OB/GYN
What is the lifetime risk of developing ovarian cancer in a woman positive for the BRCA-1 gene? 1% to 5% 5% to 10% 10% to 20% 40% to 50%
10% to 20% The risk of ovarian cancer in patients positive for the BRCA-1 mutation increases with age, with 10% to 21% developing ovarian cancer by age 50. For those with the BRCA-2 mutation, the risk is 3%.
Which types of human papillomavirus have the greatest oncogenic potential? 6 and 11 42 and 43 16 and 18 52 and 56 35 and 45
16 and 18 Types 16 and 18 are the types most associated with malignant transformation.
A 20-year-old female presents for routine gynecological care. Her mother has a history of endometriosis. What is the patient's chance of developing endometriosis? 1% 7% 12% 17%
7% A first-degree relative of a patient with endometriosis has a 7% chance of being affected.
Which of the following patients should not use an intrauterine device (IUD)? A 30-year-old G0P0 patient with a history of endometriosis A 40-year-old G2P2 patient with a history of fibroids A 40-year-old G2P2 patient with a history of ectopic pregnancy A 30-year-old G0P0 patient with a history of pelvic inflammatory disease (PID)
A 30-year-old G0P0 patient with a history of pelvic inflammatory disease (PID) Nulliparous patients who may desire future pregnancies should not have an IUD, as PID is a risk of IUD insertion and may cause infertility. Patients with a history of PID are at a higher risk of a second episode with the IUD. Fibroids and endometriosis are not contraindications, and ectopic pregnancy is a risk if pregnancy occurs with an IUD in place.
Which of the following patients should not use oral contraceptives? A 32-year-old patient whose blood pressure is 134/78 A 30-year-old patient who is a smoker A 40-year-old patient with elevated liver enzymes A 40-year-old patient taking tetracycline
A 40-year-old patient with elevated liver enzymes Active liver disease is an absolute contraindication to oral contraceptive use.
A 24-year-old nulliparous African American female presents to your office complaining of menstrual irregularity since menarche. Her menstrual cycle varies from 30 to 120 days and she sometimes has heavy bleeding during her periods. A review of systems and medical history are otherwise unremarkable. She is 64" tall and weighs 146 pounds. Her vital signs, including blood pressure, are normal. You note moderate hirsutism, with a small outer- margin moustache and a streak of hair along the midline of the lower abdomen. There is no balding, clitoral hypertrophy, or other signs of virilization. Findings on pelvic examination are normal except for slight but definite bilateral ovarian enlargement. The remainder of her physical examination is normal. What is the most useful study to evaluate this patient's complaint? Abdominal and pelvic computed tomography (CT) scans A plasma LH level and LH/FSH ratio A sex hormone-binding globulin level Urinary 17-ketosteroids and creatinine
A plasma LH level and LH/FSH ratio The patient's symptoms and appearance are consistent with polycystic ovary syndrome. The diagnosis can be further established if the patient has elevated LH levels and low levels of FSH.
What is the feature that most helps to distinguish premenstrual syndrome (PMS) from other conditions? The patient's age A history of sterilization Fluid retention Social withdrawal A regular symptom-free interval
A regular symptom-free interval By definition, PMS is cyclic with regular symptomatic and asymptomatic intervals that correspond with the ovulatory cycle.
Which of the following patients is most likely to have a recurrence of a rectocele following a surgical repair? A 38-year-old G3P3 with type 1 diabetes mellitus A 74-year-old G3P3 with type 2 diabetes mellitus A 38-year-old G3P3 with a postoperative wound infection A 74-year-old G3P3 with chronic obstructive pulmonary disease A 75-year-old G3P3 with coronary artery disease
A 74-year-old G3P3 with chronic obstructive pulmonary disease Risk factors for the vaginal wall prolapse include difficult vaginal delivery, chronic cough, repeated heavy lifting, ascites, constipation, and age-related atrophy of supporting tissue. All of these factors play a role in recurrence of a vaginal wall prolapse after surgery. Therefore, the older patient with chronic obstructive pulmonary disease had 2 risk factors (age and chronic cough) and is more likely to have a failure of her surgery.
Which of the following statements about pessaries is true? All pessaries must be removed and cleaned daily A common side effect of a pessary is urinary obstruction Pessaries may be used only to treat large pelvic organ prolapse Placement of a pessary is contraindicated in menopausal patients A pessary may permanently cure pelvic organ prolapse
A common side effect of a pessary is urinary obstruction Pessaries are devices inserted into the vagina that correct prolapse by temporarily supporting the uterus and vaginal walls and increasing the tautness of the pelvic floor structures. They come in a wide variety of styles and sizes and must be fitted to each patient. Some are designed to remain in place for months, whereas others must be removed daily. They are most successful in treating small and moderate prolapse. They can cause vaginal ulceration in menopausal patients and so are often used with estrogen vaginal cream and close follow-up. Because they seated behind the pubic symphysis, they can cause urinary obstruction if not properly fitted.
In an adolescent who is not sexually active, what is the most appropriate choice of therapy for primary anovulatory dysfunctional uterine bleeding? A low-dose, estrogen-dominant oral contraceptive Iron intramuscularly, and vitamin B12 Intermittent 5-day courses of medroxyprogesterone acetate Dilatation and curettage
A low-dose, estrogen-dominant oral contraceptive Oral contraceptives are the usual treatment for patients with primary anovulatory dysfunctional uterine bleeding after other causes have been ruled out, and when contraception and fertility-preservation are both wanted. Oral contraceptives stabilize the estrogen-progesterone cycles that are causing the dysfunctional bleeding.
A 32-year-old woman without significant past medical illnesses presents with a breast lump she found on physical examination. She is very worried about this, as her mother and older sister have both been diagnosed with breast cancer. She denied any other medical illnesses and is not taking any medications. She denies smoking, alcohol use, or illicit drug use. You attempt to aspirate the mass and no fluid is obtained. A mammogram reveals microcalcifications and no change in breast architecture. What is the next step? Biopsy Fine-needle aspiration Close observation Repeat mammogram in 6 months Reassurance
Biopsy The microcalcifications are suspicious of malignancy, as is the fact that no fluid was obtained on aspiration. These factors, combined with her family history, necessitate a biopsy.
What is a well-known potential side effect of tamoxifen? A. Endometrial cancer B. Breast cancer C. Osteoporosis D. Ovarian cancer
Breast cancer Tamoxifen is an adjuvant therapy for breast cancer and acts like an estrogen on the endometrial lining. It is associated with a six- to sevenfold increase in endometrial cancer.
A 27-year-old female presents with complaints of foul-smelling vaginal discharge. Examination shows a white discharge with a pH of 5.5 and a positive whiff test. On microscopic examination of the wet mount, what would you expect to see? Motile flagellate organisms Clue cells Gram-negative diplococci Hyphae
Clue cells Bacterial vaginosis causes a fishy odor and discharge. The odor is stronger after potassium hydroxide (KOH) is applied to the slide, resulting in a positive whiff test. Clue cells are the hallmark of bacterial vaginosis and are vaginal epithelial cells with a stippled appearance caused by the adherence of bacteria clusters to the cells.
A 22-year-old college student comes to you to discuss her most recent Pap smear, which shows low-grade squamous intraepithelial lesion (LSIL). She has never had an abnormal Pap smear before. What do you recommend? Repeat Pap in 3 months Repeat Pap in 6 months Colposcopy Hysteroscopy
Colposcopy According to the Bethesda Screening, LSIL is associated with human papillomavirus infection and an increased risk of finding neoplasia on biopsy. Therefore, patients with LSIL should undergo colposcopy and biopsy.
