Womens health Boost exam

Question: What are the two most common high-risk human papillomavirus types that are associated with high-grade lesions of the cervix and cervical cancer?

2 most common high-risk human papillomavirus types that are strongly associated with high-grade lesions of the cervix and cervical cancer are types 16 and 18.

Perimenopause

3-5 years Prolonged heavy menstruation with episodes of amenorrhea ↓ fertility ↓ estrogen ↑ FSH and LH

A 19-year-old sexually active woman presents with lower abdominal pain and purulent vaginal discharge of two weeks duration. Temperature is 98.6 °F, heart rate is 70 beats per minute, and blood pressure is 122/74 mm Hg. On exam, the patient expresses tenderness to palpation in right and left lower abdominal quadrants, has purulent cervical discharge, and expresses extreme tenderness with uterine cervical movement. Urine pregnancy test is negative. Which of the following options is the most appropriate therapy?

A Amoxicillin 500 mg PO twice daily for 14 days + ofloxacin 300 mg PO twice daily for seven days BCefoxitin 2 g IM + single dose probenecid 1 g PO + sulfamethoxazole/trimethoprim 800 mg/160 mg PO twice daily for seven days CCeftriaxone 500 mg IM + doxycycline 100 mg PO twice daily for 14 days + metronidazole 500 mg twice daily for 14 days Correct Answer DLevofloxacin 500 mg PO once daily for 14 days + single dose azithromycin 1 g PO Correct Answer ( C ) Explanation: Pelvic inflammatory disease (PID) is a an inflammatory condition of the female upper genital tract, involving the uterus, fallopian tubes, and ovaries. It results in endometritis, salpingitis, tubo-ovarian abscess, perihepatitis, and pelvic peritonitis. The most common causes of PID are the sexually transmitted pathogens Neisseria gonorrhoeae and Chlamydia trachomatis. A patient with PID may present with insidious or acute onset bilateral lower abdominal and pelvic pain, lower back pain, or with purulent vaginal discharge. It may be accompanied by constitutional symptoms including fever and chills. On exam, the patient may have lower abdominal tenderness, purulent cervical discharge, and extreme tenderness with cervix or uterus movement on bimanual exam. Palpable adnexal mass may suggest tubo-ovarian abscess. Testing for N. gonorrhoeae and C. trachomatis and other STDs should be performed if PID is suspected. PID should be diagnosed clinically. Empiric treatment should be initiated in any sexually active woman with pelvic or lower abdominal pain and no alternative explanation for her symptoms, and if one or more of the following criteria are present on pelvic exam: cervical motion tenderness, uterine tenderness, or adnexal tenderness. Empiric broad-spectrum coverage against the likely pathogens, including N. gonorrhoeae and C. trachomatis, should be given as soon as a presumptive diagnosis is made. First-line therapy for non-pregnant patients is a single 500 mg dose of ceftriaxone IM and a two week course of 100 mg PO doxycycline twice a day plus 500 mg of metronidazole twice daily for 14 days. A single episode of salpingitis can lead to infertility in 12-18% of affected women, so starting an appropriate treatment regimen promptly i

A 29-year-old G2P1011 woman is two days postpartum from a spontaneous vaginal delivery. She had a prolonged labor course and was diagnosed with intraamniotic infection intrapartum. Today, the nurse informs you that the patient is febrile and complaining of abdominal pain. On evaluation, you note uterine tenderness. She is exclusively breastfeeding her infant. What is the most appropriate treatment?

A Ampicillin B Ciprofloxacin and ceftriaxone C Clindamycin and gentamicinCorrect Answer D Metronidazole Correct Answer ( C ) Explanation: The patient most likely has endometritis, which is an infection of the uterine decidua. This is a relatively common postpartum infection and is diagnosed by the presence of maternal fever, uterine tenderness, and abdominal pain. The infection is usually polymicrobial, including anaerobic bacteria, and should be treated empirically without the need for blood or uterine cultures. Risk factors include cesarean delivery, prolonged labor, thick meconium, internal monitors during labor, and chorioamnionitis. Of the choices listed, clindamycin and gentamicin are the standard treatment. These two antibiotics provide excellent coverage with high cure rates and are safe to use in breastfeeding women. The other choices are not adequate treatment for postpartum endometritis. Although ampicillin plus sulbactam can be used as first-line treatment, ampicillin (A) alone is inadequate because it does not cover beta-lactamase producing organisms. Ciprofloxacin and ceftriaxone (B) is not a typical antibiotic regimen, and in any case, fluoroquinolones such as ciprofloxacin are relatively contraindicated in breastfeeding patients. Finally, although metronidazole (D) has excellent anaerobic coverage, it alone is not broad spectrum and should be avoided in breastfeeding when possible

A 65-year-old woman undergoes primary surgical cytoreduction for epithelial ovarian cancer. She has suboptimally cytoreduced disease with greater than 1 cm of residual disease still present. Which of the following is the best pharmaceutical treatment option for this patient?

A Carboplatin and paclitaxel intravenously Correct Answer BCarboplatin intraperitoneally CCisplatin and docetaxel intravenously DCisplatin intraperitoneally and paclitaxel intravenouslyYour Answer ??? Correct Answer ( A ) Explanation: Carboplatin and paclitaxel intravenously is the preferred first-line chemotherapy in women who have suboptimally cytoreduced disease after surgical cytoreduction for epithelial ovarian cancer. Platinum and taxane agents are used first-line. A dose-dense schedule is typically used with carboplatin administered every three weeks and paclitaxel administered once a week. This regimen is continued for a total of 15 weeks. Dose-dense therapy has shown either equivalent or, in some studies, improved outcomes when contrasted with conventional chemotherapy dosing. Usually, chemotherapy begins within two to four weeks after primary surgical cytoreduction. Delaying chemotherapy beyond four weeks after surgery has been shown in some studies to result in worse outcomes. Carboplatin (B) alone is not an acceptable regimen as chemotherapy should include both a platinum and taxane agent. Cisplatin and docetaxel (C) is an acceptable regimen; however, it is not preferred due to the increased toxic effects of cisplatin and the increase in myelosuppression with docetaxel. Cisplatin intraperitoneally and paclitaxeol intravenously (D) is the regimen used in optimally cytoreduced disease with residual disease being less than 1 cm. Intraperitoneal therapy does not penetrate larger tumors as well as intravenous therapy.

A 60-year-old G2P2 woman presents to the clinic for a progressively worsening bulge sensation in her vagina for the past eight months and urinary incontinence when she laughs. Vaginal exam reveals a palpable break in the anterior vaginal fascia which becomes more prominent with Valsalva. Which of the following historical aspects put this woman most at risk for the most likely diagnosis?

A Connective tissue disorders Correct Answer BEarly age at menarche CRadiation therapy DVaginal hysterectomy Correct Answer ( A ) Explanation: Cystocele is the descent of the urinary bladder through an anterior vaginal wall herniation. Cystocele is a form of pelvic organ prolapse. Risk factors for prolapse are increased parity, vaginal delivery, advanced age, connective tissue disorders (eg: Ehlers-Danlos), and obesity. Women with cystocele may present with the sensation of a vaginal bulge or vaginal pressure, or with urinary dysfunction or incontinence. Women may actually experience improvement in urinary incontinence as the cystocele advances, but they will likely experience increased difficulty voiding, specifically obstructed voiding. This results from the prolapse causing a "kink" in the urethra. Cystocele is diagnosed clinically with pelvic examination, which reveals a palpable bulge in the anterior vaginal wall through a break in the anterior vaginal fascia. Treatment is only indicated for symptomatic women. Management options include expectant management, conservative therapy (pelvic floor muscle strengthening, pessary), or surgical therapy with anterior colporrhaphy. Early age at menarche (B) is associated with an increased risk for breast cancer, but not for cystocele. Radiation therapy (C) is associated with an increased risk for malignancy, but not for cystocele. The role of hysterectomy (D) in pelvic organ prolapse development is unclear. The risk of future prolapse seems to be highest when hysterectomy is performed in women with pre-existing prolapse.

A 42-year-old woman presents to your office for a health care maintenance visit. You counsel her on perimenopause, symptoms, and management. Which of the following is the most common symptom of perimenopause?

A Heavy uterine bleeding B Hot flashesCorrect Answer C Sexual dysfunction D Vaginal dryness Correct Answer ( B ) Explanation: Menopause is a timepoint defined as the final menstrual period. It is preceded by a transitional phase that lasts several years called perimenopause or the menopausal transition. The hallmark and most common clinical symptom of this phase are hot flashes, menstrual irregularity, as well as hormonal fluctuations. Hot flashes are described by most women as a sudden sensation of heat centered on the upper chest and face that rapidly becomes generalized. Associated symptoms include profuse perspiration, facial flushing, and, occasionally, palpitations. Although they last only a few minutes, they can occur several times per day and are more common at night. Even though their presence can be bothersome, only a minority of women will seek medical attention. Most women in perimenopause experience changes in their menstrual pattern, but heavy uterine bleeding (A) is not common. Sexual dysfunction (C) can occur independently or as a consequence of vaginal dryness (D), and both conditions are linked to the decrease in circulating estrogen levels. These symptoms occur less frequently than hot flashes during perimenopause.

A 30-year-old woman presents with a new thin vaginal discharge with a foul odor for the past two weeks. The woman is 24 weeks pregnant. The pregnancy has been uncomplicated. She denies any associated pain or vaginal bleeding. Vaginal swab is obtained for point of care microscopy which shows the presence of clue cells. Which of the following is the best next step in management?

