womens health

If estrogen is contraindicated in a postmenopausal woman, which alternative medication can be used to treat significant hot flashes, especially if there is concurrent sleep disturbance?

Gabapentin

Administer injection every 3 months Increased risk of osteoporosis, use for maximum of two years Side effects include irregular periods and weight gain

Medroxyprogesterone Injection

You have been monitoring a 52-year-old perimenopausal woman's hot flashes. She has not had a hysterectomy. Her symptoms have been so mild that she does not require medication. However, for the past two months, her hot flashes have increased in frequency, duration and intensity. She is now asking for a medication. Which of the following is the most appropriate for medical management of her moderate to severe symptoms?

When symptoms become moderate to severe, estrogen therapy is recommended, either oral or transdermal. In women who have not had a hysterectomy, estrogen plus progestin is recommended to prevent endometrial hyperplasia.

most concerning signs for cervical cancer with a colopscopy

raised areas, sharp boarders, white and coarse areas (these are most concerning); if the area is red/yellow and peeling/rolling - this is most concerning for invasive CA

What is the most common cervical cancer

squamous cell; adenocarcinoma is the second most common

most common area for breast cancer to occur

upper outer quadrant

what group of women should not get a PAP smear

women who went under for a hysterectomy

defined as function-altering pain during menstrual flow which necessitates medical attention, namely for pain control.

dysmennorhea

A 16-year-old girl is seen in clinic due to a concern for a breast mass that she notes has been present for 3 months. The size of the mass has not changed over the previous 3-months. She is otherwise healthy and is not on any medications. On exam you note a 2 cm diameter mass on the right outer quadrant of her right breast that is rubbery, mobile, and not tender. Which of the following is the most likely diagnosis?

Fibroadenoma The patient most likely has a fibroadenoma which is the most common breast mass in adolescents and young adults. The peak incidence is between 25 and 40 years and decreases after age 40. Fibroadenomas are characterized by a painless, firm, solitary, mobile, breast mass. Fibroadenomas are partially hormone-dependent and may enlarge in pregnancy. They often involute at menopause. The lesions are not fixed to the surrounding parenchyma and slip under the palpating hand; this has led to fibroadenomas being referred to as a breast "mouse." Because there is a very small risk for malignancy, these patients should undergo monitoring for changes in size of the mass, have an ultrasound, or fine needle aspiration. Cystosarcoma phylloides (A) can occur in adolescents and can mimic a fibroadenoma. However, the tumor often grows rapidly and can become relatively large

initial lab for abnormal uterine bleeding

always rule out pregnancy with b-HCG!! Enometrial biopsy is recommended in perimenopausaul women over 45 with abnormal uterine bleeding, women younger than 45 with persistent abnormal bleeding, a history of unopposed estrogen, or no response to treatment.

A 24-year-old woman presents for follow-up after an abnormal Pap smear. Colposcopy is performed and reveals a white, sharply demarcated area on the cervix after application of acetic acid. What is the most likely diagnosis?

- cervical dysplasia: seen as a white, sharply demarcated lesion of the cervix after acetic acid is applied during a colposcopy - carcinoma in situ: appears as pink or red well-circumcised punctate lesions - invasive carcinoma: disarray of blood vessels; very disorganized - CIN 1: this is low grade; has mild cellular changes; lower 1/3 of epitheliam - CIN 2: this is high grade; moderate changes; basal 2/3 of epitheliam - CIN 3: this is high grade; severe changes of epitheliam; more than 2/3 of epithelium and full thickness lesions

CI to ethinyl estradiol

-Thromboembolic d/o -known/suspected breast CA -Smokers >35 y.o. -Uncontrolled HTN -Migraine w/aura -SLE w/antiphospholipid ab's (also shouldn't get Progesterone - Copper IUD is best choice)

describe each emergency contraception 1. plan b (levonorgestrel) 2. Ella (Ulipristal Acetate) 3. Copper IUD

