OBGYN uWise Week 2

A 28-year-old G2P0020 experienced her second miscarriage within 14 months. A recent ultrasound was notable for two uterine fibroids. The patient is worried that the fibroids may have caused her early pregnancy losses. She is otherwise healthy and has no previous surgeries. She presents to you for further consultation. Which type of fibroid is the most likely explanation of her miscarriages? A. Submucosal B. Intramural C. Subserosal D. Pedunculated E. Cervical

A. Leiomyomas are an infrequent cause of miscarriages and subfertility either by mechanical obstruction or distortion (and interference with implantation). When a mechanical obstruction of fallopian tubes, cervical canal or endometrial cavity is present and no other cause of infertility or recurrent miscarriage can be identified, myomectomy is usually followed by a prompt achievement of pregnancy. Submucosal or intracavitary myomas are most likely to cause lower pregnancy and implantation rates. Presumed mechanisms include: 1) focal endometrial vascular disturbance; 2) endometrial inflammation, and; 3) secretion of vasoactive substances. Submucosal fibroids are best treated by hysteroscopic resection.

A 20-year-old G2P2 healthy woman presents for her post-partum check six weeks after a full term normal spontaneous delivery. She has a 13 month old in addition to the six-week newborn, and is already feeling overwhelmed. She desires a reliable form of contraception. On exam, her vital signs are normal. BMI is 27. The remainder of the exam is unremarkable. Of the following, what is the most effective and appropriate form of contraception for this patient? A. Intrauterine device B. Tubal ligation C. Depo-Provera® D. Oral contraceptive pills E. Essure®

A. Long-acting reversible contraceptives (LARC) methods such as contraceptive implants and intrauterine devices are a good option for this patient. Despite high up-front costs and the need for office visits for insertion and removal, LARC methods provide many distinct advantages over other contraceptive methods as Depo-Provera® and oral contraceptives. While Depo-Provera is an effective form of contraception, it may not be the best choice in this woman with a high BMI. For this young mother who desires a reversible, but reliable form of contraception, the high effectiveness, continuation rate and user satisfaction of LARC methods would be of most benefit. Emerging evidence indicates that increasing the use of LARC methods also could reduce repeat pregnancy among adolescent mothers and repeat abortions among women seeking induced abortion. ("Increasing Use of Contraceptive Implants and Intrauterine Devices To Reduce Unintended Pregnancy," ACOG Committee Opinion, No. 450, 2009). Tubal ligation and Essure® are permanent and are not appropriate for this patient.

A 20-year-old G0 college student presents with a one-month history of profuse vaginal discharge and mid-cycle vaginal spotting. She uses oral contraceptives and she thinks her irregular bleeding is due to the pill. She is sexually active and has had a new partner within the past three months. She reports no fevers or lower abdominal pain. She has otherwise been healthy. On pelvic examination, a thick yellow endocervical discharge is noted. Saline microscopy reveals multiple white blood cells, but no clue cells or trichomonads. Potassium hydroxide testing is negative. Vaginal pH is 4.0. No cervical motion tenderness or uterine/adnexal tenderness is present. Testing for gonorrhea and chlamydia is performed, but those results will not be available for several days and the student will be leaving for Europe tomorrow. Which of the following is the most appropriate treatment for this patient? A. Metronidazole and erythromycin B. Ceftriaxone and azithromycin C. Ampicillin and doxycycline D. Azithromycin and doxycycline E. No treatment is necessary until all tests results are known

B Mucopurulent cervicitis (MPC) is characterized by a mucopurulent exudate visible in the endocervical canal or in an endocervical swab specimen. MPC is typically asymptomatic, but some women have an abnormal discharge or abnormal vaginal bleeding. MPC can be caused by Chlamydia trachomatis or Neisseria gonorrhoeae; however, in most cases neither organism can be isolated. Patients with MPC should be tested for both of these organisms. The results of sensitive tests for C. trachomatis or N. gonorrhoeae (e.g. culture or nucleic acid amplification tests) should determine the need for treatment, unless the likelihood of infection with either organism is high or the patient is unlikely to return for treatment. Antimicrobial therapy should include coverage for both organisms, such as azithromycin or doxycycline for chlamydia and a cephalosporin or quinolone for gonorrhea. Uncomplicated cervicitis, as in this patient, would require only 125 mg of Ceftriaxone in a single dose. Ceftriaxone 250 mg is necessary for the treatment of upper genital tract infection or pelvic inflammatory disease (PID).

A 50-year-old G2P2 woman has a history of menorrhagia, pelvic pain, dyspareunia, dysmenorrhea, constipation and occasional spotting in between periods. She has a three-year history of urinary urgency and frequency. The patient is concerned that she has fibroids, as her close friend was recently diagnosed with fibroids. What is the symptom most commonly associated with leiomyomas? A. Intermenstrual spotting B. Menorrhagia C. Dyspareunia D. Dysmenorrhea E. Urinary symptoms

B. The major symptom associated with myomas is menorrhagia, thought to be secondary to: 1) an increase in the uterine cavity size that leads to greater surface area for endometrial sloughing; and/or 2) an obstructive effect on uterine vasculature that leads to endometrial venule ectasia and proximal congestion in the myometrium/endometrium resulting in hypermenorrhea. Other relatively frequent symptoms include pain and pressure symptoms related to the size of the tumors filling the pelvic cavity, as well as causing pressure against the bladder, bowel and pelvic floor.

A 32-year-old G3P3 woman comes to the office to discuss permanent sterilization. She has a history of hypertension and asthma (on corticosteroids). She has been married for 10 years. Vital signs show: blood pressure 140/90; weight 280 pounds; height 5 feet 9 inches; and BMI 41.4kg/m2. You discuss with her risks and benefits of contraception. Which of the following would be the best form of permanent sterilization to recommend for this patient? A. Laparoscopic bilateral tubal ligation B. Mini laparotomy tubal ligation C. Exploratory laparotomy with bilateral salpingectomy D. Total abdominal hysterectomy E. Vasectomy for her husband

E. Both vasectomy and tubal ligation are 99.8% effective. Vasectomies are performed as an outpatient procedure under local anesthesia, while tubal ligations are typically performed in the operating room under regional or general anesthesia; therefore carrying slightly more risk to the woman, assuming both are healthy. She is morbidly obese, so the risk of anesthesia and surgery are increased. In addition, she has chronic medical problems that put her at increased risk of having complications from surgery.

A 17-year-old G0 sexually active female presents to the emergency department with pelvic pain that began 24 hours ago. She reports menarche at the age of 15 and coitarche soon thereafter. She has had four male partners, including her new boyfriend of a few weeks. Her blood pressure is 100/60; pulse 100; and temperature 102.0°F (38.9°C). On speculum examination, you note a foul-smelling mucopurulent discharge from her cervical os and she has significant tenderness with manipulation of her uterus. What is the next best step in the management of this patient?

E. Correct! The most likely cause of the symptoms and signs in this patient is infection with a sexually transmitted organism. The most likely organisms are both N. gonorrhoeae and chlamydia, and the patient should be treated empirically for both after appropriate blood and cervical cultures are obtained. There is no evidence that adolescents have better outcomes from inpatient therapy. However, since the patient also has a high fever, inpatient admission is recommended for aggressive intravenous antibiotic therapy in an effort to prevent scarring of her fallopian tubes and possible future infertility.

