Exam 4 - Part 2

1. A female patient has lower abdominal pain, nausea, and vomiting and reports missing a period 3 weeks prior. The patient reports using an intrauterine device for contraception. A serum -hCG is 1500 mIU/mL. What will the provider do, based on these findings? a. Perform a transvaginal ultrasound b. Recheck the -hCG level in 4 to 6 weeks c. Refer for a diagnostic laparoscopy d. Tell the patient that a viable pregnancy is likely

ANS: A With elevations in serum -hCG greater than 1000 mIU/mL, transvaginal US can usually detect both viable and nonviable ectopic pregnancies without subjecting women to the risks of an invasive procedure. A diagnostic laparoscopy is the definitive test for ectopic pregnancy and should be performed if the US is indeterminate. The level is already high enough that a fetus would be detectable on US, so rechecking this level is not indicated. Patients who use IUDs are at higher risk for ectopic pregnancy; telling this woman that a viable pregnancy is likely should not occur until diagnostic tests are performed.

MULTIPLE CHOICE 1. An adolescent female reports crampy pelvic pain radiating to the back, sacrum, and inner thighs during the first 2 days of each menstrual period, associated with nausea and loose tools. She asks about what causes these symptoms. What will the provider tell her? a. Excess prostaglandins, vasopressin will cause these symptoms. b. Mechanical cervical obstruction and severe uterine flexion are likely causes. c. Nulliparity and her young age are correlated with these symptoms. d. The most likely cause at her age is anovulatory menstrual cycles.

ANS: A Chemical mediators, including prostaglandins, vasopressin, and other substances originating from phospholipids, have been shown to produce the symptoms and associated symptoms of dysmenorrhea. Mechanical obstruction and severe cervical flexion have no substantial evidence to support their role in causing these symptoms. Nulliparity and age have not shown correlation with dysmenorrhea. Ovulation causes increased release of chemical mediators, so anovulatory cycles will result in fewer symptoms.

2. A female patient with vaginal atrophy is prescribed a local estrogen therapy product with conjugated equine estrogen cream. What will the provider recommend as adjunctive therapy for this patient? a. Adding progesterone to the regimen b. Pelvic floor physical therapy c. Treatment with a testosterone patch d. Trigger point injections

ANS: A Conjugated equine estrogen is absorbed systemically, so the patient will need progesterone to prevent unopposed estrogen stimulation of the endometrium. Pelvic floor PT and trigger point injections are used for dyspareunia. Testosterone patches are used for decreased arousal and desire

1. What is a possible cause of decreased arousal, libido, and orgasm in a postmenopausal woman? a. Diminished testosterone b. Endometriosis c. Low estrogen levels d. Uterine prolapse

ANS: A Diminished testosterone has been implicated in deceased arousal, libido, and orgasm in women. Endometriosis is a common cause of deep dyspareunia. Low estrogen causes vaginal dryness, coital pain, and decreased desire. Uterine prolapse causes deep dyspareunia.

3. A patient diagnosed with primary dysmenorrhea has taken nonsteroidal anti-inflammatory medications (NSAIDs) and COX-2 inhibitors without getting relief from symptoms. What will the provider suggest? a. A combined oral contraceptive (OCP) b. Complementary therapies c. Intrauterine (IUD) device implantation d. Narcotic analgesics as needed

ANS: A OCPs have demonstrated some effectiveness and should be tried in this instance. IUDs are used in Europe but have not been approved for this use in the United States. Complementary therapies have not been sufficiently studied. Narcotic analgesics are not recommended for this level of pain.

2. An adolescent female calls a primary care clinic to report that she has missed two periods and is having morning nausea and vomiting. What will the provider suggest? a. Coming to the clinic for pregnancy testing b. Making an appointment with a gynecologist c. Purchasing a home pregnancy test kit d. Referral to a community health clinic

ANS: A Patients who feel especially vulnerable and are in denial about a pregnancy may not want to take a test at home, desiring immediate guidance when a result is discovered. Referring to another provider will only alienate this adolescent further.

3. A woman who has had routine Pap tests all her adult life has an abnormal Pap. What will the provider tell her about this result? a. Colposcopy with biopsy is necessary b. She may have vaginal cancer c. She most likely has early cervical cancer d. The result most likely indicates HPV infection

ANS: A The Pap test is a screen and should be followed by colposcopy with biopsy. Women who have had Pap tests routinely are less likely to have cervical cancer.