A Initiate clindamycin intravaginally B Initiate metronidazole orally Correct Answer C Monitor symptoms throughout pregnancy D Wait until the third trimester to initiate therapyYour Answer ??? Correct Answer ( B ) Explanation: Bacterial vaginosis (BV) is a condition characterized by a transition in vaginal flora away from Lactobacillus species and toward a mix of other bacterial species which produce volatile amines, resulting in a rise in vaginal pH to > 4.5. The major bacteria detected in women with BV is Gardnerella vaginalis. BV is the most common cause of vaginal discharge in women of childbearing age. The pathologic pH environment may not result in any symptoms, but affected women may complain of an off-white, thin and homogeneous vaginal discharge with an unpleasant "fishy" odor. Diagnosis is based on the presence of at least three of the following criteria: characteristic vaginal discharge, vaginal pH > 4.5, clue cells (vaginal epithelial cells studded with adherent coccobacilli, usually at the edge of the cell) on a saline wet mount, and a positive whiff-amine test (the presence of a fishy odor when a drop of ten percent potassium hydroxide is added to a sample of vaginal discharge). Gram's stain of vaginal discharge is the gold standard for BV diagnosis. Pregnant women with BV are at increased risk of preterm birth. Metronidazole or clindamycin administered orally is the first-line therapy for pregnant patients with symptomatic BV infection. Since intravaginal yeast infection typically follows antibiotic therapy, and the condition typically improves spontaneously within a few months, therapy is only recommended for symptomatic patients. Clindamycin intravaginally (A) is thought to be safe in pregnancy, but some experts recommend against topical therapy because they believe oral therapy to be more effective against potential subclinical upper genital tract infection. Since treatment is recommended for all symptomatic patients, pregnant or not, monitoring symptoms throughout pregnancy (C) without initiating treatment would be inappropriate. There is no need to wait until a pregnant patient reaches the third trimester to initiate therapy (D), which is safe at any point throughout the pregna

A 48-year-old woman presents to the clinic worried that she has not had a period in over a year. In the past, she had irregular periods for several years. She reports vaginal dryness, insomnia, and increased irritability. Vitals are normal, but she is 12 lbs heavier than she was at her last appointment six months ago. Serum human chorionic gonadotropin and prolactin levels are normal, but follicle-stimulating hormone is elevated. Which of the following is the most likely diagnosis?

A MenopauseCorrect Answer B Pituitary adenoma C Polycystic ovary syndrome D Primary ovarian insufficiency Correct Answer ( A ) Explanation: Menopause, the permanent cessation of menstrual periods, is determined after a woman has experienced 12 months of amenorrhea without any other obvious pathological or physiological cause. It typically occurs between 48-55 years of age, with the average age of 51 in the U.S. Typical symptoms include: hot flashes (most common symptom), mood swings, vaginal dryness, painful intercourse, loss of libido, poor sleep and weight gain. Menopause is a clinical diagnosis. Laboratory studies are not routine but may be helpful. Typically with menopause, follicle-stimulating hormone will be elevated, estradiol will be low, prolactin and thyroid-stimulating hormone levels will be normal. Pituitary adenoma (B) is a cause of secondary amenorrhea with elevations in prolactin levels, low estradiol, and normal follicle-stimulating and thyroid-stimulating hormone levels. Magnetic resonance imaging of the pituitary will confirm diagnosis. Polycystic ovary syndrome (C) is a cause of secondary amenorrhea with elevated levels of testosterone and signs of virilization. Prolactin, thyroid-stimulating, follicle-stimulating, and estradiol hormone levels are typically all normal. Primary ovarian insufficiency (D) is menopause before the age of 40. Although many cases are idiopathic, genetic counseling is now recommended. Risks of prolonged estrogen deficiency should be addressed.

Hyperprolactinemia

A patient with hyperprolactinemia would present with galactorrhea or symptoms related to intracranial lesions such as visual field defects or headaches.

A 46-year-old woman presents to your office for a second opinion. She has been experiencing abnormal uterine bleeding for more than two years. Her periods are heavy, prolonged, and associated with clotting. Imaging of her uterus was unremarkable. A recent hysteroscopy with directed biopsies was negative. She has three children, all born by uncomplicated vaginal deliveries, and is not interested in future conception. She declines hormonal therapy and would like to proceed with surgical therapy. Which of the following is recommended?

AAbdominal hysterectomyYour Answer ?? BDilation and curettage CEndometrial ablationCorrect Answer DWedge resection of the uterine wall Correct Answer ( C ) Explanation: Abnormal uterine bleeding (AUB) is a gynecologic complaint that has a variety of causes, some of which can be premalignant or malignant. A comprehensive workup should be performed to classify the type of AUB according to the PALM-COEIN classification. Special attention is needed in women who are 45 years of age or older and those who have risk factors for unopposed estrogen exposure, such as those who are obese or have polycystic ovary syndrome, as these populations are at an increased risk of malignant disease. An endometrial biopsy, in this setting, is warranted as part of the workup. If premalignancy and malignancy are ruled out, surgical interventions affecting the endometrial lining can be considered. Endometrial ablation is performed via various techniques such as using radiofrequency, cautery, or thermal energy. It is a minimally invasive procedure that is performed during or after a hysteroscopy. Abdominal hysterectomy (A) is a definitive treatment for AUB but is a costly and morbid procedure and should be kept as a last resort. Furthermore, a less invasive approach to hysterectomy is preferred, particularly for this multiparous patient who is likely a good candidate for vaginal hysterectomy. Dilation and curettage (B) can be considered as a treatment of AUB in an acute setting. Wedge resection of the uterine wall (D) can be considered in the setting of adenomyosis.

A 35-year-old woman presents for routine gynecologic screening. Cervical cytology shows atypical squamous cells of undetermined significance. Reflex human papillomavirus testing is positive for strain 16. Which of the following is the best next step in management?

AAblation BColposcopy Correct Answer CExcision DRepeat cytology with HPV co-test in one year Correct Answer ( B ) Explanation: Positive HPV 16 or HPV 18 with any cytology result: colposcopy Cervical cytology with the Papanicolaou (Pap) smear is the standard screening test for cervical cancer. Atypical squamous cells of undetermined significance (ASC-US) is the most common cervical cytologic abnormality. The risk of invasive cervical cancer in women with ASC-US is low because one to two thirds are not associated with high risk human papillomavirus (HPV). Women with human papillomavirus (HPV) are at higher risk for cervical precancer or cancer. HPV strains 16 and 18 are the most commonly isolated strains in cervical cancer. Multiple sexual partners and unprotected sex increase a woman's risk of contracting HPV and therefore increase the risk of developing cervical dysplasia. The pathologic cellular changes most commonly occur at the cervical transformation zone, an anatomic landmark where the squamous epithelium of the ectocervix transitions to the glandular epithelium of the endocervix. Cervical dysplasia is most often discovered when women are in their 20s (shortly after their sexual debut). Women with cervical dysplasia are usually asymptomatic, and detection of pathologic changes usually occurs during routine cervical cytology screening. For women with ASC-US cytology, the preferred next step is HPV testing. Since one-third to two-thirds of ASC-US cases are not associated with high risk HPV, HPV testing prior to colposcopy prevents unnecessary procedures. Any women with ASC-US and positive HPV testing should be assessed for immediate risk of severe dysplasia. This requires risk calculation based on current and previous Pap and HPV test results. Colposcopy is recommended for HPV 16 or 18 with any Pap result because these aggressive types of HPV confer moderate risk of severe dysplasia even with normal cytology Ablation (A) destroys any concerning cervical lesions, and excision (C) removes any concerning lesions. Colposcopy should be performed prior to ablation or excision for women with ASC-US for triage purposes to prevent unnecessary destructive procedures for women without significant dysplasia.

An 18-year-old woman presents to the clinic with heavy and painful periods for the past two years. She has never been pregnant and a pregnancy test in the office is negative. The patient has a normal body mass index, and her pelvic ultrasound and pelvic examination are unremarkable. Which of the following is the most likely diagnosis?

AAbnormal uterine bleedingCorrect Answer BBleeding diathesis CHyperprolactinemia DPolycystic ovarian syndrome Correct Answer ( A ) Explanation: Abnormal uterine bleeding (AUB) is characterized by irregular uterine bleeding. Patients may have unpredictable bleeding that can be heavy or light, frequent or prolonged, irregular and sporadic. It is commonly associated with anovulatory menstrual cycles but some patients may have occasional ovulatory cycles. Physical examination will reveal normal pelvic exam. AUB is a diagnosis of exclusion, so other causes of anovulatory bleeding must be ruled out, such as polycystic ovarian syndrome, thyroid disease, hyperprolactinemia, intracranial or pituitary lesions, and bleeding disorders. Pregnancy is the most common cause of AUB. A urine human chorionic gonadotropin test, complete blood count, endometrial sampling, prolactin level, thyroid function tests, coagulation studies, and hormone assay are among many tests used in the workup for this diagnosis. Pelvic ultrasound can be used to rule out uterine fibroids, polyps, and polycystic ovaries. Medical therapy includes nonsteroidal anti-inflammatory drugs (NSAIDs) to decrease blood loss, oral contraceptives to support normal endometrial growth, progestins to induce normal endometrial sloughing, and desmopressin for patients with documented coagulation disorders. If medical management fails, additional evaluation with hysteroscopy and uterine curettage is warranted to evaluate for uterine pathology, including endometrial hyperplasia and carcinoma. If the patient had a bleeding diathesis (A), she would have presented with other symptoms such as frequent nosebleeds, prolonged bleeding, and easy bruising.

A 14-year-old girl presents to the clinic with lower abdominal cramping that started six months ago. The cramping always starts a day or two before her menstrual cycle and resolves after about two days. She rates the pain as "severe"; she has gone home from school and missed sports practices due to the pain. Which of the following is the most appropriate initial therapy?

AAcetaminophen BIbuprofenCorrect Answer CNorgestimate/ethinyl estradiol DTramadol Correct Answer ( B ) Explanation: Primary dysmenorrhea is characterized by recurrent, crampy, midline lower abdominal pain that occurs during menses in the absence of demonstrable disease that could account for the pain. Pain usually occurs a day or two before menstrual cycle and typically resolves within 72 hours. Menstrual uterine sloughing releases prostaglandins, which cause painful uterine contractions. Additional symptoms that may be present include nausea, diarrhea, fatigue, headache, and a general sense of malaise. The goal of treatment is to provide adequate pain relief. First-line treatment for primary dysmenorrhea is with non-steroidal anti-inflammatory drugs (NSAIDs) or combined oral hormonal contraceptives. NSAIDs inhibit prostaglandin synthesis by inhibiting cyclooxygenase. Combination oral hormonal contraceptives suppress ovulation, which prevents or decreases prostaglandin-stimulated uterine contractions. Exploratory laparoscopy may be necessary for definitive diagnosis and treatment for women who do not respond to initial therapy. Primary dysmenorrhea usually improves with age and after childbirth. Acetaminophen (A) does not have the same inhibitory effect on prostaglandin synthesis as NSAIDs, and therefore is not as effective a therapy as NSAIDs. Norgestimate/ethinyl estradiol (C) and other hormonal contraceptives can be effective therapy for dysmenorrhea, but due to serious potential side effects, such as venous thromboembolism, affected women should try NSAIDs first. Tramadol (D) binds to μ-opiate receptors and inhibits norepinephrine and serotonin reuptake resulting in an analgesic effect. Tramadol has side effects including dependency and abuse, and therefore is not recommended as first-line therapy for dysmenorrhea.