A 35-year-old G2P2 comes to the office due to heavy menstrual periods. The heavy periods started three years ago and have gradually worsened in amount of flow and duration. The periods are now interfering with her daily activities. The patient had two spontaneous vaginal deliveries. She smokes one pack of cigarettes per day. On pelvic examination, the cervix appears normal and the uterus is normal in size, without adnexal masses or tenderness. A urine pregnancy test is negative. TSH and prolactin levels are normal. Hemoglobin is 12.5 mg/dl. On pelvic sonography, a 2 cm submucosal leiomyoma is noted. An endometrial biopsy is consistent with a secretory endometrium; no neoplasia is found. Which of the following would be the best therapeutic option for this patient if she desires to have another child? A. Hysteroscopy with myoma resection B. Laparoscopic myomectomy C. Endometrial ablation D. Oral contraceptives E. Dilation and curettage

A Correct! Hysteroscopic myomectomy preserves the uterus, while removing the pathology causing the patient's symptoms. A laparoscopic approach is not indicated as the myoma is submucosal and not accessible using a laparoscopic approach. Endometrial ablation destroys the endometrium and can create Asherman's syndrome, thus it is reserved for patients who have completed childbearing. Dilation and curettage is unlikely to remove the myoma and is a blind procedure (carried out without direct visualization). Oral contraceptives would typically help with heavy menses, but are contraindicated in this patient, who is over 35 and smokes.

A 35-year-old G0 comes to the office because of six months of spotting between her periods and a desire for a pregnancy. She reports using 30 pads/cycle the last two months and has blood clots and cramping pain. Prior menses were light and required 15 pads/cycle. She has been trying to conceive for six months. Her work-up included a transvaginal ultrasound which revealed a 2 cm endometrial polyp. What is the next best step in the management of this patient? A. Hysteroscopic polypectomy B. Observation C. Combination birth control pills D. Endometrial ablation E. Hysterectomy

A Correct! Management of an endometrial polyp includes the following: observation, medical management with progestin, curettage, surgical removal (polypectomy) via hysteroscopy, and hysterectomy. Observation is not recommended if the polyp is > 1.5 cm. In women with infertility polypectomy is the treatment of choice. Hysterectomy is reserved for women with polyps and premalignant or malignant changes.

A 30-year-old G1P1 woman presents with a history of chronic vulvar pruritus. The itching is so severe that she scratches constantly and is unable to sleep at night. She reports no significant vaginal discharge or dyspareunia. She does not take antibiotics. Her medical history is unremarkable. Pelvic examination reveals normal external genitalia with marked lichenification (increased skin markings) and diffuse vulvar edema and erythema as shown in picture below. Saline microscopy is negative. Potassium hydroxide testing is negative. Vaginal pH is 4.0. The vaginal mucosa is normal. Which of the following is the most likely diagnosis in this patient? A. Lichen simplex chronicus B. Lichen sclerosus C. Lichen planus D. Candidiasis E. Vulvar cancer

A Lichen simplex chronicus, a common vulvar non-neoplastic disorder, results from chronic scratching and rubbing, which damages the skin and leads to loss of its protective barrier. Over time, a perpetual itch-scratch-itch cycle develops, and the result is susceptibility to infection, ease of irritation and more itching. Symptoms consist of severe vulvar pruritus, which can be worse at night. Clinical findings include thick, lichenified, enlarged and rugose labia, with or without edema. The skin changes can be localized or generalized. Diagnosis is based on clinical history and findings, as well as vulvar biopsy. Treatment involves a short-course of high-potency topical corticosteroids and antihistamines to control pruritus.

A 36-year-old G2P2 woman presents with irregular vaginal bleeding. Six weeks ago, she had her first Depo-Provera® injection and now she has unpredictable bleeding. She is concerned by these symptoms. She has a history of hypertension but is currently on no medications. Vital signs reveal: blood pressure 130/90; weight 188 pounds; height 5 feet 5 inches; BMI 31.4kg/m2. Which of the following is the most appropriate next step in the management of this patient? A. Reassurance B. Begin oral contraceptives C. Begin estrogen D. Insert etonogestrel implant (Implanon) E. Perform an endometrial biopsy

A. The patient should be reassured since initially after Depo-Provera injection there may be unpredictable bleeding. This usually resolves in 2-3 months. In general, after one year of using Depo-Provera, nearly 50% of users have amenorrhea.

A 32-year-old G0 presents with irregular menses occurring every six to eight weeks for the past eight months. The bleeding alternates between light and heavy. Her irregular menses were treated successfully with Medroxyprogesterone Acetate (MPA), 10 mg every day, taken for 10 days each month. By which mechanism does the MPA control her periods? A. Stimulates rapid endometrial growth and regeneration of glandular stumps B. Converts endometrium from proliferative to secretory C. Promotes release of Prostaglandin F2α D. Regenerates functional layer of the endometrium E. Decreases luteal phase inhibin production

B Correct! Patients with anovulatory bleeding have predominantly proliferative endometrium from unopposed stimulation by estrogen. Progestins inhibit further endometrial growth, converting the proliferative to secretory endometrium. Withdrawal of the progestin then mimics the effect of the involution of the corpus luteum, creating a normal sloughing of the endometrium. Stimulation of rapid endometrial growth, conversion of proliferative to secretory endometrium, and regeneration of the functional layer describe effects of estrogen on the endometrium. Inhibin is increased in the luteal phase.

A 36-year-old G0 presents due to increasing facial hair growth and irregular menstrual cycles. She has gained 40 pounds over the last three years. Her symptoms began three years ago and have gradually worsened. She has never been pregnant and is not currently on any medications. On physical exam, she is overweight with dark hair growth at the sideburns and upper lip. The pelvic exam is normal. Which of the following would you expect to find in this patient? A. Decreased luteinizing hormone levels B. Elevated free testosterone C. Decreased prolactin level D. Increased ovarian estrogen production E. Elevated 17-hydroxyprogesterone

B Correct! This patient likely has polycystic ovarian syndrome (PCOS). PCOS patients have testosterone levels at the upper limits of normal or slightly increased. Free testosterone (biologically active) is elevated often because sex hormone binding globulin is decreased by elevated androgens. LH is increased in response to increased circulating estrogens fed by an elevation of ovarian androgen production. Insulin resistance and chronic anovulation are hallmarks of PCOS. Prolactin levels may be elevated in amenorrhea but are not elevated in patients with PCOS.

A 64-year-old G2P2 woman presents with a 12-month history of severe vulvar pruritus. She has applied multiple over-the-counter topical therapies without improvement. She has no significant vaginal discharge. She has severe dyspareunia at the introitus and has stopped having intercourse because of the pain. Her past medical history is significant for allergic rhinitis and hypertension. On pelvic examination the external genitalia show loss of the labia minora with resorption of the clitoris (phimosis). The vulvar skin appears thin and pale and involves the perianal area as in the picture below. No ulcerations are present. The vagina is mildly atrophic, but appears uninvolved. Which of the following is the most likely diagnosis in this patient? A. Squamous cell hyperplasia B. Lichen sclerosus C. Lichen planus D. Candidiasis E. Vulvar cancer

B Lichen sclerosus is a chronic inflammatory skin condition that most commonly affects Caucasian premenarchal girls and postmenopausal women. The exact etiology is unknown, but is most likely multifactorial. Patients typically present with extreme vulvar pruritus and may also present with vulvar burning, pain and introital dyspareunia. Early skin changes include polygonal ivory papules involving the vulva and perianal areas, waxy sheen on the labia minora and clitoris, and hypopigmentation. The vagina is not involved. More advanced skin changes may include fissures and erosions due to a chronic itch-scratch-itch cycle, mucosal edema and surface vascular changes. Ultimately, scarring with loss of normal architecture, such as introital stenosis and resorption of the clitoris (phimosis) and labia minora, may occur. Treatment involves use of high-potency topical steroids. There is less than a 5% risk of developing squamous cell cancer within a field of lichen sclerosus.

