Women's health quiz 2 answers only
Although this patient is genetically XY, the tissues are not responsive to testosterone.
. A 13-year-old female patient, accompanied by mother, presents to your clinic with the complaint of lack of menses. After taking a thorough history and physical exam, you notice she also has little to no axillary or pubic hair. When performing a pelvic exam the external genitalia appears unambiguously female, but the patient has a blind vaginal pouch and an absent uterus. You order a genetic karyotype, which returns as 46, XY. Which of the following is most likely true about the patient's condition? A. The patient has androgen insensitivity syndrome, which is the first leading cause of primary amenorrhea. B. The testes do not need to be removed and are not associated with increased risk of testicular cancer. C. Although this patient is genetically XY, the tissues are not responsive to testosterone. D. Because this patient is genetically XY, the patient can not appear feminine.
Dilation and curettage, performed for a spontaneous miscarriage in December 2021.
. A 30-year-old hispanic female, G3P1021, presents to your clinic with a 7 month history of amenorrhea. Prior to this, the patient reports that her periods have been regular since age 13. She is sexually active with her boyfriend and uses condoms for contraception. The patient's vital signs and physical exam are unremarkable. Her urine pregnancy test comes back negative. Labs for FSH, LH, prolactin, and thyroid function are within normal limits. Based on the choices below, which component of her past medical history would increase the provider's index of suspicion for Asherman Syndrome? A. A history of an uncomplicated chlamydial infection in November 2021, which was treated promptly. B. Prior use of combined oral hormonal contraception pills from age 19-27. C. Dilation and curettage, performed for a spontaneous miscarriage in December 2021. D. Familial history of uterine fibroids in both her grandmother and mother.
She meets criteria for premenstrual dysphoric disorder (PMDD). Treatment includes GnRH agonists and hormonal contraceptives.
1. 25 y/o F presents to the clinic, accompanied by her husband, c/o "losing my mind before my period hits". Patient notes headaches, feeling helpless, anxiety, lack of energy, irritability, mood swings and sleep disturbances. She is unable to go to work when this occurs and cannot participate in her usual activities. Her husband states that she is often a "different person" during these times. Her periods are regular. She denies excessive hair growth or weight gain. She denies any history of autoimmune or endocrine conditions. What is true about this patient's condition? A. Her symptoms are most consistent with the most common cause of ovulatory dysfunction. B. The patient may have a congenital absence of GnRH. C. Her symptoms are consistent with the 3rd most common cause of primary amenorrhea. This is included in the DSM5. D. She meets criteria for premenstrual dysphoric disorder (PMDD). Treatment includes GnRH agonists and hormonal contraceptives.
Treatment of Acne and Hirsutism
1. A 24 year old well-nourished, well-developed female presents to your clinic asking about oral contraceptive pills for birth control. She recently found out she was accepted to PA school next year and wants to ensure that she will not get pregnant both before and during school. She is newly married, only has 1 sexual partner, her husband, and her PMHx includes a tonsillectomy at age 7. She takes no other medications and has no known drug or material allergies. What are some of the benefits you can share with this patient, outside of contraception, of the oral contraceptive pill (OCP)? A. Decreased risk of Breast, Ovarian, and Endometrial Cancer B. Treatment of Acne and Hirsutism C. Treatment of Depression and Anxiety D. Decreased risk of Pelvic Inflammatory Disease (PID)
Anovulation, Clomid (clomiphene citrate)
1. A 27 year-old G1P1001 female, LMP 4/5/2022 presents to your clinic with concerns of amenorrhea for 4 months. She states her presenting symptom began after recovering from COVID-19. She reports menarche at 11 years old in 2009 and states periods have been regular since menarche typically lasting 6 days, using 2 super tampons per day without history of intermenstrual bleeding. The patient and her male partner removed all forms of contraception at the end of 2021 in attempt to conceive again. She became concerned after 6 negative home pregnancy tests. The lab results return with a negative quantitative beta-hCG; TSH and prolactin levels are within normal limits. The patient is prescribed a progesterone challenge which results in menstruation on day 9. What is the diagnosis and recommended therapy if she wishes to become pregnant? A. Low Estrogen, Loestrin (estrogen and progestin) B. Anovulation, Clomid (clomiphene citrate) C. PCOS, Aldactone (spironolactone) D. Infertility, IUI or IVF
Barrier method such as male/female condoms because she is not able to take hormonal
1. A 36 year old female comes into the clinic asking for a form of contraceptive. She recently got a boyfriend and wants to be prepared. She has not been to the clinic in 6 years and did not present with any health conditions previously. Two years ago, her parents died in a car accident and since then she has gained 100 pounds. In the last two weeks she has decided to attend a fitness class twice a week. She has not previously been sexually active. Her family does not have any history of blood clots. She drinks 1 glass of wine 2-3 nights a week, and smokes 2 cigarettes daily. What form of contraception would you offer her and why? Today her vitals are 144/86, HR 89, 98% on RA, RR 16 bpm, Height: 5'2", Weight: 225lbs, BMI: 41.1 A. Oral contraceptive pills because she does not have a history of clotting, therefore oral contraceptives would be most effective for her. B. Vaginal ring (NuvaRing) because she hasn't taken pills before, so this way she won't have to remember to take them. C. Barrier method such as male/female condoms because she is not able to take hormonal contraceptives due to her health conditions. D. Transdermal patch because she is able to continue to drink her wine while she is on it.
Vasectomy for her partner
1. A 37-year-old G3P3 female presents to the primary care clinic with her 6-month old infant. She has been exclusively breastfeeding to induce lactational amenorrhea as she was not interested in hormonal contraceptives postpartum. She now is interested in contraception as she and her husband are sexually active, but have decided they do not want any more children. She currently smokes half a pack of cigarettes a day and does not drink alcohol. Which of the following contraceptive methods is the safest and most efficacious for this patient? A. Female or male condoms B. Oral contraceptive pill C. Salpingectomy D. Vasectomy for her partner
Primary amenorrhea - Complete Androgen Insensitivity Syndrome
16-year-old newly sexually active female presents to the clinic for a pain with sex. PT states that she recently had sex and stated "it hurt when I was on top." When asked when her LMP was she stated she has never had a period which she has never felt was abnormal since she is an elite gymnast. During PE you note PT is taller than average for her age and gender, with a fairly muscular build with a normal BMI, and normal breast development. During the pelvic exam you note the PT has absent pubic hair and a blind vaginal pouch. CBC, CMP, TSH and Prolactin were within normal limits. Serum testosterone and LH were high-normal range consistent with levels in post-pubertal boys, with a normal serum FSH. Based on the information given, match the type of amenorrhea with the diagnosis. A. Secondary amenorrhea - Athletic amenorrhea B. Primary amenorrhea - Kallmann Syndrome C. Primary amenorrhea - Complete Androgen Insensitivity Syndrome D. Secondary amenorrhea - PCOS
Listen to the patient's concerns and address any misinformation in a non-judgemental fashion. Inform the patient that calendar planning and coitus interruptus are not effective methods of contraception nor do they protect against STIs. Explain the risks and benefits of other contraceptive methods including; barrier methods, oral contraceptive pills, and IUDs.Offer barrier contraceptives and send the patient home with contraceptive patient education pamphlets.
19 year-old sexually active female presents to her University's women's health clinic for contraception. Patient reports that she recently began having unprotected sexual intercourse with her new boyfriend from her Biology 101 course. Patient reports that her boyfriend told her that as long as they have sex after she ovulates they can continue using the coitus interruptus method because she can't get pregnant if they have sex after she ovulates. As the provider in this clinic, you decide to counsel this patient on practicing safer sex, which of the following is the best patient education for this patient? A. Explain to the patient that only 22/100 and 24/100 women get pregnant when using coitus interruptus and calendar planning, respectively. The multiplied effectiveness is only 5/100 women pregnant, which is more effective than any barrier method. B. Explain to the patient that barrier method effectiveness is 12-24/100 women becoming pregnant, which is a safer alternative. Send the patient home with barrier contraceptives. C. Listen to the patient's concerns and address any misinformation in a non-judgemental fashion. Inform the patient that calendar planning and coitus interruptus are not effective methods of contraception nor do they protect against STIs. Explain the risks and benefits of other contraceptive methods including; barrier methods, oral contraceptive pills, and IUDs. Offer barrier contraceptives and send the patient home with contraceptive patient education pamphlets. D. Explain to the patient that only 22/100 and 24/100 women get pregnant when using coitus interruptus and calendar planning, respectively. Order a STI panel and start the patient on PEP.