A 25-year-old G1P0 at 39 weeks' gestation has been admitted to the labor and delivery department. On admission, a digital cervical examination was performed. Which of the following best describes the appropriate time for repeat cervical examinations during labor?

AAfter administration of anesthesia BEvery 15 minutes during stage twoYour Answer CEvery hour during stage one DWhen the woman feels the urge to pushCorrect Answer Correct Answer ( D ) Explanation: Repeat digital cervical examinations should be done at varying intervals during labor to confirm that dilation of cervix is progressing at an appropriate rate and to determine cervical effacement and fetal station. The first cervical examination should be performed at the time of admission. During the first stage of labor, the examinations should be performed every two to four hours. During stage two, every one to two hours is sufficient. When the woman feels the urge to push, a cervical examination is done to determine whether the cervix is completely dilated. If the woman has chosen to have anesthesia, a cervical examination should be done prior to its administration. Additionally, if the fetal heart rate becomes irregular, a cervical exam is indicated to evaluate for complications such as cord prolapse or uterine rupture. The results of the examination can be documented on a partogram, a graphical representation of the progression of dilation, in addition to the medical record A digital cervical examination should be performed prior to the administration of anesthesia, not after the administration of anesthesia (A). Every hour during stage one (B) would not be recommended, rather every two to four hours. Every 15 minutes during stage two (C) is too frequent of an interval as the recommendation is every one to two hours.

A 23-year-old G0 woman presents to the emergency department with lower abdominal pain for the past three days. She reports associated foul-smelling vaginal discharge. Her medical history is significant for chlamydia, which was treated three years ago, and an appendectomy when she was 12 years old. Her social history is significant for THC use and 15 lifetime sexual partners. A urine pregnancy test is negative. On pelvic examination, you note a mucopurulent discharge from the cervical os, two strings protruding from the cervical os, and cervical motion tenderness on bimanual exam. Which of the following historical risk factors places this patient at the highest risk for the suspected diagnosis?

AAge less than 25 BHistory of chlamydia CIntrauterine device in place DMultiple sexual partnersCorrect Answer Correct Answer ( D ) Explanation: Women with multiple sexual partners are at the highest risk of developing pelvic inflammatory disease (PID). Women who are sexually abstinent or who are in a monogamous relationship are at extremely low risk for PID. Acute PID is characterized by lower abdominal or pelvic pain and cervical, uterine, or adnexal motion tenderness on examination. Purulent cervical or vaginal discharge is also commonly present. When PID is suspected, the following tests should be performed: pregnancy test, chlamydia and gonorrhea testing, Mycoplasma genitalium testing, serology testing for syphilis, and HIV screening. Pelvic imaging with ultrasound can help identify other possible causes for pelvic pain, or the presence of complications of PID, such as tubo-ovarian abscess. The recommended treatment for mild to moderate PID includes ceftriaxone 500 mg IM as a single dose, plus doxycycline 100 mg orally twice daily for 14 days, with or without metronidazole 500 mg orally twice daily for 14 days. Severe or complicated PID (tubo-ovarian abscess, pregnancy, severe illness, nausea and vomiting, high fever, or those with no response to oral therapy) should be treated with hospitalization and cefotetan 2 g IV every 12 hours plus doxycycline 100 mg PO or IV every 12 hours. PID occurs in the highest frequency in women age 15 to 25, thus age less than 25 (A) is a risk factor but is not the highest risk factor for PID. History of chlamydia (B) is an important risk factor, but it is not the highest risk factor for PID. Two strings protruding from the patient's cervical os suggests that the patient has an intrauterine device in place (C). Modern IUDs cause minimal risk for the development of PID, thus this answer is incorrect. IUDs may remain in place during treatment of PID, but if no clinical improvement is noted within a few days of treatment, removal should be considered.

A 24-year-old woman presents with fever, chills, and painful lumps to the groin area for the past three weeks. She is sexually active with men only. Pregnancy test is negative. Upon physical examination, you note tender inguinal and femoral lymphadenopathy bilaterally with some anal fissures. There are no lesions noted on labia majora or minora. Which of the following is the treatment of choice for this patient?

AAmoxicillin BAzithromycin CDoxycyclineCorrect Answer DErythromycin Correct Answer ( C ) Explanation: Lymphogranuloma venereum is an uncommon, sexually transmitted disease caused by Chlamydia trachomatis. It is rare in industrialized countries, but it has been increasingly seen in women who are engaged in unprotected anal sex and men who have sex with men. Infection occurs after direct contact with the skin or mucous membranes of the infected partner. The organism travels to the regional lymph nodes and causes systemic disease. The disease is characterized by painless genital papules or ulcers that are self-limited, followed by painful inguinal or femoral lymphadenopathy. Patients with this condition may also present with rectal ulcerations and symptoms of proctitis. Lymphogranuloma venereum occurs in three stages. The first stage involves a rapidly healing, painless genital papule or ulcer. The second stage involves painful inguinal lymphadenopathy (appearance of "grooves sign" or large bubo) that usually occurs two to six weeks after the primary lesion. Constitutional symptoms may include fever, chills, myalgias, and malaise. This stage is when most men are diagnosed. The third stage is characterized by proctocolitis and symptoms include bloody purulent discharge, rectal pain, and tenesmus. This stage may occur many years after the original infection. Women are more likely to be diagnosed in the third stage because they usually lack symptoms in the first or second stage. Doxycycline is the drug of choice in patients who are not pregnant. Erythromycin should be used in patients who are pregnant or lactating. Sexual partners who had contact with the patient within the past 60 days should be treated for exposure with doxycycline or azithromycin. Erythromycin (B) is the drug of choice for pregnant or lactating women. Amoxicillin (C) can be used in pregnant women who are intolerant to erythromycin. Azithromycin (D) is usually used to treat partners who are exposed to infection.

A 68-year-old woman presents to clinic to discuss surgical management of her pelvic organ prolapse. She has had stage III prolapse of the uterus for the past 5 years. Pelvic muscle exercises and pessary use have not relieved her symptoms of heaviness and discomfort. Her past medical history is significant for sarcoidosis for which she takes oral prednisone. Which of the following is the most appropriate surgical option for this patient?

AAnterior colporrhaphy Your Answer ?? BHysterectomy with synthetic mesh vaginal repair CHysterectomy with uterosacral ligament suspensionCorrect Answer DPosterior colporrhaphy Correct Answer ( C ) Explanation: Pelvic organ prolapse occurs when laxity of pelvic floor muscles, ligaments, and connective leads to herniation of pelvic organs into the vaginal vault. The extent of prolapse is graded according to the pelvic organ prolapse quantification system (POP-Q). According to the POP-Q, a stage III prolapse of the uterus, as in this patient, corresponds to uterine descent anywhere from 1 cm distal to the hymen to the opening of the vaginal introitus. Although prolapse is often managed effectively with pessaries, when conservative management fails, many patients elect to undergo surgical treatment. If the prolapsed organ is the uterus, a hysterectomy is necessary to achieve symptomatic relief. A sacropexy using either the uterosacral or the sacrospinous ligaments is then performed to suspend the vagina and prevent further prolapse. Therefore, this patient is a good candidate for a hysterectomy with uterosacral ligament suspension. An anterior colporrhaphy (A) would be used to correct cystocele or urethrocele. Treatment of uterine prolapse requires apical support with hysterectomy or hysteropexy. Although synthetic mesh has been used in the correction of uterine prolapse, erosion rates as high as 20% led the FDA to stop their distribution. Therefore, hysterectomy with synthetic mesh vaginal repair (B) is incorrect. A posterior colporrhaphy (D) would be used to correct a rectocele. It involves plication of the posterior vaginal wall with distal suspension to the perineal body. It would not be appropriate for repair of uterine prolapse.

A 26-year-old woman presents to your office for health care maintenance. She reports chronic pelvic pain. A review of her records reveals several emergency room visits for acute pelvic pain with a negative evaluation. You are suspicious for domestic violence. She does not report abuse. Her physical examination is normal. Which of the following is the best next step?

AAsk about specific types of abuseCorrect Answer BCall the policeYour Answer ??? CDiscuss concerns with the patient's partner DSchedule a follow-up visit Correct Answer ( A ) Explanation: Domestic violence, or intimate partner violence (IPV), is a severe and major public health problem that is more common in women than men. It involves actual or threatened psychological, physical, or sexual harm by a current or former partner or spouse that could be both homo- or heterosexual. Although IPV can occur in any socioeconomic state or race, identified risk factors include being unmarried, low-income, and a history of childhood abuse. Physicians should be able to suspect, screen, and identify women with IPV in order to reassure patients that abuse is not normal, assess their safety, assist with referral to local resources, and be an active patient advocate. IPV results in diminished self-esteem, depression, mental trauma, physical injuries, and can lead to death. Clinical manifestations of IPV include depression, anxiety, substance abuse, pelvic pain, and noncompliance to medical appointments. There is no definitive screening algorithm for IPV, however, suggested dialogues consist of the physician directly asking about specific types of abuse such as actual or threatened, or physical or emotional. The physician should not call the police (B) or discuss concerns with the patient's partner (C) since this represents a major breach in the patient's confidentiality and could place her at risk of social and physical repercussions. It is acceptable to schedule a follow-up visit (D) only after directed questions have been asked and answered. This can enable an open line of communication after the patient leaves the physician's office

Which of the following is associated with a decreased risk for endometriosis?

AAvoiding oral contraceptives BExtended intervals of lactationCorrect Answer CIncreasing consumption of trans unsaturated fat DMaintaining a low body mass index Correct Answer ( B ) Explanation: When endometrial glands and stroma implant outside of the uterine cavity, it is known as endometriosis. The patient presentation of endometriosis depends on where the glands form. The patient is many times asymptomatic, but symptoms may include pelvic pain, dysmenorrhea, abnormal uterine bleeding, dyspareunia and hemoptysis. Extended intervals of lactation can decrease a woman's risk of endometriosis. Having multiple childbirths, increasing consumption of long-chain omega-3 fatty acids, regular exercise, and use of oral contraception may also decrease risk. Some protective factors include race, late menarche, and early menopause. Avoiding oral contraceptives (A) would not decrease the risk of endometriosis. Oral contraceptives can be used to treat the condition. Increasing consumption of trans unsaturated fats (C) will increase the risk of endometriosis. Maintaining a low body mass index (D) is also a risk factor for endometriosis.

