Women's Health
A diagnosis of osteoporosis can be made when:
bone mineral density is 2.5 standard deviations below the mean Osteoporosis can be diagnosed with a bone mineral density test (BMD). The technique used is a dual energy x-ray absorptiometry (DXA). This is the most common clinical tool used to diagnose osteoporosis. Osteoporosis can also be diagnosed when there is a fragility fracture. This can be identified on x-ray. In an absence of trauma, a fragility fracture may indicate osteoporosis, multiple myeloma or other diseases. BMD that is 2.5 or more standard deviations below the young adult mean (or T-score of -2.5 or less) constitutes a diagnosis of osteoporosis.
The first step in evaluating a breast lump is:
history and physical exam Although most patients will need further work-up of a breast mass, historical information is critically important in directing the health care provider to the next step. Historical information that should be ascertained is the location of the lump, how and when it was first noticed, whether there is nipple discharge, and whether it changes in size related to menses. Other historical information is the patient's personal and family history of breast cancer and/or history of breast biopsies.
A young female has breast buds bilaterally. This represents Tanner Stage:
2 Tanner Stage II is characterized by the formation and presence of breast buds, small areas of surrounding glandular tissue, and widening of the areola.
A patient who is scheduled for pelvic exam with PAP smear should be advised to avoid douching, sexual intercourse, and tampon use before her exam. For how long should she be advised to avoid these activities for optimal evaluation?
48 hours The general recommendation is to avoid these activities and any vaginal medication for 48 hours prior to PAP smear. Douching and tampon use can remove superficial cells which are the ones collected and used as representative samples on PAP smear. Sexual intercourse should be avoided because there can be specimen contamination by the male partner and semen can make the smear thick and difficult to read. With vaginal medications or creams, either can serve as a barrier to epithelial cell sampling.
A female patient is 35 years old. She has never had an abnormal PAP smear and has had regular screening since age 18. If she has a normal PAP smear with HPV testing today, when should she have the next cervical cancer screening?
5 years American College of Obstetricians and Gynecologists recommends screening for women over age 30 years no more frequently than every 5 years if both tests are negative and adequate screening has taken place. If she had been screened with PAP only, the recommendation for screening would be in 3 years. US Preventive Services Task Force recommends screening this patient in 5 years. Human papilloma virus (HPV) testing in combination with cervical cytology has been shown to be more sensitive than cytology alone. However, HPV alone is not recommended as a lone screening modality. Finally, HPV testing is more specific in women over age 30 years.
The frequency for cervical screening depends on the patient and her age. What is the longest recommended time interval between cervical screens for patients who are 65 years-old or younger?
5 years Cervical screening for women aged 21-29 years should take place every 3 years with cytology only. Women aged > 30 years should be screened every 5 years with cytology and HPV. Generally, women who have been adequately screened do not need screening beyond age 65 years.
The frequency for cervical screening depends on the patient and her age. What is the longest recommended time interval between cervical screens for patients who are 21-65 years of age?
5 years Women ages 21-65 who have a cervix should be screened for cervical cancer. Screening intervals every 3 years should take place for women of average risk who are aged 21-29 years. Women aged 30-65 of average risk should take place every 3 years if only cytology is performed; or every 5 years if cytology plus HPV screening takes place. Women who are at increased risk of cervical cancer should be screened more frequently. Increased risk includes females who have had cervical cancer, those who are immunocompromised, or have infection with HIV.
In collection of a specimen for a PAP smear, how is the endocervical specimen collected?
After the ectocervical specimen with a brush Ectocervical specimens are collected first to minimize any bleeding that can occur from endocervix when it is sampled. The brush is considered a superior tool for collection of endocervical specimens because it produces the highest yield of endocervical cells, and thus, is a good reflection of the health of the cervix. Alternatively, a cervical broom can be used to collect cells. It collects endocervical cells and ectocervical cells simultaneously. It is rotated for 5 turns before the samples are placed on the slide. This may be used in pregnant women.
The primary risk factor for development of breast cancer in women of average risk is:
Age Age is the most important risk factor for developing breast cancer in women of average risk. Breast cancer is more common in older women and has a higher mortality rate when discovered. Nearly 85% of breast cancer occurs in women who are 50 years of age or older. Exposure to estrogen and genetic factors are important risk factors but do not contribute to development of breast cancer as greatly as age does in women of average risk. Hence, the reason for diligent annual screening in women who are 50 years of age and older.