Based on the lab results, you are not pregnant. Your thyroid hormones are low, which means that you have what is called hypothyroidism. This can explain the symptoms you are having such as the weight gain, hair thinning, constipation, and cold intolerance. Your prolactin, which is another hormone, is high, explaining the nipple discharge. The thyroid hormones help to regulate prolactin levels, so once we correct the hypothyroidism, your prolactin levels should go back to normal. The thyroid hormone replacement is called levothyroxine, which you will need to take every day in the morning on an empty stomach, 30 minutes to an hour before you eat anything.
2. A 16-year-old female with no PMHx and no medications presents to the clinic with her mother, who demands that her daughter have a pregnancy test. The mother states that she is sure that is "knocked up". Upon further questioning, the mother states that her daughter has been gaining weight recently and has had "milk coming out of her breasts and soaking her shirt". The patient appeared very uncomfortable, and after asking the mother to step out for further questioning, the patient revealed "I have been gaining weight recently, but I haven't been eating more". She also states that her hair has been falling out a lot more, she feels cold no matter what the temperature, and has been constipated recently. When asked about her nipple discharge, the patient reports that she has been very scared about it, but knows that she is not pregnant because the discharge is "clear" and she is not sexually active. The patient agreed to a pregnancy test and the mother agreed to have more testing done. Her lab results are as follows: Urine hCG: negative, TSH: high, T4: low, Prolactin: high Given the suspected diagnosis, how should you educate the patient and her mother about the condition and the treatment? A. Your daughter is not pregnant, but her thyroid seems to be working more than it should, so there is an excess amount of hormones. I believe this is what is causing her symptoms and she will need to have an iodine uptake scan to make sure. B. Your daughter is not pregnant, but I think she may have a brain tumor that is causing her breasts to secrete fluid. We will likely need to refer you to a neurosurgeon so that they can take it out very soon. C. Based on the lab results, you are not pregnant. Your thyroid hormones are low, which means that you have what is called hypothyroidism. This can explain the symptoms you are having such as the weight gain, hair thinning, constipation, and cold intolerance. Your prolactin, which is another hormone, is high, explaining the nipple discharge. The thyroid hormones help to regulate prolactin levels, so once we correct the hypothyroidism, your prolactin levels should go back to normal. The thyroid hormone replacement is called levothyroxine, which you will need to take every day in the morning on an empty stomach, 30 minutes to an hour before you eat anything. D. Based on the labs you have primary hypothyroidism, which is causing your prolactin to spike, and you are not pregnant. It appears to be a primary hypothyroidism as your thyroid stimulating hormone is elevated and your prolactin is elevated, showing a disruption in your hypothalamic-pituitary axis. I'm going to start you on levothyroxine 1.6 mcg/kg/day to start, which should correct the hypothyroidism and the hyperprolactinemia. If your symptoms do not improve after titrating your medication to the adequate dose in the therapeutic window, I would like to do further workup to rule out other conditions on my differential.
The pt meets the criteria for premenstrual dysphoric disorder. This is a serious condition that disrupts the patient's daily functioning. The pt should limit caffeine, etoh, tobacco, chocolate, and sodium. She should try to get exercise, and take NSAIDS for pain relief. The pt may want to start hormonal contraceptives to relieve symptoms
2. A 20-year-old female comes into the clinic for a follow up regarding the symptoms she experiences prior to menstruation each month. She returns to the clinic with a completed PRISM calendar. Looking at the calendar you see that she has an increase in symptoms surrounding the 2nd week of her cycle, for 3 cycles consecutively. Her symptoms include; irritability, anxiety, depressed mood, lack of energy, concentration difficulties, and feeling overwhelmed. Patient education for this pt would include? A. The pt has PMS and should be educated that this is not a medical condition, and that she will eventually get used to the symptoms. B. The pt meets the criteria for premenstrual dysphoric disorder. This is a serious condition that disrupts the patient's daily functioning. The pt should limit caffeine, etoh, tobacco, chocolate, and sodium. She should try to get exercise, and take NSAIDS for pain relief. The pt may want to start hormonal contraceptives to relieve symptoms. C. The pt has PMS, the pt should start hormonal birth control right away, or the symptoms will continue to get worse. D. The pt needs to track her symptoms on a PRISM calendar for 6 months in order to be diagnosed with premenstrual dysphoric disorder.
Levonorgestrel 1.5 mg; 3 days
2. A 24-year-old female patient comes to be seen at the clinic after a recent sexual encounter. She explains that she had unprotected sex with a new male partner, and is concerned about the risk of pregnancy. She is not currently on any contraceptives, so she is particularly concerned. She tells you that her friend recommended a "Plan B" pill but that she wanted to seek true medical advice from a seasoned PA prior to using such methods. What is the active ingredient in the Plan B pill she is interested in, and how soon after the encounter may it be effective? A. Progestin-estrogen; 5 days B. Levonorgestrel 1.5 mg; 3 days C. Progestin-estrogen; 3 days D. Levonorgestrel 1.5 mg; 5 days
Cervical polyp that is being irritated during intercourse
2. A 39 year old Caucasian female, G3P3003, presents to the clinic with "spotty bleeding from my vagina" x 1 month. Her last pregnancy was without complications with her baby delivered 4months ago. Her LMP was 14 months ago. She is exclusively breastfeeding her baby and does not remember starting her period with her older children until they were done breastfeeding. She and her husband have been sexually active with condom usage about once a week starting about one month ago. She states intercourse creates mild discomfort, and does notice the bleeding is slightly heavier shortly after. They last had intercourse 3 days ago, and she says she has not noticed any bleeding today. A speculum exam is done and a single 1mm cervical abnormality is noted protruding from the os that is red and friable. The rest of the speculum exam is unremarkable. A biopsy is obtained and histology shows vascular connective tissue covered with normal cervical tissue. What would you expect to be the most likely cause for this patient's abnormal bleeding? A. Cervical cancer because she is postmenopausal B. Vaginal wall trauma from intercourse C. Cervical polyp that is being irritated during intercourse D. Normal period starting again
When was your LMP?
2. A 45 year old female comes into the office for symptoms of low libido that is starting to affect her marriage. Upon further questioning, she has noticed an increase in brain fog, weight loss, and it's been hard for her to get a good night's sleep. She has taken melatonin at night the last few months and it has helped her with staying asleep throughout the night. She states she also ordered a new tea her friend down the street sells that's supposed to make you more alert, and hopes it will help with her brain fog. A pregnancy test was performed and came back with a negative result. What is the most important other question you need to ask to help confirm your diagnosis? A. When was your LMP? B. When was the last time you were physically intimate with your partner? C. What changes in diet have you introduced lately? D. Have you had any other sexual partners in the last 6 months?
Polycystic ovaries
2. A G0P0 well developed, well nourished 25-year-old female presents to clinic for evaluation and management of oligomenorrhea. Her LMP was 6 months ago and she has experienced irregular periods since menarche. Through a detailed history, it is determined that she is experiencing anovulation as well. She has not been sexually active in 9 months and in office beta hCG is negative. Upon examination, she has hirsutism and cystic acne along her jawline. Although not necessary for diagnosis, what might you see on transvaginal ultrasound of this patient? A. A fetus B. Polycystic ovaries C. Uterus unicornis D. Streaked gonads
Supportive therapy and RhoGAM injection.