A 16-year-old female presents with primary amenorrhea. Physical examination is unremarkable. The patient is Tanner stage 3, with height 5'8", and weight 140 pounds. What is the most likely diagnosis? Polycystic ovary syndrome Turner syndrome Kallmann's syndrome Constitutional delay Anorexia nervosa
Constitutional delay With a normal height and weight it is unlikely she has polycystic ovary syndrome, Turner syndrome, or anorexia. In Kallmann's syndrome, patients usually present with primary amenorrhea with full breast development and absent or little pubic hair. Given her age and Tanner stage, the most likely diagnosis is constitutional delay, although a full evaluation should be made.
A 56-year-old G3P3 female presents with complaints of pelvic pressure, which is particularly prominent at the end of her shift as a cashier. Over the past month she has noted a mass at the vaginal introitus after defecation. She also notes urinary frequency and sometimes is unable to empty her bladder completely. Her past medical history is significant for two normal spontaneous vaginal deliveries, one cesarean section, hyperlipidemia, and type 1 diabetes mellitus. Her last menstrual period was 5 years ago. Medications include simvastatin and occasional NSAIDs. Examination reveals normal external genitals with an atrophic vagina and cervix. With straining there is an anterior smooth, soft mass extending 1 centimeter beyond the introitus. What is the most likely diagnosis? Enterocele Cystocele Rectocele Uterine prolapse Procidentia
Cystocele A cystocele is a defect in the anterior vaginal wall leading to herniation of the bladder and is the most common vaginal herniation. The urinary symptoms are suggestive but not diagnostic. Rectocele presents as a mass too but occurs posteriorly. Uterine prolapse refers to a fallen uterus and procidentia is a completely fallen uterus, with the uterus and cervix outside the vagina.
You examine a 49-year-old multigravida patient. On speculum examination, you notice a bulge in the anterior wall of the vagina when the patient bears down. What is your diagnosis? Cystocele Enterocele Rectocele Uterine prolapse
Cystocele When the patient bears down, her bladder bulges into the vaginal canal forming a cystocele. Bulges or protrusions in the posterior wall would be enteroceles or rectoceles.
With what are condoms associated? Decreased incidence of pelvic inflammatory disease Increased incidence of ectopic pregnancy Increased incidence of urinary tract infections Multiple birth pregnancies
Decreased incidence of pelvic inflammatory disease Condoms decrease the transmission of sexually transmitted infections and therefore also decrease the incidence of pelvic inflammatory disease.
What antibiotic is best for treatment of mastitis? Dicloxacillin Penicillin VK Tetracycline Cephalosporin
Dicloxacillin The usual organisms causing mastitis are Staphylococcus aureus and Streptococcus, making dicloxacillin or penicillin G the indicated treatment.
Which two cell types must be present on a Pap smear in order for it to be considered adequate? Endocervical and endometrial Endometrial and squamous Endometrial and epithelial Epithelial and squamous Endocervical and squamous
Endocervical and squamous To be considered adequate or satisfactory, a Pap smear must contain cells of both the exocervix (squamous cells) and the endocervical canal. Taking the sample from the transition zone of the cervix usually means both cell types will be obtained.
A 57-year-old woman presents for a routine gynecological examination without any complaints. She has been menopausal since age 54. She does have a family history of breast cancer and her mammogram 2 months ago was normal. Review of systems reveals occasional spotting with intercourse. Her examination is unremarkable, and a transvaginal ultrasound shows an endometrial lining of 9 millimeters. What do you recommend? Endometrial biopsy Pelvic ultrasound Pelvic CT Colposcopy
Endometrial biopsy Postmenopausal bleeding may present as postcoital bleeding and is the hallmark of endometrial cancer. An endometrial lining of less than 5 millimeters has a negative predictive value of 99% for endometrial cancer, so in this case endometrial biopsy should be the next step.
A 66-year-old female with a history of breast cancer 3 years ago comes in for routine gynecological care. She has been on tamoxifen for 3 years and admits to occasional spotting. Her physical examination is normal. What is the next step in the treatment of this patient? Pap smear Pelvic ultrasound Pelvic computed tomography (CT) Endometrial biopsy
Endometrial biopsy Tamoxifen acts as an estrogen on the endometrium, with endometrial cancer as a possible side effect. Subendometrial edema can occur and is not distinguishable from a thickened endometrial stripe, mandating tissue sampling via endometrial biopsy in patients with bleeding.
A 27-year-old G0P0 female presents with a 6-month history of dysmenorrhea. She has been married for 3 years and has not been using birth control. Her pain is unresponsive to acetaminophen and ibuprofen, and she has been consistently missing work for the first 2 days of her period. Examination shows an anteverted, anteflexed uterus of normal size. There is no cervical motion tenderness. The recto-vaginal examination shows some palpable firm nodules posterior to the cervix. What is the most likely diagnosis? Leiomyoma Functional cyst Endometriosis Inflammatory bowel disease
Endometriosis Dysmenorrhea and infertility are hallmarks of endometriosis, as is nodularity in the uterosacral ligament.
An 18-year-old G3P1 female had a baby boy 2 days ago by cesarean section at 39 weeks. Her pregnancy was complicated by poor weight gain and smoking. She presented with spontaneous rupture of membranes for 36 hours and fetal distress. She now has a fever of 101.3°F, her blood pressure is 110/76, and pulse is 94. Her lungs have a few rales at the bases, which clear with coughing. Her breasts are firm, tense, and tender. Her abdomen is soft, with a soft, tender fundus 3 fingers below the umbilicus. The incision is clean and dry. Her white blood cell count is 13,400/uL with 70% segmented neutrophils and 5% bands. Her hemoglobin in 10.4 g/dL and her hematocrit is 31%. What is the most likely diagnosis? Normal postpartum Breast engorgement Mastitis Atelectasis Endometritis
Endometritis Endometritis most commonly presents 2 to 3 days postpartum and is more likely in patients with spontaneous rupture of membranes greater than 24 hours, cesarean sections, and poor nutrition. The elevated white blood cell count points to an infection and the boggy tender uterus is consistent with endometritis.
A 74-year-old G5P5 female presents with a painless vaginal mass that occurs intermittently. It is most prominent if she has to strain to pass stool. She denies pain or bleeding, and states that the mass can easily be pushed back into the vaginal manually. Her past medical history includes type 2 diabetes mellitus for 23 years, four normal spontaneous vaginal deliveries, a cesarean section, a vaginal hysterectomy 10 years ago, and a hip replacement last year. Examination reveals an atrophic vagina with a soft mass that extends 2 centimeters beyond the hymen area and that is easily reducible. What is the most likely diagnosis? Cystocele Enterocele Rectocele Procidentia Uterine prolapse
Enterocele Enteroceles are caused by an upper vaginal wall defect and herniation of the pouch of Douglas. They usually contain loops of small bowel and more commonly occur after hysterectomy.
A 57-year-old white female is 4 years postmenopause and is beginning to experience dyspareunia. A pelvic examination is normal for her age. She is very concerned about maintaining her sexual ability. What do you suggest? Estrogen therapy and maintaining regular sexual activity Regular vinegar douches Sitz baths Triple sulfa vaginal cream Sexual abstinence for 3 months to allow vaginal healing
Estrogen therapy and maintaining regular sexual activity Atrophic vaginitis can occur with menopause, leading to dyspareunia. Oral and topical estrogens can help manage these changes.
What type of breast lesion is typically a single lesion that is rubbery, round, and well defined? Fibrocystic breast disease Fibroadenoma Galactocele Malignant tumor
Fibroadenoma Fibroadenomas are typically firm, discrete, mobile, nontender masses and 10% to 15% of patients have them bilaterally.
What type of breast lesion typically has single or multiple lesions that are well defined, and tender cyclically? Fibrocystic breast disease Fibroadenoma Galactocele Malignant tumor
Fibrocystic breast disease Fibrocystic breast disease is typically present in both breasts and is most tender at the time of menses.