A 42-year-old G2P2 woman presents with a two-week history of a thick, curdish white vaginal discharge and pruritus. She has not tried any over-the-counter medications. She is currently single and not sexually active. Her medical history is remarkable for recent antibiotic use for bronchitis. On pelvic examination, the external genitalia show marked erythema with satellite lesions. The vagina appears erythematous and edematous with a thick white discharge. The cervix appears normal and the remainder of the exam is unremarkable except for mild vaginal wall tenderness. Vaginal pH is 4.0. Saline wet prep reveals multiple white blood cells, but no clue cells or trichomonads. Potassium hydroxide prep shows the organisms. Which of the following is the most appropriate treatment for this patient? A. Clindamycin B. Azole cream C. Metronidazole D. Doxycycline E. Ciprofloxacin

B Vulvovaginal candidiasis (VVC) usually is caused by C. albicans, but is occasionally caused by other Candida species or yeasts. Typical symptoms include pruritus and vaginal discharge. Other symptoms include vaginal soreness, vulvar burning, dyspareunia and external dysuria. None of these symptoms are specific for VVC. The diagnosis is suggested clinically by vulvovaginal pruritus and erythema with or without associated vaginal discharge. The diagnosis can be made in a woman who has signs and symptoms of vaginitis when either: a) a wet preparation (saline or 10% KOH) or Gram stain of vaginal discharge demonstrates yeasts or pseudohyphae; or b) a vaginal culture or other test yields a positive result for a yeast species. Microscopy may be negative in up to fifty percent of confirmed cases. Treatment for uncomplicated VVC consists of short-course topical Azole formulations (1-3 days), which results in relief of symptoms and negative cultures in 80%-90% of patients who complete therapy.

A 44-year-old G1P1 woman was placed on three months of a GnRH agonist in order to diminish the size of a 5 cm submucosal myoma and allow it to be accessible to a hysteroscopic removal. About two weeks prior to surgery, she was no longer having severe menorrhagia although the drug side effects were becoming incapacitating especially the hot flashes. She decides to cancel the surgery and she stops the GnRH agonist. Which of the following is most likely to happen to the myoma? A. Continues to regress B. Resumes former growth potential C. Grows but to half of its original size D. Grows at a more rapid rate E. Becomes hemorrhagic

B. Maximal response is usually achieved by three months of GnRH agonist treatment. The reduction in size correlates with the estradiol level and with body weight. Hot flashes are experienced by >75% of patients, usually in three to four weeks after start of treatment, although they should not persist for longer than one to two months from end of treatment. After cessation of treatment, menses return in four to ten weeks, and myoma and uterine size return to pretreatment levels in three to four months. The regrowth is consistent with the fact that reduction in size is not due to a cytotoxic effect. However, it is not true that secondary to the GnRH agonist withdrawal they will grow at a more rapid rate.

A 39-year-old G1P1 woman comes to see you because of increased bleeding due to her known uterine fibroids, especially during her menses. She reports that her bleeding is so heavy that she has to miss two days of work every month. She has been using oral contraceptives and NSAIDs. Her most recent hematocrit was 27%. She is undecided about having more children. You discuss with her short and long-term options to decrease her bleeding. What is the next best step in the management of this patient? A. Blood transfusion B. Gonadotropin-releasing hormone agonists C. Endometrial ablation D. Uterine artery embolization E. Hysterectomy

B. The goals of medical therapy are to temporarily reduce symptoms and to reduce myoma size. The therapy of choice is treatment with a GnRH agonist. The mean uterine size decreases 30-64% after three to six months of GnRH agonist treatment. Unfortunately, GnRH agonist therapy is recommended for only a short period of time (3-6 months) typically before a surgical procedure, or to bridge a woman who is close to menopause. In this case, it is the best short-term option. Even though she is anemic, she is asymptomatic and able to work so a blood transfusion will not be indicated. Although uterine artery embolization and endometrial ablation effectively reduce bleeding, pain and fibroid size, they are contraindicated in a patient who desires future fertility. The failure rate is about 10-15%. A hysterectomy would obviously take care of her bleeding but would not be performed if she desires future fertility.

A 50-year-old G3P3 woman complains of menorrhagia. Physical examination is notable for a 14-week size irregularly shaped uterus. Her hematocrit is 35%. Which of the following is the next most appropriate step in this patient's management? A. Hysteroscopy B. Endometrial sampling C. Treatment with GnRH analogue D. Hysterectomy E. Myomectomy

B. The majority of patients with uterine fibroids do not require surgical treatment. If patients present with menstrual abnormalities, the endometrial cavity should be sampled to rule out endometrial hyperplasia or cancer. This is most important in patients in their late reproductive years or postmenopausal years. If the patient's bleeding is not heavy enough to cause iron deficiency anemia, reassurance and observation may be all that are necessary. Treatment with GnRH analogues to inhibit estrogen secretion may be used as a temporizing measure. This is helpful in premenopausal women who are likely to be anovulatory with relatively more endogenous estrogen. Treatment with GnRH analogues can be used for three to six months prior to a hysterectomy to decrease the uterine size and increase a patient's hematocrit. This may also lead to technically easier surgery and decreased intraoperative blood loss. Treatment with GnRH analogue can also be used in perimenopausal women as a temporary medical therapy until natural menopause occurs. Myomectomy may be an appropriate treatment for a younger patient who desires future fertility. Hysteroscopy is not indicated at this point prior to endometrial sampling. Hysterectomy is a definitive treatment for women who have completed childbearing. Particularly in a perimenopausal woman, it is important to first rule out an underlying endometrial malignancy with endometrial sampling.

A 32-year-old G0 woman with a last menstrual period three weeks ago, presents with a three-month history of a malodorous vaginal discharge. She reports no pruritus or irritation. She has been sexually active with a new partner for the last four months. Her past medical history is unremarkable. Pelvic examination reveals normal external genitalia without rash, ulcerations or lesions. Some discharge is noted on the perineum. The vagina reveals only a thin, gray homogeneous discharge. The vaginal pH is 5.0. A wet prep is shown in the image below. Which of the following is the most appropriate treatment for this patient? A. Ceftriaxone B. Doxycycline C. Metronidazole D. Azithromycin E. Penicillin

C Bacterial vaginosis is the most common cause of vaginitis. The infection arises from a shift in the vaginal flora from hydrogen peroxide-producing lactobacilli to non-hydrogen peroxide-producing lactobacilli, which allows proliferation of anaerobic bacteria. The majority of women are asymptomatic; however, patients may experience a thin, gray discharge with a characteristic fishy odor that is often worse following menses and intercourse. Modified Amsel criteria for diagnosis include three out of four of the following: 1) thin, gray homogenous vaginal discharge; 2) positive whiff test (addition of potassium hydroxide releases characteristic amine odor); 3) presence of clue cells on saline microscopy; and 4) elevated vaginal pH >4.5. Treatment consists of Metronidazole 500 mg orally BID for seven days, or vaginal Metronidazole 0.75% gel QHS for five days.

A 14-year-old G0 adolescent reports menarche six months ago, with increasingly heavy menstrual flow causing her to miss several days of school. Three months ago, her pediatrician started her on oral contraceptives to control her menstrual periods, but she continues to bleed heavily. Her previous medical history is unremarkable. The patient has a normal body habitus for her age. Appropriate breast and pubic hair development is present. Her hemoglobin is 9.1 mg/dl, hematocrit 27.8%, urine pregnancy test negative. Which of the following etiologies for menorrhagia is most likely the cause of her symptoms? A. Uterine leiomyoma B. Thyroid disorder C. Coagulation disorder D. Endometrial hyperplasia E. Chronic endometritis

C Correct! Disorders of clotting may present with menstrual symptoms in young women, with Von Willeberand disease being most common. Leiomyomas typically present in women in their 30s and 40s. Endometrial hyperplasia can occur in younger anovulatory patients, but the short duration of this patient's symptoms makes this less likely. She does not have any signs of infection or thyroid disease.