3. A 29 y/o caucasian female G2P0010 pt presents to the clinic for follow up. She is currently 17 weeks pregnant and states she had a miscarriage about 1 year ago. She is concerned because she has had some light vaginal bleeding for the past 2 weeks. You order a serum HCG which comes back positive. Patient's chart indicates that she is Rh negative. Upon physical exam the patient's cervical os is closed. Ultrasound shows no evidence of embryonic demise and no evidence of passage of products of conception. Due to her history, she is eager to know what treatments she can try in order to prevent another miscarriage. What can you recommend to the patient for this condition? A. Avoid any trauma or penetration to the vagina, including sexual intercourse, as this may increase your risk for an abortion. B. Supportive therapy and RhoGAM injection. C. Take time off work and avoid strenuous activities as that can cause stress to the fetus and increase risk for miscarriage. D. Prescribe methotrexate 2.5 mg tab PO QD x 1 day.
No evidence of fetal demise is detected on ultrasound.
3. A 30-year-old patient comes into the clinic and appears to be in acute distress. She states she has a regular prenatal visit scheduled next week but needed to be seen sooner because she has been experiencing spotting. After taking a thorough medical history, you are concerned that the patient may be having a spontaneous abortion. Out of the various spontaneous abortion classifications, a threatened abortion is at the top of your differential diagnosis. Which of the following would support the diagnosis of a threatened abortion? A. After inserting the speculum, you notice the cervical os is open. B. No evidence of fetal demise is detected on ultrasound. C. Products of conception are expelled from the uterus. D. Associated symptoms of fever, chills and uterine tenderness.
There is strong evidence that you have polycystic ovarian syndrome and are ovulating inconsistently due to the pituitary gland not releasing LH and FSH.
3. A 31-year-old female reports to your clinic complaining of difficulty conceiving. You notice that the patient has acne and small areas of facial hair. Upon chart review, you note that the patient's BMI has increased from 28.2 to 34.8 in the past 2 years. Upon further history solicitation the patient states that "it has been 37 days since my last period" and that late periods seem to be her "new normal." What education would you convey to the patient as to why her menstrual cycles are inconsistent? A. There is strong evidence that you have polycystic ovarian syndrome and are ovulating inconsistently due to the pituitary gland not releasing LH and FSH. B. With the current signs and symptoms, a karyotype test should be performed to rule out Turner Syndrome which may be the cause of your inconsistent cycles. C. The abnormal menstrual cycles are consistent with perimenopause and hormone replacement therapy alone should correct the complaint. D. Reassure the patient that this is a normal occurrence for women in her age demographic and give the patient information for local support groups for women that have similar conditions.
Endometrial Polyp
3. A 40 year old obese female with history of uncontrolled hypertension presents to the clinic complaining of intermenstrual bleeding. Patients states she and her husband are currently trying to get pregnant but they have been unsuccessful. She states she has regular menses but is spotting in between her menstrual cycles. She denies pelvic pain, heavy menses, fever, urinary frequency and abnormal vaginal discharge. Based on this information, what is the most likely diagnosis? A. Endometrial Polyp B. Endometrial Hyperplasia C. Adenomyosis D. Leiomyoma
Fragility of the epithelial tissue
3. A 53-year-old Caucasian female, G1P1001, presents to her primary care PA with a complaint of "itchiness down there." She states she is in a monogamous relationship with a male partner and the only contraceptives she utilizes are condoms. Review of systems is positive for weight gain (10 lbs in 5 months), dyspareunia, night sweats, hot flashes, vaginal pruritis, and amenorrhea for 13 months. Which changes on the physical exam would you most likely see in this patient compared to a year prior? A. Increase in subcutaneous fat in the labia majora. B. Fragility of the epithelial tissue. C. Widening of the introitus. D. Vaginal pH becoming more acidic.
Complete androgen insensitivity
3. A phenotypically appearing female patient presents to your office with failure to achieve menarche by age 16. An Estrogen-Progesterone challenge does not result in menstrual bleeding and a pelvic sonography reveals the presence of intra-abdominal gonads and the absence of a uterus. These findings are most likely the result of which condition? A. Klinefelter Syndrome B. Kallmann Syndrome C. Complete androgen insensitivity D. Turner Syndrome
Due to the age of gestation, medical abortion can be initiated
32-year-old south asian female presents to her family clinic with her partner for an annual Well Woman Exam. She states that she is glad she had her appointment because she and her partner have been having unprotected sex and thinks she might be pregnant. She states her LMP was 5 weeks ago, last intercourse was 2 days ago, and her IUD was last checked by her OBGyn provider 13 months ago, noting it was in place and normal. Beta-HcG performed in the office is positive and ultrasound confirms absence of fetal heart tone. The patient is wanting to know her options to terminate her pregnancy. What is the best course of action for the patient in regards to termination? A. Due to the age of gestation, medical abortion can be initiated B. Due to the age of gestation, recommend to the patient to another OBGyn to reassess her IUD since it appears faulty, and ask to change to oral contraceptive C. Due to the age of gestation, initiate medical abortion regimen Misoprostol 400 mcg tablets x3 orally given in office followed by Mifepristone 200mg tablets x3 orally given in office two days later followed confirmation of termination in office via transvaginal ultrasound eleven days later D. Due to the age of gestation, dilation and evacuation surgical abortion is the most appropriate method
FSH, LH
35 y/o female presents in clinic stating that she has not had a period in 3-4 months. She is well developed, well nourished, and appears to be in no distress. She states that she does not currently have an active sexual partner and has never been pregnant, and her beta-Hcg is negative. She denies using recreational drugs or alcohol, and has no medical conditions nor prescription medications. Physical exam is normal. Her fasting lipid panel and 2 hour glucose tolerance test are both normal and her TSH and prolactin are also normal. A progesterone challenge is given, and the patient does not menstruate. An estrogen and progesterone challenge is then given, and the patient menstruates. What is the next diagnostic step? A. Repeat estrogen and progesterone challenge B. FSH, LH C. Order a gene karyotype D. Hysterosalpingography
You suspect primary amenorrhea, will do a lab workup to check hormones, and will refer to endocrinology for further evaluation
4. A 15 year old, well-nourished, female presents to the clinic with her mom for concern of "not starting her period." The patient explains all of her friends at school have already started their menstrual cycle and she is curious why she hasn't started. She reports her breasts have "not gotten bigger" nor have her hips become "wider." She also denies development of under-arm or pubic hair. Mom denies any significant medical history or drug allergies for the patient. What advice would you give the patient and mom regarding her concerns? A. You explain this is normal and not to worry as her menstrual cycle may just start later in life. B. You suspect primary amenorrhea, will do a lab workup to check hormones, and will refer to endocrinology for further evaluation C. You suspect secondary amenorrhea, will do a lab workup to check hormones, and will refer to endocrinology for further evaluation D. You suspect oligomenorrhea and explain she will have infrequent periods, sometimes more than 35 days apart
Prescribe a selective progestin receptor modulator such as ulipristal acetate 30mg
4. A 19-year-old nulligravida female presents to your office and states she needs "Plan B." The patient reports she had unprotected sex four days ago, but was too afraid to tell any of her family or friends. She denies ever using hormonal contraception, and she has never had an IUD or diaphragm. What do you advise this patient based on her options for emergency contraception? A. Advise the patient to purchase an over-the-counter progestin only pill such as levonorgestrel 1.5 mg pill B. Prescribe a selective progestin receptor modulator such as ulipristal acetate 30mg C. Inform the patient that emergency contraception is not an option based on the time interval since coitus D. Prescribe the patient a long-term implantable contraception such as Nexplanon
Dilation and suction curettage to minimize risk of choriocarcinoma
4. A 25 year-old female who is 8 weeks pregnant presents to the ED with irregular vaginal bleeding and what she describes as a "brownish" discharge. She denies any pain, fever, or chills, but reports that she has been vomiting a lot lately. Her vital signs are WNL, she has been compliant with her prenatal care, and denies any drug/ETOH use. CBC is WNL. Ultrasound reveals grape-like structures in her uterus. What is the treatment of choice for this condition and why is it important that this be done as soon as possible? A. Dilation and suction curettage to minimize risk of choriocarcinoma B. Dilation and suction curettage to minimize risk of a septic abortion. C. Medical abortion to minimize risk of permanent infertility. D. Hysterectomy to minimize risk of choriocarcinoma.