1. Plan B (levonorgestrel) - Progesterone surge blocks LH surge to inhibit ovulation à doesn't do anything if ovulation has already occurred - can take w/in 72 hours of UPI; reduces risk of pregnancy by ~75%; not harmful to embryo if conception has occurred 2. Ella (Ulipristal Acetate) - Anti-progesterone agent à inhibits ovulation and makes the endometrium inhospitable to implantation - take w/in 5 days of UPI - More effective than plan B (98%) - Theoretical risk to pregnancy if already implanted (but would have to take >1 pill to cause harm) 3. Copper IUD - Can be used as EC if placed within 5 days of UPI à most effective form of EC

Describe each type of abortion 1. threatened 2. inevitable 3. incomplete 4. complete 5. missed

1. Threatened abortion: vaginal bleeding with closed internal os; cerival os is closed; no passage of fetal tissue. presents with bleeding, with or without pain, but no tissue passage and the cervical os is closed. 2. Inevitable: vaginal bleeding with open os; cervical os is open; no passage of fetal tissue. usually presents with painful cramping. There is bleeding but no passage of particles of conception and the cervical os is open. 3. Incomplete: partial passage of products of conception (POC); cervical os is open; incomplete passage of fetal tissue. vaginal bleeding or pain or both are present, the cervix is dilated, and products of conception are found within the cervical canal on examination 4. Complete: complete passage of POC; cervical os is closed; complete passage of fetal tissue 5. Missed: fetal death < 20 weeks without POC passage; cervical os is closed; no passage of fetal tissue

describe each of the following classes of contraceptions 1. Progesterin only pills 2. levonorgestrel intrauterine device and copper intrauterine device 3. etonogestrol implant (LARC; long) 4. oral contraceptives 5. condoms 6. vaginal ring

1. progesterin only pills: safe in women that are breastfeeding; not effective in pregnancy prevention in other cases 2. levonorgestrel intrauterine device and copper intrauterine device: good for patients who are on antiepileptic drugs induce hepatic metabolism of estrogen (carbamazepine, oxcarbazepine, phenobarbital, phenytoin, and topiramate). This can potentially lead to failure of any contraceptive that contains estrogen. can be used for either 3 years or 5 years depending on if it is the Skyla® or the Mirena® device. The copper intrauterine device does not contain hormones and provides effective contraception for up to 10 years 3. etonogestrol implant: Long-acting reversible contraception (LARC) such as the etonogestrol implant and intrauterine device (IUD) are first-line recommendations for adolescents requesting to initiate birth control. The etonogestrol implant is a single rod implanted in the arm that lasts for three years. It is an effective and convenient option for adolescents requesting long-term uninterrupted contraception. Pelvic exam is unnecessary, pregnancy protection begins 24 hours after insertion and fertility returns shortly after removal. 4. oral contraceptives: have a failure rate of 9%, often due to not taking the medication consistently. Adolescents may not be consistent with taking medication daily, and assessment of the patient's ability to take medication at the same time each day should be done prior to recommending this form of contraception 5. condoms: should be recommended for everyone as a means to prevent sexually transmitted infections (STIs). Failure rate for condoms in preventing pregnancy is 18%, so counseling adolescents to use condoms as a secondary method along with LARC will give best results in preventing both pregnancy and STIs. 6. vaginal ring: requires the patient to be comfortable with inserting a device inside the vagina. Young women who use tampons may be better candidates for this type of contraception. Failure rate for the vaginal ring is 9%.

A 28-year-old woman presents with difficult menses. She reports significant midline pelvic pain during the first two days of her regular menstrual cycles. The pain is so bad that she frequently misses work. Fortunately, her pain is self-limited, as the rest of her cycle is relatively comfortable. Which of the following is the most likely diagnosis?