A 42-year-old G2P2 woman presents with severe bilateral breast pain that seems to be worse around the time of menses. Physical examination reveals bilateral breast tenderness with palpation. Multiple lumps are palpated in both breasts. Mammogram reveals dense bilateral breast tissue without calcifications. What is the most likely diagnosis? Fibroadenoma Fibrocystic disease Paget's disease Mastitis Mammary duct ectasia
Fibrocystic disease The cyclic nature of the pain and benign mammogram results are consistent with fibrocystic disease.
A 26-year-old woman complains of a breast lump, which you find to be approximately 1 centimeter in diameter and tender. She reports increased tenderness this week as compared to last week. She states that she noticed it 3 months ago, and that each month it has been tender for approximately 1 week at a time. Which of the following is your best first step? Refer the patient for mammography Refer the patient for biopsy Examine the patient monthly during the next 3 months Fine-needle aspiration of the mass Assure the patient that breast cancer is unlikely in her age group
Fine-needle aspiration of the mass The cyclic nature of the mass and its tenderness are consistent with fibrocystic disease. Fine-needle aspiration can confirm the diagnosis if clear, unbloody fluid is obtained, and the mass subsequently disappears.
Which of the following has been shown to improve symptoms of premenstrual dysphoria? Diazepam Thioridazine Fluoxetine Ibuprofen
Fluoxetine Fluoxetine and venlafaxine have been shown to be effective in treating dysphoria and other symptoms associated with premenstrual syndrome.
A 23-year-old woman presents with left lower quadrant pain. On examination she is found to have a 4-centimeter left ovarian cyst, and an ultrasound shows a unilocular simple cyst. What is the best management for this patient? Start her on low-dose oral contraceptive pills Start her on high-dose oral contraceptive pills Follow up in 2 weeks Follow up in 2 months Refer for laparoscopy
Follow up in 2 months The most likely diagnosis is a follicular cyst, most of which resolve without intervention in 60 days. Recent data suggest that contrary to previous beliefs, the use of oral contraceptives does not produce a more rapid resolution. Unless the patient has severe pain suggesting ovarian rupture or torsion, laparoscopy is not needed for simple cysts in young women.
A 17-year-old girl with a chief complaint of primary amenorrhea has an unremarkable medical history. She has never been sexually active. Notable findings from the physical examination are short stature, no breast development, and normal pelvic structure. Laboratory results include an abnormally high follicle-stimulating hormone level. What is the most likely diagnosis? Uterine synechiae (Asherman's syndrome) Gonadal dysgenesis (Turner syndrome) Polycystic ovary syndrome Pituitary failure Testicular feminization
Gonadal dysgenesis (Turner syndrome) Patients with Turner syndrome have primary amenorrhea, a lack of secondary sexual characteristics, and short stature, with typically elevated levels of follicle-stimulating hormone and luteinizing hormone.
An 18-year-old white nulliparous patient comes to your office to request contraception. She had unprotected intercourse within the past 24 hours and does not want to become pregnant. After you explain all options, including nonintervention, the patient still insists she wants to be protected from pregnancy. What is the most appropriate next step? Endometrial aspiration Immediate insertion of an IUD High-dose combination oral contraceptives, two pills now and two in 12 hours Diethylstilbestrol, 50 mg twice a day for 5 days
High-dose combination oral contraceptives, two pills now and two in 12 hours Postcoital contraception, also referred to as emergency contraception, can be given within 72 hours of intercourse.
In a patient with a vaginal Candida infection, what would you expect to see on examination of a saline prep of the vaginal discharge under the microscope? Hyphae Clue cells Gram-negative diplococci Motile flagellate organisms
Hyphae A vaginal Candida infection shows hyphae and/or budding yeast on microscopic examination of discharge.
A 19-year-old white female with primary dysmenorrhea does not want to use oral contraceptives. Which drug would be best for managing this patient? Indomethacin Sulindac Ibuprofen Aspirin Acetaminophen
Ibuprofen NSAIDs and oral contraceptives are the first-line treatments for primary dysmenorrhea. Of the NSAIDs, ibuprofen is the first choice.
Women with polycystic ovary syndrome have a higher risk of which one of the following? Sexual dysfunction Pituitary adenoma Adrenal hyperplasia Impaired glucose tolerance Ovarian malignancy
Impaired glucose tolerance Patients with polycystic ovary syndrome typically have impaired glucose tolerance due to insulin resistance, and many are treated with metformin.
Which statement below represents the best definition of cervical insufficiency or incompetence? Inability of the cervix to retain a pregnancy beyond 20 weeks Inability of the cervix to retain a pregnancy in the absence of contractions Inability of the cervix to retain a pregnancy during the second trimester Inability of the cervix to retain a pregnancy with Braxton Hicks contractions Inability of the cervix to retain a pregnancy with premature labor
Inability of cervix to retain a pregnancy in the absence of contractions is the correct definition.
With what are intrauterine devices (IUDs) associated? Decreased incidence of pelvic inflammatory disease Increased incidence of ectopic pregnancy Increased incidence of urinary tract infections Multiple birth pregnancies
Increased incidence of ectopic pregnancy IUDs are associated with an increased risk of ectopic pregnancy. An IUD will not increase the risk of sexually transmitted infection, but may contribute to a more severe course of infection should the patient contract one.
With what are diaphragms associated? Increased incidence of pelvic inflammatory disease Increased incidence of ectopic pregnancy Increased incidence of urinary tract infections Multiple birth pregnancies
Increased incidence of urinary tract infections Diaphragms are used with spermicide that can alter the normal vaginal flora, resulting in an increased incidence of urinary tract infections.
Estrogen replacement in the normal menopausal female should be based on which one of the following criteria? Individualized assessment of relative risks and benefits Plasma levels of follicle-stimulating hormone Plasma levels of estradiol Vaginal cytology
Individualized assessment of relative risks and benefits Estrogen replacement therapy is based on the patient's symptoms; history of liver disease, and risk factors for breast cancer, endometrial cancer, and thromboembolic disease, among other factors.
A 22-year-old G0 female presents to the emergency department with abdominal pain that has been increasing for the past 3 days. She describes the pain as crampy with increased intensity with activity. She is sexually active and uses oral contraceptives for birth control. Her vital signs are temperature 101.3°F, blood pressure 134/78 mm Hg, pulse 84, and pain level 7/10. Her abdomen has normal bowel sounds with no masses or distention. She is tender in both lower quadrants with rebound tenderness and guarding. Pelvic examination shows normal external genitalia with a normal cervix. The uterus is normal sized with cervical motion tenderness and bilaterally tender adnexa. What is the best management of this patient? Outpatient therapy with oral cefotaxime and doxycycline Outpatient therapy with oral ceftizoxime, doxycycline, and metronidazole Admit the patient and start IV cefoxitin, clindamycin, and gentamicin Admit the patient and start IV cefoxitin
Admit the patient and start IV cefoxitin, clindamycin, and gentamicin This patient has pelvic inflammatory disease (PID), which warrants inpatient therapy because her temperature is greater than 100.4°F and she has signs of peritonitis in the rebound and guarding. Given that she has not had children, preserving fertility with IV therapy is a goal. Treatment with IV cefoxitin alone does not provide the broad-spectrum coverage needed for PID.
What is the greatest risk factor for a woman to develop breast cancer? Family history High-fat diet Nulliparity Age
Age Whereas the other factors listed all play roles in a woman's risk of developing breast cancer, age is the greatest risk factor.
A 27-year-old woman comes to your office for her annual examination. Her family history is remarkable for breast cancer. Her mother was diagnosed at age 37 and died 10 years later, and a sister who is alive and well, developed breast cancer at age 40. When should she obtain her first mammogram? Age 30 Age 32 Age 35 Age 37 Age 40
Age 32 Current screening recommendations are to start annual mammograms at age 40 except in cases of a family history of breast cancer. Women with a family history should start 5 years before the youngest first-degree relative was diagnosed. The patient's mother was diagnosed at age 37, so the patient should get her first mammogram at age 32.