Normal TSH, normal prolactin, high FSH, low estrogen
4. A 29-year-old female patient has been experiencing a lack of menses over the last 5 months. To try to conceive with her husband, she stopped combined oral hormonal contraceptive pills (OCPs) 6 months prior. She started OCPs at age 18 and has not had any issues with them. She experienced menarche at age 14. For the last two weeks she's also had difficulty at work due to episodes of uncomfortable warmth and flushing in her chest and face that last a few minutes each time. These episodes have left her feeling anxious, and she believes this has also made it difficult to have sex with her husband as she's noticed more discomfort while having sex. After testing serum hCG to confirm she isn't pregnant, which of the following lab results are most consistent with a diagnosis of premature ovarian syndrome? A. Low TSH, low prolactin, low FSH, low estrogen B. Normal TSH, normal prolactin, high FSH, low estrogen C. High TSH, high prolactin, low FSH, low estrogen D. High TSH, high prolactin, low FSH, normal estrogen
She is postmenopausal and should be treated with a combination of PO estrogen and progesterone.
4. A 46 yo G3P2103, African American female with a past medical history of hyperthyroidism presents to the clinic complaining of worsening temperature fluctuations that are keeping her up at night. She reports feeling warmer than usual, weight gain, nausea, problems sleeping, daytime drowsiness, and anxiety. She reports her LMP was 13mo ago, and states that she isn't worried about pregnancy because she has had irregular cycles for the past 2 years. She has no PMHx or FHx of cancer, heart defects, CVD, stroke, TIA, hepatic disease, or unexplained vaginal bleeding. Upon examination, the patient feels warm to the touch, is normotensive, heart displays RRR w/ CCTA with no wheezes, rales, or rhonchi. She denies smoking or drinking. She reports her last pregnancy was 10 years ago and did not breastfeed. Past procedures include 2 vaginal deliveries and 1 cesarean section in which she reports no complications. She denies any recent illness or vaccinations and is not currently on birth control. Patient's most recent pap smear was 4mo ago, with no abnormal findings. Labs were recently drawn at an endocrinologist f/u and show TSH, FT4, CBC, and CMP are within normal limits. Risks and benefits of treatment were discussed with the patient. Based on the patient's symptoms and findings, what is the best treatment plan for this patient? A. She is premenopausal and should be treated with Estradiol topical gel and PO Progestin. B. She is perimenopausal and treatment should include a Copper IUD with testosterone supplementation. C. She is postmenopausal and should be treated with a combination of PO estrogen and progesterone. D. She is postmenopausal and should be treated with low dose PO estrogen.
With this medication, beware of its effect on libido.
4. A 51-year-old Caucasian woman with a past medical history of breast cancer presents to your clinic with progressive symptoms of frequent, but mild hot flashes occurring both day and night. She finds her emotional state increasingly fluctuating. She is also experiencing sleep disturbances and anxiety. She denies any other complaints. Her LMP was approximately 16 months ago. She has no history of medical problems or affective disorders. Her pulse is 81 beats/ minute, and her blood pressure is 122/76 mmHg. Her pelvic examination reveals atrophic external genitalia, a small anteverted uterus, and no adnexal masses. The rest of her examination is completely normal. The patient gets prescribed Desvenlafaxine. Based on this information, what patient education point would be important to mention? A. With this medication, beware of the possibility of rebound hypertension. B. With this medication, beware of its effect on libido. C. With this medication, it can cause symptoms such as abnormal uterine bleeding. D. With this medication, it can possibly affect breast tissue and cause hepatotoxicity.
A non-tender, hard palpable mass
5. A 23-year-old G0P0 female patient with a past medical history of anemia presents to your clinic for a physical exam. She states her menstrual period began 3 days ago. The patient also states she has had heavy bleeding during menses "for as long as she can remember." She admits urinary frequency, constipation, and menometrorrhagia with heavy flow and a 9-day duration. What physical exam finding you expect during the bimanual exam for the suspected diagnosis? A. A non-tender, hard palpable mass B. Cervical motion tenderness C. Enlarged ovaries D. Cervical polyps
Ovulation is occurring later in her cycle, so she needs to track ovulation, and have intercourse with a positive LH surge around day 20.
5. A 29 year old female, G0P0, presents to your clinic and shares that she and her husband have been trying to conceive for 6 months with no success. She reports regular menses that last 4-5 days and a cycle length of 34 days that is consistent from month to month. She denies intermenstrual or heavy bleeding, discharge, or pain. She reports that she and her husband have intercourse on day 14 of her cycle. What are you likely to tell your patient at this time? A. To continue to have intercourse on day 14 of her cycle because the follicular phase does not vary. B. Ovulation is occurring later in her cycle, so she needs to track ovulation, and have intercourse with a positive LH surge around day 20. C. It looks like she is not ovulating. D. Her cycle length suggests that she has oligomenorrhea.
Threatened abortion
5. A 30-year-old female G1P0, 9 weeks pregnant, presents to the clinic complaining of vaginal bleeding and wants to make sure everything is okay. The patient reports pregnancy symptoms including morning sickness, fatigue, and mood swings. She reports mild bleeding for 5 days that has not decreased and occasional abdominal cramps. She has elevated beta-hCG levels. Pelvic exam shows a soft, closed cervical os and uterine size normal for 9 weeks of gestation. Her ultrasound shows a healthy fetus and heartbeat. What is the most likely diagnosis? A. Inevitable abortion B. Complete abortion C. Threatened abortion D. Missed abortion
LAM is a temporary method of birth control that can be used for the first 6 months after giving birth if you're exclusively breastfeeding. The hormones that are being produced by breastfeeding are suppressing the hormones needed for ovulation (when an egg that is ready for fertilization is released from your ovary). For this method to be effective, some doctors say you would have to nurse or pump about every 4 hours. However, proceed with caution. Most women will ovulate before their periods resume, so if you want to further prevent pregnancy, it is always a good idea to use a back-up method of birth control.
5. A 33 y/o female presents to the clinic for her scheduled 6-week postpartum follow-up. She states she's been able to breastfeed regularly without issues, appears happy and does not have any complaints aside from exhaustion. Her exam is unremarkable and is cleared to be intimate with her husband if she so wishes to be. Upon being given this information, she wants to know if she's able to get pregnant again during this period since she just gave birth. She wishes to have another child in the future, but ideally, not any time soon. Knowing about the Lactational Amenorrhea (LAM) birth control method, in layman's terms, how would you explain key concepts to the patient? A. LAM is a temporary method of birth control that can be used for the first 12 months after giving birth if you're exclusively breastfeeding. The hormones that are being produced by breastfeeding are stimulating the hormones needed for ovulation (when an egg that is ready for fertilization is released from your ovary). For this method to be effective, some doctors say you would have to nurse or pump about every 4 hours. As long as you aren't having periods, you're not ovulating. B. LAM is a temporary method of birth control that can be used for the first 6 months after giving birth if you're breastfeeding 50% of the time and bottle-feeding the other 50% of the time. The hormones that are being produced by breastfeeding are suppressing the hormones needed for ovulation (when an egg that is ready for fertilization is released from your ovary). For this method to be effective, some doctors say you would have to nurse or pump about every 4 hours. However, proceed with caution. Most women will ovulate before their periods resume, so if you want to further prevent pregnancy, it is always a good idea to use a back-up method of birth control. C. LAM is a temporary method of birth control that can be used for the first 12 months after giving birth if you're exclusively bottle-feeding. The hormones that are being produced by breastfeeding are suppressing the hormones needed for ovulation (when an egg that is ready for fertilization is released from your ovary). For this method to be effective, some doctors say you would have to nurse or pump about every 6 hours. As long as you aren't having periods, you're not ovulating. D. LAM is a temporary method of birth control that can be used for the first 6 months after giving birth if you're exclusively breastfeeding. The hormones that are being produced by breastfeeding are suppressing the hormones needed for ovulation (when an egg that is ready for fertilization is released from your ovary). For this method to be effective, some doctors say you would have to nurse or pump about every 4 hours. However, proceed with caution. Most women will ovulate before their periods resume, so if you want to further prevent pregnancy, it is always a good idea to use a back-up method of birth control.