An obese, 56-year-old woman presents to the clinic with a new and persistent non-tender mass in her right breast, which she had noticed a month ago. Past medical history is significant for menarche at age 16 years, first pregnancy at age 17 years, and breastfeeding all of her children. On exam, there is one firm, immovable mass in the right breast as well as right axillary adenopathy. Diagnostic mammogram reveals a spiculated soft-tissue mass. Which of the following risk factors likely increased this woman's risk for the most likely diagnosis?

ABecoming pregnant earlier in life BBreastfeeding her children CLate age at menarche DObesityCorrect Answer Correct Answer ( D ) Explanation: Breast cancer is the most frequently diagnosed malignancy in the world and is the leading cause of cancer death in women worldwide. Decreasing annual mortality rates over the past decade are attributed to screening mammography, which has led to earlier diagnosis. Risk factors for breast cancer include increasing age, female gender, obesity, tall stature (> 69 inches), increased estrogen levels, early age at menarche, nulliparity, becoming pregnant later in life, alcohol consumption, and a history of invasive breast cancer. Protective factors against breast cancer include breastfeeding and physical activity. Most affected women are asymptomatic and diagnosis is with screening mammogram, but some women develop a breast mass between mammograms or before the first screening mammogram. On breast exam, there may be a single, firm, immovable mass, and presence of axillary adenopathy and overlying skin changes like erythema or dimpling can indicate inflammatory breast cancer. The most specific imaging finding for breast cancer is a spiculated soft-tissue mass. Once the diagnosis is established, the affected woman must be tested for hormone receptor presence, including estrogen and progesterone receptor expression as well as human epidermal growth factor receptor overexpression. These receptors are both prognostic indicators and targets for specific therapies. Multidisciplinary management with surgical oncology, radiation oncology, and medical oncology has led to reduced mortality. Becoming pregnant early in life (A), breastfeeding (B), and late age at menarche (C) are not associated with an increased risk of developing breast cancer.

A 17-year-old G1 girl presents at 36 weeks gestation for routine prenatal care. She has no significant medical history. Blood pressure is 146/92 mm Hg, and she has 1 protein on urine dipstick. Platelet count has decreased from within normal range on initial prenatal labs to 90,000/mcL today. She reports no headache or visual changes. Which of the following must be present to meet the diagnostic criteria for preeclampsia?

ABlood pressure ≥ 140 mm Hg systolic or ≥ 90 mm Hg diastolic at least 4 hours laterCorrect Answer BProteinuria ≥ 300 mg in a 24-hour urine collection CSerum creatinine ≥ 1.1 mg/dL DUrine protein to creatinine ratio ≥ 0.3 Correct Answer ( A ) Explanation: Preeclampsia is characterized by new-onset hypertension and proteinuria after 20 weeks gestation. Risk factors for preeclampsia include nulliparity, preeclampsia in previous pregnancy, extremes of maternal age (> 40 or < 18 years), preexisting hypertension, pregestational diabetes, multifetal gestation, chronic kidney disease, antiphospholipid syndrome, lupus, and high prepregnancy body mass index. For the diagnosis of preeclampsia to be made, blood pressure must be elevated on two occasions at least 4 hours apart in combination with proteinuria or in the absence of proteinuria with signs or symptoms of significant end-organ dysfunction, which could include creatinine > 1.1mg/dL or a doubling of baseline, platelet count < 100,000/mcL, or a doubling of liver transaminases. Additional severe features include pulmonary edema and cerebral or visual symptoms. Magnesium sulfate should be initiated to prevent seizures in patients with severe features. Proteinuria ≥ 300 mg in a 24-hour collection (B) or urine protein to creatinine ratio ≥ 0.3 (D) would meet the criteria for proteinuria in the diagnosis of preeclampsia. When quantitative methods are not an option, 2+ proteinuria on a urine dipstick is sufficient to meet the criteria for proteinuria. However, the diagnosis of preeclampsia can be made without the presence of proteinuria. Serum creatinine ≥ 1.1 mg/dL (C) meets the criteria for end-organ dysfunction and is a severe feature, but this still would have to be accompanied by hypertension to meet the diagnostic criteria for preeclampsia.

A 55-year-old postmenopausal woman presents to the clinic for her annual physical exam. She has a history of estrogen receptor-positive infiltrating ductal carcinoma and is status post lumpectomy and radiation therapy. Following local treatment, she was started on anastrozole. The patient remains asymptomatic and her most recent mammogram was normal. Which of the following screening evaluations is the most appropriate recommendation for this patient?

ABone density scanCorrect Answer BBreast magnetic resonance imaging CBreast ultrasound DPositron emission tomography scan Correct Answer ( A ) Explanation: Breast Cancer is the second most common female cancer in the United States. The most common type of invasive breast cancer is infiltrating ductal carcinoma. Patients may present with a hard, nontender, immobile breast mass, although with the incorporation of screening mammography, patients often present due to an abnormal mammogram. The most common location is the upper outer quadrant of the breast. Additionally, breast skin changes such as erythema, thickening, or dimpling (peau d'orange) may be present on exam. Classic mammographic findings of breast cancer include the presence of a soft tissue mass or density and clustered microcalcifications. The most specific mammographic feature for breast cancer is a spiculated soft tissue mass. Women with abnormal imaging findings alone should undergo biopsy guided by mammogram (stereotactic biopsy), ultrasound, or breast magnetic resonance imaging (MRI). Women with a breast mass should undergo a fine needle aspiration or core needle biopsy. The diagnosis of breast cancer requires the presence of malignant epithelial cells (carcinoma) showing evidence of stromal invasion. Treatment is based on the extent and stage of breast cancer. In the early stage, treatment options often include lumpectomy or mastectomy, followed by radiation therapy. Chemotherapy may also be recommended. Patients with hormone receptor-positive (e.g., estrogen receptor-positive, progesterone receptor-positive) breast cancer should receive endocrine therapy with tamoxifen or aromatase inhibitors like letrozole or anastrozole. Post-treatment follow-up should include frequent history and physical examinations, patient education regarding the signs and symptoms of recurrence, and mammograms. It is recommended that a baseline bone density scan (i.e., dual energy X-ray absorptiometry) be performed on postmenopausal women who are taking an aromatase inhibitor, as they are at an increased risk for osteoporosis. Breast magnetic resonance imaging (B) is often used to screen women who are at a high risk for breast cancer. It is not routinely recommend

A 25-year-old woman presents to the emergency room two weeks postpartum complaining of fevers and breast tenderness. On exam, she is febrile to 102.1°F (39°C) with right-sided breast tenderness and a 4 cm x 4 cm fluctuant mass next to her nipple. What is the best next step in diagnosis?

ABreast milk culture BBreast ultrasoundCorrect Answer CFine-needle aspiration DMammogram Correct Answer ( B ) Explanation: Patients with a breast abscess present with localized, painful inflammation of the breast associated with a fluctuant, tender mass and fever. The diagnosis is made via ultrasonography demonstrating a fluid collection. Management of an abscess requires drainage along with antibiotics, and the method of drainage depends on the state of the skin overlying the abscess and its depth. A breast milk culture (A) is useful in guiding the antibiotic treatment of an abscess but is not useful in initial diagnosis. Performing a fine-needle aspiration (C) along with antibiotics is usually the first-line treatment of a breast abscess but it does not aid in diagnosis. A mammogram (D) is not useful in the diagnosis of a breast abscess. It is used as a screening and diagnostic tool for breast masses suspicious for cancer.

A 48-year-old premenopausal woman is being evaluated for an adnexal mass palpated on bimanual exam. A pelvic ultrasound reveals a fixed right ovarian 6 cm complex mass and a large amount of free fluid. CA-125 is 193 units/mL, (carcinoembryonic antigen) CEA is 2.8 ng/mL. Which of the following supports referral to a gynecologic oncologist?

ACA-125 levelYour Answer ?? BCEA level CPremenopausal status DUltrasound findingsCorrect Answer Correct Answer ( D ) Explanation: Women presenting with complex adnexal masses suspicious for malignancy who require surgical management have been shown to have improved overall survival rates when managed by a gynecologic oncologist. Referral criteria in premenopausal women include ultrasound findings suggestive of malignancy (free fluid consistent with ascites, or a nodular fixed mass), or evidence of distant metastases. In this case, the ultrasound finding should dictate referral to an oncologist. Referral for postmenopausal women include similar ultrasound or distant metastasis criteria but have a lower CA-125 cutoff of > 35 units/mL for referral. CA-125 is a protein most commonly associated with epithelial ovarian cancer, but numerous benign conditions can contribute to an elevated CA-125 level including endometriosis, pregnancy, fibroids, and pelvic inflammatory disease. It is most useful when obtained in postmenopausal women in evaluation of non-mucinous ovarian cancers. Expert opinion has recommended a CA-125 (A) cutoff of > 200 U/mL in a premenopausal woman for referral to a gynecologic oncologist and would not be the element suggesting referral in this case. CEA (B) is also a tumor marker that is commonly elevated in mucinous cancers associated with the gastrointestinal tract and ovary. Benign conditions such as smoking, mucinous cystadenoma, and inflammatory bowel disease are also associated with elevated CEA. Levels > 3 ng/mL are typically considered elevated. Premenopausal (C) status is not a cause for referral in isolation. Generally post-menopausal women presenting with a complex adnexal mass are more concerning for malignancy than premenopausal women.

A previously healthy 29-year-old G2P1A0 at 37 weeks and 4 days gestation presents to obstetric triage complaining of right upper quadrant pain that has been consistent since this morning. She also endorses a mild headache. Her blood pressure is 161/90 mm Hg and then 165/93 mm Hg on repeat 10 minutes later. Her pulse is 80 beats per minute. The fetal heart tracing is reassuring. Her physical exam is notable for hyperreflexia and her laboratory testing is remarkable for platelets at 80,000 platelets/microL. Which of the following is the best next step?

ACT of the head BDeliveryCorrect Answer CExpectant inpatient management DOutpatient management Correct Answer ( B ) Explanation: Of the available answer choices, delivery is the best next step. This patient likely has preeclampsia with severe features, given that she was previously healthy and now has severely elevated blood pressure (greater than 160 mm Hg systolic or 110 mm Hg diastolic), persistent right upper quadrant pain, and thrombocytopenia. This patient should be admitted to labor and delivery, her blood pressure should be treated with antihypertensives, and she should be started on intravenous magnesium sulfate for seizure prophylaxis. Delivery is the definitive treatment for preeclampsia with severe features, and the decision to proceed with induction of labor or cesarean delivery is based on usual obstetric indications. CT of the head (A) would be the best next step if the patient was having severe neurologic symptoms, such as if she complained of "the worst headache of her life." Given the patient is early term and has preeclampsia with severe features, expectant inpatient management (C) would be inappropriate, as the potential risk to the mother and fetus are greater than with delivery. Outpatient management (D) would also be inappropriate, given the diagnosis. Expectant management could be appropriate in select patients without severe features who are preterm

A 25-year-old G1P0 at 39 weeks' gestation presents to the hospital as she believes she is in labor. Which of the following would suggest that the woman should be admitted to the labor and delivery unit?