What is the most common side effect of injected medroxyprogesterone used for contraception? Nausea Amenorrhea Headaches Unwanted pregnancy
Amenorrhea Amenorrhea is the most common side effect, and is more common with continued use of the medication. A less common side effect is heavier bleeding.
A 48-year-old white female comes to see you because of abnormal vaginal bleeding. Her periods are lasting 3 to 5 days longer than usual, bleeding is heavier, and she has experienced some intermenstrual bleeding. Her physical examination is unremarkable, except for a parous cervix with dark blood at the os and in the vagina. She has no orthostatic hypotension, and her hemoglobin level is 11.5 g/dL. A pregnancy test is negative. Which of the following is the most important next step in management? Laboratory tests to rule out thyroid dysfunction An endometrial biopsy Oral contraceptives, 4 times a day for 5 to 7 days Cyclic combination therapy with conjugated estrogens and medroxyprogesterone acetate each month Administration of a gonadotropin-releasing hormone analog
An endometrial biopsy Intermenstrual bleeding in a woman who is perimenopausal, or any postmenopausal bleeding, requires an endometrial biopsy to rule out endometrial carcinoma.
A 32-year-old woman with no past medical history complains of secondary amenorrhea. A pregnancy test is negative and her physical examination is normal. She is given medroxyprogesterone acetate 10 mg per day by mouth for 5 days and experiences bleeding on progesterone withdrawal. What is the likely cause of her amenorrhea? Asherman's syndrome Anovulatory cycle Gonadal agenesis Ovarian failure Menopause
Anovulatory cycle The test indicates that the patient's endometrium has responded to her endogenous estrogen, but insufficient endogenous progesterone was produced to trigger menstruation. This is compatible with an anovulatory cycle. The presence of endogenous estrogen rules out menopause and premature ovarian failure, and her previously normal history rules out gonadal agenesis. The bleeding indicates that the outflow tract is intact, ruling out Asherman's syndrome.
Where is the anatomic defect in a patient with a cystocele? Anterior vaginal wall Posterior vaginal wall Pouch of Douglas (cul-de-sac) Uterosacral ligaments Round ligaments
Anterior vaginal wall An anterior vaginal wall defect is the cause of a cystocele. A posterior vaginal wall defect results in a rectocele. Laxity of uterosacral and round ligaments causes uterine prolapse, whereas herniation of the pouch of Douglas causes an enterocele.
What is the best screening method for ovarian cancer? CA-125 levels Pelvic ultrasound Careful history and physical examination Computed tomography (CT) scan
Careful history and physical examination There are currently no screening tests that are specific, sensitive, and cost effective. Until one is developed, a careful history and physical examination are the best methods.
What is an appropriate choice for treating gonococcal urethritis and cervicitis? Ciprofloxacin Cefoxitin Metronidazole Ceftriaxone
Ceftriaxone Ceftriaxone is an accepted treatment for gonococcal infections. Ciprofloxacin is no longer acceptable due to the high rate of bacterial resistance.
What is the best treatment for an incompetent or insufficient cervix? Cerclage Terbutaline Bedrest CVS Amniocentesis
Cerclage A cerclage is a suture placed around the cervix at 13 to 16 weeks in order to hold the cervix closed. McDonald's cerclage is placed at the cervicovaginal junction and a Shirodkar's cerclage is placed at the level of the internal cervical os.
Postcoital bleeding may be a symptom of what condition? Cervical cancer Uterine fibroids Ectopic pregnancy Ovarian cysts
Cervical cancer The most common symptom of cervical cancer is abnormal vaginal bleeding, which includes postcoital, postmenopausal, or intermenstrual.
A 33-year-old G3P2 female presents with a year-long history of amenorrhea. She is sexually active and uses her husband's vasectomy as birth control. Her past medical history is significant for two normal spontaneous vaginal deliveries. She also had a miscarriage, which was treated with a dilation and curettage (D&C) last year. Her pelvic examination shows a normal-sized uterus and both ovaries are nontender and normal size. What is the most likely diagnosis? Asherman's syndrome Sheehan's syndrome Kallmann's syndrome Hyperprolactinemia Hypothyroidism
Asherman's syndrome Asherman's syndrome refers to scarring of the endometrium following a D&C for a miscarriage or abortion. The most common presentation is amenorrhea.
A 73-year-old African American female presents with vaginal bleeding. It is not severe and occurs only after intercourse. She is not taking hormone replacement therapy (HRT). What is the most likely diagnosis? Cervical polyps Atrophic vaginitis Cervical cancer Endometrial cancer Endometrial hyperplasia
Atrophic vaginitis Postmenopausal women who are not taking HRT often have bleeding after intercourse because of thinning of the vaginal walls in the absence of estrogen. The patient still must be further evaluated to rule out endometrial cancer.
Which conditions are possible complications of complete pelvic organ prolapse? Bleeding, cervical cancer, and ovarian cancer Bleeding, vaginal atrophy, and urinary retention Urinary retention, cervical cancer, and vaginal atrophy Purulent discharge, ovarian cancer, and bleeding Cervical cancer, purulent discharge, and bleeding
Cervical cancer, purulent discharge, and bleeding Symptoms of pelvic organ prolapse in which the uterus and cervix protrude beyond the hymenal ring include nocturia, pressure, vaginal bulge, bleeding, purulent discharge, decubitus ulceration, and, rarely, cervical cancer. Vaginal atrophy is associated with an increased risk of prolapse, but is not a complication.
A 26-year-old G1P1 woman presents with lower abdominal pain, nausea, and vomiting. Her last menstrual period began 5 days ago. She is sexually active and has been using an intrauterine device (IUD) for the past 8 months. What is the most appropriate diagnostic test? Pregnancy test Culdocentesis Computed tomography (CT) of the abdomen Cervical cultures
Cervical cultures The patient should have cervical cultures taken to rule out a sexually transmitted infection (STI). An IUD will not increase the risk of an STI, but may contribute to a more severe course of infection should the patient contract one. Although IUDs are associated with an increased risk of ectopic pregnancy, the patient's recent menstrual period makes this a less likely cause of symptoms.
A 42-year-old G4P4 female presents to discuss birth control options. She is a smoker with a 6-year history of hypertension. She is sexually active in a mutually monogamous relationship and wants a reliable form of birth control. What is her best option? Intrauterine device (IUD) Oral contraceptives Diaphragm Condoms Vaginal ring
Intrauterine device (IUD) Smokers older than 35 years have an increased risk of cardiovascular events on hormonal forms of birth control such as oral contraceptives, patches, and vaginal rings. Since she is a multipara and in a monogamous relationship, an IUD is the best option.
What does the term metrorrhagia refer to? Heavy, excessive bleeding Irregular bleeding Infrequent bleeding Spotting Pain with menstruation
Irregular bleeding Refers to bleeding that occurs at irregular intervals, but that is not excessive. Possible causes may include anovulation, polyps, or malignancy.
Which of the following represents an advantage of injected medroxyprogesterone acetate when used for contraception? It is not causally linked with thromboembolic events. It contains low-dose estrogens. It helps prevent acne. One shot per year prevents most pregnancies.
It is not causally linked with thromboembolic events. Injected medroxyprogesterone does not contain estrogen and so does not have the associated increased risk of thromboembolic events that combination estrogen and progesterone oral contraceptives do.
Which of the following are risk factors for development of an incompetent cervix? Endometrial hyperplasia, DES exposure, and bacterial vaginosis DES exposure, Asherman's syndrome, and ionization LEEP, cone biopsy, and repeated D&Cs Uterine fibroids, repeated D&Cs, and bacterial vaginosis Bacterial vaginosis, DES exposure, and LEEP
LEEP, cone biopsy, and repeated D&Cs Risk factors for cervical incompetence include DES exposure in utero, LEEP, repeated D&Cs, cone biopsy, cauterization, or amputation. Fibroids and bacterial vaginosis are associated with premature labor but not cervical incompetence.