The condition best describes adenomyosis, and the definitive treatment is a total hysterectomy
5. A 38-year-old Caucasian female G2P2002 presents to the clinic with a history of heavy and prolonged menstrual bleeding, severe menstrual cramps, and frequent pelvic pain. The physician assistant performs a bimanual pelvic examination, which reveals a uterus that is tender, diffusely enlarged, and boggy with globular enlargement. A serum hCG is drawn and comes back as negative. The transvaginal ultrasound reveals asymmetric thickening of the myometrium, myometrial cysts, and poor visualization of the endomyometrial border. Which of the following best describes the most likely diagnosis and the definitive treatment? A. The condition best describes adenomyosis, and the definitive treatment is a total hysterectomy. B. The condition best describes adenomyosis, and the definitive treatment is low dose oral contraceptives. C. The condition best describes endometrial polyps, and the definitive treatment is surgical removal. D. The condition best describes genitourinary syndrome of menopause, and the definitive treatment is topical estrogen.
Total hysterectomy
5. A 40-year-old G3P2012 female is reporting to her primary care provider for heavy, prolonged periods over the past few months. She also mentions she has been having pelvic pain as well. She thought it was nothing but her husband convinced her she needed to go in just to make sure. You complete a pelvic exam and find a tender symmetrically enlarged boggy uterus. You diagnose her with Adenomyosis. What is the definitive treatment for this condition? A. NSAIDS and OCPs B. Intrauterine device (IUD) C. Total hysterectomy D. Menopausal hormone therapy (MHT)
Adenomyosis - total hysterectomy
5. A 42 year old G2P2002 female, BMI of 20 and no significant past medical history, presents to the clinic today in search of relief from her "heavy periods" x 2 years. Patient states "the bleeding has been so much I was soaking through my overnight pads, so now I wear a diaper overnight when I'm on my period." She additionally notes "knife like and intolerable" cramping on her period as well as pain during sexual intercourse with her husband of 20 years. She has been taking ibuprofen during her periods, but notes only mild improvement "if any". The patient denies history of estrogen contraceptive pills and denies any other medications/supplements. Physical exam reveals a boggy, enlarged uterus that is tender to palpation. Her qualitative hCG test came back negative; LKMP was 2 weeks ago on 8/4/2022. She states that she is finished with having children and does not wish to preserve fertility, she just wants the pain and bleeding to subside. What would you diagnose this patient with and what would be the BEST treatment? A. Adenomyosis - total hysterectomy B. Endometrial hyperplasia - progestin C. Adenomyosis - continue ibuprofen and add a low dose oral contraceptive pill D. Endometrial hyperplasia - discuss that this is a benign diagnosis and send her home
Refer to a pediatric endocrinologist for a workup.
A 14-year-old female presents to the clinic with her mother because they are concerned she has not started her period. Physical exam shows no axillary hair, pubic hair, or breast development. It is also noted that she has wide spaced nipples. She is at a Tanner stage 1. What is the best next step in the treatment of this patient? A. Reassure and educate the patient that this is normal. B. Refer to a pediatric endocrinologist for a workup. C. Start the patient on a low-dose hormonal birth control such as Lo Loestrin. D. Prescribe progesterone 5-10mg po once per day for 10 days to try and stimulate bleeding.
Hypergonadotropic hypogonadism
A 14-year-old female presents with her mother to your clinic with complaints of an absent menstrual cycle for over 6 months. Her mother reports "she started her period one year ago, but it has been 6 months since her last cycle and I am very concerned." After completing a focused history, you perform a thorough physical exam and notice absence of breast development, widely spaced areola, and webbing of the neck. You suspect a chromosomal abnormality and order a genetic karyotype. Her sex chromonomal results are 45XO. These findings suggest a diagnosis of? A. Hypogonadotropic hypogonadism B. Hypergonadotropic hypogonadism C. Hypogonadotropic hypergonadism D. Hypergonadotropic hypergonadism
Her rigorous training schedule has caused negative feedback on her HPA, decreasing GnRH.
A 15 year old female with normal sexual developement presents to your clinic with her mother due to concerns with her lack of menstruation. The mother states that at 13 years old, the patient experienced menarche and had normal monthly cycles starting about 10 months after that. Starting at the age of 15, the patient's cycles suddenly stopped and the mother notes that during this time she also got a new boyfriend and started gymnastics. The mother is concerned that the patient is sexually active and pregnant, but the patient tells you that she has never had vaginal sex before. After doing a thorough social history, you find that the patient does not smoke, drink, or use drugs as she is very dedicated to her gymnastics and practices 4 hours, 5 days a week with competitions on the weekends. You run an in house HCG which comes back negative and suspected a diagnosis of secondary amenorrhea. Which of the following is most likely the cause of her secondary amenorrhea. A. The patient is sexually active and only recently pregnant so her HCG is negative B. Her rigorous training schedule has caused negative feedback on her HPA, decreasing GnRH. C. She has undiagnosed Turner Syndrome D. The intense training and activities has caused her to develop Asherman syndrome, blocking endometrial proliferation and shedding.
High FSH/LH, low estrogen/progesterone
A 17 y/o female presents to the clinic today with concerns about her menstrual cycle. She has not yet had her first menses and is worried "something is wrong with her ''. Upon physical examination, you notice that the patient has a short web neck and a shield chest. You suspect that she may have a chromosomal abnormality and order a karyotype which reveals a 45XO genetic makeup. If left untreated, how will this patient's hormonal levels present? A. High FSH/LH, low estrogen/progesterone B. Normal GnRH, FSH/LH, and estrogen/progesterone C. Normal FSH/LH, low estrogen/progesterone D. Low GnRH, low FSH/LH, and low estrogen/progesterone
Explain to the patient that when your body fat drops below a certain percentage your body can't menstruate, but athletic amenorrhoea has no effect on long-term fertility once regular menstruation returns.
A 17-year-old healthy and fit appearing female presents to the clinic stating that she hasn't had a period in 5 months. She states she has always been "pretty regular". The patient states that she is sexually active and she uses condoms as her contraception method. The patient recently decided to compete in a triathlon with her dad and has been working out and training almost everyday, sometimes twice a day. After the hCG comes back negative, what patient education should you give her? A. Tell her that she needs blood work and karyotype to rule out genetic abnormalities. B. Explain to the patient that when body fat drops below a certain percentage your body stops menstruating- this is irreversible and she will be infertile. C. Tell her that there may be a concern for Asherman's syndrome D. Explain to the patient that when your body fat drops below a certain percentage your body can't menstruate, but athletic amenorrhoea has no effect on long-term fertility once regular menstruation returns.