A very common gynecologic complaint is painful menstruation, called dysmenorrhea. Most women have pain during menses, but dysmenorrhea is defined as pain that alters normal activity or requires pain medications to control. It is postulated that increased prostaglandins and leukotrienes are causative. There are three classes of dysmenorrhea: primary, which has no organic cause; secondary, which is associated with conditions such as endometriosis, pelvic inflammatory disease and intrauterine devices; and membranous, which is due to the rare passage of an endometrial cast through a constricted cervix. The typical pain questions are an important part of the history. Physical examination is usually unrevealing in primary, but not secondary, dysmenorrhea.

approach and treatments for each abnormal uterine bleeding cause -anovulatory -polymenorrhea -irregular bleeding - intermenstrual bleeding - heavy menstrual bleeding

Anovulatory pattern: assess for thyroid dysfunction, hyperprolactinemia, with TSH and PRL. asses for hypothalamic dysfunction with stress, under eating, chronic disease. Evaluate for PCOS. consider OCPs, levonorgestrel IUD, or every 3 months progesterone Polymenorrhea: trial OCPs Irregular bleeding: due to prolonged folliclar phase; trial OCPs Intermenstrual bleeding: rule out cervical pathology with pelvic exam and PAP. remove IUD if present. Trial OCPs Heavy menstrual bleeding: rule out bleeding disorder. Transvaginal ultrasound for fibroids. If above normal, trial OCPs and NSAIDs or levonorgestrel IUD

anovulatory vs ovulatory AUB

Anovulatory: Estrogen, progesterone endometrial hyperplasia/bleeding Unpredictable bleeding Ovulatory: Predictable bleeding During an anovulatory cycle, the corpus luteum does not form. Thus, the normal cyclical secretion of progesterone does not occur, and estrogen stimulates the endometrium unopposed. Without progesterone, the endometrium continues to proliferate, eventually outgrowing its blood supply; it then sloughs incompletely and bleeds irregularly and sometimes profusely or for a long time. When this abnormal process occurs repeatedly, the endometrium can become hyperplastic, sometimes with atypical or cancerous cells. In ovulatory abnormal uterine bleeding, progesterone secretion is prolonged; irregular shedding of the endometrium results, probably because estrogen levels remain low, near the threshold for bleeding (as occurs during menses). In obese women, ovulatory AUB can occur if estrogen levels are high, resulting in amenorrhea alternating with irregular or prolonged bleeding.

Pathophysiology of menopause

As the female body ages, the total number of follicles, which contain ova, decreases. As such, the ovaries become less sensitive to two pituitary hormones, luteinizing hormone and follicle-stimulating hormone. This leads to the inability to produce estrogens (namely estradiol) and progesterone, which results in an inability to regenerate and maintain the uterine epithelium. The overall effect is eventual amenorrhea, declining estradiol and progesterone levels and increased follicle-stimulating hormone levels (which is due to the loss of estradiol's negative feedback on the pituitary gland). The vasomotor instability symptoms of "hot flashes" are felt to be due to this abrupt decline in circulating estradiol. These symptoms are characterized by a chest, neck and facial flushing/warmth which occurs intermittently and mainly in the later hours of the day, which can lead to significant fatigue due to sleep interruption. Labs will show decreased estrogen and elevated follicle-stimulating hormone levels

A 60-year-old postmenopausal woman presents with painless vaginal bleeding. Her last papanicolaou smear, performed two years ago, was normal. Her pelvic exam in the office reveals a small amount of blood at the cervical os. Which of the following is the most appropriate diagnostic test?

Endometrial biopsy is the initial test for a patient with painless postmenopausal bleeding. Although atrophic vaginitis is the most common cause of postmenopausal bleeding, it is important to rule out endometrial cancer. Endometrial biopsy has few complications, is low cost and has a high sensitivity. Alternatively, a transvaginal ultrasound can be done to assess the thickness of the endometrial strip (< 3-4 mm is normal for a post-menopausal woman). Transvaginal ultrasound can be used to determine endometrial thickness as well as assess for any possible structural causes of bleeding (e.g., polyp). Remember, suspect in postmenopausal women who present with abnormal vaginal bleeding. Most common type is adennocarcinoma. Treatment is with total abdominal hysterectomy and bilateral salpingo-oophorectomy(TAH-BSO)

A 34-year-old woman presents to her outpatient primary care office complaining of feeling multiple breast masses during her last three monthly self breast exams. She states the masses are circular and mildly tender with some firm, rope-like areas in the surrounding area. In general, she has noticed increased breast tenderness and heaviness around the time of her menstrual cycle which typically resolves after her menses. She denies fever, breast erythema, nipple retraction or nipple discharge. What is the most likely cause of her breast changes?