The clinical syndrome resulting from replacement of normal vaginal flora with anaerobic bacteria is:
Bacterial vaginosis Bacterial vaginosis (BV), results when normal vaginal flora such as Lactobacillus sp. are replaced with anaerobic bacteria like Prevotella, Mobiluncus and Gardnerella. This is usually, but not always associated with sexual activity. Women who have never been sexually active are less affected.
A young female adult presents with vaginal discharge and itching. Besides trichomoniasis and yeast, what else should be included in the differential?
Bacterial vaginosis The most common cause of vaginal discharge in women of child-bearing age is bacterial vaginosis. The most common presentation is a complaint of vaginal discharge with a fishy odor, most noticeable after sexual intercourse. The vaginal discharge is cream colored and thin. Chlamydia produces a discharge but it is not reported as pruritic. Herpes does not produce a discharge. Syphilis produces a lesion.
A 4 year-old female is brought in to the clinic by her mother who reports that she is constantly scratching "her private part". The patient states that it itches. On exam, the vagina is red and irritated. How should the NP proceed?
Collect a vaginal swab of the external vagina for microscopic evaluation This child has a vaginitis. There are many diagnoses in the differential including pinworms, yeast, contact irritants from soap or bubble bath, etc. Since the diagnosis is not clear, some evaluation must occur in order to determine the diagnosis so proper treatment can be initiated. Since the description of the problem does not indicate what the diagnosis is, it is inappropriate to treat with a cortisone cream or topical antifungal.
A 16 year-old female is diagnosed with primary dysmenorrhea. She has taken over the counter ibuprofen in 800 mg increments every 8 hours during menses for the past 3 months with minimal relief of symptoms. What intervention will provide greatest relief of dysmenorrhea symptoms?
Combined oral contraceptives NSAIDs and hormonal contraceptives represent the mainstay of pharmacologic treatment for dysmenorrhea. NSAIDs produce an 80-86% response rate when used for dysmenorrhea. The general recommendation is that when one agent (NSAIDs or hormonal contraceptives) does not produce relief of symptoms, the other agent should be tried. Hence, the best choice is oral contraceptives. Both agents should be considered for women who are symptomatic with one agent only.
"Hot flashes" that occur during menopause are thought to be related to:
fluctuating estrogen levels Low estrogen levels alone do not produce hot flashes. Female first graders are known to have low estrogen levels but do not have hot flashes. The fluctuation in estrogen levels produces vasomotor symptoms referred to as "hot flashes".
A 17 year-old presents with complaints of dysmenorrhea. What finding below suggests that this is secondary dysmenorrhea?
Dysmenorrhea is not limited to menses Primary dysmenorrhea has been attributed to prolonged uterine contractions that cause ischemia to the myometrium. Some females with secondary dysmenorrhea may have a normal pelvic exam, but they tend to have an enlarged irregularly shaped uterus or tender uterus on exam. Most secondary dysmenorrhea is due to endometriosis. On physical exam, patients with secondary dysmenorrhea can have displacement of the cervix, cervical stenosis, adnexal enlargement, or nodular and/or tender uterosacral ligaments.
An adolescent female has had normal menses for almost 2 years. She has not had menses in 3 months. She is diagnosed with polycystic ovarian syndrome (PCOS). What else is a common finding?
Elevated insulin levels PCOS is a systemic disease characterized by multiple cysts about the ovaries. Overweight states are common but not obesity. Normal weight is also seen in these patients. This patient will not have a positive pregnancy test unless she is pregnant. There is no indication from the information that this is the case. She likely has had not had menses because of anovulation. There is no associated blood pressure elevation, though this should be watched closely. Elevated insulin levels are usual findings in patients who have PCOS.
A patient who takes oral contraceptive pills is at increased risk of:
gallbladder disease One of the major components of gallstones is estrogen. A patient with underlying gallbladder disease should not receive oral contraceptives (OC) since they will increase estrogen exposure and theoretically, formation of gallstones. Depression, hypothyroidism and varicose veins do not increase the risk of gallbladder disease.
Three of the following interventions are appropriately used to prevent osteoporosis after menopause. Which one is not?
Estrogen replacement therapy Prevention of osteoporosis may be optimized by elimination of risk factors and engaging in interventions that maximize bone density. Good nutrition from infancy throughout adulthood is a major component of good bone health. Others include engaging in weight-bearing exercises, adequate intake of calcium and vitamin D, smoking cessation, limiting alcohol consumption to moderate amounts, and avoidance when possible of medications that may decrease bone density (corticosteroids, anticonvulsants). Osteoporosis occurs at accelerated rates in women who are post-menopausal. The lack of estrogen can produce rapid bone loss due to bone resorption. Estrogen replacement is not used to prevent or treat osteoporosis.