A 45-year-old G2P2 comes to the office because of heavy and irregular menstrual periods. The heavy periods started three years ago and have gradually worsened in amount of flow over time. The periods are interfering with her daily activities. The patient has had two spontaneous vaginal deliveries, followed by a tubal ligation three years ago. On pelvic examination, the cervix appears normal and the uterus is normal in size without adnexal masses or tenderness. A urine pregnancy test is negative. TSH and prolactin levels are normal. Hemoglobin is 12.5 mg/dl. On pelvic sonography, she has a normal size uterus and a 2 cm simple cyst on the right ovary. Endometrial biopsy is consistent with a secretory endometrium; no neoplasia is found. What is the most likely diagnosis in this patient? A. Polycystic ovarian syndrome B. Mid-cycle bleeding C. Abnormal uterine bleeding D. Benign cystic teratoma E. Ovarian cancer

C Correct! Dysfunctional uterine bleeding is defined as irregular or increased menstrual bleeding without identified etiology. This patient had a complete workup, including TSH, Prolactin, pelvic ultrasound and endometrial biopsy, which were all normal. Mid-cycle bleeding at the time of ovulation is due to the drop in estrogen. Ovarian teratomas are not associated with abnormal menses. They typically present with abdominal or pelvic pain which may be associated with torsion. The 2 cm cyst is a functional cyst and is a common finding in ovulatory patients.

A 52-year-old G0 woman presents with long-standing vulvar and vaginal pain and burning. She has been unable to tolerate intercourse with her husband because of pain at the introitus. She has difficulty sitting for prolonged periods of time or wearing restrictive clothing because of worsening vulvar pain. She recently noticed that her gums bleed more frequently. She avoids any topical over-the-counter therapies because they intensify her pain. Her physical examination is remarkable for inflamed gingiva and a whitish reticular skin change on her buccal mucosa. A fine papular rash is present around her wrists bilaterally. Pelvic examination reveals white plaques with intervening red erosions on the labia minora as shown in below picture. A speculum cannot be inserted into her vagina because of extensive adhesions. The cervix cannot be visualized. Which of the following is the most likely diagnosis in this patient? A. Squamous cell hyperplasia B. Lichen sclerosus C. Lichen planus D. Genital psoriasis E. Vulvar cancer

C Lichen planus is a chronic dermatologic disorder involving the hair-bearing skin and scalp, nails, oral mucous membranes and vulva. This disease manifests as inflammatory mucocutaneous eruptions characterized by remissions and flares. The exact etiology is unknown, but is thought to be multifactorial. Vulvar symptoms include irritation, burning, pruritus, contact bleeding, pain and dyspareunia. Clinical findings vary with a lacy, reticulated pattern of the labia and perineum, with or without scarring and erosions as well. With progressive adhesion formation and loss of normal architecture, the vagina can become obliterated. Patients may also experience oral lesions, alopecia and extragenital rashes. Treatment is challenging, since no single agent is universally effective and consists of multiple supportive therapies and topical high potency corticosteroids

A 74-year-old G0 woman complains of vulvar pain. She reports that the pain is present every day and she has had it for the past year. It now limits her ability to exercise, and she is no longer able to have sexual relations with her partner. On exam, her BMI is 32; blood pressure is 100/60; and heart rate is 77. Her vulva has an ulcerated lesion near the left labial edge. Which of the following is the next best step in the management of this patient? A. Estrogen cream B. Clobetasol cream C. Vulva biopsy D. Laser vaporization of the lesion E. Vulvectomy

C This patient has a vulvar lesion causing her pain. The next step is to perform a biopsy to evaluate for vulvar cancer. Estrogen cream and clobetasol (a high potency steroid) are treatments for vulvadynia. To diagnosis vulvadynia, all other causes of pain must first be excluded, including infectious etiologies as well as other vulvar conditions. Laser vaporization and vulvectomy are contraindicated until a definitive diagnosis is made.

A 32-year-old G0 woman presents with a one-month history of profuse vaginal discharge with mild odor. She has a new sexual partner with whom she has had unprotected intercourse. She reports mild to moderate irritation, pruritus and pain. She thought she had a yeast infection, but had no improvement after using an over-the-counter antifungal cream. She is concerned about sexually transmitted infections. Her medical history is significant for lupus and chronic steroid use. Pelvic examination shows normal external genitalia, an erythematous vagina with a copious, frothy yellow discharge and multiple petechiae on the cervix. Vaginal pH is 7. Which of the following findings on a wet prep explains the etiology of this condition? A. Hyphae B. Clue cells C. Trichomonads D. Lactobacilli E. Normal epithelial cells

C This patient has signs and symptoms of trichomoniasis, which is caused by the protozoan, T. vaginalis. Many infected women have symptoms characterized by a diffuse, malodorous, yellow-green discharge with vulvar irritation. However, some women have minimal or no symptoms. Diagnosis of vaginal trichomoniasis is performed by saline microscopy of vaginal secretions, but this method has a sensitivity of only 60% to 70%. The CDC recommended treatment is metronidazole 2 grams orally in a single dose. An alternate regimen is metronidazole 500mg orally twice daily for seven days. The patient's sexual partner also should undergo treatment prior to resuming sexual relations.

A 37-year-old G0 woman presents with a one-week history of a mildly painful vulvar ulcer. She reports no fevers, malaise or other systemic symptoms. She recently started use of a topical steroid ointment for a vulvar contact dermatitis. She is married and has no prior history of sexually transmitted infections. She reports no travel outside the United States by her husband or herself. Her last Pap smear, six months ago, was normal. A vulvar herpes culture later returns positive for herpes simplex virus type 2. A Rapid Plasma Reagin (RPR) is nonreactive, and HIV testing is negative. Which of the following is the most likely diagnosis in this patient? A. Primary HSV episode B. Recurrent HSV-1 episode C. Recurrent HSV-2 episode D. Atypical HSV episode E. Contact dermatitis

C Two serotypes of HSV have been identified: HSV-1 and HSV-2. Most cases of recurrent genital herpes are caused by HSV-2. Up to 30% of first-episode cases of genital herpes are caused by HSV-1, but recurrences are much less frequent for genital HSV-1 infection than genital HSV-2 infection. Genital HSV infections are classified as initial primary, initial nonprimary, recurrent and asymptomatic. Initial, or first-episode primary genital herpes is a true primary infection (i.e. no history of previous genital herpetic lesions, and seronegative for HSV antibodies). Systemic symptoms of a primary infection include fever, headache, malaise and myalgias, and usually precede the onset of genital lesions. Vulvar lesions begin as tender grouped vesicles that progress into exquisitely tender, superficial, small ulcerations on an erythematous base. Initial, nonprimary genital herpes is the first recognized episode of genital herpes in individuals who are seropositive for HSV antibodies. Prior HSV-1 infection confers partial immunity to HSV-2 infection and thereby lessens the severity of type 2 infection. The severity and duration of symptoms are intermediate between primary and recurrent disease, with individuals experiencing less pain, fewer lesions, more rapid resolution of clinical lesions and shorter duration of viral shedding. Systemic symptoms are rare. Recurrent episodes involve reactivation of latent genital infection, most commonly with HSV-2, and are marked by episodic prodromal symptoms and outbreaks of lesions at varying intervals and of variable severity. Clinical diagnosis of genital herpes should be confirmed by viral culture, antigen detection or serologic tests. Treatment consists of antiviral therapy with acyclovir, famciclovir or valacyclovir.