Fibrocystic breast disorder Fibrocystic breast disease commonly presents in women age 30-50 years as multiple, small, circular, mobile, tender cystic masses. After the cysts rupture, scar tissue forms resulting in firm breasts with rope-like structures that patients can often palpate during self breast exams. Common symptoms include breast pain, breast masses or increased breast firmness. These symptoms are often worse leading up to menses and then resolve after menses conclude. There is no association with increased risk of developing breast cancer. Cysts are able to be aspirated revealing benign straw-colored fluid. Aspiration can be both diagnostic and therapeutic. Use of a supportive bra is often the only treatment needed. Most commonly caused by fluctuating estrogen levels during menstrual cycles

A 34-year-old woman presents to your office with complaints of mood swings, difficulty sleeping, headache, and fatigue that seem to be related to her menstrual cycle. She has tried lifestyle modifications, including regular exercise and healthy diet, without relief. Which of the following is the most appropriate therapy?

Fluoxetine Premenstrual syndrome is a combination of physical and behavioral symptoms that occur monthly in the luteal phase of a woman's menstrual cycle. Initial intervention is with lifestyle modifications, such as regular exercise, relaxation techniques, and dietary changes, including smaller, more frequent meals and reducing consumption of caffeine, salt, alcohol and simple carbohydrates. In patients whose symptoms are not resolved with lifestyle modifications, pharmacologic therapy with selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine, sertraline, paroxetine, or citalopram is first-line treatment. Patients who do not respond to one SSRI may respond to a different agent, so a trial of a second SSRI should occur prior to moving to second-line treatment options. SSRIs may be taken daily or during the luteal phase of the menstrual cycle only.Second-line treatment for premenstrual syndrome includes gonadotropin-releasing hormone agonists such as leuprolide (C) and oral contraceptives (D) Complaining of sleep disturbances, decreased focus, emotional lability, breast tenderness, or HA, that resolves after menstruation begins

what should surgery of breast cancer also involve

Surgery should involve a sentinel lymph node biopsy Lymph node evaluation is also important for prognostic and treatment purposes. Sentinel lymph node evaluation is now the standard of care instead of axillary node dissection and is often done along with breast conservation therapy. This provides information on the axillary lymph node status needed to make important decisions regarding adjuvant chemotherapy.

A 28-year old woman presents with several painful ulcers she has developed in the vaginal area. Examination reveals multiple 0.5 cm to 1.5 cm oval ulcers with sharply defined borders and a yellowish-white membrane. She denies recent sexual activity. Except for recurring aphthous ulcers of her mouth, her past history is unremarkable. At this time, which of the following is the most likely diagnosis?

The original description of Behçet's syndrome included recurring genital and oral ulcerations and relapsing uveitis. The genital and oral ulcers are classically painful with a necrotic center and surrounding red rim. Behcet's syndrome is more common in Japan, Korea, and the Eastern Mediterranean area, and affects primarily young adults. The cause is unknown. Two-thirds of patients will develop ocular involvement that may progress to blindness. Patients may develop arthritis, vasculitis, intestinal manifestations, or neurologic manifestations. This disease is diagnosed based on physical exam and clinical symptoms. Treatment of Behçet syndrome must be tailored to each patient's clinical manifestations. Corticosteroids are considered palliative; they are useful in controlling acute manifestations.