ACervical dilation of 4 cm Correct Answer BIntact membranes CMucus plug discharge DSporadic painful uterine contractions Correct Answer ( A ) Explanation: A patient in active labor should be admitted to the labor unit. The determination of active labor compared to false labor is based on multiple criteria. Cervical dilation of > 4 cm typically marks the beginning of the active phase. However, the rate of cervical dilation is highly variable until 6 cm when dilation accelerates to approximately 1 cm/ hour in both nulliparous and multiparous women. Other criteria for admission include uterine bleeding, abnormal fetal heart rate pattern, and ruptured membranes. Women who are not in active labor at the time of admission are at increased risk of iatrogenic intervention such as epidural, oxytocin augmentation, and cesarean section. A patient with intact membranes (B) can be discharged depending on other criteria listed above. Vaginal mucus plug discharge (C) can be a sign that membranes are ruptured and the patient should be further evaluated. Admission is not warranted if ruptured membranes are not confirmed. Sporadic painful uterine contractions (D) are not sufficient to warrant admission

A 25-year-old patient presents to the walk-in clinic for vaginal bleeding. She has been on low-dose combined oral contraceptive pills but has been nonadherent with her regimen recently. She is unsure when her last menstrual period was since she only gets minimal spotting while on birth control. Her urine pregnancy test is positive, and a serum quantitative beta-human chorionic gonadotropin level is 1,032 IU/L. A transvaginal ultrasound is performed and reveals an empty endometrial cavity. Her gynecologic history is significant for one episode of chlamydia cervicitis treated by antibiotics at the age of 18 years and an ectopic pregnancy at the age of 23 treated by methotrexate. She smokes 10 cigarettes per day. Which of the following is the strongest risk factor for the recurrence of ectopic pregnancy?

AChlamydia infection BPrevious history of ectopic pregnancyCorrect Answer CSmoking DUse of birth control pills Correct Answer ( B ) Explanation: Ectopic pregnancy is a common cause of maternal mortality in the first trimester of pregnancy. Consequently, prompt recognition and treatment are indispensable to ensure maternal wellbeing. Morbidity and mortality ensuing from ectopic pregnancies result from intra-abdominal rupture and resulting hemorrhage. Clinical features of ectopic pregnancies include abdominal pain or vaginal bleeding. Clinical suspicion should be elevated in the absence of visualization of an intrauterine gestation in the uterus. A definite diagnosis can be made if a gestational sac with a yolk sac or an embryo is visualized in the adnexa. Risk factors for ectopic pregnancies are conditions that lead to tubal damage or dysmotility of the cilia. They include smoking, chlamydia and gonorrhea infections, pelvic inflammatory disease, and Kartagener syndrome. However, a previous history of ectopic pregnancy or tubal surgery are associated with the highest odds of occurrence of ectopic pregnancy. Chlamydia infection (A) and smoking (C) are both risk factors for the occurrence of ectopic pregnancy, but a previous history of ectopic pregnancy is associated with a higher odds ratio. Conception while using birth control pills (D) is not associated with an increased risk of ectopic pregnancy.

A 32-year-old woman is having abnormal uterine bleeding for several weeks after a normal vaginal delivery. Serum hCG levels are tested and found to be elevated. They remain elevated at persistently low levels when retested after 2 months. A pelvic ultrasound reveals a hyperechoic intrauterine mass. Which of the following is the most likely diagnosis?

AChoriocarcinoma BPituitary adenoma CPlacental site trophoblastic tumorCorrect Answer DPregnancy Correct Answer ( C ) Explanation: Placental site trophoblastic tumors cause very low, persistent levels of hCG. These are malignant tumors that most commonly occur after a non-molar abortion or pregnancy. They can be diagnosed months to years after pregnancy and tend to remain in the uterus for long periods of time before spreading regionally or metastasizing. Patients typically present with abnormal uterine bleeding and pelvic pressure. When hCG levels are tested, they will be elevated at lower levels than other subtypes or gestational trophoblastic neoplasms. Pelvic ultrasound will demonstrate a hyperechoic-intrauterine mass which may invade the myometrium. Chest radiographs should be obtained to help rule out metastatic disease. Treatment in patients who do not desire fertility preservation includes hysterectomy. These types of neoplasms are generally resistant to chemotherapy. Choriocarcinoma (A) following molar or non-molar pregnancy will secrete very high levels of hCG. A pituitary adenoma (B) can cause hormonal deficiencies and abnormalities in prolactin levels, but it does not cause elevated hCG levels. Pregnancy (D) is less likely given that this patient has had persistent low levels of hCG and no intrauterine findings.

A 36-year-old woman presents to labor and delivery at 34 weeks and 2 days gestational age for new-onset headache and severe right upper quadrant pain. She reports this headache has been going on the last two days and has not resolved with oral acetaminophen. Her blood pressure on admission is 165/112 mm Hg, and repeat 15 minutes later is 172/115 mm Hg. She has never been pregnant before and has no significant past medical history. Which of the following is the most likely diagnosis?

AChronic hypertension BGestational hypertension CPreeclampsia with severe featuresCorrect Answer DPreeclampsia without severe featuresYour Answer Correct Answer ( C ) Explanation: Preeclampsia with severe features would be the most likely diagnosis, as the patient has severe-range blood pressures with a headache. Preeclampsia is a progressive disorder defined by new-onset hypertension and proteinuria or hypertension with significant end-organ dysfunction. End-organ dysfunction includes severe blood pressure elevation, central nervous system dysfunction, hepatic abnormality, thrombocytopenia, renal abnormality, and pulmonary edema. This patient has two signs of end-organ dysfunction, with her elevated blood pressures ≥ 160 mm Hg systolic and 110 mm Hg diastolic on two occasions as well as signs of central nervous system dysfunction with her severe headache. The standard interval to repeat blood pressure is 4 hours unless antihypertensive therapy is initiated sooner. The interval to confirm hypertension in the severe range may be shortened to facilitate prompt management. Chronic hypertension (A) is incorrect and is defined as hypertension prior to pregnancy or elevated blood pressures on at least two occasions before 20 weeks gestation. This patient had onset of hypertension in the third trimester of pregnancy. Gestational hypertension (B) is incorrect and is defined as hypertension without proteinuria or other signs of preeclampsia after 20 weeks gestation. This patient has evidence of end-organ dysfunction, which is consistent with preeclampsia. Preeclampsia without severe features (D) is incorrect and is defined as elevated blood pressure in pregnancy between 140-160 mm Hg systolic or 90-110 mm Hg diastolic without signs of end-organ dysfunction.

A 28-year-old G1P0 at 18 weeks gestation presents to the clinic to follow up on her Pap smear results. The cervical cytology report results indicated "atypical squamous cells: cannot exclude high-grade squamous intraepithelial lesion." Which of the following is the most likely next step in diagnosis?

AColposcopyCorrect Answer BHuman papillomavirus testing CLoop electrosurgical excision procedure DRepeat Pap smear Correct Answer ( A ) Explanation: Cervical dysplasia, also known as cervical intraepithelial neoplasia (CIN), is a premalignant condition of the squamous cell of the cervix. The major risk factor for the development of cervical dysplasia is infection with human papillomavirus. Terminology and histology classifications vary based on the degree of dysplasia present. Cytology results garnered from Pap smears can be classified as one of the following: atypical squamous cells of undetermined significance (ASC-US), atypical squamous cells: cannot exclude high-grade squamous intraepithelial lesion (ASC-H), low-grade squamous intraepithelial lesions (LSIL), atypical glandular cells of undetermined significance (AGC) and high-grade squamous intraepithelial lesion. Follow-up testing varies depending on the age of the patient and the degree of dysplasia. For patients who have a cervical cytology reporting ASC-H, the next diagnostic study is always a colposcopy regardless of HPV status. Pregnant women with cervical cytology showing ASC-H should be evaluated with colposcopy during pregnancy. Colposcopy provides a microscopic examination of the cervix, which aids in the determination of the need for a cervical biopsy. The cervical biopsy results provide histologic information and are classified as either cervical intraepithelial neoplasia 1 (i.e. mild dysplasia), cervical intraepithelial neoplasia 2 (moderate dysplasia), and cervical intraepithelial neoplasia 3 (severe dysplasia). Management depends on the cervical intraepithelial neoplasia classification as well as other clinical factors and includes the treatment options observation, loop electrosurgical procedure, cold knife cervical conization, and ablative therapies. Loop electrosurgical excision procedure (B) is a management option for cervical intraepithelial neoplasia 2 and cervical intraepithelial neoplasia 3. In patients with ASC-H, a colposcopy would be required to give a patient a histologic diagnosis. Human papillomavirus testing (C) is not required for women who present with ASC-H, as they are known to have a higher rate of human papillomavi

A 37-year-old woman presents for a routine gynecologic visit. She mentions that she has had multiple genital warts that have been treated in the past using an immune-mediated therapy. She is unsure what exactly was used but would like the same treatment. Which of the following is an immune-mediated therapy used to treat human papillomavirus?

ACryoablation BFluorouracil CImiquimodCorrect Answer DTrichloroacetic acid Correct Answer ( C ) Explanation: Human papillomavirus is the main cause of both vulvar and vaginal warts. Most anogenital warts are caused by human papillomavirus 6 or 11, both of which have low oncogenic potential. Patients typically present with genital warts that may be flat papules or verrucous lesions. There are multiple treatment options for genital warts, including both medical and surgical therapies. Medical therapies include cytodestructive therapies that directly destroy the warty tissue, such as fluorouracil and trichloroacetic acid. Another form of medical therapy is immune-mediated therapies, which work through the patient's immune system to clear the wart, such as imiquimod. Surgical therapies include cryoablation, laser ablation, and excision. There are also vaccinations that are a primary prevention of human papillomavirus infection. Cryoablation (A) is a surgical therapy to treat human papillomavirus. Fluorouracil (B) and trichloroacetic acid (D) are both examples of cytodestructive, not immune-mediated, therapies.

A 22-year-old woman presents with persistent purulent vaginal discharge for one week which began after having intercourse with a new partner. On exam, her cervix is erythematous and edematous and there is a purulent cervical discharge. There is no cervical motion tenderness. Which of the following is the most appropriate diagnostic test?