A 27-year-old G0 woman presents with a three-year history of dyspareunia. She reports a history of always having painful intercourse, but she is now unable to tolerate intercourse at all. She has avoided sex for the last six months. She describes severe pain with penile insertion. On further questioning, she reports an inability to use tampons because of painful insertion. She also notes a remote history of frequent yeast infections while she was on antibiotics for recurrent sinusitis that occurred years ago. Her medical history is unremarkable, and she is not on medications. Pelvic examination is remarkable for normal appearing external genitalia. Palpation of the vestibule with a Q-tip elicits marked tenderness and slight erythema. A normal-appearing discharge is noted. Saline wet prep shows only a few white blood cells, and potassium hydroxide testing is negative. Vaginal pH is 4.0. The cervix and uterus are unremarkable. Which of the following is the most likely diagnosis in this patient? A. Vaginal cancer B. Genital herpes infection C. Vestibulodynia D. Contact dermatitis E. Chlamydia infection

C Vestibulodynia (formally vulvar vestibulitis) syndrome consists of a constellation of symptoms and findings limited to the vulvar vestibule, which include severe pain on vestibular touch or attempted vaginal entry, tenderness to pressure and erythema of various degrees. Symptoms often have an abrupt onset and are described as a sharp, burning and rawness sensation. Women may experience pain with tampon insertion, biking or wearing tight pants, and avoid intercourse because of marked introital dyspareunia. Vestibular findings include exquisite tenderness to light touch of variable intensity with or without focal or diffuse erythematous macules. Often, a primary or inciting event cannot be determined. Treatment includes use of tricyclic antidepressants to block sympathetic afferent pain loops, pelvic floor rehabilitation, biofeedback, and topical anesthetics. Surgery with vestibulectomy is reserved for patients who do not respond to standard therapies and are unable to tolerate intercourse.

A 47-year-old G2P2 woman comes to see you because she is concerned that she has uterine fibroids, as she recently gained about 20 pounds. Her mother had a hysterectomy for large fibroids that "made her look like she was 40 weeks pregnant." She has smoked one pack of cigarettes a day for the last 35 years and reports no other medical problems. She has normal menstrual cycles. Her weight is 216 pounds and she is 5 feet 4 inches tall (BMI 37). Her exam is extremely limited by her body habitus. A Beta-hCG is negative. A pelvic ultrasound shows a 4 cm intramural fibroid. What is the next best step in the management of this patient? A. Obtain a pelvic MRI B. Perform laparoscopic myomectomy C. Counsel her on diet and exercise D. Perform a hysterectomy E. Recommend bariatric surgery

C. The mostly likely cause of this patient's weight gain is excessive dietary intake and lack of exercise. She should be counseled on healthy habits and quitting smoking. The treatment of asymptomatic relatively small fibroids is not indicated. She does not qualify for bariatric surgery based on her BMI. Bariatric surgery may be considered when BMI is greater than 40, or is between 35 to 39.9 accompanied by a serious weight-related health problem, such as type 2 diabetes, high blood pressure or severe sleep apnea.

A 23-year-old G0 woman comes to the office to discuss contraception. Her past medical history is remarkable for hypothyroidism and mild hypertension. She has a history of slightly irregular menses. Her best friend recently got a "patch," so she is interested in using a transdermal system (patch). Her vital signs are: blood pressure 130/84; weight 210 pounds; height 5 feet 4 inches. What is the most compelling reason for her to use a different method of contraception? A. Age B. Hypothyroidism C. Weight D. Unpredictable periods E. Her blood pressure

C. The patch has comparable efficiency to the pill in comparative clinical trials, although it has more consistent use. It has a significantly higher failure rate when used in women who weigh more than 198 pounds. The patch is a transdermal system that is placed on a woman's upper arm or torso (except breasts). The patch (Ortho Evra®) slowly releases ethinyl estradiol and norelgestromin, which establishes steady serum levels for seven days. A woman should apply one patch in a different area each week for three weeks, then have a patch-free week, during which time she will have a withdrawal bleed.

A 24-year-old G2P2 woman with a history of two prior Cesarean deliveries desires a tubal ligation for permanent sterilization. She has two daughters, who are 3 and 1 years old. She is very sure she does not desire any more children. She is happily married and is a stay-at-home-mom. What is the strongest predictor of post-sterilization regret for this patient? A. Not working outside the home B. Parity C. Marital status D. Age E. Children's gender

D. Approximately 10% of women who have been sterilized regret having had the procedure with the strongest predictor of regret being undergoing the procedure at a young age. The percentage expressing regret was 20% for women less than 30 years old at the time of sterilization. For those under age 25, the rate was as high as 40%. The regret rate was also high for women who were not married at the time of their tubal ligation, when tubal ligation was performed less than a year after delivery, and if there was conflict between the woman and her partner.

A 48-year-old G2P2 woman complains of progressively heavier and longer menstrual periods over the last year. Prior to this year the patient had normal periods. She denies any symptoms other than fatigue over the last few months. Physical examination is unremarkable except for the pelvic examination. The patient is noted to have an irregularly shaped 16-week size uterus. The patient's hematocrit is 28%. What is this patient's most likely diagnosis? A. Endometrial hyperplasia B. Endometrial carcinoma C. Uterine fibroids D. Uterine leiomyosarcoma E. Adenomyosis

C. The patient's history and physical examination is typical for a perimenopausal woman with probable uterine fibroids. Although it is possible that she could have underlying endometrial hyperplasia, the most likely diagnosis is uterine fibroids. Uterine leiomyosarcoma should be considered in a postmenopausal woman with bleeding, pelvic pain coupled with uterine enlargement, and vaginal discharge, but it is exceedingly rare. Endometrial hyperplasia is more common in perimenopausal women who do not ovulate regularly and postmenopausal women. Endometrial carcinoma is typically a disease of postmenopausal women, although 5-10% of cases occur in women who are menstruating and 10-15% of cases occur in perimenopausal women. For this reason, she should still undergo an endometrial biopsy. Adenomyosis may result in a symmetrically enlarged "boggy" uterus, but usually presents with dysmenorrhea in addition to menorrhagia.

A 26-year-old G2P2 woman presents with urinary urgency and dysuria for the past three days. She has a history of a urinary tract infection once. She is sexually active and uses condoms for contraception. She is otherwise healthy and does not take any medications or supplements. She does not have fever, chills, flank pain or vaginal discharge. Which of the following organisms is the most likely cause of this patient's symptoms?

Correct! Acute cystitis in a healthy, non-pregnant woman is considered uncomplicated and is very common. Escherichia coli causes 80 to 85 percent of cases. The other major pathogens are Staphylococcus saprophyticus, Klebsiella pneumoniae, Enterococcus faecalis and Proteus mirabilis. The physician must consider antibiotic resistance when determining treatment.

A 16-year-old G0 female presents to the emergency department with a two-day history of abdominal pain, nausea and vomiting. She is sexually active with a new partner and is not using any form of contraception. On examination, her temperature is 100.2°F (37.9°C), and she has bilateral lower quadrant pain, with slight rebound and guarding. On pelvic examination, she has purulent cervical discharge and cervical motion tenderness. Her white count is 14,000/mcL. What is the most appropriate next step in the management of this patient?