Which of the following contraceptive methods offers the most protection against sexually transmitted infections? Intrauterine devices (IUDs) Oral contraceptive pills Latex condoms Cervical caps Diaphragms
Latex condoms Latex condoms offer the most protection against sexually transmitted infections as well as protection against pregnancy.
A 47-year-old G3P3 female status post-tubal ligation presents for an annual examination with complaints of menorrhagia. On examination there is a palpable abdominal mass that is firm and nontender. Pelvic examination shows an enlarged uterus measuring 16 centimeters above the pubic symphysis. Urine human chorionic gonadotropin (hCG) is negative. What is the most likely diagnosis? Pregnancy Adenomyosis Leiomyoma Ovarian cyst
Leiomyoma A leiomyoma or fibroid uterus is the most likely cause of the pelvic mass associated with menorrhagia. Ovarian cysts can present as abdominal masses but the examination usually shows an adnexal mass and menorrhagia is not usually a complaint.
Which imaging technique has proved most useful for breast cancer screening in women who have had silicone breast implants? Thermography Ultrasonography Mammography Magnetic resonance imaging
Magnetic resonance imaging Silicone breast implants can decrease the efficacy of mammograms. Magnetic resonance imaging is a good alternative.
What type of breast lesion typically presents as a single lesion with an irregular shape that is firm to hard? Fibrocystic breast disease Fibroadenoma Galactocele Malignant tumor
Malignant tumor Malignant tumors also tend to be fixed and nontender. Dimpling of the skin and retractions may also be present.
A 56-year-old G3P3 female presents with a palpable breast lump that she found on breast self-examination 3 days ago. Her mammogram last year was normal. Her family history is negative for breast cancer. On examination there is a 3-centimeter firm, mobile mass under the left nipple. No nipple discharge is noted. What is the most appropriate next step? Mammogram Ultrasound Breast magnetic resonance imaging (MRI) Biopsy
Mammogram Since her last mammogram was last year, the first step should be a mammogram. The patient's age places breast cancer high in the differential diagnosis.
A 53-year-old G3P3 female was seen by you 3 weeks ago for routine examination. Her Pap smear results were normal as was her examination. There is no family history of breast cancer. She has never had an abnormal Pap and is in a mutually monogamous relationship. What are your recommendations for follow-up? Mammograms every year, Pap smears every 2 to 3 years Mammograms and Pap smears every year Mammograms every year, Pap smears every 5 years Mammograms and Pap smears every 2 to 3 years
Mammograms every year, Pap smears every 2 to 3 years Women over age 30 who have had three consecutive normal Pap smears may increase the screening interval to every 2 to 3 years according to the American College of Obstetrics and Gynecology recommendations. Women over age 50 should have annual mammograms.
A 25-year-old G1P1 female presents to the emergency department with right lower quadrant pain of 4 hours' duration. On pelvic computed tomography (CT) scan, a tooth-shaped object is noted in an enlarged right ovary. What is the most likely diagnosis? Endometrioma Serous adenoma Mature teratoma Ectopic pregnancy Corpus luteum cyst
Mature teratomas Mature teratomas or dermoid cysts contain the cell layers of tissue (ectoderm, mesoderm, and endoderm) and often contain differentiated structures from these layers such as bone, teeth, and hair. The other cysts are common in this age group but would not contain a tooth.
What is adenomyosis characterized by? Menorrhagia Oligomenorrhea Metrorrhagia An irregularly enlarged uterus
Menorrhagia Adenomyosis is characterized by menorrhagia, excessive bleeding at normally occurring intervals.
A 40-year-old woman whose menstrual periods previously lasted 5 days and involved the passing of clots, complains that her menses are now heavy (soaking up to six pads each day), still involve the passage of clots, and last for 7 days. The 30-day interval between her menses has not changed. What is the term for this condition? Oligomenorrhea Menorrhagia Metrorrhagia Dysmenorrhea
Menorrhagia Menorrhagia is defined as excessive bleeding at regular intervals.
Polycystic ovary syndrome is best treated by which medication? Metformin Thiazide diuretics Beta blockers Calcium channel blockers
Metformin Polycystic ovary syndrome is associated with insulin resistance, which can be treated with metformin.
A 22-year-old G0P0 female presents to discuss birth control options. She is recently married but wants to wait to start a family. Last year she had a laparoscopy, which showed minimal endometriosis. What is her best option? Intrauterine device (IUD) Oral contraceptives Diaphragm Condoms Vaginal ring
Oral contraceptives For patients with minimal or mild endometriosis, oral contraceptives are a good option for therapy as well as birth control.
A 27-year-old female presents with complaints of oligomenorrhea and increased chin hair. Menarche occurred at age 12 with cycles of 30 to 42 days. Examination shows an obese woman with acne and hirsutism. What is the next step in treatment? Referral to a dermatologist Oral contraceptives Clomiphene Spironolactone
Oral contraceptives The symptoms of polycystic ovary disease are due to increased androgen levels. Treatment with oral contraceptives would give the patient regular cycles as well as treating her hirsutism and acne.
Women who have a father or brother with colon cancer have an increased risk of what type of cancer? Lung cancer Vulvar cancer Clear cell vaginal cancer Ovarian cancer
Ovarian cancer Ovarian cancer is associated with family histories of ovarian cancer, breast cancer, and colon cancer.
What is dysmenorrhea associated with? Metrorrhagia Ovulatory cycles Menopause Oral contraceptive use
Ovulatory cycles Dysmenorrhea is painful menstruation and therefore is associated with ovulatory cycles.
A 26-year-old female presents with oligomenorrhea and hirsutism. A pelvic ultrasound shows slightly enlarged ovaries with a "string of pearls" sign. What is the most likely diagnosis? Polycystic ovary syndrome Endometriomas Brenner's cell tumors Corpus luteum cysts Mature teratomas
PCOS Polycystic ovary syndrome classically presents with oligomenorrhea, hirsutism, and acne. Ultrasound demonstrates slightly enlarged ovaries with multiple small cysts that often appear as a string of pearls.
What type of breast lesion typically presents as an eczematous ulceration of the nipple? Fibrocystic breast disease Fibroadenoma Paget's disease of the breast
Paget's disease of the breast Galactocele Paget's disease of the breast is a type of intraductal carcinoma that involves the skin of the nipple and areola.
A 50-year-old female presents with a 6-month history of crusting, cracking, and weeping of her left nipple. There are no palpable masses present. There is no nipple discharge. She reports trying over-the-counter skin treatments with no benefit. What is the most likely diagnosis? Eczema Mastitis Paget's disease of the breast Fibrocystic breast disease
Paget's disease of the breast Paget's disease of the breast is a type of intraductal carcinoma that involves the skin of the nipple and areola.
A 78-year-old G5P5 woman presents for a routine annual pelvic examination. She has noted some weight gain recently but has no other complaints. On examination, her abdomen is soft, nontender, and slightly obese with no palpable masses. Her liver span is 12 centimeters in the midclavicular line. She has a negative Murphy's sign. Her pelvic examination shows atrophic genitalia with a lack of rugation of the vaginal walls, and a small, nontender, mobile uterus. Her left ovary is palpable, mobile, and nontender. The right ovary is not palpable. What physical finding is abnormal in this patient? Nonpalpable right ovary Palpable left ovary Liver span of 12 centimeters Lack of vaginal wall rugation Parous cervix
Palpable left ovary After menopause, the uterus and ovaries decrease in size, and the ovaries in a 78-year-old woman should not be palpable. Palpation of an ovary raises the question of ovarian cancer, which should be ruled out in this patient.