ACulture from cervical specimens BGram's stain of cervical discharge C Nucleic acid amplification testing of cervical discharge Correct Answer DUrinalysis Correct Answer ( C ) Explanation: Nucleic acid amplification testing methods are best for detecting N. gonorrhoeae and C. trachomatis due to superior sensitivity and specificity. Nucleic acid amplification testing also allows for convenience and comfort of testing via self-collected vaginal swab or urine sample as opposed to pelvic examination for women or a urethral swab for men. The downside to nucleic acid amplification testing is that it will not provide antimicrobial susceptibility information. Treatment is directed toward the offending infectious agent. Most women with cervicitis should receive empiric antibiotic therapy covering at least C. trachomatis and N. gonorrhoeae at the time of initial evaluation, without waiting for laboratory test results. Affected sexual partners should be treated at the same time as the affected woman to prevent reinfection. Women can prevent cervicitis by practicing abstinence and by using condoms and other barrier methods during coitus. Culture from cervical specimens (A) used to be the preferred testing method for N. gonorrhoeae and C. trachomatis, but it requires the discomfort of pelvic examination for women or urethral swab for men, and is not as sensitive or specific as nucleic acid amplification testing. Gram's stain of cervical discharge (B) could show polymorphonuclear leukocytes with intracellular gram-negative diplococci indicating N. gonorrhoeae infection, and can be used for diagnosis in male patients if nucleic acid amplification testing is unavailable, but Gram's stain of endocervical specimens is not sufficient to detect infection and is therefore not recommended in women. Urinalysis (D) could show the presence of leukocytes in acute cervicitis, but is not specific for N. gonorrhoeae or C. trachomatis.

Which of the following fetal heart tracings patterns is indicative of uteroplacental insufficiency?

AEarly decelerations BLate decelerationsCorrect Answer CSinusoidal DVariable decelerationsYour Answer Correct Answer ( B ) Explanation: Fetal Heart Rate: Mnemonic VEAL CHOP Variable: cord compression Early: head compression Accelerations: okay Late: placental insufficiency Late decelerations on fetal heart tracings is indicative of uteroplacental insufficiency. Electronic fetal heart rate monitoring is commonly used to assess fetal well-being during labor. The fetal heart rate recordings may be interpreted as reassuring, nonreassuring, or ominous according to the pattern of the tracing. Reassuring patterns correlate well with a good fetal outcome, while nonreassuring patterns do not. Late decelerations are associated with uteroplacental insufficiency and are provoked by uterine contractions. Any decrease in uterine blood flow or placental dysfunction can cause late decelerations. Maternal hypotension and uterine hyperstimulation may decrease uterine blood flow. Postdate gestation, pre-eclampsia, chronic hypertension, and diabetes mellitus are among the causes of placental dysfunction. A late deceleration is a symmetric fall in the fetal heart rate, beginning at or after the peak of the uterine contraction and returning to baseline only after the contraction has ended. The descent and return are gradual and smooth. Regardless of the depth of the deceleration, all late decelerations are considered potentially ominous. A pattern of persistent late decelerations is nonreassuring and further evaluation of the fetal pH is indicated Early decelerations (A) are caused by fetal head compression during uterine contraction, resulting in vagal stimulation and slowing of the heart rate. Although these decelerations are not associated with fetal distress and thus are reassuring, they must be carefully differentiated from the other, nonreassuring decelerations. Variable decelerations (D) are shown by an acute fall in the fetal heart rate with a rapid downslope and a variable recovery phase. Variable decelerations are caused by compression of the umbilical cord and are generally associated with a favorable outcome. The true sinusoidal (C) pattern is a rare, but ominous sign and is associated with high rates of fetal

A 25-year old woman presents with dysuria and purulent vaginal discharge for four days. Which of the following physical exam findings would best support the diagnosis of acute cervicitis?

AEdematous and erythematous uterine cervixCorrect Answer BTenderness with movement of the uterine cervix CTenderness with palpation in the hypogastric region DThick, white, curd-like vaginal discharge Correct Answer ( A ) Explanation: The most common causes of infectious cervicitis are Neisseria gonorrhoeae and Chlamydia trachomatis, although herpes simplex virus (HSV) and Trichomonas vaginalis are also frequent culprits. N. gonorrhoeae, C. trachomatis, and T. vaginalis are sexually transmitted via contact with mucosal surfaces. HSV is transmitted via contact with genital lesions or infected genital secretions. Non-infective causes of cervicitis include mechanical or chemical trauma, radiation therapy, or a systemic inflammatory disease. Purulent vaginal discharge and a friable cervix are the hallmark symptoms and signs of acute cervicitis, while leukorrhea is the main symptom of chronic cervicitis. The cervix may appear swollen and erythematous on exam due to increased vascularity and edema. The diagnosis of acute cervicitis is clinical and based upon the presence of purulent or mucopurulent cervical exudate and/or sustained endocervical bleeding (friability) easily induced by gently touching the area with a swab. If cervicitis is suspected, testing should be performed to determine the cause and exclude PID. Treatment is directed toward the offending infectious agent. First-line treatment in nonpregnant adults includes ceftriaxone and doxycycline. For T. vaginalis treatment is metronidazole or tinidazole. HSV can be treated with valacyclovir or acyclovir, which are more effective when taken as early as possible after symptom onset. Tenderness with movement of the uterine cervix (B) would indicate inflammation of the upper urogenital tract (endometritis, salpingitis, tubo-ovarian abscess and pelvic peritonitis), consistent with diagnosis of pelvic inflammatory disease (PID). The etiology is often infectious due to similar bacterial pathogens seen in cervicitis. PID is managed with empiric antibiotics. Tenderness with palpation in the hypogastric region (C) could indicate a variety of pathologic conditions, including acute cystitis, PID, or acute cervicitis, and is neither sufficiently sensitive nor specifi

A 45-year-old woman presents for her annual physical exam and is diagnosed with iron deficiency anemia. Upon further questioning, the patient reveals that she has been having heavy and irregular periods for the past year. She has three children and does not plan to have any more. Pelvic examination is normal. You order a pelvic ultrasound. Which of the following findings is not consistent with the diagnosis of abnormal uterine bleeding?

AEndometrial hyperplasia BEndometrial lining thickness of four mmCorrect Answer CPresence of endometrial polyps DPresence of uterine fibroids Correct Answer ( B ) Explanation: Abnormal uterine bleeding (AUB) is menstrual bleeding of abnormal quantity, duration, or schedule. It is a common diagnosis and characterized by menstrual bleeding that is outside the normal cyclical pattern of ovulatory hormonal stimulation of the endometrial lining. It is associated with anovulatory menstrual cycles but can also be present in patients with oligoovulation. Bleeding may be excessively heavy or light and may be prolonged, frequent, or random despite patients having a normal pelvic examination. Differential diagnoses include polycystic ovarian syndrome, thyroid disease, hyperprolactinemia, intracranial or pituitary lesions, and bleeding disorders. Studies used to evaluate patients with AUB may include urine human chorionic gonadotropin test to rule out pregnancy, complete blood count to evaluate for anemia, Pap smears to rule out cervical cancer, endometrial sampling to evaluate for endometrial cancer, thyroid function tests to rule out hyper/-hypothyroidism, prolactin level to evaluate for hyperprolactinemia, liver function panels, coagulation studies, and hormone assays. Pelvic ultrasound is often the first test of choice to rule out endometrial hyperplasia, uterine fibroids, carcinoma, polyps, and polycystic ovaries. Endometrial biopsy should be performed if endometrial thickness on ultrasound is greater than four mm in postmenopausal women or if a patient is > 35 years of age with risk factors for endometrial cancer (diabetes, obesity, PCOS). This patient is likely in the perimenopausal stage due to her age and history, and does not require endometrial biopsy given her ultrasound findings as the endometrial lining is not useful in the diagnosis of perimenopausal women. The presence of endometrial hyperplasia (A), endometrial polyps (C), and uterine fibroids (D) would negate the diagnosis as they are abnormal uterine findings that are known causes of irregular menstrual bleeding

A 68-year-old woman presents to the clinic with progressive lower abdominal bloating for the past six months. Ascites is present on exam, and a right-sided adnexal mass is palpable. Pelvic ultrasonography reveals a solid complex mass on the right ovary and confirms presence of associated ascites. Which of the following is the most likely diagnosis?

AEndometrioma BEpithelial carcinomaCorrect Answer CMature cystic teratoma DSex cord-stromal tumor Correct Answer ( B ) Explanation: The incidence of ovarian cancer grows with increasing age, and at least 30 percent of all ovarian neoplasms in women over age 50 are malignant. Average age at diagnosis is 60 years. Ovarian cancer is the most common cause of gynecologic death in the United States. Epithelial carcinoma is the most common histologic type of cancer of the ovary, fallopian tube and peritoneum. Affected women usually complain of vague gastrointestinal symptoms including early satiety, bloating, and dyspepsia. Many women with ovarian cancer are asymptomatic, and symptoms are associated with advanced disease. Physical exam findings may include a pelvic or adnexal mass, abdominal distention with ascites, or a pleural effusion. Pelvic ultrasound usually shows a complex ovarian mass and ascites. Definitive diagnosis is histologic after surgical removal of the affected ovary. Surgical staging and cytoreduction followed by adjuvant chemotherapy is typical management for affected patients. The majority of women with early-stage disease will be recurrence-free at five years. Prognosis is poor for women with advanced stage disease; most of these women will relapse and mortality is high. Ovarian sex cord-stromal tumors (D) are a rare and heterogeneous group of benign and malignant neoplasms growing from the cells which would surround oocytes. Average age of onset is 50 years, and symptoms may include those of estrogen excess, including hot flashes, breast tenderness, and nausea.

A 50-year-old woman with no history of endocrine disease presents complaining of insomnia, fatigue, and hot flashes for the past year and a half, and she hasn't had a menstrual period in over a year. She denies galactorrhea. Physical exam is unremarkable. Which of the following laboratory findings is most likely to be increased?