Which form of birth control presents the highest risk to a female patient if she is exposed to a sexually transmitted disease (STD)?
IUD Exposure to an STD always increases the likelihood of contracting an STD. However, the patient is at very high risk of developing pelvic inflammatory disease when there is an implanted foreign body. An example of this is an intrauterine device (IUD). The risk is also increased with a diaphragm, but, because it is not implanted for long periods at a time, the risk is less than with an IUD.
A female should be told to take her OCP at bedtime if she experiences:
Nausea A common side effect of oral contraceptives is nausea. This is probably related to increased hormone levels (estrogen and progesterone). An easy way to combat nausea is to take the pill before going to sleep at night. Most patients will sleep through the symptom of nausea.
A 50 year-old female believes that she is "menopausal". She complains of "hot flashes" and has not had menses in 12 months. Which of the following test results may be helpful for confirmation of menopause?
Increased follicle stimulating hormone Follicle stimulating hormone (FSH) begins to rise during menopausal transition. This stage of menopause begins with variation in menstrual cycle length and ends 12 months after the final menses. If the patient is older than 45 years and menstrual cycle dysfunction has been ruled out, menopause should be considered. Possibly the best approach to diagnosing menopause is to ask and observe clinical manifestations. An elevated FSH is not necessary to make a diagnosis of menopause but is commonly done in clinical practice. Diagnosis entails a review of her symptoms. Specifically, changes in bleeding patterns, hot flashes, sleep disturbances, and genitourinary symptoms are characteristic of menopause.
A woman who is 65 years old presents to your clinic with a breast lump. She has had only normal annual mammograms and her last one was 6 months ago. What is true about this lump?
It is probably a benign lesion The vast majority of breast lumps, even in older women are benign. However, because of the risk of breast cancer in any female patient, especially an older patient, she must be evaluated for breast cancer. Fibroadenomas are common in younger women. Cysts are common throughout the lifespan. Sometimes women identify a lump, but, instead it is the lumpiness of the breast tissue and not a distinct lump.
A 54 year-old female presents with a small to moderate amount of vaginal bleeding of recent onset. She has been postmenopausal for approximately 2 years. What diagnosis is least likely?
Ovarian cancer Ovarian cancer may present as an adnexal mass, pelvic or abdominal symptoms and a variety of others. Postmenopausal bleeding (PMB) is a very uncommon presentation of ovarian cancer, but can present this way. In women with PMB, other causes of uterine pathology should be evaluated before considering ovarian pathology. In early menopause, the most common etiology is atrophy of the endometrium or vaginal mucosa. This patient is postmenopausal for approximately 2 years. Other common causes of PMB are polyps, fibroids, and endometrial hyperplasia.
Kegel exercises may be helpful for patients with what type of incontinence?
Mixed Kegel exercises are exercises used to strengthen the pelvic muscles. The usual recommendation is 3 sets of 8-12 slow velocity contractions sustained for 6-8 seconds each. These should be performed 3-4 times weekly for about 3-4 months. Kegel exercises are now known to help patients who have mixed incontinence.
An initial pharmacologic approach to a patient who is diagnosed with primary dysmenorrhea could be:
NSAIDs at the time symptoms begin or onset of menses Pain associated with dysmenorrhea is likely due to prostaglandins which can cause prolonged contraction of the uterus. This produces uterine ischemia, sometimes termed "uterine angina". NSAIDs (non-steroidal anti-inflammatory drugs) are prostaglandin synthesis inhibitors. These are usually started at the onset of menses or onset of symptoms and continued for 2-3 days depending on the symptom pattern of the patient. There is no demonstrated increase in efficacy when acetaminophen is added or given alone.
What choice below has no precautions for oral contraceptive pill use?
Varicose veins One of the major components of gallstones is estrogen. A patient with underlying gallbladder disease should not receive oral contraceptives (OC) since they will increase estrogen exposure and theoretically, formation of gallstones. Patients who are less than 6 months post-partum should avoid OCs until they are 6 months post-partum because OCs can decrease the quantity of breast milk produced. Hypertension is a contraindication to OC use because of the increased risk of stroke. Varicose veins are not a contraindication.
A patient who is 35 years old has identified a small, discrete mass in one breast. How should this be evaluated?