3. A provider sees a woman who has just learned she is pregnant with an unplanned pregnancy. What is an initial step in helping this woman make decisions about his pregnancy? a. Actively listen to the woman's concerns and questions. b. Ask the mother if the father of the baby will be involved. c. Make a referral to an obstetrician for more information. d. Offer information about both adoption and abortion.

ANS: A The initial step is to actively listen to the woman to determine what her concerns and needs are. The provider should give unbiased information and answer any questions the woman has. Asking her about the father's involvement puts an emphasis on other concerns. Referring her to an obstetrician conveys a desire to avoid helping her with her problems. Giving information that she has not asked for conveys a judgment about what she should do.

2. What is the benefit of using a liquid-based medium when performing a Pap test? a. It allows genital human papillomavirus (HPV), gonorrhea, and chlamydia testing with the same specimen. b. It is a more accurate test than the slide method of Pap testing. c. It is not necessary to use endocervical cells to obtain results. d. It is predictive of the later development of cervical cancer.

ANS: A The liquid-based medium method allows testing of HPV, gonorrhea, and chlamydia using the same specimen. It is not necessarily more accurate. It requires use of endocervical cells. It does not predict the development of cancer.

1. A female patient reports cramping, dysuria, low back pain, and nausea. A dipstick urinalysis is normal and a pregnancy test is negative. What will the provider do next? a. Obtain vaginal secretions for testing b. Refer for radiological studies c. Schedule for an endometrial biopsy d. Treat with empirical antibiotics

ANS: A The provider should continue to evaluate by getting specimens for testing to rule out active infection. Radiological studies and endometrial biopsy may be necessary if other tests are not conclusive. Empirical antibiotics should not be given until other causes are ruled out.

1. A woman who is taking oral contraceptive pills (OCPs) to prevent pregnancy calls the provider to report forgetting to take the pills for 4 days. She has not had sexual intercourse during that time. What will the provider recommend? a. Resume the pills and use a backup method the remainder of the cycle b. Stop the OCP, use an alternative method, and resume OCPs at the next cycle c. Take 2 pills daily for 4 days and use an alternative method for 4 days d. Use a morning after pill today and resume the OCPs now

ANS: A When OCPs are missed longer than 2 days, women should use an alternative method of fertility control until the end of the cycle and resume taking the pills as prescribed. It is not recommended that the pills be stopped until a new cycle begins. When pills are missed for 2 or fewer days, women should take 2 pills daily and use a backup method until the end of the cycle. The morning after pill is used when pregnancy may have occurred.

1. A 45-year-old woman has gone 120 days without a menstrual period. A pregnancy test is negative. What will the provider do, based on this symptom? a. Evaluate for various causes of amenorrhea b. Reassure her that this can be normal c. Tell her she has developed early menopause d. Tell her that this is likely perimenopause

ANS: A Women who have prolonged episodes of amenorrhea, even with FSH levels in menopausal range, may resume normal menstruation. Other causes of amenorrhea should be evaluated.

MULTIPLE RESPONSE 1. A couple who has been trying to conceive for over 9 months asks the provider about artificial reproductive therapy (ART). When discussing risks and benefits associated with these methods, what will the provider include? (Select all that apply.) a. Higher rates of pregnancy-induced hypertension b. Increased premature births c. Likelihood of increased infant birth weight d. More frequent multiple gestations e. Reduced risk of ovarian and breast cancers

ANS: A, B, D ART methods often produce multiple gestation births and increase the likelihood of premature births, along with higher rates of PIH. Infants born via ART methods more often have lower birth weights. There is an association between higher rates of ovarian cancer and use of ART.

MULTIPLE RESPONSE 1. A woman who has stopped having menstrual periods has vasomotor symptoms but does not want to use hormone replacement therapy. What measures will the provider recommend? (Select all that apply.) a. Avoiding caffeine b. Engaging in regular exercise c. Having a glass of wine each evening d. Keeping the house cool e. Trying herbal remedies

ANS: A, B, D Women with vasomotor symptoms should be counseled to avoid caffeine and alcohol, to engage in regular exercise, and to lower the thermostat. Consuming alcohol is not recommended to reduce symptoms. Herbal remedies are frequently used but have not been shown to be beneficial and many may be harmful.