Premenstrual Dysphoric Disorder; increase in exercise, ibuprofen prn, and limited caffeine intake
A 18 year-old female presents to the clinic with her partner complaining of headaches, pelvic pain, and bloating intermittently, for the last 3 months. She states that her symptoms begin a week before her period and lasts around seven days. Along with her physical symptoms, she states that lately she "just doesn't feel happy." She goes on to explain her lack of energy in daily activities, loss of appetite, inability to concentrate, and problems with sleeping. Her partner also notes that "she gets annoyed at everything he does." Based on the patient's presentation, what is the most likely diagnosis and initial corresponding treatments? A. Premenstrual Syndrome; increase in exercise, ibuprofen prn, and limited caffeine intake B. Premenstrual Dysphoric Disorder; increase in exercise, hormonal contraceptives, and increase in caffeine intake C. Premenstrual Dysphoric Disorder; increase in exercise, ibuprofen prn, and limited caffeine intake D. Premenstrual Syndrome; increase in exercise, hormonal contraceptives, and increase in caffeine intake
implant
A 21-year-old female presents to the clinic for a well visit. She currently has no complaints, but had a question for the provider about getting on birth control. She has a boyfriend and they are wanting to start being sexually active with each other. They tested themselves for STIs and are negative. She mentions that she is not ready to have a child anytime soon and wants to decrease the chances of getting pregnant. She would like an option that would be highly effective, yet would require less work for her to keep up with as she is a full time college student and has a very busy schedule. She has insurance and states that cost is not an issue for her. Which contraceptive would be best suitable for this patient? A. Birth control pills B. Female Condom C. Implant D. Injection shots
No treatment
A 25 year old female patient diagnosed as 4 weeks pregnant last week, comes into the ER with history of spastic lower back pain and profuse bleeding with clots, that has now slowly subsided over the course of 3 days. She denies fevers or chills, but has nausea. The patient states "the bleeding would not stop" and symptoms of cramping and bleeding had worsened until they completely subsided today. A PA performs a physical exam with a speculum and notices some residual blood near and closed cervical os. Given her history and physical findings, what is the appropriate treatment of choice? A. Rhogam and supportive care B. Rhogam with suction curettage C. No treatment D. D&E to remove products of conception and broad-spectrum antibiotics
Copper (Paragard) IUD
A 26-year-old female who is sexually active is looking for birth control that will last several years. She has a busy, fast-paced lifestyle and admits she is not the best at remembering to take pills. She also states that she is terrified of needles and refuses any method that involves an injection. Of the following, what is the best method of birth control to recommend for this patient based on her wishes? A. Depot medroxyprogesterone B. Mifepristone C. Estrogen/Progestin D. Copper: Paragard Intrauterine device
Oral contraceptive pills
A 27-year-old female presents with "unable to get pregnant after 2 years of trying". Physical exam and workup reveals BMI of 30.2, acne, hirsutism, fasting plasma glucose of 130 mg/dL, anovulation, and polycystic ovaries. She is diagnosed with Polycystic Ovarian Syndrome. Which of the following would be inappropriate to include in her treatment regimen? A. Metformin B. Weight loss C. Oral contraceptive pills D. Clomiphene citrate (Clomid)
Suspicion of Incomplete abortion and need to check for products of conception (POC) before deciding on a treatment plan.
A 28-year-old female presents to the ER concerned by how much she has been bleeding for the past 4 days and the severe cramps she is having. She currently has an IUD and experiences irregular menses, so she isn't sure when her LMP was, but thinks it was about 6 weeks ago. She is in a monogamous relationship and doesn't use contraception besides the IUD. Upon pelvic exam, you notice a painless chancre she didn't know was there on the posterior vaginal wall, bleeding around and through the cervix, and a 2 cm dilated cervical os. Bimanual exam reveals a boggy uterus. Why would you decide to order a transvaginal ultrasound? A. Suspicion of Incomplete abortion and need to check for products of conception (POC) before deciding on a treatment plan. B. Suspicion of Adenomyosis and need to examine the endometrium. C. Suspicion of Inevitable abortion and need to check for products of conception (POC) before deciding on a treatment plan. D. Suspicion of primary syphilis and need to rule out the possibility of spread into the uterus.
Metformin, lifestyle modification, and Clomid
A 28-year-old female with obesity presents to the clinic with concerns about fertility issues after unsuccessfully trying to get pregnant for over a year. She tracks her cycle consistently and says, "I always make sure to have sex when when my period calendar says I'm ovulating." You gather some additional history from the patient and conduct a physical exam. On physical exam, you see signs of chest and back acne, hirsutism and acanthosis nigricans. You decide to order a Hgb A1c and ultrasound. The A1c results suggest pre-diabetes at 6.1% and the ultrasound reveals numerous ovarian cysts. The patients BMI, imaging results, lab results and physical exam findings confirm your suspicion of PCOS. What is the most appropriate approach for treatment? A. Lifestyle modification; counsel patient on the importance of weight loss in managing PCOS B. Metformin, lifestyle modification, birth control pills, and management of acne and hirsutism C. Metformin, lifestyle modification, and Clomid D. Metformin alone; tell patient that ovarian cysts are normal and not a cause for concern
Supportive Care
A 32 yo female at 16 weeks gestation presents to the clinic with abnormal bleeding for the last 12 hours. She admits suprapubic pain, but denies dysuria, urinary urgency, urinary frequency, and hematuria. During pelvic exam, you note moderate vaginal bleeding and a closed cervical os, with no cervical motion tenderness. Sonohysterography reveals no evidence of fetal demise and a uterus that is still retaining products of conception. Based on the likely classification of spontaneous abortion, what is the most appropriate treatment option? A. Supportive Care B. Suction & Curettage C. Dilation & Evacuation D. Hysterectomy
Patient's history of breast cancer is a contraindication for starting OCP.
A 32-year-old female presents to the clinic to discuss birth control options. She has never been on "the pill" before but recently got married and she and her husband are not ready to have kids just yet. As you obtain a past medical history, the patient admits to getting an STI in college (chlamydia) which was treated without complications. In 2017, she was successfully treated for breast cancer that had been caught early; the patient reports breast cancer runs in her family so she had been hypervigilant when she felt a mass. She drinks 1-2 glasses of wine on the weekends and no longer smokes. Patient reports smoking around one cigarette a day for about two years in college, 2005-2007. Vital signs: Wt: 145 lbs, Ht: 62in, BMI: 26.7, BP 119/78, Temp 98.9 F. Based on this history, why would you avoid oral contraceptive pills (OCP) as an option? A. Patient's BMI is concerning; starting OCP will cause the patient to gain even more weight, putting the patient at risk for obesity. B. The patient's history of a STI is a contraindication for starting OCP as the hormones in OCP can cause a rebound infection that is more resistant to treatment. C. Patient's history of smoking is a contraindication for starting OCP. D. Patient's history of breast cancer is a contraindication for starting OCP.
Give the patient a rhogam shot and supportive treatment therapy.
A 32-year-old female who is G1P0000 and currently 2 months pregnant presents to the clinic complaining of vaginal bleeding associated with lower abdominal cramping, pelvic pressure, and lower back pain onset one day ago. She reports she has gone through 4 pads in the last 24 hours but the bleeding has improved in the last couple of hours. You perform a pelvic exam that indicates a bluish, pinpoint, and closed cervical os, dried blood on the posterior vaginal wall, no vaginal discharge, and no cervical motion tenderness. No products of conception were seen. Lab work includes RBC of 3.9, Hgb of 13.2, HCT of 37%, normal WBC, Rh negative, and a markedly elevated serum beta-hcg. Pelvic sonogram shows a viable intrauterine pregnancy with fetal heart tones at 122 bpm. How would you manage this patient? A. Order a type and cross, and give the patient a rhogam shot, large bore IV, and pitocin. B. Give the patient misoprostol, and prepare the patient for dilation and evacuation. C. Give the patient a rhogam shot and supportive treatment therapy. D. Start the patient on antibiotics, give her a rhogam shot, and prepare her for a hysterectomy.