Order a mammogram and ultrasound to assess the mass Clinical evaluation of a breast mass begins with a good history of the mass and a physical exam of the breasts, lymph nodes, neck, and chest wall. While asking about whether the mass changes with menses is a good question in history, a mammogram should be the first radiographic assessment in females with breast complaints who are over age 30. This patient is 35 years old. An ultrasound is used for evaluation of a focal abnormality in a breast, especially if it has been identified on a mammogram. In this patient, both are prudent since there is a discrete, palpable mass. Re-assessing the mass 3-10 days after next menses may be appropriate for a female younger than age 30 depending on her history and physical exam.
A 24 year-old female patient who is sexually active complains of vaginal itching. If she has bacterial vaginosis, she might complain of:
a "fishy" vaginal odor after coitus Bacterial vaginosis is a clinical syndrome where high concentrations of anaerobic bacteria replace normal vaginal flora. This produces many symptoms that cause complaints in women. The typical symptoms are a "fishy" odor emanating from the vagina, itching, and vulvovaginal pruritis and burning. A typical complaint is an unpleasant odor after coitus.
A female patient complains of dysuria with vaginal discharge. How should she be managed?
Perform an abdominal exam, urinalysis, and pelvic exam A patient with dysuria and vaginal discharge should be assumed to have an STD until proven otherwise. She could have only an STD, or an STD and a UTI. She should have a vaginal exam with cultures and swab for trichomoniasis. The abdomen should be assessed because of the potential for pelvic inflammatory disease if STDs are present. A urinalysis can exclude a urinary tract infection.
A 28 year-old female presents with a slightly tender 1.5 cm lump in her right breast. She noticed it two days ago. She has no associated lymphadenopathy and there is no nipple discharge. How should she be managed?
Re-examination after her next menses Women who are less than age 35 years, who have no associated suspicious findings of breast cancer should delay imaging studies until re-examination 3-10 days after the last menstrual period to determine whether the lump changes in size or becomes non-palpable. If there are associated suspicious findings on exam like palpable nodes, a large lump (>2.0 cm), or nipple discharge, then diagnostic evaluation should not be delayed. If management involved a return visit for re-examination after menses, and the lump is unchanged, ultrasound is certainly advised. Mammogram may not yield good information in a 28 year-old because of the density of the breast tissue. Baseline mammogram may be advised. Direction from a radiologist or breast surgeon should be sought.
What recommendation should be made to a 70 year-old female regarding mammograms?
She should have them annually as long as she has a reasonable life expectancy Breast cancer is more prevalent in older women. In fact, 85% of breast cancer occurs in women after age 50 years. Older women profit from screening with mammograms and should continue to receive screening. No age limit has been established for discontinuing mammograms.
A 20 year old female reports that her grandmother and mother have osteopenia. What should she be encouraged to do to reduce her risk of osteopenia?
Smoking cessation, weight bearing exercise Cigarette smoking accelerates skeletal bone loss. The mechanism is unknown, but, it may be due to increased metabolism of estrogen. Therefore, smoking cessation is important in prevention of osteopenia as well as other diseases and conditions. Exercise should occur at least 30 minutes three times per week to maintain bone density. This has also shown to decrease incidence of hip fractures in older women. Walking increases hip and spine density. Vitamin D (at least 1000 IU per day) and calcium intake (1200-1500 mg per day) should accompany weight bearing exercise and smoking cessation.
A 15 year-old female has never menstruated. She and her mother are concerned. What is most important for the NP to assess?
Tanner stage Tanner staging, or sexual maturity ratings are very predictable changes that occur with puberty. These should be assessed. In females, breasts and pubic hair signify specific pubertal changes that constitute maturation. These are not age specific, but at 15 years a Tanner Stage 3 or more would be characteristic of expected maturation. Menses should follow soon.
A 70 year-old female has been in a mutually monogamous relationship for the past 33 years. She has never had an abnormal Pap smear, what recommendation should be made regarding Pap smears for her?
They can be discontinued now Pap smears screen for cervical cancer. Cervical cancer is very uncommon in older women, especially those who have no risk factors. Most learned authorities agree that screening for cervical cancer can be discontinued in women aged 65-70 years unless there are risk factors (previous GYN cancer, HIV positive). This patient still needs to visit the nurse practitioner for an annual exam but sampling of cervical cells can be discontinued in a patient of this age.
After a vaginal exam, a patient received a prescription for metronidazole. What was her likely diagnosis?