1. A patient has received methotrexate therapy for treatment of an ectopic pregnancy. What information will the provider include when teaching this patient about this therapy? (Select all that apply.) a. Avoid sexual intercourse for 3 months b. Do not consume alcohol for at least 3 months c. Long-term effects include lower fertility d. Pregnancy should be avoided in the future e. Refrain from taking vitamins containing folic acid

ANS: A, B, E Patients who have been given methotrexate for an ectopic pregnancy should refrain from sexual intercourse and consumption of alcohol and vitamins containing folic acid for 3 months. Good subsequent fertility rates have been demonstrated, so women do not need to avoid pregnancy or expect poor pregnancy outcomes.

MULTIPLE RESPONSE 1. Which are greatest risk factors for pelvic inflammatory disease? (Select all that apply.) a. Age under 25 years b. Cigarette smoking c. Tubal sterilization d. Using barrier methods of contraception e. Vaginal douching

ANS: A, B, E Age under 25 years, cigarette smoking, and vaginal douching all increase the risk for PID. Tubal sterilization and barrier contraceptive methods decrease the risk.

MULTIPLE RESPONSE 1. Which underlying causes are related to chronic pelvic pain in women? (Select all that apply.) a. Postural problems b. Hepatitis c. Interstitial cystitis d. Physical abuse e. Gastrointestinal disorders

ANS: A, C, D, E Problems with posture can cause inflammation in the lower spinal column, leading to chronic pelvic pain. Inter

1. A previously healthy 22-year-old female reports experiencing pain in the rectovaginal area with sexual intercourse. What is the most likely cause of this patient's discomfort? a. Atherosclerosis b. Endometriosis c. Inadequate lubrication d. Psychological issues

ANS: B In the premenopausal woman, endometriosis is the most common cause of dyspareunia, especially when it involves the rectovaginal area. Atherosclerosis and inadequate lubrication may occur in older women. Psychological issues are less common.

1. A female patient reports vulvar pruritus and dyspareunia. The provider notes white papules on the vulva with thinning of the epithelium. What condition does the provider suspect? a. Bartholin's duct cyst b. Lichen sclerosis c. Sexually transmitted infection d. Vulvar psoriasis

ANS: B These symptoms are consistent with lichen sclerosis, with white papules and epithelial thinning being diagnostic. The other conditions may cause pruritus, but not skin lesions.

1. A postmenopausal woman who is overweight and who has hyperlipidemia and a history of infertility develops vaginal bleeding and reports a feeling of pelvic pressure. The provider suspects a genital tract cancer and refers the patient for diagnostic evaluation. What is the likely cause of this woman's symptoms? a. Cervical cancer b. Endometrial cancer c. Ovarian cancer d. Vaginal cancer

ANS: B This woman has symptoms characteristic of endometrial cancer, including her health history, bleeding, and pelvic pressure. Cervical cancer, ovarian cancer, and vaginal cancer typically do not have symptoms.

MULTIPLE RESPONSE 1. When determining the cause of a patient's abnormal uterine bleeding (AUB), which diagnostics would the provider consider initially? (Select all that apply.) a. Liver function tests b. Serum level of human chorionic gonadotropin c. Thyroid-stimulating hormone d. Total and free testosterone e. Cervical cultures

ANS: B, C, E Diagnostic tests prescribed initially for AUB include serum human chorionic gonadotropin levels, thyroid-stimulating hormone level and cervical cultures. Liver function tests and total and free testosterone levels are more advanced tests.

2. A patient is determined to have a nonruptured ectopic pregnancy within 1 week of a missed period. Which treatment will the specialist order? a. Laparoscopy b. Leucovorin rescue c. Methotrexate d. Mifepristone

ANS: C In an early nonruptured ectopic pregnancy, methotrexate is widely used. Leucovorin rescue and mifepristone are used as adjunctive medications with methotrexate. Laparoscopy is performed when a ruptured ectopic pregnancy is present.

3. A female calls the provider to report having unprotected sexual intercourse approximately 4 days prior. Which regimen will the provider recommend? a. Plan-B One-Step twice daily for 5 days b. Plan-B One-Step daily for 5 days c. Ulipristal Acetate (UA) taken one time d. Ulipristal Acetate (UA) twice daily for 3 days

ANS: C Although the OTC product Plan B is effective, its efficacy drops significantly after 72 hours. The prescription product Ulipristal Acetate (UA) is prescribed as a single dose taken within 120 hours after intercourse, but studies have shown greater efficacy for this product than Plan-B from 72 to 120 hours after unprotected sexual intercourse.