What is the most common symptom associated with endometriosis? Pelvic pain Menorrhagia Mittelschmerz Bloating
Pelvic pain Pelvic pain is the most common symptom, and can manifest as chronic diffuse pelvic pain, sacral region pain, dyspareunia, or dysmenorrhea.
What is the first step in evaluating primary amenorrhea? Karyotyping Thyroid-stimulating hormone levels Physical examination Prolactin levels Pregnancy test
Physical examination The first step in evaluating primary amenorrhea is a physical examination to determine if growth and development are otherwise normal.
Where is the anatomical defect in a patient with a rectocele? Anterior vaginal wall Posterior vaginal wall Pouch of Douglas (cul-de-sac) Uterosacral ligaments Round ligaments
Posterior vaginal wall A rectocele is associated with a weakness in the lower posterior wall of the vagina.
A 31-year-old G1P1 non-nursing mother presents with shaking chills, arthralgias, and achy muscles, and states she feels like she has the flu. She is concerned about passing it on to her 2-day-old newborn, who is doing well at present. On examination, her temperature is 101.4°F; her uterus is 4 centimeters above the pubic symphysis and is nontender. Both breasts are firm, tense, and tender with no palpable masses. There is no erythema and axillary lymph nodes are not palpable. What is the most likely diagnosis? Postpartum engorgement Mastitis Breast abscess Inflammatory breast carcinoma Influenza
Postpartum engorgement Without nursing, breast engorgement can occur and can cause fever and flu-like symptoms. A breast abscess will usually have a palpable mass, and mastitis usually presents with a wedge-shaped area of erythema.
A 19-year-old nulliparous woman presents to the emergency room with amenorrhea, nausea, and vomiting. She has a history of irregular menses and her last menstrual period was 7 weeks ago. What is the most appropriate diagnostic test? Pregnancy test Culdocentesis Computed tomography (CT) of the abdomen and pelvis Cervical cultures
Pregnancy test When exploring the etiology of secondary amenorrhea, pregnancy must always be considered. Nausea and vomiting are common in the first trimester of pregnancy.
After an episode of unprotected intercourse, when should emergency contraception be administered? Within 24 hours Within 36 hours Within 48 hours Within 72 hours
Within 72 hours The first dose of emergency contraception should be administered within 72 hours.
What has most contributed to the decreased number of cervical cancer deaths in the United States? Women are having fewer sexual partners. Women are marrying later in life. Women have decreased their smoking. Women have been compliant with Pap smear screening.
Women have been compliant with Pap smear screening. Routine Pap smears detect cervical dysplasia early and have greatly reduced the number of deaths from cervical cancer.
In relation to a clinical examination, when can a mammogram detect breast cancer? About the same time the lesion can be palpated Years before a lesion can be palpated Only a year after a lesion can be palpated Only if the lesion is cystic
Years before a lesion can be palpated Mammograms are excellent screening tools for breast cancer because they can detect lesions years before they become palpable.
A 33-year-old G1P1 female presents with complaints of a vaginal mass. She has a long history of menometrorraghia, which has increased recently. She has been able to palpate something in her vagina with her finger and notes a discomfort while sitting that she describes as feeling as though she is "sitting on something." Past medical history is significant for a deep venous thrombosis last year, cesarean section 3 years ago, and obesity. Examination shows normal external genitalia and a well-rugated vagina with a smooth, pink mass bulging into the vagina and obscuring the cervix. The mass is firm, nontender, and smooth, and fills the apex of the vagina. The uterus is of normal size, and no adnexal masses are noted. Rectovaginal examination confirms a mass effect with heme-negative stool. What the most likely diagnosis? Rectal cancer Rectocele Procidentia Enterocele Prolapsed fibroid
Prolapsed fibroid Her history of menometrorraghia could easily be caused by fibroids and those on stalks located low in the uterus can prolapse through the cervix and present as a vaginal mass. They are usually firm, smooth, and nontender. Color may range from pink to red to maroon, depending on the blood supply. Rectal cancers usually present as rough masses associated with blood in the stool. Procidentia refers to complete prolapse of uterus, cervix, bladder, and rectum. Enteroceles are soft and easily reducible.
What is the most common presenting complaint of a woman with cancer of the vulva? Polyps Pruritus Atrophy Discharge
Pruritus Vaginal pruritus is the most common presenting symptom, although many patients are asymptomatic.
A 72-year-old female presents with a concern that her previous rectocele has returned. She had a rectocele repair 4 years ago but recently notes a sensation of rectal fullness and often has to strain to defecate. With straining, she notes a mass at the vaginal opening just as she did 4 years ago. She notes somewhat smaller, more frequent bowel movements but denies melena, hematochezia, hemorrhoids, fever, weight loss, or steatorrhea. Her past medical history includes a vaginal hysterectomy with repair of cystocele 10 years ago, rectocele repair 4 years ago, hypertension for 20 years, chronic obstructive pulmonary disease, and recent lumpectomy for stage 1 breast cancer. On examination, a 3-centimeter vaginal mass is visible when she strains. It is palpable on vaginal and rectal examination as a 2-centimeter hard mass with an irregular surface. What is the most likely diagnosis? Enterocele Rectal cancer Rectocele Procidentia Cystocele
Rectal cancer Her previous history of pelvic organ prolapse makes enterocele a likely etiology except that the examination should show a soft, distensible mass with a location at the apex of the vagina. Rectoceles are soft and easily reducible, whereas the presenting mass is hard.
A 23-year-old female complains of tender masses in both breasts. She is on her menstrual cycle at this time. Examination shows multiple smooth, tender nodules in both breasts. What is the most appropriate next step? Order a mammogram Refer a patient to a surgeon Treat with hormonal therapy Reexamine the patient in 2 weeks
Reexamine the patient in 2 weeks The patient most likely has fibrocystic breast disease, which is typically present in both breasts and is most tender at the time of menses. If the lesions are suspicious on further evaluation, the patient would then require imaging and a possible biopsy.
A 43-year-old obese G2P2 female presents with menorrhagia of 11 months' duration. She also notes oligomenorrhea for the past several years. Her last menstrual period was last week and her human chorionic gonadotropin (hCG) is negative. Her hemoglobin is 9.7 g/dL and ultrasound shows a thickened endometrial lining. What is the next best step in treating this patient? Normal value hemoglobin: 12 to 18 g/dL Computed tomography (CT) scan of the pelvis Magnetic resonance imaging (MRI) of the pelvis Refer for endometrial biopsy Refer for laparoscopy Repeat the ultrasound in 3 weeks
Refer for endometrial biopsy This anemic patient has heavy infrequent menses, which suggests she is not ovulating. Her obesity and anovulation put her at risk for endometrial hyperplasia with unopposed estrogen stimulation of the endometrium. Her ultrasound shows a thickened lining, which suggests hyperplasia and is especially suspicious because she just had her period and should have a thin lining. Given the association between hyperplasia and endometrial cancer, an endometrial biopsy is mandatory.
A 37-year-old patient has a Pap smear report that reads, "Adequate specimen, high-grade squamous intraepithelial lesion (HSIL)." What is your next step in treating this patient? Continue with annual screening Have patient return for repeat Pap smear Have patient return for repeat Pap smear and human papillomavirus testing Have patient return for repeat Pap smear, and human papillomavirus and sexually transmitted infection testing Refer patient for a colposcopy
Refer patient for a colposcopy HSIL is associated with the presence of cervical intraepithelial neoplasia (CIN) II and CIN III, which may progress to cervical cancer, so further evaluation with colposcopy is recommended.