A 30-year-old woman misses work and presents to the Emergency Department with severe pelvic pain rated at 6/10. She states it began yesterday with the onset of menstruation. She has regular cycles with normal blood flow amount, but has not had this pain before. She denies spine, urologic and rectal symptoms. Vital signs are normal, and physical examination as well as pelvic ultrasound is unremarkable. Serum beta-hCG is negative. Other than referral to a gynecologist for further evaluation, which of the following is the most appropriate initial treatment?

This patient's working diagnosis is most concordant with primary dysmenorrhea, in which there is significant pain associated with the first few days of menses which alters normal activity or requires pain medication to control. Although secondary causes such as endometriosis and pelvic inflammatory disease are the most common misdiagnosis of primary dysmenorrhea, her stable presentation in this specialized setting, in conjunction with a normal initial diagnostic test, favors symptomatic control and follow-up evaluation. To treat dysmenorrhea, non-steroidal antiinflammatory medications (NSAIDs) and acetaminophen are helpful. Opioid analgesics (A) are considered second line if NSAIDs and acetaminophen fail to relieve the pain. Consider parenteral pain control if oral medications fail. Abdominopelvic heat is also beneficial. Contraceptive pills (B) are reserved for women who do not respond to pain medications.

A 26-year-old sexually active woman presents to the clinic with several days of vulvovaginal discomfort and pruritus. A pelvic exam shows copious frothy green vaginal discharge, inflamed vaginal walls, and a cervix with punctate hemorrhages. This physical exam is most consistent with which of the following causes of vaginitis?

Trichomonas vaginalis is a common infectious cause of vulvovaginal discomfort in women that will likely present with the above symptoms. Though Trichomonas vaginalis is often harbored asymptomatically for periods of 5 days to 4 weeks, patients who are diagnosed while symptomatic typically present with vulvovaginal pruritus, dyspareunia, dysuria, or pelvic discomfort. A physical exam will show a classic copious, yellow or green, frothy vaginal discharge. Examining the cervix may show punctate hemorrhages, referred to as a "strawberry cervix." The diagnostic test of choice is a wet mount of the vaginal discharge, which shows mobile trichomonads. The first line treatment for Trichomonas vaginalis is oral metronidazole.

A 22-year-old woman presents to clinic with vaginal discomfort for three days. Physical examination shows a frothy, green malodorous discharge with a strawberry cervix. No cervical motion tenderness observed. Which of the following is the most likely diagnosis?

Trichomonas vaginalis: Labs will show pH > 5, flagellated, motile, pear shaped Clinical manifestations in women include frothy, green-yellow malodorous vaginal discharge with a strawberry cervix. The pH of the discharge is typically between 5 and 6. Other symptoms include vulvar pruritus and erythema. Infected men may have symptoms of urethritis, epididymitis, or prostatitis. Vaginal or urine specimens should be obtained for highly sensitive and specific nucleic acid amplification testing (NAAT) or APTIMA Trichomonas vaginalis assay. Rapid testing for trichomoniasis is also available with high sensitivity and specificity. Motile, flagellated trichomonads may be evident on a wet-prep; however, this technique has low sensitivity so confirmatory testing is necessary, if available. First-line treatment is metronidazole 2 grams orally in a single dose or tinidazole 2 g orally in a single dose. Abstinence of alcohol is recommended with nitroimidazoles (e.g. metronidazole) due to the combination causing a disulfiram-like reaction. Individuals should abstain from sexual activity until therapy has been completed.

A 46-year-old woman presents with heavy menstrual bleeding for the past three menstrual cycles. Her bleeding is heavier than normal and her menstrual cycle lasts longer than what has been typical for her. She denies any weight changes or cold intolerance. Labs demonstrate a mild microcytic anemia, but are otherwise within normal limits. A pelvic ultrasound is ordered and shows no abnormalities. An endometrial biopsy showed secretory endometrium and is negative for any malignancy or other abnormalities. What is the most likely diagnosis?