3. A sexually active young female reports vaginal discharge and moderate vulvovaginal irritation. The examination reveals a white, noninflammatory discharge adhering to the vaginal walls, clue cells on microscopic examination, and a positive KOH (potassium hydroxide) whiff test. What will the provider do next? a. Obtain cultures of the vaginal discharge b. Order a gynecologic referral for evaluation and treatment c. Prescribe oral metronidazole 500 mg twice a day for 7 days d. Screen the patient for gonorrhea and chlamydia

ANS: C Bacterial vaginosis may be treated empirically based on the symptoms this woman has and on the three criteria noted in clinic. Metronidazole is the first-line treatment. It is not necessary to obtain cultures or to refer to a specialist.

2. Shortly after the onset of menopause, a woman begins to show signs of osteopenia. The provider orders oral bazedoxifene combined with conjugated estrogen (BZA/CE). What will the provider tell her about the purpose of this treatment? a. It will improve calcium absorption. b. It will prevent further bone loss. c. It will reduce the incidence of fractures. d. It will reverse bone loss.

ANS: C HT therapy is given to reduce bone loss, reduce the incidence of osteoporotic fractures, and reduce height loss. It does not improve calcium absorption and will not prevent further bone loss or reverse bone loss.

2. A perimenopausal woman reports a recent onset of moderate to severe pain with sexual intercourse. Which treatment will the provider prescribe initially to treat this pain? a. Botulism injections b. Topical corticosteroids c. Topical estrogen d. Water-based lubrication

ANS: C If the problem is estrogen-insufficient dryness, which occurs during menopause, topical estrogen is effective for moderate to severe pain. Botulism injections are useful when spasms are the cause of pain. Topical corticosteroids are not indicated. Water-based lubrication may be effective for mild symptoms.

What is true about genital human papillomavirus (HPV) infection in women? a. A single, isolated HPV infection will lead to cervical cancer. b. HPV subtypes causing genital warts indicate the likelihood of cancer. c. Most HPV lesions will resolve spontaneously without causing cancer. d. Most women with HPV infection will develop cervical cancer.

ANS: C Most HPV infections resolve spontaneously, especially in younger women. It is the persistence of HPV infection and not a single infection that increases the risk. The subtypes causing genital warts are not implicated in the etiology of cervical cancer. Most women with HPV infection will not develop cancer.

2. A postmenopausal woman is diagnosed with lichen planus. After several weeks of treatment with a potent corticosteroid ointment, the woman reports improvement in itching, but states that she has extreme vaginal dryness. What will the provider recommend? a. Increasing the frequency of the corticosteroid application b. Taking diphenhydramine daily at bedtime c. Using a topical estrogen cream along with the steroid d. Using petrolatum ointment to minimize drying

ANS: C Patient with concomitant vulvovaginal atrophy related to menopause may need to use topical estrogen cream to treat those symptoms. After several weeks, the corticosteroid is tapered to a lower dose, not increased. Diphenhydramine is given for itching. Petrolatum ointment is useful for external skin as a barrier but is not used internally.

2. A 35-year-old woman without a previous history of dysmenorrhea reports lower pelvic pain and irregular bleeding between periods. What is the initial action in managing this patient? a. Obtaining a pelvic transvaginal ultrasound with saline infusion b. Ordering a CBC, erythrocyte sedimentation rate, and cultures c. Performing an abdominal, pelvic, and rectovaginal examination d. Prescribing a trial of nonsteroidal anti-inflammatory medications (NSAIDs)

ANS: C Symptoms that occur later in life are more likely to be secondary dysmenorrhea and must be investigated, beginning with a thorough abdominal, pelvic, and rectovaginal exam. Other tests may be performed if indicated by findings on the physical exam. NSAIDs are first-line therapy for primary dysmenorrhea.

2. A woman asks about her risk of ovarian cancer. To best assess risk in this patient, what will the provider do first? a. Ask about parity and age of menarche b. Evaluate age of menopause c. Obtain a family history d. Order testing for the BRCA gene

ANS: C The family history is the best predictor of ovarian cancer risk. The other factors contribute, but not as significantly as family history. If there is a strong family history, testing for the BRCA gene is indicated.