A 17-year-old girl is seen by her pediatrician for complaints of periodic lower abdominal pain that she attributes to stress. She notes it lasts 2 days and is associated with bloating and constipation. Her family history is positive for irritable bowel syndrome in her mother. Menarche has not occurred. The patient denies sexual activity. Her examination shows a well-nourished female 5'7" tall and weighing 135 pounds. She is a Tanner stage 5. Pelvic examination shows normal external genitalia, but the cervix is not visible. Her urine human chorionic gonadotropin (hCG) is negative. Which would be the next best step? Refer to a gastrointestinal specialist Colonoscopy Barium enema Refer to a gynecologist Urinalysis and culture and sensitivity
Refer to a gynecologist The presence of amenorrhea in a 17-year-old girl with full sexual development warrants evaluation. The pain and absence of a visible cervix suggest a vaginal septum with the pain caused by a menstrual flow that is unable to exit the vagina.
A 34-year-old G3P3 female presents with new onset menometrorrhagia for the past 6 months. On examination she is 5'4", weighs 207 pounds, and her blood pressure is 122/78 mm Hg. Examination shows a normal size uterus with neither ovary palpable. An endometrial biopsy shows complex hyperplasia. What is the next step in treating this patient? Pelvic ultrasound or computed tomography (CT) Referral for hysterectomy Progesterone day 16 to 25 of her menstrual cycle Repeat biopsy in her next cycle Oral contraceptives
Referral for hysterectomy Eighty-five percent of endometrial hyperplasia will regress with progesterone given in the luteal phase of the cycle. However, if there is atypia associated with the hyperplasia, progression to cancer is common.
A 50-year-old white woman comes to you because she has found a breast mass. On examination, you feel a firm, fixed, nontender, 2-centimeter mass. She has no nipple discharge, and axillary nodes are palpable. You send her for a mammogram and fine-needle aspiration. The mammogram is read as "suspicious" and the cytology report reads, "a few benign ductal epithelioid cells and adipose tissue." What is the most appropriate next step? Another mammogram in 3 months Repeat fine-needle aspiration in 3 months An excisional biopsy of the mass Referral for breast irradiation Referral to a surgeon for a simple mastectomy
Referral to a surgeon for a simple mastectomy Even though the cytology report is benign, the clinical examination and mammogram are suspicious for malignancy and the mass should be treated as such.
What is the major indication for hormonal replacement therapy (HRT) in menopause? Cardiovascular protection Relief of vasomotor symptoms Prevention of breast cancer Prevention of Alzheimer's disease
Relief of vasomotor symptoms Approved indications for HRT are osteoporosis and relief of symptoms. In the past it was hoped that it would provide protection against cardiovascular disease but there is no evidence for that or for prevention of Alzheimer's disease or breast cancer.
What factor is believed to be causally related to the development of ovarian cancer? Multiparity Chronic anovulation Breastfeeding Repeated ovulation
Repeated ovulation Repeated ovulation is associated with an increased incidence of ovarian cancer. Multiparity, chronic anovulation, and breastfeeding are all associated with a decreased number of ovulatory cycles and a decreased incidence of ovarian cancer.
What is the most common benign ovarian cyst of epithelial origin? Transitional cell Mucinous Endometrioma Clear cell Serous
Serous The most common benign type of ovarian tumor is epithelial and of these, the serous type is the most common. It accounts for 50% to 70% of all benign ovarian neoplasms.
What is the most common type of ovarian cancer in the United States? Serous carcinoma Endometrioid carcinoma Undifferentiated tumor Brenner tumor Clear cell carcinoma
Serous carcinoma Most ovarian cancers are of epithelial origin and of those, serous carcinoma account for 40% to 50% of the ovarian epithelial carcinomas.
A 28-year-old G1P1 female presents for evaluation of amenorrhea of 14 months' duration. She delivered a baby 10 months ago by normal spontaneous vaginal delivery. Her pregnancy was complicated by gestational diabetes and a postpartum hemorrhage requiring several transfusions. She was unable to breastfeed and her human chorionic gonadotropin (hCG) is negative. What is the most likely etiology for her amenorrhea? Sheehan's syndrome Stein-Leventhal syndrome Polycystic ovary syndrome Asherman's syndrome
Sheehan's syndrome Severe postpartum hemorrhage can cause hypotension, which may cause necrosis of the anterior pituitary gland leading to postpartum panhypopituitarism, also known as Sheehan's syndrome. The syndrome is characterized by failure to lactate, amenorrhea, decreased breast size, loss of pubic and axillary hair, hypothyroidism, and adrenal insufficiency.
What is the organism most often responsible for infectious mastitis and breast abscesses? Escherichia coli Beta streptococci Staphylococcus aureus Mixed aerobes and anaerobes
Staphylococcus aureus The majority of isolates are S. aureus.
According to the American Cancer Society, at what age should all patients begin doing monthly breast self- examinations? Starting at age 18 Starting at age 20 Starting at age 25 Starting at age 30 Starting at age 40
Starting at age 20 The recommendations specify monthly self-examinations and annual breast examinations by a medical professional starting at age 20.
Which type of fibroid is often not seen on pelvic ultrasound? Pedunculated Subserosal Intramural Submucosal
Submucosal fibroids Submucosal fibroids may be small and yet still cause substantial bleeding. Because of their small size and location under the endometrium, they can be hard to see on ultrasound. The infusion of saline into the uterine cavity as in a saline hysterogram, allows better visualization of submucosal fibroids.
What causes endometrial hyperplasia, a pathologic condition that is usually associated with abnormal uterine bleeding? The absence of both estrogen stimulation and progesterone influence The absence of estrogen stimulation and excessive progesterone influence Persistent estrogen stimulation and excessive progesterone influence Persistent estrogen stimulation in the absence of progesterone influence
The absence of estrogen stimulation and excessive progesterone influence Endometrial hyperplasia is caused by unopposed estrogen stimulation.
Which one of the following is appropriate advice with regard to the proper use of a diaphragm and spermicidal cream for contraception? For repeated intercourse, the diaphragm should be removed and spermicidal cream reapplied. The diaphragm should be removed immediately after intercourse. The diaphragm and spermicidal cream can be inserted 2 hours before intercourse. The diaphragm should be inserted only in the squatting position.
The diaphragm and spermicidal cream can be inserted 2 hours before intercourse. The diaphragm and spermicidal cream are inserted prior to intercourse and need to remain in place for 6 to 8 hours after.
Which of the following is an indication that a patient with pelvic inflammatory disease (PID) needs to be hospitalized? The patient has multiple sex partners The infection is polymicrobial on culture. The patient has an elevated sedimentation rate Gram stain shows intracellular gram-negative diplococci The patient is pregnant
The patient is pregnant Pregnancy necessitates in-patient treatment of a patient with PID, as do suspected abscesses, inability of the patient to tolerate oral medications, and failure to respond to outpatient treatment.
A 58-year-old white woman presents to her primary care provider for a routine annual examination. Her last menstrual period was 3 years ago. She had a hysterectomy 10 years ago because of abnormal Pap smears and has not had another Pap smear since then. What do you recommend? A. There is no need for further gynecological screenings unless she develops new complaints B. Pap smear of the top of the vagina C. Ultrasound to assess the ovaries D. CT scan of the pelvis and abdomen E. Immediate referral to a gynecologist
The patient's history suggests that she had cervical intraepithelial neoplasia (CIN) and human papillomavirus (HPV). HPV can persist in the vagina following hysterectomy and may cause preinvasive lesions in the vagina. About 10% of women with CIN have concomitant preinvasive neoplasia of vulva, vagina, or anus.
What is the normal pH of the vagina in reproductive-age women? pH 2.5 to 3.5 pH 3.5 to 4.0 pH 6.5 to 7.0 pH 7.0 to 8.0
pH 3.5 to 4.0 The presence of estrogen thickens the vaginal epithelium and increases glycogen in the cells, which results in the production of lactic acid and an acid environment.