Trichomonas Trichomonas can be treated with metronidazole orally. This is usually effective and is generally well tolerated as long as the patient avoids alcohol. Alcohol in the presence of metronidazole can produce a disulfiram reaction. Another medication used to treat trichomonas is tinidazole. The exact mechanism of tinidazole is unknown, but is an antiprotozoal.
A female patient who takes oral contraceptives has just completed her morning exercise routine. She complains of pain in her right calf. Her blood pressure and heart rate are normal. She is not short of breath. Her calf is red and warm to touch. What is NOT part of the differential diagnosis?
Trochanteric bursitis Trochanteric bursitis does not produce pain in the calf. Pain is concentrated in the affected hip. While it is not likely that someone who exercises regularly would have a DVT, this patient does take oral contraceptives. Therefore, DVT should always be part of the differential given the potential risks associated with untreated DVT (pulmonary embolism).
Women who use diaphragms for contraception have an increased incidence of:
UTI The exact mechanism for increased urinary tract infections is unknown, but it is believed to be due to nonoxynol-9 induced changes in vaginal flora. Another consideration is the possible contamination that might accompany insertion before each episode of coitus. Care and cleaning of the diaphragm must take place, or that could be a contributor to increased bacteria.
A 51 year-old female patient presents with a 2 cm palpable breast mass. How should this be evaluated to determine whether it is solid or cystic in nature?
Ultrasound The diagnostic test of choice to differentiate a solid from a fluid filled breast mass is ultrasound. More than 90% of breast masses in women in the 20s to early 50s are benign. However, they must be evaluated. Clinical breast exam is unable to differentiate fluid filled from solid masses. MRI is not used unless a history of breast cancer is present. Mammography has the potential to evaluate the presence of a mass, but is of inadequate benefit in assessing whether it is fluid filled or not.
The recommended time to initiate screening for cervical cancer in women is:
at the age of 21 years Prior to 2009, the recommendation for cervical cancer screening was by age 18 years or 3 years after first sexual intercourse. American Cancer Society (ACS) and American College of Obstetricians and Gynecologists (ACOG) have updated this. The current recommendation for cervical screening is age 21 years. Cervical cancer is considered extremely rare in patients younger than 21 years.
Clue cells are found in patients with:
bacterial vaginosis The hallmark finding in a patient with bacterial vaginosis (BV) is clue cells on microscopic exam. Clue cells are epithelial cells with adherent bacteria. The most common clinical feature is an unpleasant, "fishy" smelling discharge that is more noticeable after sexual intercourse. BV can produce a cervicitis. It is a risk factor for HIV acquisition and transmission. Metronidazole is the most successful therapy. The usual oral regimen is 500 mg twice daily for 7 days. Alcohol should be avoided.
A nurse practitioner identifies filamentous structures and many uniform, oval shaped structures during a microscopic exam of vaginal discharge. These are probably:
hyphae and yeast Filamentous structures likely describe hyphae. Typically, hyphae are the mechanism that allows fungal growth. The uniform oval shaped structures are likely yeast. These can range in size but are usually large and unicellular. Visualization of hyphae and yeast should prompt an immediate diagnosis of a fungal infection. Candida albicans is a specific fungus, often found in vaginal secretions. Since there are many fungi that can produce hyphae and yeast, it is not possible to diagnose Candida albicans specifically.
A patient asks the NP's advice about an herb to help with her hot flashes. The NP knows these:
may be contraindicated in patients with history of breast cancer The herb that the patient is asking about is probably black cohosh, Actaea racemosa. It is a phytoestrogen. This means that it provides estrogen from a plant source. If estrogen is contraindicated in a patient, then it does not matter whether it comes from plants or is produced synthetically. There is a potential safety concern in using black cohosh in women with breast cancer or who are at high risk of breast cancer because of the estrogenic effects that are possible on the breasts.
An 84 year-old female patient is a resident in an assisted living facility. She has early dementia. She walks daily and has had urinary incontinence for years. Her urinary incontinence is likely to be:
mixed The most common type of urinary incontinence in women is mixed incontinence. This refers to at least two simultaneous mechanisms. Usually detrusor overactivity and impaired urethral sphincter function are present, giving mixed incontinence characteristics of urge and stress (exertional) incontinence. Stress incontinence is characterized by leakage of urine following sneezing, coughing, or laughing. Urge incontinence is characterized by the sudden urge to urinate that cannot be delayed.
Athletic amenorrhea increases the risk of:
osteoporosis Athletic amenorrhea creates states of prolonged hypoestrogenemia. This results in an increased risk of osteoporosis.