2. A woman has a history of migraines and requests oral contraceptives to prevent pregnancy. Which type of contraceptive will the provider recommend? a. Combination oral contraceptive b. Contraceptive implant c. Progestin-only contraception d. Transdermal combination product

ANS: C Women with migraine are at increased risk for stroke and should avoid estrogen-containing contraceptives. The progestin-only pill is recommended. The progestin-only pill can also cause headaches, but research reveals that healthy women taking progestin-only pills are not at risk for strokes. The other products all contain estrogen. Altering the method of administration does not alter the estrogen dose.

1. A provider is caring for a couple who are trying to conceive. To most accurately evaluate ovulation and luteal surge in the woman, what test will the provider recommend or perform? a. Basal body temperature b. Maintaining a menstrual calendar c. Plasma mid luteal progesterone concentration level d. Urinary luteal hormone home kit

ANS: D A home kit to assess urinary luteal hormone can identify the surge that precedes ovulation by 1 or 2 days; these kits, when done with an afternoon or evening urine sample, correlate well with peak serum LH. Basal body temperature is an easy, convenient, and inexpensive method to assess ovulatory function, but the resultant curves may be difficult to interpret. Menstrual calendars are less accurate. Plasma mid luteal progesterone concentration levels are presumptive of ovulation but cannot assess the quality of the luteal phase.

MULTIPLE CHOICE 1. Which patient meets the criteria currently presented for a diagnosis of current abnormal uterine bleeding? a. A 45-year old who has experienced heavy menstrual void since menses began b. A 25-year old reporting being "so fatigued after my periods" c. A 15-year old who reports "using more pads than I did when I first got my period" d. 35-year old experiencing a significant increase in bleeding over the last 8 months

ANS: D Chronic AUB has been defined as bleeding from the uterine corpus that is abnormal in duration, volume, frequency, or regularity and has been present for the majority of the past 6 months. The other options present signs that are not usual or have been confirmed as abnormal for that particular patient.

2. A sexually active female has symptoms of pelvic inflammatory disease (PID) with fever. Cultures are pending. For outpatient treatment, what will the provider order? a. Ampicillin and doxycycline b. Cefotetan and doxycycline c. Clindamycin and gentamicin d. Rocephin, doxycycline, and metronidazole

ANS: D For outpatient management, Rocephin is given once IM and then doxycycline and metronidazole are given for 14 days.

MULTIPLE CHOICE 1. A woman diagnosed with chronic pelvic pain most likely has a gynecological cause for her symptoms. Which treatment will the provider recommend initially? a. Counseling and support b. Hysterectomy c. Neurostimulation d. Oral contraceptives

ANS: D Oral contraceptives may be helpful and are a good initial choice. Counseling and support are necessary throughout management, but do not help with symptom relief. Hysterectomy may be indicated if there are more severe structural problems but does not always alleviate symptoms. Neurostimulation is used when neuropathic pain is present.

1. To help prevent unplanned pregnancies, which group of providers may make the most impact by providing contraceptive counseling to women? a. Counselors in STI clinics b. Gynecologists c. Practitioners in walk-in clinics d. Primary care providers

ANS: D Women receive most of their preventive care from nongynecologic providers, so PCPs have a unique opportunity to provide contraceptive counseling to women. Women seek care in STI clinics and gynecology clinics for specific reasons often after contraceptive counseling is no longer preventive.

3. A young female has a Pap test which reveals atypical squamous cells of undetermined significance. What will the next step be in managing this patient? a. Colposcopy with biopsy b. Endometrial sampling c. Reflex HPV DNA test d. Repeat cytology in 12 months

ANS: D Young women with ASC-US may have repeat cytology testing in 12 months. Colposcopy with biopsy is performed if low-grade intraepithelial lesions or high-grade squamous intraepithelial lesions are present. Reflex HPV DNA testing is not indicated. Endometrial sampling is performed with low- or high-grade lesions in women who are older than 35 years.

IBS Postural Physical Abuse Cystitis Multiple sex partners psychosocial trauma Abuse

Chronic Pelvic Pain Causes

Vaginal Bleeding of any amount is suspicious for _____________________ in postmenopausal women

Malignancy

Causes of abnormal uterine bleeding (PALM-COEIN)

P: Polyps A: Adenomyosis L: Leiomyomas M: Malignancy C: Coagulopathy O: Ovulatory E: Endometrial I: Iatrogenic N: Not otherwise specified

one of the leading causes of chronic pelvic pain

endometriosis

Postcoital bleeding may be a sign of ______________________

surface lesions on the genital tract or cervical or vaginal cancers