AEstradiol (Lowest) BFollicle-stimulating hormoneCorrect Answer CProlactin DThyroid-stimulating hormone Correct Answer ( B ) Explanation: Menopause is the complete cessation of menstrual periods for at least 12 months without any pathologic or physiologic cause other than natural ovarian follicular depletion. Average age at onset is 51 years. Typical symptoms include hot flashes, sleep disturbances, fatigue, weight gain, depressed mood, vaginal dryness, cognitive changes, and sexual dysfunction. Women older than 45 years of age with characteristic menopausal symptoms and amenorrhea for at least 12 months are more likely to be menopausal rather than have a new endocrine disorder, and no laboratory evaluation is needed in these women. Although serum Follicle-stimulating hormone (FSH) is often measured, a high FSH concentration is not required to make the diagnosis. Affected women are managed symptomatically. Treatments for hot flashes include lifestyle modification, vitamin E or black cohosh supplementation (widely used however research shows it as effective as placebo), venlafaxine, clonidine, or with hormone replacement therapy (HRT). Estradiol (A) is low in menopausal women due to the natural ovarian follicular depletion that occurs with age. Prolactin (C) may be elevated due to pregnancy, medications, or a lactotroph adenoma and may cause oligomenorrhea, amenorrhea, infertility and galactorrhea. Thyroid-stimulating hormone (TSH) (D) is elevated in response to low levels of serum free thyroxine (T4) in patients with hypothyroidism. Typical symptoms include fatigue, cold intolerance, weight gain, constipation, and menstrual irregularities, and patients may present with a goiter.

A 28-year-old G2P1 woman at 23 weeks gestation presents to the emergency room for painless vaginal bleeding. Prior to performing a digital vaginal examination, an ultrasound of the uterus is performed, which reveals placental tissue lying over the internal cervical os. Based on the ultrasound findings, what would you expect to learn from the patient's history that would put her at increased risk of the likely diagnosis?

AExposure to influenza during the first trimester BFetus was determined to be female at the last ultrasound CIncrease in vaginal intercourse in the past week DPrevious cesarean sectionCorrect Answer Correct Answer ( D ) Explanation: Previous cesarean section increases the risk of developing placenta previa. Placenta previa is an obstetrical disorder that results in the placenta overlying the internal cervical os. Risk factors for placenta previa include multiple gestation, previous placenta previa, increased maternal age, and previous uterine procedures. Maternal smoking, maternal cocaine use, and male fetus have also been shown to be risk factors for placenta previa. Placenta previa must be considered in a pregnant woman presenting after 20 weeks gestation with painless vaginal bleeding. Ultrasound should be first performed to determine the location of the placenta. Digital vaginal examination is contraindicated in women with placenta previa due to the increased risk of hemorrhage. Patients found to have placenta previa incidentally on pelvic ultrasound should undergo follow-up ultrasounds to determine if the placenta remains overlying the os prior to delivery. The most important step in patient management is preventing hemorrhage. Women should avoid vaginal intercourse and strenuous exercise. Women who are actively bleeding should be promptly evaluated for hemodynamic instability and be transfused if necessary. Cesarean delivery is indicated in women with placenta previa to prevent severe hemorrhage. Exposure to influenza during the first trimester (A) is incorrect. While the influenza virus can be harmful to the fetus, it is not associated with increased risk of placenta previa. Fetus was determined to be female at last ultrasound (B) is incorrect as it has been noted that a male fetus is more commonly associated with placenta previa. Increase in vaginal intercourse in the past week (C) is incorrect. While sexual intercourse can cause more bleeding in a woman with placenta previa, it is not a risk factor for developing the placenta complication.

A 54-year-old woman presents with progressively worsening vaginal irritation and dyspareunia for three years. She denies dysuria or urinary frequency. She has no past medical history of abnormal cervical cytology, and hasn't had any vaginal bleeding in the past two years. She hasn't tried any over the counter treatments for her symptoms. There is introital narrowing on external genital exam, and pelvic exam reveals dry, smooth and shiny vaginal epithelium. What is the best next step in management?

AInitiate estrogen therapy BInitiate non-hormonal vaginal moisturizer and lubricant therapyCorrect Answer CObtain cervical cytology DObtain vaginal epithelium biopsy Correct Answer ( B ) Explanation: Genitourinary syndrome of menopause (or atrophic vaginitis) is characterized by dryness, inflammation, and thinning of vaginal epithelial lining due to loss of estrogen. These changes typically occur in menopausal women, but could occur in any woman who experiences a substantial loss of estrogen, such as the postpartum period, lactation, or hypothalamic amenorrhea, or while taking anti-estrogenic medication. Affected patients may complain of vaginal dryness, burning or irritation, decreased vaginal lubrication during sexual activity, dyspareunia, dysuria, or urinary frequency. On external genital exam, the clinician may find scarce pubic hair, decreased vulvar skin turgor, introital narrowing, or fusion of labia minora. Characteristic vaginal exam findings include pale, dry, smooth and shiny vaginal epithelium with loss of rugation. Diagnosis is clinical, based on the characteristic symptoms and exam findings. Laboratory evaluation is only necessary to rule out other etiologies under consideration, including vaginal infections (bacterial vaginosis, trichomoniasis), local reactions (perfumes, soaps, panty liners, spermicides), vulvar lichen sclerosus, vulvovaginal lichen planus, or malignancy. First-line therapy for symptomatic relief is with non-hormonal vaginal moisturizers and lubricants. If therapy does not result in symptom relief, low-dose vaginal estrogen (insert, ring, cream) therapy may be used if the woman has no contraindications (estrogen-dependent malignancy). Sexual activity and/or use of vaginal dilators can help maintain healthy vaginal epithelium. Estrogen therapy (A) is the most effective therapy for genitourinary syndrome of menopause, but due to potential for adverse effects of systemic absorption, including increased risk for venous thromboembolism and breast cancer, estrogen therapy is not first-line therapy. Cervical cytology (C) is used to screen for uterine cervix cancer, and is not necessary in the work-up for genitourinary syndrome of menopause unless the patient has history of

A 24-year-old woman presents with sudden onset of lower right sided abdominal pain, nausea, and vomiting. She is not currently sexually active and pregnancy test is negative. She is found to have a right adnexal mass on exam. A pelvic ultrasound reveals an heterogenous enlarged ovary with decreased doppler flow. Which of the following is the most common risk factor for the suspected diagnosis?

AIntra-abdominal malignancy BOvarian massCorrect Answer CPregnancy DPremenopausal age Correct Answer ( B ) Explanation: Ovarian torsion is one of the most common gynecologic emergencies. It occurs when the ovary rotates on its ligamentous supports, which often blocks its blood supply. The primary risk factor for ovarian torsion is an ovarian mass (neoplasm or cyst), and the risk of torsion increases with the size of the mass. Other risk factors include reproductive age, pregnancy, and ovulation induction for infertility treatment. The classic presentation is a woman of childbearing age with acute-onset of severe pelvic pain with nausea and vomiting and an adnexal mass on exam. Since torsion can occur without an ovarian mass, and because torsion can lead to loss of ovarian function and necrosis of torsed tissue, a high index of suspicion is often needed for diagnosis. Pregnancy testing is essential since pregnancy is a risk factor for ovarian torsion, and ectopic pregnancy must be ruled out in a pregnant patient with acute-onset pelvic pain. Abdominal and pelvic ultrasound is the first imaging study of choice for suspected ovarian torsion because it is less expensive than and has similar diagnostic performance as computed tomography (CT) and magnetic resonance imaging (MRI). Definitive diagnosis is direct visualization of a torsed ovary during surgery, and prompt operative evaluation is the mainstay of treatment to preserve ovarian function. Pregnancy (C) and premenopausal age (D) are both risk factors for ovarian torsion, but the presence of an ovarian mass is the greatest risk factor. An intra-abdominal malignancy (A), such as a malignant ovarian neoplasm, actually decreases risk for ovarian torsion, possibly because malignant masses are more likely to be fixed in place.

Question: What unique organism has been identified in cultures of long-term IUD users?

Actinomyces

Adenomyosis

Adenomyosis is defined as endometrial tissue within the myometrium. It is most common in patients between the ages of 40 and 50 years. Menorrhagia and dysmenorrhea are common symptoms, and physical examination often reveals a tender, soft, symmetrically enlarged uterus.

Question: What is the name for the collective diagnostic criteria for BV?

Amsel's criteria.

Endometrioma

An endometrioma is a benign adnexal mass caused by ectopic growth of endometrial tissue, as occurs when a woman has endometriosis. These are stimulated by reproductive hormones and therefore predominantly affect premenopausal women.

Question: What are the most common types of human papillomavirus that lead to cervical cancer?

Answer: 16 and 18.

Question: How long is the average menstrual cycle?

Answer: 28 to 35 days.

Question: What approximate percentage of placental site trophoblastic tumors metastasize?

Answer: About 30 percent.

How is the definitive diagnosis of endometriosis made?

Answer: Biopsy is the only way to give a definitive diagnosis of endometriosis.

Question: What common thyroid conditions can cause secondary amenorrhea?

Answer: Both hypo- and hyperthyroidism can cause amenorrhea and are typically distinguished by a high (hypothyroidism) or low (hyperthyroidism) thyroid-stimulating hormone level.

Question: What is the tumor marker pattern associated with ovarian dysgerminomas?

Answer: Elevated beta-hCG and lactate dehydrogenase

Question: In a patient with postmenopausal bleeding, what procedure should be done to rule out malignancy?

Answer: Endometrial biopsy.

Question: Endometriosis is associated with an increased risk of which type of ovarian cancer?

Answer: Epithelial ovarian cancer.

Question: True or false: after responding to intravenous antibiotics for endometritis, the patient should be placed on oral antibiotics to complete treatment?

Answer: False.

Question: What is the recommendation for women with mastitis who desire to breastfeed?

Answer: It is recommended for women to continue breastfeeding.

Question: Are there any adverse consequences to drinking alcohol while taking metronidazole?

Answer: Yes. Drinking alcohol while taking metronidazole can lead to flushing, tachycardia, or nausea and vomiting.

Question: The ovary typically rotates around which ligament or ligaments when torsion occurs?

Both the infundibulopelvic ligament (suspensory ligament of the ovary) and the utero-ovarian ligament.

Serum concentration of which tumor marker is elevated in most women with advanced stage ovarian cancer?

CA 125 glycoprotein antigen.

Question: What is the recommended treatment to manage magnesium toxicity?

Calcium Gluconate

Question: What is the chandelier sign?

Cervical motion tenderness on exam.

Procedure can be done on Pregnant pts to r/o HPV?

Colposcopy No LOOP excision or endo cervical sampling

Chlamydia Cervicitis

Diagnosis is made by nucleic acid amplification testing (NAAT) Most commonly caused by Chlamydia trachomatis Treatment is: doxycycline (100 mg BID x 7 days), azithromycin should be used in pregnancy Reinfection testing after treatment: Non-pregnant: three months after treatment or at the first visit in the 12 months after treatment Pregnant: four weeks after treatment Most commonly reported sexually transmitted disease in the United States Consider empirically treat for concomitant gonorrhea if high risk The USPSTF recommends routine screening for chlamydia and gonorrhea in sexually active women < 25 years of age and in women age ≥ 25 years who are at increased risk

Patients with history of intrauterine exposure to which drug had an increased risk of ectopic pregnancy?