Which one of the following is true concerning Trichomonas vaginalis infection? There is a higher prevalence in women with multiple sex partners. Men are infected more often than are women. Almost all women with trichomoniasis are symptomatic. Vaginal secretions should be mixed with potassium hydroxide solution to aid in microscopic identification. Odor is the most common symptom.
There is a higher prevalence in women with multiple sex partners Trichomoniasis is a common sexually transmitted infection that can present with a pruritic discharge
You are evaluating a 38-year-old woman who has been experiencing amenorrhea for the past 8 months. She has normal secondary sexual development and shows no evidence of virilization. Her pelvic examination shows a normal cervix and fundus, and no adnexal masses. Her urine human chorionic gonadotropin (hCG) is negative. Thyroid-stimulating hormone (TSH) and serum prolactin levels are normal, but her follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels are both elevated. She does not have uterine bleeding during the withdrawal phase of a progestin challenge, but does bleed after being on conjugated estrogen (1.25 mg) for 21 days, with a progestin agent added on the last 5 days. What is the most likely diagnosis? Hypothalamic amenorrhea Asherman's syndrome Premature ovarian failure Anovulatory cycle Polycystic ovary syndrome
Premature ovarian failure The patient's lack of bleeding during the progestin challenge indicates that she was not experiencing estrogen proliferation of the endometrium. Her positive response to the combination of estrogen and progestin indicates that the problem is occurring at the ovaries, pituitary, or hypothalamus, not the uterus or vaginal tract. Her normal TSH and prolactin levels and elevated FSH and LH levels place the problem at the level of the ovaries, with a diagnosis of premature ovarian failure being most likely.
For menopausal patients with symptomatic atrophic vaginitis, what is the treatment of choice? Topical estrogen Oral estrogen Oral progesterone Topical progesterone
Topical estrogen Atrophic vaginitis is caused by a lack of estrogen. Although oral estrogen can be used to treat atrophic vaginitis, the treatment of choice is local application of estrogen to reduce the systemic risks of estrogen.
A 75-year-old woman presents with postmenopausal bleeding. Her endometrial biopsy shows well-differentiated endometrial cancer. What is the best treatment for her? Radiation therapy Chemotherapy with cis platinum Combination of radiation and chemotherapy with cis platinum Total abdominal hysterectomy with bilateral salpingo-oophorectomy
Total abdominal hysterectomy with bilateral salpingo-oophorectomy Removal of the uterus and both ovaries is the first step is staging the endometrial cancer.
A 22-year-old female presents with vulvar irritation. Pelvic examination shows erythematous labia and a frothy, greenish vaginal discharge. Her cervix appears to have petechiae. On saline wet prep numerous white blood cells are seen, as are motile organisms with flagellates. What is the most likely diagnosis? Trichomonas Candida Bacterial vaginosis Chlamydia
Trichomonas vaginalis Trichomonas vaginalis is a unicellular flagellate protozoan that can cause vulvar irritation, cervical petechiae (also known as a "strawberry cervix"), and frothy discharge. It is sexually transmitted and patients should be tested for all other sexually transmitted infections.
A 19-year-old G0 female presents with a breast lump that she found yesterday. Her mother was recently diagnosed with breast cancer at age 53 and is undergoing chemotherapy. Her maternal aunt developed breast cancer at age 48. On examination there is a 2-centimeter nontender, mobile mass in the upper outer quadrant of the left breast. What is the most appropriate next step? Mammogram Ultrasound Breast magnetic resonance imaging (MRI) Biopsy
Ultrasound Given this patient's age, the most likely diagnosis is a fibroadenoma, a benign lesion. It typically occurs as a firm, discrete, mobile nontender mass and 10% to 15% of patients have them bilaterally. Her family history of breast cancer, although worrisome for breast cancer risk later in life, does not change the likelihood of fibroadenoma. Ultrasound is the test of choice because mammograms in this age group are very difficult to interpret due to breast tissue density.
What is an absolute contraindication to postmenopausal estrogen replacement therapy (ERT)? Undiagnosed abnormal vaginal bleeding Estrogen receptor-negative breast cancer Fibrocystic breast changes Family history of deep venous thrombosis
Undiagnosed abnormal vaginal bleeding The etiology of abnormal vaginal bleeding must be determined before patients can be placed on ERT due to the possibility of endometrial cancer.
Of the following breast complaints, which warrants the closest and most persistent evaluation? Bilateral nipple discharge that has a milky appearance Cyclic occurrence of bilateral tenderness with irregular, palpable masses Unilateral, purulent nipple discharge, accompanied by tenderness Bilateral nipple irritation during nursing Unilateral, bloody nipple discharge
Unilateral, bloody nipple discharge Unilateral, bloody nipple discharge can be caused by malignancy, and so requires close evaluation. The other conditions described are unlikely to be malignant.
A 43-year-old white female presents with a 4-year history of irregular, intermittent vaginal bleeding. She is not taking hormonal therapy. Her past history is negative. Physical examination is normal except for a large, nodular uterus compatible in size with a 16-week pregnancy. Laboratory tests, including hemoglobin and urine human chorionic gonadotropin (hCG) levels, are all normal. What is the most likely diagnosis? Ovarian carcinoma Uterine leiomyoma Endometrial cancer Carcinoma of the uterine cervix Polycystic ovary syndrome
Uterine leiomyoma Although the patient's abnormal bleeding may have several possible etiologies, her large, nodular uterus is consistent with a diagnosis of a leiomyoma, or fibroid. The patient needs imaging to confirm the diagnosis.
The daughters of women who were exposed to diethylstilbestrol (DES) in utero have an increased risk of what type of cancer? Vaginal cancer Uterine cancer Breast cancer Ovarian cancer
Vaginal cancer They have an increased risk for clear cell adenocarcinoma of the vagina.
What is a risk factor for vulvar cancer? Low body-mass index Nulliparity Late menopause Oral contraceptive use
Nulliparity Nulliparity, a history of certain sexually transmitted infections, obesity, diabetes, and early menopause are all associated with an increased risk of vulvar cancer.
Which of the following are risk factors for developing breast cancer? Multiparity, late menarche, early menopause Nulliparity, late menarche, late menopause Multiparity, early menarche, late menopause Nulliparity, early menarche, late menopause
Nulliparity, early menarche, late menopause Increased exposure to estrogen is hypothesized to increase the risk of breast cancer. Early menarche, nulliparity, and late menopause all increase the duration of estrogen exposure.
What factors are thought to increase the risk of pelvic organ prolapse? Obesity, chronic cough, increasing parity, age Obesity, family history, previous hysterectomy, increasing gravidity Chronic cough, family history, early menopause, age Obesity, early menopause, increasing parity, age Increasing parity, previous hysterectomy, family history, age
Obesity, chronic cough, increasing parity, age The risk factors for pelvic organ prolapse include obesity, age, chronic cough, increasing parity, previous history of hysterectomy, repetitive heavy lifting, and chronic constipation. Family history, early menopause, and increasing gravidity are not risk factors.
A 49-year-old woman complains of several symptoms: 3 weeks of deep depressive bouts that begin rapidly and remit within 12 to 24 hours; drenching sweats without measurable fever; and intermittent muscular aches in the shoulders, hips, and low back. Her last menstrual period was 6 weeks ago. Her cycle has normally been 28 to 30 days until 6 months ago, when it began varying between 3 and 8 weeks. She always slept well until 3 weeks ago, when she began awakening with depression or attacks of diaphoresis. Which of the following is your best next course of action? A. Obtain the patient's FSH level B. Schedule the patient for D&C to rule out endometrial carcinoma C. Treat the patient for depression D. Prescribe for the patient's insomnia E. Order electrical studies of the patient's upper and lower extremities
Obtain the patient's FSH level The patient is likely perimenopausal and experiencing related symptoms. An elevated FSH level will confirm the diagnosis. The cause of the patient's symptoms needs to be identified before treatment is initiated.