abnormal uterine bleeding Abnormal uterine bleeding is a diagnosis of exclusion once all other causes of abnormal uterine bleeding are excluded. It is most common at beginning stages and end stages of reproductive age being most common in perimenopausal women. In adolescents, abnormal uterine bleeding is frequently caused by anovulatory cycles. In these patients, treatment is typically achieved with oral contraceptives. In premenopausal women, endometrial cancer should be considered before a diagnosis of AUB is made. If hormones cannot control the symptoms, surgical intervention should be considered. A dilation and curettage (D&C) procedure may stop the bleeding but could offer only temporary relief. Hormone-releasing intrauterine devices (IUD) can be used or an endometrial ablation is also a treatment option. Hysterectomy is often used as a last resort if all other treatment options fail and fertility is not a concern. Anovulatory cycles (B) are more common in adolescent girls. Hypothyroidism (C) should have been an important part of the initial work-up. The patient would also be complaining of other symptoms such as fatigue, hair loss, cold intolerance, and weight gain. A leiomyoma (D) should have been found on ultrasound. Anovulatory: Estrogen, progesterone endometrial hyperplasia/bleeding Unpredictable bleeding Ovulatory: Predictable bleeding

The presence of which of the following best differentiates premenstrual dysphoric disorder from premenstrual syndrome?

anger and irritability Etiological theories include psychological disturbance, alterations in estrogen and progesterone balance as well as serotonin function, hypoglycemia and hyperprolactinemia. Symptoms include headache, insomnia, fatigue, low energy, bloating, breast tenderness, abdominopelvic pain, depression, anxiety, dysphoria, mood lability, appetite changes, crying episodes, poor coordination and poor concentration. Symptoms typically interfere with the woman's daily life. According to the American Psychiatric Association DSM-5, mood swings, anger, irritability, sense of hopelessness or tension, and anxiety or feeling on edge associated with severe premenstrual syndrome symptoms is defined as premenstrual dysphoric disorder.

A 54-year-old woman, whose last menstrual period was more than 2 years ago, complains of vaginal dryness and irritation. She denies any recent infection or sexual activity. She is afebrile with normal vital signs. Visual inspection of the vaginal canal reveals pale, dry and shiny epithelium without frank discharge or superficial lesions. Which of the following conditions is the most likely diagnosis?

atrophic vaginitis Menopause can be defined as amenorrhea for greater than 12 months. Atrophic vaginitis, also referred to as urogenital atrophy, is a major cause of vaginal dryness in postmenopausal women, occurring in about 40% of this population. The generalized loss of estrogens, which is the hallmark hormone alteration associated with menopause, causes thinning of the urogenital epithelium. Vaginal dryness ensues, as well as burning, pruritus, discharge, bleeding and possibly dyspareunia (painful sexual intercourse subsequent to decreased vaginal lubrication). Physical examination of the vaginal canal reveals pale, dry and shiny epithelium without frank discharge or superficial lesions. Diagnosis is mainly clinical, however, it is important to consider infection and cancer in evaluating postmenopausal women with these symptoms. Treatment is lubricants, moisturizers, topical estrogen (2nd line)

A 13-year-old woman presents to the office with her mother concerned that she has not had a menstrual cycle. She is an avid runner, logging 30 miles per week. On exam she exhibits no breast development or axillary or genital hair. Her mother was 15 when she started her menstrual cycle. What is your next step?

begin workup Laboratory testing includes FSH, LH, TSH, and prolactin. If FSH is normal or reduced, this may mean the patient has chronic anovulation, functional hypothalamic amenorrhea, or polycystic ovarian syndrome (PCOS). Increased FSH with breast development is likely secondary to ovarian failure. Increased FSH without secondary sexual characteristics may be caused by congenital agenesis of the ovaries. In the patient without a uterus, serum testosterone level and karyotype should be determined. In the presence of a uterus and normal secondary sexual characteristics, serum TSH levels should be evaluated. Inducing a cycle with medroxyprogesterone (C) is a strategy used for the treatment of secondary amenorrhea. Not initiating a work up (D) is inappropriate as primary amenorrhea is defined by age 13 if no secondary sexual characteristics have developed. Avid exercise (B) can be a cause of both primary and secondary amenorrhea, by causing functional hypothalamic amenorrhea, however, this is only diagnosed after ruling out all other causes.