Diethylstilbestrol.

Question: What type of cancer are patients with untreated abnormal uterine bleeding at risk for?

Endometrial cancer.

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

Fetal scalp stimulation or fetal scalp pH measurement.

Question: Gram stain of vaginal discharge shows intracellular gram-negative diplococci bacteria. What is the diagnosis?

Gonorrhea infection v/s Obligate intracellular organism in Chlamydia

Which HPV strains are most commonly found in condyloma acuminata lesions?

HPV strains 6 and 11.

Intimate Partner Violence

Head, face, neck injuries Stated history does not correlate with exam Directly ask patient when alone Victims at highest risk during attempts to terminate relationship Management: assess immediate risk, document thoroughly, social work referral USPSTF recommends clinicians screen all women of reproductive age (Grade B) ACOG recommends clinicians screen all pregnant women at first prenatal visit, once every trimester, and at postpartum checkup

Menopause

History of amenorrhea for 12 months Sx: hot flashes, sleep disturbances, depression, or vaginal dryness Labs: decreased estrogen and elevated follicle-stimulating hormone levels

Pelvic Inflammatory Disease (PID)

History of multiple sexual partners or unprotected intercourse Lower abdominal pain, cervical motion tenderness, painful sexual intercourse PE will show mucopurulent cervical discharge Commonly caused by Chlamydia trachomatis or Neisseria gonorrhoea Outpatient treatment is ceftriaxone + doxycycline + metronidazole Fitz-Hugh-Curtis syndrome: perihepatitis + PID

Question: What is the most effective treatment for post-ablation tubal ligation syndrome?

Hysterectomy.

Question: What other fetal and placental complications are associated with placenta previa?

Malpresentation, intrauterine growth restriction, congenital anomalies, vasa previa, and velamentous umbilical cord

Mature cystic teratoma

Mature cystic teratoma or dermoid cyst, is a benign germ cell tumor and the most common benign ovarian neoplasm in the second and third decades of life. Pelvic ultrasonography reveals a complex mass with both endometriomas and mature cystic teratomas, but not ascites.

Question: What are the toxic side effects of paclitaxel?

Neuropathy, myalgias, and weaknes

A 24-year-old woman presents to the clinic complaining of cyclical pelvic pain and painful intercourse for the past year. She states that the pelvic pain occurs a few days prior to the start of menstruation. She denies any menorrhagia, abdominal pressure or vaginal discharge. She denies any history of sexually transmitted infections. Vital signs are within normal limits. Pelvic examination reveals lateral displacement of the cervix but is otherwise normal. Which of the following is the most likely diagnosis?

No painful bleeding in endometriosis AAdenomyosis BEndometriosis Correct Answer CLeiomyoma DPelvic inflammatory disease Correct Answer ( B ) Explanation: Endometriosis is defined as endometrial glands and stroma which occur outside of the uterine cavity. Lesions are most commonly located within the pelvis, but can also occur in the bowel, diaphragm, and pleural cavity. The most common site of endometriosis are the ovaries, where they are called endometriomas. Risk factors for the development of endometriosis are nulliparity, prolonged exposure to endogenous estrogen, exposure to diethylstilbestrol in utero, and lower body mass index. Women classically present during their reproductive years complaining of pelvic pain (including dysmenorrhea and dyspareunia), infertility, and ovarian mass. The location of the endometriosis can also affect the symptoms a patient will present with. For women with bladder endometriosis, symptoms are predominantly urinary frequency and urinary urgency, whereas women with bowel endometriosis may present with complaints of diarrhea, constipation, and dyschezia. Physical examination may reveal tenderness on vaginal examination, nodules in the posterior fornix, adnexal masses, and immobility or lateral displacement of the cervix or uterus. Transvaginal ultrasound and magnetic resonance imaging may reveal endometriomas, nodules on the rectovaginal septum, and bladder nodules. Definitive diagnosis requires a histologic analysis of a lesion biopsied during surgery, typically laparoscopy. For women with mild to moderate pain, treatment generally includes continuous hormonal contraceptives and nonsteroidal anti-inflammatory drugs (NSAIDs). In patients who continue to suffer from severe symptoms despite treatment with contraceptives and nonsteroidal anti-inflammatory drugs, a trial of a gonadotropin-releasing hormone agonist with add-back hormonal therapy may be warranted. Additionally, symptomatic and expanding endometriomas may require laparoscopic excision. Leiomyoma (C) is a benign smooth muscle tumor of the uterus. Menorrhagia and abdominal pressure are common. Acute pain occurs with torsion, degeneration, or expulsion of the leiomyoma through the cervix. Chronic pain is uncommon.

Question: What are risk factors for developing preeclampsia?

Nulliparity Age greater than 35 years obesity Diabetes history of preeclampsia

Primary Dysmenorrhea

Pain starts 1 or 2 days before menses Pain is only related to menstrual cycle ↑ PGF2alpha → ↑ uterine contractions Pain management: NSAIDs (first line) or acetaminophen Hormonal therapy: estrogen-progestin contraceptives

Ovarian Cancer

Patient commonly presents with vague gastrointestinal symptoms, early satiety, bloating, abdominal or pelvic pain Adnexal mass Most common histologic type is epithelial carcinoma Tumor marker: CA 125 Rule out germ cell tumors in patients < 30 years old with tumor markers such as hCG and AFP Most common cause of gynecologic death Routine screening not recommended (lack of benefit)

Breast Abscess

Patient presents with fever, malaise, painful breast lump PE will show fluctuant, tender, palpable mass Most commonly caused by Staph aureus Usually a complication of mastitis

Condyloma Acuminata

Patient presents with genital lesions PE will show cauliflower-like lesion Most commonly caused by HPV 6 & 11 HPV 16 & 18 most commonly associated with squamous cell carcinoma Most common STI Patient-applied vs clinician-applied treatments

Bacterial Vaginosis

Patient presents with malodorous vaginal discharge PE will show thin, gray or white discharge Labs will show pH > 4.5, clue cells Diagnosis is made by potassium hydroxide smear → fishy odor, whiff test, Amsel criteria Most commonly detected bacteria is Gardnerella vaginalis (usually due to decrease in Lactobacillus sp) Treatment is metronidazole

Postpartum Endometritis

Patient will be postpartum, early-onset disease < 48 hours after delivery (C-section more common) Fever, abdominal pain, foul-smelling lochia PE will show uterine tenderness Labs will show leukocytosis Most common postpartum infection Treatment is clindamycin + gentamicin GBS colonized: add ampicillin or use ampicillin-sulbactam

Pelvic Organ Prolapse

Patient will report vaginal pressure, bulge, sexual dysfunction, urinary dysfunction, or bowel dysfunction PE will show descent of one or more pelvic organs POP-Q examination is recommended before treatment Vaginal pessary should be offered as an alternative to surgery Patients without incontinence should be evaluated for occult SUI before surgery Routine intraoperative cystoscopy is recommended during POP surgery

Polycystic ovarian syndrome

Polycystic ovarian syndrome can be ruled out because the patient does not have any symptoms of hyperandrogenism and has a normal pelvic ultrasound.

Preeclampsia

Pregnancy > 20 weeks gestation or postpartum Visual disturbances, severe headaches, or asymptomatic Evaluation will show: new-onset hypertension: (≥ 140/90 mm Hg) with either proteinuria (≥ 300 mg/24 hr) or urine protein: creatinine ratio ≥ 0.3) OR significant end-organ dysfunction Treatment: delivery at 37 weeks (without severe features) and 34 weeks (with severe features) AND prevention of seizures with magnesium sulfate and prevention of permanent maternal organ damage New-onset hypertension < 20 weeks gestation: suspect molar pregnancy

Question: What is the most common cause of secondary amenorrhea?

Pregnancy.

Lymphogranuloma Venereum

Primarily seen in men who have sex with men History of recent travel to tropical and subtropical areas of the world Small, shallow painless genital ulcer PE will show tender inguinal or femoral lymphadenopathy Most commonly caused by Chlamydia trachomatis Treatment is doxycycline

Genitourinary Syndrome of Menopause (Atrophic Vaginitis)

Risk factors: natural or surgical menopause, antiestrogenic drugs Sx: dyspareunia, vulvar and vaginal dryness, bleeding, itching PE: pale, dry, shiny epithelium Caused by a decrease in estrogen Tx: lubricants, moisturizers, topical estrogen

Question: Between which structures does the sacrospinous ligament run?

Sacrum/coccyx and the ischial spine

Endometriosis

Sx: dysmenorrhea, dyspareunia, dyschezia (painful bowel movement) PE may show uterosacral nodularity or a fixed or retroverted uterus or adnexal mass Definitive diagnosis is made by laparoscopy Most common site is ovaries Tx: NSAIDs, COCs, depot medroxyprogesterone acetate, GnRH agonists, surgery

Molar Pregnancy

Sx: nausea, vomiting, abdominal pain, and vaginal bleeding PE: uterine size > than expected for dates Labs: beta-hCG higher than expected for dates Ultrasound may reveal snowstorm or bag of grapes appearance Tx: dilation and curettage New-onset hypertension* < 20 weeks gestation: suspect molar pregnanc

When a fetus is in funic presentation, what part of the fetus is over the pelvic inlet?

The umbilical cord.

Question: What complication has been associated with hospitalized pregnant women on strict bedrest?

Thromboembolism.

What is the purpose of repeat digital cervical examinations during labor?

To monitor the progression of dilation and determine effacement and fetal station.

Question: True or false: the majority of women experiencing hot flashes will continue to have these symptoms for more than 1 year.

True

Adnexal Torsion

Twisting of ovary, fallopian tube, or a paraovarian mass Patient likely to be of reproductive age, mean age 29-33.5 years Sudden onset of unilateral (right > left) abdominal and pelvic pain Laboratory abnormalities are often absent, leukocytosis may be present with necrosis Imaging: pelvic U/S for Ovarian torsion: - Enlarged heterogeneous ovarian mass - Peripheralization of the follicles may be present Definitive diagnosis and management: laparoscopic detorsion

Question: How long should patients abstain from sexual intercourse after being diagnosed with lymphogranuloma venereum?

Until antibiotic treatment is completed and symptoms have resolved.

What are Wickham striae?

White striae within involved areas or a serpentine white border classically found in lichen planus.