Correct! Although some patients can be treated with an outpatient regimen, this patient should be hospitalized for IV treatment, as she has nausea and vomiting so she might not be able to tolerate oral medications. While adolescents have no better outcomes from inpatient vs outpatient therapy, each patient should be assessed for compliance. It is important to treat aggressively in order to prevent the long-term sequelae of acute salpingitis. You would not wait for culture results before initiating treatment. Her recent sexual contacts should also be informed (by her and/or with her consent) and treated. According to the 2010 CDC treatment guidelines, there are two options for parenteral antibiotics covering both gonorrhea and chlamydia. Cefotetan or cefoxitin PLUS doxycycline or clindamycin PLUS gentamicin. For outpatient treatment, the 2010 CDC guidelines recommend ceftriaxone, cefoxitin, or other third-generation cephalosporin (such as ceftizoxime or cefotaxime) PLUS doxycycline WITH or WITHOUT metronidazole. There are alternative oral regimens as well. http://www.cdc.gov/std/treatment/2010/pid.htm

A 32-year-old G3P1 woman presents to your office today because of exposure to hepatitis B. She had vaginal and anal intercourse with a new partner three days ago and did not use condoms. The partner informed her today he was recently diagnosed with acute hepatitis B acquired from intravenous drug use and needle sharing. She has no prior history of hepatitis B infection and has not been vaccinated. She is currently asymptomatic and her examination is normal. Her urine pregnancy test is negative. What is the next best step in the management of this patient?

Correct! It is estimated that 38% of hepatitis B cases worldwide are acquired from sexual transmission. Post-exposure prophlaxis should be inititated as soon as possible but not later than 7 days after blood contact and within 14 days after sexual exposure. In individuals who are unvaccinated but exposed to persons who are HBsAG positive, recommendations are to receive one dose of HBIG (Hepatitis B Immune Globulin) and the HBV (Hepatitis B Vaccine Series). If the source is HBsAG negative or unknown status, then only the HBV series is used. If the exposed individual has been vaccinated and is a responder then no further treatment is necessary. If the exposed individual is vaccinated and a non-responder, then HBIG plus HBV or HBIG times two doses is used. Because the incubation period for the virus is six weeks to six months, checking liver function and immunologic status at this time is not indicated.

A 19-year-old G0 woman presents to the office with a two-week history of low pelvic pain and cramping. She has a new sexual partner and is on oral contraception and uses condoms. She is one week into her cycle. She has noted no vaginal discharge, itch or odor. She denies fevers or chills. She does note that she is on a new diet and has started drinking lots of water. As such, she notes that she is urinating much more frequently. Her examination is entirely unremarkable. Which of the following is the most appropriate next step in the management of this patient?

Correct! Mildly symptomatic or asymptomatic urinary tract infections are common in female patients. Urinary tract infection must be considered in patients who present with low pelvic pain, urinary frequency, urinary urgency, hematuria or new issues with incontinence. While yearly screening for chlamydia is recommended for patients less than 25 years old, this patient's symptoms are most consistent with a UTI. A pelvic ultrasound is not indicated at this point.

A 33-year-old G3P3 woman presents to the office complaining of a new onset vaginal discharge of four days duration. The discharge is thick and white. She has noted painful intercourse and itching since the discharge began. Her vital signs are: blood pressure 120/76 and pulse 78. The pelvic examination reveals excoriations on the perineum, thick white discharge, and is otherwise non-contributory. What is the most likely diagnosis in this patient?

Correct! The patient is most likely has candida vaginalis. Clinically women have itching and thick white cottage cheese like discharge. They may also have burning with urination and pain during intercourse. Herpes simplex viral infections are characterized by viral like symptoms preceding the appearance of vesicular genital lesions. A prodrome of burning or irritation may occur before the lesions appear. With primary infection, dysuria due to vulvar lesions can cause significant urinary retention requiring catheter drainage. Pain can be a very significant finding as well. Syphilis is a chronic infection caused by the Treponema pallidum bacterium. Transmission is usually by direct contact with an infectious lesion. Early syphilis includes the primary, secondary, and early latent stages during the first year after infection, while latent syphilis occurs after that and the patient usually has a normal physical exam with positive serology. In primary syphilis, a painless papule usually appears at the site of inoculation. This then ulcerates and forms the chancre, which is a classic sign of the disease. Left untreated, 25% of patients will develop the systemic symptoms of secondary syphilis, which include low-grade fever, malaise, headache, generalized lymphadenopathy, rash, anorexia, weight loss, and myalgias. Bacterial vaginosis is due to an overgrowth of anaerobic bacteria and characterized by a grayish / opaque foul-smelling discharge. Trichomonas is a protozoan and is transmitted via sexual contact. It typically presents with a non-specific yellow or greenish vaginal discharge. It does not have a systemic manifestation.

A 26-year-old G2P2 woman presents with a new onset of vulvar burning and irritation. She is sexually active with a new male partner. She is using oral contraception for birth control and did not use a condom. She thought she had a cold about 10 days ago. Which of the following is the most likely diagnosis in this patient?

Correct! The patient is most likely infected with herpes. Herpes simplex virus is a highly contagious DNA virus. Initial infection is characterized by viral-like symptoms preceding the appearance of vesicular genital lesions. A prodrome of burning or irritation may occur before the lesions appear. With primary infection, dysuria due to vulvar lesions can cause significant urinary retention requiring catheter drainage. Pain can be a very significant finding as well. Treatment is centered on care of the local lesions and the symptoms. Sitz baths, perineal care and topical Xylocaine jellies or creams may be helpful. Anti-viral medications, such as acyclovir, can decrease viral shedding and shorten the course of the outbreak somewhat. These medications can be administered topically or orally. Syphilis is a chronic infection caused by the Treponema pallidum bacterium. Transmission is usually by direct contact with an infectious lesion. Early syphilis includes the primary, secondary, and early latent stages during the first year after infection, while latent syphilis occurs after that and the patient usually has a normal physical exam with positive serology. In primary syphilis, a painless papule usually appears at the site of inoculation. This then ulcerates and forms the chancre, which is a classic sign of the disease. Left untreated, 25% of patients will develop the systemic symptoms of secondary syphilis, which include low-grade fever, malaise, headache, generalized lymphadenopathy, rash, anorexia, weight loss, and myalgias. This patient's symptoms are less consistent with syphilis, but she should still be tested for it. Human immunodeficiency virus is an RNA retrovirus transmitted via sexual contact or sharing intravenous needles. Vulvar burning, irritation or lesions are not typically noted with this disease, although generalized malaise can be. HIV can present with many different signs and symptoms, therefore risk factors should be considered, and testing offered. Trichomonas is a protozoan and is transmitted via sexual contact. It typically presents with a non-specific vaginal discharge. It does not have a systemic manifestation.

A 16-year-old G0 female presents to the emergency department with a two-day history of abdominal pain. She is sexually active with a new partner and is not using any form of contraception. Temperature is 101.8°F (38.8°C). On examination, she has lower abdominal tenderness and guarding. On pelvic exam, she has diffuse tenderness over the uterus and bilateral adnexal tenderness. Beta-hCG is <5. What is the most likely diagnosis for this patient?

Correct! The signs and symptoms of acute salpingitis can vary and be very subtle with mild pain and tenderness, or the patient can present in much more dramatic fashion with high fever, mucopurulent cervical discharge and severe pain. Important diagnostic criteria include lower abdominal tenderness, uterine/adnexal tenderness and mucopurulent cervicitis.