compare candidiasis, trichomoniasis, bacterial vaginosis

candidiasis: thick, curdy, white dischage; ph less than 4.5, negative whiff test, pseudohyphae with WBC. tx miconazole/fluconazole trichomoniasis: green/yellow discharge, pH greater than 5, positive whiff test, motile flagellinated protozoan with WBC bacterial vaginosis: gray/white discharge, greater than 4.5, positive whiff test, clue cells with few WBCs. Tx Metronidazole. this is NOT sexually transmitted; it can be caused by douching and menstruation

Which of the following represents a common risk factor for the development of a rectocele?

obesity A rectocele is the anterior protrusion of the rectum secondary to a posterior vaginal wall defect. Obesity is a common risk factor for the development of a rectocele. The most common symptom of a rectocele is the need to manually splint the vagina, perineum or rectum in order to have a bowel movement. Other common symptoms include a sensation that something is "falling out" of the rectum which may be worsening with increased intraabdominal pressure and relieved by lying down, sexual dysfunction, pelvic pressure and fecal incontinence. Additional risk factors for development of a rectocele include vaginal childbirth, pelvic surgery, collagen disorders and advanced age. Chronic constipation is associated with rectocele development because it is thought to increase the intraabdominal pressure and stretch the pudendal nerve. The diagnosis can typically be made on physical exam by palpation of a posterior vaginal bulge with straining. Imaging is not usually required for diagnosis. Management can be divided into nonsurgical and surgical options. The most effective nonsurgical option is the use of a pessary. Medications to address constipation should also be used if this is a clinical feature of the patient's disorder. The most common surgical management strategy is a posterior colporrhaphy which has an anatomic cure rate of up to 96%

A 14-year-old woman presents to clinic with some frustration over never having a menstrual period. She is short in stature and has Tanner stage 2 breast development. As you begin a gynecological exam, you realize that you cannot pass a speculum into the vagina. Which of the following is the most likely diagnosis?

primary amennorhea defined as absence of menarche by age 15 in a woman with normal growth and secondary sexual development, or age 13 in a woman without normal growth and secondary sexual development. Secondary amenorrhea, in women who have previously menstruated, is defined as absence of menses for more than 3 cycles or 6 months. The most common cause of primary amenorrhea is caused by gonadal dysgenesis due to a chromosome abnormality, while other causes include hypothalamic disease, pituitary disease, abnormal hymen (as in the patient above) or vagina development or uterine agenesis. The patient may have a family history significant for sexual development abnormalities. The most common cause of secondary amenorrhea is pregnancy, followed by abnormalities of the hypothalamic-pituitary-ovary axis, thyroid disease, and ovarian or uterine disorders.

A 32-year-old woman presents to your office for a physical exam including a Papanicolaou test (Pap smear). Lab results reveal negative cytology and positive human papillomavirus (HPV). Which of the following is the most appropriate next step in management?

repeat pap testing and HPV in one year If the Pap smear test is negative and HPV test is positive, providers may either repeat Pap smear and HPV co-testing in one year or order HPV DNA typing to detect HPV subtypes 16 or 18. These subtypes are associated with the highest risk of cervical cancer and are important to identify early, allowing for prompt intervention. Patients with significantly abnormal cytology require further evaluation with repeat cytology and HPV testing or colposcopy (B). Negative cytology would not require immediate referral for colposcopy. For women aged 30 years and older, the recommendation for a Pap smear with negative cytology and negative HPV is repeat co-testing in five years (C).

tx for er POSITIVE BREAST CANCER

tamoxifen or aromatase inhibitors like letrozole or anastrozole 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.

Patient will be a woman with a history of human papillomavirus (types 16, 18, and 33) Complaining of a vulvar lesion and pruritus PE will show unifocal vulvar ulcer, plaque, or mass, predominantly on the labia majora Most common type is squamous cell carcinoma (SCC)

vulvar cancer