Total Hysterectomy
A 35 year-old G2P1102 female presents to the clinic today complaining of heavy, prolonged uterine bleeding. Her pelvic pain is a 6/10 and has been ongoing for the past 3 months. Bimanual exam reveals a tender symmetrically enlarged boggy uterus. She is complaining that her "quality of life has decreased" and she states she is not interested in having any more children. Which of the following is the best definitive treatment plan for this patient? A. Salpingectomy B. Oral Contraceptives C. Total Hysterectomy D. Copper IUD
Ultrasound revealing "cluster of grapes" appearance of the uterus
A 35-year-old G2P1001 female patient who is 12 weeks pregnant presents for vaginal bleeding. She states that she "woke up today with brownish-red discharge" on her underwear. She denies any pelvic or abdominal pain. The patient notes that she was alarmed because she did not experience symptoms like this during her last pregnancy (her baby was delivered around 4 years ago). She does endorse more nausea and vomiting during this pregnancy than the last, but states "I thought I just got lucky with the first one." Her vital signs today are normal other than an elevated blood pressure of 142/86. You decide to investigate preeclampsia, and your suspicions are confirmed when a urinalysis reveals proteinuria. Given the patient's presentation, gestational trophoblastic disease (GTD) is high on your differential. Which of the following findings would confirm this diagnosis? A. Ultrasound revealing "cluster of grapes" appearance of the uterus B. Beta-HCG < 100,000 C. Increased fetal maternal serum alpha protein D. Uterus measuring smaller than expected for gestational stage
She is a current smoker
A 36 year-old Caucasian female presents to the clinic for her well woman exam and is wanting to discuss options for contraception. Her vitals taken by the MA and her BP 126/72 mmHg, HR is 76 bpm, and her BMI was calculated to be 27. She has a family history of breast cancer, but her most recent mammogram was unremarkable and she is BRCA negative. Her social history includes 1 glass of red wine per night, a 10 pack year history of smoking, and no drug use. She declines tobacco cessation counseling and does not plan to quit. She takes no prescription medications, but does take an OTC multivitamin. She shares she would prefer to be on oral contraceptive pills. What component of the patient history is a contraindication for starting oral contraceptive pills at this time? A. Her blood pressure B. Her BMI C. She is a current smoker D. Her family history of breast cancer
Levonogestrel IUD
A 38-year-old G3P2002 female reports to the clinic complaining of heavy, irregular bleeding for the past four months. She states that prior to this her periods were regular and "normal," but now her periods are "all over the place" and she might use twice as many tampons per day as she used to, and sometimes bleeds through a tampon and a Depends while sleeping. Denies pain or itching. Patient denies any correlation with stress or illness. Patient denies any relevant family history. Patient states that her only medication is a new antidepressant that she started taking approximately four months previously, which has brought her relief after years of depressive symptoms. Her most recent well-woman visit, six months prior, was unremarkable. She and her husband use condoms for birth control. She says that she is "completely done" having children-mostly because she doesn't want anything more to do with needles and hospitals if she can help it. Patient admits smoking 1 pack of cigarettes/day and drinking 2 glasses of wine/day. Vital signs are within normal limits. Palpation of abdomen unremarkable. No discoloration or lesions noted on inspection of external genitalia. Speculum exam unremarkable. Bimanual exam consistent with normal size and consistency of uterus, no masses appreciated. Transvaginal ultrasound revealed normal size uterus, negative for polyps, endometrial stripe approx 3 mm. Which treatment would be the best for this patient's abnormal uterine bleeding? A. Hysterectomy B. Estrogen-Progestin Contraceptives C. Levonogestrel IUD D. Endometrial biopsy and possible referral to oncology
Inevitable Abortion
A 39-year-old G2P1001 female patient who is currently 8 weeks pregnant presents to the clinic with her partner complaining of pelvic pain and cramping while pointing to her hypogastric region. She reports moderate bleeding for the last 8 days. On the physical exam you note no product of conception (POC) expelled, progressive cervix dilation of 4 cm with effaced cervical os. Upon ultrasound you note POC visualized in the uterus. Your patient is most likely experiencing a (an): A. Complete Abortion B. Inevitable Abortion C. Incomplete Abortion D. Threatened Abortion
Endometrial polyp
A 42-year-old obese female with a history of hypertension presents to the clinic complaining of intermenstrual bleeding. She reports a regular menses cycle, but light bleeding occurs between her menstruation. She is currently taking tamoxifen which she began taking 6 months ago after having breast cancer surgery. A pelvic exam is performed and a pedunculated tissue growth is visualized protruding from the external os. The Bimanual exam was normal. Based on the information, which of the following is the most likely diagnosis? A. Leiomyoma B. Adenomyosis C. Endometrial polyp D. Endometrial hyperplasia
Incomplete abortion; prescribe Rhogam and Pitocin, insert large bore IV, and perform dilation and evacuation
A 42-year-old, G3P1011, Rh- female is 14 weeks pregnant and presents to the clinic with a 2-day history of vaginal bleeding and cramping. Because her most recent pregnancy resulted in a spontaneous abortion, she wanted to go to the emergency room that night, but her husband reminded her that she had bleeding during her first pregnancy, which was carried to term. When she woke up this morning, there was even more blood than the night before, so the couple went straight to the clinic. Physical exam revealed HR: 103, BP: 89/60, oral temp: 97.8ºF, blood in the vaginal canal and uterine content visible and descending from a dilated cervical os with no cervical motion tenderness. The uterus appeared boggy and smaller than it should be at this stage of pregnancy. Ultrasound reveals some products of conception retained in the uterus. Which of the following represents the most likely diagnosis and its corresponding treatment plan? A. Inevitable abortion; prescribe Rhogam and perform dilation and evacuation B. Missed abortion; prescribe Rhogam and misoprotol and perform dilation and evacuation C. Incomplete abortion; prescribe Rhogam and Pitocin, insert large bore IV, and perform dilation and evacuation D. Septic abortion; prescribe Rhogam and broad-spectrum antibiotics, perform dilation and evacuation
Transvaginal ultrasound to measure the uterine lining
A 48 year-old caucasian, G3P1203 female with LMP 06/2019 presents to her OBGYN for vaginal bleeding that started 2 weeks ago. The patient states she goes through 1 ultra-thin pad daily and complains of suprapubic pain. Her last menstrual cycle was 3 years ago and she has not had any vaginal bleeding since starting menopause. Her last Pap smear was done 12/2020 which was normal. A full examination including a pap smear was completed in clinic today that showed blood in the vaginal vault with no other abnormalities. As the PA in charge of this case, what diagnostics would you order next? A. Hysterosalpingography to rule out acute salpingitis B. Colposcopy to sample the cervix for abnormal cells C. Transvaginal ultrasound to measure the uterine lining D. Hysteroscopy to sample the endometrium
On a bimanual exam: The uterus is large, irregular/asymmetric. Felt as a non-tender, hard and palpable mass.
A 52-year old Caucasian female presents to the clinic with abnormal and heavy menstrual bleeding along with increased pelvic pressure. She also complains of increased urinary frequency and constipation. The PA suspects the patient has Leiomyoma. Which of the following physical exam findings would correlate with the diagnosis? A. On a bimanual exam: The uterus is large, irregular/asymmetric. Felt as a non-tender, hard and palpable mass. B. The bimanual exam was unremarkable. C. On a bimanual exam: The uterus is large, symmetric, boggy, tender with globular enlargement. D. Strawberry red spots on the cervix with bleeding on contact.
