogen is secreted in the greatest amount by the ovaries during the reproductive years and is considered the most potent? Estrone(E1) Estradiol (E2) Estriol (E3) The potency and secretion of all of the above are in equal amounts.

Estradiol (E2) Estradiol (E2) is the most potent form of estrogen and is secreted in the greatest amount by the ovaries during the reproductive years. As ovarian function decreases, the production of estradiol decreases and is ultimately replaced by estrone (E1) as the major ovarian estrogen. Estrone has only a fraction of the potency of estradiol. During this time, the second ovarian hormone, progesterone, also is markedly reduced. Estrone is metabolized to estriol, which is the least potent of the three estrogens.

15-10 Which of the following statements do you use when instructing women about their fer- tile period (when they are most likely to become pregnant)? Ovulation occurs on the 14th day, plus or minus 2 days, before the next menses. Sperm are viable for 24 hours. The ovum is viable for 6 hours. The ovaries always release one ovum per month.

Ovulation occurs on the 14th day, plus or minus 2 days, before the next menses. 15-10 Answer A When instructing women about their fertile period (when they are most likely to become pregnant), tell them that ovulation occurs on the 14th day, plus or minus 2 days, before the next menses. Sperm are viable for 3 days, and the ovum is viable for 24 hours. It is essential for women to know these facts if they are using the calendar or rhythm method for preventing a pregnancy. The ovaries may release more than one ovum per month or none at all depending on the fertility status of the woman.

15-11 Herpes simplex virus can be potentially acquired through maternal transmission. This is least likely to occur before labor. during delivery. postnatally. during the neonatal period.

before labor. 15-11 Answer A Herpes simplex virus may be acquired before labor, during delivery, or postnatally. About 5% of infants with neonatal herpes acquire the virus before labor (intrauterine infection) and 85% by direct contact with the maternal genitalia or secretions during delivery. Postnatal acquisition occurs by direct contact with an infected caretaker and accounts for the other 10% of neonatal herpes infections.

15-31 The most common type of invasive breast carcinoma is infiltrating ductal carcinoma. medullary carcinoma. lobular carcinoma. infiltrating papillary carcinoma.

infiltrating ductal carcinoma. 15-31 Answer A The most common type of invasive breast carcinoma is infiltrating ductal carcinoma (70%-80%). This is followed by lobular (5%-10%); medullary (5%-7%); and Paget's, inflammatory, infiltrating papillary, tubular, and mucinous breast carcinomas (less than 5%).

15-33 Endometrial cancer, hirsutism, acne, breast cancer, increased risk of diabetes, infertility, men- strual bleeding problems, and an increased risk of cardiovascular disease are clinical consequences of mastalgia. abnormal uterine bleeding. endometriosis. persistent anovulation.

persistent anovulation. 15-33 Answer D The clinical consequences of persistent anovulation include infertility; menstrual bleeding problems, ranging from amenorrhea to dysfunctional uterine bleeding; an increased risk of cardiovascular disease; hirsutism and acne; an increased risk of endometrial cancer and breast cancer; and an increased risk of diabetes mellitus in clients with hyperinsulinemia. Therapy depends on the client. If the client wants to get pregnant, she is a candidate for the medical induction of ovulation. For the client who does not wish to become pregnant and does not complain of hirsutism but is anovulatory and has irregular bleeding, therapy is directed toward interruption of the steady-state effect on the endometrium and breast. Mastalgia is breast pain. The breast is a complex organ that is sensitive to hormones. Estradiol and progesterone stimulate breast tissue. Breast pain that positively correlates with menses is cyclic mastalgia. Cyclic mastalgia is the most common breast-related complaint seen in women's health practice. Abnormal uterine bleeding (acute) (AUB) is an episode of bleedingin a woman of reproductive age, who is not pregnant, of sufficient quantity to require immediate intervention to prevent further blood loss but at the normal time during the month. Abnormal uterine bleeding (chronic) is bleeding from the uterus that is abnormal in duration, volume, and/ or frequency and has been present for the majority of the last 6 months. Endometriosis is extrauterine growth of the endometrial glands or stroma. It is believed to occur through retrograde menstruation, differentiation of totipotential cells, or both.

15-34 Darcy, age 57, is to undergo a cone-needle biopsy for a suspicious breast mass. This procedure includes a 21- or 22-gauge needle that is used to aspirate cells from the lesion for analysis. removal of a large core of tissue from the lesion for histological evaluation utilizing a large-gauge cutting needle. removal of a wedge of tissue for examination. removal of the entire lesion.

removal of a large core of tissue from the lesion for histological evaluation utilizing a large-gauge cutting needle. 15-34 Answer B In a cone-needle biopsy, a large-gauge cutting needle is used to provide a large core of tissue from the lesion for histological examination. The results of a core-needle biopsy are as accurate as a surgical biopsy, but the procedure is less invasive with better cosmetic results. A stereotactic or ultrasound- guided biopsy can be performed on nonpalpable lesions. A 21- or 22-gauge needle is used to aspirate a cyst or extract cells from a palpable solid lesion for analysis in a fine-needle aspiration (FNA). An incisional biopsy in which a large wedge of tissueis removed for histological examination may be done when a mass is very large and cannot be removed without major surgery. An open surgical excisional biopsy (lumpectomy) involves the entire removal of a palpable mass or a nonpalpable lesion (after stereotactic or ultrasound-guided biopsy or mammographic needle localization).