A 41-year-old G3P3 reports heavy menstrual periods occurring every 26 days lasting eight days. The periods have been increasingly heavy over the last three months. She reports soaking through pads and tampons every two hours. She has a history of three uncomplicated spontaneous vaginal deliveries and a tubal ligation following the birth of her last child. On pelvic examination, the cervix appears normal and the uterus is normal in size. Which of the following tests or procedures would be most useful in further evaluation of this patient's complaint? A. Follicle stimulating hormone level B. Prolactin level C. Coagulation studies D. Pelvic ultrasound E. Hysteroscopy

D Correct! A pelvic ultrasound would image the endometrium and assess for endometrial pathology such as polyps or submucosal fibroids. In the absence of menopausal symptoms, FSH is unlikely to be helpful. The patient is unlikely to have a coagulation disorder, as she has had three spontaneous vaginal deliveries without postpartum hemorrhage. Hysteroscopy would not be helpful if the cause of abnormal bleeding is myometrial pathology such as intramural and subserosal fibroids or adenomyosis. Hyperprolactinemia is found with prolactin-secreting adenomas associated with amenorrhea.

A 34-year-old G2P2 presents with inter-menstrual bleeding for one year. The bleeding typically occurs two weeks after her menses and last two to three days. The symptoms began one year ago and the bleeding has not changed recently. She is currently taking oral contraceptives. On pelvic examination, the cervix appears normal and the uterus is normal in size and shape. Her urine pregnancy test is negative; an endometrial biopsy is negative for neoplasia. Which of the following tests or procedures would be indicated for further work-up? A. Prolactin level B. Progesterone level C. Hysterosalpingogram (HSG) D. Pelvic ultrasound E. Colposcopy

D Correct! Intermenstrual bleeding is frequently caused by structural abnormalities of the endometrial cavity, such as myomas, polyps or malignancy. An ultrasound would be helpful as the next step in diagnosis. Although an hysterosalpingogram (HSG) might reveal structural abnormalities, it is too invasive for a next step. A colposcopy would not be helpful in the diagnosis, nor would obtaining a Prolactin level, as it would be indicated for the evaluation of anovulatory bleeding. Progesterone levels are not helpful in a patient on oral contraceptives.

A 36-year-old G0 woman presents to the emergency department accompanied by her female partner. The patient notes severe abdominal pain. She states that this pain began 2-3 days ago and was associated with diarrhea as well as some nausea. It has gotten progressively worse and she has now developed a fever. Neither her partner, nor other close contacts, report any type of viral illness. She had her appendix removed as a teenager. On examination, her temperature is 102.0°F (38.9°C), her abdomen is tender with mild guarding and rebound, and she has an elevated white count. On pelvic examination, she is exquisitely tender, such that you cannot complete the examination. Pelvic ultrasound demonstrates bilateral 3-4 cm complex masses. What is the most likely underlying pathogenesis of her illness?

D. Correct! Although salpingitis is most often caused by sexually transmitted agents such as gonorrhea and chlamydia, any ascending infection from the genitourinary tract or gastrointestinal tract can be causative. The infection is polymicrobial consisting of aerobic and anaerobic organisms such as E. coli, Klebsiella, G. vaginalis, Prevotella, Group B streptococcus and/or enterococcus. Although diverticulitis and gastroenteritis should be part of the differential diagnosis initially, the specific findings on examination and ultrasound are more suggestive of bilateral tubo-ovarian abscesses. Even though this patient does not have the typical risk factors for salpingitis, the diagnosis should be considered and explained to the patient in a sensitive and respectful manner. The patient should also be questioned separate from her partner regarding the possibility of other sexual contacts.

A 49-year-old G0 woman reports that her periods have become heavier over the last year. The patient's physical exam is notable for a slightly enlarged, irregularly shaped uterus, measuring approximately eight weeks in size. A pelvic ultrasound confirms the presence of two 2 x 2 cm intramural uterine fibroids. Her endometrial biopsy reveals proliferative endometrium. The patient's friend recently had a hysterectomy due to uterine fibroids and menorrhagia, but she would like to avoid having surgery. She is interested in the medical options for treating symptomatic uterine fibroids, but has tried NSAIDs which did not seem to help much. What is the next best step in the management of this patient? A. Aspirin B. Methotrexate C. Estrogen D. Gonadotropin-releasing hormone agonists E. Indomethacin

D. Growth of uterine fibroids is stimulated by estrogen. Gonadotropin-releasing hormone agonists inhibit endogenous estrogen production by suppressing the hypothalamic-pituitary-ovarian axis. They can result in a 40-60% reduction in uterine size. This treatment is commonly used for three to six months before a planned hysterectomy in an attempt to decrease the size of the uterus, which may lead to a technically easier surgery and decreased intraoperative blood loss. In patients who are not yet menopausal, once the gonadotropin-releasing hormone agonist therapy is discontinued, the fibroids may grow again with re-exposure to endogenous estrogen. Thus, this therapy may be most useful for women who are close to menopause, as this patient is at age 49. Aspirin and methotrexate are not effective treatments for fibroids. Methotrexate is used in ectopic pregnancies. Aspirin and indomethacin will likely not help, as she did not respond to NSAIDs.

A 37-year-old G3P3 woman presents for contraceptive counseling. She and her husband have decided that they no longer plan to have children and desire permanent sterilization. Her husband refuses to have a vasectomy. On exam, her BMI is 52; blood pressure is 140/80; and heart rate is 86. She has had three previous Cesarean deliveries. Which of the following options would be the be the best method of permanent sterilization? A. Laparoscopic tubal ligation B. Mini-laparotomy with tubal ligation C. Hysterectomy D. Hysteroscopic tubal occlusion (Essure) E. Endometrial ablation

D. Hysteroscopic tubal occlusion is the best option for this patient. Hysteroscopic tubal occlusion (Essure®) can be performed in the office and places coils into the fallopian tubes that cause scarring that blocks the tubes. Patients are required to use a back up method of contraception for three months following the procedure until a hysterosalpingogram is performed confirming complete occlusion of the tubes. While tubal ligation, either by laparoscopy or mini-laparotomy, are common and effective forms of permanent sterilization, for this patient with her BMI and previous surgeries, this would carry more surgical risks. Hysterectomy is not an indicated procedure for sterilization. Endometrial ablation, or thermal destruction of the endometrial tissue, is an effective treatment for menorrhagia but is not reliable for permanent sterilization.

A 35-year-old G0 presents with irregular menstrual periods occurring every six to twelve weeks with occasional inter-menstrual bleeding. Currently, she has been bleeding daily for the last four weeks. She reports that her periods have always been irregular, but have become more so with heavier flow and cramping in the last year. She is sexually active with one partner. On physical exam, she is morbidly obese with no abnormalities detected on pelvic exam. Which of the following is the most appropriate next step in the management of this patient? A. Luteinizing hormone level (LH) B. Follicle stimulating hormone level (FSH) C. Testosterone level D. Pelvic CT E. Endometrial biopsy

E Correct! Endometrial biopsy should be performed to rule out endometrial hyperplasia or carcinoma given the history of irregular bleeding, coupled with the increased risk of these diagnoses in morbidly obese patients. While an ultrasound may be helpful, a pelvic CT is not useful in the workup for potential endometrial neoplasia. LH and FSH levels would not aid in the diagnostic workup and testosterone levels would not be useful, unless signs of hirsutism or virilization are present.