NSAID use
A 53-year-old African American G4P4 female with LMP 2/14/2020 presents today for evaluation of vaginal bleeding. She states that she first noticed bleeding 2 weeks ago while wiping after a bowel movement and assumed the source was her rectum due to a previous history of hemorrhoids. She later noticed "light pink to light red" blood in her underwear which she realized was vaginal and not rectal. She required a pantyliner when her bleeding first began but has been wearing a regular-sized maxi pad for the past 3 days. Bleeding is now described as having a moderate flow that requires changing of her pad every 6-8 hours. Patient has a history of chronic left knee pain after a fall from a bicycle 1 year ago. Pain is improved with elevation of the knee, application of a heating pad, and Naproxen taken twice daily. Patient does not take any other medications and notes that she is not being treated for any medical conditions. She denies fever, pelvic pain or abdominal cramping, changes in urination, abnormal vaginal discharge, or previous episodes of abnormal vaginal bleeding. Last pap smear was 8/19/2020 with normal findings and the patient has no history of abnormal pap smear. Family history is significant for colon cancer and lung cancer. Which of the following elements in this patient's history is a risk factor for abnormal uterine bleeding? A. Family history of cancer B. Age C. Ethnicity D. NSAID use
Vagifem (estradiol vaginal insert), a vaginal estrogen
A 57-year-old post-menopausal generally healthy woman with no prior history of hypertension, clotting risk factors, cardiovascular disease, or any previous gynecologic surgeries presents to her PA for vaginal irritation and dryness that began around four years ago. Pain during intercourse has become common. To compensate, the patient has been trying different vaginal moisturizers every day and vaginal lubrication for intercourse with little to no improvement. Which of the following would be the best pharmacological treatment option? A. Osphena (ospemifene), an oral SERM B. Angeliq (estradiol/drospirenone), an oral contraception C. Vagifem (estradiol vaginal insert), a vaginal estrogen D. Intrarosa (prasterone), a vaginal androgen insert
Tell her one type of "morning after pill" is called Plan B and it can be bought without a prescription and taken within 3 days of when she had sex.
An 18 year old WNWD female presents to your clinic concerned because she had sexual intercourse for the first time two nights ago with her boyfriend. She is not on any birth control and did not use a condom. She doesn't want to become pregnant and is worried the "morning after pill" won't work because it has been two days. Her LMP was one week ago. How do you, as the PA, counsel her? A. Tell her one type of "morning after pill" is called Plan B and it can be taken within 5 days of having sex to induce an abortion in case she is pregnant. B. Tell her one type of "morning after pill" is called Plan B and it can be bought without a prescription and taken within 3 days of when she had sex. C. Tell her it is too late to use emergency contraception and she should return in two weeks for a pregnancy test. D. Start her on an oral contraceptive pill immediately which will prevent implantation of the embryo.
Rather than having XX chromosomes, you have XY chromosomes but testosterone receptors did not effectively work during fetal development, and caused you to develop as a female.
An 18-year-old female patient presents to clinic complaining that she has never had a period. Upon physical examination you notice that the patient has ambiguous genitalia with an enlarged clitoris, and cervix was missing on the pelvic exam. The patient was sent for genetic testing and was diagnosed with Androgen Insensitivity. How would you educate this patient about their condition? A. Rather than having XX chromosomes, you have only one X chromosome, causing the testosterone receptors to be ineffective during fetal development, and therefore you developed as a female. B. Rather than having XX chromosomes, you have XY chromosomes but testosterone receptors did not effectively work during fetal development, and caused you to develop as a female. C. Rather than having XY chromosomes, you have XX chromosomes but estrogen receptors did not effectively work during fetal development, and caused you to develop as a male. D. Rather than having XY chromosomes, you have XO chromosomes but testosterone receptors did not effectively work during fetal development, and caused you to develop as a female.
Lifestyle modifications
Question 1: A 30-year-old nulligravida female comes into the clinic complaining of irregular periods and 15lb weight gain over the past 3 months. She states the first day of her last period was 40 days ago, and says her cycles usually range anywhere from 35 to 45 days. She is not sexually active. However, she states she would like to become sexually active but wants to avoid unwanted pregnancies with her irregular cycle. She denies using tobacco products but does drink 1-2 glasses of wine with dinner on the weekends. On physical exam, you note patchy hair loss on her scalp, moderate to severe acne, increased hair growth around her mouth, and broad shoulders and hips. Heart and lung sounds normal and otherwise normal exam. Vitals taken by the nurse were: HR 86 bpm, RR 12 bpm, BP 110/80 mm Hg, HT 62", WT 79 kg, BMI 32. Which of the following would be considered a first-line treatment for this patient? A. Lifestyle modifications B. Insulin once a day C. Letrozole D. Dopamine agonist
If she is prescribed estrogen, she must be prescribed progesterone.
Question 2: A 56-year-old G2P1102 female came into the clinic today for her well women's exam. When taking her history, she let you know that she hasn't had her period for 2 years now. In addition, she does not drink alcohol or use tobacco, and has never had surgery stating that "all her reproductive organs are intact." You diagnose her with menopause. She tells you one of her friends is on Menopausal Hormonal Therapy (MHT) and asks if she could start MHT to help with her night sweats and hot flashes. You discuss a treatment plan, which of the following is true? A. She should only be prescribed progesterone. B. She should only be prescribed estrogen. C. If she is prescribed estrogen, she must be prescribed progesterone. D. If she is prescribed progesterone, she must also be prescribed estrogen.
Turner Syndrome
Question 3: A 12-year-old girl and her mother present to your rural medicine clinic because her mother is concerned about her daughter's development. Before entering the room you look at the chart and notice a height of 49 inches (4'1ft), and a weight of 32kg (70lbs), placing her below the 3% mark for her age. Her mother informs you that her daughter has always been smaller than her peers, but has fallen significantly behind intellectually and physically the last year or two. A physical exam reveals wide-spaced nipples with underdeveloped breasts, a webbed neck, and hyperconvex nails. Based on this exam and her height, what would be the most likely diagnosis? A. Turner Syndrome B. Premature Ovarian Failure C. Androgen Insensitivity D. Kallman's Syndrome
The patient meets the criteria for PMDD, advise her to limit alcohol and caffeine. Discuss options such as oral contraceptives.
Question 4: A 24-year-old female presents to your clinic with concerns about her menstruation. She states she has been very irritable around her cycle for the past 6 months and has been diagnosed with an anxiety disorder for which she was given Lexapro. She has been counseled to get more sleep around the time of her period due to her lack of energy. To combat her fatigue, she drinks 3 cups of coffee throughout the day around mealtimes. She struggles with feeling overwhelmed, has concentration difficulties, and is starting to have a decreased interest in daily activities she normally enjoys like going out and getting drinks with friends. She states her symptoms are present in the final week before the onset of her menses, start to improve the first few days of her cycle and resolve once it is over. Which of the following is the best diagnostic and treatment plan? A. The patient meets the criteria for PMDD, advise her to limit alcohol and caffeine. Discuss options such as oral contraceptives. B. The patient does not meet the criteria for PMDD, advise her to increase exercise and caffeine. Discuss options such as SSRIs C. The patient does not meet the criteria for PMDD, advise her to limit alcohol and caffeine. Discuss options such as oral contraceptives D. The patient meets the criteria for PMDD, advise her to increase exercise and caffeine. Discuss options such as SSRIs
Threatened abortion
Question 5: A 27-year-old G2P1011 female presents to the emergency room with mild-moderate vaginal bleeding. She is 18 weeks pregnant, A&O x 4, and appears to be in mild distress. Her vital signs are BP: 124/84 mmHg, HR: 88 bpm, respirations: 14 breaths per minute, and temperature: 98.8 F. Upon physical exam it is noted that the cervical os is closed, there is no passage of products of contraception, and the uterus size is compatible with the number of weeks pregnant. An ultrasound is performed and there is no evidence of fetal demise. What classification should the PA use for the diagnosis of this patient? A. Inevitable abortion B. Incomplete abortion C. Threatened abortion D. Complete abortion
Threatened abortion, Rhogam, supportive therapy
Your patient is a 25-year-old female that is 18 weeks pregnant with her first child and no significant past medical history. She reports she has felt better in her second trimester with less nausea and has more energy. She presents to you today because she has been experiencing some mild to moderate vaginal bleeding for 2 days and on and off cramping. She is worried that her new exercise regimen she started recently of running a mile 4 days a week is causing this. On exam, you note the cervical os is closed, uterine size aligns with gestation, and there are no signs of passage of products of conception. Ultrasound reveals the fetal heartbeat is intact. What do you suspect and what is the treatment? A. Inevitable abortion, Rhogam, dilation and evacuation B. Complete abortion, no treatment necessary C. No treatment necessary, advise patient to reduce her physical activity to walking D. Threatened abortion, Rhogam, supportive therapy