An 18-year-old woman comes to the office due to vaginal spotting for the last two weeks. Her menstrual periods were regular until last month, occurring every 28-32 days. Menarche was at age 13. She started oral contraceptives three months ago. On pelvic examination, the uterus is normal in size, slightly tender with a mass palpable in the right adnexal region. No adnexal tenderness is noted. Which of the following tests is the most appropriate next step in the management of this patient? A. Endometrial biopsy B. Pelvic MRI C. Pelvic sonography D. Abdominal CT Scan E. Urine pregnancy test

E Correct! It is vitally important to rule out pregnancy in the evaluation of abnormal uterine bleeding. Sonography could be considered as a next step if the pregnancy test is negative in order to evaluate the adnexal finding. Abdominal CT or MRI would not be performed in this patient unless advanced adnexal pathology was found on pelvic sonography. Endometrial biopsy would rarely be indicated in a teen with abnormal bleeding, unless morbidly obese and anovulatory.

A 23-year-old G0 woman with last menstrual period 14 days ago presents to the office because she had unprotected intercourse the night before. She does not desire pregnancy at this time and is requesting contraception. She has no medical problems and is not taking any medications. In addition to offering her counseling and testing for sexually transmitted infections, which of the following is the most appropriate next step in the management of this patient? A. Observation for two weeks to establish if pregnancy occurred before initiating treatment B. Oral contraceptives now C. Oral contraceptives after her next normal menstrual period D. Emergency contraception and follow-up after next menstrual period E. Provide emergency contraception, then begin oral contraceptives immediately

E. Emergency contraceptive pills are not an abortifacient, and they have not been shown to cause any teratogenic effect if inadvertently administered during pregnancy. They are more effective the sooner they are taken after unprotected intercourse, and it is recommended that they be started within 72 hours, and no later than 120 hours. Plan B®, the levonorgestrel pills, can be taken in one or two doses and cause few side effects. Emergency contraceptive pills may be used anytime during a woman's cycle, but may impact the next cycle, which can be earlier or later with bleeding ranging from light, to normal, to heavy.

A 35-year-old G3P3 woman requests contraception. Her youngest child is seven years old. Her periods have been regular since she discontinued breastfeeding five years ago. Her past medical history includes depression that is controlled with antidepressants, and a history of deep venous thrombosis. She denies smoking or alcohol use. In the past, oral contraceptive pills have caused her to have severe gastrointestinal upset. What in her history makes her an ideal candidate for progestin-only pills? A. Depression B. Smoking history C. Severe nausea on combined oral contraceptives D. Lactation history E. Deep venous thrombosis

E. Ideal candidates for progestin-only pills include women who have contraindications to using combined oral contraceptives (estrogen and progestin containing). Contraindications to estrogen include a history of thromboembolic disease, women who are lactating, women over age 35 who smoke or women who develop severe nausea with combined oral contraceptive pills. Progestins should be used with caution in women with a history of depression.

A 31-year-old G0 woman has been diagnosed with uterine fibroids. An ultrasound confirmed the presence of two intramural fibroids measuring 5 x 6 cm and 2 x 3 cm that appear to be distorting the patient's uterine cavity. The patient has a two-year history of infertility. She has had a thorough infertility work up. No etiology for her infertility has been identified. Which of the following treatments is most appropriate for this patient? A. Hysteroscopy B. Uterine curettage C. Gonadotropin-releasing hormone agonist D. Uterine artery embolization E. Myomectomy

E. Myomectomy is warranted in younger patients whose fertility is compromised by the presence of fibroids that cause significant distortion of the uterine cavity. A myomectomy may be indicated in infertility patients when the fibroids are of sufficient size or location to be a probable cause of infertility and when no more likely explanation exists for the failure to conceive. Hysteroscopy is a procedure that involves placing a scope through the cervical os to assess the endometrial cavity. The patient has already been diagnosed with uterine fibroids that are distorting her cavity and she has already had a fluid contrast ultrasound, so it is unnecessary to perform hysteroscopy on this patient. Treatment with GnRH agonists can be useful to shrink fibroids in anticipation of surgery, or if menopause is expected soon. This patient desires future childbearing, therefore, its use would not be an appropriate option. Uterine artery embolization can be recommended for women who have completed child-bearing because of the unclear long-term effects on fertility.

A 24-year-old G1P1 woman comes to the office requesting contraception. Her past medical history is unremarkable, except for a family history of ovarian cancer. She denies alcohol, smoking and recreational drug use. She is in a monogamous relationship. She wants to decrease her risk of gynecological cancer. Of the following, what is the best method of contraception for this patient? A. Diaphragms B. Condoms C. Copper containing intrauterine device D. Progesterone containing intrauterine device E. Combined oral contraceptives

E. Oral contraceptives will decrease a woman's risk of developing ovarian and endometrial cancer. The first developed higher dose oral contraceptive pills have been linked to a slight increase in breast cancer, but not the most recent (current) lower dose pills. Women who use oral contraceptive pills have a slightly higher risk of developing cervical intraepithelial neoplasia, but their risk of developing PID, endometriosis, benign breast changes and ectopic pregnancy are reduced. Both hypertension and thromboembolic disorders can be a potential side effect from using oral contraceptive pills. Diaphragms, condoms and intrauterine devices will not lower her risk of ovarian cancer. The progesterone IUD may decrease a woman's risk for endometrial cancer but would not effect her risk for ovarian cancer, and have been associated with increased ovarian cysts.

A 35-year-old G3P3 woman comes to the office because she desires contraception. Her past medical history is significant for Wilson's disease, chronic hypertension and anemia secondary to menorrhagia. She is currently on no medications. Her vital signs reveal a blood pressure of 144/96. Which of the following contraceptives is the best option for this patient? A. Progestin-only pill B. Low dose combination contraceptive C. Continuous oral contraceptive D. Copper containing intrauterine device E. Levonorgestrel intrauterine device

E. The levonorgestrel intrauterine device has lower failure rates within the first year of use than does the copper containing intrauterine device. It causes more disruption in menstrual bleeding, especially during the first few months of use, although the overall volume of bleeding is decreased long-term and many women become amenorrheic. The levonorgestrel intrauterine device is protective against endometrial cancer due to release of progestin in the endometrial cavity. She is not a candidate for oral contraceptive pills because of her poorly controlled chronic hypertension. The progestin-only pills have a much higher failure rate than the progesterone intrauterine device. She is not a candidate for the copper-containing intrauterine device because of her history of Wilson's disease.

A 25-year-old G1 is at 18 weeks gestation. A 2 cm subserosal fibroid was noted on the anterior fundal wall of her uterus at the time of her obstetric ultrasound at 17 weeks gestation. Which of the following treatment options for the uterine fibroid is most appropriate? A. Obtain a follow up ultrasound every six weeks to follow growth of the fibroid B. Laparoscopy now to remove the fibroid C. Perform delivery by Cesarean section at term D. Perform delivery by Cesarean section at term with removal of the fibroid after delivery of the baby and placenta E. No further treatment is necessary

E. Uterine fibroids are the most common solid pelvic tumors in women. On postmortem examination, fibroids can be detected in as high as 80% of women. Most uterine fibroids are asymptomatic and do not require any treatment. Pregnant patients with fibroids usually are asymptomatic and do not have any complications related to the fibroids. Fibroids may grow or become symptomatic in pregnancy due to hemorrhagic changes associated with rapid growth, known as red or carneous degeneration. However, this is uncommon for smaller fibroids. Uncommonly, fibroids can be located below the fetus, in the lower uterine segment, or cervix, causing a soft tissue dystocia, necessitating delivery by Cesarean section. In this case, it is not indicated given the location of the fibroid. Myomectomy (removal of the fibroid) during pregnancy is contraindicated. Myomectomy at the time of Cesarean section should be avoided, if possible, secondary to the risk for increased blood loss. It is not necessary to follow the growth of fibroids during pregnancy, except for the rare cases when the fibroid is causing symptoms (primarily pain) or appear to be located in a position likely to cause dystocia.